NC0038997_Fact Sheet_20240122

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
FACT SHEET FOR EXPEDITED PERMIT RENEWALS
Basic Information for Expedited Permit Renewals
Permit Writer/Date
Charles H. Weaver 1/22/2024
Permit Number
NCO038997
Facility Name
Roaring Gap Club WWTP
Basin Name/Sub-basin number
03-07-02
County/Regional Office
Alle han Count / Winston-Salem
Receiving Stream/Stream Index #
UT to Mitchell River / 12-62- 1
Stream Classification in Permit
B-Trout ORW
Does permit need Daily Max NH3 limits?
Yes. Previous permits relied upon old WLA
recommendations for an engineering report to
be submitted evaluating the feasibility of
building a WWTP capable of treating
wastewater from a zero -flow stream. This
option was deemed financially non -feasible.
Discharge is to bare ground ca. 2000 feet from
the flowing UT, thus minimizing potential
stream impact. However, 2016 NH3 guidance
policy requires imposition of NH3 limits.
New limits will take effect in 2028 to allow
facility time to optimize existing treatment
system. Limits will be set at BAT for 100%
domestics stems due to zero -flow stream.
Does permit need TRC limits/language?
Already resent
Does permit have toxicity testing?
No
Does permit have Special Conditions?
Nutrient Reo ener for High Rock Lake
Does permit have instream monitoring?
No
Is the stream impaired (on 303(d) list)?
No
For whatparameter?
Any obvious compliance concerns?
No enforcements since 1993. Five NODS and
four NOVs during the last permit cycle.
Any permit modifications since lastpen-nit?
None.
New expiration date
12/31/2028
Changes in Draft Permit
➢ Added NH3 limits per 2016 NH3
guidance.
➢ Added monitoring for turbidity to
determine compliance with 15A
NCAC 02B.0211 (21)
➢ Added downstream temperature
monitoring to determine compliance
with 15A NCAC 02B.0211 (18)
➢ Added monitoring for dissolved
oxygen to determine compliance
with 15A NCAC 02B.0211 (6)
➢ Updated eDMR text
➢ Updated permit map
Changes to Final Permit
➢ None

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
PUBLIC NOTICE
NORTH CAROLIN
MANAGEMENT
COMMISSION/NFDES
UNIT
1617 Mail Service Center
Raleigh, NC 27699-1617
Notice of Intent to Issue
NPDES Wastewater Perini'
NCO038997 Roaring Gap Clu
WWTP The North Carolin
Environmental Management
Commission proposes to issue
a NPDES wastewater discharge
permit to the person(s) liste
below. Written comment
regarding the proposed permitj
will be accepted until M days
after the publish date of this
notice. The Director of the NC
Division of Water Resource
(DWR) may hold a publi
hearing should there be a.
significant degree of public
interest. Please mail comments
and/or information requests
to DWR at the above address.
Interested persons may visit
the DWR at 512 N. Salisbury
Street, Raleigh, NC 27604
to review the information on
file. Additional information
on NPDES permits and this
notice may be found on our!
website: https://deq.nc.gov/'S
public-notices-hearings,or by
calling [phone]. The
Roaring Gap Club, inc hasF
requested 'renewal of NPDES
permit NCO038997 for the
Roaring Gap. Club WWTP
(2663 Roaring Gap Drive,
Roaring . Gap) in Wilkes
County. This permitted facility
discharges treated domestic
wastewater to an unnamed
tributary to the Mitchell River;
in the Yadkin -Pee Dee River'
Basin. Currently ammonia'
nitrogen, fecal coliform, and
total residual chlorine are water
quality limited. This discharge
may affect future allocations in
this portion of the Yadkin -Pee
Dee River Basin.
— 12-6-1tc
NORTH CAROLINA -
ALLEGHANY COUNTY
AFFIDAVIT OF PUBLICATION
Before the undersigned, a Notary Public of said
County and State, duly commissioned, qualified and
authorized by law to administer oaths, personally
aPP care L2 e-a Val/Who being first duly sworn, deposes and says that he
(she) is
(owner, partner, publisher, or other officer employee
authorized to make this affidavit) of The Alleghany
New (name of publishing concern) engaged in the
publicatio of a newspaper known as The Alleghany
News (name of newspaper) published, issued, and en-
tered as second class mail in the City of Sparta in said
County and State; that he (she) is authorized to make
this affidavit and sworn statement, that the notice
or other legal advertisements, a true copy of which
is attached hereto, was published in The Alleghany
News (name of newspaper) on the following dates
/_6-�9,3
And that the said newspaper in which such notice,
paper, document, -or legal advertisement was published
was, at the time of each and every such publication,
a newspaper meeting all of the requirements and
qualifications of Section 1-597 of the General Statutes
of North Carolina and was a qualified newspaper
within the meaning of Section of 1-597 of the General
Statutes of North Carolina. .
Thisdayof at y 20
(signature of person makin ffidavit)
Sworn to and subscribed before me
this _day of i fW/ 20�
My Commission expire� 7

