WQ0003090_Monitoring - 09-2020_20201026

Monitoring Report Submittal
Permit Number #* wg0003090
Name of Facility:* town of liberty wastewater plant
Month:* September Year:* 2020
Report Information
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR sept 2020 spray report.pdf 1.13MB
FDF only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-t, NDAR-2, NDMLR, GW-59).
Confirmation Email Address:* [e-mail]
Name of Submitter:* tremaine fike
Signature:
9P;W1?r.
Date of submittal: 10/26/2020
This will be filled in autorratically
Initial Review
Reviewer: Williams, Kendall

Is the project number correct? * WQ0003090
Is the monitoring report r Yes r No
accepted?*
Regional Office * Winston-Salem
Accepted Date: 10/26/2020

FORM: NDMR 10-13
NON -DISCHARGE MONITORING REPORT (NDMR)
Page -1- of
Permit No.: WQ0003090
Facility Name:
Town Of Liberty - Wastewater
County:
Randolph
Month:
September
Year: 2020
PPI:
Flow Measuring Point: Influent ❑ Effluent ❑ No flow generated
Parameter Monitoring Point:
❑ Influent
Q Effluent
❑ Groundwater lowering
❑ Surface Water
Parameter Code -1050060
0040
000310
00610
00530
31613 00620
0062B
00666
60060
00600
70300
00940
00630
00010
a
e
IE E
1=y
c
x
oco
€ �@
mm
°
�°
m
as
V
LL
a
O
E
o$ o
Y
o a
o9 °
c
o 0�
C
E
o
ce
z
�
zz
oz
a
c
v
m
24-hr hrs
GPD
su
mg/L
mg/L
m /L
#/100 mL mg/L
t-
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
1!
°C
1
7:00 8
1 274,000
2
7:00 8
267,000
3
7:00 8
237,000
6.73
18.4
7.16
38.9
>2420 <0.3
10.9
1.82
0.03
10.9
<0.3
2.4
4
7:00 8
243,000
5
261,000
6
211,000
7
7:00 8
190,000
8
7:00 8
216,000
9
7:00 8
228,000
10
7:00 8
247,000
6.97
0.26
11
7:00 8
224,000
12
10:00 2
822,000
13
11:00 2
343,000
14
7:00 8
224,000
16
7.00 8
243,000
16
7:00 8
224,000
17
7:00 8
253,000
6.69
10.7
5.67
22
>2420 <0.05
10.8
5.36
0.04
10.8
<0.05
2.6
18
700 8
2,289,000
19
11:00 2
1,205,000
20
13:00 2
416,000
21
7:00 8
256,000
22
7:00 8
287,000
23
7:00 8
286,000
24
7:00 8
2979000
7.51 1
0.42
25
7:00 8
271,000
26
1,875,000
27
7:00 8
550,000
28
359,000
29
377,000
30
1,600,000
31
Average:
492,500
14.55
6.42
30.45
1.00 0.00
#REF!
3.59
0.19
10.85
0.00
2.50
Daily Maximum:
2,289,000
7.51
18.40
7.16
38.90
0,00 0.30
#REF[
5,36
0.42
10.90
0.30
2.60
Daily Minimum:
190,000
6.69
10.70
6.67
22.00
0.00 0.05
#REF!
1.82
0.03
10.80
0.05
2.40
Sampling Type.
Recorder
Monthly Avg. Llmlt:
Daily Limit:
550,000
Sample Freq .ncy:
Dairy
weekly
2. mo�th2.month
2xmonth
�2...th� 2x month
2x month
2x month
weekly
2x month
3x year
3x year
2x month
-1-

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR)
Sampling Person(s) Certified Laboratories y
Name: GLENN PRICE Name: RESEARCH & ANALYSIS LABORATORIES, INC
Name: GARRETT DREYER Name: i
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? 0 compliant ❑ Non-Comolant
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
actions) taken. Attach additional sheets if necessary.
non compliant on the date of 9/12 9/18 9/19 AND 9/26of I&I cause
Operator In Responsible Charge (ORC) Certification
ORC: Elix Tremaine Fike
Certification No.: 989290
Grade: SI Phone Number: 336 622 2990
Has the ORC changed since the previous NDMR? ❑ Yes I] No
Permittee Certification
Permittee: William Doerfer
Signing Official:
Signing Official's Title: Town Manager
Phone Number: 336 622 4276
Permit Expiration: 8/31/2024
Signature Date y nature
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
_ Y 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

