2540-FM-BWM0060
6/2005
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
Date Prepared/Revised
DEP USE ONLY
FORM 52
MUNICIPAL WASTE LANDFILL
PRIVATE WATER SUPPLY
QUARTERLY WATER QUALITY ANALYSES
Date Received
All information must be typed or legibly printed in the spaces provided. If additional space is necessary, identify each
attached sheet as Form 52, reference the item number and identify the date prepared. The “date prepared/revised” on any
attached sheets needs to match the “date prepared/revised” on this page.
General Reference: Act 101 Section 1103
SECTION A. SITE IDENTIFIER
Applicant/permittee:
Site Name:
Facility ID (as issued by DEP):
SECTION B. PRIVATE WATER SUPPLY INFORMATION
INDICATE THE LATITUDE AND LONGITUDE TO THE NEAREST ONE TENTH OF A SECOND (DD° MM' SS.S").
Facility Name:
County:
Township or Municipality:
Landowner Name:
Address:
Phone No.:
Sampling Point:
Latitude:
°
'
"
.
Longitude:
°
'
.
"
Sample Location:
Depth to Water Level:
ft.
Casing Stick Up:
ft.
Total Well Depth:
ft.
Sampling Depth:
ft.
Measured from:
Land Surface
Elevation of Water Level:
Sample Method:
Well Purged:
Yes
No
Sample Field Filtered (must be 0.45 micron)?
Sample Date:
Pumped
Well Volumes Purged:
Yes
No
Sample Collection Time:
Laboratory(ies) Performing Analysis
(include address and phone number)
Lab Certification Number(s)
Final Lab Analysis Completion Date
Sample Collector
Sample Collector Affiliation
Name/Affiliation of Person Who Filled Out Form
Were Any Holding Times Exceeded?
Comments:
Yes
No If Yes, please explain in comments field.
-1-
TOC
ft./MSL
Bailed
2540-FM-BWM0060
6/2005
Facility I.D. Number
FORM 52
MUNICIPAL WASTE LANDFILL
PRIVATE WATER SUPPLY
QUARTERLY WATER QUALITY ANALYSES
Monitoring Point I.D. No.
PS
Sample Date
1.
Inorganics (Enter all data in mg/l except as noted)
PARAMETER
VALUE†
Ammonia-Nitrogen
Bicarbonate (as CaCO3)
Calcium, total
Calcium, dissolved
Chemical Oxygen Demand
Chloride
Fluoride
Iron, total (μg/l)
Iron, dissolved (μg/l)
Magnesium, total
Magnesium, dissolved
Manganese, total (μg/l)
Manganese, dissolved (μg/l)
Nitrate-Nitrogen
†
Please indicate detection limit if analyte is not detected.
-2-
ANALYSIS METHOD NUMBER
2540-FM-BWM0060
6/2005
Facility I.D. Number
FORM 52
MUNICIPAL WASTE LANDFILL
PRIVATE WATER SUPPLY
QUARTERLY WATER QUALITY ANALYSES
Monitoring Point I.D. No.
PS
Sample Date
ANALYTES
1.
Inorganics, continued (Enter all data in mg/l except as noted)
PARAMETER
VALUE†
Nitrite-Nitrogen
pH (Standard Units), Field
pH (Standard Units), Laboratory
Potassium, total
Potassium, dissolved
Sodium, total
Sodium, dissolved
Spec Cond. (μmhos / cm), Field
Spec Cond. (μmhos / cm), Laboratory
Sulfate
Alkalinity, total
Residue, Total Filtrable at 105°C
Carbon, Total Organic
Phenolics, total (μg/l)
Turbidity (NTU)
Halogen, Total Organic (μg/l)
†
Please indicate detection limit if analyte is not detected.
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ANALYSIS METHOD NUMBER
2540-FM-BWM0060
6/2005
Facility I.D. Number
FORM 52
MUNICIPAL WASTE LANDFILL
PRIVATE WATER SUPPLY
QUARTERLY WATER QUALITY ANALYSES
Monitoring Point I.D. No.
PS
Sample Date
2.
Organics (Enter all data in μg/l)
PARAMETER
VALUE†
Benzene
1, 2-Dibromoethane
1, 1-Dichloroethane
1, 1-Dichloroethene
1, 2-Dichloroethane
Cis 1, 2-Dichloroethene
Trans 1, 2-Dichloroethene
Ethyl Benzene
Methylene chloride
Tetrachloroethene
Toluene
1, 1, 1-Trichloroethane
Trichloroethene
Trichlorofluoromethane
Vinyl Chloride
Xylene
†
Please indicate detection limit if analyte is not detected.
-4-
ANALYSIS METHOD NUMBER