WV0800234_Application_20200219

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VAMAN� LAPPLICATION FOR 2C.0100 WT;L:i, C ONSTiR['f'TiON STANDARDS:
PRIM 'i'?S DRiNKING WATER WELLS U-421 iR FSA NCAC P;C.Q3:
W.ATERSUPP—V WELLS a ES.A NiCAC 02C.M.7
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DATE: --O PE P6f IT O.t vMoe)1 i,c,6:; •�,,n��a:n15c .')tk'(rv:)r.:j�
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A. WELL OWNER — Fn:.;ngrc n.wdce= fist .bc p%opo=-,,e �.n��t:cr(.;. i'e_ ei] a) h ,- , last ilme of the busine
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�. PHYSWit L LaCATION Or WE€. T SyTL ek
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Well 1)7ll1rg Com;•retor', Name: �xy
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D. REASON FOR VARIANCE REQUEST - Include ti pe of wel(s) to be coast ucied: rule for which i1[e variance is
being requested, description of how' the allcrnaic construction .gill not endanger human health and welfare and the
coyironrnenr: and reason why construction andlor operation in accordance. with the standards is not lachmc.aliy feasiSlc
and, -'or provides equal er better protection of the groundwater.
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E. ATTACHMENTS-
(1) A map showaig general location of the propertN (including mud naatcs, NC State Route lnnibt_r, distances, a:ty
key landmarks, etc-) sufcicnt for finding the welt lomtioa-
(2) Detailed site map with scalp showtt:g location of proposed well relevant to septic systetu(s), building
foundations. properly lams. water fxrdics, potential sources of contaminationo€he= wells, etc-
(3) Submit a copy of the local well permit application and site e�alualion map (if applicable).
(4) Any other infomialion tcicvant to the variance request such as a well wnstiuction diagram showing, proposed
well liner or atypical construction tnaterialshncthods,
F. SIGNATURE(S) zz �
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S:gnalc ir(e) of WcIlTrupertr ih�act(s)
Print or 7}pe Wclt+PtropertV E7wner(s)
erson Responsible for Well 417'onctruc6m
(Tyypicailr the well driffer)
Print or Type NAir e of Pcnva Responsible for Weil Consirucr,on
(Typically the well driller)
Sigoatutr of Couury Ea}in+anrental "Q.hith specialist
Print ar .Pe t+u Et ?dame and Title of County Environmental HeAlth specialist
Per I5A NC.4C02C .01181he Secrewn! oOAxe Division o/'Water Resoi<rcis or the Division of Public Hearth ma;, require
submittal of injbi matioe deemed necessar: to make a decision on the voriance, mat, Impose cardf!lorrs as earl of the
decision, and shall respond in xririt q to the request withat 30 days of receipt of the variance recruesi. A variaree
applicant who it dissatisfied 4ah the decision of the Director mcty commm—e o contested case by iifing a petition ass
aeceitbed in US 1;OB-22 wahm 60 days ofre,•receipt of the decision.
OW-22:'Variance Rctlucst PVmt Rr 3-6-2017 Pays2

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