NC0037311_Fact Sheet_20220401

FACT SHEET FOR EXPEDITED PERMIT RENEWALS
This form must be completed by Permit Writers for all expedited permits which do not require full Fact
Sheets. Expedited permits are generally simple 100% domestics (e.g., schools, mobile home parks, etc)
that can be administratively renewed with minor changes, but can include facilities with more complex
issues (Special Conditions, 303(d) listed water, toxicity testing, instream monitoring, compliance
concerns).
Basic Information for Expedited Permit Renewals
Permit Writer / Date
Siying Chen 12/29/2021
Permit Number
NC0037311
Facility Name / Facility Class
Creekside Manor Rest Home / WW-2
County / Regional Office
Forsyth / WSRO
Basin Name / Sub -basin number
Roanoke / 03-02-01
Receiving Stream / HUC
UT Belews Creek / 030101030303
Stream Classification / Stream Segment
C / 22-27-(2)
Does permit need Daily Maximum NH3 limits
Already present
Does permit need TRC limits/language?
Already present
Does permit have toxicity testing? IWC (%) if so
No
Does permit have Special Conditions?
No
Does permit have instream monitoring?
Yes — temperature and dissolved oxygen
Is the stream impaired (on 303(d) list)?
No
Any obvious compliance concerns?
Two violation and enforcement cases (including
two NODs) during the permit cycle.
Any permit mods since last permit?
Added WWTP classification
Updated eDMR requirements
New expiration date
2/28/2027
Comments on Draft Permit?
No comment received
Most Commonly Used Expedited Language:
• 303(d) language for Draft/Final Cover Letters: "Please note that the receiving stream is listed
as an impaired waterbody on the North Carolina 303(d) Impaired Waters List. Addressing
impaired waters is a high priority with the Division, and instream data will continue to be
evaluated. If there is noncompliance with permitted effluent limits and stream impairment can
be attributed to your facility, then mitigative measures may be required".
Fact Sheet for Permit Renewal
March 2022 -- NPDES Permit NC0037311 - Page 1

Section 1. Facility Overview:
This facility is a minor facility (flow < 1 MGD) discharging 100% domestic wastewater with a design
capacity of 0.01 MGD. This WWTP utilizes the following treatment components:
• Bar screen
• Aeration basin with diffused air
• Secondary clarifier
• Tablet chlorination
• Chlorine contact basin
• Tablet dechlorination
• Sludge holding tank
Section 2. Compliance History (July 2018 — December 2021):
• One NOD for Fecal Coliform limit violation in July 2019.
• One NOD for TSS limit violation in October 2019.
Section 3. Changes from previous permit to draft:
• Added facility grade in A. (1)
• Updated eDMR footnote in A. (1) and language in A. (2)
Section 4. Comments received on draft permit:
• No comment received on draft permit.
Section 5. Changes from draft to final:
• No change to final permit.
Fact Sheet for Permit Renewal
March 2022 -- NPDES Permit NC0037311 - Page 2

Winston-Salem Journal
Advertising Affidavit
P.O Box 3159
Winston-Salem, NC 27102
NCDEQ-DIVISION OF WATER RESOURCES
1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617
Account Number
4019534
Date
January 28, 2022
PO Number Order Category Description
0000765465 Legal Notices Public Notice North Carolina Environmental Management Commission / NPDES Ur
Publisher of the
Winston-Salem Journal
Before the undersigned, a Notary Public duly commissioned, qualified, and
authorized by law to administer oaths, personally appeared the Publisher's
Representative who by being duly sworn deposes and says: that he/she is
authorized to make this affidavit and sworn statement; that the notice or
other legal advertisement, a copy of which is attached hereto, was
published in the Winston-Salem Journal on the following dates:
01/28/2022
and that the said newspaper in which such notice, paper document, or legal
advertisement was published, was at the time of each and every such
publication, a newspaper meeting all the requirements and qualifications of
Section 1-597 of the General Statutes of North Carolina.
nature of pI making affidavit)
Sworn to and subscribed before me the 28th day of Janu. 20
State of Virginia
County of Hanover
My commission expires:
Notary Public)
Linh Thuy Le
Notary Public
Commonwealth of Virginia
Reg. No. 7953581
My Comm. Expires Nov 30, 2025
THIS IS NOT A BILL. PLEASE PAY FROM INVOICE. THANK YOU

Public Notice
North Carolina Environmental
Management Commission /
NPDES Unit
1611 Mail Service Center
Raleigh, NC 11699.1617
Notice of Intent to Issue a NPDES
Wastewater Permit NC0037311
Creekside Manor Rest Home WWTP
The North Carolina Environmental
Management Commission proposes
to issue a NPDES wastewater dis-
charge permit to the person(s) listed
below. Written comments regarding
the proposed permit will be accept-
ed until 30 days after the publish
date of this notice. The Director of
the NC Division of Water Resources
(DWR) may hold a public hearing
should there be a significant degree
of public interest. Please mail com-
ments and/or information requests
to DWR at the above address. Inter-
ested persons may visit the DWR at
512 N. Salisbury Street, Raleigh, NC
27604 to review information on file.
Additional information on NPDES
permits and this notice may be
found on our website: http://deq.nc.
gov/about/divisions/water-
resources/water-resources-
permits/wastewater-branch/npdes-
wastewater/public-notices,or by
calling [phone]. William
Hammonds [P.O. Box 1487, Kerners-
ville, NC 27285-0485] has requested
renewal of permit NC0037311 for the
Creekside Manor Rest Home WWTP
in Forsyth County. This permitted
facility discharges treated domestic
wastewater to an unnamed tributary
to Belews Creek in the Roanoke Riv-
er Basin. Currently dissolved oxy-
gen, ammonia nitrogen, fecal
coliform and total residual chlorine
are water quality limited. This dis-
charge may affect future allocations
in this portion of Belews Creek.
WSJ: January 28, 2022.

