NCG140208_MONITORING REPORT_20210208

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New Submission
Stormwater NPDES Permit Data Monitoring Report
(DMR) Upload
Permit and Facility Information:
Please enter the permit number and other details for this upload.
IMPORTANT. Until the eDMR system is implemented for DEMLR Stormwater Program permits, an original
signed hardcopy of the DMR MUST be mailed to the address in your permit, in addition to this electronic
upload.
Fields marked with a red asterisk are required.
Permit Number* Enter COC or Individual Permit Number
172'6 ) L� D � O
Must begin with NCS or NCG
Facility Name:*
County: *
Monitoring Period Information:
Monitoring Period What is the YEAR of the sample date(s)?
Year: ao Q-0
Multiple DMRs from sampling periods within the same year can be uploaded together, but please upload different
years with a new submittal form.
DMR Upload* Click the upload button or drag and drop files here to attach document.
Upload
Only PDFs are accepted.
Comments:
* By checking the box and signing box below, I certify that:
https://edocs.deq.nc.gov/Forms/SW-DMR 1/2

12/3/2020
New Submission
o I have given true, accurate, and complete information on this form;
o I agree that submission of this'Data Monitoring Report (DMR) upload form is a "transaction" subject to Chapter 66,
Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act");
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General
Statutes (the "Uniform Electronic Transactions Act");
o I understand that an electronic signature on this upload form has the same legal effect and can be enforced in the
same way as a written signature; AND
o I intend to electronically sign and submit this DMR upload form.
Full Name:* A
Name of person submitting this form
Email Address: '�ct! n,� /y�+y Crrrcc Sy��f Co -Co
Phone Number:* -jcy,
Signature: * Sign
Date: * Date captured on form submission
I'm not a robot
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Submit Save as Draft
https://edocs.deq.nc.gov/Forms/SW-DMR 2/2

LIMIT VIOLATION DISCHARGE MONITORING REPORT (DMR) -- WASTEWATER
SUBMIT TO REGIONAL OFFICE*
General Permit No. NCG140000
'Use this form if any wastewater samples have EXCEEDED A WASTEWATER LIMIT for any parameter. rn
Send sample results to the DEMLR Regional Office within 30 days of receipt from the laboratory.
Certificate of Coverage No. NCG14
Facility Name: .
County: Iredell
Phone Number:
Statesville
704 �529-6364
0
N_
Sample Collection Period: Qtr 1 ❑ Qtr 2 ❑ Qtr 3 ❑ Qtr 4 ❑N Calendar Year 2020
If Monthly Monitoring: Month November
Person Collecting Samples: David Morris
Certified Laboratory: Waypoint Anaytical Lab #
Lab #
Discharge to HQW or ORW waters? Yes ❑ No ❑
Discharge to SA waters? Yes ❑ No ❑ Discharge to Tr (Trout) waters? Yes ❑ No ❑
Discharge to SB or PNA waters? Yes ❑ No ❑ If HQW, what is the 7Q10 flow rate? or Tidal, 7Q10 not available ❑
Wastewater Monitorina Reauirements
Outfall
No.
Date Sample
Collected
Daily Flow
Rate, cfs
pH,
SLI
Total Suspended
Solids (TSS), mg/l
Settleable
Solids,
mill
11'applicable
Non -Polar O&G (EPA Method 1664
(SGT-HEM)), mg/l
mo/dd/yr
or "NO FLOW"
HOW or ORW
50% of 7Q10
Indicate NO FLOWM
applicable
freshwater
6.0-9.0
sahwater
6.8-8.6
Standard
30
HOW
20
HOW I ORW and Tr, or PNA
10
HOW, ORW, SA, SO, PNA, or
anyTmat
5
No Limit
Samples above Benchmark
subject to Tiered Responses
15
001
11/18/2020
56
9.98
SM 2540 D
Permit Date 8/1/2017 — 6/30/2022 Last Revised 8-22-2017
Page 1 of 3

Certificate of Coverage No. NCG14 D❑[_Z[r
CERTIFICATION
"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 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
Signature ,
Date f24 t Z
violations." (Required by 40 CFR §122.221
Mail Benchmark Exceedance/Tier 2 DMR to Your DEMLR Regional Office Land Quality Section:
ASHEVILLE REGIONAL OFFICE
2090 US Highway 70
Swannanoa, NC 28778
[phone]
RALEIGH REGIONAL OFFICE
3800 Barrett Drive
Raleigh, NC 27609
[phone]
WINSTON-SALEM REGIONAL
OFFICE
450 Hanes Mill Road, Suite 300
Winston-Salem, NC 27103
[phone]
FAYETTEVILLE REGIONAL OFFICE
225 Green Street
Systel Building Suite 714
Fayetteville, NC 28301-5043
[phone]
WASHINGTON REGIONAL OFFICE
943 Washington Square Mall
Washington, NC 27889
[phone]
CENTRAL OFFICE
Questions for The Central Office
Stormwater Permitting Program?
[phone]
MOORESVILLE REGIONAL OFFICE
610 Last Center Avenue/Suite 301
Mooresville, NC 28115
[phone]
WILMINGTON REGIONAL OFFICE
127 Cardinal Drive Extension
Wilmington, NC 28405-2845
[phone]
Wa
Nooresvtile; �
W Il Tngton
r
Permit Date 8/1/2017 — 6/30/2022 Last Revised 8-22-2017
Page 3 of 3

Certificate of Coverage No. NCG14 00®© 5❑
CERTIFICATION
"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 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 v,olations." (Required by 40 CFR §122.221
Signature
Date vl2/-7/7
Mail Limit Violation DMR to Your DEMLR Regional Office Land Quality Section:
ASHEVILLE REGIONAL OFFICE
2090 US Highway 70
Swannanoa, NC 28778
[phone]
RALEIGH REGIONAL OFFICE
3800 Barrett Drive
Raleigh, NC 27609
[phone]
OFFICE
450 Hanes Mill Road, Suite 300
Winston-Salem, NC 27103
[phone]
FAYETTEVILLE REGIONAL OFFICE
225 Green Street
Systel Building Suite 714
Fayetteville, NC 28301-5043
[phone]
WASHINGTON REGIONAL OFFICE
943 Washington Square Mall
Washington, NC 27889
[phone]
Questions for The Central Office
Stormwater Permitting Program?
[phone]
MOORESVILLE REGIONAL OFFICE
610 East Center Avenue/Suite 301
Mooresville, NC 28115
[phone]
WILmvI bTON REGIONAL OFFICE 1
127 Cardinal Drive Extension
Wilmington, NC 28405-2845
(910)796-721.5
' tFJi;r.�--.ngMfl
Permit Date 811 /2017 — 6130/2022 Last Revised 8-22-2017
Page 3 of 3