WS0701199_Application to Construct_20240509

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY— DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A WATER SUPPLY WELL OR WELL SYSTEM
(Wells or Well Systems with a Design Capacity of 100,000 Gallons Per Day or Greater)
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct water supply wells.
1. Date: 05/09/2024 FOR OFFICE USE ONLY
2. County: Jones PERMIT NO. ISSUED DATE:
3. Applicant Town of Maysville Telephone: [phone]
Applicant's Mailing Address: 404 Main St Maysville NC 28555
Applicant's Email Address (if available): townmanager(a)townofmaysville org
4. Contact Person (if different than Applicant): Ethan Gartin (TRC) Telephone: [phone]
Contact Person's Mailing Address: 114 Edinburgh S Drive Ste 200 Gary, NC 27511
Contac Person's Email Address (if available): egartinOltrccomoanies cam
5. Property Owner (if different than Applicant): Jones County Board of Education Telephone: [phone]
Owners Mailing Address: — PO Box 187 Trenton NC 28585
Owner's Email Address (if available):
6. Property Physical Address (including PIN Number): Bynum Ave Pin83. 543207663600
City Maysville County Jones Zip Code• 28555
7. Intended use of Well or Well System: Municipal Production Well
(examples: Irrigation, consumption, etc.)
B. Will the proposed water supply well or well system replace or be added to an existing well or well system? Yes
(If yes, complete questions 7 and 8) (If no, complete question 7 and then skip to question 9)
9. Total design capacity of proposed well or well system in gallons per day (gpd): 345,600
10. If adding a well to an existing system, list the existing water supply wells In the existing system and their respective yields:
Well 1 346,600 GPD (to be replaced by proposed new well)
11. Is this a public well or well system? Yes If yes, give Public Water ID Number: 0452010
If yes, give Project Engineer and contact information: Ethan Gartin PE egartin(a trccompanies com [phone]
12. Well Contractor: TBD Well Contractor Certification No.:
Well Contractor Address:
PROPOSED WELL CONSTRUCTION INFORMATION
As required by 15A NCAC 02C .0105(0(7), attach a well
construction diagram of each well showing the following:
a. Borehole and well diameter
b. Estimated well depth
c. Screen intervals
d. Sand/gravel pack intervals
e. Type of casing material and thickness
f. Grout horizons
g. Well Head completion details
2. No. of wells to be constructed in unconsolidated
material:
3. No. of wells to be constructed in bedrock: 1.
4. Total No. of wells to be constructed: 1
(add answers from 2 and 3)
5. Estimated beginning construction date: July 1.2024
6. Estimated construction completion date: July 31, 2024
Continued on Reverse

ADDITIONAL INFORMATION
1. As required by 16A NCAC 02C .0105(f)(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.
2. As required by 15A NCAC 02C .0105(g)(3), for wells screened in multiple zones or aquifers, provide representative data on the
static water level, pH, specific conductance, and concentrations of sodium, potassium, calcium, magnesium, sulfate, chloride,
and carbonates from each aquifer or zone from which water is proposed to be withdrawn.
3. Attach any water use permits (if required). (e.g. Central Coastal Plain Capacity Use Area Permit is required In 15 eastern NC
counties by NC Division of Water Resources, visit: http:t/www.ncwater.org]
SIGNATURES
The Applicant hereby agrees that the proposed well(s) will be constructed In accordance with approved specifications and conditions of
the Water Supply Well Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina
/ Administrative Code, Subchapter 2C) and accepts full responsibility for compliance with these rules
J /�-'-'- Town Manager
Signature of Applicant or *Agent Title of Applicant or *Agent
Schumata Brown * If signing as Agent, attach authorization agreement stating
Printed name of Applicant or *Agent that you have the authority to act as the Agent.
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the applicant to construct
water supply wells as outlined in this Water Supply Well Construction Permit application and that It shall be the responsibility of the
applicant to ensure that the water supply well(s) conform to the Well Construction Standards (Title 15A of the North Carolina
Administrative Code, Subchapter2C).
Please send
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Bryce Marouis— Jones County Schoolboard
Printed name of Property Owner (if different than Applicant)
to the appropriate Division of Water Resources' Regional Office:
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
043 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone] _._
GW-22W Rev. 3-1-2016