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4989 Hwy 601NME Applicant: Kayla Norman Address: 107 Highland Road City: Mocksville State/Zip: NC 27028 Phone #: (336) 782-4329 Property Owner: Kayla Norman Address: 107 Highland Road City: Mocksville State/Zip: NC 27028 Phone #: (336) 782-4329 Property Location & Site Information Address/Road #: Subdivision: Phase: Lot: 424 US Hwy 601 North q 9 Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 North property to left of #5035 # of Bedrooms: 4 # of People: *Water Supply: NEW WELL F by. 2140 -Nations, Robed by: 2140 -Nations, Robert w: 4 8 0 ation Rate: 0 a 7 4 Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: *System Class ifiicatanfDescription: TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY SaproliteSystem? OYes ONo *Distribution Type: GRAVITY- SERIAL *Pre Treatment: 1 7 4 5 Sq. ft. 5 4 3 8 ft. 9 Inches O.C. . Feet O.C. 3 Inches Feet inches 480 GPD OR LESS) Pump Required? OYes QNo *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Tim Beeson Certification #: 3018 *EH S: 2140 - Nations. Robert Date: 0 9/ a 4 / a 0 1 5 Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Maximum Trench Depth: 3 tirC Inches Maximum Soil Cover: 2 4 Inches 0PERATIO N,PE "'MIT Davie County Health Department rte. 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Kayla Norman Address: 107 Highland Road City: Mocksville State/Zip: NC 27028 Phone #: (336) 782-4329 Property Owner: Kayla Norman Address: 107 Highland Road City: Mocksville State/Zip: NC 27028 Phone #: (336) 782-4329 Property Location & Site Information Address/Road #: Subdivision: Phase: Lot: 424 US Hwy 601 North q 9 Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 North property to left of #5035 # of Bedrooms: 4 # of People: *Water Supply: NEW WELL F by. 2140 -Nations, Robed by: 2140 -Nations, Robert w: 4 8 0 ation Rate: 0 a 7 4 Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: *System Class ifiicatanfDescription: TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY SaproliteSystem? OYes ONo *Distribution Type: GRAVITY- SERIAL *Pre Treatment: 1 7 4 5 Sq. ft. 5 4 3 8 ft. 9 Inches O.C. . Feet O.C. 3 Inches Feet inches 480 GPD OR LESS) Pump Required? OYes QNo *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Tim Beeson Certification #: 3018 *EH S: 2140 - Nations. Robert Date: 0 9/ a 4 / a 0 1 5 Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Maximum Trench Depth: 3 tirC Inches Maximum Soil Cover: 2 4 Inches CDP File Number 1913$2 -1 County ID Number: PT: Dosing Volume: — Septic Tank Manufacturer. Shoal' Draw Down: Lat. STB: 760 *Chain: Long: y Gallons: � ❑ No Installer: rim Beeson Date: i3 3/ 1 'i: / x 0 1 Certification #: 3Q18 5 Reinforced Tank: ❑ ` ❑ No *EH S: 2140. Nations, Robert *Filter Brand: POLYLOK PL -122 With Pipe Adapter NO ST Marker. ❑ Yes ❑ NO Date: 0 9/ 2 4 / 2 0 1 5 Reinforced Tank: ❑ Yes ® No Approval status' PVC unions *Schedule: ❑ No ®Approved C1 Dlsaprored Piece Tank: ❑Yes D No Approved tdtings ❑ Pump Tank Installer. Certification #: *EH S: Date: Manufacturer. Installer. PT: Dosing Volume: — Gallons: Draw Down: Inches Dater *EHS: *Chain: RiserSealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.61n.) Reinforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ NO ❑ NO Pipe Size: ❑ Yes inch diameter NO Pipe Length: feet PVC unions *Schedule: ❑ No ! Approved ❑`Disapproved Pressure Rated ❑ Yes ❑ No Approved tdtings ❑ Yes ❑ No pply Line Installer. Certification #: *EH S: Date: f Pump Type: Installer. Dosing Volume: — Gal Certification #: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ NO Check -valve ❑ Yes ❑ NO Appmval Stafus PVC unions ❑ Yes ❑ No ! Approved ❑`Disapproved Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes 0 No CDP File Number 191382 -1 Electric Equipment County ID Number: NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification #: Box Adj. To Pump Tank ❑ Yes ❑ N o Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: I , Approval Status Alarm Audible ❑Yes ❑ No p ,Approved❑ Disapproved£ Alarm Visible ❑ Yes ❑ No Y. 2140 • Nations, Robert *Operation