WV0800318_Application_20220926

North Carolina Department of Environmental Quality (DEQ) — Division of Water Resources (DWR)
VARIANCE APPLICATION FOR 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.
DATE: Sept. 22
Print clearly or type information. Illegible submittals will be returned as incomplete.
, 20 22_ PERMIT NO.: (to be completed by DWR/DPH)
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:
Queens Court HOA
Mailing Address: 9100 Reed Dr.,
City: Emerald Isle
State: NC Zip Code: 285 ALI County: Carteret
Day Tele No.: 919-796-1887 Cell No.:
EMAIL Address: [e-mail] Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 5383.10.45.0624
County: Carteret
(2) Physical Address (if different than mailing address):
City: County: Zip Code:
C. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name: Contact Person:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
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.
GW-22V Variance Request Form Rev. 3-6-2017 Page 1

Irrigation well to be drilled so that it maintains 50' from sewer lines requires it to be located less
than 25' from building foundations. Rule 15A NCAC 02C .0107(M)
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 variance request such as a well construction diagram showing proposed
well liner or atypical construction materials/methods.
F. SIGNATURE(S)
Signature(s) of Well/Property Owner(s)
Print or Type Well/Property Owner(s)
Signature of Person Responsible for Well Construction
(Typically the well driller)
Print or Type Name of Person Responsible for Well Construction
(Typically the well driller)
( 9/7, 21,5/4 �L,
Sign ure of County Environmental Health Specialist
Amy H. Guthrie Environmental Health Supervisor
Print or Type Full Name and Title of County Environmental Health Specialist
Per 15A NCAC 02C .0118 the Secretary of the Division of Water Resources 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. 150B-23 within 60 days after receipt of the decision.
G. SUBMITTAL INSTRUCTIONS
(1) For the following types of water supply wells only:
(a) Private Drinking Water Wells under 15A NCAC 02C .0300
(b) Irrigation Wells underl5A NCAC .02C .0107 with a designed capacity of less than 100,000 gallons per day
and located on the same property as an on -site wastewater system permitted by a local health department.
Prior to submittal of the variance for these types of wells, please contact your regional environmental health specialist
by visiting: http://ehs.ncpublichealth.com/contacts.htm
Submit one copy of the completed variance application to:
GW-22V Variance Request Form Rev: 3-6-2017 Page 2

Irrigation well to be drilled so that it maintains 50' from sewer lines requires it to be located less
than 25' from building foundations. Rule 15A NCAC 02C .0107(1VP
E. ATTACHMENTS —Provide the following information as attachthents 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 variance request such as a well construction diagram showing proposed
well liner or atypical construction materials/methods.
F. SIGNATURE(S)
) L H61
Sig a / re(s) of Well/Property Owner(s)
T-b b\41L
Print or Type WeH/Property Owner(s)
hrAidL4-
Signature of Person Responsible for Well Construction
(Typically the well driller)
Print or Type Name of Person Responsible for Well Construction
(Typically the well driller)
Sign ure of County Environmental Health Specialist
Amy H. Guthrie Environmental Health Supervisor
Print or Type Full Name and Title of County Environmental Health Specialist
Per ISA NCAC 02C .0118 the Secretary of the Division of Water Resources 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. 150B-23 within 60 days after receipt of the decision.
G. SUBMITTAL INSTRUCTIONS
(1) For the following types of water supply wells only:
(a)
(b)
Private Drinking Water Wells under 15A NCAC 02C .0300
Irrigation Wells underl5A NCAC .02C .0107 with a designed capacity of less than 100,000 gallons per day
and located on the same property as an on -site wastewater system permitted by a local health department.
Prior to submittal of the variance forthese types of wells, please contact your regional environmental health specialist
by visiting: http://ehs.ncpublichealth.com/contacts.htm
Submit one copy of the completed variance application to:
GW-22V Variance Request Form Rev: 3-6-2017 Page 2

