WQ0003090_Monitoring - 01-2021_20210211

Monitoring Report Submittal
Permit Number #* wg0003090
Name of Facility:* town of liberty wastewater plant
Month:* January Year: 2021
Report Information
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR jan 2021.pdf 1.3MB
PDF= 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:
S'��� 61
Date of submittal: 2/11/2021
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: 2/11/2021

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page `1_ of _1-
Permit No.: WQ0003090
Facility Name: Town Of Liberty - Wastewater County: Randolph Month: January Year: 2021
PPI:
Flow Measuring Point: 2 Influent ❑Effluent ❑ No flow generated
Parameter Monitoring Point: ❑ Influent ❑� Effluent ❑ Groundwater Lowering ❑ Surface water
Parameter Code - 01
60060
00400
00310
00610
00530
31613
00620
00625
00665
50060
00600
70300
00940
00630
00010
a,
Qd
E
V 1=
0:
O
c
O
m
E t�
Hy
O
c
w
=
a
U)
0
m
W
C
0
ie
a
v
'D tq
o O
f? �o
�y
N
€
v p
U. o
V
-S
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r
�
9 m
Cf
Y
.�Z
H
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O
}� C
� a
p
_
C
'C
Via °
OmCf=1
m
c�
HZ
a
m N
a
F 1 0
pN
C
C
°
O
+ 41
m
�_
*Z
�
m
24-hr
hrs
GPD
su
mg/L
mg/L
mg/L
#1100 mL
mg/L
mg/L
mg/L
mg/L
m IL
mg/L
mg/L
mg/L
°C
1
10:30
2
895,000
2
11:00
2
1,246,000
3
8:00
2
1,593,000
4
7:00
8
1,467,000
5
7:00
8
879,000
6
7:00
8
737,000
7
1 7:00
8
623,000
9.02
25.7
9.9
28.3
308
nd
12.5
1.7
0.64
12.7
0.2
8
7:00
8
553,000
9
12:00
2
806,000
10
12:00
2
596,000
11
7:00
8
428,000
12
7:00
8
577,000
13
7:00
8
557,000
14
7:00
8
440,000
9.43
0.47
15
480,000
16
631,000
17
478,000
181
485,000
19
7:00
8
399,000
20
7:00
6
458,000
21
7:00
8
413,000
9.21
11.2
9.4
31.6
10.9
NO
11.6
1.9
0.9
11.8
0.22
22
7:00
8
439,000
23
447,000
24
404,000
25
7:00
8
342,000
26
7:00
8
657,000
27
7:00
8
926,000
28
7:00
8
1,057,000
9.17
0.18
28
7:00
8
1,037,000
30
11:00
4
986,000
311
10:00
4
1,092,000
Average:
713,484
18.45
9.65
29.95
57.94
0.00
#REF!
1.80
0.55
12.25
0.21
Daily Maximum:
1,593,000 1
9.43
25.70
9.90
31.60
308.00
0.00
#REFI
1.90
0.90
12.70
0.22
Daily Minimum:
342,000
9.02
11.20
9.40
28.30
10.90
0.00
#REF!
1.70
0.18
11.80
1
0.20
Sampling Type:
Recorder
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Monthly Avg. Limit:
Daily Limit:
560,000
Sample Frequency:
2,0Y
weekly
2x month
2x month
2x nth
2x month
2x month_:
2x month
2x month
weekly
2x month
3x year
3x year
2x month

FORM: NDMR 10-13
NON -DISCHARGE MONITORING REPORT (NDMR)
Sampling Person(s) Certified Laboratories
Name: GLENN PRICE Name: PACE ANALYTICAL
Name: GARRETT DREYER Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? ❑ Compliant ❑r 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.
