WQ0023310_Monitoring - 04-2020_20200611

v-59PORT FORM Permit old a m 3 l o
(Saibrrft one z 11 monitoring en wish GW-59 forms)
j
Enter date monitoring results were due. +1e ill this monitoring report (GW�9 and GW-59A)
YES
O
be submitted after the established due date?
2
Was any required information missing on the GW-59 report forms?
YES
O
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
identification
YES
`NO
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?
YES
NO
If the answer to question 4 is "NO", skip to section 8.
If the answer to question 4 is "YES" list the affectel wells individually with nstituent(s) and concentration(s)
exceeding
ce provided below:
Stan �rd the �ja
rn �-
N(4,U���
5
For the constituents identified in question 4 Abovhave 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, co ce tfop(s) reD rt d, and sample collection date for each occurrence (for the last two years).
MW
311 -16-ao �,1h
Q 1 j r jQ 4 2ra
6
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 may be occurring. CONTACT THE REGIONAL
OFFICE IMMEDIATELY FOR GUIDANCE. If the answer is "NO", monitoring wells may be improperly
located; contact the Regional Office.
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 spaceQ� vided below.
If the answer to question 7 is "NO", contact the ReaiaAal Office with. 90 days; an evaluation may be
reauired to determine the impact the waste disposal switQrn aviA at the review and compliance
boundaries surrounding this facility. Failure to do s",ft subiect ffte permittee to a Notice of Violation
fines, and(orpenalties. m
� o o z
Z
y , M
O
g
The person completing this portion (GW-59A) of the monitoring report should sign below anfRubmit this
form with GW-59 forms for required wells to the address provided at the top of the current GW-59 form.
t eby ackn*whx%p#tat#wabcw& boa was wed and the ' subnM-ftd in t
7rt and cwnpleW to the best piety knov .
rwort .- 7.r1:5--Q1 - d
Signature of e i e (o A Agent) Date
G'N-59A 12/8/2003

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SUBMIT FORM ON YELLOW PAPER ONLY
.i DEPARTMENT OF BNVIRONMENTAl lOUA41'[Y,� DIVt:,QF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
'° ii�dRMA"ibN"I�RbCSSINO'UNl7 }
COMPLIANCE REPORT FORM
W7 MAIL SSRVICE CSNTSR, RAh ISSN, NC 27899 1817 Phone. [phone]
Please Print Clearly or Type
FACILITY INFORMATI N; \�
��`����\
PERMIT Number i �Iration Date:
� �, j
Facility Name: �� C�C"'� Ck1 \STD
J� \ ��'"'
Non -Discharge UIC
Permit Name (if different :
NPDES Other
Facility Address: - Wv (
S' -
TYPE OF PERMITTED OPERATION BEING MONITORED
CSC. "; (street) '
3c County u' i
❑ Lagoon ❑ Remediation: Infiltration Gallery
(city) (state) (zip)
Cray Field ❑ Remediation:
Contact Person: 'V�C'-Ck
Telephone# ��� ,GIJ `" S'J
❑ Rotary Distributor ElLand Application of Sludge
Well Location/Site Name: c�c c� �C �Gr1
S_ = No. of wells to be sampled:
El Water Source Heat Pump El Other:
(from Permit)
SAMPLING INFORMATION
° �l` ` `7 FIELD ANALYSES:
If WELL
WAS
WELL ID NUMBER (from Pgrmit):
N%i 11 ate sample collected: �(
jr)r� °C
DRY at
Well Depth:yy ft.
Well Diameter: c in.
pH 00400:�units Temp. 000ifl
Depth to Water Level 82546: C ft. below measuring
point Screened Interval: ft. to
_ft. Spec. Cond, 0009a: µMhos
time of
sampling,
Measuring Point is ft. above land surface
Relative M.P. Elevation: ft.
