NCG020019_MONITORING INFO_20191227

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
o a oO
DOC TYPE
❑ HISTORICAL FILE
�, MONITORING REPORTS
DOC DATE
❑ j o t` u C) I
YYYYMMDD

.1
ANNUAL .SUMMARY DR - WASTEWATER
IL SEND TO CENTM' L OFFICE*
PROCESS MINE/DEWATERING WASTEWATER
GENERAL PERNIIT NO. NCG020000
* Report All Wastewater discharge monitoring data an this form (including No Flow and No Discharge and Permit Limit Vioiations) by MARCH 1 of each year. if
you have limit violations, you must also have turned in a Limit Violation DIVR to your local Regional Office within 30 days of receiving sample results from a lab.
CERTIFICATE OF COVERAGE NO. NCG02 d D J � SA -MI TLE COL_ LECTION YEAR: O 19
FACILITY NAME: Fjthr ►rwk V1 � r COUNTY: N IA1
PERSON COLLECTING SAMPLES: PHONT NO. LC 19_) � 94- - 3 ?9
CERTIFIED LABORATORY: Lab # ADD TO LISTERj'E. YES ❑ NO® EMAIL: Sul r Wc] r�cDr6.Ct�t�n
Lab #
LINiTTS VIOLATIONS? YES ❑ NO ❑
Part A: Wastewater Monitoring Requirements
INDUSTRIAL SAND"? ❑ DISCHARGING TO SA WATERS'? ❑
. Outfall No.
Date Sample
Cgllectedt
50050
Total Flow
00530
Total Suspended
Solids I- :
00400'
Turbidity
I 00545
Settleable Solids:
.00400.
A(
31616
Fecal Coliforms
-
mm/ddlyr
MG
III
N-TTI
mlll
( Standard
eol/mI �
,�Ll9
)Jr
1 /3.;;
"3,9'
a
061.99,119
AlF
/
8. o.
53
I D a1 1 l9
NF
1a.5
b
ND
I
I
All mines must monitor WW discharges for TSS. Only industrial sand mine discharges are subject to TSS limits.
2 If an effluent limit is exceeded, the permittee is required to institute monthly monitoring for that parameter for the remaining permit term.
3 The discharge shall not cause an instantaneous measurement of the turbidity of the receiving water to exceed: 10' NI li for freshwater streams, lakes, and reservoirs
designated as trout waters; 25 NTU for all lakes and reservoirs, and all salt waters; 50 N'TiJ for all other streams and surface waters. Turbidity may be monitored at the
Sronnwater Discharge Outfall. Alternatively, the permittee may choose to monitor turbidity in the receiving water, directly upstream and downstream of the discharge.
4 Only facilities discharging to SA waters are required to monitor for Fecal coliforms_
sa T
le Jb s }
st-
n_—:•*�. .,f,ransn_i �zil�ntd Last Revised01-05-10
-- - - t _r-1

Part A Continued: Wastewater vlonitoring Reatdrements
Outfall No.
Date Sample
Collected`
50050
Total Flow
00530
Total Suspended
Solids'
00400
Turbidity3
00545
Settleable Solids
00400
pH
31616
Fecal Coliforms
-
mmJdd/yr
NIG
mg/l
NTU2^3
tnl/12
Standard 2
Ild
col/ml
MI AM ORIGL TAL AND ONE COPY OF THIS A,N VliAI, SUNLMARY (INCLUDING ALL "NO FLOW". "NO DISCHARGE" & LEMT
VIOLATIONS) BY MARCH ] OF.EACH YEAR TO:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANYL'FO&KA TION REPORTED:
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to
assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
I am aware that there are significant penalties for submitting false information, including the possibility of lanes and imprisonment for knowing vgolations."
(Signature of Permittee) (Date)
Permit Date: 1/1.;201.M2/31/2014 Last Revised 01-05-10
Page 2 of 2

eAnalytical s
' t�' wnwepaeelaDs.com
Laboratory Report
Wilbur Moore
Wade Moore Equipment Company
PO Box 546
Louisburg, NC 27549
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
Report Date: 03/28/2019
Date Received: 03/26/2019
Project: Sample Pick up
Pace Project No.: 92422770
Sample: Site 1 GP LabID: 92422770001 Collected: 03/26/19 06:55 Matrix: Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
SM 21308-2011
Turbidity
13.8
NTU
0.50
03/27/19 13:10
SM 2540D-2011
Total Suspended Solids
13.2
mg1L
3.1
03/27/19 15:38
SM 254OF-2011
Total Settleable Solids
ND
mUUhr
0.10
03/27/19 10:30
EPA 9040C
pH at 25 Degrees C
6.9
Std. Units
0.10
03127119 13:55 H3
ANALYTE QUALIFIERS
H3 Sample was received or analysis requested beyond the recognized method holding time.
Reviewed by: -Axx�
Terri Page
[phone]
terri,page@pacelabs.00m
Eden Certification IDs
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
North Carolina Wastewater Certification #: 633
VirginiaNELAP Certification #. 460025
Page 1 of 4