NH3/TRC WLA Calculations
Facility: Creekside Manor Rest Home WWTP
PermitNo. NC0037311
Prepared By: Siying Chen
Enter Design Flow (MGD):
Enter s7Q10 (cfs):
Enter w7Q10 (cfs):
0.01
0
0.06
Total Residual Chlorine (TRC)
Daily Maximum Limit (ug/I)
s7Q10 (CFS)
DESIGN FLOW (MGD)
DESIGN FLOW (CFS)
STREAM STD (UG/L)
Upstream Bkgd (ug/I)
IWC (%)
Allowable Conc. (ug/I)
Fecal Coliform
Monthly Average Limit:
(If DF >331; Monitor)
(If DF<331; Limit)
Dilution Factor (DF)
0
0.01
0.0155
17.0
0
100.00
17
Ammonia (Summer)
Monthly Average Limit (mg NH3-N/I)
s7Q10 (CFS)
DESIGN FLOW (MGD)
DESIGN FLOW (CFS)
STREAM STD (MG/L)
Upstream Bkgd (mg/I)
IWC (%)
Allowable Conc. (mg/I)
Ammonia (Winter)
Monthly Average Limit (mg NH3-N/I)
w7Q10 (CFS)
200/100m1 DESIGN FLOW (MGD)
DESIGN FLOW (CFS)
STREAM STD (MG/L)
1.00 Upstream Bkgd (mg/I)
IWC (%)
Allowable Conc. (mg/I)
Total Residual Chlorine
1. Cap Daily Max limit at 28 ug/I to protect for acute toxicity
Ammonia (as NH3-N)
1. If Allowable Conc > 35 mg/I, Monitor Only
2. Monthly Avg limit x 3 = Weekly Avg limit (Municipals)
3. Monthly Avg limit x 5 = Daily Max limit (Non-Munis)
If the allowable ammonia concentration is > 35 mg/L, no limit shall be imposed
0
0.01
0.0155
1.0
0.22
100.00
1.0
0.06
0.01
0.0155
1.8
0.22
20.53
7.9
Fecal Coliform
1. Monthly Avg limit x 2 = 400/100 ml = Weekly Avg limit (Municipals) = Daily Max limit (Non -Muni)

MONITORING REPORT(MR) VIOLATIONS for:
Report Date: 12/29/21 Page 1 01 6
Permit: nc0037311 MRs Betweei 7 - 2018 and12 - 2021 Region: % Violation Category:% Program Category: %
Facility Name: % Param Nam(% County: % Subbasin:% Violation Action: %
Major Minor:
PERMIT: NC0037311
FACILITY: William R Hammonds - Creekside Manor Rest Home
WWTP
COUNTY: Forsyth REGION: Winston-Salem
Limit Violation
MONITORING UNIT OF
OUTFALL LOCATION PARAMETER VIOLATION FREQUENCY
REPORT DATE MEASURE
LIMIT
CALCULATED
VALUE Over
VIOLATION TYPE VIOLATION ACTION
07 -2018 001 Effluent Chlorine, Total Residual 07/11/18 2 X week ug/I 17 18 5.9 Daily Maximum No Action, BPJ
Exceeded
07 -2018 001 Effluent Chlorine, Total Residual 07/17/18 2 X week ug/I 17 23 35.3 Daily Maximum No Action, BPJ
Exceeded
07 -2018 001 Effluent Chlorine, Total Residual 07/24/18 2 X week ug/I 17 29 70.6 Daily Maximum No Action, BPJ
Exceeded
08 -2018 001 Effluent Chlorine, Total Residual 08/10/18 2 X week ug/I 17 21 23.5 Daily Maximum No Action, BPJ
Exceeded
08 -2018 001 Effluent Chlorine, Total Residual 08/14/18 2 X week ug/I 17 36 111.8 Daily Maximum No Action, BPJ
Exceeded
08 -2018 001 Effluent Chlorine, Total Residual 08/23/18 2 X week ug/I 17 18 5.9 Daily Maximum No Action, BPJ
Exceeded
08 -2018 001 Effluent Chlorine, Total Residual 08/30/18 2 X week ug/I 17 27 58.8 Daily Maximum No Action, BPJ
Exceeded
09 -2018 001 Effluent Chlorine, Total Residual 09/25/18 2 X week ug/I 17 18 5.9 Daily Maximum No Action, BPJ
Exceeded
09 -2018 001 Effluent Chlorine, Total Residual 09/27/18 2 X week ug/I 17 31 82.4 Daily Maximum No Action, BPJ
Exceeded
10-2018 001 Effluent Chlorine, Total Residual 10/09/18 2 X week ug/I 17 22 29.4 Daily Maximum No Action, BPJ
Exceeded
10-2018 001 Effluent Chlorine, Total Residual 10/25/18 2 X week ug/I 17 29 70.6 Daily Maximum No Action, BPJ
Exceeded
11-2018 001 Effluent Chlorine, Total Residual 11/14/18 2 X week ug/I 17 37 117.6 Daily Maximum No Action, BPJ
Exceeded
12-2018 001 Effluent Chlorine, Total Residual 12/07/18 2 X week ug/I 17 36 111.8 Daily Maximum No Action, BPJ
Exceeded
12-2018 001 Effluent Chlorine, Total Residual 12/13/18 2 X week ug/I 17 22 29.4 Daily Maximum No Action, BPJ
Exceeded
12-2018 001 Effluent Chlorine, Total Residual 12/27/18 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded

MONITORING REPORT(MR) VIOLATIONS for: Report Date: 12/29/21
Page 2 o1 6
Permit: nc0037311 MRs Betweei 7 - 2018 and12 - 2021 Region: % Violation Category:% Program Category: %
Facility Name: % Param Nam(% County: % Subbasin:% Violation Action: %
Major Minor: %
PERMIT: NC0037311
FACILITY: William R Hammonds - Creekside Manor Rest Home
WWTP
COUNTY: Forsyth REGION: Winston-Salem
Limit Violation
MONITORING UNIT OF
OUTFALL LOCATION PARAMETER VIOLATION FREQUENCY
REPORT DATE MEASURE
LIMIT
CALCULATED
VALUE Over
VIOLATION TYPE VIOLATION ACTION
01-2019 001 Effluent Chlorine, Total Residual 01/10/19 2 X week ug/I 17 31 82.4 Daily Maximum No Action, BPJ
Exceeded
02 - 2019 001 Effluent Chlorine, Total Residual 02/15/19 2 X week ug/I 17 24 41.2 Daily Maximum No Action, BPJ
Exceeded
02 - 2019 001 Effluent Chlorine, Total Residual 02/21/19 2 X week ug/I 17 27 58.8 Daily Maximum No Action, BPJ
Exceeded
02 - 2019 001 Effluent Chlorine, Total Residual 02/26/19 2 X week ug/I 17 32 88.2 Daily Maximum No Action, BPJ
Exceeded
03 - 2019 001 Effluent Chlorine, Total Residual 03/06/19 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
03 - 2019 001 Effluent Chlorine, Total Residual 03/13/19 2 X week ug/I 17 23 35.3 Daily Maximum No Action, BPJ
Exceeded
04-2019 001 Effluent Chlorine, Total Residual 04/11/19 2 Xweek ug/I 17 28 64.7 Daily Maximum No Action, BPJ
Exceeded
04 - 2019 001 Effluent Chlorine, Total Residual 04/17/19 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
04 - 2019 001 Effluent Chlorine, Total Residual 04/24/19 2 X week ug/I 17 31 82.4 Daily Maximum No Action, BPJ
Exceeded
05 - 2019 001 Effluent Chlorine, Total Residual 05/08/19 2 X week ug/I 17 38 123.5 Daily Maximum No Action, BPJ
Exceeded
05 - 2019 001 Effluent Chlorine, Total Residual 05/14/19 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
06 - 2019 001 Effluent Chlorine, Total Residual 06/10/19 2 X week ug/I 17 21 23.5 Daily Maximum No Action, BPJ
Exceeded
06-2019 001 Effluent Chlorine, Total Residual 06/21/19 2 Xweek ug/I 17 39 129.4 Daily Maximum No Action, BPJ
Exceeded
06 - 2019 001 Effluent Chlorine, Total Residual 06/27/19 2 X week ug/I 17 24 41.2 Daily Maximum No Action, BPJ
Exceeded
07 - 2019 001 Effluent Chlorine, Total Residual 07/05/19 2 X week ug/I 17 24 41.2 Daily Maximum No Action, BPJ
Exceeded
07 - 2019 001 Effluent Chlorine, Total Residual 07/12/19 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded

MONITORING REPORT(MR) VIOLATIONS for:
Report Date: 12/29/21 Page 3 of 6
Permit: nc0037311 MRs Betweei 7 - 2018 and12 - 2021 Region: % Violation Category:% Program Category: %
Facility Name: % Param Nam(% County: % Subbasin:% Violation Action: %
Major Minor: %
PERMIT: NC0037311
FACILITY: William R Hammonds - Creekside Manor Rest Home
WWTP
COUNTY: Forsyth REGION: Winston-Salem
Limit Violation
MONITORING UNIT OF
OUTFALL LOCATION PARAMETER VIOLATION FREQUENCY
REPORT DATE MEASURE
LIMIT
CALCULATED
VALUE Over
VIOLATION TYPE VIOLATION ACTION
07 - 2019 001 Effluent Chlorine, Total Residual 07/25/19 2 X week ug/I 17 33 94.1 Daily Maximum No Action, BPJ
Exceeded
08 - 2019 001 Effluent Chlorine, Total Residual 08/15/19 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
09 - 2019 001 Effluent Chlorine, Total Residual 09/06/19 2 X week ug/I 17 38 123.5 Daily Maximum No Action, BPJ
Exceeded
09-2019 001 Effluent Chlorine, Total Residual 09/11/19 2 X week ug/I 17 43 152.9 Daily Maximum No Action, BPJ
Exceeded
09 - 2019 001 Effluent Chlorine, Total Residual 09/19/19 2 X week ug/I 17 22 29.4 Daily Maximum No Action, BPJ
Exceeded
09 - 2019 001 Effluent Chlorine, Total Residual 09/27/19 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
10 - 2019 001 Effluent Chlorine, Total Residual 10/29/19 2 X week ug/I 17 27 58.8 Daily Maximum No Action, BPJ
Exceeded
11-2019 001 Effluent Chlorine, Total Residual 11/15/19 2 X week ug/I 17 28 64.7 Daily Maximum No Action, BPJ
Exceeded
11-2019 001 Effluent Chlorine, Total Residual 11/25/19 2 X week ug/I 17 34 100 Daily Maximum No Action, BPJ
Exceeded
11-2019 001 Effluent Chlorine, Total Residual 11/26/19 2 X week ug/I 17 18 5.9 Daily Maximum No Action, BPJ
Exceeded
12-2019 001 Effluent Chlorine, Total Residual 12/06/19 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
12-2019 001 Effluent Chlorine, Total Residual 12/12/19 2 X week ug/I 17 27 58.8 Daily Maximum No Action, BPJ
Exceeded
01-2020 001 Effluent Chlorine, Total Residual 01/02/20 2 X week ug/I 17 24 41.2 Daily Maximum No Action, BPJ
Exceeded
01-2020 001 Effluent Chlorine, Total Residual 01/03/20 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
01-2020 001 Effluent Chlorine, Total Residual 01/31/20 2 X week ug/I 17 27 58.8 Daily Maximum No Action, BPJ
Exceeded
03 - 2020 001 Effluent Chlorine, Total Residual 03/13/20 2 X week ug/I 17 38 123.5 Daily Maximum No Action, BPJ
Exceeded

MONITORING REPORT(MR) VIOLATIONS for: Report Date: 12/29/21
Page 4 of 6
Permit: nc0037311 MRs Betweei 7 - 2018 and12 - 2021 Region: % Violation Category:% Program Category: %
Facility Name: % Param Nam(% County: % Subbasin:% Violation Action: %
Major Minor: %
PERMIT: NC0037311
FACILITY: William R Hammonds - Creekside Manor Rest Home
WWTP
COUNTY: Forsyth REGION: Winston-Salem
Limit Violation
MONITORING UNIT OF
OUTFALL LOCATION PARAMETER VIOLATION FREQUENCY
REPORT DATE MEASURE
LIMIT
CALCULATED
VALUE Over
VIOLATION TYPE VIOLATION ACTION
03 - 2020 001 Effluent Chlorine, Total Residual 03/20/20 2 X week ug/I 17 41 141.2 Daily Maximum No Action, BPJ
Exceeded
03 - 2020 001 Effluent Chlorine, Total Residual 03/23/20 2 X week ug/I 17 21 23.5 Daily Maximum No Action, BPJ
Exceeded
04 - 2020 001 Effluent Chlorine, Total Residual 04/20/20 2 X week ug/I 17 21 23.5 Daily Maximum No Action, BPJ
Exceeded
05 - 2020 001 Effluent Chlorine, Total Residual 05/22/20 2 X week ug/I 17 22 29.4 Daily Maximum No Action, BPJ
Exceeded
06 - 2020 001 Effluent Chlorine, Total Residual 06/05/20 2 X week ug/I 17 26 52.9 Daily Maximum No Action, BPJ
Exceeded
06 - 2020 001 Effluent Chlorine, Total Residual 06/19/20 2 X week ug/I 17 43 152.9 Daily Maximum No Action, BPJ
Exceeded
06 - 2020 001 Effluent Chlorine, Total Residual 06/22/20 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
07 - 2020 001 Effluent Chlorine, Total Residual 07/10/20 2 X week ug/I 17 43 152.9 Daily Maximum No Action, BPJ
Exceeded
07 - 2020 001 Effluent Chlorine, Total Residual 07/17/20 2 X week ug/I 17 39 129.4 Daily Maximum No Action, BPJ
Exceeded
07 - 2020 001 Effluent Chlorine, Total Residual 07/24/20 2 X week ug/I 17 29 70.6 Daily Maximum No Action, BPJ
Exceeded
09 - 2020 001 Effluent Chlorine, Total Residual 09/14/20 2 X week ug/I 17 21 23.5 Daily Maximum No Action, BPJ
Exceeded
09 - 2020 001 Effluent Chlorine, Total Residual 09/16/20 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
09 - 2020 001 Effluent Chlorine, Total Residual 09/25/20 2 X week ug/I 17 20 17.6 Daily Maximum No Action, BPJ
Exceeded
10 - 2020 001 Effluent Chlorine, Total Residual 10/26/20 2 X week ug/I 17 22 29.4 Daily Maximum No Action, BPJ
Exceeded
10 - 2020 001 Effluent Chlorine, Total Residual 10/28/20 2 X week ug/I 17 23 35.3 Daily Maximum No Action, BPJ
Exceeded
12 - 2020 001 Effluent Chlorine, Total Residual 12/04/20 2 X week ug/I 17 25 47.1 Daily Maximum No Action, BPJ
Exceeded

MONITORING REPORT(MR) VIOLATIONS for:
Report Date: 12/29/21 Page 5 of 6
Permit: nc0037311 MRs Betweei 7 - 2018 and12 - 2021 Region: % Violation Category:% Program Category: %
Facility Name: % Param Nam(% County: % Subbasin:% Violation Action: %
Major Minor: %
PERMIT: NC0037311
FACILITY: William R Hammonds - Creekside Manor Rest Home
WWTP
COUNTY: Forsyth REGION: Winston-Salem
Limit Violation
MONITORING UNIT OF
OUTFALL LOCATION PARAMETER VIOLATION FREQUENCY
REPORT DATE MEASURE
LIMIT
CALCULATED
VALUE Over
VIOLATION TYPE VIOLATION ACTION
12 - 2020 001 Effluent Chlorine, Total Residual 12/18/20 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
12 - 2020 001 Effluent Chlorine, Total Residual 12/22/20 2 X week ug/I 17 36 111.8 Daily Maximum No Action, BPJ
Exceeded
12 - 2020 001 Effluent Chlorine, Total Residual 12/30/20 2 X week ug/I 17 22 29.4 Daily Maximum No Action, BPJ
Exceeded
01-2021 001 Effluent Chlorine, Total Residual 01/07/21 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
01-2021 001 Effluent Chlorine, Total Residual 01/29/21 2 X week ug/I 17 21 23.5 Daily Maximum No Action, BPJ
Exceeded
02-2021 001 Effluent Chlorine, Total Residual 02/11/21 2 Xweek ug/I 17 38 123.5 Daily Maximum No Action, BPJ
Exceeded
02 -2021 001 Effluent Chlorine, Total Residual 02/15/21 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
02 -2021 001 Effluent Chlorine, Total Residual 02/17/21 2 X week ug/I 17 25 47.1 Daily Maximum No Action, BPJ
Exceeded
03 -2021 001 Effluent Chlorine, Total Residual 03/01/21 2 X week ug/I 17 18 5.9 Daily Maximum No Action, BPJ
Exceeded
03 -2021 001 Effluent Chlorine, Total Residual 03/29/21 2 X week ug/I 17 23 35.3 Daily Maximum No Action, BPJ
Exceeded
04 -2021 001 Effluent Chlorine, Total Residual 04/12/21 2 X week ug/I 17 25 47.1 Daily Maximum No Action, BPJ
Exceeded
05 -2021 001 Effluent Chlorine, Total Residual 05/06/21 2 X week ug/I 17 21 23.5 Daily Maximum No Action, BPJ
Exceeded
05 -2021 001 Effluent Chlorine, Total Residual 05/19/21 2 X week ug/I 17 24 41.2 Daily Maximum No Action, BPJ
Exceeded
06 -2021 001 Effluent Chlorine, Total Residual 06/07/21 2 X week ug/I 17 24 41.2 Daily Maximum No Action, BPJ
Exceeded
06 -2021 001 Effluent Chlorine, Total Residual 06/28/21 2 X week ug/I 17 32 88.2 Daily Maximum No Action, BPJ
Exceeded
07 -2021 001 Effluent Chlorine, Total Residual 07/16/21 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded

MONITORING REPORT(MR) VIOLATIONS for: Report Date: 12/29/21
Page 6 o1 6
Permit: nc0037311 MRs Betweei 7 - 2018 and12 - 2021 Region: % Violation Category:% Program Category: %
Facility Name: % Param Nam(% County: % Subbasin:% Violation Action: %
Major Minor: %
PERMIT: NC0037311
FACILITY: William R Hammonds - Creekside Manor Rest Home
WWTP
COUNTY: Forsyth REGION: Winston-Salem
Limit Violation
MONITORING UNIT OF
OUTFALL LOCATION PARAMETER VIOLATION FREQUENCY
REPORT DATE MEASURE
LIMIT
CALCULATED
VALUE Over
VIOLATION TYPE VIOLATION ACTION
08 - 2021 001 Effluent Chlorine, Total Residual 08/03/21 2 X week ug/I 17 36 111.8 Daily Maximum No Action, BPJ
Exceeded
08 -2021 001 Effluent Chlorine, Total Residual 08/20/21 2 X week ug/I 17 21 23.5 Daily Maximum No Action, BPJ
Exceeded
09 -2021 001 Effluent Chlorine, Total Residual 09/14/21 2 X week ug/I 17 24 41.2 Daily Maximum No Action, BPJ
Exceeded
09 -2021 001 Effluent Chlorine, Total Residual 09/30/21 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
11-2021 001 Effluent Chlorine, Total Residual 11/19/21 2 X week ug/I 17 19 11.8 Daily Maximum No Action, BPJ
Exceeded
11-2021 001 Effluent Chlorine, Total Residual 11/24/21 2 X week ug/I 17 24 41.2 Daily Maximum No Action, BPJ
Exceeded
07-2019 001 Effluent Coliform, Fecal MF, MFC 07/26/19 Weekly #/100m1 400 1,050 162.5 Daily Maximum Proceed to NOD
Broth, 44.5 C Exceeded
10-2019 001 Effluent Solids, Total Suspended - 10/03/19 Weekly mg/1 45 47 4.4 Daily Maximum Proceed to NOD
Concentration Exceeded

From:
To:
Subject:
Date:
WILLIAM HAMMONDS
Chen, Sivinq
[External] Re: NPDES Permit Issuance - NC0037311
Friday, April 1, 2022 11:47:33 AM
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to Report Spam.
Good morning!
Yea sir we did receive the email with the new permit attached.
Thank you and have a great day!
Thanks!
William Hammonds
Hammonds Management Co, LLC
PO Box 485
Kernersville, NC 27285
Office: 336-595-6004
Fax: [phone]
Cell: 336-575-6129
On Apr 1, 2022, at 10:33 AM, Chen, Siying <[e-mail]> wrote:
Good morning Mr. Hammonds,
Just want to check in with you and see if you had received the final NPDES permit
issuance for Creekside Manor Rest Home WWTP (NC0037311). I've also attached
it here.
Please respond to this email confirming that you received the attached
document, were able to open and view the document and have saved/printed
a copy for your records.
Siying (Sylvia) Chen (She/Her/Hers)
Environmental Specialist
Compliance and Expedited Permitting Unit
Division of Water Resources
North Carolina Department of Environmental Quality
Email: siving.chenc ncdenr.gov
Phone: [phone] (Office)

Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
From: Chen, Siying
Sent: Monday, March 14, 2022 11:56 AM
To: WILLIAM HAMMONDS <[e-mail]>; [e-mail]
Cc: Graznak, Jenny <[e-mail]>; Snider, Lon
<[e-mail]>; Weaver, Charles <[e-mail]>
Subject: NPDES Permit Issuance - NC0037311
Good morning Mr. Hammonds,
Attached is the final NPDES permit renewal for Creekside Manor Rest Home
WWTP (NC0037311). The permit will be effective on April 1, 2022.
Please respond to this email confirming that you received the attached
document, were able to open and view the document and have saved/printed
a copy for your records.
Thank you!
Siying (Sylvia) Chen (She/Her/Hers)
Environmental Specialist
Compliance and Expedited Permitting Unit
Division of Water Resources
North Carolina Department of Environmental Quality
Email: siying.chenPncdenr.gov
Phone: [phone] (Office)
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
<NC0037311_Final Permit 20220308.pdf>

From:
To:
Cc:
Subject:
Date:
WILLIAM HAMMONDS
Chen, Siying
Stephanie. knott(apacelabs.com
[External] Re: NPDES Permit Renewal - Electronic Distribution of NC0037311
Wednesday, January 19, 2022 3:35:09 PM
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to Report Spam.
Mr Chen -
Please be advised that we are fine with electronically submitting the information needed for
permit renewal. Our ORC takes care of all monitoring and of the plant. I take care of the
permit renewal each year from my office and receive my reports from Pace. Please submit info
for electronic submissions from the samplings at the plant to or call.
PACE ANALYTICAL
1377 South Park Drive
Kernersville, NC 27284
Email contact: [e-mail]
Phone: [phone]
Ask for Amy Ferguson
Please let me know if I can further assist in any way.
Thanks
William Hammonds
Hammonds Management Co, LLC
PO Box 485
Kernersville, NC 27285
Office: 336-595-6004
Fax: [phone]
Cell: 336-575-6129
On Jan 19, 2022, at 2:58 PM, Chen, Siying <[e-mail]> wrote:
Hi Mr. Hammonds,
My name is Siying and I'm the permit writer who has been assigned to your NPDES
permit renewal for Creekside Manor Rest Home WWTP (NC0037311).
In order to provide more convenience, control, and security to our permittees and
assist them in processing their transactions, The Division of Water Resources is
currently transitioning towards electronic correspondence. This will hopefully provide
more efficient service to our permittees and other partners and will allow us to more
effectively process and track documents. We are writing to ask you for your approval of
the transmittal of documents related to your permitting and related activities with the

Division in an electronic format. Documents will be emailed to the appropriate contact
person(s) in your organization in a PDF format.
Please respond to me through email with verification that transmittal of your
documents in an electronic manner is acceptable to you. If you have any questions,
please feel free to contact me.
Thank you!
Siying (Sylvia) Chen (She/Her/Hers)
Environmental Specialist
Compliance and Expedited Permitting Unit
Division of Water Resources
North Carolina Department of Environmental Quality
Email: siying.chen(Jncdenr.gov
Phone: [phone] (Office)
¢ }M►# c oi. iru
Daperbaait al Eimicararoalal uuullly
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Form
NPDES
NC Department of Environmental Quality - Application for NPDES Permit to Discharge Wastewater
MINOR SEWAGE FACILITIES (Before completing this form, please read the instructions. Failure to follow
the instructions may result in denial of the application.)
Facility Information
N
e
IC APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.21(j)(1) and (9))
Facility name
Creekside Manor Rest Home
Mailing address (street or P.O. box)
P.O. Box 1487
City or town
Kernersville
State
NC
ZIP code
27285
Contact name (first and last)
William Hammonds
Title
Owner
Phone number
[phone]
Email address
[e-mail]
Location address (street, route number, or other specific identifier)
6206 Reidsville Rd.
❑ Same as mailing
address
City or town
Kernersville
State
NC
ZIP code
27285
Is this application for a facility that has yet to commence discharge?
❑ Yes 4 See instructions on data submission
requirements for new dischargers.
✓
No
Applicant Information
1.3
Is applicant
✓
different from entity listed under Item 1.1 above?
Yes ❑ No 4 SKIP to Item 1.4.
Applicant name
Pace Analytical Services
Applicant address (street or P.O. box)
1377 South Park Dr.
City or town
Kernersville
State
NC
ZIP code
27284
Contact name (first and last)
Clifford Cain
Title
Operator
Phone number
[phone]
Email address
[e-mail]
1.4
Is the applicant the facility's owner, operator,
❑ Owner
✓
or both? (Check only one response.)
Operator ❑ Both
1.5
To
✓
which entity should the NPDES permitting
Facility
•
authority send correspondence? (Check only one response.)
Applicant ❑ Facility and applicant
(they are one and the same)
Existing Environmental Permits
1.6
Indicate
number
below any existing environmental
for each.)
permits.
(Check all that apply and print or type the corresponding permit
Existing Environmental Permits
p
NPDES (discharges to surface
water)
NC0037311
•
RCRA (hazardous waste)
❑ UIC (underground injection
control)
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
•
NESHAPs (CAA)
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
404)
❑ Other (specify)
Page 1

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Collection System and Population Served
1.7
Provide the collection system information requested below for the treatment works.
Municipality
Served
Population
Served
Collection System Type
(indicate percentage)
Ownership Status
100 % separate sanitary sewer
0 Own O Maintain
MHP
60
% combined storm and sanitary sewer
0 Own 0 Maintain
0 Unknown
❑ Own 0 Maintain
% separate sanitary sewer
❑ Own 0 Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
❑ Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own 0 Maintain
% combined storm and sanitary sewer
0 Own ❑ Maintain
❑ Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own ❑ Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
Total
Population
Served
60
0 Unknown
0 Own ❑ Maintain
Separate Sanitary Sewer System
Combined Storm and
Sanitary Sewer
Total percentage of each type of
sewer line (in miles)
o
100 /0
0
y0
Indian Country
1.8
Is the treatment works located in Indian
❑ Yes
Country?
✓
No
1.9
Does the facility discharge to a receiving
❑ Yes
water that flows through
✓
Indian Country?
No
Design and Actual
Flow Rates
1.10
Provide design and actual flow rates
in the designated spaces.
Design Flow Rate
0.010 mgd
Annual Average Flow Rates (Actual)
Two Years Ago
Last Year
This Year
0.006 mgd
0.005 mgd
0.004 mgd
Maximum Daily Flow Rates (Actual)
Two Years Ago
Last Year
This Year
0.012 mgd
0.007 mgd
0.006 mgd
Discharge Points
by Type
1,11
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
Total Number of Effluent Discharge Points by Type
Treated Effluent
Untreated Effluent
Combined Sewer
Overflows
Bypasses
Constructed
Emergency
Overflows
1
Page 2

