WQ0001048_Monitoring - 10-2020_20201130

GW-59A COMPLIANCE REPORT FORM Permit # g
(Submit one each monitoring period with Gfl,-59 forms.) C
I
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
;( 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",
YES
NO
identification plate, area overgrown, etc.)? If the answer is contact the Regional Office for guidance.
y
4
Are any monitored constituents equal to or above the established standards?
YES
J�
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:
(cell -# 1 5 iUG ICE Z�Mq��
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 blow, each well with constituent(s) exceeding
standards, concentration(s) reported, and sample collection date for ach occurrence (for the last two years).
C
�O G it-GZ /L
z
T1 �v o
Z� 7
03 Tj
m W
Are the monitoring wells listed in section 5 located at or beyorixtL4 re w tvaundary?
YES
No
C' C:D
If the answer is "YES", a groundwater quality problem may be currike CON ACT THE REGIONAL
OFFICE IMMEDIATELY FOR GUIDANCE. If the answer is "NO" onitoring *e#s may be improperly
located; contact the Regional Office.
a;
7
Is the permittee implementing previously approved actions required by the Division involving this
YES
NO
groundwater quality problem?
J
/`
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 facilitV. Failure to do so may subject the permittee to a Notice of Violation,
fines, and/or penalties.
-rr)C +urQll irunzhi�w . -rhele ale-Tecul
C{i61nO�4�ed 6i nc(,L-q-he 106t rfVi1 Cfi0f e4c,,gt. AlICT4-)eA)+-'uJd16I-Mv ,
i»n.Gce�ecl���U-irn�Scl(�rir�> 1�(.�rricc�nf �,��t� .
g
The person completing this portion (GW-59A) of the monitoring 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 (Comp ' e Report GW-59A) Is true and complete to the best of my knowledge.
au */ I � W
Signature of Permittee (or Authorized A t) Date
GW-59A 12/8/2003

SUBMIT FORM ON YELLOW PAPER ONLY
6
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 r '"
Please Print
FACILITY INFORMATION
Clearly or Type
PERMIT Number: Expiration Date:
Facility Name: t" 6-0
Non -Discharge "'L0010-1 UIC
Permit Name (if different): 4i- M6 Q
NPDES f4CCC)3 Z))� Other
Facility Address: C-4J' b
,&C /- C(-)
TYPE OF PERMITTED OPERATION BEING MONITORED
County �),-j4
❑ Lagoon ❑ Remediation: Infiltration Gallery
(City) (Slate( (zip)
ElSpray Field ElRemediation:
I I ,
Contact Person: O Iu.'-14j[CL
Telephone#: ZJz.SZU > �
❑ Rotary Distributor 9 Land Application of Sludge
Well Location/Site Name: ,_XvLi% P1Gnf,5He_
No. of wells to be sampled: (.0
❑ Water Source Heat Pump ❑ Other:
�T
from Permit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): vI
Date sample collected: 1C. 12-2&
FIELD ANALYSES:
WAS
Well Depth: 'j ft.
Well Diameter: z in.
pH 00400: 9 �_ units Temp. 00010: Z Z °C
DRY at
Depth to Water Level 82546: ft. below measuring point
Screened Interval: 3 ft. to
p µMhos
ft. Sec. Cond. 000sa:
time of
Measuring Point is Z ft. above land surface
Relative M.P. Elevation: ft.
—
Odor 00085:
sampling,
check
Volume of water pumped/bailed before sampling: 5
gallons
Appearance ,
here:❑
Samples for metals were collected unfiltered: X YES
❑ NO and field acidified: ❑■ YES ❑ NO
LABORATORY INFORMATION
Date sample analyzed: 10 -n- 20
Laboratory Name: f 1 m ICn(f)o')+ i d rc 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 Z /100mL
Nitrate (NO3) as N 00620 0 .0LI
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100ml- Phosphorus: Total as P 00665
mg/L
(Note: Use MPN method for NgNy turbid samples)
Orthophosphate 70507 O.OIP
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 5 -3 mg/L
Al - Aluminum 01105
mg/L
pH (Lab) 00403 Z-) • (p units
Ba - Barium 01007
ug/L
TOC 00680 - (p mg/L
Ca - Calcium oo916
mg/L
_
Chloride 00940mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002 ug/L
Chromium: Total olo34 5
ug/L
Grease and Oils 00552 mg/L
Cu - Copper 01042 G 0 , O ICE
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? d Yes (1) ❑ No (0)
Specific Conductance 000s5 J µMhos
K - Potassium 00937
mg/L VOC 7873 method #
Total Ammonia 00610 67 mg/L
Mg - Magnesium 00927
mg/L method #
(Ammonia Nitrogen; NH,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%
C 1 luki 1 e6 M - bwt6)tuCL. -3 ( � is+Ill ii 1cACiLI
Permittee (or Authorized Agent) Name and Tit1- Pleas6 print or type
GW-59 Rev.06-07-2018

