HomeMy WebLinkAboutWV0800319_Application_20220929CARTERET COUNTY HEALTH DEPARTMENT
EVIRONMENTAL HEALTH
ON -SITE WATER PROTECTION
CDP#: 346550
SITE EVALUATION
for WATER WELL
OWNER: John Daniels APPLICANT: N/A
LOCATION OF SITE: 4911 MidYette Ave, MHC
PROPOSED FACILITY: te,c.:Sk\ti. - Sin PROPERTY SIZE: DATE EVALUATED: 9 /2`f/22
TYPE WELL: 0 Individual Drinking Water 0 Shared Drinking Water irrigation ❑ Geothermal (siting conf. only)
0 New Well Replacement Well 0 Repair (as specified by certified well driller)
TYPE OF WASTEWATER: 0 Onsite Septic _installed not installed /" "Zunicipal or Community Sewer
EVALUATED BY: B. Lyles
OTHER(S) PRESENT:
COMMENTS:
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rQl WPDT Report
Area of Interest (AOI) Information
Area : 3,134,508.63 ft2
Sep 29 2022 9:45:41 Eastern Daylight Time
Known Releases of Contaminaticc Other System Roads
Underground Tank Inicrdents — Ramps. Rest Areas, Ncn-Mainline
Parcels (Polygons) - Parcels Projected Route
Non -System Roads — Other State Agency Route
Federal Route
— Non -System
— Seconder Rvute
Primary Roads
- Interstate
1:4,514
O D.033 0.06
1 1 1
O 0.05 0.1
0.12 mn
0.2 km
NCTIOT G13 un.t. E&1 Canmure, maps Garniwlva. Carle.ee Count'. 51909
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Cmsus E4rreau, USDA. Sources. Esn. hrhrs DS. LASGS. NG', P.10.5A
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1/2
9/29/22, 9:47 AM
Known Releases of Contamination
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#
Site ID
32660
Site Name
FRANCES MCNAMARA
PROPERTY
Site Type
Underground Tank
Inicidents
Data Current As Of
12/18/2019
Count
1
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NORTH 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 clearly or type information. Illegible submittals will be returned as incomplete.
DATE: Sep 28
, 2022 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:
John Daniels
Mailing Address: 4911 Midyette Ave
City: Morehead City State: NC Zip Code: 28557County: Carteret
Day Tele No.: 252-241-4062
EMAIL Address: jackdanielsmhc@aol.com
B. PHYSICAL LOCATION OF WELL SITE
Cell No.:
Fax No.:
(1) Parcel Identification Number (PIN) of well site: 636614420921000
County: Carteret
(2) Physical Address (if different than mailing address):
same as mailing address
City: State: NC 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.:
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.
Irrigation Well- variance request for:
1) 15A NCAC 02C .0107 (a)(2)(H): proposed location is less than 100'
from the sewer main located approximately 4'-6' from front property line
2)15A NCAC 02C .0107 (a)(2)(P): proposed location will also encroach on 25' setback
to existing structure/dwelling.
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. 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
Signature of Person Responsible for Well Construction (typically the well driller)
Print or Type Full Name of Person Responsible for Well Construction
(typically the well driller)
Signature YCounty E.$ironmental Health Specialist
Blakley Lyles
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
H. 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 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:
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://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications
Submit one copy of the completed
variance application to the Division
of Water Quality Regional Office
serving the area in which the well
will be located:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone: (828) 296-4500
Fax: (828) 299-7043
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5043
Telephone: (910) 433-3300
Fax: (910) 486-0707
Mooresville Regional Office
610 East Center Avenue,
Suite 301
Mooresville, NC 28115
Telephone: (704) 663-1699
Fax: (704) 663-6040
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: (919) 791-4200
Fax: (919) 571-4718
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: (252) 946-6481
Fax: (252) 975-3716
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Telephone: (910) 796-7215
Fax: (910) 350-2004
Winston-Salem Regional
Office
585 Waughtown Street
Winston-Salem, NC 27107-2241
Phone: (336) 771-5000
Fax: (336) 771-4631
Form GW-22V
Page 3 Revised February 2013
COASTAL PLAIN
Minimum Additional Construction Requirements for Wells Requiring a Variance or a Permit to the Separation distances In 16A NCAC 2C
.0107(aX2) and .01070j(3) - Applicable to areas that are Underlain by Unconsolidated Sediments and Sedimentary Rocks
POTENTIAL POLLUTION SOURCE
septic tank and elrainfield
other Subsurface ground absorption wa ste
disposal system
other sewage and liquid -waste collection or
transfer fac it ity
cesspools and privies
ahimal fE•eillcSts or maikire pile•S
Surface water(GW racharge]._.porrds, lake
other surface -...water bodIes___creeks. river
watertight sewage or liquid -waste
col Icction ortranstor facility
Ianimal barns
building foundations(cxcl uding well house)
fertilizer, pesticide, herbicide or ether
chemical storage areas
other non -hazardous solid waste landfill
non -hazardous waste storage, treatment or
disposal lagoons
industrial/municipal Sludge -spreading or
wastewater -irrigation €ite
aboveground or underground heating ail
storage tanks
all other potential sources of groundwater
contamination
sanitary landfills
chemical or petroleum fuel underground
storage tanks regulated 11Ilder 15A NCAC
2N with secondary containment
chemical or petroleum iucl underground
storage tanks regulated Under 15A NCAC
2N w/o secondary Containment
'Dd,hle cased PVC may he required
Attachment A (Form Gi1V-22%')
'MINIMUM SEPARATION DISTANCE (ft)
Standard[ Single Family I Variance
E
100
50
100
100
100
1000
100
50
100
100
50
50
SITE SPECIFIC
25
25
50
25
10❑
50
25
25
SITE SPECIFIC
MINIMUM ADDITIONAL REQUIREMENTS
PVC
>20 feet below land
tiurFace or as specified
by the Director
PVC.
