WV0800335_Application_20230531

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
:1!! niter nrpply wells not considered 'T irnte DHnldng Rater (fells" and including irrigation, indastrlal, 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: S 20,9-3 PERMIT NO.: _ _ (to be completed by DWQ/DPH)
Fal
C.
WELL OWNER - For single family residences list the property owner(s). For all others, list name of the business,
organWation, or government agency and person delegated signature authority:
Mailing Address*
City:
Da. Tele No.:
EMAIL Address:
State:
PHYSICAL LOCATION OF WELL SITE
Parcel Identification Number (PIN) of well
County: l L
Zip vCode (08unty:
Coll No.: ,J >� `,��^ t
FaxNo7Q% :� -S ' ��LN
Address (if different than mailing address):
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WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.: � r7 i
Compan-y-Namo0-AQ-0- t A- r Contact Person: _
City: t ( `/j 1 7"' State; � n , C Zip Code ounty:-
Day Tole No.: � ) tC)_ /�D(0,L / Cell No.:
E\s.AIL Address: r FaxNo.: 9r-0-
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Form G W' 22V Pu„t I Rcvis d Gcbm: 2013

F.
G.
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 w211 not endanger human health and welfare and the
environment; and reason why construction and/or operation in accordance with the standards is not tcchnicall}' feasible
and/or provides equal or better protection of the growtdwater. ^ ^ I r
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. building
(2) Detailed site map with scale sliow'ing location of proposed well relevant to septic system(s), g
foundations, property lines, water bodies, potential sources of contamination, other vvells, 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.
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 vvells 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. 141
SIGNATURES
for Well Construction (typically the well driller)
or Type Full Name of Person Responsible for
(typically the well driller)
Construction
signature of County Environmental Health Specialist
Print or Type Full Name of County Environmental Health specialist
Per 15A A`CAC 02C .0118 the Secretary of the Diiv.sion of Water Quality' or the Div;.�iom of Public `.'_ require
submittal of information deemed necessary to make a decision on the variance. may impose a, i-'Part oflhe
ce
decision, and shall respond in writing to the request within 30 dins of recetpr of the variai.,. ': quest,t v on n°tz
applicant who is dissatisfied with the decision of the Director may commence a contested case by f hr; <
described in G.S. 150B-23 within 60 days after receipt ofthe decision
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Perm GW-22V pa Sa 2

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