8602_Surry_MtAiry_MSWLF_CDLF_WQMP_FID1320110_20190430

Water Quality Sampling and Analysis Plan
Prepared for
Surry County Closed C&D and Unlined Landfills
Permit Number: 86-02
237 Landfill Road
Mt. Airy, North Carolina
Prepared by:
Municipal Engineering Services Company
PO BOX 97
Garner, NC 27529
Corporate License Number: C-0281
MESCO Project Number: G19022
This report was developed in conjunction with the Corrective Action Evaluation Report (2019)
for the Surry County Closed C&D over Unlined MSW Landfill.
hltal Jon nvo me Specialist
April 2019
MUNICIPAL ENGiNEE:RINCa
' siE:RVICE:B COMPANY9 P.A.
-
6B BHIPWA5H bRIVEy GARNER, N6 27529 -PHONE: [phone]
_ P.C. BOX 349, BOONEI NO 28607 - PHONE: [phone]
LICENSE NUMBER: C-0281

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TABLE OF CONTENTS
1 INTRODUCTION AND OBJECTIVE 1
1.1 Site Information.....................................................................................................................................1
2 MONITORING NETWORK 3
2.1
Existing Monitoring Network............................................................................................................... 3
2.2
Modifications to the Monitoring Network............................................................................................4
2.2.1 Water Quality Analysis...............................................................................................................5
2.3
Well Maintenance.................................................................................................................................6
2.4
Monitoring Schedule.............................................................................................................................
6
2.5
Sample Collection.................................................................................................................................
6
2.5.1 Set-Up.........................................................................................................................................
6
2.5.2 Field Parameters.........................................................................................................................
6
2.5.3 Field Meters................................................................................................................................
7
2.5.4 Sampling Equipment...................................................................................................................
7
2.5.5 Sampling Containers...................................................................................................................8
2.5.6 Purging........................................................................................................................................8
2.5.6.1 Via Bailer..........................................................................................................................
9
2.5.6.2 Via Pump..........................................................................................................................
9
2.5.7 Sample Collection.......................................................................................................................9
2.5.8 Collection Order.......................................................................................................................10
2.5.9 Groundwater Sample from a Bailer..........................................................................................10
2.5.10 Groundwater Sample from a Pump...........................................................................................10
2.5.11 Surface Water...........................................................................................................................10
2.5.12 Blank Samples..........................................................................................................................11
2.5.13 Chain of Custody......................................................................................................................11
2.6
Analysis...............................................................................................................................................12
2.6.1 Analytical Laboratory and Methods.........................................................................................12
3 REPORTING
13
4 CONCLUSION
14
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TABLE OF CONTENTS CONTINUED
TABLES
Table 1 (in text)_________________________________________________________________ Ground and Surface Water Monitoring Locations
Table 2 Monitoring Well Construction Details
Table 3 Water Quality Sampling Parameters
Table 4 Sampling Schedule
FIGURES
Figure1----------------------------------------------------------------------------------------------------------------------------------- Facility Map
Figure 2--------------------------------------------------------------------------------------------------------- Proposed Monitoring Network
Figure3----------------------------------------------------------------------------------------------------------------- Typical Monitoring Well
Figure 4 --------------------------------------------------------------------------------------- Graphical Plot of Standing Water Volumes
APPENDICES
Appendix A
Appendix B
Water Quality Sampling and Analysis Plan
Surry County Closed C&D over Unlined MSW Landfill
Available Well Records
Environmental Monitoring Report Form
April 2019
Page ii

I INTRODUCTION AND OBJECTIVE
This Water Quality Sampling and Analysis Plan provides clear guidelines and procedures for collecting
ground and surface water samples in accordance with North Carolina Solid Waste Management Rule 15A
NCAC 13B.1632. The sampling procedures outlined in this plan are guidelines by which sampling should be
performed. Deviation from these procedures may be warranted depending on facility conditions or unforeseen
sampling variables. Any variation in sampling procedure should be documented in the event record.
Alternative sampling procedures must conform to the Solid Waste Section Guidelines for Groundwater, Soil
and Surface Water Sampling (Guidance Document).
1.1 Site Information
The Surry County Closed C&D over Closed Unlined Landfill (Permit 86-02) is located about five miles south
of downtown Mt Airy at 237 Landfill Road. The landfill consists of two unlined sanitary units and two closed
unlined construction and demolition (C&D) waste units. The closed unlined landfill footprints total
approximately 31 acres. The northern sanitary unit is approximately 12 acres and was closed with a 24-inch
soil cap prior to 1991. The southern sanitary unit encompasses aproximately19 acres; the outermost slopes
(about 5 acres) were closed with a 24-inch soil cover and the central portion (about 14 acres) was closed in
1999 with a 24-inch cohesive clay cap. A 3.4 acre closed C&D unit is located between the sanitary units and
was closed in 1991 with a 24-inch soil cap. From 1998 until 2008, C&D waste was vertically expanded on the
top central 14 acre portion of the southern unit before being closed with a 24-inch cohesive clay cap. A
facility map is presented as Figure 1.
The landfill is located in the western piedmont. On -site elevations ranges from about 1165 ft above mean sea
level (amsl) at the peak of the southernmost C&D landfill to about 935 ft amsl along Stoney Creek to the
south. Unnamed creeks bound the landfill to the east and west, flowing generally south towards Stoney Creek.
Stoney Creek flows southeasterly between the County's closed unlined landfill and the County's active lined
MSWLF before discharging into the Ararat River.
A receptor survey was performed in June 2018 in support of the Design Hydrogeologic Study for the lined
MSW Phase 4. Based on survey results 1,115 parcels that use well water and 209 parcels that use water from
a distribution system were identified within a 2-mile radius of the landfill. The previous receptor survey,
performed in October 2012, indicated approximately 20 homes located within a 1500 foot radius of the
landfill; likely served by domestic wells as municipal water lines are not currently installed in the area.
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A water supply well located at the scalehouse, on the northern end of the facility, near the entrance. This well
is 222 feet deep and is used for non -potable purposes, such as washing trucks. Site groundwater flow and
runoff is generally to the south or southeast toward Stoney Creek, which discharges to the Ararat River.
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2 MONITORING NETWORK
2.1 Existing Monitoring Network
The current' Surry County closed landfill monitoring network includes eighteen groundwater monitoring wells
(MW-3R, MW-6, MW-7, MW-9, MW-11, MW-125, MW-121), MW-13, MW-14, MW-15, MW-16, MW-17,
MW-18, MW-19, MW-20, MW-21, MW-22, MW-23), six remediation injection wells (IW-1 through IW-6),
one background monitoring wells (MW-1), the on -site water supply well (scalehouse), and four surface water
monitoring locations (SW-1 through SW-4). Monitoring locations are listed in Table 1(within this text) and
shown on Figure 2.
The background sampling location for the landfill is upgradient monitoring well MW-1; which is located east
of the road that runs between the northern and southern closed landfill units.
Groundwater quality at the northern landfill unit is monitored on the northern, upgradient side by the on -site
water supply well (scalehouse) and MW-11; and on the southern, downgradient side by MW-7, MW-9, and
MW-20. The surface water, SW-2, is located at the southwestern corner of the northern unit.
Groundwater quality at the southern landfill unit is monitored on the eastern side by MW-12S, MW-12D,
MW-13, MW-14, MW-18, and MW-21; on the western side by MW-3R, MW-6, and MW-16; and on the
southern side by MW-15, MW-17, MW-19, MW-22, and MW-23. These wells also serve as performance
wells for nearby injection wells IW-1 through IW-5. The unnamed creeks that flow along the southeastern and
southwestern border to southern unit are monitored at locations SW-1 and SW-3, respectively, and along
Stoney Creek, to the south, at location SW-4.
Injection wells are not viable sampling locations; therefore, they are not included in the monitoring network.
They may be used for depth to groundwater measurements, on an as needed basis; however, they are provided
in this report for reference purposes only.
Well locations were selected for groundwater quality characterization and to provide for detection of changes
in groundwater quality downgradient to the landfill. As referenced in Rule 15A NCAC 13B .1633 the
horizontal relevant point of compliance for the lined landfill is defined as 250 linear feet from the
downgradient edge of waste which is also at least 50 linear feet inside the facility boundary.
'Water Quality Sampling and Analysis Plan, April 30, 2013 (DIN:18936), SWS approval, May 10, 2013 (DIN: 18938)
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2.2 Modifications to the Monitoring Network
Several modifications to the monitoring network are proposed. MW-3 was incorrectly listed in the 2013
Sampling Plan; however, it should have read MW-3RS, which was converted into IW-3; therefore it is
removed from the plan. MW-12D and MW-18 are proposed for removal from the network. MW-12D has no
reported VOC detections above MDL values in over 9 years and flows artesian; this well will remain in place.
MW-18 has no reported VOC detections above MDL values in over 9 years and is positioned outside the
potential flow pattern to intercept flow from the landfill units; this well will remain in place and continue as a
water level measurement only location.
In conjunction with new cell construction, Surry County will be building a new scalehouse. As part of that
work the scalehouse well is planned to be abandoned; therefore is proposed for removal from the monitoring
network. This well was primarily used to wash vehicles. A replacement supply well (WSW-2) is planned for
near the new scalehouse and will be included in the monitoring network.
Well locations were chosen to monitor the uppermost aquifer. Table 1 (below) lists sampling locations in the
updated monitoring network. Well construction details and other information related to monitoring location
are presented in the attached Table 2. Available well records are provided in Appendix A
Table 1: Ground and Surface Water Monitoring Locations
Sampling Point
Type
Gradient
Total
Depth (ft)
*MW-1
Background Well
Up
40
MW-3R
Monitoring Well
Down
101
MW-6
Monitoring Well
Down
29.7
MW-7
Monitoring Well
Down
23
9MW-9
Monitoring Well
Down
44
*MW-11
Monitoring Well
Up
40
MW-12S
Monitoring Well
Down
51
MW-13
Monitoring Well
Down
36
*MW-14
Monitoring Well
Down
48
*MW-15
Monitoring Well
Down
57
*MW-16
Monitoring Well
Down
36.5
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MW-17
Monitoring Well
Down
15
MW-19
Monitoring Well
Down
17
MW-20
Monitoring Well
Down
25.5
*MW-21
Monitoring Well
Down
15.5
MW-22
Monitoring Well
Down
16
MW-23
Monitoring Well
Down
17
WSW-2
Supply Well
Up
TBD
SW-1
Surface Water
Down Stream
-
SW-2
Surface Water
Down Stream
-
SW-3
Surface Water
Down Stream
-
SW-4
Surface Water
Down Stream
-
*Assessment Monitoring Location
The proposed monitoring network is shown on Figure 2.
2.2.1 Water Quality Analysis
Water quality monitoring parameters are presented in Table 3. A list specifying which sampling locations
receive particular analysis is presented as Table 4.
Detection Monitoring
The monitoring network wells and surface water locations presented in Table 1 are proposed for semi-annual
monitoring for the constituents listed in 40 CFR Part 258 Appendix I. Additional sampling parameters are
determined on a well specific basis in accordance with their detailed assessment plan.
Assessment Monitoring
Monitoring well locations MW-9, MW-11, MW-14, MW-15, MW-16 and MW-21 are proposed for
assessment monitoring including MNA analysis. Background well location MW-1 is proposed to be included
with the assessment monitoring schedule to collect data for comparison and use with statistical analysis.
Based on recent parameter detections and concentrations, assessment monitoring (CFR Part 258 Appendix II)
will be performed next in 2021, and will continue every 3rd year for these locations. The full list will be
sampled in the fall with any detections included in Appendix I sampling performed in the spring.
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Additionally, these locations will be monitored for MNA parameters both events, spring and fall. The next
sample date will be 2021 and will continue every 3rd year. MNA parameters include: alkalinity, sulfate,
sulfide, chloride, total organic carbon (TOC) chemical oxygen demand (COD), iron, biological oxygen
demand (BOD), nitrate, volatile fatty acids (VFA), ethane/ethane, dissolved hydrogen (via bubble strip),
carbon dioxide (CO2) and dissolved methane. This sampling schedule is designed to ensure the most up to
date analysis is available for future CAERs; the proposed schedule is presented as Table 4.
2.3 Well Maintenance
The monitoring locations and surrounding area shall be maintained to ensure well access, by at least a four
wheel drive vehicle, for sampling and to preserve the well integrity. Well cases should remain locked between
monitoring events and locks should be maintained with environmentally safe non -hydrocarbon based
lubricants. Brush and weeds shall be cleared from around the wells as needed without using chemical
defoliants. Surface water run-on controls shall be provided, where necessary, to prohibit erosion or
undermining of the concrete pads. The concrete pads and cases shall be evaluated at least semi-annually for
integrity and repairs performed as needed.
2.4 Monitoring Schedule
Water quality monitoring for the detection monitoring network will be performed on a semi-annual basis in
accordance with the Rule. Assessment and MNA monitoring are performed in accordance with the well
specific schedule. Specific assessment parameters are proposed for analysis every 3rd year; so data will be
available from 2 events for the CAER report, planned for 2025. A Sampling Schedule is provided as Table 4.
2.5 Sample Collection
As possible, monitoring network locations will be sampled from upgradient (background) wells to down
gradient (compliance) wells.
2.5.1 Set -Up
A clean plastic sheet shall be placed around the well to provide a clean surface for sampling equipment. The
measured total well depth and the measured depth to water, determined using a water level indicator, will be
used to compute the well's water column, using the chart included as Figure 3. The measured total well depth
will be compared to the depth indicated on the well tag as a check for siltation or blockage at depth.
2.5.2 Field Parameters
The indicator parameters pH, specific conductance, turbidity and temperature will be measured on monitoring
network locations before collecting samples. When three consecutive measurements are within a 10% range,
temperature and specific conductance are considered stable; pH is considered stable when three consecutive
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measurements are within a 0.2 unit range. Turbidity measurements assess the suspended solids in the well
column and should be recorded for locations with samples analyzed for metals concentrations. These
parameters will be recorded in the field notes for each monitoring location measured. Dissolved oxygen (DO)
and oxygen reduction potential (ORP) will also be measured with field parameters when collecting MNA
samples.
2.5.3 Field Meters
Meters will be calibrated immediately prior to purging and sampling and those readings recorded in the event
field notes. The meters shall be recalibrated at the end of each sampling event and those readings also
recorded in the field notes. Entries will include pre- and post- calibration readings as well as the model and
serial number of the equipment and the date, time, and person performing the calibration(s). Two standards,
which bracket the average or suspected measurements for pH and specific conductance, will be used at the
site.
2.5.4 Sampling Equipment
Groundwater purging and sampling may be performed using disposable polyethylene bailers, low flow pumps,
(either dedicated or non -dedicated) or Submersible Pumps. Alternative sampling equipment may be
warranted, depending on variable field conditions. Alternative equipment and procedures will conform to the
Guidance Document. Each location will be sampled with a new bailer or tubing to prevent cross -
contamination between monitoring locations. Where non -dedicated submersible pumps are used, the
following decontamination procedure will be followed:
1. Phosphate -free detergent & de -ionized or distilled water rinse.
2. De -ionized or distilled water rinse.
3. Isopropyl alcohol (isopropanol) rinse.
4. De -ionized or distilled water rinse.
The standard equipment used to conduct sampling at each well location includes
• sample containers (including blank samples, as needed),
• one wide -mouth container,
• at least two 600-ft spools of 1/4-inch nylon rope,
• at least two boxes of non -powdered, disposable gloves,
• one box of large plastic bags,
• temperature indicator,
• pH indicator,
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• conductivity indicator,
• turbidity meter,
• water level indicator,
• storage coolers and
• ice.
If the combined, total well depth to be sampled in one event exceeds 1,200 feet, additional rope will be
required to complete the sampling. If the well number to be sampled exceeds one third of the glove pairs in
stock, additional gloves will be necessary. Equipment subject to damage and contamination will be
transported in sealed, plastic bags or storage containers, or other manner to prevent damage and cross -
contamination.
2.5.5 Sampling Containers
Sample containers will be obtained from an independent North Carolina certified laboratory in a sterilized
condition. Some containers will contain a pre -measured amount of preservative, as specified in the analytical
method. During sampling, care to not rinse the container or allow the preservative to wash out will be
followed.
Sample containers will be clearly labeled to ensure proper analysis by the analytical laboratory. Samples will
be collected in the containers specified by the laboratory for their specified parameters.
2.5.6 Purging
Purging is performed prior to sampling to remove stagnant water from the well and to introduce fresh
groundwater for sampling. After determining the water amount to be vacated from a well, assemble the
purging equipment necessary (Section 2.5.4). Each well will be purged three to five well volumes (quantity of
water in the well), or until dry. If electing to use a low flow methodology, sampling may commence following
field parameter stabilization (Section 2.5.2). Wells which have low recharge rates will be purged once until
dry. Damaged, dry, low yielding or high turbidity wells may not be sampled and will be documented for
reconsideration before the next sampling event.
Based on the well quantity to be sampled and their proximity to each other, wells may be purged one after
another with sampling to follow. Sampling will occur within 24-hours of purging and as soon after well
recovery as possible. Wells which fail to recharge or produce an adequate sample volume within 24 hours of
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purging will not be sampled. Details will be documented in the field notes and included in the water quality
report.
2.5.6.1 Via Bailer
Pull the top portion of wrapping away exposing the eyelet, keeping the bailer in a stable upright position.
Using gloved hands secure rope to the bailer via the eyelet hole, suspending the bailer to remove the remaining
wrapping. To prevent potential cross -contamination, these gloves should be replaced and cannot touch the
bailer or the rope. Clean, gloved hands will slowly lower the suspended bailer into the well until the bailer
contacts groundwater. Cut the rope to length and secure it, to prevent losing the bailer, again replacing gloves.
During purging, the rope cannot touch the ground or other potentially impacted surfaces including: dirtied
plastics, gloves, boots, etc. Many methods are available and it is to the sampler's discretion which method
they use. The wind -mill method (looping the rope between thumbs), bucket method (where rope is lowered
into a clean plastic bag lining a bucket), or simply placing plastic on the ground, near the well, covering shoes,
are commonly used.
If well purging and sampling are performed at separate times, the bailer will be left suspended within the well,
above the water table, with the rope secured. The excess rope will be removed, to prevent contamination
issues. The rope may be doubled and grasped in a tight loop in one hand then covered by pulling the
corresponding hand's glove on top, inside out. The procedure can be repeated using the other hand if
necessary. The glove -encased rope should be set on top of the well head until sample time. Alternatively, the
rope remaining after securing may be gathered in a tight loop and pushed inside the 2-inch PVC well pipe and
left. Even when sampling immediately follows purging, new gloves are necessary.
2.5.6.2 Via Pump
If using low -flow pumping technology sampling may commence following field parameter stabilization using
dedicated equipment or the fresh tubing designated for the well. Grundfos pumps will require fresh tubing for
each monitoring well location. Tubing will be measured and cut wearing gloves. Fresh gloves will be utilized
for sampling. Sample bottles will be filled in the order specified in Section 2.5.8.
2.5.7 Sample Collection
Following field parameter measurements and purging, samples shall be collected from monitoring wells.
Sampling will be performed within 24 hours of purging. Wells that do not recharge or fail to provide an
adequate sample volume within 24 hours will not be sampled.
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2.5.8 Collection Order
Bottles should be filled in the following order, in accordance with the Guidance Document:
1. Volatile Organics and Volatile Inorganics
2. Extractable Organics, Petroleum Hydrocarbons, Aggregate Organics and Oil and Grease
3. Total Metals
4. Inorganic Nonmetallics, Physical and Aggregate Properties and Biologicals
5. Micobiological
6. Wet Chemistry
2.5.9 Groundwater Sample from a Bailer
To collect a sample from a bailer, lower the bailer into the well slowly, with gloved hands, to avoid releasing
any volatiles from the groundwater; the bailer should not splash or smack the water surface. Once full, the
bailer will be retrieved and containers filled by emptying the water through the hole at the bottom of the bailer.
To top off the VOC sample container, collect some groundwater in the cap and pour it onto the sample's
contents to acquire the needed meniscus to eliminate air bubbles. The polyethylene containers will be filled
and sealed with the cap, leaving about 1/2 inch of airspace at the top. In addition to collecting the samples,
water will be collected in the wide -mouth container for pH, temperature and conductivity measurements.
After sampling, sample containers will be placed in labeled and sealed plastic bags, including equipment and
trip blanks, and stored on ice in coolers. Used gloves and rope will be properly discarded.
2.5.10 Groundwater Sample from a Pump
To sample with a pump, use the same flow rate as was employed to measure the field parameters to ensure no
excess sediment stirring occurs within the well. Bottles may be filled using tubing designated for each specific
well location. Bottles will be filled from the pump in the same manner as described above when using a bailer.
If the pump used to collect groundwater samples is not suitable to collect volatile or extractable organics then
collect the other parameters and withdraw the pump and tubing. Then collect the volatile and extractable
organics.
2.5.11 Surface Water
Surface water sampling will be performed with consideration to minimize turbulence and aeration. Surface
water sample containers will be handled with gloved hands, keeping one hand near the container base. Sample
containers will be dipped at location points with extreme caution to avoid contamination at the mouth of the
container, pushing at an angle into the water, mouth up and tilted towards the stream current to fill, so as not to
lose any of the preservative into the surrounding water. If there is little current, the container may be moved
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slowly through the water laterally. During drought, if the water is not deep enough to allow for container
filling, a pool may be scooped out of the stream bottom to obtain a sample. If this option is used, the pool will
be allowed to clear before sampling. Surface water containers will be filled in the same manner and treated the
same as the groundwater samples; sealed in labeled, plastic bags, stored and transported in coolers on ice. IN
addition to sample collection, surface water will also be collected in a wide -mouth container for pH,
temperature, turbidity and conductivity measurements.
2.5.12 Blank Samples
Quality Assurance/Quality Control (QA/QC) for groundwater monitoring involves blank sample collection
and analysis to verify sample quality was not affected by sample handling or transport. Detections in blank
samples may be attributed to interactions between the sample and container, handling procedure, source water
or laboratory introduced variable.
Blank samples will be prepared, handled and analyzed as groundwater samples to ensure cross -contamination
has not occurred. Trip blanks are prepared at the laboratory and return to the laboratory in an untampered
condition. Equipment blanks, for non -dedicated equipment, will be created in the field by pouring deionized
or other non -organic water through the sampling equipment prior to sample collection. Field blanks are
collected by pouring deionized water from the lab or non -organic (Milli-Q or equivalent) water at the sampling
location into laboratory provided sample collection jars.
Quality control samples are collected to ensure that the field conditions, equipment and handling conditions
during sampling collection have not affected sample quality. Duplicate groundwater samples may also be
collected from network monitoring wells to check laboratory accuracy. Blanks, duplicate containers,
preservatives, handling, and transport procedures for surface water samples will be identical to those for
groundwater samples.
2.5.13 Chain of Custody
Trip blanks, equipment blanks and samples will travel and be stored on ice in coolers for transport to a North
Carolina -certified laboratory. Trip blanks will remain in the condition they are received from the laboratory
and will not be opened or tampered with during sampling. Samples will be carefully packed to protect sample
integrity and maintain a temperature of approximately 4 degrees Celsius.
A chain -of -custody (COC) record will be completed for each day's samples and contain the following
information:
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• sample descriptions (including QA/QC samples),
• container number,
• sample location,
• date and time,
• sample matrix (soil, water, etc.),
• laboratory analyses to be conducted,
• sampler's signature,
• regulatory agency,
• signatures for everyone through whom the samples change hands and
• sample transfer dates and times.
When the water samples reach the laboratory, they will be transferred to a sample custodian who will sign the
chain of custody documentation as a sample receipt.
2.6 Analysis
2.6.1 Analytical Laboratory and Methods
Analytical methods will follow Test Methods for Evaluating Solid Waste - Physical/Chemical Methods (SW-
846) or Methods for the Chemical Analysis of Water and Wastes and will be consistent with the DWM's
policies regarding analytical methods and reporting limits. Analysis will be performed by a laboratory
certified by the North Carolina DWM for the specified parameters. Internal water sample control in the
laboratory will be in accordance with QA/QC procedures for the laboratory. Copies of QA/QC manuals for
approved laboratories are on file at the Division of Solid Waste.
Sample and QC data shall be reviewed by the laboratory manager to identify questionable data and verify the
required QA/QC procedure is followed. The primary laboratory will verify any subcontracted laboratory
analysis shall be performed by certified laboratory procedure.
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3 REPORTING
A report summarizing the monitoring event and analytical results will be submitted to the SWS within 120
days following event completion in accordance with the Rule.
Monitoring reports will include the following:
1. Site geology and hydrogeology
2. Monitoring event procedures and results
3. A potentiometric surface map
4. Analytical laboratory results and summary tables
5. Solid Waste Environmental Monitoring Reporting Form (Appendix B); and
6. Laboratory Data (in Electronic Data Deliverable Format
Monitoring reports will be submitted electronically by e-mail, paper copies will be provided on request.
Report copies will be kept with landfill records.
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4 CONCLUSION
This Sampling and Analysis Plan, included with the Corrective Action Evaluation Report for the Surry County
Closed C&D and Closed MSW landfills, completes the requirements as described in Rule 15A NCAC 13B
.1623(b)(3). The groundwater and surface water monitoring plan is designed to be effective in the detection of
a possible release to the uppermost aquifer and continued monitoring related to corrective action.
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TABLES
TABLE I WITHIN TEXT GROUND AND SURFACE WATER MONITORING LOCATIONS
TABLE 2 MONITORING WELL CONSTRUCTION DETAILS
TABLE 3 WATER QUALITY SAMPLING PARAMETERS
TABLE 4 SAMPLING SCHEDULE

