NC0051969_Renewal (Application)_20220120

A'6 STATE a
ROY COOPER 5
Governor 5
ELIZABETH S.BISER . .
Secretary
S.DANIEL SMITH NORTH CAROLINA
Director - - - Environmental Quality
January 20, 2022
Castle Hayne Health Holdings, LLC
Attn: Charles E. Trefzger, Manager
PO Box 2568
Hickory, NC 28603-2568
Subject: Permit Renewal
Application No. NC0051969
Castle Creek Memory Care WWTP
New Hanover County
Dear Applicant:
The Water Quality Permitting Section acknowledges the January 20, 2022 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit.The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deq.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
Sincerely,
3c04•Ced
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
ec: WQPS Laserfiche File w/application
E CZ NWiorthlmington CarolinaRegio DepartmentnalOffice of
127 C EnvironmentalardinalDrive Quality IExtension DlvisI IonWilorfmington.Water ResourcesNorth Carolina 28405
o.i.�mme.n.manomu� 910.796.7215

North Carolina
Department of Environmental Quality Modified Application Form 2A
Division of Water Resources Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < 0.1 MGD
and No Pretreatment Program
NPDES Permitting Program
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

NPDES Permit Number Facility Name Modified Application Form 2A
NC0051969 Castle Creek Memory Care Modified March 2021
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 ma result in denial of the a i lication.
SECTION 1. BASIC APPLICATION INFORMATION FOR ALL APPLICANTS(40 CFR 122.21(j)(1)and(9))
1.1 ' Facility nerve •
Castle Hayne Health Holdings,LLC dba Castle Creek Memory Care
Mailing address(street or P.O.box) •
P.O.Box 26255 •
City or town State : ZIP code
o Winston-Salem NC 27114
Contact name(first and last) Title Phone number Email'address
Rodney Propst Maintenance Engineer [phone] [e-mail] '
'Location address(street,route number,or other specific identifier) ❑Same as mailing address. • •
LL 4724 Castle Hayne Road
City or town - • State - ZIP code
Castle Hayne NC 28429
- . 1.2 Is this application for a facility that has yet to commence discharge'? •
D Yes 4 See iristructions on data submission ❑ -No
requirements for new dischargers. •
'
1.3 Is applicant different from entity listed under Item 1.1 above?
❑ - Yes ✓❑ No+SKIP to Item 1.4.
' t name
•
Applicant address(street or P. .
0
City or town - ZIP code -
c
Contact name(first and last) Title Phone number Em ' ess -
•n
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_thesame)
- 1.6 Indicate below any existing environmental permits.(Check all that t apply,and print or type the corresponding permit
w number for each.) '
Existing Environmental Permits " - -
'Id ✓ NPDES(discharges to surface El RCRA(hazardous waste UIC(underground injection
• . E water), - - control)
E• NC0051969 -
c
❑ PSD(air emissions) 0 Nonattainment program(CM) ❑ NESHAPs(CM)
•
W.
Of
•
H ❑ Ocean dumping(MPRSA) ' El Dredge or fill(CWA Section , - El - Other(specify) '
- 404) ' • -
•
•
Page 1

NPDES Permit Number Facility Name Modified Application Form 2A
NC0051969 Castle Creek Memory Care 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) -
Up to 84 Persons no %separate sanitary sewer 0 Own ❑ Maintain
Z 0 %combined storm and sanitary sewer 0 Own ❑ Maintain
d El Unknown ❑ Own ❑ Maintain
Cl) %separate sanitary sewer ❑ Own ❑ Maintain
%combined storm and sanitary sewer ❑ Own ❑ Maintain
co
= ❑ Unknown ❑ Own El Maintain
0.
o %separate sanitary sewer 0 Own ❑ Maintain
0.
-0 %combined storm and sanitary sewer ❑ Own CIMaintain
03 ❑ Unknown ❑ Own ❑ Maintain
E %separate sanitary sewer ❑ Own ❑ Maintain
%combined storm and sanitary sewer ❑ Own ❑ Maintain
cn
c ❑ Unknown ❑ Own ❑ Maintain
o
Total
Up to 84 Persons
Population
o Served
Separate Sanitary Sewer System Combined Storm and
Sanitary Sewer
Total percentage of each type of 100 % /°
°
sewer line(in miles)
?' 1.8 Is the treatment works located in Indian Country?
c
o ❑ Yes ✓❑ No
0
C)
c 1.9 Does the facility discharge to a receiving water that flows through Indian Country?
CO
❑ Yes 0 No
1.10 Provide design and actual flow rates in the designated spaces. Design Flow Rate
0.012 mgd
Annual Average Flow Rates(Actual)
a Two Years Ago Last Year This Year
cc 0.006254 mgd 0.006238 mgd 0.004630 mgd
CCO
" Maximum Daily Flow Rates(Actual)
o Two Years Ago Last Year This Year
0.0155 mgd 0.0144 mgd o.011 mgd
u) 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- A Constructed
Treated Effluent Untreated Effluent Combined Sewer Bypasses Emergency
t a Overflows Overflows
t)
y
G 1
Page 2

NPDES Permit Number .Facility Name Modified Application Form 2A NC0051969 Castle Creek Memory Care Modified March 2021
Outfalls Other Than to Waters of the State of North Carolina
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.
. 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 - "
0 Continuous
gpd 0 Intermittent
■ Continuous
gpd ❑ In - '•nt
0 Continuous
gpd ❑ Intermittent
w 1.14 Is wastewater applied to land?
m ❑ Yes ❑✓ No 4 SKIP to Item 1.16.
c 1 *5 Provide the land application site and discharge data requested below.
y Land Application Site and Discharge Data
o Average Daily Volume
Continuous or
Location Size A Ited Intermittent
0 � PP (check one)
y
acre d ❑ Continuous
c gP ❑ Intermittent
acres - d - ❑ Continuous
c Intermittent
as
acres gpd ❑ -Intermittent
T1.16 Is effluent transported to another facility for treatmentprior to discharge?
o ElYes 2 No-I SKIP to Item 1.21.
. • Describe the means by which the effluent is transported(e.g.,tank truck,pipe).
1.18 Is the effluent transporte arty other than the applicant?
❑ Yes- ❑ No-I SKIP to Item 1.20.
1.19 Provide information on the transporter below. -
Tra rter Data -
Entity name "ng 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
NC0051969 Castle Creek Memory Care Modified March 2021
: In the table below,indicate the name,address,contact information, NPDES number,and average daily flow rate of the
rece acility.
Receiving Facility Data
-0 Facility name Mailing address(street or P.O.box)
d
City or town State ZIP code
o -
-UU) Contact name(first and last) I -
0
u- Phone number Email address
M
To
NPDES number of receiving facility(if any) 0 None Average daily flow rate
co
O 1.21 Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
d not have outlets to waters of the State of North Carolina(e.g.,underground percolation,underground injection)?
s ❑ Yes ❑✓ No 4'SKIP to Item 1.23.
0
o —rovide information in the table below on these other disposal methods.
d Information on Other Disposal Methods
o Disposal , ._i of Size of Annual Average Continuous or Intermittent
c Method Disposal Si a Disposal Site Daily Discharge (check one)
as ,Description Volume
co
w ac = d 0 Continuous
gp 0 Intermittent
o 0 Continuous
acres 'gp' ■ . -rmittent
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.
C Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
c 3 Discharges into marine waters(CWA Water quality related effluent limitation(CWA Section
Section 301(h)) ❑ 302(b)(2))
O 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
c Contractor name
o Kevin Woodward Lewis Farms&Liquid Waste,In
47, (company name)
Mailing address -
s (street or P.O.box) 5096 Edinboro Ln. 8155 Malpass Corner Rd.
w City,state,and ZIP Wilmington,NC 28409 Currie,NC 28435
co code
cContact name(first and Kevin Woodward Wesley Wooten
c.o last)
Phone number [phone] [phone]
Email address [e-mail]
Operational and Operate,maintain,collect Waste disposal and WWTP
maintenance samples,regulatory cleaning.
responsibilities of inspection,coordinate repair
contractor
Page 4

NPDES Permit Number Facility Name Modified Application Form 2A
• NC0051969 Castle Creek Memory Care Modified March 2021
SECTION 2.ADDITIONAL INFORMATION (40 CFR 122.21(j)(1)and(2))
c Outfalls to Waters of the State Of North Carolina
u'c• 2.1 Does the treatment works have a design flow greater than or equal to 0.1 mgd?
❑ - Yes 0 No 4 SKIP to Section 3.
o - Provide the treatment works'current average daily volume of ihflow Average Daily Volume of Inflow and Infiltration
i, filtration.
gpd
Indicate the step -facility is taking to minimize inflow and infiltration.
c
ea
0 •
2.3 Have you attached a topographic map to this application contains all the required-information?(See instructions for -
o Q. specific requirements.)
rnco
o
0' ❑ Yes
. No
E 2.4 Have you attached a process flow diagram or schematic to this application that contains all th- :,uired information?
c t° (See instructions for specific requirements.)
co
- c ❑ 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 - -
a 1. Updates to the WWTP to ensure compliance with Permit limits on Cu in effluent.
c.
•
- 2.
E
0
CD
3. •
4.
cm
-13
a 2.6 Provide scheduled or actual dates of completion for-improvements.
Scheduled or Actual Dates of Completion for Improvements -
,Affected Attainment of -
a> Scheduled - Begin End Begin
> Outfalls Operational
- c Improvement Construction Construction Discharge
0. (list outfall Level •
(from above) number) (MM/DD/YYYY) (MM/DD/YYYY) '(MMIDDIYYYY)
(MMIDD/YYYY),6
cp
1 001 07/11/2022 07/18/2022 08/17/2022 09/16/2022
a�
0- 2.
3.
4.
2.7 Have appropriate permits/clearances concerning other federal/state requirements been obtained?•Briefly explain your
response. -- ❑ Yes E No ❑ None required Or applicable -
Explanation: - - -
Authorization to Construct will be sought once project schematics are finalized.Project is being done in cooperation with' -
DEQ.
Page 5

- NPDES Permit Number Facility Name - Modified Application Form 2A
NC0051969 Castle Creek Memory Care 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 o01 Outfall Number Outfall Number
State NC
1 County • New Hanover
- w
- •0 - City or town Castle Hayne
0
`s Distance from shore. - I. ft. - ft. ft.
d Depth below surface o ft. ft. ft.
c •
Average daily flow rate 0.006 mgd mgd mgd
Latitude 3o° 20' 13.6 N ° -"•
Longitude 77° 54' 28.1f W ° ,, ° '
3.2 Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
c ❑ Yes El - No-4 SKIP to Item 3.4.
d
• s . •• so,provide the following information for each applicable outfall.
H Outfall Number Outfall Number Outfall Number-
:a Number of times per year - - - .
o discharge occurs .
a Average duration of each '
`o discharge(specify units)- :. - :-
c Average flow of each •
u) discharge mgd d mgd
cn Months in which discharge
. occurs
- 3.4 Are any of the outfalls listed under Item 3.1 equippedwith a diffuser?
❑ Yes ElNo 4 SKIP to Item 3.6.
• iefl describe the diffuser type at each applicable outfall. • - •co
- - -
Q
1 Outfall Number Outfall Number Outfall Number
d -
N
0
vi 3:6 Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from '
d ; one or more discharge points?-
co w
- ❑ Yes ❑ No-"SKIP to Section 6.
Page 6

NPDES Permit Number Facility Name Modified Application Form 2A
NC0051969 Castle Creek Memory Care Modified March 2021
3.7 Provide the receiving water and related information(if known)for each outfall.
Outfall Number 001 Outfall Number Outfall Number
Receiving water name Prince George Creek
Name of watershed,river, NE Cape Fear River
c or stream system
Q- U.S.Soil Conservation
L
d Service 14-digit watershed unknown
c code
R Name of state unknown
g management/river basin
rn
U.S.Geological Survey
0 8-digit hydrologic unknown
re cataloging unit code
Critical low flow(acute) o cfs cfs cfs
Critical low flow(chronic) o cfs cfs cfs
Total hardness at critical mg/L of mg/L of mg/L of
low flow 80 CaCO3 CaCO3 CaCO3
3.8 Provide the following information describing the treatment provided for discharges from each outfall.
Outfall Number 001 Outfall Number Outfall Number
Highest Level of El Primary ❑ Primary ❑ Primary
Treatment(check all that 0 Equivalent to ❑ Equivalent to ❑ Equivalent to
apply per outfall) secondary secondary secondary
El Secondary 0 Secondary 0 Secondary
❑ Advanced 0 Advanced 0 Advanced
❑ Other(specify) 0 Other(specify) 0 Other(specify)
s
0 - -
a Design Removal Rates by
Outfall
u)
tl1
o BOD5 or CBOD5
= Unknown
m
E
co
22 TSS Unknown % % %
1—
RI Not applicable 0 Not applicable 0 Not applicable
Phosphorus %
® Not applicable 0 Not applicable ❑ Not applicable
Nitrogen
Other(specify) 0 Not applicable 0 Not applicable El Not applicable
%
* Observed performance is a >95% removal rate.
Page 7

•
NPDES Permit Number Facility Name Modified Application Form 2A
NC0o51969 Castle Creek Memory Care 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.
Ultraviolet disinfection is used year-round. - -
o'
Outfall Number 001 Outfall Number Outfall Number
o •
g- Disinfection type Ultraviolet
iy
c
= Seasons used All
Dechlorination used? 0 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?
r❑ •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 4 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 001 - Outfall Number Outfall Number
Acute' Chronic Acute• Chronic Acute Chronic
A -
Number of tests of discharge o 20
w
water -
Number of tests of receiving 0 o
water
d
7
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 4 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 El No Flow-= < 0.1 mgd -
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and -
3.18 attached the results to this application package?
No additional sampling required by NPDES-
❑✓ Yes 0 , permitting authority. - -
Page 8

NPDES Permit Number Facility Name Modified Application Form 2A
NC0051969 Castle Creek Memory Care 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 Have you previously submitted the results of the above tests to your NPDES permitting authority?
• Yes 0 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.- •
_
(MMIDDmwY) Summary of Results
01/21/2021; All results passing.
09/27/2021;
04/29/2021;
c ,
11/02/2021
0
3.22 Regardless of how you provided your WET testing data to the NPDES permitting authority,did any of the tests result in
Al toxicity?
❑ - Yes- ❑✓ -_ No 4 SKIP to Item 3.26.
nw
.F e cause(s)of the toxicity:
d
3.24 Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes 0 ' No 4.SKIP to Item 3.26.
tails 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?
- b ' Not applicable because previously submitted
Yes information to the NPDES ermittin authori .
•
Page 9

NPDES Permit Number Facility Name Modified Application Form 2A
NC0051969 Castle Creek Memory Care 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
Information for All Applicants w/variance request(s) ❑ wl additional attachments
❑ Section 2:Additional ❑ wl topographic map ❑ wl process flow diagram
Information ❑ wl additional attachments
0 wl Table A 2 wl Table D
❑✓ Section 3:Information on ❑ wf Table B ❑ wl additional attachments
Effluent Discharges
❑ w/Table C
co
Section 4: Not Applicable
0
Section 5:Not Applicable
C)
-0 Section 6:Checklist and
Certification Statement ❑ w/attachments
N
6.2 Certification Statement
U
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. 1 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
Manager,
Charles E.Trefzger Castle Hayne Health Holdings,LLC
0Si a ,�nn Date signed
D/a0aa_
Page 10

NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0051969 Castle Creek Memory Care 001 Modified March 2021
TABLE A. EFFLUENT PARAMETERS FOR ALL POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of Methods (include
Value Units Value Units Sam•les units)
Biochemical oxygen demand
0 ML
o BODE or 0 CBOD5 15 mg/L 1.92 mg/L 156 SM 5210 B-2016 2 mg/L 0 MDL
resort one
o ML
Fecal coliform 2420 CFU/100m1 2.6 CFU/100m1 156 SM 9222 D-2015 M' 1 CFU/100 O MDL
Design flow rate 0.0155 MGD 0.005707 MGD 1095
pH(minimum) 7.50 S.U.
pH(maximum) 8.48 S.U.
Temperature(winter) 23 °C 15.8 °C 38
Temperature(summer) 32 °C 27.3 °C 38
0 ML
Total suspended solids(TSS) 44 mg/L 9.67 mg/L 156 SM 2540 D-2015 2.5 mg/L 17 MDL
1 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 I,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
Page 11

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0051969 Castle Creek Memory Care Modified March 2021
► ■::.: 'METERS FOR ALL POTWS WITH A FLOW EQUAL TO OR GREATER THAN 0.1 MGD
Maximum Daily Discharge Average Daily Discharge
Pollutant — Number of Analytical ML or MDL
Value Units Value Units Method (include units)
Samples
0 ML
Ammonia(as N) El MDL
Chlorine I ❑ML
(total residual,TRC)2 \ ❑MDL
0 ML
Dissolved oxygen ❑MDL
\ ❑ML
Nitrate/nitrite
❑MDL
O ML
Kjeldahl nitrogen ❑MDL
O ML
Oil and grease ❑MDL
0 ML
Phosphorus ❑MDL
L
Total dissolved solids o.MDL
1 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 I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
2 Facilities that do not use chlorine for disinfection,do not use chlorine elsewhere in the treatment process,and have no reasonable potential to discharge chlorine in their effluent are not
required to report data for chlorine.
EPA Form 3510-2A(Revised 3-19) Page 12

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0051969 Castle Creek Memory Care Modified March 2021
TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollu .
N. Value Units Value Units Number of Methods (include units)
Samples
Metals,Cyanide,and Total Phenols
❑ML
Hardness(as CaCO3) _ ❑MDL
Antimony,total recoverable ❑ML
❑MDL
Arsenic,total recoverable — ❑ML
❑MDL
Beryllium,total recoverable ❑ML
❑MDL
Cadmium,total recoverable II ML
❑MDL
Chromium,total recoverable ❑ML
❑MDL
Copper,total recoverable ❑ML
❑MDL
Lead,total recoverable CI ML
❑MDL
Mercury,total recoverable ❑ML
❑MDL
Nickel,total recoverable ❑ML
❑MDL
Selenium,total recoverable ❑ML
❑MDL
Silver,total recoverable ❑ML
❑MDL
Thallium,total recoverable \ ❑ML
❑MDL
Zinc,total recoverable ❑ML
❑MDL
Cyanide N. ❑ML
❑MDL
Total phenolic compounds ❑ML
❑MDL
Volatile Organic Compounds
Acrolein ❑ML
❑MDL
Acrylonitrile \ ❑ML
❑MDL
Benzene ❑ML
❑MDL
IL
Bromoform ❑❑MDL
EPA Form 3510-2A(Revised 3-19) Page 13

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0051969 Castle Creek Memory Care Modified March 2021
TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Polluta
Value Units Value Units Number of Method1 (include units)
Samples
Carbon tetrachloride ❑ML
❑MDL
Chlorobenzene ❑ML
❑MDL
Chlorodibromomethane El ML
❑MDL
Chloroethane ❑ML
❑MDL
2-chloroethylvinyl etherNN ❑ML
❑MDL
Chloroform ❑ML
❑MDL
Dichlorobromomethane ❑ML
❑MDL
1,1-dichloroethaneNN. ❑ML
❑MDL
1,2-dichloroethane ❑ML
❑MDL
trans-1,2-dichloroethylene ❑ML
❑MDL
1,1-dichloroethylene ❑ML
❑MDL
1,2 dichloropropane N.
❑ML
❑MDL
1,3-dichloropropylene ❑ML
❑MDL
Ethylbenzene ❑ML
❑MDL
Methyl bromide ❑ML
❑MDL
Methyl chloride ❑ML
❑MDL
Methylene chloride ❑ML
0 MDL
1,1,2,2-tetrachloroethane ❑ML
❑MDL
Tetrachloroethylene ❑ML
❑MDL
Toluene ❑ML
❑MDL
1,1,1-trichloroethane ❑ML
❑MDL
1,1,2-trichloroethane ❑ML
❑MDL
EPA Form 3510-2A(Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0051969 Castle Creek Memory Care Modified March 2021
TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Poll
Value Units Value Units Number of Method1 (include units)
Samples
0 ML
Trichloroethylene ❑MDL
Vinyl chloride ❑ML
❑MDL
Acid-Extractable Compounds
p-chloro-m-cresol ❑ML
❑MDL
2-chlorophenol ❑ML
❑MDL
2,4-dichlorophenol ❑ML
❑MDL
2,4-dimethylphenol ❑ML
❑MDL
4,6-dinitro-o-cresol ❑ML
❑MDL
2,4-dinitrophenol ❑ML
❑MDL
2-nitrophenol ❑ML
❑MDL
4-nitrophenol ❑ML
❑MDL
Pentachlorophenol N. ❑ML
❑MDL
❑ML
Phenol ❑ML
MDL_ ❑
2,4,6-trichlorophenol NN.\ ❑MDL
Base-Neutral Compounds
Acenaphthene I ❑ML
❑MDL
Acenaphthylene ❑ML
❑MDL
Anthracene N
- ❑ML❑MDL
Benzidine ❑ML
❑MDL
Benzo(a)anthracene ❑ML
❑MDL
Benzo(a)pyrene ❑ML
❑MDL
3,4-benzofluoranthene ❑Mt_
❑MDL
EPA Form 3510-2A(Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0051969 Castle Creek Memory Care Modified March 2021
TABLE C. ' LUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollute
Value Units Value Units Number of Methods (include units)
-N. Samples
Benzo(ghi)perylene ❑ML
❑MDL
LI ML
Benzo(k)fluoranthene ❑MDL
Cl ML
Bis(2-chloroethoxy)methane ❑MDL
0 ML
Bis(2-chloroethyl)ether ❑MDL
Bis(2-chloroisopropyl)ether L o ML
❑MDL
CI ML
Bis(2-ethylhexyl)phthalate ❑MDL
4-bromophenyl phenyl ether ❑MDL
0 ML
Butyl benzyl phthalate ❑MDL
DI ML
2-chloronaphthalene ❑MDL
4-chlorophenyl phenyl ether ❑MDL
CI ML
Chrysene ❑MDL
di-n-butyl phthalate \ CI ML
CI MDL
CI ML
di-n-octyl phthalate ❑MDL
Dibenzo(a,h)anthracene ❑MDL I
1,2-dichlorobenzene ❑ML
❑MDL
1,3-dichlorobenzene ❑ML
❑MDL
1,4-dichlorobenzene CI ML
❑MDL
3,3-dichlorobenzidine ❑ML
El MDL
ILI ML
Diethyl phthalate ❑MDL
Dimethyl phthalate MDL
2,4-dinitrotoluene N
DI❑ML
Cl MDL
2,6-dinitrotoluene ❑M`
❑MDL
EPA Form 3510-2A(Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0051969 Castle Creek Memory Care Modified March 2021
TABLE C.E UENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of Method1 (include units)
Value Units Value Units Samples
1,2-diphenylhydrazine ❑ML
❑MDL
Fluoranthene ❑ML
❑MDL
Fluorene ❑ML
❑MDL
Hexachlorobenzene ❑ML
❑MDL
Hexachlorobutadiene ❑ML
❑MDL
Hexachlorocyclo-pentadiene ❑ML
❑MDL
Hexachloroethane ❑ML
❑MDL
Indeno(1,2,3-cd)pyrene ❑ML
❑MDL
❑ML
lsophorone ❑MDL
❑ML
Naphthalene ❑MDL
Nitrobenzene ❑ML
❑MDL
0 ML
N-nitrosodi-n-propylamine ❑MDL
ML
N-nitrosodimethylamine ❑MDL
ML
N-nitrosodiphenylamine ❑MDL
Phenanthrene ❑ML
❑MDL
Pyrene ❑MDL
1,2,4-trichlorobenzene ❑NIL
❑MDL
1 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 I, Subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2A(Revised 3-19) Page 17

NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0051969 Castle Creek Memory Care 001 Modified March 2021
TABLE D.ADDITIONAL POLLUTANTS AS REQUIRED BY NPDES PERMITTING AUTHORITY
Maximum Daily Discharge Average Daily Dischar e
Pollutant Analytical ML or MDL
Gist) Value Units Value Units Number of Method1 (include units)
Samples
0 No additional sampling is required by NPDES permitting authority.
0
Ammonia 3.4 mg/L 0.196 mg/L 156 EPA 200.7, R .0511 mg/1 ML
ev 4.4,1994 ❑MDL
Copper 72 mg/L 16.4 mg/L 156 Re .4, 1 .005 mg/L ❑ML
Rev EPA 54994 El MDL
❑ML
Chloride 714 mg/L 265.9 mg/L 156 SM 4500 CI E-2011 .982 mg/L O MDL
❑ML
Dissolved Oxygen 11.29 mg/L 8.20 mg/L 156 SM 4500-0 G-2000 0.01 mg/L El MDL
Conductivity 2280 µmhos/cm 1363.2 µmhos/cm 36 ReevvA 1 198 2 ❑ML
R 10umhos/c CI MDL
Salinity 1.3 ppt 0.67 ppt 36 SM 2520 B-2011 0.1 ppt 0 ML
❑MDL
0 ML
Hardness 331 mg/L 227.9 mg/L 36 SM 2340 C-2011 2 mg/L ❑MDL
0 ML
Turbidity 35.4 NTU 10.34 NTU 36 SM 2130 B-2011 0.1 NTU EI MDL
Total Dissolved Solids 1120 mg/L 766.5 mg/L 15 SM 2540 C-2015 2.5 mg/L O1=1 MMDL
Zinc 125 mg/L 46.8 mg/L 14 EPA 200.7, 004 mg/L 0 ML
Rev 4.4, 1994 0 MDL
Flouride 1.8 mg/L 0.36 mg/L 15 SM 4500 F C-2011 0.1 mg/L ❑ML
0 MDL
❑ML
❑MDL j
❑ML
❑MDL
❑ML
❑MDL
0 ML
0 MDL
0 ML
❑MDL
0 ML
0 MDL
1 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 I,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
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