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429 Rainbow Rd (2) � �., ._ ��' . . � . � � Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 WELL PERMIT Account #: 990005269 Tax PIN/EH#: 5851-79-7020-Well Billed To: Kai Ehnes Subdivision Info: Reference Name: Location/Address: 429 Rainbow Road-27006 Proposed Facility: Residence-Well Property Size: 4.754 Acres ATC Number: 0030 . 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 T e: New� Repair Abandonment ❑ �,,,��oy �v� roposed Well Locah 'agra rti ic of Compl on],�lagra ,, v� � ,<>�f � � ..�� y�,� � � ` . � �--. �a �,I �- � /�.; , 1 �� '.,, '� v�.,ti V (� -�,�✓ � =` - L . , �-� � � �� r� � cP,� � � � � �✓ � s� � - � , ' I� \ �� "� l (� , v � �� d � Q��` �1. / � � Q1 � i 1 � / ,� � / � �' / J� / �,," "::i� `J�� •G� / �C 1 ../ / 1 � 1 v �omments: – Driller: p_t �,'/ �� Certification#: �$�G] 7�—' �/5 Grout Inspected: �' �0�,�/!J/v Well Head Inspected: � !o� ,Z —Q� GPS Coo in es!� 3�� p y�o�o w � .1`1�•77 EHS: Date:� ' � EHS: /�� Date:�,�— � !�IIQ r��Ll�"1� 6/Zz`o� W.P.7-08 r, �.' r Q� ATION FOR PRIVATE WELL PERMIT � � � avie County Environmental Health P.O.Box 848/210 Hospital Street � � �0�9 Mocksville,NC 27028 � �p� 336)751-8760/Fax(33�751-8786 � � �C�4�U�1 ***IMPORTANTk** T S AP (�SAW�. OT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name to be Billed K,9-i � �hes Contact Person k,�-, � �, heS BillingAddress ��q R.r;H bow �Qd Home Phone �36 9yp 3�60 City/State/ZIP� �/u,t.„�.�_ iJjl a 7 Q O�' Business Phone Name on Permit ifDifferent than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ite Plan Plat(to scale) Owner's Name ��'� rr es Phone Numbec 3�� 9 y0 33�0 Owner's Address y�q �t.t�-.•,,,bo w (,Q �/ City/State/Zip,¢��,�.,,�.� i(/C 700!' Property Address 4�q �2,�-;h 6 0„✓ 2� City_��,*..,�� Lot Size y. 7.��{.4 c rcr Tax PIN# 5�.�17q7 O�-o Subdivision Name(if applicable) Section/Lot# Directions To Site: I S8 —�-,► 02.�;„ 6e w �✓ 3/y r+:/� �r..re�,[... �y Lz-,�'f- 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 Cunently 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 cati a well. �-� �-a9 Signed Date • _ Site Revisit Charge _ Date(s): Client Notification Date: _ EHS: 7/1/08 Account# �o ��QI Invoice# �� ■.�■�■■�■�■�� ' � �� - �' ' �1 � �� .� �. l � �� r � �5�� ■■ . �.� ' r � �� t � � � �� / ��► � 1�#�� ■ �[ v�A� �� L,.� � ► � . . � _ v ; �..�� l �� L.��' ► ■`� 1� � �1 � �'� 1. �� / / � ` � ■ , v � ' �► 1 ■ �►"..,�� 11� � � �v ��' ��v��l� , �� w��i ■ � �� v� �w ■ ��..i r� ��■u ��/i;�� v . ■ r �� ■ ■ ,� �� . ■ �� ■�� 1�■�s�w ��- . � ,� ' �� ■ � , �� ■ �� .