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Home My WebLink AboutRBPR-01-2023-43194.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 fVater Wells"and including irrigation,industrial,and commercial wells. WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C.0108 Including monitoring and recovery wells. Print clearly or type information. Illegible submittals will be returned as incomplete. DATE: ( (7 , 20 Z 3 PERMIT NO.: (to be completed by DWQ/DPH) • A. WELL OWNER- For single family residences list the property owner(s). For all others, list name of the business, organization,or government agency and person delegated signature authority: Mari 72(-csq 3 Mailing Address: ( 0t_Jc(c s �vcic City: State: N C- Zip Code:Wiz/ County: cc Day Tele No.: 3(P 2 k7- kZ c> Cell No.: 3 - Zcf 7- 2.0 EMAIL Address: /-7f-- -1 c c ,2- rt;( Fax No.: B. PHYSICAL LOCATION OF WELL SITE (1) Parcel Identification Number(PIN)of well site: '(b o 7 (57) 3YZ P" County: Cq � (2) Physical Address(if different than mailing address): 40 Z 7 Ck 5kc,�,�15 City: State:NC Zip Code: C. WELL DRILLER INFORMATION (if known) Well Drilling Contractor's Name: NC Well Drilling Contractor Certification No.: Company Name: Contact Person: City: State: Zip Code: County: Day Tele No.: Cell No.: EMAIL Address: Fax No.: Fonn GW-22V Page 1 Revised February 2013 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. ma / c(( 7 S cc i7,7(-) g'/6 r ;�YC i'v�_ l�Z�eJ koev.,- <' �' lru-c'C�I�E' E. ATTACHMENTS—Provide the following information as attachments to this application: (I) 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 REQUIREMENTS 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 I/V 0,416- R__g-e-------- Signulu'e of Person Responsible fur Well Construction(typically the well driller) g e e c Print or Type Full Name of Person Responsible for Well Construction (typically the well driller) I / E-614, Signa e of County Environmental Health Specialist n 1f.b1I £(' d6 Print or Type Futli ame of County Environmental Health Specialist Per 15A IN/CAC 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 cis 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. 150B-23 within 60 days after receipt of the decision. Form GW-22V Page 2 Revised February 2013 Please submit this form along with a Well I North Carolina Variance Application for an existing Department of Health and Human Services private water supply well. Division of Public Health Fisting Well Variance Inspection Repoli Well Site Location: q o L? C�ham•v i -1- N .- It, 1'e 5 r a-r r 1 1..5 ) rc) N G Z,S o i 3 (Town,community,subdivision and Lot it) Address: (40 2-1 c--1A—., I a 4- �5-1 1 s 12 t)_ County: ._.._... G�.4'c.4g:,., City/ST/Zip: Ska,rt`,.I is rofc) i.1c-- 1,4L73 Date of Sit Visit:_2i?Zi?z, ( '-0s'Piv\ Well I lead ( 'oml)letion • Well Construction Date of Well Construction: V A L h a-0 r-, Is the well head 12"above land surface?YES or If unknown,was it drilled before 1972? YES o NO If no,what is the height of the casing: 6 inches If unknown,was it drilled before 7/I/2008 YE Tor Is there a sanitary well seal? YES r NO �J NO What type of well is it: Is the sanitary well seal in good repair? YES or NO �rilled Bored Hand Dug Jetted Other Are the following items present at the well head? Does the well have a cement slab? or NO Vent N D Sample Tap y f s Well Tag_(\(° Pump Tag N 0 --- Does the well appear to be grouted? YE, or NO Potential Sources of Contamination? Does the well currently meet separation requirements with known sources y�,/^� of contamination? YES or --O If no,pl ase provide distances to those it does meet: 1 � PP] ��-ei]-to l� � a� � y r�� c . Ss n ¢. t-1 via,t/...1 1 r-opoSLD 0 V Other continents: 1 Complete below. Name of person completing this form(please print):.. 3 s 5 0 N g o ytl --._.___..._____.._. SUiE �� • � ROY COOPER • Governor x4; NC DEPARTMENT OF KODY H. KINSLEY • Secretarya1 : HEALTH AND i111 ' IJ HUMAN SERVICES HELEN WOLSTENHOLME • Interim Deputy Secretary for Health • "`^^^ MARK T. BENTON •Assistant Secretary for Public Health Division of Public Health Onsite Water Protection Branch February 27, 2023 Mark and Teresa Reece 194 Douglas Rd Elkin, NC 28621 Re: Approval No.JMB2923 Private Well Located Less than 25' from Building Perimeter [Rule 15A NCAC 2C .0107(a)(2)(P)] Property location: 4027 Cheviot Hills Rd Sherrill's Ford, NC 28673 Dear Mr. and Mrs. Reece: On February 22, 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 the variance concerns a water supply well on the referenced property. A structure is proposed to be within twenty-five feet of the well. Specifically,the variance request grants you permission to use a water supply well at a distance closer than the twenty-five-foot setback to a building perimeter. Achieving the twenty-five-foot setback would be difficult given the challenges of the property. Based upon information provided by you, and the Catawba County Health Department, 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 I 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, and having a thread-less sample tap etc. 2) The well shall be sampled for the same parameters required of a newly constructed well. If samples indicate contamination, further repairs or treatment will be necessary. 3) No potential sources of groundwater contamination shall be stored near the well-head. 4) No termite treatment shall be applied to the structure within twenty-five feet of the well unless alternative methods are approved by Catawba County Health Department. 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.H.S, MS 2