irrt - University of Hawaii · 2011-06-16 · linda lingle governor of hawali o o state of hawaii department of land and natural resources state histo ric preser va tion division

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c o WELL CONSTRUCTION PERMIT

Northcutt WeD. Well No. 1223-05 Note: This permit shall be prominently displayed at the construction site until the work is completed

In accordance with Department of Land and Natural Resources. Commission on Water Resource Management's Administrative Rules, Section 13-168, entitled "Water Use, Wells, and Stream Diversion Works", this document permits the construction and testing of Nortbcutt Well (Well No. 1223-05) at TMK 5-2-021:006, Kauai, subject to the Hawaii Well Construction & Pump Installation Standards (HWCPIS - February 2004) which include but are not limited to the following conditions:

I.

2.

3.

4.

S.

6.

7.

8.

9.

10.

11.

12.

13.

14.

IS.

16.

17.

The ChailP-erson of the Commission on Water Resource Management (Commission). P.O. Box 621, Honolulu. HI 96809. shall be notified. in writing, at least two (2) weeks before any work authorized by this permit commences and staff shall be allowed to inspect installation activities in accordance with §13-168-IS, Hawaii Administrative Rules (HAR).

This permit shall be prominently displayed, or made available, at the site of construction work until work is completed.

The well construction permit sbaJ1 be for construction and testing of the well only. The permittee shall coordinate with the ClJairpmon and conduct a'pmnping test in accordana: with the HWCPIS (the latest pump test wOlksheet can be obtained by contacting Conunission staff or at www.bawaii.gov/dlur/ewrmlresoun:es.JJeI"IDits.latm) .. TheJ)CImittee shall submit to the 0Jai~ the test n:siJlts as a basis for ~g an application to install a prmumcnt~. No permanent pump may be installed until a pump installation pe.nmt is lIIJPfOVCd and issued by the Chairperson. No Withdrawal of water shall be made for purposes other tIian tc;sting without a Certificate of Pump Installation Coniplction. The permitted pump capacity described on the pump installation permit may be reduced in the event that the pump test does not support the capacity.

In basaJ ground water, the depth of the well may not exceed one-fourth (1/4) of the theoretical thickness (41 times initial bead) of the basal groIJ!Id water unless otherwise authorized by the Chairperson. If it can be shown that the well does not tap basal ground water then this condition may be waived after consultation with and acceptance by Commissinn staff. However, in no instance can the well be drilJeiI deeper than one-haIf (Ill) of the theoretical thickness without Commissinn approval.

The permittee shall incorporate mitigation measmes to prevent construction debris from entering the aquatic environment, to schedule work to avoid periods of high raintilll, and to revegetate any cleared areas as soon as possible.

In the event that historically significant remains such as artifacts, burials or concentrations of shells or charcoal are encountered durin~ construction. the permittee shall sto)) work iInd immediately contact the Department of Land and Natural Resources' State Historic Preservation DiVISion. Work may recommence only after written concurrence by the State Historic Preservation Division. .

The proposed well construction shall not adversely affect existing or future legal uses of water in the area, including any surface water or established instream flow standards. This permit or the authorization to construct the well shall not constitute a determination of correlative water rights. •

The Well Completion Report Part I shall be submitted to the Chairperson within sixty (60) days after completion of work (please contact staff or visit www.bawail.gov/dlnr/cwi'mlresources.JICrmits.latm for current form).

The permittee shall comply with all applicable laws, rules, and ordinances; non-compliance may be grounds for revocation of this permit

The well construction permit application and. if relevant, any related staff submittal approved by the Commission are incorporated into this permit by reference.

If the HWCPIS are not followed and as a consequence water is wasted or contaminated, a lien on the property may result.

Any variances from the HWCPIS shall be approved by the Chairperson prior to invoking the variance.

The work ptUJIOsed in the well construction permit application shall be completed within two (2) years from the date of permit approval, wd~ otherwise SJl!:Citied. The pc;rmit may be extended by the Chairperson upon a showing of good cause and good-faith performance. A request to ~ the ~ shall be submitted to the Chairperson no later than the date the permit expires. CIIIII \.r1 ~

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If the well is not to be used it must be properly capped If the well is to be abandoned during the course of the project then the permittee 1f! apitY l!i! a wen abandonment permit in accordance with §13-168-11(f), HAR, prior to any well sealing or plugging work. 0::' ',-!: ~c~

The permittee, its successors, and assigns shall indemnifY, defend, and bold the State of Hawaii harmless from and against any loss, li~cIaim, <i~ for PJ:OPCI1Y dl!mage. personal injury, or death &!ising ~ of any act or omissinn of the applicant, assigns, officers, employees, contractors, ~gent5.liril;t.itiis permit or relatlng to or connected With the grantmg of thIS penmt. ..';.:.;:, ; .j

"!his ~ sbaJ1. apply to the ~ shown on the application only. If the well is to be relocated, the permittee shall apply for a new well ~ mstallation penmt m 8ccordance With § 13-168-12(f), HM. __ ;-... 7.

o -:r-"l Special conditions in the attached cover transmittal letter are incorporated herein by reference. L;- ~ gj

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Date of Approval: November 6, 2009 Expiration Date: November 6, 2011

I bave read the conditions and terms of tbis permit and understand tbem. I accept and agree to meet tbese conditions as a prerequisite and underlying condition of my ability to proceed and understand tbat I sball not commence work until I bave signed, dated, and returned tbe permit to the Commission. I undentand that this permit is not to be transferred to any other entity. I also understand that non-compliance with any permit condition may be grounds for revocatiou and fines of up to S5,000 per day starting from the permit date of approval.

Driller's Signature: ~~ -< C-S7 License #: _C..:;;..-...:.2..;;..9..:...S7....;S'--__ _ Date: If jlJ-;&

Printed Name: Michael LluelIen Firm or Title: Kauai Water Well

Pleose sign both copies of this permit, retum one copy to the Commission oJJice, and retain the other for your records.

Attachment

FROM: ROY

TO:

CHENG, C. CHING, F. CHONG,A. DANBARA, S. ENGLAND, D. FUJII, N. HARDY, R. HOAGBIN, S. =c ICE,C. IMATA, A. KAWAHARA, K. KIMURA, J.

~-

CO~SSION ON WATER RESOURCE MANAat'MENT

DATE:

INIT. TO:

KUNIMURA.I. MILLS, D. OHYE, L. OHYE, M. OSHIRO, K. SAKODA, E. SWANSON, S. TORRES, A. UYENO, D. YODA, K. YOSHINAGA, M.

INIT:

SUSPENSE DATE:

FOR:

__ Approval Signature Information

(11/08)

PLEASE:

See Me Review & Comment Take Action Type Draft

__ Type Final File

__ Xerox _ copies

LINDA LINGLE GOVERNOR OF HAWAlI

o o

STATE OF HAWAII DEPARTMENT OF LAND AND NATURAL RESOURCES

STATE HISTO RIC PRESER VA TION DIVISION 601 KAMOKILA BOULEVARD, ROOM 555

KAPOLEI, HAWAII 96707

November 14,2009

MEMORANDUM

TO: Ken C. Kawahara, Deputy Director Commission on Water Resource Management

LAURA H. THIELEN OlAIRPERSON

BOARD OF [AND AND NA TIJRAL RFSOURCES COMMISS)ONONWATFRRESOURCEMANACErvteIT

RUSSELL Y. TSUJI FIRST DFPlTIY

KENC.KAWAHARA DEPUTYDIRECTOR· WATER

AQUATICRFSOURCES BOA TINGAND OCEA.N RECRFA nON

BUREAUOFffiNVEYANCES COMMISSIONONWATERRESOURCEMANAGMfJ'IT

CONSERVA nON AND COASTAL LANDS OONSERVATION AND RESOURCES ENFORCEMENT

&l<lNEERING FORESTRY AND WllDllFE HISTORIC PRESERVATION

KAHOOLAWE ISLAND RESERVE OOMMISSION lAND

STATE PARKS

Ii Log No: 2009.~7 Doc No: 0911N!10

FROM: Nancy A. McMahon, Deputy Administrator and Deputy State Historic Preservation Officer

-..

Subject:

Statc Historic Preservation Division ~ a ~~ Chapter 6E-42 llistoric Preservation Review-Well Installation Permit Application for Well No. 1223-05 (Northcutt) Kahili, Hanalei, Kaua'i Island, Hawai'i TMK: (4) 5-2-021:006

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Thank you for the opportunity to review this permit application which we received on November 9,2009.

We determine that historic properties could be affected by this project since there as already been historic properties identified and are being preserved on this parcel. In order for this project to have a no adverse affect on historic properties, we recommend the following condition be attached to this permit:

I) A qualified archaeological monitor shall be present during all ground-altering activities conducted in the project area in order to document any historic properties which may be encountered during the proposed undertaking and to provide mitigation measures as necessary. If the qualified archaeological monitor believes that there is no concerns about historic properties or burials then the monitor can be moved to an on-call status. An archaeological monitoring report must contain the following nine specifications: (1) The kinds of remains that are anticipated and where in the construction area the remains are likely to be found; (2) How the remains and deposits will be documented; (3) How the expected types of remains will be treated; (4) The archaeologist conducting the monitoring has the authority to halt the construction in the immediate area of the find in order to carry out the plan; (5) A coordination meeting between the archaeologist and construction crew is scheduled, so that the construction team is aware of the plan; (6) What laboratory work will be done on remains that are collected; (7) A schedule of report preparation; (8) Details concerning the archiving of any collections that are made; and (9) An acceptable report documenting the findings of the monitoring activities shall be submitted to the State Historic Preservation Division for review following the completion of the proposed undertaking.

Mr. Ken Kawahara Page 2

2) The State Historic Preservation Division (0' ahu office) shall be notified via facsimile upon the on-set and completion of the proposed undertaking.

Please call me at (808) 692-8015 if you have any questions or concerns regarding this letter.

LINDA LINGLE GOVERNOR OF HAWAII

Mr. Michael Lluellen Kauai Water Well P.O. Box 431 Anahola, HI 96703

Dear Mr. Lluellen:

o


COMMISSION ON WATER RESOURCE MANAGEMENT P.O. BOX 621

HONOLULU, HAWAII 96809

November 13, 2009

Pump Installation Permit Northcutt Well <Well No. 1223-05)

LAURA H. THIELEN CHAIRPERSON

WILLIAM D. BALFOUR, JR. SUMNER ERDMAN NEAL S. FUJIWARA

CHIYOME L. FUKINO, M.D. DONNA FAY K. KIYOSAKI, P.E.

LAWRENCE H. MilKE, M.D., J.D.

KEN C. KAWAHARA, P.E. DEPUTY DIRECTOR

Ref: 1123-05.pip

Enclosed are two (2) originals of your approved Pump Installation Permit for the captioned welles) that authorize permanent pump installation work for your welles). As part of the Chairperson's approval, the following special conditions were added and are part of your permit under Permit Condition 14:

Special Conditions

1. If the elevation benchmark needs to be altered, the permittee, well operator, and/or well owner shall ensure that the benchmark is transferred (or the well resurveyed) and documentation of the new benchmark shall be submitted to the Commission within sixty (60) days after the pump is installed.

