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975 Spillman Rd �- . . y .. , . , � �'.�.�4 . � . . . _ � � , Davie County Environmental Health ; _ P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 � Ip�l� WELL PERMIT Account #: 990002855 Tax PIN/EH#: 6500000008103-Well Billed To: Isenhour Homes Subdivision Info: � Address: 3411 Healy Drive `�6 ocation/Address: Spillman Road-27028 ' City: Winston-Salem Property Size: 8.35 Acres Reference Name: �I�� Proposed Facility: Residential Well Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this well will oduce water of any particular quantity or quality or for any amount of time. This permit is valid for a peri d 5 years from the date of issuance. This permit may be revoked if it is determined that there has bee a mate ' 1 change in any facdcircumstances upon which this permit was issued. Permi Type: New� epair ❑ Abandonment ❑ Proposed Well Location iagram Certificate of Completion Diagram �� / ' � C� � �� " - ��` _ - - ' _ .; , �,�� ' S�� I� �w �` '"�~�;` � � � �- � � { s � ��a� � �' �, i �, , ��t -.� , . , . �� , �� !.� � � � Comments: Driller: �vo�(S.i rd, �� /�G��'t.� Certification#:��- �. Grout Inspected: ^ }� —( � �� o� r � Well Head Inspected:� GPS Co rdin tes: � 2. �(�° ./42 EHS. Date: "�f� o� EHS• Date: �Z. W.P.7-08 , ��. . . . , . . , v t r � � �.Privat�Well'�ermit Application . , Terms 8�Conditions This application cannot be processed unless all of the required information is provided. Please complete all of the following . fields to apply for a private well permit. 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 watefs.The applicant is responsible for identifying and marking the property lines and comers.The applicant is responsible for making the site accessible. By submitting this application, the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to pertorm necessary field evaluations and procedures deemed necessary to determine the best location for a well. Applicant Information Name to be Billed* Contact Person* � Isenhour Homes, LLC Rhonda Cheyne Billing Address* City* 3411-A Healy Drive Winston Salem State" Zip Code* . NC 27103 Home Phone' Business Phone 336-659-8211 Name on Permit(if different from above) Mailing Address' City* same same State' Zip Code* . NC . 27103 Property Information Note:A survey plat or site plan must accompany this application. Please select below which form you will be submitting. Submit either your survey plat or site plan to the: � Davie County Health Department 210 Hospital St. Mocksville, NC 27028 ❑ Survey Plat ❑� Site Plan Owner's Name'' Phone Number* Page&Jennifer Eldridge 336-659-8211 Owner's Address* ��tY* 1401 Mt.Tabor Ct Winston Salem State" Zip Code* NC 27106 Property Address* City* 8.356 ac. Spillman Rd � Mocksville http://nc-daviecounty.civicplus.com/Admin/FormHistory.aspx?SID=4 4/25/2012 . � • , , ' Lot Size* ' .Tax Personal Identification Number* 8.35 acres � � � 5853062422 Subdivision Name (if applicable) Section/Lot#" n/a Directions to Site'` North on Farmington, turn right on 801, turn left on Spillman Rd, property on left - Isenhour Homes, . LLC lot sign is on the premises Development Information _ Permit Type* Facility Type* Ne�h�4'��I1 � REsi�F�ntial . Are there any septic systems currently on this site?'` No Do you intent to install a new septic system on this site?* � Yes � � *indicates required fields. http://nc-daviecounty.civicplus.com/Admin/FormHistory.aspx?SID=4 4/25/2012 I�-_ � � � � \ �� r I \ `� � ; '� \ i� ` �\ •D ,� �\ z ` `\ �� l ', _� � � � ' '1 � - . � � 1 l ' . �� 1 1, , , \, �, , , � �, , , , � I . , i �, , , , .. , � a I : � , , ;- , ' 1 � ,= . ��--= , ,y�,'�=' ' � 1 I. '�J ' � �-' � , I � . �y�_�� , � � ' / �X�� :( �� ' � 11 � � : ` ,', �� , . '�� `�- �:!,�1 ��''�' '' `,� .\ ;�� •� ��,J�y � �\�; ,` � � '�, i.� ' �, `\ �✓`� � �,"tii Wcu�n (�kr �L\ \ �, =�c�c�. � �,? c.-A�f'J��-y �-cc� -0;•1� /' -'�..^. �;cu�:� �� `� ,\ \ / . y' � z I �\ 4,� `� /' �\ i �� . � . -� . .____ _ . . _ .. - � � ;{� '�—SIiE PL�\ A �oti�Fy � E L D�A� 'l3�;�I��aN'b�' 1 AN� ��n�� CUSTOY'IER: is[N.