230 Kerr LnDavie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/Fax(336)751-8786
Account #: 990005116
Billed To: Pamela Faircloth
Reference Name:
Proposed Facility: Well
WELL PERMIT
Tax PIN/EH #: 5863-80-3903 Well
Subdivision Info:
Location/Address: 230 Kerr Lane -27006
Property Size: 21.5 acres
ATC Number: 0001
Actions of the 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 chang in any fact/circumstances upon which this permit was issued.
Permit Type: New d Repair ❑ Abandonment ❑ IUQ(v Aly&xp1e- 7 ojlov
Proposed Well Location Diagram Certificate of Completion Diagram
fox
�k O�l
hilt
3
J
1 r
Comments: k -e -eh UceL ``� or,�� / Driller: C ILJ V,&.&, � � ,
/7dV45 Certification#:
T� Grout Inspected:
Well Head Inspected: ,y�� -7 —
GPS Coordinates: 3G P6 4 / f V fir_ )?,6 17. 611
EHS: Date: 7''lQ— EHS: Date:
W.P. 7-08
qq 06b 5/1 � _J�jgjce &&qq
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AN
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llalwa,d kof h��n 336 ;3f -g! 79 1A,, W
LICATION FOR PRIVATE WELL PERMIT;
Davie County Environmental Health �
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
U ti�EN�P� ***IMPORTANT***
Ni
TIFF ANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
1
APPLICANT INFORMATION
Name to be Billed Contact Person
Billing Address Home Phone J
City/State/ZIP.gi�ludv� `%') '(�CD� B�� Phone /D ,2
Name or. Permit if DiT. crest than q10 lqLP
D
Above
P�I::ili.^.b Address Ci ;/Str&Zip
PROPERTY INFORMATION
NOTE: A survey plat or site plan must accompany 1
Owner's Name - f
Owner's Address �p
Property Address - �� , g2,�f/v
Lot Size - - A 1. - Tax PIN#,
Subdivision Name(if applicable)
Directions To Site: 15RU1 4V �-N rJ Dnat
DEVELOPMENT INFORMA ION
*Date House/Facility Corners Flagged
❑ Site Plan ZPlat (to scale)
_ Phone Number :�3 3,o q 5� !�/-�
tate/Zip
• /YL, mi'l ! , f —:5 -)1,
Permit Type: New Welly 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 comers. 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 D to
7/1/08 Account#
Invoice #
p Ivh
ON
A
• a� f - RESt EI'1rT1AL WELL CONSTRUCTION RECORD
North Carolina Department of EnvironmCnt and Natural tepr
3535
WELL CONTRACTOR CER'T'I'F'ICATION N
1. WELL CONTRACTOR;
Wail. ntractor (Indi idual) Name
VCT,/�4,J
Waif Contractor Company Nams
STREET ADDRESS J !ro 1 o 1 lkl', )4(,j,,4 DA~
City or Town State Zip Code
�(qlV
Area code- Phone number
z. WELL INFORMATION:
SITE WELL ID Wif applicablcj
WELL CONSTRUCTION PERMITi _ C)
OTHER ASSOCIATEO PERMIYig(lf applicable)_
3. WELL USE (Check Applicable Box); Residential Water Supp41V
DATE DRILLED1� — Ud
TIME COMPLETED :2 --,3e) AMD
d. WELL LOCATION,.
Depth
,
CITY. j PUAwG� COUNTY 1N4:)tl i E:J
64• WoodIee 1 P1 6 P�t-P-
G-,(J
(Se Vet Name, Nurnpers, Community, Subdivision, Lot No., Pareol. ZiF Code)
TOPOGRAPHIC I LAND SETTING:
'Ta
C 6kys I Valley 0 Fiat CRIdge 0 Other
(r.AecK api�ropfiatc 600
LATITUDE tq_ �
May ta in
LONGITUDE
"3ccodegrees,
miltuttS, seconds cr
in 0 CdCimil format
Lafaudeilongitude source,, 4nQPS o Topographic map
(,,Iocarioa of well muat be ahown on a USGS topo map and
airacbed to thin frim it not using CPS)
Material
S. WELL OWNER
A/W
I
�C.`d
OWNER'S NAME -49 t�'`r'•
/1 ` ^-
STREETADDRESS
4k) I
Ft ' in.
in.
Cily or Tawn Stato
Zip Code
,. ld)_ 7!2,_ t)-3-7.5
in.
Area code - Phone number
6. WELL DETAILS:
a. TOTAL OEPdH• _ .�^
b. DOES WELL REPLACE E?USTINGWELL7 YiSD NOD
c, WATER LEVEL Below Top of Casing: eg� C3 FT.
