WV0800274_Application_20210317

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
WATER SUPPLY WELLS UNDER 15A NCAC 02C .0107
All water supply wells not considered "Private Drinking Water Wells" and including irrigation, industrial, and commercial wells.
DATE: Mar 15
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
Including monitoring and recovery wells.
Print clearly or type information. Illegible submittals will be returned as incomplete.
2021 PERMIT NO.:
be completed by DWQ/DPH)
A. WELL OWNER — For single family residences list the property owner(s). For all others, list name of the business,
organization, or government agency and person delegated signature authority:
Hyman Supply. LLC
c/o Jon Hyman
Mailing Address: PO Box 1035
City: Morehead City State: NC Zip Code: 28557 County: Carteret
Day Tele No.: 252-648-8556 Cell No.: 252-241-0802
EMAIL Address: [e-mail] Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
C.
(1) Parcel Identification Number (PIN) of well site: 6386.18.22.7150.000
County: Carteret
(2) Physical Address (if different than mailing address):
1804 Bridges Street
City: Morehead City State: NC Zip Code: 28557
WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.: _
Company Name:
City: State:
Day Tele No.:
EMAIL Address:
Contact Person:
Zip Code: County:
Cell No.:
Fax No..
Form GW-22V Page I Revised February 2013

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.
Irrigation well- variance request for:
1) 15A NCAC 02C .0107 (a)(2)(E): Proposed well location is less than 100' from the
sewer main located approximately 36' from the front property line
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 to 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 .0107 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 of Person Responsible for Well Construction (typically the well driller)
Print or Type Full Name of Person Responsible for Well Construction
(typically the well driller)
-,h I "I, �--- V�
Signature fcounty Environmental Health Specialist
Blakley C. Lyles, REHS
Print or Type Full 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. 150B-23 within 60 days after receipt of the decision.
Form GW-22V Page 2 Revised February 2013

H. SUBMITTAL INSTRUCTIONS
(1) For the following types of water supply wells only:
(2)
(a) Private Drinking Water Wells under 15A 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 of wells, please contact your regional environmental health
specialist by visiting: http://ehs.ncpublichealth.com/contacts.htm
Submit one 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
For the following types of wells only:
(a) All Water Supply Wells under 15A NCAC 02C .0107 other than the ones listed under (1) above
(b) Wells Other than Water Supply under 15A NCAC 02C .0108. If 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:
http://l2ortal.ncdenr.or web/wg/al2s/gwl2ro/12ermit-applications
Submit one copy of the completed
variance application to the Division
of Water Quality Regional Office
serving the area in which the well
will be located:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone: [phone]
Fax: [phone]
Fayetteville Regional Office
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 27699-1628
Telephone: [phone]
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
585 Waughtown Street
Winston-Salem, NC 27107-2241
Phone: [phone]
Fax: [phone]
Form GW-22V Page 3 Revised February 2013