Odor 00085: ��',�
check
Volume of water pumped/bailed before sampling:
gallons
—/��--n
Appearance dec i r
here: ❑
Samples for metals were collected unfiltered: ❑ YES
❑ NO and field acidified: ❑ YES ❑ NO
LABORATORY INFORMATION r1 r 1 ( C!
Date sample analyzed: Z� ,`f 3G,S-� , / �-S C�- 0�6 Laboratory Name: _/n it rot -c`(� Certification No.
PARAMETERS NOTE: Values shiduld reflect dissolved and colloidal concentrations.
COD 00335 mg/L
Nitrite (NO2) as N 00515
mg/L Pb - Lead 01051 ug/L
Coliform: MF Fecal 31516 J /100mL
Nitrate (NO3) as N 00620 m
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL
Phosphorus: Total as P 00665 . 5'
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 Ci mg/L
Al - Aluminum o11o5
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)
pecific Conductance 00095 µMhos
K - Potassium 00937
mg/L VOC 7873 method #
Total Ammonia 00610 t mg/L
Mg - Magnesium 00927
mg/L method #
(Ammonia Nitrogen; NH3as N; Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L , method #
TKN as N 00525 mg/L
Ni - Nickel 01067
ug/L method #
Permittee (or Authorized Agent) Name and Title - Please print or type
GW-59 Rev. 05-02-2017 -,�c ' .— Rq — a,o

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
Facility Name: fQ '<Pl.rJ
Permit Name (if different):-
Facilitm Address: `a a
(State) (zip)
)tact Person: Al V
II Location/Site Name:
vorrype PERMIT NumberbjQ�,�A33 apiration Date:
6-{� ��^�_\C" �V�1 i Non -Discharge f V UIC
NPDES Other
TYPE OF PERMITTED OPERATION BEING MONITORED
County (r ❑ Lagoon ❑ Remediation: Infiltration Gallery
9��Pray Field ❑ Remediation:
t
Telephone#: ' S3 S El Rotary Distributor ❑Land Application of Sludge
No. of wells to be sampled: ❑ Water Source Heat Pump ❑ Other:
SAMPLING INFORMATION (� 11 11
WELL ID NUMBER (from Permit): \' \W t t tC�- \ Date sample collected:` ' oC�
Well Depth: �ft. JJJ Well Diameter: in.
Depth to Water Level 82548:_ft. below measuring point Screened Interval: ft. to ft.
Measuring Point is ft. above land surface Relative M.P. Elevation: ft.
Volume of water pumped/bailed before sampling: a t allons
Samples for metals were collected unfiltered: ❑ YES NO and field acidified: ❑ YES ❑ NO
FIELD AN�ALLYISES:
pH ooaoo: 7, c, units Temp. 000lo:�o t 9°C
Spec. Cond. 00094: µMhos
Odor o0085: 1
Appearance
If WELL
WAS
DRY at
time of
sampling,
check
here:❑
LABORATORY INFORMATION
Date sample analyzed: , - `� `{-30 S I S- q & S— 8 _ Q0 LaboratoryName: �w�
C� �—c�C\
Certification No.
