995 Spillman Rd . DAVIE COUNTY ENVIRONMENTAL HEALTH .
' ' � � j P.O.Box 848/210 Hospital Street
' � � Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
. AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990003799 Tax PIN/EH #: 5843--96-7636
Billed To: John &Kathryn Brehm ' Subdivision Info�G�1��'' ,
Reference Name: Location/Address: Spillman Road-270�8
Proposed Facility: Residence Property Size: 14.084 acres
ATC Number: 4565 Site Type:�New ❑Repair OExpansion
**NOTE**This Authorization to Construct(ATC�MLTST BE ISSIJED by the Davie County Environmental
Health Section prior to issuance of any building petmit(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 FIVE YEARS. This ATC is subject to revocation if site plans,plat or ��v
the irnended use chan e.
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Residential S cation:Buildin h �Flo #P le #Bedrooms #Batbs
Basement w/Plumbing:✓Basement/No Plumbing,_,_
Commercial Specification:Facility Type #People #People/Shift #Seats �
Lot Size Type Water Supply pesign Wastewater Flow(GPD) Site:New Repair
System Speci.fications:Tank Size f o��GAL.Pump Tank_GAL.Trench Widih 3 Trench Depth 3G."
Rock Depth�'_Linear Ft '�/$D ,
�s stated�in 15N A�CaC 98.�.1�3�i3d5�
Other: �,r��,7Fd ��ystEm� rnay a�Su b� �►.sEa ��
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Required Site Modifications/Conditions: e
Contact the Davie County Environmental Health Section for final inspecHon of this system between !��
8:30–9:30a.m.on the da of installation. Tele hone# 33 751-8760. `�i�f
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Environmental Health Specialist � Date: �'-1 Z ��
DCHD 11/06(Revised)
. I b\\'I P. ('OI�\ll' II�'VIRONMEN'I'AL III?AI:I'I I
. . , ���,
. • P.O. Itos S�l�C 210 Hospital Strect
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Account #: 990003799 Tax PIN/EH #: 5843--96-7636
Billed To: John & Kathryn Brehm Subdivision Info:
Reference Name: Location/Address: Spillman Road-27028
Proposed Facility: Residence Property Size: 14.084 acres
ATC Number: 4565 tiitz l)pc: ��\c�c Rcpair F.xpansion
••NOTE"`This Authorvaiion to Conslruct(ATC) MUST BE ISSUED by the Davie County Environmen�al
Health Sec[ion prior to issuance oCany building perntit(s), (in compliance a�th Ar[icle I1 of G.S. Chapter 130A i
Wastewater Systems. Section .I9W Sewage Trcalment and Disposal Systems). THIS AiTI'HORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD FIVE YEARS. 7ltis ATC is subject to revocaaon if site plans, plat or
ihe intcnded use change ��/G� ��� rvl
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Residen�ial Specifcation: BuildingTtipejr 4io,t,� #People ` #Bedrooms - #B.uhs_ �` ��e V
Basemen[�v/Plwnbing:._Basement/No Plumbing_
Commercial Spccification:Facility Type #People #Peoplc/Shift #Seats
L,ot Size Typc Watcr Supply Dcsign Wastewatcr Flow(GPD) Site: New_Rcpair_
Spstem Specifications: Tank Sv.e I�GAL. Pump Tank_GAL. Trench Width 3 Trench Depth �t, ' `
Rock Depth �� Linear Ft. Y$G' h�
�5 ���tea in 15N �GFC 78;.156';r!5) �
Oth¢[ . �d �v�ten= �r.av +Is � <:t�d �
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Rcquircd Site Modifications/Conditions: �c
Contact the Davie County Emironmental He•rlth Section tor final inspection of this system between ��
R:311—9:30am.on the dav af installa[ion. Tele hone#(336)751-876U. 'iJ
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Enviromnental Hcallh Specialist ��s ' v Date: l —l � ��
DCHD I I/OG (Rc��iscd)
- — i
DAV�COUNTY ENVIRONMENTA,L HEALTH
� P.O.Box 848/210 Hospital Street
. • • �, .' Mocksville,NC 27028
(336)751-$76Q Fax#(336)751-8786
OPERATION PERMIT
P ���{. , _ _ �.
