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175 Crabtree Rd (2) R-H WELL CONSTRUCTION RECORD For,Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: 14.NATER ZONES / "J FROM TO DESCRIPTION Well Contractor Name /2 Ti ft i 3 Z ft. — 1,, 3 03 6A acv0 ft .270 ft. ,2 81'-,214) NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ' 'a livable FROM TO M DL4LTER TIIIC[INESS MATERLA.L Yadkin Well Company, Inc. ft' I in. Company Name 16.INNER CASING OR TUBING eotbermal closed-loo FROM I TO I DIAMETER I THICKNESS I MATERIAL 2.Well Construction Permit#: ft. ft. 16 YR in. d �t U List all applicable well consftuction permits(i.e.Couno,State,Variance,etc.) ft ft. 3.Well Use(cllecIt well use): 17.SCREEN Water Supply Well: FROM TO DUMETER SLOT SIZE THICICYESS MATERIAL ❑Agricultural ❑Municipal/Public tot. ft. is ❑Geotherma1(Heating/Coolino.g Supply) "amesidential Water SuPPIY(single) t ft' �n• ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATERL.AL EMPLACEMENT METHOD&AMOUNT ❑hrigation & ft p r Non-Water Supply Well: -7 A0)1 . S �� 3 ❑Monitoring ❑Recovery ft o .c f tt. %-L. s Amx3 Injection Well: ft ft. ❑Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK(if a livable) ❑Aquifer Storage and Recovery []Salinity Barrier FROM To nuTlrltLiL EMPLACEMENT METHOD ft ft. ❑Aquifer Test ❑Stormwater Drainage tt. ❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary) ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,Brain size etc. ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft ft. ft. t S � 4.Date Well(s)Completed: " YWell ID#Ah L. - 7 0 '� 32 d fit ft ft.. 5a.Well Location: Phone number 3%-379- 9yq 3 ft ft. VAMC'u t i 14- Ivor Fill, u, 62A JAliNA :T,) ft ft Facility/OwnerNan/^ic /f Facility ID#(i/fapplicable) �7S 6aab'"iri-e- P� /•iOGI(SN✓ #L' ft ft Physical Address,City,and Zip 21 REMARKS ,plavi e, 03—000-W-03-01 County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: (ifwell field,one lat/long is sufficient) 3T" 19, 6 7 V N 616 3 7, .533 �/ Signature of Certified Well Contractor Date 6.Is(are)the well(s):K�'ermanent or ❑Temporary By signing this form,I hereby cent that the well(s)was(were)constructed in accordance f with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: ❑Yes or >(No copy of this record has been provided to the well owner. If this is a repair,fill otet known well co)isintcton information and explain the natutre ofthe repair under k21 remarks section or on the back ofthisform. 23.Site diagram or additional well details: You may use the back of this page to provide additional well site details or well S.Number of wells constructed: construction details. You may also attach additional pages ifnecessary. For multiple injection or non-water sipply wells ONLYwuh the same construction,you can subvtit one form. SUBMITTAL INSTUCTIONS 9.Total well depth below land surface: �+�C U (ft) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths 1fdierent(erample-3@200'and 2@100) ' construction to the following: 10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit, If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: (in.) Bit Off-6,03Y" 24b.For Ltiection Wells: In addition to sending the form to the address in 24a above, also submit a copy of this form within 30 days of completion of well 12.Well construction method:__Rotary construction to the following: (i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 t 24c.For Water Supply&Iniection Wells: In addition to sending the form to 13a.Yield(gpm) �a2 Method oftest: 4 i/ the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: HTH Amount: CU pS completion of well construction to the county health department of the county where constructed. 17 .;} 3:11rG D L G Form GW-1 North Carolina Department ofEnvironment and Natural Resources-Division of Water Quality , ► Revised Ian.2013 Builders Name: owners Name: Address: Address: Phone Number: Phone: Cell Number: 601 'I.'7 F 10,ore. Cry . i asp°� ate' x� S �I a�w APPLICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)751-8786 ***IMPORTANT*** THIS APPLICATION CANNOT BEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION - Name to be Billed XJVA WL 1( �, 1,1t-Contact Person 141 rot," Billing Address JqQX U0111904v/111_1 9& Home Phone A City/State/ZIP V_ A-1-A.. III , AIC 17J 40 Business Phone 33 6- -4.ellL4,A Email k: ° ) jeaAnn, nom C'e l/ 336. 271/- &73;- ame o Permit if Dierent than Above `la,at r & r c Mailing Address C tate/Zi PROPERTY INFORMATION *Date House/Facility Corners Flagged OTE: A survey plat or site plan must accompany this application. Included: 6ite P a Plat (to scale) Owner's Name VLA11116 4- Moo u4L �c+.c�. one Number_33�.. 37S"- ` li Owner's Address City/State/Zip Property Address 17S CCa A 1rL,L ,,0 CityJpJ.,,k-rN,t1a, A0,1, _V SlLl' 4 Tr. Lot Size Tax PINU 3 . l!t?l7-0®-p g - Q 1 A/C ubdivision Name(if applicable) Section/Lot# Directions To Site: &01 L t--P 4- E l m v r t La-F-- o n �r <r�T dpi✓c. v^ Ld DEVELOPMENT INFORMATION Permit Type: New Well Well Repair Well Abandonment Other(specify) Facility Type: Residential 3e 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. Signed 1VDate Site Revisit Charge Date(s): Client Notification Date: EHS: 7/30/09 Account# Invoice# l ,fix NA / AnCV 6�✓ / SURVEY FOR Catma.t.of amraoy NOlhtt Y/l / ��pe /�//y/� I hereby mUfy that anda my dl—tl and tupw".this plat. Iy111111/UIgyN Vande bili �Motot W e reo n and de k-1 haaoa.wall bath pom an aclud aurvaK daod V V nfenmce k Bhitit d.,Pagao:that Lha mor of th. m J" boundaries by IOUfuaaa and depown at b I:mAw;that mt `J�.. p''iLSSr�, r bahwdart-hat awwyed oro ahatn at Mvkan unaa that m.wop�r & Finance Inc. Ndt.lNy npw.aht. Is h mw ting ran j: ctba of ?z SEAL Daa4 County aha It an.daNnq trot and that tlda CLARKN Ap1MlA� TY1 St.tIO mcp meats Ua mwkww.nt of Na StmdoM.of P.,Uca , L-4246 : S I qO I7 r for lmd Surwylnq In NMN c:Una(21 NCAC 5[[.1600} DAME COUNTY/ NORTH CAROLINA iwtlhamat.I her by eakTy that the prcp.fty ll and m. IoaaUon -1.1y, a(of -tan aw th.-haraan:that 1> - -i- �..,,, ,Q. • 0 60 120 180 '- Wr�o-L o,er'i, n°°a ayb=-t:a°dia�to'omwtr ahaatoh.s on th.p—i—saewy.d,-e—pt-sham ha.cn. 111111\1111 Q Thl.1..a.1 i t N. t Awl wmE,Er AL 7 Z plot at which It weadad In Plat Book Y pop• 20 N w 0f&..(rt al MARK E. MYERS LAND SURVEYORof WW. W UD-4. County North lortlkw. 551 STANFIELD ROAD Mina-my twnd and saw this 41M day of BURLINGTON, NORTH CAROLINA 27217a° A 20 '—` (338)421-0271 EMAIU ncp1a42480gma0.com /"—L— � � n /(_/ \ P8 9 PG 201 SCALE: 1 - 100 1 DATE: 03/04/14 P..fwom d Lane Swwya L-4248 N SURVEY 8Y: MEM IDWO BY: MEM APP'D BY' MEM ORIENTED TO PLAT NORTH PRECISION: 1: 10,000 AREA: 1.04 ACt IFILE. vttn75CRMMMMcNSVIU R' E WILLIE C. ELMORE EXISTING 30' ACCESS & UTILITY EASEMENT D8 660-620 TIE PB 9 PG 201 I/r as. N 86'01'08" W 71E S w 236.10' �– EXI3nN���� N 86.03109' W Pg 9PG 20�OF. WAY I 231.36' '/e S 86'0r�3'0,.8• E j 260.44' 1'sgaaw �. t W n AFLOW aN HINOT Arm rro� " ANN G. WHITE & C-4 N Q 9 ,� w I As or 1Era6NFd nr 1Ne of PAlrnaar �'/ EDWARD WHITE a g to aP HOUS as Atm uFRAN COGAUNT. .� 1988–E / 201 14 00 "B Fhlod Petr G= 'O� /(� - '" 79.63' ) Tty[itis' Z LEGEND 'f'� �,9 adokwex barba wkv ran. PB 9 PG (n 6 Existing Iron Pipe Q am �,Qi¢ /�Cf xx MathematicalBPoint N 86.03'28" W 4' Light Pole 260.35' I/.. Broken line – not to scale ewall sma Trow t ANN G. WHITE & vu Water meter W ,11VAor lvat of Crabtra Rrr) EDWARD WHITE Pm Utility Pedestal *� Clean out 1988–E / 201 i q,S'b 3,6 1",CL4 28� r1{� �v ?r �C�7 li J �i0t7 . 3 sso Co t ed .ska (4,,,,\ Vty , c�m WELL CONSTRUCTION RECORD For Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: //V� �/ / 14.WATER ZONES /C4 yy/I t✓ �� j,�/, FROM TO I DESCRIPTION Well Contractor Naame 12-k ft. /,Z ft — J"S— ,.�V:3 6A =0 ft. .270 ft. a s-d-,m— ,fir NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER ' a lieable FROM TO DLA IETER TIItCKNESS MATERLAL Yadkin Well Company, Inc. f` in. Company Name 16.INNER CASING OR-TUBING(geothermal closed-loo FROM TO DLARIETER I THICIMSS I MATERIAL 2.Well Construction Permit 4: + ' ft. ft. 16 / in. 'W1—.21 41•C List all applicable well construction permits ri.e.County,State,Variance,etc..) it ft. in. 3.Well Use(check well use): 17.SCREEN Water Supply Well: FROM TO DLAMETER SLOT SIZE THICKNESS MATERIAL ft. ft in. ❑Agricultural ❑Municipa"ublic 0Geotherma((Heating/Cooling Supply) residential Water Supply(single) ` ft. in. ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATERLAL EMPLACEMENT METHOD&AMOUNT ❑Irrigation o ft. 3 ft. /' f Non-Water Supply Well: ❑Monitoring ❑Recovery 3 f. �/ ft. Injection Well: ft. ft []Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACIc dapplicable) FROM TO MATERIAL EMPLACEMENTMETHOD ❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft. ❑Aquifer Test ❑Stormwater Drainage ft. ft ❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sbeets if necessar ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,grain size,eta) ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Re/marks) Q ft / ft _S e 4.Date Well(s)Completed: `rte YWell ID#.AAL 7/0 0 ap? f L 32()3� 'f t. S- 7 r Irk ft ft. Sa.Well Location: Phone number 336-37!-N-- q'113 ft ft i� , :T u t ar•�a.I}-�- u., (�� s/i t,��n rl ft ft. Facility/Owner Name u Facility y/ID#(i/fapplicable) 17-5- t � /'t t3GI(51/t �IZ/ ft ft Physical Address,City,and Zip 21.REMARKS _Xv;e, 000-0--Xa3-01 County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification: (ifwell field,one lat/long is sufficient) _?S') N 016" 3 7, s3 3 ZY Signature of Certified Well Contactor Date 6.Is(are)the well(s):Xermanent or ❑Temporary By signing this fount,I hereby cert that the wells)was(were)constructed in accordance with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Construction Standards and that a 7.Is this a repair to an existing well: ❑Yes or XNO copy of this record has been provided to the well owner. Ifthis is a repair,fill out known well construction Information and explain the nature ofthe repair under#21 remorkvsection or on the back ofthisform. 23.Site diagram or additional well details: You may use the back of this page to provide additional well site details or well S.Number of wells construe ted: construction details. You may also attach additional pages ifnecessary. For multiple injection or non-water supply wells ONLY with the same construction,you can srubnnit one form. .y SUBMITTAL INSTUCTIONS 9.Total well depth below land surface: 3 u a (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For tmuhiple wells list all depths tfdierent(example-3@2 00'and 1@100) . construction to the following: 10.Static water level below top of casing: 15-0 (ft.) Division ofWater Quality,Information Processing Unit, Ifwaterlevel is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 ' 3q,, 11.Borehole diameter: Jin .) Bit Off � 24b.For I»iection Wells: In addition to sending the form to the address in 24a above, also submit a copy of this form within 30 days of completion of well 12.Well construction method: Rotary construction to the following: (i.e.auger,rotary,cable,direct push,etc.) Division of Nater Quality,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 f 24c.For Water Suaaly&Iniection Wells: In addition to sending the form to 13a.Yield(gpm) �aZ Method of test: A 1'r the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: HTH Amount: L CUPS completion of well constriction to the county health department of the county where constructed. S.WC '& DLC Form GW-1 North Carolina Department ofEnvironment and Natural Resources—Division ofWater Quality ► Revised Jan.2013 , prrrl.� 3oa; nate Site Visited:-4,2. ,/`1 By: M A Builders Name: Owners'Naine: Address: Address: Phone Number: Phone: Cell Number: bn1 1,7 �"i0rz o � L'r,b "r, . I 800 -S J l F f 77 -- r--j X � w� A APPLICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)751-8786 ***IMPORTANT*** THIS APPLICATION CANNOT BEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name to be Billed /dVn WL l 1,� -Contact Person 1114#kl Billing Address J q 0 tj-.,i4- v; l 1 . g& Home Phone� A City/State/ZIP Business Phone 33 t_ � �5�yw Email G, Ce 1/ 336 '77L/- k73,L Name o Permit ifDierentthan Above Vanhr 6,' r e c-.- Mailing Address C tate/Zi PROPERTY INFORMATION *Date House/Facility Corners Flagged OTE: A survey plat or site plan must accompany this application. Included: 6ite P14 Plat (to scale) Owner's Name ViA a b 14- Alc<-jqt, -- E-A tcu one Number .3 5 6- 375- qy t 3 Owner's Address City/State/Zip Property Address 17S Ccc 6 City, ll,Z Afb? .Fp 1 ,l Z-r. Lot Size Tax PIN# Z 3 ®-p a3_D 1 w t Subdivision Name(if applicable) Section/Lot# Directions To Site:_ &o I L 1-,¢4: 1A E 1 m v r t Li-r4 ©n C, 4y-,t," 1 �i�L an Lc / DEVELOPMENT INFORMATION Permit Type: New Well_> Well Repair Well Abandonment Other(specify) Facility Type: Residential 3( 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. 17'- Si ned Date Site Revisit Charge Date(s): Client Notification Date: EHS: 7/30/09 Account# Invoice# Al D� a' 1 �M� t y 1