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544 Becktown Rd , � ` v � DAVIE COUNTY ENVIRONMENTAL HEALTH . P.O.Box 848/210 Hospital Street Mocksville,NC 27028 • (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990005192 Tax PIN/EH#: 5755-66-2757 Bilied To: Brian Beaver Subdivision Info: Reference Name: Location/Address: Becktown Road-27028 Proposed Facility: Residence Property Size: 5 Acres ATC Number: 4931 **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems," but shall in NO WAY be jalcen as a guarantee that the system�function satisfactorily for any given period of time. C�Z.�t System Type: ( I S.T.Manufacturer� Tank Date�ank Size� 00 D • Pump Tank Size�� /_ � �/�O� ` System Installed By: E.H.�ecialist: ate: z �� d � / r ' \ I � � � ,; � 1 � . � ( 3 ��� � ���� � � � Q � �ti � � �u� I �j � ��° � r _ri� l �� ' � a���� .�� � G C � � � � . � �,.�e<< DCHD 11/06(Revised) � , ' ' : . • DAVIE COUI�TTY ENVIRONMENTAL HEALTH 4�' P.O. Box 8487210 Hospital Street � �30I Mocksville,NC 27028 1'�' Q� (336)751-8760 Fax#(336)751-8786 ,'ltiI AUTHORIZATION FOR WASTEtiVATER SYSTENI CONSTRUCTION Account #: 990005192 Tax PIN/EH#: 5755-66-2757 . Billed To: Brian Beaver Subdivision Info: Reference Name: , Location/Address: Becktown Road-27028 Proposed Facility: Residence Property Size: 5 Acres ATC Number: 4931 Site Type: ❑New ❑Repair ❑EYpansion *�NOTE**This Authorization to Constnict(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pernut(s),(in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems,Section.1900 Sewage Treahnent and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms��#Bathrooms�#People�_Basement❑ Basement plumbing❑ . Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) LotSize f.� Type of Water Supply: ❑County/City C�'Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)3�.t� Tank Size�_GAL.Pump Tanlc�GAL. �� � i — � � Trench Width3(e Max.Trench Depth 3 U , Rock Depth �'`� Linear Ft. ��� Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. �Qd. � (L-� � � OQ� ��k.� � � I � '"�o���oy �� � ��pa;r �.� �a�,�.Q --� �g� ( ��� ti° �- �- �� � �, _ 3� . �o �,;.� ` �y ��i,� �ao� Ars� `�� � �vironmental Health Specialist Date:����— C/ � �n�rr� ,.ini m__.:_.,�\ � , � ' Davie County Environmental Health � ' P.O.Box 848/210 Hospital Street , Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMTT Account #: 990005192 Tax PIN/EH#: 5755-66-2751 Billed To: Brian Beaver Subdivision Info: Address: 636 Cherry Hill Road Location/Address: Becktown Road-27028 City: Mocksville Property Size: 5 Acres Reference Name: Proposed Facility: Residential . **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Pemut Type: ew ❑Repair ❑Expansion Permit Valid for: CC7�ears ❑No Expiration Residential Specifications: #Bedrooms 3 #Bathrooms�#People J Basement0 Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Desig�Flow(GPD): 3 �V Type of Water Supply: ❑County/City CfWell �Community Well �'�S s#atecl in 1.�iA F�i;!`yC 1�3j"1.ig�i3j5� Site Modifications/Pernut Conditions: ���,��.��T���� S stem T e LTAR Initial c c c o0 0. 3 Re air � c e � t d O • �7 Site Plan �� v� �T� � I, � _��('rb't-wc��t 1 ( �p�a•,�, ,. ,�b< < f �rt�. 1 �r'n,�Ta.1 � �t?c }�:f'.e�t 5<p � �, , � sg� �� 3a 7� ��6� (�'� � �,\PC y% Un�S a3� �' W 81 1� � � Environmental Health Specialist !