322 Blevins RdDavie Countv, NC
Tax Parcel Report Friday, October 7, 201 E
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WARNING: THIS IS NOT A SURVEY
All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
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Parcel
Information
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Parcel Number:
B30000005207
Township:
Clarksville
NCPIN Number:
5823099209
Municipality:
Account Number:
82527678
Census Tract:
37059-801
Listed Owner 1:
WEST BILLY G
Voting Precinct:
CLARKSVILLE
Mailing Address 1:
6166 HAYWOOD STREET
Planning Jurisdiction:
Davie County
City: CLEMMONS
Zoning Class:
DAVIE COUNTY R -A
State:
NC
Zoning Overlay:
Zip Code:
27012-0000
Voluntary Ag. District:
No
Legal Description:
0.913 AC BLEVINS RD
Fire Response District:
COURTNEY
Assessed Acreage:
0.93
Elementary School Zone:
WILLIAM R DAVIE
Deed Date:
9/2006
Middle School Zone:
NORTH DAVIE
Deed Book / Page:
2006EO326
Soil Types:
MnB2,MdC
Plat Book:
Flood Zone:
Plat Page:
Watershed Overlay:
DAVIE COUNTY
Building Value:
0.00
Outbuilding & Extra
8450.00
Freatures Value:
Land Value:
14840.00
Total Market Value:
23290.00
Total Assessed Value:
23290.00
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Davie County,
All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
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
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NC
or arising out of the use or inability to use the GIS data provided by this website.
►� Well Construction Permit
Davie County Wealth Department
,r >s 210 Hospital Street
t-�
i r P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Property Owner: Billy Glenn West
Address: 6166 Haywood St
Cay: Clemmons
State2ip: NC 27012
Phone #: (336) 749-6877
For Office Use Only
*CDP File Number 121479
PIN Number: B30000005207
Tax Lot #: Tax Block #:
Evaluated For: WELL
PERMIT VALID UNTIL: 511412018
Applicant: Billy Glenn West
Address: 322 Blevins Road
Cay:
State2ip: NC
Phone 9:
Property Location & Site Information
Address/Road u: Subdivision:
322 Blevins Road
Yadkinville NC 27055
Site Address: 322 Blevins Road
Phase: Lot:
*Proposed use of Well:
Directions If Other:
Directions: Hwy 601 N. Right on 801 Left on Four
Corners to Left on bevins Road.
Well Contractor Information
Drilling Contractor Driller Registration
Permit Conditions
*Permit Conditions
Well location, instalation, and protection must meet all state and local regulations and must be inspected and approved by an authorized representative of
the Local Health Department, the permit maybe revoked at anytime for failure to comply with existing regulations. The siting of the well by the Health
Department is to provide protection from the knmvn possible sources of contamination. The well site may not be changed without written permission from
an authorized representative of the Local Health Departmerd. fto volume or quality of water is guaranteed by the Health Department
*Issued By: 2244 - Daywalt, Andrew *Date of Issue: 0 5 / 1 4 / a 0 1 3
01 -land Drawing Olmport Drawing
Authorized State Agent: **Site Plan/Drawing attached.**
WELL CONSTRUCTION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 121479
County File Number: B30000005207
Date: 0 5/ 1 4/ 2 0 1 3
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►pe: Well Permit ca e. oc
QN/A ft.
ZGA,P CATION 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 `
Po pe r4� L ; Ne
dISP�tb.
A&VL �)rdy
m o ind W�w-4�7
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
h
APPLICANT INFORMATION
Name i ' e Contact Person 13;1jjZ to ,
Address Home Phone
City/State/ZIPC�l erY, rr. o �v s { !\1�, 9 a l a. Business Phone lV%A
Name on Permit if Different than Above
Mailing Address 4/&6 /�ow wvoc� S�, City/State/Zip
PROPERTY INFORMATION .*Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accom any this application. Included: ❑ Site Plan ❑Plat (to scale)
Owner's Name ;1 /v C Iewu WQO T Phone Number 336-_9Vcj
Owner's Address �/ �� f-/e.,.1�3odd St, City/State/Zip CJe,r r,,o�.?S, lyC a')O/a
Property Address 3,Q a R Ie.y'f? City
Lot Size , 9 Tax PIN#
Subdivision Name(if applicable) Section/Lot#
Directions To Site: (�gl lel ±0 20/ furp, L.e:f o+v &,,r nurncts 4- Lc" -M gi�,VojS RA,
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 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.
- -b V&Pz4a��:
Signed Da
Site Revisit Charge
Date(s):
Client Notification Date: _
EHS:
7/30/09abp I -I I ��Account #_ (� l Invoice —#
• 477
130 1 351
IN N
522
366
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All data Is provided as Is without warranty or guarantee of any kind either expressed or implied Including but not limited to the implied
UVI 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 or arising out of
the use or inability to use the GIS data provided by this website. P ri n ted .May 03, 2013
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+. .,
.RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quali
�qwu "% WELL CONTRACTOR CERTIFICATION # �3
1. WELL CONTRAE
O
Well Contractor (Individual) Name
YADKIN WELL COMPANY. INC.
Well Contractor Company Name
1908 HAMPTONVILLE ROAD
Street Address
HAMPTONVILLE NC 27020
City or Town State Zip Code
336 468-4440
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# �{ q
OTHER ASSOCIATED PERMIT#(ifap licable)
SITE WELL ID #Qf applicable) 3
3. WELL USE (Check Applicable Box): Residential Water Supply 9
DATE DRILLED S - 14-J-1)13
TIME COMPLETED 5 AM ❑ PMJ
4. WELL LOCATION:
CITY:�Z �QCOUNTY f
lee.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code).
