Form GW-1 "Well Construction Record" - North Carolina

What Is Form GW-1?

This is a legal form that was released by the North Carolina Department of Environmental Quality - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 22, 2016;
  • The latest edition provided by the North Carolina Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form GW-1 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Environmental Quality.

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Download Form GW-1 "Well Construction Record" - North Carolina

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