WQ0002005_Monitoring - 03-2023_20230425 (2)

Monitoring Report Submittal
.....................................................
Permit Number#* WQ0002005
Name of Facility:* House of Raeford Rosehill
Month: * March Year: * 2023
Report Information
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR NDMR, MDAR-1, NDMLR March 2023.pdf 1.16MB
PDF Only
GW-59 GW-59 March 2023.pdf 4.94MB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
Confirmation Email Address: * Mason. [e-mail]
Name of Submitter: * Mason Drew
Signature:
41,4"Al L�
Date of submittal: 4/25/2023
This will be filled in automatically
Initial Review

Reviewer: Wanda.Gerald
Is the project number correct?* WQ0002005
Is the monitoring report accepted?* Yes NO
Regional Office* Wilmington
Reviewer: _anonymous
Review Date: 5/15/2023

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENTOF ENVIRONMENT& NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
�16117
DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
MAIL SERVICE CENTER, RALEIGH, NC 27699.1617 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10/3112023
Facility Name. House of Raeford Farms, Inc.
Non -Discharge W00002005 UIC
Permit Name (if different):
NPDES Other
Facility Address: 3333 U. S. Hwy 117 South
TYPE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
Rose Hill NC 28458 County Duplin
A Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled: 17
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 1
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2 in.
pH 0040o 6.34 units Temp. 00010 16 °C
DRY at
Depth to Water Level 82546: 3.68 ft. below measuring point Screened Interval: 2 ft. to
12
—
ft. Spec. Cond. 00094 572 µMhos
time of
sampling.
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 102.77 ft.
Odor 00085: none
check
Volume of water pumped/bailed before sampling:
3
gallons
Appearance clear
here: ❑
Samples for metals were collected unfiltered: W1 YES
❑ NO and field acidified: 0 YES ❑ NO
LABORATORY INFORMATION
Date sample analyzed: 3/1- 10/2023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615 0.03
mg/L
Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 <1
/100mL
Nitrate (NO3) as N 00620 6.96
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 10
/100mL
Phosphorus: Total as P 00665 0.08
mg/L
(Note Use MPN method for highly turoio samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units).
)Issolved Solids:Total 703oo 318
mg/L
AI - Aluminum 01105
mg/L sodium: 72
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 00680 15.8
mg/L
Ca - Calcium 00916
mg/L
Chloride oo94o 73
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
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 o0945 37
mg/L
Hg - Mercury 71900
ug/L Lab Report Attached? ❑ Yes (1) 9 No (0)
Specific Conductance 00095
µMhos
K - Potassium 00937
mg/L VOC 78732: method #
Total Ammonia 00610 <0.2
mg/L
Mg - Magnesium 00927
mg/L method # 6200C
(Ammonia Nitrogen, NH., as N, Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L , method #
TKN as N 00625 1.9
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%
Nicole Reynolds, Plant Manager
Perrniltee (or Authorized Agent) Name and Title - Please print or type
of Permdlee (of Au"orized Agent)
512023
GW-59 Rev.2/2010

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
MM1617
DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
MAIL SERVICE CENTER, RALEIGH, NC 27699.1617 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10/31/2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge W00002005 UIC
Permit Name (if different):
NPDES Other
Facility Address: 3333 U. S. Hwy l l7 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
28458 County Duplin
❑ Lagoon ❑ Remediation: Infiltration Gallery
❑ Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No, of wells to be sampled: 17
❑ Water Source Heat Pump ❑ Other:
Iron Perrnit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 2a
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2 in.
pH 00400 6,64 units Temp. 000lo 17.0 °C
DRY at
Depth to Water Level 82546: 2.93 ft. below measuring
p g point Screened Interval: 2 ft. to
12
ft. Spec. Cond. 00094 630 µMhos
time of
sampling,
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 110.72 ft.
Odor oo085 none
check
Volume of water pumped/bailed before sampling:
3
gallons
Appearance clear
here:
Samples for metals were collected unfiltered: 0 YES
❑ NO and field acidified: ® YES ❑ NO
LABORATORY INFORMATION
Date sample analyzed: 3,1-10,r2023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615 0,08
mg/L
Pb - Lead o1o51 ug/L
Coliform: MF Fecal 31616 <1
/100mL
Nitrate (NO3) as N 00620 16.8
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 110
/100ml-
Phosphorus: Total as P 00665 1.53
mg/L
(Note-. Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 703oo 468
mg/L
Al - Aluminum ol1o5
mg/L Sodium: 84.6 mg/I
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 00680 17
mg/L
Ca - Calcium 00916
mg/L
Chloride oo94o 74
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552
mg/L
Cu - Copper 01042
mg/L ORGANICS: (by GC, GCIMS, HPLC)
Phenol 32730
ug/L
Fe - Iron 01045
ug/L (Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945 33
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 00095
µMhos
K - Potassium 00937
mg/L VOC 18732 method #
Total Ammonia 0o610 <0.2
rng/L
Mg - Magnesium 00927
mg/L method # 6200C
(Ammonia Nitrogen'. NH, as N. Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L
method #
TKN as N 00625 3.4
mg/L
Ni - Nickel 01067
ug/L method #
For Remediation Systems Only Total•Total• •
certify that, to the best of my knowdedge 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
jj
DWQ-certified laboratory. I am aware that there are significant penalties for submitting false information, including the pos .ibilily of fines and imprisonment for knowing violations.
Nicole Reynolds, Plant Manager
Permittee (or Authorized Agent) Name and Title - Please orint or type
�. . •-
GW-59 Rev, 2/2010

