640001_Compliance_GW-59 Form_20191008

a` GW-59A COMPLIANCE REPORT FORM Permit # i�lt� bel�dj
(Suhrnir one cork n,enilaring Ilerlorl with GH -59 formv.)
( Enter date monitoring results were due. - a- } Will this monitoring report (OW-59 and GW-59A)
be submitted after the established due date?
Z Was any required information missing an the GW-59 report forma?
!F the answer to question t or 2 is "YES ; list in the space provided below the well iderttificalion number(s) and
explain the problems encountered in obtaining the required inllarmation.
Are any or the monitor wells in need of repair or maintenance (damaged casing, unlocked or missing cap,
ldentilication plate, area Overgrown, etc.)? !f the amwer is "Yes". conracr the Regional Office for guidance.
4 Are any monitored constituents equal to or above the established standards?
If the answer to question 4 fs YVp", skip to section 8.
!f the answer to question 4 Is "YES" list the affected wells indn avily WAh constituent(s) and concentretion(s)
exceeding standards in the space provided below.
W
V
7
rur ore consutuents identified in question 4 above, have stars
same constituent(s) In the same well(s) in the last two years?
If the answer to question 5 is'NO , skip to section 8.
If the answer to question 5 is "YES list in the space provided below, each well (
standards, concentration(s) reported, and sample collection date for each occurrentu
wells
at or
OCT 2 3 2019
if the answer is " S , a groundwater qualityproblem maybe occurrtng CONTACT THE REGIONAI
OFFICE IMMEDIATELY FOR GUIDANCE If the answer is "Non , monitoring wells may be Improperly
located; contact the Regional OfFice.
quality problem?
rr me answer to quesfdan 7 is "YES", d
If the answer to question 7 Is "No-,
the space
by the Division involving this
OCT 2 s 2019
Raleigh Regional
8 The person completing this portion (G W-59A) of the monitoring report should sign below and submit ft
form with GW-59 forms for required wells to the address provided at the top of the current GIN-59 form.
I hereby acknowledge that the above Information was evaluated and the Information submitted in this
report (Com nee Report GW-ti9A) is true and complete to the best of n y knowledge.
gnature of Pormittea (or Awhnfi7nd e"e,..r 8
all
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G W-Skirl 12/8130113

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