WQ0007144_Monitoring - 07-2023_20230825 (2)

Monitoring Report Submittal
.....................................................
Permit Number#* WQ0007144
Name of Facility:* Camp Seafarer
Month: * July
Report Information
Type *
NDMR, NDAR-1, NDAR-2, NDMLR
G W-59
Confirmation Email Address: *
Name of Submitter: *
Signature:
Date of submittal:
Initial Review
Year:* 2023
Upload Document*
Non Discharge Reports July 2023.pdf 668.29KB
PDF Only
Monitoring Well Reports July 2023.pdf 439.83KB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
[e-mail]
Stanley Eudy
8/25/2023
This will be filled in automatically

Reviewer: Wanda.Gerald
Is the project number correct?* WQ0007144
Is the monitoring report accepted?* Yes No
Regional Office* Washington
Reviewer:
Review Date:

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MON[TO RING:
COMPLIANCE REPORT FORM
FORMATION • Please PrintC/eady
Facility Name: Camp Seafarer
Permit Name (if different): YMCA of the Triangle Area, INC.
Facility Address: 2744 Seafarer Rd Arapahoe NC 28510
2744 Seafarer Rd Arapahoe (StremlNC 28510 County Pamlico
(oily) (Sla}p) (Zip)
Contact Person: Mike Askew Telephone#: [phone]
Well Location/Site Name: Lagoon No. of wells to be sampled: 5
€NFORMATION'PROCESSING UNIT. `
J t,':.
1617 MAIL SERVICE CENTER,)liALE1GH, NC27699 i6i7 Phone 919.8D7 6306
PERMIT Number. Expiration Date:
Non -Discharge WQ0007144 UIC
NPDES Other
TYPE OF PERMITTED OPERATION BEING MONITORED
L Lagoon ❑ Remediation: Infiltration Gallery
❑ Spray Field ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
JY IYir &.lfVl1 lIV r1J RIYlii l tu%-4
WELL ID NUMBER (from Permit): WeI12
Date 70a 3
If WELL
Well Depth: 20 . ft.
sample collected:
Well Diameter 2 in.
FIELD ANALYSES: a
pH o040o: yl� units Temp. ocolo: O °C
WAS
DRY at
Depth to Water Level 82546: ( 3.i7 fL below measuring point
Screened Interval: 10 ft.
to 20 ft.
Spec. Cond. 00094: -Z2,- G µMhos
time Of
Measuring Point is 1.9 ft. above land surface
Relative M.P. Elevation: 24.2
t
Odor ocos5:
sampling,
check
Volume of water pumped/bailed before sampling:5— 0XIC
gallons
Appearance
here:(—�
Samples for metals were collected unfiltered: El YES ❑
NO and field acidified: El YES
❑ NO
LABORATORY INFORMATION
Date sample analyzed:_ ZZ 7J o2 3
�P"��R G'�"1
_
�"�(
j f ^" C d
Laboratory Name:
Certifica;;o7 No. /
PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L
Nitrite (NO2) as N oos15
mg/L
Pb -Lead o1051 ugfL
Coliform: MF Fecal si6i6 /10DmL
Nitrate (NO3) as N om2o < C s 0
mg/L
Zn - Zinc o1o92 mg L
Coliform: MFTotal 315D4 E /100ml- Phosphorus: Total as P ocees
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
_mg/L
mg/L
Other (Specify Compounds and Concentration Units):
ISsolved Sollds:Total 70300 Q mg/L
AI -Aluminum 01105
mg/L
pH (Lab) 00403 units
Ba - Barium o1007
ugIL
TOC 00680 mg/L
Ca - Calcium 00918
mg/L
Chloride oo94o___30mg/L
Cd - Cadmium 01027
ug/L
Arsenic o1o02 ug/L
Chromium: Total o1o34
ug/L
Grease and Oils oo552 mg/L
Cu - Copper m42
mg/L
ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730 ug1L
Fe - Iron aiw
ug/L
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate oo945 -mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance =66 • f:Mhos
K - Potassium oo937
mg/L
VOC 7873 method #
Total Ammonia ooslo (}s mg/L
Mg - Magnesium OD927
mg/L
method #
(Ammonia Nitrogen; NHaas N; Ammonia Nitrogen, Total)
Mn - Manganese o1 oss
ug/L
method ##
TKN as N oos2s mg/L
Ni - Nickel o1os7
uglL
method #
For Remediation Systems Only (Attach Lab Reports):
Mike Askew, Director of Facilities and Boating Operations
Permittee (or Authorized Agent) Name and Title - Please print or type
GW-59 Rev.05-02-2017
In:iuent Tctal VOCS:
mg/L
Effluent Total VOCs:
(or Authorized Agent)
mg/L
VOC Removal%
t•-

SUBVJT FORM ON YELLCV,1 PAPER ONLY
DEPARTMENT OF ENVIRONMENTAL;l1UALITY - DIV, oF,wA7.ER'.RESOURCE5 F,.,
GROUNDWATER QUALITY MONITORING:
, ,
INF,ORMATIONPROCESSING UNIT'
COMPLIANCE REPORT FORM
161TMAILSERVICE.CEN,TER;'RALEIGH,NC`27899 1fi17 .Phone:[phone]a6
FACILITYINFORMATION Please Print Clearly or Type
PERMIT Number: Expiration Date:
=acility Name: Camp Seafarer
Non -Discharge WQ0007144 UIC
Permit Name (if different): YMCA of the Thange Area, INC.
