WI0400593_Injection Event Record_20230619

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400593
1. Permit Information
NCDEQ DWM, UST Section, State Lead
Permittee
TF#44919 Crossroads Center-C
Facility Name
134 Arnold Road, Lexington, NC 27295 (Davidson)
Facility Address (include County)
2. Injection Contractor Information
ATC Associates of NC, PC
Injection Contractor / Company Name
Street Address 7606 Whitehall Exec Ctr Dr, Ste 800
Charlotte North Carolina 28273
City State Zip Code
[phone]
Area code — Phone number
3. Well Information
Number of wells used for injection 1
Well IDs VEW-1 and 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
Air (-55.2 cfin for 95 (Ozone 50% of the time
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 100% air / ozone 50% of the time
If the injectant is diluted please indicate the source
dilution fluid.NA
Total Volume Injected (gal)—314,200 CF
Volume Injected per well (gal) 15 7, 100 CF
5. Injection History
Injection date(s)_Ma, 22-26, 2023
Injection number (e.g. 3 of 5)_1 of unknown
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.
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SIGNAT OF INJECTION CONTRACTOR ATE
Al Quarles, 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. Form UIC-lER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464 Rev. 3-1-2016