WI0400594_Injection Event Record_20240125

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400594 BLB
1. Permit Information
Permittee
HOLCOMB CREOSOTE
Facility Name
5016 US 601 YADKINVILLE NC YADKIN CO.
Facility Address (include County)
2. Injection Contractor Information
GEOLOGIC EXPLORATION INC.
Injection Contractor / Company Name
Street Address: 176 COMMERCE BLVD.
STATESVILLE NC 28625
City State Zip Code
[phone]
Area code — Phone number
3. Well Information
Number of wells used for injection 177
Well IDs SEE ATTACHED
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 177
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 177
Please include a copy of the GW-30 for each well
abandoned
4. Injectant Information
Perma Ox Ultra
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 7.0% AND 8.5%
If the injectant is diluted please indicate the source
dilution fluid TOWN OF YADKINVILLE NC
Total Volume Injected (gal) 73619.5
Volume Injected per well (gal) VARIED.
5. Injection History
Injection date(s) 4/19/2023-6/27-2023
Injection number (e.g. 3 of 5) UNKNOWN
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.
e4-'ev- 07/12/23
SIGNATURE OF INJECTION CONTRACTOR DATE
DAVID HALL
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