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A27 236i ���� ��i ������..J' �� ' � � s , J �� � �J �.J l�l �� J�.�..ria.-�-:i� �o „--, ,,-,r„ «m.�.�.� �'3.'� �.�.� .E� / �x Ma}� � �rc � : , �ui � d,ivi i � m ' ��se�S� .ian' � � �/ �pra�ea�esa�t ��mit �ar.�t `��lad ��r /l �`see ea� o �i�aon Type of Facility: rR' 1'`• . New x A.dditi�n . '�ate� �aa�p�9 � # of Oc�upants�ual�' �;_ # of Be�rooms o1 Proje�te3 Daiiy F1aw.� g.�,d. Proposed Wastewater System: � v�✓t ?�ist • .. � � Type: �4 " Proposed Repair: Q �C �� Type: . Pezmit Conditions• Sr � Si��' � ' . . . . Owner or Lega1 Regrese ��n��. s�� A�: ., - ��s , .- 'Iye ;4�=�*,s� of ti�is pemrit lry #he Health Departmeztt in does not guax�ntes the ,'.�„��� of ather p�. If is the rr.spons�ility of the aFPli��P�Y owner tn in. sure that aIl Petson County Plaaning and Zonmg �d Biniding Inspe�tioas ze�emeats are me� 3his �anprovement �srmit is snb jert tm revaca#ian if the site plan; �pla�'6'r� t� iateud� use c3n�nges. '3'�e ��Srovememt �'ernmit is �o� aY%stesl lip a c�ange in odvnersiiip oi the psoperiy, �s permit was issued in cmrnplianca � the pmvisions of the NortB iarolina, . `Laws ayad Rules for Sewa.,,Qe ?`re�nent axd lDisnosal Svste�s' {�,SA NCA� 1�A .1900). Pieither 'Psa�on ��untp.: mor�;t�,ie.`. '� Envirmnment�i �ealth Spe�ialist �varrsints that the septic tank systesa w�71 cantinue to fnns�on sa#isfaciority in t]ae fitfnre�oc:tli�it. the-�vatrs snp�slp wiil remaia potabie. . . ' �iwtthoa�tion t� C�nst�ct �aste�vater Spste� (.�� iur �a�aii�g �e�t) � . *. Ses site plan and additional attac3ements �). . ' � � . -. Progo eri Wastewater System: l�'►�tMPit ri�/L� ��. Ty1�e�'0. Wastewater �low-��.p.d. New � Re�air aasion � � .� 3oi1 L��B: . 3o g.p.3J $ 2 TypeofFac�ity: ��ieA:. ��4�rQqp �7L• � Basement_Yes�CNo � � ���$��P��' Sy9�� �iflH�'�Y�1.�3�� � iamk ��e; Se�rtic '��nYc:' did O��l �p Tanic: � gal iare�se'�a-�p: g�i � ]�rr�i�fe�d: T�� Ar-�: g�0 sc� it To#al Lengt9� ���o #� ' ��� Trenc3a De�d�a. . �8� am� . • -� � . �r.�c� i�id#h � f# 11r�a�an Soifl �over. _� i� ��ari �.'x�enc3a Se�aaat�on: ( #t IDis#a�bu#son: � �is€�ibartaon �oa %'� Seriai ��tribntaoan �ressaas I4la�fold . � Sn�cations: �rv�C dr' SPn'� i ; s . cQ,�, � " . � - : -. . �u#9aorizesl State Agen�: � l� 4�1 � Date: ' j7�'_ Pernut Expiration Date: - ----- - / � The type of system permitte� is � Conven�onai Ac:,�tea Alternative. I a���t #he spe�ifications of the P��- �e�ll:eb� �a�rps����ave: Date; � pCHD r�y.11/10/fl5_ e - � ��,� � �; � � ��. � �fl � i �'� s 1�, ��I � � ���� ��1.'�3� �� b^� �r-n--1 cB �_�.�.� � � aSl.�'l�� �x Ma� ' arc ' . � �UI � � �(Vf ,1 � 18 ��ie1. �S�^�.(Olil: � -: ��r.�nit'�alid �or i< �'�ee f al' Type of Facility: � k # of Oc�ants/l.�.a X of Propose3 Wastewater System: Proposea xe}�air: �� � ��lii�`4P.iH1[�i� �L'i�l$ _ l�o �a�ion � New � Addition . . ��ter ���p�y C1�2( �ooms—�-- Praje�te3 Dai1y Flow C? a� g.p,d. i �vLtR � � � Type: �Q � • Type: � Perrmit C�nditians: �, SP� S�t� S� � ' � �wne.x or Lega1 Re�rrese Authorize3 State Ageat: � • - �1��� The issuanca of tiiis permit 1iy #he Heal� Depaztment ia daes nat gnaz�ee t5e ;�,��a of ather per�its. If is the mspansx�iiity of the aPPli��P�Y owner to in s�e t�at aIl Person Couaty Plaaning and Zonmg and Bu�ing Inspections re��ments aze me� �his �acspsovement �ermit i� sub je�t #� revocatian if the site pI�; �plai''�'r� t�e iateud� use c3�es. `�e �pgovement Per�mt is �ot axleet�si 3iy a c�angs in owner"s�ip oi t3ie property. �ss permit was is�aed in c��ssplia�c� � the provisaons of the Nart,h �arolina, .� `�riws aaaai Rules for Sewa.ge ?'rea�nent aa�d 13ist�osul Svstenis' (�,SA Nf:AC 1�A .1900). PTeither 'P�rsoa ��unty:nor�;t��.