�� Date l 2—3 " G o i.p.l]-06 ; � . ��o�i �S� � . • v'S vn � ' � _ SITE EVALUATION/IMPROVEMENT PERMIT&ATC � C�-L I � . D � � � p � � Dav�e County Env�ronmental Health � � ��^ ,� P.O.Box 848/210 Hospital Street �.t Mocksville,NC 27028 �, _ . � � (336)751-8760/Faa(336)751-8786 l�i O U j P�OV 10 2�D8 ,���c'�. � Application For: Site Eva ation/[ rovement Permit Authori7aGon To Construct(ATC) Both Type of Application• ew ystem pair to Existing System Expansion/Modification of Existing System or Facility (�l�G, �'*t � ' S APPLI AT[ON CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED � ��1 �(' S-PRAi�FD fer to the INFORMAI'ION BiJLLETIN for instructions. � APPLICANT INFORMATION �,(I\� Name to be Billed V� 3Q.a Ye �' Contact Person ' � (� , Billing Address � Home Phone 3l9 ' City/State/ZIP U Business Phone 3 Name on PermiU T 'f D' rent than Above � , `V \. Mailing Address Q 1 City/State/Zip 1 ) ("�a�' PROPERTY INFORMATION *Date House/Facili rs Fla ed �11�t�� NOTE: A survey plat or site plan must accompany this application. Included Site Plan Plat(to scale) (Permit i alid for,�0 onths�h�i�p la�n,�n�o�g��p�t�on with complete /1 r— Owner's Name �'``(,1'(� J 1�"��il V C�f Phone Number��,Q `C��•�f 33 � r"�C� Owner's Address City/State/Zip �K�.�v� Ptoperly A�idr ss City Z�_ ` �� ` Lot Size ` '1 PIN# .. '7� 1• `f Subdivision Nam ' pp iCable) ectio o �' irections To Sit :� �� � — � _G� (� � � ' � - � ' �� � � � � y If the answer to any of the following questions is`yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? Yes� Does the site contain jurisdictional wetlands7 Y s o Are there any eascments or right-of-ways on the site? Yes o Is the site subject to approva(by another public agency7 es Will wastewater other than domestic sewage be generated? Yes No IF RESIDENCE FILL OUI'THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool Yes No Basement: Yes No Basement Plumbing: Yes No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similaz facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: Conventionai Accepted Innovative Altemative Other Water Supply Type: County/City Water New Welt Existing Well Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? Yes No If yes,what type? T'his is to certify that the information provided on this application is true and correct to the best of my knowtedge. I understand that any permit(s)or ATC(s)issued hereaRer are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws end tules. I understand that I am responsible for the proper identification and labeling of property lines and comecs and loc � g and flagging r siakin�the house/facility location,proposed well location and the location of any other amenities. i Site Revisit Chazge operty o er's or ownePs legal representaYive signature Date(s): �i-q '0� Client Notification Date: Date EHS: Signgiven Yes No Account# �! qZ Revised 11/06 Invoice# y � � , , ����� ���� � � � 0 C��'�:'� ���2��� . ,�� � � � � _i 4� � . � � � � � u� � � F�cs��' a��}'C' _-�-- � � � ?� 4�' � � 4 a � \ �\ ��-lJh- �� W� ��� . , , 1 1�� 1-4� 0�,�1 1�.,�'1�,1,�` ' ' � � _ -;�-: , �. z �� � �� � j�; . .�r`�=� �; • � �' i � � � i �� ,��' , 1�� i > � �i�l � ��y . �` �� � �.. s Y �� � 1 11 a � ' ��� r �� . . Y � . . 'ri. ��iR�•.9. �' tS. 1�. / �I;" A i � . �;� 7'� c���S �� � O�ntican�� Eeatur�s As Shower . � � •U��raslad Vinyl flourisig m R�u�ded brywali Cors�ers Y 5finmp f�iliri� � � •Wond-13urning Fireplace •�''�idewnlls �Leramie Lefiin�Rar.a� I . ��xtra i'��rrniu t�f�nd��vu'(4) .