Spreadsheet: 4a89a250-0d8d-4336-8d0d-a2fd8e376819
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 RESOURCES - INFORMATION PROCESSING UNIT
 |  |  |  |  |  |  |  |  |  |  |  |  | 1617 MAIL SERVICE CENTER, RALEIGH, NC 27669-1617  Phone: [PHONE]
 | 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] |  | [NAME]
 | Measuring  Point  [ft above land surface] |  | ft
 | Well Diameter |  | in
 | Screen Top  [ft below land surface] |  | [NAME]
 | [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 |  |  |  | MW- | MW-
 | 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) | NE | ug/l
 |  |  |  | BOLD values equal or exceed the corresponding 2L standard
 | I certify to the best of my knowledge and belief, the information submitted is true, accurate, and complete, and that the laboratory data was produced using approved methods of analysis by  a  DWR-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  8/2013
 |  |  |  | This area is for conditional formatting to [NAME] values at or above the 2L
 |  |  |  | False | False | False |  | False |  |  |  |  |  |  |  |  | False | False