NCG590010_Renewal (Application)_20240216 (2)

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Lauren Raup-Plummer, PE
Aqua North Carolina Inc
202 Mackenan Ct
Cary, NC 27511
Subject: Permit Renewal
Application No. NCG590010
Oakley Park WTP
Gaston County
Dear Applicant:
NORTH CAROLINA
Environmental Quality
February 19, 2024
The Water Quality Permitting Section acknowledges the February 19, 2024 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150E-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https•//deq nc gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
ec: WQPS Laserfiche File w/application
Sincerely,
Cynthia Demery
Administrative Assistant
Water Quality Permitting Section
Q��
North Carolina Department of Environmental Quality I Division of Water Resources
Mooresville Regional Office 1 610 East Center Avenue, Suite 301 1 Mooresville, North Carolina 28115
704.663,1699

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Lauren Raup-Plummer, PE
Aqua North Carolina Inc
202 Mackenan Ct
Cary, NC 27511
Subject: Permit Renewal
Application No. NCG590010
Oakley Park WTP
Gaston County
Dear Applicant:
NORTH CAROLINA
Environmental Quality
February 19, 2024
The Water Quality Permitting Section acknowledges the February 19, 2024 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150E-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https•//deg nc gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
ec: WQPS Laserfiche File w/application
Si�n�cereelly,
L- ' L L-
Cynthia Demery
Administrative Assistant
Water Quality Permitting Section
North Carolina Department of Environmental Quality I Division of Water Resources
Mooresville Regional Office 1 610 East Center Avenue, Suite 301 1 Mooresville, North Carolina 26115
704.663.1699

AOUA.
(, Essential
February 1, 2023
NC Department of Environmental Quality
Division of Water Resources
NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Application for Permit Renewal
RECEIVED
FEB 16 2024
NCDEC)/D\NR/NPDES
Aqua North Carolina, Inc.
Oakley Park Well 1 & Well 2 Treatment Plants
NPDES No. NCG590010
Gaston County
To Whom It May Concern:
Attached are the completed application Modification Application Forms 1 and
2C , process flow diagram, and topographic map. This letter and attachments
are Aqua North Carolina's request to renew the subject permit.
We are requesting a waiver of any upstream sampling requirements for both
sites due to the inability to collect samples at the locations relevant to
upstream of the discharge sites.
If you need any additional information or assistance, please feel free to contact
me at [e-mail].
Sincerely,
DocuSigned by: I -
-PUA KAW
9C8BE09BOA7B49B
Lauren Raup-Plummer
Engineering Manager

United States Office of Water EPA Form 3510-1
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
SEA°► Application Form 1
General Information
NPDES Permitting Program
Note: All applicants to the National Pollutant Discharge Elimination System (NPDES) permits
program, with the exception of publicly owned treatment works and other treatment works treating
domestic sewage, must complete Form 1. Additionally, all applicants must complete one or more of the
following forms: 2B, 2C, 21), 2E, or 2F. To determine the specific forms you must complete, consult the
"General Instructions" for this form.

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
t
GO' EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•NPDES
Applicants Not Required to Submit Form 1
1.1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete 0 No
If yes, STOP. Do NOT No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
operation or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
a
production facility?
currently discharging process wastewater?
o❑
Yes 4 Complete Form 1 No
0 Yes 4 Complete Form ❑ No
a
and Form 2B.
1 and Form 2C.
z
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
ca
of
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
c
commenced to discharge?
discharges only nonprocess wastewater?
Yes 4 Complete Form 1 No
Yes 4 Complete Form No
and Form 2D.
1 and Form 2E.
1.2.5
Is the facility a new or existing facility whose
'—
discharge is composed entirely of stormwater
a
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
Yes 4 Complete Form 1 No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
SECTION
2.1
••• AND LOCATION (40
Facility Name
Oakle Park Subdivision -Well #1 & #2 WTP
`0
2.2
EPA Identification Number
U
0
NCG590010
v
Ca
2.3
Facility Contact
Cli
Name (first and last)
-J
Title
Phone number
Lauren Raup-Plummer
Engineering Manager
[phone]
Q
Email address
[e-mail]
2.4
Facility Mailing Address
M
E
Street or P.O. box
z
202 MacKenan Drive
City or town
State
ZIP code
Cary
North Carolina
27511
EPA Form 3510-1 (revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1
OMB No. 2040-0004
2.5
Facility Location
wStreet,
route number, or other specific identifier
Q 0
Well 1 @ 133 Sequoia Dr Well 2 @ Pinto Ln
as
c
County name
County code (if known)
Gaston
0
E
City or town
State ZIP code
z
Gastonia
North Carolina 280S2
SECTION•I
•
3.1
SIC Code(s)
Description (optional)
4941
Establishments primarily engaged in distributing water for sale for domestic,
H
d
V
O
U
N
U
Z
3.2
NAICS Code(s)
Description (optional)
-a
310
Water Distribution (except irrigation)
U
co
4.1
Name 76—perator
Aqua North Carolina
O
4.2
Is the name you listed in Item 4.1 also the owner?
€
0 Yes ❑ No
w
4.3
Operator Status
S
T
❑ Public —federal ❑ Public —state ❑ Other public (specify)
o
❑r Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
Street or P.O. Box
cc
'0
202 MacKenan Drive
m
0 0
w
City or town
State
ZIP code
0 0
'a
Cary
North Carolina
27511
o
Email address of operator
[e-mail]
SECTION1
1 I
5.1
Is the facility located on Indian Land?
❑ Yes 0 No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells 1 OMB No. 2040-0004
SECTION••
1
all that apply and print or type the corresponding permit number for each)
6.1
Existing Environmental Permits (check
d
❑✓ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
water)
fluids)
y
NCG590010
w a
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
rn
K
❑ Ocean dumping (MPRSA) ❑ Dredge or fill (CWA Section 404) ❑ Other (specify)
w
SECTION1
7.1
Have you attached a topographic map containing all required information to this application? (See instructions for
C
specific requirements.)
❑r Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 26.)
SECTIONOF
1 CFR 122.21(ffl8))
Describe the nature of your business.
8.1
Operating a filter -backwash treatment system employing greensand filter technology to treat groundwater in
support of potable -water production
U)
N!
G>
C
.y
7
Co
O
7
cc
Z
SECTION
••
Does your facility use cooling water?
9.1
d
❑ Yes ❑r No + SKIP to Item 10.1.
R
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
Q, 2
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
NPDES permitting authority to determine what specific information needs to be submitted and when.)
O Y
O to
U c
SECTION
1 VARIANCE
REQUESTSI I
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
10.1
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
H
d
when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
❑✓ Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1 OMB No. 2040-0004
SECTION•
r
11.1
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2
r❑ Section 1: Activities Requiring an NPDES Permit
❑r w/ attachments
El Section 2: Name, Mailing Address, and Location
❑ w/ attachments
r❑ Section 3: SIC Codes
❑ w/ attachments
r❑ Section 4: Operator Information
❑ w/ attachments
✓❑ Section 5: Indian Land
❑ w/ attachments
�❑
Section 6: Existing Environmental Permits
❑ w/ attachments
CD
d❑
Section 7: Ma p
w/ topographic
❑ Elma w/ additional attachments
R
`o
❑r Section 8: Nature of Business
❑ w/ attachments
M
w
Section 9: Cooling Water Intake Structures
❑ w/ attachments
r
❑✓ Section 10: Variance Requests
❑ w/ attachments
a
c
y
El Section 11: Checklist and Certification Statement
❑ wl attachments
Y
d
11.2
Certification Statement
L
U
1 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 qualified personnel properly gather and evaluate 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 fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Lauren Raup-Plummer
Engineering Manager
Signature
Date signed
Do uSrgned by:
E02/01/2024
9C8BE09BOA7B49B...
EPA Form 3510-1 (revised 3-19) Page 4

United States Office of Water EPA Form 3510-2C
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
:.EPA Application Form 2C
Existing Manufacturing,
Commercial, Mining, and
Si Ivicu Itural Operations
NPDES Permitting Program
Note: Complete this form and Form 1 if your facility is an existing manufacturing, commercial, mining,
or silvicultural facility that currently discharges process wastewater.

EPA Identitication Number NPOES Permit Number Facility Name Outfall Number
NCG590010 NCGS90010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Intake
Presence or Absence
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
aily
of
Average
of
(required)
(if available)
Discharge harge
Analyses
Value
Analyses
if available
2.22
Tetrachloroethylene
El
El
E
Concentration
Mass
(127-18-4)
2.23
Toluene
El
✓
Concentration
Mass
(108-88-3)
224
1,2-trans-dichloroethylene
El
El
✓
Concentration
Mass
(156-60-5)
225
1, 1, 1 -trichloroethane
El
Concentration
Mass
(71-55-6)
226
1,1,2-trichloroethane
0
Concentration
Mass
(79-00-5)
2.27
Trichloroethylene
El
El
El
Concentration
Mass
(79-01-6)
2.28
Vinyl chloride
Ei
Concentration
Mass
(75-01-4)
Section 3.Organic Toxic Pollutants GC/MS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
El
Concentration
Mass
(95-57-8)
3.2
2,4-dichlorophenol
✓
Concentration
Mass
(120-83-2)
3.3
2,4-dimethylphenol
©
Concentration
Mass
(105-67-9)
3.4
4,6-dinitro-o-cresol
✓
Concentration
Mass
(534-52-1)
3.5
2,4-dinitrophenol
El
1:1
El
Concentration
Mass
(51-28-5)
EPA Form 3510-2C (Revised 3-19) Page 14

Identification Number Nrutb rermir Number racwry Name Uuttall Number
NCG590010 Oakley Park Subdivision -Wells #1
NCG590010 001
O
Form Approved 03/05/19
OMB No. 2040-0004
•
1
•
• 1 •'
Presence or Absence
(check one)
• '• 1Ulm
Units
(specify)
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Believed
Present
Believed
Absent
Maximum
Daily
Discarge
(requied)
Maximum
Monthly
(if
e)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
3.6
2-nitrophenol
(88-75-5)
❑
❑
❑
Concentration
Mass
3.7
4-nitrophenol
(100-02-7)
El
❑
❑
Concentration
Mass
3.8
p-chloro-m-cresol
(59-50-7)
❑
El
❑
Concentration
Mass
3.9
Pentachlorophenol
(87-86-5)
❑
❑
❑
Concentration
Mass
3.10
Phenol
(108-95-2)
El
1:1
✓
Concentration
Mass
3.11
2,4,6-trichlorophenol
(88-05-2)
❑
❑
❑✓
Concentration
Mass
Section 4.Organic Toxic Pollutants (GC/MS
Fraction
—Base /Neutral
Compounds)
4.1
Acenaphthene
(83-32-9)
❑
R1
Concentration
Mass
4.2
Acenaphthylene
(208-96-8)
El
El
✓
Concentration
Mass
4.3
Anthracene
(120-12-7)
1:1
El
✓
Concentration
Mass
4.4
Benzidine
(92-87-5)
❑
❑
©
Concentration
Mass
4.5
Benzo (a) anthracene
(56-55-3)
❑
El
El
Concentration
Mass
4.6
Benzo (a) pyrene
(50-32-8)
El
❑
1Mass
❑
Concentration
EPA Form 3510-2C (Revised 3-19) Page 15

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 ••
• '• 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
if available
4.7
3,4-benzofluoranthene
El
El
21
Concentration
Mass
(205-99-2)
4.8
Benzo (ghi) perylene
El
El
El
Concentration
Mass
(191-24-2)
4.9
Benzo (k) fluoranthene
El
E
Concentration
Mass
(207-08-9)
4.10
Bis (2-chloroethoxy) methane
❑
El
©
Concentration
Mass
(111-91-1)
4.11
Bis (2-chloroethyl) ether
❑
El
Concentration
Mass
(111-44-4)
4.12
Bis (2-chloroisopropyl) ether
❑
El
❑�
Concentration
Mass
(102-80-1)
4.13
Bis (2-ethylhexyl) phthalate
❑
❑
✓
Concentration
Mass
(117-81-7)
4.14
4-bromophenyl phenyl ether
Concentration
Mass
(101-55-3)
4.15
Butyl benzyl phthalate
O
Concentration
Mass
(85-68-7)
4.16
2-chloronaphthalene
❑
❑
❑
Concentration
Mass
(91-58-7)
4.17
4-chlorophenyl phenyl ether
Concentration
Mass
(7005-72-3)
4.18
Chrysene
El
El
El
Concentration
Mass
(218-01-9)
4.19
Dibenzo (a,h) anthracene
El
El
Concentration
Mass
(53-70-3)
EPA Form 3510-2C (Revised 3-19) Page 16

dentification Number NPDES Permit Number
NCG590010 NCG590010
Name
Oakley Park Subdivision -Wells #1 001
o ,
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 • '
Presence or Absence
• ' • 1
Intake
(check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available )
Required
q
Believed
Believed
(specify)
(p N)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
Discharge
°f
Analyses
Average
of
Analyses
(required)
(if available)
if available
Value
4.20
1,2-dichlorobenzene
❑
❑
Concentration
Mass
(95-50-1)
421
1,3-dichlorobenzene
❑❑
Concentration
Mass
(541-73-1)
4.22
1,4-dichlorobenzene
❑
El
❑
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
❑
❑
❑
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
P1
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
❑
❑❑
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
❑
❑
✓0
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
El
El
❑
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
❑
❑
❑
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
El
❑
E
Concentration
Mass
(117-84-0)
4.30
1,2-Dipheny1hydrazine
El
El
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
El
❑
Concentration
(86-73-7)
1
1Mass
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number NYUEb F'ermIt Number Facility Name Outtall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 1 001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Daily
of
Average
of
(reghrerd)
(if available)
e)
Discharge
Analyses
Value
Analyses
if available
4.33
Hexachloro benzene
Concentration
Mass
(118-74-1)
4.34
Hexachlorobutadiene
El
El
El
Concentration
Mass
(87-68-3)
4.35
Hexachlorocyclopentadiene
1:1
El
El
Concentration
Mass
(77-47-4)
4.36
Hexachloroethane
El
El
✓
Concentration
Mass
(67-72-1)
4.37
Indeno (1,2,3-cd) pyrene
El
Concentration
Mass
(193-39-5)
4.38
Isophorone
El
Concentration
Mass
(78-59-1)
4.39
Naphthalene
0
Concentration
Mass
(91-20-3)
4.40
Nitrobenzene
0
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
El
1:1
El
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
El
El
0
Concentration
Mass
(86-30-6)
4.44
Phenanthrene
✓
Concentration
Mass
(85-01-8)
4.45
Pyrene
El
1:1
El
Concentration
Mass
(129-00-0)
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 I Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
(check one)
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
(required)
(if available)
if available
Value
1,2,4-trichlorobenzene
4.46
El
El
✓
ncentration
�Moras
s
(120-82-1)
Section 5.Organic Toxic Pollutants (GC/MS
Fraction
—Pesticides)
5.1
Aldrin
✓
Concentration
Mass
(309-00-2)
5.2
a-BHC
El
1:1
El
Concentration
Mass
(319-84-6)
5.3
R-BHC
✓
Concentration
Mass
(319-85-7)
5.4
y-BHC
Concentration
Mass
(58 89 9)
5.5
b-BHC
El
1:1
✓
ncentration
�Muass
(319-86-8)
5.6
Chlordane
El
11
El
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
El
1:1
✓
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
11
El
a
Concentration
Mass
(72-55-9)
5.9
4,4'-DDD
El
El
✓
Concentration
Mass
(72-54-8)
5.10
Dieldrin
El
El
✓
Concentration
Mass
(60-57-1)
5.11
a-endosulfan
✓
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
•
Testing
Required
• 1 • •Ojkll•
Presence or Absence
check one
• • 1
Effluent
Intake
(opfional)
Units
(specify)
Believed
Present
Believed
Absent
Maximum
Daily
D(eghrerd)
Maximum
Monthly
ifavailable)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Number
of
Analyses
5.12
R-endosulfan
(115-29-7)
❑
❑
❑
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
❑
❑
❑
Concentration
Mass
5.14
Endrin
(72 20 8)
❑
❑
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
❑
❑
❑
Concentration
Mass
5.16
Heptachlor
(76-44-8)
❑
❑
❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
El
❑
El
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
❑
0
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
❑
❑''
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
❑
'❑
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
❑
0
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑
❑
El
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑
El
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
❑
❑
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

