NCG590008_Renewal (Application)_20240216

AQUA.
,w..,
E55entiai utilities company
February 1, 2023
NC Department of Environmental Quality
Division of Water Resources
NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
RECEIVED
FEB i 6 "LUL4
Subject: Application for Permit Renewal S
�CD�Q�
Aqua North Carolina, Inc. D`WR]NPDE
Fox Run Water Treatment Plant
NPDES No. NCG590008
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.
If you need any additional information or assistance, please feel free to contact
me at [e-mail].
Sincerely,
DocuSigned [ by: 1eau�—pl w+ WtY
9C8BE09BOA7849B_.
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
NCG590008
NCG590008
Fox Run Subdivision -Well #3
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
I
.8iEPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•NPDES
1.1
Applicants Not Required to Submit Form 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
rz
production facility?
currently discharging process wastewater?
oYes
4 Complete Form 1 No
Yes -* 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,
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 0 No
Yes 4 Complete Form 0 No
and Form 2D.
1 and Form 2E.
H
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 f 15).
SECTIONDD•
AND LOCATION (40
2.1
Facility Name
Fox Run Subdivision -Well #3 WTP
0
2.2
EPA Identification Number
C
J
NCG590008
'O
R
2.3
Facility Contact
Name (first and last)
Title
Phone number
Lauren Raup-Plummer
Engineering Manager
[phone]
a
Email address
[e-mail]
N
6
2.4
Facility Mailing Address
E
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
NCG590008
NCG590008
Fox Run Subdivision -Well #3
OMB No. 2040-0004
H d
2.5
Facility Location
wStreet,
route number, or other specific identifier
Q o
v
Coachwood Lane
rn
`o
County name
County code (if known)
Gaston
0
E
City or town
State ZIP code
z
Gastonia
North Carolina 28056
SECTION•
NAICS CODES1
3.1
SIC Code(s)
Description (optional)
4941
Establishments primarily engaged in distributing water for sale for domestic,
m
-o
0
U
N
V
z
3.2
NAICS Code(s)
Description (optional)
-a
eCv
310
Water Distribution (except irrigation)
V
co
4.1
Name of Operator
Aqua North Carolina
`0
4.2
Is the name you listed in Item 4.1 also the owner?
cc
R
€
❑� Yes ❑ No
w
4.3
Operator Status
S
❑ Public —federal El Public —state El Other public (specify)
o
ID Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
=
4.5
Operator Address
Street or P.O. Box
cc
a)
202 MacKenan Drive
wCity
or town
State
ZIP code
o 0
Cary
North Carolina
27511
ea
0
CL
Email address of operator
O
[e-mail]
SECTION•
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
NCG590008
NCG590008 Fox Run Subdivision -Well 43 OMB No.2040-0004
SECTION'•
1
6.1
Existing Environmental Permits (check
all that apply and print or type the corresponding permit number for each)
d
❑✓ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
a
water)
fluids)
> E
NCG590008
w a
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
rn
c
w
ElOcean dumping (MPRSA) ElDredge or fill (CWA Section 404) ❑ Other (specify)
SECTIONI
7.1
Have you attached a topographic map containing all required information to this application? (See instructions for
CU
:1
specific requirements.)
El Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 2B.)
SECTIONOF
I
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
y
N
C
3
co
O
is
Z
SECTION••
1 '
Does your facility use cooling water?
9.1
❑ Yes ❑r No 4 SKIP to Item 10.1.
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
a,
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
c Y
NPDES permitting authority to determine what specific information needs to be submitted and when.)
o
U �
SECTION
I VARIANCE
REQUESTS1 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
when.)
C
❑ 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
NCG590008 NCG590008
Fox Run Subdivision -Well #3 WTP OMB No.2040-0004
SECTIONI
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
0 Section 1: Activities Requiring an NPDES Permit
❑r w/ attachments
0 Section 2: Name, Mailing Address, and Location
❑ w/ attachments
Section 3: SIC Codes
❑ wl attachments
❑� Section 4: Operator Information
❑ wl attachments
R Section 5: Indian Land
❑ wl attachments
❑✓ Section 6: Existing Environmental Permits
❑ w/ attachments
d
m
❑✓ Section 7: Map
w/ topographic
❑ ❑ w/ additional attachments
;v
ma
c
w
❑� Section 8: Nature of Business
❑ w/ attachments
v
0 Section 9: Cooling Water Intake Structures
❑ w/ attachments
d
❑✓ Section 10: Variance Requests
❑ w/ attachments
v
c
�,
❑� Section 11: Checklist and Certification Statement
❑ w/ attachments
Y
r
11.2
Certification Statement
c.)
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:
CDocuSigned "--p"PAt r
02/01/2024
9CBBE09BOA7B496...
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.

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP OMB No. 2040-0004
Form U.S. Environmental Protection Agency
2C I -/EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS
SECTIONOUTFALL LOCATION
1.1 Provide information on each of the facility's outfalls in the table below.
Outfa
Number Receiving Water Name Latitude Longitude
001 unnamed tributary to Crow( 35' 11' 19" N FIJ 81° 9' 25" W
io
� o o
0
O
SECTION1- 1
M 2.1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
CD 3 balance? (See instructions for drawing requirements. See Exhibit 2C-1 at end of instructions for example.)
o Yes ❑ No
SECTION•
3.1 For each outfall identified under Item 1.1, provide average flow and treatment information. Add additional sheets if
necessary.
"Outfall Number** 001
Operations
Operation Average Flow
WTP Backwash Discharge 0.0024 mgd
c
mgd
A
mgd
c
H mgd
3
0 Treatment Units
U.
a, Description Final Disposal of Solid or
1! (include size, flow rate through each treatment unit, Code from Liquid Wastes Other Than
aretention time, etc.) Table 2C-1 by Discharge
EPA Form 3510-2C (Revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590008
NCG590008
Fox Run Subdivision -Well #3 WTP
OMB No. 2040-0004
3.1
**Outfall Number**
Cont.
Operations Contributing to Flow
Operation Average Flow
mgd
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C 1
Liquid Wastes Other Than l
retention time, etc.
by Discharge
.c
0
U
c
m
E
is
a
H
**Outfall Number**
Operations
o
Operation Average Flow
U_
a,
R
mgd
a
_
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
retention time, etc.)
by Dischar e
3.2
Are you applying for an NPDES permit to operate a privately owned treatment works?
❑ Yes ❑✓ No 4 SKIP to Section 4.
n
3.3
Have you attached a list that identifies each user of the treatment works?
Cn
❑ Yes ❑ No
EPA Form 3510-2C (Revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP OMB No. 2040-0004
SECTION• 1
4.1 Except for storm runoff, leaks, or spills, are any discharges described in Sections 1 and 3 intermittent or seasonal?
❑✓ Yes ❑ No 4 SKIP to Section 5.
4.2
Provide information
on intermittent or seasonal flows for each applicable outfall. Attach additional pages, if n cessary.
Outfall
Operation
Freq
uency
Flow
Rate
Average
Average
Long -Term
Maximum
Number
(list)
Duration
Days/Week
MonthsNear
Average
Dail
WTP Backwash Dischar
4 days/week
12 months/year
0.0024 mgd
0.0024 mgd
288 days
30
001
days/week
months/year
mgd
mgd
days
U_
CD
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
c
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week months/year mgd mgd days
SECTION•••1
• 1
5.1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes ❑r No 4 SKIP to Section 6.
h
5.2
Provide the following information on applicable ELGs.
w
ELG Category
ELG Subcategory
Regulatory Citation
d
n
a
Q
5.3
Are any of the applicable ELGs expressed in terms of production (or other measure of operation)?
❑ Yes No 4 SKIP to Section 6.
0
2
5.4
Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
F
Outfall
Operation, Product, or Material
Quantity per Day
Unit of
Number
Measure
d
rn
m
m
C
O
3
0
O
a
EPA Form 3510-2C (Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP OMB No. 2040-0004
SECTION' • 1
6.1 Are you presently required by any federal, state, or local authority to meet an implementation schedule for constructing,
upgrading, or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
❑ Yes No + SKIP to Item 6.3.
6.2
Briefly identify each applicable project in the table below.
Affected
Final Compliance Dates
E
Brief Identification and Description of
Outfalls
Source(s) of
o
Project
(list outfall
Discharge
Required
Projected
c.
number
E
-o
c
co
H
d
'C
CL
Q.
6.3
Have you attached sheets describing any additional water pollution control programs (or other environmental projects
that may affect your discharges) that you now have underway or planned? (optional item)
❑ Yes ❑ No El Not applicable
SECTION
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
complete. Not all applicants need to complete each table.
Table A. Conventional and Non -Conventional Pollutants
7.1
Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
❑r Yes ❑ No -* SKIP to Item 7.3.
7.2
If yes, indicate the applicable outfalls below. Attach waiver request and other required information to the application.
Outfall Number 001 Outfall Number Outfall Number
7.3
Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
H
requested and attached the results to this application package?
No; a waiver has been requested from my NPDES
❑✓ Yes ❑permitting
authority for all pollutants at all outfalls.
Table B.
Toxic Metals, Cyanide, Total Phenols, and Organic Toxic Pollutants
7.4
Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
listed in Exhibit 2C-3? (See end of instructions for exhibit.)
❑ Yes ❑ No 4 SKIP to Item 7.8.
