#5389 - 11 - 2011 - FINAL

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Laboratory Cert. #:
5389
Laboratory Name:
Young Life Windy Gap
Inspection Type:
Field Maintenance
Inspector Name(s):
Jason Smith
Inspection Date:
November 29, 2011
Date Report Completed:
January 10, 2012
Date Forwarded to Reviewer: January 10, 2012
Reviewed by:
Jeffrey R. Adams
Date Review Completed:
January 10, 2012
Cover Letter to use: _
Insp. Initial _ Insp. Reg. _ Insp. No Finding X Insp. CP _Corrected
Unit Supervisor:
Gary Francies
Date Received:
1 /17/2012
Date Forwarded to Linda:
1/23/2012
Date Mailed: 1 / 1

f'a
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P. E. Dee Freeman
Governor Director Secretary
January 24, 2012
5389
Mr. Pete Alexander
Young Life Windy Gap
120 Coles Cove Rd.
Weaverville, NC 28787
Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW
LC) Maintenance Inspection
Dear Mr. Alexander:
Enclosed is a report for the inspection performed on November 29, 2011 by Jason Smith. 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. 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
828-296-4677.
Sincerely,
Gary Francies
Certification Unit Supervisor
Laboratory Section
Enclosure
Cc Master File
Jason Smith
DENR DWQ Laboratory Section NC Wastewater/Groundwater Laboratory Certification Branch
1623 Mail Service Center, Raleigh, North Carolina 27699-1623
Location: 4405 Reedy Creek Road. Raleigh, North Carolina 27607-6445
Phone: [phone] FAX: [phone]
Internet: www.dwglab.org
One
NOft Cafohna
An Equal Opportunity 1 Affirmative Action Employer

LABORATORY NAME:
NPDES PERMIT #:
ADDRESS:
CERTIFICATE #:
DATE OF INSPECTION:
TYPE OF INSPECTION:
AUDITOR(S):
LOCAL PERSON(S) CONTACTED:
1. INTRODUCTION:
Young Life Windy Gap
NCO034304
120 Coles Cove Rd.
Weaverville, NC 28787
5389
November 29, 2011
Field Maintenance
Jason Smith
Pete Alexander
This laboratory was inspected to verify its compliance with the requirements of 15A NCAC 2H .0800 for the
analysis of environmental samples.
The facility has all the equipment necessary to perform the analyses. Since the last inspection, the laboratory
has obtained a Luminescence Dissolved Oxygen (LDO) meter. An amendment to the application was
submitted at the time of the inspection and Hach Method 10360 has been added to the list of certified
parameters. All Findings that were cited previously, except Finding L, are due to new benchsheets that were
created without including all of the required documentation. For this reason, the laboratory will be required to
submit all revised benchsheets with the reply to this report. The requirements associated with Findings A, B, C,
and D are new policies that have been implemented since the last inspection.
A. Finding: Error corrections are not performed properly.
Requirement: 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. Ref: Quality Assurance Policies for Field Laboratories.
B. Finding: The laboratory needs to increase the documentation of purchased materials and reagents.
Requirement: 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. 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

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#5389 Young Life Windy Gap
volume or weight of standard(s) used, the solvent and final volume of the solution. This information
as well as the vendor and/or manufacturer, lot number, and expiration date must be retained for
chemicals, reagents, standards and consumables used for a period of five years. Consumable
materials such as pH buffers and lots of pre -made standards are included in this requirement. Ref:
Quality Assurance Policies for Field Laboratories.
C. Finding: Data that does not meet all quality control requirements is not qualified on the Discharge
Monitoring Report (DMR).
Requirement: When quality control (QC) failures occur, the laboratory must attempt to determine
the source of the problem and must apply corrective action. Part of the corrective action is
notification to the end user. If data qualifiers are used to qualify samples not meeting QC
requirements, the data may not be useable for the intended purposes. It is the responsibility of the
laboratory to provide the client or end -user of the data with sufficient information to determine the
usability of the qualified data. Where applicable, a notation must be made on the Discharge
Monitoring Report (DMR) form, in the comment section or on a separate sheet attached to the DMR
form, when any required sample quality control does not meet specified criteria and another sample
cannot be obtained. Ref: Quality Assurance Policies for Field Laboratories.
D. Finding: Proficiency Testing (PT) samples are not documented in the same manner as
environmental samples.
Requirement: The analysis of PT samples is designed to evaluate the entire process used to
routinely report environmental analytical results. Therefore, PT samples must be analyzed and the
process documented in the same manner as environmental samples. Ref: Quality Assurance
Policies for Field Laboratories.
E. Finding: Proper units of measurement are not documented for pH (Standard Units or S.U.). Cited
previously on January 9, 2009.
Requirement: Data pertinent to each analysis must be maintained for five years. Certified Data must
consist of date collected, time collected, sample site, sample collector, and sample analysis time. The
field benchsheets must provide a space for the signature or initials of the analyst, and proper units of
measure for all analyses. Ref: 15A NCAC 2H .0805 (g) (1).
F. Finding: The time of calibration is not documented. Cited previously on January 9, 2009.
Requirement: The time of calibration must be documented whenever sample analysis is performed.
Ref: Technical Assistance for Field Analysis of pH.
G. Finding: The temperature is not analyzed within the EPA holding time.
Requirement: Immediate analysis is required. Ref: Code of Federal Regulations, Title 40, Part 136;
Federal Register Vol. 72, No. 47, March 12, 2007; Table 11.
Comment: After the last inspection, the laboratory moved the sampling location for DO and
temperature to the final discharge. When this change was implemented, the laboratory began
collecting the sample and analyzing it within fifteen minutes rather than immediately.