� �
Account #: 990003799 � �� � Tax PIf�UEH :#��84 6-7636
Billed To: John 8�Kathryn Brehm/��I���ubdivision Info: _ ` �
_ � — �
Referen�ee Name: Locatio . piffman Road-2702a
Proposed Facility: Residence � Property Size: 14.084 acres
. /. //
ATC Number: 4565
**NOTE**The issu�lce of ihis Ope�r�a on Permit shall indicate the system descn'bed on the ATC bas been installed
in compliance with Anc�le 11 of G,B.Chapter 130A, Section.1900"Sewage Treatment and Disposal Systems,"
but shall in NO WAY be taken�guarantee that the system will functian satisfactorily for any given period of
time. CQ r� ��5'� � / `
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System Type• /�"' /S.T.Manufacturer Tank Date C�' �3�r�s�� ( OG�
Pump Tank ize �
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System I ed By: �{ � � ''�'��E.H. Specialist: Q�� Yls Date: � �
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DCHD 11/06(Revised)
• i .. �
1�I� SITE EVALUATION/IMPROVEMENT PERMIT & ATC
` � 00,� Davie County Environmental Health
� 2 P.O.Box 848/210 Hospital Street
�A� � � Mocksville,NC 27028
�jP��� (336)751=8760/Fax(336)751-8786
aaN�`. o�� � �
Ap lication 1�� valuation/Improvement Permit [�YAuthorization To Construct(ATC) ❑ Both
Typ of A ion: ONew System ❑Repair to Ezisting System ❑Expansion/Modification of Existing System or Facility •
�
***IMPORTAN7***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed���-+� M � �1�T�n'l� $�NM Contact Person �
� �rt 1�7�L1�1M
Billing Address l S g � U P1,A-��. Home Phone 33�0 `i�18 q 53�-
City/State/ZIP ��v�C� C. 'L'�o o�o Business Phone 33(� �-1� Za�i�
Name on PermidATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged � $ ��'7
NOTE: A survey plat or site plan must accompany this application. Included: O Site Plan ❑Plat(to scale)
(Permit is v�lid for 60 months with site plan,no expiration with complete plat.)
Owner's Name�n� �� �P-"��[+� g'R��1�'� Phone Number33� ''q 9 ����3
Owner's Address ��Fb �6U2�0 P(AP�v City/State/Zip�A1v� t.t�-� Z"I oo So
Property Address �Y�t�-MA.r-� RD City !�OC��g�l t�e�
Lot Size ��- �.Gp-��j Tax PIN# �g Q-�-q(c�`7��3(0
Subdivision Name(if a plicable) Section/Lot#
Directions To Site: �����• o►� '��lti1.iC1turQ R� - �oa SP1U�M�MJ ) sTc�cc- o F pplJ���r
If the answer to any of the following questions is"yes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? ❑Yes L�No
Does the site contain jurisdictional wetlands? ❑Yes 6�No
Are there any easements or right-of-ways on the site? ❑Yes �No
Is the site subject to approval by another public agency? ❑Yes'�'No
Will wastewater other than domestic sewage be generated? ❑Yes o
� �4
IF RESIDENCE FILL OUT THE BOX BELOW ��� g
#People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes �No
Basement: Yes ❑No Basement Plumbing: es ❑No
IF NON-RESIDENCE 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 ❑Accepted ❑Innovative �Alternative ❑Other
Water Supply Type: ❑ County/City Water �1ew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �No
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my lmowledge. I understand that
any pe 't(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the info ation submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative
of the Dav Co ty Health Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I understan tha I a re onsible for the proper i entification and labeling of properiy lines and corners and locating and flagging
or staking c' i ation,pro well location and the location of any other amenities. .