NPDES Other
Facility Address: 2744 Seafarer Rd -Arapahoe
NC 28510
TYPE OF PERMITTED OPERATION BEING MONITORED
El -Lagoon ❑ Remediation: Infiltration Gallery
2744 Seafarer Rd Arapahoe (street) NC 28510 County Pamlico
(city) (Stale) (zip)
XJ Spray Field ❑ Remediation:
Contact Person: Mike Askew
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: Spray Field 3
No. of wells to be sampled: 5
❑ Water Source Heat Pump ❑ Other:
(from Permit)
SAMPLING INFORMATION
/
if WELL
WELL ID NUMBER (from Permit): VVELL 5
Date sample collected: ( �3
FIELD ANALY,StES:
WAS
Well Depth: 2C ft,
Well Diameter: 2 in.
pH 00400: 7+ � unitsty Temp. 000lo: f °C
DRY at
Depth to Water Level s254s:3. 1 3 ft. below measuring point Screened Interval: 10 fL to 20
ft. Spec. Cond, 00094: / 7- �� uMhos
time of
sampling,
Measuring Point is 2.2 fL above land surface
Relative M.P.•Elevation: 27.7 ft.
Odor 000s5: j,-L
check
Volume of water pumped/bailed before sampling: 10
gallons
Appearance C < G
here:❑
Samples for metals were collected unfiltered: ❑ YES
❑ NO and field acidified: ❑ YES ❑ NO
LABORATORY INFORMATION �7
/ 3'
t U
Date sample analyzed: !
LaboratoryName: Enviroment 1,INC.
Certification No.
PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD 00335 mg/L
Nitrite (NO2) as N 00615
mg/L Pb -Lead of o51 ug/L
Coliform: MF Fecal aisle /100mL
Nitrate (NO3) as N 00620 < Q, G
mg/L Zn -zinc 01092 mg/L
Coliform: MF Total 31so4 3 /100mL
Phosphorus: Total as P 00665- < C` C1
mg/L
(Note: Use MPN methodfor Nghly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Totai 70300 , .T 3 mg/L
AI -Aluminum o11os
mg/L
pH (Lab) oo4m J 3 units
Ba - Barium 01007
ug/L
TOC oo6so ' mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 mg/L
Cd - Cadmium o1o27
ug/L
Arsenic o1o02 ug/L
Chromium: Total olos4
ug/L
Grease and Oils 00552' mg/L
Cu - Copper a1o42
mg/L ORGANICS: (by GC, GC/MS, HPLC)
Phenol 3273o " u911-
Fe - Iron o1045
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 000s5 uM h os
K - Potassium 00937
mg/L VOC 7873 method #
Total Ammonia ooslo C. J 7 mg/L
Mg - Magnesium oo927
mg/L
method #
(Ammonia Nitrogen; NH3as N; Ammonia Pditrcgen, Tota:)
Mn - Manganese mom
ug1L method # -
TKN as N ow25- mg/L
Ni - Nickel o1067
ug,'L method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg,,L Effluent Total VOCs: mg/L - VOC Removal%
Mike Askew;Director of Facilities and -Boating Operations
Permittee (or Authorized Agent) Name and Title- PIease print or type Signature of Permittee (or Au orized Agentj
GW-59 Rev.05-02-2017

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
FACILITY INFORMATION. Please Pnnt crearly or Type
Facility Name: Camp Seafarer
Permit Name (if different): YMCA of the Triangle Area, INC.
