HomeMy WebLinkAboutRBPR-08-2022-41814.TIF NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
VARIANCE APPLICATION FOR 2C.0100 WELL CONSTRUCTION STANDARDS:
PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C.0300
WATER SUPPLY WELLS UNDER ISA NCAC 02C.0107
All Aver syiply walls not considered"Private Drinking!Poor rails"and tnetndi g irrigation.6 edharld,and commercial wells.
WELLS OTHER THAN WATER SUPPLY UNDER ISA NCAC 02C.0108
fiieieeirta.rorito►tg and recovery relit.
Print dearly or type information Mgt*s+ebnritfals trig be returned as incomplete.
DATE:_OctobeL19 2022 PERMIT NO.: _(to be completed by DWQMPIi)
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A. WELL OWNER-For single family residences list the property owner(s). For all others,list name of the business,
organization,or government agency adperson delegated signature authority:
imt M M QJ,Il lMwiEktyt ril c4A4.411�1
11,QA Pl 1HmG-9MAie\i Pia vDLA(3 79ST.,
Mailing Address: _521 Streaanide Lane
City; Waxiaw Via: 8173 Uoioo
Day Tele No.: _704-236-6018 Cell No.: 704-236-6018
EMAIL Address: _ziz eerthlioh tfet_: Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
(1) Paroel Identification Number(PIN)of well site: '{ri 1001 2-10 L C C4 5-
County:_Catawba
(2) Physical Address(if different then mailing address): 1400 Astoria Parkwey
City: CATA%U RAr State: lig, Zip Code: ti-*W9
C. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor':Name:
NC Well Drilling Contractor Certification No.:
Campaay Name: Contact Person:
City State: Zip Code_____ County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
Fame GW-12V Page y Revised r-d meey IOU
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 reason for the reopen is that the well may need to beput closer than 25 feel from the house in order
to avoid the supply line from the neighboring lot.
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,ctn.)sufficient for fording the well location.
(2) Detailed site map with scale showing location of proposed well relevant to septic system(s), building
foundations,property tines,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/tnethods_
F. OTHER MINIMUM CONSTRUCTION REQUIREMENTS
For water supply wells, approval of a variance will require that additional construction requirements beyond those
specified in 15A NCAC 02C .0107 be mei. Minimum additional construction requirements for Coastal Plain and
Piedmont and Mountain region wells are referenced on Attachments A and B on pages 4 and 5 of this application.
Approval of a variance will not be considered in cases where the specified minimum additional construction
requirements cannot be met.
G. SIGNATURES
Skeeter!of Person Resp.asfbk for Well Comtruction(typically the well deter)
Print er Typo Full NNW of Person Respells/Me f r Wei Construction
(typical the rsea driller)
$igoatar a of Coney E.vfraoamental Molds Spedaliet
S}C, ,:<<
Print or Type Pail Name of Comity EarfrenaunW Health Specialist
Pet ISA NCAC 02C.01/d the Secretary of the Division of Water Quality or the Division of Public Health may require
submittal of information deemed necessary to make a decision on the variance, may Impose conditions as part of the
dretston and shall respond In writing to the request within 30 days of receipt of the wrirarce request. A variance
applicant who is dissatisfied with the decision of the Director may commence a contested erase by filing a petition as
described to G.S. I S0B-23 within 60 cloys COO'receipt of the decision
Fens GW-22V Peso 2 Revised Febroery 2013
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Catawba County EnvironmentEd Heath
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