WI0400515_Injection Event Record_20220128

ATC
ENVIRONMENTAL • GEOTECNNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
February 1, 2022
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Injection Event Record — WI0400515
Ruby's Mini Mart
9118 NC Highway 62 South
Yanceyville, Caswell County, North Carolina
Incident #19825
Dear Ms. Shrestha:
RECEIVED
FEB 15 2022
NC DEQ/DWR
Central Office
ATC Associates of North Carolina, P.C. (ATC) is submitting an Injection Event Record for the
Ruby's Mini Mart site on behalf of the North Carolina Department of Environmental Quality State
Lead Program. The record documents the placement of Enviro-BAC in one monitoring well (MW-
1) associated with the above referenced site.
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Ashley M. Winkelman, P.G.
Senior Project Manager
cc: Linda Blalock, Engineer for NCDEQ
Attachments

Injection Event Record
Rub•.'s Mini Mart. Yance. ille. North Carolina
INJECTION EVENT RECORD
ATC
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North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400515
. Permit Information
NCDE(.)
Permittee
Ruby's Mini Mart
Facility Name
9118 NC Highway 62 S, Yanceyville, Caswell
County
Facility Address (include County)
Injection Contractor Information
ATC Associates of NC, P.C.
Injection Contractor / Company Name
Street Address 2725 E. Millbrook Road, Ste 121
Raleigh
City
NC
State
27604
Zip Code
1919) 871-0999
Area code — Phone number
. Well Information
Number of wells used for injection 1
Well IDS MW-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-lj'orm 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
Enviro-BAC
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 8.8%
If the injectant is diluted please indicate the source
dilution fluid. City of Raleigh Municipal Water
Total Volume Injected (gal) 10
Volume Injected per well (gal) 10
5. Injection History
Injection date(s) January 28 2022
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.
SIGNATURE OF INJECTION CONTRACTOR DATE
ATC Associates of North Carolina, P.C.
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