WQCS00002_Renewal (Application)_20211122

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Dv�lc� +� Water Resources Form CS-SSO
PART I:
This form shall be submitted to the appropriate
sanitary sewer overflow (SSO).
DWR Regional Office within five business days of the first knowledge of the
Permit Number: WQCS00002 (WQCS# if active, otherwise use WQCSD#)
Facility: Raleigh Collection System Incident #: Owner: City of Raleigh
Region: Raleigh
City: Raleigh
Source of SSO (check applicable): ®Sanitary Sewer
County: Wake
❑ Pump Station /Lift Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump
Station 6, Manhole at Westall & Bragg Street, etc.): 7104 Bellweather Ct. S.
Manhole #:
Latitude (degrees/minute/second): Longitude (degrees/minute/second):
Incident Started Dt: 11-12-2021 Time: 1109AM Incident End Dt: 11-12-2021 Time: 03:20PM
(mm-dd-yyyy) (hh:mm) AM/PM (mm-dd-yyyy) (hh:mm) AM/PM
Estimated volume of the SSO: 5157 gallons Estimated Duration (round to nearest hour): 3 hour(s)
Describe how the volume was determined: 191nlm x 27gpm
Weather conditions during the SSO event: clear/dry
Did the SSO reach surface waters? ®Yes
Volume reaching surface waters: 5220 gallons
❑ No ❑Unknown
Surface water name: Mine Basin
Did the SSO result in a fish kill? � Yes ❑ No
If Yes, what is the estimated number of fish killed? 4
SPECIFIC cause(s) of the SSO:
❑Severe Natural Conditions
❑Pump Station Equipment Failure
❑Other (Please explain in Part II)
❑ Grease
❑ Power Out
FAA] Unknown
❑Roots
❑Vandalism
❑Inflow &Infiltration
❑ Debris in line Pipe Failure (Break)
4-hour verbal notification (name of person contacted):
❑DWR ®Emergency Management Date (mm-dd-yyy): 11-13-2021Time: (hh:mm AM/PM): 07:19AM
Per G.S. 143-215.1 C(b), the owner or operator of any wastewater collection system shall:
In the event of a discharge of 1,000 gallons or more of untreated wastewater to the surface waters of the State, issue
a press release to all print and electronic news media that provide general coverage in the county where the discharge
occurred setting out the details of the discharge. The press release shall be issued within 24 hours after the owner or
operator has determined that the discharge has reached surface waters of the State.
In the event of a discharge of 15,000 gallons or more of untreated wastewater to the surface waters of the State, publish
a notice of the discharge in a newspaper having general circulation in the county in which the discharge occurs and in
each county downstream from the point of discharge that is significantly affected by the discharge. The Regional Office
shall determine which counties are significantly affected by the discharge and shall approve the form and content of
the notice and the newspapers in which the notice is published.
WHETHER OF NOT PART II IS COMPLETED, A SIG
.TURF IS REQUIRED SEE PAGE 13
Form CS-SSO Page 1

Pipe Failure Break)
Pipe size (inches)
What is the pipe material
VCP
Vitred clay pipe
What is the approximate age %J the line/ pipe (years old)
Is this a gravity line?
Is this a force main line?
Is the line a "High Priority" line?
Unknown
Yes ❑ No ❑NA ❑ NE
Last inspection dafie and findings 04/26/2021 11:05 AM -Ground erosion around exposed pipe with no visual indication
of wastewater leak, pipe appears stable.
If a force main then,
Was the break on the force main vertical?
Was the break on the force main horizontal?
Was the leak at the joint due to gasket failure ?
Was the leak at the joint due to split bell?
❑ Yes
❑ Yes
❑ Yes
I�
When was the last inspection or test of the nearest air -release valve to determine if operable?
When was the last maintenance of the air release performed? NA
If gravity sewer then,
Does the line receive flow from a force main immediately upstream
of the failed section of pipe?
If yes, what measures are taken to control the hydrogen sulfide production? NA
When was the line last inspected or videoed? NA
NA
No
�1 •
►1
i
❑NA
❑ NE
❑ NE
❑ NE
❑ NE
❑ NE
if line collapsed, what is the. condition of the line up and down stream of the failure? sewer infrastructure appears operatioal
as designed. No significant infrastructure issues observed. CCTV verification pending completion of repair.
What type of repair was made? Permanent repair. 8 ft section of VCP pipe was repaired with approximately 20 ft of
ductile iron pipe , stream banck armored with stone.
If temporary, when is the permanent repair planned? NA
Have there been other failures of this line in the past five years?
If so, then describe NA
❑NA
❑ NE
Form CS-SSO Page 12

System Visitation
ORC
Backup
Name:
Certification Number:
Date visited:
Time visited:
Carlos M Perez
1003875
11/12/2021
2:45 PM
►� -
❑ Yes
How was the SSO remediated (i./e. Stopped and cleaned up)?
8" clay pipe collapsed due to severe erosion and collapse exposing approximately 10 ft of an 8-in vitrified clay
pipe to be undermined casing a section of pipe to sepatate at the joint and fall in the creek. To control the spill,
a temporary sewer bypass was installed to stop the flow of sewer from the affected area whle repairs were completed. A
temporary spill containment site was emplaced downstream of the affected asset in order to contain the flow of sewer and
minimize the environmental impact to the surrounding land. Crews utilized ample potable water to flush the area and to
remove traces of sewer from the affected area.
As a representative for
best of my knowledge.
Person sub
Signature:
he responsible pa
ing claim:
Telephone Number:
Carlos M Perez
9192786020
I certify that the information contained in this report is true and accurate to the
Date: 11/22/2021
Title: ��\ ��
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five
business days of first knowledge of the SSO with reference to the incident number (the incident number is only generated
when electronic entry of this form is completed, if used).
Form CS-SSO
Page 13

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