WQ0036881_Injection Event Record_20230224 (4)

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number
1. Permit Information
Permittee
Facility Name
Facility Address (include County)
2. Injection Contractor Information
Injection Contractor / Company Name
Street Address
City
State Zip Code
( )
Area code — Phone number
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 applicable type):
❑ Bored ❑ Drilled ❑ 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?
n 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
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration
If the injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal)
Volume Injected per well (gal)
5. Injection History
Injection date(s)
Injection number (e.g. 3 of 5)
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.
Brian P McCann Digitally signed by Brian P McCann
Date: 2023.02.2418:04:48-05'00'
SIGNATURE OF INJECTION CONTRACTOR DATE
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