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123 Gentle Stream Ln Davie County,NC Tax Parcel Report Wednesday, January 25, 2017 { f 197 199 115 f 1 r 121 ---- - 189 __--'Q 11Qt { 120 173 r -? 123 `C -z ` 5t+� 124 158 147 f&0 L �-- ................... ��..._ ............................................................._................... __.__.. ................................... ....... . .........___................................. WARNING: THIS IS NOT A SURVEY Parcel Information Parcel Number: B301OA0005 Township: Clarksville NCPIN Number: 5814907077 Municipality: Account Number: 82530350 Census Tract: 37059-801 Listed Owner 1: BIRK ROBERT Voting Precinct: CLARKSVILLE Mailing Address 1: 3510 WIMBERLY LANE Planning Jurisdiction: Davie County City: WINSTON SALEM Zoning Class: DAVIE COUNTY R-A State: NC Zoning Overlay: Zip Code: 27106-0000 Voluntary Ag.District: No Legal Description: LOT 5 WATERS EDGE Fire Response District: COURTNEY Assessed Acreage: 1.99 Elementary School Zone: WILLIAM R DAVIE Deed Date: 12/2008 Middle School Zone: NORTH DAVIE Deed Book/Page: 007771050 Soil Types: MnB2,MdB,MdC Plat Book: 0007 Flood Zone: Plat Page: 158 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding&Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: 9 A Kl� All data is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Davie County, 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 nOUp�C NC or arising out of the use or Inability to use the GIS data provided by this website. - RECEIVE � � •- SEP 14 2015 VdT�+)(,7Ct CONSTRUCTION RECORDForAitemal Use ONLY: HEALTH This form can be used for single or multiple wells 1.Well Contractor Information: -/ 14.NATER ZONES "I � t•✓�) rROM TO I DESCRIPTION ' Well Contractor Name -23— ft. -76 ft. 303t, A 130 ft. 36 ft. 3 NC'Well Contractor Certification Number IS.OUTER CASING formol&c e,"Vells ORLTiVER(ifa Ucablc PROM TO DL�11IL"r''RT M.ATERLAL Yadkin Well Company, inc. ft. in. Company Name 16.rDINER CASING OR•TUBING(eothersual dosed-looD) PROS TO - IMAIETER TIIICMN7SS MATERUL 2.`VllpplkabructienPermionj C(✓ 4- ft. Ste- ft. G� ia. Sp ,—2 LC List allnpplicab(e iwe(lconsuvc/lalrpernllts 0.a.County,State,Palmrce;etc.) ft. ft. 3.Well Use(checkivell use): 17.SCREEN Nya ter Supply Well: PRoM TO IMMM111 SLOTSIZE THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public ft. t. in. ❑Geothermal(HeatinZ(Cooling Supply) Elesidential Nater Supply(single) ft ft. ❑Industrial/Commercial []Residential Water Supply(shared) 11-9.GROUT FROIi TO M.ATERLAL EIIPIACEIIENTNIETRODXAIIOULW ❑Irrigation ft. 3 ft. Non ZVater Supply'Yell: OMonitoring ❑Recovery 3 ft. .2 ft. � ) Injection'Well: ft. ft ❑AquiferRecharge ❑GroundivaterRemediation 19.SAND/GRAVEL PACK ifa licable) ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO AIATLRLAL EItPL4CElIENThIETHOD ❑Aquifer Test ❑Stormwater Drainage ft. ❑ExpzrimentalTechnelogy ❑Subsidence Control y , RILLINGLOG(attzchadditionalSheets ifaecessm ) ❑Geothermal(Closed Loop) ❑Tracer PROM TO DES CRIPTION(col or,hardness,sailb-ock type,e,•alnsiza etc. ❑Geothermal(Heating/Cooling Return) ❑Ofher(explain under#21 Remarks) Q ft ft. �© ►� 4.Date SYell(s)Completed: t "/ ZYe11IDi 44 PA 1 VG U ft. 2 512'ft -P., d +i C ft. ft. 5a.'4YellLocation: Phone number 3l- ZS�J-Mkc� . ft. fr. fr. Facility/Owner Name Facility LOm(ifopplicable) � / ft. ft 12.Z QL-4,de-S• 40,1 L lc ju��"J '{I►O- — _)Ucl ft. f'. PhysicalAddress,City,and Zip 21.REbLARI;.S t County Parcel IdentificationNo.(PTND 5b.Latitude and Lone tude in degrees/minutes/seconds or decimal degrees: 22•Certification:(if wall field,one lat/long is sufficient) syr /<S' �� Signature ofCertifiedWell Coat-actor Date 6.Is(arc)the ivell(s): taPei'mauent or ❑?empOrary b� sig thug rh(sfarnl,I(tereby cerrl;�•that the well(s)was(were)committed in accordance � with 15A NCAC 010.0100 or 15A NCAC 02C.0200 Well Constniction Standards and that a 7.Is this a repair to an existing well; ❑Yes or IEr1V0 copy of this record has been provided to the uvell owner. If this is n repa(r,f1l/out 7010117711-211 conslntction it jotnmtiat and explain the nature ofthe rzpalrrtuder x11 remarlcpsection or on ilia back ofthrsfwpi. 23.Site diagram or addidonal ivell details: You may use the back of this page to provide additional ivell site details or well S.Dumber of tyells constructed: construction details. You may also attach additional pales ifnecessary. For'ttnrlt(ple injection ornon-watermppl y wells ONLYi th rhe same construction,)-art can mibnrit oneform. l� SUM IITTAL INSTUCTIONS 9.Total well depth below)and surface-. � -`� (ft.) 242.For All Wells: Submit this form within 30 days of completion of well Formulrt97awells list olldepthsjdinerent(example-SG00'ntrdll!100) construction to the follovring: 10.Static n•ater level below top of casing: (ft.) Division ofWater Quality,Information Processing Unit, Ifu•aterlevel is above casrtr,;use"+" 1617 MMI Service Cen tet;Raleigh,ATC 27699-1617 11.Borehole diameter: A..) B—it Off �j 1 0�cj._ 24b,For Meet ion Welis: In addition to sending the form to the address in 24a above, also submit a copy of this form within 30 days of completion of well 12.Well consfrucliun meilrud: Rotary construction to the following: (i.e.auger,rotary,cable,du-eclpusb,etc.) Division ofWater Quality,Underground Injection Control Program, FOR NATER SUPPLY WELLS ONLY: 1636 Mail Service Center,RnIeigh,NC 276991636 ? 24c.For Witer Suonly F.Iniection Wells: In addition to sending the form to 13a.Yield(;pn) Method oftest: q1 f the address(es) above, also submit one copy of this form within 30 days of CUIDS completion of well construction to the county health department of the county 13b.Disinfection type: H`ITH Amount: where constructed. /M 61 NTMI,/ Foal OW-1 Nadi Carolina DepaiUnent of Environment and Nat ral Resources—Division ofti'later Quality [Revised lan.2013 - S. z per- , • Builders NOwners Name: ame• // // Address: I', I d/T Address: Phone: Phone Number: Cell Number: � ' � �LS' �+ n+cp �h t 'W fAu%"- n Well Construction Permit it For Once Use-Only Davie County Health Department *CDP File Number 190954 .- 210 Hospital Street PIN Number. P.Q.Box 848 •�. Tax Lot#: Tax Block#: Mocksville NC 27028 Phone:336-753-6780 Fax;336-753-1680 Evaluated For:WELL PERMIT VALID UNTIL: 7124/2020 r roperty Owner: Robert Birk Applicant: Robert Birk ddress: 123 Gentle Stream Lane Address: 123 Gentle Stream Lane City: Mocksville City: Mocksville State/Zip: NC 27028 StatefZip: NC 27028 Phone#: (336)245-8280 Phone#: (336)245-8280 Property Location & Site Information Address/Road#: Subdivision: Waters Edge; Phase: Lot: 5 123 Gentle Stream Lane *Proposed use of Well: Mocksville NC 27028 Directions If Other: Site Address: 123 Gentle Stream Lane Directions: hwy 601 North to Bowman Road,right on Bowman, 1/4 mile on right long driveway Well Contractor information Drilling Con•Ittrr\actor Driller Registration r f..l T ._ t �f N[.J/1.1✓I�l�� r....., i....1 oil 1 1..r JJ r r r rte_ r r r r r r r r r r r Permit Conditions *Permit Conditions Well location,construction and protection must meet all state and local regulations and must be inspected and approved by an authorized representative of the Local Health Department,The permit may be revoked atany time for failure to complywith existing regulations.The siting of approved well construction are (s)by the Health Department is to provide protection from the known possible 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 , 7 , / t 2 r 4 r J r a i 0 r 1 r 5 r Authorized State Agent: "tHand Drawing Qlmport Drawing Owner/Applicant Signature: **Site Pian/Drawing attached.**,-- WELL CONSTRUCTION PERMIT Davie County Health Department CDP File Number: 190954 210 Hospital Street P.Q.Box 848 County File plumber: Mocksville NC 27028 Date: 0 7 / 24 / a015 O lnch Drawing Type: Well Permit Scale: QBlock QN/A #t. �.. t-71— , Ems- t .:-- k YJ --- -------- t .,,.• ' I C WELL CONSTRUCTION PERMIT 190954 D Davie County Health Department CDP File Number. 210 Hospital Street County File Number: P.O.Box 848 Mocksville NC 27028 Date: 07 / 24la015 a Q Inch ock Drawing Type: Well Permit Scale: ONIA NfA eft, o f 00, I � l loh p�ID APPLICATION FOR PRIVATE WELL PERMIT 7- Davie County,Environmental Health P.O.Box 848/210 Hospital Street g�etb • 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 V Contact Person S(q01 Address ZS E X/ (/{iN1. L Home Phone 6,N 2q, — City/State/ZIP S V LLQ Business Phone Name on Permit if Different than Above Mailing Address /O CJl ZEA , #4 'City/State/Zip_WI 4)S—jotil Sr91_EA !� 21TI PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) Owner's Name5���.' Phone Number Owner's Address City/State/Zip Property Address_ , RA/ .e .S City Lot Size �qTax PIN# 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 Date Site Revisit Charge Date(s): Client Notification Date: EHS: 7/30/09 Account# Invoice# CIL o0/i�� • CONSTRUCTION For Office Use Only AUTHORIZATION *CDP File Number 190954- 1 w6� Davie County Health Department County ID Number: 210 Hospital Street Evaluated For: NEW •,, s. P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 3 / 1 8 / a 0 a 0 Applicant: Robert W Birk Property Owner: Robert W and Terrie L Birk Address: 3510 Wimberly Lane Apt J Address: 3510 Wimberly Lane Apt J City: Winston-Salem City: Winston-Salem State/Zip: NC 27106 State/Zip: NC 27106 Phone#: (336)245-8280 ) �' Phone#: (336)245-8280 Property Location & Site Information Address/Road#: Subdivision: Waters Edge Phase: Lot: 5 123 Gentle Stream Lane Mocksville NC 27028 Directions Structure: SINGLE FAMILY hwy 601 North to Bowman Road, right on Bowman, 1/4 mile on right long driveway #of Bedrooms: 3 #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: oC 4 rDesign ssification: Provisionally Suitable Inches Minimum Soil Cover: System? OYes �}No 1 Inches low: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Pump Required: O Yes ®No O May Be Required Nitrification Field 1 8 0 0 Sq.ft. Pump Tank: Gallons No. Drain Lines 5 1-Piece: OYes ONo Total Trench Length: 4 5 0 ft GPM--vs— ft. TDH Trench Spacing: — g Inches O.C. Feet O.C. Dosing Volume: Gallons Trench Width: 3 Inches AggregateFeet Grease Trap: Gallons Depth: inches Pre-Treatment: O NSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required: 01011 O 111 01V Page 1 of 3 CDP File Number 190954 - 1 County ID Number: ❑ Open Pump System Sheet Repair System Required:(&Yes ONO ONO, but has Available Space CDesign System Trench Spacing: g 0 Inches O. . fication: Provisionally suitable — ®Feet O.C. Trench Width: O Inches w: 3 6 0 — 3 ®Feet Soil Application Rate: 0 a Aggregate Depth: inches .� *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: LESS) 1 a Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 1 8 0 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain Lines 5 *Distribution Type: GRAVITY-SERIAL Total Trench Length: 4 5 0 ft Pump Required: OYes O No O May Be Required Pre-Treatment: O NSF OTS-I OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. a me 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. Rama tern 2000 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 may be 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 for a permit or Construction Authorization is found to have been incorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall become Invalid,and may be 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 (1938(b)). Applicant/Legal Reps. Signature Required? O Yes ONO Applicant/Legal Reps. Signature- Date: / *Issued By: 2140-Nations,Robert Date of Issue: 0 3 / 1 8 / a 0 1 5 Authorized State Agent: Malfunction Log OYeS f; ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 190954 - 1 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 03 / 18 / .2015 Q Inch Drawing Drawing Type: Construction Authorization Scale: . O Block Q N/A 01 _ ........ i.... .... L - . ......_ _ ---_ i ...... ........ -- -- -- � ` _- p _ ...... ..........I i I j f ti - _ _ - - e I --- --- - ► $ Ia ..... - - --- - __ i -- .....-- I I -- - .... I _ I -----..................__ _ __. _- __.._.._ --------- ----............- -- I i -....----- -._...................._ --- -_------............................_....---------- _...-.....-..........---........ ---- - _........................ _ .......................................................................­_­........................... ..................... ......... ...................... i i ---- P 1 _ P2 Page 3 of 3 t r • ♦ r CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 190954 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: A3./ 18 / D 0 15 Click below to import an image from an external location: Drawing Type:Construction Authorization Page 3 of 3 P1 P2