Site Revisit Charge
� pe owner's or owner's legal representative signature
� ,� Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes �No � Account# ��
Revised 11/06 Invoice# _1�
�
.�_ �. .(� '.
� , � ` �1PP IC�l7lUN FOR SI7C CVALUATIO�V/lhiPli0llLhtCM PLR�titIT - ' � � � u U �
(� '�J"
r ., Davie County Health Department
1-� ��. PnvironmentalHealthSection ��� Z .2 ZQt��J
� G P.O. Box 848/210 Hospital Street
MOcksvilla, NC 27028 � ' j� h
� �t (336)751-0760 E1�MMRONMENTAL�HEAITH ;' �Q�, �
. , , DAVIECOUNiY .w�, U'
" ���
***I�IPORTANT*** TIiI� APPLICATION CANNOT �E PROC.GS�SED UNLESS ALL TFi� R1:QUIR�D
INFORt•L7�TION IS PROVID�D_. Refer to the INFOR2SATION BULLET22d for ina�ructionB. T � '.� �
1. T7ame Lo bc Dilled���(�f-a � � �}���'k'�=�� ���-��'�'�onEact Per�on ����`� ���'�M
1•Sailinc� Addro�n ��T> �`-^�l�lu�T 3 t� Itome Phono ��cU —�"1 � �L���--
CiCy/Stato/ZIP /x�V j u"✓�i 1V�i Z�vC� IIu�inenn Phono ��� �� � -`"�Z 2
2. Namo on Permit/I�TC if Different than 7lbova
24aili�ic� Addrou� C�ty/Statn/Zip �
]. Applicstion For: � SiLc �va3uation ❑ Improvement Permit/ATC ❑ Doth
a. syacem ro sarvice: •�IIouDe ❑ 22obile Home ❑ Iluuine33 " ❑ Induntry ❑ Other
i �
5. Typo nyatem roque�tod: � Conventional ❑ conventional modified ❑ innovativo l�lac�epted
1
6. Ii- -Itesidenca: U Peoplc � 8 I3cdrooms t► DaL-2irooina ��
�Di�hwa�hcr ❑Garbago Diaposal �i4ashing Machina L�Aasement/Plun�ing ❑Uaoemen�/17o Plumbing
/
7. IL Dunineuu/Induatry /Othor: verify type � Peoplc 1t Sink�
A Commodon II Showora 1F Urinala It 1•laCnr Coolarn
IF FOODSERVICE: �� Seatu Estimated Water Ut�age (gallonn per dayl
0. Typc of vratar aupply: � County/City �T'Tell ❑ Community
�. Do fou anticipato adcliCions or cxpansions of il�c L•icilitp ti�is sys(cm is intc»dcd (o scrvc'? ❑1'cs �No
II�•cs, titi•t�at typc?
y ""*'`L7IPORT'i11Y7"'**CLILNTSAlUSTCOdIYLETETII� RL•QUIItL•D PROPCR'TY INI�ORl9AT10N RLQULS'TLll
fi1;i.O1V, rithcr a PI.AT orSITC PLA�I 4fU.ST IlESU11AfIT?T•A bv tl�c clicnt �vilh'i'IIIS APPI,ICATION.
