#5158_2023_0112_JP_FINAL

NC Department of Environmental Quality | Division of Water Resources | Laboratory Certification Branch
4405 Reedy Creek Road | 1623 Mail Service Center | Raleigh, North Carolina 27699-1623
919-733-3908

February 16, 2023

5158
Mr. Darrell J. Covington
Topsail Greens Subdivision
P.O. Box 70
Hampstead, NC 28443

Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC
WW/GW LCB) Maintenance Inspection

Dear Mr. Covington:

Enclosed is a report for the inspection performed on January 12, 2023 by Jill Puff. Where
Finding(s) are cited in this report, a response is required. Within thirty days, 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 02H .0800.

A copy of the laboratory’s Certified Parameter List at the time of the audit is attached. This list will
not 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 have questions or need additional information, please contact me at (919) 733-
3908 Ext. 251.

Sincerely,

Anna Ostendorff
Technical Assistance & Compliance Specialist
Division of Water Resources

Attachment
cc: Todd Crawford, Jill Puff, Master File #5158

On-Site Inspection Report

LABORATORY NAME: Topsail Greens Subdivision
COUNTY SUBSURFACE PERMIT #: Pender County #487797
ADDRESS: Topsail Greens Subdivision
CERTIFICATE #: 5158
DATE OF INSPECTION: January 12, 2023
TYPE OF INSPECTION: Field Maintenance
AUDITOR(S): Jill Puff

LOCAL PERSON(S) CONTACTED:

Darrell Covington

I. INTRODUCTION:

This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory
Certification Branch (NC WW/GW LCB) to verify its compliance with the requirements of 15A NCAC 02H
.0800 for the analysis of compliance monitoring samples.

II. GENERAL COMMENTS:

The facility is neat and well organized and has all the equipment necessary to perform the analyses. The
analyst was forthcoming and responded well to suggestions from the auditor.

All required Proficiency Testing (PT) Samples have been analyzed for the 2022 PT Calendar Year and the
graded results were 100% acceptable.

Any time changes are made to laboratory procedures, Quality Assurance (QA) and/or Standard Operating
Procedure (SOP) document(s) must be updated and relevant staff retrained. Staff must acknowledge that
they have read and understand the changes as part of the documented training program. The same
requirements apply when changes are made in response to Findings, Recommendations or Comments
listed in this report, to ensure the methods are 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. Revisions to the SOPs, based on the Findings, Comments and Recommendations
within this report must be submitted to this office by July 31, 2023.

The laboratory is reminded that SOPs are required to be reviewed at least every two years and are intended
to describe procedures exactly as they are to be performed. Use of the word “should” is not appropriate when
describing requirements (e.g., Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPs
for the proper use of the word “should”.

Contracted analyses are performed by Environmental Chemists, Inc. (Certification # 94).
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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: The laboratory benchsheet is lacking required documentation: the method or
Standard Operating Procedure reference.

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. Each item shall be recorded each time samples are analyzed. Analyses
shall conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC
02H .0805 (g) (2) (A).

B. Finding: The laboratory benchsheet is lacking required documentation: the 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 instrument
identification. Each item shall be recorded each time samples are analyzed. Analyses shall
conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H
.0805 (g) (2) (C).

Comment: This Finding applies to pH and Temperature.

C. Finding: The units of measure for pH (i.e., Standard Units or S.U.) are not documented on
the calibration log.

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) (L).

D. Finding: The laboratory is not documenting traceability information for purchased materials,
reagents and standards.

Requirement: 15A NCAC 02H .0805 (a) (7) (K) and (g) (7) requires laboratories to have a
documented system of traceability for the purchase, preparation, and use of all chemicals,
reagents, standards, and consumables. That system must include documentation of the
following information: 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 LCB Traceability Documentation Requirements for Chemicals, Reagents,
Standards and Consumables Policy.

Comment: This Finding applies to pH.
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E. Finding: Chemical containers are not dated when received and when opened.

Requirement: Chemical containers shall be dated when received and when opened. Ref:
15A NCAC 02H .0805 (g) (7).

F. Finding: All analytical records are not consistently maintained for five years.

Requirement: All analytical records, including original observations and information
necessary to facilitate historical reconstruction of the calculated results, shall be maintained
for five years. Ref: 15A NCAC 02H .0805 (g) (1).

Comment: The benchsheets for July and October 2022 were not available for review. The
laboratory recently had an abrupt change in staff and those benchsheets were not returned
to the current operator.

Recommendation: It is recommended that the laboratory designate a specific location
for records storage and document that in the laboratory SOPs.

Proficiency Testing

G. Finding: The laboratory is not documenting PT Sample analyses.

Requirement: All PT Sample analyses must be recorded in the same daily analysis records
(e.g., benchsheets) as for any Compliance Sample. This serves as the permanent laboratory
record. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, 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, January 1, 2023, Revision 6,
Section 4.0.

H. 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, January
1, 2023, Revision 6, Section 3.6.

Comment: This Finding applies to Settleable Residue.

Comment: Dating and initialing the instruction sheet for each prepared PT Sample would
satisfy the documentation requirement.

pH - Standard Methods, 4500 H+ B-2011 (Aqueous)

I. Finding: Values were reported that exceed the method specified accuracy of 0.1 units.

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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-2011. (6).

Comment: Per PT Vendor instructions, the PT Sample results should be reported to two
decimal places, which is an exception to the requirement for Compliance Samples.

Recommendation: The laboratory currently reports pH sample results to two decimal
places. It is recommended that the laboratory continue to measure and document sample
results on the benchsheet to two decimal places, and to round to the nearest 0.1 S.U. when
reporting results to Pender County.

J. Finding: The acceptance criterion for the check standard buffer is not being assessed.

Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data
shall be traceable to the associated sample analyses and shall consist of: the quality control
assessments. Ref: 15A NCAC 02H .0805 (g) (2) (O).

Comment: There were no instances observed where there were unacceptable results for the
check buffer.

K. Finding: The laboratory is not analyzing a post-analysis check standard buffer when analyses
are performed at multiple sample sites in a single day.

Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref:
15A NCAC 02H .0805 (g) (4).

Requirement: When performing analyses at multiple sample sites, a post-analysis calibration
verification using the check standard buffer must be analyzed at the end of the run. It is
recommended that a mid-day check standard buffer be analyzed when samples are analyzed
over an extended period of time. The post-analysis check standard buffer(s) must read within
±0.1 S.U. or corrective actions must be taken. If recalibration is necessary, all samples
analyzed since the last acceptable calibration verification must be reanalyzed, if possible. If
samples cannot be reanalyzed, the data must be qualified. Ref: NC WW/GW LCB Approved
Procedure for the Analysis of pH.

Temperature – Standard Methods, 2550 B-2010 (Aqueous)

L. Finding for Immediate Response: Temperature sensor check readings for devices used
for compliance monitoring varied more than 0.5°C from the Reference Temperature-
Measuring Device reading.

Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule.
Ref: 15A NCAC 02H .0805 (g) (4).

Requirement: To check a compliance temperature-measuring device, compare readings
at two temperatures that bracket the range of compliance samples routinely analyzed
against a Reference Temperature-Measuring Device and record all four readings. The
readings from both devices must agree within 0.5ºC. If they do not, the device may not
be used for temperature compliance monitoring. Ref: NC WW/GW LCB Approved
Procedure for the Analysis of Temperature.

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Comment: The laboratory currently uses a Baxter Scientific Glass Thermometer (Serial
#T-2010-1) for compliance measurements. The laboratory contracted with Environmental
Chemists, Inc. (Cert #94) to have the annual temperature verification performed on 3
devices on December 21, 2022. The readings on the Baxter Scientific thermometer and
the 20i DO Meter varied by more than 0.5°C. from the Reference Temperature-Measuring
Device. The readings on the Oakton pH Meter were acceptable.

Comment: A Notice of Finding for Immediate Response (NOFIR) was issued due to the
impact on reported data and so the laboratory would utilize an acceptable temperature
monitoring device more quickly than if waiting to first receive the inspection report to take
corrective action. The laboratory was instructed to submit verification that an acceptable
temperature measuring device was being used A response date of January 27, 2023 was
negotiated. The laboratory submitted a Corrective Action Plan on January 27, 2023 stating
that the Oakton pH meter would be used for compliance measurements of temperature.
No further response is required for this Finding.

Reporting

M. Finding: The laboratory does not report results of all tests on the characteristics of the effluent.

Requirement: The results of all analyses for each sample shall be reported by the certified
wastewater laboratory directly to the ORC and simultaneously to the health department and
the state. 15A NCAC 18A .1970 (n) (5).

Comment: The laboratory analyzes Settleable Residue on the effluent for operational process
control but does not report the results on the DMR.

IV. PAPER TRAIL INVESTIGATION:

The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and
contract laboratory reports to DMRs submitted to the Pender County Health Department. Data were
reviewed for Topsail Greens Subdivision WWTP (Pender County Subsurface permit # 487797) for August,
September, and November 2022. There were numerous discrepancies between reported pH values and
the DMR on the August and September reports. The current analyst assumed the responsibility of
preparing the DMR beginning in November 2022 and there were no errors on that report. The laboratory
was advised to contact the Pender County Health Department to determine whether amended DMRs would
be required.

Date Parameter Location Value on
Benchsheet Value on DMR
8/1/2022 pH Effluent 8.09 S.U. 8.27 S.U.
8/3/2022 pH Effluent 8.41 S.U. 8.25 S.U.
8/4/2022 pH Effluent 8.64 S.U. 8.64 S.U.
8/15/2022 pH Effluent 7.29 S.U. 8.55 S.U.
8/17/2022 pH Effluent 7.56 S.U. 8.14 S.U.
8/18/2022 pH Effluent 7.56 S.U. 8.01 S.U.
8/20/2022 pH Effluent 7.52 S.U. 7.95 S.U.
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8/21/2022 pH Effluent 7.54 S.U. 8.37 S.U.
8/22/2022 pH Effluent 7.63 S.U. 8.49 S.U.
8/24/2022 pH Effluent 7.54 S.U. 7.71 S.U.
8/25/2022 pH Effluent 7.73 S.U. 7.61 S.U.
8/28/2022 pH Effluent 7.62 S.U. 8.22 S.U.
8/29/2022 pH Effluent 7.60 S.U. 8.33 S.U.
8/31/2022 pH Effluent 7.62 S.U. 8.27 S.U.
9/1/2022 pH Effluent 7.64 S.U. 8.27 S.U.
9/3/2022 pH Effluent 7.36 S.U. 8.25 S.U.
9/4/2022 pH Effluent 7.59 S.U. 8.64 S.U.
9/6/2022 pH Effluent 7.55 S.U. 8.26 S.U.
9/7/2022 pH Effluent 7.80 S.U. 8.32 S.U.
9/8/2022 pH Effluent 7.69 S.U. 8.39 S.U.
9/10/2022 pH Effluent 7.75 S.U. 8.37 S.U.
9/11/2022 pH Effluent 7.53 S.U. 8.17 S.U.
9/12/2022 pH Effluent 7.51 S.U. 8.57 S.U.
9/14/2022 pH Effluent 6.97 S.U. 8.55 S.U.
9/17/2022 pH Effluent 7.31 S.U. 8.14 S.U.
9/18/2022 pH Effluent 7.37 S.U. 8.01 S.U.
9/20/2022 pH Effluent 7.36 S.U. 7.95 S.U.
9/21/2022 pH Effluent 7.31 S.U. 8.37 S.U.
9/23/2022 pH Effluent 7.19 S.U. 8.49 S.U.
9/24/2022 pH Effluent 7.36 S.U. 7.71 S.U.
9/25/2022 pH Effluent 7.20 S.U. 7.61 S.U.
9/27/2022 pH Effluent 7.20 S.U. 8.22 S.U.
9/29/2022 pH Effluent 7.24 S.U. 8.33 S.U.
9/30/2022 pH Effluent 7.30 S.U. 8.27 S.U.

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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: Jill Puff Date: January 25, 2023
Report reviewed by: Tom Halvosa Date: January 30, 2023

Certificate Number:5158
Effective Date:1/1/2023
Expiration Date:12/31/2023
Lab Name:Topsail Greens Subdivision
Address:505 Topsail Plantation Dr
Hampstead, NC 28443
North Carolina Wastewater/Groundwater Laboratory Certification
Certified Parameters Listing
Date of Last Amendment:9/1/2021
The above named laboratory, having duly met the requirements of 15A NCAC 2H.0800, is hereby certified for the measurement of the parameters listed below.
CERTIFIED PARAMETERS
INORGANIC
pH
SM 4500 H+B-2011 (Aqueous)
SW-846 9045 D (Non-Aqueous)
RESIDUE, SETTLEABLE
SM 2540 F-2015 (Aqueous)
TEMPERATURE
SM 2550 B-2010 (Aqueous)
This certification requires maintance of an acceptable quality assurance program, use of approved methodology, and satisfactory performance on evaluation samples. Laboratories are subject to civil penalties and/or decertification for infractions
as set forth in 15A NCAC 2H.0807.