446 Wagner Rd . . ` a � (
- ' DAVIE COUNTY ENVIRONMENTAL HEALTH 1' "� `�� Q�
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P.O.Box 848/210 Hospital Street �Qi� L�/
Mocksville,NC 27028 �'�
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
Acco+a�t �: 990005732 �"�x Pl�€iEH�: 5810-74-9848
�illcd Ta: Kevin Hainesworth �uk�t�i��i:.-iori Ir�fc�:
Re:fer�^E�c� N�r��e: � ��: LocationiAdr�r�ss: WagnerRoad-27028 , �
Prnpc�sQc9 Fr��ifity: Residential � � � '- F'fo�er�.y�S�ix.�: 4.946 Acres
a,TC t�u�'tbg�': 5809 . _ _
**NOTE**The issuance of this Operation Permit 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. �
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� System Type: S.T.Manufacturer ank Date 10 Tank Size O
Pump Tank Size /
System Installed By:��Qh�P �QY'f�Q,Lt E.H. Specialist:� �`aite: �CJ�
GPS Coordinate:
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DCHD 1 1/06(Revised) . � "'
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' � . ` � DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
,r�� Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Acct�ur�t �: 990005732 . ' T�x(�i�€iEN#: 5810-74-9848
BiEic;�To: Kevin Hainesworth _. � : Su�ar�i�fE�ior� lnf�: �;�:� .
f�efer�r�ce P��an��: :: . : � ,�, La�aiianiAddr�as: Wagner Road=27028 + : ;:, . `
Pro�os�c9 Fr��;ility: Residential ., . = . , , ` Pcc���r�y:S�ize: 4.946 Acres � • ,-, . , , ::;
a�TC hEu�ber: 5809 � � �- � ':' =�Site Type: (�1New ❑Repair ❑Expansion `
**NOTE**This Authorization to Construct(ATC)MLJST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(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 �"�Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size ,"1�10 Q�. Type of Water Supply: ❑County/City ❑Well ❑Community Well
, System Specifications: Design Wastewater Flow(GPD)��Tank Size��;lJl1 GAL.Pump Tank�GAL.
Trench Width� Max.Trench Depth n'�_ Rock Depth�� Linear Ft.�9 tL
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SiteModifications/Conditions/Other: C.cce�^t;_d �,�,.i�:,f; rr3.;�;� �+.,� „�:: . �. �`'�6 �u.C.1'ti13�1
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.
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Environmental Health Specialist Date:� (.J
DCHD 11/06(Revised)
. , , � Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
- Account #: 990005732 Tax PIN/EH#: 5810-74-9848
Bilied To: Kevin Hainesworth
Subdivision Info:
Address: 446 Wagner Road Location/Address: Wagner Road-27028
City: Mocksville � Property Size: 4.946 Acres
��ference Name:
Proposed Facility: Residential
**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.
Permit Type: �Tew ❑Repair ❑Expansion Permit Valid for: C�5 Years ❑No Expiration
Residential Specifications: #Bedrooms � #Bathrooms�#People � Basement❑ Basement plumbing�
Non-Residential Specifications: Facility Type . . #People #Seats .
Square Footage(or Dimensions of Facility)
Design Flow(GPD):� Type of Water Supply: ❑County/City �7We11 ❑Community Well
Site Modifications/Permit Conditions:
S stem T e LTAR
Initial � e '
Re air � ��
Site Plan
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Environmental Health Specialist Date o �/ 6
i.p.l l-06
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APPLICATIO FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
GE`V E Davie County Environmental Health � �
E P.O.Box 848/210 Hospital Street ���I -�'� �'�-� - f
A�� � 5 2011 Mocksville,NC 27028 �'�/l�- ��L�'-c-
(336)753-6780/Fax(336)753-1680
t�p � �on or: ❑ Site Evaluation/Improvement Permit L9�Authorization To Construct(ATC) • ❑ Both
� Type of Application: &�IVew System ❑Repair to Existing System pExpansion/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
Naine �1�(cU �►.� �C�11•2 C..$c.,�o 2'�-� Contact Person S ��-�
. Address �-(� �p i,.� �q +.1 e2 2 Home Phone c{c�01-a3 ��
City/State/ZIP rnp�,�,S v��� �J C a?a a� Business Phone `�'70 - (,'1 3�
Name on PermiUATC if Different than Above •
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Fla ed � � //
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan [�fat(to scale)
(Pennit is valid for 60 months with site plarr;no expiration with complete plat.)
