HomeMy WebLinkAboutWQ0003090_Monitoring - 04-2023_20230707Monitoring Report Submittal
Permit Number#* WQ0003090
Name of Facility:* town of liberty WWTP
Month: * April Year: * 2023
Report Information
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR tremaine april 2023 report.pdf 4.28MB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
Confirmation Email Address: * tfike@townoflibertync.org
Name of Submitter: * Elix Fike
Signature:
Date of submittal: 7/7/2023
This will be filled in automatically
Initial Review
Reviewer: Wanda.Gerald
Is the project number correct?* WQ0003090
Is the monitoring report accepted?* Yes No
Regional Office* Winston-Salem
Reviewer: _anonymous
Review Date: 7/7/2023
FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page _l_ of _l_
Permit No.: W00003090
Facility Name: Town Of Liberty
- Wastewater
County: Randolph
Month:
April
Year: 2023
PPI: 002
Flow Measuring Point:
❑Q influent ❑ Effluent
❑ No flow generated
Parameter Monitoring Point: ❑ influent
Q Effluent
❑ Groundwater Lowering ❑ Surface water
Parameter Code —►
00400
00610
31613
00625
50060
70300
00630
td
=
0
CD
Ea3
o
o
L
C
mM
d
-aa=
wa,2a
d
cc
Q
H y
=
G
£
O
Y
N C
O N .O
w
O
Q
U.
U
Z
F
U
~ Q y
Z Z
O
O
►�-
24-hr
hrs
su
mg/L
#1100 mL
mg/L
mg/L
mg/L
mg/L
1
2
3
7:00
8
4
7:00
8
5
7:00
8
WRIM
61
7:00
8
JAJIMM
7.11
14.2
2420
18.9
0
<0.040
7
7:00
8
8
10:00
2
9
8:00
2
10
7:00
8
11
7:00
8
12
7:00
8
8.45
0.22
RIM
13
7:00
8
14
15
16
17
Komi
18
19
7:00
8
20
7:00
8
7.16
11.4
1410
14.2
0
0.046
21
7:00
8
22
23
24
7:00
8
25
7:00
8
26
7:00
8
7.59
0.09.
27
7:00
8
28
7:00
8
29
5:30
2
t
301
10:00
2
31
Average:
12.80
1,847.21
#REF!
0.08
0.02
Daily Maximum:
8.45
14.20
2,420.00
#REF!
0.22
0.05
Daily Minimum:
7.11
11.40
1,410.00
#REF!
0.00
0.04
Sampling Type:
Grab
Grab
Grab
Grab
Grab
Grab
Monthly Avg. Limit:
-
Daily Limit:
Sample Frequency:
weekly
2x month
2x month
2x month
weekly
>°
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 permit? 2 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.
non compiliant on the day of 4/7 4/8 4/9 4/10 4/11 4/15 4/25 AND 4/29
rainfall I&I
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 [21 No
Phone Number: 336 622 4276 Permit Expiration: 8/31 /2024
(
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
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
(704)977-0981
11'7palceAnalyfical
www.pacelabs.com
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92660997
Sample: Effluent
Method
SM 2540D-2015
EPA 353.2 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
SM 521OB-2016
Colilert-18
TKN+NO3+NO2
Calculation
EPA 350.1 Rev 2.0 1993
EPA 351.2 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
EPA 365.1 Rev 2.0 1993
ANALYTE QUALIFIERS
Parameters
Total Suspended Solids
Nitrogen, NO2 plus NO3
Nitrogen, Nitrate
Nitrogen, Nitrite
BOD, 5 day
Fecal Coliforms
Performed by
Collected By
Collected Date
Collected Time
pH
Chlorine, Total Residual
Total Nitrogen
Laboratory Report
Page 1 of 1
Report Date: 04/19/2023
Date Received: 04/06/2023
Lab ID: 92660997001 Collected: 04/06/23 12:05 Matrix: Water
Results
Units
Report Limit
Analyzed
20.0
mg/L
5.4
04/07/2311:45
ND
mg/L
0.040
04/07/2311:37
ND
mg/L
0.040
04/07/2311:37
ND
mg/L
0.040
04/07/2311:37
20.2
mg/L
2.0
04/12/2315:35
2420
MPN/100ml-
1.0
04/07/2312:53
Pace
04/07/23 09:03
Garrett
04/07/23 09:03
Dreyer
04/06/2023
04/07/23 09:03
1205
04/07/23 09:03
7.11
Std. Units
04/07/23 09:03
0.00
mg/L
04/07/23 09:03
18.9
mg/L
0.040
04/19/23 07:57
Nitrogen, Ammonia
14.2
mg/L
0.40
04/15/23 11:22
Nitrogen, Kjeldahl, Total
18.9
mg/L
0.50
04/13/23 06:30
Nitrogen, NO2 plus NO3
ND
mg/L
0.040
04/18/23 12:41
Phosphorus
2.6
mg/L
0.050
04/14/2314:51
D6 The precision between the sample and sample duplicate exceeded laboratory control limits.
El Reported value should be considered a minimum estimate since it is the maximum reportable number for this method
based on the sample volume used. The true value is likely greater than the value reported.
Reviewed by:
Stephanie Knott
704-977-0981
stephanie.knott@pacelabs.com
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
Virginia/VELAP Certification #: 460025
Qualifiers
D6,EI
Page 1 of 4
CD
CD
A
A
I
Section A
Required Client information
CompaWY: Town of Libe.
Address: PO Sox 1006
Liberty, NC 27298
CHAIN -OF -CUSTODY / Analytical Request Document
The Chain -of -Custody is a LEGAL DOCUMENT. All relev2~'
Submitting a sample via this chain of custody constitutes acknowledgment and acceptance of the Pace Terms and Conditions found amaw# e
Section 8 Section C s
Required Project Information: Invoice Information:
ty spot To : 7remaine Fdca ttentiany Name: 1
dress: 92660997
urchase Order* � Quote: x
one. (338)bZ21276 FaX: roject Name: Town of Litre - Every 2 Weeks ace Project Manager, stepnan e.krort ace(abs.rom,
State t Location
equested Due Date: ro ed # aceProfite q: 13077
NC
t=lftefed
YIN
a
O
COLLECTED
Preservatives
MATRIX CAE m
y
p
C—" W.., cW
Wa r Wr ui
m
U
J
W.* �N'gtet AW
2
4
S' P
SAMPLE ID5L
c?
STRR7
END
a
v
Y
09 OL
One Cttaraciar per box. p° na
It
{A-Z, 0.9 t , -} Unar or o
T$ -s
d
Um'Caa
Sample Ids must be unique
X
Oz
p
Z
m
tOi
4C
UNS
z
m
C
0
E
E0
2U
UCs
(
f
DATE
TIME
DATE
TIME
=
z
2
C
Zm
aO
i Eftluent
(fq
P5
X
X
X
X
X
X
X
X
3"
$'
6
7'
8
_9
30
11
12
ADDMONALCO"ENI
'..RELIWWMHEDBYtAFFIUAT*N
DATE
TIME
'ACCEPTED BYIAFFILIATION
DATE
TIME,
SAMPLE CONDITIONS
^�
LM NAME AND SIGNATURE
3
u
ro
m
a
E
PRINT Name of SAMPLER. lN✓%�Y r/
LU
u z
m� z
s z
SIGNATURE of SAMP
DATE Signed:
lid
I
tx
UU}
n}
DG# — Title: ENV-1FIRM-HUN11-00,54 VQ1_TeCh Spec Sample Gondition
vace, Upon Receipt
Effective Date; 05/124-022 -------
.boratory receiving samples:
;heville 0 Eden [] Greenwoocl[] Huntersville [] RaleighE] Mechanicsville[,--] Atlantao Kernersviller/1,
Offimm Client Name: Project H:
J---urier: Fed Lx PS El —USPS
J Commercial Race -/J
arrier Tracking Number:
ustody Seat Present?
Elye5 No
Seats Intact? Dye'
El No
Date/Initials Person Examining Contents;_ HJ
icking Material:
E]Bubblp Wrap
FJBubb e Bags ONone
El
oti'ler Biological Tissue Frozen?
I
IR Gunlo 1,64- IF 0 0 2— Type of lce� ywQt 0 Blue
jler Temp ('C Correction Factor: Add/ Subtract VC!
rrected Cooler Temp ('C):__
iDA Regulated Soil ( M N/A, water sarnple'l
d samples originate in a quarantine zone within the United States; CA, NY, or SC (Check friapO?
]Yes ONo
-X
Elyes [JNo [JN/A
EJ Nc,(-,e
Temp should be above freezing to 6*c
Of temp C"'ter'a- SafyiPlvs On ice, coo, ng pr-,)
has begun
Did sar,-ple5 originate frorn a f<,ifqigTj source tin ternitio,)
J
1—C-h—am of- Custody' Present?
[yes
5amples Arr ved within Hold Time?
6Y
ON; A
2
Short Hold Time Analysis (02 hr.}?
---PTyeS ---ONO
E)N1jA
3
Rush Turn Around Time Requested?
---,_QyeS
Sufficier"t vome?
Q�111
N; A
JN�'
4
5
Correct Ccrtai(ers Used?
-Pace Containers Used?
Eyes
L]Na
ContalneFs intact?
�0_O
N;±
7,
Dissolved analysi5: Sampies Field FiltereV_
[Iy�i
EINa
—
J
�LN/��
—
8
Sample La:,iet5 Match COO
OYLs
_
( 4c,
E)NA
9.
udes Oat Wirne!l O/Analys i,� Matrix:
Headspace in VOA Vials (>5-6mm)?
Trip Bank Present?
Trip Blank Custody Sears Present?
VV
Oy`�%--E)NQ
Elyes
DO LI,,
6N.'A
------
-0 No ffN'/A
411.
jjL
li�
10
Temp Log: Temp must be maintained
at <6 C during login, record temp
every ZO minutes.
Time opene&jq U D Temp:
Time: 0 put in cooler
Time; p:
Person Contacted:
Project Manager SCURF Review:
i nt in Of,;r)iit
CLIENT NOTIFICATION/RESOLUTION
Date/Time: �
Date:
Field Data Required? Dlo
Project Manager SRF Review:
Qualtrax Document ID: 70677
Page 1 of 2
Page 3 of 4
DC# — Title, ENV-FRM-HUN1-0084 v0I—TeC—hSpec SampleCo
Upon Receipt
-Effective Date: 05/12/2022
*Check mark top half of box if pH and/or dechlorination Project
is verified and within the acceptance range for
preservation samples.
Exceptions VOA, Coliform, TOC, Oil and =irease, DRO/8015 (water) DOC, U Hl;
"Bottom half of box is to list number of bottles
***Check all unpreserved Nitrates for chlorine
Me
pH Adj u sitment Lc)g for
1 S'Imple I of pftsrvafivc of! tpon rfneipt Date -lime pfe➢efVolwfl Amount of M!,scvafive Lot $1
... adjusted ad&'A
Nw,n Whk2n,vij tbetkEs xi d15fNi),WCY Afecting WWII Carofin'a (off q?f 1,11 lce smopl�'S' a S opy of thk N)rrn UMlf I�w 5,?.w to jhIMR
that of hold, incorrect (),)t o�( tern!),'Cnof�cot�on offif.(.. (I e
Qualtrax Docurnent 1111, 10(377
Floge, 2 of 2
Page 4 of 4
aceAnal 'l'cal'o
www.pacelabs.com
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty WWTP
Pace Project No.: 92661851
Sample: Effluent
Laboratory Report
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
(704)977-0981
Page 1 of 1
Report Date: 04/12/2023
Date Received: 04/12/2023
Lab ID: 92661851001 Collected: 04/12/23 11:40 Matrix: Water
Method Parameters
Results Units
Report Limit Analyzed Qualifiers
Performed by
PACE
04/12/23 11:40
Collected By
Garrett
04/12/23 11:40
Dreyer
Collected Date
04/12/23
04/12/23 11:40
Collected Time
1140
04/12/23 11:40
pH
8.45 Std. Units
04/12/23 11:40
Chlorine, Total Residual
0.22 mg/L
04/12/23 11:40
Reviewed by: �C�lieZ
Stephanie Knott
704-977-0981
stephanie.knott@pacelabs.com
Page 1 of 2
laceAnaljdicalo
Jwww.pacolabs.com
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92663415
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
(704)977-0981
Page 1 of 1
Report Date: 05/04/2023
Date Received: 04/20/2023
Sample: Effluent
Method
Parameters
Lab ID: 92663415001 Collected: 04/20/23 13:50 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
HACH 10206
Nitrogen, Nitrate
ND
mg/L
0.30
04/21/23 10:45
SM 2540D-2015
Total Suspended Solids
19.6
mg/L
8.9
04/21/23 10:49
SM 521 OB-2016
BOD, 5 day
19.6
mg/L
2.0
04/26/23 14:36
Colilert-18
Fecal Coliforms
1410
MPN/100mL
1.0
04/21/23 12:33
Performed by
PACE
04/20/23 13:50
Collected By
Garrett
04/20/23 13:50
Dreyer
Collected Date
04/20/23
04/20/23 13:50
Collected Time
1350
04/20/23 13:50
pH
7.16
Std. Units
04/20/23 13:50
Chlorine, Total Residual
0.00
mg/L
04/20/23 13:50
TKN+NO3+NO2
Total Nitrogen
14.2
mg/L
0.040
05/04/23 13:20
Calculation
EPA 350.1 Rev 2.0 1993
Nitrogen, Ammonia
11.4
mg/L
0.30
04/29/23 13:50
EPA 351.2 Rev 2.0 1993
Nitrogen, Kjeldahl, Total
14.2
mg/L
0.50
05/04/23 06:05
EPA 353.2 Rev 2.0 1993
Nitrogen, NO2 plus NO3
0.046
mg/L
0.040
04/25/23 16:09
EPA 365.1 Rev 2.0 1993
Phosphorus
2.3
mg/L
0.050
04/27/23 10:00
Reviewed by:
Stephanie Knott
704-977-0981
stephanie.knott@pacelabs.com
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
Virginia/VELAP Certification #: 460025
Page 1 of 4
A
race"
CHAIN -OF -CUSTODY / Analytical Regi
The Chain -of -Custody is a LEGAL DOCUMENT. All rejevanf
I Submitting a sampte via this chain of custody constitutes acknowledgment and acceptance of the Face Terms and Conditions found at ht
Section A
Section B Section C
[[[
Required Client Infannxtion:
Required Project rnfattnation: trnroica Information:
�
Company: Town of LiDeny
7O: Tremaine Fike or t=
v92N3Q1.5
I
Address: PO Box 1006
1 :w — .111—
n To: E=ry Name:
FJAadreiv.
F :.. .:'. A.ovis:v ...
�[
i
malt xchasa Order #- pace Quote:
'hone' {336i622-d2?6 Fes''''E= Name. Town of Liberty • Every 2 Weeks sca PrOiect Manager ste hanM.knoi" bs_com•
< ' Stale f Locat;on
ue*tad Dve pate: x P ace Profiled: 130T7
Sc
Is Fled
ttn
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0
COLLECTED
Preservatives
Marrtx coOr'
c
txuwnc w.r.. ow
WCbr wT
W"W Wa W W o
SAMPLE [D �
all or. $
ci
START
ENp
'
Ono Character Per bo:L W" om V
w
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{A,Z Q 3I . •} C OT p
sample tds must tra Unique
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i Effluent V47
X
X
X
X
X
X X
X
2
3
A
fi
7
8
9
i0
12
'.. RCYASTtONAL COptafENT3. REIJNQUt3ti£A -` Tmbi
DATE TIME
ACCEPTED BY1AFFIL FTrON
DATE
TIME
SAMPLE CONOCnWM
�j
NANIE AND SIGNATURE
m
a
PRINT Name of SAMPLER:.::
c
>
Y
w
i
m
E i
SIGNATURE of SAMPLE DATE Signed:
� z
3
✓ 2� 2�
tt`
ov�
) a
C iIV ENV+RM-HU 1.OUd4 vt31_Tech
Spec ample Condition
CO Upon Receipt
r, .: ,ffaat tiva D�tn U5112d2022
_,. .-_..
aborzators/ receiving samples,
_
%sfaeville [] EdenGreenwood _w hluntersville D Rau h[] Mechanicsville[J AtlantaEj Kernersvillej
Client P13t"fie;
_. _.
Project R:
�ourier: [ Fed Ex []tJPS ❑USPS
Cr�rnr er ial []Pace []tither:
-arrier Tracking Plumber:
Custody Seal present? Ores ir: Seals Intact?
