W912PL22B0007 Amendment 03.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT 1. CONTRACT ID CODE

2. AMENDMENT/MODIFICAITON NO. 3. EFFECTIVE DATE 4. REQUISITION/PURCHASE REQ. NO. 5. PROJECT NO. (If applicble)

7. ADMINISTERED BY (If other than Item 6) CODE

STANDARD FORM 30 (REV. 10-83)

Prescribed by GSA FAR (48 CFR) 53.243

FACILITY CODE

9A. AMENDMENT OF SOLICIATION NO.

9B. DATED (SEE ITEM 11)

10A. MODIFICATION OF CONTRACT/ORDER NO.

10B. DATED (SEE ITEM 13)

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers is extended, is not extended.

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

(a)By completing items 8 and 15, and returning copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted;

or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment your desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPIRATION DATA (If required)

13. THIS ITEM ONLY APPLIES TO MODIFICATION OF CONTRACTS/ORDERS.

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER

NO. IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc. ) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor is not, is required to sign this document and return copies to the issuing office.

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15C. DATE SIGNED

15A. NAME AND TITLE OF SIGNER (Type or print)

16C. DATE SIGNED

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

14. DESCRIPTION OF AMENDMENT/MODIFICATION ( Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

PAGE OF PAGES

6. ISSUED BY CODE

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code) (X)

CODE

15B. CONTRACTOR/OFFEROR

(Signature of person authorized to sign)

16B. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

NSN 7540-01-152-8070

Previous edition unusable

03 Sep 7, 2022

USACE-LOS ANGELES DISTRICT

CONTRACTING DIVISION, EAST REGION BRANCH

915 WILSHIRE BLVD, SUITE 1440

LOS ANGELES, CA 90017

W912PL22B0007

Aug 9, 2022

Please see SF 30 BLOCK 14 CONTINUATION PAGE

INSTRUCTIONS

Instructions for items other than those that are self-explanatory, are as follows:

Item 1 (Contract ID Code) . Insert the contract type identification code that appears in the title block of the contract being modified.

Item 3 (Effective date) .

(1)

(2)

(3)

(4)

(5)

For a solicitation amendment, change order, or administrative change, the effective date shall be the issue date of the amendment, change order, or administrative change.

For a supplemental agreement, the effective date shall be the date agreed to by the contracting parties.

For a modification issued as an initial or confirming notice of termination for the convenience of the Government, the effective date and the modification number of the confirming notice shall be the same as the effective date and modification number of the initial notice.

For a modification converting a termination for default to a termination for the convenience of the Government, the effective date shall be the same as the effective date of the termination for default.

For a modification confirming the contacting officer's determination of the amount due in settlement of a contract termination, the effective date shall be the same as the effective date of the initial decision.

(a)

(b)

(c)

(d)

(e)

(f)

Item 6 (Issued By) . Insert the name and address of the issuing office. If applicable, insert the appropriate issuing office code in the code block.

Item 8 (Name and Address of Contractor) . For modifications to a contract or order, enter the contractor's name, address, and code as shown in the original contract or order, unless changed by this or a previous modification.

Item 9, (Amendment of Solicitation No. - Dated), and 10, (Modification of Contract/Order No. - Dated ). Check the appropriate box and in the corresponding blanks insert the number and date of the original solicitation, contract, or order.

Item 12 (Accounting and Appropriation Data) .

When appropriate, indicate the impact of the modification on each affected accounting classification by inserting one of the following entries.

(2) Accounting classification Net decrease $

Include subject matter or short title of solicitation/contract where feasible.

Item 16B . The contracting officer's signature is not required on solicitation amendments. The contracting offier's signature is normally affixed last on supplemental agreements.

(i)

NOTE: If there are changes to multiple accounting classifications that cannot be placed in block 12, insert an asterisk and the words "See continuation sheet".

Item 13 . Check the appropriate box to indicate the type of modification. Insert in the corresponding blank the authority under which the modification is issued. Check whether or not contractor must sign this document. (See FAR 43.103.)

Item 14 (Description of Amendment/Modification) .

