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STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR,MODIFY,OR ABANDON A WELL Permit No. I'aJa:Z 39
OFTtiESr,� 0S'OUftlweSf Florida Unique ID t
p PLEASE FILL OUT ALL APPLICABLE FIELDS
❑Northwest ('Denotes Required Fields Where Applicable) Permit Stipulations Required(See Attached)
[]St.Johns River
The water well contractor is responsible for completing
c ;�o• ❑South Florida this form and forwarding the permit application to the 62-524 Quad No. Delineation No,
❑Suwannee River appropriate delegated authority where applicable.
y+ �r ODEP CUP[WUPApplicationtdo.
❑Delegated Authority(If Applicable) ..OPFICIAL USE ONLY
012
`Owner,Legal Name if Corporation 'Addres 'City 'State 'ZIP 'Telephone Number
2. C — ZLk ( o.. , k erce
'Well Location-Address,Road Name or Number,City
3. 3 ZZ`k •- i ) I -- 0 o Z -- a 0 0 2�
`Parcel ID No.(PIN)or Alternate Key(Circle One) Lot 1 Block Unit
Check if 62-524: Yes No
'Section or Land Grant` 'Township `Range 'County Subdivision —
5. UOr, ttoals- rl9a—a15- 5SS6 ( MPYWe-0 t11(rtia1�-'Rmc-;{corn
'Water Well Contractor 'License Number 'Telephone Number E-mail Address!
`Water Well Contractor's Address city State ZIP
7.`Type of Work:_ onstruction Repair VModification ^Abandonment
8.'Number of Proposed Wells—_- 'Reason for Repair, Modification,or Abandonment
9.' 'fy Intended Use(s)of Well(s): `f7 D/, w, PMOINXI t 9 6�estic Landscape Irrigation _Agricultural Irrigation Site Investigationalp )
_Bottled Water Supply _Recreation Area Irrigation Livestock Monitoring
Public Water Supply(Limited Use/DOH) _Nursery Irrigation Test! 1
Commercial/industrial _`Earth-Coupled Geothermal
_Public Water Supply(Community or Non-Community/DEP)_Golf Course Irrigation _HVAC Supply A P A 19 201
_Class I Injection _HVAC Return
Class V Injection:`Recharge_,Commercial/Industrial Disposal_Aquifer Storage and Recovery_Drainage
Remediation: Recovery _Air Sparge _Other(Describe) I DO a
Other(Describe) (Note:Not all types of vrelis are permitted by a given permitting authl ntrr
10.'Distance from Septic System if 5200 ft. 7_ 5
11.Facility Description F01 12.Estimated Start Date
13.'Estimated Well Depth r r'`' ft. 'Estimated Casing Depth r�`' ft, 'Primary Casing Diameter Z in, Open Hole: From—To--ft.
14.Estimated Screen Interval:From To ft. i
15.'Primary Casing Material: Black Steel Galvanized >"— PVC Stainless Steel
Not Cased Other:
I
1 S.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 `;�_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 Additional Casing:
From To Seal Material(�Bentonite Neat Cement Other )
From To Seal Material L -Bentonite Neat Cement Other }
From To Seal Material( Bentonite Neat Cement Other )
From To Seal Material L_-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 orwater withdrawal on the owner's contiguous property covered under a Cons um ptive/Wa ter Use Permit(CUP/WUP)
or CUPIWUP Application? Yes __,4o 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
I hereby teddy lhal I vita wmpty wim the appticabie rules pf Tile s0,FWdda Admmielrative Codo,and Thal a water t xnty that t am ma turner of me property,that the mlmmalion provtdoa is accurate,and That l am aware of my
use permit or atar+cal recharya permit,d needed,has been or w•n be obtained Frier to commencement of well respansViaes undo,Chaplor 373,Florida Statutes to mamlain w oropery aoandon ma wee:or,t cendy mat ram
cptlslntcl'gn.I runner teniy that at;irdom+abon provaed,n this appiewtion is accurate and that I wilt obtain the agent for the owner.that the mfofma nn proanded is acdurale,and that I nave crfo-.d Ire owner o74nee
necessary approva:from Other federal,slate,or local govemmenls,d applicable.I agree to promdo a well ?*SignaLuj
span as stared above.Qaner consents to aibw:ng personnel of INS WIAD or Delegated Aulhony access
completion report to the DISbtct within 30 days a0or winplelion of the consf=(Oh,repair,modihWbon,or 1 wet(slle a wg me<onslruclron,rppau,mpdifKabpn.or abandonment whonzed by th.parrot
I abandonment aulMnzed by Pus permit,or mo permit ea�cnpver occurs first �
'Signature of Contractor— 'License No. of Owner or I 'Date
i
BELOW THIS LINE-FOR OFFICIAL USE ONLY
r! Ex �d 1 Hydrologist Approval
Approval Granted By Issue Date Expiration Date
rii
Fee Received S Receipt No. Check No. ! �\ �
bV
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE WMD 0 E A HE
PERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION.REPAIR,MODIFICATION,OR ABANDONMEN AC I I
DEP Form:62-532,900(1) incorporated in 62-532.400(1),P.A.C. Effective Date:October 7.2010 Page 1 of 2
l
STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,REPAIR,MODIFY,OR ABANDON A WELL IermitNo. a-to a Ero
A�,�FS11ESr Florida Unique I
yao- F 9 ue ID oy ❑Southwest PLEASE FILL OUT ALL APPLIGABLE FIELDS 1
❑Northwest (`Denotes Required Fields Where Applicable) Permit Stipulations R;
❑South Florida quired(See Attached)
x ❑St.Johns River
The wafer well contractor is responsible far completing l
this 7orm and forwarding the permit application to the 62-524 pupa No. Delineation No.
