The URL can be used to link to this page

Home My WebLink AboutWV0800301_Application_20220201NORTH 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 dearly or type information. Illegible submittals will be returned as incomplete. DATE: Jk.f L)(Lr , 20 D.g. PERMIT NO.: (to be completed by DWQ/DPH) A. 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: Mailing A•dr-ss: - c— 4-,,,.iz_ Or -- City: . , State: Zip Code:1Otounty: Day Tele No.: Ce11 No.: EMAIL Address: Fax No.: B. PHYSICAL LOCATION OF WELL SITE (1) Parcel Identific tion Numbe (PIN) of well site: County: eu 1 1 L101 (4C (2) Physical Address (if different than mailing address): City: , Vv‘ +� 1 � State: NC Zip Code: C. WELL DRILLER INFORMATION (if known) Well Drilling Contractor's Name: Cir\r,c-. NC Well Drilling Contractor Certification No.: 5-1-1<c A - Company Name: erc , . Contact Person: City: La /4-1,,) State: Zip Codg9B V?Sounty: Day Tele No.: `l 0 -(0011 DCO Cell No.: EMAIL Address: ric% eke �., r (i_vNo.: () r S-5crD Form GW-22V Page 1 Revised February 2013 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. �y1 C i` OA AnQ ilk—f— C)1/1 1(1 c'� v��j P h) Uvr bel-- 1 ? 14 S , 5 II I r m 1 ` 13 S_ /--Z��LA- 4) j1'(c' Fri) Ptri 4e_ ?okw.DA,1k04,1 c>as_ ),%is u -T-14 Loy \roilve'S �= u a-e) r e4)' c9t4Q. `Ass --)--Vk.P 04410 V.` kJ' Oe OA, 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 fmding 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 diagram showing proposed well liner or atypical construction materials/methods. F. OTHER MINIMUM CONSTRUCTION REQUIREMENTS For water supply wells, approval of a variance will require that additional construction requirements beyond those specified in 15A NCAC 02C .0107 be met. Minimum additional construction requirements for Coastal Plain and Piedmont and Mountain region wells are referenced on Attachments A and B on pages 4 and 5 of this application. Approval of a variance will not be considered in cases where the specified minimum additional construction requirements cannot be met. G. SIGNATURES Sig re of ' erso ' es y sible for We11 Construction (typically the well driller) Print or Type Full Name of Person Responsible for Well Construction (typically the well driller) Signature of County Environmental Health Specialist Print or Type Full Name of County Environmental Health Specialist Per 15A NCAC 02C .0118 the Secretary of the Division of Water Quality or the Division of Public Health may 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 described in G.S. 150E-23 within 60 days after receipt of the decision. Form GW-22V Page 2 Revised February 2013 NINE NO YUKI SASANQUA 7 DAYLILY CANJIRO SASANQUA CANJIRO SASANQUA 2 DWARF PODOCARPUS LIRIOPE 3 SOFT TOUCH HOLLY SOFT 3 SOFT PODOCARPUS EKKA SASANQUA 5 NANDINA UCH I -LOLLY TOUGH HOLLY OUCH HOLLY LIRIOPE �.: II PINE TO BE REI" LOVED G SOFT TOUCH HOLLY 3 DVIARF PODOCARPUS 3 THUJA X VIRGINIAN 0� - NEW,CONCRETE DRIVE NORTH STATE GARDENS, INC. 17015 US HWY 17 HAMPSTEAD, NC 28443 (910)443-4064 www.northstategardens.com HURCNILL DR PROPERTY LINE 1111. _ lest../...!.\ -sees. 111. u_•.wf-.w• •-fete-•••s!-.•..rpll•• .l••1....-•. . .' amesu• vs ••• • Off II ID • • el • • • • I I•1 • • I: .•••l.■•a••--• a . I. ` NI tut •.•.-set-�•w•l-sees.::■. \........\lf, \ 1as..--•••/-.all■-•l•■-••■•l •l••-•-.o Ifs::• Ia • • ■N.♦•N l� mil.• .� %1� ..\•••.•f /•-•-•■•• •-•l-•-•1./-.•-tin•• •••••-,-fain. •••-•-t••l• •••• •t••.-•••••, ••l-••.•-mil.•-••••tea•..-■ •!.-\•!•-•■.•-••••-.•••l•l•.l■ •,-)CC• C.eitIrii �w•i'91. .•-■•/.-l• •.-•\.•-•• 1,-\• ■t-I. V ■tin••l.-\\!•-••..••�•••••/\-\/.•� ■w ■-•!!l-••\line!!•-••.•—•!•l-.!r•-•f■■-.•`••••••••1•a./•a..l •••.l-•!• a el i•.-••••-•••tin■••••••••- MOM .-■•.•-••\•-•••e••�•t•,••1• •.1.•/•-...•l �••iir.\�� ••li�iu••••i• ii••.••••••••w•ius01••••1i••••■r1u...t-•-•w• , ••elf•.-•l...l•••-l•••-••••-l•••-••••-••••-••••••••••••,••••/•-••. RS•••iigi••ii�••ii••••i0ivai•\1•lYu•Miii.\i11=•�••i tSiaS�ii�i�ii� iuiNi . e S I.ie•a i�r.�.S•••0w IP nal <L 1,11■-ell\-el•■-,•l•-.•l■-••�••iii••••iinis•liiiiit� a• .••-•••••...:u.r•.-••l•-••• l•• •.-� �•?••l•evlM••••-t lt. ■••-.•l•-ta O••••••= l•-.•lf■ ti:= EOP PINE 0 BE REr LOVED tar'• ar . ' y., •? ,.1 ••••••� •o.v u.•-•.• Sallie •-•.•.-. sees. 1. •-iul•0••••u•-u•l.u•l.•u•—••••-.ql-f•.•-, .•\�.•/•-•wo.1•••1.•N. •.�-lw :.,.\./..■ll.-eu,-l•a•-•••t—••••••r•••1••.l-•■un••••-■l/l•r•)s i Ut'Utal-/-1 .-..•.-/..--sees-.•.--,..--....•,r..- f.--sees• sees-...- ■.........■......' ■.1 few-•f■l-••u-•••■.u•l•'••lu—u••-• ■■E••••—I.•l—•••••••••.•.O••.! ,...•.-. sees, a ,sees._tea WWII BE REMOVED 3 MINE NO YUKI SASANQUA 3 DWARF PODOCARPUS MAPLE 3 r'NE NO YUKI SASANQUA KANJIRO SASANQUA 4 DWARF PODOCARPUS 3 NANDNA 5 SN SI-I GASHIRA SASANQUA EPS AND BRICK WALK 4-1AG DWARF PODOCARPUE JAR riAPLE 3MINE NOYUKI SASANQUA ANQUA SN SN GASI4R 3 FIIENOYUKI SASANQUA 7 UGU`- TRUrI 'LITTLE GEri 5 AUGIJBA 5 TRANSPLANTED CAMELLIAS 1735 AZALEA DR - WL C 2021 Nort� W 7) St leX.