WQ0007144_Monitoring - 03-2022_20220427 (2)

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DWR - NonDischarge Monitoring Report Submittal y. •4 ..
NORTH CAROLINA
Enrlranmenlel QHaffly
Monitoring Report Submittal
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Permit Number#* WQ0007144
Name of Facility:* Camp Seafarer
Month:* March Year:* 2022
Report Information
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR Non-Discharge Reports 774.19KB
March 2022.pdf
PDF Only
GW-59 GW-59 March 2022.pdf 409.44KB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2,NDMLR,GW-59).
Confirmation Email Address:* [e-mail]
Name of Submitter:* Stanley Eudy
Signature:
e Sae
Date of submittal: 4/27/2022
This will be filled in automatically

Initial Review
Reviewer: Gerald,Wanda
Is the project number correct?* WQ0007144
Is the monitoring report accepted?* Yes No
Regional Office* Washington
Accepted Date: 5/10/2022

SUBMIT FORM ON YELLOW PAPER ONLY
Mail original DEPARTMENT OF ENVIRONMENTAL QUALITY DIV OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING: INFORMATION PROCESSING UNIT
and 1 copy to:
COMPLIANCE REPORT FORM 1617MAIL s$RviCE CENTER,RALEIGH,NC'276991617 :Phone.[phone]
FACILITY INFORMATION Please Print Clearly or'Type PERMIT Number: Expiration Date:',lily 3/ z 0.1.7
Facility Name: Camp Seafarer Non-Discharge WO0007144 UIC
Permit Name(if different): YMCA of the Triangle Area,INC. NPDES ... Other
Facility Address: 2744 Seafarer Rd Arapahoe NC 28510 TYPE OF PERMITTED OPERATION BEING MONITORED
2744 Seafarer Rd Arapahoe (Stree3)NC 28510 County Pamlico
IK Lagoon ❑ Remediation: Infiltration Gallery
(City) (State) (Zip)
❑ Spray Field ❑Remediation:
Contact Person: Mike Askew Telephone#: [phone] ❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name:Lagoon No.of wells to be sampled: 5 ❑ Water Source Heat Pump ❑Other:
(frem Permit)
SAMPLING INFORMATION If WELL
/
WELL ID NUMBER(from Permit): Well 2 - Date sample collected: 3( / 2-7— FIELD ANALYSES: / WAS
Well Depth: 20 ft. Well Diameter: 2 in. pH 00400:6.g3units Temp.00010: /6 e / °c DRY at
•
time of
Depth to Water Level 8254e:13..67 ft.below measuring point Screened Interval: 10 ft. to 20 ft. Spec. Cond. 00094: A 3 0 µMhos sampling,
Measuring Point is 1.9 ft.above land surface Relative M.P.Elevation: 24.2 ft. Odor 00085: NCAP-- check •
Volume of water pumped/bailed before sampling: 1-OIQ( gallons Appearance C .679A here:
Samples for metals were collected unfiltered: ❑YES ❑ NO and field acidified: ❑YES ❑NO
LABORATORY INFORMATION
Date sample analyzed: 3/24 11- Laboratory Name: Er---VIA.G/"/✓t e, 1- / Certification No. I d
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 < / /10DmL Nitrate(NO3)as N 00620 4 04 0 y-- mg/L Zn-Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL Phosphorus:Total as P 00665 Q. D 8' mg/L
(Nate: Use MPN method for highly turbid samples) Orthophosphate 70507 mg/L Other(Specify Compounds and Concentration Units):
)issolved Solids:Total 70300 f 7 mg/L Al-Aluminum 01105 mg/L
pH(Lab)00403 I34 / units Ba-Barium 01007 ug/L
TOC 00680 mg/L Ca-Calcium 00916 mg/L
Chloride 00940 3 D mg/L Cd-Cadmium 01027 ug/L
Arsenic 01002 ug/L Chromium:Total 01034 uglL
Grease and Oils 00562 mg/L Cu-Copper 01042 mg/L ORGANICS: (by GC,GC/MS, HPLC)
Phenol 32730 uglL 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 0o095 µMhos K-Potassium 00937 mg/L VOC 7873 , method#
Total Ammonia 00610 ©o G 4 mg/L Mg-Magnesium 00927 mg/L ,method#
(Ammonia Nitrogen;NN3 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%
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 laboratory analytical data was produced using approved methods of analysis by a
DWR-certified laboratory. l am aware that there are significant penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations.
