NC0075027_Fact Sheet_20221117

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 9/1/2022
Permit Number
NC0075027
Facility Name / Facility Class
Cainsway Mobile Home Park WWTP / WW-2
County / Regional Office
Forsyth / WSRO
Basin Name / Sub -basin number
Roanoke / 03-02-01
Receiving Stream / HUC
Ader Creek / 030101030204
Stream Classification / Stream Segment
C / 22-25-14-1
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 & DO
Is the stream impaired (on 303(d) list)?
No
Any obvious compliance concerns?
Twelve violation and enforcement cases
(including six NODs and six NOVs) during the
permit cycle.
Changes in draft permit?
Added WWTP classification
Updated eDMR requirements
Updated outfall map
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
August 2022 -- NPDES Permit NC0075027 - Page 1

Section 1. Facility Overview:
This facility is a minor facility (flow < 1 MGD) discharging 100% domestic wastewater with a design
capacity of 0.0432 MGD. This WWTP utilizes the following treatment components:
• Aerated equalization basin
• Bar screen
• Splitter box
• Dual extended aeration basins
• Clarifier
• Tertiary filters
• Chlorinator
• Dechlorinator
Section 2. Compliance History (April 2017 — September 2022):
• One NOD for BOD5 limit violation in June 2017.
• One NOD for temperature monitoring frequency violation in June 2017.
• One NOD for pH monitoring frequency violation in November 2017.
• One NOV for permit conditions violation detected during compliance inspection in June 2018.
• Two NOVs for ammonia nitrogen limit violations in July 2018 and August 2019.
• Two NOVs for BOD5 limit violation in October 2018 and August 2019.
• Two NODs for flow monitoring frequency violation in January 2019 and May 2019.
• One NOV for fecal coliform limit violation in August 2020.
• One NOV for permit conditions violation detected during compliance inspection in August 2021.
• One NOD for permit conditions violation in September 2021.
• One NOD for ammonia nitrogen limit violation in May 2022.
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).
• Winter ammonia nitrogen limits has been updated based on the WLA worksheet and the 2016
ammonia permitting guidance memo.
• Updated outfall map.
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
August 2022 -- NPDES Permit NC0075027 - 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
September 22, 2022
PO Number Order Category Description
0000803640 Legal Notices Public Notice North Carolina Environmental Management Commission/ NPDES Uni
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:
09/22/2022
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.
(signature of pe
Sworn to and subscribed before me the 22nd
„, „
c
State of Virginia • ON .
County of Hanover : n`i} �`, P
My commission exp jo
U.) REGISTRATION
# 329549 `r
• �p�TgRY P��'
,, 47MOlh`N,. P``'
/ O� V I RG' e\�
'1/1111111�
(Notary Public)
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 27699.1617
Notice of Intent to Issue a NPDES
Wastewater Permit NC0015021
Cainsway Mobile Home Park 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]. Cainsway
Homeowner's Association (P.O. Box
846, Walkertown, NC 27051-0846)
has applied for renewal of NPDES
permit NC0075027 for the Cainsway
Mobile Home Park WWTP in Forsyth
County. This permitted facility dis-
charges treated domestic wastewa-
ter to Ader Creek in the Roanoke
River Basin. Currently, BOD,
ammonia -nitrogen, fecal coliform,
dissolved oxygen, and total residual
chlorine are water quality limited.
This discharge may affect future al-
locations in this portion of the Roa-
noke River Basin.
WSJ: September 22, 2022.

NH3/TRC WLA Calculations
Facility: Cainsway Mobile Home Park WWTP
PermitNo. NC0075027
Prepared By: Siying Chen
Enter Design Flow (MGD):
Enter s7Q10 (cfs):
Enter w7Q10 (cfs):
0.0432
0.075
0.2
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)
0.075
0.0432
0.06696
17.0
0
47.17
36
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)
2.12 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-N1
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
0.075
0.0432
0.06696
1.0
0.22
47.17
1.9
0.2
0.0432
0.06696
1.8
0.22
25.08
6.5
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: 09/01/22 Page 1 01 3
Permit: nc0075027 MRs Betweei 4 - 2017 and 9 - 2022
Facility Name: % Param Nam( %
Major Minor: %
Region: %
County: %
Violation Category:% Program Category:
Subbasin:%
Violation Action: %
PERMIT: NC0075027
FACILITY: Cainsway Homeowners Association - Cainsway Mobile
Home Park 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
06-2017 001 Effluent BOD, 5-Day (20 Deg. C) - 06/21/17 Weekly mg/I 16.5 42 154.5 Daily Maximum Proceed to NOD
Concentration Exceeded
10 - 2018 001 Effluent BOD, 5-Day (20 Deg. C) - 10/23/18 Weekly mg/I 16.5 33 100 Daily Maximum Proceed to NOV
Concentration Exceeded
08 - 2019 001 Effluent BOD, 5-Day (20 Deg. C) - 08/06/19 Weekly mg/I 16.5 20.1 21.8 Daily Maximum Proceed to NOV
Concentration Exceeded
08 -2017 001 Effluent Chlorine, Total Residual 08/18/17 2 X week ug/I 28 33 17.9 Daily Maximum No Action, BPJ
Exceeded
09-2017 001 Effluent Chlorine, Total Residual 09/08/17 2 X week ug/I 28 39 39.3 Daily Maximum No Action, BPJ
Exceeded
09-2017 001 Effluent Chlorine, Total Residual 09/29/17 2 X week ug/I 28 29 3.6 Daily Maximum No Action, BPJ
Exceeded
10-2017 001 Effluent Chlorine, Total Residual 10/20/17 2 X week ug/I 28 38 35.7 Daily Maximum No Action, BPJ
Exceeded
12-2017 001 Effluent Chlorine, Total Residual 12/01/17 2 X week ug/I 28 35 25 Daily Maximum No Action, BPJ
Exceeded
12-2017 001 Effluent Chlorine, Total Residual 12/15/17 2 X week ug/I 28 29 3.6 Daily Maximum No Action, BPJ
Exceeded
12-2017 001 Effluent Chlorine, Total Residual 12/22/17 2 X week ug/I 28 34 21.4 Daily Maximum No Action, BPJ
Exceeded
12-2017 001 Effluent Chlorine, Total Residual 12/29/17 2 X week ug/I 28 37 32.1 Daily Maximum No Action, BPJ
Exceeded
08-2020 001 Effluent Coliform, Fecal MF, MFC 08/19/20 Weekly #/100m1 400 2,419 504.8 Daily Maximum Proceed to NOV
Broth, 44.5 C Exceeded
07-2018 001 Effluent Nitrogen, Ammonia Total (as 07/25/18 Weekly mg/I 10 10.9 9 Daily Maximum Proceed to NOV
N) - Concentration Exceeded
07-2018 001 Effluent Nitrogen, Ammonia Total (as 07/31/18 Weekly mg/1 2 3.03 51.6 Monthly Average Proceed to NOV
N) - Concentration Exceeded
08-2019 001 Effluent Nitrogen, Ammonia Total (as 08/31/19 Weekly mg/1 2 2.1 5 Monthly Average Proceed to NOV
N) - Concentration Exceeded

MONITORING REPORT(MR) VIOLATIONS for:
Report Date: 09/01/22 Page 2 of 3
Permit: nc0075027 MRs Betweei 4 - 2017 and 9 - 2022 Region: % Violation Category:% Program Category: %
Facility Name: % Param Nam(% County: % Subbasin:% Violation Action: %
Major Minor: %
PERMIT: NC0075027
FACILITY: Cainsway Homeowners Association - Cainsway Mobile
Home Park 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
05-2022 001 Effluent Nitrogen, Ammonia Total (as 05/31/22 Weekly mg/I 2 2.16 7.9 Monthly Average Proceed to NOD
N) - Concentration Exceeded
07-2022 001 Effluent Nitrogen, Ammonia Total (as 07/31/22 Weekly mg/I 2 4.26 112.9 Monthly Average None
N) - Concentration Exceeded
Monitoring Violation
MONITORING VIOLATION UNIT OF CALCULATED
REPORT OUTFALL LOCATION PARAMETER DATE FREQUENCY MEASURE LIMIT VALUE Over VIOLATION TYPE VIOLATION ACTION
12 - 2020 001 Effluent BOD, 5-Day (20 Deg. C) - 12/05/20 Weekly mg/I Frequency Violation No Action, BPJ
Concentration
01-2018 001 Effluent Coliform, Fecal MF, MFC 01/20/18 Weekly #/100m1 Frequency Violation No Action, BPJ
Broth, 44.5 C
12 -2020 001 Effluent Coliform, Fecal MF, MFC 12/05/20 Weekly #/100m1 Frequency Violation No Action, BPJ
Broth, 44.5 C
01 -2019 001 Effluent Flow, in conduit or thru 01/14/19 Continuous mgd Frequency Violation Proceed to NOD
treatment plant
05 -2019 001 Effluent Flow, in conduit or thru 05/18/19 Continuous mgd Frequency Violation Proceed to NOD
treatment plant
05 -2019 001 Effluent Flow, in conduit or thru 05/19/19 Continuous mgd Frequency Violation Proceed to NOD
treatment plant
07 - 2020 001 Effluent Flow, in conduit or thru 07/18/20 Continuous mgd Frequency Violation No Action, BPJ
treatment plant
07 - 2020 001 Effluent Flow, in conduit or thru 07/19/20 Continuous mgd Frequency Violation No Action, BPJ
treatment plant
12-2020 001 Effluent Nitrogen, Ammonia Total (as 12/05/20 Weekly mg/I Frequency Violation No Action, BPJ
N) - Concentration
10-2021 001 Upstream Oxygen, Dissolved (DO) 10/02/21 Weekly mg/I Frequency Violation No Action, BIMS
Calculation Error
11-2017 001 Effluent pH 11/04/17 Weekly su Frequency Violation Proceed to NOD
12-2020 001 Effluent Solids, Total Suspended - 12/05/20 Weekly mg/I Frequency Violation No Action, BPJ
Concentration

MONITORING REPORT(MR) VIOLATIONS for:
Report Date: 09/01/22 Page 3 of 3
Permit: nc0075027 MRs Betweei 4 - 2017 and 9 - 2022
Facility Name: % Param Nam( %
Major Minor: %
Region:
County: %
Violation Category:%
Subbasin:%
Program Category: %
Violation Action: %
PERMIT: NC0075027
FACILITY: Cainsway Homeowners Association - Cainsway Mobile
Home Park WWTP
COUNTY: Forsyth
REGION: Winston-Salem
Monitoring Violation
MONITORING
REPORT OUTFALL
LOCATION
PARAMETER
VIOLATION UNIT OF
DATE FREQUENCY MEASURE
LIMIT
CALCULATED
VALUE
Over
VIOLATION TYPE
VIOLATION ACTION
06-2017 001
10-2021 001
Reporting Violation
MONITORING
REPORT OUTFALL
Effluent
Upstream
LOCATION
Temperature, Water Deg.
Centigrade
Temperature, Water Deg.
Centigrade
PARAMETER
06/03/17 5 X week
10/02/21 Weekly
deg c
deg c
VIOLATION UNIT OF
DATE FREQUENCY MEASURE
LIMIT
CALCULATED
VALUE
Over
Frequency Violation
Frequency Violation
VIOLATION TYPE
Proceed to NOD
No Action, BIMS
Calculation Error
VIOLATION ACTION
08-2017
11 -2017
09-2021 001
10/01/17
12/31/17
Upstream Oxygen, Dissolved (DO) 09/30/21 Weekly
mg/I
Late/Missing DMR
Late/Missing DMR
Sampling Location
Missing
None
No Action, BIMS
Calculation Error
Proceed to NOD

PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Water Resources
ENVIRONMENTAL QUALITY
Memorandum
To: NPDES Complex Unit
From: Tom Belnick
Date: July 20, 2016
Subject: NPDES Permitting Guidance
NPDES Implementation of Ammonia Criteria- Update
secrermry
S. JAY ZIMMERMAN
Director
NC has still not adopted an ammonia standard, though it is on our WQS Triennial List for next
round. NC did establish ammonia chronic criteria for use in NPDES permitting back in 1989/90,
which was based on EPA's 1986 criteria development document that factored in pH/Temp across
three regions of the State (see attached). This evaluation resulted in ammonia chronic criteria of
1.0 mg/1 NH3-N (summer) and 1.8 mg/1 NH3-N (winter) for use in permitting purposes. NC
implements these chronic criteria as Monthly Averages limits utilizing instream dilution. In
2002, NC developed procedures for complimentary acute permit limits (discussed below).
The current ammonia permitting procedures should be as follows:
• The NH3/TRC Wasteload Allocation (WLA) spreadsheet automatically calculates
appropriate ammonia Monthly Average limits for summer and winter. The spreadsheet
assumes a background ammonia concentration of 0.22 mg/1.
• For any permit (new/renewal), always run the NH3/TRC WLA spreadsheet to verify
appropriate Monthly Average Ammonia Limits for protection of aquatic life.
• If the allowable ammonia concentration is greater than 35 mg/1, no limit should be
imposed.
• If the allowable concentration is less than 35 mg/1, then the allowable limit is needed and
the spreadsheet will automatically calculate it.
• For Municipal facilities, the acute limit will be expressed as a Weekly Average, and is
based on multiplying the Monthly Average limit by a factor of 3.
• For non -Municipal facilities, the acute limit will be expressed as a Daily Maximum, and
is based on multiplying the Monthly Average limit by a factor of 5.
• If a new more stringent ammonia limit is required, discuss the need for a Compliance
Schedule with senior staff and then with the Permittee.
• There is no RPA procedure used for ammonia; it is implemented strictly based on WLA
spreadsheet results (similar to TRC).
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919 707 9000

Page 12
• A sample NH3/TRC WLA is attached. In this example, the spreadsheet indicates that
Monthly Average ammonia limits of 3.2 mg/1 and 12.7 mg/1 should be imposed for
summer and winter, respectively, in order to protect for NC's chronic ammonia criteria.
Some additional considerations:
• This guidance will need to be revisited after NC formally adopts an ammonia standard for
both chronic and acute aquatic life protection.
• In the past, some ammonia limits were based strictly on protection of our DO standard
rather than ammonia toxicity, and that is why the permit writer should always verify the
correct ammonia limit with any permit renewal using the WLA spreadsheet.
• In the past, some practices allowed for maintaining a less stringent ammonia limit if the
facility was consistently passing the WET test (i.e., biology trumps chemistry). This is
no longer a valid approach and EPA would object. In April 2016 EPA expressly stated
that NC cannot use biology to override chemical results. EPA also disallowed the use of
Action Levels in permitting, in which toxicity test results (if passing) were used to
override the need for permit limits for copper/zinc/silver/iron/chloride.

AMMONIA CRITERIA TABLES (NH3 as N)
Based on EPA recommended 4-day maximum average concentration criteria
and Trout 'Waters
pH
6.8
7.5
TEMPERATURE
12°C 23°C .
1.8084 1.0028
1..8084 1.0111
Total Ammonia
(mg/I NH3 as N)
Piedmont Freshwaters
pH
2 6 °C %`
046 t�� .,0044 n^Iona ed'
. J44 .,. `� 0414
TEMPERATURE
14°C 26°C
6.8
7.5 •
1.8084 1.1344
1.8084 1.1541
Total Ammonia
(mg/1 NH3 as N)
Coast:alj Plain and Sandhills Freshwaters
•pH
6.8
7.5
TEMPERATURE
16°C • 28°C
1.7920 0.9700
1.7920 0.9864
•
(Un�� ifr�riit% �o���ia
fmgV1/N?,'a
Total Ammonia
(mg/1 •NH3 as N)
\A) mim Sonme4
10/19/89
1.8 mil/

NH3/TRC WLA Calculations
Facility: Anywhere USA
NC00
Prepared By: Tom Belnick
Enter Design Flow (MGD):
Enter s7Q10 (cfs):
Enterw7Q10 (cfs):
0.03
0.13
0.32
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)
0.13
0.03
0.0465
17.0
0
26.35
65
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)
3.80 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); capped at 35 mg/I
3. Monthly Avg limit x 5 = Daily Max limit (Non-Munis); capped at 35 mg/I
0.13
0.03
0.0465
1.0
0.22
26.35
3.2
0.32
0.03
0.0465
1.8
0.22
12.69
12.7
Fecal Coliform
1. Monthly Avg limit x 2 = 400/100 ml = Weekly Avg limit (Municipals) = Daily Max limit (Non -Muni)

From:
To:
Subject:
Date:
Charles Cain
Chen, Siyinq
[External] Re: NPDES Permit Issuance - Cainsway Mobile Home Park WWTP NC0075027
Thursday, November 17, 2022 11:46:51 AM
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to Report Spam.
Yes Ms. Siying Chen, I have received the permit and down loaded it and copied . Thanks Darrell Cain
Original Message
From: Chen, Siying <[e-mail]>
To: [e-mail] <[e-mail]>
Cc: Snider, Lon <[e-mail]>; Graznak, Jenny <[e-mail]>; Flynt, Bradley
<[e-mail]>; Weaver, Charles <[e-mail]>
Sent: Thu, Nov 17, 2022 11:00 am
Subject: NPDES Permit Issuance - Cainsway Mobile Home Park WWTP NC0075027
Hi Mr. Cain,
Attached is the final NPDES permit renewal for Cainsway Mobile Home Park WWTP (NC00750271).
The permit will be effective on January 1, 2023.
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 Chen (she/her/hers)
Environmental Specialist, Division of Water Resources
North Carolina Department of Environmental Quality
Office: [phone]
siying.chenPncdenr.gov

rrint All Pages
Print Form Only
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
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

NPDES Permit Number
NC0075027
Facility Name
Cainsway HOA
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
1
IC APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.21(j)(1) and (9))
Facility name
Cainsway
Mailing address (street or P.O. box)
P.O. Box 846
City or town
Walkertown
State
NC
ZIP code
27051
Contact name (first and last)
Daryl Cain
Title
HOA President
Phone number
[phone]
Email address
[e-mail]
Location address (street, route number, or other specific identifier)
Pinehall Road
❑ Same as mailing
address
City or town
North of Walkertown
State
NC
ZIP code
27051
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
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
1
applicant the facility's owner, operator, or both? (Check only one response.)
Owner ❑ Operator ❑ Both
1.5
To which entity should the NPDES permitting authority send correspondence? (Check
❑ Facility ❑ Applicant
✓
only one response.)
Facility and applicant
(they are one and the same)
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
water)
❑ 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
NC0075027
Facility Name
Cainsway HOA
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 0 Maintain
125
% combined storm and sanitary sewer
0 Own 0 Maintain
0 Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own ❑ Maintain
% combined storm and sanitary sewer
0 Own ❑ Maintain
❑ Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 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 0 Maintain
Total
Population
Served
125
❑ Unknown
0 Own 0 Maintain
Separate Sanitary Sewer System
Combined Storm and
Sanitary Sewer
Total percentage of each type of
sewer line (in miles)
100 %
0
/o
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
.0432 mgd
Annual Average Flow Rates (Actual)
Two Years Ago
Last Year
This Year
mgd
mgd
mgd
Maximum Daily Flow Rates (Actual)
Two Years Ago
Last Year
This Year
mgd
mgd
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
NC0075027
Facility Name
Cainsway HOA
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.
✓ 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
0 Intermittent
gpd
0 Continuous
0 Intermittent
1.14
Is wastewater applied to land?
❑ Yes
4 SKIP to Item 1.16.
✓ 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)
acresgpd
❑ Continuous
❑ Intermittent
acresgpd
❑ Continuous
❑ Intermittent
acresgpd
❑ Continuous
❑ Intermittent
1.16
Is effluent transported to another facility for
❑ Yes
treatment prior to discharge?
4 SKIP to Item 1.21.
1 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?
❑ Yes ❑ No 4 SKIP to Item 1.20.
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
NC0075027
Facility Name
Cainsway HOA
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
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
NPDES number of receiving facility (if any) 0 None
Average daily flow rate mgd
1.21
Is the wastewater disposed of in a manner other than
not have outlets to waters of the State of North Carolina
❑ Yes
✓
those a ready 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)
acres
gpd
❑ Continuous
❑ Intermittent
acresgpd
❑ Continuous
❑ Intermittent
acres
gpd
❑ 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 wastewater treatment and effluent quality) of the treatment works
responsibility of a contractor?
Yes ❑ No 4SKIP to Section 2.
1.25
Provide location and contact information for each contractor in addition to a description of the contractors operational
and maintenance responsibilities.
Contractor Information
Contractor 1
Contractor 2
Contractor 3
Contractor name
(company name)
Bradley Flynt
Mailing address
(street or P.O. box)
8467 southard Road
City, state, and ZIP
code
Stokesdale, NC 27357
Contact name (first and
last)
Bradley Flynt
Phone number
[phone]
Email address
bradley.flynt@greensboro-nc.€
Operational and
maintenance
responsibilities of
contractor
All operations and some
mantenance
Page 4

SECTION
o
2. ADDITIONAL INFORMATION
Outfalls to Waters of
NPDES Permit Number
NC0075027
(40 CFR 122.21(j)(1) and
the State of North Carolina
Facility Name
Cainsway HOA
(2))
Modified Application Form 2A
Modified March 2021
2.1
Does the treatment works have a design
❑ Yes
flow greater
than or equal to 0.1 mgd?
No 4 SKIP to Section 3.
0
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/DD/YYYY)
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
NC0075027
Facility Name
Cainsway HOA
Modified Application Form 2A
Modified March 2021
Description of Outfalls
ORMATION ON EFFLUENT DISCHARGES (40 CFR 122.21(j)(3) to (5))
Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number o01
Outfall Number
Outfall Number
State
North Carolina
County
Forsyth
City or town
Walkertown
Distance from shore
5 ft.
ft.
ft.
Depth below surface
0 ft.
ft.
ft.
Average daily flow rate
.007 mgd
mgd
mgd
Latitude
°
Longitude
"
Seasonal or Periodic Discharge Data
3.2
Do any of the outfalls described
❑ Yes
under Item 3.1 have seasonal 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 t pe at each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
Waters of
the U.S.
3.6
Does
one
✓
the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
or more discharge points?
Yes ❑ No 4SKIP to Section 6.
Page 6

NPDES Permit Number
NC0075027
Facility Name
Cainsway HOA
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 001
Outfall Number
Outfall Number
Receiving water name
Ader Creek
Name of watershed, river,
or stream system
Roanoke
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 001
Outfall Number
Outfall Number
Highest Level of
Treatment (check all that
apply per outfall)
0 Primary
0 Equivalent to
secondary
0 Secondary
❑ Advanced
❑ 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
85
TSS
93 %
%
Phosphorus
I Not applicable
%
0 Not applicable
0 Not applicable
Nitrogen
0 Not applicable
%
0 Not applicable
0 Not applicable
Other (specify)
0 Not applicable
ok
0 Not applicable
%
0 Not applicable
ok
Page 7

NPDES Permit Number
NC0075027
Facility Name
Cainsway HOA
Modified Application Form 2A
Modified March 2021
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
o01
Outfall Number
Outfall Number
Disinfection type
Hypochlorite Tablets
Seasons used
all
Dechlorination used?
❑ Not applicable
❑ Not applicable
❑ Not applicable
✓
Yes
❑ Yes
❑ Yes
❑ No
❑ No
❑ No
Effluent Testing Data
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?
❑ Yes
No
sampling required by NPDES
authority.
✓ additional
permitting
Page 8

NPDES Permit Number
NC0075027
Facility Name
Cainsway HOA
Modified Application Form 2A
Modified March 2021
Effluent Testing Data Continued
3.19
Has the POTW conducted either (1) minimum of four quarterly WET tests for one year preceding this permit application
or (2) at least four annual WET tests in the past 4.5 years?
❑ Yes ❑ No 4 Complete tests and Table E and SKIP to
Item 3.26.
3.20
Have you previously submitted the results of the above
❑ Yes
tests to your NPDES permitting
No 4 Provide
authority?
results in Table E and SKIP to
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 how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
toxicity?
❑ Yes ❑ No 4 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
Not
package?
because previously submitted
NPDES permittin. authorit .
applicable
information to the
Page 9

NPDES Permit Number
NC0075027
Facility Name
Cainsway HOA
Modified Application Form 2A
Modified March 2021
cn
Checklist and Certification Statement
0
0 rn rn
N
2
ECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
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
❑ wl variance request(s) ❑ wl additional attachments
Information for All Applicants
❑ Section 2: Additional
Information
❑ wi topographic map ❑ wi process flow diagram
❑ wi additional attachments
❑ Section 3: Information on
Effluent Discharges
❑ w/ Table A ❑ wi Table D
❑ wi Table B ❑ wi additional attachments
❑ wl Table C
Section 4: Not Applicable
Section 5: Not Applicable
❑ Section 6: Checklist and
Certification Statement
❑ w/ attachments
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.
Name (print or type first and last name)
Bradley T. Flynt
Official title
ORC
Signature
Date signed
Page 10

NPDES Permit Number
Facility Name
Outfall Number
NC0075027
Cainsway HOA
001
Modified Application Form 2A
Modified March 2021
TABLE A. EFFLUENT PARAMETERS
Pollutant
FOR ALL POTWS
Maximum Daily Discharge
Average Daily Discharge
Analytical
Methods
ML or MDL
(include
units)
Value
Units
Value
Units
Number of
Samples
Biochemical oxygen demand
IllBOD5 or ❑ CBOD5
(report one)
22
mg/I
3.2
mg/I
36
❑ ML
❑ MDL
Fecal coliform
200/100m1
#/100m1
0
#/100
36
0 ML
❑ MDL
Design flow rate
.0432
mgd
.009
mgd
36
pH (minimum)
6
su
pH (maximum)
9
su
Temperature (winter)
deg. c
14.1
deg. c
21
Temperature (summer)
deg. c
23.2
deg. c
15
Total suspended solids (TSS)
30
MG/I
4.8
mg/I
36
0 ML
0 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
NC0075027
Facility Name
Cainsway HOA
Outfall Number
Modified Application Form 2A
Modified March 2021
TABLE B. EFFLUENT PARAMETERS
Pollutant
FOR ALL POTWS WITH A FLOW EQUAL
Maximum Daily Discharge
TO OR GREATER THAN 0.1 MGD
Average Daily Discharge
Analytical
Methods
ML or MDL
(include
units)
Value
Units
Value
Units
Number of
Samples
Ammonia (as N)
❑ ML
❑ MDL
Chlorine
(total residual, TRC)2
❑ ML
❑ MDL
Dissolved oxygen
CI ML
❑ MDL
Nitrate/nitrite
❑ ML
❑ MDL
Kjeldahl nitrogen
❑ ML
❑ MDL
Oil and grease
❑ ML
❑ MDL
Phosphorus
❑ ML
❑ MDL
Total dissolved solids
❑ 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).
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 Form 3510-2A (Revised 3-19)
Page 12

TABLE
EPA Identification Number
C. EFFLUENT PARAMETERS
Pollutant
NPDES Permit Number
NC0075027
FOR SELECTED POTWS
Maximum Daily Discharge
Facility Name
Cainsway HOA
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
Metals,
Cyanide, and Total Phenols
Hardness (as CaCO3)
❑ ML
0 MDL
Antimony, total recoverable
0 ML
❑ MDL
Arsenic, total recoverable
❑ ML
❑ MDL
Beryllium, total recoverable
❑ ML
❑ MDL
Cadmium, total recoverable
❑ ML
❑ MDL
Chromium, total recoverable
0 ML
❑ MDL
Copper, total recoverable
❑ ML
❑ MDL
Lead, total recoverable
❑ ML
❑ MDL
Mercury, total recoverable
❑ ML
❑ MDL
Nickel, total recoverable
❑ ML
❑ MDL
Selenium, total recoverable
❑ ML
❑ MDL
Silver, total recoverable
❑ ML
❑ MDL
Thallium, total recoverable
❑ ML
❑ MDL
Zinc, total recoverable
❑ ML
❑ MDL
Cyanide
❑ ML
❑ MDL
Total phenolic compounds
❑ ML
❑ MDL
Volatile Organic Compounds
Acrolein
❑ ML
❑ MDL
Acrylonitrile
❑ ML
❑ MDL
Benzene
❑ ML
❑ MDL
Bromoform
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19)
Page 13

TABLE
EPA Identification Number
C. EFFLUENT PARAMETERS
NPDES Permit Number
NC0075027
FOR SELECTED POTWS
Maximum Daily Discharge
Facility Name
Cainsway HOA
Average
Outfall Number
Daily Discharge
Modified
Analytical
Method1
Application Form 2A
Modified March 2021
ML or MDL
(include units)
Pollutant
Value
Units
Value
Units
Number of
Samples
Carbon tetrachloride
❑ ML
❑ MDL
Chlorobenzene
0 ML
❑ MDL
Chlorodibromomethane
0 ML
❑ MDL
Chloroethane
0 ML
❑ MDL
2-chloroethylvinyl ether
❑ ML
❑ MDL
Chloroform
0 ML
❑ MDL
Dichlorobromomethane
0 ML
❑ MDL
1,1-dichloroethane
❑ ML
❑ MDL
1,2-dichloroethane
0 ML
❑ MDL
trans-1,2-dichloroethylene
❑ ML
❑ MDL
1,1-dichloroethylene
❑ ML
❑ MDL
1,2-dichloropropane
0 ML
❑ MDL
1,3-dichloropropylene
❑ ML
❑ MDL
Ethylbenzene
0 ML
❑ MDL
Methyl bromide
0 ML
❑ MDL
Methyl chloride
❑ ML
❑ MDL
Methylene chloride
0 ML
❑ MDL
1,1,2,2-tetrachloroethane
❑ ML
❑ MDL
Tetrachloroethylene
❑ 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

TABLE
EPA Identification Number
C. EFFLUENT PARAMETERS
NPDES Permit Number
NC0075027
FOR SELECTED POTWS
Maximum Daily Discharge
Facility Name
Cainsway HOA
Average
Outfall Number
Daily Discharge
Modified
Analytical
Method1
Application Form 2A
Modified March 2021
ML or MDL
(include units)
Pollutant
Value
Units
Value
Units
Number of
Samples
Trichloroethylene
❑ ML
❑ MDL
Vinyl chloride
0 ML
❑ MDL
Acid -Extractable Compounds
p-chloro-m-cresol
❑ ML
❑ MDL
2-chlorophenol
0 ML
❑ MDL
2,4-dichlorophenol
❑ ML
❑ MDL
2,4-dimethylphenol
❑ ML
❑ MDL
4,6-dinitro-o-cresol
0 ML
❑ MDL
2,4-dinitrophenol
❑ ML
❑ MDL
2-nitrophenol
0 ML
❑ MDL
4-nitrophenol
0 ML
❑ MDL
Pentachlorophenol
❑ ML
❑ MDL
Phenol
0 ML
❑ MDL
2,4,6-trichlorophenol
❑ ML
❑MDL
Base -Neutral Compounds
Acenaphthene
❑ ML
❑ MDL
Acenaphthylene
0 ML
❑ MDL
Anthracene
❑ ML
❑ MDL
Benzidine
0 ML
❑ MDL
Benzo(a)anthracene
0 ML
❑ MDL
Benzo(a)pyrene
❑ ML
❑ MDL
3,4-benzofluoranthene
0 ML
❑ MDL
EPA Form 3510-2A (Revised 3-19)
Page 15

TABLE
EPA Identification Number
C. EFFLUENT PARAMETERS
NPDES Permit Number
NC0075027
FOR SELECTED POTWS
Maximum Daily Discharge
Facility Name
Cainsway HOA
Average
Outfall Number
Daily Discharge
Modified
Analytical
Method1
Application Form 2A
Modified March 2021
ML or MDL
(include units)
Pollutant
Value
Units
Value
Units
Number of
Samples
Benzo(ghi)perylene
❑ ML
❑ MDL
Benzo(k)fluoranthene
0 ML
❑ MDL
Bis (2-chloroethoxy) methane
❑ ML
❑ MDL
Bis (2-chloroethyl) ether
0 ML
❑ MDL
Bis (2-chloroisopropyl) ether
❑ ML
❑ MDL
Bis (2-ethylhexyl) phthalate
0 ML
❑ MDL
4-bromophenyl phenyl ether
0 ML
❑ MDL
Butyl benzyl phthalate
❑ ML
❑ MDL
2-chloronaphthalene
❑ ML
❑ MDL
4-chlorophenyl phenyl ether
❑ ML
❑ MDL
Chrysene
❑ ML
❑ MDL
di-n-butyl phthalate
❑ ML
❑ MDL
di-n-octyl phthalate
❑ ML
❑ MDL
Dibenzo(a,h)anthracene
❑ ML
❑ MDL
1,2-dichlorobenzene
❑ ML
❑ MDL
1,3-dichlorobenzene
❑ ML
❑ MDL
1,4-dichlorobenzene
❑ ML
❑ MDL
3,3-dichlorobenzidine
❑ ML
❑ MDL
Diethyl phthalate
❑ ML
❑ MDL
Dimethyl phthalate
❑ ML
❑ MDL
2,4-dinitrotoluene
❑ ML
❑ MDL
2,6-dinitrotoluene
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19)
Page 16

TABLE
EPA Identification Number
C. EFFLUENT PARAMETERS
NPDES Permit Number
NC0075027
FOR SELECTED POTWS
Maximum Daily Discharge
Facility Name
Cainsway HOA
Average
Outfall Number
Daily Discharge
Modified
Analytical
Method1
Application Form 2A
Modified March 2021
ML or MDL
(include units)
Pollutant
Value
Units
Value
Units
Number of
Samples
1,2-diphenylhydrazine
❑ ML
❑ MDL
Fluoranthene
0 ML
❑ MDL
Fluorene
❑ ML
❑ MDL
Hexachlorobenzene
0 ML
❑ MDL
Hexachlorobutadiene
❑ ML
❑ MDL
Hexachlorocyclo-pentadiene
❑ ML
❑ MDL
Hexachloroethane
❑ ML
❑ MDL
Indeno(1,2,3-cd)pyrene
❑ ML
❑ MDL
Isophorone
❑ 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

TABLE D. ADDITIONAL POLLUTANTS
NPDES Permit Number
NC0075027
AS REQUIRED BY NPDES PERMITTING
Maximum Daily Discharge
Facility Name
Cainsway HOA
AUTHORITY
Average
Outfall Number
Daily Dischar e
Modified
Analytical
Method
Application Form 2A
Modified March 2021
ML or MDL
(include units)
Pollutant
list
Value
Units
Value
Units Number of
Samples
•
No additional sampling is required by NPDES permitting authority.
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
1Sampling 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

Permit NC0075027
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 provisions 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, the
Cainsway Homeowners Association
is hereby authorized to discharge wastewater from a facility located at the
Cainsway Mobile Home Park WWTP
Pinehall Road
North of Walkertown
Forsyth County
to receiving waters designated as Ader 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 April 1, 2017.
This permit and authorization to discharge shall expire at midnight on February 28, 2022.
Signed this day March 15, 2017
S. Jay Zimmerman, P.G., Director
Division of Water Resources
By Authority of the Environmental Management Commission
Page 1 of 6

Permit NC0075027
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.
The Cainsway Homeowners Association
is hereby authorized to:
1. Continue to operate an existing 0.0432 MGD wastewater treatment system that
includes the following components:
♦ Aerated equalization basin
♦ Bar screen
♦ Splitter box
♦ Dual extended aeration basins
♦ Clarifier
♦ Tertiary filters
♦ Chlorinator
♦ Dechlorinator
The facility is located at Cainsway Mobile Home Park on Pinehall Road, north of
Walkertown, in Forsyth County.
2. Discharge from said treatment works via Outfall 001, at the location specified on
the attached map into Ader Creek [22-25-14-1] currently classified C waters in
subbasin 03-02-01 [HUC: 0301010302] of the Roanoke River Basin.
Page 2 of 6

Permit NC0075027
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
0.0432 MGD
Continuous
Recording
Influent or
Effluent
BOD, 5-day, (20°C) — Summer* C0310
11.0 mg/L
16.5 mg/L
Weekly
Composite
Effluent
BOD, 5-day, (20°C) — Winter* C0310
22.0 mg/L
33.0 mg/L
Weekly
Composite
Effluent
Total Suspended Solids C0530
30.0 mg/L
45.0 mg/L
Weekly
Composite
Effluent
NH3 as N — Summer* C0610
2.0 mg/L
10.0 mg/L
Weekly
Composite
Effluent
NH3 as N — Winter* C0610
6.0 mg/L
30.0 mg/L
Weekly
Composite
Effluent
Dissolved Oxygen 00300
Daily average > 5.0 mg/L
Weekly
Grab
Effluent
Fecal Coliform 31616
(geometric mean)
200/100 ml
400/100 ml
Weekly
Grab
Effluent
Total Residual Chlorine 2 50060
28 pg/L
2/Week
Grab
Effluent
Temperature (°C) 00010
Daily
Grab
Effluent
pH 00400
>6.0and<9.0
standard units
Weekly
Grab
Effluent
Dissolved Oxygen 00300
Weekly
Grab
Upstream &3
Downstream
Temperature (°C) 00010
Weekly
Grab
Upstream &3
Downstream
*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. The Division shall consider all effluent TRC values reported below 50 µg/1 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 µg/1.
3. Upstream = at least 100 feet above discharge point; Downstream = at NCSR 1979.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER THAN
TRACE AMOUNTS.
Page 3 of 6

Permit NC0075027
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.
Starting on December 21, 2020, the permittee must electronically report the following
compliance monitoring data and reports, when applicable:
Page 4 of 6

Permit NC0075027
• 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
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.
Page 5 of 6

Permit NC0075027
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:
"7 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.)l
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 6