Private Drinking Water Well Application Instructions
All information on the Application and Site Plan must be completed before the application is processed. Incomplete applications and site plans will be returned to the applicant and the service will be postponed until completed. The information requested on the application is required by state regulations and is necessary to design the private drinking water well system.
An Environmental Health Specialist will be available, if requested, between the hours of 8:00 am – 9:00 am to answer any questions you have regarding the application and site plan. If you are unsure of your plans, you should bring your application to the MTW District Health Department in your county for the Environmental Health Specialist to review. Applications are processed in the order they are received with payment. The property boundary corners and home should be clearly marked (flagged) and the lot sufficiently cleared in order for the Environmental Health Specialist to perform the evaluation. Insufficiently marked or cleared lots will cause a delay in processing your application and will require an additional return visit fee. Our goal is to process your application in a timely manner. Providing us with a complete application and site plan will help us process your request in an appropriate manner.
If you have questions or comments regarding the application, please call one of our Environmental Health Specialist at:
Martin County
Robert Martin – 252.793.1627
Gene Raynor – 252.793.1628
Tyrrell County
Sam Brickhouse – 252.793.1760
Washington County
Mitchell Patrick – 252.791.3107
Martin-Tyrrell-Washington District Health Department
Private Drinking Water Well Application
* A Site Plan Is Required With This Application *
(Site Plan Not Required If Only Water Sample Requested)
Owner/Authorized Agent: ______
County of Property: ______Phone: ______
Current Mailing Address: ______
Site Location:______
______
Services Requested:
New Well Permit – $335 (Includes site inspection, grouting inspection, wellhead inspection and one compliance
water sample. There is a charge for additional water sampling.)
Well Repair Permit – No Charge (There is a charge for additional water sampling.)
Well Abandonment Permit – No Charge (Well Contractor is responsible for submitting a well
abandonment record.)
Type of Facility: Single Family Dwelling Multi-Family Dwelling Business Food Service Child Care
Other: ______
Additional Water Samples Fees:
Compliance Sample - $110 Volatile Organic - $60
Bacteriological - $60 Pesticide - $60
Inorganic Chemical - $60 Petroleum - $60
Lead only - $60 Fluoride - $60
Please check the following that apply to the property and specify location on attached site plan:
Are there any existing septic systems on this property?
Are there any existing wells, springs, or water lines on this property?
Are there any surface waters or designated wetlands on this property?
Are there any easements or right of ways on this property?
Are there any below ground chemical or petroleum storage tanks on this property?
Are there any landfills, waste storage or underground contamination on this property?
I hereby grant county and state officials permission to enter the property to conduct the services requested. The information I submitted is true, correct and complete. I understand that the permit, if issued, will only pertain to the well construction and in no way guarantees the quality of the drinking water.
Owner/Applicant Signature: ______Date:______
AMOUNT PAID: ______CHECK#: ______CASH: ______RECEIPT#: ______
CLERK SIGNATURE: ______DATE: ______
Martin County Health Department210 West Liberty Street
Williamston, NC 27892
252-793-1626 – Phone
252-793-1644 - Fax / Tyrrell County Health Department
408 Bridge Street
Columbia, NC 27925
252-793-1760 – Phone
252-766-3376 - Fax / Washington County Health Department
198 NC Hwy 45 N
Plymouth, NC 27962
252-791-3107 – Phone
252-791-3108 - Fax
Site Plan
**An example of a site plan is available to assist you in drawing this site plan**
Name: ______
Address: ______
Site Location: ______
______
______
**You are required to draw and locate the following on this site plan**
the size and dimensions of the property
the proposed location and dimension of all structures (house, proposed septic area, wells, water lines,
outbuildings, pools, decks, and drives).
the distance of the structure and the proposed septic area from the property lines.
the location of any existing septic system and wells on this property and on the adjoining properties.
location of any below ground chemical or petroleum storage tanks on the property.
any easements or right of ways shall be identified.
all property lines, corners, and structures shall be marked and the site made accessible, as deemed by the
Health Department prior to the evaluation.
Draw in the area
I hereby grant county and state officials permission to enter the property to conduct the services requested. I certify the information submitted is true, correct, and complete. I understand that I am solely responsible for the proper identification of all the items required on this site plan.
______
Signature of Owner or Owner’s Legal Representative Date
Martin County Health Department210 West Liberty Street
Williamston, NC 27892
252.793.1619 / Tyrrell County Health Department
408 Bridge Street
Columbia, NC 27925
252.793.1750 / Washington County Health Department
198 NC Hwy. 45 N
Plymouth, NC 27962
252.793.3023