295 Armsworthy RdDavie Countv, NC Tax Parcel Report Fridav, October 7, 201 E
Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1
City:
State:
Zip Code:
Legal Description
Assessed Acreag
Deed Date:
Deed Book / Page
Plat Book:
Plat Page:
Building Value:
WARNING: THIS IS NOT A SURVEY
Davie County,
------ ---- _ ..
ParcelInformation
lull
E70000010805
Township:
Farmington
5861761069
Municipality:
82532214
Census Tract:
37059-803
ADAMS KEVIN JOSEPH
Voting Precinct:
SMITH GROVE
295 ARMSWORTHY RD
Planning Jurisdiction:
Davie County
ADVANCE
Zoning Class:
DAVIE COUNTY R-20
NC
Zoning Overlay:
DAVIE COUNTY QD
27006-0000
Voluntary Ag. District:
No
1.073 AC ARMSWORTHY RD
Fire Response District:
SMITH GROVE
e: 0.98
Elementary School Zone:
SHADY GROVE,PINEBROOK
9/2010
Middle School Zone:
NORTH DAVIE,WILLIAM ELLIS
008360123
Soil Types:
MrB2,GnB2,GnC2
Flood Zone:
Watershed Overlay:
DAVIE COUNTY
92890.00
Outbuilding & Extra
0.00
Freatures Value:
Land Value: 19300.00 Total Market Value: 112190.00
Total Assessed Value: 112190.00
t+vt
4 �Au
Davie County,
All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
lull
NC
County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to
or arising out of the use or Inability to use the GIS data provided by this website.
j Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax(336)753-1680
WELL PERMIT
Account #: 989900057 Tax PIRIEH #: 5861 -76 -1069 -Well
Billed To: Randy Grubb Subdivision Info:
Reference Blame: Kevin Adams i LocationlAddress: 295 Armsworthy Road -27006
Proposed Facility: Residential Well property Siza:% `-1.073 Acres
ATC dumber: 0073
Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this
well will produce water of any particular quantity or quality or for any amount of time. This permit is valid
for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there
has been a material change in any fact/circumstances upon which this permit was issued.
Permit Type: New [] Repair ❑ Abandonment ❑
Proposed Well Location Diagram'
I Comments:
I EHS
Date:
Certificate of Completion Diagram
I W-11*1$ i� 0,
�u w
GA
Driller: Aa k Br wil
Certification #: 30n,
Grout Inspected:
Well Head Inspected:
GPS Coordinates: '°: (Z� % i� c27 11r tO
EHS: Date:
W.P. 7-08
L
`w
Davie County Environmental Health
ATC Number: 0073
Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this
well will produce water of any particular quantity or quality or for any amount of time. This permit is valid
for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there
has been a material change in any fact/circumstances upon which this permit was issued.
Permit Type: New g] Repair ❑ Abandonment ❑
Proposed Well Location Diagram
ttL
MMMIN1► ;,.
US,. =-t-u
EHS:
W.P. 7-08
Certificate of Completion Diagram
Driller: / &Loq-
Certification #: 30
Grout Inspected:
Well Head Inspected:
GPS Coordinates:
Date: 4WIt I EHS:
Date:
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax(336)753-1680
WELL PERMIT
Account #:
989900057
Tax PIN/EH #: 5861 -76 -1069 -Well
Billed To:
Randy Grubb
Subdivision Into:
Reference Name:
Kevin Adams
Location/Address: 295 Armsworthy Road -27006
Proposed Facility:
Residential Well
Property Size: 1.073 Acres
ATC Number: 0073
Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this
well will produce water of any particular quantity or quality or for any amount of time. This permit is valid
for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there
has been a material change in any fact/circumstances upon which this permit was issued.
Permit Type: New g] Repair ❑ Abandonment ❑
Proposed Well Location Diagram
ttL
MMMIN1► ;,.
