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Home My WebLink AboutPermit Application For Well ConstructionP STATE''OFrFLORIDAPERMlT PPUCATIQN TO, CO • ''REPt41R;;MQDiFY, OR°�gBAN� ON.A WELL- � • �' �r� ` DSouthwest ' r} P ' I]•NOrthWesf FILL OUTALLAPPLlt;ABList . 1 � � ('De tes _Requ(red Fie(ds VllFei ll �'St. Johns'RiYe�� pSoutfi Flgrida 7herwa ,welieontrador.'Isresponsidle this fo aad'fwward�ng?lie permit aRI �l Q' U �EWagflee R1vor gpprop 3 ,e/agatedaufAon7yWhere el - . ,.a�,,dt` �L.' 1 �• t elegatedAuthori`ty (IF'APpseab e) ��n` - - r __— F.todda ►) Pennit'Sfipuladons Required (SeefHttached) ~ T CUP,ANUP°APplicatmn;N0` 'n� _�L J 9011 �Z'1 �ZS�'u �• 'State � "ZIP - ?Telephope'N"umbe� �' ' Ctieck if 62�524. _Yes �o.; ^«oertse umber 'T�ep�ne Nlum6or E=fiiatjAdBress - i7 WatecWell ConhaURN Address _ ` a -i(_ _: __Cf I - r-r _ — — 1ate._ 7 "fypeofWork =Construction Repairotl won. _'gbandonmerttt- r8 "Numbero P- posed° --bud J Reason fartjepeG,;.Mo a3yon;orAbe Cori I 9Spacifyiintanded tJse'(s,),of WeU(sf - j�d ' r n �, 3 Y BS6G+. - � 1 i rm _Landseapesimgatlori ; .,=Agn'cuifuiai.�liri"atfoit, -- Site;i[n" " "",. _.' � _ ` ._•• - . ' �Bottted Water• Su 1� ' 9 vesUgalion ., , ^ !t PPY,- RecreatioriPueaJnjgatlo Lrivesloek 1Monitodng i �` PutilrrrWaterSu (kith UselDOH) `Nhrsery Purgation _Test PP�Y, _ - PP•v(.' ty Commercial/Intltiskial' ='Earth-Coupled'Geofhermal� r SEP 2� ;2�� PubltcallVaterSu Common[ ; or, Non-Comrnun(ty%D P) i r + � �Cla-ss I InJectiori - =.Golf Course Irrigation HVAC±Supper •! ' .- Class Uiln action~� rg J Comma"c`cfaUlndustriai isposal—Aqulfe`rStoFageand,-Recoveryr�D7atnageOHin'St�WdBCOu IRemetliation Recol7ery —�PicS a e _ other�o� ' ' �Otherrtoeserltie} _ ..(Notee.Nc[aGlypeoor�vullcsropgnntlkir6y.tr'8wenpaintowg;�-Ri iY) 1 D •Disgncerfram Septic System if �200 I � f1. "Fac fi Descri on _' ' . r _ ` +. ty �' ptT �tS Y11� 12..Esttmatecl start Date �%� :� ._ �_, l3 Estlinated WeIlrDgpthtt ?EstimatedtCasing Deq _� t fk 'P�i(nary Cas r_g Diameter 4n Open Hole From To__�ft . 14 Es�rnatetl Sereen;lnterval JFrom�� To � � ff, �` -"' - `---- 15 omffgy_ry ggli `10 tedai Black Sleet _ Palvanizetl -p1/C3 Stainless!Stael - i 1'e Secomd Casing Teleseope:Casfng Liner _ SutfarerGasing 'Diameter (ns ' ' j17 Secondary Casing f�leterte(, �.Blac[i'8teet _jGaf anri � . • _ PVC tStaifiless Steel _� Olfii:r _ _ f fe'Method of Construction Repajr orAbandonmont _ u y ar. �Rotary ._Sonic �rcable Tin � �etred � __Combination (fw9 ,orMore Methods): HandlCtrivert {lNell+PpPnt ,Sand Pofnt) Hyiiraufic+PolnE`(Dfrect+pu_sFi). _Horizonfel Dntlin Plugged by_,Appmvel �1 thod Other o 19 Proposed Grouting t to al far the Pnma Seconds rY. ry,.an Ad nal Caslirg �_ e Frorn_ 1!3 ._.Tom �� 5eal Materia(f-_Bentonite t,C-`ement_____ Q er ._—J _______j � FromS�IfMaterial�(--Bentontte�tJeatCemerit - To Seal�Mateiial (=_Bentonite 1 Neat Cement O er ' ; ' From _ To- Seai Material,(__Bentonite _Neat Cema-lit O�r y, �20 Indicate total numberof existing waifs an site -T r Ltstnumberofex(stingunused wells an site 2d isthisr�vetlorariy,`existingEyvellorwaterwnthdrawatontheow er'scontiguouspropertyco(veredunderaConsufim v^aOrUsePertnit'(EUPItiNUp) or CUP/WUPAppllcatlon? _ Yes ✓(Vo dfyes-ca• pletestttet'ollowfng,CUP,I IP`Nc:_�______— Distiict'.WeIIIDNo:__.�____' • 22 Latitude �.._ _ ELorig_itude _ _._ _ _ - - - -• �'- - - -_. _ . - _ 23 Data Obtajned Fi`prt._- ��_ ee c ve _ ___. ursw• - TE115 PERMIT IS NOT VALiD UN71L PROPERLY SIGNED BYAN Al1THpRI2ED O�FICER'UR REPRSENTATII/E OF THE WMO ORst)ELEGATED AUTtIQRRi! THE EERMITSHl4LLBF�1tAILABLEAfTHEWELLSrrEpIJR(NGALLGONB dTIOKJAEF?-AIR M00iFICI�ilON,.ORF19iM1NDONMENfACT11VtTJES:.___—-_.-�- 17EP Fo rtn 62=532 9g0 1 in grated in s2532 40n(1); FAC: Effie a 17a1e Oetober7 2010 _ J* �— "` _ ,- _ - - .•,.- (.) core.