Organize amendments or modifications under the appropriate Uniform Contract Format (UCF) section headings from the applicable solicitation or contract. The UCF table of contents, however, shall not be set forth in this document Indicate the impact of the modification on the overall total contract price by inserting one of the following entries:

Total contract price increased by $

Total contract price decreased by $

Total contract price unchanged.

State reason for modification.

When removing, reinstating, or adding funds, identify the contract items and accounting classifications.

When the SF 30 is used to reflect a determination by the contracting officer of the amount due in settlement of a contract terminated for the convenience of the Government, the entry in Item 14 of the modification may be limited to --

A reference to the letter determination; and

A statement of the net amount determined to be due in settlement of the contract.

(g)

(h)

(i)

(ii)

(1)

(2)

(3)

(4)

(5)

(6)

(i)

(ii)

(iii)

STANDARD FORM 30 (REV. 10-83) BACK

(1) Accounting classification Net increase $

W912PL22B0007

SF 30 CONTINUATION PAGE 1

September 2022 Amendment 3

Project Name: Construct Potable Wells Project Location: Luke AFB, Glendale, Arizona

SF 30 BLOCK 14 CONTINUATION PAGE

SUMMARY OF CHANGES

The purpose of this amendment is to:

• Update specification 33 11 13, section 2.6 to show permanent submersible pump operation of 480 volts, 3-phase power.

• The government will no longer be updating the bid schedule. Please bid per current schedule.

• Add 33 11 13 Attachments: Figure 1 and Drinking Water Source Approval Form.

• Extend bid opening date out to 13 September 2022, time for submission remains unchanged.

(See ).

SOLICITATION, OFFER,

AND AWARD

(Construction, Alteration, or Repair) IMPORTANT - The "offer" section on the reverse must be fully completed by offeror.

9. FOR INFORMATION

CALL:

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid and "bidder".

SOLICITATION

1. SOLICITATION NUMBER

5. REQUISITION/PURCHASE REQUEST NUMBER

CODE

6. PROJECT NUMBER4. CONTRACT NUMBER

7. ISSUED BY

11. The contractor shall begin performance within

12a. THE CONTRACTOR MUST FURNISH ANY REQUIRED PERFORMANCE AND PAYMENT BONDS?

(If "YES", indicate within how many calendar days after award in Item 12b.)

13. ADDITIONAL SOLICITATION REQUIREMENTS:

a. Sealed offers in original and

b. An offer guarantee

c. All offers are subject to the (1) work requirements, and (2) other provisions and clauses incorporated in the solicitation in full text or by reference.

d. Offers providing less than

STANDARD FORM 1442 (REV. 8/2014)

Prescribed by GSA - FAR (48 CFR) 53.236-1(d) calendar days for Government acceptance after the date offers are due will not be considered and will be rejected.

is, is not required.

copies to perform the work required are due at the place specified in Item 8 by (hour) award, YES NO notice to proceed. This performance period is mandatory negotiable.

calendar days and complete it within calendar days after receiving

12b. CALENDAR DAYS

2. TYPE OF SOLICITATION

SEALED BID (IFB)

NEGOTIATED (RFP)

3. DATE ISSUED PAGE OF PAGES

W912PL22B0007

USACE LOS ANGELES DISTRICT

CONTRACTING DIVISION

915 WILSHIRE BLVD, SUITE 930

LOS ANGELES, CA 90017

10. THE GOVERNMENT REQUIRES PERFORMANCE OF THE WORK DESCRIBED IN THESE DOCUMENTS (Title, identifying number, date)

Construct Potable Water Well, Luke AFB, Glendale, Arizona.

This Design-Bid Build (DBB) project provides infrastructure support to Luke AFB located in Glendale Az. in the northwest quadrant of the installation to replace existing Well #11 that has failed. Replace water well #11. New +/- 2,000 LF deep, 18” diameter potable well with pump. Perform drilling operation necessary to construct new potable water well. Install casing and screen, gravel filter pack and grouting. New water line connection and mixing vault between the well and ground water storage tank 1386. The project will include all necessary utilities, site improvements, pavements, communications support infrastructure, and all necessary supporting work for a complete and usable facility. Facility will be designed as permanent construction in accordance with the DoD Unified Facilities Criteria (UFC 1-200-01 and UFC 1-200-02).

