327-397 Salmons Rd ' �' � �� � � ' 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.
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Permit Type: New Repair ❑ Abandonment ❑
Pro osed Certificate of Completion Diagram
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. 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