331 Frank Short Rd Davie County,NC Tax Parcel Report Friday, December 2, 2016
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_ WARNING: THIS IS NOT A SURVEY
Parcel Number:. --K60000001902 Township: Jerusalem
NCPIN Number:- 5757447106 Municipality:
Account Number: " ' -46829620 Census Tract: 37059-807
Listed Owner 1:: MADDEN SUSAN WALTON Voting Precinct: JERUSALEM
Mailing Address 1: 337 FRANK SHORT ROAD Planning Jurisdiction: Davie County
City: MOCKSVILLE - - Zoning Class: DAVIE COUNTY R-A
State: NC Zoning Overlay:
Zip Code: 27028-5224 Voluntary Ag.District: No
Legal Description: 8.80 AC FRANK SHORT RD''. Fire Response District: JERUSALEM
Assessed Acreage: 8.62 Elementary School Zone: CORNATZER
Deed Date: 6/1994 Middle School Zone: WILLIAM ELLIS
Deed Book/Page: 001740656 Soil Types: MrC2,GnB2
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
Alldataisprovided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Davie Coun Im lied warranties of merchantabilit or fitness fora articular use.All users of Davie Coun�� p y p ty'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
NCor arising out of the use or Inability to use the GIS data provided by this website.
MT)ELL CONSTRUCTION RECOMc{ _ Use ONLY:
This form can be used farsfiLsb orindtiple walls R E C E 1
1.Well Contractor Information:
JAN 0 5
/�•/9 /I WATM ZONES ,
FROM ,TO. - DTSCRIPTION .
Wall CantactorN'•nine /S"rf
PQ H&
NCWell QmftactarCertiScatioaHwher 35.0UzMCAMr-formulN-nsea%"Vs ORMER Ufa livable)
fLA
FRO hI TO 13 AMLIM- IMCa WM bUTFRLIL
Yadkili Well Company. enc. ft in
CampanyNeme" .I6.INNER CASING OI2TUBING thermaldased-too)
FROhI TO IAL_.&IErM,, =CI4QESS W.JffnL�II•
2,.7We11ConstrictionPermittr': SAC R r
jfst all applicable Ivey eovilme lanpentdls Ile.Couny,State variance,etc,j 13
fti fL. .
3.Wd1 Use(eback*ell use):
17.9CREEN
WaterSuppiyWdl: FROM To DIAMETER SMTSM THIC(=m Ei4TERIAL
OAgricultutal OMuaicipaVPublio tt ft in
OGeotheimal(HeatigyCooling Supply).` Ptesideatull Water Supply(single) � 1D
I7IndustriWCOmmarciai OResidential Water Supply(A=d) IS.GROUT
FROM- TO TIATERM4L .&�iPL.4CE5-1EtfrlFWMQDSA1tI0IDYr
Non-VaterSnppVWcll: )
_ i?Monitotina ❑Recovery ..S it. � � i .�/ .rr 4, s.7F,r. .
Ialertlon Well:
CL%uMrRscharga ❑GroundtivaterRemediatioa 19.SAPID/GRA"MPACI{fifa limLle .:;
OAquiftStola&candRecawry OSalinityBkder FRoai To 14[ATF1:L�1L Z Lit ftihik5YFi0D
fc L
I]AquT=Tot OSto=VatcrDraiaa'ae
DExperimental Technolo f OSubsideace Control
10.DI2II57Yi GLOG attedtadditionalsbeetsifaec ) " "
❑Geaffiwmal(Closed Loop)' OTm= FROM TO DFSCKHMON(w1orhaa+n saiUnocL aerntn eta
OGeothermalffzdng/CooliogRahan) ❑other( 'lainunderRyl/R�=adcs) "0 �.( f.
4.
DateWell Complet,d: W e�. T
P r •pl � . _e� � R
Sa:WellloLatioa: hone Ilillilb
ft. f�
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Facitily/0wnerNama :: Fac tyID�EiEappli�abTal fL ft
/rlert rQ t
ft, ft.
Ylrysc-calhddrprss,6ty,mad Zap '
County i w'PatcelIdentificatianNo.(PIN) .
5b.Latitude andLoiddade in d.-grees/minutes/seconds or decimal degrees: -
(ifivell field,one la wm is7 7-
sa gicieat)
IV
Si�oahue ofCerttfied Well Conhactor Data
6.Is(are)thewell(s):'o?--anent or OTemporary,
By sigrdno rhi dorm,i Ferebj+rertgj+Mal the I 1(r)isms(rere)comrrucred fn oceordanet
idthISANCACO2C.0100orJSANCdCO2C tL00Frel/Comtnrctfon4'rm7dardsandrhata
7.Is this a repair to an existing wall: Oyes or !&o , copy ofr/us record has bcen pravlded to The well vivner.
ihfs fs a F. n �Q out Tmmvn sreQ c0"" -"an In 1717a1lon an lain th%natrtrr o rho
dTf pa,f, f°.. mp of
rapah under¢27 remorlEs section oron rhe backgjfhis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional titzli site details or well
B.Numb of wells eoustrneted; construction details. You may also attach additional paa*es ifnacessaty.
Forrwihplef ectimtornon-N'ofersirppbwel/sOIVLYwiththesmneronthuclioi,yroseon. .
r:<bmttonejorm SUBt1S1"1'A1,1NSTf1MONS '
i
9.Total well deptb b�elowland snli'•ace: �.L (ft) 24a. For All Wellm Submit this form tivithin 30 days of completion of wall
Farmull/plairellsllsrcdldeplhs(f'd(&rrg9(ecamplc-3�00'and2�g.100�" corotnuctioetothafolIolvina
10.Static•�latcrlevelbelotvtap ofewing. (ft) Divisionoii4'aterQrs]1ty,IniozzilationProcessing Un%
Ifuatsr/evel Lr cbave carina lire•••t-" ' 1ti171}?ail S zYir a Centel;Raleigl,lvC 27693-1617
11.]Boreholetliameter: Dl. �i s
(' ) _t, Off �,�5 6246.for Iniaefian Wells: In addition to sending tlla form to the addrass is 24a
abova,'also submit it copy of this form within 30 days of completion of well
2 Weil causirucfion mefnod:--'RO taL^�s eonshtiction to the follov/ine
(ie:a�yer,rotary cable, Pu ems)
DiAsion of%er lQuality,Underground Injection Control Prod am,
It WAIF SUPPLY W8T TR ONLy: 1636 Mail Service Cents,Raleigh,NC 276991636
3a:IYield(gpm) Method oftcd: 24c.For Water SOuply&Ialection Wells: In addition in sending the form to
the addresses) above, also submit one copy.of this foim tivitbin 30 days of
sinfectioa#ype: Amount;HTH 3 — ups completion of-%Q1 construction to the county hzalth department of the county
tivltere constructed.
61mGw-1-1 f ' NorthCeivlinaDepactmantofFzvi-a meat and NatiralAesouzces"Division oMaterQuality, fieYisedJan 20]3
Date' Site Visited ,��, 3� By
Builders Name:
Owners Name: ��
Address:`
Address
. Phone .Number P
hone:
Ceil Number:
au bel
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Well Construction Perm it For Office use omv
_ Davie County Health Department FICDPFileumber232606
210 Hospital Street umber:5757447106
P.O. Box 848
Mocksville NC 27028
Tax Lot# Tax Block#:
Phone:336-753-6780 Fax:336-753-1680
Evaluated For: WELL
PERMIT VALID UNTIL: 12/5/2021
Property Owner: Sue Madden Applicant: Sue Madden
Address: 337 Frank Short Rd Address: 337 Frank Short Rd
Cly: Mocksville Cty: Mocksville
State&ip NC 27028. State/Zip: NC 27028
Phone#: _(336)998-2578 =- Phone#: (336)998-2578
- Property Location & Site Information
rddress/Road #: Subdivision: Phase: Lot:
k Short Rd *Proposed use of Well:
le NC 27028
If Other:
Latitude
Longitude Directions
Site Address:331.Frank Short Rd Directions: Hwy 601 s.left on Deadmon Rd.left on
_ . Frank Short Rd
Well Contractor Information
Drilling Contractor Driller Registration
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 at any time for failure to comply with existing regulations.The siting of approved well construction
area(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, 1 1 a� , 0 , 5 , , 2 , 0 ,L1 6 ,
Authorized State Ag t: p Hand Drawing Q Import Drawing
Owner/Applicant Signature: **Site Plan/drawing attached.'*
WELL CONSTRUCTION PERMIT 232606
eµ o Davie County Health Department CDP File Number:
210 Hospital Street 5757447166
P.O. Box 848 County File Number:
4 Mocksville NC 27028 Date: 1 ,2 / 0 5 / 2 0 1 6
Olnch
Drawing Type: Well Permit Scale: OBlock
_ ON/A
{ I I
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APPLICATION FOR PRIVATE
WELL PERMIT
q ..'I n ..,c,r r,+. A r 7r1r( P(••`;7 , Ir tq ..; "tK;'• 't F7 `111# � t..; Y
Davie CountywEnv><ronmental'Health
i . 4:. ,
PO B.ox::848/210Hospital`Street
,Mocksville NC 27028
(336)753 6780/ Fax (336)75 ;'1680"'
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
i 5
Name Sl1.St_ U cA d Contact Person
Address Home Phone to 0jq P
City/State/ZIP N c— a rte,—:2g i. Business Phone
3
Email h a ;
-ria Q.S�n�,�t� ,�+I'IZ'� Ro�mv,,�9,'
Name on Permit if Different than Above
Mailing Address SG/Yri2:_. City/State/Zip
PROPERTY INFORMATION ' *Date House/Facilit Comeis•Fla'"ed '.' 02-�����' � jlV�/d u,
NOTE: A survey plat or site pl n ust accompany this application: Included.', Site'Plan 0Plat'(to scale)
Owner's Name ; Phone hfiumlier. ''
Owner's Address1^ CityState/Zi`' b Property
Address
Fr b Citya
Lot Size //7 01 CT'L Tax PIN# U-L-A4 S9!2-r74 y 1'0
Subdivision Name(if applicable) Section/Lot
Directions To Site: ��(,�(�� �1` b I/V1 bbl �YY�i l (
u
DEVELOPMENT INFORMATION
Permit Type: New Well ✓ Well Repair Well Abandonment Other(specify)
Facility Type: Residential _.--Food Service -'-- Chur6h Commercial --' `•Othei
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:
I•
The plat or map of the site must include,to scale,showing the locations of:all property boundaries,at least one of which is
referenced to a minimum of two landmarks such as identified roads,intersections,streams or lakes within 500 feet of proposed well
or well system;(B)all existing wells,identified by type of use,within 500 feet of proposed'well or well system;(C)the proposed
well or well system;(D)any test borings within 500 feet of proposed well or well system;and(E)all sources of known or potential
groundwater contamination(such as septic tank systems;pesticide,chemical or fuel storage areas;animal feedlots,as defined by
G.S. 143-215.1 OB(5);landfills or other waste disposal areas)within 500 feet of the proposed well.
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.
C - VVl )b
Applicant's Signature Date
5Ae- 1Ma.dd
Property owner or Owner's legal representative
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
11/7/2016 •7 ��/_
Account#
Invoice#