WS0801037_Application_20190618

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY—DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A WATER SUPPLY WELL OR WELL SYSTEM
(Wells or Well Systems with a Design Capacity of 100,000 Gallons Per Day or Greater)
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct water supply wells.
1, Date: May 15, 2019 FOR OFFICE USE ONLY
2. County: Columbus PERMIT NO. ISSUED DATE:
3. Applicant Columbus Regional Healthcare System Telephone: [phone]
Applicant's Mailing Address: 500 Jefferson St,Whiteville, NC 28472
Applicant`s 1=maif Address (if avai(able):
4. Contact Person (if different than Applicant): Rodney Merritt Telephone:[phone]
Contact Person's Mailing Address 310 East Main St Carrboro NO 27510 Sulte 380
Contac Person's Email Address(if available): rodneygowmllc.com
5. Property Owner(if different than Applicant): Telephone: [phone]
Owner's Mailing Address: Columbus Regional Healthcare System 500 Jefferson St.Whiteville, NC 28472
Owner's Email Address(if available):
6. Property Physical Address (including PIN Number): 0291.03-23-4959.000
City: Whiteville County: Columbus Zip Code:28472
7. Intended use of Well or Well System: Hospital Emergency Backup Water Supply
(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 proposed well or well system in gallons per day(gpd): 185,000
10. If adding a well to an existing system, list the existing water supply wells in the existing system and their respective yields:
11. Is this a public well or well system? No If yes, give Public Water ID Number:
If yes, give Project Engineer and contact information:
12. Well Contractor: Christopher Edward Deal/Cape Fear Drill.ing Services Inc Well Contractor Certification No.: 2548-A
Well Contractor Address: 111 E Fremont St,Suite 11 PO Box 1458 Burgaw NO 28425
PROPOSED WELL CONSTRUCTION INFORMATION
1. As required by 15A NCAC 02C.0105(f)(7),attach a well
construction diagram of each well showing the following: 2. No.of wells to be constructed in unconsolidated
a. Borehole and well diameter material:
b. Estimated well depth 3. No, of wells to be constructed in bedrock:
C. Screen intervals 4. Total No. of wells to be constructed: 1
d. Sand/gravef pack intervals (add answers from 2 and 3)
e. Type of casing material and thickness 5. Estimated beginning construction date:
f. Grout horizons 6. Estimated construction completion date: 3/ 7\___1 T
g. Well Head completion details
Continued on Reverse

ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
a. 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.
b. All existing wells,identified by type of use,within 500 feet of the proposed well or well system.
c. The proposed well or well system.
d_ Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination (such as septic tank systems,pesticide, chemical or fuel
storage areas,animal feedlots as defined in 1G.S. 143-215.1OB(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, ply,specific conductance, and concentrations of sodium, potassium,calcium, magnesium, sulfate,chloride,
and carbonates from each aquifer or zone from which water is proposed to be withdrawn.
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:l/www.ncwater.org]
SIGNATURES
The Applicant hereby agrees that the proposed weil(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
Chief Technology-Officer
Signature of A plicant or*Agent Title of Applicant or*Agent
Rodney Merritt __ *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 wells)conform to the Well Construction Standards(Title 15A of the North Carolina
Administrative Code, Subchapter 2C).
gnatu of VOper[ wner(if different than Applicant) Printed Property Oviner(if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources' Regional Office:
Asheville Regional Office Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [phone] Fax! [phone]
Fayetteville Regional Office Washington Regional Office Winston-Salem Regional Office
225 Green Street, Suite 714 943 Washington Square Mall 450 W. Hanes Mill Road
Fayetteville, NC 28301-5094 Washington, NC 27889 Suite 300
Phone: [phone] Phone: [phone] Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Phone: [phone]
Fax: [phone]
Mooresville regional Office Win ion Salo �n
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone] 7tc
or to
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GW-22W Rev.3-1-2016

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