US,. =-t-u
EHS:
W.P. 7-08
Certificate of Completion Diagram
Driller: / &Loq-
Certification #: 30
Grout Inspected:
Well Head Inspected:
GPS Coordinates:
Date: 4WIt I EHS:
Date:
id
WELL PERMIT
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax (336)753-1680
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
NameA
Address 1-30
City/State/ZIP —)
Name on Permit i
Mailing Address.
Different than Above
PROPERTY INFORMATION
Contact Person
Home Phone
Business Phone
City/State/Zip
*Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat (to scale)
Owner's Name Phone Number
Owner's Address City/S t /Zip
Property Address 2q6RIM,5 V6 a M4 city.adtlayce,
Lot Size Tax IN# e f (-
Subdivision Name(if applicable) Section/Lot#
Directions To Site:
DEVELOPMENT
Permit Type: New Well f Well Repair Well Abandonment Other (specify)
Facility Type: Residential Food Service Church Commercial Other
Are There Any Septic Systems Currently On The Site? YES NO
Do You Intend To Install A New Septic Svstem On This Site? YES NO
TERMS AND CONDITIONS:
This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines
with dimensions, the specific location of the facility and any existing or future appurtenances, the location of any existing septic
system, sewer lines, water lines, any existing water supplies and any surface waters. The applicant is responsible for identifying
and marking the property lines and corners. The applicant is responsible for making the site accessible.
By signing this application, the applicant signifies that they understand the terms and conditions and that they give permission for
Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to
determine the best location for a well.
N44u(�: oa
q �0
Signed
7/30/09
4/?/1,
Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account # qd 0 J
Invoice #
,--
0836
0123
Davie County, Norfl arolina
Excise Ta Paid $
DEED TRANSFER CHECKED
DATE 91- 3-10 BY 10
TAX ADMINISTRATOR
RK83bPG 1 23
04446
FILED FOR REG187RA7=
SEPTEMBER 3, 2010 9:32 AM
DATE TIME
AND ECQRDED IN BOOK 836 PAG 123
M. B T SHO , REGMEH OF DEEDS
U
DEPUTY
Mail to: Grantee 9 Aq'+ i o:.t�\oo.J ,� i�CJo c�« V� C- aawko
This instrument was prepared by: Michael J. Parker, Attorney, Mocksville, NC 27028, NTE
Excise Tax: $46.00
NORTH CAROLINA GENERAL WARRANTY DEED
STATE OF NORTH CAROLINA, DAVIE COUNTY.
THIS DEED, made this 3`d day of September, 2010, by and between ROBERT L.
SPILLMAN of Davie County, North Carolina, hereinafter called GRANTOR, and
KEVIN JOSEPH ADAMS and wife, LISA BENNICK ADAMS of Davie County,
North Carolina, hereinafter called GRANTEE.
WITNESSETH:
That the Grantor, for and in consideration of the sum of Ten and no/100 Dollars
and other good and valuable consideration to him in hand paid by the Grantee, the
receipt whereof is hereby acknowledged, has given, granted, bargained, sold and
conveyed, and by these presents does give, grant, bargain, sell, convey and confirm
unto the Grantee, his heirs and/or successors and assigns, premises in Davie County,
North Carolina, described as follows:
BEGINNING at an iron pin lying in the Eastern edge of SR 1633 (Armsworthy
Road), said POINT OF BEGINNING being Southwest corner of the within described
tract and the Northwest corner of Kenneth S. Ireland (Deed Book 105, Page 669, and
Deed Book 163, Page 806), running thence from the POINT AND PLACE OF
BEGINNING with the edge of Armsworthy Road North 02 degrees 28 minutes 54
seconds East 157.55 feet to an iron pin, Northwest corner of the within described tract
and lying in the Southern boundary of Paul McCulloh (Deed Book 49, Page 55, Deed
Book 54, Page 495, Deed Book 138, Page 819, and Deed Book 170, Page 521); thence with
McCulloh South 85 degrees 35 minutes 03 seconds East 350.81 feet to an iron pin,
Northeast corner of the within described tract and the Northwest corner of Ricky
Armsworthy; thence with Ricky Armsworthy South 03 degrees 12 minues 21 seconds
West 99.95 feet to an iron pin lying in the Northern boundary of Ireland; thence with
Ireland North 86 degrees 47 minutes 39 seconds West 140.08 feet to an iron pin; thence
with Ireland South 03 degrees 13 minutes 01 seconds West 50.00 feet to an iron pin;
thence with Ireland North 86 degrees 50 minutes 41 seconds West 208.65 feet TO THE
POINT AND PLACE OF BEGINNING, containing 1.073 acres as per plat and survey
of Grady L. Tutterow, RLS, dated January 20, 2000. This tract is a portion of the Violet
Armsworthy tract described in Deed Book 48, Page 265. This tract is also a portion of
Parcel 108 of Davie County Tax Map E-7, dated March 28,1976.
to easements and restrictions of record.
TO HAVE AND TO HOLD The above described premises, with all
appurtenances thereunto belonging, or in any wise appertaining, unto the
heirs and/or successors and assigns forever.
M
0836
0836 MWG 1 2 4
And the Grantor covenants that he is seized of said premises in fee, and has the
right to convey the same in fee simple; that said premises are free from encumbrances
(with the exception above state, if any); and that he will warrant and defend the said
title to the same against the lawful claims of all persons whomsoever.
When reference is made to the.Grantor or Grantee, the singular shall included
the plural and the masculine shall include the feminine or the neuter.
IN WITNESS WHEREOF, The Grantor has hereunto set his hand and seal, the
day and year first above written.
�t (Seal)
Robert L. Spillman
STATE OF N RTH CAO INA, DAVIE COUNTY.
I, a Notary Public of the State of North Carolina, do
hereby certify that Robert L. Spillman, Grantor, personally appeared before me this day
and acknowledged the execution of the foregoing deed.
Witness my hand and notarial seal, this the 3 day of September, 2010.
C. MARLENA PARKER
NaIMW PueuqRTZZ
MY mnq�,p,�k e�inJAA N.P.
(Se My CamMwion E�trea 4 a9 12�
STATE OF NORTH CAROLINA, COUNTY.
The foregoing certificate(s) of is (are) certified
to be correct. This instrument was presented for registration this day of
2010 at A.M., P.M., and duly recorded in
the office of the Register of Deeds of County, North
Carolina in Book Page
This the day of
Register of Deeds
A. D., 2010.
By
Assistant, Deputy Register of Deeds
Np
,1 fV' its ��e siC CC3fVS�B�: �iiC�'�. S z UED
WARRANTY DEED
NAY 13 2011 0' 12
aY:
MAIL T on Armsworthy, 382 Baltimore Road, Advance, North Carolina 27006
THIS INSTRUMENT WAS PREPARED BY: Grady L. McClamrock, Jr., 161 South Main Street,
Mocksville, NC 27028
STATE OF NORTH CAROLINA, Davie County
THIS DEED, Made this day of R I d"+ t,C1 W 2000, by and between RICKY
GORDON ARMSWORTHY and BARRY RICHARD ARIMWORTHY Co -Executors of the
Estate of VIOLET IRENE S. ARMSWORTHY and BARRY RICHARD ARMSWORTHY
(single), SHARON A. FRANCO (single), RICKY GORDON ARMSWORTHY and wife,
ELAINE W. ARMSWORTHY, MARINE A. SPILLMAN and husband, ROBERT L.
SPILLMAN of North Carolina, hereinafter called Grantors, and RICKY GORDON
ARMSWORTHY and wife, ELAINE W. ARMSWORTHY ofNorth Carolina hereinafter called
Grantee, whose mailing address is 382 Baltimore Road, Advance, North Carolina.
WITNESSETH: That the Grantor, for and in consideration of the sum of Ten and No/100 Dollars
and other good and valuable considerations to him in hand paid by the Grantee, the receipt whereof
is hereby acknowledged, has given, granted, bargained, sold and conveyed, and by these presents
does give, grant, bargain, sell, convey and confirm unto the Grantee, his heirs and/or successors and
assigns, premises in Farmington Township, Davie County, North Carolina, described as follows:
BEGINNING at an iron pin, Northeast corner of the within described tract and said POINT OF
BEGINNING lying North 85 deg. 35 min. 03 sec. West 430.24 feet from an iron pin which is the
original Northeast corner ofthe Violet Irene S. Armsworthy tract described in Deed Book 48 at Page
265, Davie County Registry, and running thence from the POINT AND PLACE OF BEGINNING
with the Western boundary of the Armsworthy Heirs South 00 deg. 00 min. 22 sec. West 86.60 feet
to an iron pin, Northeast corner ofBarry Richard Armsworthy and the Southeast,corner ofthe within
described tract, thence with Barry Armsworthy North 87 deg. 18 min. 36 sec. West 160.50 feet to
an iron pin, common corner ofBarry R. Armsworthy and Sharon Franco, thence with Sharon Franco
North 87 deg. 18 min. 36 sec. West 172.20 feet to an iron pin, North east corner of Kenneth S.
Ireland (Deed Book 105 at Page 669 and Deed Book 163 at Page 806), thence with Ireland North
86 deg. 47 min. 39 sec. West 168.58 feet to an iron pin, Southwest corner of the within described
tract and common corner with Maxine A. Spillman, thence with Spillman North 03 deg. 12 min. 21
sec. East 99.95 feet to an iron pin, Northwest corner of the within described tract, Northeast corner
ofMaxine A. Spillman and lying in the Southern boundary ofPaul McCulloh (Deed Book 49 at Page
55, Deed Book 54 at Page 495, Deed Book 138 at Page 819, Deed Book 170 at Page 521), thence
with McCulloh South 85 deg. 35 min. 03 sec. East 496.53 feet to the POINT AND PLACE OF
BEGINNING, containing 1.073 acres as per plat and survey of Grady L. Tutterow, RLS dated
January 20, 2000. This tract is a portion of the Violet Armsworthy tract described in Deed Book 48
at Page 265. This tract is also a portion of Parcel 108 of Davie County Tax Map E-7 dated March
28,1976.
Also conveyed is a perpetual non-exclusive easement 20 feet in width for purposes of ingress, egress
and regress and location of utility services including but not limited to water, electricity, telephone,
gas, cable television and sewer, across lands belonging to Grantors described above, said easement
being appurtenant to the above described tract and being more particularly described as follows:
leading from SR 1633 (Armsworthy Road) in a Eastern and Southern direction along the
Northern and Eastern boundary of the Maxine Spillman tract and being 20 feet in width and
the Northern and Eastern margin of which BEGINNING at an iron pin, Northwest corner of
DEED
TRANSFER CHECKED
DA's....�-it ..BY
TAX 9UPERVISOR
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Enviromnent and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 30316A RECEIVED
JUN 09 7011
1. WELL CONTRACTOR: 4.
Well Contractor (individual) Name
YADKIN WELL COMPANY. INC.
Well Contractor Company Name
1908 HAMPTONVILLE ROAD
Street Address
HAMPTONVILLE NC 27020
City or Town State Zip Code
3( 36) 468-4440
Area code Phone number
2. WELL INFORMATION.
WELL CONSTRUCTION PERMIT# 4)0:23
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply ix
DATE DRILLED S` 17- – / l
TIME COMPLETED G,*U o AM ❑ PM X
4. WELL LOCATION:
CITY:__ d(DU c oej C ,e. COUNTY p V / t�
afs'4b fwoV-Mi5� a.
(Street Name, Numbers, Community, Sy division, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
'Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE " DMS OR S B DD
LONGITUDE " DMS 01191 . V 2 DD
Latitude/longitude source: 03 PS OTopographic map
(location of well must be shown on a USGS topo map andatfached to
this form if not using GPS)
5. WELL OWNER
t
Owner Name —T
Street Address
City or Town State Zip Code
U
Area code Phone number
g. WATER ZONES (depth):
Top 7.2 * Bottom -;"oAW9�cIUNIIHE66fia EVAiiIhIEN7
Top
Bottom
Top Bottom
Top
Bottom
Top Bottom
Top
Bottom Ft.
Thickness/
7. CASING:
Depth
Diameter Weight Material
Top + I
Bottom .,E�Ft.
G, 1Z�� SPX PVC
Top
Bottom
Ft.
Top
Bottom
Ft.
8. GROUT:
Depth
Material Method
Top 0
Bottom__9 3'
Ft. V r(UG/=
Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN: Depth Diameter
TopBottom
Top
Ft. in.
Bottom Ft. in.
To
Botto Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
opBottom t.
Top --Bo Ilom
Top
Bottom Ft.
To
Bottom Ft.
11. DRILLING LOG
Slot Size Material
in.
in.
in.
Material
Top Bottom
Formation Description
f/9 /
.S'.: i
/
/
SIZE OFF
/
BIT SERIAL NO:
12. REMARKS:
6. WELL DETAILS:
a. TOTAL DEPTH: /0 a
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO CV
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: /) FT. ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
(Use L if Above Top of Casing) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER. /—
d. TOP CASING IS �_ FT. Above Land `
`Topp of casing terminated at/or below land surface mayay require
a variance in accordance with 15A NCAC 2C .0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD (gpm): METHOD OF TEST ret �C���� _j)- /Srd Lt/^
f. DISINFECTION: Type HTH _ Amount Cul S PRINTED NAME OF PERSON CONSTRUCTING THE WELL
/IlATr it DrEw
Submit within 30 days of completion to: Division of Water Quality - Information Processing, �� f C -"Form GWAa
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : (919) 807-6300 Rev. 2109
Date Site Visited 5—(o-(,- By://�Permit: Yes, No ,Q,,S/►c�C/
What Is Height of Well Casing? Make Sure 12" Above ?round /"e�
NeW / "
A / C.- A-, I, C �/
BUILDERS NAME: S 6_ r,�"� �'�'t
r
ADDRESS:
PHONE NUMBER: /��,►�. /,— c �� �4` O —
CA'to v e--
WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
N.i-revs
Well Contractor (individual) Name
Well Contractor Company Nal?hdkin Well Company, Inc,
STREET ADDRESS 1-lampiopyille Road
Hamptonviile, NC 27020
City
�orrTown State Zip Code
Area codc - Phone number _
2. WELL INFORMATION: , a-,de l !F3SITE WELL ID # (if applicable) ,_
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or'OTHER PERMIT # (if applicable)
WELL USE (Circle applicable use): Monitoring entia
MunicipaVPublic industrial/Commercial Agncutura)
Recovery Injection Irrigation
Other (list use)
3. WELL LOCATION:
'COUNTY fJQ % C- QUADRANGLE NAME
NEAREST TOWN:
(Street/Road Name. Number. Community, Subdivision, t No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
op Valley Flat Ridge Other
(Circle appropriate jsetting)
LATITUDE 3 J ` D .'3 May o in degrees,
L miautes, seconds, or in a
LONGITUDE f & y decimal format
LatitudeAongitude source: Topographic map
(Location of well must be sho on a USGS topo map and
attached to this form if not using GPS.)
4a. FACILITY- The name of the business where the well is located. Complete 4a and4b.
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID #(if applicable)
NAME OF FACILITY_ ,A1 E.r
STREET ADDRESS
City 6r Town glate lcd 9 � _ 3s
4b. CONTACT PERSONIWELL OWNEI:
NAME _
STREET ADDRESS
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. Total Depth: ft. Diameter:_in.
b. Water Level ( Clow Measuring Point): _ o� f ft.
