NCG140392_DMR WW_20220329

ANNUAL SUMMARY DISCHARGE MONITORING
REPORT (DMR) — WASTEWATER
SUBMIT TO CENTRAL OFFICE*
General Permit No. NCG140000
Calendar Year 2021
*Report ALL WASTEWATER monitoring data on this form (include "No Flow"PNo Discharge" and Limit Violations) from
the previous calendar year to the DEQ by MARCH 1 of each year.
Certificate of Coverage No. NCG14 0❑ 3❑®®
Facility Name: Winston-Salem
County: Forsyth
Phone Number: (336 ) 996-2841
Certified Laboratory Research & Analytical Lab
Lab #
Lab #
Total no. of outfalls monitored 1
Wastewater (WW) Discharge Outfall No. 001
Does this outfall discharge WW to SA waters?
Yes ❑
No ❑✓
Does this outfall discharge WW to SIB or PNA waters?
Yes ❑
No ❑✓
Does this outfall discharge WW to HQW or ORW waters?
Yes ❑
No ✓❑
If so, what is the 7Q10 flow rate? or Tidally influenced
waters,
7Q10 not available ❑
Does this outfall discharge WW to Trout (Tr) designated waters?
Yes ❑
No ❑✓
Were there any limit violations in the calendar year?
Yes ❑
No ✓❑
Outfall No.
Daily Flow Rate,
pH,
TSS,
SS,
Non -Polar O&G (EPA Method 1664
001
cfs
SU
mg/1
ml/l
(SGT-HEM)), mg/l
if applicable
Effluent
Limitations
Daily Maximum
0 OW or ORIN
50/0 of 7Q10
Indicate NO FLOW if
applicable
freshwater
6.0-9.0
saltwater
pp p 5G
6'v -
Standard
30
HQW
20
HQW ! ORW and Tr, or
PNA
10
HQW, ORW, SA,
SB,PNA,orany
Trot
5
No Limit
Samples above Benchmark
subject to Tiered Responses
15
Date
Sample
Collected,��
molddlyr
��.�.
�
f ��
3/31/2021
NO FLOW
6/30/2021
NO FLOW
A Z02
9/23/2021
NO FLOW
U rr-
12/30/2021
NO FLOW
Permit Date 8/1/2017 — 6/30/2022
Last Revised 8-22-2017

Certificate of Coverage No. NCG14 ] q] 9-1 2Q
CERTIFICATION
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gather and
evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons directly responsible for gathering the information, the information submitted is, to the best of my
knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for
submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Required by 40 CFR §12A22] A
Signature r4j
Date
Mail Annual Summary Wastewater DMR to the NCDEQ Central Office:
Note the address is correct — Central Files is housed in DWR (not DEMLR)
N.C. Department of Environmental Quality (DEQ)
Division of Water Resources
Attn: DWR Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
Central Files Telephone [phone]
Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at:
[phone]
Permit Date 8/112017 — 6/30/2022
Last Revised 8-22-2017