WI0800560_Injection Event Record_20220623

INJECTION EVENT RECORD

North Carolina Department of Environment and Natural Res ources – Division of Water Resources
Permit Number WI0800560
1. Permit Information
MCB Camp Lejeune Per mitt ee

Hadnot Point Fuel Farm Facilit y Na me
Were any wells abandoned during this inject ion
event ?
Yes No
If yes, please provide the following infor mation:
Number of Monitoring Wells
Number of Injection Wells 1068 Ash Street Camp Lejeune
Facilit y Addr ess

2. Injection Contractor Information
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Infor mation
DAVENPORT/Rhea JV.
Injection Contractor / Company Na me
Street Addr ess 5024 Randall Parkway
Petrobac
CBN
Injectant Type

Conc entration: 5% Wilmington NC 28403
City State Zip Code

[phone]
If the injectant is dilut ed, pleas e indicate t he source
dilut ion fluid. Lot 203 water supply

3. Well Inf ormation
Number of wells us ed for injection: 8
Well names USTHPFF-MW02, MW10R, RW02, USTHPFFC-
MW29, MW67R, MW79, MW86, MW88
Total Volume Inject ed 60 gal of Petrobac and 2000 lbs of CBN
Volume Injected per well Approx. 7.5 gal of Petrobac/
250 lbs of CBN, respectively

5. Injection History

Injection date(s) 5/2/22-5/4/22

Were any new wells installed during this injection
event ?
Yes No

If yes, please provide the following infor mation:
Number of Monitoring Wells
Number of Injection Wells
Type of Well Installed (Check applicable t ype):
Bored Drilled Direct-Push
Hand-Augured Other (specify)
Please include a copy of the GW-1 form for each
well installed.
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.

5/5/22
SIGNATURE OF INJECTION CONTRACTOR DATE
Ben Grosser
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this for m to the Division of Water Resources within 30 days of injection. Form UIC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464 Rev. 8/5/2013