WV0300112_Application_20191003

North Carolina Department of Environmental Quality (DEQ) — Division of Water Resources (DWR)
VARIANCE APPLICATION FOR WELL CONSTRUCTION STANDARDS:
PRIVATE DRINKING WATER WELL5 UNDER 15A NCAC 02C.0300
WATER SUPPLY WELLS UNDER 1SA NCAC 02C .0107
All water stytply wells not considered "Private DrinAing 11'aler 11'ells" and including irrigallon. Industrial, and commercial wells.
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
Including moniforing and recovery svells,
Print clear(i+ of Ope lnjarmatlurr. Illegible subminnLs wliJ be returned ar lncornplrta
DATE: + 20JCJ PERMIT NOa:
(to be completed by DWR/DPFi)
A, WELL OWNERS) —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:
�1�tn �l r karn0al�
Mailing Address: 1036 `5eAtningl dyyet
City: 1 jaRVzW State: a(r Zip Code: f County: 111ion
Day Tele No.:1D1 6Z67460 /t Cell No.:�O
EMAIL Address: l�"/.�Ot//LyQMeul. C&a Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PM) of well site: n(01 1 uZ
Counry:0t'lle'+d
(2) Physical Address (if different than mailing address): 5tamy.
City: County; Zip Code:
C. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name:
NC Well Dulling ContractorCcrtification No.:
Company Name:
Contact Porson:
City: State: _ Zip Code:^ County:
Day Tele No,: Cell No,;
EMAIL Address: Fax No.:
C+W22V Variance Request Form Ray. 3•(r2017 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.
E. ATTACHMENTS. Provide the following inl'omin tioil as mmchntents w this application:
(I) A map showing general location ol'the property (including roud names, NC Slate 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
wall liner or atypical construction piaterialslmethods.
SIGNATURES)
of We11/Proptrty Owners)
Print or Type
5lgnature of Person Responsihle for Well Construetion
(Typically the well driller)
Print or'fypt Name of Person Responsihte tar Wall ConstrucNoa
x , (Typically the well driller)
Signtture of County Emironmental Haltd SpecialUt
�I C(�SDrJ fP(UI (phI I L'TPILI'i� I9I'U�✓Lv✓l J�-�CI:LIIST
Print or Type Full Name and Title of County Environmental Halt pecalm
Per !SA NCAC OIC .0I18 the Secretary of the Division of Water Resources or the Division of Public NeolJh may
require suhmitlul of injormulion deemed necessary to make a decision on Jhe variance, may impose rnrditiom as part
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 may commence a contested case by filing a
petition as described in G.S. 1 SOX23 within 60 days after receipt of the decision.
fiW-22V Vtnisnoe Request Form Rcv. 3-6.2017 Pogo 2

G, SUBMITTAL INSTRUCTIONS
(1) For the following types of water supply wells only:
(a) Private Drinking Witter Wells under 15A NCAC 02C .0300
(b) Irrigation Wells uudcrl5A NCAC .02C .0107 with a designed capacity of less than 100,000 gallons per day
and located on the same property as in on -site wastewater system permitted by a local health department.
Prior to submittal of the variance I'or these types of wells, please contact your regional environmental health
specialist by visiting: hap_-klr+.nilmhliclunlih,c mi ciun•iclr.huu
Submit one copy of the completed variance application la:
North C[u•ollmn Department of Ilcnllh nn4 Ituman Services
Division of Public Ilcalth,, ravirmmiental Health Section
On -Site Witter Protection Ilranch
1632 Mall Service Cen(er
Raleigh, North Carolina 27699.1632
(?) For the following types of wells off:
(a} Ali 1Vater Supply 1Vclls under ISA 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 an 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 (GW22MR) found on our website at:
h[ip_ dcu.nc. ov.abouCdi�isianshvater-resuuree_s+alur-rseurc`-Paiuu_,•[:+�,ucr.hranclr'eruwtC., [ r
lxn[rctinNerunn[I-�eatrr-annlicnlions —
Submi[ one copy of the contpletcd
variance application to the Division
of Water Resources Regional Office
serving the area in which the well
will be located:
Ashes'ille Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone:[phone]
Fax:[phone]
Fayetteville Regional Office
225 Green Strcct, Srrite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue,
Suite 301
Mooresville, NC 28115
Telephone:[phone]
'ax*[phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699.1628
Telephone: (919) 791A200
Fax:[phone]
Washington Regional Office
943 Washington Square Mall
1ashington, NC 27889
Telephone:[phone]
Fax:[phone]
Wilmington Regional Office
127 Cazdinal Drive Extension
Wilmington, NC 28405
Telephone: [phone]
Fax:[phone]
Winston-Salem Regional
omee
450 W. Hanes Mill Rd.
Suite 300
Winston-Salem, NC 27105
Phone:[phone]
Fax:[phone]
GW.22V Vadana Request Fo[m Rev. 3.6.2017 Poge 3

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THIS IS TO OERTIFY THAT ON THE 18TH DAY OF AUGUST 2_017 AN ACTUAL SURVEY WAS MADE UNDER MY
SUPERVISION OF THE PROPERTY SHOWN ON THIS PLAT, AND THAT THE BOUNDARY LINES AND THE IMPROVEMENTS,
IF ANY, ARE AS SHOWN HEREON.
NOTES:
1. PID:06240142
2. DEED RECORDED AT DB: 6545 PG: 404
MAP RECORDED AT PQG PG:311
3. AREA COMPUTED BY COORDINATE METHOD.
4. THIS PROPERTY MAY BE SUBJECT TO ADDITIONAL RECORDED OR
UNRECORDED EASEMENTS, RIGHTS -OF -WAY, OR RESTRICTIVE COVENANTS,
OTHER THAN SHOWN,
5. THE SUBJECT PROPERTY IS NOT LOCATED IN A SPECIAL FLOOD HAZARD
AREA AS SHOWN ON MAPS PREPARED BY THE F.E.M.A. AND FEDERAL
INSURANCE ADMINISTRATION,
6. SETBACKS SHOWN ARE PER PLAT SPECIFICATIONS,
7. PROPERTY ZONED R-40,
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