WQ0036881_Injection Event Record_20231026 (2)

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
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?
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.

____________________________________________________________
SIGNATURE OF INJECTION CONTRACTOR DATE

____________________________________________________________
PRINT NAME OF PERSON PERFORMING THE INJECTION