NC0023604_Renewal (Application)_20230123

:Ali'o .
ROY COOPER , -
Governor
ELIZABETH S.BISER
Secretary
RICHARD E.ROGERS,JR. NORTH CAROLINA
Director Environmental Quality
January 23, 2023
Wilderness- NC, Inc.
Attn: Ronnie Bolt
PO Box 2136
Lexington, NC 27293
Subject: Permit Renewal
Application No. NC0023604
Wilderness-NC Lumber Plant
Davidson County
Dear Applicant:
The Water Quality Permitting Section acknowledges the January 23, 2023, receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150E-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deq.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
Sincerely,
/be--pittA/
Cynthia Demery
Administrative Assistant
Water Quality Permitting Section
ec: WQPS Laserfiche File w/application
D_E Q N Env Quality ivier e
Winorthston-SaleCarolinam Department Regional Offiofce 450 Wironmentalest Hanes Mill Road.D Suitesionof 300Wat WResourcinston-Ss
alem,North Carolina 27105
336.776.9800

_-4;14111"4"."" Wilderness-NC, Inc.�_ PO Box 2136
Lexington,NC 27293
336-474-2314
January 17, 2023
NC Department of Environment and Natural Resources
Division of Water Quality/NPDES Unit
1617 Mail Service Center
Raleigh, NC 2 7699-1 61 7
Subject: Request to Renew Permit
NPDES Permit NC0023604
Wilderness NC, Inc.
Lexington, North Carolina
Davidson County
To Whom It May Concern:
Wilderness NC, Inc. is requesting renewal of NPDES Permit NC0023604 in
accordance with Federal(40 FR 122.41) and North Carolina (15A CCAC 2H.0105 (e))
regulations. No changes have been made since the issuance of our last permit.
Wilderness NC, Inc.permit expires May 31, 2023.
You will find a renewal package attached with this letter. The following are included:
One signed cover letter requesting renewal of the permit.
Form 1 NPDES, Form 2FNPDES, a recent lab report, the 2019 permit renewal and
the 2019 Draft permit.
I have completed this as best that I can.
If I can be of any assistance,please feel free to call Belinda Milan at 336-474-2314.
RECEIVED Sincerely,
JAN 2 0 2023
Ronnie Bolt
NCDEQIDWRINPDES

Tuesday,January 17,2023 at 11:08:03 Eastern Standard Time
Subject: Re: Renewing NC0023604 Permit
Date: Thursday, December 15, 2022 at 3:30:44 PM Eastern Standard Time
From: Belinda Milan
To: Williams, Paul E
Attachments: image001.png
Do you have an email address, the phone is not going through
BELINDA MILAN
WILDERNESS NC, INC.
PHONE [phone] ext. 103
FAX [phone]
From: "Williams, Paul E" <[e-mail]>
Date:Thursday, December 15, 2022 at 9:21 AM
To: Belinda Milan <[e-mail]>
Subject: Renewing NC0023604 Permit
Belinda,
NPDES Wastewater permits are not processed out of the regional offices, only through Central Office. I am
attaching individual permit renewal information. If you will require further assistance, I would direct you to
contact the NPDES Permitting Branch at [phone].
Thank you, 1}1" `
C �llOt'k kS 1 Qr1IC ° CJ'l
Paul Williams , (1)e J c
b 5 1 5 i Jn Environmental Assistance Coordinator
Winston Salem Regional Office
North Carolina Department of Environmental Quality
Office: [phone]
[e-mail]
1 .11:)1 E Qief)
NC)H I H L AH LINA
Department of Environmental Duality
Email subject correspondence to and from this address is ect to the North
p l
Carolina Public Records Law and may be disclosed to third parties.
Page 1of1

Tuesday,January 17, 2023 at 11:26:34 Eastern Standard Time
Subject: RE: [External] Re: Renewing NC0023604 Permit
Date: Thursday, December 15, 2022 at 3:42:11 PM Eastern Standard Time
From: Williams, Paul E
To: Belinda Milan
Attachments: image002.png, image003.png
I do not have any specific individual contact information,for their unit. I did find secondary front desk
number. It is [phone]. + N p I I2 Z c-
Thank you, t Ifr$
Paul Williams
Environmental Assistance Coordinator
Winston Salem Regional Office
North Carolina Department of Environmental Quality
Office: [phone]
[e-mail]
I Q
Department of Environmental Quality
Email correspondence to and from this address is subject to the North
Carolina Public Records Law and may be disclosed to third parties.
From: Belinda Milan <[e-mail]>
Sent:Thursday, December 15, 2022 3:31 PM
To: Williams, Paul E<[e-mail]>
Subject: [External] Re: Renewing NC0023604 Permit
CAUTION:External email. Do not click links or open attachments unless you verify.Send all suspicious email as an
attachment to Report Spam.
Do you have an email address,the phone is not going through
BELINDA MILAN
WILDERNESS NC, INC.
PHONE [phone] ext. 103
FAX [phone]
Page 1 of 2

From: "Williams, Paul E" <[e-mail]>
Date:Thursday, December 15, 2022 at 9:21 AM
To: Belinda Milan <[e-mail]>
Subject: Renewing NC0023604 Permit
Belinda,
NPDES Wastewater permits are not processed out of the regional offices, only through Central Office. I am
attaching individual permit renewal information. If you will require further assistance, I would direct you to
contact the NPDES Permitting Branch at [phone].
Thank you,
Paul Williams
Environmental Assistance Coordinator
Winston Salem Regional Office
North Carolina Department of Environmental Quality
Office: [phone]
[e-mail]
11°1111111.111:1YE
NOH I H CAROLINA
Department of Environmental Quality
Email correspondence to and from this address is subject to the North
Carolina Public Records Law and may be disclosed to third parties.
Page 2 of 2

Tuesday,January 17, 2023 at 11:09:40 Eastern Standard Time
Subject: waste water permit NC0023604
Date: Monday,January 9, 2023 at 3:00:07 PM Eastern Standard Time
From: Belinda Milan
To: [e-mail] O s cri5 —
Joe,
I am trying to renew the waste water permit for Wilderness NC, Inc. I am having difficulties navigating the
forms that need to be filled out.The last renewal that I did was on short form C—minor industrial. I filled
out the forml NPDES and then it tells me to go to form 2S,this form is 23 pages long and I have no clue on
some of the information that is being asked. My number is 336-474-2314. I would appreciate your help on
this.
Thank you,
BELINDA MILAN
WILDERNESS NC, INC.
PHONE [phone] ext. 103Nicy� cK�cK 1; .1,� �, ,c�m2r FAX [phone] �n� nice
qlq- 1o7- 3(0t7
Page 1 of 1

Tuesday,January 17, 2023 at 11:10:13 Eastern Standard Time
Subject: Wilderness Nc Inc permit renewal
Date: Wednesday,January 11, 2023 at 8:59:27 AM Eastern Standard Time
From: Belinda Milan
0/9a To: _. [e-mail], [e-mail], [e-mail],
Liz"" Vv� [e-mail], [e-mail], [e-mail],
Me55u 1
,2eLua,� CN-d- [e-mail]
1 Attachments: 2019 PERMIT RENEWAL APPLICATION.pdf, CURRENT PERMIT.pdf, FORM 1.pdf, FORM 2F.pdf
,q•-log- 36715
I have been trying since the beginning of November to get help with this renewal and have not had any luck
in getting in touch with anyone. I am attaching the last permit renewal, the current permit and for 1 NPDES
and what I have filled out on form 2F NPDES. I am at a loss on how to proceed further
BELINDA MILAN 1 `� ,.
WILDERNESS NC, INC. A (:) I�S?o asC,
PHONE [phone] ext. 103
FAX [phone] iv'L
Page 1 of 1

