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327 Kayla TrailN64 r1i CDP DAVIE COUNTY ENVIRONMENTAL HEALTH `. P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 /Fax 9 (336)753-1680 OPERATION PERMIT Account #: 990005711 Tax PIN/EH #: 5833=53-8902 Billed To: Jerod Stanley Subdivision Info: Address: PO Box 57 Location/Address: Kayla Trail -27028 City: .Advance Property Size: 10 Acres - Reference Name: Proposed Facility: Residence **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article. l I of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. System Type: .S.T. Manufacturer Tank Date Tank Size_low, Pump Tank Size System Installed By: f'V'Qyl K (Ya gra L E.H. Specialist: &Date:9 GPS Coordinate: DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005711Tax PIN.%EH #: 5833-53-8902 Billed To: Jerod Stanley Subdivision Info; Reference Narne: LocationiAddress: Kayla Trail -27028 Proposed Facility: Residence Ptope f y ize: 10 Acres rte ype: flew ❑Repair ❑Expansion 1 ATQAbMlaQrThiPAu1horization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms # Bathrooms # People 2 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size )Oac Type of Water Supply: ❑County/City JgWell ❑Community Well System Specifications: Design Wastewater Flow (GPD)j Tank Size �%Q GAL. Pump Tank ,4YGAL. Trench Width ?j(,2L Max. Trench Depth_JtQ� Rock Depth Linear Ft.�/o Site Modifications/Conditions/Other: Rolk Contact the Davie County Environmental Health Section for final inspection of this system between Environmental Health Spy DCHD 11/06 (Revised) Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753,6780 / Fax (336)753-1680 -IMPROVEMENT PERMIT Account #: 990005711 Tax PIN/EH #: 5833-53-8902 Billed To: Jerod Stanley Subdivision Info: Address: PO Box 57 Location/Address: Kayla Trail -27028 City: Advance Property Size: 10 Acres Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. - Permit Type: IA.New ❑Repair ❑Expansion Permit Valid for: j95 Years ❑No Expiration Residential Specifications: # Bedrooms �3 # Bathrooms # People Z Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): , Type of Water Supply: ❑County/City XWell ❑Community Well Site Modifications/Permit Conditions: S stem Type LTAR Initial U6600 2 Repair $eAq�U(c Environmental Health Specialist Lp•11-06 _rA%o Date 1211ZCtt s_ APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street �lu�. Q 7o» 1 n (336)753-6780/ Fax (336)753-1680 a rr 1 of ��l Applica8% tte Evaluation/Improvement Permit ib Authorization To Construct (ATC) ZBoth Type of Application: Aew System ❑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 Name. s-erad C. Zoo rx(2V Contact Person Address ?O 3ox 67 Home Phone 3-1G 988'7001 City/State/ZIPAd�,nM. , h(C 2:7009 Business Phone 33G q9.Z 2-GY5 Name on Permit/ATC if Different than Above Mailing Address , 6, &K 57 r1'cUrV-K1 Y 11NPUK1V1A 11UN • • 'rDate House/Facility Corners Flagged t)re, 2Q, 2Vf NOTE: A survey plat or site plan must accompany this application. Included: PfSite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name _CQnne_ G. QeS- Jr. Phone Number 33C 948 -7038 Owner's Address 286 o,�to- Trroa City/State/ZiptkCJ= tile. , 1� IC, Z.-IOLR Property Address_ PA@9KevI&-Trl. Lot Size Qppox 10 o cces Tax PIN# 5R 3 3 S 3 $QO2 Subdivision Name(if applicable) Section/Lot# Directions To Site: Turn cif N. Hwy gal mto V,An 'Rd. an t/z ni k 4um oA4n d A&a If the answer to ariy of the following questions is ` Yes",supporting documentation must be atta'&ed: Are there any existing wastewater systems on the site? _Yes ZNo Does the site contain jurisdictional wetlands? Yes r _ No Are there any easements or right-of-ways on the site? _Yes ,LNo COLSeKe\{ i 3 (0 �f�- ptaPe,c�Y Is the site subject to approval by another public agency? _Yes /No Will wastewater other than domestic sewage be generated? Yes zNo IF