WQ0002096_Monitoring - 09-2020_20201102 (2)

GW-59A COMPLIANCE REPORT FORM Permit # k wo
(Submit one each monitoring period with GW--59 forms.)
/'1.J-`h n
I
Enter date monitoring results were due. ( ) Will this monitoring report (GIN-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
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
YES
NO
identification plate, area overgrown, etc.)? /f the answer is "Yes", contact the Regional Officefor 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 affected wells individually with constituent(s) and concentration(s)
exceeding standards in the space provided below:
mw 5 ecc� 3 Ism1, yy)w#S COL i -2, �4
5I�-
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).
►1�w 5 "3uAZ 2v2a i oL t � .9 tpvv�q I t— i1� u� � ��- Lv19 PC 2io�i
w 5 5e/lt- W 19 TO 1 5� 5 �v vn� l � r Yl k S a rl C 1L / y F-C yo�l
Or17
i11 5 5u�e. ezi q Toc. 1tp,02 4 IL,
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 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
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 subiect the permittee to a Notice of Violation,
fines, and/or penalties.
g
The person completing this portion (GW-59A) of the monitoring r@port should sign below and submit this
form with GW-59 forms for required wells to the address provided-t 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 GIN-59A) is true and complete to the best of my knowledge.
Signature of Permittee rAuthorized A ent) Date
GW-59A 12/8/2003

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
ILITY INFORMALTI.O.
Please Print Clearly or Type
lity Name: f 01NOod riwo r► Rcs+ Ham ic,
nit Name (if different):
IityAddress: 140t-CC--Q Q
Sr1j -e (street) NC, 19-7 9 10 County -e-r+t o r
(City) (State) (Zip) /�
:act Person: ana r o ar Telephone#: tX 5� 3 -O QG ! I Q
I
Location/Site Name: id I i12Q 60 d 5mk-4eVt No. of wells to be sampled:
Number: Expiration Date:
:harge i �"� UIC
Other
'PE OF PERMITTED OPERATION BEING MONITORED
❑ agoon ❑ Remediation: Infiltration Gallery
M Spray Field ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
SAMPLING INFORMATION � �!
(
# —1 I SIaU
If WELL
WAS
WELL ID NUMBER (from Permit):
Date sample collected: a
FIELD ANALYSES:
Well Depth:
Well Diameter: in.
pH 00400: 4*7 units Temp. 00olo: °C
DRY at
Depth to Water Level e25q44s: ft. below measuring point
Screened Interval: ft. to -dft.
Spec. Cond. 00094: µMhos
time of
sampling,
Measuring Point is 4% ft. above land surface l
Relative M.P. Elevation: ft.
Odor 00085:
check
Volume of water pumped/bailed before sampling: ' �a gallons
for metals were collected unfiltered: El YES ❑ NO
and field acidified: ❑ YES ❑ NO
Appearance
here:
ElSamples
LABORATORY INFORMATION
Date sample analyzed: Ym-- ff ao
Laboratory Name: Eq. J,
—Lhc
Certification No. /0
PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD oo335
mg/L
Nitrite (NO2) as N 00615
mg/L
Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616
/100mL
Nitrate (NO3) as N 00620Lf 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 1 a 3
mg/L
Al - Aluminum 01105
mg/L
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC oosso lo, / o�
mg/L
Ca - Calcium oosss
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 o1o45
ug/L
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ET"' Yes (1) [D No(0)
Specific Conductance 00095
µMhos
K - Potassium 00937
mg/L
��c
VOC 7873 method # St ! fP 24\6 G— I ,
Total Ammonia oosso
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 /o

