WI0400566_Injection Event Record_20210407

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number: WI0400566
1. Permit Information
NCDEQ, DWM, UST Section, State -Lead
Program
Permittee
TF#15063- Williams Grocery
Facility Name
2425 US Highway 21, Hamptonville, Yadkin
County, NC 27020
Facility Address (include County)
2. Injection Contractor Information
ATC Associates of NC, PC
Injection Contractor / Company Name
Street Address_7606 Whitehall Executive Center
Drive, Suite 800
Charlotte, North Carolina 28273
City State Zip Code
(704)-529-3200
Area code — Phone number
3. Well Information
Number of wells used for injection 1
Well IDs AS-1
Were any new wells installed during this injection
event?
I-1 Yes ►4 No
If yes, please provide the following information:
Number of Monitoring Wells NA
Number of Injection Wells NA
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 No
If yes, please provide the following information:
Number of Monitoring Wells NA
Number of Injection Wells NA
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
Compressed Air
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 100%
If the injectant is diluted please indicate the source
dilution fluid. NA
Total Volume Injected(gal)_22,800 cubic feet
Volume Injected per well gal)_ 22,800 cubic feet
5. Injection History
Injection date(s) March 16-19, 2021
Injection number (e.g. 3 of 5)1 of 1
Is this the last injection at this site?
Yes I 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.
3 P4 / (
SIGNATURE OF CTION CONTRACTOR DATE
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PRINT NAME OF PERSON PERFORMING THE INJECTION
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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