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Table 2
Well Construction Details
Monitoring Well
Latitude
Longitude
Date
Installed
Well
Diameter
(inches)
Total Well
Depth
(ft bgs)
Ground
Elevation
(ft amsl)
Top of
Casing
Elevation
(ft amsl)
Screen
Interval
(ft)
Geology of
Screened
Interval
Monitoring Network Wells
MW-1
36.439211
-80.568133
11/28/89
2
40
1133.15
1134.35
30-40
Clay
MW-3R
36.434725
-80.571989
9/27/94
2
101
1015.00
1017.50
86-101
Rock
MW-6
36.437431
-80.571067
9/7/94
2
29.7
1065.61
1067.67
14.7-29.7
Rock
MW-7
36.438439
-80.570722
8/23/94
2
23
1071.50
1073.50
8-23
Rock
MW-9
36.439289
-80.571508
8/22/94
2
44
1092.07
1094.07
29-44
Rock
MW-11
36.441589
-80.569558
8/15/94
2
40
1150.40
1151.80
25-40
Rock
MW-12S
36.435942
-80.567972
5/31/01
2
51
1023.25
1025.80
40-51
Rock
MW-12D
36.435964
-80.567994
5/30/01
2
100
1023.75
1027.05
90-100
Rock
MW-13
36.435036
-80.568183
5/30/06
2
36
1005.75
1008.48
21-36
Saprolite
MW-14
36.434267
-80.569239
5/30/06
2
48
1016.11
1018.80
33-48
Rock
MW-15
36.433797
-80.570467
6/22/06
2
57
1073.23
1075.96
42-57
Rock
MW-16
36.434536
-80.572117
6/21/06
2
36.5
996.67
999.54
21.5-36.5
Rock
MW-17
36.433558
-80.572517
6/1/07
2
15
1 962.26
965.43
5-15
Rock
MW-18
36.435453
-80.567050
6/1/07
2
18
980.00
983.00
8-18
Saprolite
MW-19
36.432231
-80.570556
6/1/07
2
17
942.97
946.27
7-17
PWR
MW-20
36.439025
-80.571650
6/1/07
2
25.5
1079.12
1082.19
10.5-25.5
Rock
MW-21
36.434214
-80.568717
6/1/07
2
15.5
962.22
965.36
5.5-15.5
Saprolite/PWR
MW-22
36.432928
-80.571678
6/1/07
2
16
950.23
953.40
6-16
Saprolite
MW-23
36.432828
-80.569156
6/1/07
2
17
952.09
955.31
7-17
Sandy Silt
Injection Wells (Not
Monitored)
IW-1
-
-
10/28/11
2
81.5
-
-
61.5-81.5
Rock
IW-2 (was MW-2)
36.435833
-80.568894
11/28/89
2
70
1068.36
1068.86
60-70
Clay
IW-3 (was MW-3RS)
36.434656
-80.571858
5/17/01
2
52
1018.24
1020.57
37-52
Rock
IW-4 (was MW-4)
36.434686
-80.569200
8/30/94
2
55
1025.06
1026.26
40-55
Rock
IW-5 (was MW-5)
36.434614
-80.570436
8/27/94
2
63
1077.78
1080.18
48-63
Rock
IW-6 (was MW-8)
36.439278
-80.570381
8/16/94
2
54
1086.45
1088.45
39-54
Rock
NOTE:
bgs = below ground surface
amsl= above mean sea level
btoc = below top of casing (PVC well casing)
Surry County Closed CDLF over Closed MSWLF, Mt. Airy

Table 3
Analytical Parameters
Constituents
Synonyms
Inorganics
Antimony
Arsenic
Barium
Beryllium
Cadmium
Chromium
Cobalt
Copper
Lead
Mercury
Nickel
Selenium
Silver
Thallium
Vanadium
Zinc
Field Parameters
Temperature
pH
Turbidity
Specific Conductance
Organics
Acetone
2-Propanone
Acrylonitrile
2-Propenenitrile
Benzene
Bromochloromethane
Chlorobromomethane
Bromodichloromethane
Dibromochloromethane
Bromoform
Tribromomethane
Carbon Disulfide
Carbon Tetrachloride
Tetrachloromethane
Chlorobenzene
Chloroethane
Ethyl chloride
Chloroform
Trichloromethane
Dibromochloromethane
Chlorodibromomethane
1,2-Dibromo-3-chloropropane
DBCP
1,2-Dibromoethane
Ethylene dibromide, EDB
1,2-Dichlorobenzene
o-Dichlorobenzene
1,4-Dichlorobenzene
p-Dichlorobenzene
trans- 1,4-Dichloro-2-butene
1,1-Dichloroethane
Ethyldidene chloride
1,2-Dichloroethane
Ethylene dichloride
1,1-Dichloroethylene
Vinylidene chloride
cis- 1,2-Dichloroethylene
trans- 1,2-Dichloroethylene
1,2-Dichloropropene
Propylene dichloride
cis- 1,3-Dichloropropene
trans- 1,3-Dichloropropene
Ethylbenzene
2-Hexanone
IMethyl butyl ketone
Methyl bromide
IBromomethane
Surry County Closed CDLF over Closed MSWLF, Mt. Airy

