#5371_2022_0622_TS_FINAL

INSPECTION REPORT ROUTING SHEET
To be attached to all inspection reports in-house only.
Laboratory Cert. #: 5371
Laboratory Name: SGWA
Date Mailed: ,
Special Mailing Instructions:

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
5371
Mr. Jason Melendez
SGWASA - WTP
415 Central Ave. Suite B
Butner, NC 27509-
NORTH CAROLINA
Environmental Quality
July 14, 2022
Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC
WW/GW LCB) Maintenance Inspection
Dear Mr. Melendez:
Enclosed is a report for the inspection performed on June 22, 2022 by Tonja Springer. Where
Finding(s) are cited in this report, a response is required. Within thirty days, please supply this
office with a written item for item description of how these Finding(s) were corrected. Please
describe the steps taken to prevent recurrence and include an implementation date for each
corrective action. If the Finding(s) cited in the enclosed report are not corrected, enforcement
actions may be recommended. For Certification maintenance, your laboratory must continue to
carry out the requirements set forth in 15A NCAC 02H .0800.
A copy of the laboratory's Certified Parameter List at the time of the audit is attached. This list will
reflect any changes made during the audit. Copies of the checklists completed during the
inspection may be requested from this office. Thank you for your cooperation during the
inspection. If you have questions or need additional information, please contact me at (919) 733-
3908 Ext. 259.
Attachment
cc: Todd Crawford, Tonja Springer, #5371
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ognimo.LarEm�w.iw�ri a.
Sincerely,
Beth Swanson
Technical Assistance & Compliance Specialist
Division of Water Resources
NC Department of Environmental Quality I Division of Water Resources I Laboratory Certification Branch
4405 Reedy Creek Road 11623 Mail Service Center I Raleigh, North Carolina 27699-1623
919-733-3908

On -Site Inspection Report
LABORATORY NAME: SGWASA - WTP
NPDES PERMIT #: NCO058416
ADDRESS: 415 Central Ave. Suite B
Butner, NC 27509
CERTIFICATE #: 5371
DATE OF INSPECTION: June 21, 2022
TYPE OF INSPECTION: Field Municipal Maintenance
AUDITOR(S): Tonja Springer
LOCAL PERSON(S) CONTACTED: Jason Melendez and Jonathan Yancey
INTRODUCTION:
This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory
Certification Branch (NC WW/GW LCB) to verify its compliance with the requirements of 15A NCAC 02H
.0800 for the analysis of compliance monitoring samples.
II. GENERAL COMMENTS:
The facility is neat and well organized and has all the equipment necessary to perform the analyses. Staff
were forthcoming and responded well to suggestions from the auditor.
All required Proficiency Testing (PT) Samples have been analyzed for the 2022 PT Calendar Year and the
graded results were 100% acceptable.
The laboratory is reminded that any time changes are made to laboratory procedures, QA/SOP
document(s) must be updated and relevant staff retrained. Staff must acknowledge that they have read
and understand the changes as part of the documented training program. The same requirements apply
when changes are made in response to Findings, Recommendations or Comments listed in this report, to
ensure the methods are being performed as stated, references to methods are accurate, and the QA
and/or SOP document(s) is in agreement with each approved practice, test, analysis, measurement,
monitoring procedure or regulatory requirement being used in the laboratory. In some instances, the
laboratory may need to create an SOP to document how new functions or policies will be implemented.
Revisions to the SOPs, based on the Findings, Comments and Recommendations within this
report must be submitted to this office by January 31, 2023.
The laboratory is also reminded that SOPs are required to be reviewed at least every two years and are
intended to describe procedures exactly as they are to be performed. Use of the word "should" is not
appropriate when describing requirements (e.g., Quality Control (QC) frequency, acceptance criteria, etc.).
Evaluate all SOPs for the proper use of the word "should".