The period of performance is 270 calendar days and the estimated cost range for this procurement is between $5,000,000 and $10,000,000.

This procurement is a 100% Total Small Business Set-Aside. The NAICS code is 237110, Water and Sewer Line and Related Structures Construction, with a size standard of $39.5M.

Be advised this project may be delayed, postponed, canceled or revised at any time prior to award.

8. ADDRESS OFFER TO

DoD Secure Access File Exchange (DoD Safe) at https://safe.apps.mil/

W912PL

a. NAME

OTSE A. ADIKHAI

b. TELEPHONE NUMBER (Include area code) (NO COLLECT CALLS)

213-452-3248

Section 00 73 00

1 electronic

1:00 PM

local time 13 September 2022 (date). If this is a sealed bid solicitation, offers will be publicly opened at that time. Sealed envelopes containing offers shall be marked to show the offeror's name and address, the solicitation number, and the date and time offers are due.

see*

9 August 2022

Amendment 03

17. The offeror agrees to perform the work required at the prices specified below in strict accordance with the terms of this solicitation, if this offer is accepted calendar days after the date offers are due. (Insert any number equal to or greater than the minimum requirement by the Government in writing within stated in Item 13d. Failure to insert any number means the offeror accepts the minimum in Item 13d.)

OFFER (Must be fully completed by offeror)

AMOUNTS

18. The offeror agrees to furnish any required performance and payment bonds.

19. ACKNOWLEDGMENT OF AMENDMENTS

(The offeror acknowledges receipt of amendments to the solicitation -- give number and date of each)

AMENDMENT

NUMBER

DATE.

AWARD (To be completed by Government)

CONTRACTING OFFICER WILL COMPLETE ITEM 28 OR 29 AS APPLICABLE

14. NAME AND ADDRESS OF OFFEROR (Include ZIP Code)

CODE FACILITY CODE

15. TELEPHONE NUMBER (Include area code)

16. REMITTANCE ADDRESS (Include only if different than Item 14.)

20a. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER (Type or print)

21. ITEMS ACCEPTED:

22. AMOUNT

26. ADMINISTERED BY

30a. NAME AND TITLE OF CONTRACTOR OR PERSON AUTHORIZED TO SIGN (Type or print)

31c. DATE

STANDARD FORM 1442 (REV. 8/2014) BACK

31b. UNITED STATES OF AMERICA

BY

31a. NAME OF CONTRACTING OFFICER (Type or print)

29. AWARD (Contractor is not required to sign this document.) Your offer on this solicitation is hereby accepted as to the items listed. This award consummates the contract, which consists of (a) the Government solicitation and your offer, and (b) this contract award. No further contractual document is necessary.

30b. SIGNATURE 30c. DATE

28. NEGOTIATED AGREEMENT (Contractor is required to sign this document and return and deliver all items or perform all work requirements identified on this form and any continuation sheets for the consideration stated in this contract. The rights and obligations of the parties to this contract shall be governed by (a) this contract award, (b) the solicitation, and (c) the clauses, representations, certifications, and specifications incorporated by reference in or attached to this contract.

copies to issuing office.) Contractor agrees to furnish

24. SUBMIT INVOICES TO ADDRESS SHOWN IN

(4 copies unless otherwise specified)

23. ACCOUNTING AND APPROPRIATION DATA

ITEM 25. OTHER THAN FULL AND OPEN COMPETITION PURSUANT TO

27. PAYMENT WILL BE MADE BY

10 U.S.C. 2304(c) ( ) 41 U.S.C. 3304(a) ( )

20b. SIGNATURE 20c. OFFER DATE

DUNS: TAX ID NO:

CAGE:

See Section 00 10 00 Solicitation Contract Line Item Number (CLIN) Schedule

USACE FINANCE CENTER

ATTN: CFCO-AO-D

5722 INTEGRITY DRIVE

MILLINGTON, TN 38054-5005

Amendment 03

PROJECT TABLE OF CONTENTS

DIVISION 01 - GENERAL REQUIREMENTS

01 11 00 SUMMARY OF WORK

01 14 00 WORK RESTRICTIONS

01 20 00 PRICE AND PAYMENT PROCEDURES

01 30 00 ADMINISTRATIVE REQUIREMENTS

01 32 01.00 10 PROJECT SCHEDULE

01 33 00 SUBMITTAL PROCEDURES

01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS

01 42 00 SOURCES FOR REFERENCE PUBLICATIONS

01 45 00.00 10 QUALITY CONTROL

01 45 00.15 10 RESIDENT MANAGEMENT SYSTEM CONTRACTOR MODE (RMS CM)