Table 3
Analytical Parameters
Constituents
Synonyms
Methyl chloride
Chloromethane
Methyl ethyl ketone
2-Butanone
Methyl iodide
lodomethane
4-Methyl-2-pentanone
Methyl isobutyl ketone
Methylene bromide
Dibromomethane
Methylene chloride
Dichloromethane
Styrene
Ethenylbenzene
1,1,1,2-Tetrachloroethane
1,1,2,2-Tetrachloroethane
Tetrachloroethylene
Perch loroethylene
Toluene
Methyl benzene
1,1,1-Trichloroethane
Methyl chloroform
1,1,2-Trichloroethane
Trichloroethylene
Trichloroflouromethane
CFC-11
1,2,3-Trichloropropane
Vinyl acetate
Acetic acid, ethenyl ester
Vinyl chloride
Choroethene
Xylenes
Dimethyl benzene
Monitored Natural Attenuation Parameters:
DO
ORP
Iron
Alkalinity
BOD
COD
TOC
Sulfate
Sulfide
Nitrate
Chloride
Carbon Dioxide
Ethane/Ethene
Hydrogen
Dissolved Methane
Volatile Fatty Acid
Appendix II Additional Parameter:
SVOCs
Acenapthene
Acenapthylene
Acetophenone
2-Acetylaminofluorene
2-AAF
4-Aminobiphenyl
Anthracene
Benzo(a)anthracene
Benzo(b)fluoranthene
Benzo(k)fluoranthene
Benzo(ghi)perylene
Benzo(a)pyrene
Benzyl alcohol
Bis(2-chloroethoxy)methane
Bis(2-chloroethyl) ether
Surry County Closed CDLF over Closed MSWLF, Mt. Airy

Table 3
Analytical Parameters
Constituents
Synonyms
Bis(2-chloro-1-methylethyl) ether
Bis(2-ethylhexyl)phthaIate
4-Bromophenyl ether
Butyl benzyl phthalate
p-Chloroaniline
Chlorobenzilate
p-Chloro-m-cresol
2-Chloronapthalene
2-Chlorophenol
4-Chlorophenyl phenyl ether
Chrysene
m-Cresol
3-Methylphenol
o-Cresol
p-Cresol
4-Methylphenol
Diallate
Dibenz(a,h)anthracene
Dibenzofuran
Di-n-butyl phthalate
DBP
1,3-Dichlorobenzene
m-Dichlorobenzene
3,3-Dichlorobenzidine
2,4-Dichlorophenol
2,6-Dichlorophenol
Diethyl phthalate
DEP
p-(Dimethylamino)azobenzene
7,12-Dimethylbenz(a)anthracene
3,3-Dimethyl benzidine
2,4-Dimethyl phenol
m-Xylenol
Dimethyl phthalate
m-Dinitrobenzene
4,6-Dinitro-o-cresol
4,6-Dinitro-2-methyl phenol
2,4-Dinitrophenol
2,4-Dinitrotoluene
2,6-Dinitrotoluene
Di-N-octyl phthalate
Diphenylamine
Ethyl methacrylate
Ethyl methanesulfonate
Famphur
Fluoranthene
Fluorene
Hexachlorobenzene
Hexachlorobutadiene
Hexachlorocyclopentadiene
Hexachloroethane
Hexachloropropene
Indeno(1,2,3-cd)pyrene
Isodrin
Isophorone
Isosafrole
Kepone
Methapyrilene
3-Methylcholanthrene
Surry County Closed CDLF over Closed MSWLF, Mt. Airy

Table 3
Analytical Parameters
Constituents
Synonyms
Methyl methanesulfonate
2-Methylnapthalene
Napthalene
1,4-Naphthoquinone
1-Naphthylamine
2-Naphthylamine
o-Nitroaniline
2-Nitroaniline
m-Nitroaniline
3-Nitroaniline
p-Nitroaniline
Nitrobenzene
o-Nitrophenol
2-Nitrophenol
p-Nitrophenol
4-Nitrophenol
N-Nitrosodi-n-butylamine
Ni-Nitrosodiethylamine
N-Nitrosodimethylamine
N-Nitrosodiphenylamine
N-Nitrosodipropylamine
N-Nitrosomethylethalamine
N-Nitrosopiperidine
N-Nitrosopyrrolidine
5-Nitro-o-toluidine
Pentachlorobenzene
Pentach loron itrobenzene
Pentachlorophenol
Phenacetin
Phenanthrene
Phenol
p-Phenylenediamine
Pronamide
Pyrene
Safrole
1,2,4,5-Tetrachlorobenzene
2,3,4,6-Tetrachlorophenol
o-Toluidine
1,2,4-Trichlorobenzene
2,4,5-Trichlorophenol
2,4,6-Trichlorophenol
0,0,0-Triethyl phosphorothioate
sym-Trinitro benzene
1,3,5-trinitroBenzene
Surry County Closed CDLF over Closed MSWLF, Mt. Airy

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Table 4
Sampling Schedule
Well
Detection
Monitoring
Assessment
Monitoring
pH
DO
ORP
Turbidity
Temperature
Specific
Conductivity
Alkalinity
Sulfide
Sulfate
Ferrous
Iron
Chloride
Nitrate
TOC
COD
Dissolved
Methane
VFA
CO2
Hydrogen
BOD
ethane/
ethene
MW-1*
semi
3
semi
semi
semi
semi
semi
semi
3
3
3
3
3
3
3
3
3
3
3
3
3
3
MW-3R
semi
NM
semi
NM
NM
semi
semi
semi
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
MW-6
semi
NM
semi
NM
NM
semi
semi
semi
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
MW-7
semi
NM
semi
NM
NM
semi
semi
semi
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
MW-9
semi
3
semi
semi
semi
semi
semi
semi
3
3
3
3
3
3
3
3
3
3
3
3
3
3
MW-11
semi
3
semi
semi
semi
semi
semi
semi
3
3
3
3
3
3
3
3
3
3
3
3
3
3
MW-12S
semi
NM
semi
NM
NM
semi
semi
semi
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
MW-13
semi
NM
semi
NM
NM
semi
semi
semi
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
MW-14
semi
3
semi
semi
semi
semi
semi
semi
3
3
3
3
3
3
3
3
3
3
3
3
3
3
MW-15
semi
3
semi
semi
semi
semi
semi
semi
3
3
3
3
3
3
3
3
3
3
3
3
3
3
MW-16
semi
3
semi
semi
semi
semi
semi
semi
3
3
3
3
3
3
3
3
3
3
3
3
3
3
MW-17
semi
NM
semi
NM
NM
semi
semi
semi
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
MW-19
semi
NM
semi
NM
NM
semi
semi
semi
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
MW-20
semi
NM
semi
NM
NM
semi
semi
semi
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
MW-21
semi
3
semi
semi
semi
semi
semi
semi
3
3
3
3
3
3
3
3
3
3
3
3
3
3
MW-22
semi
NM
semi
NM
NM
semi
semi
semi
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
MW-23
semi
NM
semi
NM
NM
semi
semi
semi
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
WSW-2
semi
NM
semi
NM
NM
semi
semi
semi
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NOTE:
*MW-1 is the background well for the site.
semi = well sampled semi-annually
Detection Monitoring = Appendix I list
Assessment Monitoring = Full Appendix 11 list (performed in the fall with detects re -analyzed during the spring event)
NM = Not Monitored
3 = well sampled every third year (both sampling events for MNA parameters) projected as: 2021, 2024
Assessment and MNA monitoring is scheduled for the year prior to the CAER, to ensure the most upto date analytical data is available for this report
Surry County Closed CDLF over Closed MSWLF, Mt. Airy

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FIGURES
FIGURE I SITE LOCATION (USGS TOPO)
FIGURE 2 PROPOSED MONITORING NETWORK
FIGURE 3 TYPICAL MONITORING WELL
FIGURE 4 GRAPHICAL PLOT OF STANDING WATER VOLUMES

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OnL
1100
wo
�i
yQ
9G
s1,
!y
o`er
,3
tf`R�
R
�vQ FP
0
x
`ro 1200
G
e 9'Yp�
G
w
J
120 a 52
ODLE Tft(a
1
"1A'TTRD EDGE OF WASTE
K�� BOUNDARY
�°
GORDON PAp,K LN
0� FOX RUN �N
*e`
Z) HOMEST£gD nR,
PROPOSED LINED--
PHASE 4 PROPERTY
BOUNDARY
WiMBLEDON LN o Y
,\��� R1CHMDND �JA
�o
�P
V
100 a
0
a
a
a
y
HUNTER RIDGE LN o
z
c�
USGS Mount Airy Quadrangle 2016
2000 0 1000 2000 4000
237 Landfill Road
Mount Airy, NC27030 NORTH
(36.43,-80.582)
GRAPHIC SCALE
FIGURE 1
MUNICIPAL ENGINEERING
YnE SERVICES C O M P A N Y y P.A.SITE LOCATION (USGS TOPO)
n_ Surry County Landfill
68 SHIPWASH DRIVE, GARNER, NC 27529 - PHONE: [phone] North Carolina
P.O. Box 349, BOONE, NC 28607 - PHONE: [phone]
LICENSE NUMBER: C-0281 SCALE: DATE: PROJECT NO.:
SEE SCALEBAR 4/1/2019 G19022

This page intentionally left blank.

� f �
/
/
/
/
/- 237 LANDFILL ROAD
/ SCALEHOUSE
_ GWE=1130.15 - =
If
yo
%/ CLOSED UNLINED MSW (8602-MSWLF-1983)
STOPPED RECEIVING WASTE BEFORE OCTOBER 9, 1991
/tV/
—FUTURE HOUSE
l "N
�
\ I II ACTIVE LCID <2 ACRES,)
1
cWE=1060.87��— IW-6 v \\\ \\� I lI l/ �k i i / / / / III
GWE=1046.9; \ \ I 1 MIN-1
GWE=1104.40
MW--20
11 \\ \ GWE=10
SW-2 62.98If
=
TIRE DISPOSAL AREA / I11 I� PROPOSED WSW-2
II1I IIII I I II IIII II,��
I
I I IIIII\\
ll II )Mw7�//// / J IIII V \ I � —/ // / //
Ill / / i �wE=losl.2s' / /�� I IIV A \ v i / r, n
NOW OR FORMERLY Iti
I///// / l A CLOSED UNLINED C&D(8602-CDLF-2001)
_
OWNED BY l l I /ll 11/l Ill/ Ill/ III III(IIII IIII J lI Il llllll) / II' l \ 1 \ / / / / / \ IIII III` _ �I— _ STOPPED RECEIVING C&D BEFORE JUNE 30, 2008
JOHNNY COX / l //Il// 1/ll I/II IIIIIIII\V11 / ) I/lJ /I 1�1 1 I \ VA 1\ / / (// \� II v �� CLOSURE REQUIREMENTS COMPLETED BEFORE MAY 30, 2009
11// 11/I 1/II IIII IIII IIII �l �\ � 1//I I(
/ -t — 1 — — I
/l ll �y \� �\\ \ 5-\(,rf\ III —�—�/�
p(III lI lIllII \
1 I 4 11 ll l(\ �(/ ( / /III 1\\ 11 v l � � �—, 1 1 � � ✓ � � —� v� � /l I I l vv
iwW-s v— > / / ll/
/ II .. „w� � — �/ �/ I
GWE=1045.30
1 I I II II
l/ljlll/Ill/% III III llllll 11 \/ i/�// jam/ / /%//%\IIII\ \\�\ / 11IIIIIIIIII IIIII \\���\�iI III IIII II I(�
\� \ - � l // // /// l/jllll/l llllll t IIII II IIIII � v \V // /�/// / I IIII/ �� vvv v vv L / /lj IIII IIII II IIIII vvvw v ' 11 IIII IIII I III �
/i
I CLOSED C&D OVER CLOSED UNLINED MSW (8602-CDLF ON TOP OF MSW)
Ili STOPPED RECEIVING C&D BEFORE MARCH 3, 2006
/ / / // // / _ //lI 111
j/ 1>>�r� I I / /%//� j////%/// / // I I �/ l IIII/ 111 /' / / //I� IIIJ / \\ Vv I STOPPED RECEIVING MSW BY JAN. 1, 1999
Ill IJl /��' / j // LFG EXTRACTION SYSTEM
—
\1�101f-lll
GWE=1027.921 III �C �MW-12S�%��
IfJ i 1 0 �
0 0
1 11I rl II II III I III \\ \\
�p60 \ — � I I III I `\\ \ , � % i// /� /ji � / /iii/�i RTy
II I 411�
11
%/
/j
/Jl
13
_GWE=982.03
3
-IW
GwE-'sss.54
00
/ /-3R sw�-1
=975.7
989.12 /
/ PROPERTY LINE
GWE=959.22
/; wE-9is.3a
_ you
MW/
B15iij
(lll
�,-
I
�o
GWE=948.20
I Kt
INACTIVE LINED—
// PHASE 1—
/ PTO 12/1/98 \\ \\ \\ r \�\\\\\\\\\\\\ \ \ ( 1 \ _ _ NOW OR FORMERLY
— �vavv. �vv ( r \v ����� /
MONITORED SEPERATELY _ — % \\\ }\ C// f�/ / /
- r\ ( \ \\\ \ \ STONEY CREEK —940, j OWNED BY
1 111�1 ��\�� GWE=936.92—
SHAWNA SUMMERS
zo
ACTIVE LFG EXTRACTION SW-4
�-
\
I
I
— —
LEGEND
250 EXISTING TOPOGRAPHIC CONTOURS
EXISITING ROAD/PATH
-0 o o c EXISTING CHAINLINK FENCE
—III EXISTING STRUCTURE
PERENNIAL CREEK, STREAM, ETC.
INTERMITTANT CREEK STREAM ETC.
PROPERTY LINE
- - - _ - - - - - - LINED MSWLF PHASE LIMITS
UNLINED WASTE LIMITS (APPROXIMATE)
COMPLIANCE BOUNDARY
�1060 POTENTIOMETRIC GROUNDWATER CONTOUR (10/18/18)
GWE = 2626.85 GROUNDWATER POTENTIOMETRIC ELEVATION
*MW- ELEVATION NOT USED FOR CONTOURING
sw SURFACE WATER SAMPLING LOCATION
Q MONITORING WELL
iw INJECTION WELL
WATER SUPPLY WELL
(NON -POTABLE)
A; ASSESSMENT WELL
Bw BACKGROUND WELL
GRAPHIC SCALE
zoo 0 100 200 400
( IN FEET )
I inch = 200 ft.
800
FIGURE 2
■ 11 M
Q
�
�
z
�
N
�°
L�
r
N
W
m
�N
t0
00
W
w
N
°°
Z
ZZ
°
a
w
o
r
00
L
a
IT
=
a
N
°
z
N
Ln
O
Ll
w
W
0
N
t0
002
COv
L]
Z
N
C]
ZI
z
J
LiZw
Lirn
Z
Qin
m
Q
w
Z
O
Z
w
L3
IL
°0
w
m
U
L3
�
z
�
2
m
Q
m
X
O
a
00
Wul
=°
rn
a
wo—
P%d
LLLI
o Q
U
CL
CL
C)
CL
U
W
Lr Lu
m C)
W
uj
C)
o CL
SCALE: SEE SCALE BAR
DATE:
0410112019
DRWN. BY:
R.MOSS
CHKD. BY:
M. GERMAN
PROJECT NUMBER
DRAWING NO. 1 SHEET NO.

This page intentionally left blank.

