New Submission

Submission ID#field type single line
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Yearfield type single line
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Is this a revision to the form you have previously submitted?*field type radio button
Is this a revision to the form you have previously submitted?YesNo
Are you submitting a scanned form?*field type radio button
Are you submitting a scanned form?YesNo

CONTACT INFORMATION

Contact Name*field type single line
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Email Address*field type email
Please provide the ID# for the GW1 for that needs to be revised.*field type single line
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WELL CONSTRUCTION INFORMATION

1. Who is installing these wells?*field type radio button
1. Who is installing these wells?OwnerWell Contractor

1. Well Contractor Information:

	Well Contractor Namefield type single line	NC Well Contractor Certification #field type single line	Company Namefield type single line
Well Contractor Name	Well Contractor Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	NC Well Contractor Certification #field type single line Input blocked. Maximum character limit of 4000 characters reached.	Company Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.

Please input your well contractor certification number to lookup your information. Once you have filled in the number, hit the tab key to begin the lookup.*field type single line
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1. Well Contractor Information:

	Certificate #field type number	Cert Levelfield type single line	First Namefield type single line	Last Namefield type single line	Company Namefield type single line
Well Contractor Name	Certificate #field type number	Cert Levelfield type single line Input blocked. Maximum character limit of 4000 characters reached.	First Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Last Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Company Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.

2. Well Construction Permit #:
field type single line
1× field type single line
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×
List all applicable well construction permits (i.e. Monitoring Wells, UIC- Underground Injection Control, CCPCUA-Central Coastal Plain Capacity Use Area, County, etc.)Add another permit #
What type of well is this?*field type radio button
What type of well is this?Injection WellNon-Water Supply WellWater Supply Well (includes irrigation wells)
3. Water Supply Well*field type radio button
3. Water Supply WellGeothermal (Heating/Cooling Supply)Industrial/CommercialIrrigationMunicipal/Public/CommunityResidential Water Supply (single)Residential Water Supply (shared)
3.1 Is this well > 100,000 GPD*field type radio button
3.1 Is this well > 100,000 GPDYesNo
3. Non-Water Supply Well*field type radio button
3. Non-Water Supply WellMonitoringRecovery
3. Injection Well*field type radio button
3. Injection WellAquifer RechargeAquifer Storage and RecoveryAquifer TestExperimental TechnologyGeothermal (Closed Loop)Geothermal (Heating/Cooling Return)Groundwater RemediationSalinity BarrierStormwater DrainageSubsidence ControlTracerOther

	field type single line
1×	field type single line Input blocked. Maximum character limit of 4000 characters reached.	×

4. Date well was completed and ID#

	Date Well Completed*field type date	Well ID#field type single line	Well Yieldfield type single line
Row 1×	Date Well Completed*field type date	Well ID#field type single line Input blocked. Maximum character limit of 4000 characters reached.	Well Yieldfield type single line (gallons per minute)” Input blocked. Maximum character limit of 4000 characters reached.	×

Add another well

5. Well Location
×
- Facility/Owner Name*field type single line
  (Required)
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- Facility ID#field type single line
  (If applicable)
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- County*field type drop-down
- Type and County Variablefield type single line
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- The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity Use Water Withdrawal Permit Number (CUxxxx) in Section 2. above.
- Parcel Identification No. (PIN)field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Physical Address*field type address
  Street Address
  Address Line 2
  City
  State / Province / Region
  Postal / Zip Code
  Country
- Latitude*field type number
  Decimal degrees
- Longitude*field type number
  Decimal degrees
Add
6. Is(are) the well(s):*field type radio button
6. Is(are) the well(s):PermanentTemporary
7. Is this a repair to an existing well:*field type radio button
7. Is this a repair to an existing well:YesNo
If this is a repair, fill out known well construction information and explain the nature of the repair under #21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction, only 1 GW-1 is needed.
field type number
8a. Indicate TOTAL NUMBER of wells drilled: field type number
Add
9. Total well depth below land surface: (ft.)field type single line
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
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9a. What is the depth of the casing from ground surface?field type single line
in feet
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10. Static water level below top of casing: (ft.)field type single line
If water level is above casing, use “+”
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11. Borehole diameter:field type single line
in inches
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12. Well construction method:field type radio button
12. Well construction method:AugerAir RotaryCable ToolDirect PushMud RotaryRotosonicOther
13. FOR WATER SUPPLY WELLS ONLY:
×
- 13a. Yield (gpm)field type single line
  If applicable
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- 13a. Method of test:field type single line
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- 13b. Disinfection type:*field type single line
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- 13b. Amount:*field type single line
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Add

	field type number
8a. Indicate TOTAL NUMBER of wells drilled:	field type number

14. WATER BEARING/FRACTURE ZONES

	Fromfield type single line	Tofield type single line	Descriptionfield type single line
Row 1×	Fromfield type single line in feet Input blocked. Maximum character limit of 4000 characters reached.	Tofield type single line in feet Input blocked. Maximum character limit of 4000 characters reached.	Descriptionfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

