HomeMy WebLinkAboutWater Well PermitsRon DeSantis
Mission:; Governor
To protect, promote & improve the health A0
of all people in Florida through integrated r:....'
state, county& community efforts. . s� ~ it , Scott A. Rivkees, MD
HEALTH
State Surgeon General
vision: To be the Healthiest State in the Nation
Florida Department of Health in St. Lucie County
Conditions for Issuance of Water Well Permits
91
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
SLCDOH-WELLS(aFLHEALTH.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 map and associated fee within 48 hours of well
construction or abandonment.
FILE COP
Florida Department of Health
St. Lucie County. Accredited Health Department
5150 NW Milner Drive • Port St Lucie, FL 34983 Public Health Accreditation Board
PHONE: 772/462-3800 • FAX: 772/871-5360
StLuci eCountyHealth. com
STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL
❑ Southwest
❑ Northwest
PLEASE FILL OUT ALL APPLICABLE FIELDS
(*Denotes Required Fields Where Applicable)
[]St. Johns River
`+�Outh Florida
The water nardingactorthrpermiiappble lic
(--]Suwannee River
ndforwell
this form and forwarding the permit application to the
application
appropriate delegated authority where applicable.
❑ DEP
❑ Delegated Authority (If Applicable)
Permit No. 59-31072
Florida Unique ID
Stipulations Required (See Attached)
Quad No. Delineation No.
CUPNWUP Application No.
1. ryin 4-Mamn GLIH 1lW074 irnC.rerJa W. I+Kere r 5g11S7�L-LUt 208b
*Owner, Legal Name if Co ration *Address *City *State *ZIP Telephone Number
2. i loth Twi c re �lr� IJr I v�c R- P'encmc 3 `� �? ys-
*Well Location -Address, Road Name or Number, City
3. a 333 - a.;'4 - 0001- W05 Sew
*Parcel ID No. (PIN) or Alternate Key (Circle One) Lot Block Unit
4. t33 .S 3cle S-r w6j 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 Well Contractor's Address City State ZIP
7. *Type of Work: !mil Constru�ctiioon/1❑ Repair ❑ Modification❑ Abandonment
QJ
8. *Number of Proposed Wells *Reason for Repair, Modification, orAbandonment
9. *Specify Intended Use(s) of Well(s): Date Stamper
PDomestic ❑ Landscape Irrigation ElAgricultural Irrigation ❑ Site Investigations U ltO V j C
] 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 ❑ Earth -Coupled Geothermal OCT 2 3 2020
] Class I Injection ❑ Golf Course Irrigation H
HVAC Supply Gu
HVAC Return
;lass V Injection: ❑ Recharge ❑ Commerciavindustrial Disposal ❑ Aquifer Storage and Recovery ❑ Drainage
temediation: ❑ Recovery ❑ Air Sparge ❑ Other (Describe) F OH MY
Other (Describe)
10 istance from Septic System if <_ 200 ft. 11. Facility Description r'G411 G.lz./ (R P i` ��'"�' 12. Estimated Start Date
3.*Estimated Well Depth ZO ft. *Estimated Casing Depth 100 ft. Primary Casing Diameter in. Open Hole: From To ft.
14. Estimated Screen Interval: Fromloo Tot LO ft.
15.*Primary Casing Material: Black Steel Galvanized iPG—C� 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.*Method of Construction, Repair, or Abandonment: Auger Cable Tool Jetted Rota Sonic
Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) Hydraulic oint (Direct Push)
Horizontal Drilling
Plugged by Approved Method
Other (Describe)
19. Proposed Grouting Interval for the Primary, Secondary, and Addi ' C
Fromm To _100
Seal Material ( Bentonite
at 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 )
20. Indicate total number of existing wells on site
List number of existing unused wells on site
21.*Is this well or any existing or water withdra on the owner's contiguous property covered under a ConsumptiveMater Use Permit (CUPNVUP)
or CUP/WUIP Application? Yes o yes, complete the following: CUPNWP No. District Well ID No.
22. Latitude Longitude
23. Data Obtained From: GPS Map Survey
I hereby certify that I wig comply with the applicable rules of Title 40, Florida Administrative Code, and that a water
use permit or artificial recharge permit, if needed, has been or will be obtained prior to commencement of well
construction. I further certify that all Information provided in this application is accurate and that I will obtain
necessary approval from other federal, state, or local governments, if applicable. I agree to provide a well
completion report to the District within 30 days after completion of the construction, repair, modification, or
abandonment authorized by this pemnt.t, or the permit expiration, whichever occurs first.
11213
*Signature of Contractor *License No.
Approval Granted By
Datum: NAD 27 NAD 83 WGS 84
1 certify that 1 am the owner of the property, that the Information provided Is accurate, and that I am aware of my
responsibilities under Chapter 373,Florida Statutes, to maintain or property abandon this welt or,1 certify that I am
the agent for the ow
fine information provided is aomrate, and that 1 have informed the owner of their
responsibilities as scat a ve. Owner consents to allowing personnel of This wMD or Delegated Authority access
to the well site d An eponstruction, repair, modification, or abandonment authorized by this permit.
of Owner or Agent
Issue Date Expiration Date
'Date
st Approval
Initials
IC
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. �T
1. F.A.C. Effective Date: October 7. 2010 £d 1 i :'1 ✓3l r1& .� :Page 1 of 2
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