WI0300452_Injection Event Record_20220119

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0300452
1.
2.
3.
Permit Information
NCDEQ, DWM, UST Section
Permittee
Bojangles #552, Incident # 44992
Facility Name
584 West Northwest Blvd, Winston-Salem (Forsyth), NC 27105
Facility Address (include County)
Injection Contractor Information
ATC Associates of North Carolina, PC
Injection Contractor / Company Name
Street Address 7606 Whitehall Exe Ctr Dr, Ste 800
Charlotte NC 28273
City State Zip Code
[phone]
Area code — Phone number
Well Information
Number of wells used for injection 3
Well IDs MW-2, MW-4, MW-5
Were any new wells installed during this injection
event?
❑ Yes I 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
Ivey-sol 103
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 4%
If the injectant is diluted please indicate the source
dilution fluid. City of Greensoboro Municipal Water
Total Volume Injected (gal) 1,231
Volume Injected per well (gal) 351 to 522
5. Injection History
Injection date(s) December 9-10, 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.
•er
SIGNA OF INJECTION CONTRACTOR DATE
Al Quarles
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