WI0400567_Injection Event Record_20210209

ATC
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
AECSNED
DEB 0 9 202E
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
February 5, 2021
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Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Injection Event Record — Permit # WI0400567
Langley Tire Service
113 South Staley Street
Staley, Randolph County, North Carolina
NCDEQ Incident #13623
Dear Ms. Shrestha:
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ATC Associates of North Carolina, P.C. (ATC) is submitting an Injection Event Record for the
Langley Tire Service site on behalf of the North Carolina Department of Environmental Quality
State Lead Program. The record documents the installation of three Provect ORS sleeves in one
monitoring well (MW-1) associated with the above referenced site
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
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Brian Buchanan
Staff Scientist
cc: Hassan Osman, Hydrogeologist for NCDEQ
Attachments
Ashley M. Winkelman, P.G.
Senior Project Manager

Injection Event Record
Langley Tire Service, Staley, North Carolina
INJECTION EVENT RECORD
ATC
TNTINNNNENTAL_ GEOTECNNICAL
110101116 SCIENCES • MATERIALS TESTING

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400567
1.
2.
3.
Permit Information
NCDEO
Permittee
Langley Tire Service
Facility Name
113 South Staley Street, Staley, Randolph County
Facility Address (include County)
Injection Contractor Information
ATC Associates of NC, P.C.
Injection Contractor / Company Name
Street Address 2725 E. Millbrook Road. Ste 121
Raleigh NC 27604
City State Zip Code
f 919) 871-0999
Area code — Phone number
Well Information
Number of wells used for injection 1
Well IDs MW-1
Were any new wells installed during this injection
event?
❑ Yes /1 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 ® 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
Provect ORS sleeve
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 75-85%
If the injectant is diluted please indicate the source
dilution fluid. Not Applicable
Total Volume Injected (gal) 1,038 in3- sleeve
volume
Volume Injected per well (gal) 1,038 in3-sleeve
vol.
5. Injection History
Injection date(s) Januar 7. 2021
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
❑ Yes ® 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.
z15/yr
SIGNATURE OF INJECTION CONTRACTOR DATE
ATC Associates of North Carolina. P.C.
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
Rey. 3-1-2016