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929 Ollie Harkey Rd � . ' DAVIE COUNTY ENVIRONMENTAL HEALTH . . • P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT �'�ccouE�t #: 990005290 �'�x �'l�€.%�H#: 4893-90-5959 Billet� Tca: Shelly Davis Suk��ivi�;iart 1r��o: R�:fer��r�c� Rtar��e: Lac�7tioni�,dc3r��ss: 011ie Harkey Road-27028 Propaseti Far;ility: Residence P�oper�y Six.�: 4.60 Acres ,�TC NuEnb�r: 4977 **NOTE**The issuance of this Operation Pernut shall indicate the system described on the ATC has been installed in compliance with Article 11 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. �y � �-h� � � � System Type:�� S.T.Manufacturer Tank Date -I 3Tank Size II ��� Pump Tank Size System Installed By:��%��S � �� 3-3- r 1 7 E.H.Specialist: Date: N 3�� o r. a�� w o�o �-t � . S3 � wPo! ` �� , ` � -- , �.' �� � - _ � � �� � � . -� .�``� � � - - - - , � � � ,��. �_ � ��a�rt Ao��� , ,�� , � �b �cb` I u�� � w�(� � � � � - � .-- 3 R��p� b 3, r 3 S o, �� �' � 9 Q 7-�, ��� ���� � � DCHD 11/06(Revised) ' '. ' DAVIE COUNTY ENVIRONMENTAL HEALTH ��� ' P.O.Box 848/210 Hospital Street \�� Mocksville,NC 27028 \� (336)751-8760 Fax#(336)751-8786 � � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION ,�'�cc+���t #: 990005290 '��x ���€.�EH#: 4893-90-5959 Billet�Tc�: Shelly Davis �u����visEor� Ir3ffa: , Refer��r�ce Rla€��e: Locc7tioniaci�ir�:ss: 011ie Harkey Road-27028 ProposQci F��;ifiEy: Residence F'ro�erty Siz�: 4.60 Acres f�TC Nutnb�r: 4977 Site Type: ew ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pernut(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� BasementE3Basement plumbing�� Non-Residenfial Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size �•� �C��5 Type of Water Supply: �County/City ell ❑Community Well System Specifications: Design Wastewater Flow(GPD)�"�� Tank Size l,�d AL.Pump Tank�AL. �� .� L/ �J' � Trench Width 3� Max.Trench Depth.3�G Rock Depth � �- Linear Ft. ! �v Site Modifications/Conditions/Other: A� staiet� in 15A NC�C 18A.1989j5` W �i� � use Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. �!lQ(P � �e�pu�� , 5 , � ��w ��u (� ) `I �� � 3 � � �� �5` '�� �i� .� w�� c a � l�� � � �a� ��� � . � ��.��� � � - I 1___�.� � � w u� � � �ti �7 �.�r% Environmental Health Specialist Date: � � � �/ DCHD 11/06(Revised) , ' Davie County Environmental Health , � P.O.Box 848/210 Hospital Street Mocksville,NC 27028 '--'��. (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT � � . <<�. Account #: 990005290 Tax PIN/EH#: 4893-90-5959 Billed To: Shelly Davis Subdivision Info: Address: 2152 Choplin Rd. Location/Address: 011ie Harkey Road-27028 City: Yadkinville Property Size: 4.60 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. , Pernut Type: ew ❑Repair ❑Expansion Pernut Valid for: Years ❑No Expiration Residential Specifications: #Bedrooms � #Bathrooms � #People � Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Desigx Flow(GPD):_� Type of Water Supply: ❑County/City ❑Well ❑Community Well ��5 sta�ed in 1�r� I�C�C 18�1.196�(� �� Site Modifications/Pernut Conditions: an�..,�p��:� S�t;m�i�y.,l, ���� ��, �� � ^ . S stem T e LTAR V Initial CT P 7�' Re air r ',. � � Site Plan k� � � � e�Da F/��-eq � � �����a � (�U �0 5.� �r� - � � a � � � ,30a °70� � � �. � � , � �� / / � ` r ,� ('�Q o. �c�v,�S�—°-`�J � � � � � � � � � Environmental Health Specialist Date ` � "'�� i.p.l]-06 � •' .' , , ' "�, �^ + ^ ./,..