North Carolina Department of Health and Human Services
Division of Public Health — Environmental Health Section
On -Site Water Protection Branch
1632 Mail Service Center
Raleigh, North Carolina 27699-1632
(2) For the following types of wells only:
(a)
(b)
All Water Supply Wells under 15A NCAC 02C .0107 other than the ones listed under (1) above
Wells Other than Water Supply under 15A NCAC 02C .0108. If these wells are to be constructed on property
not owned by the well owner or applicant, please also attach and submit a completed Application to Construct
a Monitoring or Recovery Well System (GW-22MR) found on our website at:
http://deq.nc. gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-applications
Submit one copy of the completed
variance application to the Division
of Water Resources Regional Office
serving the area in which the well
will be located:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue,
Suite 301
Mooresville, NC 28115
Telephone: [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional
Office
450 W. Hanes Mill Rd.
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22V Variance Request Form Rev. 3-6-2017
Page 3

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Tax Parcel Information:
Carteret County, N . C .
Owner: QUEENS COURT HOMEOWNERS ASSOCI
Current PIN: 53831045062400o
Site Address:
0
Mailing Address:
MOREHEAD CITY NC 28557
Legal Description:
COMMON AREA PH3 QUEENS COURT
Prior PIN: 15o35Bo158
City Limits: EMERALD ISLE
Rescue District:
Fire District:
Tax District: 1556
Township: WHITE OAK
Use: COMMON AREA
Land Value:
Bldg Value:
Other Value:
Total Value:
Sale Price:
Deeded Acres: o
Plat Ref: /
Deed Ref:.
Bedrooms:
NBHD: 900016
Bldg Htd Sq Ft:
Bldg Tot Sq Ft: o
Year Built:
Noise Level:
AICUZ Zone:
GIS Acres: 0.521
Roll Type: R
Deed Date: o
Bathrooms:
yL:itr .BI !Bi UEF:
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Printed September 22, 2022
•
The i,formation displayed by this webste is prepared for the hventory of real property found within this jurisdiction and is compiled from recorded deeds, plats, and other public records and data. Users of this i,formationare hereby notified that the aforementioned public primary
i,formation sources should be consulted for verification of the hformatbn contained on this site. Carteret County assumes no legal responsibiity for the information contained on this site. Carteret County does not guarantee that the data and map services wig be available to users
without interruptbn or error. Furthermore, Carteret County may modify or remove map services and access methods at will.

Fee Receive d 4100°-
Check', C or Cash•
Date Received
Received By:
SEVA57.23
CARTERET COUNTY HEALTH DEPARTMENT
3820 Bridges St. Morehead City, NC 28.557 Area I'
Phone.: [phone] Fax: [phone]
APPLICATION. Date Stakede.tfbStaff Initialf26
Well Construction Permit*
INFORMATION IS FALSIFIED, CHANGED OR SITEJS ALTERED, THE AUTHORIZATION TO CONSTRUCT
PERMIT SHALL BECOME INVALID. PERMIT IS VALID FOR 60 MONTHS.
Reque:•4 Section
Parcel ID: cg 87310363 006)
ypecf Well: Private Drinking Water Shared Drinking Water ttlnigation. Other
Type uf Application: New Construction • Replacerrient - Repair Abandonment
Proposed Use: _Residential Commercial (Design Capacity 100,000gpd)
General Inlortnittion
Owner
Name: First ewe,
V --CeNS COQ/? 140 A lost Ai are- 64i-ca-V Ann 54) 471t 047/15.
main Address St co
city E 4/1 Et t-s" state A) C Zip Z43.59 ct
Mobile'79 ,18r7 Fax
Phone: Home Work
Email co; t i; at*, 6., e 0.„.4., 5 .4,15'6 Organization C44/LC
Applicant Ifsameas owner:, Yes
ff no, complete this section and provide owners statement.
Name: First int-GPM& Last E e.)AIZI
Mailing Address - • 9e) I (2.6.&:. fle,74
City eitel EiZ. 4 7 E State A.1 'Z• l95-9 y
Phone: Home Work Mobile 9/ 5. kW. /// 13 Fax
Email /IntV01-rt C. a i.i s 4-1•6 .,C.cms, Organization CAM S
Site Specif ic Information
Parcel Address: C16
Subdivision • 0 0 Ceir.JS Lot. Phase Section Blook
CitY: CA') c•e-A
# of Acres
27:sce--
Type•of Facility: Residential •1 Multifamily Co4P/Po.S
Non:Residential(describe
improvement Pennit for Wastevvater Syatem Issued: __yes rio VN/A
Applicant must Werra Lcical Health Department if any of the following apply. Check all that apply:
_IZExisting well On property 'Utility Lines __Right of ways'
_ Existing or proposed septic tank system :,--Additional structures on property
Stump holes/buded debris Underground Fuel Tanks Faspments
other potentialtbottes of groundwater polludon — list
_Current or pending groundwater restrictions -describe
Are there any variances associated with this application'? Yes 6". No
Additional Information:
Any proposeddevelopment most be reviewed by the Wel jurisdiction for:Compliance With local ordinances and regulations.
•Additionally, you mast consult with awy state or federal agency with jurisdiction over the. proptised development -
Page 1 of 3