01 50 00 TEMPORARY CONSTRUCTION FACILITIES AND CONTROLS

01 57 19 TEMPORARY ENVIRONMENTAL CONTROLS

01 71 10 MOBILIZATION AND DEMOBILIZATION

01 74 19 CONSTRUCTION WASTE MANAGEMENT AND DISPOSAL

01 78 00 CLOSEOUT SUBMITTALS

01 78 23 OPERATION AND MAINTENANCE DATA

01 78 24.00 10 FACILITY DATA REQUIREMENTS

DIVISION 02 - EXISTING CONDITIONS

02 41 00 DEMOLITION

DIVISION 03 - CONCRETE

03 30 00 CAST-IN-PLACE CONCRETE

DIVISION 09 - FINISHES

09 90 00 PAINTS AND COATINGS

DIVISION 13 - SPECIAL CONSTRUCTION

13 34 19 METAL BUILDING SYSTEMS

DIVISION 25 - INTEGRATED AUTOMATION

25 10 10 UTILITY MONITORING AND CONTROL SYSTEM (UMCS) FRONT END AND

INTEGRATION

DIVISION 26 - ELECTRICAL

26 05 00.00 40 COMMON WORK RESULTS FOR ELECTRICAL

26 05 13.00 40 MEDIUM-VOLTAGE CABLES

26 05 19.10 10 INSULATED WIRE AND CABLE

26 05 26.00 40 GROUNDING AND BONDING FOR ELECTRICAL SYSTEMS

26 08 00 APPARATUS INSPECTION AND TESTING

26 12 19.00 40 PAD-MOUNTED, LIQUID-FILLED, MEDIUM-VOLTAGE TRANSFORMERS

26 13 01 PAD-MOUNTED DEAD-FRONT AIR INSULATED SWITCHGEAR

26 20 00 INTERIOR DISTRIBUTION SYSTEM

26 24 13 SWITCHBOARDS

26 24 16.00 40 PANELBOARDS

26 24 19.00 40 MOTOR CONTROL CENTERS

26 27 13.10 30 ELECTRIC METERS

26 29 23 SOLID STATE SPEED DRIVE (SSS) SYSTEMS UNDER 600 VOLTS

26 51 00 INTERIOR LIGHTING

PROJECT TABLE OF CONTENTS Page 1

Construct Potable Water Well Luke AFB, Glendale, AZ

September 2022 Amendment 03

DIVISION 31 - EARTHWORK

31 00 00 EARTHWORK

31 11 00 CLEARING AND GRUBBING

31 23 00.00 20 EXCAVATION AND FILL

DIVISION 32 - EXTERIOR IMPROVEMENTS

32 11 23 AGGREGATE BASE COURSES

32 31 13.53 HIGH-SECURITY FENCES (CHAIN LINK AND ORNAMENTAL) AND GATES

DIVISION 33 - UTILITIES

33 11 00 WATER UTILITY DISTRIBUTION PIPING

33 11 13 POTABLE WATER SUPPLY WELL

DIVISION 35 - WATERWAY AND MARINE CONSTRUCTION

35 45 01 VERTICAL PUMPS, AXIAL-FLOW AND MIXED-FLOW IMPELLER-TYPE

DIVISION 43 - PROCESS GAS AND LIQUID HANDLING, PURIFICATION, AND STORAGE

EQUIPMENT

43 21 29 FLOW MEASURING EQUIPMENT POTABLE WATER

-- End of Project Table of Contents --

PROJECT TABLE OF CONTENTS Page 2

Am03

Construct Potable Water Well Luke AFB, Glendale, AZ

The cement grout seal material must consist of a neat or pozzolan cement slurry containing 5.2 to 6.0 gallons of water per 94-pound sack of Portland cement. The Portland cement must conform to ASTM C150/C150M, Type II. The cement grout slurry may contain pozzolanic material (fly ash) as an additive, which complies with ASTM C618, and which must not exceed 50 percent by volume of the cement. No non-pozzolanic aggregate or sand may be added to the cement grout. The cement grout weight must be measured prior to installation as an indicator of the cement-water mix ratio. The cement grout slurry must not exceed 15.6 lb/gal (117 lb/ft3).

