WI0501108_Injection Event Record_20221008

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W 10501108
1. Permit Information
WJL Stores, LLC (formerly L&L Food Stores, Inc.)
Permittee
L&L Food Store #5
Facility Name
109 W Nash St, SPRING HOPE, NASH COUNTY, NC
Facility Address (include County)
2. Injection Contractor Information
Terraquest Environmental Consultants, P.C.
Injection Contractor / Company Name
Street Address 100 E Ruffin St
Mebane NC 27302
City State Zip Code
[phone]
Area code — Phone number
3. Well Information
Number of wells used for injection
Well IDs I NJ 1-8
8
Were any new wells installed during this injection
event?
n Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
8
Number of Injection Wells
Type of Well Installed (Check applicable type):
❑ Bored 1 1 Drilled 0 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
8
Number of Injection Wells
Please include a copy of the GW-30 for each well
abandoned..
Injectant Information
water (Inj1,2),Oxygen Biochem (Inj3-8)
Inj ectant(s) Type (can use separate additional sheets
if necessary
water only (Inj 1,2), 1 pound OBC per gallon municipal water (Inj3A)
Concentration
If the injectant is diluted please indicate the source
dilution fluid. municipal water
Total Volume Injected (gal) 100/1 , 500
Volume Injected per well (gal) 50/250
Injection History
Injection date(s) 5/3/2022,5/23,24,25/2022
Injection number (e.g. 3 of 5) 1 &2 of 4
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.
10/3/22
SIGNATURE OF INJECTION CONTRACTOR DATE
Wes Sorrells
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