WQ0003090_Monitoring - 01-2023_20230228

Monitoring Report Submittal
Permit Number#* wg0003090
Name of Facility:* town of liberty wwtp
Month: * January Year: * 2023
Report Information
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR january 2023 spray report.pdf 3.74MB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
Confirmation Email Address: * [e-mail]
Name of Submitter: * Elix Fike
Signature:
Date of submittal: 2/28/2023
This will be filled in automatically
Initial Review
Reviewer: Wanda.Gerald

Is the project number correct?* wg0003090
Is the monitoring report accepted?* Yes No
Regional Office* Winston-Salem
Reviewer: _anonymous
Review Date: 3/6/2023

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page_l_of_l_
Permit No.: WQ0003090
I Facility Name: Town Of Liberty - Wastewater
---Parameter
I County: Randolph I Month: January
Year: 2023
PPI: 002
[Flow Measuring Point: ❑ influent El Effluent No flow generated
Monitoring Point: El influent 2 Effluent El Groundwater Lowering ❑ surface water
Code
. . . . . . . .
Al
00400
00610
31613
00625
5 0060
70300
Parameter . .
0
>
V
0
E
0,
taf
a.
E
E
E
LL B
0
0
0) 0
U) Uj
,g� �<­
Ig
�E z
U
q
g ,
0
0
24-hr
hrs
su
mg/L
#/100 mL
i'411 mg/L
mg1L
mg/L
W
R',
2
NNW
A
3
7:00
8
4
7:00
8
5
12.9xe
248
18.2
0
0.042
5
7:00
8
8.31
M,
6
7:00
8
77--7-
7
11:00
2
8
11:00
",
9
7:00
8
10
7:00
8
_T
W
11
7:00
8
0.46
121
7:00
8
8.41
.................... 11
131
7:00
8
10
E-4
141
10:00
2
IN
15
13:00
2
W
16
7:00
2
17
7:00
8
IA
V
18
7:00
8
Vg
28.1
0.23
ND
X� N
19
7:00
8
8.59
13.9
201
7:00
8
21
V "e,
3,
1
NU NN
22
mll
23
7:00
8In,
24
7:00
8
4
25
7:00
8
0.17
26
7:00
8
7.82
g,%
27
7:00
8
A
28
ITT
M
29,
30
7:00
8
311
7:00 11
8
Nil
M�
Average:
13.40
774.70
#REF!
0.22tltY0.02
13.90
2,420.00
*REF!
0.46
0.04
Daily Maximum:
8.59
X
Daily Minimum:
V',
7.82
12.90
248.00
# REF!
0.00
0.04
Sampling Type:
Grab
Grab
0­1 "Ar Grab
W
Grab
1 HIS
2
Grab
"M5
Monthly Avg. Limit:
77=
.1 0311"r,
Daily Limiter :
Sample Frequency:
weekly
x month
x month
2x month
weekly
,,,V

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR)
Sampling Person(s) Certified Laboratories
Name: GLENN PRICE Name: PACE ANALYTICAL
Name: GARRETT DREYER Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? ❑✓ Compliant ❑ Non -Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
non complliant on the day of 1/5 1/13 1/23 1/24 1/26 and 1/27
rainfall I&I
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Elix Tremaine Fike
Permittee: Scott Kidd
Certification No.: 989290
Signing Official:
Grade: SI Phone Number: 336 622 2990
Signing Official's Title: Town Manager
Has the ORC changed since the previous NDMR? ❑ Yes [21 No
Phone Number: 336 622 4276 Permit Expiration: 8/31/2024
r-
�.,�-
Signature Date
Signature ate
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
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 all qualified personnel properly gathered and evaluated 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 fines and imprisonment
for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

laceAnalyfical')
f
www,pacelabs.com
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92645260
Sample: Effluent
Method
SM 2540D-2015
EPA 353.2 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
SM 521OB-2016
Colilert-18
TKN+NO3+NO2
Calculation
EPA 350.1 Rev 2.0 1993
EPA 351.2 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
EPA 365.1 Rev 2.0 1993
Parameters
Total Suspended Solids
Nitrogen, Nitrate
Nitrogen, Nitrite
BOD, 5 day
Fecal Coliforms
Performed by
Collected By
Collected Date
Collected Time
pH
Chlorine, Total Residual
Total Nitrogen
Nitrogen, Ammonia
Nitrogen, Kjeldahl, Total
Nitrogen, NO2 plus NO3
Phosphorus
Reviewed by: 1 " 11111
Stephanie Knott
704-977-0981
[e-mail]
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
North Carolina Drinking Water Certification #: 37712
North Carolina Wastewater Certification #: 40
Pace Analytical Services Eden
205 East Meadow Road Suite A, Eden, INC 27288
North Carolina Drinking Water Certification #: 37738
Laboratory Report
Page 1 of 1
Report Date: 01/15/2023
Date Received: 01/05/2023
Lab ID: 92645260001 Collected: 01/05/23 12:30 Matrix: Water
Results
Units
Report Limit
Analyzed
10.5
mg/L
6.4
01/09/2311:33
0.053
mg/L
0.040
01/05/2319:10
ND
mg/L
0.040
01/05/2319:10
9.0
mg/L
2.0
01/11/2315:12
248
MPN/100mL
1.0
01/06/2312:51
PACE
01 /05/23 12:30
Garrett
01 /05/23 12:30
Dreyer
01 /05/23
01 /05/23 12:30
1230
01 /05/23 12:30
8.31
Std. Units
01/05/23 12:30
0.00
mg/L
01/05/2312:30
18.3
mg/L
0.040
01/12/23 21:03
12.9
mg/L
0.20
01/14/2312:52
18.2
mg/L
0.50
01/12/23 03:49
0.042
mg/L
0,040
01/10/23 22:02
2.4
mg/L
0.050
01/13/23 08:23
South Carolina Laboratory ID: 99030
South Carolina Certification #: 99030001
VirginiaNELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
Virginia/VELAP Certification #: 460025
Qualifiers
Page 1 of 3

.m.x CHAIN -OF -CUSTODY Analytical Request Document
, aceAna' --;ai ,
Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fields �
'C� ��- EBillin information:
Company: Town of Liberty C g
Address:
Report To:
Copy To:
Customer Project Name/Number:
Phone:
Email:
By
_I
t E mail To:
iSite Collection Info/Address:
i
LAa USE CNLY-/affix Wnrko derjLogin Label Here a List Pace Workorder Nuniber U.-
IVITIL Log -in Number Here
Container Preservativ
U .-; z S s
Preservative rypes: (l) nitric acid, (2) 92645260
(6) methanol, (7) sodium bisulfate, (6) sc
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
Analyses Lab ProflletLine;
'State:
County/City: Time Zone Collected:
[ i
� b ample Receipt Chr F l.jn ;
/
[ ]PT[ ]MT[ ]CT [ ]ET
(
cuscody Beals SG PC �T Rr Y RP
Site/Facility ID #:
Compliance Monitoring?
[ I
` " Custody Signatures Present
Cv.:R NA
Yes No
t C ]
i
k $ rollec :or IS gtt:a.ure Pxe, e.'it.
Bottles rntsr.t
N NA i
�r7 NA
Purchase Order #:
DW PWS ID #:
d
Correct Bottles
NA
'rr
Quote #:
DW Location Code: ?
; 1
3
ufficaent Volume
1
v NA
%'
[
samplers Received on, lee
rt NA
1.
Turnaround Date Reouired:
}Immediately Packed on Ice d
m
p # €
i
f VOX Headspac A cep.,ible
i USDA. Regulated Soils
i Ne
T 3
[ ] Yes [ ] NO
)
.lam
a (
S&Tirpleo i:a Hold..ing, i:ue Eli NA. 3
[ �." Juah Chlorin i �r�
ample Disposal: ' Rush: Field Filtered (if applicable):
( -
{ € 4 E
.Tat
}
( J Dispose as appropriate ( ]Return [ ] Same Day ( ] Next Day {[ ] Yes [ ] No
Z
® k
-
Cl Stripes
(( Grzmp s H Acce-t ixb "2� 'J13 ;.
[ ] Archive: 3 [ ] Z Day [ ] 3 Day [ ] 4 Day [ ] S Day (
Analysis-.
s
( ) i
b
t u s ry
C
( ]Hold: (Expedite Charges Apply)
�
f o
}-
6
,
Su fxdo prcazen itN e
Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
i.-
#z
E
Lsad Acetate ,.rips. - -
Product (Pl. Soil/Solid (SL). Oii (OL), Wipe (WP), Air (AR), T -issue (TS), Bjoassay (B), Vapor {V}, Other (OT)
1-
1 1--7 4\y' } i g
r.:�A,' USE ONLY:
a
Customer Sample ID
/Collectedi
compor
*
Matrix Grab Composite Start)
Composite End
Res t # of P- @ # 'P
a 2 ;i_
)--
Cl Ctns CS -(c6 0 TO
Date Time
Date I Time
[ i Z U- # CL
:.Effluent
9 P C—®
€
[ Jri _
L-1,
it
1
iTvna of Era uzad:
Wet , Blue DCY Norte (SHORT HOLDS PRESENT (C72 hoofs): L_�N N/A Lab Sample Temperature info,. ,
Temp Blink Receive
[Packing Material Used: . Lab Tracking #,' Thermo ID# �K [
Effluent Monitoring _ �� .- Cooler 1 Temp Upon Receipt .E _1 oC
;Samples received via, , e Cooler 1 Therm Corr. Factor-. oC
Radchem sample(s) screened (<50) cpm}: Y N NA ( FEDEX UPS Client Courier Pace Courier i i Cooler 1 Corrected Temp oC
_BB
elinquis byJCompan i nature) (Date/Time: iReceived by/Company:(Signature)?Date/Time: j MTTLLA CY j Comments:
v
�; ;`lam '-i.l,��-- +" � � 7 �� � /✓ ?, i ''� `'
Acctnum: 3 _.
ed by/Company: (Signature} to 1me: ;Received by/Company: (Si ore} ;Date/Time: Trip Blank Received: Y N NA
i Template:
m HCL McOH TSP Other
N ? Prelogin:
2e qujshed by/Company: (Signature) ((Date/Time: Received by/Company: (Signature) Date/Time: F4Ic Non Confor mMacP(.)--:Page:v�—
-- _
w
k P3: YES / N ✓ of