(Use '*"if AbOVe Yop of Casing)
d. TOP OF CASING IS FT, Above Land Surface"
*Top of casing terminated atior below land surface may require
a,variance In accordance with'lSA NCAC 2C.011 $
a. YIELD I9pm1: _ L_ METHOD OF TESTall—�
1. DISINFECTION: Typev�//[ Amount +✓
q.
WATER ZONES (10111):
From'QTo FromTo
From To From Tom
From To From To
T. CASING: T1lickrk3Ssl
Depth Diameter Weight Material
From„ To„J Ft ! �
From To Ft•
From' To Ft.
a. GROUY:
Depth
Msterial
Method
From_ ToaQ_ Ft.
_A j
From
'Ta
Ft.
From
To
Ft,
0. SCREEN:
• Depth
Diameter Slot Size
Material
From
To,„r-,•,_
ft. in.
in.
From
To
Ft ' in.
in.
From
To
Ft, in.
in.
1o. SANDIGRAVEL PACK: -
Depth Size Materia{
From To . Ft.,,_,,,,,._,_
From Ta Ft.___
From—To— Fl.
11. DRILLING LOG
From �- o Tv1For Q ton C2scription
f
12. REMARKS;
I DoHErt6aY CERTIFY 7HA-1 THIS WELL WAS CONSTRUCTED IN ACCORDANCE; WITH
.15A WCAC 20, WELL CONSTRUCTION STANWDI,. ANO YNAT A CO$'I OF THIS
RECORD BEEN PROVIDED TO THE WELL UWMR.
- AIL A &V!!V- `7- /7
SIG TURF FCER IFIED 1^JELL C TRACTOR DATE
PRINTED NAME OF JERSON CONSTRUCTING THE/?VELI.
Sltbrnit the original to the Divi of Water Quality within 30 days. Attn: Information Mgt., Form GYV•ta
1617 Mail Service Center -Raleigh, NC 27699-1617 Phone No: (919) 733.7015 ext 568. Rev; 3107
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DAVIE COUNTY
WELL CERTIFICATE OF COMPLETION CHECKLIST
Applicant: ® aw.T: C a -4 et, r e,Wl IN
File #: 0G
Site Address: D k r ft f! h
Subdivision: Lot:
-A-ZZ
Permit Type: New Well `� Well Repair Well Abandonment Other
Facility Type: Residential Food Service Church Commercial Other
Initial Inspection
Were Setbacks Maintained? Yes No
What is the Grout Depth? ft.
If No, Explain:
What is the Grout Thickness? in.
What is the Type of Well?
Was a Well Screen Installed?
What is the Casing Type? P kS C'
Type of Drilling Fluids Used:
What is the Casing Depth? 1 ft.
Well Grout Inspection Date: -7
What is the Well Diameter? (e in.
GPS Coordinates: 36 o 1. '�15-rf _Al
What is the Well Depth? --3-1j�— ft.
EHS ID: go o ';X?CQ
ell Head Inspection
Is There an Access Port?
Is There a Vent?
/r/�
Is There a 4" Pad? ,
Is There a Hose Bibb?�
i
What is the Casing H—eight?
Is There any Grout Settlement? _
t
What is the Static Water Level? ft.
What is the Yield? GPM
Is the Well Contractor ID Plate Complete?
Is the Pump Installer ID Plate Complete?
Contractor Name: W -.e- LA�yle-aA ib t v-
Pump Installer Name: A%w.-
Contractor Certification #: /1-3-7
Date Installed: 7 -
Depth of Well:
Depth
Depth of Pump Intake: �7
Casing Depth and Inside Diameter: 1, �-
Pump Horsepower Rating:
Screened Intervals:
Opening for Piping & Wiring >_12":
Packing Intervals (Sand Packed Wells):
Yield in GPM or GPM/ft.-dd:
Static Water Level and Date Measured:
Date Well Completed: 7
Well Head Inspection Date: 2-'�'-O
EHS ID: (r-(
Construction Completed Date: r% - ( o "01?'
Contractor Reports Received Date:
Sample Date:
C
Results Mailed Date:
Certificate of Completion D te- _
Authorized Agent:
North Carolina State Laboratory of Public Health
Department of Health and Human Services
P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611.,8 4T
INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM �e
Name of System: Faircloth, Pam Source of Water:
Address: 230 Kerr Ln Source of Sample:
Advance, NC Zip: 27006
Type of Sample:
County: DAVIE Type of Treatment:
Report To: Davie Co. Health Dept.
ATTN:
Type of Analysis Private
Post Office Box 848
(336) 751-8760
Mocksville, NC 27028-0665
Courier: 09-40-06
Collected By: R NATIONS
Date:
9/29/2008.
