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195 Red Bud Ln ' � "�� Well Construction Permit . , � ForOffice Use Onlv --t Davie County Health Department *CDP File Number 200112 � . {�� ►��}s�•—•t.�� . . � 210 Hospital Street � � � , P.O. Box 848 PIN Number. H50-000-053-07 � ,� Tax Lot#: Tax.Block#: �`'°"""""� Mocksville NC 27028 � Evaluated For. WELL Phone: 336-753-6780 Fax: 336-753-1680 . � PERMIT VALID UNTIL: 3/18/2021 Property Owner. Richard Taylor Applicant: Richard Taylor Address: 195 Red Bud Lane Address: 195 Red Bud Lane . City: Mocksville ��tY: Mocksville State2ip: NC 27028 State2ip: NC 27028 ' Phone#: (336)940-2341 Phone#: (336)940-2341 � Propertv Location 8� Site Information Address/Road#: �f/�L Subdivision: Phase: ' Lot: Red Bud Lane �`�� Mocksville NC 27028 ''Proposed use of Well: Residentiai If Other: � Latitude Longitude Directions . Site Address:Red Bud Lane Directions: Hwy 158 East turn right on Sain Rd, right n Red Bud lot on the left Well Contractor Information Drilling Contractor Driller Registration �_ � � � � � � � � � � � � � � � Permit Conditions � *Permit Conditions �� . Remalnl�g . 4000 Well IocaGon,construction and protection must meet all state and locat regulations and must be inspected and approved by an authorized representative of the Local Heatth Department.The permit may be revoked at any Gme for failure to comply with e�asting regulations.The siting of approved well construction area(s)by the Health Department is to provide protection from the known possible sources of contamination.The approved well area(s)may not be changed without written pertnission from an authorized representative of the Local Health Department No volume of quality of water.is guaranteed by the Health Department '`Issued By: 2140-Nations, Robert *Date of Issue; � , 3 , � , 1 , 8 , � , a, � , 1 , 6 , Authorized State Agen � �Halld DI'aWlftg O Import Drawing Owner/Applicant Signature: '�'�Site Plan/Drawing attached.'�* , Page 1 of 2 ,• � .= . - WELL CONSTRUCTION PERMIT 200112 ; �� Davie County Health Department • CDP File Number: �- , ,�y�' �' °'' � 210 Hospital Street H50-000-053-07 � _ � P.o. Box s4s County File Number: �.� ' �g Mocksville Nc 2�o2a Date: .H_3_/;1.8./.a.0.1.6. >�'�btnO�M QUMI Q�fiCfl Drawing Type: Well Permit Scale: . . 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' . . • . � , � , . . ' . . !�N� . . . � . . . .............. :............ .............. .. ._.. . . _....... .. .... ..................:.............:............... ....... .................................... .............._.. .... ...................... .. ... ... .. .. ........,..........................,......... .......... .... Page 2 of 2 P1 P3 ,, , ._. . _ • �. , _ � • • , . ► .., • • . ��'�g'�'�N'S�i UC�'j��,�'�� • � ForIntemal Use ONLY: � This form ean ba used fcr singla ormultiple wefls 1.Wcll Contractor Infarmation: � za.tivazxx zo�Es {��i �x I I �rI /s C�� FR0�3 TD DLSCP.BTTON NellCoatractorNama I��f4 1 L�$ fG �. r L � rr 3�� - r� . � � ft. � . NCWellCantractarCectiScafionNumber 15.OUTEI:CAS formulti-casedwells O ifa lie�ble . FROhI TO DL�IHILT�R TH7QQVL55 hL�aTLRL�.L Yadkin Well Company, Inc. rr. rr. ;n. CompaayNeme IG.INNER CrISL`7G OR•TOBING eothermal doseJ-loo ' *� ITROAI TO PL�ilVIL7LR TlIICIQYIISS hL�TL•RL�.I. � 2.