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Home My WebLink AboutSAM-07-2023-200932.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 15A NCAC 02C.0108 Including monitoring and recovery wells. Print clearly or type information. Illegible submittals will be returned as incomplete. DATE: 1/2 S , 2(1 2-4 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, organizzaattion,or government agency and person delegated signature authority: g/PC- 4n7.4',! Mailing Address: cj L//t— 7&GP2- 9 t1 /2 7/- City: t e,r i//c T/ 1� State: /YL Zip Code"` 7Aounty:�/71-%7Y-z�R /-7 Day Tele No.: Cell No.: EMAIL Address: Fax No.: B. PHYSICAL LOCATION OF WELL SITE (1) Parcel Identification Number(PIN) of well site: County: (2) Physical Address(if different than mailing address): City: State: NC Zip Codc: C. WELL DRILLER INFORMATION (if known) it/ Well Drilling Contractor's Name: NC Well Drilling Contractor Certification No.: Company Name: Contact Person: City: State: Zip Codc: County: Day Tele No.: 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 protection of the groundwater. /' ram � � v ��.nc �Y7 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 systern(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 wil of be considered in cases where the specified minimum additional construction requirements cannot be m 7 G. SIGNATURES j Our• erson sponsible fur Well Construction(typically the well driller) r' or Ty peAl Name of Person Responsible for Well Construction (typically the well driller) Signature of County Environmental Health Specialist Print or Type Full Name of County Environmental Health Specialist Per 1 SA 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. 150B-23 within 60 days after receipt of the decision. Form GW-22V Page 2 Revised February 2013 D. REASON FOR VARIANCE REQUEST—Include type of wells)to be constructed:rule for which the variance is ban rammed; description of bow tie alternate construction will not endangerhuman health and welfare and the enviro cent;trod reason why coosa the uclios and/or operation is accordance withstandards is not technically feasible antiforvidal equal or better pro tec tion of the groaadwater. Fesi4-r5 4-.AL . 4( :5 !vs /co S lea te L.t c l( /-F 45 ,S`( • E. ATTACHMENTS—Provide the following information as attachments to this application: (1) A map showing genteel location of the property(including road names,NC State Rate Number,distances, any kcy landmarks,cm.)'efficient for raiding tine 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 oontinninstion,other wells,eta (3) Sehorit a copyofnbe local watt Permit application and site evatuatioa map(itapplkabk). (4) Any other ink relevant to the variance request sock as a well construction diagram showing proposed well liner or atypical construction inaierialsfneethode F. OTHER MINIMUM CONSTRUCTION REQUIREMENTS For water supply wells, approval of a variance will require that additional con:auction requirements beyond those specified ie 15A NCAC 02C .0107 be tact. Mieireem additional construction requirements for Coastal Plain and Pirdmoot and Mountain region*sib are referenced on Attachments A and B on peges 4 and S of this application. Approval of a variance be considered in cases where the specified minimum additional coast:action regcts cannot be G. SIGNATURES r Wei C+ascradion(typeca[ly fire well drMer) or Types of Parana ler Wel Censmtcdem (typically the well driller) Sloushers gotriresureetid Haiti Spedalst .-4ve.. t'r:ex_ Thar sr 1rype 11111 Names of Ceaaty&winsome*,Haul Specials Per HA NCAC 02C.0118 the Secretory oldie Division of Water Quality or the Division of Public Health stay require saberirtd of information dammed necessary to torahs a decision on tins i ariatc4 may impose conditions as parr of the decision. and shall respond Err writing to the request within 30 days of receipt of the *crimes request. A variance applicor.t who is dissatisfied wid:the dedsktat of the Director stay coinotence a contested apse by filing a petition as - deFOlg In Q-a 1_s0-V vrgAil¢0 drrltt q!a►wadi g(th.a cures. Fast OW-22V Pap 2 Revised February 2013 • North Carolina r sra tiffs'Jame aim with•Well Department of Health and HUMS Services I Variance! I �ss far pdsvie wateDivision of Table Health Weil Site Location: Address: 6 3S ' ��c b� `+..�.`�`� Lee n nty: Cx-i'y t i .ter City/ST/Zip: lore:i4 d NL zgf 7 Date of SiteVisit !l �� __ s Durk of Well C�ristiea: "f r 3/0 2 Is the well Mad 12"shove hod surface? 5;3'or NO It-unknown.was it drilled before 1,72? YES or NO If no,what is the height of the casing: inches Valmont,was it drilled before 7/UMW YES or NO is there a sanitary well seal? 14 or NO want type of wail is li Is the sanitary well seal in good repairlfior NO a• led Bored Hand Dug Jetted Other Are the following looms present at the well head? Dues the waif bane a cement aleb? or NO Van 1/ g Tap f ,P5 i �-( Well Tag V Pump Tag Q n Does the well appear to be grouted? 131 or NO IDoes the well currently meet separation requirements with known sources of cotarm dnation?YES or 44, Ifso,please provide distances to those it does meet Lcs • 2 + f. cot a r.4 . „, . 10�� a1 1easi- , Wei( wCl( lot -c crccf c d is Jess �1... • r°o' FA, - 7-'-3 ff,z Other rosraments: r Name of person completing this form(please print): s i Ti; Catawba County Environmental Health 414j4N#40 (580) J r / ' A (24) 2.6-•6359 4� 504 C 28.38 113 t P2 4^tJj • 0 0 Q76 Parcel: 369703237057, 6359 LINEBERGER RD 11n=60ft SHERRILLS FORD, 28673 This map/report product was prepared from the Catawba County,NC Geospatial Momiadon Services. Catawba County has made substantial efforts to ensure the accuracy of location and labekig Ydomnation comaned an this map or data on this report Catawba County promotes and recommends the independent verification of any data cordoned on this product by the user.The County of Catawba,its employees,agents,and personnel,bdiadaim,and shal not be held the use le for any�al damages,lass or lability,whether direct,indirect or consequential which arises or may tram map report product by any person entity. Copyright 2023 Catawba County NC 07/27/2023 e SEAT£ ROY COOPER • Governor .�, 21. ._.y'' NC DEPARTMENT OF KODY H. KINSLEY• Secretary � � 6S HEALTH AND HELEN WOLSTENHOLME • Interim Deputy Secretaryfor Health •:; � d_� __��_.- HUMAN SERVICES p y . 0, MARK T. BENTON •Assistant Secretary for Public Health Division of Public Health Onsite Water Protection Branch August 1, 2023 Mike Lineberger 6359 Lineberger Rd Sherrill's Ford,NC 28673 Re: Approval No. JMB3117 Private Well Located Less Than 100' to a Septic System [Rule 15A NCAC 2C .0107(a)(2(C)] Property location: 6359 Lineberger Rd Sherrill's Ford,NC 28673 Dear Mr. Lineberger: On July 27, 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 proposed to serve more than one connection. 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: 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. 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 2) The well shall be sampled for the same parameters as required for a 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 wellhead. 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