GW1-2021-00967_Well Construction - GW1_20210823

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Constructon Electronic •
North Carolina Department of Environmental Quality
April 1,2021
Submission ID#
G W 1-2021-00967
Are you submitting a printed form?* r Yes
r No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Alyce Bean [e-mail]
Is this a revision to the form you have previously submitted?
r Yes r No
WELL CONSTRUCTION INFORMATION
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
2412 A DONALD CUMMINGS,JR. APPLIED RESOURCE MANAGEMENT
2.Well Construction Permit#:
WQ0024756
Listall applicablewell construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
f Water Supply Well(includes irrigation wells)
3. Non-Water Supply Well* r Monitoring
r Recovery
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
8/10/2021 MW-1 R (gallons per minute)"
5.Well Location

Facility/Owner Name*
FMB At The Grove LLC Facility ID#
(Required) (If applicable)
County*
Carteret
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)
637516936014000
Physical Address* Street Address
100 Atlantic Blvd.
Address Line 2
City State/Province/Region
Atlantic Beach NC
Postal/ZZp Code Country
28512 United States
Latitude* 34.6984970000 Longitud06.7381330000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* (-- Permanent C Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)Plain 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.
8a. Indicate TOTAL NUMBER of wells drilled:
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
15 surface?
Formultiplewells listall depths ifdifferent +2,5
(example-3 a200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
5 10
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger C Air Rotary C Cable Tool
C' Direct Push r' Mud Rotary r Rotosonic
C Other
14.WATER BEARING/FRACTURE ZONES
From To Description
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)

From To Diameter Thickness Material
2.00 5.00 2.00 Sch40 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
5.00 15.00 2.00 Sch 40 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 2.00 cement poured
in feet in feet
2.00 3.00 bentonite pellets poured
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
3.00 15.00 coarse#2 poured
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
2.00 4.00 tan to light brown,fine to medium grained sands with shell fragments. No
in feet in feet hydrocarbon or obvious odors.
5.00 7.00 light to medium brown,fine to medium grained sands with shell fragments. No
in feet in feet Hydrocarbon or obvious odors.
10.00 12.00 medium brown to light gray,fine to medium grained sands with shells. No
in feet in feet hydrocarbon or obvious odors.
13.00 15.00 gray,fine to medium grained sands,with shell fragments. No hydrocarbon odor or
in feet in feet obvious odors.
21.Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
WQ0024756 Well Construction Record.pdf 72.31KB
pdf only
CERTIFICATION INFORMATION
*W 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*
Signature of Certified Well Contractor
Submittal Date 8/23/2021