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Outfalls and Other Discharge or Disposal Methods
Outfalls Other Than to Waters of the State of North Carolina
1.12
Does the POTW
for discharge
discharge wastewater to basins, ponds,
to waters of the State of North Carolina?
or other
surface impoundments that do not have outlets
4 SKIP to Item 1.14.
■ Yes
0 No
1.13
Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Impoundment Location and Discharge Data
Location
Average Daily Volume
Discharged to Surface
Impoundment
Continuous or Intermittent
(check one)
gpd
❑ Continuous
❑ Intermittent
gpd
❑ Continuous
❑ Intermittent
gpd
0 Continuous
❑ Intermittent
1.14
Is wastewater
applied to land?
4 SKIP to Item 1.16.
• Yes
III No
1.15
Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
Location
Size
Average Daily Volume
Applied
Continuous or
Intermittent
(check one)
acres
d
gip"'
0 Continuous
❑ Intermittent
acres
d
gpd
0 Continuous
❑ Intermittent
acres
gp d
❑ Continuous
❑ Intermittent
1.16
Is effluent transported
to another facility for
treatment prior to
discharge?
4 SKIP to Item 1.21.
• Yes
!rI
No
1.17
Describe the means by which the effluent is transported (e.g., tank truck, pipe).
1.18
Is the effluent
transported by a party other than
the applicant?
4 SKIP to Item 1.20.
• Yes
0
No
1.19
Provide information on the transporter below.
Transporter Data
Entity name
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
Page 3

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Outfalls and Other Discharge or Disposal Methods Continued
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving facility.
Receiving Facility Data
Facility name
Creekside Manor Rest Home
Mailing address (street or P.O. box)
P.O. Box 1487
City or town
Kernersville
State
NC
ZIP code
27285
Contact name (first and last)
William Hammonds
Title
Owner
Phone number
[phone]
Email address
[e-mail]
NPDES number of receiving facility (if any) El None
Average daily flow rate 0.005 mgd
1.21
Is the
not
■
wastewater disposed of in a manner other than
have outlets to waters of the State of North Carolina
Yes
51
those a
(e.g.,
No
ready mentioned in Items 1.14 through 1.21 that do
underground percolation, underground injection)?
4 SKIP to Item 1.23.
1.22
Provide
information in the table below on these other disposal methods.
Information on Other Disposal Methods
Description
Disposal
Method
Location of
Disposal Site
Size of
Disposal Site
Annual Average
Daily Discharge
Volume
Continuous or Intermittent
(check one)
acres
gp d
0 Continuous
0 Intermittent
acres
gp d
0 Continuous
0 Intermittent
acres
gp d
0 Continuous
0 Intermittent
Variance
Requests
1.23
Do
Consult
12
you intend to request or renew one or more of the
with your NPDES permitting authority to determine
Discharges into marine waters (CWA �
Section 301(h))
Not applicable
variances authorized at 40 CFR 122.21(n)? (Check all that apply.
what information needs to be submitted and when.)
Water quality related effluent limitation (CWA Section
302(b)(2))
Contractor Information
1.24
Are
the
•
any operational or maintenance aspects (related to
responsibility of a contractor?
Yes 0
wastewater treatment and effluent quality) of the treatment works
No *SKIP to Section 2.
1.25
Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
Contractor Information
Contractor 1
Contractor 2
Contractor 3
Contractor name
(company name)
Mailing address
(street or P.O. box)
City, state, and ZIP
code
Contact name (first and
last)
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
Page 4

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
SECTION 2. ADDITIONAL INFORMATION
(40 CFR 122.21(j)(1) and
(2))
o
a�
o
Outfalls to Waters of the State of North Carolina
2.1
Does the treatment
works have a design
flow greater
than or equal to 0.1 mgd?
No -9 SKIP to Section 3.
• Yes
✓
Inflow and Infiltration
2.2
Provide the treatment works' current average daily volume of inflow
and infiltration.
Average Daily Volume of Inflow and Infiltration
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
Topographic
Map
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
specific requirements.)
❑ Yes ❑ No
Flow
Diagram
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
(See instructions for specific requirements.)
❑ Yes ❑ No
Scheduled Improvements and Schedules of Implementation
2.5
Are improvements to the facility scheduled?
❑ Yes ❑ No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
1.
2.
3.
4.
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
Scheduled
Improvement
(from above)
Affected
Outfalls
(list outfall
number)
Begin
Construction
(MM/DD/YYYY)
End
Construction
(MM/DD/YYYY)
Begin
Discharge
(MM/DDIYYYY)
Attainment of
Operational
Level
(MM/DD/YYYY)
1.
2.
3.
4.
2.7
Have appropriate permits/clearances concerning other federal/state requirements been obtained? Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Description of Outfalls
. - r A • •
Provide the following
I 1 I ■ 1- 0 - 4,* to
information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number 001
Outfall Number
Outfall Number
State
NC
County
Forsyth
City or town
Kernersville
Distance from shore
2.5 ft.
ft.
ft.
Depth below surface
3 ft.
ft.
ft.
Average daily flow rate
0.005 mgd
mgd
mgd
Latitude
36° 12' 50"
°
° ' "
Longitude
80° 3' 49"
° "'
Seasonal or Periodic Discharge Data
3.2
Do
•
any of the outfalls described
Yes
under Item 3.1 have seasona
or
periodic
✓
discharges?
No -4 SKIP to Item 3.4.
3.3
If so, provide the following information
for each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
Number of times per year
discharge occurs
Average duration of each
discharge (specify units)
Average flow of each
discharge
mgd
mgd
mgd
Months in which discharge
occurs
Diffuser Type
3.4
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes
✓
No 4 SKIP to Item 3.6.
3.5
Briefly describe the diffuser type at each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
Waters of
the U.S.
3.6
Does the treatment works discharge or plan to discharge wastewater
one or more discharge points?
❑ Yes
NI
to waters of the State of North Carolina from
No 4 SKIP to Section 6.
Page 6

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Receiving Water Description
3.7
Provide the receiving water and related information (if known) for each outfall.
Outfall Number
Outfall Number
Outfall Number
Receiving water name
Name of watershed, river,
or stream system
U.S. Soil Conservation
Service 14-digit watershed
code
Name of state
management/river basin
U.S. Geological Survey
8-digit hydrologic
cataloging unit code
Critical low flow (acute)
cfs
cfs
cfs
Critical low flow (chronic)
cfs
cfs
cfs
Total hardness at critical
low flow
mg/L of
CaCO3
mg/L of
CaCO3
mglL of
CaCO3
Treatment Description
3.8
Provide the following information
describing the treatment provided for discharges from each outfall.
Outfall Number
Outfall Number
Outfall Number
Highest Level of
Treatment (check all that
apply per outfall)
❑ Primary
0 Equivalent to
secondary
❑ Secondary
O Advanced
O Other (specify)
0 Primary
0 Equivalent to
secondary
0 Secondary
0 Advanced
0 Other (specify)
0 Primary
0 Equivalent to
secondary
0 Secondary
0 Advanced
0 Other (specify)
Design Removal Rates by
Outfall
BOD5 or CBOD5
%
%
%
TSS
%
%
%
Phosphorus
0 Not applicable
%
0 Not applicable
%
0 Not applicable
o
/o
Nitrogen
0 Not applicable
%
0 Not applicable
,/o
0 Not applicable
Other (specify)
0 Not applicable
%
0 Not applicable
%
0 Not applicable
%
Page 7

