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939 Deadmon Rd Davie County,NC Tax Parcel Report Wednesday, January 25, 2017 �t /V _DE_ADMQN RD 0 I '� .. ..............................._ ..................._. ._........;r- ..._..___.._._........... ......_.. :-...... _..............................................._.......... ............................................................................................': ..................__._.___........._.._...._.__.............1....___.. WARNING: THIS IS NOT A SURVEY Parcel Information Parcel Number: K600000015 Township: Jerusalem NCPIN Number: 5757134574 Municipality: Account Number: 8305243 Census Tract: 37059-807 Listed Owner 1: SPRY ROY VESTAL JR Voting Precinct: SOUTH MOCKSVILLE Mailing Address 1: 953 DEADMON ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A State: NC Zoning Overlay: Zip Code: 27028 Voluntary Ag.District: No Legal Description: 16.86 AC DEADMON RD Fire Response District: JERUSALEM Assessed Acreage: 16.82 Elementary School Zone: CORNATZER Deed Date: 7/2015 Middle School Zone: WILLIAM ELLIS Deed Book/Page: 009940539 Soil Types: PaD,GnB2,RnC,PcB2,PcC2,EnB,CeB2,ChA,WATER,MsD Plat Book: Flood Zone: Plat Page: Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding&Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: 161 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 NC or arising out of the use or Inability to use the GIS data provided by this website. X001 07/11/2013 09:44 FAX �,.surF;� , .RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Er vironment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATI N#2522 1.W LL Cc�NTRACTOR: g. WATER ZONES(dep th): TOt d Adams Top230 Bottom370 Top Bottom Well Contractor(Individual)Name -_________Bottom Top Bottom Rowan Well Drilling Top Top8ottom Top Bottom, Well Contractor Company Name Thickness/ 48 Sherrs Ford 7. CASING: Depth Diameter Weight Material Street Address 0 41 6.25 sch80 vc Salisbury NC 26147 Top Bottom Ft. I? City or Town State Zip Code Top Bottom_. FI. 704 i 656-7879 Top Bottom Ft._ Area code Phone number 8. GROUT: Depth Material Method 2.WELL INFORMATION: TopO Bottom20 Ft;bentonite%em gravity WELL CONSTRUCTION PERMIT#120173 Top Bottom_Ft. .� OTHER ASSOCIATED PERMITffrappltcebte) Top„ Bottom Ft, $ITE WELL ID#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material 3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft. n. in. DATE DRILLED6/20/13 Topes Bottom FI.__in. In. TIME COMPLETED6:00 AM❑ PM( Top Bolton% _Ft._„^In. in. 4.WELL LOCATION: : 10.SANDIGRAVEL PACK: Mockville Davie Depth Size Material s CITY: COUNTY 1 Top Bottom___,__Ft.,,`_ 939 Deadmon Road Top . Bottom Ft._ (Street Nam&,Numbers,Community,Subdivision,Lot No.,Parcel,ZIP C 3de) Top Bottom _ Ft._ TOPOGRAPHIC/LAND SETTING: (check appropriata box) ❑Slope QValley ElFlat ❑Ridge ❑0ther 11.DRILLING LOG a5 •49 '49 Top Bottom Formation Description LATITUDE _"DMS 3X-XXXXXXX:W DD 0 /30 Clay LONGITUDE So Q .27 .25 "DMS 7x.xxxxxxxl,x DD 30 /26,9 granite Latitude/longitude source; IFPS Qropographic map (location of well must be shown on a USGS topo map andettaphd d to this form N not using GPS) I S.WELL OWNER I Ed Bartlett Owner Name 939 Deadmon Road _ Street Address Mocksville NC City or Town State ,tip Cc de 3c 36 998-8756 Area code Phone number 12. REMARKS: S.WELL DETAILS: A. TOTAL DEPTH:265 b. DOES WELL REPLACE EXISTING WELL? YES le NO❑ I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN c. WATER LEVEL Below Top of Casing:_. FT. ACCORDANCE WITH 15A NCAC 2C.WELL CONSTRUCTION (Use,+•If Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PR VIDEO TO THE ELL OWNER. d. TOP OF CASING Is 1 FT,Above Land Surface 'Top of casing terminated at/or below land surface may Mqu re 6/20/13 a variance In accordance with 18A NCAC 2C.01 18. GNATURE OF CERTIFIED WELL CONTRACTOR DATE e. YIELD(gpm):25 METHOD OF TESTair : Todd Adams f. DISINFECTION:Ty�Trine Amount�Z PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit within 30 days of completion to: Division of(Nater Quality- Information Processing, Form GW-1a 1617 Mail Service Conger, Raleigh,NC 27699-161,Phone:(919)807-6300 Rev.2108 -�+ Well Certification of Completion For Office Use Only y;-:• Davie County Health bepartment *CDP File Numtier 120173 210 Hospital Street PIN Number: K60000000502 f P.O.Box 848 Tax Lot#: . Tax Block#: Mocksville NC 27028 Evaluat�For����� Phone:336-753.6780 Fax:336.753.1680 (Property Owner: Ed Bartlett Applicant: Ed Bartlett Address: Deadmon Road Address: 939 Deadmon Rd CRY: Mocksville City: Mocksville StatelZip: NC 27028 State/ZiP: NC 27028 . Phone : (336)998-8766 Phone#: (336)998-8766 ' ctionS Drilling Contractor Hwy 601 S. Left on Deadmon Road, Property on t ,o,d,d , ,a,d ,a,m,s, , , , , , , , , , , , , right. beside 953 Deadmon Road. Driller Registration 1 1 1 1 1 t 1 1 1 1 1 1 . . . . Date Drilled 0 6 / 1 3 1' 2 0 1 3 Replacement WeII �Yes E]No Total Depth Ft Use of Well SINGLE FAMILY Static Water Ft Yield gpm Water Zone 1) Ft 2) Ft 3) Ft 4) Ft Chlorination Type: Amount: Casing: Depth: Ft Thickness In. Diameter In Top of Casing In. Material Depth Material Meth Grout Depth Material Method , . .2 From. 0.To. 2 0 FL BENTONITE POUR FromTo. 0,Ft. From. -. _To. _ Ft. *Liner Oate•" r Well Driller Signature • _ From .To. .Ft. Grout Inspected by: EHS#2244-oaywalt."rew 'Signature Date,O 0 1 3 Issued by. 2244'oa""alt few `Date: 0 6 / 1 4 / 2 0 1 3 Location: Tee Oet) E]Yes �No Comments Latitude -3,5d'61'4/91" Longitude: SD0 �7p'S/�2t� Suction Line F]Yes [-]No Temporary Yes �No Enclosure Yes No Well I.D.Plate MYes F-jNo Enclosure Floor Yes No Pump I.D.Plate []Yes [:]No Access Port Yes E]No Vent Yes F1 No EHS: Bib Cock Yes ❑No Issue Date: 0-7. Back Flow Yes No Water Sample Yes QNo OHand Drawing Olmport Drawing v WELL CERTIFICATE OF COMPLETION ' Davie County Health Department CDP File Number: 120173 210 Hospital Street K60000000502 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Olnch Drawing Dramin Type: Well Certificate of Com letion Scale: QBlock 9 yp P ONIA 3 !f!f I I d! , i t 1 t I i____l__--_____, e it .... — — - — ....... I i t I 1 i 1_--�----.----. - -- --1.-- � i.-�--- �.__ _-- _4 j-j-1 iso - 8-o' 30' y7,� N • Well Construction;Perm it For Office Use Only Davie County Health Department F*CDPFileumber120173 210 Hospital Street umber: K60000000502 P.O.Box 848 Mocksville NC 27028 Tax Lot#: Tax Block#: Phone:336-753-6780 Fax:336-753-1680 _EvaluatedoNrW PERMIT VALID UNTIL: 4!512018 Property owner: Edward Bartlett Applicant: Edward Bartlett Address: 939 Deadmon Road Address: 939 Deadmon Road City: Mocksville City: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)998-8766 Phone#: (336)998-8766 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Deadmon Road *Proposed use of Well: Mocksville NC 27028 Directions If Other: Site Address: Deadmon Road Directions: Hwy 601 S. Left on Deadmon Road,Property on right.beside 953 Deadmon Road. Well Contractor Information Drilling Contractor Driller Registration Permit Conditions *Permit Conditions Well location,Installation,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 maybe revoked at anytime for failure to comply with existing regulations. The siting of the well by the Health Department is to provide protection from the known possible sources of contamination. The well site may not be changed without written permission from an authorized representative of the Local Health Department. No volume or quality of wateris guaranteed by the Health Department *Issued By: 2244-Daywalt,Andrew *Date of Issue: 0 4 / 0 5 / a 0 1 3 OHand Drawing Olmport Drawing Authorized State Agent: **Site Plan/Drawing attached.** WELL CONSTRUCTION PERMIT 120173 Davie County Health Department CDP File Number: 210 Hospital Street P.O. Box 848 County File Number: Ks0000000soz Mocksville NC 27028 Date: .0.4 / © 5 Qlnch Drawing Type: Well Permit Scale: QBlock QN/A ft. elf + I . i Y UY.1Vl.._.«............_........_....... i45F —�-� '� �rf^•. l i -- -- ---- --- -' ._ !4 1 l l _ LI I _ _ __ I _�_ __.. --_ ---!_► _�_ i f Page 2 of 2 S � y �' PPLICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health A P.O.Box 848/210 Hospital Street al Mocksville,NC 27028 (336)753-6780/Fax (336)751-8786 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name to be Billed (-CI Contact Person Billing Address Home Phone 39 q ? k, City/State/ZIP pjoe IC,%V 11 I fe e- 0102& Business Phone Email 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 must accom any this application. Included: itPla Plat (to scale) Owner's Name L d ka r - e. one Nur0er S3 to 9119-0746 Owner's Address oe--a City/State/Zip n'lac S bi'( rU Z Property Address c txejq City o e Lot Size 3.(1( A o e e g Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: DEVELOPMENT INFORM TION Permit Type: New Well Well Repair Well Abandonment Other(specify) Facility Type: Residential V Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES NQ J---- Do You Intend To Install A New Septic System On This Sit . YE 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. -hoij 3 is Signed Date Site Revisit Charge Date(s): Client Notification Date: EHS: 7/30/09 Account# On Invoice# u �"-7 5 q+� q Lf a rn-L f . �