`�'� Envsronmental �ealth Sgesialist �varranis that the s�ptic t.ank sysiem mil cnntin�e to fnne�on sa#isfaeio�ily iri t�iae faitnPe�oc:#&at. the-wat�r snpgiy wiII remain }sotable. � • • ' A�at�aoa�atio� to Construct ��ste�v�ter 5�st�t (�qnmres� %r �a�a� �es�a�.t� � � *. Ses site plan mid additional attac3cmeats (_). : � � � . . Proposed Wastewater System: �dut/�:il �f��si (. Tppe�4 Wastewater �1ow ��.p.d. . New � R�air F�,papsion _ � � � � 3oi1 L��IB: ,� � g.�.ri! $ 2 ' 'I�►pe of Fac�ity: ' ��� �/�e S ' � Basement � Yes _ No � � ���$��P�.��' ���� �i�'�3Yi��$S � � • . '�ank Size: Septic i�nYc:' lp��l �p T� � g�i �Grease'.�a-ap: gai �� . 3�raim�e�d: T��i�L �-,..�: �{f �O sc� i� Toial Lengt4t �� fg ' lY�ffi� Trenc3a Dep�a � g ien .•-. �- �'�.endn �ici#fl� � it 14r�i�en Soifl �ovea : � i� Nr,�ia��B,i �"rr.�tc3a �ep�a�ticon: � �i IDistgabu#son: k �istra�ui�on �oa k Serial �ii�tnn�n�floa �ressnre �fold � . Sn�y cat� �f �� � d r� i�'"f�ro �C � . � �I . e�. � �i v�Pr'f' 4 � � t,��rs 2�. • � . . _ - . -1=ru�n�a��,vr rcZ.'L,c a�/l�c. svRs 'Z Sc..s _ . . . Aui9ao� State Agen�s: Pernzit F.xn' on Date: The type of system penmite3 is � Conven�ionai Ac:.�teu P��- 1�aee�/.L���i �8a��s�s��i�ve: Date: Alternative. I a���t +he spe�ifications of the Date: pCSD rev,11/101Q5._ , .. : � _. � s�d �� s s�� au �� ��� � ���� �� �19.f7.1-�. �1.�� '�i' �T . �`• � � 1 j �/ � .� � �.A.. V �'3� .1.L ����r-��rn TMTM� ����.� ��.�.�.�EI�a , ax M�p i � rc � Sut� � livi�ion Ph.ase Sec ion% ot # # of Bedroams Applicant: ��7Y�a-e- (�,S , � Location: � � � �:� �� �`� _.� t �� � t �' �:: ; System Type (in Accnrdance Wi�h Taf�ie Va): � TNIS �YST��li i-iAS �E��9 1RIST�,LL�� IN COi�IPLIANCE 1nitTH �►RPLlCABLE . tVORTH G'AROLINA GEi�E€?.4L SiATUTES, RC1�.ES �'dR SE1N.a.GE 3'REAT1VtE�IT AND DISPOSAL, Af�D • ALL COIVDITiONS OF � T}-3E lilliPROV�NfE�dT PER11�tT �4ND COi�STRUCT101� AllTHOR TiON. � . ,� � . 6 � � . Authorized State Agent ate lnstal{ed. By: �� ��� Date:. 3/��� � . ��dd` �° �P1�. � �� « �,�z� ` ��tr, l �'�� rr `7r�1 �� 111 � 8�/{ � � �+`�c � " l�� � � �� c Z--�s� . �� � �� � r�v-2 ( �. 5 Z L �-Sl�� s�-� ��� � �cH�, r�v. o7i?Q�o,� n m ����� ���� �������J 3�� '�u������ 9 `���� �8 � ��`1; � a; IVIa� �� Rarc�! �� Sysiterra Type (Tai�ie Va) Owner/A�plicant Su�division Address/Location Sec/Phas� Lot # � . ` o� . . . , 3l �o/O B� _ .. v . �—'z=—�i a._ �e_.s_:a!__i._T9.��.e B.e:a:m�-1 State �lD/date � �4 Capaciiy Q� gal. Tee and Filter - • Baffie Sea(ant � Riser (i� a�plicabie) T'ank Outlet Seal Permanent iVla�cer Pttma� T'�nk -- �,a a��r yai. � Wate roof ISeal�nt l�iser Water Ti ht Puera� Ci�ec� VaivelGate Valve �larm (visable and audible) Electrical Componenis Rate (gpm) . . Approved Pump fi�oc3e! 8locic Unde� Pump � PumQ Removal RopelChain . �Disia�abu�ion:�y��a� Se�ial Distribution 6�ressure fl�ani o �.ow Pressure Pipe l���r. Pipe I�ateriai and Grad� „_,_� _ _ "t/' Trencfi Widih� '3 ft. -�' � Trencf� De �h in. �✓ Trenc� Len h ed ft. V Trench Gtade � Tres�c#� S acing ✓ � Rock Depth and Qualiiy � Dams/Ste downs etc. Pressure Laierats � Hole Spac9ng - o e izs Pip�. S1e�ve Requi�ed� �etba�� From� Weils ' From Pro�ertv lines • � Surfac� Waters Public iNater Su iie �/erticai Cuts >Z ft. Water Lines Vehicle�Traffic � . EasementslRight or V� O�es°� Eas�menis Recor�ded I Co�asnen� - � pc: � d rev. 3113/Q'1 •����j �� �11.6i �� �� _ ^^ �✓ 'V �j7��� J• ��IDL�Aa'�lM'TMn �BT�L�..ffi.JL JI.. ]L�.el.�.. -..11. � � , . ...- � . • � d .r •� I�� � ���� - ` ��� -• ' �•i �� �4�•_.�J�1hL1•3: V11. �a.Y N�. � ��/ ( PB.