WI0300473_Injection Event Record_20220701

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W1 oc'473
I. permit Information
p es en f e Yrti
Permittee
15 5eruisk 37,1"
Facility Name
3(P .1 7. 3W 14;aoi 7602_
Facility Address (include County)
CoCrcl,
2. Injection ContractorInformation
on Contractor / Company _
1_11
Street Address 2i) .1) 66, Of
513
(Ttici ) li) 510‘
Area code -- Phone number
3. Well Information
umber of wells used for injection
TeII IDs J t7
Codg -
'Tere any new welis installed during this injection
vent?
Yes X No
yes,_please-provide-thefollowing infonnation:
------
umher of Monitoring Wells
'umber of Injection Wells
"ype of Well Installed (Check applicable type):
0 Bored E Drilled E Direct -Push
0 Hand -Augured [11 Other (specify)
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
2 Yes ENo
If yes, please provide the following information:
Number of Monitoring Wells /14
Number of Injection Wells 7
Please include a copy of the GW-30for each well
abandoned.
4. injectant information
X tn 610C11-CM (c)BC
Inject .(s) Type (can use separate additional sheets
if necessary
Concentration '35O!b 0E4. ref z 1.1
If the injectant is cliluted please indicatehe source
dilution f1uidJ4jji1T1 1,4 A ter
Total Volume Injected (gal) j7 5-0
Volume Injected per well (gal) 2-50 I
Injection History
Injection date(s)
Injection number (e.g. 3 of 5)
5
Is this the last injection at this site?
ri Yes S2 No
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
ST 'DARDS LAID OUT lN THE PERMIT.
NTECT ON CONTRACTO
DATE
cu..)1:1A
PRINT NAME OF PERSON PERFORNENG ThE INJECTLQN
Sub t.[ the original of this form to the Division of Water Resources within 30 days of injection.
Attn TIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016