WQ0002638_Groundwater Monitoring_20051212

SUBMIT FORM ON YELLOW PAPER ONLY . Q&O •
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
FACILITYINFORMATION Please Print Clearly or Type
Facility Name: /oaJd air t.9k/i/MoN/7AQ,rnj Weds'
Permit Name (if differs • / i
FacilitxAddress Po- OY-ZM
K
d191 . ' , tStreet) /(%G. 27.54/ s
(City)
Contact Person. ,E.tist�,MV A $/oo SLP)
•
Well Location/Site Name:10W "/ ,&Rsick hsp d
Well Identification Number (from Permit). MLci Ml.
Well Depth: 19 ft Well Diameter: in
Screened Interval: ft. to ft.
Depth to Water Level: 7.61 ft below measuring point.
County /424&'e
Telephone #c/P�G37-zo7/
No. of Wells to be Sampled: (,om nerve t)
For Groundwater Treatment Systems
Check•One L7 Influent (98)
❑ Effluent- (99)
Measuring Point (M.P.) is: / ' ft. above land surface. Relative M.P. Elevation in ft.:
Gallons of water pumped/bailed before sampling: Date sample collected: /I 2-05
. Field analysis::. pH 5.2 , Specific Conductance uMhos
Temp. T °C, Odor Nave ` Appearance CLe+oe?.
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
WATER OUALITY DIVISION, GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
RALEIGH, NC 27699.1636 Phone: [phone]
PERMIT #: • EXPIRATION DATE• woo. 2oa€
Non -Discharge 00426.38 uic •
NPDES
TYPE OF PERMITTED OPERATION BEING MONITORED
Lagoon Remedlatlon: Infiltration: Gallery
Spray Field Remediation• : A
Rotary Distributor Land Application of Sludge
Other.
Cl
NOTE: Values should reflect dissolved and
/.0
colloidal concentrations.
Date sample analyzed: /I.2-a+S >? /I $ -o9-1
Laboratory Narne. 7lL:745? Lab ��G•
Certification No. Go i
rz
ja
PARAMETERS (Samples for metals were collected unfiltered YES
COD mg/I Nitrite (NO2) as N
Coliform: MF Fecal z Ze au /100m1 Nitrate (NO3) as N
Col if
NO and field acidified YES NO)
mg/I Ni Nickel
o•y7
orm.• MF Total 1100m1 Phosphorus: Total as P 0. /2
(Note: Use MPN method for highly turbid samples) Orthophosphate
Dissolved Solids: Total 39Z mg/I Al -Aluminum
pH (when analyzed) units Ba - Barium
TOC G Os 5.0 # mg/I Ca - Calcium
Chloride to•Se mg/I - Cd - Cadmium -
Arsenic mg/1 Chromium: Total
Grease and Oils mg/l Cu - Copper
Phenol mg/I Fe - iron
Sulfate mg/I Hg - Mercury
Specific Conductance uMhos K - Potassium
Total Ammonia G. o• c Z. mg/I
TKN as N mg/1
Mg - Magnesium
Mn - Manganese
mg/I
'mg/I Pb - Lead = mg/I
mg/I . Zn - Zinc m /I
mg/I Ammonia Nitrogen _ 'mg/I
Other (Specify Compounds and Concentration Units)
mg/I
mg/I
mg/I
mg/I
mg/I
mg/I
mg/I ORGANICS: (GC,GC/MS,HPLC)
mg/l (Specify test and method #. Attach lab report.) ,
mg/1 Report Attached? Yes (1) No (0)
mg/I, VOC : method #
mg/1 - : - method # =
: method # =
'I'certify that, to the best of my knowledge and belief, the information submitted in this report is true;
using approved methods of analysis by a North Carolina DWQ (formerly DEM) certified laboratory.
'including the possibility'of fines'and'imprisonment for knowing violations.:,
GW-59
Rev. 03/200.0
(-ft
• Permlttee (or Authorized
Signature o1 Per
accurate, and.complete, and that. the laboratory analytical data;;was produced
I am aware that .there are`significantpenalties ;forsubrnitting false;informetion �'
,
e�/C
ame and Title -'Please print or type
tee (or Authorized Agent)
ent)
et. eie% !oN✓H o-r,79%C?
f 2 -/2 -✓ S-
(Date)

e
iGROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
SUBMIT FORM:ON YELLOW PAPER ONLY
FACILITY INFORMATION Please Print Clearly or Type
Facility Name: &il CpirAtipMehusedilae, y Alas
Permit Name (if different)• .