�CPJ. # � 7 P � �ection/Lot# � . o -��-� Date �� Syste9n cortrj�a�ren�r neprese�t appmximate�co�tours only. The conirrtctor must, j`lacg the system prior to loeginning the is�staAation to insure that pr,upergrade u n,asntaxreed °: ,. --- ' c.'•- ..,.v..n..�..,.n, ._.-..,.. . ., ,�-, �_----�c-f �-.. ....._. ����,cl S%s-� v� [ �� . �,,� � l � �p • � ������: 1!�t"� � `� r�. � b��'�' s� ��. �r Scale: 0 " 1�� l ��`)��K,�r��'j" c ��� � � t j'rt 3 �n---� . � `-� ,� tly (3 �, � � �V V j� � ('�,� � � �..��I����,r�. �,r� � .�'1�� � � _,.� a,� 1�� �4�`�..� � !� .T�'� ( �£'G�i�^s��; ��.:J. � .. PG��, =ev. 09/12/01 Application Dat�: � Z5 U - � ' Amount Paic�: �i200-O� Receipt#: 3 ( 0 i � ,, ,{r�� �. �,�'�� � � �1La�� �J� �`' � �� ` '�"= — � � � �.�� `�C� ��r � E�'� :c-n. w ii ar.ca s��..ira-n...cs.:n-n.�.en. )1. IE ":IL "a.�.cn, u. tti:��. Tax Map: Parcel #: � . Application for Services (Septic Systems and Wells) ` Services Re ue�ted L Improvemei�t Permit (Site Evaluation) ❑ Consiruction Authorization $200.00/$300.00 (if > 600 d) (Fee is de endent on the e of sy� C Mobile Home Replacement or Building Addition ❑ Permit RevisEon $I50.00 (if site visit re uired) � $75.00 0 Well Permit (New/Replacement) ❑ Repair of Eaisting Septic System $225.00/$125.00 No CharQe Important: If the information in t/ie application for an Improvemer:t Permit is incorrect, fulsified, or the site is altered, tl:en tlre Improvenient Permit ai:d tfie Authorization to Co�istruct shall become invalid 1) Services Re ested by: Name: ���� ,b ,C�� /o,,i��� Phone # (home): �3l S J% ,��� Address: /Q'� ��,,,,�,,,z�� J v�P %��/ _ (worlJcell): S��/ ���r✓a .��/����c7� . ,� , . B)Name and address of current owner (if different than applicant): :�, Name: Address: 3) P�-operty Description: . Lot Size: ��_ Subdi�ision: Address and/or directions. to Property: _ T�� _S� /V ,�,- Lot #: 4) I'roposed IJse anc� Type of Structure: c�j �� �ja( Residential f Busine s,rI'ype: ���� '� S� Lb � Other ___ Number of bedrooms ---���. —/ Number of people servecl (seats/employees): --- Basement: Yes � No (with plumbing: Yes / No _) Garbage disposal: Yes �No �_ . 5) Water Supgly: Private Well (Proposed Existing _� Community VJell: Public Water System: Are �here on tlie adjoining properties? No Yes (please show location on site plan) Note: A completed application must al�o i►tclude: ➢ A platlsite plan of the property th�ct shows property diniensions and tlze size and location of all proposed structures. ➢ A signed cvpy of the `Lot Preparatinn' form ver�ing that the property is ready to be evaluated. I am submitting this application t� reaguest serviees f�-um the 1'erson County Health Depai•tm��nt. �'he information �rovided is accurate. I understanc� that if any site is alter�ed or the intended us� c�anges, all permits shall becon�e i�valid. Signature (Owner/Legal Represeniutive): _ i Da�e : Q_ 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, i�C 27573 (336-597-] 790) .L��, 7� 3� �11d�� `L�� V - ., . � �''V 1V �� ]E�..�a-o� � ���.Il 1Hi��fl�. � S�'�'�. ��.�C�. . Name ��'� � � `��-- �' �r Tag lyla.p # ���Pascel #� Sub i � Section/Lot# . 10 -��-� � Autlxorized Sta.te Ag�ent • Date . �� Syste�r com,�ionen�r r�p�eser�t approximate�contours only. The contr�xctor must, fTag t,he system prior to begr'nning the is:stadlatwn to insu�se that propergrrrde is masntcrined `: S�o.� . �P� , f � !�? �' �'O . �° 5�' � � ���� �� ' ` "'. 1 " -- c �. --� � . � � �C ' 67 �o � . �� a � 1or °— � ?o � - �,B � � F'p a � / �r,�► a � .�� I � !zo ' ► r t . D-Box w i�-�^ Scale: � = i�� y,� �Zo� (�n�5 ►� � 0 N � c PCI�, t�w. 09/12/Ol ���� �� ���� �1� y 1 d �— ,� � r V�. o � � � ��� J.L� I� ��a- � � TMTMT �� ��n.II I�IL � �.1L�IE� Applicant: /��-+� `�� -�' s Location: T� q / // . . i � i s _ r T^7'7'7 . _ .v / �x . �p ' � a,rc � � Subdlivision Fh.