��xtra Wire&Brate,i.i�iirg'rtua�� •Q:�it lQnlccuses` i ��,p�„ �.S#�i� " ' . fi�r[2-��r. •Fxt��lnteriar Receptacle � ��r,f��g�lr�vr�iitchF,�Ca�i`iets � �"�1�1�� Sti�in�ess Stc�f a3rik � ^�"Can lig�ts{6) .•y�r��.��e�6fVindu��r(1) . � � • {�a��laii�iran�e e�ar� w d+" Co;�L.igkts(aj '' ' �d�.J_!I_ t�.._.i�^ ; a+• `� p�� ° L�I��ttiYt FC:1"1? "' t�s . � �` ' ��i.vUa � _� � ��;Ii�A(�;1ltiGa(P��t)C --_�T_li_:Lt oaux�ete .,�Y 'c �� k ti7 vecrd—. _bc.i.�v� tasnrrcretr,x '�4� � �' v�A '� tt �'1r �"c"��. '^1 nq��z°'•i'�- �. 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At Ihe ern� pf i��i: i:ali, ;h2 r >F;:::nsiv:: :-T�c7l �'.';�,�!';i I.s f!UI)� exi:r��.,ii�'ar•t;l; � � � ' , witli a �rand firr���CSre {WO t�lll�.'•Ifl hOOkcases (15 {f5 fOCGII pi).1 i:. �`i�r,?7Ci •:�UI�:I t:Veni;�y$ ��I- i��un-�a� �O � � 9 � r;nl�.rteininy events, Tne: llaymoflf IS IS "I�.�IIt U� �IO�Ti: FO( f;v�r; .,,:cnsir�r•. ! � � I �_________ ��� ��-t.�_��__c�n S�cx,t�t1n_�__J.!�.�.�wv __ _ _-; . � � v� 5 �Cow� c� �� �c�rs s Tnv�Trar� -- � S� � 7�U � fls;ne i�luslrations are For re reseNofive ur�ses arl•.tJi s uurc(:�ol;;fs and c �. � ,1�^� �� P P N r 4 9 `.?cl��_v���e Housii�leider Inc. � runrn dinicr.sinuz orr.a�proximaln.Optiunal or etiai(n61e teaiurrs r,�•iy ha showu o� i�;,,`{O l t�:;?U�.i�9�,7 i�`•�i;!:i S'�i,�e,1`i C f i�l�G f 9 1 i n a 2 8 u 1 1 � � � r� desa�bed.Fl�use ronsull u Home(ousullunt rer,mrd+r�g specific(emuras+hu1 me, b u p pi y l o a p a�l i c u l u r 6 m u�.D u e t o c e n l i n u o u s re f io e ma,-��a n d e n L o�ren,e:v��i o u� 7 U 4.9 2 4.4 3+ <r�i i c e•7 U 4.9 2 4.�1 4 1 i F e x � Lome selecton,we reserre tl�e right lo disconiinae or n��d+fy m�iiels r,:id feat:�res � T�� � � � � � �� � � al ui�y time,wilfiuul nolice or cbli golion.�'O-Stottsville Nousin g ientei!or. W�'k.�'.�tntesvikleHousin g.cr�rta v Hf�US1�VG C�PJ7CR: 9 t y�r a �f �` i�r;�.�!c • ��� '� s �i� #�°weS7�"�.8'�'{y� q ; t 6t a � � f�_"s s.t, ,� ��� � �� , � � � � ��' .: � � � �i � �� '� ����"�"��� ,'��i;� �� � � � � � w,>�(�.y:�i � r' �f� �"�+ f�� '�;.���������b a;�1 P i ( � � l 1 F F t I a I i �.q. n ' ��'1 1?Ii t s�a'i� � :�-������'�i�.Rz�.i-.�,�c:7 '�(� C � (�.� I�n r� �D r[�.f� I I �Z'1 C 1 , , . . � ,• DAVIE COUNTY HEALTH DEPARTMENT � ' Environmental Health Section • Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005192 Tax PIN/EH#: 5755-66-2757 Billed To: Brian Beaver Subdivision Info: Reference Name: Location/Address: Becktown Road-27028 `� Proposed Facility: Residence Property Size: 5 Acres Date Evaluated: — Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L. Slope % HORIZON I DEPTH � Texture grou G Consis[ence � r a/ Structure Y 5 IG C Mineralo p HORIZON II DEPTH �— �I— D Tex[ure rou � Consistence ` �4 i r Structure Mineralo HORIZON III DEPTH 0— Texture rou ` �'.L' Consistence Structure Mineralo '� /" HORIZON IV DEP'TH Texture rou Consistence Suucture Mineralo SOIL WETNESS RESTRICTIVE HORIZON / SAPROLITE / " : � CLASSIFICATION f LONG-TERM ACCEPTANCE RATE Q. ' P• 7 SITE CLASSIFICATION: �D � EVALUATION BY: � LONG-TERM ACCEPTANCE RATE: �• �•�� S OTHER(S)PRESENT: j'�.S REMARKS: LEGEND . Landcca�e Position . R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S -Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSI�TF.N . �� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � � NS -Non sticky SS -Sligh[ly sticky S -Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic StrLctLre ' SC -Single grain M -Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv 1:1,2:1,Mixed � Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) 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Mocksville,NC 27028 � (336)751-8760/Fax(336)751-8786 WELL PERMIT Account #: 990005192 Tax PIN/EH#: 5755-66-2751-Well Billed To: Brian Beaver Subdivision Info: Reference Name: Location/Address: Becktown Road-27028 Proposed Facility: Residential Well Property Size: 5 Acres ATC Number: 0018 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 facticircumstances upon which this permit was issued. Permit Type: New� Repair ❑ Abandonment ❑ � Proposed Well Location Diagram Certificate of Completion Diagram ��G�� ,Q G �D . • � � �pl � 1 's� I � � � 5 � ( �j x'� �.c�'' �h � � �t ��,,c p � l�--� �`n \� l�� �u �,�� ����'K G�3 Comments:��,�5� �7'-�--L.0� 1 -�d ov � Driller:����t Cc,�r��-P (l�(( �y I�i y.L�J �,�5'�Grno..�..ec� S-tnrtT i c��ra 5 Certification#: ���_� Grout Inspected: � �� '"�� �.`) Well Head Inspected: �— �'Q� �Z/f/� GPS Coordina EHS: Date: ��-3-dQ EHS: Date:�� w.r.�-os G�l;�'G(k=�.�'� , �����9 . �.� . . , K ` . ' � . ��--'� t`�, `1 � � ���Q��� ICATION FOR PRIVATE WELL PERMIT 1'"^�,� i�'�((._ I� � `i�'y�`"'� �� __---�_�''�� Davie County Environmental Health �,,., � P.O. Box 848/210 Hospita7 Street ��' ���Q C(� �-� �, ' ti�``� �,�� ', ��! E:�,� s-�� ; � �, Mocksville,NC 27028 �'^ �'' � �- ' 336)751-8760/Fag (336)751-8786 �.J � � � n ` � — ..t�.},�4:1k1 J L�fN ,r��,����j5�;��r�_..- ---.,. ***IMPORTANT*** CANNOT BE PROCESSED UNL�SS ALL OF TI�REQUIRED 1NFORMATION IS PROVIDED. �� • APPLICANT INFORMATION Name to be Billed r� � �1 Contact Person Billing Address � 1 Home Phone �J � ` � � 3 City/State/ZIP � Business Phone �D � ` �l Name on Permit if i ferent than Above � ��' � - 1 �'� �(1 � Mailing Address�����- City/State/Zip � '��i C-C/.11 PROPERTY INFORMATION *Date House/Facility Comers Flagged ��`� ��� NOTE: A survey plat or site plan must acco any this application. Included: Site Plan ❑Plat(to scale) Owner's Name ����'�� '3 ����Iv�,V Phone Number'�jLQ ���.��-�j�� Owner's Address � City/State/Zip Property Address � City '�' G Lot Size . Tax PIN# ��J�j— �i.—a h J� Subdivision Name(if applicable) Section/Lot# ' ections To Site: ��C� � i1 � ��I � � 1 L. DEVELOPMENT INFORMATION Permit Type: New Well Well Repair Well Abandonment Other(specify) Facility Type: Residential�� Food Service Church Cgmmercial Other Are There Any Septic Systems Currently On The Site? YES 0 )( Do You Intend To Install A New Septic System 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 e�sting 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 pernussion for Da�ie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to determine the best location for a well. ���L- 11� �1 � 0� 'gned ' Date Site Revisit Chae�ge Date(s): Client Notification Date: EHS: 7/1/08 Account# U�/q'Z� Invoice# - •� . . � ,�� R � � - � ;�� ����� � � ��� � � . (.� �,} �� ' - � �.�� r\ ��� � ��.��'�.���;�,�,��� � . ,,�;��il � �-.,-. G r, �"�v"� '; r �� � ���q �f � v`,.L,? '§ � r`� i-r„��� �'^;..__L T <_� , • -+) �.A-`s� -�_' � � r---�' � "r-- .� �y./ � �. . . � :..�_ '�' . � ���]�-- _;.___-------�-� ---- �`�__,�� � . ________'___'._i_...__-�.-._.._-�_.�-`- , y i� -��I���� �- � .������� ��..� ��,� �C�._ ,.,� � _ �.� �________.