WQ0002838_Monitoring - 11-2016_20161208 (2)

JVOMII rumor
UNDWATER QUALITY MONITORING:
PLIANCE REPORT FORM
Name:
Name (if
Address:
►e\\ NC County
act Person: .00ile m,t t 1-ua Telephone#
I -I
Location/Site Name: ba--I-1my- M "C_, No. of wells to be sampled: t --i
L ID NUMBER (from Permit): mo *1r 1
Depth: ft,
I to Water Level: ft. below measuring point
uring Point is 2'44 fL above land surface�1
rte of water pumped'bailed before sampling: &
(AMETERS NOTE: Values should reflect dissciv
COD
mgA
Coliform: MF Fecal�O 1 /100nd
Coliform: MF Total
/100ml
(Nuts: Use AWN memo for N9Ny N dswpas)
BEE 09
Dissolved Solids: Total
mg::
pH (when analyzed)
unit
TOC
mg/I
Chloride 42 7
mg,i
Arsenic
mg/I
Grease and Oils
mg/1
Phenol
mgF.
Sulfate
mg/I
Speck Conductance
AMhcs
Total Ammonia R]. I mail
(AenoN8 MIr0W. NHr es N: Amronia Nlpopan, Tot
TKN as N
rm ncutewauun oysrama Amy tAtaacn Lao Neports):
mee ter n... hwno Nanm arca I me - IneaBe nra9 or tym
GW -59 Rev. 112007
UNLT
PAR TMENT OF ENVIRONMENT d NATURAL RESOURCES
ISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
7 MAIL SERVICE CENTER, RALEIGH, MC 271199-16117 Phom: 1919) 7]3-7121
!RMIT NumberkKKiC002eS Expiration Date: 15111 ZDZ--O
n -Discharge UIC
IDES Other
'PE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
<$ Spray Field ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heal Pump ❑ Other:
Date sample collected: I 110,311 tp FIELD ANALYSES:
Well Diameter: in. pH I"1 •S2- unit;
Screened Interval: ft. to _ft. Spec. Ccnd. 5L
Relative M.P. Elevation: - ft. Odor Nom
�s Appearance
Laboratory Name: tk('lo }ech 7,r -c ,
colloidal concentrations.
Nitrate (NOL,) as N mgll Pb - Lead
Nitrate (NO3) as N 0.13 mg/I Zn -Zinc
Phosphorus: Total as P mg/I
Temp. 'CJ t� eC
µMhos
Certification No.ice_
mgn
m9A
Orthophosphate mg/I
Other (Specify Compounds and ration Units):
AI - Aluminum mg/I
uJ
Ba - Barium mg/I
.
C rrn C 1� mg/1
BEE 09
Cot um mg/I
Chromium.DE@ 0 8 2016 mg/I
_
Cu - Copper mg/1
ORGANICS: (by GC, GC/MS, HPLC)
Fe - OR mgA
JJ,,
q
(Specify test and method #. ATTACH LAB REPORT.)
mg/I
Report Attached? ❑ Yes (1) ❑ No (0)
K - Potassium mg/I
VOC , method # _
Mg - Magnesium mg/I
, method #
Mn - Manganese mg/I
, method # _
Ni - Nickel mg/I
, method #
I nnuent I otal VUGs:
Effluent Total VOCs:
mg/L VOC Removal°/
at
of
Im-:01

GW -59A COMPLIANCE REPORT FORM Permit #un000;83g
(Submir one each inonitoriug periodhrith GIV-59 forms.)
]
Enter date monitoring results were due.I(4) 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 -5? r,.port forma?
YES
NO
IF the answer to question 1 or 2 is 'YES", list in nm S1idCe provided below the wet/ identification number(s) and
explain the problems encountered in obtaining the iequired information
3
Arc any of the monitor wells in need of repair or mehttennnce (damaged rasing, ck
unloed or missing cap, missing
YES
'(r
identification plate, area overgrown, etc.)? If the cawe" s"tee• corrnr t the Rrgiorua Office frit guidance.
