WI0700323_Sample Collection Form_20220621

North Carolina Division of Water Resources
Laboratory (Water Sciences Section) Water Sample Collection & Submittal Form GO
Visit ID:
(optional)
Tag-,...
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Lab Use
Laboratory
Sample Number:
Only:
Location Description:
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Location Code:
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Date Received:
M/D/Y
Time Received:
(24hrformat)
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County:
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Collector:
k{ C -
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Priority:
Ambient
Routine
CDC
Emergency
g y
QA
Water
Matrix:
Surface
Ground
Waste
Blank
Solution
Foam
Location
River/Stream
Estuary
Stormwater
Monitoring Well
Effluent
Field Blank
Other:rC
lei ( ..-E:r,,
Type:
Lake
Canal
Influent
Filter Blank
TripBlank
Water Supply
(� IM IQ
DWR Region:
(based on county)
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C'� it
DWROffice:
(or agency name)
C.
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RCompiiance
Received By:
River Basin:
(� ~ ���
pate
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Delivery Method:
State Courier
Notes:
Time (24 hr):
(begin/end)
.c..�.' yn•
/ I - :/-
Hand Delivered
Other:
Sampling
Method:
Grab
Other:
Chlorinated
Filtered Dissolved analysis: Enter "MS" in
in Field check -boxes for parameters
p
Sample At /1 Secchi 1,/ A
Depth: k � Depth: (f / r 'gin file:
p p
Temperature on
Arrival ("C):
•
Composit:
De -chlorinated in Field
Lab Comments:
..is?—tA 4-E'E. I.
Col I((‘`•(cic4a ki)eaIf S 2.4,kt LL`f 2 �„ 2�O'7TA
Lot#S/
Collector( (/r r yJ+"' ! � J t , f ,, _1 "-
Collector 5 A �'�� e (G � 01 ( � , +c cC -64- A p (5 6 Ct (bl \ i u ` V♦ I f k t � V 1 c .. �,.1 % /fJ �1 l
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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 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
BOO: Biochemical Oxygen Demand, 5-day
A
X
Chloride
A
Antimony (Sb)
E
Tin [5n)
E
cBOD: Carbonaceous BOD, 5-day
A
Fluoride
A
X
Arsenic (As)
E
Titanium (Ti)
E
X
Coliform: Fecal MF
B - C
Sulfate
A
Barium (Ba)
E
Vanadium (V)
E
X
Coliform: Total MF
B - C
Chlorophyll a
A
Beryllium (Be)
E
Zinc (Zn)
E
Specific Conductance, at 25 °C
A
Color: ADM!
A
Cadmium (Cd)
E
Mercury 1631, low-level
'
TOC - Total Organic Carbon
A - G
Color: Platinum Cobalt
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
£
Other Parameters:
Cyanide, Total
A - H - P
Cobalt (Co]
E
`Organics Parameters:
pH
Y
Hexavalent Chromium (Cr6+)
A - I
Copper (Cu)
E
Acid Herbicides
A - C
MBAS {surfactants)
A
iron (Fe)
E
Organochlorine Pesticides
A - C
Nutrients Parameters:
Oil and Grease, HEM, Total Recoverable
A- D
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
{�X/
X
/// ��_
Manganese (Mn)
E
Semi -Volatile Organics (BNAs)
A - C
Total Phosphorus as P (TP)
A - D
Residue: Suspended (Suspended Solids)
A
Mercury (Hg)
E
TPH Diesel Range
A - C
X.
Nitrite as N (NO2-N)
A
Residue: Volatile/Fixed, Suspended
A
Molybdenum (Mo)
E
Volatile Organics (VOA)
A - C - F - L
Nitrate as N (NO3-N calculated)
X
TDS - Total Dissolved Solids
A
^/j
Nickel (Ni)
E
1,4-Dioxane
C - L
Orthophosphate as P (PO4)
A -.Z
Silica
A
X
"'
Potassium (K)
E
TPH Gasoline Range
A-C - F- L
Cyanotoxins:
Sulfide
A-1
Selenium (Se)
E
Pm -fluorinated Compounds (PFAS)
A-T
Microcystin
A
Tannin & Lignin
Silver (Ag)
E
Biological:
x
Sodium (Na)
E
Phytoplankton / Algae
A - R
l
Strontium (Sr)
E
rreservasive uegena tctrcle aoove as neeaea): tw) cool Str t., tts) cool «u c, a2S5V3 lwnen cnlorine Is presentj,(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, (1) (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, (M) 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
15 minutes of sample collection, (Z) filtered in field within 15 minutes using 0.45um pore size

North Carolina Division of Water Resources Water Sample Collection & Submittal Form ��
(Water Sciences Section)optional)
[,�h
isit ID:
Tag
to L4L
II,,
61/i
Lab
Laboratory
Sample Number:
Use Only:
Location Description:
r � , - � '"7
1 t F �� r) j 2
VV��// C/
Location Code:
_ � "
�r{r- +� T
L t. `, �. (' 1,
Date Received:
M/O/Y
Time Received:
(24hrformat)
/ /
•
County:
7
) C A uk +G) i f 7-
l
C_..) E
t -, F
Priority:
Ambient
Routine
Compliance
Water
Matrix:
Surface
Ground
Waste
Blank
Solution
Foam
Location
River/Stream
Estuary
Stormwater
Monitoring Well
Effluent
Field Blank
Other: (,,, C.
