316 Bracken Rd (2) 4
APPLICATION FOR SITE EVALUATION/INIPROVEMENT PERNUT & ATC
PAD Davie County Environmental Health
Dom; 3' P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax.(336)753-1680
Application For: ❑ Site Evaluation/Improvement Permit ❑Authorization To Construct(ATC) 0 Both
Type of Application: ❑New System ❑Repair to Existing System OExpansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULL TIN for instructions.
APPUC:A►NT`TNFORMATION ,J
Name _// �/'f Contact Person_ 7, Vt AQ/!
Address f 9 �/ Home Phone `'��
City/State/ZIP �L_ 7 Business Phone `
Email w
Name on Permit/A C ' Dfferent 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: 0 Site.Plan ❑Plat(to scale)
(Permit is valid for 60 m the with site plan,no expiration with complete plat.)
Owner's Name' ' A hone Number
Owner's Address .. i ip
Property Address vZ) t iv City 46 fv
Lot.Size -Z Tax PIN# 6010—
3 00—llZz
Subdivision Name(if applicable) Section/Lot#
Directions To Site: D/ brolf '1/5 —
If the answer to any of the following questions is"Yes",supporting docume tion must be attached:
Are there any existing wastewater systems on the site? Yes -
Does the site contain jurisdictional wetlands? Yes 0
Are there any easements or right-of-ways on the site? Y No
Is the S,ite:subject to approval by another public agency? /Yes No
Will wastewater other than domestic sewage be generated? Yes i1Qo
TF RESTI)ENCE FUJ.01IT THF,ROX RF.T,OW
#People #Bedrooms _ #Bathrooms Garden Tub/Whirlpoo es o
Basement: es ONo Basement Plumbing: des ONo
1F ETON-RESIDENCE Fif.J: OUT THE BQX.BEI�OW
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 ❑Alternative ❑Other
Water Supply Type: ❑ County/City.Waterew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?TT 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 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 understand that I le for the proper identification and labeling of property lines and comers and locating and flagging
or stakin ocation,proposed well location and the location of any other amenities.
Pr owner's or owner's legal representative signature Site Revisit Charge
Date(s):
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 ROOK4W—PAGEL;• f
Mail To:
WARRANTY DEED—Form WD-601 Printed and for ale by James Williams&Co.,Inc.,Yadkinville,N.C.
roar--•
STATE OF NORTH CAROLINA, Davie County.
THIS DEED, Made this 27 day of February .19 78 ,byandbetween '
Sadie Evans widow of Davie County
and state of North Carolina,hereinafter called Grantor,and Bill H. Bracken, single
of Davie County and Sesta of North Carolina,hereinafter :
i
i called Grantee,-whose permanent malling address L
WITNESSETH: That the Grantor,for and in consideration of the sum of One Hundred ($100. 00) Doffs
and other good and valuable considerations to him in hand(raid by the Grantee,the receipt whereof is hereby acknowledged,has given,granted,bargained,sold
and conveyed,and by these presents does give,grant,bargain,sell,convey and confirm unto the Grantee,his heirs and/or successors and assigns,FdamKK
-XXXXXXXXXXXXXXYXYYXYYxyxxxm=p( ( x��csubject to
thr reservations of a right of way hereinbelow set forth, premises in Clarksville Town -
ship, Davie County, North Carolina, described as follows:
BEGINNING. at a point, an iron, the common corner of Harry Belcher et ux
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
I 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 andSeabourlie ;
Childs ; thence with the line of Childs& Belcher South 88 degs. East 8.26 +
chs. to the POINT AND PLACE OF BEGINNING, containing 12. 9 acres,
more or less; as per curvey 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
i' heirs and assigns of the grantor.
NO ROLINA ?, ( AL
ROLINA
REAL ESTATEA ESTATE
EXCISE TAX CISE TAX .
