WV0800263_Application_20200826

Fee Received CARTERET COUNTY BEALT11 DEPARTMENT
Check#%'1 or Cash 3820 Bridges St. Morehead City, NC 28557 Area ca
Date Received S D Phone: [phone] Fax: [phone] Priority=
Received Byr a APPLICATION Date Staked l0 taffhzitial,;
Well Construction Permit
IF INFORMATION IS FALSIFIED,
CHANGED OR a• • :� AUTHORIZATION •CONSTRUCT
PERMITSHALI • i t u• 1VALID FOR,0 MONTHS.
n IJ 596481 ii
PemRci�ucst Scctiiiii
TypeofWell..Pdvate Drinking Water Shared Drinking ,.,..Other
Type of Application: a New Construction Replacement Repair Abandonment
ProposedUse:..Y•- 01 111•..
•-ne
7
Name: First
Last
Mailing Address al a L.EAACY LAW U�
1. 40
Home• ` • • -
Applicant 7isame as owner: - ✓Yes
If no, complete this section and provide owners statement.
Name: First Tact_
Mailing Address
City State Zip
Phone: Home Work Mobile Fax
Parcel Address:a�tri ��a(.-t�
Subdivigion:.....EERITAGL Pb
Lot a Phase Section
•
ISile.S►lecific;Gifi �ii�il�il
Black
Type of Facility: _� Residential _ Multifamily
_Nou-Residential (desmbe
# of Acres �I�"O
Improvement Permitfor Wastewater System Issued: yes
,Applicant must inform Loral Health Department if any of the foIlowing apply. Check aIl that annly:
_,Existing well on property _buried Utility Lines _Right. of ways
_ Existing or proposed septic tank system ddidonal structures on property SN F E)
_Stump holes buried debris _Underground Fuel Tanks Easements 5EE ATTACN
99
,_Other patential sources of groundwaterpollutioa —list
_Current or pending groundwater restrictions -describe
Are there any variances associated with this application? _Yes .X..No
Additional Information:
au/i
N�
Any proposed development must be reviewed by the local jurisdiction for compliance with Ioca1 ordinances and regulations.
Additionally, you must consult with any site or federal agency with jarisdiction over the proposed develapmeni
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CARTERET COUNTY HEALTH DEPARTMENT
3820 Bridges St. Morehead City, NC 28557
Phone: Z52.728-8499 Fax: [phone]
APPLICATION
Private Drinking Water Well Anp&cation Disclosure
Carteret County Health Department can accept an application for a private drinking water well permit however a you are
proposing new construction and the facility is in a location served by Carteret County Water or any other public or
community water system, you may be required to connect to that system. It is strongly recommended that you contact the
water system serving the area of the proposed facility location prior to submitting the well application. Once a site visit
has been made the fee is not refundable. If the well is installed, and your location is served by a public or community
water system, you may still be required to connect to the system
I have read and undersan
tand the above di 1psmt:
R I . r t ppr A)c
11 h �A U LEI iJE "Address of proposed facility
� .Date
ContactInformatiom Atlantic Beach Water — 252-726-1366
Carteret County Water-252-728-4755
West Carteret Water Corp. —252393-1515 PineKnollShoresWcity-25226-6848 48x 1
x10
Bogue Banks Water-252-354-3307 Town of Morehead City —252-726 6
Town of Beaufort (Public Works) — 252428-7166
Carteret County public and community water systems are not limited to the above list
Replacement Well Applications
An application for a replacement well for drinking water will be accepted when the existing weIl no longer provides a
potable or adequate water supply and the well is proposed to be removed from service.
Upon approval of the installation of the replacement well, the existing well shall be removed from service and temporarily
abandoned by capping it off, per 15A NCAC 02C .0113(s) or permanently abandoned if the well is determined to be
improperly coustructed, located or a source of contamination of the groundwater supply. A well proposed to be
abandoned or required to be abandoned shall be filled, plugged, or sealed in such a manner as to prevent the well from
being a cbannel allowing the vertical movement of water and a source of contamination of the groundwater supply, per
15A NCAC 02C .0113(b) and a certified record of abandonment provided to the Carteret County Health Department and
the NCDEQIDWR witbin 30 days after the completion of the abandonment per 15A NCAC 02C .0114(b).
Failure to permanently abandon an existing well that is improperly constructed or improperly located will subject the well
owner to the following legal remedies; Injunction Relief [G.S. 130A-181, Administrative Penalties [G.S. 130A 22(c),
Suspension or Revocation of permits (03, 130-231 and Criminal Penalties [G.S.130-Z5].
Rev.11-1945
Page 3 of 3

ENVIROMENTAL HEALTH
3820 A BRIDGES ST
MOREHE, CITY,
IT , NC 28557
SALE
MID: 2590 Store: 4053 Term: 1102
REF#: 00000002
Batch #: 021 RRN:,021812fi0552fi
o8:39:34
08105120 CVC: N
Trans ID: 0805MCVCJ36UB
APPR CODE: 08044T Manual CNP
MASTERCARD 1••
AMOUNT $100.00
APPROVED
ACCOis FIT IINGt UT
ROAIICE 111NECARO AISSURNS
WHOM
(IIEACRANI AGREENERT IF CREDIT VGNCREAI
RETAIN 1111t Co' FORNSTAIENENI
VERITHANK YOU
MERCHANT COPY

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