WS0701159_Application_20211025

RECEIVED/NCDENR/DWR
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY - AQUIFER PROTECTION SECTION OCT 12 2021
APPLICATION FOR PERMIT TO CONSTRUCT A WATER SUPPLY WELL OR WELL SYSTEM
(Wells or Well Systems with a Design Capacity of 100,000 Gallons Per Day or Greater) Water Quality
ction
PLEASE TYPE OR PRINT CLEARLY Washington Regional Office
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto.
/ f application is hereby made for a permit to construct water supply wells.
1.. Date: % ° d
2. County:
Applicant
Applicant's Mailing Address: a / 7
Applicant's Email Address. (if available):
4. Contact Person (if different than Applicant):
7.
8.
9.
Owner's Mailing Address:
Contact Person's Mailing Address:
,,�1 FOR OFFICE USE ONLY PERMIT
PERMIT NO. VvS°"-113 �'l51 ISSUED DATE: 105/Zv 2-
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- 1-e- Telephone: c2 L - . - (0 qe9 I
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Telephone:..�� CZ 3
to - Layn 6ezz.fn�i/� /116. a-7 9.--(
ontac Person's Email Address (if available): ll _ e Gam` )t is 11ir / s 6)121
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Property Owner (if different than Applicant): N td ri�.13. 1 +Liv+ r-q Telephone:
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Owner's Email Address (if available):
Property Physical Address (including zip code) and PIN Number: o2.sJ 7 Lam-C rZ I(r�L a i
Intended use of Well or Well System: V I) l G't v L t 0 ch) Pi.j (040V/Y T
(examples: irrigation, consumption, etc.). `t
Will the proposed water supply well or well system replace or be added to an existing well or well system? ("le e 5
(/fyes, complete questions 7 and 8) (If no, complete question 7 and then skip to question 9)
J
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Total design capacity of proposed well or well system in gallons per day (gpd): h f
If adding a well to an existing system, list the existing water supply wells in the existing system and their respective yields:
11. Is this a public well or well system? /1(9 If yes, give Public Water ID Number:
If yes, give Project( Engineer and contact information:f�,�
12. Well Contractor: M•b( i.- U)? �f /d"li{ei,u, �G' yf&'L'{ Well Contractor Certification No.: 2 /�—C14� 1%
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Well Contractor Address: .A� -1 Z _ - 1., I.? .cvC! d . n1� I r� . �V �a, r 7'/2)
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PROPOSED WELL CONSTRUCTION INFORMATION
1. As required by 15A NCAC 02C .0105(f)(7), attach a well
construction diagram of each well showing the following:
a.
b.
c.
d.
e.
f.
9.
Borehole and well diameter
Estimated well depth
Screen intervals
Sand/gravel pack intervals
Type of casing material and thickness
Grout horizons
Well head completion details
6. Estimated construction completion date:
.2. Number of wells to be constructed in unconsolidated
material:
1
3. Number of wells to be constructed in bedrock: (/)
4. Total number of wells to be constructed: !
(ado' answers from 2 and 3)
5. Estimated beginning construction date: 1/1/; F
//S !.; l
Continued on Reverse

ADDITIONAL INFORMATION
:.As required by 15A NCAC 02C .0105(0(5), attach a scaled map of the site showing the locations of the following:
• '._ �:. ^-.)Alt:property boundaries. at least one of which is referenced to a minimum of two landmarks suchas identified roads,
intersections; streams, or lakes within 500 feet of the proposed Well or well system.
Ali existing wells, identified by type of use, within 500.feet of the proposed well or well system.
The proposed well or'well system.
d. Any test borings. within 500 feet of proposed well or well system.
All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or Netr . storage areas. animal feedlots as defined in'G.S. 143-215.108(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well'system.
2. As required by 15A NCAC 02C .0105(g)(3), for wells screened in multiple zones or.aquifers, provide representative data on the
static water level, pH, specific conductance, and concentrations of sodium, potassium, calcium, magnesium, sulfate, ch loride,
and carbonates from each aquifer or zone from which water is proposed to be withdrawn,
3. Attach any wateruse permits (if required). [e.g. Central Coastal Plain Capacity Use Area Permit is required in 15' eastern- NC
counties by NC Division of Water Resources, visit: http://www.ncwater.org]
SIGNATURES
The Applicant herebyagrees that the proposed well(S) will be constructed in accordance with approved specifications and conditions of
the Water Supply Well Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina
Admi . istrative Code, Subchapter 2C) and accepts full responsibility for compliance with these rules
dr l' R f f '� • J'ide 1 :/i.ce l�Flt'' 9 j �rc e_ y f• y!.i r t
Sig!ateee r.Upplicant o gent title of Applicant or *Agent .J
Printed name of Applicant/or *Agent
* if signing as Agent, attach authorization agreement stating
that you have the authority to act as the Agent.
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the applicant to construct
water supply wells as outlined in this Water Supply Well Construction Permit application and that it shall be the responsibility of the
applicant to ensure that the water supply well(s) conform to the Well Construction Standards (Title 15A of the North Carolina
Administrative Code, Subs apter2C)y•
.
Signature of Property Owner (if different than Applicant)
Printed name of Property Owner (if different than Applicant)
•
DIRECTIONS
Please send the completed application to the appropriate Division of Water Quality's Aquifer Protection Section Regional Office:
Asheville Regional. Office
- 2090-U.S Highway 70 -
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
-- 3800-San rett Drive -
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Wilmington Regional Office
-i 27=Cardinat-Drive-ExtCnsion
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [phone]
Fax:. [phone]
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Bill Magette President
Office: 252-332-2265
Cell: 252-209-4676
[e-mail]
Fax: [phone]
October 6, 2021
1VIAGETl'E WELL
& PUMP COMPANY INC.
2342 US Hwy. 13 S. Ahoskie NC 27910
NCDENR
Washington Regional Office
943 Washington Square Mall
Washington NC 27889
RE: Jeffiennings Potato Farm
Deep Well Drilling Water Guaranteed
Jimmy Morris Supervisor
Office: 252-332-2265
Cell: 252-799-8403
[e-mail]
Fax: [phone]
well will have a minimum of 50' distance from other property line, streams or lakes
well that supplies their office and potato washer approximately 100' from proposed well
system will use one (1) well only
no test boring within 500'
no underground contamination septic tank is 300' ENE of proposed well site

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