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397 Salmons Rd . • Davie County Health Department ��s I� Environmental Health S e��Ely,�j, ' �,:.- , , � '� P.O. Box 848 ��: a- _, . �►�► .� �� � 4� 210 Hospital Street -3 �;m� p�, �� . Courier# : 09-40-06 - . Mocksville, NC 27028 � Phone:(336)-753-6780 � Fax:(336)-751-8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection ' '" � f� �- 336 �� � � Name: T/• �r�G W� PhoneNumber �/O� Q (Home Mailing Address: 3 � /j'1� ��J 6 �� 7T�Z-.(Work) � . /�o�sr%/P , �G Z70� � Email F����sve�ad/ ��� Detailed Directions To Site: I/S�Q�� l�I�� C d1�1 !'"D � r/1 �e r'�? 2 � cre C vrz TL Bh �o � v n � a,1 � �� Property ddress: � 7 l'���D%1 2�7 f � Please F' h STING Facility: � Name'System Installed Under: Z� Type Of Facility: �J`e Date System Installed(Month/Date/Year): �(��� Number Of Bedrooms:�Number Of People: � Is The Facility Currently Vacant? Yes � If Yes,For How Long? � Any.Known Problems? Yes No If Yes,Explain: � Please Fill In The Followin Information Abou T e NEW Facility: ' . Type Of Facility:� � ' Number Of Bedrooms: �Number of People ' �Requested By: Date Requested: • ( ignature) � � For Environmental Health Office Use Only � Ap rove Disapproved , . � . Comments: �///�Xof'l/'��_haC KS �d S`P/.�J`C ��S'� ���dlLrN d�� _�s w�1/ �►T�l,�,P �G/ Environmental Health Specialist Date: 1�= -�f— /3 *The signing of this form by the Environmental Healtti Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function prop rly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account#: � 'Invoice#: ' •f , ./ � ... . t . . . __,..� ' DAVIE COL�NTY ENVIRONMENTAL HEALTH ����l �m'� , ',: -� '� ` P.O.Box 848/210 Hospital Street � t �} , Mocksville,NC 27028 4_y�C,:C�+��d; (336)753-6780/Fax#(336)753-1680 � ' OPERATION PERMIT Accc►unt #: 990005446 Tax P1�V:EH#: 5801-56-4359 � BiElt;�7Q: Fred Brockway Su�adi�i�iorl ln��: , Ref�r�r�ce Na��e: � LocaiionrAddr�ss: Salmons Road-27028 Pro�c�s�;c9 Fa�;i€ity: Residence . � • Prop�r�y&iz�: 21 Acres a�TC N�a�ber: 5781 � **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G:S.Chapter 130A, Section.1900"Sewage Treatment and Disposal Systems," but shall in NO WAY be t�en�guarantee that the system will function satisfactorily for any given period of time. J_� w � ,r r � System Type: ��S.T.Manufacturer JN �a' Tank Date �I Tank Size� � Pump Tank Size . System Installed By: W���(14J`P 16�(�(�E.H.Specialist: Date: / ( { GPS Coordinate: �� � V-��6 • , s �- _— _ � ' , � , I ��.�v�aY : R ,, Po��J1 �� � � ! -.--, � � s !3a ,� � t I� — - --t , h'� ��O ' � -k � o°� -. , \ �,�� �4 - _ \ �g, 1� I �b' c� cfl..wib.i.rs �► � i ad` � � � y �� c �a � \, . , . ` , � aa� 'f0 c�w�v`V''� DCHD 11/06(Revised) � •. ' DAVIE COUNT'Y ENVIRONMENTAL HEALTH .