2648 Liberty Church RdAccount #: 990002085
Billed To: Sherman Dunn
Reference Name:
Proposed Facility: Well
ATC Number: 0007
Davie County Environmental Health Q,Q
P.O. Boa 848/210 Hospital Street
Mocksville, NC 27028 n g I U
(336)751-8760/ Fax (336)751-8786 75�
WELL PERMIT
Tax PIN/EH #: 5804-40-5267
Subdivision Info:
Location/Address: 2648 Liberty Ch Rd -27028
Property Size: 1.81 Acre
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 WellLocation Diagram
Certificate of Completion Diagram
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Comments: CO
Driller: 14d k. n b t 4, S
Certification #: 1303L0
Grout Inspected:
Well Head Inspected: 01 ^ (o ' 7P/N� j°� 0"10 'q
GPS Coor ' a s:
let tc w,4- (, l (�.i � c a � �- � �e "1 �
64 C («
EHS: ate: f3--�
EHS: �� Date:
W.P. 7-08
G>t7� *
68 UJA-W12NOT _R* OP
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ON FOR PRIVATE WELL PERMIT
ie County Environmental Health
P.O. Boz 848/210 Hospital Street
Mocksville, NC 27028
36)751-8760/ Fax (336)751-8786
* * *IMPORTANT* * *
THIS PLLCA. TION'CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name to be Billed 5 e r ,,, a w o L, �/ N Contact Person . !�'A e ,. ,- Q ,v d ,,,,. A,-
Billing
vBilling Address ,) -5W o y s T A ,t. ry . Home Phone 33 G -
City/State/ZIP , n c -. *s y JI i i e- pj c 'Q ' ? o ;;t g Business Phone 336. )
Name on Permit if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat (to scale)
Owner's Name S%, Q,r ,,, q,.r /J W Phone Number336-Vo)zg-S 11
Owner's Address % �J: o a a - y; s 7'� -t n.. City/State/Zip/4/4. 0 7 0 A$
Property Address 4021City
Lot Size% SIiR c , Tax PIN# =
Subdivision Name(if applicable) Section/Lot#
Directions To Site:1, � .Pa /y: O,v /r: 6 �. f► -s : i t� P =ore Y1,6 k N
DEVELOPMENT INFORMATION
Permit Type: New Well Well Repair Well Abandonment Other (specify)
Facility Type: Residential y-- Food Service Church Commercial Other
Are There Any Septic Systems Currently On The Site? YES 1-- 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.
A2z_z�.
.Signed
7/1/08
Date
Site Revisit Charge
Date(s):
Client Notification Date: _
EHS:
Account #
Invoice #
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DAVIE COUNTY
WELL CERTIFICATE OF COMPLETION CHECKLIST
Applicant: 660-r rn bu-h.�
File #:
Site Address: a to q`6 L'� 1,t C ►
Subdivision: Lot:
Permit Type: New Well _�� Well Repair Well Abandonment Other
Facility Type: Residential Food Service
Church Commercial Other
Initial Inspection
Were Setbacks Maintained? Yes V' No
What is the Grout Depth? ft.
If No, Explain:
What is the Grout Thickness? .. in.
What is the Type of Well?
Was a Well Screen Installed?
What is the Casing Type? WL
Type of Drilling Fluids Used: Wdu Gir
What is the Casing Depth? i Lb ft.
Well Grout Inspection Date:
What is the Well Diameter? b. la,S in..
GPS Coordinates:
What is the Well Depth? ft.
EHS ID:
Well Head Inspection �P
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? -0 ft.
What is the Yield? _r, -GPM
Is the Well Contractor ID Plate Complete? v-1
Is the Pump Installer ID Plate Co7plete?
Contractor Name: V ate- l:�-Q ((
Pump Installer Name: t ` �°.
Contractor Certification #: 305 te
Date Installed:
Depth of Well: 0
Depth of Pump Intake:
cc
Casing Depth and Inside Diameter:
Pump Horsepower Rating:
Screened Intervals:
Opening for Piping & Wiring >_12":
Packing Intervals (Sand Packed Wells):
6
Yield in GPM or GPM/ft.-dd:
Ov
Static Water Level and Date Measured:
Date Well Completed:
Well Head Inspection Date: -- ( O — d
EHS ID: If'-(
Construction Completed Date:
Contractor Reports Received Date:
Sample Date: <5^
Results Mailed Date:
Certificate of Completion ate:
Authorized Agent: ! d
g
RESIDENTIAL wE_ coNsrRyc rtON Rrcoitn -
North Carolina Department of Environmdnt end Onfu ai Ratources- Divis
i
on of Water Quality
WELL CONTRACTOR CERTHICA4 iON # • ) �� r+
t—
i. WELL4 ( M4 - Gw c
Well ontractor (Individual) Name
Yadkin Well Cottrpariy, Inc.
