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177 Bath Lane Lot 2• Davie County Environmental Health - P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 Account #: 990005528 Billed To: Sugar Valley Airport Reference Name: Proposed Facility: Residential -Well WELL PERMIT Tax PINIEH #: 5851 -26 -8843 -Well #1 Subdiyisiorr.ir3to: = Sugar Valley Airport Lot # LocationiAddress: Gilbert Road -27028 Pr6perty Sizb ",, 63 + Acres ATC Number: 0068 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 [P Repair ❑ Abandonment ❑ Proposed Well Location Diagram to Y � � 1 i r J Arwu-e r �- ram Comments: �M1j;Aloin 7-!t'Lcrc(— 11 � Driller: iice Certification #: Grout Inspected: 3 — 3 /0dl 3 2-' r Well Head Inspected: l �%y�ZQ & A0 GPS Co Inspected: 3 Z� oU�3�07 EHS: Date: ���� l EHS: L(k Date: !i :FqlZql W.P. 7-08 2 APPLICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health P.O. Box 848/210 Hospital Street 6 OD Mocksville, NC 27028 2 (336)753-6780 / Fax (336)753-1680 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. a, APPLICANT INFORMATIONp Name t Contact Person Address al' Home Phone -3 a-& % City/State/ZIP m 713 Business Phone �r,�j,�)r % Name on Permit if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey pipt or site plan mus�acco any t . applicatio ded:'V,Site Plan ❑Plat (to scale) Owner's Name_ (/ Phone Number Owner's Address City/State/Zip Property Address City Lot Size Tax PIN# q3 Subdivision Name(if applicable) Section/Lot# Directions To Site: DEVELOPMENT INFO ION Permit Type: New Well Well Repair Well Abandonment Other (specify) Facility Type: Residential Food Service Church Com rcial 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 7 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. Signed Date 7/30/09 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # _ Invoice # od IN -1, 41 n7., r i 1. Oeartlt*dew? stood, tertitf that th{s Plat we drawn Nader w sep rviNN trent as adtaat ow*07 Grp Mader ft osper•1.1M (dao dtaer 1pttea ratMea4 tit Book -.JL -• ►Alt ..a� . too. ) ( ether ): that ?he NaadN las def 'ntrNeriM WrWo.toorty I"I"ted its from fraa iaf*rmtiea to"* It book -- pope . ,Pape... , firot'the ratte of keeltlea as ealevietod Is 1/10.000: that this plot net MNared it atoNdAeo Witt S.S. 47-90 as ereNN, Wltaoss ON erltlaal stesoloro. rdeletretion eNn►er dad seat rA to 13 rer of Ocb*W s. o. 2010 a RB 824 O PG 319 $soh or $temp George R. Stone Sor Vol or L 3162 �s'S,ly��'�J(t';•� RotUtretIea tougher STATE OF NORTH CAROLINA COUNTY OF DNIE L *"I" os art 8ltt a. Nei uiew tato some, ►. L-Ma�owft M am of Via I No 1l+0 w bdbftd eat. In or CI . 0 a Ud Oho rota to M t SWAY SM aaMe a VAb* hfa Of toed +Moa WN ads of • "NOW r MA**w 00 Boss No ardin s that reowd o permit M talo C) ►. hest eft MMR Is of a a waW OW Y boomed In such pw*o of a awry or ssnik`kt0- tot Is rNe*detsd No to an ordinssos " alNow perm of it* 0 e, Thal tide pet i er • s -o" aim aMhq paod w paallo of WA © d. That ufe post Is of a Nevar of ateaw cal 91 ). such as urs r.earibboWn of altene taks.ia a goad!