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STATE OF FLORIDA PERMIT APPLICATION TOCONSTRUCT,
REPAIR,MODIFY,OR ABANDONA WELL
Permit No.
Florida Unique ID
Southwest
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
South Florida
62-524 Quad No. Delineation No.
Suwannee River
appropriatedelegated authority whereapplicable.
DEP
this form and forwarding the permit application to the
CUP/WUP Application No.
Delegated Authority (If Applicable)
ABOVE THIS LINE FOR OFFICIAL USE ONLY
1.
*Owner, Legal Name if Corporation *Address
*City *State *ZIP
Telephone Number
2.
*Well Location - Address, Road Name or Number, City
3.
*Parcel ID No. (PIN) or Alternate Key Lot Block Unit
4.
Check if 62-524: Yes No
*Section or Land Grant *Township
*Range *County
Subdivision
5.
*Water Well Contractor *License Number
*Telephone Number E-mail Address
6.
*Water Well Contractor’s Address City
State
ZIP
7.
*Type of Work:
Construction Repair
Modification Abandonment
8.
*Number of Proposed Wells
9.
*Specify Intended Use(s) of Well(s):
Domestic Landscape Irrigation
Bottled Water Supply Recreation Area Irrigation
Public Water Supply (Limited Use/DOH)
Public Water Supply (Community or Non-Community/DEP)
Class I Injection
Agricultural Irrigation
Livestock
Nursery Irrigation
Commercial/Industrial
Golf Course Irrigation
*Reason for Repair, Modification, or Abandonment
Date Stamp
Site Investigations
Monitoring
Test
Earth-Coupled Geothermal
HVAC Supply
HVAC Return
Class V Injection: Recharge Commercial/Industrial Disposal Aquifer Storage and Recovery Drainage
Remediation: Recovery Air Sparge
Other
(Describe)
Other
(Describe)
Official Use Only
10.*Distance from Septic System if ≤ 200 ft. 11. Facility Description 12. Estimated Start Date
13.*Estimated Well Depth ft. *Estimated Casing Depth ft.
14. Estimated Screen Interval: From
To
ft.
Primary
Casing Diameter in. Open Hole: From
To
ft.
15.*Primary Casing Material: Black Steel
Galvanized PVC
Stainless Steel
Other:
16. Secondary Casing:
Not Cased
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
From To
From To
From To
Seal Material ( Bentonite Neat Cement Other )
Seal Material ( Bentonite Neat Cement Other )
Seal Material ( Bentonite Neat Cement Other )
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 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: 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 I will comply with the applicable rules of Title 40, Florida Administrative Code, and that a water
use permit or artificial recharge permit, if needed, has been or will be obtained prior to commencement of well
construction. I further certify that all information provided in this application is accurate and that I will obtain
necessary approval from other federal, state, or local governments, if applicable. I agree to provide a well
completion report to the District within 30 days after completion of the construction, repair, modification, or
abandonment authorized by this permit, or the permit expiration, whichever occurs first.
I certify that I am the owner of the property, that the information provided is accurate, and that I am aware of my
responsibilities under Chapter 373, Florida Statutes, to maintain or properly abandon this well; or, I certify that I am
the agent for the owner, that the information provided is accurate, and that I have informed the owner of their
responsibilities as stated above. Owner consents to allowing personnel of this WMD or Delegated Authority access
to the well site during the construction, repair, modification, or abandonment authorized by this permit.
*Signature of Contractor
*License No. *Signature of Owner or Agent
*Date
BELOW THIS LINE FOR OFFICIAL USE ONLY
Approval Granted By Issue Date
Expiration Date
Hydrologist Approval
Initials
Fee Received $ 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 of 2
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