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
NMI
',VISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge WQ0002005 UIC
NPDES Other
Permit Name (if different):
Facility Address: 3333 U. S. Hwy 117 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
28458 County Duplin
❑ Lagoon ❑ Remediation: Infiltration Gallery
© Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled: 17
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 3
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2 in.
pH 00400 5.70 units Temp. 000lo 16 °C
DRY at
Depth to Water Level 82546: 4.55 ft. below measuring point Screened Interval: 2 ft. to
12
ft. Spec. Cond. 00094 414 µMhos
time of
sampling,
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 112.59 ft.
Odor 00085: none
check
Volume of water pumped/bailed before sampling:
dry
gallons
Appearance clear
here:
Samples for metals were collected unfiltered: ® YES
❑ NO and field acidified: V YES ❑ NO
LABORATORY INFORMATION
Date sample analyzed: 11 • 1012023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NOZ) as N 00615 0.07
mg/L Pb - Lead o1051 ug/L
Coliform: MF Fecal 31616 1
/100mL
Nitrate (NO3) as N 00620 0.08
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 100
/100mL
Phosphorus: Total as P 00665 0.08
mg/L
(Note use iAPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 484
mg/L
Al - Aluminum o1 t05
mg/L
Sodium: 72.3 mgA
pH (Lab) 00403
units
Ba - Barium 01007
11
TOC 00680 107
mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 91
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total 01034
11
Grease and Oils 00552
mg/L
Cu - Copper 01042
mg/L ORGANICS: (by GC, GC/MS. HPLC)
Phenol 32730
11
Fe - Iron 01045
11
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945 21
mg/L
Hg - Mercury 71900
11
Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 000s5
µMhos
K - Potassium 00937
mg/L VOC 78732: method #
Total Ammonia 00610 0.6
mg/L
Mg - Magnesium 00927
mg/L method # 6200C
(Ammonia Nitrogen, NHjas N: Ammonia Nitrogen, Total)
Mn - Manganese o1o55
ug/L method #
TKN as N 00625 3.4
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%
Nicole Reynolds, Plant Manager
Permittee (or Authorized Agent) Name and Title - Please print or type
GW-59 Rev.2/2010
of Permittee (or
/2023

SUBMIT FORM ON YELLOW PAPER ONLY
• •
DEPARTMENT OF ENVIRONMENT 13 NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
DIViS10N OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
• • •
•
1617 MAIL SERVICE CENTER, RALEIGH. NC 27699.1617 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge W00002005 UIC
Permit Name (if different):
NPDES Other
Facility Address: 3333 U. S. Hwy 117 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
28458 County Duplin
❑ Lagoon ❑ Remediation: Infiltration Gallery
K Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled: 17
❑ Water Source Heat Pump ❑ Other:
(from Permd
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 4
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2 in.
pH 00400 5.47 units Temp. 000lo 18 °C
DRY at
Depth to Water Level 82546: 2.35 ft. below measuring point Screened Interval: 2 ft. to
12
ft. Spec. Cond. 00094. 1193 NMhos
time of
sampling,
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 108.46 ft.
Odor 00085: none
check
Volume of water pumped/bailed before sampling.
dry
gallons
Appearance clear
here:
❑
Samples for metals were collected unfiltered: 0 YES
❑ NO and field acidified: 0 YES El NO
LABORATORY INFORMATION
Date sample analyzed: 31 - 10,12023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N oo615 <.02
mg/L Pb - Lead o1051 ug1L
Coliform: MF Fecal 31616 < 1
/100mL
Nitrate (NO3) as N 00620 1.60
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 315o4 310
1100mL
Phosphorus: Total as P 00665 <0.04
mg/L
(Nola- Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
ssolved Solids:Total 703oo 601
mg/L
Al - Aluminum 01105
mg/L Sodium: 183 mg/I
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOG oo68o 17.4
mg/L
Ca - Calcium 00916
mg/L
Chloride 0094o 310
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total olo34
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 oo945 20
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) 00 No (0)
Specific Conductance 00095
pMhos
K - Potassium 00937
mg/L VOC 78732: method #
Total Ammonia 00610 3.0
mg/L
Mg - Magnesium 00927
mg/L method # 6200C
(Ammonia Nitrogen, NH, as N: Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L
,method #
TKN as N 00625 4.5
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•
Nicole Reynolds, Plant Manager
Permdtee (or Authorized Agent) Name and Title - Please print or type
(or
GW-59 Rev.2/2010