PARAMETERS NOTE: Valu s should ref ect 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
1
Nitrate (NO3) as N 00620 _ mg/L
t
Zn - Zinc 01092 m /L
g
Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665 Q
Q mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L
Other (Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300 mg/L
AI -Aluminum o1105
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 _ ttMhos
K - Potassium 00937
mg/L
VOC 7873 method #
Total Ammonia 00610 I< Q mg/L
Mg - Magnesium 00927
mg/L
method #
(Ammonia Nitrogen, NH3as N, Ammonia Nitrogen, Total)
Mn - Manganese o1o55
ug/L
, method #
TKN as N 00625 mg/L
Ni - Nickel 01067
ug/L
method #
t-or Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%
ittee (or Authorized Agent) Name and Title - Please print or type Signature of Permittee (or
GW-59 Rev. 05-02-2017 ��5� �,\ y Q' C�

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF, ENVIRONMENTAL QUALITY <DIV. OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
MAIL SERVICE CENTER, RALEIGH, NC 27099,1017 Phone; 019,807.6306
FACILITY INFORMATION Please Print Clearly or Type
PERMIT Number:., A(U �S'Expiration Date: �
1
Facility Name: q(SG W �Gn �� c` `
\y (1 \ Gt�\r�C \�T, Y�
Non -Discharge JJ UIC
Permit Name (if different):
NPDES Other
Fact I'Address: I
TYPE OF PERMITTED OPERATION BEING MONITORED
(Street) / 8, County
❑ Lagoon ❑ Remediation: Infiltration Gallery
(City) (State) (zip)
pray Field ❑Remediation:
Contact Person:
c G��
Telephone#:
Rotary Distributor El Land Application of Sludge
Well Location/Site Name: Al G t .\LCrN
nNo. of wells to be sampled:_
❑ Water Source Heat Pump ❑ Other:
(from Permit)
SAMPLING INFORMATION `,\ C_( r,C-
0�_' a
If WELL
WELL ID NUMBER (from Permit): W'~
\�\\ ���1 Date sample collected: t�
FIELD ANALYSES:
WAS
Well Depth: � Sft.
Well Diameter: in.
pH 00400: �_13 units Temp. 000lo: j °C
DRY at
Depth to Water Level 82548: '. ft. below measuring
point Screened Interval: ft. to
ft. Spec. Cond. 00094: µMhos
time of
sampling,
Measuring Point is ft. above land surface
Relative M.P. Elevation: ft.
Odor 00085:
check
Volume of water pumped/bailed before sampling: 0
gallons
Appearance C_ 'Cck C—
here:❑
Samples for metals were collected unfiltered: ❑ YES
❑ NO and field acidified: ❑ YES ❑ NO
LABORATORY INFORMATION
Date sample analyzed: ) �-30 S
S % — aOLaboratory Name:
Certification No.
PARAMETERS NOTE: Value shouldlreflecf 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 (D , 10 mg/L
Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL
Phosphorus: Total as P 00665 0. Q mg/L
(Note: Use MPN method for highly turbid samples)
J
Orthophosphate 70507 mg/L
Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 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 o1o27 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 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%
Permittee (or Authorized Agent) Name and Title - Please print or
GW-59 Rev.05-02-2017
Signature of Permittee (or Authorized Agent)
Y_ 4. - L I -ao res-.ter �a
1I I a

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENTAL QUALITY • DIV. OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
�40,11
i ` INFORMATION I`ROCESSIN0 UNIT
COMPLIANCE REPORT FORM
MAIL OORVICE CENTER, RAL00N, NCvdoe9 1617 Phone; 018Rs07.008
Please Print Clearly or T pe
FACILITY INFORMA I N �-- \ \
�IV
PERMIT Number: (\ l�piration Date: — l�
vim!
Facility Name: a�5� yx>t1\ C����6(\((1\�
( �1�j�
Non -Discharge UIC
Permit Name (if different):
NPDES Other
Fa 'lity Address: �c
TYPE OF PERMITTED OPERATION BEING MONITORED
C. '�_'off (street)
County LL
❑��Lagoon ❑ Remediation: Infiltration Gallery
(City) (State) (zip)
b's-pray Field ❑ Remediation:
Contact Person: C A Q Q
Telephone#: \I' XL S3�S
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name:t roc � , \ '
No. of wells to be sampled: _
❑ Water Source Heat Pump ❑ Other:
(from Permit)
SAMPLING INFORMATION 11 \\ \ f
WELL ID NUMBER (from Permit): W — o F` Date sample collected: C>tc'k
FIELD ANALYSES:
If WELL
WAS
t
Jl
/
°C
DRY at
Well Depth: ft.
Well Diameter:in.
pH 00400:.-)1 units Temp. 000to:l / /
Depth to Water Level 82546:_ft. below measuring point
Screened Interval: ft. to _ft.
Spec. Cond. 000sa: µMhos
time of
sampling,
Measuring Point is ft. above land surface .