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Roaring Gap Club, Inc.
Attn: Randy Crouse, Public Works Director
PO Box 129
Roaring Gap, NC 28668-0129
Subject: Permit Renewal
Application No. NCO038997
Roaring Gap Club WWTP
Alleghany County
Dear Applicant:
NORTH CAROLINA
Environmental Quality
July 27, 2023
The Water Quality Permitting Section acknowledges the July 27, 2023, receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deq.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
ec: WQPS Laserfiche File w/application
Sincerely,
c�
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 West Hanes Mill Road Suite 300 1 Winston-Salem, North Carolina 27105
336.776.9800

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
�1Zoaring Gap Glub INC.
P.O. BOX 129
ROARING GAP, NC 28668
Please find enclosed the application for renewal of permit NC0038997.
14F61g 6-0(tee
Public Works Director
q1``.'C,
w
Public ~-
Works
"Serving Our Members with Enthusiasm & Excellence"
2663 Roaring Gap Drive
P.O. Box 129
Roaring Gap, NC 28668
336-363-5024 Direct Line
336-200-4412 Cell
[e-mail]
RECEIVED
JUL 2 7 2023
KDEOMR/WDES
P.O. BOX 129 • ROARING GAP NC 28668 • [phone]

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
North Carolina Modified Application Form 2A
Department of Environmental Quality Revised March 2021
Division of Water Resources
Modified Application
Form 2A
Minor Sewage Facilities < 0.1 MGD
and No Pretreatment Program
NPDES Permitting Program
RECEIVED
JUL Z 7 2023
KDEOIDWRINPDES
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
NPDES Permit Number
Facility Name
Modified Application Form 2A
Roaring Gap Club WWTP
Modified March 2021
NC0038997
NC Department of Environmental Quality - Application for NPDES Permit to Discharge Wastewater
Form
MINOR SEWAGE FACILITIES (Before completing this form, please read the instructions. Failure to follow
NPDES
the instructions mav result in denial of the aQDlication.,J
SECTI
N 1. BASIC
APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.210)(1) and (9))
Facility name
1.1
Roaring Gap Club WWTP
Mailing address (street or P.O. box)
P.O. Box 129
City or town
State
ZIP code
o
Roaring Gap
NC
28668
E
Contact name (first and last)
Title
Phone number
Email address
c
Randy Crouse
Public Works Director
200-4412
rcrouse@roaringgapclub
'
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
v
2663 Roaring Gap Drive
u_
City or town
State
ZIP code
Roaring Gap
NC
28668
1.2
Is this application for a facility that has yet to commence discharge?
❑ Yes 4 See instructions on data submission ✓❑ No
requirements for new dischargers.
1.3
Is applicant different from entity listed under Item 11 above?
❑ Yes ❑✓ No 4 SKIP to Item 1.4.
Applicant name
Applicant address (street or P.O. box)
0
City or town
State
ZIP code
_o
c
Contact name (first and last)
Title
Phone number
Email address
.Q
o.
a
1.4
Is the applicant the facility's owner, operator, or both? (Check only one response.)
✓❑ Owner ❑ Operator ❑ Both
1.5
To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
❑✓ Facility ❑ Applicant ❑ Facility and applicant
(they are one and the same)
1.6
Indicate below any existing environmental permits. (Check all that apply and print or type the corresponding permit
number for each.
E
d
Existing Environmental Permits
a.
✓❑ NPDES (discharges to surface
❑ RCRA (hazardous waste)
❑ UIC (underground injection
s
water)
control)
E
NCO038997
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
w
rn
❑ Ocean dumping (MPRSA)
❑ Dredge ge or fill (CWA Section
❑ Other (specify)
w
o
Page 1

