HomeMy WebLinkAboutWI0800549_Injection Event Record_20210622North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0800549
1. Permit Information
GPM Southeast, LLC
Permittee
GPM 3059 (Former Scotchman #59)
Facility Name
115 US Hwy 117 S, Burgaw, Pender County
Facility Address (include County)
2. Injection Contractor Information
Crawford Environmental Services, LLC
Injection Contractor / Company Name
Street Address 1701 Shenandoah Ave NW
Roanoke VA 24017
City
State Zip Code
(540 ) 343-6246
Area code — Phone number
3. Well Information
Number of wells used for injection
Well IDS MW-21
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?
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
PetroSolvTM surfactant
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 5%
If the injectant is diluted please indicate the source
dilution fluid. Potable water
Total Volume Injected (gal) 500
Volume Injected per well (gal) 500
5. Injection History
Injection date(s) June 22 & 23, 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.
jw%+'E/ 07/14/2021
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