WQ0003090_Monitoring - 08-2022_20220927

Monitoring Report Submittal
Permit Number #*
Name of Facility:*
Month: * August
Report Information
wg0003090
town of liberty wwtp
Type *
NDMR, NDAR-1, NDAR-2, NDMLR
Confirmation Email Address:*
Name of Submitter: *
Signature:
Date of submittal:
Initial Review
Year:* 2022
Upload Document*
Tremaine report.pdf 3.28MB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
[e-mail]
Elix Fike
Reviewer: Gerald, Wanda
9/27/2022
This will be filled in automatically

Is the project number correct?* wg0003090
Is the monitoring report accepted?* Yes No
Regional Office* Winston-Salem
Reviewer: _anonymous
Review Date: 10/24/2022

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR)
Page _1 _ of _1 _
Permit No.: WQ01003090 T7Facility
Name: Town Of Liberty - Wastewater
PPI: 002
TFlow Measuring Point: influent [-] Effluent [I No flow generated
Parameter Code
00400
00610
s 31613
>t
Q
E
P:
0
0
Fy
0
x
fC
0
E
E
E
LL 0
24-hr
hrs
su
mg/L
#1100 mL
1
7:00
8
2
7:00
8
3
7:00
8
4
7:00
8
7.01
119
2420
5
7:00
8
6
71
8
7:00
8
9
7:00
8
10
7:00
8
11
7:00
8
6.731
1
12
7:00
8t.
131
14
15
7:00
8
16
7:00
8
17
7:00
8
18
7:00
8
6.79
12.7
2420
191
7:00
8
20
7:30
21
11:30
2
22
7:00
8
23
7:00
8
24
7:00
8
25
7:00
8
6.99
126
7:00
1 8
27
10:00
2
th
28
12:00
2
29
7:00
8
30
7:00
8
311
7:00
8
Average:
WIN, MOP'—
13.30
2,420.00
Daily Maximum:
7.01
13.90
2,420.00
Daily Minimum:
6.73
12.70
2,420.00
Sampling Type:
Grab
Grab
Grab
Monthly Avg. Limit:
Daily Limit:
Sample Frequency:
kweekly
2x month
2x month
ICounty: Randolph Month: August Year: 2022
Parameter Monitoring Point: El Influent 7 Effluent El Groundwater Lowering El surface water
00625 50060 i,r00*1
g 1 11 1 70300 fi,%tkj 00630 kg
+ a)
>
F- W z U) 0
0
a) F- z
17.4 11kiffaNS1,11 0.16 <0.040
0.14
15.1 ENMWffiXZ'4 0.18 1112,11-U-M-112J. UUMB011 <0.040
0.18
#REF!
*REF!
0.18
0.04
#REF!
0.14
X
0.04
Grab
Grab
01,1111
Grab
�
2x month
weekly,
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? ❑ Compliant 21 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.
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 [21 No
Phone Number: 336 622 4276 Permit Expiration: 8/31/2024
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

aceAnalytical
www.pacclabs.com
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92618640
Sample: Effluent
Method
SM 2540D-2015
EPA 353.2 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
SM 521OB-2016
Colilert-18
TKN+NO3+NO2
Calculation
EPA 350.1 Rev 2.0 1993
EPA 351.2 Rev 2.0 1993
EPA 365.1 Rev 2.0 1993
Parameters
Total Suspended Solids
Nitrogen, NO2 plus NO3
Nitrogen, Nitrate
BOD, 5 day
Fecal Coliforms
Performed by
Collected By
Collected Date
Collected Time
pH
Chlorine, Total Residual
Total Nitrogen
Nitrogen, Ammonia
Nitrogen, Kjeldahl, Total
Phosphorus
Laboratory Report
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 08/18/2022
Date Received: 08/04/2022
Lab ID: 92618640001 Collected: 08/04/22 13:05 Matrix: Water
Results
Units
Report Limit
Analyzed
17.6
mg/L
7.6
08/08/2213:07
ND
mg/L
0.040
08/05/22 09:55
ND
mg/L
0.040
08/05/22 09:55
17.0
mg/L
2.0
08/10/2216:15
2420
MPN/100mL
1.0
08/05/2212:49
PACE
08/04/22 13:05
Garrett
08/04/22 13:05
Dreyer
08/04/22
08/04/22 13:05
1305
08/04/22 13:05
7.01
Std. Units
08/04/22 13:05
0.16
mg/L
08/04/22 13:05
17.4
mg/L
0.040
08/16/2216:18
13.9
mg/L
0.30
08/12/2214:00
17.4
mg/L
0.50
08/13/22 05:40
3.1
mg/L
0.050
08/12/2217:21
ANALYTE QUALIFIERS
El Reported value should be considered a minimum estimate since it is the maximum reportable number for this method
based on the sample volume used. The true value is likely greater than the value reported.
R6 The RPD between valid sample dilutions exceeded 30%.
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 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
R6
El
Qualifiers
Page 1 of 3

-;
CHAIN -OF -CUSTODY Analytical Request DOCument
LAB USE0NLY-AffixWorcorr'- "--
#`
Chain -of -Custody is a LEGAL DOCUMENT- Complete all relevent fields
Company: Town of Liberty Billing Information:
I
ALL SHADE Il
I I
1
_
Container Preservatrve T e 92618640
_ _
Aadress:
u` 2
i 8 i i
Report To:
I Email To:
"` Preservative Types: (1) nitric acid, (2) sulfuric acid, (3) hydrochloric acid, (4) sodium hydroxide, (5) zinc acetate,
{
'6) methanol, (7) sodium bisulfate, (9) sodium thiosulfate, (9) hexane, (A) ascorbic acid, IS) ammonium sulfate,
Copy To:
i Site ?^.ollection Info/Address:
(C) ammonium hydroxide, (0) TSP, (U) Unpreserved, (0) Other
Analyses Larofle/Line:
Customer Project Name/Number:
IState: County/City: Time Zone Collected:
(
( ( Leta Sa^a e Receipt C,hecrTist:
/ t IPT I IMT ( lam' E IET°
(
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[ /Yes [ ] No
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Purchase Order #: DW PWS ID #:
I
; ) Hat lcc react
( E 1 c rx�c a t ties
N NA
y' u NA
--
Quote #: DW Location Code:
3
' I i ( z u t+ cf en Volume
N NA
Co(I e y at
_
ITurnaround Date Required: Immediately Packed an Ice:
EB
Samples Received on Ice
( ! { I 0A - Head.pace Acceptable
USDA Regulated So'.ts
%� �4 N;,
Y v'
Y d N '
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f j i Rcn: dkaa Chia }npPrsenc
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[ ) Dispose as appropriate ( ] Return
1 ( ] Same Day ( I Next Day [ I Yes j ]NO
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( 12 Day [ ] 3 Day ( 14 Day ( 15 Day
Analysis:
I Sam p e p`� Acaetytable Y p, NA
Ff St-itstL___
( Hold:
' (Expedite Charges Apply)
1-..
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Y N�
" Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
Z
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tr) Y
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( Date me
I
Date
Date Time
z Iy Q_ z
:Effluent `WW 9 4 2 ' 13
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Customer Remarks / Special Conditions / Possible Hazards: gType of Ice Used: ( Wet ) Blue Dry None SHORT HOLDS PRESENT (<72 hour j: Y,', N N/A
Packing Material Used' Lab Tracking #:
Effluent Monitoring
Radchem samples) screened (<SDO cpm): Y N NA iSampies received via:
( FEDEX UPS Client Courier Pace Courier
) _
TILLU ;elarsy: ignature} Date/Time: Re v+bY/Com anysS.nature} Date/Time. B
LY
y 0 Table #:
�Uislhed by/Company:(Signature) Dae/ me: tRe edby/Compan:(Sig � ;Date/Time:
party: (Signature) I Date/Time:
W
P B:
LatT Sample Temperature into:
Temp Blank Received: NA
��.
Therm ID#: T Z" Y
Cooled Temp Upon Receipt: SAS oC
Cooler 1 Therm Corr. Factor. �e oC
Cooler 1 Corrected Temp: =oC
Comments:
Trip Blank Received: Y N NA
HCL McOH TSP other
Non Conformance(s): Page:
YES / NO ' af:

DC: Tula:0'° ---- -- — —
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�` ;r Upon Rt2ceipt S.a ,1p of}.iitlo!
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ria;:ve adjusted to[ ,d I adder
Cut at held. incorrac', re e ,a6,a, out of ro Cieca';on rf;,c, (i
P temp, m�orrau contain�rsj
Qualtrax Document ID: 70677
Page 2 of 2
Page 3 of 3

aceAnalytical"
www.pacelabo.com
i
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92620057
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 08/12/2022
Date Received: 08/11/2022
Sample: Effluent
Method Parameters
Lab ID: 92620057001 Collected: 08/11/22 14:10 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
Performed by
PACE
08/11/22 14:10
Collected By
Garrett
08/11/22 14:10
Dreyer
Collected Date
08/11/22
08/11/22 14:10
Collected Time
1410
08/11/22 14:10
pH
6.73 Std. Units
08/11/22 14:10
Chlorine, Total Residual
0.14 mg/L
08/11/22 14:10
Y
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 2