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
NPDES Permit Number
Facility Name
Modified Application Form 2A
Roaring Gap Club WWTP
Modified March 2021
NC0038997
1.7
Provide the collections stem information
re uested below for the treatment works.
Municipality
Population
Collection System Type
Ownership Status
Served
Served
indicate percenta e
100 % separate sanitary sewer
0 Own 0 Maintain
Approx. 30
100
% combined storm and sanitary sewer
❑ Own ❑ Maintain
vacation homes
❑ Unknown
❑ Own ❑ Maintain
c
% separate sanitary sewer
❑ Own ❑ Maintain
w
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
a%
separate sanitary sewer
❑ Own ❑ Maintain
a
% combined storm and sanitary sewer
❑ Own ❑ Maintain
R
❑ Unknown
❑ Own ❑ Maintain
d%
separate sanitary sewer ❑ Own ❑ Maintain
% combined storm and sanitary sewer ❑ Own ❑ Maintain
"'
ElUnknown ❑ Own ElMaintain
c
. J
Total
61
Population
100
c i
Served
Combined Storm and
Separate Sanitary Sewer System
Sanitary Sewer
Total percentage of each type of
sewer line in miles
1.8
Is the treatment works located in Indian Country?
o
❑ Yes ❑ No
1.9
Does the facility discharge to a receiving water that flows through Indian Country?
c
❑ Yes ✓❑ No
1.10
Provide design and actual flow rates in the designated spaces.
Design Flow Rate
0.13 mgd
Annual Average Flow Rates Actual
a
Two Years Ago
Last Year
This Year
0
0.0060 mgd
0.0045 mgd
0.0030 mgd
Zn
Maximum Daily Flow Rates Actual
0
Two Years Ago
Last Year
This Year
0.0o90 mgd
o.0o90 mgd
0.0060 mgd
1.11
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
Total Number of Effluent Dischar a Points by Type
a CL a)
a) �
Treated Effluent
Untreated Effluent
Combined Sewer
Bypasses
Constructed
Emergency
Overflows
Overflows
u
i
0
0
0
0
Page 2

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
NPDES Permit Number
Facility Name
Modified Application Form 2A
Roaring Gap Club WWTP
Modified March 2021
NC0038997
Outfails Other Than to Waters of the State of North Carolina
1.12
Does the POTW discharge wastewater to basins, ponds, or other surface impoundments that do not have outlets
for discharge to waters of the State of North Carolina?
❑ Yes ❑ No + SKIP to Item 1.14.
1.13
Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Im oundment Location and Dischar a Data _
Average Daily Volume
Continuous or Intermittent
Location
Discharged to Surface
(check one)
Im oundment
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
0
1.14
Is wastewater applied to land?
❑ Yes ❑✓ No SKIP to Item 1.16.
0
1.15
Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
o
Average Daily Volume
Continuous or
o
Location
Size
Applied
Intermittent
check one
acres
gpd
❑ Continuous
N
0
❑ Intermittent
❑ Continuous
0
acres
gpd
ElIntermittent
acres
gpd
❑ Continuous
❑ Intermittent
1.16
Is effluent transported to another facility for treatment prior to discharge?
0
❑ Yes m No 4 SKIP to Item 1.21.
1.17
Describe the means by which the effluent is transported (e.g., tank truck, pipe).
1.18
Is the effluent transported by a party other than the applicant?
❑ Yes ❑ No 4 SKIP to Item 1.20.
1.19
Provide information on the transporter below.
Trans oher Data
Entity name
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
Page 3