$4.00 4.00
1 The above land was conveyed to Grantor by .See Book No. ,Pagc
TO HAVE AND TO HOLD Tile,above descr• cd Fre s,yv�tit all thea urte antes h eunto eto in or i appertaining,unto the Grantee,his
heirs and/or suecessorsand assigns forever, SUDjeC1 `o Me reseNt2 onr�Yierekna'4�t&ei$�rly�l�t.
1And the Grantor covenants that he is seized of said premises in fee,and has the right to convey the unit In fee simple:that said premises are free from en-
cumbrances(withfhq exceptions pbove stated,if an •and t at he wiUv�a r rant and defersd the said title to the same against the lawful claims of all persons
j whontsoevc -- - sect to tale reservations hereinabove set out.
When recrcnce is made to the Grantor or Grantee,the singular shall include the plural and IAe masculine shall Include the feminine or the neuter.
IN WITNESS WHEREOF,The Grantor has hereunto set his hand and seal,the day and ye first
ort writhe
(SEAL) Lasi 4�JJ (SEAL)
: (SEAL) (SEAL)
STATE OF NORTH CAROLINA Davie COUNTY. . A,
Erlene W. Roberts
I, ,a Notary Public of said County,do hereby certify,that• •�
Sadie Evans
Grantor,personally appeared before nit this day and acknowledged the execution of the foregoing deed. '•w C'
Witness my hand and notarial seal,this the 27 day of February
i t/s • "� '�gg�rt
My Commission Expires:
STATE OF NORTH CAROLINA COUNTY. s tt •'
s 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 cettificatc(/)of �s
is(oft-).certified to be correct. This instrument was presented for registration this � � ('dray of -�,.�sGt�fi �a
at�IWKI„P.M.,and duly recorded in the office of the Register of Deeds of rt[G. Counry.
Nurdh Carolina,in Book _
. Page
lgzr
This tile..2 day ,A.D.,19M
By
register of lied Assistant,Deputy Register of Deeds
This Deed drawn by A John T. Brock
Appraisal Card Page 1 of 1
Ja.
DAVIE COUNTY NC 12/13/2013 9:46:32 AM
BRACKEN JOSHUA SCOTT ETAL BRACKEN MARY BETH Return/Appeal Notes: F3-000-00-072-01
UNIQ ID 8789
2526203 ID NO:5820491385
COUNTY TAX(100),FIRE TAX(100) CARD NO.1 of 1
Reval 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 C9
ONSTRUCTION DETAI MARKET VALUE DEPRECIATION CORRELATION OF VALUE
OTAL POINT VALUE Eff. BASE
BUILDING USE MOD Area UAL RATE CREDENCE TO
m
ADJUSTMENTS 971 00 1 1 1 1 1 1 1 %GOOD DEPR.BUILDING VALUE-CARD
TOTAL ADJUSTMENT TYPE:Vacant DEPR.OB/XF VALUE-CARD 0O
FACTOR MARKET LAND VALUE-CARD 78,33 zn
TOTAL QUALITY INDEX STORIES: TOTAL MARKET VALUE-CARD 78,33 C
TOTAL APPRAISED VALUE-CARD 78,330 >
TOTAL APPRAISED VALUE-PARCEL 78,330
n
TOTAL PRESENT USE VALUE-PARCEL IO
-i
TOTAL VALUE DEFERRED-PARCEL I -�
TOTAL TAXABLE VALUE-PARCEL 78,33( m
—I
PRIOR
BUILDING VALUE
BXF VALUE
.AND VALUE 76,00
PRESENT USE VALUE
DEFERRED VALUE
TOTAL VALUE 76,00
PERMIT
CODE I DATE NOTE I NUMBER AMOUNT
ROUT:WTRSHD:
SALES DATA
FF.
