WI0400592_Injection Event Record_20231121

North Carolina Department of Environmental Quality— Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W10400592
1. Permit Information
Beroth Oil Company
Permittee
Four Brothers Food Store No. 208
Facility Name
4975 Reynolda Rd Winston-Salem, Forsyth Co., NC
Facility Address (include County)
2. Injection Contractor Information
Terraquest Environmental Consultants, P.C.
Injection Contractor / Company Name
Street Address100 E Ruffin St
_Mebane, NC 2730�
City
State
(_919__) 563-9091_
Area code — Phone number
3. Well Information
Zip Code
Number of wells used for injection 2
Well IDs RW3 RW4
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
_Oxygen Biochem
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration =solubility=7 weight %
If the injectant is diluted please indicate the source
dilution fluid. municipal water
Total Volume Injected (gal) 40
Volume Injected per well (gal)
5. Injection History
Injection date(s) 11/21/23
Injection number (e.g. 3 of 5)
Is this the last injection at this site?
❑ Yes ® No
20
7of15
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.
11/22/23
SIGNATURE OF INJECTION CONTRACTOR DATE
Chris Palmer
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
Atlas: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464 Rev. 3-1-2016