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
NPDES Permit Number Facility Name Modified Application Form 2A
Roaring Gap Club WWTP Modified March 2021
NC0038997
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
facility.
—receiving
Receivin IF cilitv Data
a
Facility name
Mailing address (street or P.O. box)
a�
City or town
State
ZIP code
0
U
Contact name (first and last)
Title
0
d
Phone number
Email address
nNPDES
number of receiving facility (if any) ❑ None
Average daily flow rate mgd
C
0
1.21
Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
0
not have outlets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
R
El Yes ❑✓ No > SKIP to Item 1.23.
L
0
1.22
Provide information in the table below on these other disposal methods.
t
Information on Other Disposal Methods
o
Disposal
Location of
Size of
Annual Average
Continuous or Intermittent
Method
Disposal Site
Disposal Site
Daily Discharge
(check one)
Description
Volume
acres
gpd
❑ Continuous
❑ Intermittent
❑ Continuous
acres
gpd
❑ Intermittent
acres
❑ Continuous
gpd
❑ Intermittent
1.23
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)? (Check all that apply.
Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
❑ Discharges into marine waters (CWA ❑ Water quality related effluent limitation (CWA Section
Section 301(h)) 302(b)(2))
❑✓ Not applicable
1.24
Are any operational or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works
the responsibility of a contractor?
❑✓ Yes ❑ No +SKIP to Section 2.
1.25
Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
Contractor Information
Contractor 1
Contractor 2
Contractor 3
0
Contractor name
is
(company name
Pace Analytical
Mailing address
c
street or P.O. box
1377 South Park Drive
o
City, state, and ZIP
@
code
Kernersville, NC 27284
Contact name (first and
c0i
last)
Jessica Mize
Phone number
[phone]
Email address
Operational and
Contractor is Operator in
maintenance
Responsible Charge of Vv1NTP
responsibilities of
operations
contractor
Page 4

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
NPDES Permit Number Facility Name Modified Application Form 2A
Roaring Gap Club WWTP Modified March 2021
NC0038997
SECTION11 • •' • I
o Outfalls to Waters of the State of North Carolina
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
o
❑ Yes ❑✓ No 4 SKIP to Section 3.
0
2.2
Provide the treatment works' current average daily volume of inflow
Average Daily Volume of Inflow and Infiltration
and infiltration.
gptl
Indicate the steps the facility is taking to minimize inflow and infiltration.
o
3
0
_
s
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
M Q
specific requirements.)
6M
o
o
❑ Yes ❑ No
E
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
o
(See instructions for specific requirements.)
_ rn
a
❑ Yes ❑ No
2.5
Are improvements to the facility scheduled?
❑ Yes ❑ No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
=
0
c
a�
E
n
2.
E
0
3.
d
5
4.
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Im rovements
>
Scheduled
Affected
Outfalls
Begin
End
Begin
Attainment of
Operational
o
a
Improvement
(list outfall
Construction
Construction
Discharge
Level
E
(from above)
number)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
MM/DD/YYYY
d
s
U
2.
3.
4.
2.7
Have appropriate permits/clearances concerning other federal/state requirements been obtained? Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
NPDES Permit Number
Facility Name Modified Application Form 2A
Roaring Gap Club WWTP Modified March 2021
NCO038997
SECTION•'
• ON
Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
3.1
Outfall Number
Outfall Number
Outfall Number
State
North Carolina
County
Alleghany
V
O
0
City or town
Roaring Gap
s
Distance from shore
NA ft.
Q
y
Depth below surface
NA
0
Average daily flow rate
0.0046 mgd
mgd
mgd
Latitude
36° 25' 22' N
°
Longitude
80' 57' 46" W
°
3.2
Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
o
❑ Yes ✓❑ No + SKIP to Item 3.4.
d
3.3
If so, provide the following information for each applicable outfall.
L
y
Outfall Number
Outfall Number
Outfall Number
Number of times per year
g
discharge occurs
a
Average duration of each
o
discharge (specify units
c
Average flow of each
mgd
mgd
mgd
ti
discharge
u,
Months in which discharge
occurs
3.4
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes ❑✓ No SKIP to Item 3.6.
3.5
Briefly describe the diffuser t pe at each applicable outfall.
CL
Outfall Number
Outfall Number
Outfall Number
d
0
Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
UO vi
�
3 6
one or more discharge points?
❑✓ Yes ❑ No +SKIP to Section 6.
Page 6