To the first sig nificant
clay greater than 20 foot
below land surface or to
the souree .igolfer
100
160
SITEISOURCE
140
100
100
100
100
100
SPECIFIC
SITE/SOURCE SPECIFIC
50
50
50
50
500
500
56
86
1 d 0
100
DO NOT ISSUE
1,5A NCAC 2C:.0107(d)(4)(B), ,0107(e)(1)(A), and 2C" ,0116 provide for the abilit - to construct a well to a depth of less than 20 feet where the best
source of water exists between a depth of ten and twenty feet below the surface of the land. Because additional minimum construction requirements
necessitate that: 1) casing extend to a depth greater than 20 feet below land surface: and 2) grout extend to the fast significant clan layer greater than
20 feet below land surface or to the source aquifer, a variance to horizontal separation distances for shallow wells cased to less than 20 feet is not feasible.
Well construction information should be provided with the Application for Permit for 'Valiance detailing how minimum additional construction
requirements will be satisfied.
Form GW-22V
Page 4 Revised February 2013
PIEDMONT A ND MOUNTAINS
Mini mum Additional Construction Requirements for Wells Requiring a Variance or a Permit to the Separation Distances in 15A NCAC 2C
_0107(a)(2) and .0107(a)(3) -Applicable to areas that are Underlain by Crystalline Bedrock
POTENTIAL POLLUTION SOURCE
septic tank and draintiold
other subsurface ground absorption waste
disposal system
ocher sewage and IIq u id -waste collection or
transfer facil ity
cesspools and pnvies
anirn al feedlots or manure piles
Surfacewater(GW rechargel._.ponds, lake
other surface water bodies_._ creeks, river
seater light sewage or liquid -waste
collection or transfer facility
animal barns
building toundations{excluding well house]
fertilizer, pesticide, herbicide or other
chemical storage areas
other non -hazardous solid waste landfill
non -hazardous waste storage, treatment or
disposal lagoons
industrialfmunicipal sludge -spreading or
wastewater -irrigation site
aboveground or underground heating oil
storage tanks
all other potential sources of groundwater
contaimination
MINIMUM SEPARATION DISTANCE (ft)
Standard! Single Family I Variance
100
50
100
140
50
100
100
100
50
100
100
50
50
SITE SPECIFIC
25
25
MINIMUM ADDITIONAL REQUIREMENTS
Casing Type I Casing Depth
Grout Depth
GALVANIZED
STEEL
If Bedrock depth Is <50 feet= the
greater of 15 feet into bedrock or 40
feet below land surface
If bedrock depth le 50-100 feet: 10
feet into bedrock
If bedrock depth is >100 feet: 5 Set
into bed rack
full length
of casing'
50
5
PVC or
The or 40 I eet below land
full length
SITE SPECIFIC
GALVANIZED
STEEL
greater
surface or 5 feet into bedrock
of casing'
100
520
25
25
100
100
SITE/SOURCE
100
140
100
100
SITEISOURCE SPECIFIC
100
100
SPECIFIC
50
50
50
50
sanitary landfills
chemical or petroleum fuel underground
storage tanks regulated under 15A NICAC
2r4 with secondary containment
chemical or petroleum fuel underground
storage tanks regulated under 15A NCAC 100
2IJ wfo secondary containment
500
50
100
560
50
DO NOT ISSUE
A aril bik with a ammeter that is at least la greater than the diameter of the casing must be used to drill the cased ptrticn of the well Grout should be ir►stsIed under Pressure.
