WI0700031_Sample Collection Form_20220913

North Carolina Division of Water Resources
Laboratory (Water SciencesSection) Water Sample Collection &Submittal Form
Visit ID:
(optional)
Y
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ID Al" 1�
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Lab Use
Laboratory
Sample Number:
Only:
Location Description:
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LC r (1 7 c n ' /
Location Code:
DC O 06 J ( l) , )
'7 5 4/ /
Dote Received:
M/D/Y
Time Received:
(24 hrformat)
/ /
•
County:
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Collector:
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Priority:
Ambient
Routine
Compliance
COC
Emergency
OA
Water
Matrix:
Surface
Ground
Waste
Blank
Solution
Foam
Location
River/Stream
Estuary
Stormwater
Monitoring Well
Effluent
Field Blank
//�, ,L
Other&(J\�4E
type:
Lake
Canal
Influent
Filter Blank
Trip Blank
Water Supply 11
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I
DWR Region:
/based oa county)
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C v" C ('� `�
DWRO Office:
(or agency
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Received By:
River Basin:
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( A,9 .. (�r1 V'( 1 / c o
uate
(m/d/Y):
fb ain/endl
Q r
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Delivery Method:
State Courier
Notes:
Time(24 hr):
(begin/end)
d : I(
`-r >
IV /) .
/'t
y
Hand Delivered
ZIN,
Other:
Sampling
Method:
_
Grab
Other.
Chlo 'noted
Filtered Dissolved analysis: Enter "DIS"in
in Field check -boxes for parameters
Sample "A Secchi /A��
De the L� De the (`l,A oglnfle
Temperature on
Arrival(Y):
•
compozrt.
De -chlorin ted in Field
Lab Comments:
Lot ks/ 1..:) Awe f E c u (le( E/.��
Collector-
Comments:
�' �2.Ogil cc/ge+'t sa' �` co( (( (1 E: G'C og
Field Parameters (optional):
Preservative : Y
Water Temp ( C):
pH (s.u.):
6
Dissolved Oxygen
(Pprn):
Conductivity
(pmhos/cm):
Salinity
(PPU:
Microbiology Parameters:
Preservative
Wet Chemistry Parameters:
Preservative
Metals Parameters:
Preservative
Metals Parameters Can't:
Preservative
Alkalinity, as CaCO3, to pH 4.5/8.3
A
Bromide
A
S.
Aluminum (Al)
E
Thallium (TI)
E
B00: Biochemical Oxygen Demand, 5-day
A
X.
Chloride
A
Antimony (Sb)
E
Tin (Sn)
E
cBOD: Carbonaceous BOO, 5-day
A
Fluoride
A
X
Arsenic (As)
E
Titanium (Ti)
E
Coliform: Fecal MF
B-C
Sulfate
A
Barium (Ba)
E
Vanadium (V)
E
y
Coliform: Total MF
8- C
Chlorophyll a
A
Beryllium (Be)
E
IC
\
Zinc (Zn)
E
Specific Conductance, at 25°C
A
Color: ADMI
A
Cadmium (Cd)
E
'
Mercury 1631, low-level
I
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
K,
Chromium (Cr), Total
E
Hardness. Total as oc03- 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)
E
Acid Herbicides
A -C
MBAS (surfactants)
A
X
Iron (Fe)
E
Organochlorine Pesticides
A - C
Nut ients Parameters:
Oil and Grease, HEM, Total Recoverable
A - D
X
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
XNitrate-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
K
Manganese (Mn)
E
Semi -Volatile Organics (BNAs)
A - C
Total Phosphorus as P (TP)
A- D
Residue: Suspended (Suspended So/ids)
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)
x
TDS-Total Dissolved Solids
A
x
Nickel (Ni)
E
1,4-Dioxane
C - L
Orthophosphate as P (PO4)
A - Z
Silica
A
)C
Potassium (K)
E
TPH Gasoline Range
A-C-F-L
Cyanotoxins:
Sulfide
A-1
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)coo156°C,(B) cool <10*C,(C)0.008%Na,5,0,(when chlorine is present1.(D)H,SO4 to pH<2,(El HNO,to pH<2, CFI HCI topes<2.(GI H,PO. to off <2.CHI 6
NaOH to oil>10<11. III INH.I,SO4oH=9.3-9J. I11 zinc acetate
& N OH to pH to >9, (K) pH 6-9 ascorbic acid [when chlorine is presentl,(L) le ve no headspace, (M) ferrous ammonium sulfat [when chlorine is present),(P) ascorbic acid [when chlori e is present),(R) L ols, (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

O
443
11)
0
y
Water Sample Collection & Submittal Form
Location Code:
G
2
Location Description:
Location Type:
P.
a`
0
8
iJ
0
r�
Monitoring Well
c
00
lAL.
'0
G
E
ass
0Lu
6
LLI
UJ
LU
a
0
0
0
a
a
Metals Parameters Con
E
O
F
E.
E
E
3
a
c
00
0
M
u
4.3
co
m
Hardness, Total as caco
Organics Parameters
Acid Herbicides
Organochlorine Pesticide
Organonitrogen Pesticides
Organophosphorus Pesticides
PCBs (polychlorinated biphenyls)
Semi -Volatile Organics (BNAs)
TPH Diesel Range
Volatile Organics (VOA)
CO
0
d
TPH Gasoline Range
Perfluorinated Compounds (PFAS)
3
m
m
Phytoplankton / Algae
g
a
a
LU
LU
LIJ
LIJ
LW
LW
LIJ
Lid
LLI
UJ
LLI
0
0
oa
Metals Parameters:
£
E
c
0
c
m
E
m
Beryllium (Be)
E
E
0
3
V
O
E
E
0
0
0
a
0
0
a
Q.
E
2
0
c
c
c
O
E
a
0
2
2
E
0
E
0
0
2
E
0
Strontium (Sr)
xx
xx
X
1
No
Preservative
0
2
a
0
a
2
a
a
a
a
2
a
Wet Chemistry Paramete
2
00
0
O
0
c
O
0
Color: ADMI
0
0
V
Hexavalent Chromium (Cr6+)
Oil and Grease, HEM, Total Recoverable
Total Recoverable
O
W
Residue: Total (Total Solids)
Residue: Volatile/Fixed, Total
Residue: Suspended (Suspended Solids)
a
0
0
00
i
0
0
0
Tannin & Lignin
V
E
F
3
0
0.
a
a
a
00
00
a
O
a
a
0
a
a
a
a
a
0
0
0
E
Preservative : Y
Microbiology Parameters:
Alkalinity, as CaCO3, to pH 4.5/8.3
0
0
0
co
0
0
cBOD: Carbonaceous BOD, 5-day
oliform: Fecal MF
x
0
E
0
e
tg
0
0
s
a
TOC -Total Organic Carbon
2.7
a
0
Other Parameter
a
Nutrients Parameters
2
2
E
e as N (NO3+NO2-N)
2
2
r
a
Total Phosphorus as P (TP)
2
0
2
2
w
v
0
171
2
a
Orthophosphate as P (PO4)
0
O