WV0800290_Application_20210923 (2)

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.
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
Including monitoring and recovery wells.
Print clearly or type information. Illegible .cuhmittalc will he returned as incomplete.
DATE: /" of 1
, 20 z/ PERMIT NO.:
A. WELL OWNER — For single family residences list the property owner(s). For
organization, or government agency and person delegated signature authority:
,4l1cy
(to be completed by DWQ/DPH)
all others, list name of the business,
Mailing Address: (70Q tiSri- 04 k ..Ts I4nd c)
City: 3Ck T I44d State: /VC Zip Code: County: 3Ct.in,SCJiC k
Day Tele No.: of Sod -3, a - `7 7 act Ce11 No.:
EMAIL Address: . v ,Q 3 T f ,giv,a,1. (0M Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
(I) Parcel Identification Number (PIN) of well site:
County:
(2) Physical Address (if different than mailing address):
City:
C. WELL DRILLER INFORMATIOZ~i (if known)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.: V3 9 2 - A
Company Name: Ne ae " Li t I I(� 1 l ; Ai Contact Person:
City: 50 eel v State: Al( Zip Code: ag 9 ? County:
Day Tele No.: WO - 95— Cell No.:
State: NC Zip Code:
EMAIL Address: J) 00,3 t $'7 ezt yfrid I , (4i1 Fax No.:
Form GW-22V
lboyi
3r��s�s IC k
Page 1 Revised February 2013