-arwd Nor No or ON - 1 11 ttar111 to the dsftddm of eAdhili rK ci e. "Wt as krIII rnvr-, dianeal Is " WNW M swo lh.t ► an unshm to WWW • deftrokaesa is ow bel at aw Parsed"" edge No b prorWarra serttraed in (a) tl~ (4 shard George R. Stone, PLS rz_yd�f,_ __ IN M osM. L-3162 a Exempt Minor SmbdivWrrsl I, Andrew NeadweN, Review Officer of Dovle County. oerft y1110 or plat to which this cartffkotion Is afrmd i mquirernents for recording. gearing Orientation optic REI824 O PG 319 "NO APPRON REQUIRED 131f THE COUNTY PLANNING DEPARTMENT' PlannhV or ,r W T-4 N_ (not to stole) Filed for r�gIsiratleR of �Lr`fi.aI*eY �:Y Gilbert Road SsR•1437 KoffpaW lV LOD- all r scar dad 60' Public R/W 20'+/- Pavement In /IN sash _...�-, Pddt ��• 3 k eront fMet, Raalster of Deeds Filing Fe Peid t i CALL TABLE FOR SINTER UNE OF 0EVVTY-1kTV4jA1ff ACCESS, UTILJTY, & SEPTIC SYSTEM EASEMENT COURSE BEARING DISTANCE E-1 S 84.43'49"E 40.59' Tie line E-2 N 41042'29"E 120.180 E-3 N 41.4T29"E 100.05' E-4 N 50'23'40"E 76.62' E-5 N 72.22W E 119.09' E-6 S 85.09'08E 126.14' Tie Line E-7 S 14'00'38"W 30.16' Tie Une E-8 N 14`W35"E 30.16' Tie Une E-9 S 85Vr56"E 28.34' 1 1 E-10 N 3005r01"E 206.58' E-11 S 85.02'S6E 21.36' E-12 S 23.28'50'W 155.56' E-13 S 02.15'24"W 88.38' I E-14 S 16*34'14"E 252.59' E-15 S 04004'?9"W 176.36' � � I I Tax Lot 3.01 Tax Map E-6 r n/f Daniel S. Stanley _ _ € do Mary Beth S'taniey �! g DB 170 O PG 236 Tax Lot 4.03 Tax Ma E-6 Tax Lot 4.04 ! n/f Wayne M. Hemphill Tax Map E-6 i . C/L 30' Access, Utility, O Septic System / I n/f Denise Cynthia Wilson i- W DB 146 O PG 771 DB 144 O PG 501 W Easement f15' each side C/L) / IRS L-_5 LOT 4 fr 0.929 Acres +/- CC Tax Lot 4 Tax Map E-6 n/f Human Service Alliance, Inc. RB 824 O PG 319 IRS L-6 F F__,� t� o LOT 3 _I• o rO i► N O 0.929 Acres +/- T -Bar w/cap Fnd o see Easement Can Table / I T-2 � �`\ E-1 Sugar Valley Trail _ _ _ _ _ / IRS T-3 1 /2" EIR Fnd Utility, do Se tc System ' E-6' LOT 1 C/L 40' Access, ty, pt' ys �Tax Lot 3.03 F Easement (20 each side C/L) z S-2 Tax Map E-6 See Eosement Call Table zz u $ e ~sem F` Phase I / n/f Stephen L Leighton W W?�,, 3 _LOT 2 ' &Deborah G. Leighton RB 832 O PG 83 / E-13- °la, `I o Phase I f�12 f I of 4 Gravel Drive ' \ _ _ _ _ ` , ° R "' � / S, Ji E-15 20.00' h L-3 IRS CC L-2 IRS CC .- .-.- C/L 30' Access, Utility, dt Septic System Easement ( ' each side C/L) See Easem Call Tobl F � S ar yule CALL TABLE FOR Run2vQy PHASE it / LOTS 3 do 4 SEPTIC SYSTEM EASEMENT AREAS COURSE S-1 S-2 S-3 S-4 S-5 S-6 R/W - Right -of -Way LEGEND FC - Foos of Curb S-7 EIP - Existing Won Pipe BoC - Back of Curb S-8 13R - Existwq War Rebar PP - Power Pole S-9 P - Post LP - Light Pole S-10 CM - concrete Monument MH -Iran Hoh S 41.42'29'W 83.79' (P,:/10 C� Distance S-11 PPFS A - � � of S-1 %k - ControsN Access D8 - peed Book S-13 3 Cp _ Concrete Pipe PB - Pat Book S 87.10'30"E CMP - cotwgobd metal Pilie R8 - Record Book S-14 CPP _ Corrugabd PRastie Ptps PG - Po9e S-15 -F- tea Tear Flood ewalaary C8 - CaEeh 8�in -a- Overhead Utpftles -S- Sower line -x- Fenoa WM - Water Motor Fnd - Found WV - water Volvo n/f - Now or Formerly BM - Beth Maio Nw>Rronurnarbed Point TBM - T ry Bench Mark CL - Center' Line RRS - Rd1 Road Spike EP - Ed" of Plovernent CN - Cobh TOW4ision Pede stal TP - ToWene Pedestal ETB _=Transformer Box -W- Wrier tine CO -San Sower Clean Out X - NMP (Nonmonumonted Point) R/W MON - Concrete R/W Monument IRS