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Home My WebLink AboutRBPR-05-2023-44239.TIF NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION STANDARDS; PRIVATE DRINKING WATER WELLS UNDER ISA 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 15A NCAC 02C.0108 Including monitoring and recovery wells. Print clearly or type information. Illegible submittals will be returned as incomplete. DATE: J , 20(7/..- 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:'' :7 7/1W Mailing Address:�/ 32 V CrU )/A City: Vi.a./ e)" ,Sttate:�C Zip Code: County: (, /�' "4 � -5�" Day Tele No.: b Y ` 616 Cell No.: EMAIL Address: Fax No.: B. PHYSICAL LOCATION OF WELL SITE (1) Parcel ldenti !cati'•n umber(P yell site: County: %iiryr14 g4-V.M (2) Physical Address(if different than mailing address): City: State: NC Zip Code: C. WELL DRILLER INFORMATION(if known) Well Drilling Contractor's Name: P111/4' t S // NC Well Drilling Contractor Certification No.: 1414 4 f.5Z11 !��/ �. /N l�" - Company Name: Contact Person: City: State: Zip Code: County: Day Tele No.: ',)-' l 32- t 3 27 Cell No.: EMAIL Address: Fax No.: Form 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 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 protectiono of the groan water. l di / c e 4 - ,/b//17- t /-f(,%�;w�, ti4,t f/ w. 6 S� 0 4 o /Vie.Va jet r 4 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 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 0 ca„„, Ignature Person Responsible for Well Construction(typically the well driller) (2D‘r qdk A t\,1,)r-c l'rint or Type F 1 Name of Person Responsible for Well Construction (typically the well driller) 'f 74, Am.,.. Signature of County Environmental Health Specialist J2II CL,;� p I - Print or Type Full Name of County En ronmenlal Health Specialist Per 15A.NCAC 02C.0118 the Secretary of the Division of Water Duality 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. 150E-23 within 60 days after receipt of the decision. Form GW-22V Page 2 Revised February 2013 Catawba County Environmental Health 300,69 Itw •2328 • • • • 300.70 �? Vfi- : lL Parcel: 366801292953, 2328 CORDIA CIR 1in=50ft NEWTON, 28658 This map/report product was prepared from the Catawba County,NC Geospatial Information Services. Catawba County has made substantial efforts to ensure the accuracy of location and labeling information contained on this map or data on this report.Catawba County promotes and recommends the independent verification of any data contained on this map/report product by the user.The County of Catawba,its employees,agents,and personnel,disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct,indirect or consequential which arises or may arise from this map/report product or the use thereof by any person or entity. Copyright 2023 Catawba County NC 05/03/2023 North Carolina Please submit this farm along with a Well I Department of l lc;)l h and I luin n Services Variance Application for an e_ isring Division of Public Itcalth private►►•atersupply'well. IExisting Well Variance Inspection Report Well Site l.0c:)tlnn: L 3 L2 C. o 4,4. C-r. 4, ,Ni-,-, rdc. Ls-6 s S.r 13e.rr.....t./' W aOs J LI (1,1W,!,rumens �nhdn ill, Lot N n a,, L ) / _ Address Z 3 L$ ( a ra t c Cr - - County: G'.-}e w b C. f - City til'rZip: _N`_ 4-.,-• N c-- Z,7 r;.C8 Date ofSiteVisit. S I I IL3 - — Well Construction ell Head Coutpktion .. Date of Well Construction: Cf( 2_3 ' 2-2 Is the well head 12"above land surface' Ylior NO If unknown.was it drilled befiore 1972? YES or NO If no,what is the height of the casing:_ _ __ _ _inches If unknown.was it drilled hefore 711l20011? YES or NO is there a sanitary web seal? YCS )r NO What type of well is it: Is the sanitary well seal in good repair': YES it NO */-Dr.,_. 115.0 Bored I land Dug Jetted Other Are the following items present at the well cad? Vent / Sample Tap Does the\veil have a cement slab? YES or N )Gib / / well Tag V pump'fag v Does the well appear to be.;routed? or NO Potential Sources of Contamination? I)ne:the well currently meet separation requirements with known sources of contamination: Yl:. or NO lino.please provide distances to those it does meet:— Other comments: L... ..f ("-ii..1 f`r" 1 4,....D ,,.v)h,r .no s t-L- Ub - 20L1 — I SL S le Complete hc'lon'. Name of person completing Iltis limit (please print): Z"-c s f1 13 e 1