WI0500797_DEEMED FILES_20180409 (2)

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North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD OER)
Permit Number WI0500797
1. Permit Information
ML Barnes Jr. {M.M. Fowler, Inc.)
Permittee
WestMainBP
Facility Name
1922 W. Main S Durh NC 27703
Facility Address (Durham County)
2. Injection Contractor Information
Justin Abreu / EMS Environmental, Inc.
Injection Contractor/ Company Name
Street Address 117 South Hoover Road
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City State Zip Code E'Q
3. Well Information
APR 0,9 20/8
R Water &Qionat O Quality
fJerauons SE!cti
(919)596-04 70
Area code -Phone number
Number of wells used for injection --=--1 __
Well IDs MW-13
Were any new wells installed during this injection
event? ....L
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 form for each
well installed
Were any wells abandoned during this injection
event?
D Yes [if 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
ORC Socks -2" diameter. 12" len gth .
Jnjectant(s) Type (can use separate additional sheets
if necessary
Concentration 100%
If the injectant is diluted please indicate the source
dilution fluid. -----------
Total Volume Injected (gal) 3 ORC Socks
Volume Injected per well (gal) 3 Socks / Well
S. Injection History
Injection date(s) March 6, 2018
Injection number ( e.g. 3 of S) _S __
Is this the last injection at this site?
D Yes ~No
I DO HEREBY CERTIFY THAT ALL THE
INFQRMATJON ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARD LAID OUT IN THE PERMIT.
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Submit the original of this fo~ 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
Fenn UIC-IER
Rev. 3-1-2016
D /^-I.I.0 500 -7
North Carolina Department of Environmental Quality - Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0500797
Permit Information
ML Barnes Jr. (M.M. Fowler. Inc.)
Permittee
West Main BP
Facility Name
1922 W. Main St. Durham. NC 27703
Facility Address (Durham County)
2. Injection Contractor Information
Justin Abreu / EMS Environmental. Inc.
Injection Contractor / Company Name
Street Address 117 South Hoover Road
Durham
City
NC
State
1,919 )596-0470
Area code - Phone number
27703
Zip Code
3. Well Information
Number of wells used for injection 1
We11IDs MW-13
Were any new wells installed during this injection
event?
❑ Yes El 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 form for each
tuell 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.
Injectant Information
ORC Socks - 2" diameter. 12" leneth
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 100%
If the injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal) 3 ORC Socks
Volume Injected per well (gal) 3 Socks / Well
5. Injection History
Injection date(s) March 6. 2018
Injection number (e.g. 3 of 5) 5
Is this the last injection at this site?
❑ Yes I'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. i........__ 6-c-c...,_. '3 iSZoi a
IGNATURE OF INJECTION CONTRACTOR jt)ATE
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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 ULC-IER
Rev. 3-1-2016