WQ0003090_Monitoring - 05-2023_20230707

Monitoring Report Submittal
Permit Number#* WQ0003090
Name of Facility:* town of liberty WWTP
Month: * May Year: * 2023
Report Information
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR tremaine may 2023.pdf 4.18MB
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: 7/7/2023
This will be filled in automatically
Initial Review
Reviewer: Wanda.Gerald

Is the project number correct?* WQ0003090
Is the monitoring report accepted?* Yes No
Regional Office* Winston-Salem
Reviewer: _anonymous
Review Date: 7/7/2023

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page _1_ of _1_
Permit No.: WQ0003090
Facility Name:
Town Of Liberty - Wastewater
PPI: 002
Flow Measuring Point: ❑✓ Influent ❑ Effluent
❑ No flow generated
Parameter Code —►
00400
00610
31613
Q
R
E
id
R
E
T
Q E
.�'
.
i
C0
U '�
LL 'O
p
Q
U
O
O
24-hr
hrs
su
mg/L
#/100 mL
1
7:00
8
21
7:00
8
3
1 7:00
8
4
7:00
8
8.02
8.7
2420
5
7:00
8
6
10:00
2
7
10:00
2
Sam
8
7:00
8
9
7:00
8�
10
7:00
1 8
11
7:00
8
7.73
.i
12
7:00
8
13
14
KNOW
a
15
7:00
8
16
7:00
8
17
7:00
8
MGM
18
7:00
8
�t'
7.22
-
11.5+
2420
19
7:00
8
20
21
22
7:00
8
23
7:00
8
"
24
7:00
8
25
7:00
8
r . ,
6.15
26
7:00
8
27
10:00
2
28
11:00
2
H. a
29
8:00
2
fi` `
30
7:00
8
31
7:00
8
6.35
Average:
10.10
� 2,420.00
Daily Maximum:
8.02
11.50
2,420.00
Daily Minimum:
6.15
8.70
2,420.00
Sampling Type:
Grab
Grab
Grab
Monthly Avg. Limit:
Daily Limit:
t
Sample Frequency:
weekly
2x month,
� 2x month
County: Randolph
Month: May
Year: 2023
Parameter Monitoring Point: ❑ Influent ❑✓ Effluent ❑ Groundwater Lowering ❑ Surface Water
00625
50060
" 70300
00630
d m
Y Oy
F N L
C
iR$ F N O
w"
y U
Z
4;
15.3 ,s 00.074
0
17.1 . a, f 0 V0 , 112111 <0.040
0.5
0.7
yz
#REF!
0.24
0.04
#REF!
0.70
, 3
0.07
#REF!
0.00
0.04
Grab
Grab
Grab
2x month
weekly
� '3x year
2x month

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? [Z 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 EZ No
Phone Number: 336 622 4276 Permit Expiration: 8/31 /2024
^
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

aceAnalyfical
i
www.pacelabs.com
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92665920
Sample: Effluent
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 365.1 Rev 2.0 1993
Parameters
Total Suspended Solids
Nitrogen, NO2 plus NO3
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
Phosphorus
Laboratory Report
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 05/16/2023
Date Received: 05/04/2023
Lab ID: 92665920001 Collected: 05/04/23 14:35 Matrix: Water
Results
Units
42.9
mg/L
0.074
mg/L
ND
mg/L
0.085
mg/L
24.1
mg/L
2420
MPN/100ml-
PACE
Garrett
Dreyer
5/04/23
1435
8.02
Std. Units
0.00
mg/L
15.4
mg/L
8.7
mg/L
15.3
mg/L
2.3
mg/L
Report Limit
11.9
0.040
0.040
0.040
2.0
1.0
Analyzed
05/05/23 12:31
05/05/23 10:06
05/05/23 10:06
05/05/23 10:06
05/10/23 10:18
05/05/2312:34 El
05/04/23 14:35
05/04/23 14:35
05/04/23 14:35
05/04/23 14:35
05/04/23 14:35
05/04/23 14:35
0.040 05/16/2316:27
0.10 05/16/2313:39
0.50 05/16/23 04:18
0.050 05/16/2316:06
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
[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
Qualifiers
Page 1 of 4

7
m
CD
i�
.A
Section A
CHAIN -OF -CUSTODY 1 Analytical Refits f nnri1mpnt
The Chain -of -Custody is a LEGAL DOCUMENT. All relevan AN.e
Submitting a sarnpfe .da this chain of custody constitutes acknowledgment and acceptance of the Pace Terms and Conditions found at h
WON VZM5920
Section B Section C g
Required Project Information: Invoice Information:
y i oDo Tremaine Fike tte Ram Name:
py
: Em
rra;I; Hike townof1ioenYnc.or9 --- 11— -.
hone: 33E E22�276 Fax: :oject t ta.Ta' Town of Liberty - Every 2 Weeks ace Project Manager. Stephan e.knon pace atrs.com, Sfato f Location
equestad Due Date: rojea;y' ace Profile: 13077 NC
®saled lUsa isFlaered YJN
a 2
c o COLLECTED Preservatives >'
z
MAMIX coo¢ s o
'Jrs "V Wa's, DW
wvgor W7
w�weer AW
u
j5 2
Fad :: .} :g V
SL
SAMPLE tip ca �� a� � � STARY
t I
One Character per box. Mm ,y z 0 3i n t
IA•Z• 0-91, ; 0�r OT o w r 5+ o a m U
�g Sample ids must be unique T"'°i° " :7 0 r a
x 3� U $ .... _ d C Q E t U v
cc Z m
Y DATE TIME DATE TIME 4i a 3 = 2 = z z Z O ', ram- Z a a.
Efi•usn: W qjl: ---
X X X X X X I X X
2
3
i
8
10
L12
ADOMONAL COMMENTS Tt0A5 DATE TIME ACCE.PTEDBY/AFFILIATION : DATE TIME " PLECONixSIONS
SAMPLER
u
NAME AND SIGNATURE
PRINT Name of SAMPLER•,
SIGNATURE of SAMPLER: DATE Signed: ? 3 $ m out

ILJk�?F— I IXle: I -UUt34VUI_ I eCn tipec bam pie con aition
Upon Receipt
aboratory receiving samples,
�shevllle [] Eden E] Greenwood L] Huntersville 0 RaleighE] Mechanicsville[] Atlantan Kernersvilie'--/
ClientName!
Project M
- -
DFed EX Dups ElusPS ©Client
Commercial [Pace 00ther:_
earner Tracking Number: L
custody Seat Present? Dyes U/ No Seals intact? Dyes DNo Date/IniflaI5 Person Examining Contents;
acking Material. Dgubble Wrap ElOubble Bags [None Other Biological Tissue Fr zen?
g
hermometer: IR Gun 10: — K-'O- T 0 '0 Type of ice: gwet (:1 Blue ®Nave
Dyes EJNo E_ _ N/A
ioler Ternp ('C):_--Correction Factor: Add / Subtract ('C)
I, —4 3, IG Temp should be above freezing to 61c
)rrected Cooler Temp (*C):_ E15arnPles Out of (emP criteria. Samples on ice, cooling procc
has begun
SDA Regulated Sol] ([N/A, water sample)
id samples originate in a quarantine zone within the United States: CA, NY, or SC (check maps)? Did samples originate from a foreign source (internationa ly,
_]Yes E]No including Hawaii and Puerto Rico)? F-1yes MNo
Comments/Discrepancy;
Chain of Custody Present?
QN0
DN/A
Samples Arrived within Hold Time? ---VYes
ONO
ON/A
2.
Short Hold Time Analysis (<72 hr.)?
Vfy e.s
[_)No
[JN1A
3
Rush Turn Around Time Requested?
0YeS
[]N/A
4.
Stiff Iclent Volume?
_[ZNO
ONO
5,
Correct Containers Used?
aes
[:]No
.,DN,A
E]N/A
6.
-Pace Containers Used?
_DYe-.
01,
E)N/A
Containers Intact?jeYes
EIN(IDN/A
7,
Dissolved analysis: Samples Field Filtered?
0 Yes
ONO ___ONIA
Sample Labels Match CCC?
jYeS
[-1 No
E]N/A
9.
-includes pate/Time/ID/Analysis Matrix:
Headspace in VOA Vials (>5-6nim)?
'o.
Trip Blank Present? ElYes [:]No 13IN/A
Trip Blank Custody Seals Present?
w Yes_QNo
121q/A
Temp Log: Temp must be maintained
at <6 C. during login, record temp
every 20 minutes.
Time opened:/ 9-fS Tempi
Time: it put in cooler
Tempi
Person Contacted.
Project Manager SCURF Review:
Project Manager SRF Review;
Lot ID of split containers:
Date/Time:
Date:
gate,
Field Data Required? uYes EINO
Qualtrax Document ID. 70677 Page 1 of 2 Page 3 of 4

DCU-,-TMe. ENV-F'RM-HUN 14004 A i Tech Spec Sample CondMon
Upon Receipt
check tirm k top half of box A pH anW or cleMennaWn Project H
is verified and awthin Te acceptance mrigp for
Preservatit"I Samples
f-Axvpllmlt , w I � : ,
'Botlum half of box is to Irm number 0 bottle,
'Check A unpreserved Norates for chlunme
m
w
m
m
p1l Ad�',Mvn:,nt LoU, foe Pr,-.orvi,d �amph,,,
Page 4 M

laceAnalj4ical")
1 www.pacelabs.com
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Liberty WWTP
Pace Project No.: 92667054
Sample: Effluent
Laboratory Report
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 05/12/2023
Date Received: 05/11/2023
Lab ID: 92667054001 Collected: 05/11/23 13:15 Matrix: Water
Method Parameters
Results Units
Report Limit Analyzed Qualifiers
Performed by
Pace
05/11/23 13:15
Collected By
Garrett
05/11/23 13:15
Dreyer
Collected Date
05/11/2023
05/11/23 13:15
Collected Time
1315
05/11/23 13:15
pH
7.73 Std. Units
05/11/23 13:15
Chlorine, Total Residual
0.00 mg/L
05/11/23 13:15
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 2

J A!NCIF-L135 5° it�ly tl C�! R� t1 Eit�CU Bt9ent
iAB t arkorder ' `' :Iatsei sere or List Pam oskocder Number or
�� i Num bbea Herr E
_ . �eAraalyte3/
Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fieds
p
` a
Company Billing Information:
ContaitSEeS£sservatlt u
Address: Hry
_. - , -
✓
ML
•= Preservative types ttYrritricacid, (e 674
Report To: Email To:
(5) methanol, s7) sodiam bisulfate, (8) soclum mrmune n, car ,.ti-u• -. •, -
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (D) Other
`Copy To: Site Collection Info/Address:
Ana _.es
taaPro£ileJtsne:' :-.5
Customer Project Name/Number: State: County/Clty: Time Zone Collected:
T saaro3= aece=Pt.
/ [ [PT[ ]MT( Jam• [ ]ET
_.
riit$rodgr i3tals Preeei:rfSiit$ct- v_ i Nk
i;JresPresent
xstody- signatuN NA ' Y
Site/Facility ID It:Compliance
Monitoring?
Phone:
[,/Yes [ ] No
Collector Sicfaat=4i Rresesit . Y hT M
Hottes,ylnt3Ct
Email:
i tL4
Coxxar t - Boucles � ' r
sufficient trciume . ; = NA
Co ed By (print):
Purchase Order #:
DW PWS ID #:
�-
Quote #
DW Location Code:
Sam les Racezosd =; Ice • Y-N 73A
VOA '- Headepacs'Acccptabla - Y bt NAQ i73Da "Slu.7.ated &tails Y'N NA
Co13e
Turnaround Date Required:
imm _ late , Pa on Ice:°
y
( ] Yes [ ] No
i1
a 2es inoid3ng3ms Y N >uzs
s s�
Residual Chlorsae ^Present Sd.NA`
al:
Rush:
Field filtered (if applicable):
j ] Dispose as appropriate ( } Return
( ] Same Day [ ] Next Day
( ] Yes [ ] No
(
":.
C2 St rapB"
Samg2a giS Accegtab3e Y K NA
J 2 Day [ ] 3 Day [ ] 4 Day [ ] S Day.
Analysis:
,
( I Hold:
(Expedite Charges Apply)
: `.
Sulfide Present Y 1
Tea3Rcetate;Strips. .
Matrix Codes (insert in Matrix box be -ow): 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)
%1
Lab Sample #' f Caamu nts:
Comp /
Collected (or
Res # of
Customer Sample!D
Matrix
Grab
Composite start)
Composite End
Cl Ctns
u
Date
Time
Date
Time
I13
t3i�
E
R
Customer Remarks / Specia` Conditions / Possible Hazards: Type of ice Used: ,: Wet Blue ' Dry'' None- . - SHORT HOLDS PRESENT k72 hours)Y ; At Njr Lab Sample T&ipen iture.lnfo. -
'
packlrtgmaterial Used:iabTtacding# TemF+SiankReceasred: Y N l�A
,' .. 'Therm lOM
Cooler I Temp U parr Receipt: aC
' mples received via: Cooler i-Therm Corr. Factor - , -----PC
Radchem sample(s)-screened (4500 cpm)- Y N NA FEDEiC - '.-,UPS, _ Client ~ E ouriet . Face Courier CooierI Corr ell Temp: oC
Rel.,ir m r z (St ature} DateiT rne: Rec 'cad by/Compa: • Signature} Date/Time: 5 ONLY mmectts
uyursiSe�.no a? r
5
13
Atictnum
t- Fit ed_iq 1:fiiipany: (Signature) Date/Time: Received by/Co .ny: i turej "Date/Timer Trip Blank Received: Y N NA
Template:
Prebgin:: HCL : ' McOH T5P Other
�tReeivdby/Co�-P-ny:Signature}
Refinished by/Company: [Signature; DatejTime: Dater: ime: PM, Non Cortiorrnante(s): Page:
PS: YES / NO

aceAnalytical o
I www.pacclabs.com
Laboratory Report
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Town of Liberty
Pace Project No.: 92668229
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 06/02/2023
Date Received: 05/18/2023
Sample: Effluent
Method
Parameters
Lab ID: 92668229001 Collected: 05/18/23 14:15 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
HACH 10206
Nitrogen, Nitrate
ND
mg/L
0.30
05/19/23 18:37
SM 2540D-2015
Total Suspended Solids
40.0
mg/L
12.8
05/23/23 09:12
SM 521OB-2016
BOD, 5 day
27.7
mg/L
2.0
05/23/23 16:21
Colilert-18
Fecal Coliforms
2420
MPN/100ml-
1.0
05/19/23 13:05 El
Performed by
PACE
05/18/23 14:15
Collected By
Garrett
05/18/23 14:15
Dreyer
Collected Date
05/18/23
05/18/23 14:15
Collected Time
1415
05/18/23 14:15
pH
7.22
Std. Units
05/18/23 14:15
Chlorine, Total Residual
0.00
mg/L
05/18/23 14:15
TKN+NO3+NO2
Total Nitrogen
17.1
mg/L
0.040
05/31/23 17:00
Calculation
EPA 350.1 Rev 2.0 1993
Nitrogen, Ammonia
11.5
mg/L
0.30
06/01/23 12:21
EPA 351.2 Rev 2.0 1993
Nitrogen, Kjeldahl, Total
17.1
mg/L
0.50
05/31/23 02:23
EPA 353.2 Rev 2.0 1993
Nitrogen, NO2 plus NO3
ND
mg/L
0.040
05/24/23 15:16
EPA 365.1 Rev 2.0 1993
Phosphorus
2.9
mg/L
0.050
06/02/23 08:24
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
[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
VirginiaNELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
VirginiaNELAP Certification #: 460025
Page 1 of 4

4, in 7 ARPJ
N
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ea
w
^e
m
cn
o
w
to
A
ITEM #
H
N
3
F
3.0
o
npn
®~ , m
Y
0 ®
u' H
W
T
6 e
3
�
MATRIX CORE (see valid codas la tsfl)
SAMPLE TYPE (G=GRAH C=COMP)
m.
m
v
"
1
m
e
^p'1
m
rr
r
f0
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-IT
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® m
m
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rrr�
t1i
??
AMPLE AT COLLECTION
'.
is OF CONTAINERS
m
m
m
p
Unpreserved
m
o
-
0
K
H2804
f2
m
d
HNO3
w
H I
C
N
ro
w
NaOH
c
-
Na2S20J
Methanol
g
1
Other
Analyses Test
Y!M
�
B00 5-day
Fla.
TSS
x
Nitrate
Ammonia/Total Phos
V
A
x
TKNITN
Ul
x
Fecal Cdi
VNI
x
pH (field)
$
e
X
TRC (Field) _ (%, C PD
t
J
v'1
�.a
Cr
TEMP in G
to
Residual Chlonne (YIN)
C)i
I
Qgr
ReCeived on Ice
(YIN)
$�
A
Custody Seated
Cooler
(YIN)
N
Samples Intact
(YIN)

DGM—T ftie: F_NV® RM-HUN I -0084vol —Tech Spec Sample Condition
Upon Receipt
tis --ifff—octIve Date: 0511 240_0_____
.aboratury receiving samples:
iNsheville [] Eden 0 Greenwood [J Huntersville F] RaleighEl MechanicsvilleF U/
Atlanta❑ Kernersville—,"
Client Name:
Project It:
Courier: ed Ex DuPs MUSPS ❑Client
0 Commercial RE]
Pace EJ0ther:,___
Carrier Tracking Number:
I-<
Custody Sea] Present? Elyes No Seals Intact? EJYLs E]No
clacking Material; EJBubble Wrap E)Bubble Bags L/]None EJ othe
rhermometer: 0 IR Gun 10: Type of lcei Wet 08lue
ogler Temp Coreedlon Factor: Add / Subtract (*C)
:orrected Cooler Temp (*C):__
r-/
JSDA Regulated Soll ( n N/A, water sample)
Ad samples originate in a quarantine zone within the United States: CA, NY, or SC (check maps)?
nYes E]Nci
L 1.
Date/Initials Person Examining Contents: Hj
r Biological TISSUQ Fr en?
Oyes ONo [ZN/A
❑ None
Temp should be above freezing to VC
usamples out of temp criteria. Samples an ice, cooling proce
has begun
Did samples originate from a foreign source (internationally,
;-1-41- LA­­i; ­4 0­­ 01,-V9 M­ rl.­
C­o-m 'me n t _s/ D 1 s c' r e p a n cy
—Chain of Custody Present?
No
:]N/A
Samples Arrived within Hold Time?
dyes
[ ]No
E]N/A
2.
Short Hold Time Analysis (02 hr.)?
PlYes
CINo
®N/A
3,
hush Turn Around Time Requested?
C-1yes
YNO
[IN/A
4.
Sufficient Volume?
C:rYes
No
[)N/A
S.
Correct Containers Used?
---Pace Containers Used?
LlYes
ZYes
®No
(:] N o
EJN/A
ON/A
6.
Containers Intact? 4
6Yes
E]NO
[]N/A
7.
DiS54Samples Field Filtered?
Y �es
0 QNo
�CaN/A
8,
Sample Labels Match COC?
-includes Date/Time/ID/Analysis Matrix:
[21yes
VV
[]No
ON/A
9.
Headspace in VOA Vials (>5-6mn)?
_E3Yel
(ZN/A
10.
Trip Blank Present?
Trip Blank Custody Seals Present?
(lees
Elyes
CINO
JNo
0/A
eIN/A
11.
LL)sVuv1r_l'J 1 aqwArvlrl.c
Temp Log: Temp must be maintained
at <6 C during login, record temp
every 20 minutes.
Time opened; 15L 0 le
it; put in Cooler
Time: Temp;
Person Contacted:
Project Manager SCURF Review:
Lot ID of split containers:
CLIENT NOTIFICATION/RESOLUTION
Date/Time,
Date,
Field Data Required? UYos LJN0
Project Manager SRF Review,
Qualtrax Document ID: 70677 Page 1 of 2 Page 3 of 4

Document Name: Docuownt 1-wedNovember IS, 2021
' Bottle Identification Form JBIF) rage I of I
PkeAnalylical Document No is jing Authfxity:
I F-CAR-CS-043-Rev.01 Pa( L' Carolinas Quality Office.
*Check mark top half of box if pH and/or clechlorination is Project#
verified and within the acceptance range for preservation
samples.
Exceptions: VOA, Coliform, TOC, Oil and Grease, DRO/801S (water} DOC, UHg
"Bottom half of box is to list number of bottles
pH Adjillsiment Log for Preserved Samples
- sa"ifilp Ira type of PrfrwrvAvc, PH upoo receipt Date preservatioo Ap. JU�ted Jimprewn-Vation Amount of Preservative tat1 if
adjusted added
. ... ...... ---------
_ - -- - -�T _ _LL .—
.. . ....... ---------- - --- ...... ... ..
Note: Whenever there is a dm,(epancy affecting North Carolina compliance M this form Wilt be se.ot to the Nooh Caro9iaia DVHNH (i v,
Out of hold, incorrect prwie(VAIM-% out of k(�mf)' illwrraet CoMaio("(S'
Page 4 of 4

,�aceAnalytical
www,pacelabs.com
Tremaine Fike
Town of Liberty
PO Box 1006
Liberty, NC 27298
Project: Liberty WWTP
Pace Project No.: 92669351
Sample: Effluent
Laboratory Report
Pace Analytical Services, LLC
1377 South Park Drive
Kernersville, NC 27284
[phone]
Page 1 of 1
Report Date: 05/25/2023
Date Received: 05/25/2023
Lab ID: 92669351001 Collected: 05/25/23 10:30 Matrix: Water
Method Parameters
Results Units
Report Limit Analyzed Qualifiers
Performed by
PACE
05/25/23 10:30
Collected By
Garrett
05/25/23 10:30
Dreyer
Collected Date
05/25/23
05/25/23 10:30
Collected Time
1030
05/25/23 10:30
pH
6.15 Std. Units
05/25/23 10:30
Chlorine, Total Residual
0.05 mg/L
05/25/23 10:30
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 2

(Company:
[Address:i
[Address:
Report To:
Copy To:
Customer project tame/number:
Phone:
Email:
ID #:
Purchase Order #:
Quote #:
is a LEGAL DOCUMENT- Complete all reievent fields
jBi[fing information:
To:
Site Collection Info/Address-
State: County/City: Time Zone Collected:
[ JPT[ JMT[ ]CT [ ]ET
Compliance Monitoring?
f Vy'Yes [ ]NO
DW PWS ID #:
DW Location Code:
rurnaround Date Required: eu a6t y I.L.— — s .
I Yes [ ]No
Rush: Field Filtered (if applicable):
Dispose as appropriate f I Return ( )SarneDay [ ] Next Day [ I Yes ]No
Archive: 2 Day f 13 Day J' 14 Day 5 Day Analysis:
H04 (Expedite Charges Apply)
Matrix Codes (Insert in Nlatr#x box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW),
Produnt (P), Soil/Solid {5l.}, Oil (OL), Wipe (WP), Air (AR), issue (TS), Bioassay (8), Vapor 1,Vl, Other (OT)
Comp
i Collected (or Composite End
Customer Sample ID Matrix Grab11 Composite Start)
F —Date I Time 1 Date I Time
M
Customer Remarks / Specia Conditions / Possible Hazards; Type of Ice Used-, wet Blue Dry None
Packing Material Used.
Radchem sample(s) screened (<500 cprri): Y N NA
Refinad�'-ed Moari-V-(SiRnatLjre)'\11 I Date/Time: -----TReceiyedby/Company,-4S gnature)
r')
LAB USE ONLY- Affix Workorder/Logm Label Here or List Pace Workorder Number or
MTJL Login Number Here
A% XL 26690151
VIT ALL SHADE, W
Container Preservative Type
2
" Preservative Types: (1) nitric acid, (2) sulfuric 92669351
(6) methanol, (7) sodium bisulfate, IS) sodium t
(C) ammonium hydroxide, (D) TSP, (U) Unpreservea, tut uther
Anafv�,; kil-ah Profil /I inp-
Receipt cnecr-iist;
C7sample
Custody Seals Present/Intact Y N NA
Custody Signatures Present Y N NA
collector Signature Present Y 9 NA
Bottlesintact y N NA
Correct Bottles y IT NA
Sufficient Volume Y 9 NA
Samples. Received on Ice Y N NA
VOA - Seadspace, Acceptabae y N NA
-3
USDA Regulated Soils y N NA
Samples in Holding Time Y 9 NA
0
Residual Cblorine Present y N NA
Cl Strips:
Sample pH Acceptable Y N NA
PH Strips:
Sulfide Present y N NA
Lead Acetate Strips:
LAB USE ONLY.
Lab Sample Comments:
I
N N/A Lab Sample Temperature Info.
Lab Tracking
Temp Blank Received, Y N INA
Tberrr ID#.
Cooler I Temp Upon Receipt: _oC
Samples received via:
Cooler I Therm Corr. Factor: oc
FEDEX UPS Client
Courier
Pace Courier Cooler I Corrected Temp-. oC
DateJTime:
VTJL LAB USE ONLY Comments-,
`(S J
Table 4:
Date/Time:
Atctnurn;
Ternplare:
Trip Blank Received. Y N NA
HCL MeOH TSP Other
Pi4hawshed by/Cornpany: f8ignaturel,
M
Received
pm, Non Corformance(s): Page:
PS: YES / NO I of: -

aceAnalytical o
www,pacolabs.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
Project: Town of Liberty
Pace Project No.: 92669959
Page 1 of 1
Report Date: 06/01/2023
Date Received: 05/31/2023
Sample: Effluent
Method Parameters
Lab ID: 92669959001 Collected: 05/31/23 13:45 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
Performed by
Pace
05/31/23 13:45
Collected By
Garrett
05/31/23 13:45
Dreyer
Collected Date
05/31/2023
05/31/23 13:45
Collected Time
1345
05/31/23 13:45
pH
6.35 Std. Units
05/31/23 13:45
Chlorine, Total Residual
0.07 mg/L
05/31/23 13:45
C�ZLrut t<
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Page 1 of 2

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DATE
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
May 2023
Liberty N.C.W.W.T.F.
Freeboard Lagoon Inches
0
0
0
0
0
0
0
0
0
1
2
3
4
5
6
7
7 1/2
R
1.0
5 1/4
3
R
0.3
2 1/4
3
2 1/2
2
1 1/2
2 1/2
2 1 /4
1 3/4
R
0.3
1 1 /4
R
0.3
1
R
0.3
0
0
TOTAL 2.2

ponm:woAR1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR4) Page _1__o*_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? 2 Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑ Compliant 0 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 NDAR-1? ❑ Yes 2 No
Phone Number: 336 622 4276 Permit Exp.: 8/31/24
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

poRm:woAn1 10-13 NON -DISCHARGE APPLICATION REPORT (WDAR-) Page _2_-»f_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?
Q Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? 2 Compliant ❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? 2 Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? O Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑ Compliant [21 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.
INCHES CAUSE OF I&I RAI
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
CZ 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