Are any monitored constituents equal to o• ahave the ostablished standards?
ygS
4
If th answer to question 4 is 'NO' skip ro section y.
lI the answer to question 4 /s "YES" list the a/iecte:1 wells individual:v with consirtuent(s) and ooncentrefion(s)
exceeding standards in -the space provided below.
5
For the constituents Identified In question 4 above, have standards been exceeded previously for the
YES
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
N the answer to question 5 I "YES", list in the space provided below, each well with constituents) exceeding
standards, concentration(s) reported, and sample correction date for each occurrence (for the last two years).
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 occuMng. CONTACT THE REGIONAL
OFFICE IMMEDIATELY FOR GUIDANCE. N the answer Is "NO'; monitoring wells maybe Improperly
located; contact the Regional Office.
Is the permittee Implementing previously approval actions requlrod by the Divislon involving this
YES
NO
groundwater quality problem?
If the answer to question 7 is "YES", describe those ect,als in the space provided below.
-
Nth* answer to question 7 I "NO", contact tits Regional 011lca within W days• an evaluation may ba
reautred to determine the Impact the waste dl nosai system is having at the view and comnNance
bounciarles
surtoundlna this facility. Fallure to do so may su6lect the genllNtee to a Notice o/Vfolatlon
Nnes, and/orgenaltles.
The person compledng this portion (G W 59A) of the monHoring report sho Wd sign below and submit this
g
form with GW -59 forms for required wells to the address provided at the top or the current GW -59 form.
I hereby acknowledge that the above Information was evaluated and the Information submitted in this
report (Compliance Report GW -59A) is true and complete to the best of my^knowledge.
C'�/lJ4AJLlI/�
_ ______
Signature of Perm ttoe (or Authorized Agent) Date
GW-i9A 12/8/2UU3

=R QUALITY MONITORING:
REPORTFORM
Name:
Name (if
Address:
,a•,,t•"
County
act Person: �P,,vs TelephonaMCM-�(-
Location/Site Name: eerhus+ Yh iae_. No. of wells to be sampled:.
VAVtN UNLY
ATMENT.OF ENVIRONMENT 6 NATURAL RESOURCES .. -
ION OP WATER QUALITY -INFORMATION PROCESSING UNIT
MAIL SERVICE CENTER, RALEIGH, NC 27699.1617 Phone:[phone]
:RMIT Numberk.OUO(.l)e-}L9 xpimtion Dale: v 13t1 ZOZC
m -Discharge UIC
'DES Other
'PE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
Spray Field ❑ Remediation:
❑ Rotary Olstributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
L ID NUMBER (from Per2 mit): mw
Date sample collected: al �I iL2
FIELD ANALYSES:
AI - Aluminum
r vveu
AS
Depth: tg • rJ ft. -
Well Diameter: in.
pH 5, units Temp. 1110-1 °C
DRY at
i to Water Level: ft. below measuring point
Screened Interval: ft. to ft.
Spec. Cond. 041 µMhos
mg/I
time of
wring Point is ft. above land surface
Relative M.P. Elevation: _ ft.
Odor: Nor -,P_
Cu - Copper
samplin
ne of water pumped/bailed before sampling: _a
Iles for metalswerecbIiPCtFrtllnfnt w.& tilt vFc -
gallons
-M-Mn �..,, seu a�ca:a_z--n:.�� RY.�::-- - - ---
Appearance Ve]: A ('_j Flit
--:- -- - ..- - _ _ -- - -- - -- - -
_
check
here: r
- 1-
sample analyzed: 11 1\(p - 11
(AAtI1=H5 NOTE: Values should reflectdiswly
COD mgA
Coliform: MF Fecal Z cc /100m!