1'ro �crt}•1)iuicnsions• ��+ ��`T ��� NIt1T�DIIiECI'IOnS(frum 11�Iocics��illc)to I'Ii01'LRTI':'
'I':ix OfGcc I'Il`t: �� �����'� �'L'7'�D ��J"�L3 � ' �F'I�'r!'Jvlc�►G�T��.S. i'3> � •—
Proper(y rtddress: Road Namc ✓1?�LL NV��-1 �f'—� LY�� <�� Sf'lLh,1`�'Y.�'�- '� �'�L�
c,�y�z;n �c��i�sy��c,� NL Z�02� �A-�� •,����,zr�l� �=�
ICin a Subdi��isioit pruvidc iiifoi•riiatio�i,:ts f lolvs: �����—ti�� ��'�' ��'� �C'►�'��
' __� �
rr:►,nc: � S10'�
Scclion: 131ock: Lof: Datc homc corncrs Ilaggcd: �� � ��
'1'liis is (u ccr(ifj•tl�al llic inCorc»atiou providcd is corrcct to tlic bcst of niy l.no�vlcdgc. I undcrsl�ncl llint any perinit(s)
issucd l�crc:iflcr are subjcct (o suspcnsion or rcvocation,if thc sitc plans or intcndcd usc cl�angc,or iC tlic informalion
subniil(cd in lhis application is i�IsiGcd or changcd. I,nlso,rurdcrslairrl drut I rr�rt respousrLlc for all cicurgcs i�lcru•r•crl jran
tlris af�plicaliv�r. I, hcrcby,Uivc conscut to thc Autl�orizcc] Rcprescnfati�•c of tlic a��ic Cow�t �IIcal(li Dcparhucut
(o ct�lcr i�p�n abovc dcscribcd pi•opci•t)'localcd i�i llavic County and oti�'nc y � ���U�� GC:I�'�'�,�'
to conduct all tcsting pr ccclin�cs as�icccssar��lo dcicriniuc tlic sifc suitabilil �.
.
DA7'I: �� �7 �� SIGI�ItI'1'URL
TIIIS AKL;A 111AY B�USLD rOR DI2�L1'��ING YOUR Sl'TI;PLAN(Includc:�I!oI tl�c follotirinb: L�isting aud proposccl
propci-ty lincs and dimettsious, siructures, setbacics, and septic locations). � .
Sitc Itcvisit Cl�argc �
. Da tc(s): '
� � ���1 ( ��,y Clicnt Notification Datc:
� �/ �I�IS:
�- d'� �Y`�� /
V �c" � � 7�
Sign�ivcn !t?� �, '• wAccowtt No.
.� �o� ���
Rc��iscd llCIIll(05/03 Im•oicc No. �
_ _ � � ���c- �--
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� •;:.� '. � DAVIE COUNTY HEALTH DEPARTMENT
• ' � • Environmental Health Section
" Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003799 Tax PIN/EH#: 5843-39-2576 JB
Billed To: John&Kathryn Brehm Subdivision Info: �. �o �
Reference Name: Location/Address: Spillman Road-27028
Proposed Facility: Residence Property Size: 14.084 acres Date Evaluated: /2��'d�
>
Water Supply: On-Site Well v Community Public
Evaluation By: Auger Boring Pit Cut
FAC'TOR5 1 2 3 4 5 6 7
Landsca e sition
Slope% �,
HORIZON I DEPTH (o '� (
Texture rou GL d`C �
Consistence �- (/t�
Structure ,�p�- �—
Mineralo - / ,
HORIZON II DEPTH �' L 8 r)
Texture rou
Consistence T
Structure / f%
Mineralo _%
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou �
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE , (-
SITE CLASSIFICATION: ' G � EVALUATION BY: ��
LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope �
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain� H-Head slope
T�ut�rs � .
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
.nN4IS .N .
Mois
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�
� NS-Non sticky SS-Slightly sticky � S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
��
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-Thiclrness 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)
LTAR-Long-term acceptance rate-gaUday/ft2 DCHD OS/OS(Revised)
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Environmental Heaith Section
P. 0. Box 848/210 Hospital Street
Courier 09-40-06
Mocksville, NC 27028
336 751-8760 '���
�� ( )
� �
December 9,2005
John&Kathryn Brehm
188 Woodburn Pl. -
Advance,NC 27006
Re: Site Evaluation/ Spillman Road 2 sites
Tax Office PIN: #5843-93-2576
Dear Client(s):
As requested, a representative from our office visited the aforementioned sites on
December 8,2005. Based on the information provided on the Application for Site
Evaluation and after an evaluation was completed on the sites,they were found to be
provisionally suitable for the installation of on-site sewage systems.