__._________ ________,________-------_____ ,______________----�---- __ . y . ' � . . . . . . .. . . . . . . . . t � . � • � � '-� . . . . . ,d,a5TA7pg, �/1:.�. �ff\ fj V!��<)i.��t� �y •� � � � ' � „ RESfDENTIAL WELL CONSTRUCTION RECORD � . � North Carolina Depaitment of Bnv"tmnment and Natural Resourccs-Division of Water Quality . � M 4.ur � . �...- . .. . . __ . �� . � ' � . .. •�Qf1�M� .. ... : �"�. . ..... . . ' - . WELL CONTRACTOR CERTIFICATION# '����1 � 1.WELL CONTRACTOR: f. DISINFECTION:Type�_Amount� �CIQ�I�:-�5 �� _/� L b�,C� g. WATER ZONES(depth): Weli ontractor(ind' ' uai)Name From��To .:3 Z� From To (� � � L From 7o From To eli Contractor Company Name From To From To STREET ADDRESS p 6. CASING: Thickness! Depth,,, ', Dia�neter Weig�t : Material � � � (� From �_To�_F��_ '�� ,� City or Tawn State Zip Code From To ft t�� �'[�� ��� . From To Ft . Area code- Phone number � - T. GROUT: . Depth Material Method Z:WELL INFORMATiON: + / _ , f ���� ��� . r / From = To,,�,s 1 Ft. STCE W ELL tD i!(ti applica6le) ��5�.� -�l•�` ���� From To Ft. STATEWELLPERMIT#(�tapplicable) From To Ft QWQ or OTHER PERMIT#(if appiicableL e. SCREEN: Depth Diameter 5�ot Size Material WELL USE(Check App(i�able 8ox): esidential Water SuPPty� From To FL in: in. ) Frort�_To Ft in. in. DATE DRILLED / + ��""�� From To Ft in. in. T1ME COMPt.E'fED `r�� AM p PM� _ . 9. SANDIGRAVEL PACK: 3.YVELL LO TION-� Depth SiZe Material CITY: �G}.��1.'���I/-G. COUNTY , C'i i=' Fro To Fk , ��-�r, P�-.a�o��__: F�,: Ya �� (SUeei N� Numbers. mmu . ubdiwsfon.Lot Na,Pamel,Zip Code) '"'e, _ . TOPOGRAPHtC/LAND SETTING: 10.DRIWNG LOG ❑Slope ❑Va�iey ❑Flat ❑Ridge pOther From So Formation Descript�on (check appropriate box) �J ' : : �G� -� . '�� May be in degees. `.� � �-� LATITUDE �,� minuta;saonds or � � �� ,-�l�. - LONGf{'UDE in a decimai format< y��i'1 ?� .,�(1; -�t __. —— '._' .^`- -. Latitude/longitude source: pGPS`. OTopographic map - � �1..�, ' (locaUon of wetlmust 6s shown on a USGS topo map and . attached to this form d rrot using GPS) ,i' 4.WELL OWNER � . OWNER'SNAME ��L��i.y�S�G'��l �t. /J�E - ST�2 ET DDRESS � � • ' 2_ • �-�lS L�;��L .'Uz� '�.�tl4l�� ' �City or Tov���-.L'-- Stffie Z'ip Cade ' � � Area e- Phonenumber - . 11. REMARKS: S.WELL DETAILS: � a. TOTAL DEPTH: !�' b. DOES WELL REPIACE�XlSTING WELL? YES p NO p . 100 FIEREBY CERTIFY TMA7THIS WELL WAS CONSTRUCTED M ACCORDANCE WtTH c. WATER LEVEL.BeIow Top of Casing: ��1 FT. �sa Ncac zc,WEII CANSTRUC710N STANDAROS.ANO THATA COPY OF 7HiS (Use'+'HA�OVe TOp Of C8S1�9� " ', RECORO NAS BEEN PRCMDEDiD7HE WELIOWNER /� d. 70P GF CASING IS�FT.Above Lend Surface' /1/',�..i'"/.. ! �?,C�,.. .J� , • . 'Top of casinp terminated aUor belaw tand sudace may require �' G�--��� � a variance fi accordance with 15A NCAC 2C.0118: S i G N A T U R E O F C E R T I F I E D W E LL C O N T R A C T O R D A T E e. YIELD(gpm}: 4' METHOD OF TEST�,_ � I!--'� ' �b ��``�J , PRI�N�AME OF PERSON CONSTRUCTING THE WEtL Submit the originai to fhe Divtsion of Water Quality wiEhin 30 days: Attn:lnformation Mg�, Fom,�w-�a 1617 Mait Service Cec+ter—Raleigh,NC 27699-1617 :-Phone No.(919)733 7015 ext 568. �,7� ' � Uec.�ji. LtFV� llttm ;�in,ori� . ' 1..:,:..,,. �..^ .,l: y' .0d6 � nvvv i nu ��n �t��ia �-x.,, �..._.. ._. .� ..: . � , L�,�...,,.� ,,, � r V L 1/ ♦ � � " 33675`18788.' " P,� . l pwc 0� 03`04:41p bavie County Environrr�nt�, � . . , . . . . . . , • . . .. ' , � : . . a . , Aav��Co�}nty Envixo�,rne�ti�;T�eaitb.: : . ' ' �.