435 Foster RdAccount #: 990001700
Billed To: Dennis Brown
Reference Name:
Proposed Facility: Well
ATC Number: 001 to
Davie County Environmental Health
P.O. Bog 848/210 Hospital Street
ocksvilte,-DC 27028
36)75:WELL
760/ Fax ( 751-8786
PERMIT
_ Tax PIN/EH M 5706-88-6090 .
Subdivision Info:
Location/Address: 435 Foster Road -27028
Property Size: 130 acres
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 2-- Repair ❑ Abandonment ❑
Proposed Well Location Diagram
Certificate of Completion Diagram
e 011,e
•' R �t
jro i`.� 1100
row
�J
I
V
i
.
n�
Comments: XU , ja �� ��o �-c_
Driller: M)Ryk, d 5(mc,
Certification
% Y S{ I',
�/`fr
Grout Inspected:
Well Head Inspected:
ZZ
.GPS Coo at yr U
EHS: Date: G
EHS: /'/ Date: G
W.P. 7-08 Q/a4Y ✓&be
ru t�:
vS
At HEALTH
UNTY___._._
CATION FOR PRIVATE WELL PERMIT
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)75178760/ Fax (336)751-8786
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name to be Billed 0� Contact Person 0"R111,11" &IJ24c%
Billing Address 113 5 Home Phone '7-16
City/State/ZIP 122,2 (11,,r i � Business Phone
Name on Permit if Different than Ab&e r -
Mailing Address City/State/Zip
PROPERTY INFORMATION
*Date House/Facility Corners Flagged 4? -/1- or
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat (to scale)
Owner's Name -9qpuPhone Number
Owner's Address City/State/Zip,
Property Address r%/ ! a� City ! " Z �, C :� � Z
Lot Size Li u � Tax PIN# 5706
Subdivision Name(if applicable) Section/Lnt# nz
Directions To Site: U -(JV (f��% t'U -, P4<5-61C�lk/b-M S )l� LAR)Z) G fx/
DEVELOPMENT INFO ON
Permit Type: New Well Well Repair Well Abandonment Other (specify)
Facility Type: Residential L/ 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.
CYL
Si ed v
7/1/08
11
-114
Date �
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account # /100
Invoice # !„/Pq 1
QoM�kPS - Davie County NC Public Access
.%
Davie County, NC - GIS/Mapping System
Page 1 of I
<3 lq
Click Here To Start Over Quick Search: (County ID c
Active Layer. Use Map Tips GIE
. ... .... . .... ..
PARCELS (Map Tips Available)
0
&O11tv'sMap Layers I Results I
http://maps.co.davie.nc.usIGoMapslmapllndex.cfin?mainmapservice=gomaps&CFID=412... 9/17/2008
A
j
"IJ
http://maps.co.davie.nc.usIGoMapslmapllndex.cfin?mainmapservice=gomaps&CFID=412... 9/17/2008
RESIDENTIAL WBLL-comnVcrlorrRFcoRo
North Caroline Dcpuunem of Emkonma.t and NstuW Raoumu. DIAlon or Wsta Quality
WELL CONTRACTOR CERTIFICATION N -;//
1. WELL CONTRACTOR:
S7-iEtJc-_tt1 M, C� HAmI3ERs
W d Convaaa (hdMdtA NWM
m t3 624 s
Wed Ccnvactor Gar>pam Num
C
STREET ADDRESS / % q 1 (d , FRioN� J�
S7"RTE� VIGGE iU CG %7
City a Town State TJp Code
2� o >.819-33
A,e, cod. Phm,e number
L WELL INFORMATION:
SITE WELL ID Wamksba)
STATE WELL PERM T80 aoc+0"I
DWQ or OTHER PERMIT W sppkeb4)
WELL USE (Choc- Apptloabls BCo: Residential Watx Supply Q
DATE DRILLED
TIME COMPLETED AMO PM
3. WELL LOCATION:
:.
GN
CITY: ds t.� COUNTY tL �
tsa," Hama, Nvnb«t. Corr maty.•
bubdhhbrl Ld No., P.re.t,bp Erdo)
TOPOGRAPHIC /LAND SETTING: '
o Slope ovadeyy fa•Flat 0 RldpeMq be In &voce.
O ower•
LATrTUDE $d 9 or
LONGITUDE loidit""I bras«
.
LldrodcAongimZc so,=: oOPS OTopo;raphle map
• (bc,tbn d w►I must Ds ilro►rn on a tl30d tipo rtrp anQ
Alred d to Wa firm I not ushp OPS)
1. WE11 OYi'T•!ER /
OWNER'S NAME.d�.o
STREET ADDRESS
City or Tcwn Stals Zp Cods
3 94o - 47 WaS
Iv as Cade • Phar ncxnbW
L WELL DETAILS:
a TOTAL DEPTH:
b. -DOES WELL REPLACE EXISTING WELL? YES DINO 0
c. WATER LEVEL UowTop of CukV . 3 �% FT.
