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144 Ollie Harkey Rd Davie County,NC Tax Parcel Report Monday,November 7, 2016 2111 A 2601 `xl 1-2573 , 2496 2493 y i 2479 G 2471 01'- 144-,,, 128 ,,� *1.. } `• `�.._ OLLIE HARKEY-RD s o 2433- i 5 { WARNING: THIS IS NOT A SURVEY Parcel Number:. B20000000101 Township: Clarksville NCPIN Number: 5803582989 Municipality: Account Number: 8303445 Census Tract: 37059-801 Listed Owner 1: BECK ROBIN MICHELLE Voting Precinct: CLARKSVILLE Mailing Address 1: - 156 PEPPERSTONE-DRIVE Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A,R-20 State**- : NC Zoning Overlay: Zip Code: 27028 Voluntary Ag.District: No Legal Description:- 3.562 AC LIBERTY:CHURCH RD Fire Response District: LONE HICKORY Assessed Acreage: 3.56 Elementary School Zone: WILLIAM R DAVIE Deed Date: 4/2014 Middle School Zone: NORTH DAVIE Deed Book/Page: 009540371 Soil Types: MnB2,MdC,MdE Plat Book: 11 Flood Zone: Plat Page: 197 Watershed Overlay: DAVIE COUNTY Building Value: 0.00 Outbuilding&Extra 0.00 Freatures Value: Land Value: 23390.00 Total Market Value: 23390.00 Total Assessed Value: 23390.00 161 All data is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Davie County, 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 NCor arising out of the use or Inability to use the GIS data provided by this website. r OPERATION PERMIT orice se n v ' e rte. Davie County Health Department r*C7DPFileumber 123396-1 210 Hospital Street ssoaas7ass P.O. Box 848 umber. Mocksville NC 27028 Evaluated For. NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: David Beck Property owner: Evelyn Diane Dickens Address: 156 Pepperstone Drive Address: 2601 Liberty Church Road CRY: Mocksville CRY: Yadkinville - State/Zip: NC 27028 StatefZip: NC 27028 Phone#: (336)492-7549 Phone 4: (336)492-7549 Pro a Location 8 Site information Address/Road #: Subdivision: Phase: Lot: 144 011ie Harkey Rd Yadkinville NC 27055 Directions - US Hwy601 North, turn left on LibertyChurch Road. Structure: � - SINGLE FAMILY : Then lft on 011ie Harkey road, beside Church. ;r of Bedrooms. Property second Drive on Right. #of People: "Water Supply: NEW WELL lip Issued by. '`System Classification/Description: TYPE III G.OTHER NON-CONN.TRENCH SYSTEMS "CA issued by: SaproliteSystem? OYes (QNo Design Flow: 4 8 0 *Distribution Type: PUMP TO GRAVITY Pump Required? -- Q QNo Soil Application Rate: 0 a 5 Pre Treatment; Drain field Nitrification Field 1 9 6 0 SQ-ft- *System Type: INFILTRATOR QUICK STANDARD Na. Drain Lines 5 Installer: Sherman Dunn Total Trench Length: 4 9 0 ft. Certification#: 2702 Trench Spacing: _ 9 Inches O.C. Feet O.C. 'EH S: 2140-Nations,Robert Trench Width: 3 Qinches _ Feet Date: 1 0 / 0 5 / .2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Approval Status Maximum Trench Depth: 3 6 ® �Approvetl�� Disapproved Inches Maximum Soil Cover: 2 4 Inches z CDP File Number 123396 - 1 County ID Number: 03497469 Septic Tank Manufacturer. shoal Lat. STB: 760 Long: ' Gallons: 1000 Installer: Sherman Dunn Date: 0 6 / 1 6 / x 0 1 6 Certification#: 2702 THS: S: 'Filter Brand: POLYLOKPL-122 With Pipe Adapter ST Marker. ❑ Yes O N0 Date: 1 0 / 0 5 / x 0 1 6 Reinforced Tank: El Yes ® NO Approval SEatus Piece Tank: ❑ Yes ® N o C] Approved❑ Dlsapproved Pump Tank Manufacturer. shoal Installer. SHerman Dunn PT: 1250 Certification#: 2702 - Gallons: 363 THS: 2140-Nations,Robert Date: 0 6 / . 1 6 / a 0 '1 6 Date: 1 0 / 0 5 / 2 0 1 6 RiserSealed 0 Yes ❑ No RiserHeight: Yes ❑ No (Min:6 in.) ApprovatStatus Reinforced Tank: ® Yes ❑ NO_ © Approvedo.Dlsapproved 1 Piece Tank: ®__Yes ❑ No A - Supply Line Pipe Size: a inch diameter Installer: Sherman Dunn Pipe Length. 