Coliform: MF Total /100ml
(Nob: Use MPN motl,oe for i; N* Mid samges)
Dissolved Solids: Total I ko?, _mg/;
PH (when analyzed) units
TOC mg/I
Chloride mgR
Arsenic _ Ig mg/I
Grease and Oils Mgll
Phenol mg/I
Sulfate mg/I
Specific Conductance µMhos
Total Ammoniamg/I
IAmm Nitrogen; NHoes N, Anrmde mftpen, To W)
TKN as N
-v, nenroumuu„ oysrnn,a unry IAmacn Lao mepOrs)'
7
GW -59 Rev. 12007
Laboratory Name: q -m
colloidal concentrations.
Nitrite (NO,) as N mg/1 Pb -,Lead
Nitrate (NO3) as N 610110 mg/I Zn. Zinc
Phosphorus: Total as P mg/I
Certification No. _
mg/I
mg/1
Orthophosphate
mg/I
Other (Specify Compounds and ConcentraWits):
AI - Aluminum
TITO
mg/I
Be - Barium
mg/I
Ca - Calcium
mg/1
Cd - Cadmium
mg/I
Chromium: Total
mg/I
Cu - Copper
mg/I
ORGANICS: (by GC, GC/MS, HPLC)
Fe - Iron
mg/I
(Specify test and method #. ATTACH LAB REPORT.)
Hg - Mercury
mg/I
Report Attached? ❑ Yes (1) ❑ No (0)
K- Potassium
mg/1
VOC , method#
Mg - Magnesium
mg/I
Mn - Manganese
mg/I
Ni - Nickel
mg/I
Innuent Iota) vUGs'.
Effluent Total VOCs.
method #
method #
method #
VOC Removal%

GLV -59A COMPLIANCE REPORT FORM Perinit #wQn aga>g
tStfbmil one ea, h fnowforing pe:iud wifh (ill'' -50 lnnas.)
GW -59A 12/8/211113 -
Enter r date monitoring results were due. (jl SQift(i1 Will this monitoring report (GW -59 and GW -59A)
YES
be submitted after the established due date?
2
Was any required information missing on the GW -59 report forma?
yES I
0 -
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 ; equired information.
3
.Are any of the monitor wells in need of repair or maintenance (damaged casing, unlocked or missing cap, missing
YES
identification plate, area overgrown, etc.)? If the cwiv,r is "Yes", crntacf the Regional Ofcefor guidance.
Are any monitored constituents equal to or abova the established standards?
4
If the answer to question 4 is "NO', skip to section t?.
N the answer to question 4 Is "YES" list the affected viells individually with constiruent(s) and concentration(s)
exceeding standards in the space provided below
5
For the constituents Identified In question 4 abova, have standards been exceeded previously for the
NO
same constituent(s) in the same well(a) In the last two years?
If the answer to question 5 is "NO", skip to section 8
N the answer to question S Is "YES", list in the space provided below, each well with constituent(s) exceeding
standards, concentration(s) reported, and sample col/ertion date for each occurrence (for the last two years).
6
Are the monitoring wells listed in section 5 located at or beyond the review boundary?
YES
NO
N the answer is "YES", a groundwater quality problem may be occurring. CONTACT THE REGIONAL
OFFICE IMMEDIATELY FOR GUIDANCE. N the answer Is "NO", monitoring wells may be improperly
located, contact the Regional Office.
Is the permittee Implementing previously approvrd actlorrs requlra7 by the Division involving this
YES
NO
groundwater quality problem?
If the answer to question 7 is 'YES" dascdbe those an'inns in the space provided below.
- ---
-if the enswes, to quesfion•7 is "NO", contact the B fL)nai Office witbbr 90 days• an evoivatlo4 mai be '
f
required to determine the impact the waste g jWosgI system is havine at the review and compliance
boundaries surrounding this facility, Failure"do so may subtest the permittee to a Notice of Wolaa
Anes. andfotpenaNles.
g
The person completing this portion G- W59A) ofof the rnonitoring 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 Information was evaluated and the Information submitted in this
report (Compliance Report GW -59A) Is true and complete to the best of my knowledge.
