WI0501034_Injection Event Record_20230613

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0501034
1. Permit Information
Wake County Public School System
Permittee
Willow Springs Elementary School
Facility Name
6800 Dwight Rowland Rd, Wake County
Facility Address (include County)
2. Injection Contractor Information
Mid -Atlantic Associates
Injection Contractor / Company Name
Street Address 409 Rogers View Ct
Raleigh NC 27610
City State Zip Code
( 919 ) 250-9918
Area code — Phone number
3. Well Information
Number of wells used for injection 6
Well IDs MW-1, MW-3, RW-I, RW-2, RW-3, RW-
4
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?
❑ 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
Gravity injection of approximately 120 gallons of 4% solution
of BioSolve Clear surfactant into existing wells MW-1, MW-3,
RW-1, RW-2, RW-3. and RW-4 on 4/14/23
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 4%
If the injectant is diluted please indicate the source
dilution fluid. Willow Springs municipal water
supply
Total Volume Injected (gal) 120
Volume Injected per well (gal) 10 to 25
5. Injection History
Injection date(s) Sept 27-28, 2019, Dec 22, 2020,
10/28/21
Injection number (e.g. 3 of 5) 4 of 4
Is this the last injection at this site?
❑ Yes ® No — TBD will evaluate results.
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.
S\k&—.a �_'_ 6/13/2023
SIGNATURE OF INJECTION CONTRACTOR DATE
Gary Fischer
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