WI0800541_Injection Event Record_20201214

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Resources
Permit Number WI0800541
1. Permit Information
MCB Camp Lejeune
Permittee
Building 645
Facility Name
645 Brewster Blvd Camp Lejeune
Facility Address
2. Injection Contractor Information
DAVENPORT/Rhea JV.
Injection Contractor / Company Name
Street Address 400 Carl St Unit 202
Wilmington
City
NC
State
28403
Zip Code
[phone]
Area code — Phone number
3. Well Information
Number of wells used for injection: 3
Well names UST645-MW27, MW40, MW41
Were any new wells installed during this injection
event?
nYes ® No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
T e 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
Petrobac
CBN
Injectant Type
Concentration: 5%
If the injectant is diluted, please indicate the source
dilution fluid. Lot 203 water supply
Total Volume Injected 21 gal of Petrobac and 750 gal
of CBN
Volume Injected per well Approx. 7 gal of Petrobac/
250 gal of CBN, respectively
5. Injection History
Injection date(s) 10/28/20-12/9/20
Injection number (e.g. 3 of 5) 1 of 1
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.
12/9/20
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.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 8/5/2013