WS0500151_Application_20190304

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY — DIVISION OF WATER RESOURCE,
APPLICATION FOR PERMIT TO CONSTRUCT A WATER SUPPLY WELL OR WELL SYSTtM
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(Wells or Well Systems with a Design Capacity of 100,000 Gallons Per Day or Greater) a C
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PLEASE TYPE OR PRINT CLEARLY �
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant therein, I .�
application is hereby made for a permit to construct water supply wells. p
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1. Date: — FOR OFFICE USE ONLY
2. County: PERMIT NO. (� (w ISSUED DATE:
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3. Applicant T le hone: W
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Applicant's Mailing Address:
Applicant's Email Address (if available): /� C�$d ev
4. Contact Person (if different than Applicant): 5�fm R-- Telephone: 56Y Q
Contact Person's Mailing Address: ?1d
Contac Person's Email Address (if available): ^//tL
5. Property Owner (if different than Applicant): u. C. POW(r410 ZX& L6erelephone:
Owner's Mailing Address: Rim GJV(&,j 5 /(JC_
Owner's Email Address (if available):
6. Property
City:
7. Intended use of Well or Well System: _
(examples: irrigation, consumption, etc.)
8. Will the proposed water supply well or well system replace or be added to an existing well or well system?
(If yes, complete questions 7 and 8) (If no, complete question 7 and then skip to question 9)
9. Total design capacity of roposed well or well system in gallons per day (gpd): �(/7/6 k Ayy ! q gam/
10. If adding a well to an existing system, list the existing water supply wells in the existing system and
Atheir respective yields:
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11. Is this a public well or well system? �'�
If yes, give Public Water ID Number:
If yes, give Proje t Engineer and contact information:
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12. Well Contractor:
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Well Contractor Certification No.:
Well Contractor Address: '
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PROPOSED WELL CONSTRUCTION INFORMATION
1. As required by 15A NCAC 02C .0105(f)(7), attach a well
2 No. of wells to b onstructed in unconsolidated
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construction diagram of each well showing the following:
a. Borehole and well diameter✓
material:
3. No. of wells to be constructed in bedrock: _, 3
b. Estimated well depth ✓
4. Total No. of wells to be constructed:
C. Screen intervals 0 11)
d. Sand/gravel pack intervals t3lik /
(add answers from 2 and 3)
5 Estimated beginning construction date: 1�' k Zvi
e. Type of casing material and thicknesses-
f. ✓
6. Estimated construction completion date: (g
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Grout horizons
g. Well adjccopm�plletion details

Continued on Reverse
ADDITIONAL INFORMATION
As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
wd All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections, streams, or lakes within 500 feet of the proposed well or well system.
All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
The proposed well or well system.
Any test borings within 500 feet of proposed well or well system. tkw
All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.10B(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
2. As required by 15A NCAC 02C .0105(g)(3), for wells screened in multiple zones or aquifers, provide representative data on the
static water level, pH, specific conductance, and concentrations of sodium, potassium, calcium, sulfate, chloride,
and carbonates from each aquifer or zone from which water is proposed to be withdrawn.7agnesium,
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3. Attach any water use permits (if required). [e.g. Central Coastal Plain Capacity Use Area Permit is required in 15 eastern NC
counties by NC Division of Water Resources, visit: http://www.ncwater.org]
SIGNATURES
The Applicant hereby agrees that the proposed well(s) will be constructed in accordance with approved specifications and conditions of
the Water Supply Well Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina
Administrative Code, Subchapter 2C) and accepts full responsibility for compliance with these rules
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tureof Appli nt or *Agent Title of Appli nt or *Agent
�n c.+ e/ 6 UZ * If signing as Agent, attach authorization agreement stating
Printed name of Applicant or *Agent that you have the authority to act as the Agent.
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the applicant to construct
water supply wells as outlined in this Water Supply Well Construction Permit application and that it shall be the responsibility of the
applicant to ensure that the water supply well(s) conform to the Well Construction Standards (Title 15A of the North Carolina
JJ Administrative Code, Subchapter 2C).
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Si ature of Property Owner (if different thanApplicant) Printed name of Property Owner (if Aifferent than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources' Regional Office:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]

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ENGINEERING
POST OFFICE BOX 01721
RALEIGH. NORTH CAROLINA 27675 lj
PHONE: [phone]
FIRM NC LICENSE NUMBER C4222
REVISION HISTORY
REV DESCRIPTION I DATE I BY
ORIGINAL PLAN SIZE: 24' X 36"
PRELIMINARY
PLANS
DO NOT USE FOR CONSTRUCTION
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SCALE: 1 INCH =100 FEET
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PANTHER LAKE RD SUBDIVISION
PANTHER LAKE RD
WAKE COUNTY, NC
PONDEROSA GROUP LLC
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APPROVED BY: FLM
PROJECT NO.: 18070
WELL SITES MAP
C-1
SHEET 1 OF 1