�,A{�-1 � 1 � ,.-:.,`` ��� ION�� SITE EVALUATION/IMPROVEMENT PERMIT & ATC ,,, � 2��9 ` Davie County Environmental Health ,': , . MP.� 2� P.O.Box 848/210 Hospital Street Mocksville,NC 27028 .,,; t,,, `�' �'` G�ySF.�t���"�� (336)751-8760/Fax(336)751-8786 v��p������p�;�� EN p�'�E � / App 'cation For• ite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) [�7/Both Type ication: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed j�Qy`�u �• �.U�S Contact Person SylQ,I�U �GW�S Billing Address 2152 C1-� ���N 1�_ Home Phone�33���-lQ�t3S�3 City/State/ZIP ycxcl�i�Nu i\�e.. NC 2'�OSS Business Phone �33(p)L[�p`�-p'1 S, Name on PernudATC if Different than Above�0.SaV� �JqNCe ��uJN� SI�e��c� N�Cc3`�, �UIS Mailing Address 2152. Cho \i 2d City/State/Zip�qc��i�u��l� 1`� 2-1 OS S PROPERTY INFORMATION *Date House/Facility Corners Flagged 5 21 O NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan C�lat(to scale) (Pernut is valid for 60 months with site plan,no expiration with com lete plat.) Owner's Name"�q�o� �ANCe ��'oWN�Sh2��t�! ��Cd�2 �alU�� Phone Number L331o�q t��-l�3$ Owner's Address 215� �00\�N l�d. City/State/Zip�Ad��tvV�\\2 NC 2�055 Property Address City ��'-�SV t 1\e Lot Size�.lQ� �tC,. Tax PIN# OS� Subdivision Name(if applicable) Section/Lot# Directions To Site: ��_No�C� ��o ; er� C�n�rc.h �d a,cv .�, t� �.ir N � o (�t\�e. �,�c\he� �d . I���eC`�h,t � M��eS acv ��-4- If the answer to any o the follow gm questions s"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes [�1Go Does the site contain jurisdictional wetlands? ❑Yes [9�To Are there any easements or right-of-ways on the site? ❑Yes C►7�10 Is the site subject to approval by another public agency? L�I'es�� Will wastewater other than domestic sewage be generated? ❑Yes C�o IF RESIDENCE FILL OUT THE BOX BELOW #People �' � #Bedrooms �_ #Bathrooms 'L Garden Tub/Whirlpool 6"�es ❑No Basement•. �'Yes ❑No Basement Plumbing: Lti7'Yes ❑No IF NON-RE5IDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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 systemrequested: �onventional C�ccepted �Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water B'�1ew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �'F10 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 pernut(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 deternune compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location,proposed well location and the location of any other amenities. S J11"�`""'� � .`������ Site Revisit Charge Property o er's or owner's legal representative signature Date(s): 5' ^L�.�C+ Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# � V Revised 11/06 Invoice# �� i I. , {� C IH".. Rl k Q (� �'�/2.� � //J M1 .�,� 1 ROY TURNER l�,1 Y T T I I �a. . � ` /�'��' 1�� � Pv � '�f� , .� I(� � � F101I2Y fUNI�C Of �(�(y,�, . � \ / � I � p0 ��r p Nal SlM t .a:f '}� , �,.,� ��y}(f�T �l:frl IY f H . E R'i:"4 l / C`/ ^� �_" �J/ ����/ 1...'1 t R��Lf Hf .�..t�iw:5 f � � I X 5000 ��,. ar n . . , � S ' . EaiIJ L A.'FJ'�tJ O.:FI:RF�+i v t ve M �!fa.n O �� 7H6 DAV FND ACINbKIFCGtC s�� 1 u w-w NI m l,:r . •gE /�S•S�F ,' 7y(;K�L E7.ECUT�CN OF 1HE fONF- Gi w, „��F� �g` 3 � GM�C:(�RT�FH�AIE WRNE:S MY •a^c �w� - F. ... � � tWdU JlID NOTM7��L�THIS rrrt.x[�x��;,xa.�:�.r- c;+ /�o�� �S����a I �Cuf oF'�2�"�/(77. .,:�,ti,a,.�„�iu, \ oN�po 4 � : w�..,,..Ha�.�:,.,.i ny z a tn, 1• / // � � � MY.CONJACSKNI EXP6rES � ���Q��.