WQ0003090_Monitoring - 02-2022_20220330

Monitoring Report Submittal
........ ......... ......... ......... .........
Permit Number #* WQ0003090
Name of Facility:* TOWN OF LIBERTY WWTP
Month: * February Year: * 2022
Report Information
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR feb 2022 spray.pdf 3.61MB
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: 3/30/2022
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:
4/18/2022

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page _1_ of _1_
Permit No.: W00003090 Facility dame: Town Of Liberty - Wastewater
County: Randolph Month: February
Year: 2022
PPI: 002
Flow Measuring Point: 21 Influent ❑ Effluent ❑ No flow generated
Parameter Monitoring Point: ❑ Influent ❑✓ Effluent ❑ Groundwater Lowering ❑ Surface water
Parameter Code - 0
S0060
00400
00310
00610
00630
31613
00620 !
00625
00665
50060
06600
70300
00940
00630
00010
C
o
m
O
,
p
O
Q
1-
ai
La
�
y
c
«+
riax
CL
24-hr
hrs
GPD
su
mg/L
mg/Lmg/L
#/100 mL
mgl4
mg/L
mg/L
mg/L
mg&
mg/L
mg/L
mg/L
°C
1 7.00
8
261,000
2 7:00
8
273,000
3 7:00
8
229,000
7.22
5.4
14.9
8.2,
9.7
ND
22.4
Z5
0.9
22.5
0.081
4 7:00
8
362,000
5 12:00
2
478,000
61 11:00
2
322,000
7 7:00
8
246,000
8 7:00
8
620,000
9 7:00
8
411,000
10 7:00
8
315,000,
8.37
0.03
11 7:00
8
291,000
121
312,000
13
207,000
14 7:00
8
2,66,000
15 7:00
8
282,000
16 7:00
8
212,000
17 7:00
8
236,000
8.93
38.2
1 15.9
41.3` ,:
365
ND
25
3,5
0.7
25
ND
18 7:00
8
257,000
19
318,000
20
225,000
21 7:00
8
218,000
22
'216,000
23 7:00
8
288,000
24 7:00
8
287,000
7.24
0.79
25 7:00
8
307,000
26 11:00
2
267,000
27 11:00
2
270,000
28 7:00
8
345.000
Average:
295,172
21.80
15.40
' 24.75
59.50
0,100
1 #REF!
$.00
0.61
23:75
0.04
Daily Maximum:
620,000
8.93
38.20
15.90
41.30 '
365.00
0.00
#REF!
3.50
0.90
25.00
0.08
Daily Minimum:
207,600
7.22
5.40,
14.90
8,20
9.70
0.00
#REF!
2.50
0.03
22.50
0.08
Sampling Type:
Recorder
Grab
Grab ,
Grab
Grab
Grab
Grab' ,
Grab
Grab
Grab
Grab
Grab
Monthly Avg. Limit:
Daily L1mlt:j
550,000
Sample Frequency:1
Daily I
weekly
2x month
2x month
2xmonth
2x month
1, 2x month I
2x month
2x month
weekly
2x month I
3x year
I 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? 7 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.
NFALL I&I
THE FEB 03 2022 THE CHLORINE RESIDUAL WAS TYPE IN WRONG. CHANGE WITH PEN ON THE LAB REPORT AND CORRECT CHLORINE RESIDUAL IS 0.9
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 NDMR? ❑ Yes No
Phone Number. 336 622 4276 Permit Expiration: 8/31/2024
9
3 Z -
Signature Date
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