Permit completed by: _ Z Authorized State Agent: Owner/Applicant Signature: Date of Issue: 0 9/ 2 4 / 2 0 1 5 This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A .1900 at, Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served by a TYPE u A sewage septic system. Rule .1961 requires that a Type TYPE 11 A. septic system meet the following criteria: Minimum System Review By The Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCertified Operator. NIA Reporting Frequency By Certified Operator. NIA Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operatoror a private certified operator forthe life of the septic system. Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing Ulmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 191382 -1 County File Number: 27028 Date: Q Inch Scale: QBlock ON/A EMMMM MMM MM M ■ CONSTRUCTION AUTHORIZATION ° N Davie County Health Department 210 Hospital Street P.O. Box' 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Kayla Norman Address: 107 Highland Road City: Mocksville StatefZip: NC 27028 Phone #: (336) 7824329 For Office Use Only *CDP File Number 191382-1 County ID Number: Evaluated For NEW Township: oeouTvwn utu ._... 0 6/ 0 4/ a 0 a 0 Property Owner: Kayla Norman Address: 107 Highland Road City: Mocksville State/Zip: NC Phone #: (336) 782-4329 27028 Address/Road #: Subdivision: Phase: Lot: US Hwy 601 North Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 North property to left of #5035 # of Bedrooms: 4 # of People: "Water Supply: NEW WELL Dunn i ^f'1 System Specifications Minimum Trench Depth: a 4 ;Inches Site Classification: Provisionally Suitable Saprolite System? OYes @No Minimum Soil Cover: 1 a Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 inches Soil Application Rate: 0. 1 7 5 Maximum Soil Cover: 2 4 Inches *System Classification/Description: *Distribution Type: GRAVITY - PARALLEL (eq. d -box) TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 250% REDUCTION 1 -Piece: OYes (SNIo Required Pump Required: OYes @No OMay Be Nitrification Field 1 7 4 5 Sq. ft. Pump Tank: Gallons No. Drain Lines 4 1 -Piece: Oyes ONol Total Trench Length: 4 3 6 ft. GPM—vs— ft. TDH Trench Spacing: _ 9 OInches O.C. . * Feet O.C. Dosing Volume: _ Gallons Trench Width:Veet . ches 3 _ Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: 01 011 0111 011V Dunn i ^f'1 CDP File Number 191382 -1 County ID Nu;nber. • • ❑ Open Pump System Sheet KeDalr5v5r@m KeQUIre0:V TeS k- Nu IJIVu, but rias Available Space I '- ��•� ' Trench Spacing: ches O.1 9 Weet "Site Classification: Provisionally Suitable — O.C. Design Flow: Trench Width:4 ,Feet Inches 4 8 0 — Depth; SoilAggregate Application Rate: 0 a 7 5 inches .� Minimum Trench Depth: 4 'System Classification/Description: .1 Inches TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6 'Proposed System: 25% REDUCTION Inches Maximum Soil Cover: a 4 Nitrification Field 1 7 4 5 Sq. ft. Inches No. Drain tines "Distribution Type: GRAVITY - PARALLEL (eq. d -box) 4 Total Trench Length: 4 3. 6 Pump Required: Oyes @No OMay.Be Required ft. \ Pre Treatment: ONSF OTS -1 OTS -II "Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. "Permit Conditions The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and maybe issued at the same time the Improvement Permit issued (NCGS 130A-336(b)� If the installation has not been completed during the period of validity of the Construction Permit, the information submitted In the application fora permit or Construction Authorization is found to have been Incorrect, falsified or changed, or the site Is altered, the permit or Consbvctlon Authorization shall become Inwild, and maybe suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance; monitoring, reporting and repair (1939(b)). Applicant/Legal Reps. Signature Required? OYes ONo Applicant/Legal Reps. Signature• Date:. / 'Issued By: Authorized State 2140 - Nations, Robert Date of Issue:. 