HomeMy WebLinkAbout2021 March - Whitewater LMassachusetts Department of Environmental Protection
eDEP Transaction Copy
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Username: EBELAIR
Transaction ID: 1263034
Document: Groundwater Discharge Monitoring Report Forms
Size of File: 2661.26K
Status of Transaction: Submitted
Date and Time Created: 3/17/2021:2:18:11 PM
Note: This file only includes forms that were part of your
transaction as of the date and time indicated above. If you need
a more current copy of your transaction, return to eDEP and
select to "Download a Copy" from the Current Submittals page.
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Groundwater Permit
2.Tax identification Number
MONITORING WELL DATA REPORT
2021 FEB MONTHLY I
3.Sampling Month & Frequency
A. Facility Information
important:when
filling out forms on 1. Facility name,address:
the computer, use 'MAYFLOWER PLACE
only the tab key to a.Name
move your cursor-
do not use the 1579 BUCK ISLAND ROAD
return key. b.Street Address
1. 'YARMOUTH IMA 102673
c.City d.State e.Zip Code
2. Contact information:
k All
MARK WEINBERGER
a.Name of Facility Contact Person
2035574777 mweinberger@maplewoodsl.com
b.Telephone Number c.e-mail address
3. Sampling information:
12/12/2021 IWH ITEWATER
a.Date Sampled(mm/dd/yyyy) b.Laboratory Name
DOUG MURPHY
c.Analysis Performed By(Name)
B. Form Selection
1. Please select Form Type and Sampling Month&Frequency
Monitoring Well Data Report-2021 Feb Monthly
All forms for submittal have been completed.
2. - This is the last selection.
3. - Delete the selected form.
gdpdls 2015-09-15.doc• rev. 09/15/15 Groundwater Permit Daily Log Sheet• Page 1 of 1
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Groundwater Permit
MONITORING WELL DATA REPORT 2.Tax identification Number
'2021 FEB MONTHLY
3. Sampling Month&Frequency
C. Contaminant Analysis Information
• For"0", below detection limit, less than (<)value, or not detected, enter"ND" <
• TNTC=too numerous to count. (Fecal results only)
• NS = Not Sampled
• DRY= Not enough water in well to sample.
Parameter/Contaminant MW-1 MW-2 MW-3D MW-3M MW-3S MW-4D
Units Well#: 1 Well#: 2 Well#: 3 Well#:4 Well#: 5 Well#:6
PH 15.9 , 5.8 6.1 6.3 6.2 6.1
S.U.
STATIC WATER LEVEL I 6.89 9.51 8.62 8.88 18.89 110.63
FEET
SPECIFIC CONDUCTANCE 1333 402 277 245 304 298
UMHOS/C
mwdgwp-blank.doc•rev. 09/15/15 Monitoring Well Data for Groundwater Permit• Page 1 of 1
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Groundwater Permit I. I Cllllll Ill/Ill./01.
MONITORING WELL DATA REPORT IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
2. Tax identification Number
;2021 FEB MONTHLY
3. Sampling Month&Frequency
C. Contaminant Analysis Information
• For 11011, below detection limit, less than (<)value, or not detected, enter"ND" <
• TNTC=too numerous to count. (Fecal results only)
• NS = Not Sampled
• DRY= Not enough water in well to sample.
Parameter/Contaminant MW-4M MW-4S MW-5 MW-6 MW-8D MW-8S
Units Well#: 1 Well#: 2 Well#: 3 Well#:4 Well#: 5 Well#: 6
PH 5.8 5.9 5.9 6.1 6 5.8
s.u.
STATIC WATER LEVEL 9.74 10.43 7.52 8.44 10.84 8.61
Fttl
SPECIFIC CONDUCTANCE 278 234 332 305 388 396
UMHOS/C
mwdgwp-blank.doc•rev. 09/15/15 Monitoring Well Data for Groundwater Permit• Page 1 of 1
UUIG CIN VI 1 I I l/ICVUVI I- \J1\/ul IlIVVOLCI 1./10ld 1Qlyc I I 0111 I. 1 clll111 IYUIIIUGI
Groundwater Permit
DAILY LOG SHEET 2.Tax identification Number
2021 FEB DAILY
3. Sampling Month&Frequency
A. Facility Information
Important:When
filling out forms on 1. Facility name,address:
the computer, use MAYFLOWER PLACE
only the tab key to a.Name
move your cursor-
do not use the
1579 BUCK ISLAND ROAD
return key. b.Street Address
YARMOUTH 1MA 02673
1114: c.City d.State e.Zip Code
2. Contact information:
I! i I IMARK WEINBERGER
a.Name of Facility Contact Person
12035574777 Jmweinberger@maplewoodsl.com
b.Telephone Number c.e-mail address
3. Sampling information:
12/28/2021 {WH ITEWATER
a.Date Sampled(mm/dd/yyyy) b.Laboratory Name
.DOUG MURPHY
c.Analysis Performed By(Name)
B. Form Selection
1. Please select Form Type and Sampling Month&Frequency
Daily Log Sheet-2021 Feb Daily
— All forms for submittal have been completed.