�s Sec ion! ot i,# of Bedrooms v -. � �� i . .:- `� .�' :. r _ . . . �e , ���[ .� +: �' c . _. i . . .. _.. . . .... '. . . Syst�m Type (in Accordance Wifih Tai�le Va): � THIS SVSTE3i� F��►S �E�� lR{STALLFD 1TV C�4�IPLlANC� l�t �TH APPLlCABLE . NORTH G'AROLlY�4A GENER.4L STATUTES, RCI�.ES FOR SEIiVV,4GE TR�Ti�tEi�T A�ID DfSPaSAL, AN� • ALL COP+lDITi�NS OF � THE 9[i�PROVE�ENT PER11�6T AbVD C�i�STRUCTIOf� .�UTHOi� ION. - . r^ � y�� _: � �g� D �' Authorized State Agent ate � `�l � �' lnstalied. By. �` �� � Date: � � g � ' �� � � ��� �r�,� ��� �. g' � $rl�t.• s ��ar � �' c � `z� � ��(� ��QS-� 3�' a � 9 ra�'`� � w� s s� l �ra�.e ��so,' ( M� x � 1Z -�2--�7 �r-s �� S�Q l �f2 FCHD, rev. C7129/G=' � � ����3G �'��K �NS�'��`�3C)� ��E��9S?' �'��� 99 � �� Ta;lViap ��a�. Rarce! #__��� Syste� Typ� (Tabie Va) Ow�erlAppiicant Subdivision Address/L�cafion SeclPhas� Lofi # � Se��c. T��aE� �na�S�U�a� R�a�a ��t�oea n�� In��� a� � State �lD/date �� Capacity �nch� Tee and Filter - Baffle Seaiant Riser ('rF applicable) �'ank Outlef Seal Permanent Niarker Pcarna� T�nk /Sealant Riser Water Tight � Paa�re� Ct�ec� ValvelGate Valve �11arm visa�le ancf au�ible Elecirical Companents ' Rate m .. A rovesi Pum fViodel Biocic Unde�- Pum � Pum Removai Ro e/Chain . � Dis���sa.e�ion: �ys�m � Se�ial Distribution � d�ressure fl�ani o �.ow Pressure Pi e A r. Pi e 11�11ateriai and Gra� Valves � � L w;atn� 3 �. De�th /Sl in. Trenc� G�ade � Trenc� Spacing Rock Depth and Quaiiiy Dams/S#epdowns etc. Pressu�e Laierals � Hoie Spac�ng � � o e izs Pipe. S1e�ve Turr�--u�slProtectors Required' Se�oa�� IFrom� Wells From Propertv fines Surface Waters Pub(ic 1Nater Sup�i ve�t;�i c� (>2 �. Water Lines Vehicle �Traffic - , �Easements/Righf ofi V' �er � . Easements Recorded e e *eratoo- oi Tri-Pariate Agre�enen Come�ten� . . pc:�d rev. 3t'l3/Q'1 � . ���,�� ���� �� . �, � �:� ���� I�irn�vn.u-�.?rn.a�p,-�,.��.��:]L �.a��,IL�]L-n . WELL PERMIT - PLEASE SEE ATTACHED PLAN FOR WELL SI.TE LAYOUT Tax Map �� �'arcel # Subdivision: Location: Township: Lot # Type of Water Supply: �C Individual _ Community Public Requirements: ' Site Approved By: S Liner: Grouting Appro y: l 6 D Installed by: . Well Log: ,,� , Depth set: _ Pump Tag: Grouted: _ Well Tag: �— Date: Air Vent: Hose Bib: Water Sample: Casing Height: I/ _ Concrete Slab: Well Driller: �'�n� Well Approved by: �'`� � r�/c«(S j ****See Attached Site Sketch**** � Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: Date• � l� � PCHD rev O1/27/04 � North Carolina State Laboratory of Public Health �d�% -�- 3� Department of Health and Human Services y P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: Lewis, Retrac Address: Robertson Rd Roxboro, NC Zip: County: PERSON Report To: Person Co. Health Dept. AnN: 325 South Morgan Street (336) 597-2371 Roxboro, NC 27523 Courier: 02-33-15 Collected By: J WILEY Date: 9/8/2008 Location of sampling point: Inside tap Remarks: Source of Water: Well Source of Sample: Type of Sample: Raw Type of Treatment: None Type of Analysis Private Time: 3:30:00 PM Parameters Results Units Date Analyzed: Alkalinity as CaCO3 131 mg/I 9/9/2008 Arsenic <0.001 mg/I 9/9/2008 Calcium 34.2 mg/I 9/9/2008 Chloride IC 7 mg/I 9/9/2008 Copper <0.05 mg/I 9/9/2008 Fluoride 0.24 mg/I 9/9/2008 Iron 0.70 mg/I 9/9/2008 Hardness as CaCO3 (Ca,Mg) 116 mg/I 9/9/2008 Magnesium 7.5 mg/I 9/9/2008 Manganese 0.50 mg/I 9/9/2008 Lead <0.005 mg/I 9/9/2008 pH 7.6 Std. units 9/9/2008 Zinc 0.53 mg/I 9/9/2008 Date Received: 9/9/2008 