WELL CONSTRUCTION RECORD (GW-11
For Infernal Usc Only:
I. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
hC Well Conaactor Certification Number
Applied Resource Management
Company home
2. Well Construction Permit II:1NQ0024756
List all applicable sudi ramtrut unn prongs (r t 11. t ounn% titan, I uriwecv etc)
3. Well Use (check well use):
Wrier Supply W ell:
❑Agricultural
©Geothermal (IleatingiCoolrng Supply)
❑ Indastrtal/C om menial
❑Irrigation
°Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (sham )
❑Wells100.000 GPD
Non-11'alcr Supply Well:
°Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Tcchnolotry
❑Geothermal (Closed Loop)
❑Geothermal (t1:ating/Coohng Return)
❑Groundwater Rcmcdialian
❑Salinity Barrier
1DStormuater Drainage
❑Subsidence Control
❑Tracer
°Other (explain under 021 Remarks)
d. Date W'ellis) Completed: 08110/2021 Well 1D0 MW 1 R
5a. Well Location:
FMB At The Grove LLC.
Facility Owner Name
Fee. ny IDN (ifappltcahk)
100 Atlantic Boulevard Atlantic Beach 28512
rhlstral dddreu. City end zip
Carteret 637516936014000
County Parcel Idetri1cniion No. (PIN)
5b. 1 allfude and longitude In degrecslminuteslseconds or decimal degrees:
(ifwell Geld. one Lvftoap is surname)
34 41 54.59 ,N 76 44 17.28
6. 13(are) the wets): CtPermanrnl or ❑Temporary
11'
7.13 Ibis a repel'. 10 an existing well: °Yes or 5Nu
(/Ihir h a repair fill Out blown wen rarntnre tam infrtrtnnrrun lent rq hwi the nature of thr
n pulr under 21 n marks .secetnn ar on the hoc/ of thh firmer
8. For GroprabelDPr or Closed -Loop Geothermal Wells hating the same
construction, only I GW-I n needed Indicate TOTAL NUMBER of wells
dtilkch
9. Total a ell depth below land surface: 15 ill.)
A armuhiple i.e./ft list all rhptlet 1fdifferent (aaeapk- .432OO' mad2a11ul')
10. Slate water level below top oreasing: 5 (fL
Iflevier level it afore rutIng. for
1 I. Borehole diameter. 10 (In.)
12. % ell construction method: Auger
!lie raper, rotary, cable enact matt. CM 1
FOR WATER SUPPLY WELLS ONLY:
13n.' leld (gpm)
131. Disinfection type;
lethad priest:
►mount:
li. WATER ZONES
FTtoM
TO
DEsCILIII oo
rt.
n.
ft.
n.
IS OUTER CASING (ror
mu1N<nsed wells OR LINER gfa
Me)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+2 n•
5 rL
2 in.
Sch 40
PVC
16. INNER CASING OR T
BING frtothertrai doted -WO
atom
TO
DIAMETER
THICKNESS
MATERIAL
n.
fL
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
Trireic-NCSS
MATERIAL
5 IL
15 fL
2 im
.010
Sch 40
PVC
(L
ft.
le.
t
IL GROUT
Fonsi
TO
MATERIAL
EMPLACLtIMTs1LT11DDAANIINAT
0 rt•
2 rt.
Cement
Poured
2 n•
3 n•
Bentonite Pellets
Poured
rt.
n.
If. SAND11RAVEL
PACK
(Irapplkablel
FROM
TO
MATERIAL
EMPLICEME\TMLTIN10
3 rt.
15 rL
Coarse #2
Poured
rt.
n.
20. DRILLING
LOG (attaeb
additional Aeon, if oeerssary)
FROM
TO
DESCRIPTION Kolar, hardarn,.sWrvck type. crooks rim. nci
it
rt.
See Attached
ft.
It.
ft.
f
fL
ft.
rL
fL
rt.•_
n.
n.
n.
21. REMARKS
22. Cerllric it1oa::
st�g>tutr,e� of wdl ca�auret1l/
8/16/2021
Due
l I srpernp tltls fume, l lamb) rent& char the well(t) Inn (x err) tvnstruttrd at utttoldanre to ith
1SA NLdt_ 02C 0100 ur 1JA NC.IC ICC 0200 Hell Lrnntructlern Sitmdanlr and that u rapt
refrhtt rrrnnlItat been mudded tot the well inviter
23. She diagram or rdditionni well details:
You may use the back of this page to provide additions) well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary
24. SUBMITTAL INSTRUCTIONS
Submit this CW-I within 30 days of well completion per the following:
2.113. For MI %%ells: Onginal form to Division of Water Resources (DWR)
Information Processing Unit. 1617 MSC, Raleigh, NC 27699.1617
24b. For Ioiectioo Welts: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply oral Oneo•Loop Geothermal Return Wells: Copy to the
county environmental health department orthc county when: installed
24d. For Water WVelis Inducing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, l61 I MSC, Raleigh, NC 27699-161 I
Form GW.i Nonh Caroline Depenment ofEn%ironmenial Quoin), - Minim of Wucr Rcsouares
Resit ed 6-6,2018

FMB AT THE GROVE LLC
NCDEQ PERMIT # WQ0024756
100 ATLANTIC BOULEVARD
ATLANTIC BEACH, NC
MW-1 R
Drilled by: Applied Resource Management, P.0
Logged by: J. Zuncich
Date: 8/10/21
Depth
(ft.)
Description
Water
Content
Blow
Count
2 - 4
Tan to Tight brown, fine to medium grained sands with shell
fragments. No hydrocarbon or obvious odors.
Low
Grab
5 - 7
Light to medium brown, fine to medium grained sands with
shell fragments. No hydrocarbon or obvious odors.
Moderate
HP
10 - 12
Medium brown to light gray, fine to medium grained sands with
shells. No hydrocarbon or obvious odors.
High
HP
13 - 15
Gray, fine to medium grained sands, with shell fragments. No
hydrocarbon odor or obvious odors.
High
HP
HP = Hydraulic Push