WI0100106_Injection Event Record_20200620

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources —Division of Water Resources
Permit Number t,J= 0 t Oo 1b(o
1. Permit Information
2.
N G.
Permittee
Facility Name
Facility Address
Injection Contractor Information
Injection Contractor / Comp'Xny N
Street Address (p0p4 �ondt�S �u�%
CaYu.,n.y►u.2 SC, 2ge15
City State Zip Code
Area code — Phone number
3. Well Information
Number of wells used for injection
Well names
Were any new wells installed during this injection
event?
[X 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 GW4form for each
well installed.
`Catu-Irms wUt SwbMi}itcl prio< injcviio
Were any wells abandoned during this injection
event?
❑ Yes No
If yes, please provide the following
information:
g
Number of MonitorinWells
Number of Injection Wells
Please inclarde a copy of the GW-30 for each tivell
abandoned
4. Injectant Information
Ito 011 k 4341
Injectant Type
0
Concentration a
If the Injectant is diluted please indicate the source
dilution fluid. W—MI 2r
Total Volume Injected 2�� 000 qa� ons
Volume Injected per well 24 000_
5. Injection History
Injection dates) 'J * 1� • Znhl• •-r'4�rti �o • OZ • Z01'�'
Injection number (e.g. 3 of 5) q'
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,
OF
PRINT NriME OF PERSON
CONTRACTOR DATE
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. 8/5/2013