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#5389 Young Life Windy Gap
H. Finding: The collection/analysis time is not clearly documented.
Requirement: Data pertinent to each analysis must be maintained for five years. Certified Data must
consist of date collected, time collected, sample site, sample collector, and sample analysis time. The
field benchsheets must provide a space for the signature or initials of the analyst, and proper units of
measure for all analyses. Ref: 15A NCAC 2H .0805 (g) (1).
Comment: The temperature is analyzed with the Dissolved Oxygen (DO) meter. When the laboratory
updated benchsheets, the temperature result was recorded on a separate sheet from the DO result.
This caused the linkage with the collection/analysis time of the DO to be lost.
1. Finding: Proper units of measurement are not documented for Temperature (°C).
Requirement: Data pertinent to each analysis must be maintained for five years. Certified Data must
consist of date collected, time collected, sample site, sample collector, and sample analysis time. The
field benchsheets must provide a space for the signature or initials of the analyst, and proper units of
measure for all analyses. Ref: 15A NCAC 2H .0805 (g) (1).
J. Finding: The time of calibration is not documented. Cited previously on January 9, 2009.
Requirement: The time of calibration must be documented whenever sample analysis is performed.
Ref: Technical Assistance for Field Analysis of Dissolved Oxygen.
K. Finding: The calibration of the LDO meter is not properly documented.
Requirement: A record of instrument calibration where applicable, must be filed in an orderly manner
so as to be readily available for inspection upon request. Ref: 15A NCAC 2H .0805 (g) (2).
Requirement: Meter calibration must be documented whenever sample analysis is performed. Ref:
Technical Assistance for Field Analysis of Dissolved Oxygen.
Comment: The lab was recording the elevation and salinity of the calibration, which was how the
membrane electrode meter was calibrated. The LDO meter displays the calibration slope after
calibration, which is what must be recorded to document the calibration.
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Comment: The laboratory was not documenting the value obtained for the gel standard. The North Carolina
Administrative Code, 15A NCAC 2H .0805 (g) (1) and (2) state: Data pertinent to each analysis must be
maintained for five years. A record of instrument calibration where applicable, must be filed in an orderly
manner so as to be readily available for inspection upon request. The Technical Assistance for Field Analysis
of Total Residual Chlorine states: The value obtained for the check standard (verification of ± 10% recovery)
must be documented whenever sample analysis is performed. Notification of acceptable corrective action
(i.e., the value of the gel standard has been recorded beginning November 30, 2011) was received by
electronic mail on January 9, 2012. No further response is necessary for this finding.
L. Finding: The laboratory is reporting values below the established reporting limit. Cited previously on
January 9, 2009.
Requirement: The concentrations of the calibration standards must bracket the concentrations of the
samples analyzed. One of the standards must have a concentration equal to or below the lower
reporting concentration for Total Residual Chlorine. Ref: Technical Assistance for Field Analysis of
Total Residual Chlorine.

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#5389 Young Life Windy Gap
Comment: Since the lowest standard concentration verified with the most recent curve verification was
13 pg/L, values below this must be reported as <13 pglL. The reporting limit for Total Residual
Chlorine may change each year depending on the standard concentrations verified by the contract
laboratory. Please note the lowest verified standard concentration each time the curve verification is
performed and update tine reporting limit if needed.
M. Finding: Effluent samples were analyzed for process control and not reported on the DMR.
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 monthly report forms. Ref: 15A NCAC
02B .0506 (b) (3) (J).
Recommendation: Process control sampling should continue to be performed by analyzing these
samples at a location that is not the final effluent.
The paper trail consisted of comparing field testing records and contract lab reports to Discharge Monitoring
Reports (DMRs) submitted to the North Carolina Division of Water Quality. Data were reviewed for Young
Life Windy Gap (NPDES permit #NC0034304) for May, June, and July, 2011. No transcription errors were
detected. The facility appears to be doing a good job of accurately transcribing data.
We are concerned with the findings that were cited previously and not corrected. Findings E, F, and J were
due to benchsheets being updated after the last inspection that did not include all of the required
documentation. For this reason, please submit all updated benchsheets with the reply to this report. If
needed, further technical assistance will be provided to ensure complete documentation.
Laboratory Decertification Ref: 15A NCAC 2H .0807 (a) (1), (13) and (14):
A laboratory may be decertified for any or all parameters for up to one year for any or all of the following
infractions:
(1) Failing to maintain the facilities, or records, or personnel, or equipment, or quality control program
as set forth in the application, and these Rules; or
(13) Failing to respond to requests for information by the date due; or
(14) Failing to comply with any other terms, conditions, or requirements of this Section or of a Laboratory
certification.
Correcting the above -cited findings 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.
Report prepared by: Jason Smith Date: January 10, 2012
Report reviewed by: Jeffrey R. Adams Date: January 10, 2012