WV0800230_Application_20190918

North Carolina Department of Environmental Quality (DEQ) — Division of Water Resources (DWR)
VARIANCE APPLICATION FOR WELL CONSTRUCTION STANDARDS:
PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C .0300
WATER SUPPLY WELLS UNDER 15A NCAC 02C .0107
All neater supply cells not considered 'Private Drinking Hater (fells" and including in1gation, industrial, and commercial wells.
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
hsluding monitoring and recovery wells.
Print clearly or type inforatatioa. Illegible submittals »,ill be retzurted as incmnplete.
DATE: September 3 20 19 PERMIT NO.:
(to be completed by DWR/DPH)
A. WELL OWNER(S) — For single family residences, list all persons appearing on property deed. For all others, list name
of the business/government agency and person and title with delegated signature authority:
Mr. David Ward
Mailing Address: 2830 Hydrangea Place
city: Wilmington State: NC Zip Code: 28403 County: New Hanover
Day Tele No.: 910-617-3657 Cell No.:
EMAIL Address: [e-mail] Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
C
(1) Parcel Identification Number (PIN) of well site: R05416-008-003-001
county: New Hanover
(2) Physical Address (if different than mailing address):
City: County:
WELL DRILLER INFORMATION (if known)
Well Drilling Contractors Name: James Laine Cornette, PG, CWD
NC Well Drilling Contractor Certification No.: 2424-A
Company Name: Applied Resource Management, PC
Code:
Contact Person: James Cornette
City: Hampstead State: NC Zip Code: 21141
Day Tele No.: 910-270-2919 Cell N
EMAILAddress: [e-mail]
Pender
Fax No.: 910-270-2988
GW-22V Variance Request Ponn Rev. 3-6-2017 Page 1

D. REASON FOR VARIANCE REQUEST — Include type of well(s) to be constructed; rule for which the variance is
being requested; description of how the alternate construction will not endanger human health and welfare and the
environment; and reason why construction and/or operation in accordance with the standards is not technically feasible
and/or provides equal or better protection of the groundwater.
The irrigation well will be drilled approximatley 15' from the SE corner of the stand alone
garage and approximatley 15' to a sewer line. The well casing will be grouted along its entirety
and will not present a threat to human health or the environment. 2. (M) and 3. (B)
E. ATTACHMENTS — Provide the following information as attachments to this application:
(1) A map showing general location of the property (including road names, NC State Route Number, distances, any
key landmarks, etc.) sufficient for finding the well location.
(2) Detailed site map with scale showing location of proposed well relevant to septic system(s), building
foundations, property lines, water bodies, potential sources of contamination, other wells, etc.
(3) Submit a copy of the local well permit application and site evaluation map (if applicable).
(4) Any other information relevant to the variance request such as a well construction diagram showing proposed
well liner or atypical construction materials/methods.
F. SIGNATURE(!
Mr. David Ward
Print Type
Signature of Person Responsible for Wel
(Typically the well driller)
Mr. James Laine Corvette, PG, CWD
Print or Type Name of Person Responsible for Tell Construction
(Typically the well driller)
Signature of County Environmental Health Specialist
Print or Type Full Name and Title of County Environmental Health Specialist
Per 1 SA NCAC 02C.0118 the Secretary of the Division of Mater Resources at- the Division of Public Health may require
submittal of information deemed necessary to nwke a decision on the variance, may impose conditions as parr of the
decision, and shall respond in writing to the request within 30 days of receipt of the variance request. A variance
applicant who is dissatisfied with the decision of the Director nray commence a contested case by filing a petition as
described in G.S. 150B-23 within 60 darts after receipt of the decision.
GW-22V Variance Request Form Rev. 3-6-2017 Page 2

G. SUBMITTAL INSTRUCTIONS
(1) For the following types of water supply wells only:
(a) Private Drinking Water Wells under 15A NCAC 02C .0300
(b) Irrigation Wells underl5A NCAC .02C .0107 with a designed capacity of less than 100,000 gallons per day
and located on the same property as an on -site wastewater system permitted by a local health department.
Prior to submittal of the variance for these types of wells, please contact your regional environmental health specialist
by visiting: http://ehs.ngpublichealth.com/contacts.htm
Submit one copy of the completed variance application to:
North Carolina Department of Health and Human Services
Division of Public Health — Environmental Health Section
On -Site Water Protection Branch
1632 Mail Service Center
Raleigh, North Carolina 27699-1632
(2) For the following types of wells only:
(a) All Water Supply Wells under 15A NCAC 02C .0107 other than the ones listed under (1) above
(b) Wells Other than Water Supply under 15A NCAC 02C .0108. If these wells are to be constructed on property
not owned by the well owner or applicant, please also attach and submit a completed Application to Construct
a Monitoring or Recovery Well System (GW-22MR) found on our website at:
http://deq.nc. gov/about/divisions/water-resources/water-resources-perm its/wastewater-branch/ground-water-
nrotection/eround-water-annlicat ions
Submit one copy of the completed
variance application to the Division
of Water Resources Regional Office
serving the area in which the well
will be located:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue,
Suite 301
Mooresville, NC 28115
Telephone: [phone]
Fax: [phone]
Z
N-SALEM \
RALEIGH
EVILLE WASHINGTON
ILL
�FAYETTEVILLE S /
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone:[phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional
Office
450 W. Hanes Mill Rd.
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22V Variance Request Form Rev. 3-6-2017 Page 3

f.