Today's Date: 9/29/2008 Report Date: 9/26/2008 Ref: 12304 Login Batch: Reported By: ���(� Sample Number: AB77711 Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. Presence of E. coli (bacteria) generally indicates that the water has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample received and should not be regarded as a complete report on the water supply. Inorganic Analysis: Recommended limits for drinking water. Sample should not exceed levels listed below. Alkalinity Arsenic Calcium Chloride Copper Fluoride Hardness G No established limits 0.01 mg/1 No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established limits Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 ��17�1 ��� PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant ���{rqG l-ZWi S Address � ��p�,�6h I��l• County �P fSa� �, Collected By T� Date Collected q— 29 �OFf Time Collected_ f/-.35 Source: .I�'Well ❑ Spring ❑ Other Location: ❑ House Tap 0'R'ell Tap ❑ Other dN �e � Sa"�j�� C51,o�> o harge Charge / ���������*�*��*����������*�*�����������*����**�**��*�*�*****,��**������:�**����* �**������*����**����*����*���*�������*�������*�*������*������*�����*����**�**� Total Coliform FecaUE. Coli Results Present Absen�t ❑ �� ❑ �1 Reported By �O ( 0 bactreport PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant ��Yq����� S Address �� Y�}�on �d . County I�� r5o� .�. . Collected By �S Date Collected �-Zq-D$� Time Collected � l�'�g Source: �'Well ❑ Spring ❑ Other Location: ❑ House Tap pNo �� ge� l ❑Charge QWell Tap O Other C H��� �����*���*���***������*����������������������*����**�*�*����*�**���**���*��*�* ***������*����*��������*���*������*������**�*��*����*���*���*�**�*�**�*�*��*�* Total Coliform FecaVE. Coli Results Present Absent C� ❑ � � Reported By �C� � bactreport �� ,.�;r�-� . �..��.__ :�4-. % j ; .... �,�I . �r' � } .... . J!� `l�� t WELL ABANDONMENT RECORD North Carolina Department of Lnvironmcnt and Natural Resources- Division of �Vater Quality WEl.L Ca1�iTRACT�R CERTIFICA170N # Zi 7 67 l. VNELL CONl'RaCTOR: 1 f4r;5 (�j i� ...,. \Vell Coalractur ( Individual) Namc —�t�c i.! cil �� : i �_ ' "�' ..------ �Vcll Contractor Company tanie / i S'IRECT ADDRESS q II 6 P: � Pf /L � l^� Z R '�iXlo� ^Q .�vL 275� y Ciry or Z'ou•n Swic Zip Code C�3.C---� - —$� y — o� _. Area code - Phone numbcr 2. �YELt INEURIb'[ATION: S1TE WELL [D t# (if applicablc) STATE 14'ELL PER.111T # (:f applicableL COUN'I'Y WELL PER114IT i� (ifappticable)_� DWQ or UTHER PER1�11T � (ifapplicable} WELL USE (Circic applicablc usc): Monitorine nt� DiunicipaL`Public IndustrlaUCommerclal A�ricultaral Recover}• InjecUon Irri�atlon d�her (list use) �__ ___. 3. tiVELL LOCA'iION: COUNTY�7u�,e— QUAbRANGLENAA7E NEAR.EST T04VN: �Z o �C %4�9 � �._ �C': i:0� IZ� (SVeeVRoad Name, Number, Commvnity, Subdivision, Lot No., Paree4 �P Codc} TOPOC' FiAP F{IC ! L ANp S ETi1NG: 51opc Vallcy Flat Ri�ge Other (Circle appropriate settin� L.ATITUDG �1aY bc in degccs, -- miuutzs, seconds, or in a LO?IGI'fCTDE decimaPformat Latitude/longitudc source: GPS Topographic map (Lacation aJ x�ei! nrust be shown on a USGS topa rrap and attached to thisjorm rf nat using GPS) da. FACILII Y-The namc of:lte b�sine,as ult:rc tlie wcll is loc:ucd_ CornplNe 4a aad4b. (If a rcsidrnial weH, skip 4a; complete ab, well owner iaforimrioo onL,v.j FACTLlTY iD it(ifapplicable) N,�MF•. OF FACILITY STREE"C ADDRESS Ciq• or Town State Zip Code 4b. CUN'['ACT PERSONIWELL 0�3'NGR: NAME �ff1'[.�L �C✓i� STRCET ADDRESS �GtpS'a S%Q IZC�hr: Jsa� i��_ �otb��, �vL �75�]�l City or Town S�ate Zip Code ��6� - s `1P- r 7 n�J Area codz - Phonc aumber S. WELL �ET'AILS: � a, Total Dcpth:� � ft. Diamctcr: ��7 in. b. Watcr Levci (13elo�v I�t:asuring Poinl): �� EL h'fcasuring point is;�_._ R. above land surface. 