SUBMIT FORM ON YELLOW PAPER ONLY
PARTMENT OF ENVIRONMENT 8 NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
J.WD
ISIONOF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
7 MAIL SERVICE CENTER, RALEIGH, NC 27699.1617 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge W00002005 UIC
Permit Name (if different):
NPDES Other
Facility Address: 3333 U. S. Hwy 117 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
28458 Count Duplin
y
Lagoon El Remediation: Infiltration Gallery
❑■ Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled: 17
❑ Water Source Heat Pump ElOther:
from Permit`
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 5
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2 in.
pH 00400: 6.41 units Temp. 000lo 19 ''C
DRY at
Depth to Water Level 82546: 9.25 ft. below measuring point Screened Interval: 2 ft. to
12 ft. Spec. Cond. 00094: 787 uMhos
time of
sampling.
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 101.26 ft.
Odor 00085: none
check
Volume of water pumped/bailed before sampling:
3
gallons
Appearance clear
here:
Samples for metals were collected unfiltered: 0 YES
❑ NO and field acidified: ® YES ❑ NO
LABORATORY INFORMATION
Date sample analyzed: 3:1 - 10,12023
Laboratory Name: Environmental Chemists Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615 <0.02
mg/L Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 <1
/100mL
Nitrate (NO3) as N 00620 <0.02
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 26
/100mL
Phosphorus: Total as P 00665 <0.04
mg/L
(Note Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
Dissolved Solids:Total 7o3oo 518
mg/L
Al - Aluminum 01105
mg/L Sodium: 27.2 mg/I
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC omm 1.9
mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 200
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
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 <5
mg/L
Hg - Mercury 71900
ug/L Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 00095
uMhos
K - Potassium 00937
mg/L VOC 78732: method #
Total Ammonia 00610 0.2
mg/L
Mg - Magnesium 00927
mg/L method # 6200C
(Am""m'a Nitrogen, NH3 as N' Ammonia Nitrogen. Total)
Mn - Manganese 01055
ug/L method #
TKN as N 00625 0.9
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%
Nicole Reynolds. Plant Manager
Permdtee (or Authorized Agent) Name and Title - Please print or type
(or
GW-59 Rev.2/2010

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENT d NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
EN1617
DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
MAIL SERVICE CENTER, RALEIGH, NC 27699.1617 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge W00002005 UIC
Permit Name (if different):
NPDES Other
Facility Address: 3333 U. S. Hwy l l7 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
28458 County Duplin
❑ Lagoon ❑ Remediation: Infiltration Gallery
■❑ Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled: 17
❑ Water Source Heat Pump ❑ Other:
T "T P_-rlf'
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 6
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2 in.
pH 00400: 5.21 units Temp. 00010 17 "C
DRY at
Depth to Water Level 82546: 5.70 ft. below measuring point Screened Interval: 2 ft. to
12
—
ft. Spec. Cond. DDD94 6.2 µMhos
time of
sampling,
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 140.45 ft.
Odor 00085: none
check
Volume of water pumped/bailed before sampling
3
gallons
Appearance clear
here: ❑
Samples for metals were collected unfiltered: 0 YES
El NO and field acidified: ® YES El NO
LABORATORY INFORMATION
Date sample analyzed: 3,1-1012023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615 <0.02
mg/L Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 <1
1100mL
Nitrate (NO3) as N 00620 <0.02
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 <1
/100mL
Phosphorus: Total as P 00665 <0.04
mg/L
lNole Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 7030o 36
mg/L
Al - Aluminum 01105
mg/L Sodium: 1.96 mg/I
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOG 00680 10.3
mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 <5
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
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 D0945 <5
mg/L
Hg - Mercury 71900
ug/L Lab Report Attached? ❑ Yes (1) [10-1 No (0)
Specific Conductance 00095
µMhos
K - Potassium 00937
mg/L
VOC 78732 method #
Total Ammonia 00610 0.3
mg/L
Mg - Magnesium 00927
mg/L method # 6200C
(Ammonia Nitrogen, NH,as N, Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L , method #
TKN as N D0625 1.2
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%
Nicole Reynolds, Plant Manager
Permittee (or Authorized Apent) Name and Title - Please print or type
i J'r t
d Permdtee
GW-59 Rev.2/2010