(Use ••• IAbove Top d Cukg)
d. TOP OF CAEING IS • % FT. Abw.v Lend Sud"I
'Top d ea&kV Wrmhatsd Wcr brow land Surface mW rsquk*
a YwU nos In s000rdsnos v th I Lk NCAO 20.011 L
.. YIELD (gpm+ . I O METHOD OF TUT.
f. C)ISMICTION: Typs,_j
p. WATER ZONES (dspN):
From To 7�
Fra. a9 2, To 0,9 3
Fran To
6. CASINO:
Amount
From To
From To '
From To
Thlctu U
Depth D er W lIQN at
Fran_ To i_. FL _
Fran______ To FL
From To FL
7. GROUT: Depth Atatertat blodiotl
FraTL-d_ Tom FL
FraT�._,_ To Ft
FmmT . _„_ To FL
L SCREEN: Depth
Diameter Slot Stn Malerlat
Fra__;___ To
FL
In. h.
FrortL,,,`— To
FL
In' h.
From To
FL
In h.
t. $AU IPORAVEL PACK:
.
Depth .
Size. .. t,4atutat
Frm _,_Tc
FL
Frcm---_To
FL
FronL;__TO
FL
10. DRILLING LOG
From To
Formation Desettlon
Ln (i O d
PG rim
11. REMARKS:
OO HLRUY CERTIIY TMAT T}ee WtLL WAS C HSTXXM0 a AC=AW041 Wm.
W W-44 !0. WILL COaIIMCTM iTANGAROt<. AW r MT A COP' Of Tf0
MWAO KAe eatrr PROVfDED TO T111 WILL OWNM
IIGNA RE OF CERTIFIED WELLtONTRACTOR DATE
c --y N• C9i441 r;aeg,'
'RIKTED NAME OF PERSON CONSTRUCTING THE WELL
Submtt the orlglnal to the Dly)sion of Water Quality within SO days. Attn., information Mgt, Form GW to
11617 Mall Servlao Cantor— Rslolph, NO 47699.1117 Phono No. (919) 733.7016 ext 661. RN 70
DAVIE COUNTY HEALTH DEPARTMENT
-IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name VDate No 7030
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
-1
No. Bedrooms No. Baths Y2 No. in Family
Garbage Disposal YES NO Specifications for System:
Auto Dish Washer YES NO ED
Auto Wash lvla^hine YES F1 NO E)
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
end I
'A'
Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985.
Final Installation Diagram:
System Installed by
Certificate of Completion L
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guari-ritee-th"at'the-system-will function --
satisfactorily for any given period of time.
f� p
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER _
Davie County Health Department R F. E U �,,'� E D
.NPlr l iV Environmental Health Section
tD - P. O. Box 665 FEB - 1993
J'; Mocksville, NC 27028
1. Application/Perm
Mailing Address
Home Phone 20 y ! U
%2 " 5 26 3 Business Phone toy- 2 %,2 - 33%-?
2. Name on Permit if Different than Above
3. Application/Permit for:
4. System to Serve: ,R House
❑ Business ❑ Industry
5. If house, mobile home: Subdivision
❑ General Evaluation
❑ Mobile Home
❑ Other
No. of People
No. of Bedrooms
No. of Bathrooms a
c2
q
Dwelling Dimensions / p / X
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks _
No. of Commodes No. of Urinals
No. of Lavatories
No. of Water Coolers
KSeptic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
,N Basement/No Plumbing
R Washing Machine
K Dishwasher
Garbage Disposal
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Public Q )l Private /� // ❑ Community
8. Property Dimensions 3 /• 4 Ac- a Sewage Disposal Contractor ��S/L&r 4 l�h� �� brfloe-
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes �Z No
If yes, what type?
"NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
L 6R
pr)
Sr ,
er dio - �q���� �� a✓,e ca �� � �
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this ap lication.
�— y 3 co, LA -D.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1. I OWN the property. ❑ 2. I DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (12-90)
r �
L
ItM
IV
1
4 ,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME V'r'q4V>')
ADDRESS
PROPOSED FACIILTY 45es�e.
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE 14S-Iff
Water Supply: On -Site Well E/ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2
3
4
Landscape position
Sloe %
—
_
-
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
,
Structure
/k
Mineralogy
/
.'(
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
t
SITE CLASSIFICATION: _As- ! w �'6 ;"q- EVALUATED BY: y� //
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
LEGEND
DCHD(01-901
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
Moist
VFR-Very friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm
Wet
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
Mineraloizy
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 watet or inches from land surface to soil colors
with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
........................... ......................................
..................................................................
.........■...................... ..............................■.
■■■!■..■■■.■.■.I„'111■■■.i■■■■■■■■■■■[r:i�■.■.■■■■■u■■■.■■■■■■■■■■■■■■■
.........................../...................... ............■.■
ME
1::::::"MMMM:: �:::::: MEMNON� MENNEN MENNENlMEMNONi�
......................................... .........■..... ■■■■■■■■
...................................■...■.:■■■■■■■■■N■.■....■.■■■■■
...................................... .......... . ..............
......................................:...■■.■N■�■■C■■■■NI■■■■■■N
................................ .... ........■. ■.
■.■■ .■■.■.................................�.■.�......... ............ ....
■■■■.■.■■■■■■■■■■■■■■■■■■.■■■■■■■■■■.■■■■■■■�._..■..■Ne■C.■■.■■�■
................................ ................................
.................................... .... ........................
::::::: ::: ME
■■■■..■N■■■.■...■■....!■■■..■■■■■■■N.■..■■■■■■■.■■■...■:■■N■■■■
■■■.■■..■.■.■.■■■.■..■■■■■MEN■■N.■■■.■i■■■■■■■■■.■■■■■■■■■■■■■■■■