WI0400547_Compliance_20200522

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W10400547
1, Permit Information
ATC, of North Carolina PC
Permittee
Mast General Store
Facility Name
3565 NC Hwy 194 South, Sugar Grove,
Watauga County, NC 28679
Facility Address (include County)
2. Injection Contractor Information
ATC of North Carolina PC
Injection Contractor / Company Name
Street Address: 7606 Whitehall Executive Center
Drive Suite 800
Charlotte, North Carolina, 28273
City State Zip Code
[phone]
Area code — Phone number
3. Well Information
Number of wells used for injection 2
Well IDs MW1R , MW-2
Were any new wells installed during this injection
event?
❑ Yes ® No
If yes, please provide the following information:
Number of Monitoring Wells NA
Number of Injection Wells NA
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 form for each
well installed
Were any wells abandoned during this injection
event?
❑ Yes � No
If yes, please provide the following information:
Number of Monitoring Wells NA
Number of Injection Wells NA
Please include a copy of the GW-30 for each well
abandoned
4. Injectant Information
Provect-ORS
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration NA
If the injectant is diluted please indicate the source
dilution fluid. NA
Total Volume hijected (gal) NA
Volume Injected per well (gal) NA
5. Injection History
Injection dates) _MaY 7, 2020
Injection number (e.g. 3 of 5) 2 VA
Is this the last injection at this site?
❑ Yes [K No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANNDARDS LAID OUT IN THE PERMIT.
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SIGNAT OF INJECTION CONTRACTOR DATE
Jacob Miller
PRINT NAME OP PERSON PERFORD4ING TI-IE INJECTION
Submit the original of this form to the Division of Water Resources
Form UIC-IER
Rev. 3-1-2016