#5303_02_2014_final

MCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
April 3, 2014
5303
Mr. Jeff Carlisle
PO Hoffer Treatment Facility
508 Hoffer Road
Fayetteville, NC 28301
John E. Skvarla, III
Secretary
Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC)
Maintenance Inspection
Dear Mr. Carlisle:
Enclosed is a report for the inspection performed on February 18, 2014 by Ms. Tonja Springer.
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
919-733-3908.
Sincerely,
Dana Satterwhite
Environmental Program Supervisor
Laboratory Certification Branch r
Enclosure
cc: Tonja Springer
Water Sciences 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
Phone: [phone] FAX: [phone]
Internet: www.dwglab.orp
An Equal Opportunity 1 Affirmative Action Employer

LABORATORY NAME:
WATER QUALITY PERMIT # :
ADDRESS:
CERTIFICATE #:
DATE OF INSPECTION:
TYPE OF INSPECTION:
AUDITOR(S):
LOCAL PERSON(S) CONTACTED:
INTRODUCTION:
On -Site Inspection Report
P.O. Hoffer Treatment Facility
NCO076783
508 Hoffer Dr.
Fayetteville, NC 28301
5303
February 18, 2014
Field Maintenance
Tonja Springer
Jeff Carlisle, Wayne Egan, James Merritt and Glen English
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.
GENERAL COMMENTS:
The laboratory was clean and well organized. The facility has all the equipment necessary to perform the
analyses.
Current quality assurance policies for Field Laboratories and approved procedures for the analysis of
the facility's currently certified parameters were provided at the time of the inspection.
The requirements associated with Findings A, C, D, E F, and H have been implemented by our program
since the last inspection.
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 bulb in the Total Residual Chlorine
(TRC) meter.
Comment: Instrument identification was not documented on the benchsheet. The NC WW/GW LC
Approved Procedure for the Analysis of Total Residual Chlorine document states: 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 benchsheet which included the
instrument ID) was received by email on 2/27/2014. No further response is necessary for this
finding.

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#5303 P.O. Hoffer Treatment Facility
Comment: Facility name was not documented on the benchsheet. The NC WW/GW LC Approved
Procedure for the Analysis of Total Residual Chlorine document states: The following must be
documented in indelible ink whenever sample analysis is performed: Facility. Demonstration of
acceptable corrective action (i.e., an updated benchsheet which included the facility name) was
received by email on 2/27/2014. No further response is necessary for this finding.
A. Finding: The laboratory needs to increase the documentation of purchased materials and
reagents, as well as documentation of standards and reagents prepared in the laboratory.
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 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.
Comment: An updated benchsheet, which included documentation of traceability for the TRC
purchased reagents and standards, was received by email on 2/27/2014.
Comment: The preparation of the TRC standards used to make the annual verification curve
must be documented as well.
B. Finding: Several instances of writing over a number as a means of error correction were
observed.
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.
Proficiencv Testing
Comment: The Proficiency Testing Requirements document, February 20, 2012, Revision 1.2, serves
as a guide to the PT sample requirements of the NC WW/GW LC program. In addition
to clarifying the regulatory requirements for proficiency testing, this document answers many common
questions concerning evaluation of PT sample results. Highlighted changes and a condensed version
can be found on the following web page: http://portal.ncdenr.org/web/wq/lab/cert/field/pt
C. Finding: The laboratory is not designating the correct method code(s) for Proficiency Testing
(PT) sample results.
Requirement: To ensure that you are reporting the correct method, review your certificate
attachment (i.e., certified parameter list). The method must include the entire method reference