6. CASINC: a. Casing Dcptli (if kno�i�n): b_ C:uing Rcmovcd: Laigtli biamcicr � � f[. � /�� in. �j p _ fl. � � . in. 7. DISINFECf[ON: �/�_ C`►� (.4maun�of65°/a-?5% calcium liy�oc6loril� usedl 8. SEALiNC MATER/AL: Neat Cement Ccment lb. Watcr gal. Rentonite Bentonite lb. Type: Slu�}�_ Pellets__ Water gal. Othcr Type material Amount Sand Cement Cemcnt [b. �4fater gal. 9. EXPLAiN I►iETEIOD OF EhIPLACEI�LEN'[ OF hiATER1AL: �o k; rl , l0. WELL DIAGR.4 VI: Draw a detailed sketch of thc w•ell on thc back of this form shou•ing total depth, depth and diamet..^r of s�xeens (if any) remaining in the well, gravel ioterva4 intervals of casiog perforalions, and depths and types of fi11 materiais usod. 11. DATE WELL ABANDONED �� - f 6- n� I DO H CitGBY CER"C[PY TH.4T TH�S WELL WAS ABANDOV ED dv ACCORDAMCC V✓j['Ii ISA YCAC 2C, ��LL CONSTRUCI iON 5"AI�tDARDS, AND TFIAT A GOPY OF T[�S RCCORD H.45 BEG.V PROVIDED TO THE 1VEZL OW�ER -� f.,�� �" I !-Qb S[GNATURE OF CER17r[ED WELL CONTRACTOR llATE S1GNA7VREOF PRiVATE V1'ELL O�\'NER ABANDONI�G THE WELI. DATE (Tlic private w•dl owner must be aa mdividual who asrsenalh• abar�dons his�iec residenlial well in acoordancc wi:h l5A NCAC 2C .O l� 3.) J i�(A✓.S t�af'! Pf►'G PRIATED KAhtE OF PERSON ABAN'DONING TFlE N'ELL Submit a copy to the owner and the ori; inal Yo thc Di��iston ot \Vater Quatily withio 30 da}�s. Fom� Gti�'-30 Attn: lnformation hlaRagement, 1617 11ai1 Scrviec Centcr —Raleigh, NC 27G99-1617, Phonc No. (9l9) 733-7015 cat 568. Re��. Si06 9'd 9LZ6-869-9�£ a;}auae8 •� y}iay{ dOZ��O 80 9l Ue(' �� . . _ - _- ": -..: ti �•-r•.:.�.:_•. --::: -�4..... . . ,s.� •w;-::. ^; _ `�1, _ .�- �: - r,�.�: ��F��-�`- �-�A - � o�e��► � 3�C� � � � r��- � �, � �����I��:� ��.��.�-.�...--.� ��--�.�-._ ,. �,�,;.�_� � . . � � _ . ,r.�o _t�a..� ,,..�trM c�� c 1 c�� tc � � ��:�,m �`��`�� �- � �_q-ov - � } � - - - . ���.: � ��,� . . Da� Da�! � crout ]t,og : 2 /"� l��� : awner. . G'�lra, c G. c�v 5 Tax Map /� 7 rarcei � 23 G Locatian: � �cNss •+ 3?y I�p/b�r�son �2oP• (� Subdivi.�ion: �� . - � Lot � ----- � y - (�C - WeII Coastracfion Distanco F�m n�r� Pm�ty L'me (Mina�um 10 feet) L' �� D�tan�ce fivm Septic System (� 60 feet) l � r� Total �ith: �l, b� Y�eld: '� GPM - St�c Water LeveL• � 8 Wata'Beariu�To�es:Depth 2S9 f� ft ft ft Q � . � �dn� ��: " � . . �Q °r" _ � F�—iL� -� Z- ft. n�: G%�, . 't�►�: �a. s� . � . w�eight Thicl�es� � l�!� Heightahov$ Groemd: /_ 2 in � ; Drive Sho� � I�o Any problems e�catt�ed w}u7e seWng casing9 Xes ,%No ��,�,�„ �� • - Gt-aat: - - . " - Nea� Saad/Cem�t ✓Conct�te GraveUCeu� . -�. A�vnular Space Wi�. • inc�es WaRcr m A�tular Spac� Yes .� No �� � Me�aod of Cxro� Pump�d p�ure � potmed ,/ Dcpth �_ to Za_ Ft 11�at�ials IIsecL- • - N� Bags PorHxud ceme� '�Veigi�t o� L Bag Pouads . _ Ifmn�e (sanci, 8rave], cut�ngs) —ltatio to _ . ID plai�es ✓ Yes�l�Io 4 a4 slab %�Ye,s � No - Ianer_ ' - . _ „� Depth: I�te h�st�ue.d: DriHiag Log Grou� Insfalled by. ' Lacatidn Drawi�g �kom �o $orma#ion � 'r 2 / � a�'` ,,. ) . � - i Z 3H S(�a e Cr � '� D . a c..�G r o y� . � I ` r^. � - Je �� f.� 1�.��. r�e.o/ rt d _ ; E� c�rtify that t�e abo�ve' iFsfaa�n�atia�t is cor�i and t�at this wcll �vas � in � wi$i regulatians s� fw�f� 5y tive Persan CauaiyHea28i Depar�t .' - �a�are oiCeat�xcbQr in # 3�61 n� - � � --o S � • YamP I�aI�at ��An i�A�OR: bJGI/YL� � tW �! � D�//! in 7 SEBfe RCgtS�dilOII �lIIri�et: �� f0 f ``.'