CC - 1/2" Rebor Set Control Monument 100 0 100 200 300 GRAPHIC SCALE - FEET BEARING DISTANCE S 85.02'56"E 59.78' Tie Une S 85'02'56"E 107.24' S 85.02'56"E 21.43' N 30'57'01 "E 61.43' N 30.57'01 "E 61.43' N 77.36'00"W 91.92' S 41.42'29'W 83.79' S 41.42'29'W 68.92' N 85.02'56'* 114.36' S 66'09'31 "E 30.23' Tie Une S 85002'56"E 37.16' N 33.30'38"E 124.67' S 87.10'30"E 42.84' N 22.44'22"E 17.73' N 74.08'57"W 76.87' I (we) hensby oertify that I am (we aro) the owner(S) of the property described herem which is located in the su""an kalsdation of Davie County and that I hereby adopt this subdivision plan with my free oaneent, estateshed miMmum building setback lines and dedkxite all sh ots. alleys, wallm port and other site and easements to public or private use as noted. r ' .Zero Zo 40,4__ M6 OwuKtQ s 10 �y\ t Neel Rood { GrIn Building Septic Repair Area House Easement for LOTS 3 See Ca.l Tax Lot 4 Tax Map E-6 B 824 OPG 319 f Human Service Alliance, Inc. R PROPERTY UNE CALL TABLE P14ASEN/L07S3O4 COURSE BEARING DISTANCE L-1 S 85.55'41 "E 224.90' L-2 S 04.04'19"W 180.00' L-3 S 04.04' 19'W 180.00' L-4 N 85'55'41 "W 224.94' L-5 N 04.04'38"E 180.00' L-6 N 04.04'38"E 180.00' L-7 N 85'55'41 "* 224.92' l� IT��I�►I�Ia�lil�1_�::•� COURSE BEARING DISTANCE T -i S 27.11'56"* 26.35' T-2 S 83.45'05"E 60.17' T-3 S 04.04'38'W 454.79' T-4 N 04004'38"E 669.22' AN LOT 1 Septic System Easement Area F 4% See Phase I Plot LOT 2 Septic System Easement Area Survey f ori See Phase I Plat Sugar Valley Airport 100 YEAR FLOOD HAZARD ZONE (AE) -F Phase ff REFERENCE "FIRM" (FLOOD INSURANCE RATE MAP) MAP NUMBER: 3710584000J LOT 3 do Lot 4 PANEL 5840, DATE. 9-17-2008 Port of Tax Lot 4 E Tax Map E-6 Record Book 824 O Page 319 F F LOT 3 Acreage: 0.929 Acres +/- OWNER. LOT 4 Acreage: 0.929 Acres +/- Human Service Alliance NOTES: 3983 H.S.A. Circle 1. Zoning: R-20 Total LOTS 3 do 4 Acreage: 1.858 Acres +/- Winston-Salem, N.C. 27101 2. Minimum Building Setback Lines: All Area Computations by Coordinate Geometry Front: 30', Rear. 30, Side: 15' SCALE TOWNSHF COUNTY STATE DATE 3. Watersliod Classification: None 1 " = 100' Farmington Davie North Carolina 10-13-2010 4. No USGS or NCGS Monuments found within 2000• of site. Stone Land Surveying Company 5. All shown distances are measured SURVEYED: elmMirteee Firm Cartiiloole Nwnbw: t:-CM4 ,hoe oto. horizontal ground dwancea• Dg,MT 761OS2 6. NI proposed homes shall be constructed MAppED: George Nobut Stone, KS L-3162 MAP NO. with the lowest floor being a minimum of 113 Drum Lone (336) 998-4733 761052 2' abovethe 8FE (722' NAVD 88). GRS Mocksvilie, N.C. 27028 ESIDENTML \VELL CONSTRUCTION RECORD �EC'V 1l North Carolina Department of Environment and Natural Resources- Division of Water Quality APR 0 8 2011 WELL CONTRACTOR CERTIFICATION 9'57-72- DA11lECUUNiYHEgLfhpt1HKffrElu 1. WELL C NTRACTOR: At" LP M L l Well Contract r (Individual) Name YADKIN WELL COMPANY. INC. Well Contractor Company Name 1908 HAMPTONVILLE ROAD Street Address HAMPTONVILLE NC 27020 City or Town Slate Zip Code t 336 ) 468-4440 Area code Phone number 2. WELL INFORMATION: WELL CONSTRUCTION PERMIT# D O OTHER ASSOCIATED PERMITt(d Eppl.cable) SITE WELL ID V(d applicable) /C - 5? 