HomeMy WebLinkAboutWater Well Permit ApplicationMission:
To protect, promote & improve the health
of all people in Florida through integrated
state, county & community efforts.
HEALTH
Vision: To be the Healthiest State in the Nation
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
S LCDOH-WELLS(a--) 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 772-873-49.31 and speak with Environmental
Health Staff or provide notification by email to SLCDOH-WELLS(cD-FLHEALTH.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: 7721462-3800 • FAX: 7721871-5360
StLucieCountyHealth.com
— aa STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
��}} orrrrsrtr REPAIR, MODIFY OR ABANDON A WELL
❑ Southwest
p PLEASE FILL OUT ALL APPLICABLE FIELDS
x ❑ Northwest (*Denotes Required Fields Where Applicable)
2 ❑St. Johns River
: aSouth Florida The water milcontrnctorisresponsibleforcompleting
r this form and forwarding the permit application to the
r 9c�AWE'T 9 ❑Suwannee River appropriate delegutetnuthnrirytvherapplfrnLle.
❑ DEP
❑ Delegated Authority (If Applicable)
Permit No.
Unique ID 59-29543
Stipulations Required (See Attached)
I62-524 Quad No. Delineation No. I
CUP/WUP Application No.
1. WJH LLC 3300 Battleground AVE Ste 230 Greensboro NC, 27410 7724163-4143
*Owner, Legal Name if Corporation *Address *City *State *ZIP Telephone Number
2.7507 Miramar Ave Fort Pierce FL 34951
'Vl/ell Location - Address, Road Name or Number, City
3.1301-601-0072-000-7 26 5 1
"Parcel ID No. (PIN) or Altemate Key (Circle One) Lot Block Unit
4.14 34S 39E St. Lucie Lakewood Park Check if 62-524:❑ Yes ❑ No
'Section or Land Grant 'Township *Range *County Subdivision
5, Scott's Drilling, Inc. 11213 772-489-6117 scottsdrilling@bellsouth.net
'Water Well Contractor 'License Number *Telephone Number E-mail Address
6.5014 Palm Drive Fort Pierce FL 34982
*Water Woll Contractor's Address City State ZIP
7. *Type of Work: ❑✓ Construction ❑ Repair ❑ Modification❑ Abandonment
$. *Number of Proposed Wells One 'Reason for Repair, Modif� orAbmidonmant
9. *Specify Intended Use(s) of Weii(s): A D D 7¢wIIJIVVr1�/\
] Domestic ❑Landscape Irrigation ❑ Agricultural Irrigation ❑ Site Investigations
] Bottled Water Supply ❑ Recreation Area Irrigation ❑ Livestock ❑ Monitoring
] Public Water Supply (Limited Use/DOH) ❑ Nursery Irrigation ❑ Test
] Public Water Supply (Community or Non-Community/DEP)❑ Commercial/Industrial F Earth -Coupled Geothermal JUN 2 4 201E
] Class I Injection ❑ Golf Course Irrigation HVAC Supply
HVAC Return
;lass V Injection: ❑ Recharge ❑ Commercial/industrial Disposal ❑ Aquifer Storage and Recovery ❑ Drainage DOH in St Lude COL
teemediation: ❑ Recovery El Air Sparge ❑ Other (Describe) AUIRAMeNft wra
1'Qther (Describe)
0.* r istance from Septic System if 5 200 ft. _` 11. Facility DescriptionResldence 12. Estimated Start Date
*Estimated Well Depth 120 ft. *Estimated Casing Depth 100 ft. Primary Casing Diameter 2 in. Open Hole: From To ft.
4. Estimated Screen Interval: From 100 To 120 n•
5.*Primary Casing Material: Black Steel Galvanize ,/ PVC Stainless Steel
Not Cased Other:
6. Secondary Casing: Telescope Casing Liner Surface Casing Diameter in.
17. Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel Other
18,aMethod of Construction, Repair, or Abandonment: Auger Cable Tool Jetted �Rota��'� Sonic
Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) HyDirect Push
Horizontal Drilling Plugged by Approved Method Other (Describe)
19. Proposed Grouting Interval for the Primary, Secondary, and Add itio ingx
From 0 To 100 Seal Material ( Bentonite eat Cement) Other )
From To Seal Material ( Bentonite �. eemenl Other )
From To Seal Material ( Bentonite Neat Cement Other )
From To Seal Material ( Bentonite Neat Cernent Other )
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 wi wal on the owner's contiguous property covered under a Consumptive/Water Use Permit (CUP/WUP)
or CUPANUP Application. Yes Q No es, complete the following: CUPIWUP No. District Well ID No.
22. Latitude Longitude
23, Data Obtained From: GPS Map Survey Datum: NAD 27 NAD 83 WGS 84
I hureby eordfy Vial I will comply adth the appiioablu mloc of TOI. 40, Florida Admtniseativo Code, and that .—I., I certify that I am the comer of Iho property, that the informatinn provided is accurate. and that I am twmo .(my
use pemdt or anificinl rerhargn permit, if needed, has been or will be obtained prior to wmmeamment nftvell m3ponsibindas under Chapter 373, Florida Statutes. to maintain or property abandon this wea: oaf I cedily that I am
construction. I further ceitify that all information provided In this applieatton is accurate and that I vrll obtain the agent for Ihu ovrnor, that the Information provided is accurate. and that I have informed the otmor of their
necessary approval from other federal, state, or local govemments, if applicable. I same to provide a wen responsibindes as stated above. Dome consents to aliomdng personnel of this VAID or Delegated Aumorily access
completion report to the Diunictwhtien 30 days after completion of Ore construction, repair• modification. or to the tell site ,fig the canstmadrn, repair, modification, or abandonment authorized by this permit.
abandonment ' ad by this peuni4 of the permit explatlon, vrtrlcnevaf 1ONre Nst. -�
11213
'Signature of Contractor 'License No. "Signah�te of Owner or Agent 'Date
Approval Granted By
Fee Received
Issue Date(0(4 71 r 7 — Expiration Date
Receipt No. �� Check No.
Hydrologist Approval
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED 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.
Ip
F.A.C. Effective Date: October T, 2010 Page 1 of