2. - This is the last selection.
3. - Delete the selected form.
gdpdls 2015-09-15.doc• rev. 09/15/15 Groundwater Permit Daily Log Sheet• Page 1 of 1
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Groundwater Permit11111111111111
2.Tax identification Number
DAILY LOG SHEET
12021 FEB DAILY
3. Sampling Month &Frequency
C. Daily Readings/Analysis Information
Date Effluent Reuse Irrigation Turbidity Influent pH Effluent Chlorine UV
Flow GPD Flow GPD Flow GPD pH Residual Intensity
(mg/I) (%)
1 9076 I = I- 7.2
2 8933 I7.1
3 9122 I L� I 7.1 l=
4 9798 = 7—I 7.2 II
5 10043 = 7.3
6 10043 =
7 10043
8 9986 7.3
9 8978 _____.JI OM _.
10 8761 I = = 7.3
11 9255 7.4 NM
12 9077 I = = 7.2
13 9077 I ! J
14 9077 �.__ I I
15 9077 I
16 9329 I I 7.2 I
17 9254 1
E--1 704 I
18 9098 II 7.3 I
19 9339 I 7.1 I
20 9339 I l 1 = I I
21 F9-3j.6-7 I I I
22 10122 I I F.-- 7.3
23 10038 I = r7-3--------I
24 1-99-5-T--I 7.2
25 11250 I 7.4 J
26
r8-8-i(7---1 7.5 MI
27 8870 I f
28 8870 I
29
30
31
gdpols.doc•rev. 09/15/15 Groundwater Permit Daily Log Sheet• Page 1 of 1
's 1441004 VI I\GJV41 VG 1 14l041.141 I— VI VVI IVYYQIGI 1JIJ41 Mal 1,0 I I'1,.10111 I. I GI II III 1,14111401
.. Groundwater Permit 2.Tax identification Number
DISCHARGE MONITORING REPORT
12021 FEB MONTHLY
3. Sampling Month&Frequency
A. Facility Information
Important:When
filling out forms on 1. Facility name,address:
the computer, use 'MAYFLOWER PLACE
only the tab key to a.Name
move your cursor {
do not use the 1579 BUCK ISLAND ROAD
return key. b.Street Address
'YARMOUTH MA 102673
,ray c.City d.State e.Zip Code
0(
2. Contact information:
IFNAkil
,rte..
MARK WEINBERGER
a.Name of Facility Contact Person
12035574777 Imweinberger@maplewoodsl.com
b.Telephone Number c.e-mail address
3. Sampling information:
12/23/2021 IRI ANALYTICAL
a.Date Sampled(mm/dd/yyyy) b.Laboratory Name
'NICOLE SKYLESON
c.Analysis Performed By(Name)
B. Form Selection
1. Please select Form Type and Sampling Month&Frequency
I Discharge Monitoring Report-2021 Feb Monthly
- All forms for submittal have been completed.
2. - This is the last selection.
r
3. = Delete the selected form.
