WI0700087_Sample Collection & Submittal Form_20220228

North Carolina Division of Water Resources
Laboratory (Water Sciences Section) Water Sample Collection &
ubmittal Form j �5
Visit
(optional)D
�p9 E P1
j( t1r
C. l \
Lab
Laboratory 1
Sample Number:
Use Only:
Location Description:
=` %
1 iJ ( u c % s'7
yr 1. v
Location Code:
f (
t i\ ` - 6 ["
> (
Date Received:
M/D/Y
Time Received:
(14hrformat)
/ /
•
County:
-}—.
r\ r
i l ,
Collector.
j \
(
Priority:
Ambient
Routine
Compliance
COC
Emergency
QA
Water
Matrix:
Surface
Waste
Blank
Solution
Foam
Location
Type:
Lake
Canal
Influent
Filter Blank
Blank
(Gli
I (a
DWR Region:
(based on count y1
J ;.7
L, l._r CA I''\
DWR Office:
(or agencynome)
/1
` \ '�'
(
1? 1
1
(y[\Ground
7\
—�
Received By:
River Basin:
- 'AO
L \
-V-.
LlJ 1
Vine/
(m/d/YJ:
'twain/pre!)tTrip
( / ! R �-)•
iNi A- /
—
—
Delivery Method:
State Courier
Notes:
Time (24 hr):
(begin/end)
/
O •
t
%�
! 1 •
^Field
LrWaterSup•ly
Hand Delivered
; 1-
Other:
Sampling
Method:
Grab
Other:
Chlorinated
Filtered Dissclved
in Field check
analysis: Enter "DIS" in
-boxes for parameters
Sample (� Secchi
1 I ( ogin file:
Depth: C Depth: (�
Temperature on
Arrival (°C):
•
Composit=
De -chlorinated in Field
Lab Comments:
Lot #s 1 ' r
Collector <..') r\ V') (C C c� (((: E. 6 l t.? OVV\
Comments: \(
- i
> I;f) / <5 1 rCt (. Q E �. [ LA E AG�
Field Parameters (optional) :
Preservative : Y
Water Temp(°C):
pH (s.u.):
/
(-' •'
Dissolved Oxygen
i
(wpm):
Conductivity
(µmhos/cm):
Salinity
(PPt);
Mic obiology Parameters:
Preservative
Wet Chemistry Parameters:
Preservative
Metals Parameters:
Preservative
Metals Parameters Con't:
Preservative
Alkalinity, as CaCO3, to pH 4.5/8.3
A
Bromide
A
Aluminum (Al)
E
Thallium (TI)
E
BOD: Biochemical Oxygen Demand, 5-day
A
><
Chloride
A
Antimony (Sb)
E
Tin (Sn)
E
cBOD: Carbonaceous BOD, 5-day
A
Fluoride
A
`..Arsenic
!
(As)
E
Titanium (Ti)
E
x
Coliform: Fecal MF
B - C
Sulfate
A
Barium (Ba)
E
Vanadium (V)
E
Coliform: Total MF
B - C
Chlorophyll a
A
Beryllium (Be)
E
Zinc (Zn)
E
Specific Conductance, at 25°C
A
Color: ADMI
A
Cadmium (Cd)
E
Mercury 1631, low-level
TOC - Total Organic Carbon
A - G
Color: Platinum C4alt
A
Calcium (Ca)
E
Boron (B)
E
Turbidity
A
COD: Chemical Oxygen
Demand
A - D
y
�`�\
Chromium (Cr), Total
E
Hardness, Total as CaCO3 - by titration
E
Other Parameters:
Cyanide, Total
A - H - P
Cobalt (Co)
E
Organics Parameters:
pH
Y
Hexavalent Chromium
(Cr6+)
A - I
]Copper
J;✓:
(Cu)
E
Acid Herbicides
A - C
MBAS (surfactants)
A
Iron (Fe)
E
Organochlorine Pesticides
A - C
Nut ients Parameters:
Oil and Grease, HEM,
Total Recoverable
A - D
y
Lead (Pb)
E
Organonitrogen Pesticides
A - C
Ammonia as N (NH3-N)
A - C - D
Phenols, Total Recoverable
A - D - M
Lithium (Li)
E
Organophosphorus Pesticides
A - C
Nitrate -Nitrite as N (NO3+NO2-N)
A - D
Residue: Total (Total
Solids)
A
Magnesium (Mg)
E
PCBs (polychlorinated biphenyls)
A - C
Total Kjeldahl Nitrogen as N (TKN)
A - D
Residue: Volatile/Fixed,
Total
A
Y.