it
9
Document
Laboratory receiving samples:
Asheville ❑ Eden❑ Greenwood ❑
JM�Ghent Name:
conrtan Ex OUPS SP
Commardaf a[e q'ther._
fame: Document R=, February 7, MIS
n Raa1 s SCUR Pa e 1 of2
No... inuina Autlwrlty:
•Rw.06 her Carollnad CluaktY ONke
-' � lainrhanitsvflle[]
WO # W: 92422770 _
11111111111III IN
92422770 1111
Custody Simi Pwant? 1QYe3 ' I[INo Snh intett? DYea ONO
i
r 0710(Inhhls Person Examining Contmn: 1J �-e' t�
PatfdnlMaterial: QBubbfeWrap Q6ubbie&-W rjflone [:I' Other Biological Tbw FrozenT
Thermom*ter: of i0 S� Typs of kv. 611-C QBtw QNOM �e' ONO NJA
[]IR Gun RY.
Cooler Temp ('C)r Correction Factors Add/Subinet CC) — 0 - I Temp should be chow freezing to 6'C
Cooler Temp Corrarted ('CI: r .
Q4ruflles out of tranp uReAe. Ssmp'.n On tre, ma:14 Proem
her begun
USDA RegWiledSoll (Q N/A, Wateramp!ej
CW sam0ies PX u In a ginrenth: done within the United Stites: CA, Nck Y, or SC lchemaps)? Did tmpin originate tram a reretpn source lh lono9v,
rlrr.. Fir
ComnitaulDiscrepiner,
Chain Of Custody Present?
Yes
0.
A
1. '
Sam .n Arrived whhin Hofd Thad?
d
ONO
ORIA
2.
Short NOW T1mo Anolyds, 102 hr.)?
a
OKfA
3,
Rush -Turn ued
Around Time O ted7
0Y.
hN.
4.
Suflklent Volume
a
a
ONIA
S.
Corns Co' Wners used?
•l.cantalnenthed?
�Ytl
n
ONO
No
ONJA
OPJA
Fi.
Containers Inuct?
LIN.
N A
7.
Muolved ans h: Sampto Fleld ghered7
Del
0110
A
B.
SamphlAbabMatchCOC7
dnckudds Ana Mntrta:
ns
❑Xe
[]NIA
9•
Had? alnvOAAals sEjnm7
a
No
!A
10,
Trip Bleb jvesert?
Trip01agCuzrogSeilsPresent? _.
Do
Yes
Ono
QNo ....
WA
JA
11.
------- com _
....�......_T_.,.._ __�...,_..._._.__. r...w.Lot tDofzp6tcontainers: .� ....
ctm NoirN[AT1DN/RESournum ,
Person contacted:
Date/nme:
i
Project Menager SCURF Review: Lf Date:
Project Mansgn SRF Review: Date:
Page 2of4

It
A�,am CHAIN-OFCLEMOY / Analytical Request Docurnent.
T _.. TM C► *d O- ,u nwv b • LeG LL DocumEur- AI vdwmt Odda 6a OWOPOW .00r *.
a.�aee A ate• Os7"" 6
_ _ M
SESSIONS
■■����■■■■■■■�■�
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SIMONSON
®
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immmmmosson
SEEMS■■mrm�■■■s■■■on■■
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EMISSION
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Document Na:
'Check mark top halt of box if pH and/or dechlorinatlon Is
verified and within the acceptance range for preservatlon
samples.
tifespik= VDA� Coafofm, Tor; olland6nut, DWIN15 (water) DOC, L1Ha
"Bottom half of box Is to fist number of bottle
7. 201A
Page I of 2
kwlna nuf dtr.
�WO# : §-2-4227-70 - -
PM: THP Due Date: 04/05/19
CLIENT: 91-Wade Moor
PH Adjustment
Log for preserved Samples
svnplao Type of premmew pH upon nulpt
eats pnsemtlenadja+led Tim p erertlon
adlutnd
AmountoffrutMLNa
added
Lots
IrOY:W11e1,MrGMr�1,•Oii�p+rl Y.11—a,ry— telPn-—0".. TOr4mf—rL."r --rypr,nr ... u­UN1ieUOr,—'lu..
ew of hQK VWWNCt Pretor•elhr4 out of to"P. kmoeY:t CoAte41or4.
Page 4 of 4

ceAnalytical
r+vw,paealeesaom
Laboratory Report
Wilbur Moore
Wade Moore Equipment Company
PO Box 546
Louisburg, NC 27549
Project: Sample Pickup
Pace Project No.: 92422770
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
Report Date: 03/28/2019
Date Received: 03126/2019
Sample: Site 1 GP
Lab ID: 92422770001 Collected: 03/26/19 06:55 Matrix: Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
SM 213013-2011
Turbidity
13.8
NTU
0.50
03/27/19 13:10
SM 2540D-2011
Total Suspended Solids
13.2
mg1L
3A
03/27/19 15:38
SM 2540E-2011
Total Settleable Solids
ND
mUUhr
0.10
03/27/19 10:30
EPA 9040C
pH at 25 Degrees C
6.9
Std. Units
0.10
03127/19 13:55 H3
ANALYTE QUALIFIERS
H3 Sample was received or analysis requested beyond the recognized method holding time.
Reviewed by: v�
pxw—
Terri Page '
[phone]
[e-mail]
Eden Certification IDs
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
North Carolina Wastewater Certification #: 633
VirginiaAIELAP Certification #: 460025
Page 1 of 4

A
a7w
Laboratory recalvinl samples:
Ashavitle ❑ Eden❑ Greenwood El
CgentNama: J�, \,UNac Matte-
�
Courier dEa UPS P9
❑ Commtrtjaf eu er.
custody Sol Present? ❑Yu �No Seals Intact?
'�W ,l",n - - �� nnerhanitsvilleeD
Huntarsv' V " 92422 /% I 0 _-- -
)rn�ent,af
111111111111111fily
92422770
❑Yu ON.
1' Date/Inkgh Nrsen (xarnbib+d Cenrentx: V ea' t1�--��_., _
Packing Mitarial: ❑Eubblo Wrap ❑3ubble Bags Ylhone ❑' Other rluabilcamm Fraun7 ' S
Thermamater; I005 type ofka; LJtvn u•- ❑No PN/A
DR Gun m, q l' ��10 �Nau ff
Cooler TIRW ('CI: Correcllon Factor: Add/5ubtr4ct CC) Temp should be above hemIng to VC
Cooler Temp Corrected ('Q: e
QSrmplp out d tent/ "Wis. Samples an Im, taaang Process
to been
USDA Regulated saw (❑ NIA. Water»mp!o)
O d nmpld a In a quarantInd zone wftNn the UnIted Stares: CA, NY, or SC ([hock maps)? OW sarnoes od&mte hum a (arelpr swam Ih�+ don!hr,
T'lv.r MdAn,MewatlaMPuermKbm7f*Ycs YWn
Commis olme
Chsinaf PrpenTi
Yn
Ho
A
L
Sam .er Arrbred whhln Maid TIrrN?
a
o
A
i.
Short Hold Ttme A to cT2 hr.
a
Hv
N A
3.
Rush wo Around Time Requested?
n
e
A
a.
SdfRtient Volume?
A.
Ha
N A
CorrmembilnersUred7
-PsteiantalmmUsed?
tat
n
[jNv
Na
•QNJA
N AContaintre
k7.
Intact?
as
No
N A
Misohsd aru 1s: Sam ti ndd IiRered7
ea
No
A
d.
Semph IAbels Mazch CDC7
4nc6Was D D An ll Matft:
a
ONO
ON/A
9.
'
duds is In VOA Vials >S•bmm ?
e
He
A
20.
Trip 91ant Pwarrti
Trl Olsnt Sall Preaent7
�'e
a
[]No
Ha
N/A
A
II.
i
I�
—�.Lot lDofxplttoantelnen: --
—
j uirm HOTiNrATIOPI LTOLUnOH
Parton contattad:
j� Gate/Timm
Project ManaSar SCURF RoWIVA L/
Projact Manage SRF Review.
Date: ? L Y l el
Date•.
Page 2 of 4