�� s�ainr��o��o��■n�� oins��s�� ■nn■��■��n . �n��n��s�r�� m ��os�nin�s■��■s� ��n��m�� ■�■�e�■�n�e�n��■�ae�� m��s s�e�.r�n ■ni■�r�ein��in�n��■n��■� ��■��m�� n�s��■ � m��e��e�� Q � ��r� �� _ �r� .� �■�a�� v��n ■��■�� ■�� s�� in��a��n �in�n�� .�r� �sin�ne�� o��r�� m��m�n�.��r�� s��oo�s�o�� ■��s��o�� ain��in��e��e� �s��in��v�� r�� s��s��r�� s��s��o�ins� o��s��r�� m�� n��r�� s��m�na�� ■��e��en��o��o�� s��e��n� �n��■�n��in�in■r�� ■��in��r�� m��m ��in��ninm��ren�� m�m�� n�n�� e��o�� o��o�� n� Reports http://maps.co.davie.nc.us/GoMaps/reports/report.cfin?CFID=54099... � • ' Davie County, NC Tax Parcel Report i � 0 � 0 m z i— ` ` — a ' � a \ _ � _ � — � \ � � � _ _ _ — � _ I — I _ _ J S611 � � ��vniirvuac mi5 �5 Noi n suttve�� Monday, 4/27/2009 Parcel Number: D60000001807 '.ivs map rs prepared for the invento!y ��,i PIN Number. 5851797020 -cal property found wdhin[hs Jurisdien,•n. pP��F � -�r,tl is wmplled from recorded deeds, p�at�. A«oun[Number: 000082529182 -.nd o[her publk records and data. Uscrs ot � Lis[ed Owner#L EHNES KAI T thls map are hereby notified tha[[he p q� Listed Owner#L EHNES TIFFANY A -;foremen[ioned public Onmary infortna[an �� N Mailing Address 1: 429 RAINBOW ROAD �r urces should be consuhed for verification Mailing Address Z �,f the informatbn coniained on[h5 map. C'Ty: ADVANCE � -'iz County and mapping company assume 5[ate: NC ��o �e9al responsibi�ity fnrMe infirmatlon ��,..��.. �. ;�,nthismap. ZipCode: 27006 Legal Destnption: 4.754 AC RAINBOW RD Acreage: 4J5400000 Deed Da[e: 020080131 Deed Bookand Page: 007440787 Plat Book: Plat Page: Building Value: 165680 Outbuilding and Ext2 Features Zq340 Value: Land Value: 57490 Total Market Value: 247510 TotalAssessed Value: 247510 I ul I 4.�27;7009 7:-12 PM ,'. . .• • � . , DAVIE COUNTY � � WELL CERTIFICATE OF COMPLETION CHECKLIST Applicant: ��r I- (�v�.e S File #: _�-3 6- Site Address: �� I�„1 Subdivision: Lot: . 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? oZ �o ft. If No, Explain: What is the Grout Thickness? �. in. What is the Type of Well? ' �� Was a Well Screen Installed? 7� What is the Casing Type? ��i Type of Drilling Fluids Used: �1�!-c�`E-c.o'' What is the Casing Depth?