Facility Address: 2744 Seafarer Rd Arapahoe NC 28510
2744 Seafarer Rd Arapahoe (streri) NC 28510
County Pamlico
(Contact Person: Mike Askew Telephone#: [phone]
Well Location/Site Name: Spray Field 3 No. of wells to be sampled: 5
PERMIT Number: Expiration Date. S� 3
Non -Discharge WQ0007144 UIC
NPDES Other
TYPE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
Spray Feld ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
Rruuiruivv IM LIKI KI IUN
•-
If WELL
WELL ID NUMBER (from Permit): Well 6
Date sample collected: L 3 oZ
�j
FIELD ANALYSES:
WAS
Well Depth: 20 ft.
Well Diameter. 2 in.
pH omoo:733 units Temp owo:2—D,9 oC
DRY at
Depth to Water Level s2s4s-� fL below measuring point
Screened Interval: 10 ft: to
20 ft.
Spec. Cond. 00094: 13 µMhos
time of
MeasuringPoint is 2.75 fL above land surface/
Relative M.P. Elevation: 202 it.
Odor 000ss: /✓� h-
sampling,
Volume of water pumped/balled before sampling: / 6
Appearance j) /
check
here:a
--gallons
Samples for metals were collected unfiltered: ❑ YES ❑
NO and field acidified: ❑ YES ❑ NO
p y _
LABORATORY INFORMATION 2
Date sample analyzed: [ /l3 �
/ J _
Laboratory Name: Enviroment 1,INC.
Certification No. C
PARAMETERS NOTE: Values sh uld reflect dissolved and colloidal concentrations.
COD 00335 mg/L
Nitrite (NO2) as N oasis
mg/L
Pb - Lead o1os1 ug/L
Coliform: MF Fecal 31616 /100mL
Nitrate (NO3) as N oo62o <�y ,
mg/L
Zn - Zinc 01092 rgj_
Coliform: MF Total 315o4 < ( 1100mL Phosphorus: Total as P oo665 < O. O 'll
mg/L
(Note: use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L
Other (Specify Compounds and Concentration Units):
Issolved SoIids:Totai 7o30o mg/L
AI -Aluminum o11as
mg/L
pH (Lab) 00403 . 7 units
Ba - Barium o1oo7
uglL.
TOC aosso mg/L
Ca - Calcium oasis
mg/L
Chloride oo940 Z mg/L
Cd - Cadmium =27
ug/L
Arsenic oloo2 ug/L
Chromium: Total o1o34
ug/L
Grease and Oils oo552 mg/L
Cu - Copper o1o42
mg/L
ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730 ug/L
Fe - Iron oim
ug/L
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate oog4s mg/L
Hg - Mercury 71soo
ugIL
Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 000ss µMhos
K - Potassium oos37
mg/L
VOC 7873 method #
Total Ammonia ooslo iJ mg/L
Mg - Magnesium oos27
mg/L
,
method #
(Ammonia Nitrogen; NF6as N; Ammonia Nitrogen, Total)
Mn - Manganese o1o55
ug/L
, method #
TKN as N 00625 mg/L
Ni - Nickel 01o67
ug/L
method #
ruc rcemeaiaiion aystems unly (Ariacn LaD tteports); innuert I etas vucs: mg/L Effluent Total VOCs: mg/L VOC Removal%
Mike Askew, Director of Facilities and Boating Operations
Permittee (or Authorized Agent) Name and Title -Pleas a print or type
GW 59 Rev. 05-02-2017

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
DEPARTMENT OF<ENVIRONMENTAL QUALITY -'DIV. OF WATER RESOURCES
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
1617 MAIL SERVICE CENTER, RALEIGH, NC27699-1617 Phone:, 919=B07-6306
FACILITY INFORMATION . Please PrintCleedyorType
PERMIT Number: Expiration Date:
Facility Name: Camp Seafarer
Non -Discharge WQ0007144 UIC
Permit Name (if different): YMCA OF THE Triangle Area, INC.
NPDES Other
Facility Address: 2744 Seafarer Rd Arapahoe NC
28510
TYPE OF PERMITTED OPERATION BEING MONITORED
2744 Seafarer Rd Arapahoe cStreci) NC 28610
CountyPamlico
•
El Lagoon ❑ Remediation: Infiltration Gallery
(City) (Stale) (zip)
N Spray Field ❑ Remediation:
Contact Person: Mike Askew
Telephone#: [phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: Spray Field 2
No. of wells to be sampled: 5
❑ Water Source Heat Pump ❑ Other.
