ccpcua app

APPLICATION FOR WATER USE PERMIT IN THE http:llwww.tiewater.org/CCPCUA North Carolina Environmental Management Commission
CENTRAL COASTAL PLAIN CAPACITY lUsE AREA Department of Environmental Quality, Division of Water Resources
1611 Mail Service Center, Raleigh, NC 27699-1611, phone: [phone]
2 ew Application El Application for Permit Renewal ❑Permit Amendment []Temporary Permit Permit #
I. Applicant Information: n _ /+
(a)Applicant: 1A®�ulA:> *5t�P�t\i' t-JrJSiTz0C7 L I0Ai Of"PAry J(^J(_
(Name of Person, Company, or Corporation)
! 5 0 -7 LIVE vie 4AAVZ -rt. "
(b) Mailing Address:- �uoT� A City: �xLV ��� i State: �-- Zip Code:
(c) Facility Address: 1(a 9 0 'RO EIZr5 Ro . —6W 1?D'f2;—, County: V?=
(d) Authorized Contact Person: A0A4 S 1 ryt( &4 F i7ZE5 iZ t tJi 7 � Z - Z44 -7 ­ 4401
(Name) (Title) (Phone Number)
t�i 0 �11� c a O lf~n 5 t rvt O,.1cO N s �R c/cit tU nl . CD
(Email Address) (Fax Number)
II. Puruose(s) for which water is to be used (check all that aADI
(a)Public Water Supply System (PWSID# _ }*
(b) __Livestock Supply, describe briefly
(c) Agricultural Irrigation, describe briefly
(d) Aquaculture, describe briefly
(e) ✓ Mining, describe briefly ' 13UV Rv W t-C c..i 4 rR 1 aJ G
(f)Industrial, describe briefly
(g) Other, describe briefly
*If (a) above is checked and applicant is a unit of local government, then applicant must have an adopted Local Water Supply Plan {G.S. 143-355(l) and (m)).
III. Source(s) of Ground Water (attach extra sheets if necessarv): (a) Fill in table below. Devths: feet below land surface. Land surface elevation: feet above mean sea level,
Well)
Sump
ID
Latitude
(decimal
degrees
ex. 34.264567)
Longitude
(decimal
degrees
ex,77.263546)
Date
constructed
Diam-
eter
(inches)
Well
Depth
or
max pit
depth
feet
Depth to
top of
screen or
open hole
(feet)
Depth to
bottom of
screen or
open hole
(feet)
Depth to
pump
intake
(feet)
Pump
capacity
(gallons
/minute)
Pump type
(submersible,
turbine_.)
Depth
to
top of
gravel
pack
feet
Land
surface
elevation
(feet,
MSL)
Existing
(E) or
Proposed
(P) or
Abandon
A
Maximum
number of
gallons to be
vvitbdrawn
daily
of
Hours
to be
pumped
daily
DWR CCPCUA-2 Revised September 30, 2015

(b) Totaled daily withdrawals from ground water = 3 Z gallons.
If (b) above exceeds 100,000 gallons, a Central Coastal .Plain Capacity Use Area permit satisfies the requirement for a water withdrawal registration {G.,S. 143-215.22(H)},
Items IV through XII will require more space for completion than provided, please attach additional sheets as necessary.
IV. Document additional mining permit application requirements as listed in 15A NCAC 02E .0502 d 4 or reference materials submitted under G.S. 74-41
Mining permit # Maximum pit depth (ft): Za # of excavated acres:
V. Document additional Aquifer Storage and Recovery pm&Tam (ASR) permit application requirements as listed in 15A NCAC 02E .0502(d)(6).
VI. Locate_ sources of withdrawal (attach the relevant portion[s] of a map indicating roads and road names and note the following information — you may access
maps online at http:llrvww.ncwater.org/CCPCUA and follow the link to the Ground Water Data Mapserver):
(a) county(ies) in which withdrawal sources are located
(b) labeled positions of all wells and sumps listed in section III. (a)
(c) locations of all existing water supply wells within 1500 feet of the wells listed in section III. (a)
(d) locations of all discharge points for water withdrawals covered under this application
VII. Document conservation measures by user tvne:
(a) public water systems (15A NCAC 02E .0502(d)(5)(A))
i, Do you have a water conservation —based rate structure (ex. Plat rates, increasing block rates, seasonal rates or quantity based surcharges)?
ii. Do you have a water loss reduction program (ex. annual water audits, in -field leak detection, leak repair)?
iii. Do you have a water conservation ordinance for irrigation?
iv. Do you offer a retrofit program (ex. Low flow shower heads, toilet flappers, faucet aerators)?
v. Do you have a public education program?
vi. Evaluation of feasibility of water reuse?
(b) other users besides agricultural irrigators (I5A NCAC 02E .0502(d)(5)(13))
i. Do you audit your water use by type of activity? (for example process make-up water, non -contact cooling water)
ii. Implementation schedule for feasible measures identified in the above item for conservation or reuse of water at the facility.
(c) agricultural irrigators (15A NCAC 02E .0502(d)(5)(C))
Total acres to be irrigated: Irrigation Method: Crops: _
VIII. Substantiation for the amount of withdrawal requested: Submit documentation that justifies the total withdrawal requested. Documentation could include
design plans, development plans, planning studies, operation reports, past pumping records, etc. If withdrawals are to be seasonal or vary significantly from
month -to -month throughout the year, describe the reasons for the variations and specify those variations. Fill in table below.
Average Daily Water Use from Previous Calendar Year (gallons per day)
January
February
March
April
May
June
July
August
September
October
November
December
Daily Use
0.
p
p
0
©
0
# of days
IX. Disposal of water: Describe how the water will be disposed of after it has been used. NPDES permit # ?61voiA? �000WV L
DWR CCPCUA-2 Revised September 10, 2015