4 6 0 feet Certification 4: 2702 *EH S. 2140-Nations,Robert "Schedule: 40 Pressure Rated C] Yes ❑ NO Date: 1 0 I 0 5 / .1 0 1 6 Approved fittings Yes ❑ No Approval Status ®;Approved 0' Disapproved Pump e e e t Pump Type: Zoeler Installer: Sherman Dunn ("Dosing Volume: — Gal Certification#: 2702 Draw Down: Inches THS: 2140-Nations,Robert "Chain: ROPE Date: 1 0 / 0 5 / x 0 1 6 Valves Accessible p Yes ❑ NO Flow Adjustment Valve 0 Yes ❑ No Check-valve Yes ❑ No Approval Status: PVC unions p Yes ❑ NO `' , ®`Approved❑ Dlsapproved Vent Hole Q Yes ❑ No Anti-siphon Hole Q Yes ❑ NO 23396 - 1 $803497469 CDP Fite Number � County ID Number: Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer: shermanDunn Box 12 inches Above Grade Q Yes ❑ No 2702 Certification : Box Adj. Pump Tank Q Yes ❑ No -Conduit Sealed ❑ .Yes ❑ No "EH S: 2140-Nations,Robert Pump Manualty0perabte ❑ Yes ❑ No "Activation Method:PIGGYBACK Date: 1 . 0 0 5 / 2 0 1 6 ;Approval Status Alarm Audible ❑ Yes ❑ No ® Approved❑ Disa roved; Alarm Visible pp - _ ❑ Yes ❑ N o 2140•Nations,Robert "`Operation Permit_completed by: Authorized-State Age Date of Issue: 1 0 1 1 a a 0 1 6 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A .1900 et Seq.,and all conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE III G. Sewage Septic system. -Rule.1961 requires theta Type TYPE III G. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA M anagement,Entity: OWNER Minimum-System Inspection/Maintenance Frequency ByCedified Operator: NIA Reporting Frequency By Certified Operator: NIA Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule .1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as tong as the system is in use,and other requirements for the continued proper performance of the system. It shalt also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 123390 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5803497469 P.O.Box 848 County File Number: Mocksville NC 27028 Date: I l Q Inch Scale: , pslock DrawingDrawing Type: Operation Permit pN/A b �'�-- k VA 1 i , I r I � _ "`CONSTRUCTION For Office Use Only _ AUTHORIZATION *CDP File Number 123396-1 Davie County Health Department County ID Number: 5803497469 Yjv r 210 Hospital Street Evaluated For: NEW P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 1 0 / a a / a 0 1 8 Applicant: David Beck Property Owner: Evelyn Diane Dickens Address: 156 Pepperstone Drive Address: 2601 Liberty Church Road City: Mocksville City: Yadkinville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)492-7549 Phone#: (336)492-7549 Property Location � Site Information Address/Road#: Subdivision: Phase: Lot: Liberty Church Road Yadkinville NC 27055 Directions Structure: SINGLE FAMILY US Hwy 601 North, turn left on Liberty Church Road. Then left on 011ie Harkey road, beside Church. Property #of Bedrooms: second Drive on Right. #of People: *Water Supply: NEW WELL System Specifications Minimum Trench Depth: a 0 (Design lassification: Ps shallow Placement Inches Minimum Soil Cover: ite System? O Yes 9 No Inches Flow: 4 8 0 Maximum Trench Depth: a 0 Inches Soil Application Rate: . 0 a 5 Maximum Soil Cover: Inches *System+Classification/Description: *Distribution Type: PUMP TO GRAVITY TYPE III B.SYSTEM MINGLE EFFLUENT PUMP Septic Tank: 1 0 0 0 Gallons *Proposed System.: 25%REDUCTION 1-Piece: O Yes (&No J. Pump Required: (&Yes O No O May Be Required Nitrification Field Sq.ft. Pump Tank: 1 0 0 0 Gallons No Drain`Lines 1-Piece: OYes ®No Total Trench,Length: 4 8 0 ft GPM--vs-- ft. TDH Trench Spacing: Inches O.C. __ 8Feet O.C. Dosing Volume: _ Gallons Trench Width0Inches O Feet Grease Trap: Gallons =,'Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01011 O III 01V Page 1 of 3 QDP File'Number 13396 - 1 County ID Number: 5803497469 ❑ Open Pump System Sheet Repair System Required:®Yes ONO O No, but has Available Space R epairSystem Trench Spacing: Inches O.C. fication: PS Shallow Placement — Feet O.C. Trench Width: O Inches w: 4 8 0 _ O Feet Soil Application Rate: 0 5 Aggregate Depth: inches .