WQ0035049_Monitoring - 11-2021_20211221 (4)

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DWR - NonDischarge Monitoring Report Submittal
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NORTH CAROLINA
Enrlranmenlel QHaflly
Monitoring Report Submittal
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Permit Number#* WQ0035049
Name of Facility:* Maple Hill WWTP
Month:* November Year:* 2021
Report Information
..................................................................................................................................................................................................................................................................................................
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR November2021 NDMR ND... 9.13MB
PDF Only
GW-59 November2021 Groundwat... 2.25MB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2,NDMLR,GW-59).
Confirmation Email Address:* [e-mail]
Name of Submitter:* Kenny Keel
Signature:
Date of submittal: 12/21/2021
This will be filled in automatically
Initial Review
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Reviewer: Mokashi, Poorva
Is the project number correct?* WQ0035049
Is the monitoring report accepted?* Yes No
Regional Office* Wilmington
Accepted Date: 1/27/2022

SUBMIT FORM ON YELLOW PAPER ONLY
_
mail original ro._PART-RENT IX BIWIROPREENT&NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING: art i copy
to i= OF WATER QUALITY_ _4AtFoRIAA_ molgetcteessoso.worr
COMPLIANCE REPORT FORM 1511 WAIL SERVICE CEP/1ER.RALBOH,PIC MES4617 Poorer(ria)733.3111
FACILITY INFORMATION Reaw Print C*Nly at--Typo PERMIT Number: W00036048 Expiration Date: March 31:2-026
Facility Name: Maple Hdl WWTF-Wastewater ling-an System Non-Discharge W000350-4g UIC
Permit Name(if different): NPDES Other
Facility Address: 306 Maple hill School Rd TYPE OF PERMITTED OPERATION BEING MONITORED
Maple Hill KG 28454-7612 County Ponder ______ U Lagoon 0 Rernedietion: Infiltration Gallery
• Spray Field D Remediation:
-Contact Person Christopher Rickert _ Telephone*: 910k259-1570 Rotary Disirtutor [hand Application of Sludge
ell Lor,:ationiSite Name mW-1 No,of welts to be sampled: 4 0 Water Source Heat Pump D au ler
Sr--FLING I I: OMATION —
If WELL
-LL 10 NUMBER(from Permit): MW-1 Date sample collected: t 114,2021 FIELD ANALYsEs; WAS
r all Depth: 20 it Well Diameter 2 in, pH 004C-0: 5•6 units Temp.Dem: 19.4 °C DRY at
_
time of
Depth to Water Level azs4s: 13.3 ft.below measuring point Screened Interval 3 ft. to 20 ft Spec.Gond,°crow: gMhos
sampling,
Measuring Point is 3 ft above land surface Relative M.P. Elevation: 33 ft: 010f M-395: None ambit
Volume of water pumpecitailed before sampling: 1CJ gallons Appearance Teaclear here.11
Samples for metals were collected unfiltered: E YES 0 NO and field acidffied 0 YES :D NO
LABORATORY INFORMATION
Date sample analyzed November 41,Ktvembet 24-2021 Laboratory Name: Environmental Chemists,Inc: Certification No 94
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 60335 r:11, Nitrite(NO2)as N soots .c0:02 molt Pb-Lead mei ugIL
Coliforin: MF Fecal aisle <-1 1100rni. Nitrate(NO3)as N 00520 0:07 mg.M_ Zn-Zinc 01092 rngiL
Cetifomt MF Total 31604 /100mL Phosphorus:Total as P guess rnWL
(04")141, Use MFN.rtVir-rM tcf 1,1-glti WWI&2.,, s`,
Orthophosphate-70507 mglL Other(Specify Compounds and Concentration Units):
tissolved Solids Total 70500 266 mglL Al-Aluminum altos mgiL
pH(Lab)004o3 5.6 units Ba-Barium mgoi uglL
TOC mese 7.1 mglL Ca-Calcium°ogle mg&
Chloride ces4g 81 mgiL Cd=Cadmium 01°27 UgiL
Arsenio 01002 ug/L Chromium:Total 01034 ust
Grease and Oils oos52 mglL Cu-Capper 01042 mg& ORGANICS: (by GC,GC/MS, HPLC)
Phenol 32730 ug/1 Fe-Iron 01045 uoll.. ISPeerfY test and method#.ATTACH LAB REPORT.)
