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HomeMy WebLinkAboutWater Wells Permitr Mission: ;,: Tg prgtect, promote & improve the health ofall people in Florida through integrated state, county & community efforts. HEALTH Vision: To be the Healthiest State in the Nation RECEIVED Governor MAY 3 12019 ST. Lucie County, Permitting 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`anyvell. a. Call the FDOH — St. Lucie Well Line at 772-873-4936 or email SLCDOH-WELLS at' ,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-WELLS[a).FLHEALTH.GOV • Submit revisions to permit and/or site reap 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 FloridaHealth.gov Accredited Health Department Public Health Accreditation Board STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, REPAIR, MODIFY, OR ABANDON A WELL ❑ Southwest PLEASE FILL DUTALL APPIUMLE FIELDS 0 Northwest ('Denotes Required Fields Where Applicable) ESL Johns River 7hewaterwelicordractorlsresponsible forcompietIng ®South Floridathis form and forwardlaythepermJtapplication tothe ❑Suwannee River opproprfatadelegatedntrthorliywhereapplicable. ❑ DEP Q Delegated Authority (If Applicable) ss-mc, r40.5lD -SP — !CQ5 t—lQ9 No. 59-29353 Unique iD Permit Stipulations Required (See Attached) 62-524 Quad No. Delineation No, CUPANUP Application No, 1 WJH, LLC/ WJHFL, LLC 3300 Battleground Avenue, Suite 230 Greensboro, NC 27410 2490 -Owner, Legal Name It corporation 'Address -city "State 'ZIP Telephone Number 2.7103 BROOKLINE AVENUE, FORT PIERCE, FL 34951 `We11 Location -Address, Road Name or Number, City 3.1301-611-0130-000-3 25 106 9 'Parcel ID No. (PIN) orAltemate Key (Circle One) Lot Block Unit 4.01 34S 39E ST LUCIE LAKEWOOD PARK "Section Check if 52-5240 Yes ❑ No or Land Grant 'Township "Range *County Subdivision 5, Scott's Drilling, Inc. 11213 772-489-6117 scoftsdrilling@bellsouth.net 'Water Well Contractor "License Number "Telephone Number E-mail Address 6.5014 Palm Drive Fort Pierce FL 34982 *Water Well Contractor's Address City State ZiP 7. *Type of Work: 0 Construction ❑ Repair ❑ Modification❑ Abandonment 8. "Number of Proposed Wells ONE °ReasonforRepalr,Modl(Icallon,orAbandonment 9. *Specify Intended Use(s) of Well(s): Domestic V ® Landscape Irrigation Bottled Water Supply Recreation Area irrigation Agricultural Irrigation ❑ Livestock ❑ ©' Site Investigations Monitoring L v L Public Water Supply (Limited Use/DOH) ❑ Nursery Irrigation ❑ Test Public Water Supply (Community or Non-Community/DEP)❑ Class I Injection Commercial/industrial Golf Course irrigation Earth -Coupled Geothermal HVAC Supply' MAY 1 2019 El HVAC Return s V Injection: El Recharge ❑ Commercial/Industrial Disposal © Aquifer Storage and Recovery ❑ Drainage ON In St Lucie edlatlon: ❑ Recovery ❑ Air Sparge ❑ Other (oescrlbe) Other tDescribe) 10. Istance from Septic System if S 200 ft, 11. Facility DescdptionSing a family residence 12. Estimated Start Date *Estimated Well Depth 120 ft. 'Estimated Casing Depth 100 ft, Primary Casing Diameter 2 1n. Open Hole: From To R 14. Estimated Screen Interval: From 100 To 120 ft, 15. `Primary 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 Other 18."Methad of Construction, Repair, or Abandonment: Auger Cable Tool Jetted QtRotal�) Sonid Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) . Hy o nt (Direct Push) , Horizontal Drilling Plugged by Approved Method Other (Describe) 19. Proposed Grouting Interval for the Primary, Secondary, and ItionaFLasitl From o To 100 Seal Material ( Bentonit ,/ Neat Cement Other ) From To Seal Material ( Bentonite a UP Other 1 From To Seal Material ( Bentonite Neat Cement Other_ } From To Seal Material ( Bentonite Neat Cement Other } 20. Indicate total number of eldsting wells on site _ List number of existing unused wells on site _ 21.9s this well or any existing well or water wC%/No on the owner's contiguous props� yt covered under a Consumptive/Water Use Permit (CUPANUP) or CUPMIUP Application? Yes If yes, complete the following: CUPMIUP No. District Well ID No. 22. Latitude j 23. Data Obtained From: GPS Map Survey I herohy aattiy that I vt0 aotnpy tvptr 0e appUeabte rules of Tido aa, Fladde AdmNlatietNe Coda, and thnl a water use peradt m aNddal redtmge twrmlt If Handed, has been or W11 he abialned pdar to etmvnencement afwetl, conetrud{ott. I MrNer pertly 'tat aU Ydmmadon provrdad br this oppVeedon Is saturate and dwt l Oat ohtav, neeeaaary epprovel tram other Iederal, stela, a local govaratnenly, If app7cable, I spree to provide a well aompladon rcpanto rho OhldolvAdfrn 30 daiq aaer onmpletlon er the wnsbucUon, repair,,00dlaoaUan, m ahan auUrorixedlryUrkperrttit,wtltapamdtexptradon,whtcheveroecuroraat a �t ---�"' 11,213 * tune of Contrat3ar —, °license No. Approval Granted By Fee Received Receipt No. lssue Datum: NAD 27 NAD 83 __ WGS e4 I cettly that am the owner *(the property, that the rnforotation provided Is morale, and Ow I am aware,ormy responsibilities under chapter 373, FINWa Slattdes, to maintain or properly abandon this wag; or, I eedlty That I am the agent for the ouar, that Ow infennatlon provided is aceutate, and that I have Informed ilia comer of their rasponalbmlla as crated above, Ownor anent'to allowing peraonnei of live UVhiD or Dalmlatod Authoriy, access to the wall ago dwbv the cx_e4qcU0n, repair, modirreadm, m Ind by Uds ponnll °Signature of Owner or AA 11111111111101111 ELVIrallon Date Check No. 'Date Hydrologist Approval loulahs THIS PERMIT KNOT 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. Page 1 of