Mike Askew,Director of Facilities and Boating Operations Lr/ -- q �-.� -2
Permittee(or Authorized Agent)Name and Title-Please print or type Signnatur6 of Permittee(or Authorized Agent) (Date)
GW-59 Rev.05-02-2017

•
SUBMIT FORM ON YELLOW PAPER ONLY
Mail original DEPARTMENT OF ENVIRONMENTAL QUALITY DIV.OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING: IN
and 1 copy to; FORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM 1617 MAIL SERVICE CENTER RALEIGH,NC.2769S-1617 Phone::[phone]
FACILITY INFORMATION Please Print Clearly or Type PERMIT Number: Expiration Date:In/-I — 3/ ,2 0.2-7
Facility Name: Camp Seafarer Non-Discharge WQ0007144 LAD
Permit Name(if different): YMCA of the Triange Area,INC. NPDES Other
Facility Address: 2744 Seafarer Rd •Arapahoe NC 28510 TYPE OF PERMITTED OPERATION BEING MONITORED
2744 Seafarer Rd Arapahoe (street) NG 28510 Count
y Pamlico E Lagoon ❑ Remediation:Infiltration Gallery
(City: (Slate) (Zip)
Spray Field ❑Remediation:
Contact Person: Mike Askew Telephone#: [phone] ❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name:Spray Field 3 No.of wells to be sampled: 5 ❑ Water Source Heat Pump ❑ Other:
(from Permit)
SAMPLING INFORMATION 1 If WELL
WELL ID NUMBER(from Permit): WELL 5 Date sample collected: 312z r ZZ FIELD ANALYSES: WAS
Well Depth: 20 ft. Well Diameter: 2 In. pH 00400:41",a units Temp. Do010:I • ° / °C DRY at
M time of
Depth to Water Level 82546:lt,33 ft. below measuring point Screened Interval: 10 ft. to 20 ft. Spec. Cond. 00094: 37, , hos sampling
Measuring Point is 2.2 ft.above land surface Relative M.P. Elevation: 27.7 ft. Odor moss: ivc.n^L check
Volume of water pumped/bailed before sampling: lG gallons Appearance CC.c7 c.0 here: i
Samples for metals were collected unfiltered: DYES D NO and field acidified: ❑YES ❑NO
LABORATORY INFORMATION
Date sample analyzed: 3 l A2.1 A), Laboratory Name: Enyiroment 1,1NC. Certification No.
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L Nitrite(NO2) as N D0615 mg/L Pb-Lead 01051 uglL
Coliform: MF Fecal 31.616 ' j /100mL Nitrate(NO3)as N 00620 -c G� G mg/L Zn-Zinc o1092 mg/L
Coliform:MF Total 31504 /100mL Phosphorus:Total as P 00665 'C 0 . 04. mg/L
(Note: Use MPN method for highly turbid samples) Orthophosphate 70507 • mg/L Other(Specify Compounds and Concentration Units):
Dissolved Solids:Total70300. 4'4`(3 mg/L Al-Aluminum 01105 mg/L
pH (Lab)00403 I•.9 units Ba-Barium 01007 ug/L .
TOC 00660 mg/L Ca-Calcium 00916 mg/L
•
Chloride 00940 � mg/L Cd-Cadmium 01027 ug/L
Arsenic o1002 uglL Chromium:Total 01034 ug/L
Grease and Oils 00552 mg/L . Cu-Copper 01042 mg/L ORGANICS: (by GC, GC/MS, HPLC)
•
Phenol 32730. uglL Fe-Iron 01045 uglL (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 uMhos K-Potassium 00937 mg/L VOC 7873 , method#
Total Ammonia 00610 O-0 4- mg/L Mg-Magnesium 00927 mg/L , method# •
(Ammonia Nitrogen;NH°es N;Ammome Nitrogen,TotaE) Mn-Manganese 01055 uglL 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%
certify that,lathe best of my knowledge and belief,The information submitted in this report is true;accurate;and complete;and that the laboratory analytical data was produced using approved methods of analysis by a
'W R certified tabbretory. lam aware that there are significant penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations..
