316 Bracken Rd Well Construction Perth it For Office Use Only
Davie County Health Department *CDP File Number 124590
�- 210 Hospital Street
P.O.Box 848 PIN Number: F3=000-00-072-01
=•' Mocksville NC 27028 Tax Lot#: Tax Block#:
Phone:336-753-6780 Fax:336-753-1680 Evaluated For.WELL
PERMIT VALID UNTIL: 5/21/2020
Property Owner: Tim Wall Applicant: Tim Wall
Address: 234 Sheffield Farms Trail Address: 234 Sheffield Farms Trail
City: Harmony City: Harmony
State/Zip: NC 28634 State2ip: NC 28634
Phone#: (336)831-5885 Phone#: (336)831-5885
Property Location & Site Information
Address/Road#: �(� Subdivision: Phase: Lot:
Bracken Road *Proposed use of Well:
Mocksville NC 27028
Directions If Other.
Site Address: Bracken Road Directions: Hwy 601 N.on right just past Happy Trail,
Bracken Rd on right, property on right at end.
Well Contractor information
Drilling Contractor Driller Registration
1 1 1 1 I
Permit Conditions
*Permit Conditions
1
Well location,construction 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 may be revoked at any for failure to compywith existing regulations.The siting of approved well construction
area(s)by the Health Department Is to provide protection from the known possible sources of contamination.The approved well area(s)may not be changed
without written permission from an authorized representative of the Local Health Department.No volume of quality of water Is guaranteed by the Health
Department..
*Issued By: 2140-Nations, Robert *Date of Issue; 01 5 / a 1 1 / 2 1 0 1 1- 5 1
Authorized State agent: ®Hand Drawing Olmport Drawing
Owner/ApplicantSigna '�*Site Plan/Drawing attached.**
WELL CONSTRUCTION PERMIT 124590
µ 6 Davie County Health Department CDP File Number:
210� Hospital Street F3-000-00-072-01
P.O. Box 848 County File Number:
Mocksville NC 27028 Date: 0 5 / 2 1 / 2 0 1' 5
aw
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Drawing Type: Well Permit Scale: QNiA k
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APPLICATION FOR PRIVATE WELL PERMIT
RECEIVED Davie County.Environmental Health
P.O.Box 848/210 Hospital Street
late: Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name �� �✓� �� Contact Person
Address Home Phone 3-ye— k Ys-:Y-
City/State/ZIP
s-:J'City/State/ZIP 2 V-/3 Business Phone
Name on Permit if Different than Above
Mailing Address Sa.4e— 'City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or plan m t accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
Owner's Name 7-2,1 k/a /1 Phone Number
Owner's Address 2 3 y sl�yf,e / •..-��r T/ 44 f"exl' -City/State/Zip ,04.-
PropertyAddress 3Qv City /Nd�bd.%/t
Lot Size /3 PC.--v Tax PIN#
Subdivision Name(if applicable) Section/Lot#
Directions To Site: G Dl A) 3^:&S 114
- ---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.
Si Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
7/30/09 Account#
Invoice#
OPERATION PERMIT or iticeuseurilv
Davie County Health Department *CDP File Number 124590-1
210 Hospital Street F3-000-00-072-01
P.O. Box 848 County ID Number
Mocksville NC 27028 Evaluated For. NEW
Phone:336-753-6780 Fax:336-753-1680 Township.
Applicant: Tim Wall Property Owner: Scott Joshua Bracken
Address: 149 Chance Lane Address: 319 Windward Circle
City: Mocksville City: Mocksville
StatefZip: NC 27028 State0p: NC 27028
Phone#: (336)831-5885 Phone#:
Property Location & Site Information
r
dress/Road#: Subdivision: Phase: Lot:
316 Bracken Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 N. on right just past Happy Trail, Bracken
Rd on right, property on right at end.
#of Bedrooms: 3
#of People:
*Water Supply: NEW WELL
*IP Issued by. 21ao-Nations,Robert "System Classification/Description:
TYPE 11 A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert
Saprotite System? QYes Q No
Design Flow: 3 6 0 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Pump Required?
QYes QNo
Soil Application Rate: 0 - 2 5 *Pre Treatment:
Drain field
rNo. DminLines
on Field 1 4 4 0 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD
3 Installer: Brian McDaniel
Total Trench Length: 3 6 0 g• Certification#: 1118
Trench Spacing: — 9 Inches O.C.