Relative M.P. Elevation: ft.
Odor 00085:
check
Volume of water pumped/bailed before sampling: A(
gallons
Appearance
here: ❑
Samples for metals were collected unfiltered: ❑ YES
NO and field acidified: ❑ YES ❑ NO
LABORATDate sample anaRY INFORMATION
z dR ATION 4 _ S� S 7 d-S U-�OLaboratory Name: -I)o ���-
(�(� Certification No.
PARAMETERS NOTE: Valueg shout 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 L /100mL
Nitrate (NO3) as N 00620 o Q ' mg/L
Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665 < d mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507 mg/L
Other (Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300 SS 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 a 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 Q, mg/L
Mg - Magnesium 00927 mg/L
method #
(Ammonia Nitrogen, NH, as N; Ammonia Nitrogen, Total)
Mn - Manganese o1o55 ug/L
, method #
TKN as N 00625 mg/L
Ni - Nickel 01067 ug/L
method #
For Remedlation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%
certify that, to the best of my knowledge and belief, the information submitted in this report is true, accurate, and complete, and that the labr-a,ry a ialy',cF d,.a wr,,. produced using approved methods of analysis by a
DWR-certified laboratory. I am aware that there are significant penalties for submitting false information, including the possibility of fines ar , i, piis,,nm:r'. for uim ng violations.
Irk-
ig a re of Permittee (or Authorized Agent) ._

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
x�tt , DEPARTMENT OR ENVIR©NMONTAL QUALITY. • DIV. OF WATER RESOURCES ,
iN�t�v�ul,�I1QN'f�Flt�11 8SINQ'UNIT,
COMPLIANCE REPORT FORM
�I;MIIL9RVIC6"CEFI(Slt,`RAIii3H,NCx18891817 Phone;919-eo7B3o8
FACILITY INFORMATI0�9 Please Print Clearly or Type
�--, LL ,l � /,
I
PERMIT Number: O0 Hpiration Date:
Facility Name: Q�Sc7t�`� �n\�q�jb���\li'„'
Vy�S�
Non -Discharge UIC
NPDES Other
Permit Name (if different):
Facilit Address: lvL ,
TYPE OF PERMITTED OPERATION BEING MONITORED
{ c�(6 (Street)
County \,
❑ Lagoon ❑ Remediation: Infiltration Gallery
(City) (State) (zip)
ray Field ❑ Remediation:
Contact Person: irk ��
Telephone#: -I l l7 Z13
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: Q, a ;ccO 3�Qo
Qc E_No. of wells to be sampled:
El Water Source Heat Pump El Other:
_
(from Permit
SAMPLING INFORMATION (f, �> l
WELL ID NUMBER permit): \` �� 1\ \`�\ Date ` _
FIELD ANALYSES:
If WELL
WAS
(from
Well Depth: 1 ft.
sample collected:
Well Diameter: in.
r�
pH ooaoo:� units Temp. 000lo: �� Tj °C
DRY at
Depth to Water Level 82548: q t j ft. below measuring point
Screened Interval: ft. to
Spec. Cond. 000ga: µMhos
time
_ft.
sampling,
Measuring Point is ft. above land surface
Relative M.P. Elevation: ft.
Odor 00085: 2�
check
Volume of water pumped/bailed before sampling: q3
gallons
Appearance (_'j C Gt
here: ❑
Samples for metals were collected unfiltered: ❑ YES ❑ NO and field acidified: ❑ YES ❑ NO
LABORATORY INFOR ATION
Date sample analyzed: ,'f —301 S-1 / 5'r� a
YS _ ll Laboratory Name: 1\ (0�
t !
Certification No. C C_
PARAMETERS NOTE: Value& should ref ect dissolved
colloidal concentrations.
