NCG100197_DMR_20201218

Stormwater Discharge Monitoring Report
for North Carolina Division of Energy, Mineral and Land Resources General Permit No. NCGl00000
Date submitted 12/18/2020
CERTIFICATE OF COVERAGE NO. NCG10 0 1 9 7 SAMPLE COLLECTION YEAR 2020
FACILITY NAME Pull -A -Part of Winston-Salem��rE�`'�. Il/frrr�999�AMPLEPERIOD❑Jan-June ❑■July -Dec
COUNTY Forsyth - or ❑ Monthly° (monthl
PERSON COLLECTING SAMPLES Shane Bond DEC 3 0 2020DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
LABORATORY Pace Analyitcal Services, Inc. Lab Cert. # 381 El,,
❑Water Supply ❑SA
Comments on sample collection or analysis: �Etv , . " + ILE" Mother c
DWR SECTION
Part A: Stormwater Benchmarks and Monitoring Results
PLEASE REMEMBER TO SIGN ON PAGES 2 AND/OR 3 4
Total event rainfalls 0.5 or ❑ No discharge this period?'
Outfall
No.
Date
Sample
Collected,
mo/dd/year
PH,
Standard
Units
Total Suspended
Solids (TSS),
mg/L
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), mg/L
Ethylene Glycol,
mg/L
Lead, Total
Recoverable,
mg/L
Total Toxic
Organics3,
g/L
New Motor or
Hydraulic Oil
Usage,
gal/mo
Benchmark
6.0 - 9.01
100 or 502
15
8,000
(Tiers 2 and 3)
0.075
1.0
-
Parameter Code
-
00400
C0530
00S52
_
77023
01051
78141
NCOIL
1
6/16/2020
7.14
6.5
<5.0
141
<0.025
N/A
3
1
9/29/2020
1 7.5
1 43.5
1 <5.0
<5.0
<0.025
.0267
3
Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier 1 or Tier 2 responses in the General
Permit.
'If pH values outside this range are recorded in sampled stormwater discharges, but ambient precipitation pH levels are lower, then the lower threshold of this benchmark
range is the pH of the precipitation (within instrument accuracy) instead of 6 S.U. Readings from an on -site or local rain gauge (or local precipitation data) must be documented
to demonstrate background concentrations were below the benchmark pH range of 6-9.
'See General Permit Table 1, identifying the especially sensitive receiving waters classifications where the more protective benchmark applies.
'For purposes of this permit the definition of Total Toxic Organics is that list as stated in Appendix D, Table II of Chapter 40 Code of Federal Regulations (CFR) Part 122.
4Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
'Total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
'For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
Permit Date: 11/1/2018-05/31/2021
Form SWU-251, Last Revised 11/1/2018
Page 1 of 2

Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan may request that DEMLR waive monitoring of total toxic organics. The solvent
management plan shall include a list of the total toxic organic compounds used along with other requirements listed in the General Permit. For those facilities allowed such a waiver,
the discharger shall sign the following certification statement:
Solvent Management Plan Certification Statement
"Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit monitoring requirement for total toxic organics (TTO), I
certify that to the best of my knowledge and belief, no dumping of concentrated toxic organics into the stormwater or areas which are exposed to rainfall or
stormwater runoff has occurred since filing the last discharge monitoring report. I further certify that this facility is implementing all the provisions of the solvent
management plan included in the Stormwater Pollution Prevention Plan." _
Llo,s /= tofu' X. /.3I S/2-5s -/j—
Name (Print name)
Title (P ' t title)
Sig re
Mail Original to:
Division of Water Quality
Attn: Central Files
1617 Mail Service
Center
Raleigh, North Carolina 27699-1617
/�z Aa Id, d
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 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."
of
Permit Date: 11/1/2018-05/31/2021
Date
Form SWU-251, Last Revised 11/1/2018
Page 2 of 2

a
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this form, please visit: htto://h2o.erlr.state.ne.us/su/Forms Documents.htm#miscforms
Permit No.: N/C/_
Facility Naire: _
County: r
Inspector: —5-V
Date of Inspection:
Time of Inspection:
or Certificate of Coverage No.: N/C/G/ /_/_/_/ /_/
Total Event Precipitation (inches): • 5o
M11L1L4FW& .'L
Was this a Representative Storm Event? (See information below) @/Yes ❑ No
Please check your permit to verify if Qualitative Monitoring must be performed during a representative
storm event (requirements vary).
....... .......... _ ....
A "Representative Storm Event" is a storm event that measures greater than 0.1 inches of rainfall and that
is preceded by at least 72 hours (3 days) in which no storm event measuring greater than 0.1 inches has
occurred. A single storm event may contain up to 10 consecutive hours of no precipitation.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
(Signature of Permittee or Designee)
1. Outfall Description:
Outfall No. #/ Structure (pipe, ditch, etc.) ► p e,
Receiving Stream:
Describe the industrial activities that occur within the outfall drainage area: ',
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: )1 Q" 4: i rt
3. Odor: Describe any
chlorine odor, etc.):
odors that the discharge may have (i.e., smells strongly of oil, weak
Page I of 2
S WU-2a2-t I2608

4. Clarity: Choose the number which best describes the clarity of the discharge, where l is clear
and 5 is very cloudy:
1 2 4 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
0 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
1 2,) 3 4 5
7. Is there any foam in the stormwater discharge? Yes No
8. Is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may be
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SWU-242-112608