BOWLIdentification Form (BIF)
Dccumen;
F•CAR-CS-043-Rev.oI
*Check mark top half of box if pH and/or d,2cilorination is
verified and within the acceptance range for pr eserv3tion
samples,
Cali c-m TCC;-, CCC, LLH�
Bottom half of box is to list number of bottles
Project tt
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Sample Ip
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Type of Preservative
pH upon receipt
_
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Cate preservation adjusted
Time presarvatian
adjusted
Amount of Prese,
added
native
�_.._, _,. ,,,,e ��� ���„ t „once sample,, a crpy a! this farm will 6e sent to thr� Aiarin Catalina GEH�`1R Certifi
ut of hold, incorrect preservative, out of ternp, incorrect containers. cation Office ('r.e.
Page 3 of 3

aceAnal ica(
www.pacelabs.com
i
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92646602
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 01/12/2023
Date Received: 01/12/2023
Sample: Effluent
Method Parameters
Lab ID: 92646602001 Collected: 01/12/23 13:00 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
Performed by
PACE
01/12/23 13:00
Collected By
Garrett
01/12/23 13:00
Dreyer
Collected Date
01/12/23
01/12/23 13:00
Collected Time
1300
01/12/23 13:00
pH
8.41 Std. Units
01/12/23 13:00
Chlorine, Total Residual
0.46 mg/L
01/12/23 13:00
{fir"ue 4 e�
Reviewed by
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 2