v
CHA04-OF-CUSTODY! Analytical Request Document
Ths Chs r .0 of B a LEGRL DOMMBff. AN MWMS ftMa nao ba aQap�d aodsa�lY•
sin AMIT
,rew..en..,�wder wa,ewa�eawn,ma s,dc.er,�r , d ,
„a. &k 77 77�x
■ERN
!.QMMEM■■ammo■■
Emmons■■■■■■
E■mmmmmr■m■ommm■■■
■ommmns■■s■■
®
■mmmmr■■mommm■m■
■■■m■E■■EE■■
®
■m■
mmmoE■■mm■■o■
■omm■mmomsom
M
■■rrrr■■■■mmono0
■m■onsmollsommoolls
■■mm■■
®
■■m
mmmoss■mm■■mo
■mmmmnnmoon■
■■rmrr■■s■mma■E■
■onson
maon■
■ommmommmm■■o■■m■■
■■mom■■■■■■■
mom
mmm■■■■m■mm■■
■mmm■ns■mmo■
rm
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0
I

t,r
Dmmerlt Name:
Sam le Condlllon Upon Rat,
�• Document No.:
FG4R•CS-0g;.itev-0
*Check mark top half of box H pH and/or dechlorination is
verified and within the acceptance range for preservation
samples.
buptlanu VOA Collform, Mr. oil and Greue, DRD/WIS lwarerl DOG U.HB
•$Bottom half of box Is to list number of bottle
rWOW 92422770
prolePM: THP Due Date: 04/05/19
CLIENT: 91-Wado Floor
.I
'2
z
ry
'
i
gz
pH Adjustment
Log for Preserved Samples
sampaiD Typealpnsamtlw pHupmr«Wpt
Date pmemilonadlwtod
TlmapniffV&Uan
adJsntad
Amountafhalmuw Lot
added
n ON: wngmvvrUrn n a oY V paM uracvna is mynr, • SPY m inn ryrni ana ar iam ,o w noon Nrona utnnn u rai,sauon Vriic� 1�-a•
OolarIwld•%VWMn prawNolM, out of temp. v:tarna tent -Wen.
Page 4 of 4

.. Pace Analytical Services, LLG
8701 Canference Drive
w aceAnalytrcal® Raleigh, NC 27607
www,parelAbs.Com [phone]
Page 1 of 1
Laboratory Report
i
Wilbur Moore
Report Date: 07/10/2019
Wade Moore Equipment Company Date Received: 06/28/2019
PO Box 546
Louisburg, NC 27549
Project: Stormwater
Pace Project No.: 92434971
Sample: SITE 1 GP Lab ID: 92434971001 Collected: 061281i9 12:15 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
EPA 180.1 Rev 2.0 1993 Turbidity 8.2 NTU 1.0
07/09/19 0137 H1
SM 2540D-2011 Total Suspended Solids 114 mg1L 5.0
07/05/19 21:09
SM 254OF-2011 Total Settleable Solids 0.53 mIJUhr 0.11
07/10/19 00:35 H1
EPA 9040C pH at 25 Degrees C 6.7 Std. Units 0.10
07/07/19 13:20 H3
WORKORDER QUALIFIERS
WO: 92434971
I
!
[1] Samples were lost due to Fed -Ex wanted ran OOH per Betty Jo
ANALYTE QUALIFIERS
H1 Analysis conducted outside the EPA method holding time.
H3 Sample was received or analysis requested beyond the recognized method holding time.
v�
Reviewed by:
Terri Page
i
[phone]
[e-mail]
;
Asheville Certification IDs
j
2225 Riverside Drive, Asheville, NC 28804 North Carolina Wastewater Certification #: 40
Florida/NELAP Certification #: E87648 South Carolina Certification #: 99030001
Massachusetts Certification #: M-NC030 VrginiaNELAP Certification #: 460222
North Carolina Drinking Water Certification #: 37712
j
I Page 1 of 4

CHAIN -OF -CUSTODY I Analytical Request Document
Ito ChAh,,d-C,-_Jcdy IS g LEGAL DOW MEMr Aln6evaMflakL%n-ctboomOoodaemmtdy.

ttocirment Nama: Document February 7, 2016
Sample Condlgan U on Recel t SCUR Pa e 1 a! 2
CB/�17alj�ICa1 Document No.: IssuingAurhority:
F-CAA-tS•033-Rev.06 Pace Carolinas Ctuall DNice
Laboratory recefving sa rnples:
Asheville ❑ Eden[] Greenwood ❑ HtlntersvN
Name; WOW 924-3497t1
Client Name: -
Courier. Fad Ex UPS PS 1� Clientf l
ort
El Commercial ❑Pace ❑other:____ 92434971
Custody Seal Prosent7 []Yes E No Seals rnlact7 Oyes ❑No �Yvsn[1
Date/Initlab Person Examining Cantents:�- 7
Packing Material: ❑Bubble wrap . Qeubble gags Ermone 0 other mmicarcal Tlasua oten?
©
Thermoeter; (�` rrY.t []Biwa []None Dyes ONO [f N/A
Y�5 TyP•arlw: L�`IR Gun ID:
Cooler Temp ('C(: Corrattlon Factor: Add/Subtract ('C) '—'O. f
1 Temp should 6e above Freelfng to 6'C
Cooler Temp Corrected Elsa. -Was out of tamp cRteda. Samples on ke, codfng process
���� has begun
USDA Regulated Soll ((QIt/A, watersamplel
Did samples originate in a guarandne tone within the United Spies• CA, NY, or SC ((heck maps)? Dld [ample? ai:zlinata lrom a forclan [ource (Internasiomi,iy,
M— 1-1—i—l.'A—u�,.,-,o—d o.,.»n at'.»I'iw.. fin.
Headspaca In YDA Nals 1>5.6mm s
COMMEra1S/SAMPLE DISCREPANCY veld Dare Requlred7 ❑Yes ❑No
l
Lot 10_of_split con Lainan:
CLIENT NOTIFICATION/RESOLUTION I
I
i
Parson contacted: _ .. Date/Time:
Protect Manager SCURF Review;
Proles Manager SRF Review. -
Page 2 of 4
I
I
Parson contacted: _ .. Date/Time:
Protect Manager SCURF Review;
Proles Manager SRF Review. -
Page 2 of 4
I
I