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
'Slope ❑ Valley ❑ Flat []Ridge ❑ Other
LATITUDE 0'_ Z,. ODMSOR DD
LONGITUDE d7 76 � ffDMS OR DD
Latitude/longitude source: EIGPS Mropographic map
(location of well must be shown on a USGS topo map andaftached to
this form if not using GPS)
5. WELL OWNER
�ti, ha c 6A)e-rt
Own* Name
322 y er
Street Address
/1 d c oirC- j,- t vll�
City or Town State Zip Code
(33 r?`eq- X977
Area cotle Phone number
6. WELL DETAILS: 7^
a. TOTAL DEPTH: 0' 04
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOS
c. WATER LEVEL Below Top of Casing: .30 FT.
(Use "+" if Abbve Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm)• METHOD OF TEST 4 rDiem;
.
f. DISINFECTION: Type HTH Amount_ CUPS
8. GROUT: Depth Material / Method
Top-0 Bottom 3�Ft. Qt,1��'t,I' CA'.✓ �
(�
Top 3 Bottom 3Ft.�")-61tl111 -510",
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top / Bottom
�t. in. in.
Top - Bottom Ft. in. in.
Top - �� Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top BottomFt.
Top_ Bottom -4—
Top Bottom Ft.
11. DRILLING LOG
TopBot. � tom
I/i` /?7`
12L -IL;- l :Z q6
=141 l ;2 931
12. REMARKS:
Material
Formation Description
ro ,
rf �- (--�
JUN 0 5 2013
g. TER,ZONES (d pf ):
r +
TO
Top vt y Bottom
Topi'��TO�rnYt'�" '
rnh'L) I -j
' Top Bottom
Top Bottom
Thickness/
7. CASING: Depth // ` Diameter Weight Material
411 1 0.2r f )2, ;i t P V C -
Top Bottom Ft.
Top Bottom Ft.
Top BottoFt.
m
8. GROUT: Depth Material / Method
Top-0 Bottom 3�Ft. Qt,1��'t,I' CA'.✓ �
(�
Top 3 Bottom 3Ft.�")-61tl111 -510",
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top / Bottom
�t. in. in.
Top - Bottom Ft. in. in.
Top - �� Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top BottomFt.
Top_ Bottom -4—
Top Bottom Ft.
11. DRILLING LOG
TopBot. � tom
I/i` /?7`
12L -IL;- l :Z q6
=141 l ;2 931
12. REMARKS:
Material
Formation Description
ro ,
rf �- (--�
Q, f. P/ i- s I);,/
�!n�lJc✓
.iE.,r.7 5 q C
Bit Serial No:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
j 14 L', L C_1G, v 1..
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 3day of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : (919) 807-6300
Date Site Visited By:yQ Permit: eNo
What Is Height of Well Casing? Make Sure 12".,Above Ground Level!!!!
4 •S ice` 400
Form GW -1a
Rev. 2/09
BUILDERS NAME:
ADDRESS:
PHONE NUMBER:
of c
by: 54-JJblb.ilbdU VULH
Well Construction Permit
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
rC
ropertyOwner: BillyGlennWest
ddress: 6166 Haywood St
ffY. Clemmons
Staterzip: NC 27012
Phone #: (336) 749-6877
F'AUE 01/01
• *CDP 1=t1e�'��lumb�t;•;. '.'�',; •. . .
:. F'fiJ:IVtimber::B30�i�i••�'
Tilt Lot
•,.�Ev�ludtetl.��For`v1i1=L1'` • . •`•.. , .
PERMIT VALID UN -TIL: 5/14/2018
Applicant: Billy Glenn West
Address: 322 Blevins Road
CRY:
State2ip: NC
Phone #:
Property Location & site Information
AddressfRoad 0: Subdivision:
322 Blevins Road
Yadkinville NC 27055
Site Address: 322 Blevins Road
Drilling Contractor
'Permit Conditions
Phase: Lot:
"Proposed use of Well:
Dire. If Other: ,
Directions: Hwy 601 N. Right on 801 Left on Four
Comers to Lek on bevins Road.
Weil Contractor Information
Driller Registration
Conditions
Well location, instsll Won, and protection must meet alt state anti local regulallona anti must be inspected and approved by an authorized represergattve of
the Local Heelth Depattment, the permit maybe invoked at anytime for failure to comply with existing regulations. Thea stung of the welt by the Mealth
Department M to p.ovwc prottrciion from the lmoovn posslbte ;sources of contaaltnattm. The tired site may not be changed without written pe:fmKsion from
an authorized reprementnthm of the Loco Heatth Department. No vcl mee or quality of water Is guaranteed by the Health Department
"issued 8y: 2244 - Daywalt, Andrew "date of issue: 0 5 / 1 4 / ;2 0 1 3
Aulhorized State Agent: ** ®Hand Drawing OImport Drawing
- Site Plan/Drawing attached.**
dt / lb/ 1bl.i by: b4 JJb /bdl bUU VULN F AUL FAL/ b1
. WELL CONV7RUCTION PERMIT 129479
Davie County Health Department CQP File Number
210 Hospital Street
P.U. Box 848 County File Numbersa000000s2o�
Mocksville NC 27028 pad; e 5/ 1 4/ I a 1 3
U Inch
Drawing Type: Well Permit Scale: , osv o k —'ft
�, �.. • mel07!
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