WQ0003090_Monitoring - 10-2022_20221130

Monitoring Report Submittal
Permit Number #*
Name of Facility:*
Month: * October
Report Information
WQ0003090
Town of Liberty WWTP
Type *
NDMR, NDAR-1, NDAR-2, NDMLR
Confirmation Email Address:*
Name of Submitter: *
Signature:
Date of submittal:
Initial Review
Year:* 2022
Upload Document*
Tremaine (1).pdf 3.49MB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
[e-mail]
Elix Fike
spy
Reviewer: Gerald, Wanda
11 /30/2022
This will be filled in automatically

Is the project number correct?* WQ0003090
Is the monitoring report accepted?* Yes No
Regional Office* Winston-Salem
Reviewer: _anonymous
Review Date: 12/13/2022

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR)
Page _1_ of _1_
Permit No.: WQ0003090
Facility Name: Town Of Liberty - Wastewater
County: Randolph
Month: October
Year: 2022
PPI: 002 T-Flow
Measuring Point: 2 Influent El Effluent ❑ No flow generatedParameter Monitoring Point: ❑ Influent 0 Effluent ❑Groundwater Lowering ❑Surface Water
Parameter Code
p
00400
00610
K
31613
00625
50060
70300
00630
. . . . . . . . . .
>43
0
R
01a, U)
4",
41 +
2
0
w,
0 -6
M cc
E
F- Cn
CL
E
E
U.
16 z
F- Cn
Inv 11, z
0
U g
24-h r
0
hrs
su
mg/L
NINE
#/100 mL
mg/L
mg1L
mg/L
mg/L
0 101
1111
E5 W11,11
21
1
kk
3
1 7:00
8
41
7:00 1
8
5
1 7:00
8
k"j
011111
21 11
6
7:00
8
j
11
6.97
"M
13.2
24 20
g 15.8
0.1
Haw
XTWI.N&
<0.040
1
7
7:00
8
R
117"A 01
tj
�
NO
NI
N
A
8
10
7:00
8
a
8
N
11
12
7:00
7:00
8
13
7:00
8
7.32
k
U
0.12
14
7:00
15
14:00
2
A
161
12:00
2
171
7:00
8
71
7:00
1 8
WIN
W 1
a
181
8
W
191
201
7:00
7:00
1
1 8
7.05
�R V BA,�
17.5
2420
2 7.5
"'AR
0.11
0
0. 93
4-
211
7:00
1 8
221
15:00
2
All
231
13:00
2
"d
241
7:00
8
251
7:00
8
M,
RN
261 7:00 8
!"a
""R
271 7:00 8
0.1
4
281 7:00 8
Og
k
291
N,"a UM
301
N
A
31 7:00 8
Average:
15.35
2,42C )00
#REF!
0.11
0.05
Daily Maximum:
Y",
7.43
17.50
2,420.00
*R F!
0.12
0.09
Daily Minimum:
6.97
13.20
2,420.00
#REF!
0.10
0.04
Sampling Type:
Grab
Grab
Grab
Grab
Grab
311",
Grab
"i
Monthly Avg. Limit:
"I
010, n
. ..... oq
Dail Limit
.......
.....
U
M
IV e
Sample Frequency:
weekly
2x month
"', #� , 2x month
`,;� "
eekly
3x year
2x month

FORM: NDMR 10-13
NON -DISCHARGE MONITORING REPORT (NDMR)
Sampling Person(s) Certified Laboratories
Name: GLENN PRICE Name: PACE ANALYTICAL
Name: GARRETT DREYER Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your perrnir? U Compliant <J Non -Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
antion(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC:
Elix Tremaine Fike
Permittee: Scott Kidd
Certification
No.: 989290
Signing Official:
Grade:
SI Phone Number: 336 622 2990
Signing Official's Title: Town Manager
Has the ORC changed since the previous NDMR? ❑ Yes 0 No
Phone Number: 336 622 4276 Permit Expiration: 8/31 /2024
izi
Signature Date
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
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 all qualified personnel properly gathered and evaluated 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

aceAna1 y ical 0
`
www,pacelabs.com
i
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
(704 )977-0981
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92629783
Page 1 of 1
Report Date: 10/18/2022
Date Received: 10/06/2022
Sample: Effluent
Method
Parameters
Lab ID: 92629783001 Collected: 10/06/22 13:05 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
SM 2540D-2015
Total Suspended Solids
24.0
mg/L
5.6
10/07/22 19:22
EPA 353.2 Rev 2.0 1993
Nitrogen, NO2 plus NO3
ND
mg/L
0.040
10/07/22 09:49
EPA 353.2 Rev 2.0 1993
Nitrogen, Nitrate
ND
mg/L
0.040
10/07/22 09:49
EPA 353.2 Rev 2.0 1993
Nitrogen, Nitrite
ND
mg/L
0.040
10/07/22 09:49
SM 521OB-2016
BOD, 5 day
17.9
mg/L
2.0
10/12/22 11:40
Colilert-18
Fecal Coliforms
2420
MPN/100ml-
1.0
10/07/22 12:56
Performed by
PACE
10/06/22 13:05
Collected By
Garrett
10/06/22 13:05
Dreyer
Collected Date
10/06/22
10/06/22 13:05
Collected Time
1305
10/06/22 13:05
pH
6.97
Std. Units
10/06/22 13:05
Chlorine, Total Residual
0.10
mg/L
10/06/22 13:05
TKN+NO3+NO2
Total Nitrogen
15.8
mg/L
0.040
10/17/22 15:35
Calculation
EPA 350.1 Rev 2.0 1993
Nitrogen, Ammonia
13.2
mg/L
0.30
10/13/22 15:31
EPA 351.2 Rev 2.0 1993
Nitrogen, Kjeldahl, Total
15.8
mg/L
0.50
10/14/22 05:16
EPA 365.1 Rev 2.0 1993
Phosphorus
2.9
mg/L
0.050
10/17/22 21:07
Reviewed by:
C��f'P�LFnu��ll �:eC�
Stephanie Knott
704-977-0981
[e-mail]
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
North Carolina Drinking Water Certification #: 37712
North Carolina Wastewater Certification #: 40
Pace Analytical Services Eden
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
South Carolina Laboratory ID: 99030
South Carolina Certification #: 99030001
Virginia/VELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
VirginiaNELAP Certification #: 460025
Page 1 of 3

; i ���t�-� -CUSTODY Ana!yt'scaf Request Document
cenalyttcai
Chain -of -Custody is a LEGAL DOCUMENT -Complete all relevent fields
`Company: Town of Liberty i
Billing Information:
Address:
ReportTo:
€ Email To:
Copy To:
Site Collection info/Address-
Customer Customer Project Name/Number:
€State: County/City: Time Zone Collected:
/ [ ]PT[ ]MT[ ]CT [ ]ET
Phone:
Site/Facility ID #: Compliance Monitoring?
[ Yes ( ] No
Email:
Cojlected B rint):
d Purchase Order #: DW PWS ID #:
Quote #: DW Location Code:
Collec
[Turnaround Date Required: imme lately Pack on Ice:
] Yes [ ] No
ple Disposal•
{{ Rush: I Field Filtered (if applicable):
Yes [ ] No
( ] Dispose as appropriate (J Return
i [ ] Same Day [ ] Next Day [ ]
[ J Archive:
s [ ] 2 Day [ ] 3 Day [ ] 4 Day [ j S Day Analysis:
( J Hold:
(Expedite Charges Apply)
` Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
0-4-1 1oti cn uc Ii i M 1 nil MI) Wine (WP). Air (AR). Tissue ITS), Bioassay (B), Vapor (V), Other (OT)
.
,...; WOA'.yGbG7ta� .�,. ,,
1111111II�III IIIIIIII
Container Nreservative Type "
Lab Protect Manager:
u i 2.s._ 18,_�
*' Preservative Types: (1) nitric acid, (2) sulfvrc acid, (3)hydrochloric
acid, (4) sodium hydroxide, (5) zinc acetate,
(6) methanol, (7) sodium bisulfate, (8) sodium thiosuffate,
(9) hexane, (A) ascorbic acid, (B) ammonium sulfate,
(C)ammonium hydroxide,(D) TSP,(U) Unpreserved,(0) Other 's
Analyses
Lab Profife/Line
Lab Sample Rrc,ip.
r(
Y t
[
K � e
Cas od, 8irrnttures nz�r:e:lt
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Collector si�atx�e uses t
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€
t [[q (
.. correct Bottles
1
Sufficient volume
�Y7
samples Received on ice PA,
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€ 10,ik uead_pa a Acceptable
USDA Regulated Soils
O
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Re nau LCs' rzo xfsrrt _'
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Sample o't Aa ag Y -' NA
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Customer Sample ID ( Matrix *
€
�EfFluent WW
Comp J [ Collected (or
( ) Composite End
Grab Composite Start
Res # of h= i Z ' ( [ Lab sample it : comments'.
iv E I
Cl Ctns 0 ,
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m Z Ls: a E- ] -_
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5 XX
Date
9 Jb 8tii-
Time Date
65�
Time
Customer Remarks / Special Conditions / Possible Hazards: Type of ice Used: ' WeV " Blue ury None (�nvn i, rlvt.uz rrncacia r €­ „--i
Packing Material Used: A �E Lab Tracking#:
Effluent Monitoring — • —� —:
��'samples received via:
Radchem sample(s) screened [dSC}O cpm): Y N ` NSA FEDFSC UPS Client Court Pace Courier
Relinquish r ure) {Date/Time: Re ' ,d� y/Compan',, (Signatur Date/Time: M��d i
Table fZ.
iiAcum:
squished b r, pany: (Signature) ---_ Dat /Time: iReceived'Dy/ or pany: (Signature) Date/Time: " iETemp late:
CD 1
ro s ;Prelogin:
Relrw et d by/Company: (Signature) : Date/Time: Received by/Company: (Signature) w i Date/Time: pM
aM
Temp Blank Received: Y NA
Therm 10# 6
Cooler 2 Tem U an Receipt (y oC
Cooler I Therm Corr, Factor:" i
moC
Cooler I. Corrected Temp: oC
Comments:
Trip Blank Received: Y N NA
HCL McOH TSP Other
Non Confonnance(si Page:
YES NO of:

B tale Irl nt{fic3z{nn Form (3{Fj r3 ;� 1 a
1. �,u iC�i it Ply l ji r3 :i
F•CAR CS-043-Rxv.C1 c C'I _, _,
'Check mar" top halt of box if pN and/or is
verified and within the acceptance rang' for preservation
samples.
E.tcePticr, VC-', Cnli;cr,-�t, T.',C, 01 3;,' C eat., DRO"'3015 CCC, U HE
'Bottom half of box is to list number of bottles
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Sample ID
Type of PreServ:ative
pH upon receipt
Cate preservation adjusted
Time preservation
adjusted
Amount of Preservative
added
tot ft
—
w,,r,: vvne,ieva L.—e 1� a u;x:. pdn�y a: ,ea{ng r+o, m �-ara{na compnance samples, a Copy of this form :vill he lent to the North Carolina DEHNR Ca iiica;icn Qnc�a ji,e.
Out of hold, incorre preservative, out of temp, incorrect containers.
Page 3 of 3

aceAnal�/fical o
J`
/ www.pacelabs.com
i
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92631046
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 10/17/2022
Date Received: 10/13/2022
Sample: Effluent
Method Parameters
Lab ID: 92631046001 Collected: 10/13/22 14:25 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
Performed by
PACE
10/13/22 14:25
Collected By
Garrett
10/13/22 14:25
Dreyer
Collected Date
10113/22
10/13/22 14:25
Collected Time
1425
10/13/22 14:25
pH
7.32 Std. Units
10/13/22 14:25
Chlorine, Total Residual
0.12 mg/L
10/13/22 14:25
n1iFi>ue 1Y
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 2

C HAIN-CF-CUSTODY Analytical Request Docomen"t i
Chain -of -Custody is a LEGAL DOCUMENT- Complete all relevent fields
Company ___:_' Billing information:
Town of Liberty
Report To: Email To:
Copy To: Site Collection Info/Address:
Customer Project Name/Number: State: County/City:
Time Zone Collected:
[ ]PT[ ]MT[ jCT [ JET
Uil B USE 0 N, L y - A, *i x �! zllr! C C" & L' 7 ' Acgilt I.-fere o., U,, Pz;cc! ','Jcrkoroei Nt;robt- o;-
MTP_ :Number Hern
W g 01 # 9" 2" 63' 10 94 6
ALL SHAI
Container Preservative I
Preservative Types: (1) nitric acid, (2) su 92631046
(G) methanol, (7) sodium bisulfate, (8) sodium rn]OSUITILU, t�j . ..........
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
f Phone,
1SIte/FacilitylD4:
compliance monitoring?
E m'.'i 1T
/Yes ]No
cted B Purchase Order
DW PWS ID #:
Quote #:
DW Location -Code:
Co - ed
Turnaround Date Required:
Immediately Packed on Ice:
Yes ]No
e I i a
Rush:
Field Filtered (if applicable):
Dispose as appropriate Return Same Day Next Day
[ ] Yes ]No
Archive: __
Hold:_—
. [ ]ZDay [ ]3Day 14Day 5 Day
(Expedite Charges Apply)
Analysis: NN
1:2
0
7
Matrix Codes (insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (INW), tt I I ­E
im c:nillqniieq fq i nil (011 Wine (WPI. Air (ARI, Tissue ITS), Bioassay (B), Vapor (V), Other (OT)
Custody _Seals Present/Intact
Y M' ,
C,,,tcdy Si,g.t,=ea Present
Y NA
Coll(-ctor Fjyntturc Present
Y X NA
Bottle-s intact
N NA
Cr Bottles
y 14 NA
_nt V-olum e
Suffic dent
y N "M
'3amples Received or. Ice
von Neadspace Acceptable
y to Wrk
tiSDA Regulated
V N W_
Sampleo in Hold:Lxic; Time
Y N VIA
Fesidual C1111orine Present
Y, to NA
Cl strips:
Sanrp10 ptf Aaaeptable
pF Strips
ride preaont
NA
Lead Acetate Stripe;
LT- R USE ONLY,
Customer Sample ID matrix
Como Collected (or
Grab CompositeStart)
Date Time
r"u
Composite End
Composite
"L
Res
C
= i Lab Sample # 1 Col=crlto:
of
tns —
3:
Pate Time
E jWW
9
X_ X, t
Ebj-----�—
-' —�"�`"
--fit"'_
_ j____•__i__—__ i��-----�.�..!
(
. .. .. ........ .
... ._.......�.� ...�..,.. .....,�.» �..,�».� ....,._. ..— ,. ..s
T.
Customer Remarks / Special Conditions Possible Hazards: !Type of ice Used: 'Net Blue Dry None MULOZ) J'NtZ='41 tcf4 FTUIJTZ�>J: I N "/- I -- _­­- �­ -I,-,---
Temp, Blank Received:
Y N NA
Packing Material Used: i Lab Tracking #:
Therm 1lan04.
Cooler I Temp Upon Receipt., oC
Effluent Monitoring,Samples received via Cooler I Therm Corr. Factor: —oc
kadchem sample(s) screened (<500 cpm): Y N NA FEDEX UPS Client Courier p eace Courier j Cooler I Corrected Temp: cC
MTJL LAB USE ONLY Comments:
i atone) �Date/Time_- LRece�ived by/Company: (Signature) t Date/Time:
3
L
IK C or (Signature}
I iTempfate!
ed by/Company: (Signature) 0 7t e//Ti m a: Received by/Company: mpany: Date/Time: Trip Blank Received', Y N NA
(D Prelogln;
HCL MeCH TSP Other
i �
2eSaquished by/Company: (Signature) Date/Time: Received by/Company: (Signature) Date/Time: j PM: Non ConfOrmance(s): Page�
ri P B: YES I NO of:

laceAnalyfical"'
www.pacelabs.com
i
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92632256
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 11/02/2022
Date Received: 10/20/2022
Sample: Effluent
Method
Parameters
Lab ID: 92632256001 Collected: 10/20/22 12:35 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
HACH 10206
Nitrogen, Nitrate
ND
mg/L
0.30
10/21/22 09:30
SM 254OD-2015
Total Suspended Solids
42.4
mg/L
8.6
10/24/22 10:49
SM 521OB-2016
BOD, 5 day
31.6
mg/L
2.0
10/26/22 11:49
Colilert-18
Fecal Coliforms
2420
MPN/100mt-
1.0
10/21/22 13:57
Performed by
PACE
10/20/22 12:35
Collected By
Garrett
10/20/22 12:35
Dreyer
Collected Date
10/20/22
10/20/22 12:35
Collected Time
1235
10/20/22 12:35
pH
7.05
Std. Units
10/20/22 12:35
Chlorine, Total Residual
0.11
mg/L
10/20/22 12:35
TKN+NO3+NO2
Total Nitrogen
27.6
mg/L
0.040
10/31/22 15:11
Calculation
EPA 350.1 Rev 2.0 1993
Nitrogen, Ammonia
17.5
mg/L
0.50
10/28/22 13:29
EPA 351.2 Rev 2.0 1993
Nitrogen, Kjeldahl, Total
27.5
mg/L
2.5
10/28/22 06:08
EPA 353.2 Rev 2.0 1993
Nitrogen, NO2 plus NO3
0.093
mg/L
0.040
10/31/22 11:26
EPA 365.1 Rev 2.0 1993
Phosphorus
4.0
mg/L
0.050
10/27/22 19:16
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
North Carolina Drinking Water Certification #: 37712
North Carolina Wastewater Certification #: 40
Pace Analytical Services Eden
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
South Carolina Laboratory ID: 99030
South Carolina Certification #: 99030001
VirginiaNELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
VirginiaNELAP Certification #: 460025
Page 1 of 3

LAB USE ONLY -Affix Workorder/Login Label Here or List Pace Workorder Number or
rw
.'-FaceAnalvtical
Company: Town of Liberty
Address:
Report To:
Copy To:
Customer Project Name/Number:
Phone:
Email:
Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fields
Billing lnfjrm;.t,-1
iuuuiimiuiiiuu
92632256
Email To: — Preservative Types: (1) nitric acid, (2) sulf,
(6) methanol, (7) sodium bisulfate, IS) sodium thiosullate, (9) hexane, (A) ascorbic acid, (B) ammonium sulfate,
Site Collection Info/Address: (C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) other_
Analyses gLab Profile./Line:
State: County/City: Time Zone Collected: Lab Sample Receipt Checklist.
[ ]PT[ ]MT[ ]CT ET Custody Seale Prereat/lntacL Y&RA
Site/Facility ID #:
Compliance Monitoring7 l Custody Siquacurer Prereritt (0> �'T ?2A
Yes )No Collector Sigrature Eresen 3�7s NA
sottlee
Purchase Order #: DW PWS to 9: Correct Bottles AT tIA
Quote DW Location Code: rufficier.t Volume (fp t; - N A
Samples Received oo ice (r)tl riA
im-m-e-diately Packed on ice: vox - Beadspace P-icceptable -Ir N
Turnaround Date Required: I I 1- 11 11 . a,
Yes ]No
2
0
1
— cfJU ate 0 5
samples i;i holdirq Time
Residual Chloria C1 strip6; e Pie e-l"
T
VN f4A
1� to
e Disposal: Rush: I Field Filtered (if applicable):
Dispose as appropriate Return Same Day [ ]Next Day ]Yes ]No
z
Samc;la OF Acceptible
r w tM
Archive: )2Day 13Day [ J4Day 5 Day t Analysis:
Hold: Expedite Charges Apply) I%;
0
z
0
z
I
11
tc3f£de Pres at -
T, Acetace stripe:
Matrix Codes (insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
Product Soil/Solid (SQ, Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (8), Vapor (V), Other (OT)
(d
I'll
-
:6
LAB USE ONLY-.
(P),
r
F-
2�
a)
Lab Sample Comments;
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Temp Blank Received . Y N NA i
Packing Material Used: Lab Tracking
Therm IDt,.
cc
Cooler 1 Temp Upon Receipt:
Effluent Monitoring "4 CC
Samples received via� Cooler I Therm Corr. Factor: —
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ourfer ace Courier� Cooler I Corrected Temp: -1111.�-oc
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r aceAnal�/fical
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www.pacelab$.com
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i
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92633314
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 10/27/2022
Date Received: 10/27/2022
Sample: Effluent
Method Parameters
Lab ID: 92633314001 Collected: 10/27/22 11:30 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
Performed by
PACE
10/27/22 11:30
Collected By
Garrett
10/27/22 11:30
Dreyer
Collected Date
10127122
10/27/22 11:30
Collected Time
1130
10/27/22 11:30
pH
7.43 Std. Units
10/27/22 11:30
Chlorine, Total Residual
0.10 mg/L
10/27/22 11:30
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 2

H I C N -C F 'STODY AnaiyticaI Requestum Docent
V
cal
Complete all reievent fields
Company: Town of Liberty i Bii;lng Information -
Report To:
Copy ­T I. -
Project Name/Number:
Phone
Email:
Site/Facility ID #:
LAB USE ONLY- Affix Workorder/LoRin Ubel Here orUstPace `vVc,rkorderNumber or
A A
WO#:924633314
ALL SHADE
Container
92633314
- Preservative Types:(!) nitric acid, (2) sulfuric aciu, tit r:yui­­w­
(6) methanol, (7) sodium bisulfate, (8) sodium thiosulfate, (9) hexane, (A) ascorbic acid. (8) ammonium sulfate,
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
Analyses Lab Profile/Line:
State: County/City: Time Zone Collected:
1. f Eab
Email To:
Site Collection -info/Address:
Purchase Order 44:
Quote 4:
Turnaround Date Required:
[JPT1 ]MT( JCT1 JET
custcdv Seals prent/lntact
YN la
Compliance Monitor!
Cus" od%, Sign atur,�u Preselit
y K NA
I /Yes ]No
t Present
Y NT KA
DW PWS ID #:
Bottles inte�:t
cOrre C t Bottles
y ZT NA
1: N �Z'
DW Location Code:
S ufficient 'volume
y N N'111
Samples 'Reoeived or ice
y N NA
Immediately Packed on Ice:
=% - Headspace AcceptaLle
y N Wi
Yes )No
USL�A B"equiated soi!8
y TEA
A
S&=21es -4n Holding Tim�
y k, N)"
�rr�ple Disposal: Rush: Field Filtered (if applicable): Residual Chlorine Present Y, N N"
I Dispose as appropriate Return Same Day Next Day ]Yes ]No
[ ]3Day J4Day [ ]5 Day Analysis- Sr pis
(Expedite Charges Apply) Semple pil P�C=epLablQ
I Archive: 12Day
]Hold: ri.
I Sul-P�id- Presrmt:. V N NA
Matrix Codes (Insertin Matrix box below): Drinking Water (DW), Ground Water(GW), Wastewater(WW), 75 Lea� A4!etate strips:
Product (P), Soil/Solid (SQ, Oil (OL), Wipe (WP), Air (AR), Tissue ITS}, Bioassay (B), Vapor (V), Other (0T) tl L,%B USE cltl!Y:
Comp/ Collected (or Res #of AD
Composite End LaiSarnale 9 / corrmanrss
Customer Sample ID Matrix 1 11 Grab Composite Start) Cl Ctns j 76
Date
iEffluent *W g 1047/1-17,
Time 9 Date Time
0X
_4
Customer Remarks / Special Conditions / Possible Hazards: Type of Ice Used; wet Blue Dry None SHORT HOLDS PRESENT (<72 hours), Y N N/A
* Effluent Monitoring
(Signature)
Packing Material Used: I Lab Tracking 0-
€Samplesreceived via'.
Radchem sample(s) screened (<500 cpm),, Y N NA FEDEX UPS Client Courier Pace Courier
Date/Time: lRe ved by/Company: (Signature) lDate/Time: MTJL LAB USE ONLY
i
Table 9:
Acctnum:
Jal:6/Time: I!Received by/CL,Yhpany.'(Signature) JDate/Time:
Reli�uished by/Company: (Signature,' Date/Time: Received by/Company: (Signature)
r')
me:
Lab Sample Temperature Into:
Temp Blank Received: Y N NA
Therm DO:
Cooler I Temp Upon Receipt: __oC
Cooler 1 Therm Corr. Factor: of
Cooler I Corrected TempoC
-
Comments:
Trip Blank Received: Y N NA
HCL MeOH TSP Other
Non Conformance(t): Page:
YES I NO :of:

NEW
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
October 2022
Liberty N.C.W.W.T.F.
Freeboard Lagoon Inches
24 1 /2
24 1 /4
24 R 4.0
19 3/4
19
18 3/4
18 1/2
18 1/4
18
17 3/4
17 1/2
17 1/4
17
16 3/4
16 1/2
16 1/4
16 R 0.3
15
15 1/4
15 1/4
15 1/2
15 1/2
15 1/4
15 1/2
15 3/4
15 3/4
15 1/2
16
16 1/2
16 1/4
16 1/4
TOTAL 4.3

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _1_ of _2_
Permit No.: W00003090
Facility Name: Town of Liberty - Wastewater
county: Randolph Month: October
Year: 2022
Field Name:
2
-
Field Name:
4
Did irrigation occur
'
Area (acres):
( )�
19.7SIP.
(acres):
Area acres
��
17.02
at this facility/.�t�
t
Cover Crop:
FESCUE
tr
�j x Cover Crop:FESCUE
j ��
�;K ¢'t�
a,,
111 -�, ia'
4 d
MW
Hourly Rate (in):
0.21
Hourly Rate (in):
0.21
Q YES ❑ No
Annual Rate (in):
52
1 'A ` ` �� Annual Rate (in):
52
"
Weather
Freeboard
Field Irrigated?
0 YES ❑ No
Field Irrigated?
❑ YES ❑ NO
g
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CL
°F
in
ft
ft
gal
min
in
in
' • 'z - gal
min
in
in
21
3
R
4
4
5
$
9
10
11
. �
12
v
13
&
141
15�1
r'
16
1.251
321,000
180
0.60
0.2019
A
18
C
58
s eta ¢t'
20
C
40
1.25
21
22
23
C
70
1.25
x s
321,000
180
0.60
j k
24
C
58
1.25
25
'�. y
i z
26
4tr. 4
», _, a
271
C
50
1.25
28
''.112 Px s
29
C
60
1.25
�� � }� a�� �' a,i
sri<+}nkc a 4sj k�iti a� i
4�ii�#iF� �G i ����,�� j�.
321,000
180
0.60
0.20`
30
31
CL
59
1.25,,
1 1 1,:.,
a�1� ,j�F . t �,ka,�i� 281,000
180
0.61
0.20
Monthly Loading:
963,000
1.80
a,mv.t ?,, `lr 281,000
0.61
12 Month Floating Total (in):
'�
22.20
,c
34.74

FORM: NDAR-1 10-13
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit? 2 Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? 2 Compliant ❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? ❑✓ Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? ElCompliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑✓ Compliant ❑ Non -Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC:
Elix Tremaine Fike
Permittee:
Scott Kidd
Certification No.: 989290
Signing Official:
Grade:
SI Phone Number: 336 622 2990
Signing Official's Title: Town Manager
Has the ORC changed since the previous NDAR-1? ❑ yes 2 No
Phone Number: 336 622 4276 Permit Exp.: 8/31/24
�
Signature Date
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
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 all qualified personnel properly gathered and evaluated 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _2_of_2_
Permit No.: W00003090
Facility Name: Town of Liberty - Wastewater
County: Randolph Month: October
Year: 2022
a v
eld Name:
Field
6
it F a
"��� "`���^ �
Field Name:
8
Did irrigation occur��
Area (acres):
15.1
Area (acres):
21.68
at this facility?
y
Cover Crop:
FESCUE
�, ,«
Cover Crop:
FESCUE
Hourly Rate (in):
0.21
Hourly Rate (in):
0.21
(] YES ❑ No
t.`�•
+. +a °
a. >
-
Annual Rate (in):
52�
` a
Annual Rate (in):
52
Weather
Freeboard
Field Irrigated?
❑ YES ❑ No
�� '
Field Irrigated?
❑ YES 0 NO
P `�
't` ..
N 'p
'6
E
?`
Y
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Of
E 07
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N
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E `°
'� n
E r n
R
�
� a
7 a
°F
in
ft
it
gal
min
in
in
I , , } i
v
gal
min
in
in
2
3
R
4._.�..�F;b,�,
\
10,
5
6
7
8
1013
;w
12
14
.
i \ t
31 ti
16
a `
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19
20
21
22
23
24
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261
\ aa. 1:4' tom,t•aah?�,x,:.'k�:i'Y�„Y�iP.<IkR
�'a
271
28
C
55
2917
�� � o�i�;ar •tiyrv`� � h'a:� ,�Aa. ,.a:_
�.,�,, 4;�>(z �., , ,},�,faa.�..y,,..��� r,..?v �'av;.. aka..,,
a . x�„a„f S
30
Monthly Loading:
0
0.00�
..a F
0
0.00
12 Month Floating Total (in):
28.57
xxxp
30.52

FORM: NDAR-1 10-13
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit?
2 Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? 2 Compliant ❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? ❑✓ Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? 0 Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? EJ Compliant ❑ Non -Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Elix Tremaine Fike
Permittee:
Scott Kidd
Certification No.: 989290
Signing Official:
Grade: SI Phone Number: 336 622 2990
Signing Official's Title: Town Manager
Has the ORC changed since the previous NDARA? ❑ Yes El No
Phone Number: 336 622 4276 Permit Exp.: 8/31/24
ZZ,
Z_
Signature Date
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
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 all qualified personnel properly gathered and evaluated 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617