gdpdls 2015-09-15.doc• rev. 09/15/15 Groundwater Permit Daily Log Sheet• Page 1 of 1
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DISCHARGE MONITORING REPORT
12021 FEB MONTHLY
3. Sampling Month&Frequency
D. Contaminant Analysis Information
• For"0", below detection limit, less than (<)value, or not detected, enter"ND"
• TNTC=too numerous to count. (Fecal results only)
• NS= Not Sampled
1. Parameter/Contaminant 2.Influent 3.Effluent 4.Effluent Method
Units Detection limit
BOD ND 17.5 _ 3.0
MG/L
TSS 40 _.._.. 13 Y I 2.0
MG/L
TOTAL SOLIDS 360
MG/L
AMMONIA-N ND
MG/L
NITRATE-N 3.4 0.25
MG/L
TOTAL NITROGEN(NO3+NO2+TKN) 5.2 0.25
MG/L
OIL&GREASE ND 0.5
MG/L
infeffrp-blank.doc•rev. 09/15/15 Groundwater Permit Discharge Monitoring Report•Page 1 of 1
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Groundwater Permit 2.Tax identification Number
MONITORING WELL DATA REPORT
12021 QUARTERLY 1
3. Sampling Month&Frequency
A. Facility Information
Important:When
filling out forms on 1. Facility name,address:
the computer, use MAYFLOWER PLACE
only the tab key to a.Name
move your cursor-
do not use the 1579 BUCK ISLAND ROAD
return key. b.Street Address
rsi YARMOUTH IMA [02673
c.City d.State e.Zip Code
2. Contact information:
IFFA/1 MARK WEINBERGER
a.Name of Facility Contact Person
12035574777 mweinberger@maplewoodsl.com
b.Telephone Number c.e-mail address
3. Sampling information:
12/26/2021 1RIANALYTICAL
a.Date Sampled(mm/dd/yyyy) b.Laboratory Name
NICOLE SKYLESON
c.Analysis Performed By(Name)
B. Form Selection
1. Please select Form Type and Sampling Month&Frequency
Monitoring Well Data Report-2021 Quarterly 1 •
r-
- All forms for submittal have been completed.
2. - This is the last selection.
3. - Delete the selected form.
gdpdls 2015-09-15.doc• rev. 09/15/15 Groundwater Permit Daily Log Sheet• Page 1 of 1
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. Groundwater PermitIIIIIIIIIIIIIIIIIMIIIIIIIIIIIIIIIIIIII
2.Tax identification Number
MONITORING WELL DATA REPORT
2021 QUARTERLY 1
3. Sampling Month &Frequency
C. Contaminant Analysis Information
• For'IO", below detection limit, less than (<)value, or not detected, enter"ND" <
• TNTC=too numerous to count. (Fecal results only)
• NS = Not Sampled
• DRY= Not enough water in well to sample.
Parameter/Contaminant MW-1 MW-2 MW-3D MW-3M MW-3S MW-4D
Units Well#: 1 Well#:2 Well#: 3 Well#:4 Well#: 5 Well#:6
NITRATE-N IND ND ND ND IND 1 ND
MG/L
TOTAL NITROGEN(NO3+NO2+TK I ND ND ND ND ND ND
MG/L
TOTAL PHOSPHORUS AS P 0.077 ND 0.024 ND 0.024 0.022
MG/L
ORTHO PHOSPHATE ND ND ND ND ND I ND
MG/L
mwdgwp-blank.doc• rev. 09/15/15 Monitoring Well Data for Groundwater Permit• Page 1 of 1
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Groundwater Permit
L'`. "� 2.Tax identification Number
MONITORING WELL DATA REPORT
12021 QUARTERLY 1
3. Sampling Month&Frequency •
C. Contaminant Analysis Information
• For"0", below detection limit, less than (<)value, or not detected, enter"ND" <
• TNTC=too numerous to count. (Fecal results only)
• NS= Not Sampled
• DRY= Not enough water in well to sample.
Parameter/Contaminant MW-4M MW-4S MW-5 MW-6 MW-8D MW-8S
Units Well#: 1 Well#:2 Well#:3 Well#:4 Well#: 5 Well#:6
NITRATE-N ND ND ND ND ND ND
MG/L
TOTAL NITROGEN(NO3+NO2+TK ND ND ND ND ND ND
MG/L
TOTAL PHOSPHORUS AS P 0.025 ND 0.070 ND 0.053 0.024
MG/L
ORTHO PHOSPHATE IND ND ND ND ND ND
MG/L
mwdgwp-blank.doc•rev. 09/15/15 Monitoring Well Data for Groundwater Permit• Page 1 of 1
LJUI CCIU VI I\COMA I.G I I VICVlllJI I- Vi WWI IIAVVC1lcl ✓IJId ICIyc I IVJ IC III I. r CI II Ill IVU111V01
INN571
Groundwater Permit
MONITORING WELL DATA REPORT 2.Tax identification Number
;2021 ANNUAL
3. Sampling Month&Frequency
A. Facility Information
Important:when
filling out forms on 1. Facility name,address:
the computer, use 'MAYFLOWER PLACE
only the tab key to a.Name
move your cursor-
do not use the I579 BUCK ISLAND ROAD
return key. b.Street Address
JYARMOUTH IMA 102673
c.City d.State e.Zip Code
ti
2. Contact information:
X11 r_ (MARK WEINBERGER
a.Name of Facility Contact Person
12035574777 Imweinberger@maplewoodsl.com
b.Telephone Number c.e-mail address
3. Sampling information:
12/26/2021 (RI ANALYTICAL
a.Date Sampled(mm/dd/yyyy) b.Laboratory Name
'NICOLE SKYLESON
c.Analysis Performed By(Name)
B. Form Selection
1. Please select Form Type and Sampling Month&Frequency
I Monitoring Well Data Report-2021 Annual
— All forms for submittal have been completed.