Mike Askew,i7irector of Facilities and Boating Operations ✓19 1'
Perrnittee(or Authorized Agent)Name and Title-Please print or type Signature of Perrnittee(or Authorized Agent) (Date)
GW-5.9 Rev.05-02-2017

•
SUBMIT FORM ON YELLOW PAPER ONLY
Mail original DEPARTMENT OF ENVIRONMENTAL.QUALITY DIV.:OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING: INFORMATION PROCESSING UNIT
and 1 Copy to:
COMPLIANCE REPORT FORM 1617 MAIL SERVICE CENTER RALEIGH NC 2769 9-1 61 7 Phone;919-807-6306
FACILITY INFORMATION Please Print Clearly or Type PERMIT Number: Expiration Date:P1 3/. .2-02,7
Facility Name: Camp Seafarer Non-Discharge WQ0007144 UIC
Permit Name(if different): YMCA of the Triangle Area,INC. NPDES Other
Facility Address: 2744 Seafarer Rd Arapahoe NC 28510 TYPE OF PERMITTED OPERATION BEING MONITORED
2744 Seafarer Rd Arapahoe (Stet) NC 28510 Count
y Pamlico El Lagoon El Remediation: Infiltration Gallery •
(City) (Slate) (tip;
IE Spray Field ❑ Remediation:
Contact Person: Mike Askew Telephone#: [phone] ❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name:Spray Field 3 No.of wells to be sampled: 5 ❑ Water Source Heat Pump ❑ Other:
(from Permit)
SAMPLING INFORMATION , / If WELL
WELL ID NUMBER(from Permit): Well 6 Date sample collected: 3!-0`! .2-2- FIELD ANALYSES: WAS
Well Depth: 20 ft. Well Diameter: 2 in. pH 00400:4`,t3 units Temp.00o1o: 13o?°C DRY at
time of
'Depth to Water Level 82546: .0 q. ft. below measuring point Screened Interval: 10 ft. to 20 ft. Spec.Cond.00094: Cb a pMhos sampling
Measuring Point is 2.75 ft.above land surface Relative M.P. Elevation: 20.2 ft. Odor 00065: MO/ , check
Volume of water pumped/bailed before sampling: /0 gallons Appearance CG 0 vla r here:
Samples for metals were collected unfiltered: ❑YES ❑ NO and field acidified: ❑YES ❑NO
LABORATORY INFORMATION
Date sample analyzed: 3 f L/;,/, Laboratory Name: Enviroment 1,INC. Certification No. /0
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L Nitrite(NO2)as N coals mg/L Pb-Lead a1051 ug/L
Coliform: MF Fecal 31616 ! /100mL Nitrate(NO3)as N 00620 <0j, 0 f- mg/L Zn-Zinc o1092 mg/L
Coliform: MF Total 31504 /100mL Phosphorus:Total as P 0o665 Oa 0 D mg/L
(Note: use MPN method for highly turgid samples) Orthophosphate 70507 mg/L Other(Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300 130 mg/L Al-Aluminum 01105 mg/L
i
pH(Lab)00403 S. f units Ba-Barium 01007 ug/L
TOC 00680 mg/L Ca-Calcium o0s16 mg/L
Chloride 00940 31 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 ug1L Fe-Iron 01045 ug/L (Specify test and method#.ATTACH LAB REPORT.)
Sulfate o0s45 mg/L Hg-Mercury 71soo ug/L Lab Report Attached? ❑ Yes(1) ❑ No(0)
Specific Conductance 00095 p.Mhos K-Potassium 00937 mg/L VOC 7873 , method#
Total Ammonia 00610 <0.2 0+ mg/L Mg-Magnesium 00927 mg/L , method#
(Ammonia Nitrogen;NH3as N:Ammonia Nitrogen,Total) Mn-Manganese 131055 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%
L.certify that,to the best of my knowledge and belief,.the information submitted in this report is true,accurate,and complete,and that the laboratory analytical data was 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 and imprisonment for knowing violations. .
Mike Askew, Director of Facilities and Boating Operations l,[T i 1"/ ---.6' �
Permittee for Authorized Agent)Name and Title-Please print or type Signature of Permittee(or Authorized Agent) (Date)
GWW 59 Rev.05-02-2017

SUBMIT FORM ON YELLOW PAPER ONLY
Mail original DEPARTMENT OF ENVIRONMENTAL QUALITY DIV.OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING: INFORMATION PROCESSING UNIT
and 1 copy to:
COMPLIANCE REPORT FORM 16171u1A1L SERVICE ICENTER,j,RALEIGH,NC276991617 -Phone:[phone]
FACILITY INFORMATION Please Print Clearly or Type PERMIT Number: Expiration Date:/mil--3/ 2Os'
Facility Name: Camp Seafarer Non-Discharge W00007144 UIC
Permit Name(if different): YMCA OF THE Triangle Area,INC. NPDES Other
Facility Address: 2744 Seafarer Rd Arapahoe NC 28510 TYPE OF PERMITTED OPERATION BEING MONITORED
2744 Seafarer Rd Arapahoe [Street) Nc 28510 County Pamlico ❑ Lagoon ❑Remediation: Infiltration Gallery
tQtyr (Stale) (ZIP) ® Spray Field ❑ Remediation:
Contact Person: Mike Askew Telephone#: [phone] ❑ Rotary Distributor ❑Land Application of Sludge
Well Location/Site Name:Spray Field 2 No.of wells to be sampled: 5 ❑ Water Source Heat Pump ❑Other:
(from Permit)
SAMPLING INFORMATION If WELL
WELL ID NUMBER(from Permit): WELL 7 Date sample collected: a jzz/ 2- FIELD ANALYSES: WAS
Well Depth: 12 ft. Well Diameter: 2 in. pH 00400: C•9knits Temp.arm: /6 •'2-°C DRY at
time of
Depth to Water Level 6254s: I,"7 I ft.below measuring point Screened Interval: 2 ft. to 12 ft. Spec.Cond.00094: SSb 11Mhos sampling,
Measuring Point is 1 ft.above land surface Relative M.P.Elevation: 25.8 ft. Odor 00085: /✓a.vL: check
Volume of water pumped/bailed before sampling: I 0 gallons Appearance C4.4/ here:
Samples for metals were collected unfiltered: ❑YES E NO and field acidified: ❑YES ❑NO
LABORATORY INFORMATION
Date sample analyzed: 312.E )-), Laboratory Name: Enviroment 1,1NC. Certification No. [0
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 00335 < f mg/L Nitrite(NO2)as N 00615 mg/L Pb-Lead 01051 ug/L
Coliform: ME Fecal 31616 /100mL Nitrate(NO3)as N 00620 •Q, 0 el- mg/L Zn-Zinc o1092 mgfL
Coliform:MF Total 31504 /100mL Phosphorus:Total as P 00665 < O e C' +, mg/L •
(Note: USa MPN method for highly turbid samples) Orthophosphate 70507 mglL Other(Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300 t GA 0 mglL Al-Aluminum 01105 mglL
pH (Lab)00403 5 ,), units Ba-Barium 01007 uglL
TOC o06so mgfL Ca-Calcium oos1s mg/L
Chloride 00940 3 mg/L Cd-Cadmium 01027 ug/L
Arsenic 01002 ug/L Chromium:Total 01034 ug/L
Grease and Oils 00552 mg/L Cu-Capper 01042 mgfL ORGANICS:(by GC, GC/MS, HPLC)
Phenol 32730 ug/L Fe-Iron 01045 uglL (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 IzMhos K-Potassium 00937 mglL VOC 7673 , method#
Total Ammonia oos10 'C-0. O-d- mg/L Mg-Magnesium 00927 mg/L, , method#
(Ammonia Nitrogen;Nliaas N;Ammonia Nitrogen,Total) Mn-Manganese 01055 ug/L , method#
TKN as N oos25 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 VOC Removal%
I certify that to the best of my knowledge and belief,the information submitted in this report is irue,accurate,and complete,and that the laboratory analytical data was produced using approved methods of analysis by a
lDWR-certified laboratory..:I am aware that there are significant penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. ,
Mike Askew, Director of Facilities and Boating Operations L :z l�� 2Z.
