WI0400359_Injection Event Record_20200429

APR 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.
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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