WQ0002096_Monitoring - 02-2022_20220329

GW-59A COMPLIANCE REPORT FORM Permit# ,'\JQ ODDS'2-Oq 4
(Submit one each monitoring period with GW-59 forms.)
I Enter date monitoring results were due.( ICI" ) 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
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. a
--r
3 Are any of the monitor wells in need of repair or maintenance(damaged casing,unlocked orinissing cap,missing YES NO
identification plate,area overgrown,etc.)?If the answer is "Yes", contact the Regional Ofce for guidance.
4 Are any monitored constituents equal to or above the established standards? (Y 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 concenction(s)
exceedin standards in the space provided below:
m�- ,—)C kS.3lprn dL-
5 For the constituents identified in question 4 above, have standards been exceeded previously f4the /VES 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).
(DI Ig)20 m w-5 -roc, I t,9 is tVi,I l- L,12.112.( mu; -5r,4I S 14)1110.,
9I28ia mw -5 Tic- IL to-htnilL 4It3I21 Mtk- 61"i 9.i5mjIt✓
/17i21 " -5 -i'DL i6.32tnjI1--
6 Are the monitoring wells listed in section 5 located at or beyond the review boundary? YES (NiD
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 8
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.
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 GW-59A)is true and complete to the best of my knowledge.cSigna f P ittee(or Authorize Agent) Date
GW-59A 12/8/2003

Environment 1, Incorporated
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P.O.BOX 7085,114 OAKMONT DRIVE I • • , PHONE[phone]
OREEtIVILLE,N.C.27835 7085 PAX(252)758-0833
ID*3 377 A
AHOSKIE ASSISTED LIVING
240 SOUTH EARLY STATION RD.
AHOSKIE, NC 27910 DATE COLLECTED, 02/28/22
DATE REPORTED t 03/02/22
REVIEWED/BY I
Well 84 Analysis Method
PARAMETERS Date Analyst Code
Fecal Col(form (MF),/100 MI5 <1 02/28/22 DIJ 9222D-15

rdPOO loll MI4 ilp [10)1©©ITPCTIIRgd Drinking pater ID, 37715
raataratar ID, 10
I
114 OAKMONT DRIVE PHONE[phone]
GREENVILLE,N.C.27858 FAX[phone]
ID#: 377
AHOSKIE ASSISTED LIVING
240 SOUTH EARLY STATION RD.
AHOSKIE, NC 27910 DATE COLLECTED: 02/16/22
DATE REPORTED : 03/07/22
REVIEWED BY: �r� `
Well #4 Well #5 Well #7 Analysis Method
PARAMETERS Date Analyst Code
Fecal Coliform (MF), /100 Mls FAULTY <1 <1 02/16/22 HCE 9222D-06
Ammonia Nitrogen as N, mg/I 0.34 0.05 <0.04 02/18/22 TRJ 350.1 R2-93
Nitrate Nitrogen as N, mg/1 <0.04 0.86 <0.04 02/17/22 KES 353.2 R2-93
Total Phosphorus as P, mg/1 1.27 0.12 <0.04 03/03/22 TRJ 365.4-74
Total Organic Carbon, mg/1 6.73 18.36 <1.00 03/03/22 HMM 5310C-14
Chloride, mg/I 44 4 45 02/21/22 DNS 4500CLB-11
Total Dissolved Residue, mg/I 100 210 230 02/17/22 HCE D5907-13
Fecal Colifonn SM 9222D-15: Well N4 sample received with>0.5 mg/I total residual chlorine.Client will ressmple.
I

