Spreadsheet: f7a5c9fd-3286-4ed0-85ef-8972e3f38db3
Sheet: GW-59 Summary Table

 |  |  |  |  |  |  |  |  |  |  |  | Mail original and 1 copy to:
 | GROUNDWATER QUALITY MONITORING: |  |  |  |  |  |  |  |  |  |  |  | DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
 | COMPLIANCE REPORT FORM |  |  |  |  |  |  |  |  |  |  |  | DIVISION OF WATER QUALITY - INFORMATION PROCESSING UNIT
 |  |  |  |  |  |  |  |  |  |  |  |  | 1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617  Phone: (919) 733-3221
 | FACILITY INFORMATION |  | Please Print Clearly or Type
 | Facility Name: |  |  |  |  |  |  |  |  | Permit Type: |  | NPDES |  | Expiration Date:
 | Permit Name (if different): |  |  |  |  |  |  |  |  | PERMIT Number:
 | Facility Address:
 |  |  | (Street) |  |  |  |  |  |  | TYPE OF PERMITED OPERATION BEING MONITORED |  |  |  | Ash Impoundment Groundwater
 |  |  |  |  |  | County
 | (City) |  |  | (State) | (Zip)
 | Contact Person: |  |  |  |  | Telephone#
 | Well Location/Site Name: |  |  |  |  | No. of wells to be sampled:
 |  |  |  |  |  |  |  | (from Permit)
 | Monitoring Well Construction Information
 |  |  |  | Well ID Number (From Permit)
 |  |  | Units | MW- | MW- | MW- | MW- | MW- | MW- | MW- | MW- | MW- | MW- | MW- | MW- | MW- | MW- | MW-
 | Well Depth  [ft below land surface] |  | ft
 | Measuring Point (toc) [ft above land surface] |  | ft
 | Well Diameter |  | in
 | Screen Top  [ft below land surface] |  | ft
 | [NAME][ft below land surface] |  | ft
 | Relative Measuring Point Elevation |  | ft
 | Sampling Information and Field Analysis
 | CHECK IF DRY WELL AT TIME OF SAMPLING
 |  | 15A-2L | Units
 | Sample Date
 | Water Level [ft below measuring pt.] (82546) |  | ft
 | Volume of Water pumped/bailed |  | gal
 | Temperature (00010) |  | deg. C
 | Odor (00085)
 | Appearance
 | Specific Cond - field (00094) |  | umhos/cm
 | pH - field (00400) | 6.5 - 8.5 | SU
 | Laboratory Information
 | Laboratory Name |  |  |  |  |  |  | Certification # |  |  |  | Samples for metals were collected unfiltered: |  |  |  | Yes | No
 | Sample Analysis Date |  |  |  |  |  |  |  |  |  |  |  |  | and field acidified: |  | Yes | No
 |  | 15A-2L | Units
 | Sb - Antimony (01097) | 1 | ug/l
 | As - Arsenic (01002) | 10 | ug/l
 | Ba - Barium (01007) | 700 | ug/l
 | B - Boron (01022) | 700 | ug/l
 | Cd - Cadmium (01027) | 2 | ug/l
 | Cl - Chloride (00940) | 250 | mg/l
 | Cr - Chromium (01034) | 10 | ug/l
 | Cu - Copper (01042) | 1 | mg/l
 | Fe - Iron (01045) | 300 | ug/l
 | Pb - Lead (01051) | 15 | ug/l
 | Mn - Manganese (01055) | 50 | ug/l
 | Hg - Mercury (71900) | 1 | ug/l
 | [NAME] (01067) | 100 | ug/l
 | Nitrate (NO3) as N (00620) | 10 | mg/l
 | Se - Selenium (01147) | 20 | ug/l
 | SO4 - Sulfate (00945) | 250 | mg/l
 | Tl - Thallium (01059) | 0.2 | ug/l
 | TDS - Total Diss. Solids (70300) | 500 | mg/l
 | Zn - Zinc (01092) | 1 | mg/l
 | Al - Aluminum (01105) |  | ug/l
 |  |  |  | BOLD values equal or exceed the corresponding 2L standard
 | 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 possibility of fines and imprisonment for knowing violations.
 | Permittee (or Authorized Agent) Name and Title - Please print or type |  |  |  |  |  |  |  |  | Signature of Permittee (or Authorized Agent) |  |  |  |  |  | Date
 | GW-59CCR  01/2011
 |  |  |  | This area is for conditional formatting to [NAME] values at or above the 2L
 |  |  |  | False | False | False |  | False |  | False |  |  |  | False |  |  | False | False