2. - This is the last selection.
3. — Delete the selected form.
gdpdls 2015-09-15.doc• rev. 09/15/15 Groundwater Permit Daily Log Sheet• Page 1 of 1
.,.I ✓UI GQU VI I SCOIJUI VG I I VlGG .1IVI I- VI VI.1I IUVVaLGI ✓IJVI 101 I I VVI 0111 I. f 0111111 IVUI II1J01
4. Groundwater Permit
MONITORING WELL DATA REPORT 2•Tax identification Number
2021 ANNUAL
3. Sampling Month&Frequency
D. VOC Analysis Information
• If VOCs are present, please indicate the amounts of the individual compounds in pg/I.
• For"0", below detection limit, less than (<)value, or not detected, enter"ND"
• NS = Not Sampled
• DRY= Not enough water in well to sample.
Parameter/Contaminant MW-1 MW-2 MW-3D MW-3M MW-3S MW-4D
Units Well#: 1 Well#:2 Well#: 3 Well#:4 Well#: 5 Well#: 6
ACETONE IND ( ND ND ND ND ND
UG/L
BENZENE IND ND ND ND ND ND
UG/L
1,1 DICHLOROETHANE I ND ND ND ND ND ND
UG/L
1,2 DICHLOROETHANE I ND IND ND ND ND ND
UG/L
1,1 DICHLOROETHYLENE I ND ND ND ND I ND ND
UG/L
CIS-1,2-DICHLOROETHYLENE I ND ( ND ND ND ND ND
UG/L
TRANS 1,2 DICHLOROETHYLENE 1 ND I ND ND ND ND ND
UG/L
ETHYL BENZENE ND ND ND ND ND ND
UG/L
METHYLENECHLORIDE ND ND ND ND ND ND
UG/L
TOLUENE ND ND ND ND ND I ND
UG/L
O-XYLENE I ND ND ND I ND ND ND
UG/L
P/M XYLENE ND ND I ND ND ND ND
UG/L
CARBON TETRACHLORIDE 'i ND ND ND ND ND IND
UG/L
CHLOROFORM !ND ( IND ND ND I ND ND
UG/L
2-BUTANONE(MEK) !,ND I ND I ND ND ND ND
UG/L
mwdgwp-blank.doc• rev. 09/15/15 Monitoring Well Data for Groundwater Permit• Page 1 of 1
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� 1-01.41 GGU VI I\GJVUI I..G I I VI.GllllVI I - VI VI.111l.VVQIGI VIJVI IQI yG I I VVI 01111 I. CIIIIIl IYUIIIVGI
2.Tax identification Number
_ Groundwater Permit
MONITORING WELL DATA REPORT 2021 ANNUAL
3. Sampling Month&Frequency
D. VOC Analysis Information
• If VOCs are present, please indicate the amounts of the individual compounds in pg/I.
• For"0", below detection limit, less than (<)value,or not detected, enter"ND"
• NS = Not Sampled
• DRY= Not enough water in well to sample.
Parameter/Contaminant MW-1 MW-2 MW-3D MW-3M MW-3S MW-4D
Units Well#: 1 Well#: 2 Well#:3 Well#:4 Well#: 5 Well#:6
4-METHYL-2-PENTANONE(MIBK ND 'ND ND ND ND ND
UG/L
TRICHLOROETHYLENE ND ND ND ND ND ND
UGIL
TETRACHLOROETHYLENE ND ND ND ND ND ND
UG/L
1,1,1 TRICHLOROETHANE I ND ND ND ND ND ND
UG/L
VINYLCHLORIDE ND ;IND ND i ND ND ND
UGIL
STYRENE ND ND ND 1 ND ND J ND
UG/L
CHLOROBENZENE ND ND ND ND ND I ND
UG/L
METHYL TERTIARY BUTYL ETHE ND ND ND ND ND ND
UG/L
CHLOROETHANE ND ND 1 ND ND ND ND
UG/L
1,2-DICHLOROPROPANE ND ND ND ND ND ND
UG/L
DIBROMOCHLOROMETHANE ND IND ND ND ND I ND
UG/L
1,1,2-TRICHLOROETHANE !ND ND ND I ND ND ND
UG/L
2-CHLOROETHYLVINYL ETHER I ND ND ND ND ND IND
UG/L
BROMODICHLOROMETHANE ND ND ND ND ND ND
UG/L
BROMOFORM ND ND ND ND ND ND
UG/L
mwdgwp-blank.doc• rev. 09/15/15 Monitoring Well Data for Groundwater Permit• Page 1 of 1
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i Groundwater Permit11111111111111111111111111.11111
IL
MONITORING WELL DATA REPORT 2.Tax identification Number
2021 ANNUAL
3. Sampling Month&Frequency '
D. VOC Analysis Information
• If VOCs are present, please indicate the amounts of the individual compounds in pg/I.
