#5218_0311finalTS_2015_

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NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
4/29/15
5218
McCain Correctional Hospital WWTP
Sandhills Regional Maintenance
Philip Smith
180 Sandhills Drive
Raeford, NC 28376
Donald R, van der Vaart
Secretary
Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC)
Maintenance Inspection
Dear Mr. Smith:
Enclosed is a report for the inspection performed on March 11, 2015 by Tonja Springer. I apologize
for the delay in getting this report to you. Where finding(s) are cited in this report, a response is
required. Within thirty days of receipt, please supply this office with a written item for item
description of how these finding(s) were corrected 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 2H .0800.
Copies of the checklists completed during the inspection may be requested from this office. Thank
you for your cooperation during the inspection. If you wish to obtain an electronic copy of this
report by email or if you have questions or need additional information, please contact us at (919)
733-3908.
Attachment
cc: Tonja Springer
Sincerely,
Dana Satterwhite, Environmental Program Supervisor
Division of Water Resources
Water Sciences Section
INC Wastewater/Groundwater Laboratory Certification Branch
1623 Mail Service Center, Raleigh, North Carolina 27699-1623
Location: 4405 Reedy Creek Road, Raleigh, North Carolina 27607
Phone: [phone] FAX: [phone]
Internet: www.dwoIab.org
An Equal Opportunity '.AffrmativeAction Employer

INSPECTION REPORT ROUTING SHEET
To be attached to all inspection reports in-house only.
Laboratory Cert. #:
Laboratory Name:
Inspection Type:
Inspector Name(s):
Inspection Date:
Date Report Completed:
Date Forwarded to Reviewer:
Reviewed by:
Date Review Completed:
Cover Letter to use:
Unit Supervisor/Chemist III:
Date Received:
Date Forwarded to Linda:
Date Mailed:
5218
McCain Correctional Hospital WWTP
Field Maintenance
Tonia Springer
March 11, 2015
March 25, 2015
March 25, 2015
Jason Smith
March 26, 2015
❑ Insp. Initial
❑ Insp. No Finding
❑ Corrected
❑ Insp. Reg.
❑ Insp. CP
® Insp. Reg. Delay
Dana Satterwhite
3/26/2015
4/28/2015
1.�-

On -Site Inspection Report
LABORATORY NAME: McCain Correctional Hospital WWTP
NPDES PERMIT #: NCO035904
ADDRESS: Sandhills Regional Maintenance
180 Sandhills Drive
Raeford, NC 28376
CERTIFICATE #:
DATE OF INSPECTION:
TYPE OF INSPECTION:
AUDITOR(S):
LOCAL PERSON(S) CONTACTED:
I. INTRODUCTION:
5218
March 11, 2015
Field Maintenance
Tonja Springer
Philip Smith
This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater
Laboratory Certification (NC WW/GW LC) program to verify its compliance with the requirements of 15A
NCAC 2H .0800 for the analysis of environmental samples.
II. GENERAL COMMENTS:
The laboratory was clean and well organized. The facility has all the equipment necessary to perform the
analyses.
PT samples for the 2015 proficiency testing calendar year have not yet been analyzed. The laboratory is
reminded that these results must be submitted to this office directly from the vendor by September 30,
2015.
Current quality assurance policies for Field Laboratories, an example benchsheet and approved
procedures for the analysis of the facility's currently certified parameters were provided at the time of
the inspection.
Contracted analyses are performed by Statesville Analytical (Certification #440).
The requirement associated with Finding B has been implemented by our program since the last
inspection.
III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
Documentation
Recommendation: The laboratory's data defensibility would be improved with the addition of an
instrument maintenance log. This can be as simple as a description in a comment box on a
benchsheet. One example of instrument maintenance is replacing a probe on the pH meter.