Time: 11:22:00 AM
Location of sampling point: Well head
Remarks: Permit # 0001, GPS 36*
01.456N / 80"
27 61W „,
Parameters
° Results
Units
Date Analyzed:
Silver
<0.05
mg/1
9/30/2008
Alkalinity as CaCO3
mg/I
9/30/2008"
Arsenic<0.001.,mg/I
9/30/2008
Barium
`<0.1
mg/I
€ 9/30/2008
Calcium
mg/I "��"�
X9/30/2008
Cadmium
<0.001
= mg
9/30/2008
Chromium
mg_.;9/30%2008
Copper
<0 05
mg11 =
9/30/2008
Fluoride
�<0.20_
9/30/2008
Iron
<0.10
mg/I-
9/30/2008
Hardness as CaCO3 (Ca,Mg)"."'
41,
mg/I _
9/30/2008
Mercury'
<0.0005
mg/I :; "
"9/30/2008
Magnesium
3.7
mg/I ,
9/30/2008
Manganese
<0.03
mg/l:
9/30/2008
Sodium
7
mg/I
9/30/2008
Nitrite as N
<0.10
mg/I
9/30/2008
Nitrate as N
<1.0.
mg/I
9/30/2008
Lead
<0.005
mg/I
9/30/2008
pH
6.6
Std. units,
9/30/2008
Selenium
<0.005
mg/I
9/30/2008
Zinc
<0.05
mg/I
9/30/2008
Date Received: 9/30/2008
Today's Date: 10/23/2008
Report Date: 10/23/2008
Ref: 13586 Login Batch:
Reported By: "Aw�
Sample Number: AB79164
Information and Recommendations for Uses of Private Well Water
For Biological Contaminants Found 'in ,stem:
North Carolina Occupational and Environmental Epidet' iology ;Blrarrch (DEEB)
For Additional Advice and Information call 919-707-5900x'
Namdi; �"VC I. 41
Sample Identification Number: Iq6131fj-�
i -T 10 2008
County
1E. ?MENT ,
Information on Your Private Well Water
Your well water was laboratory tested for biological contaminants (total coliform and fecal coliform bacteria).
Total coliform bacteria are found in soil and fecal coliform bacteria are found in animal and human waste. The
presence of total coliform or fecal coliform bacteria in well water indicates that the well may have structural
deficiencies or that the well was not properly disinfected.
Recommendations for Uses of Your Private Well Water
No coliform bacteria were found in your well water. Therefore, your water could be used for drinking,
cooking, washing dishes, bathing, and showering.
Total coliform and/or fecal coliform bacteria were detected in the resample which indicate that
pathogenic bacteria from human'or animal waste could possibly enter the well. There may be a
problem with the construction of the well, the water source, or operation of the well. The water may
not be safe. If you have been drinking the well water and are pregnant,'nursing, have a child
in the household under 5 years of age, or Immunocompromised (such.as an individual with
AIDS, cancer, hepatitis, dialysis or surgical procedures) inform your physician of the results.
The well needs to be inspected by the local health department or a local well contractor to determine
the problem with the well and to give guidance on how to correct the problem. You should resample
your water after proper well inspection and disinfection to make certain that the problem does not
recur. If the contamination is a recurring problem, you should investigate the feasibility of drilling a
new well or installing a point -of -entry disinfection unit which can use chlorine, ultraviolet light, or
ozone.
L Do not use the water for drinking, cooking, washing dishes, bathing, or showering unless
you boil it for at least one minute.
Other Comments
j
May 2008
North Carolina State Laboratory of Public Health= £
Department of Health and Human Sevices "'14
p
P. O. Box 28407 - 306 N. Wilmington St. - Raleigh, N. C. 27611-8047
e Q T
COLIFORM ANALYSIS - PRIVATE WATER ,SUPPLY
11
Name of Owner or Tenant: Faircloth, Pam Countyr F,f FNIJENT j
Address: 230 Kerr Ln Advance, NC ZIP: 27006
Source: Well Type of Sampling Point: Well head
Collected By: RN Date: 9/29/2008 Time: 11:22 AM
Signed By: Nation, Rob Analysiis7ype: Private
Report To: Davie Co. Health Dept.,,-.-;` y
K_
Total Coliform
Fecal/E. coli
t
Sample No: AB13195 " �; t Date Receroed 9/30/2008 ,0,�Time Received: 9:15:00 AM
.01
Date
Date Reported: 10/1/2008 Today's Date: 10/1/2008
j � anti
Comments: NevVlwell errnit-#,'0001 ° ` i
�� ���I �'�� yrI'•�'����i
nyh
Davie Co. Health Dept.
ATTN: Nation, Rob
Post Office Box 848
Mocksville, NC 27028-0665
Courier 09-40-06