The permittee is responsible for all conditions of the permit. This includes ensuring the submission of a completed Well Completion Report Part II form within sixty (60) days after the pump installation work is completed. Be advised that you may be subject to fines of up to $5,000 per day for any violations of your permit conditions starting from the permit approval date.

Please sign both permit originals and return one copy to the Commission office for our files.

IMPORTANT - Pump installation shall not commence until a fully signed permit is returned to the Commission.

If you have any questions, please call Charley Ice of the Commission staff at 587-0218 or toll-free at 274-3141 (Kauai), extension 70218.

Sincer ly,

(L~~L . L RAH. TH LEN -tv Ch irperson

Enclosure

c: Stephen Northcutt (with applicable comments - DOH WWB, CWB) USGS KauaiDWS

o PUMP INSTALLATION PERMIC ' Northcutt Well, Well No. 1223-05

Note: This permit sllall be prominently displayed at tile site until tile work is completed

In accordance with Department of Land and Natural Resources, Commission on Water Resource Management's Administrative Rules, Section 13-168, entitled "Water Use, Wells, and Stream Diversion Works", this document permits the pump installation for Northcutt Well (Well No. 1223-05) at TMK 5-2-021:006, Kauai, subject to the Hawaii Well Construction & Pump Installation Standards (HWCPIS - February 2004) which include but are not limited to the following conditions:

1. The Chairperson to the Commission on Water Resource Management (Commission), P.O. Box 621, Honolulu, HI 96809, shall be notified, in writing, at least two (2) weeks before any work covered by this permit commences and staff shall be allowed to inspect installation activities in accordance with § 13-168-15, Hawaii Administrative Rules (HAR).

2, No withdrawal of water shall be made other than for testing until a Certificate of Pump Installation Completion has been issued by the Commission.

3. This permit shall be prominently displayed, or made available, at the site of construction work until work is completed.

4. The pump installation permit shall be for installation of a 49 gpm rated capacity, or less, pump in the well. This permanent capacity may be reduced in the event that the pump test data does not support the capacity.

5. A water-level measurement access shall be permanently installed, in a manner acceptable to the Chairperson, to accurately record water levels.

6. The permittee shall install an approved meter or other appropriate means for measuring and reporting withdrawals and appropriate devices or means for measuring chlorides and temperature at the well head.

7. Well Completion Report Part II shall be submitted to the Chairperson within sixty (60) days after completion of work (please contact staff or visit www.hawaii.gov/dlnr/cwrm/resources _permits.htm for current form).

8. The permittee, well operator, and/or well owner shall comply with all applicable laws, rules, and ordinances, and non-compliance may be grounds for revocation of this permit.

9. The pump installation permit application and, if relevant, any related staff submittal approved by the Commission are incorporated into this permit by reference.

10. If the HWCPIS are not followed and as a consequence water is wasted or contaminated, a lien on the property may result.

11. Any variances from the HWCPIS shall be approved by the Chairperson prior to invoking the variance.

12. The work proposed in the pump installation permit application shall be completed within two (2) years from the date of permit approval, unless otherwise specified. The permit may be extended by the Chairperson upon a showing of good cause and goodfaith performance. A request to extend the permit shall be submitted to the Chairperson no later than the date the permit expires.

13. The permittee, its successors, and assigns shall indemnify, defend, and hold the State of Hawaii harmless from and against any loss, liability, claim, or demand for property damage, personal injury, or death arising out of any act or omission of the applicant, assigns, officers, employees, contractors, and agents under this permit or relating to or connected with the granting ofthis permit.

14.

Date of Approval: Expiration Date:

November 6, 2009 November 6, 2011

I have read the conditions and terms of this permit and understand them. I accept and agree to meet these conditions as a prerequisite and underlying condition of my ability to proceed and understand that I shall not commence work until I and the pump installer have signed, dated, and returned the permit to the Commission. I understand that this permit is not to be transferred to any other entity. I also understand that non-compliance with any permit condition may be grounds for revocation and fines of up to $5,000 per day starting from the permit date of approval.

Installer's Signature: C-57, C-57a, or A License #: C-29578 Date:

Printed Name: Michael Lluellen Firm or Title: Kauai Water Well

Please sign both copies of this permit, return one copy to the Commission office, and retain the other for your records.

Attachments

...



Dear Mr. Lluellen:

c




November l3, 2009

Well Construction Permit Northcutt Well <Well No. 1223-05)

LAURA H THIELEN CHAIRPERSON


CHIYOME L. FUKINO, M.D. DONNA FAY K. KIYOSAKI, P.E.

LAWRENCE H. MilKE, M.D, J.D.

KEN C. KAWAHARA, PE. DEPUTY DIRECTOR

Ref: 1223-05.wcp

Enclosed are two (2) copies of your approved Well Construction Permit for the captioned welles) that authorize well construction activities but excludes installation work for a permanent pump. As part of the Chairperson's approval, the following special conditions were added and are part of your permit under Permit Condition 17:

Special Conditions

1. Attached for your information are copies of the Department of Health's (DOH) review comments. Please note DOH's requirements related to discharge of effluent from well drilling and testing activities. Also, please contact the Noise Radiation and Indoor Air Quality Branch at 586-4700 to check compliance with construction noise permit requirements for this project.

Please refer to the Permit Processes Worksheet (transmitted with your acknowledgement letter) for further information regarding the process of drilling a well and installing a pump.

No withdrawal of water shall be made other than for testing purposes until a certificate of pump installation completion has been issued by the Commission.

Please sign both permit originals and return one copy to the Commission office for our files. For copies of the aquifer pump test worksheet, please call staff or visit www.state.hi.us/dlnr/cwrm/forms.htm.

IMPORTANT - Drilling work shall not commence until a fully signed permit is returned to the Commission. The permit shall be prominently displayed or made available at the construction site during construction. Be advised that you may be subject to fines of up to $5,000 per day for any violations of your permit conditions starting from the permit approval date.

If you have any questions, please call Charley Ice of the Commission staff at 587-0218 or toll-free at 274-3141 (Kauai), extension 70218.

~~fpL RAH. T LEN

alrperson

Enclosures

c: Stephen Northcutt (with applicable comments - DOH WWB, CWB) USGS KauaiDWS

/

c o WELL CONSTRUCTION PERMIT

Northcutt Well, Well No. 1223-05 Note: This permit shall be prominently displayed at the construction site until the work is completed

In accordance with Department of Land and Natural Resources, Commission on Water Resource Management's Administrative Rules, Section 13-168, entitled "Water Use, Wells, and Stream Diversion Works", this document permits the construction and testing of Northcutt Well (Well No. 1223-05) at TMK 5-2-021:006, Kauai, subject to the Hawaii Well Construction & Pump Installation Standards (HWCPIS - February 2004) which include but are not limited to the following conditions:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

The Chai'Eerson of the Commission on Water Resource Management (Commission), P.O. Box 621, Honolulu, HI 96809, shall be notified, in writing, at least two (2) weeks before any work authorized by this permit commences and staff shall be allowed to inspect installation activities in accordance with §13-168-15, Hawaii Administrative Rules (HAR).

This permit shall be prominently displayed, or made available, at the site of construction work until work is completed.

The well construction permit shall be for construction and testing of the well only. The permittee shall coordinate with the Chairperson and conduct a pumping test in accordance with the HWCPIS (the latest pump test worksheet can be obtained by contacting Commission staff or at www.hawaii.gov/dlnr/cwrmlresources_permits.htm). The permittee shall submit to the Chairperson the test results as a basis for supporting an application to install a permanent pump. No permanent pump may be installed until a pump installation permit is approved and issued by the Chairperson. No Withdrawal of water shall be made for purposes other ilian testing without a Certificate of Pump Installation Completion. The permitted pump capacity described on the pump installation permit may be reduced in the event that the pump test does not support the capacity.

In basal ground water, the depth of the well may not exceed one-fourth (114) of the theoretical thickness (41 times initial head) of the basal ground water unless otherwise authorized by the Chairperson. If it can be shown that the well does not tap basal ground water then this condition may be waived after consultation with and acceptance by Commission staff. However, in no instance can the well be drilled deeper than one-half (112) of the theoretical thickness without Commission approval.

The permittee shall incorporate mitigation measures to prevent construction debris from entering the aquatic environment, to schedule work to avoid periods of high rainfall, and to revegetate any cleared areas as soon as possible.

In the event that historically significant remains such as artifacts, burials or concentrations of shells or charcoal are encountered during construction, the permittee shall stoJl work and immediately contact the Department of Land and Natural Resources' State Historic Preservation DiVision. Work may recommence only after written concurrence by the State Histonc Preservation Division.

The proposed well construction shall not adversely affect existing or future legal uses of water in the area, including any surface water or established instream flow standards. This permit or the authorization to construct the well shall not constitute a determination of correlative water rights.

The Well Completion Report Part I shall be submitted to the Chairperson within sixty (60) days after completion of work (please contact staff or visit www.hawaii.gov/dlnr/cwrm/resources _permits.htm for current form).

The permittee shall comply with all applicable laws, rules, and ordinances; non-compliance may be grounds for revocation of this permit.

The well construction permit application and, if relevant, any related staff submittal approved by the Commission are incorporated into this permit by reference.

If the HWCPIS are not followed and as a consequence water is wasted or contaminated, a lien on the property may result.

Any variances from the HWCPIS shall be approved by the Chairperson prior to invoking the variance.

The work proposed in the well construction permit application shall be completed within two (2) years from the date of permit approval, unless otherwise specified. The permit may be extended by the Chairperson upon a showing of good cause and good-faith performance. A request to extend the permit shall be submitted to the Chairperson no later than the date the permit expires.

If the well is not to be used it must be prorerly caf:,ped. If the well is to be abandoned during the course of the project then the permittee must apply for a well abandonment permit in accordance with § 3-168- 2(t), HAR, prior to any well sealing or plugging work.

The permittee, its successors, and assigns shall indemnify, defend, and hold the State of Hawaii harmless from and against any loss, liability, claim, or demand for property damage, personal injury, or death arising out of any act or omission of the applicant, assigns, officers, employees, contractors, and agents under this permit or relating to or connected with the granting of this permit.

This permit shall apply to the location shown on the application only. If the well is to be relocated, the permittee shall apply for a new well construction/pump installation permit m accordance with §13-168-12(t), HAR.

Special conditions in the attached cover transmittal letter are incorporated herein by reference.

Date of Approval: November 6,2009 Expiration Date: November 6, 2011 ater Resource Management

I have read the conditions and terms of this permit and understand them. I accept and agree to meet these conditions as a prerequisite and underlying condition of my ability to proceed and understand that I shall not commence work until I have signed, dated, and returned the permit to the Commission. I understand that this permit is not to be transferred to any other entity. I also understand that non-compliance with any permit condition may be grounds for revocation and fines of up to $5,000 per day starting from the permit date of approval.

