NC0044750_Regional Office Historical File Pre 2016

WHY01% I%Wvlwwv 1110WIU
Facility: d( G�? S Cr P Permit No.: ���
�1 Pipe No,:
Monthly Average Violations
MonthNear: 1" K UU
1
Parameter Permit Limit DMR Value % Over Limit Action
_ (ACC
Weekly/Daily Violations
Date Parameter Permit Limit Limit Type DMR Value % Over Limit Action
s � (CYO %
Monitoring Frequency Violations
Date Parameter Permit Frequency Values Reported # of Violations Action
I Other Violations/Staff Remarks:
No: Y-�e"U (ous �a w•t E-InS
L'Q - one
Supervisor Remarks:
Completed by: Loy �A I
Assistant Regional
Supervisor Sign Off: —AL �,
Regional Supervisor Sign
Off:
Date: P1j,4 I
Date: FI ( I I (I
Date:

EFFLUENT 4
PNrPDESPERMIT NO. NC 0044750 DISCHARGE NO. 001 MONTH May YEAR 2015
FACILITY NAME Jacob's Creek Nursing Home CLASS II COUNTY Rockingham
CERTIFIED LABORATORIES R & A Laboratories, Inc. CERTIFICATION NO. 34
(List additional laboratories on the backside/page 2 of this form) JUL _ 9 2015
OPERATOR IN RESPONSIBLE CHARGE (ORC) Clifford Cain GRADE III CERTIFICATION NO. 1 237
PERSON(S) COLLECTING SAMPLES Operators ORC PHONE [phone] r< IN
CHECK BOX IF ORC HAS CHANGED PERSON(S) COLLECTING SAMPLES Operators
�. . .N
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES
DIVISION OF WATER QUALITY
1617 MAIL SERVICE CENTER OA
RALEIGH, NC 276"-1617
I r1 I! 10 71
omm=
(SIGNATURE OF OPWOR IN RESPONSIBLE CHARGE) R EI1/ p
BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT ISFDGEJ
ACCURATE AND COMPLETE TO THE BEST OF MY KNOW 15 :
id
AboveNumeAnd ni
®®®®®
Copy DWQ Form MR-1 (01/00)

Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements
(including weekly averages, if applicable)
V
Noncompliant
The permittee shall report to the Director or the appropriate Regional Office any noncompliance that potentially threatens public
health or the environment. Any information shall be provided orally within 24 hours from the time the permitte became aware of the
circumstances. A written submission shall also be provided within 5 days of the time the permittee becomes aware of the
circumstances.
If the facility is noncompliant, please attach a list of corrective actions being taken and a time -table for improvements to be
made as required by Part II.E.6 of the NPDES permit. '
"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 a qualified personnel properly gather and evaluate the information submitted. 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 there are significant
penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
Date
electronically)
1721 Bald Hill Loop Madison NC 336-548-9658 05/31/2017
Permittee Address Phone Number Permit Exp. Date
Certified Laboratory (2)
Certified Laboratory (3)
Certified Laboratory (4)
Certified Laboratory (5)
ADDITIONAL CERTIFIED LABORATORIES
PARAMETER CODES
Certification No.
Certification No.
Certification No.
Certification No.
Parameter Code assistance may be obtained by calling the NPDES Unit at at [phone], or by visiting the Surface Water Protection Section's
web site at h2o.enr.state.nc.us/wos and linking to the Units information pages.
Use only units of measurement designated in the reporting facility's NPDES permit for reporting data.
* No Flow / Discharge From Site: Check this box if no discharge occurrs and, as a result, there are no data to be entered for all of the
parameters on the DMR for the entire monitoring period.
** ORC On Site?: ORC must visit facility and document visitation of facility as required per 15ANCAC8G.0204.
*** Signature of Permittee: If signed by other than the permitte, then the delegation of the signatory authority must be on file with the state per
15ANCAC213.0506 (b) (2) (D).
Copy DWQ Form MR-1 (01/00)

RESEARCh & ANA[yTICAI
LABORATORIES, INC.
Analytical/Process Consultations
Re: Jacob's Creek — May 2015 Fecal Coliform
Since I had high Fecal Coliform results in the month of May, I replaced bulbs in June
2015.
-Clifford Cain, ORC
P 0. Box 473 • 106 Short Street • Kernersville, North Carolina 27284 • 336-996-2841 • Fax [phone]
www.randalabs.com

DMR Review Record
acllity: S A,r�b1, C r--N2 Permit No.: W-,-c 4cj1 < Pipe No.. , k MonthNear: /y
Monthly Average Violations
Parameter Permit Limit DMR Value % Over Limit Action
Weekly/Daily Violations
Date r Parameter Permit Limit Limit Type DMR Value % Over Limit Action
L��° ' L�Cfo �b
Monitoring Frequency Violations
Date Parameter Permit Frequency Values Reported # of Violations Action
Other Violations/Staff Remarks:
139 S 6�
supervisor Remarks: pJ
Completed by: � c �A <11,
I
Assistant Regional
Supervisor Sign Off:
04
Regional Supervisor Sign
Off:
Date: �b ! S'
Date: S
Date:

EFFLUENT
4
NPDES PERMIT NO. NC 0044750 DISCHARGE NO. 001 MONTH September YEAR 2014
FACILITY NAME Jacob's Creek Nursing Home CLASS II COUNTY Rockingham
CERTIFIED LABORATORIES R & A Laboratories, Inc. CERTIFICATION NO. 34
(List additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC) Clifford Cain GRADE III CERTIFICATION NO. 11237
PERSON(S) COLLECTING SAMPLES Operators ORC PHONE [phone]
CHECK BOX IF ORC HAS CHANGED PERSON(S) COLLECTING SAMPLES O erators
s
Mail ORIGINAL and ONE COPY to: P)
t 6 �Ja
ATTN: CENTRAL FILES X O
DIVISION OF WATER QUALITY (SIGNATURE OF TOR RESPONSIBLE G) DATE
1617 MAIL SERVICE CENTER BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
RALEIGH, NC 27699-1617 ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
Nov 12 gnu
Copy DWQ Form MR-1 (01/00)

RESEARCh & ANA[YTICAI
LABORATORIES, INC.
Analytical/Process Consultations
Re: Jacob's Creek Nursing Home — Daily exceeded Fecal Coliform on 9/17/14
On September 16, 2014 maintenance personnel noticed UV lamp inoperable. There were
no new lamps on site. The bad lamp was replaced with an old lamp. New lamps were
ordered. I sampled 9/17/14 and fecal coliform was 440 col/100 ml. On September 20,
2014 the old UV lamp was replaced with the new lamp. I sampled September 23, 2014
and fecal Coliform was 18 col/100 ml.
Clifford Cain, ORC
P.O. Box 473 • 106 Short Street • Kernersville, North Carolina 27284 • 336-996-2841 • Fax [phone]
www.randalabs.com

NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Division of Water Quality
Charles Wakild, P.E.
Director
December 17, 2012
Toyna Hemric, Administrator
Granite Falls Ltc LLC
1721 Bald Hill Loop
Madison NC 27025
Subject: NOTICE OF VIOLATION
Permit No. NCO044750
Jacob's Creek Nursing & Rehabilitation Center
Rockingham County
Dear Ms. Hemric:
Dee Freeman
Secretary
A review of Jacob's Creek Nursing & Rehabilitation Center's monitoring report for September
2012 showed the following violations:
Parameter
Date
Limit Value
Reported Value
Limit Type
Coliform, Fecal MF, M-FC
09/06/12
400 #/100ml
500 #/100m1
Daily
Broth,44.5 C
Maximum
Exceeded
Parameter
Date
Measuring
Violation
Frequency
Flow, in conduit or thru
09/29/12
Continuous
3
treatment plant
Flow, in conduit or thru
09/30/12
Continuous
3
treatment plant
Remedial actions, if not already implemented, should be taken to correct the above
noncompliance problem. Please be aware that violations of your NPDES permit could result in
North Carolina Division of Water Quality, Winston-Salem Regional Once One
Location: 585 Waughtown St, Winston-Salem. North Carolina 27107 NorthCarolina
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org Natu�/ f
An Equal Opportunity1 Affirmative Action Employer ` L`y

enforcement action for this by the Division of Water Quality for this and any additional
violations of State law.
If you should have any questions, please do not hesitate to contact Mike Thomas at (336) 771-
5000.
Sincerely,
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
cc: SWP — Central Files
WSRO Files

�6� — 2 O l2. — �—�`'� - U CD 41
Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record
Facility: t6 Permit/Pipe No.: t` CDOSSI-5o Month/Year
Parameter
Monthly Average Violations
Permit Limit DMR Value % Over Limit
Weekly/ l Violations
Date Parameter Permit Limit/ rvpe DMR Value %Over Limit
g-e 4w I ImmL SCOL ZS
Monitoring Frequency Violations
Date Parameter Permit Frequency Values Reported # of Violations
-'f—L Flow C..Isr• �y ✓ �s
9 3.� Flo.✓ _ Cain �� o �s
Other Violations
k- /S� eA46 �-I J /tick
Completed by:
Regional Water Quality
Supervisor Signoff.
00V
Date: / z1l� l 2-
—T— r
Date: J��

a rtr-tar-1vMu
N.C. Dept. of ENR
EFFLUENT DEC 0 5 2012
PPPPFP
Win , -Salem
NPDES PERMIT NO. NC 0044750 DISCHARGE NO. 001 MONTH September YEAR
FACILITY NAME Jacob's Creek Nursing Home CLASS II COUNTY Rockingham
CERTIFIED LABORATORIES R & A Laboratories, Inc. CERTIFICATION NO. 34
(List additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC) Clifford Cain GRADE III CERTIFICATION NO. 11237
PERSON(S) COLLECTING SAMPLES Operators ORC PHONE [phone]
CHECK BOX IF ORC HAS CHANGED]-� PERSON($) COLLECTING SIMPLES Operators
Mail ORIGINAL and
ATTN: CENTRAL FILES
DIVISION OF WATER QUALI'C T a 1201
1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617 CiENTRAL MEE
DMISOG
X
�!a
(SIGNATURE Ob6kRATOR IN RESPONSIBLE CHARGE) DATE
BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
_
`0
> o
y
O
r•
O
50050
00010
00400
50060
00310
00610
00530
31616
00300
00600
00665
00625 1 00630 1 00095 1 TGP3D
FLOW
3
.y
°'
F
av
disinfection
U
G
�°,
o
c
�
H
.@
d
>°q,
a
Enter Parameter Code
Above Name And Units
Below
EFF
INF
d
q x
Daily
Daily
Week)
NSA
Week)
Weekly
WeeklyWeeklyWeeklyWeeks
HRS
HRS
amr
MGD
e
SU
/1
m /1
m /1
m /1
#100/ml
m /1
m /I
1
0.0061
2
0.0061
3
0,0061
Holiday ------ --------------------------------------------------------------------------- -------------------- ----------------------- ---------
4
1121
0.35
1'
0.0061
28.0
5
1312
0.30
B
0.0049
28.0
6
1410
0.30
1
0.0044
29.0
7.6
2.14
0.683
65
500
<0.1
7
1223
0.50
Y
0.0043
28.0
7.7
8
0.0035
9
0.0035
101
1418
1 0.35
Y
1 0.0035
25.0
11
1439
0.25
Y
0,0296
27.0
7,8
<2.0
7.0
48
12
1420
0.40
1
0.0088
26.0
8.2
13
0610
0.25
B
0.0101
25.0
14
1320
0.25
11
0.0063
23.0
15
0.0093
161
1
1
0.0093
17
1005
0.25 1
B
0.0093
24.0
18
1331
0.40
1'
0.0229
24.0
19
1230
0.30
Y
0.0045
24.0
7.6
20
1408
0.45
1'
0.0077
23.0
<2.00
0.171
10
<0.1
21
1321
0.40
Y
0.0051
24.0
1
8.0
22
0.0083
23
0.0083
24
1222
0.35
1'
0.0083
22.0
25
1254
0.30
Y
0.0052
21.0
7.6
<2.00
11.0
13
26
1511
0.25
1'
0.0093
22.0
27
1230
0.25 1
Y 1
0.0059
23.0
28
1216
0.70
Y
0.0074
23.0
7.8
29
30
31
\ ERAGE
0.0080
24.7
� ::
<2.00
0.427
8.0
42
7.9
<0.1
11_AXLMUM
0.02.96
29.0
7.8
2.14
0.683
11.0
500
8.2
<0.1
MINIMUM
0.0035
21.0
7.6
<2.00
0.171
6.5
10
7.7
<0.1
mp. (C) / Grab (G)
R
G
G
G
C
C
C
G
C
C
C
G
C
C
C
Monthly Limit
0.20
1 =>6<9
1 N/A
30.0
30.0
200.0
=>5.0
PiF®81%
Copy DWQ Form MR-1 (01/00)

Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements
(including weekly averages, if applicable)
Compliant
ERr
Noncompliant
The permittee shall report to the Director or the appropriate Regional Office any noncompliance that potentially threatens public
health or the environment. Any information shall be provided orally within 24 hours from the time the permitte became aware of the
circumstances. A written submission shall also be provided within 5 days of the time the permittee becomes aware of the
circumstances.
If the facility is noncompliant, please attach a list of corrective actions being taken and a time -table for improvements to be
made as required by Part II.E.6 of the NPDES permit.
"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 a qualified personnel properly gather and evaluate the information submitted. 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 there are significant
penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
J shire Authoriz
t
ittee (P ase rin
c 0-16-/li
S' atur of Pe itee)4* Date
050red unless su mitted electronically)
1721 Bald Hill Loop Madison NC 336-548-9658 05/31/2012
Permittee Address Phone Number Permit Exp. Date
Certified Laboratory (2)
Certified Laboratory (3)
Certified Laboratory (4)
Certified Laboratory (5)
ADDITIONAL CERTIFIED LABORATORIES
PARAMETER CODES
Certification No.
Certification No.
Certification No.
Certification No.
Parameter Code assistance may be obtained by calling the NPDES Unit at at [phone], or by visiting the Surface Water Protection Section's
web site at h2o.enr.state.nc.us/was and linking to the Unit's information pages.
Use only units of measurement designated in the reporting facility's NPDES permit for reporting data.
* No Flow / Discharge From Site: Check this box if no discharge occurrs and, as a result, there are no data to be entered for all of the
parameters on the DMR for the entire monitoring period.
** ORC On Site?: ORC must visit facility and document visitation of facility as required per 15ANCAC8G.0204.
*** Signature of Permittee: If signed by other than the permitte, then the delegation of the signatory authority must be on file with the state per
15ANCAC213.0506 (b) (2) (D).
Copy DWQ Form MR-1 (01/00)

PAC
O: NC 0044750 DISCHARGE NO: 001 MONTH: August YEAR: 2012
NAME: Jacob's Creek COUNTY: Rockingham
STREAM: Ho¢an's Creek STREAM: Ho an's Creek
LOCATION: 2308 Bridge LOCATION: 2189 Bridge
Upstream Downstream
1000100030000400
0031C00340
31616
00995
yi
Enter Parameter Code above
o
>
vC
�
Name and Units Below
b
q
y
Ci
u
U
lWftklylWeeklyj
Weekly
Weekly
HRS
eC
mg/1
SU
mg/1
mg/1
100m1
mhos/cm
2
4
6
8
10
12
1418
19.0
9.1
14
16
18
20
22
24
26
28
1311
18.0
9.3
#
30
1
1
1
AVERAGE
20.0
8.9
Monthly
Maximum
Monthly
18.0
8.1
Minimum
10001q003010
00400
0031q00340
31616
100995
yEnter
Parameter Code above
V
M
�
Name and Units Below
p
U
C
E�'
to
A
Uq
ti
N
Q
Mo.
y
pOq
u
U
�
F
A
WeeklyjWeeklyl
I
I I
Weekly
Weekly.
HRS
aC
mg/1
SU
mg/1
mg/1
100m1
mhos/cm
11410119.01
8.8
11301118.01
9.2
20.0
8.9
18.0
8.4
Copy DEM Form MR-3 (11/84)

ppppppp,
Re: Jacob's Creek Nursing Home — Daily exceeded Fecal Coliform on 9/6/12
I have cleaned bulbs and UV canister. No Further exceedence.
Clifford Cain, ORC

pppppp,
Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: L2 rot Y� 4:�, T:::—rA 1.s Or I ILL
-
Mailing Address: 1 i \ , I lA ti I I I —
City: NV &a 4.So r-\ State: NC_ Zip: a1%V;k"5 Phone #:
Email address:
Signature:
Facility N;
ui
......:...................
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade:
Biological WWTP Ok, Surface Irrigation
Physical/Chemical Land Application
Collection System
Operator in Responsible Charge (ORC)
Print Full Name:
Certificate Type / Grade / Number: �w� 31 1► a�� Work Phone #: (33J )qqb -DLa L
Signature: Date: �� -�"
Ll
VV
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
l'
Certificate Type / Grade / Number: �� c� cT %� Work Phone #: (U) 19 LV ,M Y/
Signature: Date: IV_lUZ J/
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
.................................................................................................................................................
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: emai :- rl i MA 4W
Mail or fax a copy to the Asheville
Fayetteville
Mooresville
Raleigh
appropriate Regional Office: 2090 US Hwy 70
225 Green St
610 E Center Ave
3800 Barrett Dr
Swannanoa 28778
Suite 714
Suite 301
Raleigh 27609
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Fax: [phone]
Phone:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington Sq Mall
127 Cardinal Dr
585 Waughtown St
Washington 27889
Wilmington 28405-2845
Winston-Salem 27107
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Revised 03-2014

ppppppp,
Facility Name: r ��� ( v `�u `�G1 �- Permit #: NC-OZ) q 4 2 SD
_—
................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number: yaw 13) �� a q Work Phone #: Lyto F)
Signature: Date: /!l� % ty
"1 certify that 1 agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #: ( 1
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission,"
...............................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
........................................................................................................................................................................
Revised 03-2014

Mike
From: Mickey, Mike
Sent: Monday, January 14, 2013 11:22 AM
To: '[e-mail]'
Subject: Jacobs Creek - NCO044750
Jim C. or Cliff C. —Trying to head off having to send a NOV. The computer noted the following issues on the October
DMR. For months prior to October, flow values were reported continuously as required. Was the change inflow
reporting related to Ron Boone's directive?
A corrected DMR needs to be submitted for the D.O. value. If flow values are available for the weekend, please submit
them also. Let me know what you decide. Thanks, Mike.
Jacobs Creel. — _TC0044 750 — October 2012 DNIR
Parameter
Date Omitted
11easurement Freguencv
Violations
Flow (MGD)
10:'6
Continuous Recording
1
Flow (MGD)
10;`7
Continuous Recording
1
Flow (MGD)
10:1113
Continuous Recording
1
Floe- (MGD)
10 114
Continuous Recording
1
Flow (MGD)
1 &'20
Continuous Recording
1
Flog (MGD)
1021
Continuous Recording
1
Flow (MGD)
10,27
Continuous Recording
1
Flog- (MGD)
10,28
Continuous Recording
1 1
Parameter
Date
Reported Value
Permit Limit
I Limit Tvpe
Dissolved Ox gen
10 5
1 <7.6 mg L*
16.0 mg.1 or greater
I Daily Minimum
the less than sign ("<'") cannot be used for reporting dissolved oxygen Values_
Mike Mickey
Mike.Mickev(@NCDENR.gov
NC Division of Water Quality
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North
Carolina Public Records Law and may be disclosed to third parties.
s; Q.�Wgs1w \ C.�
vl�.\,�-_
1

Rockingham
NCO04475O
#MULTIVALUE
Jacob's Creek Nursing & Rehabilitation Center
Daily Minimum Milligrams
Not Reached 2012 10 001 DO, Oxygen, Dissolved 10-05-2012 Weekly per Liter 60' -100'
Frequency
Flow, in conduit or thru
Gallons per
Violation
2012
10
001
treatment plant
10-06-2012
Continuous
Day
Million
Frequency
Flow, in conduit or thru
Gallons per
Violation
2012
10
001
treatment plant
10-07-2012
Continuous
Day
Million
Frequency
Flow, in conduit or thru
Gallons per
Violation
2012
10
001
treatment plant
10-13-2012
Continuous
Day
Million
Frequency
Flow, in conduit or thru
Gallons per
Violation
2012
10
001
treatment plant
10-14-2012
Continuous
Day
Million
Frequency
Flow, in conduit or thru
Gallons per
Violation
2012
10
001
treatment plant
10-20-2012
Continuous
Day
Million
Frequency
Flow, in conduit or thru
Gallons per
Violation
2012
10
001
treatment plant
;10-21-2012
Continuous
Day
Million
Frequency
Flow, in conduit or thru
Gallons per
Violation
2012
10
001
treatment plant
10-27-2012
Continuous
Day
Million
Frequency
Flow, in conduit or thru
Gallons per
Violation
2012
10
001
treatment plant
10-28-2012
Continuous
Day

Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record
Facility: _ Q� Pernut/Pipe No.: �UXJ\Ukq.,,�'" MonthlYear n(+
C�
Average Violations
Parameter Permit Limit DMR Value % Over Limit
�Iy
iolations
Date Parameter Permit Lirnit/Type DMR Value % Over Limit
Monitoring Frequency Violations
Date Parameter Permit Frequency Values Reported # of Violations
Other Violations
Completed by: �x Date:
Regional Water Quality za Supervisor Signoff: '� Date: `3
�b�9 0LYJ-Ij

� EFFLUENT
FDES PERMIT NO. NC 0044750 DISCHARGE NO. 001 MONTH October YEAR.' 2
FACILITY NAME Jacob's Creek Nursing Home CLASS II COUNTY Rockin>?ham . �'
CERTIFIED LABORATORIES R & A Laboratories, Inc. CERTIFICATION NO. 34 �-
(List additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC) Clifford Cain GRADE III CERTIFICATION NO. 11237
PERSON(S) COLLECTING SAMPLES Operators ORC PHONE [phone]
CHECK BOX IF ORC HAS CHANGEDn PERSONS&OLLECTING SAMPLIf Operators
Mail ORIGINAL and ON t�
ATTN: CENTRAL FILES � X V
DIVISION OF WATER QUALITY pE� p Zp (SIGNATURE OF &WATOR IN RESPONSIBLE CHARGE) DATE
1617 MAIL SERVICE CENTER BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
RALEIGH, NC 27699-1617 CG�YV�K�Y ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
aE
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Above Name And Units
Below
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a
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weekly
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Weekly
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Copy DWQ Form MR-1 (01/00)

Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements
(including weekly averages, if applicable) Compliant
U
Noncompliant
The permittee shall report to the Director or the appropriate Regional Office any noncompliance that potentially threatens public
health or the environment. Any information shall be provided orally within 24 hours from the time the permitte. became aware of the
circumstances. A written submission shall also be provided within 5 days of the time the permittee becomes aware of the
circumstances. -
If the facility is noncompliant, please attach a list of corrective actions being taken and a time -table for improvements to be
made as required by Part II.E.6 of the NPDES permit.
"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 a qualified personnel properly gather and evaluate the information submitted. 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 there are significant
penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
James IvI C e"ghire (Authorized Aeent
Perini
a (Pl ase rint e
Si ature f Permite * Date
e red unless s bmitted electronically)
1721 Bald Hill Loop Madison NC 336-548-9658 05/31/2017
Permittee Address Phone Number Permit Exp. Date
Certified Laboratory (2)
Certified Laboratory (3)
Certified Laboratory (4)
Certified Laboratory (5)
ADDITIONAL CERTIFIED LABORATORIES
PARAMETER CODES
Certification No.
Certification No.
Certification No.
Certification No.
Parameter Code assistance may be obtained by calling the NPDES Unit at at [phone], or by visiting the Surface Water Protection Section's
web site at h2o.enr.state.nc.us/was and linking to the Unit's information pages.
Use only units of measurement designated in the reporting facility's NPDES permit for reporting data.
* No Flow / Discharge From Site: Check this box if no discharge occurrs and, as a result, there are no data to be entered for all of the
parameters on the DMR for the entire monitoring period.
** ORC On Site? : ORC must visit facility and document visitation of facility as required per 15ANCAC8G.0204.
*** Signature of Permittee: If signed by other than the permitte, then the delegation of the signatory authority must be on file with the state per
15ANCAC213.0506 (b) (2) (D).
Copy DWQ Form MR-1 (01/00)

P11/2013
14:43 336-9960326
R & A LABORATORIES
PAGE 01/12
13 IRESF-.ARCh & ANA[VTICAI
LkORAYORIES, INC.
Arralytir:31.'ProCes!'. Con�,ulr.A4wrv,
FACSIMILE MESSAGE
Date: 1, \U l--�> -
From: �,:L�
Research & AnalyticaYl Laboraatories, Inc.
Telephone [phone]
Fax [phone]
To:
11 f 771 — 4&--!>\
Commc% ts:
Pages to .Fallow:
Mailing Address:
PO Box 473
Ke.rnersville, NC 27285
Shipping Address:
106 Short Street
Kerner.svil.l.e, NC 27284
PC Boy. 473 0 106 Short `-freer 0 Kernersville, North Cbrohno 27284. 0 336/996-2841

PP116r2013 14:43 336-9960326 R & A LABORATORIES PAGE 11f12
EFFLUENT
NPDES PERMIT NO. NC 0044750 DISCHARGE NO. O 1 MONTH October YEAR 2012
FACILITY NAME rlacoWs Creek Nursing Home CLASSII COUNTY Rockingham
CERTIFIED LABORATORIES R & A Laboratories Inc. CERTIFICATION NO. 34
(List additional laboratories on the baekside(page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC) Clifford Cain GRADE III CERTIFICATION NO, 11237
PERSONS) COLLECTING SAMPLES Operators _ - ORC PRONE. 336m9_ -2 41
CHECK ROX iF ORC HAS CHANGED PE4S)CTINGSAMPLES Operators
Mail ORIGINAL and ONE COPY to: t, %_, %fATTN: CENTRAL FILES X ((/DIVISION of WATER QUALITY RATOR IN RESPONSIBLE CIfARGE) DATE
1617 MAIL SERVICE CENTER BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
RALEIGH, NC 27699-1617 ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
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F116/p20p13 14:43 336-9960326 R & A LABORATORIES PAGE 12/12
EFFLUENT
NPDES PERMIT NO. NC 001MO I D1 SCHARGE NO.001 MONTH November YEAR 2012
FACILITY NAME Jaoob's Numi Q H= I CLASS ILL COUNTY Rockingham
CERTIFIED LABORATORIES R & A Laboratorics. Inc. _ _ .— CERTIFICATION NO- 34
(List additional laboratories on the backsidetpar 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC) Cliffor_d_C_ain ORADE II CERTIFICATION NO. 11237
PERSON(S) COLLECTING SAMPLES Operators ORC PHONE [phone]
CHECK BOX IF OR HAS CHANGEDL] PERSON(S) COLLECTING SAMPLES
Mail ORIGINAL and COPY to: �I
ATTN_ CENTRAL FILTS X
DIVISION OF WATER O LITY (SIGNAT .MR ATOR TN RESPONSIBLE CHARGE) DATE
1617 MAR, SERVICE CI; R BY THIS SIGNATURE. I CERTIFY THAT THIS REPORT IS
RALEIGH, NC 276"-16 ACCURATE AND COKPLFTE TO TfM REST OF MY KNOWLEDGE.
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prr"
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
23 October 2012
Jacob's Creek Nursing Center
Attn: Ms. Tonya Hemric
1721 Bald Hill Loop
Madison, NC 27025
Subject: Compliance Evaluation Inspection
NPDES Permit NCO04475
Rockingham County
Dear Ms. Hemric:
Dee Freeman
Secretary
Mr. Mike Thomas of the Winston-Salem Regional Office of the North Carolina Division of Water Quality
conducted a compliance evaluation inspection of the Jacob's Creek facility on 18 October 2012. The assistance
and cooperation Mr. Clifford Cain, Operator in Responsible Charge was greatly appreciated. Inspection
findings are summarized below.
The wastewater treatment plant is located behind the Jacob's Creek facility on corner of Bailey Road and
Bald Hill Loop, in Madison, North Carolina. The plant consists of a comminutor, flow equalization basin, two
aeration basins with diffused aeration, two secondary clarifiers, sand filter, ultra violet disinfection, an effluent
pump station, and an aerobic digester. Treated effluent from the WWTP is discharged to Hogan's Creek, which
is currently classified as Class C waters in the Roanoke River basin.
Site Review
The entire system appears to be very well maintained and clean. Mr. Cain indicated that there is a great
deal of cooperation between himself and the Jacob's Creek staff to ensure that maintenance needs are addressed
as they arise. Maintenance and Operations logs were thorough and up to date at the time of inspection.
The outfall and receiving stream were observed during the inspection. No foam, floating sludge, or other
signs of detrimental impact of the discharge to the receiving stream. The right of way to the stream was in
excellent shape.
Documentation Review
Discharge monitoring reports (DMR) were reviewed and compared with laboratory reports. No mistakes or
transcription errors were noted. Lab data, including chains of custody were reviewed with no discrepancy
found. Mr. Cain performs has the appropriate certifications to conduct all of the field analyses required by the
permit. His records of certification, meter maintenance and calibration were all complete.
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107 One
Phone: [phone] FAX: [phone] Customer Service:1-877-623-6748 NorthCarolina
Internet: www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer

rese
ppreciate your efforts to effectively operate and maintain this treatment system. No additional
to this letter is required. If you have questions regarding the inspection or this letter, please do not
hesitate to contact Mr. Thomas or me at [phone].
Sincerely,
W. Corey Basinger
Regional Supervisor
Surface Water Protection
Winston-Salem Region
Attachments:
1. BIMS Inspection Report
Cc: WSRO — SWP w/ atch
Central Files w/ atch
NPDES West Branch w/ atch

United States Environmental Protection Agency
Form Approved.
Washington, D.C. 20460
EPA
EPA
OMB No. 2040-0057
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 I� 2 15 I 31 NCO044750 111 121f'
12/10/18 117 18I C I 19I S I 20 LJ
Remarks
2111111111I111IIII IIII IIII IIII 1IIIIIIIIII I I I I I I 1 61
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 QA — — — ---- - --- Reserved--------------
67 I 169 70 I I 71 IU 72 (N I 73 LU 74 751 I I I I I I 180
L—
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 permit Number)
Jacob's Creek Nursing &Rehabilitation Center
01:33 PM 12/10/18
12/08/01
Exit Time/Date
Permit Expiration Date
1721 Bald Hill Rd
Madison NC 27025
02:00 PM 12/10/18
17/05/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
Clifford Curtis Cain/ORC/336-996-2841/
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
Toyna Hemric,1721 Bald Hill Loop Madison NC 27025N Contato
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit Flow Measurement .Operations & Maintenance ■ Records/Reports
Self -Monitoring Program Sludge Handling Disposal Facility Site Review Effluent/Receiving Waters
Laboratory
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
Michael S Thomas WSRO WQ///
Sign ture of ManagementReviewer Agency/Office/Phone and Fax Numbers Date
jlye� D(1W 4AS&O 23-ck- -z,,:�,-(Z
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page # 1

NPDES
yr/mo/day
31 NCO044750 I11 121
12/10/18 117
Inspection Type
18 _1
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Page # 2

C0044750
P 0/18/2012
Owner - Facility: Jacob's Creek Nursing & Rehabilitation Center
Inspection Type: Compliance Evaluation
Record Keeping
Yes
No
NA
NE
Are records kept and maintained as required by the permit?
■
❑
❑
❑
Is all required information readily available, complete and current?
■
❑
❑
❑
Are all records maintained for 3 years (lab. reg. required 5 years)?
■
❑
❑
❑
Are analytical results consistent with data reported on DMRs?
■
n
n
❑ ,
Is the chain -of -custody complete?
■
00
n
Dates, times and location of sampling
■
Name of individual performing the sampling
■
Results of analysis and calibration
■
Dates of analysis
■
Name of person performing analyses
■
Transported COCs
■
Permit: N
Ins ection Date: 1
Are DMRs complete: do they include all permit parameters?
■
❑
❑
❑
Has the facility submitted its annual compliance report to users and DWQ?
■
n
n
n
(If the facility is = or > 5 MGD permitted flow) Do they operate 24/7 with a certified operator on each shift?
❑
❑
■
❑
Is the ORC visitation log available and current?
■
❑
❑
❑
Is the ORC certified at grade equal to or higher than the facility classification?
■
❑
❑
❑
Is the backup operator certified at one grade less or greater than the facility classification?
■
❑
❑
❑
Is a copy of the current NPDES permit available on site?
■
❑
❑
❑
Facility has copy of previous year's Annual Report on file for review?
■
❑
❑
❑
Comment:
Permit
Yes No
NA
NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new application?
❑
❑
■
❑
Is the facility as described in the permit?
■
❑
❑
❑
# Are there any special conditions for the permit?
❑
■
❑
❑
Is access to the plant site restricted to the general public?
■
n
❑
❑
Is the inspector granted access to all areas for inspection?
■
In
n
n
Comment:
Laboratory
Yes
No
NA
NE
Are field parameters performed by certified personnel or laboratory?
■
❑
❑
❑
Page # 3

Permit: NCO044750
Inspection Date: 10/18/2012
Owner -Facility: Jacob's Creek Nursing &Rehabilitation Center
Insoection Tvoe: Compliance Evaluation
Laboratory
Are all other parameters(excluding field parameters) performed by a certified lab?
# Is the facility using a contract lab?
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees Celsius)?
Incubator (Fecal Coliform) set to 44.5 degrees Celsius+/- 0.2 degrees?
Incubator (BOD) set to 20.0 degrees Celsius +/- 1.0 degrees?
Comment:
Effluent Sampling
Is composite sampling flow proportional?
Is sample collected below all treatment units?
Is proper volume collected?
Is the tubing clean?
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees Celsius)?
Yes No NA NE
Yes No NA NE
❑ ❑ ■ ❑
■ ❑ ❑ ❑
■ ❑ ❑ ❑
❑ ❑ ■ ❑
❑❑❑■
Is the facility sampling performed as required by the permit (frequency, sampling type representative)? ❑ ❑ ❑ ■
Comment:
Upstream / Downstream Sampling Yes No NA NE
Is the facility sampling performed as required by the permit (frequency, sampling type, and sampling location)? ■ ❑ ❑ ❑
Comment:
Equalization Basins Yes No NA NE
Is the basin aerated? ■ ❑ ❑ ❑
Is the basin free of bypass lines or structures to the natural environment?
■ ❑
❑
❑
Is the basin free of excessive grease?
■ ❑
❑
❑
Are all pumps present?
■ ❑
❑
❑
Are all pumps operable?
■ ❑
❑
❑
Are float controls operable?
■ ❑
❑
❑
Are audible and visual alarms operable?
❑ ❑
■
❑
# Is basin size/volume adequate?
■ ❑
❑
❑
Comment:
Aeration Basins
Yes No
NA
NE
Mode of operation
Ext. Air
Type of aeration system
Diffused
Page # 4

permit: NCO044750 Owner - Facility: Jacob's Creek Nursing & Rehabilitation Center
PInspection Date: 10/18/2012 Inspection Type: Compliance Evaluation
Aeration Basins Yes No NA NE
Is the basin free of dead spots?
Are surface aerators and mixers operational?
Are the diffusers operational?
Is the foam the proper color for the treatment process?
Does the foam cover less than 25% of the basin's surface?
Is the DO level acceptable?
Is the DO level acceptable?(1.0 to 3.0 mg/1)
Comment:
Secondary Clarifier
Is the clarifier free of black and odorous wastewater?
Is the site free of excessive buildup of solids in center well of circular clarifier?
Are weirs level?
Is the site free of weir blockage?
Is the site free of evidence of short-circuiting?
Is scum removal adequate?
Is the site free of excessive floating sludge?
Is the drive unit operational?
Is the return rate acceptable (low turbulence)?
Is the overflow clear of excessive solids/pin floc?
Is the sludge blanket level acceptable? (Approximately'/. of the sidewall depth)
Comment:
Filtration (High Rate Tertiary)
Type of operation:
Is the filter media present?
Is the filter surface free of clogging?
Is the filter free of growth?
Is the air scour operational?
Is the scouring acceptable?
Is the clear well free of excessive solids and filter media?
Yes No NA NE
Yes No NA NE
Down flow
Page # 5

Permit: NC0044750 Owner - Facility: Jacob's Creek Nursing & Rehabilitation Center
Inspection Date: 10/18/2012 Inspection Type: Compliance Evaluation
Filtration (High Rate Tertiary) Yes No NA NE
Comment:
Pumps-RAS-WAS Yes No NA NE
Are pumps in place? ■ ❑ ❑ ❑
Are pumps operational?
■
❑
❑
. ❑
Are there adequate spare parts and supplies on site?
■
❑
❑
❑
Comment:
Flow Measurement - Effluent
Yes
No
NA
NE
# Is flow meter used for reporting?
■
n
❑
❑
Is flow meter calibrated annually?
■
❑
❑
❑
Is the flow meter operational?
■
❑
❑
❑
(If units are separated) Does the chart recorder match the flow meter?
■
n
❑
❑
Comment:
Effluent Pipe
Yes
No
NA
NE
Is right of way to the outfall properly maintained?
■
n
n
❑
Are the receiving water free of foam other than trace amounts and other debris?
■
❑
❑
n
If effluent (diffuser pipes are required) are they operating properly?
n
n
■
n
Comment:
Aerobic Digester
Is the capacity adequate?
Is the mixing adequate?
Is the site free of excessive foaming in the tank?
# Is the odor acceptable?
# Is tankage available for properly waste sludge?
Comment:
Standby Power
Is automatically activated standby power available?
Is the generator tested by interrupting primary power source?
Is the generator tested under load?
Was generator tested & operational during the inspection?
Do the generator(s) have adequate capacity to operate the entire wastewater site?
Yes No NA NE
Yes No NA NE
❑■n❑
■n❑❑
■nn❑
❑ ■ ❑ ❑
■n❑❑
Page # 6

Mpprp,
Permit: NCO044750 Owner - Facility: Jacob's Creek Nursing & Rehabilitation Center
Inspection Date: 10/18/2012 Inspection Type: Compliance Evaluation
Standby Power Yes No NA NE
Is there an emergency agreement with a fuel vendor for extended run on back-up power? ■ 0 Cl Q
Is the generator fuel level monitored?
Comment: No generator test was conducted during the inspection.
Operations & Maintenance
Is the plant generally clean with acceptable housekeeping?
■ ❑ ❑ 0
Yes No NA NE
■000
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable Solids, pH, DO, Sludge ■ ❑ 0
Judge, and other that are applicable?
Comment:
Page # 7

PPPPPPF,
Beverly Eaves Perdu
Governor
NCDENR
North Carolina Department of Environment and
Division of Water Quality
e Charles Wakild, P.E.
Director
JAMES M CHESHIRE
AUTHORIZED AGENT
1721 BALD HILL LOOP
MADISON NC 27025
Dear Mr. Cheshire:
March 6, 2012
Natural Resources
RECEIVED
N.C.Dept. of ENR
MAR 0 8 2012
Winston-Salem
Regional Office
Dee Freeman
Secretary
Subject: Receipt of permit renewal application
NPDES Permit NCO044750
Britthaven of Madison WWTP
Rockingham County
The NPDES Unit received your permit renewal application on November 29, 2011. A member of the
NPDES Unit will review your application. They will contact you if additional information is required to complete
your permit renewal. You should expect to receive a draft permit approximately 30-45 days before your existing
permit expires.
If you have any additional questions concerning renewal of the subject permit, please contact Bob Guerra at
[phone].
Sincerely,
� Z REN 011
Dina Sprinkle
Point Source Branch
cc: CENTRAL FILES
Winston-Salem Regional Office/Surface Water Protection
NPDES Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604 One
Phone: [phone] FAX: [phone] Customer Service:1-877-623-6748 NorthCarolina
Internet: wvuw.ncwaterquality.org �atura!!r�
An Equal Opportunity 1 Affirmative Action Employer

NIFFF,
NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to:
N. C. Department of Environment and Natural Resources
Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit C0044750
If you are completing this form in computer use the TAB key or the up - down arrows to move from one
field to the next. To check the boxes, click your mouse on top of the box. Otherwise, please print or type.
1. Contact Information:
Owner Name
Hillco Ltd.
Facility Name
Jacob's Creek Nursing & Rehabilitation Center
Mailing Address
1721 Bald Hill Loop
City
Madison
State / Zip Code
North Carolina/27025
Telephone Number
[phone]
Fax Number
[phone]
e-mail Address
2. Location of facility producing discharge:
Check here if same address as above
Street Address or State Road
City
State / Zip Code
County
3. Operator Information:
Name of the firm, public organization or other entity that operates the facility. (Note that this is not
referring to the Operator in Responsible Charge or ORC)
Name Research & Analytical Laboratories, Inc.
Mailing Address P.O. Box 473
City Kernersville
State / Zip Code North Carolina/27285
Telephone Number [phone]
Fax Number [phone] r HiNtR18 3o21C1
-.vnn un IHM-MN3O
ttoa s ti noN
g g & 0 �la7t�1
1 of 4 Form-D 1 /06

NPDES APPLICATION - FORM D
PPForppr'ivately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Facility Generating Wastewater(check all that apply):
Industrial
❑
Number of Employees
Commercial
❑
Number of Employees
Residential
❑
Number of Homes
School
❑
Number of Students/Staff
Other
®
Explain: Nursing
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Nursing Home
Population served: 161
S. Type of collection system
❑ Separate (sanitary sewer only) ® Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points 1
Outfall Identification number(s) 001
Is the outfall equipped with a diffuser? ® Yes ❑ No
7. Name of receiving stream(s) (Provide a map showing the exact location of each outfall):
Hogans Creek
8. Frequency of Discharge: ® Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: Duration: _
9. Describe the treatment system
List all installed components, including capacity, provide design removal for BOD, TSS, nitrogen and
phosphorus. If the space provided is not sufficient, attach the description of the treatment system in a
separate sheet of paper.
0.025 Wastewater facility consisting of the following:
-Flow equalization
-Aeration basins
-Clarifiers
-Sand filters
-Chlorine contact chamber with chlorination
-Aerobic digester
2 of 4 Form-D 1 /06

NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0.025 MGD
Annual Average daily flow 0.008 MGD (for the previous 3 years)
Maximum daily flow 0.018 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ® No
12. Effluent Data
Provide data for the parameters listed. Fecal Coliform, Temperature and pH shall be grab samples, for all other
parameters 24-hour composite sampling shall be used. Effluent testing data must be based on at least three samples
and must be no more than four and one half years old.
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Number of
Samples
Biochemical Oxygen Demand
(BOD5)
3.61
<2
mg/ L
48
Fecal Coliform
112
1.57
col/ 100 mis
48
Total Suspended Solids
25.0
3.42
mg/L
48
Temperature (Summer)
29.0
24.6
°C
149
Temperature (Winter)
21.0
14.7
°C
52
pH
8.5
N/A
SU
48
13. List all permits, construction approvals and/or applications:
Type Permit Number Type
Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA) Ocean Dumping (MPRSA)
NPDES NCO044750 Dredge or fill (Section 404 or CWA)
PSD (CAA) Special Order of Consent (SOC)
Non -attainment program (CAA) Other
14. APPLICANT CERTIFICATION
Permit Number
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
James M. Cheshire Authorized Agent
Printed name of Person Signing Title
3 of 4 Form-D 1/06

PPPFor ri ately owned
L
Signa ure " f Applicant
NPDES APPLICATION - FORM D
mn ent systems treating 100% domestic wastewaters <1.0 MGD
Date
North SOolina General Statute 143-215.6 (b)(2) states: Any person who knowingly makes any false statement
representation, or certification in any application, record, report, plan, or other document files or required to be
maintained under Article 21 or regulations of the Environmental Management Commission implementing that Article, or
who falsifies, tampers with, or knowly renders inaccurate any recording or monitoring device or method required to be
operated or maintained under Article 21 or regulations of the Environmental Management Commission implementing
that Article, shall be guilty of a misdemeanor punishable by a fine not to exceed $25,000, or by imprisonment not to
exceed six months, or by both. (18 U.S.C. Section 1001 provides a punishment by a fine of not more than $25,000 or
imprisonment not more than 5 years, or both, for a similar offense.)
4 of 4 Form-D 1 /06

111
II.
W S � 6
RECEIVED
N.C.Dept. of ENR
WASTEWkT1 ER SYSTEM MAR 2 12012
PERFORMANCE ANNUAL REPORT Winston-Salem
2011 Regional Office
General Information
Facility Name:
Responsible Entity:
Contact Person:
Applicable Permit (s)
Jacob's Creek Nursing Home
Darren Bullins
Tonya J. Hemric
NPDES Permit No. NCO044750
Description of collection system or process:
1 15,000 gal. and 1 10,000 gal. extended aeration package plants with clarifier and chlorine
contact chambers going to tiertiary filters to a post aeration tank out to receiving waters.
Performance
Summary of system performance for calendar year 2011:
January 2011 Compliant with effluent limitations
February 2011 Compliant with effluent limitations
March 2011 Compliant with effluent limitations
April 2011 Compliant with effluent limitations
May 2011 Compliant with effluent limitations
June 2011 Compliant with effluent limitations
July 2011 Compliant with effluent limitations
August 2011 Compliant with effluent limitations
September 2011 Compliant with effluent limitations
October 2011 Compliant with effluent limitations _
it
November 2011 Compliant with effluent limitations
V 15 December 2011 Compliant with effluent limitations

III. Notification
Annual notice posted in facility.
IV. Certification
I certify under penalty of law that this report is complete and accurate to the best of my
knowledge.
Darren Bullins
Responsible Person
Maintenance Supervisor
Title
Jacob's Creek Nursing Home
Entity
January 24, 2012
Date

/usorc
Are
NCDENR
North Carolina Department of Environment and Natural
Beverly Eaves Perdue
Governor
Ms. Anne Skow
Britthaven of Madison
1721 Bald Hill Loop
Madison, NC
Dear Permittee:
27025
Division of Water Quality
Coleen H. Sullins
Director
November 7, 2011
RECEIVED
N.C.Dept. of ENR
NOV 21 2011
ResoU 'Ces Winston-Salem
Regional Offloe
Dee Freeman
Secretary
Subject: Renewal Notice
NPDES Permit NCO044750
Britthaven of Madison WWTP
Rockingham County
Your NPDES permit expires on May 31, 2012. Federal (40 CFR 122.41) and North Carolina (15A
NCAC 2H.0105 (e)) regulations state that permit renewal applications must be filed at least 180 days prior
to expiration of the current permit. If you have already mailed your renewal application, you may
disregard this notice.
Your renewal package must be sent to the Division postmarked no later than December 3, 2011.
Failure to request renewal by this date may result in a civil penalty assessment. Larger penalties may be
assessed depending upon the delinquency of the request.
If any wastewater discharge will occur after May 31, 2012, the current permit must be renewed.
Discharge of wastewater without a valid permit would violate North Carolina General Statute 143-215.1;
unpermitted discharges of wastewater may be assessed civil penalties of up to $25,000 per day.
If all wastewater discharge has ceased at your facility and you wish to rescind this permit, contact
me at the telephone number or address listed below.
Use the enclosed checklist to complete your renewal package. The checklist identifies the items you
must submit with the permit renewal application. If you have any questions, please contact me at the
telephone number or e-mail address listed below.
Sincerely,
Charles H. Weaver, Jr.
NPDES Unit
cc: Central Files
Winston-Salem Regional Office, Surface Water Protection
NPDES File
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 One
512 North Salisbury Street, Raleigh, North Carolina 27604 NorthCarolina
Phone: [phone] / FAX [phone] / [e-mail] Naturally
An Equal Opportunity/Affirmative Action Employer — 50%a Recycled/10% Post Consumer Paper

NPDES PERMIT NCO044750
BRITTHAVEN OF MADISON WWTP
ROCKINGHAM COUNTY
The following items are REQUIRED for all renewal packages:
➢ A cover letter requesting renewal of the permit and documenting any changes at the facility since
issuance of the last permit. Submit one signed original and two copies.
➢ The completed application form (copy attached), signed by the permittee or an Authorized
Representative. Submit one signed original and two copies.
➢ If an Authorized Representative (such as a consulting engineer or environmental consultant) prepares
the renewal package, written documentation must be provided showing the authority delegated to any
such Authorized Representative (see Part II.B.1 Lb of the existing NPDES permit).
➢ A narrative description of the sludge management plan for the facility. Describe how sludge (or other
solids) generated during wastewater treatment are handled and disposed. If your facility has no such
plan (or the permitted facility does not generate any solids), explain this in writing. Submit one signed
original and two copies.
The following items must be submitted by any Municipal or Industrial facilities discharging
process wastewater:
Industrial facilities classified as Primary Industries (see Appendices A-D to Title 40 of the Code of Federal
Regulations, Part 122) and ALL Municipal facilities with a permitted flow >_ 1.0 MGD must submit a
Priority Pollutant Analysis (PPA) in accordance with 40 CFR Part 122.21.
The above requirement does NOT apply to privately owned facilities treating 100%
domestic wastewater, or facilities which discharge non process wastewater (cooling
water, filter backwash, etc.)
Send the completed renewal package to:
Mrs. Dina Sprinkle
NC DENR / DWQ / Point Source Branch
1617 Mail Service Center
Raleigh, NC 27699-1617

-
- ��mravtnrIII Madison
A To C No. 044750A01
Issued April 30, 2008
Engineer's Certification
___`--_-----_.---------
RECEIVED
N.C. Deot. of ENR
AUG 0 12011
Winatan-Salem
Regional Ctfice
I, A i ll;an, A. rfo t f , as a duly registered Professional Engineer in
the State of North Carolina, having been authorized to observe (periodically/weekly/full time)
the construction of the modifications and improvements to the Britthaven of Madison WWTP,
located on Bald Hill Loop in Rockingham County for Britthaven of Madison, hereby state that,
to the best of my abilities, due care and diligence was used in the observation of the following
construction:
Installation of an in line UV disinfection system in an insulated enclosure with
audible and visual alarms, spare lamps to be kept on site, and abandonment of a
chlorine disinfection system, in conformity with the project plans, specifications,
and other supporting data subsequently filed and approved by the Department of
Environment and Natural Resources.
I certify that the construction of the above referenced project was observed to be built within
substantial compliance and intent of the approved plans and specifications.
Signature" , _
Registration No. d s 2 2
Date �-� �- • 17 , 20 o 8
GAR0 �10•,
Loans
9. 0, 04%y<9
Send to: Construction Grants &
"'.0
DENR/DWQ
------16--3 Mail Service Ceenter----.-
Raleigh, NC 27699-1633
o .`

Aqua North Carolina, Inc.
A To C No.088854A01
Issued December 15, 2010
Engineer's Certification
��� ��,� %�. , as a duly registered Professional Engineer in
1, weekly/full time)
the State of North Carolina, having been authorized tntsto the Pine oLakes Subdivision s on -Well 92,
the construction of the modifications and improvaeNorth Carolina, Inc., hereby state that, to the
located on Gloria Road in Surry County for Aqua
best of MY abilities, due care and diligence was used in the observation of the following
_
construction:
ite
Installation of a dechlorination system utilizing sodium and pursuant th the e fast
track application received on December 2, 2010, ad in co
Minimum Design Criteria for Dechlorination Facilities.
I certify that the construction of the above referenced project was observed to be built
within substantial compliance and intent of the approved plans and specifications.
Sign,
Date
Send to:
Registration No./- -
Construction Grants & Loans
DENR/DWQ
1633 Mail Service Center
Raleigh, NC 27699-1633
MAR 21 2011
OWUTION G
LOM

14.
Aqua North Carolina, Inc.
A To C No. 088927AOI
Issued O I I
March 28, 2iAX.'t��,.a';�`F:
Engineer's Certification
as a duly registered Professional Engineer in
the State of North Carolina, having
been authorized to obsery (periodicallyfweekly/full time)
ision
the construction of the modifications and improvements oo A Aqua North Carolina, ea ow ubdi�'hereby
Well 41, located on Anthony Road in Guilford County q
state that, to the�best of my abilities, due care and diligence was used in the observation of the
following construction:
Installation of a dechlorination system utilizing5011,ium and in conformitiosulfate y with he the
fast track application received on March 25,
Minimum Design Criteria for Dechlorination Facilities.
I certify that the construction of the above ref re c ed la project sp as o served to be built
within substantial compliance_and intent of the appro p
Signature
Date
Registration No.
Send to: Construction Grants & Loans
DEN R/D W Q
1633 Mail Service Center
Raleigh, NC ?7699-163 3
f1-i. ♦4
* Note: Plastic feed tubing was used in lieu of stainless steel tubing in keeping with approval by
in email from Mr. Seth Robertson to Mr. Scott Smart, dated April 20, 2011.

Thomas, Mike
From:
Basinger, Corey
Sent:
Monday, January 31, 2011 3:44 PM
To:
Scardina, Maureen
Cc:
Thomas, Mike
Subject:
NC0044750 Dec 2010 DMR
Maureen,
The Dec. 2010 DMR for NC0044750 Britt Haven Rest Home is most likely going to be a few days late.
The lab called to let me be aware that their ORC is seriously ill and they were just notified today.
The lab has been contracted by the permittee to take over operation of the facility and will be preparing the DMR as
soon as possible.
I will be in touch as I know more.
Thanks.
Corey
Corey Basinger
Interim Regional Supervisor
Surface Water Protection Section
[e-mail]
NC DENR Division of Water Quality
585 Waughtown Street
Winston-Salem, NC 27107
[phone]
Fax [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.

Nrittlfavew' An v cw,0y o
February 16, 2010
NCDENA
State of North Carolina
Department of Environmental and
Natural Resources
Division of Water Quality
1617 Mail Service Center
Raleigh, N.C. 27699-1617
Dear Sir:
RECEIVED
M - Not. of ENR
FEB 2 2 2010
.=-Salem
Regional Office
Britthaven of Madison
1721 Bald Hill Loop
Madison, North Carolina 27025
Telephone: [phone]
Fax: [phone]
QI OR= @ 12 0
FEB 17 2010
Enclosed is the February 16, 2010 Performance Annual Report for
Britthaven of Madison.
Sincerely,
1Fonya c is
Administrator

Performance Annual Report
L General Information
Facility/System Name: Britthaven of Madison
Responsible Entity: Larry A. Bryant 4336 548-9658 .
Person in Charge/Contact: Tonga J. Hemric
Applicable Permit(s): N C0044750
Oper. Li,c. # 6839
description of Collection System or Treatment Process:
1 15,000- gal. and 1 10,000 gal. extended aeration package plants
with clarifier and chlorine contact chambers going to tiertary filters \
1-n a nn.Gt- aPrabnn tank out to receivinq waters.
Text Summaryof System Performance for Calendar Year - 2Q09 ,
There were no violations on our mdnitoring of the systems for 2009.
List (by month) any violations of permit conditions or other environmental regulations. Monthly
lists should include discussion of any environmental impacts and corrective measures taken to
address violations.

PPPPPP_
Etc.
III. Notification
State how this report has been made available to users or customers of the system and how those
users have been notified of its availability.
This report is posted on a bulletin board made visible to our residents
and empl.yees.
IV. Certification
I certify under penalty of law that this report is complete and accurate to the best of my
knowledge. I further certify that this report has been made available to the users or customers of
the named system and that thoseusers have been notified of its availability.
Resp nsibl erson Date
.Title Maintenance Supervisor
Entity

Water Resources
ENVIRONMENTAL QUALITY
November 30, 2015
Toyna Hemric, Administrator
Granite Falls Ltc LLC
1721 Bald Hill Loop
Madison, NC 27025
Subject: NOTICE OF VIOLATION (NOV-2015-LV-0758)
NPDES Permit No. NCO044750
Jacob's Creek Nursing & Rehabilitation Center
Rockingham County
Dear Ms. Hemric:
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Director
A review of Jacob's Creek Nursing & Rehabilitation Center's monitoring report for July 2015
showed the following violations:
Parameter
Date
Limit Value
Reported Value
Limit Type
Coliform, Fecal MF, M-
7/8/2015
400.000
600.000 #/100m1
Daily Maximum
FC Broth,44.5C
#/100m1
Exceeded
Coliform, Fecal MF, M-
7/15/2015
400.000
2,600.000
Daily Maximum
FC Broth,44.5C
#/100m1
#/100m1
Exceeded
Remedial actions, if not already implemented, should be taken to correct the above noncompliance
problem. Please be aware that violations of your NPDES permit could result in enforcement action
by the Division of Water Resources for this and any additional violations of State law.
If you have any questions regarding this letter, please contact Lon Snider or me at the letterhead
address or phone number, or by email at lon.sniderkncdenr.gov or sherri.knightkncdenr.gov_.
cc: WSRO
Sincerely,
Sherri V. Knight, P. E.
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ — WSRO
450 W. Hanes Mill Road, Suite 300, Winston-Salem, North Carolina 27105
Phone: [phone] FAX: [phone] Customer Service 1-877-623.6748
Internet. www.ncdenr.gov - www.ncwater.org

DMR Review Record
Facility: �4td, �ez�C l�.rls�n�, Permit No.: NC-OOLq �5 C� Pipe No.: CL) t MonthNear:
Monthly Average Violations
Parameter Permit Limit DMR Value % Over Limit Action
Date Parameter
Permit Limit
--car
Li c:
-iS -tip I
�tw,
Date Parameter
Violations/Staff Remarks:
Weekly/Daily Violations
Limit Type DMR Value
i
Monitoring Frequency Violations
Permit Frequency Values Reported
'z,- ' t- J
Supervisor Remarks: N a V
Completed by:�
Assistant Regional
Supervisor Sign Off: �.
Regional Supervisor Sign
Off:
% Over Limit
S
SS a
# of Violations
Date: rl ,s
Action
.NLy
Action
Date: I ( I & f 17
Date:

EFFLUENT I/
NPDES PERMIT NO. NC 0044750 DISCHARGE NO.001 MONTH July YEAR 2015
FACILITY NAME Jacob's Creek Nursing Home CLASS II COUNTY Rockingham
CERTIFIED LABORATORIES R & A Laboratories, Inc. CERTIFICATION NO. 34
(List additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC) Clifford Cain GRADE III CERTIFICATION NO. 11237
PERSON(S) COLLECTING SAMPLES Operators ORC PHONE [phone]
CHECK BOX IF ORC HAS CHANGED PERSON(S) COLLECTING SAMPLES Operators
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES Ell:
DIVISION OF WATER QUALITY I-
1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617
,,C7 (SIGNATURE OF bPL'{ATOR IN RESPONSIBLE CHARGE) -ILIA Er ENR
By THIS
ACCURATE AND T OMP COMPLETE TO THE B, I CERTIFY THATEST THIS
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Copy DWQ Form MR-1 (01/00)

IIESEARCH Ol ANALY 1 ICAL
LABORATORIES, INC.
Analytical/Process Consultations
Re: Jacob's Creek — July 2015 Fecal Colifonn
Since June 3`d I had to replace the bulbs again on August 13d', therefore we believe that
the bulb that was replaced in June was defective.
-Clifford Cain, ORC
P.O. Box 473 • 106 Short Street • Kernersville, North Carolina 27284 • 336-996-2B41 • Fax [phone]
www.randalabs.com

Water Resources
ENVIRONMENTAL QUALITY
November 30, 2015
Toyna Hemric, Administrator
Granite Falls Ltc LLC
1721 Bald Hill Loop
Madison, NC 27025
Subject: NOTICE OF DEFICENCY (NOD-2015-LV-0149)
NPDES Permit No. NCO044750
Jacob's Creek Nursing & Rehabilitation Center
Rockingham County
Dear Ms. Hemric:
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Director
A review of Jacob's Creek Nursing & Rehabilitation Center's monitoring report for June 2015
showed the following violations:
Parameter
Date
Limit Value
Reported Value
Limit Type
Coliform, Fecal MF, M-
FC Broth,44.5C
6/9/2015
400.000
#/100ml
580.000 #/100ml
Daily Maximum
Exceeded
Remedial actions, if not already implemented, should be taken to correct the above noncompliance
problem. Please be aware that violations of your NPDES permit could result in enforcement action
by the Division of Water Resources for this and any additional violations of State law.
If you have any questions regarding this letter, please contact Lon Snider or me at the letterhead
address or phone number, or by email at Ion. snider(,ncdenr.gov or sherri.knight&ncdenr.gov.
cc: WSRO
Sincerely,
ATE Y
Sherri V. Knight, P. E.
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ — WSRO
450 W. Hanes Mill Road, Suite 300, Winston-Salem, North Carolina 27105
Phone: [phone] FAX: [phone] Customer Service 1-877-623-6748
Internet: www.ncdenr.gov - www.ncwater.org

Facility: �..c� CrL
DMR Review Record
Permit No.: ��Cp Pipe No.:
Monthly Average Violations
Permit Limit DMR Value
Cam=
Month[Year:
% Over Limit
Action
Weekly/Daily Violations
Date Parameter Permit Limit Limit Type DMR Value % Over Limit ��Action
Date Parameter
Other Violations/Staff Remarks:
Supervisor Remarks: N v ()
Completed by:
Monitoring Frequency Violations
Permit Frequency Values Reported # of Violations Action
Assistant Regional
Supervisor Sign Off: "J
Regional Supervisor Sign
Off:
Date: 1l 3 '
Date: I I L / (,'
Ls -
Date:

OA
AUG 2 6 Z015 EFFLUENT
v
NPDES PERMIT NO. NC 0044750 DISCHARGE NO.001 MONTH June YEAR 2015
FACILITY NAME Jacob's Creek Nursing Home CLASS H COUNTY Rockingham
CERTIFIED LABORATORIES R & A Laboratories, Inc. CERTIFICATION NO. 34
(List additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC) Clifford Cain GRADE III CERTIFICATION NO. 11237
PERSON(S) COLLECTING SAMPLES Operators ORC PHONE [phone]
CHECK BOX IF ORC HAS CHANGED PERSON(S)fOLLECTING SAMPLES Operators
Mail ORIGINAL and ONE RECEIVE ! % �Z �l
ATTN: CENTRAL FILES N.C.Dept. of 1R X 7
DIVISION OF WATER QUAL SEP (SIGNATURE OPERATOR IN RIZSPONSIBLE CHARGE) DATE
1617 MAIL SERVICE CENTE $ BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
RALEIGH, NC 27699-1617 Winston Sa m ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
Re ional0 .ce
50050
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50060
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jp/F@sm�
Copy DWQ Form MR-1 (01/00)

PPV
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
December 23, 2009
EDEC
R
5521 09Mr. Larry A. Bryant Britthaven of Madison
1721 Bald Hill Loop
Madison, NC 27025-
SUBJECT: Wastewater/Groundwater Laboratory Certification Renewal
FIELD PARAMETERS ONLY
Dear Mr. Bryant:
The Department of Environment and Natural Resources, in accordance with the provisions of NC GS 143-215-
.3 (a) (10), 15 NCAC 2H .0800, is pleased to renew certification for your laboratory to perform specified
environmental analyses required by EMC monitoring and reporting regulations 15 NCAC 2B .0500, 2H .0900 and
2L .0100, .0200, .0300, and 2N .0100 through .0800.
Enclosed for your use is a certificate describing the requirements and limits of your certification. Please review
this certificate to insure that your laboratory is certified for all parameters required to properly meet your
certification needs.
Please contact us at 919-733-3908 if you have questions or need additional information.
Sincerely
Pat Donnelly
Certification Branch Manager
Laboratory Section
Enclosure
cc: Ramon Cook
Dana Satterwhite
Winston - Salem Regional Office
DENR DWQ Laboratory Section NC Wastewater/Groundwater Laboratory Certification Branch
1623 Mail Service Center, Raleigh, North Carolina 27699-1623
Location: 4405 Reedy Creek Road. Raleigh, North Carolina 27607-6445
Phone: [phone] FAX: [phone]
Internet: www.dwqlab.org
An Equal Opportunity \ Affirmative Action Employer Customer Service: 1-877-623-6748 www.ncwaterquality.org
Nne
orthCarohna
Naturallrf

STATE OF NORTH CAROLINA DEPARTMENT OF THE
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
LABORATORY CERTIFICATION PROGRAM
In accordance with the provisions of N.C.G.S. 143-215.3 (a) (1), 143-215.3 (a)(10) and NCAC 2H.0800:
2010
BRITTHAVEN OF MADISON
Is hereby certified to perform environmental analysis as listed on Attachment I and report monitoring data to DWQ for
compliance with NPDES effluent, surface water, groundwater, and pretreatment regulations.
By reference 15A NCAC 2H .0800 is made a part of this certificate.
This certificate does not guarantee validity of data generated, but indicates the methodology, equipment, quality control procedures,
records, and proficiency of the laboratory have been examined and found to be acceptable.
This certificate shall be valid until December 31, 2010
Certificate N 5521 V
r
Pat Donnelly

Lab Name: Britthaven of Madison
Address: 1721 Bald Hill Loop
Madison, NC 27025-
Attachment I
North Carolina Wastewater/Groundwater Laboratory Certification
Certified Parameters Listing
Certificate Number: 5521
Effective Date: 01 /01 /2010
Expiration Date: 12/3112010
Date of Last Amendment:
The above named laboratory, having duty met the requirements of 15A NCAC 2H.0800, is hereby certified for the measurement of the parameters listed below.
CERTIFIED PARAMETERS
INORGANICS
DISSOLVED OXYGEN
Std Method 4500 O G
pH
Std Method 4500 H B
TEMPERATURE
Std Method 2550B
J
This certification requires maintance of an acceptable quality assurance program, use of approved methodology, and satisfactory performance on evaluation samples. Laboratories are
subject to civil penalties and/or decertification for infractions as set forth in 15A NCAC 2H.0807.

Tonya Hemric
Britthaven of Madison
1721 Bald Hill Loop
Madison, NC 27025
March 9, 2009
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Winston Salem Regional Office
585 Waughtown Street
Winston Salem, NC 27107
To whom it may concern:
RECEI- yEp --�
N.C. Deot. of ENR
MAR 1 12009
Winston-Salem
Regional Office
This letter is to inform you that I, Tonya Hemric, am the new administrator as of March,
2008. Please note this change in your records and when sending information, such as
inspection information, etc. Thank you for your cooperation.
Sincerely,
4nya He i
Adminis or
me
n

LTIFAA
FF An
NCDENR .
North Carolina Department of Environment and Natural
Division of Water Quality
Beverly Eaves Perdue Colleen H. Sullins
Governor Director
4 March 2009
Ms. Anne Skow
Britthaven of Madison
1721 Bald Hill Loop
Madison, NC 27025
SUBJECT: Compliance Evaluation Inspection
NPDES Permit NCO044750
Britt Haven of Madison Wastewater Treatment Plant
Rockingham County
Dear Ms. Skow:
Resources
Dee Freeman
Secretary
Mr. Ron Boone of the Winston-Salem Regional Office (WSRO) of the NC Division of Water
Quality (DWQ or Division) conducted a compliance evaluation inspection (CEI) of the Britt Haven
of Madison wastewater treatment plant (WWTP) on 25 February 2009.. The assistance and
cooperation of Mr. Larry Bryant, Operator in Responsible Charge (ORC), was greatly
appreciated. Inspection findings are summarized below and an inspection report is attached for
your records.
2. The plant is located behind (north of) the Britt Haven of Madison building, on the northeast corner
of Bailey Road and Bald Hill Loop Road, in Madison, Rockingham County, North Carolina. The
plant currently consists of a comminutor, flow equalization basin, two aeration basins with
diffused aeration, two secondary clarifiers, a sand filter, ultraviolet (UV) disinfection, an effluent
pump station and an aerobic digester. The plant description in the permit needs to be updated to
list both the comminutor and the new UV disinfection system, which was installed in January
2008 according to Mr. Bryant. Please ensure this is accomplished when you submit the renewal
application during the next permit renewal cycle. Additionally, the Division never received the
signed engineer's certification for the installation of the UV system. Please provide the engineer's
certification along with your reply to this letter. Treated effluent from the WWTP is discharged to
Hogan's Creek, which is currently classified as Class C waters in the Roanoke River basin.
SITE REVIEW
3. The entire system appears to be well maintained. No operational or maintenance issues were
noted during the inspection. Mr. Bryant stated, that the aerobic digester is monitored and pumped
periodically based on the solids content of the sludge. Records of sludge removal are kept in Britt
Haven's administrative offices.
4. The plant was not discharging during the inspection. The outfall and receiving stream were
evaluated. There was no foam, floating solids or other signs of detrimental impact of the
discharge to the receiving stream. The right-of-way to the stream is well maintained.
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107 One
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748 NorthCarolina
Internet: www.ncwaterquality.org Natura!!r�
An Equal Opportunity 1 Affirmative Action Employer

Ms. Anne Skow
Britt Haven of Madison Wastewater Treatment Plant
NPDES Permit NCO044750
Page2 of 2
DOCUMENTATION REVIEW
5. Mr. Bryant's operator visitation records were reviewed and found to be complete and current. Mr.
Bryant has various logs that he uses to record different items. It was suggested that he combine
these logs into one bound type book that he could use for his operation/maintenance (O&M)
logbook. He currently does not have a specific O&M logbook as required. Please note that,
although this is the ORC's responsibility, Britt Haven of Madison is ultimately responsible for all
such records. Should the operation of the facility change to another operator at any time in the
future, Britt Haven must retain all O&M records.
6. Discharge monitoring reports (DMR) were reviewed and compared with laboratory reports. No
mistakes or transcription errors were noted. At Mr. Bryant's request, Research and Analytical
Laboratories (R&A) currently performs all field and non -field analyses required by the permit. Britt
Haven does have a field lab certification though, which allows Mr. Bryant to perform the field tests
for pH, temperature and dissolved oxygen. All lab data, including chains of custody (COC), were
reviewed. Only one discrepancy was noted on the COCs; Mr. Bryant's copies of the COC's do
not contain the signature of the individual from R&A to which he relinquishes the samples. Mr.
Bryant stated that he does not normally obtain this copy from them when he drops off the
samples at the laboratory. He was advised that he must begin getting the signed copy of the
COC from the lab when he delivers the samples.
7. No reply to this letter is necessary at this time. If you or Mr. Bryant needs assistance or if you
have questions regarding the inspection or this letter, please contact Mr. Boone or me at
[phone].
Sincerely,
Steve W. Tedder
Water Quality Regional Supervisor
Winston-Salem Region
Division of Water Quality
Attachments:
BIMS Inspection Checklist
CC: Central Files w/ atchs
NPDES West Unit w/ atchs
WSRO/SWP Files w/ atchs
L&V-t-Y A, 9,YCIVN.
115 HW o�re1Q
f aj I- N c ;?`7 z s
L7

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 INI 2 U 51 3I NCO044750 111 12I 09/02/25 117 181 C 191.1 201LI
L-J u U U
Remarks
21IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII111111IIII__H6
Inspection Work Days Facility Self -Monitoring Evaluation Rating 81 CA ----------------------- --Reserved ----------- —---- ---
67I 169 70 U 71 IJ 72 (N ( 73 LU 74 751 I I I I I I 180
�--�
Section B: FacilityData
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
Entry Time/Date
Permit Effective Date
POTW name and NPDES permit Number)
09:00 AM 09/02/25
07/06/01
Britthaven of Madison WWTP
Exit Time/Date
Permit Expiration Date
1721 Bald Hill Rd
Madison NC 27025
11:00 AM 09/02/25
12/05/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
Larry A Bryant//910-548-9658 /
Larry A Bryant/ORC/910-548-9658/
Name, Address of Responsible Official/Title/Phone and Fax Number
Anne Skow,1721 Bald Hill Loop Madison NC Contacted
27025//336-548-9658/3365481299 No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit Flow Measurement Operations & Maintenance Records/Reports
Self -Monitoring Program Sludge Handling Disposal Facility Site Review Effluent/Receiving Waters
Laboratory
Section D: Summary of Find in/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
WSRO WQ//704-663-1699 Ext.2202/
Ron Boone X-C
Signature QA Revie r Agency/Office/Phone and Fax Numbers Date
�Manent
, 3-G—Of
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page # 1

NPDES
yr/mo/day
31 N00044750 I11 121
09/02/25 1
17
InspecUon Type
18, _,
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Please refer to inspection summary letter.
Page # 2

Permit: NCO044750 Owner - Facility: Britthaven of Madison WWTP
Inspection Date: 02/25/2009 Inspection Type: Compliance Evaluation
Record Keeping Yes No NA NE
Are records kept and maintained as required by the permit? ❑ ■ ❑ ❑
Is all required information readily available, complete and current? ❑ ■ ❑ ❑
Are all records maintained for 3 years (lab. reg. required 5 years)?
■
❑ ❑
❑
Are analytical results consistent with data reported on DMRs?
■
❑
❑
❑
Is the chain -of -custody complete?
❑
■
❑
❑
Dates, times and location of sampling
■
Name of individual performing the sampling
■
Results of analysis and calibration
Dates of analysis
■
Name of person performing analyses
■
Transported COCs
■
Are DMRs complete: do they include all permit parameters?
■
❑
❑
❑
Has the facility submitted its annual compliance report to users and DWQ?
❑
0
❑
(If the facility is = or > 5 MGD permitted flow) Do they operate 24/7 with a certified operator on each shift?
❑
❑
■
❑
Is the ORC visitation log available and current?
■
❑
❑
❑
Is the ORC certified at grade equal to or higher than the facility classification?
■
❑
0
❑
Is the backup operator certified at one grade less or greater than the facility classification?
■
❑
❑
❑
Is a copy of the current NPDES permit available on site?
■
❑
❑
❑
Facility has copy of previous year's Annual Report on file for review?
❑
❑
■
❑
Comment: Please refer to inspection summary letter.
Permit
Yes
No
NA
NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new application?
❑
❑
■
❑
Is the facility as described in the permit?
❑
■
❑
❑
# Are there any special conditions for the permit?
❑
■
❑
❑
Is access to the plant site restricted to the general public?
■
❑
❑
❑
Is the inspector granted access to all areas for inspection?
■
❑
❑
❑
Comment: Please refer to inspection summary letter.
Laboratory
Yes
No
NA
NE
Are field parameters performed by certified personnel or laboratory?
■
❑
❑
❑
Page # 3

Permit: NCO044750
Inspection Date: 02/25/2009
Owner - Facility: Britthaven of Madison WWTP
Inspection Type: Compliance Evaluation
11
Laboratory
Yes
No
NA NE
Are all other parameters(excluding field parameters) performed by a certified lab?
0
❑
❑ ❑
# Is the facility using a contract lab?
0
❑
❑ ❑
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees Celsius)?
❑
❑
❑ ■
Incubator (Fecal Coliform) set to 44.5 degrees Celsius+/- 0.2 degrees?
❑
❑
❑ E
Incubator (BOD) set to 20.0 degrees Celsius +/- 1.0 degrees?
❑
❑
❑ 0
Comment: Please refer to inspection summary letter.
Effluent Sampling
Yes
No
NA NE
Is composite sampling flow proportional?
❑
❑
0 ❑
Is sample collected below all treatment units?
m
❑
❑ ❑
Is proper volume collected?
0
❑
❑ ❑
Is the tubing clean?
❑
❑
0 ❑
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees Celsius)?
❑
❑
❑ N
Is the facility sampling performed as required by the permit (frequency, sampling type representative)? ❑ -
Is the basin free of bypass fines or structures to the natural environment?
0 ❑ ❑ ❑
Is the basin free of excessive grease?
0 ❑ ❑ ❑
Are all pumps present?
0 ❑ ❑ ❑
Are all pumps operable?
0 ❑ ❑ ❑
Are float controls operable?
E ❑ ❑ ❑
Are audible and visual alarms operable?
❑ ❑ E ❑
# Is basin size/volume adequate?
E ❑ ❑ ❑
Comment: Please refer to inspection summary letter.
Aeration Basins
Yes No NA NE
Mode of operation
Ext. Air
Type of aeration system
Diffused
Page # 4

PF
Permit: NCO044750 Owner - Facility: Britthaven of Madison WWTP
Inspection Date: 02/25/2009 Inspection Type: Compliance Evaluation
Aeration Basins Yes No NA NE
Is the basin free of dead spots? ■ ❑ ❑ ❑
Are surface aerators and mixers operational?
0000
Are the diffusers operational?
■
❑
❑
❑
Is the foam the proper color for the treatment process?
■
❑
❑
❑
Does the foam cover less than 25% of the basin's surface?
■
❑
❑
❑
Is the DO level acceptable?
❑
❑
❑
■
Is the DO level acceptable?(1.0 to 3.0 mg/1)
❑
❑
❑
■
Comment: Please refer to inspection summary letter.
Secondary Clarifier
Yes
No
NA
NE
Is the clarifier free of black and odorous wastewater?
■
❑
❑
❑
Is the site free of excessive buildup of solids in center well of circular clarifier?
❑
❑
■
❑
Are weirs level?
■
❑
❑
❑
Is the site free of weir blockage?
■
❑
❑
❑
Is the site free of evidence of short-circuiting?
■
❑
❑
❑
Is scum removal adequate?
■
❑
❑
❑
Is the site free of excessive floating sludge?
■
❑
❑
❑
Is the drive unit operational?
❑
❑
■
❑
Is the return rate acceptable (low turbulence)?
■
❑
❑
❑
Is the overflow clear of excessive solids/pin floc?
■
❑
❑
❑
Is the sludge blanket level acceptable? (Approximately'/. of the sidewall depth)
■
❑
❑
❑
Comment: Please refer to inspection summary letter.
Filtration (High Rate Tertiary)
Yes
No
NA
NE
Type of operation:
Down flow
Is the filter media present?
■
❑
❑ ❑
Is the filter surface free of clogging?
■
❑
❑ ❑
Is the filter free of growth?
■
❑
❑ ❑
Is the air scour operational?
❑
❑
■ ❑
Is the scouring acceptable?
❑
❑
■ ❑
Is the clear well free of excessive solids and filter media?
■
❑
❑ ❑
Page # 5

Permit: NC0044750
Inspection Date: 02/25/2009
Owner - Facility: Britthaven of Madison WWTP
Inspection Type: Compliance Evaluation
11
Filtration (High Rate Tertiary)
Yes
No
NA NE
Comment: Please refer to inspection summary letter.
Pumps-RAS-WAS
Yes
No
NA NE
Are pumps in place?
■
❑
❑ ❑
Are pumps operational?
■
❑
❑ ❑
Are there adequate spare parts and supplies on site?
■
❑
❑ ❑
Comment: Please refer to inspection summary letter.
Disinfection - UV
Yes
No
NA NE
Are extra UV bulbs available on site?
■
❑
❑ ❑
Are UV bulbs clean?
■
❑
❑ ❑
Is UV intensity adequate?
■
❑
Q ❑
Is transmittance at or above designed level?
■
❑
❑ ❑
Is there a backup system on site?
■
❑
❑ ❑
Is effluent clear and free of solids?
■
❑
❑ ❑
Comment: Please refer to inspection summary letter.
Flow Measurement - Effluent
Yes
No
NA NE
# Is flow meter used for reporting?
■
❑
❑ ❑
Is flow meter calibrated annually?
❑
■
❑ ❑
Is the flow meter operational?
■
❑
❑ ❑
(if units are separated) Does the chart recorder match the flow meter?
❑
❑
■ ❑
Comment: Please refer to inspection summary letter. Water meter from well house
that serves home is used for reporting flow.
Pump Station - Effluent
Yes
No
NA NE
Is the pump wet well free of bypass lines or structures?
■
❑
❑ ❑
Are all pumps present?
■
❑
❑ ❑
Are all pumps operable?
■
❑
❑ ❑
Are float controls operable?
■
❑
❑ ❑
Is SCADA telemetry available and operational?
❑
■
❑ ❑
Is audible and visual alarm available and operational?
■
❑
❑ ❑
Comment: Please refer to inspection summary letter.
Effluent Pipe
Yes
No
NA NE
Page # 6

Permit: NCO044750
inspection Date: 02/25/2009
Owner - Facility: Britthaven of Madison WWTP
Inspection Type: Compliance Evaluation
Effluent Pipe
Yes
No
NA
NE
is right of way to the outfall properly maintained?
■
❑
❑
❑
Are the receiving water free of foam other than trace amounts and other debris?
■
❑
❑
❑
If effluent (diffuser pipes are required) are they operating properly?
❑
❑
■
❑
Comment: Please refer to inspection summary letter.
Aerobic Digester
Yes
No
NA
NE
Is the capacity adequate?
■
❑
❑
❑
Is the mixing adequate?
■
❑
❑
❑
Is the site free of excessive foaming in the tank?
■
❑
❑
❑
# Is the odor acceptable?
■
❑
❑
❑
# Is tankage available for properly waste sludge?
■
❑
❑
❑
Comment: Please refer to inspection summary letter.
Standby Power
Yes
No
- NA
NE
Is automatically activated standby power available?
❑
■
. ❑
❑
Is the generator tested by interrupting primary power source?
❑
■
❑
❑
Is the generator tested under load?
■
❑
❑
❑
Was generator tested & operational during the inspection?
❑
■
❑
❑
Do the generator(s) have adequate capacity to operate the entire wastewater site?
■
❑
❑
❑
Is there an emergency agreement with a fuel vendor for extended run on back-up power?
■
❑
❑
❑
Is the generator fuel level monitored?
■
❑
❑
Comment: Please refer to inspection summary letter.
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? ■ ❑ ❑ ❑
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable Solids, pH, DO, Sludge ■ ❑ ❑ ❑
Judge, and other that are applicable?
Comment: Please refer to inspection summary letter.
Page # 7

f4'_K t
NCDENR .
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
4 March 2009
Ms. Anne Skow
Bdtthaven of Madison
1721 Bald Hill Loop
Madison, NC 27025
SUBJECT: Compliance Evaluation Inspection
NPDES Permit NCO044750
Britt Haven of Madison Wastewater Treatment Plant
Rockingham County
Dear Ms. Skow:
Dee Freeman
Secretary
Mr. Ron Boone of the Winston-Salem Regional Office (WSRO) of the NC Division of Water
Quality (DWQ or Division) conducted a compliance evaluation inspection (CEI) of the Britt Haven
of Madison wastewater treatment plant (WWTP) on 25 February 2009.. The assistance and
cooperation of Mr. Larry Bryant, Operator in Responsible Charge (ORC), was greatly
appreciated. Inspection findings are summarized below and an inspection report is attached for
your records.
2. The plant is located behind (north of) the Britt Haven of Madison building, on the northeast corner
of Bailey Road and Bald Hill Loop Road,in Madison, Rockingham County, North Carolina. The
plant currently consists of a comminutor, flow equalization basin, two aeration basins with
diffused aeration, two secondary clarifiers, a sand filter, ultraviolet (UV) disinfection, an effluent
pump station and an aerobic digester. The plant description in the permit needs to be updated to
list both the comminutor and the new UV disinfection system, which was installed in January
2008 according to Mr. Bryant. Please ensure this is accomplished when you submit the renewal
application during the next permit renewal cycle. Additionally, the Division never received the
signed engineer's certification for the installation of the UV system. Please provide the engineer's
certification along with your reply to this letter. Treated effluent from the WWTP is discharged to
Hogan's Creek, which is currently classified as Class C waters in the Roanoke River basin.
SITE REVIEW
3. The entire system appears to be well maintained. No operational or maintenance issues were
noted during the inspection. Mr. Bryant stated. that the aerobic digester is monitored and pumped
periodically based on the solids content of the sludge. Records of sludge removal are kept in Britt
Haven's administrative offices.
4. The plant was not discharging during the inspection. The outfall and receiving stream were
evaluated. There was no foam, floating solids or other signs of detrimental impact of the
discharge to the receiving stream. The right-of-way to the stream is well maintained.
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107 One
Phone: [phone] \ FAX: [phone] \ Customer Service:1-877-623-6748 NorthCarohna
Internet: www.ncwaterquality.org
Njatura!lY
An Equal Opportunity \ Affirmative Action Employer

Ms. Anne Skow
Britt Haven of Madison Wastewater Treatment Plant
NPDES Permit NCO044750
Page2 of 2
DOCUMENTATION REVIEW
5. Mr. Bryant's operator visitation records were reviewed and found to be complete and current. Mr.
Bryant has various logs that he uses to record different items. It was suggested that he combine
these logs into one bound type book that he could use for his operation/maintenance (O&M)
logbook. He currently does not have a specific O&M logbook as required. Please note that,
although this is the ORC's responsibility, Britt Haven of Madison is ultimately responsible for all
such records. Should the operation of the facility change to another operator at any time in the
future, Britt Haven must retain all O&M records.
6. Discharge monitoring reports (DMR) were reviewed and compared with laboratory reports. No
mistakes or transcription errors were noted. At Mr. Bryant's request, Research and Analytical
Laboratories (R&A) currently performs all field and non -field analyses required by the permit. Britt
Haven does have a field lab certification though, which allows Mr. Bryant to perform the field tests
for pH, temperature and dissolved oxygen. All lab data, including chains of custody (COC), were
reviewed. Only one discrepancy was noted on the COCs; Mr. Bryant's copies of the COC's do
not contain the signature of the individual from R&A to which he relinquishes the samples. Mr.
Bryant stated that he does not normally obtain this copy from them when he drops off the
samples at the laboratory. He was advised that he must begin getting the signed copy of the
COC from the lab when he delivers the samples.
7. No reply to this letter is necessary at this time. If you or Mr. Bryant needs assistance or if you
have questions regarding the inspection or this letter, please contact Mr. Boone or me at
(336)7,71-5000.
Sincerely,
A; e�'11__
Steve W. Tedder
Water Quality Regional Supervisor
Winston-Salem Region
Division of Water Quality
Attachments:
BIMS Inspection Checklist
CC: Central Files w/ atchs
NPDES West Unit w/ atchs
WSRO/SWP Files w/ atchs
3110}tim„y-
M�,�Q sow J N ;2-7U.2 6

s
Permit: NCO044750 Owner - Facility: Britthaven of Madison WWTP
Inspection Date: 02/25/2009 Inspection Type: Compliance Evaluation
Effluent Pipe
Yes
No
NA NE
Is right of way to the outfall properly maintained?
■
❑
❑ ❑
Are the receiving water free of foam other than trace amounts and other debris?
■
❑
❑ ❑
If effluent (diffuser pipes are required) are they operating properly?
❑
❑
■ ❑
Comment: Please refer to inspection summary letter.
Aerobic Digester
Yes
No
NA NE
Is the capacity adequate?
■
❑
❑ ❑
Is the mixing adequate?
■
❑
❑ ❑
Is the site free of excessive foaming in the tank?
■
❑
❑ ❑
# Is the odor acceptable?
■
❑
❑ ❑
# Is tankage available for properly waste sludge?
■
❑
❑ ❑
Comment: Please refer to inspection summary letter.
Standby Power
Yes
No NA NE
Is automatically activated standby power available?
❑
■
-❑ ❑
Is the generator tested by interrupting primarypower source?
❑
■
❑ ❑
Is the generator tested under load?
■
❑
❑ ❑
Was generator tested & operational during the inspection?
❑
■
❑ ❑
Do the generator(s) have adequate capacity to operate the entire wastewater site?
■
❑
❑ ❑
Is there an emergency agreement with a fuel vendor for extended run on back-up power?
■
❑
❑ ❑
Is the generator fuel level monitored?
■
0
❑ ❑
Comment: Please refer to inspection summary letter.
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? ■ ❑ ❑ ❑
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable Solids, pH, DO, Sludge ■ ❑ ❑ ❑
Judge, and other that are applicable?
Comment: Please refer to inspection summary letter.
Page # 7

Permit: NCO044750 Owner - Facility: Britthaven of Madison WWTP
Inspection Date: 02/25/2009 Inspection Type: Compliance Evaluation
Aeration Basins
Yes
No NA NE
Is the basin free of dead spots?
■
0 0 Q
Are surface aerators and mixers operational?
Q
Q ■ Q
Are the diffusers operational?
■
Q 0 Q
Is the foam the proper color for the treatment process?
■
❑ O 0
Does the foam cover less than 25% of the basin's surface?
■
Q 0
Is the DO level acceptable?
❑
O Q ■
Is the DO level acceptable?(1.0 to 3.0 mg/1)
0
0 ❑ ■
Comment: Please refer to inspection summary letter.
Secondary Clarifier
Yes
No NA NE
Is the clarifier free of black and odorous wastewater?
■
0 Q ❑
Is the site free of excessive buildup of solids in center well of circular clarifier?
O
Q ■ O
Are weirs level?
■
❑ Q 11
Is the site free of weir blockage?
■
Q 00
Is the site free of evidence of short-circuiting?
■
Q 0 O
Is scum removal adequate?
■
❑ 0 13
Is the site free of excessive floating sludge?
■
Q 0 ❑
Is the drive unit operational?
0
Q ■ Q
Is the return rate acceptable (low turbulence)?
■
0 0 Q
Is the overflow clear of excessive solids/pin floc?
■
Q
Is the sludge blanket level acceptable? (Approximately Y. of the sidewall depth)
■
Q 0
Comment: Please refer to inspection summary letter.
Filtration (High Rate Tertiary)
Yes
No NA NE
Type of operation:
Down flow
Is the filter media present?
■
0 0
Is the filter surface free of clogging?
■
Q 11
Is the filter free of growth?
■
Q Q 0
Is the air scour operational?
❑
❑ ■ ❑
Is the scouring acceptable?
❑
11 ■ 0
Is the clear well free of excessive solids and filter media?
■
Q 0
Page # 5

Permit: NC0044750 Owner - Facility: Britthaven of Madison WWTP
Inspection Date: 02/25/2009 Inspection Type: Compliance Evaluation
Filtration (High Rate Tertiary) Yes No NA NE
Comment: Please refer to inspection summary letter.
Pumps-RAS-WAS Yes No NA NE
Are pumps in place? ■ ❑ ❑ ❑
Are pumps operational?
■ ❑
❑ ❑
Are there adequate spare parts and supplies on site?
■ ❑
❑ ❑
Comment: Please refer to inspection summary letter.
Disinfection - UV
Yes No
NA NE
Are extra UV bulbs available on site?
■ ❑
❑ ❑
Are UV bulbs clean?
■ ❑
❑ ❑
Is UV intensity adequate?
■ ❑
❑ ❑
Is transmittance at or above designed level?
■ ❑
❑ ❑
Is there a backup system on site?
■ ❑
❑ ❑
Is effluent clear and free of solids?
■ ❑
❑ ❑
Comment: Please refer to inspection summary letter.
Flow Measurement - Effluent
Yes No
NA NE
# Is flow meter used for reporting?
■ ❑
❑ ❑ .
Is flow meter calibrated annually?
❑ ■
❑ ❑
Is the flow meter operational?
■ ❑
❑ ❑
(If units are separated) Does the chart recorder match the flow meter?
❑ ❑
■ ❑
Comment: Please refer to inspection summary letter. Water meter from well house
that serves home is used for reporting flow.
Pump Station - Effluent
Yes No
NA NE
Is the pump wet well free of bypass lines or structures?
■ ❑
❑ ❑
Are all pumps present?
■ ❑
❑ ❑
Are all pumps operable?
■ ❑
❑ ❑
Are float controls operable?
01300
Is SCADA telemetry available and operational?
❑ ■
❑ ❑
Is audible and visual alarm available and operational?
■ ❑
❑ ❑
Comment: Please refer to inspection summary letter.
Effluent Pipe
Yes No
NA NE
Page # 6

Permit: NCO044750 Owner - Facility: Britthaven of Madison WWTP
Inspection Date: 02/25/2009 Inspection Type: Compliance Evaluation
Record Keeping
Yes No NA NE
Are records kept and maintained as required by the permit? ❑ ■ ❑ ❑
Is all required information readily available, complete and current? ❑ ■ ❑ ❑
Are all records maintained for 3 years (lab. reg. required 5 years)?
■
❑
❑ ❑
Are analytical results consistent with data reported on DMRs?
■
❑
Q ❑
Is the chain -of -custody complete?
❑
■
❑ ❑
Dates, times and location of sampling
■
Name of individual performing the sampling
■
Results of analysis and calibration
0
Dates of analysis
■
Name of person performing analyses
■
Transported COCs
■
Are DMRs complete: do they include all permit parameters?
■
❑
❑ ❑
Has the facility submitted its annual compliance report to users and DWQ?
❑
Q
A ❑
(If the facility is = or > 5 MGD permitted flow) Do they operate 24/7 with a certified operator on each shift?
❑
❑
■ ❑
Is the ORC visitation log available and current?
000
❑
Is the ORC certified at grade equal to or higher than the facility classification?
■
❑
Q ❑
Is the backup operator certified at one grade less or greater than the facility classification?
■
❑
❑ ❑
Is a copy of the current NPDES permit available on site?
■
❑
❑ ❑
Facility has copy of previous year's Annual Report on file for review?
❑
❑
■ ❑
Comment: Please refer to inspection summary letter.
n__vea
Yae
Nn
NO NF
(If the present permit expires in 6 months or less). Has the permittee submitted a new application?
❑
❑
■ ❑
Is the facility as described in the permit?
❑
■
❑ ❑
# Are there any special conditions for the permit?
❑
■
❑ ❑
Is access to the plant site restricted to the general public?
■
❑
❑ ❑
Is the inspector granted access to all areas for inspection?
■
❑
❑ ❑
Comment: Please refer to inspection summary letter.
Laboratory
Yes
No
NA NE
Are field parameters performed by certified personnel or laboratory?
■
❑
❑ ❑
Page # ' 3

Permit: NCO044750 Owner - Facility: Britthaven of Madison WWTP
Inspection Date: 02/25/2009 Inspection Type: Compliance Evaluation
Laboratory Yes No NA NE
Are all other parameters(excluding field parameters) performed by a certified lab? ■ ❑ ❑ ❑
# Is the facility using a contract lab? ■ ❑ ❑ ❑
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees Celsius)? ❑ ❑ ❑ ■
Incubator (Fecal Coliform) set to 44.5 degrees Celsius+/- 0.2 degrees? ❑ ❑ ❑ N
Incubator (BOD) set to 20.0 degrees Celsius +/- 1.0 degrees? ❑ ❑ ❑ 0
Comment: Please refer to inspection summary letter.
Effluent Sampling Yes No NA NE
Is composite sampling flow proportional? ❑ ❑ 0 ❑
Is sample collected below all treatment units? M ❑ ❑ ❑
Is proper volume collected? ■ ❑ ❑ ❑
Is the tubing clean? ❑ ❑ 0 ❑
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees Celsius)? ❑ ❑ Cl 0
Is the facility sampling performed'as required by the permit (frequency, sampling type representative)? ❑ ❑ ❑ E
Comment:. Please refer to inspection summary letter.
Upstream / Downstream Sampling Yes No NA NE
Is the facility sampling performed as required by the permit (frequency, sampling type, and sampling location)? ■ ❑ ❑ ❑
Comment: Please refer to inspection summary letter.
Equalization Basins Yes No NA NE
Is the basin aerated? N ❑ ❑ ❑
Is the basin free of bypass lines or structures to the natural environment?
0 ❑ ❑ ❑
Is the basin free of excessive grease?
0 ❑ ❑ ❑
Are all pumps present?
N ❑ ❑ ❑
Are all pumps operable?
N ❑ ❑ ❑
Are float controls operable?
0000
Are audible and visual alarms operable?
❑ ❑ 0 ❑
# Is basin size/volume adequate?
❑ ❑ ❑
Comment: Please refer to inspection summary letter.
Aeration Basins
Yes No NA NE
Mode of operation
Ext. Air
Type of aeration system
Diffused
Page # 4

NPDES yr/mo/day Inspection Type
3I NCO044750 I11 12I 09/02/25 I17 18ICI
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Please refer to inspection summary letter.
yg/w
AL% �; /�r�. / C'o �osio�If
N't "7 (tiL CL-(\ L--�
ly� CLJ
Page # 2
1

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 INI 2 I5� 31 NCO044750 I11 121 09/02/25 117 181 CI 19u 201
t...r s_ u �J
Remarks
21111111111111111111111111 111111111111 1111111111_l6
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 OA ------------Reservv(eWWd ----
671 169 70 UI 71 U 72 U 73 W 74 75I I I I I I I 180
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 permit Number)
09:00 AM 09/02/25
07/06/01
Britthaven of Madison WWTP
Exit Time/Date
Permit Expiration Date
1721 Bald Hill Rd
Madison NC 27025
11:00 AM 09/02/25
12/05/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
Larry A Bryant//910-548-9658 /
Larry A Bryant/ORC/910-548-9658/
Name, Address of Responsible Official/Title/Phone and Fax Number
Anne Skow,1721 Bald Hill Loop Madison NC Contacted
27025//336-548-9658/3365481299 No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit 0 Flow Measurement Operations & Maintenance Records/Reports
Self -Monitoring Program 0Sludge Handling Disposal Facility Site Review Effluent/Receiving Waters
Laboratory
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
Ron Boone WSRO WQ//704-663-1699 Ext.2202/
Signature of Man ment Q A;�R�evirAgency/Office/Phone and Fax Numbers Date
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page # 1

Permit: NCS000030 Owner - Facility: Air Products & Chemicals Inc
Inspection Date: 11/18/2009 Inspection Type: Compliance Evaluation
Inspection Summary:
Please refer to attached inspection summary letter.
Reason for Visit: Routine
14rl1 heV e k,2 4/- _qa,(( z�-e-,L
J d 4"L
ai
Dry r + Lk
Page: 2

Compliance Inspection Report
Permit: NCS000030 Effective: 10/01/05 Expiration: 09/30/10 Owner: Air Products & Chemicals Inc
SOC: Effective: Expiration: Facility: Air Products & Chemicals Inc
County: Rockingham 225 Equity Rd
Region: Winston-Salem
Reidsville NC 27320
Contact Person: David V Eberle Title: Phone: [phone]
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Inspection Date: 11/18/2009 Entry : 01:30 PM
Primary Inspector: Ron Boone
Secondary Inspector(s): _
Reason for Inspection: Routine
Permit Inspection Type: Stormwater Discharge, Individual
Facility Status: ❑ Compliant ■ Not Compliant
Question Areas:
0 Storm Water
(See attachment summary)
Certification: Phone:
Exit Time: 02:30 PM
Phone: [phone]
I ,2
`{-/Zc�!� Ext.2202
Inspection Type: Compliance Evaluation
Page: 1

A i
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
24 November 2009
Air Products & Chemicals, Inc.
Attn: Mr. David R. Grim, Site Manager
225 Equity Drive
Reidsville, NC 27320
Subject: Compliance Evaluation Inspection
NPDES Individual Stormwater Permit NCS000030
Air Products & Chemicals, Inc.
Rockingham County
Dear Mr. Grim:
Ron Boone of the Winston-Salem Regional Office (WSRO) of the NC Division of Water Quality
(DWQ or the Division) conducted a compliance evaluation inspection (CEI) at the subject facility
on 18 November 2009. Your assistance and cooperation during the inspection was greatly
appreciated. An inspection checklist is attached for your records and the inspection findings are
summarized below.
2. The facility is located at 225 Equity Drive, in Reidsville, Rockingham County, North Carolina.
Stormwater related to industrial activity is discharged from the site to an unnamed tributary to Little
Troublesome Creek, which is currently classified as Class C, nutrient -sensitive waters (NSW) in
the Cape Fear River basin.
Documentation & Monitoring Review
3. The Stormwater Pollution Prevention Plan (SP3) is complete and current. The only discrepancy
noted was that stormwater training is currently being done every five years, rather than every year
as required by the permit. Please begin yearly training as soon as possible and document as
required.
4. Qualitative and analytical (Q&A) monitoring has been accomplished as required and no problems
have been encountered. There are only two SDOs, but Air Products has permission from the
Division to monitor only outfall 001 as representative. Permission was granted via DWQ letter
dated February 1995 and letter is on file in the WSRO. Qualitative monitoring is required at both
outfalls regardless of representative outfall status.
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone: [phone] FAX: [phone] Customer Service:1-877-623-6748
Internet www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer
Nne
orthCarohna
Naturally

Air Products & Chemicals, Inc., NCS000030
Attn: Mr. David R. Grim, Site Manager
Compliance Evaluation Inspection
11 /24/2009
Page 2 of 2
Site Review
5. The site was very clean and well maintained. Mr. Boone noted no issues or concerns.
6. You are reminded that violations of the NCS000030 permit are subject to civil penalty
assessments not to exceed $25,000 per day, per violation. Your efforts to establish and
implement an effective stormwater management program are greatly appreciated.
7. Thank you for your cooperation in this matter. Should you have any questions, please feel free to
contact Mr. Boone or me at [phone].
Sincerely,
Steve W. Tedder
Water Quality Regional Supervisor
Winston-Salem Region
Division of Water Quality
Attachments:
1. BIMS Inspection Checklist
cc: SWP -WSRO
Central Files
Stormwater Permitting Unit

Permit: NCS000030 Owner - Facility: Air Products & Chemicals Inc
Inspection Date: 11/18/2009 Inspection Type: Compliance Evaluation
Stormwater Pollution Prevention Plan
Does the site have a Stormwater Pollution Prevention Plan?
# Does the Plan include a General Location (USGS) map?
# Does the Plan include a "Narrative Description of Practices"?
# Does the Plan include a detailed site map including outfall locations and drainage areas?
# Does the Plan include a list of significant spills occurring during the past 3 years?
# Has the facility evaluated feasible alternatives to current practices?
# Does the facility provide all necessary secondary containment?
# Does the Plan include a BMP summary?
# Does the Plan include a Spill Prevention and Response Plan (SPRP)?
# Does the Plan include a Preventative Maintenance and Good Housekeeping Plan?
# Does the facility provide and document Employee Training?
# Does the Plan include a list of Responsible Party(s)?
# Is the Plan reviewed and updated annually?
# Does the Plan include a Stormwater Facility Inspection Program?
Has the Stormwater Pollution Prevention Plan been implemented?
Comment: Please refer to attached inspection summary letter.
Qualitative Monitoring
Has the facility conducted its Qualitative Monitoring semi-annually?
Comment: Please refer to attached inspection summary letter.
Analytical Monitoring
Has the facility conducted its Analytical monitoring?
# Has the facility conducted its Analytical monitoring from Vehicle Maintenance areas?
Comment: Please refer to attached inspection summary letter.
Permit and Outfalls
# Is a copy of the Permit and the Certificate of Coverage available at the site?
# Were all outfalls observed during the inspection?
# If the facility has representative outfall status, is it properly documented by the Division?
# Has the facility evaluated all illicit (non stormwater) discharges?
Comment: Please refer to attached inspection summary letter.
Reason for Visit: Routine
Yes No NA NE
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4000
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■nnn
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/■nnn
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Yes No NA NE
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Page: 3

02/20/2009 15:56 336-9960326 R & A LABORATORIES PAGE 02/02
Water Pollution Control System Operator Designation Form
WKSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Mailing Address:
City: MA� ISOr1 State: Zip: Phone : Lnp)
Signature: . i e A . Date: �Q~'0l
Facility Name:Permit#; 1
-�.a � t f1%`Qt[� �rc�Ol't� .........�..utJggr7S0
1 SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Facility Type & Grade:
Grade Grade
Biological WWTP Surface Irrigation NIA
Physical/Chemical Land Application N/A
Collection System
................................................................... .
Operator in Responsible Charge (ORC)
Print Full Name:
Certificate Type / Grade I Number:, Work Phone##: )a Syg �-
-k Signature Date; (4 .�
l certify that I agree to my designation as the Operator in Responsible Charge for the facility noted, I understand and will abide by the
rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to dose, can result in
Disciplim y Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Fill] Name:
Certificate Tkpe/ Grade / Number: �� Work Phone
Signature: hate:
"I ccrtify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by
the rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can
ret.ttlt in Disciplinary Actions by the Watcr pollution Control Systcm Operators Ccnification Commission,"
.................. ........................................... I ............... I........... .... .............. .. .............. I.,..............
Mail or r2x to: WPCSOCC
1618 Mail Service Center
Raleigh, NC 27699-1618
Fax:919l733-1338
(Sec next page for designation of addiiionnl back-up operators, Designation or mart than one baCk-up operator is optional.)
Revised 1-2008

2 - :4_4- W__ -, - C 1-4 .. (I..- - i I A n - 11, 1 -7 <-- ., 7 1 I'A /" Ci , 2 /%-A
INDIVIDUAL NPIDES WASTEWATER DISCAZR_69 PERMIT PRE -INSPECTION CHECKLIST
.... ... .
...........
All information/documentation listed below must be available to the DWQ inspector at the scheduled inspection.
....... ......... ....
..........
...... .....
............
...
. .
d
1
Discharqe Monitoring Reports
Dates:
Through:
2
Lab Data, field and non -field
Dates:
Through:
3
Chain of Custody Forms
Dates:
Through:
4
Copies of current field lab certifications and lab certification / Ftres 73;Z!2� -
5
If outside lab is used to conduct non -field parameters, lab's name dnd certificafion /number. KIA
6
Complete copy of the NPDES permit 0/<,
7
Status of SOC or moratorium issuance and ongoing related issues if applicable) �
8
ORC and BORC current certifications _6 kk
9
Wastewater annual report if applicable)
10
Daily Operator's Log/ORC Visitation Log
11
Plant operations/maintenance to - W--, � L
12
Process control data, which includes field param6ters tested and equipment calibrations
13
Flow meter calibration record
14
Flow Charts Oaz SiAl�
15
Influent and effluent samplers L I L 0
16
Generator inspection and test run records may ask to run generator under load)&
17,
Spill response plan with current emergency contacts
18
Sludge/re iduals hauling records
19
Visual inspection of plant and treatment units tj�
20
Stream must be accessible for inspection at discharge point
....
.................. ... ......... . .. ; ; .; - ; -;
.............................
................. ....................
.......... .. .........
-1-1 .. ..... .....
Call
with Questions:
Ron Boone
NC Department of Environment and Natural Resources
Division of Water Quality
Winston-Salem Regional Office
1(336) 771-5000
1 Fax: [phone]
V
)A, 4
10% 914
Aff
4t,

MONITORING REPORT(MR) VIOLATIONS for:
Permit: MRs Between: and Region:
Facility Name: Param Name: County:
Major Minor:
Report Date: 02/25/09 Page: 1 of 1
Violation Category: Program Category:
Subbasin: Violation Action:
PERMIT: FACILITY: COUNTY: REGION:
MONITORING OUTFALL / VIOLATION UNIT OF CALCULATED
REPORT PPI LOCATION PARAMETER DATE FREQUENCY MEASURE LIMIT VALUE VIOLATION TYPE VIOLATION ACTION
12/31 /69

Permit Enforcement History by Owner
02/25/09
1
Owner: Britthaven Of Madison
Facility: Britthaven of Madison VVVVTP
Permit: NCO044750
Region: Winston-Salem County: Rockingham
Penalty Remission Enf EMC
EMC OAH Collection
Has
Assessment Penalty Enforcemen Request Enf Conf Remission Hearing
Remission Remission Memo Sent
Pmt
Case
Case Number MR Approved Amount t Costs Damages Received Held Amount Held
Amount Amount to AGO Total Paid
Balance Due
Plan
Closed
LV-2002-0363 08/28/02 $250.00 $99.00
$349.00
$.00
No
09/13/02
LV-2002-0429 09/16/02 $250.00 $99.00
$349.00
$.00
No
10/16/02
Total Cases: 2 $600.00 $198.00
$698.00
$•00
Total Penalties: $698.00
Total Penalties after remissionlsl:
$698.00

i3rimlfavem, jac. NCUD 4475�
February 18, 2009
NCDENA
State of North Carolina
Department of Environmental and
Natural Resources
Division of Water Quality
1617 Mail Service Center
Raleigh, N.C. 27699-1617
Dear Sir:
Britthaven of Madison
r--
1721 Bald Hill Loop
I RECEivEL: Madison, North Carolina 27025
N.C. Dept. of ENR Telephone: [phone]
FEB 2 5 2069 Fax: [phone]
Winston-Salem
Regional Office
Enclosed is the February 18, 2009 Performance Annual Report for
Britthaven of Madison.
Sincerely,
t-onya dic
Administrator
F E B 2 0 2009
DENR - WATER QUALITY
POINT SOURCE BRANCH

Pr
RECEIVED
Performance Annual Reports
DENR - WATER QUALITY
I. General Information POINT SOURCE BRANCH
Facility/System Name: Britthaven of Madison
Responsible Entity: Ley A. Bryant [phone]
Person in Charge/Contact: Anne Skow
Applicable Permit(s): N c0044750
open. Lic. # 6839
Description of Collection System or Treatment Process:
1 15,000 gal. and 1 10,000 gal. extended aeration package plants
with clarifier and chlorine contact chambers going to ti,ertary filters
to a post aeration tank out to receiving waters.
H. Performance
Text Summary of System Performance for Calendar Year 2008
There were no violations on our monitoring of the systems for 2008.
List (by month) any violations of permit conditions or other environmental regulations. Monthly
lists should include discussion of any environmental impacts and corrective measures taken to
address violations.

Etc.
M. Notification
State how this report has been made available to users or customers of the system and how those
users have been notified of its availability.
This report is posted on a bulletin board made visible to our residents
and employees.
IV. Certification
I certify under penalty of law that this report is complete and accurate to the best of my
knowledue. I further certify that this report has been made available to the users or customers of ;
the named system and that those users have been notified of its availability.
� �� 02/18/2009
Resp nsibl erson Date
Title Maintenance Supervisor
Entity

Y
December 19, 2008
5521
Mr. Larry A. Bryant
Britthaven of Madison
1721 Bald Hill Loop
Madison, NC 27025-
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
SUBJECT: Wastewater/Groundwater Laboratory Certification Renewal
FIELD PARAMETERS ONLY
Dear: Mr. Bryant
Coleen H. Sullins, Director
Division of Water Quality
RECEIVED
N ^ .^,sot, of ENR
JAN 0 7 2009
rvmsten-Salem
Regional Office
The Department of Environment and Natural Resources, in accordance with the provisions of NC GS 143-215-
.3 (a) (10), 15 NCAC 2H .0800, is pleased to renew certification for your laboratory to perform specified
environmental analyses required by EMC monitoring and reporting regulations 15 NCAC 2B .0500, 2H .0900 and
2L .0100, .0200, .0300, and 2N .0100 through .0800.
Enclosed for your use is a certificate describing the requirements and limits of your certification. Please review
this certificate to insure that your laboratory is certified for all parameters required to properly meet your
certification needs.
Please contact us at 919-733-3908 if you have questions or need additional information.
Sincerely,
/r-4�7- 3�O
Pat Donnelly
Certification Branch Manager
Laboratory Section
Enclosure
cc: Ramon L. Cook
Dana Satterwhite
Winston-Salem Regional Office
NoAhCarolina
Naturally
Laboratory Section 1623 Mail Service Center; Raleigh, NC 27699-1623 Phone [phone]
Location: 4405 Reedy Creek Road; Raleigh, NC 27607 FAX [phone]
Internet: www.dwglab.org/Customer Service 1-877-623-6748
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper

STATE OF NORTH CAROLINA DEPARTMENT OF THE
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
LABORATORY CERTIFICATION PROGRAM
In accordance with the provisions of N.C.G.S. 143-215.3 (a) (1), 143-215.3 (a)(10) and NCAC 2H.0800:
Field Parameter Only
BRITTHAVEN OF MADISON
Is hereby certified to perform environmental analysis as listed on Attachment I and report monitoring data to DWQ for
compliance with NPDES effluent, surface water, groundwater, and pretreatment regulations.
By reference 15A NCAC 2H .0800 is made a part of this certificate.
This certificate does not guarantee validity of data generated, but indicates the methodology, equipment, quality control procedures,
records, and proficiency of the laboratory have been examined and found to be acceptable.
This certificate shall be valid until December 31, 2009
Certificate No. 5521

Britthaven of Madison
1721 Bald Hill Loop
Madison, NC 27025-
Attachment
North Carolina Wastewater/Groundwater Laboratory Certification
Certified Parameters Listing
FIELD PARAMETERS ONLY
Certificate Number: 5521
Effective Date: 01 /01 /2009
Expiration Date: 12/31/2009
Date of Last Amendment:
The above named laboratory, having duly met the requirements of 15A NCAC 21-1.0800, is hereby certified for the measurement of the parameters listed below.
CERTIFIED PARAMETERS
INORGANICS
DISSOLVED OXYGEN
Std Method 4500 O G
pH
Std Method 4500 H B
TEMPERATURE
Sid Method 2550E
This certification requires maintance of an acceptable quality assurance program, use of approved methodology, and satisfactory performance on evaluation samples. Laboratories are
subject to civil penalties and/or decertification for infractions as set forth in 15A NCAC 21-1.0807.

Michael F. Easley, Governor
i William G. Ross Jr., Secretary
rNorth Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
August 28, 2008
5521
Mr. Larry A. Bryant
Britthaven of Madison
1721 Bald Hill Loop
Madison, NC 27025-
RECEIVED
N.C. Dent of ENR
SEP o 4 2=
Winston-Salem
Regional Office
SUBJECT: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC)
Initial Laboratory Certification Inspection
Dear Mr. Bryant :
Enclosed is a report for the inspection performed on July 22, 2008 by Mr. Ramon Cook.
Where finding(s) are cited in this report, a response is required. Within 30 days of receipt,
please supply this office with a written item for item description of how these finding(s) were
corrected. For certification maintenance, your laboratory must continue to carry out the
requirements set forth in 15A NCAC 2H .0800.
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 us at 919-733-3908.
Sincerely,
Dana Sa erwhite
Certification Unit Supervisor
Laboratory Section
Enclosure
cc: Ramon Cook
Winston-Salem Regional Office
N"ose
,�Carolina
Jvatrrra!!y
North Carolina Division of Water Quality 1623 Mail Service Center Raleigh, NC 27699-1623 Phone [phone] Customer Service
Internet: www.dwqlab.org Location: 4405 Reedy Creek Rd Raleigh, NC 27607 Fax [phone]
An Equal Opportunity/Affirmative Action Employer — 50% Recycled110% Post Consumer Paper

LABORATORY NAME:
NPDES PERMIT #:
ADDRESS:
CERTIFICATE #:
DATE OF INSPECTION:
TYPE OF INSPECTION:
AUDITOR(S):
LOCAL PERSON(S) CONTACTED:
I. INTRODUCTION:
On -Site Inspection Report
Britthaven of Madison
NCO044750
1721 Bald Hill Loop
Madison, NC. 27025
5521
July 22, 2008
Field Initial
Ramon L. Cook
Larry Bryant
This laboratory was inspected to verify its compliance with the requirements of 15A NCAC 2H .0800 for the
analysis of environmental samples.
If. GENERAL COMMENTS:
The laboratory is spacious and well equipped. All facilities and instrumentation are well maintained.
Some further quality control procedures need to be implemented. A technical assistance document is
attached for ATC verification of the pH meter. It is required that all relevant data pertinent to each
analysis must be maintained for five years. Calibration logs must be filed in an orderly manner so as to
be readily available for inspection upon request.
III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
pH — Standard Methods, 18th Edition, 4500 H+ B
Dissolved Oxygen — Standard Methods, 18th Edition, 4500 O G
Temperature — Standard Methods, 20th Edition, 2550B
A. Finding: The temperature -sensing device on the pH, DO, and thermometers, used to obtain
temperature readings has not been calibrated against an NIST certified or traceable
thermometer annually. Also, the temperature correction is not posted on the meters.
Requirement: All thermometers, or temperature sensing devices on field meters, must meet NIST
specifications for accuracy and must be calibrated against a NIST certified or NIST traceable
thermometer annually (every twelve months) and proper corrections made and documented. The
thermometer reading must be less than 1 °C from the NIST certified reading to be acceptable.
Also document any correction that applies on both the instrument and on a separate sheet to be
filed. A correction factor must be posted on the thermometer/meter even if that correction
factor is zero degrees. The temperature sensor must be calibrated annually even if it is not being
used to report temperature. Ref: North Carolina Wastewater/Groundwater Laboratory Certification
(NC WW/GW LC) Policy February 2006

Ppp
Page 2
Lab 9552 BBritthaven of Madison
B. Finding: The laboratory is not recording the "units of measure" on its benchsheets.
Requirement: Certified Data must consist of date collected, time collected, samples site,
sample collector, and sample analysis time. The field bench sheets must provide a space for the
signature of the analyst, and proper units of measure for all analyses. Data pertinent to each
analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1).
C. Finding: The laboratory is not recording the collection or analysis time, the analyst initials and
date on laboratory records.
Requirement: Data pertinent to each analysis must be maintained for five years. Certified Data
must consist of date collected, time collected, sample site, sample collector, and sample analysis
time. The field benchsheets must provide a space for the signature or initials of the analyst, and
proper units of measure for all analyses. Ref: 15A NCAC 2H .0805 (g) (1).
PH — Standard Methods, 18t�' Edition, 4500 H+ B
D. Finding: The Automatic Temperature Compensator (ATC) has not been verified.
Requirement: The ATC must be verified annually (i.e., every twelve months) by analyzing a
buffer at 250C (the temperature that conductivity values are compensated to) and a
temperature(s) that bracket the temperature ranges of the samples to be analyzed. This may
requirethe analysis of a third temperature reading that is > 25°C. Ref: NC WW/GW LC Policy
Statement February 2006.
IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing field testing records to Discharge Monitoring Reports (DMRs)
submitted to the North Carolina Division of Water Quality. Data were reviewed for Britthaven of
Madison (NPDES # NC0044750) for January, February, and March 2008. No transcription errors were
detected. The facility appears to be doing a good job of accurately transcribing data.
V. CONCLUSIONS:
Correcting the above -cited findings and implementing the recommendations will help this lab to produce
quality data and meet certification requirements. The inspector would like to thank the staff for its
assistance during the inspection and data review process. Please respond to all findings.
Report prepared by: Ramon L. Cook Date: July 22, 2008
Report reviewed by: David Livingston Date: July 31, 2008

PPPPFF'
Technical Assistance Procedure
Automatic Temperature Compensator (ATC) Check Procedure for pH meter:
The following must be performed on an annual (i.e., 12 month) basis:
1. Pour an adequate amount of buffer into a beaker or other container and analyze at 25° C.
Document the temperature and pH value.
2. Lower the temperature of the buffer by placing the container in cool water or a refrigerator
to less than the lowest anticipated sample temperature and analyze. Document the
temperature and pH value.
3. If samples greater than 250 C are to be analyzed, perform the following additional step:
Place the container in warm water, or a water bath and raise the temperature above 25° C
to greater than the highest anticipated sample temperature and analyze. Document the
temperature and pH value.
As the temperature increases or decreases, the value of the buffer must be within ± 0.1 S.U. of
the true value of the buffer.
Comment: Anticipated temperatures can be obtained from a review of the Discharge Monitoring
Reports (DMRs) from the peak summer and winter months. Historical data should provide a
reasonably accurate estimation of ranges that will bracket the expected sample temperatures.

_,gyp
G
_� 7
pig r
C sifflAb„,..
Mr. Larry Bryant
Britthaven of Madison
1721 Bald Hill Loop
Madison, North Carolina 27025
Dear Mr. Bryant:
5(11-w
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
April 30, 2008 MAY 0 6 �rJ�c_
Winston-Salem
Regional Office
SUBJECT: Authorization to Construct
A to C No. 044750A01
Britthaven of Madison
Britthaven of Madison WWTP
Rockingham County
A letter of request for Authorization to Construct was received November 19, 2007, by
the Division, and final plans and specifications for the subject project have been reviewed and
found to be satisfactory. Authorization is hereby granted for the construction of modifications to
the existing 0.025 MGD Wastewater Treatment Plant, with discharge of treated wastewater into
Hogans Creek in the Roanoke River Basin.
This authorization results in no increase in design or permitted capacity and is awarded
for the construction of the following specific modifications:
Installation of an in line UV disinfection system in an insulated enclosure with
audible and visual alarms, spare lamps to be kept on site, and abandonment of a
chlorine disinfection system, in conformity with the project plans, specifications,
and other supporting data subsequently filed and approved by the Department of
Environment and Natural Resources.
This Authorization to Construct is issued in accordance with Part III, Paragraph A of
NPDES Permit No. NCO044750 issued April 23, 2007, and shall be subject to revocation unless
the wastewater treatment facilities are constructed in accordance with the conditions and
limitations specified in Permit No. NC0044750.
The sludge generated from these treatment facilities must be disposed of in accordance
with G.S. 143-215.1 and in a manner approved by the North Carolina Division of Water Quality.
In the event that the facilities fail to perform satisfactorily, including the creation of
nuisance conditions, the Permittee shall take immediate corrective action, including those as may
be required by this Division, such as the construction of additional or replacement wastewater
treatment or disposal facilities. No'� Carolina
None
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 Phone [phone] Customer Service
Internet: www.ncwaterguality.org 512 N. Salisbury St. Raleigh, NC 27604 FAX [phone]
An Equal Opportunity/Affirmative Action Employer — 501/6 Recyded/10% Post Consumer Paper

Mr. Larry Bryant
April 30, 2008
Page 2
The Winston-Salem Regional Office, telephone number [phone], shall be notified
at least forty-eight (48) hours in advance of operation of the installed facilities so that an on site
inspection can be made. Such notification to the regional supervisor shall be made during the
normal office hours from 8:00 a.m. until 5:00 p.m. on Monday through Friday, excluding State
Holidays.
Upon completion of construction and prior to operation of this permitted facility, a
certification must be received from a professional engineer certifying that the permitted facility
has been installed in accordance with the NPDES Permit, this Authorization to Construct and the
approved plans and specifications. Mail the Certification to: Construction Grants & Loans,
DWQ/DENR, 1633 Mail Service Center, Raleigh, NC 27699-1633.
Upon classification of the facility by the Certification Commission, the Permittee shall
employ a certified wastewater treatment plant operator to be in responsible charge (ORC) of the
wastewater treatment facilities. The operator must hold a certificate of the type and grade at
least equivalent to or greater than the classification assigned to the wastewater treatment
facilities by the Certification Commission. I .
The Permittee must also employ a certified back-up operator of the appropriate type and
grade to comply with the conditions of T15A:8G.0202. The ORC of the facility must visit each
Class I facility at least weekly and each Class II, III and IV facility at least daily, excluding
weekends and holidays, must properly manage the facility, must document daily operation and
maintenance of the facility, and must comply with all other conditions of T15A:8G.0202.
A copy of the approved plans and specifications shall be maintained on file by the
Permittee for the life of the facility.
During the construction of the proposed additions/modifications, the permittee shall
continue to properly maintain and operate the existing wastewater treatment facilities at all times,
and in such a manner, as necessary to comply with the effluent limits specified in the NPDES
Permit.
You are reminded that it is mandatory for the project to be constructed in accordance
with the North Carolina Sedimentation Pollution Control Act, and when applicable, the North
Carolina Dam Safety Act. In addition, the specifications must clearly state what the contractor's
responsibilities shall be in complying with these Acts.
Prior to entering into any contract(s) for construction, the recipient must have obtained all
applicable permits from the State.
Failure to abide by the requirements contained in this Authorization to Construct may
subject the Permittee to an enforcement action by the Division of Water Quality in accordance
with North Carolina General Statute 143-215.6A to 143-215.6C.

Mr. Larry By
Apri130, 2008
Page 3
The issuance of this Authorization to Construct does not preclude the Permittee from
complying with any and all statutes, rules, regulations, or ordinances which may be imposed by
other government agencies (local, state, and federal) which have jurisdiction.
One (1) set of approved plans and specifications is being forwarded to you. If you have
any questions or need additional information, please contact Ken Pohlig, P.E. at telephone
number [phone].
Sincerely,
Coleen H. Sullins
MM:kp1(-411-
cc: William A. Gold, P.E. — Meridian Engineering, PA
Rockingham County Health Department
DWQ Winston-Salem Regional Office, Surface Water Protection
Technical Assistance and Certification Unit
Point Source Branch, NPDES Program
Daniel Blaisdell, P.E.
Ken Pohlig, P.E.
Michelle McKay, E.I.
ATC File

F"F'
P!B!ritthaven of Madison
C No. 044750A01
Issued April 30, 2008
Engineer's Certification
1, , as a duly registered Professional Engineer in
the State of North Carolina, having been authorized to observe (periodically/weekly/full time)
the construction of the modifications and improvements to the Britthaven of Madison WWTP,
located on Bald Hill Loop in Rockingham County for Britthaven of Madison, hereby state that,
to the best of my abilities, due care and diligence was used in the observation of the following
construction:
Installation of an in line UV disinfection system in an insulated enclosure with
audible and visual alarms, spare lamps to be kept on site, and abandonment of a
chlorine disinfection system, in conformity with the project plans, specifications,
and other supporting data subsequently filed and approved by the Department of
Environment and Natural Resources.
I certify that the construction of the above referenced project was observed to be built within
substantial compliance and intent of the approved plans and specifications.
Signature
Date
Registration No.
Send to: Construction Grants & Loans
DENR/DWQ
1633 Mail Service Center
Raleigh, NC 27699-1633

Nathavefr, JNC.
February 26, 2008
NCDENA
State of North Carolina
Department of Environmental and
Natural Resources
Division of Water Quality
1617 Mail Service Center
Raleigh, N.C. 27699-1617
Dear Sir:
RECEIVED
N.C. Deot. of ENR
MAR 1 12008
Winston-Salem
Regional Office
Britthaven of Madison
1721 Bald Hill Loop
Madison, North Carolina 27025
Telephone: [phone]
Fax: [phone]
F 18 2 8?008
Enclosed is the February 26, 2008 Performance Annual Report for
Britthaven of Madison.
Sincerely,
Anne Skow, Administrator

I.
Performance Annual Report
General Information
Facility/System Name: Britthaven of Madison
Responsible Entity: Larry A. Bryant ( 336) 548-9658
Person in Charge/Contact: Anne Skow
Applicable Permit(s): N 00044750
Oper. Lic. # 6839
Description of Collection System or Treatment Process:
1 15,000 gal. and 1 10,000 gal. extended aeration package plants
with clarifier and chlorine contact chambers going to tiertary filters
to a post aeration tank out to receiving waters.
II. Performance
Text Summary of System Performance for Calendar Year 2007
We had the following violations on our monitoring of the s stems for 2007.
List (by month) any violations of permit conditions or other environmental regulations. Monthly
lists should include discussion of any environmental impacts and corrective measures taken to
address violations.
DATE
PARAMETER PERMIT LIMIT
REPORTED VALUE
UNITS
06/29/07
TSS
45
53
mg/1
11/16/07
Residual Chlorine
28
140
ug/1
11/23/07
Fecal Coliform
400
500
per 100 ml
Next weeks
monitoring indicated
system back
in compliance.

Etc.
III. Notification
State how this report has been made available to users or customers of the system and how those
users have been notified of its availability.
This report is posted on a bulletin board made visible to our residents
and employees.
IV. Certification
I certify under penalty of law that this report is complete and accurate to the best of my
knowledge. I further certify that this report has been made available to the users or customers of .
the named system and that those users have been notified of its availability.
Z. 08
Resp nsibl erson Date
Title Maintenance Supervisor
Entity

of W-A TFR
P P 70i�'
3PG
}z
r
—1
Ms. Anne Skow
Britthaven of Madison
1721 Bald Hill Loop
Madison, NC 27025
Subject: Notice of Violation - Effluent Limitations
Britthaven of Madison
NPDES No. NCO044750
NOV-2008-LV- 0086
Rockingham County
Dear Ms.Skow:
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
February 13, 2008
A review of the self -monitoring report for the month of November 2007, revealed.the
following effluent limit violation(s):
Daily Maximum
Date Parameter Permit Limit Reported Value Units
11/16 Residual Chlorine 28 140 ug/F
11/23 Fecal Coliform 400 500 per 100 ml
Remedial actions, if not already implemented should be taken to correct the above
noncompliance problem(s). Please be aware that violations of your NPDES permit could subject you
to enforcement action by this Division with the possible assessment of civil penalties of up to
$25,000 per day per violation. Should you have any questions, please do not hesitate to contact
David Russell at [phone].
Sincerely,
/+� _ Steve W. Tedder
IdA Water Quality Supervisor
cc: Compliance Group one
Central Files N Carolina
WSRO tunally
North Carolina Division of Water Quality 585 Waughtown Street Phone [phone] Customer Service
Winston-Salem Regional Office Winston-Salem, NC 27107 Fax [phone]
Internet: www.ncwaterqualily.org
An Equal Opportunity/Affirmative Action Employer — 50% Recycledl10% Post Consumer Paper

PV
Cover Sheet from
Staff Member to
Regional Supervisor
�1 OV - )to -��_ 00?�
DINIR Review Record
Facility: & X V Clt�) Permit/Pipe No.: NC Month/Year /U���� /r 7
Monthly Average Violations
Parameter Permit Limit DMR Value % Over Limit
— m AX ,
.IW/Daily Violations
Date Parameter
It 16
Permit LimitfTvpe
DMR Value
% Over Limit
Monitoring
Frequency Violations
Date
Parameter
Permit Frequency
Values Reported
# of Violations
Other Violations
4!
Completed by:
Regional Water Quality
Supervisor Signoff:
Lk e11-" 6 rl
�140
Date:Lb
, /!
Date: «/OY'

PPV
MONITORING REPORT(MR) VIOLATIONS for:
Report Date 01/31/08 Page 4 of 5
Permit: 1
MRs Between: 11-2007
and 11
2007 Region: Winston-Salem
Violation Category: Limit
Violation Program Category: NPDES WNJ
Facility Name: %
Param Name: 'A
County: I
Subbasin: j
Violation Action:
Major Minor. %
PERMIT: NCO044750
FACILITY: Britthaven Of Madison - Britthaven of Madison WWTP
COUNTY: Rockingham REGION: Winston-Salem
Limit Violation
MONITORING OUTFALL I
VIOLATION
UNIT OF
CALCULATED
REPORT PPI LOCATION
PARAMETER
DATE
FREQUENCY
MEASURE
LIMIT VALUE
VIOLATION TYPE VIOLATION ACTION
11 -2007 D01 Effluent
Chlorine, Total Residual
11/16/07
2 X week
ug/I
28 140
Daily Maximum Exceeded None
11 -2007 001 Effluent
Coliform, Fecal MF, M-FC
11/23/07
Weekly
#/100m1
400 500
Daily Maximum Exceeded None
Broth,44.5C
PERMIT: NCO032182
FACILITY: Sunset Apartments - Sunset Apartments
COUNTY: Watauga
REGION: Winston-Salem
Limit Violation
MONITORING OUTFALL /
VIOLATION
UNIT OF
CALCULATED
REPORT PPI LOCATION
PARAMETER
DATE
FREQUENCY
MEASURE
LIMIT VALUE
VIOLATION TYPE VIOLATION ACTION
11 -2007 001 Effluent
Coliform, Fecal MF, M-FC
11/13/07
Weekly
#/100ml
400 3,700
Daily Maximum Exceeded None
Broth,44.5C
PERMIT: NCO069761
FACILITY: Town of Beech Mountain - Pond Creek WWTP
COUNTY: Watauga
REGION: Winston-Salem
Limit Violation
MONITORING OUTFALL/
VIOLATION
UNIT OF
CALCULATED
REPORT PPI LOCATION
PARAMETER
DATE
FREQUENCY
MEASURE
LIMIT VALUE
VIOLATION TYPE VIOLATION ACTION
11 -2007 001 Effluent
Coliform, Fecal MF, M-FC
11/10/07
Weekly
#/100ml
400 6,200
Weekly Geometric Mean None
Broth,44.5C
Exceeded

f 7M
EFF NT JAN 3 0 2007 14
PPDES PERMIT NO. /1/(�OD tf 7S © G'�� �[ll3c� LJ 7
DISCHARGE NO. D/�� MONTH � YEAR
FACILITY NAME � 7h!�71So^j CLASS-;�V' COUNTY Gz-G�''i.z�Ce'/{��!
OPERATOR IN RESPONSI LE -CHARGE (ORG) Gt�iYl GRADE„ PHONE?74 -
CLfyED
CERTIFIED LABORATORIES,( .�`' - (2)
CHECK BOX IF ORC I CHANGED Q PERSON(S) COLLECTING SAMPLES
FEB 0 4 CFO
Mail ORIGINAL and ONE COPY to:
�Yins:cn Sa: iL, / Z Z% /
/�.�4/r�y'�4 �''� / ! 7
ATTN: CENTRAL FILES x
DIVISION OF WATER QUALITY__._ te' '" � _... (SIGNATURE OF OPEPATOR IN RESPONSIBLE CHARGE) DATE
1617 MAIL SERVICE CENTER BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
RALEIGH, NC 27699-1617 ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
d
50050
00010
00400
50060
00310
00610
00530
31616
00300
00600
00665
W1641
d
*
FLOW
ENTER PARAMETER CODE ABOVE
WEF
NAME AND UNITS BELOW
INF ❑
y
x
A P"
A pV
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O MG/L
HRS
HRS
Y LIN
MGD
° C
UNITS
UG/I.
MG/L
MG/L
MG/L
#/100ML
MG/L
MG/L
MG/L
6'
2
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AVERAGE !�/%� �� r�J �•D �i �p %i 3, T
;:�"aa,{S';'z.''
MINIMUM i D// —1!>
Coni}iE(C)LGirab(G3':
Limit
DWQ Form MR-1 (01/00)

PPV
Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements
All monitoring data and sampling frequencies do NOT meet permit requirements
Compliant
1-1
Noncompliant
If the facility is noncompliant, please comment on corrective actions being taken in respect to equipment, operation, maintenance, etc.,
and a time -table for improvements to be made.
"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. 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 there are significant penalties for
submitting false information, including the possibility of fines and imprisonment for knowing violations."
Permittee (Please print or type)
Signature 6f Permittee* Date
(Required)
Permittee
Address
Phone Number
Permit Exp. Date
PARAMETER CODES
00010
Temperature
00556
Oil & Grease
00951
Total Fluoride
01067
Nickel
50060 Total
00076
'Turbidity
00600
Total Nitrogen
01002
Total Arsenic
01077
Silver
Residual
00080
Color (Pt -Co)
00610
Ammonia Nitrogen
01092
Zinc
Chlorine
00082
Color (ADMI)
00625
Total Kjeldhal
01027
Cadmium
01105
Aluminum
Nitrogen
00095
Conductivity .00630
Nitrates/Nitrites
01032
Hexavalent Chromium
01147
Total Selenium
71880 Formaldehyde
00300
Dissolved Oxygen
01034
Chromium
31616
Fecal Coliform
71900 Mercury
00310
BOD5
00665
Total Phosphorous
32730
Total Phenolics
81551 Xylene
00340
COD
00720
Cyanide
01037
Total Cobalt
34235
Benzene
00400
pH
00745
Total Sulfide
01042
Copper
34481
Toluene
00530
Total Suspended
00927
Total Magnesium
01045
Iron
38260
MBAS
Residue
00929
Total Sodium
01051
Lead
39516
PCBs
00545
Settleable Matter
00940
Total Chloride
01062
Molybdenum
50050
Flow
Parameter Code assistance may obtained by calling the Point Source Compliance/Enforcement Unit at [phone] or by visiting
the Water Quality Section's web site at h2o.enr.state.nc.us/w9 and linking to the Unit's information pages.
Use only units designated in the reporting facility's permit for reporting data.
* ORC must visit facility and document visitation of facility as required per 15A NCAC 8G .0204. L 0 1 C_J, l
** If signed by other than the permittee, delegation of signatory authority must be on file with the�state ger 15A NCACIB;.0506 (b)
(2) (D)•
k f

Y 61
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
January 4, 2008
Mr. Larry Bryant
Britthaven of Madison
1721 Bald Hill Loop
Madison, North Carolina 27025
SUBJECT: Request for Additional Information
Britthaven of Madison
Britthaven of Madison WWTP
UV Installation
ATC No. 44750A01
Rockingham County
Dear Mr. Bryant:
A review of the plans and specifications in support of the request for Authorization to
Construct has been completed by the Construction Grants and Loans Section (CG&L). The
comments resulting from this review are being transmitted directly to your engineer for
clarification and resolution; a copy is attached for your reference. Our goal is to issue the
Authorization to Construct as soon as possible. If a complete response is not received within 30
days, the application and supporting information will be returned.
Upon receipt of satisfactory responses from your engineer to our comments, the review of
the plan documents will be completed. If you have any questions concerning this matter, please
do not hesitate to contact Michelle McKay, E.I., State Project Review Engineer, at
[phone].
Sincerely,
X,
Cecil G. Madden, Jr., P.E., Supervisor
Construction Grants and Loans Section
Design Management Unit
13"M
Attachment to all
cc: William A. Gold, P.E. — Meridian Engineering, PA
DWQ Winston-Salem Regional Office
Daniel Blaisdell, P.E.
Cecil G. Madden, Jr., P.E.
Michelle McKay, E.I.
ATC Files
Construction Grants and Loans Section One
1633 Mail Service Center Raleigh NC 27699-1633 NorthCarohna
Phone: [phone] / FAX: [phone] / Internet: www.nccgl.net NaturallffAn Eaual O000rtunity/Affirmative Action Emplover — 50% Recvcled/10% Post Consumer Paper

Construction Grants & Loans Section
Design Management Unit
Britthaven of Madison
Britthaven of Madison WWTP
UV Installation
ATC No. 44750A01
Request for Additional Information
General Comments
. RFc 1 e0
JAN082aw
Wlnt�pn •y01v, i.
Rpional pry�a
1. Provide three (3) sets of final plans and specifications to this office, labeled "Final. Not
Released for Construction".
2. Please verify that the additional power requirements for operation of the UV system can be met
by the existing power supply at the WWTP.
3. The UV system should have the ability to notify the ORC of lamp/unit failures. Spare lamps and
a module must be kept on site.
4. Does the WWTP have backup power? If not, then an alternate means of disinfection should be
provided. If this alternate method is chlorination, then dechlorination should be provided.
5. Confirm the quality of the effluent is suitable for UV disinfection. For example, according to the
specifications the maximum concentration level for Turbidity is 5 NTU and for Suspended
Solids is 10 mg/L.
Review of Plans
1. We suggest including a recommended lamp -cleaning schedule on the plans for the operator to
follow.
Review of Specifications
1. Specifications for the S5000C indicate this model is for indoor use only.

Michael F. Easley. Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
December 20, 2007
Mr. Larry Bryant
Britthaven of Madison
1721 Bald Hill Loop
Madison, North Carolina 27025
SUBJECT: Acknowledgement of Request for an
Authorization to Construct
Britthaven of Madison
Britthaven of Madison WWTP
UV Installation
NPDES Permit No. NCO044750
Dear Mr. Bryant:
The Construction Grants and Loans Section received your request for an Authorization to
Construct and the supporting documentation on November 19, 2007. We will notify you and
your engineer upon completion of our review. Your project has been assigned to Michelle
McKay, E.I. She can be reached at [phone].
If you have any questions concerning this matter, please contact me at [phone].
Since ly,
Cecil G. Madden, Jr., P.E., Supervisor
Construction Grants and Loans Section
Design Management Unit
AR/dr
cc: William A. Gold, P.E. — Meridian Engineering, PA
DWQ Winston-Salem Regional Office
WQ Central Files
Michelle McKay, E.I.
Anita Reed, E.I.
ATC Files
Construction Grants and Loans Section One
1633 Mail Service Center Raleigh NC 27699-1633 NorthCarolina
Phone: [phone] / FAX: [phone] / Internet: www.nccgl.net )VatimallyortCanAn Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper

�OF W A rF90 Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
0 Coleen H. Sullins, Director
Division of Water Quality
January 11, 2008
MEMORANDUM
TO: Michelle McKay, E.I., Project Review Engineer
Design Management Unit
Thru: Steve Tedder, Regional Water Quality Superviso
WSRO
From: David Russell, Environmental Specialist)
WSRO
Subject: A to C Britthaven of Madison WWTP
UV Disinfection Unit
NPDES Permit No. NCO044750
Rockingham County.
The request to add a UV disinfection unit to this existing 0.025 mgd WWTP. The
plant routinely meets effluent limits with the exception of the residual chlorine limit.
This UV unit will eliminate the need to add chlorine to the effluent.
It is recommended the A to C to construct a UV disinfection unit be issued.
Should you have questions contact David Russell at (336) 771- 4967.
CC: Central Files
SRO
I r Carohna
Aaiura!!y
North Carolina Division of Water Quality 585 Waughtown Street Phone [phone] Customer Service
Winston-Salem Regional Office Winston-Salem, NC 27107 Fax [phone]
Internet: www.ncwaterqualitv.ora
An Equal Opportunity/Affirmative Action Employer— 50% Recycledl10% Post Consumer Paper

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
December 20, 2007
MEMORANDUM
TO: Steve Tedder, Regional Water Quality Supervisor
Winston-Salem Regional Office, Division of Water Quality
FROM: ice~ Michelle McKay, E.I., Project Review Engineer
Design Management Unit
SUBJECT: Request for an Authorization to Construct
Britthaven of Madison, Britthaven of Madison WWTP, UV Installation
NPDES Permit No. NCO044750
Plans, specifications and supporting documents have been received for the subject
project. It is requested that comments and recommendations, including the items listed below, be
received by January 22, 2008 from the Regional Office Staff -
Procedure No. 4 Comments
Schedule for Issuance of the NPDES Permit
SOC, or Other Schedules Which Must be Met
Status of Stormwater Permit, if applicable
Confirm if the Proposed Method and Sequence for Construction of
Additions/New Facilities is Acceptable.
Groundwater Comments
Standby Power Needs
Compliance With N. C. Well Construction Standards
CAMA
X Recommendations for inclusion in the Authorization to Construct
For your reference, review and comments on the above items, plan documents are submitted as follows:
X Plans and Specifications
Subsurface/Soils Report
Power Outage Information
Other
If you have any questions, please contact Michelle McKay, E.I. at [phone].
Attachment
no
cc: Michelle McKay, E.I.
Anita Reed, E.I. / ATC Files
Construction Grants and Loans Section
1633 Mail Service Center Raleigh NC 27699-1633 One
Phone: [phone] / FAX: [phone] / Internet: www.nccgl.net North Carolina
An Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper Aaturallff

I
North Carolina Division Of Water Quality
Construction Grants & Loans SectionE
Authorization To Construct (ATC) Application Formd°� <,
(To Be Used On and After August 1, 2007)
Date: 10/31 /2007 tUl C "'
Permittee/Owner Name: Britthaven of Madison Professional Engineer of Record: William A. Gold
Contact Person: Mr. Larry Bryant Engineering Firm: Meridian Engineering, P. A.
Address: 1721 Bald Hill Loop Address: 600-D Plaza Boulevard
Madison, N. C. 27025 Kinston, N. C. 28501
Telephone Number: [phone] Telephone Number: [phone]
Please Note: The following items and information must be Information Is
submitted to be considered a complete application Provided
package. If any applicable item is missing the package will
be returned as incomplete.
Remarks/Explanation
1
Letter of request for ATC from Permittee/Owner or
authorized agent with written authorization.
2
Brief description of the proposed project.
3
Complete copy of the NPDES permit or public notice of
a draft NPDES permit.
4
Design capacity in Million Gallons per Day (MGD).
®
0.025 MGD
If new or expanding design capacity is greater than or
5
equal to 0.5 MGD, include a copy of Finding Of No
❑
Significant Impact (FNSI).
Two sets of plans: signed, sealed, and dated by a NC
6
Professional Engineer and stamped "Final Drawing -
Not Released For Construction".
7
Two sets of technical specifications: signed, sealed,
❑
Included in item #6
and dated by a NC Professional Engineer.
Two sets each of process, design, buoyancy, and
8
hydraulic profile calculations: signed, sealed, and dated
❑
Not Applicable
by a NC Professional Engineer.
9
Hydraulic profile and a flow schematic with sizes of
❑
Not Applicable
Major components on 8%" X 11" paper.
Documentation that a Soil & Erosion Control permit
10
application has been submitted to the Division of Land
❑
Not Applicable
Resources.
Residuals Management Plan for all new or expanding
11 facilities
producing residuals, or when modifying
❑
Not Applicable
residual
facilities.
12
Construction Sequence Plan for all modifications.
®
Not Applicable
13 110
volt GFCI receptacle and potable water source
included
on plans.

Please Note: The following items and information must be
Information Is
submitted to be considered a complete application
Provided
Remarks/Explanation
package. If any applicable item is missing the package will
be returned as Incomplete.
14
Hydrogeologic information must be provided if a
❑
Not Applicable
potential for groundwater contravention exists.
15
For abandonment of WWTPs: a statement that the
❑
Not Applicable
facility will be properly disconnected.
16
All property lines, construction easements, permanent
❑
Existing Facilities
easements, and ROW shown.
17
All wells within 200 feet of project shown.
❑
Existing Facilities
18
All houses and places of public assembly within 100
®
Existing Facilities -Plan Included
feet shown.
Wetlands, watercourses, and drainage features within
19
50 feet of all wastewater treatment or storage facilities
®
None within 50'
shown.
20
Identify on the plans each water body's watershed
On site plan
classification.
21
Plan sheets for all applicable disciplines.
22
Reliability per NCAC 2T .0505 (1).
❑
23
Identify 100 year flood elevation on plans.
®
On site plan
24
North arrow on each plan sheet.
25
Horizontal and vertical control.
26
Subsurface investigation for new structures.
❑
Not Applicable
Municipal/Public Facilities, also include the following:
Engineer's Certification signed, sealed, and dated by
27
the Engineer Of Record stating that the project
❑
complies with G.S. 133-3.
28
Minority Business Forms for Local Government
❑
Projects.
29
Minority Business Guide.
❑
30
Dispute Resolution with mediation for Local
❑
Governments.
31
Contract Duration included.
❑
Projects funded through CG&L must include the
32
Submittal Checklist, found under Plans &
❑
Specificiations at:
http://www.nccal.net/Enciineering/plans.html

J
Acribian Cnginee�ing, V. 3.
V. ®. TSox 1291, 28503
600 -M VYa3a 38oulebarb
Riuotou, Portb Carolina 28501
Terepbone 1-252 -522 -2587
October 29, 2007
Construction Grants and Loans
1633 Mail Service Center
Raleigh, N. C. 27699-1633
Ref: Britthaven of Madison Wastewater Treatment Plant
NPDES Permit No. NCO044750
Rockingham County
Dear Sir:
Find attached a design for the installation of a UV Sterilizer for the outflow
effluent from the existing waste treatment plant at Britthaven of Madison. This
unit will meet the criteria your Winston-Salem office outlined in a letter to
Britthaven October 6, 2006. This letter requests a review of the plans and an
Authorization to Construct. The current chlorinator disinfection system will be
abandoned and no longer used.
If you have any questions or additional requirements around the design, please
call me (252-522-2587). Thank you for your cooperation.
Sincerely,
William A. Gold, P. E.
WAG/ilo
Enclosures(5)
CC: Ms. Dannie Kennedy-Hillco Support
Ms. Anne Skow-Britthaven of Madison
•.•`��N CARC, `4
,� A •..........!D4
io
.00
YY
SEAS
Y 4
�•. !y'•�NG INE�e'' ©�•�v
, �A M, A'Gp,••.

BRITTHAVEN INC.
P.O. BOX 5338
KINSTON, NC 28501
252-523-8700
November 7, 2007
Construction Grants and Loans
1633 Mail Service Center
Raleigh, N.C. 27699-1633
Attn: Anita Reese_ -- ------ - --
Ref: Britthaven Of Madison Wastewater Treatment Plant
NPDES Permit No. NCO044750
Rockingham County
Dear Ms. Reece,
By way of this letter I am designating Meridian Engineering, P; A. (William A.
Gold, P.E.) as our authorized agent in the permitting process described above.
Thank you for your cooperation.
Si erely,
Dannie Kenned
Manager
Dek/Sbb
CC: William A. Gold, P.E.-Meridian Engineering, P.A.
Ms. Anne Skow-Britthaven of Madison

fHertbtan (ffngineertrtg, V. Of.
,V. ®. JBox 1291, 28503
600 -M Vta3a Joutebarb
Rin$ton, Portb Carotina 28501
Tetepbone 1-252 -522 -2587
November 12, 2007
Construction Grants and Loans
1633 Mail Service Center
Raleigh, N. C. 27699-1633
Ref: Britthaven of Madison Wastewater Treatment Plant
NPDES Permit No. NCO044750
Rockingham County
Project Scope of Work
This project involves the installation of an on-line UV sterilizer to sterilize the
effluent output of the Britthaven of Madison packaged waste treatment plant.
Current flows are 25,000 gallons per day design and 12,000 gallons per day
average actual. Peak flow is 14.8 gpm (20,000 gpd rate) as measured by flow
meters. The UV sterilized is a Sanitron S 5000C which has a capacity to sterilize
60M gallons per day (83 gallons per minute). Connections to tie into the
existing line will be 2" with 2" unions for equipment maintenance and
replacement. The unit will have it's own console to monitor performance and
operation. A brochure of the equipment is attached along with the engineering
drawings of the installation. Note that the current chlorinator disinfection
system will be abandoned in place.

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3
models S2400C &
S5,000C, S 0,000C, S15,000C9 SF01000C
& S25,000C High Capacity Sy4tems
Installation, Operation & Maintenance
i
CEATLANTIC U ULTRAVIOLET
CORPORATION
375 Marcus Boulevard • Hauppauge, NY 11788 • USA
631.273.0500 • Fax: [phone]
e-mail: [e-mail]
Extensive Product Information Available at:
wvvw.0 traviolet.com
Document No. 98-1132C • Revised June 2007 • 02003-2007 Atlantic Ultraviolet Corporation

TECHNICAL SPECIFICATIONS
Table 4 - Technical Specifications
_LI005dOdt
DtU U �.
250
333
Flow Rate (GPM):
40
83
166
416
Flow Rate (GPH):
2400
5,000
10,000
15,000
20,000
25,000
Inlet\Outlet Size:
2"m NPT
2"m NPT
2"m NPT
2"m NPT
2"m NPT
2"m NPT
Number of Lamps:
1
2
4
6
8
10
Lamp Model No.:
GX48L
GX48L
GX48L
GX48L
GX48L
GX48L
Length:
521/."
521/,"
52 Y."
52 Y."
521/."
al 1i."
Width:
6'/1,"
171,
21 Y."
21 '/,"
21 '/."
21 'h"
Height:
11 '/,"
15"
343h"
53 '/4"
71 '/,"
90 /"�
Chamber Diameter:
5 'h"
5 'h"
5 'h"
5 th"
5 '/,"
5 '/?
Shipping Weight (Gross):
49 Lbs
116 Lbs
267 Lbs
400 Lbs
534 Lbs
670 Lbs
Voltage:m
120V
120V
120V
120V
120V
120V
Amps:
1.17A
2.34A 4.68A
7.02A
9.36A
11.7A
Frequency:
60Hz
60Hz 60Hz
60Hz
60Hz
60Hz
Power Consumption:®
140 Watts
280 Watts 560 Watts
840 Watts
1120 Watts
1400 Watts
Lamp Watts:
110 Watts
220 Watts 440 Watts
660 Watts
880 Watts
I100 Watts
Max Operating Pressure:
100 PSI
100 PSI 100 PSI
100 PSI
100 PSI
100 PSI
Ambient Temperature:
33° F - 100°
33° F - 100° F 33° F - 100° F
33° F - 100° F
33° F - 100° F
33° F - 100° F
Quartz Sleeve:
1
2 4
6
8
10
Drain Plug:
%." NPT
%." NPT %4" NPT
'/." NPT
%4" NPT
%4" NPT
Lamp Out
Indicator:
Translucent
Sight Port
Translucent Translucent
Sight Port Sight Port
Translucent
Sight Port
Translucent
Sight Port
Translucent
Sight Port
Ultraviolet Monitor: m
Optional
Optional Optional
Optional
Optional
Optional
Audio Alarm: m
Optional
Optional Optional
Optional
Optional
Optional
Solenoid Valve: T
Optional
Optional Optional
Optional
Optional
Optional
Time Delay Mechanism: ®
Optional
Optional Optional
Optional
Optional
Optional
Elapsed Time Indicator:
Optional Optional Optional
Optional
Optional
Optional
O 220V 50Hz, 220V 60Hz, units are also available. Cons t ac ory for specific voltage requirements.
® Use of this option is recommended by U.S. Public Health Service "Criteria for Acceptability of an Ultraviolet Disinfection Unit."
Originally issued April, 1966.
m Total power consumption, including ballast loss (based on 120V unit).
14

INSTALLATION
1. Remove water purifier from shipping carton. Inspect water purifier, power cord and plug for damage. Do not operate if
there is any damage to the purifier, power cord or plug. SANITRON® Model S2400C is shipped with the lamp packed
separately. Keep the lamp aside for installation once the purifier has been properly installed.
2. Units occasionally experience damage in shipment due to the fragility of the quartz sleeve. It is, therefore, recommended
to inspect the water purifier for damage to the quartz sleeve after it has been removed from the shipping carton. Each end
of the unit as well as the inlet and outlet should be viewed to see if the quartz sleeve has experienced damage. If the
quartz sleeve shows signs of damage it should be replaced before the purifier is pressurized. See "Quartz Sleeve
Cleaning or Replacement" in the "Maintenance" section for the proper method of replacing the quartz sleeve in your
water purifier.
Figure 2 - Recommended Installation
Note:
Solenoid plugs Into the top of the Time Delay,
Use of Metal Pipe is recommended for 12'
and the Time Delay into the Ultraviolet Monitor
past elbow to the Inlet or from the outlet.
(avoids ultraviolet degradation of exposed plastic pipe)
OPTIONAL EQUIPMENT
Cold Water Line
Two Minute Time Delay Elbow
POINT OF USE
(POU)
COMMON
Solenoid Valve
Incoming PRE TREATMENT or
Water PUMPIkNd DEVICES
Flow Control Valve
ulb Wao W.I., Purta.r.
should be Installed closest
to the
Supply» LDeio>ifzer
-.q--Elbow
point of us..
2 Water.""Softener
9 Garbon'Elters (GAC)
Outlet Une to
point of use
4.-m"ere Tink 5 Micron Filter
S P06um p
OPTIONAL EQUIPMENT
to be as short
& RevetSgOsmoeis
Ultraviolet Monitor
as possible
1 Valve Fardters —1► Audio Alarm
Valve
Nqt flcht ii5ler Purifiers
theuldbeinslided dosesf
Union
todapbntb(ti a 000
_�. `,a, x
Union
12" Manual Wiper_
6' Minimum
���
Clearance for
II
� ----�I
Gland Access
Recommended Minimum Clearance
For Lamp or Quartz Sleeve Removal
Wall Mounting Wt
Ultraviolet Water Purifier
OPTIONAL EQUIPMENT
3. The water purifier should be mounted horizontally on a flat dry surface. Secure the water purifier using the mounting
holes in the ballast housing or with the optional wall mounting kit. The purifier should not be solely supported by its
plumbing connections.
4. The water purifier must be connected to the cold water line only.
5. It is recommended that a 5-micron sediment filter be installed, in line, prior to the water purifier. The sediment filter will
stop or trap any particulates from entering the water purifier. Particulates may cause damage to the quartz sleeve, as well
as interfere with the purifier's ability to disinfect the water. The sediment filter may also help to reduce the amount of
routine cleaning of the quartz sleeve.
6. Shut off valves should be installed on both the inlet and outlet sides of the water purifier. The use of bypass valves is not
recommended. The shut off valves allow the purifier to be isolated from the water supply, which is required when
removing the quartz sleeve.
7. Unions should be installed on both the inlet and outlet of the water purifier; this will allow easy removal of the water
purifier from the plumbing, if required. Apply Teflon® tape to threads of inlet and outlet ports to ensure a tight seal.
8. When all plumbing connections are complete, allow water to enter the water purifier at a low flow rate, until the purifier
is pressurized. With the purifier pressurized, it should be checked for leaks. Once it is determined that there are no leaks,
the inlet valve can be fully opened.
9. Install lamp following the steps in "Lamp Installation or Replacement" section.
A CAUTION: Lamp and quartz sleeve are easily damaged. Exercise care when installing lamp.
10.Once the plumbing hook ups are made, it is a good practice to disinfect the "downstream" plumbing between the purifier
and point of use. This is done by introducing chlorine into the purifier chamber, a 100-ppm of chlorine is suggested. With
the chlorine in the purifier chamber, turn the ultraviolet purifier on. Open the "downstream" outlet until a chlorine odor is
noticed. Close the outlet and allow the chlorine to remain in the plumbing for three (3) hours. Flush the plumbing with
ultraviolet purified water; allow the water to run for several minutes before use. This will allow the ultraviolet lamp to
reach its full germicidal output.

RECOMMENDED OPTIONS
I. Guardian" Ultraviolet Monitor*: Visually indicates the level of germicidal ultraviolet energy that penetrates the
quartz sleeve and the water within the water purifier. The ultraviolet monitor is capable of operating an optional
audio alarm and/or solenoid valve. The ultraviolet monitor will detect reduction of ultraviolet levels due to:
• Fouling or deposits on the quartz sleeve.
• Poor ultraviolet transmission through the water; color, turbidity, and organic or other impurities in the water can
reduce or interfere with the transmission of ultraviolet rays.
• Lamp outage, component or power failure.
• Depreciation of the lamp output due to usage or other cause. Lamp output gradually depreciates with use. Lamp
replacement is recommended once each year.
2. SentryTM Safety Sensor: Pilot lamps provide constant visual monitoring of normal operation. In the event of power
or lamp failure the safety sensor indicates an alarm condition. The safety sensor is capable of operating an optional
audio alarm and/or solenoid valve.
3. SteralertTm: Lamp Status Alarm produces a high pitched, pulsed tone when the purifier is no longer functioning due
to lamp or power failure.
4. SureFLOM: Flow Control Valve, limits water flow to the rated capacity of the purifier. The flow control valve is
located in line prior to the water purifier, and should be protected from ultraviolet exposure by the use of a
90-degree elbow fitting between the flow control valve and the water purifier.
5. Audio Alarm*: Activated by the Ultraviolet Monitor or Safety Sensor, alerts the user to any malfunction detected.
6. Solenoid Valve*: Operated in conjunction with the Ultraviolet Monitor, Safety Sensor or Time Delay Mechanism,
this valve prevents water flow through the water purifier when an abnormal condition is detected or in the event of
power failure.
7. Elapsed Time Indicator: A non-resettable display of the water purifier operating hours. Useful for scheduling and
recording maintenance and lamp replacement.
S. Time Delay Mechanism*: Provides a 2-minute warm up period during which the ultraviolet lamp achieves its full
germicidal output before the water is allowed to flow through the water purifier. The time delay mechanism is used
in conjunction with, and is electrically connected to the Solenoid Valve.
Wall Mount Kit: (S2400C) Stainless steel wall brackets provide quick and easy installation and professional finish.
Pre -drilled and ready to install. Optimizes free air circulation to cool ballast housing.
*Use of this option is recommended by U.S. Public Health Service "Criteria for Acceptability of an Ultraviolet
Disinfection Unit." Originally issued April, 1966
OPTIONAL ACCESSORIES
Table 2 - Optional Accessories
%„ tJ,Rnal, „cessaries,
Ayai.lable lox;
GuardianTM Ultraviolet Monitor - AnaloglDigital
S2400C, S5,000C - S25,000C
Sentr T'" Safety Sensor
S2400C, S5,000C - S25,000C
SteralertT"'
S2400C, S5,000C - S25,000C
Audio Alarm
S2400C, S5,000C. - S25,000C
Elapsed Time Indicator - Universal Input
S2400C, S5,000C - S25,000C
Time Delay Mechanism
S2400C, S5,000C - S25,000C
Wall Mounting Kit
S2400C
Solenoid Valve- Brass (1-1/2") T
S2400C
Solenoid Valve - Brass (1-1/2") ®
S2400C
Solenoid Valve - Brass (2") T
S5,000C - S25,000C
Solenoid Valve - Brass (2") O
S5,000C - S25,000C
SureFLOTm Flow Control - PVC (2") ®
S2400C
SureFLOT" Flow Control - Stainless Steel 2" ®
S2400C
SureFLOTm Flow Control - PVC (2" Union) 0
S5,000C - S25,000C
Options are available for operation
at 120v 60Hz or 220v 50Hz.
Not all options may be available
for all models, consult factory for
availability.
i0 Solenoid requires 10-PSI for
satisfactory operation.
® Solenoid operates at 0-PSI and up.
m Unless otherwise specified:
PVC flow controls are supplied.
All PVC and Stainless Steel flow
controls are male NPT.

A=&
A
NM'kNR�
North Carolina Departmt3id Natural Reaoutr�ee
DMaion of Watier Quality
F. Eastey, Qovemor
S. 9kow
Liven. Inc.
Bald Head Loop
con. North' CarolI= 27025
MDam 0. Rose, Jr., Secretary
Alan W.10mek, RE, Director
April 23, 2007
Subject' Issuance of NMF_S Fermit N00044756
Britthavgn of MadisQm V W
Rockingham County
Division personnel have reviewed and approved your application for renewal of the subject permit.
Amkft
63r, we are forwarding the attached NPDES discharge permit. 7l'bia permit is issued
•p U=tto-the •requ rem�ents of-North.Carolina:Gese St U&te..143-215:�•aud Uw-M motuFidum,of
between North Carolina and the. U.S. Envitorimental Protection Agency dated May 9.
i (or as'subseque amended)..
t if parts, t frequ�e�ncies or sampling requirements contained in this permit are
table to you, you have the right to an adjudieatory hearing upon written request within
(30) days Mowing receipt of this letter. This request must be in the foriao► of a vaitten petition..
y to Chapter I50B of the North Cuolina. General Statutes, and fried wfM. the Office of
trative Hea=i=igs (fi714 Mail Service t3trutr, Raleigl, North Carolina 27699-ta714). Unless
su deugarid xs made, this decision shall be fugal and binding
PI note that this permit in not transferable after Halite to the nivisioa�L. 'Ihe Llivlsion may
req " modification or revocation and reissuauee of the permit This permit dom not a5wt the 1W
emmts to obtain other permits Which may be required by the Division of Water Quality or
is required by the Division of Land Resources, the Coastal Area Managquneat Act or ICY other
1 F or Laval governmental pmm* that may be required.
if have axxy questiaona canceTr�ing this permit please contact Vanessa Manuel. at telephone
n [phone], extension 532.
Sincerely,
: r : Alan W. RUmek. P.E.
Attg is
1; Co. DWQ/SWF Central Files
DWQ/SWF Winston-Salem Regional Ofce
1@1� art Service Ceritar, Aaielgh, NorB1 t�coina 27@991t3t7
$12 . Seua W S , RaWgk North Carofma 2M N Caro
ka
•91A••73i4Oi IFAX a10-73H7te/trtemet wmem m �AMAappatunilylAIRont o Aolon E►tplWar- Sr% Ragdsd O%.Post Cargi er Paper
atrrr-�

gerxnit lvco044750
STATE OF NORTR CAROLNA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QIIALITY ,
, ... �Ei2IVlIT •
TO DiscHARGE WASTEWATER UNDER Tim
NAL= AL POLLUTANT RISCBARGE :RDMATION !`Y2TEM
comylimce *ith the'provisions of North Cazolina General Statute 143-215.1, other
lawW standards and regulatipns promulgated and adopted by the North Cambia&
En
vironmentel Management Commission, and the Federal Water Pollution Control Act; as
is hereby authorized to discharge wastewater from a facility located' -at the we
Britthaven Of Madison WftP
Bald Hill Loop '
Southeast of Madison,
Rockiaghsm County -
to receiving waters designated as Hoga ns in the Roanoke Viver Basin
m w=dance with* effluent limits, monitoring requiremtntas and other conditions
set forth in Parts I, Ii, M and IV hereof.
Ths permit shalt bew=c effective June 1, 2007. .
permit and authorization to discharge shall expire at midnight on May 31, 2012.
ed this 44 April 23, 2007.
IQimek, P.E.,
Division of Waver Quality
rBy Authority of the Euv" mental Management Commission
y

Ail I
the I
F.
4",
Permit 9C0044750.
SUPPLEMENT TO PERMIT COVER SHEET
tka NMES permits' issued' -to . W3,'fi%cMty, Whither for aperatica or discharge 'are hereby
An of tWe permit issuance, my previou&4 issued permit bearing this uUmber is no labor
Ttere&re, the e=Iusive authority to operate and discharge from tWa bmthty arises under
t conditions, requirements, terms, and provisiosrs included herein.
Brit avert Inc. ,
is hereby authorized to:
ntinue to operate an =dsfing 0.025 MOD dual package wastewater treatment
3tem with the following compon";
# Flow equalization
Aeration basins
7r, -C
♦ Chlorine contact chamber with chlorination
♦ Flow mmsuremeat
♦ Aerobic digester
facility is located southeast of Madison at. Brittlieven of Mhdison, at 1721
Hal Loop in Rockingham County.
,large from said.. treatment works at thelocation specified on the attach6d
into Hogans Creek, classified C waters in the Roanoke River Basin.

Permit NICO044750
A' 1.) MPFLVElgT LMTS AND 1NOWTORING REQFJJLRLME M — FINAL
DU tCH he period be6nning on June 1, 2007, alut lasting until May 3I, 20I2, the perniitroee is authotiaed m treated vl"tewater from rnittall 001. Such discharges shall be limited grid Jmoni�red
as "d below: by the PGsrafttee
-
- -.. Mw.wAM �wou UUAO MOD
Cantinuoua
usMorJ=fftclent
C - 00310 30 45
Grab
Effluent
a Total Sus 45
Wa
Clrab
Effluent
M
. Ammonia Tow as • - 00640
2/Month
Grab
Elft wt
orm, ROW MF, M-FC Smth,44.6C - 31616
200' 1 400 8r100mi
Week
Grab
�
Effluent
Ch
Dial Residual - 50060 28
2 /Week
Grab
Effluent
. C
5 i
Crab
Effluent
00
on pissow - Who
4ab
Effluent
Sv
is US • 38260 18.6 IL
2/month
Effluent
H
00400
S.U.
W
Grab
EfRuent
T
re, Water ..Can' rade • 0001t) C
W
UpsDownesam
Grob
0
t>fasulved - 00300
Weekly
Grab
uofteem
Do &
ftat
NCSR.2308bridge; DOWnst m m = at the 14CSR 2189 budge.
amge dissolved oxygen effiuent concmtrznion abZ notbe
Less thou 6,0 mg/L611
Aot be Ims than6.0 staadavd units nor gteaur than 9.0 standard units.
Th
shall be no discharge of floating solids or via-61e fo= m other than trace amounts