WI0400631_Injection Event Record_20241120

North Carolina Department of Environmental Quality—Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400631
Were any wells abandoned during this injection
1. Permit Information BEEJU, LLC event?
Permittee ® Yes ❑ No
Rick's Food Mart If yes,please provide the following information:
Facility Name Number of Monitoring Wells
1122 E Morehead St,Burlington,Alamance Co.,NC
Facility Address (include County) Number of Injection Wells 3
2. Injection Contractor Information Please include a copy of the GW-30 for each well
abandoned
Terraquest Environmental Consultants,P.C.
4. Injectant Information municipal water
Injection Contractor/Company Name Injectant(s) Type(can use separate additional sheets
Street Address 100 E Ruffin if necessary
_Mebane,NC 27302 Concentration
City State Zip Code If the injectant is diluted please indicate the source
dilution fluid.
919 563-9091
Area code—Phone number Total Volume Injected(gal) 375
3. Well Information Volume Injected per well(gal) 125
Number of wells used for injection 3 5. Injection History
Well IDs INJ1, INJ2,INJ3 Injection date(s) 11/12/24
Were any new wells installed during this injection Injection number(e.g. 3 of 5) 1 of 5
event? Is this the last injection at this site?
® Yes ❑ No
If yes,please provide the following information: ❑ Yes X❑ No
Number of Monitoring Wells
I DO HEREBY CERTIFY THAT ALL THE
Number of Injection Wells 3 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 1,,AID OUT IN THE PERMIT.
❑ Hand-Augured ❑ Other(specify) 4o,;�>Awa, 11/19/24
Please include a copy of the GW-1 form for each SIGNATURE OF INJECTION CONTRACTOR DATE
well installed.
Wesley Sorrells
PRINT NA E OF PERSON PERFORMING THE INJECTT
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