WV0800327_Application_20230313

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
I;m
B.
C.
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: 20 PERMIT NO.: (to be completed by DWQ/DPH)
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 Address: I 1 `j -� 5 11; � ' "
City: () 1 ` 7 State: A C
Day Tele No.:
Zip Coder*9V'County:(unic k
Cell No.: / gC - j qq ` 9 � --
EMAIL Address: AM Wt @ Llmci;k. Com Fax No.:
PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well si
County:
(2) Physical Address (if different than mailing address):
City:
WELL DRILLER INFORMA
Well Drilling Contractor's Name:
known)
State: NC Zip Code:
as
NC Well Drilling Contractor Certification No.: '-7 3 q g - A
Company Name: 1` al 3r41' 5 W d l b r%mjjn Contact Person: loin eLj' '
City: C7d 0(eer1 MOV State: VC, Zip Code:? County: k
Day Tele No.: '7[ 0 O a - Cell No.: t
EMAIL Address: Danlit it 3T 7PL jMq- , (tom Fax No.:
Form GW-22V Page 1 Revised February 2013