414 Crescent Dr (2)Davie County, NC Tax Parcel Report Friday, October 7, 201 E
WARAIAG: TH15 15 AUT A SURVEY
Parcel Information
Parcel Number:
J10000004301
Township:
Calahaln
NCPIN Number:
5708101268
Municipality:
Account Number:
82527380
Census Tract:
37059-801
Listed Owner 1:
NICHOLS JASON BLAKE
Voting Precinct:
SOUTH CALAHALN
Mailing Address 1:
414 CRESCENT DRIVE
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:
2.656AC NORTH OF 1-40
Fire Response District:
COUNTY LINE
Assessed Acreage:
3.18
Elementary School Zone:
COOLEEMEE
Deed Date:
12/2006
Middle School Zone:
SOUTH DAVIE
Deed Book / Page:
006920600
Soil Types: PaD,PcC2,CeB2,ChA
Plat Book:
0008
Flood Zone:
Plat Page:
293
Watershed Overlay:
DAVIE COUNTY
Building Value:
218490.00
Outbuilding & Extra
Freatures Value:
0.00
Land Value:
22580.00
Total Market Value:
241070.00
Total Assessed Value:
241070.00
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 articular use. All users of Davie County's p ty p GIS website shall hold harmless the
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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.
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` Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax(336)753-1680
WELL PERMIT
Account #, 990005649
Billed To: Blake Nichols
Reference Name:
Proposed Facility: Residential - Well
Tax-hlN.,EH #: 5708 -10 -1268 -Well
Subdivision Info:
LocationiAddress: Cresent Drive --27028
Property Size;' -2 '686 Acres
ATC Number: 0075
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 ❑
Prbposed Well Location Diagram
Certificate of Completion Diagram
\Y .) I
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InaComments:
Driller:
• u pL wA
Certification
=6A__ 11 `
Grout Inspected:
Well Head Inspected: �ht'tt!
GPS Coordinates:
EHS: Date:
EHS: Date:cS Lel/
N
W.P. 7-08
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APPLICATION FOR PRIVATE 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
Name E k
-Ali did /S Contact Person ti k /4
Address 01 fidtlmK
aj2 Home Phone
City/State/ZIP-441)-
-1 — 6 Business Phone
Name on Permit if Different than Above
Mailing Address
City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan ust accompany this application. Included: ❑ Site Plan ❑Plat (to scale)
Owner's Name Plk ��� /� /Ucl2nls Phone Number
Owner's Address City/State/Zip
Property Address 01246" City
Lot Size Tax PIN# /G�
Subdivision Name(if applicable) Section/Lot#
Directions To Site:
DEVELOPMENT INFO ON
Permit Type: New Well 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 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 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.
Signed
7/30/09
Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account #
Invoice #
' DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
ATC Number: 5754
Site Type: JXNew ❑Repair ❑Expansion
**NOTE** This Authorization to Construct (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, Seefion .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
COgSTRUCT 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 3 # Bathroom4�4 People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats_
Square Footage(or Dimensions of Facility)
Lot Size 2 •(A oz Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) _Tank Size 1090 GAL. Pump Tank #X GAL.
Trench Width) Max. Trench Depth_,_ K, , Rock Depth Linear Ft.'Vop
Site Modifications/Conditions/Other: AS stated in 15A NCIAC ^''a^of 3
a0Ce ..ys-te51S 11"3;.ay also be use
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
DCHD 11/06 (Revised)
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #:
990005649 Tax PIMEH #: 5708-10-1268
Billed To:
Blake Nichols Subdivision Info:
Reference Nance:
LocationiAddress: Cresent Drive -27028
Proposed Facility:
Residence Properly Size:: 2.686 Acres
ATC Number: 5754
Site Type: JXNew ❑Repair ❑Expansion
**NOTE** This Authorization to Construct (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, Seefion .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
COgSTRUCT 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 3 # Bathroom4�4 People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats_
Square Footage(or Dimensions of Facility)
Lot Size 2 •(A oz Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) _Tank Size 1090 GAL. Pump Tank #X GAL.
