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STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL Permit No._
❑Southwest pLD%SEFILLOUTALLAPPLiCABLEFIELDS Florida Unique
O Northwest (•Denote s Required Ffe(ds Where Applicable) Per(rSQp t(I�l
❑St. Johns River
nr
OSoulh Florida owalorwolleonfracforfsraspons3fe}orcomplofing
7htsfoml and forwanilag the pennIt appllcalion lathe
El Suwannee River apprepdafodelegaredauthority whore applicable.
O DEP
0 Delegated Authority (if Applicable)
1. J O-A1
or
3. Jy -1 —V Scl--
•Parcel ID No. (PIN) crA
4._ 8q • .
'Section or Land Grant
6. •�aVe c,l f+UlllydGtOf
r
Le
Quad No. Delineation No.
No.
F L3���Z-Zvi-�
*State 'ZIP •Teleohone Numb
Lot Block Unit
Check if 62 524: Yes No
E-mallAddress
• � •
7.'Type of Work:-4 Construction _Repair _Modification Abandonment
8. 'Number of Proposed Wells 'ReosonforRepal, Modlgeatlan,arAbandonment
ED
9.'3p�ciry Intended Use(s) of Well(s):
_Domestic Landscape Irrigation Agricultural Irrigation Site Investigation
_Bottled Water Supply _Recreallon Area Irrigation Livestock Monitoring
`i Limited UseIDOH Nursery Irrigation Test
Public Water Supply ) CommerciaUlndustrial• Earth -Coupled Geothermal APR 214015
_Public Water Supply (Community or Non-Community/DEP)—Golf
Course Irrigation =HVAC Supply
_Class I Injection _HVAC Return
h Dept.
Class V Injection: Recharge_ CommerclaVlndustrial Disposal Aqulrer Storage and Recovery _Drainage St. Ude-County
of
Remediation: c
my HE
my _Recovery _AfrSparge Other(oescdba) NVIF
LTH DIVISION
so
se
_Other (Describe) (Nola: Nolan types olwells are penntuad bye given petmllung oulhan ) .
i0'D(slance from Septic System it _200 ft. _ `J s .` —11. Facility Description //iPr-- 12. Estimated Start Date
13'Estimated Well Depth 75_ft. 'Estimated Casing Depth_65 ft. 'Primary Casing Diameter_ in. Open Hole: From ---To — ft.
14. Estimated Screen Interval: From rJ To2-5 it.
l5 `Primary Casing Material: Black Steel Galvanlzed PVC Stainless Steel
NotCased Other.
16. Secondary Casing: Telescope Casing Liner Surface Casing Diameter in.
17. Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel Olher
18'Method of Construction, Repair, orAbandonment: Auger Cable Tool Jetted Rotary Sonic
Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) Hydraulic Point (Direct Push)
Horizontal Drilling Plugged by Approved Method Other (Describe)
19. Proposed Grouting Interval for the Primary, Secondary, and A04orial Casing:
From 2� To Seal Material (_Bentonlle at Cement Other 1
From Tc Seal Material �Bentonile t Cement Other )
From To Seal Material �Bentonite eat Cement Other t
FIL& opy
From To=Seal Material �Benlonl Neat Cement Other )
20. Indicate total number of existing wells onisite List number of existing unused wells on site
21,1sthiswelloranyexistingwellorwaterwllhdraw on the owner's contiguous propertycoveredunderaConsumplivelWaterUsePermit (CUP/WUP)
or CUP/WUPApplication? Yes o If yes, 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
1hemjycondy1ho11witltsmpywUhtho■ppVmbtendasat701a40,FbddaAdmWstmWoGudo,andlholawater Icwddylholtamthoownarofihoproporp;UotNobdomulbnprorlladlsaavratrVAtholtamwvoormy
usnpann0.oredVkrnl MchsMs pormlL K flooded. has boon orwtl boebtatned pdarto wounanmmonletwou- rosponsM0les undorchaptora)a. FlorHoelolulas, to meinlaa,orpmpodyabandon lhlswo%o, I caftihollam
mnsWrlloh.I(udhorcod7ylholotllNamouongovrdad lnAlsepplWonlsaavrato end that lWabtnbr Ua daentfoflho ovmv, Ihollha Wormol6n ptovldodketamb, andlhotlhwatalofinedlhe awnvofNaV
n000ssoryappmvalfrom color federal, auto, orcaleevommotds,Uappusbto.inproutopmvhto swatl rotpealtbaaecnslteledebovo. oam0teontlnlcleo0mv1n0psrsannolellhtcWMeorOsbpotedAoAodyntmss
aC,MPbdll tbnrapodl0 the elsldotwONn oo dAys sttorcomptoUcn of the consWellon, rapafr,modiOeaVan, er Whowagstoduft1he mnsw ton,mps%medukatbn,crobandonmonleuthadradbythtponra
ebondanmonteulha trod by this pomdt, orlhe pomdtaxp1m9on.whichwarocaits NIL
gnature of Contractor 'License No. r§jbnature of Owner orAgent 'Date
Approval Granted By
Fee Received $ v ReceiptNo.;
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BYANAUTI
PERMIT SHALL BEAVAILA13LEATTHE WELL SITE DURING ALL COI
Issue Date'TI Ay (1") Expiration Date LUI ,A'9 I I HydrologistApproval
mamb
Chock No.
DER OR REPRESENTATIVE OFTHE WMD OR DELEGATED AUTHORITY. THE
REPAIR, MODIFICATION. ORABANDONMENTACTIVITIES.
DEP Form: 62-532.900(1) Incorporated In 62 532A00(1), F.A.C. Elfeclive Date: October 7,2010 Page 1 o1`2