#251_2016_1216_AO_FINAL

To be attached to all inspection reports in-house only.
Laboratory Cert. #:
251
Laboratory Name:
Town of Carolina Beach
Inspection Type:
Municipal Maintenance
Inspector Name(s):
Anna Ostendorff, Gary Francies, Beth Swanson
Inspection Date:
12/14/2016 — 12/15/2016
Date Forwarded for Initial
Review:
January 27, 2017
Initial Review by:
Beth Swanson
Date Initial Review
Completed:
January 30, 2017
Cover Letter to use:
❑ Insp. Initial
❑Insp. No Finding
®Corrected
(to use: rt click, properties, deck)
❑ Insp. Reg
❑Insp. CP
❑Insp. Reg. Delay
Unit Supervisor/Chemist III:
Gary Francies
Date Received:
February 2, 2017
Date Forwarded to Admin.:
2/15/2017
Date Mailed:
2/17/2017
Special Mailing Instructions:

Water Resources
ENVIRONMENTAL QUALITY
February 17, 2017
251
Ms. Lisa Courtney
Town of Carolina Beach
1121 N. Lake Park Blvd.
Carolina Beach, NC 28428
ROY COOPER
ou,
MICHEAL S. REGAN
,, ,,
S. JAY ZIMMERMAN
SUBJECT: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC)
Maintenance Inspection
Dear Ms. Courtney:
Enclosed is a report for the inspection performed on December 14 and 15, 2016 by Anna Ostendorff,
Beth Swanson and myself. I apologize for the delay in getting this report to you. Since the Finding(s)
cited during the inspection were all corrected prior to the completion of the enclosed report, a response
is not required. The staff is commended for taking the initiative in correcting the Findings in such a timely
manner. For Certification maintenance, your laboratory must continue to carry out the requirements set
forth in 15A NCAC 2H .0800.
A copy of the laboratory's Certified Parameter List at the time of the audit is attached. This list will reflect
any changes made during the audit. Copies of the checklists completed during the inspection may be
requested from this office. Thank you for your cooperation during the inspection. If you wish to obtain an
electronic copy of this report by email, or if you have questions or need additional information, please
contact me at [phone].
Sincerely,
Gary Francies, Technical Assistance/Compliance Specialist
Division of Water Resources
Attachment
cc: Anna Ostendorff
Master file

LABORATORY NAME: Town of Carolina Beach
NPDES PERMIT #: NC0023256
ADDRESS: 404 Dow Road
Carolina Beach, NC 28428
CERTIFICATE #: 251
DATE OF INSPECTION: December 14, 2016 & December 15, 2016
TYPE OF INSPECTION: Municipal Maintenance
AUDITOR(S): Anna Ostendorff, Gary Francies and Beth Swanson
LOCAL PERSON(S) CONTACTED: Lisa Courtney and Bill Raymond
I. INTRODUCTION:
This laboratory was inspected by representatives of the North Carolina Wastewater/Groundwater
Laboratory Certification (NC WW/GW LC) program to verify its compliance with the requirements
of 15A NCAC 2H .0800 for the analysis of environmental samples.
II. GENERAL COMMENTS:
The laboratory was clean and well organized. The laboratory has been proactive in implementing
regulatory updates since the last inspection in 2007. The laboratory staff were forthcoming and
promptly implemented the necessary changes in response to the Findings from the inspection.
All required Proficiency Testing (PT) samples have been analyzed for the 2016 PT calendar year
and the graded results were 100% acceptable.
The laboratory submitted their Quality Assurance (QA) and/or Standard Operating Procedures
(SOP) documents in advance of the inspection. These documents were reviewed and editorial
and substantive revision requirements and recommendations were made by this program
outside of this formal report process. Although subsequent revisions were not requested to be
submitted, they must be completed within one year.
The laboratory is reminded that any time changes are made to laboratory procedures, the
laboratory must update the QA/SOP documents and inform relevant staff. Any changes made
in response to the pre -audit review or to Findings, Recommendations or Comments listed in this
report must be incorporated to insure the method is being performed as stated, references to
methods are accurate, and the QA and/or SOP documents is in agreement with each approved
practice, test, analysis, measurement, monitoring procedure or regulatory requirement being
used in the laboratory. In some instances, the laboratory may need to create an SOP to
document how new functions or policies will be implemented.
The laboratory is also reminded that SOPs are intended to describe procedures exactly as they
are to be performed. Use of the word "should" is not appropriate when describing requirements