Well Contractor Company Name
STREETADDRESS 1908 Hamptonville Road
Hamptonville NC 27020
City or Town State Zip Code
3t 36 t- 468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #Ilf applicable) ,44c
STATE WELL PERMIT#(If applicable)
DWi] or OTHER PERMIT #Cd applicable) jf2 d 6 7
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED ? ~ ( 5—.7-06 9
TIME COMPLETED d AM ❑ PMIT
3. WELL LOCATION: n
CITY., �t CO�U�NTY,punGi Lf! rL
(Street Name, Numbers, CommunitySlUbOrAsion, Lot 196., Parcel. Zip Code)
TOPOGRAPHIC/ LAND SETTING:
lope ❑Valley pFlat ❑Ridge ❑Other
(check appropriate box)
�y May bo do degrees,
LATITUDE 3 v �� . LS . minutes,sceondsor
LONGITUDEZQO , SeK;L iaadxima[format
Latitude/longitude source: OPS ❑Topographic map
(location of welmust be hown on a USGS (opo map and
aHached to this formYnot using GPS)
4.WELLOWNER op- I" H- '
OWNER'S NAME
STREET ADDRESS 4.4 6 v: t c 11
— hu,c %t tt/rW L% V&,,�-
City or Town State Zip Code
(�?4, �-ril'? Gf 2 85- LloZs
Area code - Phono number
5. WELL DETAILS:
a. TOTAL DEPTH:
L DISINFECTION: Type !'H
Amount CUPS
g. WA2ANE3 h
From O f� ToFrom
To
From To From
Tc
From To • From
To
S. CASING:
r / Dept h i drysDit
Fro TO (�TO Ft (
Thickness!
Weight Matetiat
From To R.
From To Ft.
T. GROUT: Depth 'L _Material Method
Fro D To A( R. 6144 -AJ M i n/
Frort To Ft. r _po%
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To FI. --][n. In.
From Tc R. In. in.
9, SANDIGRAVEL PACK:
Dopth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From O—IdTg,�
W.
Description
r/
J IF -Cf
21 y -,-R -A' tG
_Bi i- Sari a l No. Si 7P off
11. REMARKS:. 5-- q q5 -
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOO
�1 (.IDOHEREBYCElii1FYTMTTHiSWELL WAS CONSTRUCn�INACCORDANCEWITH
c. WATER LEVEL Below Top of Casing: i57 Fr, tan HCAC 2e„ WELL CCNSTRUCT>0N STANDARDS, ArmTtwTA COPY OFTHIS
(Use "+' U Above Top or Casing) RECORD HAS BEEN PRO✓DEDTOTHE WELL OWNER.
d. TOP OF CASINO IS _ '' FT. Above Land Surface'
`Top of casing terminated at/or below land surface mayrequire SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance In accbrdance vdth 15A NCAC 2C.0118. �
e. YIELD (gpm): METHOD OF TEST Air Pump _M J1 � =' Ccty-C
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit eSlgi al to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699.1617 Phone No. (819) 733 7015 ext See.
Date site visited by permit - Yeses. No
l0 56 0
Form GW -1 a
Rev. 7/05
Aurl ,08 08 Q8:49a Davie County Environmenta 3367518786
r
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
WELL PERMIT
Account M 990002085
Billed To: Sherman Dunn
Reference Name:
Proposed Facility: Well
ATC Number: 0007
p.2
Tax PIN/EH #: 580440-5267
Subdivision Info:
Location/Address: 2648 Liberty Ch Rd -27028
Property Size: 1.81 Acre
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
1 � '
1 .0 r." '1
0, VIA
LLD
5
t �
Comments:_
W.P. 7-08
Certificate of Completion Diagram
Driller:
Certification A
Grout Inspected: _
Well Head Inspected:
GPS Coordinates:
1 EHS:
Date: