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HomeMy WebLinkAboutWS0801052_Application_20200310ADDITIONAL INFORMATION As required by 15A 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. 143-215.1013(5), landfills, or other waste disposal areas) within 500 feet of the proposed well or well system. 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calcium, magnesium, sulfate, chloride, and carbonates from each aquifer or zone from which water is proposed to be withdrawn. 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://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 L6 V ive Code, Subchapter 2C) and accepts full responsibility for compliance with these rules tll Pender County Utilities Director Signature of 4plicant or *Agent Title of Applicant or *Agent Mr. Kenny Keel, PE * 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, Subchapter 2C). Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant) DIRECTIONS Please send the completed application to the appropriate Division of Water Resources' Regional Office: Asheville Regional Office Raleigh Regional Office Wilmington Regional Office 2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405 Phone: (828) 296-4500 Phone: (919) 791-4200 Phone: (910) 796-7215 Fax: (828) 299-7043 Fax: (919) 571-4718 Fax: (910) 350-2004 Fayetteville Regional Office 225 Green Street, Suite 714 Fayetteville, NC 28301-5094 Phone: (910) 433-3300 Fax: (910) 486-0707 Mooresville Regional Office 610 East Center Avenue Mooresville, NC 28115 Phone: (704) 663-1699 Fax: (704) 663-6040 Washington Regional Office 943 Washington Square Mall Washington, NC 27889 Phone: (252) 946-6481 Fax: (252) 975-3716 Winston-Salem Regional Office 450 W. Hanes Mill Road Suite 300 Winston-Salem, NC 27105 Phone: (336) 776-9800 Fax: (336) 776-9897 GW-22W Rev. 3-1-2016 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: March 5, 2020 2. County: Pender FOR OFFICE USE ONLY PERMIT NO. ISSUED DATE: 3. Applicant Pender County Public Utilities Telephone: 910 799-8755 Applicant's Mailing Address: 605 East Freemont Street Burgaw, 28425 Applicant's Email Address (if available): I(KeeKftendercountyric.gov 4. Contact Person (if different than Applicant): James L. Cornette Telephone: 910.270.2919 Contact Person's Mailing Address: P.O. Box 882 Hampstead NC 28443 Contact Person's Email Address (if available): _iim armnc com 5. Property Owner (if different than Applicant): Applicant Telephone: Owner's Mailing Address: Owner's Email Address (if available): 6. Property Physical Address (including PIN Number): 15060 Hwy 17 Pin # 3292 08 6686 0000, 586 Sloop Point Loop Road Pin # 4204 81 8064 0000 City: Hampstead County: Pender Zip Code: 28443 7. Intended use of Well or Well System: Public Water Supply. (examples: irrigation, consumption, etc.) 8. Will the proposed water supply well or well system replace or be added to an existing well or well system? No (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): >720,000 GPD 10. If adding a well to an existing system, list the existing water supply wells in the existing system and their respective yields: 11. Is this a public well or well system? Yes If yes, give Public Water ID Number: 7071011, W04/RW4 (Kiwanis), W06/RW6 (Annex) If yes, give Project Engineer and contact information: McKim and Creed, Tony Boahn, PE, TBoahn(c)-MckimCreed.com Contractor: ARM, Donald Cummings Well Contractor Certification No.: 2412-A Well Contractor Address: P.O. Box 882 Hampstead NC 28443 PROPOSED WELL CONSTRUCTION INFORMATION As required by 15A NCAC 02C .0105(f)(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: 2 3. No. of wells to be constructed in bedrock: 0 4. Total No. of wells to be constructed: 2 (add answers from 2 and 3) 5. Estimated beginning construction date: 3/18/20 6. Estimated construction completion date: 5/18120 Continued on Reverse