#551_2017_0920_BS_FINAL

INSPECTION REPORT ROUTING SHEET
To be attached to all inspection reports in-house only.
Laboratory Cert. #:
551
Laboratory Name:
Townsend Water Treatment Plant
Inspection Type:
Municipal Maintenance
Inspector Name(s):
Beth Swanson
Inspection Date:
September 20, 2017
Date Forwarded for Initial
Review:
October 2, 2017
Initial Review by:
Anna Ostendorff
Date Initial Review
Completed:
October 4, 2017
Cover Letter to use:
❑ Insp. Initial ® Insp. Reg
❑Insp. No Finding ❑Insp. CP
❑Corrected
❑Insp. Reg. Delay
Unit Supervisor/Chemist III:
Dana Satterwhite
Date Received:
October 5, 2017
Date Forwarded to Admin.:
October 26, 2017
Date Mailed:
October 27, 2017
Special Mailing Instructions:

Water Resources
ENVIRONMENTAL QUALITY
October 27, 2017
551
Ms. Marie Shandor
Townsend Water Treatment Plant
6268 Bryan Park Road
Browns Summit, NC 27214
ROY COOPER
MICHEAL S. REGAN
S. JAY ZIMMERMAN
Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC)
Maintenance Inspection
Dear Ms. Shandor:
Enclosed is a report for the inspection performed on September 20, 2017 by Beth Swanson, 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,
Dana Satterwhite, Environmental Program Supervisor
Division of Water Resources
Attachment
cc: Beth Swanson, Master File #551

• • 1 . • •
LABORATORY NAME: Townsend Water Treatment Plant
NPDES PERMIT #: NCG590017 (NC0081671 prior to July 2017)
ADDRESS: 6268 Bryan Park Road
Browns Summit, NC 27214
CERTIFICATE #: 551
DATE OF INSPECTION: September 20, 2017
TYPE OF INSPECTION: Municipal Maintenance
AUDITOR(S): Beth Swanson
LOCAL PERSON(S) CONTACTED: Marie Shandor, Telora Kalu, Mark Hill Jr. and Tiffini Burlingame
I. INTRODUCTION:
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 2H .0800 for the analysis of environmental samples.
II. GENERAL COMMENTS:
The laboratory is spacious and neat. The records are well organized and easy to retrieve. All staff
were receptive to the inspection process and together they presented a work culture commitment
to quality.
All required Proficiency Testing (PT) Samples have been analyzed for the 2017 PT Calendar Year
and the graded results were 100% acceptable.
The laboratory submitted their Quality Assurance (QA) and/or Standard Operating Procedures
(SOP) document(s) in advance of the inspection. These documents were reviewed and editorial
and substantive revision requirements and recommendations were made by this program
outside of this formal report process. Although subsequent revisions were not requested to be
submitted, they must be completed by November 30, 2018.
The laboratory is reminded that any time changes are made to laboratory procedures, the
laboratory must update the QA/SOP document(s) and inform relevant staff. Any changes made
in response to the pre -audit review or to Findings, Recommendations or Comments listed in this
report must be incorporated to insure the method is being performed as stated, references to
methods are accurate, and the QA and/or SOP document(s) is in agreement with each
approved practice, test, analysis, measurement, monitoring procedure or regulatory
requirement being used in the laboratory. In some instances, the laboratory may need to create
an SOP to document how new functions or policies will be implemented.
The laboratory is also reminded that SOPs are intended to describe procedures exactly as they
are to be performed. Use of the word "should" is not appropriate when describing requirements

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(e.g., Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPs for the proper
use of the word "should".
Requirements that reference 15A NCAC 2H .0805 (a) (7) (A), stating "All analytical data pertinent
to each certified analysis must be filed in an orderly manner so as to be readily available for
inspection upon request", are intended to be a requirement to document information pertinent to
reconstructing final results and demonstrating method compliance. Use of this requirement is not
intended to imply that existing records are not adequately maintained unless the Finding speaks
directly to that.
Contracted analyses are performed by Meritech, Inc. (Certification # 165).
The most recent revisions of the 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
Comment: Temperature correction was not properly documented. The thermometer being used
for measuring the sample temperature at receipt had two different temperature corrections
documented. There were two stickers, one labeled with a correction of ±0A °C and one with ±0.8
°C. Per the thermometer calibration log, the actual correction is +0.8 °C, and that is the correction
the analyst has been using. NC WW/GW LC Policy states: The thermometer/meter readings must
be less than or equal to 10C from the NIST certified or NIST traceable thermometer reading. The
documentation must include the serial number of the NIST certified thermometer or NIST
traceable thermometer that was used in the comparison. Also document any correction that
applies (even if zero) on both the thermometer/meter and on a separate sheet to be filed.
Acceptable corrective action (i.e., the old stickers were removed and a new one with a correction
of +0.8 °C was affixed to the thermometer) was performed by the laboratory and approved by the
auditor during the inspection. No further response is necessary for this Finding.
A. Finding: The laboratory benchsheet is lacking pertinent data: value from the
measurement system.
Requirement: All laboratories must use printed laboratory bench worksheets that include
a space to enter the signature or initials of the analyst, date of analyses, sample
identification, volume of sample analyzed, value from the measurement system, factor and
final value to be reported and each item must be recorded each time samples are
analyzed. Ref: 15A NCAC 2H .0805 (a) (7) (H).
Requirement: All analytical data pertinent to each certified analysis must be filed in an
orderly manner so as to be readily available for inspection upon request. Ref: 15A NCAC
21-1.0805 (a) (7) (A).
Comment: The thermometer calibration log does not include units of measure (i.e., °C) for
temperature.
B. Finding: The laboratory needs to increase the traceability documentation of purchased
materials and reagents.
Requirement: All chemicals, reagents, standards and consumables used by the
laboratory must have the following information documented: Date received, Date Opened

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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. 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.
Requirement: Supporting records shall be maintained as evidence that these practices
are being effectively carried out. All analytical records must be available for a period of five
years. Ref: 15A NCAC 2H .0805 (a) (7) and (a) (7) (G).
Comment: The laboratory writes the date opened on reagent and consumable containers,
but not in an alternate location that can be retained for five years.
Quality Control
C. Finding: The laboratory does not report results of all tests on the characteristics of the
effluent when duplicate sample analyses are performed.
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 2B .0506 (b) (3) (J).
Comment: The first sample result is reported. The sample and duplicate may be
averaged and reported or the duplicate value must be reported in the comments section of
the eDMR.
Proficiency Testing
D. Finding: The laboratory is not documenting PT Sample analyses in the same manner as
routine Compliance Samples.
Requirement: As specified in 15 NCAC 2H .0800, in order to meet the minimum
standards for Certification, laboratories must use acceptable analytical methods. The
acceptable methods are those defined or referenced in the current State and federal
regulations for the environmental matrix being tested. All samples, (including PT
Samples) that are, or that may, be used for Certification purposes, must be analyzed using
approved methods only. All PT Samples are to be analyzed and the results reported in a
manner consistent with the routine analysis and reporting requirements of Compliance
Samples. Laboratories must document any exceptions. 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, May 31, 2017,
Revision 2.0.
E. Finding: The laboratory does not have a documented plan for PT procedures.
Requirement: Each laboratory shall develop and maintain a document outlining the
analytical quality control practices used for the parameters included in their certification.
Supporting records shall be maintained as evidence that these practices are being
effectively carried out. Ref: 15A NCAC 2H .0805 (a) (7).