Sulfate 00945 mg/L Hg-Mercury 71900 ug/L Leh Repoli Attached? u Yes(1) 0 No(0)
!---::,*--ale Conductance Pews uMhos K-Potassium 00937 mg/L VOC 7e732: . method#
Total Ammonia ousig <02 mg/L Mg-Magnesium oow regIL , method e
tA,N-AwPa 1.-; 0er.:Nhios N;Arrreue 4trziaer Theab
Mr.=Manganese 01055 uglL method#
TKN as N 00025 olg/L Ni-Nickel 010e7 141_ method#
For Remediabon Systems Only(Attach Lab Reports): Influent Total VOCs trial Effluent Total VOCs: mg& VOC Removal%
I ttrtfy tw h)lb.test,,_-,4 aly irv,,s*A3*AfTtl E:4-4i,,,f:the mf.-mk,-,T11:-.,r,-‘,....Drnatel ill V-,,2,--3-rees-e ts Ifi,t,am-q-20-z-ArTi C--4011,Citie :44-P-11 ahv irre-M-Lviwary--11,247ritc-51,71:ro wz4 mairti3 u-sifrg norci,,Enz:-rfltions-1 z.-si•Aysi,-,3 by A
C hri510Pher Pie*:etlj SuperinterKion1
Permiriee c ..Atelwtzed Ager1)Name en4 Tit*.Rease atilt 0(113 &gee-lure d6 P ittee{Or AI 01102.0 Ages11) (034e)
Gw--59 Rev.212010

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Mail original i I'a'ARTM ENT Of ENVIRONWO4T&NATURAL RESOURCES_
1GROUNDWATER QUALITY MONITORING: ond I coin to: 4. OF WATER CktALITV4IW-04NdATkOA.. L-PRoCESOINO upoT
COMPLIANCE REPORT FORM 1417 MAR SERVICE CENTER RALIEJOK NC 27692-1611 Ph one:pip T13-322,1
FA_ _91_.LITY INFORMATION rleaoe Print Deady or Type PERMIT Number: WQ003-5049 bOration Date Marth 31.2026
Facdity Name_ Maple Hill vitvrrF-Wastewaterinigation Smarr) Non-Discharge IIV09035049 U IC
Permit Name(if different): NPDES Other_
Facility Address: 306 Maple Hill School Rd TYPE OF PERMITTED OPERATION BEING MONITORED
Maple HA NC 28454-7612 County Pander Li Lagoon 0 Remediation: infiltration Gallery
- -
M Spray Field 0 Rernsiiii8tICIn
Contact Person: Christopher Pickett Telephenee; 910-259-1570 : 0 Rotary Distributor D Land Application of Sludge
Well Locate-N.8de Name;MW2 No.of wells to be sampled: 4 ID Water Source Heat Pump Li Other,
SAMPLING INFORM Tai,J___ON If WELL
WELL ID NUMBER(from Permit): MYV-2 Date same coliecte4 1114/2021 FIELD ANALYSES! WAS
Well Depth: 12 t Well Diameter.2 in. pH 03400:5-3 units Temp.(10310; 171 C DRY at
-
Depth to Water Level e25.46:10.E ft below measuring point Screened Interval: 3 ft. 10 12 ft. Spec,Cond.ems uMnos time of
sampling,
Measuring Point is 3 ft,above land surface Relative M.P.Elevation: 31 i5 ft_ Odor CitiOsa5 None check
Volume of water pumped/hailed before sampling: IC gallons Appearance White iTumib here:La
Samples for metals were collected unfiltered; 0 YES 0 NO and field acidified: Li YES 0 NO
LABORATORY INFORMATION
Date sample analyzed;Noverrkbef.4,4tmbH 24/2021 Laboratory Name! Environmental Chemists,INC, CertitCatiOn Ne, 94
PARAMETERS NOTE:Values shook'reflect dissolved and colloidal concentiations.
