NC0087980_Fact Sheet_20220818

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
Charles Weaver — 8/18/2022
Permit Number
NC0087980
Facility Name
Pine Hall Elementary School WWTP
Basin Name/Sub-basin number
Roanoke / 03-02-01
Receiving Stream
Eurins Creek
Stream Classification in Permit
WS-IV Stream Index: 22-26
Does permit need Daily Max NH3 limits?
N/A
Does permit need TRC limits/language?
No
Does permit have toxicity testing?
No
Does permit have Special Conditions?
Temporary Means of Disinfection
Does permit have instream monitoring?
No
Is the stream impaired (on 303(d) list)?
No
Any obvious compliance concerns?
No enforcements since 2009, one NOV and
two NODs in the previous permit cycle
Any permit mods since last permit?
No
New expiration date
2/28/2027
Changes to existing Permit?
Updated eDMR requirements
Changes to Draft Permit?
None
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".
• TRC language for Compliance Level for Cover Letters/Effluent Sheet Footnote:
"The facility shall report all effluent TRC values reported by a NC certified laboratory
including field certified. However, effluent values below 50 µg/L will be treated as zero
for compliance purposes."

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
MEMORANDUM
To:
From:
Subject:
NORTH CAROLINA
Environmental Quality
June 6, 2022
Jeff-Br.ya n b7rh y
NC DEQ / DWR / Public Water Supply
Winston-Salem Regional Office
Charles H. Weaver, Jr.
NPDES Unit
Review of Draft NPDES Permit NC0087980
Pine Hall Elementary School WWTP
Stokes County
Please indicate below your agency's position or viewpoint on the draft permit and return this
form by July 6, 2022. If you have any questions on the draft permit, please contact me at
919-707-3616 or via e-mail [[e-mail]].
RESPONSE: (Check one)
Concur with the issuance of this permit provided the facility is operated and maintained
properly, the stated effluent limits are met prior to discharge, and the discharge does not
contravene the designated water quality standards.
Concurs with issuance of the above permit, provided the following conditions are met:
Opposes the issuance of the above permit, based on reasons stated below, or attached:
Signed
North Carolina Department of Environmental Quality Division of Water Resources
512 North Salisbury Street 1611 Mail Service Center Raleigh, North Carolina 27699-1611
919.707.9000
Date: (2/7/2-7-
NORTH CAROLINA ���� /
Department of Environmental Quality\

NORTH CAROLINA
STOKES COUNTY
AFFIDAVIT OF PUBLICATION
Before the undersigned, a Notary Public of said County and State, duly
commissioned, qualified and authorized by law to administer oaths,
personally appeared Sandra Hurley who being first duly
sworn, deposes and says: that he (she) is Regional Publisher
(Publisher or other officer or employee authorized to make affidavit) of
ADAMS PUBLISHING GROUP, LLC, engaged in the publication of a
newspaper known as THE STOKES NEWS, published, issued, and entered
as periodicals class mail in the city of King in said County and State; that
he (she) is authorized to make this affidavit and sworn statement; that the
notice or other legal advertisement, a true copy of which is attached hereto,
was published in THE STOKES NEWS on the following dates:
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 of the requirements and
qualifications of Section 1-597 of the General Statutes of North Carolina
and was a qualified newspaper within the meaning of Section 1-597 of the
General Statutes of North Carolina.
This 14 day of
, 2022
Signa - of person making : 'davit ,
Sworn to and subscribed before me, this 2 7
;111- - , -2022
Notary Public
My Commission expires: / // e/Z 3
FERRIS W. SIMPSON
NOTARY PUBLIC
BURRY COUNTY, N.C.
day of
Public Notice
North Carolina
Environmental Management
Commission/NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Notice of Intent to Issue a NP-
DES Wastewater Permit
NC0044954 South Stokes
High School WWTP, and
NC0087980 Pine Hall Ele-
mentary School WWTP
The North Carolina Environ-
mental Management Commis-
sion proposes to issue a NP-
DES wastewater discharge
permit to the person(s) listed
below. Written comments re-
garding the proposed permit
will be accepted until 30 days
after the publish date of this
notice. The Director of the NC
Division of Water Resources
(DWR) may hold a public hear-
ing should there be a signific-
ant degree of public interest.
Please mail comments 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. Ad-
ditional information on NPDES
permits and this notice may be
found on our website:
http://deq.nc.gov/abouUdivi-
s i o n s/ovate r- re so u rce s/wate r-
re so u rc es-pe rm i is/w a stewate r-
branch/n pdes-wastewater/pub-
lic-notices.or by calling (919)
707-3601. The Stokes County
Board of Education (PO Box
50, Danbury, NC 27016) has
requested renewal of NPDES
permit NC0044954 for the
South Stokes High School
WWTP. This permitted facility
discharges treated wastewater
to Little Neatman Creek in the
Roanoke River Basin. Cur-
rently, fecal coliform and total
residual chlorine are water
quality limited. This discharge
may affect future allocations in
this portion of the Roanoke
River Basin. The Stokes
County Board of Education
(P.O. Box 50, Danbury, NC
27016-0050) has requested re-
newal of NPDES permit
NC0087980 for the Pine Hall
Elementary School WWTP.
This permitted facility dis-
charges treated domestic
wastewater to Eurins Creek in
the Roanoke River Basin. Cur-
rently, fecal coliform is water
quality limited. This discharge
may affect future allocations in
this portion of the Roanoke
River Basin.
Publish: 6-23-22 70061991x2

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
S. DANIEL SMITH
Director
Stokes County Schools
Attn: Ricky Goins, Maintenance Dir.
PO Box 50
Danbury, NC 27016-0050
Subject: Permit Renewal
Application No. NC0087980
Pine Hall Elementary School WWTP
Stokes County
NORTH CAROLINA
Environmental Quality
March 15, 2022
Dear Applicant:
The Water Quality Permitting Section acknowledges the March 15, 2022 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deq.nc.gov/permits-requlations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
ec: WQPS Laserfiche File w/application
Sincerely,
Actin
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
North Carolina Department of Environmental Quality Division of Water Resources
Winston-Salem Regional Office 1450 West Hanes Mill Road, Suite 300 I Winston-Salem. North Carolina 27105
336.7769800

North Carolina
Department of Environmental Quality
Division of Water Resources
Modified Application Form 2A
Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < 0.1 MGD
and No Pretreatment Program
NPDES Permitting Program
RECEIVED
MAR 15 2022
NCDEQ/DWR/NpDES
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

NPDES Permit Number
NC0087980
Facility Name
Pine Hall Elementary School
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 mar result in denial of the alication
Facility Information
I IN:1E:_t•1��,
1.1
[yart•d• •- ,»ty��Ii.YCtrldd:ii��'�i�nif�>Fr�rlr�ll
Facility name
Pine Hall Elementary School WWTP
Mailing address (street or P.O. box)
P.O. Box 50
City or town
Danbury
State
NC
ZIP code
27016
Contact name (first and last)
Ricky Goins
Title
Maintenance Director
Phone number
[phone]
Email address
[e-mail]
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
1400 Pine Hall Road
City or town
Pine Hall
State
NC
ZIP code
27042
1.2
Is this application
for a facility that has yet to commence
4 See instructions on data submission
requirements for new dischargers.
discharge?
Yes
✓ No
Applicant Information
1.3
Is applicant different
from entity listed under Item
1.1 above?
Item 1.4.
IN Yes
✓ No 4 SKIP to
Applicant name
Applicant address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
1.4
Is the applicant
the facility's owner, operator, or both? (Check only one response.)
❑ Operator
Both
✓ Owner
•
1.5
To which entity
should the NPDES permitting authority send correspondence? (Check only one response.)
❑ Applicant ❑ Facility and applicant
(they are one and the same)
• Facility
Existing Environmental Permits
1.6
Indicate below any existing environmental permits. (Check all that apply and print or type the corresponding permit
number for each.)
Existing Environmental Permits
✓ NPDES
(discharges to surface
❑ RCRA (hazardous waste)
❑ UIC (underground injection
control)
water)
NC0087980
❑ PSD (air emissions)
II Nonattainment
program (CAA)
❑ NESHAPs (CAA)
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
404)
❑ Other (specify)
Page 1

NPDES Permit Number
NC0087980
Facility Name
Pine Hall Elementary School
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
❑ Own 0 Maintain
% combined storm and sanitary sewer
❑ Own 0 Maintain
0 Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own ❑ Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
0 Unknown
❑ Own 0 Maintain
% separate sanitary sewer
0 Own 0 Maintain
% combined storm and sanitary sewer
❑ Own 0 Maintain
0 Unknown
0 Own 0 Maintain
separate sanitary sewer
0 Own ❑ Maintain
%combined storm and sanitary sewer
0 Own 0 Maintain
0 Unknown
0 Own 0 Maintain
Total
Population
Served
Separate Sanitary Sewer System
Combined Storm and
Sanitary Sewer
Total percentage of each type of
sewer line (in miles)
00 /0
10
0
/0
Indian Country
1.8
Is the
•
treatment works located in Indian
Yes
Country?
0
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
0.004 mgd
Annual Average Flow Rates (Actual)
Two Years Ago
Last Year
This Year
0.002 mgd
o.002 mgd
0.002 mgd
Maximum Daily Flow Rates (Actual)
Two Years Ago
Last Year
This Year
0.0033 mgd
0.0038 mgd
0.0032
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
ooi
Page 2

NPDES Permit Number
NC0087980
Facility Name
Pine Hall Elementary School
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 discharge wastewater to basins, ponds,
for discharge to waters of the State of North Carolina?
❑ Yes
or other
surface impoundments that do not have outlets
4 SKIP to Item 1.14.
p 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
0 Continuous
❑ Intermittent
gpd
0 Continuous
❑ Intermittent
1.14
Is wastewater
applied to land?
4 SKIP to Item 1.16.
• Yes
• 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
gpd
0 Continuous
0 Intermittent
acres
gpd
0 Continuous
0 Intermittent
acres
gpd
0 Continuous
0 Intermittent
1.16
Is effluent transported
to another facility for
treatment prior to discharge?
4 SKIP to Item 1.21.
• Yes
PI 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
NC0087980
Facility Name
Pine Hall Elementary School
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
Pine Hall Elementary School
Mailing address (street or P.O. box)
P.O. Box 50
City or town
Danbury
State
NC
ZIP code
27016
Contact name (first and last)
Ricky Goins
Title
Maintenance
Phone number
[phone]
Email address
[e-mail]
NPDES number of receiving facility (if any) 0 None
Average daily flow rate 0.002 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 SI
those already mentioned in Items 1.14 through 1.21 that do
(e.g., underground percolation, underground injection)?
No 4 SKIP to Item 1.23.
1.22
Provide
information in the table below on these other disposal methods.
Information on Other Disposal Methods
Disposal
Method
Description
Location of
Disposal Site
Size of
Disposal Site
Annual Average
Daily Discharge
Volume
Continuous or Intermittent
(check one)
acresgpd
0 Continuous
❑ Intermittent
acresgpd
❑ Continuous
0 Intermittent
acres
gpd
0 Continuous
❑ Intermittent
Variance
Requests
1.23
Do
Consult
•
•
you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)? (Check all that apply.
with your NPDES permitting authority to determine what information needs to be submitted and when.)
Discharges into marine waters (CWA Water quality related effluent limitation (CWA Section
Section 301(h)) 302(b)(2))
Not applicable
Contractor Information
1.24
Are
the
•
any operational or maintenance aspects (related to
responsibility of a contractor?
Yes ✓
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
NC0087980
Facility Name
Pine Hall Elementary School
Modified Application Form 2A
Modified March 2021
SECTION
2. ADDITIONAL INFORMATION
(40 CFR 122.21(j)(1) and
(2))
o
c
a)
d
0
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 4 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
specific requirements.)
❑ Yes
to this application
that contains all the required information? (See instructions for
No
•
E
cE
co
LL o
2.4
Have you attached
(See instructions
a process flow diagram or schematic to this application that contains all the required information?
for specific requirements.)
❑ No
• Yes
Scheduled Improvements and Schedules of Implementation
N N N
Are improvements to the facility scheduled?
❑ Yes ❑ No -4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
1.
2.
3.
4.
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
Scheduled
Improvement
(from above)
Affected
Outfalls
(list outtall
number)
Begin
Construction
(MM/DD/YYYY)
End
Construction
(MM/DD/YYYY)
Begin
Discharge
(MM/DD/YYYY)
Attainment of
Operational
Level
(MM/DD/YYYY)
1.
2.
3.
4.
Have appropriate
response.
permits/clearances concerning other federal/state requirements
❑ No
been
obtained? Briefly explain your
None required or applicable
• Yes
•
Explanation:
Page 5