��..._. , E S �\ /. Og� o' �,S I /� S%S'U Y J�.ivts;,N S 0E 2 ,,.. O 9 P� ` 1P N•9' / O P`• Z •I� � � � P E 9�0 5^, W � �E �• 3 �,• �� N�`hep' . J. P 6�0.1� � O., PC � . �E 5? 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Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION A�ccount #: 990005290 Tax PIN/EH#: 4893-90-5959 Billed To: Shelly Davis Subdivision Info: Reference Name: Location/Address: 011ie Harkey Road-27028 D� Proposed Facility: Residence Property Size: 4.60 Acres Date Evaluated: �i�-�.�� Water Supply: On-Site Well • � Community Public Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH — - � p .. Texture grou C � G Consistence Structure hC Mineralo �' ' HORIZON II DEPTH Texture rou Consistence Structure Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS �- ?S a RESTRICTIVE HORIZON / � SAPROLITE � CLASSIFICATION S LONG-TERM ACCEPTANCE RATE • � �"'- SITE CLASSIFICATION: �� EVALUATION BY: � Gl/dl��'�- LONG-TERM AC�EPTANCE RATE: � • �✓� OTHER(S)PRESENT: REMARKS: LEGEND I.andscaoe Position R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope CC -Concave slope CV-Convex siope T-Teirace FP-Flood plain H -Head slope Texture S -Sand LS -Loamy 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 CON IST,N .E DS4]S� VFR-Very friable FR-Friable FI-Firnn VFT-Very firm EFT-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 . Mineralo�v 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) 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) TTAR _T.nno_term a�rantanrP ratP_ aal/�av/ft7 T�Trr�nc�nc m__.:__�� . . � ,� .� .......�............................�............................. ■�����..a��■����n��==::::■:■��■��■�����i::::==■_�■���■������■����■ :..�����n�����������������■�����■ ■������s���������-.�������������■ ■���������■�������■�■����■■���■�■�■�■�■e����■���■■s��■��.,�■�t���■ ■■■��������■����■����■���■■■�������■■���■�����■■������■■■�������e�■ ■�������■i����������■■��■��■���v■■�■e���■�■���������■■��■��■������■ ■s■■�����i��■�����■���■�o■�■�������■o�������■�������■������■■■��■�� ■��������i������������a����������������■����■���������������������■ 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■��■��■■�����■�������■�■��■����■�■��������■�■����■�■■����t�����■■ ■������■��■��������������������■ ■������������������������������■ ■■������■�■��■�■�■■�■���������■������������■�������������■�������■ ■�■������������■■■���■��■■�■��■����v■■����■■���������■����■�����■■ Davie County, NC Tax Parcel Report Friday, October 7, 201 E 929 WARNING: THIS IS NOT A SURVEY Parcel Information Parcel Number: C10000000205 Township: NCPIN Number: 4893905959 Municipality: Clarksville Account Number: 82530501 Census Tract: 37059-801 Listed Owner 1: BROWN J VANCE Voting Precinct: CLARKSVILLE Mailing Address 1: 929 OLLIE HARKEY RD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: Zip Code: 27028-0000 Voluntary Ag. District: No Legal Description: 4.61 AC OLLIE HARKEY RD LOT 2 Fire Response District: LONE HICKORY Assessed Acreage: 4.54 Elementary School Zone: WILLIAM R DAVIE Deed Date: 2/2009 Middle School Zone: NORTH DAVIE Deed Book / Page: 007820339 Soil Types: PcC2,CeB2 Plat Book: 0005 Flood Zone: Plat Page: 030 Watershed Overlay: DAVIE COUNTY Building Value: 229300.00 Outbuilding & Extra 0.00 Freatures Value: Land Value: 32600.00 Total Market Value: 261900.00 Total Assessed Value: 261900.00 t vt 