WV0800218_Application_20190520

Mike Lewis.jpg
5/19/2019
property lines, water bodies. potential sources orcontaminatioo. other wells, e
(3) Submit a copy of the local wdl permit applieation.and site Mahretion mapf applicable).
sation relevant. to Ic variance rogtiesi such as a well inn diagram showing proposed
(4) My other info:utl
well hirer or atypical construction materiaLimethods.
F ..
OTHER 11!iiNIMUM CONS'TBUCnON REQUIREMENTS
trcriicats and those specified
Foc.waler 5Wply.��• approval of a variance will "Wre that additional cot>swctio rcqu' �
for Coastal Plain and Picdaiont aiid.
in 15A; NCAC 02C .0107 be meL Minknufn additional eoustructian.requiTe n.
Moantain neon wells arc tzter�ertoed on Attachrtteitis A and B on pager 4 and S of spplicatioa Appranial of a variance
will not be considered in cases where the specified minimum additional corutncetion r luircmcnts cannot be tDeL
G
SCGNATURE(S�
: Signatnre(s) of sty OT!Osy
Print or'Iype Well/Property Owner(s)
.
--4 ignatum of Person Responsible for.Well Coastruetioa
(fyVkally the well drifted
A. v (S �✓
Print or Type Name of Person Responsible for Weil Coastruc on
(Cipimlly the well driller)
.:
Signature of County Environmental Health Specialist
Print or Type Full Name Lwnd_Mile of County Environmental Qealt peaalist
Per ! SA NCAC 02C ,0118 the Secretary of the Division of Waver Resmuces or the ivlsion of Public Health may regttirt:
tubnrl[Id of information d_4L d nee my to nuzie o decision on the `variance. ray impose con lions ar par of the
in writing to Ox request within i0 tecei _ o the 'once re crest. A variance applicant
dechrion, acid shall: respond ' rig R9 days: oJ. pt J 9 vP�
rd.wilh:rhe decision of the; Director way conimerice a contest6d.case y frlin� a petition as lir..scribed in G.
- whoas ditwisfi .

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