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#5371 SGWASA - WTP
Contracted analyses are performed by Meritech, Inc. (Certification # 165).
Approved Procedure documents for the analysis of the facility's currently certified Field Parameters were
provided at the time of the inspection.
III. FINDINGS. REQUIREMENTS. COMMENTS AND RECOMMENDATIONS:
Documentation
A. Finding: The laboratory is lacking a documented training program.
Requirement: Each laboratory shall develop and implement a documented training program
that includes the following: that staff have the education, training, experience, or demonstrated
skills needed to generate quality control results within method -specified limits and that meet
the requirements of these Rules; that staff have read the laboratory quality assurance manual
or applicable Standard Operating Procedures; that staff have obtained acceptable results on
Proficiency Testing Samples pursuant to Rule .0803(1) of this Section or other demonstrations
of proficiency (e.g., side -by -side comparison with a trained analyst, acceptable results on a
single-blind performance evaluation sample, an initial demonstration of capability study
prescribed by the reference method). Ref: 15A NCAC 02H .0805 (g) (5).
B. Finding: The laboratory benchsheet is lacking required documentation: the method or
Standard Operating Procedure reference, the instrument identification, the time of
collection, time of analysis.
Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall
be traceable to the associated sample analyses and shall consist of: the method or Standard
Operating Procedure; the instrument identification; the date and time of collection; the time of
sample analyses (when required to document a required holding time or when time -critical
steps are imposed by the method, a federal regulation, or this Rule). Each item shall be
recorded each time samples are analyzed. Analyses shall conform to methodologies found in
Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (2) (A), (C), (F) and (H).
Comment: The Total Residual Chlorine (TRC) method reference is documented as SM 18th
ED 4500 Cl G and Hach 10014. The SM reference method will need to be updated and the
Hach method must be removed since this is not the method the laboratory is following. The
pH method reference is not documented.
Comment: The laboratory benchsheet contains a single collection time and sample analysis
time for pH and TRC. It is unclear to which parameter these times apply. The pH and TRC
samples are brought back to the laboratory for analysis with only one time for sample
collection and one time for sample analysis.
C. Finding: The laboratory is not documenting all traceability information for purchased
materials, reagents and standards.
Requirement: 15A NCAC 02H .0805 (a)(7)(K) and (g)(7) requires laboratories to have a
documented system of traceability for the purchase, preparation, and use of all chemicals,
reagents, standards, and consumables. That system must include documentation of the
following information: Date received, Date Opened (in use), Vendor, Lot Number, and
Expiration Date (where specified). A system (e.g., traceable identifiers) must be in place
that links standard/reagent preparation information to analytical batches in which the
solutions are used. Documentation of solution preparation must include the analyst's
initials, date of preparation, the volume or weight of standard(s) used, the solvent and final

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#5371 SGWASA — WTP
volume of the solution. This information as well as the vendor and/or manufacturer, lot
number, and expiration date must be retained for primary standards, chemicals, reagents,
and materials used for a period of five years. Consumable materials such as pH buffers,
lots of pre -made standards and/or media, solids and bacteria filters, etc. are included in
this requirement. Ref: NC WW/GW LCB Traceability Documentation Requirements for
Chemicals, Reagents, Standards and Consumables Policy.
Comment: The traceability log has a space to document the Date Opened but it is not
being filled in.
Quality Control
D. Finding: SOPs have not been developed and/or updated for all the methods included on
the laboratory's Certified Parameter Listing (CPL).
Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule.
A copy of each analytical method or Approved Procedure and Standard Operating
Procedure shall be available to each analyst and available for review upon request by the
State Laboratory. Standard Operating Procedure documentation shall state the effective
date of the document and shall be reviewed every two years and updated if changes in
procedures are made. Each laboratory shall have a formal process to track and document
review dates and any revisions made in all Standard Operating Procedure documents.
Supporting Records shall be maintained as evidence that these practices are implemented.
Ref: 15A NCAC 02H .0805 (g) (4).
Comment: An SOP describes the method in such detail that an experienced analyst
unfamiliar with the method can obtain acceptable results and meet documentation
requirements. SOPs must describe in detail how a method is performed in that particular
laboratory.
Comment: The laboratory has begun working on the TRC SOP using the NC WW/GW
LCB SOP template. The laboratory does have an SOP for pH, but it only includes
procedural steps.
Proficiency Testing
E. Finding: PT Samples for pH are not being analyzed in the same manner as routine
Compliance Samples.
Requirement: Laboratories are required to analyze an appropriate PT Sample by each
parameter method on the laboratory's CPL. The same PT Sample may be analyzed by one
or more methods. Laboratories shall conduct the analyses in accordance with their routine
testing, calibration and reporting procedures, unless otherwise specified in the instructions
supplied by the Accredited PT Sample Provider. This means that they are to be logged in
and analyzed using the same staff, sample tracking systems, standard operating
procedures including the same equipment, reagents, calibration techniques, analytical
methods, preparatory techniques (e.g., digestions, distillations and extractions) and the
same quality control acceptance criteria. PT Samples shall not be analyzed with additional
quality control. They are not to be replicated beyond what is routine for Compliance Sample
analysis. Although, it may be routine to spike Compliance Samples, it is neither required,
nor recommended, for PT Samples. PT sample results from multiple analyses (when this
is the routine procedure) must be calculated in the same manner as routine Compliance
Samples. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section
3.6.

