WI0400356_DEEMED FILES_20140827

RECEIVED/DENR/DWR
AUG 2 7 2014
INJECTION EVENT RECORD
Water Quality Re~ional
North Carolina Department of Environment and Natural Resources -Division of Water :f'e9§Ml!l4"5 Sec ion
Permit Number Lv/0 '(OtJ.1!"6 c1 /vfof'70~s-'(
1. Permit Information
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Permittee
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Facility Name
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Facility Address
2. Injection Contractor Information
Were any wells abandoned during this injection
event?
D Yes _gj_No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells _______ _
Please include a copy of the GW-30for each well
abandoned.
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Injection Cont ctor / Company Name f-C ·
Injectant Information
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Street Address loo ~ (v.{(!;.. Sl--
City State Zip Code
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Area code -Phone number
3. Well Information
Number of wells used for injection __ 8 __ _
Were any new wells installed during this injection
event?
0 Yes gJ 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 O Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form for each
well installed.
Injectant T ~
Concentration ':f :JU p t:e,A,£
If the injectant is diluted please indicate the source
dilution fluid. ------------
Tot al Volume Injected [ , 'f 4' 1/4,,J
Volumelnjected pc, well O-i 3~f (.,. J ( ,,_.f {
5. Injection History
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Injection date(s) _____ ..:__/_-c _____ _
Injection number ( e.g. 3 of 5) __ _,_(--=o::.._C __ (; __
Is this the last injecti~ at this site?
D Yes LB-No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BE T OF MY KNOWLEDGE AND THAT THE
INJEC ON W PERFORMED WITHIN THE
ST AN ARDS L OUT IN THE PERMIT.
8 1,-,)'1
DATE
PRINT NAME OF PERSON PERFORMING 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. 8/5/2013