O Suwannee River appropriate delegated authority where applicable.
yCpA; � ❑DEP CUPIWUP ApplicationNo.
00elegated Authority(If Applicable)
ABOVETHIS LINE-FOR OFFICIAL USE ONLY
I
Owner,Legal Name If Corporation 'Addres `City `State 'ZIP I `Telephone Number
7 s6
Well Location-Address,Road Name or Number,City
3. - ?ZZa' '—' i I I — &02 — QGO Z
`Parcel ID No.(PIN)or Alternate Key(Circle One) Lot Bieck Unit
4. S+, Lo cot
'Section or Land Grant 'Township `Range `County Subdivision Check if 62-524:_Yes _No
5. Der B0.X-red- llD� '1�2-�tS-�SSb�i �IPULJeIIDrLllina �ma�l.com
`Water Well Contractor 'License Number 'Telephone Number E-mail Address
6. P.D. b o>< 5 t'l 4 Fo 4- P i-etc Le— FL
`Water Well Contractor's Address city State ZIP
7.`Type of Work:— onstruction Repair —Modification _Abandonment.
8.'Number of Proposed Wells_ 'Reason for Repair, Modification,or Abandonment
9.`specify Intended Use(s)of Wells p g ��nzC� g �Investlgation � 6J LJ l�t��Domestic Landsca a Irri ation A ricultural Irri ation Site 16J��JI000=!!!{dl�� v
—Bottled Water Supply _Recreation Area Irrigation _Livestock _Monitoring
_Public Water Supply(Limited Use/DOH) —Nursery Irrigation —Testl,
_Public Water Supply(Community or Non-Comm unity/DEP)— A11 Commercial/Industrial Earth-Coupled Geothermal APR
g 204E�
Golf Course Irrigation —HVAC Supply
_Class(Injection — _HVAC Return
Class V Injection:—Recharge_Commercial/Industrial Disposal—Aquifer Storage and Recovery—Drainage
Remediation: _Recovery _Air Sparge Other,(Describe) I DORIAMAgr Coi di
_Other(Describe) (Note:Not all types of wells are permuted by a gwen permitting aul iongy
10.'Distance from Septic System if<_200 ft. 7_ S-} 11.Facility Description 5�Q- ( 12.Estimated Start Date
13.`Estimated Well Depth 10 �'- ft. `Estimated Casing Depth �" ft. `Primary Casing Diameter ? in. Open Hole: From To ft.
14.Estimated Screen Interval:From To 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 Jetted _Rotary Sonic
Combination(Two or More Methods) Hand Driven(Well Point,Sand Point) Hydraulic Point(Direc(Push)
Horizontal Drilling Plugged by Approved Method Other(Describe)
19.Proposed Grouting Interval for the Primary,Secondary,and Additional Casing:
From To Seal Material(__Bentonite Neat Cement Other )
From To Seal Material(_Bentonite Neat Cement Other )
From To Seal Material _Bentonite Neat Cement Other I )
From To Seal Material( Bentonite Neat Cement Other I )
20.Indicate total number of existing wells on site List number of existing unused well ls on site
21.'Is this well or any existing well or water withdrawal on the owner's contiguous property covered under a consumptive/Watelr Use Permit(CUP/WUP)
or CUP/WUP Application? Yes _-No If yes,complete the following:CUP/WUP No. District Well ID No.
22.Latitude Longitude
23.Data Obtained From: GPS Map Survey Datum:. NAD 27 NAD 83 WGS 84
I hereby certify that 1 will cwm%y with the applicable ndas of Tillo 40,Florida Adm.mMI.W.code,end that a water i certitj that I am Inn owner el the property,Ihel Ne mfarmelien Drondatl a atatrale,and lhm I am aware of my
se permit or orllf al recharge permit,if needed,has been or wdl be oblained pnor to eommeneement of web responsibilities under Chaplet 373.Flardo Statutes la maintain or araperty abandon Nis woi1.or.I eadity that)am
eoosWcenn.I further ceniy Ihal ag Information provided in this aliotical'wr.is accurate and that I will obtain the agent for the owner(het the irirarma pr,provided is acCWete.and that i have Warned the-of of inert
ssary appr of Prom oMe,federal,state,orloeal governments.If applicable.I agree to wowda a well resod -- as stated above.Owner�onsenls Io allowing personnel ai Ifi5 WMD or Delegalad Aulhodly access
cempiefon report tome District mlrsn 30 days allarcomplelbn of Inn construction.repair,medlfcabon,ar I e well side unng the eonsimchim re mq madifmlian.or abandonment authorized by this permit.
abandonment aulhamed by This pormN,or The permit expiration,whichever occurs first.
dS
'Signature of Contractor— 'License No. ign )rAom 'Date
BELOW THIS LINE-FOR OFFICIAL
Approval Granted By - Issue Date y/1 /7• Expiration D tie I dr st p_o
m I
Fee Received $ Receipt No. Check No.
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BYAN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE WMD O D A O 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),FA.C. Effective Date:October7,2010 I Page 1 of