WV0800328_Application_20230316

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
A.
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 ive/ls.
DATE: Mar 13
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
Including monitoring and recovery wells.
Print clearly or type lnfornration. Illegible submittals will be returnee as incomprere.
2023 PERMIT NO.:
be completed by D WQ/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:
Karl Blackleg Blue Treasure LL
Mailing Address: 105 Weston Estates Way
City: Cary State: NC
Day Tele No.: 919-481-3000
EMAIL Address: [e-mail]
B. PHYSICAL LOCATION OF WELL SITE
(1)
(2)
Zip Code: 27513 County: Wake
Cell No.:
Fax No.:
Parcel Identification Number (PIN) of well site: 7306.20.71.9375
County: Carteret
Physical Address (if different than mailing address):
193 Freedom Park Rd.
City: Beaufort
C. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
City: State: _
Day Tele No.:
EMAIL Address:
State: NC Zip Code: 28516
Contact Person:
Zip Code:_ County:
Cell No.:
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)(1-1): proposed location is less than 100'
from the sewer main (see attached site plan)
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 of County Euvironm&iial Health Specialist
Chris Barfield, REHS
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 wt;iting 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.
Form GW-22V Page 2 Revised February 2013

H. SUBMITTAL INSTRUCTIONS
(1) For the following types of water supply wells only:
(2)
(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: httl3:Hehs.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
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 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:
b-q://portal ncdenr org/web/wa/ans/gwprn/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: [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
Wilmington Regional Office
1628 Mail Service Center
127 Cardinal Drive Extension
Raleigh, NC 27699-1628
Wilmington, NC 28405
Telephone: [phone]
Telephone: [phone]
Fax: [phone]
Fax: [phone]
Washington Regional Office
Winston-Salem Regional
943 Washington Square Mall
Office
Washington, NC 27889
585 Waughtown Street
Telephone: [phone]
Winston-Salem, NC 27107-2241
Fax: [phone]
Phone: [phone]
Fax: [phone]
Form OW-22V
Page 3 Revised February 2013

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WELL CONSTRUCTION PERMIT
CDP File Number:
County File Number:
Date:
Drawing Type:
u
150
9
WELL TO STORMRM DRAINAGE O
N 161.2'
,r TO SWIMMING POOL
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• MAIL KIOSK
j BEAU COAST WESTAMENITY SITE
a WELL LOCATION PLAN
Y
*�PURPOSE: WELL TO BE USED TO KEEP AMENITY
POND WATER SURFACE AT THE DESIRED LEVEL
--�-- WITHERSRAVENEL INC.
DATE 02-MARCH-2023
SCALE
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3/13/23, 2:41 PM about:blank
Area of Interest (AOI) Information
Area : 3,134,508.63 ftz
Mar 13 2023 14:41:36 Eastern Daylight Time
Known Releases of Contamination Non -System Roads
Bramitie!d Agreements — F.deml Rout.
0 Pre-Regluatory Landfdlc — NorS"em
Above Ground Petroleum Indents OOIP.(System Roads
Romps, ReslAmas, Nan-Molnl:ne
Unde:graund Tank inicidenls
Projected Route
Parcels (polygons) -Parcels
1:9,028
0 0.05 01 0.2 ml
0 0.1 0.2 0.4'rrt
n "rT GIS Ur" E:111Sn,NSI, Us -cr n _: w at:,;
o .use rote m ,e c ucaces o carol,
ee9hcNmbeux. M1w, NEIIflASA. USSS, LI1, NPG, US Cewu: 0-9,
about:blank 1/2

3/13/23, 2:41 PM
Known Releases of Contamination
aboubblank
#
- Site ID :
Site Name
Site Type .
Data Current As Of
" . Count
1
14011-10-016
Pace Conservation
Center
Brownfield Agreements
12/05/2019
1
2
NONGD0000200
Beaufort Refuse Dump
Pre-Regluatory Landfills
8/22/2019
1
All North Carolina Department of Environmental Quality (NCDEQ) GIs data is expressly provided "AS IS" and "WITH ALL FAULTS". The
NCDEQ makes no warranty of any kind, express or implied, concerning this information, including but not limited to any warranties of
merchantability or witness for any particular purpose. The NCDEQ assumes no responsibility or legal liability concerning the Data's accuracy,
reliability, completeness, timeliness, or usefulness. The data is not intended to constitute advice nor is it to be used as a substitute for specific
advice from a professional. Users should not act (or refrain from acting) based upon information in the Data without independently verifying
the information and obtaining any necessary professional advice. Users are solely responsible for ensuring the accuracy, currency and other
qualities of any products derived from or in connection with the NCDEQ's Data. The Data is collected from various sources and may be
modified over time without notice to improve spatial andattribute accuracy. The NCDEQ disclaims responsibility for the spatial accuracy and
attribution of GIS features and makes no warranty concerning same.
about:blank 2/2

