WI0400035_Injection Event Record_20230928

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD ER
Permit Number �Nh 09
1. Permit Information
A'e_i r• �O
Pernnittee
Facility � � ge,, Q
V V� L i+a\I , W L�
Facili Address (iNclude ounty)
2. Injec�-t n Contractor Infor ation
wca,
Injection Contractor/ Company Name r
Street Address L 1I7 �N, 0a a ('
C- 2ILH O
City State Zip Code
Area code — Phone number
3. Well Information
Number of wells used for injection
Well ]Ds N—� .Ali
xM
WerA any new weAs wstalle urmg this ecthan 1
event? t i�-
��I [ w_tom �
ElYes Ef 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
NC.
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
� woA P Qi'CA
Injectant(s) Type (can use separRie additional sheets
if necessary
Concentration
If the injectant Is�dilute tJ�please in icate t e source i
dilution fluid. 11j►�'� 1�
Total Volume Injected (gal) k �
Volume Injected per well (gal) PQ ' 0
5, Injection History
Injection date(s)
r d~11 L 10 _lam 'L,�S
r(, Anjection number (e.g. 3 of 5}
Is this the last injection a
'tAds 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
STANDA S LAID OUT IN THE PERMIT.
TNIECTION CONTRACTOR DATE
Submit the original of this form to the Division of Water Resources within 30 days of injection. Form U1C-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464 Rev. 3-1-2016