188 Ashley Brook Ln Lot 8 (2):)a
M
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
9 " 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
�oUN�4 NC or arising out of the use or inability to use the GIS data provided by this website.
_ WARNING: THIS IS NOT A SURVEY
Parcel
Information
Parcel Number:
H304OA0013
Township:
Mocksville
NCPIN Number:
5729665406
Municipality:
Account Number:
78858000
Census Tract:
37059-806
Listed Owner 1:
WHITLOCK JANE B
Voting Precinct: NORTH MOCKSVILLE COUNTY
Mailing Address 1:
202 ASHLEY BROOK LANE
Planning Jurisdiction:
MOCKSVILLE
City: MOCKSVILLE
Zoning Class: MOCKSVILLE GR,OSR
State:
NC
Zoning Overlay:
Zip Code:
270284101
Voluntary Ag. District:
No
Legal Description:
LOT 8 RICHARDSON ESTATE
Fire Response District:
MOCKSVILLE
Assessed Acreage:
0.56
Elementary School Zone:
WILLIAM R DAVIE
Deed Date:
9/2003
Middle School Zone:
NORTH DAVIE
Deed Book / Page:
005110847
Soil Types:
ApB,PcC2,CeB2
Plat Book:
0004
Flood Zone:
Plat Page:
031
Watershed Overlay:
MOCKSVILLE
Building Value:
156240.00
Outbuilding & Extra
0.00
Freatures Value:
Land Value:
16500.00
Total Market Value:
172740.00
Total Assessed Value:
172740.00
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
9 " 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
�oUN�4 NC or arising out of the use or inability to use the GIS data provided by this website.
A
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax(336)753-1680
WELL PERMIT
Account #: 990004483
Billed To: Jane Whitlock
Reference Name:
Proposed Facility: Residential -Well
Tax.PIN,EH #: 5729 -66 -5406 -Well
Subdivision lnfo;, Richardson Estates Lot #7> �
LocationiAddress: Ashley Brook Lane -27028
Ptoporty Size: , « see map
ATC Number: 0082
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 Repair ❑ Abandonment ❑
Proposed Well Location Diagram
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ommen s:
EHS: ate:1�
W.P. 7-08
Certificate of Completion Diagram
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Driller: �(Aa v.n V fa
Certification #:
Grout Inspected: 7—
Well Head Inspected:... •:
GPS Coordinates:
EHS:
Date:
APPLICATION FOR PRIVATE WELL PERMIT
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax (336)753-1680
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
./
Name .J f e Contact Person W
Address L / /U Home Phone 3 3�
City/State/ZIP Business Phone i
Name on Permit if Different 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.
Owner's Name
Owner's Address
Property Address %ZPRsI
Lot Size Tax PPD10
Subdivision Name(if applicable) / /v S
Directions To Site: hoeW A614
Included: ❑ Site Plan ❑Plat (to scale)
Phone Number
—City/State/Zip
—City
DEVELOPMENT INFO ON
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 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.
*A1
Signed
Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
7/30/09 Account # _
Invoice #
GoMAPS - Davie County NC Public Access
A ,
Davie County, NC - GIS/Mapping System
> > ! "It
Click Here To Start Over
Active Layer. RUseMap Tips
PARCELS (Map Tips Available) j
M30000009201
4.000 AC BRANTLEY FARM
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http://maps.co.davie.nc.us/gomaps/map/Index.cfm 7/l/2011
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RESIDENTIAL \YELL CONSTRUCTION RECORD
North Carolina Department of Envirorunent and Natural Resources- Division of Nater Quality
NULL CONTRACTOR CERTIFICATION # 3034A r�rl"LS
1. WELCO TRACTOR: 0
Alk 7), or') 01
Well Contractor (Individual) Name
YADKIN WELL COMPANY. INC.
