DNR Form 542-0163 "Petition for Variance From Well Separation Rules" - Iowa

What Is DNR Form 542-0163?

This is a legal form that was released by the Iowa Department of Natural Resources - a government authority operating within Iowa. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2014;
  • The latest edition provided by the Iowa Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DNR Form 542-0163 by clicking the link below or browse more documents and templates provided by the Iowa Department of Natural Resources.

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Download DNR Form 542-0163 "Petition for Variance From Well Separation Rules" - Iowa

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IOWA DEPARTMENT OF NATURAL RESOURCES
ENVIRONMENTAL SERVICES DIVISION
ANIMAL FEEDING OPERATIONS PROGRAM
PETITION FOR VARIANCE FROM WELL SEPARATION RULES IAC 567-65.12(9), 65.108 (3)
Pursuant to 561 Iowa Administrative Code Chapter 10, Waivers or Variances from Administrative Rules, a petitioner
must provide comprehensive justification of a proposed request for a waiver or variance to an administrative rule as
adopted by the Department of Natural Resources (DNR).
This form will assist you in providing all pertinent information that is necessary for the DNR to grant a variance. The
form must be submitted to the DNR and must contain an adequate amount of factual and concise information. The
obligation rests with the petitioner to provide convincing evidence to justify the granting of a waiver or variance. You
may provide additional information or attach additional pages if needed. The DNR reserves the right to require
additional information to further support request for a variance. While the DNR is required to consider a request for
variance it is not required to grant a variance even if all requested information is provided.
Petitions will be evaluated by the DNR. The DNR reserves the right to place any condition on the variance. If
information is not inclusive, concise, or does not adhere to the justifications and/or proof the petitioner has
submitted, the variance may be denied. Upon review, the DNR will grant or deny the variance in writing.
The petition will be reviewed by DNR staff to evaluate whether the proposed construction meets the standard of
“substantial equivalent performance to the separation distance.” Specifically, the DNR will evaluate whether or not
the private well is acting or has the potential to act as a direct conduit to an aquifer.
Use of this form is not required, but your request will be automatically denied if you fail to submit all the information
described in this form.
All petitions for a variance should be completed, signed and submitted to the DNR. One complete copy shall be
submitted to the Office of the Director: 502 E 9th St, Des Moines IA 50319-0034. A second complete copy shall be
submitted to the Iowa DNR, AFO Program, ATTN: AFO Engineer Iowa DNR – FO3, 1900 N Grand, Gateway North Mall,
Spencer IA 53101. A third copy must be submitted to the appropriate Field Office, see link to addresses below.
For the addresses or contact information for the appropriate Department Field Office:
http://www.iowadnr.gov/InsideDNR/DNRStaffOffices/EnvironmentalFieldOffices.aspx
For animal feeding operations facilities requiring a Construction Permit, this petition should be submitted at the time
of application.
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DNR Form 542-0163
IOWA DEPARTMENT OF NATURAL RESOURCES
ENVIRONMENTAL SERVICES DIVISION
ANIMAL FEEDING OPERATIONS PROGRAM
PETITION FOR VARIANCE FROM WELL SEPARATION RULES IAC 567-65.12(9), 65.108 (3)
Pursuant to 561 Iowa Administrative Code Chapter 10, Waivers or Variances from Administrative Rules, a petitioner
must provide comprehensive justification of a proposed request for a waiver or variance to an administrative rule as
adopted by the Department of Natural Resources (DNR).
This form will assist you in providing all pertinent information that is necessary for the DNR to grant a variance. The
form must be submitted to the DNR and must contain an adequate amount of factual and concise information. The
obligation rests with the petitioner to provide convincing evidence to justify the granting of a waiver or variance. You
may provide additional information or attach additional pages if needed. The DNR reserves the right to require
additional information to further support request for a variance. While the DNR is required to consider a request for
variance it is not required to grant a variance even if all requested information is provided.
Petitions will be evaluated by the DNR. The DNR reserves the right to place any condition on the variance. If
information is not inclusive, concise, or does not adhere to the justifications and/or proof the petitioner has
submitted, the variance may be denied. Upon review, the DNR will grant or deny the variance in writing.
The petition will be reviewed by DNR staff to evaluate whether the proposed construction meets the standard of
“substantial equivalent performance to the separation distance.” Specifically, the DNR will evaluate whether or not