Owner's Name��G�iN n� Dc�ib<< �-�v+��S�-✓o2� Phone Nuinber y Qo7-a 3 ��
Owner's Address (,.,, City/State/Zip o17 0��
Property Address City�Abt,�S����t '
Lot Size Gf,�'/U(o R CdZe S Tax PIN# , /p-y�f-�j��l
Subdivision Name(if applicable) Section/Lot#
Dir�ctions To Site:(�o1 -}c� f31,q�,k�.,cld�c2 R. -4-�+kw 1_ TvQ� 2.�04+:1. o r.�� w�4W��. �.
- %41 m�l� o ., �2..1�1n�- -
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? 1C Yes No
Does the site contain jurisdictional wetlands? Yes ?C No
Are there any easements or right-of-ways on the site? �'es �No
Is the site subject to approval by another public agency? Yes �No
t. Will wastewater other than domestic sewage be generated? �Yes No
IF R�SIDENCE FILL OUT THE BOX BEbOW
#People #Bedrooms _,,,� #Bathrooms__�___ Garden Tub/Whirlpool C�'es �No
Basement: es ❑No Basement Plumbing: G�es ❑No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business 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 system requested: LU.�onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: Cl County/City Water L�New Well ❑Existing Well ❑ Commwiity Well
_ _
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �o
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my kno�vledge. I understand
that any pennit(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 determine compliance with applicable
laws and niles. I understand that I am responsible for the proper identification and labeling of property lines and corners and
loca ing and gging or staki e house/facility location,proposed well location and the location of any other amenities.
Site Revisit Charge
o erty owner's or owner's legal representative signature
Date(s):
g-S'—ao�/ Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No � � ( �'�%�%� Account# v73Z
Revised 11/06 � (i J� (� n� Invoice# _�r�_
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' � , • � . , DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiliSite Evaluation �
APPLICANT I FO MATION .�i'�t�RTY INFORMATION
Account #: 990 Tax PIN/EH#: 5810-r •
Biiled To: Ke�in Hainesworth Subdivision Info:
Reference Name: Location/Address: Wagner Road-27028
Proposed Facility: Re idential Property Size: 4.946 Acres Date Evaluated:
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring Pit Cut
FACTO S 1 2 3 4 5 6 7
Landscape position
Slope % � la
HORIZON I DEPTH
Texture grou L -
Consistence •
Structure
Mineralo
,
HORIZON II DEPTH
Texture rou
Consistence
S tructure
Mineralo �
HORIZON III DEPTH
Texture rou
Consistence
S tructure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICI'IVE HORIZ N
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPT CE RATE
SITE CLASSIFICATIO _� EVALUATION BY: �
LONG-TERM ACCEPT NCE RATE: ' OTHER(S)PRESENT: f��'I�l-�SG(� !i`
REMARKS:
LEGEND
i.andsca�e Position .
R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope
CC-Concave slope V-Convex slope T-Terrace FP-F1ood plain H-Head slope
T.eutuTg
S -Sand LS -Loam 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
.ONST�TF,N .E
a'IQIs�
VFR-Very friable -Friable FI-Firm VFT-Very firm EFI-Extremely�rm
�
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
MineraloQv
1:1,2:1,Mixed
lYotes
Horizon depth-In inches '
Depth of fill -In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U( nsuitable)
Soil wetness-Inches fro land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classi�cation-S(suitable ,PS(provisionally suitable),U(unsuitable)
T TAR -T.nna-tarm arrant nrP fAYP�OAj�l�AVIFY7 T/`TiT!�C/AC m__.:__��
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' �'. Davie Cou�ty Environmental Health �����/� `��.�/L
�f P.O.Box 848/210 Hospital Street ��
Mocksville,NC 27028 � lF'�����
(336)753-6780/Fax(336)753-1680 n��//�
IC 7
WELL PERMIT
Acc�u�t #: 990005732 "��x F�l�€.%EH#: G3000000208
BiElcd Ta: Kevin Hainesworth Su�i�i�fi4iarZ ln�o:
f�e��E-�r�ce N����: LocationrAd�E���s: Wagner Road-27028 .