RESIDENCE FILL OUT THE BOX BELOW # People 2 # Bedrooms 3 # Bathrooms —3 Garden Tub/Whirlpool ❑Yes o Basement: ❑Yews vo Basement Plumbing: ❑Yes io IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total'Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: {conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City. Water td New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes QrNo 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 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 I understand that I am sponsible' for the proper identification and labeling of property lines and corners and ?era�,*,flagging ors k g th 12 ho e/faci location, proposed well location and the location of any other amenities. Site Revisit Charge operty owner's or owner's legal representative ignature / Date(s): �= Client Notification Date: Date EHS: Sign given ❑Yes ❑No Revised 11/06 A0 b I3I Account # Invoice # O� GoMaps GIS Pae 1 of 6 NO-% laa�e'- gous-p- and give are, apPmyo r-,oA►orNS_ - req, shed sep{sc ase- 40 0,eeoftldk4t wka{euer s�slerl, �eceSsosy. New propose -ca eorr\ecs 4o CkC.Loo-6dock ►0 acce �cac-�, http://maps. co. davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 6/20/2011 Billed To: Jerc Reference Name: Proposed Facility: Re: Water Supply: Evaluation By: \ FAC DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation INFORMATION 10R--RTY . I Tax PIN/EH #: 5833-�� o ,d Stanley Subdivision Info:. Location/Address: Kayla Trail -27028,,/ idence Property Size: 10 Acres Date Evaluated: On -Site Well Community i Auger Boring_ Pit .S 1 2 Slope % 1, HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON H DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON 0 r 3 1 4 Public Cut 5 .6 2 n 7 ELSMW� i�W';IPi SAPROLITE I I I L 0ki CLASSIFICATION 5 f LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATIO �5 EVALUATION BY: 1kN (� c LONG-TERM AC CEPV NCE RATE: ' 2i OTHER(S) PRESENT. REMARKS: LEGEND Landscape Posi ion R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope V - Convex slope T - Terrace FP - Flood plain H -Head slope Texture S - Sand LS -Loam 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 CONSIST .NCE Moist VFR - Very friable F Z - 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 Structure SC - Single grain M Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy • PR - Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth- In inches Depth of fill - In inches Restrictive horizon - Thic ness and inches from land surface Saprolite - S(suitable), U( nsuitable) 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) T TAR - Inn v_term arrant: %nrp rntP - Oal lri a V lfY7 TI/"IT Tr% n c 1AC m __ _. _ _ JN t A TTT T/, • 1TT vw1 Billed To: Jerc Reference Name: Proposed Facility: Re: Water Supply: Evaluation By: \ FAC DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation INFORMATION 10R--RTY . I Tax PIN/EH #: 5833-�� o ,d Stanley Subdivision Info:. Location/Address: Kayla Trail -27028,,/ idence Property Size: 10 Acres Date Evaluated: On -Site Well Community i Auger Boring_ Pit .S 1 2 Slope % 1, HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON H DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON 0 r 3 1 4 Public Cut 5 .6 2 n 7 ELSMW� i�W';IPi SAPROLITE I I I L 0ki CLASSIFICATION 5 f LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATIO �5 EVALUATION BY: 1kN (� c LONG-TERM AC CEPV NCE RATE: ' 2i OTHER(S) PRESENT. REMARKS: LEGEND Landscape Posi ion R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope V - Convex slope T - Terrace FP - Flood plain H -Head slope Texture S - Sand LS -Loam 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 CONSIST .NCE Moist VFR - Very friable F Z - 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 Structure SC - Single grain M Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy • PR - Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth- In inches Depth of fill - In inches Restrictive horizon - Thic ness and inches from land surface Saprolite - S(suitable), U( nsuitable) 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) T TAR - Inn v_term arrant: %nrp rntP - Oal lri a V lfY7 TI/"IT Tr% n c 1AC m __ _. _ _ JN SAPROLITE I I I L 0ki CLASSIFICATION 5 f LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATIO �5 EVALUATION BY: 1kN (� c LONG-TERM AC CEPV NCE RATE: ' 2i OTHER(S) PRESENT. REMARKS: LEGEND Landscape Posi ion R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope V - Convex slope T - Terrace FP - Flood plain H -Head slope Texture S - Sand LS -Loam 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 CONSIST .NCE Moist VFR - Very friable F Z - 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 Structure SC - Single grain M Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy • PR - Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth- In inches Depth of fill - In inches Restrictive horizon - Thic ness and inches from land surface Saprolite - S(suitable), U( nsuitable) 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) T TAR - Inn v_term arrant: %nrp rntP - Oal lri a V lfY7 TI/"IT Tr% n c 1AC m __ _. _ _ JN ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■ ■■■■■■■■■ ■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■e■■■■■�rr��rr�tr®®®r�ri■I®r�rrr�rrtt■ �■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■I ■■■■■■■■■■i■■■■■■■■■■:=a■■■tt■■IB■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■r,■■■■■■■■■■a■an■■■tt■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■t!■■*le■■■■■�■■e■eli■■■tt■t�i■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ iiiiiM"EMiiir■mmimiiiiiii iiiiON MONSONar■imiiiiiiiiit�rr - Davie County Environmental Health P.O. Box 848/210 Hospital Street ' Mocksville, NC 27028 (336)753-6780/Fax(336)753-1680 WELL PERMIT Account #: 990005711 Tax PIN/EH #: 5833-53-8902 Billed To: Jerod Stanley Subdivision Info: Address: PO Box 57 Location/Address: Kayla Trail -27028 City: Advance Property Size: 10 Acres ATG-* : OOgg Propo coscteeesno�hmployeof the Davie County EH Section shall in no way be taken as a guarantee that this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any fact/ciicumstances upon which this permit was issued. Permit Type: New Dd Repair ❑ Abandonment ❑ W.P. 7-08 °/P/Ji//-Z 194 Proposed Well Location Diagram Certificate of Completion Diagram O � ' NN v. r Comments: 04,p Driller: Certification #:3h Grout Inspected: _` V ( 2(Q 2-5( Well Head Inspected: n a l ao /z GPS Coordinates: ° ° ZiZ W' EHS: Date: 17 EHS: Date: �� W.P. 7-08 °/P/Ji//-Z 194 E,� APPLICATION FOR PRIVATE WELL PERMIT l�j� E G Davie County Environmental Health AA P.O. Box 848/210 Hospital Street P 2 9, 2011 A SU2120"" Mocksville, NC 27028 p (336)753-6780 / Fax (336)753-1680 BY: fUc1 S%�,. BY: l r )k II_ir L ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name Jef O d Sf omleU Contact Person . exock V0111e,Y Address govtn a Home Phone336 8 7001 City/State/ZIP �.�'o 2-70 �jSUJ(�e Business Phone 336 qG2 26YS Name on Permit if Different than Above Mailing Address'City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged DEVELOPMENT INFORMATION 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 signing1his 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. Si ned 7/30/09 9 ZQ Date Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Invoice # ; ,4w .'3'. V Jl� JAI, i ULl no 353 Yl WO, (102.69A) 8902 410 W -V 10.11A 215 0663 4 0 2 203 ,' 464 (113.27A) 8096 Soil Type: MsC `AR Soil Type: ChA Soil Type: MsC Soil 203 Type: 286 KpY�A1R� EnB Soil Type: MrB2 Soil Type: IrB Soil Type: WATER 353 Soil Soil Type: Type: MSC ChA Page 1 of 6 PI20.5e. f CI C.'' - u4use- end I)riUv., Orc, AO-lugsicd 5cp41e, c0c - 40 ascot-tida4e, wkc���uer 5yi1er--L m,Cq.Ssc ^Y. NC�� p�opotc l corhP_c s 40 am e. i'Ca.CA, htt ://ma s.co.davie.nc.us/GoMa s/ma /ma .cfm?CFID=4129&CFTOKEN=61640881 6/20/2011 .RESIDENTIAL WELL CONSTRUCTION RECORD RECEIVED North Carolina Department of Environment and Natural Resources- Division of Water Quality !