WV0800331_Application_20220317

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 trot considered "Private Drinking fflater R'ells" mid including irrigation, industrial, mid commercial wells.
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
Including monitoring acid recovers, wells.
Print clearly or type information. Illegible submittals will be returned as incomplete -
DATE: KWCh 11 , 20,�; PERMIT NO.: (to be completed by DWQIDPH)
A. WELL OWNER — For single family residences list the property o Amer(s). For all others, list name of the business,
organization, or government agency and person delegated signature authority:
r
Mailing Address: `� �� � �n 12n*A
City: � State: ! v� Zip Cod "-County: �� _ U12° i
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site:
County: {�
(2) Physical Address (if different than mailing address): Sar�Gry��c.t% Y'Y1_
City: V u Y-P- &.acj/) State: NC Zip Code:
C. WELL DRILLER INFORMATION (if known)
Well DrillingContractor's Name: 1 P&Ad
A
NC Well Drilling Contractor Certification No.: >y[ 01T1
Company Name: rDY11ContactPerson: YWA
City: State: Zip CodeCounty: r
Day Tele No.: 0 — Cell No.:
EMAIL Address: cdai 0, LdV' t .Fax No.: 0 to 22
Gum
Form CW-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.
Try 0104- rAlA I1 I r*I• / �ek,-aCkl5f 04— PYvD&rxAj / /�Y,
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 Kr Well Construction (typically the well driller)
( n r15 i Jz", i
Print or Type Full Name of Person Responsible for Well Construction
(typically the well driller)
Signature of County Environmental Health Specialist
Print or Type Full Name of County Environmental Health Specialist
Per 15A 1VCAC 02C .0118 the Secretary of the Division of Water Quality or the Division oj'Public Health map require
submittal of information deemed necessary to make a decision on the variance, map 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 map commence a contested case by filing a petition as
described in G.S. I50B-23 within 60 days after receipt of the decision.
Form GW-22V Page 2 Revised February 2013