WV0700168_Application_20230307

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
.411 water suppl}•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 inforutation. Illegible submittals will be returned as incomplete.
DATE: ? o� , 2020
G r z�Existing permit number(if applicable)WyC-1 CJ 6 D Issued Date: b 3 Exp. Date: k')
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:
Mailing Address: tt3l`e� '�O,r t`u -d.
City: States` }t' Zip Code:XA�S 16 County: ti, rl, € °'
Day Tele No.: 10-- q�'q-llq-/ Cell No.:
EMAIL Address: ; ,�e4.,�^,��y t}l;fi,,�." . �`�j1i Fax No.:
B. PHYSICAL LOCATION OF WELL SITE /
(1) Parcel Identification Number(PIN)of well site: 12 Lr •'i o 1
County: Lm.Lct
(2) Physical Address(if different than mailing address):
City: OX t: 1�611 I It County: JCe,-Lg0 Zip Code: 1
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.:
GW-22V Variance Request Form Rev.7-13-2020 Page 1

D. REASON FOR VARIANCE REQUEST —Include type of well(s) to be constructed; rile 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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ACE,,. ��'•;!`rF�,�� �4>,t t.'r"
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E. ATTACHMENTS—Provide the followin�infonnat�:oon 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 systeni(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 snap (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)
C�
Signature(s) '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)
Signature of County Endronmental Health Specialist(for Private Water Wells)
Print or Type Full Name and Title of County Environmental Health Specialist(for Private Water Wells)
Per 15A NCAC 02C .0118 the Secr•etruy of the Division of Water Resources or the Division of Public Health may
require submittal of irtfor•nration deemed necessary to make a decision on the variance, tray 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 cis described in G.S. 150E-23 within 60 days after receipt of the decision.
GIV-22V Variance Request Form Rev.7-13-2020 Page 2

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://elrs.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) All Water Supply Wells under 15A NCAC 02C .0107 other than the ones listed under(1)above
(b) Wells Other than Water Supply under I SA 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:
httu://deg.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-braiieli/Rroun d-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 1 R HI
1. .
will be located:
- 0
Asheville Regional Office Raleigh Regional Office Wilmington Regional Office
2090 U.S.Highway 70 1628 Mail Service Center 127 Cardinal Drive Extension
Swannanoa,NC 28778 Raleigh,NC 27699-1629 Wilmington,NC 28405
Telephone: [phone] Telephone: [phone] Telephone:[phone]
Fax: [phone] Fax: [phone] Fax: [phone]
Fayetteville Regional Office Washington Regional Office Winston-Salem Regional
225 Green Street,Suite 714 943 Washington Square Mall Office
Fayetteville,NC 28301-5043 Washington,NC 27889 450 W.Hanes Mill Rd.
Telephone:[phone] Telephone: [phone] Suite 300
Fax:[phone] Fax: [phone] Winston-Salem,NC 27105
Phone:[phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue,
Suite 301
Mooresville,NC 28115
Telephone: [phone]
Fax: [phone]
GW-22V Variance Request Fonii Rev.7-13-2020 Page 3

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2/14/23, 10:22 AM Hydrogeologic Framework Query Results
Calculated Cross-Section ❑well
■ Screen
N Land Surface
200
❑Surflcial
■Upper Tertiary CU
p ❑Upper Tertiary
■Yorktown CU
I7 Yorktown
-200 ■Pungo River CU
❑Pungo River
■Castle Mayne CU
400 3 ■Castle Kiyne
■Beaufort CU
w
❑Beaufort
p -600 ■Peedee CU
> ❑Pcedce
(D
W ■Black Creek CU
-800 ❑Black Creek
■Upper Cape Fear CU
El Cape Fear
1000
■Lower Cape Fear CU
reppppp� ■Lower Cape Fear
■Lower Cretaceous CU
-1200
©Lower Cretaceous
❑Basement
-1400
0.00 0.47 0.95 1.42 1.90 2.37 2.85 3.32 3.80 4.27
Distance miles --estimated FW1SW:Wrt. )cl. bc. ticf. Icf. Ica
Excluding the following boreholes:
https://www.ncwater.org/Data_and_Modeling/Ground_Water_Databases/framework.php 3/3

2/14/23, 10:22 AM Hydrogeologic Framework Query Results
Framework Query Results Borehole Hydrogeology
Scroll to bottom half of 16 A B
U.-
C
®�
page for cross-section. v
ZM ❑surriclal
Framework Map with �4 -184 ■Upper Tertiary CU
borehole locations is
shown to the right and Well Of ❑Upper Tertiary
,'
■Yorktown CU
maybe viewed in a -3aa --
■Yorktown
separate window.
�f ■Pungo River CU
-584
Cross-section line is ■Pungo River
oriented approximately: ■Castle Rayne CU
W-E(101 degrees) �auE -784 ■Castle Rayne
X H 1 ;, ■Beau fort CU
4114 0 3 6 9 mi � -984 0 Beaufort
w e 0 ' ■Peedee CU
00 F8f
>-1.184 ®Pestle¢
N
W ■Bla[kCreekCU
Well of Interest Point of Interest -1.384 ■Buck Creek
■Upper Cape Fear CU
Location: 35.496000,-76.716300; Well Depth: 210 feet; Screen Depth: ❑Upper Cape Fear
200 feet; Land Surface(estimated): 7 feet; 1.584 ■Lower tape Fear CU
Show Map ■Lower Cape Fear
-1.784 ■Lower Cretaceous CU
Approximate depths to(and elevations of)hydrogeological units(feet): ■Lower Cretaceous
SURFICIAL I YKNCONF YKN CLHCONF CLH ❑tiascrnent
-2(10) 56(-48) it 74(66) 134( 126) L164(-156U 1,984 Cross-hatching indicates casing
depth.
• Hydrogeologic unit top depths estimated to well depth.
USGS National Elevation Dataset 1/3 Arc Second Elevation=7 feet -2.184
Units shown in this color may not be fully present due to erosion or non-deposition.l
Boreholes
exclude A A: Texas Gulf TW-3,O 16S;Land Surface:6.66 feet;Location:
35.444305,-76.699131;Geophysical Logs Hydrogeologi nits
exclude s B: Hub's Rec Station,N 15X;Land Surface:4 feet;Location:35.516576,
-76.649871;Water Levels.Geophysical Logs Hydrogeologic Units
exclude c C: Coastal Plains Rodman No. 1,N 17L;Land Surface: 16 feet;Location:
35.545833,-76.779167;Geophysical Logs,By,¢Mgeologic Units
https://www.ncwater.org/Data_and_Modeling/Ground_Water_Databases/framework.php 2/3