Driller's Signature: C-S7 License #: C-29578 --~~--~---------

Date:

Printed Name: Michael Lluellen Firm or Title: Kauai Water Well

Please sign both copies of this permit, return one copy to the Commission office, and retain the other for your records.

Attachment

FROM: CHARLEY

ANAKALEA, P. BAUER,G. CHING, F. DANBARA, S. FUJII, N. GOODING, K.

-1-HAROY,R. ~ HIGA,D. ~ ICE, C. IMATA, R.

WELL NUMBER 1223-05

~ WELL CONSTRUCTION

o COMMISSION ON WATER RESOURCE MANAGEMENT

ROUT SLIP FOR PERMIT ISSUANCE 5/19/05

o Ov 0 OATE:.l!3.'!!l!.'I:!!1.~~~ ___ SUSPENSE DATE:

KUNIMURA, I. NAKAMA, L. NAKANO, O.

-3-0HYE,M.

SAKOOA, E. 2 SUBIA, S.

SWANSON, S. UYENO, D. YODA, K. YOSHINAGA, M.

Ii Approval Signature

-3-lnformation

Northcutt Well

ATTACHMENTS FOR WELL CONST;TION PERMIT: 1 COVER LETTER 2 PERMIT (2x)

COMMENTS: 3 SOWB 4 WWB 5 CWB 6 HEER 7 LD 8 HP 9 OCCL

10 SMA --

11 WELL CHECK PRINTOUT -r ~ PUMP INSTALLATION

TO BE SENT TO APPLICANT

FOR OFFICE USE ONLY

ATTACHMENTS FOR PUMP INSTALLAJION PERMIT: 1 COVER LETTER ../ . 2 PERMIT (2x) =z

COMMENTS: 3 SOWB 4 WWB 5 CWB 6 HEER 7 LO 8 HP 9 OCCL

10 SMA 11 GLENN'S WORKSHEET

TO BE SENT TO APPLICANT

FOR OFFICE USE ONLY

PLEASE:

See Me -1-Review & Comment

Take Action Type Draft

-2-Type Final

4 File Xerox copies

t,ltJ1)-02-i?QC19 .12: 57 From: DOWSRFE WRTER BRRl'lH 8085864351 To:8[/,0 587 0219 P.7/9

• f RECEIVED

SAFE DRINKING WATER BRANr.H -U{,7 t; aw

UNOA LINGLE. ;<~ lAURA Ii THIHEN OOVEJl:NilA OF "'~W"II


COMMISSION ON WATER RESOURCE MANAGEMENT po 60X621


October 6, 2009

WIL.lIAM O. 6ALFOUR, JR. SUMNER EF\OMAN NEAL S. I<UJIWAAA

CHIVOME l. FUKINO, M 0 DONNA FAY K I(IYOSAI(I. P E LAWRENCE 1-1. 1.4111(1:, M.D., J. D.

In General: III 3, ~S

Q ;;; 1/l-D 0 'V~< use = DIY"'"

TO: Honorable Chiyome L. Fukino, M.D., Director Department of Health Attention: 1;omas See) Chief) Wastewater Branch

: location = /<!/.,"'"-t,,!1> ; KI'\ IIA

(abe,-~e)(be1ow)urc line grd. etev. = <) .. ~'

...stuart Yamada,.Chief, Safe Drinking Water Branch Alec Wong, ChIef, Clean Water Branch

well dia. = 4" well depth ~ !,' 0 I

.':):;".:'~/(; X~i4.A! j,,4,f.Jl.lJl (( Dr. Keith Kawaoka, Office of Hazard Evaluatio

1n an,

FROM: ~aura H. Thielen, Chairperson . 4 \-~ Commission on Water Resource Management

SUBJECT: Well Construction/Pump Installation Permit Ap Northcutt Well (Well No. 1223-05)

Transmitted for your review and comment is a copy ofth~ captioned Well Construction/Pump Installation permit application.

We would appreciate your comments on the captioned application for any conflicts or inconsistencies with tht': programs, plans, and objectives specific to your department. Plea!&! respond by returning this cover memo form by November 6. 2009. ]fwe ~o not receive comments or a requ~st for additional review time by this datt':, we will assume that you have no comments.

Please find the attached maps to locate the proposed well., If you have any questions about this permit application, request additional information, or request additional review time, please contact Charley Ice of the Commission staff at 5&7~0218.

CLss A ttachment( s)

RESPONSE: rue II

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t 1 [ 1

~b.i. "",JI quahfk. " • ''''''''0 which " ... 11 .crvc 3!: " oource of pot .. \>ll' WIlICT 10 a publ" waltr ~y.I"m (drfin.d <0$ :;erving 25 or more ~ople al ItHl 60 day. per y.,... or h". I S or ,nore ,.rv,ce "onn.~"Qn$) lI'Id '"11$1 r\l~elvo Dire'tOl' of HM.lth ..pprovol1!!l!u: to .ts us<: to oo",~ly w,th H.waii AdminlOtral,ve Rules (MAR). T'tle II. Chapter 20. Rules Rel3tjng~o Potable Water Sy.tCni". §11·ZO·29 ,

ThIs well does not qualify as 8 souree ~etVi"~ • pubhc w.ter sy.tem (serves less th&n 21 pepple or mQre p"QP)e at le8~t 60 days per year or IS ltrvlce oonnecllon»;and ,f .he well water '. u..:d for <;\rink.n~. the private OWIIM .bould ,.~t fQr i;>al',,,,,<!I<!gill8\ lIDd "hem\~al presence lIerore ittlt~tm8 ,~~" ~5C ""d rgul.",<!y mO'ljlor tile Water ~lIl1hl~ thereafter However. ,frulure plQnn,d UJ;C tTom th;$ Soo<t;¢ ;."0<1'.' to .... od tbo public water :;y.tom <;\cfimli01l then Director of Health appronl is required prior to implcl'IIl'lIIi\liOn

If the wcllis used tesupply both patabl~ and """-polabl,, purpo~~~ In Ii Single system. tM !.\ser shall e1uJlinate eros~.eonnl'~tlons and ba~fiow Ct)lltle.::tiOtt$ \)y phY~lcany $.p~illg PQI~bI" <I.\Id nQIl"POla1:>le sYSlems by an air gap or an 3\'proveCl baekflQw prQVl'nlcr. and by "I,,;orly labeling ~I1IJOnpGt"ble Spigols with W,,",lng Signs to prov.nlll\advert~1)1 ~O!l.,,"'pt'o .. "'( 'lOn'pohb!. Wilt.,. B""kflow proV.ntlQn devic~g shOuld be routln"ty ,nspected ~nd tl'stl'c!

For the applu:an\'s mformatlon. a source ofpouibl. w~.tow"t"r"o!).lam(natiot\ 1)'$ [I ,6 .. O)~ )"o~kd ncar the propo.od woll suc (mformal.on anaoh"d)

An NPDBS pon",1 is reqUired

Other relevant DOH I1lleilregula!lOn~, ttlf6r1n;!.!ion, or reQOmm~ati0ll5 ate att&~""d

In the evelu thsi Ibe IOCalion of the ",,,1) ~Ililll~es hili IS still within the tl",cel described on t~,S OlPpho:/.IIolI. our diVIsion tOMld~rs the tomlllcnts 10 5\.)1 b .. apph(:~blc. anI! we do not n~~d 10 reVIQW thc new Iccalion

[ 1 No commen!ciob)cClIon&

Contact Person: !vJ/(J':'I;'£L. Mlr1oJ~

Signed: ~...d.."""",-",c:)::--~---Phone:

Date: ,

S&-~B j} 1-2 /01

t--.JOl)-02-2.£j09 .12:57 From:DOWSAFE WATER BRANH 8085864351 To:8P" 587 0219

CWRM Applioation Source; Northcutt We~l (State Well No. 1223-05)

Safe Drinking Water Branch (SDWB) - Engineering Section

See attached private water wells information sheet.

?DWB - underground Injection Control (UIC): Section

The UIC Program has the following comments specific to this Application:

P.W9

In general, a shallow well, or a well; that recharges quickly from local rainfall, should Dot be used as a potable water source because such a w~ll increases the risk of having unsatisfactory groundwater quality that when consumed may compromise health. Factbrs that directly influence a well's groundwater quality include wastewater disposal systems (cesspools, septic systems, drainage wells), lawn/garden/crop-growing actiVities, and even the proximity to the ocean where salt water intrusion may OCCUl:".

The siting of a drinking water source; below the Ule line affects the allowed potential for new: injection well construction. New injection wells will then be prohibited within setback areas defined in Chapt¢r 11-23. We suggest that surrounding landowners be inform~d of this proposed action because it may affect the deveJ..opn1ent potential of t.he properties wi thin the setback are~.

Well water quality should be initiallv and periodically tested for it's acceptable and intended use, especially if for human consumption. Water quality: should not be presumed acceptable and unchanging. ~and-based activities around the well and within the well's' recharge area may, over time, have an unacceptable effect on the well's water quality. Well construction materials and related equipment could also affect water quality.

Questions about UTC may be direoted to Chauncey Hew at 586-4258.

t'-lC],)-02-2009 ,12: 57 From: DOWSAFE WATER BRANH 8085854351 To:8[lP 587 0219

WARNING! As the owner of a privately-owned well, you!should NOT assume that

water from your well is safe for consumption. It is your responsi~ility to make sure that your well water is safe to drink. The only way to do this is to have yo~r well regularly tested for bacteriological and chemical contaminants.

There are no regulations contrOlling water quality in private wells iserving individual residences as there are for public water systems (public or privately owned 4tiliti9S supplying water to 25 or more people or 15 service connections). In other words, there a~e no enforceable limits for contaminants and no requirements for regular testing. Private wells are often found in rural areas, where many activiti~s such as onsite wastewater disposal:can contaminate the ground water.

U.S. ENVIRONMEtAlAL PBOTECTION AGENCV (EPA) RECOMMENDATlbNS

The EPA recommends that privata well owners test their well wa~r each year for such contaminants as Total Coliform Bacteria, Nitrates, as well as any!other conta.minants that may be of concern in your area. More frequent testing may be appr~riate it you suspect a problem. EPA also suggests that you consider testing for pesticides. orga~iC chemicals. and heavy metals before using it for the first time. Please refer to the EPA website on Private Drinking Water Wells at http://www.eca.gov/safewater!priyatewell$/faQ_htrol

OTHER COltTAMINANTS

Water testing can be very expensive. It is important that you spel1d time to identify what other potential contaminants may b~ of concern. Ptease refer to the EPA website on Private Drinking Water Wells at http://www.epa.gQV/Safewater/privateweIlSlWhaty~ucand.Q.html for more helpful information. Be aware of What and how you use ~nd dispose of household and garden chemicals. Also determine the location of nearby septic t~nks or cesspools, and agricultural or industrial activities In the area. General Informatio~ on known chemical contamination of ground water in Hawaii can also be found at the: DOH website 'NWW_hawaii_gov/healtb/envirQnmental/waterlsdwblconmaps/pdficc,mmapsQ5_pdf

LASORATORIES

Local commercial labOratories can be found in the yellow pages 0' the telephone book under "Laboratories. Analytical." Whenever possible, utilize a laborato~ that is certified or approved for the specific drinking water tests and carefully follow their instr~ctions for colleoting, storing, and transporting the samples. Just be sure to ask the lab to use EPA approved methods for drinking water analysis. A list of labs certified or approved by the pepartment of Health can be found at \WNt.hawaii.qov/heal1h/eOYironmental/w<at~rls.dWb/sdwb/~dffTesting%20babs.pdt _ As lab certification status changes constantly. confirm their status wh'~n you contact the lab. Please note that the list is limited to currentty regulated contaminants in publiC water systems.

