WI0400598_Injection Event Record_20240223

North Carolina Department of Environmental Quality—Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W10400598
Were any wells abandoned during this injection
1. Permit Information event?
❑ Yes ❑S No
NCDEQ/DWM/UST/State Lead Program
Permittee If yes,please provide the following information:
Battleground Texaco Number of Monitoring Wells 0
Facility Name
Number of Injection Wells 0
1703 Battleground Ave, Greensboro, Guilford Co.,NC
Facility Address (include County) Please include a copy of the GW-30 for each well
abandoned
2. Injection Contractor Information
WithersRavenel during MMPE by Eastern 4. Injectant Information
Environmental Management,LLC Air Inje
Injection Contractor/Company Name
ctant(s) Type(can use separate additional sheets if
Street Address 115 MacKenan Drive
necessary
Cary NC 27511 Concentration N/A If
City State Zip Code
the injectant is diluted please indicate the source
919 469-3340 dilution fluid. N/A
Area code—Phone number
3. Well Information Total Volume Injected(gal) N/A
Volume Injected per well(gal) N/A
Number of wells used for injection 1
5. Injection History
Well IDs AS-1
Injection date(s) 2/19/2024 to 2/23/2024
Were any new wells installed during this injection
event? Injection number(e.g. 3 of 5) 4
❑ Yes ® No
Is this the last injection at this site?
If yes,please provide the following information: ❑ Yes © No
Number of Monitoring Wells 0
I DO HEREBY CERTIFY THAT ALL THE
Number of Injection Wells 0 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
❑ Bored ❑ Drilled ❑ Direct-Push STANDrS LAID OUT IN THE PERMIT.
❑ Hand-Augured ❑ Other(specify) �L�
3/12/2024
SIGNATURE OF INJECTION CONTRACTOR DATE
Please include a copy of the GW-1 form for each
well installed.
David C.Vail,E.I.
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