169 Briar Cliff Ln Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 I
(336)753-6780/Fax(336)753-1680 d 1 lv
WELL PERMIT
Account #: 990005785 Tax PIN/EH#: C00000012
Billed To: Kenneth Mason Subdivision Info:
Address: 169 Briarcliff Lane Location/Address: 169 Briar Cliff Lane-27028
City: Mocksville Property Size: 9.44 Acres
Reference Name: WELL
REPAIR
Propo$ctdionscot he e/mployeesrof the Davie County EH Section shall in no way be taken as a guarantee that this
Awell 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❑ Repair [R Abandonment ❑
Proposed Well Location Diagram Certificate of Completion Diagram
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Comments: "4ct 1,l Driller:
(' luVIA [PaVatf Certification#:
r h Grout Inspected:
Well Head Inspected:
GPS Coo inat s:
EHS: Date: EHS: Date:
W.P.7-08
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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
WELL PERMIT
Account #: 990005785 Tax PIN/EH#: C00000012
Billed To: Kenneth Mason Subdivision Info:
Address: 169 Briarcliff Lane Location/Address: 169 Briar Cliff Lane-27028
City: Mocksville Property Size: 9.44 Acres
Reference Name: WELL Abandonment
Proposed Facility: Well Abandonment
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❑ Repair ❑ Abandonment ® .
Proposed Well Location Diagram Certificate of Completion Diagram
• Remove pump,piping and wiring from well
• Excavate down to 3 feet below ground surface
• Excavation should be at least 1 foot around the
casing
• Remove casing down to excavation level
• Chlorinate well with 70%hypochlorite solution
• Fill well with concrete to excavation level and 1
foot around the casing
• Cover with soil
• Owner/Agent,must call and schedule
abandonment
Comments: Driller:
Certification#:
Grout Inspected:
Well Head Inspected:
GPS Coordinates:
EHS: Date: EHS: Date:
W.P.7-08
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http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 .11/21/2011