COD 00335 mg/L
Nitrite (NO2) as N 00615 mg/L
Pb - Lead o1o5i ug/L
Coliform: MF Fecal 31616 C-, /100mL
Nitrate (NO3) as N 00620 mg/L
Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL Phosphorus:
Total as P 00665 G n 1 mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507 mg/L
Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 (S 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 oogao S 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 � a t a mg/L
Mg - Magnesium 00927 mg/L
method #
(Ammonia Nitrogen; NH3as N, Ammonia Nitrogen, Total)
Mn - Manganese 01055 ug/L
, method #
TKN as N 00625 mg/L
Ni - Nickel 01067 ug/L
method #
For Remedlation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%
I certify that, to the best of my knowledge and belief, the information submitted in this report is true, accurate, and complete, and that the labr-a' ,ry a ialy,ce dr.a w;,,. produced using approved methods of analysis by a
DWR-certified laboratory. I am aware that there are significant penalties for submitting false information, including the possibility of fines ar , ',• pns ,nm :r. for moc ng violations.
nc_�L - V �p
r �r
mitt6e (or Authorized Agent) Name and Title - Please print or type Signature of Permittee (or Authorized Agen7
GW-59 Rev.
1 1 1
I�

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENTAL QUALITY • DIV, OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
1847 MAIM, SERVICE CENTER, RALEIGH, NO 27609.1017 Phone: 919,007,6306
FACILITY INFORMATIQN I Please Print Clearly orType �� r
/�I �
PERMIT Number: kN U 0 Q33 �cSiration Date:
U
Facility Name: W CA csc-(a�C s f1 T�.rt"1�0r
/ (� 1l
Non -Discharge UIC
Permit Name (if different):
NPDES Other
Fa ilit Address: U LA 1
(Street)
TYPE OF PERMITTED OPERATION BEING MONITORED
Ck �3 C
County
❑ Lagoon ❑ Remediation: Infiltration Gallery
(city) (Slate (zip)
pray Field ❑ Remediation:
Contact Person: C
Q
Telephone#: p �� "" S3 U S
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: C '\\"-
G QC o Flo. of wells to be sampled:
❑ Water Source Heat Pump ❑ Other:
J (from Permit)
SAMPLING INFORMATION t'
WELL ID NUMBER (from Permit):LV J t,\( Date sample collected: i o��
FIELD ANALYSES:
If WELL
WAS
Well Depth: 1 Sft.
Well Diameter: in.
pH 00400:�_',_; units Temp. 000lo:I°C
DRY at
Depth to Water Level 825487-0 ft. below measuring point Screened Interval: ft.
to _ft.
Spec. Cond. 00094: µMhos
time of
sampling,
Measuring Point is ft. above land surface
I Relative M.P. Elevation:
ft.
Odor 00085:
check
Volume of water pumped/bailed before sampling: S C1(
allons
Appearance (lye
here: ❑
Samples for metals were collected unfiltered: ❑ YES
O and field acidified: ❑ YES ❑ NO
LABORATORY INFOR.NATIIOrN /, { n
Date sample analyzed:Lf --o( ) ,��3 VZ S' 1 f S� / a-S� Laboratory Name: U 1 co C
G
Certification No. 1 _
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 :::L C /100mL
Nitrate (NO3) as N 00620 mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL
Phosphorus: Total as P 00665 a
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 1 mg/L
Al - Aluminum o11oe
mg/L
pH (Lab) 00403 units
Ba - Barium 01007
ug/L
TOC 00680 mg/L
Ca - Calcium 00915
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 EtMhos
K - Potassium 00937
mg/L VOC 7873 method #
Total Ammonia 00610 L. Q mg/L
Mg - Magnesium 00927
mg/L method #
(Ammonia Nitrogen, NH3as N; Ammonia Nitrogen, Total)
Mn - Manganese o1o55
ug/L
, method #
TKN as N 00625 mg/L
Ni - Nickel 01067
ug/L
method #
itteL (or Authorized Agent) Name and Title - Please print or type
GW-59 Rev.05-02-2017
* 'f — -w) a 0 M{/ Lc,(-