WI0501094_Injection Event Record_20221003

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North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER) OCT 0 2022
Permit Number W10501094
1. Permit Information
Eaton Corporation
Permittee
Eaton Roxboro Facility
Facility Name
2564 Durham Road, Roxboro, NC 27573
Facility Address (include County)
2. Injection Contractor Information
Draper Aden Associates/TRC
Injection Contractor / Company Name
Street Address114 Edinburgh South Drive Suite 200
NC 27511
City State Zip Code
[phone]
Area code — Phone number
3. Well Information
Number of wells used for injection 2
Well IDs IW-27B and IW-28B,
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 2
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.
DWG
'antralEa/DOffrce
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
EOS Pro and BAC-9
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration EOS Pro: 5:1 (Potable
Water:Product); BAC-9: 10^10 DHC/Liter
If the injectant is diluted please indicate the source
dilution fluid. Fire hydrant on site
Total Volume Injected (gal) 2,842 gal
Volume Injected per well (gal) 1,421 gal/well
5. Injection History
Injection date(s)_ 9/19/2022 - 09/23/2022
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.
9/28/2022
SIGNATURE OF INJECTION CONTRACTOR DATE
Sean Jarvah
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form 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. 3-1-2016