In stallat1cn using a tremme pipe Is acceptable Ir the space to be grouted Is free of ebstrucba
Attachment B (Form GW-22V)
Form GW-22V
Page 5 Revised February 2013
O.DP 3 s--,d
Fee Received4100`"
Check# CC-- or Cash
Date Received 57712s
Received By: Kg
CARTERET COUNTY HEALTH DEPARTMENT
3820 Bridges St. Morehead City, NC 28557 Area
Phone: 252-728-8499 Fax: 252-222-7753 Priority
APPLICATION Date Staked 9/8/z. Staff Initial&
Well Construction Permit
IF INFORMATION LS FALSIFIED, CHANGED OR SITE IS ALTERED, THE AUTHORIZATION TO CONSTRUCT
PERMIT SHALL BECOME INVALID. PERMIT IS VALID FOR 60 MONTHS.
Pcrmil ILcqucsl Secliun
Type of Well: Private Drinking Water Shared Drinking Water V Irrigation Other
Type of Application: New Construction Replacement Repair _ Abandonment
Proposed Use: Residential Commercial (Design Capacity c 100,000gpd)
Parcel ID:lo3 (nb1kji 11949 a4OO
Owner
Name: First hit
General Infurmalinn
Last 17oin1e\S -
Mailing Address 49 it 14 k rt LA e-\ e P U
City 1M DtT1trecd C,l State 10 C. Zip a $355-1
Phone: Home Work Mobile Asa -ayl- 48(Pa�Fax
Email,1(p c �'.� sYl k ciS i�(� Ce Act . CID d \ Organization
Applicant If same as owner Yes
If no, complete this section and provide owners statement.
Name: First Last
Mailing Address
City State Zip
Phone: Home Work Mobile Fax
Email Organization
1 Site Sime.ific Infurtnatiun 1,� �1
Parcel Address: Li 11 L% ICl �4 a c ii��rw • City: �' iaC2,t l L t
Subdivision: J
Lot Phase Section Block # of Acres
Type of Facility: VResidential _ Multifamily
Non -Residential (describe )
Improvement Permit for Wastewater System Issued: _yes no %/N/A
Applicant must inform Local Health Department if any of the following apply. Check all that apply:
✓Existing well on property Buried Utility Lines _Right of ways
_ Existing or proposed septic tank system _Additional structures on property
Stump holes/buried debris _Underground Fuel Tanks _ Easements
-Other potential sources of groundwater pollution — list
_Current or pending groundwater restrictions -describe
Are there, any variances associated with this application? Yes _No
Additional Information:
Any proposed development must be reviewed by the local jurisdiction for compliance with local ordinances and regulations.
Additionally, you must consult with any state or federal agency with jurisdiction over the proposed development
Page 1 of 3
CARTERET COUNTY HEALTH DEPARTMENT
3820 Bridges St. Morehead City, NC 28557
• Phone: 252-728-8499 fax: 252-222-7753
APPLICATION
Well Construction Permit
OwnerTOMln —DerYweiS !Parcel14Liar)9alob0
Site Sketch: Provide an accurate diagram of property with dimensions, proposed or existing building location(s) with
setbacks to two property lines, proposed or existing wastewater system location, existing and/or proposed water source
location, potential sources of contamination, driveways and any other characteristics or activities on the property or
adjacent property that could impact groundwater quality or suitability of the site for well construction.
(Initial) Pioperty is staked Applicant will call when property is staked
A re -inspection fee of $30 is required if the lot is not accessible and/or staked.
Application will be returned after sixty (60) days if Carteret County Environmental Health has not been notified that site
is staked and accessible. Fees paid for application are forfeited when application is returned to applicant or agent.
S!_na(t!I'_ °ection
The site evaluation is performed based on the information contained in this application. Any changes to the site or
structure locations, the property lines, proposed or existing waste water system. location shall be cause to revoke the Well
Permit. I have read this application and certify the information provided herein is true, complete and correct.
Authorized county and state officials are y .- . right of entry to conduct necessary inspections to determine compliance
with applicabl : w rules.I erst, that la�mp'� _ , responsible for the proper identification and staking of all
property!' • i i n , ,n . , • 4 • ere acct., ,.a complete site evaluation can be performed
(REQUIRED) Date Z
Prop
wner's signature or authorized
Page 2 of 3
CARTERET COUNTY HEALTH DEPARTMENT
3820 Bridges St. Morehead City, NC 28557
Phone: 252-728-8499 Fax: 252-222-7753
APPLICATION
Private Drinking Water Well Application Disclosure
Carteret County Health Department can accept an application for a private drinking 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 installed, and your location is served by a public or community
water system, you may still be required to connect to the system.
