WI0400494_Injection Event Record_20180709

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400494
1. Permit Information
Pyramid Environmental & Engineering
Permittee
Pleasant Garden Curb Market
Facility Name
4700 Pleasant Garden Rd., Pleasant Garden,
Guilford Co., NC 27313
Facility Address (include County)
2. Injection Contractor Information
Mika Trifunovic / Pyramid Environmental &
Engineering
Injection Contractor / Company Name
Street Address 503 Industrial Avenue
Greensboro
City
NC
State
[phone]
Area code — Phone number
27406
Zip Code
3. Well Information
Number of wells used for injection 3
Well IDs: RW-1, MW-9, and MW-10
Were any new wells installed during this injection
event?
❑ Yes Q No
If yes, please provide the following information:
Number of Monitoring Wells NA
Number of Injection Wells NA
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 Q No
If yes, please provide the following information:
Number of Monitoring Wells NA
Number of Injection Wells NA
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
ORC Advanced socks produced by Regenesis
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 100%
If the injectant is diluted please indicate the source
dilution fluid.NA
Total Volume Injected (gal) 20 ORC Adv. socks
Volume Injected per well (gal)8, 9, and 3 socks
5. Injection History
Injection date(s) Jul 5, 2018
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
n 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.
/-/0-/ -%e-a(ze-ec' &ef2,0e
SIGNATURE OF INJECTION CONTRACTOR DATE
Danny Oldham / Pyramid Environmental. & Eng.
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