WQ0002096_Monitoring - 02-2020_20200401 (2)

GW-59A COMPLIANCE REPORT FORM Permit #
(Submit one each monitoring period with GW-59 forms.)
1
Enter date monitoring results were due.( Jj,,YW ) Will this monitoring report (GW-59 and GW-59A)
YES
NO
be submitted after the established due date?
2
Was any required information missing on the GW-59 report forms?
YES
NO
IF the answer to question 1 or 2 is "YES", list in the space provided below the well identification number(s) and
explain the problems encountered in obtaining the required information.
3
Are any of the monitor wells in need of repair or maintenance (damaged casing, unlocked or missing cap, missing
YES
NO
identification plate, area overgrown, etc.)? If the answer is "Yes ", contact the Regional Office for guidance.
4
Are any monitored constituents equal to or above the established standards?
YE
NO
If the answer to question 4 is "NO", skip to section 8.
If the answer to question 4 is "YES" list the affected wells individually with constituent(s) and concentration(s)
exceeding standard in he space provided b low:
�Y1►ti I��cti �ol �orir� I f
5
For the constituents identified in question 4 above, have standards been exceeded previously for the
YES
'NO
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 with constituent(s) exceeding
standards, concentration(s) reported, and sample collection date for each occurrence (for the last two years).
Are the monitoring wells listed in section 5 located at or beyond the review boundary?
YES
NO
If the answer is "YES", a groundwater quality problem maybe occurring. CONTACT THE REGIONAL
OFFICE IMMEDIATELY FOR GUIDANCE. If the answer is "NO", monitoring wells maybe improperly
located; contact the Regional Office.
7
Is the permittee implementing previously approved actions required by the Division involving this
YES
NO
groundwater quality problem?
If the answer to question 7 is "YES", describe those actions in the space provided below.
If the answer to question 7 is "NO", contact the Regional Office within 90 days; an evaluation may be
re uired to determine the impact the wastAdis osal s s m is having at the review and com liance
boundaries surrounding this facility. Failide to do so subject the permittee to a Notice of Violatioffi
fines, and/or penalties. D
o �►
a �
chi c-4 i, ! a
8
The person completing this portion (GW-59,_Ri) of the mon ring report shoLqsigV1j4e1ow and submit this
form with GW-59 forms for required wells taffhe address provided at the top of the current GW-59 form.
_,
1 hereb acknowledge that the above information was evaluated and the information submitted in this
repo ( ompliance Report GW-59A) is true and complete to the best of my knowledge.
� r2 3 ZU
Signatur Permi ee (or Authorized Agent) Date
GW-59A 12/8/2003

w.
EmwohmuqpM Flo hCupumbd
Drinking Water IDs 37715
114 OAKMONT DRIVE
GREENVILLE, N.C. 27858
PINEWOOD MANOR INC.
240 SOUTH EARLY STATION RD.
AHOSKIE ,NC 27910
FAX
ID#: 377
DATE COLLECTED: 02/10/20
DATE REPORTED : 02/17/20
REVIEWED BY:
4-
Effluent
Well #4
Well #5
Well #7
Analysis
Method
PARAMETERS
Date
Analyst
Code
BOD, mg/I
32
02/11/20
TMR
521OB-11
Fecal Coliform (MF), /100 MIS
3000
1
< 1
< 1
02/10/20
HJO
9222D-06
Total Suspended Residue, mg/l
27
02/11/20
MAR
254013-11
Ammonia Nitrogen as N, mg/I
7.61
0.07
0.12
0.07
02/11/20
AKS
350.1 112-93
Total Igeldahl Nitrogen as N,mg/I
15.48
02/14/20
BLD
351.2 112-93
Nitrate -Nitrite as N, mg/I
0.05
02/11/20
BLD
353.2 112-93
Nitrate Nitrogen as N, mg/I
<0.04
<0.04
<0.04
02/11/20
BLD
353.2 112-93
Total Phosphorus as P, mg/1
1.99
02/14/20
TLH
365.4-74
Total Organic Carbon, mg/1
2.17
6.73
< 1.00
02/10/20
SEJ
531OC-11
Total Dissolved Residue, mg/I
92
114
216
02/11/20
HJO
2540C-II