F�ro�c�s�;c9 F;��;ility: Residential Well �� �fope►#.y S�iz�: �3.946 Acres .
'�,�Acfions o��the�mployees of the Davie County EH Sectiori 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 facticircumstances upon which this permit was issued.
Permit Type: New�Repair ❑ Abandonment ❑ T____ _____.___.�._ __.__..._.�_..____._____.__.__.__
Proposed Well'Location Dia am Certificate of Completion Diagram
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Comments: t- �W Driller:
( '�� `�
Certification#: S 23Z
Grout Inspected: � ���Z
Well Head Inspected:����`J� .�2��/(,(p��2- G'���
GPS Coordinates: ��/2 �
. EHS: Date: � � EHS: ate: S �7 20/ y
W.P.7-08 �� �LV I� �
5�;� �
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�� ' APPLICATION FOR PRIVATE WELL PERMIT (j ///,�f
Davie County Environmental Health 0 Z� T'� ` +��O
�(� P.O. Box 848/210 Hospital Street / Gj/ ��.? ��i�� TD��
� � '—' Mocksville,NC 27028 � l���e1p f
(336)753-6780./Fax(336)753-1680
**xIMPORTAN7�*X
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION ���V lw �l�'l j�/�.l`(,v p h
Name /�A/'�S�ILt � /y�..� �V 1 C-/-�C��Contact Person 'rj�QZ�2,3/Z
Address Home Phone
City/State/ZIP Business Phone 7��
Name on Permit if Different than Above '
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey 1 t or site pl n must acco y this applicat' n. Included: 0 Site Plan OPlat(to scale)
Owner's Name eVl'!� w�i�l �e �1 Phone Number
Owner's Address City/State/Zip
Property Address City
LotSize TaxPIN# 3��Od00ZD�
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 I�tend To Install A New Septic System On This Site? YES i/ 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 ma::ir.g 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.
�-._. / - /�' - I�
igned Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
7/30/09 Accotmt# ��3Z
�y�� � I� ����( Invoice#
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GoMAPS - Davie County NC Public Access
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; - I1 p �+!��+�..=L�..�,,,,� t r , � ' ` , t` `�5 �`1 � Thursday, January ]9 2012
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***WARNING: THIS IS NOT A SURVEY!***
This map is prepared for the inventory of real properiy found within this jurisdiction, and is compiled from recorded '�
deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map. The
County and mapp�ng company assume no legal responsib�lity for the information contained on this map.
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May 24 12 08:12a Advanc,ed Wel� Drilling, L 8282412445 p,1
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��`�•�'��,����= �iI�.SID.EN�IAL WELL CONSTRUCTIOrI RECORD
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��t�''� � North Carolina Depardnern af Environment sad Nadrral Reso�r�ces•Di��ision of Water Qualiry .
<�.��\•�`� ��� . -
��'� �L� WELL CONT�LACTOR CERTIFICATION#F 3232
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1.WELL COM'RACTOR: g..WATER ZONES(de '
icha�! W. S�aw Top�O 6oUom th� Top Bottam
Weq Contrador(Individuai;Name Top 9ohorrr Top BoHom
Advanced Weli Drillin�, LLC Yop Bottom -�oP aot�an
Well Contractor Compar�y Name • 77tickness!
2221 Pum.p Road = T. cas��: aepth a�ter w�t�c �ai
StreetAddress . : Tap � Bottorn �D� Ft. 61/4" hAaW PVG
Catawba NC 286�9 Top $Wtom F�.
C�y or Ta�m State Zip Cade Top - �� ��
c 8ag� 241-43Q0 �
?uea cnc3e Phone number ; a GROUT: Deplt► Material Method
2.WELL tNFORMATION: : Top � BoKom��t. BentOnite Poured
WELL CONSTRUCTIOiV PERMIT� �q O 00 S� 3 c� � : Top Bottcm Ft.
OTHER ASSOGATED PERMCT#(it app�icable) � Top 8ottam Ft.