CARTERET COUNTY. HEALTH DEPAR'VMENT
3820 Bridges St: Morehead City, NC 28557
Phone; 252-7284490 Fax [phone]
APPLICATION
Willi Construction Pernik qedb
Owner 0065:NS Coo 1164 iparcankseqi.tg OEMs
Site Sketch: Provide au accurate diagram of property with ctunensions, proposed= existing,buildinglocation(s) with
setbacks to two property lines, proposed or existinawastewater system location, existing and/or proposed water source
location, potential sources cbittainination, driveways and any other characteristics or activities on the property or
acracent property that could iinpact groundwaterquality or saitability of thesite for Well Construction.
(Initial) Property is stshed ,Applicant will call when pritilerty is staked ,
A re-inspectiontee of $30 is requir" eci if the lot is not accessible and/Or Staked..
Application will be returned after sixty (60),days if Carteret County Environmental Health has not heentotified that site
is Staked• and aceessille.,Fees paid for•application am forfeited when applicatiotis returned toupplicant-deagent.
Sigliatun:
The site evaluation is perfontted.based on the inforniation-contained inthis application. Any. changes to the site or
stricture locations, the property lines, proposed or existing waste water system location shall be cause to revoke the Well
permit. X have read this.application and,certifythe information provided herein is true, complete and correct.
Authorized countyand state officials are granted right of entry to conduct necessary inspections to determine compliance
with applicable laws and rules. I understand u ft lam solely responsibli lot the proper idendfication and staking of all
propes lu7and d the site accessible so a complete site evaluation can be pedbimed.
Property owner's: or authorized agent (REQUIRED) Date
faasiFt,C4/1 - aim) Hair TrefilA kg• 444re kir.a..7:1)41 sea)
Page 2 of3

CARTERET COUNTY HEALTH DEPARTMENT
3820 Bridges St Morehead City, NC 28557
Phone: [phone] Fax: [phone]
APPLICATION
et
Private Drinking Water Well Application Disclosure
•Carteret County Health Department can accept an application for a private driidcing water well permit however if you. are
proposing new construction and the facility is in a location served by Carteret County Water or any other public or
community water system, you may be required to connect to that system. It is strongly recommended that you contact the
water system serving the area of the proposed facility location prior to submitting the well application. Once a site visit
has been•made the fee is not refundable. If the well is ineallPd, and your location is served by a public or community
water system, you may still berequired to connect to the system.
x71 I have awl understand the above 'disclosure:
ircbler& 1.-c-ozr Signature
glop 0;69 aelne4w...0 rsee Address of proposed facility
g(ZY/Z2- Date
Contact Information:
Carteret County Water - 252-728-4755 Atlantic Beach Water - 252-726-1366
West Carteret Water Corp. - 252-393-1515 Pine Knoll Shores Water - 252-247-4353 x 10
Bogue Banks Water - 252-354-3307 Town &Morehead City -252-726-6848 x 1
Town of Beaufort (Public Works)-- 252-728-7466
Carteret County public and community water systems are not limited to the above list.
Replacement Well Applications
An application for a replacement well tor thinking water Will be accepted When the eidsting well no longer provides a
potable Or adequate water supply kid the well ia proposed:to be removed from.service
Upon approval of the installation of the replacement well, the existing well Shall be removed film! service and temporarily
abandoned by capping it off, per ISA NCAC 02C .0113(a) or permanently abandoned if the well is determined to be
iniproperly constructed, located or a source of contamination of the groundwater supply. A well proposed to be
abandoned or required to be abandoned shall be filled, plugged, or sealed in such a manner as to prevent the well from
being -a channel allowing, the vertical movement of water and a source of ContaMination of the groundwater supply, per
15A NCAC 02C 01 13(b) and a certified iecord of abandonment provided to the Carteret County Health, Department and
the NCDEQ/DWR within-30 days after the completion !gibe abandonment per 15A NCAC 02C .0.114(b).
Failure to pennanently abandon.an existing well that is improperly constracted orimproperiy located will- subject the well
miner to the following legal remedies;lijunctioa Relief [G.S. 130A-18], Administrative Penalties [G.S. 130A-22(c),
Suspensiortor Revocation of, permits [G.S. 130=23] and Criminal Penalties [G..5.130;25]
,Reti.1149,15'
Page.3 of 3