Feet O.C. *EH S: 2140-Nations,Robert
Trench Width: 3 Inches
• Feet Date: 0 6 / 2 3 / 2 1 0 5
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4Inches Approval Status
Maximum Trench Depth: 3 6 Inches
®=Approvetl Disapproved
Maximum Soil Cover., a 4
Inches
CDP File Number 124590 - 1 County ID Number: F3-0°aoao72-o1
Septic Tank
Manufacturer. Shoaf Lat.
:
STB: 760 Long
Gallons:
1000 Installer, Brian McDaniel
Certification#: 1118
Date: 0 3 / 0 1 / x0 1 5
'EHS: 2140-Nations,Robert
"Filter Brand: POLYLOK PL-122 With Pipe Adapter
ST Marker: El Yes ® No oats: a 0 1 6
6 / a 3 /
Reinforced Tank: ❑ Yes ® No Appoval Status
tPiece Tank: ❑ Yes ® No '® Approve ❑:Disapproved
Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: 'EH$:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
Riser Height: El Yes C3 No (Min.6 in.) pP q rovalStatus
einforcedTank: El Yes El No ❑ gPP
rove 0,Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
FPipe
ize: inch diameter Installer:
gth: feet Certification#:
Schedule: 'EHS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings [I Yes ❑ NoApprovaISfetus
❑ Approved❑ Disapproved
ump Rgqulrement
Pump Type: Installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches "EHS:
*Chain: /
Date:
Valves Accessible ❑ Yes ❑ NO
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No Approval'status
PVC unions Q Yes ❑ NoCI Approved❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole El Yes ❑ NO
CDP File Number 124590 - 1 County ID Number: P3-000.00.072.01
Electric Equipment
rNEMA4X Box or Equivalent ❑ Yes ❑ No Installer:
Box 12 inches Above Grade ❑ Yes ❑ No
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ NO
Conduit Sealed ❑ Yes ❑ No *ENS:
Pump Manually Operable ❑ Yes ❑ NO
*Activation Method: Date:
Approval Status
Alarm Audible ❑ Yes ❑ No
❑ Approved 0",.""D isapproved
Alarm Visible ❑ Yes ❑ No
2140•Nations.Robert
*Operation Permit completed by:
Authorized State Agen Date of Issue: 0 6 / 1 5 / 2 0 1 5
Owner/Applicant Signature:
This system has been installed in compliance with applicable NC General Statutes:Article 11,Chapter 130A, Rules for
Sewage Treatment and Disposal,15A NCAC 18A.1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE 11 A sewage septic system.
Rule.1961 requires that a Type TYPE 11 A septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: NIA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator:N/A
Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract
with a public management entitywith a certified operatoror a private certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a
public management entitywith a certified operator for the life of the septic system.
Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements formaintenance and
operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as long as the
system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 124590 - 1
Davie County Health Department CDP File Number:
210 Hospital Street F3-000-00-072:01
P.O.Box County File Number:
Mocksville NC 27028 Date:
Olnch
Drawing Draw0
Drawing Type: Operation Permit Scale: . ON A k
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CONSTRUCTION For Office Use Only
AUTHORIZATION *CDP File Number 124590- 1
="F' Davie County Health Department County ID Number:F3-000-00-072-01
J 210 Hospital Street Evaluated For: NEW
.!°, �. P.O. Box 848 Township:'
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax: 336-753-1680 0 5 / a 1 a 0 a 0
Applicant: Tim Wall Property Owner: Scott Joshua Bracken
Address: 149 Chance LaneAddress: 319 Windward Circle
City: Mocksville 7 City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)831-5885 Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Bracken Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 N. on right just past Happy Trail, Bracken Rd on
right, property on right at end.
#of Bedrooms: 3
#of People:
*Water Supply: NEW WELL
System Specifications
Minimum Trench Depth: a 4
resign
sification: Provisionally suitable Inches
Minimum Soil Cover: 1 a
System? QYes ®No Inches
ow. 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 a 5 Maximum Soil Cover: a 4 Inches
*System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0
Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes ®No
Pump Required: QYes ®No O May Be Required
Nitrification Field 1 4 4 0 Sq.ft. Pump Tank: Gallons
No. Drain Lines 3 1-Piece: QYes ONo
Total Trench Length: 3 6 0 ft, GPM--vs— ft. TDH
Trench Spacing: Inches O.C.