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
FACILITY INFORMATION Please Print
Clearly or Type
PERMIT Number: Expiration Date:
Facility Name: m`a)D
Non -Discharge U) CCNC)QI? UIC
NPDES HaC,3ZC, ) Other
Permit Name (if different):Lb+6-"`eC �L2
1
Facility Address: � �iLUI M`e 6
G LD
TYPE OF PERMITTED OPERATION BEING MONITORED
County
❑ Lagoon ❑ Remediation: Infiltration Gallery
(City) (Slate) (zip)
❑ Spray Field ❑ Remediation:
Contact Person: (1 h 1Cf .b-f)', i')kJCL
Telephone#: z� Z U L�
❑ Rotary Distributor [A Land Application of Sludge
Well Location/Site Name: `� CX Fi 06 P
No. of wells to be sampled:
❑ Water Source Heat Pump ❑ Other:
from Perrnil
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 10
Date sample collected:
FIELD ANALYSES:
WAS
Well Depth: a ft.
Well Diameter: in.
pH ooao0:-5 C) units Temp. 000lo: L °C
DRY at
Depth to Water Level 82546: L4 _ft. below measuring point Screened Interval: z ft. to
ft. Spec. Cond. 00094: �j �j µMhos
time of
Measuring Point is ft. above land surface
Relative M.P. Elevation: ft.
Odor 00065: Y)Cj) C
sampling,
check
Volume of water pumped/bailed before sampling: 5
gallons
Appearance C- CA,
here:❑
Samples for metals were collected unfiltered: K YES
❑ NO and field acidified: ❑■ YES ❑ NO
LABORATORY INFORMATION
Date sample analyzed: lCi-n ZU
Laboratory Name: Lf-ly I (Of>fY)(J l i 1/
Y )C Certification No. IC)
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 < i /100ml-
Nitrate (NO3) as N 00620 0 •16
mg/L Zn - Zinc 01092 m9 /L
Coliform: MF Total 31504 /100ml-
Phosphorus: Total as P 00665
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507 O 0 `.�"
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 3 (,,, mg/L
Al - Aluminum oil o5
mg/L
pH (Lab) 00403 5 O units
Ba - Barium 01007
ug/L
TOC 00680 3 �JC> mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 < mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002 ug/L
Chromium: Total 01034 �J
ug/L
Grease and Oils 00552 mg/L
Cu - Copper 01042 ��.(jI(�
mg/L ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730 ug/L
Fe - Iron 01045
ug/L
(Specify test and method#j ATTACH LAB REPORT.)
Sulfate 00945 mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? � Yes (1) ❑ No (0)
Specific Conductance 00095 5 5 µMhos
K - Potassium 00937
mg/L VOC 7873 method # (j
Total Ammonia 00610 Ll 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%
Permittee (or Authorized Agent) Name and Title - Ple se print or type
GW-59 Rev.06-07-2018

SUBMIT FORM ON YELLOW PAPER ONLY
ROUNDWATER QUALITY MONITORING:
OMPLIANCE REPORT FORM
Name:
Name (if different):
IIf-
(city)
or
n� lid LM
6/33i) County
(S(atel (Zip)
tact Person: Ch(, cL b-T) 4 )co ct_ Telephone#: 052- 6Zy-§'S s V
I Location/Site Name: `3 �ti 1A �L- I I% No. of wells to be sampled: Lx
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
INFORMATION PROCESSING UNIT
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617
PERMIT Number: t� Expiration Date: 5;'- s_3L LUL
Non -Discharge UIC
NPDES Other
TYPE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
❑ Spray Field ❑ Remediation:
❑ Rotary Distributor EAand Application of Sludge
❑ Water Source Heat Pump ❑ Other:
ILL ID NUMBER (from Permit): U Date sample collected:
II Depth: -aft. Well Diameter: in.
)th to Water Level 82546:�ft. below measuring point Screened Interval: ft. to )3 ft.
asuring Point is 7_ft. above land surface Relative M.P. Elevation: ft.
ume of water pumped/bailed before sampling: gallons
nples for metals were collected unfiltered: ❑■ YES ❑ NO and field acidified: ❑■ YES ❑ NO
FIELD ANALYSES:
pH 00400:4,-2 units
Spec. Cond. 00094:
If WELL
Temp. 000lo: Z I °C DRY at
g C µMhos time of
Odor 00085: (>GYl f �,.,r....�:,,
check
Appearance Glen( here:❑
lte sample analyzed:
Id -n-z 0
Laboratory Name:
L)Nj (C (iK)L
f( +_T_�
(I -)C Certification No. 10
1RAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615
rng/L
Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616
Z_ /100mL
Nitrate (NO3) as N 00620
L,, (off
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
Q .. 03
mg/L
Other (Specify Compounds and Concentration Units):
solved Solids:Total 70300
j� mg/L
Al -Aluminum 01105
mg/L
pH (Lab) 00403
y , units
Ba - Barium 01007
ug/L
TOC oosso
mg/L
Ca - Calcium 00916
mg/L
Chloride 00940
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total 01034
<5. O
ug/L
Grease and Oils 00552
mg/L
Cu - Copper 01042
<O.QI
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? W Yes (1) ❑ No (0)
ecific Conductance 00095
d µMhos
K - Potassium 00937
mg/L
VOC 7673 method #
Total Ammonia 00610
<Q-Du 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 Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%
GW-59 Rev.06-07-2018