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#251 Town of Carolina Beach
(e.g. Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPS for the proper
use of the word "should".
Laboratory Fortified Matrix (LFM) and Laboratory Fortified Matrix Duplicate (LFMD) are also
known as Matrix Spike (MS) and Matrix Spike Duplicate (MSD) and may be used
interchangeably in this report.
Requirements that reference 15A NCAC 2H .0805 (a) (7) (A), stating "All analytical data pertinent
to each certified analysis must be filed in an orderly manner so as to be readily available for
inspection upon request", are intended to be a requirement to document information pertinent to
reconstructing final results and demonstrating method compliance. Use of this requirement is not
intended to imply that existing records are not adequately maintained unless the Finding speaks
directly to that.
Contracted analyses are performed by Environmental Chemists, Inc. (Certification # 94).
Approved Procedure documents for the analysis of the facility's currently certified Field
Parameters were provided at the time of the inspection.
The laboratory is no longer land applying sludge and requested the deletion of pH by SW-846
9045 D (Non -Aqueous) from their Certified Parameter List (CPL). This deletion was made
effective on January 27, 2017.
III. FINDINGS REQUIREMENTS COMMENTS AND RECOMMENDATIONS:
Quality Control
Comment: The laboratory was not consistently checking thermometers against a National
Institute of Standards and Technology (NIST) traceable thermometer every 12 months. One
instance was observed where 14 months elapsed between verifications. North Carolina
Administrative Code, 15A NCAC 2H .0805 (a) (7) (0) states: All thermometers must meet NIST
specifications for accuracy or be checked, at a minimum annually, against a NIST traceable
thermometer and proper corrections made. Notification of acceptable corrective action (i.e., a
statement that the due dates for thermometer calibration are recorded on an annual calendar with
an implementation date of January 9, 2017) was received by email January 13, 2017. No further
response is necessary for this Finding.
Comment: The auto-pipettor was not calibrated twice per year. The auto-pipettor, which was only
used to spike samples analyzed for Ammonia, was last calibrated December 16, 2015. NC
GW/WW LC Policy states: Mechanical volumetric liquid -dispensing devices (e.g., fixed and
adjustable auto-pipettors, bottle -top dispensers, etc.) must be calibrated at least twice per year,
approximately six months apart. Notification of acceptable corrective action (i.e., a statement
that volumetric pipettes are now used for all critical measurements and a statement reflecting
this change was added to the Ammonia benchsheet with an implementation date of December
21, 2016) was received by email January 13, 2017. No further response is necessary for this
Finding.
Proficiency Testing
Comment: The laboratory did not have a documented plan for analysis of PT samples. North
Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) states: Each laboratory shall develop
and maintain a document outlining the analytical quality control practices used for the
parameters included in their certification. Supporting records shall be maintained as evidence

