WI0500242_Permit (Completion)_20241015

Department of Environmental Quality- Division of Water Resources
STATUS OF INJECTION WELL(S)/PERMIT RESCISSION REQUEST FORM
Permit Number: WI0500242
Permittee Name(s): United Parcel Service
Mailing Address: 2535 Edward Babe Gomez Drive, Omaha,NE 68107
Physical Address of Well(s) (if different than mailing address): 1108 Instrument Drive
City Rocky Mount County Nash Zip Code 27804
Daytime Telephone No.: 402-250-9777 Cell No.:
Email Address: [e-mail]
Please check the selection which most closely describes the current status of your system:
1) ( Well(s) still used for injection activities
2) ( Well(s)not used for injection but used for other purposes: a)(Water Supply
b)( Recovery
c)( Irrigation
d)( Monitoring
3) (x) Injection discontinued and:a)(Well(s)temporarily abandoned
b)(Well(s)permanently abandoned
c)(Well(s)not abandoned
4) ( Injection well(s)never constructed ( N/A injection well(s)never proposed
Well(s)Abandonment/Comments:
If you checked(3)(a) or(b), attach a copy of the GW-30 (Well Abandonment Record). If not applicable, then describe
the method used(or to be used)to abandon the well(s),including a description of how the well were sealed and material
used. If the work below is proposed,a GW-30 will need to be submitted to the UIC Program 30 days after abandonment.
Well abandonment documentation is attached.
Permit Rescission:
If you checked(2),(3),or(4)and will not use a well for injection on this site in the future,you should request rescission
of the permit. Do you wish to rescind the permit?
(x) Yes ( No
Certification:
"I hereby certify,under penalty of law,which I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
9/18/24
Signature Date
Denise Dixon,P.G. Project Manager,Arcadis
Name Title
GW-68 Injection Well Status Form Rev.3-1-2016 Page 1 of 1