202 Dutchman Creek Rdy.
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
Account #: 990003505 OPERATION PERINfg PIN/EH #: 5766-56-9254.MH
Billed To: Avery Sealey ; Subdivision Info:
Reference Name: &ehnizd f Y&S,q,4) &)bbl'44 Location/Address: Dutchman Creek-27006
Proposed Facility: Residence Property Size: 2.04 Acres
ATC Number: 4854
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems,"
but shall in NO WAY be taken as a guarantee that the system will fifftion satisfactorily for anyeven period of (n
time.('" (� 1
System.Type: S.T. Manufacturer �r Tank Date Tank Size ( /
Pump Tank Size —
System Installed By: 1N` w^' V, E.H. Specialist:
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DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751--8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Jos
Account #: 990003505
Billed7o: Avery Sealey
Reference Name:
Proposed Facility: Residence
ATC Number: 4854
Tax PIN/EH #: 5766-56-9254.MH
Subdivision Info:
Location/Address: Dutchman Creek -27006
Property Size: 2.04 Acres
Site Type: (mow ❑Repair ❑Expansion
**NOTE**. This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter .130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use chanee.
Residential Specifications: # Bedrooms 3 # Bathrooms cZ # People D. Basement❑ Basement plumbing❑
Non=Resident! al Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: ❑County/City YWell ❑Community Well
I d
System Specifications: Design Wastewater Flow (GPD) _Tank Sized GAL. Pump Tank GAL.
� Q �
Trench Width 36 rrMax. Trench Depth 2 Le Roc kk Depth �oZ Linear Ft. U d
�
As in 15A NCAC 38A:1969(5)
Site Modifications/Conditions/Other: accepted Systems may also be usetdl
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
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Environmental Health Specialist
DCHD 11106 (Revised)
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Date:
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
IMPROVEMENT PERMIT
Account #: 990003505 Tax PIN/EH M 5766-56-9254.MH
Billed To: Avery Sealey Subdivision Info:
Address: 202 Dutchman Creek Road Location/Address: Dutchman Creek -27006
City: Advance Property Size: 2.04 Acres
Reference Name:
Proposed 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.
Pennit Type: ew ❑Repair ❑Expansion Permit Valid for: QIT"ears ❑No Expiration
Residential Specifications:. # Bedrooms # Bathrooms_# People Z Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow GPD : Type of Water Supply: ❑ County/City21rell ❑ CommunityWell v
As stated in 15A NCAC 18A.1969(5) -%Z)
Site Modifications/Permit Conditions: neceptnd Systems may also be usnd a`
System Type LTA
R
Initial A e- -r O , a
Repair p p ,
Site Plan
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Environmental Health Specialist Date
i.p.l l -06
N F TE EVALUATION/IMPROVEMENT PERMIT & ATC
vie County Environmental Health
P.O. Box 848/210 Hospital Street
\J� A Mocksville, NC 27028
tv4EIAV,336)751=8760/ Fax (336)751-8786
Applica 'on For: a valuation/Improvement Permit ❑ Authorization To Construct(ATC)oth
Type of ication: ❑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.
APPLICANT INFORMATION
Name to be Billed
Billing Address
City/State/ZIP
Name on Permit/ATC if Different than
Mailing Address _:?V -;Z D,(fC/i /N
PROPERTY INFORMATION
Contact Person. \ '
_ Home Phone -33 f�
Business Phone
*Date House/Facility Corners
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Namec"�QTIi! F Phone Number
Owner's Address City/State/Zip
-Pxcnertv Address &141,011) ru lrgeerpd - City
Lot Size Tax PIN# 5 ip6�6(/O--QZ
-S b ivision Name(if applicable)-JVSection/Lot#
Directions To Site: b, t5"T uli )AI, 01 S- - A��/1Cb1. 1'IZi�e
the answer to any of the following questions is ."yes", supporting'documentationn st be attached.