COD Eo3,35 mg/L Nitrite(NO2)as N S0615 ‹0.02 mgit. Pb-Lead 01051 ugh.
Celifenn-MF Fecal:ow <1 /10OrnL Nitrate(NO3)as N 004320 1 02 nag& Zn-Zinc 111092 mgil
Coliform MF Total 31504 il0CmL Fhosp..horus:Total as P ooasS mg/L
iii,,-, 1.1-.%A.WN rrefircA for h,gr!tv mUd EaTipits) Orthophosphate 70507 rribiL Other(Specify Compounds and Concentration Units):
)issolved Solds:Total 7.03M 398 mg/L A-Aluminum et 105 mg/L
pH(Lab)noioa 5.3 units Be-Barium 01007 liS/1.
TOC mew 44.0 mg/L Ca-Calcium trots eigit
Chloride oos4o 40 mg/L C-d-Cadmium 01027 ugit
Arsenic 01002 ug/L Chromium:Total otea4 ugil.
Grease and Oils oo552 Mgil Cu-Copper 01042 nrigit ORGANICS:(by GC,GC/MS, I-IPLC)
=Phenol avno ug.IL Fe-Iron C*045 ugit (SPeolly teat and method N.ATTACH LAB REPORT.)
Sulfate ov45 mg/L. Hg-Mercury 7 1 giCsj ugil Lab Report Attached? CI Yes(1) 0 No(0)
Specific Conductance cocas. uhihos K-Potassium[ass? mg/L VOC 79732: Method#
Total ArhrnohiS ON 10 0.2 mg/L Mg-Magnesium C092? mg/L ,method#
(kritnr4ii.Nittwa;YiH,,es N,Airmtet$I.4:riii-sesi TOM
Mn-Manganese 01-055 ugiL ,method#
TKN as N 00625 ingtiL NI-Nickel o teat _____ugh. .method#
For Remediation Systems Only(Attach Lab Reports): Influent Total VOCs mg1L Effluent Total VOCs: mg/L VOC Removal%
I c'ewlsii mei' Ic'Itii-"l'"iiit ri'''ma'''''''avi,--'aga a"',;M-all ta,e'n-WfM7-C-Tan 51,,trn!iliKi in ewi reissial is!nod:;adz-di-we_and ostriOssises_and itidaa Ss,jet otaisey ariivikii-A date,i,_eiii i-,,,i,fii,ii,,,,,..al ilvicisTrd.,,,,-,ii„„j„,td-.ii„... ..iii,
Clinstophier Pidett IS uparinteedBnt /2
P5fillittee Of AU-11101111,Z Agent) are and Tieo-Please pint Of typo Sl_grature o Perm -lor Authofizeo Pert) l'Abo)
GW-59 Rev,212310

SUBMIT FORM ON YELLOt' PAPER ONLY
mail original is, - :- -
GROUNDWATER QUALITY MONITORING; ,.s.,4'_ ,i PROCESSING
OMPLIANCE REPORT FORM aid 1 copy to,
Phenol
FACILITYINFORMATION ,qe Print'roar•o Type PERMIT Number WQ403 9 Expiration Date: March 31,2026
Facility'Name: Maple Hal WW1F-Wastewater Irrigation Sy5t m Nor-Discharge Wa0038049 UI — -
Permit Name of different): NPDES Other —
-Facility`Address: 303 MaNe loll School Rd TYPE Of P RMTI tED OPERATION BEING MONITORED
Maple Hill NC 28154-7612 County Pender 0 Lagoon 0 Rerrediation Infiltration Gallery
— M Spray Field El Remediation:
Contact Person_ Chnstophsr Pic-keel Telephone#i nl1 0 Rotary Distributor 0 Land App liosdon of Sludge
'Nell LocatioruSite Name:M—3 No of wells to be sampled: 4 0 Water Source Heal Pump D Other_
-- — -'=ram P x --
SAMPLING INFORMATION If WELL
WELL ID NUMBER(from Permit): Mutt-3 Date same poll ed 11 i4i2021 FIELD ANALYSES: WAS
Well Depth fI. Well Diameter. 2 in. pH awed: 6.3 units Temp.ooc-o 19.0 QC DRY at
Depth to Water Level 025.457 4.g ft.Dow measuring point Screened Interval: 3 ft to 20 ft, Spec Cond. coes4. uMhos time of
sampling,
Measuring Point is 3 ft.above land surface Relative M.P,Elevation: 34.5 ft. Odor e5: Nye che€k
• plume of water purrip ailed before sampling 10 gams Appearance Cle r/Tan here
J Sarn.les for metals were collected u nLiltere€t: 0 YES 0 NO and field sodfi : 0 YES 0 NO
LM TORY INFORMATION
Date sample analyze Nov a ber 4 rr r 24 t-_ Laboratory Name: Environmental Chemists, Inc, Certification No. 94
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 00336 mg.& Nitrite(NO7)as N poets <0.02 m/L Pb Lead°iom= ug1L
____
Colrforrn: MF Fooal 3151e <1 1100rmL Nitrate NDs)as N of 20 °At ma1L Zn-Zinc ai392 mg/L
Colifarm: MF Total ai 504 11oOmt. Ptiospliorus_Total as P asses rigit
-i ua�dam;r+-Su? t r ty 11,1t4d sa-oes)
Ortnoptlosphate lase._ -mgILL Other(Specify Compounds end_Concentration Units):
1 solved Solids:Total 7oado 41g mglL Al-Aluminum 01105 mg
pH(Lab)00403 53 units Ea-Barium 01007 ug/L — —TOC Oesee, 9.3 rng L Ca-Calcium ie rrigIL
Chloride 17,0940 78 mgit< Cd=Cadmium ain27 ugfL
Arsenic 01 72 ugft. Chromium:Total 01034 Ka
Grease and Oils 00552 mgiL Cu-Copper 01042 rngiL ORGANICS: (by GC,GCiMS. l-IPLC)
Phenol 3273t ug1L Fe-Iron piO4s owl. (Specify test and method O.ATTACH LAB REPORT.)
Sulfate X40 molt_ leg-Mei cury 71 aco ug/L Lab Retort Attached? [I Yes(1) C No(p)
-.,peolfc Coridu nce ptvlhos K-Potassium r 7 mak VOC7a?s2: method##
Total Ammonia maw <0-2 mg/L Mg-Magnesium ooa mgL method IV
'c_ Mn-Manganese moss ug1L .method
TKN as N 00626 rngiL Ni-Nickel41057 ug/L method#
For Remediation Systems Only(Attach Lab Reports): Influent Total VOCs. rng/L Effluent Total VOCs: mgft VOC Removal%
1 yi- ±.I-TNT-tes!nI MI aisawitticasa ha palcaasta Sutarattel _
W-L :.;r.> try r -^. e ball f r ;WEE,-sue i`-pint n a.-e-s-t-4 1 : -- - _n a .,_.:,--,.ntii11.147-a meosslatalds of Y- -asj L.
-- .a_a LLF rid,,,,,tali,--,_,,-.._
Chn5t€pher Pi sett i Superintendent
Perrn=tt (or AuthontAgent)Nam*and Tide=Plea pint or type Stenatwe or Panrotea A rror�z€d A, Vie:
G4r=59 Rev..2/2010

SLIUMIT FORM ON YELLOW PAPER ONLY
Mail original Iii:114-ARTMENT Of EKVIROIMMIrr i.ktATUAAI.RESOURCEt i
GROUNDWATER QUALITY MONITORING: and i cOpy to: i,-OF WATER QuAuTY4NFcRatknott PROCM w u
COMPLIANCE REPORT FORM 417 MAL.BERME CENnFti ULM-It NC 2ThaVIII17 Mom:[phone]
FACILITY INFORMATION Pleas°Prim Greatly or Type PERMIT Number WQ0035049 Expiration Date: March 31,2026
Facility Name: Maple Hill WWTF=Wastewater Irrigation Sysiem Nori-Discharge W03035049 UIC
Perrnit Name(if different): NPDES Other
!Facility Address -316,Mab4e Hili Sc,ne4 Rd TYPE OF PERMITTED OPERATION_BEING MONITORED
—
maple MID NC 284541-7812 County Pander D Lagoon 0 Rernediation: Infiltration Gallery
M Spray Field 0 Re-mediation:
Contact Person. Christopher Pickett Telepnorieg 91G.259-1570 0 Rotary Distributor LI Land Application of Sludge
Well L -ationtSite Name:MW-4 No, of wells lobe s.arinpied: 4 El Water Source Heat Pump 0 Other
fk-xn Pemtt-
SAMPLING INFORMATION If WELL
WELL la NUMBER(from Perndt): MW4 Date sample collected: 111412021 FIELD ANALYSES: WAS
Well Depth: 20 ft% Well Diameter 2 in. pH i)o4oc: 63 unas Temp XO-10: 18.2 aC DRY at
Depth to Water Level e25-4e:11-9- ft.below measuring point Screened Interval: 3 ft, to 20 ft. Spec.Cond. mask uMhos
, time of
sampling,
Measuring Point is 3 ft. above land surface Relative M.P. Elevation; 35-5 ft, Odor MI5: None 'check
— -_
Volt me of water pumped/balled before sampling: 10 gallons Appearance Clem/leo 'hereu
Samples for metals were collected unfiltered DYES 0 NO and field acidified: L YES 0 NO
!LABORATORY INFORMATION
Date sample analyzed!Novac-Oet 4-4vilarn5e1,247202:1 fia Laboratory Name, Environmental Chemists:Int, Certction No, 94
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 00335.- mg/L Nitrite N-02.i as N coels •t0.02 mg/L Pb-Lead etiost ughi
COlitorm MF Fecal 3 isia <1 1100tra Nitrale(NO3)as lir 006- 20 0.28 mg/L Zn-Zinc ei 09Z mg/L
Ccliform: MF Total 315-14 /100rnt Phosphorus:Total as P atees mg/L
.N:ite: Use VP.N de0-,dd fff NV4y-1-. swrTdes)
Orthophdspbate 70507 M91- Other(Spedfy Compounds and Concentration Units):
Dissolved Solids Total lolos 374 mg/L Al-Aluminum sites mg:IL
pH(Lab)c0403 6.3 units Ba-Barium et 007 ugfL
TOC car 36..7 rng/L Ca-Calcium 03010 mg/I
Chloride 00434c 24 _ _ mg/L Cd-Cadmium mon ug.fl.
-—
Arsenic at N2 titalt Chromium,:Total 01334 ught
Grease and Oils 00852 mg/L Cu-Copper t1042 mg/L ORGANICS. (by GC,GC/MS.HPLC::
Phenol 3273o ug7L, Fe-Iron 01045 ugit. (Specify teat and method#.ATTACH LAB REPORT.)
Sulfate ceso rngiL Ho-Mercury nsoc ug/L Lab Report Attached? LI Yes(I) E No(DI
-
-;4ecific Conductance mass pMhos K-Potassium bow rrigit VOC 78732: method# _
Total Ammonia reesiti 0.4 mg/L Mg-Magnesium 0e427 incit .method#
4.P. pap letp.-: :reiimi.N:ov, a hvt-,Legen,TO4) Mr-Manganese 0055 t1411- , method#
— —
TKN as N a2s... mg/L Ni-Nickel 01(1137 119h method itt
— —' ---
POT Rernediation Systems Only(Attach Lab Reports): Influent Total VOCs_ mgli_ Effluent Total VOCs: mg/L VOC Removal%
I veretv that IP MO Opat pa rpe kneWpdpee am Dew,in4 Int.fmaoon cesblealeepc te rap vervaP Ts me,ort..oviiied,arid crvitgete.,„:8riti[kat pea keiparataly aeatiyariaj aWa,eve$OPPLIMagt Pain approved reetwals:pF prelims by a- :