9 Feet O.C. Dosing Volume: Gallons
Trench Width: 3 Inches
Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre-Treatment: O NSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01011 O III 01V
Page 1 of 3
•
CDP File Number 124590 - 1 County ID Number: F3-000-00-072-01
❑ Open Pump System Sheet
Repair System Required:®Yes O No O No, but has Available Space
CDesign
System
Trench Spacing: g O Inches O. .
ification: Provisionally Suitable — ®Feet O.C.
Trench Width: j Inches
w: 3 6 0 — 3 Feet
Soil Applicatiori Rate: 0 a 5 Aggregate Depth: inches
.�
*System Classification/Description: Minimum Trench Depth: a 4 Inches
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover:
LESS) 1 a Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
Nitrification Field 1 4 4 0 Sq. Maximum Soil Cover: a 4 ft. Inches
No. Drain Lines 3 *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
Total Trench Length: 3 6 0Pump Required: OYes ®No O May Be Required
ft. ,
Pre-Treatment: O NSF OTS-I OTS-II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Re.-mi�9
750
*Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. Characters
2000
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been
completed during the period of validity of the Construction Permit,the information submitted In the application for a permit or Construction
Authorization is found to have been Incorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? O Yes O No
Applicant/Legal Reps. Signature: Date:
*Issued By: 2140-Nations,R ert Date of Issue: 0 5 / a 1 / ..1 0 1 5
Authorized State Ag Malfunction Log O Yes
Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 124590 - 1
210 Hospital Street
County File Number: F3-000-00-072-01
P.O.Box 848
Mocksville INC 27028 Date: 0 5 / a 1 / a 0 15
O Inch
Drawing Drawing Type: Construction Authorization Scale: , 00 Neck ft.
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Page3of3
P1 P2
r CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 124590 - 1
P.O.Box 848 F3-000-00-072-01
Mocksville NC 27028
County File Number:
Date: 05) -2-1 / .1 0 15
Click below to import an image from an external location: Drawing Type:Construction Authorization
POL V I..D G w M9-Ot,
f w
Page 3 of 3
P1 P2
CONSTRUCTION For office Use only
AUTHORIZATION "CDP File.Number 124590.-1
Davie County Health Department County ID Number.F3-000-00-072-01
21.0 Hospital Street Evaluated For. NEW
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 5 / a 1 / a 0 a 0
Applicant: Tim Wall Property Owner: Scott Joshua Bracken
Address: 149 Chance Lane Address: 319 Windward Circle
City: Mocksville City: Mocksville
State/Zip: NC 27028 State0p: NC 27028
Phone#: (336)831-5885 Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Bracken Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 N. on right just past Happy Trail, Bracken Rd on
right, property on right at end.
#of Bedrooms: 3
#of People:
*Vltater Supply: NEwwELL
System Specifications
CFIowMinimum Trench Depth: a 4
:
Classification: Provisionally suitable Inches
Minimum Soil Cover. 1 a
OYes (j+ No Inches
3 6 0 Maximum Trench Depth: 3 6 Inches
SoilApplication Rate: 0 .1 5 Maximum Soil Cover: a 4
Inches
*System Classification/Description: 'Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0' 0 _ Gallons
*Proposed System: 25%REDUCTION 1-Piece: OYes @No
Pump Required: OYes ®No OMay Be Required
Nitrification Field 1 4 4 0 Sq.ft. Pump Tank: Gallons
No.Drain Lines 3 1-Piece: OYes ONo
Total Trench Length: 3 6 0 ft, GPM—vs— ft. TDH
Trench Spacing: Inches O.C.
9 , gFeet O.C. Dosing Volume: _ Gallons
Trench Width: Inches
3 . Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre Treatment: %NSF OTS-1 OTS-11
Septic Tank Installer Grade Level Required: 01011 %III %IV
Pone i of Z
CDP Fite Number 1245901- 1 County ID Number. F3-000-00-072-01
❑ Open Pump System Sheet
Repair System Required:@Yes ONO ONO, but has Available Space '
riDesign
System Trench Spacing: Inches 0. .
ification: Provisionally Suitable, — 9 E*03 Feet 0.C.
