NC0001970_Compliance Report Form_20230123

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING: Mail Original DEPARTMENT OF ENVIRONMENT&NATURAL RESOURCE S l
to: WATER QUALITY DIVISION, GROUNDWATER SECTION
COMPLIANCE REPORT FORM 1636 MAIL SERVICE CENTER
RALEIGH,NC 27699-1636 Phone:[phone]
FACILITY INFORMATION '/ l pease Print Clearly or Type
Facility Name: J
V /J��j/ r PERMIT#: ,�C-O �'/C EXPIRATION DATE: --•iy ?•/ 0`'/-1
Permit Name (if different): _ / Non-Discharge r UIC
Facility Address: S S �/ /1 r, J Jam' NPDES .Ti - `)J`-''/ j`7J
c', 's""" ., TYPE OF PERMITTED OPERATION BEING MONITORED
y.S � �' /'��, ''--K`-'`/� County /'J. ��T/
icily) Sia� , �/LtL�' c Lagoon Remediation: Infiltration Gallery
Contact Person: /� C' �' j Telephone#: .i'D �G) /2 ✓ 9
Well Location/Site Name: 'w-/`-'" # / No. of Wells to be Sampled: A Spray Field Remediation:
(from°emit) Rotary Distributor Land Application of Sludge
Well Identification Number(from Permit): v\/A - / For Groundwater Treatment Systems Other.
Well Depth: .. `T ft. Well Diameter: / in. Check One:0 Influent (98)
Screened Interval: /`/ _ft. to .% `/ ft. ❑ Effluent (99) NOTE; Values should reflect dissolved and
Depth to Water Level: /J 6 ft. below measuring point. colloidal concentrations.
Measuring Point(M.P.) is: It. above land surface. Relative M.P. Elevation in ft.:
Gallons of water pumpecl/bailed before sampling: Date sample collected://"/7 2- Date sample analyzed: //-•) ,2. 2.
-Field analysis: pH 15•e'' , Specific Conductance uMhos Laboratory Name: �p•-•/,_,,2Or n4k,1-)-.
Temp. l'• s °C, Odor Appearance Certification No. # n L/
PARAMETERS (Samples for metals were collected unfiltered ; YES NO and field acidified K YES NO)
COD mg/I Nitrite (NO2) as N L 0.0,---' mg/ Ni - Nickel mg/1
Coliform: MF Fecal /100m1 Nitrate (NO3) as N S•u i mg/ Pb - Lead mo/I
Coliform: MF Total /100m1 Phosphorus: Total as P mg/ Zn -Zinc mg/I
(Note:Use MPN method for highly turbid samples) Orthophosphate 0.6c). mg/ Ammonia Nitrogen 0.-2 mg/I
Dissolved Solids: Total ,7 ,' mg/I Al - Aluminum O r/J? mg/ Other (Specify Compounds and Concentration Units)
pH (when analyzed units Ba - Barium mg/ S.d,�,r)-. c/00 is/2
TOC ' l 0. 5 mg/I Ca - Calcium • mg/
Chloride 1 Z. mg/I Cd - Cadmium mg/
Arsenic mg/I Chromium: Total mg/ ✓� �(2 - f 2o�.o�/ S.,6 7 , S/L
Grease and Oils I mg/I Cu - Copper mg/
Phenol mg/I Fe - Iron mg/ ORGANICS: (GC,GC/MS,HPLC)
Sulfate z mg/I Hg - Mercury mg/ (Specify test and method #. Attach lab report.)
Specific Conductsnce uMhos K - Potassium__ mg/ Report Attached? Yes (1) No (0)
Total Ammonia I ! mg/I Mg - Magnesium mg/ VOC : method # =
TKN as N mg/I Mn - Manganese mg/ : 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 analytical data was produced
using approved methods of analysis by a North Carolina DWO(formerly DEM)certified laboratory. I am aware that there are significant penalties for submittitlg fa152 iffOrrflOtiatt`.