0 6/ 0 4/.1 0 1 5 Malfunction Log OYes @Hand Drawing 01mport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Wile County Health Department CDP File Number: 191382 -1 210 Hospital Street P.o. Box 848 County File Number: Mocksville NC 27028 Date: 0 6/ 0 4/ 2 0 1 5 O Inch Drawing Drawing Type:. Construction Authorization Scale: . . . QN/A k ft. CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital street CDP File Number: 191382-1 P.O. Box 848 Mocksville NC 27028 County File Number. Date: .0.6 ./ 04 /2015 Click below to import an Image from an external location: Drawing Type: Construction Authorization O V d 53' A6 I � > Q t7 --/T 0 7 tj tl /0 w,�� For Office Use Only . 3 I� IMPROVEMENT PERMIT Applicant: Kayla Norman Address: 107 Highland Road City: Mocksville State/Zip: NC 27028 Phone #: (336) 782-4329 Address/Road #: US Hwy 601 North Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: NEW WELL / *S rcperty Owner: Kayla Norman Address: 107 Highland Road City: Mocksville State/Zip: NC 27028 (336) 782-4329 Subdivision: Phase Provisionally Suitable Saprolite System? O Yes (9 No Design Flow: 4 8 0 Soil Application Rate: 0 a T 5 *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR *Proposed System: 25% REDUCTION Directions Hwy 601 North property to left of #5035 Minimum Trench Depth: Maximum Trench Depth: Septic Tank: 1 -Piece: Pump Required: Pump Tank: 1 -Piece: Repair System Required:(&Yes ONo ONO, but has Available Space Lot: a 4 Inches' 1 a 6 Inches 1 0 0 0 Gallons O Yes ® No OYes O No O May Be Required Gallons O Yes O No Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Soil Application Rate: 0 a 7 5 Maximum Trench Depth: 3 6 Inches *.System Classification/Description: Pump Required: OYes (& No O May be Required TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25% REDUCTION Page 1 of 3 CDP File Number 191382 - 1 County ID Number: *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. cRamahning 750 *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Site Plan The Improvement Permit shall be valid for 5 years from date of Issue with a site plan (means a drawing not necessarily drawn to O scale that shows the existing and proposed property lines with dimensions, the location of the facility and appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat (means a property surveyed prepared by a registered land O surveyor, drawn to a scale of one inch equals no more than 60 feet, that includes: the specific location of the proposed facility and appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters. Plat also means, for subdivision lots approved by the local planning authority and recorded with the county register of deeds, a copy of the recorded subdivisions plat that Is accompanied by a site plan that Is drawn to scale). The Department and Local Health Department may impose conditions on the issuance and may revoke the permits for failure of the system to satisfy the conditions, the rules, or this article. This permit Is subject to revocation if the site plan, plat, or intended use changes (NCGS 130A -335(f)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance, monitoring, reporting, and repair (.1938(b)). Applicant/Legal Reps. Signature Required? O Yes O No Applicant/Legal Reps. Signature: Date: / / "Issued By, 2140 - Nations, Robert Authorized State Date of Issue: 0 3/ 2 7/.2 0 1 5 OValid without Expiration? O Create CA? ® Hand Drawing O ImportDrawing **Site Plan/Drawing attached.** Page 2 of 3 chanscws Remaining 750 IMPROVEMENT PERMIT 191382-1 Davie County Health IDepartment CDP File Number: 210 Hospital Street P.O. Box 848 County File Number: Mocksville NC 27028 Date: / / O Inch Drawing Drawing Type: Improvement Permit Scale: , O Block O N/A ft. r it e s 0 S i Page 3 of 3 P1 P2 IMPROVEMJENT PERMIT Davie County Health Department 210 Hospital Street CDP File Number: 191382 -1 P.O. Box 848 Mocksville NC 27028 County File Number: Date: .0.3 . / . a. 7 . / . 