WV0800238_Application_20200406

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION STANDARDS:
PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C.0300
dl(wmer+'uPOIY wells WATER SUPPLY WELLS UNDER 15A NCAC 02C.010'7
considered "Private Dr(nhing Wafer Wells"and including ga5on industrial, and crommercial wells.
WELL LS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
Including monitoring and recovery wells.
Print c(earyy or 1W informar(on.
DATE: f' 1 Off_ 20
PERMIT NO.:
be completed by D WQ/DPH)
WELL
A. rge OWNER -For single family residences list the property owner(s). For all others, list name of the business,
y$ovemment ncy and person del'gtted sig�ahne authority:
City. d,50
State: &- Zip Codel;;saf}� County;
DayTeleNo.: �� tZ 1
r EMAIL Address: � �`� Cell No.:_i„�---
i a.y IZeSS EWI - .
ed/LFaz No.:
R• PHYSICAL LOCATION OF WELL SITE Gat W�
(1) Parcel Identification Number(plN) of well site: dp.a0/
County:,44-j__—_ 1
(2) Physical Address (if different than mailing address);
City;
State: NC Zip Code: _
C. WELL DRILLER INFO RMATI iflmowv)
Well Drilling Contractor's Name: .0 I 1 _. —J 1
NC Well Drilling Co��pnn�p�p(r_aaaetor�� CCJ�ertification No.: ,3 9�' r A
Company Narne: �Ic1'II ((( .Uf. )Itl1
City: .511/ Contact Person:
--'---//—'�-- St"
Zip Code:.itJYl Coup Day Tele No.: 9T�0 . 0 �L - 8,Z ty'
EMAIL. Address:_ _ JJQt1 Cell No.: 9!0
_Q1P 8%l� q/ny'l Cdq Fax No.;
Fans GW-22V
Page I
Revised 1`6n y2013

D. REASON FOR VARIANCE REQUEST — Include type of well(s) to be constructed; 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.
0-1Ot1IM "kk AAX At Orlekar OfdaAlf J 1.1.11 IA1e11s.
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 in 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 map (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 .1)107 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 specified minimum additional construction
requirements cannot be met.
G. SIGNATURES
Signature o_f,,fibsson Responsible for Well Consiraetion (ttYppically the well driller)
�� LCArs/ � ,'.`sn x
Print Type Fail Name of Person Respamible for Well Construction
(typically the well drmer)
Signature of County Environmental Health Specialist
Print or Type Fall 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 G.S. 15OB-23 within 60 days after receipt of the decision.
Form GW-22V Page 2 Revised February 2013

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