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450 Cedar Grove Church RdDavie Countv, NC . - Tax Parcel Report Friday. October 7, 201 f WARNING: THIS IS NOT A SURVEY i _s Parcel Information a Parcel Number: K70000004601 Township: Fulton NCPIN Number: 5767859026 Municipality: �oUN Account Number: 8300088 Census Tract: 37059-804 Listed Owner 1: MCILWAIN BRIAN D Voting Precinct: FULTON Mailing Address 1: 450 CEDAR GROVE CHURCH ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: Zip Code: 27028-0000 Voluntary Ag. District: No Legal Description: CEDAR GROVE CHURCH Fire Response District: FORK Assessed Acreage: 10.00 Elementary School Zone: CORNATZER Deed Date: 7/2010 Middle School Zone: WILLIAM ELLIS Deed Book / Page: 008320050 Soil Types: PaD,PcB2,ChA,WATER Plat Book: 10 Flood Zone: Plat Page: 235 Watershed Overlay: DAVIE COUNTY Building Value: 246400.00 Outbuilding & Extra Freatures Value: 1700.00 Land Value: 71420.00 Total Market Value: 319520.00 Total Assessed Value: 319520.00 O [�� 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 �oUN �r NC County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to the Inability to the GIS data by this website. S� or arising out of use or use provided Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 Account #: 989900057 Billed To: Randy Grubb Reference Name: Brian & Deanna Mcilwain Proposed Facility: Residental Well WELL PERMIT Tax PINiEH #: 5767 -94 -1969 -Well Subdivision Info: LocationiAddress: 4501 Cedar Grove Church Road -270 Property Size: 10 Acres ATC Number: 0061 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 [A Repair ❑ Abandonment ❑ Proposed Well Location Diagram Certificate of Completion Diagram VA J% Com ents: C41 -e l ( �,{� Driller: Certification#: Grout Inspected: i1 <4e- Well Head Inspected: GPS Coordinates: EHS: Date: EHS: Date: W.P. 7-08 Aug 09 10 01:25p Information Seovices 3367531680 p.1 I APPLICA'FION FOR PRIVATE WELL PE PP Davie County Environmental Health AP.. 201 A P.0. Box 3481210 Hospital Street Mocksville, SNC 27028 ® (336)753-67801 Fax (336)753-1680 ***1,UP0,kTAN�** THIS A.PPLI 'TION CANNOT EEPROCLVED UNLESS .ALL OF THE REQZTREJ APPLICANT NFOR�IATION _ Name �? l �h /� Contact Person _ 4 Address O ecr _ Home Phone�� City/State Z x 702— Business Phone y Name on Permit ir Different than Above _ Mailing Addres, CityiState,Zip PROPERTY 1161 ORMATION NOTE: A survey 61W or site plan Owner's Name Owner's Addres :_A Property Addres 41�-CV C 1 Lot Size Subdivision Na e(if applicable) Directions To S e: accompan -,_ thi pr� AUS 1 6 2010 TION IS *Dale House/Facility Corners Flaged I 'icadon. Included: 1 Site Plav ❑Plat ( o scale) �11[.G'✓I Phone Numbex 337/-,5'z3 ,a_./ City!State(2;ip i_ I Tax PINP__P/6f �f- 376 47 9 44- /f 1 � �' DEVELOPME T INFORMATION Perini? Type: s w l ,// NVell Repair _ Well Abandonr_ient � OtYer (specify) Facility Type: ;1'."C'Systerns I'antial Food Servic:! Church C rmercial j Other Are There Any Currently On The `lite? `:-ES N � � Do You Intents ljo, Install A New Septic System O: a This ;lite? YES NO i TERMS AND CO DITIONS: This applicatiDnin Pt be acccntpanied by a plat or site pl..n of the properly that includes the existing an proposed property lines with dimensions, t specific location of the facility and aiy ex sting or future appurtenances, the loca ars of any exis ng septic system, sewer line ,water lines, any existing vsa:er supplir.s and any surface waters. The applicant is responsible for ident4ing and marking the pi operry lines and comers. The appL��-rit :s responsible for making the ;i,.e accessible' By signing this application, &.e applicant signifies tha they understand the terms and conditions and th- t they g:va permission for Davie County EnArpni ental Health representatives rr perfo,m necessary field evaluations and proced—es deemed necessary to dctcrmin_� the best ccation for a well. { 71 3OX9 011 Dat Site Revisit Chargc fClient Notific4tio Date: _ ERS: - Account # _ 00057- s_J Ill-,oico 4 *74Y / fj-�Ouljo • "'�'� DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751.