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
FACILITY INFORMATION Please Print Clearly or Type
PERMIT Number: Expiration Date:
Facility Name: 'o- m 0
Non -Discharge Lv(�CM104T UIC
Permit Name (if different): 0— )7 -P
NPDES PGC C32CD) Other
Facility Address: C L) I ( I F5 16
776cvU
TYPE OF PERMITTED OPERATION BEING MONITORED
l Str t; �4C 4S5-' County pl ��
❑ Lagoon ❑ Remediation: Infiltration Gallery
(City) (State) (Zip)
El Spray Field El Remediation:
Contact Person: Lh6C`�.. &)` l�.b'1(,�,iLV
,�/
Telephone#: z�Z �JZ4- J� L�
❑ Rotary Distributor Land Application of Sludge
Well Location/Site Name:
No. of wells to be sampled:
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 5
Date sample collected: r,-ZTZO
FIELD ANALYSES:
WAS
Well Depth: $ft.
Well Diameter:in.
pH 00400:q 13 units Temp. 000lo: - I °C
DRY at
Depth to Water Level 625as:�ft. below measuring point Screened Interval: 3 ft. to
ft. Spec. Cond. 00094: 1 � io µMhos
time of
Measuring Point is Z ft. above land surface
Relative M.P. Elevation: ft.
_
Odor 00085: C)0")-r—
sampling,
check
Volume of water pumped/bailed before sampling:
gallons
Appearance L1-ec�
here:❑
Samples for metals were collected unfiltered: X YES
❑ NO and field acidified: K YES ❑ NO
LABORATORY INFORMATION
Date sample analyzed: io-n-7(..)
LaboratoryName: 1 nN t (MMt�)j
Z
(X Certification No. lC)
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 I /100mL
Nitrate (NO3) as N 00620 G(), CC-}
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 O • G3
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 �( �j mg/L
Al - Aluminum oil o5
mg/L
pH (Lab) 00403 C) . �n 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 S 5 d
ug/L
Grease and Oils 00552 mg/L
Cu - Copper 01042 <0,01 Q
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? ICI Yes (1) ❑ No (0)
Specific Conductance 00095 µMhos
K - Potassium 00937
mg/L VOC 7873 method #
Total Ammonia 00610 () .Z 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 Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%
("TO I i�� '�1�� SIG ) t JDI� iL haul cE�
Permittee (or Authorized Agent) Name and Title - Please print or type
t;vv-5a
Nev. ub-u /-zul $