(from Permit)
SAMPLING INFORMATION
`% /
If WELL
WELL ID NUMBER (from Permit): WELL 7
Date sample collected: ` 1` 3
2- 3
FIELD ANALYSES:
WAS
Well Depth: 12 ft.
Well Diameter. 2 In.
I a
pH 00400: Q:+ units Temp. 000lo: / $ r OC
DRY at
Depth to Water Level s2546 ft. below measuring
p g • g point
Screened interval: 2 ft. to
12 ft.
Spec. Cond. ©0094: �Z< G µMhos
time
li
sampling,
Measuring Point is 1 fit. above land surface
Relative M.P. Elevation: 25.8 ft.
Odor 00065: tMCA, 4
check
Volume of water pumped/balled before sampling:7—DoT
gallons
Appearance C4 /b'k
here:❑
Samples for metals were Collected unfiltered: ❑ YES ❑
NO, and field acidified: ❑ YES ❑ NO
LABORATORY INFORMATION /3
Z
Date sample analyzed: `3/ 3
Laboratory Name: Enviroment 1,INC.
Certification No. / G
PARAMETERS NOTE: Values should reflect' dissolved and colloidal concentrations.
COD 00335 mg/L
Nitrite (NO2) as N 00615
mg/L
Pb - Lead o1051 ug/L
Coliform: MF Fecal 31616 /100mL
Nitrate (NO3) as N 00620 p G
mg/L
Zn -Tint 01092 mg/L
Coliform: MF Total 31504 /100mL Phosphorus:
Total as P oo66s C U
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L
Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 160 mg/L
Al -Aluminum oleos
mg/L
pH (Lab) 00403 17, units
Ba - Barium 01007
ug/L
TOC oo680 mg/L
Ca - Calcium 00916
mg/L
Chloride cow 3 mg/L
Cd - Cadmium 01027
uglL
Arsenic olo02 ug/L
Chromium: Total 01034
ug/L
Grease and Oils oo5s2 . mg/L
Cu - Copper 01042
mg/L
ORGANICS: (by GC, GC/MS, HPLC)
Phenol 3273o ug/L
Fe - Iron 01046
ug/L
(Specify test and method #, ATTACH LAB REPORT.)
Sulfate oo945 mg/L
Hg - Mercury 71soo
ug/L
Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 000m �tMhos
K - Potassium 00937
mg/L
VOC 7873 method #
Total Ammonia coslo C C:) r mg!L
Mg - Magnesium oo927
mg/L,
method #
(Ammonia Nitrogen; NH3as N; Ammonia Nitroge-, Total%
Mn - Manganese 01055
ug/L
method #
TKN as N oo62s ma/L
Ni - Nickel o1o67
ug/L
method #
For Remediation Systems Only (Attach Lab Reports)
Director of Facilities and Boating Operatsns
Permutes .;or Authorized Agent) Name and Title -Tease pri--.i ar iy�a
Influent Total VOCs:
mg/L Effluent Total VOCs:
mg/L
VDC Removal%
G'Al-59 Rev.05-02-2017

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENT rig NATURAL RESOURCES
GROUNDWATER QUALITY MONITORING:
DIVISION OF. WATER QUALITY -INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM'
16.17MAIL: SERVICE; CENTER,RAL'EIGH,NC27699:1617 Phone:(919)`7334221''
PERMIT Number: Wqo Expiration Date; "3 -I'2
� �-7
FACILITY INFORMATION Please Print Cleativ or Type
Facility Name:, Camp Seafarer
Non -Discharge UIC
Permit Name (if different): YMCA of the Triangle Area, INC.
NPDES Other
Facility Address: 2744 Seafarer Rd
TYPE OF PERMITTED OPERATION BEING (MONITORED
❑ Lagoon ElRemedlation: infiltration Gallery
Arapahoe NC 28510 County Pamlico
® Spray Field ❑ Remediation:
Contact Person: Mike Askew
Telephone#:[phone]
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: Spray Field 2
No. of wells to be sampled: S
❑ Water Source Heat Pump ❑ Other:
(Irom Permit)
SAMPLING O
JT
��
If WELL
_INFORMAT
WELL ID NUMBER (from Permit): Well 8
Date sample collected: � 3 �a
�' FIELD ANALYSES:
%. 3#' Temp.�Od oC
WAS
Well Depth: 12ft.
Well Diameter. 2 in.
pH units
DRe of
De th to Water Level:( o � ft. below measurin oint
p . � 9 P
Screened interval: 2 ft to
12 fit. Spec. Cond. �� i U' µMhos
sampling,
Measuring Point is 1 ft, above land surface
Relative M.P. Elevation: 15.3 ft.