`VellCoastructionPermit#:�lS O � � ` ic � ic . �,�' in• �h �� /' List all app!leable wel!conctrucllon pu�nits(I a Coimry,Smte,Yarfance,ete.J ft fL in. •3.�Yc11 Use(cl�ecl:svell vse): 17.SCREEN tiYatcrSupply�Vcll: r•r.oni zo DL�,itIETER SLOTSIZE zaiciav�ss 11IAT'�R1±L • �Agricultursil OMunicipa!/Public .,. ' ft. ft in ❑Geotherma}(Heating/Coolin�Supply) �1'.esidential'LVaterSupply(sin�le) ft ft fa. ❑IndustriaUCommercial ❑Residential Water Supply(shared) I8.GROi1T FROi4I TO b747'LRL�L L'IIPLACEl14ENTM1lETHOD&ATIOUN'I' OIrri�ation O ft, fr. G � � Lt ll� � Non-�1'ater Supply tiYcll: ' / OMonitorin� ❑Recovery � * � f�� '�+ r� ��Lt 1 .t'�^ /� Injection�vell: ft. ic • �AquiferRecharga ❑GroundwaterFemediatioa 19.S9ND/GRAVELPACIi�fa t;�aule FROhI TO MA7TRL�L . TDIPL�CLIILNT14IlTADD :'{'�.�..,- OAquifer Stora�e and Recovery ❑Salinity Barrier i�• tc • ' _ " ❑AquiferTest �5tormrnterDcaina�e � • � tG ft ❑Experimental Technolo� ❑Subsidence Control , 20.bF.7LLINGLOG attaehadditionalsheetsifnecessa ' ❑Cieotherma](ClosedLoop) OTraeer ori 70 •DLSCTi7PTI0N(cotarh�rdness,soiVroeic e,�raSncueeta OGeothermal(FIeatinJCoolingRe[um) ❑Other(ex Iainunder�2lRemarks ic (� o � �. , . y /� C_ �( ,{ ft- (J 'f4 • p � C, 4.Datc�rVe11(s)Comp]eted:H�`3'ellID#/'7/y'�� gZ , � 5a.FVd1 Location: Phone number 3 ys�rj'7 u � '� sc V� f� f�F,�. ��,,r,� $� tr. �� fr. �� ' � ; 4�� U�� Za v lor� �� e1' 11S �` 4 � � �:� i� Facilitv/O�vnuNama Fac�itvID�(' aoplieabTel �tL� { fc it 1 �� /�r��c�.r.�L.s� f/yh�c/`�r � �.� Fliy�i�ai ha�,�s,ary,ena z�p z�.xErL9xi:s , lv q,u i e�• x ` . County Pamel IdentificatioaNa(PII� , , , • Sb.I�atitude and Lone tude in d brees/minntes/seconds or decimal degrees: 22.Certi6cation: � � �`' (if�vell fiatd,one IaVlong is�ieat) �'�� < �-_�' � ` —�� JX 3� 5�r Z 3 N �6 7l. �� y N � .'�:,; <<_ � �. �� -ziy�• :;,;�: SignaNre ofCertified WeU Canhactor Data 6.Is(fls'e�tlie�Yell(s):�e1-tnanent or OTemporary By s�o rii7o rhis fnrn�,I hereby cerrTfy Tho�1hr tiveT!(a)irar(rerc)cotuilucted in accordance wiL115ANCAC 07C.0100 orlSANGlC 01C.0300�e11 Cavstructian$tm,dards and rhat a. 7.Is this a repai�•to aa esistina ivell: OXes ol- �o • copy ofthls record has been pravided to The tvell aimer. I this fs a repar7,fill ou1 hnmm tiireII consUuclian information and explvtn fhe nnture of rha , mpairzmdrr�2lremar7EtaecftonoronfhebaeL-oJthiaform. , 23.Sittdiaa amoradditional�velldetails: You may use the bacl:of this pa�e to protride additional�va11 site dztails or�vell 8.Number of tivells eonstrncted: • � ' construction deta�s.You may also attach additional pages if necessary. For mtrltipla�njecfian ornon-?ratrr.npph��rells ONlPivi�h fhe smae con.tfruelioa,ybv ean submit oneform. SUE113ITTA.L INSTITGTIONS \ 9.Totallve]id�piL 6elo�vlan�surfaec: �'�� (ft) .29a. k'orAll 1Vc1Is: Submit this form within 30 days of completion of well Far mvlr/pla vef(r lisr oll de�ilu lfdAarurr(t.tnmple-3«�00'cmdl a700� const[uction to the follotvino ;,_�i' 10.Static tvater lei�el bdon•top of casin�• ' 1 L�t�` (ft) Dirision of{�Vater Qu:�lity,Infoi-mation Proecssiag Unit, Ifu•aterlevef!s above cartng,usa"+H • fl617 tl�tn31 Sravice Centei•,R�leigL,I�TC 27699-16Y7 /' �.yj, lI.Borehole diameter: (iv.) $Z'C Of f 1� : I O� 2s6.For 7niectian�Vell�: Lt addition to sen3in�tha form to the addrzss in?4a "'� ' ' ' abovz,slso submit a copy of this form tvithin 30 days of eompletion of�vell i2.