non compliant on the date of 1/1
cause of I&I
112 1 /13 1 /16 1 /26 1/27 1 /28 1/2 11
Operator In Responsible Charge (ORC) Certification Permittee Certification
ORC: Elix Tremaine Fike Permittee: Scott Kidd
Certification No.: 989290 Signing Official:
Grade: Si Phone Number: 336 622 2990 Signing Officials Title: Interm Town Manager
Has the ORC changed since the previous NDMR? ❑ Yes El No Phone Number: 336 622 4276 Permit Expiration: 8/31/2024
h
Signature Date Signature Gate
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. 1
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

ceAnalytical
www.pacelabs.com
Pace Analytical Services, LLC
106 Short St.
Kemersville, NC 27284
336-996-2841
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92515420
Page 1 of 1
Report Date: 01 /20/2021
Date Received: 01/07/2021
Sample: Effluent Grab
Lab ID: 92515420001 Collected: 01/07/21 13:25 Matrix: Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
HACH 10206
Nitrogen, Nitrate
ND
mg/L
0.30
01/07/21 20:55
SM 254OD-2011
Total Suspended Solids
28.3
mg/L
8.6
01/11/21 14:33
SM 521OB-2011
BOD, 5 day
25.7
mg/L
2.0
01/13/21 10:13
Colilert-18
Fecal Coliforms
308
MPN/100mL
1.0
01/08/21 10:51
Performed by
PACE
01/07/21 13:25
Collected By
Garrett
01/07/21 13:25
Dreyer
Collected Date
01/07/21
01/07/21 13:25
Collected Time
13:25
01/07/21 13:25
pH
9.02
Std. Units
01/07/21 13:25
Chlorine, Total Residual
0.64
mg/L
01/07121 13:25
TKN+NO3+NO2
Total Nitrogen
12.7
mg/L
0.52
01/19/21 15:07
Calculation
EPA350.1 Rev 2.01993
Nitrogen, Ammonia
9.9
mg/L
0.10
01/14/21 10:06
EPA 351.2 Rev 2.0 1993
Nitrogen, Kjeldahl, Total
12.5
mg/L
0.50
01/15121 01:50
EPA 353.2 Rev 2.0 1993
Nitrogen, NO2 plus NO3
0.20
mg/L
0.040
01 /13/21 12:07
EPA 365.1 Rev 2.0 1993
Phosphorus
1.7
mg/L
0.050
01/20/21 12:42
Reviewed by: c am" `�
Stephanie Knott
336-996-2841
[e-mail]
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
North Carolina Drinking Water Certification #: 37712
Pace Analytical Services Eden
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
Virginia/VELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
Virginia/VELAP Certification #: 460025
Page 1 of 2

oy,-2
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CHAIN -OF -CUSTODY Analytical Request Document LAj
Sa Ll:,-,AL DOC-LIMEN"! - :ill re-leveril. Fields
r01'�;P, !r-i-Orl-rolict . I:
92515420
er Number or
y
En i3il Tu: PI Psk, I wa I ivp I vpps: (3) nitric acid, t2) SWILWO' - ,Kill, 1�)'!Illdrodlklfic al ill, (41 5­061illy, hydroxide,(5) zinc ArCIR;r,
4 (G) ;awiiik.l, (7) so,lawi, biskll,'al�, (0) .oi;4IjI,I (9) inxenr, lA) 651-Ulbl( ildi.;, I'M 01-411161 IlLJ I'll ;Ul,
(Q d1l'i"ofliwil ilyth'-Xide, (D) 131, (U) 0IIpFtStfVt2d, (I - - I) GOILF
111111-11'YIUTy: I ime lone ucliectecl:
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C"110 ti I,,: F-Vii Lu'Cadutt Code:
101-1411-WHIQ' h, 1'�Icl ud ',)It K,
t',F!l1I-L1pI
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U'Cl 411 hl'5 %I JJI-y,
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Y N NA
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hwl,,A 0:; 1 U '..,1 i i I", 'J'i TjjL
Pr r 'I lu 1 7, w 117'r :-, r--,, 1-
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�4,;pjpjl- h I "Imalf-ol-
. . ........
