WI0400091_DEEMED FILES_20180216

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North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400091
1. Permit Information CEIVFD, CJEOJ[J ,
Gilbarco Veeder-Root
Permittee
Gilbarco Veeder-Root
Facility Name
7300 W. Friend! Ave . Greensboro . NC
Facility Address (include County)
2. Injection Contractor Information
EnviroTrac Ltd .
Injection Contractor/ Company Name
Street Address 7343 W. Friendl Ave , Suite J
Greensboro NC 27410
City State Zip Code
(336 ) 763-6025
Area code -Phone number
3. Well Information
Number of wells used for injection -=16"-----------
Well IDs IW-1 throu gh IW-16
Were any new wells installed during this injection
event?
D Yes ~ No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells _______ _
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 fo rm for each
well installed.
Were any wells abandoned during this injection
event?
D Yes [g] No
If yes, please provide the following information :
Number of Monitoring Wells ______ _
Number oflnjection Wells. _______ _
Please include a copy of the GW-30for each well
abandoned.
4 . Injectant Information
H vdro 2:en oas
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 1.6 to 1.9 pp m dissolved in water
If the injectant is diluted please indicate the source
dilution fluid.~N~A.__ __________ _
Total Volume Injected (gal) Continuous passive gas
injection
Volume Injected per well (gal)-=N-'-'A'--"---------
5. Injection History
Injection date(s) Continuous in jection started
2/15/18
Injection number (e .g. 3 of 5)-"'N-"A'--"--------
Is this the last injection at this site?
D Yes [g] 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
S' D A S LAID OUT IN THE PERMIT.
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CONTRACTOR DATE
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ING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn : UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016