� *System Classification/Description: Minimum Trench Depth: a 0 Inches TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover: Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: a 0 Inches Maximum Soil Cover: Nitrification Field Inches Sq.ft. No. Drain Lines *Distribution Type: PUMP TO GRAVITY Total Trench Length: 4 8 0 ft Pump Required: ®Yes O No O May Be Required Pre-Treatment: O NSF OTS-1 OTS-11 *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been completed during the period of validity of the Construction Permit,the information submitted in the application for a permit or Construction Authorization is found to have been incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? O Yes (&No Applicant/Legal Reps.Signature: Date: *Issued By: 2244-Daywalt,Andrew Date of Issue: 1 0 a a I a 0 1 3 Authorized State Agent: DLA_ .I U11�liQ�IJ( QJ1 Malfunction Log OYes ®Hand Drawing O Import Drawing Total Time:(HH:MM) **Site Plan/Drawing attached.** Page 2 of 3 0 0 Hours 3 0 Minutes S-8-C/A ISSUED-NEW CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 210 Hospital Street 5803497469 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 10 / .2a / a013 Olnch Drawing Drawing Type: Constructio Authorization Scale: , O Block D 7 S r AV WtIA I-ij 51 IUD '1� r �e 1 �4k Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital street CDP File Number: P.O.Box 848 5803497469 Mocksville NC 27028 County File Number: Date: 1-0 / . . / . 0 13 Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3 of 3 P1 P2 PAID C� APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC a -, — �—/3 3 Davie County Environmental Health Reoly d n P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Application For: O Site Evaluation/Improvement Permit H Authorization To Construct(ATC) kBoth Type of Application: 13New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility IMPORTANT'•'THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed Da V 1 t F)e Ck Contact Person--:\�)QY,(J Sea k Billing Address S S v G Home Phone,33U-LJ q-,1•le 5 S 1 City/State/ZIP QCYSyi let ne. a'aoag Business Phone 3319' 90g - Name on Permit/ATC if Different than Above Mailing Address city/state/Zip / / PROPERTY INFORMATION *Date House/FacilityComers Flagged �-N.13 NOTE: A survey plat or site plan must accompany this application. Included:R Site Plan O Plat(to scale) (Permit is valid foQr 60 months with site plan no expiration with complete plat) Owner's Name�.,�ZQ T1 1� �14Irxa VCAa n S Phone Numbe (A'y��15� Owner's AddressQ1Q0\ l�1Xta�Ch,.trch kpQcl City/State/ZipYu�(`illy.11e, (� r.� 4 CiCfeS Property Address \�mbet CA'tu,iCh (Ctxti city YCk0V%nyiIte. Lot Size FCaI Tax PIN#.Sm O.3 Lf cl 7 y 011 -10 � Subdivision Name(ifapplicable) Section/Lot# — SU,fvexicd Directions To Site:(op\ (I(Xsln -1,=5 l(2rr k- (Yn CY) CJW\e )6orli.2a4 toad bcS5CleChu(Gh ��,Cog.^04 SeCord fivt, �O— C�Qlh+ If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? Dyes IWO Does the site contain jurisdictional wetlands? ayes Flo Are there any easements or right-of-ways on the site? Oyes 6610 Is the site subject to approval by another public agency? Dyes t8<0 Will wastewater other than domestic sewage begenerated? ❑Yes PRo IF RESIDENCE FILL OUT THE BOX BELOW #People —_ #Bedrooms #Bathrooms 3 Ye- Garden Tub/Whirlpool H'1'es DNo Basement:i?Yes DNo Basement Plumbing: Ryes ONo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: 56nventional OAccepted ❑Innovative OAltemative ❑Other