WS0701143_Application_20200319

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:
2. County
3. Applicant
FOR OFFICE USE ONLY
r
PERMIT NO. r �' �� ��ll ISSUED DATE: - j (>
� Telephone: _ � 3 � _ 7 7
Applicant's Mailing Address: ' ' F[ & L ✓ l �
Applicant's Email Address (if available):
4. Contact Person (if different than Applicant):
Contact Person's Mailing Address:
Contac Person's Email Address (if available):
5. Property Owner (if different than Applicant):
Owner's Mailing Address:
Owner's Email Address (if available):
Telephone: RECENEWNWENRIDWR
MAR 19 ZO
Telephone: Water Ouality
ona
Washington Regional Office
6. Property PhKi
sical Address (including PIN Number): `� �5 t'� ��w
c
City: ik bi ! County: t rrell Zip Code:
7. Intended use of Well or Well System:
(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?
(If yes, complete questions 7 and 6) (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): 2 ?^U V J t
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? /V U If yes, give Public Water ID Number:
If yes, give Project Engineer and contact information:
12. Well Contractor:
Well Contractor Address: 7 g 1 f r t/ (I a 0,1C.
Well Contractor Certification No.: 3 1 7 / -A
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
No. of wells to be constructed in unconsolidated
material:
No. of wells to be constructed in bedrock:
Total No. of wells to be constructed:
(add answers from 2 and 3)
Estimated beginning construction date:
Estimated construction completion date:
4
Continued on Reverse

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ADDITIONAL 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. 143-215.10B(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
2. 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.
3. 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
Administrative Code, Subchapter 2C) and accepts full responsibility for compliance with these rules
we�i�<<l1
Si patur_f Applican or *Agent Title of Applicant or *Agent
0A v+'t� Lew i S
Printed name of Applicant or *Agent
* If signing as Agent, attach authorization agreement stating
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: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [phone] Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22W Rev. 3-1-2016

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3/11/2020 dl-agd.cc/PRC/nciTyrrelilindex.php?pid=112
Tyrrell County North Carolln 3n�649 ' _3
112 1 or 2 1 TOU 01 006 1/112017 1 1f1/2c17
A a� ME"Hip
BISHOP JOHN E JR s GRACE
P 0 BOX 749
COLUMBIA NC 27)25
2250 HWY 94 N
SEE PLAT C 35 M
k
CHK HOUSE UP PRIVATE RD
&red
7 f41.WM?TpV AtiS VALL[ `�
Q CLASS SIZE i 5ASERAT&IADJUSTIADJUSI RATE ' TUNITS
1M SL GSITE
1.00
' 412, Qp0'
9-12, 000
612, 000
EOA OPNOFFR]
2.26
43,380
$41495
2.2E
$10,160
COD OPNOFFRD
61T FDDFFRO
1.2E
$3,380
$4,495
1.25
$5,754
5.20
$540
$?18
5.2
43,735
4511 WDOFFRD
•8.07
$250
-333
3.07
62,683
TOTAL ACRES
17.21
TOTAL LAND%.ALLE:
534332
11.1
- i:5=fl lt.
A441i/Sx1E5
LAN CLASS
SIZE
USE SOIL TYPE I
RATE
9LDGSITE
1.04
ND
WD
c0 OPNOFFRD
2.26
U01
$1,200
O
60 OPNOFFRD
1.28
U04
$990
61 WDOFFRD
5.20
U43
$205
1z
61 WDOFFRD
8.07
U39
$45
TOI.AL DEFERRED VALLE:
S16,924
TOTAL L \D USE VAL-
s;-
SECIION SOFT
SIHT GRADE AREA
RPCN
DE CBS(:
'
1.
v 0
,0.65
;; DPNPORCH i20
i.07 C
120
$2,836
0.86 MO
0.36
0.86
0.8E
0.36
Olaf
O.s6
4.36
$12,000
$2,712
$1,247
$i,o66
$343
4
20 A.
400
Z
B .
120
-rrTffi-�A 1 1.00 SP120U20L2011 1.00 SMOU20L201
$1,463
i DNdELLING CABIN24'
"A MI y
PIERS I
LERTB&B
OTHER $VILDIhG ATTRIBUTES
PERCENT COMPLETE
(BAT85,
FIREPLACES,
ETC.)
41,f93
I00}
FINE
NO HEAT
F�FPLAc5ENT COST NEw: $34, 241 FLNAL BLILDD Gl--kL E: S18 487
nos
STRUCTURE LENGTH
RAIE
CON] AD ^ T E
UNITS
vALuE03-47-10
40:40: 0 Y
13CSTELBLDG
3CSTELBLDG
53C SLAB
59C SLAB
58C SHELTER
53 C SHELTER
82C COLD 3TG
SOD TANK
iREI-Mir
4E4
60 t
20
40 f
30 *
40
20 •
1 ,
30
20
16
16
30
20
18
1
$20.50
$21.00
$4.42
$4.42
66.62
$6.70
596.00
$590.00
0.9 $13.45
0.9 $18.90
0.9 $3.98
0.9 $3.93
0.9 $5.96
0.9 $6.40
0.9 549. 44
0.9 $446.04
1,800
1,2130
320
640
900
361
360
1
$33,2i3
$22,632
$1,273
12,146
$5,36i
$4,843
$24, 624
$446
SALE AMpUNTT
fr.r_.
'943,332
$20,247
$26 501
$90,039
79.2%
91.5}
352.4%
164.2%
ti J
LAG7
aL]3
DUT
PnRC
DATE: 1/112025 TOTAL OLT B1ILDL1G VALTE: 994,988
LAST
dl.agd.cclPRC/nc/Tyrrell/index.php?pid=112 212

3/11 /2020
dI.agd.cclPRCInclTyrreIIli ndex.php?pid=il l
Tyrrell County, NC
Card 1 of 2
Card 2. of 2'
Sim MCDENR/DWR
MAR 19 2020
water 0o ty
WWnat c t+ns section
Washington Regional Office
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