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168 Klickitat TrailDavie Countv, NC Tax Parcel Renort Friday. October 7. 20 1 f WARRING: TH15 15 NOTA SURVEY Parcel Information Parcel Number: G700000155 Township: Shady Grove NCPIN Number: 5860213967 Municipality: Account Number: 82514543 Census Tract: 37059-803 Listed Owner 1: DIAZ JUVENAL PONCE Voting Precinct: WEST SHADY GROVE Mailing Address 1: PO BOX 96 Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: DAVIE COUNTY QD Zip Code: 27006-1956 Voluntary Ag. District: No Legal Description: TRACT 1 1.075AC DIAZ S/D Fire Response District: CORNATZER - DULIN Assessed Acreage: 1.08 Elementary School Zone: CORNATZER Deed Date: 3/2000 Middle School Zone: WILLIAM ELLIS Deed Book / Page: 003280141 Soil Types: EnB,RnD Plat Book: 0009 Flood Zone: Plat Page: 173 Watershed Overlay: DAVIE COUNTY Building Value: 24280.00 Outbuilding & Extra 0.00 Freatures Value: Land Value: 22080.00 Total Market Value: 46360.00 Total Assessed Value: 46360.00 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. Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax(336)753-1680 Account #: 990004001 Billed To: Juvenal Diaz Reference Name: Proposed Facility: Residential Well WELL PERMIT Tax PINIEH #: 5860 -31 -0963 -Well Subdivision Info: LocationiAddress: 157 Klickitat Trail -27006 Property Size: 8 Acres ATC Number: 0 072 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 itis 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 iagram Certificate of Completion Diagram 119 l nts: Driller: Certification #: Q Grout Inspected: Well Head Inspected: GPS Coordinates:] EHS: Date: EHSULAA�14�—Date: W.P. 7-08 S��Le . I., . - * " W �-, u qW Ffix • E G E IV LICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health APR 0 5 2011 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION -11 Name UU 2 Contact Person �'�!( '70�✓ /�`' Address Home Phone 9-4 LO City/State/ZIPfiMotuee- /V 04 Business Phone Name on Permit if Di Brent tharf Above Mailing Address r' fI Yy1e, City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat (to scale) Owner's Name Phone Number Owner's Address City/St tewip Property Address /, 1(%�t eff.rz / City ' E Lot Size Tax PIN# Subdivision Name(if pap licable) Section/Lot# --J //� Directions TA Site: /d -5- ./ Al wm �Ze,? . 0;i Av 4Gt�d'lop DEVELOPMENT 1NFORMAT46N 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 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. Aiiigned 7/3 0/09 8l� Date Site Revisit Charge Date(s): Client Notification Date: _ EHS: Account # _ Invoice # DAVIE COUNTY. ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 ATC Number: 4646 Site Type: ( e'w ❑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 Waltewater Systems, Section .1900 Sewage Treatriient 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 chance. 0 Residential Specifications: # Bedrooms It # Bathrooms_,2�# People Basement[N Basement plumbingyz ti Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size Q /` !> Type of Water Supply: ❑ County/City i?<ell ❑ Community Well System Specifications: Design Wastewater Flow (GPD) Tank Size 11 d06 GAL. Pump Tank 14 dQ6GAL. Trench Width �- -- Max. Trench Deptb?G rt Rock Depth Linear Ft. �e �° Site Modifications/Conditions/Other: As stated in 15A NCAC 18A.,-.969(5) aftepred—SYStellis May a soave used 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. • � C�V�jia�' G��5't� 5Gk-�du �� d�PocvCw-,u,`f �.-t�• jnSQ,�'LIG1 Pn6r �a SeT� no / b � �+ Pc►��D 7A�rK G2� �-2 llrc/- C o 1.cnc'E .t itJ�jp ,j6 a.l.