WI0400577_Injection Event Record_20220128

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W10400577
1. Permit Information
G. Matthew James, P.G.
Permittee
Country Cupboard (TF 24248)
Facility Name
9681 NC HWY 700, Pelham, Rockingham Co., NC
Facility Address (include County)
2. Injection Contractor Information
Eastern Environmental Management, LLC
Injection Contractor / Company Name
Street Address p0 Box 4030
Rocky Mount NC 27803
City State Zip Code
( 252 ) 443-2224
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?
❑ 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?
n Yes Xn 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
Air Sparge - Clean Air
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration Continuous
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)
Injection number (e.g. 3 of 5) '—
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
David Vail
01/28/2022
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