*'ii �, � v $ a�d�C wS�' I.CP�1: � l.t r Pum� Mak� � M«�i: � Sr�� � �i s�u an� �tin�- ` � z � G.a �. � h«+eh�+ certifg t�at tl�is pum� was inslalled a�d �e arr.11 I�ad-c�mpl�ed ac�g to tf�e Paxan Co�fy Wdl Rul,es m e�ect m ti�s daGe and ti� a cogy oP dns i�s 1� tia-tiu weIl owuer_ . Pmnp �iler �e '� Dat,� �— ' � PCFID rev O1f27/U4 , l'd 9LZ6-869-9££ a};auae8 •� y}iay{ d8���0 80 96 u�f �� :_.. ,_... - . :-� :�-... _ �..�. - h::;. - -- -- � 3 y 6a :,_ --�-.� � v�. �,��.� �; -:.z._�. �:-v � - o���. �'h, b V x�� �r� _ n `�- v�.., . �.���: - ` �-A � ���� . u - . :.,�,,�_ .- _- _:.�: - t � � � �e aar.�.t � �+/z 1 � �;,rll+�a .n ... :`� �:. :: ^ ::�" ��r����"- ��..�. - �- - -... . ��'� �����.��-� ���:�:�: p� a a 1— ( r—oY _.. �� 7Yac � croat Lag . �OC'dtiolL' r � T2tX lUl�l � � �% ��� #� Z 3 � ob� o� S�-A� - — --- Lot # r---- _ , Wdl Con�stra�oa Disiance Fi�om n� Pm�y �� LO feet) f a r Disiaace fivm Segtic S�+sbeui (� 6o feec) l o+� Tota[ Deptfi: �-fo �$ Yeld: �' . GPM - Staiic Wa#er I,eveL- �,� ft Waf�er Searing � Dep$� G.� �} ft ft ft � • ' Depib: Fi�m . U #0 6 2 .i� I?iau�: 6 ly in . T�+p� Gatv�ncded Stecl �_ . � We� Thickness: •� y� Height above Gmund: 1_ Z in � � Dciv� Shc�c: ��/Yes No Axry probleu�s euco� wiu�e setting casm� yes ✓No If`�s" give reason. - - � N� �� ✓ Cocicx�eie GraveUCe�t • '• � SP� �� • mehes Water in Aimular Spacc Yes _,,�No � � ' Mefi�od of Cm� P�god. Pr� Pottrerl .� Depti� O� to ��. Ft i1c[atetiaLs IIsaL . No. Bags Port]aud ocm�eu�t � Weig$t o€1 �ag Poimds . ffu�tuu�e (s�and, 8��, �) —Itatio to _ -. ID plat� ✓`Y�s ` No 4 x 4 slab ✓`Y'es No � . Liner: ' � --- �fl� _ ~ D�re InstaIIed: G�roer� Instal%d by: I�+om Z 2- 2 Dri��ling Lag � L.ocaiinn Drs�vviag � -� ,V �o �,,, , � ���6�� ���►���������a�����m����� ��� c�cyg� n�. . . 6�g�ad�rc of C.o�or _ � . ID#�c� n� . �- l!� � S _ , . . � r� i� �p �0II �= ' �" �G ��St�.te R,e�s�. PT�ber: � �P �P�=— � UD _ft J"c Wa �%evel: r Z L g --�-- 't�p M� & ModcL- � E�ump Sirde and Ra�n�.��hp �� gpm ��3► �fY t� ti�is punag was iast�Iled a�d t�e wc11 head�comopLr�ed acco�dmg i� ti�e Pason Cocmty Well Rules in �ect �u t�ss date and tim# a capg of ti�is s+eca� � to �the weil owaer. . �p � � � "` � Date: ' i'((� rev U 1I27l04 Z'd �LZ6-86S-9EE a;}auae8 •� y}ia}{ d86�b0 80 96 u�f �3 _.. _... ._ --. .�... - ;.z�...;.; .... _. a: - �,:: _ �: . : _ - --.f:_ :� - =� - � � o�� �_ 3�f �� - 'l•����. •yk� t_ ••�•'�-�"' - � —__ • ���;.a.f._�. /t�w.n �'��+����.�. ��� : �4.�.^„ -~: � • - - .-��'��..�: '�� . � � -� �1 � ��� . -..-1:. _ :�.:_ : %:_ .. �.•:: --.� :� . '. $ . �0 .°��(� r— i�-� fl . . �.�.��,��--- .�ti..,.: �_.: �-� - �;�; �.�. .. C�oat Log . Owner_ .i�P1�Yac� f�wr'� - TaxMap 2� Pa�ei#�_$ Locati.on: c� p „,. 3�d a cr�. ,� Subdiv�isiaa►: � - Lot # � ..�. WeII Cnnstructi;os Distance From neare� Property Line (ll�nnn�.um i0 fcet) L a�' Distance � Se�tia Syst� �n 6o feet) -CoD Tola! Depth: � bv ft Yeid: z- GPM • St�fic Water Level: 1 S ft Water B�ring Zo�nes: Depth !. d1,SG f� ft g ft � ' n�m; F���_r.� � 4! �. n���: f�'ly m . � c�t,�� s� �` . . . wei� Tiiic�ess: �`�.'6 ]ereight above Gr+o�ma: (� in ; Dri�e 3hoe: � Yes No Any probleins eacouute�+ed wh�e se�ng casim�g� yes ✓AIo If `�es" gi� reason: . �� ' Nsa� SandlCeuuent ✓ Conc�te GcaveUCeu�nt - •�- Anaular Spacx Wi+d� • inches Wa#cx m AunuL�r Spacc Yes ✓ No M�od of Grout Pucuped. Pre�me � P� _,� � DeptIi ___Q__ tn Z� Ft 11�steriais IIscd: . Na. Bags P�d ocm� ' Weight o€1 Bag � Po�mds . If � (sat�d, gcavet, �) —12atio to . ID P� �Yes� i�To 4 x 4 slab Yes�No Liner: � `� ��' . � �� �s�: Groak Installod by — To u � DriBing Log Locafion Drawi�tg JO� /.� I.Yl�. f� a� [ het�hy ce�fy dr�t r$e abov�� i�€�on is � and that i�is wey was c�r.s��tea in a�ar�ace "wi8� �u1a�a�s -s�t fi� bY � � Ca�mtyH�c Deg�me�., • - �adure aiCoutrsecbor ID# 3 �� twrup xns�ai�en.