WQ0033770_Monitoring - 03-2021_20210504 (2)

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING: Mail original DEPARTMENT�� N NME APRo� 1Y I OF WATER RESOURCES
ING UNIT
COMPLIANCE REPORT FORM and 1 copy to: 1617 MAIL SERVICE CENTER,RALEIGH,NC27699-1617
FACILITY INFORMATION Please Print Clearly or Type W PERMIT Number: W00033770 12/31/21
Facility Name: Carolina plantation W Expira
TP Non-Discharge UICtion Date:
Permit Name(if different): NPDES Other Infiltration system
Facility Address: 100 Carolina Plantation Road TYPE OF PERMITTED OPERATION BEING MONITORED
Jacksonville Nc 28540 Count
y 0 Lagoon ❑Remediation:Infiltration Gallery
Jeff Jarman P ElSpray Field CIRemediation:
Contact Person: Telephone#: [phone] 0 Rotary Distributor 0 Land Application of Sludge
Well Location/Site Name: carol i na P1 antati on No.of wells to be sampled:3 0 Water Source Heat Pump LJ Other: underdrai ns
(from Permit)
SAMPLING INFORMATION If WELL
WELL ID NUMBER(from Permit):� #'Z — / Date sample collected: 3 IIj/Z( FIELD ANALYSES: WAS
,Ipft
Well Depth: . Well Diameter: i•Ziin. pH 00400: units Temp.00010: °C DRY at
Depth to Water Level 82546: // ft.below measuring point Screened Interval: ft. to ft. Spec. time of
/� Cond. 0009a. µMhos sampling,
Measuring Point is 2 ft.above land surface Relative M.P.Elevation: ft. Odor oo06s: check
Volume of water pumped/bailed before sampling: gallons Appearance here
Samples for metals were collected unfiltered: ®YES 0 NO and field acidified: in YES 0 NO
LABORATORY INFORMATION
Date sample analyzed: Laboratory Name: Certification No.
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L Nitrite(NO2)as N oo61s mg/L Pb-Lead o1os1 ug/L
Coliform: MF Fecal 31616 /100mL Nitrate(NO3)as N 00620 mg/L Zn-Zinc o1092 mg/L
Coliform:MF Total 31504 /100mL Phosphorus:Total as P 00665 mg/L
(Note Use MPN method for highly turbid Samples) Orthophosphate 70507 mg/L Other(Specify Compounds and Concentration Units):
)issolved Solids:Total 70300 mg/L Al-Aluminum o11os mg/L
pH(Lab)00403 units Ba-Barium 01007 ug/L
TOC 00680 mgJL Ca-Calcium 00916 mg/L F r F 1V e D
Chloride 00940 mg/L Cd-Cadmium 01027 i it .ug/L
Arsenic 01002 ug/L Chromium:Total 01034 - *in- Mw 0 4 202l
Grease and Oils 00552 mg/L Cu-Copper 01042 mg/L ORGANICS:(by GC,G ' `HPLC) -
Phenol 32730 ug/L Fe-Iron o1045 ug/L (Specify test and me A6H'LAB REPORT.)
Sulfate 00945 mg/L Hg-Mercury 71900 ug/L Lab Re Agbthdd� Yes(1) ❑ No(0)
specific Conductance 00095 µMhos K-Potassium 00937 mg/L VOC 7873 method#
Total Ammonia oo6io mg/L Mg Magnesium 00927 mg/I method#
(Ammonia Nitrogen:NH,as N.Ammonia Nitrogen.Total) Mn-Manganese()loss ,method it
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 Totel VOCs: mg/L VOC Removal%
I certify that.to the best of my knowledge and belief.,the informat(on submitted in this report is true.accurate.and complete.and that the laboratory ana:ylical data was produced using approved methods of analysis by a
rii.,.'F-licertified laboratory l am aware that there are significant p4nalties for submitting false information.including the possibility of fines and imprisonment for pnowinq vlinlations
RECEIVED
Permittee(or Authorized Agent)Name and Title-Please print or type U Signori or Perrrrittee • Authorized Agent) (Data)
GW-59 Rev.06-07-2018 �/ MAY 04 2021
4 D twice

SUBMIT FORM ON YELLOW PAPER ONLY
•
GROUNDWATER QUALITY MONITORING: Mail original DEPARTMENT OF NFORMATIONPROCESSING U T�WATER RESOl1RCEs i
COMPLIANCE REPORT FORM and 1 copy t0: 1617 MAIL SERVICE CENTER,RALEIGH,NC 27699-1617
FACILITY INFORMATION Please Print CreatlyorType PERMIT Number: w00033770 Expiration Date: 12/31/21
Facility Name: Carolina plantation wWTP Non-Discharge UIC
Permit Name(if different): NPDES Other Infiltration system
Facility Address: 100 Carolina Plantation Road TYPE OF PERMITTED OPERATION BEING MONITORED
Jacksonville NC 28540
County El Lagoon ❑Remediation: Infiltration Gallery
❑ Spray Field 0 Remediation:
Contact Person: Jeff JarmanTelephone#: 910-330-8167 0 Rotary Distributor ❑Land Application of Sludge
Well Location/Site Name: Carolina Plantation No.of wells to be sampled:3 ❑ Water Source Heat Pump ©Other: underdrains
(from Penni)
SAMPLING INFORMATION If WELL
WELL ID NUMBER(from Permit): --" Z Date sample collected: 5//7 ( FIELD ANALYSES: WAS
Well Depth: ft. Well Diameter: 1.tYin. pH 00400: units Temp.000to: °C DRY at
time of
Depth to Water Level 82546: lG ft.below measuring point Screened Interval: /S ft. to ft. Spec.Cond.00094: µMhos sampling,
Measuring Point is 2 ft.above land surface Relative M.P. Elevation: ft. Odor moss. check
Volume of water pumped/bailed before sampling: gallons Appearance here:❑
Samples for metals were collected unfiltered: ®YES ❑NO and field acidified: It YES 0 NO
LABORATORY INFORMATION
Date sample analyzed: Laboratory Name: Certification No.
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L Nitrite(NO2)as N 0061s mg/L Pb-Lead otosi ugh
Coliform:MF Fecal 31616 /100mL Nitrate(NO3)as N o062o mg/L Zn-Zinc 01092 mg/L
Coliform:MF Total 31504 /100mL Phosphorus:Total as P 00665 mg/L
(Note. Use MPN method for ray axbd samples) Orthophosphate 70507 mg/L Other(Sp
ecify Compounds and Concentration Units):
)issolved Solids:Total 70300 mg/L Al-Aluminum altos mg/L
pH(Lab)00403 units Ba-Barium oio07 ug/L
TOC 00680 mg/L Ca-Calcium 00916 mg/L
Chloride 00940 mg/L Cd-Cadmium 01027 ug/L
Arsenic tit002 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 o0610 mg/L Mg-Magnesium 00927 mg/L ,method#
(Aromas Nitrogen,NH,as N.Ammonia Nitrogen,Total) Mn-Manganese°loss 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 spbmdted in this report is 1«.e.accurate and complete,and that the aooratory enaytcat data Was produced using approved methods of analysis by a
01NR-certified laboratory 1 am aware that there are significant penalties for submitting false information ndudinq the possibm'.ty of Ines and imprisonment for knowing isolations.
Peree(or Authorized Argent)Name and Title- lease print or Signature of Permittee(or AuthonzelAgent) /�J
mtt (Gate)
GW-59 Rev.06-07-2018
—,;- —

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING: Mail original �PARTMENTOF ENVIRONMENTAL QUALITY-DIV.INFORMATIONPPROCESSINGUNIT�WATER RESOURCES
COMPLIANCE REPORT FORM and 1 copy to:
1617 MAIL SERVICE CENTER,RALEIGH,NC 27669.1617
FACILITY INFORMATION Please Pnnt Clearly or Type PERMIT Number: w00033770 Expiration Date: 12/31/21
Facility Name: Carolina plantation (e TP Non-Discharge UIC
Permit Name(if different): NPDES Other Infiltration system
Facility Address: 100 Carolina Plantation Road TYPE OF PERMITTED OPERATION BEING MONITORED
Jacksonvi 11 e - ' Nc 28540 County 0 Lagoon ❑Remediation: Infiltration Gallery
0 Spray Field 0 Remediation:
Contact Person: Jeff Jarman Telephone#: [phone] 0 Rotary Distributor •❑Land Application of Sludge
Well Location/Site Name: Carolina Plantation No.of wells to be sampled:3 ❑ Water Source Heat Pump ©Other. underdrains
(from Permt)
SAMPLING INFORMATION / If WELL
WELL ID NUMBER(from Permit): —3 Date sample collected: 3/�!/2/ FIELD ANALYSES: WAS
Well Depth: 1Q ft. Well Diameter: /,Z tn. pH ooaoo units Temp.000to °C DRY at
time of
Depth to Water Level 82546: /ci ft.below measuring point Screened Interval: r 5—ft. to _ft. Spec.Cond.00094 µMhos sampling,
Measuring Point is Z. ft.above land surface Relative M.P.Elevation: ft. Odor 00085. check
Volume of water pumped/bailed before sampling: gallons Appearance here:n
Samples for metals were collected unfiltered: ®YES 0 NO and field acidified: U YES 0 NO
LABORATORY INFORMATION
Date sample analyzed: Laboratory Name: Certification No.
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/1.. Nitrite(NO2)as N 00615 mg/L Pb-Lead o10s1 wiL
Coliform: MF Fecal 31616 /100mL Nitrate(NO3)as N 00620 mg/L Zn-Zinc 01092 mg/L
Coliform:MF Total 31504 /100mL Phosphorus:Total as P 00665 mg/L
(Note Use MPN method for nighty turbid samples) Orthophosphate 70507 mg/L Other(Specify Compounds and Concentration Units):
)issolved Solids:Total 70300 mg/L Al-Aluminum o1105 mg/L
pH(Lab)00403 units Ba-Barium 01007 ug/L
TOC o068° mg/L Ca-Calcium 00916 mg/L
Chloride 00940 • mg/L Cd-Cadmium 01027 ug/L
Arsenic olooz 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 owes ugh (Specify test and method#.ATTACH LAB REPORT.)
Sulfate 00945 mg/L Hg-Mercury 71900 ug/L Lab Report Attached? 0 Yes(1) 0 No(0)
Specific Conductance o0095 µMhos K-Potassium 00937 mg/L VOC 7873 ,method#
Total Ammonia 00610 mg/L Mg-Magnesium 00927 mg/L .method#
(Ammonia Nitrogen.NH,as N.Ammonia Nitrogen,Tote) Mn-Manganese°loss ug/L .method#
TKN as N 00625 mg/L Ni-Nickel 01067 ug/L _Th ,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
flWR-certified laboratory t am aware that there are significant penalties for submitting false on,including the possibility of fines and imprisonment for knowing violations..
\CV `- \ a `` Ajkr � �y 4,1 Z\
PeondtN(or AtAhorized Agent)Name and Title-Pieaie print or type Signature of Permdtee(or Authorized Agent) (Date)
GW-59 Rev 06-07-2018

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING: Mail original DEPARTMENT OF ENVIRONMENTAL QUAUTY-DIV,OF WATER RESOURCES
1 copy t0: INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM and1617 MAIL SERVICE CENTER,RALEIGH,NC 27699-1617
FACILITY INFORMATION Please Print Clearly or Type PERMIT Number: W00033770 Expiration Date: 12/31/21
Facility Name. Carolina plantation WWTP Non-Discharge UIC
Permit Name(if different) NPDES Other Infiltration system
Facility Address: 100 Carolina Plantation Road TYPE OF PERMITTED OPERATION BEING MONITORED
Jacksonville NC 28540 Count
y 0 Lagoon ❑Remediation:Infiltration Gallery
)eff barman 0 Spray Field 0 Remediation:
Contact Person Telephone* 910 330 8167 0 Rotary Distributor 0 Land Application of Sludge
Well Location/Site Name: Carolina Plantation No.of wells to be sampled:3 ❑ Water Source Heat Pump ©Other: underdrains
(from Perm')
SAMPLING INFORMATION M , � If WELL
WELL ID NUMBER(from Permit): Y c.- `7 Date sample collected:-3//j/Z/ FIELD ANALYSES: WAS
Well Depth: /a--ft. Well Diameter:/• DRY at
tin. pH Qum units Temp.000lo: C
Depth to Water Level 82546: ft.below measuringtime of
7 point Screened Interval: l S ft. to _ft. Spec.Cond.000sa. µMhos sampling,
Measuring Point is 'f ft.above land surface Relative M.P. Elevation: ft. Odor 00085: check
Volume of water pumped/bailed before sampling: gallons Appearance herein
Samples for metals were collected unfiltered: t YES Cl NO and field acidified: •YES Cl NO
LABORATORY INFORMATION
Date sample analyzed: Laboratory Name: Certification No.
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L Nitrite(NO2)as N 00615 mg/L Pb-Lead o1os1 ug/L
Coliform:MF Fecal 31616 /100mL Nitrate(NO3)as N 00620 mg/L Zn-Zinc o1o92 mg/L
Coliform:MF Total 31504 /100mL Phosphorus:Total as P 00665 mg/L
(Note: Use MPN method for higNy turNd 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 units Ba-Barium 01007 ug/L
TOC 00680 mg/L Ca-Calcium 00916 mg/L
Chloride o0940 mg/L Cd-Cadmium 01027 ug/L
Arsenic o1002 ug/L Chromium:Total 01034 ug/L
Grease and Oils oo55z mg/L Cu-Copper o1042 mg/L ORGANICS:(by GC,GC/MS,HPLC)
Phenol 32730 ugll_ Fe-Iron 01045 ug/L (Specify test and method X.ATTACH LAB REPORT.)
Sulfate 00945 mg/L Hg-Mercury 71900 ug/L Lab Report Attached? 0 Yes(1) 0 No(0)
pecific Conductance 00095I
µMhos K-Potassium 00937 mg/L VOC 7873 method*
Total Ammonia 00610 mg/L Mg-Magnesium 00927 mg/L method#
(Ammonia Nitrogen.NH,as N,Ammonia Nitrogen.Tot ) 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 analysts 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 knavmg violations
`(\n(\(\C=-CYO `�(`Q �'�i�1 (1\f \Wk2- .4j2 ),Z-
PemNtlee(or Authorized Agent)Name and Title-Please print or type Signature Signature of Permrttee for Authorized Agent)/ / (Date)
GW-59 Rev 06-07-2018 \J

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING: Mail original DEPARTMENT OF ENVIRONMEN PROCESSING UNITOF WATER RESOURCES
INFORMCOMPLIANCE REPORT FORM and 1 copy to: 1617 MAIL SERVICE CENTER,RALEIGH,NC 27699-1617
FACILITY INFORMATION Pnnt Clearly or Type w00033770 12/31/21
PERMIT Number: Expiration Date.
Facility Name: Carolina plantation war,
Non-Discharge_ UIC
Permit Name(if different): NPDES Other Infiltration system
Facility Address: 100 Carolina Plantation Road TYPE OF PERMITTED OPERATION BEING MONITORED
3acksonville NC 28540 Count
y 0 Lagoon 0 Remediation:Infiltration Gallery
Jeff Jarman 0 Spray Field 0 Remediation:
Contact Person: Telephone#: [phone] 0 Rotary Distributor ❑Land Application of Sludge
Well Location/Site Name: Carolina Plantation No.of wells to be sampled:3 ❑ Water Source Heat Pump Q Other: underdrains
(from Permit)
SAMPLING INFORMATION If WELL
WELL ID NUMBER(from Permit): f Z— Date sample collected: 1/JZ/ FIELD ANALYSES: WAS
Well Depth: /`Tt. Well Diameter:/•Zcn. pH woo. units Temp.000to- °C DRY at
Depth to Water Level sz5a6: I ft.below measuringpoint Screened Interval: ft. to _ft. Spec. Mhos time of
/ /� Cond.00094: µ sampling,
Measuring Point is Z ft.above land surface Relative M.P.Elevation: ft. Odor 00085 check
Volume of water pumped/bailed before sampling: gallons Appearance herein
Samples for metals were collected unfiltered: E YES 0 NO and field acidified: ®YES 0 NO
LABORATORY INFORMATION
Date sample analyzed: Laboratory Name: Certification No.
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L Nitrite(NO2)as N owls mg/L Pb-Lead 01051 ugh.
Coliforrn MF Fecal 31616 /100mL Nitrate(NO3)as N 00620 mg/L Zn-Zinc 01092 mg/L
Coliform:MF Total 31504 /100mL Phosphorus:Total as P 00665 mg/L
(Note Use MPN method for highly turtsd samples) Orthophosphate 70507 mg/L Other(Sp
ecify Compounds and Concentration Units):
)issolved Solids:Total 70300 mg/L Al-Aluminum 01105 mg/L
pH(Lab)00403 units Ba-Barium 01007 ug/L
TOC o068o mg/L Ca-Calcium oos16 mg/L
Chloride 00940 mg/L Cd-Cadmium 01027 ug/L
Arsenic at002 ug/L Chromium:Total 01034 ug/L
Grease and Oils ooss2 mg/L Cu-Copper 01042 mg/L ORGANICS:(by GC,GC/MS,HPLC)
Phenol 3273o ug/L Fe-Iron ot0a5 ug/L (Specify test and method#.ATTACH LAB REPORT.)
Sulfate 00945 mg/L Hg-Mercury 71900 ug/L Lab Report Attached? 0 Yes(1) 0 No(0)
Specific Conductance 0oo95 µMhos K-Potassium 00937 mg/L VOC 7873 ,method#
Total Ammonia 00610 mg/L Mg-Magnesium 00927 mg/L ,method#
(Ammonia Nitrogen.NH,es N:Arrvrortia Nitrogen,Total) Mn-Manganese°toss ug/L ,method#
TKN as N o0625 mg/L Ni-Nickel oto67 ug/L ,method#
For Remediation Systems Only(Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: . mg/L VOC Removal'd.
I certify that.to the best of my knowledge aril belief the information submitted in this report is true.accurate.and complete.and that the labOralory anaryucal data was produced using approved methods of analyr,s try•a
-.PAIR-certified laboratcry I am a:rare that there are significant nenal ies for submita rig false information including the nossI.bil iy of fines and imprisonment for knoai�,i
\C 't \\(\ .---- -\6 \CC\CD.SiCn tr\Q,CNC\\ 2=e—._ / 0,
Peittee(or Authonzed Agent)Name and Tits-Please print or type Signature of Permitte t(or Authorized Agent) (Or�1
rm
GW-59 Rev 06-07-2018

SUBMIT FORM ON YELLOW PAPER ONLY
Mail original DEPARTMENT OF ENVIRONMENTAL QUALITY-DIV.OFWATERRESOURCES
GROUNDWATER QUALITY MONITORING:
and 1 copy t0: INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM 1617 MAIL SERVICE CENTER,RALEIGH,NC 27699-1617
FACILITY INFORMATION Please Print Clearly or Type PERMIT Number: W00033770 Expiration Date. 12/31/21
Facility Name. Carolina plantation WWTP Non-Discharge UIC
Permit Name(if different): NPDES Other Infiltration system
Facility Address. 100 Carolina Plantation Road TYPE OF PERMITTED OPERATION BEING MONITORED
Jacksonville NC 28540 County 0 Lagoon 0 Remediation:Infiltration Gallery
'''" ❑ Spray Field 0 Remediation:
Contact Person: Jeff Jarman Telephone#: [phone] 0 Rotary Distributor - 0 Land Application of Sludge
Well Location/Site Name: Carolina Plantation No.of wells to be sampled: 3 0 Water Source Heat Pump ©Other underdrains
ikon Permm)
SAMPLING INFORMATION If WELL
WELL ID NUMBER(from Permit): —40 Date sample collected: 31//2. I FIELD ANALYSES: WAS
Well Depth: /i ft. Well Diameter:!.Z rtn. pH 00400 units Temp. 00010 °C DRY at
Mhos time of
Depth to Water Level 82546:ere 3 ft.below measunng point Screened Interval: /5 ft to _ft. Spec.Cond.00094 µ sampling,
Measuring Point is Z ft.above land surface Relative M.P.Elevation: ft. Odor 00085• check
Volume of water pumped/bailed before sampling: gallons Appearance here ri
Samples for metals were collected unfiltered: U YES ❑NO and field acidified: U YES 0 NO
LABORATORY INFORMATION
Date sample analyzed: Laboratory Name: Certification No
PARAMETERS NOTE:Values should reflect dissolved and colloidal concentrations.
COD 00335 mgiL Nitrite(NO2)as N 00615 mg/L Pb-Lead oiosi ug/L
Conform: MF Fecal 31616 /100m1 Nitrate(NO3)as N 00620 mg/L. Zn-Zinc 01092 mg/L
Coliform.MF Total 31504 /100ml. Phosphorus:Total as P owes mg/L
(Note Use MPN method for hghly turbid samples) Orthophosphate 70507 m /L Other(Specify
g Compounds and Concentration Units):
,issolved Solids:Total 70300 mg/L Al-Aluminum o11os mg/L
pH(Lab)00403 units Ba-Barium 01007 ug/L
TOC 00680 mg/L Ca-Calcium 00916 mg/L
Chloride 00940 mg/L Cd-Cadmium 01027 ug/L
Arsenic o1002 ug/L Chromium:Total 01034 ug/L
Grease and Oils 00552 mgiL 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? 0 Yes(1) ❑ No(0)
Specific Conductance 00095 µMh0S K-Potassium o0937 mg/L VOC 7873 ,method*
Total Ammonia 00610 mg/L Mg-Magnesium 00927 mg/L ,method N
(Ammonia Nitrogen,NH,as N Anrnonra Nitrogen.Tole) Mn-Manganese 01055 ug/L ,method U
TKN as N 00625 mg/L Ni-Nickel 01067 ug/t. ,method U
For Remediation Systems Only(Attach Lab Reports): Influent Total VOCs mg/L Effluent Total VOCsA mg/L VOC Removal%
I certify that,to the best of my knowledge and belief,the informal,..-- .:Omitted in this report is true accurate and complete and that the laboratory analytical data was produced using approved methods of analysis by a
OWR.certified laboratory. I am aware that there are significant pe^..-'!es for submitting false information.including the possrtNbty of fines and imprsonment for knowing v,olations
/ ('' --) 41' t-31-1\
Per m itee(or Authorized Agent)Name and Title-Please print or type V I Signature of Permlttee(or Authorized Agent) Mote)
GW-59 Rev 06-07-2018 J