[ ]Yes C_ Pio hate/initials Pei son Examining Contents;
ticking Material Q8ubb1 a l ] 3ubWe Begs f 'Mona C)the> piotggic.ai Tissut? Frozen?
herinonleter: o
Cl lR cr,r5 la� I `i Type or Ise:
[.]Ye, [_...JNr, N/A
VfWel [18I;,e [J ivnne
aoier Temp (°C );_ Correction Factc r; Add J Spbirar.t ('C)
_
..i'ej�m'yp shouid be above fccersng tcs 6 C
)#
otrected Cooler Tent � "
�,,,J$.S iTt j73e5 Gist of to"'Y'. ry fr to if .�r2 a�._ S 0^. r , ��(70 `.-°� p,r
ISDA Regulated Sort V.1 N/A: water s,a,^ipie)
i;as bog,;ea
>d samf ep {3riglnate in a quarantine CA, 147
res Jri o
Scjcl c.K m=tips}' I'll Sara c; cr <atti Ir;�n a : ,,r i t:n
r
it 6'ng Aiwa, and put. (' ruC j `fh
Cornments/tiiSCrepanGY,
Chain at Custody Present?
f�ve'
[ �„
jtdJs 1 1 I
Sa r riles Arrived within HU'd Time?
Short. Hold Time Analysts (02 hr )?
,
rRU to Tufn AiOUnd Tllfne ftelaUCStC'iS?
_i ��t5
(% !
�ip %A jj
t
�seni V iurr c?
if t:...
S
rrei.: Crn Dine r� Used
41ar
l rns
)Wf
-.-3
g Cccitainefs Used?
---------- - - -- - -- ---_
----
I Cor;talnF?rS Intact?
Dissolved analysis: Samples Field filtered?
(,]Yes
(:j,d,7
Sample Labels Ptau:h CUC3
(:r�s
.
Olw,
ONJ,1
-Includes Date/Time/ID/Analysis IYlatrit<:
Headspace in VOA Vials (ya-bmrn)?
7ri Blank Present?
p
Elr ,
Yet
Otio
jP;ct
rA
raJA
10
11
Trip (Bank Custody Seals Present?
rl
CC3htirlENTS/SAMPLE [3iSCREPANC'l
Field Dina Requited? C]Yes [grip
of split containers
Temp lag: Temp must be maintained CLIENT NOTIFICATION/RESOLUTION
at <6 C during login, record temp
every 2O minutes.
Time opened: ) Temp;
Time: I j q put m cooler
Tdmet Tempt
Person Contacted;
Project Manager SCURF Revlewe Date:
Project Manager SRF Review; Date:
Quallrax Document ID: 70677
Page 1 of 2
Page 3 of 4
#_ Title: -f RIVI-H NI-0084 < 1 chSpec Sara le- oiic9ltion
Mier,flute �a�te: 4Xs11;�1�Q��
*Cheek mark trap half of box if ptl and/or dechlorination Project I!
is verified and within the acceptance range for
preservation sai'nplen, 1
Exceptiom VON (o6form, FOC, {ail and <iteta5e, DRO/80IS
"Bottom half of box is to list n£araataer of bottles
*"Check all taratareserved Nitrates for chlorine j
pH Adjustment Log for preserved Samples
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Page 4 of 4
IaceAnal ical
jwww,pacelabsxom
I
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92664168
Sample: Effluent
Laboratory Report
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
(704)977-0981
Page 1 of 1
Report Date: 04/26/2023
Date Received: 04/26/2023
Lab ID: 92664168001 Collected: 04/26/23 11:15 Matrix: Water
Method Parameters
Results Units
Report Limit Analyzed Qualifiers
Performed by
PACE
04/26/23 11:15
Collected By
Garrett
04/26/23 11:15
Dreyer
Collected Date
04/26/23
04/26/23 11:15
Collected Time
1115
04/26/23 11:15
pH
7.59 Std. Units
04/26/23 11:15
Chlorine, Total Residual
0.09 mg/L
04/26/23 11:15
Reviewed by:
Stephanie Knott
704-977-0981
stephanie.knott@pacelabs.com
Page 1 of 2
DATE
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
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
R
0
April 2023
Liberty N.C.W.W.T.F
Freeboard Lagoon Inches
0.5
1.0
TOTAL 6.2
FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _1_of_2_
FORM: NDAR-1 10-13
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit?
D Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
[Z Compliant
❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit?
2 Compliant
❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site?
❑✓ Compliant
❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?
❑ Compliant
Ej 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.
IS AT 0 INCHES CAUSE OF I&I RAINF.
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 E21 No
Phone Number: 336 622 4276 Permit Exp.: 8/31 /24
s j a�
�-�._ --3
Signature I ate
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_
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?
❑J 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?
❑J Compliant
❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?
❑ Compliant
[21 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 [21 No
Phone Number: 336 622 4276 Permit Exp.: 8/31/24
AV
Signature Date
Signature D to
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