WQ0002096_Monitoring - 06-2020_20200729

GW-59A COMPLIANCE REPORT FORM Pet l:l[t # ` tJ00�by
(Submit one each manitoring period with t; i3'-59 forms.)
1
Enter date monitoring results were due. ) 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 i 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 standards in the space prov�ided below.
l-
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 sampf ollection date for each occurrence (for the last two years).
W-61 i� �- 1 c� , o2 w►� �i, - J ur1 t, l201
mjlL- 5ef+ 261F
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.
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
required to determine the impact the waste disposal system is having at the review and compliance
boundaries surrounding this facility. Failure to do so may subject the permittee to a.Notice of Violation,
fines, and/or penalties. 1—
r-
�m
g
The person completing this portion (GW--59A) of the gsonitoring report should sign below and submit this
form with GW-59 forms for required wells to the address provided at the top of the current GW-59 form.
I hereby acknowledge that the above information was evaluated and the information submitted in this
report (Compliance Report GW-59A) is true and complete to the best of my knowledge.
X,104-,- `1 Z 0 Z0
Sig natur ermittee (or A orized Agent) Pate

SUBMIT FORM ON YELLOW PAPER ONLY
• .
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
• •
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: 919-807;6306
Please Print Clearly
Type FACILITY INFORM y or yp
PERMIT Number: Expiration Date: �V
Facility Name: I A e(J(yJ Man l� r Rc sf
N©m -e,
Non -Discharge CJ(J () q UIC
Permit Name (if different):
NPDES Other
Facility Address: m_ L-_ari Rhin
TYPE OF PERMITTED OPERATION BEING MONITORED
BvySk-kc(street) G 2r1 10
County H er+]�br=❑
Lagoon ❑ Remediation: Infiltration Gallery
(City) (state) (zip)
ray Field El Remediation:
Q �tv�
Contact Person: I lu+ I4
cp
Telephone#: �5 i 3-7 / I
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: t
No. of wells to be sampled:
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): iT
Date sample collected: ) /�
FIELD ANALYSES:
WAS
Well Depth:
Well Diameter: in.
pH 00a00: units Temp. 000lo: °CDRY
at
Depth to Water Level 82 6ft. below measuring point
*ft.
Screened Interval: ft. to
Mhostime
ft. Spec. Cond. 00094: µsampling,
of
Measuring Point is �� above land surface Relative M.P. Elevation: ft.
I
Volume of water pumped/bailed before sampling: �_ gallons
Odor 00085:
Appearance bUy
check
here:❑
Samples for metals were collected unfiltered: El YES El NO and field acidified: El YES ❑ NO
LABORATORYINFORMAT N //--
Date sample analyzed: I — iP I L
LaboratoryName: L ill%I �D }'I>°j'� ) /
hcJ, Certification No. ! V
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)S
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 Ctj mg/L
AI - Aluminum o11o5
mg/L
pH (Lab) 00403 units
Ba - Barium 01007
ug/L
TOC 00680 0. 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 d 6 5 mg/L
Mg - Magnesium 00927
mg/L
method #
(Ammonia Nitrogen; NH3asN; Ammonia Nitrogen, Total)
Mn - Manganese 01055
11 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
• •
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
T l t Cl i P Please Print or Type FACILITY INFORMAT ON
PERMIT Number: Expiration Date: V d a
Facility Name: i 11 ) b6d fflar)60 RC4
Horn c
Non -Discharge W&Mc 6 94 UIC
Permit Name (if different):
NPDES Other
Fa ' i y Address: Oa
&,cO
TYPE OF PERMITTED OPERATION BEING MONITORED
(Street) G 0 7 (C
County
El Lagoon ❑ Remediation: Infiltration Gallery
(city) (state) (zip)
[}'Spray Field El Remediation:
Contact Person:RP
�j (�
Telephone#: ~Jl 3 —Q�7�
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: , ' t-wrqVT,-ejj:No.
of wells to be sampled:_
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION
45
�S in I-)
IfWELL
WAS
WELL ID NUMBER (from Permit):
Date sample collected: LIJ
FIELD ANALYSES:
Well Depth: �ft.
Well Diameter: in.
pH ooa00: units Temp. 000lo: °C
DRY at
Depth to Water Level 825446:_ft. below measuring point
Screened Interval: 43 ft. to
ft. Spec. Cond. 00094: µMhos
time of
sampling,
Measuring Point is ,rft. above land surface
Relative M.P. Elevation: ft.
Odor 00085:
check
Volume of water pumped/bailed before sampling: _gallons
Appearance
here:❑
Samples for metals were collected unfiltered: ❑ YES ❑
NO and field acidified: ❑ YES ❑ NO
LABORATORY INFORMATION
Date sample analyzed: 0 t
�/
Laboratory Name: Cw l ibna& I } L 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 <t 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 mg/L
Al - Aluminum olim mg/L
pH (Lab) 00403 units
Ba - Barium 01007 ug/L
TOC 00680 J 1 + mg/L
Ca - Calcium 00916 mg/L
Chloride 00940 mg/L
Cd - Cadmium 01027 ug/L
Arsenic 01002 ug/L
Chromium: Total o1o34 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 6105 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 #
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
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
FACILITY INFORMATION n Please Print Clearty or Type
Rats -�
PERMIT Number: � Expiration Date:
bb0
Facility Name: Y t n eo�d� n�5 r
�- �1©m
Non -Discharge W UIC
Permit Name (if differen)J:
NPDES Other
Facility.Address: � �Q
TYPE OF PERMITTED OPERATION BEING MONITORED
-e-, (Street) Ak
County Q
❑ Lagoon ❑ Remediation: Infiltration Gallery
(City) (State) (zip)
R-Spray Field ❑ Remediation:
Contact Person: Q�
Por
`,
Telephone#: Zj ����^ d S _In '
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: A<W6
No. of wells to be sampled:
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION//
If WELL
WELL ID NUMBER (from Permit): r7
Date sample collected: t0 �� W
FIELD ANALYSES:
°C
WAS
DRY at
Well Depth: 14ft.
Well Diameter: in.
pH oo400:-�,,�units Temp. o0010:
time of
Depth to Water Level 82546:_ft. below measuring point
Screened Interval: ft. to ft. Spec. Cond. 00094: µMhos
sampling,
Measuring Point is g, ft. above land surface
Relative M.P. Elevation: ft.
Odor 00085:
check
Volume of water pumped/bailed before sampling: 41
gallons
Appearance
here:❑
Samples for metals were collected unfiltered: ❑ YES ❑ NO and field acidified: ❑ YES ❑ NO
LABORATORY INFORMATION
]�
FIl1iIC6r)YVICAJ- Certification No. `0
Date sample analyzed:
Laboratory Name:
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 < Ole
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 %� mg/L
Al - Aluminum ollo5
mg/L
pH (Lab) 00403 units
Ba - Barium 01007
ug/L
TOC 00680 / c 0 C� t mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002 ug/L
Chromium: Total o1o34
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 b , V 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 o1067
ug/L method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOG Removal%