�.B�x 8a.s�x.io idlo��;a�si�aec" ;�. � . . . "Mo'ckavil)c;,IvC'�7.aZe: '"�� ' - ;� • . , ' � • (33�'F51-67GUt Xo.�r�33�781-87t16. ;; • . - . - . . ' i'. . . . " - . � w�`,I,7;.g�nn�r . � � � ` • �. Acccunt #:• 990QD519z'� . � ' � 7ax RINJEM#;.•.675r8Cr275.1-Well• . • • Bi1�ed To: erian geaver • � . ! . Subdiv�sion.fnfo��" � .-•:•.�• • ' � � .. ' Referenc�Namo: • � • .tioc�:lan/Atld�e�s!- �iecktiyu�!n Ft0ad-27o28 • . ..,;,.:_ ' Proposed FacUlly: .Resid�ntlal W�li � Ptoperty 31iQ:i. •5 A�i"es � - ' , . , M ! . • _ - t ' ATC Number: 001� � ' ' � • '. . : . ' _ . : . ' _ � ?s.ctions of tho cm�loyecs af thc t��vic Gofiaty EIi 5ection ab�!in no a'�?�b�taken.�s a•gu�[aniec,that ihis . . . .wcl t v�11t•prrciducc wAtcr nf any puiticu�ar qvaneity orquelity or fvr.any,amourii af:t�:.Tbas pes�ooit is�blit! . - , far a}�c�dod v�5 years Ernr�i'thc data of issirance. 'I'b!s permit may be re�oked i��iz is duerinined tFini•�t�cro . - '. has becn a t»atai►sl chat�gc in any fact�cir��Zmstanoes uQon whioh•thia joii�nit�+as�ssucd., • • - ; ' . � _ Peim�it Typc: New(� I�epair[] .ae►.bandc�un�nt:(�.. . . . . ' . � • . . ' i : Ptopoecd.Wel!i;ocadoa A)agr�tr�• ` � CerltH.cate bf Cazn�Ictian}�iagrarta� . . �a.►�'--�� ' �;. � . ' ' ,p �,R�„�=. , . r� . . , • .' . � � ry • ' . ,�� -, •��. . i' • _- .' • ' , . . ' . . ; ��r ` � �� . ' . 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' � . . • • • � • • •;, • . . . . . . • w.r.rfis • . . � • .� • . , " ' • . • � • . : � ��� .� ' � �� . ..� � � ' . � . .� � • � . _ � . � . _ . .. . . . ., • • � � . ' WATER SAMPLE�SEWAGE SYSTEM CHECK REGIUEST Date Requested: GJ�I—D� 1 � , QAVIE COUNTY ENVIRONMENTAL HEALTH SECTION Received By � � WATER SAMPLE TYPE: O Bacterial D Protected � O Chemical ,�p O Unprotected O Dug � O Other: /UQGc.� ( ��� O Bored O Drilled � O Outside Spigot: O Other: � � SEWAGE SYSTEM CHECK• O Yes Vacant O Yes O Approv d � � , O No O Disapproved Owner's Name: �G VG B yer's me � Property Ad ress: l N � � ' "L � Di ections: ,� �j Speciallnstructions: 1�� . Letter To: Closing Date: '`.� .J �/J Attn: --------- ---�-�-�r-- � .J � �� � Date Taken: �/�� � Charges: � ��L Telephone• - � By: n � �'i�+l�� �b��P�1.0�'e aG : �.asy, g �J �[�'�� . ��v • • • • ' a�,,E SGy7F 4 � ��� � --• — • . :BOx 28047 North Carolina State Labo at 306 .Wilmington St. �� ��i--�� � ��� Rale gh,NC 27611-8047 � - Env�ronmental c�e�� htt :/sl h.state.nc.us �•�«,�,;�• Mi�robiol gy JUN 16 2009 Fax: e. 919-733-8695 Certificate of A alysis DAVIE COUNTY HEALTH DEPARTMENT Report To: Name of System: DAVIE CO ENVIRONMENTAL HEALTH Brian Beaver P O BOX 848 544 Becktown Road MOCKSVILLE, NC 27028 MOCKSVILLE, NC 27028 StarLiMS Sample ID: ES061009-0055001 Collected: 06/09/2009 11:30 Robert Nations IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Received: 06/10/2009 09:49 Benjamin Saavedra ES Microbiology ID: 5793 Sample Source: New Well Well Permit Number: GPS Number: N35°49.125 Sampling Point: Well 0018 W80°29.705 Sample Description: Comment: Environmental Microbiology-Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Darneice Lyons 06/11/2009 E.Coli, COlilert Absent Darneice Lyons 06/11/2009 Report Date: 06/12/2009 Reported By: Susan Beas/ey ,Page.1 of 1 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 watec Sample should not exceed levels listed below. Alkalinity I�10 established limits Iron 0.30 mg/1 Arsenic 0.01 mg/1 Lead 0.015 mg/1 Calcium No established limits Magnesium No established limits Chloride 250 mg/1 Manganese 0.05 mg/1 Copper l.3 mg/1 Nitrate 10 mg/1 (as N) Fluoride 4 mg/1 Nitrite 1.0 mg/1 (as N) Hardness No established lirrucs pH Not less than 6.