Are there any existing wastewater systems on the site? ❑Yes; o
Does the site contain jurisdictional wetlands? ❑Yes C�����
Are there any easements or right-of-ways on the site? ❑Yes L�P�4'o
Is the site subject to approval by another public agency? ❑Yes CR— o
Will wastewater other than domestic sewage be generated? ❑Yes CR10--'
IF RESIDENCE FILL OUT THE BOX BELOW
FA
# People o2- # Bedrooms ,9 # Bathrooms _ Garden Tub/Whirlpool ❑Yes ❑No
Basement: []Yes ❑No Basement Plumbing: ❑Yes ❑No
IF NON -RESIDENCE FILL OUT THE BOX BELOW
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:,.2C-o'nventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water 2-gew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes
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 Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
or staking the house/facili 4oyation, pro osed ell location and the location of any other amenities.
/ Site Revisit Charge
Provffyowner's or es legal representative signa
Date(s):
f Client Notification Date:
Date EHS: '
Sign given ❑Yes ❑No Account #�
Revised 11/06 Invoice #
-11,.4047
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(TIE) PLACED
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438
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DUKE ENERGY CORP.
D.B. 94, PG. 106
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S 85.20'19' E
AREA= 2.040 AC.
. INCLUDES S.R. 1814 R/W
384.12
N 85.18'56' V
TOTAL= 429.12
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GOMAPS - Davie County NC Public Access Page 1 of 1
Davie County, NC GIS/Mapping System
a�sV Click Here To Start Over Quick Search: (County ID c
Active Layer. Rusemap TPs
GIs
PARCELS (Map Tips Available)
MapLayers (Results
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http://maps.co.davie.nc.usIGoMapslmap/Index.cfm?maimnapservice=gomaps&CFID=412... 4/14/2008
APPLIAEa'dNr'II IbIF®9jffUMWN
Billed To: Avery Sealey
Reference Name:
Proposed Facility:.. Residence
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
Tax PIN/EH #: 576MCF TY INFORMATION
Subdivision Info:
Location/Address: 202 Dutchman Creek -27006
Property Size: 30 acres Date Evaluated: 7 =0 C�
Water Supply: On -Site Well Community
Evaluation By: Auger Boring Pit
Public
FACTORS
1 2
3 4 5 6 7
Landscape position
L . L
1—
Slope %
733,
HORIZON I DEPTH
—Y4
G—
Texture group
5rq L
S;
Consistence
P i r r Cr'-
P "
Structure
E
MineralogyS
O
HORIZON II DEPTH
Texture group�S
G
Consistence
Structure
Mineralogy
0
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
t
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
P 5
S
LONG-TERM ACCEPTANCE RATE
5
U, }15—
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
EVALUATION BY:
OTHER(S) PRESENT:
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
Moist
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
NS - Non sticky 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
Notes
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)
TAR - Long-term acceptance rate - gal/day/ft2 nr-urn nIzinc
�-3 0
0 0 0
DAVIE COUIN'TY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)75 1-_-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account M 990003505 Tax PIN/EH M 5766-56-9254.MH
Billed:To: Avery Sealey
Subdivision Info:
Reference Name:cation/Address:
Dutchman Creek -27006
Proposed Facility: Residence
Property Size: 2.04 Acres
ATC Number: 4854
i
Site Type: lbw ❑Repair ❑Expansion
**NOTE** This Authorization to Co TC) MUST BE
If
ISSUED by the Davie'County Environmental
Health Section prior to issuance of any building permit(s), (in
compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS.
This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential. Specifications: # Bedrooms —3 # Bathrooms 0- # People �L BasementO Basement plumbing❑
Non:Residential Specifications: Facility Type # People # Seats—
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: ❑County/City Nell OCommunity Well
System Specifications: Design Wastewater Flow (GPD)Q_Tank Size / GAL. Pump Tank GAL.
Trench Width 36 rr Max. Trench De th3G' " Roc�C Depth 01 Linear Ft.
9,
As skated in 15A NC1C969{a9
Site Modifications/Conditions/Other: ,accepted Systems may also he u5c
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Tele hone # (336)7 51-8760.
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Environmental Health Specialist
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Date:
' Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
WELL PERMIT
Account #: 990005224 Tax PIN/EH #: 5766-57-9572
Billed To: Susan Robbins Subdivision Info:
Reference Name: Location/Address: 174 Dutchman Creek Rd. -27006
Proposed Facility: Residence Property Size: 2 Acres
ATC Number: 0024
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 [vf � Repair ❑ Abandonment ❑
W.P. 7-08
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Proposed Wt 11 Location Diagram. ,
Certificate of Completion Diagram
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Comments: /f/l(,is /ot e.e
Driller: a WO &N -rus
Certification #- 35-310-5 o Y/h
Grout Inspected: a— 0P,&.A1
Well Head Inspected: /Q — /
GPS Coo rd' es:
EHS: � Date: ff
EHS: ate:
W.P. 7-08
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SEB � 6 2009
CATION FOR PRIVATE WELL PERMIT
Davie County Environmental Health
P.O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
***IMPORTANT***
APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name to be Billed , 16 Contact Person vef
Billing Address '% r¢ A Home Phone 3 _
City/State/ZIP C_' Business Phone
Name on Permit if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION
*Date House/Facility Comers
NOTE: A survey at�or site pl ccompany this Ii tion., Included: rte Plan OPlat (to scale)
Owner's Name must 0S ! i/ s Phone N ber,�I--
Owner's Address City/State/Zip tt,
Property Address / �b ICIf City /� (✓U � /%C
Lot Size J�C' Tax PIN# 37,�6 - 5-7-Y372,
Subdivision Name(if applicable) I Section/Lot#
Directions To Site: C, (,) t) / -4 -,S- CD / —
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 SiteYES 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 comers. 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
7/1/08
Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account # 6ZZD
Invoice # /
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Nlocksville, NC 27028
(336)751-8760 Fax# (336)751:8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990003505
Billed:To: Avery Sealey
Reference Name:
Proposed Facility: Residence
ATC Number: 4854
fduiIDS
Tax PIN/EH M 5766-56-9254.MH
Subdivision Info:
Location/Address: Dutchman Creek -27006
Property Size: 2.04 Acres
Site Type: C<ew ❑Repair OExpansion
**NOTE** This Authorization to Constrict (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms # Bathrooms a # People� Basement❑ Basement plumbingO
Non=Residential Specifications: Facility Type # People # Seats
oa Square Footage(or Dimensions of Facility)
r �Lot Size Type of Water Supply: OCounty/City �ell OCommunity Well
ystem Specifications: Design Wastewater Flow (GPD) �Tank Size i GAL. Pump Tank GAL.
rV ,1
�IU J
Trench Width 36rMax. Trench De th 3Jt-" Rock Depth 0Linear Ft. y�0
As stated in 551 NC C -18A.1 69(5)
Site Modifications/Conditions/Other: accepted Systems may also be u5G
i Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
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Environmental Health Specialist.
DCHD 11106 (Revised)
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DAVIE COUNTY
WELL CERTIFICATE OF COMPLETION CHECKLIST
C,
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File #: of 1{
Applicant: �.�-r.��c h
Site Address: �y ,����h,,,.,a�, �'f,c.P
Subdivision: Lot:
Permit Type: New Well/Well Repair
Well Abandonment Other
Facility Type: Residential ✓ Food Service
Church Commercial Other
Initial Inspection
Were Setbacks Maintained? Yes No
What is the Grout Depth? ft.
If No, Explain:
What is the Grout Thickness? in.
What is the Type of Well?
Was a Well Screen Installed?
What is the Casing Type?
Type of Drilling Fluids Used:
What is the Casing Depth? ft.
Well Grout Inspection Date:
What-is the Well Diameter? in..
GPS Coordinates:
What is the Well Depth? ft.
EHS ID:
Well Head Inspection
Is There an Access Port?
Is There a Vent?
Is There a 4" Pad?
Is There a Hose Bibb?
What is the Casing Height?
Is There any Grout Settlement?
What is the Static Water Level? ft.
What is the Yield? GPM
Is the Well Contractor ID Plate Complete?
Is the Pump Installer ID Plate Complete?
Contractor Name:
Pump Installer Name:
Contractor Certification #:
Date Installed:
Depth of Well:
Depth of Pump Intake:
Casing Depth and Inside Diameter:
Pump Horsepower Rating:
Screened Intervals:
Opening for Piping & Wiring >_12":
Packing Intervals (Sand Packed Wells):
Yield in GPM or GPM/ft.-dd:
Static Water Level and Date Measured:
Date Well Completed:
Well Head Inspection Date:
EHS ID:
Construction Completed Date:
Contractor Reports Received Date:
Sample Date:
Results Mailed Date:
Certificate of Completion Date:
Authorized Agent:
,rJr.,l..
RESrbrJYT1'AL wLL CONSTRUCTION RECO
North Carolina Department of EnAronwint and Natural R o ` Qaality
WELL CONTRACTOR CERTIFICATION H � 3535
1. WELL CONTRACTOR:
�f C' o f/ J��� y9•r' '
Wail Cgrtractor (1 dividual) Name
WcIt Contractor Company Name
STR}r^E—TADDF"ESS ��0,(o�1Q
A4kto �lt�-c.1
City or Town State Zip Code
63 -qcl-j- ,P1sJ -flel
Area tbdi- Phone number
2.WELL INFORMATION: -
SITE WELL !O #(if applicablc)
WELt CONSTRUCTION PERMIT#_,� a�
OTHER ASSOCIATED PERM1YOCirapplicable)
3. WELL USE (Check Applicable Boa); Reskiantial.Water Supp
DATE DRILLE1),_3—Z'7—"Cj T
TIME COMPLETED .-i'Q d AMo Me
a. WELL LOCATION: r
CITY:AAl git (? COUNTY I cf CJ
.,�c� t't Cif -eek 193:2 070
(So•et:t Namr, Numbers, Community, Subdivision, Lot No., Pwwl, ZIp Codr)
TOPOGRAPHIC I LAND SETTING!
(a'lope 0 vai!ey .0 Flat 0 Ridge 0 Other
(check appmp(We bo' E May ba in degrees,
LAT.ITUDE miautse, socorAs or
�p,.� c in a decimal r0aw
LONGITUDE .CLD 4G• ���cLfcJ
Latil;uderlongitude source; aPS a Topographic snap
(?ocatior ofwau meat be shown on a USGS topo map and
ah ached to this form if notvaing CPS)
5. WELL OWNER
OWNER'S NAME
STF EE A.DORESS I �� q,6A1S Cijee&A
City or Town State Zip Code
L'31—t.)- f'&-- �(Z Y
I Area code - Phone number
G. WEr„LpGTAILS,
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTINGVVELt.7 YESO NCO
c. WATER LEVEL Below Top of Casing: —66 FT.
(Use "*" if Above Top of Casing)
d. TOP OF CASlNti 1S FT, Above Land Surfacrz"
Top of casing terminate aUor below land surface may require
a variance In accordance with 1 SA NCAC 2C .0118• r
e. YIELD ($p,n): _mr.THOD OF TEST Z211—
t. DISINFECTION: Type -4
g. WATER ZONE.S(deptlt):
From, To
From_ _Yo
Frdm - To
7. CASING'.
From",,,.._._ To
From To„____.__
From To
T11iCKns3St;t
Deptrt Diameter Weight Material
From�� Tol�Q Ft. 6 /,FTt� S-0, -2( 0�
t=rom To Ft.
—
From_ To Ft. _
a. GROUT: Depth Mater!i.!
Method
y
. FromTo
Q
/
,weFrom D "Ta 12 Ft. Al',* -,4L=
�x
From To Ft.
4 r it7e
9. 4009MR, Depth Diameter Stere Materia!
FromEc Toj?�J- Ft.irs.
From To Ft. In,
In, '_
From To Ft, in.
I).
10. SANDIGRAVEL PACK:
Depth Size Materia!
From To Ft.
.From To Ft. Y ,_
Ft.
11. DRit-LING LOG
Fr to .o Fo ltign/Description
12. REMARKS:
! Do HEMOY CG"RTtFY THAT THIS WELL WAS CONSTRUCTS IN ACCMANCE WITH
15A NCAC YC, wELL CONSTRUCTION STi+NDAAIaO r. AtiO YeA T A COPi QF THil7
RECORD HA3 9et:N DROMOr-D TU THEW ELL OWTJEIR ,
SIGNATURE OF CERTIFIED WELL C JTRACTOR DATE
t'
PRINTED NAME F PERSON CONSTRUCTIN THE WELL
Subrnit the original to the Division of Water Quality within $0 days.' Attn: Information Mgt.,
1517 Mail°Service Center- Raleigh, NC 27688.1617.• Phone No. (819) 733-7015,oxt 5ti8.
Form Gvll-1a
Rev, 3/07
North Carolina State Laborato ry Publig P.O. Box 28047
306 N. Wilmington St.
Environmental Sciences Raleigh, NC 27611-8047
htto://slph.ncoublichealth.com
MicrobiologyNOV 16 2010 Phone: 919-733-7834
DAVIECOUNTYHEALTH0I=PARfMEN7 919-733-8695
Certificate of Analysis
Report To: --,-Name of System:
DAVIE CO ENVIRONMENTAL HEALTH SUSAN ROBBINS
P O BOX 848 174 DUTCHMAN CREEK RD
MOCKSVILLE, NC 27028 MOCKSVILLE, NC 27028
EIN:566000295EH
{
StarLiMS Sample ID: ES111210-0009001"
111111111111111 IN 11111111111111111111111111111111111!1111111 11
ES Microbiology ID: 22325
GPS Number: N35055.023
W080030.998
Sample Description:
Comment:
Environmental Microbiology - Colilert Profile
Collected: 11/10/2010 "--.11:33 1—% Robert Nations
Received: 11/11/20101 09:13 = I Joy Hayes
Sample Source: New Well; +~ Well Permit Number:
SamplingPoint: Well head;,,..,, � 0024
F+
Method: SM 92238
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert „Absent Darneice Lyons 11/12/2010
E. Coli, Colilert Absent Darneice Lyons 11/12/2010
Report Date: 11/12/2010
Explanations of Coliform Analysis:
Reported By: Susan Beasley
If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present,
the water is considered unsafe for drinking purpose. Presence of E. coli (bacteria) generally indicates that the water
has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample
received and should not be regarded as a complete report on the water supply.
P.O
28047
North Carolina State LaboratoryPubli 306 N. filming
306 N. Wilmington St.
Environmental Sciences Raleigh, NC 27611-8047
http.//slph.ncoublichealth.com
MICiObl0�0 NOV 1 6 2010 Phone: 919-733-7834
Microbiology DAVIECOUNTYHEALfH0hPARrMEN7 919-733-8695
Certificate of Analysis
Report To: Name of System:
DAVIE CO ENVIRONMENTAL HEALTH" ''h SUSAN ROBBINS
P 0 BOX 848 174 DUTCHMAN CREEK RD
MOCKSVILLE, NC 27028 MOCKSVILLE, NC 27028
EIN:566000295EH
StarLiMS Sample ID:
ES111210-0009001
Collected" -11/10/2010 11:33
"s Robert Nations
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
;,Received11%11%2010 09:13
aJoyHayes
ES Microbiology ID:
22325
Sample Source New Well
Well Permit Number:
GPS Number:
N35055.023
Sampling Point ;= Well head
0024
W080030.998
'
Sample Description:
Comment:
z
Environmental Microbiology= Colilerf Profile
Method: SM 9223B
Test Name: Colilert
Analyte
Test Result
Analyst Date
Total. Coliform, Colilert Absent Darneice•Lyons 11!12/2010
E. coli, Colilert Absent r Darneice'tyons 11/12/2010
ReportDate: 11/12/2010
Explanations of Coliform Analysis:
Reported By: Susan Beasley
If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present,
the water is considered unsafe for drinking purpose. Presence of E. coli (bacteria) generally indicates that the water
has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample
received and should not be regarded as a complete report on the water supply.
