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�pAY 41` Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
NC DEGIDWR W 10400360
Central0we Permit Number
1. Permit Information
Jamal K. Hajeh
Permittee
Pleasant Grove Mini Mart
Facility Name
6203 N. NC Highway 62, Burlington, Alamance Co.
Facility Address (include County)
2. Injection Contractor Information
Terraquest Environmental Consultants
Injection Contractor / Company Name
Street Address100 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 4
Well IDs MW17, MW18, MW19, MW20
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 lorm for each
well installed
Were any wells abandoned during this injection
event?
❑ Yes 0 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
Oxygen BioChem
lnjectant(s) Type (can use separate additional sheets
if necessary
Concentration —solubility=7 Weight %
If the injectant is diluted please indicate the source
dilution fluid. municipal water
Total Volume Injected (gal) 60 gallons
Volume Injected per well (gal)1 5 gallons
5. Injection History
Injection date(s) 4-22-20
Injection number (e.g. 3 of 5) 8 Of 20
Is this the last injection at this site?
❑ Yes 0 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.
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SIGNATURE OF INJECTION CONTRACTOR DATE
Chris Palmer
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