CHAIN -OF -CUSTODY Analytical Request Document LAS USE ONLY- Affix Worlcord€>r/Low- o—, W-1nreinr Nt,mhar nr
li _ N"
aeeAr�ar seal WO# : 92620057
-�,
Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fields i
Company:w Town of Liberty Billing information: -
l Container PreservativeALSADED AF
Address:92620057
1, � {
' ReMrt To: Email To: y � " Preservative Types: (1) nitric acid, (2) sulfuric acid, (3) hydrochloric acid, (4) sodium hydroxide, (5) zinc acetate,
{ t (G) 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) Unpreserved, (0) Other
Analyses Lab Profile; Line:
Customer Project Name/Number: State: County/City: Time Zone Collected: ! j (, I Lab Sample Peceipe Chc:r-kl uc:
f ]PT[ ]MT[ ]Cr [ ]ET $
i Phone: Site/Facility ID #:
Compliance Monitoring? )
Email:
[ /Yes [ ] No
qt{seed By(print): Purchase Order #:
DW PWS ID #:
V ote #:
DW Location Code:
kColie y (s' Turnaround Date Required:
Immediately Packed on Ice.
1
[ ]yes [ ] No
mple Disposal: Rush:
Field Filtered (if applicable):
(( [ Dispose as appropriate [ ] Return , [ ] Same Day [ ] Next Day
[ ] Yes [ ] No
( ] Archive: ? [ ] 2 Day [ ] 3 Day ( ] 4 Day [ ] 5 Day
i
Analysis:
[ IHold: (Expedite Charges Apply)
" Matrix Codes (Insert in Matrix box below). Drinking Water (DW), Ground Water (GW), Wastewater (WW), 1i
Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
Comp/ Collected (or Res #of
Composite End W
Customer Sample ID Matrix Grab Composite Start)-� Cl Ctns
Date ' Time Date Time t 9 =ot
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Customer Remarks /Special Conditions / Possible Hazards: [Type of Ice Used: Wet Blue Dry None
t.-_.._-..._—-.._..._-_—_.....m._e.__v_ .W_____
( packing Material Used:
* Effluent Monitoring
Relinquish aT"i - 'grtatvre)
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N
Date/Time:
sample(s) screened (<500 cpm): Y N NA
RelAquished by/Company: (Signature) Date/Time: i Received
). Custody Seals Present"latac If N NA
CuGtodg S:..gnatureR Present. Y N NA
Collector Signature Prese.,_. Y V Nei
Ba tlece Zritact Y N NA
(correct Bottles Y N NA .
.. ( Sufficient Volume Y M NA
samples Pectived or. ice Y N NA, §g# VOA - Headspace Acceptable Y N NA
S JSAsA Regulated Soils :' Y N NA
( S( Samples in Hold.i nq Time. Y N WA
( Residw.11 CH lorxne Present Y N OVA
( Ct Strirrs
Sample PH Ac eptable Y N NA
PH Strzpa:
Sulfide Pres�-rc y P. NA
( Lead Acetate Strips:
3 ; LAS USS ONLY:...
B Lab Sample it / Comments:
i
(
{
I
SHORT HOLDS PRESENT (G72 hours) Y N N/A
��LabTracking#:
pies received via:
FEDEX UPS Client Courier Pace Courier
Date/Time: a MTJL LAB USE ONLY
[Table#.
Lab Sa m p le Te in perat u re 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:
Template: Trip Bank Received: Y N NA
Pre[ogin HCL McOH TSP Other
Date/Time:
PM Non Conformance(-,): Page:
FS: YES / P40 of:

aceAnalytical"
www.pacalabs.com
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92621276
Sample: Effluent
Method
SM 254OD-2015
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 350.1 Rev 2.0 1993
EPA 351.2 Rev 2.0 1993
EPA 365.1 Rev 2.0 1993
Parameters
Total Suspended Solids
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, Ammonia
Nitrogen, Kjeldahl, Total
Phosphorus
Laboratory Report
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 08/31/2022
Date Received: 08/18/2022
Lab ID: 92621276001 Collected: 08/18/22 11:15 Matrix: Water
Results
Units
Report Limit
Analyzed Qualifiers
19.3
mg/L
8.9
08/23/2210:35
ND
mg/L
0.040
08/19/2216:30
ND
mg/L
0.040
08/19/2216:30
ND
mg/L
0.040
08/1912216:30
13.8
mg/L
2.0
08/24/2218:51
2420
MPN/100mL
1.0
08/19/2213:01 1g,El
PACE
08/18/22 11:15
Garrett
08/18/22 11:15
Dreyer
08/18/22
08/18/22 11:15
1115
08/18/22 11:15
6.79
Std. Units
08/18/22 11:15
0.18
mg/L
08/18/22 11:15
15.1
mg/L
0.040
08/30/22 09:57
12.7
mg/L
0.30
08/31/2212:35 M1
15.1
mg/L
0.50
08/30/22 02:42
3.0
mg/L
0.050
08/29/2217:59
ANALYTE QUALIFIERS
1g >2419.5
El Reported value should be considered a minimum estimate since it is the maximum reportable number for this method
based on the sample volume used. The true value is likely greater than the value reported.
M1 Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS) recovery.
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 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
Virginia/VELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
Virginia/VELAP Certification #: 460025
Page 1 of 3

` CHAIN -OF -CUSTODY Analytical Request Document
'�cetinalyiical
Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fields
Company: Town of Liberty Billing information:
Address:
I
i Report To: JEmaif To: j
i c i
Copy To: Site Collection Info/Address:
A° WO#:92621276
11111111111111111111111
92621276
r Number' or
5
u( Z 8" t 1 1
— Preservative Types: (1) nitric acid, (2) sulfuric acid, (3) hydrochloric acid, (4) sodium hydroxide, 15) zinc acetate,
(6) methanol, (7) sodium bisulfate, (9) sodium thiosutfate, (9) hexane, (Al ascorbic acid, (B) ammonium sulfate,
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
Customer Project Name/Number:
tate: County/City: Time Zone Collected:
;
Lao Sacmple Fece pt CY c kl se
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/ ( ]PT[ ]MT[ ]CT j
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Phone: Site/Facility ID #:
Email: t
€
Compliance Monitoring?
[ Yes [ ] No
,%
`s C ected B ( it): Purchase Order #:
DW PWS ID #:
9
Quote #:
DW Location Code:
[
Sxraple.s Pe eived an Icer),
vO - aeadnpace kcceptible
v ,
v N!
Turnaround Date Required:
Imme iate y Pac ed on Ice:
Lllet
[ ]Yes [ )No
fQ
j
j j
USDA Regulated Sous
Sarnples in Holding Time
Reaid ttl chlorine Present
1 'N NA
y N UA
ample Disposal: Rush:
Field Filtered (if applicable):
[ ] Dispose as appropriate ( ] Return
( ] Same Day [ ] Next Day
[ ] Yes ( ] No
Z
Cl Strips:
pe pH eptak Ia
Y N 147
( ] Archive _
[ ] 2 Day j ) 3 Day [ ) 4 Ray [ ] 5 Day
Analysis
(:b
P14 Slrypo'Ac
( )Hold:
(Expedite Charges APPIY)
~
(
h
W
Su.ltide, Previent
¢ Gocud T,c:tixte" Strips;
T N NA
Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
Product (P), Soil/Solid (SL), Oil (OL), Wipe (W P), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
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Comp / ; Collected (or
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Res
Composite End Cl
# of
Ctns
�Z
Date Time
Date Time
M
-
U- CL
Effluent
1WW
g � Zi
itt,j
5
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1
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Customer Remarks /Special Conditions/ Possible
Hazards: TYPe iue Used Blue Dry Nane
SHORT HOLDS PRESENT (<72
hours N W N/A W�
EabSampfe Temperature into
Temp Blank Rece ved: Y �' NA
Packing Material Used:
Lab Tracking #:
i%
Therm ID#:C? a? i
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Page 2 of 2
Page 3 of 3

aceAnalytical
www.pacclabs.com
1
I
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92622390
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 08/26/2022
Date Received: 08/25/2022
Sample: Effluent Lab ID:
Method Parameters
92622390001 Collected: 08/25/22 11:50 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
Performed by
PACE
08/25/22 11:50
Collected By
Garrett
08/25/22 11:50
Dreyer
Collected Date
08/25/22
08/25/22 11:50
Collected Time
1150
08/25/22 11:50
pH
6.99 Std. Units
08/25/22 11:50
Chlorine, Total Residual
0.18 mg/L
08/25/22 11:50
xN
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 2

' m
CHAIN -OF -CUSTODY Analytical Request Document0
LAB USE ONLY- Affix WorkoederJLogin Label Here or list Pace Worhorder Number or
: 222390
- Chain -of -Custody is a LEGAL DOCUMENT -Complete all relevant fields
!
A`L SHADEl
Company. _ Town of Liberty
Billing Information:
Container Preservative Typ
_ i lli l lflllll!! l 11 llf
82622390
— Preservative Types: (I) nitric acid, (2) sulfun,
Report To:
Email To:
i
(6) methanol, (7) sodium bisulfate, (8) sodium thiosulfate, (9) hexane, (Al ascorbic acid, (B) ammonium sulfate,
(Q ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
Copy To:
Site Collection I nfo/Address:
Analyses
Lab Profile/Line: s
Customer Project Name/Number:
(State: County/City: Time Zone Collected:
i �p
Lab Sample Receipt Che } 1 3t: )
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Custody Sigm turoc Present v IN N!
Site/Facility ID Compliance Monitoring?
,Phone:
{ [ Yes [ ]No
€
[
Signature Present. Y N NA
Co,lector
Email:
S
(
Bottles intact y N NA
correct Bottles X N NA e
Ca cted B t): Purchase Order #: DW PWS ID #:
Quote#: DW Location Code:
d€
i
[
Sufficient ,toluene ' U Mk
€
II
I
.Samples Received on ice Y N NA
VOA - BeaWspace Acceptable y N tip,
Collected 8 signati Turnaround Date Required: Immediately Packed on Ice:
- .J- [ )Yes [ ] No
(v
i"SbA. Iteq�a' a:ed. S:aw 10: v t7 A;A 1
v
Samples it :cold rg Time Y N NA
Residual Chleriao Present Y N NA
Sample Disposal Rush: Field Filtered (if applicable):
{ ] Dispose as appropriate [ ] Return [ ) Same Day j ] Next Day it ] Yes [ ] No
c
`p
Cl ple Strips:
sample px Acceptable ptab? e Y P t�
{ ] archive: [ ] 2 Day [ ] 3 Day [ ] 4 Day [ ] S Day
Analysis:
`..0
,�
ttt
pH
[ ]Hold: (Expedite Charges Apply)
S.ziffda Present Y :S tFl;
Sulfide
Lead Acetate Strips:
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)
II
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rn
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Comp / Collected (or
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(# of
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Date
Time
Effluent Ww 9 111_v
0
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Temp
j Packing Material Used., Lab Tracking 4: Therm [D#k Received: Y N NA
Effluent Monitoring l I Cooler 1 Temp Upon Receipt: _oc
! Samples received via: Cooler 1 Therm Corr. Factor: oC
Radchem sample(s) screened (<S00 epm)_ Y N NA FEDEX UPS Client Courier Pate Courier Cooler 1 Corrected Temp., oC
MTJL LAB USE ONLY [ Comments:
Relinavi e b aterej Date/Time: +RReec ived by/Co m pany.;(Signature) Date/Time:
(
''�! Z�/ �� f U✓ v fP 3'/8� { L Table
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Trip
) Prelogin: HCL McOH TSP Other
..r_ I Date/Time: quished by/Companw y: (Signare) i Date/T___Received Received by/Company: (Signature) i 1Pm: s Non Conformance(s): i Page:
N +PB: 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
29
30
31
August 2022
Liberty N.C.W.W.T.F.
Freeboard Lagoon Inches
9
R
0.5
9 1/2
10 1/2
12
13
14
14 1/4
14 1/2
14 1/2
16 1/2
16 1/2
16 1/2
17 1/4
17 1/2
17 3/4
R
0.5
17 1/4
17
17
17 1/4
18
18 1/2
R
1.2
17 3/4
R
0.5
17 1/4
17
17 3/4
18 1/4
19
R
0.5
19 1/2
19
20
21
TOTAL 3.2

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?
❑ Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? 2 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? 0 Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? 0 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.
ON THE DATE OF 8/26/2022
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 NDAR-1? ❑ Yes [21 No
Phone Number: 336 622 4276 Permit Exp.: 8/31/24
Signature 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

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? 0 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? El 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 ❑ 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.
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 NDAR-1? ❑ Yes EZ 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