HomeMy WebLinkAboutWell Water PermitWE
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)
El St. Johns-Rlvel;-,
South Floritjai`
The waterwellcontractorisresponsiblefor completing
El Suwannee River
this form and forwarding the permitapplication to the
appropriate delegatedouthority where applicable.
❑ DEP
❑ Delegated Authority (If Applicable)
No.
Unique ID
Stipulations Required (See Attached)
62-524 Quad No. Delineation No.
CUP/WUP Application No.
1. John & Danielle Hendry 5 li Akf r\1w`. eZ) � � waY, C, , -� 1-`'St� f�_ 3� �� &1.,- 772-834-8898
Owner, Legal Name if Corporation -Address *City *State *ZIP Telephone Number
2. 18100 Wagon Wheel Lane, Fort Pierce FL
-Well Location - Address, Road Name or Number, City
3.3211-701-0004-000-7 2
*Parcel ID No. (PIN) or Alternate Key (Circle One) Lot Block Unit
4.11 39S 38E St Lucie Carlton Country Estates Check if 62-5240 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: Q Construction ❑ Repair ❑ Modification❑ Abandonment
8. *Number of Proposed Wells 01"l - 'Reason for Repair. Modification, or Abandonment
9. *Specify Intended Use(s) of Well(s): Date Stamp
Domestic ❑ Landscape Irrigation [] Agricultural Irrigation H
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)❑ Commercialflndustrial ❑ Earth -Coupled Geothermal
❑ Class I Injection ❑ Golf Course Irrigation H
HVAC Supply
HVAC Return
Class V Injection: ❑ Recharge ❑ Commercial/Industrial Disposal ❑ Aquifer Storage and Recovery ❑ Drainage
Remediation: ❑ Recovery ❑ Air Sparge ❑ Other (Describe)
❑ Other (Describe) Official Use Only
9 Q.?Distance from Septic System if 5 200 ft. 100 t 11. Facility DescriptionSingle Family Residence 1 estimated Start Date '7—i S— 114
IVEstimated Well Depth 130 ft. *Estimated Casing Depth 110 ft. Primary Casing Diameter 2 in. Open Hole: From To ft.
14. Estimated Screen Interval: From 110 To 130 ft.
15."Primary Casing Material: Black Steel Galvanized ,/ PVC„„, Stainless Steel
Not Cased Other:
16. Sec Casin co a ing -- Surface tr g amet n.
17. Secondary. asin terial,,*� Black S e Galvanized Stainless Steel Other
18.*Method of Construction, Repair, or Abandonment: Auger Cable Tool Jetted �/ Rotary , Sonic
Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) Hydra lic Point (Direct Push)
Horizontal Drilling Plugged by Approved Method Other (Describe)
19. Proposed Grouting Interval for the Primary, Secondary, and Additional Casing:
From 0 To 110 Seal Material (
Bentonite ea emen 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 well or water withdrawal on the owner's contiguous property covered under a Consumptive/Water Use Permit (CUP/WUP)
or CUP/WUP Application. Yes */ No If yes, complete the following: C WUP No. District Well ID No.
22. Latitude
Longitude
23. Data Obtained From: GPS Map Survey
I hereby certify that 1 will comply with the applicable rules of Title 40, Florida Administrative Code, and that a water
use permit or artfigal 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, it applicable. I agree to provide a well
completion report to the District %thin 30 days after completion of the construction, repair, modification, or
abandonment authorized by this permit, or the permit expiration, whichever occurs first
�.=-= �—.�• 11213
of Contractor 'License No.
Approval Granted By
Fee Received $
Receipt No.
Datum: NAD 27 NAD 83 WGS 84
1 certify that I all,
the comer oftha property,. that the Information provided Is accurate, and that 1 am aware of my
responsibilities under Chapter 373. Florida Statutes, to maintain or property abandon this well; or, I certify that I am
the agent for the owner, that the information provided is accurate, and that I have informed the owner of their
responsib0i0es as staled above. Ovmer consents to allowing personnel of this wr1D of Delegated Authority access
to the wall site during the cons - c.on, repair, modification, or abandonment authorized by this permiL
`Signature of Own r or Agent °Date
Issue Date Expiration Date Hydrologist Approval
Initials
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.
Form: 62-532.900(1) Incorporated in 62-532.400(1), F.A.C. Effective Date: October 7. 2010 Pano I of 9
Permit No.
SOUTHWEST FLORIDA WATER MANAGEMENT DISTRICT
2379 BROAD STREET, BROOKSVILLE, FL 34604-6899
PHONE: (352) 796-7211 or (800) 423-1476
W W W. SWFWMD. STATE. FL. US
ST. JOHNS RIVER WATER MANAGEMENT DISTRICT
4049 REID STREET, PALATKA, FL 32178-1429
PHONE: (386) 329-4500
W W W. SJRWM D.COM
NORTHWEST FLORIDA WATER MANAGEMENT DISTRICT
152 WATER MANAGEMENT DR., HAVANA, FL 32333-4712
(U.S. Highway 90, 10 miles west of Tallahassee)
PHONE: (850) 539-5999
WWW.NWFWMD.STATE.FL.US
SOUTH FLORIDA WATER MANAGEMENT DISTRICT
P.O. BOX 24680
3301 GUN CLUB ROAD
WEST PALM BEACH, FL 33416-4680
PHONE: (561) 686-8800
WWW.SFWMD.GOV
SUWANNEE RIVER WATER MANAGEMENT DISTRICT
9225 CR 49
LIVE OAK, FL 32060
PHONE: (386) 362-1001 or (800) 226-1066 (Florida only)
WWW. MYSUWANNEERIVER. COM
Comments:
*General Site Map of Proposed Well Location
Identify known roads and landmarks. Give distances from all reference points or structures, septic systems, sanitary hazards, and contamination sources, if applicable.
DEP Form 62-532.900(1) Incorporated in 62-532.400(1), F.A.C. Effective Date: october7, 2010 Page 2 of 2