RECORD ATE DEED INDICATE SALES
BOOK IPAGE M0jYR TYPE U1.1 PRICE
006E126 4 00 WL E V
0104 125 2 197 WD X V
HEATED AREA
NOTES
SUBAREA UNIT ORIG% SIZE ANN DEP % OB/XF DEPR. L
a
GS RPL OD UA DESCRIPTIO LTH H NIT PRICE GOND LDG+Y / FACT Y EY RATE V GOND VALUE
TYPE AREA CS OTAL OB XF VALUE 0 �=
IREPLACE m
UBAREA
OTALS TTJc
WILDING DIMENSIONS
NO INFORMATION p
I
GHEST THERADJUSTMENTS LAND TOTALD BEST USE LOCAL FROM DEPTH/ LND COMO ND NOTES OUNIT LAND UNT TOTAL ADJUSTED LAND LANDE CODE ZONING TAGE DEPT SIZE MOD FACT RF AC LC TO OT TYPEPRICE UNITS TYP ADJST UNIT PRICE VALURAL AC 0120 528 0 1.0940 4 0.8700 +02-IS+00+00+00 RT 6 700.0 12.281 AC 0.95 6 378.4 7833 TAL MARKET LAND DATA 12.281 78 33TAL PRESENT USE DATA
1 � �
jry
SG C, C,
bs 5p ti550 5 -�P �
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http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=F30000007201 12/13/2013
I
• • DAVIE COUNTY HEALTH DEPARTMENT
_ Environmental Health Section
Soil/Site Evaluation
APPLICANT iNFORMATION PROPERTY INFORMATION
Awn#:#: 990006157 T4%RllN l4:#: 173-000-00-072=01
B ftblQ'o: Tim Wall S CttdiBi�tmh�fAfo:
Lghl1' s: Bracken Road-27028
P ffV!iMVty: Residence Pmt§iB(%e: 12.280 Ac DStB E1Wu8t8Wd:
I
1
Water Supply: j On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position I
Slope% t, I
HORIZON I DEPTH I
Texture groupi.
Consistence I
Structure I
Mineralogyf
HORIZON II DEPTH
Texture groupi
Consistence I
Structure i
Mineralogyi
HORIZON III DEPTH
Texture group
Consistence I
Structure i
Mineralogy1
HORIZON IV DEPTH i
Texture group iI
Consistence iI
Structure I
MineralogyI
SOIL WETNESS I
RESTRICTIVE HORIZON 1
SAPROLITE
CLASSIFICATION I:
LONG-TERM ACCEPTANCE RATE I'
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: i
REMARKS:
LEGEND
Landscape 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. ,
MOM
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
NNS--Non sticky j 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
1:1,2:1,Mixed
LYQteB
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-Lone-term accentance rate-val/dav/ft2 ruIun nvnc PD-A.-AN
Well Construction Permit For Office Use Only
* Davie County Health Department *CDP File Number 124590
Vo
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 uor: WELL
Evalated F
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 M (336) 831-5885 Phone#: (336)831-5885
Property Location & Site Information
Address/Road M 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
=Ddilling a for ✓ \ ( S Driller Registration
oo 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 , / 1 .1111 / , 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
6 04 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: 05 / .21 / 2015
0 Inch
Drawing Type: Well Permit Scale: 0 Block
0 N/A
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Page 2 of 2
Pi P3
WELT{.CONSTRUCTION RECORD
For Internal Use ONLY.
This form can be cud for single or multiple welt
1.Well Contractor Information:
Edwin Mullis .1+.WATERZONFS
5FROM TO DESCRIPTIONWell Contractor Name R' 320 R• 1/2
3518-A " 565 ti 2112
NC Well CommacrCertitication Number I5.OtITERCASING Tormul0esdelORteable
TO DTN
?Es
FROM R
MATERIAL
Gopher Utility Services Inc. o 86 rt. 16118 la. sdr 21 I PVC
CompanyNamc 16ANNERCA.SINGORTURING thermal clostd-I*oDl
12A590 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit k: G`r:7
.7U
Girt all gy41cubk erll permits([e Ckwo,.State,Ibriawc.h#rcthm,etc.)
3.Well Use(check well use): n.scREEN
Water Supply%Veil: MOM To DIAMETER SLOT S17E THICKNESS MATERIAL
OAgricultural OhlunicipaVPublic R. R in.
