NCG500651_Permit (Issuance)_20110414

ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
April 14, 2011
Mr. Charles Mullis
Plant Operations Manager
Moses Cone Health System
618 South Main Street
Reidsville, NC 27320
Subject: General Permit No. NCG500000
Certificate of Coverage NCG500651
Annie Penn Hospital
Rockingham County
Dear Mr. Mullis:
In accordance with your application for discharge, the Division is forwarding herewith the subject Certificate of Coverage
to discharge under the subject state-NPDES general permit. This permit is issued pursuant to the requirements of North
Carolina General Statue 143-215 .1 and the Memorandum of Agreement between North Carolina and the US
Environmental Protection agency dated July 17, 2007 (or as subsequently amended).
The following information is included with your permit package:
• A copy of the Certificate of Coverage for your treatment facility
• A copy of General Wastewater Discharge Permit NCG500000
• A copy of a Technical Bulletin for General Wastewater Discharge Permit NCG500000
If any parts, measurement frequencies or sampling requirements contained in this general permit are unacceptable to
you, you have the right to request an individual permit by submitting an individual permit application. Unless such demand
is made, the certificate of coverage shall be final and binding.
Please take notice that this Certificate of Coverage is not transferable except after notice to the Division of Water Quality.
The Division of Water Quality may require modification or revocation and reissuance of the certificate of coverage. This
permit does not affect the legal requirements to obtain other permits which may be required by the Division of Water
Quality or permits required by the Division of Land Resources, Coastal Area Management Act or any other Federal or
Local governmental permit that may be required. If you have any questions concerning this permit, please contact Bob
Guerra at telephone number 919/807-6387 or by email at bob.guerra(a�ncdenr.gov.
een H. Sullins
cc:
Winston-Salem Regional Office, Surface Water Protection
NPDES General Permit Files
Central Files
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone] \ Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity \ Affirmative Action Employer
NorthCarolina
,Naturally

Permit NCG50065 1
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
General Permit NCG500000
Certificate of Coverage NCG500651
TO DISCHARGE NON -CONTACT COOLING WATER, COOLING TOWER AND BOILER
BLOWDOWN, CONDENSATE, EXEMPT STORMWATER, COOLING WATERS ASSOCIATED
WITH HYDROELECTRIC OPERATIONS, AND SIMILAR WASTEWATERS UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provisions of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
Moses Cone Health System
is hereby authorized to discharge wastewater from a facility located at the
Annie Penn Hospital
618 South Main Street
Reidsville, NC 27320
Rockingham County
to receiving waters designated as Troublesome Creek, a class WS-III NSW water in the Cape
Fear River Basin,
in accordance with effluent limitations, monitoring requirements and other conditions set
forth in Parts I, II, III and IV of the General Permit NCG 500000, as attached.
This permit shall become effective April 14, 2011.
This Certificate of Coverage shall expire at midnight on July 31, 2012.
Signed this day April 14, 2011.
Col: s' H. Sullins., Direct
D. sion of Water Quality
By Authority of the Environmental Management Commission

Moses Cone Health System
Annie Penn Hospital WWTP
Latitude: 36° 21' 10" N State Grid: Reidsville
Longitude: 79° 40' 05" W Permitted Flow: N/A
Receiving Stream: Troublesome Creek Sub -Basin: 03-06-01
Drainage Basin: Cape Fear River Basin Stream Class: WS-III NSW
NPDES Permit No. NCG500651
Rockingham County

Beverly Eaves Perdue
Governor
MEMORANDUM
To:
ATA
�iur
NCDENR
North Carolina Department of Environment and Natural Resources "
Division of Water Quality
Coleen H. Sullins Dee Freeman
Director Secretary
Lisa Edwards
NC DENR 1 DEH / Regional Engineer
Winston-Salem Regional Office
April 11, 2011
From: Bob Guerra
NPDES Program
Subject Review of NPDES Boiler Blow Down General Permit NCG500651
Moses Cone Health System —Annie Penn Hospital WWTP
Rockingham County
Please indicate below your agency's position or viewpoint on the proposed permit modification and retum this form as
soon as possible. If you have any questions on the proposed modification, please contact me at [phone] or e-mail
bob.auerraea ncdenr.gov
00000000O000000000000000000000000000000000000000000000000000000000000000
SE: (Check one)
Concur with the issuance of this permit provided the facility is operated and maintained properly, the stated effluent
limits are met prior to discharge, and the discharge does not contravene the designated water quality standards.
Concurs with issuance of the above permit, provided the following conditions are met:
Opposes the issuance of the above permit, based on reasons stated below, or attached:
Signed
#747D
1617 Mall Service Center. Raleigh, North Carolina 27699-1617
location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Rhone: 919-807-63001 FAX: [phone] Customer Service:1-877-623-6748
Internet vekw.nomaterquarrty.org
An Equal Opportunity %AtermatdreAdon Employer
One
No Carolina

cc: Central Files
WSRO
To:
SOC PRIORITY PROJECT: Yes
If Yes, SOC No.
Permits and Engineering Unit
Water Quality Section
No X
Attention: Charles Weaver
Date: 03 March 2011
NPDES STAFF REPORT AND RECOMMENDATION
County: Rockingham
Permit No. NCG500651
PART I - GENERAL INFORMATION
1. Facility and Address:
Annie Penn Hospital
Moses Cone Health System
618 South Main Street
Reidsville, NC 27320
2. Date of Investigation: 1 November 2010
3. Report Prepared by: Mike S. Thomas
WSRO-SWP
3 March 2011
4. Persons Contacted and Telephone Number:
Charles Mullis
336-951-4000
5. Directions to Site:
6. Discharge
Point (s) , List for all discharge points:
Latitude: 36° 21' 10"
Longitude: 79° 40' 05"
USGS Quad No. b20gW USGS Quad Name Reidsville
7. Site size and expansion area consistent
X Yes No If No, explain:
8. Topography (relationship to flood plain
flood plain
with application?
included) : Above

9. Location of nearest dwelling: ±270 feet
10. Receiving stream or affected surface waters:
Troublesome Creek 16-06-0.3
a. Classification: WS-III NSW
b. River Basin and Subbasin No.: 03-06-01
c. Describe receiving stream features and pertinent
downstream uses: commercial, industrial, residential
Part II - DESCRIPTION OF DISCHARGE AND TREATMENT WORKS
1. a. Volume of Wastewater to be permitted: 104 gallons max
(Ultimate Design Capacity)
b. What is the current permitted capacity of the Waste
Water Treatment facility? N/A
c. Actual treatment capacity of the current facility
(current design capacity)? N/A
d. Date(s) and construction activities allowed by previous
Authorizations to Construct issued in the previous two
years. N/A
e. Please provide a description of existing or
substantially constructed wastewater treatment
facilities; N/A
f. Please provide a description of proposed wastewater
treatment facilities. Typical boiler blowdown
configuration with addition of Ancotreat 1140
manufactured by Chemaqua.
g-
Possible toxic impacts to surface waters: None known
h. Pretreatment Program (POTWs only):
in development approved
should be required not needed X
2. Residuals handling and utilization/disposal scheme:
a. If residuals are being land applied, please specify
DWQ-AP Permit No. N/A
Residuals Contractor
Telephone No.

NPDES Permit Staff Report
b. Residuals stabilization: PSRP PFRP
Other
c. Landfill:
d. Other disposal/utilization scheme (Specify):
3. Treatment plant classification (attach completed rating
sheet) .
4. SIC Code (s) : 8062
Primary 16 Secondary 02
Main Treatment Unit Code: 0 0 0 X 0
PART III - OTHER PERTINENT INFORMATION
1. Is this facility being constructed with Construction Grant
Funds or are any public monies involved. No
2. Special monitoring or limitations (including toxicity)
requests: None at this time.
3. Important SOC, JOC or Compliance Schedule dates: (Please
indicate) N/A
Date
Submission of Plans and Specifications
Begin Construction
Complete Construction
PART IV - EVALUATION AND RECOMMENDATIONS
WSRO recommends reissuance of NPDES Permit NCG500651 in
accordance with Division guidelines.

ATA
NCDENR
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Division of Water Quality / Water Quality Section
National Pollutant Discharge Elimination System
NCG500000
FOR AGENCY USE ONLY
Date Received
Year
Month
Dav
AO/A
!r
14. -
Certificate of Coveraae
NtICIGIslololbtSll.
Check tk
Amount
M.ROh /
/D0.00
permit A
sinned to
Hi) b a t i e /'/'a
NOTICE OF INTENT
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG500000: Non -contact cooling water, boiler blowdown, cooling tower blowdown, condensate, and
similar point source discharges
(Please print or type)
1) Mailing address. of owner/operator:
Anne Tenn J-c p;-&I +
Ynases Cone. Neal Sys e_m
Company Name
Owner Name
Street Address 1 1 �S01.1 h rr l Q
City he 1,ds ; J I e State Ale., ZIP Code a 73D
Telephone No. 336v 95) -'t':FAD Fax: 3 Lo 951 - 449121
* Address to which all permit correspondence will be mailed
2) Location of facility producing discharge:
Facility Name r]rli e. -Pe.!')/'1 �QSp1 aJ
Y
Facilit Contact h1ir!eS (nu ! I is
Street Address 60i? SDu+h imai n S-b-ee-.
City --R-€ e ,AJ i114). State Pi C
County -PInCaC i rl VI, �tM
Telephone No. �10 4Ss - Ono Fax: 33 to yS� ` /9
ZIP Code a731
3) Physical location information:
Please provide a narrative description of how to get to the ftjcility (use street names, state road numbers,
and distance and direction from a roadway intersection). Lorr1v- et 4 /-JQrr►[� 5n S-r?d-
ci (Y
O�n ipt e _ Ave. I n tom- erksu ► 1 I E.
(A copy of a county map or USGS quad sheet with facility clearly located on the map is required to be submitted with this application)
4) This NPDES permit application applies to which of the following :
OtNew or Proposed
❑ Modification n r
Please describe the modification:
❑ Renewal
Please specify existing permit number and original issue date:
5) Does this facility have any other NPDES permits?
14 No
❑ Yes
If yes, list the permit numbers for all current NPDES permits for this facility:
NOV `L22010
DEMF-;,—TER QUALITY
POINT SOURCE BRANCH
6) What is the nature of the business applying for this permit? I4eo..J4 0_.a
Page 1 of 4
04/05

NCG500000 N.O.I.
7) Description of Discharge:
a) Is the discharge directly to the receiving water? ❑ Yes [ No
If no, submit a site map with the pathway to the potential receiving waters clearly marked. This
includes tracing the pathway of the storm sewer to the discharge point, if the storm sewer is the only
viable means of discharge.
b) Number of discharge points (ditches, pipes, channels, etc. that convey wastewater from the
property): 1
c) What type of wastewater is discharged? Indicate which discharge points, if more than one.
Discharge point(s) #:
Discharge point(s) #: W 4:94.11on5 r
Discharge point(s) #:
Discharge point(s) #:
Discharge point(s) #:
(Please describe "Other")
d) Volume of discharge per each discharge point (in GPD):
#1: b . #3: #4
e) Please describe the type of process (i.e., compressor, NC unit, chiller, boiler, etc.) the wastewater is
being discharged from, per each separate discharge point (if applicable, use separate sheet):
S
❑ Non -contact cooling water
Pci Boiler Blowdown
❑ Cooling Tower Blowdown
❑ Condensate
❑ Other
8) Please check the type of chemical added to the wastewater for treatment , per each separate discharge
point (if applicable, use separate sheet):
❑ Biocides Name: Manuf.:
slid Corrosion inhibitors Name: Af1(10-ree(++ ! ND • Manuf.: (}y
❑ Chlorine Name: Manuf.: UU
❑ Algaecide Name: Manuf.:
❑ Other Name: Manuf.:
❑ None
9) If any box in itern (8) above, other than none, was checked, a completed Biocide 101 Form and
manufacturers' information on the additive is required to be submitted with the application for the
Division's review. Ni
10) Is there any type of treatment being provided to the wastewater before discharge (i.e., retention ponds,
settling ponds, etc.)? ❑ Yes g No
If yes, please include design specifics (i.e., design volume, retention time, surface area, etc.) with
submittal package. Existing treatment facilities should be described in detail. Design criteria and
operational data (including calculations) should be provided to ensure that the facility can comply with the
requirements of the General Permit. The treatment shall be sufficient to meet the limits set by the
general permits.
Note: Construction of any wastewater treatment facilities requires submission of three (3) sets
of plans and specifications along with the application. Design of treatment facilities
must comply with the requirements of 15A NCAC 2H .0138. If construction applies to
this discharge, include the three sets of plans and specifications with this application.
Page 2 of 4 04/05

NCG500000 N.O.I.
11) Discharge Frequency:
a) The discharge is: 0 Continuous )i Intermittent 0 Seasonalo
i) If the discharge is intermittent, describe when the discharge will a�occur{;�' t bl c mo
e& r. le ' kan� lers and er3c��►, boiler owe. 0. � {v n-v •
ii) If seasonal check the month(s) the discharge occurs: 0 Jan. ❑ Feb. 0 Mar. 0 Apr.
0 May 0 Jun. 0 Jul. 0 Aug. 0 Sept. 0 Oct. ❑ Nov. 0 Dec.
b) How many days per week is there a discharge? ,5 Cap
c) Please check the days discharge occurs:
0 Sat. 0 Sun. [pan. Tue. Wed. C(Thu)(❑ Fri.
12) Pollutants:
Please list any known pollutants that are present in the discharge, per each separate discharge point (if
applicable, use separate sheet): Ai O
13) Receiving waters:
a) What is the name of the body or bodies of water (creek, stream, river, lake, etc.) that the facility
wastewater discharges end up in? If the site wastewater discharges to a separate stormsewer
system (4S), name the operator of the 4S (e.g. City of Raleigh). p ilde.5On9e C�rGek
b) Stream Classification:Sul(-FQCe.. 1/Jci e.Y
14) Alternatives to Direct Discharge: Seetmack •
Address the feasibility of implementing each of the following non -discharge alternatives
a) Connection to a Municipal or Regional Sewer Collection System
b) Subsurface disposal (including nitrification field, infiltration gallery, injection wells, etc.)
c) Spray irrigation
The alternatives to discharge analysis should include boring logs and/or other information indicating that
a subsurface system is neither feasible nor practical as well as written confirmation indicating that
connection to a POTW is not an option. It should also include a present value of costs analysis as
outlined in the Division's "Guidance For the Evaluation of Wastewater Disposal Alternatives"
15) Additional Application Requirements:
For new or proposed discharges, the following information must be included in triplicate with this
application or it will be returned as incomplete.
a) 7.5 minute series USGS topographic map (or a photocopied portion thereof) with discharge location
clearly indicated.
b) Site map, if the discharge is not directly to a stream, the pathway to the receiving stream must be
clearly indicated. This includes tracing the pathway of a storm sewer to its discharge point.
c) If this application is being submitted by a consulting engineer (or engineering firm), include
documentation from the applicant showing that the engineer (Or firm) submitting the application has
been designated an authorized Representative of the applicant.
d) Final plans for the treatment system (if applicable). The plans must be signed and sealed by a North
Carolina registered Professional Engineer and stamped -"Final Design -Not released for construction".
Page 3 of 4 04/05

NCG500000 N.O.I.
e) Final specifications for all major treatment components (if applicable). The specifications must be
signed and sealed by a North Carolina registered Professional Engineer and shall include a narrative
description of the treatment system to be constructed.
I certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing: htIh6 /1/Is
Title: P/4Af lr t boo.S QA)Q el--
w
11•/Go•/D
(Signature of Applicant)
North Carolina General Statute 143-215.6 b (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any
application, record, report, plan or other document filed or required to be maintained under Article 21
or regulations of the Environmental Management Commission implementing that Article, or who
falsifies, tampers with or knowingly renders inaccurate any recording or monitoring device or method
required to be operated or maintained under Article 21 or regulations of the Environmental
Management Commission implementing that Article, shall be guilty of a misdemeanor punishable by
a fine not to exceed $25,000, or by imprisonment not to exceed six months, or by both. (18 U.S.C.
Section 1001 provides a punishment by a fine of not more than $25,000 or imprisonment not more
than 5 years, or both, for a similar offense.)
(Date Signed)
Notice of Intent must be accompanied by a check or money order for $100.00 made payable to:
NCDENR
'ez, Mail three (3) copies of the entire package to:
NPDES Permits Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Final Checklist
This application will be returned as incomplete unless all of the following items have been
included:
❑ Check for $100 made payable to NCDENR
❑ 3 copies of county map or USGS quad sheet with location of facility clearly marked on map
❑ 3 copies of this completed application and all supporting documents
❑ 3 sets of plans and specifications signed and sealed by a North Carolina P.E.
❑ Thorough responses to items 1-7 on this application
❑ Alternatives analysis including present value of costs for all alternatives
Note
The submission of this document does not guarantee the issuance of an NPDES permit
Page 4 of 4 04/05

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