WI0400555_Injection Event Record_20201028

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W10400555
1. Permit Information
Speedway, LLC
Permittee
Speedway 6929
Facility Name
4019 Reynolda Road
Facility Address (include County)
2. Injection Contractor Information
Mid -Atlantic Associates, LLC
Injection Contractor / Company Name
Street Address 409 Rogers View Ct
Raleigh NC
27610
City State Zip Code
( 919 ) 250-9918
Area code — Phone number
3. Well Information
Number of wells used for injection
Well IDS MW-6
1
Were any new wells installed during this injection
event?
❑ Yes ❑x 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
well installed.
Were any wells abandoned during this injection
event?
n Yes ❑x 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
EnviroClean
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration
2.5
If the injectant is diluted please indicate the source
dilution fluid. Tap Water from the Facility
Total Volume Injected (gal) 250 gallons
Volume Injected per well (gal)
5. Injection History
Injection date(s) 10-28-2020
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
❑x Yes ❑ No
250 gallons
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.
12-2-2020
SIGNATURE OF INJECTION CONTRACTOR
Troy L. Holzschuh
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. 3-1-2016