Well Lot 4 & 3Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax(336)753-1680
WELL PERMIT
Account #: 990005528
Billed To: Sugar Valley Airport
Reference Name:
Proposed Facility: Residential Well
Tax.F INIEH #: 5851 -26 -8843 -Well #2
Suidi isian info: Sugar Valley Airport Lot# 4 &:.3
.:i:LocationiAddress: Sugar Valley Trail -27028
Ptopefty,Siz :` ` .Z3 + Acres
ATC Number: 0069
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 fact/circumstances upon which this permit was issued.
Permit Type: New [R Repair ❑ Abandonment ❑
Proposed Well Location Diagram
SSP; C_ `tao-kis
�A
A
�0
I sGK k
Certificate of Completion Diagram
' '/ a r
Comments: /1/��•ti,��l��� g 5-e l�l�a It Driller: � QC lr` �'Iti w•2
Certification #:
S,xto S Grout Inspected: f��l"�
Well Head Inspected: /o/yI22w
GPS C ordinates: D
EHS: Date: EHS: L Date: lG/ZV2
W.P. 7-08
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
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
V -
INP UR. V 11UN
Address-
City/State/ZIP
Name on Permit
Mailing Address
Contact Person��.�
Home Phone3�56 w 21- gL
_Business Phone � 5?9,1? SP 71_
City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey pl or site plan must
Owner's Name
Owner's Address 40
Property Address
Lot Size
Subdivision Name(if applicable)
Directions To Site:
Tax PIN# " AV,6-1-
uded: %e'Site Plan OPlat (to scale)
Phone Number
City/State/Zip
City
Section/Lot#
-21
DEVELOPMENT INFO ION
Permit Type: New Well Well Repair Well Abandonment O her (specify)
Facility Type: Residential Food Service Church . Com cial 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 specific 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 application, the applicant signifies that they understand the terms and conditions and that they give permission for
Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to
determine th best location for a well.
Signe Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
7/30/09 Account #
-rbill Invoice_ #
�� 'bqV
_or:••....... -v'
? :oFESSIo '• ti9
. a SEAL
0 L-3162 Q, _
OAC .sv,R
ROGER /
I declare that on 2t ` 1 S 20 J ,
we surveyed the property shown on
this plot:
X-6" - P*4
IV 0
Tie Line
05/8" EIR Fnd N 04.04 38"E
669.22'
(not to scale)
Tax Lot 4
Tax Map E-6
n/f Human Service Alliance, Inc.
RB 824 O PG 319
Proposed House Lot 3
Existing Ground Elevations (NAVD)
G1: 719.31'
G2: 719.93'
G3: 720.16'
G4: 720.52'
G5: 720.31'
G6: 720.73'
G7: 720.64'
G8: 720.25'
Proposed House Lot 4
Existing Ground Elevations (NAVD)
G9: 720.06'
G10: 719.87'
G11: 719.79'
G12: 719.39'
G13: 719.40'
G14: 718.60'
G15: 719.56'
G1 6: 720.08'
R/W - Right-of-way
EIP - Existing Iron Pipe
EIR - Existing Iron Rebar
P - Post
CM - Concrete Monuinei
IRS - Mon Rector Set
PSL - Property Line
WControlled Accom
- concrete Pips
CMP - Coirrugoted Metal Pi"
CPP - Plastic Pipe
-F- 166 Year Flood Boundary
-O- overhead UNtip
-s%- Fence
Find - Found
n/f - Now ser Formerly
JIlxfP - Nonmorvanented Point
a - Center Line
EP - Edge of Pavement
TP - Telephone Pedestal
-W- Water Line
aaaasaaaa■
aaaaaaaaa■
4 Garp Robse Scans, Askssirtsl Land Suini"ar, L -31C., wrtMy to one
of the /ebswlnq as 1 9se1 duti
to e. E✓;
C] G. That this wet Is Of a anis, matt Ia. a sub•ANsia, or lased WOM
the we of a corgi or rrWAdliasq that has e, cod "VMS that
reexdotss Prwls of km*
b. That this plot Is of a survey Met is bootad in s ch portion of a
GWAb ser rrw 1000% Mat Ise unregulated in to on ordlnonos
that reouk"o preate Of lmxd:
aC. nwit this plat Is of a wvef' of an ekle6ng Parc x or parceM
of land.
d. That MN plat Y of a survey of another category, such as the
recomWnatlon of awIp Parcell, a court-ordered survey or other
exception to the delinklon of wbdMslon:
E] a. That the lWarmallon - 11,11 to this surveyor is such that I om
I , , to molt a d-tsnrrnstion to the hast of r 9' proNpiorxel
abft ce to pavlaiar corAck" in (a) through 'd) above.
