WI0300331_Injection Event Record_20200827

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0300331
1. Permit Information
Linda Beam
Permittee
Corner Store
Facility Name
896 Oakrid,ge Farm Hwy, Mooresville, NC 28115
Iredell County
Facility Address (include County)
2. Injection Contractor Information
_Geological Resources, Inc.
Injection Contractor / Company Name
Street Address_3502 Hayes Road
_Monroe, NC 28110
City State Zip Code
[phone]
Area code — Phone number
3. Well Information
Number of wells used for injection 4
Well IDs AS-1, AS-2, ASA MW-6 &
MW-IA
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 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 Wells
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
EHC-O
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration Solid
If the injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal)_five (5) 3 foot long,
1.5 inch dia. Socks
Volume Injected per well (gal) Solid
5. Injection History
Injection date(s) 07/29/20
Injection number (e.g. 3 of 5)_8 of 10 (estimated)
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.
�� 8/10/20
, ,,4 ,�SIGNATURE 01F INJECTION CONTRACTOR DATE
Randy Smith
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. 3-1-2016