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
�16117
DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
MAIL SERVICE CENTER, RALEIGH, NC 27699.1617 Phone [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge W00002005 UIC
Permit Name (if different):
NPDES Other
Facility Address: 3333 U. S. Hwy l l7 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
28458 County Duplin
❑ Lagoon ❑ Remediation: Infiltration Gallery
X Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled:
17
❑ Water Source Heat Pump ❑ Other:
(from Permd)
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 7
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2
in.
pH 00400 7.01 units Temp. 000lo 22 °C
DRY at
Depth to Water Level 82546: 10.90 ft. below measuring point Screened Interval: 2
ft. to
12
ft. Spec. Cond. 00094. 1297 µMhos
time of
sampling,
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 88.01
ft.
Odor oo085: none
check
Volume of water pumped/bailed before sampling:
dry
gallons
Appearance clear
here: ❑
Samples for metals were collected unfiltered: ® YES
❑ NO and field acidified: ® YES
❑ NO
LABORATORY INFORMATION
Date sample analyzed: 3%1 - 10/2023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615 <0.02
mg/L
Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 ,1
/100mL
Nitrate (NO3) as N 00620 0.07
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 >8000
1100mL
Phosphorus: Total as P 00665 0.12
mg/L
(Note Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 7o3oo 600
mg/L
Al - Aluminum oiim
mg/L Sodium: 103 mg/I
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 0068o 38.4
mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 90
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
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 <5
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) IN No (0)
Specific Conductance 00095
µMhos
K - Potassium 00937
mg/L
VOC 78732: method #
Total Ammonia o0610 56.6
mg/L
Mg - Magnesium U0927
mg/L
method # 6200C
(Ammonia Nitrogen. NH, as N, Ammonia Nitrogen. Total)
Mn - Manganese 01055
ug/L
, method #
TKN as N 0062s 61.3
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%
Nicole Reynolds, Plant Manager
Pennittee (or Authorized Agent) Name and Title - Please print or type
GW-59 Rev.2/2010

SUBMIT FORM ON YELLOW PAPER ONLY
•
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
•
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phonw [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge WO0002005 UIC
NPDES Other
Permit Name (if different):
Facility Address: 3333 U. S. Hwy l l7 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
28458 County Dupiin
❑ Lagoon ❑ Remediation: Infiltration Gallery
N Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled:
17
❑ Water Source Heat Pump ❑ Other:
(from Permit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 8
Date sample collected: March
1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2
in.
pH 00400 7.17 units Temp. 000lo 16 °C
DRY at
Depth to Water Level 82546: 8.75 ft, below measuring point Screened Interval: 2
ft. to 12
ft. Spec. Cond. 00094: 848 µMhos
time of
sampling,
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 85.73
ft.
Odor 00085 none
check
Volume of water pumped/bailed before sampling
3
gallons
Appearance clear
here: ❑
Samples for metals were collected unfiltered: 0 YES
El NO and field acidified: ® YES
El NO
LABORATORY INFORMATION
Date sample analyzed: 11 - 10/2023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615 <0.02
mg/L Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 <1
/100mL
Nitrate (NO3) as N 00620 5.36
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 >8000
/100mL
Phosphorus: Total as P 00665 1.25
mg/L
(Note-. Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
Dissolved Solids:Total 703oo 582
mg/L
Al - Aluminum oilo5
mg/L Sodium: 4.4 mg/I
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOG 0068o 6.8
mg/L
Ca - Calcium oo916
mg/L
Chloride 00940 6
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total 01034
uglL
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 20
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 00095
uMhos
K - Potassium 00937
mg/L VOC 78732: method #
Total Ammonia 00610 4.5
mg/L
Mg - Magnesium 00927
mg/L method # 6200C
(Ammonia Nitrogen: NH3 as N. Ammonia Nitrogen. Total)
Mn - Manganese 01055
ug/L
, method #
TKN as N 00625 7.4
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 analysis by a
DWQ-certified laboratory. I am aware that there are significant penalties for submitting false information, including the pxssibilily of fines and imprisonment for knowing violations.
Nicole Reynolds, Plant Manager E ff,
r •- Y.
GW-59 Rev.2/2010

SUBMIT FORM ON YELLOW PAPER ONLY
• •
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge W00002005 UIC
Permit Name (if different):
NPDES Other
Facility Address 3333 U. S. Hwy 117 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
28458 CountyDuplin
El Lagoon 0 Remediation: Infiltration Gallery
® Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled:
17
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 9
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2
in.
pH 00400: 8.20 units Temp. 0oolo: 19 °C
DRY at
Depth to Water Level 82546: 7.20 ft. below measuring point Screened Interval: 2
ft. to
12
—
ft. Spec. Cond. 00094: 281 µMhos
time of
sampling,
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 98.65
ft.
Odor 00085: none
check
Volume of water pumped/bailed before sampling:
3
gallons
Appearance clear
here: ❑
Samples for metals were collected unfiltered: 0 YES
❑ NO and field acidified: 0 YES
❑ NO
LABORATORY INFORMATION
Date sample analyzed: 31 - 1012023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615 <0.02
mg/L Pb - Lead o1o51 ug/L
Coliform: IMF Fecal 31616 <1
;100mL
Nitrate (NO3) as N 00620 2.18
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 8
/100mL
Phosphorus: Total as P 00665 0.18
mg/L
(Note Use MPN method for highly turbid sampes)
Orthophosphate 70507
p
m /L Other (Specify Compounds
g ( fy pounds and Concentration Units):
issolved Solids:Total 70300 198
mg/L
Al - Aluminum of lo5
mg/L Sodium: 1.39 mg/I
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 00680 3.9
mg/L
Ca - Calcium 00916
mg/L
Chloride oo94o <5
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552
mg/L
Cu - Copper 01042
mg/L ORGANICS: (by GC, GCIMS, HPLC)
Phenol 32730
ug/L
Fe - Iron 01045
ug/L
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945 10
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) ME No (0)
Specific Conductance 00095
µMhos
K - Potassium 00937
VOC 78732: , method #
Total Ammonia 00610 <0.2
mg/L
Mg - Magnesium 00927
mg/L
method # 6200C
(Anxnonia Nitrogen. NH3as N, Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L
method #
TKN as N 0062.5 0.7
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 analysis by a
DWO-certified laboratory. I am aware that there are significant penalties for submitting false information, including the posy, bility of fines and imprisonment for knowing violations.
Nicole•.Manager0
Permittee (or Authonzed Agent) Narne and Title - Please print or type S17t �r6 of Permittee (or AuthonAd Agent) D.
GW-59 Rev. 212010

