1807 Hwy 801SWell Abandonment Record
_ Davie
210 Hospital Street, P.O. Box 848
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Property Owner: Timothy V. Potts
Address: 1807 NC Hwy 801 South
City: Advance
State2ip: NC 27006
Phone r: (336) 97.1-5133
For Office Use Only
*CDP File Number 122726-1
PIPJ Number: G8-000-00-034
Tax Lot #: Tax Block #:
Evaluated For: NEW �
Applicant: Timothy V. Potts
Address: 1807 NC H%vy 801 South
Cay: Advance
State/Zip: NC 27006
Phone ;ff: (336) 971-5133
Site Address: 1807 NC Hwy 801 South Directions: Hwy 158 turn right on 801 going south, on
left just past Potts Road.
Drilling Contractor Well Location
Latitude:
Driller Registration
Longitude:
Well:
Type:
Nearest Structure:, , , , ,Ft
Fill Material: Material: Method:
Total Depth: , Ft From:, ., ,Ft To , , , Ft
Diameter: , In. From:, , , ,Ft To , , Ft
Static Water. , , Ft From:, , , ,Ft To , Ft
Water Removed: Cement Plug:From:. , , ,Ft To, , Ft
Plumbing Removed:
Well Grouted:
Casing Removed: , , , Ft
;omments:
dig 3 it. down below ground surface and 111. around casing. Fill casing to excavated level and put a tft. concrete cap. you can then fill the
remainder of the hole with dirt to ground surface.
Issued By: 22441-oaywa».Andrew
*Date ofIssue: ,0,8,1,1,4,1,2,0,1 ,3, Authorized State Agent:
0Hand Drawing 0 Import Drawing
Well Abandonment Record
Davie County Health DepartmentCDP File Number: 122726-1
210 Hospital Street
P.O. Box 848
frtocksville NC
Drawing Type Well Abandonment Record
County File Number: G8.000.00-034
27028 Date: 0 8 / 1 4 / 2 0 1 3
Qinch
Scale: QBlock
QNIA
Page 2 of 2
APPLICATION FOR PRIVATE WELL PERMIT
Davie County Environmental Health
P.O. Boz 848/210 Hospital Street
Mocksville, NC :27028
(336)753-6780 t Fax (336)751-8786
*"IMPORTANT*"
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
to be Billed
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Contact Person Su ,Wt -V-
;Address /
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Home Phone 3 S Co - 91
tate/ZIP
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Business Phone
on Permit if Different than
ig Address
PROPERTY INFORMATION
-600-00- 0
*Date House/Facility Corners Flagged C2,, /& 0 4(111
OTE: A survey plat or site plan must accompy this application. Included: Site Plan Plat (to scale)
Owner's Name �". #A a. Phone Number
Owner's Address City/State/Zip
Property Address Ci
of Size Tax PIN#
Subdivision Name(if applicable) Section/Lot#
Directions To Site:
DEVELOPMENT INFORMATION
Permit Type: New Well Well Repair Well Abando ent er (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.
3
Si a Date
Site Revisit Charge
LH
):
Notification Date:
7/30/09 Account #
Invoice #
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