HomeMy WebLinkAboutWI0400500_DEEMED FILES_20180924f/VJbL.OU Svp
North Carolina Department of Environmental Quality
INJECTION EVENT -RECORDivision
IIER of Water Resources
Permit NumberktKOW
1. Permit information Were any wells abandoned during this injection
event?
._ ❑Yes A
No
Permittee
If yes, please provide the following information:
FacMYhName. — Number of Monitorin Wells
g
Facility Address (inclu ounty) �,� (j }� G
2. Injection Contractor Information ��
Ue -A� _%"
Injection Contractor / Company Name
Street AddressCRLer
G ZpD-i
City State Zip Code
Area code — Phone number
3. Well Information
Number of wells used for injection z
Well IDs M — 1 * M IAI - C:�
Were any new wells installed during this injection
event? SAP 24 20
❑ Yes � No
Water Quality
If yes, please provide the following Ymlawtatlons
Number of Monitoring Wells
Number of Injection Wells
Type of Well Installed (Check applicable type):
❑ Bored ❑ DrilIed ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW� for each
well installed.
Number of Injection -Wells
Please include a copy of the GW-30for each well
abandoned::
4. Injectant Information
In'ectan�- - ----
(s)1'ype (can use separate additional sheets
if necessary
Concentration M7
If the injectant is dt' 1uted p(ease indicate the source
dilution fluid. W -1-or
i n j f
Total Volume Injected (gal) n 10 c �Lxb
Volume Injected per well (gal)fi;d I n
5. 5 adln e c Injection History Q hwev
Injectiondate(s) m6pr U Zt�(lg
Injection number (e.g. 3 of 5)
Is this the last injection at this site?
❑ Yes X No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
BY�CTION WAS PERFORMED WITS THE
LAID OUT IN THE PERMIT
A OF INJECTION CTOR DATE
Submit the original of this form to the Division of Water Resources Attn: UIC Prowithin 30 days of injection.
Prop -am, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464 Form UIC-IER
Rev, 3-1-2016