Type:
Lake
Canal
Influent
Filter Blank
Trip Blank
Water Supply ff
1' I
DWR Region:
(based on county)
il \,
L j k,.A (i U
DWRofface:
(or agency name)
Z (
C�� �
V
.�S
Received By:
River Rosin:
fl f i
�� - lr` �u COm/d/YI
lll ��t ( 1
More
/hpainlendf
! ,
, / , �/ d.
/ /
coc
Emergency
OA
—
B
—
Delivery Method:
State Courier
Notes:
Time (24hr):
(begin/end)
; ��
/ : C.di...•
�;�
Hand Delivered
t 0iJ
Other:
Sampling
Method:
Method:
Grab
Other:
Chlorinated
Filtered Dissolved analysis: Enter "D15" In
in Field check -boxes forparameters
Sample ,t `/jt Secchi f.11 ,�`
i 1 L �[,t •gin file -
Depth: Depth:
Temperature on
Arrival ('C):
•
comaosir
De -chlorinated in Field
Lab Comments:
Laths/ 1 e—t A ( --rc`CA j Co (('�dFz(A,, 130 .6f16` s t ietc.,►v,. Lo1-# o,)) c.2o3 T7
Collector ` -
Comments:
Field Parameters (optional):
Preservative : Y
Water Temp ( C):
pH (s.u.):f-�
•
` ' '�
Dissolved Oxygen
(ppm):
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.S/8.3
A
A
X.Bromide
Aluminum (Al)
E
Thallium (T1)
E
SOD: Biochemical Oxygen Demand, 5-day
A
` '
Chloride
A
Antimony (5b)
E
Tin (Sn)
E
cBOD: Carbonaceous BOD, 5-day
A
Fluoride
A
'?(Arsenic
(As)
E
Titanium (Ti)
E
\A_Coiiform:
Fecal MF
B - C
Sulfate
A
Barium (Ba)
E
Vanadium (V)
E
x
Conform: 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 Cobalt
A
x
Calcium (Ca)
E
Boron (B)
1
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 Chromium (Cr6+)
A - I
X,,
Copper (Cu)
F
Acid Herbicides
A - C
MBAS (surfactants)
A
x
Iron (Fe)
E
Organochlorine Pesticides
A -C
Nutrients Parameters:
Oil and Grease, HEM, Total Recoverable
A - D
i.Lead
(Pb)
E
Organonitrogen Pesticides
A - C
Ammonia as N (NH3-N)
A - C - 0
Phenols, Total Recoverable
A - D - M
Lithium (Li)
E
Organophosphorus Pesticides
A - C
X
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
X
Manganese (Mn)
E
Semi -Volatile Organics (BNAs)
A - C
Total Phosphorus as P (TP)
A - D
Residue: Suspended (Suspended Solids)
A
Mercury (Hg)
E
TPH Diesel Range
A - C
°Nitrite
as N (NO2-N)
A
Residue: Volatile/Fixed, Suspended
A
Molybdenum (Mo)
E
Volatile Organics (VOA)
A - C - F - L
Nitrate as N (NO3-N calculated)
,
TDS - Total Dissolved Solids
A
)Nickel
(Ni)
E
1,4-Dioxane
C - L
Orthophosphate as P (PO4)
A - Z
Silica
A
X
Potassium (K)
E
TPH Gasoline Range
A - C - F - L
Cyanotoxins:
Sulfide
A -J
Selenium (Se)
E
Perfluorinated Compounds (PEAS)
A - T
Microcystin
A
Tannin & Lignin
Silver (Ag)
E
Biological:
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% Na25203 )when chlorine is present], (D) H2504 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, (1) zinc acetate
& NaOH to pH to >9, (K) pH 6-9 ascorbic acid [when chlorine is present), L) leave no headspace, (M) 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
15 minutes of sample collection, (Z) filtered in field within 15 minutes using 0.45um pore size