Trench Width: QInches
w: 3 6 0 — 3, U Feet
Soil Application Rate: 0 - a 5 Aggregate Depth: inches
`r Minimum Trench Depth: .2 4
"System Classification/Description: Inches
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480,GPD OR LESS) Minimum Soil Cover. 1 2 Inches
'Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
_ _
Nitrification Field 1 4 4 0 Sq.tit. Maximum Soil Cover: a 4 Inches
No. Grain Lines "Distribution Type: GRAVITY-PARALLEL(eq.d-box)
3
Total Trench Length: 3 6 Pump Required: Oyes @No OMay Be Required
Pre-Treatment: ONSF OTS-1 OTS-II
"Site Modifications
No grading or construction activity is allowed in areas designated for system and repairwithout approval of Health Department.
'Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization for Wastewater System Construction shall bevalid fora person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been
completed during the period of validity of the Construction Permit,the information submitted In the appllcation fora permit or Constriction
Authorization is found to have been Iricorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person ownirig or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
Applicant/Legal Reps.Signature Required? OYes ONO
Applicant/Legal Reps.Signature: Date:,
2140-Nations,R rt 0 5 .2 1 / a 0 1 5
Issued By: Date of Issue:
Authorized State Ag Malfunction Log OYes
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
• Davie County Health Department CDP File Number: 124590- 1
210 Hospital StreetF"00-00-072-01
P.O.Box Bas County File Number:
Mocksville NC 27028 Date: 0 5 / a 1 / a 0 1 5
Q Inch
Drawing Drawing Type: Construction Authorization Scale: . QBlock
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Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/.Fax(336)753-1680_ .
IMPROVEMENT PERMIT
Account #: 990006157 Tax PIN/EH#: F3-000-00-072-01
Billed To: Tim Wall Subdivision Info:
Address: 149 Chance Lane Location/Address: Bracken Road-27028
City: Mocksville Property Size: 12.280 Ac
Reference Name:
Propo�sVd Facility: (Residence
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: DRepair OExpansion Permit Valid for: 5 Years�DNo Expiration
Residential Specifications: #Bedrooms_#Bathrooms. 3 #People Basement8$asement plumbing0r
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
eW
Design Flow(GPD): Ce Q Type of Water Supply: ❑County/City XWell ❑Community Well
As stEted In 15A NCAC 18A.19&3(;,
Site Modifications/Permit Conditions: mcceRted Systems Wa„8#, I
System Type LTAR
Initial < 0. a 5—
Re airNcc
Site Plan
�O"T2
1°
Environmental Health Specialist /5Date
i.p.11-06 /
• f
• APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
'PAW - Davie County Environmental Health
DO; 3' P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax.(336)753-1680
Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPT JCANT INFORMATION
Named �/�f / Contact Person
Address rrf 9 ,4 ov Home Phone
City/State/ZIP 7 Business Phone
Email s,-k',-7—
Name
Name on Permit/A C ' Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Comers Flagged
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site.Plan ❑Plat(to scale)
(Permit is valid for 60 mths with site plan,no expiration with complete plat.)
Owner's Name'.' . 4,PhoneNumber
Owner's Address i(/ .. i ip
Property Address City f`
Lot.Size Tax PIN# �-66d f�lL6ZZ ••ab j
Subdivision Name(if applicable) Section/Lot#
Directions To Site: &dj —Io •^ d v
If the answer to any of the following questions is"Yes",supporting docurn?eation must be attached:
Are there any existing wastewater systems on the site? Yes -
Does the site contain jurisdictional wetlands? Yes !No
Are there any easements or right-of-ways on the site? X e No
.,....
Is the Stgsu _
bject to approval by another public agency? _ es No,
Will wastewater other than domestic sewage be generated? Yes ,IQo
TF RESIDENCF,FTT,T,OI IT TNF,BOX BF.T.OW
#People #Bedrooms _ #Bathrooms Garden Tub/Whirlpoo es-ago-
Basement
o
Basement: es ONO Basement Plumbing: O'fes ❑No
IF ETON-RESTDF,NCE FIL,I:,OTJT THE B0XBEL0W
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: Conventional ❑Accepted ❑Innovative ❑Altemative ❑Other
Water Supply Type: ❑ County/City.Water ew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?-a Yes .2-1 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 knowledge. I understand that
any permit(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 De artment to conduct necessary inspections to determine compliance with applicable laws and rules.