� ��nca�r.�i E �ve,l1 s�z�c�� rr�: �6 9/� � � 'Z o b $ siatic �vai�r i.cv+eL $ --�`— °ump Maloe & Model: ,- {�R c� �� Pum� Siae mnd Rax�in� -�}�p _% gpm =�Y �Y ��s p� was insbtled an�d t�e wdi head�c�mpie�ed a�cord"mg to t�ee Pasan Casnf3r Wetl Rules ut effect m t�is c�abe and tfiat a oapy of �is recorci has bee� �vided b��e weil owuer. , ��� - � i�-- G�� � � t-����d � ��o�� £'d SLZ6-869-9£� a}�auae8 •� y}iay{ d86�b0 80 96 ��(' �- -� �` ..-_ -,;_-- �• _ =�=`�; ���.:` .�r'. • f'� ~.- . a � � � �•. 4 � � + ��� • � r���' � �����;'� �' `_� ! 1 �>� .z-►---- , ,�� � .:� Q, a �. l�ar�Pr�L w� J �� r:l►� �y '`r-��--.._. �:`=;;.�:<<_� { �. �...- a -� :.r _. _ :���::v����:����:`� ]Ea��:��;s;��a��:�.:.�=- �3E��t.��� � � �-- i 5 � � -�.. Graut I.og . Owuu: .� E-� f u L L�✓�5� ' Tax Map � Pamel #Z 3 6 LocahQll= ..�[.r.��._� �f3� � � fZ�ib�. 'r � Q•� • � . -- Subdivi.sion� � Lot # . Wea Constrac6on Distance F�om nearesE P�pexty Line (�I"inimum 10 feet) l 0'r Distance fi�mSep�ic S`ysb� GO feet) � 0'4 �t Total llcpth: t�Jf D. ft Yeld: GPM • Staiic Waier i.evei: �� g Wai�er Beariag Zo�tes: I3ep#h � I 4 ft f� #t ft � n� ��_ r� 3 D �. n;� l..���� �- � c���a s�i �_ . - Weigi� Ttrickness: �1,� /r Height abave Groimd: �_ in � r Dcive Shae: Yes No .Aay probtems eucou�d wh�1e s�ng casing� Xes �Na If "y►es" 9ive reason: [;�r+aab - • . . Nea� SandlCement = . Anau�ar Sp�ce'4fi'�dth • M�od of Cro�� Pumped. � T, .� :.,�__, � _ _� C,a�e GraveUCement mch,es Wata m Amaular Sp-ace Yes ' No Press�nc - Patn�ecl Dtplii � to Ft No_ Bags Portiand �t ' Weight o� 1$ag Poimds If t�a�+c (saad, grave�, cut�) — Ratio to - IDplat�rYes�No 4x4s1ab�Yes_No xaner: " � _ .;,., Depth: Dare inshalled: DrilGng Log Cmw� TiostaIIed by_ — Locatioa Drxwiug FYom To Rorntai�oa - K . � r: .d�... ,�, �. • / • , �y i v � r 1 � �-- . �; � _ _ �,r , . '`�` " �°i','�}�, - . ., - ; . [ he.re�ry cx�tify th�# t� above• iafo�ian is coa�xx and �ar l�is well was oa�ns�s�d m a�rda� wi$� regalatia�s �x foa�i by ti� �.'erson C:uttnty H�ealth Depaztmc�it � � �atare of Ca�r � �7�/ ID # 2 6 7 Date . / ^ I �- �� _ ' - Pa�ug Yn�Qmeut Pum�p Ins�lIati� Coutracbor_ ��G� rn e a y W G i! Stafe �aa Numi�e=: �"2' 6� �- �P �P� �� O o ft Siatic Wat,er Level: z S $ Pump Mak� & Mcrdel: �z a� j w� �� e� _� Siz� aad Ra�m� . { �_�_ � t b,e�sy cestify timit this pamp �vas i�tatled a�d ti�c wr.�i hea�d.-ooin�let+ed. accvrding to the Pe=san Ca�miy Well Ru%s ia effe¢ ��sis date and that a eopy of this iecotd i�as beefl. pnowidod bo-the weII ownez _ � �,�.�e � �/�- - - nace: �1--+ r-�� �ca� revoin7� b'd 9LZ6-865-9�� e�awe8 •� y}ia}{ d61�ti0 80 9l ��f i , ' � ; i�. J:C�: _ _ 'OC�IATES= � ' C _ R _ ��S � . _ _._ -- Uv ` _ �� _ �Q�� _ ��""'�_' 2 � . ___ : _ . . , � �� : .. . _ .. . ; - � � _ _ ���- _ ,. ; _._ - - � •. � : : _�� �' , : � �_ - :r�-.�- 6 _ ; �; -_ �- -- ._- � � �°�-;��a� �, � A2; � � , 2, � NF � �,�-'�, , Q2�� _; ,i '" i � ��-` �-- � , ` I � S 13' 07 ` . � : - �-- _ - .-�� � 1 J7 . - - - ''� 701 � 13p5 � �.. ' ! � � Tp SR -' 1� \ 'a� 1 � U -o �s ti Z. S) �" 1 �� • G cP i. �\ , r t v 1 � ts, a �.. u� � � �, -. _ � _ --\ ti��'; � ; c,� �__ _ ' , ` _ \ a Y. �� 1 � ��._ �, ` `� , 1 `, v� '`��" 1 � �'�'4' � ,� � � �` 'Ci . � ,` � % vF���c�2 �• � �"�� 1 F , �, " C . F `� � .,,,•� � � ��-.,U• �� �G _ �� �� � �j° n , _ __ -- -- - _.'. " _ — 1 U 0 `� � q.j 3 . ��� /\ . - \ F,1Af�t� A. R06E R 1 SOh! D.B. 285, P. %�16 IF cordjkc� C(iNld'[ R tJ89°57'S0"W � � ; �_ , W ij� � , �� p - r�r C` ,'"--- � . , , ,- _ � CAKOL YfJ R ___- U.ti. 'l61 ; 1 Ul: (i.� - --..._--- _ CH