"Application for Water Withdrawal Permit - Groundwater" - Prince Edward Island, Canada

ADVERTISEMENT
ADVERTISEMENT

Download "Application for Water Withdrawal Permit - Groundwater" - Prince Edward Island, Canada

Download PDF

Fill PDF online

Rate (4.8 / 5) 6 votes
Page background image
Application for Water Withdrawal Permit -
Groundwater
Freedom of Information and Protection of Privacy
Personal information on this form is collected under section 31(c) of the Freedom of Information and
Protection of Privacy Act as it relates directly to and is necessary for an application for a permit under
subsection 5(1) of the Water Act Water Withdrawal Regulations to extract groundwater. If you have any
questions about this collection of personal information, you may contact the Manager of the Water and Air
Monitoring Section, 11 Kent Street, Jones Building, Charlottetown, PE C1A 7N8, (902) 368-5054.
Please supply as much detail as possible.
Incomplete forms may be rejected, returned, or result in a delayed response.
1. Applicant Information
(Applicant will become the permit holder)
Applicant:
Contact Name:
Mailing Address:
City/Town:
Province:
Postal Code:
Tel:
Cell:
E-mail:
2. Type of Application
New Permit
Amendment to Permit
Renewal of Permit
_____________
Associated Groundwater Exploration Permit number
Number of existing permit___________________
3. Property/Well Location
Location:
Property Number:
Page 1 of 3
Application for Water Withdrawal Permit -
Groundwater
Freedom of Information and Protection of Privacy
Personal information on this form is collected under section 31(c) of the Freedom of Information and
Protection of Privacy Act as it relates directly to and is necessary for an application for a permit under
subsection 5(1) of the Water Act Water Withdrawal Regulations to extract groundwater. If you have any
questions about this collection of personal information, you may contact the Manager of the Water and Air
Monitoring Section, 11 Kent Street, Jones Building, Charlottetown, PE C1A 7N8, (902) 368-5054.
Please supply as much detail as possible.
Incomplete forms may be rejected, returned, or result in a delayed response.
1. Applicant Information
(Applicant will become the permit holder)
Applicant:
Contact Name:
Mailing Address:
City/Town:
Province:
Postal Code:
Tel:
Cell:
E-mail:
2. Type of Application
New Permit
Amendment to Permit
Renewal of Permit
_____________
Associated Groundwater Exploration Permit number
Number of existing permit___________________
3. Property/Well Location
Location:
Property Number:
Page 1 of 3
4. Well Specifications and Water Quality Requirements
Purpose of Well(s):
Well Driller’s Name:
Special Requirements (Fresh\Salt\Other):
Well
Northing/
Easting/
Type of Well
Well
Well
Casing
Proposed
Name
Latitude
Longitude
(Drilled\Dug\
Depth
Diameter
Length
Pumping
Other –
(Circle
(Circle One)
(Circle One)
Rate
Specify):
One)
(in or cm):
(ft or m):
(igpm):
(ft or m):
Total Average Pumping Rate (igpm):
Total Peak Pumping Rate (igpm):
If more than 4 wells are developed, please attach details of additional well information.
5. Anticipated Pumping Schedule
Well
Period of Use
Hours/day
Days/week
Months/Year
Name
If more than 4 wells are developed, please attach details of additional well pumping schedule.
6. Supporting Documentation
Please indicate which of the following documents are being attached. Be sure to include any required to
be submitted by the Groundwater Exploration Permit.
Pumping test report
Driller’s logs
Water general chemistry report
Water metals and volatile organic compounds (VOC’s) report
Stream flow measurement report
Hydrogeological report
Others (Specify :)
______________________________________________
Page 2 of 3
7. Property Owner’s Signature
If the applicant/permit holder is not the property owner, the property owner’s signature is required to
acknowledge that the applicant has the necessary permission of the property owner to hold and utilize
the permit being applied for.
As property owner, I confirm that I give permission to the applicant to hold a Water Withdrawal Permit
for a well on my property indicated above and utilize said well as will be described in the permit. I
understand that this permission will be considered to be given until such time as I inform the Dept. of
Environment, Energy and Climate Action in writing that the permission has been withdrawn. I
understand that I may withdraw this permission at any time.
Property Owner ’s Signature:
Date:
Applicant’s Signature:
Date:
Make cheques payable in the amount indicated below to the Minister of Finance
Send the completed application form to:
Hydrogeologist
Department of Environment, Energy and Climate Action
11 Kent Street
PO Box 2000
Charlottetown, PE
C1A 7N8
Phone: (902) 368-4668
Fax: (902) 368-5830
Email:
qli@gov.pe.ca
Type of Permit and Fee:
Type of Permit
5-year
Fee ($)
3
Water withdrawal permit – well < 25 m
/day supplying water supply system
50
3
Water withdrawal permit renewal or amendment – well < 25 m
/day supplying water supply system
25
Water withdrawal permit – low capacity well
100
Water withdrawal permit renewal or amendment – low capacity well
50
3
Water withdrawal permit – high capacity well ≤ 1,000,000 m
/yr
2,000
3
Water withdrawal permit renewal or amendment – high capacity well ≤ 1,000,000 m
/yr
1,000
3
Water withdrawal permit – high capacity well > 1,000,000 m
/yr
3,000
3
Water withdrawal permit renewal or amendment – high capacity well > 1,000,000 m
/yr
1,500
Water withdrawal permit transfer
25
A fee for the issuance or renewal of a water withdrawal permit may be pro-rated for permits valid for less than 5
years.
Page 3 of 3
Page of 3