WI0700518_Injection Event Record_20211101

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Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WJ (276205)
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1. Permit Information
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Permittee (�
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Facility Name J
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Facility Address (include County)
2. Injection Contractor Information
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Injection Contractor / CompaName
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Street Address
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Area code — Phone number
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State
27s/3
Zip Code
3. Well Information
Number of wells used for injection
Well IDs
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 ap
Bored Drilled
Hand -Augured ❑ Other (specify)
licable type):
Direct -Push
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
Number of Injection Wells
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
( \ii 1:(0 Gr)ar Go
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration go�rl 140
5 Ibs iv/ 2.Sq 1�
If the injectant is diluted please indicate the source
dilution fluid. CI -hi 0(1'f el'
Total Volume Injected (gal) Z zi 20
Volume Injected per well (gal) 20
5. Injection History
Injection date(s)
Injection number (e.g. 3 of 5)
Is this the last4u.jection at this site?
Yes No
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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
ST
ARDS LAID OUT IN THE PERMIT.
CONTRACTOR DATE
'SIGNATURE OF LN
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