U;-to;-incr Rlcrnarl* LJ*xclol Lunditions V.ziWe
...........
Hazards: 'Type of h N Used:
Vv e I Blue DI y Nufle
SHORT HOMS PRESF14T (<72 )ou;ZT
packing Material Used:
Lab Tracking It:
Temp Blank Received: Y N NA
Therm lD#:
Cooler I Temp Uppii Roreipl; c,C
R,.-� 6 1 n I s�i r. I p I r:
t: I ct, I I d j'r 5 00 (::j Y lq NA
"LlIllpfus received Via:
Cooler I Therm Corr. ractor: oC
I FDFX I I VS
Client Courir-r Pa( e. Courie)
Woler I Corrected Tempi; pC
Rvih'ylkilel, 1 jjsimy:
lLl%?'C1'I"l';I'Ik,: (Sign - I I L I 1'r,)
M I X LAB USL ONLY
Co r I'l 1". it- I t t S:
F:,J 111, 41:
Ar( inurn:
(a
:vr.d
I MlPkli P.:
Frip lilwile HLreived: Y NNA
CD
rPrelogin:
HCL MeOH Tsp 0111cl
R>�7nquished by/Company: (Signature)
'Date/Time: -77R�Tjlv-ed
—by/Company:
Non Conformance(s): Page:
N)
. ..... ..... ........
...... .... -------------
. ....... . ..... .... . . . . . . .................. ...... .... . ---------- ------
`PB:
YES / NO of:

aceAnalyilcal
www.pacelabs.cam
Pace Analytical Services, LLC
106 Short St.
Kemersville, NC 27284
336-996-2841
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty Effluent
Pace Project No.: 92516682
Page 1 of 1
Report Date: 01/18/2021
Date Received: 01/14/2021
Sample: Effluent Lab ID: 92516682001 Collected: 01/14/21 14:45 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
Performed by PACE 01/14/21 14:45
Collected By Garrett 01/14/21 14:45
Dreyer
Collected Date 01/14121 01/14121 14:45
Collected Time 14:45 01/14/21 14:45
pH 9.43 Std. Units 01/14/21 14:45
To apermum—mc— 0.47 deg C 01/14/21 14:45
Reviewed by: C�5
Stephanie Knott
336-996-2841
[e-mail]
Page 1 of 2

CHAIN -OF -CUSTODY Analytical Request Document
i : •PaceAnalyticai
Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fields
Company: Town of Liberty Billing Information:
i
Address:
I
Report To: Email To:
Copy To: Site Collection Info/Address:
Customer Project Name/Number: State: County/City: Time Zone Collected:
/ [ ]PT[ ]MT[ ]CT [ ]ET
1 Phone: Site/Facility ID #: Compliance Monitoring?
Email: [ /Yes [ ] No
Collected By (13YrinFtj:. Purchase Order #; DW PWS ID #:
l 7rvti �t'I I° �• Quote #: DW Location Code:
Collected y<ignature)::- Turnaround Date Required: Immediately Pace on Ice:
LAB USE ONLY- Affix Workorder/Login Label Here or List Pace Workorder Number or
MTJL Log -in Number Here o
ALLSH W0# • 9 5166�2 a
Container Preservath ++ ++ + I
Preservative Types: (1) nitric acid, (2 925 ifi682
(6) methanol, (7) sodium bisulfate, (8) s�
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
—� 1---1
1
[ J Yes [ ] No
Sample Disposal:
Rush:
Field Filtered (if applicable):
( ] Dispose as appropriate ( ] Return
[ )Same Day [ ] Next Day
[ ] Yes [ ] No
f I Archive:
[ ] 2 Day [ ] 3 Day [ ] 4 Day [ J 5 Day
`
[ I Hold:
(Expedite Charges Apply)
Analysis:
*
Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
II
Customer Sample ID
Matrix *
Comp /
Grab
Collected (or
Composite Start)
Composite End
Res
CI
# of
Ctns
m
=
�C/
Date
Time
Date
Time
Effluent
--
_—WW
9
Customer Remarks / Special Conditions / Possible Hazards:
* Effluent Monitoring
Relinquished by/Company: (Signature)
r
Relinquished by/Company: (Signature)
Relinquished by/Company:
Analyses
-
Lab Profile/Line:
,a, Sample Pwveipi. Chr>CY.l. ,oL :
Custody o"ealo Present./inLar, Y N NA
Custody Signdtures Present. Y N NA
Collector. 3i51nature Present Y N NA
T
BWA:la�s Intact Y N NA
Correct Bottln8 Y N NA
Sufficient Volume Y N NA
H
Sampluo Received on ice Y N NA
V0A • He dopaoe Acceptable Y N NA
m
USDA Regulated Soils Y N NA
LE
SamPleo ill Hulding 'rinse Y N NA
d
Residual Chlorine Pxwaew. Y N NA
c
Cl `ltxapc:
OC
_
Sample pFl Accrapt:at7l.i+...:.:..�..•-.,-•Y V NA
pH Scrips: _
U
Sulficim PreocuL Y N NA
ip
Lcad Acetate Strips:
7
v_
uJ
t,AH USE ONLY•
W
Lab Sample q / Comment.n:
cc
0
H
Type of Ire used: Wet Blue Dry
None
;SHORT HOLDS PRESENT (<72 hours):
Y N N/A
Packing Material Used:
PLab Tracking
Radchem samples) screened (<SDO cpY
N NA
;Samples received via.m):
FEDF.X UPS
Client Courier Pace Courier
Time: Received by/Company (SigatLVe)
Date/Time:MTJL
LAB USE ONLY
i 't J \
_
1� �`
1
`-�
ITableIt:
Acctnum:
Time:
Received by/Company: (Signure)
at�
ate/Time:
I
ffff
eTernplate:
(
J)relogin:
j Date/Time: 'Received by/Company: (Signature}-'���•�--'��[Date/Time�I,M:
�PB:
Lab Sample Temperature Info:
Temp Blank Received: Y N NA
Therm ID#:
Cooler 1 Temp Upon Receipt: _. uC
Cooler 1 Therm Corr. Factor: oC
Cooler 1 Corrected Temp: oC
Comments:
Trip Blank Received: Y N NA
HCL McOH TSP other
Non Confurrnance(s); Page:
YES / NO i of:

f
PaceAnalytical
W".pecelabs.cem
Pace Analytical Services, LLC
106 Short St.
Kemersville, NC 27284
336-996-2841
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty 1/21/21
Pace Project No.: 92517907
Page 1 of 1
Report Date: 01 /31 /2021
Date Received: 01 /21 /2021
Sample: Effluent Grab
Lab ID: 92517907001 Collected: 01/21/21 12:30 Matrix: Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
HACH 10206
Nitrogen, Nitrate
ND
mg/L
0.30
01/22/21 10:24
SM 254OD-2011
Total Suspended Solids
31.6
mg/L
10.0
01/22/21 10:51
SM 521OB-2011
BOD, 5 day
11.2
mg/L
2.0
01/27/21 14:36 R6
Colilert-18
Fecal Coliforms
10.9
MPN/100mL
1.0
01122/21 12:31
Performed by
PACE
01/21/21 12:30
Collected By
Garrett
01/21/21 12:30
Dreyer
Collected Date
01/21/21
01/21/21 12:30
Collected Time
12:30
01/21/21 12:30
pH
9.21
Std. Units
01/21/21 12:30
Chlorine, Total Residual
0.90
mg/L
01/21/21 12:30
TKN+NO3+NO2
Total Nitrogen
11.8
mg/L
0.52
01/29/21 15:40
Calculation
EPA 350.1 Rev 2.0 1993
Nitrogen, Ammonia
9.4
mg/L
0.10
01/30/21 11:43
EPA 351.2 Rev 2.0 1993
Nitrogen, Kjeldahl, Total
11.6
mg/L
0.50
01/28/21 02:28
EPA 353.2 Rev 2.0 1993
Nitrogen, NO2 plus NO3
0.22
mg/L
0.040
01/28/21 12:37
EPA 365.1 Rev 2.0 1993
Phosphorus
1.9
mg/L
0.050
01 /28/21 07:56
ANALYTE QUALIFIERS
R6 The RPD between valid sample dilutions exceeded 30%.
Reviewed by:
Stephanie Knott
336-996-2841
[e-mail]
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
North Carolina Drinking Water Certification #: 37712
Pace Analytical Services Eden
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
Virginia/VELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
Virginia/VELAP Certification #: 460025
Page 1 of 2

�_ za� 1 Y ��- STODY Anal tical Request ::--- — ---�
...CHAIN-OF-CU �_ ..._._. �:� �_ _ y _. t- :-q�:.r,
LAB USE ONLY- Affix Workorder/Login label Here or List Pace Workorder Number or
st Document `
aceAnalytical Y p lev `S-�y WO# • 925 17907
Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fields
Company: �TDWn Of Libe - Billing Information:
ALL SHADEf
Address:
Report To:
Copy To: M.
Customer Project Name/Number:
Phone:
Email:
ID #:
- — Container PreservatiyeType
u 2 8 r 92517907 �r
** Preservative Types: (1) nitric acid, (2) sulfuric r
1 (6) methanol, (7I sodium bisulfate, (8) sodium thiosulfate, (9) hexane, (A) ascorbic acid, (B) ammonium sulfate,
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
Analyses Lab Profile/Line:
State: County/City: Time Zone Collected: — 1,ab Sample sic .i��i Checkl nl
/ [ ]PT[ )MT[ ]CT ( ]ET
Email To:
Site Collection Info/Address:
Purchase Order#:
Quote #:
Turnaround Date Required:
Custody Seals Present;/1'nt.act
Y N
NA
Compliance Monitoring?
[ Yes ( ]No
Custody SigntiLuree Present.
Collector Signatuate Prov nt
BOLL1es 1nLact
Y N
Y N
Y N
NA
NA
NA
DW PWS ID #:
correct aut tlen
Y N
NA
DW Location Code:
d
Sufficient Volume
Samples Received on Ice
V0A Neadep.ace AceLptab.le
Y N
Y N
Y N
NA
NA
NA
Imme iatel Pace on Ice:
y
m
USDA Re ulated Soils
Y N
NA
--- — [ ] Yes [ ] No W
O Sample.o in Holding '1'imrt Y N NA
Sample Disposal: Rush: Field Filtered (if applicable): f2 Re:,i dual Chlorine Present: Y N NA
[ ) Dispose as appropriate [ ] Return ( ) Same Day [ ] Next Day [ ] Yes [ ] No Z Cl strips : _
[ ) Archive: [ ] 2 Day [ ] 3 Day [ j 4 Day [ ] 5 Day
[ ]Hold: Analysis:
(Expedite Charges Apply)
" Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
" Comp / Collected (or Composite End
Customer Sample ID Matrix Grab Composite Start)
Date Time Date Time 11
(Effluent
Z coo
0
Z iY
(`I
II
'-'`
Samp1r. pH ACCeptable Y N NA
p11 5tripu: _
Su1.l i.dr. Pre VOW: - - — Y N NA
bijad Acetat.E Strips:
F- Z
N
GAR USE ONGY•
l.ab Sample It ; Commr.rttn:
Res
#of
Cl
Ctns
p =
U
LL
UU
�co Z
lL
n
H
Customer Remarks / Special Conditions / Possible Hazards: Type of Ice Used: Wet Blue Dry None
Packing Material Used:
* Effluent Monitoring
Relinquished /� (Signature)
Relinquished by/Company: (Signature)
Relinquished by/Company: (Signature)
Radchem samples) screened (<500 cpm): Y N NA
Date/Time: Received by/Company: (Signature)
D9te/Tipe: Received by/Company: (signature)
ny:
MMENN-01
HORT HOLDS PRESENT (<72 hours):
Y N N/A
ab Tracking M.
rL
'Samples received via:
FEDFX UPS Client
Courier Pace Courier
-[Date/Time:
MTJL LAB USE ONLY -
r
Table #:
IACLtnunt:
Date/Time:
Template:
Prelogin:
(Date/Time:
c
r
; Irll:
Lab Sample Temperature Into:
Temp Blank Received: Y (V NA
Therm ID#: �� U-1 oo- I
Cooler i Temp Upon Receipt: oC
Cooler i Therm Corr. Factor: oC
Cooler I Corrected Temp: ', , 1lnC
Comments:
Trip Blank Received: Y N NA
HCL McOH TSP Other
Non Confonnance(s): � Pager
YES / NO of:
0
N
m
rn
a

aceAnalytical
www.pacelabs.cem
Pace Analytical Services, LLC
106 Short St.
Kernersville, NC 27284
336-996-2841
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92519062
Page 1 of 1
Report Date: 01 /29/2021
Date Received: 01 /28/2021
Sample: Effluent
Method Parameters
Lab ID: 92519062001 Collected: 01/28/21 12:19 Matrix: Water
Results Units Report Limit Analyzed Qualifiers
Performed by
PACE
01/28/21 12:19
Collected By
Garrett
01/28/21 12:19
Dreyer
Collected Date
01/2812021
01/28/21 12:19
Collected Time
12:19
01/28/21 12:19
pH
9.17 Std. Units
01/28/21 12:19
Chlorine, Total Residual
0.18 mg/L
01/28/21 12:19
Reviewed by:
Stephanie Knott
336-996-2841
[e-mail]
Page 1 of 2

CHAIN -OF -CUSTODY Analytical Request Document
,� :..- aceAr7alytical
Chain -of -Custody is a LEGAL DOCUMENT- Complete all relevent fields
Company: Tnwn of I iherty _ Billing Information:
Address:
Report To:
Copy To:
Customer Project Name/Number:
Phone: Site/Facility ID #:
Email:
f
Email To:
Site Collection Info/Address:
State: County/City: Time Zone Collected:
/ [ ]PT[ ]MT[ ]CT [ ]ET
Compliance Monitoring?
[ /Yes [ ] No - nc
[ Collected By (print): j Purchase Order #:
i
DW PWS ID #:
Quote #:
DW Location Code:
11
Colleded_signature: Turnaround Date Required:
�
immediately yPac e on Ice_
�~
[ ] Yes [ ] No
m
LL
Field Filtered (if applicable):
Disposal: Rush:
' c
[ ] Dispose as appropriate [ ] Return [ ] Same Day ( ] Next Day
[ ] Yes [ ] No
,Sample
[ ] Archive: [ ] 2 Day [ ] 3 Day ( ] 4 Day [ ] 5 Day
Analysis:
'
0
L
[ ]Hold: (Expedite Charges Apply)
* Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
Product (P), Soil/Solid (SL), Oil (OL), wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
• v
g
rn
_
*
I Comp /
i
Collected (or
Composite End
Res
# of
y
Customer Sample ID
Matrix
Grab
Composite Start)
CI
Ctnsn
CL
i-
Date
Time
Date
Time
Effluent
w
g
l�' 2(
fZf �}
0
-R
Customer Remarks / Special Conditions / Possible Hazards: 'Type of Ice Used: Wet Blue Dry None
Packing Material Used:
Effluent Monitoring
Radchern samples) screened (<500 cpm): Y N NA
Relinquished by/Company: (Signature) Date/Time: Received b- Co(npa (' ure)
Rel ni quished by/Company: (Signature) )17ate/Time Receive y/C peu : ignature)
Relinquished by/Company: (Signature) Date/Time: Received by/Company: (Signature)
LAB USE ONLY- Affix Workorder/Login Label Here or List Pace Workorder Number or
MTr' M
wog:92519062
- - ALL SHADEDfL
1111111111111
Container Preservative T e
*' Preservative Types: (1) nitric acid, (2) sulfuric acit
(6) methanol, (7) sodium bisulfate, (8) sodium thiosulfate, (9) hexane, (A) ascoroic aao, la) ammonium Wldli-,
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
Analyses ILab Profile Line:
Lao .um}7L9 RerrxPL Unmexiist:
Custody Sealo Present/intact Y N NA
Custody Signatures Present Y N NA
Collect:oi Signature Present Y N NA
Bottler Intact Y N NA
Correct Bottles Y N NA
Suffialent volume. Y N NA
Sampten Reweived on Tr_e Y N NA
VOA Heacisimce Acceptable Y N NA
USBA Regvlate:l Soils Y N NA
Samplos in Holding Time Y N NA
Residual (:hlorine Present Y N NA
Cl St•ripo:
Sample PH Acceptable �Y N NA
pH Strips:
Sulfide Present Y N NA
Lead ACetaLe St r.iPU:
1,AS USE ONLY:
imb Somtaio If / Commem ri:
SHORT HOLDS PRESENT 1<72 hours):
Y N N/A
Lab Sample Temperature Info:
Lab Tracking #:
^�
Temp Blank Received: Y N NA
Therm IDM
Cooler 1 Temp Upon Receipt: _oC
Samples received via:
Cooler 1 Therm Corr. Factor: oC
FEDEX UPS Client
Courier Pace Courier
Cooler 1 Corrected Temp: _ __oC
—Date/Time—
ate/Time
�MTJLLABU_SL'ONLY
_ comments:
Table#:
Acctnum:
Date/Time:
Template:
_
Trip Blank Received: Y N NA
p
I
Prelogin:
HCL McOH TSP Other
��Oate/Time: ��
GPM:
• - _._ � ) ._._____�_..�.
Non Conformanca(s); :Page:
[
Pfl:
YES / NO I of:

DATE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
January 2021
Liberty N.C.W.W.T.F.
Freeboard Lagoon Inches
R 2.0
R 0.2
R 0.2
R 0.2
R 1.0
R 0.6 SN 1.0
R 1.7
TOTAL 5.9

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _1_ of _2_
Permit No.: W00003090
Facility Name: Town of Liberty - Wastewater
County: Randolph
Month: January
Year. 2021
Did irrigation occur
at this facility?
Field Name:
1
Field Name:
2
Field Name:
3
Field Name:
4
Area (acres):
19.56
Area (acres):
19.54
Area (acres):
18.98
Area (acres):
16.78
Cover Crop:FESCUE
Cover Crop:
P'
FESCUE
Cover C roP�
FESCUE
Cover Cr
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?
❑Q YES ❑ NO
Field Irrigated?
17 YES � NO
Field Irrigated?
❑ YES ❑ NO
a,m
�a
«m
a
=.
o�CL
._7a
a
M
an
d
-E
Q
a
=a
i
yc
o
ao
o
i
a
1=
o
5o
c
_E
m
a
?
EN
m
er
Eoa
-
a
>
~Emim
�
EE
aG
�E
OF
in
ft
ft
gat
min
in
In
gal
min
In
in
gal
min
In
In
gal
min
In
In
1
2
R
2
3
4
5
C
45
1 0
281,000
180
0.62
0.21
6
C
38
0
327,000
180
0.62
0.21
321,000
180
0.61
0.20
7
8
R
0.2
9
10
III
C
1
0f0.2
12
13
C
39
0
325,000
180
0.63
0.21
281,000
180
0.62
0.21
14
C
39
0
327,000
180
0.62
0.21
321,000
180
0.61
0.20
16
R
0.2
16
171
C
1 50
1 0
281,000
180
0.62
0.21
18
C
40
0
327,000
180
0.62
0.21
321,000
180
0.61
0.20
19
C
52
0
325,000
180
0.63
0.21
20
21
C
38
0
327,000
180
0.62
0.21
321,000
180
0.61
0.20
281,000
180
0.62
0.21
22i
C
51
0
325,000
180
0.63
0.21
23
241
C t
36
1
0
327,000
180
0.62
0.21
25
R
1
26
27
R
0.6
28
29
301
C 1
40
0
327,000
180
0.62
0.21
311
R 1
1
1.7
Monthly Loading:
1,962,000
3.69
42.03
1,284,000
2.42
39.60
976,000
1.89
26.22
24,000 1,1
2.47
31.62
12 Month Floating Total (In):

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _2_ of _2_
Permit No.: W00003090
Facility Name: Town of Liberty - Wastewater
County: Randolph
Month: January
Year: 2021
Did irrigation occur
Field Name:
5
Field Name:
6
Field Name:
Field Name:
8
at this facility?
O YES ❑ NO
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
Weather
Freeboard
Field Irrigated?
[ YES ONO
Field Irrigated?
Q YES ❑ NO
Field Irrigated?
YES No
Field Irrigated?
I] YES NO
c
c�
_
°
°
m
m
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N
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a.a
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oa
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y,e : c
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Gc toss
J g J
OF
in
ft
ft
gal
min
In
in
gal
min
In
In
gal
min
In
in
gal
min
in
In
1
2
R
2
3
4
5
C
50
0
299,000
180
0.60
0.20
fi
71
C
33
0
252,000
180
0.61
0.20
370,000
180
0.62
0.21
81
R
0.2
9
10
11
C
1010.21
299,000
1 180
0.60
0.20
350,000
180
0.59
0.20
12
13
14
15
R
0.2
16
17
C
36
0
1
350,000
1 180
0.59
0.20
18
19
PC
36
0
370,000
180
0.62
0.21
201
C
38
0
299,000
180
0.60
0.20
252,000
180
0.61
0.20
350,000
180
0.59
0.20
21
22
CL
42
0
370,000
180
0.62
0.21
23
C
39
0
299,000
180
0.60
0.20
1
1
350,000
180
0.59
0.20
24
CL
44
0
252,000
180
0.61
0.20
25
R
1
26
27
R
0.6
28
29
G 1
45 1
0
252,000
180
0.61
0.20
30
C
41
0
370,000
180
0.62
0.21
31
R
1.7
Monthly Loading:
1.196.000
2.41
31.64
1,008,000
2.46
40.12
1,480.000
2.46
40.72
1,400,D00
2.38
28.24
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?
121 Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
I] Compliant
❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit?
❑� Compliant
❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site?
[D Compliant
❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?
❑ Compliant
❑J 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.
Raifall of 6.9
IOperator In Responsible Charge (ORC) Certification II Permittee Certification
ORC: Elix Tremaine Fike
Certification No.: 989290
Grade: SI Phone Number: 336 622 2990
Has the ORC changed since the previous NDAR-1? ❑ Yes [21 No
Z14
Signature
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
Permittee:
Scott Kidd
Signing Official:
Signing Official's Title: Interim Town Manager
Phone Number: 336 622 4276 Permit Exp.: 8/31 /24
Date Signature Date
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 infonnation 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)
Did the application rates exceed the limits in Attachment B of your permit?
I1 Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? 0 Compliant ❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? I] Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? 2 Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑ Compliant ❑✓ 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 W.
Raifall of 5.9
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 NDAR-1? ❑ Yes El No
Permlttee Certification
Permittee:
Scott Kidd
Signing Official:
Signing Official's Title: Interim Town Manager
Phone Number: 336 622 4276 Permit Exp.: 8/31/24
f r
Signature Date Signature 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 submltting 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