HomeMy WebLinkAboutEHPR-12-2022-42954.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 15A NCAC 02C.0107
All water supply wells not considered"Private Drinking Water Wells"and Including irrigation.industrial,and commercial wells.
WELLS OTHER THAN WATER SUPPLY UNDER ISA NCAC 02C.0108
Including monitoring and recovery wells.
Print dearly or type information. f/legible submittals will be returned as incomplete.
DATE: FE!J 'T , 20 aq 3 PERMIT NO.: (to be completed by DWQ/DPH)
A. WELL OWNER—For single family residences list the properly owner(s). For all others, list name of the business,
organization,or government agency and person delegated signature authority:
E&A I61_11Ck
Fi4r'i L0�� 7 S l bet14 51- S i-6ksv, Ile, �e 5i�v7?
Mailing Address: 3 7 C +�►�ppI/5 Enik_ i<i✓
City:'5tf /-i 5 State: Ae, Zip Coder v'6732ouunty::/ C -I-At/MA
Day Tele No.: 70 CP—8�"3`6/57 Cell No.: 7 O4 213-
EMAIL Address:e Ltd CO Fax No.:
B. PHYSICAL LOCATION OF WELL SITE Q � Q `
(1) Parcel Iden ification Number(PIN)of well site: C! /' 1- r 3 3-/ L/5---
County: (il-(4 14JM LOT- So
(2) Physical Address(if different than mailing address): _
-37 )7 ('A . 162-2 0r
City: 5/4C/24,//S !-tee State:NIC Zip Code: g6 7
C. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: A/tc
NC Well Drilling Contractor Certification No.:
Company Name: Contact Person:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
FomrOW-22V Page I Revised Fcbrasry2013
D. REASON FOR VARIANCE REQUEST—Include type of well(s)to be constructed; rule for which the variance is
being requested; description of bow 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.
Vanetncp YL2ectex C 5 C Afe,11l'n 4e, lit
41 5-h 5e 4iL- w h irh `��{ 'gh VI Well,
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. OTHER MINIMUM CONSTRUCTION REQUIEM'S
For water supply wells, approval of a variance will require that additional construction requirements beyond those
specified in 15A NCAC 02C .0107 be met. 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
ignatu of Person Responsible for Well Construction(typically the well driller)/// �t�1 j4��/f'
Print or Type Full Name of Person Responsible for Well Construction
(typically the well driller)
S a ture of County•E s'irinmental Health Specialist
>
Print or Type Full Name of County En iroamental Health Specialist
Per 15A NCAC 02C.0118 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
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. 1SOB-23 within 60 days after receipt of the decision.
Form GR+-22V Page 2 Revised February 2013
Please submit tltis_fornr along with a Well
North Carolina Variance Application for an existing
Department of Health and Human Services private water supply welt
Division of Public Health
l:\isting Well Variance Inspection Repots
Well Site Location: 1-- J J e F r ') 1\J G C G 1- c vv Lc, 6 ? 7 0 L q s-9.3 Li Z
(Town,community,subdivision and Lot ti)
Address:_3- / 7 C= r ;13 00 0 r County:_ . -1- , ,y.... c.`.
City/ST/Zip: slr,Q., r r I!-t e r j Nf 2Y61 3 Date of SiteVisit: ( I l
I /-C ILL
T— -
Well Construction
Well Head Completion
Date of Well Construction: t /A _ Is the well head 12"above land surface. YE or NO
If unknown,was it drilled before 1972? YES or If no, what is the height of the casing:. inches
5
If unknown,was it drilled before 7/1/2008. YIDS r NO Is there a sanitary well seal? l r NO
What type of well is it: Is the sanitary well seal in good rcpau?YES or NO
(131114 Bored Hand Dug Jetted Other Are the folio\,'ng items present at the well I ad?
Vent Sample Tap
Does the well have a cement slab? YES or NO - ---_ - —
�� Well Tag Pump Tag
Does the well appear to be grouted?CYE� Jor NO
Potential Sources of Contamination?
Does the well currently meet separation requirements with known sources of contarnination? YL or NO i
If no,please provide distances to those it does meet:_ Vc, r- ,;,r,% - r�c v) S ' +' s 1 1,:A -r^p r
L7 -\S+.r.+c-1`•" 6r S <' 'N -1�JCI ,' ). �1 4,.._ _K�_`_ _- _I_0,._ ° 2'Y-' 3"E'.`,
f
Other comments:
Name of person completing this form(please print): j 5, '1 l? y ) g-S I i 0
NOTES:
LEGEND
•PROPERTY MAT BE SUBJECT TO RECORDED OR PHYSICAL SURVEY
UNRECORDED RENTS OF WATs OR PAEEIENTS -__ FOR
NOT OBSERVED R\W REOHT-OF-WAY MEGAN D.BLACK
•TUTS swrrtY WAS PERFORATED WHOM PIE BENEFIT J PB 33-145 c\L EDGECEITREPOf PAVEMENT
OF A TIRE SEARCH.