` . � • � P.O.Box 848/210 Hospital Street ' ' ' Mocksville,NC 27028 � (336)753-6780/Fax#(336)753-1680 ' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Accou�t #: 990005446 T�x PlNi�N#: 5801-56-4359 � BiEle�To: Fred Brockway Suf�divi�ian (n#o:. ' - Refer�r3ce E��r���: LocaiioniAddr�ss: Salmons Road-27028 Pro�c�sgr] Fa�i€iEy: Residence Pfo�erty�Siz�: 21 Acres � � • Site Type: �ew ORepair ❑Expansion � EOTC Number: 5781 **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 Wastewater Systems,Section.1900 Sewage Treatment 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 on the intended use change. �• Residential Specifications: #Bedrooms � #Bathrooms3�S #People J Basement� Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) I1�2� . Lot Size � , QG«5 Type of Water Supply: ❑County/City �Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)� V Tank Size �,�4�GAL.Pump Tank�GAL. d n T ,� /,, � Trench Width ��l Max.Trench Depth� Rock Depth �a Linear Ft.CO`7� Site Modifications/Conditions/Other: � Contact the Davie County Environmental Health Section for final inspection of this,system between 8:30—9:30a.m:on the da of installation. Tele hone 336 751-8760. //y/� ' �� • �� � ' � ��° .' � \ �� . _ � �' ,� / / � ` � . �) a �J � / � � � �� � � � Y� / r �� � �. 1�\ i � � � , \� / � I � � � /, a � i I ' � � � .. _ _ 4, h � � � « � ^ �,�' �� � /� / � �. , ' � � � \ � �\�i ��� `� � 0�� �� �/ 3 �s Environmental Health Specialis� Date: �� ���� � DCHD 11/06(Revised) / . t . � i .' �' + . � . � � � , : �� . Davie County Environmental Health ' P.O.Box 848/210 Hospit�l Stre�t – , Mocksville,NC 27028 � � (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMTT � �, �33'q Gk�xqe� ���O�a�c Account #: 990005446 Tax PIN/EH#: 5801-56�4�& Billed To: Fred Brockway Subdivision Info: Address: 3624 Edgemoor Court Location/Address: Salmons Road-27028 City: Clemmons, ,, Property Size: 21 Acres f� Reference Name: Proposed Facility: Residence � **NOTE**This Improvement Permit DOES NOT authorize the constructiori of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the ' construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit.is subject to _ revocation if site lans,plat or the intended use change. Permit Type: � ew ❑Repair ❑Expansion Permit Valid for: 5 Years ONo Expiration Residential Specifications: #Bedrooms ' 1 #Bathrooms � #People � BasementC�Basement plumbingf3 Non-Residential Specifications: Facility Type #People #Se ts Square Footage(or Dimensions of Facility) Design Flow(GPD): �V`�' Type of Water Supply: ❑County/City Well ❑Community Well As stated in 15A f�CAC �.8A.1969(51 Site Modifications/Permit Conditions: aeceptP� 5�rsfems rna�� a�st�� b� �i�^c' � S stem T e LTAR Initial C . Re air Site Plan � � \ � �� \ C � � � ��/ . � �� I , . • . 4 t. , a� /� _` \ • . ` ;� � � �� �' $ � �J� . � / �' �� l � / � � �� .� � � �� � .� ��.� � � � �� . � �, �,� o� �' � . b �� y �, � �,o � _ x�"���' . �� �- -__-� � �� . Environm alth Specialist ;i�� Date L —�� 5 i.p.11.06 '/ta � / f� ' �.._'.':..� _ � ^ , , ,,' _ _ � � \ ����'���0 SITE EVALUATION/IMPROVEMENT PERMIT & ATC l ""� ��`' Q1 Davie Count Environmental Health - �� � � . � Y �,� r ` � "� M�� ` � P.O. Box 848/210 Hos pital Street � 3�C�� �Q�S ��,�', `�••' ���j� Mocksville,NC 27028 � ' ` "� ,.�, ��� (33G)753-6780/Fax(336)753-1680 �`\��p�,.:VC�U, . Ap�ilication For• , ite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Typ o ication: ❑New System ❑Repair to Existing System OExpansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORI�IATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION 'e� � G� �, Name to be Billed �/e�.� �1�� L'/�l�l/¢ Contact Person s�'?