GW-59 GW-QualityMonitoringReportFormRev. 06-07-2018

SUBMIT FORM ON YELLOW PAPER ONLY
GW-59 Rev. 06-07-2018
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
FACILITY INFORMATION Please Print Clearly or Type PERMIT Number:Expiration Date:
Facility Name:Non-Discharge UIC
Permit Name (if different):NPDES Other
Facility Address:TYPE OF PERMITTED OPERATION BEING MONITORED
County Lagoon
(City) (State) (Zip)Spray Field
Contact Person:Telephone#:Rotary Distributor
Well Location/Site Name:No. of wells to be sampled:Water Source Heat Pump
Remediation: Infiltration Gallery
Remediation:
Land Application of Sludge
Other:
(from Permit)
SAMPLING INFORMATION
WELL ID NUMBER (from Permit):Date sample collected:FIELD ANALYSES:
Well Depth:ft.Well Diameter:in.pH 00400: units Temp. 00010: oC
Depth to Water Level 82546: ft. below measuring point Screened Interval:ft.to ft.Spec. Cond. 00094:µMhos
Measuring Point is ft. above land surface Relative M.P. Elevation:ft.Odor 00085:
Volume of water pumped/bailed before sampling:gallons Appearance
Samples for metals were collected unfiltered:YES NO and field acidified:YES NO
LABORATORY INFORMATION
Laboratory Name:Certification No.
PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L Nitrite (NO2) as N 00615 mg/L Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 /100mL Nitrate (NO3) as N 00620 mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665 mg/L
(Note: Use MPN method for highly turbid samples)Orthophosphate 70507 mg/L Other (Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300 mg/L Al - Aluminum 01105 mg/L
pH (Lab) 00403 units Ba - Barium 01007 ug/L
TOC 00680 mg/L Ca - Calcium 00916 mg/L
Chloride 00940 mg/L Cd - Cadmium 01027 ug/L
Arsenic 01002 ug/L Chromium: Total 01034 ug/L
Grease and Oils 00552 mg/L Cu - Copper 01042 mg/L ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730 ug/L Fe - Iron 01045 ug/L (Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945 mg/L Hg - Mercury 71900 ug/L Lab Report Attached?Yes (1)No (0)
Specific Conductance 00095 µMhos K - Potassium 00937 mg/L VOC 7873 , method #
Total Ammonia 00610 mg/L Mg - Magnesium 00927 mg/L , method #
(Ammonia Nitrogen; NH3 as N; Ammonia Nitrogen, Total)Mn - Manganese 01055 ug/L , method #
TKN as N 00625 mg/L Ni - Nickel 01067 ug/L , method #
For Remediation Systems Only (Attach Lab Reports):Influent Total VOCs:mg/L Effluent Total VOCs:mg/L VOC Removal%
I certify that, to the best of my knowledge and belief, the information submitted in this report is true, accurate, and complete, and that the laboratory analytical data was produced using approved methods of analysis by a
DWR-certified laboratory. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.
Permittee (or Authorized Agent) Name and Title - Please print or type Signature of Permittee (or Authorized Agent)(Date)
Date sample analyzed:
If WELL
WAS
DRY at
time of
sampling,
check
here:
Mail original
and 1 copy to:
(Street)
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
INFORMATION PROCESSING UNIT
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617