I
SUBMIT FORM ON YELLOW PAPER ONLY
Mail original DEPARTMENT OF ENVIRONMENTAL QUALITY-DIV.OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING: and 1 copy to: INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM 1617 MAIL SERVICE CENTER,RALEIGH,NC 27699-1617 Phone: [phone]
FACILITY INFORMATIO CY Please Print Clearly or Type PERMIT NumberI t Expiration Date: 9 3o/ 'LAL5
Facility Name: Rh 05 k t. A a i rS LiI C W W i )- Non-Discharge V uoo2O�I10 UIC
Permit Name(if different):n 1,, NPDES Other
Fa ijity Address: L40 50(14- t ,61 .- A --t 6n rOaci. TYPE OF PERMITTED OPERATION BEING MONITORED
1he9sk, (Street) K„ I �1cj lb County Ht r'4 ford ❑ Lagoon ❑ Remediation: Infiltration Gallery
1 (City) (� /V(State) (Zip) �J G pray Field ❑ Remediation:
Contact Person: P. ain d c Telephone#: 2 c"G-SI 3 '_l C1/ ❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: raj
t '-e "�No. of wells to be sampled: , ❑ Water Source Heat Pump ❑ Other:
9 (from Permit)
SAMPLING INFORMATION ��p yn� // If WELL
WELL ID NUMBER(from Permit): I f�I/ I V� - i Date sample collected: -/1 (eiQ'L FIELD AN LYSES: WAS
Well Depth: 1 9 ft. Well Diameter: 2- in. pH 00400: units Temp.00010: °C DRY at
Depth to Water Level 82546:7- ft. below measuring point Screened Interval: LI- ft. to i / ft. Spec. Cond.00094: µMhos time of
sampling,
Measuring Point is Z.5 ft. above land surface Relative M.P. Elevation: ft. Odor 00085: check
Volume of water pumped/bailed before sampling: I /✓� gallons Appearance YY1 Udd\1 here:
Samples for metals were collected unfiltered: ❑YES ❑ NO and field acidified: ❑YES ❑ NO
LABORATORY INFORMATION t-
Date sample analyzed: Q 1 1 6 - J 3 1 'L2 Laboratory Name: E14�i roi()(eyt I/ LVIC-. Certification No. /0
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L Nitrite(NO2)as N oos15 mg/L Pb-Lead 01051 ug/L
Coliform: MF Fecal 31616 1 /100mL Nitrate(NO3)as N 00620 <0,0 4 mg/L Zn-Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL Phosphorus: Total as P oosss /. 2-7 mg/L
(Note: Use MPN method for highly turbid samples) Orthophosphate 70507 mg/L Other(Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300 I DO mg/L Al-Aluminum 01105 mg/L
pH (Lab)00403 units Ba-Barium 01007 ug/L
TOC 00680 w,73 mg/L Ca-Calcium 00916 mg/L
Chloride 00940 f+L mg/L Cd-Cadmium 01027 ug/L
Arsenic 01002 ug/L Chromium:Total 01034 uglL
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 ooslo o, 3f-- 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%
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 Nosibility of fines and imprisonment for knowing violations.
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a D - U�Y11,t1�5-�-r prPermittee(or Auorized Agent)Nam d Title- lease print or type lillgatur&Permittee(or A. orized Agent) (Date)

SUBMIT FORM ON YELLOW PAPER ONLY
Mail original DEPARTMENT OF ENVIRONMENTAL QUALITY-DIV.OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING: and 1 copy to: INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM 1617 MAIL SERVICE CENTER,RALEIGH,NC 27699-1617 Phone:[phone]
Please Print Clearly or Type PERMIT Number: Expiration Date:
FACILITY INFORMATION II U '.
Facility Name: 6- Sk,�. Ass tSk[t U d ttn3 W w 1 F- Non-Discharge WQ Q(JC;+7(;)G(2 UIC
Permit Name(if different): ,n NPDES Other
Facility Address: 240 Stt�+-h L al-\y S i- -1bn 11Qa,1 d TYPE OF PERMITTED OPERATION BEING MONITORED
(Street) �J c, I 27 9 I b County H er 4
k cAvi, -—O r{l ❑ Lagoon ❑ Remediation: Infiltration Gallery
(City) (State) (Zip)
2 'Z rG © Spray Field Remediation:
Contact Person: and y_ Telephone#: � — ' 13 7 7 I ❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: c[�1^t,1y N 't No.of wells to be sampled: 3 ❑ Water Source Heat Pump ❑ Other:
r 1 (from Permit)
SAMPLING INFORMATION �,1 5 If WELL
WELL ID NUMBER(from Permit): (I)IA) - Date sample collected: III t 12. FIELD ANALYSES: WAS
Well Depth: 2,1 ft. Well Diameter: Z., in. pH 00400: 62.(-)units Temp.00010: °C DRY at
time of
Depth to Water Level 82546: 7 ft. below measuring point Screened Interval: 6, ft. to 24 ft. Spec. Cond.00094: µMhos sampling,
Measuring Point is Q.: ft.above land surface Relative M.P. Elevation: ft. Odor 00085: _ check
Volume of water pumped/bailed before sampling: 2. gallons Appearance C/6 U C i
I here:
Samples for metals were collected unfiltered: ❑YES ❑ NO and field acidified: ❑YES ❑ NO
LABORATORY INFORMATION /�t
Date sample analyzed: /(�- 31 3)t 2 Laboratory Name: &i1✓i (D Yl vlt O'l t. I .L in CA 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 < I /100mL Nitrate(NO3)as N 00620 04 Sf (p mg/L Zn-Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665 O, t 2 mg/L
(Note: Use MPN method for highly turbid samples) Orthophosphate 70507 mg/L Other(Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300 I- I v mg/L Al-Aluminum o11o5 mg/L
pH (Lab)ooao3 units Ba-Barium 01007 ug/L
TOC 00680 i 0 '3 mg/L Ca-Calcium 00916 mg/L
Chloride 00940 y- 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 o0s10 (5; 0 5 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%
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
SWR-certified laboratory. I am aware that there are significant penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations.
, oak1q Pt f vY) k-fbr — A a m In I uitir` ZHZZ
Permittee(or Authorized Agent)Name d Title-Please print or type Sign-4111174yy
e(or Author' Agent) (Date)