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0023604 OMB No.2040-0004
U.S.Environmental Protection Agency
Form Application for NPDES Permit to Discharge Wastewater
NPDES �"�EPA
GENERAL INFORMATION
SECTION 1.ACTIVITIES REQUIRING AN NPDES PERMIT(40 CFR 122,21(f)and(f)(1))
1.1 Applicants Not Required to Submit Form 1
Is the facility a new or existing publicly owned Is the facility a new or existing treatment works
1.1.1 treatment works? 1.1.2 treating domestic sewage?
If yes, STOP. Do NOT complete 0 No If yes,STOP. Do NOT 1E No
Form 1.Complete Form 2A. complete Form 1.Complete
Form 2S.
1.2 Applicants Required to Submit Form 1
1.2.1 Is the facility a concentrated animal feeding 1.2.2 Is the facility an existing manufacturing,
operation or a concentrated aquatic animal commercial,mining,or silvicultural facility that is
a. production facility? currently discharging process wastewater?
p [] Yes-) Complete Form 1 No ❑ Yes 3 Complete Form 0 No
a- and Form 2B. 1 and Form 2C.
1.2.3 Is the facility a new manufacturing,commercial, 1.2.4 Is the facility a new or existing manufacturing,
co
mining,or silvicultural facility that has not yet commercial,mining,or silvicultural facility that
commenced to discharge? discharges only nonprocess wastewater?
m Yes -) Complete Form 1 No 0 Yes 4 Complete Form �✓ No
a and Form 2D. 1 and Form 2E.
1.2.5 Is the facility a new or existing facility whose
discharge is composed entirely of stormwater
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
0 Yes 4 Complete Form 1 [] No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x)or
b 15 .
SECTION 2. NAME, MAILING ADDRESS,AND LOCATION(40 CFR 122.21(f)(2))
2.1 Facility Name
Wilderness NC,Inc.
0 2.2 EPA Identification Number
m
0
m 2.3 Facility Contact
Name(first and last) Title Phone number
-a
Ronnie D Bolt Owner [phone]
Email address
[e-mail]
2.4 Facility Mailing Address
co Street or P.O.box
PO Box 2136 _
City or town State ZIP code
Lexington NC 27293
Page 1
EPA Form 3510-1(revised 3-19)

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05119
NC0023604 OMB No.2040-0004
3 2.5 Facility Location
E.' Street,route number,or other specific identifier
a 0 7578 115 HWY 64 East
rn
_ c County name County code(if known)
RI 'lit Davidson
City or town State ZIP code
at
Z Thomasville NC 27360
SECTION 3.SIC AND NAICS CODES(40 CFR 122.21(f)(3))
3.1 SIC Code(s) Description(optional)
321912-32113
0
0
c.)
U)
U
z 3.2 NAICS Code(s) Description(optional)
as
U
U)
SECTION 4. OPERATOR INFORMATION(40 CFR 122.21(f)(4))
4.1 Name of Operator
Ronnie D Bolt
O 4.2 Is the name you listed in Item 4.1 also the owner?
® Yes ❑ No
• 4,3 Operator Status
b ❑ Public—federal ❑Public—state ❑ Other public(specify)
0 0 Private ❑ Other(specify)
4.4 Phone Number of Operator
[phone]
4.5 Operator Address
o Street or P.O.Box
g PO Box 2136
c y City or town State ZIP code
o v Lexington NC 27293
Q Email address of operator
O [e-mail]
SECTION 5. INDIAN LAND(40 CFR 122.21(f)(5))
0 5.1 Is the facility located on Indian Land?
713 2 ❑Yes ❑✓ No
EPA Form 3510-1(revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03105/19
NC0023604 OMB No.2040-0004
SECTION 6.EXISTING ENVIRONMENTAL PERMITS(40 CFR 122.21(f)(6))
6.1 Existing Environmental Permits(check all that apply and print or type the corresponding permit number for each)
m NPDES(discharges to surface ❑ RCRA(hazardous wastes) ❑ UIC(underground injection of
inwater) fluids)
NCG210295
w co ❑ PSD(air emissions) ❑ Nonattainment program(CM) ❑ NESHAPs(CM)
w ❑ Ocean dumping(MPRSA) ❑ Dredge or fill(CWA Section 404) ❑✓ Other(specify)
Air permit 02916R24
SECTION 7. MAP (40 CFR 122.21(f)(7))
7.1 Have you attached a topographic map containing all required information to this application?(See instructions for
0. specific requirements.)
2
❑✓ Yes ❑ No ❑CAFO—Not Applicable(See requirements in Form 2B.)
SECTION 8. NATURE OF BUSINESS(40 CFR 122.21(f)(8))
8.1 Describe the nature of your business.
Green lumber is brought to Wilderness NC,Inc by different vendors to be kiln dried. The lumber will run through the
N stacker line where it is put on sticks and counted. It is tagged with the name of customer,the type,grade,thickness
cand species of lumber. The lumber is then placed in the kiln to dry. When taken out of the kiln the lumber is taken
off sticks graded and repacked according to species,grade and length. We then store the lumber until it ships.
m
0
w
SECTION 9.COOLING WATER INTAKE STRUCTURES(40 CFR 122.21(f)(9))
9.1 Does your facility use cooling water?
❑ Yes ❑✓ No 4 SKIP to Item 10.1.
CO E. 9.2 Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r).Consult with your
NPDES permitting authority to determine what specific information needs to be submitted and when.)
o .
o as
U c
SECTION 10.VARIANCE REQUESTS(40 CFR 122.21(f)(10))
10.1 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)?(Check all that
apply.Consult with your NPDES permitting authority to determine what information needs to be submitted and
when.)
❑ Fundamentally different factors(CWA ❑ Water quality related effluent limitations(CWA Section
a Section 301(n)) 302(b)(2))
[l Non-conventional pollutants(CWA (] Thermal discharges(CWA Section 316(a))
.03
Section 301(c)and(g))
✓❑ Not applicable
Page 3
EPA Form 3510-1(revised 3-19)