RESEARCh & AIYAlyT1CAI
LAWRATORIES, iAC.
For: Town of Liberty
P.O. Box 1006
Liberty, NC 27298
Attn: Kevin Coble
Report of Analysis
9/17/2020
ANki'jy'��i
aa`D NC#34 Z��
S NC#37701
i
:lient Sample ID: Effluent
— —
—
iite: Town of Liberty
Lab Sample 1D: 86956-01
— - -- —
T
Collection Date: 9/3/2020
11:45
Parameter
Method
Result
Units
Rep Limit
Analyst Anal sis DateRime
Ammonia Nitrogen
SM 4500 NH3 D-2011
7.16
-
—
--
mg/L
0.1
FK
9/8/2020
— -
BOD-5
SM 5210 B-2011
18.4
mg/L
2
HW
9/4/2020
1545
Chlorine Residual
SM 4500 Cl G-2011
0.03
ug/L
9/3/2020
1145
Fecal Coliform QT
Colilert 18
>2420
MPN/100ml 1
BJ
9/3/2020
1432
Nitrate + Nitrite
Hach 10206
<0.3
mg/L
0.3
FK
9/4/2020
0830
Nitrate Nitrogen
Hach 10206
<0.3
mg/L 9
0.3
FK
9/4l2020
0830
>H
SM 4500 H+B-2011
6.73
Std. Units
9/3/2020
1145
.otal Kjedjahl Nitrogen
Hach 10242
10.9
mg/L
1
FK
9/17/2020
'otal Nitrogen
Calc
10.9
mg/L
1
otal Phosphorous
SM 4500 P E-2011
1.82
mg/L
0.05
BJ
9l9I2020
otal Suspended Solids
SM 2450 D-2011
38.9
mg/L
5
AW
9/3/2020
NA = not anolyzed
;c
Box _ 473 106 ShortStreet Kernersville, North Carolina 27284 Tel: [phone] Fax: [phone] www.randalabs.com
Page 1

lies -;arch & Analytical
I Laboratories, Inc.
i
Analytical / Process Consultations
Phone [phone]
CHAIN OF CUSTODY RECORD
Water/ IVastewater I A sc.
Company Town Of Liberlly
Job No.
Street Address
Project Effluent
(Is't and 3rd weeks)
r
�
f
City, Sta(e, Zip
Sampler Name (I' se Print)
�
^
r
ai
n
+.
Contact Phone
Sampler 4i n' 'Uwe)
-
i
eo
Sample Number
1'emp Res, Chlorine
Sample
o
m
a
Date 'Dime Comp CraI
(Lab Use Qnly)
„C Cl Removed
Matrix sample Location ! LD.
Z
U
T
E E
o 0
a
V
a:
a:
n:
VorN
SorM
M
M
`�' t= 1•'.r''y ;i`<< \
;''.`i ['.=?
W Effluent
0 1
1
1
3
I
1
!Zn�y Date/Dime
Relinquished By r Uatefl'imc
Received By
Remarks:
Requested Analysis
BOD, TSS, NH3N, F.Coli,
TKN, NO3-N, T. Nitrogen
T. Phosphorus
Effl«eutt
pH:
TRC:
** March, July, November: Add Cl- and TDS to Eff sampling 1st Wk **
On Ike + Sample "Temperature at receipt ) LI 0C

RESEARCh ""..NAIyTICAI
I AbORATORkSp NC.
For: Town of Liberty
P.O. Box 1006
Liberty, NC 27298
Attn: Tremaine Fike
Client Sample ID: Effluent
Site: Town of Liberty
Parameter
Chlorine Residual
pH
Method
SM 4500 Cl G-2011
SM 4500 H+B-2011
Report of Analysis
9/14/2020
��'�G�►f► SLY ��'i�
:.i ; •.
+4Gi• 2 �4
0 NC #34 z: -
NC #37701
�(t`
•9 - 5.
Lab Sample ID: 87291-01
Collection Date: 9/102020 12:25
Result Units Rep Limit Analyst Analysis DatelTime
0.26 ug/L 9/102020 1225
6.97 Sid. Units 9/102020 1225
NA = not analyzed
P.O. Box 473 106 Short Street kemersville, North Carolina 27284 Tel: [phone] Fax: [phone] www.randalabs.com Page i