� � U'j � Bilking Address �ba �� vnpn�- !'i'h Home Phone 3 3,6 '� 7 /� City/State/ZIP Q rv�m!�/�s , iVC Z�0 (2. Business Phone 3 3 6 9 2( 7 7��2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facilit Corners Fla ed NOTE: A survey plat or site plan must accompany this application. Included: � Site Plan �'f'lat(to scale) - (Permit is valid for 60 months with site p an,no expiration with complete plat.) Owner's Name 7�0 herf� I�ea.ry ,S'a1in o�t,S Phone Number Owner's Address Cit}•/State/Zip Property Address m o S City /f'1 o CKS v i LL� Lot Size / re S Tax PIN# ,5��0 �— .�(o" 5Ua(o Subdivision Name(if applicable)_ Sec n/ ot# /� Directions T Site: U.S li1�S rn '� r -f o�! � ie� iQo� rn G�'� �i'f' O�( �/ ICIU �( �T I M n1 r`4 6 SR ��{t '- T D p oa N e If th nswer to any of the fo lowing questions is"Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? Yes XNo Does the site contain jurisdictional wetlands? Yes X No Are there any easements or right-of-ways on the site? ZCYes No S ff P�a,'� Is the site subject to approval by another public agency? Yes XNo � � . ' Will wastewater other than domestic sewage be generated? Yes XNo IF RESIDENCE FILL OUT THE BOX BELOW , ;. - #People � #Bedrooms � #Bathrooms�_ Garden Tub/Whirlpool p_�Yes �No Basement: ❑Yes [y1�Vo Basement Plumbing: ❑Yes �To IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness Total Square Footage of Building #People # Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons pei day)_ (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Altemative ❑Other " Water Supply Type: ❑ County/City Water �YNew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of e facili this s em is intended to serve? ❑ Yes �No If yes,what type? _ _ '. j _.. . - - __ --- ---.._ _ _... _ 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 permit(s)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. 1 hereby grant right of entry to the Authorized Representative of tl�e Davie County Health Departmer.t to conduct necessary inspections to determine compliance with applicable . laws and rules. I understand that I am responsible for the proper identification and labcling of property lines a�id corners and locatin nd flag�'ng or�stakins the ho�!se/facility location,proposed well location and the location of any other amenities. � -'�-��L� Site Revisit Charge Property owner's or ow•n 's legal re;�resentati��e signature Date(sj: Client Notitication Date: Dr�te -- — I F,HS: -- Sign given ❑Yes ONo � � Account# �� Revised 11/06 Invoice# �M ;: - ' � i . �, � , _ .�- , � - � , 'o . t � � � . �, s � � � o� o ��j a � Q � � �, � � �+ ¢ � Cs' �` � .. 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'_�_'6;�'_U10 • A 1��2s�s6 � �i iwV 42�41 ie� . / . . '++�.. 1 � � � � � = O� � :"' `?ti b� �tiy � ? r,�� Q'�,�� - f # P yU_ �� v� `n t a��b� � � N � /�y�'� �P C n ��ar � � y � 1 AREA = 0.952 ACRES a �� �' +�- QC � \ ��� w �� ' � \ �`� � . AREA�24.6C . � f i � RMA MAE Sq(,Mppg.NE1RS E � '� DB. 36 PG.37,Sg '� � '� � S�VEYED By o � ��TTEROW 14/9�G CO3 p � � �r N , �, -�s� - 5� r� �'�;Q ^�� . O ., �, � �� w .ri.•�� � � . .`�� 6�°�� ► �� 3o I 10'O t,�d� / I'� ��8�� f � M � 0 d' E o �_ ' � � r n q ry N (� � � I ' � � f \ � � � � Z - �: �, . 