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#5218 McCain Correctional Hospital WWTP
Comment: The laboratory needed to increase the documentation of purchased reagents. Lot Numbers
were being documented. The Quality Assurance Policies for Field Laboratories document states: All
chemicals, reagents, standards and consumables used by the laboratory must have the following
information documented: Date Received, Date Opened (in use), Vendor, Lot Number, and Expiration
Date. Consumable materials such as pH buffers and lots of pre -made standards are included in this
requirement. This requirement is a new policy that has been implemented by our program since the last
inspection. Demonstration of acceptable corrective action (i.e., an updated benchsheet with all
traceability information with an implementation date of 3/19/2015) was received by email on March 19,
2015. No further response is necessary for this finding.
Comment: The laboratory benchsheets for Temperature, DO and pH were lacking pertinent data:
Instrument identification. The NC WW/GW LC Approved Procedure for the Analysis of pH, NC WW/GW
LC Approved Procedure for the Analysis of Temperature, and NC WW/GW LC Approved Procedure
for the Analysis of Dissolved Oxygen (DO) documents state: The following must be documented in
indelible ink whenever sample analysis is performed: Instrument Identification. This requirement is a new
policy that has been implemented by our program since the last inspection. Demonstration of acceptable
corrective action (i.e., an updated completed benchsheet with instrument identification with an
implementation date of 3/19/2015) was received by email on March 19, 2015. No further response is
necessary for this finding.
Comment: Several instances of writing over a number as a means of error correction were observed.
The Quality Assurance Policies for Field Laboratories document states: All documentation errors must
be corrected by drawing a single line through the error so that the original entry remains legible. Entries
shall not be obliterated by erasures or markings. Wite-Out®, correction tape or similar products designed
to obliterate documentation are not to be used. Write the correction adjacent to the error. The correction
must be initialed by the responsible individual and the date of change documented. All data and log
entries must be written in indelible ink. Pencil entries are not acceptable. Notification of acceptable
corrective action (i.e., a statement that "Write-Overs will be done in the proper manner") was received
by email on March 19, 2015. No further response is necessary for this finding.
Comment: The laboratory benchsheets for Temperature, DO, and pH only documented one time with no
clarification that the sample was analyzed "in -situ". The NC WW/GW LC Approved Procedure for the
Analysis of pH states: Document date and time of sample analysis. Alternatively, one time may be
documented for collection and analysis with the notation that samples are measured in situ or
immediately at the sample site. The NC WW/GW LC Approved Procedure for the Analysis of
Temperature states: Document date and time of sample analysis. Alternatively, one time may be
documented for collection and analysis with the notation that samples are measured in situ or
immediately at the sample site. The NC WW/GW LC Approved Procedure for the Analysis of DO states:
Document date and time of sample analysis. Alternatively, one time may be documented for collection
and analysis with the notation that samples are measured in situ or immediately at the sample site.
Demonstration of acceptable corrective action (i.e., an updated completed benchsheet with a
statement that samples are analyzed "in situ" with an implementation date of 3/19/2015) was received
by email on March 19, 2015. No further response is necessary for this finding.
A. Finding: All original records were not on file
Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC
2H .0805 (g) (1).
Comment: Data omission, as noted in the Paper Trail section of this report, can be perceived as
falsification of data.

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#5218 McCain Correctional Hospital WWTP
PH — Standard Methods, 4500 H+ B-2000
Temperature — Standard Methods, 2550 B-2000
Comment: The temperature sensor on the pH meter used to obtain reported temperature values had
not been checked against a National Institute of Standards and Technology (NIST) traceable
thermometer within the past 12 months. The NC WW/GW LC Approved Procedure for the Analysis of
Temperature states: Thermometers and temperature measuring devices, used to measure
temperature for compliance monitoring, must be checked every 12 months against a NIST traceable
thermometer. The thermometer/meter readings must be less than or equal to 10C from the NIST
traceable thermometer reading. The documentation must include the serial number of the NIST
traceable thermometer that was used in the comparison. Document any correction that applies on
both the thermometer/meter and on a separate sheet to be filed. Demonstration of acceptable
corrective action (i.e., a copy of the temperature sensor verification) was received by email on March
19, 2015. No further response is necessary for this finding.
Dissolved Oxygen — Hach 10360-2011, Rev. 1.2 (LDO)
Comment: The method that was being referenced on the benchsheet (i.e., SM 4500 O G-2001) did not
match the method that was referenced on the laboratory's certified attachment. The laboratory is using a
Luminescence Dissolved Oxygen (LDO) probe. Notification of the change in methodology was not sent
to our office within 30 days of this change in equipment and methodology. The North Carolina
Administrative Code, 15A NCAC 2H .0805 (c) (7) states: A certified laboratory must submit a written
amendment to the certification application each time that changes occur in methodology, reporting
limits, and major equipment. The amendment must be received within 30 days of such changes.
Demonstration of acceptable corrective action (i.e., the method was changed to the Hach 10360-2011,
Rev. 1.2 (LDO) method and an updated certified attachment was emailed to the lab on March 24, 2015
with an effective date of March 19, 2015). An updated benchsheet that was implemented on 3/19/2015
was received by email on 3/19/2015 with the correct method referenced. No further response is
necessary for this finding.
B. Finding: The meter's calibration is not documented each analysis day.
Requirement: The following must be documented in indelible ink whenever sample analysis is
performed. Meter calibration and meter calibration time(s). Ref: NC WW/GW LC Approved
Procedure for Analysis of Dissolved Oxygen (DO).
Requirement: Instruments are to be calibrated according to the manufacturer's calibration
procedure prior to analysis of samples each day compliance monitoring is performed. For LDO
sensors that cannot be calibrated, the calibration must be verified each day of use. This can be
performed by back calculating the theoretical DO for the current air calibration conditions (e.g.,
temperature, elevation, barometric pressure, etc.). The calculated DO value must verify the
meter reading within ±0.5 mg/L. Refer to the Dissolved Oxygen Meter Calibration Verification
handout that was given at the time of the inspection. If the meter verification does not read
within ±0.5 mg/L of the theoretical DO, corrective action must be taken. Ref: NC WW/GW LC
Approved Procedure for Analysis of Dissolved Oxygen (DO). Please submit completed
benchsheets for the month of April with the response to this report.
Comment: The laboratory must document each time that a calibration is performed. Calibration
documentation must include the following, where applicable to the instrument used and the type of
calibration performed: elevation, temperature, barometric pressure (in mmHg), salinity, slope, or
%efficiency. Simply recording a final reading (in mq/L) for instruments that auto calibrate (e.g.,
LDO sensors and Membrane Electrodes that AUTOCAL) is also acceptable.

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#5218 McCain Correctional Hospital VWVfP
Comment: An updated completed benchsheet was submitted by email on March 19, 2015 but it
did not have sample results for DO documented to show that the calibration and calibration time is
being documented. Updated completed benchsheets with the calibration being documented was
submitted on April 2, 2015.
Proficiency Testing
Comment: The laboratory was not documenting Proficiency Testing (PT) sample analyses in the same
manner as environmental samples. Results are documented on the vendor's reporting form and faxed.
The Proficiency Testing Requirements, February 20, 2012, Revision 1.2 document states: All PT
sample analyses must be recorded in the daily analysis records as for any environmental sample. This
serves as the permanent laboratory record. Notification of acceptable corrective action (i.e., a statement
that "PT Analysis will be put on the bench sheet") was received by email on March 19, 2015. No further
response is necessary for this finding.
C. Finding: The laboratory is not analyzing Proficiency Testing (PT) samples in the same manner
as environmental samples.
Requirement: All PT samples are to be analyzed and the results reported in a manner
consistent with the routine analysis and reporting requirements of compliance samples and any
other samples analyzed according to the requirements of 15A NCAC 2H .0800. Ref: Proficiency
Testing Requirements, February 20,'2012, Revision 1.2.
Comment: The laboratory was analyzing pH PT samples multiple times and reporting an average
of all results. Environmental samples are not analyzed and reported in this manner.
Comment: The laboratory's common practice was to analyze a known standard along with the PT
sample as additional quality control. Since this is not performed with all environmental samples, it
is considered additional quality control. However, known samples are recommended when
analyzing remedial PT samples as part of the troubleshooting and corrective action process.
IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.)
and contract lab reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina
Division of Water Resources. Data were reviewed for November and December, 2014 and January,
2015. The following errors were noted:
Date
Parameter
Location
Value on Benchsheet
Value on DMR
11/26/2014
DO
Effluent
9.7 mg/L
No value
reported'
12/29/2014
Temperature
Effluent
No value documented
14 °C
12/29/2014
pH
Effluent
No value documented
6.9 s.u.
1/15/2015
pH
Effluent
6.4 s.u.
6.3 s.u.2

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#5218 McCain Correctional Hospital WWTP
In order to avoid a possible monitoring frequency violation' and questions of legality2, it is
recommended that you contact the appropriate Regional Office for guidance as to whether amended
Discharge Monitoring Reports 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 recommendations will help this lab to
produce quality data and meet certification requirements. The inspector would like to thank the staff for
its assistance during the inspection and data review process. Please respond to all findings and
include an implementation date for each corrective action.
Report prepared by: Tonja Springer Date: March 25, 2015
Report reviewed by: Jason Smith Date: March 26, 2015