Accelerator additives must not be used unless approved. Water used for preparing the grout slurry must be potable. The specific constituents of the cement grout must be approved.

The Contractor must provide a cement mix design, the mix water source, and the specific constituents of the cement grout prior to the start of cementing operations. The cement grout slurry must be mixed thoroughly and be free of lumps. Cement grout that does not meet the requirements of this specification or is not adequately mixed will be rejected.

2.5.2 Bentonite Grout

Make high-solids bentonite grout from sodium bentonite powder, granules, or a combination of the two. Mix water from an approved source with these powders or granules to form a thick bentonite slurry. The slurry must consist of a mixture of bentonite and the manufacturer's recommended volume of water to achieve an optimal seal. The slurry must contain at least 20 percent solids by weight and have a density of 9.4 lb/gallon of water or greater.

2.6 PERMANENT PUMP

Permanent pump must be an approved submersible type with a capacity sufficient to deliver 1,500 gpm. Connect the pump to the pump controls by a three-wire drop line. Provide galvanized steel pipe conforming to ASTM A53/A53M piping for the well drop line. Operate the pump on 480 volts, 60 Hz, 3-phase power, with the motor of sufficient size to operate the pump under the maximum operating conditions without exceeding its rating. Equip the pump with necessary controls to provide for automatic operation of the pump.

PART 3 EXECUTION

3.1 PREPARATION

3.1.1 Protection of Existing Conditions

Maintain existing survey monuments and wells, and protect them from damage from equipment and vehicular traffic. Repair any items damaged during this work. Reinstall wells requiring replacement due to Contractor negligence according to these specifications. Protect wells scheduled for abandonment from damage so that abandonment may be performed according to these specifications. Prior to commencement of drilling, obtain written approval from the local utility companies to drill at each site, to avoid disturbing buried utilities.

3.1.2 Decontamination

Clean the drill rig, drill rods, drill bits, augers, temporary casing, SECTION 33 11 13 Page 13

Construct Potable Water Well Luke AFB, Glendale, AZ

Well Location: B(02-01)05ACC

2-Foot Stickup

39 Feet

1,700 Feet

1,720 Feet 1,730 Feet

1-Foot Stickup

580 Feet

Not To Scale Notes:

All diameters are OD unless otherwise stated

30-inch LCS Surface Casing (0.375-inch wall thickness)

42-inch Surface Borehole

Sand Cement Grout Seal

Formation Stabilizer (pea gravel / Tacna / or similar)

Bentonite Seal

18 ⁄5 8 -inch HSLA Steel Standard-Flo Louvered Well Screen (0.075-inch slots, 0.312-inch wall thickness) [Option 1 – 316L Stainless Steel]

Filter Pack (Colorado Silica Sand 6x9 Mesh)

18 ⁄5 8 -inch HSLA Steel Blank Casing (0.312-inch wall thickness) [Option 1 – 316L Stainless Steel]

HSLA Steel Bottom Plate (0.312-inch wall thickness) [Option 1 – 316L Stainless Steel]

Casing Centralizers (40-foot spacing)

540 Feet

570 Feet

18 ⁄5 8-inch HSLA Steel Blank Casing (0.312-inch wall thickness) [Option 1 – 316L Stainless Steel]

FIGURE 1

Well 20 Preliminary Well Design

Luke Air Force Base Glendale, Arizona

28-inch Borehole

HSLA = High Strength Low Alloy

Static Water ~284 feet bls

Construct Potable Water Well W912PL22B0007

Arizona Department Of Environmental Quality Drinking Water Source Approval Form

Samples To Be Taken At Source Only

System ID# Sample Date

ADEQ Project Number

New System YES NO

New Source YES NO

System Name _____:_______ (24 Hr clock) Sample Time

55-______________________________ Well ID Number

Surface Water Intake ID Number

Owner/Contact Person Phone Number

Owner/Contact Person Name

This form is to be filled out completely, and all pages are to be submitted together. If more than one laboratory participated in the analyses, please attach a copy of the original laboratory report, signed by the performing laboratory, to the back of this form.

