WI0400603_Injection Event Record_20220915

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number
W10400603
1. Permit Information
RJ Reynolds Tobacco Co.
Permittee
Wake Health Parking Lot
Facility Name
799 N Research Pkwy, Winston-Salem, Forsyth Cc.
Facility Address (include County)
2. Injection Contractor Information
AST Environmental, Inc.
Injection Contractor / Company Name
Street Address 1567 CIF Pours Dr.
Harrisonburg KY 22802
City State Zip Code
5( 40) 820-3465
Area code — Phone number
3. Well Information
Number of wells used for injection 17
Well IDs IP-01 through IP-17
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 17
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 17
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
BOS 200+
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 36%
If the injectant is diluted please indicate the source
dilution fluid. local hydrant
Total Volume Injected (gal) 2,550
Volume Injected per well (gal) 150
5. Injection History
Injection date(s) 08/15-16/2023
Injection number (e.g. 3 of 5) 1
Is this the last injection at this site?
❑ Yes E 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.
09/08/23
SIGNATURE OF INJECTION CONTRACTOR DATE
Nathan Thacker
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-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464 Rev. 3-1-2016