B.,esuJ-,TS

Once the lab provides you with the test results, you will be in a better position to de1ermine if your well water is safe to drink or what contaminant you need to tr~at for_ Generally. you shOUld compare the results with Federal (www_e a. v stew ter cl. ) and State ( aii_ ov/h I h . nm ntal/w r wb/sdwbl f ~Q.20 Cl. df) drinking water standards. Where your test results are greater than the State or F. deral maximum contaminant levels, your well water should be considered as unsafe for conSUn!lption.

Dd,28, 2009 3:06PM DOH-HE~R.OFFI~E 808-586-7537 No,3908 p, 10

~~

liNDA lINGL~ a'OYSRNQIl ()F HA ..... AlI

HEC[IV~D OEPARl HENT OF HEALTH

LAURA H. THIELEN ClKA.lR"FI$QN

. lDa~ OCT .. 8 A q: q2

HEER OfFICE STATE OF HAWAII

DEPARTMENT O~ LAND AND NATURAL RESOURCES

COMMISSION ON WATI;R RESOURCE MANAGEMENT P.o. BOXS2f

HONOLULU. HAWAII ssaoo

October 6, 2009

Wlll.IAM D. BALFOUR, JR. Sl1MN~R.E~DMAN NEAL S. FUJIWARA

CHIYOME L. FUKINO, M.D. DONNA fAY K. KIYOSAKI, P.E. LAWRENC~ H. MilKE, M.D., J.D.

KEN C. KAWAHARA, P.E. DEI"'UlYDrREC>T.:tn

TO: Honorable Chiyome L. Fukino, M.D., Director Department of Health Attention: Tomas See, Chief, Wastewater Bfanch

St.llart Yamada, Chief, Safe Drinking Water Branch ~'lec Wong, Chief, Clean Water Branch

'\Dr. Keith Kawaoka, Office of Hazard Evaluation an Emergency Response

FROM: flI1:.aura H. Thielen, Chairperson t~. 4tAJL \." Commission on Water Resource Management

SUBJECT: Well ConstructionJPurnp Installation Permit Ap lication Northcutt Well (Well No. 1223-05)

Tl'ansmitted for your review and comment is a copy of the captioned Well Construction/Pump Installation permit application.

We would appreciate your comments on tIle captioned application for any conflicts or inconsistencies with the programs, plans, and objectives specific to your department. Please respond by returnine this cover memo form by N ovem ber 6, 2009. If we do not receive comments or a request for additiOnal review time by this date, we wilf assume that you have no comments.

Please find the attached maps to locate the proposed well. If you have any questiolls about this permit application, request additional information) or request additional review time, please contact Chal'ley Ice ofthe Commission staff at 587-0218.

CI:ss Attachment(s)

RESPONSE:

( 1

( ]

[ )

I )

[ 1

II

[ 1 [ ]

This well qualifies a. a so\ll"ce which will serve as 3. sauroe of potable \Valer !o a public water system (dellil~d 'IS urving 25 or mor~ people all.liSt 60 day.; per l'~'r or has 15 or mote suvico c~nl1.olions) and mwt <ec.ive Direotor of Heal til apprllvalRrilU: to ilg Ug~ 10 comply with Hawaii Admil'listt31ive Rilles (HAR), Tille I L CQ"I't~r 20. Rules Ralali1lB to l'oloble Water SysMms, §l 1.20-l9.

This well does n<)1 qu~lilY AS a aOUice seNil'lg a puhlic",ater syslem (iN'V.$I~ss th,n 25 peopl~ or Inore people at leilit 60 day!; per yoiii' or 15 servic~ t(l(lneotlons) and iflhe well wal .... l~ used for drinking, III .. private owner IhOllld test tor baol~rlological and chemical p~senoc beror~ il'liliating such usc iJ"Idroutillely mQnitor (he water Q.ualily thereafte,. Rowever, iffutur" pl;\ll1l~d use from lhi~ source inQre.ses to mccllhe public ''''ler system dcfiniti~n Ihen Direclor ofHeallh apPrclval 15 required I!!!2r to implemenlation.

lfille w~1I i~ u~ed!o $upply bOlh I?olablc and naa-po(able p~!pose3 in a single ;YS,em. the user shall eJimiJIal1l crOSS"OClUlcclioll& &lid billcUl"w COitn~ilQns by physically BCp8J"al")8 pOI.hle lIIld non-polable Syslems by an air gap Ot an approved b~ckflow prcwntec, and by dearly labelinsaU nun· potable spigOIS \.ilh wlIrnin,Ksign& (0 prevMl il\.idl!.!1~nt oonsumption ofnon,p~(~hic water. Backllc>IV preven.ion devices sho"ld b" rOulinl'ly inspecled ofInd f.~II'I!.

II d.l)e5 nOI appear that Ihis well will be used for ~onsumplille pU'l'osea and ia nOI subjecllQ Safe Drinking Waler alrg\llalionB.

for rhe appJio~nt'8 information, ill sOlllce (ll'possible wsstewal8r conl~min.tion []I! [ Ilg not loca!ed ne~r the proposed well sile (intonnation attached).

An NPDES pCllllit is required,

Other relevanl DOH rule&lr.8ul~tiQns. infonnation, Or reoommendalions are alta~hed,

fillh. ellen( Ih~t lho lotation of the well clion,Kos bUl is slill within I~O p9Tvcl deBClib~d on thi; appliesljon. our division (;on~deri !h~ comments 10 &li1l b. applicable, and we do Ilot Jle~d 10 review the new localion.

p<. No commenlMobjection;

Contact Person: }(rcA",a..'n:l 'Ya.\met Phone: Sg~ -09 Sf

.signed:~~ Date: 16,i.;rr-A,c:::J!j?

o Charley F Ice/DLNRlStateHiUS

10/12/200909:18 AM

To [email protected]

cc

bcc

Subject Re: Green Valley, Northcutt[j

So we did! I'm dealing with so many applications, the connection was not obvious. This documentation makes no connection to the well site: the only address on it is a property in Kapaa, not Moloaa. The Dayenu Corporation has dealings in several places on Kaua'i? Do the Northcutts also have multiple interests on Kaua'i?

[email protected]

[email protected]

10109/200907:40 PM To Charley.F.lce@hawaiLgov

cc

Subject Re: Green Valley, Northcutt

sorry I thought you asked for some verification for Northcutt.

-----Original Message-----From: Charley.F [email protected] To: [email protected] Sent: Fri, Oct 9, 2009 5:29 pm Subject: Green Valley, Northcutt

We received the Green Valley Investment well application, and attached was a Real Property Assessment sheet signed by Northcutts. Was that sent my mistake, and do you need it for something else?

Cho .. 'cy lee H yclrol ogi st

HaV\€lii Water Comm ission 1151 P unchb o»\>l 227 Kal an im of;: u P .0 .Box 621, Honolulu 96809 (808) 587-0218

~ ,.


TO:

FROM:

o




October 6, 2009

Honorable Chiyome L. Fukino, M.D., Director Department oyHealth Attention: \'Tomas See, Chief, Wastewater Branch

Stuart Yamada, Chief, Safe Drinking Water Branch Alec Wong, Chief, Clean Water Branch


WILLIAM D. BALFOUR, JR SUMNER ERDMAN NEAL S. FUJIWARA

CHIYOME L FUKINO, M.D. DONNA FAY K KIYOSAKI, PE



Dr. Keith Kawaoka, Office of Hazard Evaluation an Emergency Response

\-- Commission on Water Resource Management a.t"Laura H. Thielen, Chairperson ~~. 4;AJL

SUBJECT: Well Construction/Pump Installation Permit Ap lication Northcutt Well (Well No. 1223-05)

Transmitted for your review and comment is a copy of the captioned Well ConstructionlPump Installation permit application.

We would appreciate your comments on the captioned application for any conflicts or inconsistencies with the programs, plans, and objectives specific to your department. Please respond by returning this cover memo form by November 6, 2009. If we do not receive comments or a request for additional review time by this date, we will assume that you have no comments.

Please find the attached maps to locate the proposed well. If you have any questions about this permit application, request additional information, or request additional review time, please contact Charley Ice of the Commission staff at 587-0218.

CI:ss Attachment(s)

RESPONSE: [ 1 This well qualifies as a source which will serve as a source of potable water to a public water system (defined as serving 25 or more people at least 60

days per year or has 15 or more service connections) and must receive Director of Health approval prior to its use to comply with Hawaii Administrative Rules (HAR), Title II, Chapter 20, Rules Relating to Potable Water Systems, § 11-20-29.

[ 1 This well does not qualify as a source serving a public water system (serves less than 25 people or more people at least 60 days per year or 15 service connections) and if the well water is used for drinking, the private owner should test for bacteriological and chemical presence before initiating such use and routinely monitor the water quality thereafter. However, if future planned use from this source increases to meet the public water system definition then Director of Health approval is required prior to implementation.

[ 1

[ 1

)< [ 1

~ [ 1

If the well is used to supply both potable and non-potable purposes in a single system, the user shall eliminate cross-connections and backflow connections by physically separating potable and non-potable systems by an air gap or an approved backflow preventer, and by clearly labeling all nonpotable spigots with warning signs to prevent inadvertent consumption of non-potable water. Backflow prevention devices should be routinely gecte<!;o and tested. .. ", ('")

.. u>c>

;0:::: :~~:~~:~s t:~o::~:~: ~:~:r::::dp:O:s::s:~~:::t:~:::::t::~:~j:~: :::::a~:~n:~:t:a;:::::I:~:~:[te (information ahed).~ ~;u I ~1U'liTl

\0 ..... OC""J _l.. __ ",

Other relevant DOH rules/regulations, information, or recommendations are attached. One-Stop database screen ~ ;;:;;::: In the event that the location of the well changes but is still within the parcel described on this application, our division considers the commeMrto stil~ 2: 8

An NPDES permit is required.

applicable, and we do not need to review the new location. (.j) ;;;;');:E ~ "~ i?'\ No comments/objections _ .. : \, " \:i ,f:- f'T1rTj

Contact Per~. Lori V0';te[, '::r,0, O;i .<auai 241-3323 en ~::o

Signed: ---,V=-W11----'_~ ___ . __ ' __ ~_~_. Date: ['0 -O~ -0'1

" .. , .....". 1.--""., c· '. ')

ar 6 ldl:l B 130 601 H8Nvod H31Vi,,31SVM

HllV3H jO lN3~1~Vd3a

IWS Permit Profile

~'~ General ~ Site Info . Ii] IWS System : ~ Documents i !Hl BPA • ~ Notes

Application Information

Permit 10: 21079

Legacy File#: 4010

eHawaii 10: N/A

Variance 10: rl -----,

IWS Type: Septic Tank

Island: Kauai

Status: Plan Approved

Engineer: Brian Hennessy

TMK: 1452021007 t Street Address: LIK:..:A:..:;HI:;:LI:..:;M:..:;A..;;.K.:;..A:.:..I.::.ST.:..,:. ___________________ ............I

Street Address 2:

Suite/ Apt.:

City: ILK:..:I~~UE.::.A~ __________________ --JI,HI

Zip Code:

Assigned To: Tateyama, Joe

Source: WWB r-----------------------Description: '--____________________ ___

[Review InfornlaUonl----------.....

