wq0003090_Monitoring - 08-2021_20210920

Monitoring Report Submittal
Permit Number #*
Name of Facility:*
Month:* August
Report Information
wg0003090
town of liberty wastewater plant
Type *
NDMR, NDAR-1, NDAR-2, NDMLR
Confirmation Email Address:*
Name of Submitter:*
Signature:
Date of submittal:
Initial Review
Year:* 2021
Upload Document*
20210920105315307.pdf 4.05MB
FDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-t, NDAR-2, NDMLR, GW-59).
tfike@to\Anoflibertync.org
e tremaine fike
c, 2!ve t'�Fewww
Reviewer: Saunders, Erickson G
9/20/2021
This will be filled in automatically

Is the project number correct? * Wg0003090
Is the monitoring report r Yes r No
accepted?*
Regional Office * Winston-Salem
Accepted Date: 9/29/2021

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page _1_ of _1_
Permit No.: W00003090
Facility Name: Town Of Liberty - Wastewater
County: Randolph
Month: August
Year: 2021
PPI: 002
Flow Measuring Point: 2✓ Influent [:1 Effluent ❑ No flow generated
Parameter Monitoring Point: ❑influent Effluent ❑Groundwater Lowering ❑surface water
Parameter Code 0.
60050
00400
00310
00610
00530
31613
00620
00625
00665
50060
00660
70300
009940
00630
00010
p
c
0
d
'
W
q
R
O
E
7
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t
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w+St0
Z Z
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2
ia
F-
24-hr
hrs
GPD
su
mg(L' 'I
mg/L
mg/L
#/100 mL
mg/L
mg/L
mg1L
mg/L
mg/L'
mg/L
mg(L
mg/L
°C
1
190,000
2
7:00
8
199,000
3
7:00
8
196,000
4
199,000
5
199,000
7.08
13.8
6.5
35.3
2420
ND
11.7
2.1
0.15
117
ND
61
179,'OW
7
369,000
8
1,415,000'
9
272,000
10
228,000
11
7:00
8
207,000
12
7:00
8
202,000 "
7.43
0.19
13
7:00
8
192,000
14
10:00
2
239,000
15
11:00
2
208,000
16
7:00
8
231,000,
17
7:00
8
389,000
18
7:00
8
654,000 '
7.1
33.4
6.3
64
2420
NID
26.7
2.5
0.13
26.8 '
0.042
19
7:00
8
421,000
20
7:00
8
443,000
21
11:00
2
410,000
22
11:30
2
301,000
23
7:00
8
157,000
24
7:00
8
231,000 ;
25
7:00
8
207,000
26
7:00
8
207,000
7.3
0.08
27
7:00
8
204,000
28
216,000
29
222,000
30
7:00
8
177,000
31
7:00
8
197,000
Average:
295,516
23.60'
6.40
49.65
2,420.00
0,00
#REF!
2.30
0.14
19.25'
0.02
Daily Maximum:
1,4%000'
7.43
33.40
6.50
64.00
2,420.00
0.00
#REF!
2,50
0.19
26.80'
0.04
Daily Minimum:
157,000 ',
7.08
13,80
6.30
35.30
2,420.00
0�00
#REF!
2.10
0.08
11,70
0.04
Sampling Type:
Recorder i
Grab
Grab
Grab
Grab
Grab
Grab:
Grab
Grab "'
Grab
Grab,":
Grab
Monthly Avg. Limit:
Daily Limit:
550,000,'
Sample Frequency:
Daily
weekly
I 2xmonth,l
2x month
2xmonth
2x month
2x month
2x month
2x month
weekly
lac 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? 0 Compliant 7 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
rainfall I&I
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 Official's Title: Town Manager
Has the ORC
changed since the previous NDMR? ❑ Yes (] No
Phone Number: 336 622 4276 Permit Expiration: 8/31/2024
oe
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 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