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Effluent Testing Data Treatment Description Continued
3.9
Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season, describe below.
Outfall Number
Outfall Number
Outfall Number
Disinfection type
Seasons used
Dechlorination used?
•
Not applicable
■ Not applicable
■ Not applicable
■
Yes
■ Yes
■ Yes
•
No
• No
■ No
3.10
Have you completed monitoring for all Table A parameters and attached the results to the application package?
• Yes
• No
3.11
Have you conducted any WET tests during the 4.5 years prior to the date of the application on any of the facility's
discharges or on any receiving water near the discharge points?
• Yes
■ No 4 SKIP to Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
Number of tests of discharge
water
Number of tests of receiving
water
3.14
Does the POTW use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
• Yes 4 Complete Table B, including chlorine.
• No 4 Complete Table B, omitting chlorine.
3.15
Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
• Yes
■ No
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
3.18
attached the results
to this application package?
No
sampling required by NPDES
authority.
MI Yes
additional
•
permitting
Page 8

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Effluent Testing Data Continued
3.19
Has the POTW
or (2) at least
conducted either (1) minimum of four quarterly WET tests for one year preceding this permit application
four annual WET tests in the past 4.5 years?
❑ No 4 Complete tests and Table E and SKIP to
Item 3.26.
• Yes
3.20
Have you previously submitted the results of the above
❑ Yes
tests to your NPDES permitting
No Provide
authority?
results in Table E and SKIP to
4
■
Item 3.26.
3.21
Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
(MMODNYYY)
Summary of Results
3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
toxicity?
❑ Yes ❑ No -3 SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
3.24
Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.25
Provide details of any toxicity reduction evaluations conducted.
3.26
Have you completed Table E for all applicable outfalls
❑ Yes
and attached the results to the application package?
❑ Not applicable because previously submitted
information to the NPDES •ermittin. authori .
Page 9

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
SECTION 6. CHECKLIST
AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
Checklist and Certification Statement
6.1
In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not
all applicants are required to provide attachments.
Column 1
Column 2
Section 1: Basic Application
request(s)
• w/ variance
■ w/ additional attachments
Information for All Applicants
Section 2: Additional
❑ w/ topographic
map
attachments
■ w/ process flow diagram
•
Information
■ w/ additional
Section 3: Information
• w/ Table
A ❑ w/ Table D
B ❑ w/ additional attachments
C
❑ wl Table
❑ w/ Table
on
Effluent Discharges
Section 4: Not Applicable
Section 5: Not Applicable
Section 6: Checklist
and
w/ attachments
Certification Statement
6.2
Certification Statement
1 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. 1 am aware that there are significant penalties for submitting false information, including the possibility of fine
and imprisonment for knowing violations.
Name (print or type first and last name)
Clifford Cain
Official title
Operator
Signature
end C.ai-y--....
Date signed
1,—,A)----)6121
Page 10

NPDES Permit Number
Facility Name
Outfall Number
NC0037311
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
TABLE A. EFFLUENT PARAMETERS
FOR ALL POTWS
Maximum Daily Discharge
Average Daily Discharge
Analytical
Methods
ML or MDL
(include units)
Pollutant
Value
Units
Value
Units
NSamplest
Biochemical oxygen demand
❑ BODs or 0 CBODs
(report one)
25.8
mg/L
9.29
mg/L
156
varies
0 ML
NA ❑ MDL
Fecal coliform
1050
col/100m1
1.33
col/1o0m1
156
varies
ML
NA ❑❑ MDL
Design flow rate
0.012
mgd
0.005
mgd
780
pH (minimum)
7.0 (minimum)
N/A
pH (maximum)
8.6
Std. Units
Temperature (winter)
20
°C
13.78
°C
109
Temperature (summer)
29
°C
23.3
°C
151
Total suspended solids (TSS)
47
mg/L
9.7
mg/L
156
varies
0 ML
NA MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 11

11
NC0037311 — Creekside Manor Rest Home
'itude:
36°12'49"
2gitude: 80°03'49"
Quad Name: Belews Creek
Stream Class: C
Receiving Stream: UT to Belews Creek
Sub -Basin: 03-02-01
Hydrologic Unit: 03010103
Forsyth County
[map not to scale]

Sludge Management Plan
Creekside Manor Rest Home WWTP
NPDES Permit No. NC 0037311
Sludge from the Creekside Manor Rest Home wastewater treatment plant are disposed of in the
following manner:
Solids are collected in the sludge holding tank and digested aerobically. The excess solids
are periodically pumped and hauled by Carolina Septic a licensed septic pumper contractor
and disposed of at the City of Greensboro waterwater treatment plant.

Permit NC0037311
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other
lawful standards and regulations promulgated and adopted by the North Carolina
Environmental Management Commission, and the Federal Water Pollution Control Act,
as amended,
Hammond Properties
is hereby authorized to discharge wastewater from a facility located at the
Creekside Manor Rest Home
6206 Reidsville Road
Kernersville
Forsyth County
to receiving waters designated as an unnamed tributary to Belews Creek in subbasin 03-02-
01 of the Roanoke River Basin in accordance with effluent limitations, monitoring
requirements, and other conditions set forth in Parts I, II, III and IV hereof.
This permit shall become effective July 1, 2018.
This permit and authorization to discharge shall expire at midnight on February 28, 2022.
Signed this day May 29, 2018
Linda Culpepper, Interim Director
Division of Water Resources
By Authority of the Environmental Management Commission
Page 1 of 6

Permit NC0037311
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are hereby
revoked, and as of this issuance, any previously issued permit bearing this number is no longer
effective. Therefore, the exclusive authority to operate and discharge from this facility arises under the
permit conditions, requirements, terms, and provisions included herein.
Hammond Properties
is hereby authorized to:
1. Continue to operate an existing 0.01 MGD wastewater treatment system that
includes the following components:
♦ Bar screen
♦ Aeration basin with diffused air
♦ Secondary clarifier
♦ Tablet chlorination
♦ Chlorine contact basin
♦ Tablet dechlorination
♦ Sludge holding tank
This facility is located in Kernersville at Creekside Manor Rest Home off Reidsville
Road in Forsyth County.
2. Discharge from said treatment works via Outfall 001, at the location specified on
the attached map into an unnamed tributary to Belews Creek [stream index 22-
27-(2)], currently classified C waters in subbasin 03-02-01 [HUC: 03010103] of
the Roanoke River Basin.
Page 2 of 6

