WV0800227_Application_20190821

NORTH CA OMNA l)F,-AjZ'lMFWF OF ENVIRONMENT AND NAT.UIL'u, Rr:SOI]RC'1:S
VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION STANDARDS:
PRIVATE DRINKING WATER WELLS ENDER ISA NCAC 02C.0300
WATER SUPPLE' WELLS ENDER 15A NCAC 02C.0107
V xote, meppg7 w Av rxx rand** d "Prnrrw Dnnobn Winer We.Ys `oxd weladnig o-rgnton, and vinal, and coruix mo? wells,
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C.0108
Luludmg wumi3nnTS wed rc::usrr well:.
Prinz rleflHp or Qpe information, i&ge'Ne suBmitwki will be re(Mrfla<av iruoaplcty
DATE: 4 / ,_„�, 20/]�' PERMrr NO.: V �ZZ _(s be eomplctc6 by 1)�A'CNOPH)
A. WELL OWNER - For single 1'umil} m i(f aces list Lk prvpu y owner(s). Tor all others, fist name of dic husip�ss,
osganizaliort, or gevo•.rmcnl agency mid. pelsrnl 3elezated signature swll(06-
�-'._.1l,_1, G AA. _ I I e .r
B.
C.
Mailinp, Adclmss. )J O 1p9'0 i. X b--5 r
City: 17[ee N(. J(3SAQ6 S1a(c. PIL Zip Codc)Svg9Cou '.':_. t-!
Day Talc No. _ !`� + _ Coll No- [ to - Sa o -7� �-
FCMAiL Address: Cr C 14�a 1� l i �C��Ct.crAr: No.:
PHYSICAL LOCATION OF WELL SITE
(1) Panel ldetitificati(xi Nu-.Hx, 1'1N1 of wdl site: / / U
(2) Physical AddTuss (ifdiffuent tnan mailing
City: i r4, "5ev4c.4" Stacc: NC Zip Code:: ; Y
WELL DRILLER INFORMATION (i!'an4)%vR)
u'cil DnI ing ConLmclos's Name: C !) d'2' —'3)-a
Nc "Weli ;billing Contractor Ccrtifica6on No.: c9 19 55
Conzp�rny Name- Q ..4 fl l _ Il (fit. �> :t+� CUn26x;i S'Ct'.wn: �A.�y C�cL.lc S .�,
Ci1u: G. )'/ L . ....._..,._ SSnte �C Zip Co@u.; t)' o`( Crntnty
Dal '1'elc No.: _ Cel] N'n.: _?Z0 - i S =lrs
F.MALL Addtess:,4 � elm Ifyre. f/rite Cam" T'ax Va,.
IJC- l� Siu.tP� r Ufa
Fen n)0w,nv I'a 1
RngsaR 1.- ebfvery 20 1 3

la, REASON HOR VARIANCE REQUEST — Include type of well(s) to bo constructed; rule for which the variance is
hying rcgoestcd; description of how the alternate construction will not endanger human licalth and welfare and the
ent•irorunent, and reason why construction and/or operation in accordance with the standards is not technically feasible
and/or prnides equal or better protection of the groundwater.
LASS ,Emit � '2 r , f: o r .r- 416— LL / 4
E. ATTACMMF NIS — Provide tho following information as attachments to this application:
(1) A snap showing general location of the property (including road rian,cs. NC State Route Number, distances- an}
kev landmarks, etc.) sufficient for finding the well location.
(2) Detailed site ntap with scale showing location of proposed well tolevant to septic s?stem(s). building
rouridations. property lines, water bodies, potential sources of contamination. other wells, etc.
(3) Submit a copy of the local well permit application and Site cNaluation snap (if applicable)
(4) Any otlter infolriation relevant to the Variance request such as a well construction diog"vi showing proposed
well liner or atypical conslruction ntateriaisfinethods.
F. SIGNATURE(S)
—U
Signafure(s) of WetVProperty OT tier(s)
`9
Print ar T. pe Weil.Troperty Owner(s)
sigrto uyr or un R,xpunsihte For Well Construction
ypically the well driller)
Print or Typr Nome of Pcrwn ll apuusibk for Wdl Constrrrcliun
(Typically the well driller)
Si}pocdme of Connty Emimnmemtal health SpecialM
Print or Type Full Name and Tittc of Coanty i3nvirnnmental Health Specielim
Per 15A NC'AC 02C.Ot 18 the ,Secretary ofthe Division of WaterResonrces or the Drvision ejPulihc fleolth mere require
submittal of tnformotion deemed necessary to make a derision on the variance, may impose condrdons cis part of fhe
decision, and sha11 rc.epond in writing to the rcgnest within 30 days of receipt of the variance req-uew A variance
applicant who is divsatrsffed wah the decision of the Director may commence a cnnte.eted cave by f+fing n petition as
described in G-S 1508-23 w;lhin 60 days after receipt of'rW derision.
Gw'-2 V V.vancc R2 quest norm Re, 3-6-Nf17 l'are2

A
4/0