SUBMIT FORM ON YELLOW PAPER ONLY
UNDWATER QUALITY MONITORING:
PLIANCE REPORT FORM
ITY INFORMATION / I 1 Please
Facility Name: 1 111-[.Lt.1CXJU
Permit Name (if different):
,ntt):
Faci 'ty Address: c � o OyTh tar
©S z (Street) AJ C
(city) ,, J (state)
(�6 1Gl
Contact Person: 1Par ker
Well Location/Site Name: JIoew-5
or
Wi
10 County nCHcrttnra
Telephone#: 513 J q I
ei-a 7 No. of wells to be sampled:
SAMPLING INFORMATION �} n G �o
WELL ID NUMBER (from Permit): T Date sample collected: 0�6
Well Depth: 1 ft. Well Diameter: /" in.
Depth to Water Level 82546: ID ft. below measuring point Screened Interval: ip ft. to
Measuring Point is A 5 ft. above land surface Relative M.P. Elevation: ft.
Volume of water pumped/bailed before sampling: �` I a gallons
:r DEPARTMENT OF ENVIRONMENTAL QUALITY - DN: OF WATER RESOURCES
INFORMATION PROCESSING UNTf '
1847 NAIL SERVICE CENTER, RALEIGH, NC 2769D-081T ;.Ptwne; 01"071306
PERMIT Number:
I- 17 Q Expiration Date: Q U
Non -Discharge WWCO'7c 6 -I 1 UIC
NPDES Other
TYPE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
EYSpray Field ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
FIELD ANALYSES:
pH oo400:L11 units
Spec. Cond. 00094:
Odor 00085:
Appearance L OU here:❑
Temp. 00010: °C DRY at
uMhos time of
Samples for metals were collected unfiltered: ❑ YES
❑ NO and field acidified: ❑ YES
❑ NO
LABORATORY INFORMATIOR_
�� 10 /ao
Laboratory Name: En V.
nc,
Certification No.
Date sample analyzed: ?
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 < a U mg/L
Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL
Phosphorus: Total as P 00885
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L
Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 q3
mg/L
All - Aluminum 01105
mg/L
pH (Lab) 00403 units
Ba - Barium 01007
ug/L
TOC 00680 o . IP4 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? 2 Yes (1) ❑ No (0) i
VOC 7873 method # S YY1 tD Z00 C J
Specific Conductance 00095 µMhos
K - Potassium 00937
mg/L
Total Ammonia 00610 t 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 #
c— o--- Ah+l— Q..#.ma nnly l044arh I ah Rannrts1* Influent Total VOCs: mq/L triluent I Oial vut.5: lly/, •�� -v
tdvv-ozi Rev. uD-vc-cU 1 1

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
ity Name:
fit Name (if different):
itv Address: r
(Street)
or Type
County
,C/
(City) (State) (Zip) r (�
Contact Person: d -e r Telephone#: IV - S i 3 - f� `7 l
Well Location/Site Name: C No. of wells to be sampled:_
from Permit
SAMPLING INFORMATION �f WELL ID NUMBER (from Permit): # �j r1p 9
! Date sample collected: -1 a0 ao
Well Depth: -( ft. Well Diameter:in. Q
Depth to Water Level a25gdas: ft. below measuring point Screened Interval: ft. to -/ ft.
Measuring Point is a " ft. above land surface
I ft.
Relative M.P. Elevation:
Volume of water pumped/bailed before sampling: /I gallons
Samples for metals were collected unfiltered: ❑ YES ❑ NO and field acidified: ❑ YES ❑ NO
RMIT Number: Expiration Date:
V
n-Discharge 4 Wcao / p� UIC
'DES Other
PE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
Spray Field ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
If WELL
FIELD ANALYSES: WAS
pH ooaoo:'_tt units Temp. 000to: °C DRY at
Spec. Cond. 000sa: µMhos time ofsampling,
Odor 00085: check
Appearance C I6 01 here:
❑
LABORATORY INFORMATION I /
�0
rr
No. O
Date sample analyzed: pi �" /
a�
Laboratory Name: Gn 1/. ,G.
—�
Certification
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 (
/100mL
Nitrate (NO3) as N 00620 Q, y 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 2.31
mg/L
Al - Aluminum o1 to5
mg/L
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 00680 2
mg/L
Ca - Calcium 00916
mg/L
Chloride oogao
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total oto34
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 o1045
ug/L
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? R' Yes (1) ❑ No(0)
pecific Conductance 00095
µMhos
K - Potassium 00937
mg/L
VOC 7e73 method # SY)IN&WO C - 1 1f
Total Ammonia 00610 D a
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 Svstems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOGs: mg/L vuc rcemovaf7o