Trench Width) Max. Trench Depth_,_ K, , Rock Depth Linear Ft.'Vop
Site Modifications/Conditions/Other: AS stated in 15A NCIAC ^''a^of 3
a0Ce ..ys-te51S 11"3;.ay also be use
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
DCHD 11/06 (Revised)
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•JILILESIDE'NTML WELL CONSTRUCTION RECORD c
I EGEIVED
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # �Q 3 6.4 AUG 10 2011
DAVIE COUN I YHEALI t1VENAkt(t ENE
1. WELL CONTRACTOR:
Mu'f>-/74'IV 'A. ZroW/)
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
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT*
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (CheckApplicableBox): Residential Water Supply
DATE DRILLED7—
— 6 — //
TIME COMPLETED 4'36 AM ❑ PMX
g. WATER ZONES (depth): �^
Tap .2 / ' Bottom --49 /a T�pjren Bottom
Top -2 7`' - Bottom .2 80 Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
TopV:f4 Bottom / 7y Ft. 6
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top O Bottom
Top 3 Bottom
Top Bottom Ft.
9. SCREEN: Depth Diameter
Topottom Ft. in
TopB
ItFt. in
Top / Boo Ft. in
otlo
4. WELL LOCATION: 10. SANDIGRAVEL PACK:
Depth Size
CITY: v G l( r /.,I COUNTY n L f Top Bottom Ft.
��lC�—rSJ Top Bottom Ft.
(Street Na e, N tubers, Community, Subdivision, Lot No., Parcel, Zip Code) TO BottomFt.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope ❑Valley ❑Flat ❑Ridge
❑Other
LATITUDE °_'
" DMS OR D
LONGITUDE °_'
"DMS OR ��DD
Latitudellongitudesource: MGPS
❑Topographic map
(location of well must be s own on a
USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
1'4(,6
Zr
/"/ e, �/%/
Owner
Name
/
Street Address
1?4&cFc5-,,l,Y -
hG 2 r2o
City or Town
State Zip Code
(3 4) !i? - I //� o
Area code tho e number
G. WELL DETAILS:
a. TOTAL DEPTH: 322
�
11. DRILLING LOG
Top Bottom
/ %M Is
G / 322
/
12. REMARKS:
Slot Size Material
in.
in.
in.
Material
Formation Description
/tee/
SIZE OFF (_; , 00 t "
BIT SERIAL NO: Q 6 +� j
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOJ�r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
L Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
c. WATER LEVE
(Use if Above Top of Casing) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP CASING IS `i FT. Above Land Surface /)'
'Topp of casing terminated at/or below land surface may require r�l� �_ .�J
a variance in accordance with 15A NCAC 2C .0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD (gpm): METHOD OF TEST Q/f W4kl w
j
f. DISINFECTION: Type HTH _ Amount QUIDS 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 f — l l By: Permit: Yew No
What Is Height of Well Casing? Make Sure 12" Above Ground �Leve l!!!!
BUILDERS NAME:
ADDRESS:
PHONE NUMBER:
V
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax (336)753-1680
WELL PERMIT
Account #: 990005649
Billed To: Blake Nichols
Reference Name:
Proposed Facility: Residential - Well
RECEIVED,
AUG 10 2011
DAVIE CUUN f Y HLAU HU!: titNI41F ,
Ta3c.PIWEH #: 5708 -10 -1268 -Well
.Subdivision Iffo: /
:•-LacationiAddress: Cresent Drive -'27028
Property-Sizt:: •,,2`686 Acres -
ATC Number: 0075
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.
i •'
Permit Type: New Repair ❑ Abandonment ❑
W.P. 7-08
u
Proposed Well Location Diagram;
Certificate of Completion Diagram
1
Comments:'Driller:
Certification #:
Grout Inspected:
Well Head Inspected:
GPS Coordinates:
EHS: Date:
EHS: Date:
W.P. 7-08
u