All Results Shall Be Reported In Milligrams Per Liter (mg/L) Unless Otherwise Specified.

Please Mail This Completed Form To:

Arizona Department Of Environmental Quality Technical Review Unit

Drinking Water Section (5415B-2) 1110 W Washington St, Phoenix, AZ 85007

Reactivated Source NOYES

Construct Potable Water Well Luke AFB, Glendale, AZ

***Inorganic Chemical Analysis***

*Action Level Laboratory Information

Specimen Number:_______________ Lab ID Number:_____________Name:_________________________________________________ Comments:_______________________________________________________________________ Authorized Signature:_______________________________________________________________

***Physical Analysis***

Laboratory Information Specimen Number:______________ Lab ID Number:_____________Name:_________________________________________________ Comments:_______________________________________________________________________ Authorized Signature:_______________________________________________________________

Analysis Method MCL

Reporting Limit

Contaminant Name

Cont.

Code

Analysis Run Date Result

Exceeds

MCL

Exceeds Reporting Limit

0.01 0.005 Arsenic 1005 □ □ 2 1 Barium 1010 □ □

0.005 0.0025 Cadmium 1015 □ □

0.1 0.05 Chromium 1020 □ □ 1.3* 0.050 Copper 1022 □ □

4.0 0.5 Fluoride 1025 □ □ 0.015* 0.0025 Lead 1030 □ □

0.002 0.001 Mercury 1035 □ □ 10 2.5 Nitrate (as N) 1040 □ □ 1 0.25 Nitrite 1041 □ □

0.05 0.025 Selenium 1045 □ □

0.006 0.003 Antimony 1074 □ □

0.004 0.002 Beryllium 1075 □ □

0.2 0.1 Cyanide (as free id ) 1024 □ □

0.05 Nickel 1036 □ □

0.002 0.001 Thallium 1085 □ □

Analysis Method

Contaminant Name

Cont.

Code

Analysis Run Date Result

Sulfate 1055 Sodium 1052

PH 1925

Alkalinity 1927 Hardness/Calcium 1918 Langelier Index 1997 Temperature (ºC) 1996 Total Dissolved Solids-TDS 1930

Construct Potable Water Well Luke AFB, Glendale, AZ

***Synthetic Organic Chemical Analysis***

*Aroclor results may be submitted in lieu of PCB

Laboratory Information Specimen Number:_______________ Lab ID Number:_____________Name:_________________________________________________ Comments:_______________________________________________________________________ Authorized Signature:______________________________________________________________

Analysis Method MCL

Reporting Limit

Contaminant Name

Cont.

Code

Analysis Run Date Result

Exceeds

MCL

Exceeds Reporting Limit

0.07 0.0001 2,4-D 2105 □ □

0.05 0.0002 2,4,5-TP (Silvex) 2110 □ □

0.002 0.0002 Alachlor 2051 □ □

0.003 0.001 Toxaphene 2020 □ □

0.003 0.0001 Atrazine 2050 □ □

0.04 0.0009 Carbofuran 2046 □ □

0.001 0.00004 Pentachlorophenol 2326 □ □

0.002 0.0002 Chlorodane 2959 □ □

0.0002 0.00002 Dibromochloropropane(DBCP) 2931 □ □

0.00005 0.00001 Ethylene Dibromide (EDB) 2946 □ □

0.0004 0.00004 Heptachlor 2065 □ □

0.0002 0.00002 Heptachlor Epoxide 2067 □ □

0.0002 0.00002 Lindane 2010 □ □

0.04 0.0001 Methoxychlor 2015 □ □

0.0005 0.0001 PCB (Polychlorinated Biohenyls) 2383 □ □

0.0002 0.00002 Benzo(a)Pyrene 2306 □ □

0.2 0.001 Dalapon 2031 □ □

0.006 0.0006 Di(2-ethylhexyl)phthalate 2039 □ □

0.4 0.0006 Di(2-ethylhexyl)adipate 2035 □ □

0.007 0.0002 Dinoseb 2041 □ □ 3x10-8 5x10-9 2,3,7,8-TCDD (Dioxin) 2063 □ □

0.02 0.0004 Diquat 2032 □ □

0.1 0.009 Endothall 2033 □ □

0.002 0.00001 Endrin 2005 □ □

0.7 0.006 Glyphosate 2034 □ □

0.001 0.0001 Hexachlorobenzene 2274 □ □

0.05 0.0001 Hexachlorocyclopentadiene 2042 □ □

0.2 0.002 Oxamyl 2036 □ □

0.5 0.0001 Picloram 2040 □ □

0.004 0.0007 Simazine 2037 □ □

Construct Potable Water Well Luke AFB, Glendale, AZ

***Aroclor (PCB Screening Test)***

Specimen Number:_______________ Lab ID Number:_____________Name:_________________________________________________ Comments:_______________________________________________________________________ Authorized Signature:______________________________________________________________

***Volatile Organic Chemical Analysis***

Laboratory Information Specimen Number:_________________ Lab ID Number:_____________Name:______________________________________________ Comments:_____________________________________________________________________ Authorized Signature:___________________________________________________________

Analysis Method

Reporting Limit

Contaminant Name

Cont.

Code

Analysis Run Date Result

Exceeds Reporting Limit

0.00008 Aroclor 1016 2388 □

0.02 Aroclor 1221 2390 □

0.0005 Aroclor 1232 2392 □

0.0003 Aroclor 1242 2394 □

0.0001 Aroclor 1248 2396 □

0.0001 Aroclor 1254 2398 □

0.0002 Aroclor 1260 2400 □

Analysis Method MCL

Reporting Limit

Contaminant Name

Cont.

Code

Analysis Run Date Result

Exceeds

MCL

Exceeds Reporting Limit

0.007 0.0005 1,1Dichloroethlene 2977 □ □

0.2 0.0005 1,1,1-Trichlorethane 2981 □ □

0.005 0.0005 1,1,2-Trichloroethane 2985 □ □

0.005 0.0005 1,2-Dichloroethane 2980 □ □

0.005 0.0005 1,2-Dichloropropane 2983 □ □

0.005 0.0005 Benzene 2990 □ □

0.005 0.0005 Carbon Tetrachloride 2982 □ □

0.07 0.0005 cis-1,2 Dichloroethylene 2380 □ □

0.7 0.0005 Ethylbenzene 2992 □ □

0.1 0.0005 (mono) Chlorobenzene 2989 □ □

0.6 0.0005 o-Dichlorobenzene 2968 □ □

0.075 0.0005 para-Dichlorobenzene 2969 □ □

0.1 0.0005 Styrene 2996 □ □

0.005 0.0005 Tetrachloroethylene 2987 □ □ 1 0.0005 Tolune 2991 □ □

0.1 0.0005 Trans-1,2-Dichloroethylene 2979 □ □

0.005 0.0005 Trichloroethlene 2984 □ □

0.002 0.0005 Vinyl Chloride 2976 □ □ 10 0.0015 Xylenes, Total 2955 □ □

0.07 0.0005 1,2,4-Trichlorobenzene 2378 □ □

0.005 0.0005 Dichloromethane 2964 □ □

Construct Potable Water Well Luke AFB, Glendale, AZ

***Radiochemical Analysis***

*Do not analyze for this contaminant unless notified by ADEQ

Laboratory Information Specimen Number:______________ Lab ID Number:_____________Name:______________________________________________ Comments:_____________________________________________________________________ Authorized Signature:____________________________________________________________

***Asbestos Analysis***

Specimen Number_______________ Lab ID Number______________ Name__________________________________________________ Comments:_________________________________________________________________________ Authorized Signature:________________________________________________________________

Analysis Method MCL

Reporting Limit

Contaminant Name

Cont.