� units Zinc 5.0 mg/1 ,. ., . .�� , ' . � , • j ,�;:tf "y�"� t, ' ;�"'� � �' � North Carolina State Laboratory of Public Health ����. �w�" � `�� � � ��_ ��� � - Department of Health and Human Services j P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 276141�Q�,7 � ' r �d ' �INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM,�TH rtFNar�r��Fn�T Name of System: geaver, Brian Source of Water: Address: 544 Becktown Rd Source of Sample: Mocksville, NC Zip: 27028 Type of Sample: County: DAVIE T ype of Treatment: Report To: Davie Co. Health Dept. ATTN: Robert Nations Type of Analysis Private Post Office Box 848 (336) 751-8760 . Mocksville, NC 27028-0665 Courier: 09-40-06 Collected By: R NATIONS Date: 6/9/2009 Time: 11:30:00 AM Location of sampling point: Well Remarks: Permit#0018, GPS N35"49.125/W80'29.705 Parameters Results Units Date Analyzed: Silver <0.05 mg/I 6/10/2009 Alkalinity as CaCO3 63 mg/I 6/10/2009 Arsenic <0.005 mg/I 6/10/2009 Barium <0.1 mg/I 6/10/2009 Calcium 20.3 mg/I 6/10/2009 Cadmium <0.001 mg/I 6/10/2009 � Chloride IC <5.0 mg/I 6/10/2009 Q ; , �"":�-• � Chromium <0.01 mg/I 6/10/2009 �.;� -. ;,- Copper <0.05 mg/I 6/10/2009 A� � �� " �� ;-' �z ; �` , ; Fluoride 1 J6 mg/I 6/10/2009 ��', c_i' ; "'�=� ' _, � ; _ ;� ; Iron <0.10 mg/I 6/10/2009 �-�• t�• r-C- � t-'.. __� I Hardness as CaCO3 (Ca,Mg) 68 mg/I 6/10/2009 ��-� �� � � " � . ; Mercury <0.0005 mg/I 6/10/2009 "-- �' �, ' .. a� �- . �` Magnesium 4.2 mg/I 6/10/2009 �� �" ` e; � :,.-, :. 1 Manganese <0.03 mg/I 6/10/2009 � -• �: � : , �:>.-::. :: Sodium 10 mg/I 6/10/2009 � c� � �.�>;: Nitrite as N <0.10 mg/I 6/10/2009 � Nitrate as N <1.0 mg/I 6/10/2009 _4~ - Lead <0.005 mg/I 6/10/2009 pH 7.7 Std. units 6/10/2009 Selenium <0.005 mg/I 6/10/2009 Sulfate 16 mg/I 6/10/2009 Zinc <O.Q5 mg/I 6/10/2009 Date Received: 6/10/2009 Report Date: 7/6/2009 Reported By: � Today's Date: 7/6/2009 Ref: 8089 Login Batch �gp60037 :; Sample Number: AB90632 } t' • .. ' North Carolina Division of Public Health Occupational and Environmental Epidemiology Branch,Epidemiology Section INORGA1vIC CHENIICAL ANALYSIS REPORT � Private well water fnformatian and recommendatlons County: ��V�� Name: "����'� Sample Id Ntunber: ��9��3Z" Location: Reviewer ��� ANALYSIS REPORT Your well water was tested for 15 metals,plus nitrates,nitrites,and pH. The results were evaluated using the federal drinking wat�r standazds. The pH is a measure of the acidity of the water. Drinking water may contain substances that can occur naturally in water or can be inhoduced into the water from man-made sources. (These recommendations aze based on inorganic chemical analysis only.) . TEST RESULTS AND USE RECOMMENDATIONS Your well water meets federal drinking water standards. Your water can be used for drinking, cooking,washing,cleaning,bathing, and showering: The following substance(s)exceeded federal drinlcing water standards. Your water can be used for drinking,cooking,washing,cleaning,bathing,and showering,but aesthetic problems such as bad taste,odor,stauung of porcelain, etc.may occur. You may want to install a household water treatment