WV0800298_Application_20211208

North Carolina Department of Environmental Quality (DEQ) — Division of Water Resources (DWR)
VARIANCE APPLICATION FOR WELL CONSTRUCTION STANDARDS:
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.
PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C .0300
Print clearly or type information. Illegible submittals will be returned as incomplete.
DATE:
Existing permit number (if applicable) WI Issued Date: Exp. Date:
Permit No. for new projects (to be completed by DWR/DPH) WI
A. WELL OWNER(S) - For single family residences, list all persons appearing on property deed. For all others, list name
of the business/government agency and person and title with delegated signature authority:
�b h S 0 r km: Iy l'Gi r w�
61dt`rlys
2020
Mailing Address: S 5 Ja Jta r s
City: L; 1 (ot..--a( State: /' - Zip Code:X8i7('I County: Peek -de v
DayTeleNo.: 91 ci` ?-029ib
Ce11 No.:
EMAIL Address: r•ob jarri`50jot,.so..-Bursery:co.'.. Fax No.:
B. PHYSICAL LOCATION OF WELL SITE (1) Parcel Identification Number (PIN) of well site:33/7IIr`
" UO"71 -
County: P e Yt $ ,^
(2) Physical Address (if different than mailing address):
City: County: Zip Code:
C. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: -10yt n- 1 bY1 d{�
NC Well Drilling Contractor Certification No.: 3 V & 5 4
Company Name: D i $ (Np, 1 / U r I 1 i w� C Contact Person: liva;14-A-» Km en o„leGt
City: E(n.�e71-4-ev: 1I State: AA- Zip Code:?/1 County: L(4 b'r
Day Tele No.: q l I'( R 37 L/U Cell No.: C(/O es-0 7 S7
EMAIL Address: 5-4 re 1/4PIf6(0,,.. FaxNo.:
GW-22V Variance Request Form Rev. 7-13-2020 Page 1

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 (refences to attached documents are acceptable).
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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 vari. ce request such as a well construction diagram showing proposed
well liner or atypical construction mate '. s/methods.
F. SIGNATURE(S)
c(s) of Well/Property Owner(s)
rOQJiCJ, �phosor)
Print or Type Well/Property Owner(s)
Signature of Person Responsible for Well Construction
(Typically, the/hewell driller)
/Cot,kri. ► o A. L c`
Print or Type Name of Person Responsible for Well Construction
(Typically, the well driller)
Signature of County Environmental Health Specialist (for Private Water Wells)
Print or Type Full Name and Title of County Environmental Health Specialist (far Private Water Wells)
Per 15A NCAC 02C .0118 the Secretary of the Division of Water Resources or the Division ofPublic Health may require
submittal of infonnation deemed necessary to make a decision an 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.
GW-22V Variance Request Form Rev. 7-13-2020 Page 2