I have rea above
losure:
Signature
Address of proposed facility
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 of Morehead City — 252-726-6848 x 1
Town of Beaufort (Public Works) — 252-728-7166
Carteret County public and community water systems are not limited to the above list.
Replacement Well Applications
An application for a replacement well for drinking water will be accepted when the existing well no longer provides a
potable or adequate water supply and the well is proposed to be removed from service.
Upon approval of the installation of the replacement well, the existing well shall be removed from service and temporarily
abandoned by capping it off, per 15A NCAC 02C .01 I3(a) or permanently abandoned if the well is determined to be
improperly 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 .0113(b) and a certified record of abandonment provided to the Carteret County Health Department and
the NCDEQ/DWR within 30 days after the completion of the abandonment per 15A NCAC 02C .0114(b).
Failure to permanently abandon an existing well that is improperly constructed or improperly located will subject the well
owner to the following legal remedies; Injunction Relief [G.S. 130A-18], Administrative Penalties [G.S. 130A-22(c),
Suspension or Revocation of permits [G.S. 130-23] and Criminal Penalties [G.S.130-25].
Rev.11-19-15
Page 3 of 3
CARTERET COUNTY HEALTH DEPARTMENT
Environmental Health Division
3820 A Bridges Street
Morehead City, NC 28557
Phone (252) 728-8499 Fax (252) 222-7753
OWNER'S STATEMENT
TO: The Environmental Health Division
SUBJECT: Authorization for Representation as Agent for Owner and Permission to Access Property
I, Bohr :. J. to' as Jl- (print), hereby authorize (print) to act
as my agent in the process of application for an on -site wastewater system permit or a water well
permit for 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 acknowledged their representation of below property).
Location:Li 9 II 14►c4TTr iV0 e_ PIDN#
In addition to the above, the Environmental Health Division has my permission to access the above
listed property.
Should you need additional information, please contact
Owner's
(Name: 'n rl� P
Address:'19 I VA 1r.d6P_ Pak-,
City:PIDC?'111, L'ij State: fl9C Zip:oi 1
Phone: as a- act 1- y D(a
Email: 1CLC-\S �.CdW-e\S k'e,
Owner's Signature: Date:
•
ENVIROMENTAL HEALTH
3820 BRIDGES ST STE A
MORE HEAD CITY, NC 28557
(252) 728-8550
SALE
REF#: 00000002
Batch #: 250002 RRN: 200100002
09107122 1629:50
APPR CODE 020536
VISA
***********"9437
AMOUNT
Chip
$100.00
OW,
DANIEL JOHN
v1 .ER
AID A0000000031010
TVR: 80 00 00 80 00
TSI: 68 00
I AGREE TO PAT ABOVE TOTAL AMOUNT
III ACCORDANCE IEITN CARO ISSUER'S
AGREEMENT
(MERCHANT AGREEMENT IF CREDIT VOUCHER)
• 0 RETAIN THIS CPI FOR STATEMENT
VERIFICATION
MERCHANT COPY
Tax Parcel Information:
Carteret County, N.C.
Owner: DANIELS,JOHN J III ETUX CAROL
Current PIN: 63664420921000
Site Address:
4911 MIDYETTE AVE
MOREHEAD CITY
Mailing Address:
4911 MIDYETTE AVENUE
MOREHEAD CITY NC 28557
Legal Description:
L4 BL MITCHELL VILLAGE
Prior PIN: 13015E0 8o 5
City Limits: MOREHEAD CITY
Rescue District:
Fire District:
Tax District: 1.351
Township: MOREHEAD
Use: RESIDENTIAL
Land Value:
Bldg Value:
Other Value:
Total Value:
Sale Price:
Deeded Acres: 0.357
Plat Ref: 3 / 155
Deed Ref: 1596 / 308
Bedrooms: 4
NBHD: 5100 02
Bldg Htd SC1 Ft: 2525
Bldg Tot Sq Ft:
Year Built: 1965
Noise Level:
AICUZ Zone:
GIS Acres: 0.393
Roll Type: R
Deed Date: 20180103
Bathrooms: 2.5
The information displayed by this webste is prepared for the inventory of real property found within this jurisdiction and is compiled from recorded deeds, plats, and other public records and data. Users of this information are hereby notified that the aforementioned public primary
information sources should be consulted for verification of the informatbn contained on this site. Carteret County assumes no legal responsibility for the information contained on this site. Carteret County does not guarantee that the data and map services will be available to users
without interruption or error. Furthermore, Carteret County may modify or remove map services and access methods at rkAll.
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