WV0800233_Application_20200103

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION
PRIVATE DRINKING WATER WELLS UNDER 15ANCACO2C.0300
WATERSUPPLYWELLS UNDER I5ANCACO2C.0107 DEC 23 2019
All water supply wells not considered `Private Drinking. Water Wells" and including irrigation, industrial, and commercial wells.
Water Quality Regional
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108 OperationSS: coon
Including monitoring and recovery wells. Wlltnln2ton Re,1lo;tal Offli
Print clearly or type information. Illegible submittals will be returned as incomplete.
DATE: 12-Z2 , 20_/1 PERMIT NO.: W'/0860233 _(lobe 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:
Wl'll/'tw» F'Kar� h 7Jrr iota/e
Mailing Address: /
City: tJ - State: NG Zip Code;ZM 2County: �rZWSW/G/`
Day Tele No.: -I q10 26 2 3 1l,P1 Cell No.:
EMAILAddress: )4WrliIale-I SeJr-'rV--C60qaxNo.:
B. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: d026 /io 93 39
County: bra 7 s w ok A
(2) Physical Address (if different than mailing address): 6 66 xlaq a I & rye. / t ve, Sw
City: sa Leo a State: NC Zip Code: 2 (?46 2-
C. WELL DRILLER INFORMATION (if known) �1
Well Drilling Contractor's Name: 5k 2.rs ire-®/ /fir.'!/� h
NC Well Drilling Contractor Certification No.: 2485 A 65ea-n
Company Name: ////{?
SA/P/%6r- ��/ ? Contact Person:
City: State: NG Zip Code County: �rtu7SW/G�
DayTeleNo.: q/Q 612.82t746 CellNo.:
EMAIL Address: SiLipp? is i1�e!/ lJcti700 • Fax No.:
II CO/4i
Form GW-22V Pagel - Revised February 20D

D. REASON FOR VARIANCE REQUEST — Include type of well(s) to be constricted; 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.
�"5uhir�ersih/e cwr� `ve/l s�'irri' avian o�/ � our
dt�rstandir it/C u 'es Q `ve/ to 6 e Zsram hOryVs
rs1d4 iah . l''s Well h1bald he < 25' M the ncneze /V16L
r6tL17d1hq the homeas aikua/foe?t�rii'rt, %he well siie is
T ' near septic fa ri gs/see mav�) and- woc-/d he clese
-to /of /.%ne. _
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 snap (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 specked minimum additional construction
requirements cannot be met.
G. SIGNATURES
Signature of Person Responsibly for Well Construction (typically the
or Type Full Name of *rson Whponsible for Well Construction
(typically the well driller)
Signature of County Environmental Health
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 C.S. 150B-23 within 60 days after receipt of the decision.
Fovn GW-22V Page 2 Revised February 2013

H. SUBMITTAL INSTRUCTIONS
(1) For the following types of water supply wells only:
(2)
(a) Private Drinking Water Wells under 15A NCAC 02C .0300
(b) Irrigation Wells underl5A NCAC .02C .0107 with a designed capacity of less than 100,000 gallons per day
and located on the same property as an on -site wastewater system permitted by a local health department.
Prior to submittal of the variance for these types of wells, please contact your regional environmental health
specialist by visiting: htth://ehs.ncr)ublichealth.com/contacts.htm
Submit one copy of the completed variance application to:
North Carolina Department of Health and Human Services
Division of Public Health — Environmental Health Section
On -Site Water Protection Branch
1632 Mail Service Center
Raleigh, North Carolina 27699-1632
For the following types of wells only:
(a) All Water Supply Wells trader 15A NCAC 02C .0107 other than the ones listed under (1) above
(b) Wells Other than Water Supply under 15A NCAC 02C .0108. If these wells are to: be constructed on property
not owned by the well owner or applicant, please also attach and submit a completed Application to Construct
a Monitoring or Recovery Well System (GW-22MR) found on our website at:
htti)://I)ortal.ncdenr. ore/web/wo/ahs/ewpro/hermit-applications
Submit one copy of the completed
variance application to the Division
of Water Quality Regional Office
serving the area in which the well
will be located:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue,
Suite 301
Mooresville, NC 28115
Telephone: [phone]
Fax: [phone]
WINSTONSALEM
RALEIGH
Raleigh Regional Office
Wilmington Regional Office
1628 Mail Service Center
127 Cardinal Drive Extension
Raleigh, NC 27699-1628
Wilmington, NC 28405
Telephone:[phone]
Telephone: [phone]
Fax: [phone]
Fax: [phone]
Washington Regional Office
Winston-Salem Regional
943 Washington Square Mall
Office
Washington, NC 27889
585 Waughtown Street
Telephone: [phone]
Winston-Salem, NC 27107-2241
Fax: [phone]
Phone: [phone]
Fax: [phone]
Form G W-22 V Page 3 Revised February 2013

COASTAL PLAIN
Minimum Additional Construction Requirements toe Wells Requiring Variance Ora Permit to the Separation Distances in 16A NCAC 20
p.0107(a)(2) and _0107(a)(3) - Applicable to areas that are Underlain by Unconsolidated Sediments and Sedimentary Stocks VTI p �POYENY4AL pbLL
ON Vc�
SORC
MINIMUM SEPARATION DISTNCE (fq � MINIMUM ADDITIONAL REQUIREMENTS
water kighk sewage or liquid waste
coneotlon ortran Sfor Iaclliry
animal barnfs
building fountl ations; e%clugm welt house
_._n—ii,.....__._.—_11—s .. ..._...._._.—,_._._.—_.__
sanita landfills
chemical or petroleum duel underground
storagctanks regulated candor 15A NCAC
2N wim ss nda containment
Cheen cal or pOtrO 0um due0 underground
Storage tanks regulated under 15A NCAC
2N uvlo secenda contalnmen¢
'd:oubla caseaw.,r, mess ra revalQea
Attacbraellt A (f•orin GN -22y. )
A
OA NC ACX .010?(d)(41)QB), .0107(e)(1)(,1), and 2C.0116 prat de for the ability to construct a -well to a depth of less than 20 feet where the best
source of it exists bemeen a depth often and tiventy feet below the surface of the Lind. Because additional natal,aum coustivcttan l•equieenxents
necessitate that: 1) casing extend to a depth greater than 20 feet below land surface: Ind 1) grout extend to the first significant clan lager greater than
20 feet below Lind surface of to the source aquifer. a 4-al•iince to horizontal Separation distances for shaHow hells cased t0 less than 20 feet is not feasible.
tJ ell consttilction inforinatiou should be provided with the .Application for permit for Variance detailing how mi¢litnaln additional construction
requirements s4ill be satisfied.
Form G W-22 V Page 4 Revised February 2013

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