ElMommuM % hmpumbd
114 OAKMONT DRIVE
GREENVILLE, N.C. 27858
PINEWOOD MANOR INC.
240 SOUTH EARLY STATION RD.
AHOSKIE ,NC 27910
PHONE [phone]
FAX [phone]
ID#: 377
DATE COLLECTED: 06/15/20
DATE REPORTED : 06/22/20
v
REVIEWED BY: i
Effluent
Well U4
Well #5
Well N7
Analysis
Method
PARAMETERS
Dale
Analyst
Code
BOD, mg/l
64
06/16/20
GNB
521OB-11
Fecal Coliform (MF), /100 Mls
< 10
< 1
1
< 1
06/15/20
HJO
922213-06
Total Suspended Residue, mg/l
76
06/16/20
TMR
2540D-11
Ammonia Nitrogen as N, mg/l
0.08
0.05
0.06
<0.04
06/16/20
TM
350.1 112-93
Total Kjeidahl Nitrogen as N,mg/l
20.42
06/19/20
TCW
351.2 112-93
Nitrate -Nitrite as N, mg/l
0.11
06/16/20
DTL
353.2 112-93
Nitrate Nitrogen as N, mg/I
0.05
<0.04
<0.04
06/16/20
DTL
353.2 112-93
Total Phosphorus as P, mg/l
2.66
06/18/20
DTL
365.4-74
Total Organic Carbon, mg/I
2.18
11.96
1.09
06/15/20
SF.J
531OC-11
Total Dissolved Residue, mg/I
99
100
276
06/16/20
HJO
2540C-11

F,nvironment 1, Inc. CHAIN OF CUSTODY RECORD
P.O. Box _7985. 114 Oakmont Dr. ! Page 1 of 1
n, nVil01e NC 77RSR /
environment) inc.com
DISINFECTION
CHLORINE NEUTRALIZED AT COLLECTION
Phone [phone] •Fax [phone]
CHLORINE
L
pH CHECK (LAB)
CLIENT: 377 week: 28
UV
P
P
P
P
P
P
P
P
P
P
CONTAINER TYPE.P/G
VEWOOD MANOR INC.
❑ NONE
) SOUTH EARLY STATION RD.
CHEMICAL PRESERVATION
IOSKIE NC 27910
❑
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G
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C
C
C
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COLLECTION
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SAMPLE LOCATION
DATE
TIME
Effluent
�) 5
% )
5
CLASSIFICATION:
WASTEWATER (NPDES)
DRINKING WATER
Well #4
(g ) S }
7
`'
Well #5
5
j
5
Well #7
6-1 1
5
jDWR/GW
Ij SOLID WASTE SECTION
CHAIN OF CUSTODY (SEAL) MAINTAINED
DURI PMENT/DELIVERY
Y N
SAMPLES COLLECTED BY.
(Please Print)
fa o d V rckrker
SAMPLES 4ECEIVED IN LAB AT C
RE bWl ED (SAMPLER)
ATEMME .
RECEIVE (SIG.)
DATE�IME
COMMENTS:
��151AC ���
s77�
RELIN SHED BY (SIG.)
DATEMME
RECEIVED BY (SIGV
DATEMME
RELINQUISHED BY (SIG.)
DATEMME
RECEIVED BY (SIG)
DATEMME
PLEASE READ Instructions for completing this form on the reverse side. Sampler must place a "C" for composite sample or a "G" for
FORM us Grab sample in the blocks above for each parameter requested. N2 381126