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` I.!2 dI Contractor Information:
f` Christopher WachterI K WATER ZONES
Well Contractor Nante FROM '> TO I DESCRIPTION
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NC Wdi Comlutor Cahfication Number.
py•�� _ Inc. 15.OIiTER CASING for mnldcated wells OR'LINER a
CL�I[Ylming' s t�•IQi1'�e!9P.I7Ml iltS, I FROM, TO DuwErER TRICKK 01 nrAT€RIAI.
Company Name r;_,. +1 ft. I R• 6 6/8 in. .188 vC,
I&INNER CASING OR TI7I MG 46eeniai cl 2.Wen Con action Permit#• FRO. To
_ DIAPIETEIa TNICM.1112 MATERIAL
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Water supply Well: SCREEN ' ' 1
Agricultural'. /Public =..R,
z 17.
~ .Municipal 7ft.
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Geotftetmai(HBattng/Cooling Supply) Residential Water Supply(single)
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109 ■■r_.` ,s 1 RROfYl9 TO R9ATiiR(Ar. l EMPLACBh�NTMLI°dIIODBAPoIOIJNi I
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Mon c0I FOrt Cement 1 Pour '
Ygjection Well: Ovely ft.T R.
Aquifer Rediirge 00roundwater Remediation R'
Aquifer StOi*and Recovery OSalinity Barrier 19 SAP►DIGRAVEL PACK if a ' cable
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LGeodwrinal
woute'^,,_ p,,patiosidcnce Cuniroinnaf(Closes DTraCe[ 20.DRILLING.LOG attacbaddidioanta ifo
eatin in Return . Other lain under 921 Remarkso ''� DIISCRriPlloN extor 6erdce� err
d.®ate Wetl(e)Completed: 'J -21 Well 1Dlt
5A.Wen Location:
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Pact71 , \vner Name � �•�
Faml;'ty 1DU(if ap:.,cicabk) �. ft. tt• .
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Physical Address,City.and Zip Pt. fL `
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ess,aetlwvs ins C,r.rTio� _-__F
c ouray Parcel Identification No.(PIN) 1 -
fib Latitude aI11 Iolsglltlde In degreesledoutes/seconds Or decimal degrees: 1 Orwell field,one latliong is Taaeiem) f
��.Certification•
-710 //2.-AM
v.nb"Urly iuc nw e
n)�Irorwauene yr Lj i empumrY „ e:r. ---•s
7.15 this a repair to an existing well: Yes Oi ONO iiiit juiin,i neiehy cexi6y dilli iite weii(s)wav(were)coffiilucred in acXW'danCe
0041110 r1mir.Jlll d k�rotrwu tvc0 ua wlmdian t �t ISA NCAC'OZG.U1f10 or/SA NC:AC•OZI:.OZ00 Wdl Conrincction Smndards and that a
repair tm&r#21 m wrkr wdla»or on/hdhadc ojlh jorm exp+als the natrotsvjtlu+ copy ofthix reconthav been ptvrvlded to the well owner.
23.Site diagram or additional well details:
L For Geoprobdopir or a0iled-gyp Geothermal Wells having the same You may use the backof this page to provide additional well site details or well
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tiriiirAi: At[9q i,Cis i...49- carstrtct:nn details. Vna mad sic^ a!tai.h s•.Rr!itinaal Hates ifrnrx=acary
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9.Total well depth below land surface:
I%or tntfilp/e wells list all depths ildorent fa—Pie-3@200•and 2@100') ( ) 2411. For All Weller: Submit this form within 30 days of completion of well
1
10.static water level below top of casing: construction to the following:_ � (f&)if water level is above caving Use'.I•'. Division of Water Resources,Information Processing Unit,
1617:ilail Service Center,Ralelgly NC 2709-1617
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K018f�/ 2��`^!. �!gp°•hTMit One.Ow"Or fats rn„r,.utm�n :�:maw nt rmm�lnni\n nr
12.Well construction method: • •• IN \9/em
VA augm;rotary,cable,direct push,etc.). construction to the following:
FOR WATER SUPPLY 17 ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
A97
v:..v.i.....`�\ !.V.woat.,,t wr:o.r. Air Rotary 24e.r,t„aw Water a9ut±nly&)r!leetloII.
Wdh: In addition to sending the form to
ai trill ;.I'w` :'t�:�`::�^-..•.� 21-n-'-e, nlsn si!bm-it nrp r. v of thig 4hsrn :vtthin -w.tl8x,o at
Ate, a0'wiwP Nnw kn+M. ®mount! ,�t�DO G u.v � ,�„�,�,�„ •7••«•••�•••••«�..0�l.o ...h.
l yr .: ._ ._ _..
t:tlt.tillGttUll Vt r,M9t W91pN NVHV,I av wa.,ia, � ���
where constructed. .,.,,•....._..a_ .,
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016