dentification Number NF utb Hermit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
O. 1 1A17D,
Form Approved 03/05/19
OMB No. 2040-0004
�-
Presence or Absence
• ' 1
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
D`segchaag a
Dischuired)
Daily
of
Average
of
(if arge)
Discharge
Analyses
alue
Analyses
if available
Toxaphene
5.25
El
El
Concentration
Mass
(8001-35-2)
t Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
MZ
Presence or Absence
Intake
(check one) Effluent
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
Discharge Discharge Analyses Analyses
(required)
if available if available)Value
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
❑ Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
1
Bromide
❑
✓
❑
Concentration
Mass
(24959-67-9)
2
Chlorine, total
❑
❑
Concentration
ug/L
10
9.92
109
Mass
residual
3.
Color
❑
0
Concentration
Mass
4.
Fecal coliform
❑
0
Concentration
Mass
5
Fluoride
❑
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
❑
0Concentration
Mass
7'
Nitrogen, total
❑
✓
❑
Concentration
Mass
organic (as N)
8.
Oil and grease
❑
❑
Concentration
Mass
9
Phosphorus (as
❑
❑
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
❑
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
❑
ID
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCGS90010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence
Intake
check one Effluent
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
Discharge Discharge Analyses Analyses
(required) Value
if available if available
12
Sulfite (as SOs)
Concentration
Mass
(1426545-3)
13.
Surfactants
Concentration
Mass
14.
Aluminum, total
Concentration
Mass
(7429-90-5)
15.
Barium, total
❑
❑
Concentration
Mass
(7440-39-3)
16.
Boron, total
El❑
Concentration
Mass
(7440-42-8)
17.
Cobalt, total
❑
✓
Concentration
Mass
(744048 4)
18
Iron, total
❑
✓
Concentration
Mass
(7439.89-6)
19
Magnesium, total
❑
0
Concentration
Mass
(7439-95-4)
Molybdenum,
Concentration
20.
total
El
7439-98-7
Mass
21
Manganese, total
Concentration
nng/L
1.02
0.37
17
Mass
(7439-96-5)
22
Tin, total
Concentration
Mass
(7440-31-5)
23
Titanium, total
Concentration
Mass
(7440-32-6)
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park Subdivision -Wells
#1 001
OMB No. 2040-0004
Presence or Absence
check
one)
Effluent
Intake
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum Long -Term
Long -Term
Present
Absent
Discharge
Monthly Average Daily Number of
Average Number of
(required)
Discharge Discharge Analyses
Value Analyses
if available if available)
24. Radioactivity
Alpha. total
❑
0
Concentration
r
Mass
Beta, total
❑
❑�
Concentration
Mass
Radium, total
El
El
Concentration
Mass
Radium 226, total
Concentration
Mass
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
1.
Asbestos
❑
2.
3.
4.
Acetaldehyde
Allyl alcohol
Allyl chloride
❑
❑
❑
0
0
5.
Amyl acetate
❑
6.
Aniline
❑
0
7.
Benzonitrile
❑
0
8.
Benzyl chloride
❑
9.
Butyl acetate
❑
❑�
10.
Butylamine
❑
11.
Captan
❑
Z
12.
Carbaryl
❑
❑�
13.
Carbofuran
❑
❑�
14.
Carbon disulfide
❑
❑�
15.
Chlorpyrifos
❑
❑�
16.
Coumaphos
❑
17.
Cresol
❑
❑�
18.
Crotonaldehyde
❑
19.
Cyclohexane
❑
❑�
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
I MR! *TJ � I I • ,9
Presence or Absence
Pollutant check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
20.
2,4-D (2,4-dichlorophenoxyacetic acid)
❑
❑r
21.
Diazinon
❑
❑r
22.
Dicamba
❑
❑r
23.
Dichlobenil
❑
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
❑�
26.
Dichlorvos
❑
0
27.
Diethyl amine
❑
❑r
28.
Dimethyl amine
❑
❑r
29.
Dintrobenzene
❑
0
30.
Diquat
❑
0
31.
Disulfoton
❑
❑r
32.
Diuron
❑
❑r
33.
Epichlorohydrin
❑
❑r
34.
Ethion
❑
❑r
35.
Ethylene diamine
❑
0
36.
Ethylene dibromide
❑
❑r
37.
Formaldehyde
❑
38.
Furfural
❑
❑✓
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
� Absence
1 '1• 7B�elieved
Pollutant one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed (specify units)
Present Absent
39. Guthion ❑
40.
Isoprene
❑
❑
41.
Isopropanolamine
❑
42.
Kelthane
❑
❑�
43.
Kepone
❑
0
44.
Malathion
❑
0
45.
Mercaptodimethur
❑
0
46.
Methoxychlor
❑
0
47.
Methyl mercaptan
❑
0
48.
Methyl methacrylate
❑
0
49.
Methyl parathion
❑
0
50.
Mevinphos
❑
0
51.
Mexacarbate
❑
0
52.
Monoethyl amine
❑
0
53.
Monomethyl amine
❑
0
54.
Naled
❑
0
55.
Naphthenic acid
❑
0
56.
Nitrotoluene
❑
0
57.
Parathion
❑
0
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
1 ' 1 • 1 • 1
Presence or Absence
Pollutant check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
58.
Phenolsulfonate
❑
❑✓
59.
Phosgene
❑
❑✓
60.
Propargite
❑
❑✓
61.
Propylene oxide
❑
El
62.
Pyrethrins
❑
❑✓
63.
Quinoline
❑
64.
Resorcinol
❑
0
65.
Strontium
❑
0
66.
Strychnine
❑
❑✓
67.
Styrene
❑
❑✓
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid)✓
❑
❑
69.
TIDE (tetrachlorodiphenyl ethane)
❑
El
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
❑
❑
71.
Trichlorofon
❑
❑✓
72.
Triethanolamine
❑
❑✓
73.
Triethylamine
❑
74.
Trimethylamine
❑
❑✓
75.
Uranium
❑
❑✓
76.
Vanadium
❑
0
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number
Facility Name Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park
Subdivision -Wells #1 001
OMB No.2040-0004
1 • 1 �
1 � 1
�
Presence or Absence
Pollutant
(check one)
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
77.
Vinyl acetate
❑
R
78.
Xylene
❑
79.
Xylenol
❑
0
80.
Zirconium
❑
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05119
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No.2040-0004
�•�� 7R.7'
TCDDCongenersPollutant Usedor Results of Screening Procedure
Manufactured e
Present Absent
2,3,7,8-TCDD ❑ ❑ 0
EPA Form 3510-2C (Revised 3-19) Page 33

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
TABLE
A. CONVENTIONAL AND NON
CONVENTIONAL POLLUTANTS (40 CFR
122.21(g)(7)(iii))l
Effluent
Intake
Pollutant
Waiver Units
Requested
0 tional
Maximum
Maximum
Long -Term
(Specify)
(if applicable)
Daily
Monthly
Average Daily
Number of
Long -Term
Number of
Discharge
Discharge
Discharge
Analyses
Average Value
Analyses
(required)
if available
if available
❑
Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.
1'
Biochemical oxygen demand
El
Concentration
Mass
(BOD5)
2'
Chemical oxygen demand
El
Concentration
Mass
(COD)
Concentration
3.
Total organic carbon (TOC)
✓❑
Mass
Concentration
mg/L
40
9.16
108
4.
Total suspended solids (TSS)
✓❑
Mass
Concentration
5.
Ammonia (as N)❑
Mass
6.
Flow
❑
Rate
mgd
0.0012
0.0012
282
Temperature (winter)
°C
°C
7.
Temperature (summer)
°C
°C
pH (minimum)
❑
Standard units
SM.
6.7
7.2
78
8.
pH (maximum)
❑
Standard units
SM.
8.7
7.2
78
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 9

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available )
1
Testing
Required
q
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Long-
Term
Average
Value
Number
of
Analyses
❑ Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.
Section 1. Toxic Metals, Cyanide, and Total Phenols
1.1
Antimony, total
(7440-36-0)
❑
❑
❑
Concentration
Mass
1.2
Arsenic, total
(7440-38-2)
El
❑
El
Concentration
Concentration
1.3
Beryllium, total
(7440-41-7)
El
El
El
Concentration
Concentration
1.4
Cadmium, total
(7440-43-9)
El
❑
El
Concentration
Concentration
1.5
Chromium, total
(7440-47-3)
❑
❑
El
Concentration
Concentration
1.6
Copper, total
(7440-50-8)
❑
El
ElConcentration
Mass
1.7
Lead, total
(7439-92-1)
El
❑
El
Concentration
Concentration
1.8
Mercury, total
(7439-97-6)
❑
❑
El
Concentration
Concentration
1'9
Nickel, total
(7440-02-0)
El
El
El
Concentration
Concentration
1.10
Selenium, total
(7782-49-2)
El
❑
El
Concentration
Concentration
1.11
Silver, total
(7440-22-4)
El
❑
El
Concentration
Concentration
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Intake
Presence or Absence
(check one)
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Tenn
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
e)Discharge
f available)
if available
Value
1.12
Thallium, total
❑
El❑
Concentration
Mass
(7440-28-0)
1.13
Zinc, total
❑
❑
❑
Concentration
Mass
(7440-66-6)
1.14
Cyanide, total
Concentration
Mass
(57-12-5)
1.15
Phenols, total
Ej
❑
❑✓
Concentration
Mass
Section 2.Organic Toxic Pollutants (GC/MS
Fraction
—Volatile Compounds)
21
Acrolein
❑
❑
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
✓
Concentration
Mass
(107-13-1)
2.3
Benzene
❑
❑
Concentration
Mass
(71-43-2)
2.4
Bromoform
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
El
El
El
Concentration
Mass
(108-90-7)
2.7
Chlorodibromomethane
✓
Concentration
Mass
(124-48-1)
2.8
Chloroethane
El
❑
❑
Concentration
Mass
(75-00-3)
EPA Form 3510-2C (Revised 3-19) Page 12

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
•
Testing
Required
• TM '
Presence or Absence
check one
• '• 1
Units
(P ty)
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge)
(if
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Lon
Term
Average
alue
Number
of
Analyses
2.9
2-chloroethylvinyl ether
(110-75-8)
ID
Concentration
Mass
Mass
2.10
Chloroform (67-66-3)
El
El
0
Concentration
Mass
2.11
Dichlorobromomethane
(75-27-4)
0
Concentration
Mass
212
1,1-dichloroethane
(75-34-3)
El
1:1
El
Concentration
Mass
2.13
1,2-dichloroethane
(107-06-2)
0
Concentration
Mass
2.14
1,1-dichloroethylene
(75-35-4)
E
Concentration
Mass
2.15
1,2-dichloropropane
(78 87 5)
✓
Concentration
Mass
2.16
1,3-dichloropropylene
(542-75-6)
E
Concentration
Mass
2.17
Ethylbenzene
(100-41-4)
0
Concentration
Mass
2.18
Methyl bromide
(74-83-9)
✓
Concentration
Mass
219
Methyl chloride
(74-87-3)
Concentration
Mass
2.20
Methylene chloride
(75-09-2)
0
Concentration
Mass
2.21
1 1,2,2- tetrachloroethane
(79-34-5)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 13

EPA Identification Number NHIJEb Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
(91r,1401:
Testing
Required
kill
Presence or Absence
(check one)
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Units
(specify)
Believed
Present
Believed
Absent
Maximum
Daily
h
Discharge
Maximum
Monthly
Discharge le
available)
Long -Term
Average
Daily
Discharge
(if available)
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
2.22
Tetrachloroethylene
(127-18-4)
❑
❑
❑
Concentration
Mass
2.23
Toluene
(108-88-3)
❑
✓
Concentration
Mass
2.24
1,2-trans-dichloroethylene
(156-60-5)
Concentration
Mass
225
1,1,1-trichloroethane
(71-55-6)
❑
❑
❑
Concentration
Mass
226
1,1,2-trichloroethane
(79-00-5)
❑
❑
❑✓
Concentration
Mass
2.27
Trichloroethylene
(79-01-6)
❑
❑
El
Concentration
Mass
2.28
Vinyl chloride
(75-01-4)
❑
❑
El
Concentration
Mass
Section 3.Organic Toxic Pollutants (GC/MS Fraction
—Acid Compounds)
3.1
2-chlorophenol
(95-57-8)
❑
❑
Concentration
Mass
3.2
2,4-dichlorophenol
(120-83-2)
El
El
El
Concentration
Mass
3.3
2,4-dimethylphenol
(105-67-9)
❑
❑
©
Concentration
Mass
3.4
4,6-dinitro-o-cresol
(534-52-1)
✓
Concentration
Mass
3.5
2,4-dinitrophenol
(51-28-5)
✓
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 14

dentification Number NPDES Permit Number Facility Name Outfall Nu
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
D(
D(if
Daily
of
AValuee
of
eqischarge ui edge
available)
Discharge
Analyses
Analyses
if available
3.6
2-nitrophenol
❑
❑
❑✓
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
El
El
✓
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
❑
✓❑
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
✓❑
Concentration
Mass
(87-86-5)
3.10
Phenol
✓
Concentration
Mass
(108-95-2)
3.11
2,4,6-trichlorophenol
❑
El
0
Concentration
Mass
(88-05-2)
Section 4.Organic Toxic Pollutants (GC/MS
Fraction
—Base /Neutral
Compounds
4.1
Acenaphthene
❑
❑
❑✓
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
✓
Concentration
Mass
(208-96-8)
4.3
Anthracene
✓
Concentration
Mass
(120-12-7)
4.4
Benzidine
❑
❑
©
Concentration
Mass
(92-87-5)
4.5
Benzo (a) anthracene
❑
❑
❑
Concentration
Mass
(56-55-3)
L46Benzo
(a) pyrene
❑
❑
❑
Concentration
Mass
(50-32-8)
EPA Form 3510-2C (Revised 3-19) Page 15

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 I Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
14.7
•
Testing
Required
• 1 • •
Presence or Absence
(check one)
• • • 1
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge e
(required)
Q )
Maximum
Monthly
Discahrge)
(if
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Number
of
Analyses
3,4-benzofluoranthene
(205-99-2)
El
❑
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
El
El
✓
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
❑
❑
❑
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
1:1
El
©
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
❑
❑
✓
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
❑
❑
❑✓
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
El
❑
❑✓
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
❑
❑
❑✓
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
❑
❑
❑✓
Concentration
Mass
4.16
2-chloronaphthalene
(91-58-7)
❑
❑
❑
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
El
El
✓
Concentration
Mass
4.18
Chrysene
(218-01-9)
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
El
El❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 I Oakley Park Subdivision -Wells #1 1 002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Dail
of
Average
of
(required)
(if available)
Discharge
Analyses
Analyses
if available)Value
4.20
1,2-dichlorobenzene
❑
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
❑
❑
❑�
Concentration
Mass
(541-73-1)
4.22
1,4-dichlorobenzene
❑
❑
❑�
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
❑
❑
❑�
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
✓❑
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
❑
❑
El
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
❑
❑
✓❑
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
El
El
❑�
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
El
❑
❑
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
❑
❑�
Concentration
Mass
(117-84-0)
4.30
1,2-Diphenylhydrazine
❑
El
❑�
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
El
Mass
Mass
(206-44-0)
4.32
Fluorene
❑
❑�
Concentration
1 Mass
(86-73-7)
1
EPA Form 3510-2C (Revised 3-19) Page 17

LNA Identification Number
NCG590010
Name
NCG590010 Oakley Park Subdivision -Wells #1 002
0
Form Approved 03/05/19
OMB No. 2040-0004
14.33Hexachlorobenzene
• 1
Pollutant/Parameter
(and CAS Number, if available)
•
• 1 • '
Presence or Absence
(check one)
• ' • 1
Units
(specify)
Effluent
Intake
(optional)
Testing
Required
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Long-
Term
Average
Value
Number
of
Analyses
(118-74-1)
El❑
Concentration
Mass
4.34
Hexachlorobutadiene
(87-68-3)
❑
❑
❑r
Concentration
Mass
4.35
Hexachlorocyclopentadiene
(77-47-4)
❑
❑r
Concentration
Mass
4.36
Hexachloroethane
(67-72-1)
❑
El
❑
Concentration
Mass
4.37
Indeno (1,2,3-cd) pyrene
(193-39-5)
El
Concentration
Mass
4.38
Isophorone
(78 59-1)
El
El
El
Concentration
Mass
4.39
Naphthalene
(91-20-3)
❑
❑
Concentration
Mass
4.40
Nitrobenzene
(98-95-3)
El
El
Concentration
Mass
4.41
N-nitrosodimethylamine
(62 75 9)
El
El
Concentration
Mass
4.42
N-nitrosodi-n-propylamine
(621-64-7)
❑
❑
Concentration
Mass
4.43
N-nitrosodiphenylamine
(86-30-6)
❑
❑
❑
Concentration
Mass
4.44
Phenanthrene
(85-01-8)
❑
❑
r
Concentration
Mass
4.45
Pyrene
(129-00-0)
❑
❑
1Mass
❑
Concentration
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 I Oakley Park Subdivision -Wells #1 1 002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Daily
of
Average
of
(eghrerd)
ifavailablischarle
e)
Discharge
Analyses
Value
Analyses
if available
4.46 1,2,4-trichlorobenzene
❑
❑
❑✓
Concentration
Mass
(120-82-1)
Section 5.Organic Toxic Pollutants GCIMS
Fraction
—Pesticides
5.1
Aldrin
❑
❑
❑✓
Concentration
Mass
(309-00-2)
5.2
a-BHC
El
El
❑
Concentration
Mass
(319-84-6)
5.3
Q-BHC
❑
❑
❑
Concentration
Mass
(319-85-7)
5.4
y-BHC
❑
❑
Concentration
Mass
(58 89 9)
5.5
b-BHC
El
ElMass
El
Concentration
(319-86-8)
5.6
Chlordane
❑
❑
❑
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
❑
El❑
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
El
❑
❑
Concentration
Mass
(72-55-9)
5.9
4,4'-DDD
❑
❑
❑
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
❑
❑
Concentration
Mass
(60-57-1)
5.11
a-endosulfan
❑
❑
❑
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells 41 002
O. '1 \ 11-
Form Approved 03/05/19
OMB No. 2040-0004
1
Pollutant/Parameter
(and CAS Number, if available)
ILl
Testing
Required
[01 IRWI 0 11101'
Presence or Absence
(check one)
974 1153141
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
i
Monthly
Discharge
(if available)
Long-Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Lon g'
Term
Average
Value
Number
of
Analyses
5112
R-endosulfan
(115-29-7)
❑
❑
0
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
Concentration
Mass
5.14
Endrin
(72-20-8)
❑
❑
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
Concentration
Mass
5.16
Heptachlor
(76-44-8)
✓
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
0
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
El
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
❑�
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
❑�
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑�
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑�
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
❑
❑
0
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
TOXICTABLE B. 1E,
TOTAL PHENOLS,1
ORGANIC TOXIC'•
1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Lon
(and CAS Number, if available)
(and
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Absent
Discharge
Discharge
Dailyof
Discharge
Analyses
Average
Analyses
(required)
(if available)
if available
Value
�Toxaphene
5.25
0
Concentration
Mass
(8001-35-2)
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
• Ell
Presence or Absence
check one Effluent Intake
(Optional)
Pollutant Units Maximum Long Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
(required) Discharge Discharge Analyses Analyses
Value
if available if available
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
© Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
1
Bromide
❑
❑
Concentration
Mass
(24959-67-9)
2'
Chlorine, total
✓
❑
❑
Concentration
ug/L
10
9.91
114
Mass
residual
3.
Color
❑
H
Concentration
Mass
4.
Fecal coliform
❑
Concentration
Mass
5
Fluoride
❑
S
Concentration
Mass
(1698448-8)
6
Nitrate -nitrite
❑
Concentration
Mass
7'
Nitrogen, total
❑
✓
❑
Concentration
Mass
organic (as N)
8.
Oil and grease
El
Concentration
Mass
g'
Phosphorus (as
❑
❑
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
IDConcentration
Mass
(14808-79-8)
11.
Sulfide (as S)
❑
21
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
JEPA
Presence or Absence Intake
(check one) Effluent
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Average Number of
Present Absent Discharge
Discharge Discharge Analyses Analyses
(required) (if available if available)Value
12
Sulfite (as S03)
(14265-45-3)
El
❑
Concentration
Mass
13.
Surfactants
❑
H
Concentration
Mass
14
Aluminum, total
(7429-90-5)
✓
Concentration
Mass
15.
Barium, total
(7440-39-3)
❑
❑
Concentration
Mass
16.
Boron, total
(7440-42-8)
❑
❑
Concentration
Mass
17.
Cobalt, total
(744048-4)
❑
❑
Concentration
Mass
18
Iron total
(7439-89-0)
El
❑
Concentration
Mass
19
Magnesium, total
(7439-95-4)
El
ID
Concentration
Mass
Molybdenum,
Concentration
20.
total
(7439-98-7)
El
Mass
21
Manganese, total
(7439-96-5)
Concentration
nng/L
4.64
1.26
16
Mass
22
Tin, total
(7440-31-5)
El
✓
Concentration
Mass
23
Titanium, total
(7440-32-0)
Ei
0
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park Subdivision -Wells
#1 002
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum Long -Term
Long -Term
Present
Absent
Discharge
Monthly Average Daily Number of
Number of
Average
(required)
Discharge Discharge Analyses
Analyses
1
if available if available)Value
24. Radioactivity
Alpha, total
El
Concentration
Mass
Beta, total
❑
2
Concentration
Mass
Radium, total
El�
Concentration
Mass
Radium 226, total
El
�
Concentration
Mass
Sampling shall be conducted according to sutticlently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
1 ' I • 1 • 1
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
1.
Asbestos
❑
❑r
2.
Acetaldehyde
❑
❑r
3.
Allyl alcohol
❑
0
4.
Allyl chloride
❑
❑�
5.
Amyl acetate
❑
6.
Aniline
❑
❑�
7.
Benzonitrile
❑
❑✓
8.
Benzyl chloride
❑
9.
Butyl acetate
❑
0
10.
Butylamine
❑
❑�
11.
Captan
❑
❑✓
12.
Carbaryl
❑
❑✓
13.
Carbofuran
❑
❑�
14.
Carbon disulfide
❑
15.
Chlorpyrifos
❑
❑r
16.
Coumaphos
❑
171
17.
Cresol
❑
0
18.
Crotonaldehyde
❑
Z
19.
Cyclohexane
❑
Z
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
1 'I• 1 • 1
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
120.2,4-D
(2,4-dichlorophenoxyacetic acid)
❑
21.
Diazinon
❑
22.
Dicamba
❑
H
23.
Dichlobenil
❑
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
21
26.
Dichlorvos
❑
❑r
27.
Diethyl amine
❑
0
28.
Dimethyl amine
❑
0
29.
Dintrobenzene
❑
0
30.
Diquat
❑
31.
Disulfoton
❑
❑r
32.
Diuron
❑
❑r
33.
Epichlorohydrin
❑
❑�
34.
Ethion
❑
Z
35.
Ethylene diamine
❑
Z
36.
Ethylene dibromide
❑
❑r
37.
Formaldehyde
❑
0
38.
Furfural
❑
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
1 ' 1 • 1 • 1
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge
(specify units)
Present Absent
39.
Guthion
❑
❑r
_
40.
Isoprene
❑
❑�
41.
Isopropanolamine
❑
H
42.
Kelthane
❑
❑✓
43.
Kepone
❑
0
44.
Malathion
❑
45.
Mercaptodimethur
❑
❑�
46.
Methoxychlor
❑
47.
Methyl mercaptan
❑
48.
Methyl methacrylate
❑
❑�
49.
Methyl parathion
❑
❑✓
50.
Mevirl
❑
❑r
51.
Mexacarbate
❑
❑�
52.
Monoethyl amine
❑
❑�
53.
Monomethyl amine
❑
❑r
54.
Naled
❑
❑r
55.
Naphthenic acid
❑
❑r
56.
Nitrotoluene
❑
21
57.
Parathion
❑
ID
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells ill 002 OMB No, 2040-0004
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
158.Phenolsulfonate
❑
S
59.
Phosgene
❑
Z
60.
Propargite
❑
❑r
61.
Propylene oxide
❑
12
62.
Pyrethrins
❑
R
63.
Quinoline
❑
64.
Resorcinol
❑
❑�
65.
Strontium
❑
0
66.
Strychnine
❑
❑�
67.
Styrene
❑
❑�
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetra chlorodiphenyl ethane)
❑
0
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
propanoic acid
❑
❑
71.
Trichlorofon
❑
❑�
72.
Triethanolamine
❑
❑r
73.
Triethylamine
❑
❑r
74.
Trimethylamine
❑
H
75.
Uranium
❑
❑�
76.
Vanadium
❑
❑�
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park Subdivision -Wells #1 002
OMB No. 2040-0004
1 1•
1 � 1 �
Presence or Absence
Pollutant
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
77.
Vinyl acetate
❑
78.
Xylene
❑
❑r
79.
Xylenol
❑
H
80.
Zirconium
❑
El
Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCGS90010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
• ' • 1 • 1 • 1 1 1 �
TCDD Presence or
Congeners Absence
Pollutant Used or check one Results of Screening Procedure
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD El ❑ ❑�
EPA Form 3510-2C (Revised 3-19) Page 33

Raw Raw
Water Water
Well #1 Well #2
Greensand M Mov I
Greensand
Water Chlorine Distribution Chlorine Water
Treatment Disinfection Disinfection Treatment
Facility Facility _
Outfall 001 Out all 002
McGill Branch; Catawba McGill Branch; Catawba
River Basin River Basin

Aqua North Carolina, Inc.
Oakley Park Subdivision Wells #1, #2 WTP
Latitud 35° 12' 32"(001) State Grid: Gastonia, North
35° 1 P 50" (002) YenWited Flow: N/A
Lonaltude: 81° 16, 02" (001) Stream Class: C
8 1* IS' 40" (001) Drainage Basin: Catawba River Basin
Recetvbm&ream: Mc Gilt Branch Sub -Basin: 03-08-37
Facility
Location jaw,.`
not to scale
M'DIrS Permit No. NCO086142
No r _th oaston County

DocuSign
Certificate Of Completion
Envelope Id: 2FC710DOCOE142F6B9EOF2BB32A44E45
Status: Completed
Subject: Here is your signed document: Oakley Park_NCG90010_Permit renewal 2.3.2024.pdf
Source Envelope:
Document Pages: 54
Signatures: 2
Envelope Originator:
Certificate Pages: 1
Initials: 0
Lauren Raup-Plummer
AutoNav: Disabled
[e-mail]
Envelopeld Stamping: Disabled
IP Address: 144.202.188.252
Time Zone: (UTC-05:00) Eastern Time (US & Canada)
Record Tracking
Status: Original
Holder: Lauren Raup-Plummer
Location: DocuSign
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[e-mail]
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Signature
Timestamp
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"u� "—P"MLY
Viewed: 2/2/2024 2:24:43 PM
Engineering Manager
9C8BE09B0A7B495
Signed: 2/2/2024 2:26:39 PM
Aqua North Carolina, Inc.
Freeform Signing
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AOUA,.
�-sserrai
February 1, 2023
NC Department of Environmental Quality
Division of Water Resources
NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Application for Permit Renewal
Aqua North Carolina, Inc.
Oakley Park Well 1 & Well 2 Treatment Plants
NPDES No. NCG590010
Gaston County
To Whom It May Concern:
Attached are the completed application Modification Application Forms 1 and
2C , process flow diagram, and topographic map. This letter and attachments
are Aqua North Carolina's request to renew the subject permit.
We are requesting a waiver of any upstream sampling requirements for both
sites due to the inability to collect samples at the locations relevant to
upstream of the discharge sites.
If you need any additional information or assistance, please feel free to contact
me at [e-mail].
Sincerely,
EDocuSigned by:
" .P"Mtr
9CBBE09BOA7B49B_.
Lauren Raup-Plummer
Engineering Manager

United States Office of Water EPA Form 3510-1
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
�E� Application Form 1
General Information
NPDES Permitting Program
Note: All applicants to the National Pollutant Discharge Elimination System (NPDES) permits
program, with the exception of publicly owned treatment works and other treatment works treating
domestic sewage, must complete Form 1. Additionally, all applicants must complete one or more of the
following forms: 2B, 2C, 2D, 2E, or 2F. To determine the specific forms you must complete, consult the
"General Instructions" for this form.

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1
OMB No. 2040-0004
U.S. Environmental Protection Agency
Form
1
\-/EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•NPDES
Applicants Not Required to Submit Form 1
1.1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete No
If yes, STOP. Do NOT 0 No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
Eoperation
or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
a
production facility?
currently discharging process wastewater?
w
Yes -+ Complete Form 1 No
0 Yes -* Complete Form ❑ No
a
and Form 2B.
1 and Form 2C.
C1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
.=
commenced to discharge?
discharges only nonprocess wastewater?
d❑
Yes 4 Complete Form 1 �✓ No
Yes 4 Complete Form No
and Form 2D.
1 and Form 2E.
1.2.5
Is the facility a new or existing facility whose
discharge is composed entirely of stormwater
a
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
❑ Yes 4 Complete Form 1 No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
b )(15).
SECTIONDD-
• •
Facility Name
2.1
Oakle Park Subdivision -Well #1 & #2 WTP
0
2.2
EPA Identification Number
.M
0
J
NCG590010
a
2.3
Facility Contact
d
Name (first and last)
Title
Phone number
a
Lauren Raup-Plummer
Engineering Manager
[phone]
Q
rn
Email address
c
[e-mail]
2.4
Facility Mailing Address
Street or P.O. box
z
202 MacKenan Drive
City or town
State
ZIP node
Cary
North Carolina
27511
EPA Form 3510-1 (revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1
OMB No. 2040-0004
N
2.5
Facility Location
wStreet,
route number, or other specific identifier
a 0
rn
Well 1 @ 133 Sequoia Dr Well 2 @ Pinto Ln
c
County name
County code (if known)
0
Gaston
E _j
City or town
State ZIP code
z
Gastonia
North Carolina 28052
SECTION1
NAICS CODES1
3.1
SIC Code(s)
Description (optional)
4941
Establishments primarily engaged in distributing water for sale for domestic,
H
G1
°
U
Z
3.2
NAICS Code(s)
Description (optional)
M
310
Water Distribution (except irrigation)
U
C0
4.1
Name of 0 erator
Aqua North Carolina
0
4.2
Is the name you listed in Item 4.1 also the owner?
R
c
El Yes ❑ No
w
4.3
Operator Status
R
❑ Public —federal ❑ Public —state ❑ Other public (specify)
o
❑r Private ❑ Other
(specify)
4.4
Phone Number of Operator
[phone]
=
4.5
Operator Address
°
Street or P.O. Box
A
E
202 MacKenan Drive
c `
City or town
State
ZIP code
0 0
a
Cary
North Carolina
27511
o
Email address of operator
O
[e-mail]
SECTION1
1 1
5.1
Is the facility located on Indian Land?
MU
C J
❑ Yes ❑✓ No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells 1 OMB No. 2040-0004
SECTION'•
1
all that apply and print or type the corresponding permit number for each)
6.1
Existing Environmental Permits (check
d
NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
c
water)
fluids)
NCG590010
J a
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
w
❑ Ocean dumping (MPRSA) ❑ Dredge or fill (CWA Section 404) ❑ Other (specify)
SECTION1
Have you attached a topographic map containing all required information to this application? (See instructions for
7.1
C
specific requirements.)
❑r Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 213.)
SECTIONOF
1
Describe the nature of your business.
8.1
Operating a filter -backwash treatment system employing greensand filter technology to treat groundwater in
support of potable -water production
M
M
N
C
y
00
0
a
Z
SECTION••
1 CFR 122.21(ffl9))
9.1 Does your facility use cooling water?
a
❑ Yes ❑r No + SKIP to Item 10.1.
M i
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
o, 2
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
_ U)
.O
NPDES permitting authority to determine what specific information needs to be submitted and when.)
O 9
C
SECTION
1 VARIANCE
REQUESTS1 1
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
10.1
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
y
d
when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
❑✓ Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1 OMB No. 2040-0004
SECTION1
CERTIFICATION STATEMENT (40
11.1
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2
El Section 1: Activities Requiring an NPDES Permit
r❑ w/ attachments
0 Section 2: Name, Mailing Address, and Location
❑ w/ attachments
El Section 3: SIC Codes
❑ w/ attachments
❑✓ Section 4: Operator Information
❑ w/ attachments
✓❑ Section 5: Indian Land
❑ w/ attachments
�❑
Section 6: Existing Environmental Permits
❑ w/ attachments
a
❑ Section 7: Ma p
w/ topographic
❑ Elw/ additional attachments
o
map
c
Section 8: Nature of Business
Elw/ attachments
w
❑✓ Section 9: Cooling Water Intake Structures
❑ w/ attachments
d
✓❑ Section 10: Variance Requests
❑ w/ attachments
c
h
Section 11: Checklist and Certification Statement
❑ w/ attachments
s
11.2
Certification Statement
U
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 qualified personnel properly gather and evaluate 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 fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Lauren Raup-Plummer
Engineering Manager
Signature
Date signed
by:
EDocuSigned
"—p"Kiv
02/01/2024
9C8BE0960A7649B_.
EPA Form 3510-1 (revised 3-19) Page 4

United States Office of Water EPA Form 3510-2C
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
^EPA Application Form 2C
Existing Manufacturing,
Commercial, Mining, and
Silvicultural Operations
NPDES Permitting Program
Note: Complete this form and Form 1 if your facility is an existing manufacturing, commercial, mining,
or silvicultural facility that currently discharges process wastewater.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long-
Term
Average
Value
Number
of
Analyses
2.22
Tetra chloroethylene
(127-18-4)
Concentration
Mass
2.23
Toluene
(108-88-3)
Concentration
Mass
2.24
1,2-trans-dichloroethylene
(156-60-5)
El
❑
❑
Concentration
Mass
2.25
1, 1, 1-trichloroethane
(71-55-6)
❑
El
El
Concentration
Mass
226
1,1,2-trichloroethane
(79-00-5)
❑
❑
❑�
Concentration
Mass
2.27
Trichloroethylene
(79-01-6)
❑
❑
❑�
Concentration
Mass
2.28
Vinyl chloride
(75-01-4)
❑
Q
Concentration
Mass
Section 3.Organic Toxic Pollutants(GC/MS
Fraction
—Acid Compounds
3.1
2ichlorophenol
(95-57-8)
0
Concentration
Mass
3.2
2 4-dichlorophenol
(120-83-2)
❑
❑
❑
Concentration
Mass
3.3
2 4-dimethylphenol
(105-67-9)
©
Concentration
Mass
3.4
4,6-dinitro-o-cresol
(534-52-1)
❑
✓
Concentration
Mass
3.5
2,4-dinitrophenol
(51-28-5)
❑
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 14

Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 • •
• • • 1
Presence or Absence
Intake
(check one)
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
(required)
(if available)
if available)
Value
3.6
2-nitrophenol
❑
❑
✓
❑
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
❑
El
El
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
❑
❑
❑
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
❑
❑
❑
Concentration
Mass
(87-86-5)
3.10
Phenol
❑
❑
El
Concentration
Mass
(108-95-2)
3.11
2,4,6-trichlorophenol
❑
❑
❑
Concentration
Mass
(88-05-2)
Section 4.Organic Toxic Pollutants (GC/MS
Fraction
—Base /Neutral
Compounds)
4.1
Acenaphthene
❑
❑
❑
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
✓
Concentration
Mass
(208-96-8)
4.3
Anthracene
El✓
Concentration
Mass
(120-12-7)
4.4
Benzidine
❑
El
©
Concentration
Mass
(92 87 5)
4.5
Benzo (a) anthracene
❑
❑
❑✓
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
❑
❑
❑
Concentration
Mass
(50-32-8)
EPA Form 3510-2C (Revised 3-19) Page 15

oentitication Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells ##1 001
Form Approved 03/05/19
OMB No. 2040-0004
wa •utou 1:1 r_jwwwf_jj III gaill•
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
q
MTV-
Presence or Absence
check one
• '• 1
Units
(p ty)
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absentof
Maximum
Daily
Discharge dd
(required)
Maximum
Monthly
Discharge
f available)
Long -Term
Average
Discharge
if available
Number
Analyses
Long-
Term
Average
Number
Analyses
4.7
3,4-benzofluoranthene
(205-99-2)
1:1✓
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
El
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
El
✓
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
El
©
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
✓
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
El
11El
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
a
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)1:1
✓
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
✓
Concentration
Mass
4.16
2-chloronaphthalene
(91 58 7)
✓
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
Concentration
Mass
4.18
Chrysene
(218-01-9)
El
Z
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
✓
Concentration —
_J_
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
911
1 • • 1 k
ou 11111112614 111181
Intake
Presence or Absence
(check one)
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
14.201,2-dichlorobenzene
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
❑
El
❑✓
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
❑
❑
0
Concentration
Mass
(541-73-1)
422
1,4-dichlorobenzene
❑
❑
21
Concentration
Mass
(106-46-7)
4.23
3 3-dichlorobenzidine
❑
❑
❑
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
0
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
❑
❑
❑✓
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
❑
❑
❑
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
❑
❑
✓❑
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
❑
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
El❑
Concentration
Mass
(117-84-0)
4.30
1,2-Dipheny1hydrazine
El
1:1
✓
Concentration
Mass
(as azobenzene)(122-66-7)
4.31
Fluoranthene
❑
❑
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
✓
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590 I Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
TOXICTABLE B. 1E,
TOTAL PHENOLS,1
ORGANIC TOXIC'•
1
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
if available
4.33
Hexachlorobenzene
11
El
ElConcentration
Mass
(118-74-1)
4.34
Hexachlorobutadiene
❑
❑
❑✓
Concentration
Mass
(87-68-3)
4.35
Hexachlorocyclopentadiene
El
❑
✓❑
Concentration
Mass
(77-47-4)
4.36
Hexachloroethane
❑
❑
✓❑
Concentration
Mass
(67-72-1)
4.37
Indeno (1,2,3-cd) pyrene
❑
❑
✓❑
Concentration
Mass
(193-39-5)
4.38
Isophorone
❑
❑
✓❑
Concentration
Mass
(78-59-1)
4.39
Naphthalene
❑
✓❑
Concentration
Mass
(91-20-3)
4.40
Nitrobenzene
❑
❑
El
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
❑
❑
✓❑
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
❑
❑✓
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
❑
❑
❑✓
Concentration
Mass
(86-30-6)
4.44
Phenanthrene
❑
❑
❑✓
Concentration
Mass
(85-01-8)
4.45
Pyrene
✓
Concentration
(129-00-0)
1
1Mass
EPA Form 3510-2C (Revised 3-19) Page 18

NCG590010
NHUE6 Hermit Number
NCG590010
Name
Oakley Park Subdivision -Wells #1
0
Outfall Number
001
Form Approved 03/05/19
OMB No. 2040-0004
•
1
•
• 111191.1011
Presence or Absence
• '• 1
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
D
Discharge
Daily
of
Average
of
(requi edge
f available)
Discharge
Analyses
Value
Analyses
if available
4.46
1,2,4-trichlorobenzene
0
Concentration
Mass
(120-82-1)
Section 5.Organic Toxic Pollutants (GC/MS
Fraction
—Pesticides)
5.1
Aldrin
El
11
El
Concentration
Mass
(309-00-2)
5.2
a-BHC
Concentration
Mass
(319-84-6)
5.3
R-BHC
Concentration
Mass
(319-85-7)
5.4
y-BHC
❑�
Concentration
Mass
(58-89-9)
5.5
b-BHC
Concentration
Mass
(319-86-8)
5.6
Chlordane
❑
❑
❑�
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
❑
❑
❑�
Concentration
Mass
(50-29-3)
5 8
4,4'-DDE
El
ElMass
❑�
Concentration
(72-55-9)
5.9
4,4'-DDD
❑
❑
❑
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
❑
0
Concentration
Mass
(60-57-1)
5.11
a-endosulfan
❑
El
El
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

oenntication Number NPUEb Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1
001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
•
Testing
Required
• 1 • ".1cf, k111042
Presence or Absence
check one
• ' • I
Units
(p ty)
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
D(eq (required)
Maximum
Monthly
Discharge
(if available)
e)
Long -Term
Average
Daily
Discharge
if available
Number
Analyses
Long'
Term
Average
Value
Number
of
Analyses
5.12
R-endosulfan
(115-29-7)
El
❑
❑
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
❑
❑
❑
Concentration
Mass
5.14
Endrin
(72-20-8)
❑
❑
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
❑
❑
El
Concentration
Concentration
5.16
Heptachlor
(76-44-8)
❑
❑
✓
❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑
'❑
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
❑
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
❑
❑''
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
❑
El
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
❑
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑
❑
El
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑
Concentration
Mass
5.24 1
PCB-1016
(12674-11-2)
❑
❑
0
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 • •
• • • 1
Presence or Absence
Intake
check one)
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Daily
of
Average
of
f available)
Discharge
Analyses
Analyses
f available
IToxaphene
5.25
Concentration
Mass
(8001-35-2)
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence
Intake
7
JE;PAIdentification
(check one) Effluent
(Optional)
Units
Pollutant Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
(required) Discharge Discharge Analyses Value Analyses
if available if available
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
❑ Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
1
Bromide
❑
✓
❑
Concentration
Mass
(24959-67-9)
2'
Chlorine, total
❑
❑
Concentration
ug/L
10
9.92
109
Mass
residual
3.
Color
El
Concentration
Concentration
4.
Fecal coliform
❑
❑
Concentration
Mass
5
Fluoride
❑
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
❑
0
Concentration
Mass
7'
Nitrogen, total
El
ID
Concentration
Mass
organic (as N)
8.
Oil and grease
El
0
ConcentrationMass
9
Phosphorus (as
❑
❑
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
0
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence
check one Effluent Intake
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
Discharge Discharge Analyses Analyses
(required) if available if available Value
12
Sulfite (as S03)
(14265-45-3)
❑
✓
❑
Concentration
Mass
13.
Surfactants
❑
❑�
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
❑
❑
Concentration
Mass
15.
Barium, total
(7440-39-3)
❑
✓
❑
Concentration
Mass
16.
Boron, total
(744042-8)
❑
❑
Concentration
Mass
17.
Cobalt, total
(7440484)
❑
✓
❑
Concentration
Mass
18
Iron, total
(7439-89-0)
❑
❑
Concentration
Mass
19
Magnesium, total
(7439-954)
❑
❑
Concentration
Mass
20.
Molybdenum,
total
7439-98-7
❑
El
Concentration
Mass
21
Manganese, total
(7439-96-5)
❑
❑
Concentration
mg/L
1.02
0.37
17
Mass
22.
Tin, total
(7440-31-5)
El
IDConcentration
Mass
23
Titanium, total
(7440-32-0)
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park Subdivision -Wells #1
001
OMB No. 2040-0004
Presence or Absence
Intake
(check
one)
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum
Long -Term
Long -Term
Present
Absent
Discharge
Monthly
Average Daily Number of
Average Number of
(required)
Discharge
Discharge Analyses
Analyses
Value
(if available)
if available
24. Radioactivity
Alpha, total
El
Concentration
Mass
Beta, total
❑
0
Concentration
Mass
Radium, total
❑
Concentration
Mass
Radium 226, total
❑
0
Concentration
Mass
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3511(Revised 3-19) Page 25

EPA Identification Number NPDES Permit Number
NCG590010 NCG590010 Oakley Park
Presence or Absence
Pollutant (check one)
Believed Believed
Present Absent
Facility Name Outfall Number
Subdivision -Wells #1 001
Reason Pollutant Believed Present in Discharge
Form Approved 03/05/19
OMB No, 2040-0004
Available Quantitative Data
(specify units)
1.
Asbestos
❑
0
2.
Acetaldehyde
❑
ED
3.
Allyl alcohol
❑
0
4.
Allyl chloride
❑
5.
Amyl acetate
❑
❑�
6.
Aniline
❑
❑�
7.
Benzonitrile
❑
❑�
8.
Benzyl chloride
❑
0
9.
Butyl acetate
❑
❑�
10.
Butylamine
❑
❑�
11.
Captan
❑
12.
Carbaryl
❑
E
13.
Carbofuran
❑
0
14.
Carbon disulfide
❑
15.
Chlorpyrifos
❑
❑r
16.
Coumaphos
❑
0
17.
Cresol
❑❑
18.
Crotonaldehyde
❑
0
19.
Cyclohexane
❑
0
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
1 '19I • 1
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
20.
2,4-D (2,4-dichlorophenoxyacetic acid)
❑
R
21.
Diazinon
El
RV22.
Dicamba
❑
R
23.
Dichlobenil
❑
El
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
❑�
26.
Dichlorvos
❑
27.
Diethyl amine
❑
❑�
28.
Dimethyl amine
❑
❑�
29.
Dintrobenzene
❑
30.
Diquat
❑
❑�
31.
Disulfoton
❑
❑r
32.
Diuron
❑
❑r
33.
Epichlorohydrin
❑
❑r
34.
Ethion
❑
❑r
35.
Ethylene diamine
❑
0
36.
Ethylene dibromide
❑
❑✓
37.
Formaldehyde
❑
❑r
38.
Furfural
❑
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
39.
Guthion
❑
0
40.
Isoprene
❑
❑�
41.
Isopropanolamine
❑
0
42.
Kelthane
❑
❑�
43.
Kepone
❑
44.
Marathion
❑
0
45.
Mercaptodimethur
❑
0
46.
Methoxychlor
❑
0
47.
Methyl mercaptan
❑
❑�
48.
Methyl methacrylate
❑
0
49.
Methyl parathion
❑
0
50.
Mevinphos
❑
❑r
Mexacarbate
El
�
r51.
52.
amine
ElMonoethyl
❑�
53.
Monomethyl amine
❑
El
54.
Naled
❑
❑�
55.
Naphthenic acid
❑
❑�
56.
Nitrotoluene
❑
ID
57.
Parathion
❑
❑r
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
1 •ti• � � 1 �
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
58. Phenolsulfonate ❑
59.
Phosgene
❑
60.
Propargite
❑
El
61.
Propylene oxide
❑
62.
Pyrethrins
❑
❑r
63.
Quinoline
❑
64.
Resorcinol
❑
E
65.
Strontium
❑
❑r
66.
Strychnine
❑
❑r
67.
Styrene
❑
El
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
a
69.
TDE (tetra chlorodiphenyl ethane)
❑
E
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
❑
O
71.
Trichlorofon
❑
❑�
72.
Triethanolamine
❑
❑�
73.
Triethylamine
❑
❑�
74.
Trimethylamine
❑
❑r
75.
Uranium
❑
❑�
76.
Vanadium
❑
Z
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park Subdivision -Wells #1 001
OMB No. 2040-0004
1 '1f
1 • 1
Presence or Absence
07TVinyl
Pollutant
(check one) Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
acetate
❑
M
78.
Xylene
❑
0
79.
Xylenol
❑
0
80.
Zirconium
❑
0
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No.2040-0004
Its] '•I I : • ' 1 • 11M
TCDD Presence or
Congeners Absence
Pollutant Used or check one Results of Screening Procedure
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD 11❑
EPA Form 3510-2C (Revised 3-19) Page 33

EPA Identification Number NPDES Permit Number Facility Name
Outfall Number
Form Approved 03/05/19
NCG59001O NCG590010 Oakley Park Subdivision -Wells #1
002
OMB No. 2040-0004
Effluent
Intake
Waiver
o tional
Maximum
Maximum
Long -Term
FmCheck
Pollutant
Requested Units
(specify)
Daily
Monthly
Average Daily
Number of
Long -Term
Number of
(if applicable)
Discharge
Discharge
Discharge
Analyses
Average Value
Analyses
(required)
if available
if available
here if you have applied to your NPDES permitting authority
for a waiver for all of the pollutants listed on this table for the noted outfall.
1'
Biochemical oxygen demand
r
Concentration
Mass
(BODs)
2'
Chemical oxygen demand
❑
Concentration
Mass
(COD)
Concentration
3.
Total organic carbon (TOC)❑
Mass
Concentration
nng/L
40
9.16
108
4.
Total suspended solids (TSS)
❑✓
Mass
Concentration
5.
Ammonia (as N)
❑✓
Mass
6.
Flow
❑
Rate
nngd
0.0012
0.0012
282
Temperature (winter)
✓❑
°C
°C
7.
Temperature (summer)
✓❑
°C
°C
pH (minimum)
❑
Standard units
s.U.
6.7
7.2
78
8.
pH (maximum)
❑
Standard units
S.U.
8.7
7.2
78
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 9

EPA Identification Number NPUE6 Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
o ,
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•01101
11 L, I Bill
• '• 1FIT
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
(and
Required
Believed
Believed
(specify)
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.
Section 1. Toxic Metals, Cyanide, and Total Phenols
1.1
Antimony, total
El
1:1
✓
Concentration
Mass
(7440-36-0)
1.2
Arsenic, total
1:1✓
Concentration
Mass
(7440-38-2)
1.3
Beryllium, total
El
Concentration
Mass
(7440-41-7)
1.4
Cadmium, total
✓
Concentration
Mass
(7440-43-9)
1.5
Chromium, total
✓
Concentration
Mass
(7440-47-3)
1.6
Copper, total
✓
Concentration
Mass
(7440-50-8)
1.7
Lead, total
El
El
✓
Concentration
Mass
(7439-92-1)
1.8
Mercury, total
Concentration
Mass
(7439-97-6)
1.9
Nickel, total
❑
❑
❑
Concentration
Mass
(7440-02-0)
1.10
Selenium, total
❑
❑
❑
Concentration
Mass
(7782-49-2)
1.11
Silver, total
❑
❑
El
Concentration
Mass
(7440-22-4)
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
O. 7 %AITD,
Form Approved 03/05/19
OMB No. 2040-0004
Testing
Required
9-
Presence or Absence
check one
1 -�
Units
(specify)
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
(and
Believed
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Lon
Term
Average
Value
Number
of
Analyses
1.12
Thallium, total
(7440-28-0)
❑
❑
❑
Concentration
Mass
1.13
Zinc, total
(7440-66-6)
Concentration
Mass
1.14
Cyanide, total
(57-12-5)
❑
❑
0
Concentration
Mass
1.15
Phenols, total
❑
❑
0
Concentration
Mass
Section 2.Organic Toxic Pollutants (GC/MS
Fraction
—Volatile Compounds)
2.1
Acrolein
(107-02-8)
Concentration
Mass
2.2
Acrylonitrile
(107-13-1)
El
El
❑
Concentration
Mass
2.3
Benzene
(71-43-2)
El
❑
El
Concentration
Mass
2.4
Bromoform
(75-25-2)
❑
a
Concentration
Mass
2.5
Carbon tetrachloride
(56-23-5)
El❑
Concentration
Mass
2.6
Chlorobenzene
(108-90-7)
El
❑
❑
Concentration
Mass
2.7
Chlorodibromomethane
(124-48-1)
❑
El
ID
Concentration
Mass
2.8
Chloroethane
(75-00-3)
❑
El❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 12

EPA Identification Number NPDES Permit Number
NCG590010 NCG590010
Name
Oakley Park Subdivision -Wells #1
Outfall Number
002
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
aily
Discharge
i isch
available)
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
2'9
2-chloroethylvinyl ether
(110-75-8)
El
❑
✓
Concentration
Mass
2.10
Chloroform (67-66-3)
El
El
2
Concentration
Mass
2.11
Dichlorobromomethane
(75-27-4)
a
Concentration
Mass
2.12
1,1-dichloroethane
(75-34-3)
1:1✓
Concentration
Mass
2.13
1,2-dichloroethane
(107-06-2)
1:1
El
✓
Concentration
Mass
2.14
1,1-dichloroethylene
(75-35-4)
1:1✓
Concentration
Mass
2.15
1,2-dichloropropane
(78-87-5)
El
1:1
0
Concentration
Mass
216
1,3-dichloropropylene
(542-75-6)
El
El
0
Concentration
Mass
217
Ethylbenzene
(100-41-4)
El
1:1
0
Concentration
Mass
2.18
Methyl bromide
(74-83-9)
✓
Concentration
Mass
2.19
Methyl chloride
(74-87-3)
0
Concentration
Mass
2.20
Methylene chloride
(75-09-2)
Q
Concentration
Mass
221
1,1,2,2-tetrachloroethane
(79-34-5)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 13

EPA Identitication Number
NCG590010
Name
NCG590010 I Oakley Park Subdivision -Wells #1
Uuttall Number
002
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Poll utantlParameter
(and CAS Number, if available )
•
• 1 •'
Presence or Absence
(check one)
• '• 1
Units
(specify)
Effluent
Intake
(optional)
Testing
Required
q
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long-
Term
Average
Value
Number
of
Analyses
2.22
Tetrachloroethylene
(127-18-4)
❑
❑
ID
Concentration
Mass
2.23
Toluene
(108-88-3)
Concentration
Mass
2.24
12-trans-dichloroethylene
(156-60-5)
✓
Concentration
Mass
2.25
1, 1, 1 -trichloroethane
(71-55-6)
El✓
Concentration
Mass
2.26
1,1,2-trichloroethane
(79-00-5)
❑
❑
❑
Concentration
Mass
2.27
Trichloroethylene
(79-01-6)
El
❑
❑
Concentration
Mass
2.28
Vinyl chloride
(75-01-4)
❑
❑
❑
Concentration
Mass
Section 3.Organic Toxic Pollutants (GCIMS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
(95-57-8)
El
❑
❑
Concentration
Mass
3.2
2,4-dichlorophenol
(120-83-2)
El
❑
❑
Concentration
Mass
3.3
2,4-dimethylphenol
(105-67-9)
❑
❑
©
Concentration
Mass
3.4
4,6-dinitro-o-cresol
(534-52-1)
El
❑
❑
Concentration
Mass
3.5
2,4-dinitrophenol
(51-28-5)
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
(and
Testing
Required
Presence or Absence
check one
Units
(specify)
Believed
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Dischge
if available
Number
of
Analyses
Lon
Term
Average
Value
Number
Analyses
3.6
2-nitrophenol
(88-75-5)
❑
❑
❑
Concentration
Mass
3.7
4-nitrophenol
(100-02-7)
❑
❑
❑
Concentration
Mass
3.8
p-chloro-m-cresol
(59-50-7)
❑
❑
❑
Concentration
Mass
3.9
Pentachlorophenol
(87-86-5)
❑
❑
Concentration
Mass
3.10
Phenol
(108-95-2)
Concentration
Mass
3.11
2,4,6-trichlorophenol
(88-05-2)
❑
❑
❑
Concentration
Mass
Section 4.Organic Toxic Pollutants GC/MS
Fraction
—Base /Neutral
Compounds
4.1
Acenaphthene
(83-32-9)
❑
❑
❑
Concentration
Mass
4.2
Acenaphthylene
(208-96-8)
❑
❑
❑
Concentration
Mass
4.3
Anthracene
(120-12-7)
Concentration
Mass
4.4
Benzidine
(92-87-5)
Concentration
Mass
4.5
Benzo (a) anthracene
(56-55-3)
Concentration
Mass
4.6
Benzo (a) pyrene
(50-32-8)
✓
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCGS90010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
1
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
1 1 �'
Presence or Absence
check one)
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
4.7
3,4-benzofluoranth ene
(205-99-2)
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
❑
❑
21
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
❑
El
©
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
El
❑
❑
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
O
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
❑
❑
Z
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
El
El
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
✓
Concentration
Mass
4.16
2-chloronaphthalene
(91 58 7)
❑
❑
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
❑
✓
Concentration
Mass
4.18
Chrysene
(218-01-9)
❑
❑
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
El❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number
NCG590010 NCG590010
Facility
Oakley Park Subdivision -Wells 41
o,
Outfall Number
002
Form Approved 03/05/19
OMB No. 2040-0004
IC I&N-Al 01111141] IN
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Analyses
if available)Value
4.20
1,2-dichlorobenzene
❑
r
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
❑
r❑
Concentration
Mass
(541-73-1)
4.22
1,4-dichlorobenzene
❑
❑
r
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
❑
❑
❑
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
21
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
❑
❑
❑
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
❑
❑
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
❑
❑
❑
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
❑
❑
❑
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
❑
❑
Concentration
Mass
(117-84-0)
4.30
1,2-Diphenylhydrazine
El
El
❑
Concentration
Mass
(as azobenzene)(122-66-7)
4.31
Fluoranthene
❑
❑
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
❑
❑
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Testing
Required
Presence or Absence
(check one)
Units
(specify)
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Long -
Term
Average
Value
Number
of
Analyses
4.33
Hexachlorobenzene
(118-74-1)
❑
❑
❑
Concentration
Mass
4.34
Hexachlorobutadiene
(87-68-3)
❑
❑
H
Concentration
Mass
4.35
Hexachlorocyclopentadiene
(77-47-4)
❑
❑
0
Concentration
Mass
4.36
Hexachloroethane
(67-72-1)
El
❑
❑
Concentration
Mass
4.37
Indeno (1,2,3-cd) pyrene
(193-39-5)
❑
❑
Concentration
Mass
4.38
Isophorone
(78-59-1)
❑
El
❑✓
Concentration
Mass
4.39
Naphthalene
(91-20-3)
❑
❑
❑✓
Concentration
Mass
4.40
Nitrobenzene
(98-95-3)
El
El
Concentration
Mass
4.41
N-nitrosodimethylamine
(62 75 9)
El
El❑
oncentration
rMass
4.42
N-nitrosodi-n-propylamine
(621-64-7)
❑
❑
Concentration
Mass
4.43
N-nitrosodiphenylamine
(86-30-6)
❑
❑
0
Concentration
Mass
4.44
Phenanthrene
(85-01-8)
El
El❑
Concentration
Mass
4.45
Pyrene
(129-00-0)
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
°f
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
4.46 1,2,4-trichlorobenzene
El
❑
❑
Concentration
1 Mass
(120-82-1)
Section 5.Organic Toxic Pollutants(GC/MS Fraction
—Pesticides
5.1
Aldrin
❑
❑
❑
Concentration
Mass
(309-00-2)
5.2
a-BHC
❑
El
❑
Concentration
Mass
(319-84-6)
5.3
R-BHC
El
El
❑
Concentration
Mass
(319-85-7)
5.4
y-BHC
El
❑
❑
Concentration
Mass
(58 89 9)
5.5
b-BHC
El❑
❑
Concentration
Mass
(319-86-8)
5.6
Chlordane
❑
❑
a
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
❑
❑
❑
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
❑
❑
❑
Concentration
Mass
(72-55-9)
5.9
4,4'-DDD
❑
❑
❑
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
El
❑
Concentration
Mass
(60-57-1)
5.11
o-endosulfan
❑
❑
❑
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

Identification Number NHUL6 Hermit Number i acmty Name Uuttall Number
NCG590010 NCG590 I Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Testing
Required
Presence or Absence
(check one)
Units
(specify)
Effluent
Intake
(optional)
15.12
Pollutant/Parameter
(and CAS Number, if available)
(and
Believed
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Lon
Term
Average
Value
Number
°
Analyses
(i-endosulfan
(115-29-7)
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
❑
❑
❑
Concentration
Mass
5.14
Endrin
(72-20-8)
El
❑
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
❑
❑
❑
Concentration
Mass
5.16
Heptachlor
(76-44-8)
❑
❑
❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑
El
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
El
❑
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
El0
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
❑
El
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
❑
El
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑El
21
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑
Z
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
❑
❑
'❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1
002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available )
Required
q
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Daily
Average
of
f available)
Discharge
Analyses
Analyses
if available
Toxaphene
5.25
El
1:10
Concentration
Mass
(8001-35-2)
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG59OO10 NCG59O01O Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
Presence or Absence Intake
check one) Effluent (Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Discharge Discharge Analyses Average Analyses
(required) if available if available Value
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
© Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
1'
Bromide
❑
H
Concentration
Mass
(24959-67-9)
2
Chlorine, total
❑
❑
Concentration
ug/L
10
9.91
114
Mass
residual
3.
Color
❑
El
Concentration
Mass
4.
Fecal coliform
❑
0
Concentration
Mass
5
Fluoride
❑
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
❑
❑✓
Concentration
Mass
7.
Nitrogen, total
❑
❑
Concentration
Mass
organic (as N)
8.
Oil and grease
❑
❑✓
Concentration
Mass
9
Phosphorus (as
❑
❑
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
❑
0
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
Presence or Absence
(check one) Effluent Intake
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
Discharge Discharge Analyses Analyses
(required) if available if available Value
12
Sulfite (as So
(14265-45-3)
❑
✓
❑
Concentration
Mass
13.
Surfactants
❑
❑✓
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
❑
❑
Concentration
Mass
15
Barium, total
(7440-39-3)
❑
❑
Concentration
Mass
16.
Boron, total
(7440-42-8)
❑
❑
Concentration
Mass
17.
Cobalt, total
(7440-48-4)
❑
0
Concentration
Mass
18
Iron total
(7439-89-6)
❑
❑
Concentration
Mass
19
Magnesium, total
(7439-954)
❑
❑✓
Concentration
Mass
20.
Molybdenum,
total
(7439-98-7)
❑
❑✓
Concentration
Mass
21'
Manganese, total
(7439-96-5)
El
❑
Concentration
mg/L
4.64
1.26
16
Mass
22.
Tin, total
(7440-31-5)
El
❑✓
Concentration
Mass
23
Titanium, total
(7440-32-6)
❑
a
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG59O010
NCG590010 Oakley Park Subdivision -Wells
#1 002
OMB No. 2040-0004
Presence or Absence
JEPA
check one
Effluent
Intake
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum Long -Term
Long -Term
Present
Absent
Discharge
Monthly Average Daily Number of
Average Number of
(required)
Discharge Discharge Analyses
Value Analyses
if available if available
24.
Radioactivity
Alpha, total
❑
�
Concentration
Mass
Beta, total
❑
�
Concentration
Mass
Radium, total
El
El
Concentration
Mass
Radium 226, total
❑
0
Concentration
Mass
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
I '1� 1MUMM
Presence or Absence
Pollutant check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
1.
Asbestos
❑
ED
2.
Acetaldehyde
❑
0
3.
Allyl alcohol
❑
❑✓
4.
Allyl chloride
❑
0
5.
Amyl acetate
❑
0
6.
Aniline
❑
FD
7.
Benzonitrile
❑
❑r
8.
Benzyl chloride
❑
0
9.
Butyl acetate
❑
❑r
10.
Butylamine
❑
❑r
11.
Captan
❑
❑✓
12.
Carbaryl
❑
❑✓
13.
Carbofuran
❑
0
14.
Carbon disulfide
❑
❑r
15.
Chlorpyrifos
❑
❑r
16.
Coumaphos
❑
❑r
17.
Cresol
❑
❑r
18.
Crotonaldehyde
❑
❑✓
19.
Cyclohexane
❑
ID
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No.2040-0004
1 ' 1 • 1 • 1
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
20.
2,4-D (2,4-dichlorophenoxyacetic acid)
❑
21.
Diazinon
❑
22.
Dicamba
❑
0
23.
Dichlobenil
❑
El
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
0
26.
Dichlorvos
❑
0
27.
Diethyl amine
❑
0
28.
Dimethyl amine
❑
0
29.
Dintrobenzene
❑
0
30.
Diquat
❑
0
31.
Disulfoton
❑
0
32.
Diuron
❑
0
33.
Epichlorohydrin
❑
0
34.
Ethion
❑
0
35.
Ethylene diamine
❑
0
36.
Ethylene dibromide
❑
0
37.
Formaldehyde
❑
0
38.
Furfural
❑
0
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
ence or Absence
1 ' 1 •7Present
Pollutantcheck one Available Quantitative Data
ed Believed Reason Pollutant Believed Present in Discharge(specify units)
Absent
39.
Guthion
❑
F-1
40.
Isoprene
❑
❑r
41.
Isopropanolamine
❑
0
42.
Kelthane
❑
❑✓
43.
Kepone
❑
H
44.
Malathion
❑
❑✓
45.
Mercaptodimethur
❑
Z
46.
Methoxychlor
❑
R
47.
Methyl mercaptan
❑
El
48.
Methyl methacrylate
❑
❑r
49.
Methyl parathion
❑
❑✓
50.
Mevinphos
❑
❑r
51.
Mexacarbate
❑
H
52.
Monoethyl amine
❑
0
53.
Monomethyl amine
❑
0
54.
Naled
❑
Z
55.
Naphthenic acid
❑
❑✓
56.
Nitrotoluene
❑
❑r
57.
Parathion
❑
El
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
1 '1• elmliim, IZUM
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
58.
Phenolsulfonate
❑
2
59.
Phosgene
❑
Z
60.
Propargite
❑
❑r
61.
Propylene oxide
❑
121
62.
Pyrethrins
❑
0
63.
Quinoline
❑
R
64.
Resorcinol
❑
❑r
65.
Strontium
❑
❑r
66.
Strychnine
❑
Z
67.
Styrene
❑
0
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetrachlorodiphenyl ethane)
❑
Z
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
propanoic acid]
❑
❑
71.
Trichlorofon
❑
72.
Triethanolamine
❑
73.
Triethylamine
❑
❑r
74.
Trimethylamine
❑
0
75.
Uranium
❑
❑✓
76.
Vanadium
❑
0
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park Subdivision -Wells #1 002
OMB No. 2040-0004
•1•
1
Presence or Absence
Pollutant
check one Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
77.
Vinyl acetate
❑
0
78.
Xylene
❑
❑✓
79.
Xylenol
❑
❑✓
80.
Zirconium
❑
❑r
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
•••1 • 1 • 11 1 �
TCDD Presence or
Congeners Absence
Pollutant Used or check one Results of Screening Procedure
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD ❑ ❑ Fl�
EPA Form 3510-2C (Revised 3-19) Page 33

SRI q. rdM M NINA DANTIAM I OEM ffirors. MRANTA I w
Raw
Raw
Water
Water
Well #1
Well #2
Greensand — Greensand
Water Chlorine Distribution Chlorine Water
Treatment nfection Disinfection Treatment
I.L
Facility MLFacility
Outfall 001 Outfall 002
McGill Branch; Catawba McGill Branch; Catawba
River Basin River Basin

Aqua North Carolina, Inc.
Oakley Park Subdivision Wells #1 , #2 WTP
Latitude: 35" IT 32"(001) State Grid: Gastonia, North
350 11' 50" (002) Perndtted Flaw: N/A
J'O witude: 81° 16' 02" (001) Stream class: C
81° 15' 40" (001) Drainage Basin: Catawba River Basin
Receiving Strewn: Mc Gill Branch Sub -]rosin: 03-08-37
Facility`
Location
not to scale
r
�NPD�S Permit No. NC0086142
N-Jaston County

DocuSign
Certificate Of Completion
Envelope Id: 2FC710DOCOE142F6B9EOF2BB32A44E45
Status: Completed
Subject: Here is your signed document: Oakley Park_NCG90010_Permit
renewal 2.3.2024.pdf
Source Envelope:
Document Pages: 54
Signatures: 2
Envelope Originator:
Certificate Pages: 1
Initials: 0
Lauren Raup-Plummer
AutoNav: Disabled
[e-mail]
Envelopeld Stamping: Disabled
IP Address: 144.202.188.252
Time Zone: (UTC-05:00) Eastern Time (US & Canada)
Record Tracking
Status: Original
Holder: Lauren Raup-Plummer
Location: DocuSign
2/2/2024 2:22A6 PM
[e-mail]
Signer Events
Signature
Timestamp
Lauren Raup-Plummer
by:
Sent: 2/2/2024 2:24:31 PM
[e-mail]
[DocuSign'd
atn Vv- "-P(A0%K,t,Y
Viewed: 2/2/2024 2:24:43 PM
Engineering Manager
9G8BE09BOA7Ba%
Signed: 2/2/2024 2:26:39 PM
Aqua North Carolina, Inc.
Freeform Signing
Security Level: Email, Account Authentication
Signature Adoption: Pre selected Style
(None)
Using IP Address: 144.202.188.252
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
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Completed
Security Checked
2/2/2024 2:26:44 PM
Payment Events
Status
Timestamps

AOUA-
Essent al
February 1, 2023
NC Department of Environmental Quality
Division of Water Resources
NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Application for Permit Renewal
Aqua North Carolina, Inc.
Oakley Park Well 1 & Well 2 Treatment Plants
NPDES No. NCG590010
Gaston County
To Whom It May Concern:
Attached are the completed application Modification Application Forms 1 and
2C , process flow diagram, and topographic map. This letter and attachments
are Aqua North Carolina's request to renew the subject permit.
We are requesting a waiver of any upstream sampling requirements for both
sites due to the inability to collect samples at the locations relevant to
upstream of the discharge sites.
If you need any additional information or assistance, please feel free to contact
me at [e-mail].
Sincerely,
DocuSigned by:
9C8BE09B0A7B49B
Lauren Raup-Plummer
Engineering Manager

United States Office of Water EPA Form 3510-1
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
:.EPA Application Form 1
General Information
NPDES Permitting Program
Note: All applicants to the National Pollutant Discharge Elimination System (NPDES) permits
program, with the exception of publicly owned treatment works and other treatment works treating
domestic sewage, must complete Form 1. Additionally, all applicants must complete one or more of the
following forms: 2B, 2C, 21), 2E, or 2F. To determine the specific forms you must complete, consult the
"General Instructions" for this form.

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1
OMB No. 2040-0004
U.S. Environmental Protection Agency
Form
1
1="EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•D
i
Applicants Not Required to Submit Form 1
1.1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete 0 No
If yes, STOP. Do NOT r❑ No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
operation or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
a
production facility?
currently discharging process wastewater?
o❑
Yes + Complete Form 1 0 No
0 Yes 4 Complete Form ❑ No
a
and Form 2B.
1 and Form 2C.
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
commenced to discharge?
discharges only nonprocess wastewater?
Yes -+ Complete Form 1 0 No
❑ Yes 4 Complete Form 0 No
and Form 2D.
1 and Form 2E.
1.2.5
Is the facility a new or existing facility whose
'—
discharge is composed entirely of stormwater
a
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
Yes 4 Complete Form 1 No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
bI Y, 15).
SECTIONDD•
• •
Facility Name
2.1
Oakle Park Subdivision -Well #1 & #2 WTP
0
2.2
EPA Identification Number
C
J
NCG590010
2.3
Facility Contact
Name (first and last)
Title
Phone number
Lauren Raup-Plummer
Engineering Manager
[phone]
Q
a>
Email address
c
[e-mail]
2.4
Facility Mailing Address
E
Street or P.O. box
z
202 MacKenan Drive
City or town
te
FNot
ZIP code
Cary
th Carolina
27511
EPA Form 3510-1 (revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1
OMB No. 2040-0004
H
2.5
Facility Location
YStreet,
route number, or other specific identifier
Q 0
Well 1 @ 133 Sequoia Dr Well 2 @ Pinto Ln
rn
0
County name
County code (if known)
cc
Gaston
E _j
City or town
State ZIP code
z R
Gastonia
North Carolina 28052
SECTION1
NAICS CODES1
3.1
SIC Code(s)
Description (optional)
4941
Establishments primarily engaged in distributing water for sale for domestic,
H
d
0
O
0
y
V
z
3.2
NAICS Code(s)
Description (optional)
M
310
Water Distribution (except irrigation)
U
N
4.1
Name of 0 erator
Aqua North Carolina
0
4.2
Is the name you listed in Item 4.1 also the owner?
cc
c
❑ Yes ❑ No
w
4.3
Operator Status
S
❑ Public —federal ❑ Public —state ❑ Other public (specify)
o
r❑ Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
g
w
Street or P.O. Box
cc
E
�
202 MacKenan Drive
w
w
City or town
State
ZIP code
_7,= c
o V
o
Cary
North Carolina
27511
Q
Email address of operator
O
[e-mail]
SECTIO IN
5. INDI1
1
R
5.1
Is the facility located on Indian Land?
J
❑ Yes ❑� No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells 1 OMB No. 2040-0004
SECTION••
1
all that apply and print or type the corresponding permit number for each)
cc
6.1
Existing Environmental Permits (check
d
❑✓ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
`o Co
water)
fluids )
=•
NCG590010
w a
rn
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
x
❑ Ocean dumping (MPRSA) ❑ Dredge or fill (CWA Section 404) ❑ Other (specify)
LU
SECTIO
I
Have you attached a topographic map containing all required information to this application? (See instructions for
7.1
cc
specific requirements.)
2
❑r Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 26.)
SECTIONOF
1
Describe the nature of your business.
8.1
Operating a filter -backwash treatment system employing greensand filter technology to treat groundwater in
support of potable -water production
N
to
d
c
y
3
m
O
7
i6
Z
SECTION••
1
9.1 Does your facility use cooling water?
d
❑ Yes ❑r No 4 SKIP to Item 10.1.
R a
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
Q, 2
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
. U'
NPDES permitting authority to determine what specific information needs to be submitted and when.)
O
O =
SECTION1
VARIANCE
REQUESTS1 1
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
10.1
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
H
when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
❑✓ Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1 OMB No. 2040-0004
SECTION1
CERTIFICATION STATEMENT (40
11.1
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2
r❑ Section 1: Activities Requiring an NPDES Permit
w/ attachments
❑✓ Section 2: Name, Mailing Address, and Location
❑ w/ attachments
❑r Section 3: SIC Codes
❑ w/ attachments
El Section 4: Operator Information
❑ w/ attachments
r❑ Section 5: Indian Land
❑ w/ attachments
�❑
Section 6: Existing Environmental Permits
❑ w/ attachments
d
2
Section 7: Map
El Section
w/ topographic
w/ additional attachments
mapEl
co
c
Section 8: Nature of Business
❑ w/ attachments
0 Section 9: Cooling Water Intake Structures
❑ w/ attachments
r
d
U
-a
Section 10: Variance Requests
❑ w/ attachments
c
2
Section 11: Checklist and Certification Statement
Elw/ attachments
Y
t
11.2
Certification Statement
U
1 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 qualified personnel properly gather and evaluate 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 fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Lauren Raup-Plummer
Engineering Manager
Signature
Date signed
UocuSig�ed by.
E�A. _PtU*,%t r
02/01/2024
9CBBE09BOA7B49B..
EPA Form 3510-1 (revised 3-19) Page 4

United States Office of Water EPA Form 3510-2C
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
�E�► Application Form 2C
Existing Manufacturing,
Commercial, Mining, and
Silvicultural Operations
NPDES Permitting Program
Note: Complete this form and Form 1 if your facility is an existing manufacturing, commercial, mining,
or silvicultural facility that currently discharges process wastewater.

ioentitication Number NPOES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1
001
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long'
Term
Average
Value
Number
of
Analyses
2.22
Tetrachloroethylene
(127-18-4)
r
Concentration
Mass
2.23
Toluene
(108-88-3)
❑
❑
❑r
Concentration
Mass
2.24
1,2-trans-dichIoroethylene
(156-60-5)
El❑
r
Concentration
Mass
2.25
1, 1, 1 -trichloroethane
(71-55-6)
El❑
❑
Concentration
Mass
2.26
1,1,2-trichloroethane
(79-00-5)
ElEl❑
Concentration
Mass
2.27
Trichloroethylene
(79-01-6)
El❑
❑
Concentration
Mass
2.28
Vinyl chloride
(75-01-4)
El
El
El
Concentration
Mass
Section 3.Organic Toxic Pollutants GC/MS
Fraction
—Acid Compounds
3.1
2-chlorophenol
(95-57-8)
❑
❑
❑
Concentration
Mass
3.2
2,4-dichlorophenol
(120-83-2)
❑
❑
Concentration
Mass
3.3
2,4-dimethylphenol
(105-67-9)
©
Concentration
Mass
3.4
4,6-dinitro-o-cresol
(534-52-1)
❑
❑
Concentration
Mass
3.5
2,4-dinitrophenol
(51-28-5)
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 14

dentification Number NHULb Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
(check one)
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Long-
Term
Average
Value
Number
of
Analyses
3.6
2-nitrophenol
(88-75-5)
❑
❑
0
Concentration
Mass
3.7
4-nitrophenol
(100-02-7)
El
1:1
El
Concentration
Mass
3.8
p-chloro-m-cresol
(59-50-7)
El
❑❑
Concentration
Mass
3.9
Pentachlorophenol
(87-86-5)
❑
❑❑
Concentration
Mass
3.10
Phenol
(108-95-2)
❑
Concentration
Mass
3.11
2,4,6-trichlorophenol
(88 05 2)
✓
Concentration
Mass
Section 4.Organic Toxic Pollutants (GC/MS Fraction
—Base /Neutral
Compounds)
4.1
Acenaphthene
(83-32-9)
Concentration
Mass
4.2
Acenaphthylene
(208-96-8)
❑
Concentration
Mass
4.3
Anthracene
(120-12-7)
❑
❑
❑
Concentration
Mass
4.4
Benzidine
(92-87-5)
❑
❑
©
Concentration
Mass
4.5
Benzo (a) anthracene
(56-55-3)
❑
❑
Concentration
Mass
4.6
Benzo (a) pyrene
(50-32-8)
❑
❑
❑�
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
•
LOCI 11111101:
ILI Is]1 • •
• ' •tills]
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
4.7
3,4-benzofluoranth ene
(205-99-2)
❑
El
❑
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
✓
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
❑
✓
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
❑
❑
❑
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
❑
❑
✓
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
✓
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
❑
❑
❑
Concentration
Mass
4.16
2-chloronaphthalene
(91-58-7)
❑
❑
❑
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
El
El
r
Concentration
Mass
4.18
Chrysene
(218-01-9)
El
El
r
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
❑
1
❑
1
❑
1
Concentration
1 Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCGS90010 NCG590010 Oakley Park Subdivision -Wells #1 001
o,
.11­
Form Approved 03/05/19
OMB No. 2040-0004
• 1
• Gill
L, 10111l1 • '
• ' 19126111111111111111 Gylla&110119190
Presence or Absence
(check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
(and
14.201,2-dichlorobenzene
Required
Believed
Believed
(specify)
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
°f
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
El
❑�
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
❑
❑
❑�
Concentration
Mass
(541-73-1)
422
1,4-dichlorobenzene
❑
❑
El
Concentration
Mass
(106-46-7)
4.23
3 3-dichlorobenzidine
❑
❑�
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
❑✓
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
❑
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
✓
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
El
❑
❑
Concentration
Mass
(117-84-0)
4.30
1,2-Dipheny1hydrazine
❑
El
❑�
Concentration
Mass
(as azobenzene)(122-66-7)
4.31
Fluoranthene
❑
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
❑
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
•
1
•
Ilc Lee, - ik 820
' • 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
4.33
Hexachlorobenzene
❑
✓
Concentration
Mass
(118-74-1)
4.34
Hexachlorobutadiene
11
❑
El
Concentration
Mass
(87-68-3)
4.35
Hexachlorocyclopentadiene
Concentration
Mass
(77-47-4)
4.36
Hexachloroethane
❑
Concentration
Mass
(67-72-1)
4.37
Indeno (1,2,3-cd) pyrene
❑
❑
❑✓
Concentration
Mass
(193-39-5)
4.38
Isophorone
❑
❑
❑
Concentration
Mass
(78-59-1)
4.39
Naphthalene
❑
❑
❑
Concentration
Mass
(91-20-3)
4.40
Nitrobenzene
❑
❑
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
El
❑
❑
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
❑
❑
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
❑
✓
Concentration
Mass
(86-30-6)
4.44
Phenanthrene
❑
❑
Concentration
Mass
(85-01-8)
4.45
Pyrene
Concentration
Mass
(129-00-0)
EPA Form 3510-2C (Revised 3-19) Page 18

dentification Number NPDES Permit Number Facility Name Outfall Nu
NCG590010 NCG59001 I Oakley Park Subdivision -Wells #1 001
O. 1 %A17-
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
(check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
4.46
1,2,4-trichlorobenzene
El
El
El
Concentration
1 Mass
(120-82-1)
1
1
Section 5.Organic Toxic Pollutants (GC/MS
Fraction
—Pesticides)
5.1
Aldrin
❑
❑
❑
Concentration
Mass
(309-00-2)
5.2
a-BHC
❑
ElConcentration
Mass
(319-84-6)
5.3
R-BHC
1:1
El
✓
Concentration
Mass
(319-85-7)
5.4
y-BHC
❑
❑
❑✓
Concentration
Mass
(58-89-9)
5.5
b-BHC
✓
Concentration
Mass
(319-86-8)
5.6
Chlordane
�
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
El
El
El
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
❑
❑
Concentration
Mass
(72-55-9)
5.9
4,4'-DDD
❑
El
El
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
El
❑✓
Concentration
Mass
(60-57-1)
5.11
a-endosulfan
El
El
✓
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and
(and CAS Number, if available)
•
Testing
Required
• • •'
Presence or Absence
check one
• '• 1
Units
(specify)
Effluent
Intake
(optional)
Believed
Believed
Absentof
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Discharge a
g
if available
Number
Analyses
Lon
Term
Average
Value
Number
Analyses
5.12
(3-endosulfan
(115-29-7)
❑
❑
❑
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
❑
❑
❑
Concentration
Mass
5.14
Endrin
(72 20 8)
❑
❑
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
❑
El
El
Concentration
Mass
5.16
Heptachlor
(76-44-8)
❑
❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑
❑''
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
❑
El
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
❑
El
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
❑
El
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
ElEl
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑
❑
0
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑
El
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
El
❑
❑''
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

dentification Number NPDES Permit Number Facility Name Outfall Nu
NCG590010 NCG590010 Oakley Park Subdivision -Wells #f1 001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
(check one)
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long
(and CAS Number, if available)
15.25(8001-35-2)
Required
Believed
Believed
(specify)
Average
Number
Term
Number
Present
Absent
Daily
Monthly
Daily
°f
of
Discharge
Discharge
Discharge
Analyses
Average
Analyses
(required)
(if available)
(if available
value
Toxaphene eConcentration
Mass
Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03105/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence
Intake
(check one) Effluent
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
Discharge Discharge Analyses Value Analyses
(required)
if available if available
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
❑ Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
1
Bromide
❑
❑
Concentration
Mass
(24959-67-9)
2'
Chlorine, total
✓
❑
❑
Concentration
ug/L
10
9.92
109
Mass
residual
3.
Color
❑
❑✓
Concentration
Mass
4.
Fecal coliform
El
ElConcentrationMass
5
Fluoride
❑
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
❑
Concentration
Mass
7'
Nitrogen, total
El❑
✓
Concentration
Mass
organic (as N)
8.
Oil and grease
El
ElConcentrationMass
9
Phosphorus (as
❑
❑
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
❑
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
El❑✓
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells 41 001 OMB No. 2040-0004
Presence or Absence Intake
check one Effluent (Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Discharge Discharge Analyses Average Analyses
(required) if available if available Value
12
Sulfite (as SOs)
(14265-45-3)
❑
✓
❑
Concentration
Mass
13.
Surfactants
❑
0
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
❑
❑�
Concentration
Mass
15
Barium, total
(7440-39-3)
❑
❑
Concentration
Mass
16.
Boron total
(744042-8)
❑
❑
Concentration
Mass
17.
Cobalt, total
(7440484)
❑
✓
❑
Concentration
Mass
18
Iron, total
(7439-89-6)
❑
✓
❑
Concentration
Mass
19
Magnesium, total
(7439-95-4)
❑
❑
Concentration
Mass
20.
Molybdenum,
total
7439-98-7
❑
0
Concentration
Mass
21
Manganese, total
(7439-96-5)
❑
❑
Concentration
mg/L
1.02
0.37
17
Mass
22.
Tin, total
(7440-31-5)
El
0Concentration
Mass
23
Titanium, total
(7440-32-6)
❑
✓
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells #1 001
OMB No. 2040-0004
Presence or Absence
Intake
(check
one)
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum Long -Term
Long -Term
Present
Absent
Discharge
Monthly Average Daily Number of
Number of
Average
(required)
Discharge Discharge Analyses
Analyses
Value
if available if available)
24. Radioactivity
Alpha, total
El�
Concentration
Mass
Beta, total
❑
�
Concentration
Mass
Radium, total
El�
Concentration
Mass
Radium 226, total
Concentration
Mass
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No.2040-0004
52. 1 MITD� 7
1 '1• 1 • 1MUM) M
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
.
13.
Asbestos
❑
0
.
Acetaldehyde
❑
Allyl alcohol
❑
0
4.
Allyl chloride
❑
0
5.
Amyl acetate
❑
❑�
6.
Aniline
❑
❑r
7.
Benzonitrile
❑
0
8.
Benzyl chloride
❑
❑�
9.
Butyl acetate
❑
❑r
10.
Butylamine
❑
0
11.
Captan
❑
❑✓
12.
Carbaryl
❑
ED
13.
Carbofuran
❑
❑r
14.
Carbon disulfide
❑
15.
Chlorpyrifos
❑
0
16.
Coumaphos
❑
ID
17.
Cresol
❑
0
18.
Crotonaldehyde
❑
0
19.
Cyclohexane
❑
0
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence
Pollutant check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
20.
2,4-D (2,4-dichlorophenoxyacetic acid)
❑
❑r
21.
Diazinon
❑
✓❑
22.
Dicamba
❑
El
23.
Dichlobenil
❑
121
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
26.
Dichlorvos
❑
0
27.
Diethyl amine
❑
❑r
28.
Dimethyl amine
❑
❑�
29.
Dintrobenzene
❑
❑�
30.
Diquat
❑
0
31.
Disulfoton
❑
❑�
32.
Diuron
❑
❑✓
33.
Epichlorohydrin
❑
R
34.
Ethion
❑
❑r
35.
Ethylene diamine
❑
El
36.
Ethylene dibromide
❑
❑✓
37.
Formaldehyde
❑
❑�
38.
Furfural
❑
❑�
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPDES Permit Number
NCG590010 NCG590010 Oakley Park
I ' I • I • 1
Presence or Absence
Pollutant (check one)
Believed Believed
Present Absent
Facility Name Outfall Number Form Approved 03/05/19
Subdivision -Wells #1 001 OMB No. 2040-0004
�
Reason Pollutant Believed Present in Discharge Available Quantitative Data
(specify units)
39.
Guthion
❑
40.
Isoprene
❑
41.
Isopropanolamine
❑
0
42.
Kelthane
❑❑
43.
Kepone
❑
❑�
44.
Marathion
❑
❑�
45.
Mercaptodimethur
❑
0
46.
Methoxychlor
❑
0
47.
Methyl mercaptan
❑
❑r
48.
Methyl methacrylate
❑
0
49.
Methyl parathion
❑
0
50.
Mevinphos
❑
0
51.
Mexacarbate
❑
El
52.
Monoethyl amine
❑
El
53.
Monomethyl amine
❑
❑r
54.
Naled
❑
❑r
55.
Naphthenic acid
❑
0
56.
Nitrotoluene
❑
0
57.
Parathion
❑
0
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
1 • 1 • 1 • 1 �
Presence or Absence
Pollutant check one Available Quantitative Data (specify units)
Believed Believed Reason Pollutant Believed Present in Discharge
Present Absent
58.
Phenolsulfonate
❑
❑r
59.
Phosgene
❑
❑✓
60.
Propargite
❑
0
61.
Propylene oxide
❑10
62.
Pyrethrins
❑
Z
63.
Quinoline
❑
M
64.
Resorcinol
❑
ID
65.
Strontium
❑
❑r
66.
Strychnine
❑
❑r
67.
Styrene
❑
❑r
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetrachlorodiphenyl ethane)
❑
0
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
❑
❑
71.
Trichlorofon
❑
❑�
72.
Triethanolamine
❑
El
73.
Triethylamine
❑
74.
Trimethylamine
❑
❑r
75.
Uranium
❑
P
76.
Vanadium
❑
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 I NCG59M1 n I Oakley Park Subdivision -Wells # 1 1 nni OMB No. 2040-0004
'1•
1 • 1
Presence or Absence
(check one)
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(specify units)
Pollutant
Believed
Present
Believed
Absent
77.
Vinyl acetate
❑
0
78.
Xylene
❑
❑�
79.
Xylenol
❑
80.
Zirconium
❑
❑r
Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

EPA Identification Number NPDES Permit Number Facility Name Ouuall Number Form Approved 03/05119
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No.2040-0004
•'•1 • 1 • WLWA&A11 �1 I
TCDD Presence or
Congeners Absence
Pollutant Used or check one Results of Screening Procedure
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD Rl
EPA Form 3510-2C (Revised 3-19) Page 33

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 I Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
TABLE
A. CONVENTIONAL AND NON
CONVENTIONAL POLLUTANTS (40 CFR
122.21(g)(7)(iii))
Effluent
Intake
Pollutant
Waiver
Requested Units
0 tional
Maximum
Maximum
Long -Term
(if applicable) (Specify)
Daily
Monthly
Average Daily
Number of
Long -Term
Number of
Discharge
Discharge
Discharge
Analyses
Average Value
Analyses
(required)
if available
if available
❑
Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.
1'
Biochemical oxygen demand
r
Concentration
Mass
(BOD5)
2.
Chemical oxygen demand
❑
Concentration
Mass
(COD)
Concentration
3.
Total organic carbon (TOC)
❑r
Mass
Concentration
mg/L
40
9.16
108
4.
Total suspended solids (TSS)
r❑
Mass
Concentration
5.
Ammonia (as N)
r❑
Mass
6.
Flow
❑
Rate
mgd
0.0012
0.0012
282
Temperature (winter)
❑r
°C
°C
7.
Temperature (summer)
❑r
°C
°C
pH (minimum)
❑
Standard units
S.U.
6.7
7.2
78
8.
pH (maximum)
❑
Standard units
S.U.
8.7
7.2
78
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 9

dentification Number NPOES Permit Number Facility Name Outfall Number
NCG590010 NCGS90010 I Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
TOXICTABLE B.
1E,
TOTAL PHENOLS,1
ORGANIC TOXIC'•
1
Pollutant/Parameter
(and CAS Number, if available )
Testing
Required
q
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
( 4
Maximum
Monthly
Discharge f available)
(
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long-
Term
Average
Value
Number
of
Analyses
❑ Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.
Section 1. Toxic Metals, Cyanide, and Total Phenols
1.1
Antimony, total
(7440-36-0)
El
❑
❑
Concentration
Mass
1.2
Arsenic, total
(7440-38-2)
El
❑
❑
Concentration
Mass
1.3
Beryllium, total
(7440-41-7)
El
❑
❑
Concentration
Mass
1.4
Cadmium, total
(7440-43-9)
El
El
El
Concentration
Mass
1.5
Chromium, total
(7440-47-3)
❑
❑
❑
Concentration
Mass
1.6
Copper, total
(7440-50-8)
❑
❑
❑
Concentration
Mass
1.7
Lead, total
(7439-92-1)
El
El
El
Concentration
Mass
1.8
Mercury, total
(7439-97-6)
❑
❑
✓
❑
Concentration
Mass
1.9
Nickel, total
(7440-02-0)
❑
❑
❑
Concentration
Mass
1.10
Selenium, total
(7782-49-2)
❑
❑
❑
Concentration
Mass
1.11
Silver, total
(7440-22-4)
❑
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 11

Identification Number NVULb YeMll Number i-aclllry Name Uuttall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
2. 1 %A/TD,
Form Approved 03/05/19
OMB No. 2040-0004
B. TOXIC METALS, CYANIDE,
TOTAL PHENOLS,
AND
ORGANICTABLE
POLLUTANTS ' t
Presence or Absence
(check one)
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
11.12Thallium,
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Daily
of
A e
of
(required)
(if
Discharge
Analyses
Value
Analyses
if available
total
❑
❑
Concentration
Mass
(7440-28-0)El
1.13
Zinc, total
El
1:1
El
Concentration
Mass
(7440-66-6)
1.14
Cyanide, total
❑
❑
❑�
Concentration
Mass
(57-12-5)
1.15
Phenols, total
Concentration
Mass
Section 2.Organic Toxic Pollutants (GC/MS
Fraction
—Volatile Compounds)
2.1
Acrolein
El
El
El
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
Concentration
Mass
(107-13-1)
2.3
Benzene
❑
❑
❑�
Concentration
Mass
(71-43-2)
2.4
Bromoform
❑
❑
Z
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
❑
❑
ID
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
El
❑
❑
Concentration
Mass
(108-90-7)
2.7
Chlorodibromomethane
❑
❑
❑
Concentration
Mass
(124-48-1)
2.8
Chloroethane
❑
❑
Concentration
Mass
(75-00-3)
EPA Form 3510-2C (Revised 3-19) Page 12

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No, 2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
°f
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
2'9
2-chloroethylvinyl ether
1:1
El
✓
Concentration
Mass
(110-75-8)
2.10
Chloroform (67-66-3)
z
Concentration
Mass
2.11
Dichlorobromomethane
El
El
E
Concentration
Mass
(75-27-4)
212
1,1-dichloroethane
Concentration
Mass
(75-34-3)
2.13
1,2-dichloroethane
O
Concentration
Mass
(107-06-2)
2.14
1,1-dichloroethylene
El
El
[E]
Concentration
Mass
(75-35-4)
2.15
1,2-dichloropropane
0
Concentration
Mass
(78-87-5)
2.16
1,3-dichloropropylene
El
1:1
0
Concentration
Mass
(542-75-6)
217
Ethylbenzene
1:1Mass
Concentration
(100-41-4)
2.18
Methyl bromide
O
Concentration
Mass
(74-83-9)
2.19
Methyl chloride
O
Concentration
Mass
(74-87-3)
2.20
Methylene chloride
Concentration
Mass
(75-09-2)
221
1,1,2,2-tetrachloroethane
0
Concentration
(79-34-5)
1
1Mass
EPA Form 3510-2C (Revised 3-19) Page 13

EPA Identification Number I NPOES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
(check one)
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
(if available
Number
°f
Analyses
Long'
Term
Average
Value
Number
of
Analyses
2.22
Tetra chloroethylene
(127-18-4)
❑
Concentration
Mass
2.23
Toluene
(108-88-3)
El
El
21
Concentration
Mass
224
1,2-trans-dichloroethylene
(156-60-5)
❑
❑
❑�
Concentration
Mass
2.25
1,1,1-trichloroethane
(71-55-6)
❑
El
Concentration
Mass
226
1,1,2-trichloroethane
(79-00-5)
❑
❑
0
Concentration
Mass
2.27
Trichloroethylene
(79-01-6)
❑
❑
0
Concentration
Mass
2.28
Vinyl chloride
(75-01-4)
❑
❑
2
Concentration
Mass
Section 3.Organic Toxic Pollutants (GC/MS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
(95-57-8)
El
10
El
Concentration
Mass
3.2
2,4-dichlorophenol
(120-83-2)
❑
❑
❑
Concentration
Mass
3.3
2,4-dimethylphenol
(105-67-9)
©
Concentration
Mass
3.4
4,6-dinitro-o-cresol
(534-52-1)
Concentration
Mass
3.5
2,4-dinitrophenol
(51-28-5)
❑
❑
0
Concentration
1 Mass
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 I Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Poll utant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
if available
3.6
2-nitrophenol
11
❑
❑
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
✓
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
❑
❑
❑
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
❑
❑
✓❑
Concentration
Mass
(87-86-5)
3.10
Phenol
El
11
El
Concentration
Mass
(108-95-2)
3.11
2,4,6-trichlorophenol
❑
✓❑
Concentration
Mass
(88-05-2)
Section 4.Organic Toxic Pollutants GC/MS
Fraction
—Base /Neutral
Compounds
4.1
Acenaphthene
❑
❑
❑
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
El
El
El
Concentration
Mass
(208-96-8)
4.3
Anthracene
✓
Concentration
Mass
(120-12-7)
4.4
Benzidine
©
Concentration
Mass
(92-87-5)
4.5
Benzo (a) anthracene
❑
❑
❑
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
El
❑
Z
Concentration
Mass
(50-32-8)
1
EPA Form 3510-2C (Revised 3-19) Page 15

dentification Number NPDES Permit Number Facility Name Outfall Nu
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1
002
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and
(and CAS Number, if available)
Testing
Required
Presence or Absence
(check one)
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Di hr a
if scaarge
Number
Analyses
Long -
Term
Average
Value
Number
Analyses
4.7
3,4-benzofluoranthene
(205-99-2)
El
El
21
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
El
El
©
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
El
ID
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
Z
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
El
1:1
Z
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
El
1:1
✓
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68 7)
El
El
✓
Concentration
Mass
4.16
2-chloronaphthalene
(91 58 7)
El
1:1
El
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
El
✓
Concentration
Mass
4.18
Chrysene
(218-01-9)
2
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
El
El
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
-
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long.
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Number
Present
Absent
D(eg
Discharge
Daily
of
eragTerm
Avaluee
of
(required)
f available)
Discharge
Analyses
Analyses
if available
4.20
1,2-dichlorobenzene
El
�
�
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
❑
❑✓
Concentration
Mass
(541-73-1)
4.22
1 4-dichlorobenzene
❑
El
❑
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
❑
❑
❑
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
El
❑
❑
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
❑
❑
❑
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
❑
El
❑✓
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
❑
❑
❑
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
❑
Concentration
Mass
(117-84-0)
4.30
1,2-Dipheny1hydrazine
El
❑
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
❑
❑
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 I Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
14.33Hexachlorobenzene
•
Testing
Required
1 1 • -
Presence or Absence
(check one
• ' •111811
Effluent
Intake
(optional)
Units
(specify)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
g
if available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
(118-74-1)
❑
ElConcentration
✓
Mass
4.34
Hexachlorobutadiene
(87-68-3)
❑
❑
❑✓
Concentration
Mass
4.35
Hexachlorocyclopentadiene
(77-47-4)
❑
❑
❑
Concentration
Mass
4.36
Hexachloroethane
(67-72-1)
❑
❑
❑
Concentration
Mass
4.37
Indeno (1,2,3-cd) pyrene
(193-39-5)
Concentration
Mass
4.38
Isophorone
(78-59-1)
❑
❑
❑
Concentration
Mass
4.39
Naphthalene
(91-20-3)
❑
❑
❑r
Concentration
Mass
4.40
Nitrobenzene
(98-95-3)
❑
❑
❑r
Concentration
Mass
4.41
N-nitrosodimethylamine
(62-75-9)
❑
❑
❑r
Concentration
Mass
4.42
N-nitrosodi-n-propylamine
(621-64-7)
El
El
Concentration
Mass
4.43
N-nitrosodiphenylamine
(86-30-6)
❑
❑
0
Concentration
Mass
4.44
Phenanthrene
(85-01-8)
❑
❑
21
Concentration
Mass
4.45
Pyrene
(129-00-0)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available )
Required
q
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Dail
of
Average
of
availabllee)
Discharge
Analyses
Analyses
if available
4.46
1,2,4-trichlorobenzene
❑
O
Concentration
Mass
(120-82-1)
Section 5.Organic Toxic Pollutants GC/MS
Fraction
—Pesticides
5.1
Aldrin
❑
❑
El
Concentration
Mass
(309-00-2)
5.2
a-BHC
El
El
El
Concentration
Mass
(319-84-6)
5.3
R-BHC
Concentration
Mass
(319-85-7)
5.4
y-BHC
El
El
Z
Concentration
Mass
(58-89-9)
5.5
b-BHC
El
1:1
El
Concentration
Mass
(319-86-8)
5.6
Chlordane
El
El
El
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
El
El
El
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
Concentration
Mass
(72-55-9)
5.9
4,4'-DDD
O
Concentration
Mass
(72-54-8)
5.10
Dieldrin
a
Concentration
Mass
(60-57-1)
5.11
a-endosulfan
✓
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

EPA Identification Number NPDES Permit Number
NCG590010 NCG590010
ame
Oakley Park Subdivision -Wells #1
Outfall Number
002
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
(and
•
Testing
Required
•.10 101111.10-110•
Presence or Absence
(check one)
' • 1
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Long
Term
Average
Value
Number
of
Analyses
5.12
R-endosulfan
(115-29-7)
✓
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
El
21
Concentration
Mass
5.14
Endrin
(72-20-8)
❑
❑
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
Concentration
Mass
5.16
Heptachlor
(76-44-8)
❑
El
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑
El
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
❑
21
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
❑
El
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
El
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
El
❑
0
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
El
❑
Concentration
Mass
5.24
PCB-1016
1 (12674-11-2)
❑
E]❑
Concentration
I
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells 41 002
P. l %A/TD
Form Approved 03/05/19
OMB No. 2040-0004
•-
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Dischalerge
ischa rg
Analyses
Value
Analyses
i
�Toxaphene
5.25
Concentration
Mass
(8001-35-2)
t Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
Presence or Absence
check one Effluent Intake
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
(required) Discharge Discharge Analyses Analyses
Value
if available if available
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
© Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
1
Bromide
❑
❑
Concentration
Mass
(24959-67-9)
2'
Chlorine, total
❑
❑
Concentration
ug/L
10
9.91
114
Mass
residual
3.
Color
❑
0
Concentration
Mass
4.
Fecal coliform
❑
❑
Concentration
Mass
5
Fluoride
❑
✓
❑
Concentration
Mass
(1698448-8)
6
Nitrate -nitrite
El
0
ConcentrationMass
7'
Nitrogen, total
El
El
Concentration
Concentration
organic (as N)
8.
Oil and grease
❑
0
Concentration
Mass
9
Phosphorus (as
❑
a
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
❑
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
ElE
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
Presence or Absence
Intake
(check one) Effluent
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
Discharge Discharge Analyses Value Analyses
(required)
(if available) (if available)
12.
Sulfite (as S03)
❑
❑
Concentration
Mass
(14265-45-3)
13.
Surfactants
❑
0
ConcentrationMass
14.
Aluminum, total
❑
❑
Concentration
Mass
(7429-90-5)
15.
Barium, total
❑
❑
Concentration
Mass
(7440-39-3)
16.
Boron, total
❑
❑
Concentration
Mass
(7440-42-8)
17.
Cobalt, total
❑
❑
Concentration
Mass
(7440-48-4)
18
Iron total
❑
❑
Concentration
Mass
(7439.89-6)
19
Magnesium, total
❑
0
Concentration
Mass
(7439-954)
Molybdenum,
Concentration
20.
total
❑
0
(7439-98-7)
Mass
21
Manganese, total
❑
❑
Concentration
mg/L
4.64
1.26
16
Mass
(7439-96-5)
22.
Tin, total
❑
❑�
Concentration
Mass
(7440-31-5)
23
Titanium, total
❑
❑
Concentration
Mass
(7440-32-6)
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG59O010
NCG590010 Oakley Park Subdivision -Wells
#1 002
OMB No.2040-0004
Presence or Absence
check one
EffluentIntake
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum Long -Term
Long -Term
Present
Absent
Discharge
Monthly Average Daily Number of
Average Number of
(required)
Discharge Discharge Analyses
Value Analyses
if available if available
24.
Radioactivity
Alpha, total
El
Concentration
Mass
Beta, total
❑
ID
Concentration
Mass
Radium, total
El
El
Concentration
Mass
Radium 226, total
El
0
Concentration
Mass
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
• 1r AbsencePollutant one Reason Pollutant Believed Present in Discharge Available Quantitative Data
1 '1• 7�elieved Believed (specify units)
Present Absent
1. Asbestos ❑ ❑✓
2.
Acetaldehyde
❑
FD
3.
Allyl alcohol
❑
❑✓
4.
Allyl chloride
❑
F, 1
5.
Amyl acetate
❑
ID
6.
Aniline
❑
ED
7.
Benzonitrile
❑
0
8.
Benzyl chloride
❑
0
9.
Butyl acetate
❑
M
10.
Butylamine
❑
2
11.
Captan
❑
0
12.
Carbaryl
❑
0
13.
Carbofuran
❑
Z
14.
Carbon disulfide
❑
M
15.
Chlorpyrifos
❑
El
16.
Coumaphos
❑
17.
Cresol
❑
❑✓
18.
Crotonaldehyde
❑
0
19.
Cyclohexane
❑
0
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No.2040-0004
• �• 1 • 1
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
120.2,4-D
(2,4-dichlorophenoxyacetic acid)
❑
0
21.
Diazinon
❑
❑r
22.
Dicamba
❑
R
23.
Dichlobenil
❑
10
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
0
26.
Dichlorvos
❑
❑�
27.
Diethyl amine
❑
❑�
28.
Dimethyl amine
❑
29.
Dintrobenzene
❑
❑r
30.
Diquat
❑
31.
Disulfoton
❑
32.
Diuron
❑
❑r
33.
Epichlorohydrin
❑
❑r
34.
Ethion
❑
❑r
35.
Ethylene diamine
❑
Z
36.
Ethylene dibromide
❑
❑r
37.
Formaldehyde
❑
0
38.
Furfural
❑
❑�
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge
(specify units)
Present Absent
39.
Guthion
❑
❑�
40.
Isoprene
❑
0
41.
Isopropanolamine
❑
❑✓
42.
Kelthane
❑
0
43.
Kepone
❑
0
44.
Malathion
❑
0
45.
Mercaptodimethur
❑
0
46.
Methoxychlor
❑
0
47.
Methyl mercaptan
❑
0
48.
Methyl methacrylate
❑
0
49.
Methyl parathion
❑
0
50.
Mevinphos
❑
0
51.
Mexacarbate
❑
0
52.
Monoethyl amine
❑
0
53.
Monomethyl amine
❑
0
54.
Naled
❑
0
55.
Naphthenic acid
❑
0
56.
Nitrotoluene
❑
0
57.
Parathion
❑
0
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No.2040-0004
1 'I/ 1 e 1
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
58. Phenolsulfonate ❑ 0
59.
Phosgene
❑
0
60.
Propargite
❑
❑�
61.
Propylene oxide
❑
El
62.
Pyrethrins
❑
63.
Quinoline
❑
64.
Resorcinol
❑
❑�
65.
Strontium
❑
B
66.
Strychnine
❑
H
67.
Styrene
❑
[R]
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetrachlorodiphenyl ethane)
❑
H
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
propanoic acid]
❑
❑
71.
Trichlorofon
❑
72.
Triethanolamine
❑
❑r
73.
Triethylamine
❑
❑�
74.
Trimethylamine
❑
75.
Uranium
❑
0
76.
Vanadium
❑
0
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park Subdivision -Wells #1 002
OMB No. 2040-0004
1 •1•
1 9, 1
Presence or Absence
Pollutant
check one Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
77.
Vinyl acetate
❑
0
78.
Xylene
❑
2
79.
Xylenol
❑
❑�
80.
Zirconium
❑
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
TCDD Presence or
Congeners Absence
Pollutant Used or check one Results of Screening Procedure
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD E
EPA Form 3510-2C (Revised 3-19) Page 33

�E17 raw W.T]!i.7I DIVIT[a I MIMA Eq6w 91YANTA I:
Raw Raw
Water Water
Well #1 Well #2
Greensand Greensand
Water Chlorine Distribution Chlorine E Water
Treatment nfection Disinfection Treatment
IL
FacilityL Facility_
Outfall 001 Out all 002
McGill Branch; Catawba McGill Branch; Catawba
River Basin River Basin

Aqua North Carolina, Inc.
0aldey Park Subdivision Wells #1, #2 WTP
Latitude: 35° 12' 32" (001) State Grid: Gastonia, North
35° I I' 50" (002) Perniltted Flow: N/A
Louaitude: 81°16'02"(001) Stream Class: C
81° IS' 40"(001) Drainage Basin: Catawba RiverBasi❑
ReceivingStreo-un: Mc Gill Branch sub-Bnsin: 03-08-37
Facility
�ri t
Location
not to scale
7 NPDES Permit No. NCO086142
North Gaston County

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