Odor
check
Volume of water pumped/bailed before sampling: 3 _ %)t-"Y gallons
Appearance I'44/41
here:
Samples for metals were collected unfiltered: ❑YES ❑ NO and field acidified: ❑ YES ❑ NO
LABORATORY INFORMATION �j i f
Date sample analyzed: J // -3 /)-5
Laboratory Name: Environment 1, Inc. Certification No. 410
PARAMETERS NOTE: Values should reflect dissolved and
colloidal concentrations.
COD mg/l
Nitrite (NO,.) as N
mgh Pb - Lead mg/l
Coliform: MF Fecal/100ml
Nitrate (NO3) as N < G a
mg/I Zn - Zinc mg/I
Col iform: MF Total C ( /100m1
Phosphorus: Total as P -< O G !`
mg/1
(Note: Use MPNme(hodfor highly turbidsamples))
Orthophosphate
mg/I Other (Specify Compounds and Concentration Units):
Dissolved Solids: Total o G mg/l
Al - Aluminum
mg/l
pH (when analyzed) 3, G units
Ba- Barium
mg/1
TOC mg/I
Ca - Calcium
mg/I
Chloride _mg11
Cd - Cadmium
mg/I
Arsenic mg/I
Chromium: Total
mgll
Grease and Oils mg/I
Cu - Copper
mg/1 ORGANICS: (by GC, GC/MS, HPLC)
Phenol mg/I
Fe - Iron
mg/1 (Specify test and method #. ATTACH LAB REPORT.)
Sulfate mgll
Hg - Mercury
mg/1 Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance µMhos
K- Potassium
mg/I VOC method #
Total Ammonia _mg/I
Mg - Magnesium
mg/1 method #
(Ammonia Nitrogen; NK- as N: Ammonia Nitrogen, Total)
Mn - Manganese-
mg/I , method #
TKN as N mg/I
Ni - Nickel
mg/1 method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs:
Mike Askew, Director of Facilities and Boating Operations
Permittee (or Authorized Agent) Name and Title - Please print or type
GW-59 Rev.112007
m91L Lrnueni l oral vuL s: „ y
rmittee (or Authorized Agent)

GW-59A COMPLIANCE REPORT FORM Permit # r7l 'HL
(Submit one each monitoring period with GlIP--59 forms.)
1
Enter date monitoring results were due. ) Will this monitoring report (GW-59 and GW-59A)
•YES
NO
be submitted after the established due date.
2
Was any required information missing on the GW-59 report forms?
'YES
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.
3
Are any of the monitor wells in need of repair or maintenance (damaged casing, unlocked or missing cap, missing
YES
NO
identification plate, area overgrown, etc.)? If the answer is "Yes", contact the Regional Office for guidance.
4
Are any monitored constituents equal to or above the established standards?
NO
If the answer to question 4 is 'NO", skip to section 8.
If the answer to question 4 is "YES" list the affected wells individually with constituents) and concentration(s)
exceeding standards in the space provided below:
Wkt-C. # )�, IIIC14 P// S %
wIftc .fir $ fi/0 P// i � 3�
5 .
For the constituents identified in question 4 above,.hav_e standards been Qggcgpded_ previously,for the ..
NPS
I�IO.
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 5Is "YES'; list in the space provided below, each well with constituents) exceeding
standards, concentrations) reported, and sample collection date for each occurrence (for the last two years).
7/31
6
Are the monitoring wells listed in section 5 located at or beyond the review boundary?
YES
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 maybe improperly
located; contact the Regional Office.
7
Is the permittee Implementing previously approved actions required by the division involving this
'YES
N
groundwater quality problem?
If the answer to question 7 is "YES" describe those actions in the space provided below.
ff the answer to question 7 is. "NO" contact the Regional Office within 90 days; an evaluation may be
required to determine the Impact the waste disposal system is having at the review and com fiance
boundaries surroundinq this facility, Failure to do so may sub ect the permittee to a Notice of Violation
f
fines, and/or penalties.
9t:P&/ZTrn . 1116A py I� rh bN l ,wry AMC 1%-'1Z 4 r
wig #11- C 7-C/ P-- o��icL� g%�� j d, 3
g
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.
l hereby acknowledge that the above information was evaluated and the Information submitted in this
report (Gomp_jance Report GW-59A) is true and complete to the best of my knowledge:
/.2y/a3
Signature of Per ittee (or Authorized Agent} Date
i
r
1Z
GW-59A 12/8/2003