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HomeMy WebLinkAboutWI0400360_Injection Event Record_20200504AECENED �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. // /`CI'f.T•>rf.� Dlgllsgy sl 11 . Ryan D.K DN: cn=Ryan D. Kenm., o=TerteyueA Ert+iramunlal, ou, I. 20M.Lrs9lema2:52 c.wm, c.US Dale: 2020.0�.2J 15'.02:g2-01'OP 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