illl
l
I
l �
Document Name: Document Revised: February 7, 7018
sample Candltlon Upon Recelpt(SO1R) Page 1 of 2
C8RI13ljdiC81 Document No.: Issuing AuthMty:
F{AR•CS-O33•Rev,06 Pace CarollnafQua:I ONlcc
I
I
'[hack mark tap half of box If pH and/or dechlorfnatlon Is Praj �`�92434971
-------verified and whhfn the acceptance range for preservation -""- � '� Due Date � 07/08/ 19
samples. PM: THE
EacepllOns: yOA, Corlform, TOC, Oil and Grease, DROJE015 (watcr) DOC, Lwg CLIENT ; 91-Wade Moor I
"Bottom half of box Is to Ilst number of bottle
I
0
mono
MOMEN
Millis
0
Nk1MEk14M0H0kq1M
NMMMM
0
MENIMMENNIMMENEM
SOMEONE
ME
none
MHOMMEMER
pH Adjustment Log for,Preserved Samples
Sampla to
Type of Prasesvetivs
pH upenredlpt
Date pmservr[Wn adjusted
'
Tlme prlrerralloo
edJuttld
Amount al Aresemath"
added
late
I
Wore: wnenever s nere Is a ottdepancy viecurj horn "form comps arce umples, a copy or tryr rorm will to sent to Via North Cara7yla ottirm trenmceeQn OmCc toe. i
Oil of hold. intorrett psasarvalMe, out or temp, Incorrect contalnars.
I
1
Page 4 of 4

acmnalytical
www.pacelabs.com
I
Laboratory Report
Wilbur Moore
Wade Moore Equipment Company
PO Box 546
Louisburg, NC 27549
Project: Stormwater
Pace Project No.: 92434971
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
Report Date: 07/10/2019
Date Received: 06/28/2019
Sample: SITE 1 GP
Lab ID: 92434971001 Collected: 06/28/19 12.15 Matrix: Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
EPA 180.1 Rev 2.0 1993
Turbidity
8.2
NTU
1.0
07/09/19 03:37 H1
SM 254OD-2011
Total Suspended Solids
114
mg1L
5.0
07105119 21:09
SM 254OF-2014
Total Settleable Solids
0.53
mL/Llhr
0,11
07/10/19 00:35 H1
EPA 9040C
pH at 25 Degrees C
6.7
Std. Units
0.10
07107/19 13:20 H3
WORKORDER QUALIFIERS
WO: 92434971
[1j Samples were lost due to Fed -Ex wanted ran OOH per Betty Jo
ANALYTE QUALIFIERS
H1 Analysis conducted outside the EPA method holding time.
H3 Sample was received or analysis requested beyond the recognized method holding time.
Reviewed by:
Terri Page
[phone]
terri.page@pacelabs.00m
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
FlohdalNELAP Certification #: E87648
Massachusetts Certification M M-NCO30
North Carolina Drinking Water Certification #: 37712
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
VrginialVELAP Certification #: 460222
Page 1 of 4

J
Do"mon, Name:
Document Revised: February 7, 2alS
Sam fe Conditlon U an Aecaf t SCUR
Pa .1002
i
L�1Cai
OoCumentNo.:
_ fssutngAutharity:
F-CAA-CS-033-Rev.06
PaceCatdh sCluall Office i
Laboratory receiving samples:
— - � — Asheville ❑ Eden[]
Greenwood ❑ Huntersvll
W0 _:- 92 �p_� 971- � __ .�
ie�Lj� r
MEMIMSMIN Client Name:
Projectf
I!
I
Courier. UFod Ea
UPS OUIPS Client
I I
I
I I II
I
II
I I II
I I
I I
II ,
❑ Commercial ❑Pace
❑other:_
92434971
1
Custody Seal Present? Qyes 2No
Seals Intact? ❑Yes [:]NO
(Q q ,
este/lnid•la fhrson Ta4mfning Contents:- l
Packing Material: QBubble Wrap - ❑Bubble Bags I1Nane ❑ other Biological T(esw oten?
Thermometer: Toot' ) ❑Yes ❑Vo N/A
rA Gun 10: V�\T1--�� typ•aflu: let ❑Blw ❑None
Cooler Temp ('CI: W Correctfon Factor: Add/Subtract ('C) —O • ,
Temp should be above fredltng to fi'C
Cooler Temp Corrected ('CL- []Seriples out of reap c6terla. Samples on Ice, coo:ing prmts
has begun
USDA Regulated Soll (rr/a water sample)
OW samples originate In a ouanndne cone within the United States: CA, NY, or SC (Checi maps)? aid samples originate fmm a foreign source llnternailona'ly,
rlv.< rlu. f-1u,.
Comments/ahcre nc :
Chain of Cutody Present?
Yer
ONO
EIWA
1.
Samples Arfted within Hold Tlme?
Ves
0110
N/A
2.
Short Hold Tlme Analysis 1<72 hr.)?
Yes
EK,
QN/A
3.
Rush Turn Around Time Requested?
OY.
N.
Il A
4.
Suf dent Volume?
Yes
011.
N/A
S.
Caned Containers Used?
-Pace Coetainers Used)
Ye
oua
Ne
❑ra/A
NA
6.
Containers intact?
Yry
fro
OmJA
7,
Dissolved analysts: Samples Held Filtered?
Y
No
N A
B.
Sample labels Match CDC?
-tndudes Date/Timep/Analysts Matrix:
Yea
❑Na
❑N/A
9.
Headspace In VDA Vials 1>5-5mm ?
Del
Ao
r'/A
10.
Trip Blank Present?
Trip Blank Custody Seals Present?
Oros
C3Y..
❑Ne
JIND
n/A
ftA
11.
CGMMEMS/SAMPLE DISCREPANCY
.. Lot16 ofspptwntain_erti:
CLIENT NOTIFICATION/RESOLUTION
Field Data Required? Yes ❑Na
Person contacted: Date/Tlme:
Prolect Manager SCURF Review: �
Date: ts L' f
Project Managor SAF Aevlaw: Date:
I
Page 2 of 4

ewn-•
A
I
CHAIN -OF -CUSTODY! Analytical Request Document
iho Chakra -Gus y IS a LEGAL DOCUMENT. M noiwaM VeW rnua oo =np*W aavravdy,
e.0- a s«cw c ir III _