George R. Stone, PLS
Professional UG. ,,r.yo,. L-3162
-1/2" EIR Fnd N 0400 '38"E
Beo�On*:PZM27
n
PB
Tax Lot 4.03
Tax Map E-6
n/f Wayne Morris Hemphill
DB 146 O PG 771
Chain-link Fence x
Crosses P/L
180.00'
2• SAW
LOT 4
0.929 Acres +/—
Tax Lot 4.08
Tax Map E-6
N
N
co
Z
00
1r
Ln
U
t
Pro
G19 �s�Ck_
Proposed T
Septic Tank Propos
ed Hose GIB
Lowest finish
C14 GI Floor 725,U4VD
Glp C1p G9
80.6' Pro -posed peck
I i
I
LEGEND FC - Face of Curb
BoC - Sock of Curb
PP - Power POW
LP - Light Pole
MH - Man Hole
CH - Chord Distance
P/0 - Part of
DB - Deed Book
P8 - Plat Book
RB - Record Book
PC-
ppoopqe�
ce - CoEch Bolin
-S- Sewn Lits
WM - water Meter
Wv - water Volvo
BM - Bench Mark
TBM - Tarnpo�y Bench Mark
RRS - Ra'I Rood Spkxe
CN - Cable Television Pedestal
ETB - Electric Tronsfo►mur Box
CO - Sanitary Sewer Clean Out
112" EIR Fnd
73.63'
180.00' Total
I
i
I
0I
of
'I
I
I
I
I
I
E
-- 44.5,-------
1/2" EIR Fnd _ N 0400 34 8"E 180.00'
NOTE:
This property is subject to all easements. right-of-ways,
streets and wseeements, if any. as the some may appear of
record in the office of the Register of Deeds. Clark of Court.
Town or County Tax Office or which may how been acquired by
prescript'r.s use. This survey is subject to any facts that may
be disclosed by a full and accurate title search. NOT furnished
as of Mho date.
This mop or drawinngg and any accompanying
docurrtenta are fumh*md to the penson(s) named
thereon and no atterotions or use by others
is permitted unless authorized by Stone Land Surveying Co.
Certified copies of this survey map will not be issued
beyond nirovV90) days of the original survey date.
Mop not for recordation.
Precisior 1:10,000+
1/2" EIR Fnd
100 Year Flood Hazard Zone (AE)
Reference "FIRM" (Flood Insurance Rate Map)
F Mop Number: 3710584000J
Panel: 5840, Date: 9-17-2008
BFE: 722' NAVD
� F
eFE. Y2?' F
F
LOT 3
0.929 Acres /-- to
00
Ln
Tax Lot 4.07 Ln
Tax Map E-6
rn
N
N
io
0
-----------------
Proposed Deck
-- 29.4' G7 G8
Proposed House
t _ Proposed
Lowest Finish Floor: 725' NAVD Septic Tank
G6 G5 G2 G1
G4 G3 -
Proposed Deck
-----------------Ln
-i
I
I
I1 0l
P osed Well
I
I 8 I 10'
106.37' 88.33' I 91.67'
S 04-04'19"W 1/2" EIR Fnd 180.00' Total S 04'04' 19"W 112" EIR Fnd
_
I �
CA .Revised 20.
Septic
�-� c S
�-- Ref ---- .
Ystern Eos
erence Revised _-- ement (10'
--_Su9or s each side --�
VolleY Ai of CIL)
�. rt_Phose11 cel s
of
Valley
,
A' _
2rport
ZGnZUCz ��
NOTES:
1. Zoning: R-20
2. Minimum Euikling Setback Lines:
Front: 30'. Rear. 30'. Sick: 15'
3. Watershed Classification: None
4. No USGS or NCGS Monuments found
within 2000' of site.
5. Proposed homes for LOTS 3 do 4 shall
be constructed with the krwest finish floor
eievoiion a minimum of 2' cbowe the WE (722'NAVD).
Tax Lot 4
Tax Map E-6
n/f Human Service Alliance, Inc.
RB 824 O PG 319
Vicinity Mop (Not to Scale)
Tie Line
S 04° 304 8"W 112" EIR Fnd
454.79'
(not to scale)
F
F
F
,F
To x Lot 4
Tax Map E-6
n/f Human Service Alliance, Inc.
RB 824 O PG 319
F
C/L 40' Access & Utility Easement
(20' each side of C/L)
Reference PB 10 O PG 275
Site Plan for:
Lots 3&4
Sugar Valley Airport
Phase II
LOTS 3 & 4
SUGAR VALLEY AIRPORT
Phase II
Plat Book 10 O Page 275
Tax Lots 4.07 & 4.08
Tax Map E-6
Record Book 824 O Page 319
Area LOT 3: 0.929 Acres
Area LOT 4: 0.929 Acres
Area Computations by Coordinate Geometry
SCALE TOWNSHIP COUNTY STATE DATE
1" = 30' Farmington Davie North Carolina 2-15-2011
Stone Land Surveying Company
MT,D SURVEYED: in
Busess Firm certificate Number: C-1704 761NOL34
Geor" Robert Store, PLS L-3162 Wap NO.