SUBMIT FORM ON YELLOW PAPER ONLY
PARTMENT OF ENVIRONMENT & NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
W1617
ISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
MAIL SERVICE CENTER, RALEIGH, NC 27699-1817 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge W00002005 UIC
Permit Name (if different):
NPDES Other
Facility Address: 3333 U. S. Hwy 117 South
TYPE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
Rose Hill NC 28458 County Duplin
0 Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No, of wells to be sampled:
17
❑ Water Source Heat Pump ❑ Other:
(from Perma)
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 10
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2
in.
pH 00400 7.71 units Temp. 000lo 18 °C
DRY at
Depth to Water Level 82546: 9.35 ft. below measuring point Screened Interval: 2
ft. to 12
—
ft. Spec. Cond. 00094: 1620 NMhos
time of
sampling,
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 89.81
ft.
Odor 00085 none
check
Volume of water pumped/bailed before sampling:
3
gallons
Appearance clear
here:❑
Samples for metals were collected unfiltered: ® YES
❑ NO and field acidified: ® YES
❑ NO
LABORATORY INFORMATION
Date sample analyzed 31 - 1012023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N oo615 0.15
mg/L
Pb - Lead o1o51 ug/L
Coliform: MF Fecal 31616 <1
/100mL
Nitrate (NO3) as N 00620 <0.02
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 137
/100mL
Phosphorus: Total as P 00665 8.83
mg/L
(Note Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 980
mg/L
Al - Aluminum 01105
mg/L Sodium: 227 mg/l
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 00680 7•2
mg/L
Ca - Calcium 00916
mg/L
Chloride 0094o 339
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
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 oo945 <5
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 00095
NMhos
K - Potassium 00937
mg/L VOC 78732 , method #
Total Ammonia o0610 75.3
mg/L
Mg - Magnesium 00927
mg/L method # 6200C
(Ammonia Nitrogen: NHI as N; Ammonia Nitrogen. Total)
Mn - Manganese olo55
ug/L
method #
TKN as N 00625 80.1
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%
Nicole Reynolds, Plant Manager
Permittee (or Authorized Agent) Name and Title - Please print or type
(or
GW-59 Rev.212010

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENT 8 NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: l919) 733-3221
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge W00002005 UIC
NPDES Other
Permit Name (if different):
Facility Address: 3333 U. S. Hwy 117 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
29458 County Duplin
❑ Lagoon ❑ Remediation: Infiltration Gallery
All Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled:
17
❑ Water Source Heat Pump ❑ Other:
Ilrom PermM1
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 11
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2
in.
pH 00400 7.15 units Temp. 000lo 17 °C
DRY at
Depth to Water Level 82546: 8 80 ft. below measuring point Screened Interval: 2
ft. to 12
ft. Spec. Cond. 00094: 1230 luMhos
time of
sampling.
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 85.19
ft.
Odor 00085• none
check
Volume of water pumped/bailed before sampling:
3
gallons
Appearance clear
here:
Samples for metals were collected unfiltered: R1 YES
❑ NO and field acidified: ® YES
❑ NO
LABORATORY INFORMATION
Date sample analyzed: 3r1 - 10/2023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615 0.03
mg/L
Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 <1
/100mL
Nitrate (NO3) as N 00620 0.03
mg/L
Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 >8000
/100mL
Phosphorus: Total as P 00665 9.93
mg/L
(Note Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 703oo 630
mg/L
Al -Aluminum 01105
mg/L Sodium: 90 mg/I
pH (Lab) 00403
units
Ba - Barium 01007
uglL
TOG o058o 18
mg/L
Ca - Calcium 00916
mg/L
Chloride oos4o 83
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
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 <5
mg/L
Hg - Mercury 71900
ug/L Lab Report Attached? ❑ Yes (1) ■❑ No (0)
Specific Conductance 00095
ftMhos
K - Potassium 00937
mg/L VOC 78732: method #
Total Ammonia 00610 59.4
mg/L
Mg - Magnesium 00927
mg/L method #
(Anmionia Nilrogm NH.,as N, Ammonia Nitrogen, Total)
Mn - Manganese o1o55
ug/L , method #
TKN as N 00625 63.4
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%
Nicole Reynolds, Plant Manager
Permittee (or Authorized Agent) Name and Title - Please print or type
(or
GW-59 Rev.2/2010