aceAnalXical
r www.pacelabs.com
1
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Pace Analytical Services,
1377 South Park [
Kernersville, NC 2'
(704)977-1
Page 1
Report Date: 02/27/2022
Date Received: 02/03/2022
Project: Town of Liberty
Pace Project No.: 92585901
Sample: Effluent Lab ID: 92585901001 Collected: 02/03/22 09:22 Matrix: Water
Method
Parameters
Results
HACH 10206
Nitrogen, Nitrate
ND
SM 2540D-2015
Total Suspended Solids
8.2
EPA 350.1 Rev 2.0 1993
Nitrogen, Ammonia
14.9
SM 521OB-2016
BOD, 5 day
5.4
Colilert-18
Fecal Coliforms
9.7
Performed by
Pace
Collected By
Glenn Price
Collected Date
02/03/2022
Collected Time
0922
pH
7.22
Chlorine, Total Residual
0.9
Units
Report Limit
Analyzed Qualifier;
mg/L
0.30
02/04/2218:42
mg/L
3.8
02/04/2211:44
mg/L
0.50
02/04/22 20:02
mg/L
2.0
02/0812217:39
MPN/100mL
1.0
02/04/2210:25
02/03/22 09:22
02/03/22 09:22
02/03/22 09:22
02/03/22 09:22
Std. Units
02/03/22 09:22
mg/L
02/03/22 09:22
TKN+NO3+NO2
Total Nitrogen
22.5
mg/L
0.52
02/25/22 16:15
Calculation
EPA 351.2 Rev 2.0 1993
Nitrogen, Kjeldahl, Total
22.4
mg/L
1.0
02/24/22 04:04
EPA 353.2 Rev 2.0 1993
Nitrogen, NO2 plus NO3
0.081
mg/L
0.040
02/15/22 09:25
EPA 365.1 Rev 2.0 1993
Phosphorus
2.5
mg/L
0.050
02/15/22 19:01
Reviewed by: C"'Y���u Sl<
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 Certification #: 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
VirginiaNELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
VirginiaNELAP Certification #: 460025

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s a LEGAL DOCUMENT -Complete all relevent fields WO# : a2585Q0 "1
- -- ----_ _ d d ::ii
✓vn of Liberty Billing Information:
ALL SHE
/Number:
Email To:
Site Collection Info/Address:
State: County/City:
I /
i
" 2 $Container Preservative II II' II II III �� I I'I III
92585901 —
Preservative Types: (1) nitric acid, (2)
(6) methanol, (7) sodium bisulfate, (8) sodium tnlosuitate, ty) hexane, jA) ascorbic acid, (6) ammonium sulfate,
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
--- Analyses Lab Profile/Line:
Time Zone Collected: ---"-- L:ih sample «ceipt checklist --
[ 1 PT [ 1 MT [ 1 CT [ ] ET
Custody Srrllo Present, Int:,ct 7 4 HA
Site/Facility ID #: Compliance Monitoring?
cun•tody signatures Pn_senc
, lY r1P.
[ Yes [ ] No
Collector signature P> eacnt
1I t17,
Purchase Order #: DW PWS ID #:
Bottles TritacC
correct Bottles
N NA
to HA
ttl
i Quote #: DW Location Code:
suffici-mnt Vr_dume
W NA
e—c Immediate) Packed on
I' l Turnaround Date Required: Y
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samp*eo recai-.ed Or: rce
'AJA - tieaa_:pa.-- Accept:,.! 1,2
NA
Y tl
( ] Yes [ ] No
USDA Rzoqul,red Soil::
-in
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p
Samples Hr lding Yimr-
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Rush: Field Filtered (ifapplicable):
Residual chlorine Prose: t
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( ] Return [ ] Same Day [ )Next Day [ ] Yes [ ] No
Z
_ [ ] 2 Day f 13 Day [ 14 Day [ ] 5 Day
Z
75
Srample pH Aec•�otac l.. //
G114 HA
_ (Expedite Charges Apply) ; Analysis:
c)
0
l
l scrips:
tide Present y N RS-
n Matrix box below): Drinking Water (DWI, Ground Water (GW), Wastewater (WW),
Z
(SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
Vj
Comp / Collected (or Res
j # of H
Z
m
Commence:
Matrix * Grab - Composite Start) I Composite End Cl
Ctns p
o
U
m
U
Date ' Time Date j Time
Z tL
CL
wW g o3 ZZT�ZZ i 5 /�_ _X X —^
:
ecial Conditions / Possible Hazards: Type of Ice Used: Wet Blue Dry None
R
Datf
Packing Material Used:
Radchem sample(s) screened (<500 cpm): Y N NA
Wimp: f Rece}red by_/Company: (Signature)
SHORT HOLDS PRESENT (<72 hours): Y N N/A
Lab Tracking #:
pies received via:
FEDEX UPS Client
Date/Time: i j q<C
Courier Pace Courier
MT1L LAB USE ONLY
Table #:
Acctnum:
Lab Sample Temperature Info:
Temp Blank Recejv d: Y ® NA
Therm ID#:
Cooler 1 Temp Upon Receipt: 2% oC
Cooler 1 Therm Corr. Factor: '1 oC
Cooler 1 Corrected Temp: C
Comments:
ny: (Signafure)
Received
Trio Plank Received: Y Q NA