X. Document plans to retrofit wells as described in 15A NCAC 02E .0502(i): Describe the methods and proposed schedule to retrofit wells which currently have
pump intakes deeper than the top of the uppermost confined aquifer that yields water to the well.
XI. Document intermittent user status as described in 15A NCAC 02E .0507(13):
(a) persons who withdraw ground water less than 60 days per calendar year; or
(b) persons who withdraw less than 15 million gallons of ground water in a calendar year; or
(e) aquacultural operations licensed under G.S. 106-761 using ground water for the initial filling of ponds or refilling of ponds no more frequently than
every five years,
XII. Document Cretaceous Aquifer Reduction requirements:
(a) Identify Cretaceous Aquifer Zone wells and associated percent reduction requirements using the CCPCUA Cretaceous Aquifer Zones map available
from the Division of Water Resources {include documentation for wells to be excluded from reduction requirements due to 15A NCAC 02E .0503(8)
or 15ANCAC 02E .0503(9)).
(b) Document Aquifer Storage and Recovery program (ASR) total net withdrawals.
(c) Approved Base Rate Calculation for Cretaceous Aquifer Zone wells as described in 15A NCAC 02E .0507(1); choose the larger of i., ii. or iii.:
i. total calendar year 1997 water use in gallons by well;
ii. total August 1, 1999 through July 31, 2000 water use in gallons by well; or
iii. an adjusted water use rate calculation based on the larger of i. or ii. and the following:
A. documentation of water use reductions made since January 1, 1992, ,
B. actual or estimated water use from wells approved by the Division of Environmental Health by August 1, 2002;
C. percent of plant nursery operation using low volume micro -irrigation; or
D. documentation of other relevant information
(d) Plans for Reduction (use attached worksheet):
i. calculate difference between estimated water demand and approved base rate minus Cretaceous Aquifer reductions at year 2008, 2013 and 20J 8
ii. identify new water sources and probable yields
XIII. Temporary Permit for Cretaceous Aquifer Reduction Wells:
(a) Document static water level trends to be level or upward trending after January 1, 2012 or over the previous year from present day (This may involve
construction and measurement of monitoring wells by permit holders); and
(b) Document pump intakes to be above the top of the shallowest Cretaceous aquifer screened by the well. Pump installation records are required. In
addition, geophysical logs may be submitted for validation of the top of the aquifer; and
(c) Document present day pumping water levels to be above the top of the shallowest Cretaceous aquifer screened by the well; and
(d) If applicable, document chloride concentrations obtained from monitoring wells or unused production wells screened and gravel packed in one
Cretaceous aquifer to be fresh (< 250 mg/1) for 3 previous years from present day and do not trend toward higher concentrations or other site specific
data which will allow determination of susceptibility to salt water encroachment.
XIV. Certification: I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached
documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe the submitted information is
true, accurate, and complete.
(Signature) (Name) (Official Title) (Date)
DWR CCPCUA-2 Revised September 30, 2015