WI0300453_Injection Event Record_20210608

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0300453
1. Permit Information
Southern Concrete Materials, Inc.
Permittee
Kerr's Hickory Ready Mixed Concrete, Inc.
Facility Name
1126 Ist Ave SW
Hickory, Catawba County, NC 28602
Facility Address (include County)
2. Injection Contractor Information
CES of NC, PLLC
Injection Contractor / Company Name
Street Address 5104 Reagan Drive, Suite 7
Charlotte NC
28206
City
State Zip Code
( 980 ) 819-9333
Area code — Phone number
3. Well Information
Number of wells used for injection Two (2)
Well IDs MW-4, RW-5
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?
n 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
PetroSolv by ETEC, LLC (Surfactant)
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration —2.5%
If the injectant is diluted please indicate the source
dilution fluid. Potable Water
Total Volume Injected (gal) 1,185.6
Volume Injected per well (gal) 588.4, 597.2
5. Injection History
Injection date(s) 5/27/2021
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.
6/3/2021
SIGNATURE OF INJECTION CONTRACTOR DATE
Aaron Williamson
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