MAPPEO: 113 Drum lone (336) 998-4733 761OL34
GR$ Mocksville, N C. 27028
o
n
~
a„
N
Pinebrook Dr
V
cr
SR 1437 o
Gilbert Rd _
o l
1
o
i
SR 1437
F
Y
M p I
0
in al
N
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o_
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in
M
O
Vicinity Mop (Not to Scale)
Tie Line
S 04° 304 8"W 112" EIR Fnd
454.79'
(not to scale)
F
F
F
,F
To x Lot 4
Tax Map E-6
n/f Human Service Alliance, Inc.
RB 824 O PG 319
F
C/L 40' Access & Utility Easement
(20' each side of C/L)
Reference PB 10 O PG 275
Site Plan for:
Lots 3&4
Sugar Valley Airport
Phase II
LOTS 3 & 4
SUGAR VALLEY AIRPORT
Phase II
Plat Book 10 O Page 275
Tax Lots 4.07 & 4.08
Tax Map E-6
Record Book 824 O Page 319
Area LOT 3: 0.929 Acres
Area LOT 4: 0.929 Acres
Area Computations by Coordinate Geometry
SCALE TOWNSHIP COUNTY STATE DATE
1" = 30' Farmington Davie North Carolina 2-15-2011
Stone Land Surveying Company
MT,D SURVEYED: in
Busess Firm certificate Number: C-1704 761NOL34
Geor" Robert Store, PLS L-3162 Wap NO.
MAPPEO: 113 Drum lone (336) 998-4733 761OL34
GR$ Mocksville, N C. 27028
RESIDENT1,4L WELL CONSTRUC'ITON RECORD
1 rT °% North Carolina Department of Environment and Nahlral Resources- Division of \baler Quality
r
•�' `` \TELL CONTRACTOR CERTIFICATION 9
1. WELL CONTRACTOR:
J dJ 7 (n1 P'k j » zri
Well Contra for (Individual) Name
YADKIN WELL COMPANY. INC.
Well Contractor Company Name
1908 HAMPTONVILLE ROAD
Street Address
HAMPTONVILLE NC 27020
City or Town State Zip Code
( 336) 468-4440
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# Mr 2
OTHER ASSOCIATED PERMIT4(d eppl cable)
SITE WELL ID tr(if applicable)_ 144.k -- 5' 3 3
3. WELL USE (Check Applicable Box): Residential Water Supplylu-
DATEDRILLED-L(-I
TIMECOMPLETED �•� AMD Pf1E1
RECEIVE®
g. WATER ZONES (depth): , grr, APR 0 8 2011
Top r Bottom 31` o DAVIEC(�tt1 h. EAJH0EPAF2( ENi
Top PLV Bottom o1Lty Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 4/ Bottom �� Ft.SVe-)( UG
Top Bottom Fl
Top Bottom Fl.
8. GRO T: Depth Materf al Method
Tcp i� Bottom 3 FL �f Ib _ (4,*,,( -1-K
Top_F Bottom --57t—( Ft M 0
Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size Material
Top_ Bottom-- Ft in in _
Top Bottom Ft. in in. _
Top Bottom Ft ---ill in _
4. WELL LOCATION: 10. SAND/GRAVEL PACK:
( Depth Size Material
CITY: Z//gCCd'c rt"'� ; COUNTY/ V Top Bollom_ Fl_
Top Bottom Ft _-
(Sfreet Nam , tlumbers,l✓ommunity, Subdiyfsion, Lot No, Parcel, Zip Code) Top Bollom FI.--
TOPOGRAPHIC
.—TOPOGRAPHIC / LAND SETTING: (check appropriale bot)
t lope E)Valley ❑Flat HRidg•� ❑Other
LATITUDE _" DMS OR 3 S ?�= DD
LONGITUDE " DMS OR .5'
/ZO DD
Latitude/longitude source: OPS QTopographic map
(location of melt must be s own on a USGS topo map andaltached to
(his form if not using GPS)
5. WELL OWNER
Owner flame
Street Address
City or Town State Zip Code
( 33 (' ) !92 5T7 X98 3y�/
Area code Phone number
6. WELL DETAILS: p
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES E) NO
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: ? FT. ACCORDANCE WITH 15A 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. TOP OF CASING IS FT. Above Land Surface' �J�j11
'Top of casing terminated atlor below land surface may require �1 �e,C•[[:i �- i y
a variance in -accordance with 15A NCAC 2C .0118. TURE CERTIFIED WELL CONTRACTOR DATE
o�
e. YIELD (gpm): o METHOD OF TEST r J 004-Y U
f. DISINFECTION: Type HTH _ Amount //6 9 S PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 607-6300
Date Site Visited Z -23 --/ ! By:Permit: Yes No
11. DRILLING LOG
Topp Bottojm,
a?dl 3Zt2
/
/
12. REMARKS:
Formation Description
SIZE OFF -. O a 'a
BIT SERIAL NO:
Iahat Is Height of 6Iell Casing? Make Sure 12" Above Ground Level!!!!
Form GW -1a
Rev. 2109
ela 1 I "yo
Pin c ^4;eH 641 cr+'
l vjuc-
�l etJ�r-V