WV0800221_Application_20190716

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NOR'1'14 CAROLINA l)fTAR'l'N :,NL T 01.' LNV1RONMENT AND NATU1 LAL RLa)URCES
V ARU CE APPLICATION I OR X.0100 Wk'l<fL CONSTRUCTION STA IIARDS:
)r'RIVA.TE DRLQ KING WATER WELLS UNDER 1E5A NCAC 02C .0300
WATER SUPPLY WELLS UNDER 15A NC AC 02C .0107
AR %vafersrrpi* ivellsna considcr&i -FrFvle1)?7nbflg water rr'dis" orr� itw* ns indrrstp-t-xQadiroeftmareiral we-Lb.-
WM?I, ILS O'rfWR THAN WATER SUPPLY UNDER I5A NCAC 02C .0108
hirNdiug ;n9niun ng and veravery ive-10-
Pr' of e!e[arLy or type infrrrnzari arx, Illegible subMiUu1s WX be PWruYhe d as irweymplt-be.
DATE: + � - IV 20 1}1Mi4'1IT NO.: (to be completed by l)Vk Q. j)[3H)
WELL OWNER -For suigJc ><arr& residences list tic propuw owner(s). For all otluors, 1L-�L narne of the biuiiness,
orgat atiot-L or goiermicmt agency and person delegated signature aathonty:
Mai lir.gAddrL.-,s: r + -4.
Day "1 lu No.: Cell N,.= 910
LMAM Add s: CYA % t a
PHYSICAL LOCATION OF WELL SITE
(] , Parccl tdmfification Nuri bi r {Pll, j of well site, Z>
County: + Jg---1 bra r
(2) Phvsical Addre�N (if &JI&emt than mailing addresq):
City_ T Qtatc- NC Zip Code: ---
WELL D RiLLER INFOR ATiON (if �mmxm)
Well Dril14 Contra etnr's Name: G, /' - qt75
Nc Weil 1}rilling ecmtract(r Cfnlifzcai on No.: O--#.
Company Narno: . _ ._ -cu . D0L.It. Contact Person: .? r!, 3-d -pw-5
City- _ C...>. I 4-- ta#eA-<— Zip Code o9 Cowtiv_ yV
Day Tcle No.: Cell No.: `� � 0 - J'q r 'y �
1'MA1L Fiddre:s,s:A—Q,j, 4j-cjt Fax NO.=
FOML'YW-22y Parma t Rcvis, c FcbFuwry 2013

D. REASON FOR VARIANCE REQUEST — Include t5'Pc of well(s) to be cous( ur,(4 rd; ale for which the varianci
b6ng requc: ;tpd; description of how tho alt,-Tnate constructioa will not endangcr buruan health and wc- farc avd
environment; and reason why construction rt +`or operation in accordance with the g#andard5 is not tecbOcally feast
nndloT provi&S Cqual or bcmr protection of tht gxoundwayer.
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F. ATTACHMENTS — Provide the foliowiug infonpationas atiacluutnis to this application;
l) A reap sbowing -general io<,.a ion of the groperny (in cludirkg road rr ttcs, C Siate Route Ntunbicr, distances.
kev Landmarks, etc.) suff6ci at for finding the well location,
i Detailed site trap with scale Showing location of proposed wall relevarct to mptic systems). build
f undatiorts, prpperty lutes, watcr bullies, potential sem-o" of contamination, outer wells. etc.,
(} j Submit a copy of the Iocal well pumit application arkd site evaluation snap (if applicable),
(4) Any outer irti'onnaiion rch� vattt to iirc varianc�c request such as a wVe11 cous€ruofion diagram shoWitkg Propo
weR Fitter or atypical Ganstructkyn matcrisls}methods.
F. SIGNATURE(S)
Sign atarc(s) ofWel rovertyolprnerts)
Fxinr or "fie WePiProperty 09vneL�-,)
S013 re of Per Reshot iblc for Well C'onstruetien
Call, thew ell dfiNor}
PI`i3lY r a iiffl�llli l'e1111 LljW)11k;le for Well C'onstractica
(`iypiudl v the w0l driller)
�SignatU3,e of 4COurkry Env7ronrnenta) Health SIv6Hlist
ry Priut or 1pt, Stull Nmne and Twe orcounty Environmental Health Speedalisr
Per }5A NCAC 02C. 01,E 8 Me Secre 10ry of the ,Division of'Walet Resources or the Division of Publk Headdh awry req
sithrfrillal of l9fortr7afton deemed rtees,sary to make a decision an The variance, mqL, impose curzdirinr7s as' park vj
decision, and shall rvsPand in writing to the request wilhin 30 days of receipV of the variance reglesi. A vark
appficaW who is disw isfied whh the dachsioii of'the Director wo, commence u v&niesfedcaL�v by,feling a petifioa
described in G.S. j5OB-?,3 within 60 cry--s after receipt of 'the de6sion-
GW-22V Variamc 12equcq Form yeti. 3-6-2017

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