WI0400540_Injection Event Record_20210225

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400540
1. Permit Information
_Blue Ridge Geological Services, Inc./ M5
Permittee
Former Vitafoam
Facility Name
_2222 Surrett Dr, High Point, Randolph
Facility Address (include County)
2. Injection Contractor Information
_Blue Ridge Geological Services, Inc.
Injection Contractor / Company Name
Street Address 7356 Belmont Drive
Trinity
City
NC
State
27370
Zip Code
[phone]
Area code — Phone number
3. Well Information
Number of wells used for injection 2
Well IDs MW-2 and DW-1
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
_Potassium Permanganate (RemOx) Cylinders_
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration
If the injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal)
Volume Injected per well (gal)_2 18-inch cylinders
5. Injection History
Injection date(s) Feb 25, 2021
Injection number (e.g. 3 of 5) 2 of 2
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.
/3zi
DATE
SIGN F INJECTION CONTRACTOR
PRINT NAME
ERSON 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