% hmpun. Nd
114 OAKMONT DRIVE
GREENVILLE, N.C. 27858
PINEWOOD MANOR INC.
240 SOUTH EARLY STATION RD.
AHOSKIE ,NC 27910
*400vatar ZOO to
PHONE [phone]
FAX [phone]
ID#: 377
DATE COLLECTED: 09/28/20
DATE REPORTED : 10/15/20
REVIEWED BY:
Effluent
Well #4
Well #5
Well #7
Analysis
Method
PARAMETERS
Date Analyst
Code
HOD, mg/l
54
09/29/20
KDS
5210B-11
Fecal Coliform (MP), /100 Mls
13000
< 1
3
< 1
09/28/20
GNB
9222D-06
Total Suspended Residue, mg/I
58
09/29/20
HJO
254OD-I1
Ammoula Nitrogen as N, mg/I
15.76
0.18
0.17
0.12
09/30/20
TLH
350.1 112-93
Total K,jeldahl Nitrogen as N,mg/I
29.96
10/02/20
KES
351.2 R2-93
Nitrate -Nitrite as N, ing/1
0.06
09/29/20
DTL
353.2 112-93
Nitrate Nitrogen as N, mg/I
<0.04
10/01/20
ICES
353.2 R2-93
Nitrate Nitrogen as N, mg/1
<0.04
<0.04
09/29/20
DTL
353.2 R2-93
Total Phosphorus as P, mg/I
3.81
10/02/20
TLH
365.4-74
Total Organic Carbon, mg/I
6.72
12.64
1.02
09/29/20
SEJ
531OC-11
Total Dissolved Residue, mg/1
123
143
231
09/29/20
JMS
2540C-11