Including the possibility of fines and imprisonment for knowing violations. . p` h ,
( z
Pem to r uthorized Agent)Name and Title-Please print or type
l;W-FN - -

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING: Mail Original DEPARTMENT OF ENVIRONMENT&NATURAL RESOURCES
to: WATER DUALITY DIVISION,GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
COMPLIANCE', REPORT FORM RALEIGH.NC 27699-1636 Phone:[phone]
FACILITY INFORMATION /� Please Print Clearly or Type
Facility Name: /✓A/ V /�7 �`�etc-- PERMIT#: PG 0'1:11-' j 3 EXPIRATION DATE:,lz-,/,y / �( /%�
Permit Name (if different): Non-Discharge r UIC
Facility Addr ss: 3S`/ /J rs -./ NPDES /, 1rz`-a.'>✓ ?-5v
F' C"-''� �s�ree1r 'fer `/l County ((' /''J/ TYPE/OF PERMITTED OPERATION BEING MONITORED
Icxyt `D `A/QY IS1216(Gn{ ,` (ZIP) Telephone# k� �� /�/� V Lagoon Remediation: Infiltration Gallery
Contact Person: /
Well Location/Site Name: /tA44,-, 4 z No. of Wells to be Sampled: / Spray Field Remediation:
(fromPem,Iq Rotary Distributor Land Application of Sludge
Well Identification Nymber(from Permit): i/�- For Groundwater Treatment Systems Other.
Well Depth: 1 ft. Well Diameter: in. Check One:❑ Influent (98)
Screened Interval: 41 ft. to j `/ ft. ❑ Effluent (99) NOTE; Values should reflect dissolved and
Depth to Water Level: w.6 ft. below measuring point. colloidal concentrations.
Measuring Point(M.P.)is: ft. above land surface. Relative M.P. Elevation in ft.:
Gallons of water pump�d/bailed before sampling: '`-",/}-- Date sample collected: J/'(')'3 Date sample analyzed: , j 1-4:3—a
`�
Field analysis: pH 14' '0.`rSpecific Conductance uMhos Laboratory Name: ,t CNNN.ePGh-.c")
Temp. .N"' °C,Odor Appearance Certification No. # > V
PARAMETERS (Sam les for metals were collected unfiltered / YES NO and field acidified YES NO)
COD mg/I Nitrite (NO2) as N mg/ Ni - Nickel mg/1
Coliform: MF Fecal ! /100m1 Nitrate (NO3) as N mg/ Pb - Lead moil
Coliform: MF Total /100m1 Phosphorus: Total as P mg/ Zn -Zinc mg/I
(Note:Use MPN method for highly turbid samples) Orthophosphate mg/ Ammonia Nitrogen mg/I
Dissolved Solids: Total mg/I Al -Aluminum mg/ Other (Specify Compounds and Concentration Units)
pH (when analyzed) units Ba - Barium mg/
TOC mg/1 Ca - Calcium • mg/
Chloride mg/I Cd- Cadmium mg/
Arsenic mg/I Chromium: Total mg/
Grease and Oils mg/I Cu - Copper mg/
Phenol mg/I Fe - Iron mg/ ORGANICS: (GC,GC/MS,HPLC)
Sulfate mg/I Hg - Mercury mg/ (Specify test and method #. Attach lab report.)
Specific Conductance uMhos K- Potassium_ mg/ Report Attached? Yes (1) No (0)
Total Ammonia • mg/I Mg - Magnesium mg/ VOC : method#_
TKN as N mg/I Mn - Manganese mg/ : -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 analytical data teas produced
using approved methods of analysis by a North Carolina DWO(formerly DEM)certified laboratory. I am aware that there are significant penalties for submitting fai52 iflfbrtrntiort-
Including the possibility of fines and imprisonment for knowing violations. , ifir r, ,fir 1'1e - • •
• -
n ' /� ) ::i
'7 A . on ed Agent)Name and Title-Please print or type
► i..- / a- l-s Di v1

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING: Mail Original DEPARTMENT OF ENVIRONMENT&NATURAL RESOURCES
to: WATER QUALITY DIVISION,GROUNDWATER SECTION
COMPLIANCE REPORT FORM 1636 MAIL SERVICE CENTER
RALEIGH,NC 27699-1636 Phone:[phone]
FACILITY INFORMATION I �1 (_—Ple se Print Clearly or Type
Facility Name: / .4cy ►° 11 7 1"`, PERMIT#: (JAI c-O .1 c 73 EXPIRATION DATE: •-J 7 d �/ / 3/ am" •
Permit Name (if different): � / Non-Discharge UIC
)
Facility Address: 3� `/ /r C^��°--r NPDES Ale: DocD0 / C7
(r-v1 ''''/ js"re" N•`-- a6` `)/ County l��e I;ar. TYPE 1F PERMITTED OPERATION BEING MONITORED
P)2 ` c (4'1L ✓' Lagoon Remediation: Infiltration Gallery
Person: �'�✓�r',Isiy ) Telephone#: - '/o /-i)L 2 J 9
Well Location/Site Name: tea'" :3 No. of Wells to be Sampled: / Spray Field Remediation:
t'O'"p`"""1 Rotary Distributor Land Application of Sludge
Well Identification Number(from Permit): I. 0 For Groundwater Treatment Systems Other.