Environment 1, Inc. CHAIN% OF CUSTODY RECORD
P.U. Box 7085• 114 Oakmont Dr. / page 1 uf' . 1
`Greernv?Ile. NC 27858
PI
Z4
14
I (2
environment l inc.com
DISINFECTION
CHLORINE NEUTRALIZED AT COLLECTION
Phone [phone] • Fax [phone]
acHLORINE
•
/
pH CHECK (LAB,
CLIENT: 377 Week: 11
UV
P
P
P
P
P
P
P
P
P
P
CONTAINER TYPE, P/G
NEWOOD MANOR INC.
❑ NONE
0 SOUTH EARLY STATION RD.
CHEMICAL PRESERVATION
1:3A
HOSHIE NC 27910
G
A
C
C
C
A
C
C
A
A - NONE D - NAOH
o
52) 287-4153
i '
w Z
w
E!
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r
LU
B - HNO, E - HCLJ
�0o
= 0
9 w
Z
9
I.C.
.3
z
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a
cc
W C- H.SO, F- ZINC ACETATE/NAOH
COLLECTION
U x
8G
y
u
x
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v
�F
G- NATHIOSULFATE
SAMPLE LOCATION
DATE
TIME
o
k" a
ci
F
<
F
Z
z
E-
F
Effluent
-}'��
! ��
5
`
ZWASTEW SIFICATION:
Well #4
_
5
ATER (NPDES)
DRINKINGWATER
Well #5
5
Well #7
"'
�,�
5
Ij DWR/GW
Ij SOLID WASTE SECTION
CHAIN OF CUSTODY (SEAL) MAINTAINED
DURING S MENT/DELIVERY
N
SAMPLES CHMECTED BY:
(P Print) /�
SAMPLES RE(EIVED IN LAB AT __ , C
A ER)
DATE/TI
E I Y(SIG.)
D TE1TIME
COMMENTS:
=Hj(SIG.)
RELINQU HED BY (SIG.)
DATE/TIME
REC ED BY (SIG.)
DATE/i1ME
RELINQUISHED BY (SIG.)
DATETIME
RECEIVED BY (SIG.)
DATE/TIME
PLEASE READ Instructions for completing this form on the reverse side. Sampler must place a "C for composite sample or a "T for O
FORM x5 Grab sample in the blocks above for each parameter requested. ri_ 373417

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
FACILITY INFORMATION Please Print Clearly - Type
n
Facility Name: f h C'.i,�lood !'1')a nog �St Ho my
PERMIT Number: J�� Expiration Date: `-}' � Ci � (✓
Non -Discharge �t)b ow U9 UIC
Permit Name (if different):
NPDES Other
Facility Address: L L4C) COW-tj Earl � ,S u oo
7-)oact
TYPE OF PERMITTED OPERATION BEING MONITORED
19h� t( I c IStreeU � Z� q / (�
I`
Count y 'r—r o rA
❑Lagoon ❑Remediation: Infiltration Gallery
(City) (State) (ZIP)
Par
S❑ La' —Spray Field Remediation:
®
Contact Person: Rand-ef'
Telephone#: ��i _a �-
`►) 53
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: i -cyiou d Srr'W,-e1
No. of wells to be sampled:
❑ Water Source Heat Pump ❑ Other:
-�
from Permit
SAMPLING INFORMATION
WELL ID NUMBER (from Permit):�
Date sample collected: A
o Ig U
FIELD ANALYSES:
If WELL
WAS
Well Depth: I ft.
Well Diameter:in.
pH ooaoo: units Temp. 00010: °C
DRY at
Depth to Water Level 825a6: ft. below measuring
p g point
Screened Interval: ft.
to
ft. Spec. Cond. 000sa: µ Mhos
time of
Measuring Point is 5ft. above land surface
Relative M.P. Elevation:
ft.
Odor 00085:
sampling,
check
Volume of water pumped/bailed before sampling: gallons
Appearance Ci E m u X
here:❑
Samples for metals were collected unfiltered: ❑ YES ❑ NO and field acidified: ❑ YES
❑ NO
LABORATORY INFORMATI N
— a 1 / av
L 0
hyt rohmenf I
Date sample analyzed: 9 1 lobo
Laboratory Name: L
; Ly)Cr Certification No.
PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L
Nitrite (NO2) as N 00615
mg/L Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 /100mL Nitrate (NO3) as N 00620 < C)t &) 4 mg/L
Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L
Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 cIl mg/L
Al -Aluminum 01105
mg/L
pH (Lab) 00403 units
Ba - Barium 01007
ug/L
TOC 00680 ) mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002 ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552 mg/L
Cu - Copper 01042
mg/L
ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730 ug/L
Fe - Iron 01045
ug/L
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945 mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 00095 µMhos
K - Potassium 00937
mg/L
VOC 7873 method #
Total Ammonia 00610 U G mg/L
Mg - Magnesium 00927
mg/L
method #
(Ammonia Nitrogen; NH3 as N; Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L
, method #
TKN as N 00625 mg/L
Ni - Nickel 01067
ug/L
method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
I
• •
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
• • •
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
FACILITY INFORMATION, Please Print
-A
Clearly or Type
PERMIT Number: Expiration Date:
Facility Name: f i ,nevzod Manor
1
� �S� HDm ej
I,�,Il/� Non -Discharge �006d 0 & UIC
Permit Name (if different):
NPDES Other
Facility Address: 2q o _�1Q L{ f h Carl iy S t'Gl _' 10,1 goo
TYPE OF PERMITTED OPERATION BEING MONITORED
hosKI e, (street)
12-7
/ p County H If dr
❑ Lagoon ❑ Remediation: Infiltration Gallery
(city) Q ,/Il> zip)
04-�
pray Field ❑ Remediation:
Contact Person: LW I Qi ei(state^
I �
Telephone#: i o� �7 ��
S�
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: Pt Y -e'wo S ra d,r!
No. of wells to be sampled: 3
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION
WELL ID NUMBER Permit): -4 5
i�
If WELL
WAS
(from
Date sample collected:
FIELD ANALYSES:
Well Depth: 2 ` ft.
Well Diameter: 2 in.
pH 00400: 5,q units Temp. 000lo: °C
DRY at
Depth to Water Level 82546:ft. below measuring point
Screened Interval: ZP
to 2 ft. Spec. Cond. 000sa: µMhos
time offt.
21
sampling,
Measuring Point is ft. above land surface
Relative M.P. Elevation:
ft. Odor 00085:
check
Volume of water pumped/bailed before sampling: 3
gallons
Appearance brown 17&tax
here: ❑
Samples for metals were collected unfiltered: El YES
El NO and field acidified: El YES El NO
LABORATORY INFORMATI IN
_ II 4),AU
— L
Ln Vr ��nm�n �� J nC"
Date sample analyzed: IG/ao
Laboratory Name:
I Certification No.
PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L
Nitrite (NO2) as N 00615
mg/L Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 /100mL
Nitrate (NO3) as N 00620
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 14 mg/L
Al - Aluminum 01105
mg/L
pH (Lab) 00403 units
Ba - Barium 01007
ug/L
TOC oosao b,73 mg/L
Ca - Calcium 00916
mg/L
Chloride oosao mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002 ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552 mg/L
Cu - Copper 01042
mg/L ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730 ug/L
Fe - Iron 01045
ug/L (Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945 mg/L
Hg - Mercury 71900
ug/L Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 00095 FtMhos
K - Potassium 00937
mg/L VOC 7873 method #
Total Ammonia 00610 ©i mg/L
Mg - Magnesium 00927
mg/L method #
(Ammonia Nitrogen; NH3asN; Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L , method #
TKN as N 00625 mg/L
Ni - Nickel 01067
ug/L method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%
GW-59 Rev.05-02-2017

