#5192_2020_0218_AO_FINAL

Laboratory Cert. #:
5192
Laboratory Name:
City of Henderson -Kerr Lake Regional Water System
Inspection Type:
Field Municipal Maintenance
Inspector Name(s):
Anna Ostendorff
Inspection Date:
February 18, 2020
Date Forwarded for Initial
February 20, 2020
Review:
Initial Review by:
Thomas Halvosa
Date Initial Review
February 24, 2020
Completed:
❑ Insp. Initial ® Insp. Reg
Cover Letter to use:
❑Insp. No Finding ❑Insp. CP
❑Corrected
(to use: rt click, properties, check) ❑Insp. Reg. Delay
Unit Supervisor/Chemist III:
Beth Swanson
Date Received:
3/6/2020
Date Forwarded to Admin.:
3/16/2020
Date Mailed:
Special Mailing Instructions:

ROY COOPER
Governor
MICHAEL S. REGAN
Secretory
S. DANIEL SMITH
Director
NORTH CAROLINA
.Environmental Quality
March 17, 2020
5192
Ms. Clarissa Lipscomb
City of Henderson -Kerr Lake Regional Water System
P.O. Box 1434
Henderson, NC 27536
Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW
LC) Maintenance Inspection
Dear Ms. Lipscomb:
Enclosed is a report for the inspection performed on February 18, 2020 by Anna Ostendorff.
Where Finding(s) are cited in this report, a response is required. Within thirty days of receipt,
please supply this office with a written item for item description of how these Finding(s) were
corrected. Please describe the steps taken to prevent recurrence and include an implementation
date for each corrective action. If the Finding(s) cited in the enclosed report are not corrected,
enforcement actions may be recommended. For Certification maintenance, your laboratory must
continue to carry out the requirements set forth in 15A NCAC 2H .0800.
A copy of the laboratory's Certified Parameter List at the time of the audit is attached. This list
will reflect any changes made during the audit. Copies of the checklists completed during the
inspection may be requested from this office. Thank you for your cooperation during the
inspection. If you wish to obtain an electronic copy of this report by email or if you have
questions or need additional information, please contact me at [phone] Ext. 259.
Sincerely,_
r
Beth Swanson
Technical Assistance & Compliance Specialist
Division of Water Resources
Attachment
cc: Anna Ostendorff, Dana Satterwhite
North Carolina Department of Environmental Quality [ Division of Water Resources
4405 Reedy Creek Road 1 1623 Mail Service Center Raleigh, North Carolina 27699-1623
NORTH CAROUNA
Dq.d-mcd 919.733.3908

LABORATORY NAME:
NPDES PERMIT #:
ADDRESS:
CERTIFICATE #:
DATE OF INSPECTION:
TYPE OF INSPECTION
AUDITOR(S):
LOCAL PERSON(S) CONTACTED
I. INTRODUCTION:
City of Henderson -Kerr Lake Regional Water System
NC0083101
280 Regional Water Lane
5192
February 18, 2020
Field Municipal Maintenance
Anna Ostendorff
Clarissa Lipscomb
This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater
Laboratory Certification (NC WW/GW LC) program to verify its compliance with the requirements
of 15A NCAC 02H .0800 for the analysis of environmental samples.
II. GENERAL COMMENTS:
The facility is neat and well organized and has all the equipment necessary to perform the
analyses. Benchsheets are well designed, easy to follow and concise. Records are well
organized and easy to retrieve.
The inspectorwouldlike to commend the laboratory for- staying current with changes- in
laboratory certification program requirements and proactively implementing new requirements
prior to the on -site inspection. The laboratory has well established Standard Operating
Procedures (SOPs) for all parameters. The laboratory plans to review and update the SOPs in
compliance with the revised 15A NCAC 02H .0800 Rules prior to the July 1, 2020
implementation deadline.
All required Proficiency Testing (PT) Samples have been analyzed for the 2020 PT Calendar Year
but the results have not yet been received from the vendor.
Contracted analyses are performed by Pace Analytical Services, LLC — Asheville (Certification #
40) and Pace Analytical Services, LLC — Eden (Certification # 633).
Approved Procedure documents for the analysis of the facility's currently certified Field
Parameters were provided at the time of the inspection.