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#251 Town of Carolina Beach
that these practices are being effectively carried out. Notification of acceptable corrective action
(i.e., a statement that the laboratory QA Manual was updated to include analysis of Proficiency
Testing samples with an implementation date of December 20, 2016) was received by email
January 13, 2017. No further response is necessary for this Finding.
Bacteria — Enterococci — IDEXX Enterolert® (MPN) (Aqueous)
Comment: It was the laboratory's practice to quantify the Total Residual Chlorine (TRC) using a
spectrophotometer when verifying the sample did not contain TRC. This is not required and a
visual Presence/Absence check using DPD may be performed instead.
Comment: The laboratory was not analyzing sample duplicates. The laboratory currently
analyzes fewer than 20 samples per month. North Carolina Administrative Code, 15A NCAC 2H
.0805 (a) (7) (C) states: Except for Oil and Grease (EPA Method 413.1), settleable solids or where
otherwise specified in an analytical method, analyze five percent of all samples in duplicate to
document precision. Laboratories analyzing less than 20 samples per month must analyze at least
one duplicate each month samples are analyzed. Notification of acceptable corrective action (i.e.,
a statement that one sample per month is duplicated with an implementation date of December
21, 2016) was received by email January 13, 2017. No further response is necessary for this
Finding.
BOD — Standard Methods, 5210 B-2001 (Hach 10360-2011, Rev. 1.2) (LDO) (Aqueous)
Comment: The laboratory is using a Luminescent Dissolved Oxygen (LDO) probe, but was not
aware that NC WW/GW LC grants Certification for this technology based upon Hach Method
10360 or ASTM Method D 888-09 C. The laboratory's CPL was amended to replace the Standard
Methods 5210 B-2001 method with the Standard Methods 5210 B-2001 (Hach 10360-2011, Rev.
1.2) (LDO) method with an effective date of January 27, 2017.
Recommendation: It is recommended that the blank acceptance criterion on the benchsheet be
updated to 0.20 mg/L. Currently, it is labeled as 0.2 mg/L. The SOP and laboratory practice use
the criterion 0.20 mg/L, which is required by the method.
Comment: The time samples are placed in the incubator is not clearly documented. This is
needed to clearly demonstrate compliance with the incubation time requirement. Two batches of
samples are analyzed beginning on the same day but at different times. The benchsheet only
documented the first time samples were placed in the incubator. North Carolina Administrative
Code, 15 NCAC 2H .0805 (a) (7) (A) states: All analytical data pertinent to each certified
analysis must be filed in an orderly manner so as to be readily available for inspection upon
request. Notification of acceptable corrective action (i.e., a copy of the updated benchsheet that
more clearly states the actual times sample batches were placed in the incubator that was
implemented on December 21, 2016) was received by email on January 13, 2017. No further
response is necessary for this Finding.
BOD — Standard Methods, 5210 B-2001 (Hach 10360-2011, Rev. 1.2) (LDO) (Aqueous)
Residue, Suspended —Standard Methods, 2540 D-1997 (Aqueous)
Comment: It is acceptable to use different duplicate acceptance criteria for samples of different
concentration levels. For example, Suspended Residue Effluent samples may have an
acceptance criterion of ± mg/L, while Influent samples may have an acceptance criterion of ±
percent.

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#251 Town of Carolina Beach
Comment: The laboratory was not randomly selecting samples for duplication. The laboratory
practice was to duplicate the influent sample only. Standard Methods, 5020 B-2010. (2) (f).
states: When appropriate (Table 5020:1), randomly select routine samples to be analyzed twice.
Standard Methods, 2020 B-2010. (2) (f) states: When appropriate (Table 2020:11), randomly select
routine samples to be analyzed twice. Notification of acceptable corrective action (i.e., a statement
that Influent and Effluent samples are randomly selected for duplication with an implementation
date of January 12, 2017 for BOD and December 22, 2016 for Suspended Residue) was received
by email January 13, 2017. No further response is necessary for this Finding.
Chlorine, Total Residual — Standard Methods, 4500 Cl G-2000 (Aqueous)
Comment: The instrument identification listed on the benchsheet was incorrect. The benchsheet
identified the previous meter used, but had not been updated to reflect the current meter in use.
The NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine document
states: The following must be documented in indelible ink whenever sample analysis is
performed: Instrument Identification. Notification of acceptable corrective action (i.e., a copy of
the updated benchsheet that includes the correct instrument identification that was
implemented on December 19, 2016) was received by email January 13, 2017. No further
response is necessary for this Finding.
Comment: Values less than the established reporting limit were being reported on the
electronic Discharge Monitoring Report (eDMR). Only one .instance was noted in the data
reviewed where the measured value was less than the reporting limit. The NC WW/GW LC
Approved Procedure for the Analysis of Total Residual Chlorine document states: The
concentrations of the calibration standards must bracket the concentrations of the samples
analyzed. One of the standards must have a concentration equal to or below the lower reporting
concentration for Total Residual Chlorine. The lower reporting limit must be less than or equal
to the permit limit. Notification of acceptable corrective action (i.e., a statement that all samples
that measure less than the current reporting limit of 10 pg/L will be reported as <10 pg/L on the
eDMR and will be implemented when completing the January 2017 eDMR) was received by
email January 20, 2017. No further response is necessary for this Finding.
Conductivity —Standard Methods, 2510 B-1997 (Aqueous)
Comment: The Automatic Temperature Compensator (ATC) has not been verified. The NC
WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity)
document states: The ATC must be verified annually (i.e., every twelve months) by analyzing a
conductivity standard at 25°C (the temperature that conductivity values are compensated to)
and temperatures that bracket the temperature ranges of the samples to be analyzed. This may
require the analysis of a third temperature reading that is > 25°C. Notification of acceptable
corrective action (i.e., a statement and documentation demonstrating that the ATC check was
performed on December 20, 2016 using a standard at 5.2, 25.0 and 40.8°C and that the results
agreed within ±10%, and that a reminder was added to an annual calendar to prevent recurrence)
was received by email January 13, 2017. No further response is necessary for this Finding.
Comment: Samples were being diluted. The NC WW/GW LC Approved Procedure for the
Analysis of Specific Conductance (Conductivity) document states: Conductivity samples must not
be diluted. Notification of acceptable corrective action (i.e., a statement that samples are no
longer diluted and a copy of the updated benchsheet that now states "Do not dilute samples" that
was implemented on December 20, 2016) was received by email January 13, 2017. No further
response is necessary for this Finding.