I underst�11le for the proper identification and labeling of property lines and comers and locating and flagging
or stakinocation,proposed well location and the location of any other amenities.
Pr w
oner's or owner's legal representative signature Site Revisit Charge
Date(s):
f Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account#
Revised 11/06 Invoice# /���
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Printed:Dec 13, 2013
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 or arising out of the use or
inability to use the GIS data provided by this website.
DEED 80[1K10_PAGEL;?f
Mail To: that
WARRANTY DEED—Form WD-601 Printed and for sale by James Williams&Co.,Inc.,Yadkinville,N.C.
. 5�1a'c raaa»�a�
STATE OF NORTH CAROLINA, Da to County.
THIS DEED, made" 27 dayof February 19—LL,by and between '
Sadie Evans, widow ' of Davie County
and state of North Carolina,hereinafter called Grantor,and Bill H. Bracken, single
of Davie County and state of North Carolina,hereinafter :
i
called Crantee,-whose permanent mailing address is
' WITNESSETH: That the Grantor,for and in consideration of the sum of One Hundred ($100. 0) Dollars
and other good and valuable considerations to him in hand eaid by the Grantee,the receipt whereof is hereby aeknowledgad,hu given,granted,bargained,sold
and conveyed,and by these presents does give,grant,bargain,sell,convey and confirm unto the Crantee,his heirs angor successors and Iusigns,p2aw=
j -�GXXXXXXxYXYX.XXXXYYXYYXXX7QY�j](�(� lr�lac jrxxaw=subject to
thr reservations of a right of way hereinbelow set forth, premises in r0sillie sTown - '
ship, Davie County, North Carolina, described as follows:
BEGINNING. at a point, an iron, the common corner of Harry Belcher et ux
j and Monroe Jordan, the Northeast corner of the within described tract, I
! and thence from the beginning South 03 degs. 45 min. West 3. 63 chs. to
a stone, Southwest corner of Monroe Jordan; thence South 03 degs. 45
min. West 12.91 chs, to a stone, Southeast corner of'the within described
1 tract; thence North 86 degs. West 8. 00 chs. to a point, the Southwest
corner of the within described tract; thence North 13 degs. West 6. 75 chs.
i to a point, corner of Minnie Bracken; thence with the line of Minnie Bracken
North 03.degs. 45 min. East 10.00 chs, to a point, the Northwestern corner
of the within described tract, common corner of Minnie Bracken andSeabourne ;
Childs ; thence with the line ofChllds& Belcher South 88 degs. East 8. 26 {
chs. to the POINT AND PLACE OF BEGINNING, containing 12. 9 acres,
more or less; as per curvet' of S. L. Talbert, R.L.S.
The grantor expressly reserves a 20-foot right of way for purposes of
ingress-and egress across the above described tract to the existing State
maintained road. This reservation is to run with the land in favor of the
he and assigns of the grantor.
i .. �
NO ROLINA ":j t' NST ROLINA
i REAL ESTATE /� AL ESTATE
EXCISE TAX1,h, EXCISE TAX .
$4.00 $4.00
-.
h
i
The,bore land was conveyed to Granter by •See Hook No. ,Page
TO HAVE AND TO HOLD The above desci c;I prem s, th all the a uric ancec h eunto belot�gia r iset!
e appertainng,uato the Grantee,his
heirs and/or successors and assigns forever, subject o r�ie resp •va ioni KereltlaDW� � �Ut.
l And the Grantor covenants that fie is seized o said premises in fee,and has the right to convey the same in fee simple.that said premises are fres from en-
cumbrances(with hq exceptions pbove stated,if an •and that he will via r ran t and defersd the said title to the same against the lawful claims of all persons
whomsoever. sU9jeCt to the reservations erelnabove set out.
When reference Is made to the Grantor or Grantee,the singular shall include the Plural and vAc masculine shall include the feminine or the neuter.
IN WITNESS WHEREOF,The Grantor has hereunto set his hand and seal,die day and ye first 0 a writte
(SEAL) f�{.reC,� � a4i,& (SEAL)
: (SEAL) (SEAL)
STATE OF NORTH CAROLINA- Davie COUNTY.