Manganese (Mn)
E
Semi -Volatile Organics (BNAs)
A - C
Total Phosphorus as P (TP)
A - D
Residue: Settleable
A
Mercury (Hg)
E
TPH Diesel Range
A - C
''.(litrite
r
as N (NO2-N)
A
Residue: Suspendei
(Suspended Solids)
A
Molybdenum (Mo)
E
Volatile Organics (VOA)
A - C - F - L
Nitrate as N (NO3-N calculated)
Residue: Volatile/Fixed,
Suspended
A
'Nickel
(Ni)
E
1,4-Dioxane
C- L
Orthophosphate as P (PO4)
A - Z
(`TDS
- Total Dissolved
Solids
A
Potassium (K)
E
TPH Gasoline Range
A - C - F - L
Cyanotoxins:
Silica
A
Selenium (Se)
E
Perfluorinated Compounds (PFAS)
A - T
Microcystin
A
Sulfide
A -1
Silver (Ag)
E
Biological:
Tannin & Lignin
Sodium (Na)
E
Phytoplankton / Algae
A- R
Strontium (Sr)
E
Preservative Legend (circle above as needed): (A) cool 56 C, (B) cool <10 C, (C) 0.008% Naz>z03 [
& NaOH to pH to >9, (K) pH 6-9 ascorbic acid [when chlorine is present], L) leave no headspace,
15 minutes of sample collection, (Z) filtered in field within 15 minutes using 0.45um pore size
en chlorine is present], (D) HzSO,
) ferrous ammonium sulfate [when chlorine is present),(P) ascorbic acid [when chlorine is present],(R) Lugols, (T) Trizma [when chlorine is present),(Y) analyzed within

North Carolina Division of Water Resources Water Sample Collection &
Laboratory (Water Sciences Section)
ubmittal Form ('`� �`?
L,) e. l (
Visit ID:
(optional)
Tag E-$
ID
` j
W L, 1
Lab
7
Laboratory
Sample Number:
Use Only:
r. \ .�
Location Description: '. - L�-' e `. J i� /
(
Location Code:
n r +
! 6 , c:� L t
llliii 111
Dote Received:
M/O/y
Time Received:
(24hrformat)
/ /
•
i-
County:�; +� �" p `,s
i
Collector:
(l
�
,� _.
(1" �•
Priority: .
Ambient
Routine
Compliance
COC
Emergency
QA
Water
---
Matrix:
-
Surface
Ground
Waste
Blank
Solution
Foam
---.
Location
River/Stream
Estuary
Stormwater
MonitoringWell
Field Blank I i
Other: G c o-0,1(✓d':�^'i
Type:
Lake
Canal
Influent
Filter Blank
Trip Blank
Water Supply
A-(
DWR Region:
(based on county)
:r `, : 1 —.
L. ) ✓� , �%
4
DWR Office:
(or agency name)
\
L.
rl
(' ��.�
V
X
Received By:
River Basin:
1� L"\ 0 c.-) A �'�
\
uare
im/d/yJ,
/begin/endl
/ r �/
/ I ^-
),
,1
1 /-i—
l� (lt /
—
^Effluent
Delivery Method:
State Courier
Notes:
Time 124hrJ:
(begin/end)•(
l 0 • 1 �°�
�,j
l
j\! -
f I l
Hand Delivered
Other:
Sampling
Method:
Grab
Other:
Chlorinated
Filtered Dissolved
in Field check
analysis: Enter "015" in
-boxes for parameters
Sample Secchi `/ ft[
I / i `( y F ogin file:
Depth: Depth: Y
Temperature on
Arrival (*CJ:
•
1
Composite
De -chlorinated in Field
Lab Comments:
Lotus/ �:::-.)A.,\,\,)tt Ut0LL� EcA �i,Z0�,, c..."d
Collector
Comments:
I ()v� AJ C� ,, I,f.
�(;I(J.
J
Field Parameters (optional)
Preservative : Y
Water Temp (C):
pH (s.u.)
