WQ0003090_Monitoring - 04-2022_20230127

Monitoring Report Submittal
Permit Number#* WQ0003090
Name of Facility:* Town of Liberty NC WWTP
Month: * April
Report Information
Type *
Revised - NDMR, NDAR-1, NDAR-2, NDMLR
Year:* 2022
Upload Document*
april spray 2022.pdf
PDF Only
3.49 M B
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: 1/27/2023
This will be filled in automatically
Initial Review
Reviewer: Wanda.Gerald

Is the project number correct?* W00003090
Is the monitoring report accepted?* Yes NO
Regional Office* Wilmington
Reviewer: _anonymous
Review Date: 3/15/2023

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page _1_ of _1_

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? IJ 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.
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 El No
Phone Number: 336 622 4276 Permit Expiration: 8/31 /2024
17- If
Z e- off.
0
Signature Date
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

I�VacieAnalytical
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
Page 1 of 1
Report Date: 04/21 /2022
Date Received: 04/07/2022
Project: Town of Liberty WW
Pace Project No.: 92597755
Sample: Effluent Lab ID: 92597755001 Collected: 04/07/22 12:15 Matrix: Water
Method
SM 2540D-2015
EPA 353.2 Rev 2.0 1993
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
ANALYTE QUALIFIERS
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
Total Suspended Solids
7.8
mg/L
2.5
04/11/22 15:00
Nitrogen, NO2 plus NO3
0.077
mg/L
0.040
04/07/22 16:42
Nitrogen, Nitrate
ND
mg/L
0.040
04/07/22 16:42
Nitrogen, Nitrite
0.065
mg/L
0.040
04/07/22 16:42 R1
BOD, 5 day
15.2
mg/L
2.0
04/12/22 20:40
Fecal Coliforms
2420
MPN/100ml-
1.0
04/08/22 10:25 El
Performed by
Pace
04/07/22 12:15
Collected By
Garrett
04/07/22 12:15
Dreyer
Collected Date
04/0712022
04/07/22 12:15
Collected Time
1215
04/07/22 12:15
pH
7.77
Std. Units
04/07/22 12:15
Chlorine, Total Residual
0.05
mg/L
04/07/22 12:15
Total Nitrogen
14.7
mg/L
0.040
04/21/22 11:13
Nitrogen, Ammonia
11.9
mg/L
0.20
04/15/22 14:20
Nitrogen, Kjeldahl, Total
14.7
mg/L
0.50
04/21/22 02:06 M1
Nitrogen, NO2 plus NO3
ND
mg/L
0.040
04/18/22 11:46
Phosphorus
2.3
mg/L
0.050
04/18/22 21:16
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.
M1 Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS) recovery.
R1 RPD value was outside control limits.
Reviewed by:u�C
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, NC 27288
Nnrth r arnlinn nrinkinn Water r:artifinntinn #- 37718
South Carolina Laboratory ID: 99030
South Carolina Certification #: 99030001
VirginiaNELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
VirniniaNFl AP Cartificntinn 0- 4Rnn7Fi

CHAIN -OF -CUSTODY Analytical Request Document
'aceAnalyfical
Chain -of -Custody is a LEGAL DOCUMENT -Complete all relevent fields
': Town of Liberty ! Billing Information:
x C Email To:
i
Site Collection Info/Address:
r Project Name/Number: State: County/City: Time Zone Collected:
/ [ ]PT[ ]MT[ )CT [ ]ET
"Site/Facility ID #: Compliance Monitoring?
[ Yes [ ] No
4I B t : Purchase Order #: DW PWS ID #:
A Quote #: DW Location Code:
tur Turnaround Date Required: Immediately Packed on Ice:
[ ] Yes [ ] No
)isposal: Rush: Field Filtered (if applicable):
:e as appropriate [ ] Return [ ] Same Day [ ) Next Day E [ ) Yes ( ] No
e: [ ) 2 Day [ ] 3 Day [ ) 4 Day [ ] 5 Day ! Analysis:
(Expedite Charges Apply)
Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
t (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), vapor (V), Other (OT)
LAB USE ONLY- Affix Workorder/Login Label Here or List Parr
ALL SHADE® i I
Container ALL
T e `" 1
$ - �— 92597755
** Preservative Types: (1) nitric acid, (2) sulfuric ac;. _ rr woium hydroxide, (5) zinc acetate,
(6) methanol, (7) sodium bisulfate, (8) sodium thiosulfate, (9) hexane, (A) ascorbic acid, (B) ammonium sulfate,
(C) ammonium hydroxide, (D)TSP, (U) Unpreserved, (0) Other
10-
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Lab Sample Receipt Clechiist:
Custody Seals Present/Intact N A
Custody Signatures Present.0
Collector Signature Present N NA
Bottles Intact N NA
Correct Bottles N NA
Sufficient Volume N NA
Samples Received on Ice N
VOA - Headsoace Acceptable Y N
USDA Regulated Soils„N
Samples in Holding 'Time , A
Residual Chlorine Present Y N N
Cl Stripe:
Sample pH Acceptable Y P
pH Strips:
Sulfide Present. y
Lead Acetate Strips:
LAB USE ONLY:
( Lab Sam le # / Comments:
Comp / Collected (or Res # of t— £ Z a) , P
r Sample ID Matrix *
Composite End =
Grab Composite Start} Cl Ctns ci r) � E U
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j Radchem sample(s) screened (<500 cpm): Y N NA
Date/Time: ° eceiver/C':'.mpany:( gn6re)
Received by/Company: (Signature)
SHORT HOLDS PRESENT (<72 hours): Y N N/A
Lab Tracking #:
pies received via:
FEDEX UPS Client
1
Courier Pace Courier
MTJL LAB USE ONLY
Table #:
Acctnum:
LaD:)ampie iernperature;mu:
Temp Blank Received: Y tN7 NA
Therm ID#:�Y
Cooler 1 Temp Upon Receipt: C
Cooler 1 Therm Corr. Factor: oC
Cooler 1 Corrected Temp: oC
Comments:
Template:
Trip Blank Received:
Prelogin:
HCL McOH TSP
PM:
Non Conformance(s): i
PB:
YES / NO
N NA
Other
Page:
of:

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1�;a'ceAnalyficalo
www.pacelabs.com
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Page 1 of 1
Report Date: 04/15/2022
Date Received: 04/14/2022
Project: Town of Liberty
Pace Project No.: 92599261
Sample: Effluent Lab ID: 92599261001 Collected: 04/13/22 13:55 Matrix: Water
Method Parameters
Results Units
Report Limit Analyzed Qualifiers
Performed by
PACE
04/14/22 13:55
Collected By
Garrett
04/14/22 13:55
Dreyer
Collected Date
04/14122
04/14/22 13:55
Collected Time
1355
04/14/22 13:55
pH
7.65 Std. Units
04/14/22 13:55
Chlorine, Total Residual
0.02 mg/L
04/14/22 13:55
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]