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#5371 SGWASA — WTP
Comment: The laboratory is currently analyzing pH PT Samples in duplicate and
averaging the results. Compliance pH sample are not analyzed in duplicate and the values
cannot be arithmetically averaged. Sample duplicates are not a required QC element for
Field Parameters.
F. Finding: The laboratory is not documenting PT Sample analyses in the daily analysis records.
Requirement: All PT Sample analyses must be recorded in the daily analysis records as for
any Compliance Sample. This serves as the permanent laboratory record. Ref: Proficiency
Testing Requirements, February 19, 2020, Revision 5, Section 3.6.
Requirement: The laboratory shall retain all records necessary to facilitate historical
reconstruction of the analysis and reporting of analytical results for PT Samples. This means
the laboratory must have available and retain for five years [pursuant to 15A NCAC 02H .0805
(a) (7) (E) and (g) (1)] all of the raw data, including benchsheets, instrument printouts and
calibration data, for all PT Sample analyses and the associated QC analyses conducted by
all parameter methods. Ref: Proficiency Testing Requirements, February 19, 2020, Revision
5, Section 4.0.
Requirement: The analysis of Proficiency Testing (PT) Samples is designed to evaluate the
entire process used to routinely analyze and report Compliance Sample results. PT Samples
must be analyzed the same as Compliance Samples. Also. documentation must be made on
the same benchsheets used for Compliance Samples. Ref: NC WW/GW LCB Proficiency
Testing Samples Analyzed and Documented Same as Compliance Samples Policy.
Comment: PT Sample results are entered into the online reporting form and not documented
on the laboratory benchsheet. The NC WW/GW LCB `Proficiency Testing Samples Analyzed
and Documented Same as Compliance Samples' Policy was updated on March 9, 2022 to
include the requirement that PT Sample analysis be documented on the same benchsheet
that is used for Compliance Samples.
G. Finding: The laboratory is not documenting the preparation of PT Samples.
Requirement: PT Samples received as ampules are diluted according to the Accredited PT
Sample Provider's instructions. It is important to remember to document the preparation of PT
Samples in a traceable log or other traceable format. The diluted PT Sample then becomes a
routine Compliance Sample and is added to a routine sample batch for analysis. No
documentation is needed for whole volume PT Samples which require no preparation,
however the instructions must be maintained. Ref: Proficiency Testing Requirements,
February 19, 2020, Revision 5, Section 3.6.
Comment: Dating and initialing the instruction sheet for each prepared PT Sample would
satisfy the documentation requirement.
pH — Standard Methods, 4600 H' B-2011 (Aqueous)
H. Finding: Values were reported that exceed the method specified accuracy of 0.1 units.
Requirement: By careful use of a laboratory pH meter with good electrodes, a precision of
±0.02 unit and an accuracy of ±0.05 unit can be achieved. However, ± 0.1 pH unit represents
the limit of accuracy under normal conditions, especially for measurement of water and poorly
buffered solutions. For this reason, rei)ort PH values to the nearest 0.1 pH unit. Ref: Standard
Methods, 4500 H+ B-2011. (6).

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#5371 SGWASA — WTP
Comment: The laboratory is reporting pH to two decimal places on the Discharge Monitoring
Report (DMR).
Comment: Per PT Vendor instructions, the PT Sample results should be reported to two
decimal places, which is an exception to the requirement for Compliance Samples.
Recommendation: It is recommended to continue to document the pH result to 2 decimal
places on the benchsheet and round to one decimal when reporting compliance data. An
example benchsheet was sent after the inspection that included a column to document the
pH meter reading and a second column for Final reported pH.
Total Residual Chlorine — Standard Methods, 4500 Cl G-2011 (Aqueous)
Comment: The laboratory is analyzing a duplicate for TRC. The average of the two is being
reported. Sample duplicates are not a required quality control element for Field parameters. It is
recommended that the laboratory no longer analyzed duplicates for TRC.
Finding for Immediate Response: The laboratory is not verifying the instrument's Factory -
set Calibration Curve initially and every 12 months.
Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref:
15A NCAC 02H .0805 (g) (4).
Requirement: Annual Factory -set Calibration Curve Verification: This type of calibration
curve verification must be performed initially, at least every 12 months and any time the
instrument optics are serviced. Zero the instrument with a Calibration Blank and then analyze
a Method Blank and a series of five standards (do not use gel or sealed liquid standards for
this purpose). The calibration standard values obtained must not vary by more than ±10%
from the known value for standard concentrations greater than or equal to 50 pg/L and must
not vary by more than ±25% from the known value for standard concentrations less than 50
pg/L. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine
(DPD Colorimetric by SM 4500 Cl G-2011).
Comment: During the inspection, it was noted that the laboratory was not verifying the
factory -set calibration curve every 12 months and did not know when a 5-standard
calibration curve verification was performed last. Since the lack of a calibration curve
verification has the potential to severely impact the validity of the data, a Notice of Finding
for Immediate Response (NOFIR) was issued and emailed to the laboratory on June 22,
2022. A response due date of July 15, 2022 was negotiated. The laboratory has contacted
Meritech, Inc. to perform the calibration curve verification. Respond with a copy of the
curve verification and the corrective actions taken to prevent further recurrence for
this Finding.
J. Finding for Immediate Response: The Factory -set Calibration Curve is not checked with
a Daily Check Standard each day that samples are analyzed.
Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule.
Ref: 15A NCAC 02H .0805 (g) (4).
Requirement: When an annual five -standard Factory -set Calibration Curve verification is
used, the laboratory must check the calibration curve each analysis day. To do this, the
laboratory must zero the instrument with a Calibration Blank and analyze a Daily Check
Standard (gel -type standards are most widely used for these purposes). The value
obtained for the Daily Check Standard must read within ±10% of the true value of the Daily

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Check Standard for standards >_50 pg/L and within ±25% of its true value for standards <50
pg/L. If the obtained value is outside of the acceptance limits, corrective action must be
taken. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual
Chlorine (DPD Colorimetric by SM 4500 Cl G-2011).
Comment: During the inspection, it was noted that the laboratory at some point in the past
had been preparing and analyzing two daily chlorine standards at concentrations of 10 pg/L
and 30 pg/L, but this is no longer current practice. The laboratory is not analyzing a Daily
Check Standard. Since the lack of the calibration check has the potential to severely impact
the validity of the data, a NOFIR was sent by email to the laboratory on June 22, 2022. A
response due date of July 15, 2022 was negotiated. Due to budget restraints the laboratory
will be unable to order the gel standards until July 1, 2022. Once the gel standards are
received, Meritech Inc. will assign the true value to the gel standard. Respond with a copy
of the gel standard true value assignment and a benchsheet showing the daily
calibration being performed and the corrective actions taken to prevent further
recurrence.
Reporting
K. Finding: The laboratory does not report all characteristics of the pollutants analyzed from
the effluent.
Requirement: The results of all tests on the characteristics of the effluent, including but
not limited to NPDES permit monitoring requirements, shall be reported on the monthly
report forms. Ref: 15A NCAC 02B .0506 (b) (3) (J).
Comment: Since the pH meter displays the sample temperature along with pH results, the
analyst documents the temperature value on the benchsheet. The laboratory does not have
an NPDES permit requirement for Temperature. However, since the laboratory is
documenting the effluent temperature, the results of the analyses must be included in the
comments section of the DMR with a note that they are uncertified values. If the laboratory
continues to analyze the Temperature of the effluent, certification of this parameter will be
required.
Recommendation: It is recommended that the laboratory no longer document the
Temperature of their effluent.
L. Finding: Data qualifiers from the contract laboratory reports are not being transferred to
the DMR.
Requirement: Each certified Field Laboratory shall be in accordance with Paragraph (e)
of this Rule. Ref: 15A NCAC 02H .0805 (g) (17).
Requirement: Reported data associated with quality control failures, improper sample
collection, holding time exceedances, or improper preservation shall be qualified as such.
Ref: 15A NCAC 02H .0805 (e) (5).
Comment: The sample collected on December 2, 2021 and analyzed on December 7, 2021
by Meritech Inc. was lacking the following qualification on the DMR: TSS — Y — Elevated PQL
*due to insufficient sample size.
M. Finding: The laboratory is not correctly transcribing analytical results from the contract
laboratory to the DMR.

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Requirement: Daily analyses must be performed using EPA -approved methods that are
capable of producing results less than or equal to the corresponding permit limits, where
such methods exist. In the case of `non -detect' values, permittees (or their laboratories) are
expected to report daily values to the Practical Quantitation Level (PQL) for each parameter
(or "<[PQL] for values less than the PQL). Ref: Precision in Discharge Monitoring Reports,
Section 3.1.
Comment: Values below the detection limit are consistently reported as "0" instead of the
listed detection limit preceded by the less than (<) symbol.
Comment: See the table in the Paper Trail Investigation section.
IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and
contract laboratory reports to DMRs submitted to the North Carolina Division of Water Resources. Data
were reviewed for SGWASA - WTP (NPDES permit # NC0058416) for October 2021, November 2021
and December 2021. The following errors were noted:
Date
Parameter Location
Value on Benchsheet
*Contract Laboratory Data
Value on
DMR
10/5/2021
Ammonia Nitrogen
Effluent
*<O.1 m /L
0 m /L
10/5/2021
Fluoride
Effluent
*<O.10 m /L
0 m /L
10/5/2021
Copper
Effluent
*<0.002 m /L
0 m /L
10/5/2021
Total Phosphorus
Effluent
*<0.020 m /L
0 m /L
10/5/2021
Total Residual Chlorine
Effluent
No value
0 /L
11/4/2021
TSS
Effluent
*<2.5 m /L
0 m /L
11/4/2021
Copper
Effluent
*<0.002 m /L
0 m /L
12/2/2021
TSS
Effluent
*<2.7 m /L
0 mg/L
Contract laboratory results for Turbidity (6.2 NTU) and TSS (3 mg/L) were reported on the DMR for
December 16, 2021, instead of December 15, 2021.
To avoid questions of legality, it is recommended that you contact the appropriate Regional Office for
guidance as to whether an amended DMR(s) will be required. A copy of this report will be made available
to the Regional Office.
V. CONCLUSIONS:
Correcting the above -cited Findings and implementing the Recommendation(s) will help this laboratory to
produce quality data and meet Certification requirements. The inspector would like to thank the staff for
their assistance during the inspection and data review process. Please respond to all Findings and
include supporting documentation, implementation dates and steps taken to prevent recurrence
for each corrective action.
Report prepared by: Tonja Springer Date: June 27, 2022
Report reviewed by: Michael Cumbus Date: June 27, 2022

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