I'VaceAnalyfical'
www.pacelabs.com
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92553779
Sample: Effluent
Method
Parameters
HACH 10206
Nitrogen, Nitrate
SM 2540D-2011
Total Suspended Solids
SM 521OB-2011
BOD, 5 day
Colilert-18
Fecal Coliforms
Performed by
Collected By
TKN+NO3+NO2
Calculation
EPA 350.1 Rev 2.0 1993
EPA 351.2 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
EPA 365.1 Rev 2.0 1993
ANALYTE QUALIFIERS
El
L2
Reviewed by:
Collected Date
Collected Time
pH
Chlorine, Total Residual
Total Nitrogen
Laboratory Report
Page 1 of 1
Report Date: 08/18/2021
Date Received: 08/05/2021
Lab ID: 92553779001 Collected: 08/05/21 14:10 Matrix: Water
Results
Units
Report Limit
Analyzed Qualifiers
ND
mg/L
0.30
08/05/2118:22
35.3
mg/L
14.7
08/06/2112:57
13.8
mg/L
2.0
08/11/2122:08 L2
2420
MPN/100mL
1.0
08/06/2112:25 El
PACE
08/05/21 14:10
Garrett
08/05/21 14:10
Dreyer
08/05/21
08/05121 14:10
1410
08/05/21 14:10
7.08
Std. Units
08/05/21 14:10
0.15
mg/L
08/05/21 14:10
11.7
mg/L
0.52
08/18/2111:22
Nitrogen, Ammonia
6.5
mg/L
0.10
08/14/21 13:47
Nitrogen, Kjeldahl, Total
11.7
mg/L
0.50
08/14/21 06:11
Nitrogen, NO2 plus NO3
ND
mg/L
0.040
08/13/21 13:49
Phosphorus
2.1
mg/L
0,050
08/12/2114:52
Reported value should be considered a minimum estimate since it is the maximum reportable number for this method
based on the sample volume used. The true value is likely greater than the value reported.
Analyte recovery in the laboratory control sample (LCS) was below QC limits. Results for this analyte in associated
samples may be biased low.
Stephanie Knott
704-977-0981
[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 3

t CHAIN -OF -CUSTODY Analytical Request Document
LAB USE ONLY- Affix Workorder/Login Label Here or List Pace Workorder Number or i
I
Log-in Number Here
!
.�ceAnalytical
Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fields
■ ■ �
ALL SHAG W 2553779
Company: Town of Liberty ;Billing Information:
IAddress:
Container Preservative T,
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11111111111111111111111
•• Preservative Types: (1) nitric acid, (2) sul 02553779
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(6) methanol, (7) sodium bisulfate, (8) sodiL
(C) ammonium hydroxide, (D) TSP, (U) Unpreservea, iui vu—
Copy To: Site Collection Info/Address:
Analyses
Lab Profile/Line:
Customer Project Name/Number: jState: County/City: Time Zone Collected:
Lab Sample Receipt Checkliat:
] / I ]PT[ JMT[ ]CT I ]ET
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Custody Seals Present/Intact Y �tr.
Custody Signatures Present rm
)Phone:
Site/Facility ID #:
Compliance Monitoring?
Email:
[[ /Yes [ ] No
Collector Signature Present N NA
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Bottles Intact N NA
correct Bottles N NA
Collected By ( i
Purchase Order #:
DW PWS ID #:
Quote#:
DW Location Code:
Sufficient Volume N NA
D_
Samples Received on Ice N NA
VOA - Headspace Acceptable Y 'N 8)k
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Turnaround Date Required:
Immediately Packed on Ice:
[ ]Yes ( ]No
USDA Regulated Soils Y NA
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Samples in Holding Time 6G'Fl19,
Residual Chlorine,4r�gt Y N
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( j Dispose as appropriate [ ] Return[
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Radchem sample(s) screened (<500 cpm): Y N NA
Relinquished by/any:(Signature) TDate/rme: Received by/;ny:(Signature)
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Date/Time: �MTJL LAB USE ONLY
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Lab Sample Temperature Info:
Temp Blank R . d: tY .� NA
Therm ID#:
Cooler 1 Temp Upon Receipt: oC
Cooler 1 Therm Corr. Factor: oC
Cooler 1 Corrected Temp: �S-oC
Comments:
Trip Blank Received: Y NA
HCL McOH TSP Ot er
Non Conformance(s): 'Page:
YES / NO 1 of:

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1"ace Analytical
www.pacelabs.com
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: TOWN OF LIBERTY
Pace Project No.: 92555082
Page 1 of 1
Report Date: 08/13/2021
Date Received: 08/12/2021
Sample: EFFLUENT LabID: 92555082001 Collected: 08/12/21 12:30 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
Performed by PACE 08/12/21 12:30
Collected By Garrett 08/12/21 12:30
Dreyer
Collected Date 08/12/21 08/12/21 12:30
Collected Time 1230 08/12/21 12:30
pH 7.43 Sid. Units 08/12/21 12:30
Chlorine, Total Residual 0.19 mg/L 08/12/21 12:30
C
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 2

_"
,CHAIN -OF -CUSTODY Analytical Request Document
I
,,�_,PlaceAnalytical Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fields
)mpany: Town of Liberty BBilling Information:
Address: ]
ReportTo: Er
Copy To: Sit
Customer Project Name/Number: St
Phone: Site/Facllity ID #:
Email: _
C ec�prj Purchase Order#:
Quote #:
ollecTurnaround Date Required:
i I To:
Collection Info/Address:
_. County/City: Time Zone Collected:
/ [ ]PT[ ]MT[ ]CT [ ]ET
Compliance Monitoring?
Yes [ ]No
DW PWS ID #:
DW L -cation Code•
LAB USE ONLY- Affix Workorder/Logy ,`,[ '
MTJL Lc W V
ALL SHADED ARE, 11111111 II III I III II III
92555082
rnntniner Preservative Type " _ ..
•• PreservativeTypes: (1) nitric acid, (2) sulfuric acid, (3) hydrochloric acid, (4) sodium hydroxide, (5) zinc acetate,
(6) methanol, (7) sodium bisulfate, (8) sodium thiosulfate, (9) hexane, (A) ascorbic acid, (B) ammonium sulfate,
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
II
immediately Packed on ice: a
'[ ]Yes [ ]No (D
Rush: Field Filtered (if applicable): M a)Sample Disposal: e
( ] Dispose as appropriate ( ] Return [ ] Same Day I ] Next Day ( ] Yes [ ]No
[ ) 2 Day [ ] 3 Day [ ) 4 Day [ ] 5 Day
( ]Archive: Analysis: �
( ] Hold: (Expedite Charges Apply) ' U
' Matrix Codes (insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW), II v
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Comp / Collected (or Res # of w
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Date Time Date Time CL I H
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Customer Remarks / Special Conditions / Possible Hazards: Type of Ice Used. Wet Blue Dry None
Packing Material Used:
. Effluent Monitoring
Radchem sample(s) screened (<500 cpm): Y N NA
I
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N � I
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SHORT HOLDS PRESENT (<72 hours): Y N N/A
Lab Tracking #:
Lab Sample Receipt Checklist:
Custody Seals Present/Intact Y N NA
custody Signatures Present Y N NA
Collector Signature Present Y N NA
Bottles Intact Y N NA
Correct Bottles Y N NA
Sufficient Volume Y N NA
Samples Received on Ice Y N NA
VOA - Headspace Acceptable Y N NA
USDA Regulated Soils Y N NA
Samples in Holding Time Y N NA
Residual Chlorine Present Y N NA
Cl Strips:
Sample pH Acceptable Y N NA
PH Strips:
Sulfide Present Y N NA
Lead Acetate Strips:
LAB USE ONLY:
Lab Sample # / Comments:
pies received via:
FEDEX UPS Client Courier Pace Courier
Date ime: MTJL LAB USE ONLY
l7 ,1 -.. � � Table #:
Lab Sample Temperature Info:
Temp Blank Received: Y N NA
Therm ION:
Cooler 1 Temp Upon Receipt: _oC
Cooler 1 Therm Corr. Factor: oC
Cooler 1 Corrected Temp: PC
Comments:
Date/Time: Template: Trip Blank Received: Y N NA
HCL McOH TSP Other
Prelogin:
Date/Time: PM: Non Conformance(s): Page:
'PB: YES / NO of:

aceAnalyfTeal o
( www.pacelabs.com
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92556146
Page 1 of 1
Report Date: 08/31/2021
Date Received: 08/18/2021
Sample: Effluent
Method
Parameters
Lab ID: 92556145001 Collected: 08/18/21 12:15 Matrix: Water
Results Units Report Limit Analyzed Qualifiers
SM 2540D-2011
Total Suspended Solids
64.0
mg/L
25.0
08/19/21 16:19
EPA 353.2 Rev 2.0 1993
Nitrogen, NO2 plus NO3
0.042
mg/L
0.040
08/18/21 16:40 M1,R1
EPA 353.2 Rev 2.0 1993
Nitrogen, Nitrate
ND
mg/L
0.040
08/18/21 16:40
EPA 353.2 Rev 2.0 1993
Nitrogen, Nitrite
0.089
mg/L
0.040
08/18/21 16:40
SM 521OB-2011
BOD, 5 day
33.4
mg/L
2.0
08124/21 16:19 B1
Colilert-18
Fecal Coliforms
2420
MPN/100mL
1.0
08/19/21 12:39 El
Performed by
PACE
08/18/21 12:15
Collected By
Garrett
08/18/21 12:15
Dreyer
Collected Date
08/18/21
08/18/21 12:15
Collected Time
1215
08/18/21 12:15
pH
7.10
Std. Units
08/18/21 12:15
Chlorine, Total Residual
0.13
mg/L
08/18/21 12:15
TKN+NO3+NO2
Total Nitrogen
26.8
mg/L
0.52
08/31/21 15:54
Calculation
EPA 350.1 Rev 2.0 1993
Nitrogen, Ammonia
6.3
mg/L
0.10
08/27/21 13:11
EPA 351.2 Rev 2.0 1993
Nitrogen, Kjeldahl, Total
26.7
mg/L
2.5
08/28/21 05:59
EPA 353.2 Rev 2.0 1993
Nitrogen, NO2 plus NO3
ND
mg/L
0.040
08/25/21 11:10
EPA 365.1 Rev 2.0 1993
Phosphorus
2.5
mg/L
0.050
08/30/21 22:44
ANALYTE QUALIFIERS
B1 Less than 1.0 mg/L DO remained for all dilutions set. The reported value is an estimated greater than value and is
calculated for the dilution using the least amount of sample.
El Reported value should be considered a minimum estimate since it is the maximum reportable number for this method
based on the sample volume used. The true value is likely greater than the value reported.
M1 Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS) recovery.
R1 RPD value was outside control limits.
C
Reviewed by:"�
Stephanie Knott
704-977-0981
[e-mail]
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
North Carolina Wastewater Certification #: 40
Florida/NELAP Certification #: E87648
South Carolina Certification #: 99030001
North Carolina Drinking Water Certification #: 37712
Virginia/VELAP Certification #: 460222
Pace Analytical Services Eden
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Wastewater Certification #: 633
North Carolina Drinking Water Certification #: 37738
VirginiaA/ELAP Certification #: 460025
Page 1 of 7

�New_nF_f I1ST(lnY Ana[vtical Request Document ` LAB USE ONLY- Affix Workorder/Login Lp' ' " --' r" n-,- ur�rlknrder Number or
I
17,0aceAnalXical Chain -of -Custody is a LEGAL DOCUMENT- Complete all relevent fields
I muL tog- e _,O# : 92556 / 45
ALL SHADED AREA', 111111111111111
Company: Town of Liberty
i Billing Information:
Cunt finer Preservative T e " _ 92536145
u 2 8 j
"" Preservative Types: (1) nitric acid, (2) sulfuric acid, (3) hydrochloric acid, (4) sodium hydroxide, lei
Address:
r
ReportTo:
Email To:
(6) methanol, (7) sodium bisulfate, (8) sodium thiosulfate, (9) hexane, (A) ascorbic acid, (B) ammonium sulfate,
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
Copy To:
Site Collection Info/Address:
Analyses
Lab Profile/Line:
Customer Project Name/Number:
State: County/City: Time Zone Collected:
Lab Sample Receipt Checklist:
/ [ ]PT[ ]MT[ ]CT [ ]ET
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Custody Signatures Present Y N NA
Collector Signature Present Y N NA
Bottles Intact Y N NA
correct Bottles Y N NA
Sufficient Volume Y N NA
Samples Received on Ice Y N NA
VOA - Headspace Acceptable Y N NA
USDA Regulated Soils Y N NA
Samples in Holding 'rime Y N NA
Residual chlorine Present Y N NA
Cl Strips:
Sample pH Acceptable Y N tan
pB Strips:
Sulfide Present Y N NA
Lead Acetate Strips:
LAB IIS8 ONLY:
3a mp # /Comments:
Sample
Phone:
Email:
Site/Facllity ID #:
_
Compliance Monitoring?
9[�Yes [ ]NO
Col cted By ( ri
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Quote #:
DW PWS ID #:
6 DW Location Code:
ected B re):
Turnaround Date Required:
Ilmmediately Packe on Ice:
I6
([ ] Yes [ ]NO
ample Disposal:
[ ] Dispose as appropriate [) Return
[ I Archive:
[ ]Hold:
Rush:
[ ] Same Day ( ] Next Day
[ ] 2 Day [ ] 3 Day [ ] 4 Day [ J 5 Day
(Expedite Charges
(Field Filtered (if applicable):
[ ] Yes [ ] No
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)
Customer Sample lD
(
(
j Matrix"
Comp /
Grab
( Collected (or
( Composite Start)
� Composite End
Res
CI
# of
Ctns
Date
Time
Date
Time
Effluent
wW
g
t
5
1
f
i
I
r
i
Customer Remarks / Special Conditions / Possible Hazards:
Type of Ice Used: Wet Blue Dry None
SHORT HOLDS PRESENT (<72 hours):
Y N N/A
Lab Sample Temperature Info:
i
Temp Blank Received: Y N NA
ID#:
Packing Material Used:
Lab Tracking #:
ITherm
p Effluent Monitoring
i
Cooler 1 Temp Upon Receipt: _oC
Cooler 1 Therm Corr. Factor: oC
Cooler 1 Corrected Temp: oC
Comments:
Radchem sample(s) screened (<500 cpm): Y N NA
Samples received via:
FEDEX UPS Client Courier Pace Courier
Relinquish - ature) JDat 7 e:
j(
Received byX pany: (Signature)
i'
Date/Time:
'
MT1L LAB USE ONLY
Table#:
Acctnum:
Regquis a y/Company: (Signature) ate ime:
N
eceived by/Company: (Signature)
Date/Time:
Template:
Prelogin
Trip Blank Received: Y N NA
HCL McOH TSP Other
Rel uished by/Company: (Signature) 1 Date/Time: i
J
j
Received by/Company: (Signature)
I
Date/Time:
PM:
PB:
Non Conformance(s): Page:
YES / NO of:

VacieAnalyfica(
j1
www.pacelabs.com
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92557923
Sample: Effluent Field
Laboratory Report
Page 1 of 1
Report Date: 08/27/2021
Date Received: 08/26/2021
lab ID: 92557923001 Collected: 08/26/21 13:55 Matrix: Water
Method Parameters
Results Units
Report Limit Analyzed Qualifiers
Performed by
PACE
08/26/21 13:55
Collected By
Garrett
08/26/21 13:55
Dreyer
Collected Date
08/26/21
08/26/21 13:55
Collected Time
1355
08/26/21 13:55
pH
7.30 Std. Units
08/26/21 13:55
Chlorine, Total Residual
0.08 mg/L
08/26/21 13:55
C�
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 6

