Sizemore_19860107

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POLLUTION INCIDENT' REPORTING FORM
i 1. Incident Ision of Environmental Management
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a — GROUNDWATER SECTION
2. Tabulate only
1. Emergency response '" tru^U?: • C l 5. Re-evaluation : #
A 2. Compliance investig 11i�`I 4st If£� ,� ��(/'// 6. Other
POTENTIAL HAZARDS � �� VLcS� �.�. � � issons 4. Explosives 5.. Fire
Incident Name
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L City/Town
Address l
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County Region
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PERSON REPORTING INCIDENT
Name
Date
Time
'
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Company/Agency- 0
Telephone
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Briefly escr1be Incident
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REPORTED BY: 1. Responsible party 6
Government agency 3. Private party
RECOMMENDED ACTION
0-1Investigation complete
3. Initiate/complete cleanup 5. Technical support
7. Enforcement action
112.. Continue Investigation
4. Long-term remedial action 6. Drill crew
8. Monitoring plan
Comments
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Signature
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Date
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GW-61 Revised 11/85 North Carolina Department of Natural Resources and Community Development

POLLUTION INCIDENT REPORTING FORM
Inclden
County 7:j LOCATION OF INCIDENT

Name of
System: a C,
Address: -W
County:
Report To: �/10 fq
Address:
Telephone Number:
Collected By:
Date Collected:: -
STATE LABORATORY OF PUBLIC HEALTH
DIVISION.OF HEALTH SERVICES
N.C. DEPARTMENT OF HUMAN -RESOURCES
P.O. BOX 28047 306 N. WILMINGTON ST., RALEIGH 27611
:ORGANIC CHEMICAL ANALYSES
PETROLEUMS
Complete All Items Above Heavy Line
(See Instructions on Reverse Side)
zip 'Z 7 TZ
0Urce of Water:
) Ground Both
Surface Purchased
rce of Sample:
Distribution Tap House Tap
A 1)w4
Well Tap
'Rype of Sample:
Raw
lTreated
hype of Treatment:
None Lime
Chlorinated Soda Ash'
Filtered
Water Softener'
Time: PM Alum -',Other
Location of Sampling Point:
(Address where sample was c@ledj4d) -7,�
Remarks:
State Drinking Water Parameters
(Required)
Results
.(CHLORINATED HYDROCARBONS:)
Endrin
Metho�
Toxa I
(CHLOROPHENOX41
2,4—D
2.4.5—
mg/I
chlor mg/I
ne mg/I
mg/I
mg/I
4
Type of Sample:
Regular Private'
Check Special
WRI rM bTb I trV1 I.U. NUMULK K;UVY FRUM MAILING LAftL)
Optional Parameters (List as needed)
Results
Received
-.-,Date Recei
2. -
Date Reported
�76
Reported By
j
Date Extracted Z 1�,'
Date Analyzed
/7, -
Laboratory N Umber'`_
Comments
,
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V
DHS Form 2886 7/79
Mildred A. Kerbaugh
Laboratory
Director

5Rq F, I
6 1 A I L, J t- JNUf-< J f-i (—At-CULIINA
DEPARTMENT OF NATURAL RESOURCES
AND COMMUNITY DEVELOPMENT
RALEIGH, NORTH CAROLINA
4954 1 NE
5R4 tRAnfivi '86
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