'Check mark top half of box If pH and/or dechlorinatlon Is Prof WO#, , 9243497 1
verified and within the acceptance range forpresetvation . Due Date: m7/08/18 7
samples. PM : THP
Exception: VOA, Collform, TOC, 04 and Grease, DHO/8O15 (water) DOC. Wig CLIENT: 91—Wade MOOT'
"Bottom half of box Is to list number of bottle
hlkmk
kESSIME
ELLEN
8
MEMO
ESEELEMIN
01
Ills
0
0
10a
�ia�a
nri�nC
memo
p
i
�i
u
pH Adjustment Log for Preserved Samples
Sample ID
type DI prnervadva
pH vpon recelpt
Date pretervalion adjusted
time prarervatloa
adlutted
Amount of premrvatlw
added
tot r
blote: Whenever there Is a dltbepanty aifenlq Norh Gral'rra mmpldree samp4gl, a copy of lNt farm w;II tesanl to tha North Carolina OEM1p Cenikation Meii.e,
Out of hold, incorrect presrvadve, om of temp, ImmrFact mntalnart.
Page 4 of 4

laceAnalyfical"
www.pacelabacom
Laboratory Report
Wilbur Moore
Wade Moore Equipment Company
PO Box 546
Louisburg, NC 27549
Project: Site 1 GP
Pace Project No.: 92435111
Pace Analytical Services, LLC
6701 conference Drive
Raleigh, NC 27607
[phone]
Page i of 1
Report Date: 07/03/2019
Date Received: 07/01/2019
Sample: Site i GP
Lab ID: 92435111001 Collected: 07/01/19 08:00 Matrix:
Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
SM 21308-2011
Turbidity
18.6
NTU
0.50
07/02/19 16:08
SM 25400-2011
Total Suspended Solids
12.9
mg1L
2.5
07/02/19 12:49
SM 2540E-2011
Total Settleable Solids
ND
rnULlhr
0.10
07102/19 13:13
EPA 9040C
pH at 25 Degrees C
6.4
Std. Units
0.10
07103/19 14:08 H3
ANALYTE QUALIFIERS
H3 Sample was received or analysis requested beyond the recognized method holding time.
Reviewed by: v_�
Terri Page ^
[phone]
terri,[e-mail]
Eden Certification IDs
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
North Carolina Wastewater Certification #: 633
VirginiaNELAP Certification #: 460025
Page 1 of 4

r
Document Name;
Document Revised: February 7, 2018
��nn�,h�,�t��
Sample Condidon Upon Recel t SCUA
Page 1 of 2
Document No.:
.' ace^' Weal'
F-CAA-CS-033-Rev.
Laboratory receiving samples:
Asheville ❑ Eden❑ Greenwood []
Sample Ctjsvdifloi� Client Name:
=Courlar: [JFedAR — UPS — SPU S
❑ Commercial ❑Pete ❑Other;
Custody Seal Present? ❑Yes [�No Seals Intact? ❑Yes
❑No
Issuing Authority: `
06 Pace Carolinas Quality Office
Huntersville ❑ Raleigh[ Mechanicsville❑
Project #: WO# • 92435 111 1
len
92433111
rrur-f- r � I
Date/tnitlais Person Examining Contanu i
i f
Packing Material: []Bubble Wrap . (]Bubble Bags one g i ❑ Other Biological Tissue
Thermometer: Q{��'�y Des ❑No �N/A
❑ IR Gun Rif 1L! W(b Type of Ice: �et []Blue []None i
. I
Coaler Temp j'C]: 5. ..,J Correction Factor: Add/Subtract ('C) O .
Cooler Tamp Corrected 'C ; �• � Temp should be above freezing to ti'C
P { I []samples out of temp criteria. Samples on Ice, cooling process
has begun
USDA Regulated Soil (dN/A, water sample)
Did samples originate In a quarantine zone within the united States: CA, NY, or SC (check maps)? Old samples originate from a forelan source (Internationally,
Flyes i1ND Inrludlna Itawall and Puerto RIrn17 r1Ynz nNn
Comments/Dlscra an ;
Chain of Custody Present?
Ycs
Na
N/A
1.
Samples Arrived within Hold lime?
as
Ho
N A
2.
Short Hold Time Ana sla 02 hr.
Yes
No
N A
3.
Rush Turn Around Time Requested?
Y■s
Ho
N A
4.
Sufficient Volume?
es
No
[--]N/A
5.
Correct Containers Used?
-Pace Containers Used?
es
Yes
❑No
NO
❑NIA
N/A
6.
Containers Intact?
rs
Ho
N A
7.
Dissolved analysts: Sam les Field Filtered?
No
N/A
a.
5ample Labels Match COC?
-includes Date/fIrnellD/Anal sis Matrix:
T Yes
+
❑No
❑N/A
9.
Heads ace in VOA Vials (>S-Gmm)?
Yes
No
10,
Trip Blank Present?
TripBlank Custody Seals Present?
❑Yas
Yas
[]NO
Ho
:�Nll
11.
COMMENTS/SAMPLE DISCREPANCY
Lot ID of s lit containers:
CLIENT NOTIFICATION/RESOLUTION
Person contacted:
Date/Time:
Field Data Required? Des []NO
Project Manager SCURF Review: Date: j /11C
Project Manager SRF Review: Date;
Y
I
I
Page 2 of 4

