NCG550588_Compliance Evaluation Inspection_20200305

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
S. DANIEL SMITH
Director
Thomas Gagliardo
7616 Middle Drive
Greensboro, NC 27409
NORTH CAROLINA
Environmental Quality
March 5, 2020
SUBJECT: Compliance Evaluation Inspection
Certificate of Coverage #NCG550588 — General Permit 550000
Single -Family NPDES Wastewater Treatment System
2754 Lynchburg Rd. Westfield, NC 27409
Stokes County
Dear Mr. Gagliardo:
On March 4, 2020, staff of the North Carolina Division of Water Resources' Winston-Salem
Regional Office (DWR) performed a compliance inspection of the single-family NPDES
wastewater treatment system located at the subject property. This compliance inspection was
conducted by DWR staff person Mr. Justin Henderson. Currently, there was no residence present
on the property, thus no wastewater is being generated. The wastewater treatment system is
considered inactive at this time. This inspection reflects compliance with Permit No. NCG550588.
Please be aware that should a residence be constructed on the subject property in the future, and
the permitted facilities described in the subject permit become active, proper operation and
maintenance as specified in Permit Conditions Part I. C. (effluent monitoring requirements), and
Part I. D. (operation, maintenance, & records) shall be performed.
If you have any questions concerning this letter, you may contact Mr. Justin Henderson or me at
[phone].
Singe �S gt5e�d by:
, -T
I"L
SMdtr
Lori"§nider9'9egional Supervisor
Water Quality Regional Operation Section
Division of Water Resources, NCDEQ-WSRO
enc.: Inspection Report
cc: Laserfiche Files (electronic copies)
D � North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office [ 450 West Hanes Mill Road, Suite 300 I Winston-Salem, North Carolina 27105
NOh �HCARO UHA
^^ •^ �ku^m I u�•i` r 336.776.9800

United States Environmental Protection Agency
Form Approved.
EPA Washington, D.C. 20460
OMB No. 2040-0057
Water Compliance Inspection Report
Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 IN I 2 15 I 3 I NCG550588 111 12 I 20/03/04 I17
18 I S J 19 L G] 201 I
211111 1 1 I I I I II I I I I I I I I I I I I 1 I I I I
I I I I I I II I I I I I f6
Inspection
Work Days Facility Self -Monitoring Evaluation Rating 131 QA
---------------------- Reserved -------------------
671
70 I I 71 I I 72 I r I
u ty
73 I I 174 751 I I I I I I I80
I I i
Section B: Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
Entry Time/Date
Permit Effective Date
POTW name and NPDES oermit Number)
10:30AM 20/03/04
13/08/01
2745 Lynchburg Road
2745 Lynchburg Rd
Exit Time/Date
Permit Expiration Date
Westfield NC 27053
11:00AM 20/03/04
18/07/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
Thomas Paul Gagliardo,7616 Middle Dr Greensboro NC 27409//336-254-8034/
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Other
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers
Date
Justin L Henderson Docusigned by: DWR/WSRO WQ/336-776-9701/
t,tshv , ('�t,IWt,k,V 6V'3/5/2020
D51F3525961`8113496...
Signature of Management Q A Reviewer cusigned by: Agency/Office/Phone and Fax Numbers
S�,
'i ,du-
Lon Snider E�-51349E225C94EA...
Date
3/5/2020
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page#

NPDES yr/mo/day Inspection Type
NCG550588 I11 121 20/03/04 117 18 JCJ
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
No residence was present on the property, therefore no wastewater was being generated. The
wastewater treatment system authorized by the subject permit is currently inactive. Should a residence
be constructed on the property in the future and the wastewater treatment system be reactivated,
proper operation and maintenace in accordance with all permit requirements shall be performed.
Page#

Permit: NCG550588
Inspection Date: 03/04/2020
Other
Comment:
Owner - Facility: 2745 Lynchburg Road
Inspection Type: Compliance Evaluation
Yes No NA NE
Page#

SINGLE FAMILY
RESIDENCE FIELD INSPECTION CHECKLIST
Inspector Name(s): Justin Henderson
Date of Inspection: 03104/2020
Arrival Time:10:30am
Departure Time:
Property Owner Name: Paul Gagliardo
Phone Number(s): [phone]
Certificate of Coverage #:
NCG550588
Physical Address of Treatment System: 2754
Lynchburg Rd,
City: Westfield
Zip Code:
27409
County: Stokes
Mailing Address of Property Owner: 7616 Middle
Drive
City: Greensboro
Zip Code:
27409
County: Guilford
NOTE: All required items are indicated with an asterisk(*).
#
Question
Yes
No
NIA
N/E
Remarks:
I. Residency/Ownership
1.
1 Is Permittee the current owner of the SFR?
X
II.
Required System Components (Part I, Sec. A)
No residence is currently on the property thus the
wastewater treatment system is inactive.
1.
When was the system constructed? 09/18/1995. 450 GPD
2.
If constructed prior to 1 Aug '07, does system have:
a. Septic tank?*
X
b. Single pass or multi -phase sand filter?*
X
c. Disinfection?*
X
3.
If constructed on or after 1 Aug '07, does system have:
a. Septic tank with riser.*
b. Primary & secondary sand filters, or primary sand filter with
recirculating pump tank system?*
X
c. Chlorination & dechlorination or other equivalent means of
disinfection; specify type?*
d. Effluent pipe with post -aeration appartus?*
X
III. System Layout & History
Inactive
1
Does permittee have a map showing the layout of the treatment
system?
X
2.
Does permittee know the location of all system components, i.e. septic
tank, sand filiters, chlorinator, dechlorinator, ultraviolet systems, pump
systems, outlet/discharge, post -aeration apparatus?*
X
3.
Has sewage ever backed up into the house or have there been any
other problems/issues?
X
IV. Analytical Monitoring (Part I, Sec. A)
NIA inactive.
1.
Has the permittee conducted the required analytical monitoring?*
2.
Is analytical monitoring conducted by a NC certified laboratory?* (Part
ll, Sec. D, Para. 2)
3.
Do analytical monitoring results show compliance with permit limits?*
4.
jAre samples taken at the effluent?*
5.
jAre samples representative?* (Part II, Sec. D, Para. 1)
V. Septic Tank (Part I, Sec. A)
NIA inactive.
1
Has septic tank been pumped within 3 to 5 years of the issuance of the
certificate of coverage?* If yes, when?
2
Is tank maintained at all times to prevent seepage of sewage to the
surface of the ground?*
3
Is tank checked at least yearly to determine if solids must be removed
or if other maintenance is necessary?*
4
Are tank solids disposed at a location and in a manner compliant with
all local and state regulations?*
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VI. Filters (Part I, Sec. A)
Subsurface filters.
1.
jAre filters checked weekly to confirm proper operation?*
X
VII. Chlorination (Part I, Sec. A)
NIA inactive.
1.
Are chlorination tablets wastewater rated?*
2.
Are there chlorination tablets in the chlorinator?*
3
Are chlorination systems checked weekly to confirm proper operation
and an adequate supply of tablets?*
21
Vill. Dechlorination (Part I, Sec. A)
1.
Are dechlorination tablets wastewater rated?*
X
2.
Are there dechlorination tablets in the dechlorinator?*
X
3.
Are dechlorination systems checked weekly to confirm proper
operation and an adequate supply of tablets?*
X
4.
1 Is the dechlorinator labeled "Dechlorination Only"?*
X
IX.
Ultraviolet (UV) (Part I, Sec. A)
1.
Does permittee know how to determine if the UV system is working
properly?*
X
2.
Is the UV disinfection system working properly?*
X
3.
Do they know how to clean and replace UV bulbs?
X
4.
1 Do they have extra UV bulbs on site?
X
5.
jAre UV systems checked weekly to confirm proper operation?*
I X
X.
Pump Systems (Part II, Sec. C, Para. 2)
1.
Are pumps working properly?*
X
2.
Is the high water alarm in the pump tank operational?*
X
3.
Does the permittee know how to check the pump and high water alarm
to ensure operability?
X
XI. Post -Aeration Apparatus (Part II, Sec. C, Para. 2)
1.
Is the post -aeration apparatus in good repair and functioning
properly?*
XII. Detecting Problems/System Failure
NIA
1
Is there evidence of sewage surfacing or ponding, i.e. soggy soils,
sewage seeping up through the ground?
2.
Does any area of the property appear to be greener with vegetation
growth than the rest of the property?
3.
If standing sewage/soggy soils are observed, are there signs of
human/animal traffic in the area?
4.
Is system properly operated/maintained at all times? (Part II, Sec. C,
Para. 2)
XIII.
Effluent Pipe & Discharge
1.
Did you observe the end of the discharge pipe?
2.
Was the outlet discharging?
3.
Was the discharge clear and free of solids?
4.
Was there visible discharge in more than trace amounts of floating
solids or foam?* (Part I, Sec. A)
5.
Is there any evidence of solids at the end of the pipe or in nearby
ditches or creeks?
6.
Is the outlet submerged or does it appear that it may become
submerged at any time?*
XIV. Bypasses & Upsets (Part II, Sec. C, Para. 4 & 5, Part II, Sec. E, Para. 6)
NIA
1.
Does all wastewater from the home drain to the treatment system?*
X
2.
Does permittee avert and report system bypasses and upsets as
required?*
X
Page 2 of 3 NCG550588 2745 Lynchburg Rd. Westfield.xlsx 3/5/2020, 7:47 AM

XV.
II, Sec.
Records & Records Retention (Part I, Sec. A; Part II, Sec. D, Para. 4; Part II, Sec. E, Para.1 & Part
D, Para. 5)
NIA
1
Does permittee document all activites as required, i.e. the activities
covered in parts 4 thru 9 of this checklist?*
2.
Does permittee retain all required records on site for at least three
years?*
3.
Is the following information recorded for each measurement, sample, inspection & maintenance activity,
etc.?*
a. The date, exact place and time?*
b. Individual who performed the sampling, measurements, inspection
& maintenance activities?*
c. Date(s) that laboratory analyses were performed?*
d. Individual who performed laboratory analyses?*
e. The analytical techniques or methods used?*
f. The results of laboratory analyses?*
NOTES:
Previous CEI - 8/5/2013 - compliant.
Fees up to date.
Property is vacant.
Page 3 of 3 NCG550588 2745 Lynchburg Rd. Westfield.xlsx 3/5/2020, 7:47 AM