1, Erlene W. Roberts
a ,.••'"""•• ' r',
Notary Public of said County,do hereby certify that
Sadie Evans ' +Fi 71"1 f•� '
Grantor,personally appeared before me this day and acknowledged the execution of the foregoing deed. i t• r'r:
Witness my hand and notarial seal,this the2 7 day of February 1781
My Commission Expires:
STATE OF NORTH CAROLINA COUNTY. •��' M •A �•
1. .a Notary Public of said County,do hereby certify that
.i Grantor,personally appeared before me this day and acknowledged the execution of the foregoing deed.
Witness my hand and notarial seal,this the_ day of
My Commission Expires: ,N.P.[SEAL)
STATE OF NORTH CAROLINA,_ --COUNTY.
The foregoing certificate)of
is(we)certified to he correct. This instrument was presented for registrationdray
.at�C s_{�ieAM.,P.M.,and duly recorded in the office of the Register of Deeds of adz'
(-' 2.1m C, County.
North Carolina,in Hook�p PageL Z3
:'his die. day f_LT „A.D.,19,L.
By
44ister of IK-ed Assistant,Deputy Register of Deeds
This Deed drawn by John T. Brock
Appraisal Card Page 1 of 1
DAVIE COUNTY NC 12/13/2013 9:46:32 AM
BRACKEN JOSHUA SCOTT ETAL BRACKEN MARY BETH Return/Appeal Noes: F3-000-00-072-01
UNIQ ID 8789
2526.03 ID NO:5820491385
COUNTY TAX(100),FIRE TAX(100) CARD NO.1 of 1
eval Year:2013 Tax Year:2014 12.90 AC OFF BRACKEN RD 12.280 AC SRC=Inspection
raised b 07 on 06/07/2007 02003 EATON'S CHURCH TW-02 C- EX-AT- LAST ACTION 20110725 ca
ONSTRUCTION DETAI MARKET VALUE DEPRECIATION CORRELATION OF VALUE
OTAL POINT VALUE Eff. BASE
BUILDING USE MOD Area UAL RATE RCN EYB AYB REDENCE TO R
m
ADJUSTMENTS 97 00 %GOOD EPR.BUILDING VALUE-CARD 0 Z
OTAL ADJUSTMENT TYPE:Vacant EPR.OB/XF VALUE-CARD 0p
ACTOR ARKET LAND VALUE-CARD 78,33 W
OTAL QUALITY INDEX STORIES: OTAL MARKET VALUE-CARD 78,33 C
OTAL APPRAISED VALUE-CARD 78,330 >
OTAL APPRAISED VALUE-PARCEL 78,33 v?
OTAL PRESENT USE VALUE-PARCEL 0 CD
OTAL VALUE DEFERRED-PARCEL -�
OTAL TAXABLE VALUE-PARCEL 78,330 m
PRIOR
UILDING VALUE
BXF VALUE
.AND VALUE 76,00
RESENT USE VALUE
EFERRED VALUE
OTAL VALUE 76,000
PERMIT
CODE I DATE NOTE I NUMBER AMOUNT
OUr:WTRSHD:
SALES DATA
FF.
RECORD DATE DEED INDICATE SALES
OOK IPAGE!!0jYR TYPE / PRICE
006E P126 4 P000 WL EV
0104 125 2 1197Fd WO X V
HEATED AREA
NOTES
` SUBAREA UNIT ORIG% SIZE ANN DEP % OB/XF DEPR L
G
GS RPL OD UA DESCRIPTIO TH NIT PRICE COND LDG# / FACT Y EY RATE V GOND VALUE
TYPE I AREA CS OTAL OB XF VALUE
IREPLACE m
UBAREA
OTALS
0
UILDING DIMENSIONS
NO INFORMATION p
IGHEST THE RADJUSTMENTS LAND TOTAL p
NO BEST USE LOCAL FRON DEPTH/ LND COND ND NOTES OA UNIT LAND LINT TOTAL ADJUSTED LAND LAND
N
SE CODE ZONING TAGE EPT SIZE MOO FACT RF AC LC TO OT TYPE PRICE UNITS TYP ADIST UNIT PRICE VALUE NOTES
0
URAL AC 0120 528 0 1.0940 4 0.87001+02-15+00+00+00 1 RT 1 6,700.00 12.281 AC 0.95 6,378.40 7833 r
OTAL MARKET LAND DATA 12.261 78 33
OTAL PRESENT USE DATA
SG G C
SPS yS 5Q �r
58�� S,�KBk 5y �P �
S3k>4g K
5 sx�
of i-e
http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=F30000007201 12/13/2013
• - DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
.I
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
AVQQ&n#:#: 990006157 Tc13oR4W 1#:#: F3-000-00-072=01
BitMV21cro: Tim Wall S t#it�i8iglbit�fRfo:
L4 tlt(A ' s: Bracken Road-27028
P ff 4t'aliill y: Residence PMWWW%e: 12.280 Ac DMet€fWu d:
I
. I
Water Supply: On-Site Well Community Public
Evaluation By: j Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position I
Slope% I
HORIZON I DEPTH I
Texture groupi.:
Consistence I
Structure I
MineralogyI
HORIZON 11 DEPTH !