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
P.O. Box 28047
306 N. Wilmington St.
Raleigh, NC 27611-8047
http://siph.ncr)ublichealth.com
Phone: 919-733-7834
Fax: 919-733-8695
Report To: ROBERT NATIONS
Name of Sys t CEIVEp
DAVIE CO ENVIRONMENTAL HEALTH
SUSAN ROBBI SC U 3 2010
Arsenic
0AVIEC0l1 NTY HEALrh 0LPAR rMENT
0.010
mg/L
P O BOX 848
174 DUTCHMAN CREEK RD
MOCKSVILLE, NC 27028 Courier # 09-40-06,:- r
MOCKSVILLE, NC 27028
EIN: 666000295EH
< 0.001
StarLiMS ID: ES111210-0005001 Date Collected: 11/10/10
Time Collected: 11:33 AM
Date Received: 11/12/10
Collected By: Robert Nations
Sample Type: Sampling Point: Well head
Well Permit #: 0024
Sample Source: New Well Temp. at Receipt: 4.0
GPS #: N35°55.023/W080130.998
Sample Description: I
`
Comment:
< 0.01
0.10
mg/L
New Well I (Profile)
< 0.05
Analyte
Result
Allowable Limit
Unit Qualifier(s)
Arsenic
< 0.005
0.010
mg/L
Barium
< 0.1
2.00
mg/L
Cadmium
< 0.001
0.005
mg/L
Calcium
20;�
mg/L
Chloride
25.00
250
mg/L
Chromium
< 0.01
0.10
mg/L
Copper
< 0.05
1.3 _
mg/L
Fluoride
0.33
2.00 ,r.
mg/L
Iron
0.25
Lead
< 0.005
0.015
mg/L
Magnesium---.. _ _
1
mg/L
Manganese
< 0.03
0.05 ,
mg/L
Mercury
< 0.0005
0.002
mg/L
Nitrate
1.50
10.00
mg/L
Nitrite
< 0.10
1.00
mg/L
pH
8.9
N/A
Selenium
< 0.005
.0.05
mg/L
Silver
< 0.05
0.10
mg/L
Sodium
29.00
mg/L
Sulfate
< 5.00
250
mg/L
Total Alkalinity
69
mg/L
Total Hardness
56
mg/L
Zinc
< 0.05
5.00
mg/L
Report Date: 11/30/2010
Page 1 of 1
Reported By: DeAke 7idoKed
WATER SAMPLE/SEWAGE SYSTEM CHECK REQUEST
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
Date Requested: /_% " IO
Received By
WATER SAMPLE TYPE:
Bacterial O Protected
O Chemical O Unprotected O Dug
O Other: lV60 O Bored O Drilled
O Outside Spigot:
O Other:
SEWAGE SYSTEM CHECK: O Yes Vacant: O Yes O Approved
O No O Disapproved
Owner's Name: 1
S i�clS Buyer's Name
Property Addre s:
f1 -I"2e
Direction • - 5
/ p S
ON
Specia nstructions:
Letter To:
Closing Date:
Attn:
--------------- --
Date Taken: — ! Ci — b
Charges:
Telephone:
I By;