129 Woodvale Dr . � , DAVIE C:OUNTY HEALTH DEPARTMENT
'' (Septic Tank) Lnprovements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR�Ct���.�+ y ' +,�; i�- r ,.., DATE ��' - :` i� 1 G, PERMIT
LOCATION �l �f,tJ � �!`..f r�.� �; ,�:,� � t ; � ��" �� ,'�'r Jai�C.. ��. ���3
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SUBDIVISION NAME LOT N0. SECTION. OR BLOCK NO.
HOUSE (�' MOBILE HOME BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
N0. BEDROOMS ,,.� N0. B�ATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑ _ NO ❑ � '- ��� , ���f;}� J ,-
SITE SUITABLE YES ❑ NO ❑ �G:�s"�i' L�yz- ���b.^ __:.
SIZE OF TANK /��� al. ��� : ~p � � _
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NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual �Public ❑
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IMPROVEMENTS PERMIT BY 4�.t� 1��/".� 7,'��-� INSTALLED BY Ot�iJ
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CERTIFICATE OF COMPLETION ' ` `"�^' '
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BY-
(8/16/73) *Construction must comply� with all other applicable State and local regulations
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� • � Davie County Environmental Health ��
P.O.Boz 848/210 Hospital Street l �)
Mocksville,NC 27028 y� Q�I lJ°
(33G)751-8760/Fag(33�751-8786 ' (�4
WELL PERMIT �
Account #: 990005125 � Tax PIN/EH #: 5708-98-3077-Well ��S
Billed To: James T. & Peggy Winfrey Subdivision Info: �,\
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Reference Name: . Location/Address: 129 Woodvale Drive-27028 `\
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Proposed Facility: Well Property Size: 8.43 Acres �E ��1
ATC Number: 0004
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 ma.y be revoked if it is determined that there
has been a material chan in any fact/circumstances upon which this permit was issued.
Permit Type: New Repair ❑ Abandonment ❑ �(`�
Proposed Well Location Diagram Certificate of Completion Diagram �
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Comments:_�_� �l�i `,,�"Y'� Driller: ����
f�- `�✓-e � � � � ��S Certification#:
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Grout Inspected: — ` � ✓lJ� 7`�
Well Head Inspected: � - "'Q � /�
GPS Coor ' tes: `' Y, �� . p (,v
EHS: ' �� Date: �-���c� EHS: �e,�.7'��y�i'l� Date: 7— —
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W.P.7-08
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Q � ��,I TI N FOR PRIVATE WELL PERNIIT
���- avie ounty Environmental Health
�*E`�.����,EA� . . Boz 848/210 Hospital Street
��Rp��,���OU��� Mocksville,NC 27028 �
(336)751-8760/Fax(336)751-8786
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED iJNI.�SS ALL OF TF�REQUIItED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name to be Billed V�►1���5 �'� � �� Contact Person
Billing Address 2 Home Phone QZ�-��,��
City/State/ZIP %'YI6@ V�I�P NL� Z.?02� Business Phone
Name on Permit if Different than Above
Ma,iling Address ��/11�L City/State/Zip
II e�.s ' wa e��s
PROPERTY ORMATION J �� *Date House/Facili Corners Fla ed
NOTE: A survey plat or site plan must accompany this application. Included: �Site Plan ❑Plat(to scale)
Owner's Name c5/� � �/Z.-'' Phone Number
�rlc� �
Owner's Address City/State/Zip
Property Ad ess City
Lot Size � l S Tax PIN# ��08•�-��7
Subdivision Name(if applicable) Section/Lot# 3 %��
Directions To Site: . �/(�• / � Q�N >-
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DEVELOPMENT INFORMATION
Pernut 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 I�iO
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 specific location of the facility and any existing or future appurtenances,the location of any e�usting sepdc
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 application,the applicant signifies that they understand the terms and conditions and that they give permission
for Da�ie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary
to deternune the best location for a well.
� � , � �- �� -08�
Signe Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
�iiios A��o,�t# 5 25
Invoice# /nK(/
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07/24/2908 21:30 7042784599 STEELE WELL COMPANY PAGE 01/01
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'�''•�' � ; �k- 1lESIDENTTi .AL WELL CONSTRUCTION R.ECORD
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S '•r� �,��` � North Carolina Department of Environment and Natural Re.srnmces-Division of Water Quality
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�'"••����''� � W�LL CONTRAC70R CERTIFICATI.ON# 2020
1.WBLL CCNTRACTOR: f. OISINFECTION:Type HTH Amount 1 CU P
JASON STEELE g. WATEK[ONES(CepVt):
We��Conuac�or(Indlviduaq Name From 120 To 120 From 160 To 160
STF...FI.F WFI_I_CO INC From 200 To 200 , From. . To
Weli Contrdctor Company Name From To Frotn To
STREET ADDRESS 335 HILL HAVEN DR 7. cASING: 7t+itkness/
CLEVELAND NC 27013 Prom °eptn o�mseer wr�yi�i Material
�_To 1(1R Fl� ?7� pV(:
Ciry or Town State Zip Code From To FI,
7( p,4 �;�T�.q�qy F�om Tv Fr.