Facility Address* tfa.e
C oX 278
AN9/c4.
ei/ County 1/4Rre
CoacPerson* i,41o4yA8/00 ' ,,RIP) , Telephone #�9�
: qJ 639-24 7/
Well Location/ Site Name:/v161s ,C6 2 •;cie/Z/. No. of Wells to be Sampled• S-
' tlrom P.rmll)
Well Identification Number (from Permit). M lJ r Z
Well Depth:. 20 ft. Weil Diameter: .1/ in
Screened interval: ft. to ft
Depth to Water Level: 'S!S ft below measuring point.
For Groundwater Treatment Systems
Check One: ❑ Influent (98)
❑ Effluent (99).
Measuring Point (M.P.) is:1$ ft. above land surface. Relative M.P. Elevation in ft,:
Gallons of water pumped/bailed before sampling: _ Date sample collected: //-2-0. y
Field analysis: pH_...' / • , Specific. Conductance uMhos -
Temp. °C, Odor //o Appearance G 4
PARAMETERS (Samples for metals were collected. unfiltered YES NO
n m"Nitrite (NO2) as N
COD
Coliform: MF Fecal 1 e-Fu. /100m1
Cohform: MF Total
(Note: Use MPN method for highly turbid samples)
Dissolved Solids: Total /H7 mg/I
pH (when analyzed) units
TOC /, 7 7' mg/
Chloride Z2.2 mg/
Grease and Oils mg/
mg/
Phenol
Sulfate mg/
mg/
Specific Conductance uMhos
Total Ammonia 3,0�• mg/
TKN as. N mg/
Arsenic
GW-59
Rev. 03/2000
/100m1 Phosphorus: Total as P
Orthophosphate
Al - Aluminum
Ba - Barium
Ca - Calcium
Cd -. Cadmium
Chromium: Total
Cu - Copper
Fe - Iron
Hg - Mercury
K - Potassium
Mg - Magnesium
Mn - Manganese
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
WATER QUALITY DIVISION, GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
RALEIGH. NC 27699.1636 Phone: [phone]
PERMIT #: • EXPIRATION DATE•/V012 2608
Non -Discharge 43goce2438 UIC
NPDES -
TYPE OF PERMITTED OPERATION BEING MONITORED
__ Lagoon Remedlatfon: Infiltration •Gallery
Spray Field Remt diation .
Rotary Distributor Land Application of',Sludge ��
Other: - 4.*
,NOTE: Values should reflect dissolved and
colloidal concentrations.
Date sample analyzed: //-2-0,5- ? /% 8-as'
Laboratory Name- 7:ei>esr44-4 1,ciG.
Certification No. oG 7 ,
and field acidif ed YES NO)
mg/ Ni - Nickel mg/I
mg/I Pb - Lead mg/l-.
Zn - Zinc mg/I
Ammonia Nitrogen mg/I
Other (Specify Compounds and Concentration Units)
Nitrate (NO3) as N •to:o2'
cs. eta mg/
mg/I
mg/
mg/
mg/
mg/
mg/
mg/
mg/
mg/
mg/
mg/
mg/
ORGANICS: (GC,GC/MS,HPLC)
(Specify test and method #. Attach lab report.)
Report Attached? Yes (1) No (0)
VOC : method #
. method #
: method # =
P.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 p wduced4.
using approved` methods of analysis'by a North Carolina DWQ (formerly DEM) certified laboratory. I am aware that there are significant penalties, for submitting faiseas 'inforormation „
including the possibility of fines and'imprisonment for knowing violations..';
Co Ley r/ c e /o'..., /Va n 43 eft
Permittee (or Authorized Agent) Name and Title - Please print or type f ow a o-1w 9 /CSC
'�A." 12-1�—os
Signature of rmittee (or Authorized Agent)
(Date)

SUBMIT.FORM.ON YELLOW PAPER ONLY
(Note: Use MPN method for highly turbid samples) Orthophosphate
Dissolved Solids: Total 6.5S mg/ Al. -Aluminum mg/1TOC
(when analyzed) units Ba - Barium mg/I
/• mg/ Ca - Calcium mg/1
Chloride - 2Z.2 mg/ -Cd - Cadmium mg/I.
