HomeMy WebLinkAboutDEPT OF HEALTH APPLICATION TO CONSTRUCT REPAIR MODIFY ABANDON WELL�\ 1
STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR,,MODIFY,, OR''ABANDON A WELL
O Southwest PLEASE FILL OUT ALL APPLICABLE FIELDS
-ElNorffiWest Metiotes:Required Fields V Gre.Applicable)
0 St• Johns River
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1:7Suvvannee:River. rhisfanunndforwarr)inyrhep¢rmrtnpphtnrinnrofbe.
QD> P°rrarpmu[•nereporen�ulhaogtvhrienpplkable.
O Delegated AUthority (if Applicable)
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Permit No.
Ronda Unique ID
Permit Stipulations. Required (See Attached)
62-524,qund No. Delineation Nd.
CUPNVUP Applicatlon No. .
Lot Block
Yes DO No
7• i ypeoflNorks Construction Repair City
❑ p ❑ Modification[] Abandonment
8. umber Df;Rroposed Wells
IALP
g. pacify Intended Use(s) of Well(s); an on RaRag/Mod , rl
Domestic `r- Q
Landscape Irrigation
Ir Agricultural irrigation Site Investigations.
a
Bottled INater,Supply ®Recreation Area Irrigation Livestock
ublic Water 5upply(Limited Use/DOH ` MoNlor)ng
lublldWaler Su ) Y } Nursery lrrigation Test
Supply (Community Non-CoMMURit /DEP Commercia�a"On nBl 20,
C,•.•,� 1ass.1 Injection Earth -Coupled Geothermal JUN 2 O
Golf Course irrigation HVAC Supply
las -V INOCtlon: ❑ Recharge ❑ COmmerciaVlndUstrial Disposal HVAG Return
1:1Aquifer Storage and,Recovery Drainage
Rem diatio E BRecovery [] Alr Sparge El Other (oaauibu) DOH in St;ther LQde G
❑'`
10 * istance from 5eptic stem if 5 200 ft. 11. Facility Description .
3.'�sfimated Well De lF� - 12.�Estimated
1Start Date -
/ p ft. ."Estimated Casing Depth
_fl. PrimaryCasing Diameter in. Open Hole: 'From To - ft.
14. Estimated Screen Interval: From To
15'P � , �.ft.
mary Casing Material` Black Steel Galvanized PVC
Stainiess•Sleel
( Not:Caseii Other..
16. S condaryCasing; Telescope Casing liner Surfaco Casing Diameter in.
17, S condary Casing Material. Black Steel Galvanized PVC Stainless Steal
Other
1&�M [hod of Construction Repair, or'Abandonment: Auger Cable Tool Jetted.
Combination (T%vo.or•More Methods Rotary Sonic
Hand Driven (Well Paint, Sand Point} Hect Push)
Horizontal Drilling Plugged -by Approved Method Qlher moscnbal
iB. Pr posed Grouting Int rvai for the Primary, Secondary, iind Addifi n asin i
F m- Tp �Q -Seal Material ( Sentonit Neat Cement Other
FrI)m To Seal Material ( Bentonite }
r n Other )
From To
Seai Material ( Benlonite Neat Cement Other t
Seal Material(• Bentonite Neat:Cement Other ) 20 in cafeaofalnumber ofexisting walls on site
Unumber ofexisting .unused -wells on slid
21 'Is his well orany exlstingg'viell 'or water wlttrd the owner's contiguous piopertryy covered'undera ConsumptiverWatarUr;e permit (CUPM1Up)
or, UPMIUP,Appilcatlon7" Yes No yes, complete the foilowng: CUPMIUP No.
22. La Rude- District Well ID No.. .
tude
23 Data Obtained From: GPS Ma Survey
i twwty n,r ur,�t n Mnmea Datum NAD 27 NAD-83 WG584
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tna D°mor wtltlehlrachWprpvinmAnatnoA.Itnt4Aon uti wYbr, ubrdnWy,riur to eamnwncamMturwep 'leu8rytlullnnt the tlwRtlrorlirp WaPtrrry;Nit Ulu intarnaeon urowJedre.;cr .n.
cuwhueUt tluMer cetYN OinJtntom,ne�,..,. .. .... .. ,
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Issue Date f0fi0„ Es on, Data+: Hydrolo iSt
Fee Re I lived S fl .. Provo]
ReceiptNo. Check No. bAW
THIS PE MR IS.NOT VALiD.UNTIL PROPERLY AN:AUTHORIZED OFFICER OR REPRESENTATIVE OF THE •WMD OR DELEGATED AUTHORITY. THE
PERMIT PHALLBEAVAILABLE ATTHEGVELLSITSIGNED BYEDURINGALL60NSTRUCTtnN QPPAIt7
ion
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