HomeMy WebLinkAboutWater Well Permits206 Y - a22
Mission:
to pt6tect promote & improve the health
of all people in Florida through Integrated
.state, county & community efforts.
Vision: To be the Healthiest State in the
tua ypc°aJOafi��� ;s
O101 IO Nn` u"ad
Ron DeSantis
Governor
Scott A. Rivkees, MD
State Surgeon General
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-WELLSCa)FLH EALTH. 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 provide notification by email to SLCDOH-WELLSCZDFLHEALTH.GOV
• 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 Accredited Health Department
5150 NW Milner Drive • Port St Lucie, FL 34983 Public Health Accreditation Board
PHONE: 772t462-3800 • FAX: 77218715360
StLucieCountyHealth.com ,
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STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL
[]Southwest
PLEASE FILL OUrALLAPPLICABLE FIELDS
❑Northwest
('Denotes Required Fields Where Applicable)
❑Sr
❑SouthFlorida
The water woRYnhpaorlsmsponslb(ororromp/oeng
❑Suwannee River
Nisfwmand fonward,'nglhepennRapp6cefiontothe
appropriate dalagaledeuthodfy Whore epp➢cable.
❑DEP
0 Delegated Authority (If Applicable)
2101
Lvts
Unique
38INTI WI
Required (See Attached)
No. Oellneetlon No,
,state 'ZIP
L I Block Unit
'County Subdivision Check it 62-524:_Yes No
JbL5— -+7Z,Z1SS8?C µ1PV0plyDe-.//Ik
;ense.Number `relephoneNumber E-mail Address
7. `Type of Work: N Construction
r_Repair _Modification —Abandonment
8.*Number of Proposed Wells 1 'Reason for Ratak, Niodigealion,orgbandanmont
9. 'Specify Intended Use(s) of Well ): D �fq^�Sq►�Qry��\y//7
_Domestic endscape Irrigation _Agricultural Irrigation Site Investigation L
_Bottled Water Supply —Recreation Area Irrigation _Livestock _Monitoring
Public Water Supply (Limited UsetDOH) _Nursery irrigation Test
Public Water supply (Communil or Non-Community/DEP)—CommerciaUinduatrial _Earth -Coupled Geothermal MAY 2 6 2020
_Golf Course Irdgalloh , HVAC Supply
_Class I Injection _HVAC Return
Class V Injection:—Rechargd _CommerclaUlndusldal Disposal Aquifer Storage and Recovery -Drainage
Remedialion: _Recovery —Air Sparge _Other (Describe) OH to St Lucie Counibe7 IR0f3MNf6ALrHEAL H
_Other(Dosgibe) (No ten Not all typos 0f� Is ere ponlitedby a given pennioing authority)
I0.'Distance from Septic System if 1200 ft. 570 f 11. Facility Description s'F C12. Estimated Start Dale
13.'Estimated Well Depth 10 a ft. *Estimated Casing Depth �a ft `Primary Casing Diameter Z in. Open Hole: From_TO_ft.
14. Estimated Screen Interval: From_Toft.
15.•Primary Casing Material:- _Black steel _Galvanized PVC _Stainless Steel
_Not Cased _Other:
1 B. Secondary Casing: _Telescope Casing _ Liner _ Surface Casing ,Diameter' In.
17. Secondary Casing, Material: _Black Steel _Galvanized _PVC _Stainless Steel Other
18.'MethodofConstruction, Repair, orAbandonment: Auger _Cable Tool _Jelled Rotary _Sonic
_Combination (Tyro or More Methods) _Hand Driven (Well Point, Sand Point) _Hydraulic Point (Direct Push)
_Horizonlal Drilling _Plugged by Approved Method _Other (Doscdbo)
19. Proposed Grouting Interval for the Primary, Secondary, and Additional Casing:
From To Seal Material tBentanite Neat Cement Other )
From Tc Seal Material {_,._8entonite_Neat Cement Olher )
From 7c Seal Material (_Bentanile_Neat Cement — Other )
From Tlr Seal Material iBentonile_Neat Cement_Other)
20. Indicate total number ofexisting wells on site List numberof existing unused wells on site
21'Is this well orany existing well orwater with rawal on the owner's contiguous property covered under a Consumptivelwater Use Permit(CUPIWUP)
_ or CUP/WUP Application? Yea oIf yes, complete the following: CUPIWUP No. Dlsldcl WeII ID No.
22. Latitude Longitude
23.Data.ObtainedFrom: _GPS `_Map _Survey Datum: _NAD27NAD83------- WGS84
a
/ / U zf- -95; li � = --
Approval Granted By � Issue Dato NoZero Expiration Date Hydrologist Appr val �a
Foe Received S Receipt No. Chock No.
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE WMD OR DELEGATED AUTHORITY. THE
PERMIT'SHALL BEAVAIL'ABLE AT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICATION, OR. ASANDONMENTACTIVITIES.