CHAIN -OF -CUSTODY Analytical Request document
01/1.o 4nahltira1'
LAB USE ONLY- Affix Workorder/Logir
MTJL Lo
" Chain-ot-custody is a LtuHL L tVLv,wtav I - Lvn,P,Ma a„ , o,ovo i I--
ALL SHADED AREa
Container Preservative Type ** 92599261
I
: Town of Liberty [Billing Information:
s
i
y Email To:
" Preservative
(6) methanol,
(C) ammonium
Types: (1) nitric acid, (2)
(7) sodium bisulfate, (8) sodium
hydroxide, (0)TSP, (U) Unpreserved,
sulfuric acid,
thiosulfate,
(0)
(3) hydrochloric
(9) hexane,
Other
acid, (4) sodium hydroxide, (5) zinc acetate,
(A) ascorbic acid, (8) ammonium sulfate,
Site Collection Info/Address:
Analyses
Lab Profile/Line:
r Project Name/Number: State: County/City: Time Zone Collected:
[ ]PT[ ]MT[ ]CT [ ]ET
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Lab Sample Receipt Checklist:
Custody Seals Present/Intact Y N NA !
Custody Signatures Present Y N NA
Collector Signature Present Y N NA
Bottles Intact Y N NA
correct Bottles Y N NA
Sufficient Volume Y N NA V
Samples Received on Ice YES NA
VOA - Headspace Acceptable Y N NA
USDA Regulated Soils Y SS NA
Samples in Holding Time Y N NA
Residual Chlorine Present Y N NA
Cl Strips:
( Sample. pH Acceptable Y.N NA
( px Stripe:
Sulfide Present Y N.NA !
Lead Acetate Stripe:
LAB USE ONLY:
Lab Sample # ; Comments:
Site/Facility ID #:
Compliance Monitoring?
( Yes ( ] No
Purchase Order -.
Quote #:
DW PWS ID #:
DW Location Code:
y ign u Turnaround Date Required:
Immediately Packed on Ice:
[ ]Yes [ ]No
)isposal: Rush:
e as appropriate [ ] Return ( ] Same Day [ ) Next Day
e: [ ] 2 Day [ ] 3 Day [ ] 4 Day [ ] 5 Day
(Expedite Charges Apply)
Field Filtered (if applicable):
[ ] Yes [ ] No
Analysis:
Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
t (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
r Sample ID Matrix ;
Comp / Collected (or
Grab Composite Start)
Date Time
Res # of
Composite End Cl Ctns
Date Time
it Ww
Y 2
I
1
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__
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IiaVi Gamnio Tomnnratura lnfn•
Remarks / Special Conditions / Possible Hazards: Type of Ice Used: Wet blue ury hone
Packing Material Used:
-jent Monitoring
by/Company:
Radchem 5ample(s) screened (<500 cpm): Y N NA
ny: (S
led by/Company: (Signature) 1, Date/Ti me: Received by/Company:
Lab Tracking #:
pies received via:
FEDEX UPS Client Courier Pace Courier
Date/Time: f r_ MTJL LAB USE ONLY
& Table#:
Template:
Prelogin:
PM:
PEI:
Temp Blank Received: Y N NA
ThermID#:
Cooler I Temp Upon Receipt: _oC
Cooler 1 Therm Corr. Factor: oC
Cooler I Corrected Temp: oc
Comments:
Trip Blank Received: Y N NA
HCL McOH TSP Other
i---
Non Conformance(s): Page:
YES / NO of:

/JVaceAnalytical'
www.pacelabs.com
I
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 05/05/2022
Date Received: 04/21/2022
Project: Town of Liberty
Pace Project No.: 92600408
Sample: Effluent Lab ID: 92600408001 Collected: 04/21/22 12:25 Matrix: Water
Method
Parameters
SM 2540D-2015
Total Suspended Solids
EPA 350.1 Rev 2.0 1993
Nitrogen, Ammonia
EPA 353.2 Rev 2.0 1993
Nitrogen, NO2 plus NO3
EPA 353.2 Rev 2.0 1993
Nitrogen, Nitrate
EPA 353.2 Rev 2.0 1993
Nitrogen, Nitrite
SM 521OB-2016
BOD, 5 day
Colilert-18
Fecal Collforms
TKN+NO3+NO2
Calculation
EPA 351.2 Rev 2.0 1993
EPA 353.2 Rev 2.0 1993
EPA 365.1 Rev 2.0 1993
ANALYTE QUALIFIERS
Performed by
Collected By
Collected Date
Collected Time
pH
Chlorine, Total Residual
Total Nitrogen
Nitrogen, Kjeldahl, Total
Nitrogen, NO2 plus NO3
Phosphorus
Results
Units
Report Limit
Analyzed Qualifiers
21.0
mg/L
6.2
04/2512213:53
11.7
mg/L
0.50
04/24/2214:29
ND
mg/L
0.040
04/21/2216:55
ND
mg/L
0.040
04/21/2216:55
ND
mg/L
0.040
04/21/2216:55
20.4
mg/L
2.0
04/27/2214:17
2420
MPN/100ml-
1.0
04/22/22 09:45 El
Pace
04/21/22 12:25
Garrett
04/21/22 12:25
Dreyer
04121 /2022
04/21/22 12:25
1225
04/21/22 12:25
7.56
Std. Units
04/21/22 12:25
0.12
mg/L
04/21/22 12:25
17.2
mg/L
0.040
05/05/2215:50
17.2
mg/L
0.50
05/05/22 02:00
ND
mg/L
0.040
04/28/2211:09 M1
2.8
mg/L
0.050
05/03/2218:15
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.
M1 Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS) recovery.
Reviewed by: C*) 6- �
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, 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

CHAIN -OF -CUSTODY Analytical Request Document
LAB USE ONLY -Affix workordegLoJL g'ron Babel Here or List Pace Workorder Number or
aceAnalytical
Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fields
ALL SHADED ARE
ly: Town Of Liberty
Billing Information:
Container Preservative T e I II II I I I I I
,.
u 2 $1 1 2600408
"" Preservative Types: (1) nitric acid, (2) sulfuric acid, (3) K.
To:
Email To:
(6) methanol, (7) sodium bisulfate, (8) sodium thiosulfate, (9) hexane, (A) ascorbic acid, (B) ammonium smrate, t
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other y
Site Collection Info/Address:
Analyses
Lab Profile/Line:
er Project Name/Number:
State: County/City: Time Zone Collected:
a
Lab Sample Receipt checklist:
/ [ ]PT[ ]MT[ ]CT [ ]ET
l
Custody Seals PreSeISt11ntaCt Y N NA
custody Signatures Present Y N NA
Site/Facility ID #:
Compliance Monitoring?
[Yes [ ]No
i
Collector Signature Present Y N NA C
Bottles Intact Y N NA
Correct Bottles Y N NA
A By r' Purchase Order #:
DW PWS ID #:
Quote #:
DW Location Code:
Sufficient Volume Y N NA
0
Samples Received on Ice Y N NA
VOA - Headspace Acceptable Y N NA
:d B tur Turnaround Date Required:
Immediately Packed on Ice:
[ ) Yes [ ] NO
USDA Regulated 'Soils Y N NA
O
~
Samples in Holding Time Y N NA
Residual Chlorine Present Y N NA
Disposal: Rush:
Field Filtered (if applicable):
)se as appropriate [ ] Return [ ] Same Day [ ] Next Day
[ J Yes ( ] No
Z
Cl Strips:
ive: [ ] 2 Day [ ] 3 Day [ ) 4 Day [ ] 5 Day
Z 76
tom••)
Sample pH .Acceptable Y N 14A
(Expedite Charges Apply)
Analysis:
O
Z
Y
9�'
1
II
t
S
C
..'
pH Strips:
Sulfide Present y N NA
Lead Acetate Strips:
�
c Codes Insert in Matrix box below): Drinking Water DW , Ground Water GW , Wastewater WW ,
( ) g t ) t ) ( )
ct (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
h— Z
a),
LAB USE ONLY:
Lab Sample # l Comment@:
P
Comp / � Collected (or
Res
# of
er Sample ID Matrix *
Grab Composite Start)
Composite End
CI
Ctns
C] A
._
O v
J
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Date
Time
ate Time
m Z
u: a
1t—
nt WW
g
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er Remarks / Special Conditions / Possible Hazards: ;Type of Ice Used: Wet Blue Dry None
Packing Material Used:
fluent Monitoring
Radchem sample(s) screened (<500 cpm): Y N NA
sbedEorRpmfs �hature) Date/Time: Received by/Compan (Signature)
shed by/Company: (Signature) ; Dalte/Time: I Received
shed by/Company: (Signature) � Date/Time: k Received by/Company:
SHORT HOLDS PRESENT (<72 hours): Y N N/A
Lao oampie i emperdiure imu:
Lab Tracking #:
Temp Blank Received: Y N NA
Therm ID#:
Cooler 1 Temp Upon Receipt: oC
>amples received via:
Cooler 1 Therm Corr. Factor: oC
FEDEX UPS
Client Courier Pace Courier
Cooler 1 Corrected Temp: oC
Date/Time:
- MTJL LAB USE ONLY
Comments:
Table #:
Acctnum:
!Date/Time:
Template:
Trip Blank Received: Y N NA
9q
(Prelogin:
HCL McDH TSP Other
e Date/Time:
lI
PM: I
Non Conformance(s): Page:
PB:
YES / NO of:

f aceAnalyiical a
/ www.pacelabs.com
I
Tremaine Pike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 04/28/2022
Date Received: 04/28/2022
Project: Town of Liberty
Pace Project No.: 92601630
Sample: Effluent Lab ID: 92601630001 Collected: 04/28/22 11:45 Matrix: Water
Method Parameters
Results Units
Report Limit Analyzed Qualifiers
Performed by
Pace
04/28/22 11:45
Collected By
Garrett
04/28/22 11:45
Dreyer
Collected Date
04/28/2022
04/28/22 11:45
Collected Time
1145
04/28/22 11:45
pH
7.52 Sid. Units
04/28/22 11:45
Chlorine, Total Residual
0.03 mg/L
04/28/22 11:45
Reviewed by:�"
Stephanie Knott
704-977-0981
[e-mail]

