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HomeMy WebLinkAboutWS0801069_Application_20220803NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES 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) PLEASE TYPE OR PRINT CLEARLY In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto, application is hereby made for a permit to construct water supply wells. 1. Date: (J �3 P- 2. 0 County: Columbus FOR OFFICE USE ONLY PERMIT NO. ISSUED DATE: Applicant Columbus Counry Telephone: 910-642-2828 Applicant's Mailing Address: 205 Lee Avenue, Whiteville NC 28472 Applicant's Email Address (if available); hnobledcolumbnam.arg 4. Contact Person (if different than Applicant): Contact Person's Mailing Address: Contac Person's Email Address (if available): Telephone: 0 Property Owner (if different than Applicant): Cnlnmhus nCounty Board of Telephone: 910-642-5168 Educatio Owner's Mailing Address: 817 idashington Street, Whiteville, NC 28472 Owners Email Address (if available): k=L5.0rolumbus k12.nc.us Property Physical Address g tt cluding'PIN Number): 40 Stallion Drive (PIN: 0155.00-64-1728.000) City: Tabor City County: Columbus Zip Code: 28463 7. Intended use of Well or Well System: !n (examples: Irrigation, consumption, etc.) ^� 8. Will the proposed water supply well or well system replace or be added to an existing well or well system? / VV (If yes, complete questions 7 and 8) (If no, complete question 7 and then skip to question 9) 9. Total design capacity of proposed well or well system in gallons per day (gpd): o25a1 a Dy 10. 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? _yt-5 If y/r F— ec l'is, give Public Water ID Number: " v � - o p b If yes, give Project Engineer and /coontact information: (s,e e -, r �j Y- . P -Q r, ,5- n A 12, Well Contractor: J0-A0,%ytayt amr On kA Well Contractor Certification No.: 3V6 Jr' A - IJrlll7ng 6e 90(0 Af , -F%1 A� F Ae��/ t p Well Contractor Address: c c ur wye'f�PVr ���! ✓vG cY0 .3 L'� PROPOSED WELL CONSTRUCTION INFORMATION t. As required by ISA NCAC 02C .0105(f)(7), attach a well construction diagram of each well showing the following: 2, No, of wells to be constructed in unconsolidated a. Borehole and well diameter material: I b. Estimated well depth 3. No. of wells to be constructed In bedrock: O C. Screen Intervals 4. Total No. of wells to be constructed: t d. Sand/gravel pack Intervals (add answers from 2 and 3) e. Type of casing material and thickness 5. Estimated beginning construction date: I. Grout horizons 6. Estimated construction completion dater g. Well Head completion details Continued on Reverse ADDITIONAL INFORMATION 1. As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following: a. All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads, Intersections, streams, or lakes within 500 feet of the proposed well or well system. b. All existing wells. Identified by type of use, within 500 feet of the proposed well or well system. C. The proposed well or well system. d. Any test borings within 500 feet of proposed well or well system. e. All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel storage areas, animal feedlots as defined In G.S. 143.215.106(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, chloride, and carbonates from each aquifer or zone from which water is proposed to be withdrawn. 3. Attach any water use 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: hfipJ/wvnv.ncwater.org) SIGNATURES The Applicant hereby agrees 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 16A of the North Carolina eAdministrative Code, Subchapter 2C) and accepts full responsibility for compliance with these rules X D �ublic ll-1-i1;+ies _J�)irec4-or Signature of Applicant or "Agent Title of Applicant or *Agent �NQY01d 1-loblesIFsigning asAgent, attach authorization agreement stating `Prinled name of Applicant or "Agent 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, Subchapter 2Ct(1. i mUZ M Signature of Property Owner (if different n Applicant) Printed name of Property Owner (if different than Applicant) DIRECTIONS Please send the completed application to the appropriate Division of Water Resources' Regional Office: Asheville Regional Office Raleigh Regional Office Wilmington Regional Office 2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405 Phone: (828) 296.4500 Phone: (919) 791-4200 Phone: (910) 796-7215 Fax: (828) 299-7043 Fax: (919) 571.4718 Fax: (910) 350-2004 Fayetteville Regional Office 225 Green Street, Suite 714 Fayetteville, NC 28301-5094 Phone: (910) 4333300 Fax: (910) 486-0707 Mooresville Regional Office 610 East Center Avenue Mooresville, NC 28115 Phone: (704) 663-1699 Fax: (704) 663-6040 Washington Regional Office 943 Washington Square Mall Washington, NC 27889 Phone: (252) 946.6481 Fax: (252) 975-3716 Winston-Salem Regional Office 450 W. Hanes Mill Road Suite 300 Winston-Salem, NC 27105 Phone: (336) 776.980D Fax: (336) 770-9897 GW-22W Rev. 3.1.2016