S1TE WELL IQ#(Ifeppticabte} 9. SCREEI3: Depth �iameber Slot Size Mate�tal
3.WEIt USE{Chectt App�cable Bo�- ResidenGal Watet Supply pf Tvp Ba��ttom Ft ir� in.
DATE ORELLED 5'��+-ly�. Top Soltom F;. in, in.
TIME COMPtETED �=� AM p pM[� � Top Boftom FL in. in.
4.VYELL LOGATION• : 10.SANtDtGRAYEL PACK:
Y�n '� Depth Size Material
CITY: 1 11 OC7�Sy 1�,� couNrY �J i e- Top Bottom Ft.
�'�to l.l~.s�, r.ei-�. a'�Do1.� TOP Bottom Ft.M
(5hea!Name,Nttm CcmmuNly,SubdivisEon,t�t No..Pa�el,Zip Code) TOp Ba�CRt F�
Toaoc�Hjc r u�reo sErnNc_ e�aac�w��
❑Slope pVatlay ❑Flat ❑R'�dge ❑Other . 11.ORIL'LlNG LAG
Tro,p ttorp ormation Description
lATITUDE ��' 4 a a-"�61S DQ s�_f
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� Lat�csdeAangiiude Sovrce: [�PS []ToPo9raphic map -rc�-..1_1,�..��.� r�t�v. 1
(fxation of wen must 6e snovm orr e uSGS ropo map�andaeteched� �
�hls fbrm Nno�using GPS) I
5.WEI.L OWPiER � A /
KL'�I��R i'TQ��nGSG.:�Oc���-�0.di� MGS: !._
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Cityy crTowrt State Trp Code j �
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Area code Pnone nurnber .
12. ftEMARKS:
6.WELL DETAItS: ��
a. Tora�.o�x:�p� _ �
b. DOES�fYELLREPLACEEX1S71NGkIfF1.L? YESQ M1�O� : IUO.HEREBY�RTIFY'ftiATTHISWELI.WASCONSTRUCTEDIP!
c. WATER L.EVEt.Befow Top of Casing' ✓� � FT. A�ORDRMCE WITH 15A NCAC 2C,WELL CONSTRUCTIaN
(Use'r��f Above Top of Casing) = STANOhROS;AND THAT A COPY OF THIS RECORD tiAS 9EEN
� PRQVIDED TO 7HE WEt�OWNER.
a. 1'OP OF c.�lstNG is___�,,_�d_��FT above L.and Surface•
'Top of.psing telrnlnated sUof Delaw IartQ suttace may reqaire �/���, 5�l�o'Z
. .....e..:..�.w...r,...�e..A►h��C.�IJf."d[`7[� fS71A' - ��yAGOF�C6R 1FICG1NtL CTOR OWTE
e. YIEIA(9Pm}: � I�ETHODOFTEST Q�f �i'Lr1CtC-��y,�Vf�tla.i
f. DtSINFECTION:Type F�TH Amouc�t Z ta�Ie�S : PRtNtEQ NAME OF PERSON CONSTRIiCTING THE WELL
SubmiLwittiM��O.days of�sompletion;�or�3.irlsionof Water�Gtcralify=.�Ir�farmaf�or��P�ocess.ing,• Form GW-1a
"a6i7Mail:S�rviceCenter;Raie[gFi,�NC�27699-1bh;photie:-.f949}8QZ=6300 ' � _ � • : �. � Rev.2109
May 29 12 10:11a Advanced Well Drilling, L 8282412445 p,2
,:�;;:Rnit�� �
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�- -� � � RESIDENT�4L v►��.L coNsr�t�c�tox x�coan
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������� Norih(:amlina Depar�aent of Eavironment and Nntaral Rcsources-Divisian of Weter Qualiry
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�"y='�'"'��'"� W ELL CO1�tTRACTOR CERTIFICATIUN# 3232
'f.WELL"CONTRACTOR: g.� WA1ER ZONES(deptfi
MICI71e) �IV. SI18W Top�C? 8ott��� Top Bottom
WeU Contractor(tnd'nridual)Nama Tap 8ottom Tap 8ottom
Advanced Well Drillin�, LLC roP Botcom Top ao�tan
Wetl Contrattor Company Name -
- 7bickttess!