Well Depth: 'i( ft. Well Diameter: `i/ in. Check One:❑ Influent (98)
Screened Interval: /9 ft. to ,-3 ft. ❑ Effluent (99) NOTE; Values should reflect dissolved and
Depth to Water Level: is "'ft. below measuring point. colloidal concentrations.
Measuring Point(M.P.)'is: ft above land surface. Relative M.P. Elevation in ft.: /
/7, �,Z
Gallons of water pumped/bailed led before sampling: J . Date sample collected: /f./7 0 Date sample analyzed: f
Field analysis: pH ) , Specific Conductance uMhos Laboratory Name: &rN t/'l2."r�1-1-66'-,.
Temp.j - s °C, Odor Appearance Certification No. # rj y
PARAMETERS(Samples for metals were collected unfiltered f' YES NO and field acidified 1YES NO)
COD 11 mg/I Nitrite (NO2) as N ZO.° mg/ Ni - Nickel mg/1
Coliform: MF Fecal i /100m1 Nitrate (NO3) as N //24 mg/ Pb - Lead ma/I
Coliform: MF Total I /100m1 Phosphorus: Total as P mg/ Zn -Zinc mg/I
(Note:Use MPN method f4'highly turbid ss) Orthophosphate 0.o> mg/ Ammonia Nitrogen e O a mg/I
Dissolved Solids: Total sample mg/I Al -Aluminum V, a g mg/ Other (Specify Compounds and Concentration Units)
pH (when analyzed units Ba - Barium mg/
TOC %.3 mg/I Ca - Calcium • mg/ 0 )LA )a.1 r>�//
Chloride I /(3' mg/I Cd - Cadmium mg/
Arsenic I mg/I Chromium: Total mg/ P: ` - + AO—A--LP)-1 L.6L1 r-,j/L
Grease and Oils I I mg/1 Cu - Copper mg/
Phenol I ! mg/I Fe - Iron mg/ ORGANICS: (GC,GC/MS,HPLC)
Sulfate I mg/I Hg - Mercury mg/ (Specify test and method#. Attach lab report.)
Specific Conducta ce uMhos K- Potassium_ mg/ Report Attached? Yes (1) No (0)
Total Ammonia mg/I Mg - Magnesium mg/ VOC : method #_
TKN as N ' mg/I Mn - Manganese mg/ : .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 analytical data was produced
using approved methods of analysis by a North Carolina DWO(formerly DEM)certified laboratory. I am aware that there are significant penalties for submitiitlg false irifortrratian
Including the possibility of fines and imprisonment for knowing violations. , 7 _ P`Ci /"1(
Permits t I)"thorized Agent)Name and Title-Please print or type

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING: Mail Original DEPARTMENT OF ENVIRONMENT&NATURAL RESOURCES 1
to: WATER DUALITY DIVISION,GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
COMPLIANCE REPORT FORM RALEIGH,NC 27699-1636 Phone: [phone]
FACILITY INFORMATION j�� 1, 1 Plese Print Clearly or Type _
Facility Name. • ✓✓A- V Athy/ PERMIT#: ,>'V<--QJ0'j S>J EXPIRATION DATE: uli 3 i �i
Permit Name (if different): / Non-Discharge UIC l
,s-4.-- ✓c NPDES ✓ire-�. J C
Facility Ad ss: (s)�1)
1
1 ' ,�� C � County A-Lip 1,•''' TYPE 9F PERMITTED OPERATION BEING MONITORED
tCny)tac ,,,/,,)^w rjtexL)( (,,, v`>'1 o 2 7= c�:.') 4v Lagoon Remediation: Infiltration Gallery
Contact Person. � Telephone#:
Well Location/Site Name: S'C''ic'"C/-,'-r` /f No. of Wells to be Sampled: Spray Field Remediation:
prom Permit) Rotary Distributor Land Application of Sludge
Well Identification Number(from Permit): V`/_11/1 For Groundwater Treatment Systems Other:
Well Depth: 1) ft. Well Diameter: in. Check One:❑ Influent (98)
Screened Interval: 7- ft. to �- ft. ❑ Effluent (99) NOTE; Values should reflect dissolved and
Depth to Water Level: /d '' ft. below measuring point- colloidal concentrations.