Water Supply Type:fl County/City Water IR'New Well nExisting Well n Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes Q'NO If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permits)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and eating and flagging or staking the house/facility location,proposed well location and the location of any other amenities. �-5 S-,4 Site Revisit Charge Property o er's or owner's legal representative signature I:\ p Date(s): \'�p'a��3 Client Notification Date: Date EHS: Sign given OYes ONO1, !J Account# Revised 11/06 /✓ Invoice# 74 A 73-Z C� COW Wal C�� 66- r� r/ 1 �3' Oy � 144 C15 .,4 K 20M /`•" `r �� LAlLh 50 ft �r �. review orricer or. uavie %,ounry, certify that the map or plat to which this certification is affixed meats all statutory requirements for recording. Plat Bc REVIEW OFFICER DATE Filing fe( CIO w Q, N �w w � I iJ S 84#06'341 E ' 36.28 ' AT S 84 34 F ' • NAIL A�. 3 IRON NEW 93.69 EXISTING IRON IRON W u�^ COOK Cqa a_ ro � � NEW IRON '2 \1 A��cs r s�S68 \v 0 REE Gt REBAR g& IP RIR SPIKE Davie County,NC Tax Parcel Report Wednesday,Septembe.. ]1. 1 01691 Is fZcx, Reay\;Rl 'px r it E6 y2W1 Chi X594 o• 2639 V,2'442528 X261 Shore Ln - _ `2589 -- 187 153 2rpt � -� _ `1496 `2493 — — -- L2479 12471, `2468 4128 al -011ie Harkey Rd 1421 --- m 41 w0/r ,� eiSE '3 38E WARNING:THIS IS NOT A SURVEY Parcel Information Parcel Number: 8200000001 Township: Clarksville NCPIN Number: 5803497469 Municipality: Account Number: 21084000 Census Tract: 37059-801 Listed Owner 1: DICKENS ROBERT LEE Voting Precinct: CLARKSVILLE Mailing Address 1: 2601 LIBERTY CHURCH ROAD Planning Jurisdiction: Davie County City: YADKINVILLE Zoning Class: DAVIE COUNTY R-20,R-A Stale: NC Zoning Overlay: Zip Code: 270550000 Voluntary Ag.District: No Legal Description: 9.01 AC LIBERTY CHURCH RD Fire Response District: LONE HICKORY Assessed Acreage: 8.71 Elementary School Zone: WILLIAM R DAVIE Deed Dale: 12/1985 Middle School Zone: NORTH DAVIE Deed Book/Page: 001290335 Soil Types: MnC2,MnB2,MdC,MdE Plat Book: Flood Zone: x Plat Page: Watershed Overlay: - Building Value: 89300.00 Outbuilding&Extra 1610.00 Freatures Value: Land Value: 47710.00 Total Market Value: 138620.00 Total Assessed Value: 138620.00 DAVIE COUNTY HEALTH DEPARTMENT i Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION David Beck 156 Pepperstone Drive 5803497469 Mocksville,NC 27028 Off-Liberty Church Road 336 909-0225 fi. Owner-Evelyn D.Dickens Water Supply: On-Site Well Community Public Evaluation By: Auger Boring_ Pit Cut FACTORS 1 2 3 4 Q Landscape position` G G L C Slope% Ai/O HORIZON I DEPTH 119- 0 -3U Texture group L S L C. 1 C Consistence r , Structure Pitt ev,Sr Mineralogy !?0 HORIZON H DEPTH 6n 17- Texturerou C I,Raw � � Consistence UP-151 pl' . OFT Structure ,.I 'A4, tl �+ Mineralogy 2:/ Z. HORIZON III DEPTH (, _ Texture group Consistence Structure Mineralogy HORIZON IV DEPTH _ Texture group Consistence - - - Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION - LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY. LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS -Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S -'Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SIL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Dist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 3Y91 NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic . SP-Slightly plastic P-Plastic VP-Very plastic Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness'and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(su-able),PS(provisionally suitable),U(unsuitable) TTAR -T.nnv-term arrr•ntnnrP rntP- onl/rinv/ft) nr•T rn ne 1ne m___e..AN 1 i f ■■ecce■■■■■■■■■■ee■■■■E■■■M■■■■■■■■■■■■■■■■■■■■■■■■■eMMe■■M■■■■■/■ ■/e■ecce■■/■■/■■■■e■■■E■s■■■■■■c■■■/M■c/s■■MM■■M/e■■■■■■/■■■■■e■■■ ■■■■/■■c■■/■■M■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■/■■■/M■■■■NM/MecN■■ ■//■/■■■■cls■:::: ■■■/■■/■e■■■■MMi■■■■Mee■/ce■c■■II■■■■■c■■■■■■/e■c■ ■■■c■e■M■■Ilea■e/■N■■■M/■■■M■■■■■■■■■■■M■■■■■/■■■II■■■■c■■■■■/c■cME■ ■ecce■■■■/II■■■■■■■■O■■■■■■■■■■■■■■■■■■►�■ae■■■■cMII■e//M■/■/■■■■■■/■ ■■■/■■■■■elle■■■■■■■e■■■■■c■■c■■■■e■■Mer�>4»■■■e■■e1I■■■■e/■■N■■■■■■■■ ■■■e■■eec■Ilea■/■■■■■■■■■■■■■■■■■■■■■■■�.