WM0401513_WW0401513 permit applicaiton part 2_Winston Weaver_20240223

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s)be secured? Lockable Flush
material: 5 Mount well pad
3. Number of wells to be constructed in bedrock: 2 6. Estimated beginning construction date: 2/26/24
4. Total Number of wells to be constructed: 7 7. Estimated construction completion date: 311/24
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C.0105(0(5),attach a scaled map of the site showing the locations of the following:
a. All property boundaries,at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections,streams,or lakes within 500 feet of the proposed well or well system.
b. All existing wells,identified by type of use,within 500 feet of the proposed well or well system.
C. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination(such as septic tank systems,pesticide,chemical or fuel
storage areas,animal feedlots as defined in G.S.143-215.10B(5),landfills,or other waste disposal areas)within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant assu es re onsibility for ensuring that the well(s)will be located,constructed,maintained,and abandoned in
accordance with 15A NCAC 02C.
Manager of Operations
Signature of Applicant or*Agent Title of Applicant or*Agent
Michael T. Spence If signing asAgent,attach authorization agreement stating
Printed name of Applicant or*Agent that you have the authority to act as(lie Agent.
If the property is owne by someone other than the Applicant,the property owner hereby consents to allow the Applicant to construct
elj s)as outlinpd in is ell bnstruclion Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensur that e w I ) ill be located,constructed,maintained,and abandoned in accordance with 15A NCAC 02C.
Douglas Wiggins
n t e f openj Ow r(if di an Applicant) Printed name of Property Owner(if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources'Regional Office:
Asheville Regional Office Raleigh Regional Office Wilmington Regional Office
2090 U.S.Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swannanoa,NC 28778 Raleigh,NC 27609 Wilmington,NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [phone] Fax: [phone]
Fayetteville Regional Office Washington Regional Office Winston-Salem Regional Office
225 Green Street,Suite 714 943 Washington Square Mall 450 W.Hanes Mill Road
Fayetteville,NC 28301-5094 Washington,NC 27889 Suite 300
Phone: [phone] Phone: [phone] Winston-Salem,NC 27105
Fax: [phone] Fax: [phone] Phone: [phone]
Fax: [phone]
Mooresville Regional Office °
610 East Center Avenue Win ton Sale �\
Mooresville,NC 28115 at sa i %
Phone: [phone] ' — a in a
Fax: [phone] 1
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yet,rville
Wit ngton
GW-22MiR(Rev.5-26-2022)