#5036_2017_0406_AO_FINAL

INSPECTION REPORT ROUTING SHEET
To be attached to all inspection reports in-house only.
Laboratory Cert. #:
5036
Laboratory Name:
Town of Macclesfield
Inspection Type:
Field Maintenance
Inspector Name(s):
Anna Ostendorff, Gary Francies
Inspection Date:
April 6, 2017
Date Forwarded for Initial
April 25, 2017
Review:
Initial Review by:
Beth Swanson
Date Initial Review
April 25, 2017
Completed:
❑ Insp. Initial
® Insp. Reg
Cover Letter to use:
❑Insp. No Finding
❑Corrected
❑Insp. CP
❑Insp. Reg. Delay
(to use: rt click, properties, checks
Unit Supervisor/Chemist III:
Gary Francies
Date Received:
April 27, 2017
Date Forwarded to Admin.:
5/3/2017
Date Mailed:
5/312017
Special Mailing Instructions:

ROY COOPER
Water Resort ces
6 NVIRONMENTAt. OUAL�T`(
May 3, 2017
5036
Mr. Phillip Wainwright
Town of Macclesfield
P.O. Box 185
Macclesfield, NC 27852
MICHEAL S. REGAN
S. JAY ZIMMERMAN
Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC)
Maintenance Inspection
Dear Mr. Wainwright:
Enclosed is a report for the inspection performed on April 6, 2017 by Anna Ostendorff and myself.
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].
Sincerely,
Gary Francies, Technical Assistance/Compliance Specialist
Division of Water Resources
Attachment
cc: Anna Ostendorff
master file
Water Sciences Section
NC Wastewater/Groundwater Laboratory Certification Branch
1623 Mail Service Center, Raleigh, North Carolina 27699-1623
Location: 4465 Reedy Creek Road, Raleigh, North Carolina 27607
Phone: [phone] FAX: [phone]
Internet: http:/tdeg.nc.gov/abouttdivisionslwater-resources/water-resources-datalwater-sciences-home-pagellaboratorycertification-branch

------- - On Si#eAnsp
LABORATORY NAME:
NPDES PERMIT #:
ADDRESS:
CERTIFICATE #:
DATE OF INSPECTION:
TYPE OF INSPECTION:
AUDITOR(S):
Town of Macclesfield
NC0050661
771 South Fountain Rd
Macclesfield, NC 27852
5036
April 6, 2017
Field Municipal Maintenance
Anna Ostendorff and Gary Francies
LOCAL PERSON(S) CONTACTED: Phillip Wainwright
INTRODUCTION:
This laboratory was inspected by representatives of the North Carolina Wastewater/Groundwater
Laboratory Certification (NC WW/GW LC) program to verify its compliance with the requirements
of 15A NCAC 2H .0800 for the analysis of environmental samples.
II. GENERAL COMMENTS:
The laboratory was clean and has all the equipment necessary to perform the analyses. Staff was
forthcoming and receptive to implementing the required changes.
All required Proficiency Testing (PT) samples for the 2017 PT calendar year have not yet been
analyzed. The laboratory is reminded that results must be received by this office directly from the
vendor by September 30, 2017.
Requirements that reference 15A NCAC 2H .0805 (g) (1), stating "Data pertinent to each analysis
must be maintained for five years. Certified Data must consist of date collected, time collected,
sample site, sample collector, and sample analysis time. The field benchsheets must provide a
space for the signature or initials of the analyst and proper units of measure for all analyses", are
intended to be a requirement to document all pertinent information for historical reconstruction of
data. It is not intended to imply that existing records are not adequately maintained unless the
Finding speaks directly to that.
Contracted analyses are performed by Environment 1, Inc. (Certification # 10).
Current Quality Assurance Policies for Field Laboratories and Approved Procedure documents for
the analysis of the facility's currently certified Field Parameters were provided at the time of the
inspection.
III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
Documentation
A. Finding: All original records are not on file.

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10
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Requirement: Data pertinent to each analysis must be maintained for five years. Ref. 15A
NCAC 2H .0805 (g) (1).
Comment: The in -situ measurements for Dissolved Oxygen (DO) and Temperature are
recorded on a piece of paper in the field and then transferred to the benchsheet upon
returning to the laboratory. This original paperwork is then discarded.
Finding: The laboratory does not have a system of reagent traceability in place.
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. This information must be
retained for chemicals, reagents, standards and consumables used for a period of five
years. Consumable materials such as pH buffers and lots of pre -made standards are
included in this requirement. Ref: Quality Assurance Policies for Field Laboratories.
Comment: Using the log sheet provided by the inspector during the audit would satisfy
this requirement.
Finding: Data that does not meet all Quality Control (QC) requirements is not qualified
on the electronic Discharge Monitoring Report (eDMR).
Requirement: When QC failures occur, the laboratory must attempt to determine the
source of the problem and must apply corrective action. Part of the corrective action is
notification to the end user. If data qualifiers are used to qualify samples not meeting
QC requirements, the data may not be useable for the intended purposes. It is the
responsibility of the laboratory to provide the client or end -user of the data with sufficient
information to determine the usability of the qualified data. Where applicable, a notation
must be made on the electronic Discharge Monitoring Report (eDMR) form, when any
required sample quality control does not meet specified criteria and another sample
cannot be obtained. Ref: Quality Assurance Policies for Field Laboratories.
Comment: The laboratory was not transcribing data qualifiers from the contract
laboratory reports to the eDMR. The following omissions were noted: The Influent and
Effluent BOD samples from August 20, 2016 were reported to the laboratory with a
qualifier "b" which indicates the blanks depleted >0.20 mg/L.
Proficiency Testing
A
E.
Finding: The preparation of PT samples is not documented.
Requirement: PT samples received as ampules must be diluted according to the PT
provider's instructions. The preparation of PT samples must be documented in a
traceable log or other traceable format. The diluted PT sample becomes a routine
environmental sample and is added to a routine sample batch for analysis. Ref:
Proficiency Testing Requirements, February 20, 2012, Revision 1.2.
Comment: Dating and initialing the instruction sheet for the preparation of the Total
Residual Chlorine PT would satisfy the documentation requirement.
Finding: The laboratory is not documenting PT sample analyses in the same manner as
environmental samples.

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Requirement: All PT sample analyses must be recorded in the daily analysis records as
for any environmental sample. This serves as the permanent laboratory record. Ref:
Proficiency Testing Requirements, February 20, 2012, Revision 1.2.
Comment: The analysis of PT samples is designed to evaluate the entire process used
to routinely report environmental analytical results; therefore, PT samples must be
analyzed and the process documented in the same manner as environmental samples.
F. Finding: Additional QC is analyzed with PT samples.
Requirement: Laboratories shall conduct proficiency tests in accordance with their
routine testing, calibration and reporting procedures, unless otherwise specified in the
instructions supplied by the PT provider. They shall not be analyzed with additional
quality control or replicated beyond what is routine for environmental sample analysis.
Results from multiple analyses (when this is the routine procedure) must be calculated
in the same manner as routine environmental samples. Ref: Proficiency Testing
Requirements, February 20, 2012, Revision 1.2.
Comment: In general, laboratories must not analyze PTs with known concentrations
along with PTs of unknown concentrations, as this is not the routine testing protocol for
environmental samples. This is not to say that they cannot be used for troubleshooting
purposes before analyzing a remedial PT. This would be considered part of the
corrective action plan.
Chlorine, Total Residual — Standard Methods, 4500 Cl G-2000 (Aqueous)
G. Finding: The time of the meter calibration verification is not being documented.
Requirement: The following must be documented in indelible ink whenever sample
analysis is performed: Meter calibration and meter calibration time(s). Ref: NC WW/GW
LC Approved Procedure for the Analysis of Total Residual Chlorine.
Comment: Utilization of the benchsheet supplied by the auditor on April 13, 2017 via
email would fulfill this documentation requirement.
H. Finding: The laboratory is not analyzing a reagent blank with prepared standards.
Requirement: Reagent Blank: A reagent blank (sometimes also referred to as a
method blank) is only required when laboratory water is used to make quality control
and/or calibration standards. If you are using a sealed standard (e.g., gel) for your daily
check standard, a reagent blank would only be analyzed when preparing the annual 5-
point calibration curve or 5 annual calibration curve verification standards. Ref: NC
WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine.
Comment: A reagent blank is made from the same laboratory water source used to
make QC and/or calibration standards with DPD. The concentration of reagent blanks
must not exceed 50% of the reporting limit (i.e., the lowest calibration or calibration
verification standard concentration) or corrective action must be taken.
Comment: The laboratory uses standards prepared by the contract laboratory to
perform the annual factory -set calibration curve verification. The contract laboratory also
provides an aliquot of their laboratory water used to prepare the standards so that a
reagent blank may be analyzed.

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Finding: The laboratory was not calculating the overall correlation coefficient of the
annual factory -set standard curve verification.
Requirement: The overall correlation coefficient of the curve must be Z0.995. Ref: NC
WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine.
Comment: Utilization of the Excel spreadsheet calculator provided by the auditor via
email on April 13, 2017 would fulfill this requirement.
J. Finding: The 15-minute hold time is not being consistently met.
Requirement: Analyze within 15 minutes. Ref: Code of Federal Regulations, Title 40,
Part 136; Federal Register Vol. 77, No. 97, May 18, 2012; Table 11.
K. Finding: The laboratory did not verify the Gel® Standard concentration before initial use
nor every 12 months thereafter.
Requirement: Purchased "Gel -type" or sealed liquid ampoule standards may be used
for daily standard curve verification only. These standards must be verified initially and
every 12 months thereafter, with the standard curve. When this is done, these standards
may be used after the manufacturer's expiration date. Ref: NC WW/GW LC Approved
Procedure for the Analysis of Total Residual Chlorine. Please submit a copy of the gel
verification with the report reply.
Comment: The laboratory is using the manufacturer specified concentration as the true
value.
L. Finding: Values less than the established reporting limit are being reported on the
eDMR.
Requirement: The concentrations of the calibration standards must bracket the
concentrations of the samples analyzed. One of the standards must have a
concentration equal to or below the lower reporting concentration for Total Residual
Chlorine. The lower reporting limit must be less than or equal to the permit limit. Ref: NC
WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine.
Comment: Based on the most recent factory -set curve verification, the reporting limit is
10 pg/L. Any samples that measure below the reporting limit must be reported on the
eDMR as <10 pg/L.
pH — Standard Methods, 4500 H' B-2000 (Aqueous)
M. Finding: Values were reported that exceed the method specified accuracy of 0.1 units.
Requirement: By careful use of a laboratory pH meter with good electrodes, a precision
of ±0.02 unit and an accuracy of ±0.05 unit can be achieved. However, ± 0.1 pH unit
represents the limit of accuracy under normal conditions, especially for measurement of
water and poorly buffered solutions. For this reason, report PH values to the nearest 0.1
PH unit. Ref: Standard Methods, 4500 H+ B-2000. (6).

Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous)
N. Finding: The DO meter is not being properly calibrated according to the manufacturer's
calibration procedure.
Requirement: Instruments are to be calibrated according to the manufacturer's calibration
procedure prior to analysis of samples each day compliance monitoring is performed. Ref:
NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen.
Comment: The laboratory no longer had the user manual for the DO meter and received
guidance from their contract lab on how to calibrate in June or July of 2016, which was
incorrect. A digital copy of the user manual was located online and provided to the
laboratory by email on April 13, 2017.
Temperature — Standard Methods, 2550 B-2000 (Aqueous)
O. Finding: The National Institute of Standards and Technology (NISI) traceable
thermometer used to check annual temperature sensors had expired.
Requirement: NIST traceable thermometers used to verify the calibration of other
thermometers or temperature sensors (i.e., limited use only) must be recalibrated in
accordance with the manufacturer's recalibration date and the process documented. If
no recalibration date is given, the NIST traceable thermometer must be recalibrated
every 5 years. Ref: NC WW/GW LC Approved Procedure for the Analysis of
Temperature.
P. Finding: The temperature sensing device on the D.O. meter, used to obtain reported
temperature values for compliance monitoring, has not been calibrated against a NIST
traceable thermometer every 12 months.
Requirement: All thermometers and temperature measuring devices used for
compliance monitoring must be checked every 12 months against a NIST traceable
temperature measuring device and the process documented. NIST traceable
temperature measuring devices used for this verification must have a stated accuracy of
at least ± 0.5 °C. The thermometer/meter readings must be less than or equal to 0.5 °C
from the NIST traceable temperature measuring device reading. The calibration
verification documentation must include the serial number of the thermometer/meter
being checked and the NIST traceable temperature measuring device that was used in
the comparison. Document the verification data and keep on file. Ref: NC WW/GW LC
Approved Procedure for the Analysis of Temperature.
Comment: The temperature sensor calibration was last verified on February 10, 2016.
Q. Finding: The NIST thermometer certificate was not on file.
Requirement: NIST traceable temperature
must have a stated accuracy of at least
Procedure for the Analysis of Temperature.
measuring devices used for this verification
±0.5 'C. Ref: NC WW/GW LC Approved
Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A
NCAC 21-1.0805 (g) (1).

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Chlorine Total Residual — Standard Methods, 4500 Cl G-2000 (Aqueous)
Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous)
pH — Standard Methods, 4500 H+ B-2000 (Aqueous)
Temperature — Standard Methods, 2550 B-2000 (Aqueous)
R. Finding: The benchsheet was lacking pertinent data: instrument identification.
Requirement: The following must be documented in indelible ink whenever sample
analysis is performed: Instrument Identification. Ref: NC WW/GW LC Approved
Procedure for the Analysis of Total Residual Chlorine, NC WW/GW LC Approved
Procedure for the Analysis of Dissolved Oxygen, NC WW/GW LC Approved Procedure
for the Analysis of pH, NC WW/GW LC Approved Procedure for the Analysis of
Temperature.
Comment: Utilization of the benchsheet supplied by the auditor on April 13, 2017 via
email would fulfill this documentation requirement.
IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks,
etc.) and contract lab reports to eDMRs submitted to the North Carolina Division of Water
Resources. Data were reviewed for Town of Macclesfield (NPDES permit # NC0050661) for
March and August, 2016. The following errors were noted:
Value on
Benchsheet
Date
Parameter
Location
Value on eDMR
*Contract Lab
Data
3/29/2016
pH
Effluent
7.36 S. U.
7.29 S. U.
3/3/2016
Temperature
Effluent
No Val Neon
13 °C
3/14/2016
Temperature
Effluent
7.19 S. U.
14 °C
3/22/2016
Temperature
Effluent
No Val Neetue on
13 °C
3/23/2016
Temperature
Effluent
No Val Neetue on
14 °C
3/24/2016
Temperature
Effluent
15 °C'
16 °C
8/4/2016
pH
Effluent
7.40 S. U.
7.34 S. U.
8/1/2016
DO
Effluent
7.37 mg/L
7.2 mg/L
8/4/2016
Temperature
Effluent
No Val Neon
26 °C
8/15/2017
TKN
Effluent
0.45 mg/L*
0.045 mg/L
1. The Temperature reported on the eDMR was the temperature recorded from the sample pH analysis

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Given the number of transcription errors noted, it is recommended the laboratory implement a
system of peer review prior to submitting the completed eDMR.
It is recommended that you contact the appropriate Regional Office for guidance as to whether
an amended eDMR will be required. A copy of this report will be made available to the Regional
Office.
V. CONCLUSIONS:
Correcting the above -cited Findings 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 and implementation dates for each corrective action.
Report prepared by: Anna Ostendorff
Report reviewed by: Beth Swanson
Date: April 25, 2017
Date: April 27, 2017

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