0
ch
w
a
CHAIN -OF -CUSTODY/ Analytical Request Document
The Chak-i-d 4k sbody Is a LEGAL DOCUMENT. All mlem3M tlelds moist be ComptetW accurately.
NAME
I•
r
,
■■■■■■■■■■■■■■■■
■■■■■■■■■■■■
■o■■■mm■■■■■■■■■
■■■■■moss■■■
■■■■■■■■■■■■■■■■
ENEMIES
is
■m■■■■■■m■■■■■■■
■■■s■sss■s■■
■■■■■■■■■■■■
■■■■■■■■■■■■■■■■
■■■■■■■■■m■■
■■■■■■■■■■■■■■■■
■■■■s■s■■s■■
■■■■■■■■■■■■■■■■■
■■■■■■s■■■■■
■■■�■■■■�■■■■■■■
■■■■■■■■■■■■
MENMAI
WWI.
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&W
ROMM

I
Document Name:
Oocument Revised: February 7, 2018
+
8C8Ar181y>*fC81
Sample Condition Upon Rece[ t(SCUR)
Page 1 of 2
Document No.:
Issuing Authority:
F- AR-CS-033-Rev.06
Pace Carolinas Quality office
*Check mark top half of box If pH and/or dechlorination is Project # ' O# : 9243511 1
verified and within the acceptance range for preservatlon W
samples. PM: THP Due Date: 07/11/29
Exceptions: VOA, Collform, TOC, Oil and Grease, DRO/801S (water) DOC, LLHg CLIENT: 91—Wade Moor a
"Bottom half of box is to list number of bottle
��iiia�►��iiai���iiiii■ii�a►i
NOMMMOONOMON
Ll
0
ONEMEN
SOMMEOM
0 0'
NONSENSE
ski
kin
on
MENOMON
IMMENOEEMN
oin�as�ii►ii
HOMMMOs►°
0
pH Adjustment
Log for Preserved Samples
Sample ID
Type of Preservative
pH upon receipt
Date presarvation adjusted
Time preservation
adjusted
Amount of Preservative
added
lot U
Note: whenever there IS a 0[Screpancy ilfact[h$ North Carolina compliance samples, a copy Or this Corm Will IR sent to the Nonn Carolina DEhNK artlt[MlOn Un=ce 11.0.
Out of hold, Incorrect preservative, out of temp, Incorrect containers.
[
Page 4 of 4

aciMnalytrcal
t ww�vpecelshs oam
Laboratory Report
Wilbur Moore
Wade Moore Equipment Company
P4 Box 546
Louisburg, NC 27549
Project: Site 1 GP
Pace Project No.: 92435111
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27807
[phone]
I Page 1 of 1
Report Date: 07103/2019
Date Received: 07/01/2019
Sample: Site 1 GP
Lab ID: 92435111001 Collected: 07/01/19 08:00 Matrix:
Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
SM 213OB-2011
Turbidity
18.6
NTU
0.50
07/02/19 16:08
SM 254OD-2011
Total Suspended Solids
12.9
mg/L
2.5
07102/19 12:49
SM 2540E-2011
Total Settleable Solids
ND
mUUhr
0.10
07/02/19 13:13
EPA 9040C
pH at 25 Degrees C
6.4
Sid. Units
0.10
07103/19 14:08 H3'
ANALYTE QUALIFIERS
H3 Sample was received or analysis requested beyond the recognized method holding time
Reviewed by: �}
Terri Page
[phone]
teni.page@pacelabs.00m
I
Eden Certification IDs
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
North Carolina Wastewater Certification #: 633
l/irginiaNELAP Certification #: 460025
Page 1 of 4

n
Document Name:
Document Revised: February 7, 2018
.
Sam ie Condition Upon Recel t SCUR
Page 2 of 2
�,�f
, 8C0A78:j�C�
Document No.:
IssuingAutharity:
F-CAR-CS•033-Rev.06
Pace Carolinas Quality Office
Laboratory receiving samples:
Asheville ❑ Edert❑ Greenwood ❑ Huntersvllle ❑ Ralelghu?( Mechanicsvlfle❑
• Client Name: project p: WO# : 92435111 1
404rtoF; -- ____.--©Fed•Fat_=_.._ 1)PS _ - ses _ Mien 41,141LI1 llIW. ILL ■u
Commercial
82435311 j
Custody Seal Present? []Yes EeNo Seals intact? ❑ ❑Yes No
n off
Data/Initials Person Examining contentL
Packing Material: ❑Bubble Wrap - ❑Bubble Bags Clone ❑ Other Biological Tissue F zen?
Thermometer: { 5 ❑Yes []No ATV/A
❑IR Gun IDxQ i TYP@ pf tco: Wet ❑Blue []None
Cooler Temp ('C): �j. 3 Correction Faitor.Add/Subtract ('C) —O ,
Temp should be above freezing to 6'C
Cooler Temp Corrected Co., 3 • a Elsa mplas out of temp criterla. Samples on Ice, cooling process
has begun '
USDA Regulated Sall (dN/A, water sample}
Did samples originate In a quarantine zone within the United States: CA, NY, or SC (check maps)? Old samples originate from a foreign source (Internationally,
FlYns rINn indudine Hawaii and Puerto Rlenl? 11Yes nNa
Comments/Discrepancy:
Chain of Custody Present?
E Y.
ON-
N/A
1.
Samp les Arrived within Hold Time?
Yes
ONo
N/A
2.
Short Hold Time Ana sis 02 hr.
Pas
ONo
QNJA
3.
Rush Turn Around Time Requested?
Yes
gN.
N/A
A.
Sufftclent Volume?
s4.
riN.
N A
s.
CarrectContalners Used?
-Pace Containers Used?
— "ei"
Yes
`❑F!o
Nb
❑M/A
N/A
b.
Containers Intact?
es
QNo
❑N A
7.
Dissolved anal sls: Samples Field FlItered7
Y
No
N/A
8,
Sample Labels Match CDC?
includes Date/Tfine/ID/Anal sls Matrix:
Yes
[]IJe
❑N/A
9.
i
Heads ace in VOA Vials >5.6mmj?
oves
ONO
A
I0.
Trip Blank Present?
Trip Blank Custody Seals Present?
©Yes
Yes
[]NoN/
13No
N/A
11.
COMMENTS/SAMPLE DISCREPANCY Field Data Required? ❑Yes []No
Lot ID of split containers:
CLIENT NOTIFICATION/RESOLUTION
Person contacted: DateMme:
Project Manager SCURF Review:
Date:
Projsrct Manager SftF Ravlew:
Dater
1C� ,
i
Page 2 of 4

