WI0100106_Injection Event Record_20150415

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Quality
Permit Number W T 0100t No
Were any wells abandoned during this injection
1 . Permit Information event?
M, lt � ❑ Yes ® No
Permittee If yes, please provide the following information :
�d ( m y Avi dve y :IA ALA � le., ( or . tau ( i Number of Monitoring Wells
Facility Name
Number of Injection Wells
I $ 0 ` )wvt�vit,,a Rol• � S�n �vi�, 1� (. Z$SO (o
Facility Address Please include two copies of the GW130 for each
well abandoned.
2 . Injection Contractor Information
4 . Injectant Information
�J uv��(. ' (,aw►w� on S �n eft n [.ryr i nab
Injection Contractor / Company Name ( b/s n* ) - ( ' %,
Injectant Type
Street Address 6OC4 ?04% r5 �jottir
Concentration �Ie
Catrc,+nyi4�- sc� 2R (� I �
City State Zip Code If the injectant is diluted please indicate the source
dilution fluid. Ir.�atcr
( (� �- ) 28 � - lZ � s
Area code — Phone number Total Volume Injected 131 , 49 (o gal [ oA5
3 . Well Information Volume Injected per well �W ' ( - Z (. 1 000 Jo, l(oow
rtW - 3 = 25 � 49c� gallons
Number of wells used for injection Z 5 . Injection History
Well names -T� W ' I S W ' 3 Injection dates) ' I S ,rw 4 . 14 • i 5
Were any new wells installed during this injection Injection number (e.g. 3 of 5) S
event?
?❑. Yes ❑ No Is this the last injection at this site?
❑ Yes ® No
If yes, please provide the following information :
Number of Monitoring Wells I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
Number of Injection Wells Z THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
Type of Well Installed (Check applicable type) : STANDARDS LAID OUT IN THE PERMIT.
❑ Bored N Drilled ❑ Direct-Push
❑ Hand-Augured ❑ Other (specify) � +
� 154 is
S GN TfeAE OF INJECTION CONTRACTOR DATE
Please include two copies ofform GW-I b for each � 5 r ai5b
well installed. PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection. Form UIC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 276994636, Phone No. 919-733 -3221 Rev. 07/09