WV0800253_Application_20200709

North Carolina Department of Environmental Quality (DEQ) — Division of Water Resources (DWR)
VARIANCE APPLICATION FOR WELL CONSTRUCTION STANDARDS:
PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C .0300
WATER SUPPLY WELLS UNDER 15A NCAC 02C .0107
d/I iratersupp/v wells tact considered "Private A -In ing Water Wells" and including irrigation, industrial, and cammercial nells
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
Including monitoring and recoten- isvAs
Print clearly or type hViarmatlon. Illegible subutinaly will be returned as incomplete.
DATE: June 5 12020 PERMIT NO.: (to be completed by DWR/DP14)
A. WELL OWNER(S) — For single family residences, list all persons appearing on property deed. For all others, list name
of the business/government agency and person title with delegated signature authority:
Mr. Larry Cabral
Mailing Address: 308 West West Street
City: Southport State: NC Zip Code: 28461 County: Brunswick
Day Tele Na.: 973-803-327fi Cell No.: 973-803-3276
EMAIL Address: [e-mail] Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 209615634424
County: Brunswick
(2) Physical Address (irdirferent than mailing address):
City: County: Zip Code:
C. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: James Cornette, PG, CWD
NC Well Drilling Contractor Certification No,: 2424-A
Company Name: Applied Resource Management, PC Contact Person: James Corvette, PG, CWD
City: Hampstead State: NC Zip Code:28"3 County: Perkier
Day Tele No.: 910-270-2919
Cell No
EMAIL Address: [e-mail] Fax No.:
GW-22V Variant Request roan Reh, 34-2017 l'ugC l

D. REASON FOR VARIANCE REQUEST — Include type of well(s) to be constructed; rule for which the variance is
being requested; descriptionn of how the alternate construction will not endanger human stealth raid welfare and the
environment; and reason why ronsttuction and/or operation in accordance with the standards Is not technically feasible:
and/or provides equal or better protection of the groundwater.
The irri arson well will be drilled aproximatiey 25' West of the house and 80' from the
sanitary sewer manhole. The well casing II be grouted along Its entirety and will not present a
threat to the human health or the environment. 15A NCAC 02C .0107 r
E. ATTACHMENTS — Providc 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 ror finding the well location,
(2) Detailed site map with scale showing location of proposed well relevant to septic systetn(s), buiWing
foundations, property lines, water bodies, potential sources of contamination, other wells, etc.
(3) Submit a copy ordte 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. SIGNATURE(
Mr. Larry Cabral
Print or Ty- perty 0 s)
signature orPerson Respowibie forWeil Cunstruetlon
(Typically the well driller)
Mr. James Comette
Print nrType Name of Person Raponsilrle forNirell Construction
(Typically the well driller)
Sfilmiure orCounty Environmental llealth Speefalist
Print or Type Full.Nomc a Title of County Em Iron mental Health Specialist
Per 1s.4 NG4C 02C.0118 the Secretary of lire Division of firaler Resources or ilia Dii*islon afpublic Heallh may require
,tubmtttal of Infurnrallan deemed necessary to make a decision an the variance, tray impose conditions as part of the
decision, and shall respond in uniting to the request within 30 days of receipt of tire variance request. A variance
applicant ►vha is dissatisfied ivith tire decision of the Dtreelor may conmience a contesled case by filing a petition as
described in G. S, I SOB-23 within 60 days after receipt of the decision
OW 22V Variance Request Form Rev 3-&2017 ll u 2

G. SUBMITTAL INSTRUCTIONS
(1) For the following types of water supply wells ga(v_:
(a) Private Drinking Water Wells under I SA 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 ofwells, please contact your regional environmental health specialist
by visiting-, {p:lfefts.nepubliehsahl com'contacts.httr�
Submit pne 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
(2) For the following; types ofwells wly:
(a) All Water Supply Wells under 15A NCAC 02C .0107 other than the ones listed under (1) above
(b) Welis Other than Water Supply under 15A NCAC 02C .0108. 1 f 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:
hltQ:�rdcq nc �ovrabout�divisio t•'w•sucr-resvurccs�+�ate-rssourGrs-nertnits+w� - cEt±ground
peat ect lonlground-wol er-applicnl ions
Submit one copy of the completed
variance application to the Division
or Water Resources Regional Office
serving the area in which the well
will be located:
Asheville Regional Office
2090 U.S. Highway 70
Swaananoa, NC 28778
Telephone: (828) 296A500
Fax: [phone]
Fayetteville Regional OMee
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]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1629
Telephone; (919) 791-420D
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: [phone]
Fax- [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional
Office
450 W. Hanes Mill Rd.
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
OW-22V Variance Request roan Rev. 3.6.2DI7 eaci 3