4" X 4" STEEL CASE
WITH HINGED LID
PVC VENTED CAP, NO LESS
THAN 2.5' ABOVE GROUND
SURFACE
<
4'
I
NOTE: SHALLOW WELLS REQUIRE A MINIMUM
OF 5' COMBINED THICKNESS OF GROUT
AND BENTONITE.
2' x 2' CONCRETE COLLAR, NOT
TO EXCEED V IN ORDER TO
DIMINISH EFFECTS OF
EROSION AROUND CONCRETE
COLLAR
GROUT BACKFILL, NEAT CEMENT
< 5% BENTONITE POWDER BY VOLUME
OR BENTONITE GROUT
2" (NOMINAL) SCHEDULE 40 PVC
FILTER PACK SHOULD
V MIN BENTONITE PELLET SEAL
EXTEND A MIN. OF V ABOVE
THE SCREEN AND NO MORE
THAN 2' ABOVE
SAND FILTER PACK
(NC #2 S)
SCREENINTERVAL
NOT TO EXCEED 15'
0.01" MACHINE SLOTTED SCREEN, PVC
END CAP, PVC
MAX 1' FILTER PACK
BELOW SCREEN
TYPICAL
MONITORING WELL
FIGURE 3

32
28
h
24
20 - z
c
c�
16
o A'
12
a�
8
6"
4
0
0 1 2 3 4 5 6 7 8 9 10
Gallons of Water in Well
GRAPHICAL PLOT OF STANDING VOLUMES OF WATER
PLATE C

APPENDIX A
AVAILABLE WELL RECORDS

This page intentionally left blank.

sruc.,
NONRESIDENTNONRESIDENTM WEi LL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2663
1. WELL CONTRACTOR:
Derry Hunevcutt
Well Contractor (Individual) Name
Derry's Well Drillinca Inc.
Well Contractor Company Name
44283-A NC 24/27/73
Street Address
Albemarle NC 28001
City or Town State Zip Code
7r 04 ) 982-9070
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(inapplicable) WIQ400176
SITE WELL ID #Cdapplicable) lW-1
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
IndustriallCommercial ❑ Agricultural 0 Recovery ❑ injection N(
Irrigationo Other ❑ (list use)
DATE DRILLED 10/28/11
4. WELL LOCATION:
419 Landfill Road
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Ararat COUNTY SUrrV
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
[]Slope []Valley ❑Flat 6Ridge []Other
K@WCD 36 -Annngtnnnnnnnnl CL ROR 3 4nnnn CC
KMWWCD75 -+nnngtnnnnnnnnr CL ROR 89J"nnnn CC
Latitude/longitude source: WPS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Surry .o_ Closed MSS F
Facility Name Facility ID# (if applicable)
4.19 Landfill Road
Street Address
Ararat NG 27007
City or Town State Zip Code
Mr_ _ferry Sn= (Public Works Dirednrl
Contact Name
PO Box 1542
Mailing Address
Mount Airy NG 27030
City or Town State Zip Code
(336 t1 401-8376
Area code Phone number
d. TOP OF CASING IS 3.00 FT. Above Land Surface`
°Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
: e. YIELD (gpm): na METHOD OF TEST
f. DISINFECTION: Type na
Amount na
g. WATER ZONES (depth):
Top 75'(?) Bottom_jZQ)- Top
Bottom
Top Bottom Top
Bottom
Top Bottom Top
Bottom
Thickness/
: 7. CASING: Depth Diameter
Weight Material
Top +3.00 Bottom 61.40 Ft. 2"
sch 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 57,00 Bottom 60.00 Ft. Bent. Chips Gravity
Top 0 Bottom 57.00 Ft. Neat Cement Tremie
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 61.40 Bottom 81.40Ft. 2 in. 0.02 in. PVC
= Top Bottom Ft. in. in. High Flow
Top Bottom Ft. in. in. 1/8"sDacin0
10. SAND/GRAVEL PACK:
Depth Size
Top 60.00 Bottom 84.00 Ft_#3
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Material
Filter Sand
: Top Bottom Formation Description
0 / 41.00
41.00 / 43.00
43.00 / 47.00
47`00 184.00
63 / 63.50
70 / 70.50
75 / 77
80 / 80.50
12. REMARKS:
Fracture
Fracture
Fracture
Fracture
6. WELL DETAILS I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
: 15A C 2C, WELL CONSTRUCTION TANDARDS, AND THAT A Cop'
OP OF THIS
a. TOTAL DEPTH $1.40' : RE HAS BEEN PRO I DTO E WELLOWNER.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO N TUR ZFCERTIFl5D`Wr:LLC0yPACTOR DATE
c. WATER LEVEL Below Top of Casing: 53.00 Fr. pew LHunMij t
(Use "+" if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form Rev. 1/08/08
1617 Mail Service Center, Raleigh, NC 27699461, Phone: [phone]

N: C. Department of Human Resources
Division of Health Services /
' WELL COMPLETION RECORD r
//l7. ////Z,' L /
COMPLETE ALL INFORMATION REQUESTED BELOW FOR EACH WELL INSTALLED, AND RETURN FORM TO THE N.C.
DEPARTMENT OF HUMAN RESOURCES, SOLID AND HAZARDOUS WASTE MANAGEMENT BRANCH,
P. O. BOX 2091, RALEIGH, N.C. 27602
NAME OF SITE: PERMIT NO.:
/�
CCu ry —7 -e' en
ADDRESS: OWNER (print):
7d( �C1lL iz ( Lc=�<<v Y
DRILLING CONTRACTOR: REGISTRATION NO.:
Casing Type:
Ly dia.
_ in.
Grout Depth:
from �_ to �_ ft. - dia.
�` in.
Casing Depth:
�
from �� toS.L_ ft. - dia.
in.
Bentonite Seal:
from 2'9 to 3 O ft. - dia.
G in.
Screen Type:
dia.
.-! in.
Sand/Gravel PK:
from 30 to !�Q ft. - dia.
in.
Screen Depth:
from to �40 ft. - dia.
.4 v in.
Total Well Depth:
from to # = ft. - dia.
in.
Static Water Level:
1
I feet from top of
casing
Date Measured — /—
Yield (gpm): Method of Testing: I G7-.UI Casing is /'— feet above land surface
DRILLING LOG
DEPTH
FROM TO FORMATION DESCRIPTION
/}-
REMARKS:
DATE: ��— L SIGNATURE --
I
Solid A Ftwnrdou. Wave Mu,.ee+++cnt Br,r,cE. ``.� s
LOCATION SKETCH
(show distance to numbered roads, or other map reference points)
C. J'�•.; � l c
--
_— 1

' WELL COMPLETION RECORD % Z"
/�4 -7-
-IPLETE ALL INFORMATION REQUESTED BELOW FOR EACH WELL INSTALLED, AND RETURN FORMTOTHE N.C.
_.1RTMENT OF HUMAN RESOURCES. SOLID AND HAZARDOUS WASTE MANAGEMENT BRANCH,
BOX 2091, RALEIGH, N.C. 27602
AE OF SITE: PERMIT NO.:
L L ��
)RESS: OWNER (print):
� J n
1 %C� 101 JctJ % C, L%O/% )L�Z(
LUNG CONTRACTOR: REGISTRATION NO.:
G`6G`fn ,J ILvT
ig Type: dia. in. Grout Depth: from to ft. - dia.J-- <7" in
ig Depth: from to k. - dia. _-4 in. Bentonite Seal: from j I to ft. - dia. in..
:n Type: P i/ — dia. I- , . in. Send/Gravel PK: from �� to �J ;;> ft. - dia. in.
:n Depth: from 40 to — t LL ft. - dia. � in. Total Well Depth: from z_ to '% ft. - dia. �v r in.
c Water Level: -- feet from top of casing Date Measured
I (gpm): - Method of Testing: Q {"' Casing is /— feet above land surface
LOCATION SKETCH
(show distance to numbered roads, or other map rderence points]
MARKS:
\.TE: SIGNATURE:
_ 33N2(6i85) �' �j.f / /
d 6i `. -dam W— Mu,Wr.r,x &moth ! � !-"' �`i J' �L�1s C �(-,
- ��. - -,., .,. va. e.., w,,. vn w..0 a..•a v, ,v.a w. o................�.......��.�. .......-.....�. _� a�mw

North Garolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: GAI Consultants
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Let Long. RO
Minor Basin
Basin Code
Header Ent. GW-1 Ent
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 446 PERMIT NUMBER:
N/A
1.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: Mt. Airy County:
Surry
SR 2015
(Road, Community, or Subdivision and Lot No.)
DEPTH
DRILLING LOG
2.
OWNER Surry County Attn: Jerry Snow
From To
Formation Description
ADDRESS PO Box 706
0 — 13
Red clay
(Street or Route No.)
Dobson NC 27017
13 - 16
Extremely weathered
City or Town State Zip Code
schist
3.
DATE DRILLED 9-27-94 USE OF WELL Monitoring
4.
TOTAL DEPTH 103'
5.
CUTTINGS COLLECTED YES F7 NOD
16 — 30.7
Slightly weathered
6.
DOES WELL REPLACE EXISTING WELL? YES x7 NOF]
schist
7.
STATIC WATER LEVEL Below Top of Casing: t70.5 FT.
(Use "+" if Above Top of Casing)
30.7 — 102
Schist
8.
TOP OF CASING IS Z.5 FT. Above Land Surface'
Casing Terminated at/or below land surface is Illegal unless a variance is issued
in
accordance with 15A NCAC 2C .0118
N/A
9.
YIELD (gpm): METHOD OF TEST
10.
WATER ZONES (depth): 85 to 102 ft
11. CHLORINATION: Type
N/A
Amount
12. CASING:
Wall Thickness
t2. 5
Depth86
Diameter
or Weight/Ft. Material
From
To
Ft. 2"
Sch 40 PVC
From
To
Ft:
From
To
Ft.
13. GROUT:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
SR 2015
Depth Material Method
From 0 To 80 Ft neat cement grout \�
From 80 To 82.6 Ft. bentonite pellets
14. SCREEN:
Depth Diameter Slot Size Material
From __gr_To 1ni Ft 2 in. -010 in. PVC
From To Ft. in. in.
From To Ft. in. _ - in.
15. SAND/GRAVEL PACK:
Depth Size
From 82.6 To 102 Ft.
From To Ft.
1�. REMARKS: Monitoring Well 3R
Material
silica
N <—
Water first encountered at 85 to 95 ft
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
K
SIGNATUR OF CONTRACTOR OR AGENT D TE
a.a-...b..; i—i rr. rlc,Aci n of

MONITORING WELL
IR
i i=M low
CONSTRUCTION LOG ENGINEERING, INC
PROJECT: Mt. Airy Water Quality Assessment MONITORING WELL ID: MW-3RS
LOCATION: Mt. Airy, NC CONSTRUCTION DATE: 5/17/2001
STAND PIPE CONSTRUCTION
GEOLOGIC UNI
MEASURING POINT ELEVATION. 1020.57 ft AMSL
PAD DIMENSIONS 3 feet x 3 feet
GROUND SURFACE ELEVATION 1018.24 ft AMSL
BOREHOLE DIAMETER 9 inches to 14 feet below qrade
4 inches from 14 feet to bottom
ANNULAR SPACE SEAL
TYPE OF SEAL Roanoke Portland Cement
Tremie grouted
RISER TYPE PVC
RISER DIAMETER 2 inches
TOP OF FILTER PACK SEAL
ELEVATION 988.57 ft AMSL
DEPTH 32 feet
FILTER PACK SEAL TYPE Shur Plug 3/8 inch chins
TOP OF FILTER PACK
ELEVATION 985.57 ft AMSL
DEPTH 35 feet
FILTER PACK TYPE #3 oraded well sand
FILTER PACK SOURCE DSI
TOP OF SCREEN
ELEVATION 983.57 ft AMSL
DEPTH 37 feet
SCREEN TYPE PVC
SCREEN DIAMETER 2 inches
SLOT SIZE 0.010 inch
BOTTOM OF SCREEN
ELEVATION 968.57 ft AMSL
DEPTH 52 feet
BOTTOM OF BOREHOLE
ELEVATION 968.57 ft AMSL
DEPTH 52 feet

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: GAI Consultants
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat Long. RO
Minor Basin
Basin Code
Header Ent. GW-1 Ent
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 446 PERMIT NUMBER: ti�A
1 . WELL LOCATION: (Show sketch of the location below)
Nearest Town: Mount Airy County: Surry
SR 2015
(Road, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
2. OWNER Surry County From To Formation Description
ADDRESS PO Box 706 0 — 5 Sandy silt with
(Street or Route No.) trace clay
Dobson NC 27017
City or Town State Zip Code
3. DATE DRILLED 8-30-94 USE OF WELL Monitoring 5 - 56.4 Gray garnet mica
4. TOTAL DEPTH 56.4' schist with quartz
5. CUTTINGS COLLECTED YES ❑ NOF_XI veins
6. DOES WELL REPLACE EXISTING WELL? YES = NO�x
7. STATIC WATER LEVEL Below Top of Casing: 35 FF.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
' Casing Terminated aUor below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118
9. YIELD (gpm):— METHOD OF TEST
10. `,HATER ZONES (depth): 46 to 56.4 ft
11. CHLORINATION: Type
Amount
If additional space is needed use back of form
12. CASING:
Wall Thickness
LOCATION SKETCH
Depth
Diameter or Weight/Ft. Material
(Show direction and distance from at least two State
From +2
To 40.4
Ft.
2" Sch 40 PVC
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
SR 2015
13. GROUT:
Depth
Material Method
From 0
To 38
Ft.
Cement Grout
4MW4/
From 38
To 39
Ft.
Bentonite Pellet
14. SCREEN:
Depth Diameter Slot Size Material
From 40.4 To 55.4 Ft 2 in. •010 in. .PVC
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 39 To 56.4 Ft 2 Sand
From To - Ft. N 4--
16. REMARKS: Monitorinq Well 4 Water first encountered at 46 ft
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
io
SIGNATUf".11
F CONTRACTOR OR AGENT DATE
;W-1 RFV 9l91 Sut mit to Division of Environmental Management and copy to well owner.

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: GAI Consultants
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO. _
Lat Long. RO
Minor Basin
tea&, coop
Header Ent. GW-1 Ent
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 446 PERMIT NUMBER: N/A
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Mount Airy County: Surry
SR 2015
(Road, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
2. OWNER Surry County
PO B706 From To Formation Description
OX
ADDRESS 0 - 5 Red clay
(Street or Route No.)
Dobson NC 27017
City or Town State Zip Code
3. DATE DRILLED 8-27-94 USE OF WELL Monitoring
4. TOTAL DEPTH 64.:1
5. CUTTINGS COLLECTED YES ❑ NO�'
6. DOES WELL REPLACE EXISTING WELL? YES C N0I7
7. STATIC WATER LEVEL Below Top of Casing: 39.5 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
Casing Terminated at/or below land surface is illegal unless a variance is issued
In accordance with 15A NCAC ZC .0118
9. YIELD (gpm):— METHOD OF TEST
10. WATER ZONES (depth): 51 to 64.7 ft
i, CHLORINATION: Type . Amount
12. CASING:
Wall Thickness
Depth Diameter or Weight,ft. Material
From +2 To - 8 Ft. 2" SCh 40 PVC
From To Ft.
From -To- Ft.
13. GROUT:
Depth Material Method
From 0 To 45 Ft. Cement Grout
From 45 To 46 Ft. Bentonite Pellet
14. SCREEN:
Depth Diameter Slot Size Material
From 48 To 63 Ft 2 in. -010 in PVC
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
"From 46 To 64.7 Ft. 2 Sand
From To Ft. N
16. REMARKS. Monitoring Well 5 Water first encountered at 51 ff-
5 - 16 Tan sandy silt
16 - 64.7 Gray garnet mica
schist with granite
intrusions
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roacs. or other map reference points)
SR 2015
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
vo-
SIGNAT E OF CONTRACTOR CR AGENT DA
GW-1 REV. 9 Suu onainal to Civiston. of Enwrormental Management and cony to well owner

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: GAI Consultants
FOR OFFICE USE CNLY
QUAD. NO. SERIAL NO.
Lat Long. RO
Minor Basin
Basin Code
Header Ent. GW-1 EnL
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 446 PERMIT NUMBER: N/A
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Mount Airy County: Surry
SR 2015
(Road, Community, or Subdivision and Lot No.)
2. OWNER Surry County
ADDRESS PO Box 706
(Street or Route No.)
Dobson NC 27017
City or Town State Zip Code
3. DATE DRILLED 9-7-94 USE OF WELL Monitoring
4. TOTAL DEPTH 30.7
5. CUTTINGS COLLECTED YES ❑ NOf­x1
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOf_x
7. STATIC WATER LEVEL Below Top of Casing: 22.55 FT.
(Use "+' if Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
' Casing Terminated atlor below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118
9. YIELD (gpm):— METHOD OF TEST
10. WATER ZONES (depth): 20.55 to 30.7 tt
DEPTH
From To
0 - 15.5
15.5 - 30.7
DRILLING LOG
Formation Description
Brown to tan sandy
silt with trace clay.
Gray garnet mica
schist with granite
intrusions .5-1'
thick
1. CHLORINATION: Type . Amount If additional space is needed use back of form
12. CASING:
Wall Thickness
Depth
Diameter or Weight/Ft. Material
From +2
To
14.7 Ft.
2" Sch 40 PVC
From
To
Ft.
From
To
Ft.
13. GROUT:
Depth
Material Method
From 0
To
12 Ft.
Cement Grout
From 12
To
13 Ft.
Bentonite Pellet
14. SCREEN:
Depth Diameter Slot Size Material
From 14.7 To 29.7 Ft 2 in. .010 in PVC
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 13.0 To 30.7 Ft 2 Sand
From To Ft. N <-
16. REMARKS: Monitoring Well 6
LOCATION SKETCH
(Show direction and distance from at least two State
Roacs. cr other map reference points)
SR 2015
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH-15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
GNATU�4 OF CONTRACTOR OR AGENT DATE
GW-1 REV. 9191 SUbmtt 01t6inal to Diotsion. of Envtrornnental Atanaaement and cony to weir owne•

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: GAI Consultants
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat Long. RO
Minor Basin
Basin Code
Header Ent_ GW-1 Ent
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 446 PERMIT NUMBER: N/A
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Mount Airy County: Sorry
SR 2015
(Road, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
2. OWNER Surry County From To Formation Description
ADDRESS PO Box 706 1 — 5 Tan sandy silt
(Street or Route No.)
Dobson NC 27017
City or Town State Zip Code 5 — 10
3. DATE DRILLED 8-23-94 USE OF WELL Monitoring
4. TOTAL DEPTH 24' --
5. CUTTINGS COLLECTED YES ❑ NO x II 10 — 15
6. DOES WELL REPLACE EXISTING WELL? YES = NOD
7. STATIC WATER LEVEL Below Top of Casing: 12.75 FT -
(Use '+' if Above Top of Casing) 15 — 18.5
B. TOP OF CASING IS 1.8 FT. Above Land Surface'
' Casing Terminated avor below land surface is illegal unless a variance is issued 18.5 — 24
in accordance with i5A NCAC 2C .0118
9. YIELD (gpm):— METHOD OFT EST
10. WATER ZONES (depth): 10.95 to 24 ft
1. CHLORINATION: Type Amount
12. CASING:
Wall Thickness -
Depth Diameter or WeightiFt. Material
From +1`8 To 8 Ft. 2" Sch 40 PVC
From To Ft.
From To Ft.
13. GROUT:
Brown clayey silt w/
rock fragments
Orange clayey sand
medium to coarse
Brown sandy silt
Gray sc ist
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roacs, or other map reference points)
SR 2015
Depth
Material
Method }
From 0
To 6
Ft. Cement
Grout 11
From 6
To 7
Ft. Bentonite
Pellet
14. SCREEN:
Depth
Diameter Slot Size
Material MW
From 8
To 23
Ft 2 in. .010
in PVC
From
To
Ft. in.
in.
From
To
Ft. in.
in.
15. SAND/GRAVEL
PACK:
Depth
Size
Material
S d
From 7 To 24 Ft. 2 an
From To Ft. N E--
16. REMARKS: Monitoring Well 7.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATUR OF CONTRACTOR OR AGENT DATEGW-1 REV. 9,91 SuLmit original to Division of Envirorrnental Management and coot' to well owner

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
1RILLING CONTRACTOR: GAI Consultants
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
tat Long. RO
Minor Basin
Basin Code
Header Ent GW-1 Ent
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 446 PERMIT NUMBER: N/A
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Mount Airy County: Surry
SR 2015
(Road, Community, or Subdivision and Lot No.)
2. OWNER Surry County
ADDRESS PO Box 706
(Street or Route No.)
Dobson NC 27017
City or Town State Zip Code
3. DATE DRILLED 8-16-94 USE OF WELL Monitoring
4. TOTAL DEPTH 55.3
5. CUTTINGS COLLECTED YES ❑ NOF
6. DOES WELL REPLACE EXISTING.WELL? YES C N0
7. STATIC WATER LEVEL Below Top of Casing: 41.1 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 2.3 FT. Above Land Surface'
' Casing Terminated at/or below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118
9. YIELD (gpm):— METHOD OF TEST
10. WATER ZONES (depth): 38.8 to 55.3 ft
1. CHLORINATION: Type
1. CASING:
DEPTH
From To
0-45
45 — 55.3
DRILLING LOG
Formation Description
Tan to brown sandy
silt
Gray schist
Amount If additional space is needed use back cf form
Wall Thickness
+2.3
Depth39
Diameter or Weight'Ft.
2" Sch
Material
40 PVC
From
To
Ft.
From
To
Ft.
From
To
Ft.
13. GROUT:
Depth
Material
Method
From 0
To 36
Ft.
Cement
Grout
From 36
To 37
Ft.
Bentonite
Pellet
14. SCREEN:
Depth
Diameter Slot Size
Material
From 39
To 54
Ft 2
in. .010
in PVC
From
To
Ft.
in.
in.
From
To
Ft.
in.
in.
15. SANDIGRAVEL PACK
Depth
Size
Material
From 37
To 55.3 Ft
2
Sand
From
To
Ft.
16. REMARKS:
Monitoring
Well 8
LOCATION SKETCH
(Show direction and distance from at least two State
Roacs. cr other map reference points)
SR 2015
RIIIIIIIIIIIIIIIIEM
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATUR OF CONTRACTOR OR AGENT f DATE
GW-1 REV 9'91 ;mil nal u _iwsion of E'rnro^;newai ".Ianaaen-e r,' -.no coo': r� we ''r�ner

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
`RILLING CONTRACTOR: GAI Consultants
FOR OFRCE USE ONLY
QUAD. NO. SERIAL NO.
Lat Long. RO
Minor Basin
Basin Code
Header Ent. GW-t Ent
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 446 PERMIT NUMBER: N/A
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Mount Airy . County: Surry
SR 2015
(Road, Community, or Subdivision and Lot No.)
2. OWNER Surry County
ADDRESS PO Box 706
(Street or Route No.)
Dobson NC 27017
City or Town State Zio Code
3. DATE DRILLED 8-22-94 USE OF WELL Monitoring
4. TOTAL DEPTH 43.8
5. CUTTINGS COLLECTED YES NO FTI
6. DOES WELL REPLACE EXISTING WELL? YES [_I NOFx
7. STATIC WATER LEVEL Below Top of Casing: 3 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING I5 2.3 FT. Above Land Surface"
Casing Terminated at/or below land surface is illegal unless a variance is issued
in accordance with 15A NCAC ZC .0118
9. YIELD (gpm):— METHOD OF TEST
10. WATER ZONES (depth): _13_4 t-n 43-R ft
CHLORINATION: Type
CASING:
4mount
Wall Thickness
+2Depth 28.8 Diameter or Weightift. Material
.3
From To Ft. 2" Sch 40 PVC
From To Ft.
From To Ft.
13. GROUT:
DEPTH DRILLING LOG
From To Formation Description
0 - 43.8 Brown to tan sandy
silt
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roacs, or other map reference paints)
SR 2015
Depth Material Method {
From 0 To 25.5 Ft Cement Grout
From 25.5 To 26.5 Ft Bentonite Pellet
14. SCREEN:
Depth Diameter Slot Size Material MW 9
From 28 - 8 To 43.8 Ft 2 in. • 010 in. PVC
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 26.5 To 43.8 Ft 2 Sand
From To Ft. N 4-
16. REMARKS: Monitoring Well 9
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C: WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
o
SIGNATURE O CONTRACTOR OR AGENT DATE
CW-1 REV 9191 mn on al to =ia <_wn ni E:,; vor�nont:;, ".'.anaaemer,^. and ccov t_ :•:e ! )Nne,

North Carolina - Department of Environment. Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: GAI Consultants
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat. Long. RO
Minor Basin
Basin Cade
Header Ent GW-1 Ent
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 446 PERMIT NUMBER: N/A
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Mount Airy County: Surry
SR 2015
(Road, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
2. OWNER Surry County
PO BOX 706 From To Formation Description
ADDRESS 0 - 17.5 Red to brown sandy
(Street or Route No.)
Dobson NC 27017
City or Town State Zip Code
3. DATE DRILLED 8-15-94 USE OF WELL Monitoring
4. TOTAL DEPTH 41'
5. CUTTINGS COLLECTED YES i7 NOF i1
6. DOES WELL REPLACE EXISTING WELL? YES NOFX
7. STATIC WATER LEVEL Below Top of Casing: 20.92 FT.
(Use"." if Above Top of Casing)
8. TOP OF CASING IS 1.5 FT. Above Land Surface
Casing Terminated at/or below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118
9. YIELD (gpm):— METHOD OF TEST
10. WATER ZONES (depth): 36 to 41 ft
1. CHLORINATION: Type
.2. CASING:
Deoth
From +1.5 To 25
From To
From To
13. GROUT:
Amount
Wall Thickness
Diameter or Weight/'Ft. Material
Ft. 2" Sch 40 PVC
Ft.
Ft.
17.5 - 41
silt with trace clay
Gray garnet mica
schist
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
SR 2015
Depth Material Method { MW li``
From 0 To 22 Ft Cement Grout
From 22 To 23 Ft. Bentonite Pellet
14. SCREEN:
Depth Diameter Slot Size Material
From 25 To 40 Ft 2 in. •010 in PVC
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 23 To 41 Ft. 2 Sand
From To Ft. N
16. REMARKS: Monitoring Well 11 Water first encountered at 36 ft
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWmER.
SIGNA UR F CONTRACTOR CR AGENT "ArE
GW1 REV. 991 SuLmit -�ral to —_iyi<.ior. of E::vuoc;rental !.!anagen+Fnt ono cocv t: N .rNre'

MONITORING WELL
CONSTRUCTION LOG
PROJECT: Mt. Airy Water Quality Assessment
LOCATION: Mt. Airy, NC
GEOLOGIC UN
ENGINEERING, INC.
MONITORING WELL ID: MW-12S
CONSTRUCTION DATE: SJ31/2001
STAND PIPE CONSTRUCTION
MEASURING POINT ELEVATION 1025.80 ft AMSL
PAD DIMENSIONS 3 feet x 3 feet
GROUND SURFACE ELEVATION 1023.25 ft AMSL
BOREHOLE DIAMETER 9 inches to 5 feet below arade
4 inches from 5 feet to bottom
ANNULAR SPACE SEAL
TYPE OF SEAL Roanoke Portland Cement
RISER TYPE PVC
RISER DIAMETER 2 inches
TOP OF FILTER PACK SEAL
ELEVATION 1017.25 ft AMSL
DEPTH 6 feet
FILTER PACK SEAL TYPE Shur Plug 3/8 inch chips
TOP OF FILTER PACK
ELEVATION 1014.05 It AMSL
DEPTH 9.2 feet
FILTER PACK TYPE #3graded well sand
FILTER PACK SOURCE DSI
TOP OF SCREEN
ELEVATION 1012.25 ft AMSL
DEPTH 11 feet
SCREEN TYPE PVC
SCREEN DIAMETER 2 inches
SLOT SIZE 0.010 inch
BOTTOM OF SCREEN
ELEVATION 972.25 ft AMSL
DEPTH 51 feet
BOTTOM OF BOREHOLE
ELEVATION 972.25 ft AMSL
DEPTH 51 feet

MONITORING WELL
CONSTRUCTION LOG
PROJECT: Mt. Airy Water Quality Assessment
LOCATION: Mt. Airy, NC
GEOLOGIC UN
LA1tt!
ENGINEERING, INC
MONITORING WELL 1D: MW-12D
CONSTRUCTION DATE: 5/30/2001
STAND PIPE CONSTRUCTION
MEASURING POINT ELEVATION 1027.05 ft AMSL
PAD DIMENSIONS 3 feet x 3 feet
GROUND SURFACE ELEVATION 1023.75 ft AMSL
BOREHOLE DIAMETER 9 inches to 5 feet below grade
4 inches from 5 feet to bottom
ANNULAR SPACE SEAL
TYPE OF SEAL Roanoke Portland Cement
Tremie grouted
RISER TYPE PVC
RISER DIAMETER 2 inches
TOP OF FILTER PACK SEAL
ELEVATION 939.75 ft AMSL
DEPTH 84 feet
FILTER PACK SEAL TYPE _Shur Plug 3/8 inch chips
TOP OF FILTER PACK
ELEVATION 936.65 ft AMSL
DEPTH 87.10 feet
FILTER PACK TYPE lt3 graded well sand
FILTER PACK SOURCE DSI
TOP OF SCREEN
ELEVATION 933.75 ft AMSL
DEPTH 90 feet
SCREEN TYPE PVC
SCREEN DIAMETER 2 inches
SLOT SIZE 0.010 inch
BOTTOM OF SCREEN
ELEVATION 923.75 ft AMSL
DEPTH 100 feet
BOTTOM OF BOREHOLE
ELEVATION 923.75 ft AMSL
DEPTH 100 Feet

LOG OF BORING: MW-13
Surry County Closed, Mt. Airy
Project No. G06061.0
Drilling contractor: Derry's Well Drilling
Date started:
5/30/2006
Surface elevation:
1005.75 ft (MSL)
Drill rig & method: 7.75" OD HSA
Date ended:
5/30/2006
Top of pipe elevation:
1008.48 ft (MSL)
Logged by: J. Pfohl
Completion depth:
44.00 ft
Depth to water (TOB):
32.00 ft
Stickup height:
2.73 ft
Depth to water (24hrs):
24.17 ft
Q a— 0 m Well Diagram
Q E E Description of Material & Remarks M
U) U) n 1N
Saprolite - Silty Sand
5
5
2
(7
C
�
10
E
y
U
>
a
0
a
U
N
15
20
0
m
25
a
U
a
a
a
C
�
N
'C
U
�
30
0
Water observed while drilling
0
(V
35
40
0
m
0
m
Auger Refusal Top of Competent Rock 961.75 ft. amsl.
45
Boring terminated at 44.0 feet
Municipal Engineering Services Company, P.A.
Operation/Construction Managers Civil/Sanitary Engineers Environmental Studies Page 1 of 1
PO Box 97, Garner, North Carolina 27529(919) 772-5393PO Box 349, Boone, North Carolina 28607(828) 262-1767