JOY:bnerb teeteaeatPep i Pre a:ewe tra 1:70M Ara 51-1774kCall Mr0.1tieft!rat-lar-nprto false,...nrcyrillat,"1 eiduttinz rke;bombyley•cb ttbes art4 rifM17.5,701 MS:T-4 MAI'
Christopher Pickett iSurinteneent --if—cZ,-z.it---Y-'2-041/4r,-d,42-'2(- .",,,_;•, ?:: /Z--_ZeT)'.__ .,---- - _
reri iiddeo ICI Autr .Awrt)Name and Tdie-Reade print C4 type &W.-11,0e dr F'ednidve(w Aulhorized Agent) tome)
GW-59 Rev,272010

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ANALYTICAL&C 0 NS ULTING CHFM'I T I a,,,INMIensay o13 men a Saha:r i I), ,Ms 0RD1
P° der County Utility OperationsDate of Report. Nov 30, 1
Post Office Box 995Customer
Burg Burgaw NC 28425 Cu tom r ID: 08100095
: ntlors Chris Rickert Reit 0. 1-2071'
Project ID: Maple Hill WT (Monitoring Wells'
riab l l Sample ID: Collect ulr t /T m atria Sampled 101
1-51 07 Site: -2 1'1/22./2021 10 01.5 AM Vilater JC / nv roc m
Test Method Results Date Analyzed
Total Dissolved Solids (TDB) 5M 25,0 62015 798,mdit, 1 11 d20 1
Chlorid txx,oar ii.I r serer 175 P'ng/L 11 / 0 ;1
6
l �N� �, �1� t�� .� m.���-„�.m����., _Lab lllt Date/Tirol
Matrix
il
Sa
Co
.Sam
1- 1 11Site: Mini-Mini-2 ip,urg g ill'/ / 0 1 10:15 AM Water JC P/Ern riro h rn
TEst Method Results aItAnalyzed
Total Dis,solved Solids (T S') s 52112C;20 398 mg/L. 11/23/20 1
Chloride NIKI C i E42ON 40 g/L 11,124/20/21
La lls Sample ID: Collect e„Ito/Time„Ito/Time Matrix Sampled
21-51912 Site: Milliii3 11 2 // 0 1 10:2.5 AM Water JCt1',/I n lr ch4m
test th d Resultt Analyzed
Total Dissolved Solids (IDS) SM 2540 -2: P5 418 mg/L 111/2 3a/'20 1
Ohlorlde SWUM CI Easo f 150 r g/L 11/2420 1
Lab 1D Semple ID: Collect Date/Time Matti* Sampled by
1- 1 1 Sits; •3 (purg ) 11/ /20 1 '10:35 AM Water J B,/Frnviror°h m
Test Method Results Date Analyzed
-3ot l Dlssolverl Selins (TDB) SM 25,142 6201'5 419 mg/I... 11/ / 021
hlP° s stern r d ,- 1°R err"g/t
fiCrud ' 11/ � �"1?;��tl' 1
Lab ID ample l Collect Date/Time Mat Sal pled by
21-5.1914 Site: m, 111/ / 0 1 10:,45 AM Water JCBIEnviroc,hern
Test Method Results Date n l°, d
Total Dissolved olv Solids (-MS) SIM 2S40 6,2015 363 molt, 11/ "; /2 1
Chloride 5M,4500 CP E.,2011 21 molt, 11,1 4/2 11
2U:6,2071e

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151 71(1 11w9,45,5,,"' Irnow551 Ni)ml[no, 115J1, 2/951 5 2512-1/"' 'ft202 lb,•)'5,/I a»,
11111111111111:111111111111111„'.„::,115,11,11,1111,811s1,11111111111IIIIIIIIIIIIII11111111111111»idol,11,1111111111151,1111111111,111,
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AN ALYTICA A ('ONSIA riNei CNC rs Hoti,'564,Nrof k flUM; 4111'
nder County Utility Operations Date of Report: Nov 30, 2021
Post Office Box 9B5 Chi tom It PO#:
Burgaw NC 28425 Cu 4 torner ID: 0810005
Attention Chris Pickett R poet 2021-20710
Prol,ici.ID: Maple Hill wwr (Monfl,ornn Wels)
Lab ID Sample ID: Collect Datinliitle Matrix Sampled by
2 1-51915 Site: Mill/-4 (purge) 1112212021 10.50 AM Water eiEnverochem
Test Math d Results Deli Analyzed
Total Dssolvecil Sciida (-1EiS) Siot#°#4 dUl 374 mo/L 11/23/2021
Chloride SMdttrttt) t,-X111 4 rogii 11/24/2021
, 9.(mmrermrarrerrrerrernmainnwmal
CommentReviewed by
1000nr00,10,0 0,00lii. 00400,0m0t
Report# 20214,071C+
rJan#

Environmental C:he"na"st,"Inc,, WUrnfington, NC Lab#94
VViltrington, NC 28405
,m.C:).3 92.0223
Sample Receipt Checklist
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�lJmbrrl�" ���� ��� `m. .m�. � ..._�.. � r Number: l � � _ �,a �' ��'
r
mrl �t� nrt leytfi gaAroup f� CJl � FemdFtt C aMf I��N. � r aitveu," RIa�Vals present on the•cooier?