Area cotle- PhOne number
2.WELL INFORMATION: 6. GROUT: Depth Mateclal � Method
From 0 70 20 rt SAN�MIX MIX
SITE WELL ID S(d eppi�cabis) From To Ft.
1NELL CONSTRUCTION PERMITit 990005125 DAVIE From Tv Ft
OTHER ASSOCIATED PERMRi{('�t eppticatNe)
9. SCREEN: Depth Digmeter Slot Size Maferial
3.WELI USE(Check AppHcable Boz�: Residenti8l Wgt�r Suppy 0 From To FL In. in.
DATE DRILLED 7R310$ Frvm To �t. in, in.
T1ME COMPLETED AM 0 PM 0 From To Ft in. in,
�.we���ocnnon: 10.BAND/CRAVEL PACK:
CiN: MOCKSVILLE �p�My DAVIE de�m S'ze Mate"a�
From To Ft.
12'�WOODV�LE DR MOCKSVILLE NC 27028 From To Ft.
(Skeet Name.Numbars.COmmunity.SuDdNslon.Lot No..Paroel,Zip CoQC) FfDRI To Ft
• TOPOGRAPHIC/LAND SETTING:
0 Slops 0 Vatlay U Flat X Rldpe tl UNe�
(eheck appropiiate baod 7t.DRILLING LOG
May be in degre�. From To Formation Descriptio�
LAT1TlJ0E 35 54 74z minutes,seccmds m � � _ CLAY
LONGITUDE 8� 39 397 in a dccimal formot 70 9 c--aNn-g�NF
—— �96 305 r,Ran�irF
Latitude/longitude source-N G4S o Topographic mnp
(leptlen e/wo/l n►uaf be shown on a USGS topo map O�r! •
artached ro fhis lorm N not using GPS)
6.WELL�WN6R
OWNER'S rvAMe �AMES T 3.I'ECCY WINFREY �
$TREET ApDRESS 129 WOODVALE DR
M�CKSVILI_E N(: 9709R
City or Town State Zip Code
3� 36 �_492-5246
Area code- Phone numbcr 1.2. RrMARKS:
6.YVELL DETAItS: " � �
w. TOTAI DEPTH: 305� -
�!. DOES WELL REPLACE EXIS7ING YYEll.7 YESDC NO O �pp}1EREB�CE���'THAT TNi5 NIELL WAS LONS7RUCTED�N ACCORDANGE WITH
15A NCAC 2C.WELL CON$TFiUCTIQN STANDARD3.AND TMAT A COPY OF TMIS
c_ WATER LEVEL RP.low TOp Of CASif10' SO FT, RECARD wS BEEN PHO�IDEDTO THE WELLOWNER.
(Use"+"if Above Top of Casing) 7I23/08
d TOP OF CASING IS 2 FT.AbOve lentl Surface• r —
`Top oi c�eing terminaled aVor belvw la�d ow'FOCo mey roqufro RE OF CERTIFIED WELL CONTRACTOR DATE
a variance in ao�ordarice wim 15A NC�4C zC.o+�e. �ASON STEELE
o. YIELD(gpm): 6 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WEI.I
Submlt the original to the Division of Wat�r Quafity within 30 days. Attn:�nformation Mgt� ��GW-1a
1617 Malt Senrice Center—Ralelgh,NC 27699-1617 Phone No.(918)733-7015 ext 568. Rev.3/07
DAVIE COUNTY HEALTH DEPARTMENT
, , ,• -• (Septic Tank) Improvements Permit and Certificate of Completion
�.�,=; ; . .
, , . � • (Ground Absorption Sewage Disposal System - .G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR�'r r;c.,.., 1 ,t �, :� {E ; .,, DATE '-� - �' 1- i�,,,,, PERMIT
'f , �T
� LOGATION �F Y t,i.1 - �, �..��'� 'r �' � �f��� �..� f. ` - ''J' ��.;. 1\� 10 0 3
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� SUBDIVISION NAME � LOT N0. SECTION OR BLOCK N0.
HOUSE l�' MOBILE HOME $USINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
N0. BEDROOMS � N0. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑ NO ❑ ��J. , , _� 1-
SITE SUITABLE YES ❑ NO ❑ �' '-ri� �:: � ; � /L�''�`�� ���'� '.. �_
SIZE OF TANK f+�d'� gal.
( �
NITRIFICATION FIELD � J sq. ft.
DEPTH OF STONE IN LINES:
WATER 'SUPPLY: Individual �Public ❑
IMPROVEMENTS PERMIT BY �,�;..{� ��'��,�,���,���� INSTALLE.D BY ��� (
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CERTI FICATE OF COMPLETION� BY �r�,! f �I�:��,.V,��-,�,�,.. � Date � � ~``� � '� `��
(8/16/73) *Construction must comp .�y,�with all other applicable State and local regulations
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