r
��a CHAM-OF-CUSTODY Analytical Request Document
1aceAnalyt%Ca,f
Chain -of -Custody is a LEGAL DOCUMENT -Complete all relevent fields
Company: Town of Liberty ' Billing Information:
Address:
Report To: _ Email To:
s,
CapyTo:� [Site Collection Info/Address:
Customer Project Name/Number: ?State: County/City: Time Zane Collected:
/ [ ]PT[ )MT[ ICT [ ]ET
Phone:
Site/Facility ID #:
Compliance Monitoring?
Email:
[ Yes [ ] No
Co cted By (
[ Purchase Order #:
DW PWS ID #: j
C/sQuote
#:
DW Location Code:
(Co�Disposal:
Turnaround Date Required:
Immediate y Pace on Ice:
[ ] Yes [ ] No
SaRush:
Field Filtered (if applicable):
[ ] Dispose as appropriate (
] Return
[ ] Same Day [ ) Next Day [ ] Yes [ ] No
[ ] Archive:
[ ] 2 Day [ ] 3 Day [ ] 4 Day
[ ] 5 Day
Analysis:
If ] Hold:
(Expedite Charges Apply)
LAB USE ONLY- Affix Workorder/Login Label Here or List Pace Workorder Number or
MTJL Log -in Number Here
ALL SH
Container Preservatk,
"sPreservative Types: (1)nitric acid, (2; I '�
(6) methanol, (7) sodium bisulfate, (8) s �1��� g,2�
(C) ammonium hydroxide, (D) TSP, (U) L
V
II� II
i�
N
m
c
* Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW), m I
f Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT) Ir 1:2
5 Profile/Linen
Lab Sample Receipt Checklist
Custody Seals Present/Intact
Y N%N
Custody Signatures Present
Y NiN-
Collector Signature Present
Y N
NA"
Bottles intact
Y ri
NA
Correct Bottles
Y N
NA
Sufficient Volume
Y t1
NA
Samples Received on ice
Y N
NA
VOA - Headspace Acceptable
Y N
NA
USDA Regulated Soils
N
NAB
Samples in Holding Time
': N
NAI
Residual Chlorine Present
Y N
NA
C1 Strips:
Sample pti Acceptable
Y N
NA
PH Strips:
_
Sulfide Present
Y N
NA
Lead Acetate Strips:
I... M.r r MT.Y -
Comp/ Collected (or
Res
#of m ! ) ) Lab Sample # I Commento:
I Customer Sample ID
Matrix *
Grab Composite Start)
i Composite End
Cl
;—
Ctns m
I
Date Time
a IF- 9 �`
Date
Time
'Effluent
g
0
j
Customer Remarks / Special Conditions / Possible Hazards: j Type of Ice Used: Wet Blue Dry None SHORT HOLDS PRESENT (<72 hours): Y N N/A
Packing Material Used: Lab Tracking #:
"Effluent Monitoring
rr7
by/Company: (Signature)
by/Company: (Signature)
Radchem sampie(s) screened (<500 cpm): Y N NA
Date/Time: R�ec�ewed by/CopFP y: (Signature)
Received
by/Company:(Signature)
pies received via:
FEDEX UPS Client
Courier Pace Courier
Date/T'ime: i�j; j
MTJL LAB USE ONLY
Table#:
[cct
num:
Date/Time:
kTemplate:
IPrelogin:
PB:
Lab sample Temperature into:
Temp Blank Received: Y N
YJq;
Therm ID#:
Cooler 1 Temp Upon Receipt:
oC
Cooler 1 Therm Corr, Factor:
oC
Cooler 1 Corrected Temp:
oC
Comments:
Trip Blank Received: Y N NA
HCL McOH TSP Other
Non Conformance(s): �j Page:
YES / NO 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
August 2021
Liberty N.C.W.W.T.F.
Freeboard Lagoon Inches
23 3/4
22
23 1 /2
23
24
25
25
R
5.0
21 1/2
18
19 1/2
20 1 /2
20 1 /4
20 1 /4
21
21 1 /4
R
1.3
20
R
1.0
19
R
1.4
16 1/2
15 1/2
R
1.0
16
15 1/2
15 3/4
16 1/4
17 1/2
18
19 1/2
20 1 /2
20 3/4
21
21
21 1 /2
TOTAL 9.7

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _1_ of_2_

FORM: NDAR-1 10-13
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit?
7 Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
Q Compliant
❑ Nan -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?
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.
of 9.7
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 Official's Title: Town Manager
Has the ORC changed since the previous NDAR-1? ❑ Yes ED No
Phone Number: 336 622 4276 Permit Exp.: 8131/24
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 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_

FORM: NDAR-1 10-13
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit? 2 Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? 2 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? 21 Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑ Compliant EZ 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.
CAUSE
Raifall of 9.7
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 Official's Title: Town Manager
Has the ORC changed since the previous NDAR-1? ❑ Yes 21 No
Phone Number: 336 622 4276 Permit Exp.: 8/31 /24
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 property 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