Spreadsheet: d03462bc-71b5-411a-9d8b-41f0d5ef5c11
Sheet: Sheet1

GROUNDWATER QUALITY MONITORING: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Mail original and 1 copy to: |  |  |  | DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES                                                                 DIVISION OF WATER RESOURCES - INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617    Phone: [PHONE]
FACILITY INFORMATION |  |  |  |  |  |  |  |  |  |  | Please Print Clearly or Type |  |  |  |  |  |  |  |  |  | PERMIT Number: |  |  |  |  |  |  | Expiration Date:
Facility Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Non-Discharge |  |  |  |  |  | UIC
Permit Name (if different): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | NPDES |  |  |  |  |  | Other
Facility Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | TYPE OF PERMITTED OPERATION BEING MONITORED
(Street) |  |  |  |  |  |  |  |  |  |  |  |  |  | County |  |  |  |  |  |  |  | Lagoon |  |  |  | Remediation: Infiltration Gallery
 |  | (City) |  |  |  |  |  |  |  | (State) |  | (Zip) |  |  |  |  |  |  |  |  |  | Spray Field |  |  |  | Remediation:
Contact Person: |  |  |  |  |  |  |  |  |  |  |  |  |  | Telephone#: |  |  |  |  |  |  |  | Rotary Distributor |  |  |  | Land Application of Sludge
Well Location/Site Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | No. of wells to be sampled: |  |  |  |  | Water Source Heat Pump |  |  |  | Other:
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | (from Permit)
SAMPLING INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | If WELL WAS DRY at time of sampling, check here:
WELL ID NUMBER (from Permit): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date sample collected: |  |  |  |  |  | FIELD ANALYSES:
Well Depth: |  |  |  |  |  |  |  | ft. |  |  |  |  |  |  |  | Well Diameter: |  | in. |  |  |  | pH 00400: |  | units | Temp. 00010: |  |  |  | oC
Depth to Water Level 82546: |  |  |  |  |  |  |  | ft. below measuring point |  |  |  |  |  |  |  | Screened Interval: |  | ft. | to |  | ft. | Spec. Cond. 00094: |  |  |  |  |  | mMhos
[NAME] is |  |  |  |  |  |  |  | ft. above land surface |  |  |  |  |  |  |  | Relative M.P. Elevation: |  |  | ft. |  |  | Odor 00085:
Volume of water pumped/bailed before sampling: |  |  |  |  |  |  |  |  |  |  |  |  | gallons |  |  |  |  |  |  |  |  | Appearance
Samples for metals were collected unfiltered: |  |  |  |  |  |  |  |  |  |  | YES |  | NO |  | and field acidified: |  | YES |  | NO
LABORATORY INFORMATION
Date sample analyzed: |  |  |  |  |  |  |  |  |  |  |  |  |  | Laboratory Name: |  |  |  |  |  |  |  |  |  |  |  |  | Certification No.
PARAMETERS |  |  | NOTE: Values should reflect dissolved and colloidal concentrations.
 |  |  |  |  | COD 00335 |  |  |  |  |  | mg/L |  |  |  | Nitrite (NO2) as N 00615 |  |  |  |  | mg/L |  |  | Pb - Lead 01051 |  |  |  |  | ug/L
 |  |  |  |  | Coliform: MF Fecal 31616 |  |  |  |  |  | /100mL |  |  |  | Nitrate (NO3) as N  00620 |  |  |  |  | mg/L |  |  | Zn - Zinc 01092 |  |  |  |  | mg/L
 |  |  |  |  | Coliform: MF Total 31504 |  |  |  |  |  | /100mL |  |  |  | Phosphorus: Total as P 00665 |  |  |  |  | mg/L
 | (Note:  Use MPN method for highly turbid samples) |  |  |  |  |  |  |  |  |  |  |  |  |  | Orthophosphate 70507 |  |  |  |  | mg/L |  | Other (Specify Compounds and Concentration Units):
 |  |  |  |  | [NAME]:Total 70300 |  |  |  |  |  | mg/L |  |  |  | Al - Aluminum 01105 |  |  |  |  | mg/L
 |  |  |  |  | pH (Lab) 00403 |  |  |  |  |  | units |  |  |  | Ba - Barium 01007 |  |  |  |  | ug/L
 |  |  |  |  | TOC 00680 |  |  |  |  |  | mg/L |  |  |  | Ca - Calcium 00916 |  |  |  |  | mg/L
 |  |  |  |  | Chloride 00940 |  |  |  |  |  | mg/L |  |  |  | Cd - Cadmium 01027 |  |  |  |  | ug/L
 |  |  |  |  | Arsenic 01002 |  |  |  |  |  | ug/L |  |  |  | Chromium: Total 01034 |  |  |  |  | ug/L
 |  |  |  |  | Grease and Oils 00552 |  |  |  |  |  | mg/L |  |  |  | Cu - Copper 01042 |  |  |  |  | mg/L |  | ORGANICS: (by GC, GC/MS, [NAME])
 |  |  |  |  | Phenol  32730 |  |  |  |  |  | ug/L |  |  |  | Fe - Iron 01045 |  |  |  |  | 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 00095 |  |  |  |  |  | mMhos |  |  |  | K - Potassium 00937 |  |  |  |  | mg/L |  | VOC 78732: |  |  | , method #
 |  |  |  |  | Total Ammonia 00610 |  |  |  |  |  | mg/L |  |  |  | Mg - Magnesium 00927 |  |  |  |  | mg/L |  |  |  |  | , method #
 | (Ammonia Nitrogen; NH3 as N; Ammonia Nitrogen, Total) |  |  |  |  |  |  |  |  |  |  |  |  |  | Mn - Manganese 01055 |  |  |  |  | ug/L |  |  |  |  | , method #
 |  |  |  |  | TKN as N 00625 |  |  |  |  |  | mg/L |  |  |  | Ni - Nickel 01067 |  |  |  |  | ug/L |  |  |  |  | , method #
For Remediation Systems Only (Attach Lab Reports): |  |  |  |  |  |  |  |  |  |  |  |  |  | Influent Total VOCs: |  |  |  | mg/L |  |  |  | Effluent Total VOCs: |  |  |  | mg/L |  |  |  | VOC Removal%
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
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)