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#251 Town of Carolina Beach
Dissolved Oxygen — ASTM D 888-09 C (LDO) (Aqueous)
Comment: The laboratory is using a Luminescent Dissolved Oxygen (LDO) probe, but was not
aware that NC WW/GW LC grants Certification for this technology based upon Hach Method
10360 or ASTM Method D 888-09 C. Standard Methods 4500 O G-2001 is specifically for analysis
by membrane electrode. The laboratory's CPL was amended to replace the Standard Methods
4500 O G-2001 method with the ASTM D 888-09 C (LDO) method with an effective date of
January 27, 2017.
Comment: The laboratory benchsheet was lacking pertinent data: barometric pressure and
percent saturation. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (A) states:
All analytical data pertinent to each certified analysis must be filed in an orderly manner so as to
be readily available for inspection upon request. Notification of acceptable corrective action
(i.e., a copy of the updated Daily Sample Collection Sheet that includes the barometer reading
and percent saturation that was implemented January 12, 2017) was received by email on
January 13, 2017. No further response is necessary for this Finding.
Nitrogen, Ammonia — Standard Methods, 4500 NH3 D-1997 (Aqueous)
Comment: The preparation for the LFM was not documented. This is considered pertinent
information. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) states: Each
laboratory shall develop and maintain a document outlining the analytical quality control
practices used for the parameters included in their certification. Supporting records shall be
maintained as evidence that these practices are being effectively carried out. Notification of
acceptable corrective action (i.e., a copy of the updated Ammonia benchsheet that includes the
preparation for a 5.0 ppm LFM that was implemented December 21, 2016) was received by email
January 13, 2017. No further response is necessary for this Finding.
Comment: The percent recovery for the LFMD was not calculated. The percent recovery was
only calculated for the LFM. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7)
states: Each laboratory shall develop and maintain a document outlining the analytical quality
control practices used for the parameters included in their certification. Supporting records shall
be maintained as evidence that these practices are being effectively carried out. Notification of
acceptable corrective action (i.e., a statement that the LFMD percent recovery is calculated and
documented on the benchsheet with an implementation date of December 21, 2016 along with a
copy of a completed benchsheet) was received by email January 13, 2017. No further response
is necessary for this Finding.
Comment: Preservatives were not added to the method blank. The laboratory was analyzing a
method blank but was not adding the acid used to preserve samples to the method blank.
Standard Methods, 1020 B-2011. (5). states: A reagent blank (method blank) consists of reagent
water (see section 1080) and all reagents (including preservatives) that normally are in contact
with a sample during the entire analytical procedure. The reagent blank is used to determine
whether and how much reagents and the preparative analytical steps contribute to measurement
uncertainty. Notification of acceptable corrective action (i.e., a statement that the acid which is
used for sample preservation is added to the initial method blank with an implementation date of
December 21, 2016) was received by email January 13, 2017. No further response is
necessary for this Finding.
Comment: The Laboratory Fortified Blank (LFB) was not properly prepared. The laboratory was
analyzing a purchased 5.0 mg/L standard to serve as both the LFB and the Second Source.
However, the LFB must be prepared using the laboratory's reagent water and any reagents used
to preserve samples. Standard Methods, 1020 B-2011. (6). states: A laboratory -fortified blank

