WV0800228_Application_20190821

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A10YTllCAJt(A,NAL'±Yttk'1"191:1;EII'1,:iiVNZON TIENTA` IJATCIKI?.,Rt:S:iIRCyS
VARIANCE APPLICATION FOR 2€..0100 WELL CONSTRUCTION STANDARDS -
PRIVATE DRINKING WATER VrTiLI.S UNMER 15A NCAC 5.".0 A30
WATER SUPPLY WEI IS bNDER I SA NCAC G-(` .aid'r
Ag w.xrr supply zrx erNsmi , ,'.! PrApre b7v k ng Ii'aarr Wef(s' and 1rcC liq lrr;gntinn. i oEur af, rxd xrwno.x:n! rrriLs.
tVCLI.S UFNER THAN WAT)C& SUPPLY UNDER 15A NCAC 9,C.0108
Imm-6, q Momrovmo ocd recovarf nxil:.
n.:.,...r_.u_ .._ .......:.. r .......:.... : u...,.: r.r» .�a...:.,..r, v: ur � .............a .... r..,.,,e., �.,..
PATE: �� /�' - -' z6�`3 PERMIT NO.: Jb V/�yl ' (u� 5c co;rys d by L4'ipT)K--lj
Al' LL OWNER - For s ogly fftmily ,wxlcnu s 1r.A the prglv_1;) o vner(s;. Fa•' all OLhcrs, cis? utae of ttu: business,
oipinizMtoa, uw gav(sn:mwL ugrepav 3omd pu wn dclepled signature Qodloi ily.
Ndailing Adirc,�v: 1-6 D p 6 64K,
C'iry; 12& It Z,'T )A .�_ Stafc: X c- Zip Cade, Cumty:
Wy Tc1e No._
'v1A1J, Addme:-N: Fax No.:
MYStc:Ar, LOCATION Of WELL SfTF
(1) Parcel Ias,7itific,31km Nurnbcr (PPhil of wah gym' %j 6 �{ �iQ XT % i !(']
County. AAktv
(2j Physical I cicr ,,� (k diff,Tell ihett Lnsilinh ad(h—: ):
crly.
WEi,L MILLER INFORMATION Cif itnnr:+)
$Laic: J �(, Zip (�Dd':
V;cll Diilfrog Cbffiractar's Nnme: e F
*fi; Wcl; lhiii';rg Coriteactcs Certific Lon No- al-i 95'
C.csrpany Nacre:
S4xctc Zip cude'l&vy Ccruntr:.tJ.e ,l Eirf..cz`
P_a: Tcic No,:
Cdi 14o.:_ 9 /0 - 31 r -oo '5
l�?fV.rkft,.gdcktiss:p�ln AvJrir a,2'ii.� � J•��xHo.�.
6 .00 7 Saui4..Jv��
Foam r;--? 111 Rlgd I Re utcf Fein u%n ]J13

U. REASON FOR V.APIANCE REQUEST — include typz of well(s) fn be misnwwd; rule far which :lie varianc. is
being re.-xsted; desumpdon of bow the alternate constructioa will rot cridangv i:urnan llea;tlt and w6fare and
enviremneazt_ and reason wits con:.soclion arwlor opermiou in ,accordance with the standards is not icc::r:icaily feasible
:atd`or pro"Ims equal err `h<twr pootec,;Eioort )f ih� gtoundrvati:s f
E. ATTACHMENT'S — Provi&, the follev:i.ig inrwr:tarion as atlxluneuts to �Ms applica vas!
(!; A map showing general location of the praaurik (including road nws es_ PC Sta,e Route Mimber, dist:utces, anti
key lanuaarks, M.) serf icient for finding dw Hell location.
(2) Detailed sae map a^:rJr scale showing location of proposed well relavani m septic syslem(sf. building
faanda!ioris proptny lines, wat=- bodies, putcrit;al soa7ccs oicontamigation, cqo ter wells. etc.
!3) Submit a copy of this, kcal well p nnet application and Bite e�.alaar:ou map (ir applicabic).
(-i) Any oti = infminaim rclevani to the rvriaacc rcqut!si such as a well construction diagram sliowmg proposed
well liner or aEypical construction mri imtiai,Slmethods.
ff. SIG;VATURE(5) � a
si;pawrs(s} o('Wrlfi Property- Ou qs)
Chad A Teeter
Print at Type WOWF,nport)
3i a o erson Res"Lsihle for WeR Coixuvettml
(Typically lbr i*cn driller)
Print or�l)-pe lVairm of Pcrsou $esponsi6f[ SYr R'd!1 Cnrisc:uctidn
(Typically tee vtdi driller)
SiglraratC of Cdu ntr P.nY.-aatncntxl Efvddt SpccialeAi
Prat or Type Full Name srul Title of 0L ntv Emimo -Riat Mnith Specialist
Per 1Sh14'Cit(:02C.0118Nee5ecrefaf-yoftheDivieionof6VaterkssaurceaO-ZjwDivision cfPuhlit Health wvrequfre
.vuhmitrai of injnrmaaon deemed necessare to made a decrmon an the variancz rnoy imnn:e conr;itions err parr eif ;he
decision, and shall mspond in wfiting to the request K;rhin 30 lux car recei;n of the variance rmijuert. A variance
applicanr who is di.rsali.cfied with the decla!on of 0w Doyctor may cammcnce a canie,tlea crier kv filing a or-'W rat o.r
described to G.S. I `OF-23 nifhA; hG derv., r.%fir rrccirr etjtrd decLrron.
Gti`-2Z"J Va:iancc Qcr.U.;St Form k.;v. 3-! 2i11 i Pagc 2

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