•ACORN TO YEAR ALL SETBACKS AND ZONING POE PUBLIC DRANACE EASEMENT
REGULATIONS PRIOR TO ANY PIAJWNG OR LOT#31
CONSTRUCTION. SSE UTILITY POLE LOT
EASEMENT 3715 CARIBOU DR-SHERRILLS FORD,NC
•OINEN4UNS Of ALL IARROMDADDS SNOW ON / I I tt 1 T POLE LOT R29&M30,HIGHLAND LIEN,MAP 1
TNB PEAT MOULD NOT BE SCALED OR RECCU
UPON FOR DESIGN OR CONSTRUCTION WITHOUT r ovERNEAn UTILITY UNE
A FIELD sERRxoox of Ad.ON_TrEU. / I FENCE MOUNTAIN CREEK TOWNSHIP,CATAWBA COUNTY,NC
PROPERTY CORNER MARKERS ME FOUNO CORNERS 14 R3M I SCALE:1'•SD'
•MIENS ORENWSE NOTED AS'SET". S B'21'B 2•:,. ' I --.-R\W USE
•'"6 PR°°`" 0 NOT TOLOCATED`"A E00 TM BOUNDARY LANE DEDMON SURVEYS
FLOOD PUN ACCORDING ID THE CUFREHT MIA SUP -. s s In ROM
Pi, , T a ___�; ROBERT DEDMON,PLS O3Bg9
CHUCKPOOVEY,PL58�762
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J M i i 3704 NC HIGHWAYW6 NORTH
IJ P.O.BOX 494-DENVER,NC 28D37
i v506 AC+- 8 314 9 0 8
4 'dV' PB 33-145 I LICENSE NO.Co453
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CDrVO R0d1UB Length chord chore Beer. PR 33-145 g`ROM / 0
Cl 805.34. 8.48. 8.48' 8 01`88'29•E
c2 447.70' 280.08. 278.52' B I0.27'04'W LOTS28 / / SITE
03 322.60' 38.70' 38.88' 8 25.12'02'W / T
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.d ,�o''., ROY COOPER • Governor
-i, li., NC DEPARTMENT OF
W t HEALTH AND KODY H. KINSLEY• Secretary
HUMAN SERVICES HELEN WOLSTENHOLME • Interim Deputy Secretary for Health
•.k ",o'_ MARK T. BENTON •Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
March 20, 2023
Megan Black and Elliot Rothman
627 S Mulberry St
Statesville, NC 28673
Re: Approval No. JMB2949
Private Well Located Less Than 100' to a Septic System [Rule 15A NCAC 2C
.0107(a)(2(C)]
Property location:
3717 Caribou Dr
Sherrills Ford, NC 28673
Dear Ms. Black and Mr. Rothman:
On March 17, 2023, the On-site Water Protection Branch received your request for a
variance from the Well Construction standards, Title 15A North Carolina Administrative
Code Subchapter 2C .0100. The request for a variance concerns a water supply well on
the referenced property currently serving one well. Another home is proposed to connect
to the well.
Specifically, the variance request grants you permission to use an existing water supply
well at a distance closer than the one-hundred-foot setback to a septic system. Achieving
the one-hundred setback would be difficult given the challenges of the property.
Based upon information provided by the Catawba County Health Department, and the
property owner, it is my finding that based upon current conditions as the site exist
today (as well as the current proposal for use of the structure) you meet the conditions
necessary for approval of a variance as specified by 15A NCAC .0118 (a) (1) and (2).
On that basis and if the following conditions are met, the requested variance is
approved:
NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH
LOCATION:5605 Six Forks Road,Raleigh, NC 27609
MAILING ADDRESS:1642 Mail Service Center, Raleigh, NC 27699-1642
www.ncdhhs.gov • TEL:919-707-5874 • FAX:919-845-3972
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
1) The well/wellhead shall meet all current 2C. 0100 standards, including but not limited
to being properly grouted, terminated at least 12" above land surface, properly
sealed, having a thread-less sample tap etc.
2) The well shall be sampled for the same parameters as required for newly constructed
well. If samples indicate contaminants, further repairs/treatment may be required.
3) No potential sources of groundwater contamination shall be stored near the well-head.
The granting of this variance is for the well location only. It in no way relieves the owner
or agent from other requirements of the North Carolina Well Construction Standards
including, but not limited to the requirements in 15A NCAC 2C .0113(b)to repair or to
abandon any well which acts as a source or channel for the migration of contamination.
This approval does not imply sufficient water quality. Further, the approval does not
relieve your responsibility to comply with any other applicable Federal, State, or local
laws or regulations.
If you have any questions regarding this variance, please contact me at (828) 713-3335.
Sincerely,
John M. Brooks R,E.1-1.S, MS
2