�r�Vdl ca,ulructiun me[iiot3: RO�aI'� eon-truetionto the followiqg; (i.e.augrs.mtxry,eable,directpusb,eG:.) ' ''' . Division af Water Quslily,Undergrouad Injectinn Contro]Arogram, FOR 1VATER SiTPPLYtiVELTS OIYI,Y: 1G36 Mail Service Center,Rxle3gb,NC 27699-163G 13a.Yietd(y�pm) V blethod oftes#:_Q�1� 24c.For'FVater Supplv BIniection Nells: In addition to sendin�the form to tha address(es) above, Blso submit ono copy of this form within 30 days of 13b.Disinfecfiontype: HTH Amount: t Cll S completion of tivell construction to the county health department of the eounty �^ whera constructed. (• '� '' r` - FoimGW-1 , NorthCurolinaDepartmentoFEnvir�nmta[andNaturalResoures-DivuionofSYaterQualiry Fet�ised7an.2013 . : -. c c/ � ,� T�a�F-c Ritc �Tiaii-cra• ��;y"��J"l� Rq•U� l� r�T O0 : � .�., :�. ., . „ . . �, , �, Builders Name: 'Owners Name: . ., , . � Address: � Address: , . , , Phone Number: Phone: Cell Number: "L2`-� , . .b Gr� �' k G��, � . � � ` �� `� �(D� f � � W , �,�� G� � �� , � 1`� Sa �� . �� . , ��°�Cgl�.� � . � ,� S�J� 03 � . . - X (,,r��.s � ..—,, , ,1� �� • � � . :..iv .`�� I�+ ( i1 � �.� . � . �r -..,� . . _ .:�::,� , • P�� APPLICATION FOR PRIVATE WELL PERMIT Dace,2' � � Davie County Environmental Health „�a�; � `� P.O.Box 848/210 Hospital Street � �te:t1�•.w Mocksville,NC 27028 (33�753-6780/Fax(33�753-1680 ***IMPORTANT''** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED 1NFORMATION IS PROVIDED. ' APPLICANT INFORMATION . Name , Contact Person M a��-� n C'�.�� Address Home Phone C1 - c� l, City/State/ZIP � Business Phone ( (o� ,3c,(5�3b5� Email -1�� y . Name on Permit if Different than Above Mailing Address City/State/Zip � PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey lat or site plan must accompany this application. Included: [�Y3ite Plan ❑Plat(to scale) Owner's Name 'G�llOU� Phone Number��?�L��-1 -�j -3C�Z- � Owner's Address 1 City/State/Zip ��('([;6�V� � �e �YI�C�700� Property Address ^ City Lot Size , Tax PIN# 30 Subdivision Name(if applicable) Cl e SectionlLot# Directions To Site: �' � � i -Ir'�!1 2 DEVELOPMENT INFORMATION 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 .V Do You Intend To Install A New Septic System On This Site? YES NO TBRMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed properiylines with d"unensions,the specific location of the facility and any existing or futureappurtenances,the location of any existing septic system,sewer lines,water lines,any existing water supplies and any surface waters. The applicant is responsible for idet�3fying and marking the properly 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 permiseon for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to determine the best location for a well. � Signed • Date 7/30/09 Account# Invoice# �.,. . . ,tr�D a L�`" " • DAVIE COUNTY HEALTH DEPARTMENT S�p /o'. o a �" ' '_ � .IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE:issued in Compliance With Article I I of G.S.Chapter 130a � ��' • S itary Sewage Systems � Permit Number Name ��c�w�z� �`Av, UK Date � �3' �� N� t 588 `� �`,� Location ��y 3 a t�� o c s �� '�. -��J, �� G'�l u� O.I.T� t� ' �-1. � �� Q�' S�e=es� cm / �.e • �� { � Subdivision Name Lot No. Sec.or Block No. Lot Size � G'wo House � Mobile Home_ Business Industry No. Bedrooms r �.No..,Balhs 3' ' No. in Family � _ PublicAssembly Other i;�..