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0023604
OMB No.2040-0004
SECTION 11.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and (d))
11.1 In Column 1 below,mark the sections of Form 1 that you have completed and are submitting with your application.
For each section,specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 9 Column 2
❑ Section 1:Activities Requiring an NPDES Permit ❑ w/attachments
❑ Section 2:Name, Mailing Address,and Location ❑ w/attachments
❑ Section 3:SIC Codes ❑ w/attachments
El Section 4:Operator Information ❑ w/attachments
❑ Section 5:Indian Land ❑ w/attachments
❑ Section 6:Existing Environmental Permits ❑ w/attachments
w/topographic
El Section 7:Map ❑ map ❑ wl additional attachments
o ElSection 8:Nature of Business El w/attachments
❑ Section 9:Cooling Water Intake Structures ❑ wl attachments
❑ Section 10:Variance Requests ❑ w/attachments
y ❑ Section 11:Checklist and Certification Statement ❑ wl attachments
YC
11.2 Certification Statement
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 fine and imprisonment for knowing violations.
Name(print or type first and last name) Official title
r.r�nnt o l Ot.YAQ. ,
Signature Date signed
VI 7/a.3
;KZ
RECEIVED
BAN 2 0 2023
NQDEQ/DWR/NP
s
Page 4
EPA Form 3510-1(revised 3-19)

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0023604 Wilderness NC,Inc OMB No.2040-0004
Form U.S Environmental Protection Agency
2F c EPA Application for NPDES Permit to Discharge Wastewater
NPDES STORMWATER DISCHARGES ASSOCIATED WITH INDUSTRIAL ACTIVITY
SECTION 1.OUTFALL LOCATION (40 CFR 122.21(g)(1))
1.1 Provide information on each of the facilit 's outfalls in the table below
Outfall Receiving Water Name Latitude Longitude
Number
001 UT to Flat Swamp Creek 35° 46' 39" 80° 07' 12"
C
0
002 UT to Flat Swamp Creek 35° 46' 31" 80° 07' 13"
0
0
SECTION 2. IMPROVEMENTS(40 CFR 122.21(g)(6))
2.1 Are you presently required by any federal,state,or local authority to meet an implementation schedule for constructing,
upgrading,or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
❑ Yes ❑✓ No 4 SKIP to Section 3.
2.2 Briefly identify each applicable project in the table below.
Brief Identification and Affected Outfalls Final Compliance Dates
Source(s)of Discharge
Description of Project (list outfall numbers)
Required Projected
y
w
C
N
E:
a)
O
Q.
describing anyadditional waterpollution control programs(or other environmental projects
2.3 Have you attached sheets desc g p g
that may affect your discharges)that you now have underway or planned?(Optional Item)
❑ Yes ❑✓ No
EPA Form 3510-2F(Revised 3-19) Page 1

