WV0800291_Application_20211007

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
A.
B.
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 watersupply wells not considered 'Private Drinking Mater Wells " and including irngation, industrial, and comnnerchd wells.
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
Including monitoring and recovery wells.
Print clearly or type information. Illegible submittals ivill be returned as incomplete.
DATE: / _ % 20 PERMIT NO.: VV "yp O 0M I to be completed by DWQ/DPH)
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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:
Eev-„4 .tAo * -06�k1 M d(Aa.
Mailing Address: (i ?-" /C V
City: State: b_ Zip Code AYO County: A/,Yr,�✓l
Day Tele No.: ro,2 �2 Cell No.:
EMAILAddress:r13G��'C".MSn/-GO�j Fax No.:
PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site:
County:
(2) Physical Address (if different than mailing address): 9 313 d /vlCke_ R—d-
City:
C. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: % O,u v
State: NC Zip Code: 2 8 PO 5�
NC Well Drilling Contractor Certification No.:. .j (p 5 6
Company Name: Qo As4 A) LcJ-e II OIL )I.t� Contact Person: %y J?nh-,� Sof
City: C�954/e 7Shyyuc+ State: ' Zip Code;2�a7 County:.yew .J,4-4, vex
Day Tele No.: �/ o 9 9 Cell No.:
EMAIL Address: C o,ufe.�er P 8 3 via A 00 .Gut Fax
Form OW-22V Page t Revised Febmary 2013

D. REASON FOR VARIANCE REQUEST -- Include type of well(s) to be constructed; rule for which die 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.
E. ATTACHMENTS — Provide the following information as attachments to this application:
(1) it map showing general location o1'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 diagiam showing proposed
well liner or atypical construction materials/methods.
F. SIGNATURE(S)
Print m•Type Well/Property Owner(s)
Sipuiature of Person Responsible for Well Construction
(Typically the well driller)
Print or Type Nambte for Well Construction
(Typically the well driller)
Signatnre of County Environmental Health Specialist
_...__.--------.._._�..�.-- ___�.��.._-------------`--
Print or —Type Full Name and Title of County Environmental Health Specialist
Per I SA NCAC 02C .0118 the Secrefory of the Divisiod of Water Resources or the Division afPublic Health mqv 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
doreribed in G.S. 15OB-23 within 60 clays after receipt ofthe decision.
GW-22V Variancs Request Form 12ev. 3-6-2017 Pa&u 2

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