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HomeMy WebLinkAboutWM0100503_Monitoring Well Construction Record TMW-1_20220128 WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016 1. Well Contractor Information: Well Contractor Name NC Well Contractor Certification Number Company Name 2. Well Construction Permit #: List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) 3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single) □Industrial/Commercial □Residential Water Supply (shared) □Irrigation Non-Water Supply Well: □Monitoring □Recovery Injection Well: □Aquifer Recharge □Groundwater Remediation □Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage □Experimental Technology □Subsidence Control □Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks) 4. Date Well(s) Completed: Well ID# 5a. Well Location: Facility/Owner Name Facility ID# (if applicable) Physical Address, City, and Zip County Parcel Identification No. (PIN) 5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W 6. Is(are) the well(s): □Permanent or □Temporary 7. Is this a repair to an existing well: □Yes or □No 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. 8. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells drilled: 9. Total well depth below land surface: (ft.) For multiple wells list all depths if different (example- 3@200’ and 2@100′) 10. Static water level below top of casing: (ft.) If water level is above casing, use “+” 11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount: 14. WATER ZONES FROM TO DESCRIPTION ft. ft. ft. ft. 15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. 16. INNER CASING OR TUBING (geothermal closed-loop) FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. ft. ft. in. 17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ft. ft. in. ft. ft. in. 18. GROUT FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT ft. ft. ft. ft. ft. ft. 19. SAND/GRAVEL PACK (if applicable) FROM TO MATERIAL EMPLACEMENT METHOD ft. ft. ft. ft. 20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.) ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. 21. REMARKS 22. Certification: Signature of Certified Well Contractor Date 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. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTRUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells: In addition to sending the form to the address in 24a above, also submit one copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636 24c. For Water Supply & Injection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of completion of well construction to the county health department of the county where constructed.