Cl Geothermal(HeatingfCooling Supply) M11csidential Water Supply(single) It. ft. la
❑lnduslriaVCommet¢ial OResidrntt
tialWatSupply(shated) ta.GROlrr
FROM TO - MATERIAL EMPLACEMENT METTIOD&AMOUNT
Mitigation 0 n' 26 R- bentonite pour
Nan-Water Supply Well:
R rL
ONIonitoling ❑Recovery
Injection Well: (L
0Aquifi7Recharge OGroundwwcrRemediation '19.SAND/GRAVEL PACK ifs ieable
FROM TO MATERIAL-- EMPLACEMENTMEr110O
OAqulfer Storage and Recovery OSalinity Barrier M R
OAquiferTcstt OStormwaterDrainage R IL
OExperimental Technology OSabsidence Control
r 20.DRILLING LOG attach oddidenat shack if seeessa
Meothermal(Closed loop) (Tracer FROM I TO DESCRIPTION calor,lord-w WVmk tvm vain star,rias
OGeothemtat(lleatin Conlin Return) OOthcr(explain under 421 Remarks) 0 FL 40 It. red dirt mixed with layers of brown
7-1-15 40 0. 80 e- soft sandstone
4.Doll:Well(s)Completed: Well IDA
80 n. 84 rL medium hard sandstone
So.Wen Location: 85 n. 585 fL led granite gray black with streaks of white cl
Tim Walt ft. n
Facility/Owner Name Facility IDN(if applicable) ft.316 Bracken Road Mocksville N C 27028 n rc
Physical Address.city.and Zip 21.REMARKS
Davie
County Parcel Idcati6cation No.(PiN)
Sb.Latitude and Longitude in degrees/minuteslseconds or decimal degrees: 22.Certification.
(if wcli fictd,one lat/long is suR)ckw)
35.963837 N 80.608454 w
tgmtuic of Certified Well Contractor Date
6.Is(are)the well(s): OPermaneat or OTemporary gj.,igtsi„x this Jimm I hereby cert&that the uvilfs)km(marc)rowtrucW in aL%-twdtmr
Wth 15A NCAV 0X',0100 or dSA NCAC 02[•,021101*11 C irnuructinn Vantfanis surd that u
7.Is this a repair to an esisting well: OYcs or 0No ctgry tfth&reavrrd has been pntvkkd M the hell uuner
lfihlt is a repMr fill aid kmnrn ur11 comrruction kf trmtttan and erplain the nature ofthc
repair utkkr e21 remarks sevium or an dw back nfth"first 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
B.Number of wells constructed:1 construction details. You may also attach additional pages ifnecessary.
Awmuh0c1*rt wrrrrrrn-nwwaulytlyWeitzONLYWIhthesamecon"ctkaLjxarcan
submit w,e forna SUBh1tTTAL INSTUCTIONS
9.Total well depth below land surface:585 (f(,) 24a.For All Wella. Submit this form within 30 days of completion of well
for sredl/ple wrUr An aUJcprhs lfJ,((cm0(anaptic•J?Z00'um1 T1@1007 Construction to the following:
10.Static water level below lop or easing:37 ((t,) Division of Water Resources,Information Processing Unit.
Lf earerlevcl if nhoty caning we"r-. 1617 Mall Service Center,Raleigh,NC 27699.1617
11.Borehole diameter.6 (in.) 24b.For infection Welts 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 methad: construction to the following:
(ie.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh.NC 27699-1636
13s.Yield(gpm)3 Method of lest.Air 24c.For Water Suppiv&falection Wells:
Also submit one copy or this form within 30 daysofcompletion of
13h.Disinfection type:HTH Amonat•30 ounces well construction to the county health department of the county where
constructed,
Form GW-I North Carolina Ucpa tmnt of Eavirummcat and Natural Rcsoutces-Division of Water Resources Revised August 2013 .