Submit Date: 14/2/2002

Reviewed: 14/8/2002 -Plan Approved: 14/8/2002 -No Final Approval Ltr: -Inspection Date:

Final Approval: -Termination Date: -I Payment InformatioflJ----------------------------------------.

Payment Type: Check Number: LI ________________________ ~ Amount: ""10 ____ -1

Payor:

Added By: phsieh 2/26/200710:52 AM Last Modified:

http://onestop.eha.local/wwblPermits/addEditPermit.aspx?PermitlD=c3975f50-fe7f-4adf-b985-edb6e922ae69

Page .. l .... ~1 ,

"

o

()

10/812009

REAL PROPERTY ASSESSMENT DIVISION DEPARTMENT OF FINANCE

COUNTY OF KAllAl 4444 RICE ST.. SUITE 454 241-6222

LIHUE. KAUAI. HAWAII 96766

PETITION TO DEDICATE L-\ND FOR AGRICULTURAL USE NEW PETITrON

. .. . . .. PETITION TO CHANGE USE (SEE") :::z::.. ... otl Prepare 2 c~ples of thIs petltlon. CopIes must be. sIgned by all partIes having legalmterest in the petitioned land (for example. husband and wife). %\lit separate pet1t1on shall be requited for each mdlVldual parcel. or apartment or unit of a condominium property regime. A copy of this petition shall be returned to Ihe. petitioner. Submit all petItions to the director of Finance by September I. A tax map or facsimile showing the area to b. dedicated, the homesIte area ,f any. non-ded,cated and unsuitable area, must accompany each copy of petition.

~c;:.~;~:~;.---T-~::-;--=]7-~¥.!f§:~~~-~~------2. Mailing Address of Assessment Notice ; 4, Telephone No. I ClI Rural

I

I 0'1 0 K -Q..G\ l 0 h <l Rucu;l Res 3'-1 h· Q..tU.K I' ClI Urban

.kqpaa) H:t:' 9(,:1ifb. Bus&'~. 13JSj ClI Conservation

6. Present uses of parcels. 7 Specific Agricultural or RancLhi:::n-g'U75:-:e7(S-::):-------------------l

Callie rub: bin:) t.hn~i~l ~cl~b'2J Iqn+.s Q.V\d +ree~ ! dedicate my land to the followmg agricultural uses· (Be specific-such as pineapple, vegetable crops, fruit crop, flower crop, poultry, cattle pasture, etc.) Note: A statement of the petitioner's pasture rotation. crop cycle planting. harvesting or marketing schedule of products, livestock or animals shall be submitted.

--.0---- ...

I AJrriCUltu~~··:r Ranching Use I Area To Tax Key Area of Parcel I Dedi£~

I --. I

- I '''-''', "'- -_.,". ~.

• ~. n,," __

---+ I .. -I I ! =1=- ..... _-_. -I

"- I

+ I +--I -+"- _I

1 I I !

._- I _v_~··· ...

-Be--I-unusable Area Non-Dedicated

±==ted I A. Dc.m" Do' h:'" ~

. I I I I -L--L . J +=---+-+--1 ---l

-J.---+-----+---4 I

9. .*' hereby petition to change the dedicated use of Petition NoK-q Ci9 A.-.-dedicated ~.~~ by changing ~e <! c.cI« e... use '" d I hl~ ~d , .• \"\Q \ P Iq ~..l~ q V\ ~ .L-.. .' existing iledicoted

I I Total Area

, • to ______ .. _TT_"se ___ .!~ ~c..s. Items 10 thru 15 are to be tilled in only If petitioner'. land is leased. lfit area new area

is, only copy of the lease document must be attached hereto. Only one copy of lease document need acwmpany a set of the petition.

10. Lessor's name and mailing address: 12. Lease rental schedule: Ill. Term of lease (years)

Lease document is attached: -------.'1-;5-. '!'s'lea-s-e -rec...J..o-rd'ed-T".-:-l-;th-e'B;:;"u-re-au-o·f;;'C;:;--on-v-e-y-an-c-es-:-?;;". ---1 (check one) Yes ClI No [J Yes ClI No ClI

13. Expiration oflease 1

14.

16. As a petitioner ofl';-nd(s) situated within the State's Agricultur;;ri.and Use District, [hereby petition Iha' 'he Period of Dedication be (check one) r:;,/

ClI 10 Years 'III" 20Y . ..:.ear:::.;cs ____ _

To facilitate statute-required investigation of this petition, I hereby grant to the Real Property Assessment Division a right of entry to land described above as well as access to existing soil survey informatIOn and to inte~pretive data compiled from this SOUTce. . I hereby declare that my land can be best used for the foregoing purptlSC or changes and if this petition is approved, I \\ill use my land for such purposes in accordance with applicable ordinances. I understand that failure to observe the restrictions of the use oflhis land shall cancel the dedication and special tax assessment privitege retroactive to the date of the dedication. and that additional taxes and penalties, due and owing as a result of a breach ofthe dedication shall be a paramount Hen upon the

property, In accordanc: :th applicable ordinanc~._ .... c... ~ • \ . \ l ...J1 ~...'j Q ..... ~ DO NOT WRITE HERE =l- ~- L,f 1\ Jj,)f!f--i LC:VT\ ___ ctU __ lk

Signature of Ov.'ner or Agent· Date

Date Recelved: ._- .1...",' .J1&Vt1n udt Jr~~ 0 ~ Assessor' _____ _ _ __ __ __ ;~',g atuT. 0 "'ner 8ent* Da ..

[d 10-Year Dedication j [d 20-Y ear DedicatIOn -- Signature O-fOV.l1;~ or Agent' Date

::::::N:~:==l~::::'o ~~== -~n;r~ofOwn.r(>T Agent' Da ..

• An agent acting on the behalf of the owner or lessor must submit written proof of agency status to ",<;sessor. For owners to petition to change or amend the dedicated use

I. Check [J change at top right. Submit tax map or facsimile showing change. 2. Complete items I, 2,3.4, S, & 9. For item 9 write in the Petition Number and effective tax year as noted on the Notice of Approval and

complete appropriately. 3. All parties having legal interest shall sign and date the P'~tiiion.

j :~, '!J • fit _~ . '1 I' J ) 'l

, ,." ;,J) -'..1

9Z: LW £ - d3S 00.

c Charley F To [email protected] Ice/DLN RlStateH iUS

cc 09/29/2009 05:33 PM

bcc

Subject Re: Northcutt application[:]

We're ready to route this for review, and notice that Northcutt is not mentioned in the MLS as a landowner . Who interest did he take, and does he have documentation?

[email protected]

[email protected]

09/27/200903:45 PM To Charley.F.lce@hawaiLgov

cc

Subject Re: Northcutt application

sorry the lot number is 006, not james bond ... 007.

-----Original Message-----From: [email protected] To: [email protected] Sent: Wed, Sep 23,200912:25 pm Subject: Northcutt application

You have indicated that the TMK is parcel 7, but the maps all show it as parcel 6. Please review and confirm.

Chellrl¢}, 1(;..,Hydrologist

HSV\eii Water Comm ission '1151 P unchbo'lll 227 Kalanim OklJ

P .O.Box621, Honolulu 96809 (808) 587-021 8

o Well Check Program 411104 - Revised for update to Well Standards (February 2004)

Data Input

Well Number Well Name Ground Elevation Cement Grout Grouting Method Hole Diameter Total Depth Water Level Public Water Supply Well? Solid Casing Material Solid Casing Specification Solid Casing Length Solid Casing Diameter Solid Casing Wall Thickness Open Casing Length

Results

Well Depth Theoretical Thickness of Aquifer 1/4 Aquifer Thickness Depth of Well below Sea Level

Well Casing Minimum Wall Thickness

Material Minimum Thickness per standards Wall Thickness Provided

Minimum Length of Solid Casing 90% of ground to top of aquifer Length of solid casing Provided

Casing Material (for pvc only - check for 200' limit)

Annular Space Depth of Grouting

Calculated Depth of Grouting Depth of Grouting provided

Minimum Annular Space required Thickness of Annular Space

yes no

steel stainless steel

1223-05 Northcutt Well

positive displacement

no pvc plastic Schedule 40

pvc plastic no requirement

Schedule 40

o

50 100

12 150 4.4 Depth to water 140

plastic

130 4

0.250 20

A

180.4 "l···~ 45.1 o1Y'1. -100 too deep ftJI#Ir Section 2.2

0.25 no standard Section 2.4(b)

126 130 okay Section 2.4(c)

in compliance Section 2.4(d) okay Section 2.4(d)

98 100 okay Section 2.6(c) 1.5

4 okay Section 2.6(d)

pvc plastic abs plastic thermoset plastic other

pvc plastic Schedule 40 Schedule 80 other

positive displacement other

steel public steel non public

steel ANSI/AWWA C200 API Spec. 5L ASTMA53 ASTMA139 ASTMA606 other

#N/A

0.237

stainless steel ASTMM09 other

pvc plastic Schedule 40 Schedule 80 other

CO~ION ON WATER RESOURCE MANAGEMENT 0 ROUTE SLIP FOR NEW APPLICATIONS

FROM: CHARLEY

CHING, F. FUJII, N. GOODING, K.

-1-HARDY, R. ii' HIGA, D.

-2-HOAGBIN, S. -S-ICE,C.

IMATA, R. -3-KAWAHARA,K.==

DATE: 2-Sep-09

KUNIMURA, I. NAKAMA,L.

