WI0800536_Injection Event Record_20200728

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Resources
Permit Number WI0800536
1. Permit Information
MCB Camp Leieune
Permittee
Gottschalk Marina
Facility Name
728 Cross St. Camp Leieune
Facility Address
2. Injectiion Contractor Information
DAVENPORT/Rhea JV.
Injection Contractor / Company Name
Street Address 400 Carl St Unit 202
Wilmington NC 28403
City State Zip Code
[phone]
Area code — Phone number
3. Well Information
Number of wells used for injection 5
Well names UST31-MWO1, MW02, MW05, AS-6, and AS-10
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
e of Well Installed (Check applicable type): T
Bored ❑ Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
❑Yes ® No
If yes, please provide the following information:
Number of Monitoring Wells.
Number of Injection W
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
Petrobac CBN
Injectant Type
Concentration: 5%
If the inj ectant is diluted please indicate the source
dilution fluid. Lot 203 water supply
Total Volume Injected 24 gal and 800 gal,
respectively
Volume Injected per well —6 gal and —200 gal,
respectively
5. Injectiion History
Injection date(s) 06/10/20 to 06/11/20
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
NYes ❑ 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.
06/19/20
SIGNATURE OF INJECTION CONTRACTOR DATE
Ben Grosser
PRINT NAME 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. 8/5/2013