LOG OF BORING: MW-14
Surry County Closed, Mt. Airy
Project No. G06061.0
Drilling contractor: Derry's Well Drilling
Date started:
5/30/2006
Surface elevation:
1016.11 ft (MSL)
Drill rig & method: 7.75" OD HSA/6" OD DTH
Date ended:
5/30/2006
Top of pipe elevation:
1018.80 ft (MSL)
Logged by: J. Pfohl
Completion depth:
48.00 ft
Depth to water (TOB):
38.00 ft
Stickup height:
2.69 ft
Depth to water (24hrs):
38.50 ft
w
a)E
Q
(D_
0
cn
m
F
cn
Description of Material & Remarks
Well Diagram
N
d
J
Y
U
5
10
15
20
25
30
35
40
45
50
Saprolite - Silty Sand
-———————— —————————————--——--————————————————————————
Auger Refusal - Top of Competent Rock 1012.11 ft amsl
Schist, tan interlayered with saprolite, highly fractured.
-----------------------------------------------------
Gneiss- gray moderatley hard
——————————————————————--——--————————————————————————
Schist - brown, fractured
----------------------------------------------------
Gneiss
Schist - brown, dry
----------------------------------------------------
Gneiss
----------------------------------------------------
Schist
Groundwater observed - solvent odor
-----------------------------------------------------
Gneiss
0
U
0
�
d
N
a
ci
>
d
a
N
a�
a�
U
U
d
O
a
N
O
U)
O
O
(V
=
Boring terminated at 48.0 feet
Municipal Engineering Services Company, P.A.
Operation/Construction Managers Civil/Sanitary Engineers Environmental Studies Page 1 of 1
PO Box 97, Garner, North Carolina 27529 [phone]PO Box 349, Boone, North Carolina 28607(828) 262-1767

LOG OF BORING: MW-15
Surry County Closed, Mt. Airy
Project No. G06061.0
Drilling contractor: Derry's Well Drilling
Date started:
6/22/2006
Surface elevation:
1073.23 ft (MSL)
Drill rig & method: 7.75" OD HSA/4" OD DTH
Date ended:
6/22/2006
Top of pipe elevation:
1075.96 ft (MSL)
Logged by: J. Pfohl
Completion depth:
57.00 ft
Depth to water (TOB):
49.50 ft
Stickup height:
2.73 ft
Depth to water (24hrs):
49.74 ft
w
Q
a)
❑
Q
a_
(n
(D_
0
E
W
m
F=
cn
Description of Material & Remarks
Saprolite Silty Sand
PWR - Hard Drilling
----------------------------------------------------
Auger Refusal - Top of Competent Rock 1045.23 ft amsl - Schist
----------------------------------------------------
Highly weathered rock
----------------------------------------------------
Returned to competent rock
Well
Diagram
V
Q
J
Y
5
10
20
25
30
35
40
45
50
55
60
o
c�
U
a�
0
m
Y
a
C
U)
0
U
U
d
0
U
N
U
a
U
U)
o
0
s
0
N
�:..
Boring terminated at 57.0 feet
Municipal Engineering Services Company, P.A.
Operation/Construction Managers Civil/Sanitary Engineers Environmental Studies Page 1 of 1
PO Box 97, Garner, North Carolina 27529 [phone]PO Box 349, Boone, North Carolina 28607(828) 262-1767

LOG OF BORING: MW-16
Surry County Closed. Mt. Airy Project No. G06061.0
Drilling contractor: Derry's Well Drilling Date started: 6/21/2006 Surface elevation: 996.67 ft (MSL)
Drill rig & method: 7.75" OD HSA/4" OD DTH Date ended: 6/21 /2006 Top of pipe elevation: 999.54 ft (MSL)
Logged by: J. Pfohl Completion depth: 36.28 ft Depth to water (TOB):
Stickup height: 2.87 ft Depth to water (24hrs): 26.94 ft
w
QE
a�
Q
U)
Q_
0
_
W
m
F
M
U7
Description of Material & Remarks
Well Diagram
JoR
N
d
J
Y
U
5
10
15
20
25
30
35
40
45
Saprolite - Silty Sand
Au-er Refusal - Top of Competent Rock 987.67 ft amsl
Gneiss/Schist
0
C7 N
2------------------------------------------------
E
a
a
U
V)
N
0
m
U
U
� = d
d O
C t
� U
N
0
0
0
0
(V
Boring terminated at 36.3 feet
Municipal Engineering Services Company, P.A.
Operation/Construction Managers Civil/Sanitary Engineers Environmental Studies Page 1 of 1
PO Box 97, Garner, North Carolina 27529 [phone]PO Box 349, Boone, North Carolina 28607(828) 262-1767

LOG OF BORING: MW-17
Surry County, Mt. Airy Closed
Project No. G07063.0
Drilling contractor: Derry's Well Drilling
Date started:
6/1/2007
Surface elevation:
962.26 ft (MSL)
Drill rig & method: 5.5" DTH
Date ended:
6/1/2007
Top of pipe elevation:
965.43 ft (MSL)
Logged by: J. Pfohl
Completion depth:
15.32 ft
Depth to water (TOB):
9.48 ft
Stickup height:
3.17 ft
Depth to water (24hrs):
8.83 ft
w
Q
Q_
m
Well Diagram
Q
0
E
F=
Description of Material & Remarks
U)
W
a
Y
U
Gniess; grey, competent
N
J R
o U
0
a
o
- a
5
o
m
N
Q
a
a
m
Y
10
-U O
`m o
u� o
U
a
� o
v
U)
15
Boring terminated at 15.3 feet
20
25
30
35
40
45
Municipal Engineering Services Company, P.A.
Operation/Construction Managers Civil/Sanitary Engineers Environmental Studies Page 1 of 1
PO Box 97, Garner, North Carolina 27529 [phone]PO Box 349, Boone, North Carolina 28607(828) 262-1767

LOG OF BORING: MW-18
Surry County, Mt. Airy Closed Project No. G07061.0
Drilling contractor: Derry's Well Drilling Date started: 6/1/2007 Surface elevation:
Drill rig & method: 7.75 OD HSA w/ SS Date ended: 6/1/2007 Top of pipe elevation:
Logged by: J. Pfohl Completion depth: 18.15 ft Depth to water (TOB): 10.18 ft
Stickup height: Depth to water (24hrs): 9.98 ft
Q
rj
Q
U)
Q_
0
E
� cn
m
F=
in
Description of Material & Remarks
Silty Sand; Dark brown with red clay nodules. micaceous, moist
Well Diagram
16
65
o U
0
Silty Sand/Saprolite; moderate brown, few angular schist fragments,
a
0
5
dense relic structure, micaceous, moist
CO U
V)
U N
89/10
:::°.,::: ,::
Silty Sand/Saprolite; dark brown, angular schist fragments, defined relic
0]
structure, micaceous, moist
a
a
10
_ a
U _O
d U)
-O O
50/5
. °
Silty Sand/Saprolite; same as above with more schist fragments, slightly
C �
N
weathered rock, wet
o
15
a
U
Boring terminated at 18.1 feet
20
25
30
35
40
45
Municipal Engineering Services Company, P.A.
Operation/Construction Managers Civil/Sanitary Engineers Environmental Studies Page 1 of 1
PO Box 97, Garner, North Carolina 27529 [phone]PO Box 349, Boone, North Carolina 28607(828) 262-1767

LOG OF BORING: MW-19
Surry County, Mt. Airy Closed
Project No. G07063.0
Drilling contractor: Derry's Well Drilling
Date started: 6/1/2007
Surface elevation:
942.97 ft (MSL)
Drill rig & method: 7.75 HSA w/SS, 5.5 DTH
Date ended: 6/1/2007
Top of pipe elevation:
946.27 ft (MSL)
Logged by: J. Pfohl
Completion depth: 17.10 ft
Depth to water JOB):
10.03 ft
Stickup height: 3.30 ft
Depth to water (24hrs):
9.57 ft
Q_
m
Well Diagram
Q
Q
0
E
F=
Description of Material & Remarks
M
rj
a_
M
a
Y
U_
21
Sandy Silt; dark brown, with few black root fragments, high organic
content, micaceous, moist
o
U
U
a
5
v
U
N U)
HSA Refusal on Rock seam (begin DTH)
N
50/3•..
----------------------------------------------------
PWR; moderately weathered rock, schist, brown, micaceous, dry
s•::;
10
� o
50/2
NO Recovery - PWR; moderately weathered rock, brown, schist
� o
' a
0
15
a
U)
TOP OF COMPETENT ROCK = 925.89 ft amsl
(V
Boring terminated at 17.1 feet
20
25
30
35
40
45
Municipal Engineering Services Company, P.A.
Operation/Construction Managers Civil/Sanitary Engineers Environmental Studies Page 1 of 1
PO Box 97, Garner, North Carolina 27529 [phone]PO Box 349, Boone, North Carolina 28607(828) 262-1767

LOG OF BORING: MW-20
Surry County, Mt. Airy Closed
Project No. G07061.0
Drilling contractor: Derry's Well Drilling
Date started:
6/1/2007
Surface elevation:
1079.12 ft (MSL)
Drill rig & method: 5.5 DTH w/SS
Date ended:
6/1/2007
Top of pipe elevation:
1082.19 ft (MSL)
Logged by: J. Pfohl
Completion depth:
25.64 ft
Depth to water JOB):
20.93 ft
Stickup height:
3.07 ft
Depth to water (24hrs):
19.53 ft
QQ_
m
Well Diagram
Q
0
E
F=
Description of Material & Remarks
o
rj
U)
U)
M
a
19
Silty Sand with Clay; red -brown, moderately cohesive, moist
Y
U_
84/9
Silty Sand/Saprolite; dense angular rock fragments, few black silt
partings, micaceous, dry
c
5
a
0
HSA Refusal - TOP OF COMPETENT ROCK = 1072.12 ft amsl
v
o N
Gneiss grey competent, no evident fractures
10
15
a�
n
a
groundwater encountered
6
Y
� O
a �
-o 0
� o
u� o
j
20
CL
0
v
U
(V
25
Boring terminated at 25.6 feet
30
35
40
45
Municipal Engineering Services Company, P.A.
Operation/Construction Managers Civil/Sanitary Engineers Environmental Studies Page 1 of 1
PO Box 97, Garner, North Carolina 27529 [phone]PO Box 349, Boone, North Carolina 28607(828) 262-1767

LOG OF BORING: MW-21
Surry County, Mt. Airy Closed Project No. G07063.0
Drilling contractor: Derry's Well Drilling Date started: 6/1/2007 Surface elevation: 962.22 ft (MSL)
Drill rig & method: 7.5 OD HSA w/SS, 5.5 DTH Date ended: 6/1/2007 Top of pipe elevation: 965.36 ft (MSL)
Logged by: J. Pfohl Completion depth: 15.41 ft Depth to water (TOB): 6.23 ft
Stickup height: 3.14 ft Depth to water (24hrs): 6.10 ft
Q_
m
Well Diagram
Q
Q
0
E
F=
Description of Material & Remarks
a
rj
a_
M
a
14
Silty Sand; dark brown, micaceous, high organic content, few angular
Y
U_
schist fragments, moist
= o
5
----------------------------------------------------
HSA Refusal on rock seam
o �
°' N
----------------------------------------------------
= Q
a
85
Sandy Silt/Saprolite; relict structure, wet, almost PWR
o
TOP OF COMPETENT ROCK = 952.22 ft amsl
a o
>
0
large fracture - water encountered
v
U)
N
15
Boring terminated at 15.4 feet
20
25
30
35
40
45
Municipal Engineering Services Company, P.A.
Operation/Construction Managers Civil/Sanitary Engineers Environmental Studies Page 1 of 1
PO Box 97, Garner, North Carolina 27529 [phone]PO Box 349, Boone, North Carolina 28607(828) 262-1767

LOG OF BORING: MW-22
Surry County, Mt. Airy Closed
Project No. G07063.0
Drilling contractor: Derry's Well Drilling
Date started:
6/1/2007
Surface elevation:
950.23 ft (MSL)
Drill rig & method: 5.5 OD DTH
Date ended:
6/1/2007
Top of pipe elevation:
953.40 ft (MSL)
Logged by: J. Pfohl
Completion depth:
16.04 ft
Depth to water JOB):
4.63 ft
Stickup height:
3.17 ft
Depth to water (24hrs):
4.60 ft
QQ_
m
Well Diagram
Q
0
E
F=
Description of Material & Remarks
rj
co
U)
a
.
Sandy Silt; dark brown, few black root fragments, high organic content,
Y
U
y
23
micaceous, moist
2 0
U
Sandy Silt/Saprolite; moderately brown, dense, several angular rock
m s
5
fragments, moist, heavily weathered rock
(V
83
Sandy Silt; same as above, wet
N
d
d
Y
10
75
o
o
�
U o
u >
d
50/3
TOP OF COMPETENT ROCK = 936.23 ft amsl; moderately weathered
15
gneiss, wet
N
Boring terminated at 16.0 feet
20
25
30
35
40
45
Municipal Engineering Services Company, P.A.
Operation/Construction Managers Civil/Sanitary Engineers Environmental Studies Page 1 of 1
PO Box 97, Garner, North Carolina 27529 [phone]PO Box 349, Boone, North Carolina 28607(828) 262-1767

LOG OF BORING: MW-23
Surry County, Mt. Airy Closed
Project No. G07063.0
Drilling contractor: Derry's Well Drilling
Date started:
6/1/2007
Surface elevation:
952.09 ft (MSL)
Drill rig & method: 7.75 OD HSA w/SS
Date ended:
6/1/2007
Top of pipe elevation:
955.31 ft (MSL)
Logged by: J. Pfohl
Completion depth:
17.10 ft
Depth to water (TOB):
8.19 ft
Stickup height:
3.22 ft
Depth to water (24hrs):
8.16 ft
Q
rj
Q
U)
Q_
0
E
U)
m
F=
Description of Material & Remarks
Sandy Silt with clay; red -brown, relict structure, organic debris, moist
Well Diagram
N
M
a
Y
U_
J N
20
2 t6
� U
U
33
Sandy Silt; dark brown, few balck organic silt nodules, micaceous, moist
a
0
5
a
U
N U)
CO (V
35
Sandy Silt; same as above, wet
= a
10
a
m
Y
� o
d U
� o
41
Sandy Silt; moderate brown, few angular schist fragments, micaceous,
c p
� o
' a
wet
15
Boring terminated at 17.1 feet
20
25
30
35
40
45
Municipal Engineering Services Company, P.A.
Operation/Construction Managers Civil/Sanitary Engineers Environmental Studies Page 1 of 1
PO Box 97, Garner, North Carolina 27529 [phone]PO Box 349, Boone, North Carolina 28607(828) 262-1767

1 r ONRESIDENTIAL WELL CONSTRUCTION RECORD Mw. 13
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2663
1. WELL CONTRACTOR:
Derry Huneycutt
Well Contractor (Individual) Name
Derry's Well Drilling
Well Contractor Company Name
STREET ADDRESS 44283-A NC 24/27/73
Albemarle NC 28002
City or Town State Zip Code
704 - 982-3070
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring © Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 5/30/06
TIME COMPLETED 2:30
3. WELL LOCATION:
CITY: Ararat
AM PM El
COUNTY NC
419 Landfill Road 27007
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
®Slope ❑ Valley ❑ Flat [:]Ridge ❑ Other
(check appropriate box)
LATITUDE 316v_�G aSS. J (M'M May be in degrees,
minutes, seconds or
LONGITUDE SC 34 -Of, SW 1 in a decimal format
Latitude/longitude source: gGPS El Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY- is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY Surry Co. Closed Landfill
STREET ADDRESS 419 Landfill Road
Ararat NC 27007
City or Town State Zip Code
CONTACT PERSON Mr. Jerry Snow
MAILING ADDRESS PO Box 1542
Mount Airy NC 27030
City or Town State Zip Code
33(_ 6 _)- 401-8376
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 35.78'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E4
c. WATER LEVEL Below Top of Casing: 26.90 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 3.00 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): na METHOD OF TEST na
f. DISINFECTION: Type na Amount na
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter WeF% Material
From 0 To 20.78 Ft. 2" sc
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 16.5 Ft Neat Cement Tremie
From 16.5 To�— Ft. 318" Bentonite Chips Pour
From 35.78 To 44 Ft Neat Cement Tremie
8. SCREEN: Depth Diameter Slot Size Material
From 20.78 To 35.78 Ft.2" in. 0.10 in. PVC
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From 19.5 To 35.78 Ft. #2 Filter Sand
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 44 fe
11. REMARKS:
MW-13 Installed as type II MW for monitoring downgradient of closed MSWLF
I DO HEREBY C FYTHATTH WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C LL C TR ON STANDARDS, AND THAT A COPY OF THIS
RECOR H EES OVI 0THE WELL OWNER.
7/1/06
SIGNA E OF CERTOIED WELL CONTRACTOR DATE
©1 rty vAev,r✓#
PRINTECINAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev. 7/05

