HomeMy WebLinkAboutWell PermitSTATE OF FLORIDA PERIt4iTAPPLICATION TO CONSTRUCT,
RePAIIR, MODIFY, OR ABANDON A'4YElLL
�'. 0 SOuthwW PLEASE RL4 OUT ALL APr LICABLa FIE L03
❑Northwest {•Denotes Requl red Fleids Where Appilc3bia)
0St Johns River
❑South Flo dda tTfhrs form a.n �rfn,,,fcnwprrsefpoalrtfrramrrprrpF1j,
El Suwannee River Opptuptivu +egaraduurh6;IL-y reepp7Farhe
❑DEP
❑ delegated ALrthorky (if Appilcab10)
No. 59-30611
Un:quelD- - - -
Strpcfaiiona Required (See, Machad)
162-524 Quad No. - Dsilnoation Na.
CUPPMJPApplicatl;m No.
,c I I --q11, AT/ �x-�. r„ r — T r . • � Stale -LIE Telephone Number
2. .. = ,ft '4: �;
' ell Laca6 n - ddress Road turn rNum6er, City
3.
4, "Farce! ID No. IN) or Rite a .[C�}, Lot 61cxk irrli,
_ ' f ohs if 52 Yes ❑ Na
'Seca ar grant T ship e]��
r4 er W 1 C n c 'la ens Ivum er a umber E
+f
Address
err'ti
Odell Contr c± rr ddre
T. 'Typeyjm of Wor ; Cdnstrtltti Repair ❑ Nlpdifirzliun[] Abandonment
8. 'rNurrfber of Propose Wells-Remnk ?6 prFMoo
, ..
ciry lnte"dad Usem of Wei (s). ate Iarnp
mestic Landscape Irrigallon Agdculturallrrlga]on site investigaftrtslad Water Supply Recreation
r
Area Irrigation LlvesioCk fAcn]toring
Puhllo Waler Supply (Lfmiled Use/DC)H) Nursery" atian Test MAY �Y / �� n
M
Public Water 5vppiy {Community or Non-CornmunifylDEP]� Cor.le,, rlAndusinaf Earth -Coupled Geothermal
cla
Class I injection ❑❑❑❑❑ Coff Course Irdgauorn HVAC Supply
WAC Return WH atClass V Injection: ❑ Recharge ❑ CommerclevindustrTa€ Disposal ❑ Aclurier Storage and ReCoveery ❑ Orainag rtR„ ��'�
Rernadlatlan:
❑ Recovery[] Sparge ❑ Other IDeamhel VNMENTAL
EALTH
❑ Other (Od+0+tal DlTicici ilea Drly
1t7.'Df3lance from Septic S' If S•Y00 ft. 11. Fad] rp5on 12. Estimated Stan ❑2[e
13.alwat;matad Wail Depth rL •EstimateC
rlf�Y
CaslDg Depth ft. FRmaryOrs€ng diameter Tn. Open -
tad Screen Interval: 00it. - 4T -
�JANPs+ From To
imary Casing Material_ Black steel Galvanlzad 8tafnle3s Steel
Hot Cased ❑ther-
S ondary Casing: i Telescope. Casing Liner Surfaca, Casing Diameter in.
. SecandaryCasing Mat40ait Blade Steel GaNanized PVC Stainless Steel Other
IS.*Method of Construction, Reepalr, orAbandonmant Arrger Cable Tool .Tatted otary sonic
Combination (Two or More Methods) Hsnd Driven (thrall Point, Sand Point) Hydrau c o n( [DlreCt PusY[)'
Horizontal Driilig9 - Plugged. by Approved Method Other tC,rtr brl
1S. Propose^outing In or the Primary, Secondary, and rg;
Front To
Other s
Seat Material ( Bentoraie4MttCC:rr5'r
From To Seal Material [ Sentonite Other }
From To
Seal Material { SOMCnite Neat Cement Other
FrarrL To Seal 1rlaterlal { B mile !Meat Cement Otter }
20. Inalcate
total number of existing "Us on site List number of ex[sting tmused wel s on seta
T�
21.'fa this we l or cry existing well or watt: Wthdrawal on tha owner's cenriaurla roperrNs covered undera COnsurnptiverwater Use Parmt (CUPMUP)
or CLIPh+4L3P A,apt callon Yes No If yes, cvmp!ete the fU-SIE rl-lyp 4VUP No.
O: Dlslr[ot Well ID No.
21 Laiftude LongftWe
21 Data Obfained From: i GP$ Map survey Datum: tyP7D
4d 27 F 83 —:WGS 84
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aarroMLMlaexW ML&fie yi�n1ar�ln�r
S�mpkaeaai' 'CG aM1 lapau, rxaaCSuiu,,a Il lra rat a3. duh9Ararri.Yratieryf k,mMa+a�an naYr.daa [>rc>V*V OWV` A11P WXY 1S
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el[
Approval Gran lad 9y t'Iat \1- W Emratlon!?ate i l 1� L d Hy;:;0:o-7'.s• hPProvei
—Issue
Fes ReceNed- $ Receipt No, Check No. 1 ITH;j
THIS PERMIT IS NOT'VALID 6NTiL PROPERLY SfGNED SY AN AUTHORIZED OFFICER OR REPRE8ENTATPJE OF THE 41r D OR DL'LEGATELI AUTHORIPERMIT SHALL BEAVAILASLE AT THE WELL SITE OUR INGALL CONSTRUCTION,
REPAIR MWIF€CATION, 0R ABANDONMENT ACTIM-LIES.