WV0800224_Application_20190816 (2)

NOR'1I1 CAROLFNA DEYARTM€ Nl' Or ENVIRON& ENT A-M) NKFURAL RL'SOURCFS
VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION STANDARDS:
PRIVATE DRINKING WATER WELLS (;N DER 15A NCAC 02C.0300
WATER SUPPLY WELLS UN1)E• R ISA NCAC 02C .0107
All waler.mpply wells n?!cwtsrtdnd "'Praxde7Jr�r� T41ff li'elh"and Oelrtd"". imy WM, industrend_ and rnmmenctnd w g,.
WELLS OTHER THAN RATER SUPPLY UNDER 1SA NCAC 02C _010$
lwljtdirg lnun izorm, and nearer- mals.
�� rr ^rnaf cwarry� ur rvpe MJwmanan. rtr aenee quOmEtAw�sf�wrU be returnecd o irs wplete.
DATE: - 20—a PERMIT NO.: •�•� "OOZ!{m t compEclod b, I)W(1:'UE'H)
A. WELL OWNER —For single familyr ". tdcarces 11M the plap[aV ownM(f ,% For all other list name of the business,
otgani2atiun, or pvcuumflt agency' and pe son delegaled signamle authority:
MailingAcklress: _L-�UlNEF -3'.
Citv
Day Tcic N1,.: SG
EMA{L Addnra3: �. Sit ,al cep
cell
Fax
14 PHYSICAL LOCATION OF WELL SITE
(1) Palcel Ideniifiealicm Number {PIN} of wdl site Al/E
C=11v.
(2) Physical Address (if different than mailing addtcc s;q
City:
C. WELL DRILLER INFORMATION (if knuxvn)
Statc: NC Zip Code:
Well Frilling Contmctor'sNRrne: [S,L}]24 'Toj'�S
NC R'e11Driiliag Contraebn Certification No.:
Company Name. b4_A1 AT Conlacl]Px. ) : C S'
Cih - (J . !M ti a L: FUG Zip Cade b ountIl exa AlArcw_
Day{'cic No,
Cell No.:!U 39 S'19 0
EMAIL Address A-L0 C1J� If ..,.%24,11 ,V I Fax
Boll uw-z2v i ,.
+tie 1 Re.4setl Pehrvuy 2013

gp, REASON FO92 VARlIAJtiCE REQf,'FST -- 7aclude type of wells) to be construeted, rule fer which the vat
being requested; description of how the allerratc construction will not endanger human health and welfare
environment. and reason why construction and!or operation in au-xdarcc with the standards is not iceltaicaliv
and+or provides equal or better protection of the groundwater.
E. ATTACHMENTS - Provide the following inrottnition as attachntents to this application.
(1) A map show ing general location of &W property (including road natnes. NC State Route Number, distar
key landmarks, etc-) sufficient for fz.ttiing the well location.
(2) Dclailed site rr,-p with scale sltowing i0ention of pmposcd wc" relevant 10 sep is systean(s),
foundations, property tines, w-Wr bodies, polrinr ! sources of contain naton, other wells. ciL
(3) Submit a Dopy of litc local .Loll permit application and site evaluation map (if applicable).
(4) Any other infoznaiion relevant to the variance request such as a well consfMcuon diavrans showing ;
well liner or slypical consmiction matcrialslmethods.
F. SM-NATiJUE(S)
Print or .ype WeWFTol;erty (yyner�s)
Person Respouainle for Wcli Cotcirnere0u
( e}•pic,Ily the welt driller)
---_�.. G ... __ Prim, Type Nr�mc of penult Responsible for Well Const-wilon
(Typically the well driller)
—_._ Signanrrr of County $ovintcn 6t•-aith Spccin:1t—_..T—.—
Yrint or Type F1t3t Pd:aaae arxB. Tide of Cuunty 8nyirnumen,Cal l[exlYh Spe:anl7t
Per 1 dR rNCHC(2C.0)18 the b:ecrerary of the Diwsion of Water Pesoura'es or the Qi mon of Public Health MC
t'UhM tfal ofinformelion deemed nece wlly to make a decision on the variance, mqv impale condjPor.e to p
decision, and .shoot respomj in writing, to the request w ahin 30 days of receipt of the va. ance request A
applicant Who is dissatisfied with the docisior: of the Direc(or may commence a confe,ttedcase by)'JinAa p
descrfbed in J.S. 150R-23 within GG days oftr receipt of'the dects:an.
43W-22V V31kaOG: Requcsi'r omt Rev.