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STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL
❑Southwest PLEASE FILL OUT ALL APPLICABLE FIELDS
❑ Northwest ('Denotes Required Fields Where Applicable;
❑ St Johns River
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❑Suwannee River twpiopddlndeleyatedouMotliyvhereappOmLle
❑ DEP
• Delegated Authority (If Applicable)
(Permit No. 59-29548
Florida Unique ID
Pemtit Stipulations Required (See Attached)
62-524 Quad No. Delineation No
3300 Battleground AVE Ste 230 Greensboro, NC 37410
or Number, City
772-453-4143
Telephone Number
3.1301-613-0042-000-5 7 138 11
*Parcel ID No. (PIN) or Alternate Key (Circle One) Lot Block Unit
4.12 34S 39E St. Lucie Lakewood Park Check it62-524:❑ Yes ❑ No
'Section or Land Grant 'Township 'Range "County Subdivision
5. Scotts Drilling, Inc. 11213 772-489-6117 scottsddlling@bellsouth.net
'Water Well Contractor %cens"e Number *Telephone Number E-mail Address
6.5014 Palm Drive Fort Pierce FL 34982
-Water Well Contractors Address City Stale ZIP
7. 'Type of Work: ❑✓ Construction ❑ Repair ❑ Modification❑ Abandonment
8. *Number of Proposed Wells One 'ReasonfmRepah. f a. _
9. 'Specify Intended Use(s) of Well(s): E ' l
✓ Domestic Landscapelrrigation Agricultural Irrigation Site Investigations
Bottled Water Supply ® Recreation Area Irrigation Livestock ® Monitoring
❑ Public Water Supply (Limited Use/DOH) ❑ Nursery Irrigation ❑ Test JUN 5 2019
®Public Water Supply (Community or Non-CommunitylDEP)® Commercialflndustrial Earth -Coupled Geothermal
Class I Injection Galf Course Irrigation HVAC Supply
HVAC Return
Class V Injection: ❑ Recharge ❑ CommerclalAndustrial Disposal ❑ Aquifer Storage and Recovery ❑ DrainalFEDH In St Lude County
RemediatiomE] Recovery❑ Air Sparge ❑ Other (Dmmlho) ENV( ONMENTALbdgAL1
❑/O/ther (Dc.mIx:)
t�oistance from Septic System if 5 200 ft. '1,5' 11. Facility Description esl ence 12. Estimated Start Date
13.`Fstimated Well Depth 120 It. '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, ✓ PV Stainless Steel
Not Cased Other:
16. Secondary Casing: Telescope Casing Liner Surface Casing Diameter in.
17. Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel Other
I S.'Method of Construction, Repair, cr Abandonment: Auger Cable Tool Jetted ✓ Rotary Sonic
Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) Hy ,Ic dnt (Direct Push)
Horizontal Drilling Plugged by Approved Method Other (Descota)
19. Proposed Grouting Interval for the Primary, Secondary, and Additional Casing:
From o To 100 Seal Material ( Bentonite Neat Cement Other )
From To Seal Material ( Bentonite Neat Cement Other )
From To Seal Material ( Bentonite Neat Cement Other )
From To Seal Material ( Bentonite Neat Cement Other 1
20. Indicate total number of existing wells on site List number of existing unused wells on site
21.'Is this well or any existing well or water withdra the owners contiguous property covered under a ConsumptiveANater Use Permit (CUPAAfUP)
or CUPANUP Application? Yes No If)+es, complete the foltowing: C N UP No. District Welt ID No.
22. Latitude Lon
23. Data Obtained From: GPS Map Survey Datum: _NAD 27 _NAD 83 WGS 84
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11213
'Signature of Contractor 'License No. 'Signalur�ewnerer Agenl ^Date
BELOW THIS LINE -FOR OFFICIAL USE ONLY
Approval Granted By Issue Date Exp,.Ucn Date Z �d ydrotogist Approval
Alvah
Fee Received S Receipt No. Check No.
THIS PERMIT IS NOT VALID UNTIL PROPERLY IGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE WMD OR DELEGATED AUTHORITY. THE
PERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICATION, OR ABANDONMENT ACTIVITIES,
Mission:
To protect, promote & improve the health
of all people in Florida through integrated
state, county & community efforts.
•��e,bIrtl �I�(�
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
Ran DeSantis
Governor
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 provide notification by email to SLCDOH-WELLSaFLHEALTH.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 • Division of Disease Control and Health Protection
Bureau of Environmental Health
5150 NW Milner Drive
Port St Lucie, FL 34983
PHONE: 772/873-4931 • FAX: 772/595-1306
FloddaHealth.gov
Accredited Health Department
Public Health Accreditation Board