Signature of Permittee (or Authorized Agvnt)-------------- Date
GW -59A 12/8/211113 -

DWATER QUALITY MONITORING:
ANCE REPORT FORM
Name:
Name (if
Address:
NC
SI ID\a1T VnDhI /1 I VGI 1 f 1\ 1 on... nw V
CountyW Ca.KC
9ct Person: Telephone#:q!Q'Lj:A1-10GtV
Location/Site Name:]�pr �,f S'� No. of wells to be sampled:
L ID NUMBER (from Permit): m W Date sample collected: I- 3I IID
Depth: ft. Well Diameter: in.
I to Water Level: A ft. below measuring point Screened Interval: ft. to _
wring Point is I —ft. above land surface Relative M.P. Elevation: ft.
Is of water pumped/bailed before sampling: gallons
sample analyzed:JUSIlt, 11 13aI 11 s
tAMETERS NOTE: Values should reflect dissoly
COD
mg/I
Coliform: M.F FecalI100m1
Coliform: MF Total
/100m1
(Nola: Um MPN ma6Od tar N" 0add SWV")
Hg - Mercury
Dissolved Solids: Total 1910
mg/I
PH (when analyzed)
units
TOC 11-15
mg/I
Chloride 215 —mg/I
, method #
Arsenic
mgt;
Grease and Oils
mgll
Phenol
mg/I
Sulfate
mg/I
Specific Conductance
PMhos
Total Ammonia
mg/I
(AMTONa MUOW. NH3" N; AnalWa Nibop N To )
TKN as N
o, r\C•,ICVIYV VII
GW -50 Rev. 12007
MTMENT OF ENVIRONMENT A NATURAL RESOURCES
.ION OFWA7ER QUALITY -INFORMATION PROCESSING UNIT
MAIL SERVR:E CFNTER, RALEIGH, NC 27699-1617 Phona:19191 7�2-7221
.NMII NumbeMVIAtA��Elviration Date: 1 1 L.OL
n -Discharge UIC
IDES Other
'PE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon � ❑ Remediation: Infiltration Gallery
Spray Fiptd ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
FIELD ANALYSES: AS
PH 5 )'1 units Temp. 15,L4 aC DRY at
R Spec. Cond. $7 µMhos time of
Won samplin
Odor check
Appearance Veru Mua �2� -- - here: -F-
Laboratory Name: me -r TM� �.� , Certification No.
colloidal concentrations.
Nitrite (N%) as N mg/1 Pb - Lead mg/I
Nitrate (NO3) as N ��, mg/I Zn -:Zinc mg/I
Phosphorus: Total as P mg/I
Orthophosphate Mgt[ Other (Specify Compounds and Concentwnits):
At - Aluminum mg/I
Be - Barium mg/I DEC f 9106
Ca - Calcium mg/l
Cd - Cadmium mg/I -
Chromium: Total mg/I
Cu - Copper
mg/I
ORGANICS: (by GC. GC/MS, HPLC)
Fe - Iron
mg/I
(Spectfy test and method #..ATTACH LAB REPORT.)
Hg - Mercury
mg/I
Report Attached? ❑ Yes (1) ❑ No (0)
K - Potassium
mg/1
VOC , method #
Mg - Magnesium
mg/I
, method #
Mn - Manganese
mg/I
method #
Ni - Nickel
mg/1
, method #
Only JALWGn Lae Reports): InnUent total VUGS:
Effluent Total VOCs
mglL VOC Removal%

(;W -59A ('OMPIAANCE REN)RT h(MM Permit 414 0-)g38
1'a/,m;t uric ra, a nr� :i: oriry periwt r:;;.! i:Il -:::i ibrars.)
1
enter oate monitoring results were due. LLI..W 1uV) 7yili th`:s muniton:,g report (uJy-59 and GW -59A)
as submitted after the established due date?
Was; any required information missing on the Gw- P9 report fume? --- -- --- --- --
IF the answer h, quas5cn 1 cr 2 is "}'ES", list !n the sr.ac-; nro�`dBd r.elcw the well identification numb-er(s) and
explain the f,roblems encountered !n obtaining 1!1. F,':, role; m�ticn.
YES
Z
WS
---I
YES
QDJ
I
3
Are any of the monitor wells in need of repair or maine.nance (dant-aged caring, unlocked or missing cap, missing
identification plate, arra overgrown. e1c.)? I/!He oal,vpt i.t "Yrs"..::node•. me Pegronai OfceJor guidance.
, Ars any monitored constituents equal to or above tYe estaLhsf ed Undarda'7
q
yEq
U the answer to question 4 is
If the answer to question I is "YES" list the atyPi7to.I wells indwrdualb' with crnstituent(s) and concentration(s)
exceeding standards in Ine space provided be.bw.'
5
For the consttutents Identlfled Fin 4 above, have aWndud6 been exceeded previouaty tow the
some constituent(s) In the same well(s) In tho last two yearn?
YES
-- -
�—
YES
NO
If the answer to question 55 is WO', skip to secho^ d --------
If the answer to question 5 Is "YES", list in Ilia soa,xa provided below, each wet/ with constituents) exceeding
standards, concentration(s) reported, and sample :ofection date for eccil occurrence (to[ the last two years).
6
Are the monitoring wells listed ir, section 5 located at or beyond the review boundary?
If the answer is "YES", a groundwater quallry p,obWim may he occurring. CONTACT THE REGIONAL
OFFICE IMMEDIATELY FOR GUIDANCE. If the answar is "NO", monitoring wells maybe Improperly
located; contact the Regional OIFlce.
Is the permittee Implementing previously approved actions ie-qulred by the Division involving this
groundwater quality problem?
7
YES
NO
If the answer to question 7 is -YES", describe !hese ,cerins in the space provided below.
HMO answer to question 7 is "NO", contact the R fonel Offlcs wlthM 80 davs: an eva/uatiorr may he
required to determine the Impact the waste dlaonce
boundaries surrounding this facility, Failures d�
fMess s�mev sub ecE the permittee to a Noftca o1 Vlo/aflon
androrwnaltles.
g
The person completing this portion (GW-59Aj -of them. onitoAng reprHt should sign below and submit this
Iorm with GW -59 forms for required wells to the addmss provided at the top of the current GW -59 form.
1 hereby acknowledge that the above Informatlon was evaluated and the information submitted in this
report (Compliance Report GW -59A) Is true and c emplete to the best of my knowledge.
r u
Signature of Permittee (or Agent) ' Dat
GW-59A 12/8/2MM

JUDMI I r'UKM UN Tt1 I uW YAl'tr1 ONLY
Effi
PARTMENT OF; ENVIRONMENT S NATURAL RESOURCES
:R QUALITY MONITORING: VISION Or, WATER QUALITY -INFORMATION PROCESSING UNIT
REPORT FORM ffs,17 MAIL SERVICE CENTER, RALEIGH, NC 27999-1917 Phune:1919) 777-3221
Name: Oej
Name (if different):
Address: r n l
vca 1L1ct 1 rv1, CountyNNO-re,
act Person: -oke- iYit� e} -J S Telephone#: "n114( cA l-
Location/Site Name: Qe P (7h0.0 4r- r' • W— No. of wells to be sampled: _
L ID NUMBER (from Permit):
Depth: , A ft.
T to Water Level: I t 5 ft. below measuring point
uring Point is eq ft above land surface
ne of water pumped/bailed before sampling: I_
XMIT Numbs r.V-UV W �aLf5ll5iration Date: a I J 1 1 610 Li
In -Discharge UIC
'DES Other
'PE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
5C Spray Foo ❑ Remediation:
❑ Rotary distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
Date sample collected: I Ia3 -11-iii FIELD ANALYSES: WAS
Well Diameter: in. pH 5,34 units Temp. _.,% -C DRY at
Screened Interval: ft. to R. Spec. Coad.