.1
k7aVLical Chain -of -Custody is a LEGAL DOCUMENT- Complete all relevant fields
LAB USE ONLY- Affb(WvrktrderJLogin Label Here or List Pace Workorder Number or
MTJL Log -in Number Here
Company: Town of Liberty
t5jiii rig it iiii, iiI.Wull.
-ALLS
WO#: 902.646602"
Address:
I Container Preser%ia
�.To,
[crud
ma T
Preservative Types: (1) n1tric acid,
---l—S—fte-Collection
(6) methanol, 1`7]sodiurn bisu!fate,
92646602
iCoc TO:
info/Address:
(C) ammonium hydroxide, ('D) 75P, (L
Analyses
ILaD KrUnfeM, ne:--�,
Customer Project Name/Number:
State: County/City: Time Zone Collected:
'LabSaMgle Receipt cbealilist;
]PT[ ]MT[ ]CT ET
Custody Seal s'Prevent/ Intact )r 9 NA
Phone: Site/Facility ID #: Compliance Monitoring?
CtIsccidy Signatures ?re5ettt y 9 NX
c:Vl oector signatuza Preoent Y 9 XA-
Email:
[Yes No
y N NA
Cpliected B t, Purchase Order #: DW PWS ID #:
Carrect Bottles Y IT NA
Volwae Y to 14A
Quote
DW Location Code:
Sufficient
samples R—eceived on lea y- R NA
cot na Turnaround Date Required: immediate Packed on Ice:
V0,A - Heaclspace Acceptable Yid NA
Yes ]No
USDA ReV2,%iteci Soils Y N XA
LL
Samples in Holding Tilire, r N FIX
?a4RIs—posal: j Rush:
Field Filtered (if applicable):
mResidual
dlilor#ne Present y N NA
Dispose as appropriate Return Same
Day Next Day Yes ]No
Cl strips.
Sarkole PH Acceptable Y N Vik
Archive: 12Day [
13Day 1 ]4Day 5 Day Analysis:
PH strIps:
Hold: (Expedite Charges Apply)
Sulfide Present N KA.
Matrix Codes tInsert in Matrix box below): Drinking
Water (DW), Ground Water (GW), Wastewater (WW),
1,"d Pa einte Strips:
Product (P), Soil/Solid (SQ, Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (8), Vapor (V), Other (OT)
LAB TUSE QN
Comp Collected (or Res of
Lab Sam le coaurrentr-
P
Customer Sample ID Matrix
Composite End
Grab Composite Start) CI Ctns
U- -re
Date Time Date Time
5(-� Mate
Effluent 1WW
g
0
n1A
'Lab
Customer Remarks/ Special Conditions Possible - Hazards: Type of, Ice Used, Wet Blue Dry None:
SHORT HOLDS PRESENT (<72 hours). Y N N/A Sample Temperature Info:
Tenp Blank Reived: Y N N4
ec
Packing Material Used:
LabTrar-king#:
Therm ID#:
Effluent Monitoring
Cooler I Temp Upon Receipt: oc
Samples received via:
Cooler I Thermt Corr. Factor, oc
tp
[RR,d,he, sampte(s) screened (<500 cpm). Y N NA
FEDEX UPS Client
Cciurler Pace Courier' 'Cooler I Corrected Temp: — 'C
nature)
Relin ed bj (Signature)
Date/Time: Re ived by/Company
Date/Time: lc�
T M I JL LAB USE ONLY Comments.
V(gnature
Table #'
eddy" y: (Signature}
Date fT 'received y/Company: (Signature)
Time:
Date/Time:
Accmum*
Template. Trip Blank Received: Y N NA
CD
HCL MeOH, TSP other
R quished by/Company: (Signature)
tDate/Time: Received by/Company: (Signature)
Date/Time:
PM� 7'Page:
Non Con1brmancc(,;):
I
-------
;f YES / NO of:
------

laceAnalyticalo
www.pacalabs.com
I
i
a
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92647722
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 01/31/2023
Date Received: 01/19/2023
Sample: Effluent
Method
Parameters
Lab ID: 92647722001 Collected: 01/19/23 12:55 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
HACH 10206
Nitrogen, Nitrate
ND
mg/L
0.30
01/20/23 16:09
SM 254OD-2015
Total Suspended Solids
70.4
mg/L
18.5
01/19/23 20:22
SM 521OB-2016
BOD, 5 day
26.7
mg/L
2.0
01/25/23 09:14
Colilert-18
Fecal Coliforms
2420
MPN/100mL
1.0
01/20/23 12:22 El
Performed by
PACE
01/19/23 12:55
Collected By
Garrett
01/19/23 12:55
Dreyer
Collected Date
01119/23
01/19/23 12:55
Collected Time
1255
01/19/23 12:55
pH
8.59
Std. Units
01/19/23 12:55
Chlorine, Total Residual
0.23
mg/L
01/19/23 12:55
TKN+NO3+NO2
Total Nitrogen
28.1
mg/L
0.040
01/27/23 20:05
Calculation
EPA 350.1 Rev 2.0 1993
Nitrogen, Ammonia
13.9
mg/L
0.30
01 /26/23 16:02
EPA 351.2 Rev 2.0 1993
Nitrogen, Kjeldahl, Total
28.1
mg/L
2.5
01/27/23 04:53
EPA 353.2 Rev 2.0 1993
Nitrogen, NO2 plus NO3
ND
mg/L
0.040
01/26/23 14:34
EPA 365.1 Rev 2.0 1993
Phosphorus
3.0
mg/L
0.050
01/31/23 11:45
ANALYTE QUALIFIERS
El Reported value should be considered a minimum estimate since it is the maximum reportable number for this method
based on the sample volume used. The true value is likely greater than the value reported.
Reviewed by:
Stephanie Knott
704-977-0981
stephanie.l<[e-mail]
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
North Carolina Drinking Water Certification #: 37712
North Carolina Wastewater Certification #: 40
Pace Analytical Services Eden
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
South Carolina Laboratory ID: 99030
South Carolina Certification #: 99030001
Virginia/VELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
Virginia/VELAP Certification #: 460025
Page 1 of 3

