MO-9494_47003_CA_O_20231115_IER

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_WI0300495____________________

1. Permit Information Bumgarner Oil Company, Inc., attn: Zach Bumgarner Permittee Little Market Basket #1
Facility Name 3541 Taylorsville Hwy, Statesville, Iredell Co, NC 28677 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
[phone] Area code – Phone number 3. Well Information Number of wells used for injection ___1________
Well IDs_____AS1_________________________ 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
__ambient air___AIR SPARGE PILOT TEST_____ Injectant(s) Type (can use separate additional sheets
if necessary Concentration ___________________________
If the injectant is diluted please indicate the source dilution fluid.____________________________
Total Volume Injected (gal)____________________ Volume Injected per well (gal)_________________ 5. Injection History Injection date(s)_________11/15/23__________ Injection number (e.g. 3 of 5)____1 of 4__________
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.

________ Ryan D. Kerins ___________ _11/15/23__
SIGNATURE OF INJECTION CONTRACTOR DATE
____Ryan D. Kerins______________________________________________ PRINT NAME OF PERSON PERFORMING THE INJECTION