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 0110- NNC or arising out of the use or Inability to use the GIS data provided by this website. ` Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 WELL PERMIT Account #: 990005290 Billed To: Shelly Davis Reference Name: Proposed Facility: Residential -Well ATC Number: 0034 Tax PIN/EH #: 4893905959 -Well Subdivision Info: Location/Address: 011ie Harkey Road -27028 Property Size: 4.61 Acres 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 change in any fact/circumstances upon which this permit was issued. Permit Type: New U Repair ❑ Abandonment ❑ Proposed Well Location .j �u QQ J�� 2M�• —� l�t�r We. �4 u �,pt^ h . Comments: EHS: W.P. 7-08 rl- Certificate of Completion Diagram Driller: lgat4w Bmwn Certification #: '30$6 Grout Inspected: Well Head Inspected: GPS Coordinates: c� ° . f • .2 %y/�y; • Date: APPLICA r FOR PRIVATE WELL PERMIT i County Environmental Health P. .Boz 848/210 Hospital Street Mocksville, NC 27028 f 751-8760/Fax(336)751-8786 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name to be Billed . i Contact Person SAeNk-7V t S Billing Address 5 jM Ra. Home Phone 33 \ - 3B City/State/ZIP IgdY��N.� �1P_ t�1C 2�OS5 Business Phone (_'53U) 4- 0-01S\ Name on Permit if Different than Above 3NCSo� ` VQN t° wt,,� I ShQA d bgoj i Mailing Address 2(c-,2 Choo\%N City/State/Zi i PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan Eclat (to scale) Owner's Name-TgeeoN \jotvice_ Phone Number (.33(p) C(U - Uq 3B Owner'sAddress215 C1no \iN City/State/Zip'[gdkiNJ►\le, NC 2-1055 Property Address1 City laoc`hSvi\\2 Lot Size . ji � NC Tax IN# , Subdivision Name(if applicable) Section/Lot#� }- Directions To Site: 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 SiteYES ✓ 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. Si ed Date Site Revisit Charge Date(s): Client Notification Date: EHS: 7/1/08 Account # Invoice # ivlap Frame Page 1 of 1 Davie County, NC - GIS/Mapping System Click Here To Start Over Quick Search: (County ID or O�)ner Ni Active Layer. 0 Use rllap Tips M W, p Tips Available}r Addre IREDELL 00155ft http://maps.co.davie.nc.us/GoMaps/map/mapframe. cfm?CFID=35713 &CFTOKEN=84491... 5/27/2009 --4K c 1'KE/ LKi M .,=C:•Eo.v41. nm, C.: I•� U�' J ���••' IROT IURNER._Y.'1`Y T -,f F4VARr,fUELIC O�F�{ •, DEn-. u•Y: N.3 ;lnt.}, .a:a ,:CA •Lr D—C]•y-'i l'rf'. rt/.1 'Y �+',.«�f.«E IN�R' �I-i.•'•,~.a 'l Ww.0 Nw Mose .mi W Ily 28.,.5^+_ °7 9� ) I O+ J[S.Q;j J..:�✓..Ff�Xk�� 8_Ft; Pk •'i ,:5000�� T�.. •. • Er,y. ;My1 R IL! A°PFJ;+EJ DAY AND AC/: NLECGLO .,': • ., F:t.. ,cE n`. n'. �: Is•a :• -•u' .t; TNCi DY :3ER: EXECUTIC'NOF THE FONT- ,,,1,, „I N M::PN]1•L, Ipl,np .. cHn Eao.: (:E211FY:AT'E WRt+E%S MY LOCATION MAP E(AJK) A DNOT`A�I/EIy�,'L TNR 1'KE/ LKi M .,=C:•Eo.v41. nm, C.: _ 494.0• - \ OF .�77 ♦, :,UnE,Mfd. .4 _ _ _ _ FARM_ ROAD _ - -_ _ _ _ _I _ - _ - - - - _ _ _ - _ _ _ f 'r N,Y COM/ng+L<NL fXP1R0l ' Ww.0 Nw Mose .mi W Ily 28.,.5^+_ °7 9� ) I O+ J[S.Q;j J..:�✓..Ff�Xk�� f S \ L LINDSAY 6 STEVE GUNTER BK. 100 P19O � I LOCATION MAP J C P 7P a � •a t3 ,•' �N♦ 5g0 1W 6� 0. 5f O �•9 1 YPJE N•a100 /,3i• L Sit. 1]l At -3 t• •ho ' app pI^ o 'cNWE reams 2 S v o o NSA 3SEa q,� / s• Ot > � W At't� O' �• O P I EvO o i�� Gy ,ra• L s .S• �C s f p•3 P ��' L/ C` o P o I • 9,� i I o• g: I' I I 130.0-----_ _ 494.0• - 2]6,5+ 248,x- ------ _ _ _ _ FARM_ ROAD _ - -_ _ _ _ _I _ - _ - - - - _ _ _ - _ _ _ -_� --2319-34= o X57 -5_15'W _ KENNETH LEE FOSTER PK.83 P.537 BK.76 PAGES 51, 6 5,2 L LINDSAY 6 STEVE GUNTER BK. 100 P19O I LOCATION MAP TA 0KIN COUNTY MELVER W. REAVIS EST, a--s�---- ' - •::--; :.