system to address aesthetic problems. Barium Cadmium Chromium Fluoride Iron Ma esium Man anese Selenium Silver Sodium Zinc H The following substance(s)exceeded federal drinking water standards: We recommend that your well water not be used for drinkin�or cookin�,unless you install a water treatment system to remove the circled substance(s). However,it may be used for waslung,cleaning,bathing, and showering. Arsenic Barium Cadmium Chromium Co er Fluoride Lead Iron Ma nesium Man anese Merc Nitrate/Nitrite Selenium Silver Sodium Zinc H Re-sampling is recommended in months. Re-sample for lead and/or copper. Take a first draw,S minute, and 15 minute sample inside the house(preferably the kitchen)and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source of the lead and/or copper. Contact your local health department for re-sampling assistance. OTHER CONSIDERATIONS Routine well water sampling for the above substances is recommended every two to three yeazs. Sample your well water when there is a known problem or contamination in your azea, after repairs or replacement of your well, or after a flooding event. Contact your local health department for sampling inshuctions. Contact your local health department for more lnformation or go to htta•//www eai state nc/eai/oii/hsfactsheet.htmi March 10,2004 __�.__ _._- � . , � __-----�-..._... North Carolina State Laboratory of Public ealt����.����� � Department of Health and Human Serviaes � P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, . C. 276��i�88�72009 � � INORGANIC CHEMICAL ANALYSIS - PRIVATE WATEI�j,�����,HEN�THD EPURT�nFniT Name of System: Beaver, Brian Source of Water: Address: 544 Becktown Rd Source of Sample: Mocksville, NC Zip: 27028 Type of Sample: County: DAVIE Type of Treatment: Report To: Davie Co. Health Dept. ATTN: Robert Nations Type of Analysis Private Post Office Box 848 (336) 751-8760 Mocksville, NC 27028-0665 Courier: 09-40-06 � Collected By: R NATIONS Date: 6/9/2009 Time: 11:30:00 AM Location of sampling point: Well Remarks: Permit#0018, GPS N35*49.125/W80'29.705 Parameters Results Units Date Analyzed: Silver <0.05 mg/I 6/10/2009 Alkalinity as CaCO3 63 mg/I 6/10/2009 Arsenic <0.005 mg/I 6/10/2009 Barium <0.1 mg/I 6/10/2009 Calcium 20.3 mg/I 6/10/2009 Cadmium <0.001 mg/I 6/10/2009 Chloride IC <5.0 mg/I 6/10/2009 Chromium <0.01 mg/I 6/10/2009 Copper <0.05 mg/I 6/10/2009 Fluoride 1.76 . mg/I 6/10/2009 Iron <0.10 mg/I 6/10/2009 Hardness as CaCO3(Ca,Mg) 68 mg/I 6/10/2009 Mercury <0.0005 mg/I 6/10/2009 Magnesium 4.2 mg/I 6/10/2009 Manganese <0.03 ' mg/I 6/10/2009 Sodium 10 mg/I 6/10/2009 Nitrite as N <0.10 mg/I 6/10/2009 Nitrate as N <1.0 mg/I 6/10/2009 Lead <0.005 m g/I 6/10/2009 pH 7.7 Std. units 6/10/2009 Selenium <0.005 mg/I 6/10/2009 Sulfate 16 mg/I 6/10/2009 Zinc <0.05 mg/I 6/10/2009 Date Received: 6/10/2009 Report Date: 7/6/2009 Reported By: � Today's Date: 7/6/2009 Ref: 8089 Login Batch `pg060Q371 _� Sample Number: AB90632 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 watec Sample should not exceed levels listed below. Alkalinity IVo established limits Iron 0.30 mg/1 Arsenic 0.01 mg/1 Lead 0.015 mg/1 Calcium No established limits titagnesium No established limits Chloride 250 mg/1 Manganese 0.05 mg/1 Copper (.3 mg/1 Nitrate 10 mg/1 (as N) Fluoride 4 mg/1 Nitrite l.0 mg/1 (as N) Hardness No established iirruts pH Not less than 6.� units Zinc 5.0 mg/1