WI0300414_Injection Event Record_20230901

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0300414
1. Permit Information
NCDEQ-State Lead Program
Permittee
Tom Saw_yer's Arlington Park — Inc. No. 24155
Facility Name
1205 Martin Luther King Jr, Drive
Greensboro, Guilford Co, NC 27406
Facility Address (include County)
2. Injection Contractor Information
Al Quarles / ATC Associates of North Carolina, P.C.
Injection Contractor / Company Name
Street Address 7606 Whitehall Exec Ctr Dr, Ste 800
Charlotte NC 28273
City State Zip Code
(704 ) 529-3200
Area code — Phone number
3. Well Information
Number of wells used for injection 1
Well IDS MW-5
Were any new wells installed during this injection
event?
❑ Yes ® No
If yes, please provide the following information:
Number of Monitoring Wells 0
Number of Injection Wells 0
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
_Air
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 100%
If the injectant is diluted please indicate the source
dilution fluid. None
Total Volume Injected (gal) approx. 16,130 ft3
Volume Injected per well (gal) approx. 16,130 ft3
5. Injection History
Injection date(s) 8/28/23 — 9/1/23
Injection number (e.g. 3 of 5) 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.
11/15/23
SIGNATt4RE OF INJECTION CONTRACTOR DATE
Al Quarles, ATC Associates of North Carolina, P.C.
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