WI0400500_Injection Event Record_20180807

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North Carolina Department of Environmental Quality
INJECTION EVENT RECORD DivisionT R of Water Resources
Permit NumberW t 014 00506
1. Permit Information
Pennittee
OlbUnCil.afaMAL
Fac' y Name
1014 M;11 ,
Facility Address (inclu ounty)
2. Injection Contractor Information
uilow!
&Mt, NC,
Injection Contractor / Company Name
Street Addres
k�Cetn ra N G TY-16-1
City State Zip Code
c 30) 851° 150
Areacode— Phone -number
3. Well Information
Number of wells used for injection
11.►,er
Z
Well IDs KIN I M Vu "5 RECEIVED/NCpEO
Were any new wells installed during this injection
event? SEP 24 2018
❑ Yes 1 No
water Quality
If yes, please provide the following IftiPnoifitahrations S
Number of Monitoring Wells
Number of Injection Wells
Type of Well installed (Check applicable type):
0 Bored ❑ Drilled ❑ Direct -Push
0 Hand -Augured 0 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-3Q for each well
abandoned.
4. Injectant Information
n�►►
Injectant(s) Type (can use se
ifnecessary parate additional sheets
Concentration _ C
If the injectaot is dkuted please indicate the source
dilution fluid. IA.% P/�' t ( it,
Total Volume Injected (gal) 2 i n /05 a (10-5
Volume Injected per well (gal)L1<)�, �ij;xed l n
5coalIor 1eQchwecl
Injection History
Injection date(s) rnb w, Za Ip Y
Injection number (e.g. 3 of 5) / 2
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
CTION WAS PERFORMED WITHIN THE
LAID OUT IN THE PERMIT.
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
OF INJECTION CC CTOR DATE
r�
Form UIC-IER
Rev. 3-1-2016