Brownfields Section
Description of Dataset
• Includes program description and description of the types of sites contained in the dataset.
• Primary criteria for the data being included in this project.
The North Carolina Brownfields Program (NCBP) is established by the Brownfields Property Reuse Act for
the purposes of developing or re -developing property that is abandoned, idle, underused and that has
been impaired by the potential liability associated risk of contamination. NCBP sites consist of properties
having a Notice of Brownfields Property (Notice) recorded at a county register of deeds office. The Notice
incorporates a signed Brownfields Agreement, an associated surveyed plat map and a legal description of
the property. The recorded plat map defines the boundary of affected parcels, and shows the locations
and dimensions of the areas of potential environmental concern. Brownfield properties may include
residential, commercial, industrial, public and institutional uses.
The primary criteria for the brownfields dataset inclusion is based upon confirmed or suspected
contamination resulting from various sources including those on and off -site. The brownfields property
may or may not have an existing incident or release under another agency having regulatory jurisdiction
listed by this tool and thereby having the possibility of containing multiple known sources of
contamination for its location. In addition, a brownfields property may only have the perception of
contamination based on historical information where contaminant data does not exist.
Contaminants potentially present
Brownfields Sampling Recommendations:
• Please refer to any contaminant specific sampling of other known sources of contamination
found in close proximity or within the brownfield boundary.
• Sampling should be based upon constituents identified in the recorded Notice of Brownfields
Property
Contact Information
Program Manager:
Bruce Nicholson 919-707-8330
Program Administrative Assistant:
Shirley Liggins 919-707-8383
Western Supervisor:
Tracy Wahl 828-251-7460
Easter Supervisor:
Sharon Eckard 919-707-8379
Property Management Unit:
Joselyn Harriger 704-235-2195
[e-mail]
[e-mail]
[e-mail]
[e-mail]
[e-mail]

DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH, ENVIRONMENTAL HEALTH SECTION
ON -SITE WATER PROTECTION BRANCH
SOILlSITE EVALUATION
for ON -SITE WASTEWATER SYSTEM -
(Complete all fields in full)
OWNER: car
ADDRESS:
PROPOSED FACILIT
LOCATION OF SITE:
WATER SUPPLY: ❑ Private D Public
EVALUATION METHOD: ❑ Auger Borh
2
3
M
Sheet _ of
CDP #:
.ICANT: Ttlei itA�sv APPLICATIONDATE:3 2 23
e�'Is�c, DATE EVALUATED:
DESIGN W `.19 FLO49): PROPERTY SIZE:
2 Ilk( PROPERTY RECORDED:
0 Well 0 Spring
❑ Pit ❑ Cut
❑ Other _
TYPE OF
n
Process
DESCRIPTION
wmAL SYSTEM
REPAIR SYSTEM
OTHER FACTORS (.1946):
SITE CLASSIFICATION (.1948):
EVALUATED BY: CA
OTHER(S) PRESENT:
Available Space (.1945)
System Type(s)
Site LTAR

LEGEND
use the follolvinp standard abbreviations
SOIL
CONVENTIONAL
LPP
MINERALOGY/
LANDSCAPE POSITION GROUP
TEXTURE
.1955 LTAR"
1957 LTAR*
CONSISTENCE
STRUCTURE
CC (Concave Slope)
I
S (Sand)
1.2 - 0.8
0.6 - 0.4
SEXP (Slightly Expansive)
G (Single Grain)
CV (Convex Slope)
LS (Loamy Sand)
EXP (Expansive)
M (Massive)
D (Drainage Way)
CR (Crumb)
DS (Debris Slump)
II
SL (Sandy Loam)
0.8 - 0.6
0.4 - 0.3
GR (Granular)
FP (Flood Plain)
<1"ribbon
L(Loam)
SBK (Subangular Blocky)
FS (Foot Slope)
H (Head Slope)
Ill
Si (Silt)
0.6 - 0.3
0.3 - 0.15
A13K (Angular Blocky)
PL (Platy)
L(Linear Slope)
SiCL(Silty Clay Loam)
PR (Prismatic)
N (Nose Slope)
1"-2" ribbon
CL (Clay Loam)
R(Ridge)
SCL(Sandy Clay Loam)
MOIST
WET
S (Shoulder Slope)
SiL (Silt Loam)
T(Terrace)
VFR(Very Friable)
NS(Non-sticky)
IV
SC (Sandy Clay)
0.4-0.1
0.2-0.05
FR(Friable)
SS (Slightly Sticky)
>2" ribbon
Sic (Silty Clay)
FI (Firm) -
S (Sticky)
C (Clay)
VFI (Very Firm v. Very Sticky)
VS (Very Sticky)
O (Organic)
None
None
EFI (Extremely Firm)
NP (Non -plastic)
*Adjust LTAR due to depth, consistence, structure, soil wetness, landscape, position, wastewater flow and quality.
SP (Slightly Plastic)
P (Plastic)
NOTES
DEPTH
VP (Very Music)HORIZON
In inches below natural soil surface
DEPTH OF FILL
In inches from land surface
RESTRICTIVE HORIZON
Thickness and depth from land surface
SAPROLITE
S(suitable) or U(unsuitable)
SOIL WETNESS
Inches from land surface to free water or inches from land surface to soil colors with chrome 2 or less - record Mansell color chip designation
CLASSIFICATION
S (Suitable), PS (Provisionally Suitable), or U (Unsuitable)
Evaluation of saprolite shall be
by pits.
Lang -terra Acceptance Rate (LTAR): gal/day/ftt
Shaw profile locations and other site features (dimensions, reference or benchmark, and North)
Fv'e-Av, Pwv k