Permit NC0037311
Part I
A. (1) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
[15A NCAC 02B.0400 et seq., 15A NCAC 02B.0500 et seq.]
Beginning with the effective date of this permit and lasting until expiration, the Permittee is
authorized to discharge treated wastewater from Outfall 001. Such discharges shall be limited
and monitored' by the Permittee as specified below:
PARAMETER
Parameter Code
EFFLUENT LIMITATIONS
MONITORING REQUIREMENTS
Monthly
Average
Daily
Maximum
Measurement
Frequency
Sample
Type
Sample
Location
Flow 50050
0.010 MGD
Weekly
Instantaneous
Influent or
Effluent
BOD, 5-day, (20°C) C0310
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
Total Suspended Solids C0530
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
NH3 as N - Summer* C0610
2.0 mg/L
10.0 mg/L
Weekly
Grab
Effluent
NH3 as N - Winter* C0610
4.0 mg/L
20.0 mg/L
Weekly
Grab
Effluent
Dissolved Oxygen 00300
Daily average > 5.0 mg/L
Weekly
Grab
Effluent
Dissolved Oxygen 00300
Weekly
Grab
U & D 2
Fecal Coliform 31616
(geometric mean)
200/100 ml
400/100 ml
Weekly
Grab
Effluent
Total Residual Chlorine 50060
17 pg/L
2/Week
Grab
Effluent
Temperature (°C) 00010
Daily
Grab
Effluent
Temperature (°C) 00010
Weekly
Grab
U & D 2
pH 00400
> 6.0 and < 9.0 standard units
Weekly
Grab
Effluent
*Summer: April 1 - October 31
*Winter: November 1 - March 31
Footnotes:
1. The permittee shall submit discharge monitoring reports electronically using the NC DWR's eDMR
application system [see A. (2)].
2. U: approximately 100 feet upstream from the outfall. D: approximately 300 feet downstream
from outfall.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER THAN
TRACE AMOUNTS.
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Permit NC0037311
A. (2) ELECTRONIC REPORTING OF MONITORING REPORTS
[NCGS 143-215.1 (b)]
Federal regulations require electronic submittal of all discharge monitoring reports
(DMRs) and program reports. The final NPDES Electronic Reporting Rule was adopted
and became effective on December 21, 2015.
NOTE: This special condition supplements or supersedes the following sections within
Part II of this permit (Standard Conditions for NPDES Permits):
• Section B. (11.) Signatory Requirements
• Section D. (2.) Reporting
• Section D. (6.) Records Retention
• Section E. (5.) Monitoring Reports
1. Reporting Requirements [Supersedes Section D. (2.) and Section E. (5.) (a)1
The permittee shall report discharge monitoring data electronically using the NC DWR's
Electronic Discharge Monitoring Report (eDMR) internet application.
Monitoring results obtained during the previous month(s) shall be summarized for each
month and submitted electronically using eDMR. The eDMR system allows permitted
facilities to enter monitoring data and submit DMRs electronically using the internet.
Until such time that the state's eDMR application is compliant with EPA's Cross -Media
Electronic Reporting Regulation (CROMERR), permittees will be required to submit all
discharge monitoring data to the state electronically using eDMR and will be required to
complete the eDMR submission by printing, signing, and submitting one signed original
and a copy of the computer printed eDMR to the following address:
NC DEQ / Division of Water Resources / Water Quality Permitting Section
ATTENTION: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
If a permittee is unable to use the eDMR system due to a demonstrated hardship or due
to the facility being physically located in an area where less than 10 percent of the
households have broadband access, then a temporary waiver from the NPDES electronic
reporting requirements may be granted and discharge monitoring data may be submitted
on paper DMR forms (MR 1, 1.1, 2, 3) or alternative forms approved by the Director.
Duplicate signed copies shall be submitted to the mailing address above. See "How to
Request a Waiver from Electronic Reporting" section below.
Regardless of the submission method, the first DMR is due on the last day of the month
following the issuance of the permit or in the case of a new facility, on the last day of the
month following the commencement of discharge.
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Permit NC0037311
Starting on December 21, 2020, the permittee must electronically report the following
compliance monitoring data and reports, when applicable:
• Sewer Overflow/Bypass Event Reports;
• Pretreatment Program Annual Reports; and
• Clean Water Act (CWA) Section 316(b) Annual Reports.
The permittee may seek an electronic reporting waiver from the Division (see "How to
Request a Waiver from Electronic Reporting" section below).
2. Electronic Submissions
In accordance with 40 CFR 122.41(1) (9), the permittee must identify the initial recipient
at the time of each electronic submission. The permittee should use the EPA's website
resources to identify the initial recipient for the electronic submission.
Initial recipient of electronic NPDES information from NPDES-regulated facilities means
the entity (EPA or the state authorized by EPA to implement the NPDES program) that is
the designated entity for receiving electronic NPDES data [see 40 CFR 127.2(b)].
EPA plans to establish a website that will also link to the appropriate electronic reporting
tool for each type of electronic submission and for each state. Instructions on how to
access and use the appropriate electronic reporting tool will be available as well.
Information on EPA's NPDES Electronic Reporting Rule is found at:
http: / /www2.epa.gov/ compliance / final-national-pollutant-discharge-elimination-
system-npdes-electronic-reporting-rule.
Electronic submissions must start by the dates listed in the "Reporting Requirements"
section above.
3. How to Request a Waiver from Electronic Reporting
The permittee may seek a temporary electronic reporting waiver from the Division. To
obtain an electronic reporting waiver, a permittee must first submit an electronic
reporting waiver request to the Division. Requests for temporary electronic reporting
waivers must be submitted in writing to the Division for written approval at least sixty
(60) days prior to the date the facility would be required under this permit to begin
submitting monitoring data and reports. The duration of a temporary waiver shall not
exceed 5 years and shall thereupon expire. At such time, monitoring data and reports
shall be submitted electronically to the Division unless the permittee re -applies for and is
granted a new temporary electronic reporting waiver by the Division. Approved electronic
reporting waivers are not transferrable. Only permittees with an approved reporting
waiver request may submit monitoring data and reports on paper to the Division for the
period that the approved reporting waiver request is effective.
Information on eDMR and the application for a temporary electronic reporting waiver are
found on the following web page:
http: / / deq.nc.gov/ about/ divisions/water-resources/ edmr
4. Signatory Requirements [Supplements Section B. (11.) (b) and Supersedes
Section B. (11.) (d)1
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Permit NC0037311
All eDMRs submitted to the permit issuing authority shall be signed by a person
described in Part II, Section B. (11.)(a) or by a duly authorized representative of that
person as described in Part II, Section B. (11.)(b). A person, and not a position, must be
delegated signatory authority for eDMR reporting purposes.
For eDMR submissions, the person signing and submitting the DMR must obtain an
eDMR user account and login credentials to access the eDMR system. For more
information on North Carolina's eDMR system, registering for eDMR and obtaining an
eDMR user account, please visit the following web page:
http: / / deq.nc.gov/ about/ divisions/water-resources/ edmr
Certification. Any person submitting an electronic DMR using the state's eDMR system
shall make the following certification [40 CFR 122.22]. NO OTHER STATEMENTS OF
CERTIFICATION WILL BE ACCEPTED:
"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."
5. Records Retention [Supplements Section D. (6.)1
The permittee shall retain records of all Discharge Monitoring Reports, including eDMR
submissions. These records or copies shall be maintained for a period of at least 3 years
from the date of the report. This period may be extended by request of the Director at
any time [40 CFR 122.41].
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