HomeMy WebLinkAboutWater Permit Application�--411,0%4_NE74W 4�—771E��
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STATE OF FLORIDA. PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL
❑Southwest PLEASE FILL OUT ALL APPLICABLE FIELDS
[INorthwest (`Denotes Required Fields Where Applicable)
❑St. Johns River The water weifcnntractorkresponsible farcomplefing
South Florida ddsform and fomnrdingthepermirapplication totile
❑Suwannee River applopNdtedelegait!doutirmitywiien uppilcoble.
❑ DEP
❑ Delegated Authority (if Applicable)
1. John & Susan Testa PO Box 13296 Fort Pierce, FL 34979
2. Z401 dOt If h7Lult fwau ...,.. ,......, — — •-- -
`Well Location -Address, Road Name or Number, City
3, 1334-.7u f—uuvG—vuv— t
'Parcel ID No. (PIN) or Alternate Key (Circle One)
4.34 34S 39E St Lucie
*Section or Land Grant *Township *Range "County
5, Scott's Drilling, Inc. 11213
*Water Well Contractor •License Number
6,5014 Palm Drive
`W t r Well Contractors Address
Permit No. 59-29515
Florida Unique ID
Permit Stioulations Required (See Attached)
Clued No. Delineation No.
FUP Application No:
772-519-2316
Telephone Number
- see,C1lirOt
Lot I Block Unit
Pine Acres Check if 62-524:❑ Yes ❑ No
Subdivls)on
772-489-6117 scottsdrilting_@bellsouth.net
`Telephone Number E-mail Address
Fort Pierce FL 34982
City State ZIP
ae
7. `Type of Work: ❑✓ Construction ❑ Repair ❑ Modification❑ Abandonment -Reason tar Repair.
S. `Number of proposed Wells ONE
f W ll j•
0. *Specify Intended Uses) o
Domestic ❑ Landscape Irrigation
Agricultural Irrigation
H
Site Investigations
Monitoring
Bottled Water Supply ❑ Recreation Area Inrigation
❑
Livestock
Nursery Irrigation
❑
Test
❑ Public Water Supply (Limited Use/DOH)
❑ Public Water Supply (Community or Non-Community/DEP)®
Commercialilndustrial
Golf Course Irrigation
Earth -Coupled Geothermal
HVAC Supply
❑ Class I Injection
HVAC-Retum
Class V Injection: ❑ Recharge ❑ Commerciallindustrial Disposal
❑ Aquifer Storage and Recovery ❑ Drainage
Ran+Pdiation: ❑ Recovery ❑ Air Sparge ❑ Other
(Describe)
)(her (Describe)
0.'D'I tance from Septic System if 5200 fL '1U t" r 11. Facility Descril
3 �EM'Imated Well Depth 120 ft. -Estimated Casing Depth 100 ft.
MAY 2 9 2019
in St Lucie
on e51 ence 12. Estimated Start Date
Primary Casing Diameter 2 in. Open Hole: From To ft.
14. Estimated Screen Interval: From 100 To 120 ft.
15.'Pdmary Casing Material: Black Steel Galvanized PVC 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 her
18.°fvlethod of Construction, Repair, or Abandonment: ryr
Auger Cable Tool Jetted H d u: nt (DirectP sh)otary c
Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) Y
Horizontal Drilling Plugged by Approved iVlethod Other (Describe)
19. Proposed Grouting Interval for the Primary, Secondary, and Ad onaheasi�n�q
From--2— To 100 Seal Material ( Bentonit J Neat Cement) Other )
From To Seal Material ( Bentonite t -t.n emOther
From To Seal Material ( Bentonite Neat Cement Other
From To Seal Material ( Bentonite Neat Cement Other
Li
20. Indicate total number of existing wells on site List number of existing unused wells on site
21 1Is this well or any existingg well orwaterwi d wa orris the owner's contiguous propeD covered under a Consumptiv D!strict Well D No. (CUPM/UP)
or CUPIWUP Application? Yes No Iflvas, complete the following. Cl1PiIVUP No.
22. Latitudeftit�
23. Data Obtained From: GP5 Map Surveyapmvd.d b.owlelo, Arid trial Datum: NAD 27___---MAD 83 WGS 84
I holaby Canty thal l Nla damply vAw wo opp eable'rat .al"n0o 40. Florida AdmbiL•tmoo Code, and that. vaster 1i6pmplEifaes undo Chopla]7]. Floridongtulca ,'Io nutnlain er proPab abandon nda lar Iine ce Nu,a' I�am
use patNl a mdadat tedtofpe permit,lfasapded-haa been or el9 be obtained pilot to aommcncanell oftve0 Wao ant for Waucna,lhal lholntormodon procidedla n,xurate,and that l have Informed lha mvna oftrteh
wnrWeoan. INrlhereaatyatat all tnfotmaVon pfocidcdin athappaw0onk mariataond that vAl obtain rocppa,dbiraas as Uatedabovo. Ovner cament. to aaovdnp PCnonnd of WSVJrIDaDelenotad Auwodryaceeca
nceeasary approval (ram other ftidvN. aWla,.totalaovemmenh. ifappOeWe.7vn,ee to provide avea to U,avfea ulo tla ll ,e eohsWcdon. repalr,madiriodm,, or abandanmmt aud,nitad by Oda parAt.
abandonment
oahWctv4dtin 7a days aaereomphaanotptO wrCWcaen.repnir, modifiraaon, or
abandonment city Utbt � - rthe permi eapiioam,rAdehover orals real.
11213
gnature of ontractor
'License No. Signalu o OwnerorAgent •Date
. .
Issue Date Expiration Date AZOHydrologist Approval
Approval Granted By ltddds
Fee Received $ Receipt No. Check No.
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. pane 1 of