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Requirement: Laboratories must have a documented plan (this is usually detailed in the
laboratory's Quality Assurance Manual or may be a separate SOP of how they intend to
cover the applicable program requirements for Proficiency Testing per their scope of
accreditation. This plan shall cover any commercially available PT Samples and any inter -
laboratory organized studies, as applicable. The laboratory must also be able to explain
when PT Sample analysis is not possible for certain methods and provide a description of
what the laboratory is doing in lieu of Proficiency Testing. This shall be detailed in the plan.
The plan must also address the laboratory's process for submission of PT results and
related Corrective Action Reports (CARs). Ref: Proficiency Testing Requirements, May 31,
2017, Revision 2.0.
F. Finding: Additional 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 Certified Parameter List (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, May 31, 2017, Revision 2.0.
Comment: The laboratory purchases an extra known QC standard to analyze with the PT
Sample.
G. 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 (e.g., pH), but it is recommended that the instructions be
maintained. Ref: Proficiency Testing Requirements, May 31, 2017, Revision 2.0.
Comment: Dating and initialing the instruction sheet for each prepared PT Sample would
satisfy the sample preparation documentation requirement.
Chlorine, Total Residual — Hach 10014 ULR (Aqueous)
Recommendation: It is recommended that Total Residual Chlorine (TRC) units be documented
as pg/L rather than mg/L, since that is the unit of measure from the meter and how the results are
reported on the electronic Discharge Monitoring Report.

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Recommendation: It is recommended that the row titled "LCS" be removed from the benchsheet,
since an additional standard is not needed beyond the daily check and it is no longer being
performed.
H. Finding: The laboratory is not generating a 3-standard calibration curve daily or a 5-
standard calibration curve every 12 months.
Requirement: For colorimetric analyses, a series of five standards for a curve prepared
annually or three standards for curves established each day or standards as set forth in
the analytical procedure must be analyzed to establish a standard curve. The curve must
be updated as set forth in the standard procedures, each time the slope changes by more
than 10 percent at mid -range, each time a new stock standard is prepared, or at least
every twelve months. Each analyst performing the analytical procedure must produce a
standard curve. Ref: 15A NCAC 2H .0805 (a) (7) (1).
Requirement: Annual Laboratory -generated Calibration Curve: Analyze a calibration
blank to zero the instrument and then analyze a series of five standard concentrations (not
counting the blank) that bracket the range of the sample concentrations to be analyzed.
The obtained values are programmed into the instrument, computer spreadsheet,
scientific calculator, or plotted manually. Sample results are obtained by comparison to the
linear regression of those values. The standard materials used must be of an acceptable
purity. Each analyst performing the test must have an individual calibration curve. This
type of curve must be performed annually (i.e., at least every 12 months). Ref: NC
WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine.
Comment: Prior to the inspection, a 5-standard calibration curve was last generated on
August 15, 2016.
Finding: The laboratory benchsheet is lacking pertinent data: value from the
measurement system.
Requirement: All laboratories must use printed laboratory bench worksheets that include
a space to enter the signature or initials of the analyst, date of analyses, sample
identification, volume of sample analyzed, value from the measurement system, factor and
final value to be reported and each item must be recorded each time samples are
analyzed. Ref: 15A NCAC 2H .0805 (a) (7) (H).
Requirement: All analytical data pertinent to each certified analysis must be filed in an
orderly manner so as to be readily available for inspection upon request. Ref: 15A NCAC
2H .0805 (a) (7) (A).
Comment: The laboratory analyzes a reagent blank per the Hach 10014 ULR procedure
and a manganese interference sample which are used to calculate the result for reporting.
The reagent blank and manganese sample results and the final calculated value to be
reported are documented on benchsheets, but the original sample reading from the meter
is not. This is needed to demonstrate that the calculations are performed correctly.
J. Finding: The laboratory benchsheet is lacking pertinent data: units of measure.
Requirement: All analytical data pertinent to each certified analysis must be filed in an
orderly manner so as to be readily available for inspection upon request. Ref: 15A NCAC
2H .0805 (a) (7) (A).

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Requirement: All laboratories must use printed laboratory bench worksheets that include
a space to enter the signature or initials of the analyst, date of analyses, sample
identification, volume of sample analyzed, value from the measurement system, factor and
final value to be reported and each item must be recorded each time samples are
analyzed. Ref: 15A NCAC 2H .0805 (a) (7) (H).
Comment: This Finding applies to the benchsheet where the reagent blank and
manganese interference readings are documented.
pH — Standard Methods, 4500 H+ B-2000 (Aqueous)
K. Finding: Instances were observed where the pH calibration check standard did not read
within ± 0.1 S.U. of the true value and no corrective action was taken.
Requirement: Use a pH meter accurate and reproducible to 0.1 pH unit (as
demonstrated daily by acceptable performance of a check standard buffer) with a range
of 0 to 14 and equipped with temperature -compensation adjustment. The meter must be
calibrated with at least two buffers. In addition to the calibration buffers, the meter
calibration must be verified with a third standard buffer solution. The calibration and
check standard buffers must bracket the range of the samples being analyzed. The
check standard buffer must read within ±0.1 S.U. to be acceptable. If the meter
verification does not read within ±0.1 S.U., the meter must be recalibrated before any
samples are analyzed. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH.
Comment: If the check buffer does not read within ±0.1 S.U., the lab should first try
pouring a new aliquot of the check buffer and reading it again. If it still does not read within
±0.1 S.U., the meter must be recalibrated. If, after recalibration, the check buffer does not
read within ±0.1 S.U., the meter and/or probe operation may be suspect and may require
servicing. If the laboratory does not have a back-up meter/electrode, or another
meter/electrode cannot be procured, the associated data must be qualified as an estimate
due to QC failure. Since this data may be considered non -compliant by the permitting
authority, it is recommended that the analysis be performed by another Certified
Laboratory until the problem is corrected.
pH — Standard Methods, 4500 H+ B-2000 (Aqueous)
Chlorine, Total Residual — Hach 10014 ULR (Aqueous)
Comment: Duplicate analyses are not required for pH and TRC.
L. Finding: The laboratory benchsheet was lacking pertinent data: instrument identification.
Requirement: All analytical data pertinent to each certified analysis must be filed in an
orderly manner so as to be readily available for inspection upon request. Ref: 15A NCAC
2H .0805 (a) (7) (A).
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 and NC WW/GW LC Approved Procedure for
the Analysis of pH.
Comment: The instrument ID is not listed on the results benchsheet for either parameter
and the pH meter is not consistently written on the calibration log, where there is a space
to document it.

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Residue, Suspended — Standard Methods, 2540 D-1997 (Aqueous)
M. Finding: The laboratory is not basing the reporting limit on the minimum weight gain
required by the method,
Requirement: Choose sample volume to yield between 2.5 and 200 mg dried residue. If
volume filtered fails to meet minimum yield, increase sample volume up to 1 L. Ref:
Standard Methods, 2540 D-1997 (3) (b).
Requirement: The minimum weight gain allowed by any approved method is 2.5 mg.
Choose sample volume to yield between 2.5 and 200 mg dried residue. This establishes a
minimum reporting value of 2.5 mg/L when 1000 mL of sample is analyzed. If complete
filtration takes more than 10 minutes increase filter diameter or decrease sample volume.
In instances where the weight gain is less than the required 2.5 mg, the value must be
reported as less than the appropriate value based upon the volume used. Ref: NC
WW/GW LC Policy.
Comment: As discussed at the inspection, if less than 1 L of sample is used and the
weight gain is less than 2.5 mg, the adjusted reporting limit is determined by the following
calculation: 2.5 mg *1000/ volume used in mL.
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 Townsend Water Treatment Plant (NPDES permit #
NC0081671) for March and June 2017 and (NPDES permit # NCG590017) for July 2017. No
transcription errors were observed. The facility appears to be doing a good job of accurately
transcribing data.
V. CONCLUSIONS:
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: Beth Swanson Date: October 2, 2017
Report reviewed by: Anna Ostendorff Date: October 4, 2017

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