WI0400572_Injection Event Record_20210701

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400572
1. Permit Information
NCDEQ — State Lead Program
Permittee
Former Center Station — NCDEQ Inc. 44047
Facility Name
2800 Center Road, Boonville, Yadkin County, NC
Facility Address (include County)
2. Injection Contractor Information
WithersRavenel
Injection Contractor / Company Name
Street Address 115 MacKenan Drive
Ca
City
NC
State
( 919 ) 469-3340
Area code — Phone number
27511
Zip Code
3. Well Information
Number of wells used for injection 1
Well IDs MW-1
Were any new wells installed during this injection
event?
❑ Yes ® 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?
❑ 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
Provectus ORS Sleeve
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration _ 1.75 pounds of ORS per sleeve
If the injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal)
Volume Injected per well (gal)
5. Injection History
Injection date(s) 7/1/2021
Injection number (e.g. 3 of 5) 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.
SIGNATURE OF INJECTION CONTRACTOR
8/10/2021
DATE
Elizabeth A. Allyn, Senior Project Manager
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