• For"0", below detection limit, less than (<)value, or not detected, enter"ND"
• NS= Not Sampled
• DRY= Not enough water in well to sample.
Parameter/Contaminant MW-1 MW-2 MW-3D MW-3M MW-3S MW-4D
Units Well#: 1 Well#:2 Well#: 3 Well#:4 Well#: 5 Well#: 6
1,1,2,2-TETRACHLOROETHANE IND ND ND ND ND ND
UG/L
CHLOROMETHANE ND ND ND ND ND ND
UG/L
BROMOMETHANE I ND { ND ND ND ND ND
UG/L
CARBONDISULFIDE I ND ND ND ND ND ND
UG/L
2-HEXANONE ND ND ND ND ND ND
UG/L
ACROLEIN I ND ( ND ND ND ND ND
UG/L
ACRYLONITRILE I ND ND ND ND ( ND ND
UG/L
TRANS-I,3-DICHLOROPROPENE t IND ND ND ND ND ND
UG/L
CIS-1,3-DICHLOROPROPENE ND ND ND ND ND ND
UG/L
mwdgwp-blank.doc• rev. 09/15/15 Monitoring Well Data for Groundwater Permit• Page 1 of 1
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., Groundwater Permit2. Tax identification Number
MONITORING WELL DATA REPORT
12021 ANNUAL I
3. Sampling Month & Frequency
D. VOC Analysis Information
• If VOCs are present, please indicate the amounts of the individual compounds in pg/I.
• For"0", below detection limit, less than (<)value, or not detected, enter"ND"
• NS = Not Sampled
• DRY= Not enough water in well to sample.
Parameter/Contaminant MW-4M MW-4S MW-5 MW-6 MW-8D MW-8S
Units Well#: 1 Well#: 2 Well#:3 Well#:4 Well#: 5 Well#:6
ACETONE 'ND } 1 ND ND ND ND ,ND I
UG/L
BENZENE I ND ND ND ND ND ND
3
UGIL
1,1 DICHLOROETHANE ,ND ( ND IND ND ND ND
UG/L
1,2 DICHLOROETHANE I ND ( ND ND ND ND ND
,
UG/L
1,1 DICHLOROETHYLENE ND , IND I ND ND ND ND
UGIL
CIS-1,2-DICHLOROETHYLENE ND ND ND ND ND ND
UG/L
TRANS 1,2 DICHLOROETHYLENE ND ND ND ND ND ND
UG/L
ETHYL BENZENE ND ( ND ND ND ND ND
UG/L
METHYLENECHLORIDE ND ( ND ND ND ND ND
UG/L
TOLUENE ND ND ND ND ND ND
UG/L
O-XYLENE ND ND ND ND ND ND
UG/L
P/M XYLENE ND ND ND ND ND ND
UG/L
CARBON TETRACHLORIDE 'ND 'ND I ND ND I ND ND
UG/L
CHLOROFORM ND ND 1 ND ND I ND ND
UG/L
2-BUTANONE(MEK) ND ND 1 ND , `ND j I ND ND
UG/L
mwdgwp-blank.doc• rev. 09/15/15 Monitoring Well Data for Groundwater Permit• Page 1 of 1
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lio Groundwater Permit
MONITORING WELL DATA REPORT 2.Tax identification Number
2021 ANNUAL ,
3. Sampling Month &Frequency
D. VOC Analysis Information
• If VOCs are present, please indicate the amounts of the individual compounds in pg/I.
• For"0", below detection limit, less than (<)value, or not detected, enter"ND"
• NS = Not Sampled
• DRY= Not enough water in well to sample.