CHAIN -OF -CUSTODY Analytical Request Document
L
~ LAB USE ONLY- Affix Workorder/Login Label Here or List Pate Workorder Number or
r.r
MTIL Log -in Number, Here
fi"aceAi181J/ k cif
Chain -of -Custody is a LEGAL DOCUMENT- Complete all releventfields
@
] Billing Information:
Company: TownDf Liberty
7 g
�. -
LL
Confaaner P va
" Preservative Type,-. (1) nitric acid,
92647722
;Address: _
Report To:
Email To`
ej_niethanol, (74 sodiurn bisulfate; (S)
(C ammonium hydroxide, (D) TSP, (U)
Copy To:
Site Collection Info/Address:
Analyses
LabPrflleiliieil` _ _)
Customer Project Name/Number:
State: County/City: Time Zone Collected:
a (,
Lab Sample Receipt Checklir3t; j
/ [ ]PT[ ]MT[ ICT I ]ET
Custody Seals Present/lbtact Y Wk
sLodY-Stu=ee Pre�L Pak
Phone:
Site/Facility ID #:
Compliance Monitoring?
Email:
[ +'Yes ( )No
Collector Signature Presant N la
1f
t
3
Bottles Irtact lid P11fi
correct, &or-: J es 7 N i E
Collected By int):
Purchase Order #:
DW PWS ID #:
QLOte #:
DW Location Code:
I
e
I
i
of icient 'talu»e N NA
e e�
I� `
Sr�mFslar� Received on Ice );s' P2Fz t
JOA - Headspace P—acepta'ble Y 9
Coll j:
pTurnaround Date Required:
Immediate Pace on ice:
y
I ]Yes [ 1 No
i Y6
o
]
t
USIA Regulated Soils Y 3T
Sc�mglao irz I olUinct T� zae N a
Rezzidxtai Chlorine present )r NA j
amp,e asposai:
Rush:
Field Filtered (if applicable):
( ] Dispose as appropriate ! ] Return
[ l Archive:
' I ]Same Day [ ] Next Day
{ ] 2 Day [ ] 3 Day [ ] 4 Day [ ] 5 Day
{ ) Yes [ ] No
( Z
Z /
Cl Straps -
Samplepx Acce table N NAf
Hold:
( ](ExpedlteChargasAPPh9
Analysis:
, 18
8 ;]�
ZZ a
l
pH Strips -_ .... .
Sulfide Present Y R �
ead Acetate Strips:
* Matrix Codes (Insert in Matrix box below); Drinking Water (DW), Ground Water (GW), Wastewater (WW),
Product P , Soil/Solid SL , Oil OL , Wipe WP , Air (AR), Tissue TS , Bioassay B), Vapor (V), Other (OT)Cn
ll�
tJILAB
F- Z v 4
- 'Li
UCIE ONLY:§
Lib Sanple 4 / Cnmrenres k
Camp /
Collected (or
Res
of
Customer Sample ID Matrix
Grab
Composite Start)
Composite End (
Cl
Ctns
0 co
�
Z
Date
I Time
Date Time
:, LL Q
Effluent IWWg
i Z"J?
(
5
Fr
3
i(
�NNJA
------ --
Customer Remark J Special Conditions I Possible Hazards:
Type of ice Used: et Flue Dry None SHORT HOLDS PRESENT (<72 hours). Y Lab Sample Temperature Info: f
Effluent Monitoring
ui%� y/Co ny: (Sigh ture)
rnpany: (Signature)
co
N
RelAuished by/Company: (Signature)
Packing Material Used: -GLab Tracking # TeZrtP Blank Reteav dT �f OtV NA
Th-,rtts IL'#: L
Cooler l Temp Upon Receipt: ` oC
Samples received via: Cooler l Therm Corr; Factor - f cC
Radchem samples) screened (<500 ;rpm): Y N NA FEDEX _ UPS Client Courier Pace Courier Cooler l Corrected Temp- o[ j
Date/Time: Rec -ved by./Company: (Signature) Date/Time: MTJL ONLY Comments: 1
f
j j��
't J it Z3 Table #;
f)dd Zi
-� W cctnum:'
Date/Time: Re eived by/ mpa : (Signature) Date/Time: i
Il Template: � Trip Blank Received: Y N NA
(
HCL McOH TSP tither
Date/Time: i Received by/Company: (Signature) Date/Time: 3
(FR4: ; Non Conformance(s): s Page:
Po: YES / NO of: _

ti fSot`le Idemification Form (BIF
—_— ) F-CA R•CS-C43•Rev.Cl
P 1 .. ± -
17
Ci,e�: rear top ha!f of box if pH and/or dechlorination is
verlil'_d an-_' Lvfthln i!iE' a_ceptance rang—" for preservation
sarnp!tis,
ry
bottom ha!i of box is to list number of bottles
v vv ti d
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diu,ted Time presertation Amount of Preservarie
added v
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adjusted \
a COPY of this t•.orm wiil bii en
Sample ID I
Type of Preservative
pH upon receipt__
eceip
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sent to the hl�� �n ear I,na CcH;lR C ert fication OHir."
of h,?IU, incorrect preser'ra:ive, out of temp, incorrect containers. _ (i.e.
Page 3 of 3

r aceAnalXical
/ www.pacolabs.com
r
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92648947
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 01 /27/2023
Date Received: 01/26/2023
Sample: Effluent Lab ID: 92648947001 Collected: 01/26/23 12:25 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
Performed by PACE 01/26/23 12:25
Collected By Garrett 01/26/23 12:25
Dreyer
Collected Date 01/26/23 01/26/23 12:25
Collected Time 1225 01/26/23 12:25
pH 7.82 Std. Units 01/26/23 12:25
Chlorine, Total Residual 0.17 mg/L 01/26/23 12:25
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 2

-laceAnalyltical
Company: TOWil ai ! iberfy
Address:
r Report To,
Copy To
Customer Project
Phone: Site/Facility ID #:
Email:
[Purchase Order#:
i� 1 Quote #:
is a LEGAL DOCUMENT - Complete, all relevent fields
( � LAS USE ONLY- Affix]Workorder/Login Label Here or List Pace Workorder Number or������
MTJL l g-in Number Here
648947
[ Billing Information:
R
I j
Container
Email To: - .. Preservative Types (1) nitric acid, (2) 92648947 1
. (6) methanol, (7)sodium besnifate, (8) sc ,..t ammonium sulfate,
)site Collection Info/Address: (C) ammonium hydroxide, (o) TSP, (U) Un,.._—. uiner
Analyses
LaD Pronie/tine:
State: County/City: Time Zone Collected:
)
Lab sample Rec�e;,pu Mheaklis-t
/ [ ]PT[ ]MT[ ]CT [ ]ET
11
l custody SealL; Freseor/laza= Y N 14A
Custody sign tures Present k U km
Compliance Monitoring?
[ `Yes [ ] No
Collector signature P eseriz Y 11 Wk
Bottles Intact: y U NA 3
correct Bottles Y is NA i
DW PWS ID #:
DW Location Code.
! €
Sufficient Volume y Iv NA ;
tt
s Samples Received on ice y to NSA 3
Call
Turnaround Date Required:
Immediately Packed on Ice:
I 70
vole �IGaiS ac&cr� ?mcepcabl.e : W NA
[ ]Yes [ ] No
us;) Regulated snails y 11 NA
a)
(
Sa;mpIcs in Holding Time Y, IT,
Rea rkaal Chlorine present Y 21 ST,
e {sposal:
Rush:
Field Filtered (if applicable):
[ j Dispose as appropriate [ J Return
( ] Same Day [ J Next Day
[ ]Yes [ ] No
Cl qtr po:
] j Archive:
[ ] 2 Day [ ] 3 Day [ ] 4 Day [ ] 5 Bay
Analysis:
o
6 c
I
sample, pm Accopcable : N �
PH strip
( ] Hold:
(Expedite Charges Apply)
�}
(
8u1i irla i or nt _ y IT =
Iead Aceete Strips °
* Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
at m
9
666
LeAS ,os8 ON X r a
Lab 'Sample # / Cormoritr: )
k
Comp/
( Collected (or
Res
#of
Customer Sample ID Matrix x
Grab
Composite Start)
Composite End
CI
Ctns
L
Date
Time
Date Time
Effluent ww
9
I Z r
0'
'
Customer Remarks! Special Conditions J Possible Hazards:
Type of Ice Used: Wet Blue Dry None SHORT HOLDS PRESENT (<72 hours): Y N Nfl+ Lab Sample Temperature Infer
Packing Material Used: Lab Tracking #. Temp Blank Received: Y N NA
Therm lD#:
Effluent Monitoring {
Cooler I Temp Upon Receipt; oC
Samples received via. Coder I Therm Corr. Factor. oC
Radchem sample(s) screened (<SGQ cpm): Y N NA FEDEX UPS Client Courier ace Courier, Cooler 1 Corrected Temp: CC
-
uis /C :(S nature)
Date/Time:
Rece' ed by/Company:(Signature)
%
De/Time:
1 S
NIT1L
I
Y Comments.
i r2
��
Z�..` J
Table#:
-z IJ
at/Time:
r
Received by/C parry: gnature)
Date/Time:
Acctnum:
Template:
p
# Trip Blank Received: Y i
ed pany:(Signature)
CDi
HCL McOH TSP Oth
n'
L
f Date/Time:
- --- -- ——
I Received by/Company: (Signature)
(
—
date/i ime:
iPrelogin:
ePNt:
l
G Non Conformance(s): 'Pap
Aquished by/Company: (Signature)
N
PE:
YES / NO o'

MINI
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
January 2023
Liberty N.C.W.W.T.F.
Freeboard Lagoon Inches
9
R
0.3
8
81/4
9
R
1.0
61/4
51/2
6
6
53/4
R
0.3
31/2
4
5
R
1.2
21/2
1 1/2
1 3/4
2
21/4
23/4
31/4
33/4
41/4
41/2
R
1.0
1/2
0
0
R
0.5
0
0
0
0
0
R
0.3
0
R
0.3
TOTAL 5.4

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _1_ of -2-
Permit No.: W00003090
Facility Name: Town of Liberty - Wastewater
County: Randolph
Month: January
Year: 2023
Field Name:
2
xtt
e Name:
4
Did irrigation occurOtt
110
Area (acres):
19.7
0_0
Area (acres):
17.02
at this facility?
Cover Crop:
FESCUE
Cover Crop:
FESCUE
Hourly Rate (in):
0.21
Hourly Rate (i
E YES El NO
Annual Rate (in):
52
Annual Rate (in):
52
Weather
Freeboard
Field Irrigated?
El YES [E] NO
Field Irrigated?
❑ YES ❑ NO
0
d
E
Q
U) M
CL W
m .2
E 2
.2 'a
. E
C
:6
a
E
E .2
E
-74
0
g, CL
0 CL
>
0 0
0 CL
> <
0
0 0
_j
CL
Lo
3:
F
in
ft
ft
gal
min
in
in
gal
min
in
in
1
R
0.3
2
3
C
51
0.75
281,000
180
0.61
0.20
4
R
5
6
C
40
0.5
1,210" MWO W11'', I
7
8
5M,
9
R
0.3
10
C
36
0.5
321,000
180
0.60
0.20
C
55
0.5
,
281,000
180
0.61
0.20
11
V
121
C
61
0/1.2
0.5
14
C
47
0
321,000
180
0.60
0.20
10
15
C
40
0
16
17
C
45
0
281,000
180
0.61
0.20
18
19
C
60
0
0
32 1,000
180
0.60
0.20
1
20
C
50
d
21
22
R
V
231
241
C
32
0
101", W"P1,115
321,000
180
0.60
0.20
281,000
180
0.61
0.20
R
0.5
25
N.,
26
51,11�ilt"V'kl") 01
27
C
37
0
321,000
180
0.60
0.20
28
C
41
0
C
45
0
281,000
180
0.61
0.20
29
IN
30,
R
0.3
311
R
0.3
1,605,000
-7-00UMMM
Monthly Loading:
12 Month Floating Total (in):

FORM: NDAR-1 10-13
Did the application rates exceed the limits in Attachment B of your permit?
[Z Compliant
❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
0 Compliant
❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit?
❑ compliant
❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site?
0 Compliant
❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?
❑ Compliant
❑� Non -Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of
the non-compliance and
describe the corrective
action(s) taken. Attach additional sheets if necessary.
FREEBOARDI
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Elix Tremaine Fike
Permittee:
Scott Kidd
Certification No.: 989290
Signing Official:
Grade: SI Phone Number: 336 622 2990
Signing Official's Title: Town Manager
Has the ORC changed since the previous NDAR-1? ❑ Yes 0 No
Phone Number: 336 622 4276 Permit Exp.: 8/31/24
1 2 3
Signature ate
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
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 all qualified personnel properly gathered and evaluated 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 fines and imprisonment for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _2_ of _2_
Permit No.: WQ0003090
Facility Name: Town of Liberty - Wastewater
County: Randolph
Month: January
Year: 2023
,g
"'M AN"W"14"I"Ifta V
'kif�
Field Name:
6
Field Name:
8
Did irrigation occur
's
Area (acres):
15.1
Area (acres):
21.68
at this facility?
Cover Crop:
FESCUE
Cover Crop:
FESCUE
R
Hourly Rate (in):
0.21
Hourly Rate (in):
0.21
El YES El NO
'I'll
Annual Rate (in):
52
Annual Rate (in):
52
Weather
Freeboard
Mg.'s,
Isx
I' RN, Z
FieldIrrigated?
[Z YES El NO
M
Field Irrigated?
El YES El NO
CD
0
.2
0) Xi
C
E
g
E
Q
CL
0
0. cc
.2
.2
0 CL
>
CD
CL
>
E
i=
cc
0
E
'Tc 0 cc
M 3: 0
LL
Co CL
0
x
Lh
'F
inVia:
MWE W, U,
gal
min
in
in
gal
min
in
in
I
R
0.3
2
C
40
0.75
ANA
3
PC
59
0.75
R
1
4
6
C
50
7
C
39
252,000
180
0.61
0.20
R
0.3
9
10
W
gg
11
C
34
0.5
121
C
45
0/1.2
0.5
252,000
180
0.61
0.20
-OWN,
13
'14
16
C
45
0
17
C
52
0
252,000
180
0.61
181
0
mg"I'r gg
350,000
180
0.59
0.20
19
PC
40
10 .. .. . . .... ....
20
C
57
0
50
0
252,000
180
0.61
0.20
F1$M
21
C
ti I M
22
R
1
N
23
24
25
R
0.5
26
27
C
51
0
"U"
350,000
180
0.59
0.20
28
C
58
0
29
C
50
0
252,000
180
0.61
0.20
4",
R
0.3
301
"A"
31
R1
1
0-3 1
77260,000
Monthly Loading:
73-5,553
1.19
12 Month Floating T
27.03
. . . . . . . . . . .
. . . . . 1
26.74

FORM: NDAR-1 10-13
Did the application rates exceed the limits in Attachment B of your permit?
21 Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? [Z Compliant ❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? 0 Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? EZ Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑ Compliant [Z Non -Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
CAUSE OF I&I RAINFALL
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC:
Elix Tremaine Fike
Permittee:
Scott Kidd
Certification No.: 989290
Signing Official:
Grade:
SI Phone Number: 336 622 2990
Signing Official's Title: Town Manager
Has the
ORC changed since the previous NDAR-1? ❑ Yes El No
Phone Number: 336 622 4276 Permit Exp.: 8/31 /24
Signature Date
If
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
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 all qualified personnel properly gathered and evaluated 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 fines and imprisonment for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617