■/■■■■■■11■■■/■a■■ece■eMc■■ Ecce■■■c■■IIe■■■■■■■■■■■■■■■■■■■N//■■■u�,;:��■■11■■■el■■e■■ee■■■■/■■■■■ ■■■■■■■■cell■■■N/■■■c■■■■■■■■■/■■■■■c■����■■■II■■■■IM■c//■■■Mce■eM■■■ ■■/■■■/■■■11■■■■■■■■M■■■■■■■■■■■■■eeM■■Mceee■Ilce■■le■■■E/■■■NOM■■■■■ ■■MMNa■■■/IIe/■■■■■■■e■//■■■■■/e■ ■■■■/e■■E■eI■/e■IOM■■E■MM■■E■■■■E■ ■E■c/e■e■■Ilea/■N■■c■■■■■■s■■■■■■■■■■■■■■■■■■el■■■■I■■■■■■■a■■■■■■■■■ ■/ecce■■■■IIe■■■■■/■/■■///■■■/■■Me■■■■■N■■■■■el■■■■i■■■■■■■■■■■■■■■■■ ■■■c■Me■M■IIe/ecce/■ee■■■■■■e■■■■ee■■■■■■■■M■■I/M■■>I■■M■■Me■■■■M■■■■■ U■■■ce■�II■■■■c1�1■■■/■■I�I■■//■■I�c/ee■c1�1■celc■■�Ic■cN■■1�1■M■■■■1�, 1 ■■MOM■ II■■O■■ ■■■■■■ ■■■■■■ ' ■■■■■■ ■■■I■■■ M■■■■■ ■■■■■■ ■NM■■■e■cell■■/■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■t.�■tl■■■c■■■■■■■■■e■■■ ■■/■■■■/■■IIe■■/■■■■■■■■■■■■■■■■■■■■■■■■■Me■■■1/M■■le■■■■■E■■■■■c■■■■ ■■■/■eee■■II■■e■■■■■■■■E■■■■■■■■■■■■e■■/■■e■■■1■■Mtl■■■■■■■■■■■■■■■■■ ■■■■■■e■■■IIe■■■■■■■■■■■■■■■■■e■■I�Icc■■rl■MMM■■1//etl■c/c/■■e■■■■■c■■■ ■eee■■c■■■11■■MMM■■■■■■/■■■■■■■■It ■■■�•�■■■■■■iN■■■1■■■■■■■■■■■■■■■e■ ■■■■■■/■■■Ile■■■/■■■■/■■■■■■■ell■■■■■■■i�■/■Meel�'7M■■I■■■■■■///■■■///■■ ■■■■■eee■e11M■■■■■■eee■/■■■■■■li■■r/■■■el■■■■■■■■■■tl■■■■■■■■■■■■■■■■■ ■/■■■■■■■■11■■■■/■■■■■■■■■■/well■■moi/■Mei■■■eee■■■■■1■■■■//■■■■■■■/■■■ ■■■■■■■■■■le■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ell■■■■■■■M■■■/■OMEN ■■■■■■■■le■IlilAell1e11N■■■elle■■■■■O■■■■/elle■Iele®®■ecce■_■_ce■/M■■/■■s■■■■■■■ WELL CONSTRUCTION RECORD Vorinternal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: 14.WATER ZONES FROM TO DESCRIPTION Well Contractor Name ?+t ft ft - fL NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a IicaUle FROM TO DIAMETER THICKNESS MATERIAL Yadkin Well Company, Inc. rt f. in. Company Name 16.INNER CASING OR.TUBING eotbermal closed-loo FROM TO DIAMETER THICKNESS hIATERIAL 2.Well Construction Permit#t: a' , .� 1 /C it List all applicable well couhvctionpennits(i.e.County,State,Variance,etc.) + , ft ft in. 3.Well Use(check well use): 17.SCREEN Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public ft. ft. in. ❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft, in. ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ❑Irrigation ft. ft. ' t Non Water Supply Well: +, ft ��� tt i; ❑Monitoring ❑Recovery Injection Well: ft. ft. ❑Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft ft.To MATERIAL ENIPLACEMENTMETHOD ❑Aquifer Test ❑Stormwater Drainage ft. ft. ❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attar:h additional sheets if necess2r ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soilirock rain size etc. ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) O ft. t; ft /' ft. �+ -•ft 4.Date Well(s)Camp]eted:b` '.t ( Well IDII A4L t f1-15 ft .1 .� ft. �'1' l..Ltt'I�t r°;,.t„ • 5a.Well Location: Phone number r 5 .) ft "IfK rt 1 ( s x/ j� / , ret .1�tlUl obi, �Z�+� it. ft. Facility/Owner Name Facility ID#(if applicable) I � �} applicable) ft ft lq 0//1' Y 1 10 k 11 ft. ft. Physical Address,City,and Zip 21.REMARKS 4!z County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification (if well field,one lat/long is sufficient) „ r T5l S_ N 0 S©-3. #0, 351 W • Signature of Certified Well Contractor Date 6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with 15A Ar-4C 02C.0100 or 15A NCAC 02C.0200 Nell 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 out known well construction hvformation and explain the nature of the repair wider#21 remarks section or an the back of this form. 