Arsenic mg/ Chromium: Total
Grease and Oils mg/I
Phenol mg/ Cu - Copper mg/I
Sulfate mg/ Fe - Iron, mg/1
Specific Conductance mg/ Hg - Mercury m /I
uMhos K - Potassium mg/I
Total Ammonia o-o,y mg/ Mg - Magnesium mg/1
TKN as N mg/ Mn -.Manganese mg/1
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
WATER QUALITY DIVISION, GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
RALEIGH. NC 27699.1636 Phone: [phone]
PERMIT #: -
Non -Discharge
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
FACILITY INFORMATION.
Facility Name: o4,_ 4 fl rlgt
Permit Name (if different)•
Facility Address: /? o. /30x 278
i4 (went)
tcurt �y,GQ it/C. 27501
Contact Person. 6^464f A. ¢>;ro:il s ;1vP1
Well Location/ Site Name: d.3 c 4aee.:ear t
Well Identification Number (from Permit)• M4J''3
Well Depth: S() ft Well Diameter: ' .i -in
_Screened Interval: ' ft. to ft
Depth to Water Level: /S ft below measuring point, 1
Measuring Point (M.P.) is: /.75 ft. above land surface. Relative M.P. Elevation in ft.:
Gallons of water pumped/bailed before. sampling: Va Date sample collected:
Field analysis: pH , Specific .Conductance uMhos
Temp. _ QC, Odor / /We Appearance CLe 4
Please Print Clearly or Type
County h144de ff
Telephone #: t 1V(4.3? 24o7/
No. of Wells to be Sampled• '
from Permit)
For Groundwater Treatment Systems
Check One: 0 influent (98)
❑ Effluent (99)
EXPIRATION DATE• Nay Za08
CaepaOo2(38 UIC
NPDES
TYPE OF PERMITTED OPERATION BEING MONITORED
._ Lagoon Remedlatlori: Infiltration Gallery
, X Spray Field Remediation:
Rotary Distributor Land Application of lElifdge 'r4
Other. 01
NOTE: Values should reflect dissolved and
colloidal concentrations.
t-3
CO
cri
Date sample analyzed: //2: AS. is //- 8-05
Laboratory Name. 70-eresr 446 -Z.c/c
Certification No GG7
'1
Other
PARAMETERS (Samples for metals were collected unfiltered YES NO and field acidified YES NO) as N
COD mg/ . .Nitrite(NO2)
Conform: MF Fecal - 4 I eau- ( 1-1/6mg/I Ni - Nickel
/100m Nitrate (NO3) as N /•' . mg/1 Pb - Lead
Coliform:..MF Total /100m Phosphorus: Total as P .4 ou>S mg/I Zn - Zinc
mg/I Ammonia Nitrogen
(Specify Compounds and Concentration Units)
mg/I
mg/I
mg/I
mg/1
ORGANICS: (GC,GC/MS,HPLC)
(Specify.test and method #. Attach lab report.)
Report Attached? Yes (1) No (0)
VOC : method # =
: method # =
: method #
t 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,datawas producOd„
using approved methods of analysis'by a North Carolina DWQ (formerly DEM) certified laboratory.' I am aware that.there are' significant penalties for.submitting false,informationrk
'including the possibility of fines`andimprisonment for knowing violations.:
GW-59
Rev. 03/2000
• e_ Pr-/ d e "e,. n /'%4 n 4 rVe/. Tww o7'3Sp/C2
Pennittee (or Author Kit,ent�ameend Title Please print or type
l�-r.� /2:,2 V t -
• Signature . Permittee (or Authorized Agent) . - (Date)

I- ,, ' COMPLIANCE REPORT FORM
GROUNDWATER QUALITY MONITORING:
SUBMIT FORM ON YELLOW PAPER ONLY
FACILiTYINFORMATION • Please Print Clearly or Type
;Facility Name•, )' W ©fA.i/ /e,2 fiNa ,1 72' �ha /ls
• Permit Name (if different •
Facility Address: ' i' O 30)eZ78
(sueaq „ye_
(slate)
Well Location/ Site Name.: M ¥M/
2,s(cti County f�Aatela
Telephone #: t94iG39-Zd'7/
No. of Wells to be Sampled: S
Perm
..: Well Identification Number (from Permit)• Ally 1'-S/' o
Well Depth: _` /H.-3' . -:ft Well Diameter: 'V in
;Screened trttervai:. ft: to ft
Depth to Water Level: /2, S ft below measuring; point.
Measuring Point (M.P.) Is: ft, above fend surfce. Relative M.P. Elevation' in ft.:
I
(CIly)ly) /
`•
Contaot Person.
)
For Groundwater Treatment Systems
Check One: L7 Influent (98)
Ci Effluent (99)
Gallons of water pumpedt'alled before sampling:. 1 Date sample collected: 2• d•
5`
Field analysis: ' pH S. 2 , Specific Conductance uMhos
Temp._°C, Odor. N4i/e Appearance Choucjj
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
WATER DUALITY DIVISION, GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
RALEIGH. NC 27699.1636 Phone: [phone]
PERMIT #: • EXPIRATION DATE•/udv 2 CB
Non -Discharge Leaaoo2438 UIC
NPDES
TYPE OF PERMITTED OPERATION BEING MONITORED •
Lagoon Remediation: Infiltration Gallery
• is Spray Field Remediation: • •
Rotary Distributor Land Application of Sludge c
Other. 0
NOTE: Values should reflect dissolved and
colloidal concentrations.
rrl•.
tq
tom,
Thate,sample analyzed: // 2-o6' io
Laboratory Name. "Aelresr,c 44
Certification No. 061
PARAMETERS (Samples • for metals were collebted unfiltered YES ' ' NO and field acidified YES NO) COD • mg/I Nitrite (NO2) as N mg/I. Ni - Nickel
Coliform: MF Fecal z /GFaI- /100m1 Nitrate (NO3) as N 0•92 mg/I Pb - Lead
Coliform: MF Total • /100mI •• Phosphorus: Total as"P 0•"5 mg/l Zn -Zinc
(Note: Use MPN method for highly turbid samples) - Orthophosphate
Dissolved Solids: Total 7•Y-o mg/I Al - Aluminum
- pH (when analyzed) units • Ba - Barium
TOC - /•OZ 4 mg/I Ca - Calcium Chloride " 29.0 . mg/I- . Cd - Cadmium
rr g/I ' Chromium* Total
Arsenic
-Grease and Oils
Phenol
Sulfate • ,.
Specific Conductance . -
Total Ammonia a- 0.02
TKN as N .
mg/I Cu - Copper
mg/I Fe = Iron •
mg/I • Hg - Mercury
uMhos . K - Potassium
mg/I Mg - Magnesium
mg/I- Mn - Manganese
mg/I
mg/I
mg/I
mg/I -Ammonia Nitrogen mg/I
mg/ Other (Specify Compounds and Concentration Units)
mg/
mg/I - -
mg/ - -
mg/
mg/
mg/
mg/
mg/
mg/
• mg/
ORGANICS: (GC,GC/MS,HPLC) '
(Specify test and method ft.-Attach lab report.)
Report Attached? Yes (1)••• No. (0)
VOC : method # =
method # =
method #
I' certify that,.to the best of my knowledge and belief,, the information submitted in this report is true,
using approved' methods of analysis by a North Carolina DWQ (formerly DEM) certified laboratory.
'including the possibility of fines and'imprisonment for knowing violations.- ry
GW-59
Rev. 03/2000
COL& y
Permitter) (or Authorized Age
accurate, and complete, and that the laboratory analyticaf,datawas producett
am aware that.there are significant, penalties for;submitting falsenformaliionr ,.
Narne and Title - Please print or type
•
Slgnature of P4rmittee (Or Authorized Agent)
G... -► . '
4ya9 e
1.2-/2—o.7
(Date) •

SUBMIT FORM ON YELLOW PAPER ONLY
GW-59
Rev. 03/2000
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
FACILITY INFORMATION • •I; Please Print Clearly or Type
,Facility Name: 1 4c/ 46CA �;c,C/iS9aw7:04, ly (ill
Permit Name (if different):
Facility Address ' " P. /30Y 2 7R
Altr jet {Street) ' , it1G 22S0�
(cu» (state) (vP) County ! • ��e
lt
Contact Person• Telephone #: 61)&39-2o7/
Well Location/ Site Name: t:J $ i No. of Wells to be Sampled• T�� • . ,• .:, 1� from Portn 1)
Well Identification Number. (from Permit)• Mb) 44..5"
' . Well Depth: �� ��•' /G. A/ . :_n � .Well Diameter: '' y • in • For Groundwater Treatment Systems
Screened"interval:` �- ft. to � ft ,� Check One; 0 Influent. (98)
Depth to Water Level: /0/1 ft below measuring point.
EI Effluent. (99)
Measuring Point (M.P.) is: ft.o_above land surface. Relative M.P Elevation in ft.:
Gallons of water pumped/balled before sampling: ' Date. sample collected: //--2- 05
Field analysis: pH �o , Specific Conductance. uMhos
:Temp.:±°C, Odor. /.AC 'i; Appearance aeets' .
Mail Original
to:
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
WATER aUALITY DIVISION, GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
RALEIGH. NC 27699.1836 Phone: [phone]
PERMIT #: EXPIRATION DATE'/l0V.2008
Non -Discharge LJ¢1 alAIR o38 UIC .
NPDES-
TYPE QF PERMITTED OPERATION BEING MONITORED .;
- Lagoon Remediation: Infiltration' Gallery'
Y Spray Field Remediation• r `:
Rotary Distributor Land Application of Sludgd
Other:
,vim
NOTE: Values should reflectdissolved and
colloidal concentrations. p •A
Date sample analyzed: //-2-o5- . jp //cig-d:FT
Laboratory Name' Ti2/7 v Lab Z (/c, x''
Certification No. ! '7
PARAMETERS (Samples for metals were collected: unfiltered • . YES
COD NO and field acidified YES NO)
mg/I Nitrite (NO2) as N mg/I Ni - Nickel
Coliform: MF Fecal 23ocFrylOoml Nitrate N0 as o.SZ mg/Img/I
Coliform: MF Total 3) N Pb Le
ad ead mg/I
/100m1 ' Phosphorus: Total as P 4 0.O,$ mg/I Zn - Zinc (Note: Use MPN method for highly turbid samples) Orthophosphate mg/I
mg/I Ammonia Nitrogen mg/I
Dissolved Solids: Total 47.5 mg/I Al - Aluminum
pH (when analyzed) units Ba -Barium mg/I Other (Specify Compounds and Concentration Units)
TOCd.Somg/I
Chloride mg/I Ca -Calcium mg/I
. 32. 9 ' mg/I. Cd -• Cadmium mg/I
Arsenic mg/I '. Chromium: Total mg/I
Grease and Oils nig/I Cu - Copper mg/i
Phenol mg/I Fe - Iron
Sulfate mg/I Hg - Mercury gA ORGANICS: (GC,GC/MS,HPLC) .
Specific Conductance uMhos . K - Potassium mg/I(Specify test and method #: Attach lab report.)
Total Ammonia G o.a2 mg/I " Report Attached? Yes (1).• No. -, (0)
mg/I •Mg - Magnesium m : method #
TKN as N mg/I Mn - Manganese mg/I VOC
g : method #
: method # =
' 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 analyticalldata was produged�`
using approved methods of analysis' by a North Carolina DWQ°(formerly DEM) certified laboratory.' I am, aware that. there are significant for.; submitting faisetmformation
including the' possibility of fines`and'imprisonment for knowing violations.: .
Co Le y. , . r• Ce e /b w h ' i74" 49 eir 7..., (49/ed
Perrnittee (or Authorized Age Name and Title - Please print or type
'` /2--/ 2 -os
Signature of P ttee (or Authorized Agent)
•
(Date) •

SUBMIT FORM ON YELLOW PAPER ONLY
GW-59
Rev, 03/2000
Well Identification Number (from permit): ild 'S
Well Depth: /G. 4/ ft. Well Diameter:' l/ in.
Screened Interval: • ft. to ft (
Depth to Water Level: ft. below measuring point.
GROUNDWATER .QUALITY: MONITORING:
COMPLIANCE REPORT FORM
FACILITY INFORMATION : ` I Please Print Clearly or Type
Facility Name' Tom/ oFi4,c.9.e.G / ,yexii7beMi t)e//S
Permit Name
(if different):
Facile Address. a.�o•X 27�
(sm.)
(Clly) (Slate) d at County�c1
Contact Person: Telephone #( /pG39--20>/
Well Location/ Site Name: N1 Gd 'E5' No. of Wells to be Sampled:
(6;m a.rmh)
For Groundwater Treatment Systems
Check One: D Influent (98)
❑ Effluent (99)
Measuring Point (M.P.) is: ft above land surface. Relative M.P. Elevation In ft.:
Gallons of water pumped/bailed before sampling: :I Date sample collected: //-2ff-0..c
Field analysis: pH ;Specific Conductance uMhos
Temp._°C, Odor _ Appearance
Mail Original
to:
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
WATER QUALITY DIVISION, GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
RALEIGH NC 27699-1836 Phone: [phone]
PERMIT #:
Non -Discharge
• EXPIRATION DATE.