�wre�+ones r/o��s f� � �E�EI D<V H«LT DRWE - _I S E N H O U R— R'Cq F� ° �' A M�LY ��''I��! WINSTON-Sd1.En�NG 771C3 xou[� �.�! � ,�,g--��lJ'�`=4�`;��D� 1L11E►�`--��'I�T'.Y�L^V6'ELIL CONSTRUCTION R�CORID �d ].� ,�,� �� ,� i��c°� North Carolina Department of Environment and Natural Resources-Division of Water Quality •s�'"nnur�i��r . • � �'''�*�""""-� W�LL CONTRAC'I'OR CERTIb'ICATION# S�.3 �i r� �� 1.Wq�ELL 1CONTRACTOR: n g. WATER ZOfVES(depth): � � /"IGl 1 'f'`l�w �. i,/`t�1,,!/1 Top ��Bottom .�ys� Top Bottom Well Contractor(Individual)Name Top �( 7'Bottom ��1�r Top Bottom YADKIN WELL COMPANY. INC. � ' Top sottom Top sottom Well Contractor Company Name Thickness! 1908 HAMPTONVILLE ROAD = �. ca,s�NG: oePtfi oiameter Weight n�ater�a� StreetAddress ; Top�Bottom ��9 Ft. �i��Z.I�� S17 -.2/ UG HAMPTONVILLE NC 27020 : Top Bottom Ft. City or Town State Zip Code Top eottom Ft. 3c 36 � 468-4440 . Area code Phone number 8. GROUT: Depth Material Method 2.WELL INFORMATION: � Top b Bottom ' ' �-c v� .� Ft.�z.,ra��f L C�� WELL CONSTRUCTION PERMIT��Dl7DOOQ Q ��Q 3 —�t,J�G�op 3 Bottom ..1 t� Ft��v74�.c>f� S�Ur� ��Q, OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft. SITE WELL ID#(if applicable) �� 'Q�� 9. SCREEN: Depth Diamefer Slot Size Material 3.WELL U5E(Check Appiicable Box): Residential Water Supply� Top Bottom t. (n. in. DATE DRILLED �S -�Z z � I�.c. Top Botto Ft. in. (n. TIMECOMPLETED / ��S� AM❑ PM� Top ottom Ft. in. in. 4.WELL LOCATION• 10.SANDIGRAVEL PACK: � �} Depth Size Maferial cmr: �. G�-rv�'(�r- COUNTY /✓G'!.v% �� - Top Bottom Ft. ' �� (I�« L Tap B m Ft. (Street Name,Numb's,Community,Sub ivision,Lot No.,Parcel,Zip Code) Top Boftom Ft. TOPOGRAPHIC/LAND SETTING: (check appropriafe box) �Slope ❑Valley pFlat ❑Ridge ❑Other 11.DRILLING LOG • : Top Bottom Formation Descripfion LATITUDE �',��}��,��"DMS OR DD �_/ O � Sn i f LONGITUDE��°��_"DMS OR DD � � � �y� --��'cf l,''��''" Latitude/longitudesource: �PS ❑Topographicmap lyr� ,� �0;; � �cri� G�.;n��'v (location of well musf be shown on a USGS fopo map andatfached to � this form ifnof using GPS) � ' / 5.WELL OWNER /� � / G{/G � ��GY Y'�A�G � / ` Owner Name� � / Street Address • • / . / - City or Town • State Zip Code / (S�� - /�s�/G v �� r��. ��i r/%��. Area code Phone number � 12. REMARKS: 6.WELL DETAILS: 3 v� � ' a. TOTAL DEPTH: b. DOES WELL REPLACE EXISTING WELL? YES❑ NO�}' I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN c. WATER LEVEL Below Top of Casing: �CS 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. 70P OF CASING IS�_FT.Above Land Surface* .� �� /� 'Top of casing terminated at/or below land surface may require : ��►�� '��' .t�JJia7.�u'�m, S—Z.2— /� a variance in accordance with 15A NCAC 2C.0118. "SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE e. YIELD(gpm): � METHOD OF TEST !�c<'� �?/�g ff.�z w �. '��'� w n f. DISINFECTION:T y pe HTH _ Amount��,s PRINTED NAME OF PERSON CONSTRUCTING THE WELL �►�+7 r .- s��vCN . Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-1a 9617 Mail Service Center,Raleigh,NC 27699-161,Phone:(919)807-6300 Rev.2/os Date Site Visited S—1�1.2. BY:--��%�Permito Yes No � ��t�'y C�� - s�G l t .�.--- What Is Height of Well Casing? Make Sure 12" �ve Ground Level! ! ! ! Bu�n�s �: .-L s�h r.�. ►- � �y►��" � . . � -__--• �DxEss- ��l/ l��u (y ��, . _ . . . l� ` �. ' PHONE NUMBEft: �'( Z ,— S �D � t c ( . I , , _ � l S:,>�;. Yy � , �Se i�� r�� -� �° 5 �� Qd� � �, � �J � �� . ��r�(,= �] � � �I . �'��`�`�`� �� Sol S� �---- �, �' . ��ao-�,�/f ��,�,r�,..J �o h �d. Gv F^��rsy�r GGt. .q�p.�a,. . WATER SAMPLE�SEWAGE SYSTEM CHECK REGIUEST Date Requested: %�ItY� Z� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION Received By WATER SAMPLE TYPE: �acteriai O Protected Chemical i ,, �„ // O Unprotected O Dug O Other: � O Bored O Drilled Outside Spigot: O Other: ��..��..��.��.��.� SEWAGE SYSTEM CHECK: O Yes Vacant: O Yes O Approved O No O Disapproved Owner's Name: �_S Buyer's Name Property Address: Directions: � , s Speciallnstructions: �Letter To: Closing Date: Attn: ---------------------- - Q- U(�-. c� � Date Taken• ' ' - ( Charges• Telephone: � � By: