WI0501143_Injection Event Record_20240926

North Carolina Department of Environmental Quality—Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0501143
1. Permit Information Were any wells abandoned during this injection
event?
_Betty Holthouser ❑ Yes ® No
Permittee
If yes,please provide the following information:
_Betty Holthouser Property
Facility Name Number of Monitoring Wells
4811 Dodsons Crossroads ,Hillsborough, Orange Co. Number of Injection Wells
Facility Address(include County)
Please include a copy of the GW-30 for each well
2. Injection Contractor Information abandoned.
4. Injectant Information
Injection Contractor/Company Name Terraquest _Oxygen Biochem
Environmental Consultants,P.C. Injectant(s) Type(can use separate additional sheets
if necessary
Street Address 100 E Ruffin St Concentration 1 pound per gallon of water
_Mebane,NC 27302 If the injectant is diluted please indicate the source
City State Zip Code dilution fluid. municipal water
(_919__)_563-9091 Total Volume Injected(gal)_-50
Area code—Phone number
Volume Injected per well(gal) 1-10,2-5, 3-9,4-5, 5-
3. Well Information 4, 8A-11,11A-4
Number of wells used for injection 7 5. Injection History
Well IDs MW 1,2,3,4,5,8A,11 Injection date(s) 9/26/24
Were any new wells installed during this injection Injection number(e.g. 3 of 5) 1 of 5
event?
❑ Yes ® No Is this the last injection at this site?
❑ Yes ® No
If yes,please provide the following information:
I DO HEREBY CERTIFY THAT ALL THE
Number of Monitoring Wells INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
Number of Injection Wells INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
Type of Well Installed(Check applicable type):
❑ Bored ❑ Drilled ❑Direct-Push 10/1/24
❑ Hand-Augured ❑ Other(specify) SIGNATURE OF INJECTION CONTRACTOR DATE
Harrison Revels
Please include a copy of the GW-1 form for each PRINT NAME OF PERSON PERFORMING THE INJECTION
well installed.
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