NCG120105_DMR_20210203

1 /28/2021
Submission Completed
NORiN CAROLINP
Stormwater NPDES Permit Data Monitoring Report
(DMR) Upload
Permit and Facility Information:
Please enter the permit number and other details for this
NC Department cf
Environmental Quality
Received
FEB 0 3 2021
Winston Salem
Rce7ional oiiice
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
NCG120105
Must begin with NCS or NCG
Facility Name: * Kersey valley Landfill
County: * Guilford
After uploading here, the original signed hardcopy must be mailed to:
DEQ Winston-Salem Regional Office
Attn: DEMLR Stormwater Program
450 West Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Further contact details at https://deq.nc.gov/contact/regional-offices/winston-
salem
Monitoring Period Information:
... _. _.........._.............................................................................................................................................................
Monitoring Period What is the YEAR of the sample date(s)?
Year:* 2021
Multiple DMRs from sampling periods within the same year can be uploaded together, but please upload different
years with a new submittal form.
https://edocs.deq.nc.gov/Forms/Form/Submit 1/2

1 /28/2021
Submission Completed
r .%
DMR Upload * Click the upload button or drag and drop files here to attach document.
NCG12-DMR Wet Weather KV NO Flow.pdf 212.83KB
Only PDFs are accepted.
Comments:
* By checking the box and signing box below, I certify that:
„«s
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:* Michael Wayne Spencer
Name of person submitting this form
Email Address: * [e-mail]
Phone Number: * 336-688-3454
Signature: *
Date: * 01 /28/2021
https:fledocs.deq.nc.gov/Forms/Form/Submit 2/2

i
NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG120000
Landfills
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMR) Upload form_ within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DEMLR Regional Office.
Certificate of Coverage No. NCG121 0 1 110 1 5 Person Collecting Samples:
Facility Name: Kersey Valley Landfill Laboratory Name: City of High Point Water Quality
Facility County: Guilford Laboratory Cert. No.: 55
Discharge during this period: ❑ Yes N No (if no, skip to signature and dote)
Has your facility implemented mandatory Tier response actions for any benchmark exceedances? M Yes [:]No
If so, which Tier (I, II, or III)? II
Part A: Analvtical Monitoring Requirements for Outfalls with Industrial Activities— Benchmarks in (Red)
Parameter
Parameter
Outfall 1
Outfall2
Outfall3
Outfall 4
Outfall 5
Code
N/A
Receiving Stream Class
WS-IV;CA:*
WS-IV;CA:*
WS-IV;CA:*
WS-IV;CA:*
WS-IV;CA:*
N/A
Date Sample Collected MM/DD/YYYY
46529
24-Hour Rainfall in inches
C0530
TSS in mg/L (100 or 50*)
00400
pH in standard units (6.0 — 9.0)
Fecal Coliform per 100 ml of
31616
freshwater (1000)
Chemical Oxygen Demand in mg/L
00340
(120)
Part B: Vehicle & Equipment Maintenance Areas — Benchmarks in (Red)
Parameter
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
Code
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
00552
Non -Polar Oil & Grease in mg/L (15)
New Motor/Hydraulic Oil Usage in
NCOIL
gal/month
* Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery-Areas-(PNA) - have a benchmark TSS limit of 50 mg/L. All other water classifications have a benchmark of 100 mg/L.
Notes (optional):
"I certify by my signature below, 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."
Signature of Permittd4 or Delegated Authorized Individual
1 /28/2021
Date