SUBMIT FORM ON YELLOW PAPER ONLY
Mail original DEPARTMENT OF ENVIRONMENTAL QUALITY-DIV.OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
and I Copy t0: INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM 1617 MAIL SERVICE CENTER,RALEIGH,NC 27699-1617 Phone:[phone]
FACILITY INFORMATION Please Print Clearly or Type PERMIT Number: Expiration Date: 14 36/2er:5
Facility Name: ki-n0,54 ifq:S5 t s k d LA I/I t1 5 VIJ N T I Non-Discharge !,b U&CnLO UIC
Permit Name(if different): C NPDES Other
Fa ftyAddress: r/-"�O aarl\1 _S-ickion <Qad J TYPE OF PERMITTED OPERATION BEING MONITORED
J+)OS L, v (Street) No f o /27�I6 County Htr4 f Qrd ❑ Lagoon ❑ Remediation: Infiltration Gallery
(City) /V(State) (Zip) Spray Field 0 Remediation:
Contact Person: and . Parke.- Telephone#:2S2— 51 3 Y_59 / ❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: , C 4‘ No.of wells to be sampled: 3 ❑ Water Source Heat Pump 0 Other:
(from Permit)
SAMPLING INFORMATION )) I If WELL
WELL ID NUMBER(from Permit): I / / RI' 7 Date sample collected: .-:-/I�►' /2C._ FIELD ANALYSES: WAS
Well Depth: /9 ft. Well Diameter: 2 in. pH 00400: 17:-,3 units Temp.00010: °C DRY at
time of
Depth to Water Level 82546:/OVA ft. below measuring point Screened Interval: `i' ft. to /9 ft. Spec. Cond.00094: µMhos sampling,
Measuring Point is .5 ft.above land surface Relative M.P. Elevation: ft. Odor 00085: check
Volume of water pumped/bailed before sampling: gallons Appearance C/Qu CI/ here:
Samples for metals were collected unfiltered: ❑YES ❑ NO and field acidified: ❑YES ❑ NO I
LABORATORY INFORMATION 2 l I s
2/
Date sample analyzed: / tF -_ 3/3/22--- Laboratory Name: El✓ fl6Yt✓>7 ci1 t ( / ZnGi Certification No. U
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. I /100mL Nitrate(NO3)as N 00620 <D, 0 Li- mg/L Zn-Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665 4 U i d+ mg/L
(Note. Use MPN method for highly turbid samples) Orthophosphate 70507 mg/L Other(Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300 23 0 mg/L Al-Aluminum 01105 mg/L
pH (Lab)00403 units Ba-Barium 01007 ug/L
TOC 00680 < I,UZ mg/L Ca-Calcium 00916 mg/L
Chloride 00940 45 mg/L Cd-Cadmium 01o27 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) 0 No(0)
Specific Conductance 00095 µMhos K- Potassium 00937 mg/L VOC 7873 , method#
Total Ammonia o0610 <0, 0`j- 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%
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 possitiiity of Pints and imprisonment for knowing violations.
0QuIQ '� iv)fro�� — Rdn). nl�frc+or 3/Zz/2Z
Permittee(or Authorized Agent)Name and�le-Please print or type Sion: . Per b-e(or Authorize. gent) (Date)