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
=
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
0
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
FACILITY INFORMATI Please Print Clearly or Type
Facility Name: I i)fV_b()d %�C{,oe es�- /Ojj)eJ
PERMIT Number: Expiration Date: `T 36 AC ;
Non -Discharge V'NQ00Q20q% UIC
Permit Name (if different):
�-4 (✓
NPDES Other
Fa 'I' y Address: So U _ar-1 q
+ ck-liDY] oGA
TYPE OF PERMITTED OPERATION BEING MONITORED
V J G � y � Q /'
0 K-1 � (Street) -7 I (� Count
(City) (State) zip)
,❑,/L�poon El Remediation: Infiltration Gallery
D
Contact Person: AO v)d I ar
[� 2
Telephone#: 7 /5J
Litt Spray Field ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: Pid<%)()Oj -V
r tt7jT No. of wells to be sampled:
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION r-�
abolAo
If WELL
WELL ID NUMBER (from Per it):
N
Date sample collected:
FIELD ANALYSES:
WAS
Well Depth: ft.
Well Diameter: in.
pH 00400: b a / units Temp. 00010: °C
DRY at
-I—
ft. below measuring point Screened Interval: �ft. to
Depth to Water Level 82546: r�ft.
>i
ft. Spec. Cond. 000sa: µMhos
time of
Measuring Point is
—
sampling,
bove land surface
Relative M.P. Elevation: ft.
Odor 00085:
check
Volume of water pumped/bailed before sampling: A
gallons
Appearance CIOURV
here:
❑
Samples for metals were collected unfiltered: El YES
❑ NO and field acidified: ❑ YES El NO
LABORATORY INFORMATIO
o bo _ - t+ aG
CC.� �
E5
Date sample analyzed: I
Laboratory Name: r)V, r0r) MCA>�
, T-J1Gr Certification No. �G
PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L
Nitrite (NO2) as N 00615
mg/L
Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 f /100mL
Nitrate (NO3) as N 00620 L (j, �} L+
mg/L
Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100ml-
Phosphorus: Total as P 00665
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L
Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 '2- I Lf mg/L
Al - Aluminum 01105
mg/L
pH (Lab) 00403 units
Ba - Barium 01007
ug/L
TOC 00680 1 , UU mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002 ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552 mg/L
Cu - Copper 01042
mg/L
ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730 ug/L
Fe - Iron 01045
ug/L
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945 mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 00095 µMhos
K - Potassium 00937
mg/L
VOC 7873 method #
Total Ammonia 00610 =7 mg/L
Mg - Magnesium 00927
mg/L
method #
(Ammonia Nitrogen; NH3 as N; Ammonia Nitrogen,Total)
Mn - Manganese 01055
ug/L
, method #
TKN as N 00625 mg/L
Ni - Nickel 01067
ug/L
method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%