ZiAnalytical�'
CHAIN -OF -CUSTODY Analytical Request Document
LAB USE CINLY- Affix Workorder"
m
y: Town Of Liberty Billing information:
AI.L�SI�AE17 J 111
Container Preservative 92601630
o: Email To:
" Preservative
(6) methanol,
(C) ammonium
Types: (1)
(7) sodium
hydroxide,
nitric acid, (2)
bisulfate, (8) sodium
(D) TSP, (U) Unpreserved,10)
sulfuric acid,
thiosulfate,
(3) hydrochloric
(9)
Other
hexane,
acid, (4) sodium hydroxide, (5) zinc acetate,
(A) ascorbic acid, (B) ammonium sulfate,
Lab Profile/Line:
Site Collection Info/Address:
Analyses
:r Project Name/Number: State: County/City: Time Zone Collected:
/ [ JPT[ ]MT[ JCT [ ]ET
II
a
CL
M
li
`o
U
9)f}
76
�
:
i
!
Lab Sample Receipt checklist:
Custody Seals Present%Intact Y N NA
Custody Signatures Present Y N NA
collector Signature Present Y N NA I
Bottles. Intact Y N NA
Correct Bottles Y N NA
Sufficient Volume Y N NA
Samples Received on Ice -Y N NA
VOA ; Headspace Acceptable Y N NA
USDA Regulated Soils -Y N NA
Samples in Holding Time Y N NA
Residual Chlorine Present Y N NA
Cl Strips:
Sample pii Acceptable Y N NA
pH Strips:
Sulfide Present Y N NA
Lead Acetate Strips:
LAB USE ONLY:
Lab sample t Comments:
Site/Facility ID #:
Compliance Monitoring?
[YES [ ]NO
d B , t): Purchase Order #:
Quote #:
DW PWS ID #:
DW Location Code:
j By Turnaround Date Required:
Imme lately Packs on Ice:
[ ]Yes [ ]NO
Disposal: Rush:
se as appropriate [ } Return [ ] Same Day [ J Next Day
re: [ ] 2 Day [ ] 3 Day [ ] 4 Day ( ] 5 Day
(Expedite Charges Apply)
Field Filtered (if applicable):
( ] Yes [ ] No
Analysis:
Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
A (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
:r Sample ID
Matrix `
Comp / Collected (or
Grab Composite Start)
D to Time
Composite End
Res
CI
# of
Ctns
Date
Time
it
WW
9
0
!r Remarks / Special Conditions / Possible Hazards: Type of ice Used: wet Blue Dry None
Packing Material Used --
lent Monitoring
Radchem sample(s) screened (<500 cpm): Y N NA
Tipne: Received by/Company: ($ignature)
by/Company: (Signature) I E*e/Ome: ( Received
.hed by/Company: (Signature) � Date/Time: { Received by/Company:
(Signature)
Temp Blank Received: Y N NA
Lab Tracking #:
ThermID#:
I Cooler 1 Temp Upon Receipt: oC
_
>amples received via
Cooler 1 Therm Corr. Factor: oC
FEDEX UPS Client Courier Pace Courier
Cooler 1 Corrected Temp: oC
Date/Time:
MTJL LAB USE ONLY
Comments:
�7 Y i
Table #:
,cctnum: -
emplate: Trip Blank Received: Y N NA
relogin: HCL McOH TSP Other
M: Non Conformance{s}: ,Page:
B: YES / NO j of.

llm.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
16
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
b
Ali
R
Upril 202S
Liberty N.C.W.W.T.F.
Freeboard Lagoon Inches
m
2.0
0.5
TOTAL 3.3

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _1_ of _2_

FORM: NDAR-1 10-13
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit?
❑✓ Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? ❑� 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? ❑✓ 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.
WE WENT OUT OF COMPLIANT ON THE DATE OF 01/03/2022 CAUSE OF RAINFALL. THE RAINFALL TOTAL OF 4.0 INCHES OVER TWO DAYS PERIOD.
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 EZ No Phone Number: 336 622 4276 Permit Exp.: 8/31124
Signature Date 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-'I) Page _2_ of _2_

FORM: NDAR-1 10-13
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit? El Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? P'l Compliant ❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? 21 Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? [Z 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 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-17 ❑ Yes O No
Phone Number: 336 622 4276 Permit Exp.: 8/31/24
45 2 z
Signature Date
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