Dissolved Oxygen
(ppm):
Conductivity
(µmhos/cm):
Salinity
(ppt):
Mic obiology Parameters:
Preservative
Wet Chemistry Paramelters:
Preservative
Metals Parameters:
Preservative
Metals Parameters Con't:
Preservative
Alkalinity, as CaCO3, to pH 4.5/8.3
A
Bromide
A
X\
Aluminum (Al)
E
Thallium (TI)
E
BOD: Biochemical Oxygen Demand, 5-day
A
\x
'
Chloride
A
Antimony (Sb)
E
Tin (Sn)
E
cBOD: Carbonaceous 80D, 5-day
A
Fluoride
A
X.
Arsenic (As)
E
Titanium (Ti)
E
�(
'(`�`
Coliform: Fecal MF
B - C
Sulfate
A
Barium (Ba)
E
Vanadium (V)
E
Coliform: Total MF
B - C
Chlorophyll a
A
Beryllium (Be)
E
Zinc (Zn)
E
Specific Conductance, at 25°C
A
Color: ADMI
A
Cadmium (Cd)
E
Mercury 1631, low-level
I
TOC - Total Organic Carbon
A - G
Color: Platinum Cooalt
A
X
Calcium (Ca)
E
Boron (B)
E
Turbidity
A
COD: Chemical Oxygen
Demand
A - D
X.
Chromium (Cr), Total
E
Hardness, Total as CaCO3- by titration
E
Other Parameters:
Cyanide, Total
A - H - P
Cobalt (Co)
E
Organics Parameters:
pH
Y
Hexavalent Chrom
um (Cr6+)
A - I
X
Copper (Cu)
E
Acid Herbicides
A - C
MBAS (surfactants
A
Iron(Fe)
E
Organochlorine Pesticides
A - C
Nut ients Parameters:
Oil and Grease, HEM,
Total Recoverable
A - D
Lead (Pb)
E
Organonitrogen Pesticides
A - C
Ammonia as N (NH3-N)
A - C - 0
Phenols, Total Rec
verable
A - D - M
Lithium (Li)
E
Organophosphorus Pesticides
A - C
Nitrate -Nitrite as N (NO3+NO2-N)
A - D
Residue: Total (Total
Solids)
A
X
Magnesium (Mg)
E
PCBs (polychlorinated biphenyls)
A - C
Total Kjeldahl Nitrogen as N (TKN)
A - D
Residue: Volatile/Rxed,
Total
A
K
Manganese (Mn)
E
Semi -Volatile Organics (BNAs)
A - C
Total Phosphorus as P (TP)
A - D
Residue: Settleabl
A
Mercury (Hg)
E
TPH Diesel Range
A - C
x
4 `Nitrate
Nitrite as N (NO2-N)
A
Residue: Suspend
d (Suspended Solids)
A
Molybdenum (Mo)
E
Volatile Organics (VOA)
A - C - F - L
as N (NO3-N calculated)
Residue: Volatile/
xed, Suspended
A
)Nickel
(Ni)
E
1,4-Dioxane
C - L
Orthophosphate as P (PO4)
A - Z
` !
X
' \
TDS -Total Dissolv
d Solids
A
X.
Potassium (K)
E
TPH Gasoline Range
A - C - F - L
Cyanotoxins:
Silica
A
Selenium (Se)
E
Perfluorinated Compounds (PFAS)
A - T
Microcystin
A
Sulfide
A - J
Silver (Ag)
E
Biological:
Tannin & Lignin
Sodium (Na)
E
Phytoplankton /Algae
A - R
Strontium (Sr)
E
Preservative Legend (circle above as needed): (A) cool 56 C, (B) cool <1u°C, (C) 0.008% Na25203 [when chlorine is present], (D) H2SO4 to pH <2, (E HNO3 to pH <2, (F) HCI to pH <2, (G) H3PO4 to pH <2, (H) 6N NaOH to pH >10<11, (I) (NH4)2504 pH=9.3-9.7, (J) zinc acetate
& NaOH to pH to >9, (K) pH 6-9 ascorbic acid [when chlorine is present],(L) leave no headspace, QM) ferrous ammonium sulfate [when chlorine is present),(P) ascorbic acid [when chlorine is present],(R) Lugols, (T) Trizma [when chlorine is present],(V) analyzed within
15 minutes of sample collection, (Z) filtered in field within 15 minutes using 0.45um pore size