NCG550491_Compliance Evaluation Inspection_20191031

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
Donald Davis
2055 Davis Ridge Rd.
Kernersville, NC 27284
NORTH CAROLINA
Environmental Quality
October 31, 2019
SUBJECT: Compliance Evaluation Inspection
Certificate of Coverage #NCG550491 — General Permit 550000
Single -Family NPDES Wastewater Treatment System
2055 Davis Ridge Rd. Kernersville, NC 27284
Forsyth County
Dear Mr. Davis:
On October 23, 2019, staff of the North Carolina Division of Water Resources' Winston-Salem
Regional Office (DWR) performed a compliance inspection of the single-family NPDES
wastewater treatment system located at the subject property. This compliance inspection was
conducted by DWR staff person Mr. Justin Henderson. Inspection of the wastewater treatment
system reflects compliance with Permit No. NCG550491.
If you have any questions concerning this letter, you may contact Justin Henderson or me at (336)
776-9800.
Sincerely,
EDocuSigned by:
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145B49E225C94EA...
Lon Snider, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ-WSRO
enc: Inspection Report
cc: Laserfiche (electronic copies)
D E Q�� North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 West Hanes Mill Road, Suite 300 I Winston-Salem, North Carolina 27105
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United States Environmental Protection Agency
Form Approved.
EPA Washington, D.C. 20460
OMB No. 2040-0057
Water Compliance Inspection Report
Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 IN I 2 15 I 3 I NCG550491 111 12 I 19/10/23 I17
18 I S J 19 L G] 201 I
211111 1 1 I I I I II I I I I I I I I I I I I 1 I I I I
I I I I I I II I I I I I f6
Inspection
Work Days Facility Self -Monitoring Evaluation Rating 131 QA
---------------------- Reserved -------------------
671
70 I I 71 I I 72 I r I
u ty
73 I I 174 751 I I I I I I I80
I I i
Section B: Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
Entry Time/Date
Permit Effective Date
POTW name and NPDES oermit Number)
09:OOAM 19/10/23
13/08/01
2055 Davis Ridge Road
2055 Davis Ridge Rd
Exit Time/Date
Permit Expiration Date
Kernersville NC 27284
10:OOAM 19/10/23
18/07/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
Donald F Davis,2055 Davis Ridge Rd Kernersville NC 27284//336-454-2795/
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Other
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers
Date
Justin L Henderson DocuSigned by: DWR/WSRO WQ/336-776-9701/
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D51F3525961`8113496..
10/31/2019
Signature of Management Q A R PcuSigned by: Agency/Office/Phone and Fax Numbers
Date
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7�1451349E225C94EA
10/31/2019
...
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page#

NPDES yr/mo/day Inspection Type
NCG550491 I11 121 19/10/23 117 18 ICI
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Dear Mr. Davis:
On October 23, 2019, staff of the North Carolina Division of Water Resources' Winston-Salem
Regional Office (DWR) performed a compliance inspection of the single-family NPDES wastewater
treatment system located at the subject property. This compliance inspection was conducted by DWR
staff person Mr. Justin Henderson. Inspection of the wastewater treatment system reflects compliance
with Permit No. NCG550491.
Page#

Permit: NCG550491
Inspection Date: 10/23/2019
Other
Comment:
Owner - Facility: 2055 Davis Ridge Road
Inspection Type: Compliance Evaluation
Yes No NA NE
Page#