Texture groupI
Consistence I
Structure I
Mineralogyi
HORIZON III DEPTH
Texture group
Consistence i
Structure i
MineralogyI
HORIZON IV DEPTH I
Texture grouI
Consistence i I
Structure I
Mineralogyi
SOIL WETNESS I
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION I:
LONG-TERM ACCEPTANCE RATE I
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: i
REMARKS-
LEGEND
I, n s ape Position
R-Ridge . S -Shoulder L-Linear 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.
CONSISTENCE .
�Q1St •
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
NS-Non sticky I 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
Mineralogy I
1:1,2:1,Mixed
riQte�
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness 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 accentance rate- ual/davM2 ru�un nail c
Well Construction Permit For office Use Only
Davie County Health Department *CDP File Number 124590
210 Hospital Street
PIN Number: F3-000-00-072-01
P.O. Box 848
Mocksville NC 27028 Tax Lot#: Tax Block#:
Phone: 336-753-6780 Fax: 336-753-1680 Evaluated For: WELL
PERMIT VALID UNTIL: 5/21/2020
Property Owner: Tim Wall Applicant: Tim Wall
Address: 234 Sheffield Farms Trail Address: 234 Sheffield Farms Trail
City: Harmony City: Harmony
State/Zip: NC 28634 State/Zip: NC 28634
Phone#: (336) 831-5885 Phone#: (336) 831-5885
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
• Bracken Road *Proposed use of Well:
Mocksville NC 27028
Directions If Other:
Site Address: Bracken Road Directions: Hwy 601 N. on right just past Happy Trail,
Bracken Rd on right, property on right at end.
Well Contractor Information
Drilling Con a for ✓ \ ( s Driller Registration
Permit Conditions
*Permit Conditions
Characters
Remaining
4000
Well location,construction 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 may be revoked at any time for failure to comply with existing regulations.The siting of approved well construction
area(s)by the Health Department is to provide protection from the known possible sources of contamination.The approved well area(s)may not be
changed without written permission from an authorized representative of the Local Health Department.No volume of quality of water is guaranteed by the
Health Department.
*Issued By: 2140-Nations, Robert *Date of Issue, 0 , 5 , / , a, 1 , / , a , 0 , 1 , 5 ,
Authorized State Agent: ®Hand Drawing O Import Drawing
Owner/Applicant Signa *Site Plan/Drawing attached.**
Page 1 of 2
WELL CONSTRUCTION PERMIT 124590
Davie County Health Department CDP File Number:
CIO 41
210 Hospital Street
'
P.O. Box 848 County File Number: F3-000-00-072-01
Mocksville NC 27028 Date: 05 ID 1 / .1015
O Inch
Drawing Type: Well Permit Scale: O O N/A
ft.
01,
............... ...
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.......... ......i
I
--. ......... .._.... -_ -. - -- - - ---
--
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loo
I
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...................................... _
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............................_ .._..............
I ... ........... .....
i
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___l 1 ........ ... ... I ......... . .....................................................
Page 2 of 2
P1 P3
WELL CONSTRUCTION RECORD For Internal UseON1.Y:
This form can be used for single or multiple wells
1.Well Contractor Information:
Edwin Mullis :14.WATER ZONES
- FROM TO DFSCRIMON
Well Contractor Name 315 '' R 320 R. 112
3518-A 505- IL 565 IL2112
NC Well ColttrtictorCertiBeationNumber I&MITER CASING(for T!E__sedwelb ORLf\ER Na iicable
FROM TO- DU?1EFER 7111CKNESS AIATERIAL.
