WI0800330_Injection Event Record_20130325

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources—Division of Water Quality
Permit Number W10800330
Were any wells abandoned during this injection
1. Permit Information event?
Commanding General,G-F/EMD/EQB U Yes ❑ No
Permittee If yes,please provide the following information:
MCIEAAST-MCB CAMLEJ Number of Monitoring Wells
Facility Name
Number of Injection Wells 9
12 Post Lane,Camp Lejeune,NC 28547
Facility Address Please include two copies of the GW-30 for each
well abandoned.
2. Injection Contractor Information
CATLIN Engineers and Scientists 4. Injectant Information
Regenesis ORC Advanced®Pellets
Injection Contractor/Company Name
220 Old Dairy Road Injectant Type
Street Address
Wilmington NC 28408
Concentration 50 Pounds per Well
City State Zip Code If the injectant is diluted please indicate the source
dilution fluid.
9( 10 j 452-5861
Area code—Phone number Total Volume Injected 450 Lbs.
3. Well Information Volume Injected per well 50 Lbs..
Number of wells used for injection 9 5. Injection History
Well names IP-1 Through IP-9 Injection date(s) April 16- 18,2013
Were any new wells installed during this injection Injection number(e.g. 3 of 5) 1 of 1
event?
[X] Yes ❑ No Is this the last injection at this site?
[I Yes ❑ No
If yes,please provide the following information:
Number of Monitoring Wells I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
Number of Injection Wells 9 THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
Type of Well Installed (Check applicable type): STANDARDS LAID OUT IN THE PERMIT.
[x1 Bored ❑ Drilled ❑Direct-Push
❑ Hand-Augured ❑ Other(specify) SIGNATI fRrOF INJECTION CONTRACTOR DATE
Please include two copies ofform GW-Ib for each
well installed. PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection. Form UIC-IER
Attn:UIC Program, 1636 Mail Service Center,Raleigh,NC 27699-1636,Phone No.919-733-3221 Rev.07/09