NPDES Permit Number
NC0087980
Facility Name
Pine Hall Elementary School
Modified Application Form 2A
Modified March 2021
SECTION 3. INFORMATION
ON
Provide the following
EFFLUENT DISCHARGES (40 CFR
information for each outfall. (Attach
122.21(j)(3) to (5))
additional sheets if you have more than three outfalls.)
a
$
C3
0
c
n
0
0
3.1
Outfall Number o01
Outfall Number
Outfall Number
State
North Carolina
County
Stokes
City or town
Pine Hall
Distance from shore
16 ft.
ft.
ft.
Depth below surface
5 ft.
ft.
ft.
Average daily flow rate
0.0010 mgd
mgd
mgd
Latitude
36° 19' 59" N
° "
°
Longitude
80° 2' 55" W
° ' "
"
Seasonal or Periodic Discharge Data
3.2
Do
•
any of the outfalls described
Yes
under Item 3.1 have seasonal or
periodic
0
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
0
No 4 SKIP to Item 3.6.
3.5
Briefly describe the diffuser tf
pe 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
v
to waters of the State of North Carolina from
No 4SKIP to Section 6.
Page 6

NPDES Permit Number
NC0087980
Facility Name
Pine Hall Elementary School
Modified Application Form 2A
Modified March 2021
Receiving Water Description
1
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
mg/L 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
0 Secondary
❑ Advanced
❑ Other (specify)
❑ Primary
❑ Equivalent to
secondary
0 Secondary
0 Advanced
0 Other (specify)
❑ Primary
❑ Equivalent to
secondary
0 Secondary
0 Advanced
0 Other (specify)
Design Removal Rates by
Outfall
BOD5 or CBOD5
%
%
0/0
TSS
Phosphorus
❑ Not applicable
%
0 Not applicable
0 Not applicable
Nitrogen
❑ Not applicable
0 Not applicable
0 Not applicable
Other (specify)
0 Not applicable
%
0 Not applicable
0 Not applicable
Page 7

NPDES Permit Number
NC0087980
Facility Name
Pine Hall Elementary School
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?
U
Not applicable
❑ Not applicable
❑ Not applicable
❑ Yes
❑ No
•
Yes
■ Yes
❑ No
•
No
3.10
Have you completed monitoring for all Table A parameters and
❑ Yes
attached the results
to the app
ication package?
• No
3.11
Have you conducted
discharges or
any WET tests during the 4.5 years prior to
on any receiving water near the discharge points?
the date of the
application on any of the facility's
SKIP to Item 3.13.
• Yes
• No 4
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
reasonable potential
use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
to discharge chlorine in its effluent?
Complete Table B, including chlorine. ❑ No 4 Complete Table B, omitting chlorine.
• Yes 4
3.15
Have you completed
package?
monitoring for all applicable Table B pollutants
and attached
the results to this application
• Yes
■ No
3.18
Have you completed
attached the results
monitoring for all applicable Table D pollutants
to this application package?
required by
No
your NPDES permitting authority and
sampling required by NPDES
authority.
• Yes
additional
•
permitting
Page 8

NPDES Permit Number
NC0087980
Facility Name
Pine Hall Elementary School
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
four annual WET tests in the past 4.5
quarterly WET tests for one year
years?
preceding this permit application
tests and Table E and SKIP to
• Yes
• No 4 Complete
Item 3.26.
3.20
Have you previously
submitted the results of the above
tests to your NPDES permitting
4 Provide
authority?
results in Table E and SKIP to
■ Yes
■ No
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
(MM/DD/YYYY)
Summary of Results
3.22
Regardless of
toxicity?
how you provided your WET testing
data to the NPDES permitting authority,
did any of the tests result in
Item 3.26.
• Yes
• No 4 SKIP to
3.23
Describe the cause(s) of the toxicity:
3.24
Has the treatment
works conducted a toxicity reduction
evaluation?
Item 3.26.
• Yes
IN No 4 SKIP to
3.25
Provide details of any toxicity reduction evaluations conducted.
3.26
Have you completed
Table E for all applicable outfalls
and attached the results to the application
Not
package?
because previously submitted
NPDES .ermittin. authori .
• Yes
• applicable
information to the
Page 9

SECTION 6. CHECKLIST
NPDES Permit Number
NC0087980
AND CERTIFICATION STATEMENT (40
Facility Name
Pine Hall Elementary School
CFR 122.22(a) and (d))
Modified Application Form 2A
Modified March 2021
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
MI
Information for All Applicants
MIwl
variance request(s)
•
wl additional attachments
al
Section 2: Additional
Information
0
•
w/ topographic map
wl additional attachments
•
w/ process flow diagram
•
Section 3: Information on
Effluent Discharges
•
■
•
w/ Table A
w/ Table B
w/ Table C
•
■
wl Table D
w/ additional attachments
m
s
cal
c
0
Section 4: Not Applicable
To
w
m
o
Section 5: Not Applicable
c
0
Section 6: Checklist and
Certification Statement
•
w/ attachments
o'
Y
0
m
6.2
Certification Statement
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 fine
and imprisonment for knowing violations.
NameJ(print or type first and last name)
`
T�k ,..N.,..) V C� 1nS
Official thief) :r e,v�ur o "¢
1`nA..nTt.nAnca.-d- rac..'.4. as
Signature
Date signed
Page 10

NPDES Permit Number
Facility Name
Outfall Number
NC0087980
Pine Hall Elementary School
001
Modified Application Form 2A
Modified March 2021
TABLE A. EFFLUENT PARAMETERS
FOR ALL POTWS
Maximum Daily Discharge
Average Daily Discharge
Analytical
Method1
ML or MDL
(include units)
Pollutant
Value
Units
Value
Units
Number of
Samples
Biochemical oxygen demand
0 BOD5 or ❑ CBOD5
(report one)
15.5
mg/L
<2
mg/L
52
❑ ML
❑ MDL
Fecal coliform
2
MPN/100m1
1
MPN/100m1
52
0 ML
❑ MDL
Design flow rate
0.009
MGD
0.0019
MGD
N/A
..
pH (minimum)
6
Std. Units
pH (maximum)
6.9
Std. Units
Temperature (winter)
18
°C
11.76
°C
65
Temperature (summer)
26
°C
20.46
°C
45
Total suspended solids (TSS)
6.1
mg/L
<5
mg/L
52
❑ ML
❑ 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

EPA Identification Number
NPDES Permit Number
NC0087980
Facility Name
Pine Hall Elementary School
Outfall Number
Modified Application Form 2A
Modified March 2021
TABLE B. EFFLUENT PARAMETERS
FOR ALL POTWS
WITH A FLOW EQUAL
Discharge
TO OR GREATER THAN 0.1 MGD
Average Daily Discharge
Analytical
Methods
ML or MDL
units)
(include
Pollutant
Maximum Daily
Value
Units
Value
Units
Number of
Samples
Ammonia (as N)
❑ ML
❑ MDL
Chlorine
(total residual, TRC)2
❑ ML
❑ MDL
Dissolved oxygen
El ML
❑ MDL
Nitrate/nitrite
❑ ML
❑ MDL
Kjeldahl nitrogen
0 ML
❑ MDL
Oil and grease
0 ML
❑ MDL
Phosphorus
❑ ML
0 MDL
Total dissolved solids
❑ ML
❑ MDL
' 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).
2 Facilities that do not use chlorine for disinfection, do not use chlorine elsewhere in the treatment process, and have no reasonable potential to discharge chlorine in their effluent are not
required to report data for chlorine.
EPA Fomi 3510-2A (Revised 3-19)
Page 12

EPA Identification Number
TABLE C. EFFLUENT PARAMETERS
NPDES Permit Number
NC0087980
FOR SELECTED POTWS
Facility Name
Pine Hall Elementary School
Outfall Number
Modified
Analytical
Method'
Application Form 2A
Modified March 2021
ML or MDL
(include units)
Maximum Daily Discharge
Average Daily Discharge
Pollutant
Value
Units
Value
Units
Number of
Samples
Metals, Cyanide, and Total Phenols
Hardness (as CaCO3)
❑ ML
❑ MDL
Antimony. total recoverable
0 ML
❑ MDL
Arsenic, total recoverable
❑ ML
❑ MDL
Beryllium, total recoverable
CI ML
❑ MDL
Cadmium, total recoverable
CI ML
❑ MDL
Chromium. total recoverable
❑ ML
❑ MDL
Copper, total recoverable
0 ML
❑ MDL
Lead. total recoverable
❑ ML
❑ MDL
Mercury, total recoverable
0 ML
❑ MDL
Nickel, total recoverable
❑ ML
❑ MDL
Selenium, total recoverable
❑ ML
❑ MDL
Silver, total recoverable
❑ ML
❑ MDL
Thallium, total recoverable
0 ML
❑ MDL
Zinc, total recoverable
❑ ML
❑ MDL
Cyanide
❑ ML
❑ MDL
Total phenolic compounds
0 ML
❑ MDL
Volatile Organic Compounds
Acrolein
❑ ML
❑ MDL
Acrylonitrile
0 ML
❑ MDL
Benzene
0 ML
❑ MDL
Bromoform
I
0 ML
0 MDL
EPA Form 3510-2A (Revised 3-19)
Page 13

EPA Identification Number
TABLE C. EFFLUENT PARAMETERS
Pollutant
NPDES Permit Number
NC0087980
FOR SELECTED POTWS
Pine
Facility Name
Hall Elementary School
Outfall Number
Modified
Analytical
Method*,
Application Form 2A
Modified March 2021
ML or MDL
(include units)
Maximum Daily Discharge
Average Daily Discharge
Value
Units
Value
Units
Number of
Samples
Carbon tetrachloride
❑ ML
❑ MDL
Chlorobenzene
❑ ML
❑ MDL
Chlorodibromomethane
0 ML
❑ MDL
Chloroethane
❑ ML
❑ MDL
2-chloroethylvinyl ether
0 ML
❑ MDL
Chloroform
❑ ML
❑ MDL
Dichlorobromomethane
❑ ML
❑ MDL
1,1-dichloroethane
0 ML
0 MDL
1,2-dichloroethane
❑ ML
❑ MDL
trans-1,2-dichloroethylene
ID ML
❑ MDL
1,1-dichloroethylene
El ML
❑ MDL
1,2-dichloropropane
0 ML
❑ MDL
1,3-dichloropropylene
0 ML
❑ MDL
Ethylbenzene
0 ML
❑ MDL
Methyl bromide
0 ML
❑ MDL
Methyl chloride
0 ML
❑ MDL
Methylene chloride
0 ML
❑ MDL
1,1,2,2-tetrachloroethane
El ML
❑ MDL
Tetrachloroethylene
0 ML
❑ MDL
Toluene
❑ ML
❑ MDL
1,1,1-trichloroethane
❑ ML
❑ MDL
1,1,2-trichloroethane
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19)
Page 14

EPA Identification Number
TABLE C. EFFLUENT PARAMETERS
NPDES Permit Number
NC0087980
FOR SELECTED POTWS
Maximum Daily Discharge
Pine
Facility Name
Hall Elementary School
Average
Outfall Number
Daily Discharge
Modified
Analytical
Methods
Application Form 2A
Modified March 2021
ML or MDL
(include units)
Pollutant
Value
Units
Value
Units
Number of
Samples
Trichloroethylene
o ML
0 MDL
Vinyl chloride
❑ ML
❑ MDL
Acid -Extractable Compounds
p-chloro-m-cresol
o ML
❑ MDL
2-chlorophenol
❑ ML
0 MDL
2,4-dichlorophenol
❑ ML
❑ MDL
2,4-dimethylphenol
❑ ML
❑ MDL
4,6-dinitro-o-cresol
❑ ML
❑ MDL
2,4-dinitrophenol
❑ ML
❑ MDL
2-nitrophenol
❑ ML
❑ MDL
4-nitrophenol
❑ ML
0 MDL
Pentachlorophenol
❑ ML
❑ MDL
Phenol
❑ ML
❑ MDL
2,4,6-trichlorophenol
❑ ML
❑ MDL
Base -Neutral Compounds
Acenaphthene
o ML
❑ MDL
Acenaphthylene
❑ ML
❑ MDL
Anthracene
❑ ML
❑ MDL
1'
Benzidine
❑ ML
❑ MDL
Benzo(a)anthracene
❑ ML
❑ MDL
Benzo(a)pyrene
❑ ML
❑ MDL
3,4-benzofluoranthene
0 ML
❑ MDL
EPA Form 3510-2A (Revised 3-19)
Page 15

EPA Identification Number
TABLE C. EFFLUENT PARAMETERS
Pollutant
NPDES Permit Number
NC0087980
FOR SELECTED
Maximum Daily
POTWS
Discharge
Pine
Facility Name
Hall Elementary School
Average
Outfall Number
Daily Discharge
Modified
Analytical
Method',
Application Form 2A
Modified March 2021
ML or MDL
(include units)
Value
Units
Value
Units
Number of
Samples
Benzo(ghi)perylene
0 ML
❑ MDL
Benzo(k)fluoranthene
0 ML
❑ MDL
Bis (2-chloroethoxy) methane
0 ML
0 MDL
Bis (2-chloroethyl) ether
0 ML
0 MDL
Bis (2-chloroisopropyl) ether
0 ML
❑ MDL
Bis (2-ethylhexyl) phthalate
0 ML
❑ MDL
4-bromophenyl phenyl ether
0 ML
❑ MDL
Butyl benzyl phthalate
0 ML
❑ MDL
2-chloronaphthalene
0 ML
❑ MDL
4-chlorophenyl phenyl ether
0 ML
❑ MDL
Chrysene
❑ ML
❑ MDL
di-n-butyl phthalate
0 ML
0 MDL
di-n-octyl phthalate
0 ML
❑ MDL
Dibenzo(a,h)anthracene
0 ML
❑ MDL
1,2-dichlorobenzene
0 ML
❑ MDL
1,3-dichlorobenzene
0 ML
❑ MDL
1,4-dichlorobenzene
0 ML
❑ MDL
3,3-dichlorobenzidine
❑ ML
❑ MDL
Diethyl phthalate
0 ML
❑ MDL
Dimethyl phthalate
0 ML
❑ MDL
2,4-dinitrotoluene
❑ ML
❑ MDL
2,6-dinitrotoluene
0 ML
❑ MDL
EPA Form 3510-2A (Revised 3-19)
Page 16

EPA Identification Number
TABLE C. EFFLUENT PARAMETERS
Pollutant
NPDES Permit Number
NC0087980
FOR SELECTED POTWS
Maximum Daily Discharge
Pine
Facility Name
Hall Elementary School
Average
Outfall Number
Daily Discharge
Modified
Analytical
Method1
Application Form 2A
Modified March 2021
ML or MDL
(include units)
Value
Units
Value
Units
Number of
Samples
1,2-diphenylhydrazine
❑ ML
❑ MDL
Fluoranthene
❑ ML
❑ MDL
Fluorene
0 ML
❑ MDL
Hexachlorobenzene
0 ML
❑ MDL
Hexachlorobutadiene
0 ML
❑ MDL
Hexachlorocyclo-pentadiene
❑ ML
❑ MDL
Hexachloroethane
❑ ML
❑ MDL
Indeno(1,2,3-cd)pyrene
❑ ML
❑ MDL
Isophorone
0 ML
❑ MDL
Naphthalene
❑ ML
❑ MDL
Nitrobenzene
❑ ML
❑ MDL
N-nitrosodi-n-propylamine
❑ ML
❑ MDL
N-nitrosodimethylamine
❑ ML
❑ MDL
N-nitrosodiphenylamine
❑ ML
❑ MDL
Phenanthrene
❑ ML
❑ MDL
Pyrene
❑ ML
❑ MDL
1,2,4-trichlorobenzene
❑ ML
❑ 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).
EPA Form 3510-2A (Revised 3-19)
Page 17

NPDES Permit Number
NC0087980
Facility Name
Pine Hall Elementary School
Outfall Number
Modified Application Form 2A
Modified March 2021
Analytical ML or MDL
Method, (include units)
TABLE D. ADDITIONAL POLLUTANTS AS REQUIRED BY NPDES PERMITTING
AUTHORITY
Maximum Daily Discharge Average Daily Dischar
a
Pollutant
(list) Value
Units Value
Units
Number of
Samples
• No additional sampling is required by NPDES permitting authority.
❑ ML
❑ MDL
❑ ML
❑ MDL
0 ML
0 MDL
❑ ML
❑ MDL
0 ML
❑ MDL
❑ ML
0 MDL
0 ML
0 MDL
0 ML
0 MDL
❑ ML
0 MDL
0 ML
0 MDL
0 ML
❑ MDL
0 ML
❑ MDL
0 ML
❑ MDL
❑ ML
0 MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ 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 18

Sludge Management Plan
Pine Hall Elementary School
NPDES Permit No. NC 0087980
Sludge from the Pine Hall Elementary School wastewater treatment plant are disposed of in the
following manner:
Solids accumulate in the septic and recirculation tanks. The tanks are pumped annually by
Green Way Solutions Group, a licensed septic pumper from Concord, NC and solids are
disposed of at the City of Winston-Salem Wastewater Treatment Plant.

•
1417P.i4%.4-11
r
p ,—.-J
ryc.,:„—;
0 I •
\N!:.N.17 4‘ 4.1
NC0087980 - Pine Hall Elementary School.
Latitude: 36"19'53"
Longitude: 80°02'56"
IGS Quad: Belews Lake
._eceiving Stream: Eurins Creek
Hydrologic Unit: 03010103
Stream Class: WS-1'V
Subbasin: 03-02-01
Facility
Location
)1, C,'•• )
(
Stokes County
Map not to scale

Water Resources
ENVIRONMENTAL QUALITY
November 14, 2016
Mr. Ricky D. Goias
Stokes County Schools
P.O. Box 50
Danbury, NC 27016
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Director
Subject: Issuance of NPDES Permit NC0087980
Pine Hall Elementary School WWTP
Class WW-1
Stokes County
Dear Mr. Goins:
The Division of Water Resources (the Division) hereby issues the attached NPDES permit for the
subject facility. This permit is issued pursuant to the requirements of North Carolina General
Statute 143-215.1 and the Memorandum of Agreement between North Carolina and the U.S.
Environmental Protection Agency dated October 15, 2007, or as subsequently amended.
We have made the following updates to your previous permit with no subsequent changes from the
draft permit mailed to you:
> Section A. (3) has been added to require electronic submission of effluent data. Federal
regulations require electronic submittal of all discharge monitoring reports (DMRs), effective
December 21, 2016.
> Regulatory citations have been added to the permit.
> An updated outfall map has been included.
No later than December 21, 2016, federal regulations require electronic submittal of all discharge
monitoring reports (DMRs) and specify that, if a state does not establish a system to receive such
submittals, then permittees must submit DMRs electronically to the Environmental Protection
Agency (EPA). The final NPDES Electronic Reporting Rule was adopted and became effective on
December 21, 2015.
The requirement to begin reporting discharge monitoring data electronically using the NC DWR's
Electronic Discharge Monitoring Report (eDMR) internet application has been added to your final
NPDES permit. [See A. (3)] For information on eDMR, registering for eDMR and obtaining an
eDMR user account, please visit the following web page:
http://deq.nc.gov/about/divisions/water-resources/edmr.
For more information on EPA's final NPDES Electronic Reporting Rule, please visit the following
web site:
http://www2.epa.gov/compliance/final-national-pollutant-discharge-elimination-system-npdes-
ele ctronic-rep orting-rule .
If any parts, measurement frequencies, or sampling requirements contained in this permit are
unacceptable, you have the right to an adjudicatory hearing, upon written request submitted within
thirty (30) days after receiving this letter. Your request must take the form of a written petition
conforming to Chapter 150B of North Carolina General Statutes, and you must file it with the Office
State of North Carolina I Environmental Quality I Water Resources
1617 Mail service Center I Raleigh, North Carolina 27699-1617
919 807 6300

of Administrative Hearings, 6714 Mail Service Center, Raleigh, North Carolina 27699-6714. Unless
such a demand is made, this permit shall remain final and binding.
Please note that this permit is not transferable except after notice to the Division. The Division may
require modification or revocation and reissuance of the permit. This permit does not affect the legal
requirements to obtain other permits which may be required by the Division of Water Resources or
any other Federal, State, or Local governmental permits that may be required.
If you have questions, or if we can be of further service, please contact Meredith Wojcik at
[[e-mail]] or call [phone].
S. Jay Zimmerman, P.G., 'rector
Division of Water Resources, NCDEQ
Enclosure: NPDES Permit NC0087980 (Issuance Final)
hc: Central Files
NPDES Program Files
WSRO Files
ec: Mr. Ricky D. Goins [[e-mail]]

Permit NC0087980
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,
Stokes County Board of Education
is hereby authorized to discharge wastewater from a facility located at the
Pine Hall Elementary School WWTP
1400 Pine Hall Road
Pine Hall
Stokes County
to receiving waters designated as Eurins 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 March 1, 2017.
This permit and authorization to discharge shall expire at midnight on February 28, 2022.
Signed this day November 14, 2016.
S. Zimmerman, P.G., Direc or
Division of Water Resources
By Authority of the Environmental Management Commission
Page 1 of 7

Permit NC0087980
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.
Stokes County Board of Education
is hereby authorized to:
1. Continue to operate an existing 0.004 MGD wastewater treatment system with the
following components:
• Septic tank
• Dosing chamber
• Recirculation system
• Surface sand filter
• Ultraviolet disinfection
The facility is located at Pine Hall Elementary School, located at 1400 Pine Hall Rd
near Pine Hall in Stokes County.
2. Discharge from said treatment works via Outfall 001, at the location specified on
the attached map into Eurins Creek [stream index: 22-26], currently classified
WS-IV waters in subbasin 03-02-01 [HUC: 0301010303] of the Roanoke River
Basin.
Page 2 of 7

Permit NC0087980
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 1 by the Permittee as specified below:
EFFLUENT CHARACTERISTICS
Parameter Code
EFFLUENT LIMITATIONS
MONITORING REQUIREMENTS
Monthly
Average
Daily
Maximum
Measurement
Frequency
Sample
Type
Sample
Location
Flow 50050
0.004 MGD
Continuous
Recording
Influent or
Effluent
BOD, 5-day, (20°C) C0310
30.0 mg/L
45.0 mg/L
2/Month
Grab
Effluent
Total Suspended Solids C0530
30.0 mg/L
45.0 mg/L
2/Month
Grab
Effluent
NH3 as N C0610
Monthly
Grab
Effluent
pH 00400
'_ 6.0 and < 9.0
standard units
2/Month
Grab
Effluent
Fecal Coliform 31616
(geometric mean)
200/100 mI
400/100 mI
2/Month
Grab
Effluent
Temperature (°C) 00010
Weekly
Grab
Effluent
Total Nitrogen C0600
(NO2+NO3+TKN)
QuarterlyGrab
Effluent
Total Phosphorus C0665
Quarterly
Grab
Effluent
Footnotes:
1. No later than December 21, 2016, the permittee shall begin submitting discharge monitoring
reports electronically using the NC DWR's eDMR application system [see A. (2)].
See Condition A. (3) for instructions should the facility's permitted UV system fail and an alternate
means of disinfection is required. Total residual chlorine monitoring requirements and limits are
applicable if chlorine compounds are used for disinfection.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER THAN
TRACE AMOUNTS.
Page 3 of 7

Permit NC0087980
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 and specify that, if a state does not establish a system to
receive such submittals, then permittees must submit monitoring data and reports
electronically to the Environmental Protection Agency (EPA). 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.)
• Section D. (2.)
• Section D. (6.)
• Section E. (5.)
Signatory Requirements
Reporting
Records Retention
Monitoring Reports
1. Reporting Requirements {Supersedes Section D. (2.) and Section E. (5.) (a)1
Effective December 21, 2016, 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.
Page 4 of 7

Permit NC0087980
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
Page 5 of 7

Permit NC0087980
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].
Page 6 of 7

Permit NC0087980
A. (3) TEMPORARY MEANS OF DISINFECTION
[NCGS 143-215.3 (a)(2)]
In the event that the wastewater treatment plant's ultraviolet (UV) disinfection system
should fail, underperform, or otherwise be removed from effective service, the permittee
or his agent should immediately inform the Water Quality Regional Operations Section
staff of the Wilmington Regional Office of this development and discuss temporary,
alternate means for disinfection of the effluent.
If chlorine compounds are used as temporary means of disinfection, the total residual
chlorine (TRC) concentration of the effluent must be monitored on a daily basis while
this method of disinfection is in use and values must be reported on the discharge
monitoring report. TRC in the effluent may not exceed 17 µg/ L; therefore,
dechlorination methods may also be necessary to ensure protection of water quality in
the receiving stream.
In the event that TRC monitoring should occur, the Division shall consider all effluent
TRC values reported below 50 pg/L to be in compliance with the permit. However, the
Permittee shall continue to record and submit all values reported by a North Carolina
certified laboratory (including field certified), even if these values fall below 50 pg/L.
Use of a disinfection system other than the permitted UV system during circumstances
not deemed as emergency and/or temporary (replacement of lamps, lamp cleaning or
maintenance, etc.) will be considered a violation of the terms of this permit.
Page 7 of 7

Stokes County Schools
Pine Hall Elementary School WWTP
NPDES Permit 86011
Receiving Stream: Eurins Creek
Stream Segment: 22-26
River Basin: Roanoke
County: Stokes
Stream Class: WS-IV
Sub -Basin #: 03-02-01
HUC: 0301010303
SCALE
1:24,000
,ram"#"117,41
4
arikik,VM/AlleAAlkipiel
Facility Location ,M*,.�
scale not shown,
36.333056°,-80.048889°
USGS Quad: Belews Lake

Winston-Salem Journal
Advertising Affidavit
NC DIVISION OF WATER RESOURCES
ATTN: JENNIFER BURDETTE
1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617
P.O Box 3159
Winston-Salem, NC 27102
OCTflE@MOWM
1 7 2016
DEQ-WATER RESOURCES
401 & BUFFER PERMITTING
Account Number
4023513
Date
October 10, 2016
Date Category
Description
Ad Size Total Cost
10/10/2016
Legal Notices
Public Notice North Carolina Environmental Management Comi 2 x 33 L
402.78
KIMALEY JOHNSON
NOTARY PUBLIC
i FORSYTH COUNTY
4 STATE OF NORTH CAR
1 MY COMMISSION EXPIRES
820
Publisher of the
Winston-Salem Journal
Forsyth County
Before the undersigned, a Notary Public of Forsyth County, North Carolina, duly
commissioned, qualified, and authorized by law to administer oaths, personally appeared D.
H. Stanfield, who by being duly sworn deposes and says: that he is the Controller of the
Winston-Salem Journal, engaged in the publishing of a newspaper known as
Winston-Salem Journal, published, issued and entered as second class mail in the City of
Winston-Salem, in said County and State: that he is authorized to make this affidavit and
sworn statement: that the notice or other legal advertisement, a true copy of which is
attached hereto, was published in the Winston-Salem Journal on the following dates:
10/10/2016
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 and was a qualified newspaper within the meaning of Section 1-597 of the General
Statutes of North Carolina.
This i 0th day of October, 2016
1
(signature of person ' . i'ng affidavit)
Sworn to and subscribed before me, this I0th day of October, 2016
My Commission expires Skid • 1? Z0 2,0
(No . Public)
TLJ10 10 klfT A 1311 1 Ell = A 0C 1) A V CDAl1A 11k1\inir. TLJ A h11! Vf11 1

Public Notice
North Carolina Environmental Management Commission/NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Notice of Intent to Issue a NPDES Wastewater Permit
The North Carolina Environmental Management Commission proposes to is-
sue a NPDES wastewater discharge permit to the person(s) listed below.
Written comments regarding the proposed permit will be accepted 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 signifi-
cant degree of public interest. Please mail comments and/or information re-
quests to DWR at the above address. Interested persons may visit the DWR
at 512 N. Salisbury Street, Raleigh, NC to review information on file. Addi-
tional information on NPDES permits and this notice may be found on our
website• http://deq.nc.qov/about/divisions/water-resources/water-resourc
es-permits/wastewater-branch/npdes-wastewater/public-notices , or by
calling [phone].
Carolina Water Service requested renewal of permit NC0060461/Abington
Subdivision WWTP/Forsyth County; Facility discharges to Belews
Creek/Roanoke River Basin. Currently Dissolved Oxygen, Fecal Coliform,
Total Residual Chlorine, and Ammonia Nitrogen are water quality limited.
Town of Walnut Cove requested renewal of permit NC0025526 for its
WWTP/Stokes County; Facility discharges to Town Fork Creek/Roanoke Riv-
er Basin. Currently, ammonia nitrogen, fecal coliform, and total residual
chlorine are water quality limited.
Stokes County Schools requested renewal of permit NC0087980/Pine Hall El-
ementary School WWTP. Facility discharges to Eurins Creek/Roanoke River
Basin. Currently, fecal coliform is water quality limited.
WSJ: October 10, 2016

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
Meredith Wojcik — 9/19/2016
Permit Number
NC0087980
Facility Name
Pine Hall Elementary School WWTP
Basin Name/Sub-basin number
Roanoke / 03-02-01
Receiving Stream
Eurins Creek
Stream Classification in Permit
WS-IV Stream Index: 22-26
Does permit need Daily Max NH3 limits?
No
Does permit need TRC limits/language?
No
Does permit have toxicity testing?
No
Does permit have Special Conditions?
No
Does permit have instream monitoring?
No
Is the stream impaired (on 303(d) list)?
No
Any obvious compliance concerns?
No. Fecal coliform and total suspended solids
exceedance violations are the main source of
NODs for the current permit cycle
Any permit mods since last permit?
No
New expiration date
2/28/2022
Changes to 2011 Permit?
Added eDMR requirements
Added regulatory citations
Changes to Draft Permit?
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".
• TRC language for Compliance Level for Cover Letters/Effluent Sheet Footnote:
"The facility shall report all effluent TRC values reported by a NC certified laboratory
including field certified. However, effluent values below 50 µg/L will be treated as zero
for compliance purposes."

Stokes County Schools
STOKES COUNTY BOARD OF EDUCATION
Sonya M. Cox, Chair
Patricia M. Messick, Vice Chair
Rebecca P. Boles
William F. Hart
Jamie B. Yontz
SUPERINTENDENT
Dr. Brad Rice
ASSISTANT SUPERINTENDENT
Tony George
www.stokes.k12.nc.us . t00 Courthouse Circle . PO Box 50 . Danbury, NC 27016 . Phone: [phone] . Fax: [phone]
August 5, 2016
NCDENR/DWR/NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Attn: Mr. Wren Thedford
Re: Pine Hall Elementary School WWTP NPDES Renewal Application Cover Letter
NC NPDES Permit No. NC0087980
Stokes County, NC
Dear Mr. Thedford,
'�T`'y�.,-aka +r"�•���y � @gr�. ,�^ y �t ZT11 �{
ECEI S7' :r.FI V �C L QJD
AUG 162016
v
As required for all NPDES renewal application packaages, on behalf of the Stokes County Board of Education,
we request renewal of the Pine hall Elementary School WWTP NPDES Premit No. NC0087980.
There have been no modifications to the facility since the issuance of the last permit.
Sincerely,
Stokes County Schools
Ricky Goins, Director of Maintenance

Stokes County Schools
STOKES COUNTY BOARD OF EDUCATION
Sonya M. Cox, Chair
Patricia M. Messick, Vice Chair
Rebecca P. Boles
William F. Hart
Jamie B. Yontz
SUPERINTENDENT
Dr. Brad Rice
ASSISTANT SUPERINTENDENT
Tony George
www.stokes.k12.nc.us . 100 Courthouse Circle . PO Box 50 . Danbury, NC 27016 Phone: [phone] . Fax: [phone]
August 5, 2016
Description of Waste Water Treatment System Components
Pine Hall Elementary School WWTP
1400 Pine Hall Road
Pine Hall, NC 27042
Stokes County, NPDES Permit No.: NC0087980
NC - LQ/.lV,V:
AUG 16 2016
Water Quality
Permitting Section
The existing Pine Hall Elementary School WWTP includes the following components:
• Septic tank (+8,000 gallons)
• Dosing chamber (+2,800 gallons)
• Recirculation tank (3,500 gallons)
• Surface sand filter (+1,640 sq. ft.)
• Dual ultraviolet disinfection unit
„ 92.Z emPIGT:

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
INC0087980
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 Stokes County Board of Education
Facility Name Pine Hall Elementary School WWTP
Mailing Address P.O. Box 50
City Danbury
FECL
State / Zip Code NC 27016
AUG 16 2016
Telephone Number [phone]
Fax Number [phone]
e-mail Address [e-mail]
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road
City
State / Zip Code
County
1400 Pine Hall Road
Pine Hall
NC 27042
Stokes
3. Operator Information:
Name of the firm, public organization or other entity that operates the facility. (Note that this is not
referring to the Operator in Responsible Charge or ORC)
Name Research and Analytical Laboratories, Inc.
Mailing Address P.O. Box 473 - 106 Short Street
City Kernersville
State / Zip Code NC 27285 - 27284
Telephone Number [phone]
Fax Number
e-mail Address
( )
[e-mail]
1 of 3 Form-D 11/12

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 Homes
School ® Number of Students/ Staff 180 / 30
Other ❑ Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
High School
Number of persons served: 210
5. Type of collection system
® Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points 1
Outfall Identification number(s) 001
Is the outfall equipped with a diffuser? ❑ Yes ® No
7. Name of receiving stream(s) (NEW applicants: Provide a map showing the exact location of each
outfall):
Eurins Creek
8. Frequency of Discharge: ® Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: Duration:
9. Describe the treatment system
List all installed components, including 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.
See description of waste water treatment system components on separate sheet of paper
attached.
2 of 3 Form-D 11 /12

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0.004 MGD
Annual Average daily flow 0.0013 MGD (for the previous 3 years)
Maximum daily flow 0.0072 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ►/ No
12. Effluent Data
NEW APPLICANTS: 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 monthly average. If only one analysis is reported, report as daily maximum.
RENEWAL APPLICANTS: Provide the highest single reading (Daily Maximum) and Monthly Average over
the past 36 months for parameters currentlq in our permit. Mark other parameters "N/A".
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BOD5)
14.6
2.10
MG/L
Fecal Coliform
<2420
1.47
C01 / 100ML
Total Suspended Solids
35.8
3.61
MG/L
Temperature (Summer)
28
21.02
°C
Temperature (Winter)
18
11.03
°C
pH
6.9
N/A
SU
13. List all permits, construction approvals and/or applications:
Type
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES
PSD (CAA)
Non -attainment program (CAA)
Permit Number
NC0087980
14. APPLICANT CERTIFICATION
Type
NESHAPS (CAA)
Ocean Dumping (MPRSA)
Dredge or fill (Section 404 or CWA)
Other
Permit Number
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
Ricky Goins Director of Maintenance
Printed name of Person Signing Title
Signature of Applicant 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 11 /12