HomeMy WebLinkAboutWI0300436_Injection Event Record_20210706North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number
W10300436
1. Permit Information
Speedway, LLC
Permittee
Speedway 7971 (Former WilcoHess 351)
Facility Name
1343 Rock Barn Rd, Conover, NC
Facility Address (include County)
2. Injection Contractor Information
Mid -Atlantic Associates, LLC
Injection Contractor / Company Name
Street Address 409 Rogers View Ct
Raleigh
City
NC
State
27610
Zip Code
( 919 ) 250-9918
Area code — Phone number
3. Well Information
Number of wells used for injection 1
Well IDs MW-3
Were any new wells installed during this injection
event?
❑ Yes 0 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?
n Yes 0 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
EnviroClean
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 4%
If the injectant is diluted please indicate the source
dilution fluid. Tap water at the facility
Total Volume Injected (gal) 105 gal
Volume Injected per well (gal) 105 gal
5. Injection History
Injection date(s) 7/6/20
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
0 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.
SIG
9/1/20
Tt4REl JECT_LICONTRACTOR DATE
James Young
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. 3-1-2016