NONRESIDENTIAL WELL CONSTRUCTION RECORD MW W 14
North Carolina Department of Environment and Natural. Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2663
1. WELL CONTRACTOR:
Derry Huneycutt
Well Contractor (Individual) Name
Derry's Well Drilling
Well Contractor Company Name
STREET ADDRESS 44283-A NC 24/27/73
Albemarle NC 28002
City or Town State Zip Code
982-3070
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or 01fHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring © Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 5/30/06
TIME COMIPLETED 630 AM ❑ PM E:i
3. WELL LOQATION:
CITY: Ara�lrat COUNTY NC
419 Landfill Road 27007
(Street Nartie, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGR�IIPHIC / LAND SETTING:
El Slope ❑,/alley & Flat ❑ Ridge El Other
(heck appropriate box)
LATITUDE 36'ab 03.1115 May be in degrees,
minutes, seconds or
LONGITUDE _0 4 0 11.3441 T in a decimal format
Latitude/longitude source: B GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITYl is the name of the business where the well is located.
FACILITYJID #(if applicable)
NAME OFIFACILITY Surry Co. Closed Landfill
i
STREET ADDRESS 419 Landfill Road
i
Ararat NC 27007
City or Town State Zip Code
CONTACT PERSON Mr. Jerry Snow
MAILING ADDRESS PO Box 1542
Mount Airy NC 27030
City
or Town State Zip Code
( 336
j_ 401-8376
Phone number
Area code,-
5. WELL DETAILS:
TOTAL
DEPTH: 48.03'
a.
b. DOES
WELL REPLACE EXISTING WELL? YES ❑ NO B
c. WATE
LEVEL Below Top of Casing: 41.19 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 3.00 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): na METHOD OF TEST na
f. DISINFECTION: Type na Amount na
g. WATER ZONES (depth):
From 38.18 To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Wehi % Matterial
From 0 To 33.03 Ft.2" sc PVC
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 29.5 Ft. Neat Cement Tremie
From 29•5 To Ft. 3/8" Bentonite Chips Pour
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From 33.03 To 48.03 Ft.2" in. 0.10 in. PVC
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From 32 To 48.03 Ft. #2 Filter Sand
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 6 Soil
6 48.03 PWR to Rock
11. REMARKS:
MW-14 Installed as type II MW for monitoring downgradient of closed MSWLF
I DO HEREBY C FY THAT THIS E L WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC �2c�!-L CON UC O STANDARDS, AND THAT A COPY OF THIS
RECORD N P IDE HE WELL OWNER.
7/1/06
SI U O CE IF DWELL CONTRACTOR DATE
D1101 R. "n cv c "ft
PRINTEP NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Srvice Center— Raleigh, INC 27699-1617 Phone No. [phone] ext 568. Rev. 7/05

4r;�rt
<,
NONRESIDENTIAL WELL CONSTRUCTION RECORD (AW
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2663
1. WELL C
NTRACTOR:
Derry H
neycutt
Well Contractor
(Individual) Name
Derry's
ell Drilling
Well Con
ractor Company Name
STREET
DDRESS 44283-A NC 24/27/73
NC 28002
Albema le
ity
or Town State Zip Code
704
_ 982-3070
Area cod
Phone number
2. WELL IN
ORMATION:
SITE W
LL ID #(if applicable)
STATE
ELL PERMIT#(if applicable)
DWQ or
THER PERMIT #(if applicable)
WELL USE (Check
Applicable Box) Monitoring © Municipal/Public ❑
Industrial/C
mmercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation
Other ❑ (list use)
DATE DR
LLED 6/22/06
TIME CO
PLETED 8:30 AM ❑ PM
3. WELL LO
ATION:
CITY: Ar
rat COUNTY NC
419 Land
ill Road 27007
(Street Na
e, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGR
PHIC / LAND SETTING:
glSlope ❑
Valley ❑ Flat ❑ Ridge ❑ Other
LATITUD
LONGITU
check appropriate box)
1J, Oi . 17'$ May be in degrees,
minutes, seconds or
E Ii 3 • �� 3� in a decimal format
Latitude/1
ngitude source: 4GPS ❑Topographic map
(locatio
of well must be shown on a USGS topo map and
attach
d to this form f not using GPS)
4. FACILITY
is the name of the business where the well is located.
FACILITY
ID #(if applicable)
NAME OF
FACILITY Surry Co. Closed Landfill
DDRESS 419 Landfill Road
STREET
NC 27007
Ararat
City or
own State Zip Code
CONTACT
PERSON Mr. Jerry Snow
DDRESS PO Box 1542
MAILING
NC 27030
Mount Ai
City
o Town State Zip Code
( 336 )
401-8376
Area code
Phone number
S. WELL DETAILS:
a. TOTAL
EPTH: 56.98'
b. DOES
ELL REPLACE EXISTING WELL? YES ❑ NO p
c. WATER
LEVEL Below Top of Casing: 52.47 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 3.00 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): na METHOD OF TEST na
f. DISINFECTION: Type na Amount na
g. WATER ZONES (depth):
From 49.47 To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter W i Material
From 0 To 41.98 Ft, 2" Sc� V PVC
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 37.5 Ft Neat Cement Tremie
From 37.5 To4UM� Ft. 3/8" Bentonite Chips Pour
From To Ft.
a. SCREEN: Depth Diameter Slot Size Material
From 41.98 To 56.98 Ft.2" in. 0.10 in. PVC
From To Ft. in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth Size Material
From 40.38 To 56.98 Ft. #2 Filter Sand
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 28 Soil
28 56.98 Rock
11. REMARKS:
MW-15 Installed as type 11 MW for monitoring downgradient of closed MSWLF
I DO HEREBY CE YTHAT THIS ELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WL
CO RUCT STANDARDS, AND THAT A COPY OF THIS
RECORD N P TR E WELL OWNER.
7/1 /06
SIG A U OF CERTI D WELL CONTRACTOR DATE
Derry v
PRINT D NAME 09 PERSON CONSTRUCTING THE WELL
Submit the riginal to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Se ice Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568, Rev. 7105

1 1' ONRESIDEN7'IAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2663
1. WELL CONTRACTOR:
Derry Huneycutt
Well Contractor (Individual) Name
Derry's Well Drilling
Well Contractor Company Name
STREET ADDRESS 44283-A NC 24/27/73
Albemarle NC 28002
City or Town State Zip Code
70( 4 mil_ 982-3070
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring © Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 6/21/06
TIME COMPLETED 8:15 AM E� PM El
3. WELL LOCATION:
CITY: Ararat COUNTY NC
419 Landfill Road 27007
(Street Name, Numbers, Community, Subdi\Asion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
}Slope Walley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE JI 16 Oq .'Cg0 k May be in degrees,
minutes, seconds or
LONGITUDE0 in a decimal format
Latitude/longitude source: 4IGPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY- is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY Surry Co. Closed Landfill
STREET ADDRESS 419 Landfill Road
Ararat NC 27007
City or Town State Zip Code
CONTACT PERSON Mr. Jerry Snow
MAILING ADDRESS PO Box 1542
Mount Airy NC 27030
City or Town State Zip Code
( 336 )- 401-8376
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 36.28'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
c. WATER LEVEL Below Top of Casing: 26.94 FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 3.00 FT. Above Land Surface*
*Top of casing terminated attor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): na METHOD OF TEST na
f. DISINFECTION: Type na Amount na
g. WATER ZONES (depth):
From 23.94 To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Wightt Material
From 0 To 21.28 Ft. 2" scPh 40 PVC
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 18.25 Ft Neat Cement Tremie
From 18.25 Tom— Ft. 318" 6entonite Chips Pour
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From 21.28 To 36.28 Ft. 2" in. 0.10 in. PVC
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From 20.5 To 36.28 Ft. #2 Filter Sand
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 9 Soil
9 36.28 Rock; Gneiss
11. REMARKS:
MW-16 Installed as type II MW for monitoring downgradient of closed MSWLF
I DO HEREBY C FY THAT IS L AS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C LL CO uc-n ANDARDS, AND THAT A COPY OF THIS
RECORD EENP DED T WELL O ER.
I
7/1/06
SIGNATL,PE OF CERTIFIOWELL CONTRACTOR DATE
I)s rh/ V �V%iLV &-
PRINTE NAME OFfPERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information. Mgt., Form GW-1b
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev. 7/05

SI ire
{ NoNRESIDENTIAL WELL CONSTRUCTION RECORD
y: If o North Carolina Department of Environment and Natural Resources- Division of Water Quality
�`� • > ? WELL CONTRACTOR CERTIFICATION # 2663
1. WELL CONTRACTOR:
Derry Huneycutt
Well Contractor (Individual) Name
Derry's Well Drilling Inc.
Well Contractor Company Name
STREETADDRESS 44283-A NC 24/27/73
Albemarle NC 28002
City or Town State Zip Code
7( 04 )- 982-9070
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-17
WELL CONSTRUCTION PERMIT#(if applicable)
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring❑ Municipal/Public❑
Ind ustrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑
Irdgationp Other❑ (list use)
DATE DRILLED 6/1/07
TIME COMPLETED 9:30 AMI1 PM❑
4. WELL LOCATION:
CITY: Ararat COUNTY NC
419 Landfill Rd. a7007
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope Ip Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
36.4338922 May e in degrees,
LATITUDE _ _ minutes, seconds or
LONGITUDE 80.572245 in a decimal format
Latitude/longitude source: 0 GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
6. FACILITY- is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY Surry Co. Closed MSWLF
STREET ADDRESS 419 Landfill Rd.
Ararat NC 27007
City or Town State Zip Code
CONTACT PERSON Mr. Jerry Snow
MAILING ADDRESS PO BOX 1542
Mount Airy NC 27030
City or Town State Zip Code
(336 )-401-8376
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 15.32
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOS
c. WATER LEVEL Below Top of Casing: 8.83 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 3.00 FT. Above Land Surface'
'Top of casing terminated attor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): na METHOD OF TEST na
f. DISINFECTION: Type na Amount na
g. WATER ZONES (depth):
From 10 To 10.5 From To
From To From To
From To From To
7. CASING: Thickness/
Depth plameter Wei ht Material
From 0 To 5.32 Ft. 2 SCA4fl PVC
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From 0 To 3 Ft. Neat Cement Pour
From--3- To 5.10 Ft. 3/8" Bent. Chips Pour
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From 5.32 To 15.32 Ft. 2 in. 0.01 in. PVC
From To Ft. in. in.
From To Ft. in. - in.
10. SAND/GRAVEL PACK:
Depth Size Material
From 5.IG To IS-32 Ft. #2 FilteF Sand
From To Ft.
From To Ft.
11.DRILLING LOG
From To Formation Description
Q I S- 31 Rock } Gr.:g Gat is s
12. REMARKS:
�+^wngradient of closedMSWLF
I DO HEREBY CE Y THAT THIS WEL AS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, L PRO CONS UCTION TANDAROS, AND THAT A COPY OF THIS
RECORD H S N EDT E WELL OW
SIGNA R OF CERTI IE EL CONTRACTOR DATE
Decn� l.- 4t, lie(ACA
PRINTED E OF PERSON C STRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev. 3/07

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2663
1. WELL CONTRACTOR:
Derry Huneycutt
Well Contractor (Individual) Name
Derry's Well Drilling Inc.
Well Contractor Company Name
STREET ADDRESS 44283-A NC 24/27/73
Albemarle NC 28002
City or Town State Zip Code
7( 04 )_ 982-9070
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MWA 8
WELL CONSTRUCTION PERMIT#(if applicable)
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring El Municipal/Public❑
Industrial/Commercial❑ Agricultural❑ Recovery[] Injection❑
Irrigation[] OtherD (list use)
DATE DRILLED 6/1/07
TIME COMPLETED 1:20 AM❑ PM®
4. WELL LOCATION:
CITY: Ararat COUNTY NC
419 Landfill Rd. a100 7
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope I Valley 0 Flat ❑ Ridge 0 Other
(check appropriate box)
May be in degrees,
LATITUDE 36.433015639 minutes, seconds or
LONGITUDE 80.572032 in a decimal format
Latitude/longitude source: 0 GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. FACILITY- is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY Slurry Co. Closed MSWLF
STREET ADDRESS 419 Landfill Rd.
Ararat NC 27007
City or Town State Zip Code
CONTACT PERSON Mr. Jerry Snow
MAILING ADDRESS PO Box 1542
Mount Airy NC 27030
City or Town State Zip Code
(336 1-401-8376
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 18.15
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOE)
c. WATER LEVEL Below Top of Casing: 9•98 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 3.00 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): na METHOD OF TEST na
f. DISINFECTION: Type na Amount na
g. WATER ZONES (depth):
From 6.98 To 18.15 From To
From To From To
From To From To
7. CASING: Thickness/
Depth lameter Weight Material
From 0 To 8.15 Ft. 1 S(:nl+u F'VU
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From 0 To 5 Ft. Neat Cement Tremie
From_5 To 7 Ft. 3/8" Bent. Chi Pour
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From 8.15 To 18.15 Ft. 2 in. 0.01 in. PVC
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
From 7 To 1% J S Ft. #2 Foke.
Sand
From To Ft. —
From —To— Ft.
11.DRILLING LOG
From To Formation Description
O 3.5 $, S f
3,5 t�•Ig
1'N4 P r� [n1 [ iJI t0�
12. REMARKS:
WAf 1 o I n aars type tt MVV f.,F MgRlt9ring
Agradient of closed 11 SWI 1=
I DO HEREBY C FY THAT THIS W L WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C L CON RU I STANDARDS, A THAT A COPY OF THIS
RECORD EN P IDE T THE WELL OWN
V-a8-o
SIGNA UR F CERTI IED LL CONTRACTOR DATE
Dexyq L - hu
PRINTED N ME OF PERSON CO STRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev. 3/07

