FA-3898_29796_P_O_20230413_Injection Event Record

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
North Carolina Department of Environmental Quality – Division of Water Resources INJECTION EVENT RECORD (IER)
Permit Number___WI0600188__________________
1. Permit Information ____Parnell Oil Company__________ Permittee
_POCO Shop #1_______________________ Facility Name _____97 N. Fayetteville St, Parkton, NC 28371____ Facility Address (include County) 2. Injection Contractor Information __Terraquest Environmental Consultants, P.C._____ Injection Contractor / Company Name
Street Address______100 E. Ruffin St__________ ___Mebane________NC___________27302_____
City State Zip Code (__919__) __563-9091_______________
Area code – Phone number 3. Well Information Number of wells used for injection ____1_______ Well IDs________MW10_____________________ 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
____peroxide______________________________ Injectant(s) Type (can use separate additional sheets
if necessary Concentration ____7.9 weight percent___________ If the injectant is diluted please indicate the source dilution fluid.____________________________ Total Volume Injected (gal)______15 gallons____ Volume Injected per well (gal)____ 15 gallons____ 5. Injection History
Injection date(s)__________4/13/23_____________
Injection number (e.g. 3 of 5)____3 of 10________ 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.
_____________________________________________________4/17/23___ SIGNATURE OF INJECTION CONTRACTOR DATE _Chris Palmer__________________________________________________ PRINT NAME OF PERSON PERFORMING THE INJECTION