6e)Q0502438 uic
NPDES
ay. Zoo
TYPE OF PERMITTED OPERATION BEING MONITORED
Lagoon Remediatlon: Infiltration Gallery
Spray Field
Rotary Distributor
Remedlation• •.a
Land Application of Slud ge
Other.
NOTE; Values should reflect dissolved and cc-r1-3
colloidal concentrations. N
Date sample analyzed: - • //- Z9. - O..5-‘
Laboratory Name• Ti2J7es7 I4. .TA1C--
Certification No. C 7
PARAMETERS (Samples for metals were collected'unfiltered
mg/
/100m
/100m
mg/
units
mg/
mg/
mg/
mg/
mg/
mg/
uMhos
/
mg/
COD
- Coliform: MF Fecal • / C fu
Coliform: MF Total -
(Note: Use MPN method for highly turbid samples)
Dissolved Solids: Total
pH (when analyzed)
TOC
Chloride
Arsenic
Grease and 011s
Phenol
Sulfate
Specific Conductance
Total Ammonia
•TKN as N
YES
Nitrite (NO2) as N
Nitrate (NO3) as N
Phosphorus: Total as P
Orthophosphate
Al - Aluminum mg/
Ba - Barium g
Ca - Calcium • • mg/
mg/
mg/
mg/
mg/
Hg - Mercury m /
K - Potassium mg/
Mg - Magnesium mg/
Mn Manganese mg/
NO
and field acidified YES NO) •
mg/ Ni - Nickel mg/1
mg/I • Pb - Lead mg/I
mg/ _ • . Zn - Zinc mg/I.
mg/I Ammonia Nitrogen mg/I
Other (Specify Compounds and Concentration Units)
Cd - Cadmium
Chromium: Total
Cu - Copper
Fe Iron
ORGANICS: (GC,GC/MS,HPLC)
(Specify test and method #. Attach lab report.)
Report Attached? Yes (1:) No (0)
-VOC : method # =
: method # =
: method # _
tcertify that, tothe best of my knowledge and belief,the information submitted in this report is true, accurate, and complete, and that the laboratory analyticaldatawas produced.F
-using approved' methods of analysis by a North Carolina DWQ (formerly DEM) certified laboratory: 1 amaware thatthere are significant penalties, for submitting faiseinformaliori
-•- including the possibility of fines and' imprisonment for knowing violations.:
Co `c y Ae 7o-1.., ., "414 -► * 9 e oc Wt., it o f 9-, 3 je i( Pennittee (or Authorized Age Name and Title !Please print or type
.�. I. -
a
Signature of Pe Rae (or Authorized Agent)
(Date)

1
GW-59A COMPLIANCE REPORT FORM : Permit # 4.)c 600Z637$
(Submit one each monitoring period with GW-59 forms.)
Enter date monitoring results were due. (/2.3/--25) Will this monitoring report (GW-59 and GW-59A)
be submitted after the established due date?
YES
No
2
3
Was any required information missing on the GW-59 report forms?
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.
Are any of the monitor wellsin need of repair or maintenance (damaged casing, unlocked or missing cap, missing
identification plate, area overgrown,: etc.)? If the answer is "Yes'; contact the Regional Office for guidance.
YES
YES
a
4
5
6
Are any monitored constituents equal to or above the established standards?
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:.
YES
NO
For the constituents identified in question 4 above, have standards been exceeded previously for the
same constituent(s) in the same well(s) in the last two years?
If the answer to question 5 is WO", skip tosection8. •-
If the answer to question 5 is "YES'; list in the space provided below, each well with constituent(s) exceeding .
"standards, concentrations) reported, and sample collection date for each occurrence (for the last two years).
7
8
Are the monitoring wells listed in section 5 located at 'or beyond the review boundary?
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.
Is the permittee implementing previously approved actions required by the Division involving this
groundwater quality problem? ,
YES -
NO
YES
NO
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.mav subject the permittee to a Notice of Violation,
fines, and/or penalties:
YES
NO
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 fop of the current GW-59 form.
`l a eby acknowledge tha tFie a ve iitforn atlo w se�ra uat 'd a nd�the tr f m t on) ub ' a 'r'-ram
report jCompuanceReport GW 59A)Is;true andtcomplete ta�ih t of my:'knowledge. z
" ep e4 I. La.
Signature of Perniittee (or duthorized Agent)
12..i2-05••
Date
GW-59A . :: 12/8/2003