-4-0HYE,M. SAKODA, E. SWANSON, s. ~ UYENO, D. YODA, K. YOSHINAGA, M.-

SUSPENSE DATE:

Approval -3-Signature -4-lnformation

I V-( ') ( M~ WELL NUMBER 1 ~1-3· 05"

lrJ WELL CONSTRUCTION

WELL NAME Northcutt

~ PUMP INSTALLATION

ATTACHMENTS FOR APPLICATION BROCESSING - Both applicant & staff generated 1 TRANS. LETTER /

2 PERMIT PROCESS TABLE

3 CWRMMAP

4 APPL. FORM (11 COPIES)

5 USGS MAPS (11 COPIES)

6 TAX MAPS (11 COPIES)

7 PARCEL OWNER VERIF.

8 CONTRACTOR VERIF.

9 ALL INFO FILLED IN

-+ ± MLS PRINTOUT + DCCA LICENSE SCREEN PRINTOUT

¥L~l'-C~

9-Sep-09

PLEASE:

See Me -1-Review & Comment

Take Action --Type Draft acknow letter -2-Type Final, label file folder, update People.db -S-File

Xerox copies

WUP Number NA ------------------D WUPA

10 BACKGROUND CHECK

11 $25 FEE DEPOSIT SLIP

12 DHP/CDUP/SMA pre·screen JlA.... (SMA map printout http://gis.hicentral.com/website/parcelzoning/viewer.htm.,or INGRID'S SMA/CD MAP) (LUC map printout http://luc.state.hLus/luc_maps.htm., or INGRID'S SMA/CD MAP)

FOLDER: D MADE NEW FILE FOLDER, ATTACHED

~ FILE FOLDER ALREADY MADE, IN FILE CABINET

INCOMPLETE ACTION DATES:

DATE ACTION



Dear Mr. Lluellen:

o Q




October 6, 2009

LAURA H THIELEN CHAIRPERSON


CHIYOME L. FUKINO, M.D. DONNA FAY K. KIYOSAKI, PE. LAWRENCE H. MilKE, M.D., J.D.


1223-05.wcpia.acc

Well Construction/Pump Installation Permit Application for Well No. 1223-05

We acknowledge receipt, on September 27, 2009, of your completed Well Construction/Pump Installation permit application and filing fee for the Northcutt Well (Well No. 1223-05). You can expect your application to be processed within ninety (90) days from this date.

For your information, the attached table describes the process, responsible parties, and deadline requirements for drilling or modifying a well and installing, modifying, or replacing a pump.

By this acceptance letter, we are also notifying the well operator/landowner that water may not be pumped for purposes other than testing until the certificate of well construction/pump installation completion letter is issued to the well operator and landowner. Additionally, the permitted pump capacity described on the pump installation permit may be reduced in the event that the pump test does not support the capacity. No certificate of pump installation will be issued until the Commission has determined that the pump capacity will not have adverse effects on the aquifer, other nearby wells, or streams. In other words, you may need to remove the pump and install a smaller pump at the Commission's discretion before you can withdraw water for purposes other than testing.

If you have any questions about your permit application, please contact Charley Ice of the Commission staff at 587-0218 or toll-free at 274-3141 (Kauai), extension 70218.

CI:ss Attachment

c: Stephen Northcutt

Sincerely,


TO:

FROM:

o o




October 6, 2009

Honorable Chiyome L. Fukino, M.D., Director Department of Health Attention: Tomas See, Chief, Wastewater Branch

Stuart Yamada, Chief, Safe Drinking Water Branch Alec Wong, Chief, Clean Water Branch



CHIYOME L. FUKINO, M.D. DONNA FAY K. KIYOSAKI, PE.

LAWRENCE H. MilKE, MD, J.D.


Dr. Keith Kawaoka, Office of Hazard Evaluation an Emergency Response

\.-- Commission on Water Resource Management llfLaura H. Thielen, Chairperson ~t1. 4WL

SUBJECT: Well ConstructionlPump Installation Permit Ap lication Northcutt Well (Well No. 1223-05)

Transmitted for your review and comment is a copy of the captioned Well ConstructionlPump Installation permit application.

We would appreciate your comments on the captioned application for any conflicts or inconsistencies with the programs, plans, and objectives specific to your department. Please respond by returning this cover memo form by November 6, 2009. Ifwe do not receive comments or a request for additional review time by this date, we will assume that you have no comments.


CI:ss Attachment( s)

RESPONSE:

[ I

[ I

[ I

[ I

[ I

[ I

[ I

[ I

[ I

This well qualifies as a source which will serve as a source of potable water to a public water system (defined as serving 25 or more people at least 60 days per year or has 15 or more service connections) and must receive Director of Health approval prior to its use to comply with Hawaii Administrative Rules (HAR), Title II, Chapter 20, Rules Relating to Potable Water Systems, §11-20-29.

This well does not qualify as a source serving a public water system (serves less than 25 people or more people at least 60 days per year or 15 service connections) and if the well water is used for drinking, the private owner should test for bacteriological and chemical presence before initiating such use and routinely monitor the water quality thereafter. However, if future planned use from this source increases to meet the public water system definition then Director of Health approval is required I!!iill: to implementation.

If the well is used to supply both potable and non-potable purposes in a single system, the user shall eliminate cross-connections and backflow connections by physically separating potable and non-potable systems by an air gap or an approved backflow preventer, and by clearly labeling all nonpotable spigots with warning signs to prevent inadvertent consumption of non-potable water. Backflow prevention devices should be routinely inspected and tested.

It does not appear that this well will be used for consumptive purposes and is not subject to Safe Drinking Water Regulations.

F or the applicant's information, a source of possible wastewater contamination I Jis II is not located near the proposed well site (information attached).

An NPDES permit is required.

Other relevant DOH rules/regulations, information, or recommendations are attached.

In the event that the location of the well changes but is still within the parcel described on this application, our division considers the comments to still be applicable, and we do not need to review the new location.

No comments/objections

Contact Person: Phone: --------------------------------------------

Signed: ________________ __ Date:


TO:

FROM:

SUBJECT:

c o




October 6, 2009

Morris Atta, Administrator

Land Division f t I Ken C. Kawahara, P.E., Deputy Director (J. ~L---Commission on Water Resource Management

Well ConstructionlPump Installation Permit App cation Northcutt Well (Well No. 1223-05) TMK (4) 5-2-021:006



CHIYOME L. FUKINO, MD DONNA FAY K KIYOSAKI, P.E.


KEN C. KAWAHARA, PE DEPUTY DIRECTOR

Transmitted for your review and comment is a copy of the captioned Well Construction/Pump Installation permit application.

We would appreciate your comments on the captioned application with regard to the programs, plans, and objectives specific to your division. Please respond by returning this cover memo form by November 6, 2009. Ifwe do not receive comments or a request for additional review time by this date, we will assume you have no comments.


CI:ss Attachment( s)

RESPONSE:

[ ] A water lease/pennit is required ofthis applicant and an application for such will be requested by our division,

[ ] A water lease/pennit is not required of this applicant.

[ ] A water lease/pennit has been obtained by the applicant through lease no. __________ _

[ ] Other relevant Land Division rules/regulations, infonnation, or recommendations are attached.

[ ] No objections

[ ] Other comments:

Contact Person: _________________ _ Phone: -------

Signed: __________________ _ Date: --------


TO:

FROM:

SUBJECT:

c o




October 6, 2009

Dr. Puaalaokalani Aiu, Administrator

Historic Preservation ttl Ken C. Kawahara, P.E., Deputy Director ~o,. ~~ Commission on Water Resource Management

Well Construction/Pump Installation Permit Ap lication Northcutt Well (Well No. 1223-05) TMK: (4) 5-2-021:006



CHIYOME l. FUKINO, M.D. DONNA FAY K KIYOSAKI, PE.




We would appreciate your comments on the captioned application with regard to the programs, plans, and objectives specific to your division. Please respond by returning this cover memo form by November 6, 2009. Ifwe do not receive comments or a request for additional review time by this date, we will assume you have no comments.

Please find the attached maps to locate the proposed well. If you have any questions about this permit application or request additional review time, please contact Charley Ice of the Commission staff at 587-0218. If you require additional information regarding specific information that can be provided by the applicant, please contact the applicant directly at the contact information provided on the application form.

CI:ss Attachment(s)

RESPONSE:

[ ] This is a [ ] public (county or state) project [ ] private project and [ ] will [ ] may disturb historic sites.

[ ] We concur that the work described under this permit will not disturb historic sites.

[ ] We do not concur that the work described under this permit will not disturb historic sites. We require the following for our concurrence:

Contact Person: Phone: ------------------------------------- -------------

Signed: __________________ ___ Date: _______ _


Mr. Ian Costa, Director Planning Department County of Kauai

c o


COMMISSION ON WATER RESOURCE MANAGEMENT po. BOX 621


October 6, 2009

4444 Rice Street, Ste. A473 Lihue, Hawaii 96766

Dear Ms. Costa:

Special Management Area Use Permit Requirements for Well Construction/Pump Installation Permit Application

Northcutt Well (Well No. 1223-05)


WILLIAM D. BALFOUR, JR SUMNER ERDMAN NEAL S. FUJIWARA

CHIYOME L. FUKINO, M.D. DONNA FAY K. KIYOSAKI, PE.




We would appreciate your comments on the captioned application with regard to the SMA permitting requirements specific to your division. Please respond by returning this cover memo form by November 6, 2009. Ifwe do not receive comments or a request for additional review time by this date, we will assume you have no comments.


~0.T~L--~r!YirersonHrLEN CI:ss

RESPONSE:

[ ] This well project [ ] requires [ ] does not require a SMA. If a SMA is required it [ ] has [ ] has not been approved and [ ] is [ ] is not currently active.

[ ] Other relevant rules/regulations, information, or recommendations are attached.

[ ] No objections

[ ] Other comments:

Contact Person: __________________ _ Phone: --------

Signed: _____________________ _ Date: _______ _

I.INDA LINGLE CiO"~~~OF: OF ,..,,o\W,A1I

TO:

FROM:

F rom-DEPT OF HEALTH "'IV I RONMENTAL MNGMT 8085864352

STATE OF HAWAII DEPA.RTMENi 0': LAND AND NA TUAAL. ~ESOURCES

COMMISSION ON WATER RESOURCE MANAGEMi:NT PO aOX621

HONOLULU. /1AWAII ~$OS

October 6,2009

Honorable Chiyome L. fLlkino, M.D., Director Department of Health Anel1tion: Toma.s See, Chief, Wastewater Branch

T-656 P.OOS/004 F-857

~"URA H. THIELEN 'H~R~RtiOfII

WILLIAM D. eAL~OUR, JR SUMNeR ERDMAN NEAL S. FUJIWARA

CHIYOMj; L. FUt(INO. M O. DONN" FAY K KIVOSAKI. P.E. ~AWR£NCE H. MilKE. M.D .. )0.

KEN C. KAWAHARA. P.E. ~PLJT\' !)1I~.ec'1'O"

2BSSOCT S

Stuart Yamada, Chief, Safe Drinking Water Branch ~lec Wong, Chief, Clean Water Branch Dr. Keith Kawaoka, Office of Hazard Evaluation an Emepency Response

\" Commission on Water Resource Management ~aura H. Thielen, Chairperson 1:::' 4u'~

SUBJECT: Well Construction/Pump Installation Permit Ap lication Northcutt Well (Well No. 1223-05)

Transmined for your review and comment is a copy of the captioned Well Construction/Pump Installation pelmit application.

