WI0400035_Injection Event Record_20230831

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number 1 ay oD
Were any wells abandoned during this injection
1. Permit Information 1 event? ❑LJ ,�
Yes No
Permittee If yes, please provide the following information:
Number of Monitoring Wells
Facility Na e
Number of Injection Wells
-�jC-
Facili�Address in Iude Co nty) Please include a copy of the GW-30 for each well
—-� abandoned.
2. Injection Contractor Information
4. Injectant Information
o
Injection Contractor / Company Name
` Injectant(s) Type (can use separat additional sheets
Street Address 7S We � 1 if necessary
Concentration
City State Zip Code
If the inJectant 's tlut d lease indicate �1h�our��
dilutionfluid. aW��
Area code - Phone number
Total Volume Injected (gal) /�8
3. Well, Information
Volume Injected per well (gal)
Number of wells used for injection l�
5. Injection History
Well IDs /Ily1-I, Pw Z� MW-(c,C Mvy.-kdf AW,�lJ, k(?A -1E,
N`vg-l<< NVnt--(3,pW— i�a1��^Ig)tw-S ��v�Injection date(s)
~`� � -t� cW-rZ 9
Were any new wells installed during this injection c b
event? l �(- j3 t l W -ic.� �lw �L� Injection number (e.g. 3 of 5) d l"
❑ Yes
Is this the last injectionat this site?
If yes, please provide the following information: ❑ Yes [ No
Number of Monitoring Wells
I DO HEREBY CERTIFY THAT ALL THE
Number of Injection Wells INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
Type of Well Installed (Check applicable type): INJECTION WAS PERFORMED WITHIN THE s,
❑ Bored ❑ Drilled ❑ Direct -Push SIANDAIqS LAID OUT IN THE PERMIT.
Hand -Au ecif
❑ urcd ❑ Other (specify)� V �� �Ilv , V��� &hm
Please include a copy of the GW-I forin for each SIGNATUR OF IN i
CTIN CONTRACTOR DATE
well installed.
PRINT ME NPE'
PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection. Form UIC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-907-6464 Rev. 3-1-2016