/f IL. WELL CONTRACTOR CERTIFICATION # 3 63 6 NOV 0 8 2011 1. WELL CONTRACTOR: MG+fAe-W S. .b/'owil Well Contractor (Individual) Name YADKIN WELL COMPANY. INC. Well Contractor Company Name 1908 HAMPTONVILLE ROAD Street Address HAMPTONVILLE NC 27020 City or Town State Zip Code 336 468-4440 Area code Phone number 2. WELL INFORMATION: WELL CONSTRUCTION PERMIT# 50 7�—S 3 — Q0 Z_ OTHER ASSOCIATED PERMIT#(if applicable) SITE WELL ID #(if applicable)_Q/y 3. WELL USE (Check Applicable Box): Residential Water Supply DATE DRILLED )0--16- 11 TIME COMPLETED -1j,'30 AM ❑ PM)�f 4. WELL LOCATION: h CITY:-_. f�f,t dr`lG COUNTY 1�_a Y& -- (Street Name, Numbers' CommunIty, Subdivision, Lot No., Parcel, Zip Code) TOPOGRAPHIC / LAND SETTING: (check appropriate box) Slope ❑ Valley 0 Flat 0 Ridge 0 Other LATITUDE 316 _ °0�"DMS OR DD LONGITUDE k /` _° , e.29.r " DMS OR DO Latitude/longitude source: PGPS Qfopographic map (location of well must be shown on a USGS topo map andattached to this form if not using GPS) 5. WELL OWNER re rd A. __ Si ;, g. WATER ZONES (depth Top_ Bottom Top Bottom Top Bottom Top Bottom ' Top Bottom Top Bottom -In. in. Thickness/ = 7. CASING: Depth Diameter Weight Material : Top P/ Bottom 33 Ft. , ILS" SD2-2I PVC Top Bottom Ft. Top Bottom Ft. 8. GROUT. Depth Material Method Top D Bottom 3 Ft. 9 t- yl;f J /'qv Top 3 Bottom -2 2 Ft. BL.�n��`}a st jet a Top Bottom Ft. Owner Name K S� Street Address ",�4 'k C! XlG City or Town State Zip Code Area code Pffne number 6. WELL DETAILS: a. TOTAL DEPTH: a 9. SCREEN: Depth V Diameter Slot Size Material Top Bottom Ft. in. in. TO Bottom Ft. -In. in. To Bot to Ft. in. In. 10. SANDIGRAVEL PACK: Depth Size Material Top Bottom Ft. Top Bottom Ft. Top Botto Ft. 11. DRILLING LOG Top Bottom Formation Description --�--1 /0 I o• l 9d .So I E G rAl f''ke. 90-/ / 12. REMA S: c b. DOES WELL REPLACE EXISTING WELL? YES 0 NOf 1��� I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN c. WATER LEVEL Below Top of Casing: 0 FT. ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION (Use "+" if Above Tap of Casing) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. d. TOP OF CASING IS + FT. Above Land Surface' 'Top of casing terminated at/or below land surface may require �% �i`� /0 . ZG / a variance in accordance with 15A NCAC 2C.01 18. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE e. YIELD (gpm): 60 METHOD OF TESTIJ f. DISINFECTION: Type HTH ._ Amount.. J CUP s PRINTED NAME OF PERSON CONSTRUCTING THE WELL All 477 + )2Cw Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW -1a 1617 Mail Service Center, Raleigh, NC 27699-161, Phone : (919) 807-6300 Rev. 2/09 Date Site Visited /4/-(CBY=If Permit: Yes� No What Is Height of Well Casing? Make Sure 12" Above Ground Level!!!! Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 /Fax (336)753-1680 WELL PERMIT RECEIVED NOV 0 8 2011 Account #: 990005711 Tax PIN/EH #: 5833-53-8902 Billed To: Jerod Stanley Subdivision Info: Address: PO Box 57 Location/Address: Kayla Trail -27028 City: Advance Property Size: 10 Acres Reference Name: Propol ctions�op he employees of the Davie County EH Section shall in no way be taken as a guarantee. that this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any fact/circumstances upon which this permit was issued. Permit Type: New [• Repair ❑ Abandonment ❑ W.P. 7-08 Proposed Well Location Diagram Certificate of Completion Diagram f' N, r r I Comments: ` ) Driller: 11 k Certification #: Grout Inspected: Well Head Inspected: GPS Coordinates: EHS: Date: EHS: Date: & Z W.P. 7-08