NCG030124_2022 DMR_20221021

STORNIWATER DISCHARGE OU1 FALL(SDO)
MONI'l ORING REPORT
Permit Number NCS NCG030124 SAMPLES COLLECTED DURING CALENDAR YEAR: 2022
(phis monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
FACILITY NAME Wieland Copper Products,LLC COUNT-Y Stokes
PERSON COLLECFING SAIIIPLE(S) Clifford Cain PIIONE NO.(336 )445-4526
CERTIFIED LABORA'I ORY(S) Pace Analytical-Eden Lab tl
Lab 0
SIGNATURE OF PERMIYFEE OR DESIGNEE
RF,OUIRF:D ON PAGE 2.
Part A:Specific Monitoring Requirements
Oulfall Date 50050
No. Sample Total Total TSS Total CU Lead Oil&Grease Total Zinc PH
Collected Flow(if a Rainfall
mo/dd/vr MG inches
MG/L MG/L MG/L MG/L MG/L
001 9/30122 1,20 2.25 15.6 0.654 0.0016 ND 0.0655 6.4
002 1 9/30122 &223 2.25 10.1 0.239 0.0028 ND 0.0028 &3
003 9/30/22 0.433 2.25 16.7 0.745 0.0020 ND 0.238 6-5
004 9/30/22 0.693 2.25 52.7 1.090 0.0070 ND 0.0971 &4
005 9/30/22 0.347 2.25 16.3 0.637 0.0016 ND 0.184 6-6
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?0)cs Gno
(if yes,complete Part 13)
Part B:Vehicle Maintenance Activity Monitorin Re uirements
Oulfall Date 50050 00556 00530 00400
No. Sample Total Flow Total Oil&Grease Non-polar Total pH Now.Motor
Collected (ifapplicable) Rainfall (ifappL) O&G/fPll Suspended Oil I[sage
(Method 1664 Solids
SG-F-HEM),if
appl.
mo/ddhr MG inches mVA m /l unit gaLlmo
N/A
Form SWU-247,last revised 611212015
Page I of 2

S'l ORNI EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Date 9/30/22 Alin Central Files
Total Event Precipitation(inches): 2.25 1617 Mail Service Center
Event Duration(hours): __(only ifapplicable-see permit.) Raleigh,North Carolina 27699-1617
(if more than one storm went Nsas sampled)
Date NIA
Total Event Precipitation(inches):__
Event Duration(hours): (only if applicable see permit)
"1 certify,under penalty of law,that this document and all attachments Acre 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 nonage 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 Mare that there are significant penalties for submitting false information,
including the possibility of finGi and imprisonment for knowing violations."
Z �2
(S`ignature of Permi ee) (Date)
Form S W U-247,last revised 611212015
Page 2 of 2

Footnotes:
1 Total Toxic Organics sampling is applicable only for those facilities which perform metal finishing operations,manufacture ss-niconductorx,oranufaaure ciaxnmic crystals,m
manufacture cathode nay tuba For purposes of this permit the definitions of Total Toxic Organics is that definition contained in the EPA Effluent Guidelines for the facilities subjea-t
to the rcquirancnt to sample(for metal finishing use the definition as found in 40 CFR 433,1 1;for semiconductor manufacture use the definition as found in 40 CFR 469.12;for
cloctnmic crystal manufacture u c the dairiition as found in 40 CFR 469.22;and fix cathode-ray tube manufacture use the definition found in 40 CFR 469-31),
Facilities that develop a solvent management plan to be inccxporatod into the Stormwatcr Pollution Prcnantien Plan may make a request to DWQ that monittmng of total toxic
organics be waived The solvent managartct plan shall include a list of the total toxic organic cxtmpounds used;the method of dupnxd used instead of dumping,such as
reclamation,contract hauling,or incineruicm;and the procedures for assuring that toxic organics do not routinely spill or le a into the sto onwater. For those facilities allowed such
a waiver,the discharger s'nall include the following signed certification suimcni on the discharge monitoring report
"Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit monitoring n quir=cnt for
total toxic organics(TTO),I certify that to the host of my knowla%c and belief,no dumping of concentrated toxic organics into the
stormw•ater or areas which are exposed to rainfall or stormwatcr rur.ofThas occurred since filing the last discharge monitoring report. 1
further certify,that this facility is implementing the solvate managanatt plan included,in die Stnrmwatcr Pollution Prevention flan"
)
X ,1 JX D E A,ti tl�
Name(pknasc print
A _
it le
nature ate
"I certify,tinder penalty of law,that this document and all attachments were prepared under my direction or supervislon 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 systeta,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 floes and ipiprisonment for knowing violations."
(Signature of Per ittee) (hate)
Form MR-03
Page 2 of 2

£m ironrtental
Quc4ty
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this jomi,please visit htros:'!deg.ne.,ovlabout'divisions.'enerty-mineral-land-
resources'enerw-mineral-land-permits/stormwater-pennitslnpdce-industrial-swstab-1
Permit No.: NICI_l_l_l_1_l_l / or Certificate of Covera,e No.: N/C/G/0/3/0/
f ` l I
Facility Name: WI e.-1 Ct-Y1C1 (' (-, p f ('trl
County: Phone No.
Inspector: KIAJ
1 ,
Date of Inspection: —30—r�
Time of Inspection: ` tYw
t2
Total Event Precipitation(inches):
All permits require qualitative monitoring to be performed during a"measurable storm event."
A"measurable storm event" is a storm event that results in an actual discharge from the permitted site
outfall. The previous measurable storm event must have been at least 72 hours prior. The 72-hour storm
1 interval does not apply if the permittee is able to document that a shorter interval is representative for
local storm events during the sampling period,and the pennittee obtains approval from the local DEMLR
Regional Office.
By tlus signature, I certify that this report is accurate and complete to the best of my knowledge:
(Signatur f Pennittee or Designee)
1. Outfall Description:
Outfall No. _OD f Structure(pipe,ditch, etc.):
Receiving Stream:
Describ industrial activities that occur within the outfall drainage area:
r,MLice—
Page I of 2
SNW-242.List modified 0728/2017

2. Color: Describe the color of the discharge usi g basic colors(red,brown, blue, etc.) and tint
(light, medium, dark)as descriptors: f eeLr r 4)1:7-
3. Odor: Describe ainyY distinct odors that the discharge may have(i.e.,smells strongly of oil,weak
chlorine odor, etc.):
4. Clarity: Choose the number which best describes the clarity of the discharge, where I is clear
and 5 is very cloudy:
0 2 3 4 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stonmvater discharge,where I is no solids and 5 is the surface covered with floating solids:
ID
2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stonnwater discharge,where I is no solids and 5 is extremely muddy:
0 2 3 4 5
7. Is there any foam in the stonnwater discharge? O Yes ® No.
8. Is there an oil sheen in the stonnwater discharge:? OYes m No.
9. Is there evidence of erosion or deposition at the outfall'? O Yes d No.
10. Other Obvious Indicators of Stormwater Pollution:
List and describe fQb''og
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or crosion!deposition may he
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SwU-2.12,tact modified 07/28/2017

I
Ent ir(3nrxnra!
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this fornr,please visit hams://deg.nc.sovlabout`divisions,'enerav-mineral-land-
resources'enerev-m i neral-land-permi is/stormwater-pennits/npdes-industrial-sw#tab--1
i
Permit No.: N/C/_/ l I_l_l l_I_l or Certificate of Coverage No.: N/C/G/0/3/0/
Facility Name: W1 Cl CLn C C)pO f C
County:
//- 1i�D�� n Phone No.
Inspector: l ��&ILr11IA t 'A in
Date of Inspection:
Time of Inspection: L14l�
Total Event Precipitation(inches): 2
Alf pennits require qualitative monitoring to be performed during a"measurable storm event." i
A"measurable storm event"is a storm event that results in an actual discharge from the permitted site I
outfall. The previous measurable storm event must have been at least 72 hours prior. The 72-hour storm
interval does not apply if the permittee is able to document that a shorter interval is representative for
local storm events during the sampling period,and the pennittee obtains approval from the local DEMLR
`Regional Office. y_
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
(Signs f Permittee or Designee)
1. Outfall Description: np
Outfall No. VQ�k Structure(pipe,ditch, etc.): pet-,
Receiving Stream:
Describe tote industrial activities that occur within the outfall drainage area:
Page I of 2
SWU-242,Last modified 07P-8l2017

2. Color: Describe the color of the discharge using basic colors(red,brown, blue, etc.)and tint �
(light, medium,dark)as descriptors: ,
3. Odor: Describe any dist��odors that the discharge may have(i.e.,smells strongly of oil,weak
chlorine odor,etc.): J
4. Clarity: Choose the number which best describes the clarity of the discharge,where 1 is clear
and 5 is very cloudy:
2 3 4 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stormwater discharge,where 1 is no solids and 5 is the surface covered with floating solids:
L'I
2 .34 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge,where l is no solids and 5 is extremely muddy:
11 I 2 3 4 5
7. Is there any foam in the stormwater discharge? O Yes 0 No.
8. Is there an oil sheen in the stormwater discharge? 0Yes g�No.
9. Is there evidence of erosion or deposition at the outfalI) o Yes Qai'o.
10. Other Obvious Indicators of Stormwater Pollution:
List and describe ��
Note: Low clarity,high solids, and/or the presence of foam, oil sheen,or erosion/deposition may be
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SNVU-242,Last modified 07128R017

i
i
Envircrnertat
Qua:ity
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance onfllingoul thisjorm,please visit httiwfldea.nc.00v!abouddivisions/enerey-mineral-land-
resources.�enerev-ini neral-land-nermi ts/stormwater-pennits/npdes-industrial-s%vgtab4
Permit No.: N/C/_/_/ / /_/_I_/ or Certificate of Coverage No.: N/C/G/0/3/o/
Facility Name: G-r\C-1
County: S Phone No.
Inspector: t
Date of Inspection:
Time of Inspection:
Total Event Precipitation(inches): I ZJ
All permits require qualitative monitoring to be performed during a"measurable storm event."
A"measurable storm event"is a storm event that results in an actual discharge from the permitted site
outfall. The previous measurable storm event must have been at least 72 hours prior. The 72-hour storm
interval does not apply if the petmittee is able to document that a shorter interval is representative for
local storm events during the sampling period,and the pennittee obtains approval from the local DE&fLR
Regional Office.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
/,,WJ,4 ik
(Signs of PeLmittee or Designee)
1. Outfall Description: ' ,,
Outfall No. ` a Structure(pipe, ditch,etc.): _d,a 7t A
Receiving Stream:
Describe the industrial activities that occur within the outfall drainage area:
Page l of 2
SW U-2A2,Last modified 07/28/2017

2. Color: Describe the color of the discharge using ba is colors(red,brown,blue,ctc.)and tint
(light, medium, dark)as descriptors: �?')() If2/1
3. Odor: Describe aVy0istinct odors that the discharge may have(i.e., smells strongly of oil,weak
chlorine odor,etc.): 191-le
4. Clarity: Choose the number which best describes the clarity of the discharge,where l is clear
and 5 is very cloudy:
4 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stormwater discharge,where I is nod solids and 5 is the surface covered with floating solids:
( 1 / 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge,where I is no solids and 5 is extremely muddy:
1 2 G) 4 5
7. Is there any foam in the stormwater discharge? O Yes dMo.
8. Is there an oil sheen in the stormwater discharge? OYes of-NCI.
9. Is there evidence of erosion or deposition at the outfall? o Yes O*No.
10. Other Obvious Indicators
iIndicators of Stormwater Pollution:
List and describe ► y;,�
Note: Low clarity, high solids, and/or the presence of foam,oil sheen,or erosion/deposition may be
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SWU-242.Last modified 0728.2017

g�7 i
En:ironnental
Stormwater Discharge Otitfall (SDO)
Qualitative Monitoring Report
For guidance on filling out thisjorm,please visit hUps:'/deg.nc.aov/about'divisionslenerev-mineral-land
resources'ener,v-ini neral-land-oermiW.-,torTnwater-pennitslnpdes-itidustrial-sci n tab-
Permit No.: NIC/_/ I l l I_l_1 or Certificate of Coverage No.: N/Q GI OQ3 O I
Facility Name: Wl d axY C-1
County: Phone No.
Inspector: y
Date of Inspection: - : 3&j—�
Time of Inspection: Lo
Total Event Precipitation(inches): Z` ZS
All permits require qualitative monitoring to be performed during a"measurable storm event."
A"measurable storm event"is a storm event that results in an actual discharge from the permitted site
outfall. The previous measurable storm event must have been at least 72 hours prior. The 72-hour storm
interval does not apply if the permittee is able to document that a shorter interval is representative for
local storm events during the sampling period,and the permittee obtains approval from the local DENILR
Regional Office.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
1 �
(Sigpatur f Perrruttee or Designee)
1. Outfall Description:
Outfall No. (k) -4 Structure(pipe,ditch,etc.): 4fA
Receiving Stream:
Describe the indu trial activities that of cur within the outfall drainage area:
Page 1 of 2
SWU-242,Last modificd 07/282017

2. Color: Describe the color of discharge usin-basic colors(red,brown,blue,etc.)and tint
(light, medium, dark)as descriptors: C'
3. Odor: Describe any distinct odors that the discharge may have(i.e., smells strongly of oil,weak
chlorine odor, etc.): W w-y-
4. Clarity: Choose the number which best describes the clarity of the discharge,where l is clear
and 5 is very cloudy:
I 2 �; j 4 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stormwater discharge,where 1 is no solids and 5 is the surface covered with floating solids:
CC) 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge,where 1 is no solids and 5 is extremely muddy:
] 2 3 4 5
7. Is there any foam in the stormwater discharge? o Yes 0'No.
8. Is there an oil sheen in the stormwater discharge? oYes 6 No.
9. Is there evidence of erosion or deposition at the outfall? o Yes VNo.
10. Other Obvious Indicators of Stormwater Pollution:
List and describe 0O'Dt
Note: Low clarity,high solids,and/or the presence of foam,oil sheen,or erosion/deposition may be
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SWU-242,List modified 0MHP-017

Environmental
Quality
Stormwater Discharge Outfall (SDO)
Qualitative 'Monitoring Report
For guidance on filling out this form,please visit https://dea.nc._ov'about.'divisionsiencrev-mineral land
resoureeslener_v-mineral-land-permits/stormwater-pennits/npdes-industrial sw,tab--t
Permit No.: N/C/_/_I / /_/_/ / or Certificate of Coverage No.: N/C/G/0/3/0/
Facility Name: W1 O DU'1C1 r
County: LPhone No.
Inspector: Ozik
Date of Inspection:
Time of Inspection: i'zM
Total Event Precipitation(inches): ` Z
All permits require qualitative monitoring to be performed during a"measurable storm event."
A"measurable storm event"is a stone event that results in an actual discharge from the permitted site
outfall. The previous measurable storm event must have been at least 72 hours prior. The 72-hour storm
interval does not apply if the permittee is able to document that a shorter interval is representative for
local storm events during the sampling period,and the permittee obtains approval from the local DEh1LR
Regional Office. -�
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
(Signature kf ennittee or Designee)
1. Outfall Description: 1
Outfall No. Structure(pipe,ditch,etc.):
Receiving Stream:
Describe the industrial activities that occur within the outfall drainage area:
cwuc 4211)6
Page l of 2
SWU-242,Last modified 0712812017

2. Color: Describe the color of discharge us'na basic colors(red,brown,blue,etc.)and tint
i
(li,-ht, medium,dark)as descriptors:
3. Odor: Describe any d�ff stinet odors that the discharge may have (i.e.,smells strongly of oil,weak-
chlorine odor,etc.): ALX)e--
4. Clarity: Choose the number which best describes the clarity of the discharge,where 1 is clear
and 5 is very cloudy:
I C23 4 5
�. Floating Solids: Choose the number which best describes the amount of floating solids in the
stormwater discharge,where 1 is no solids and 5 is the surface covered with floating solids:
(1 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge,where 1 is no solids and 5 is extremely muddy:
1 2 3 4 5
7. Is there any foam in the stonmwater discharge? o Yes 40 No.
8. Is there an oil sheen in the stormwater discharge? OYes Q'No.
9. Is there evidence of erosion or deposition at the outfall? O Yes 0*i4o.
10. Other Obvious Ind' ators of Stormwater Pollution:
List and describe
Note: Low clarity,high solids,and/or the presence of foam,oil sheen,or erosion/deposition may be
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
swtt-242,Last modified 07/28l2017

Q �7 Pace Analytical Services,LLC
' a c Al aYica! 1377 South Park Drive
Kemersville,NC 27284
wwx.pacelabs.corn [phone]
Page 1 of 2
Laboratory Report
Tony Sprinkle Report Date: 10/20/2022
Wieland Copper Products Date Received: 10/03/2022
3990 US 311 Hwy North
Pine Hall, NC 27042
Project Wieland Copper-SW
Pace Project No.:92628717
Sample: 001 Lab ID: 92628717001 Collected: 09/30/22 16:30 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
SM 254OD-2015 Total Suspended Solids 15.6 mg/L 2.5 10/04/22 16:49
EPA 1664B Total Petroleum Hydrocarbons ND mg/L 4.9 10/12/22 00:15
EPA 200.8 Rev 5.4 Copper 654 ug/L 20.0 10/10/22 18:59
EPA 200.8 Rev 5.4 Lead 1.6 ug/L 1.0 10/10/22 05:11
EPA 200,8 Rev 5.4 Zinc 65.5 ug/L 10.0 10/10/22 05:11
Performed by PACE 09/30/22 1630
Collected By Cliff Cain 09/30/22 16:30
Collected Date 09/30/22 09/30/22 16:30
Collected Time 1630 09/30/22 16:30
pH 6.4 Std. Units 09/30/22 16:30
Temperature 17.0 deg C 09/30/22 16:30
Sample: 002 Lab ID: 92628717002 Collected: 09/30/22 16:40 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
SM 2540D-2015 Total Suspended Solids 10.1 mg/L 2.5 10/04/22 16:46
EPA 1664E Total Petroleum Hydrocarbons ND mg/L 4.9 10/12/22 00:15
EPA 200.8 Rev 5.4 Copper 239 ug/L 10.0 10/10/22 19:11
EPA 200-8 Rev 5.4 Lead 2.8 ug/L 1.0 10/10/22 05:22
EPA 200.8 Rev 5.4 Zinc 44.3 ug/L 10.0 10/10/22 05:22
Performed by PACE 09/30/22 16:40
Collected By Cliff Cain 09/30/22 16:40
Collected Date 09130/22 09/30/22 16:40
Collected Time 1640 09/30/22 16:40
pH 6.3 Std.Units 09/30/22 16:40
Temperature 16.0 deg C 09/30/22 16:40
Sample: 003 Lab ID: 92628717003 Collected: 09/30/22 16:50 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
SM 254OD-2015 Total Suspended Solids 16.7 mg/L 2.9 10/04/22 16:51
EPA 1664B Total Petroleum Hydrocarbons ND mg/L 4.9 10/12/22 00.15
EPA 200.8 Rev 5.4 Copper 745 ug/L 20.0 10/10/22 19:15
EPA 200.8 Rev 5.4 Lead 2.0 ug/L 1.0 10/10/22 05:26
EPA 200.8 Rev 5.4 Zinc 238 ug/L 100 10/10/22 19:15
Performed by PACE 09/30/22 16:50
Collected By Cliff Cain 09/30/22 16:50
Collected Date 09130122 09/30/22 16:50
Collected Time 1650 09/30/22 16:50
pH 6.5 Std. Units 09/30/22 16:50
Temperature 18.0 deg C 09/30/22 16:50
Page 1 of 5

�/ �(.�U Pace Analytical Services,LLC
11' a^Q ^nalXica' 1377 South Park Drive
lil, !li Kemersvtlle,NC 27284
www.pacelabs,com [phone]
Page 2 of 2
Sample: 004 Lab ID: 92628717004 Collected: 09/30122 16:52 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
SM 2540D-2015 Total Suspended Solids 52.7 mg1L 4.8 10/04/22 16:46
EPA 1664B Total Petroleum Hydrocarbons ND mg/L 4.9 10/12/22 00:15
EPA 200.8 Rev 5.4 Copper 1090 ug/L 20.0 10/10/22 19:18
EPA 200.8 Rev 5.4 Lead 7.0 ug/L 1.0 10/10/22 05:30
EPA 200.8 Rev 5A Zinc 97.1 ug/L 10.0 10/10/22 05:30
Performed by PACE 09/30/22 16:52
Collected By Cliff Cain 09/30/22 16:52
Collected Date 09/30122 09/30/22 16:52
Collected Time 1652 09/30/22 16:52
pH 6.4 Std.Units 09/30/22 16:52
Temperature 18.0 deg C 09/30/22 16:52
Sample: 005 Lab ID: 92628717005 Collected: 09/30/22 17:00 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
SM 2540D-2015 Total Suspended Solids 16.3 mg/L 2.7 10/04/22 16A8
EPA 16648 Total Petroleum Hydrocarbons ND mg/L 4.9 10/12/22 00:15
EPA 200 8 Rev 5A Copper 637 ug/L 20.0 10/10/22 19:30
EPA 200-8 Rev 5.4 Lead 1.6 ug/L 1.0 10/10/22 05:34
EPA 200.8 Rev 5.4 Zinc 184 ug/L 10.0 10/10/22 05:34
Performed by PACE 09/30/22 17.00
Collected By Cliff Cain 09/30/22 17:00
Collected Date 09/30/22 09/30/22 17:00
Collected Time 1700 09/30/22 17:00
pH 6.6 Std.Units 09/30/22 17:00
Temperature 16.0 deg C 09/30/22 17:00
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Pace Analytical Services Charlotte
South Carolina Laboratory ID:99006 South Carolina Certification#: 99006001
9800 Kincey Ave.Ste 100,Huntersville,NC 28078 South Carolina Drinking Water Cert.#:99006003
North Carolina Drinking Water Certification#:37706 Florida/NELAP Certification#:E87627
North Carolina Field Services Certification#:5342 Kentucky UST Certification#:84
North Carolina Wastewater Certification#: 12 Louisiana DoH Drinking Water#. LA029
South Carolina Laboratory ID:99006 VirginiaNELAP Certification#:460221
Pace Analytical Services Asheville
2225 Riverside Drive,Asheville,NC 28804 South Carolina Laboratory ID:99030
Florida/NELAP Certification M E87648 South Carolina Certification#:99030001
North Carolina Drinking Water Certification#.37712 VirginiaNELAP Certification#:460222
North Carolina Wastewater Certification#:40
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 2 of 5

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Carrier Tr3c!<ing Number:
Cust--dy Seal Pr_ser:? [I'fes I?iC Se3!s Intact? 71'/2s ❑tiz C3teJ1ritia!s Person Sxaminin;Con
)3 A. M3terial: L='mot:_E3gi El :re C C:hEr Biiiegical Issue Fr
ry
'hermemeter: ❑ IR Gun IC: 14-12—T O b L Tryc of Ica: ❑'r:et ❑?Ice ❑?I_nz QY�s ❑?!0 1i
aeler Tarp('C): D L Carre::ion Fs:tar.Ad /Su`'tr=('C) — ' Temp s`Ccld to aoeve freezing to
I- ❑=ar..Fl2s cu:cf tome t..•_ra.Sa^
Torre:?:C3cl2r Tamp('C): U has be;un
:SDA Re;jlated Soil(a N/A,water sample)
:id samp",crgin3:a in a Gs3r;n;ir.3 zone within the United St31as:G:,NY,cr SC(-he:k mars)? Ci3 sam;Ias crj n3:e f:-+3 forel;n Sew
OIYes M-1.3 it c'ud:rit H3:v aii acd Puenn;:cci?M"i:
I Ccmmar.t:/vi:zrenancrt
Chain of Custcdy Present? jf fes ❑a3 f]N/A 1 1.
Samcles. v-hin Held Tare? IJY+; rirJa rN" l2.
5.crt Hc!d T.r- analysis(<72 hr.)? •vas !�io C)WA 3.
P.u:h Tura Around Time R2_ues:+:? ❑,,p�res to ❑I;s A.
Suff!c!entVslurna? (ryes Clio ❑r11A I5.
Ccrre:t Ccrtaiiners Used? ['f res ❑n' ❑a/A 16.
-Pace Ccr.t3iners Used? [fvas Otto ❑!I/A
ecntalr.erIntact? 0Ves pea On"'. 17.
Cissctv?d era:ysis:53r Iles Field Filtartd? Oves O!Ne []23/A 13.
Sample Labels klatch COO Cry- 0,;0 ❑rt/A 4.
-Includes D3te/Time/10/Analysis Matrix: WT I
' He3dseace in VOA Vials M-61--m)? ❑Yes O::e 0'%"%
Trip Elan%Present? CYes ❑ao IfA
Trio Elan%Cu"'d'!Seals Pro«nt? j 1Y25 Ona ffi/A
COM.- ENTS/SAUIPLS DISCREPANCY Field Data Raga
Lot ID of sclit containers:
Feverl
p Leg:Temp must be maintained CLIENT NOTiFlCATIONJRSSOWT10N
6 C during login,record temp
20 minutes.
e ern;
2S 0 Temp: .S
e:( 3 O o put in cooler
Time: Temp:
Person Cent3ctad: Da:erime:
Project Manager SCURF Review: r Date:
Project Niana;er SRF Review: Date:
Ousltrax Document ID:70677 Papa 1

Document Name: I Occument Issued:November 15,2021
Bottle Identification Form(3IF) Pap 1 of 1
1�581ce
Ana,�tiCdl' I Document No.: Issuing Authority:
F-CAR-CS-033-Rev.01 I Pace Carolinas Quality CffiCe
*Check mark top half of box if pH and/or dechlorination is Project#
verified and within the acceptance range for preservation
samples. w le ( (li�/� C
Exceptions:VOA,Coliform,TOC,Oil and Grease,DRO/30_5(water)DOC,LLHg
*`Bottom half of box is to list number of bottles
< Zoo
`u <
iL d u -U y v W n n 9 CV V V ? �".. Z 1 1
U v V Q C Z U C 7 \ C 2
O V A V '_ N O < rl Z L1 \ U U N C! •'J 6,
G G C N C < C �_ _ G O N \_ C
2 O c
c m 7
< u a n C
< < J < O O O> O C C C C
E o OEE rr E of E E
E v M n ._. Q rZn a v '•�i `~ r�'n m it n � �
u oo
C. a a a a L L l7 V l7 V l7 t7 V V V l� O :^ ^� m o ci
s m c o `m c m m o 3 < < < < < < o > > o > > m ¢ > c
' N1 I ' 1 I I N?�-, 'r I I I I I 1
211 ( N11\, 1\NI 1 1 III
31N 11 1 11I N\
I " l 1 ( I I I2 \NI I I 1 11 N
I \N\\l \1 51 � I� ' 12 I III
NN\ I I I I IN
I II N NNN I I I I I
e
10
I
' I I I NN\\sI I \—N \1 I L NNNN I N \1 I I I I 11 T
11IN 1
I
2I
\1 NNNI —L I I L EN
pH Adjustment Log for Preserved Samples
Sample ID Type of Preservative pH upon receipt Date preservation adjusted Time preservation Amount of Preservative Lot a
adjusted added
r
Note:Whenever there is a discrepancy affecting North Carolina compliance samples,a copy of this form will be sent to the North Carolina DEHNR Certification Office(i.e.
Out of hold,Incorrect preservative,out of temp,incorrect containers.
Page 5 of 5