_ ^%1 p Mhos lime of
N n
Relative M.P. Elevation: ft. Odor sampling,check
S _Appearance _f)Udu here:
and- -- ---- - ----- ---- -- - _.. -- -- -- ------ -
andfteldecidifed: ❑YES Il�INo
sample analyzed: Laboratory Name:
ZAMETERS NOTE: Values should reflect dissolved and colloidal concentrations
COD MG11
Nitrite (NO,) as N
mg/I
Coliform: MF Focal (��fJ /100ml
Nitrate (NO3) as N ©• (oe mg/I
Coliform: MF Total /100ml
Phosphorus: Total as P
mg/I
(Nob: use NPN meplod for NeyY Iurdd se 0.1
Orthophosphate
mg/I
��"
Dissolved Solids: Total % GUr mgA
AI -Aluminum
mg/l
PH (when analyzed) units
Be - Barium
mg/I
TOC�, mg/I
Ca - Calcium
mg/I
Chloride mg/I
Cd - Cadmium
mg/I
Arsenic mg/I
Chromium: Total
mg/I
Grease and Oils mgn
Cu - Copper
mg/I
Phenol mgn
Fe - Iron
mg/I
Sulfate mg/I
Hg - Mercury
mg/I
Specific Conductance AMhas
K - Potassium
mg/I
Total Ammonia
g - Magnesium
mg/I
(Anmw a Ntrolli Nly as N; Ammwra Nluoli n, Tote)
Mn - Manganese
mg/I
TKN as N mg/I
Ni - Nickel
mg/I
rv1 ne:meu:nslon ayswms Umy (Arracn Lao Keports): Influent Total VOCs:
Miss for Auftnzed ApsnO Name and Title - Please Mal or two
GW -59 Rev. 1/2007
Certification No.
Pb - Lead mgn
Znl-Zincmg/I
Other (Specify Compounds and Condon Units):
ORGANICS: (by GC, GC/MS, HPLC)
(Specify test and method #. ATTACH LAB REPORT.)
Report Attached? ❑ Yes (1) ❑ No (0)
VOC , method "#
method #
method #
method #
Effluent Total VOCs.
mg/L VOC Removal

GW -59A COMPLIANCE REPORT FORM Permit A Q0D0Gea9
(Subunit one ear h xmnitoriug pe. and u,ifh GIV-59 fortis.)
]
En date aerate om nitoring results were due. (T WIII 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 G1�-59 n•port forma.,
YES
p
IF the answer to question 1 or 2 is 'YES", list in the spate provioed below the well identification number(s) and
explain the problems encountered in obtaining the required information.
I
3
Arc amy of the monitor wells in need of repair or maims nance (daw,,ned casing, unlocked or missing cap, missing
YES IO
identification plate, area osergrown, etc.)? If the answcr .s "Yes ", crnmct the Regional Once for guidance.
4
Are any monitored constituents equal to or above the eatabllahad etandards7
YES I
NO
If the answer to question 4 is "NO', skip to sectiun 8.
If the answer to question 4 /s "YES" list the affected wells individually with consfituent(s) and concentration(s)
exceeding standards in the spare provided below,
5
For the constituents identified In question 4 above, have standards been exceeded previously for the
YES
O
same constituents) in the same well(s) in the last two years?
---
If the answer to question 5 is 'NO', skip to section 8.
If tiro answer to question 5 /s "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).
Are the monitoring wells listed in section 5 located at or beyond the review boundary?
YES
NO
If the answer is "YES", a groundwater qual/ty problem may L•e occurring. CONTACT THE REGIONAL
OFFICE IMMEDIATELY FOR GUIDANCE. N the answer Is "NO" monitoring wells may be improperly
located; contact the Regional Offlce.
']
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.
H the answer to question 7 /s "NO", contact thgRgglonal 0117ca wltitln 90 days- Mn evaluation may be
regu/red to determine the Imgect the waste d/sgosa! system !s having st the review and comgllance
boundaries surrounding this facility, I -allure to da so may subieot (be germAY" to a Notice of Violation
flnes. andiorimnaWes.
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 Information was evaluated and the Information submitted in this
report (Compliance Report GW -59A) Is true and complete to the beat of my knowledge.
111 G
Aub -- —
Signature of Permittee (oror Authorized Agent) Date
GW -59A 12/8/2003