WV0800300_Application_20220107

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION STANDARDS:
PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C .0300
WATER SUPPLY WELLS UNDER 15A NCAC 02C .0107
All water supply wells not considered "Private Drinking Water Wells" and including irrigation, industrial, and commercial wells.
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
Including monitoring and recovery wells.
Print clearly or type information. Illegible submittals will be returned as incomplete.
DATE: 20 v?,� PERMIT NO.:
(to be completed by DWQ/DPH)
A. WELL OWNER — For single family residences list the property owner(s). For all others, list name of the business,
organization, or government agency and person delegated signature authority:
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Mailing Address: 1%U n C26tn"1
City: n State: � Zip Code: :)�ounty: (�
Day Tele No.: a Cell No.:
EMAIL Address: Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site:
County: (2) Physical Address (if different than mailing address): 14
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City: State: NC Zip Code:
C. WELL DRILLER INFORMATION (if known) c
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:FPAY-D1 WViC&ontact Person: Y .S
City: State: ,) Zip Code{�7County: i►'�
Day Tele No.: (o - WA _0 (0 17 Cell No.: O - & 0 4 6�-qf
EMAIL Address: 01 (" Fax No.: —�
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Form GW-22V Page I Revised February 2013

D. REASON FOR VARIANCE REQUEST — Include type of well(s) to be constructed; rule for which the variance is
being requested; description of how the alternate construction will not endanger human health and welfare and the
environment; and reason why construction and/or operation in accordance with the standards is not technically feasible
and/or provides eoual or better protection of the groundwater.
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E. ATTACHMENTS — Provide the following information as attachments to this application:
(1) A map showing general location of the property (including road names, NC State Route Number, distances,
any key landmarks, etc.) sufficient for finding the well location.
(2) Detailed site map with scale showing location of proposed well relevant to septic system(s), building
foundations, property lines, water bodies, potential sources of contamination, other wells, etc.
(3) Submit a copy of the local well permit application and site evaluation map (if applicable).
(4) Any other information relevant to the variance request such as a well construction diagram showing proposed
well liner or atypical construction materials/methods.
F. OTHER MINIMUM CONSTRUCTION REQUIREMENTS
For water supply wells, approval of a variance will require that additional construction requirements beyond those
specified in 15A NCAC 02C .0107 be met. Minimum additional construction requirements for Coastal Plain and
Piedmont and Mountain region wells are referenced on Attachments A and B on pages 4 and 5 of this application.
Approval of a variance will not be considered in cases where the specified minimum additional construction
requirements cannot be met. -*-1 ,
G. SIGNATURES
re of Ppisosible for Well Construction (typically the well driller)
I. h
Fdti-Namie`ol'Perken Responsible for Well Construction
(typically the well driller)
Signature of County Environmental Health Specialist
Print or Type Full Name of County Environmental Health Specialist
Per 15A NCAC 02C .0118 the Secretary of the Division of Water Quality or the Division of Public Health may require
submittal of information deemed necessary to make a decision on the variance, may impose conditions as part of the
decision, and shall respond in writing to the request within 30 days of receipt of the variance request. A variance
applicant who is dissatisfied with the decision of the Director may commence a contested case by filing a petition as
described in G.S. 150E-23 within 60 days after receipt of the decision.
Form GW-22V Page 2 Revised February 2013

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