Before and ImprovementJAuthorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions,please feel free to contact this office.
Sincerely,
fa�t cB��,/��,'
Robert B. Hall,Jr.,R.S.
Environmental Health Specialist
RBH/dlf
• . DAVIE COUNTY HEALTH DEPARTMENT
• " = ' Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INES?RMATION
I'I�� � ��� �
� �'►'�v� �l��►�. y �i e �
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Water Supply: On-Site Well v Community Public ? � ��^d�
Evaluation By: Auger Boring / Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca sition Lt LL
Slo %
HORIZON I DEPT'H �� 6-
Texture rou G c
Consistence
Structure �
Mineralo ` � ; •
HORIZON II DEPTH ��,-"l -
Texture rou G
Consistence
Structure � '" -4'A4ti
Mineralo � �:� .
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo -
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFTCATION
LONG-TERM ACCEPTANCE RATE � o•� �
SITE CLASSIFICATION: �:7 ui�u y� ~ EVALUATION BY:
i
LONG-TERM ACCEPTANCE RATE: •� OTHER(S)PRESENT:
_. .,
REMARKS•
,. LEGEND
I, n s e Position : ` •
R-Ridge S-Shoulder L-Lineaz.slope FS-Foot slope N-Nose slope -
CC-Concave slope CV-Convex slope T-Terrace 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 .
.ONSIST .NC , ;
�'�41St �
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
'}5.�' .� ' ,
,
� NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky;
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very'plastic '
�YLIi�� _ ,
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
1YQtr�
Horizon depth-In inches -
Depth of fill-In inches
Restrictive horizon-Thickness and inches fmm 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) �
LTAR-Long-term acceptance rate-gallday/ft2 . DCHD OS/OS(Revised)
; • Davie County Environmental Health
. ' : P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33�751,8760/Faa(33�751-8786
IlVIPROVEMENT PERNIIT
Account #: 990003799 Tax PIN/EH#: 5843-39-2576 JB
Billed To: John &Kathryn Brehm Subdivision Info:
Address: 188 Woodburn Place , LocationlAddress: Spillman Road-27028
City: Advance Property Size: 14.084 acres
Reference Name:
Proposed Facility: Residence
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Corrstruct 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). Ttus Improvement Permit is subject to
revocation if site plans,plat or the intended use change.
Permit Type: L�1ew �Repair �Expansion Permit Valid for: �5 Years ❑No Expiration
Residential Specitications: #Bedrooms ' �3 #Bathrooms 3 #People�_Basement�Basement plumbing0
Non-Re.cidentiat Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): 3 (a0 Type of Water Supply: ❑County/City �,Well �Community Well
As stated in 15A f�C�:C 18f..196Q(5j .
Site Modifications/Permit Conditions: ��cepz�d Systems may alsc� b;: t.asEcl
S em e LTAR
�niaat a , -
R � Ck� s O�a
site Plaa /+;
P°,,���a
�1 �S �-oc a�c� o �
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Environmental Health Specialist � -- -Date /-/Z'0 7
i.p.l 1-06 `.
�„ .. , ta, .. . .. -- ..
��i�' �' ' �. . .KESI��ENT�4L w�i.t,corisritv�oi� .. ..
��.]`� . � North Carolina lleparhnent oflinvironm�nt and Natural K.a"�oat�es-Ilivision of Water Quslity
• Y . . '�1�..1 w ... . .
� ••...V..,...• ' wEi.i,corrrxncroR cER�c��ii�iv� ��.� l� .
1. CONT CTOR: � • • L DISINFECTION:Type �H Amount� S
1��/ .��r!'cr� ���+�n� a w zor�s�ae
Well Cor�tracUor(I n d i v i dua q Name • From,�,To� From To
Yad]cin Wel.l Compariy, II1C. From ' To From To
Well Conttador Coi�any Name • From To From To
STREET ADDRES3 1908 Hamptonville Road s. casmu3: Thickness/
� Depth� p%S r ��/ � t ['iai
Hamptonville NC ' 27020 � From�_To R(e.