2 0 1.5 . Click below to import an image from an external location: Drawing Type: Improvement Permit Page 3 of 3 1 1 P2 APPLICATION FOR SITE-EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Environmental Health CA h Wzfc 96Y9 P.O. Box 848/210 Hospital Street fitd C eilip, Mocksville,NC 27028 3b�- N(a3.53`6Y� (336)753-6780/ Fax (336)753-1680 �2 Applicati � �Evalu*provement Permit Authorization To Construct (ATC) ❑Both Type of A ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Address PROPERTY INFORMATION Contact Person Home Phone 33(0 14CIa 7 a'(0 S _ 7,R1 Business Phone , a�, j .corn 16 Above City/State/Zip I 16IW NOTE: A survey plat or site plan must accompany this application. Included:;❑ Site Plan ❑Plat(to scale) (Permit is v lid fo 60 the with site plan, no expiration with complete plat.) Owner's Name 14 V N' Q rYYLl 6-fi Phone Number Owner's Address I City/State/Zip Property Address pU / City Lot Size Tax PIN# Subdivision Name(if-annlicable) Section/Lot# E Specify Problem Occurring: ll0M tU IF RESIDEN E FILL OUT THE BOX B LOW # People— # Bedrooms ,#`Bathrooms Garden Tub/Whirlpool ❑Yes o Basement: es []No Basement Plumbing: es ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Total Square Footage of Building aJ 00 #People _q # Sinks S # Commodes rivals Estimated Water Usa e ay (Attach documen a ' filar facility water consumption) FO ONLY: # Seats Type system requested: Udonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ko If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge: I!I understand that any permit(s) or ATC(s) issued hereafter 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 and rules. I unders and that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging r s e se/fa " ' o t'on, ro osed well location and the location of any other amenities. Prop o e or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: 'Date EHS: Sign given ❑Yes ❑No Revised 11/06 Account Invoice # C,� �q � LC) 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 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 Printed: Feb 20, 2015 S of the use or inability to use the GIS data provided by this website. h D� t <;x,.115 J �t a�'966 8117 r M. 1, y 2799 `t �1t � Coo •,` N �� t 4'1 \t & 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 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 Printed: Feb 20, 2015 S of the use or inability to use the GIS data provided by this website. APPLICANT INFORMATION Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION us�wy�olN 54,r�s On -Site Well Community Auger Boring Pit Public Cut SITE CLASSIFICATION: Y EVALUATION BY: U41MOM _ LONG-TERM ACCEPTANCE RATE: v ' ✓ 'Ot OTHER(S) PRESENT: REMARKS: LEGEND Landscape 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 CONSISTENCE Moist VFR - Very friable FR - Friable FI -Firm VFI - Very firm, EFI Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL'- Platy PR - Prismatic Mineralog 1:1, 2:1, Mixed 1YQte8 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) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) HORIZON I DEPTH Consistence -�r��r�i�� HORIZON H DEPTH • C�C�l�lIE►!�®®® �•i1'_'�®®®I Texture group -�C•�'l'�fr'-�®® ConsistenceHORIZON IV DEPTH Texture group Consistence Mineralogy SOIL WETNESS SAPROLITE CLASSIFICATION • _7��■rr�i��®i��r® SITE CLASSIFICATION: Y EVALUATION BY: U41MOM _ LONG-TERM ACCEPTANCE RATE: v ' ✓ 'Ot OTHER(S) PRESENT: REMARKS: LEGEND Landscape 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 CONSISTENCE Moist VFR - Very friable FR - Friable FI -Firm VFI - Very firm, EFI Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL'- Platy PR - Prismatic Mineralog 1:1, 2:1, Mixed 1YQte8 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) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) WELL CONSTRUCTION RECORD For Internal use ONLY. This form can be used for single or multiple wells I1. Well Contractor Information: • h ,yC . 4..1 -r- 1 \ 4, QCl a. !y FROM - TO DESCRWnON l•,u O L Well contractor Name ft R V CV t— 3 5 3 R R NC Well Contractor Certification Number FROM TO DIAMETERT MATERL4L r , V o _ V j�� jj l t/ Qilt� '�„ ., R R tcw w LU C) Company Name • �y� t.,I„ (] 2. Well Construction Permit #: I � � ^ � � `J! FROM TO DIAMETER TffiCKIYESS MATERIAL � R � - _ List all applicable well permits (Le. County, State, variance, Injecnorc ete) R R is 3. Well Use (check well use): Water Supply Well: FROM I TO 'DIAMETER - SLOT Sr7E TffiCTCNESs MATERIAL - . ❑Agricultural ❑Nfunicipal/Public in ❑Geothermal (Heating/Cooling Supply) Xesidential Water Supply (single) fr• ' ❑Industrial/Commercial ❑Residential Water Supply (shared) ... sMR FROM - TO MATERIAL EMPLACEMENT METHOD & AMOUNT ❑Irri •on R 23 R r 1 Non-Water Supply Well GY . ❑Monitoring❑Recovery R . R Injection Well: R R ' ❑Aquifer Recharge ❑Groundwater Remediation . ❑Aquifer Storage and Recovery ❑Salinity BarrierR FROM TO MATERIAL EMPLACEMENT METHOD R, %s. t. ❑Aquifer Test ❑Stormwater Drainage :: _ , Z" ft fL ❑Experimental Technology ❑Subsidence Control ' . ❑Geothermal (Closed Loop) ❑Tracer _ FROM . TO...... DESCR[FnON (color, huddess, cml/roeh tne, grziueta j ❑Geothermal (Heating/Cooling Return) ❑Other (explain raider #21 Remarks) ft ft 1 ft ft I 4. Date Well(s) Completed: G-4–is well IDI# R& 1 5a. Well Location: oc 5 R R Nd -aw� L; 604.1 0►. plc , rrt, tt R Facility/Owner ame .. Facility IDN (if applicable) R R 07 11ckja tid R.r1 - /lloC(•v+VdG R ft Physical Address, Ciry, an ry w County Pared Identification.No. (PINj.. 5b. Latitude and Longitude in degreeshminutes/seconds or decal degrees: 22. Certification: (if well field, one lathong is sufficient) 3G 0.3 3 K.- as. � Signature o Date" I 6 Is (are) the wen dPermanent or ❑Temporary si this orm .l hereb c that the wells as ere constructed in oceortAm By SninB f Y � O ( ) ha avith ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Sia dards and that 7. Is this a repair to an existing well: -' ❑Yes or.: ❑Ifo copy ofthrs record has been provided to the well owner. if this is a repair, fill out known well construction it fora 6tron and explain the nature of the repair under *21 remarks section or on the back bfthis form. 23. Site diagram Or additional well details: l You may use the back of this page to provide additional well site details or we 8. Number of wells constructed: construction details. You may also attach additional pages if necessary. For multiple infection or non-water supply wells ONLY with the same construction, you can f submit one form. SUBMITTAL INSTUCTIONS 9. Total well depth below land surface: - ' (ft.) : 24a. For An Wells: Submit this form within 30 days of completion of we For multiple wells list all depths rfdrfferent (example- 3@200' and 2@I00) construction to the following:' �} b.'' 10. Static water level below:top ofcasing: �R) Division of WaterResonrces, Information Processing Unit, If water level is above casing, use -+" 1617 Matt Service Center, Raleigh; NC 27699-1617 11. Borehole diameter. (in.) Mb. For Iniection Wells ONLY: In addition to (sending the form to the addre 24a above, also submit a copy of this form within 30 days of completion of 12. Well construction method: construction to the following: i (i.e. anger, rotary. cable, ffirect push, -etc.) . Division of Water Resources; Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mafl Service Center, Raleigh, NC 27699-1636 13a.'Yield (gpm) d Method rY 24c. For Water Supply & Injection Wells: I of test: Also submit one copy of this form within 30 of completion of 13b. Disinfection type: Amounts / U well construction to the county health department of *the county where constructed. I Form GW-1 North Carolina Department of Eavirovment and Natural Resources -Division of Water Resources Revised August 2 Well Construction Perm it (Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville, NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Property owner. Kayla Norman Address: 107 Highland Road City: Mocksville State/Zip: NC 27028 Phone M (336) 782-4329 Applicant: Kayla Norman Address: 107 Highland Road City: Mocksville State/Zip: NC 27028 Phone #: (336) 782-4329 Property Location & Site Information Address/Road M Subdivision: US Hwy 601 North Mocksville NC 27028 Site Address: US Hwy 601 North Phase: Lot: *Proposed use of Well: Residential Directions if Other. Directions: Hwy 601 North property to left of #5035 Well Contractor information Drilling Contractor Driller Registration r r r c-,� *Permit Conditions I Well location, construction and protection must meet all state and local regulations and must be inspected and approved by an authodzed representative of the Local Health Department. The permit may be revoked at any time for failure to compywith'existing regulations. The siting of approved well construction area(s) by the Health Department Is to provide protection from the known possibte sources of contamination. The approved well area(s) may not be changed without written permission from an authorized representative of the Local Health Department. No volume of quality of water is guaranteed by the Health Department._ _ *Issued By: 2140 - Nations, Robert *Date of Issue; 0 , 5 / a 19 / a r 0 r 1 15 Authorized State Agent,-/ ®Hand Drawing Olmport Drawing Owner/Applicant Signature: **Site Plan/Drawing' attached.** WELL CONSTRUCTION PERMIT dv Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 amw Drawing Type: Well Permit CDP File Number: 191382 County File Number: ' Date: 0 5/ 2 9 1 0 1 5 Q Inch Scale: OBlock QN/A = ft. WELL CONSTRUCTION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 191382 County File Number: Date: 05129 !2015 Drawing Type: Well Permit 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 Old �a 16 1 j rrQdQedl� V63-535� *"IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS (PROVIDED. APPLICANT INFORMATION Name oy pmn Contact Person K V -L Orr> -mn Address t d . Home Phone 3?a[P -1 1� a City/State/ZIP 'MO CSVJIIP C rq10 C3L 9 Business Phone Name on Permit if D than Above Mailing Address 'City/State/Zip PROPERTY INFORMATION . *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included: VSite Plan OPlat (to scale) Owner's Name 9.OL, ��hr ml� Phone Number 'Xil $ a H 3 act Owner's Address City/State/Zip Property Address L4 0 N O 1,4+ City Lot Size Ta IN Subdivision Name(if applicable i/ Seff j�tion/Lot# Directions To Site: r� (� I , i NGl U%1)T- i1 KGS, - - - -DEVELOPMENT INFORMATION - - - - - - - - - - - - - - - - - - -- - - - - -I - - - - - - 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 Date 7/30/09 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Invoice 4 ��III I,F Parcel #: B30000002906 Davie.County, NC - Basic Estate Search Basic Search Real Estate Search Tax Bill Search Sales Search 0 View Property Record for this Parcel View Mao for this Parcel View Tax Bill Information Parcel #: B30000002906 Account #:8305215 Propertv Values Owner Information 195 51 Tax Codes Land: RMAN KAYLA& NORMAN TIMOTHY I9M90 Market: ADVLTAX - COUNTY ssessed: 23082 89 US HWY 601 N TT FIREADVLTAX - FIRE TAX CKSVILLE ENC 27028 P operty Information Township nd (Units/Type): 5.400 AC CLARKSVILLE [Address: 4989 N US HWY 601 Deed Information Local tonin Date: 07/2015 Book: 00993 Page: 0939 Plat Book: Page: Le al Description PIN 5.401 AC HWY 601 5823052799 Propertv Values uildin 195 51 BXF• Land: 35,31 Market: 230 82 ssessed: 23082 Deferred: Sales Information No. Book Page Month Year Instrument Qual/UnQual Improved Price L 00577 0336 10 2004 WD Unqualifled Vacant 0 2 00993 0939 07 2015 WD Unqualifled Vacant 0 View Property Record for this Parcel View Map for this Parcel View Tax Bill Information « Return to Basic Search Page 1 of 1 oP. riot, Davie County Web Site All information on this site is prepared for the Inventory of real property found within Davie County. All data is compiled from recorded deeds, plats, and other public records and data. Users of this data are hereby notified that the aforementioned public information sources should be consulted for verification of the information. All Information contained herein was created for the Davie County's Internal use. Davie County, Its employees and agents make no warranty as to the correctness or accuracy of the information set forth on this site whether express or Implied, in fact or In law, including without limitation the implied warranties of merchantability and fitness for a particular use. If you have any questions about the data displayed on this website please contact the Davie County Tax Office at (336) 753-6120. 1.5.9 http://maps.daviecountync.gov/itsnet/View.aspx?prid=1484630 8/23/2016