It
0
m
co
d
---- CHAIN-OF-CUSTODY!-Ana"cal-Request Document- . - -
The Chain-of-(� Is a LEGAL V OGU SENT All relevant tl" must he wed acoumb y.
mom
Tn
' r
-
■
RR
Mold■■■■■■■■
■■l■■momm■■■
■■■■■■■Y■■■■■■■■
■■■■■■moo■■■
■■■■■■■■■■■■■■■■
■■■■■■■■■■■■
■■■■■■■■■■■■■■■■
■■■■■■■■■■■■
INS
■■■■■■■■■■■■■■■■
■■■m■■momm■■
2
■■l■■l■o■m■■
■■■■■■■■■■■■■■■■
■■■■■loom■■■
■l■■■■■■■■m■■■l■
mm■mml000■■■
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■■■■■■■■■■m■■■■■
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■■■■mmommomm
■■■■mm■■■m■■
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mom
r..

3
8C8ARf 1C8i,
Document Nance:
Sample Condition U on Recei t SOJR
Document Revised: February 7, 2018
Rage 1 of 2
Document No,:
F-CAR-CS-033-Rev.06
issuing Autharlty:
Pacearoasua { lln Quality Office
"Check mark top half of box If pH and/or dechlorination is Project #i
verified and within the acceptance range for preservation
samples.
Exceptions: VOA, Coliform, TOC, 09 and Grease, DRO/801S (water) DOC, LLHS
"Bottom half of box is to list number of bottle
i
I
WOW 92435111 1
PM% THP Due Date: 07/21/19
CLIENT: 81-Wade Moor i
RON
SEENEENNEENNEEN
NEENNEENE
MENEENNEENNEE
ENEEMENNEENEMEN
man
OMEN
NEENEEDGENEEMED
pH Adjustment
Log for Preserved Samples
Sample ID
Typo of Preservative
pH upon receipt
Date prasetvatlon adjusted
Time preservation
adjusted
Amount of Praservethre
added
Lot N
Note: Whenever there 15 a dlscrepancy affecting North Carolina compliance samples, a copy of this term Will oe sent to tee Nonn tarouna MANIA renmcatron mice 11,0.
Out of hold, Incorrect preservative, out of temp, Incorrect contalnert,
I
i
Page 4 of 4

aceAnalyiical
! www.pacelabs.com
Wilbur Moore
Wade Moore Equipment Company
PO Box 546
Louisburg, NC 27549
Project: SITE 1 GP
Pace Project No.: 92458841
Sample: SITE 1 GP
Method
EPA 180.1 Rev 2.0 1993
SM 254OD-2011
Slut 254OF-2011
EPA 9040C
ANALYTE QUALIFIERS
Parameters
Turbidity
Total Suspended Solids
Total Settleable Solids
pH at 25 Degrees C
Laboratory Report
Pace Analytical services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
Report Date; 12/31/2019
Date Received: 12/27/2019
Lab ID: 92458841001 Collected: 12/27/19 12:00 Matrix: Water
Results
Units
Report Limit
Analyzed Qualifiers
74.5
NTU
1.0
12/2811915:34
68.7
mg/L
6.7
12/31119 11 :28
ND
mULlhr
0.10
12/2811915:02
7.1
Std. Units
0.10
12/29/19 15:21 H3
H3 Sample was received or analysis requested beyond the recognized method holding time.
Reviewed by: V
Terri Page
[phone]
[e-mail]
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
Massachusetts Certification #: M-NCO30
North Carolina Drinking Water Certification #: 37712
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
VrginiaNELAP Certification #: 460222
Page 1 of 3