�ft. Well Grout Inspection Date: �t -� -d� , o What is the Well Diameter'? � in.. . • GPS Coordinates: e � � / What is the Well Depth? �� J ft. EHS ID:� Well Head Inspection Is There an Access Port? Is There a Vent? ✓ Is There a 4" Pad? Is There a Hose Bibb? ✓ What is the Casing Height? Is There any Grout Settlement? �C� 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: ___,�c� c � c� � F( � Pump Installer Name: v5 Contractor Certification #: � O3 �f Date Installed: � - � Depth of Well: �"� � Depth of Pump Intake: � � 5 � �� Casing Depth and Inside Diameter: �� x � � Pump Horsepower Rating: �. Screened Intervals: fV/ 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: i � -� � Well Head Inspection Date: ��..�� EHS ID: 'Z ( L(C� � Construction Completed Date: � � � --�`� Contractor Reports Received Date: G �� Sample Date: � �� l Results Mailed Date: Certificate of Completion Date: � � ��'-�� Authorized Agenfi �L, �v� r/l��1 Jun 04 09 08:52p DANA CLAYTON 276-957-1705 p.2 y.- • .. ��}' . ' . '.`y,y�A4'� �� ,' ` �'� =��fr'' 3�Z�` ` � w� ;� S� RESIDE�ti'TYAL �'YELL CONSTRUC7'IUr!t£COItU t�j � �:�, . _ .. �, I ; � ��'�.yil,�� +✓► � �4�':.J•' r � tiunh Carofma Dcp�rtmcm ui L'n.irunmccu a�,c P+atucai tccsuvr�-cr U:.-isron��t•a�rc t�uab:; ��`�•�• WELL CONITRACTOR CEi2TlFICATIQI�`n_��q li I 1.WEtI CONTRAC7 R: L DtSINFECTION:Typc Amount_ 8�_ : _].G�J �IWO-�1 q. WATERZON£Sloeptri I � �Yell"ml�ac�a (Ina�vidu�l N e F�om_� To�!> =rar•-_•-•----•.To •--•-•--- � . ��_`J�)LL� ��(�i From Tc r�5n= IL•� . 'rYeA GontraCtCt Comp3nrNamr From Tu =ipm 1 c ' � STREE'. :+DDR=SS� 7 I`�/�.i t],�,_ 6. CASING: Trrckness ! ; Oeptn /[y ametei 'Ne /6/�,�ena� I : ��— "X� �I� From p�To�F1.3e_._�� J�LCe.._ : ; ' Ci,;u Towr. Spce Zip Code Fwm To Fc �--^ j � � � From To Ft. � ( Area co0e-,Pha�e nu�*+br• , . (1 ' ;. GROUT: Oepin naaiena� Memoo i � 7.WEI�INFORMATIOk: ��.� �,, Frpn� To,�F1.1�!` ��j(�. � � SfTE wELt�O s(i�app�cawe: F�orn Tc FI ---• I � •, ST:�TE 1PlE:.I P£RMtli{aaopucawsl �� To Ft - : ; 1 ( ' ' DWQ o:OTHER PERMIT�t(if aDDu��1 B. SCREEN; :.ep:r. Gamete� 51�5�.e M�enal � i / = � WELLUSE;Cneck.4ppbcawe8wcj. RaiCem�WalerSu�lyC F`� TJ `� �^ a' -_� _ � � � I i Q rrom To F� _in w: I � DATE DRILLEO.�'Z"��1 Fiom To Ft. m iw � I TIMECOMPLETED�'�3b .UAC� PM� � , 9. SANDlG(tAVEL PACK: i � dep�n S¢e n�a�en� � 3.WELL LOCA71pN: �� rom To Ft. i ;ITY COUNTY i p� To �t. ' s QZ'01 ��.►�Cr..) �7�_ I -- -- � , F:om To FI. � � ;Svker Namt.I.'umosrs.Gonrnuniry.SuDahswrt l.c[Na.•P+rc�1-LC Gooe) i TDPOCR.�PHIC/IA�D SE7TING: t0.ORILUNG LOG . � � ,s� 3vaney C �� OR;dge ❑Other From Ta Formatwn pescrip�ion ; � �cneU app�op�iau ooa� ! May bc in Je;rees. � : ( :r.T:TUDE � _ miwtes.saomuo� � in a Cecimal iomu� � 1 �ONGITUDE� � � � s. � � . � i.:�u�udttlongiwdc sc�urcr: pGYS CTopographic map l ��_ I � (boatiort o/we1 musl ne shown ort a USGS fopo map and � a[tac�ed Ia 1tis for.n/no(using GPS) ! � e� „ �(.