NC0044750_Renewal (Application)_20211229

NPDES Permit Number Facility Name Modified Application Form 2A
Modified March 2021
NC0044750 Jacob's Creek Nursing&
Form NC Department of Environmental Quality-Application for NPDES Permit to Discharge Wastewater
NPDES MINOR SEWAGE FACILITIES(Before completing this form,please read the instructions.Failure to follow
the instructions may result in denial of the application.)
SECTION 1.BASIC APPLICATION INFORMATION FOR ALL APPLICANTS(40 CFR 122.210)(1)and(9))
1.1 Facility name
Jacobs Creek Nursing&Rehabilitation Center/Owners Granite Falls Ltc.LLC
Mailing address(street or P.O.box)
1721 Bald Hill Loop
City or town State ZIP code
o Madison NC 27025
Contact name(first and last) Title Phone number Email address
Shannon Knight
g [phone] [e-mail]
Location address(street, route number,or other specific identifier) m Same as mailing address
City or town State ZIP code
1.2 Is this application for a facility that has yet to commence discharge? RECEIVED
❑ Yes 4 See instructions on data submission ❑✓ No
requirements for new dischargers. F C 2 9 ZOZI
1.3 Is applicant different from entity listed under Item 1.1 above?
❑✓ Yes El No 4 SKIP to Item 1.NCDEQ/DWRJNPDES
Applicant name
Pace Analytical Services
Applicant address(street or P.O.box)
1377 South Park Dr.
City or town State ZIP code
Kernersville NC 27284
Contact name(first and last) Title Phone number Email address
Clifford Cain Operator [phone] [e-mail]
a 1.4 Is the applicant the facility's owner,operator,or both?(Check only one response.)
❑ Owner ❑✓ Operator ❑ Both
1.5 To which entity should the NPDES permitting authority send correspondence?(Check only one response.)
❑✓ Facility ❑ Applicant 0 Facility and applicant
(they are one and the same)
1.6 Indicate below any existing environmental permits. (Check all that apply and print or type the corresponding permit
number for each.)
Existing Environmental Permits
a ❑ NPDES(discharges to surface ❑ RCRA(hazardous waste) ❑ UIC(underground injection
• water) control)
1= NC0044750
2 ❑ PSD(air emissions) ❑ Nonattainment program(CM) ❑ NESHAPs(CM)
rn
N El Ocean dumping(MPRSA) El Dredge or fill(CWA Section ❑ Other(specify)
w 404)
Page 1

NPDES Permit Number Facility Name Modified Application Form 2A
NC0044750 Jacob's Creek Nursing& Modified March 2021
1.7 Provide the collection system information requested below for the treatment works.
Municipality Population Collection System Type Ownership Status
Served Served (indicate percentage)
%separate sanitary sewer 0 Own 0 Maintain
1 161 100 %combined storm and sanitary sewer ❑ Own ❑ Maintain
CD
❑ Unknown 0 Own 0 Maintain
c %separate sanitary sewer 0 Own 0 Maintain
combined storm and sanitary sewer ❑ Own 0 Maintain
0. 0 Unknown ❑ Own 0 Maintain
a %separate sanitary sewer ❑ Own 0 Maintain
o °%a combined storm and sanitary sewer 0 Own ❑ Maintain
E0 Unknown 0 Own ❑ Maintain
w %separate sanitary sewer 0 Own 0 Maintain
co %combined storm and sanitary sewer 0 Own ❑ Maintain
c 0 Unknown ❑ Own 0 Maintain
Total
°1 Population 161
ci Served
Separate Sanitary Sewer System Combined Storm and
Sanitary Sewer
Total percentage of each type of ° °
sewer line(in miles) 0 100
1.8 Is the treatment works located in Indian Country?
c •
o 0 Yes 0No
A 1.9 Does the facility discharge to a receiving water that flows through Indian Country?
c ❑ Yes ❑✓ No
1.10 Provide design and actual flow rates in the designated spaces. Design Flow Rate
0.025 mgd
Annual Average Flow Rates(Actual)
ni
Two Years Ago Last Year This Year
c
c c 0.006 mgd 0.005 mgd o.004 mgd
.7 LT Maximum Daily Flow Rates(Actual)
o Two Years Ago Last Year This Year
o.o11 mgd 0.012 mgd 0.007 mgd
H 1.11 Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
c Total Number of Effluent Discharge Points by Type
a. 1). Constructed
w Combined Sewer
t a Treated Effluent Untreated Effluent Overflows Bypasses Emergency
Overflows
N_
O 1
Fage 2

NPDES Permit Number Facility Name Modified Application Form 2A
NC0044750 Jacob's Creek Nursing& Modified March 2021
Outfalls Other Than to Waters of the State of North Cardima
1.12 Does the POTW discharge wastewater to basins,ponds,or other surface impoundments that do not have outlets
for discharge to waters of the State of North Carolina?
❑ Yes ❑ No 4 SKIP to Item 1.14.
1.13 Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Impoundment Location and Discharge Data
Average Daily Volume Continuous or Intermittent
Location Discharged to Surface (check one)
Impoundment
O Continuous
gpd ❑ Intermittent
❑ Continuous
gpd 0 Intermittent
O Continuous
gpd ❑ Intermittent
a
$ 1.14 Is wastewater applied to land?
❑ Yes ❑✓ No-) SKIP to Item 1.16.
c 1.15 Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
Continuous or
° Location Size Average Daily Volume Intermittent
Applied (check one)
acres 0 Continuous
gPd 0 Intermittent
acres ❑ Continuous
gpd ❑ Intermittent
acres 0 Continuous
gpd ❑ Intermittent
1.16 Is effluent transported to another facility for treatment prior to discharge?
❑ Yes m No-4 SKIP to Item 1.21.
1.17 Describe the means by which the effluent is transported(e.g.,tank truck,pipe).
1.18 Is the effluent transported by a party other than the applicant?
❑ Yes ❑✓ No-) SKIP to Item 1.20.
1.19 Provide information on the transporter below.
Transporter Data
Entity name Mailing address(street or P.O.box)
City or town State ZIP code
Contact name(first and last) Title
Phone number Email address
Page 3

NPDES Permit Number Facility Name Modified Application Form 2A
NC0044750 Jacob's Creek Nursing& Modified Mardi 2021
1.20 In the table below,indicate the name,address,contact information,NPDES number,and average daily flow rate of the
receiving facility.
Receiving Facility Data
Facility name Mailing address(street or P.O.box)
cu
Jacob's Creek Nursing and Rehabilitation Center 1721 Bald Hill Loop
City or town State ZIP code
0 Madison NC 27025
Contact name(first and last) Title
.00 Shannon Knight Administration
Phone number Email address
[phone]
o0 NPDES number of receiving facility(if any) 0 None
Average daily flow rate 0.005 mgd
c 1.21 Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
not have outlets to waters of the State of North Carolina(e.g., underground percolation,underground injection)?
❑ Yes El No SKIP to Item 1.23.
0 1.22 Provide information in the table below on these other disposal methods.
Information on Other Disposal Methods
o Disposal Location of Size of Annual Average Continuous or Intermittent
Method Disposal Site Disposal Site Daily Discharge (check one)
Description Volume
acres gpd ❑ Continuous
0
❑ Intermittent
O Continuous
acres gpd ❑ Intermittent
O Continuous
acres gpd ❑ Intermittent
1.23 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)?(Check all that apply.
co in Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
A ❑ Discharges into marine waters(CWA ❑ Water quality related effluent limitation(CWA Section
cr
vs GI Section 301(h)) 302(b)(2))
❑ Not applicable
1.24 Are any operational or maintenance aspects(related to wastewater treatment and effluent quality)of the treatment works
the responsibility of a contractor?
❑ Yes ❑ No*SKIP to Section 2.
1.25 Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
Contractor Information
Contractor 1 Contractor 2 Contractor 3
0
Contractor name
(company name)
Mailing address
(street or P.O.box)
o City,state,and ZIP
code
0 Contact name(first and
c� last)
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
Page 4

NPDES Permit Number Facility Name Modified Application Form 2A
NC0044750 Jacob's Creek Nursing& Modified March 2021
SECTION 2.ADDITIONAL INFORMATION(40 CFR 122.21(j)(1)and(2))
o Outfalls to Waters of the State of North Carolina
= 2.1 Does the treatment works have a design flow greater than or equal to 0.1 mgd?
rn
o Cl Yes ❑✓ No 4 SKIP to Section 3.
` 2.2 Provide the treatment works'current average daily volume of inflow Average Daily Volume of Inflow and Infiltration
and infiltration.
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
a
fa
0
0
2.3 Have you attached a topographic map to this application that contains at the required information?(See instructions for
al R specific requirements.)
0
O.
0 ❑ Yes El No
0
rr
E 2.4 Have you attached a process flow diagram or schematic to this application that contains all the required information?
0 `° (See instructions for specific requirements.)
ur o ❑ Yes ❑ No
2.5 Are improvements to the facility scheduled?
❑ Yes ❑ No 4 SKIP to Section 3.
= Briefly list and describe the scheduled improvements.
0
co
1.
E
w
2.
E
0
d
3.
ai
co
4.
R 2.6 Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
Affected Attainment of
Scheduled Outfalls Begin End Begin Operational
2 Improvement Construction Construction Discharge
(from above) (list outfall (MM/OD/YYYY) (MM1DD/YYYY) (MM/DD/YYYY) Level
number) (MM/DD/YYYY)
1.
2.
3.
4.
2.7 Have appropriate permits/clearances concerning other federal/state requirements been obtained?Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

NPDES Permit Number Facility Name Modified Application Form 2A
NC0044750 Jacob's Creek Nursing& Modified March 2021
SECTION 3.INFORMATION ON EFFLUENT DISCHARGES(40 CFR 122.21(j)(3)to(5))
3.1 Provide the following information for each outfall.(Attach additional sheets if you have more than three outfalls.)
Outfall Number 001 Outfall Number Outfall Number
State NC
County Rockingham
0 City or town Madison
Q Distance from shore 24 ft. ft. ft.
Depth below surface 4 ft. ft. ft.
cu
Average daily flow rate 0.005 mgd mgd mgd
Latitude 36° 22' 54"
Longitude 79° 54' 28"
3.2 Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
o ❑ Yes No 4 SKIP to Item 3.4.
d
3.3 If so,provide the following information for each applicable outfall.
Outfall Number Outfall Number Outfall Number
Number of times per year
discharge occurs
a Average duration of each
discharge(specify units)
Average flow of each
discharge mgd mgd mgd
.1, Months in which discharge
occurs
3.4 Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes ❑ No. SKIP to Item 3.6.
3.5 Briefly describe the diffuser t pe at each applicable outfall.
0.
Outfall Number 001 Outfall Number Outfall Number
U)
N
0
15 vi 3.6 Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
one or more discharge points?
0 Yes No-*SKIP to Section 6.
Page 6

NPDES Permit Number Facility Name Modified Application Form 2A
NC0044750 Jacob's Creek Nursing& Mortified March 2021
3.7 Provide the receiving water and related information(if known)for each outfall.
Outfall Number Outfall Number Outfall Number
Receiving water name
Name of watershed,river,
5 or stream system
n
.c U.S.Soil Conservation
O Service 14-digit watershed
o code
To Name of state
management/river basin
rn
U.S.Geological Survey
0 8-digit hydrologic
CC cataloging unit code
Critical low flow(acute) cfs cfs cfs
Critical low flow(chronic) cfs cfs cfs
Total hardness at critical mg/L of mg/L of mg/L of
low flow CaCO3 CaCO3 CaCO3
3.8 Provide the following information describing the treatment provided for discharges from each outfall.
Outfall Number Outfall Number Outfall Number
Highest Level of 0 Primary 0 Primary 0 Primary
Treatment(check all that ❑ Equivalent to ❑ Equivalent to 0 Equivalent to
apply per outfall) secondary secondary secondary
❑ Secondary 0 Secondary 0 Secondary
❑ Advanced 0 Advanced 0 Advanced
❑ Other(specify) ❑ Other(specify) 0 Other(specify)
nDesign Removal Rates by
u Outfall
0
d
BOD5 or CBOD5 % % %
d
d TSS % % %
I—
❑Not applicable 0 Not applicable 0 Not applicable
Phosphorus o% uk %
0 Not applicable 0 Not applicable 0 Not applicable
Nitrogen o% % ok
Other(specify) ❑Not applicable 0 Not applicable ❑Not applicable
%
Page 7

NPDES Permit Number Facility Name Modified Application Form 2A
NC0044750 Jacob's Creek Nursing& Modified March 2021
3.9 Describe the type of disinfection used for the effluent from each outfall in the table below.If disinfection varies by
season,describe below.
0
_
0
U
c Outfall Number Outfall Number Outfall Number
0. Disinfection type
U
d
Seasons used
Dechlorination used? ❑ Not applicable ❑ Not applicable ❑ Not applicable
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
3.10 Have you completed monitoring for all Table A parameters and attached the results to the application package?
❑ Yes ❑ No
3.11 Have you conducted any WET tests during the 4.5 years prior to the date of the application on any of the facility's
discharges or on any receiving water near the discharge points?
❑ Yes ❑ No SKIP to Item 3.13.
3.12 Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number Outfall Number Outfall Number
Acute Chronic Acute Chronic Acute Chronic
is
Number of tests of discharge
co
water
Number of tests of receiving
water
3.14 Does the POTW use chlorine for disinfection,use chlorine elsewhere in the treatment process,or otherwise have
reasonable potential to discharge chlorine in its effluent?
❑ Yes 4 Complete Table B,including chlorine. ❑ No Complete Table B,omitting chlorine.
3.15 Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
❑ Yes ❑ No
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
3.15 attached the results to this application package?
El Yes ❑ No additional sampling required by NPDES
permitting authority.
Page 8

NPDES Permit Number Facil ty Name Modified Application Form 2A
NC0044750 Jacob's Creek Nursing& Modified March 2021
3.19 Has the POTW conducted either(1)minimum of four quarterly WET tests for one year preceding this permit application
or(2)at least four annual WET tests in the past 4.5 years?
❑ Yes ❑ No 4 Complete tests and Table E and SKIP to
Item 3.26.
3.20 I Have you previously submitted the results of the above tests to your NPDES permitting authority?
❑ Yes ❑ No 4 Provide results in Table E and SKIP to
Item 3.26.
3.21 Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Date(s)Submitted Summary of Results
(MMIDD/YYYY)
•o
m
c
co 3.22 Regardless of how you provided your WET testing data to the NPDES permitting authority,did any of the tests result in
toxicity?
cr' 0 Yes 0 No 3 SKIP to Item 3.26.
a 3.23 Describe the cause(s)of the toxicity:
C
w
w
3.24 Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes ❑ No 3 SKIP to Item 3.26.
3.25 Provide details of any toxicity reduction evaluations conducted.
3.26 Have you completed Table E for all applicable outfalls and attached the results to the application package?
Cl Yes ❑ Not applicable because previously submitted
information to the NPDES 'ermittin•authorit .
Page 9

NPDES Permit Number Fadlity Name Modified Application Form 2A
NC0044750 Jacob's Creek Nursing& Modified March 2021
SECTION 6.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
6.1 In Column 1 below,mark the sections of Form 2A that you have completed and are submitting with your application.For
each section,specify in Column 2 any attachments that you are enclosing to alert the permitting authority.Note that not
all applicants are required to provide attachments.
Column 1 Column 2
Section 1: Basic Application w/variance❑ request(s)Information for All Applicants ❑ ❑ w/additional attachments
❑ Section 2:Additional ❑ w/topographic map ❑ w/process flow diagram
Information ❑ w/additional attachments
❑ w/Table A ❑ w/Table D
Section 3:Information on
❑ Effluent Discharges ❑ w/Table B ❑ w/additional attachments
❑ w/Table C
a
R
Section 4:Not Applicable
0
Section 5:Not Applicable
U
❑✓ Section 6:Checklist and w/attachments
n
Certification Statement
6.2 Certification Statement
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 fine
and imprisonment for knowing violations.
Name(print or type first and last name) Official title
Clifford Cain Operator
Signature Date signed
1? tri2 (Loib —af)')`f
Page 10

i
NPDES Permit Number Facility Name Outiall Number ti1odified Application Form 2A
Modified March 2021
NC0044750 Jacob's Creek Nursing& im
TABLE A.EFFLUENT PARAMETERS FOR ALL POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of Methods (include units)
Value Units Value Units Samples
Biochemical oxygen demand
❑ML
BODE or 0 CBOD5 15.33 mg/L <2 mg/L 156 Varies NA
0 MDL
(report one)
❑ML
Fecal coliform 2420 col/100m1 2.38 col/100m1 156 varies NA ❑MDL
Design flow rate 0.012 mgd 0.005 mgd 780
pH(minimum) 6.8(minimum) Std. Units
pH(maximum) 8 Std Units
Temperature(winter) 21 °C 14.9 `C 109
Temperature(summer) 31 'C 24.6 "C 151
0 ML
Total suspended solids(TSS) 51 mg/L 6.9 mg/L 156 NA ❑MDL
I Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter 1,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).

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Granite Falls LTC, LLC
Facility
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Jacob's Creek Nursing & Rehabilitation Center ..Vt. . .r.t . •
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Latitude: 36°22'53"N State Quad• Mayodan
Longitude:, 79°54'28"W Permitted Flow: 0.025 MGD
NPDES Permit NC 00::7f:54:0 - L
Receiving Stream: Hogan's Creek Stream Class: C
Drainage Basin: Roanoke River Basin Sub-Basin: 03-02-02/03010103 North Rockingham County

SLUDGE MANAGEMENT PLAN
Jacob's Creek Nursing & Rehabilitation Center
WASTEWATER TREAMENT PLANT
NPDES PERMIT NO. NC0044750
Sludge from the Jacob's Creek Nursing & Rehabilitation Center wastewater treatment plant
is disposed of in the following way:
Solids are collected in the sludge holding tank and digested
aerobically. The excess solids are periodically pumped and
hauled by Billingseley Septic Tank, a licensed septic pumper
contractor and disposed of at the City of Reidsville.