207 Mr Henry RdDavie Countv. NC
Tax Parcel Renort Friday. October 7. 201 f
WARNING: THIS IS NOTA SURVEY
Parcel Information
Parcel Number:
K30000000102
Township:
Calahaln
NCPIN Number:
5717536192
Municipality:
Account Number:
31440250
Census Tract:
37059-801
Listed Owner 1:.
GUYE TOMMY ALLEN
Voting Precinct:
SOUTH CALAHALN
Mailing Address 1:
207 MR HENRY ROAD
Planning Jurisdiction:
Davie County
City: MOCKSVILLE
Zoning Class:
DAVIE COUNTY R -A
State:
NC
Zoning Overlay:
Zip Code:
27028-5356
Voluntary Ag. District:
No
Legal Description:
10.50 AC MR HENRY RD
Fire Response District:
COUNTY LINE
Assessed Acreage:
10.44
Elementary School Zone:
COOLEEMEE
Deed Date:
11/1992
Middle School Zone:
SOUTH DAVIE
Deed Book / Page:
001660273
Soil Types: PaD,PcB2,PcC2,EnB,MsC,ChA,MsD
Plat Book:
Flood Zone:
Plat Page:
Watershed Overlay:
DAVIE COUNTY
Building Value:
133440.00
Outbuilding & Extra
Freatures Value:
13580.00
Land Value:
66860.00
Total Market Value:
213880.00
Total Assessed Value:
213880.00
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County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to
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noUN�� 1� C or arising out of the use or Inability to use the GIS data provided by this website.
1
r Davie County Environmental Health
P.O. Box 848/210 Hospital Street 1
Mocksville, NC 27028
(336)753-6780 / Fax (336)753-1680
WELL PERMIT
Account #: 990005650 Tax PIN/EH #: 5717 -53 -6192 -Well Repair
Billed To: Tommy Guye Subdivision Info:
Reference Fume: WELL REPAIR LocationrAddress:.207 Mr. Henry Road -27028
Proposed Facility: Residential Well Repair Properly Size: , -'10:50 Acres
ATC dumber: 0070
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
NsG O ��Ve
Certificate of Completion Diagram
f
Comments: (�?' �� Q��lj7
60M
Driller:
Certification Certification #:
Grout Inspected:
Well Head Inspected:
GPS Coordinates:
EHS: Date:
EHS: Date:
W.P. 7-08
a
LICATION FOR PRIVATE WELL PERMIT
�GErvE Davie County Environmental Health
r Z�i� P.O. Box 848/210 Hospital Street
A Mocksville, NC 27028
nv(336)753-6780 / Fax (336)753-1680
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name Contact Person
Address Home Phone
City/State/ZIP -e Business Phone
Name on Permit if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application.
Owner's Name
Owner's Address
Property Address(} 7 8641z
Lot Size Tax PtN#'
Subdivision Name(if,aPp•l,ic ble)
DirjaOons To Site: zqq ' &(/ tv , arl'i nit/ rQe�1 /1 i
DEVELOPMENT INFORMATION
Included: ❑ Site Plan ❑Plat (to scale)
Phone Number
—City/State/Zip
Permit Type: New Well Well Repair t/ 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
p,
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 or a well.
ig ed Date
7/30/09
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account # 56
Invoice #
RLSIDLNTIt1L Wi;LLcoNSTauCTION RECORD RECEIVP�-,
North Carolina Department of Environment and Natural Resources- Division of Rater Quality APR 0 8
WELL CONTRACTOR CERTIFICATION # a5l D— DMECUUlNIYHEAuhr-)tl-HnlrVLl�
1. WELL CONTRACTOR:
Well Contr ctor (Individual) Name
YADKIN WELL COMPANY. INC.
Well Contractor Company Name
1908 HAMPTONVILLE ROAD
Street Address
HAMPTONVILLE NC 27020
City or Town Slate Zip Code
336 t 468-4440
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(d-p I C ble)_
SITE WELL ID #(il applicable) _zR— � 3 f
3. WELL USE (Check Applicable Box): Residential Water Supply p$
DATE DRILLED 3_-10- 1
TIME COPAPLETED \ T-= GC AM 0 PPA p
g. WATER ZONES (depth):
Top 7d e? Bottom 7l,
Top Bottom
Top Bottom
Top Bollom
Top Bollorm
Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top Bcdlom Fl. _
Top_ Bottom Ft.
Top Bottom Fl.
6 GROUT: Depth Malarial I.lethod
Tcp__o Boltom FI. _
Top Bollom Ft
Top _ Boltom Fl
9. SCREEN: Depth Diameter Slot Size Llalerial
Top_ Bottom-- FI —`in —__ in _
Top Bollom FI _ in —� in _
Top Bollom FI ___in —__ in _
4. WELL LOCATION:
10, SANDIGRAVEL PACK:
f�iitt.� .
CITY: MCoCdt(//��P�
COUNTY 10ajZ P-
Depth Size
Top
Boltom_ Ft_
Top__Botlonl
Ft_
(Sireel flame, IJumbers. Co inuni ,
Subdivisio , Lol No, Parcel, Zip Code)
Top
Bollom FI __,
TOPOGRAPHIC/ LAI JD SETTING: (check appropriale box)
tR'Slope ❑Valley []Flat ❑Ridge ❑Other
LATITUDE _" DMS OR 3=s; DD
LONGITUDE " Dh1S ORVl DD
Latitude/longitude source: 03PS []Topographic map
(location of trell must be sl own on a USGS Popo map andattached to
this form if not using GPS)
5. WELL OWNER
Owner'Name
Street Address
City or Town Stater Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPT14: 16 3 Q e Cv
b. DOES WELL REPLACE EXISTING WELL? YES O IJO
c. WATER LEVEL Below Top of Casing: 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.01 18.
e. YIELD (gpm):— METHOD OF TEST atm
i. DISINFECTION: Type HTH _ Amount Clips
11. DRILLING LOG
Top Bollom
l (a�•t�
(C)
/
r.laterial
Formation Description
Di '/
SIZE OFF
OFF
BIT SERIAL NO: 0°31(yyh'
12. REMARKS: �
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED III
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
ATURE OVARTIFIED WELL CONTRACTOR DATE
ad -1 L., f, -7v ( 3
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of Completion to: Division of Water Quality - Information Processing, Form GW -1a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2109 /v 3
Date Site Visited 3 --?—!( By:__ _4;;�_Perndt: Yes? NO 3 6 i — t
What Is Height of Well Casing? Make Sure 12" Above Ground Level!!!!
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