Measuring Point(M.P.)'is: ft. above land surface. Relative M.P. Elevation in ft.:
Gallons of water pump wiled before sampling: J Date sample collected: !/ -- . Date sample analyzed: 1 l ))--?2
Field analysis: pH >,)- , Specific Conductance uMhos Laboratory Name: J V VInrch,c5-,,
Temp. ys'5 °C, Odor Appearance j Certification No. Ct/
PARAMETERS (Samples for metals were collected unfiltered / YES _____NO and field acidified YES NO)
COD mg/I Nitrite (NO2) as N 2.n.00- mg/ Ni - Nickel mg/I
Coliform: MF Fecal I /100m1 Nitrate (NO3) as N O.aO mg/ Pb - Lead ma/1
Coliform: MF Total II ! /100m1 Phosphorus: Total as P mg/ Zn - Zinc c mg/I
(Note:Use MPN method tot highly turbid samples) Orthophosphate 00,0 mg/ Ammonia Nitrogen 3 mg/I
Dissolved Solids: Total i030 mg/I Al - Aluminum O. 3/y mg/ Other (Specify Compounds and Concentration Units)
pH (when analyzed? units Ba - Barium mg/
TOC mg/I Ca - Calcium • mg/ Ste;frY -30 3 /1--
Chloride 11 t:).1q mg/I Cd- Cadmium mg/
Arsenic I i mg/I Chromium: Total mg/ lt'' -i Af)`i 12?'Pr'' 0_0 r�x-h
Grease and Oils 1 mg/I Cu - Copper mg/
Phenol I ' mg/I Fe - Iron mg/ ORGANICS: (GC,GC/MS,HPLC)
Sulfate `J S mg/I Hg- Mercury mg/ (Specify test and method #. Attach lab report.)
Specific Conductance uMhos K - Potassium_ mg/ Report Attached? Yes (1) No (0)
Total Ammonia • mg/I Mg - Magnesium mg/ VOC : method #_
TKN as N mg/I Mn - Manganese mg/ : -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 analytical data was produced
using approved methods of analysis by a North Carolina DWO(formerly DEM)certified laboratory. I am aware that there are significant penalties for submittitlg fain.if 1F rf tit7fh
including the possibility of fines and imprisonment for knowing violations. , /r/�� tp,A,Nfr /-16
Permit (or •u •orized Agent)Name and Title-Please print or type

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING: Mail Original DEPARTMENT OF ENVIRONMENT&NATURAL RESOURCES
to: WATER QUALITY DIVISION,GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
COMPLIANCE REPORT FORM RALEIGH,NC 27699-1636 Phone:[phone]
FACILITY INFORMATION t / l ) Please Print Clearly or Type
Facility Name: V'�/✓`� `X PERMIT#: : 0.‘) .' /r3 EXPIRATION DATE: S""1 y .31 do/t.
Permit Name (if different): / Non-Discharge UIC
Facility Ad Ss: 1 351) N/-:.;.5,sJ A/', NPDES fvr 0co-)I GJ
F-A i s` ' (s're*" tir'`- 3`') County i'-3`' ' 1; 4 TYPE QF PERMITTED OPERATION BEING MONITORED
(tCar) Is I c tnvl < < V Lagoon Remediation: Infiltration Gallery
Person- /�'�' �� Telephone#: c/J a�7 � ��/2
Well Location/Site Name: '64s`= Q4 w°"�' '16 No. of Wells to be Sampled: Spray Field Remediation:
tlrom vermlq Rotary Distributor Land Application of Sludge
Well Identification Number(from Permit): r
) For Groundwater Treatment Systems Other.
Well Depth: //2' ft. Well Diameter: - in. Check One:0 Influent (98)
Screened Interval: U ft. to 1t/, ft. 0 Effluent (99) NOTE; Values should reflect dissolved and
Depth to Water Level: y 3'`) ft. below measuring point. colloidal concentrations.