Add additional zones

15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)

	Fromfield type number	Tofield type number	Diameterfield type number	Thicknessfield type single line	Materialfield type single line
Row 1×	Fromfield type number in feet	Tofield type number in feet	Diameterfield type number in inches	Thicknessfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Materialfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

Add additional Outer Casing or Liners

16. INNER CASING OR TUBING (geothermal closed-loop)

	To*field type number	From*field type number	Diameter*field type number	Thicknessfield type single line	Materialfield type single line
Row 1×	To*field type number in feet	From*field type number in feet	Diameter*field type number in inches	Thicknessfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Materialfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

Add Additional Inner Casing or Tubing

17. SCREEN

	Fromfield type number	Tofield type number	Diameterfield type number	Thicknessfield type single line	Materialfield type single line
Row 1×	Fromfield type number in feet	Tofield type number in feet	Diameterfield type number in inches	Thicknessfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Materialfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

Add additional Screen

18. GROUT

	Fromfield type number	Tofield type number	Materialfield type single line	Emplacment Method & Amountfield type single line
Row 1×	Fromfield type number in feet	Tofield type number in feet	Materialfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Emplacment Method & Amountfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

Add additional Grout

19. SAND/GRAVEL PACK (if applicable)

	Fromfield type number	Tofield type number	Materialfield type single line	Emplacment Methodfield type single line
Row 1×	Fromfield type number in feet	Tofield type number in feet	Materialfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Emplacment Methodfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

Add additional Sand and Gravel Pack

20. DRILLING LOG

	Fromfield type number	Tofield type number	Description (color, hardness, soil/rock type, grain size, etc.)field type single line
Row 1×	Fromfield type number in feet	Tofield type number in feet	Description (color, hardness, soil/rock type, grain size, etc.)field type single line Input blocked. Maximum character limit of 4000 characters reached.	×

Add additional drilling logs

21. Remarks
field type multi line
row 1 field type multi line
Add
22. Site diagram or additional well details:field type file upload
You may upload additional well construction information here.
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pdf only

	field type multi line
row 1	field type multi line

FORM UPLOAD

What type of upload will you be doing?*field type radio button
What type of upload will you be doing?Single GW-1'sMulti GW-1's
*** If you are uploading more than one GW1 form, please upload them in batches by well type.
Well Type*field type radio button
Well TypeAgricultural/IrrigationAquifer RechargeAquifer Storage and RecoveryAquifer TestExperimental TechnologyGeothermal (Closed Loop)Geothermal (Heating/Cooling Return)Geothermal (Heating/Cooling Supply)Groundwater RemediationIndustrial/CommercialInjectionIrrigationMonitoringMunicipal/Public/CommunityOtherRecoveryResidential Water Supply (single)Residential Water Supply (shared)Salinity BarrierStormwater DrainageSubsidence ControlTracerWells > 100,000 GPD
File Upload*field type file upload
Drop files here
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Submission Datefield type date
Date will be captured on form submission

CERTIFICATION INFORMATION

*field type checkbox
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23. Certification*field type signature
Signature of Certified Well Contractor
Submittal Datefield type date
Date will be captured on form submission

24. SUBMITTAL INSTRUCTIONS

field type richtext
Submit this GW-1 within 30 days of well completion per the following:
23a. For All Wells: Original form to Division of Water Resources DWR), Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
23b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC) Program, 1636 MSC, Raleigh, NC 27699-1636
23c. For Water Supply and Open-Loop Geothermal Return Wells: Copy to the county environmental health department of the county where installed.
23d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA Permit Program, 1611 MSC, Raleigh, NC 27699-1611

WELL CONSTRUCTION RECORD (GW-1)

CONTACT INFORMATION

24. SUBMITTAL INSTRUCTIONS