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
NPDES Permit Number
Facility Name
Modified Application Form 2A
Roaring Gap Club WWTP
Modified March 2021
NCO038997
37
Provide the receivin water and related information if known for each outfall.
Outfall Number I
Outfall Number
Outfall Number
Receiving water name
UT to Mitchell River
Name of watershed, river,
0
or stream system
Upper Pee Dee Basin
U.S. Soil Conservation
Service 14-digit watershed
o
code
030401010501
Name of state
3:
managementiriver basin
Pee Dee River Watershed
.5
U.S. Geological Survey
8-digit hydrologic
cataloging unit code
03040101
Critical low flow (acute)
cfs
cfs
cfs
Critical low flow (chronic)
cfs
cfs
cfs
Total hardness at critical
mg/L of
mg/L of
mg/L of
low flow
CaCO3
CaCO3
CaCO3
3.8
Provide the following information
describing the treatment pr vided for discharges from each outfall.
Outfall Number
Outfall Number
Outfall Number
Highest Level of
❑ Primary
❑ Primary
❑ Primary
Treatment (check all that
❑ Equivalent to
❑ Equivalent to
❑ Equivalent to
apply per outfall)
secondary
secondary
secondary
0 Secondary
❑ Secondary
❑ Secondary
❑ Advanced
❑ Advanced
❑ Advanced
❑ Other (specify)
❑ Other (specify)
❑ Other (specify)
QDesign
Removal Rates by
Outfall
BODS or CBOD5
90 %
%
%
d
E
TSS
90
m Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
%
m Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
%
%
%
Other (specify)
❑ Not applicable
❑ Not applicable
❑ Not applicable
Fecal Coliform
o
99 /o
%
Page 7

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
NPDES Permit Number
Facility Name
Modified Application Form 2A
Roaring Gap Club WWTP
Modified March 2021
NC0038997
3.9
Describe the type of disinfection used for the effluent from each outf all in the table below. If disinfection varies by
season, describe below.
Ultra -violet light disinfection with chlorination/dechlori nation back-up system
a
c
c
0
Outfall Number 1
Outfall Number
Outfall Number
0
.S
Disinfection type
UV Light with chlorination -
U
dechlorination back-up system
0
Seasons used
All
d
E
d
Dechlorination used?
❑ Not applicable
❑ Not applicable
❑ Not applicable
~
❑✓ Yes
❑ Yes
❑ Yes
❑ No
❑ No
❑ No
3.10
Have you completed monitoring for all Table A parameters and attached the results to the application package?
✓❑ Yes ❑ No
3.11
Have you conducted any WET tests during the 4.5 years prior to the date of the application on any of the facility's
discharges or on any receiving water near the discharge points?
❑ Yes © No 4 SKIP to Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
Number of tests of discharge
rn
water
Number of tests of receiving
water
15
LU
w
3.14
Does the POTW use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
❑ Yes 4 Complete Table B, including chlorine. ✓❑ No 4 Complete Table B, omitting chlorine.
3.15
Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
0 Yes ❑ No
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
3.18
attached the results to this application package?
0 Yes ❑ No additional sampling required by NPDES
permittingauthority.
Page 8

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
NPDES Permit Number
Facility Name
Roaring Gap Club WWTP
Modified Application Form 2A
Modified March 2021
NCO038997
3.19
Has the POTW conducted either (1) minimum of four quarterly WET tests for one year preceding this permit application
or (2) at least four annual WET tests in the past 4.5 years?
❑ Yes ❑✓ No + Complete tests and Table E and SKIP to
Item 3.26.
3.20
Have you previously submitted the results of the above tests to your NPDES permitting authority?
❑ Yes ❑ No 4 Provide results in Table E and SKIP to
Item 3.26.
3.21
Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
Summary of Results
MM/DD/YYYY
m
c
0
R
3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
o
toxicity?
�'
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
d
ui
w
3.24
Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.25
Provide details of any toxicity reduction evaluations conducted.
3.26
Have you completed Table E for all applicable outfalls and attached the results to the application package?
❑ Yes Not applicable because previously submitted
information to the NPDES permifting authority.
Page 9

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
NPDES Permit Number
Facility Name Modified Applicabon Form zA
Roaring Gap Club WWTP Modified March 2021
NC0038997
SECTION•
1
In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
6.1
each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not
all applicants are required to provide attachments.
Column 1
Column 2
❑✓ Section 1: Basic Application
❑ w/ variance request(s) ❑ w/ additional attachments
Information for All Applicants
Section 2: Additional
❑ wl topographic map ❑ w/ process flow diagram
❑
Information
❑ wl additional attachments
© w/ Table A © wl Table D
❑ Section 3: Information on
© w/ Table B ❑ w/ additional attachments
Effluent Discharges
E
❑ w/ Table C
d
R
Section 4: Not Applicable
0
�v
Section 5: Not Applicable
d
�a
Section 6: Checklist and
✓❑
❑ wl attachments
Certification Statement
.r
Y
6.2
Certification Statement
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 qualified personnel properly gather and evaluate 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 fine
and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Randy Crouse
Public Works Director
nature
Date signed
Page 10

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
NPDES Permit Number
Facility Name
Outfall Number
W
Roaring Gap Club WTP
NC0038997
Modified Application Form 2A
Modified March 2021
Maximum Daily Discharge
Average Daily Discharge
Analytical
ML or MDL
Value
Units
Number of
Pollutant
Value Units
Methods
include units
( )
Samples
Biochemical oxygen demand
Ei BOD5 or ❑ CBOD5
2.0 mg/I [a MDL
(report one
34.7
mg/I
2.3
mg/I
53
SM5210 B-2011
❑ ML
Fecal coliform
341
/100 ml
1.44
/100 ml
153
1 ❑ MDL
Design flow rate
0.009
MGD
0.0046
MGD
153
pH (minimum)
6.3
pH (maximum)
6.9
Temperature (winter)
4
deg. C
11.6
deg. C
53
Temperature (summer)
25
deg. C
18.6
deg. C
53
Total suspended solids (TSS)
17'9
mg/I
1.5
mg/I
53
SM2540 D-2011
❑ ML
❑MDL
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 11

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
Identification Number NPDES Permit Number I Facility Name Outfall Number
Roaring Gap Club WWTP
Modified Application Form 2A
Modified March 2021
Average Daily Discharge
Analytical
ML or MDL
Maximum Daily
Discharge
Value
Units
Value
Units
Number of
Pollutant
Methods
include units
( )
Samples
Ammonia (as N)
4.3
mg/I
0.40
mg/I
53
EPA 350.1
El ML
0.10 mg/I 17 MDL
Chlorine
❑ ML
total residual, TRC 2
❑ MDL
❑ ML
Dissolved oxygen
❑ MDL
❑ ML
Nitrate/nitrite
❑ MDL
❑ ML
Kjeldahl nitrogen
❑ MDL
❑ ML
Oil and grease
❑ MDL
Phosphorus
1.9
mg/I
0.83
mg/I
9
EPA 365.4
0 ML
0.05 mg/I ❑ MDL
❑ ML
Total dissolved solids
❑ MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 GFR i 36 ror the analysis oT ponutams or ponutant pararnerurs vi
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
2 Facilities that do not use chlorine for disinfection, do not use chlorine elsewhere in the treatment process, and have no reasonable potential to discharge chlorine in their effluent are not
required to report data for chlorine.
EPA Form 3510-2A (Revised 3-19) Page 12

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Moainea Hppucauon rorm zH
Roaring Gap Club WWTP
Modified March 2021
NCO038997
-1111160A
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant Number of
Method' (include units)
Value Units Value Units
Samples
Metals, Cyanide, and Total Phenols
❑ ML
Hardness (as CaCO3)
❑ MDL
❑ ML
Antimony, total recoverable
❑ MDL
❑ ML
Arsenic, total recoverable
❑ MDL
❑ ML
Beryllium, total recoverable
❑ MDL
❑ ML
Cadmium, total recoverable
❑ MDL
❑ ML
Chromium, total recoverable
❑ MDL
❑ ML
Copper, total recoverable
❑ MDL
❑ ML
Lead, total recoverable
❑ MDL
❑ ML
Mercury, total recoverable
❑ MDL
❑ ML
Nickel, total recoverable
❑ MDL
❑ ML
Selenium, total recoverable
❑ MDL
❑ ML
Silver, total recoverable
❑ MDL
❑ ML
Thallium, total recoverable
❑ MDL
❑ ML
Zinc, total recoverable
❑ MDL
❑ ML
Cyanide
❑ MDL
❑ ML
Total phenolic compounds
❑ MDL
Volatile Organic Compounds
❑ ML
❑ MDL
❑ ML
trile
❑ MDL
[Benzene
❑ ML
❑ MDL
❑ML
rm
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 13

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
Roaring Gap Club WWTP
Modified March 2021
NC0038997
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant Number of
Method' (include units)
Value Units Value Units
Samples
❑ ML
Carbon tetrachloride
❑ MDL
❑ ML
Chlorobenzene
❑ MDL
❑ ML
Chlorodibromomethane
❑ MDL
❑ ML
Chloroethane
❑ MDL
❑ ML
2-chloroethylvinyl ether
❑ MDL
❑ ML
Chloroform
❑ MDL
❑ ML
Dichlorobromomethane
❑ MDL
❑ ML
1,1-dichloroethane
❑ MDL
❑ ML
1,2-dichloroethane
❑ MDL
❑ ML
trans-1,2-dichloroethylene
❑ MDL
❑ ML
1,1-dichloroethylene
❑ MDL
❑ ML
1,2-dichloropropane
❑ MDL
❑ ML
1,3-dichloropropylene
❑ MDL
❑ ML
Ethylbenzene
❑ MDL
❑ ML
Methyl bromide
❑ MDL
❑ ML
Methyl chloride
❑ MDL
❑ ML
Methylene chloride
❑ MDL
❑ ML
1,1,2,2-tetrachloroethane
❑ MDL
❑ ML
Tetrachloroethylene
❑ MDL
❑ ML
Toluene
❑ MDL
❑ ML
1,1,1-tdchloroethane
❑ MDL
❑ ML
1,1,2-tdchloroethane
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 14

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application form 2A
Roaring Gap Club WWTP
Modified March 2021
NC0038997
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant Number of
Method' (include units)
Value Units Value Units Samples
❑ ML
Trichloroethylene
❑ MDL
-
❑ ML
Vinyl chloride
❑ MDL
Acid -Extractable Compounds
❑ ML
p-chloro-m-cresol
O MDL
❑ ML
2-chlorophenol
❑ MDL
❑ ML
2,4-dichlorophenol
O MDL
O ML
2,4-dimethylphenol
❑ MDL
❑ ML
4,6-dinitro-o-cresol
❑ MDL
❑ ML
2,4-dinitrophenol
❑ MDL
O ML
2-nitrophenol
❑ MDL
O ML
4-nitrophenol
❑ MDL
❑ ML
Pentachlorophenol
❑ MDL
❑ ML
Phenol
❑ MDL
O ML
2,4,6-trichlorophenol
❑ MDL
Base -Neutral Compounds
❑ ML
Acenaphthene
- --
❑ MDL
-
❑ ML
Acenaphthylene
❑ MDL
❑ ML
Anthracene
❑ MDL
O ML
Benzidine
O MDL
O ML
Benzo(a)anthracene
❑ MDL
❑ ML
Benzo(a)pyrene
❑ MDL
❑ ML
3,4-benzofluoranthene
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 15

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
EPA Idenbfication Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 1A
Roaring Gap Club WWTP
Modified March 2021
NC0038997
WINE•' ••
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant Number of
Method' (include units)
Value Units Value Units
Samples
❑ ML
Benzo(ghi)perylene
❑ MDL
❑ ML
Benzo(k)fluoranthene
❑ MDL
❑ ML
Bis (2-chloroethoxy) methane
❑ MDL
❑ ML
Bis (2-chloroethyl) ether
❑ MDL
❑ ML
Bis (2-chloroisopropyl) ether
❑ MDL
❑ ML
Bis (2-ethylhexyl) phthalate
❑ MDL
❑ ML
4-bromophenyl phenyl ether
❑ MDL
❑ ML
Butyl benzyl phthalate
❑ MDL
❑ ML
2-chloronaphthalene
❑ MDL
❑ ML
4-chlorophenyl phenyl ether
❑ MDL
❑ ML
Chrysene
❑ MDL
❑ ML
di-n-butyl phthalate
❑ MDL
❑ ML
di-n-octyl phthalate
❑ MDL
❑ ML
Dibenzo(a,h)anthracene
❑ MDL
❑ ML
1,2-dichlorobenzene
❑ MDL
❑ ML
1,3-dichlorobenzene
❑ MDL
❑ ML
1,4-dichlorobenzene
❑ MDL
❑ ML
3,3-dichlorobenzidine
❑ MDL
❑ ML
Diethyl phthalate
❑ MDL
❑ ML
Dimethyl phthalate
❑ MDL
❑ ML
2,4-dinitrotoluene
❑ MDL
❑ ML
2,6-dinitrotoluene
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 16

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
EPA Identification Number NPDES Permit Number Facility Name
Roaring Gap Club WWTP
NCO038997
Maximum Daily Discharge Averag,
Pollutant
Value Units Value
1,2-diphenylhydrazine
Fluoranthene
Fluorene
Hexachlorobenzene
Hexachlorobutadiene
Hexachlorocyclo-pentad iene
Hexachloroethane
Indeno(1,2,3-cd)pyrene
Isophorone
Naphthalene
Nitrobenzene
N-nitrosodi-n-propylamine
N-nitrosodimethylamine
N-nitrosodiphenylamine
Phenanthrene
Pyrene
1,2,4-trichlorobenzene
t Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved ui
required under 40 CFR Chapter I, Subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2A (Revised 3-19) Page 17

DocuSign Envelope ID: B8AOE7D1-3E51-4E61-9758-7D8D89DBAA91
NPDES Permit Number Facility Name Outfall Number
moamea Nppucaaan runn Zh
Roaring Gap Club WWTP
Modified March 2021
NCO038997
•� • •• • • •• •'
Maximum Daily Discharge -Average Daily Dischar a
Analytical ML or MDL
Pollutant
(list) Value Units Value Units Number
Method' (include units)
Samples
❑ No additional sampling is required by NPDES permitting authority.
❑ ML
Total Nitrogen
13.2
mg/I
3.71
mg/I
9
-�9_ ibtDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
— ---
❑ ML
❑ MDL
——
❑ML
❑ MDL
OML
❑ MDL
-- - -
-
❑ML
❑ MDL
0 ML
❑ MDL
-
—
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
—- —
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 4U L;Fk i36 Tor the analysis or pouutanrs or powtarn pafamereis yr rCyurreu
under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 18