��.�,i�y : (� 4.WELI OVYNEA Q� ,�q � t OWI:ER'S Nd+ME L.+Q7 #y�j�,, ,� � _. _ �_ �- i } ST►�EETADgRES� '�I�I !G+/�1,r.2�/J � , c �-r',�X,(r.sv,u� e�iG 2'?�c ' i � i �iry vr Town Stale Zip Cooe ' . �. --�..-_�.�.�_ I :uea caoe- Pnone numor � ' ': 3 1 11. !t£h1 aftKS: ' ; s.w�.�oeTaiLs: j I i ------ --�-----_.--•------ --•- � I a. TOTAL DEPTli: �� ; I b. DOES W£L�REPIACE EXISTING WELL? YES p NO G� � . j I IC� ' ERT,G7 T T►fl$ Ll W�SCCMSINJCT`J�-%�CCOitli:.nCE.'�YTr. c. WA?ER k.�VEL 8etow ToR d Casmg: �� FT. i �C x ✓Eu c srauCr siu outps �t:u;a co�.a'iti�s � iUse'•'�Aaave Tep ol Casmg) coao seEN v �t rHe�E�:a�«e n ; I � � woove lana Su:�ace' �� ! O. TOP OF CAS�NG 7S 6�_� ' � -Top ot casyg��*+�a�eo auor eelow IanC surtace may reCcr.�e SIGN:.T R£�F ER71F� LL CONTi� pR pnTE • � a vanance�n atcaoanCe with i511 NCAC 2C.017 8. . ` e. Y1ElO;gpm} .L�.SiETY.^..D OF TESTK� i �� PRENTEO NA6AE RSON CONSTRUCTING iHE VJ=_ L i • Submit the origina!to tt►e Division of Water Qua(ity within 30 days. Attn: information ufgt., �a,R,�,n.;; 1R�7 J MsI�CYN�I`P Cnnter-Raleioh.NG 27699-7617 �Ylpf)C IVO.1717j io,i-iti7�exi�oi. U,,,. :,n:. •t � ` . �. ��5rn7F4� �.�.'�� ph�o.a,�3ox 2 047 � - � � y North Carolina State Laborat Pul�lic��l��h 30 :` \ �� 6 N.Wil ington St. Raleigh,N 27611-8047 � ; -�� y Environmental Scie ces J U L 1 � 2 0 0 9 htt ://sl h. ate.nc.us �� ""��"" � IVIICI"OE710I0 Phone: 91 -733-7834 ��,µ,,,o� gy Fax: 91 -733-8695 Certificate of Analy is DAVIE COUNTY HEALiH DEPARTMtiVT Report To: Name of System: DAVIE CO ENVIRONMENTAL HEALTH Kai Ehnes P O BOX 848 429 Rainbow Rd MOCKSVILLE, NC 27028 MOCKSVILLE, NC 27028 StarLiMS Sampie ID: ES062309-0005001 Collected: 06/22/2009 10:50 Robert Nations I�IIIII��I�III�IIIIIIIIIII�I�IuIIIIIIIIIIQUI�uIIu�IIII�IIIIIIIIII�IIIII�IIIII�I�III Received: 06%23/2009 08:44 Angela Heybroek ES Microbiology ID: 6255 Sample Source: New Well Well Permit Number: GPS Number: N35°59.466 Sampling Point: Well 0030 W80°29.771 Sample Description: Comment � Environmental Microbiology-Colilert Profile Method: SM 92236 Test Name: Colilert _ Analyte Test Result. Analyst Date Total Coliform, Colilert Present Darneice l.yons O6/25i2009 E.coli,Colilert Present ` ' Dameice Lyons 06/25/2009 r.w�.._.,._._:..::__ ` . _... ,_ a,, ____"__.__------� ; '*� �' `'� z +x^�� _. I' �r `� � g � � � ��` � �� y . . .; � v�.i��.7�• 9 � 4 Report Date 06/26/2009 Repo ed y:_ y . _ . - _ :�� , . � �� 2009 ' �- :�,��,�;�,.}+:,, ;�; Q t ` .' :.�"I . � Etl�!t�::�::�e,~�fa1 �__��-`�i_.�i:�.`,,',:1�' t�f��i?a'�,,i'j Page 1 of 1