NCG020721 DMR WW (3)

PROCESSIIVI M DEWATERING WASTEWATER DISCHARGE MONITORING REPORT (DMR)
Please Mail Original And One Copy To Mailing Address Below
GENERAL PERMIT NO. NCG020000
Part A: Facilitylrrformation
Samples Collected In Quarter: 10 20 3 40 (all samples shall be reported nithln 30 days following monitoring period)
1C -W
Certificate Of Coverage No. NCG02 County of Facility
Facility Name Wil I( C K C..& Name of Laboratory
Facility Contact KipbeirtS_ - Lab Certification it
Facility Contact Phone No. 25 2) 614 -'7 55� N.4Me 0J
Part B: Process Wastewater and Mine Dewatering Wastewater Monitoring Requirements C4 tlt.'rif , I
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1010
Za ,&IV OF Il h- 6J2c7 P 4 .
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Date 500501. t : . , T l,vf
osoQD400 00545
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Outfall Recelvld Stream nme Sam Ie Collected
Number; .. g P :DaIlgFloivt pH _- Tatal,Sospended Solids Tar6[dity settleable $oltds':
1 Measured continuously using a flow measuring device or estimated using maaufacturer)s pump curves and pump logs
Part C. Certification
"I certify, ander 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 evaluatethe 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 siguifieant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violatiopsk" A
s
(Signa re of Per 56
t (Date)
Pail D: Mailing Address
Attn: Central Files, DENR, N.C. Division of Water Quality, 1617 Mail Service Center, Raleigh, NC 27699-1617
REC
AUG 2 4 2015
CENTRAL FILES
DWR SECTION
SWU-244.012005
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