City or Town State Zip Code From To R.
3c 36 �. 468—�440 . Frorr� ro FtL
Area code- Phone number • •
2.VYELL INFORMA710W � � T. GROIIf: Depth Mated I Method
' ,� Frort���To 3 R. p°���►��
SITEWELLID#pTappticable) ��' � l(� From_j To�_R C.1Nl+E'+c �Uw�
• STATE WELL PERMIT�(if appticable� • FrorrL To Ft.
DWQ or OTHER PERMff#(if app6cable) 8. SCREEN: Depth Diameber� Slot 5[ze Material
VYELL USE(Check Applicable Box): Residentfal Water Suppy j� From To Ft in. in.
`1 � From � To Ft. tn. in.
DA7EDRILLED !ot -�� "O� From To R. in. tn.
TIME COMPLETED �� �� 9. SAND/GRAVEL PACK•
3.WELL LOCATION: ' Depth � S¢e Mffiedal .
CITY: �C.�►3 �`L 4(/G�COUN7Y � From To Ft
From To Ft
� � /°j� Nc�r� �� ' � From To F't.
(Street ame,N ers,Commtu�t�jl, uS bdivts os►,Lot No.,Parcel,Zip Code) .
TOPOGRAPHIC/IAND SE7TING: 10.DRILLING LOG • _
�bPe ovai�ey pFlat ❑Rid9e pott►er • From To Formation Description
c�neac ePwnr�t��� D --5v �'�.�
�y��a��, �
LATITUDE 3 ;� � m;�„��� SO '— 7O �c�'C.�L_
LONGITUDE�� ��. -L'vS m°docmulfotmat 70`o7�/a 'eyc� �---
Latitude/longitude sow�ce: pGPS p�'opograptric map
(hcafion of weB mus!be show»on a USG8 lopo map and .
aitached to�Is furm�not usdr�g GPS) .
4.WELL OWNER ��j n
. OWNER'S NAME_�C►Iv!�V��, �`t .
STREET ADDRESS "
City or Tw�m State . Zip Code
�_�_ ��}- �arial Np, Giz[� c�ff
� Area code- Phone number •
• 11. REMARICS: •
6.YVELL DETAIL.S: � r
a. TOTAL DEPTH� Q •
b. DOES VYELL RE1PlACE EXISTING WELL? YES p NO� •
� 'I DO NEREBY CEKiiFYTHAT'ilit3 W ELL WAS CONSfRUCiED IN ACCORDANCE WRN
c. WATER LEVEL BelowTop of Casing: C, FZ'. �an rrcac zc,wEu corisrnucnori srnwoazns.AND7HATA COPY OF 7HIS .
(Use'+'�AboveTopafCasine) R ow�semr�rtaivoEOTo'rt�w��owNat.
d. TOP OF CASINCi IS � . FT.Above Land Sudece' �%'1 P/!?1Y)�.�U✓ ��1�'u"'���'�/a��'-��'� .
`Top of casing terminated aUor below land surfece rtmy require SIGNATURE OF CERTIFlED W ELL CONTRACT R DATE
a variance in e�ccbrdance wHh 15A NCH�C 2C.0118. /
e.�YIELD(9Pm):_�Q�_____M�}iOD OF TEST �r P�P !`.f-s?�f7"h� �a�l�� G/��lh»+rr�
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submlt the original to the Division of Water Quality within 30 days. Attn:Intortnatlon Mgt, F�,,,Gw-�a
1817 Mall Servtce Center–Ralelph,NC 27698-1617 Phone No.(819)733 7018 ext 568. • Rev.7105
Date site visited --Z —Q y erct�it - � Yes N� •
f?a%��� r� ���'J����G�et�' .� .
3..440�-d'G S� '
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