WI0400592_Injection Event Record_20241120

North Carolina Department of Environmental Quality—Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W10400592
Were any wells abandoned during this injection
1. Permit Information event?
❑ Yes ® No
Beroth Oil Company
Permittee If yes,please provide the following information:
Four Brothers Food Store No. 208 Number of Monitoring Wells
Facility Name
Number of Injection Wells
_4975 Reynolda Rd Winston-Salem,Forsyth 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
_Terraquest Environmental Consultants, P.C.
Injection Contractor/Company Name _Oxygen Biochem
Injectant(s)Type(can use separate additional sheets
Street Address_100 E Ruffin St
if necessary
_Mebane,NC 27302 Concentration =solubility=7 weight% If
City State Zip Code
the injectant is diluted please indicate the source
(_919 )_563-9091
Area code—Phone number dilution fluid. municipal water
3. Well Information Total Volume Injected(gal) 100
Volume Injected per well(gal) 25
Number of wells used for injection_4
5. Injection History
Well IDs RW2,RW3,RW4,RW5
Were any new wells installed during this injection Injection date(s) 11/15/24
event? Injection number(e.g. 3 of 5) 11 of 15
❑ ®Yes No Is this the last injection at this site?
If yes,please provide the following information: ❑ 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) 4�>A"4�
11/18/24
Please include a copy of the GW-1 form for each _SIGNATURE OF INJECTION CONTRACTOR DATE
well installed. Harrison Revels
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