ROY COOPER
Covemor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
Will Funderburk
Ponderosa Group LLC
4820 Boulder Creek Lane
Raleigh, NC 27613
Dear Mr. Funderburk:
NORTH CAROLINA
Environmental Quality
02/05/2019
Re: Preliminary Well Site Approval
Myatt Mill S/D
Water System No.: NC0392085
Wake County
On February 1, 2019, I met with Jon Frazier, P.E. and conducted a preliminary investigation
of the proposed well sites listed below. The proposed wells have been assigned Water
System Facility (WSF) Identification Numbers and Sampling Point Codes as indicated.
I WSF ID
Sampling
Well Site Description
Preliminary Latitude &
No.
Point Code
Longitude
$174 RW4
100' radius around the proposed
35°35'19"
well location at the preliminary
78042'33"
coordinates
BF5
[ RW5
100' radius around the proposed
35035'24"
well location at the preliminary
78042'51"
coordinates
BF6
RW6
100' radius around the proposed
35o35'24"
well location at the preliminary
78042'34"
coordinates
This letter is provided by the Public Water Supply (PWS) Section, in accordance with
rule .0305(b) of the Rules Governing Public Water Systems (15A NCAC 18 C), to provide
permission to drill wells at the listed sites in order to establish water quality and quantity
and suitability of the wells as a source for a public water system.
In addition, this "preliminary well site approval" is to acknowledge that, according to the
information and documentation provided, we understand that the proposed wells are
QAIIIIIIIINk—NN.�_North Carolina Department of Environmental Quality I Division of Water Resources
25 Raleigh Regional Office 1 3800 Barrett Drive I Raleigh, North Carolina 27609
�a e�naUu
+**��� 919.791.4200

located on lots so that the area within 100 feet of the wells are owned or controlled by the
person supplying the water and that the supplier of water will protect the well lots from
potential sources of pollution and construct landscape features for drainage and diversion
of pollution as required in rule .0203(1). In addition, we understand that you have
determined that the proposed well locations satisfy the minimum horizontal separation
distances specified in rule .0203 (2) and summarized in the following table:
Distance (in
Potential Source of Pollution
feet
100
• From any sanitary sewage disposal system, sewer, or sewer pipe (unless sewer is
constructed of water main materials and joints, in which the sewer pipe shall be
at least 50 feet from the well.
• From buildings, mobile homes, permanent structures, animal houses or lots,
cultivated areas to which chemicals are applied.
• From surface water.
• From a chemical or petroleum fuel underground storage tank with secondary
containment.
• From any other potential source of pollution not listed in this table.
200
• From a subsurface sanitary sewage treatment and disposal system designed for
3,000 or more gallons of wastewater a day, unless your well water source is a
confined aquifer.
300
• From any cemetery or burial ground.
500
• From a septage disposal site.
• From a chemical or petroleum fuel underground storage tank without secondary
containment
• From the boundary of a ground water contamination area.
• From a sanitary landfill or non -permitted non -hazardous solid waste disposal
site.
1,000
• From a hazardous waste disposal site or in any location which conflicts with the
North Carolina Hazardous Waste Management Rules cited in NCAC 13A.
We also understand that the owner will ensure that the lots are graded or sloped so that
surface water is diverted away from the wellheads and that the lots are not located within
the 100-year floodplain and not subject to flooding in accordance with rule .0203(4).
PWS Section "Authorization to Construct" and "Final Approval"
Subsequent to well drilling and evaluating water quality and quantity (e.g., collecting and
analyzing samples and performing a 24-hour well drawdown test) the owner must submit
an "Application for Approval of Engineering Plans and Specifications For Water Supply
Systems" to document proposed well completion (e.g., selected pump, wellhead and well
house details) and associated transmission lines, treatment and/or storage facilities and
other critical information about the public water system to the PWS Section, Raleigh
Regional Office. The regional office will check the plans and specifications submitted for the
completeness of the well and well site information. If this information is complete, the
submittal will be forwarded to the PWS Section, Plan Review Unit in Raleigh, for technical
review. If this information is incomplete, the regional office will contact the engineer for
the materials necessary to complete the submission.

in accordance with rule .0305(a) no construction shall be undertaken until the PWS Section
sues an 'Authorization to Construct" letter. In addition, in accordance with .0309(a) the
new wefts and all associated treatment, storage or transmission/distributions lines shall
mot be placed into service until the PWS Section has issued a "Final Approval." These steps
are described in the Engineering Planning and Development Guidance Document available
-n hqp://ncwater.or files/pws/planreview/EPD Guidance.pdf.
Be aware that plans, specifications and reports for the new wells must be certified bv:
Professional Engineer. Therefore, it is recommended that a Professional Engineer or
Licensed Geologist (or their designated representative) experienced in the construction of
water supply wells, conduct on -site monitoring of well construction. At a minimum, certain
critical phases of well construction such as installation and grouting of casing should be
monitored. In many situations it may be necessary to go beyond the minimum
requirements in order to protect the public health and ground water resources.
Other Agency Approvals Required
This PWS Section "preliminary well site approval" letter does not address other agency
applicable rules and requirements pertaining to well construction and registration.
Local county well construction rules and ordinances may include additional requirements.
Well construction must meet the standards specified in the Well Construction Standards
(15A NCAC 2C). Be aware that these rules require a permit to be obtained from the Water
Quality Regional Operations Section of the Division of Water Resources before a well is
constructed if it is anticipated that the new well will be part of a water system with a design
capacity of 100,000 gallons per day or greater. In addition, these rules require that wells
be constructed by a properly certified well driller. For more information contact the Water
Quality Regional Operations Section at 919-807-6338 or htti)://I)ortal.ncdenr.org/web/wq/,aps.
Sincerely,
�4
Boris Chertock
Environmental Engineer
Raleigh Regional Office
Cc: Central Files
W. Allen Hardy, Engineering Supervisor
Wake County Health Department
Consulting Engineer, Jon Fraser P.E.

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