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0023604 Wilderness NC,Inc OMB No.2040-0004
SECTION 3.SITE DRAINAGE MAP(40 CFR 122.26(c)(1)(i)(A))
c 3.1 Have you attached a site drainage map containing all required information to this application?(See instructions for
4 specific guidance.)
CO R M
® Yes ❑ No
SECTION 4. POLLUTANT SOURCES(40 CFR 122.26(c)(1)(i)(B))
4.1 Provide information on the facility's pollutant sources in the table below.
Outfall Impervious Surface Area Total Surface Area Drained
Number (within a mile radius of the facility) (within a mile radius of the facility)
specify units specify units
001
specify units specify units
002
specify units specify units
specify units specify units
specify units specify units
specify units specify units
4.2 Provide a narrative description of the facility's significant material in the space below. (See instructions for content
requirements.)
y
O
co
co
O
a
4.3 Provide the location and a description of existing structural and non-structural control measures to reduce pollutants in
stormwater runoff. (See instructions for specific guidance.)
Stormwater Treatment
Codes
Outfall from
Number Control Measures and Treatment Exhibit
2F-1
(list)
EPA Form 3510-2F(Revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0023604 Wilderness NC,Inc OMB No.2040-0004
SECTION 5. NON STORMWATER DISCHARGES(40 CFR 122.26(c)(1)(i)(C))
5.1 I certify under penalty of law that the outfall(s) covered by this application have been tested or evaluated for the
presence of non-stormwater discharges. Moreover, I certify that the outfalls identified as having non-stormwater
discharges are described in either an accompanying NPDES Form 2C, 2D,or 2E application.
Name(print or type first and last name) Official title
Signature Date signed
a> 5.2 Provide the testing information requested in the table below.
Onsite Drainage Points
Outfall
Description of Testing Method Used Date(s)of Testing Directly Observed
Number During Test
d
co
E
0
0
-
SECTION 6.SIGNIFICANT LEAKS OR SPILLS(40 CFR 122.26(c)(1)(i)(D))
6.1 Describe any significant leaks or spills of toxic or hazardous pollutants in the last three years.
Q none
U)
0
N
l6
J
U
:t-
0)
N
SECT1011 7. DISCHARGE INFORMATION (40 CFR 122.26(c)(1)(i)(E))
See the instructions to determine the pollutants and parameters you are required to monitor and,in turn,the tables you must
o complete. Not all applicants need to complete each table.
7.1 Is this a new source or new discharge?
o ❑ Yes 4 See instructions regarding submission of ❑✓ No 4 See instructions regarding submission of
estimated data. actual data.
cu
E Tables A,B,C,and D
7.2 Have you completed Table A for each outfall?
❑ Yes ❑ No
EPA Form 3510-2F(Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0023604 Wilderness NC,Inc OMB No.2040-0004
7.3 Is the facility subject to an effluent limitation guideline(ELG)or effluent limitations in an NPDES permit for its process
wastewater?
0 Yes ❑ No 4 SKIP to Item 7.5.
7.4 Have you completed Table B by providing quantitative data for those pollutants that are(1)limited either directly or
indirectly in an ELG and/or(2)subject to effluent limitations in an NPDES permit for the facility's process wastewater?
❑ Yes ❑ No
7.5 Do you know or have reason to believe any pollutants in Exhibit 2F-2 are present in the discharge?
❑ Yes ✓❑ No 4 SKIP to Item 7.7.
7.6 Have you listed all pollutants in Exhibit 2F-2 that you know or have reason to believe are present in the discharge and
provided quantitative data or an explanation for those pollutants in Table C?
❑ Yes ❑ No
7.7 Do you qualify for a small business exemption under the criteria specified in the Instructions?
❑ Yes +SKIP to Item 7.18. ✓❑ No
7.8 Do you know or have reason to believe any pollutants in Exhibit 2F-3 are present in the discharge?
❑ Yes ❑✓ No 4 SKIP to Item 7.10.
d 7.9 Have you listed all pollutants in Exhibit 2F-3 that you know or have reason to believe are present in the discharge in
Table C?
o ❑ Yes ❑ No
O 7.10 Do you expect any of the pollutants in Exhibit 2F-3 to be discharged in concentrations of 10 ppb or greater?
w
0 Yes ❑✓ No 4 SKIP to Item 7.12.
7.11 Have you provided quantitative data in Table C for those pollutants in Exhibit 2F-3 that you expect to be discharged in
o> concentrations of 10 ppb or greater?
❑ Yes ❑ No
7.12 Do you expect acrolein, acrylonitrile,2,4-dinitrophenol,or 2-methyl-4,6-dinitrophenol to be discharged in concentrations
of 100 ppb or greater?
❑ Yes ❑✓ No 4 SKIP to Item 7.14.
7.13 Have you provided quantitative data in Table C for the pollutants identified in Item 7.12 that you expect to be
discharged in concentrations of 100 ppb or greater?
❑ Yes ❑ No
7.14 Have you provided quantitative data or an explanation in Table C for pollutants you expect to be present in the
discharge at concentrations less than 10 ppb(or less than 100 ppb for the pollutants identified in Item 7.12)?
❑ Yes ❑ No
7.15 Do you know or have reason to believe any pollutants in Exhibit 2F-4 are present in the discharge?
❑ Yes ❑✓ No 4 SKIP to Item 7.17.
7.16 Have you listed pollutants in Exhibit 2F-4 that you know or believe to be present in the discharge and provided an
explanation in Table C?
❑ Yes ❑ No
7.17 Have you provided information for the storm event(s)sampled in Table D?
❑ Yes ❑ No
EPA Form 3510-2F(Revised 3-19) Page 4

Pace Analytical Services,LLC
aceAnalytical 1377 South Park Drive
/arKernersville,NC 27284
www.pacelabs.com [phone]
Page 1 of 1
Laboratory Report
Accounts Pa able Report Date: 01/11/2023
y Wilderness NC, Inc. Date Received: 01/04/2023
P.O. Box 2136
Lexington, NC 27292
Project: Wilderness NC
Pace Project No.:92644854
Sample: Effluent Lab ID: 92644854001 Collected: 01/04/23 09:00 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
SM 2540D-2015 Total Suspended Solids ND mg/L 2.5 01/06/23 09:02
EPA 350.1 Rev 2.0 1993 Nitrogen,Ammonia ND mg/L 0.10 01/09/23 13:00
SM 5210B-2016 BOD,5 day ND mg/L 2.0 01/10/23 14:46 B2
Colilert-18 Fecal Coliforms 1.0 MPN/100mL 1.0 01/05/23 10:17
ANALYTE QUALIFIERS
B2 Oxygen usage is less than 2.0 for all dilutions set. The reported value is an estimated less than value and is calculated
for the dilution using the most amount of sample.
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Pace Analytical Services Eden
205 East Meadow Road Suite A,Eden, NC 27288 North Carolina Wastewater Certification#:633
North Carolina Drinking Water Certification#:37738 VirginiaNELAP Certification#:460025
Page 1 of 4

CHAIN-OF-CUSTODY / Analytical ReqiioQt nnrlfmant
. ace The Chain-of-Custody is a LEGAL DOCUMENT.All relevai �JO# : 92644854
I Submitting a sample via this chain of custody constitutes acknowledgment and acceptance of the Pace Terms and Conditions found at
Section A Section B Section C
Required Client Information: Required Project Information: Invoice Information: III I
I HIM
I 111
III
D
Company. Wilderness NC,Inc Report To David Perdue Attention:
Address 313 New Cut Road Copy To'. Company Name: 92644854
Lexington,NC 27292 Address:
Email [e-mail] Purchase Order#. Pace Quote
Phone'. JFax: \Project Name: Weeky Bottles Pace Project Manager: stephanie.knotti pacelabs corn, Stator Location
Requested Due Date. Project#i Pace Profile it; TBD I NC
Requested Analysis Filtered(YIN
III a 2
o O COLLECTED Preservatives >-,
MATRIX CODE V z
Drinking Water Ow E 6 O
Wafer WT a
Waste Water WW _ * Z
Product P N j-
SAMPLE ID o�5v° OL START END o In M al
One Character per box. ate a P w w a z to la
(A-Z,0-9/,-) other OT o t m w a m en >. U
8 •i * Sample Ids must be unique Trssu8 TS w a z 0 U°' oc . a
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m DATE TIME DATE Nit
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ADDI IIONAL COMMf:NTS RELINQUISHED BY/AFFILIATION 1` DATE TIME ACCEPTED BY/AFFILIATION DATE TIME SAMPLE CONDITIONS
{ l LAP, /- - 3 'f! ��� ,,_ )" ,.t x, 7-`/-23 `?: r4
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o t SAMPLER NAME AND SIGNATURE U o in c
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IV PKINT Name of SAMPLER:'-�:V t - a o a5.-- a-..
A SIGNATURE of SAMPLER; (�"`j DATE Signed: � `� w c43.t>- °o>- m y

f=dace Upon Receipt
i •••^cu:1"r• Effective Date:05/12.2022
Laboratory receiving samples:
Asheville L_ Eden � Greenwood n Huntersvil(e Raleigh I Mechanicsville Atianta:1 Kernersvilie
Zil
Client Nam e•
Project r.
„\j i H e Yoe s �(
Courier: Fed Ex ❑UPS CUSPS CCIi_nt
❑Commercial EPaz ❑Other:
Carrier Tracking Number:
Custody Seal Present? Dyes 21,13 Seas Intact? ❑Yes ONo. H S
Date/Initials initials Person Examining Contorts:
Packing Material: DEubble Wrap DEu
—c!e 2a-, •,acne Ei Other Biological Tissue Frozen?
[lees DNa On,'A
Thermometer: D IR Gun ID: 12_ l'O ° Type of Ica: 2Wet Blue N^
ne
Cooler Temp('C): �' / Correction Factor:Add/Subtrazt('C) .— 4
Temp should be above freezing to 6*C
3 - 9 ❑
Corrected Cooler Temp('C): 5.arr.pies cut of temp criteria.Samples cn ice,cooling pyres;
has begun
USDA Regulated Soil(9 N/A,weter sample)
Cid sample;originate in a quarantine zone within the United States:CA,PIY,cr SC(check maps)? Cid samples criginata
❑Yes I_iNo from;far=_ign source(internationally,
irciud.ag Hawaii and Puerto R.co)?Dyes ❑;io
II Comments;Ciscreoane/:
Chain cf Custody Present? es ❑Nc flirt/A 11.
Sam;les Arrived within Hold Time? ayes Elmo D1N',: 12.r-,.
Short Hold Time Analysis(< t
72 hr.)? r-es DNo EN/A I 3.
Rush Turn Around Time Rscuested? Eves [i io ❑N/A 14.
Sufficient Volume? [27es flu DN/A 15,
Correct Containers Used? Q`res D,Na ❑N/A 6.
-Pace Containers Used? 2Yes No Dt'A
Containers intact? LC-:es No Q;t.'A 17.
Dissolved analysis:Samples Field Filtered.? Eves Drio r7rtu., 18.
Sample Labels Match COC? Q'?es ❑too ON/A 9.
-Includes Date/Time./ID/Analysis Matrix: 7
Headsaace in VOA Vials(>5-5mm)? Dyes DNoi/A 10.
Trip Blank Present? Dyes Dna
Trip Blank Custody Seals Present? Dyes DFIaLrfN/A
COMMENTS/SAMPLE DISCREPANCY Field Data Required? Dyes DNo
Lot ID of split containers:
Temp Log:Temp must be maintained CLIENT NOTIFICATION/RESOLUTION
at<S C during login,record temp -
every 20 minutes.
Time opened:11 1 () Temp: Li,
f
Time: ( ( .4 0 put in cooler
Time: Temp:
Person Contacted: _____.___._.
Da±errime:
Project Manager SCURF Review: Date:
Project Manager SRF Review: Date:
Qua)ttrax Document ID:70677 Page 1 of 2
Page 3 of 4

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A r
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A

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0023604 Wilderness NC,Inc OMB No.2040-0004
a Used or Manufactured Toxics
2 7.18 Is any pollutant listed on Exhibits 2F-2 through 2F-4 a substance or a component of a substance used or
manufactured as an intermediate or final product or byproduct?
0
❑ Yes ❑✓ No 4 SKIP to Section 8.
0
7.19 List the pollutants below, including TCDD if applicable.
1. 4. 7.
2. 5. 8.
0 3. 6. 9.
SECTION 8. BIOLOGICAL TOXICITY TESTING DATA(40 CFR 122.21(g)(11))
8.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made on
any of your discharges or on a receiving water in relation to your discharge within the last three years?
co
❑ Yes ❑✓ No 4 SKIP to Section 9.
u 8.2 Identify the tests and their purposes below.
>, Submitted to NPDES
u Date Submitted Test(s) Purpose of Test(s)
Permitting Authority?
'— ❑ Yes ❑ No
o ❑ Yes ❑ No
❑ Yes ❑ No
SECTION 9.CONTRACT ANALYSIS INFORMATION(40 CFR 122.21(g)(12))
9.1 Were any of the analyses reported in Section 7(on Tables A through C)performed by a contract laboratory or
consulting firm?
0 Yes ❑ No 4 SKIP to Section 10.
9.2 Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1 Laboratory Number 2 Laboratory Number 3
Name of laboratory/firm
c
0
E
Laboratory address
f0
0
V
o Phone number
U
Pollutant(s)analyzed
EPA Form 3510-2F(Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0023604 Wilderness NC,Inc OMB No.2040-0004
SECTION 10.CIfCKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
10.1 In Column 1 below,mark the sections of Form 2F that you have completed and are submitting with your application. For
each section,specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not
all applicants are required to complete all sections or provide attachments.
Column 1 Column 2
❑ Section 1 ❑ w/attachments(e.g.,responses for additional outfalls)
❑ Section 2 ❑ w/attachments
❑ Section 3 ❑ wl site drainage map
❑ Section 4 ❑ w/attachments
❑ Section 5 ❑ w/attachments
❑ Section 6 ❑ w/attachments
❑ Section 7
0 Table A ❑ w/small business exemption request
co
c ❑ Table B ❑ w/analytical results as an attachment
w ❑ Table C ❑ Table D
❑ Section 8 ❑ w/attachments
o ❑ Section 9 ❑ w/attachments(e.g., responses for additional contact laboratories or firms)
tce
CD ❑ Section 10 ❑
U
10.2 Certification Statement
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 fine
and imprisonment for knowing violations.
Name(print or type first and last name) Official title
Rar}n« D 73014 6t
Signature Date signed
- � i//7/2,3
EPA Form 3510-2F(Revised 3-19) Page 6

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NC0023604 Wilderness NC,Inc OMB No.2040-0004
TABLE A. CONVENTIONAL AND NON CONVENTIONAL PARAMETERS(40 CFR 122.26(c)(1)(i)(E)(3))l
You must provide the results of at least one analysis for every pollutant in this table. Complete one table for each outfall. See instructions for additional details and requirements.
Maximum Daily Discharge Average Daily Discharge Source of
(specify units) (specify units) Number of Storm Information
Pollutant or Parameter Grab Sample Taken Flow-Weighted Grab Sample Taken Flow-Weighted Events Sampled (new sourcelnew
During First During First dischargers only;use
30 Minutes Composite 30 Minutes Composite codes in instructions)
1. Oil and grease
2. Biochemical oxygen demand(BOD5)
Total3. Chemical oxygen demand(COD)
4. Total suspended solids(TSS)
5. phosphorus
7. Total nitrogen(as N)
pH (minimum)
8.
pH (maximum)
1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e., methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I,subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2F(Revised 3-19) Page 7

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NC0023604 Wilderness NC, Inc OMB No.2040-0004
TABLE B. CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.26(c)(1)(i)(E)(4)and 40 CFR 122.21(g)(7)(vi)(A))1
List each pollutant that is limited in an effluent limitation guideline(ELG)that the facility is subject to or any pollutant listed in the facility's NPDES permit for its process wastewater(if the
facility is operating under an existing NPDES permit).Complete one table for each outfall. See the instructions for additional details and requirements.
Maximum Daily Discharge Average Daily Discharge Source of
(specify units) (specify units) Number of Storm Information
Pollutant and CAS Number(if available) Grab Sample Taken Flow-Weighted Grab Sample Taken Flow-Weighted Events Sampled (new source/new
During First During First dischargers only;use
30 Minutes Composite 30 Minutes Composite codes in instructions)
1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e., methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2F(Revised 3-19) Page 9

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NC0023604 Wilderness NC, Inc OMB No.2040-0004
TABLE C.TOXIC POLLUTANTS,CERTAIN HAZARDOUS SUBSTANCES,AND ASBESTOS(40 CFR 122.26(c)(1)(i)(E)(4)and 40 CFR 122.21(g)(7)(vi)(B)and(vii))'
List each pollutant shown in Exhibits 2F-2, 2F-3,and 2F-4 that you know or have reason to believe is present.Complete one table for each outfall.See the instructions for additional
details and requirements.
Maximum Daily Discharge Average Daily Discharge Source of
(speci units) (specify units) Number of Storm Information
Pollutant and CAS Number(if available) Grab Sample Taken Grab Sample Taken (new source/new
During First Flow-Weighted During First Flow-Weighted Events Sampled dischargers only;use
30 Minutes Composite 30 Minutes Composite codes in instructions)
1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e., methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2F(Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility name Outfall Number Form Approved 03/05/19
NC0023604 Wilderness NC, Inc OMB No.2040-0004
TABLE D. STORM EVENT INFORMATION (40 CFR 122.26(c)(1)(i)(E)(6))
Provide data for the storm event(s)that resulted in the maximum daily discharges for the flow-weighted composite sample.
Number of Hours Between
Duration of Storm Event Total Rainfall During Beginning of Storm Measured and Maximum Flow Rate Total Flow from Rain Event
Date of Storm Event (in hours) Storm Event End of Previous Measurable Rain During Rain Event (in gallons or specify units)
(in inches) Event (in gpm or specify units)
Provide a description of the method of flow measurement or estimate.
EPA Form 3510-2F(Revised 3-19) Page 13