Fee Received --1`lt'IIYI� CARTERET COUNTY HEALTH DEPARTMENT
Check#_dr. or Cash 3820 Bridges St. Morehead City, NC 28557 Area
Date Received—3 Phone: [phone] Fax: [phone] Priority a
Received By: APPLICATION Date Staked4Waa�Staff Initial-W
Well Construction Permit jK*'rp3•,
IF INFORMATION IS FALSIFIED, CHANGED OR SITE IS ALTERED, THE AUTHORIZATION TO CONSTRUCT
PERMIT SHALL BECOME INVALID. PERMIT IS VALID FOR 60 MONTHS.
Parcel 1D: 730620719375000
Type of Well: Private Drinking Water Shared Drinking Water X Irrigation -A—Other
Type of Application: X New Construction Replacement Repair _ Abandonment
Proposed Use: Residential -X Commercial (Design Capacity < 100,000gpd)
MMOMM
Owner
Name: First Karl Last Blackley
Mailing Address 105 Weston Estates Way
City Carr State NC Zip 27513
Phone: Home Work 919481-3000 Mobile [phone] Fax [phone]
Email karl aprestondev com Organization Blue Treasure, LLC
Applicant If same as owner: Yes
If no, complete this section and provide owners statement.
Hudson
Name: First
Mailing Address 14b0 taSt Arlin 'Ton tsiy0
city Greenville State NC zip 27858
Phone: Home Work 252-353-2000 Mobile [phone] Fax [phone]
Email Organization Hudson Brothers Construction Company
Parcel Address: 193 Freedom Park Rd. City: Beaufort
Subdivision: Beau Coast West
Lot n/a Phase n/a Section n/a Block n/a # of Acres 5.97
Type of Facility: _ Residential _ Multifamily
XNon-Residential (describe Clubhouse -A enities
)
Improvement Permit for Wastewater System Issued: yes —no X 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

e = C'ARTERET COUNTY HEALTH DEPARTMENT �Nx
3820 Bridges St. Morehead City, NC 28557
Phone: [phone] Fax: [phone]
APPLICATION
Well Construction Permit
Owner Karl Blarklgy arcel ID:130620719375
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
odiorrnt mmnrrtv that ennid imnort amundwnter nuniity nr suitability of the site for Well constmctinn._-
(Initial) Property Is staked JJEL 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. Pees paid for application are forfeited when application is returned to applicant or agent.
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 granted right of entry to conduct necessary inspections to determine compliance
with applicable laws and rules. I understand that I am solely responsible for the proper ident(fication and staking of all
property linters aqi comers and making the site accessible so a complete site evaluation can be performed.
Property o4ner's signature or authorized agent (REQUIRED) Date
Page 2 of 3

CARTERET COUNTY HEALTH DEPARTMENT
3820 Bridges St. Morehead City, NC 28557
Phone: [phone] Fax: [phone]
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 read and understand the above disclosure:
n/a
Signature
n/a Address of proposed facility
ZVI
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 Apnlicatiions
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 .0113(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.l 1-19-15
Page 3 of 3

CARTERET COUNTY HEALTH DEPARTMENT
Environmental Health Division
3820 A Bridges Street
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 Permission to Access Property
1, Karl Blackley (p,i tJ, hereby authorize Tyler Hudson tRdral 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: 193 Freedom Park Rd. PIDN # 730620719375000
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: Karl Blackley - Blue Treasure, LLC
Address: 105 Weston Estates Way
City,, Cary State: NC Zip: 27513
Phone: [phone]
[e-mail]
Owner's Signature�7�.'\ -N 4"A ` Date: Z- z� 3

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