232 Odell Myers Rd3avie Countv, NC Tax Parcel Report Fridav, October 7, 201 E
WARNING: "PHIS IS NUT A SURVEY
Parcel Information R
Parcel Number: H90000004205 Township: Shady Grove
NCPIN Number:
5789548471
Municipality:
Account Number:
82518343
Census Tract:
37059-804
Listed Owner 1:
DIGIOVANNI FRANCIS J
Voting Precinct:
EAST SHADY GROVE
Mailing Address 1:
232 ODELL MYERS ROAD
Planning Jurisdiction:
Davie County
City:
ADVANCE
Zoning Class: DAVIE COUNTY R -A
State:
NC
Zoning Overlay:
Zip Code:
27006-7435
Voluntary Ag. District:
No
Legal Description:
1.000 AC ODELL MYERS RD
Fire Response District:
ADVANCE
Assessed Acreage:
1.02
Elementary School Zone:
SHADY GROVE
Deed Date:
1/2005
Middle School Zone:
WILLIAM ELLIS
Deed Book / Page:
005890804
Soil Types:
Pc132
Plat Book:
Flood Zone:
Plat Page:
Watershed Overlay:
DAVIE COUNTY
Building Value:
83100.00
Outbuilding & Extra
Freatures Value:
0.00
Land Value:
19550.00
Total Market Value:
102650.00
Total Assessed Value:
102650.00
9 tt� 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
�ofJry c� NC or arising out of the use or inability to use the GIS data provided by this website.
WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
WellContractor Name (or well owner personally abandoning well on hiss Ur property)
/
�l/"1o' C
NC Well Contractor Certification Number
fin )12 Dom /'C"
Compar} ame
2. Well Construction Permit #:
llu all applicable well permits (Le. Cuunp. Siote. Variance, lnjeuiam eic) ifb-own
3. Well use (check well use):
❑Agricultural
OGeothermal (Heating/Cooling Supply)
❑ 1ndustrial/Commercial
Non -Water Supply
Mquifer Recharge
OAquifer Storage and Recovery
0Aquifer Test
OFxperimental Technology
❑Geothermal (Closed Loop)
�Mun paliPubtic
[9Residential Water Supply (single)
OResidential Water Supply (shared)
OGroundwater Remediation
OSalinity Barrier
OStormwater Dminage
OSubsidence Control
McBee!`
OOther (explain under
4. Date well(s) abandoned: I ;i Ll I q
Sa. Well location:
L.L.
Foriraemal Use ONLY: RECEIVED
WELL MANDONMENT DETAILS JAS'
7a. Number of wells being abandoned: V
For multiple tnjecdon ar non -grater sapp/}n t QJYLY .tvithudie same
cmtstuclionlabandaimentynncmisubmitonefomi. lJ gffA LTH
7b. Approximate volume of water remaining in well(s):_ _(gal.)
FOR WATER SUPPLY WELLS ONLY- f r
7c. Type of disinfectant used: qua. we
7d. Amount of disinfectant used: (Ocz,
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
O BentoniteChipsorPellets
• Sand Cement Grout
❑ Dry Clay
0a crete Grout
0 Drill Cuttings
• Specialty Grout
O Gravel
❑ Bentonite Slurry
B'6 a (explain under 7g)
7E For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
i W e
aL cP— 0
t
Co a 'yp , 11-; c eft SVf-��cDr . ,tlndln f
�a.+rr'nrTTe C�o� y� rr1#Q"l1 C�1;1�' 1 �JC Vou�rr�� W`CIOv�
Facility/Ow=Name Facility ID4 (ifapplicable) $• Cern tion:
23a. octet Nlu-f(-s UAk',ee. AjC
Physical Address, City, and Tip Pat - of Certified Well Contractor or Well Owner
tiVCL By signing this forn, I hereby cert that the wells) was (were) abandoned in
County Parcel Idcatifiation No. (PIN) accordance with ISA NCAC 02C.0100 or 20.0200 Well Construction Standards
and t/rata copy ofthis record 1w beenprovided io the well otrner.
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field, me
eeld,me t�a7t/long is sufficient)
N 093F h3'ty'of5-3- W
CONSTRUCTION DETAIL.,& O�WELL(SLBEINC ARAN—D0N-E0
Attach well construction necaW(s) Jaratlable. For multiple ti jectlon or nor --anter supply
writs ONLYudth tine same construction ithur dolmen, you con submit oneform
6a. Wen WN:
6b. Total well depth: 144) (ft)
6c. Borehole diameter. �q (in.)
6d. Water level below ground surface: go (ft)
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandortmetrt details You may also attach additional pages if necessary.
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division ofWater Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617 .
10b. For Lnleetion Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
6e. Outer casing length (if known): Q (ft) 10c. For Water Suonly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
'
6E Inner casing/tubing length (if known): q 5 (ft) - niters abandoned.
6g' Screen length (if known): (ft)
Form GW -30 Nath Carolina Department of Environment and Natural Resources — Division of Watcr Resources Raised August 2013