HomeMy WebLinkAboutSLC Conditions for Issuance of Water Well PermitsMission:
To protect promote & improve the health
of all people in Florida through integrated
state, county & community efforts.
Ron DeSantis
Governor
H tit Y'6.d�
HEALTH
Vision: To be the Healthiest State In the Nation
Florida Department of Health in St. Lucie County
Conditions for Issuance of Water Well Permits
Effective July 24, 2017
Contact the Florida Department of Health in Saint Lucie County (FDOH —St. Lucie)
prior to constructing or abandoning any well.
a. Call the FDOH — St. Lucie Well Line at 772-873-4936 or email
SLCDOH-WELLS(a)FLHEALTH.GOV
b. Provide the following information:
i. Permit number
ii. Driller name
iii. Address
iv. Date and time to begin construction/abandonment
A minimum of 24 hours' notice is required before constructing any public water supply
wells. Please call our main office at 772-873-4931 and speak with Environmental
Health Staff or prouidei6otification by email to SLCDOH-WELLSCaD_FLHEALTH.GOV � ?,;: A°;�;
Submit revisions to permit and/or site map and associated fee within 48 hours of well
construction or abandonment.
Florida Department of Health
St. Lucie county • Division of Disease Control and Health Protection
Bureau of Environmental Health
5150 NW Milner Drive
Pad St Wde, FL34983
PHONE: 7721873-4931 • FAX: 7721596-1306
FloridaHealth.gov
Accredited Health Department
Public Health Accreditation Board
5&-5 F- iq f M°
STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR
ABANDON A WELL
D Southwest
PLEASE FILL OUT ALL APPLICABLE FIELDS
D Northwest
("Denotes Required Fields Where Applicable)
D St. Johns River
Florida
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LI Suwannee River
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❑ DEP
D Delegated Authority (If Applicable)
UniquelD 59-29545
Stipulations Required (See Attached)
Quad No. Delineation No.
UP Application No.
1. WJH LLC 3300 Battleground AVE Ste230 Greensboro, NC 27410 772-4534143
'Owner, Legal Name if Corporation "Address -city 'State *ZIP Telephone Number
2.7002 Penny LN Fort Pierce FL 34951
'\Nell Location -Address. Road Name or Number, City
3.1301-611-0180-000-4 10 109 09
'Parcel ID No. (PIN) or Alternate Key (Circle One) I, _ t(-�" Lot Block Unit
4.01 34S 39E St. Lucie L6i.kPto, d \ r''r"k— Check if 62-524:❑ Yes ❑ No
'Section or Land Grant "Township *Range "County Subdivision
5. Scotts Drilling, Inc. 11213 772-489-6117 scottsddiling@bellsouth.net
'Water Well Contractor 'License Number 'Telephone Number E-mail Address
6.5014 Palm Drive Fort Pierce FL 34982
'Water Well Contractor's Address City State ZIP
7. Type of 0fork: ❑✓ Construction ❑ Repair ❑ Modification❑ Abandonment
8.'Number of Proposed Wells One
9. `Specify Intended Use(s) of Well(s):
'RewanfmRepa'v. NoS�,orAbandorvneN
Jj
pmmnyn
✓❑ Domestic Q Landscape Irrigation
❑ Bottled Water Supply Lj Recreation Area Irrigation
Agricultural Irrigation
Livestock
❑
❑
Site Investigations
Monitoring
❑ Public Water Supply (Limited Use/DOH)
❑
Nursery Irrigation
❑
Test
JU N 6 2019
Public Water Supply (Community or Non-CommunitylDEP)❑
CommerciaVlndustrial
n
Earth -Coupled Geothermal
Class I Injection
❑
Golf Course Irrigation
fLH�J
HVAC Supply
HVAC Return
lass V Injection: ❑ Recharge ❑ CommerGaVintlustrial
Disposal ❑Aquifer Storage and Recovery ❑ Drainage
DOH in St Lucie CofTH
demediation:❑ Recovery❑ Air Sparge ❑ Otter
(0esmbs)
n�ItIher (Oesc3e)
/ io.'Idistanoe from Septic System if 5 200 ft. _*_�S 11. FacirrtyDescriptionKBSidenee 12. Estimated Start Date
` .'Estimated Well Depth 120 ft. `Estimated Casing Depth 100 ft. Primary Casing Diameter 2 in. Open Hole: From _To _ft.
14. Estimated Screen Interval: From 100 To 120 ft.
15.'Primary Casing Material: Black Steel Galvanized '� PVC Stainless Steel
J V J"jti Not Cased 'Other.
r
16. Secondary Casing: Telescope Casing Liner Surface Casing Diameter in. -
17. Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel Other
18.'Method of Construction, Repair, er Abandonment: Auger Cable Tool Jetted Rotary Sonic
Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) H olnt (Direct Push)
Horizontal Drilling Plugged by Approved Method Other (oesuibei
19. Proposed Grouting Interval forthe,Primary, Secondary, and AdAitlenSTCHintri,
From B
To 100
Seal Material (
Bentonite
,/ Neat Cement )
Other )
From
To
Seal Material (
Bentonite
Other )
From
To
Seal Material (
Bentonite
Neal Cement
Other )
From
To
Seal Material (
Bentonite
Neat Cement
Other )
20. Indicate total
number of existing wells on site
List number of existing unused wells on site
2 Lots this well or any existin�well or water withdrawal-dr the owner's contiguous property covered under a Consumptive/Water Use Permit (CUPAA]UP)
or CUPANUP Application. Yes No yes, complete Ore follovnng: C lWUP No. District Well ID No.
22. Latitude Longlfude
23. Data Obtained From: GPS Map Survey Dalum: _NAD 27 _NAD 83 WGS 84
I ae mMrable ndn of Tda 40. Florida Admwml ap& ecd, and my a vutn Iru4NTmlem be wvnv of Ae weoMY. mm Pa h,rwma4on waddedh amvole.oMd
11213j
°License No. 'Signajord'of Owner or Agent "Date
Approval Granted By +�� Issue DateWfif 2017Expiration Dale /L/(� Hydrologist Approval
T 1� WJila
Fee Received S Receipt No. Check No.
THIS PERMIT IS NOT VAUD UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE IMAD OR DELEGATED AUTHORITY. THE
PERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICATION, OR ABANDONMENT ACTIVITIES.