WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Quality Revised Jan. 2013
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. 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:
5. 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. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
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.)
13. 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.
24. Submittal Instructions:
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, 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 a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Geothermal 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.
For Internal Use ONLY:
