NC0073571_Regional Office Historical File Pre 2016

North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
September 10, 2015
Mr. Mervyn R. King
7700 US Hwy 158
Stokesdale, NC 27357
Subject: NOTICE OF VIOLATION (#NOV-2015-)LV-0583)
Permit No. NCO073571
Countryside Manor WWTP
Guilford County
Dear Mr. King:
Donald van der Vaart
Secretary
A review of the Countryside Manor WWTP monitoring report for June 2015 showed the following
violation:
Parameter
Date
Limit Value
Deported Valve
Limit Type
Fecal Coliform
6/5/2015
400/100ml
600/100ml
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 or require any additional information, please contact Mike Mickey at (336)
776-9697.
Sincerely,
t� 'I
Sherri V. Knight, PE
Assistant Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources
cc: David Merritt ([e-mail])
DWQ Central Files
�': ,. �
450 West Hanes Mill Road, Suite 300, Winston-Salem, NC 27105
Phone: [phone] \ Internet: www.ncwaterguality.org
An Equal Opportunity \ Affirmative Action Employer— Made in part by recycled paper

DMR ReAsw Record
Facility: Permit No.:
Pipe NO,
Manthiv Averaae Violations
MonthNear;
�vAe Ici
Parameter Permit Limit DMR Value, % Over Limit Action
W9kIY/§ail.Violations
Date Parameter Permit Limit. Limit Type DMR Value % Over Limit Action
Mo nIWIna Freauengy Violations
Date Parameter Permit Frequency Values Reported # of Violations Action
Other Violations/Staff Remarks:
'upervisor Remarks:
Completed by:
Assistant Regional
Supervisor Sign off:
Regional Supervisor Sign
Off:
bate:—"\
Date:
Date:

EFFLUENT
NPDES PERMIT N0: � �N DISCHARGE NO.C-,O_ MONTH Yk?A-R g
FACILITY NAME_A CLASS COUNTY
CERTIFIED LABORATORY (1)_ _ Wic%R % Z�t.k4l-- CERTIFICATfON'NO. % G
(list additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC)_ t A A g CC W V Pa2L- - GRADE �.� - CERTIFICATION NO. (-
PERSQN(S)COLLECTINGSAMPLES iaetC, QA.J("t--- ORCPHONE _31(y
CHECK BOX IF ORC HAS CHANGED N0. FLO / DIS GE FROM SITE
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES x- �.
DIVISION OF WATER QUALITY (SIGNATURE OF OPERATORIN RESP N51B E CI.RGE) DATE
161'7-MAIL SERVICE CENTER BY TINS SIGNATURE, I CERTIFY THAT THIS REPO RT IS,
RALEIGH. NC 27699-16I7 ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE:
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DWQ Form MRA (1 I/04)

North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
June 12, 2015
Dr. Mervyn R. King
7700 US Hwy 158
Stokesdale, NC 27357
Subject: NOVICE OF DEFICIENCY (# NOD-2015-MV-0090)
NPDES Permit No. NCO073571
Countryside Manor WWTP
Guilford County
Dear Dr. King:
Donald van der Vaart
Secretary
A review of the Countryside Manor WWTP monitoring report for March 2015 showed the following
monitoring violation:
Parameter
Plate
Permit Frequency
Values Reported
# of Violations
Chlorine
3/23 — 3/27
2/Week
1
1
Thank you for your attention to this matter. Remedial actions should be taken to correct the cause(s) of this
violation. Unresolved violations may lead to the issuance of a Notice of Violation and/or assessments of
civil penalties.
If this violation is due to a transcription error, and certifiable data are available to rectify the noncompliance,
we ask that you please submit an amended DMR(s) to the Division of Water Resources. Send two copies of
the amended report to:
Attn: Central Files
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
If you should have any questions, please do not hesitate to contact Mike Mickey at [phone].
Sincerely,
Sherri V. Knight, PE
Assistant Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources
cc: David Merritt ([e-mail])
Central Files — SWP /S V
450 West Hanes Mill Road, Suite 300, Winston-Salem, NC 27105
Phone: [phone] \ Internet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer — Made in part by recycled paper

Facility: \,(�
Parameter
DMR ReAw Record
Permit No.: Pipe No.: (�o\
Monthly Average Violations
Month/Year: V���\�
® Permit Li DMR Value % Over Limit
Weekly/Daiiv Violations
Action
Date Parameter Permit Limit imit Type DMR Value % Over Limit Action
Monitoring Frequency Violations
Date Parameter Permit Frequency Values Reported # of Violations Action
Other Violations/Staff Remarks:
Supervisor Remarks: _ f -
Completed by:�
Assistant Regional —
Supervisor Sign Off:
Regional Supervisor Sign
Off:
Date:
1r
s
t
Date:
S
Date:

TiA
PECEIVED SE,
N.C.Dept-. ofENR
EFFLUENT'
Winst Lon -Salem
Regional Offi
NPDES PERMIT NO. JAIR 4 M3 MAN OA DISCHARGE NO.
-FACILITY NAMER&�*Omgwimirl -0-4-00AN&W CLASS COUNT u
CERTIFIED LABORATORY (1) "FX�TC-'C-M t#J(:, CERTIFICATION NO. /&-05
(list additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC) MIVC, LJ GRADE CERTIFICATION NO. 6 61,
PERSON(S) COLLECTING SAMPLES O&C., W.' �)AJQ(— ORC PHONE33r.
CHECK BOX IF ORC HAS CHANGED NO L0W / DISCHARGE FROM SITE
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES x
.DIVISION OF WATER QUALITY (SIGNATURE OF OPERATOR 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.
DWQ Form MR-] (11104)

North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
May 4, 2015
Dr. Mervyn King
Countryside Manor, Inc.
P.O. Box 829
Stokesdale, NC 27357
SUBJECT: Compliance )Evaluation Inspection
Countryside Manor WWTP
NPDES Permit No. NCO073571
Guilford County
Dear Dr. King:
Donald van der Vaart
Secretary
On April 30, 2015, Mike Mickey of this office met with Joel King and Ricky Shepherd from
Countryside Manor and Mark Nault and Patrick Merritt from Meritech to perform a Compliance Evaluation
Inspection on the Countryside Manor wastewater treatment system. The inspection fmdings are detailed
below and an inspection checklist is attached.
I. Permit
The NPDES permit expires April 30, 2016. At renewal, the permit will require that the monthly Discharge
Monitoring Reports (DMRs) for Countryside Manor be submitted electronically per new EPA rules.
II. Self -Monitoring Program
The DMRs were reviewed for the period March 2014 through February 2015. The facility was found to be
compliant with the effluent limits in the NPDES permit (see data summary attached). In regards to the
permit monitoring requirements, it was noted that one daily effluent temperature value was omitted on July
18, 2014. This issue was previously addressed in correspondence from this office.
M. ]Flow Measurement
The NPDES permit requires weekly instantaneous flow reporting. It was noted that the operator was simply
guessing at the flow values listed on the DMR based on past experience. This is not acceptable. The facility
has an operable ultrasonic meter that Countryside Manor is paying to have calibrated annually. The totalized
readings from the flow meter should be used for reporting accurate flows on the DMR. As discussed during
the inspection, a weekly flow value should be computed by dividing the total flow volume by the number of
days between readings.
IV. Sludge handling and Disposal
Solids are removed from the digester by Gann Brothers Septic Service. The pumping records are maintained
by the Countryside Manor maintenance staff. The unit was last pumped on December 19, 2014.
450 West Hanes Mill Road, Suite 300, Winston-Salem, NC 27105
Phone: [phone] \ Internet: www.ncwaterguality.ore
An Equal Opportunity \ Affirmative Action Employer— Made in part by recycled paper

Dr. Mervyn King
Page 2
May 4, 2015
V. Operations and Maintenance
No operation and maintenance issues were noted. Soda ash is added to the aeration basin and alum is added
at the splitter box to help the system meet the total phosphorus limit.
VI. Facilitv Site Review
The existing 0.015 MGD single train in -ground package plant consists of the following: aerated equalization
tank, bar screen, aeration basin, circular clarifier, sludge holding tank, tablet chlorinator, contact tank,
ultrasonic flow meter, tablet dechlorinator and concrete/rip-rap lined effluent channel. It was noted that
sample collection was occurring at the v-notch weir prior to the dechlor unit due to the difficulty in filling
samples bottles from the effluent pipe. The monitoring regulations (15A NCAC 2B .0503) state that effluent
samples should be collected after all treatment processes.
VU. Records/Reports
A comparison of the February 2015 monitoring report with the corresponding laboratory data sheets from
Meritech showed that the laboratory analytical results were transcribed onto the DMR correctly. However,
there was an issue with the transcription of temperature data from the operator's records to the DMR. Many
effluent temperature values were off by one degree. Care should be taken when transcribing the field data so
that it is accurate.
VIH. Effluent/Receiving Waters
The system discharges into Troublesome Creek, class "WS-III, NSW" waters in the Cape Fear River Basin.
The effluent was observed clear at the rip rap lined ditch near the creek on the day of the inspection.
Should you have any questions concerning this report, please contact Mike Mickey or me at (336)
776-9697.
Sincerely,
AII V_ 4_-
�ru
Sherri V. Knight, PE
Assistant Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources
cc: David Merritt ([e-mail])
Marc Nault ([e-mail])
"Qentrai

e
Permit: NCO073571 Owner - Facility: Countryside Manor WWTP
Inspection Date: 04/30/2015 Inspection Type: Compliance Sampling
Permit
Yes No NA NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new
❑
❑
No
application?
Is the facility as described in the permit?
■
❑
❑
❑
# Are there any special conditions for the permit?
❑
.0
❑
❑
Is access to the plant site restricted to the general public?
■
❑
❑
❑
Is the inspector granted access to all areas for inspection?
■
❑
❑
❑
Comment: A review of the monthly Discharqe Monitorinq Reports (DMRs) found Countryside Manor to
be compliant with the effluent limits for the review period March 2014 through February 2015.
Operations &c 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 N ❑ ❑ ❑
Solids, pH, DO, Sludge Judge, and other that are applicable?
Comment: The 0.015 MGD in -around package plant consists of the followin
*bar screen
*EQ basin (aerated)
*aeration tank with dual blowers
*circular clarifier
*sludge holding tank (aerated)
*tablet chlorinator w/contact tank
*tablet dechlorinator
*flow meter
Record Keeping
Yes No NA NE
Are records kept and maintained as required by the permit?
E
❑
❑
❑
Is all required information readily available, complete and current?
S
❑
❑
❑
Are all records maintained for 3 years (lab. reg. required 5 years)?
❑
❑
❑
0
Are analytical results consistent with data reported on DMRs?
❑
E
❑
❑
Is the chain -of -custody complete?
0
❑
❑
❑
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
❑
Page# 3

4
Permit: NCO073571 Owner -Facility: Countryside Manor WWTP
Inspection Date: 04/30/2015 Inspection Type: Compliance Sampling
Record Keeping Yes No NA NE
(If the facility is = or> 5 MGD permitted flow) Do they operate 24/7 with a certified operator ❑ ❑ E ❑
on each shift?
Is the ORC visitation log available and current?
0❑
❑
❑
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?
❑
❑
N
❑
Comment: A comparison of the February 2015 DMR with the certified laboratory data and the operator's
records showed that the results were accurately transcribed onto the monitoring report
except for temperature in February 2015. Numerous temperature values on the DMR were
actually one degree off from the temperature values listed in the operators records. Careful
attention should be paid while transcribing the data.
Bar Screens
Yes No NA NE
Type of bar screen
a.Manual
b.Mechanical
❑
Are the bars adequately screening debris?
0
❑
❑
❑
Is the screen free of excessive debris?
0
❑
❑
❑
Is disposal of screening in compliance?
0
❑
❑
❑
Is the unit in good condition?
0
❑
❑
❑
Comment: The Countryside Manor staff are responsible for raking the bar screen.
Equalization Basins
Yes No NA NE
Is the basin aerated?
E
❑
❑
❑
Is the basin free of bypass lines or structures to the natural environment?
E
❑
❑
❑
Is the basin free of excessive grease?
N
❑
❑
❑
Are all pumps present?
0
❑
❑
❑
Are all pumps operable?
E
❑
❑
❑
Are float controls operable?
E
❑
❑
❑
Are audible and visual alarms operable?
E
❑
❑
❑
# Is basin size/volume adequate?
0
❑
❑
❑
Comment: The EQ pumps have functioning audible and visual alarms.
Aeration Basins Yes No NA NE
Page# 4

I
Permit: NCO073571
Owner -Facility: Countryside Manor WWTP
Inspection Date: 04/30/2015
Inspection Type: Compliance Sampling
Aeration Basins
Yes No NA NE
Mode of operation
Ext. Air
Type of aeration system
Diffused
Is the basin free of dead spots?
0
❑
❑
❑
Are surface aerators and mixers operational?
❑
❑
0
❑
Are the diffusers operational?
0
❑
❑
❑
Is the foam the proper color for the treatment process?
N
❑
❑
❑
Does the foam cover less than 25% of the basin's surface?
0
❑
❑
❑
Is the DO level acceptable?
❑
❑
❑
Is the DO level acceptable?(1.0 to 3.0 mg/I)
❑
❑
❑
0
Comment: Single aeration basin.
Secondary Clarifier
Yes No NA NE
Is the clarifier free of black and odorous wastewater?
0
❑
❑
❑
Is the site free of excessive buildup of solids in center well of circular clarifier?
❑
❑
0
❑
Are weirs level?
E
❑
❑
❑
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)
❑
❑
❑
E
Comment: Single circular clarifier with paddles on the bottom to move solids.
Aerobic Digester
Yes No NA NE
Is the capacity adequate?
0
❑
❑
❑
Is the mixing adequate?
E
❑
❑
❑
Is the site free of excessive foaming in the tank?
0
❑
❑
❑
# Is the odor acceptable?
0
❑
❑
❑
# Is tankage available for properly waste sludge?
❑
❑
❑
Comment: Solids are pumped by Gann Brothers Septic Service. The Countryside Manor mainten'c
staff maintain the pumping records. The unit was last pumped on December 19, 2014.
Page# 5

Permit: NCO073571
Inspection Date: 04/30/2015
Owner -Facility: Countryside Manor WVVTP
Inspection Type: Compliance Sampling
Disinfection -Tablet
Yes No NA NE
Are tablet chlorinators operational?
E
❑
❑
❑
Are the tablets the proper size and type?
E
❑
❑
❑
Number of tubes in use?
3
Is the level of chlorine residual acceptable?
❑
❑
❑
E
Is the contact chamber free of growth, or sludge buildup?
E
❑
❑
❑
Is there chlorine residual prior to de -chlorination?
❑
❑
❑
Comment: Four tube chlorinator followed by the contact chamber.
De -chlorination
Yes No NA NE
Type of system ?
Tablet
Is the feed ratio proportional to chlorine amount (1 to 1)?
❑ ❑
E
❑
Is storage appropriate for cylinders?
❑ ❑
■
❑
# Is de -chlorination substance stored away from chlorine containers?
❑ ❑
N
❑
Comment:
Are the tablets the proper size and type? 0 ❑ ❑ ❑
Are tablet de -chlorinators operational? 0 ❑ ❑ ❑
Number of tubes in use? 4
Comment: The dechlor unit is located in -ground beside the package plant.
Flow Measurement - Effluent
Yes No NA NE
# Is flow meter used for reporting?
N
❑
❑
❑
Is flow meter calibrated annually?
N
❑
❑
❑
Is the flow meter operational?
0
❑
❑
❑
(If units are separated) Does the chart recorder match the flow meter?
❑
❑
E
❑
Comment: The facilitv has an ultrasonic meter and v-notch weir. The meter was last calibrated on
August 20, 2014 by Carolina Technical Services. It should be noted that the operator was
simply entering weekly flow values on the DMR based on past numbers, even though daily
totalizer readings are being recorded. The flow meter should be used to report values
based on actual usage. As discussed during the inspection, each weekly flow value should
be computed by dividing the total flow volume by the number of days between readings.
Effluent Pipe Yes No NA NE
Is right of way to the outfall properly maintained? N ❑ ❑ ❑
Are the receiving water free of foam other than trace amounts and other debris? 0 ❑ ❑ ❑
If effluent (diffuser pipes are required) are they operating properly? ❑ ❑ 0 ❑
Page# 6

Permit: NC0073571
Inspection Date: 04/30/2015
Effluent Pipe
Owner -Facility: Countryside Manor WWiP
Inspection Type: Compliance Sampling
Yes No NA NE
Comment: Effluent is discharged into Little Troublesome Creek class "WS-III NSW' waters in the
Cape Fear River Basin.
It should be noted that effluent samples are currently being collected prior to the dechlor unit.
The monitoring regulations state that effluent samples should be collected after all treatment
processes The possibility of installing an access point was discussed so that bottles could
be filled easily from the effluent pipe.
Page#

Data Summary
'Countryside Manor WWTP
NPDES Permit No. NCO073571
Self -Monitoring Data Summary
March 2014 — February 2015
Parameters
Monthly Avg.
Permit Limits
Monthly Avg. Limit
Violations per DMIR
Daily Maximum
Permit Limits
Daily Max. Limit
Violations per DMI2
Flow (MGD)
0.015
None
-
NA
BOD (mg/1)
30.0
None
45.0
None
TSS (mg/l)
30.0
None
45.0
None
NH3-N (mg/1)
(5.4 / 23.5)*
None
(27.0 — 35.0)*
None
D. Oxygen (mg/L)
-
NA
> 5.0 **
None
Fecal (#/100 ml)
200
None
400
None
T. Chlorine (ug/1)
-
NA
28.0***
None
T. Phosphorus (mg/L)
2.0****
None
-
NA
pH (S.U.)
-
NA
(6.0 — 9.0) range
None
* (Summer / Winter limits)
** Daily Average limit
*** TRC values reported below 50 ug/L are considered compliant.
* ** Quarterly average limit.

AZT*
NCDENR
North'Carolina Department of Elv.irorim.ent and Natural Resources
Pat McCrory Donald van der Vaart
Governor Secretary
March 5, 2015 .
Dr. Mervyn. R. King
7700 US Hwy 158.
Stokesdale; NC 273.57
Subject: NOTICE OF DEFICIENCY (#.NOD-2015-MV-0018)
NPDES Permit No. 'NC0073571
Countryside Manor WWTP
Guilford County
Dear Dr. King:
A review of the Countryside Manor WWTP monitoring report for December 20 showed the following
monitoring violation:
Parameter Date Permit Frequency Values Reported #. of Violations
PH 12/15=12/19 Weekly 0 1
Thank you for your'attention to this matter. Remedial actions should be taken to correct the cause(s) of this
violation.. Unresolved violations may lead to the issuance of a Notice of Violation and/or assessments of .
civil penalties.
If this.violation is due to a transcription error, and certifiable data are available to. rectify the noncompliance,
we ask that you please submit an amended DMR(s) to the Division of Water Resources. Send two copies of
the amended report to:
Attn: Central Files
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
If you should have any questions, please do not hesitate to contact Mike Mickey at [phone].
Sincerely,
Sherri V. Knight, PE
Assistant Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources
CC: David Merritt (david.merritt@.)m 'tech-labs.com)
Central Piles = SWP /.Aw
450 West Hanes Mill Road, Suite 300, Winston-Salem, NC 27105
Phone: [phone].\ Internet: www.ncwaterguality.ore
An Equal opportunity\ Affirmative Action Employer —Made in partby recycled paper

OMR Review Record
�Facility: C.Q�v ��, \�r�',� Permit No.: Pipe No.: MonthNear: _
v* z�, — 30�`�� MQ ���� onthl Avera a Violations
Parameter Permit Limit DMR Value % Over Limit Action
llileekly/Daily Violations
Date
Parameter
Permit Limit imit T e DMR Value
% Over Limit Action
Monitoring Frequency Violations
Date
Parameter
Permit Frequency Values Reported
# of Violations Action
Other Violations/Staff Remarks:
>upervisor Remarks: , �q
Completed by:
Assistant Regional
Supervisor Sign Off: ,ijl�iv�/
Regional Supervisor Sign
Off:
Date: a-1 - 15
Date:
Date:

i
KI.C.Deat. ofENR
F-E
FFLUENT
nston-Salem
TMS
gnce . r
NPDES PERMIT NO. _:Cep b;' — lonal ODID RGE NO._ QO l MONTH aEAR
3 FACILITY NAME_ G titT;t1t�113;Qix CLASS �COUNTY Frl3f 1,�bD
CERTIFIED LABORATORY (1)_(�'1�R j Z�
CERTIFICATION NO._
(Iist additional laboratories on the backside/page 2 of this form) -
OPERATOR IN RESPONSIBLE CHARGE (ORC) WUi PC w NiiuCC
PERSON(S) COLLECTING SAMPLES M ' ,16, Rj(}Jrr
CHECK BOX IF ORC HAS CHANGED C-
GRADE" CERTIFICATION NO. C� S
ORC PHONE _ a
N FLO / DISCHARGE FROM SITE
Mail ORIGINAL and ONE COPY to:
• ATTN: CENTRAL FILES MAIL SERVICE
x(
DIVISIONWATER QUALITY SIGNATURE FOP, IN P SIBLE CHARGE) DATE
RALAL ERVICE CENTER BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
EIGH, NC 27699-1617 �f ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
DWQ Form MR-] (11/04)

k
¢ ®©
_ A�14
ENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
October 7, 2014
Dr. Mervyn R. King
7700 US Hwy 158
Stokesdale, NC 27357
Subject: NOTICE OF DEFICIENCY (# NOD-2014-MV-0051)
NPDES Permit No. NCO073571
Countryside Manor WWTP
Guilford County
Dear Dr. King:
John E. Skvarla, III
Secretary
A review of the Countryside Manor WWTP monitoring report for July 2014 showed the following
monitoring violation:
Parameter
Date
Permit Frequency
Values Reported
# of Violations
Temperature
7/18/14
5/Week
4
1
Remedial actions should be taken to correct the cause(s) of this violation. The violations described
above should be abated immediately and properly resolved. Unresolved violations may lead to the
issuance of a Notice of Violation and/or assessments of civil penalties. Thank you for your attention to
this matter.
If you should have any questions, please do not hesitate to contact Mike Mickey at [phone].
Sincerely,
Sherri V. Knight, PE
Assistant Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources
cc: David Merritt _([e-mail])
Central Files - SWP
N.C. Division of Water Resources
585 Waughtown Street, Winstion-Salem, NC 27107
Phone: [phone] Internet: www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer — Made in part by recycled paper

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ATTN: CENTRAL FILES x Z(;
DIVISION OF WATER QUALITY (SIGNAT RE OF OPERATOR IN MSPONSFBLE CHARGE) DATE,
1617 MAIL SERVICE CENTER BY THIS IGNATURE, I CERTIFY THAT THIS REPORT IS
RALEIGH, NC 27699-1617 ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
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DWQ Form MR-1 (11/04)

R4#WA-1,
NC®ENR
Borth Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
May 9, 2014
Dr. Mervyn King
Countryside Manor, Inc.
P.O. Box 829
Stokesdale, NC 27357
SUBJECT: Compliance Evaluation Inspection
Countryside Manor WWTP
NPDES Permit No. NCO073571
Guilford County
Dear Dr. King:
John E. Skvarla, III
Secretary
On May 7, 2014, Mike Mickey of this office met with Ernie Newman and Ricky Shepherd from
Countryside Manor and Mark Nault, ORC, and David Merritt from Meritech to perform a Compliance
Evaluation' Inspection on the wastewater treatment system serving Countryside Manor. The treatment
facility was found to be in compliance with the effluent limits of the NPDES permit, except for two daily
maximum violations. The inspection findings are detailed below and an inspection checklist is attached for
your records.
I. Permit
The NPDES permit was issued effective June 1, 2011 and expires April 30, 2016. Please note that upon
renewal, your permit will specify a date for you to begin submitting DMRs electronically per the new EPA
rules requiring NPDES permittees to electronically submit DMRs. -
H. Self -Monitoring Program
The monthly self -monitoring reports (DMRs) were reviewed for the period March 2013 through February
2014. The facility was found to be compliant with all NPDES effluent limits, except for one daily maximum
fecal coliform violation that occurred on March 18, 2013 and one daily. maximum TSS violation that
occurred on December 5, 2013 (see data summary attached). These violations were previously addressed
by correspondence from our office. In regards to the permit monitoring requirements, it was noted that all
sampling was performed per the frequencies specified in the permit.
One paperwork issue noted involves the permittee signature on the back of the DMR. Currently, Marc Nault
is signing the back of the DMR forms. The permit [Part H, Section B(11)] requires that the permit holder
sign all reports unless a duly authorized representative has been designated. If you wish for someone to
continue to sign for you, please submit a Delegation of Signature Authority letter for our files (see example
letter attached).
III. Flow Measurement
The NPDES permit requires weekly instantaneous flow reporting. Flow values reported on the DMR are
obtained using an ultrasonic meter with v-notch weir. The ORC documents the weekly totalizer readings on
a log book kept in the blower building. Carolina Technical Services last calibrated the meter in August 2013.
Please make sure that the flow meter is calibrated in 2014 per Part H, Section D(3) of the permit.
N.C. Division of Water Resources
585 Waughtown Street, Winstion-Salem, NC 27107
Phone: [phone] Internet: www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer— Made in part by recycled paper

Dr. Mervyn King
Page 2
May 9, 2014
IV. Sludge Handling and Disposal
Solids are removed from the digester by Gann Brothers Septic Service for disposal at the Town of Madison
WWTP. Pumping records are maintained by the Countryside Manor maintenance staff.
V. Operations and Maintenance
The facility appeared to be competently operated and maintained. Due to a recent plant upset and subsequent
TSS issues, a polymer is being mixed in a bucket and added to the aeration basin to temporarily aid settling.
In addition, soda ash and alum are regularly added at the splitter box to help the system meet the total
phosphorus limit.
VI. Facility Site Review
The existing 0.015 MGD single train in -ground package plant consists of the following: aerated equalization
tank, bar screen, aeration basin, circular clarifier, sludge holding tank, tablet chlorinator, contact tank,
ultrasonic flow meter, tablet dechlorinator and concrete/rip-rap lined effluent channel. Sampling typically
occurs at the v-notch weir prior to dechlorination due to the difficulty in obtaining a sample from the effluent
pipe.
VH. Records/Reports
A review of the facility files indicates that all records are being maintained according to the permit. A
comparison of the February 2014 self -monitoring report with the corresponding laboratory data sheets from
Meritech showed that all values were transcribed onto the DMR correctly. One issue was noted with the
reporting of total phosphorus quarterly averages on the DMR. A quarterly phosphorus computed average
should not be listed in the total phosphorus column under parameter code 00665. Only the monthly average
should be listed under that parameter code. You can create another column for the quarterly total phosphorus
value to assist in judging compliance (without the parameter code and daily values in that column).
VHI. Effluent/Receivins Waters
The system discharges into Troublesome Creek, class "WS-III, NSW' waters in the Cape Fear River Basin.
The effluent was clear on the day of the inspection.
Should you have any questions concerning this report, please contact Mike Mickey or me at (336)
771-5000.
Sincerely,
:J
Sherri V. Knight, PE
Assistant Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources
cc: David Merritt (via email: [e-mail])
Marc Nault (via email: [e-mail])
Central Files
-0R'

Data Summary .
Countryside Manor WWTP
NPDES Permit No. NCO073571
Self -Monitoring Data Summary
March 2013 — February 2014
Parameters
Monthly Avg.
Permit Limits
Monthly Avg. Limit
Violations per DMR
Daily Maximum
Permit Limits
Daily Max. Limit
Violations per DMR
Flow (MGD)
0.015
None
-
NA
BOD (mg/1)
30.0
None
45.0
None
TSS (mg/I)
30.0
None
45.0
52 mg/L on 12/5/13
NH3-N (mg/1)
(5.4 / 23.5)'r
None
(27.0 — 35.0)*
None
D. Oxygen (mg/L)
-
NA
> 5.0 **
None
Fecal (#/100 ml)
200
None
400
1,070 on 3/8/13
T. Chlorine (ug/1)
-
NA
28.0***
None
T. Phosphorus (mg/L)
2.0't'��'I'
None
-
NA
pH (S,U.)
-
NA
(6.0-9.0) range
None
* (Summer / Winter limits)
** Daily Average limit
***TRC values reported below 50 ug/L are considered compliant.

Permit: NCO073571
Inspection Date: 05/07/2014
Permit
Owner -Facility: Countryside Manor WWTP
Inspection Type: Compliance Evaluation
(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: A review of the monthly self -monitoring reports (DMRs) for the period
March 2013 through February 2014 found the Countryside Manor WWTP to be
compliant with the effluent limits, except for one daily maximum fecal coliform violation
that occurred on 3/18/13 and one daily maximum TSS violation that occurred on
12/5/13. In addition, it was noted that all monitoring was performed per the frequencies
specified in the permit.
One paperwork issue noted involves the permittee signature on the back of the DMR.
Currently Marc Nault is signing the DMR. The permit [Part II, Section B(11)] requires
that.the permit holder sign all reports unless a duly authorized representative has been
designated by the permittee. If you wish for someone to continue to sign for you, please
submit a Delegation of Signature Authority letter for our files (see example letter
attached).
Operations & Maintenance
Is the plant generally clean with acceptable housekeeping?
Yoe Ml AI9 mr:
Yoe Nl Ale MP
®❑ ❑ ❑
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable Solids, pH, DO, Sludge I®❑ ❑ ❑
Judge, and other that are applicable?
Comment: . The 0.015 MGD in -ground package plant system consists of the following:
* bar screen
aerated equalization tank with pumps and audible/visual alarms
* aeration tank with dual blowers
circular clarifier
* aerated sludge holding tank
* tablet chlorinator with contact tank
* tablet dechlorinator
* effluent flow meter
Record Keeping
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)?
Yes No NA NE
®❑ ❑ ❑
®❑ ❑ ❑
®❑ ❑ Cl
Page # 3

Permit: NCO073571 Owner - Facility: Countryside Manor WWTP
s
Inspection Date: 05/07/2014 Inspection Type: Compliance Evaluation
Record Keeping
Yes No NA NE
Are analytical results consistent with data reported on DMRs?
11 ❑ ❑ ❑
Is the chain -of -custody complete?
Q Q Q
Dates, times and location of sampling
p
Name of individual performing the sampling
go
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 Q ® Q
(If the facility is = or > 5 MGD permitted flow) Do they operate 24/7 with a certified operator on each shift?
❑ Cl ® ❑
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?
IR ❑ ❑ ❑
Is a copy of the current NPDES permit available on site?
® Q Q ❑ "
Facility has copy of previous year's Annual Report on file for review?
❑ ❑ 0 ❑
Comment: A comparison of the February 2014 DMR with the certified laboratory
sheets showed that all parameters were accurately transcribed onto the DMR.
One issue pointed out during the inspection concerned the total phoshporus quarterly
average value being shown on the DMR. Please do not list a computed quarterly
average for total phosphorus in the total phosphorus column of the DMR under
parameter code 00665. Only the monthly average should only be listed under that
parameter code. You may create another column for the quarterly total phosphorus in
order to judge compliance, without the parameter code or daily values.
Type of bar screen
a.Manual
b.Mechanical Q
Are the bars adequately screening debris? f ❑ ❑ ❑
Is the screen free of excessive debris? ®❑ ❑ ❑
Is disposal of screening in compliance? ® Q Q Q
Page # 4

Permit: NCO073571 Owner -Facility: Countryside Manor WWTP
Inspection Date: 05/07/2014 Inspection Type: Compliance Evaluation
Bar Screens Yes No NA NE
Is the unit in good condition? Fp n ❑ n
Comment: The Countryside Manor staff are responsible for raking the bar screen.
Screenings are placed in a five gallon bucket to drain before disposal in the on -site
trash can.
Equalization Basins
Yes No NA NE
Is the basin aerated?
n n n
Is the basin free of"bypass lines or structures to the natural environment?
®❑ ❑ n
Is the basin free of excessive grease?
®❑ ❑ n
Are all pumps present?
n ❑ ❑
Are all pumps operable?
®❑ ❑ ❑
Are float controls operable?
® n n n
Are audible and visual alarms operable?
®❑ n ❑
# Is basin size/volume adequate?
®❑ ❑ n
Comment: The audible and visual alarms for the EQ pumps were tested and were
found to be operable.
Aeration Basins
Yes No NA NE
Mode of operation
Ext. Air
Type of aeration system
Diffused
Is the basin free of dead spots?
®❑ ❑ n
Are surface aerators and mixers operational?
❑ ❑ ® ❑
Are the diffusers operational?
in El n ❑
Is the foam the proper color for the treatment process?
®n n n
Does the foam cover less than 25% of the basin's surface?
®❑ ❑ ❑
Is the DO level acceptable?
❑ ❑ ❑ 81
Is the DO level acceptable?(1.0 to 3.0 mg/1)
❑ ❑ n B
Comment: There is a single aeration basin. The diffusers are staggered in the bottom
of the basin to promote efficient mixing.
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?
B ❑ n ❑
Page # 5

Permit: NC0073571 Owner -Facility: Countryside Manor WWTP
Inspection Date: 05/07/2014 Inspection Type: Compliance Evaluation
Secondary Clarifier
Yes
No NA NE
Is the site free of weir blockage?
®
Q Q Q
Is the site free of evidence of short-circuiting?
®
Q Q Q
Is scum removal adequate?
®
Q Q Q
Is the site free of excessive floating sludge?
®❑
❑ ❑
Is the drive unit operational?
❑ ❑ ❑
Is the return rate acceptable (low turbulence)?
®
Q ❑ Q
Is the overflow clear of excessive solids/pin floc?
®
Q ❑ ❑
Is the sludge blanket level acceptable? (Approximately'/< of the sidewall depth)
❑
❑ ❑
Comment: The single circular clarifier has paddles on the bottom for solids removal.
The weirs were level.
Aerobic Digester
Yes No NA NE
Is the capacity adequate?
®❑
Q Q
Is the mixing adequate?
®
Q Q Q
Is the site free of excessive foaming in the tank?
®
Q Q Q•
#.Is the odor acceptable?
®❑
Q Cl
# Is tankage available for properly waste sludge?
®❑
❑ ❑
Comment: Solids are removed by Gann Brothers Septic Service for disposal at the
Madison WWTP. The Countryside Manor maintenance staff maintains the pumping
records.
Disinfection -Tablet
Yes No NA NE
Are tablet chlorinators operational?
IN ❑ ❑ Q
Are the tablets the proper size and type?
in ❑ ❑ ❑
Number of tubes in use?
3
Is the level of chlorine residual acceptable?
Q Q Q RR
Is the contact chamber free of growth, or sludge buildup?
®Q Q Q
Is there chlorine residual prior to de -chlorination?
Q Q Q
Comment: The chlorinator unit and contact tank are located beside the clarifier. Three
of the four tubes are currently being used.
De -chlorination
Yes No NA NE
Type of system ?
Tablet
Is the feed ratio proportional to chlorine amount (1 to 1)?
❑ ❑ ® ❑
Page # 6

Permit: NCO073571 Owner -Facility: Countryside Manor WWTP
Inspection Date: 05/07/2014 Inspection Type: Compliance Evaluation
De -chlorination
Yes No NA NE
Is storage appropriate for cylinders?
❑ ❑ ® ❑
# Is de -chlorination substance stored away from chlorine containers?
❑ ❑ ® ❑
Comment:
Are the tablets the proper size and type?
®❑ ❑ ❑
Are tablet de -chlorinators operational?
❑ ❑ ❑
Number of tubes in use?
2
Comment: The dechlorination unit is located in the ground beside the package plant.
Flow Measurement - Effluent
Yes No NA NE
# Is flow meter used for reporting?
®❑ ❑ ❑
Is flow meter calibrated annually?
®❑ ❑ ❑
Is the flow meter operational?
I] ❑ ❑
(If units are separated) Does the chart recorder match the flow meter?
❑ ❑ ® ❑
Comment: The permit requires weekly instantaneous flow reporting. An ultrasonic
meter and v-notch weir are used to measure flow. Carolina Technical Services last
calibrated the meter back in August 2013. The meter will need to be calibrated again in
2014.
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: The effluent is discharged into Troublesome Creek, "WS-III; NSW' waters
in the Cape Fear River Basin.
Page # 7

<Date>
Mr. Charles Weaver
NPDES Compliance Unit
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
<Facility Name>
NPDES No. NC
Dear Mr. Weaver:
By notice of this letter; I hereby delegate signatory authority to each of the following individuals for
all permit applications, discharge monitoring reports, and other information relating to the
operations at <Facility Name> as required by all applicable federal, state, and local environmental
agencies specifically with the requirements for signatory authority as specified in 15A NCAC
2B.0506.
Name Title
If you have any questions regarding this letter, please feel free to contact me at <Phone Number>.
Sincerely,
<Facility Officers Name>
<Facility Officers Title>
cc: Winston-Salem Regional Office (Attn: Mike Mickey, NCDENR, 585 Waughtown St, Winston-Salem, NC 27107)

Notice of Finding for Immediate Response
The .following .finding(s) is/are found to be of such a nature that immediate
resolution is required. A corrective action response is to be forwarded to:
DWR Laboratory Certification Branch
1623 Mail Service Center
Raleigh, N.C. 27699 -1623
Parameter and Finding
Total Residual Chlorine — SM 4500 Cl G-2000
Finding: T burato s ug he pry a ulpmtfor"�i aleitlualChlorine. (VTR) ana'ys.
Requirement: Facilities and equipment. Each laboratory requesting certification must contain or be equipped
with the following: Glassware, chemicals, supplies, and equipment required to perform all analytical
procedures included in their certification. Ref: 15A NCAC 02H .0805 (a) (6) (H).
Requirement: See attached letters dated August 14, 2001 and May 1, 2008 regarding Division equipment
requirements for the analysis of TRC.
Comment: All data reviewed were for facilities that had TRC permit limits. However, a Hach Pocket
Colorimeter II is being used which the attached letters state is only allowed for facilities without a permit limit.
The laboratory indicated that they have a spectrophotometer that meets the requirements that is mainly used
for TRC analyses for toxicity. This meter is capable of being used with a battery in a field setting.
1. Please sign and return this form by Monday June 2, 2014.
2. Please submit a list of facilities (including NPDES permit numbers) that are affected as well as the
approximate time frame of the use of an unapproved meter. This information is due by June 13, 2014.
3. Please submit a current curve verification (using the battery as a power source) of an approved meter
and confirm that it is being used for all facilities. This information is due by June 13, 2014.
Auditor:
Lab Name: /leritech, Inc.
Date:
Cert #: 165
By signature I verify that I have read and understand the Finding described above.
Signature of responsible party: Date:
Name of responsible party:
(please print)
First
MI Last
The corrective action response must be received no later than: Date: Specified Above
A copy of this document must be submitted with the corrective action response letter.
Rev 05/30/2014

ENVIRONMENTAL LABO'RATORIES
A Div&;on of Water Technology and Controls, Inc.
June 6, 2014
Mt. Jason Smith,, Chemi.st. II
MC WW/GW Laboratory Ceiftification
NC DENR/Divisior of Water Resources
Sciences Section
As'1110-v,i,ile Regional Offi-ce
20'9,0 U.S. Highway 70
Swannanoa, NC 28179
Wat6r QUality, Pro,4rams Water
RE: Response to Notice of Finding for Immediate Response, May ' )0,. 20.14.
Dear Mr. Smith:
In response to your request we have -implemented the',following steps.:
I Requested .form was completed, signed, and, sent to,you via email on June 25
2014,
2. The following, is, zi, list ofaffected facilities: Crowd 'MHP -(NC0055?55),. Se7en
/Tietex,(NC00013 )48), Cornerstone Confere ' rice-Ctr. (NC0046809.); Stone
HighwayC00,60,623)-, Quail, Acres: (NCO05925 1).. C�o:t:.H:I�pqy j7d, M, -aTior
Q S..",
9�5i'� 1), andliavv,River Park- (NC0046019). Non -approved- chlorine meters
were used in these facilities approximately -since 2009.
u t 3. Please see attached current chlorine curve information: from: the apptovedme or.
This meter was calibrated in the field operation mode, using
sr ing a 12V car power.
battery supply. This meter will be used in all,the facilities listed above beginning
June 9, 2014!
If you have, any questions concerning this matter., -please give me a call.
, Z">
Sincerely,
Kris Pa�xlak-
Laboratory Manager
I
Meritech., Inc.
Ph: 336 )6 342 4748
642 Tamco Road ® P.O. Box 27 - Reidsville, NC 27320
[phone] 0 [phone] Fax

Page 22
#165 Meritech, Inc.
highly contaminated (free product) non-soil/sediments (debris). Any other use of ultrasonic extraction is
considered a "significant modification" of the EPH Method. Ref: MADEP, May 2004, Rev. 1.1, Table 4.
Comment: The laboratory uses a modified version of the soil/sediment extraction process from the MADEP
VPH method, substituting acetone for methanol.
Comment: The complete list of approved EPH extraction procedures for water and soil/sediment samples is
presented in Table 4. Alternative extraction procedures other than those listed are acceptable, provided that
the laboratory can document acceptable matrix- and petroleum product -specific performance. However, use
of an alternative extraction procedure is considered a "significant modification" of the EPH method pursuant
to Section 11.3.1.1 and as such would preclude obtaining "presumptive certainty' status for any analytical
data produced using an alternative EPH extraction procedure. Ref: MADEP, May2004, Rev. 1.1, Section 9.1.
Comment: Any method modification approval must come from the data receiving agency (i.e., the Division of
Waste Management, UST Section).
cccc. Finding: Units of measure were not documented on the EPH extraction log in the column for fractionation.
Requirement: All laboratories must use printed laboratory bench worksheets that include a space to enter
the signature or initials of the analyst, date of analyses, sample identification, volume of sample analyzed,
value from the measurement system, factor and final value to be reported and each item must be recorded
each time samples are analyzed. Ref: 15A NCAC 2H .0805 (a) (7) (H).
Die d'lParamefers
Comment: The laboratory performs two types of field parameter analyses. They have one certified WWTP operator
that operates Crown MHP (NPDES permit #NC0055255), Burlington Mfg. Services (NPDES permit #NC0001384),
Cornerstone Conference Center (NPDES permit #NC0046809), Stone Highway (NPDES permit #NC0060623), Quail
Acres (NPDES permit #NC0059251), Countryside Manor (NPDES permit #NC0073571), and Haw River Park
(NPDES permit #NC0046019). Other laboratory employees collect river basin samples for the North Carolina
Monitoring Coalition Program. The WWTP operator and Monitoring Coalition samplers use different benchsheets.
The Findings for Field Parameters will individually indicate to which category they apply (i.e., NPDES or Monitoring
Coalition).
Commen the Iborafiorywasnoffisin'gthe prop'er®qupt>ntftor�Totaf�Resiclual�Clllorineanal se .The North
Carolina Administra ive Code, 15A NCAC 2H .0805 (a) (6) (H) states: Facilities and equipment. Each laboratory
requesting certification must contain or be equipped with the following: Glassware, chemicals, supplies, and
equipment required to perform all analytical procedures included in their certification. A Division letter dated August
14, 2001 states: "This letter serves as notification to facilities with effluent permit limits for Total Residual Chlorine
(TRC) that effective July 1, 2002, the Division of Water Quality expects these facilities to utilize an instrument or
method that will detect and measure TRC concentrations to levels that are below the permit discharge requirements.
Please note that if a facility has no effluent limit for TRC (just a monitoring requirement), then use of a hand-held
meter, sometimes described as a pocket colorimeter, and the reporting of <100 pg/L as a TRC value is acceptable.
The Environmental Protection Agency (EPA) and the State have determined that in the interest of overall program
equity, to ensure water quality protection, and to comply with 15A NCAC 2B .0505 (e) (4), the Division will require all
facilities with TRC limits to utilize instruments or methods that will produce detection and reporting levels that are
below the permit discharge requirements for TRC." The laboratory was using a pocket colorimeter at all of the
NPDES permit facilities listed in the above comment and they all have low level TRC limits. It was determined that the
laboratory initially purchased a meter capable of low level TRC analysis, but returned to using the pocket colorimeter
when the meter did not work well. The laboratory has been using the pocket colorimeter since approximately 2009. A
Notice of Finding for Immediate Response (NOFIR) was issued to the laboratory regarding this issue and a copy was
provided to the Winston-Salem Regional Office staff. The laboratory replied to the NOFIR with an acceptable curve
verification on an approved meter and indicated that the approved meter would be put into use beginning June 9,
2014. No further response is necessary for this finding.
Recommendation: The inconsistencies between the benchsheets used by the two field units are the cause of
several of the Field Parameters Findings. Merging the existing benchsheets into one or creating a new benchsheet
(to be used by both units) that will encompass all of the needs for both units is recommended.

LABORATORY NAME:
ADDRESS:
CERTIFICATE #:
d7�ATE QF II PECTION:
TYPE OF INSPECTION:
AUDITOR(S):
LOCAL PERSON(S) CONTACTED:
INTRODUCTION:
On -Site Inspection Report
f t g nc.
P.O. Box 27
Reidsville, NC 27320
165
20�28—,f2 14
Commercial Maintenance
Jason Smith, Jeff Adams, Todd Crawford, Gary Francies, Nick Jones,
Dana Satterwhite, and Tonja Springer
Kris Pawlak, David Merritt, and Ian Bailey
This laboratory was inspected by representatives of the North Carolina Wastewater/Groundwater Laboratory
Certification (NC WW/GW LC) program to verify its compliance with the requirements of 15A NCAC 2H .0800 for the
analysis of environmental samples.
II. GENERAL COMMENTS:
The laboratory was clean and well organized. The facility has all the equipment necessary to perform the analyses.
Analytical data pertinent to each certified analysis was filed in an orderly manner and was readily available for
inspection upon request. Laboratory personnel were accessible to answer questions that arose during the inspection.
Some laboratory documentation was incomplete, inaccurate and additional quality control procedures need to be
implemented. The laboratory must take steps to bring operations into compliance with changes in federal
regulations, particularly 40 CFR Part 136 Methods Update Rules; the most recent was published on May 18, 2012.
Many Standard Operating Procedures (SOPs) were in direct conflict with method and/or regulatory requirements,
did not describe in detail how procedures are performed and personnel were not always following the procedures
as described in the SOPs.
The laboratory is reminded that any time changes are made to laboratory operations; the laboratory must update
the Quality Assurance (QA)/Standard Operating Procedures (SOP) document(s). Any changes made in response
to the Findings, Recommendations or Comments listed in this report must be incorporated to insure the method is
being performed as stated, references to methods are accurate, and the QA and/or SOP document(s) is in
agreement with approved practice and regulatory requirements. In some instances, the laboratory may need to
create a SOP to document how new functions or policy will be implemented. The laboratory must also take steps
to insure that all personnel are aware of the changes made; that they have fully implemented those changes and
steps have been taken (e.g., detailed SOPs and guidance documents, documented training and demonstration of
proficiency with new procedures, etc.) to prevent recurrence of findings.
The requirements associated with Findings A, N, 0, P, Q, T, HH, KK, YY, ZZ, LLL, MMM, and HHHH have been
implemented by our program since the last inspection.
III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
Documentation
Recommendation: The laboratory currently maintains only the most recent SOP revision date. It is recommended
that SOP review dates, in addition to revision dates, be maintained. It is recommended that SOPs include a revision
and review history with relevant dates (e.g., effective, review and revision dates) and a brief description of the
change(s) made.
Recommendation: Copies of each reference method are included in each SOP. However, the introduction section,
which lists the approval year for Standard Methods methods, is not included to verify that the document is actually the
most recently approved version. This means that further research (comparing page numbers and text to the approved

WAT
Michael F. Easley
*;e Governor
7 William G. Ross, Jr., Secretary
> „. North Carolina Department of Environment and Natural Resources
' . Gregory J. Thorpe, Ph.D., Acting Director
Division of Water Quality
August 14, 2001
Dear NPDES Pemuttee:
This letter serves as notification to facilities with effluent permit limits for Total Residual Chlorine (TRC)
that effective July 1, 2002, the Division of Water Quality expects these facilities to utilize an instrument
or method that will detect and measure TRC concentrations to levels that are below the permit discharge
requirements. Please note that if a facility has no effluent limit for TRC (just a monitoring requirement),
then use of a hand-held meter, sometimes described as a pocket colorimeter, and the reporting of <100
ug/L as a TRC value is acceptable. The Environmental Protection Agency (EPA) and the State have
determined that in the interest of overall program equity, to ensure water quality protection, and to
comply with 15A NCAC 2B .0505(e)(4), the Division will require all facilities with TRC limits to utilize
instruments or methods that will produce detection and reporting levels that are below the permit
discharge requirements for TRC.
North Carolina has hundreds of NPDES permitted facilities that are required to limit the amount of TRC
that is discharged from their effluent to the receiving waters of the State, Typically these limits are set at
either 17 or 28 micrograms per liter (ug/L) of wastewater discharged. The EPA has approved two
methods for low-level TRC analyses: the Amperometric Titration Method and the DPD Colorimetric
Method. The Amperometric Titration Method is a classic chemistry analysis performed in a laboratory
setting. Larger facilities with on -site laboratories frequently use this method and achieve reliable, low-
level results of their testing. Many permitted facilities with TRC limits are small and/or have no on -site
laboratory. Because TRC must be analyzed within 15 minutes of sample collection due to its volatile
nature, these facilities are not able to send these samples out for analysis to a commercial lab. They must
rely on a field technique, which will typically utilize the low-level DPD Colorimetric Method. There are
portable instruments available that have the capability of analyzing TRC in the range of 10-15 ug/L.
The Division realizes that changing the method of TRC measurement will not be without difficulty on the
part of the permittees, The permittees will have to evaluate and purchase or otherwise obtain access to
instruments and become both educated and proficient in their use. Please be advised while these
instruments are advertised as portable, permittees may have to prepare special on -site facilities to ensure
their most reliable operation. For these.reasons, permittees will not be required to use the more sensitive
instruments until July 1, 2002.
If you have questions about the contents of this letter, please contact Vanessa Manuel at [phone],
extension 532. The Division of Water Quality thanks you for your cooperation and understanding in this
matter.
Sincerely,
E. Shannon Langley, Supervisor
Point Source Compliance/Enforcement Unit
NCl FN7R
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 [phone] Customer Service
1 800 623-7748

�& WAr�c�Q
� Y
May 1 2008
To: NPDES Permittees
Subject: Total Residual Chlorine 50 ug/l Compliance Level
Michael F. Easley, Governor
State of North Carolina
William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
In a previous letter dated August 14, 2001, the Division of Water Quality (DWQ) notified
NPDES permittees that water/wastewater treatment facilities with Total Residual Chlorine
(TRC) effluent limits would be required to use analytical methods that produce detection levels
below their permit limit by July 1, 2002. [Note: TRC permit limits are typically set between 17
to 28 ug/1 for discharge to freshwater systems, and 13 ug/1 for discharge to saltwater systems].
This requirement was based on an Environmental Protection Agency (EPA) audit of the NC
enforcement program. It was also necessary to ensure water quality protection and compliance
with state monitoring regulations [15A NCAC 2B.0505(e)(4)].
Since that time, DWQ has received several inquiries regarding difficulties with the new
analytical methods, primarily focused on 1) lack of precision with field instrumentation at low
TRC levels for both water and wastewater treatment plants; and 2) manganese interference with
TRC measurement at several water treatment plants. Some facilities have overcome these
problems through various changes, such as: 1) switching dechlorination chemicals; 2) adding a
second dechlorination feed; 3) changing analytical methods; 4) incorporating manganese
correction; 5) switching to UV disinfection; 6) removing sludge from water treatment plant
settling basins. Also, the DWQ Laboratory Certification staff have provided extensive field
assistance for the new lab methods. Still, some analytical issues remain. In response to the
permittee's concerns, the Division is providing the following changes to its TRC requirements:
❑ TRC Compliance Level Changed to 50 ug1l. DWQ continued discussions with EPA
regarding analytical difficulties with TRC measurements, and in March 2008 received
EPA approval to allow '.a 50 ug/l TRC compliance level. This will not change the
analysis, annual verification of meter performance, or data reporting, but simply how the
reported values will be evaluated by DWQ from a compliance standpoint. Facilities will
still be required to report actual results on their monthly DMR submittals, but for
compliance purposes all TRC values below 50 ug/1 will be treated as zero. For example,
if the facility has a TRC limit of 17 ug/1 and reports a TRC value of 40'ug/1 on the DMR,
this value will be considered compliant under this new policy. This new compliance
level is effective March 1, 2008 (beginning with March 2008 DMR submittals). .
DWQ will continue to incorporate TRC effluent limitations into NPDES permits for all
water/wastewater treatment facilities that discharge chlorine -bearing wastestreams to surface
waters. While this new TRC compliance level of 50 ug/1 is effective beginning March 1, 2008, it
will be incorporated into existing NPDES permits with TRC effluent limits upon permit renewal.
At that time, the following TRC footnote language will added to the Effluent Limitations Sheet:
"The facility shall report all effluent TRC values reported by a NC certified laboratory including
field certified. However, effluent values below 50 ug/1 will be treated as zero for compliance
purposes."
Division of Water Quality, Point Source Branch Telephone [phone] NOne Caro spa
1617 Mail Service Center, Raleigh, North Carolina 27699-1611 FAX [phone] atucMa
512 N. Salisbury Street, Raleigh, North Carolina 27604 On the Internet at h //h2o.enrsta1anc.us/ . ✓ ru fJ
An Equal Opportunity/Affirmative Action Employer

Page 2 of 2
May 1., 2008 '
TRC 50 41 Compliance Memo
DWQ reserves the right to modify this policy in the future as analytical methods evolve. If you
have questions about the content of this letter, please contact Tom Belnick at [phone],
extension 543. If you need assistance with your TRC analytical methodology, please contact
Gary Francies with the DWQ Water Quality Lab at [phone]
Sincerely,
Matt Matthews, Supervisor
Point Source Branch
2

Mickey, Mike
From: Mickey, Mike
Sent: Friday, May 09, 2014 10:45 AM
To: [e-mail]; '[e-mail]'
Subject: Countryside Manor Inspection Report and eDMR info.
Attachments: Countryside Manor.pdf
David and Marc — Please find the NPDES inspection report attached. Additionally, below is the Division's eDMR web
page. The "User Registration" link will route you to the registration form that must be submitted to Raleigh.
http://Portal.ncdenr.org/web/wq/admin/bog/ipu/edmr

a q,y
(CDE R
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Water Quality Regional Operations Section
Pat McCrory Thomas A. Reeder John E. Slcvarla, III
Governor Director Secretary
March 19, 2014
Dr. Mervyn R. King
7700 US Hwy 158
Stokesdale, NC 27357
Subject: . NOTICE OF VIOLATION (# NOV-2014-LV-0113)
NPDES Permit No. NCO073571
Countryside Manor WWTP
Guilford County
Dear Dr. King:
A review of the Countryside Manor WWTP monitoring report for December 2013 showed the following
violation:
Parameter
Date
Limit Value
Reported Value
Limit Type
TSS
12/05/13
45 mg/1
52 mg/1
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 should have any questions, please do not hesitate to contact Mike Mickey at [phone].
Sincerely,
rig"�% r ' ,,,v
W. Corey Basinger
Regional Supervisor
Water Quality Regional Operations
Division of Water Resources
cc: David Merritt (via email: [e-mail])
Central Files - SWP
WtO.
North Carolina Division of Water Resources, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
Internet: hftp://www.ncwater.org/
An Equal Opportunity\ Affirmative Action Employer
One
NofthCar®lina,
Nat9rall

;»
Y- Facility: 1-1C�xnc
a
MR Review Record
Permit No.: Pipe No.:
Monthly Average Violations
MonthNear:
Parameter
Permit Limit
DMR Value
% Over Limit Action
Vlr� I Dail
iolations
Date
Parameter
Permit Limit Limit Type
DMR Value
% Over Limit Action
Monitoring Frequency Violations
Date
Parameter •
Permit Frequency
Values Reported
# of Violations Action
Other Violations/Staff Remarks:
Supervisor Remarks: �16 V
Completed by:
Date:
Assistant Regional
Supervisor Sign Off:
Date:
Regional Supervisor Sign
Off:
Date: (�—

EFFLUENT Tel
(DA FEB
lgx
T:
EDT YEAR NPDES PERMIT DISCHARGE NO, 00 MONTH M
FACILITY NAMEICN,�IRSAL&5'—(-' lUp P— CLASS -GUNT
CERTIFIED LABORATORY (1) CERTIFICATION NO. —
(list additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC) M/9RG LO, tJrq UCC GRADE CERTIFICATION No.
PERSON(S) COLLECTING SAMPLES MA*-, 00cr ORC PHONE
CHECK BOX IF ORC HAS CHANGED
NO FLOW/ DISCHARGE FROM SITE*
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES
DIVISION OF WATER QUALITY
1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617 1
BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
ACCURATE AND COMPLETE TO THE BEST OF My KNOWLEDGE.
PAC?-rt Fift, "j6+j &Z
DWQ Form MR-1 (11/04)
�
�3 0.L

Mickey, Mike
From: Mickey, Mike
Sent: Friday, January 24, 2014 11:03 AM
To: [e-mail]
Subject: ORC Updates Needed.
Attachments: ORC Designation Form - Revised 6-12-2012.pdf
David — We are trying to clean up the ORC database to make the new eDMR process go smoothly. Patrick is still listed as
the ORC for Cornerstone and Countryside. Can you submit the attached form with the correct ORC/backup
information? Thanks, Mike.
Cornerstone Conf Ctr- NC0046809
Designated Operators:
,'Location Class.,
Operator Cert
Name
Status
*Role
*Effective Dt
y Expiration Dt
Notificatioi
WW-2
VJW-2111794
Merritt, Patrick A.
Active
ORC
1212912,003
0112512007
WVV-2
W JV-2110559
Merritt, David R.
Active
Backup
0111612007
0112512007
Countryside Manor —NC0073571
Designated Operators
!*Location Class. Operator
Cert
� Name
I Status
,*Role
.Effective Dt
Ex iration Dt
Notificatio
WW-2
WVV-2111794
Merritt, Patrick A.
Active
ORC
10103f2002
06/2212004
WVV-2
WW-2110569
Merritt, David R_
Active
Backup
10/0312002
0612212004
Mike Mickey
Mike.Mickev(cDNCDENR.eov
NC Division of Water Resources
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.
1

-- 9
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat.McCrory Tom A. Reeder
Governor Acting Director
June 19, 2013
Dr. Mervyn R. King
7700 U.S. Hwy 158
Stokesdale, NC 27357
Subject: NOTICE OF VIOLATION (# N®V-2013-LV-0360)
NPDES Permit No. NCO073571
Countryside Manor WWTP
Guiford County
Dear Dr. King:
John E. Skvarla, III
Secretary
A review of the Countryside Manor monitoring report for March 2013 showed the following violation:
Parameter
Date
Limit Value
Reported Value
Limit Type.
Fecal Coliform
3/18/13
400/100 ml
>1,070/100 ml
Daily Maximum
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 Quality for this and any additional violations of State law.
If you should have any questions, please do not hesitate. to contact Mike Mickey at [phone].
Sincerely,
�a z�
W. Corey Basinger
Regional Water Quality Supervisor
Winston-Salem Region
Surface Water Protection Section
cc: David Merritt (via email: [e-mail])
Central Files - SWP
CTR
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
N®rc' h Carolina
An Equal Opportunity 1 Affirmative Action Employer

�s
Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record
ns
Facility.: � vlss� Penn-it/Pipe No.: Month/Year
Parameter
thly Average Violations
Permit Limit DMR Value
ail Violations
Date Parameter Permit LimitrFv e
Date
Parameter
Over Limit
DMR Value % Over Limit
Monitoring Frequency Violations
Permit Frequencv Values Reported # of Violations
Other Violations 1 i
Completed by: Date:
Regional Water Quality
Supervisor Signoff: Date: ��
aoj

)EFFLUENT TMS WCltldp% by Erm"I
NPDES PERMIT NO.ML&Q
DISCHARGE No._()C) MONTH M/9)eCA=:1=iEf;QA pQ
_�OJ6:'
FACILITY NAMEQ��,�_-` CLASS_
)__ COUNTY.&
CERTIFIED LABORATORY (1)
CERTIFICATION No..
(list additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC). M/IW- w 14 u a— GRADE'D_ CERTIFICATION NO. iG5/
PERSON(S) COLLECTING SAMPLES
ORC PHONE
--------- - - 7-
CHECK BOX IF ORC HAS'
G 19 - - I - FLOW DISCHARGE FROM SITE
Mail ORIGINAL and ONE COPY40*
ATTN: CENTRAL FILES "M A 1 "0 8,, 2- 0,19 X.
DIVISION OF WATER QUALITY (SIGNATURE F OPERATOR IN N1--6jrU1N61BL6 CHARGE) --DATE
, S�_� �R �
1617 MAIL SERVICE CENTER GENTRAL FILE By THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
RALEIGH, NC 27699-1617 _1A r)l - . - ACCURATE AND COMPLETE TO THE REST OF MY KNOWLEDGE.
DWQ Form MP-1 (11/04) 6 7C

Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements
(including weekly averages, if applicable) 25
Compliant
All monitoring data and sampling frequencies do NOT meet permit requirements
- 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
permittee 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.
' 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 managed 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."
/17)-,ac.- P , /JAL) L7'
Permittee (Please print or type)
Signature df Permittee*** ' r Date
(Required unless submitted electronically)
Permittee Address Phone Number e-mail address Permit Expiration 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 [phone] or by visiting the Surface
Water Protection Section's web site at h2o.enr.state.nc.us/wqs 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 occurs 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 15A NCAC 8G .0204.
*** Signature of Permittee: If signed by other than the permittee, then the delegation of the signatory authority must be on
file with the state per 15A NCAC 2B .0506(b)(2)(D).
Page 2

r°'
A4A
VIA
NCDENR
North Carolina Department of Environment and natural
Division of Water Quality
Pat McCrory Charles Wakild, P.E.
Governor Director
March 28, 2013
Dr. Mervyn R. King
7700 US Hwy 158
Stokesdale, NC 27357
Subject: NOTICE OF VIOLATION (# NOV-2013-MV-0050)
NPDES Permit No. NCO073571
Countryside Manor WWTP
Guilford County
Dear Dr. King:
Resources
John E. Skvarla, III
. . Secretary
A review of the Countryside Manor WWTP monitoring report for December 2012 showed the following
violation:
Parameter
Date Omitted
Measuring Frequency
Violation
T. Nitrogen
Oct — Dec 2012
Quarterly
1
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 Quality for this and any additional violations of State law.
Regulations require that quarterly samples be collected at equal intervals of three consecutive months.
Previous quarterly sampling in 2012 for Countryside. occurred in January, April & September. An
example of the correct quarterly months would be: 1) Jan, April, July, Oct; or 2) Feb, May, Aug, Nov; or
3) March, June, Sept, Dec.
If you should have any questions, please do not hesitate to contact Mike Mickey at [phone].
Sincerely,
,_94(0AC&/b
W. Corey Basinger
Regional Water Quality Supervisor
Surface Water Protection Section
cc: David Merritt (via email: [e-mail])
Central Files - SWP
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
One
No thCarolina.
An Equal Opportunity 1 Affirmative Action Employer

Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record
Facility.: Cu Permit/Pipe No.: '0'tt1 j'J1 Month/Year L
Parameter
.
Date
Date Parameter
Monthly Average Violations
it imit DMR Value % Over Limit
Violations
Type DMR Value % Over Limit
Monitoring Frequency Violations
Date Parameter Permit Fre uencv Values Reported # of Violations
sec. � . N•��CS� e J Q�
W
Other Violations
Completed by: y Date:
Regional Water Quality
Supervisor Signoff: A&i%� Date:
J

{ EFFLUENT
FEB
NPDES PERMIT NO, � I `� aO�i�:yswi ( DISCHARGE NO. ®O MONTH
FACILITY NAME C , =-z tir�`i&ffi—j5 -i�14 ----�
CLASS,_ COUNTY_ a-l}l L;yokb
CERTIFIED LABORATORY (1) Mi✓62l`"i`G{-� Z� CERTIFICATION NO. j (4S
(list additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC) WI19W_ Ld,fJ U� -t GRADE': CERTIFICATION NO. C� j
PERSON(S) COLLECTING SAMPLES MW Lo, jjj+,7 - ORC PHONE
CHECK BOX IF ORC HAS GHHteE
L� NO LOW /DISCHARGE FROM SITE
Mail ORIGINAL and ON�"�i�}PI
ATTN: CENTRAL FILES 20� x z�,,� P I _ 3r� I�
DIVISION OF WATER QUALITY (SIGNATU E F OPERATOR IN RE ONSIBLE CHARGE) / V DATE
1617 MAIL SERVICE CENTER BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
RALEIGH, NC 27699-1617 cc:� - ®, a C11 ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
DWQ Form MR-1 (11/04)

a
Y ��
" ' q.,�
NI, C EN RA
North Carolina Department of Environment and Natural
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
May 31, 2012
Mr. Mervyn R King
7700 US Hwy 158
Stokesdale, NC 27357
Subject: NOTICE OF VIOLATION (# NOV-2012-LM-0024)
NPDES Permit No. NCO073571
Countryside Manor WWTP
Guilford County
Dear Mr. King:
Resources
Dee Freeman
Secretary
A review of the Countryside Manor WWTP monitoring report for February 2012 showed the following.
violations:
Parameter
Date
Limit Value
Reported Value
Limit Type
Fecal Coliform
02/09/12
400 #/100m1
600 #/100ml
Daily Maximum Exceeded
Parameter
Date Omitted
Measuring Frequency
Violation(s)
Temperature
02/04/12
5 X week
1
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 Quality for this and any additional violations of State law.
If you should have any questions, please do not hesitate to contact Mike Mickey at [phone].
Sincerely,
W. Corey Basinger
Winston—Salem Water Quality Supervisor
Surface Water Protection Section
cc: Central Files - SWP
WS@''U
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.newaterquality.org
Nofth Carolina
An Equal Opportunity 1 Affirmative Action Employer

Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record.
Facility: �,Ll�s� Stl`}���� Permit/Pipe No.: �����i�Si Month/Year
nthly Average Violations
Parameter
Permit Limit DMR Value
%Over Limit
4k-nyrolations
Date
Parameter
Permit Limitgype DMR Value
% Over Limit
Monitoring Frequency Violations
Date
Parameter
Permit Frequencv Values Reported
# of Violations
Other Viol
-ix�LL4, Now'
Completed by: Date:
Regional Water Quality Ahm�h�
Supervisor Signoff: Date:

EFFLUENT
NPDES PERMIT N0. t!4G DISCHARGE NO. ®p ( MONTH 11�
FACILITY NAME_Ct�T'�ySi�� �'1�4J0 CLASS_ COUNTY
CERTIFIED LABORATORY(l) MGR l JA �P�G CERTIFICATION NO.
(list additional laboratories on the backside/page 2 of this form)
iRFC f ;` D
of 04IR
o•1.2M1,A 2 9 2012
OPERATOR IN RESPONSIBLE CHARGE (ORC) M19� lid I NA U LI i GRADE '-aCERTIFICATION NO. % !�6
PERSON(S) COLLECTING-.SAMPLES--MA1Fe---W',-MIJOLT ORC PHONE — — 'a
CHECK BOX IF ORC HAS CHANGED' A Nq FLOW / DISCHARGE FROM SITE
Mail ORIGINAL and ONE COP;Y�fo:
- /
ATTN: CENTRAL FILES x viL f✓ ti
DIVISION OF WATER QUALITY.... _ (SIGNATURE O OPERATOR IN SPO BLE 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.
a
DWQ Form MR-1 (I I/04)

Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements
(including weekly averages, if applicable)
Compliant
All monitoring data and sampling frequencies do NOT meet permit requirements
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
permittee 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 H.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 qualified personnel properly gather and evaluate the information
submitted. Based on my inquiry of the person or persons who managed 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." `� tea' ' `'•;
Permitte (Please print or type)
SignatLYe of Permitte *** Date
(Required unless submitted electronically)
Permittee Address Phone Number e-mail address Permit Expiration 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 [phone] or by visiting the Surface
Water Protection Section's web site at h2o.enr.state.nc.us/wds 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 occurs 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 15A NCAC 8G .0204.
*** Signature of Permittee: If signed by other than the permittee, then the delegation of the signatory authority must be on
file with the state per ISA NCAC 2B .0506(b)(2)(D).
Page 2

„i
A�` • '' .,
r , �
NCDENR
North Carolina Department of Environment and
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, PE
Governor Director
February 17, 2012
Dr. Mervyn King
Countryside Manor, Inc.
P.O. Box 829
Stokesdale, NC 27357
SUBJECT: Compliance Evaluation Inspection
Countryside Manor WWTP
NPDES Permit No. NCO073571
Guilford County
Dear Dr. King:
Natural Resources
Dee Freeman
Secretary
On February 15, 2012, Mike Mickey of this office met with Ernie Newman and Mark Nault, ORC,
to perform a Compliance Evaluation Inspection on the wastewater treatment system serving Countryside
Manor. This type of inspection consists of two basic parts: an in office file review and an on -site
inspection of the treatment facility. The attached EPA inspection form notes the eight (8) areas that were
evaluated. The findings and observations are outlined below:
I. Permit
The NPDES permit was recently reissued with an effective date of June 1, 2011.
111. Self -Monitoring Program
The monthly self -monitoring reports (DMR's) were reviewed for the period January 2011 through
November 2011. The facility was found to have violated the quarterly average phosphorus limit on two
occasions during the above time frame (see data summary attached). These violations were
previously addressed by correspondence from this office. Total phosphorus levels began improving in
October with the addition of aluminum sulfate. In regards to the permit monitoring requirements, it was
noted that all sampling was performed per the frequencies specified in the permit.
Ill. Flow Measurement
The NPDES permit requires weekly instantaneous flow reporting. Flow values reported on the DMR are
obtained using an ultrasonic meter with v-notch weir. Carolina Technical Services last' calibrated the
meter in August.
IV. Sludge Handling and Disposal
Solids are removed from the digester by Gann Brothers Septic Service for disposal at the Town of
Madison WWTP. Pumping of the digester occurs at approximately three to four month intervals.
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
ne
NorthCarohna
Naturally
An Equal Opportunity 1 Affirmative Action Employer

Dr. Mervyn King
Page 2
February 17, 2012
V. Operations and Maintenance
The facility appeared to be competently operated and maintained. No problems or concerns were noted.
VI. Facility Site Review
The existing 0.015 MGD single train package plant consists of the following: aerated equalization tank,
bar screen, aeration basin, circular clarifier, sludge holding tank, tablet chlorination, contact tank, tablet
dechlorination and concrete/rip-rap lined effluent channel. Sampling typically occurs at the v-notch weir
prior to dechlorination due to the difficulty in obtaining a sample from the effluent pipe.
Vli. Records/Reports
A review of the facility files indicates that all records are being maintained according to the permit. A
comparison of the November 2011 self -monitoring report with the corresponding laboratory data sheets
showed that all values were transcribed onto the DMR correctly.
Vill. Effluent/Receiving Waters
The system discharges into Troublesome Creek, class "WS-III, NSW' waters in the Cape Fear River
Basin. The effluent was clear on the day of the inspection.
Should you have any questions concerning this report, please contact Mike Mickey or me at (336)
771-5000.
Sincerely,
W. Corey Basinger
Regional Water Quality Supervisor
Surface Water Protection Section
cc: Patrick Merrit (Meritech, Inc., 642 Tamco Road, P.O. Box 27, Reidsville, NC 27320)
Central Files
�W'

Countryside Manor y1 WTP
NPDES Permit No. NCO073571
Self -Monitoring Data Summary
January 2011 — November 2011
Parameters
Monthly Avg.
Permit Limits
Monthly Avg. Limit
Violations per DMR
Daily Maximum
Permit Limits
Daily Max. Limit
Violations per DMR
Flow (MGD)
0.015
None
-
NA
BOD (mg/1)
30.0
None
45.0
None
TSS (mg/1)
30.0
None
45.0
None
�NH3-N (mg/1)
(5.4 / 23.5)*
None
(27.0 — 35.0)*
None
D. Oxygen (mg/L)
-
NA
> 5.0 **
None
Fecal (#/100 ml)
200
None
400
None
T. Chlorine (ug/1)
-
NA
28.0***
None
T. Phosphorus (mg/L)
2.0
2"d & 3rd quarters****
-
NA
pH (S.U.)
-
None
(6.0 — 9.0) range
None
* (Summer / Winter limits)
** Daily Average limit
***TRC values reported below 50 ug/L are considered compliant.
**** Total Phosphorus quarterly average violations:
The April, May, June average of 2.26 mg/L violated the 2.0 mg/L quarterly average limit.
The July, August, September average of 6.1 'mg/L violated the 2.0 mg/L quarterly average limit.

United States Environmental Protection Agency
Form Approved.
EPA Washington, D.C.20460
OMB No. 2040-0057
Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/molday Inspection Type Inspector Fac Type
1 I N I 2 15 I 31 NCO073571 111 121 12/02/15 117 18I C I 19I S I 20I I
Remarks
211 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 16
Inspection Work Days Facility Self -Monitoring Evaluation Rating 131 CIA ------------ —--- -----Reserved-------------
67I 169 70131 711 I 72I N I 73 L _j 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)
11 /O6/01
08:50 AM 12/02/15
Countryside Manor WWTP
Exit Time/Date
Permit Expiration Date
7700 US Hwy 158
Stokesdale NC 27357
09:45 AM 12/02/15
16/04/30
Name(s) of Onsite Representative(s)fTitles(s)/Phone and Fax Number(s)
Other Facility Data
///
Marc W Nault/ORC/336-341-8971/
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
Ernie Newman,PO Box 829 Stokesdale NC 273570829//336-643-6301/3366439906 Yes
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit 0 Flow Measurement Operations & Maintenance N Records/Reports
Self -Monitoring Program M Sludge Handling Disposal Facility Site Review
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 M WSRO WQ//336-771-5000/
�Mickey
Signatur�q, of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page # 1

Permit: NCO073571
Inspection Date: 02/15/2012
Permit
Owner -Facility: Countryside Manor WWTP
Inspection Type: Compliance Evaluation
(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: The NPDES permit was reissued effective June 1, 2011. The review
period for this inspection was January 2011 through November 2011. Effluent violations
noted for this time period invovled two quarterly average phosphorus violations
(April/May/June = 2.26mg/L and July/August/September = 6.1 mg/L). The phosphorus
levels at the WWTP began to improve in October with the addiont of aluminum sulfate at
the splitter box. In regards to the monitoring reports, it was noted that all of the required
data was submitted in the reveiw period evaluated.
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? ■ n n n
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable Solids, pH, DO, Sludge ❑ ■ ❑ ❑
Judge, and other that are applicable?
Comment: Solids are removed from the digester every 3 to 4 months by Gann
Brothers Septic Service for disposal at the Town of Madison WWTP.. Solids are
concentrated in the digester by pumping the clear supernatant back to the EQ basin.
Record Keeping
Yes NO NA
rvt
Are records kept and maintained as required by the permit?
■ ❑ ❑
❑
Is all required information readily available, complete and current?
■ 00
❑
Are all records maintained for 3 years (lab. reg. required 5 years)?
■ ❑ ❑
n
Are analytical results consistent with data reported on DMRs?
■ ❑ ❑
❑
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
■
Are DMRs complete: do they include all permit parameters?
■ n n
n
Page # 3

Permit: NCO073571 Owner -Facility: Countryside Manor WWTP
Inspection Date: 02/15/2012 Inspection Type: Compliance Evaluation
Record Keeping Yes No NA NE
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? n D ■ n
Is the ORC visitation log available and current? ■ n n n
Is the ORC certified at grade equal to or higher than the facility classification? ■ n n n
Is the backup operator certified at one grade less or greater than the facility classification? ■ n n n
Is a copy of the current NPDES permit available on site? ■ D D fl
Facility has copy of previous year's Annual Report on file for review? n n ■ n
Comment: A comparision of the November 2011 DMR with the corresponding certified
laboratory data sheets showed that all results were properly transcribed onto the
self -monitoring report.
r5__ �_'__.-_
Type of bar screen
a.Manual ■
b.Mechanical n
Are the bars adequately screening debris? ■ n n n
Is the screen free of excessive debris? ■ n n n
Is disposal of screening in compliance? ■ n n n
Is the unit in good condition? ■ n n n
Comment: The Countryside Manor staff are responsible for raking the bar screen.
Equalization Basins
Yes No
NA NE
Is the basin aerated?
■
n
n n
Is the basin free of bypass lines or structures to the natural environment?
■
D
D D
Is the basin free of excessive grease?
■
n
n n
Are all pumps present?
■
n
n n
Are all pumps operable?
■
n
n n
Are float controls operable?
■
n
n n
Are audible and visual alarms operable?
■
n
D D
# Is basin size/volume adequate?
■
❑
n n
Comment: The audiblie and visual alarms for the EQ pumps are mounted on the shed
adjacent to the WWTP.
Page # 4

Permit: NCO073571 Owner -Facility: Countryside Manor WWTP
Inspection Date: 02/1512012 Inspection Type: Compliance Evaluation
Aeration Basins
Yes No NA NE
Mode of operation
Ext. Air
Type of aeration system
Diffused
Is the basin free of dead spots?
■ n n n
Are surface aerators and mixers operational?
n n ■ n
Are the diffusers operational?
■ n n n
Is the foam the proper color for the treatment process?
■ n n n
Does the foam cover less than 25% of the basin's surface?
■ n n n
Is the DO level acceptable?
n�ln■
Is the DO level acceptable?(1.0 to 3.0 mg/1)
n n n ■
Comment: A single aeration basin.
Secondary Clarifier
Yes No NA NE
Is the clarifier free of black and odorous wastewater?
■ n n n
Is the site free of excessive buildup of solids in center well of circular clarifier?
n n ■ n
Are weirs level?
n n n
Is the site free of weir blockage?
■ n n n
Is the site free of evidence of short-circuiting?
■ n n n
Is scum removal adequate?
■ n n n
Is the site free of excessive floating sludge?
■ n n n
Is the drive unit operational?
■ n n n
Is the return rate acceptable (low turbulence)?
■ n Cl n
Is the overflow clear of excessive solids/pin floc?
■ n n n
Is the sludge blanket level acceptable? (Approximately % of the sidewall depth)
n n n ■
Comment: The single circular clarifier has paddles on the bottom for solids removal.
The weirs were level and the clarifier effluent was clear of pin floc.
Disinfection -Tablet
Yes No NA NE
Are tablet chlorinators operational?
■ n n n
Are the tablets the proper size and type?
■ n n n
Number of tubes in use?
2
Is the level of chlorine residual acceptable?
n n n ■
Is the contact chamber free of growth, or sludge buildup?
■ n n n
Page # 5

Permit: NC0073571
Inspection Date: 02/15/2012
Owner -Facility: Countryside Manor WWTP
Inspection Type: Compliance Evaluation
Disinfection -Tablet Yes No NA NE
Is there chlorine residual prior to de -chlorination? ■ n ❑ ❑
Comment:
Type of system ?
Tablet
Is the feed ratio proportional to chlorine amount (1 to 1)?
n
n
E n
Is storage appropriate for cylinders?
❑
❑
■ n
# Is de -chlorination substance stored away from chlorine containers?
n
n
■ n
Comment:
Are the tablets the proper size and type?
■
n
n n
Are tablet de -chlorinators operational?
■
n
n n
Number of tubes in use?
1
Comment:
Flow Measurement - Effluent
Yes
No
NA NE
# Is flow meter used for reporting?
®
n
n n
Is flow meter calibrated annually?
■
n
n n
Is the flow meter operational?
■
n
n n
(If units are separated) Does the chart recorder match the flow meter?
n
n
■ n
Comment: The permit requires weekly instantaneous flow reporting. An ultrasonic
meter with v-notch weir is used to measure flow. Carolina Technical Services last
calibrated the meter back in August.
Aerobic Digester Yes No NA NE
Is the capacity adequate? ■ ❑ n n
Is the mixing adequate? ■ n n n
Is the site free of excessive foaming in the tank? ■ n n n
# Is the odor acceptable? ■ n n n
# Is tankage available for properly waste sludge? ■ n n n
Comment: Solids are removed by Gann Brothers Septic Service for disposal at the
Madison WWTP.
Page # 6

Mickey, Mike .
From: Hudson, Gary
Sent: Wednesday, February 15, 2012 3:41 PM
To: Mickey, Mike
Subject: RE: Countryside Manor - NC0073571
10-4 Mike. I'll call him today.
From: Mickey, Mike
Sent: Wednesday, February 15, 2012 3:37 PM
To: Hudson, Gary
Subject: Countryside Manor - NC0073571
Gary — Ernie Newman said he is still interested in a technical assistance visit. They failed their quarterly average
phosphorus limit April/May/June and July/August/September. They started adding aluminum sulfate by hand in
October so their values have improved.
Mike Mickey
Mike.IVlickevPNCDENR.eov
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.

Ai
NCDENR
North Carolina Department of Environment and Natural
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
February 29, 2012
Mr. Ernie Newman, Plant Operations Manager
Countryside Manor WWTP
P.O. Box 829
Stokesdale, NC 27357
SUBJECT: Technical Assistance Consultation
Countryside Manor Wastewater Treatment Plant
NPDES Permit No. NCO073571
Guilford County
Dear Mr. Newman:
Resources
Dee Freeman
Secretary
On February 28, 2012, Gary Hudson of this office met with Ricky Shepherd, Mark Nault (ORC), and
you to perform a Technical Assistance Consultation visit on the Countryside Manor Wastewater Treatment
Plant. The request was prompted by permit violations for quarterly violations of your phosphorus limits. At the
time of my visit Mr. Nault had already researched the problem and set up the addition of soda ash to raise the
pH levels, and dosing the aeration tank with aluminum sulfate to flocculate and precipitate the phosphorous.
Since the addition of the soda ash and alum, the plant has been in complete compliance. It is my
professional opinion that the ORC of this facility will continue working diligently to reduce the amount of
phosphorous in the effluent. If I can be of any further assistance, please do not hesitate to contact me. My e-
mail address is: gary.hudson(a-ncdenr.gov. Should you have any questions concerning this report, you can
also contact me at [phone].
Sincerely,
Gary Hudson
Regional Consultant
Winston-Salem Regional Office
cc: Patrick Merritt, Meritech, Inc. P.O. Box 27 Reidsville, NC 27320
TACU
VMRO
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
Nne
orthCarohna
An Equal Opportunity 1 Affirmative Action Employer

Countryside Manor, Inc.
Mr. W. Corey Basinger
Regional Supervisor
Surface Water Protection Service
N.C.DePt. of ENR
DEC 2 g 2011
Winston-Salem
December 27, 2011
Subject: Notice of violation and recommendation for enforcement received at Countryside
Manor December 27, 2011, Certified # 7009 2250 0004 1083 5909 Total Phosphorus 3rd quarter
limits.
Dear Mr. Basinger,
Attached you will find response to the above mention violation. Also a response from September
2011 from Countryside Manor, Inc. suggesting we would welcome any technical assistance from
NCDENR could offer in regards to this problem.
Remedial action by Countryside manor and Meritech, Inc. are now showing positive results as
indicated by Meritech, Inc.
Countryside Manor, Inc. does request technical assistance to explain how permit limits are set for
our geographical location? Has there ever been an occasion where limits are raised?
Please feel free to call me or visit our location at any time.
Sincerely,
Ernie Newman,
Plant Operation Manager
7700 U.S. Highway 158 • P.O. Box 829 • Stokesdale, North Carolina 27357 Telephone [phone] • Fax [phone]
www.RetireAtCountryside.com 9 [e-mail]

E
Kx Uate/lime UtL-1!b-1fUIIlwtU) I4: Jb
W,28/2011 14:33 3363421522
JJbJUCI5CC
F. UUC
#2003 P.002/002
MERITEC � INCm
ENVIRONMENTAL LABO ATORIES
A Division of Water Technology a d Controls, Inc.
December 28, 2(111
Dear Mr. Basinger:
This letter is in response to the NOV dated 12/21/21
for Total phosphorus. To help bring down the phos
level with soda ash and adding aluminum sulfate to
staff has been looking for any cleaning products thf
Since we have been adding the chemicals the phosl
now they are at or below the quarterly limit of 2.0 r
Please give me a call if you have any further questi
DEC 2
Winston-salem
I 1 for Countryside Manor WWTP
torus we have been raising the pH
he aeration basin. Also the on site
may be contributing to the problem.
.orus levels have been dropping and
Sincerely,
tt
642 Tamco Road • P.O. Box 27 • Re sville, NC 27320
[phone] • (336) 342 522 Fax

September 29, 2011
Mr. W. Corey Basinger
Regional Supervisor
Surface Water Protection Section
Subject: Notice of Violation -Effluent Limits
Nov.-2011 LV-0439
Countryside Manor WWTP
NPDES No. NC 0073571
Guilford County
Dear Mr. Basinger,
Our total phosphorous for the 2"d quarter has exceeded the permit limit by 0.26mg/L and we continue to
have a fluctuation in this parameter into the 3rd quarter.
Countryside Manor is working closely with our operator, Meritech, Inc., and began remedial actions in July
2011, to correct this problem. Although results have not been what we hoped for by this time, ongoing efforts are
being made daily to correct the non-compliance.
Just wanted you to know Countryside Manor takes any non-compliance seriously and welcome any help
you may have to offer in regards to this problem.
Sincerely,
Ernie Newman,
Plant Operations Manager
cc: Miles Stanley
Steve Edgerton

ANY
NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
December 21, 2011
CERTIFIED MAIL 9 7009 2250 00041083 5909
RETURN RECEIPT REQUESTED
Mr. Ernie Newman
Plant Operations Manager
Countryside Manor, Inc.
P.O. Box 829
Stokesdale, NC 27357
Subject: NOTICE OF VIOLATION and RECOMMENDATION FOR ENFORCEMENT
Countryside Manor WWTP
Permit No. NC
Guilford County
Dear Mr. Newman:
Dee Freeman
Secretary
A review of the Countryside Manor WWTP monitoring report for September 2011 showed the following violation:
Parameter
Date
Limit Value
Reported Value
Limit Type
Total Phosphorus
July — Sept. 2011
2.0 mg/l
6.1 mg/1
Quarterly Average
A Notice of Violation/Notice of Recommendation for Enforcement (NOV/NRE) is being issued for the noted
violation ofNorth Carolina General Statute (G.S.)143-215.1 and NPDES Permit No. NCO073571. Pursuant to G.S.
143-215.6A, a civil penalty of not more than twenty-five thousand dollars ($25,000:00) may be assessed against any
person who violates or fails to act in accordance with the terms, conditions, or requirements of any permit issued
pursuant to G.S. 143-215.1. If you wish to provide additional information regarding the noted violation, request
technical assistance, or discuss overall compliance please respond in writing within ten (10) days after receipt of this
Notice. A review of your response will be considered along with any information provided on the September 2011
Discharge Monitoring Report. You will then be notified of any civil penalties that may be assessed regarding the
violations. If no response is received in this Office within the 10-day period, a civil penalty assessment may be
prepared.
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone: [phone] FAY,: 336-771-46301 Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
Nne
orthCarolina
Natllrally
An Equal Opportunity 1 Affirmative action Employer

Remedial actions, if not already implemented, should be taken to correct any problems. The Division of
Water Quality may pursue enforcement actions for this and any additional violations. If the violations are of a
continuing nature, not related to operation and/or maintenance problems, and you anticipate remedial construction
activities, then you may wish to consider applying for a Special Order by Consent.
If you have questions concerning this matter, please do not hesitate to contact Mike Mickey or me at (336)
771-5000.
Sincerely,
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
cc: Point Source Branch
SWP — Central Files
R.(F1.

Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record3��
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Parameter Permit Limit DM//R Value
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Permit Limit/Tvpe
% Over Limit
Y b
DMR Value % Over Limit
Frequency Violations
ether Violations �
c
Values Reported # of Violations
Completed by: Date:
Regional Water Quality
Supervisor Signoff. Date:

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Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES
DIVISION OF WATER QUALITY
(SIGNATURE F OPERATOR IN FONSIBI-Fr',.CHARGE) DATE
1617 MAIL SERVICE CENTER f i , to :;fTt
BY THIS SIGNATURE, I CERTIFY THAT THIS ;REP6RT IS
RALEIGH, NC 27699-1617 lSiO(1
ACCURATE AND COMPLETE TO m TEST OF MY KNOWLEDGE.
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EFFLUENT
NPDES PERMIT NO. MlIns,7 I DISCHARGE NO. 0p ( MONTHy�' YEAR 1g,
FACILITY NAME C,ir^'1s� I^'VAfJ0 CLASS _ COUNTY_ JS-131 i;'o-'D
CERTIFIED LABORATORY (1)_ i1eR ITC-,QA T4,3C. CERTIFICATION NO. t (a S
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OPERATOR IN RESPONSIBLE CHARGE (ORC) /119k- V3,NA UC L GRADE'"- CERTIFICATION NO. '56
PERSON(S) COLLECTING SAMPLES-A'I/C b�, Aii}�t�C : ORC PHONE -I-
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CHECK BOX IF ORC HAS CHANGED �i.G '��f E''di? F aPO
FLOW / DISCHARGE FROM SITE*
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES " ' x
DIVISION OF WATER QUALITY i (SIGNATURERATOR?1NOF OPEE CHARGE) DATE
is'iSiOf 5 xl4iii
1617 MAIL SERVICE CENTER rZf CilUnf i [)Yllf3w` BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
RALEIGH, NC 27699-1617 L_.______ _-� v�=-ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
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DWQ Form MR-1 (11/04)

Mickey, Mike
From:
Weaver, Charles
Sent:
Tuesday, November 22, 2011 5:17 PM
To:
Smith, Jennifer
Cc:
Mickey, Mike
Subject:
RE: NCO073571 flow monitoring
NCO073571 has two flow phases.
Flow monitoring at the current phase [0.015 MGD] is Weekly Instantaneous.
Flow monitoring at expansion phase [0.03 MGD] is Continuous Recorder.
BIMS matches the permit.
As far as I know, they are still at 0.015 MGD.
CHW
From: Smith, Jennifer
Sent: Tuesday, November 22, 2011 11:41 AM
To: Weaver, Charles
Subject: NCO088307 & NCO073571
NCO073571 = flow is continuous but for some reason I updated the violation to invalid permit (must be b/c user had originally said BIMS
calc)
Jennifer Smith, Business & Technology Application Specialist
NC DENR / ITS / DWQ
Phone: [phone]
Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be
disclosed to third parties unless the content is exempt by statute or other regulation.

ME
Countryside Manor, Inc.
Mr. W. Corey Basinger
Regional Supervisor
Surface Water Protection Section
Subject: Notice of Violation -Effluent Limits
Nov.-2011 LV-0439
Countryside Manor WWTP
NPDES No. NC 0073571
Guilford County
Dear Mr. Basinger,
71DIeptof
N.ROG011
m
Raglonal Office
September 29, 2011
Our total phosphorous for the 2nd quarter has exceeded the permit limit by 0.26mg/L and we continue to
have a fluctuation in this parameter into the 3rd quarter.
Countryside Manor is working closely with our operator, Meritech, Inc., and began remedial actions in July
2011, to correct this problem. Although results have not been what we hoped for by this time, ongoing efforts are
being made daily to correct the non-compliance.
Just wanted you to know Countryside Manor takes any non-compliance seriously and welcome any help
you may have to offer in regards to this problem.
Si , e)�
ni Newman,
l
Plant Operations Manager
cc: Miles Stanley
Steve Edgerton
7700 U.S. Highway 158 • P.O. Box 829 • Stokesdale, North Carolina 27357 Telephone [phone] • Fax [phone]
www.RetireAtCountryside.com • [e-mail]

Beverly Eaves Perdue, Governor
15 September 2011
Dr. Mervin King
Countryside Manor
7700 US Hwy 158
Stokesdale, NC 27357
SUBJECT: Notice of Violation - Effluent Limitations
NOV-2011-LV-0439
Countryside Manor WWTP
NPDES No. NCO073571
Guilford County
Dear Dr. King:
.' Am
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Dee Freeman., Secretary
Coleen H. Sullins, Director
Review of the self -monitoring report for the month of June 2011 revealed the following quarterly
average effluent limitation violation:
Date Parameter Permit Limit Retorted Value Units
2nd Qtr Total Phosphorous 2.0 2.26. mg/1
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 the Division with the possible assessment of civil penalties of up to $25,000 per day, per violation. Should
you have any questions, please contact this Office at [phone].
Sincerely,
W. Corey Basinger
Regional Supervisor
Surface Water Protection Section
cc: WSRO, Central Files-SWP
Guilford Co. Health Dept.
Winston-Salem Regional Office One
585 Waughtown Street, Winston-Salem, North Carolina 27107 NorthCarolina
Phone: [phone] / Fax: [phone] / Internet: www.ncwaterquality.org NatmallyAn Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper

Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record
Facility:&*16� PernutfPipe No.:
D-1-3 Month(Year �(
Monthly Average Violations
Parameter Permit Limit DMR Value % Over Limit
ations 44"(7
Date Parameter Permit Limit/Tvpe DMR Value % Over Limit
Monitoring Frequency Violations
Date Parameter Permit Frequency Values Reported # of Violations
Other Violations
Date: A
Completed by: Regional Water Water Quality Date:
Supervisor Signoff:

RECEIVED
N.C. Dept of ENR p
AUG 2 9 2011 EFFLUENT L Cp�
Vlinston-Salem AUG 1-8. 20fl 7Eq
I
NPDES PER-MM-N( io - L7 DISCHARGE NO. QOJ MONTH S0Q YEAR L
FACILITY NAE_clt� y(Sil�5 �^'IAIJp CLASSY_ COUNTY��
CERTIFIED LABORATORY (1) MCR l 1-k :ro CERTIFICATION NO _j (d S
(list additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC) Aji9PC V3. (JA U CC GRADE e) CERTIFICATION
PERSON(S) COLLECTING SAMPLES MAf,(, O ORC PHONE -3q
CHECK BOX IF ORC HAS CHANGED NO FLOW / DISCHARGE FROM SYTE�, ' h
Mail ORIGINAL and ONE COPY to: " ---Ir �' I�
ATTN: CENTRAL FILES
DIVISION OF WATER QUALITY
,1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617
BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS-r�
ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. ! `
DWQ Form MR-1 (I1/04)

Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements
(including weekly averages, if applicable) EVf
Compliant
All monitoring data and sampling frequencies do NOT meet permit requirements F7
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
pemuttee became aware of the circumstances. A written submission shall also be provided within 5 days of the time the
pemuttee 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 qualified personnel properly gather and evaluate the information
submitted. Based on my inquiry of the person or persons who managed 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." MARL W I /V A JL.
"-R� L
Permitte (Please print or e)
Signature of Permittee*** Date
(Required unless submitted electronically)
Permittee Address
Certified Laboratory (2)
Certified Laboratory (3)
Certified Laboratory (4)
Certified Laboratory (5)
Phone Number e-mail address Permit Expiration Date
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 [phone] or by visiting the Surface
Water Protection Section's web site at h2o.enr.state.nc.us/wqs 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 occurs 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 15A NCAC 8G .0204.
*** Signature of Permittee: If signed by other than the permittee, then the delegation of the signatory authority must be on
file with the state per 15A NCAC 2B .0506(b)(2)(D).
Page 2

NPD,Es NC. N 00-73 5? I DIsc IAR E N®. 001
MONTH JuNC� YEAR
FACILITY NAME_ J COUNTY_. �o rcl STREAM %04O(ne. 2ee.K b� S M
STREAI4l -Tov � o e
LOCATION 100 f� co�,. w I I
DEM Form MR-3 (12/93)
LOCATION Pa; NC-s7, S \03
Upstream Downstream

Beverly Eaves Perdue, Governor
Dr. Mervin King
Countryside Manor
7700 US Hwy 158
Stokesdale, NC 27357
SUBJECT: Notice of Violation - Effluent Limitations
NOV-2011-LV-0061
Countryside Manor WWTP
NPDES No. NCO073571
Guilford County
Dear Dr. King:
n.+:axssm�
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Dee Freeman., Secretary
14 February 2011 Coleen H. Sullins, Director
Review of the self -monitoring report for the month of November 2010 revealed the following daily
effluent limitation violation:
Date Parameter Permit Limit Reported Value Units
11/30 Fecal Coliform 400.0 >600 #/100ml
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 the Division with the possible assessment of civil penalties of up to $25,000 per day, per violation. Should
you have any questions, please contact this Office at [phone].
Sincerely,
W. Corey Basinger
Interim Regional Supervisor
Surface Water Protection Section
cc: WSRO, Central Files-SWP
Guilford Co. Health Dept.
Winston-Salem Regional Office
585 Waughtown Street, Winston-Salem, North Carolina 27107
Phone: [phone] Fax: [phone] Internet: www ncwaterguality.org
NorthCarolina
,Xaturallry
An Equal Opportunity/Affirmative Action Employer — 50% Recycled110% Post Consumer Paper

Cover Sheet from
Staff Member to
Regional Supervisor
IR Review Record
ty
Facility: C—Vilnto-19-.C--�—Pern-it[PipeNo.: OC-y° 23s11 Month/Year 1-bVZ011
Parameter
Monthly Average Violations
Permit Limit DMR Value % Over Limit
Weekly/Daily Violations
Date Parameter Permit LMU I'vpe DMR Value %Over Limit
Monitoring Frequency Violations
Date Parameter Permit Frequency Values Reported # of Violations
Other Violations
�L Gef[sG� Ytacd /LLD e7 • r �r r ��r(kc� cce( c7 /G 51i&U/,ftez>, -5
Completed by: Date:
Regional Water Quality' �'�732061
Supervisor Signoff: Date:

RECEIVED
N.C. Dpot. of ENR
North Carolina Department of Environment and Natural Resou
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
October 14, 2010
ERNIE NEWMAN
PLANT OPERATIONS MANAGER
COUNTRYSIDE MANOR INC
PO BOX 829
STOKESDALE NC 27357
Winston-Salem
Subject: Receipt of permit renewal application
NPDES Permit NCO073571
Country Manor WWTP
Guilford County
Dear Mr. Newman:
Secretary
The NPDES Unit received your permit renewal application on October 13, 2010. A member of the
NPDES Unit willreview 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 Jeff Poupart at
[phone].
Sincerely,
L�� JJ-0'�
Dina Sprinkle
Point Source Branch
cc: CENTRAL FILES
---DES
n� R,.e? g'0 alj iific�/Surface Water Protection
NPDDESES Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone] \ Customer Service: 1-877-623-6748
Internet: www.ncwatergLiality.org
An Equal Opportunity \ Affirmative Action Employer
NorthCaro].iraa

Countryside Manor, Inc.
Professional Care Center for the Elderly
Mrs. Dina Sprinkle
NC DENR/DWQ/Point Source Center
1617 Mail Service Center
Raleigh, NC 27699-1617
Dear Mrs. Sprinkle,
%i.0 n(,;)t, of ENR
OCT 2 2 2010
Winston-Salem
Regional Orf ce
Oct. 11, 2010
Enclosed you will find the required information with application for renewal of
WWTP permit # NC0073571.
There has been one physical change at our WWTP facility since the issuance of
the last permit may 1, 2006. Linder the direction of the ORC Patrick Merritt, Certificate
#11794, of Meritech, Inc. Our in house maintenance staff assisted Kace Environment,
Inc. to install dechlorination facility. Re: A to C #073571A01, Oct. 5, 2007.
The sludge management for WWTP #NC007351 is provided by Gann Brothers
Septic Service, Inc. (License #10731I) phone # [phone]. When sludge pumping is
required or requested by ORC, Gann Brothers Septic Service is contacted to remove same
and be responsible for proper disposal.
If you have any questions please contact me at Countryside Manor, Inc. at 336-
643-6301. Thank you.
S' cerel y,
e wman,
�7 Plant Operations Manager
1J D
D
OCT 32010
7700 U.S. Highway 158 • P.O. Box 829 • Stokesdale, North Carolina 27357 • Telephone [phone] • Fax [phone]
www.retireatcountryside.com • [e-mail]

NPDES APPLICATION FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to:
N. C. DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit C00
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 mozyy t� Q)
Facility Name (✓GU�t lyVwk LA� i +j C_'
Mailing Address To &f�C.r --1 '?pp 1�t5 f �ticTtl y 5SS7"
City
�5 _:0 /CCU
State / Zip Code A)
Telephone Number ( ,) & 43
Fa7�.Number. 43W p 4 3 v CICj0, 40 -- - --
e-mail Address
2. Location of facility producing discharge:
Check here if same address as above j� r
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 -R44-R ( 1 6-C.O ) UU
Mailing Address I �) j 217
City P4,51 d S V i ( (
State / Zip Code J(J ­7 3 �
Telephone Number (?)�)" 3 qZ lf-7 4q
Fax Number (j�) 3 4; 2i 1 5 2-
1 of 3 Form-D 05108

NPDES APPLICATION — FORM D
For privately 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 Hnmec
School ❑ Number of Students/Staff 1
Other Explain: �w5;hS Y60- l
Describe the source(s) of wastewater (example: subdivision, mo ile home park, shopping centers,,
restaurants, etc.):
Population served:
S.. Type of collection system
® Separate. (sanitary sewer only) ❑Combined . (storm sewer_an.d sanitary sewer)
6. Outfall Information:
Number of separate discharge points `O
Outfall Identification number(s) tV
Is the outfall equipped with a diffuser? P Yes ❑ No
7. Name of receiving stream(s) (Provide a map showing the exact location of each outfall):
S. Frequency of Discharge: ( Continuous Intermittent
If intermittent:
Days per week discharge occurs: 7— Duration: _
9. Describe the treatment system
List all installed components, including capacities, 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.
7r Scnf-t-2�
—64-
SiU,kf, OA.Y" a T.
��� I rc,—� G �► (G'�('evJ�iAyv ��! i`�'w G � (o; r,�l.� t�n��71��du
2 of 3 Form-D 05/08

NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0 • 015 MGD
Annual Average daily flow MGD (for the previous 3 years) J
Maximum daily flow gO e �13 ' GD (for the previous 3 years) Cj_
11. Is this facility located on Indian country?
❑ Yes A 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. If more than one analysis is reported, report daily maximum
and moniivy average. If only one analysis is reported, report as daily maximum.
Biochemical Oxygen Demand (BODS)
G
r'ecal Coliform'
> O ea fcd�►,Z
��CaC % ly yl�.
Cat - ol)� .
-- - —
Total Suspended Solids
Temperature (Summer)
�` , C
C
c -
Temperature (Winter)
17
PH
13. List all permits, construction approvals and/or applications?,
Type Permit Number Type
Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA) Ocean Dumping (MPRSA)
NPDES All', 0617-1 '�:2j Dredge or fill (Section 404 or CWA)
PSD (CAA) Other
Non -attainment program (CAA)
14. APPLICANT CERTIFICATION
hermit 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.
Printed name of Person Signing Title
-- /1- A)
Date
North Carolina 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 knowingly 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.)
3 of 3 Form-D 05/08

DISCHARGE
POINT 001'� •
-modrl
F �f r
WRIJ FOR 'A
1 / �►'�,r��_���, —'Alm
®N 1�
`. lr
Countryside Manor, Inc.
County: Rockingham Stream Class: WS-III, NSW
Receiving Stream: Troublesome Creek Sub -Basin: 030601
Latitude: 36° 14' 41" Grid/Ouad: C19NW
Longitude: 79' 57' 30" .
Facility
Location r `
(not to scale)
NORTH NPDES Permit No. NC0073571

A.
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
September 23, 2010
RECEIVED
CERTIFIED MAIL RETURN 7009-1680-0002-2464-7767 N.C. Dept. of F " "
RECEIPT REQUESTED SEP 2 7 20%
Winston-Sk,,,
ROgion2l C" o�
Subject: NOTICE OF VIOLATION
Countryside Manor WWTP
NPDES Permit NCO073571
Guilford County
NOV-2010-LR-0063
Mr. Mervyn R. King
Countryside Manor
7700 US Hwy 158
Stokesdale, North Carolina 27357
Dear Mr. King:
6�
Dee Freeman
Secretary
This is to inform you that the Division of Water Quality did not received your monthly monitoring report
for June 2010 until August 24. Also, the July 2010 report was not received until September 20, 2010.
This is in violation of Part 11, condition D(2) of the NPDES permit, as well as 15A NCAC 2B .506(a),
which requires the submittal of Discharge Monitoring Reports no later than the last calendar day
followingthe he reporting- period. Failure to submit reports as required will subject the violator'to the
assessment of a civil penalty of up to $25,000 per violation.
Additionally, this letter provides notice that this office will recommend the assessment of civil penalties if
future reports are not received within the required time frame during the next twelve (12) reporting
months. The Division must take these steps because timely submittal of discharge monitoring reports is
essential to the efficient operation of our water quality programs. We appreciate your assistance in this
matter. If you have any questions about this letter or discharge monitoring reports, please contact me at
919-807-6388.
Sincerely,
Maureen Scardina
cc: Maureen Scardina, NPDES Unit
IVDWQ Winston-Salem Regional Office Supervisor, Surface Water Protection
Central Files
1617 Mail Service Center, Raleigh, -North Carolina 27699-1617 --
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone] Customer Service:1-877-623-6748
Internet: hftp://portal.ncdenr.org/web/wq/home
Northcarohna
An Equal Opportunity 1 Affirmative Action Employer

HCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins 3 March 2010
Governor Director
Dr. Mervin King
Countryside Manor
7700 US Hwy 158
Stokesdale, NC 27357
SUBJECT: Compliance Evaluation Inspection
Countryside Manor WWTP
NPDES Permit No. NCO073571
Guilford County
Dear Dr. King:
Dee Freeman
Secretary
A Compliance Evaluation Inspection was performed on the Countryside Manor wastewater treatment facility on Tuesday,
March 2, 2010 by Corey Basinger of the Winston-Salem Regional Office. Patrick Merritt, ORC and Ernie Newman were
present for the subject inspection. The inspection consisted of two parts: an on -site inspection of the treatment facility and
an in -office file review. The following are the findings from the subject inspection.
I. Permit
The NPDES permit for the Countryside Manor WWTP became effective on May 1, 2006 and expires on April 0, 2011.
II. Records/Reports
A daily visitation log was available at the site. Information contained in this daily log included field parameter data. The
flow meter calibration Was conducted on August 19, 2009. The Annual Performance Report has not yet been
submitted for calendar year 2009.. This report is due by April 1, 2010. Please submit this report to this Office as
soon as it is completed.
IIl. Facility Site Review
The 0.015 MGD treatment works consists of a bar screen, aerated equalization tank, aeration tank, secondary clarifier,
aerated sludge holding tank, tablet chlorination, chlorine contact chamber, dechlorination unit and rock step aeration.
V. Effluent & Receiving Waters
The Countryside Manor WWTP discharges to Troublesome Creek (Class WS-III NSW waters in the Cape Fear River
Basin). On the date of the inspection, the effluent appeared free of solids, debris and foam.
V..Flow Measurement
Flow is required to be measured instantaneously. A Prosonic FMU 861 flow meter is used at the facility. The meter was
last calibrated on August 19, 2009. A 22 '/2 ° V-notch weir is used in conjunction with the flow meter.
VI. Self -Monitoring Program
A review of the discharge monitoring reports (DMRs) for the time period of October 2008 through October 2009 showed
that the Countryside Manor WWTP experienced no effluent limitation and/or monitoring violations.
VII. Compliance Schedules
No compliance schedule to evaluate.
VIIl. Laboratory
All of the samples are taken to a contract lab (Meritech, Inc.) for analysis.
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone: [phone] FAX: [phone] l Customer Service: 1-877-623-6748
Internet: www.ncvvaterquality.org
An Equal Opportunity \ Affirmative Action Employer
011C
NoithCarolina
Natm,,ralll(

i�
IX. Operations and Maintenance
The facility has experienced difficulties since late January 2010 when a power outage left the system without air for over 12
hours. The system never seemed to recover and has been re -seeded twice. The seed material was taken from Britt Haven
Rest Home in Rockingham County. On the date of inspection, the facility had excessive foam in the aeration basin and the
clarifier was cloudy. The effluent was relatively clear with no visible solids, foam or debris observed. According the ORC,
the dissolved oxygen level in the aeration basin was in the 1.0 to 3.0 mg/L range. It was suggested to the ORC to contact
Mr. Gary Hudson, WWTP Consultant with the Division for technical assistance with this issue. The diffusers appeared to
be functioning properly and both blowers/motors were operational. The filters are replaced every four to six months. The
visual high water alarm for the equalization basin was not functional during the inspection. The visual alarm must
be repaired/replaced immediately. No solids, foam or debris was observed in the stream. The upstream sampling point
is 100 feet upstream of the discharge and the downstream sampling point is located at NCSR 2103.
X. Sludge Utilization/Disposal
Solids are removed as necessary by a licensed hauler. The most recent removal occurred on March 1, 2010.
,XI. Pretreatment Stormwater, Pollution Prevention, Multimedia
Not applicable for this facility
XII. Sewer Overflow
No sewer overflows were reported during the review period.
XIII. Other
Corey Basinger of the Winston-Salem Regional Office conducted the previous inspection on April 9, 2008. If you should
have any questions or concerns regarding this report, please contact this Office at [phone],
Sincer ly,
(. l
Steve W. Tedder
Water Quality Supervisor
Cc: Patrick Merritt, ORC (Meritech, Inc., 642 Tamco Road, PO Box 27, Reidsville, NC 27320)
Mr. Ernie Newman (Countryside Manor)
Guilford County Health Department
Central Files, `wlsao�_

Form Approved
OMB No.2040-0057
Approval Expires
8-31-98
+.
United States Environmental Protection Aaencv. Washington_ D.C.. 20460
Section A: National Data System Coding
Transaction Code NPDES No. Yr/Mo/Day Inspection Type Inspector FacilityType
N 5 NCO073571 10-03-02 C S 2
Facility Evaluation Rating BI QA ..........Reserved...........
4 N N
Section B: Facility Data
Name and Location of Facility Inspected:
Entry Time:
Permit Effective
0930 hrs.
Date: May 1, 2006
COUNTRYSIDE MANOR
GUILFORD COUNTY
Exit Time:
Permit Expiration
1020 hrs.
Date: April 30, 2011
Name(s) of On -Site Representative(s): Title(s): Phone No(s):
Mr. Patrick Merritt ORC 336-342-4748 or cell 336-601-2180
Mr. Ernie Newman
Name, Address of Responsible Official:
Title: Owner
Dr. Mervin King
Countryside Manor
Phone No. 336-643-6301
Contacted? No
7700 US Hwy 158
Stokesdale, NC 27357
Section C: Areas Evaluated During Inspection
X Permit X Flow Measurement X Operations/Maintenance NA Sewer Overflow
X Records/Reports X Self -Monitoring Program X Sludge Handling/Disposal NA Pollution Prevention
X Facility Site Review X Compliance Schedules NA Pretreatment NA Multimedia
X Effluent/Receiving Waters NA Laboratory NA Stormwater NA Other:
Section D: Summary of Findings/Comments
See attached Compliance Inspection Form.
REVIEW PERIOD October 2008 - October 2009
Name(s) and Signature(s) of Inspectors:
Agency/Office/Telephone:
Date:
4AN E-k� ✓
DWQ / WSRO / [phone]
vda �a
Signature of Revi er:
Agency/Office:
Date:
DWQ / WSRO / [phone]
2 - SU

Permit: NCO073571
Inspection Date: 03/02/2010
Owner - Facility: Countryside Manor WWTP
Inspection Type: Compliance Evaluation
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? ■ n n n
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable Solids, pH, DO, Sludge ■ n n n
Judge, and other that are applicable?
Comment:
Permit
Yes
No
NA NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new application?
n
n
■ n
Is the facility as described in the permit?
■
n
O n
# Are there any special conditions for the permit?
■
❑
Cl n
Is access to the plant site restricted to the general public?
■
❑
n n
Is the inspector granted access to all areas for inspection?
■
n
n ❑
Comment:
Record Keeping
Yes
No
NA
NE
Are records kept and maintained as required by the permit?
■
n
n
n
Is all required information readily available, complete and current?
■
n
n
n
Are all records maintained for 3 years (lab. reg. required 5 years)?
■
n
n
Cl
Are analytical results consistent with data reported on DMRs?
■
n
n
n
Is the chain -of -custody complete?
■
❑
n
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
■
Are DMRs complete: do they include all permit parameters?
■
❑
n
n
Has the facility submitted its annual compliance report to users and DWQ?
n
■
o
n
(If the facility is = or > 5 MGD permitted flow) Do they operate 24/7 with a certified operator on each shift?
n
n
■
n
Is the ORC visitation log available and current?
■
Cl
n
n
Is the ORC certified at grade equal to or higher than the facility classification?
■
n
❑
n
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?
■
n
❑
Page # 3

Permit: NC0073571 Owner - Facility: Countryside Manor WWTP
Inspection Date: 03/0212010 Inspection Type: Compliance Evaluation
Equalization Basins
Yes No NA NE
Is the basin aerated?
0 Cl 0 El
Is the basin free of bypass lines or structures to the natural environment?
0 Q ❑
Is the basin free of excessive grease?
® Q ❑
Are all pumps present?
n n n
Are all pumps operable?
Are float controls operable?
n n p
Are audible and visual alarms operable?
❑ N 0 Cl
® 0 ❑ ❑
# Is basin size/volume adequate?
Comment: Visual alarm not functional
Secondary Clarifier
Yes No .NA NE
Is the clarifier free of black and odorous wastewater?
■ El ❑ Q
Is the site free of excessive buildup of solids in center well of circular clarifier?
0 0 ❑
■nnn
Are weirs level?
0 ❑ Q
Is the site free of weir blockage?
Is the site free of evidence of short-circuiting?
®❑ ❑ ❑
Q ❑ Cl
Is scum removal adequate?
®❑
Is the site free of excessive floating sludge?
® Q ❑
Is the drive -unit operational?
Is the return rate acceptable (low turbulence)?
® ❑ ❑ ❑
■ n n C3
Is the overflow clear of excessive solids/pin floc?
Is the sludge blanket level acceptable? (Approximately'/4 of the sidewall depth)
® n 0 n
Comment: clarifier was cloudy
Yes No NA NE
Aeration Basins
Ext. Air
Mode of operation
Diffused
Type of aeration system
® Q Q El
Is the basin free of dead spots?
Are surface aerators and mixers operational?
a 0 Cl 0
N Q ❑ Q
Are the diffusers operational?
® Q Cl Q
Is the foam the proper color for the treatment process?
Page # 5

1qI
Permit: NC0073571 Owner - Facility: Countryside Manor WWTP
Inspection Date: 03/02/2010 Inspection Type: Compliance Evaluation
De -chlorination
IiVII1111UHL.
Are the tablets the proper size and type?
Are tablet de -chlorinators operational?
Number of tubes in use?
Comment:
Yes No NA NE
■ n n ❑
2
Page # 7

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4
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor
Dr. Mervin King
Countryside Manor
7700 US Hwy 158
Stokesdale, NC 27357
Director 10 February 2010
SUBJECT: Notice of Violation - Effluent Limitations
NOV-2010-LV-0060
Countryside Manor WWTP
NPDES No. NCO073571
Guilford County
Dear Dr. King:
Dee Freeman
Secretary
Review of the self -monitoring report for the month of November 2009 revealed the following monthly
average and daily effluent limitation violations:
Parameter
Permit Limit
Reported Value
Units
Total Suspended Solids
30.0
32.0
mg/L
Date Parameter
Permit Limit
Reported Value
Units
11/3 Total Suspended Solids
45.0
89.0
mg/L
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 the Division with the possible assessment of civil penalties of up to $25,000 per day, per violation. Should
you have any questions, please contact this Office at [phone].
Sincerely,
Steve W. Tedder
Water Quality Supervisor
cc: WSRO, Central Files-SWP
Guilford Co. Health Dept.
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 ARirmative action Employer
One
NorthCarolina
�Natlwlly

Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record
Facility: Permit/Pipe No.: AIO�06 7'3 --.�l Month/Year �Zdz)�
Parameter
—TS-S
Date
11 3
Date
Parameter
,T�-$5
Monthly Average Violations
Permit Limit DMR Value % Over Limit
,30
WeeklyAcmgviolations
Permit LimitJTvpe DMR Value % Over Limit
45.0 89 91a9 ��
Monitoring Frequency Violations
Parameter Permit Frequency Values Reported # of Violations
Violations/
Completed by:
Regional Water Quality
Supervisor Signoff:
N4✓
Date: . e ki:�B Z040
Date: aZ
�Dv- lr,10-bv_bbb0

EFFI, NT
NPDES PERMIT NO. h!C. 00-735'71 DISCHARGE NO. 001 MONTH "'j � YEAR?
FACILITY NAME Ccan�rr Sl{"b.�pr CLASS --= COLS 'Y_ C�v1 ra
OPERATOR IN RESPONSIBLE CHARGE SORC) a�oi�K �rri GRADE PHONE_33 b �W a �F7 �#�
CERTIFIED LABORATORIES (1) �1e1'I gn Inc (2)
CHECK BOX IF ORC HAS CHANGED ® PERSON(S) COLLETING SAMPLES Mccci+t {
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES
DIVISION OF WATER QUALITY
1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617
) a)a9 i0q
BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
ACCURATE AND COMPLETE TO THE BEST OF MY KNOR'LEDGE.
JAN 2, 9 00
DWQ Form MR-1 (O1/00) FEB 0 2 2� dO
Winston-Salem
Regional Oiiice

Facility. Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements ❑
Compliant
All monitoring data and sampling frequencies do NOT meet permit requirements
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 ail 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."
/=('V111`;cn
Permitt e (Ple se print or type) j
la�a`i I t
Signature of Permittea" Date
(Required)
--?-700 i�vay ISI
Permittee Address
�o:e5�gle_ NG
316.(43. 6301
Phone Number
".3o, o(o
Permit Exp. Date
PARAMETER CODES
00010 Temperature
00556 oil & Grease
00951
Total Fluoride
01067
Nickel
50060 Total
Residual
00076 Turbidity
00600 Total Nitrogen
01002
Total Arsenic
01077
Silver
Chlorine
00080 Color (Pt -Co)
00610 Ammonia Nitrogen
01092
Zinc
00082 Color (ADMI)
00625 Total Kjeldhal
01027
Cadmium
01105
Aluminum
00095 Conductivity
Nitrogen
00630 Nitrates/Nitrites
01032
Hexavalent Chromium
01147
Total Selenium
71880 Formaldehyde
00300 Dissolved Oxygen
01034
Chromium
31616
Fecal Coliform
71900 Mercury
00310 BODS
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/wQs and linking to the Unit's
information pages.
Use only units designated in the reporting facility's permit for reporting data.
* GRC must visit facility and document visitation of facility as required per 15A NCAC SG .0QJ.
If signed by other than the permittee, delegation of signatory authority must be on file with tb6 state per 15A`NCAC 2B .0506 (b)
(2) (D)•

-NPI)ES NO. N L 00%3 5? 1 DISCHARGE Nei. 001 MONTH NO\J YEAR � i
FACILITY NIAME Lemon at ry S �e (Y} ano _ COUNTY &,j Tor d
STREAM -Ir-ou�\e,SoMe- Cc'ee-K
LOCATION of'00y--- 0\?,�A j 1
Upstream
STREAM. (.reeK
LOCATION PT\- OC SK a W3
Downstream
00010
00400 00310 00300
31616
1
00010
00400
00310
00300
31616
00095
Enter Parameter Code
Enter Parameter Code
Above Name and
x
y�
a
��
Above Name and
U
b
a > V
d
Units Below
c
U
:9
h
a
Units Below
on
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7
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c. •�
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on d o w
Cho
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Waygal
eq
to
y
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u
6
2
umhos/
umhos/
""
`m
HRS
° C
Units mg/1 mg/1
#/100m1
HRS
° C
Units
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F#1100"I
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1 9 - Nlivr

RECEIVED
�, beet or PMR
NC®ENR
Fces
T 0 2 '20U9 i
North Carolina Department of Environment and Natural Resouq
oWinstnoals Office
Division of Water Quality
_ _J
Beverly Eaves Perdue
Governor
Mervyn R King
7700 US Hwy 158
Stokesdale, North Carolina 27357
Dear Mr. King:
Coleen H. Sullins Dee Freeman
Director Secretary
September 25, 2009
Subject: Notification of Jordan Lake Nutrient Requirements
NPDES Permit-NC007357-1�
Countryside Manor WWTP
Guilford County
Governor Bev Perdue recently signed legislation to complete passage of rules for the Jordan Lake
Nutrient Management Strategy. The Strategy includes a Wastewater Discharge rule (T15A NCAC 02B
.0270) that applies to your wastewater treatment facility: Pursuant to Sub -Item (6)(d) of the rule, I am
writing to notify you of the nutrient allocations assigned to your facility.
This letter addresses only certain provisions of the Jordan Lake Wastewater Discharge rule. I encourage
you to familiarize yourself with the remainder of this rule.
Nutrient Allocations. The Wastewater Discharge rule establishes the maximum loads of nitrogen and
phosphorus that can be released from wastewater treatment facilities into the Jordan Lake watershed.
The rule provides that these wasteload allocations are to be divided among the existing facilities in
proportion to (with specific exceptions) their 2001 permitted flows. It also provides that facilities
permitted to discharge 100,000 gpd or more are to receive nitrogen and phosphorus limits equivalent to
their individual allocations.
Your facility has been assigned nitrogen and phosphorus allocations. The allocations are expressed as
annual mass loadings delivered to the lake. Due to foreseeable losses between the discharge point and
the lake, they are also expressed as the equivalent discharge loads at the point of discharge. The
delivered and the corresponding discharge allocations assigned to your facility are as follows:
NCO073571
Delivered Allocation
(lb/yr)
Transport
Factor (%)
Discharge Allocation
(lb/yr)
Total Nitrogen
460
42
1,096
Total Phosphorus
69
38
183
2001 Permitted Flow: 0.03 MGD (as defined in Wastewater Discharge rule)
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone] Customer Service:1-877-623-6748
Intemet www.ncwaterquality.org
One
NorthCarolina
An Equal Opportunity 1 Affirmative Action Employer

Mervyn R King
Notification of Jordan Lake Nutrient Requirements
September 25, 2009
Nutrient Limits. Your facility will not receive new nutrient limits at this time. However, any nutrient
limits already in your NPDES permit will remain in effect.
If the facilities permitted for less than 100,000 gpd, as a group, approach their allocations for nitrogen
or phosphorus, the Division will consider whether nutrient limits are necessary to protect water quality
at that time. In the event that nutrient limits become necessary, the limits would equal your facility's
discharge allocations.
Nutrient Trading. The rule provides that, when one utility connects to another, the allocations held by
the closing facility are transferred to the remaining facility. The rule also provides for the trading of
allocations among dischargers within each of the major Jordan subwatersheds. Be sure to consult with
the Divisions NPDES staff before you consider selling allocation: transactions can have profound
implications for your facility and its permit.
If you have any questions regarding these allocations, please contact me at [phone] or at
mike. [e-mail].
Sincerely,
Alcc—QU-I�
Coleen H. Sullins
cc: Miles E. Stanley - 7700 US Hwy 158, Stokesdale, NC 27357
Wl;nston-Salem Regional Office
NDPES Files
Central Files
2

EI TE H
.. l
INCx
ENVIRONMENTAL LABORATORIES
A Division of Water Technology and Controls, Inc.
Annual Performance Report
Countryside Manor Retirement Village
Year January 1,— December 31, 2008
I. General Information
Facility/System Name: Countryside Manor WWTP
=Oc of ENR
MAY 15 2009
irtn;:Crl•aalem
Regional Office
Responsible Entity: Mr. Mervin King PO Box 829, 7700 US_Hiway
158 Stokesdale NC 27357 336-643-6301
Person in Charge/Contact: Ernie Neuman
Applicable Permit(s): WWTP NC0073571 - RECEIVED.
Description of Collection System or Treatment Process: MAY 13 2009
A Grade II Wastewater treatment plant consisting of bar screen,'�tiotcoVected
,R . MALITY
activated sludge basin, clarifier and chlorination systems treats at is
throughout by a collection system. POINT SOURCE BRANCH
H. Performance
Text Summary of System Performance for Year 2008:
The systems operated with no bypasses or system overflows during this period.
The Following Violations Occurred During 2008.
July, Fecal Coliform Daily Violation.
November, Fecal Coliform Daily Violation.
Office: 106-A South Walnut Circle P.O. Box 8808 Greensboro, NC 27419 [phone]
Laboratory: 642 Tamco Road Reidsville, NC 27320 [phone]

III. Notification
A copy of this report will be made available to all system users.
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.
i
Res onsible Person:
Z--
%�
Ti e: 1
Date:
Office: 106-A South Walnut Circle P.O. Box 8808 Greensboro, NC 27419 [phone]
Laboratory: 642 Tamco Road Reidsville, NC 27320 [phone]

Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record
Facility: Permit/Pipe No.: !`�'�77 ( Month/Year Zoo
Auo�
Parameter
Monthly Average Violations
Permit Limit DMR Value % Over Limit
Weekly ail Violations
Date Parameter Permit Limitgype DMR Value % Over Limit
"i5 S 4-6 AS 4 . ;1 0/0
Date
Parameter
Other Violations
Completed by:
Regional Water Quality
Supervisor Si-noff:
Monitoring Frequency Violations
Permit Frequency Values Reported # of Violations .
Date: .Z Z*V,
Date:

of ENR
I FEB x 3 20'9
Winston-Salem EFFLUENT
Regional Office
MS
NPDES P VITI�0-j�1C 0�73s ( DISCHARGE NO. 001 MONTH �e<- YEAR o2
FACILITY NAME C,o.>CLASS - COUNTY C-�rtiazglL ark .
OPERATOR IN RESPONSIBLE CHARGE (ORC) GRADE a PHONE-jjk-j!j z 414E
CERTIFIED LABORATORIES (1) Me64gal -rams, (2)
CHECK BOX IF ORC HAS CHANGED A PERSON(S) nLECTING SAMPLES 4�riLr e.rci+t
Mail ORIGINAL and ONE COPY to: II M
ATTN: CENTRAL FILES-� (]x0 g l Pj l�� N iA �®�j®
DIVISION OF WATER QUALITY (SIGNATURE OF OPERAT R IN RESPONSIBLE CHARGE) DATE_
1617 MAIL SERVICE CENTER BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS FEH2099---
RALEIGH, NC 27699-1617 ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. /
• � D
DWQ Form MR-1 (01/00)

Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements
Compliant
All monitoring data and sampling frequencies do NOT meet permit requirements
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."
r'1 van �:n�
Permitt e (Please print or t e)
Signature of Per ittee" Date
(Required)
-?700 NG 37357 y •3o, o(o
Permittee Address Phone Number Permit Exp. Date
PARAMETER CODES
00010
Temperature
00556
Oil & Grease
00951
Total Fluoride
00076
Turbidity
00600
Total Nitrogen
01002
Total Arsenic
00080
Color (Pt -Co)
00610
Ammonia Nitrogen
00082
Color (ADMI)
00625
Total Kjeldhal
01027
Cadmium
Nitrogen
00095
Conductivity
00630
Nitrates/Nitrites
01032
Hexavalent Chromium
00300
Dissolved Oxygen
01034
Chromium
00310
BOD5
00665
Total Phosphorous
00340
COD
00720
Cyanide
01037
Total Cobalt
00400
pH
00745
Total Sulfide
61042
Copper
00530
Total Suspended
00927
Total Magnesium
01045
Iron
Residue
00929
Total Sodium
01051
Lead
00545
Settleable Matter
00940
Total Chloride
01062
Molybdenum
01067
Nickel
01077
Silver
01092
Zinc
01105
Aluminum
50060 Total
Residual
Chlorine
01147 Total Selenium 71880 Formaldehyde
31616 Fecal Coliform 71900 Mercury
32730 Total Phenolics 81551 Xylene
34235 Benzene
34481 Toluene
38260 MBAS
39516 PCBs
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/wos 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.
** If signed by other than the permittee, delegation of signatory authority must be on file with the state per 15A NCAC 2B .0506 (b)
(2) (D)•

k%,
NPDES NO. N(-E>'D_7.35_71 DISCHARGE NO. —MONTH J)e- YEAR 2W6
FACILITY NAME (_0Jf\�TjS'1�.MoA0(- COUNTY—& � TO(4
snzEAm r-V o6� \eWne- Cree-K
LOCATION \ 00 �' ck'bo'J e- 00��ok I i
Upstream
r7—
00010
00400
00310
00300
3 616
00095
Enter Parameter Code
9
Above Name and
abi C
Units Below
U
kn
a
Pa
c
OU
0
2
X
`4
J5
0.0
U
UU
umhos/
,
FIRS
C
Units
mg/1
mg/1
#/100M1
HMMMM7
09MMOMM29
2
-
..... ...........
4
6
aimaffiffimffiM
81
alAft
iojjr,-�.o
*6q 0
121
fig`{
W
141
161
am=
M"
W
. . . . . . . . . . . . .
1
-7 1 a 03Ti
20
irk
1
224.
1
24164
1-0
1
q.10
261
2*,.R*.,N.1N1
281
1
1
1
1
301
1
Average
(P (0
Minimum
'I
STREAM __Fo�)P�'PScfte Cce_eK,
LOCH TION Pt\- OC-S?, 5003
DEM Form MR-3 (12/93)

1
Beverly Eaves Perdue, Governor
✓
Dee Freeman, Secretary
rNorth
Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
Dr. Mervin King
Countryside Manor
7700 US Hwy 158
Stokesdale, NC 27357
SUBJECT: Notice of Violation - Effluent Limitations
NOV-2009-LV-0042
Countryside Manor WWTP
NPDES No. NCO073571
Guilford County
Dear Dr. King:
9 February 2009
Review of the self -monitoring report for the month of November 2008 revealed the following daily
maximum effluent limitation violation:
Date Parameter Permit Limit Reported Value Units
11/24 Fecal Coliform 400.0 600.0 4/100m1
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 the Division with the possible assessment of civil penalties of up to $25,000 per day, per violation. Should
you have any questions, please contact this Office at [phone].
cc: WSRO, Central Files-SWP
Guilford Co. Health Dept.
Mailing Address Phone [phone]
1617 Mail Service Center Fax [phone]
Raleigh, NC 27699-1617
Sincerely,
Steve W. Tedder
Water Quality Supervisor
Location N2AhCarolina
512 N. Salisbury St. Naturally
Raleigh, NC 27604
Internet: www.ncwatergualitv.ore Customer Service 1-877-623-6748
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper

I',
Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record % /
Facility: &OAtM ji Permit/Pipe No.: &a-g 3� 1 Month/Year LW Zee)�
11,4db�P— WkO
Monthly Average Violations
Parameter Permit Limit DMR Value % Over Limit
Weekly/Daily Violations
Date
Parameter
Penrvt Li nitfl'vpe
DMR Value
%Over Lima
Date Parameter
Completed by:
Regional Water Quality
Supervisor Signoff:
Monitoring Frequency Violations
Permit Frequency Values Reported # of Violations
Date: 9F2� 7,�-o
Date: 12- `.— 0 r
P �[t) I/- -Z,/) --dq - L V/, d Z).42

6
F
E ENT
NPDES PERMIT NO. tAC_ 00-73S-71 DISCHARGE NO. 00I MONTH_
FACILITY NAME CLASS = COU1
OPERATOR IN RESPONSIBLE CHARGE ORC) GRADE a
CERTIFIED LABORATORIES (1) eri (2)
CHECK BOX IF ORC HAS CHANGED PERSON(S)0 - CTING SAMPLES a
Mail ORIGINAL and ONE COPY to: `1 n
ATTN: CENTRAL FILES X I'o�C7` C6
DIVISION OF WATER QUALITY (SIGNATURE O OPERA IN RESPONSIBLE CHAR E)
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.
I
Regional Office
DWQ Form MR-1 (01/00)

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
F-1
Compliant
1117
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. B ased 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
00010
Temperature
00076
Turbidity
00080
Color (Pt -Co)
00082
Color (ADMI)
00095
Conductivity
00300
Dissolved Oxygen
00310
BOD5
00340
COD
00400
pH
00530
Total Suspended
Residue
00545
Settleable Matter
CG
I
n K►n
PerrrAttee lease print or type)
Signa e of Pe m ttee** Date
(Required)
Phone Number
PARAMETER CODES
00556
Oil & Grease
00951
Total Fluoride
00600
Total Nitrogen
01002
Total Arsenic
00610
Ammonia Nitrogen
00625
Total Kjeldhal
01027
Cadmium
Nitrogen
00630
Nitrates/Nitrites
01032
Hexavalent Chromium
01034
Chromium
00665 Total Phosphorous
00720
Cyanide
01037
Total Cobalt
00745
Total Sulfide
01042
Copper
00927
Total Magnesium
01045
Iron
00929
Total Sodium
01051
Lead
00940
Total Chloride
.01062
Molybdenum
01067 Nickel
01077 Silver
01092 Zinc
01105 Aluminum
W
Permit Exp. Date
50060 Total
Residual
Chlorine
01147
Total Selenium
71880 Formaldehyde
31616
Fecal Coliform
71900 Mercury
32730
Total Phenolics
81551 Xylene
34235
Benzene
34481
Toluene
38260
MBAS
39516
PCBs
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/wqs and linking to the Unit's information pages.
Use only units designated in the reporting facility's permit for reporting data.
64 Z - M1�
* ORC must visit facility and document visitation of facility as required per 15A NCAC 8G .0204.
**If signed by other than the permittee, delegation of signatory authority must be on file with�-6e°"state per 15A NCAC 2B .0506 (b)
(2) (D)•

A
NPDES NO. N(,0t)-73-5-71 DISCHARGE NO. 001 - MONTR 0 0\) YEARS 9�
FACILITY NAME - \"-M0,A0(- COUNTY Grv%AT0(4
7-
STREAM r04\eA)Me- CteeK
LOCATION 1 OC) f� ch100V --- 00��c, I t
Upstream
00010
00400
00310
00300
31616
00095
Enter Parameter Code
Above Name and
Units Below
U
4)
0
ou
U
E
c)
U
U
umhosl
HRS
IC
Units,
mg/1
mg/1W100MI
2
is
JR10
-75
81
1
101
1
141
161
1
"MM%WWM
181
1
201119�-
1
1
22
241
e �
Lf OQ
-M
of t
-�M
2616
1
sa
281
1
1
1
1
1
1
301
1
or
Average
-7
Minimum
STREAM- (-CttK-
LOCATION ffi`[ Oc-S?, a103
Downstream
DEM Form MR-3 (12/93)

Dr. Mervin King
Countryside Manor
7700 US Hwy 158
Stokesdale, NC 27357
SUBJECT: Notice of Violation - Effluent Limitations
NOV-2008-LV-0506
Countryside Manor WWTP
NPDES No. NCO073571
Guilford County
Dear Dr. King:
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
3 November 2008
Coleen H. Sullins, Director
Division of Water Quality
Review of the self -monitoring report for the month of July 2008 revealed the following daily
maximum effluent limitation violation:
Date Parameter Permit Limit Reported Value Units
7/8 Fecal Coliform 400.0 >600 4/100ml
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 the Division with the possible assessment of civil penalties of up to $25,000 per day, per violation. Should
you have any questions, please contact this Office at (336) 771=5000.
Sincerely,
Steve W. Tedder
Water Quality Supervisor
cc: WSRO, Central Files-SWP
Guilford Co. Health Dept.
Nne
or Carolina
Ntllrvillf
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.ncwaterquality.org
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper

Cover Sheet from
Staff Member to
Regional Supervisor
DMR Review Record I
Facility: MAwQ- Permit/Pipe No.: 9"01;5h Month/Year
Monthly Average Violations
Parameter Permit Limit DMR Value % Over Limit
Weekly/Daily Violations
Date Parameter Permit Limit/Tvt)e DNIR Value % Over Limit
Monitoring Frequency Violations
Date Parameter Perrriit Frequency Values Reported # of Violations
Other Violations
Completed by: Date:
Regional Water Quality
Supervisor Signoff: Date:
3L 0ca'_U019
/V,fv WV-4PO- L. �- 65-b�

s
EFFLUENT
NPDES PERMIT NO. tAL 00-715-71 DISCHARGE NO. 001 MONTH "Sj�i YEAR a
FACILITY NAME La,3n�rr S%�p-1"1-onor CLASS '-M COUNTY C7 O—�ora
OPERATOR IN RESPONSIBLE CHARGE (ORC) a�Ci;OC Merr.it GRADE PHONE 33 b 3y 47 48
CERTIFIED LABORATORIES (1) e1`i} c • (2)
CHECK BOX IF ORC HAS CHANGED ® PERSON(S) CO LECT G SAMPLES a�ri�K Merritt
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES X
DIVISION OF WATER QUALITY (SIGNATURE OF OPERATOR SPONSIBLE 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.
I11 I
11.11
11.1
11 1
11. 1
11 1
11 11
1111
11
®
•
NAME AND UNITS BEL •
iiYi:a
•
mmmw��
Cm
i�
a
9
a
mom���m�mmmmmmmm��m
mmmm
������m�mm�mam��m
MOM=�m�������������
M
m
.
ma�����■��m��mmmmm�o�
mimmiis��mm���mmmm�m
m
: fm=��m�m���smmmm��
`
DWQ Form MR-1 (01/00)

Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements F7
Compliant
All monitoring data and sampling frequencies do NOT meet permit requirements
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. B ased 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."
t(' i A K+ n
Perrtlittee. lease print or type)
V_te�. �1-2"6(t
Signa e of ermittee" Date
(Required)
—?_)00 \�Oy 158 SNOKeslak= Nc, 3310•(e43, 001 y.30, V6
Permittee Address Phone Number Permit Exp. Date
00010
Temperature
00556
00076
Turbidity
00600
00080
Color (Pt -CO)
00610
00082
Color (AD.NU)
00625
00095
00300
00310
00340
00400
00530
00545
Conductivity
Dissolved Oxygen
BOD5
COD
pH
Total Suspended
Residue
Settleable Matter
1/� 1
Oil & Grease
Total Nitrogen
Ammonia Nitrogen
Total Kjeldhal
Nitrogen
Nitrates/Nitrites
00665 Total Phosphorous
PARAMETER CODES
00951 Total Fluoride
01002 Total Arsenic
01027 Cadmium
01067
Nickel
01077
Silver
01092
Zinc
01165
Aluminum
50060 Total
Residual
Chlorine
01032 Hexavalent Chromium 01147 Total Selenium 71880 Formaldehyde
01034 Chromium 31616 Fecal Coliform 71900 Mercury
32730 Total Phenolics 81551 Xylene
00720
Cyanide
01037
Total Cobalt
34235 Benzene
00745
Total Sulfide
01042
Copper
34481 Toluene
00927
Total Magnesium
01045
Iron.
38260 MBAS
00929
Total Sodium
01051
Lead
39516 PCBs
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/wqs 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 .02(l. t e j _JS
** If signed by other than the permittee, delegation of signatory authority must be on fil6t_Wjjh t4A tajteper 5��NCAC 2B .0506 (b)
(2) (D)•

NP,DES NO. N L 00-7.3 5 -71 —DISCHARGE NO. O O MONTH YEAR 'c-?Ot
FACILITYNAME. LOJA�TyS\�P—M,,AO(- COUNTY Uv� Turd
7- STREAM rOu�? DME-Ctef-K STREAM
LOCATION
Upstream
LOCATION Pt-\C NC-SK a\03
Downstream
100010
00400100310
00300
-31616
00095
---T--T-
Enter Parameter Code
a
Above Name and
u.im BI.\,
c
u
u
Fi
unihos/
FIRS
'C
Units
Mg/l
Mg/l
#1100n-1
y.
Iola
',,\o
7,10
00
DEM Form MR-3 (12/93)

�rp

ection
z Coutrty: GUILFORD
River Basin
Report To WSROSP
Collector:
C BASINGER
Region:
WSRO
Sample Matrix:
Surfacewater
Loc. Type:
Effluent
Emergency Yes/No
COC Yes/No
wArFA�G
RECEIVED 0Y
Dept. of ENR
APR 3 0 2000 %
Winston-Salem VISItID
Regional oince
Loc. Descr.: COUNTRYSIDE MANOR
Sample ID:
PO Number #
Date Received:
Time -Received:
Labworks LoginlD
Date Reported:
Report Generated
Location ID: WSROSPNLC I Collect Date: 04/09/2008 1 Collect Time:: - 09:30 1 Sample Depth
Sample Qualifiers and Comments
Routine Qualifiers
For a more detailed description of these qualifier codes refer to www.dwglab.org. under Staff Access
AB28700
8W2493
04/10/2008
07:66
MMATHIS
4/25/08
04/25/2008
A -Value reported is the average of two or more determinations
N3-Estimated concentration is < PQL and >MDL
B1-Countable membranes with <20 colonies; Estimated NE -No established PQL
B2- Counts from all filters were zero.
B3- Countable membranes with more than 60 or 80 colonies; Estimated P-Elevated PQL due to matrix interference and/or sample dilution
Q1-Holding time exceeded prior to receipt at lab.
B4-Filters have counts of both >60 or 80 and < 20; Estimated
Q2- Holding time exceeded following receipt by lab
B5-Too many colonies were present; too numerous to count (TNTC)
J2- Reported value failed to meet QC criteria for either precision or accuracy; Estimated PQL-Practical Quantitation Limit -subject to change due to instrument sensitivity
U- Samples analyzed for this compound but not detected
J3-The sample.matrix interfered with the ability to make any accurate determination; Estimated X1-Sample not analyzed for this compound
J6-The lab analysis was from an unpreserved or improperly chemically preserved sample; Estimated
N1-The component has been tentatively identified based on mass spectral library search and has an estimated value
I AR
Laboratory Section>> 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone] Page 1 of 2

Sample ID AB28700
�C DWQQ .Laboratory Section 1�esufts
Location ID: r WSROSPNLC Collect Date: 04/09/2008
Loc. Descr.: COUNTRYSIDE MANOR Collect Time:: 09:30
Visit ID
CAS # Analyte Name PQL Result Qualifier Units Analyst/Date Approved By /Date
LAB
Sample temperature at receipt by lab 0.7 °C DSAUNDERS MMATHIS
Method Reference 4/10/08 4/10/08
MIC T • ,
BOD, 5-Day in liquid 2.0 e24�G6!1 mg/L ADEXTER MOVERMAN
Method Reference APHA5210B
4/10/08
4/21/08
Coliform, MF Fecal in liquid
1
5 Q1
CFU/100ml
PCOTTEN
MOVERMAN
Method Reference APHA9222D-20th
4/10/08
4/21/08
NUT
NH3 as N in liquid
0.02
0.08
mg/L as N
MOVERMAN
CGREEN
Method Reference LaclO-107-06-1-J
4/10/08
4/16/08
Total Kjeldahl N as N in liquid
0.2
2.1
mg/L as N
MOVERMAN
CGREEN
Method Reference Lachat107-06-2-H
4/15/08
4/16/08
NO2+NO3 as N in liquid
0.02
0.94
mg/L as N
MOVERMAN
CGREEN
Method Reference LaclO-107-04-1-c
4/10/08
4/16/08
Phosphorus —total as P in liquid
0.02
mg/L as P
MAJAYI
CGREEN
Method Reference LaclO-115-01-lEF
4/15/08
4/25/08
Laboratory Section>> 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone] Page 2 of 2

DIVISION/OAF ENVIRONMENTAL MANAGEMENT WATER QUALITY FIELD -LAB FORM (DMA) ///�
COUNTY Cam'/G�i0�7A Lab Number:
PRIORITY d
SAMPLE TYPE Date Received: 4 ir, O D b
RIVER BASIN C4? ��i�-� n(� Timer_
REPORT TO: ARO FRO MRO RRO WaRO WIR S TS L_IAMBIENT ❑ QA ❑ STREAM et=U EFFLUENT Rec'd by: y� From: Bu_ Couri r-Hand Del
AT BM
Other COMPLIANCE ❑ CHAIN ❑ LAKE ❑ INFLUENT DATA ENTRY BY: (^it;
/��' OF CUSTODY
Shipped by: Bus Cburief, Staff, Other a EMERGENCY ❑ ESTUARY DATE REPORTED:
COLLECTOR(S): C. a-4—.5" G JF_ %��
Estimated BOD Range: 0- 25-65/40-130 or 300 plus STATION LOCATION: �-�/&NMe-V5.,,�E �AJd
Seed: Yes ❑ No ❑ Chlorinated: YesX No ❑ REMARKS:
Station } Date Begin (yy/mm/dd) I Timee� Begin Date End T1me End Depth DM DB DBM Value Type Composite. Sninplc:-'1 e
A— H L T S 13 CGNXX
1
vuo oav mg/1
2
COD High 340 mg/1
3
COD Low 335 mg/I
4
!�
Collform: MF Fecal 31616 /100m1
5
Collform: MF Total 31504 /100ml
6
Collform: Tube Fecal 31615 /100m1
7
Coliform: Fecal Strep 31673 /100ml
8
Residue: Total 500 mg/1
9
Volatile 505 mg/I
�10
Fixed 510 mg/I
_l1
Residue: Suspended 530 mg/I
12
�13
Volatile 535 mg/I
Fixed 540 m9/1
14
pH 403 units
15
Acidity to pH 4.5 436 mg/I
16
�17
Acidity to pH 8.3 435 mg/I
Alkalinity to pH 8.3 415 mg/I
18
Alkalinity to pH 4.5 410 mg/1
19
TOC 680 mg/I
20
Turbidity 76 NTU
Chloride 940 mg/1
Chi a: Tri 32217 ug/l
Chi a: Corr 32209 ug/l
Pheophytin a 32213 ug/1
Color: True 80 Pt -Co
Co1or:(PH ) 83 ADMI
Color: pH 7.6 82 ADMI
Cyanide 720 mg/1
Fluoride 951 mg/1
Formaldehyde 71880 mg/1
Grease and Oils 556 mg/l
Hardness Total900 mg/l
Specific Cond. 95 2
uMhos/cm
MBAS 38260 mg/l
Phenols 32730 ug/I
Sulfate 945 mg/I
Sulfide 745 mg/I
X
NH3 as N 610
mg/l
x
TKN as N 625
mg/l
.�
NO2 plus NO3 as N 630
mg/l
K
P: Total as P 665
mg/I
PO4 as P 70507
mgA
P: Dissolved as P 666
mgA
CdCadmium 1027
ug/1
Cr,Chromium:Tota11034
ugA
Cu<;opper1042
ug/I
Ni-Nickel 1067
ug/i
Pb-Lead 1051
ug/l
Zn-Zinc 1092
ug/l
Ag-Silver 1077
ug/I
Al -Aluminum 1105
ug/l
Be -Beryllium 1012
ug/I
Ca-Calclum 916
mgA
Co -Cobalt 1037
ug/1
Fe -Iron 1045
ugA
Sampling Point %
Conductance at 25 C
Water Temperature
D.O. mg/I
pH
Alkalinity
Acidity
Air Temperature (C)
pH 8.3 pH 4.5
pH 4.5 pH 8.3
2
94
10
300 1.
400 1•
82244 431
82243 182242
20
Salinity %
Precipition On/day)
Cloud Cover %
Wind Direction (Deg)
Stream Flow Severity Turbidity Severity
Wind Velocity M/H can Stream Depth ft.
Stream Width ft.
480
45
32 '
36
1351 1350
35 64 14
DM1/Reu1_.,i tnlw;

Report to: _WSRO.
Sample Anomaly Report (SAR)
Lab Number:
Station Location:
AB28700
Countryside County: Guilford
Manor
Sample Type: Effluent
Date collected: 4/9/08
Affected Parameter(s): BOD
Sample ID:
NCO073571
Region: Winston Salem
Priority: Compliance Collector: C.Basinger
Date received: 4/10/08 Date analyzed: 4/10/08
Analytical Area (check one):
❑ WCH ❑ METALS
❑NUT ®MICRO
The following anomalies occurred (check all that apply):
❑Samples
❑Improper container used
❑VOA vials with headspace
❑Sulfide samples with headspace
❑Samples not received, but listed on fieldsheet
❑Samples received, but not listed on fieldsheet
❑Mislabeled as to tests, preservatives, etc.
❑Holding time expired
❑Prior to receipt in lab
❑After receipt in lab
❑Insufficient quantity for analysis
❑Sample exhibits gross non -homogeneity
❑Sample not chemically preserved properly
❑pH out of range (record pH):
El Improper chemical
❑Residual chlorine present in sample
❑Color interference
❑Heavy emulsion formed during extraction
❑Sample bottle broken in lab - no reportable results
❑VOA ❑SVOA
❑PEST
❑Quality Control
❑Instrument failure — no reportable results
❑Analyst error — no reportable results
❑ Surrogates
❑None added
[]Recovery outside acceptance limits
❑Spike recovery
❑None added
❑Recovery outside acceptance limits
❑Failed to meet criteria for precision
❑Internal standards
❑Blank contamination
❑QC data reported outside of controls (e.g., QCS, LCS)
❑Incorrect procedure used
❑SOP intentionally modified with QA and Branch Head
approval
❑Invalid instrument calibration
❑Elevated detection limits due to:
❑Insufficient sample volume
®Other (specify): The calculated seed correction exceeded the range of 0.6 to 1.0 mg/L resulting in a G6 qualifier. The seed
correction factor was 1.600.
Comments:
Corrective Action:
❑Samples were rejected by DWQ Lab. Authorized by: Date:
❑Accepted and analyzed after notifying the collector or contact person and determining that another sample could not be secured.
❑Sample(s) on hold until:
®Sample reported with qualification. Data qualification code used:G6
❑Other (explain):
Notification Required? ❑ Yes ❑ No
Person Contacted: Date:
Form completed by: ela Dexte Date: 4/16/2008
Lead Chemist Review (initial):
BIOCHEM
❑ METALS
Branch Head Review (initi 1 `q-6f
QA/QC Review 0 al):
❑ PEST
❑VOA,
❑SVOA
Logged into database by (initial):
QA\Fotms\Labomtory\SAR 10/23/Oldbs

Report to: _WSRO
.....--_..-J
Sample Anomaly Report (SAR)
Lab Number:
Station Location:
Sample Type:
Date collected:
AB28700
Countryside
Manor
Effluent
4/9/08
Affected Parameter(s): BOD
Sample ID
County: Guilford
NCO073571
Region: Winston Salem
Priority: Compliance Collector:
Date received: 4/10/08 Date analyzed
Analytical Area (check one):
❑ WCH ❑METALS
[-]NUT ®MICRO
The following anomalies occurred (check all that apply):
❑Samples
❑Improper container used
❑VOA vials with headspace
❑Sulfide samples with headspace
❑Samples not received, but listed on fieldsheet
❑Samples received, but not listed on fieldsheet
❑Mislabeled as to tests, preservatives, etc.
❑Holding time expired
❑Prior to receipt in lab
❑After receipt in lab
❑Insufficient quantity for analysis
❑Sample exhibits gross non -homogeneity
❑Sample not chemically preserved properly
[I pH out of range (record pH):
❑Improper chemical
❑Residual chlorine present in sample
❑Color interference
❑Heavy emulsion formed during extraction
❑Sample bottle broken in lab - no reportable results
❑Other (specify):
C.Basinger
4/10/08
❑VOA ❑SVGA
❑PEST
❑Quality Control
❑Instrument failure — no reportable results
❑Analyst error — no reportable results
❑Surrogates
❑None added
❑Recovery outside acceptance limits
[]Spike recovery
El None added
❑Recovery outside acceptance limits
❑Failed to meet criteria for precision
❑Internal standards
❑Blank contamination
®QC data reported outside of controls (e.g., QCS, LCS)
❑Incorrect procedure used
❑SOP intentionally modified with QA and Branch Head
approval
❑Invalid instrument calibration
❑Elevated detection limits due to:
❑Insufficient sample volume
Comments: Both of the two glucose glutamic acid standards were above the acceptable range of 167.5 to 228.8 mg/L at 232 mg/L
and 233 mg/L, The sample was seeded
Corrective Action: Ongoing investigation to determine the cause of high GGA standard results.
❑Samples were rejected by DWQ Lab. Authorized by: Date:
❑Accepted and analyzed after notifying the collector or contact person and determining that another sample could not be secured.
❑Sample(s) on hold until:
®Sample reported with qualification. Data qualification code used:G5
❑Other (explain):
Notification Required? ❑ Yes ❑ No
Person Contacted: Date:
Form completed by:[Angela Dexte Date: 4/16/2008
Lead Chemist Revie (initial):
MBIOCHEM
METALS
❑ PEST
❑VOA
Branch Head Review (initi u� o
QA/QC Review
QA\Fotms\ abotatory\SAR tc'U`" I•'� J'
❑SVOA
Logged into database by (initial):
10/23/01dbs

J
Report to: _WSRO Sample Anomaly Report (SAR)
Lab Number: _
Station Location:
Sample Type:
Date collected: 4/9/08
Affected Parameter(s):
AB28700
Countryside
Manor
Effluent
BOD
Sample ID: NCO073571
County: Guilford Region: Winston Salem
Priority: Compliance Collector:
Date received: 4/10/08 Date analyzed:
Analytical Area (check one):
❑ WCH []METALS
❑NUT ®MICRO
The following anomalies occurred (check all that apply):
❑Samples
❑Improper container used
❑VOA vials with headspace
❑Sulfide samples with headspace
❑Samples not received, but listed on fieldsheet
❑Samples received, but not listed on fieldsheet
❑Mislabeled as to tests, preservatives, etc.
❑Holding time expired
❑Prior to receipt in lab
❑After receipt in lab
El Insufficient quantity for analysis
[]Sample exhibits gross non -homogeneity
El Sample not chemically preserved properly
❑pH out of range (record pH):
El Improper chemical
❑Residual chlorine present in sample
❑Color interference
❑Heavy emulsion formed during extraction
El Sample bottle broken in lab - no reportable results
C.Basinger
4/10/08
❑VOA ❑SVOA
❑PEST
El Quality Control
El Instrument failure — no reportable results
❑Analyst error — no reportable results
❑ Surrogates
❑None added
❑Recovery outside acceptance limits
❑Spike recovery
❑None added
❑Recovery outside acceptance limits
®Failed to meet criteria for precision
❑Internal standards
❑Blank contamination
❑QC data reported outside of controls (e.g., QCS, LCS)
❑Incorrect procedure used
❑SOP intentionally modified with QA and Branch Head
approval
❑Invalid instrument calibration
❑Elevated detection limits due to:
❑Insufficient sample volume
®Other (specify): The sample contained excess reducing agents. It took 30 drops of bi-iodate to neutralize the sample.
Comments: The %RPD for the duplicate sample was above the limit of 20 at 24. The BOD mg/L for the duplicates were 30.8 and
24.2. The sample was seeded
Corrective Action:
❑Samples were rejected by DWQ Lab. Authorized by: Date:
❑Accepted and analyzed after notifying the collector or contact person and determining that another sample could not be secured.
❑Sample(s) on hold until:
®Sample reported with qualification. Data qualification code used:J2
❑Other (explain):
Notification Required? ❑ Yes ❑ No
Person Contacted: Date:
Form completed by: [Angela Dexterl( �_�,�,Qjy`�L �J t �X , Date: 4/16/2008
Lead Chemist Review, (initial):
�
MBIOCHEM_ P ❑PEST ❑SVGA
ETALS ❑VOA
Branch Head Review (initia
QA/QC Review (init' ): �h' /Og Logged into database by (initial):
QA\Forms\ aboratory\SAR 10/23/Oldbs

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
09 April 2008
Dr. Mervin King
Countryside Manor
7700 US Hwy 158
Stokesdale, NC 27357
SUBJECT: Compliance Evaluation Inspection
Countryside Manor WWTP
NPDES Permit No. NCO073571
Guilford County
Dear Dr. King:
Coleen H. Sullins, Director
Division of Water Quality
A Compliance Evaluation Inspection was performed on the Countryside Manor wastewater treatment facility on
Wednesday, April 9, 2008 by Corey Basinger of the Winston-Salem Regional Office. Patrick Merritt, ORC was present for
the subject inspection. The inspection consisted of two parts: an on -site inspection of the treatment facility and an in -office
file review. The following are the findings from the subject inspection.
I. Permit
The NPDES permit for the Countryside Manor WWTP became effective on May 1, 2006 and expires on April 30, 201 L
The new permit was modified to include a Total Residual Chlorine (TRC) limit of 28 ug/1 effective November 1, 2007. An
Authorization to Contruct (No. 073571AO1) was issued October 5; 2007 with actual installation completed October 17,
2007. The professional engineer's certification was received on January 18, 2008.
II. Records/Reports
A daily visitation log was available at the site. Information contained in this daily log included field parameter data. The flow meter calibration was conducted in August 2007. The Annual Performance Report has not yet been submitted for
2007. This report was due by April 1, 2008. Please submit this report to this Office
III. Facility Site Review
The 0.015 MGD treatment works consists of a bar screen, aerated equalization tank, aeration tank, secondary clarifier,
aerated sludge holding tank, tablet chlorination, chlorine contact chamber, dechlorination unit and rock; step aeration.
V. Effluent & Receiving Waters
The Countryside Manor WWTP discharges to Troublesome Creek (Class WS-III NSW waters in the Cape Fear River
Basin). On the date of the inspection, the effluent appeared free of solids, debris and foam.
V. Flow Measurement
Flow is required to be measured instantaneously. A Prosonic FMU 861 flow meter is used at the facility. The meter was
last calibrated in August 2007. A 22 '/2 ° V-notch weir is used in conjunction with the flow meter.
VI. Self -Monitoring Program
A review of the discharge monitoring reports (DMRs) for the time period of January 2007 through December 2007 showed
that the -Countryside Manor WWTP experienced no effluent limitation and/or monitoring violations.
VII. Compliance Schedules
No compliance schedule to evaluate.
VIII. Laboratory
All of the samples are taken to a contract lab (Meritech, Inc.) for analysis.
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.ncwaterquality.org
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper
Nose Carolina
�tumily

IX. Operations and Maintenance
The diffusers appeared to be functioning properly and both blowers/motors were operational. The filters are replaced every
four to six months. The visual high water alarm for the equalization basin was not functional during the inspection.
These alarms must be repaired/replaced immediately. No solids, foam or debris was observed in the stream. The
upstream sampling point is 100 feet upstream of the discharge and the downstream sampling point is located at NCSR
2103.
X. Sludge Utilization/Disposal
Solids are removed as necessary by a licensed hauler.
XI. Pretreatment, Stormwater, Pollution Prevention, Multimedia
Not applicable for this facility
XII. Sewer Overflow
No sewer overflows were reported during the review period.
XIII. Other
Corey Basinger of the Winston-Salem Regional Office conducted the previous inspection on May 9, 2007. If you should
have any questions or concerns regarding this report, please contact this Office at [phone].
Sincerely,
Steve W. Tedder
Water Quality Supervisor
Cc: Patrick Merritt, ORC (Meritech, Inc., 642 Tamco Road, PO Box 27, Reidsville, NC 27320)
Mr. Ernie Newman (Countryside Manor)
Guilford County Health Department
Central Files,%)KSRgt7Mk

Form Approved
OMB No.2040-0057
Approval Expires
8-31-98
°
United States Environmental Protection ALyencv- Washington. D.C.. 20460
Section A: National Data System Coding
Transaction Code NPDES No. Yr/Mo/Day Inspection Type Inspector FacilityType
N 5 NCO073571 08-04-09 C S 2
Facility Evaluation Rating BI QA ..........Reserved...........
4 N N
Section B: Facility Data
Name and Location of Facility Inspected:
Entry Time:
Permit Effective
0915 hrs.
Date: May 1, 2006
COUNTRYSIDE MANOR
GUILFORD COUNTY
Exit Time:
Permit Expiration
0955 hrs.
Date: April 30, 2011
Name(s) of On -Site Representative(s): Title(s): Phone No(s):
Mr. Patrick Merritt ORC 336-342-4748 or cell 336-601-2180
Name, Address of Responsible Official:
Title: Owner
Dr. Mervin King
Countryside Manor
Phone No. 336-643-6301
Contacted? No
7700 US Hwy 158
Stokesdale, NC 27357
Section C: Areas Evaluated During Inspection
X Permit X Flow Measurement X Operations/Maintenance NA Sewer Overflow
X Records/Reports X Self -Monitoring Program X Sludge Handling/Disposal NA Pollution Prevention
X Facility Site Review X Compliance Schedules NA Pretreatment NA Multimedia
X Effluent/Receiving Waters NA Laboratory NA Stormwater NA Other:
Section D: Summary of Findings/Comments
See attached Compliance Inspection Form.
REVIEW PERIOD January 2007 - December 2007
Name(s) and Signature(s)oflnspectors:
Agency/Office/Telephone:
Date:
DWQ / WSRO / [phone]
Signature of levie r:
Agency/Office:
Date:
DWQ / WSRO / [phone]

Permit: NCO073571
Inspection Date: 04/09/2008
Owner - Facility: Countryside Manor VWVTP
Inspection Type: Compliance Sampling
Compliance Schedules
Yes
No
NA
NE
Is there a compliance schedule for this facility?
®
n
n
n
Is the facility compliant with the permit and conditions for the review period?
■
n
n
n
Comment: TRC limit took effect 11/1/07. Dechlor added since last inspection.
Operations & Maintenance
Yes
No
NA
NE
Is the plant generally clean with acceptable housekeeping?
■
El
0
El
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable Solids, pH, DO, Sludge ■ ❑ ❑ ❑
Judge, and other that are applicable?
Comment:
•• V...- Gl- \IA AI
(If the present permit expires in 6 months or less). Has the permittee submitted a new application?
n
n
■
n
Is the facility as described in the permit?
■
n
n
n
# Are there any special conditions for the permit?
®
❑
❑
❑
Is access to the plant site restricted to the general public?
■
n
n
n
Is the inspector granted access to all areas for inspection?
■
n
n
n
Comment: TRC limit took effect 11/1/2007.
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?
®
n
n
n
Are all records maintained for 3 years (lab. reg. required 5 years)?
®n
n
n
Are analytical results consistent with data reported on DMRs?
®
n
n
n
Is the chain -of -custody complete?
■
n
n
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
Are DMRs complete: do they include all permit parameters?
®n
n
n
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? n n ® n
Page # 3

4
Permit: NCO073571 Owner - Facility: Countryside Manor WWTP
Inspection Date: 04/09/2008 Inspection Type: Compliance Sampling
Record Keeping
Yes
No
NA
NE
Is the ORC visitation log available and current?
®
❑
❑
❑
Is the ORC certified at grade equal to or higher than the facility classification?
®n
n
n
Is the backup operator certified at one grade less or greater than the facility classification?
®n
n
n
Is a copy of the current NPDES permit available on site?
®
❑
❑
171
Facility has copy of previous year's Annual Report on file for review?
®
n
n
n
Comment: No annual report on file with WSRO at time of inspection.
Effluent Pipe
Yes
No
NA
NE
Is right of way to the outfall properly maintained?
■
n
n
n
Are the receiving water free of foam other than trace amounts and other debris?
n
n
n
If effluent (diffuser pipes are required) are they operating properly?
Comment:
Flow Measurement - Effluent
Yes
No
NA
NE
# Is flow meter used for reporting?
S
❑
O
❑
Is flow meter calibrated annually?
®
❑
fl
❑
Is the flow meter operational?
®
0
❑
❑
(If units are separated) Does the chart recorder match the flow meter?
n
n
®
n
Comment:
Aerobic Digester
Yes
No
NA
NE
Is the capacity adequate?
®
❑
❑
❑
Is the mixing adequate?
®
n
❑
[l
Is the site free of excessive foaming in the tank?
®
❑
❑
11
# Is the odor acceptable?
®
❑
❑
❑
# Is tankage available for properly waste sludge?
E2
❑
❑
rl
Comment:
Bar Screens
Yes
No
NA
NE
Type of bar screen
a.Manual
b. Mechanical
❑
Are the bars adequately.screening debris?
®
n
❑
n
Is the screen free of excessive debris?
®
n
n
n
Page # 4

Permit: NC0073571 Owner - Facility: Countryside Manor VWVrP
Inspection Date: 04/09/2008 Inspection Type: Compliance Sampling
Bar Screens
Yes
No
NA
NE
Is disposal of screening in compliance?
■
❑
❑
❑
Is the unit in good condition?
■
❑
❑
n
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?
■
n
❑
0—
Are all pumps present?
®❑
❑
❑
Are all pumps operable?
®
❑
❑
❑
Are float controls operable?
■
❑
❑
❑
Are audible and visual alarms operable?
❑
■
❑
❑
# Is basin size/volume adequate?
■
❑
❑
❑
Comment: Alarms did not function during inspection. Needs immediate attention and
repair/replacement.
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?
®n
n
n
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?
❑
❑
m
❑
Is the return rate acceptable (low turbulence)?
❑
❑
❑
Is the overflow clear of excessive solids/pin floc?
®❑
❑
n
Is the sludge blanket level acceptable? (Approximately of the sidewall depth)
®
n
❑
❑
Comment:
Mode of operation Ext. Air
Type of aeration system Diffused
Page # 5

I
Permit: NCO073571
Inspection Date: 04/09/2008
Owner - Facility: Countryside Manor WM/TP
Inspection Type: Compliance Sampling
Aeration Basins
Yes
No
NA
NE
Is the basin free of dead spots?
®n
n
❑
Are surface aerators and mixers operational?
IN
❑
❑
❑
Are the diffusers operational?
®n
n
n
Is the foam the proper color for the treatment process?
®n
n
n
Does the foam cover less than 25% of the basin's surface?
®n
n
n
Is the DO level acceptable?
Is the DO level acceptable?(1.0 to 3.0 mg/1)
®n
n
n
Comment:
Disinfection -Tablet
Yes
No
NA
NE
Are tablet chlorinators operational?
®n
n
n
Are the tablets the proper size and type?
®n
Number of tubes in use?
4
Is the level of chlorine residual acceptable?
®
❑
❑
❑
Is the contact chamber free of growth, or sludge buildup?
o
n
n
n
Is there chlorine residual prior to de -chlorination?
Comment:
- I • .. _ -
V-
u
uA
u=
Type of system ?
Tablet
Is the feed ratio proportional to chlorine amount (1 to 1)?
®n
n
n
Is storage appropriate for cylinders?
®
n
n
n
# Is de -chlorination substance stored away from chlorine containers?
®n
n
n
Comment:
Are the tablets the proper size and type?
❑
❑
n
Are tablet de -chlorinators operational?
Igo
n
n
Number of tubes in use?
Comment:
Effluent Sampling
Yes
No
NA
NE
Is composite sampling flow proportional?
Is sample collected below all treatment units?
®
Cl
n
n
Is proper volume collected?
®
n
n
n
Page # 6

14
Permit: NCO073571
Inspection Date: 04/09/2008
Effluent Sampling
Is the tubing clean?
Owner - Facility: Countryside Manor VWVfP
Inspection Type: Compliance Sampling
Is proper temperature set for sample storage (kept at 1.0 to 4.4 degrees Celsius)?
011011
■ n n n
Is the facility sampling performed as required by the permit (frequency, sampling type representative)? ■ n f_1 n
Comment:
Upstream / Downstream Sampling Yes No NA NE
Is the facility sampling performed as required by the permit (frequency, sampling type, and sampling location)? ■ n n n
Comment:
Page # 7

� ► r. 1'��Ire,�ti�an� �Ki.�g==
A To C No. 073571A01
Issued October 5, 2007
JAN 2006
Winston-Salem
Regional ��
Engineer's Certification
I, , 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 Countryside Manor WWTP,
located on US Hwy 158 inKTAT rdgCourity3f, r Dr. Mervyn R. King, hereby 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 utilizing sodium sulfite pursuant to the fast
track application received on September 27, 2007, and in conformity with the
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.
Signature
Registration No.
Date /a/07
Send to: Construction Grants & Loans ``a�, � ASS/C
DENWDWQ
= 9� SEAT. ,
1633 Mail Service Center
Raleigh, NC 27699-1633
® �
>s�0 61Nc�• Q-���

zm�
Countryside Manor, Inc.
Professional Care Center for the Elderly r
Octobe 11, 2007
Core inger
N 'vision Water Quality
585 Waughtown Street
Winston Salem, NC 27107
Subject: Installation of De -chlorination Unit
Countryside Manor WWTP
NPDES Permit # NCO073571
Guilford County
Dear Mr. Basinger,
REC�
N-C, Dept. of ENR
OCT 12 2007
Winston-5'alem
Regicnal Office
This letter is to keep you informed of the upgrade to above location. On Wednesday, October
10, 2007, Countryside Manor received approval of Fast Trac Application from the Raleigh
office, to install the de -chlorination unit required to meet the term of our new permit.
This unit is scheduled to be installed on Wednesday, October 17, 2007. Kace Environmental,
Inc. has been contracted to handle the installation, Ken Deaver is project manager,
[phone]).
Sincerely,
Ernie Newman
Operations Manager
Countryside Manor
7700 U.S. Highway 158 • P.O. Box 829 • Stokesdale, North Carolina 27357 • Telephone [phone] • Fax [phone]
www.retireatcountryside.com • [e-mail]

Mr. Ernie Newman
Countryside Manor, Inc.
PO Box 829
Stokesdale, North Carolina 27357
SUBJECT:
Dear Mr. Newman:
Michael KV,Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
October 5, 2007
Authorization to Construct
A to C No. 073571A01
Dr. Mervyn R. King
Countryside Manor WWTP
Dechlorination Facilities
Guilford County
Coleen H. Sullins, Director
Division of Water Quality
t;IVED
" -t of ENR
OCT 10 2007
nSWn-Salem
Regional Office
A fast track application for Authorization to Construct dechlorination facilities was
received on September 27, 2007, by the Division. Authorization is hereby granted for the
construction of modifications to the existing Countryside Manor, with discharge of treated
wastewater effluent into Troublesome Creek in the Cape Fear 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 a dechlorination system utilizing sodium sulfite pursuant to the fast
track application received on September 27, 2007, and in conformity with the
Minimum Design Criteria for Dechlorination Facilities.
This Authorization to Construct is issued in accordance with Part III, Paragraph A of
NPDES Permit No. NCO073571 issued April 12, 2006, and shall be subject to revocation unless
the wastewater treatment facilities are constructed in accordance with the conditions and
limitations specified in Permit No. NC0073571.
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.
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
No a hCarolina
Naturally
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 Phone [phone] Customer Service
Internet: www.ncwateMuality.org 512 N. Salisbury St. Raleigh, NC 27604 FAX [phone]
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper

Mr. Newman
October 5, 2007
Page 2
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.
Putsuant to `15A NCAC 2H .0140, upon completion of construction and prior to operation
of these permitted facilities, the completed Engineering Certification form attached to this permit
shall be submitted to the address provided on the form.
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.
The Permittee must also employ a certified back-up operator of the appropriate type and
grade to comply with the conditions of T 15A: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 T I 5A: 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.
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.

Mr. Newman
October 5, 2007
Page 3
If you have any questions or need additional information, please do not hesitate to contact
Cecil G. Madden, Jr., P.E. at telephone number [phone].
Sincerely,
I
,�-,Coleen . Sullins
D
AR/cgm
cc: Scott E. Snyder, P.E., HSMM, Spartanburg, SC
Guilford County Health Department
Technical Assistance and Certification Unit
Daniel Blaisdell, P.E.
Point Source Branch, NPDES Program
Cecil G. Madden, Jr., P.E.
Anita Reed, E.I.
ATC File

Dr. Mervyn R. King
A To C No. 073571A01
Issued October 5, 2007
Engineer's Certification
I, , 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 Countryside Manor WWTP,
located on US Hwy 158 in Guilford County for Dr. Mervyn R. King, hereby 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 utilizing sodium sulfite pursuant to the fast
track application received on September 27, 2007, and in conformity with the
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.
Signature
Date
Registration No.
Send to: Construction Grants & Loans
DENR/DWQ
1633 Mail Service Center
Raleigh, NC 27699-1633

A' Corir prete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
Mr. Ernie Newman, Plant Ops, Mngr.
Countrysiei ,Aftnor, inc.
PO Box E-9
Stolcesdale, NC 27357
X Signature
j 1 �❑ I j
X � � '�'1 ; � '� w `�N ��� ❑ AgentAddresser
B. Receiv d by (Printed ame) C' to f Deli en
D. Is dellivery address different frorr►item 1? U Yes
If YES, enter delivery address below: ❑ No
3. Serv' Type
ertified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
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Domestic� RetuIrn Receipt
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102595-02-M-154

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UNITED STATES P-0 _ 'tE;$9RV
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• ,�... ..... ... M ." :�'.... ... `La;:, ` _Permit No. G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
NCDENR - Division of Water Quality
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585 Waughtownreet
Winston-Salem, NC 27107