� `. Garb,age Disposal 'YES ❑ NO � ' SRecitications tor Syst��m;� �, Auto,pish Wasrer YES;[�NO ❑ •:�.� ; / 00� �A,rr�., – � •�� Auto Wash Ma:hin�e' YES p'�,.NO p� „ '•'�p�� 1 �, �� - �,,, _�s.. �,. `'s . '`�.� ,:n..�. Type Water Supply _ __— � . . •This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change, , o� /G� � • � � � Uoi � � " . ,, -. ( , . . � . . � �� , :� ' . i � V S '� �h''` ` { F� . , , r �; .� improvements permit by`��e.�*'^" C�'�'"r" •Contact a representative of the Davie Counry Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M,or 4:30-5:00 P.M.on day of completioh.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by � � �� J �p �7 Certif a erof Go /`►�� Date -�/" /7'' •7he signing of this certificate shail indicate that the system described above has been installed in compliance with the standards set forth in the above regulation,but shall in NO way be taken as a guarantee that the system will function , satisfactorily for any given period of time. � . " , .. .,.,,�.- _ _ __ . _ � . _, c,�,. �.« _ r.,:,.� �.-, •: _ , .; , _ _ , . .r. � ., _ _ _ ,,. . . , . . c1 r' ¢ � .l _ _, , , .. . , ,/�DD -.�rt,,;�r ,,,,.y � '7 �� a =�� ' ��,�'�"' " ' DAVIE COUNTY HEALTH DEPARTMENT S�� /oa. �o d,- �° . - - IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIO�J ___ 'NOT�E`Issued in Compliance With Article I I of G.S.Chapter 130a ��.'�' '� _ � S itary Sewage Systems � Permit Number ;Name \�-�p��z t� � W�1� U K Date � � 3' I � N� 1 5� C� �„ , �� ` Location � �l�� o c 5 v�� , �' �• �� _ , � � ' �` O�.rc� t� ' c� 3'� �� a�,.�t.N� S�.a e�' cS'c' �� ,(� k , . Subdivision Name .'-•/� �`�v Lot No. Sec. or Block No. Lot Size � �'�°� House � Mobile Home _� Business -- Industry �� . u � No. Bedrooms I .No,.Baths _�'' ' No. in Family � _ Public Assembly Other ..`:�`, 1 �� •,'. .t +T. '.� . . r Garbage Disposal YES p t�0 � �t"4� '� `�: `' � - .�,,.,,, SRecifications for Syste� � Auto pish Was�►er YES,[g� NO p "Y t�: ! a O�► – D '�p� Auto Wash Ma;Fiin� . YES (g�,;,NO p� ��,R �y � �. � � �► ��, GI I °� � v� �V.1 �...�., � �,. p v x TYPe Water Supply �� --- ��3 � _I,6 ,.,�� 1 �� 'This permit Void if sewage..system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site�p�ans or the intended'use change. � , . . . QY� . . . ., � . t� , . /G r� , . . f , i uai j` . . , � . "°h, ; �1 � /. ' ; 'r , / `� . .' . � � O u S �. ':Y? . .. ;. 1` . . i . . . .. � , . . Y . � � .. . . . . � i i }c c,' y � ... . - � , � � �� . . . � � _. � �.�.� � � . ' Improvements permit by -- �— ��,~� *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completiofi.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by _ .. Ji; ,'/ . � �� O � /y �� ' Certificat�-oi-Gompl�2in /�� Date -��/�� "The signing of this certificate shalt indicate that the system described above has been installed in compliance with � the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. . '- �.