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[laboratory control standard (LCS)] is a reagent water sample (with associated preservatives) to
which a known concentration of the analyte(s) of interest has been added. An LFB is used to
evaluate laboratory performance and analyte recovery in a blank matrix. Notification of acceptable
corrective action (i.e., a statement that the 5.0 mg/L LFB is prepared in house using reagent water
and the associated preservatives and a copy of the updated Ammonia benchsheet which
documents the recipe that was implemented on December 21, 2016) was received by email
January 13, 2017. No further response is necessary for this Finding.
pH — Standard Methods, 4500 H+ B-2000 (Aqueous)
Comment: Units of measure were not consistently documented on the benchsheet. North
Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (H) states: All laboratories must use
printed laboratory bench worksheets that include a space to enter the signature or initials of the
analyst, date of analyses, sample identification, volume of sample analyzed, value from the
measurement system, factor and final value to be reported and each item must be recorded
each time samples are analyzed. Notification of acceptable corrective action (i.e., a copy of the
updated benchsheet that includes units of measure in all relevant column headings that was
implemented on December 19, 2016) was received by email January 13, 2017. No further
response is necessary for this Finding.
Residue, Suspended — Standard Methods, 2540 D-1997 (Aqueous)
Comment: The samples are not weighed to constant weight, nor is an annual multiple weighing
study to verify the adequacy of the drying time, performed. NC WW/GW LC Policy states:
Constant weights must be documented. The approved methods require the following: "Repeat
the cycle of drying, cooling, desiccating, and weighing until a constant weight is obtained or until
the weight change is less than 4% of the previous weight or 0.5 mg, whichever is less." In lieu
of this, an annual study documenting the time required to dry representative samples to a
constant weight may be performed. Verify minimum daily drying time is greater than or equal to
the time used for the initial verification study drying cycle. Drying cycles must be a minimum 1
hour for verification. Notification of acceptable corrective action (i.e., a copy of the acceptable
drying study that was performed on December 16, 2016, and a statement that it will be repeated
each year) was received by email January 13, 2017. No further response is necessary for this
Finding.
Temperature — Standard Methods, 2550 B-2000 (Aqueous)
Recommendation: It is recommended that all Temperature results reported for compliance
monitoring be rounded to whole numbers as recommended by the Precision in Discharge
Monitoring Reports document. A copy of this document was made available to the facility.
Comment: Sample analysis time was not clearly documented. There was only one time
documented on the benchsheet, with no statement that the sample was analyzed in situ or on site.
The NC WW/GW LC Approved Procedure for the Analysis of Temperature document states: The
following must be documented in indelible ink whenever sample analysis is performed: Date and
time of sample collection; Date and time of sample analysis — Alternatively, since EPA requires
samples to be analyzed immediately, one time may be documented for collection and analysis
with the notation that samples are measure in situ or immediately at the sample site (i.e.,
immediately following collection at a location as near to the collection point as possible). When
this `one time' option is used, state that the documented time is both collection and analysis time.
Notification of acceptable corrective action (i.e., a copy of the Daily Sample Collection Sheet that
was updated to state samples are analyzed in situ that was implemented on January 12, 2017)
was received by email January 13, 2017. No further response is necessary for this Finding.

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#251 Town of Carolina Beach
IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks,
etc.) and contract lab reports to electronic Discharge Monitoring Reports (eDMRs) submitted to
the North Carolina Division of Water Resources. Data were reviewed for the Town of Carolina
Beach WWTP (NPDES permit # NC0023256) for July and September 2016. No transcription
errors were detected. The facility appears to be doing a good job of accurately transcribing
data.
V. CONCLUSIONS:
All Findings noted during the inspection were adequately addressed prior to the completion of
this report. The inspectors would like to thank the staff for its assistance during the inspection
and data review process. No response is required.
Report prepared by: Anna OstendorFf Date: January 25, 2017
Report reviewed by: Beth Swanson Date: February 2, 2017

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