HomeMy WebLinkAboutWI0400451_Injection Event Record_20220316North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400541
1.
2.
3.
Permit Information
NCDEQ/DWM/UST/Trust Fund Branch
Permittee
Foster / D&M Market
_Duke
Facility Name
Nicks Road, Mebane, Caswell County, NC
_54
Facility Address (include County)
Injection Contractor Information
WithersRavenel during MMPE by Eastern
Environmental Management, LLC
Injection Contractor / Company Name
Street Address 115 MacKenan Drive
Cary NC 27511
City State Zip Code
( 919 ) 469-3340_
Area code — Phone number
Well Information
Number of wells used for injection 1
Well IDs AS-1
Were any new wells installed during this injection
event?
❑ Yes a No
If yes, please provide the following information:
Number of Monitoring Wells 4
Number of Injection Wells 1
Type of Well Installed (Check applicable type):
❑ Bored /1 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 I 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
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration
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) 3/28/2022 — 4/1/2022
Injection number (e.g. 3 of 5) 2
Is this the last injection at this site?
❑ Yes 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.
4/14/2022
SIGNATURE OF INJECTION CONTRACTOR DATE
Elizabeth A. Allyn
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