w aC M �r� e m„ C he mrt l0
I
mV s�nads were pre
,sent,
4
iu,,,.J YES t� NO "mil 6� IAM custody - ��' Sr mM err �._
theyIrorm C'r�"fit *rr?
� a t,�r�rl q�1
M Pairs temperature upon 4 d k'G,{i�`I �C 1
[Ori inal 'temperature ar ratur upon re�rr p'r c ed tr:m¢R
Tern :ar r rtarre Blank�qi�, Gan q�). Thomas
0 q M Betties
WW1 temperature rm r��tu�rw= { � 6�7 EMS �1�r Against
�a]�:
, Trace ti �3 r Correa:io� Fa
6YES �_
1.
G ter f Tp.gJ
gr,/QA notified?
YE 0 ,n.NC) m re p proper custody pro
atliru cif cooler e ra e
NO M6rurrror'r
d ��
w r aM e re ling r , _
�r Ira ImcrM-r . .� .) followed?
Were sample ale tl
a � � Miatrw on the L l�r?
samples k�" M� 4" ma"mam —
GC➢ listed
usrm l r t sample
ar Vr containers?
1,1
—Ai M 0 NO, ; re collection r date time listed on the COO"?' .._
Were tests to he performed fisted on the'CDC?
"
YES )dc samples um rr
containers for each test?
...... _.
YES 0 NO'
��._. m.,....10 Did samples,arrive in condition far W � test? _m
ov1.:r
J.il Vid 3: arll a 6rr ,a fr. M dfl vJIIImbM lJrd �)�l ,'YES C tJ 12„ Wera samples sexerri within pro rr hol
ding,tmr Y rr requested tests?
ts?p
) ES 0 NO I.3, Were acid preserved samplecr received at pH of r2?
.. .._,_.
p.ES OI NO' 14 Were r an do Sargipies received at a pH t
��.
� �. .�.� samples rr�eIrrie�V a���a pH �
m.� .1.9. Were NE11.it Yrfeinot rm m eiwr..lilrlC a chlorins rt mr�r a:�..
s LA a M cr~
YES � r,Mr�
�� 1.° lX Were Sulfide/Cyanide received r:::M°loruuti �.., l r G) S� spy �, ..,,. .�
ra
a �
residual of ( ,5 0 YES r /q
O N7 Were �rtM � Mr � afa filtered in rti, field wlt6lr1r rrrr tes?
*" rC of 4`r;'xG,T4tiYr �I i rrtr ¢�"Nla � rrm`d f,m6 hm�tr'� of ao w �O� Cru and r�r o dr�u sq'r:�d u�a Phfir?�vt�a rI,;U.IIrn,)lr Irk.