-8786 AUTHORIZATION FOR WASTEWATER SYSTENI.CONSTRUCTION Account #: 989900194 Billed:To: Brian & Deanna Mcllwain Reference Name: Proposed Facility: Residence ATC Number: 4853 Tax PIN/EH #: 5767-94-1969 Subdivision Info: Location/Address: Cedar Grove Church Road -27028 Property Size: 23.25 Acres Site Type: DKew ORepair ❑Expansion **NOTE** This Authorization to Constrict (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section. 1900 Sewage Treatment 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 3 # People BasementR-Basement plumbing2-- Non=Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size 03. 5 Type of Water Supply: ❑County/City Gell ❑Community Well System Specifications: Design Wastewater Flow (GPD) 'AC06OTank Size�'GAL. Pump Tank J4 GAL. Trench Width Max. Trench Depth 3( Rock Depth Linear Ft. Site Modifications/Conditions/Other: Ars stated in 15A NCAC 18A.1969(;i) aoe S �teI11; ,1i 3; uis�"�o Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of ins;LU ittl4_n. Telephone # (336)751-8760. Ck r Environmental Health Specialist ;y1 r C!(il�'erU tl� l� Lz Y \ 5' -Ihc ati Date: _.. RESIDENTIAL `YELL CONSTRUCTION RECORD ��� North Carolina Department of Environment and Natural Resources- Division of Water Qualm WELL CONTRACTOR CERTIFICATION # 1. /41,1 Well11 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 336 468-4440 3D 3 �'A SEP 012010 DAVIECOUNTYHEHLFHOEPARFMEN t g. WATER ZONES (depth): Top U -Bottom `IS TVfen Bottom Tope Bottom y �l ��T/qp"Bottom Top 3 ` Bottom S'O `l To y M Bottom Thickness/ 7. CASING: "Depth Diameter Weight Material Top Yd Bottom -7_ Ft. 6. 1 zSAP, 4. Top Bottom Ft. Top Bottom Ft. Area code Phone numberQ ���� S D� G : 8. GROUT: Depth Material 2. WELL INFORMATION: lTop _ Bottom 3 Ft&/6, '& e -1-11,r WELL CONSTRUCTION PERMIT# 5-7to/ %- 1 t "` a' 4 a -0 /Top'_ Bottom J5- OTHER ASSOCIATED PERMIT#(ifapplicable) Top Bottom Ft. SITE WELL ID #(if applicable) — -z 9. SCREEN: Depth Diameter Slot Size Method (o red V tJZ- r 3. WELL USE (Check Applicable Box): Residential Water Supply Top Bottom t. in. DATE DRILLED - % - �D t Top Bottom Ft. in. in. J-rv� To Bette—zf Ft. n in. TIME COMPLETED AM ❑ PM.{� 4. WELL LOCATION: 10. SAND/GRAVEL PACK - Depth Size Material CITY:— !/iyLlG COUNTY ; Top Bottom Ft. Top Bottom Ft. (Street Name, Numbers, Community, Subdivision, Lot o., Parcel, Zip Code) Top PZ Ft TOPOGRAPHIC / LAND SETTING: (check appropriate box) b4clope ❑Valley []Flat []Ridge ❑Other tv LATITUDE " DMS OR OODD LONGITUDE o I" DMS OR &51!�AL-VI DD Latitude/longitude source: A�PS aopographic map (location of well must be sfiown on a USGS topo map andattached to this form if not using GPS)�y 5. WELL OWNER oe ^` d 6�-fgh Gt�c Ll��a.ih Owner NameTr Street Address 1/ c 14 City or T State Zip Code Area code Phone number 6. WELL DETAILS: a. TOTAL DEPTH: 11. DRILLING LOG Top Bottom I --/�—/ .3 1/_S_ / / / 12. REMARKS: Material Formation Description r t-R/yo7TI d/r, % t^ . my b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOJ(d' `" I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN c. WATER LEVEL Below Top of Casing: u FT. ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION (Use "+^ if Above Top of Casing) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN j PROVIDED TO TH WELL OWNER. d. TOP OF CASING IS FT. Above Land Surface' 'Top of casing terminated atlor below land surface may require • G O2 lo a variance in accordance with 15A NCAC 2C .0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE e. YIELD (gpm): 3, METHOD OF TEST f. DISINFECTION: Type HTH _ Amount ICCUUP PRINTED NAME OF PERSON CONSTRUCTING THE WELL 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. 2/09 Date Site Visited 5^--.2.0 —(o By: 1,,W Permit: Yes o What Is Height of Well Casing? Make (?4�d.4 Sure 12" Above Gro d Level!!!! ec-l— « Z. _, ..,,. e),"4/ ., /, ,. . . BUILDERS NAME: ADDRESS • 3 0 kP A c Gr U PHONE NUMBER: 601 1.5 �r.Aug '18' 10 03:16p Y Information Selvioes 3367531630 p.1 Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksvilie, Nr- 27028 (336)753.6790! Fax (336)753-1680 NVUL MIMIT ACc,c-unt „I: j 983900357 ax PiN/EH -9 5767 -94 -1969 -Well Billcd 7a: ; Randy Grubb Subdivision Into: Reference Nam Brian & Deanna Mcilwain Locatiop. Addreus: 4507 Cedar Grove C.huroh goad -270 rlmp used Facllit . Residental Well Prr,mty Size: 10 Acres I ' ATC Numba 0081 ,fictions ofh'c eniploy=5 of the Davie C,ouaty EH Seder: -mall in no way be taken as a guarantee that thi , well p duce :voter of any particular qusntirr o- qua) 4), or for any Amount of ;uvI.e. �::s p"rrr it is -a cd for a porio of S years from the dee of issuance. This permit may beyrevoked if it is detirmirae:d that t1 er.; has been a Sr.�terial change it any fkcticircumstances upon which this pm-init Was issued. j Permit W.P. >•08 New ErA-"' Repair 17 Abandonment Ir posed Well Locatior, Diagram y I Certificete of Cotr_pletian Diagram I i Cer fflication 4i;-- �c__�� r:q [.;;paled:--- i _,_ - I — -- —` _-- i WC -A Head Ins3: ceted; :WS Coordinates: yz,,,I)rte:eT��7_�Eil-JSI-p—«r..w'.� DAVIE COUNTY WELL CERTIFICATE OF COMPLETION CHECKLIST Applicant: 5NA64wh,1 File Site Address: G61C1V-00vt Subdivision: PJA Lot:. Permit Type: New Well X Well Repair Well Abandonment Other Facility Type: Residential K Food Service M Church Commercial Other ' Initial Inspection 212 Were Setbacks Maintained? Yes V/ No What is thaGrout Depth? Z1.5 ft. If No, Explain: What is the Grout Thickness? 2 in. What is the Type of Well? Was a Well,Screen Installed? f' What is the Casing Type? c Type of Drilling Fluids Used: Wu�CIr What is the Casing Depth? ft. Well Grout Inspection Date: i 23 6 What is the Well Diameter? in.. GPS Coordinates: What is the Well Depth? 'L`66 ft. EHS ID: Well Head Inspection NY� ���a-sl�Yr�l Is There an Access Port? Is There a Vent? Is There a 4" Pad? Is There a Hose Bibb? What is the Casing Height? Is There any Grout Settlement? What is the Static Water Level? ft. What isI he Yield? GPM Complete? Is the Pump Installer ID Plate Complete? Is the Well Contractor ID Plate Contractor Name: 11 \At kk % Sods M— Pump Installer Name: Contractor Certification Date Installed: Depth of Well: Depth of Pump Intake: ' Casing Depth and Inside Diameter: Pump Horsepower Rating: Screened Intervals: Opening for Piping & Wiring >_12": Packing Intervals (Sand Packed Wells): Yield in GPM or GPM/ft.-dd: Static Water Level and Date Measured: Date Well Completed: Well Head Inspection Date: EHS ID: Construction Completed Date: Contractor Reports Received Date: Sample Date: Results Mailed Date: Certificate of Completion Date: Authorized Agent: