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<br />APPLICATION TO CONSTRUCT, REPAIR, MODIFY OR ABANDON WELL
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<br />SOUTHWEST FLORIDA
<br />WATER MANAGEMENT DISTRICT
<br />2379 Broad Street, Brooksville, Fi 34609-6899 Ph: (904) 796-7211
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<br />Permit No.
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<br />StiPUI~
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<br />WUP Application No,
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<br />..,17-524 Well
<br />-yll/ t/ 7 tr
<br />Owner No.
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<br />AB()'vt lltl' IIrJt F(Jn OFFlC:IAL LJSf (HH 'y
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<br />Owner, legal Name ot Enli1y It Corpora
<br />.-; -IS ~; ',l ) h ~\ \ (,-, \ r., t '.~
<br />Well location - Address, Road Name or Number, City, Zip
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<br />.-'10\1(' n( ., "\ .
<br />c,j\ - t <:" '.)''0/. ", f/{ ~ )5. itve 61(/ .IJ,,'1-)', -;;,! n I
<br />..... Address ,.' \ fity. ZIp Telephone Number
<br />C) 'J(" \- ;;U \ ) n I I Y }" ~ i.( "3 ~ \'. 'i C
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<br />1.
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<br />2.
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<br />3.
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<br />Drilling Contractor
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<br />Address
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<br />City
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<br />4. Number of Wells:
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<br />_ Domestic
<br />_ Public Water Supply
<br />_ Recovery
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<br />5. Application for:
<br />....:i...... New Cons1ruction
<br />_ Repair/Modify
<br />_ Abandonment
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<br />7. Method of Construction:
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<br />8.
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<br />County
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<br />l-i t"\ c'
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<br />A-v~
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<br />13ro(
<br />Ucen No.
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<br />'-=3-3 b I ((
<br />State Zip
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<br />Check the Use of Well:
<br />
<br />llrrigation
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<br />- Heat Pump/AeSupply
<br />- Class V Heat Pump/AC Return
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<br />6. Casing ~,' or Liner _ (check one)
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<br />_ Black Steel
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<br />- Galvani~e.d
<br />-1 PVC ,.
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<br />t- Rotary - eable Tool _ Combination _ Auger
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<br />_ Livestock
<br />_ Industrial
<br />- Class I Injection Well
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<br />- Test (WUP)
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<br />_ Monitor (type:
<br />_ Other (
<br />
<br />)
<br />)
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<br />- Other (specify:
<br />Seal Material:" r ...: 1J r
<br />) ... 1/
<br />'::;.
<br />
<br />Diameter:
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<br />Subdivision Name
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<br />NW NE
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<br />9. Quarter Quarter Section ~ .5 'S (Indicate WelI0n Chart)
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<br />10. Section N Township ~ '\ Range ;l,,/
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<br />11. On 6-lnch Wells or Larger:
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<br />latitude
<br />
<br />,
<br />,
<br />, 0 ,
<br />---~----:----~---
<br />, 0 ,
<br />, 0 ,
<br />, 0 ,
<br />
<br />longitude
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<br />- - - ~- - - -If - -~- ---
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<br />, 0 ,
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<br />SW SE
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<br />12. I hereby certify that I will comply with the rules of Chapter 40-9.:3,. florida Administrative Code, and that a
<br />water use permit or artificial recharge permit, if needed, has ~n'or will be obtained prior to commence-
<br />ment of well construction. I further certify that all information proVided on this application is accurate and
<br />that I will obtain necessary approval from other federal, state, ("local governments, if applicable, I agree
<br />to provr a well completion report to the District within 30, ~~,a/.ter drilling ope~tions cease.
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<br />I /'1. I <-..~ ~7 -) '- fi, {V. - I j 0 'J
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<br />Signature ot Contractor I ~se No.
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<br />- Other (specify'
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<br />Lot
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<br />Block
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<br />Unit
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<br />Drew a map of well/ocIItIon and Indlute ""-"-
<br />IIIIiIh /III .X.. IdIIIItlfy /mown I'CMM and 1a1ld1rlarb:
<br />prrwIda dIIIta-. ""'-" well and IandtnMlta.
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<br />North
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<br /><: J ni\, f,..' 4 '.-
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<br />South
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<br />13. Is this well or any other well or water withdrawal on the owners'q,ontiguous property covered under a Water Use Permit (WUP) or WUP Application? _ Yes _ No
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<br />If Yes, provide WUP No. WeII/;D. No.
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<br />I certify that I am the owner of the property, that the inforl1UJ~,Pro..vided on well location is accurate, and that I am aware of my responsibilities under Chapter 373,
<br />Florida Statutes, to maintain or properly abandon this weD;. Dr.V~Certity that I am (he agent for the 0WfI8{0 that the information provided is accurate, and that I have
<br />informed the owner of his responsibilities as stated above. / /. ..l, ." _ /i "j I ! ({ "-
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<br />a.wn8r or Agent's Signature /
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<br />Granted By:
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<br />TIde: ~ ~-, ~ 4't-:A Date: I Q ,. IS - 'f';;
<br />("' '/7--- -, 'j
<br />Owner Number: Fee Received: $ 5-., CL Receipt No.: C. ( ..' Check No.:'" [L
<br />THIS PERMIT NOT VALID UNTIL PROPERLY SIGNED BY AN OFFI6ER(!)F5WFWMD(R).IT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL DRILLING OPERATIONS.
<br />SF 306 (3) REV. 9192
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<br />a.'~~"".
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