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#5192 City of Henderson -Kerr Lake Regional Water System
Documentation
A. Finding: The laboratory is not documenting traceability information for purchased
materials and reagents, nor in-house preparation of standards and reagents.
Requirement: Chemical containers shall be dated when received and when opened.
Reagent containers shall be dated, identified, and initialed when prepared. Chemicals and
reagents exceeding the expiration date shall not be used. Chemicals and reagents shall
be assigned expiration dates by the laboratory if not given by the manufacturer. If the
laboratory is unable to determine an expiration date for a chemical or reagent, a one-year
time period from the date of receipt shall be the expiration date unless degradation is
observed prior to this date. The laboratory shall have a documented system of traceability
for all chemicals, reagents, standards, and consumables. Ref: 15A NCAC 02H .0805 (g)
(7).
Requirement: All chemicals, reagents, standards and consumables used by the
laboratory must have the following information documented: Date received, Date Opened
(in use), Vendor, Lot Number, and Expiration Date (where specified). A system (e.g.,
traceable identifiers) must be in place that links standard/reagent preparation information
to analytical batches in which the solutions are used. Documentation of solution
preparation must include the analyst's initials, date of preparation, the volume or weight of
standard(s) used, the solvent and final volume of the solution. This information as well as
the vendor and/or manufacturer, lot number, and expiration date must be retained for
primary standards, chemicals, reagents, and materials used for a period of five years.
Consumable materials such as pH buffers, lots of pre -made standards and/or media,
solids and bacteria filters, etc. are included in this requirement. Ref: NC WW/GW LC
Policy.
Comment: Dates received and opened were documented on the chemical containers.
While this can provide a traceability link to analyses by looking at the dates that the
chemicals were in use, that link is lost once the bottles are discarded. A log sheet that may
be used for documenting traceability of purchased materials was provided by email
February 19, 2020. A log sheet that may used for documenting preparation of standards
and reagents was provided by email March 6, 2020.
B. Finding: -The -laboratory -benchsheets for pH and Total Residual -Chlorine -(TRC) are -
lacking required documentation: the method or Standard Operating Procedure and
instrument identification.
Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data
shall be traceable to the associated sample analyses and shall consist of: the method or
Standard Operating Procedure and instrument identification. Each item shall be recorded
each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (A) and (C).
C. Finding: The laboratory benchsheets for pH and TRC are lacking required
documentation: Units of measure.
Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data
shall be traceable to the associated sample analyses and shall consist of: the proper units
of measure. Each item shall be recorded each time samples are analyzed. Ref: 15A
NCAC 02H .0805 (g) (2) (Q.

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#5192 City of Henderson -Kerr Lake Regional Water System
Comment: The TRC benchsheet has both units (i.e., pg/L and mg/L) in the column
headings with the instruction to circle the applicable one. However, this is not being done.
Recommendation: Since all data is required to be reported in pg/L, it is recommended
that the mg/L units be removed from the "TRC results" and "Daily Check Standard
Obtained Value" column headings and the "TRC check standard True Value" footnote on
the benchsheet.
Proficiency Testing
D. Finding: The laboratory is not documenting the preparation of PT Samples.
Requirement: PT Samples received as ampules are diluted according to the Accredited
PT Sample Provider's instructions. It is important to remember to document the
preparation of PT Samples in a traceable log or other traceable format. The diluted PT
Sample then becomes a routine Compliance Sample and is added to a routine sample
batch for analysis. No documentation is needed for whole volume PT Samples which
require no preparation, however the instructions must be maintained. Ref: Proficiency
Testing Requirements, February 19, 2020, Revision 5, Section 3.6.
Comment: This Finding applies only to the TRC PT sample. Dating and initialing the
instruction sheet would satisfy the documentation requirement.
E. Finding: Additional Quality Control (QC) beyond what is routine for Compliance Samples
is being analyzed with PT Samples.
Requirement: Laboratories are required to analyze an appropriate PT Sample by each
parameter method on the laboratory's CPL. The same PT Sample may be analyzed by
one or more methods. Laboratories shall conduct the analyses in accordance with their
routine testing, calibration and reporting procedures, unless otherwise specified in the
instructions supplied by the Accredited PT Sample Provider. This means that they are to
be logged in and analyzed using the same staff, sample tracking systems, standard
operating procedures including the same equipment, reagents, calibration techniques,
analytical methods, preparatory techniques (e.g., digestions, distillations and extractions)
and the same quality control acceptance criteria. PT Samples shall not be analyzed with
additional quality control. They are not to be replicated beyond what is routine for
Compliance Sample analysis. Although, it may be routine to spike Compliance Samples, it
is neither required, nor recommended, for PT Samples. PT sample results from multiple
analyses (when this is the routine procedure) must be calculated in the same manner as
routine Compliance Samples. Ref: Proficiency Testing Requirements, February 19, 2020,
Revision 5, Section 3.6.
Comment: The laboratory is analyzing a known QC sample from the PT vendor along
with the blind PT Sample. The additional known QC sample is not analyzed with routine
compliance samples. The laboratory may continue to order and analyze the known QC
sample as part of their quality assurance plan but the known QC sample may not be
analyzed on the same day as the blind PT sample.
F. Finding: The laboratory is not documenting PT Sample analyses in the same manner as
routine Compliance Samples.

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#5192 City of Henderson -Kerr Lake Regional Water System
Requirement: All PT Sample analyses must be recorded in the daily analysis records as
for any Compliance Sample. This serves as the permanent laboratory record. Ref:
Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6.
Requirement: The laboratory shall retain all records necessary to facilitate historical
reconstruction of the analysis and reporting of analytical results for PT Samples. This
means the laboratory must have available and retain for five years [pursuant to 15A NCAC
02H .0805 (a) (7) (E and (g) (1))] all of the raw data, including benchsheets, instrument
printouts and calibration data, for all PT Sample analyses and the associated QC analyses
conducted by all parameter methods. Ref: Proficiency Testing Requirements, February 19,
2020, Revision 5, Section 4.0.
Comment: PT Sample results are currently only being documented on the reporting form
provided by the vendor. The PT results must be documented on a benchsheet in the same
way a compliance sample is documented to demonstrate that all calibration and QC
requirements were met.
Recommendation: It is recommended the laboratory implement an additional level of data
review prior to submitting the Discharge Monitoring Report (DMR) each month.
G. Finding: The laboratory does not report results of all tests on the characteristics of the
effluent.
Requirement: The results of all tests on the characteristics of the effluent, including but
not limited to NPDES permit monitoring requirements, shall be reported on the monthly
report forms. Ref: 15A NCAC 02B .0506 (b) (3) (J).
Comment: The laboratory is voluntarily analyzing Turbidity and Temperature beyond the
permit compliance monitoring requirements. The laboratory must either discontinue this
practice or report the results in the comments section of the Discharge Monitoring Report
(DMR) with a notation that the data is uncertified.
Chlorine, Total Residual — Standard Methods, 4500 Cl G-2011 (Aqueous)
H. Finding: The laboratory is not analyzing a Method Blank with laboratory -prepared
standards
Requirement: Method Blanks would be required when using laboratory -prepared
standards [including Proficiency Testing (PT) Samples] and anytime sample dilutions are
performed. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual
Chlorine (DPD Colorimetric by SM 4500 Cl G-2011).
Comment: The prepared PT Sample is considered a laboratory -prepared standard.
Comment: The Method Blank is deionized or distilled water from the same source used to
prepare the calibration verification standards or the PT Sample, and is analyzed like a
sample (i.e., with DPD/buffer added). The concentration of the Method Blank must not
exceed 50% of the reporting limit (i.e., the lowest calibration verification standard
concentration) or corrective action must be taken.

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#5192 City of Henderson -Kerr Lake Regional Water System
I. Finding: The true value of the gel -type standard is not being assigned properly.
Requirement: To assign a true value to the gel -type or sealed liquid standard:
1. Zero the instrument with the calibration blank.
2. Read and record gel standard values.
3. Repeat steps 1 and 2 at least two more times.
4. Assign the average value as the true value.
Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine
(DPD Colorimetric by SM 4500 Cl G-2011).
Comment: The laboratory is assigning the true value to the gel -type standard annually by
measuring the concentration once. A true value is being assigned for the same standard
by each analyst, resulting in different true values for the same standard and instrument
combination. Only one true value is to be assigned per gel -type standard for each
instrument.
J. Finding: Values less than the established reporting limit are being reported on the DMR.
Requirement: For all calibration options, the range of standard concentrations must
bracket the permitted discharge limit concentration, the range of sample concentrations to
be analyzed and anticipated PT Sample concentrations. One of the standards must have
a concentration less than the permitted Daily Maximum Limit. The lower reporting limit
concentration is equal to the lowest standard concentration. Sample concentrations that
are less than the lower reporting limit must be reported as a less -than value. Ref: NC
WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD
Colorimetric by SM 4500 Cl G-2011).
Comment: The laboratory has established a lower reporting limit of 15 lag/L. Samples with
concentrations less than that must be reported as < 15 lag/L on the DMR.
IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks,
etc.) and contract lab reports to DMRs submitted to the North Carolina Division of Water
Resources. Data were reviewed for the City of Henderson -Kerr Lake Regional Water System
(NPDES permit # NC0083101) for November and December 2019, and January 2020. The
following errors were noted:
Date
Parameter
Location
Value on
Denchsheet
Value on
DMR
11/19/2019
Fluoride
Effluent
No value
0 mg/L
reported
pH, Total Residual
12/30/2019
Chlorine, *Total
Effluent
Collected on
Reported for
Suspended Residue,
12/30/2019
12/29/2019
*Fluoride, *Turbidity

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#5192 City of Henderson -Kerr Lake Regional Water System
---]1/14/2020 Total Hardness Effluent *27,200 pg/L 272 mg/L
*Contract Laboratory data
The laboratory does not report "non -detect" results from the commercial laboratory as "less
than" values. It is recommended that the laboratory include the "<" sign when reporting
undetected analytes in order for the monthly average to be properly calculated. The NC DEQ
document titled Directions for Completing Monthly Discharge Monitoring Reports states: For
calculation purposes only, recorded values of less than a detectable limit (< #.##) may be
considered to equal zero (0) for all parameters except Fecal Coliform, for which values of 'less
than" may be considered to be equal to one (1). Values of results which are less than a
detectable limit should be reported in the daily cells using the "less than" symbol (<) and the
detectable limit used during the testing (or the value with appropriate unit conversion). Please
note there is never a case when an average would need to be recorded along with a "less than"
symbol.
Correcting the above -cited Findings and implementing the Recommendations will help this
laboratory to produce quality data and meet Certification requirements. The inspector would like
to thank the staff for their assistance during the inspection and data review process. Please
respond to all Findings and include supporting documentation, implementation dates
and steps taken to prevent recurrence for each corrective action.
Report prepared by: Anna Ostendorff Date: February 20, 2020
Report reviewed by: Tom Halvosa Date: February 24, 2020

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