We would appreciate your comments on the captioned application for any conflicts or inconsistencies with the programs, plans, and objectives specific to your department. Please respond by returning this covel' memo form by November 6,2009. lfwe do not receive comments or a request for additional review time by this date, we will assume that you have no comments.

Please find the attached maps to locate the proposed well. If you have any questions about this permit application, request additional information, or request additional review time, please contact Charley Ice ofthe Commission staff at 587-02\8.

CI:ss Anachment( s)

RESPONSE: [ I

[ J

[ J

( 1

r 1

( 1

f!Vf' [ 1

This well qualifies as a SO\ITt" willoh will SI;ITVC lIS 8 source OfPOlll.bl" wlll"r ,,, iI pubJiQ water sy.rem (defln"d~. ~ .. rvjng 2S or more p~Opl. '11",01$\ 60 Q"Y$ p"'r Y<.lilr or h ... IS Qr more service cOIlMa;o".) ""d RlU.' r • ..,ive Director of Heald. appluv.1 priG. ~o ils \lse 10 comply w.1i> }llIwilii Adminisrrariw. RUh;S (HAR). Title II. Chaplct 20. Rule, Reol'!!;ng 10 P(>lllblc Wmcr Sysrems, §11·211-29.

Thi; w"U /16<0. '0\ qQ.lify ~, "80111'0" serving a 'publio ",aret .y ... m (."fV¢~ less Than 2S people <It'mOr. poopl" illl ... ST 60 days per )_ or IS ~rvicc ~onnC>Q!ioos) urn! If TM well waler is used for dl'inki,,!\, thOl priv;:\lc owner lihould TeSI fat bocrdl';oIQgio;ll iIfld Qhcmi,al presence btlfor" initiilting s~h uac IIIld rominel), mOlliTor The \V&t(r Il.ualiry 1}lIoro~ft~r. j·IQWover. iffurl\t( pl&llllcd u'" frum Ihis ~III~ im>r,ssca ro mccIl!." public wgtcr sysTcm dcfitliliOn Ihen Director ofHcairh approval IS t6qui",d nrinr to imj)l~mcnratioll.

It'lbo w~lll$ \l~ 10 ~~pl'ly bo~h porablcalld Ilon-jl(lrlibl. purpD~ In A single S),SI'tn. rhe USCI .hall ehmil\iUO oro~H:onn~ctioll; and ~kflDW I1Onnl:~1l0llS by physi;ally stparating porable and nlln-j)otilbl., ~)'slcms by an air gap Ot M ~pprovcd backtlow prCVenlBl'l and by olurl)' labeling all !lOll. pOTable SpiSClU wirh ",arning .il!l"IQ pn:v~nt inadvcltcllt consumplion Dfnon·p(>t:lbl~ warer Backflow prl!,ontiDn d"lI1oos shollid be ''O''lin~ly In'p,,"~c4 and rflsted.

For the applic81ll's infonnaLioll. a sourCe "fpo.~hl~ w~s(;,.\iatcr COlllilnill&Iior. IIi. II i~ not located neil!' the plopO!ed won sile (infonnatioll a![al;I,e~)

An NPDES PCllllll is ICqllircd.

Otllt,· tel.voml nOli r~I""/r"!O\llMion~. mfonnmion. Of fcco.nm""d~lj\ln~ ilr~ alli\Qhed.

III rhl!> (M,nl lI'Ial In" IOOjjli<>n of ch~ w~lI changes bUT is slili .... irhin Ih~ pam~l d~sQflb~d on Ihis applicarion, our division cOIlsidm the t(lmm~nts to srill M apjlli,,~blc. and W~ do nOl need to iCvicw th~ new IO"~li\ln

I 1 No ~omm'mBlon.leG(]OnB

Contact Person: ~~ (,...~ Phone;

Signed: __ ~T-F~ __ ~+-=-~ ___ _ Dale:

10-19'-2009 12: 31 pm F rom-DEPT OF HEAL THf'hlV I RONMENTAL MNGMT 8065864352 T-656 P.001/004 F-857

I

Fax to: Company:

Fax No.:

FAX TRANSMITTAL State of Hawaii Department of Health Environmental Management Division

Clean Water Branch - Engineering Section Phone No.: (808) 586-4309

Fax No.: (808) 586-4352

Mr. Ryan Imata~. Charl~ Ms. Denise Mills Commission On Water Resource Management Department of Land and Natural Resources 587-0219

Date: l Q . lS' c~ . Fax from: Joanna 1. Setoa

Total Pages, inc!' cover: 2+ 2

SUbject: Well Construction/Pump Installation Permit Application(s) Well No(s). 11,:Z.1"05 J 04t.2..-0}

The Department of Health, Clean Water Branch (CWB) has the following comments:

1. For Well-Drilling Activities

Any discharge to State waters of treated process wastewater effluent associated with well drilling activities is regulated by Hawaii Administrative Rules (HAR), Title 11, Chapter 55, Appendix I, effective October 22, 2007, and compiled June 15,2009. Treated process wastewater effluent covered by this general pennit includes well drilling slurries, lubricating fluids wastewater, and well purge wastewater. This general permit does not cover well pump testing. The applicable Notice of Intent (NOI) Forms and filing fee shall be submitted at least 30 calendar days before the start of discharge to the:

Department of Health Clean Water Branch 919 Ala Moana Boulevard, Room 301 Honolulu, Hawaii 96814-4920

The CWB-NOI Forms are available online at http://www.hawaii.govlhealthienvironmental/water/cleanwater/formsIgenl-index.htrnl. Inquiries may be directed to the eWB at (808) 586-4309 or by fax (808) 586-4352.

2. For Well Pump Testing

The discharger shall take all measures necessary to prevent the discharge of pollutants from entering State waters. Such measures shall include, if necessary, containment ofinitial discharge until the discharge is essentially free of pollutants. If the discharge is entering a stream or river bed, best management practices shall be implemented to prevent the discharge from disturbing the clarity of the receiving water. If the discharge is entering a stonn drain, the discharger must obtain written permission from the owner of the storm drain prior to discharge. Furtherrnore~ best management practices shall be implemented to prevent the discharge from collecting sediments and other pollutants prior to entering the stonn drain.

10-1~-2009 12:31pm From-DEPT OF HEALTH ~NVIRONMENTAL MNGMT 8095864352 T-656 P.OOZ/004 F-857

/ Mr. Ryan Imata I Mr. Charley Ice / Ms. Denise Mills Commission On Water Resource Management

FAX TRANSMITTAL Page 2

3. For Construction Activities Disturbing One (1) OT More Acres of Total Land Area

By HAR, Title 11, Chapter 55, Appendix C, effective October 22,2007, and compiled June 15, 2009, an NPDES penult or Notice of General Pennit Coverage is required before the start of the construction activities that result in the disturbance of one (1) or more acres of total land area, including clearing, grading. and excavation. The total land area includes a contiguous area where multiple separate and distinct construction activities may be taking place at different times on different schedules under a larger common plan of development or sale. An NOI (see Conunent No. I, above) shall be submitted 30 calendar days before the start of construction activities.

Search Results

o Page 1 of 1

Assessed values reflect tax year 2009 for all islands. Taxes reflect tax year 2009.

Search criteria: TMK Taxkey 4-5-2-21-6

PUBLIC RECORD DATA Taxkey Subdiv ICondo Tnr Address Owner I Lessee Bds Bths Land area Liv area Last Sale Instr

r .4-5-2-21-6 [J Kahili Makai --DROPPED 0 3/31/1999 DEED $3i Subd PARCEL--

r .4-5-2-21-6-11:1 MANA MELE F 4254 SAIN, FAMILY 4 3 2.28 ac 2,642 KAHILI TRUST/ETAL

r .4-5-2-21-6-21:1 MANA MELE

r .4-5-2-21-6-31:1 MANA MELE

r .4-5-2-21-6-41:1 MANA MELE

r .4-5-2-21-6-51:1 MANA MELE

MAKAI ST, Apt 1

F KAHILI MAKAI ST, Apt 2

F KAHILI MAKAI ST, Apt 3

F 4240 KAHILI MAKAI ST, Apt 4

MAX & HAN NAH 0 0 2.12 ac LLC

PERRY, E 2 5 2.67 ac GORDON & 1/2 LEESA D/ETAL

SOMERS, JANET 3 3 2.40 ac D TR/ETAL 1/2

F KAHILI DAYENU MAKAI INC/ETAL ST, Apt

1 0 16.76 ac 1/2

5

o 8/30/2001 DEED $5~

3,986 3/19/2003 DEED $8~

2,510

480 6/25/2007 DEED

This information has been supplied by third parties and has not been independently verified by Hawaii Information Service and is therefore not uaranteed.

Copyright ©9/29/2009 by Hawaii Information Service

LWJLt~ wi U f~ iVlfu 6Y\~t6W~

http://webrel.hawaiiinfonnation.comlREsearchIHIS/Searchisearch ]UB.asp?NOCACHE= 1254281146421 9/29/2009

c [email protected]

09/27/200903:45 PM

o To Charley.F.lce@hawaiLgov

cc

bcc

Subject Re: Northcutt application

[,"~t~~1· 'j~:-:-~-:~'~!~~~ij~'~~!i~~~~pll~dfu.

sorry the lot number is 006, not james bond ... 007.

-----Original Message-----From: [email protected] To: [email protected] Sent: Wed, Sep 23,200912:25 pm Subject: Northcutt application

You have indicated that the TMK is parcel 7, but the maps all show it as parcel 6. Please review and

confirm.

Chorley Ice Hydrologist

HaV\€lii Water Comm ission 1151 P unchboV\l 227 Kalanim oku P .O.Box621 , Honolulu 96809 (808) 587-0218

o DOCUMENT N .: DCTMENT OF LAND AND NATURAL RESOUQ

UAC OR ATTACHED WORKSHEET DATE S b 1 2009 eptem er ,

SRC/ COST F YR APP D OBJ CTR PROJECT PH ACT AMOUNT NAME/DESCRIPTION (WANG INPUT)

S 10 326 C 1026 0752 (1 ) $25.00 Kauai Water Well Money Order #17206451458

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

TOTAL $ 25.00

REMARKS: LINE (1) Kauai Water Well (Michael Lluellen) WC/PIP Appl TMK: 5-2-21 :007

LINE (2) LINE (3 LINE (4) LINE (5) LINE (6) LINE (7) LINE (8) LINE (9) LINE (10)

--- STATE OF HAW{Q, 0 ,.!!;;. For Official Use Only:

" DEPARTMENT OF AND NATURAL RESOURCES COMMISSION ON WATER RESOURCE MANAGEMENT DEI'EIVEO

I APPLICATION FOR A WELL CONSTRUCTION I ,\ v,." I "H lt/ATER

~t~;1\}WY.~" it I\. GEMENT PUMP INSTALLATION PERMIT R ,,~~ yI' -"" •

-.It AUG 3' AM 10: I ,

Instructions: Please print in ink or type and send completed application with attachments to the Commission on Water Resource Management, P.O. Box 621, Honolulu, Hawaii 96809. Application must be accompanied by 10 copies and a non-refundable filing fee of $25.00 payable to the Dept. of Land and Natural Resources. The Commission may not accept incomplete applications. For assistance, call the Regulation Branch at 587"()225. For further information and updates to this application form, visit http://www.hawaii.gov/dlnr/cwrm.