NON-RESIDENTIAL
4 1 � ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2663
1. WELL CONTRACTOR:
Derry Huneycutt
Well Contractor (Individual) Name
Derry's Well Drilling Inc.
Well Contractor Company Name
STREET ADDRESS 44283-A NC 24/27/73
Albemarle NC 28002
City or Town State Zip Code
7( 04 )- 982-9070
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-19
WELL CONSTRUCTION PERMIT#(if applicable)
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring11 Municipal/Public❑
Ind ustrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑
Irrigationp Other❑ (list use)
DATE DRILLED 6/1 /07 -
TIME COMPLETED 11:50 AM® PM❑
4. WELL LOCATION:
CITY: Ararat COUNTY NC
419 Landfill Rd. a 7 00 %
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope It Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box) May be in degrees,
LATITUDE 36.433015639 minutes, seconds or
LONGITUDE 80.572032 in a decimal format
Latitude/longitude source: i GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. FACILITY- is the name of the business where the well is located.
FACILITY ID Cif applicable)
NAME OF FACILITY Slurry CO. Closed MSWLF
STREETADDRESS 419 Landfill Rd.
Ararat NC 27007
City or Town State Zip Code
CONTACT PERSON Mr. Jerry Snow
MAILING ADDRESS PO Box 1542
Mount Airy NC 27030
City or Town State Zip Code
( 336 )- 401-8376
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 17.10
b. DOES WELL REPLACE EXISTING WELL? YES❑ NON
c. WATER LEVEL Below Top of Casing: 9•57 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 3.00 FT. Above Land Surface`
*Top of casing terminated attor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): na METHOD OF TEST na
If. DISINFECTION: Type na Amount na
g. WATER ZONES (depth):
From 10 To 17.10 From To
From To From To
From To From To
7. CASING: Thickness/
Depth plameter Weight Material
From 0 To 7.10 Ft. 2 scnl+u 11yu
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From 0 To 4 Ft. Neat Cement Tremie
From_4 To 6 Ft. 3/8" Bent. Chips Pour
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From 7.10 To 17.10 Ft. 2 in. 0.01 in, PVC
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
From 6 To 1 7.10 Ft. #2 ; flier Send
From To Ft. -
From -To- Ft.
11.DRILLING LOG
From To Formation Description
0 6S S
6.t 4.9 a
4.9 17-16
12. REMARKS:
rlou�Tadiont of closed AQS\A(I_F
I DO HEREBY C IFY THAT THIS LL WAS CONSTRUCTED IN ACCORDANCE WITH.
15A NCAC 2C LL CO TR TI N STANDARDS, AND THAT A COPY OF THIS
RECORD H EN P VID T THE WELL O
O'V C
SIGNjrLJV OF CERTIFIEC&VELL CONTRACTOR DATE
PRINTED NA E OF PERSON CON T UCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev. 3/07

�lI y
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2663
1. WELL CONTRACTOR:
Derry Huneycutt
Well Contractor (Individual) Name
Derry's Well Drilling Inc.
Well Contractor Company Name
STREET ADDRESS 44283-A NC 24/27/73
Albemarle NC 28002
City or Town State Zip Code
7( 04 )-982-9070
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *(if applicable) MW-20
WELL CONSTRUCTION PERMIT#(if applicable)
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring® Municipal/Public❑
Industrial/Commercial❑ Agricultural❑ Recoveryp Injection❑
Irrigation❑ Other❑ (list use)
DATE DRILLED 6/1/07
TIME COMPLETED 10:30 AMD PM❑
4. WELL LOCATION:
CITY: Ararat COUNTY NC
419 Landfill Rd. a 7 0 Q 7
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope 0 Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
May be in degrees,
LATITUDE 36.4326887 minutes, seconds or
LONGITUDE 80.56910777 in a decimal fonnat
Latitude/longitude source: 0 GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. FACILITY- is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY Surry Co. Closed MSWLF
STREET ADDRESS 419 Landfill Rd.
Ararat NC 27007
City or Town State Zip Code
CONTACT PERSON Mr. Jerry Snow
MAILING ADDRESS PO BOX 1542
Mount Airy NC 27030
City or Town State Zip Code
33(_ 6 )- 401-8376
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25.64
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOD
c. WATER LEVEL Below Top of Casing: 19.53 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 3.00 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
- a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): na METHOD OF TEST na
f. DISINFECTION: Type na Amount na
g. WATER ZONES (depth):
From 17 To 17.5 From To
From To From To
From To From To
7. CASING: Thickness/
Depth plameter Weight Material
From 0 To 10.64 Ft, 2 sc1`14v 11yu
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From 0 To 7 Ft. Neat Cement Tremie
From 7 To 9.5 Ft. 3/8" Bent. Chips Pour
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From 10.64 To 25.64 Ft. 2 in. 0.01 in. PVC
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
From 9.5 To 15.64 Ft. #2 filter Sand
From To Ft. -
From -To- Ft.-
1 I.DRILLING LOG
From To Formation Description
0 S/�.� 8 raw✓i
7 �,(n 1R 011=3S co'
12. REMARKS:
downgradient of clesgd MSWLF
I DO HEREBY CE Y THAT THIS W L WAS CONSTRUCTED IN ACCORDANCE WITH
I5A NCAC 2C, CON RU TI STANDARDS, AND THAT A COPY OF THIS
RECORD A N P IDE T T HE WELL OWNE
�- aS40`7
SIGN UR F C R IE WELL CONTRACTOR DATE
Oefro L 1 I u new{ fE
PRINTED qPE OF PERSON CQJSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No, [phone] ext 568. Rev. 3/07

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
`` •<�kw2. ! '' WELL CONTRACTOR CERTIFICATION # 2663
1. WELL CONTRACTOR:
Derry Huneycutt
Well Contractor (Individual) Name
Derry's Well Drilling Inc.
Well Contractor Company Name
STREET ADDRESS 44283-A NC 24/27/73
Albemarle NC, 28002
City or Town State Zip Code
7( 04 )- 982-9070
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *(if applicable) MW-21
WELL CONSTRUCTION PERMIT#(if applicable)
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring Municipal/Public❑
Industrial/Commercial❑ Agricultural❑ Recovery[] Injection❑
Irrigationp Other❑ (list use)
DATE DRILLED 6/1 /07
TIME COMPLETED 3:30 AM❑ PMG
4. WELL LOCATION:
CITY: Ararat COUNTY NC
419 Landfill Rd. 27007
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope II Valley ❑ Flat ❑ Ridge 0 Other
(check appropriate box) May be in degrees,
LATITUDE 36.434277833 minutes, seconds or
LONGITUDE 80.568596 in a decimal format
Latitude/longitude source: 0 GPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. FACILITY- is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY Surry Co. Closed MSWLF
STREET ADDRESS 419 Landfill Rd.
Ararat NC 27007
City or Town State Zip Code
CONTACT PERSON Mr. Jerry Snow
MAILING ADDRESS PO BOX 1542
Mount Airy NC 27030
City or Town State Zip Code
336 )-401-8376
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 15.41
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOD
c. WATER LEVEL Below Top of Casing: 6.10 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 3.00 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): na METHOD OF TEST na
f. DISINFECTION: Type na Amount na
g. WATER ZONES (depth):
From 6 To 6.50 From To
From To From To
From To From To
7. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 5.41 Ft. 4 5c:nL+v I'VU
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From 0 To 3 Ft. Neat Cement Tremie
From 3 To--5 Ft. 3/8" Bent. Chi Pour
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From 5.41 To 15.41 Ft. 2 in. 0.01 in. PVC
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
From 5 To ISM I Ft. #2 `ilte; R'"A - -
From 15.41 To IID Ft.
From To Ft.
11.DRILLING LOG
From To Formation Description
a
S 6.
16 Sa t
16 It, a vs
12. REMARKS:
WA -21 Installed as type II MW for menitering
doWngradient-af clesed MSWLF.
11
1 DO HEREBY C FY THA THI LL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C LL CO RU STANDARDS, AND THAT A COPY OF THIS
RECOR H EN P to THE WELL NE ,.ry
CJ
SIGN T OF CERT WELL CONTRACTOR DATE
PRINTED NAIU OF PERSON COKVRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev. 3/07

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2663
1. WELL CONTRACTOR:
Derry Huneycutt
Well Contractor (Individual) Name
Derry's Well Drilling Inc.
Well Contractor Company Name
STREET ADDRESS 44283-A NC 24/27/73
Albemarle NC 28002
City or Town State Zip Code
7( 04 )- 982-9070
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-22
WELL CONSTRUCTION PERMIT#(if applicable)
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring Municipal/Public❑
Industrial/Commercial❑ Agricultural❑ Recovery(] Injection❑
Irrigationp OtherO (list use)
DATE DRILLED 6/1 /07
TIME COMPLETED 2:00 AM❑ PMO
4. WELL LOCATION:
CITY: Ararat COUNTY NC
419 Landfill Rd. 27007
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope B Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
May be in degrees,
LATITUDE 36.435334111 minutes, seconds or
LONGITUDE 80.567269 in a decimal format
Latitude/longitude source: III GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. FACILITY- is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY Surry CO. Closed MSWLF
STREET ADDRESS 419 Landfill Rd.
Ararat NC 27007
City or Town State Zip Code
CONTACT PERSON Mr. Jerry Snow
MAILING ADDRESS PO Box 1542
Mount Airy NC 27030
City or Town State Zip Code
33( 6 _)- 401-8376
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 16.04
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOE
c. WATER LEVEL Below Top of Casing: 4.60 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 3.00 FT, Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): na METHOD OF TEST na
f. DISINFECTION: Type na Amount na
g. WATER ZONES (depth):
From 1.60 To >16.04 From To
From To From To
From To From To
7. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 6.04 Ft.4 6un-+U NVI:
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From 0 To 3. Ft. Neat Cement Tremie
From 3 To 5 Ft. 3/8" Bent. Chi Pour
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From 6.04 To 16.04 Ft. 2 in. 0.01 in. PVC
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
From 5 TO1(! 04 Ft. #2 Rlter SaAd
From To Ft.
From To Ft.
11.DRILLING LOG
From To Formati n Descri tion
S
3.5 I�.Oy n.
12. REMARKS:
downgradient of clesed MSWLF
I DO HE/C12
FY THA THIS - LL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCCO R T N STANDARDS AND THAT A COPY OF THIS
RECORP VID D THE ER.
<9- "--V—d
SIGNATU OF CERTIFI WELL CONTRACTOR DATE
w
PRINTED E OF PERSON CON TRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1 b
1617 Mail Service Center— Raleigh, NC 276.99-1617 Phone No. [phone] ext 568. Rev. 3/07

S�:9rki
y NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2663
1. WELL CONTRACTOR:
Derry Huneycutt
Well Contractor (Individual) Name
Derry's Well Drilling Inc.
Well Contractor Company Name
STREETADDRESS 44283-A NC 24/27/73
Albemarle NC 28002
City or Town State Zip Code
7( 04 )- 982-9070
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-23
WELL CONSTRUCTION PERMIT#(if applicable)
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring® Municipal/Public❑
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑
Irrigation❑ Other❑ (list use)
DATE DRILLED 6/1/07
TIME COMPLETED 4:20 AM❑ PME
4. WELL LOCATION:
CITY: Ararat COUNTY NC
419 Landfill Rd. 27007
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope ® Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box) May be in degrees,
LATITUDE 36.439015556 minutes, seconds or
LONGITUDE 80.571788 in a decimal format
Latitude/longitude source: 0 GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. FACILITY- is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY Surry Co. Closed MSWLF
STREET ADDRESS 419 Landfill Rd.
Ararat NC 27007
City or Town State Zip Code
CONTACT PERSON Mr. Jerry Snow
MAILING ADDRESS PO BOX 1542
Mount Airy NC 27030
City or Town State Zip Code
(336 )- 401-8376
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 17.10
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO0
c. WATER LEVEL Below Top of Casing: 8.16 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 3.00
FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with
15A NCAC 2C .0118.
e. YIELD (gpm): na
METHOD OF TEST na
f. DISINFECTION: Type na
Amount na
g. WATER ZONES (depth):
From 5.16 To 17.10
From To
From To
From To
From To
From To
7. CASING:
Thickness/
0
Depth lameter Weight
7.10 f.
Material
From
To
Ft. SL'n<+u
11VU
From
To
Ft.
From
To
Ft.
8. GROUT:
Depth
Material
Method
From 0
To 4
Ft. Neat Cement
Tremie
From-4—
To 6.05
Ft, 3/8" Bent. Chits
Pour
From
To
Ft.
9. SCREEN:
Depth
Diameter Slot Size
Material
From 7.10
To 17.10
Ft. 2 in. 0.01 in,
PVC
From
To
Ft. in. in.
From
To
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
_
Size Material
From 6. 05
To) 7.10 Ft. #2 Filter Sand
From
To
Ft.
From
To
Ft.
11.DRILLING LOG
From To Formation Description
0 3,5 S W
3,S iY.lo ,
ALMA
J
12. REMARKS:
dowAgradient of closed MSWLP.
I DO HEREBY IFY THA THIS W L WAS CONST CTED IN ACCORDANCE WITH
15A NCAC 2 LL CO RU T STANDARDS D THAT A COPY OF THIS
RECOR EEN P ID �T THLWQLLQW06VT
v
SIG ATU OF C RTIFJM WELL CONTRACTOR DATE
OF PERSON CONSTRUCTING
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1 b
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev. 3107

APPENDIX B
ENVIRONMENTAL MONITORING REPORT FORM

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CD (data loaded: Yes /
'NU utNK Environmental Monitoring
Division of Waste Management - Solid Waste
Reporting Form
Notice: This form and any information attached to it are "Public Records" as defined in NC General Statute 132-1. As such, these documents are
available for inspection and examination by any person upon request (NC General Statute 132-6).
Instructions:
• Prepare one form for each individually monitored unit.
• Please type or print legibly.
Attach a notification table with values that attain or exceed NC 2L groundwater standards or NC 2B surface water standards. The notification
must include a preliminary analysis of the cause and significance of each value. (e.g. naturally occurring, off -site source, pre-existing
condition, etc.).
• Attach a notification table of any groundwater or surface water values that equal or exceed the reporting limits.
• Attach a notification table of any methane gas values that attain or exceed explosive gas levels. This includes any structures on or nearby the
facility (NCAC 13B .1629 (4)(a)(i).
• Send the original signed and sealed form, any tables, and Electronic Data Deliverable to: Compliance Unit, NCDENR-DWM, Solid Waste
Section, 1646 Mail Service Center, Raleigh, INC 27699-1646.
Solid Waste Monitoring Data Submittal Information
Name of entity submitting data (laboratory, consultant, facility owner)
Contact for questions about data formatting. Include data preparer's name, telephone number and Email address:
Name: Phone:
E-mail:
NC Landfill Rule: Actual sampling dates (e.g.,
Facility name: Facility Address: Facility Permit # (.0500 or .1600) October 20-24. 2006)
Environmental Status: (Check all that apply)
Initial/Background Monitoring ❑ Detection Monitoring
of data submitted: (Check all that apply)
Groundwater monitoring data from monitoring wells
Groundwater monitoring data from private water supply wells
Leachate monitoring data
Assessment Monitoring
Methane gas monitoring data
❑
Corrective action data (specify)
❑
Other(specify)
❑ Corrective Action
Notification attached?
e No. No groundwater or surface water standards were exceeded.
Yes, a notification of values exceeding a groundwater or surface water standard is attached. It includes a list of groundwater and surface water
monitoring points, dates, analytical values, NC 2L groundwater standard, NC 2B surface water standard or NC Solid Waste GWPS and
preliminary analysis of the cause and significance of any concentration.
Yes, a notification of values exceeding an explosive methane gas limit is attached. It includes the methane monitoring points, dales, sample
values and explosive methane gas limits.
Certification
To the best of my knowledge, the information reported and statements made on this data submittal and attachments are true and correct.
Furthermore, I have attached complete notification of any sampling values meeting or exceeding groundwater standards or explosive gas
levels, and a preliminary analysis of the cause and significance of concentrations exceeding groundwater standards. I am aware that there
are significant penalties for making any false statement, representation, or certification including the possibility of a fine and imprisonment.
Facility Representative Name(Print) Title (Area Code) Telephone Number
Signature
Facility Representative Address
NC PE Firm License Number (if applicable effective May 1,
Dale
Affix NC Licensed/ Professional Geologist Seal
Revised 6/2009

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