284 Jamestowne DrDavie Countv. NC Tax Parcel Report Friday. October 7. 201 f
1'.' • '4 `"0"m y_MR_I IV 63101911II: I U 1143x'4
I yr
9 1fl16
Parcel Information
All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to
or arising out of the use or Inability to use the GIS data provided by this website.
Parcel Number:
H600000080
Township:
Shady Grove
NCPIN Number:
5759715404
Municipality:
Account Number:
8304982
Census Tract:
37059-804
Listed Owner 1:
FRANK HAROLD
Voting Precinct:
WEST SHADY GROVE
Mailing Address 1:
137 RALPH ROAD
Planning Jurisdiction:
Davie County
City: MOCKSVILLE
Zoning Class:
DAVIE COUNTY R -A
State:
NC
Zoning Overlay:
Zip Code:
27028
Voluntary Ag. District:
No
Legal Description: 8.24 AC OFF CORNATZER RD LOT 4
Fire Response District:
CORNATZER - DULIN
Assessed Acreage:
8.39
Elementary School Zone:
CORNATZER
Deed Date:
5/2015
Middle School Zone:
WILLIAM ELLIS
Deed Book / Page:
009870894
Soil Types: WeC,GnB2,PcB2,RnC,GnC2,RnD
Plat Book:
Flood Zone:
Plat Page:
Watershed Overlay:
DAVIE COUNTY
Building Value:
9750.00
Outbuilding & Extra
Freatures Value:
0.00
Land Value:
27650.00
Total Market Value:
37400.00
Total Assessed Value:
37400.00
I yr
9 1fl16
Davie County,
1�T
1� C
All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to
or arising out of the use or Inability to use the GIS data provided by this website.
Account #: 990005268
Billed To: Harold Frank
Reference Name:
Proposed Facility: Residence
ATC Number: 0029
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
WELL PERMIT
Tax PIN/EH #: 5759 -71 -5404 -Well
Subdivision Info:
Location/Address: Jamestowne Drive -27028
Property Size: 8 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 � Repair ❑ Abandonment ❑
Proposed Well Location Diagram
300 W,10
nL ,X
NR
Comments: A& "T b -e IM i Id r,MU�
I o., \[ 1,00
S�P1Jt C
EHS:
W.P. 7-08
Certificate of Completion Diagram
Driller: & u & dp
Certification #:
Grout Inspected: -7
Well Head Inspected:
GPS Coordinates:
Date: .%'Il/ 4Y I EHS:
Date:
TION FOR PRIVATE WELL PERMIT
avie County Environmental Health
P.O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)75178760/ Fax (336)751-8786
Vi * * *IMPORTANT* * *
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name to be Billed ZD d r9d Alt- Contact Person
Billing Address ,3 / Home Phone lfl �- Y� f Z
City/State/ZIP '/ (i ZZO -Lk Business Phone
Name on Permit if Different than Above
Mailing Address
City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners
NOTE: A survey plait site plp must accompany this application. Included: @Y§ite Plan ❑Plat (to scale)
Owner's Name1Zp,Q7�1,� Phone Number
Owner's Address City/State/Zip
Property Address OW%N City /#OCy 1,;'
Lot Size Tax PIN# S75g • 1%- 5`'i0y
Subdivision Name(if applicable S ctio ot#
Directions T Site: 2 a B � //✓ %N /i -r
Ily _��n,o��n,,1�1Pel
DEVELOPMENT INFORMATION
Permit Type: New Well r/ 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 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 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.
A" Z,
Signed
7/1/08
�1- 09
Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account #
Invoice #
DAVIE COUNTY
WELL CERTIFICATE OF COMPLETION CHECKLIST
Applicant: r6ny-
File #:
Site Address: j0V0C6+6WVu bylyf-
Subdivision: Lot:
Permit Type: New Well �C_ 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?
If No, Explain:
What is the Grout Thickness? I— in.
What is the Type of Well? do I `M
Was a Well Screen Installed? PIA
What is the Casing Type?
Type of Drilling Fluids Used: V-yA+CV'
What is the Casing Depth? _ ft.
Well Grout Inspection Date: 7Z$ jol
What is the Well Diameter? _ (P in..
GPS Coordinates:
What is the Well Depth? _ ?.� s 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:
Aug 03 09 10:44a DANA CLAYTON
276-957-1705 P.2
l 3. W EL- LO -AT IDN:
COUNT
i .5u rrr Nanc. hun,orrs. Gormmururr- SLborwon, Lot 40.. Pa.-cet. 2 x
rp Co)
OPOGRAPHIC i :.AhO SE S\G•
I
I _SionA .0V&ley '�eFlal !Ridge :)O•dter
I.r E :k app: opr•ale Vogt
' i`1sy be M deerres. :
i :moi -RUDE 3 _ _— Miwus scconcso:
r
in a ccamal 1[xth-rt
Uititudedungitudc: source- UC PS GTo?ographic rnsa i I
• 9ocarr_•n o1 weF MUS rbe slx>wn on a USG S:opo map and
iar:acned % Int$ f •rrn :not us. )9 GFS) !
4. VVE-L OWNER
! 6tr.':.iR-S VANE.
STHE=' ADDRESS —
Sla-m Zip Cooe
S. tJVELL DE -AILS: I
i
a. TOTAL DEPTN'_
b. DOES WELL REPLACE EXIS-ING WELL? YES _ tJc
I I
c. WATER I -E VEL 5clav - v:: 01 r-asatg: -,!�&— F" t
;Use -+' f Aawe Top G' Casing)
d. TOP OF CASING 15 %• FT. Abovo Lams Surface' It
•Top of casings :errmraied alto( uelow .ani sur'aca may recNrre
a .rariance in acco(aance w In 15A NCAC 2C.01 IS
1 e. !I.LD (gprn) G.7 ME'HOD OF TEST !SIJ
5.-ANprGFAVEL PACK.
Ceplr• SIc Materia. i
frorr. To F ----
F: on T'o
10. DRILL!NG LOG
From Tc
D V,.
Y
Farmaacn Descriplon
c
11. RENIARFCS:
I
rl'w)nIhAI riC'::?'- ♦145 Ci�'r218a1C:E::.n-is:J•:Ii:.r{i :a:••
QAC 2c AELL C;.7rtSIF 1 N S'lu+LIANCS AND :;r.T :• _.^,?• (r In15
Ec-;.; • .; ::r FRG cU 1C NE wEt.i CJ�•.'NE:1
SIGN;• U?c ERTIF! ,: RAC -CR )AT[
PRINTED NAhl_=RF YSON CC MTRU ;TING -HE 'lVc.t I
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., torn: Gia - :a
1617 Mail Seriice Center- Raleigh, NC 27699-1617 Phone No. (919) 733.7015 ext 568. ice•. 710L
RESIDENTIAL WELL
CONSTRUCTION RECORD
y t ,Q'• 1Utlh Curti'ma ucpalrncia vi L-mi:um-cm amid
::au.ral kesuutcr_• Unstuh j \Vatct r iu;ali�
ri
•-- NVELL CONTRACTOR CE wnFICATIUR #
—�
1. Y GUNTRA^T R:
I. OISINf_CTION: Typo Amount
:
I
WATER.'.ONES;acr!n;
l I :atlrae•Q�`tndn•dual, Name
10 ---
-�
•
-_-1 Flrt„�J..EC..
I
--�,
---•--'-- fL ___ t'Car: _ •.:
:•+e)r:,onoactor Con-pzany
cr xr to F(rr.
�Naarrnt
a "REE'. r•UU 2ESS il !Wt��C +' i /-tom"
5 CASING:
t� �f•' //II-�/%'/^T 7/�
De tLl drllelE7 L•Z'(�j(, rel: t
d:Ena
---
` C•tr ..., T,ri State Zip Code
F:L•rrr- _ To • __._—.. ..—._.
.--._-_
i
Ft
: Alea %;WL- Phone :»tuber
WELL INFORMATION f
?• GROUT: Depth 18teua. fear )
SITE::E:L IU aptapFrcA i I
xr�- to F! - -----
-
--
STATE %NE__ PERMrTHitdaoarcaclel +
!
=tar.:-- Te F: _----_
-
I DWQ or OTHER PER1.111. F(if applicable" c_ I i
3. SCREEN: ::aFtr: Drame{e: SIU! ]r(N
hia:er•ad I
f!
WELL,ELWELL,USE tC:hc,:kApahc:ame Sox) Res}7ential Wale: S,.ppw•-
7c
=rom F: -------- �.� _ —_.r �-_-.
From rC -t rn u:
.... !
.---•
i
--7 �?
DRILLED—�I_ �a��_
_ _
Flom'c ~_Ft—_ -Ili "--
--_
DATE
r !n
TIME COM?LETED-__ .-•----___--- •'um - PA7,;
!
1
l 3. W EL- LO -AT IDN:
COUNT
i .5u rrr Nanc. hun,orrs. Gormmururr- SLborwon, Lot 40.. Pa.-cet. 2 x
rp Co)
OPOGRAPHIC i :.AhO SE S\G•
I
I _SionA .0V&ley '�eFlal !Ridge :)O•dter
I.r E :k app: opr•ale Vogt
' i`1sy be M deerres. :
i :moi -RUDE 3 _ _— Miwus scconcso:
r
in a ccamal 1[xth-rt
Uititudedungitudc: source- UC PS GTo?ographic rnsa i I
• 9ocarr_•n o1 weF MUS rbe slx>wn on a USG S:opo map and
iar:acned % Int$ f •rrn :not us. )9 GFS) !
4. VVE-L OWNER
! 6tr.':.iR-S VANE.
STHE=' ADDRESS —
Sla-m Zip Cooe
S. tJVELL DE -AILS: I
i
a. TOTAL DEPTN'_
b. DOES WELL REPLACE EXIS-ING WELL? YES _ tJc
I I
c. WATER I -E VEL 5clav - v:: 01 r-asatg: -,!�&— F" t
;Use -+' f Aawe Top G' Casing)
d. TOP OF CASING 15 %• FT. Abovo Lams Surface' It
•Top of casings :errmraied alto( uelow .ani sur'aca may recNrre
a .rariance in acco(aance w In 15A NCAC 2C.01 IS
1 e. !I.LD (gprn) G.7 ME'HOD OF TEST !SIJ
5.-ANprGFAVEL PACK.
Ceplr• SIc Materia. i
frorr. To F ----
F: on T'o
10. DRILL!NG LOG
From Tc
D V,.
Y
Farmaacn Descriplon
c
11. RENIARFCS:
I
rl'w)nIhAI riC'::?'- ♦145 Ci�'r218a1C:E::.n-is:J•:Ii:.r{i :a:••
QAC 2c AELL C;.7rtSIF 1 N S'lu+LIANCS AND :;r.T :• _.^,?• (r In15
Ec-;.; • .; ::r FRG cU 1C NE wEt.i CJ�•.'NE:1
SIGN;• U?c ERTIF! ,: RAC -CR )AT[
PRINTED NAhl_=RF YSON CC MTRU ;TING -HE 'lVc.t I
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., torn: Gia - :a
1617 Mail Seriice Center- Raleigh, NC 27699-1617 Phone No. (919) 733.7015 ext 568. ice•. 710L