1 � � � . I ' ��. �� N W I . _ al �i , os� "' `o �:I o 'NI z =1 . � . � 30 EASEMENT (' as�s "e` � _ ._ � � �°j n � N zr ar,o+� ��_ 1°' -- -- I i'�"° R_I N E9'44'SE E. -- �� + �23•891otol • ^ � �i•�\ N 06i'�S4o02' E� �;;.� 1 �, � • . � DAVIE COUNTY HEALTH DEPARTMENT • . . � • � Environmental Health Section ' Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005446 Tax PIN/EH#: 5801-56-5426 Billed To: Fred Brockway Subdivision Info: Reference Name: Location/Address: Salmons Road-27028 /�, Proposed Facility: Residence Property Size: 21 Acres Date Evaluated: � �� !v Water Supply: On-Site Well / Community Public Evaluation By: Auger Boring�-_ Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osi6on � Slope% ']__ HORIZON I DEPTH �- . O Texture grou - G Consistence -- Structure Mineralo HORIZON II DEPTH Texture rou Consistence Structure 2� Mineralo HORIZON III DEPT'H ' Texture rou Consistence / Structure A Mineralo .C HORIZON IV DEPTH Texture rou � Consistence Structure � Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE ' CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: � EVALUATION BY: � f LONG-TERM ACCEPTANCE RATE: �r� ✓ ' OTHER(S)PRESENT: REMARKS: LEGEND i.andscane 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 T�xtur� ' • • S-Sand LS-Loamy sand SL-Sandy loam� ' .�,L-Loam � SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay : , CON�ISTENCE �415� VFR-Very friable FR-Friable FI-Firm VFT-Very firm EFT-Extremely firm � � NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic 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._.....,���..����..�......- ■����■�������������������r����■���������ii�����..��.-.,.--���..�.�/\\��■ ■���������■���������■■■������■■■�������������■������������■���11��■ ■������■■����v�������■■���■■������������������a�■�����a���■����a�■ ■���������������■�������������������■■�����■���������������������■ ■�e������������������������������■������■�■��■������������������■ ■������������������������������■ ■�����o��■������■������������■�■ ■����������o��������■�����■�������■■����������������������■����■�■ ■�■��■�■�������■�����■����■��■e��s�■�����■�������■�■��������■�■�■■ ' �' � �� � � ' Davie County Environmental Health , . P.O.Box 848/210 Hospital Street Mocksville,NC 27028 •(336)753-6780/Fax(336)753-1680 , WELL PERMIT �ccount #: 990005446 Tax P1F�FfEH#: 5801•56-4359-Well .'. : Bifle=d To: Fred Brockway . . Sufadi�i�iorr lnfo:; � . RefereE�ce Rian�e: �.. , .. '~ LocationJAddr��s: Saimons Road-2Z028 • . . _ Propc�sQc9 Faciiity: Residential Weli -r r:�, � � :- ..�., P�o�er#y�Size:-�'�-'21.01 Acres = �.• . • �., ; r =f� ATC Nu�rtber. 0078 . . . . , . . .. � .: _. 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 facdcircumstances upon which this permit was issued. -------.------------_.__.. ____ � _.._____...__.__..______.__.___._..______._.__..._...____.._._ Permit Type: New Repair ❑ Abandonment ❑ Pro osed Certificate of Completion Diagram -,1�t'_ 1�' � (,tJ�G ry ' ' ,� , �s��� �� ` r ' � 41 \ c� � `�. � �:c ` ��5�' =�`, �S � �_ � � .� , �, . 4- � __` � , � . �� '� Or�u��QY .� ;� _ �os��-�' - . Comments: Driller: `' �E b l " l� Certification#: ��(D�� Grout Inspected: � ' �.