WM0100453_Application_20190610

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1 pate: 6/10/2019
2. County:. Haywood PVRMITNO tkDSQU4S"y ISSOEDOATEi
3 What type of Weil are you applying for?(madtodng-or recovery): Moni(odaa
4. AppllcanC First Citizens. Bank Telephone: 19 9-71Q:4189
Appllcan's Melling Address: 4300 SIX Forks Road... Ralalah North Carolina:27609
Applicant's Email Address (If available); AINaoASonntae allVsonsagntaagfltdtoltizenscom
8. contact .Person (Ifdigerdnt'than Applicant),;: James C. Bevers, PE ECS 6oulliedel 4,W Telephone:... 828,8683307
Contact Person's MallingAodress: 1900 Handersonyllla.Rtlat) Sulta 10 ASOsville WC:28803
ContactPerson's Email Address (if avallable), Iheveisfiecsllallledmom.
6, Property OWner(if di6arent than Applicant):% Tom Pinter. Telephone: 828v456-3993
Property .Owners Melling; Address: d78 Old Olvde,Raad,:WavaesvllleNonh Caroline:28706.
Property OWnere Email Address (If available):
7. Property Physical Address(Including PINNuplher) 111..Gld Clvdg,(foad:)?I 8827+205772 878rI1tWay PjN:8827.21-9010
9. Type offacllity or site fop which thewell(s) :shim) needed: residential& worship:.
(ex: non..4spherga facl(ilywaste dispossl slte landgll, D$T,.oto,)
10 Are there; anycurreptweterqualitypermilspr incidents associated With thisfacility or site? Ifso, list permit and/orincidentno(s).
.No
11. Type of contaminants beingmonitored or mcovered: VGCst SVOFra
(wn organics, nutrients, haRW matel% ate;)
12, Are them any existingwells, as, sociated With the proposed Wallis)? Ifyes,.howmany? No
Existing Monitoring or.Recovely Well'Constructlan pemiglNo(s).:. No.
13. Distance from prop, Deed well(a) to nearest known waste or pollution aoLpmQ,(ln feet): N!A
14. Are there any Watereupplywells loosted4Qss then 6004petfrom the,pmposed Wells)?. yes.
Ifyes, give dlslance(s): 6004hot
15. Well Contractor; JGD'llina Unification No.: 4328
Well Contractor Address: 124 PIsaah Rd. Eppley, South Colin 29642

PROPOSED WELL CONSTRUCYIONrINF'ORMATION
1. As required by IMNCAC.02C,0106(n(7)i affach a wellconstibollon dlegramof each well showing the following;
a. Borehole end well diameter e: Typaaf casing material and thickness
b:. Eatlmated well depth \ 4 Omut horizons
a: Screen Intervals 9 Well 4000 edmpla(loe details
d; Sendlgfavelpack lydervale
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Ndmporolwalla to be constructed In unconsolidated 1. HOW wi)I theWali(s)pa esourad2.
material: y4 _-exEanaioncao. temoorery
3. Numberofwellstapeconsfructed'.Inbedropk,. o. 6.. Estimated beginningconstruction date: 6124149.
4. Total Number of wale to be constructed:. 3 7. Ealtmated construction completion date: 6/24119
(add ensw'am from 2 and3) (Within 98 houm dt'ihptalldtion)
..-.. _ADDITIONAUNFORMAVONi
1. An required by 15A NCA0 020 .OseB(Q(B), aft.i asca tni map eftha atlashowing thg locations of the following
1,
c.
d.
a.
Printed Hama of Applioantor figeni
Sign ,oR.raparty©wner(if diff envman,Appllgsnla
SIGNATURES
TlflaofApp1lcant or Agent brlgAfl�
ffslgning attAgent affach autho0zadondgreamentstaf)ng
that yotrhaM the aoth5dty fo actea the Agent
T'•ary P+'la
Rr�`ldled Z-M ohProperlyQwner(ifdifferent than Applloant)

DI13EC7IONS-
Pleads serxi taeoodipleted application to the apptcprlete Oldslaniof Water Resources' Regional Oflidei..
Ashovllle'Re9lonal O(Otie
20g0 US, Highway 70
SWennehgo,NO 28778
Phone: [phone].
Fake (028):2994043
Fayetteville Regional Office
226. Green Sheet,Suite 714
Fayetteville, NO28301-3094
Phone: .[phone].
Fax:: [phone]
Mooresville Regional Office
610 East CenterAvenue
Mooresville, NO 28115
Phone: [phone]
Fax:. (704)663,6040.
Raleigh. Regional OlRce
3600.0a(rett0nve
R9ldlgh, NO 27609
Phone' (959)7g7.4200
Fax:[phone]
Washington Regional Offrde
943 WashingtahSquare lMall
.
Washington, NO 27889''
Phone; [phone]
Fax:. (262)076J718
Wilmington Regional:ORice
127 Cardinal.Otiva Extension:
Wllmindton, NO 28408
Phone: (910) 7,98�7215
Fax: (910}.36,0-2904
Winston4elem Regional Office
450'W, Hahee Mill Road
Suite 300
W Inslon-Salem,. NO 27105
Phone: ($88) 7.76-9800
Fax: [phone]
GW-22MR Rev, 4A-2016

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