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 if necessary. For multiple h!ection or non-water supply wells ONLY with the some construction,you can submit ane form. \ SUBMITTAL INSTUCTIONS 9.Total well depth below land surface: , ? (ft.) 242. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths if dijerent(example-3@200 and 2@100) construction to the following: 10.Static water level below top of casing: ' `r (Tt,) 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 ' , /, r 24b.For Iniection 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,directpush,etc.) Division of Water Quality,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) t Ov i r 24c.For Water Supply&Iniection Wells: In addition to sending the form to fi IVfetl7od of test: the address(es) above, also subunit one copy of this form within 30-days of 13b.Disinfection type: HTH Amount: Cups completion of well construction to the cotuit health department of the county r where constructed. i -r , • •I t L_ 0,-.I 11 Form GW-1 North Carolina Department ofEnvironment and Natural Resources-Division of Water Quality Revised Jan.2013 9- Date Site Visited: By: P-N, 3uilders Name: Owners Name: Nddress: Address: Phone Number: Phone: Cell Number: Re As A �> , 1-91 75`i t SOH — 'i�`b 3 . - 31 7 ILOLl , , �1� ' ,�� t Well Construction Permit For Office Use Only Davie County Health Department *CDP File Number 123396 �9 � L 210 Hospital Street PIN Number: 5803497469 P.O. Box 848 Mocksville NC 27028 Tax Lot#: Tax Block#: Phone: 336-753-6780 Fax:336-753-1680 Evaluated For: NEW PERMIT VALID UNTIL: 11/25/2018 Property Owner: Evelyn Diane Dickens Applicant: David Beck Address: 2601 Liberty Church Road Address: 156 Pepperstone Drive City: Yadkinville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)492-7549 Phone#: (336)492-7549 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Liberty Church Road *Proposed use of Well: Yadkinville NC 27055 Directions If Other: Site Address: Liberty Church Road Directions: US Hwy 601 North,turn left on Liberty Church Road.Then left on 011ie Harkey road,beside Church. Property second Drive on Right. Well Contractor Information Drilling Contractor Driller Registration Permit Conditions *Permit Conditions Well location,installation,and protection must meet all state and local regulations and must be inspected and approved by an authorized representative of the Local Health Department,the permit may be revoked at any time for failure to comply with existing regulations. The siting of the well by the Health Department is to provide protection from the known possible sources of contamination. The well site may not be changed without written permission from an authorized representative of the Local Health Department. No volume or quality of water is guaranteed by the Health Department. *Issued By: 2244-Daywalt,Andrew *Date of Issue: 1 1 / a 5 / a 0 1 3 ®Hand Drawing O Import Drawing Authorized State Agent: **Site Plan/Drawing attached.** tal Time:(HH:MM) W-6-Well Construction Permit Issued-New Paae 1 of 2 WELL CONSTRUCTION PERMIT °semo- Davie County Health Department CDP File Number: 123396 210 Hospital Street 5803497469 P.O. Box 848' Y� Count File Number: Mocksville NC 27028 Date: 11 /25 / .2013 ��+9tR nn�x Q4N1 O Inch Drawing Type: Well Permit Scale: . O Block Q N/A ft. fir; w _.602, -Y7S - �---- 0,&0 i (171 1 l , _ l40- . i �_._. _........ ._ _. _ ..._ ....... ._ . i I _ _ . ... . . ... A. -•- Page 2 of 2 n� nn