WI0100106_Injection Event Record_20162204

North Carolina Department of Environmental Quality—Division of Water Resources
INJECTION EVENT REC®I2D (IEI2)
Permit Number W1:010010(p
Were any wells abandoned during this injection
1. Permit Information event?
❑ Yes ® No
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Permittee If yes, please provide the following information:
fO,rMV AMA(" _I�n Ar,Gk1 LO (.P'a. Fka t 6 Number of Monitoring Wells
Facility Name
Number of Injection Wells
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Facility Address (include County) Please include a copy of the GW-30 for each well
abandoned.
2. Injection Contractor Information
'1 4. Injectant Information
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Injection Contractor/Company Name K So1 ipn
Injectant(s)Type(can use separate additional sheets
Street Address (QO(A ?0'1445 (Au k if necessary
�QwAk SL 2 R(015- Concentration o'o
City State Zip Code
If the injectant is diluted please indicate the source
Z66 - dilution fluid. Qo-f tir
Area code—Phone number
Total Volume Injected(gal) 50 0 !!joA0,1 S
3. Well Information
Volume Injected per well(gal) �W'1 0 ,21 b70 �11&A
Number of wells used for injection 3 Tw-3A r g5,2oo �41a+S
5. Injection History Rj- 3 = 1Z 570 3,41onS
We11IDs Sty"I, T ICJ -3 A � 'Rvi • 3
Injection date(s) 4.OA •Ilo -VAtlu. 13 K,
Were any new wells installed during this injection
event? Injection number(e.g. 3 of 5) (o
Yes ❑ No
Is this the last injection at this site?
If yes, please provide the following information: ❑ Yes Q No
Number of Monitoring Wells
I DO HEREBY CERTIFY THAT ALL THE
Number of Injection Wells INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
Type of Well Installed (Check applicable type): INJECTION WAS PERFORMED WITHIN THE
❑ Bored [Z Drilled ❑ Direct-Push STANDARDS LAID OUT IN THE PERMIT.
❑ Hand-Augured ❑ Other(specify)
Please include a copy of the GW-1 form for each 81WAtORE OF INJECTION CONTRACTOR DATE
well installed
PRINT t4AME OF PERSON PERFORMING 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.3-1-2016