COASTAL PLAIN
Minimum Additional Construcdon Requirements for Wallis Requiring a Variameoora. Permit to the Separatlon Waft nces In 1SA NCAC2C
.01-07(aX2) and .0107(n)(3) - A,pplicable to areas that are Underlain by Un corasotida$ed Sedimermis and Sedimentary Ttocks
POTENTIAL POLLUTION SOURCE MiNiMUIN SEPARATION DISTANCE (ft) i MINIMUM ADDITIONAL REQUIREMENTS
Standard I SlnEplo Pam kly I ansimg ago I crInsfing 22 th I Grout Da th
so He tank and drainfield
oith-or subsurface ground absorption wasto
als osal tern
otner sewage and liquid -Waste collection or
facility
cesspools and privics
animal feedlots or manure pilas
Surfacowatar GW rocha a __. adc, lake
othcr surface orator bodhes...crooks rive
100
s0
30
100
100
100
100
100
s0
100
100
50
so
SITE SPECIFIC
26
25
watertight sewage or liquid -waste
50 28
coltoctionortransforfacili
animal darns 100 50 SITE SPECIFIO
1bui9dingfoundataon oacludin well kaccsc 25 23
sarsitary landfills
ohcm ical or pc trolcu m fact undcrground
storages tanKs rogulatod under I5A NCAC
2N with seconds containment
c etm ca ar parrs eum uel unciargroun
storagetanks regulated under 15A NCAC
s o 8 e t
D.I. cased PVC may be required
Attachment A (Form GW-221')
100 1 100
100 100
SITEISOURCE
100 100 SIPSCIFIC
00 s0
50 50
PVC
>20 feet below land To the ffirst sagniaieamt
surface or as specified clay greater than 20 feet
by the Director below land surface -orto
the source aquifer
PVC'
SITE/SOURCE SPECIFIC
500 500
30 50
DO NOT ISSU E
100 100
15A N-CAC ZC .0107(d)(4)(1B), .0107(e)(1)(.-i), and 2C .0116 pro,*Ide for the ability to construct a well to a depth of less; than 20 feet where the best
source of water existsbetween a depth of ten and twouty feet below the surface of the land_. Bec.ause additional minimum construction requirements
necessitate that: 1) casing extend to a depth greater than 20 feet beI'ow land surface: and 2) grout extend to thke first significant claT layer greater than
20- feet below Lord surface or to the source aquifer, a variance to horizontal separation distances for shallow -sells cased to less than 20 feet is not feasible.
RVell construction in form.-ition :should be proidde-d -with the Application for Permit for Variance detailing how minimum additional construction
requirements m1H be satisfied.
Form GW-22V Page 4 Revised February 2013

PIEDMONT" AND MOUNTAINS
Minimum Additional Construction Requirements for Wells Requiring a Variance or a Permit to the Separation Distances in 16A NCAC 2C
.0107(a)(2) and .0107(a)(0)-Appllcable to areas that are Underlain by Crystalline Sedro-ek
POTENTIAL PQLL4ITION SOURCEMINIMUM1 SEPARATIOW IDISTANCE MINIMUM ADDITIONAL REQUIREMENTS
Standard I Sin ale Family Variance I I Casing Type I Casing Depth 1 GratatOe h
septic tank and drainfleld
other subsurface ground absorption waste
disposal system
other sewage and liquid -waste collection or
transfrarfaedh
cesspools and rlvdes
animal feedlots or manure Eilee
Surtisce wrate W recha a ... ponds, lake
other surface AYater tirades... creeks, river
water tight saviage orr liquid -waste
collection or transfer facilipj
anlmal hams
building foundationstexcluding well house
farrtil ixor, postic id e, h Arlbicido or other
them@cal store a areas
other non-hazartdaus solid waste landfill
non -hazardous waste storage. tmatmentor
die asallagoons
Industrialimunicipal sludge -spreading or
wastewater-irriciatfan site
abovegrowrad or underground heating oil
storage tanks
all other potential sources of g roundw,ater
,contamination
aanita,ry Ian dfi I I s
chemlcal-or petrolt:umfuel underground
storage tanks regulated under 15A NCAC
2NWit2h secondaEM conitaintment
chew®calor petroleum fuel underground
storage tames regulated under 15A NCAC
2N w10 seconclaily containment
100
50
50
1ao
100
100
ion
100
so
100
1 100
W
50 ]SITE
SPECIFIC
25
25
50
25
SITE SPECIFIC
100
gp
25
26
adrock depth Is <50 frost:
deft of 15 feet into bedrock or
below lanai surface
GALVANIZED If "draeK depth is 50.1100 fret 1 fall length
STEEL feet intolmdra* I ofcaaingt
If bedrock depth is }%0- feet 5 fee
into tbodrock
IvG pr The greater of 40 fact below Hand full length
GALVANIZED surface or 5 feed into bedrocK of Casing'
STEEL
IOU
100
SITOSCURCE
SPECI FCC
SITEMOURCE SIPECIFM
Ilan
100
100
100
100
100
50
50
50
so
rA drill bit with a diameter Ihmt is at least Ira grealer thcrr the diamieter of lho caang must be used to drill the cased pertim of the well. Groul should be installed under pressure.
In stallatiar using a tremrac pipe Is acceptable If the space to be grouted Is free of olastrucua
Aftiachmemt $ (Form Girl'=22Y)
Form GW-22V Page 5 Revised February 2013

Carteret County, N.C.
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March 15, 2021
The information displayed by this website is prepared for the inventory of real property found within this jurisdiction and is compiled from recorded deeds, plats, and other public records and data. Users of this information are hereby notified that the aforementioned public primaryinformation
sDurces should be consulted forverification of the information contained on this site. Carteret County assumes no legal responsibility for the information contained on this site. Carteret County does not guarantee that the data and map services will be available to users without interruption
or error. Furthermore. Carteret County may modifv or remove mao services and access methods at will.

3/15/2021
WPDT Report
Area of Interest (AOI) Information
Area : 3,134,508.8 ftz
Mar 15 2021 10:50:03 Eastern Daylight Time
Known Releases of Ccntanvnation
Dry Cleaning Solvent Cleanup Sites
QAbove Ground Petroleum Incidents
Underground Tanklnicidents
Parcels (Polygons) - Parcels
Ilan -System Roads
— Federal Route
— Non -System
Other System Reacs
— Ramps, Rest Areas, Ncn-Mainline
— Projected Route
t9,02a
0 0.05 0.1 0.2 mi
0 0.1 0.2 DA km
!:COOT VS V O, Esl, NASA, N-Vk UY'. FEW, Erl Ct 11W& i[y ,\LJs
(k:rvntnx—, .:.rxret C —ty, M— & NC,h ;::r�i�. i 1;71,
Gmnr.v, Sc,4: ,,i,, tNCRiWNT P. L 3GS. CPA_ NPS. US
,.Y(YGJ. tiJrC1J, US.JA
Mi

3/15/2021
Known Releases of Contamination
#
Site ID
Site Name
Site Type
Data Current As Of
Count
1
DC160002
Sunshine Cleaners
Dry Cleaning Solvent
Cleanup Sites
12/11/2019
1
2
5797
UTS BEAUFORT
Underground Tank
12/18/2019
1
CENTRAL OFFICE
Inicidents
3
32947
BRIDGES STREET-1600
Underground Tank
12/18/2019
1
Inicidents
All North Carolina Department of Environmental Quality (NCDEQ) GIS data is expressly provided "AS IS" and "WITH ALL FAULTS". The
NCDEQ makes no warranty of any kind, express or implied, concerning this information, including but not limited to any warranties of
merchantability or witness for any particular purpose. The NCDEQ assumes no responsibility or legal liability concerning the Data's accuracy,
reliability, completeness, timeliness, or usefulness. The data is not intended to constitute advice nor is it to be used as a substitute for specific
advice from a professional. Users should not act (or refrain from acting) based upon information in the Data without independently verifying
the information and obtaining any necessary professional advice. Users are solely responsible for ensuring the accuracy, currency and other
qualities of any products derived from or in connection with the NCDEQ's Data. The Data is collected from various sources and may be
modified over time without notice to improve spatial andattribute accuracy. The NCDEQ disclaims responsibility for the spatial accuracy and
attribution of GIS features and makes no warranty concerning same.
2/2

Superfund Section
Description of Dataset
The Superfund Section investigates, prioritizes, monitors and remediates uncontrolled and unregulated hazardous
substances and waste disposal sites. The Superfund Section's data presented here is tracked under program areas:
The Inactive Hazardous Sites Branch, Dry -Cleaning Solvent Cleanup Act Program and Federal Remediation Branch.
The Inactive Hazardous Sites Branch is responsible for oversight and approval of the assessment and remediation
of hazardous substances contaminated sites. This includes historical and recent accidental releases of hazardous
substances and pollutants, but excludes discharges associated with DEQ permits, agricultural operations,
petroleum releases and sites covered by the other Branches in the Section.
The Dry -Cleaning Solvent Cleanup Act Program's responsibilities include administration and oversight of the
assessment and cleanup of certified dry-cleaning solvent contaminated sites; and conducting compliance
inspections and enforcement actions to ensure that active dry-cleaning facilities and wholesale distribution
facilities are compliant with applicable regulations.
The Federal Remediation Branch works cooperatively with the US EPA to implement the federal Superfund
program under the Comprehensive Environmental Response Compensation and Liability Act of 1980 (CERCLA). The
section helps US EPA apply their resources on sites with the most severe contamination and on those needing
immediate emergency actions, while working to identify those fewsites where federal enforcement authority will
be appropriate.
For more in depth information about the Superfund Section and its programs, please visit their website at
http://deg.nc.gov/about/divisions/waste-management/superfund-section
All of the sites are on the Superfund Section's inventory due to the high likelihood of contamination being present
at the site.
Contaminants potentially present
Superfund Section Sampling Recommendations:
• Volatile Organic Compounds
• Semi -Volatile Organic Compounds
• Hazardous Substance List Metals
• Herbicides and Pesticides
Contact Information
To request additional information related to sites that are managed by the Superfund Section please contact the
following Branch Managers:
Inactive Hazardous Sites Branch: Charlotte Jesneck at 919-707-8327 or [e-mail]
Dry -Cleaning Solvent Cleanup Act Program: Peter Doorn at 919-707-8369 or [e-mail]
Federal Remediation Branch: Qu Qi at 919-707-8325 [e-mail]

UST Section
Descriotion of Dataset
The Underground Storage Tank (UST) Section's data presented here is representative of two different
programs within the Section; the UST program and the Aboveground Storage Tank/Non-UST (AST)
program. While the UST data specifically relates to UST systems, the AST data may be related to a
variety of release sources, i.e. AST systems, fuel tanker spills, illegal dumping, etc. Whereas, the UST
data is specific to releases of regulated substances from USTs. All UST Section features presented in this
tool represent locations where the latest reports document confirmed or assumed exceedance(s) of the
NC Groundwater Quality Standard and/or the Soil -to -Groundwater Maximum Soil Contaminant
Concentrations (MSCCs).
Contaminants Potentially Present
UST and AST Program Sampling Recommendations:
• Volatile Organic Compounds
• Semivolatile Organic Compounds
• Metals (Cr and Pb)
Contact Information
To request additional information from the UST Section please contact the NCDEQ Regional Office
assigned to the area of interest and ask to speak with a member of the UST Section. A map of the UST
Section's Regional Office coverage areas and phone numbers can be viewed by following this link. The
UST Section's Regional Office contact information is also presented below.
UST Section - Regional Office Contact Information
Asheville (ARO) — 2090 US Highway 70, Swannanoa, NC 28778 [phone]
Fayetteville (FAY) — 225 Green Street, Suite 714, Systel Building, Fayetteville, NC 28301(910) 433-3300
Mooresville (MOR) — 610 East Center Avenue, Suite 301, Mooresville, NC 28115 [phone]
Raleigh (RRO) —1628 Mail Service Center, Raleigh, NC 27699 [phone]
Washington (WAS) — 943 Washington Square Mall, Washington, NC 27889 [phone]
Wilmington (WIL) —127 Cardinal Drive Extension, Wilmington, NC 28405 [phone]
Winston-Salem (WS) —450 West Hanes Mill Road, Suite 300, Winston-Salem, NC 27105, [phone]
Guilford County Environmental Health, 400 West Market Street, Suite 300, Greensboro, NC 27401, [phone]

CARTERET COUNTY HEALTH DEPARTMENT
EVIRONMENTAL HEALTH
ON -SITE WATER PROTECTION
CDP #: 35 Z 1 DI
SITE EVALUATION
for WATER WELL
OWNER: �� `I(rYt�✓v� S�1'a �y
ADDRESS:
LOCATION OF SITE: q- o � (' G T 03C
PROPOSED FACILITY: ktI A PROPERTY SIZE:
TIME OF VISIT
DATE EVALUATED: Z 23 21
3 1", (Zi
TYPE WELL: ❑ Individual Drinking Water ❑ Shared Drinking Water irrigation ❑ Geothermal (siting confirmation only)
4N, ew Well ❑ Replacement Well ❑ Repair (as specified by certified well driller)
TYPE OF WASTEWATER: ❑ Onsite Septic _installed not installed Municipal or Community Sewer
EVALUATED BY:� Ly
OTHER(S) PRESENT:
COMMENTS:
Show profile locations and other site features (dimensions, reference or benchmark, and North).
ITJ
e
5Um ,fit �
Cam. CA \ ��
C Lh L ( Ii��
to �1-
41
L?

lop Cbv kk
Fee Received CARTERET COUNTY HEALTH DEPARTMENT
Check# P,l' , or Cash 3820 Bridges St. Morehead City, NC 28557 Area q�
Date Received 1-' 11' 74 Phone: [phone] Fax: [phone]/Li Priority 2_
Received By: APPLICATION Date Staked Staff hritial1) W
Well Construction Permit Pr owv\Q�
IF INFORMATION IS FALSEFIED, CHANGED OR SITE IS ALTERED, THE AUTHORIZATION TO CONSTRUCT
PERMIT SHALL BECOME INVALID. PERMIT IS VALID FOR 60 MONTHS.
Parcel ID: 6 2463 a8,}1 000b
Type of Well: Private Drinking Water Shared Drinking Water Irrigation Other
Type of Application: ✓ New Construction Replacement Repair _ Abandonment
Proposed Use: Residential ✓ Commercial (Design Capacity < 100,000gpd)
Owner
Name: First LLC Last C I a Jo ^ 'i V mav'\
Mailing Address
City MocCtr+Qra, State NC Zip__a5iS5:1: _
Phone: Home WorkMobile a57t^)ILO%Oa Fax
Email Koinnc A Con Organization
Applicant If same as owner: zyes
If no, complete this section and provide owners statement,
Name: First Last
Mailing Address
City State
Phone; Home Work
�p—
Mobile Q%44I-0B004\ Fan
Email Organization
Pazcel Address:
Subdivision:
Lot �_ Phase _ Section Block # of Acres • , 3}
Type'of Facility: _Residential _Multifamily
✓Non -Residential (describe l_e�- )
Improvement Permit for Wastewater System Issued: _yes _ no ZN/A
Applicant must inform Local Health Department if any of the following apply. Check all that apply:
_ Existing well on property Buried Utility Lines _Right of ways
_ Existing or proposed septic tank system _Additional structures on property
_ Stump holes/buried debris _Underground Fuel Tanks v Easements
_Other potential sources of groundwater pollution — list
_Current or pending groundwater restrictions -describe
Are there any variances associated with this application? Yes No
Additional Information:
Any proposed development must be
reviewed
by the local jurisdiction for compliance
with local ordinances and regulations.
Additionally, you must consult with
any state
or federal agency with jurisdiction over
the proposed development.
Page l of 3

CARTERET COUNTY HEALTH DEPARTMENT
3820 Bridges St. Morehead City, NC 28557
Phone: [phone] Fax: [phone]
APPLICATION
Well Construction Permit
Owner Nymc,,N�arcelID: i
Site Sketch: Provide an accurate diagram of property with dimensions, proposed or existing building locations) with
setbacks to two property lines, proposed or existing wastewater system location, existing and/or proposed water source
location, potential sources of contamination, driveways and any other characteristics or activities on the property or
adiacent nrnnerty that wild impact eroundwater duality or suitability of the site for well construction.
(Initial) Property is staked ' ;'�`� Applicant will call when property is staked
A re -inspection fee of $30 is rdquired if the lot is not accessible and/or staked.
Application will be returned after sixty (60) days if Carteret County Environmental Health has not been notified that site
is staked and accessible. Fees paid for application are forfeited when application is returned to applicant or agent.
The site evaluation is performed based on the information contained in this application. Any changes to the site or
structure ►ocations, the property lines, proposed or existing waste water system location shall because to revoke the Well
Permit. I have read this application and certify the information provided herein is true, complete and correct.
Authorized county and state officials are granted right of entry to conduct necessary inspections to determine compliance
with applicable laws and rules. 1 understand that 1 am solely responsible far the proper identification and staking of all
property lines a/t rs and making the site accessible so a complete site evaluation� ! can be performed.
Property owner's signature or authorized agent (REQUIRED) Date
Page 2 of 3

CARTERET COUNTY HEALTH DEPARTMENT
3820 Bridges St. Morehead City, NC 28557
Phone: [phone] Fax: [phone]
APPLICATION
Private Drinkina Water Well Application Disclosure
Carteret County Health Department can accept an application for a private drinking water well permit however if 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.
[ have read ankd understand the above disclosure:
Signature
tY 0
iE F >� < + r + -Address of proposed facility
Contact Information:
Carteret County Water-252-728.4755 Atlantic Beach Water-252-726-1366
West Carteret Water Corp. - 252-393A515 Pine Knoll Shores Water - 252-2474353 x 10
Bogue Banks Water - 252-354-3307 Town of Morehead City - 252-726-6848 x 1
Town of Beaufort (Public Works) - 252-728-7166
Carteret County public and community water systems are not limited to the above list.
Replacement Weii Apniications
An application for a replacement well for drinking water will be accepted when the existing well 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(a) or permanently abandoned if the well is determined to be
improperly constructed, 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 channel allowing the vertical movement of water and a source of contamination of the groundwater supply, per
15A NCAC 02C .01 13(b) and a certified record of abandonment provided to the Carteret County Health Department and
the NCDEQ/DWR within 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. 130A48], Administrative Penalties [G.S. 130A-22(c),
Suspension or Revocation of permits [G.S. 130-23] and Criminal Penalties [G.S.130-25].
Rev.
ll-19-15
Page 3 of 3

CARTERET COUNTY HEALTH DEPARTMENT
Environmental Health Division
3820 A Bridges Street
Morehead City, NC 28557
Phone [phone] Fax [phone]
OWNER'S STATEMENT
TO: The Environmental Health Division
SUBJECT: Authorization for Representation as Agent for Owner and Permission to Access Property
r , (ri t ,hereby authorize % : i': f v , i `r Ii { {' nnt) to act
as my agent in the ptocess of application for an on -site wastewater system permit or a water well
permit for the property listed below:
(Real Estate Agents or other agents contracted to act as property representatives shall provide a copy
of the signed contract verifying owner has acknowledged their representation of below property).
x
Location: ` PIDN# 6 3UIUaII500Z
In addition to the above, the Environmental Health Division has my permission to access the above
listed property.
Should you need additional information, please contact:
Owner's
Address:
City State: Zip: {J !

fL
ENVIRO A B%DGESAS28551
3820 A CITY, NO
•MOREHE 252�728.8550
1
SALE 1102
Store: 4053 Term,
M�
2590 REF a4810960a A9
RRN: 14•,35:23
Batch 1<: 018 tit,
021,7121
Trans ID: 461048705230199
APPR CODE: 523870 Manual GNP
\j1SA **«*8485
$A00.00
AMOUNT
APPROVED
THPNK VOU
CUSTOMER COPS

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