2540-PM-BWM0180
6/2005
Date Prepared/Revised
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
DEP USE ONLY
Date Received
FORM 10
CONSTRUCTION/DEMOLITION WASTE LANDFILLS
BASELINE GROUND WATER ANALYSES
This form must be fully and accurately completed. All required information must be typed or legibly printed in the spaces pr ovided. If
additional space is necessary, identify each attached sheet as Form 10, 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: Section 277.116
SECTION A. SITE IDENTIFIER
Applicant/permittee
Site Name
Facility ID (as issued by DEP)
An application for a construction/demolition waste landfill shall contain a description of the chemical characteristics of each
aquifer in the proposed permit area and adjacent area, based on at least six (6) months of monitoring data. This description
shall be based on quarterly sampling and analysis from each monitoring well. Submit separate forms for each sample
analysis.
SECTION B. FACILITY INFORMATION
Monitoring wells must be designed and constructed in accordance with Department standards. INDICATE THE LATITUDE
AND LONGITUDE TO THE NEAREST ONE TENTH OF A SECOND (DDº MM’ SS.S”).
Monitoring Point Number:
Well
Spring
Stream
Upgradient/Upstream
Location: County
Sampling Point:
Downgradient/Downstream
Municipality:
Latitude:
’
º
Depth to Water Level:
.
”
Longitude:
ft.
Measured from:
’
º
ft.
Elevation of Water Level:
Sampling Depth:
ft.
Volume of Water Column:
Total Well Depth:
ft.
Sampling Method:
No
Well Volumes Purged:
Yes
Sample Field Filtered (must be 0.45 micron)?
Spring Flow Rate:
Yes
”
.
Land Surface
Casing Stick Up:
Well Purged:
Other
Pumped
TOC
ft./MSL
gal.
Bailed
No
GPM
Sample Date (mm/dd/yy):
Sample Collection Time:
Sample Collector’s Name:
Sample Collector’s Affiliation:
Laboratory(ies) Performing Analysis:
Were any holding times exceeded?
Yes
No. If yes, please explain in comments field.
Lab Certification Number(s):
Lab Sample Number(s):
Final Lab Analysis Completion Date:
Name/Affiliation of Person who Filled out Form
Comments:
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Grab
2540-PM-BWM0180
6/2005
I.D. No.
Monitoring Point No.
Sample Date
SECTION C. PARAMETERS(all data in mg/l except as noted)
VALUE†
PARAMETER
Chemical Oxygen Demand
Chloride
Iron (µg/l), Total
Iron (µg/l), Dissolved
Lead (ug/l), Total
Lead (ug/l), Dissolved
pH (standard units), Field
pH (standard units), Laboratory
Sodium, Total
Sodium, Dissolved
Specific Conductance (µmhos/cm), Field
Specific Conductance (µmhos/cm), Laboratory
Sulfate
Total Organic Carbon
Total Organic Halogen (µg/l)
† Please indicate detection limit if analyte is not detected.
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ANALYSIS
METHOD NUMBER