3. WELL USE (Check Applicable Box): Residential Water Suppl {5 DATE DRILLED "1�- TIME COMPLETED 61. Co AM ❑ PC'I¢ g. WATEF ZONES (depth : Top 31 Bottom 31 Top Bottom Top Bottom Top Botton Top Botton Top Bottorn LONGITUDE °_' Thickness/ 7. CASING: Depth Diameter Weight Material Top��Bottom '_FLfO•��5 rsV�'� _ -, Top Bottom Fl Top Bollom Ft. E. GROUT: Depth Material Method Tcp � Bottom—;3: Ft. � •n�"M - fp TcBottom 30 FI F!1' anx Q Top Bottom Fl 9. SCREEtI. Depth Diameter Slot Size fdaterial Top Bottom__ Ft in in _ Top Bottom FL_ in in Top Bottom FL_ in in _ 4. WELL LOCATION: 10. SAND/GRAVEL PACK: —� Depth Size CITY: ((fir ,�/a- COUNTYTop Bollom_ Fl _ Top__Boltom Ft (Street Name, Numbers, Community. Subdivision, Lot No, Parcel, Zip Code) Top Bottom F L _ TOPOGRAPHIC /LAND SETTING: (check appropri3le box) Slope ElValley ❑Flat DRidga DOlher LATITUDE °_' _" DMS OR DD LONGITUDE °_' " DMS OR 6 S -Z DD Lat Jude/longitude source: PPS QTopographic map (location of well must be shcavn on a USGS Popo map andattached to this form if not using GPS) 5. WELL OWNER St�'g 1, Owner Jame t Vo let, ' 41 Lia r -1 r.p or Street Addr29s City or Town Stale Zip Code Area code Phone number 6. WELL DETAILS: a. TOTAL DEPTH: b. DOES WELL REPLACE EXISTING WELL? YES O 110,e i e. WATER LEVEL Below Top of Casing: FT. (Use "+" if Above Top of Casing) d. TOP OF CASING IS I FT. Above Land Surface' 'Top or casing terminated aUor below land surface may require a variance in accordance with 15A NCAC 2C.01 18. e. YIELD (gpm): 30 METHOD OF TEST /r �0" A A f. DISINFECTION: Type HTH _ Amount -lb, CupS 11. DRILLING LOG Top Fygllgn� It o' Ufa / 3�ta• / / 1 12. REMARKS: r.taterial Formation Description SIZE OFF • C) (0� BIT SERIAL NO: Nclper- C�r`3. r►l�ss �t I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER �ATURBWFCERTIFIED WELL CONTRACTOR DATE PRINTED N ME OF PERSON CONSTRUCTING THE WELL Submit within 30 days of completion to: Division of Water Quality - Information Processing, 1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807.6300 Date Site Visited ,Z ,,313--V-By: VO Permit: Yes No What Is Height of Well Casing? Make Sure 12" Above Ground Level!!!! Form GW -1a Rev. 2/09 i �o/ I dr'( x 1. tsar" flabo Uwft P1 LwW Swmyw L -315X ovVy to ow of Ise F, I - I as kWbded Ums. [@ or &r: 0 4L Thd ode plat is of 43 sw ve riot crealse a ab*AAm of kind 1U se sm a em* or WAVACk"ft tud has an that regulutes I I of We: b. 1hat oft pht Is of a riney fast Is 1, In such P" do of a owj*or ­ikIpdlbJ%@tbvwequkftdastDsnwdkww* od .11' po"0011001100A 0 C. Thet Oft plot Is of a swww of an I Il pwool or pemele of ism. d. Dwk okle pld Is of a w vq of IN I p, ) such 4m the ru-- , -- of , " I a esert—wdered or other 0004en ft- &A I N 1-1 of VA&Asim 0 %A ow h" wigNm6ft to thb wurvWsr is such that I am uft" to wm*o 9 -1 16 -0 to Ift beg of "w p I am" as to 0 In (4) Slaup (4) George R. Stone, PLS L-3162 Site Plan ;V Up CD C) 0 C) 0 3/4" VP Fnd rll_k� .... I- ""o . (L V-7 S L-3162 I declare that an 47 ' I ) . 20 Y?I- we surveyed the property shown on this plob Tie Una S 82*39*16"E 293.00' (D 4 40 Tax Lot 2.02 z Tax Map E-6 0 n/f Allen J. Hutchins -4 & Faye J. Hutchins 8 DB 98 0 PG 132 C! LOT 2 1;t PB 9 0 PIS 15 M Tex Lot 19 Tax Map D-6 n/f 9"tt Form, LLC RB 812 0 PG 181 S 82*37*W'E 139.96' FC - Face of Curb 3/4" EIP Bent/Fnd IRS CC EIR - ExistIng iron Rebar PP POW4W Pole P - poet LP - tjot Pole C/L 10, W MH - Man Hole eachone Eca's?"ent Bid& tip 0 Of C/0 P/0 - Port of N D13 - Dead Book 74*08-04-1w Pe - fW Book Shed F-1 S 82-37'60"E 180.10' q/ 2" OP Fnd Building LOT 2- 0.937 Acres UY. 72' ---------- 'a 3'2.00'— 0. Proposed t L House IRS CC Location Point 8 rn House Concrete -------------- Drive S 0 ------------- Gravel Drive Approximate N 17*05*40"E Septic -:, LOT 1 133.93' 1 system Lr h 1.006 Acres Cqwml Drive z Location C/L 30' Access Easement (15* each side line �-B) NOTE: This prop" is subject to all easernents. righi:-of-ways, strests and osessernarft, If any, as the son" rnay appear of record In the of the Register of Opeds. Clerk of Coutt Town or County Tax office or which may have been acquired by prescriptivv use. This survey is subject to any facts that may be disclo*4 by a ftA mid accurate title sewch. NOT furnished an of this date. This rT=p or drmA"q and any occo"Worryms docurn4oft ore furrwsW to the peiew s Uwvon and no alterations or use by athen; is permitted -61 authorized by Stone Land Surveying Co. certified copies of thia Survey fh0p will not be issued beyond -nW90) days of the ongind su-sy "a - Map not for r000rdation. Precision 7:10,000+ Tex Lot 4.01 Tax Map E-6 n/f Babbitt Form, LLC RB 812 0 PG 160 I I - C\, % I t A S UR Tie Line 169.2 S 88039'55"E 39.33' L /2" EIP Fnd 3/4" Elp Fnd IPFnd .3/4 'Jil .w 3/4" EIP Fnd 32-09 129-10' N slr��Z� Bath Lane 10'+/- Private Gravel Road 40.1'+/— Private Easement per D8 38 0 PG 132 S " - wight-of-" LLUM FC - Face of Curb FJP - Existirig Iran Pipe BoC Back of Curb EIR - ExistIng iron Rebar PP POW4W Pole P - poet LP - tjot Pole cm - Concrete Monufflent MH - Man Hole RS - Won Rebor Set CH - Chord Distance PA - Prop" uns P/0 - Port of C/A - Controlled Access D13 - Dead Book CP - cwcreta Pipe Pe - fW Book CMP - corrugaw mew P" RB - Rocopd Book CPP - Corrugated Plastic Pips PG - PM -F- 100 Year Flood Boundary ce - C t Basin --0- Overhead Militias -S- Sews Une -X- Fence WU - Water "or Fnd - Found WV - water Vol" n/f - Nft or Forrnerly SM - Bunch Mark found within 2000' of site TBU - Tamp Bunch Mark CIL - Center Une RRS - Roil R= Sp" EP - Edge of Pa"mont CTV - Catile Tslvoipian Pedes al TP - Telephom Pod ET9 - Electric Tronvforrner Pox -W- Water Una 00 - Sanitary Sewer Clean Out IRS CC — 112" Rebar Set Control Comer X - NMP (Nonmonumented Point) Part of Tax Lot 4 Tax Mop E-6 n/f Human Service Alliance a NC Non -Profit Corporation RB 824 0 PG 319 Site Plan for: Human Servie Alliance, A NC Non—Profit Corporation LOT 2 Port of Tax Lot 2.01 Tax Mop E-6 NOTES: PIN 5851274990 1. Zoning: R-20 LOT 2 Acreage: 0.937 Acres 2. kfinimum Building Setback Unes: Area Computations by Coordinate Geometry Front: 30', Rear. 30'. Side: 15' SCALL TOWNSW OOUNTY STATE WE 3. Watershed Classification: None 4. No USGS or NCGS Monuments 1 50' Farmington Davie North Carolina 9-11-2012 found within 2000' of site Stone Land Surveying Company SURVEYM: RS,PH &&*wu Firm Cortiticalle Mxnber C-1704 10012S George Robert Stocle, PLS L-3152 MAPPED- MAP NO. 1 13 Drurn Lane (336) 998-4733 GRS A 10012S Mocksville, N.C. 27028