774 Williams Rd (2) Davie County,NC Tax Parcel Report Friday, December 9, 2016
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. ,A WARNING: THIS IS NOT A SURVEY
LEE 4 � � ParcelInformataori
Parcel Number: 1700000032 Township: Fulton
NCPIN Number:: 5768667498 Municipality:
Account Number: 79819190 Census Tract: 37059-804
Listed.Owner 1:' __' WILLIAMS TINA ELAINE.'"' Voting Precinct: FULTON
Mailing Address 1:- 774 WILLIAMS RD ,.:: , Planning Jurisdiction: Davie County
City: _ ADVANCE- Zoning Class: DAVIE COUNTY R-A
NC Zoning Overlay:
-Zip-Code: _- 27006 Voluntary Ag.District: No
Legal Description: 19.58 AC WILLIAMS RD Fire Response District: FORK
Assessed Acreage: 18.52 Elementary School Zone: CORNATZER
Deed Date: 5/1996 Middle School Zone: WILLIAM ELLIS
Deed Book/Page: 001870556 Soil Types: GnB2,GnC2,EnB,MsD
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: Outbuilding&Extra
Freatures Value:
Land Value: Total Market Value:
Total Assessed Value:
161 L__ 11 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.
UCTI N RECORD(GW-1)' For internal Use Only:
nformation:
14.WATER ZONES
FROM TO DESCRIPTION
455 ft. 460 ft. fracture
tt. ft.
.
tractor Certifiiccation Number 15.OUTER CASING for multi cased wells OR LINER if a liable
.a Drill Inc FROM TO DIAMETER THICKNESS MATERIAL
'P
16.
0 ft. 63 ft- 6.25 in- sdr21 pvc
p: �{3926Q 16.INNER CASING OR TUBING eothermal closed-loo
Well Construction Permit#: 1 G vv FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. is
3.Well Use(check well use): ft. fL is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
Agricultural []Municipal/Public 0 ft. ft. is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. ;d
1ndustriaUCommercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft, bentonite pump 4 bags
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK if a liable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 11L ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardnea seWmcktype, ins etc
Geothermal(Heating/Cooling Cooling Rettrm) Other(explain under#21 Remarks) FROM
ft, 20 ft• Clay
4.Date Well(s)Completed:10-13-16 Well ID# 20 ft. 45 ft. sandy soil
5a.Well Location: 45 ft. 55 ft- sand rock
Tina Williams 55 ft- 63 ft- granite
Facility/Owner Name Facility ID#(if applicable) ft. ft.
77W Williams Rd Advance NC 27006 fL .
Physical Address,City,and Zip fL ft.
davie 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. erti cation:/
35 54'7.4 N 80 27'46.8 W /
�-. /---h
10-13-16
6.Is(are)the well(s)Ex Permanent or Temporary Signa o CertifiWell ntractor Date
By signing this form 1 he by cert that the well(s)was(were)constructed in accordance
7.Is this a repair to an misting well: [3Yes or x)NO with 15A NCAC C. or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out!Drown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back of thisform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:485 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3@200'and 2@1001 construction to the following.
10.Static water level below top of casing:55 (ft.) Division of Water Resources,Information Processing Unit,
ifwater level is above casing,use"4 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 13 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
air rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method. construction to the following-
(i.e.auger,rotary,able,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)25 Method of test:blow 24c.For Water Su°Dly&Iniection Wells: In addition to sending the form to
hth70% 1202 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Foran GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
ob
Well Construction Permit For office use only - .
Davie County Health Department *CDP Fite Number 139268
-� 210 Hospital Street PIN Number
P.O. Box 848
�• � # >,Tax Block#:
°`^"'• Mocksville NC 27028 Tax Lot
Evaluated
WELL
Phone:336-753-6780 Fax: 336-753-1680
PERMIT VALID UNTIL: 9/19/2019
Property Owner: Tina Williams Applicant: Tina Williams
Address: 776 Williams Road Address: 776 Williams Road
City: Advance City: Advance
State/Zip: NC 27006 State/Zip: NC 27006
Phone#: (336)998-3394 Phone#: (336) 998-3394
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Williams Road
*Proposed use of Well
Advance NC 27006
Directions If Other.
Site Address:Williams Road Directions: Hwy 64 East to Cornatzer Rd.tum left to
Williams Rd.tum right to 776 williams on Right
Well Contractor Information
Drilling Contractor Driller Registration
I 1I I I ,
Permit Conditions
*Permit Conditions
Remaining
4000
Well location,construction 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 eAsting 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 permission 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- 0 9 / 1 9 / , D, 0 , 1 , 4
O Hand Drawing O ImportDrawing
Authorized State Agent: **Site Plan/Drawing attached.**
n--- 4 —L•
WELL CONSTRUCTION PERMIT
4 Davie County Health Department CDP File Number: 139268
210 Hospital Street
P.O. Box 848 County File Number:
Mocksville NC 27028 Date: 09 / 19 / 2014
0Inch
Drawing Type: Well Permit Scale: O Block =
O N/A
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Page 2 of 2.
RECEIVED
APPLICATION FOR PRIVATE WELL PERMIT SEP f �A14
Davie County Environmental Health
'VD '� �„ P.O.Box 848/210 Hospital Street DC HEALTH
nn �(� Mocksville,NC,27028
(336)753-6780/Fax(336)751-8786
***IMPORTANT***
[THWISAPPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name to be Billed -T;/V0 Lj; 11.CtM Contact Person 7-;N4 W j'1 f;a m s
Billing Address 774, 1AXs Home Phone 334- '798'-3.37,Y
City/State/ZIP U Nce NC 9*4rtess Phone call 336 - 7 7573
Email
Name on Permit if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plator site plan must accompany this application. Included: Site Plan Plat (to scale)
Owner's Name T%'NA L.) (k: