WV0800275_Application_20210317

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION STANDARD50
PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C AM
WATER SUPPLY WELLS UNDER 15A NCAC AI
All water supply wells not considered "Private Drinking Rater Wells " and including g
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
Including monitoring and recoven welh
Print clearly or type information. Illegible submittals »ill be returned as incomplete-
DATE: / I /2 20_ PERMIT NO.:
A. WELL OWNER — For single family residences list the property owner(s). For all others_ hst name of thebGSMCSL
organization, or government agency and person delegated signature authont%
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Mailing Address: 11 Sr(6 n5 *V Rrobi
City: W i I Mi rh Fug State: NL
Zip Code 1 i
Day Tele No.:
EMAILAddress: ` yr+li R'ce^
PHYSICAL LOCATION OF WELL SITE
(I) Parcel Identification Number (PIN) of well site:
County: Nev' 4 "yr e./—
(2) Physical Address (if different than mailing address):
City: "
WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
County: �= "
CetiNo.: �/C-
Far No-:
Ame QS e4c �-e.
State: NC Zip Code:
ett Crti3O)Er'
,to -�—A
Company Name: Cc. pe_ Fcek Qr j l ro g S<r -'1 *4eontact Petsen:
City: [� ^ uQ� v� State: N'C_ Zip Code: T tL5 Count\
Day Tele No.: ! I v Z S g L5 2 Cell No.:
EMAIL Address: Ct C wp7ez - ^11 Fax No.: %
Form OW-22V
Pap 1 C.c\- %zct Fdxrar\ 2111 i

D. REASON FOR VARIANCE REQUEST - Include type of well(s) to be constructed- rule for wiztzli *CMONO= a
being requested: description of how the alternate construction Hill not endanger human heater" tine Mid fit
em ironment. and reason %%hv construction and/or operation in accordance with the �°d� a n''' t rrr't `
and,lor provides equal or better protection of the groundwater
Le, e Tho^ (DO �t 4of sc.n I fa Mr�t� {-�cjC
E. ATTACHMENTS - Promi tde the follovving information as attachments to this appitcatror:
t 1) map showing genertl location of the propert\ (including road names. SC Stair Rain:: ^'a"" —
am key landmarks. etc) sufficient for finding the well location.
(2) Detailod site map t%ith scale showing location of proposed Well rcleyam to sepw nuCm =- nuiidms
foundations. propertii Imes, water bodies. potential sources of contammanon other welts.
t :1 Submit a copy of the local well permit application and site ccaluation map (tf appltairr; :
14) An\ other information releN ant to the \ariance request such as a Well con_svucts n dutp- stt �umz p*on +-
t�ell liner or atypical construction materials/methods.
F. OTHER MINIMUM CONSTRUCTION REQUIREMENTS
For eater supph wells. approval of a yarianec will require that additional conctruzrtor. =ur.wn=rrm tr'or.
specttied in I5A NCAC 02C .0107 be met Minimum additional construction rcqurrcments in- ;-mwm "tau tit.
Piedmont and Mountain region \%ells arc referenced on Attachments A and B on pages 4 arc ` a ants atuut a:
Appm\al of a Nanance stiill not be considered in cases \Nhcrc the spe.ufied mmrmua eac
requirements cannot be met
G. SIGNATURES
Sipature of Person Rmpomihic for Well ConstrLCrinn (hpcWh dowJt fie"
Print or Tvpc Full Name of Person Re%rxin.ihic Gir w cll t .in.;
Ihpicalh the well dnikn
Sgtnaturc of ( ounty Fin tronmental liraltl!
Print or T.� pc Full \arts, of ( aunts Fnt troon"tal FlnIe - Sjr.�Mh.
Per ISA NCAC 0:C 0/ IR fhe .Secrelan' ofth<° 1)1ivstrnt of R`alltr or Shr 11r+
j am
suhtxrftal ojrnf<>rmalron deemed neeY.curn' to make a d{exttidMe pe C.ax
decision mud .shall reslxmd rn w rrtrne to the ngeeacf rrsli�ae jt? �� 40 MW qrso
QM11canr who is dlssatt.cfied with fhe decr.gon of zlit &p*Clar •a0JMMMM
described to G.S. I50B-23 wrfhrn 6t) A." after rrrer � � l 4F
M of � lncer�oa
Fan OW.22V
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