HomeMy WebLinkAboutAPPROVED Well PermitSF-2LI2'-+47,3
STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL
O Southwest PLEASE FILL OUT ALL APPLICABLE FIELDS
D Northwest ('Denotes Required Fields Where Applicable)
D St. Johns River
D South Florida Alewater (amandf forwarding
is the ble
for completinghe
this form and lorvmrdinglhe permit application to the
DSuwannee River appropriate delegated authority where applicable.
D DEP
D Delegated Authority (If Applicable)
Permit No. 59-32971
Florida Unique ID
Permit Stlpulatlons Required (See Attached)
Quad No. Delineation No.
UP Application No.
,nip
I grasso
k (?wnerG Le al,Name if Corporation `Address CI State *ZIP Telephone Number
12. 521suriset'blvd fort pierce F ;, ?7 kV`1 __
VVCII Wt.d LIL)n- 34�2e=UCU IV dltil I IVUIr1UCi, VI �
3.
'Parcel ID No. (PIN) or Altemate Key (Circle One) L Block Unit
4. 02 36s 40e saint loucie a dvllVL�Check if62-524:❑ Yes ❑ No
'Section or Land Grant 'Township `Range 'County Subdivision
5, Yandry Palenzuela 11358 (561)718-1102 PbwelldriIling@gmail.com
'Water Well Contractor `License Number 'Telephone Number E-mail Address
6. 4541 royal palm beach blvd West palm beach FI 33411
`Water Well Contractor's Address City State ZIP
7. -Type of Work: ❑X Constructionl❑ Repair ❑ Modification❑ Abandonment
8. 'Number of Proposed Wells `Reason for Repair. Modification, or Abandonment
9. `Specify Intended Use(s) of Well(s): i P p O n%)(
Domestic Landscape Irrigation Agricultural Irrigation Site Investigations (.� v L
Bottled Water Supply H Recreation Area Irrigation 8 Livestock 8 Monitoring
Public Water Supply (Limited Use/DOH) ❑ Nursery Irrigation Test
Public Water Supply (Community or Non-Community/DEP)❑ Commercial/Industrial Earth -Coupled Geothermal F E ❑❑ U 1 1 2022
Class I Injection ❑ Golf Course Irrigation HVAC Supply
HVAC Return
Class V Injection: ❑ Recharge ❑ Commercial/industrial Disposal ❑ Aquifer Storage and Recovery ❑ Drainage
Remediation: ❑ Recovery ❑ Air Sparge ❑ Other iDescnbe) F OH T I I our
❑ Other (Descdbe)
10'Distance from Septic System if 5 200 ft. 15 11. Facility Description newriouse 12. Estimated Start Date aSap
13'Estimated Well Depth 40 ft. "Estimated Casing Depth 0 ft. Primary Casing Diameter 2 in. Open Hole: From To ft.
14. Estimated Screen Interval: From 30 To 40 ft.
15'Pdmary 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) Hydra: (Direct Push)
Horizontal Drilling Plugged by Approved Method Other (Describe)
19. Proposed Grouting Interval for the Primary, Secondary, and Addi ' ng:
From_ To 30 Seal Material ( Bentonite at Cem 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 0 List number of existing unused wells on site 0
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: CIJP/WUP No. District Well ID No.
22. Latitude Longitude
23. Data Obtained From: GPS Map Survey Daturn: NAD 27 NAD 83 WIGS 84
1 herby ca lify that I -Ml comply with the applicable rules o1 TNIo 40, Florida Adi in strative Code, and that a water 1 oertiry dial I am tine tamer of tho property. that the information Ittovlded Is accprele, and drat I am aware of my
utter permit a etifidal mchar" permit, if ... ded, he. boon or vAt be obtained p pmr to eanrneneemrnl at-0 reaponeib11d,. undo Chapter ]73. Fle6de etet.l . I. maintain ar pr op.dy.banden dos war: or.l certify that l om
aan.tn too.. ! h.fier certify tl+at.d inlomwtlon provided N M. epplicatlon r scarrste sad riot 1 vr.0 opoofn tiro open! M the a+mar, that M. Niamation provided is arur.le, end Het I have informed the +.mar al Char
neberiary approval hum other federal, et&w. a bcel gerammonte, if opplIcabk. I +gran to provide • waN ..ponsaNU.s .e Wud above, Ovmer cenenr. to abowtnp panomel of mia WA7� err Oelege4d Authority sear:
=1et1., p thWhe Wbict wladn 30 deye alMr eompletien oftlw conY4Velion, repair madrfieebon o, to the w.l.Ne Wring me eenabuetion,repair, inelikoflel,or abandonment authoAted by M. permit.
abnndWrit plhorixed by Wa pemit, a the pemtk axpbatibn. vjjdrir/1w<r aeeurn oral
e h z ue l� 11358 (�/" 2/2/22
'Slgna a onu for 'License No. 'Signature of Owner u?Aent 'Date
I Approval Granted By
Approval
Imtiab
Fee Received $V 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.
DEP Form: 62.532.900(1) Incorporated In 62-532.400(1), F.A.C. Effective Date: October 7, 2010 Page 1 i
Issue Dale
Date