�a x.- •- - 34.70 ACRES CLA RKSVILLE 7W P, DAV IE COUN7Y•N•C. SEE: BK.28 P.519 _- m13 'op OAvI E CO, n A 'e—A. 6 CAP F ROAD (NOTE: IRONS SET ON RIW WHERE LOT CORNERS 1N i RD.) ? 1 ��J I' •"..1 O—EW IRON PIN •_ EX, 57,NG STONE �P P 3p O c z -., ]G_:•; 30. -i :: ,<%.Pis SURVEY BY ' ;...OF{. .?n1�,/: ,.K. I -•s DAVIE SURVEYS MOCKCKjSVILLE N.C. PHONE: 634-31913 _....-• -. .,i .. �� ef RLS O 50, ,00• 200' OA TE: 6-28.1977 SCA LE: 1••100• G-��I aD � O c Im ! o o• m �`►r RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # 3031n 1. WELL CONTRACTOR: .pa-�14I.W Lr &OL 1 Well Contractor (individual) Name YADKIN WELL COMPANY, INC. Well Contractor Company Name STREET ADDRESS _1908 HAMPTONVILLE ROAD HAMPTONVILLE NC 27020 City or Town State Zip Code 3� 36 )-468-4440 Area code- Phone number 2. WELL INFORMATION: SITE WELL ID #(if applicable) A,4 J — WELL CONSTRUCTION PERM IT#-q�g3`10S-f I'll - U.eII OTHER ASSOCIATED PERMIT#(d applicable) 3. WELL USE (Check Applicable Box): Residential Water Suppl� DATE DRILLED—4 — 23 - 09 TIME COMPLETED 3 i r1O AMU PMX 4. WELL LOCATION: �� JJ CITY: .f&Lh )L, / l �e//- // COUNTY u e (Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) TOPOGRAPHIC / LAND SETTING: U Slope a Valley U Flat Ridge U Other (check appropriate box) May be in degrees, LATITUDE 3 --C (0 1, z-7 1 minutes, seconds or LONGITUDE _L 0 ' 1.SIrS in a decimal format Latitude/longitude source: liC'P o Topographic map (location of wetl must be shown on a USGS topo map and attached to this form if not using GPS) 5. WELL OWNER j OWNER'S NAME VuicC. 61''JCuv. S 9I61"I STREET ADDRESS 26 VY e—," 14,c_k)H;, [U K.fhij,C"N C 2,uSJ- City or Town State Zip Code t ) 3.16_ qc4- (is -or Area code - Phone number 6. WELL DETAILS: a. TOTAL DEPTH: b. DOES WELL REPLACE EXISTING WELL? YESU NO)< c. WATER LEVEL Below Top of Casing: SU FT. (Use "+" if Above Top of Casing) d. TOP OF CASING IS I FT, Above Land Surface - 'Top of casing terminated atfor below land surface may require a variance in accordance with 15A NCAC 2C.01 18. e. YIELD (gpm): /0 METHOD OF TEST AIR PUMP f. DISINFECTION: Type HTH Amount g. WATER ZONES (depth): From 19 S To 9 G From To From To From To From To From To 7. CASING: Thickness/ Depth Diameter Weight Material From {- I To 136 Ft.b, Q�� 0, f&'-* From To Ft. From To Ft. 8. GROUT: Depth Material Method From G Too Ft. 4 From To Ft. From To Ft. 9. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. From To Ft. In. In. From To Ft. in. in. 10. SAND/GRAVEL PACK: Depth Size Material From To Fl. From To Ft. From To Ft. 11. DRILLING LOG From To Formation Description O --i Ste. / 4CA / —UL)' 1',h nil SIZE OFF: BIT SERIAL NO: '777 ff 12. REMARK - ^ ,Alto a W I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN FROM ED TO THE WELL OWNER <r J . rx-� 6 - z.f -o y SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit theor gin I -t (the Division of Water Quality within 30 days. Attn: Information Mgt., 1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. (919) 733-7015 ext 568. DATE SITE VISITED C,217-oq BY:12 9 VERMIT � NO Form GW -1a Rev. 3107 Paw-- 336- y /-'37G0 S (�- 12 qov WHAT IS HEIGHT OF WELL CASING? MAKE SURE 12" ABOVE GRID. LEVEL