8002_NeedmoreRoad_May/Nov2016GWMR_20170524

DENR USE ONLY: Paper Report Electronic Data - Email CD (data loaded: Yes / No ) Doc/Event #: NC DENR Division of Waste Management - Solid Waste Environmental Monitoring
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, NC 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 E-mail address:
Name: Phone:
E-mail:
Facility name: Facility Address: Facility Permit #
NC Landfill Rule:
(.0500 or .1600)
Actual sampling dates (e.g.,
October 20-24, 2006)
Environmental Status: (Check all that apply)
Initial/Background Monitoring Detection Monitoring Assessment Monitoring Corrective Action
Type of data submitted: (Check all that apply) Groundwater monitoring data from monitoring wells Methane gas monitoring data Groundwater monitoring data from private water supply wells Corrective action data (specify) Leachate monitoring data Other(specify) Surface water monitoring data
Notification attached? 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, dates, 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
Affix NC Licensed/ Professional Geologist Seal
Revised 6/2009
Date
Facility Representative Address
NC PE Firm License Number (if applicable effective May 1, 2009)