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#5303 P.O. Hoffer Treatment Facility
as is written on your certificate attachment (i.e., certified parameter list). Ref: Proficiency
Testing Requirements, February 20, 2012, Revision 1.2.
Comment: Designating the correct method code(s) will ensure you receive proper credit for the
parameter method technologies on your current certificate attachment. When a PT provider
utilizes a web -based submittal system, where the laboratory selects the analytical method from
a pull -down list, it may be necessary to edit the choices given. Technical difficulties should be
addressed with the PT provider.
Comment: The method descriptions listed on the 2013 proficiency testing evaluation report
were not compatible with the laboratory's current certificate attachment. The method reference
for the 2013 PT results should have been designated as follows: SM 4500 CI G-2000.
D. Finding: PT samples have not been distributed among qualified personnel from year to year.
Requirement: Laboratories shall also ensure that PT samples are equally distributed among
personnel trained and qualified for the relevant tests, which represents the routine operation of
the work group at the time the PT study is conducted, Ref: Proficiency Testing Requirements,
February 20, 2012, Revision 1.2.
E. Finding: The laboratory is not documenting PT sample analyses in the same manner as
environmental samples.
Requirement: All PT sample analyses must be recorded in the daily analysis records as for any
environmental sample. This serves as the permanent laboratory record. Ref: Proficiency
Testing Requirements, February 20, 2012, Revision 1.2.
Comment: 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.
Comment: PT sample results are documented only on the vendor's data entry form and final
report.
F. Finding: The preparation of PT samples is not documented.
Requirement: PT samples received as ampules must be diluted according to the PT provider's
instructions. The preparation of PT samples must be documented in a traceable log or other
traceable format. The diluted PT sample becomes a routine environmental sample and is added
to a routine sample batch for analysis. Ref: Proficiency Testing Requirements, February 20,
2012, Revision 1.2.
Total Residual Chlorine — Standard Methods 4500 CI G-2000
Comment: The laboratory has been using the liquid reagents. At the time of the inspection they
indicated they will be switching to DPD powder.
Recommendation: The range of the annual verification curve analyzed on 4/19/2013 was 10, 20, 50,
100, 200, 400 pg/L. The permit limit is 28 pg/L. It is recommended that the annual verification curve be
performed this year in the following range: 20, 30, 50, 200 and 400 pg/L.
G. Finding: A check standard is not analyzed each analysis day.

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#5303 P.O. Hoffer Treatment Facility
Requirement: When a five -standard annual standard curve verification is used, the laboratory
must check the calibration curve each analysis day. To do this, the laboratory must analyze a
calibration blank to zero the instrument and analyze a check standard each day that samples
are analyzed. The value obtained for the check standard must read within 10% of the true value
of the check standard. If the obtained value is outside of the ±10% range, corrective action
must be taken. Ref: NC WW/GW LC Approved Procedure for Analysis of Total Residual
Chlorine.
Requirement: Document the true value of the check standard. Ref: NC WW/GW LC Approved
Procedure for Analysis of Total Residual Chlorine.
Comment: The laboratory personnel indicated at the time of the inspection that they will be
ordering gel standards to use as the daily check standard. When received, the laboratory is
required to assign the gel standard a true value. This true value is then updated annually at the
time of the curve verification.
H. Finding: A reagent blank was not analyzed when the annual verification curve was analyzed on
4/19/2013.
Requirement: A reagent blank (sometimes also referred to as a method blank) is only required
when laboratory water is used to make quality control and/or calibration standards. If you are
using a sealed standard (e.g., gel) for your daily check standard, a reagent blank would only be
analyzed when preparing the annual 5-point calibration curve or 5 annual calibration curve
verification standards. Ref: NC WW/GW LC Approved Procedure for Analysis of Total
Residual Chlorine.
Comment: A reagent blank is made from the same laboratory water source used to make
quality control and/or calibration standards with DPD. The concentration of reagent blanks must
not exceed 50% of the reporting limit (i.e., the lowest calibration or calibration verification
standard concentration), unless otherwise specified by the reference method, or corrective
action must be taken.
I. Finding: Concentrations less than the established reporting limit of 10 lag/L are being reported
on the Discharge Monitoring Report (DMR).
Requirement: For analytical procedures requiring analysis of a series of standards, the
concentrations of those standards must bracket the concentration of the samples analyzed. One
of the standards must have a concentration equal to the laboratory's lower reporting concentration
for the parameter involved. Ref: NC WW/GW LC Approved Procedure for Analysis of Total
Residual Chlorine.
Comment: If the recommended (see recommendation above) concentrations of 20, 30, 50, 200
and 400 lag/L are used in preparing the next calibration curve verification, the reporting limit
would be 20 lag/L.
IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing laboratory benchsheets and contract lab reports to Discharge
Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Resources. Data were
reviewed for August and November, 2013 and December, 2014. No transcription errors were detected.
The facility appears to be doing a good job of accurately transcribing data.

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#5303 P.O. Hoffer Treatment Facility
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.
Report prepared by: Tonja Springer Date: March 14, 2014
Report reviewed by: Jason Smith Date: March 14, 2014

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:
5303
P.O. Hoffer Treatment Facility
Field Maintenance
Tonia Springer
February 18 2014
March 14, 2014
March 14. 2014
Jason Smith
3/21 /2014
❑ Insp. Initial ® Insp. Reg.
❑ Insp. No Finding ❑ Insp. CP
❑ Corrected
Dana Satterwhite Nbtl
3/21/2014
4/2/2014
q
44/2014 LC,