sb r
!'�" ��u�r�rr`R a "",�urot"@r m iIDrr.Y r�ue�,kr,."wq for^"�V�rr,mrnr �, o ,,.,�� "� r � � . „
1 �^ rr, �wru �Br �I:� ,�r+r,9 rp'�.m ar�r��art rq�a��r irNr�:;" r"dr;"
mole Preservation:
Sara M� �Va1mu`Yll late
any
mara6 for
5 incorrectly
b preserved or with r<atsMra rn" It sM were received hmmreclypreserved and were adjusted accord
ngN
'bA adding (circle oriel' mi,5f1 HNCa tI4Y' Na �N
Time of prem°wtirrr If more
e than one prerervrc01"UIye is 1 e'ded n� coruCnts
..m _ below
Note.I pt;i'y f l�!'.(:!!met io?tl°Jo":e lnarna3,ASf''y m')r)rlcOfrm:cOy, re5,,orw'ea sample 7 m..Li,ialQ a now 111art Lieu11
�,a�:�u.�Qr, in ram.-. .,,,,.w�,.,... ... ...,..w,,,,... ,.,w:.,...��..,,..,..,i.
W
In07,i M a silo r red a"I al riaa)y.HJ, by m. un V,.tutotne "01 hC W25 1ICAVrled,sure aalno:�'r rrrwx
d two Sytia�fi�}Al)if � y the
eat, a �,,,, ....: ,,...,
,Vrrlamiqe �K�nryMrq+�( ). were received with M�1 ��, °��
COMMENTS: a���.m.a.,,,w,w .a.... o.. ,..., _ .r. ::: ,,, _��� _ _ ,,�e . ... . ._ _ �::: ._..� �,...�
— DO C �' Re,v

-99*-719 -------iii 9E92 Windmill Way Wtirnington,NC 2E405
kik-t=riii ENVIRONMENTAL CHEMISTS, INC OFFICE:910-392-0223 FAX [phone]
NCDENR:DWG CERTIFICATION ti-94 NODHES: DLS CERTIFICATION 9 37729 i nfct4nvirurimerdaicherrtistsicorn
Analytical&Comultir-9 CIierntsts
COLLECTION AND CHAIN OF CUSTODY
,
[IClierkt: - C - !PROJECT NAME: kit, - - gli - ik..1i /1 ;REPORT NO: - 1., 1 - -o,
.- -- i --------
- --- . _
1 ADDRESS, -CONTACT NAME: i Li f es:. /
PO NO:
assimmimms-.,_
;,-
'REPORT TO: - PHONE/FAX i
COPY TO:
Ismal:
Eartykled B.: SAMPLE TYPE:I influent,E =Effluent,W=Weil,ST=Stream, SO.---Sod,SL=Sludge,Other:
I --
1 a a CollectionPRESERVATION 1 I
1 ,_ 1-
Sample Identification I 1
i
1 . I ra- i-S = . e I itt- e 1 4 1 ml wl _iii317--; Aid L'-' -'4 w 3 W ANALYSIS REQUESTED
i 1 a 1 -7T„ Z .,_ 1 z-. Ea I -a- 1 Eidlo, 1 :- zilY Lotm
1 m E eTem fi 10 ---- , '--- i 6_, - Z 2. 1X - z . .-- :1161 i
Tim 1 1 tik ' 1 LL4 = 1
iff" le I tr.42 GIP ! I i
i ic ' pl 1 4 1 I 1
I .eifi it Vi i i ' 1 i
I f4u7i tifi-V. I . I te. - ,
r ; -
1 1
G _ ;
it I
i 44 Q q
1 1
cto,m 0 ,t1 1 ; i 1 1
! i t
Y? I
( r G 1 c.,
. 111111111111 i ___:
P -1 1
I 1 1 1
i - a i 1
a -1
1 1
"ridncE-DEcHLORINATIONi Sams for Ammonia,TiKtai c eatilitm Pfilai and Becier41 rnult be dec.ltiorinated Nis ppm Er Ii5)in the itegd at the thhe of chhection, She Tvee-A-6-e ler in StrucbwIS i
--4---.- 4
% 4
1 Trarisfe r Relinquished By: i Oaten-Wee Received By: DateiTime 1
i 1 i
12.. [
i ,I2
a
Temperature when Received'Ci - Acceptd:
ite----- -
-- 4 Rjected: Resample e attestd:
Delivered By= Received ay: s - Date: 4-. ie
—7- _ -- — Time: fj. f
Comments: ' TURN OUND: