WQ0002096_Monitoring - 02-2023_20230426

Monitoring Report Submittal
.....................................................
Permit Number#* WQ0002096
Name of Facility:*
Month: * February
Report Information
Ahoskie Assisted Living
Year:* 2023
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR AAL Mar23 NDMR.PDF 265.42KB
PDF Only
GW-59 AAL GW-59A.PDF 2.88MB
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: * Paula Armstrong
Signature:
Date of submittal: 4/26/2023
This will be filled in automatically
Initial Review

Reviewer: Wanda.Gerald
Is the project number correct?* WQ0002096
Is the monitoring report accepted?* Yes No
Regional Office* Washington
Reviewer:
Review Date:

GW-59A COMPLIANCE REPORT FORM Permit # VV rt) (P
(Submit one each monitoring period with GW-59 forms.)
1
Enter date monitoring results were due. Will this monitoring report (GW-59 and GW-59A)
YES
NO
be submitted after the established due date.
2
Was any required information missing on the GW-59 report forms?
YES
NO
IF the answer to question 1 or 2 is "YES", list in the space provided below the well identification number(s) and
explain the problems encountered in obtaining the required information.
3
Are any of the monitor wells in need of repair or maintenance (damaged casing, unlocked or missing cap, missing
YES
NO
identification plate, area overgrown, etc.)? If the answer is "Yes", contact the Regional Office for guidance.
4
Are any monitored constituents equal to or above the established standards?
YES
NO
If the answer to question 4 is NO", skip to section 8.
If the answer to question 4 is "YES" list the affected wells individually with constituent(s) and concentration(s)
exceeding standards in the space provided below:
to vw - .5 mF= Fe co-i j o I I tD(r)L-
rnw -5 TD C
5
For the constituents identified in question 4 above, have standards been exceeded previously for the
YES
NO
same constituent(s) in the same well(s) in the last two years?
If the answer to question 5 is NO", skip to section 8.
If the answer to question 5 is "YES", list in the space provided below, each well with constituent(s) exceeding
standards, concentration(s) repotted, and sample collection date for each occurrence (for.the last two years).
(11W -5 MF F C6J 21106m t. 211-712i M W-5 6- C, l 5.34p m51 - L/Il�l2z
w 5 roc, jC LrvS1-241'7121 Mw 5 MF Fecc4 W/91 "
rnw-E)-rot✓ ie, ((v rn5ji--Ojai/ a4
(nw-5 7oG 1 9,LN ✓V1 1L. C1jf3)21
Are the monitoring wellslisted in section 5 located at or beyond the review boundary?
YES
60
If the answer is "YES", a groundwater quality problem may be occurring. CONTACT THE REGIONAL
OFFICE IMMEDIATELY FOR GUIDANCE. If the answer is "NO", monitoring wells may be improperly
located; contact the Regional Office.
7
Is the permittee implementing previously approved actions required by the Division involving this
YES
O
groundwater quality problem?
If the answer to question 7 is "YES", describe those actions in the space provided below.
If the answer to question 7 is "NO", contact the Regional Office within 90 days: an evaluation may be
required to determine the impact the waste disposal system is having at the review and compliance
boundaries surrounding this facility. Failure to do so may subject the permittee to a Notice of Violation,
fines, and/or penalties.
8
The person completing this portion (G W--59A) of the monitoring report should sign below and submit this
form with GW-59 forms for required wells to the address provided at the top of the current GW-59 form.
I hereby acknowledge that the above information was evaluated and the information submitted in this
report ( nee Report GW-59A) is true and complete to the best of my knowledge.
2
sij-z—
Signafbrwlbfmi ee (or Authorized A ent) Date
GW-59A 12/8/2003

SUBMIT FORM ON YELLOW PAPER ONLY
• •
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
-
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
Please Print
FACILITY INFORMATION`/I (� 1,.,
Clearly or Type
PERMIT Number: Expiration Date: � Z
Facility Name: lust Ie) I ► IS+ea �l JI ►RYA
vi Aj y F
Non-Dischargecoz/oC1 UIC
Permit Name (if different):
NPDES Other
Facility Address: 2 SO 10
d
TYPE OF PERMITTED OPERATION BEING MONITORED
` (street) G L%
1U County
❑ Lagoon ❑ Remediation: Infiltration Gallery
(City) (State) (zip)
Spray Field El Remediation:
Contact Person: kudq ParKer
Telephone#:
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: a el
No. of wells to be sampled: _13
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION /y� I
WELL ID NUMBER Permit): 1114� — "j
Date �LI �j' 0L3
If WELL
WAS
(from
sample collected:
FIELD ANALYSES:
Well Depth: Iq ft.
Well Diameter: in.
pH 00400: 4,q units Temp. 000lo: °C
DRY at
Depth to Water Level szsp
j5 ft. below measuring point Screened Interval: y- ft. to � -r ft.
Spec. Cond. oosao: µMhos
time ofsampling,
pas:
Measuring Point is 2_t�ft. above land surface
Relative M.P. Elevation: ft.
Odor 00085:
check
Volume of water pumped/bailed before sampling: .
gallons
Appearance i'y'ladd
here:❑
Samples for metals were collected unfiltered: ElYES
❑ NO and field acidified: ❑ YES ❑ NO
LABORATORY INFORMAT ON
_
L:hVl
Date sample analyzed: 2
Laboratory Name: r0O MW f
Certification No.
PARAMETERS NOTE: Values should reflect dissolved
and colloidal concentrations.
COD 00335 mg/L
Nitrite (NO2) as N 00615
mg/L
Pb - Lead o1o51 ug/L
Coliform: MF Fecal 31616 I /100ml-
Nitrate (NO3) as N 00620 �p� OL.
mg/L
Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100ml-
Phosphorus: Total as P 00665 0, z-L+
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L
Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 �j mg/L
AI - Aluminum oilm
mg/L
pH (Lab) 00403 units
Ba - Barium 01007
ug/L
TOC oosao / (� mg/L
Ca - Calcium 00916
mg/L
Chloride oosao .3 if mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002 ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552 mg/L
Cu - Copper 01042
mg/L
ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730 ug/L
Fe - Iron 01045
ug/L
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945 mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) ❑ No (0)
pecific Conductance 00095 µMhos
K - Potassium 00937
mg/L
VOC 7873 method #
Total Ammonia 00610 0; Cl� mg/L
Mg - Magnesium 00927
mg/L
method #
(Ammonia Nitrogen; NH, as N; Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L
, method #
TKN as N 00625 mg/L
Ni - Nickel 01067
ug/L
method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%

SUBMIT FORM ON YELLOW PAPER ONLY
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
FACILITY INFORMATION Please Print Clearly or Type
PERMIT Number: Expiration Date: q3C) UG
Facility Name: A 5TXj c fi,sS, .$� L., V � ►�
_
a �u G(.l i F
Non -Discharge UL�( (?0020 9lo UIC
Permit Name (if different):
NPDES Other
Facility Address: ,,T0, Wj-) E7gr 1 V S+af vn OCi
TYPE OF PERMITTED OPERATION BEING MONITORED
Ah DSK i e, (Street) n% G r,% 1 D County er � Ord
❑ Lagoon ❑ Remediation: Infiltration Gallery
(City) (State) (Zip)
EVSpray Field El Remediation:
/
w Contact Person: i�lt l lt,i�% Pci-
Telephone#: O5IZ Sl3 — 8759 I
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: �S,(2raVf-,.eIG{.
No. of wells to be sampled:'q
❑ Water Source Heat Pump ❑ Other:
from Permit
SAMPLING INFORMATION _
MW
If WELL
WELL ID NUMBER (from Permit):
Date sample collected:
FIELD ANALYSES:
WAS
Well Depth: Z 1 ft.
Well Diameter: Z in.
pH 00400:5 0 units Temp. 000lo: °C
DRY at
Depth to Water Level 82546: ft. below measuring point Screened Interval: to
I
ft. Spec. Cond. 00094: µMhos
time of
Measuring Point is 2,-5 ft. above land surface
_%ft.
Relative M.P. Elevation: ft.
Odor 00085:
sampling,
check
Volume of water pumped/bailed before sampling: _ gallons
Appearance Du o y
here: ❑
Samples for metals were collected unfiltered: El YES
El NO and field acidified: ❑ YES El NO
LABORATORY INFORM TION
Date sample analyzed: — �bl V�
Laboratory Name:
Certification No. Q
PARAMETERS NOTE: Values should reflect dissolved
and colloidal concentrations.
COD 00335 mg/L
Nitrite (NO2) as N 00615
mg/L Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 i U /100mL
Nitrate (NO3) as N 00620 C, (� T
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504 /100mL
Phosphorus: Total as P 00665
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 A90 mg/L
Al - Aluminum olim
mg/L
pH (Lab) 00403 units
Ba - Barium 01007
ug/L
TOC 00680 13 , 3 mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002 ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552 mg/L
Cu - Copper 01042
mg/L ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730 ug/L
Fe - Iron 01045
ug/L (Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945 mg/L
Hg - Mercury 71900
ug/L Lab Report Attached? ❑ Yes (1) ❑ No (0)
pecific Conductance 00095 µMhos
K - Potassium 00937
mg/L VOC 7873 method #
Total Ammonia 00610 (� e U I I' mg/L
Mg - Magnesium 00927
mg/L method #
(Ammonia Nitrogen; NH3 as N; Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L method #
TKN as N 00625 mg/L
Ni - Nickel 01067
ug/L method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%
Permittee (or Authorized Agent) We and Title - Please print or type

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
FACILITY INFORMATION Please Print Clearly or Type
Facility Name: )oi gi-o ft i,4ed LI✓I lit biiiNirF
Permit Name (if different):
Facility Address: nc'Iy � Utkf &Gi r q S4aki on ��
�}�asyu -c,/ (street) , / 79/% County -e77 f>r�-C..
(City) (State) (zip)
Contact Person: -Aady rp cc.rker Telephone#:
Well Location/Site Name: e I CL No. of wells to be sampled: 3
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
INFORMATION PROCESSING UNIT
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
PERMIT Number: Expiration Date: 3C) LG15
Non -Discharge waowfOLA UIC
NPDES Other
TYPE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
Q"'Spray Field ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
SAMPLING INFORMATION IY�
WELL ID NUMBER (from Permit):
Date sample collected:
FIELD ANALYSES:
If WELL
WAS
Well Depth: ft.
Well Diameter: L in.
pH 00400: 4,7 1 units Temp. 000lo: °C
DRY at
Depth to Water Level 82546: � ft. below measuring point
Screened Interval: !'�' ft. to ft.
Spec. Cond. 000sa: µMhos
time ofsampling,
Measuring Point is 2-5 ft. above land surface
Relative M.P. Elevation: ft.
Odor 00085:
check
Volume of water pumped/bailed before sampling: gallons
Appearance �. {� GC!'
here:
❑
Samples for metals were collected unfiltered: El YES El NO
and field acidified: El YES El NO
Date sample analyzed ` •— �1 a
Laboratory Name: Env
I ry nm Cat 41, � i'�t Certification No. % �!
PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615
mg/L
Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 { I
/100mL
Nitrate (NO3) as N 00620 C)t Oq mg/L
Zn - Zinc 01092 mg/L
Coliform: MF Total 31504
/100mL
Phosphorus: Total as P 00665 < Q : pL� mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L
Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 a 3o
mg/L
Al - Aluminum 01105
mg/L
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 00680 1 -
mg/L
Ca - Calcium 00916
mg/L
Chloride 00940 3
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552
mg/L
Cu - Copper 01042
mg/L
ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730
ug/L
Fe - Iron 01045
ug/L
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) ❑ No (0)
pecific Conductance 00095
µMhos
K - Potassium 00937
mg/L
VOC 7873 method #
Total Ammonia 00610 (?' () y
mg/L
Mg - Magnesium 00927
mg/L
method #
(Ammonia Nitrogen; NH3asN; Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L
method #
TKN as N 00625
mg/L
Ni - Nickel 01067
ug/L
method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%
Permittee (or Authorized Aqent)

Emwo OmuM Flo h@(0TP@TM%d
114 OAKMONT DRIVE
GREENVILLE, N.C. 27858
AHOSKIE ASSISTED LIVING
240 SOUTH EARLY STATION RD.
AHOSKIE, NC 27910
PHONE [phone]
FAX [phone]
ID#: 377
DATE COLLECTED: 02/08/23
DATE REPORTED : 02/22/23
REVIEWED BY: //— �✓ ` `
Effluent
Well #4
Well //5
Well H7
Analysis
Method
PARAMETERS
Date Analyst
Code
BOD, mg/l
41
02/08/23
BLV
521OB-16
Fecal Coliform (M F), /100 MIS
200
< 1
10
< 1
02/08/23
BNC
9222D-15
Total Suspended Residue, mg/l
32
02/09/23
ADR
254OD-15
Ammonia Nitrogen as N, mg/l
13.30
0.08
<0.04
<0.04
02/13/23
TRJ
350.1 R2-93
Total Kjeldahl Nitrogen as N,mg/l
18.50
02/16/23
TRJ
351.2 R2-93
Nitrate+Nitrite as N, mg/l (calc)
0.04
353.2 R2-93
Nitrate Nitrogen as N, mg/l
<0.04
<0.04
0.04
<0.04
02/09/23
BMD
353.2 R2-93
Nitrite Nitrogen as N, mg/1
0.04
02/09/23
BMD
353.2 R2-93
Total Phosphorus as P, mg/l
2.28
0.24
0.05
<0.04
02/16/23
BMD
365.4-74
Total Organic Carbon, mg/l
4.14
13.31
1.96
02/21/23
HMM
531OC-14
Chloride, mg/l
43
34
2
38
02/13/23
HMV
4500CLB-11
Total Dissolved Residue, mg/l
310
89
220
230
02/09/23
BNC
D5907-13
Total Nitrogen, mg/l (calc)
18.54

FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page of
Permit No.: WQ0002096
Facility Name: Ahoskie Assisted Living
County: Hertford
Month: February
Year: 2023
PPI: 001
Flow Measuring Point: [D Influent ❑ Effluent ❑ No flow generated
Parameter Monitoring Point: []Influent ❑� Effluent ❑ Groundwater Lowering ❑ Surface Water
Parameter Code -- 10
50050
00400
00310
31616
00630
00610
00625
00630
00665
50060
00940
70300
00620
00600
00615
r0
19
U 1-
Oto
c
O
H fn
o
ry
G
Q
LL=
O
0 0. 0
E
Q
Y O`
p Z
F.
,2
z
y
O N
L
a
C
O O
W U
O
O
U
d y
O y 0
O u)
O
�_
Z
O D
Z
_
.�
Z
24-hr
hrs
GPD
su
mg1L
#1100 mL
mg1L
mg1L
mg1L
mg1L
mg1L
mg1L
mglL
mg1L
mg1L
mg1L
mg1L
1
10:00
0.5
1,099
2
10:00
0.5
1,099
3
1,099
4
1,099
5
1,099
6
1,099
7
1,099
8
08:00
1.5
1,099
7.3
41
200
32
13.3
18.5
0.04
2.28
1.3
43
310
<0.04
18.54
0.04
9
10:00
0.5
1,099
10
10:00
0.5
1,099
11
10:00
0.5
1,099
12
10:00
0.5
1,099
13
1,099
14
1,099
15
1,099
16
1,099
17
1,099
18
1,099
19
10:00
0.5
1,099
20
1,099
21
1,099
22
1,099
23
1,099
241
10:00
0.5
1,099
25
1,099
26
1,099
27
1,099
28
1,099
29
30
31
Average:
1,099
41.00
200,00
32.00
13.30
18.50
0.04
2.28
1.30
43.00
310.00
0,00
18.54
0.04
Daily Maximum:
1,099
7.30
41.00
200.00
32.00
13.30
18.50
0.04
2.28
1,30
43.00
310.00
0,04
18.54
0.04
Daily Minimum:
1,099
7.30
41.00
200.00
32.00
13.30
18.50
0.04
2.28
1.30
43.00
310.00
0.04
18.54
0.04
Sampling Type:
Estimate
Grab
Grab
Grab
Grab
Grab
Grab
Calculated
Grab
Grab
Grab
Grab
Grab
Calculated
Grab
Monthly Avg. Limit:
7,500
Daily Limit:
Sample Frequency:
Continuous
Weekly
I 31year
I 3/year
3lyear
3/year
31year
I 3lyear
3/year
Weekly
3/year
I 3/year
I 3/year
3/year
31year

FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page of
Sampling Person(s) Certified Laboratories
Name: Randy Parker Name: Environment 1, Inc.
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? Q 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: Randall Parker
Permittee: Ahoskie Assisted Living
Certification No.: 996843
Signing Official: Paula Armstrong
Grade: SI Phone Number: 252-287-4153
Signing Official's Title: Administrator
Has the ORC changed since the previous NDMR? ❑ Yes Q No
Phone Number: 252-513-8591 Permit Expiration: 4/30/2025
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-1) Page
Permit No.: WQ0002096
Facility Name: Ahoskie Assisted Living
County: Hertford
Month: February
• • • •
this facility
•Na
- I
®at
®.
Area (acres):
.: ..
..
..
Be P•.
� ..
F-11 YES ■ NO
NCO-.
1Hourly
-.
!
. -.
1
MM VA ZVI r410311
�-
Annual Rate (in)::
Field lrrigated?�
0 •
mommom
Monthly•.• •

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of
Did the application rates exceed the limits in Attachment 6 of your permit?
❑� Compliant
❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
Q 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.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Randall Parker
Permittee:
Ahoskie Assisted Living
Certification No.: 996843
Signing Official: Paula Armstrong
Grade: SI Phone Number: 252-287-4153
Signing Officials Title: Administrator
Has the ORC changed since the previous NDAR-1? ❑ Yes 0 No
Phone Number: 252-513-8591 Permit Exp.: 4/30125
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 superv:sion 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 of
Permit No.: WQ00
Did irrigation
at this facia
7 YES E: NO
Weather
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w
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in
mm
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m =
m =
m =
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m =
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Facility Name:
Ahoskie Assisted Uving
u'
•
Annual Rate (in):!
Field Irrigated?
w
w
Monthly Loadii
12 Month Floating Total (i
0 0.00
County: Hertford
Month:
February
Year:
Field"Name
Field Name:
Area acres
Area (acres):
Cover'Crop:
Cover Crop:
Hourly -Rate (in):
Hourly Rate (in):
Annual.Rate (in):
Annual Rate (in):
❑ NO
Fieid'Irriga4ed?
[ YES
NO
Field Irrigated?
_I YES
E M
C F E
0 _0
N
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in
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0.00
2023
❑ NO
rt

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of
Did the application rates exceed the limits in Attachment B of your permit?
Q Compliant
❑ Nan -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?
0 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?
❑r 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: Randall Parker
Permittee:
Ahoskie Assisted Living
Certification No.: 996843
Signing Official: Paula Armstrong
Grade: Sl Phone Number: 252-287-4153
Signing Official's Title: Administrator
Has the ORC changed since the previous NDAR-1? ❑ yes ❑� No
Phone Number: 252-513-8591 Permit Exp.: 4/30/25
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 pen 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