WQ0003090_Monitoring - 01-2022_20220225

Monitoring Report Submittal
Permit Number #* WQ0003090
Name of Facility:* Town of Liberty WWTP
Month: * January Year: * 2022
Report Information
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR jan 2022.pdf 4.28MB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
Confirmation Email Address:* [e-mail]
Name of Submitter: * Tremaine Fike
Signature:
Date of submittal: 2/25/2022
This will be filled in automatically
Initial Review
Reviewer: Gerald, Wanda

Is the project number correct?* WQ0003090
Is the monitoring report accepted?* Yes No
Regional Office* Winston-Salem
Accepted Date:
3/29/2022

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page _1_ of _1_
Permit No.: WQ0003090 Facility Name: Town Of Liberty - Wastewater County: Randolph Month: January
Year: 2022
PPI: 002
Flow Measuring Point: Q Influent ❑ Effluent ❑ No flow generated
Parameter Monitoring Point: ❑ Influent 0 Effluent ❑ Groundwater Lowering ❑ Surface water
Parameter Code --o.
60050
00400
00,310
00610
00530
31613
00621
00625
00665
50060
00600
70300
0 940
00630
00010
07
m
Q£
a-
p
O
F�
O
°o
u
a
QLa
M
eaa
E
E
i
_
U. 0
ri
c
m
c
�
of
coo
o
m
H z
maai
cEV
24-hr
hrs
GPD
su
gag/l
mg/L
sng/L
#1100 mL
mg/l
mg/L
mg/L
mg/L
/l
mg/L
mg/L
mg/L
°C
1
11:00
3
246,000
2
14:00
3
284,000
3
7:00
8
1,562,000
4
7:00
8
1,151,000'
5
7:00
8
520,000
6
1 7:00
8
343,000
7.47
ND
17.3
18.4
210
0,047
30.1
3.6
0.47
30,11
0.047
7
7:00
a
322,000
8
11:00
3
322,000
9
11:00
3
201,000
10
7:00
8
716,000
11
7:00
8
445,000
12
7:00
8
377,000
13
7:00
8
248,000
7.55
0.47
14
7:00
8
247,000
15
249,000
16
4:00
13
230,000
17
505,000
181
580,000
19
10:00
5
569,000
7.45
ND '
18.4
8.2
435
ND .
27.4
3.1"
0
27A
0.042
20
10:00
5
645,000
21
7:00
8
801,000
22
563,000
23
421,000
24
7:00
8
285,000
25
7:00
8
298,000
26
7:00
8
323,000
27
7:00
8
343,000
7.69
0.14
28
7:00
8
300,000
29
33:30
3
300,000
30
12:30
3
259,000
311
7:00
8
249,000
Average:
448,516
0.00
17.85
13.30 ''
302.24
.0.132
#REF!
3.35
0.27
28.75
0.04
Daily Maximum:
1,562,0010
7.69
0,00
18.40
18.46
435.00
0.05'
#REF!
3.60
0.47
30.10
0.05
Daily Minimum:
201,000
7.45
0.00
17.30
8.20
210.00
0,05i
*REF!
3.10"
0.00
27AG
0.04
Sampling Type:
Recorder
Grab
Grab
Grab
Grab
Grab
Grab;
Grab
Grab
Grab
Grab
Grab
Monthly Avg. Limit:
Daily Limit:
550,000
Sample Frequency:
Daily
I weekly
I 2x month
2x month
2xmonth
1 2x month
2x month
2x month
2x month
weekly
2x MCI'
o
3x year
3x year
2x month
"

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR)
Sampling Person(s) Certified Laboratories
Name: GLENN PRICE Name: PACE ANALYTICAL
Name: GARRETT DREYER Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? 21 Compliant ❑ Non -Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
NON COMPLIANT ON THE DATES OF 113 1/4 1110 1/18 1/19 1/20 1/21 AND 1122
RAINFALL I&I
Operator in Responsible Charge (ORC) Certification Permittee Certification
ORC: Elix Tremaine Fike Permittee: Scott Kidd
Certification No.: 989290 Signing Official:
Grade: SI Phone Number: 336 622 2990 Signing Official's Title: Town Manager
Has the ORC changed since the previous ND ❑ Yes 21 No Phone Number: 336 622 4276 Permit Expiration: 8/31/2024
fir,,.
ure ate Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge. 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 all qualified personnel properly gathered and evaluated 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

11!;a1ceAnalytical'
www.pacelabs.com
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
RMT-077MMATAUT � 6
Tremaine Fike
Town of Liberty
P® Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92581285
Page 1 of 1
Report Date: 01/20/2022
Date Received: 01/06/2022
Sample: Effluent Lab ID: 92581285001 Collected: 01/06/22 11:45 Matrix:
Water
Method Parameters
Results
Units
Report Limit
Analyzed Qualifiers
SM 2540D-2015 Total Suspended Solids
18.4
mg/L
5.0
01/10/22 10:32
EPA 350.1 Rev 2.0 1993 Nitrogen, Ammonia
17.3
mg/L
0.20
01/07/22 14:08
EPA 353.2 Rev 2.0 1993 Nitrogen, NO2 plus NO3
0.047
mg/L
0.040
01/07/22 17:57
EPA 353.2 Rev 2.0 1993 Nitrogen, Nitrate
0.047
mg/L
0.040
01/07/22 17:57
EPA 353.2 Rev 2.0 1993 Nitrogen, Nitrite
ND
mg/L
0.040
01/07/22 17:67
SM 521OB-2016 BOD, 5 day
ND
mg/L
2.0
01/12/22 13:49 B2
Colilert-18 Fecal Coliforms
210
MPN/100ml-
1.0
01/07/22 13:04
Performed by
PACE
01/06/22 11:45
Collected By
Garrett
01/06/22 11:45
Dreyer
Collected Date
01/06/22
01/06/22 11:45
Collected Time
1145
01/06/22 11:45
pH
7.47
Std. Units
01/06/22 11:45
Chlorine, Total Residual
0,47
mg/L
01/06/22 11:45
TKN+NO3+NO2 Total Nitrogen
30.1
mg/L
0.52
01/19/22 16:56
Calculation
EPA 351.2 Rev 2.0 1993 Nitrogen, Kjeldahl, Total
30.1
mg/L
2.5
01/15/22 04:39
EPA 353.2 Rev 2.0 1993 Nitrogen, NO2 plus NO3
ND
mg/L
0.040
01/19/22 11:32
EPA 365.1 Rev 2.0 1993 Phosphorus
3.6
mg/L
0.050
01/18/22 23:30
ANALYTE QUALIFIERS
B2 Oxygen usage is less than 2.0 for all dilutions set.
The reported value is an estimated less than value and is calculated
for the dilution using the most amount of sample.
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NO 28804
Florida/NELAP Certification #: E87648
North Carolina Drinking Water Certification #: 37712
North Carolina Wastewater Certification #: 40
Pace Analytical Services Eden
205 East Meadow Road Suite A, Eden, NO 27288
North Carolina Drinking Water Certification #: 37738
South Carolina Laboratory ID: 99030
South Carolina Certification #: 99030001
Virginia/VELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
Virginia/VELAP Certification #: 460025
Page 1 of 3

CHAIN -OF -CUSTODY Analytical Request Document
LAS USE ONLY- Ar '
r .FalceAna/yCrcal'
Chain -of -Custody is a LEGAL DOCUMENT- Complete all relevent fields
:, npany: TDWn of Liberty iBillingInfarmationALL
:
KAddress: M — Container Preset 92581285
�� --
u i I 8 [ _
Report To: Email To: ; "` Preservative Types: (1) nitric acid, (2) sulfuric acid, {3) hydrochloric acid, (4) sodium hydroxide, (5) zinc acetate,
(6) methanol, (7) sodium bisulfate, (8) sodium thiosulfate, (9) hexane, (A) ascorbic acid, (B) ammonium sulfate,
Copy To: Site Collection Info/Address: (C) ammonium hydroxide, (D) TSP, (U) Unprese ved, (0) Other
Analyses Lab Profile/Line
Customer Project Name/Number: state: County/City: Time Zone Collected: Lab Sample Receiptt Checkli t:
/ I ]PT[ ]MT[ ]CT [ ]
Custody Seals Present/Intact N
I
' rN
Phone: Site/Facility ID #: Compliance Monitoring? s d Custody Signatures Prescntt NA
Collector Signature RresenN NA
Email: [ Yes [ ] No
IIott-cs Intact ;N NA
`Collected B (print): ;Purchase Order #: DW PWS ID #: [ correct Bottle, N NA
I
(Quote #: )DW Location Code: [ sufficient volume Us 1oH
s Samples Received on Tce ''t7 NA
Immediately Packed on lee: D
Co IJ signat }: Turnaround Date Required: Y vaA xead pace Acceptable Y ra(r
[ ] Yes [ ] No o 1 USDA Regul Led soils A N I
({ Simple n Holding Lime LY'ta� NA
)Sample Disposal: Rush: Field Filtered (if applicable): � Re. idu ii Chlo 1n R c' t Y 6v NA
[ j Dispose as appropriate I ) Return [ ]Same Day ( ]Next Day [ ]Yes [ ] No �Z i ) Cl Strips:i(
@@@ € Sample
pH Ac-m Cab,1c
i[ )Archive: [ ] 2 Day [ ] 3 Day ( ] 4 Day [ ] s Day Z
Analysis: I € ptt script
'[ )Hold: p (Expedite Charges Apply) 0 O t Sultide Present Y 11,fN,
Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water {GW), Wastewater {WW), Z Z ' u Lead Ac=_•t,ce Str:ipc:
it' Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
Z"AB USE ONLY:
Comp / Collected for Res # of I— Z i at I Lab Sample ai / comments:
Customer Sample ID Matrix " Grab Composite Start} Composite End v
P Cl Ctns C) _ ; W
T Date _ i j Date Time m Z Q
i. Effluent iWW 19 t ��� �� �J 'X i I�_
Y j---1_
Customer Remarks /Special Conditions /Possible Hazards: Type of Ice Used: wet , Blue Dry None [SHORT HOLDS PRESENT (<72 hours): Y `N _ N/A Lab Sample Temperature info:
Temp Blank Rece ed Y N NA
Packing Material Used: 3Lab Tracking #:
Therm ID#: _fi q
Cooler t Temp U oon Receip oC
* Effluent Monitoring
)[Samples received via: Cooler 1 Therm Corr. Factor. 1s C
d Radchem sample(s) screened (<500 cpm): Y N A
FEDEX UPS Client Courier as
Courser Cooler 1 Corrected Temp: , LDC
-iReli j_(Signature) � [B Comments: Y/Company: (Signature) MTJL LA
bie#
/ 1. <.Acctnum:
Reli�uished by/Company: (Signature) DXleTlarne':-Al Received b man (Signature) DateJTime: t
Y p y{ g ) Template: I Trip Blank Received: Y N NA
p
m ��
HCL McOH TSP Other
ro i ) , Prelogio:
ReliRpulshed by/Company: (Signature) Date/Time: Received by/Company: (Signature) i Date/Time:
ca ( IPM: Non Conformance(s): !Page:
!PB: YES / NO of:

ra $eA ail lical,
Bottle Identification Form (BIF
Document No.:
F-CAR-CS-043-Rev.01
Page I of I
Issuing Authority:
Pace Carolinas Quality Office
--..---.... .. .may ..w...,., , 1,,, ui,.nI —u ca.lnvlllla LIU11 IJ YrV)lCIH
--.
verified and within the acceptance range for preservation
samples.
Exceptions: VOA, Coliform, TOC, Oil and Grease, DRO/3015 (water) DOC, LLHg
"Bottom half of box is to list number of bottles
j h ��.1, �• p ,
u
�O
Vva
uG
�•`aaaZ
0.
a
�
_n
a
rvz
v
Z
<
<w
d
°`
O
O
•
=
"tOs'',
=
a
8-
a
c
v
O
c
G
^
a
Z
,
n
lD
u
O
N
v
i
a
c..
a
O.
c
O'.c
T
2
Q
N
O
'D
O
2
=
O
N
<Z
O
O
7
Z
2
O
u
G
G
2
an
E
u
=
Z
c
D
'K
�'
a
a
a
E
E
<
E
<
C
E
J
N
O
¢
Q
Q
<
Q
a
w
-
v
-
w
m
-E
E
c
n
o
o
Q,,
E
E
o
E
E
u`,
�
E
o
<
y
E
m
E
E
j
E
E
0
m
E
E
E
E
_
•vl i
:N
.'O
n
�n
v
p
V'
O
O
O
O
>
O
p
O
C'
E
li
E
.c+
,.M'
,m.!
..�'
,.rv..:
..D
'V1
Z
N
co
W
=
X
rl
m
V1
v1
m
Q
m
Z
m
F-
m
M
m
O.
m
:e
¢
X
F
F
G
-
Z
a
m
m
m
to
m
m
m
m
lS
C9
4
l7
4
t7
Q
l9
Q
l9
Q
t7
4
l7
L]
l7
>
l9
>
C7
O
>
�.
>
a
a
l7
m
¢
>
C
l
2
4
5
NN
6
N
&
I
E
9
N
10
11
12
i pH Adjustment Log for Preserved Samples
Sample ID_
Type of Preservative j
pH upon receipt
Date preservation adjusted
Time preservation
Amount of Preservative
Lot It
i
adjusted
aidded
�
I
nre• Wh--,
th— is —A;....
--• ---•••',r' — - ­vy • , � --, v — gene to the worm L-aronna ULHINR Certification Office (i.e.
ut of hold, incorrect preservative, out of temp, incorrect containers,
I
Page 3 of 3

aceAnalyfical
www.pacelabs.com
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92582656
Page 1 of 1
Report Date: 01/14/2022
Date Received: 01/13/2022
Sample: Effluent
Method Parameters
Lab ID: 92582656001 Collected: 01/13/22 12:25 Matrix: Water
Results Units Report Limit Analyzed Qualifiers
Performed by
PACE
01/13/22 12:25
Collected By
Garrett
01/13/22 12:25
Dreyer
Collected Date
01/13/22
01/13/22 12:25
Collected Time
1225
01/13/22 12:25
pH
7.55 Std. Units
01/13/22 12:25
Chlorine, Total Residual
0.47 mg/L
01/13/22 12:25
c�nu�ltc�
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 2

CHAIN -OF -CUSTODY Analytical Request Document
aceAnalytical
' Chain -of -Custody is a LEGAL DOCUMENT -Complete all relevent fields
Company: Town of Liberty Billing Information:
Report To:
Copy To:
Customer Project Name/Number:
Phone:
Email:
Co} ected By (print):
Email To:
Site Collection Info/Address:
State: County/City: Time Zone Collected:
/ [ )PT[ ]MT[ ]CT [ ]ET
Site/Facility ID #: Compliance Monitoring?
[ Yes [ ]NO
LAB USE ONLY- Affix Workorder/Login Label Here or List Pace Workorder Number or
WO#:92582656
AL
Container SHAC
Preservative
92582656
Preservative Types: (1) nitric acid, (2) sulfuric auu, t" —
(6) methanol, (7) sodium bisulfate, (8) sodium thiosulfate, (9) hexane, (A) ascorbic acid, (b) amttiu-
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
1.
DW PWS ID #: 0
DW Location Code:
II
Immediately Packed on Ice: a
_ [ ] Yes [ ] No a)
-�I w
Sample Disposal: Rush: Field Filtered (if applicable): m
[ ] Dispose as appropriate [ ] Return ( ) Same Day [ ] Next Day [ ] Yes [ ]NO
[ ] Archive: [ ] 2 Day ( ) 3 Day [ J 4 Day [ ] 5 Day o
[ Analysis:
)Hold: (Expedite Charges Apply) A _
1� U
Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW), II
Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
Comp / Collected (or Res # of m m
Customer Sample ID Matrix * Grab Composite Start) Composite End Cl Ctns m
t Date [ Time Date I Time a
Purchase Order f::
Quote #:
Turnaround Date Required:
Customer Remarks / Special Conditions / Possible Hazards: Type of Ice Used: Wet Blue Dry None
Packing Material Used:
Effluent Monitoring
Radchem samples) screened (<500 cpm): Y N NA
Date/Time: I ec ed by/Company: (Sjgnoture)
i
ed by/Company: (Signatu
anquished by/Company: (Signature) Date/Time: I Received
N 9
SHORT HOLDS PRESENT (<72 hours): Y N N/A
Lab Tracking #:
pies received via:
FEDEX UPS Client
Date/rime G
Date/Time:
Date/Time:
Lab Sample xeceapc cnecxiasc:
Custody Seals Present/Intact Y N NA
Custody Signatures Present Y N NA
Collector Signature Present Y N NA
Bottles Intact Y N NA
Correct Bottles Y N NA
Sufficient Volume Y N NA
Samples Received on Ice Y N NA
VOA - Headspace Acceptable Y N NA
USDA Regulated Soils Y N NA
Samples in Holding Time Y N NA
Residual Chlorine Present Y N NA
Cl Strips:
Sample pH Acceptable Y N NA
PH Strips:
Sulfide Present Y N NA
Lead Acetate Strips:
LAB USE ONLY:
Lab Sample if / Comments:
Courier Pace Courier
MTJL LAB USE ONLY
)Table #:
Acctnum:
Template:
Prelogin:
PM:
PB:
Lab Sample Temperature Info:
Temp Blank Received: Y N NA
Therm ID#:
Cooler 1 Temp Upon Receipt: _oC
Cooler 1 Therm Corr. Factor: oC
Cooler 1 Corrected Temp: oC
Comments:
Trip Blank Received: Y N NA
HCL McOH TSP Other
Non Conformance(s): Page:
YES / NO I of:

c�
11�;aceAnalytical
www.pacelabs.com
r
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92583214
Sample: Effluent
Method
SM 254OD-2015
EPA 350.1 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
SM 521OB-2016
Colilert-18
TKN+NO3+NO2
Calculation
EPA 351.2 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
EPA 365.1 Rev 2.0 1993
Parameters
Total Suspended Solids
Nitrogen, Ammonia
Nitrogen, NO2 plus NO3
Nitrogen, Nitrate
Nitrogen, Nitrite
BOD, 5 day
Fecal Coliforms
Performed by
Collected By
Collected Date
Collected Time
pH
Chlorine, Total Residual
Total Nitrogen
Nitrogen, Kjeldahl, Total
Nitrogen, NO2 plus NO3
Phosphorus
Page 1 of 1
Report Date: 02/01 /2022
Date Received: 01/19/2022
Lab ID: 92583214001 Collected: 01/19/22 11:05 Matrix: Water
Results
Units
Report Limit
Analyzed
8.2
mg/L
3.3
01/20/2210:01
18.4
mg/L
0.50
01/20/2217:13
0.042
mg/L
0.040
01/1912218:00
ND
mg/L
0.040
01/19/2218:00
0.040
mg/L
0.040
01/19/2218:00
ND
mg/L
2.0
01124/2218:25 B2
435
MPN/100ml-
1.0
01/20/2210:55
Pace
01/19/22 11:05
Garrett
01/19/22 11:05
Dreyer
01/19/2022
01/19/22 11:05
1105
01/19/22 11:05
7.45
Std. Units
01/19/22 11:05
0.00
mg/L
01/19/22 11:05
27.4
mg/L
0.52
01/28/2217:06
27.4
mg/L
2.5
01/22/2205:31
ND
mg/L
0.040
01/28/2212:53
3.1
mg/L
0.050
01/31/22 21:13
ANALYTE QUALIFIERS
B2 Oxygen usage is less than 2.0 for all dilutions set. The reported value is an estimated less than value and is calculated
for the dilution using the most amount of sample.
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
North Carolina Drinking Water Certification #: 37712
North Carolina Wastewater Certifcation #: 40
Pace Analytical Services Eden
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
South Carolina Laboratory ID: 99030
South Carolina Certification #: 99030001
Virginia/VELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
Virginia/VELAP Certification #: 460025
Qualifiers
Page 1 of 4

CHAIN -OF -CUSTODY Analytical Request Document
_ . aceAnaly4ical
- Chain -of -Custody is a LEGAL DOCUMENT -Complete all relevent fields
iberor
LAB USE c WO#:92583214 �
I
II I II' II II III � II'II Iil
Container 92583214 -- —
u 1 2 1 8 1 [1 1 1 11
Company: Town of Liberty
Billing Information:
Address:
Report To:
Email To:
** Preservative
(6) methanol,
(C) ammonium
Types:
(7) sodium
hydroxide,
(1)
nitric
bisulfate,
(D) TSP,
acid, (2)
(8) sodium
(U) Unpreserved,
sulfuric acid, (3) hydrochloric
thlosulfate, (9) hexane,
(0) Other
acid, (4) sodium hydroxide, (5) zinc acetate,
(A) ascorbic acid, (B) ammonium sulfate,
Copy To:
Site Collection Info/Address:
Analyses
Lab Profile/Line:
Customer Project Name/Number:
State: County/City: Time Zone Collected:
/ [ ] PT [ ] MT [ ] CT [ )ET
Z
O
Z
C
F-
0
m
d
O
F-
Z
iv
Z
Z
ri
Z
o
li
h
A.'
Illy
-p
(D
a
4
O
U
F-
Lab sample Receipt Checklist:
^
Custody Seals Present/Intact Y y,�NA
Custody Signatures Present ' )NA
Collector Signature Present Y NA
Bottles Intact Y N NA
Correct Bottles Y N NA
Sufficient volume Y N NA
Samples Received on Ice Y N NA
VOA - Headspace Acceptable Y N NA
USDA Regulated Soils Y N NA
Samples in Holding Time Y N NA
Residual Chlorine Present Y N NA
Cl Stripe:
Sample pH Acceptable Y N NA
pft stripe:
Sulfide Present Y N NA
Lead Acetate Strips:
LAB USE ONLY:
Lab Sample d / Comments:
Phone:
Email:
Site/Facility ID #:
Compliance Monitoring?
[ Yes [ ]NO
Collected Bk4Z
Purchase Order #:
Quote #:
DW PWS ID #:
DW Location Code:
o
Turnaround Date Required:
immediately Packed on Ice:
[ ]Yes [ ] NO
ample Disposal:
[ ] Dispose as appropriate ( ] Return
[ J Archive:
[ ]Hold:
Rush:
[ )Same Day [ ] Next Day
[ ] 2 Day [ J 3 Day [ ] 4 Day [ J 5 Day
(Expedite Charges Apply)
Field Filtered (if applicable):
[ ] Yes ( ] No
Analysis:
* Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater [WW),
Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
Customer Sample ID
Matrix *
Comp/
Grab
Collected (or
Composite Start)
Composite End
Res
CI
#of
Ctns
Date
Time
Date
Time
Effluent
WW
g
j y
p
15
X
X
X1
Customer Remarks / Special Conditions / Possible Hazards:
Effluent Monitoring
R
IG
Type of Ice Used: Wet Blue Dry None
SHORT HOLDS PRESENT (<72 hours):
Y N N/A
Lab Sample Temperature Info:
Temp Blank Received: Y N NA
Therm ID#:
Cooler 1 Temp Upon Receipt: _oC
Cooler 1 Therm Corr. Factor: oC
Cooler 1 Corrected Temp: oC
Comments:
Packing Material Used:
Lab Tracking M
Radchem sample(s) screened (<500 cpm): Y N NA
Samples received via:
FEDEX UPS Client Courier Pace Courier
p Relin e y/ pawy n ture}
G�
_ �
Date/Time:
1 11747
b
Received by/Comps .Signature}
(^.��/
Date/Time:
� � (C� _ Z%' I) C D
MTJL LAB USE ONLY
Table #:
Acctnum:
ui ed ompany: (Signature}
Co
IP r.�
D te/ me:
Received by/C mp ny: (Signature)
Date/Time:
Template:
Prelogln:
PM:
pB:
Trip Blank Received: Y N NA
HCL McOH TSP Other
Reli- uished by/Company: (Signature)
Date/Time:
Received by/Company: (Signature)
Date/Time:
Non Conformance(s): Page:
YES / NO { of:

1710 96edjayR'/
l-
Sa^iole Ccnd:ion. U3on Rece.pt (SCUP' n L c 2
F-CAR-05-033-Rrv.C3 Ps�e
Laboratory receiving samples:
Asheville ❑ Eden❑ Gre2w,vood ❑ Huntersville El Raleigh❑ Mechanicsville' II Ad3nta❑ Kernersvi;le
Client Name:
Project n. - —/ -"O �,y )it U
Courier. ❑Fad Ex ❑UPS ❑LISPS [-]client
I� 1 �'� V�
❑ Commercial 0�e ❑Other.
CustodySeal Present? ❑cYes ❑-No Seals Intact? ❑Yes ❑,10
Data/Initials Parson Examining contents: t-/ ry _S
�Iac'king Material: ❑Bubble �,Vrap []Bubble Bz,s [ Piene ❑ Other Biological Tissue Frozen?
rhermometer. Dyes ❑'lo D'l/A
❑ IR Gun ID:? (� `� MCet ❑Blue ❑None
Type of Ice:
4 Correction Factor:
;Dolor Temp: c� ' Add/Subtract (T) Temp should be above free,i„g to 6°C
❑Samples cut of ternp criteria. Samples on ice, cooling process
ooler Temp Corrected (°C): L (. 2- has begun
JSDA Regulated Soil (❑ N/A, water sample)
)id samples originate in a quarantine zone within the United States: CA, NY, or SC (check mars)? Did samples originate from a foreign source (in(-rn-ticnally,
(lYes Imo. Plo , 4 puartn air t'� I—
l Comments/Discrepancy:
Chain of Custody Pres2nt?
/
®'Aes
❑wo
❑N/A
( L
Samples Arrived within Held Time?
des
[], to
❑N/A
2.
Shcrt Hold Time Analysis (02 hr.)?
EDY s
ON
❑N/.A
13.
Rush Turn Around Time Requested?
Dyes
U Flo
❑N/A
4.
Sufficient Volume?
DY s
ON
❑rl/A
5,
Correct Containers Used?
D�Y.5/
❑'lo
❑N/A
6.
-Pace Containers Used?
17"10
❑AI/A
Containers Intact?
as
❑Mc
❑N/.A
7.
Dissolved analysis: Samples Field Filtered?
❑yes
(]NO
(/
13.
Sample Labels klatch COC?
[) as
❑rIo
❑N/A
9.
-Includes Date/Time/ID/Analysis Matrix:
w
10.
Headspace in VOA Vials (>5-6mm)? Dyes ❑rIo [D>lA
Trip Blank Present?
❑Yes
❑No
Qv/A
11,
Trip Blank Custody Seals Present?
❑yes
❑No
A
CONINIENTS/SAMPLE DISCREPANCY
WENT NOTIFICATION/RESOLUTION
Person contacted:
Date/Time:
Lot ID of sclit containers:
Field Data Required? ❑Yes ❑`Ic
Project Manager SCURF Review:
Date:
Project Manager SRF Review: Date:

q 10 b a5ed
Document Name:
Document Issued: November 15, 2021
aCBAf)c?�y1fCc7�
Bottle Identification Form (BIF)
Page 1 of 1
Document No.;
F-CAR-CS-043-Rev.01
Issuing Authority:
Pace Carolinas Quality Office
*Check mark top half of box if pH and/or dechlorination is Project #
verified and within the acceptance range for preservation
samples.
Exceptions: VOA, Coliform, TOC, Oil and Grease, DRO/8015 (water) DOC, LLHg
**Bottom half of box is to list number of bottles
`
f0
aE
_
N
c
u
E
a
m
W
'L
c
D
u
.`"a
E
a
m
W
Z
c
0
u
rn
E
O
j
q
m
Z\
W
o,
C
U
ti
w
Q.
m
V
S
O
ry
=
u
A
E
N
ul
a
m
V
T
O
z
=
v
E
a
m
z
N
u
¢
N
u
ro
E
M
N
a
m
N
=
Z
u
m
E
N
m
a
m
a
lv
v
L
o
'S
z
VN
N
v
n
O
W
E
H
l7
4
nl
a
_
U
i
N
E
¢
m
'�
A
l9
¢
a.
c
¢E
E
m
l7
d
N
V
n
N
=
N
n
d
�5
_
M
l7
¢
N
V
N
=
tl
JE
E
m
l7
d
4
V
E
¢
E
o
m
l�
m
l7
4
v
u
=
¢
>>
E
O
m
t9
®
_
vi
z
q
E
O
T
to
>
a
Z
w
d.
c
O¢
>
E
O
m
l7
>
a
O
m
O¢
>
E
O
Oat
l7
®
d
o
ul
.m7...
d
O
>
z
�_'
V
>
I
m
�»
it
ut
I
N
�
O
N
sn
m
s
Z
ro-
m
m
---
>
N
c
JE
O
o
q
Q
z
c
O
'VE1
p
�
>
Z
>
V
N
n
c
`
¢d
O
O=1
l7
Ct
1
z
3
---NN
-
-
— -
-
4
5
6
7
8
9
10
11
12
pH Adjustment Log for Preserved Samples
Sample ID Type of Preservative pH upon receipt Date preservation adjusted Time preservation Amount of Preservative Lot It
adjusted I added
Note: whenever there is a discrepancy affecting North Carolina compliance samples, a copy of this form will be sent to the North Carolina DEHNR Certification Office (Le
Out of hold, incorrect preservative, out of temp, incorrect containers.

aceAnal�/fcal
J`
www.pacelabs_com
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92584780
Page 1 of 1
Report Date: 01/28/2022
Date Received: 01/27/2022
Sample: Effluent Lab ID: 92584780001 Collected: 01/27/22 11:00 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
Performed by Pace 01/27/22 16:25
Collected By Garrett 01/27/22 16:25
Dreyer
Collected Date 01/27/2022 01/27/22 16:25
Collected Time 1100 01/27/22 16:25
pH 7.69 Std, Units 01/27/22 16:25
Chlorine, Total Residual 0.14 mg/L 01/27/22 16:25
Reviewed by: C f
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 2

CHAIN -OF -CUSTODY Analytical Request Document
-. aceAnaJ�ica!
- - ' Chain -of -Custody is a LEGAL DOCUMENT -Complete all relevent fields
LAB USE ONLY -Affix Worko wog : 92584780
ALL SHADE
II � 1111111JillIJill'I�
Company: Town Of Liberty
Billing Information:
Container Preservative T 192584780
Address:
Report To:
Email To:
'• Preservative
Types: (1)
nitric
acid, (2)
sulfuric
acid,
(3) hydrochloric
acid, (4) sodium hydroxide, (5) zinc acetate,
(b) methanol,
(C) ammonium
(7) sodium
hydroxide,
bisulfate,
(D) TSP,
(8) sodium
(U) Unpreserved,
thiosulfate,
(0)
(9)
Other
hexane, (A) ascorbic acid, (B) ammonium sulfate,
Copy To:
Site Collection Info/Address:
Analyses
Lab Profile/Line:
Customer Project Name/Number:
State: County/City: Time Zone Collected:
Lab Sample Receipt Checklist:
/ [ ]PT[ ]MT[ ]CT ( ]ET
I
Custody Seale Present/Intact Y N NA
Custody Signatures Prevent Y N NA
Collector Signature Present Y N NA
Bottles intact Y N NA
Correct Bottles Y N NA
Phone:
Email:
Site/Facility ID #:
Compliance Monitoring?
[ Yes [ ]No
Collected By (print):
Purchase Order #:
DW PWS ID #:
�r7 Cam--
Quote #:
DW Location Code:
II I
m
v
II
m
I1
m
9;
8
- —
U
m
-�
m
m
Sufficient volume Y N NA
Samples Received on Ice Y N NA
VOA - Headspace Acceptable Y N NA
USDA Regulated Soils Y N NA
Samples in Holding Time Y N NA
Residual chlorine Present Y N NA
Cl Stripe:
Sample pH Acceptable Y N NA
pH Strips:
Sulfide Present Y N NA
Lead Acotate Stripy:
LAB USE ONLY:
Lab Sample # / Comments:
Co ature).
Turnaround Date Required:
Immediately Packed on Ice:
[ ]Yes [ ]No
Sarfiple Disposal:
[ J Dispose as appropriate ( ] Return
[ ] Archive:
[ ] Hold:
Rush:
[ ] Same Day [ ] Next Day
[ ] 2 Day [ ] 3 Day [ ] 4 Day [ ] 5 Day
(Expedite Charges Apply)
Field Filtered (if applicable):
[ ] Yes [ ] No
Analysis:
Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
Customer Sample lD
Matrix
Comp/
Grab
Collected (or
Composite Start)
Composite End
Res
Cl
#of
Ctns
CL
Date
I Time
Date
Time
Effluent
WW
9
MR,
11c7p
0
i
Customer Remarks J Special Conditions / Possible Hazards:
Type of Ice Used: Wet Blue Dry None
SHORT HOLDS PRESENT (<72 hours): Y N N/A
Lab Sample Temperature Info:
Temp Blank Received: Y N NA
Therm ID#:
Packing Material Used:
Lab Tracking #:
Effluent Monitoring
Cooler 1 Temp Upon Receipt: oC
Cooler 1 Therm Corr. Factor: oC
Cooler 1 Corrected Temp: oC
Comments:
Radchem sample(s) screened (<S00 cpm): Y N NA
Samples received via:
FEDEX UPS Client Courier Pace Courier
Relinquish_ �/J=o�rspan ture)
%� `
Date/Time: /
2 I,
Received by/Company: 'gnature)
Date/Time:
0
MTJL LAB USE ONLY
Table #:
Acctnum:
[/�
ql�ed by/Company: (Signature)
late/time:
Received by/Co m an : (Si ature)
Date/Time:
Template:
P
Trip Blank Received: Y N NA
CD
NPrelogin:
HCL McOH TSP Other
Non Conformance(s): Page:
YES / NO of:
R N quished by/Company: (Signature)
i
Date/Time:
i
Received by/Company: (Signature) )
�
Date/Time:
PM;
IPS:

January 2022
Freeboard Lagoon Inches
2O1/2
20
R
0.5
10 1/2
R
3.5
13 1/2
12 1/4
R
0.3
12
13 1/2
15
15
R
(l8
13
12
13
14
18
1O 1/2
10 3/4
SN
2.0
15
14
13
12
11
SN
2.5
S3/4
73/4
O1/2
71/2
81/4
& 1/4
1O 1/2
11 1/2
SN
0.5
1O 1/2
83/4
TOTAL 1(l1

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page_1_ of_2_

FORM: NDAR-1 10-13
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit?
L Ccir,pliant ❑ Not, , ,,y liana
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? C compliant ❑ Nor. Cmi liaut
Was a suitable vegetative cover maintained on all sites as specified in your permit? C', compliant ❑ Nor: Cmil liant
Were all setbacks listed in your permit maintained for every application to each permitted site? G❑❑ compliant ❑ Non Cmgliaut
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑ compliant 1 Non C,mlliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-c-rpliamae and describe :F e c OFE --I':Vt=
action(s) taken. Attach additional sheets if necessary.
WE WENT OUT OF COMPLIANT ON THE DATE OF 01/03/2022 CAUSE OF RAINFALL. THE RAINFALL TOTAL OF 4.0 INCHES OVER TWO DAYS PERIOD
Operator in Responsible Charge (ORC) Certification
ORC: Elix Tremaine Fike
Certification No.: 989290
Grade: SI Phone Number: 336 622 2990
Has the ORC changed since the previous NDA?-I? ❑ Yes EZ No
Signature Date
By this signature. I certify that this report is accurrate and complete to the best of my knowledge.
Permittee Certification
Permittee:
Scott Kidd
Signing Official:
Signing Official's Title: Town Manager
Phone Number: 336 622 4276 Permit Exp.: 81r31124
Signature Oa Ie
1 certify, under penalty of law, that this document and all attachments were prepared ur de- my direction or super mion in ❑c:c d.=. i ice
with a system designed to assure that all qualified personnel properly gathered and evaluated the information su'.:rr; t- I. Easesc r my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering e inic rmtrt,rr, th,
information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that the v are si: in lic=. nt
penalties for submitting false information, including the possibility of fines and imprisonment for knowinn � .) a for:>.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _2_ of_2_

FORM: NDAR-1 10-13
Did the application rates exceed the limits in Attachment B of your permit? [21 Compliant EINon-Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? P1 compliant [] Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? 2 compliant EINon-Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? [Z Compliant D Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? El compliant [21 Nan -Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
WE WENT OUT OF COMPLIANT ON THE DATE OF 01/03/2022 CAUSE OF RAINFALL. THE RAINFALL TOTAL OF 4.0 INCHES OVER TWO DAYS PERIOD.
I I
Operator in Responsible Charge (ORC) Certification Permittee Certification
ORC: Elix Trernaine Fike Permittee: Scoft Kidd
Certification No.: 989290 Signing Official:
Grade: S1 Phone Number: 336 622 2990 Signing Official's Title: Town Manager
Has the ORC changed since the previous NDAR-11? El Yes EZ No Phone Number: 336 622 4276 Permit Exp.: 8/31/24
Signature / Date Signature / Datl
By this signature, I certify that this report is accurrate and complete to the best of my knowledge. 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 all qualified personnel property gathered and evaluated 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617