Code

Analysis Run Date Result

Exceeds

MCL

Exceeds Reporting

Limit 15 pCi.L Adjusted Gross Alpha 4000 □

3 pCi/L Gross Alpha 4002 □ 30ug/L

1ug/L Combined Uranium 4006 □ □

Uranium 234 4007 Uranium 235 4008 Uranium 238 4009

5 pCi/L 1 pCi/L Combined Radium 4010 □ □ 1 pCi/L Radium 226 4020 □ 1 pCi/L Radium 228 4030

* 4 mrem 4 pCi/L Gross Beta 4100 □ □

* 20,000 pCi/L 1,000 pCi/L Tritium 4102 □ □

* 10 pCi/L Strontium-89 4172 □

* 8 pCi/L 2 pCi/L Strontium-90 4174 □ □

* 1 pCi/L Iodine-131 4264 □

* 10 pCi/L Cesium-134 4270 □

Analysis Method MCL

Contaminant Name

Cont.

Code

Analysis Run Date Result

Exceeds

MCL

7 MFL Asbestos 1094 □

Reporting Limit

0.01MFL

Construct Potable Water Well Luke AFB, Glendale, AZ

***MICROBIOLOGICAL ANALYSIS***

ONLY REPORT FECAL RESULT IF TOTAL COLIFORM RESULT IS POSITIVE

LABORATORY INFORMATION

>>>To be filled out by laboratory personnel<<<

Specimen Number________________ Lab ID Number______________ Name__________________________________________________ Comments:_________________________________________________________________________ Authorized Signature:________________________________________________________________

DWAR 9: Revised 2021

Analysis Method MCL

Contaminant Name

Cont.

Code

Test Start Date/Time

Analysis Run Date/Time Result

Present 1 or More Coliform Total Coliform 3100

Analysis Method MCL

Contaminant Name

Cont.

Code

Test Start Date/Time

Analysis Run Date/Time Result

Present 1 or More Coliform Fecal Coliform

Construct Potable Water Well Luke AFB, Glendale, AZ

INSTRUCTIONS FOR USING THE ARIZONA DRINKING WATER

SOURCE APPROVAL REPORTING FORM

Revised 2021

SYSTEM ID: This is a unique 5 digit Public Water System Identification (PWSID) number assigned to each public water system by ADEQ.

SYSTEM NAME: Should be in the legal name which the water system will be known as when the system is built.

Always notify the Department in writing of any name or ownership change.

ADEQ PROJECT NUMBER: This is the number assigned by ADEQ when the project is first submitted for an “Approval to Construct”.

NEW SYSTEM: If this is a new system and a system in number has not yet been assigned by ADEQ, then mark “YES”, and be sure that the project number is filled in.

NEW POE: If this source represents a new point of entry (POE) for your system, then mark “YES” on the form. This will allow ADEQ to assign a new point of entry number and the appropriate monitoring year for this point of entry.

WELL ID NUMBER: The Department of Water Resources’ registration number goes here. This number always begins with a 55-. If the new source does not constitute a new point of entry, fill in the existing point of entry number that this source is joining.

SURFACE WATER INTAKE ID NUMBER: This number must be assigned by ADEQ. If the new source does not constitute a new point of entry, fill in the existing point of entry number that this source is joining.

SAMPLE DATE: The date the specimen was collected in mm/dd/yy format.

SAMPLE TIME: The time the specimen was collected in hh:mm format (24 hr clock time).

OWNER/CONTACT PERSON NAME: The first and last name of the owner or owner’s representative, (contact person) who should be contacted with sample results.

OWNER/CONTACT PHONE#: The daytime phone number of the owner’s representative, (contact person) who should be contacted with sample results.

SAMPLE TYPE: The compliance reason for specimen collection. Only the relevant sample types for each contaminant group are provided on the ADEQ forms.

SPECIMEN NUMBER: A unique 15 character (max) alphanumeric code that identifies a particular sample used to test one contaminant or one category of contaminants. If reporting on different reporting forms, a different (unique) number is required for each contaminant group and for each report.

NOTE: These definitions are general in nature. For specific questions regarding your laboratory submittal, please contact the Arizona Department of Environmental Quality (ADEQ) Water Quality Compliance Section at 1-800-234-5677, ext.

4648, or 602-771-4648.

Construct Potable Water Well Luke AFB, Glendale, AZ

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