Measuring point is ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): ft. —�-- in.
b. Casing Removed: ft. in.
7. DISINFECTION:
(Amount of 65%-75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement q110 lb.
Water gal.
Bentonite
Bentonite .lb.
Type: Slurry_ Pellcts_
Water gal.
Other
Type material
Amounti
Sand Cement
Cement lb.
Water gal.
2oixe 72—?3I
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
v
10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this
form showing total depth, depth and diameter of screens (if any) retraining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materials used.
11. DATE WELL ABANDONED 5 — e 7 - 2 (911
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
Wrm VA4,4CAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF
THIS FfECOJD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons hivbcr residential well
in accordance with ISA NCAC 2C.01 13.)
�Da.rrcn 9. tie-) ( - -&5-68 -A
PRINTED NAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and`the original to the Division of Water Quality within 30 days-
Attn: Information Management, 1617 Mail Service Center— Raleigh, NC 27699-1617, Phone No. (919) 733-7015 ext 568.
S46•�
Form GW -30
Rev. 5/06
tiU1LUt'iK,S NAME: --1�-.,r�•�tivrr.��.ib�r�(
ADDRESS:
PHONE NUMBER: !� l� O
�OJ f��r�/ S�
1
l
f
Ile (b c
if - �—-2o k
�Y
lt.
i�0 v Q—,
ESIDEENTM WELL CONSTRUCTION RECORD
North Carolina Department of Enviromnent and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 303"
1.. WELL CONTRACTOR:
Well Contractor (Individual) Name
YADKIN WELL COMPANY. INC.
Well Contractor Company Name
1908 HAMPTONVILLE ROAD
Street Address
HAMPTONVILLE NO 27020
City or Town State Zip Code
( 336 ) 468-4440
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PEP,MIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)_T�z
3. WELL USE (Check Applicable Box): Residential Water Supply"
DATE DRILLED S-- /9– //
TIME COMPLETED .S ,' _� n AM ❑ PM I
4. WELL LOCATIO
CITY: C- COUNTY PCid f
In 1 wo t,q & Ad -
(Street Na e, Nu bers, Com' munity, Subdivision, Lot o, Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
.11"S'lope ❑Valley ❑Flat ❑Ridge ❑Other p��
LATITUDE " DMS OR S- O J D
LONGITUDE " DMS OR �� D
Latitude/longitude source: Kps Qfopographic map
(location of well must be s own on a USGS topo map andattached to
this form if not using GPS)
5. WELLDOWNER
/( czz h � Svc f
Owner Name
Street Address
City or Town State Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: /n2
b. DOES WELL REPLACE EXISTING WELL? YESX NO ❑
r�
c. WATER LEVEL Below Top of Casing: C- a FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS `/ FT. Above Land Surface -
'Top of casing terminated attor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): aO METHOD OF TEST 4j, / u i•-,
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth): I
Top %r Bottom ! Top Bottom
Tope_ Bottom I ((, Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
TopBottom Ft. 6, 14S- 7W -.2l Arc
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top D Bottom 3 Ft. A.+cvl4, (X11f' S liriv
Top S Bottom TF Ft. Ut,xnmt Sl�r�j i�•.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SANDIGRAVEL PACK:
Depth Size Material
Top Bottom Ft.
TOP Bottom Ft.
Top/Bottomz Ft.
11. DRILLING LOG
Top Bottom
—/ :9 `
8 qf) .
90 ' / !22'
/
/
12. REMARKS:
Formation Description
So,`l
SIZE OFF y , 9-7/ /j
BIT SERIAL NO: c/ .j �?/ 7
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
A147T 4 -
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW -1a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2109
Date Site Visited By: Permit: Yes No —
What Is Height of Well Casing? Make Sure 12" Above Ground Tever!!!!
fPo y � 9?�f�3 s