WI0400579_Injection Event Record_20211227

;ETC
ENVIRONMENTAL • GEDTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
January 24, 2022
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
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 # WI0400579
Amos Grocery
5378 NC Highway 704 East
Sandy Ridge, Stokes County, North Carolina
NCDEQ Incident No. 12530
Dear Ms. Shrestha:
iECEIVED
JAN 2 8 2022
NC DEQ/DWR
Central Office
ATC Associates of North Carolina, P.C. (ATC) is submitting an Injection Event Record for the
Amos Grocery site on behalf of the North Carolina Department of Environmental Quality State
Lead Program. The record documents an air sparge event on wells AS-1 and AS-2 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.
V
Ashley M. Winkelman, P.G.
Senior Project Manager
cc: Herb Berger, LG, Hydrogeologist for NCDEQ
Attachments

Injection Event Record
Amos Grocery, Sandy Ridge. North Carolina
RECEIVED
JAN 2 8 2022
NC DEQ/DwR
Central Off
INJECTION EVENT RECORD
ATC
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RECEIVED
North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER) JAN 2 S 2022
Permit Number WI0400579
1.
2.
3.
Permit Information
NCDEQ
Permittee
Amos Grocery
Facility Name
5378 NC Hwy 704 E. Sandy Ridge, Stokes County.
NC
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
[phone]
Area code — Phone number
Well Information
Number of wells used for injection 2
Well 1Ds AS-1 and AS-2
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.
NC DEQ/DWR
,a�..i r1Hir-c:
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
Continuous Air — approx. 3.900 ft/min
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration Not Applicable
If the injectant is diluted please indicate the source
dilution fluid. Not Applicable
Total Volume Injected (gal) Not Applicable
Volume Injected per well (gal) Not Applicable
5. Injection History
Injection date(s) December 27-31.2021
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
❑ Yes /1 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.
C�-�, V —
1/24/22
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
Rev. 3-1-2016