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENT 8 NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
�1617MAJL
DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
SERVICE CENTER, RALEIGH, NC 27699.1617 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge W00002005 UIC
Permit Name (if different):
NPDES Other
Facility Address: 3333 U. S. Hwy 117 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
28458 CountyDuplin
ID Lagoon El Remediation: Infiltration Gallery
A Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled:
17
❑ Water Source Heat Pump ❑ Other:
from Perml
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 12
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 20 ft.
Well Diameter: 2
in.
pH 00400: 6.91 units Temp. 00010 19 "C
DRY at
Depth to Water Level 82546: 7.02 ft. below measuring point Screened Interval: 2
ft. to t7
ft. Spec. Cond. 00094, 284 µMhos
time sampling,
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 82.18
ft.
Odor 00085: none
check
Volume of water pumped/bailed before sampling:
3
gallons
Appearance clear
here: ❑
Samples for metals were collected unfiltered: 21 YES
❑ NO and field acidified: ® YES
❑ NO
LABORATORY INFORMATION
Date sample analyzed: 31 - 10,2023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615 <0.02
mg/L Pb - Lead o1o51 ug/L
Coliform: MF Fecal 31616 <1
/100mL
Nitrate (NO3) as N 00620 3,01
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 210
/100mL
Phosphorus: Total as P 00665 0.33
mg/L
(Note Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 703oo 202
mg/L
Al - Aluminum 01105
mg/L Sodium: 22 mg/I
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 0068o 22.6
mg/L
Ca - Calcium 00916
mg/L
Chloride oo94o 31
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
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 13
mg/L
Hg - Mercury 71900
ug/L Lab Report Attached? ❑ Yes (1) ❑ No (01
Specific Conductance 00095
µMhos
K - Potassium 00937
mg/L
VOC 78732: method #
Total Ammonia 00610 0.8
mg/L
Mg - Magnesium 00927
mg/L method # 6200C
(Ammonia Nitrogen: NHt as N, Armnonia Nitrogen. Total)
Mn -Manganese 01055
uglL ,method #
TKN as N 00625 3.7
mg/L
Ni - Nickel 01067
ug/L method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs:
Nicole Reynolds, Plant Manager
Permittee (or Authorized Agent) Name and Title - Please print or type
mg/L Effluent Total •
ind that the laboratory analytical data
ility of fines and imprisonment for knc
111121
mg/L VOC Removal%
GW-59 Rev.212010

SUBMIT FORM ON YELLOW PAPER ONLY
-• .
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
�
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms. Inc.
Non -Discharge W00002005 UIC
Permit Name (if different):
NPDES Other
Facility Address: 3333 U. S. Hwy 117 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
28458 County Duplin
❑ Lagoon ❑ Remediation: Infiltration Gallery
Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled:
17
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 13
Date sample collected: March 1. 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Weil Diameter: 2
in.
pH ooaoo: 7.86 units Temp. 000lc 20 "C
p,
DRY at
Depth to Water Level 82546: 5.25 ft. below measuring point Screened Interval: 2
ft. to 12
ft. Spec. Cond. 00094 447 pMhos
time of
sampling.
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 81.47
ft.
Odor 00085: none
check
Volume of water pumped/bailed before sampling:
3
gallons
Appearance clear
here:❑
Samples for metals were collected unfiltered: 0 YES
❑ NO and field acidified: © YES
❑ NO
LABORATORY INFORMATION
Date sample analyzed: 311 - 10,12023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD D0335
mg/L
Nitrite (NO2) as N 00615 <0.02
mg/L
Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 <1
/100mL
Nitrate (NO3) as N 00620 0.03
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 >8000
/100ml-
Phosphorus: Total as P 00665 1.34
mg/L
(NoteUse MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 703oo 268
mg/L
Al - Aluminum 01105
mg/L Sodium: 4.33 mg/I
pH (Lab) D0403
units
Ba - Barium 01007
ug/L
TOC 00680 10.8
mg/L
Ca - Calcium 00916
mg/L
Chloride Dow <5
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
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 7
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) 0 No (0'i
Specific Conductance 00095
uMhos
K - Potassium 00937
mg/L
VOC 76732: , method #
Total Ammonia oo610 2.3
mg/L
Mg - Magnesium 00927
mg/L method # 6200C
(Ammonia Nitrogen. NH, as N: Ammonia Nitrogen. Total)
Mn - Manganese 01055
ug/L , method #
TKN as N 00625 11.6
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%
Nicole Reynolds, Plant Manager
Permittee (or Authorized Aqent) Name and Title - Please print or type
GW-59 Rev.2/2010

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENT8 NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
�11111111117
DMSION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
MAIL SERVICE CENTER, RALEIGH, NC 27699.1617 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge W00002005 UIC
Permit Name (if different):
NPDES Other
Facility Address: 3333 U. S. Hwy 117 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
28458
County Duplin
❑ Lagoon ❑ Remediation: Infiltration Gallery
9 Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled:
17
❑ Water Source Heat Pump ❑ Other:
IBom Permit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 14
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2
in.
7.7s p.
pH o0400: units Temp. o0010 19 °C
DRY at
Depth to Water Level 82546: 6.05 ft. below measuring point Screened Interval 2
ft. to
12
ft. Spec. Cond. 00094. 789 pMhos
time of
sampling.
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 82.33
ft.
Odor 0008s: none
check
Volume of water pumped/bailed before sampling:
dry
gallons
Appearance clear
here: ❑
Samples for metals were collected unfiltered: ® YES
❑ NO and field acidified: ® YES
❑ NO
LABORATORY INFORMATION
Date sample analyzed: 3/1 - 1ur2023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615 <0.02
mg/L
Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 12
/100mL
Nitrate (NO3) as N 00620 0.03
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 >8000
/100mL
Phosphorus: Total as P 00665 2.74
mg/L
(Note. Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 605
mg/L
Al - Aluminum o11o5
mg/L
Sodium: 8.42 mg/I
PH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC oo68o 59.6
mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 18
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
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 10
mg/L
Hg - Mercury 7190o
ug/L
Lab Report Attached? ❑ Yes (1) ❑■ No (0)
Specific Conductance OW95
pMhos
K - Potassium 00937
mg/L
VOC 78732: method #
Total Ammonia 00610 0.2
mg/L
Mg - Magnesium 00927
mg/L method # 6200C
(Ammonia Nitrogen. NHi as N, Ammonia Nitrogen, Total)
Mn - Manganese oio55
ug/L
method #
TKN as N 00625 2.9
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%
Nicole Reynolds, Plant Manager
Permdtee (or Authorized Agent) Name and Title - Please print or type
r xb
GW-59 Rev.2/2010

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
Facility Name: House of Raeford Farms, Inc.
Permit Name (if different):
Facility Address: 3333 U. S. Hwy 117 South
Rose Hill NC
intact Person: Joe Teachey
ell Location/Site Name: map on file
or
28458 County Duplin
Telephone#: [phone]
No. of wells to be sampled: 17
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699.1617 Phone: [phone]
PERMIT Number:
Expiration Date: 10.2023
Non -Discharge W00002005
UIC
NPDES
Other
TYPE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon
❑ Remediation: Infiltration Gallery
X Spray Field
❑ Remediation:
❑ Rotary Distributor
❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 15
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 14 ft.
Well Diameter: 2 in.
pH o0400: 7.08 units Temp. 000lo 17 "C
DRY at
Depth to Water Level 82546: 5.50 ft. below measuring point
Screened Interval: 2 ft. to 12 ft.
Spec. Cond. 00094: 693 µMhos
time of
sampling.
Measuring Point is 2 ft. above land surface
Relative M.P. Elevation: 82.33 ft.
Odor 00085: none
check
Volume of water pumped/bailed before sampling dry gallons
Appearance clear
here:
❑
Samples for metals were collected unfiltered: ® YES El NO
and field acidified: ® YES ❑ NO
ate sample analyzed: 3/1 - 10,12023 Laboratory Name: Environmental Chemists
ARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615 <0.02
mg/L
Coliform: MF Fecal 31616 3
1100mL
Nitrate (NO3) as N 00620 0.26
mg/L
Coliform: MF Total 31504 540
/100mL
Phosphorus: Total as P 00665 0.48
mg/L
(Note Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L
ssolved Solids:Totai 70300 476
mg/L
At - Aluminum 01105
mg/L
PH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC oo6ao 8.8
mg/L
Ca - Calcium o0916
mg/L
Chloride oo94o 19
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552
mg/L
Cu - Copper 01042
mg/L
Phenol 32730
ug/L
Fe - Iron 01045
ug/L
Sulfate 00945 92
mg/L
Hg - Mercury 71900
ug/L
0ecific Conductance 00095
µMhos
K - Potassium 00937
mg/L
Total Ammonia 00610 <0.2
mg/L
Mg - Magnesium o0927
mg/L
(Anvmma Nitrogen. NH3as N, Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L
TKN as N 00625 1.5
mg/L
Ni - Nickel 01067
ug/L
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs
Nicole Reynolds, Plant Manager
Permittee (or Authorized Agent) Name and Title - Please print or type Sip
GW-59 Rev.2/2010 /
Certification No. 94
Pb - Lead olosl ug/L
Zn - Zinc 01092 mg/L
Other (Specify Compounds and Concentration Units):
Sodium: 10.6 mg/I
ORGANICS: (by GC, GC/MS, HPLC)
(Specify test and method #. ATTACH LAB REPORT.)
Lab Report Attached? ❑ Yes (1) 2 No (0)
VOC 76732: method #
. method # 6200C
method #
method #
lnd that the laboratory analytical data
,Ility of fines and imprisonment for kn
mg/L VOC Removal%

