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HomeMy WebLinkAbout#5257_2023_0502_JP_FINALNC Department of Environmental Quality | Division of Water Resources | Laboratory Certification Branch 4405 Reedy Creek Road | 1623 Mail Service Center | Raleigh, North Carolina 27699-1623 919-733-3908 May 11, 2023 5257 Mr. Billy Benton Brunswick County Utilities Northwest WTP P.O. Box 249 Bolivia, NC 28422 Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Benton: Enclosed is a report for the inspection performed on May 2, 2023 by Jill Puff. Where Finding(s) are cited in this report, a response is required. Within thirty days, please supply this office with a written item for item description of how these Finding(s) were corrected. Please describe the steps taken to prevent recurrence and include an implementation date for each corrective action. If the Finding(s) cited in the enclosed report are not corrected, enforcement actions may be recommended. For Certification maintenance, your laboratory must continue to carry out the requirements set forth in 15A NCAC 02H .0800. A copy of the laboratory’s Certified Parameter List at the time of the audit is attached. This list will not reflect any changes made during the audit. Copies of the checklists completed during the inspection may be requested from this office. Thank you for your cooperation during the inspection. If you have questions or need additional information, please contact me at (919) 733- 3908 Ext. 259. Sincerely, Beth Swanson Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Jill Puff, Anna Ostendorff, Todd Crawford, #5257 On-Site Inspection Report LABORATORY NAME: Brunswick County Utilities Northwest WTP NPDES PERMIT #: NC0057533 ADDRESS: 3954 Clear Well Drive NE Leland, NC 28451 CERTIFICATE #: 5257 DATE OF INSPECTION: May 2, 2023 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR(S): Jill Puff LOCAL PERSON(S) CONTACTED: Billy Benton and Philip McCulloch I. INTRODUCTION: This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) to verify its compliance with the requirements of 15A NCAC 02H .0800 for the analysis of compliance monitoring samples. II. GENERAL COMMENTS: The facility is neat and well organized and has all the equipment necessary to perform the analyses. Staff were forthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples for the 2023 PT Calendar Year have not yet been analyzed. The laboratory is reminded that results must be received by this office directly from the vendor by September 30, 2023. The laboratory did not have Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) in place for all currently certified parameters. These documents must be submitted for review as specified in Finding A. Any time changes are made to laboratory procedures, Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) must be updated and relevant staff retrained. Staff must acknowledge that they have read and understand the changes as part of the documented training program. The same requirements apply when changes are made in response to Findings, Recommendations or Comments listed in this report, to ensure the methods are being performed as stated, references to methods are accurate, and the QA and/or SOP document(s) is in agreement with each approved practice, test, analysis, measurement, monitoring procedure or regulatory requirement being used in the laboratory. In some instances, the laboratory may need to create an SOP to document how new functions or policies will be implemented. Page 2 #5257 Brunswick County Northwest Utilities WTP The laboratory is reminded that SOPs are required to be reviewed at least every two years and are intended to describe procedures exactly as they are to be performed. Use of the word “should” is not appropriate when describing requirements (e.g., Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPs for the proper use of the word “should”. Contracted analyses are performed by Environmental Chemists Inc. (Certification # 94). Approved Procedure documents for the analysis of the facility’s currently certified Field Parameters were provided at the time of the inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: SOPs have not been developed for all of the methods included on the laboratory’s Certified Parameters Listing (CPL). Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. A copy of each analytical method or Approved Procedure and Standard Operating Procedure shall be available to each analyst and available for review upon request by the State Laboratory. Standard Operating Procedure documentation shall state the effective date of the document and shall be reviewed every two years and updated if changes in procedures are made. Each laboratory shall have a formal process to track and document review dates and any revisions made in all Standard Operating Procedure documents. Supporting Records shall be maintained as evidence that these practices are implemented. Ref: 15A NCAC 02H .0805 (g) (4). Comment: The laboratory does have an SOP for Total Residual Chlorine (TRC). Comment: The laboratory must have updated QC/SOP documents for the parameters included on their CPL by December 31, 2023. These must be submitted for review upon completion. SOP templates have been developed and are available for download on the NC WW/GW LCB website. B. Finding: The laboratory benchsheet is lacking required documentation: the method or Standard Operating Procedure reference; and the instrument identification. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the method or Standard Operating Procedure; and the instrument identification. Each item shall be recorded each time samples are analyzed. Analyses shall conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (2) (A) and (C). C. Finding: The units of measure for pH (i.e., Standard Units or S.U.) are not documented on the calibration log. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the proper units of measure. Each item shall be recorded each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (L). D. Finding: The laboratory is not documenting all traceability information for purchased materials, reagents and standards. Page 3 #5257 Brunswick County Northwest Utilities WTP Requirement: 15A NCAC 02H .0805 (a) (7) (K) and (g) (7) requires laboratories to have a documented system of traceability for the purchase, preparation, and use of all chemicals, reagents, standards, and consumables. That system must include documentation of the following information: Date received, Date Opened (in use), Vendor, Lot Number, and Expiration Date (where specified). Consumable materials such as pH buffers, lots of pre- made standards and/or media, solids and bacteria filters, etc. are included in this requirement. Ref: NC WW/GW LCB Traceability Documentation Requirements for Chemicals, Reagents, Standards and Consumables Policy. Comment: The lot numbers of the pH buffers and the TRC gel standard are not documented on the calibration log or benchsheet. Comment: The traceability log for the laboratory was created prior to the audit and after current consumables were put into service. The dates opened were not able to be documented for the consumables currently in use (See Finding E) but the log has a space dedicated for this purpose. E. Finding: Chemical containers are not dated when opened. Requirement: Chemical containers shall be dated when received and when opened. Ref: 15A NCAC 02H .0805 (g) (7). Proficiency Testing F. Finding: The laboratory is not documenting PT Sample analyses in the same manner as routine Compliance Samples. Requirement: All PT Sample analyses must be recorded in the same daily analysis records (e.g., benchsheets) as for any Compliance Sample. This serves as the permanent laboratory record. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.6. Requirement: The laboratory shall retain all records necessary to facilitate historical reconstruction of the analysis and reporting of analytical results for PT Samples. This means the laboratory must have available and retain for five years [pursuant to 15A NCAC 02H .0805 (a) (7) (E) and (g) (1)] all of the raw data, including benchsheets, instrument printouts and calibration data, for all PT Sample analyses and the associated QC analyses conducted by all Parameter Methods. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 4.0. Comments: The results of the PT Sample analyses were written on the vendor instruction sheets. G. Finding: PT Samples are not analyzed in the same manner as routine Compliance Samples. Requirement: Laboratories are required to analyze an appropriate PT Sample by each Parameter Method and in each associated matrix on the laboratory’s CPL. The same PT Sample may be analyzed by one or more methods. Laboratories shall conduct the analyses in accordance with their routine testing, calibration and reporting procedures, unless otherwise specified in the instructions supplied by the Accredited PT Sample Provider. This means that they are to be logged in and analyzed using the same staff, sample tracking systems, standard operating procedures including the same equipment, reagents, calibration techniques, analytical methods, preparatory techniques (e.g., digestions, Page 4 #5257 Brunswick County Northwest Utilities WTP distillations and extractions) and the same quality control acceptance criteria. PT Samples shall not be analyzed with additional quality control. They are not to be replicated beyond what is routine for Compliance Sample analysis. Although, it may be routine to spike Compliance Samples, it is neither required, nor recommended, for PT Samples. PT sample results from multiple analyses (when this is the routine procedure) must be calculated in the same manner as routine Compliance Samples. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.6. Comment: Standards that are provided with the true values in a sealed envelope, are not considered PT Samples and do not meet the PT requirements outlined in 15A NCAC 02H .0800. Laboratories must not analyze additional standards with known concentrations along with PT Samples with unknown concentrations, as this is not the routine testing protocol for Compliance Samples. This is not to say that they cannot be used for troubleshooting purposes before analyzing a remedial PT Sample on a separate day. This would be considered part of the corrective action plan. Comment: The laboratory is analyzing the PT Sample multiple times and averaging the results, which is not how Compliance Samples are treated. Sample duplicates are not required for Field Parameters. H. Finding: The laboratory is not documenting the preparation of PT Samples. Requirement: PT Samples received as ampules are diluted according to the Accredited PT Sample Provider’s instructions. It is important to remember to document the preparation of PT Samples in a traceable log or other traceable format. The diluted PT Sample then becomes a routine Compliance Sample and is added to a routine sample batch for analysis. No documentation is needed for whole volume PT Samples which require no preparation, however the instructions must be maintained. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.6. Comment: This Finding applies to TRC. Comment: Dating and initialing the instruction sheet for each prepared PT Sample would satisfy the documentation requirement. I. Finding: The laboratory does not always document instrument calibration prior to analyzing PT Samples. Requirement: A record of instrument calibration or calibration verification shall be documented and available for inspection upon request. Ref: 15A NCAC 02H .0805 (g) (3). Requirement: The laboratory shall retain all records necessary to facilitate historical reconstruction of the analysis and reporting of analytical results for PT Samples. This means the laboratory must have available and retain for five years [pursuant to 15A NCAC 02H .0805 (a) (7) (E) and (g) (1)] all of the raw data, including benchsheets, instrument printouts and calibration data, for all PT Sample analyses and the associated QC analyses conducted by all Parameter Methods. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 4.0. Comment: The calibration of the TRC meter was not documented on the most recent date of the PT Sample analysis. Page 5 #5257 Brunswick County Northwest Utilities WTP Quality Control J. Finding: The laboratory is lacking a documented training program. Requirement: Each laboratory shall develop and implement a documented training program that includes the following: that staff have the education, training, experience, or demonstrated skills needed to generate quality control results within method-specified limits and that meet the requirements of these Rules; that staff have read the laboratory quality assurance manual or applicable Standard Operating Procedures; that staff have obtained acceptable results on Proficiency Testing Samples pursuant to Rule .0803(1) of this Section or other demonstrations of proficiency (e.g., side-by-side comparison with a trained analyst, acceptable results on a single-blind performance evaluation sample, an initial demonstration of capability study prescribed by the reference method). Ref: 15A NCAC 02H .0805 (g) (5). K. Finding: The laboratory is not calibrating the mechanical volumetric liquid-dispensing devices used for critical measurements at least once every twelve months. Requirement: Mechanical volumetric liquid-dispensing devices (e.g., fixed and adjustable auto-pipettors and bottle-top dispensers) shall be calibrated at least once every twelve months. Ref: 15A NCAC 02H .0805 (g) (10). Comment: Preparation of the annual PT Samples is considered a critical measurement. Comment: A volumetric pipet can be used to prepare dilutions and alleviate the need to have the auto-pipettors calibrated. pH - Standard Methods, 4500 H+ B-2011 (Aqueous) L. Finding: Values were reported that exceed the method specified accuracy of 0.1 units. Requirement: By careful use of a laboratory pH meter with good electrodes, a precision of ±0.02 unit and an accuracy of ±0.05 unit can be achieved. However, ± 0.1 pH unit represents the limit of accuracy under normal conditions, especially for measurement of water and poorly buffered solutions. For this reason, report pH values to the nearest 0.1 pH unit. Ref: Standard Methods, 4500 H+ B-2011. (6). Comment: Per PT Vendor instructions, the PT Sample results should be reported to two decimal places, which is an exception to the requirement for Compliance Samples. M. Finding: The laboratory is not analyzing a check standard buffer after calibration and prior to sample analysis. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Instruments are to be calibrated according to the manufacturer’s calibration procedure prior to analysis of samples each day compliance monitoring is performed. Calibration must include at least two buffers. The meter calibration must be verified with a third standard buffer solution (i.e., check buffer) prior to sample analysis. Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH. Requirement: All check standard buffers must read within ±0.1 S.U. to be acceptable. If the meter verification does not read within ±0.1 S.U., corrective actions must be taken before Page 6 #5257 Brunswick County Northwest Utilities WTP any samples are analyzed. Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH. Comment: When analysis of the check buffer begins, the true value, obtained value and assessment of the acceptance criterion must be documented on the calibration log. Chlorine, Total Residual – Standard Methods, 4500 Cl G-2011 (Aqueous) N. Finding for Immediate Response: The laboratory is not verifying the factory-set calibration every 12 months. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Annual Factory-set Calibration Curve Verification: This type of calibration curve verification must be performed initially, at least every 12 months and any time the instrument optics are serviced. Zero the instrument with a Calibration Blank and then analyze a Method Blank and a series of five standards (do not use gel or sealed liquid standards for this purpose). The calibration standard values obtained must not vary by more than ±10% from the known value for standard concentrations greater than or equal to 50 μg/L and must not vary by more than ±25% from the known value for standard concentrations less than 50 μg/L. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: This Finding applies to the Hach DR-6000 spectrophotometer used to measure compliance samples for TRC. The laboratory agreed to submit proof of acceptable verification of the factory-set curve for the chlorine meter used for compliance monitoring by May 16, 2023. Comment: The laboratory was instructed to add the date of the annual verification to the benchsheet. O. Finding: The true value of the gel-type standard is not determined properly. Requirement: The State Laboratory may develop Approved Procedures for Field Parameters based upon the methods in any of the sources referenced in Parts(a)(1)(A) through (F) of this Rule. Ref: 15A NCAC 02H .0805 (a) (1) (F). Requirement: To assign a true value to the gel-type or sealed liquid standard: 1. Zero the instrument with the calibration blank. 2. Read and record gel standard value. 3. Repeat steps 1 and 2 at least two more times. 4. Assign the average value as the true value. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: When a true value is assigned every 12 months, these standards may be used after the manufacturer’s expiration date. It is only necessary to assign a true value to the gel- type or sealed liquid standard which falls within the concentration range of the calibration curve used to measure sample concentrations. For example, if you are measuring samples against a low-range calibration curve, a 200 μg/L standard would be verified, and not the 800 μg/L standard since the 800 μg/L standard would be measured using a high-range calibration curve. Page 7 #5257 Brunswick County Northwest Utilities WTP Comment: The laboratory received new gel standards on April 19, 2023 and assigned a true value by taking a single reading of the standard on the Hach DR6000 spectrophotometer. P. Finding: Samples are being filtered without documentation. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Statement that samples were filtered, when applicable. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Reporting Q. Finding: The laboratory does not report results of all tests on the characteristics of the effluent. Requirement: The results of all tests on the characteristics of the effluent, including but not limited to NPDES permit monitoring requirements, shall be reported on the monthly report forms. Ref: 15A NCAC 02B .0506 (b) (3) (J). Comment: The effluent from the water treatment plant is analyzed weekly by Environmental Chemists, Inc. (#94) for Chlorate and Chlorite by EPA 300.1. These are not certifiable parameters per Certification Rule 15A NCAC 02H .0804, but still must be reported on the Discharge Monitoring Report (DMR) and qualified as “uncertified data”. An additional comment may be added to explain that NC does not offer certification for those parameters. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract laboratory reports to DMRs submitted to the North Carolina Division of Water Resources. Data were reviewed for Brunswick County Utilities Northwest WTP (NC0057533) for December 2022, January 2023, and February 2023. No transcription errors were observed. The facility appears to be doing a good job of accurately transcribing data. V. CONCLUSIONS: Correcting the above-cited Findings will help this laboratory to produce quality data and meet Certification requirements. The inspector would like to thank the staff for their assistance during the inspection and data review process. Please respond to all Findings and include supporting documentation, implementation dates and steps taken to prevent recurrence for each corrective action. Report prepared by: Jill Puff Date: May 9, 2023 Report reviewed by: Tonja Springer Date: May 9, 2023 Certificate Number:5257 Effective Date:1/1/2023 Expiration Date:12/31/2023 Lab Name:Brunswick County Utilities Northwest WTP Address:3954 Clear Well Drive NE Leland, NC 28451 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:12/18/2017 The above named laboratory, having duly met the requirements of 15A NCAC 2H.0800, is hereby certified for the measurement of the parameters listed below. CERTIFIED PARAMETERS INORGANIC CHLORINE, TOTAL RESIDUAL SM 4500 Cl G-2011 (Aqueous) pH SM 4500 H+B-2011 (Aqueous) This certification requires maintance of an acceptable quality assurance program, use of approved methodology, and satisfactory performance on evaluation samples. Laboratories are subject to civil penalties and/or decertification for infractions as set forth in 15A NCAC 2H.0807.