WI0400354_DEEMED FILES_20140927

RECEfVED/DENR/DWR
AUG 2 7 2014
INJECTION EVENT RECORD
Water Quality R~lonal
North Carolina Department of Environment and Natural Resources -Division of Water f>tH§m!\W1 5 Se Ion
Permit Number wt O '(Oo 3.r6 <' l.vto f~ ~r'(
1. Permit Information
~o.ll o,t G~t ~"'J
Permittee
CranJvz~w AfA.toco
Facility Name
'fRS-'?/l.'t--v,f~ t<lf,~F!,'1. _ _f; ~~
Facility Address
2. Injection Contractor Information
Were any wells abandoned during this injection
event?
0 Yes ,&lNo
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.
~~1.,,,,L Gs,r6~..._.{.,,/ C,, ti I ' 4.
Injection Cont ctor / Company Name f .C •
Injectant Information · /
Ox¼)e,,_ t o,d/.e..,,_._
Street Address loo ~ (1,,1,((!:.. Sl--
City State Zip Code
~ %J 'tot-ti
Area code -Phone number
3. Well Information
Number of wells used for injection __ 8 __ _
Were any new wells installed during this injection
event?
0 Yes gj No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells _______ _
Type of Well Installed (Check applicable type):
0 Bored O Drilled O Direct-Push
0 Hand-Augured O Other (specify) __ _
Please include a copy of the GW-1 form for each
well installed.
lnjectant T ~
Concentration ':J-:3U p oe,,,,/
If the injectant is diluted please indicate the source
dilution fluid. ------------
Tot al Volume Injected /. , 'j' .. 1/4;,,J
Volume Injected per well O-i..J« ((.,._ J ( ,_.{{
5. Injection History
&{r Jr Injection date(s) _____ _;,_'/_~ _____ _
Injection number (e.g. 3 of 5). __ .,__(-=-o_(' __ b_
Is this the last injecti~ at this site?
0 Yes LB-No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BE T OF MY KNOWLEDGE AND THAT THE
INJEC ON W PERFORMED WITHIN THE
STAN ARDS L D OUT IN THE PERMIT.
8 zJt'I
DATE
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 8/5/2013