Permittee(or Authorized Agent)Name and Title-Please print or type Signature of Permittee(or Authorized Agent) (Date)
GW-59 Rev.05-02-2017

SUBMIT FORM ON YELLOW PAPER ONLY
Mail original DEPARTMENT OF ENVIRONMENTAL QUALITY DIV.OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING: and 7
INFORMATION PROCESSING U EIT
copy to:
COMPLIANCE REPORT FORM 1617 MAIL SERVICE CENTER RALEIGH,NC 27699.1617 Phone.[phone]
FACILITY INFORMATION. Please Print Cfeariy or Type PERMIT Number: Expiration Date:nu)r 1/ OA7
Facility Name: Camp Seafarer Non-Discharge W00007144 uIC
Permit Name(if different): YMCA of the Triangl Area,INC. NPDES Other
Facility Address: 2744 Seafarer Rd Arapahoe NC 28510 TYPE OF PERMITTED OPERATION BEING MONITORED
2744 Seafarer Rd Arapahoe (Street' NC 28510 County Pamlico ❑ Lagoon ❑ Remediation: Infiltration Gallery
(city) • (Stale) (LIP) ❑ibt Spray Field ❑ Remediation:
Contact Person: Mike Askew Telephone#: [phone] ❑ Rotary Distributor ❑Land Application of Sludge
Well Location/Site Name:Spray Field 2 No. of wells to be sampled: 5 ❑ Water Source Heat Pump ❑ Other:
(from Permit)
SAMPLING INFORMATION - If WELL
WELL ID NUMBER(from Permit): Well 8 Date sample collected: 3/ -' /.2.k FIELD ANALYSES: WAS
Well Depth: 12 ft. Well Diameter: 2 in. pH 00400:.9irunits Temp.Pool 0:IC."'7 °C DRY at
Depth to Water Level 82546: 7 ft. below measuring point Screened Interval: 2 ft. to 12 ft. Spec.Cond.00094: 3-I. 7 (Mhos time of
--- sampling,
Measuring Point is 1 ft.above land surface Relative M.P. Elevation: 15.3 ft. Odor 00085: /' '" check
Volume of water pumped/bailed before sampling: 3-D' v' gallons Appearance C2.419A here:
Samples for metals were collected unfiltered: DYES ❑ NO and field acidified: ❑YES ❑NO
LABORATORY INFORMATION 31z2� 1-�
Date sample analyzed: Laboratory Name: Enviroment 1,INC. Certification No. 10
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 < I /100mL Nitrate(NO3)as N o0szo C. 0 ii- mg/L Zn-Zinc o1o92 mg/L
Coliform:MF Total 31504 /100mL Phosphorus:Total as P 00665 too /f- mg/L
(Note: use MPN method for higity turbd samples) Orthophosphate 70507 mg/L Other(Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300 ' mg/L Al-Aluminum o11os mg/L
pH(Lab)00403 Sr f units Ba-Barium 01007 ug/L
TOC 00680 mg/L Ca-Calcium 00915 mg/L
-
Chloride 00940 /3 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 uglL (Specify test and method#.ATTACH LAB REPORT.)
Sulfate 00945 mg/L Hg-Mercury 71900 uglL Lab Report Attached? ❑ Yes(1) ❑ No(0)
Specific Conductance 00095 )LMhos K-Potassium 00937 mg/L VOC 7873 , method#
Total Ammonia o0610 Of 10 mg/L Mg-Magnesium 00927 mg/L ,.method#
(Ammonia Nitrogen;NHs as N;Ammonia Nitrogen,Total) Mn-Manganese 01 oss uglL ,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%
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 laboratory analytical data was 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 and imprisonment for knowing violations.
Mike Askew, Director of Facilities and Boating Operations, ifi-/`p f 2 a-
��1-a-
Permittee(or Authorized Agent)Name and Title-Please print or type Sigrfature of Permittee(or Authorized Agent) (Date)
GW-59 Rev.05-02-2017

GW-59A COMPLIANCE REPORT FORM Permit# Wqt 0007114
(Subnail one each monitoring_period with GIP-59 forums.)
Z Enter date monitoring results were due.( / 04) 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 15.0K
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? )E 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:
WELL 4S4,0 toll + -3
L° " p/I 1, 1-3
l/+rc-[( P 7'
5 _ For the constituents identified in question 4 above, have standards been exceeded previous y 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 est two years).
ImvC L °G aw PH 3sctsa 101,13!/?- . .5; 5 '7/I-/a1 i 1-.ro' 1-/ oa
I,�c[ c ��+�- p/a :c� /V i/�� 1 , r 6' '2//iL/at ) S;74, lac/a 1
0.4-Zc. 8 4e1-- PH .5 IA/3//9 5 S'C '7/01/,21 ++ S;° i &/p/d
{ Are the monitoring wells listed in section/5 located at or beyond tFie review boundary? YES NQ�
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 IN
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 permittoe to a Notice of Violation,
fines, and/or penalties. AL�,C/( )
ro km /- ./ff 11 C72IJ r /-t"c— /Z-r G1 o ,9.L c=zp 10E=
4/ / 2_.
8 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(Compliance Report OW-59A)Is true and complete to the best of my knowledge.
ILI
t -
9
Si nature of Permittee(or Authorized A(gent) Date
GW-59A 12/8/2003