;heck mark top half of box if pH and/or dechlorination is Project #
!rified and within the acceptance range for preservation
mples.
:eptions: VOA, Coliform, TOC, Oil and Grease, DRO/3015 (water) DOC, LLHg
Bottom half of box is to list number of bottles
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pH Adjustment Log for Preserved Samples
1ple ID
Type of Preservative
pH upon receipt
Date preservation adjusted
Time preservation
Amount of Preservative
Lot y
adjusted
added
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 (i.e,
hold, incorrect preservative, out of temp, incorrect containers.

Vac,Analytical
www.pacelabs.com
i
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92587564
Pace Analytical Services,
1377 South Park [
Kernersville, NC 2'
(704)977-1
Page 1
Report Date: 02/11 /2022
Date Received: 02/10/2022
Sample: Effluent Field Lab ID: 92587564001 Collected: 02/10/22 10:55 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifier;
Performed by Pace 02/10/22 10:55
Collected By Garrett 02/10/22 10:55
Dreyer
Collected Date 02/10/2022 02/10/22 10:55
Collected Time 1055 02/10/22 10:55
pH 8.37 Std. Units 02/10/22 10:55
Chlorine, Total Residual 0.03 mg/L 02/10/22 10:55
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]

CHAIN -OF -CUSTODY Analytical Request Document
talyflC2/
Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fields
Town of Liberty Billing Information:
{ Email To:
Site Collection Info/Address:
ame/Number: State: County/City: Time Zone Collected:
J [ ]PT[ ]MT[ ]CT [ ]ET
xSite/Facility ID #: Compliance Monitoring?
U [ /Yes [ ] No
Purchase Order #: DW PWS ID #:
Quote#: DW Location Code:
LAB USE ONLY -Affix Workorder/Login Label Here or List Pace Workorder Number or
MT1L Log -in Number Here
ALL SHADWO#L:92587564
Container Preservative Ty_
** Preservative Types: (1) nitric acid, (2) sulf
(6) methanol, (7) sodium bisulfate, (8) sodiw 92587564
(C) ammonium hydroxide, (D) TSP, (U) Unpre_
use): 'Turnaround Date Required: Immediately Packed on Ice:
[ ] Yes [ ] No
Rush: Field Filtered (if applicable):
riate [ ] Return ( ] Same Day [ ] Next Day [ ] Yes [ ] No
[ ] 2 Day [ ] 3 Day [ ] 4 Day [ ] 5 Day
(Expedite Charges Apply) Analysis:
�rt in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
olid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT) r�
Lab Sample Receipt Checklist:
Custody Seals PresentlIntact Y f,7 NA
Custody Signatures Present L N NA
Collector Signature Present N NA
Bottler Intact N NA
Correct Bottles N NA
Sufficient Volume '.14 NA
Samples Received on Ice , , N NA
VOA - Headspace Acceptable Y N ,A
USDA Regulated Soils* Y ,;NA
Samples in Holdinq Time i)N NA
Residual ChlorinePresent Yj1 NA
Cl Strips:
Sample pH Acceptabl4 , N NA
PH Strips: w t'
Sulfide Present Y N NrV
Lead Acetate Stripe:
i,AR TIM nMI,V-
Matrix *
I'
Comp / Collected for
Grab Composite Start)
Date Time
Composite End
Res # of ! w k ( Lab Sample df i Comments:
[� r
CI G Ctns )
Q ( I
Date i Time
i �i
i
'Special Conditions / Possible Hazards: Type of Ice Used: Wet Blue Dry None
Packing Material Used:
r
Radchem sample(s) screened (<500 cpm): Y N NA
span i nature) Date/Time:�� ; Received by/Company: (Signature)
(Signature) (IlateF`rime: I Received by/Company: (Signature)
SHORT HOLDS PRESENT (<72 hours): Y N N/A
LaD barnple i ernperature imo:
Lab Tracking#_.-_..____
Temp Blank R c iv!: Y N, NA
Therm
Cooler 1 Temp Upon Receipt , oC
>amples received via:
Cooler 1 Therm Carr. Factor oC
FEDEX UPS Client
Courier Pace Courier
ICooler 1 Corrected Temp: oC
Date/Time:) i (
MT1L LAB USE ONLY
Comments:
Table #:
Acctnum:
Date/Time:
;Template:
Trip Blank Received. Y fy NA
�Prpinpin-
HCL McOH TSP Other

Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
zl ,lace Analytical
iwww.pecolabs.com
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Page 1 of 1
Report Date: 03/02/2022
Date Received: 02/17/2022
Project: Town of Liberty
Pace Project No.: 92588849
Sample: Effluent Lab ID: 92588849001 Collected: 02/17/22 12:05 Matrix: Water
Method
Parameters
HACH 10206
Nitrogen, Nitrate
SM 2540D-2015
Total Suspended Solids
SM 521OB-2016
BOD, 5 day
Colilert-18
Fecal Coliforms
TKN+NO3+NO2
Calculation
EPA 350.1 Rev 2.0 1993
EPA 351.2 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
EPA 365.1 Rev 2.0 1993
ANALYTE QUALIFIERS
Performed by
Collected By
Collected Date
Collected Time
pH
Chlorine, Total Residual
Total Nitrogen
Nitrogen, Ammonia
Nitrogen, Kjeldahl, Total
Nitrogen, NO2 plus NO3
Phosphorus
Results
Units
Report Limit
Analyzed Qualifiers
ND
mg/L
0.30
02/18/2210:48
41.3
mg/L
16.7
02/21/2213:55
38.2
mg/L
2.0
02/23/2217:27 B1
365
MPN/100ml-
1.0
02/18/2212:59
Pace
02/17/22 17:25
Garrett
02/17/22 17:25
Dreyer
02/17/2022
02/17/22 17:25
1205
02/17/22 17:25
8,93
Std. Units
02/17/22 17:25
0.70
mg/L
02/17/22 17:25
25.0
mg/L
0.52
03102/2217:20
15.9
mg/L
0.30
02/21/2215:41
25.0
mg/L
2.5
03/02/22 08:20
ND
mg/L
0.040
02/28/2213:53
3.5
mg/L
0.050
03/01 /22 20:30
B1 Less than 1.0 mg/L DO remained for all dilutions set. The reported value is an estimated greater than value and is
calculated for the dilution using the least amount of sample.
Reviewed by: 4�
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 Certification #: 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
VirginiaNELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
Virginia/VELAP Certification #: 460025

aceAnalyficali CHAIN -OF -CUSTODY Analytical Request Document
Chain -of -Custody is a LEGAL DOCUMENT- Complete all relevent fields
,parry: Town of Liberty Billing Information:
ress:
ort To: Email To:
vTo: Site Collection Info/Address:
LAB USE ONLY- Affix Workorder/Login Label Here or List Pace Workorder Number or
MT1L Log -in Number Here
ALL SHAD
u� 2� 8 0 ntainer Preservative al
1111111111111111111111
Preservative Types: (1) nitric acid, (2) sulfu 92588849
(6) methanol, (7) sodium bisulfate, (8) sodiun
(C) ammonium hvdroxide, (D) TSP, tUl Uncreseiveu, wi vtner
Analyses
Lab Profile/Line:
Lab Sample Receipt —Checklist: 1
Comer Project Name/Number: State: County/City: Time Zone Collected:
/ [ ]PT[ ]MT[ ]CT [ ]ET�
I
Custody Seale Present/Intact YNA
Custody Signatures Present' N NA I
ne:
Site/Facility ID #:
Compliance Monitoring?
ail:
(Yes [ ] NO o
Collector Signature Present N NA
d
Bottles Intact NNA 1
Correct Bottles Y' N NA
ected By (print):
Purchase Order #:
DW PWS ID #:
Quote#:
DW Location Code:
Sufficient Volume. 'g N NA
Samplers Received on Ice :j N NA
VOA - Headspace Acceptable Y N a
t ):
Turnaround Date Required:
Immediately Packed on ICE: d
[ )Yes ( ] No
USDA Regulated Soils Y (V tqA
o
Samples in Holding Time ;"$ N NA
Residual chlorine Present Y'-N tdA
iple DI sal:
Rush:
Field Filtered (if applicable): F-
)ispose as appropriate [ ] Return
[ J Same Day [ ] Next Day
[ ]Yes [ ] No Z
Cl strips: V
S
archive:
[ ] 2 Day [ ] 3 Day [ ] 4 Day [ ] 5 Day
Z
Analysis: �
Sample pH Acceptab�q s ` Y N NA
pti Strips:
cold:
(Expedite Charges Apply)
Y O
II
Sulfide Present X N NA
Lead Acetate Strips: 1 t
atrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW), Z Z
oduct OP,Soil/Solid (S,Oil (OL), Wipe ( P),Air (AR), T ssue tTS), Bioassay (B), Vapor (V),Other (OT) tfY
Cn F-
m
LAB USE ONLY:
Lab Sample # / Comments:
Comp /
Collected (or
Res
# of I— Z
tomer5am le ID
A
Matrix *
Grab
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Composite End
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v
U
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m Z
Ly o-
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j
Date
Time
Date
Time
luent
WW
g
`
5
i
d
[
tomer 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:
Packing Material Used: m l Lab Tracking #: Temp Blank Received: Y N NA
C Therm iD#:
i
Effluent Monitoring i Cooler 1 Temp Upon Receipt: _oC
_ _
amples received via: Cooler 1 Therm Corr. Factor: aC
Radchem sample(s) screened (<50o cpm): Y N NA FEDEX UPS Client Courier Pace Courier Cooler 1 Corrected Temp: oC
squished b Co ture) Date/Time: Receive /Co f (Signature) Date/Time: MT1L LAB USE ONLY - Comments: f
Table #:
f 0Z, lilt
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e y C - (Signature) D te/ me: Received by/Company: (Signature) Date/Time: Tr) Blank Received: Y N NA
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o Prelogin: HCL McOH TSP Other
wished by/Company:(Signature) Date/Time: Received by/Company:(Signature) Date/Time: I
PM: Non Conformance(s). Page:
o
I IPg; YES / NO of: G

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laceAnalytical
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
Page 1 of 1
Report Date: 02/25/2022
Date Received: 02/24/2022
Project: Town of Liberty
Pace Project No.: 92589967
Sample: Effluent Lab ID: 92589967001 Collected; 02/24/22 11:04 Matrix: Water
Method Parameters
Results Units
Report Limit Analyzed Qualifiers
Performed by
Pace
02/24/22 16:19
Collected By
Glenn Price
02/24/22 16:19
Collected Date
02/24/2022
02/24/22 16:19
Collected Time
1104
02/24/22 16:19
pH
7.24 Std. Units
02/24/22 16:19
Chlorine, Total Residual
0.79 mg/L
02/24/22 16:19
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]

� '�
CHAIN -OF -CUSTODY Analytical Request Document
aceAnalytical
`
Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fields i
mpany: Town of Liberty
Billing Information:
t
cress
port To:
i
�Email To:
uyTo:
Site Collection Info/Address:
stomer Project Name/Number:
State: County/City: Time Zone Collected:
/ [ ]PT[ )MT[ ]CT [ ]ETi
)ne:
Site/Facility ID #:
Compliance Monitoring?
ail:
) [ y/Yes j ]NO
lect (print):
Purchase Order#:
DW PWS ID #:
Quote #:
DW Location Code:
ected By (signature):
Turnaround Date Required:
Immediately Packed on Ice:
[ ] Yes [ ] No i
nple Disposal:
Rush:
Field Filtered (if applicable):
Dispose as appropriate [ ]Return
( )Same Day [ ]Next Day
[ ] Yes ( ] No i
Archive:
[ ] 2 Day [ ] 3 Day [ ] 4 Day [ ) 5 Day
Hold:
{Expedite Charges Apply)
Analysis:
tatrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
-oduct (P), Soil/Solid (SQ, Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
a Comp J Collected (or
Aomer Sample ID j Matrix" Composite End
Grab Composite Start)
Date Time Date Time
luent 1 9
I
T-- e
I k �
(I
i
z �
P
LAB USE ONLY -Affix Workorder/LORin Label Here or List Pace Workorder Number or
2
ALL SHADEC
Container Preservative Type + iJ
j 92589967
-Preservative Types: (1) nitric acid, (2) sulfuric acio, t�l
(6) methanol, (7) sodium bisulfate, (8) sodium thiosulfate, (9) hexane, (A) ascorbic acid, (8) ammonium � ....,..
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
I �
-a
�LL
c
C
\� U
11
Res # of i(D i m
Cl Ctns ! F5
tomer Remarks / Special Conditions / Possible Hazards: yType of Ice Used., Wet Blue Dry None
Packing Material Used:-m
Effluent Monitoring
Radchem sample(s) screened (<500 cpm): Y N NA
nquished by/r knpany: (Signa;tupe/ haa*Timp: j Received by/Company: (Signature)
Jqu
r
(Signature)
Date/Time: j Received by/Company: (Signature)
me: I Received
SHORT HOLDS PRESENT (<72 hours): Y N N/A
Lab Tracking It:
pies received via:
FEDEX UPS Client
Date/Time:
Date/Time:
Lab Sample Receipt Checklist:
Custody Seals Present./Intact Y\ 'NA
Custody Signatures Present f N
Collector Signature Present Ni23A t y�i
Bottles* Intact �td NA i"'4
Correcr Bottles .'I NA
Sufficient folume. PJ.rt
Samples Received on Ice N NA
VOA - Headspace Acceptable V N 16;1
USDA Regulated Soils NA
Samples in HG2dinn_ Time N NA
Residual Chlorine Present gJ NA
Cl Strips: r•,...p,� _�
Sample pH R"r_cptable NYJA
pH Strips:
Sulfide Present t�' „Y.•ke N7�3
Lead Acetate Strips
LAB USE ONLY:
Lab Sample 4 / Comments:
Courier Pace Courier
MT1L LAB USE ONLY
Table
Acctnum:
Template:
Prelogin:
PM:
Lab Sample Temperature Info:
Temp Blank Receive
Therm ID#:
Cooler 1 Temp Upon Receipe,
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 of:

DATE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
February 2022
Liberty N.C.W.W.T.F
Freeboard Lagoon inches
11 1/4
12
11
R
0.6
10
R
0.3
9
8
8
R
0.3
7 1 /2
R
0.4
5
6
7
8
8 1/4
8 1 /2
8 3/4
9 1 /4
9 3/4
R
0.3
9 1/2
9 1/4
9 1/2
9 3/4
10 3/4
11 1 /4
R
0.3
10 1/2
10
10 114
10 1 /2
R
0.3
10

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?
2 Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? 23 Compliant ❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? 0 Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? ❑✓ Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑ Compliant 2 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.
WE WENT OUT OF COMPLIANT ON THE DATE OF 01/0312022 CAUSE OF RAINFALL. THE RAINFALL TOTAL OF 4.0 INCHES OVER TWO DAYS PERIOD.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Elix Tremaine Fike
Permittee:
Scots Kidd
Certification No.: 989290
Signing Official:
Grade: SI Phone Number: 336 622 2990
Signing OfficiaPs Title: Town Manager
Has the ORC changed since the previous NDAR-1? Yes 2 No
Phone Number. 336 622 4276 Permit Exp.: 8/31 /24
Signature Date
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

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _2_ 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?
EZ Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? ❑✓ Compliant ❑ Non -Compliant
Was a suitable vegetative cover maintained On all sites as specified in your permit? ❑✓ Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? ❑✓ Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑ Compliant EZ 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.
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
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 NDARA? ❑ Yes No
Phone Number: 336 622 4276 Permit Exp.: 8/31/24
I-X_
�., -3 z Zz 2
Signature Date
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