� `" � ( 12 J�, N Well Head Inspected: �� ����L/�l� GPS Coordinates: ���54•�j04/l/ �d°y6'�o EHS: Date: ' '� � EHS: �Q�411� Date: , W.P.7-08 f .-. . � • ,��- � . • • � APPLICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 � ***IMPORTAN7'�** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name � �ZOCC Contact Person Address Home Phone (� - City/State/ZIP {� � � 0�Z Business Phone ,�G��(� .,?7SjZ Name on Permit if Diff'erent than Above � Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) Owner's Name S''/1/� Phone Number Owner's Address � City/State/Zip Property Addr ss City Lot Size , Tax PIN# �'�/-�(���/.��� Subdivision Name(if applicable) Section/Lot# Directions To Site: DEVELOPMENTINFO ON 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 specifc 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 ion,the applicant signifies that they understand the terms and conditions and that they give permission for Davie nty Enviro ental Health representatives to perform necessary field evaluations and procedures deemed necessary to dete ine the ation for a well. , � Si ed ate Site Revisit Charge Date(s): Client Notification Date: EHS: 7/30/09 Account# � Invoice# ;d5��7'4.V � � . N +�W��7 �{` � ' . . ;�� �{�.33'w DS ltESIDENTIAL �V�LL CONSTRUCTION R�CORD �,� F.`'- North Catolina Department of Environment and Natural Resources-Division of�Vater Quali c("'� u �'• 'p': ,�,� ^�„ ' T�f �EC���,/�..<<..d `"°""""-% �V�LL CONTRACTOR CERTIrICATION# 3 d 3 6A � JUI_ 15 2011 oAviE cuuN�r��,u r,�tt�N�r�E,�-, 7.WELL CONTRACTOR: ys g. WATER ZONES(depth): M a � f h e w � • ,D�tj W/� � Top S �Bottom�_� Top Bottom Well Contractor(Individual)Name Top Bottom Top Bottom YADKIN WELL COMPANY. INC. : ' Top eottom -rop eottom Weil Contractor Company Name Thicknessl 1908 HAMPTONVILLE ROAD � 7. CA51NG: Depth �iameter Weight Materia� StreetAddress - P�_ __�_ ��a : To Bottam � Ft . 5vre-ZI P✓C HAMPTONVILLE NC 27020 : Top eottom Ft. City or Town State Zip Code Top Bottom Ft. 3r 36 � 468-4440 Area code Phone num6er 8. GROUT: Depth Material Method 2.WELL INFORMATION: Top � Bottom 3 Ft.B�nf ni�L C�(.`1 r�Cv� WELL CONSTRUCTION PERMIT#__ O O �Q Top 3 Bottom a y Ft.,Stn tQ�.'}�� .S/v��j Pum OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft. SITEWELLID#(iapplicabie)� "' '�� 9. SCREEN: Deptf� Diameter SlotSize Material 3.WELL USE(Check Appiica6le Box): Residential Water Supply�$ Top ottom in. in. DATE DRILLED 6 - it 7� /f Top Bottom Ft. in. in. TIME COMPLETED �}',�3 v AM❑ PM C�C To_ Botto Ft. in. in. 4.WELL LOCATION: 10.SANDIGRAVEL PACK: , � Depth Size Material CITY: '�'InC�S G� ��G COUNTY : Top ottom t. ��'� � ��2___ f- � Top Bottom Ft. ( treet Name,Numbe�4Communiry,Subdivision,Lot No.,Parcei,Zip Code) Top Botto Ft. TOPOGRAPHIC/LAND SEITING: (check appropriate box) � Slope ❑Valley ❑Flat ❑Ridge ❑Other 11.DRILLING LOG p Top Bottom Formation Description LATITUDE „��°SO. 9a 0 "DMS OR DD : cD / �f(, � ���`� ' LONGITUDE�"��c�,�.?9"DMS OR DD ' ��� y�� , So7� ,�n�� c. LatitudeAongitudesource: �PS �T'opographicmap �� S�2 ' Hk� � G�ai9�f . (location of�vell musF be sho�vn on a USGS fopo map andattached to � fhis Form if nof using GPS) � . � 5.WELL O1IVNER � . c9 W / Owner Name • � / Street Address � h'W G �''�1 v r' C!v �'l G 2�10 2 �' I City orTown State Zip Code / SIZE OFF `f' S66�� AreC� �G� _�„ ���� / BIT SERIAL NO: Q 3 y/O�, Pf�one number 12. REMARKS: 6.WELL DETAILS: i • a. TOTAL DEPTH: -s 6 � . b. �OES WELL REPLACE EXISTING WELL? YES❑ NO�j (' I DO HEREBYCERTIFYTHATTHIS WELL WAS CONSTRUCTED IN c. WATER LEVEL Below Top of Casing: �d FT. ACCORDANCE WITH 75A NCAC 2C,WELL CONSTRUCTION • (Use"+"if Above Top of Casing) � STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. d. TO?OF CASING 15 -� � FT.Above Land SurFace` n ,( � •Top of casing terminated aUor below land surFace may require L ,(1�,�G�i1� 6-� a variance in accordance with 15A NCAC 2C.011 S. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE e. YIELD(gpm): 7 METHOD OF TEST ��' K b.� : �Q 7C���� �, ,8�pw� f. DISINEECTION:Type HTH �. Amount � Cil S PRINTED NAME OF PERSON CONSTRUCTING THE WELL ME+Y7� a- DRCW ' Submit within 30 days of completion to: Division of Water Quality- Information Processing, �orm GW-1a '1617 Mail Service Center,Raleigh,NC 27699-161,Phone:(919)807-6300 ' Rev.2los Date Site Visited — 2—! By: � Permi.t: YJes, No /Si,ll-� �"'Y�h -- • - -. , �----- �-ur a�-..,���. _�-nnn .PVP - - - - BUILDERS NAN.�: �'t�j�j�.,�rcG. lii,:G�C�^�P ' . � ,.f .J .,' :,^ I` AnD�ss: 2.3 z � �/,.?,a 5�.�i ,A 4 �e..� �:, . �,�-� 5 � � r�3 Pxo� �Ex: �, 4�� -- 3 3l� � � � �' .S 1�`�' S_..,---------. , l " v��� . �° �" �,4.. � ,� �� . � y " .. , ,.� x _ 7 ��.,/� tb9 �' � 1✓�p �(,,�ti S . . . � . � , . � , ���i�� a._� . � .... w... ................... ............. ���' ��'�__ �-" a • . . . � ----� RE�FI�/�C� . . JUI_ 15 2011 �� 'jy . Davie County Environmenta� Health �AVIE CUUN I YHEA,UH��Nq}�fM��l . P.O, Box 848l210 Hospital Street 1Vlocksvil[e,NC 27028 , (336)753-6780/Fax(336)i53-1680 WELL PERI7TT Accr.►u�f #: 990005446 �'���1ctiI.�EH-�: 5801-56-4359-WeII �3�lIE� Ta: Fred Brockway . Si��division Infa: . • • Ref�c�E�ee Nanie: . � . � ':• �.o�a#ion:Address: Salmons Road-27028 • . . . . . Prop�sed c-a�i:ity: Residential Well � • � - �'r�pzrtySize:���=�=21.01 Acres • • � • �� • f\TC l��mb�r. 0078 . � • . ... � � . . Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this weIl 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 ciate of issuance. This permit may be revoked if it is determined that there has been a material change in any facticircumstances upon which this perrrtit was issued. .... . . . ..._........_. . _ _. _-�—•---. ._.._..._ ..__......_ .. .. . . . . .- � ---. ... .. . . ._. ... .. _. . . Permit Type: New Repair ❑ Abandonment ❑ Pro sed Certificate of Cornpletion Diagram f �� � QS�<� �(�� _ �� � f 4/ � � r Ca0 `� � ,�' ' .� 5 � , 1� • . �� � _.�� . , �/ � '� Dri u�"'�'Y _ ���� Comments: � Driller: ' " Certification'#: Gr'ouT Inspected: 1�1�e11 Head Inspected: � GPS Coordinates: EHS: Date: ' 'r EHS: Date: � ' i6�� 1,/_ J / . �� � 1 � � � ��, � ; � � - � � � � � � , .� Na '� � �� � .� �.� ; � % r � �-������ ;: ,� � � ��, � . x �° � ` , � � --�.�_��: _ �# ��, �o � �_:� , ��.�, �r� , ,_,__ _ - ,'` � ��' r� �' � . C� L i ,�� �� ;� � � a � � � _.�- �� ��:� � I� %, � �� ' � S s l ; �,/ , ,-- ,� � r � � ;�t � � _ � /� ! �-. 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