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HomeMy WebLinkAboutWI0400359_Injection Event Record_20200429APR 2 W°id2OCarolina Department of Environmental Quality — Division of Water Resources INJECTION EVENT RECORD (IER) NO DEQ/DWR Central Office Permit NumberW10400359 1. Permit Information Beroth Oil Company, Inc. Permittee Former Gladys Martin Facility Name 1291 Zephyr Rd, Elkin NC 27030 Facility Address (include County) 2. Injection Contractor Information Terraquest Environmental Consultants, P.C. Injection Contractor / Company Name Street Address 100 E. Ruffin St Mebane NC 27302 City State Zip Code 919 563-9091 Area code — Phone number 3. Well Information Number of wells used for injection 2 Well IDs MW5,RW6/MW10 Were any new wells installed during this injection event? ❑ Yes ❑■ No If yes, please provide the following information: Number of Monitoring Wells Number of Injection Wells Type of Well Installed (Check applicable type): ❑ Bored ❑ Drilled ❑ Direct -Push ❑ Hand -Augured ❑ Other (specify) Please include a copy of the GW-1 torm 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 Number of Injection Wells Please include a copy of the GW-30 for each well abandoned 4. Injectant Information Oxygen BioChem Injectant(s) Type (can use separate additional sheets if necessary Concentration —solubility=7 Weight % If the injectant is diluted please indicate the source dilution fluid. `Hater Total Volume Injected (gal) 30 Volume Injected per well (gal) 15 5. Injection History Injection date(s) 4/8/20 Injection number (e.g. 3 of 5) 6 Of 8 Is this the last injection at this site? ❑ Yes ❑■ 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 STANDARDS LAID OUT IN THE PERMIT. oig_ Rm Iayzn D. uxins orv: ea -cyan o. Ken�rs, o-r�aq,ev emramnenut au. mfe; 20.04. 4 14:0 ues Kp 4%', `US Dale: 2020.Od.2d dd:Ol:06 -0d'00' SIGNATURE OF INJECTION CONTRACTOR DATE Doug Tucker Submit the original of this form to the Division of Water Resources within 30 days of injection. Form UIC-IER Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464 Rev. 3-1-2016