Emflu oo fim@04 too hc© pcowm, -4
114 OAKMONT DRIVE
GREENViI_LE, N.C. 27858
CLIENT: PINEWOOD MANOR INC.
240 SOUTH EARLY STATION RD.
AHOSKIE, NC 27910
REVIEWED BY:
VOLATILE OROMICS
- u .^,a clnnn-ti
w"tar..we aot to
PHONE [phone]
FAX [phone]
CLIENT ID: 377
ANALYSTt DTL
DATE COLLECTED: 09/28/20 Page: 1
DATE ANALYZED; 10/08/20
DATE REPORTED: 10/15/20
PARAMETERS, ugll
Well N4
well #5
Well p7
1. Benzene
<0.50
<O.50
<0.50
2, Bromobenzeue
<0.50
<0.50
<0.50
3, Bromochloromethane
<0.50
<0.50
<0.50
4. Bromodichloromelhane
<0.50
<0.50
<0.50
5. Bromoform
<0.50
<0.50
<0.50
6. Bromometbane
<0.50
<0.50
<0.50
7. N-Butylbenzene
<0.50
<0.50
<O.SO
8, Sac-Butylbenzene
<0.50
<0.50
<0,50
9. Teri-Butylbenzene
<0,50
<0,50
<O.SO
10, Carbon Tetrachloride
<0.50
<0.50
<0.50
11. Chlorobenzona
<0.50
<0.50
<0.50
12. Chloroclhane
<Me
<0.50
<0.50
13. Chloroform
<0.50
<0.50
<0.50
14, Chioromethane
<0.50
<0.50
<0.50
15. 2-Chlorotohtene
<0.50
<0.50
<0.50
16, 4-Chlorololuene
<0.50
<0.50
<0.50
17. Dlbromochloromelhane
<0.50
<0.50
<0.50
18. 1,2-Dibromo-3-Chloropropane
<0.50
<0,50
<0.50
19. 1,2-Dibromoethane
<0,50
<0.50
<0.50
20. Dibrontomelhane
<0.50
<0.50
<0.50
21. 1,2-Dichlorobenzene
<0.50
<0.50
<0.50
22, 1,3-Dichlorobenzene
<0.50
<0.50
<0.50
23. 1,4-Dichlorobenzene
<0.50
<0.50
<0,50
24, Dichlorodilluoromethane
<0.50
<0.50
<0.50
25. 1,1-Dichloroethattc
<0.50
<0,50
<0,50
26. 1,2-Dichloroethane
<0.80
<0.50
<0150
27. 1,1-Dichloroethene
<0.50
<0.50
<0.50
28. Cis-1,2-Dichlorcethene
<0.50
<030
<0.50
29. trans-1,2-Dichloroethene
<0,50
<0150
<Mill
30. 1,2-Dicltloropropatte
<040
<030
<0.50
31. 1,3-Dicltloropropatte
<0.50
<0.50
<0.50
32. 2.2-Dichloropropane
<0.50
<0.50
<0.50
33. 1.1-Dichloropropene
<0,50
<0.50
<0150
34. Cis-1,3-Dichloropropene
<0.50
<0,50
<0.50
35. trans-1,3-Dichloropropettc
<0.50
<0,50
<0.50
36. Euhylbenzene
<0.50
<0,50
<0.50
37. Hexachlorobuiadiene
<0.50
<0.50
<0.50
38. Isopropylbenzene
<0.50
<0.50
<0.50
39, 4-isopropylioluene
<0.50
<0.50
<0.50
40, Mothylenc Chloride
<0.50
<0.50
<0.50
41. Naphthalene
<0.50
<0150
<0.50
42. Propylbenzene
<0.50
<0.50
<0.50
43, Styrene
<0.50
<0.50
<0.50
44. 1,1,1,2-Teirachloroetl:ane
<0.50
<0.50
<0.50
45. 1,1,2,2-Teirachloroetltatte
<0.50
<0.50
<0.50
46. Tetrachloroethene
<0.50
<0.50
<0.50
47. Toluene
<0.50
<0.50
<0.50
48. 1,2,3-Trichlo robenzene
<0.50
<0.50
<0.50

EwhvnuM Flo hgwpgm ,d
114 OAKMONT DRIVE PHONE [phone]
GREENVILLE, N.C. 27858 FAX [phone]
CLIENT: PINEWOOD MANOR INC. CLIENT ID: 377
240 SOUTH EARLY STATION RD.
AHOSXIE, NC 27910 ANALYST: DTL
DATE COLLECTED: 09/28/20 Page: 2
DATE ANALYZED: 10/08/20
DATE REPORTED: 10/15/20
REVIEWED BY:
VOLATILE ORGANIC3
STD. METHODS 620OC-11
PARAMETERS, ug/I
Well N4
Well N5
Well N7
49. 1,2,4-Trichlorobenzene
<0.50
<0.50
<0.50
50. 1,1,1-Trlchloroethane
<0.50
<0.50
<0.50
51. 1,1,2-Trlchloroethnne
<0.50
<0.50
<0.50
52. Trlchloroethene
<0.50
<0.50
<0.50
53. Trichlorofluoromethane
<0.50
<0.50
<0.50
54. 1,2,3-Trichloropropane
<0.50
<0.50
<0.50
55. 1,2,4-Trimethylbenzene
<0.50
<0150
<0.50
56. 1,3,5-Trimelhylbenzene
<0.50
<0,50
<0.50
57, Vinyl Chloride
<0.50
<0.50
<0.50
58. Total Xylenes
< 1.00
< 1.00
< 1.00
59. Methyl Terl Butyl Ether
< 1.00
< 1.00
< 1.00