Measuring Point(M.P.)is: It. above land surface. Relative M.P. Elevation in ft.:
Gallons of water pumped/bailed before sampling: /.!�- Date sample collected: /1 r7 J , Date sample analyzed: /7 a�
Field analysis: pH St'li , Specific Conductance uMhos Laboratory Name: V//''moo Gam-,""
Temp. 3 °C, Odor Appearance _ Certification No. # J`J
PARAMETERS (Samples for metals were collected unfiltered Y YES NO and field acidified YES NO)
COD mg/I Nitrite (NO2) as N CO.OD_ mg/ Ni - Nickel mg/I
Coliform: MF Fecal /100m1 Nitrate (NO3) as N 7 1, mg/ Pb - Lead ma/1
Coliform: MF Total /100m1 Phosphorus: Total as P mg/ Zn -Zinc mg/I
(Note:Use MPN method for highly turbid samples) Orthophosphate 0 mg/ Ammonia Nitrogen 0.,(-) mg/I
Dissolved Solids: Total l .5 mg/1 Al - Aluminum 3t t mg/ Other (Specify Compounds and Concentration Units)
pH (when analyzed) units Ba - Barium mg/
TOO 3,ci mg/I Ca - Calcium • mg/ 6....4 so,-, 3..-7 i-1,z/y
Chloride I 1 /7 mg/I Cd - Cadmium mg/ ,)
�� Q `✓�
Arsenic I i mg/I Chromium: Total mg/ / z i' 7 K� G
Grease and Oils I mg/I Cu - Copper mg/
Phenol mg/I Fe - Iron mg/ ORGANICS: (GC,GCIMS,HPLC)
Sulfate mg/I Hg - Mercury mg/ (Specify test and method #. Attach lab report.)
Specific Conductance uMhos K- Potassium_ mg/ Report Attached? Yes (1) No- CO)
Total Ammonia I mg/I Mg - Magnesium mg/ VOC : method #_
TKN as N mg/I Mn - Manganese mg/ : -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 analytical data was produced
using approved methods of analysis by a North Carolina DM(formerly DEM)certified laboratory. I am aware that there are significant penalties for submitiirlg false iflfbrmatidl?'
Including the possibility of fines and imprisonment for knowing violations. Pi ,r 72 ,
I Permute ?rue Agent)Name and Title-Please print or type

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING: Mail Original DEPARTMENT OF ENVIRONMENT& NATURAL RESOURCES
to: WATER DUALITY DIVISION,GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
COMPLIANCE'REPORT FORM RALEIGH NC 27699-1636 Phone:[phone]
FACILITY INFORMATION 1,. Pease Print Clearly or Type
• i Ir AO icy ra--'4. PERMIT#: N -O )(7.))0 EXPIRATION DATE: -j 1 1 3) c 1 l-
Facility Name: /
Permit Name (if different): r Non-Discharge UIC
Facility Address: S_/ � r .1 NPDES f✓f: O-"'0 / (;-)0
PA,5=.0-1 'sieeqitiel Jg'3 ii Or z j.a� TYPE F PERMITTED OPERATION BEING MONITORED
tcly) fa RIP) County
Contact Person: 1 r:1c' ri j,1!re )C Telephone II: ''(� a4) `I,/) Lagoon Remediation: Infiltration Gallery
ti Spray Field Remediation:
Well Location/Site Name: ''� i^ "' S. No.of Wells to be Sampled:
(from Permit)
Rotary Distributor Land Application of Sludae
Well Identification Number(from Permit): .-3 For Groundwater Treatment Systems Other.
Well Depth: J 7 ft. Well Diameter: ,._,2 in. Check One:❑ Influent (98)
Screened Interval: 7 ft. to ft. ❑ Effluent (99) NOTE; Values should reflect dissolved and
Depth to Water Level: s-1 ft. below measuring point.
colloidal concentrations.