2221 Pum� Road = 7. cas�ac: oevcn D€arneler we�nt Material
St�eet Address Top 0 eottorn �o� Ft. 6114° heav�y„ PVC
Cat�,wba NC 28609 T,P ��� �,
. City or Town State Zip Code T
� aag,,,,} 2�?-��� . cP Bottom FL
Area code l�hone aumber - 8. GROU7: Deptti Matedal Method
2.VYELL�IFORMATION: ; Top � Boltom�F:. eentanite Poured
wFw ca�srRucriaN Pe�m� q q o 0o s� 3 a - z� soeom F:.
OTHER ASSOCIATED PERMIT#[dappacable) ToP Bauom FE. . .
SITE V1lEt11D#�r a�'pGcablea--- . 9. SCREEN: Uepth diameter Stot 8ize Naterlat
3.WELL LlSE(CheckAppf�cable Box): ResidenUal Water Supp►y� � Top Battem ft �a. In.
DATE DRILIEb S"'�V'l a. Top BaHom Ft. in. in.
T1ME COMPLE7ED �= �_ AM p PM(� Top_„_^Boricrn ft in. in.
4.YYELL LOCATION: : 10.SAN�1CiRAVE1.PACK:
c�rr �C`noeaC.sy�� ie, o�c,n, s�e M�ai
COUNTY T!R1! T o p B o t t o m F t
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-- {S�eet hlame,Ku�Gomfr�ufs�y,�5ubdivision,Lot Na,Parcel,Zip Codey ToA $OltCm Ft
TQPOGRAPHIC/l.ArlD SE7TUttG: (check appropriatabw�
pSlope ❑Vatley ❑Flat pRldge OOthec 11.DRItUNGLOG
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Latitudellong�udesDurce: []GPS [�iopograpAiCrs�ap ��� "
{foceUon af wellmust be sAown on a USGS tc�v maFrenuhttaGrsdlo �
this fam Hnotusir►g GPS) 1
5.WELL OWNER � n • /
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OHmerName �
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sueet A�ddress �
4�Y1 ocaGsv i�le: t�c. a'7�a� ,
Ciry or Tawrt State Zip Cade �
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Area code Phone number
: '12 �R�NIARKS
6.YVELL DETATI.S: ,
a. TOTl.tl.4�PTFi• �a��
h_ DOESINELL REPLACE EXIS�lNG WELL? YES� NO�
; 1 DO.}iEREBY-CERTIFY�TIiAT THIS 1NELL 1NAS CONSTRUCTEO IN
c. {tIFATER LE1�L Befow Top oi Casing: 5 � FT, : ACC08DA1JCE WIT�1�15A NCAG 2C,V�IELL CONS'CRt1CTlON
(Use'+"df Above Top of Casing) = STAtJDAR05.J�ND�kWT A COPY�THtS RECORD HAS BEEN
� PROVIDED'T'��Tl1E YV�LL OV111YER
tL 7�P OF CA3f1YG(S___�j_�O,_FT:Abov�Lant!Surface'
`Top oi casi�g ter�Inated aVoa below la�su�'�e may�+equ�le �� . (� ,�'—"`r��-i�1o2
s�va.iano�in oeeardaneo wier+i5A iJC`Jif.'1[:.M1B- - D7C:t�l.1TURG OF C6fi IFICD W6LL�.0 7R11�C'fOR QAT�
e. Y�ELO(9[�n1: � METHOD OF TEST Air ����€..�. �J S'!�c-�uJ
f. DISINFECTION:Type ��"� Amount 2 tablets : PRIN'fiED NI�ME OF PERSON COkYSTRUCTING TH�WEii.
Submi�anr�ttiin 30_ttajrs nf comptetio�tb:�ivisi�p:of Wafec.Qirality==fnfonnaticrs.Pr?oeess'ic�,• Form Gw-1 a
Is�'I'�:�Ad�l$8NTC6 C�A�Efi Ralelgti.-N�.2769g16'1;"-F�horte�:.#9'19j�80Z=G�00 . : . . •. .• . - .. - Rev.2l09