1040 Cherry Hill Rd Davie County Environmental Health
• P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(331)753-6780/Fax(3367753-1680
WELL PERMIT
Account 1: 99000567.1 ; . Taiel? EHf� X60000008101=We98
S
Billed To: Keith and Michele Smith ". 0 s'=W,xc
� "
__
Reference fame: :. E.e�lio�^"!fir � Ot%M Hill
Proposed Facility: Residential Well ,r.•r> P'Salz`,= .L f e• .+_ .. .
ATC Number. 0115 a51
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
fora 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.
ermi ype: ew M Repair Abmidairin ❑ "i
. al
Proposed Well Location Di Certificate of Completion Diagram x
G
U
Comments: fid!' ./CO �Lo Driller. t
' annla a1w Certification#:
Grout Inspected. �lll(D ?D13
Well Head Inspected: PrU '7 l 2N 1 Z o 3
GPS Coordinates:
EHS t Date: /�/ls3//2 EHS. Date:
stiw� •7�u//i3
CATION FOR PRIVATE WELL PERMIT
( � Davie County Environmental Health
P.O.Box 848210 Hospital Street
`�E�, p fi X012 Mocksville,NC 27028
(336)753-6780/Fax(336)751-8786
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name to be Billed (lr<.►ztp Contact Person Kai'
Billing Address J4 aS We, k e Dt- Home Phone 04j- &R 9-fJOQ 5
ity/State/ZIP Saltsbwca AC PEIql Business Phone --To4'-a o a -t-200(p
Email o(inA , c-+-•
Cc,/1-
ame on Permit if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Comers Flagged
OTE: A survey pl t or site plan must accompany this application. Included: Site Plan Plat (to scale)
Owner'sName Phone Number U(44o3 3-1/0,25-
er's Address 4 5 L)r City/State/Zip S'aSLi S b wK ��C', .9011'r
Property Address 05'er-cm W City X10 Cksu alp
Lot Size IliTax PIN#
Subdivision Name(if applicable) Section/Lot# N�
Directions To Site: .
DEVELOPMENT INFORMATION
Permit Type: New Well X Well Repair Well Abandonment Other(specify)
Facility Type: Residential X _ 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? S 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.
Signed Date
Site Revisit Charge
ate(s):
lient Notification Date:
HE
7/30/09 Account#
�V 10) Invoice# _
S
1
Appraisal Card Page 1 of 1
' DAVIE COUNTY NC 12/12/2012 11:04:57 AM
MITHGERALD KEITH SMITH MICHELE G Return/Appeal Notes: N6-000-00-081-01
herryHill RD UNIQ ID 968169 SPLIT FROM ID 24326
300383 ID NO:5755639985
COUNTY TAX(100),FIRE TAX(100) CARD NO.1 of 1 0
Reval Year:2009 Tax Year:2013 49.899 ac Cherryhlll Rd(Tct 2) 49.899 AC 49.899 AC SRC-
_
raised by 19 on 05/31/2011 05003 CHERRYHILL TW-05 C- EX- AT- LAST ACTION 20120522
ONSTRUCTION DETAIL MARKET VALUE DEPRECIATION CORRELATION OF VALUE
OTAL POINT VALUEEff. BASE
BUILDING USE MOD Area UAL RATE RCN EYB AYB - CREDENCE TO
Cl
ADJUSTMENTS 97 00 %GOOD DEPR.BUILDING VALUE-CARD 0 m
TOTAL ADJUSTMENT TYPE:Vacant DEPR.OB/XF VALUE-CARD
FACTOR MARKET LAND VALUE-CARD 215,04
OTAL QUALITY INDEX STORIES: - OTAL MARKET VALUE-CARD 215 040
TOTAL APPRAISED VALUE-CARD 215,04 .m:
TOTAL APPRAISED VALUE-PARCEL 215,04
TOTAL PRESENT USE VALUE-PARCEL 51,65
TOTAL VALUE DEFERRED-PARCEL 163,39
TOTAL TAXABLE VALUE-PARCEL 51,650
PRIOR
BUILDING VALUE -
BXFVALUE _
LAND VALUE
PRESENT USE VALUE
DEFERRED VALUE
OTALVALUE
PERMIT
CODE DATE I NOTE I NUMBER AMOUNT
ROUT:WTRSHD:
SALES DATA 0
FF.
RECORD DATE I DEED INDICATE SALES
BOOK IPAGE jMlk I TYPE /U /I PRICE
0860 648 16 00111 WD' I Q I V 1 21500
HEATED AREA
a�'
NOTES
split per plat 2011 ?
2X24 CP
SUBAREA UNIT ORIG% SIZE ANN DEP % OB/XF DEPR. c
GS RPL OD UALI DESCRIPTIONLTH HUNIT PRICE GOND BLDG#L/ FACT V EY RATE V GOND VALUEo
TYPE AREA /o CS TOTAL OB/XF VALUE 0o
FIREPLACE n
SUBAREA
TOTALS
w
BUILDING DIMENSIONS
LAND INFORMATION
HIGHEST THER ADJUSTMENTS LAND TOTAL
AND BEST USE LOCAL FRON DEPTH/ LND COND ND NOTES ROA UNIT LAND UNT TOTAL ADJUSTED LAND LAND
USE CODE ZONING TAGE DEPTH SIZE 1 MOD FACT I RF AC LC TO OT TYPE PRICE UNITS TYP ADJST UNIT PRICE VALUE NOTES
RURAL AC 0120 893 0 0.8500 1 4 0.7800-02+00+00-10-10 RP 6,500.0 49.899 4,309.5C 21504
crk
TOTAL MARKET LAND DATA 49.899 215,04
GRII 5110 0 0 1.0000 5 1.0000 705.00 10.410 AC 1.00C 705.00 733
GRI II 5210 0 0 1.0000 5 1.0000 480.00 7.559 AC 1.00C 480.0 362
GRI III 5310 0 0 1.0000 5 1.0000 310.00 3.320 AC 1.00C 310.00 102
FRSTII 6210 0 0 1.0000 5 1.0000 160.00 1.690 AC 1.00C 160.0 27
RST II1 6310 0 0 1.0000 5 1.0000 155.0 10.34C AC 1.000 155.00 160 ,
-RST IV 6410 0 0 1.0000 5 1.0000 85.0 7.97 AC1.00 85.0 67
RL HOMSITE 5000 0 0 1.0000 5 1.0000 4,309.50 8.61 AC 1.00 4,309.5 37105 DNQ
OTAL PRESENT USE DATA 49.89 51,65
http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=N60000008101 12/12/2012
Box 28047
North Carolina State Laboratory Public Health 0372 District Drive
Raleigh,NC 27611-8047
Environmental Sciences htto://sloh.ncr)ublichealth.com
fit{ V -fi'
Microbiology Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Report To: Name of System:
DAVIE CO ENVIRONMENTAL HEALTH KEITH SMITH
P O BOX 848
1040 CHERRY HILL RD
MOCKSVILLE,NC 27028 MOCKSVILLE,NC 27028
EIN:566000295EH COURIER#:09-40-06
StarLiMS Sample ID: ES072513-0056001 Collected: 07/24/2013 10:45 Andrew Daywalt
111111111 111111 111 11111 111111 11111 11111 11111 1111 111111 11111 11111 11111 111 Received: 07/25/2013 08:35 Angela Heybroek
ES Microbiology ID: Sample Source: New Well Well Permit Number:
GPS Number: Sampling Point: Well head 115
Sample Description:
Comment:
Environmental Microbiology-Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform,Colilert Present Darneice Lyons 07/26/2013
E.coli,Colilert Absent Darneice Lyons 07/26/2013
Report Date: 08/01/2013 Reported By: Susan Beasley
Explanations of Coliform Analysis:
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.
TA
047
North Carolina State Laboratory of Public Health '0. ox 280 Drive
Environmental Sciences RECE'lV n, .n ublich8047
// I h.nc ublichealth.com
Inorganic Chemistry one: 919-733-7308
QUAMAUG 1
Certificate of Analysis 2 20fjx: 919-715-8611
DC HEAT TI-I
Report To: ANDREW DAYWALT Name of System:
DAVIE CO ENVIRONMENTAL HEALTH KEITH SMITH
P O BOX 848
1040 CHERRY HILL RD
MOCKSVILLE, NC 27028 Courier#09-40-06 MOCKSVILLE, NC 27028
EIN: 566000295EH
StarLiMS ID: ES072513-0036001 Date Collected: 07/24/13 Time Collected: 10:45 AM
Date Received: 07/25/13 Collected By: Andrew Daywalt
Sample Type: Sampling Point: Well head Well Permit#: 115
Sample Source: New Well Temp. at Receipt: 7.0 GPS#:
Sample Description:
Comment:
New Well I (Profile)
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 350 mg/L
Chloride 12.00 250 mg/L
Chromium <0.01 0.10 mg/L
Copper <0.05 1.3 mg/L
Fluoride 1.60 4.00 mg/L
Iron <0.10 0.30 mg/L
Lead <0.005 0.015 mg/L
Magnesium 3 mg/L
Manganese <0.03 0.05 mg/L
Mercury <0.0005 0.002 mg/L
Nitrate 1.30 10.00 mg/L
Nitrite _ < 0.10 1.00 mg/L
pH 7.4 N/A
Selenium <0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 33.00 mg/L
Sulfate 680.00 250 mg/L
Total Alkalinity 57 mg/L
Total Hardness 880 mg/L
Zinc 1.60 5.00 mg/L
Report Date: 08/05/2013 Reported By: Arno/d Ha//
Page 1 of 1
a
RES`IDENI"Ii4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# OL r`•`c il� I't °�
tµ=r b1f p
1.WELL CONTRACTOR: t� g. WATER ZONES(depth): \ 'A o"'S
1'"4 ft It 1A eel_- ./J , �f o 1,,i I Top ��J Bottom �I�' � %Top Bottom
Well Contractor(Individual)NameTop 3 q 7 Bottom Top Bottom
Y_ ADKIN WELL COMPANY. INC. : ' Top *IS' Bottom `Top Bottom
Well Contractor Company Name Thickness/
1908 HAMPTONVILLE ROAD 7. CASING: Depth Diameter Weight Material
Street Address Top _Bottom , Ft.-6�i�� 9i"11
HAMPTONVILLE NC 27020 Top Bottom Ft. -
City or Town State Zip Code Top Bottom Ft.
( 336 ) 468-4440
Area code Phone number 8. GROUT: Depth Material j Method
2.WELL INFORMATION: ® Top 6 Bottom 3 Ft. 81,4ply"fie-a-'s —(./ i
WELL CONSTRUCTION PERMIT# D to — w Top 3 Bottom �a Ft.11 t. ♦•nn;4c. ;iu'r P.11 ^
OTHER ASSOCIATED PERMIT#(ifapplicable) Top Bottom Ft.
SITE WELL ID#(if applicable) 33.1
g. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply' Top BottomFt. in. .in.
<
DATE DRILLED 0 Lf '"� �� TopBo Ft. fn. In.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM p'
4.WELL LOCATION: 10.SANDIGRAVEL PACK:
Depth Size Material
CITY: &14 (g no a�/e COUNTY
/ < Top Bottom Ft.
ZL D E 0 1,�1 e(,in/. .f7��1� ��. TopE�� om Ft.
(Street Name,Numbers,Community,SLk6divislon,Lot No.,Parcel,Zip Code) Top Bottom Ft. ;
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
'Slop ❑Valley ❑Flat ❑Ridge ❑Other 11:DRILLING LOG
e •
Top Bottom Formation Description
LATITUDE 2 1;"�,5Z"DMS OR DD Q
LONGITUDE DMS OR DD2,3
/ .3 l/"� �n�'f (y.-A.c/•�G
Latitude/longitude source: PPS Dropographic map
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) l
5.WELL OWNER
1 �
•� '1� a � ,� 11-0/Z
Owner Name /
Street Address /
M6
City or Town State Zip Code / S . L f
Area code Phone number 12. REMARKS: Bit Serial NO:
6.WELL DETAILS: �' cAtaktll &Gg— 11°1ftyat/I r�.cl.s °
a. TOTAL DEPTH: a ,,n ti._1 ���ew c7J tion
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 16 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use°+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface* rte'
*Top of casing terminated attor below land surface may require
a variance in accordance with 15A NCAC 2C.01 18. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 3 METHOD OF TEST A;r Pte,. j
f. DISINFECTION:Type HTH Amount I 1A CUIDS PRINTED NAME OF-PERSON CONSTRUCTING THE WELL
5ubmwih n 30 days of com'pfetlon to: Division of Water Quality- Information Processing, Form GW-1a
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:(919)807-6300 Rev.2/09
�°�'`���R'''Date Site Visited 3--.2_, 1 Y By:40Permit: y--e—s No
Y/t/CYiele- -sh.i /A(&cgV-c,/,t��a.. h{�". Cvjyt
What Is Height of Well Casing? Make Sure 12" Above Ground Level! ! ! !
BUIEDERS NAME'
ADDRESS
PHONE NUMBER'
r
G�
Tre
r
" l �
b.i/•11/:ZU1J UU:14 J:3b15:31b8b DUEH F'A(at. b1/01
. Davie County Environmental Health
P.O.Box MW10 Hospifgl Strxt
Mucksville,NC 27028
(336)753.6780/Fax(336)753-1680
WE1..L PEI NIff
A060UM tF 9901}0567.1 - TPRIMM 'N60000008101-Weft
l 'To-- K6#h end Whele Smititi .' l Jl ' y l9l i :v^ w:r ,::5 , •,.,•tr.
Rbft ericb.l'+lat3a : .. Qom'/ ikl lay IHf1Il8�� 11 +.
Pira F;Acg r - Reehieaal Well �=r !• . .. r. , l�t�g� 'v •i'/g e. .• , .. :;.,.�,;;:. .
AOC Number- 0115 L .1. •.1 Y,.! �i?.71 .:G i;'i
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 anypartieular quantity or quality or for any amount of time. "is•permit is'va.lid
for a period of 5 years from the'date of issuance. 11iis permit may be revoked if it is doermincd that there
has been a material change in any fact/circumstanccs upon which this permit was issued.
etmi pe: New LISL jkupatr *bMtdarment[]
Proposed Well Location Di ` Certificate of Completion Diagram
G '
to
q
Comments: /CO' Driller:
certlficatio t 1t:
Grout Inspected:- --
Well Read inspected:
GPS Coordinates:
E148: .... _ Date: �� ERS: __ Date:
W.P.7-08