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
FACILITY INFORMATION Please Print Clearly or Type
<
PERMIT Number: Expiration Date:
`,,, I,t^
Facility Name: CC' )+0-raeCt MdD
Non -Discharge W} W)d(-I' "� UIC
Permit Name (if different):
NPDES Other
Facility Address: G jt k..(
TYPE OF PERMITTED OPERATION BEING MONITORED
r1�1 S e"4C Z'65:J0 County Pi4'
❑ Lagoon ❑ Remediation: Infiltration Gallery
(City) (State) (zip)
❑ Spray Field El Remediation:
Contact Person: ctucl 61iU-1, �lC%
Telephone#: Z 5Z�-�S y
❑ Rotary Distributor [9 Land Application of Sludge
Well Location/Site Name: CCa nef 'Hod
No. of wells to be sampled:
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): I
Date sample collected: IC,-p- 20
FIELD ANALYSES:
WAS
Well Depth: -a-ft.
Well Diameter: z in.
pH 00400: Z units Temp. 000lo: ZI °C
DRY at
Depth to Water Level 82546:') ft. below measuring point Screened Interval z ft. to
S'
ft. Spec. Cond. 00094: (vCj µMhos
time of
Measuring Point is Z- 33 ft. above land surface
Relative M.P. Elevation: ft.
—
Odor 00085: 17Cd� C
sampling,
Volume of water pumped/bailed before sampling: S
gallons
Appearance CI)eCl
here:❑
Samples for metals were collected unfiltered: ❑■ YES
❑ NO and field acidified: ❑■ YES ❑ NO
LABORATORY INFORMATION
Date sample analyzed: 10-_0 20
Laboratory Name: J-�
rc Certification No. /Q
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 5Ll
mg/L Zn - Zinc 01092 m9 /L
Coliform: MF Total 31504 /100mL
Phosphorus: Total as P 00665
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507 0,1`
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70900 "D mg/L
Al - Aluminum oil o5
mg/L
pH (Lab) 00403 5. Z. units
Ba - Barium 01007
ug/L
TOC 00680 J. I U, mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 'S mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002 ug/L
Chromium: Total 01034 Q
ug/L
Grease and Oils 00552 mg/L
Cu - Copper 01042 .0 I L
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? T� Yes (1) ❑ No (0)
Specific Conductance 00095 (p µMhos
K - Potassium 00937
mg/L VOC 7873 method # / �C I
n_
Total Ammonia 00610 mg/L
Mg - Magnesium 00927
mg/L method #
(Ammonia Nitrogen; NH, as N; Ammonia Nitrogen, Total)
Mn -Manganese oloss
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%
0 -c:.�(1�51`(1 ,, ���� 111�.� IC ,7 i /i 64i CJ II`I-j4(*(—
Permittee (or Authorized Agent) Name and Title - Pleade print or type
GW-59 Rev.06-07-2018

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
FACILITY INFORMATION Please Print Clearly or Type
`��
F
PERMIT Number: Expiration Date:
Facility Name: C� fl to N-f t �� rn
Non -Discharge ii.�l 014-0 UIC
Permit Name (if different): ti l}0 �� 111�
NPDES j �1�� 3ZL��� Other
Facility Address:
TYPE OF PERMITTED OPERATION BEING MONITORED
1 reeti
(I 1 PC DS6_50
County (
❑ Lagoon ❑ Remediation: Infiltration Gallery
(City) (Slate) (zip)
❑ Spray Field El Remediation:
Contact Person: C r ct 6m I',h(-1 I J_
Telephone#: Z-5Zu J��S
�/
❑ Rotary Distributor al -and Application of Sludge
Well Location/Site Name: j--i t i I­2)
No. of wells to be sampled: (_-1
❑ Water Source Heat Pump ❑ Other:
from Permit)
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit):
Date sample collected: jC)-n-Z()
FIELD ANALYSES:
WAS
Well Depth: ID ft.
Well Diameter: z in.
pH 00400:4__� units Temp. 000lo: Z j °C
DRY at
Depth to Water Level ersas:Lo ft. below measuring point
Screened Interval: �J ft.
to I
ft. Spec. Cond. 000sa: µMhos
time ofsampling,
Measuring Point is ft. above land surface
Relative M.P. Elevation:
ft.
Odor 00085: liQ7 t'
check
Volume of water pumped/bailed before sampling:
gallons
Appearance 0 tK�
here:❑
Samples for metals were collected unfiltered: ❑■ YES ❑ NO and field acidified: ❑■ YES
❑ NO
LABORATORY INFORMATION
Date sample analyzed: j0-1_)-Z C
11
Laboratory Name: LrWi YCf>1Y U)i Z , I F. Certification No. { ��
PARAMETERS NOTE: Values should reflect dissolved and
colloidal concentrations.
COD 00335 mg/L
Nitrite (NO2) as N 00615
mg/L Pb - Lead o1051 ug/L
Coliform: MF Fecal 31616 U (� /100mL
Nitrate (NO3) as N 00620 L� , C Lj
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 C , C I
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 t i mg/L
Al -Aluminum 01105
mg/L
pH (Lab) 00403 U units
Ba - Barium 01007
ug/L
TOC 00680 6_,. to(0 mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 LA mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002 ug/L
Chromium: Total 01034 46,C)
ug/L
Grease and Oils 00552 mg/L
Cu - Copper 01042 <C, 010
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? t Yes (1) ❑ No (0)
Specific Conductance 00095 j µMhos
K - Potassium 00937
mg/L VOC 7873 , method # (220c_j
Total Ammonia 00610 C . C mg/L
Mg - Magnesium 00927
mg/L method #
(Ammonia Nitrogen; NH, 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%
Permittee (or Authorized Agent) Name and Tit e - Please print or type
of Permittee (or Authorized Agent)
(Date)
=zo
GW-59 Rev.06-07-2018