7y
iddress
ate, Zip
lumber
Ottly)
t
Research & Analytical
Laboratories, Inc.
Analytical / Process Consultations
Phone [phone]
Phone
Date I Time
jpq isii By Date/Time
(O 2J 'tj'j
inquished By I Daterrime
CHAIN OF CUSTOD Y R.ECORD
Water/Wastewater
project Effluent (211d, Mi and Silo weeks)
�'
»
Sampler Name (Please Print)
QQ»
Sampi %nature
s
O
z
Temp Res. Chlorine Sample
o
S
t
°i
U
v
�.
v
dv-
"C CI. Removed Matrix Sample Location ! I.D.
o
®
is
a
c7
a:
o:
a:
Y or N S or W
z
«
^�
,
^�
'� 11
y Z6 W EMuaat
0
By
Remarks:
On lee I Sample Temperature at receipt
MISC.
No sample -
Effluent
PH: • %
TRQ U. Z4
oC

- -- - ESEARCh '.NA[yTICAI
.boRATOR1ESr NC.
For: Town of Liberty
P.O. Box 1006
Liberty, NC 27298
Attn: Tremaine Fike
Client Sample ID: Effluent
Site: Town of Libert}
Parameter
Ammonia Nitrogen
BOD-5
Fecal Coliform QT
Nitrate + Nitrite
Nitrate Nitrogen
pH
Total Kjedjahl Nitrogen
Total Nitrogen
Total Phosphorous
Total Suspended Solids
Method
SM 4500 NH3 D-2011
SM 5210 B-2011
Colilert 18
SM 4500 NO3 E-2011
(SM 4500 NO3 E-2011)-(SM
4500 N 02 B-2011)
SM 4500 H+13-2011
Hach 10242
Calc
SM 4500 P E-2011
SM 2450 D-2011
Report of Analysis
9/29/2020
ogl-
IV.
A�
W NC #34 Z.- - w
NC #37701 i
• ��RECt�� �5 ice•~
yj�FD Ate`*�s+
Lab Sample ID:
87694-01
Collection Date:
9/17/2020 13:35
Result
Units
Re imit Analyst Analysis Date/Time
5.67
mg/L
0.1
FK
9/21/2020
10.7
mg/L
2
HW
9/18/2020
1600
>2420
MPN/100ml 1
BJ
9/17/2020
1649
<0.05
mg/L
0.05
LP
9/17/2020
1745
<0.05
mg/L
0.05
LP
9/17/2020
1745
6.69
Std. Units
9/17/2020
1335
10.8
mg/L
1
FK
9/25/2020
10.8
mg/L
1
5.36
mg/L
0.05
BJ
9/22/2020
22.0
mg/L
5
AW
9/21/2020
,— -,,u, vncwy[eU
P.O. Box 473 106 Short Street Kernersville, North Carolina 27284 Tel: [phone] Fax: [phone] www.randalabs.com Page 1

Research & Analytical
Laboratories, Inc.
Analytical / Process Consultations
I'honc (336) 9196-2841
Company Town
+treet Address
::ity, State, Zip
:ontact Phone
tiamplr Number
(1.NI) Use 0111%) Date "Ilile
Relinquished fly / DateCiime
Job No.
CHAIN OF CUSTODY RECORD
Water/ Mule water I Misc.
"Project Effluent (Ist and 3rd weeks)
d
v
X
Sampler Name (Please Print)
G
�
i
—
Sampler "gtnttbrc
C
0
C
r
w
o
e V
p lies. Chlorine Sample
o
Grah Removed Matrix Sample Location / I.D.
.,C CI.
p
�;
E
E
E
e
u
�;
Z.
1'orN SorWi
Z
r;
.�
.�
—
.�
..
—
.� v
A
C" , w Grfluent
0
1
1 T
t
F
1
Receive)
fly
Remarks:
Un Ice
Requested Ana1►sis
BOD, TSS, NH3N, F.Coli,
TKN, NO3-N, T. Nitrogen
T. Phosphorus
Effluent
pH:
-rRC:
** March, July, November: Add CI- and TDS to F.ff sampling 1st Wk **
Saalple Temperature at receipt U '—C

RESEARCIi NA[yTICA[
LAbORA70R1E5, NC,
For: Town of Liberty
P.O. Box 1006
Liberty, NC 27298
Attn: Tremaine Fike
Client Sample ID: Effluent
Site: Town of Liberty
Parameter Method
Chlorine Residual SM 4500 Cl G-2011
pH
SM 4500 H+B-2011
Report of Analysis
9/27/2020
P5 NC #34 y�
S NC #37701
'+mac ` �O�:t 4'•f'� •tiA
Lab Sample ID: 88033-01
Collection Date: 9/24/2020 9:04
Result Units Reo Limit Analyst Analysis Date/Time
0.42 ug/L 9124t202O 0904
7.51 Std. Units
9/24/2020 0904
NA = not analyzed
P.O. Box 473 106 Short Street Kernersville, North Carolina 272114 Tel: [phone] Fax: [phone] www.randalabs.com Page 1

r . Research & Analytical
Laboratories, Inc.
^ •'� Analytical / Process Consultations
Phone [phone]d1
)mpany Town of Liberty Job No.
reef Address
ty, State, Zip
intact Phone
Sample Number
(la+b Use
(h+ly) Date 1'inte
CHAIN OF CUSTODY RECORD
Hider / Mislewater I hlisc'.
Saniplcr Si nature
�elijvprishcd By Datefl'ime eceir d [3
Relinquished By Date/Tiurc Received By
Remarks:
Requested Analvsis
No sample - pH, TRC On
Effluent
pH: 7-5-1
Oil Ice I Sample •Temperature at receipt T
RC: _ O v L

September 2020
Liberty N.C.W.W.T.F.
Freeboard Lagoon Inches
DATE
1
0
2
0
3
0
4
0
5
0
6
1/2
7
1
8
2
9
2
R 0.3
10
2
11
2
R 2.0
12
0
13
0
14
0
15
0
16
0
17
0
R 3.0
18
0
19
0
20
0
21
0
22
0
23
0
24
0
R 1.5
25
0
R 0.3
26
0
27
0
28
0
29
0
R 1.4
30
0
31
0
TOTAL 8.5

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page Ti_ of _2_
Permit No.: WQ0003090 Facility Name: Town of Liberty - Wastewater County: Randolph Month: September Year: 2020
Field Name: 1 Field Name: 2 Field Dame: 3 Field Name: 4
Did irrigation occur
Area (acres): 19.56 Area (acres): 19.54 Area (acres): 18.98 Area (acres): 16.78
at this facility? Cover Crop: FESCUE Cover Crop: FESCUE Cover Crop: FESCUE Cover Crop: FESCUE
YES ❑ No Hourly Rate (in): 0.21 Hourly Rate (In): 0.21 Hourly Rate (in): 0.21 Hourly Rate (In). 0.21
Annual Rate (in): 52 Annual Rate (in): 52 Annual Rate (in): 52 Annual Rate (in): 52
Weather Freeboard Field Irrigated? (] YES NO Field Irrigated? YES ❑ No Field Irrigated? ❑ YES r7 NO Field Irrigated? YES ❑ No
E
= 5E�.e
E
cri Ew z-t wEeE S. o c ooE, _co a >o F 4MQ xoo o o � �E - � a '
j
OF in ft ft gal min in in gat min In in gal min in In gal min In In
1
2 C 84 0 281,000 180 0.62 0.21
3 C 76 0 327,000 180 0.62 0.21 321,000 180 0.61 0.20
4
5
a C 1 72 0 281,000 180 0.62 0.21
7 C 56 0 327,000 180 0.62 0.21
8 C 59 0 321,000 180 0.61 0.20
9 CL 0.3 0
10
11 C 70 2 0 1 281,000 180 0.62 0.21
12
13 C 75 D 1 327,000 180 0.62 0.21
14 C 65 0 321,000 180 0.61 0.20
16
16 C 76 0 281,000 180 0.62 0.21
17 R 3
18
19 C 75 0 281,000 180
20 0.62 0.21
21 C 55 0 321,000 180 0.61 0.20
22
23 C 75 1 0 327,000 180 0.62 0.21
24 R 1.5
25 R 0.3
26
27
28 PC 78 0 321,000 180 0.61 0.20
29 PC 76 1.4 0 327,000 180 0.62 0.21
30
31
Monthly Loading: 1,635,000 3.08 1,605,000 3.03 0 0.00 1,405,000 3.08
12 Month Floating Total (in): 38.51 39.34 22.11 37.63

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? El Compliant ❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? Q Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? p compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑ Compliant p 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.
THE LAGOON FREEBOARD IS NON COMPLIANT CAUSE OF RAINFALL AND I&I. of 8.5 inches Rai
ORC:
Operator in Responsible Charge (ORC) Certification
Elix Tremaine Fike
Certification No.: 989290
Grade: Sl Phone Number:
Has the ORC changed since the previous NDAR-1?
0
336 622 2990
❑ Yes ❑r No
1a,eQ1.2v?B
Signature r Date
By this signature, I certify that this report is accurate and complete to the best of my knowledge.
Permittee:
William Doerfer
Signing Official:
Permittee Certification
Signing Official's Title: Town Manager
Phone Number. 336 622 4276 Permit Exp.: 8/31/24
of f+ewre Date
I certify, under penalty of law, that this do ument 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 irdonnafion 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_
Permit No.: WQ0003090
Facility Name: Town of Liberty - Wastewater
county: Randolph
Month: September
Year: 2020
Did irrigation occur
at this facility?
D YES ❑ NO
Field Name:
5
Field Name:
6
Field Name:
7
Field Name:
8
Area (acres):
18.3
Area (acres):
15.1
Area (acres):
22.12
Area (acres):
21.68
Cover Crop;
FESCUE
Cover Crop:
FESCUE
Cover Crop:
FESCUE
Cover Crop:
FESCUE
Hourly Rate (in):
0.21
Hourly Rate (in):
0.21
Hourly Rate (In):
0.21
Hourly Rate (in):
0.21
Annual Rate (In):
52
Annual Rate (in):
52
Annual Rate (in):
52
Annual Rate (In):
52
T
l0
Weather
Freeboard
Field Irrigated?
[] yEs NO
Field Irrigated?
0 yES NO
Field irrigated?
yES Q No
Field Irrigated?
� 01
E £ CR
>a �'r
❑ yES (] No
C E.
� E3'v
°B �xa
$
V
,3
e
6
c
19
m
L°
rymp
O.R
cm
�ft
m 9�
E2
>-C
4/
E
�'E
RJ
�.c
W a
°�
is:ft O!
aZ �
boo
�_�
m
E�
0o
>a
m F
Em
�'
Cl
!�C 7.0 L
�A Eo'o
°� *9=�
01 'O
� m
�a
>a
Q�.i.
Ew
��
C
v
°�
7 �'C
Env
_�
OF
In
ft
gal
min
In
in
gal
min
in
in
gal
min
in
In
gal
min
In
in
1
CL
70
0
252,000
180
0.61
0.20
370,000
180
0.62
0.21
2
CL
74
0
299,000
180
0.60
0.20
3
4
C
72
0
252,000
180
0.61
0.20
370,000
180
0.62
0.21
5
C
76
0
299,000
180
0.60
0.20
8
7
8
C
85
0
370,000
180
0.62
0.21
9
CL
84
0.3
0
252,000
180
0.61
0.20
10
11
C
81
2
1 0
299,000
180
0.60
0.20
12
13
141
C
1 84
1 0
1
370,000
180
0.62
0.21
161
C
1 67
0
252,000
180
0.61
0.20
16
CL
62
0 1
299,000
180
0.60
0.20
17
R
3
18
19
20
C
75
0
299,000
180
0.60
6.20
21
22
C
69
0
252,000
180
0.61
0.20
370,000
180
0.62
0,21
23
24
R
1.5
25
R
0.3
28
271
PC 1
76
0
370,000
180
0.62
0.21
28
C 1
68
0
252,000
180
0.61
0.20
29
PC
1.4
30
31
Monthly
Loading:
1,496,000
3.01
38.11
1,512,000
3.69
42.24
2,220,000
3.70
42.73
0
0.00
30.75
12 Month Floating Total (In).

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit? El Compliant ❑Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
❑� Compliant ❑lion -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? El Compliant ❑lion -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? El Compliant El Non -compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑ Compliant 2 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.
THE LAGOON ARD 1S
FREEBONON COMPLIANT CAUSE OF RAINFALL AND I&I. of 8.5 inches Ra
ORC:
Operator in Responsible Charge (ORC) Certification
Efix Tremaine Fike
Certification No.: 989290
Grade: SI Phone Number: 336 622 2990
Has the ORC changed since the prevlous NDAR-1? ❑ Yes Q No
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
li Permittee:
Signing Official:
William Doerfer
Permlttee Certification
Signing Official's Title: Town Manager
Phone Number: 336 622 4276 Permit Exp.: 8/31124
/J4.
—a26.�}
Signatur Date
I certify, under penalty of taw, 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