WI0501133_Injection Event Record_20240304

North Carolina Department of Environmental Quality—Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0501133
Were any wells abandoned during this injection
1. Permit Information event?
❑ Yes ® No
NCDEQ-DWM-UST-State Lead Program—
Permittee If yes,please provide the following information:
Alston's Convenient Mart Number of Monitoring Wells
Facility Name
Number of Injection Wells
1159 Dr.Martin Luther King Jr.Blvd,Warrenton,Warren Co,NC
Facility Address (include County) Please include a copy of the GW-30 for each well
abandoned.
2. Injection Contractor Information
4. Injectant Information
CATLIN Engineers and Scientists
Injection Contractor/Company Name PetroSoly
Injectant(s) Type(can use separate additional sheets
Street Address_1044 Washington St. if necessary
Ralei h NC 27605 Concentration 5% surfactant, 95%water
City State Zip Code
If the injectant is diluted please indicate the source
919 838-2875 dilution fluid._Municipal water from spigot
Area code—Phone number
Total Volume Injected(gal) 525
3. Well Information
Volume Injected per well (gal)_525
Number of wells used for injection One
5. Injection History
Well IDS MW-1R
Injection
Were any new wells installed during this injection date(s) 3/4/2024
event?
❑ Yes ® No Injection number(e.g. 3 of 5)-1 of 1
If yes,please provide the following information: Is this the last injection at this site?
® Yes ❑ No
Number of Monitoring Wells
I DO HEREBY CERTIFY THAT ALL THE
Number of Injection Wells INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
Type of Well Installed(Check applicable type): INJECTION WAS PERFORMED WITHIN THE
❑ Bored ❑ Drilled ❑Direct-Push STANDARDS LAID OUT IN THE PERMIT.
❑ Hand-Augured ❑ Other(specify) Dap
3/13/2024
Please include a copy of the GW-1 form for each SIGNATURE OF INJECTION CONTRACTOR DATE
well installed.
Sean O'Neil
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