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENT 8 NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
EM1617
DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge WQ0002005 UIC
Permit Name (if different):
NPDES Other
Facility Address: 3333 U. S. Hwy 117 South
TYPE OF PERMITTED OPERATION BEING MONITORED
Rose Hill NC
28458 County Duplin
❑ Lagoon ❑ Remediation: Infiltration Gallery
X Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled: 17
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 16
Date sample collected: March 1, 2023
FIELD ANALYSES:
WAS
Well Depth: 15 ft.
Well Diameter: 2 in.
pH 00400: 5.51 units Temp. 000lo 19 "C
DRY at
Depth to Water Level 82546: 6.02 ft. below measuring point
Screened Interval: 2 ft. to
12
—
ft. Spec. Cond. 00094: 48.6 µMhos
time of
sampling.
Measuring Point is 3 ft. above land surface
Relative M.P. Elevation: 106.00 ft.
Odor 00085 none
check
Volume of water pumped/bailed before sampling:
dry
gallons
Appearance clear
here:
Samples for metals were collected unfiltered: W] YES
❑ NO and field acidified: 0 YES ❑ NO
LABORATORY INFORMATION
Date sample analyzed: 3/1-1012023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615 0.04
mg/L Pb - Lead o1o51 ug/L
Coliform: MF Fecal 31616 <1
/100mL
Nitrate (NO3) as N 00620 0.34
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 82
/100mL
Phosphorus: Total as P 00665 0.26
mg/L
(Note'. Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300 53
mg/L
Al - Aluminum ol105
mg/L Sodium: 1.23 mgil
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 00680 2.6
mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 <5
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total o1034
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 <5
mg/L
Hg - Mercury 71900
ug/L Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 00095
µMhos
K - Potassium 00937
mg/L
VOC 78732: method #
Total Ammonia 00610 1.7
mg/L
Mg -Magnesium 00927
mg/L method # 6200C
(Ammonia Nllrogenl NHjas N: Ammonia Nitrogen. Total)
Mn - Manganese 01055
ug/L , method #
TKN as N 00625 0.7
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%
Nicole Reynolds, Plant Manager
Permdtee (or Authorized Agent) Name and Title - Please print or type
(or
&f,
GW-59 Rev.2/2010

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENT 8 NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
Emil
IVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 10-2023
Facility Name: House of Raeford Farms, Inc.
Non -Discharge W00002005 UIC
Permit Name (if different):
NPDES Other
Facility Address: 3333 U. S. Hwy 117 South
TYPE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
Rose Hill NC 28458 County Duplin
■❑ Spray Field ❑ Remediation:
Contact Person: Joe Teachey
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: map on file
No. of wells to be sampled: 17
❑ Water Source Heat Pump ❑ Other:
(from Permit
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): 17
Date sample collected: March 1. 2023
FIELD ANALYSES:
WAS
Well Depth: 14 ft.
Well Diameter: 2 in.
pH 00400: 5.63 units Temp. ooala 17 °C
DRY at
Depth to Water Level 82546: 3.60 ft. below measuring point Screened Interval: 2 ft. to
12
—
ft. Spec. Cond. 00094: 788 µMhos
time of
sampling.
Measuring Point is 2 ft. above land surface
Relative M.P. Elevation: 105.82 ft.
Odor 00085: none
check
VOIUme of water pumped/bailed before sampling,
dry
gallons
Appearance clear
here:
❑
Samples for metals were collected unfiltered: 0 YES
❑ NO and field acidified: R1 YES ❑ NO
LABORATORY INFORMATION
Date sample analyzed: 3 1 - 10/2023
Laboratory Name: Environmental Chemists
Certification No. 94
PARAMETERS NOTE: Values should reflect
dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N oo615 <0.02
mg/L Pb - Lead o1o51 ug/L
Coliform: MF Fecal 31616 <1
/100mL
Nitrate (NO,) as N 00620 <0.02
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 700
/100mL
Phosphorus. Total as P 00665 0.07
mg/L
(NoteUse MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 183
mg/L
Al - Aluminum 01105
mg/L Sodium: 55.1 mg/l
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 00680 7.1
mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 90
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552
mg/L
Cu - Copper 01042
mg/L ORGANICS: (by GC. G&MS, HPLC)
Phenol 32730
ug/L
Fe - Iron 01045
ug/L (Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945 8
mg/L
Hg - Mercury 71900
ug/L Lab Report Attached? ❑ Yes (1) 11111 No (0)
Specific Conductance 00095
µMhos
K - Potassium 00937
mg/L VOC 78732 method #
Total Ammonia 00610 <0.2
mg/L
Mg - Magnesium 00927
mg/L method # 6200C
(Ammonia Nitrogen, NH, as N, Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L method #
TKN as N 00625 0.8
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%
Nicole Reynolds, Plant Manager
Pemtittee (or Authorized Agent) Name and Title - Please print or type
GW-59 Rev.2/2010