Gopher Utility Services Inc. 16118 In. I sdr21 I pvc
CompanyNamc 1t:iNNERCASI\GORTl1BING thermalelased-loo
1245.70 FROM TO - DIAMETER nOCKNESS MATERIAL
2.Well Construction Permit 0: R. R. 4
Litt all afyrlhahle urll pernrnt(Lea Gnat.State.15rrancv.ln)ccthm,etc.}
3.Well Use(check well use): IZSCREEIV
Water Supply Well: FROM TO DIAMETER SLOTSIZE ntICKNFSS MATERIAL
13Agriculturrl DAttmicipat Public R. fL la
❑Geothermal(Heating/Cooling Supply) E1ResidenaiA Water Supply(single) IL % In.
Olndustrial/Commercial DResidentialWater Supply(shared) iLGRO11T
FROM TO MATERIAL E\IPLACE\IENTA.LTIIOD&AMOUi•T
❑lni ation 0 ft28 R bentonite pour
Non-Water Supply Well:
• fL
Monitoring ❑Recovery R
Injection Well: R R
OAquifcrRecharge ❑GroundwatcrRcmotliation 19.SANDIGRAVELPA,CK Ifo icable
OAquifer Storage and Recovery OSalinity Barrier FRokt TO MATERIAL M
EXIPL%CEENTSIM10D
IL R
DAquifer Test OStormwaterDminage 2 ft.
DExperimenlal Technology OSubsidcnce Control
r 20.DRILLING LOG attach additional sheeb if aecessa
❑Geothermal(Closed Loop) OTraecr FROM To - DES-CRIMON calor.aardata.aoRlwk tt in stw.elcl
❑Geothermal(IIcAtin Coofin Return) OOthcr(explain under#21 Remarks) 0 1'1• 0 R• red dirt mixed with layers of brown
7-1-1540 R. 80 n• soft sandstone
a.Date Well(s)Completed: Well IDN 80 fL 84 IL medium hard sandstone
So.well Locations 85 9L585 IL lied granite gray black with streaks of white q
Tim Wall
It.
ft.
FacilitylOwnerName Facility lDN(ifapplicable) fL fL
316 Bracken Road Mocksville N C 27028 ,t. �L
Physical Address,City,and Zip 21.REMARKS
Davie u
County' Parcel ldcatificaiian No.(PIN)
Sb.Latitude and Longitude in degrees/minnteslseconds or decimal degrees: 22.Certification:
(if well field.one lWlong is sufficient)
35.963837 N 80.608454 w -2 r�rls
igrature of Certified Well Contractor Date
6.1s(arc)the well(s): f2aPertrmaent or OTempornry It.r itgning ehh fiani.i herrh),ceriJ6,than the uvll t)wtlr(were)comirucW in w trdance
whh iJA NCAV 020.01 M)or IJA IVCAC 02C.0200 1*11 C omtrua dam Saandanis coral rhar u
7.is this a repair to an existing well: OYcs or 0No ctyry gfihG record has Bern pnwkU tr the well outrer
lfihli is a reptur,fill war tmnrn wc11 construction hyirmaiion arki explain the nature afthe
repair urakr 021 remark,irctmararon die hark rf#hrs furor. 23.Site diagram or additional well details-.
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed:1 construction details.You may also attach additional pages if necessary.
Ar muhrp}e lrgeciiaet ur iauan•uwttrsty'pf)•wells Mr udth or some Canso sirekuL)tw sort
smhnu)care furor SUBb117TAL INSTUCTIONS
9.Total well depth below land surface:585 VW 24a.For All Wells: Submit this form within 30 days of completion of well
I`wMraldple weUr 1111 all drphr J(d1ffCrcrrt(,rumple•I?:00'aml2:torr) construction to the following:
10.Static water level below top creasing:37 VQ Division of Water Resources.Information Processing Unit,
if warerlc+cl is shave casing use.,I' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.6 (in.) 24b.For infection We11c ONLY: In addition to sending the form to the address in
Air Rotary 24a above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger.rotary.cable,direct push.etc.)
Division or Water Resources,Underground Injection Contra)Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) Method of lest:3 Air 241 For Water Suapiv&Iateetion Wells:
Also submit one copy of this form within 30 clays of completion of
13b.Disiafection type:HTH Amounts 30 ounces well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Dep==t of Environmcat and Natural Resources-Division of Water Resources Revised August 2013