Well Contractor Company Name
1908 HAMPTONVILLE ROAD
Street Address
HAMPTONVILLE NO 27020
City or Town State Zip Code
( 336) 468-4440
Area code Phone number
2. WELL INFORMATION: O 0Y2
WELL CONSTRUCTION PERMIT# T72 rj - 66, - VG [. GJ el
OTHER ASSOCIATED PERM IT#(f - pliccaajbllee)�
SITE WELL ID #(if applicable) /`l f -f n 24/
3. WELL USE (Check Applicable Box): Residential Water Supply($'
DATE DRILLED 7-22-11
TIME COMPLETED y, 3,7 APA ❑ PM t
4. WELL LOCATION:
CITY: 6,1t.F 1/' I:A COUNTY
//��412' ,
(Street Name, Numbers, Commune , Subdivision, Lot No, Parcel, Zip Code)
TOPOGRAPHIC f LAND SETTING: (check appropriate box)
lope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE S °_rJ�" DMS OR DD
LONGITUDE 9-6 ° 35,793 "DMS OR DD
Latiludellongitude source: ;WS C]Topographic map
(location of well must be sroot,vn on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Or Name
Street Address
City or Town Stale Zip Code
Area code Phone -number
6. WELL DETAILS:
a. TOTAL DEPTH: 3 2A
9. WATER ZONES (depth):.-� 5`�
Top S Bottom (, Top Bottom
Top i Bottoml (� Top Bottom
Top c* S—� Botlom c21/6- � Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top Bottom 1" Ft. K42Y SA[ -9I NG
Top Bottom Ft. 6, Zs" 046" (,n flv Me:
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom__,(— Ft. G�I'r &pave
Top G Bottom Ft. R:�, �c•lk S%u,�I 4u z
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top . Bottom Ft. in. in
Top Bottom � Ft. in in.
Top Botlom FI in in.
10. SANDIGRAVEL PACK:
Depth Size
Top Bottom Fl.
Top Bottom Ft.
Top Bottom Ft.
Material
11. DRILLING LOG
Top Bottom, Formation Description
s,D4/
""IlQ
/
/
SIZE OFF 3; q71
/ BIT SERIAL NO: I)3tf7(�
12. REMARKS. l
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
I DO HEREBY CERTIFYTHAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: S® FT. ACCORDANCE WITH 15A NCAC 2C. WELL CONSTRUCTION
(Use "+" if Above Top of Casing) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP CASING ( FT. Above Land Surface*J��j.�
'Topp of casing terminated at/or below land surface may require r 7
a variance in accordance with 15A NCAC 2C.01 18. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
J METHOD OF TEST
e. YIELD(gPm)�� -��
f. DISINFECTION: Type HTH _ Amount CUPS PRINTED NAME OF PERSON CONSTRUCTING THE WELL
MAT t v DRE iv- 7 ZI—I I e" 47F -,r (k&%s 7'22-IV1
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. 2109
Date Site Visited'�22 _l By:Permit: Yes No
What Is Height of Well Casing? Make Sure 12" Above Ground Level!!!!
L4 -11
BUILDERS NAME:
ADDRESS:
PHONE NUMBER:
m
. ; ,07!1.112011 08:42 (FAX) P.0021002
Davie County Environmental Health
P -o. Box 8481210 Hospital Street
Mocksvflle, NC 27028
(336)753-67801 Fax (336)753-1680
vL4 `j, WELL PERMTr
Account #: 990004483 Tax.PIN1EH # 5729 -66 -5406 -Well '
Billed To: Jane Whitlock Subdivision:lnfo; Richardson Estates Lot.97fS
Reference Name: :•.:LocaUon/Address: -Ashley Brook Lane -27028 ;•
Proposed i=aciEity Residential -Well Pcopdtfy SEze •*eisee map
ATC Number: 0082
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 maybe 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 ❑
Proposed Well Location Diagram
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46 2.
Certificate of Completion Diagram
Al
Driller.
Certificat'iort:
Gi-out Inspected: _
Well. Head Inspected:
11.05 Coordinates: _
EHS: te:=►(� EHS:
Date: