HomeMy WebLinkAboutWater Well PermitsSTATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL
❑ Southwest
❑ Northwest
❑ St. J,ohncRiyer
1 South Florida
LI uwannee Iver
❑ DEP
❑ Delegated Authority (If
PLEASE FILL OUT ALL APPLICABLE FIELDS
(*Denotes Required Fields Where Applicable)
The water well contractor is responsible for completing
this form and forwordirrg thepermit application to the
appropriate delegated authority where applicable.
1. Brian and Laura Black 6444 Hope
*Owner, Legal Name if Corporation
2. TBA Brocksmith Road
"Well Location -Address, Road Name or Number,
3.2320-501-0044-000-7
TParcel ID No. (PIN) or Altemate Key (Circle One)
4.20 35S 39E
Permit No.
Florida Unique ID
Permit Stipulations Required (See Attached)
62-524 Quad No.
CUP/WUP Application No.
Delineation No. I
772-216-1710
Telephone Number
3
Block Unit
Check if 62-524:❑ Yes ❑ No
"Section or Land Grant *Township ''Range *County Subdivision
5. Scottts 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: ❑✓ Construction ❑ Repair ❑ Modification❑ Abandonment
Court, Port St Lucie, FL 34986
tddress *City "State
:iffy
13
Lot
St Lucie McNurlen Farms
8. *Number of Proposed Wells ONE
*Reason for Repair, Modifical
9. *Specify Intended Use(s) of Well(s):
t/❑ Domestic ❑ Landscape Irrigation
❑
Agricultural Irrigation ❑
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)❑
Commercial/Industrial ❑
Earth -Coupled Geothermal
❑ Class I Injection
❑
Golf Course Irrigation 8
HVAC Supply
HVAC Return
lass V Injection: ❑ Recharge ❑ Commercial/Industrial Disposal ❑ Aquifer Storage and Recovery ❑ Drainage
Remediation: ❑ Recovery ❑ Air Sparge ❑ Other (Describe) Official Use only
❑ Other (Describe)
10."Distance from Septic System if <_ 200 ftP2 11. Facility Description. ing a Family Residence 12. Estimated Start Date
IVEstimated Well Depth 120 ft. *Estimated Casing Depth 100 ft. Primary Casing Diameter 2 in. Open Hole: From To ft.
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.*Method of Construction, Repair, or Abandonment: Auger Cable Tool Jette< ( Rotary Sonic
Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) Hy rau Ic oint (Direct Push)
Horizontal Drilling Plugged by Approved Method Other (Describe)
19. Proposed Grouting Interval for the Primary, Secondary, and ieaa! SasiLq:
From 0 To 100 Seal Material ( Benton' a Neat Cement Other )
From To Seal Material ( Bentonite eat Cement Other )
From To Seal Material ( Bentonite Neat Cement Other 1
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 wit n the owner's contiguous property covered under a Consumptive/ Water Use Permit (CUP/WUP)
or CUP/WUP Application. Yes No, yes, complete the following: CUI'/WUP No. District Well ID No.
22. Latitude ongitude
23. Data Obtained From: GPS Map Survey Datum: NAD 27 NAD 83 WGS 84
l hereby —fily that I vtit comply with the applicable rules of 711e 49, Florida Administrative Code. and that a water I certify that I am the mmer of the property, that the information provided Is accurate, and that I am aware of my
use permit or artificial recharge permit, if needed, has been or will be obtained prior to commencement of wet responsibifilies under. Chapter 373, Florida Statutes, to maintain or properly abandon this m1l; re, I certify that I am
construction. 1 further certify that at information provided in this application is accurate and that 1 vrit obtain the agent for the otmer, that the information provided is accurate, and that I have Informed lha otmer of their
necessary approval from otter federal, state, or local governments. If applicable. I agree to provide a well responsibilities as stated above. Omer consents to ellotving personnel of this MAD or Delegated Authority access
completion report to the District within 30 days after completion of the construction, repair, modification, or to the well site during the construction, repair, modification, or abandonment authorized by this permit.
abandonment authorized by this permit, or the permit expeation. vfiichaver occurs first!
11213
*Signature of Contractor I *License No. *Signature of Owner or Agent "Date
Approval Granted By I Issue Date Expiration Date Hydrologist Approval I
Fee Received $ Receipt No. Check No. Initals
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.
DEP Form: 62-532.900(1) Incorporated in 62-532.400(1), F.A.C. Effective Date: October 7, 2010 Pagel of 2