� Environme ta)ealth Specialist �,/%%�� Date: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004001 Tax PIN/EH #: 5860-31-0963 Billed To: Juvenal Diaz Subdivision Info: Reference Name: Location/Address: Klickitat Trail -27006 Proposed Facility: Residence_ Property Size: 8 acres ATC Number: 4646 Site Type: ( e'w ❑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 Waltewater Systems, Section .1900 Sewage Treatriient 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 chance. 0 Residential Specifications: # Bedrooms It # Bathrooms_,2�# People Basement[N Basement plumbingyz ti Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size Q /` !> Type of Water Supply: ❑ County/City i?<ell ❑ Community Well System Specifications: Design Wastewater Flow (GPD) Tank Size 11 d06 GAL. Pump Tank 14 dQ6GAL. Trench Width �- -- Max. Trench Deptb?G rt Rock Depth Linear Ft. �e �° Site Modifications/Conditions/Other: As stated in 15A NCAC 18A.,-.969(5) aftepred—SYStellis May a soave used 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. • � C�V�jia�' G��5't� 5Gk-�du �� d�PocvCw-,u,`f �.-t�• jnSQ,�'LIG1 Pn6r �a SeT� no / b � �+ Pc►��D 7A�rK G2� �-2 llrc/- C o 1.cnc'E .t itJ�jp ,j6 a.l.� Environme ta)ealth Specialist �,/%%�� Date: J .4 f ` .� a .�.,..� AE SIDE, WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- Division of Wnler Quality WELL CONTRACTOR CERTIFICATION # �57)- EC�/Ep 1. WELL CONTRACTOR: ( g. WATER ZONES (depth): r� y� r tCcv Q v' Tope_ Bollom /% �i �y (f6p �'� Y PA IMI Well Contractor (Ind iduel) Name : Top dO5- Bottom (p' 3> b' GQQLI JI YIltd b , r.HF2t 1EN1 YADKIN WELL COMPANY. INC. Topa'll{ Bottom 3 ' S Top Bottom Well Contractor Company Name 1903 HAMPTONVILLE ROAD Street Address HAMPTONVILLE NC 27020 City or Town Slate Zip Code f 336) 468-4440 Area code Phone number 2. WELL INFORMATION: n WELL CONSTRUCTION PERMIT# 0 O'7 2 OTHER ASSOCIATED PERMIT#(fzppl,cable) SITE WELL ID #(if applicable) A A R-,.5- 7 7 Thickness/ 7. CASING: Depth Di metter Weight Material Tope Bollom_L �Fl. Top Bottom Ft. Top Bollom Ft. 8. GROUT: Depth Material Method, Top_0 Bottom 5 Fl. 1'�',lY/��GtJIC,I Top_S- Bottom -2k ;iTc Top Bottom Fl. 9. SCREEN: Depth Diameter SlotSize Material 3. WELL USE (Check Applicable Box): Residential Water Supply Top Bottom Fl in in _ DATE DRILLED_ Y'elG' I/ Top Bollom Ft. in in _ TIME COMPLETED 6) , �Ci� APA [IPNh Top Bollom Fl. --in. in _ this firm ifnol using GPS) 4. WELL LOCATION:10. SAND/GRAVEL PACK 5. WELL OWNER / r�P, JuVer.a� Depth Size t:laterial CITY:c(/Cf``vi Ciif COUNTY Top Bollom FL_ _ KI K [n _6A rr( Top Botlom Ft. (Street Name, Numbers, Community, Subdivision, Lot No, Parcel, Zip Code) Top Bollom FI._� TOPOGRAPHIC / LAI ID SETTING: (check appropriate box) Slope ❑Valley ❑Flat ❑Ridge ❑Other 11. DRILLING LOG LATITUDE °S�' 6^'?� "DMS OR DD Top Bollom ' LONGITUDE RV ° l I "DMS OR DD Laliludellongilude source: *PS Ql"opographic map n87 �—/-- (location of well mint be shown on a USGS lopo map andaltached to / this firm ifnol using GPS) / 5. WELL OWNER / r�P, JuVer.a� /lQC1. 1JjGt7 / Owner Name / / 6 S E Street Address / plc. 27000 / City or Town State Zip Code / /f�� (3A 907- C/-PS7 / Area code Phone number 12. REMARKS: 6. WELL DETAILS: a. TOTAL DEPTH: 36), b. DOES WELL REPLACE EXISTING WELL? YES ❑ tJO� c. WATER LEVEL Below Top of Casing: 35' FT. (Use "+" if Above Top of Casing) d. TOP OF CASING IS FT. Above Land Surface* 'Top of casing terminated allor below land surface may require a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): 50 w METHOD OF TEST I I I r_ f. DISINFECTION: Type HTH _ Amount cup Formation Qescriplion So` A6 or, SIZE OFF F� BIT SERIAL NO: 16,?