WELL LOCATION INFORMATION f-1. STATE WELL NO. (if already assigned) 12. WELL NAME .~SlAND 14. TMK ~ 2- _ zl ~)K ~&\;\ - : -- PiiiI zone sec parcel

The following must be attached before this appUcation is accepted as complete: • Portion of 7.S-Minute Series USGS topographic map (scale 1 :24,000) with well location labeled and include the name of the quad map • Property tax map, showing weillocalion referenced to established property boundaries • Photograph of the proposed well site .A SChematIC diagram showing the well site, access road and proposed well infrastructure • For dug wells attach a grading plan with cross section profiles s~ existing and finish grades

5. WELL OPERATOR'S ~ 'I Well Operator's Contact

~T~I.JbJ rrr ~~ez3-/37.5 6. LANDOWNE:;' NAM;CO:P~NYC I Landowner's Contact

\/VeIl Operator's Maifing Address

1070 1G£,~#A-"";Zo"'P JCIJ-nI..d • JI,' 9f.s74~ Landowner'SjA~vV ~ F--

Well Operator's Phone I Well Operator's Fax ~ operator's E-mai:4J

Landowner's Phone I Landowner's Fax I Landowner'sE408H ,,-AJj ,£:TU,f;) , .cat.,

PROPOSED WELL CONSTRUCTION PROPOSED PUMP INSTALLATION 7. Proposed Work 8. Construction Type 10. Proposed Work 11. Proposed Pumping Rate, gpm ~thod of flow measurement

}i!J Construct New Well Jl!Drilled Ja"'lnstall New Pump (gallons per minute) Iowmeter o Modify Existing Well DOug o Replace Pump ~q f~1h o Other (explain) o Abandon/Seal Well o Shaft

12. Proposed Amount of o Tunnel Withdrawal, gpd (galions per day)

9. Is this well part of a battery of wells? 0 Yes ~o 'ZLjc.:x:; 14. Proposed Surveyor name and license number (a surveyor is required for all Well Construction Perml .. and may be required for some Pump

Installation Permits) ?L~ ~~.~Q...

PROPOSED USE

o 15. Municipal (water systems serving greater than 25 individuals or 15 service connections)

\;t 16. Domestic Number of units to be served: ,

o 17. Industrial (describe)

o 18. Irrigation (describe crop and no. of acres)

o 19. Military (describe)

o 20. Other (deicrlbe)

OTHER LEGAL REQUIREMENTS If required, items 21. and 22. must be obtained before the Commission can legally issue a permit: 21. Conservation District Use Permit (COUP) o Well is in Conservation District

o Required, COUP # date approved o Not Required (attach documentation from OCCL) o I have not checked with OCCL about whether or not a COUP Is required. I understand that checking with OCCL prior to making this

application will expedite my review. I further understand that issues raised by this agency may delay or result in denial ofthe pennit issuance, or revocation ofthe permit after it Is issued.

o Well is not in Conservation District p'1 have not checked if well is in or out of Conservation District. I understand that checking if the well Is in a Conservation District may expedite my

review. I further understand that issues raised may delay or result in denial of the permit issuance or revocation of the oermit after It is Issued. 22. Special Management Area Permit (SMAP) o Required, SMA # date approved o Not Required (attach documentation from applicable County agency) .YJ' I have not checked with the county about whether or not an SMA Permit is required. I understand that checking with the County prior to making this

application may expedite my review. I further understand that issues raised by this agency may delay or result in denial of the permit Issuance, or revocation of the permit after it Is issued.

23. State Historic Preservation Division (SHPD) of the Department of Land and Natural Resources o I have consulted with the HPD regarding potential impacts of weH construction activities on historic sites. I have attached applicable documentation

from the HPD. J;t I have not consulted with the HPD regarding potential impacts of well construction activities on historic sites. I understand that checking with the HPD

prior to making this application may expedite my review. I further understand that Issues raised by this agency may delay or result in denial of the permit issuance or revocation of the permit after it is issued. Additionally, the history of past land use Is attached.

24. Water Use Permit No. (if applicable):

Additional remarks, explanations, etc. (attach additional sheet If more space is needed)

NOTE: Signing below indicates that the signatories understand and swear that the information provided is accurate and true to the best of their knowledge. Further, the signatories understand that upon permit approval: 1) the proposed work is to be completed within two (2) years ofthe approval date; 2) the contractor shall submit to the Commission a well completion/abandonment report within 80 days after the completion date of the permitted work; 3) in the event that the application is not completed correctly, any permit may be suspended until the item is brought in to compliance, and any work done while the permit Is In suspension may result in fines of uo to $5000/day.

2tZLL~ DRlj~ER (:UI?;;j~if application is for Well Construction) 26. PUMP INSTALLER (Mult be filled out if application is for Pump Installation)

~ htu.4iL C-~57~ ~ ~rvL C!--'*V8. L_.;:;:!JlJj " /,.fi1 L,,".oe No Licen~: name ,~-57/C-57a1A License No.

1M 6¥ kIf-; P.d--m fIL,--'-. < '~,,/ $-Y-<'1 Signature rint ~ Date S~_ l4!4A om. f.?J i?~ i-,j r!rtJH, iA,!/; P6,tpy IF!~(/?/ k A"ddress ddress

~57-'1{~r Ltu~Ic~/~14t Phone Fax E-mail Phone Fax E-mail

..

1'" ........ , i I. ,

f ,. ! ~ I t • " 1',,';

c

o o

PROPOSED WELL SECTION (Please attach schematic if different from diagram provided below)

Hole Diameter: I-z..- in.

Elevation at top of casing '2--ft., msl* lr--r Minimum of 2' Radius & 4" Thick Concrete Pad (to contain benchma surveyed to nearest 0.01 ft.) ..£t)

b' ~~. r Ground Elevation: ft., msl· b :.:",: ,',<:I, ...... " •• <:1.

//~\ '\>., '., ///m.' ///NO'.' ..... :.4:,', Please refer to the ... Cement Grout: ft. t,.'.; ,'. BAlIAn WELL 'ONSTRU~IIQN A~ (min. 70% of distance from ':'"f'" : .. ~.

.;. ... : .. ' PYMP m,sTALLATIOl'i STANDARDS ground elevation to top of .:: ;. :~$ water surface or 500 ft., .~ ::: ;.:. to ensure that your as-built is in compliance with .... applicable standards . whichever is less.) ... ,6: :.~.~.: "1>.,

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Grouting method: Annular space between hole ':.'~' :.1" Solid Casing: (~ 90% x (Ground Elev.-Water Level Elev» '~.:.: ~.:.:

~ositive and casing (1.5" for positive ":1>' ,:1>' Total Length: L$~ ft . displacement, 3" for other . ;.:. ;.:.

displacement methods): ffi .'.:~:. Nominal Diameter: In. '!>., .. ::', ,'" a Other V .4"

~ :':':4 t.',;", Wall Thickness: in. in. - :,'l· q

": Bottom Elevation: - RO ft., msl* ! ....

Rock or Gravel Packing: - l- ij i' Total Depth :z..6'ft. ;;rPerforated r---,

~ Open Casing: a Screen

L.SD ft. Material: t 2,0 a Crushed Basalt Total Length: ft. 9?~

V Nominal Diameter: ~ in. o Rounded Gravel 16g~ " Wall Thickness: in.

Estimated Water Level Bottom Elevation: -LOO ft., msl*

Elev;o:

I ft. msl* _L- I 1-[-

note: Neither bentonite nor mud should be used in saturated zone during drilling

Open Hole:

Length: ft.

Diameter: in. '----- Bottom Elevation: ft., msl*

* The approximate elevation must be referenced to mean sea level (msl) at the time of application filing. Final elevations of well components shall be submitted in the Well CompletionJWell Abandonment reports and referenced to a benchmark which has been established by a surveyor licensed by the State.

For non-saH water Basal Wells - bottom elevation of well should not be deeper than 1/4 of aquifer thickness or,

Bottom Elevation of Well Limit = (Water Elevation _ 41 x Water ~e! Eleyation )

Example: Estimated + 2 n. Water Leval Elev. -+ Bottom Elevation of WeH limit = ( 2 - ~) = -18.5 fl.

§olid Casing Magrial: Carbon Steel: compliant with (check one or more): a ANSIIAWNA C200 0 API Spec. 5L 0 ASTM A53 a ASTM A 139

And compliant with (check one or more): 0 ASTM A242 (or A606) 0 Type E 0 Type S 0 Grade B 0 Other

Stainless Steel: (check one): 0 ASTM M09 (production wells) 0 ASTM A312 (monitor wells)

ASS Plastfc conforming to ASTM F480 and ASTM 01527: (check one) a Schedule 40 a Schedule 80

PVC Plastic conforming to ASTM F480 and (ASTM 01785 or ASTM 02241): (check one): .¢' Schedule 40 0 Schedule 80 0 Schedule 120

Thermoset Plastic: (check one) a Filament Wound Resin Pipe conforming to ASTM 02996

o Centrifugally Cast Resin Pipe conforming to ASTM 02997

o Reinforced Plastic Mortar Pressure Pipe conforming to ASTM 03517

o Glass Fiber Reinforced Resin Pressure Pipe conforming to AWWA C950

o PTFE Fluorocarbon Tubing conforming to ASTM 03296

o FEP Fluorocarbon Tubing conforming to ASTM 03296

Open Casing Material: Carbon Steel: compliant with (check one or more): 0 ANSIIAWNA C200 a API Spec. 5L 0 ASTM A53 a ASTM A 139

And compliant with (check one or more): 0 ASTM A242 (or A606) 0 Type E 0 Type S 0 Grade B a Other

Stainless Steel: (check one): 0 ASTM M09 (production wells) 0 ASTM A312 (monitor wells)

ABS Plastic conforming to ASTM F480 and ASTM 01527: (check one) 0 Schedule 40 0 Schedule 80

PVC Plastic conforming to ASTM F480 and (ASTM 01785 or ASTM 02241): (check one): 2f Schedule 40 0 Schedule 80 a Schedule 120

Thermoset Plastic: (check one) 0 Filament Wound Resin Pipe conforming to ASTM 02996

a Centrifugally Cast Resin Pipe conforming to ASTM 02997

a Reinforced Plastic Mortar Pressure Pipe conforming to ASTM 03517

o Glass Fiber Reinforced Resin Pressure Pipe conforming to AWWA C950

a PTFE Fluorocarbon Tubing conforming to ASTM 03296

o FEP Fluorocarbon Tubing conforming to ASTM 03296

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