Measuring Point(M.P.)is: ft. above land surface. Relative M.P. Elevation in ft.:
Gallons of water pumped/bailed before sampling: i"'�l`, Date sample collected: I)"/2-, Date sample analyzed: f/-� J;-" 9-a-
Field analysis: pH M") "i' , Specific Conductance uMhos Laboratory Name: .�✓'16 ".!R �- �""
Temp. o'�"`' °C, Odor Appearance Certification No. 4 �1
PARAMETERS (Samples for metals were collected unfiltered f YES NO and field acidified VYES NO)
COD mg/I Nitrite (NO2) as N mg/ Ni - Nickel rng/I
Coliform: MF Fecal /100m1 Nitrate (NO3) as N mg/ Pb - Lead mo/I
Coliform: MF Total /100m1 Phosphorus: Total as P mg/ Zn - Zinc mg/I
(Note:Use MPN method for highly turbid samples) Orthophosphate mg/ Ammonia Nitrogen mg/I
Dissolved Solids: Total mg/I Al - Aluminum mg/ Other (Specify Compounds and Concentration Units)
pH (when analyzed units Ba - Barium mg/
TOC I mg/I Ca - Calcium • mg/
Chloride mg/I Cd - Cadmium mg/
Arsenic mg/I Chromium: Total mg/
Grease and Oils mg/I Cu - Copper mg/
Phenol I ' mg/I Fe - Iron mg/ ORGANICS: (GC,GC/MS,HPLC)
Sulfate I mg/I Hg - Mercury mg/ (Specify test and method #. Attach lab report.)
Specific Conductance uMhos K - Potassium____ mg/ Report Attached? Yes (1) No (0)
Total Ammonia • mg/I Mg - Magnesium mg/ VOC : method#_
TKN as N mg/I Mn - Manganese mg/ : .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 analytical data was produced
using approved methods of analysis by a North Carolina DWO(formerly DEM)certified laboratory. I am aware that there are significant penalties for submitting fain,iflfbrrftAtielir.
Including the possibility of fines and imprisonment for knowing violations. , q V)
g ) Perms 4'7• ,u '•rized Agent)Name and Title-Please print or type
r;W-Fc

GW-59A COMPLIANCE REPORT FORM Permit # NC G)Od/f7
(Submit one each monitoring period with G l-59 forms.)
1 Enter date monitoring results were due.( ;—t y -21 Will this monitoring report(GW-59 and GW-59A) YES fN0
be submitted after the established due date? /
2 Was any required Information missing on the GW-59 report forms? (YES\l NO
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.
W<<( a ) try . A;0 LO �
3 Are any of the monitor wells in need of repair or maintenance(damaged casing,unlocked or missing cap,missing YES p
identification plate,area overgrown,etc.)?If the answer is "Yes".contact the Regional Office for guidance. r
4 Are any monitored constituents equal to or above the established standards? YES NO
If the answer to question 4 is "NO" skip to section 8.
If the answer to question 41s "YES"list the affected wells individually with constituent(s)and concentration(s)
exceeding standards in the space provided below:
Vt/t vtit 44- 4 4. Ctit 1 y ��j i a 9 1©0 tr,`PLO viA
5 For the constituents Identified In question 4 above, have standards been exceeded previously for the ES 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).
342, ai- ac t6
6 Are the monitoring wells listed In section 5 located at or beyond the review boundary? e NO
If the answer is "YES", a groundwater quality problem maybe 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 NO
groundwater quality problem?
If the answer to question 7 is "YES", describe those actions in the space provided below.
If the answer to question 71s "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 permlttee to a Notice of Violation,
fines,and/or penalties.
��l/�7 /ic y lla 5 4%e& rem eoe; t;.ti wt=t 1 s 5 de .
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 Informaflori was evaluated arid the Information sutim t thisF
report(Compliance Report GW-59A)Is true and com let.to'the best Of m kn wlad '^ t . r "1
ik.q(17)
Sig t f ermittee(or Authorized Agent) Date

Monitoring Well#2 Monitoring Well#3
Chlorides ppm TDS ppm Chlorides ppm TDS ppm
Date Date
11/19/2020 No water No water 11/19/2020 13 52
1/21/2021 138 315 1/21/2021 29 216
3/29/2021 14 536 3/29/2021 25 79
7/29/2021 64 377 7/29/2021 243 508
11/23/2021 689 1370 11/23/2021 281 559
1/26/2022 51 418 1/26/2022 356 538
3/29/2022 242 446 3/29/2022 232 396
7/25/2022 836 1480 7/25/2022 271 506
11/17/2022 No water No water 11/17/2022 106 295
Monitoring Well#4A
Chlorides ppm TDS ppm
Date
11/19/2020 284 546
1/21/2021 369 801
3/29/2021 209 416
7/29/2021 427 612
11/23/2021 613 944
1/26/2022 458 796
3/29/2022 549 1000
7/25/2022 521 987
11/17/2022 429 1000