WM0100573_Well Construction Record_20240508

WELL CONSTRUCTION RECORD (GW-1)
4. Date Well(s) Completed: Well ID#
5a. Well Location:
Facility/Owner Name Facility ID# (ifapplicable)
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 anexisting 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 topof casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.)
12. Well constructionmethod:
(i.e. auger, rotary, cable, direct push, etc.)
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 welldetails:
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
whereconstructed.
Form GW-1 North Carolina Department of Environmental Quality - Division ofWater Resources Revised --201
Print Form
For Internal Use Only:
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
NC Well Contractor Certification Number
Ca
Company Name
2. Well Construction Permit#:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check welluse):
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.
Water Supply Well:
Municipal/Public
Residential Water Supply(single)
Residential Water Supply(shared)
Agricultural
Industrial/Commercial
Irrigation
17. SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.in.
ft.ft.in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
Non-Water Supply Well:
Monitoring Recovery
ft.ft.
ft.ft.
Injection Well:
Aquifer Recharge GroundwaterRemediation
Aquifer Storageand Recovery SalinityBarrier
Aquifer Test Stormwater Drainage
Experimental Technology SubsidenceControl
Geothermal (Closed Loop) Tracer
Geothermal (Heating/Cooling Return) Other (explain under #21Remarks)
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
1. Well Contractor Information:
Well Contractor Name