NCG120105_2021 DMR_20210128

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG120000
Landfills
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMR) Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DEMLR Regional Office.
Certificate of Coverage No. NCG12
Facility Name: Kersey Valley Landfill
Person Collecting Samples:
Laboratory Name: City of High Point Water Quality
Facility County: Guilford I Laboratory Cert. No.: 55
Discharge during this period: ❑ Yes ❑■ No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions for any benchmark exceedances? ❑■ Yes ❑ No
If so, which Tier (I, II, or III)? II
Part A: Analytical Monitoring Requirements for Outfalls with Industrial Activities— Benchmarks in (Red)
Parameter
Parameter
Outfall 1
Outfall 2
Outfall 3
Outfall 4
Outfall 5
Code
N/A
Receiving Stream Class
WS-IV;CA:*
WS-IV;CA:*
WS-IV;CA:*
WS-IV;CA:*
WS-IV;CA:*
N/A
Date Sample Collected MM/DD/YYYY
46529
24-Hour Rainfall in inches
C0530
TSS in mg/L (100 or 50*)
00400
pH in standard units (6.0-9.0)
Fecal Coliform per 100 ml of
31616
freshwater (1000)
Chemical Oxygen Demand in mg/L
00340
(120)
Part B: Vehicle & Equipment Maintenance Areas — Benchmarks in (Red)
Parameter
Parameter
Outfall
Outfa I I
Outfall
Outfall
O utfa I I
Code
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
00552
Non -Polar Oil & Grease in mg/L (15)
New Motor/Hydraulic Oil Usage in
NCOIL
gal/month
* Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HOW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of 50 mg/L. All other water classifications have a benchmark of 100 mg/L.
Notes (optional):
"I certify by my signature below, 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 fines and imprisonment for
knowing violations."
Signature of Permitteg or Delegated Authorized Individual
1 /28/2021
Date