the private well is acting or has the potential to act as a direct conduit to an aquifer.
Use of this form is not required, but your request will be automatically denied if you fail to submit all the information
described in this form.
All petitions for a variance should be completed, signed and submitted to the DNR. One complete copy shall be
submitted to the Office of the Director: 502 E 9th St, Des Moines IA 50319-0034. A second complete copy shall be
submitted to the Iowa DNR, AFO Program, ATTN: AFO Engineer Iowa DNR – FO3, 1900 N Grand, Gateway North Mall,
Spencer IA 53101. A third copy must be submitted to the appropriate Field Office, see link to addresses below.
For the addresses or contact information for the appropriate Department Field Office:
http://www.iowadnr.gov/InsideDNR/DNRStaffOffices/EnvironmentalFieldOffices.aspx
For animal feeding operations facilities requiring a Construction Permit, this petition should be submitted at the time
of application.
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07/2014 cmc
DNR Form 542-0163
PETITION FOR VARIANCE FROM WELL SEPARATION RULES IAC 567-65
Petitioner Information
Name:
Address:
City:
State:
Zip:
Telephone:
Email:
Facility Information
Name:
Address:
City:
State:
Zip:
Telephone:
5-digit AFO Facility Number if known:
Legal Description (¼ ¼, ¼, Section, Tier, Range, County):
¼ ¼
¼
Section
Tier
Range
County
Basic Information: The items in bold are required for evaluation of the variance request. Items in plain print will make
the evaluation process easier and faster.
1.
Location of well(s) and existing and proposed animal feeding operation structures for which separation
distances apply:
a. Include a map or drawing clearly showing the location(s) of all wells and proposed structures that
are to be considered for this variance. Include elevation lines or overlay a topographic map.
b. Clearly label these features using names and numbers consistent with all relevant documentation.
c. Indicate distances between relevant items on the map. Include a scale and north arrow.
2. Well construction details:
a. Provide a drillers log or reference online information: Check the Iowa DNR’s GEOSAM database
(http://ifis.iowafloodcenter.org/ifis/more/geosam/) to determine if well construction details are
available online. Private well tracking numbers may also provide staff with useful details.
b. Well depth:
c. Static Pumping Level and Pumping Water Level:
d. Description of subsurface materials (for example, clay 0-10 ft, sand 10-15 ft., etc.):
e. Year constructed:
f. Casing diameter:
g. Grouting material and description of condition:
h. Description of any well-head protection such as a concrete pad, berm, or elevation of the well
compared to possible contamination sources:
3. Water use description:
a. How is the well-water used (livestock watering, human consumption, irrigation, etc)?
b. Pumping rate:
c. Water use permit number if more than 25,000 gallons per day are withdrawn:
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DNR Form 542-0163
4. Recent (less than 6 months) water analysis for Nitrate–N from a certified laboratory. Please ask the
laboratory for proper sampling and shipping requirements prior to sampling (specific bottles may be
required). A copy of the lab report should be included with the variance petition. The County Sanitarian may
be contacted for assistance.
Petitioner’s Justification:
1. Is this petition submitted in conjunction with a construction permit application?
Yes
No
2. Describe which separation distances are not going to be met.
3. Describe why the construction is necessary and how it will lead to additional water protection.
4. Describe how conditions of the site minimize potential contamination of the well(s) in question.
5. Describe in detail undue hardship to the producer and/or operation if a variance were not granted.
6. Are there any public agencies, political subdivisions of the state or federal government, person or entity which
may be affected by the granting of the proposed waiver or variance?
Yes
No
If yes, you must provide the name(s); address (es), telephone number(s), and other relevant contact information.
7. If the waiver or variance is granted, would it pose a threat to any person’s rights? If so, how?
The DNR shall grant or deny a petition for a variance with 120 days of the receipt of the petition. Failure of the DNR to
grant or deny a petition within the required time period shall be deemed a denial of that petition by the DNR. A
variance is void if the material facts are not true or if facts have been withheld. The DNR reserves the right to cancel a
variance at any time if the DNR finds that the facts as stated in the request are not true, material facts have been
withheld, the alternative means of compliance provided in the variance have failed to achieve the objectives of the
statute, or the requester has failed to comply with the conditions of the variance. By signing this petition you certify
that all information listed on this petition and the attached additional information is factual and accurate.
Signature:
Position:
Date:
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