CARTERET COUNTY HEALTH DEPARTMENT
Environmental Health Division
3820 A l3ridges Strpet
Morehead City, NC 28557
Phone [phone] Fax [phone]
OWNER'S STATEMENT
TO: The -Environmental Health Division
SUBJECT:. Authorization for Representation. as Agent for Owner and Pemission to Access Property
dirc 12DgGVA-1 MYTFsTET'e..2. ,t hereby authorize 4.17 (print) to act
as my agent in the process of application for an on -site wastewater system ',emir or a water well.
permit far the property listed below:
(Real Estate Agents or other agents contracted to act as property representatives shall provide a copy
Of the.signed contract- verifying owner has acknovvledged theirtepresentation of Mow property).
Location: /00 4.7-tra De—L.-C.)67 PION it 53133 103 6c-i 3sg LICOD
In -addition to the above, the Environmental Health Division has my permission to access the above
listed property.
Should you need 'acklitiong infonnation, please contact:-
Ownees Name: OdEeAs Cooa-er i4OA 4.44-7±e Wr-ra---r44,50x1
Address: C/6 zi g
city: 4 4 erfo Gre state: /0 Zesr7
Phone:
FthM1ct, ,( 4,‘ SCHA CcA-4/1 5 4104 . 2/1
,,Chniers Signature: Date: Li
VOA Per57-7YeAT- 4og-a-rA) i4Q-747-ETZ64. -roP &fa' kke-crege145Adu
9

q ij o0 -Reed
`1-Yr kprp
I�145,k.e-1
F�IVIROMENTAL HEALTH
3820 BRIDGES ST STE A
MORIEIEAD CITY, NC 28557
[phone]
SALE
REP#: 00000002
Batch #: 237001 RRIt 260100001
09:19:43
08125122 CVC: M
APPR CODE: 025579 NP Manualal C
VISA NP
*******M•**2102
AMOUNT
$100.00
APPROVED
X
I AGREE 10 PAT AIfMVE TOTAL MUM
IR ACCORO0.110E01111 CARD
ISSUER'S
GREEUECT
itIERCHART
RREEEIII IF CREDIT NER)
COPT TOR STAIEUEIIi
UERIVICAT1011
MERCHANT COPY

Tax Parcel Information:
Owner: QUEENS COURT HOMEOWNERS ASSOCI
Current PIN: 538310369384000
Site Address:
0
Mailing Address:
MOREHEAD CITY NC 28557
Legal Description:
COMMON AREA QUEENS COURT
Prior PIN:15o35Bo118
City Limits: EMERALD ISLE
Rescue District:
Fire District:
Tax District: 1556
Township: WHITE OAK
Use: COMMONAREA
Land Value: $2
Bldg Value: $o
Other Value: $0
Total Value: $2
Sale Price: $o
Deeded Acres: o
Plat Ref: /
Deed Ref: 583 / 3i8
Bedrooms:
NBHD: 900016
Bldg Htd Sq Ft:
Bldg Tot Sq Ft: o
Year Built:
Noise Level:
AICUZ Zone:
GIS Acres: 5.589
Roll Type: R
Deed Date: o
Bathrooms:
Carteret County, N.C.
Printed August 25, 2022
The nformatton displayed by this webste is prepared for the hventory of real property found WINn this Jurisdiction and is compiled from recorded deeds, plats, and other pudic records and data Users of the hfamafion are hereby notified Net the aforementioned pudic primary
hformabon sources should be consulted for verification of the hformatbn contained oh this site. Caderet County assumes no bgal responsiblity for the Information contained on tNs site. Carteret Canty does not guarantee that Medals end mop services wil be available to users
xithout lnterm• bn or error. Furthermore. Carteret Coen m mod or renove rro• services and access methods at Wll.