WO#:92458841
CHAIN -OF -CUSTODY Analytical Request Document-o�x-Atwod>r
ce,4r�i3fytica!' m6L U
Chain -of -Custody, is a LEGAL DOCUMENT -Copl meteallrelevemfields
CD m liy . Billing InnvC'7C� -J41.L: SIiAUED ARE 92458841
Address pb �J^ :)- - ��Llsbu% 1v�e 4;n- 5�J CoMmnerPreservative !a �8
SCN. u
Report To: , t�'(h _ r,
Email io: -
• • preurvs:;, a Types: (s) iirtrz and. (2)9diunc nod, {3) Erydrocrloric ac1Q 14) sodn�m Yrydnxdda, {sl Inc axta�e
:.{6J
1 a sl�a'�+
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t�Unrid: {il sodhari hlsuifate, l!� soEhun thlosulfa[g, (9) Fim�ie. W]'as'rar6fc aild tB) ammoMui�i sJEarc. -.
[ganynoriioeitlet4'tB)TSv:Mi#+orrse+++ed.[QJothrr -. • .-. - .. .�- .... -.. ._...-_ . -
-
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SI 'an f,/Add � , 1
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.Cl~
Analyses
lab"Profile/Lore::'
Custtmner Project Ntame/Number.
State: County/Gty: Time Zonexollected:
-
:. yaer.ssaplo ;Receipt cnnctiist
/ 11PTI fMT1 Icr 1 1ET
'
_-
��C.'aetoify �Scals.';Praenet7rrtEaCtT, N..
'CoaLody'Sigriatiureo `.Piccent:' - F A
Phone
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Compliance Monitorit`g7
Email.(
}Yes (.]JNo'r
=
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;'Col leefar.Si4�?atn.e_:rreaeat' Ma
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Quote tt:
DW Location Code::
: f „;
_
$attieient •volnmc;'..: ', _ _ _ :tin
"
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'SampTeeRaceived as Ise a.
vas Iieedapeco setepielsla x st
Collected By (signature): Turnaround Date Required; Immediately Papzd on Ice:
]Yes I ) No
R7saa .sequlatAd soxih : a:
Samplce is So"Idtrsq;Ttm
Sample Disposal; Rush: Feld E:t(tered (if applicable):
:r
'VVV$jjj
Residual ClSlerine'rrasent : • T '}
'Strips'::;'. ':.','
[ )Dispose as approprL-rtc I 1 Return [_ ).Same Day { ) Next Day { j Yes [ 1 No
'
ti �'
Cl ; - .:-
1 Ardilve: 1 12 Day 1 13 Day 1 14 Day I 1 S Day Analysis:
_
{I
Gnxiple pe AcF aptabia . x N
pe stcipa :. N.,
I ]Hold;-, (F.xpedteChamesAVPN)
.
t �•
_
Sulfide Present Y,N�
-'• '
• Matrix Codes (Insert in Matrix box below): Drinking Water (D1N), Ground Water (GM, Wastewater
-
;: JLa3d':licetetb Strfpe i`- ... .'
Product (P), Soil/Solid [SQ, oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (17, Other (OT)
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Customer Sample ID Matrix' Grab Composite Start) Composite End CI Ctas
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Date Time Date Time
i F1 t �
-
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—.._
Customer Remarks / Specia! Zonditions'/ Possible Hazards:
TYpdof.icc Vsed:!'t ,• et. ": [3!u
- -Dry :: ,: `None
SHORT FIOLDSPRESENT tj hie rs)' : f : �� N/A::"
Lab Sample Temperature Info:
Temp Blank Received:? - Y N' NA ,
Paclang Materia[Used.
lab Tradung
Therm tuts:.
31:5:2"4 .- � �
:gaoler 1 Temp Upon Receipt: oC"
t
Radct em samplc(sJ screened {t500 Cpm) Y N ' NA
mples received vea
ei 1 Therm Carr F :+ oC
Cool - actor. d�
-.
FE�IX ; ' U_PS. Ckent... Courier - . Pace C_auner -.;: • .
.. r Cooler l" Co_rtcrted Temp: S . t -oC
- tammenu'
ReEiriq ' d b1/Co a i na rcJ:
DatekMme;
Received Company {Signature+
-
Oatefime:
_MTJL LAB USE ONLY
Tab1e
A[ctnu[n:
Template." .. :
Reli utshed b
n9 Y Rany {Si awre)
Date�me
eiv /Company: (Signature)
Date/Time:
`..Trip Blank Received: Y N NA
Relinquished by/Company. (Signature):=teMrre:
-
Pretogi ^}--� jl r ;
� J f L f � : -
HCL McOH �' . -TSP Other
Received by/Company: (Signature)
Date/T'ime:
PM:
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a:)PB:.:
Z] /i J
YES / NO oF.
m
N
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- r
F p�umen��PwvlbsLv& FebruerY i,2015
D=tnent Mayo . `i �} z
sample Candltion Upon Rec SCUR r
CBS ' Document Nm' MgAtrhtsf!tty;
F.
___n....pu. Miira
+check mark top half of box 1f pH and/or dechforinatfon is Project f> ;
verffled and within the acceptance range for preservation
.. .1
samples.: {' •-.• �� � i,
0,,pejatts VQa CalMomy 1Y)e; 011 end Grease, 01018015 (water) DAC,11H9
;+8°ttarri half of box 1s to list number of bottle i
T;�
°z z
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9 r
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pH gd]ustrnent tog for Preserved Samples �L-"Sample l° Type of Pra3efvative pH trAan rncNpe Oats presemuon adjusted 7�ne du
Note. Wtranever there Ls a dlrQe1P�eY aFfacttngNorth Pjtalln11 mmpllance sampler, a mpY of this corm w1R 6e tent to the 7iarthGrd1na OEHft� Certinquea Ofna p•e. ,
out of hold, lncarmct prasorvatfve, out of temp,1ncor.act w(%talners, ti
I
Page 3 of 3

acanalyti{cal
ww.pacelase.com
Laboratory Report
Wilbur Moore
Wade Moore Equipment Company
PO Box 546
Louisburg, NC 27549
Project: SITE 1 GP
Pace Project No.: 92458841
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
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Report Date: 12/31/2019
Date Received: 12/27/2019
Sample: SITE 1 GP
Method Parameters
Lab ID: 92458841001 Collected: 12/27/19 12:00 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
EPA 180.1 Rev 2.0 1993 Turbidity
74.5 NTU
1.0
12/28/19 15:34
SM 254OD-2011 Total Suspended Solids
68.7 mg1L
6.7
12/31/19 11:28
SM 254OF-2011 Total Settleable Solids
ND mULlhr
0.10
12128119 15:02
EPA 9040C pH at 25 Degrees C
7.1 Std, Units
0.10
12/29/19 15:21 H3
ANALYTE QUALIFIERS
H3 was received or analysis requested beyond the recognized method holding time.
\Sample
' �
Reviewed by: lj`
Terri Page
[phone]
[e-mail]
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804 North Carolina Wastewater Certification #; 40
FloridalNEt-AP Certification #: E87648 South Carolina Certification #: 99030001
Massachusetts Certification #: M-NCO30 Virginia/VELAP Certification #: 460222
North Carolina Drinking Water Certification #: 37712
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AnaCalCHAIN-OF-CUSTODY Analytical Re9pest Document
.11�2ce"'
Chair _ —Custody is a LEGAL DOCUMENT - Cornpleie all L-'Wft' fields
Cam icy . Billing tnl*�,,
Address:
COIL
Report TO: EnnaffTo%�44tn'
Sit t'g!rA!n If - AM
Customer Project Name/Number. State: County/city: Time Zoncj;wiected:
PT I CT ET
pfxxie: Siteffadllty!D 9: Compliance MoniZka?
Emag: I I Yes 1 -1 jqo _­
'(0i
Coflected By (print):
Purchase Order ft:
DW PWS ID #:
Quote
DW Location code'
Collected By (signature):
Turnaround Date Required:
Immediately Packed an ke:
Yes k )NO
Sample Disposal:
Rush-
Field Filtered (if applicable):
I I Dispose as appmprla6c Return
•Same Day )Next Day
l 1 Yes INO
I I Arrhwe:
]2 Day 1 13 Day 1 14 Day I 15 Day
Analysis:
I How;
(Eq"tL Charges Apply)
• Matrix Codes (insert in Matrix box below), Drinking Water (DW). Ground Water (GM, Wastewater (WWI,
Product (P), Soil/Wld (SIJ, 00 (OL), Wipe (WP), Air (AR), Tissue MI, Bioassay [B). Vapor Other (07)
Comp /
Collected (or
Composite Enda
Res
it of
-'T
Customer Sample ID
matrix
Grab
Composite Start)
Ctns
s
7
Date I
Time
Date I
.Time
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ALL HADEDARE
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