WM0701151_Application_20201201

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NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY — DIVISION OF WATER RERCES
APPLICATION FOR PERMIT TO CONSTRUCT A WATER SUPPLY WELL OR WELL S�
(Wells or Well Systems with a Design Capacity of 100,000 Gallons Per Day or Gre;qt)Q
PLEASE TYPE OR PRINT CLEARLY ��h870 re�Q�
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulatint thereto,
application is hereby madam fnr o nnrmif in —ncrri int —nfcr co in niv 1-110 A:
1. Date:
2. County: Dare
Wo
FOR OFFICE USE ONLY ++ --c—
PERMIT NO. G &10116 I ISSUED DATE:
3. Applicant Dare County Water Department Telephone: [phone]
Applicant's Mailing Address: 600 Mustian Street, Kill Devil Hills, NC 27948
Applicant's Email Address (if available): pat. irwin(a)darenc.com
4. Contact Person (if different than Applicant): _ Patrick Irwin, Public Utility Director Telephone: [phone]
Contact Person's Mailing Address: 600 Mustian Street Kill Devil Hills NC 27948
Contact Person's Email Address (if available): Pat. irwin(a-)darene.com
5. Property Owner (if different than Applicant): N/A (Same as applicant) Telephone:
Owner's Mailing Address:
Owner's Email Address (if available):
6. Property Physical Address (including PIN Number): PIN #. 051619511312
City:Frisco County: Dare Zip Code:27936
7. Intended use of Well or Well System: Additional raw water capacity for water 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? Yes
(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):
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? Public If yes, give Public Water ID Number: Water System No.: NC 04-28-025; Serial
No. WSMP : 00-02089
If yes, give Project Engineer and contact information: Quible & Associates, PC; Cathleen M. Saunders, P.E.
PO Drawer 870, Kitty Hawk, NC 27949, [e-mail]
12. Well Contractor: Skipper's Well Drilling & Pump Service, Inc. Well Contractor Certification No.: 13769
Well Contractor Address: 107 Oakland Ave. Leland NC 28451-8487
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
Continued on Reverse
No. of wells to be constructed in unconsolidated
material: 3
No. of wells to be constructed in bedrock: 0
Total No. of wells to be constructed: 3
(add answers from 2 and 3)
Estimated beginning construction date: Fall 2020
Estimated construction completion date: Winter 2020
ADDITIONAL INFORMATION
35, Z3gq �516115

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1. 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
Dare Coun Water Public Utilities Director
Signature of Applicant or "Agent Title of Applicant or *Agent
Patrick Irwin
tf 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).
N/A (Same As Applicant)
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
3800 Barrett Drive
Wilmington, NC 28405
2090 U.S. Highway 70
Raleigh, NC 27609
Phone: [phone]
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Winston-Salem Regional Office
Washington Regional Office
450 W. Hanes Mill Road
Fayetteville Regional Office
943 Washington Square Mall
Suite 300
225 Green Street, Suite 714
Washington, NC 27889
Winston-Salem, NC 27105
Fayetteville, NC 28301-5094
Phone: [phone]
Phone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
GW-22W Rev. 3-1-2016
GW-22W (Rev. 7/11)