WV0800341_Application_20230829

-North Carolina Department of Environmental Quality (DEQ) — Division of Water Resources (DWR-)
VARIANCE APPLICATION FOR WELL CONSTRUCTION STANDARDS:
WATER SUPPLY WELLS UNDER 15A NCAC 02C .0107 .
All water supply wells not considered "Private Drinking Water Wells " and including irrigation, industrial, and enmmercial wells.
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
Including monitoring and recovery wells.
PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C .0300
Print clearly or type information. Illegible submittals will be returned as incomplete.
DATE: August 08, 2023
Existing permit number (if applicable) Issued Date: _—Exp. Date: ---
Permit No. for new projects (to be completed by DWR/DPH)
A. WELL OWNER(S) — For single family residences, list all persons appearing on property deed. For all others, list name
of the business/government agency and person and title with delegated signature authority:
B.
C.
Massen ill J W Trustee and AMy C
Mailing Address: 6600 Brookshire Drive ----
City: Fuquay Varina State: NC_. _ Zip Code:27526_ County: Wake
Day Tele No.: 919-614-2909 __ Cell No.:919-614-2909
EMAIL Address: [e-mail] _ Fax No.:___..__
PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: par id 025907 pin 536410450747
County: Onslow.
(2) Physical Address (if different than mailing address): 410 Water Street
City: Swansboro_ County: Onslow Zip Code: __
WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
City: _ State: _
Day Tele No.: _
EMAIL Address:
GW-22V Variance Request Form Rev. 7-13-2020
Contact Person:
Zip Code: County:
Cell No.:
Fax No.:
Page 1

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 equal or better protection of the groundwater (refences to attached documents are acceptable).
I want to have an irrigation well installed on propgrty. There is an old grave about 55' west of the
proposed well site and public sewer about 50' east from proposed well site.
This well will be shared with both adjoining parcels for irrigation only
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. SIGNATURE(S)
IT 1/lelt/iOP /"VIES 11a►J/ An,r
Print Wr' Type W
Signature ofilerson Responsible for Well Construction
(Typically, the well driller)
Print or Type Name of Person Responsible for Well Construction
(Typically, the well driller)
Signature of County Environmental Health Specialist (for Private Water Wells)
Print or Type Full Name and Title of County Environmental Health Specialist (for Private Water Wells)
Per 15A NCAC 02C .0118 the Secretary of the Division of Water Resources or the Division of Public Health may require
submittal of information deemed necessafy 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. 150B-23 within 60 days after receipt of the decision.
GW-22V Variance Request Fonn Rev. 7-13-2020 Page 2

J Wayne and Amy C Massengill
410 Water Street
r
Swansboro, NC
Mailing Address: 6600 Brookshire Drive, Fuquay Varina, NC 27526
Cell 919-614 2909
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