Parameter/Contaminant MW-4M MW-4S MW-5 MW-6 MW-8D MW-8S
Units Well#: 1 Well#: 2 Well#: 3 Well#:4 Well#: 5 Well#:6
4-METHYL-2-PENTANONE(MIBK ND ND ND ND ND ND
UG/L
TRICHLOROETHYLENE IND ND ND ND I ND ND
UG/L
TETRACHLOROETHYLENE ND ND ND ND ND ND
UG/L
1,1,1 TRICHLOROETHANE !ND ND ND ND ND ND
UG/L
VINYLCHLORIDE I ND ND ND ND ND ND
UG/L
STYRENE !ND I ND ND ND ND ND
UG/L
CHLOROBENNE I
ZEND ND ND ND ND ND
UG/L
I
METHYL TERTIARY BUTYL ETHE IND ND ND ND ND ND
UG/L t
CHLOROETHANE IND I ND ND ND ND ND
UG/L
1,2-DICHLOROPROPANE ND ND ND ND ND ND
UG/L
DIBROMOCHLOROMETHANE 1 ND ND ND ND ND ND
UG/L
1,1,2-TRICHLOROETHANE 'ND I ND ND ND ND ND
UG/L
2-CHLOROETHYLVINYL ETHER ;ND ND ND ND ND ND
UG/L
BROMODICHLOROMETHANE ND ND ND I ND ND ND
UG/L
BROMOFORM ',.ND I ND I ND ND 1 ND__.W_.. ND
UG/L
mwdgwp-blank.doc• rev. 09/15/15 Monitoring Well Data for Groundwater Permit• Page 1 of 1
uw Gau vI I%GOIJIAI UG I I uLGl,lluII- VI VUI Iurralci VIOI.,I nal I I VyI 0111 I. I GI II Ill IYUI I IUGI
Groundwater Permit
` 2.Tax identification Number
MONITORING WELL DATA REPORT
;2021 ANNUAL
3. Sampling Month &Frequency
D. VOC Analysis Information
• If VOCs are present, please indicate the amounts of the individual compounds in pg/I.
• For"0", below detection limit, less than (<)value, or not detected, enter"ND"
• NS = Not Sampled
• DRY= Not enough water in well to sample.
Parameter/Contaminant MW-4M MW-4S MW-5 MW-6 MW-8D MW-8S
Units Well#: 1 Well#: 2 Well#: 3 Well#:4 Well#: 5 Well#:6
1,1,2,2-TETRACHLOROETHANE ND ND ND ND ND I ND
UG/L
CHLOROMETHANE ND ND ND ND ND ND
UG/L
BROMOMETHANE ND ND IND ND ND ND
UG/L
CARBONDISULFIDE ND ND ND ND ND ND
UG/L
2-HEXANONE ND ND ND ND ND ND
UG/L
ACROLEIN ND ND ,ND ND ND ND
UG/L
ACRYLONITRILE ND ND ND ND ND ND
UG/L
TRANS-1,3-DICHLOROPROPENE ND ND ND ND ND ND
UG/L
CIS-1,3-DICHLOROPROPENE ND ND ND ND ND ND
UG/L
mwdgwp-blank.doc• rev. 09/15/15 Monitoring Well Data for Groundwater Permit• Page 1 of 1
-� LJUI GQU VI I\GJl/UI VG I I VIGVIIVI I- VI VU114YYQLG1 LJIJV1101 VG I I WWI0111 I. f 0111111 IWII1V01
Groundwater Permit
2.Tax identification Number
Facility Information
Important:When 'MAYFLOWER PLACE
filling out forms on
a.Name
the computer, use
only the tab key to 1579 BUCK ISLAND ROAD
move your cursor- b.Street Address
do not use the YARMOUTH MA 02673
return key. c.City d.State e.Zip Code
4 11 Certification
"I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted.
I Based on my inquiry of the person or persons who manage the system,or those persons directly responsible for gathering the
information,the information submitted is,to the best of my knowledge and belief,true,accurate and complete. I am aware that the
moot
are significant penalties for submitting false information,including the possibility of fine and imprisonment for knowing violations."
ELIZABETH BELAIR 3/17/2021
Any person signing a.Signature b.Date(mm/dd/yyyy)
a document under
314 CMR 5.14(1)or
(2)shall make the Re.ortin. Packa'e Comments
following PLANT MET ALL DISCHARGE PERMIT REQUIREMENTS FOR FEBRUARY 2021.
certification
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gdpols 2015-09-15.doc• rev. 09/15/15 Groundwater Permit• Page 1 of 1