�77 I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER r t( -/g -/l SI URE OlPtERTIFIED WELL CONTRACTOR DATE PRIf ED NA)AE CFPERSON CONSTRUCTING THE WELL Submit within 30 days of completion to: Division of Water Quality - Information Processing, 1617 Mail Service Center, Raleigh, NC 27699.161, Phone :(919) 807.6300 '? Date Site Visited ' I/ By:__,�5 Permit: oe No Ja+*ell lihat Is Height of 69ell Casing? Make Sure 12" Above Ground Level!!!! Form GW -1a Rev. 2/09 BUILDERS NAME: ADDRESS: 6o( Su j / V� v�irn 4 c 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.ncpublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 Report To: ANDREW DAYWALT Name of System: DAVIE CO ENVIRONMENTAL HEALTH FRED BROCKWAY P O BOX 848 MOCKSVILLE, NC 27028 Courier # 09-40-06 EIN: 566000295EH StarLiMS ID: ES112311-0035001 Date Collected: 11/22/11 Time Collected: 11:15 AM Date Received: 11/23/11 Collected By: Andrew Daywalt Sample Type: Sampling Point: Well head Well Permit #: 78 Sample Source: New Well Temp. at Receipt: 17.5 GPS #: 35058.900N/80040.280W Sample Description: Comment: Nitrate sample improperly preserve; therefore results may not be valid. Sample needs to be cooled to 4*C upon collection. 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 19 mg/L Chloride < 5.00 250 mg/L Chromium 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.95 2.00 mg/L Iron 1.60 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 8 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 7.3 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 28.00 mg/L Sulfate 43.00 250 mg/L Total Alkalinity 88 mg/L Total Hardness 80 mg/L Zinc < 0.05 5.00 mg/L Report Date: 12/08/2011 Page 1 of 1 Reported By: W46C xt North Carolina State Laboratory Public Health 306 N. Wilmington St. Environmental Sciences Raleigh, NC 27611-8047 http://slph.ncpublichealth.com Microbiology Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis Report To: DAVIE CO ENVIRONMENTAL HEALTH Name of System: JUVENOL DIAZ RECENEC P O BOX 848 157 KLICKITAT TR JAN 17 2012 MOCKSVILLE, NC 27028 ADVANCE, NC 27006 EIN:566000295EH COURIER #: 09-40-06 Starl-iMS Sample ID: ES011112-0019001 111111111111111111111111111 HE 11111111111111111111111111111111111111111111111111111111111111 ES Microbiology ID: 33187 GPS Number: Sample Description: Comment: Environmental Microbiology - Colilert Profile Test Name: Colilert Analyte Test Result Collected: 01/10/2012 10:45 Received: 01/11/2012 07:54 Sample Source: Well Sampling Point: Well Head Andrew Daywalt Joy Hayes Well Permit Number: Method: SM 92238 Analyst Date Total Coliform, Colilert Absent Joy Hayes 01/12/2012 E. coli, Colilert Absent Joy Hayes 01/12/2012 ReportDate: 01/12/2012 Explanations of Coliform Analysis: Reported By: Susan Beasley FuaAjA�- 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. Box 8047 North Carolina State Laboratory of Public Health 06 N. Wilmiington St. Raleigh, Nn 27611-8047 Environmental Sciences http://slph.cpulichealth.com Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis Report To: ANDREW DAYWALT Name of System:RECEIVED DAVIE CO ENVIRONMENTAL HEALTH JUVENAL DIAZ DEC 13 2011 P O BOX 848 157 KLICKITAT TR. MOCKSVILLE, NC 27028 Courier # 09-40-06 ADVANCE, NC 27006 EIN: 566000295EH StarLiMS ID: ES112311-0034001 Date Collected: 11/22/11 Time Collected: 10:30 AM Date Received: 11/23/11 Collected By: Andrew Daywalt Sample Type: Sampling Point: Well head Well Permit #: 72 Sample Source: New Well Temp. at Receipt: 17.0 GPS #: 35056.680N/80028.609W Sample Description: Comment: Nitrate sample improperly preserve; therefore results may not be valid. Sample needs to be cooled to 4*C upon collection. 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 25 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 2.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 6 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 6.4 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 12.00 mg/L Sulfate 11.00 250 mg/L Total Alkalinity 89 mg/L Total Hardness 87 mg/L Zinc < 0.05 5.00 mg/L Report Date: 12/08/2011 Page 1 of 1 Reported By: M& i