� , r. �-r -. � � � � � � APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT � Davie County Health Department Environmental Health Section �� P. O. Box 665 Mocksville, rvc 2�o2a ��A� 2 � �� 1. Application/Permit Requested By ��C�'��U � . � 1 Y ________.,...,._� Mailing Address �+ 4 �x �68 Home Phone �g�'�a�s M 0 C��SVI�P , �� 28 Business Phone �J� � " ��s� 2. Name on Permit if Different than Above 3. Appllcation for: ❑General Evaluation a Septic Tank Installation Permit 4. System to Serve: �House ❑ Mobile Home O Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # � p BasemenUPlumbing No. of People � -�[ BasemenUNo Plumbing No. of Bedrooms �� ,Washing Machine . No. of Bathrooms 3 �Dishwasher Dwelling Dimensions �v � � ❑ Garbage Disposal • 6. If business, industry, place of public assembly, other: Specify rype No. of People Served No. of Sinks No. of Commodes No.of Urinals No.of Lavatories No. of Water Cooters No. of Showers Water Usage Figures 7. Type of water supply: O Public $( Private p Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes .C�No If yes,what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subJect to revocation, if site plans or the intended use change. Effective October 1, 1989. - - _._ _. Directions,to Property: �,�, �`5--8 -��,.�5 �J rl,57��I.- �� • /c� 7`�., �. Yl�h-�' � �a�.� �Pc1• ��,�'�-, o'� ,y��-s �� Ce� r�� s �j'Gl�..e < `Ou G� /� /i7� G�OC�S � �i-{�� ls 5�7r-� � . � / � /!� J / < �G C'�C!'.e ,�rG! - , 7`�?�r' ��c <2Jl So � .�� c�`r.C�� - c o �� 1 �ze-e-� ,�' �=��/��-�-� G�� 'ns � �r �, i�- /� � �� _ ". �,� � �� , � �� . . ��2� . . ' � � � This is to certify that the information provided is correct to the best of my knowledge, and I underst I am responsible for all charges incurred from this application. f � oZ 3 -,%`� , DATE SIGNA E CONSENT�SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: �1. I OWN the property. p 2. I DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representa' of the D�vie un H Ith D art ent�en t�r upon above described property located in Davie County and owned by � d . , %Q / r to conduct all testing procedures as necessary to determine said site su'.ability for a groun orption sewage treatment and disposal system. � s'�� a3 �� DATE SIGNA E , DCHD(1/93) .-� . � , -.� N. 4 � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME � ��-`t� v� '�C.I� \ P� l b� DATE EVALUATED � -3 -q� ADDRESS S �v�A PROPERTY SIZE � �r� PROPOSED FACIILTY �o ''g S'' LOCATION OF SITE �`�s�- �� Water Supply: On-Site Well Community Public Evaluation By��,'� AugerBoring 1/ Pit Cut FACTORS 1 2 3 4 Landsca e osition S S S Slo e Z � - -" - s� �' _)5� _ 5° HORIZON I DEPTH (�.' 2`' 1 2.�� 2 Texture rou L. C l_. C �_ C �- Consistence =� � �- '� Structure G, � C �.'� �,� Mineralo 1' � � �� \ �� HORIZON II DEPTH � ' � '" .��,�' .� `' ' Texture rou <' � Z- L Consistence t' ,- � Structure �4`S- '�'�`C ��k � � Mineralo ` 1 l ', ) �, I 1: � HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS Ss sS .S� s RESTRICTIVE HORIZON - — -- SAPROLITE — — — CLASSIFICATION S S �.z, .S L0�1G-TERM ACCEPTANCE RATE �\ � � � y SITE CLASSIFICATION: _____� • S EVALUATED BY: LDNG-TERM ACCEPTANCE RATE: p � `�I OTHER(S) PRESENT: � � � � � REMARKS: �9�� a-. ��-� �s�� tiU�`J. �" - �� c�"'�o LEGEND Landscape Position R-Rid�e 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 SICL-Silty c:lay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure ;iC-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 - 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