3
7.5
Have you checked "Testing Required" for all toxic metals, cyanide, and total phenols in Section 1 of Table B?
w
❑ Yes No
7.6
List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s) identified
in Exhibit 2C-3.
Primary Industry Category
Required GC/MS Fraction(s)
Check applicable boxes.
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
EPA Form 3510-2C (Revised 3-19) Page 4

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG59OOO8
NCG590008
Fox Run Subdivision -Well #3 WTP
OMB No. 2040-0004
7.7
Have you checked "Testing Required" for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?
❑ Yes No
7.8
Have you checked 'Believed Present' or 'Believed Absent" for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required?
❑✓ Yes ❑ No
7.9
Have you provided (1) quantitative data for those Section 1, Table B, pollutants for which you have indicated testing is
required or (2) quantitative data or other required information for those Section 1, Table B, pollutants that you have
indicated are 'Believed Present' in your discharge?
❑ Yes ❑r No
7.10
Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
❑ Yes + Note that you qualify at the top of Table B, 0 No
then SKIP to Item 7.12.
'c
7.11
Have you provided (1) quantitative data for those Sections 2 through 5, Table B, pollutants for which you have
c
determined testing is required or (2) quantitative data or an explanation for those Sections 2 through 5, Table B,
y
pollutants you have indicated are `Believed Present' in your discharge?
H
❑ Yes ❑✓ No
d
Table C. Certain Conventional and Non -Conventional Pollutants
ts
7.12
Have you indicated whether pollutants are "Believed Present' or `Believed Absent' for all pollutants listed on Table C
t
for all outfalls?
0 Yes ❑ No
c
7.13
Have you completed Table C by providing (1) quantitative data for those pollutants that are limited either directly or
indirectly in an ELG and/or (2) quantitative data or an explanation for those pollutants for which you have indicated
`Believed Present'?
4
Yes ❑ No
w
Table D.
Certain Hazardous Substances and Asbestos
7.14
Have you indicated whether pollutants are `Believed Present' or "Believed Absent' for all pollutants listed in Table D for
all outfalls?
0 Yes ❑ No
7.15
Have you completed Table D by (1) describing the reasons the applicable pollutants are expected to be discharged
and (2) by providing quantitative data, if available?
❑ Yes ❑r No
Table E. 2,3,7,8-Tetrachlorodibenzo- -Dioxin 2,3,7,8-TCDD
7.16
Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions, or do you
know or have reason to believe that TCDD is or may be present in the effluent?
❑ Yes + Complete Table E. ❑✓ No 4 SKIP to Section 8.
7.17
Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes ❑✓ No
SECTIONOR
MANUFACTURED TOXICS
Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
8.1
an intermediate or final product or byproduct?
w
❑ Yes ❑r No + SKIP to Section 9.
8.2
List the pollutants below.
c •-
1. 4. 7.
0
N
2. 5. 8.
3. 6. 9.
EPA Form 3510-2C (Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG59OOO8 NCG590008 Fox Run Subdivision -Well #3 WTP OMB No. 2040-0004
SECTION• • • 1
9.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on (1) any of your discharges or (2) on a receiving water in relation to your discharge?
❑ Yes ❑✓ No 4 SKIP to Section 10.
�,
9.2
Identify the tests and their
ur oses below.
.5Test(s)
Purpose of Test(s)
Submitted to NPDES
Date Submitted
X
Permitting Authority?
0
F
cc
ElYes ElNo
0
m0
❑ Yes ❑ No
❑ Yes ❑ No
SECTION•
Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
10.1
❑✓ Yes ❑ No 4 SKIP to Section 11.
10.2
Provide information for each contract laboratory or consulting
firm below.
Laboratory Number 1
Laboratory Number 2
Laboratory Number 3
Name of laboratory/firm
Water Tech Laboratories Inc
aLaboratory
address
5 Pinewood Plaza Dr
c
Granite Falls, INC 28630
Q
cc.o
c
c.�
Phone number
[phone]
Pollutant(s) analyzed Total Suspended Solids,
Turbidity, Manganese,
Hardness
SECTIONDD
• •R•
Has the NPDES permitting authority requested additional
information?
11.1
c
❑ Yes
❑ No 4 SKIP to Section 12.
0
11.2
List the information requested and attach it to this application.
0
1. 4.
R
c
0
:0
2. 5.
-a
Q
3. 6.
EPA Form 3510-2C (Revised 3-19) Page 6

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590008 NCGS90008 Fox Run Subdivision -Well #3 WTP OMB No.2040-0004
SECTION•
CERTIFICATION STATEMENT (40
In Column 1 below, mark the sections of Form 2C that you have completed and are submitting with your application.
12.1
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 complete all sections or provide attachments.
Column 1
Column 2
❑✓ Section 1: Outfall Location
❑✓ w/ attachments
❑✓ Section 2: Line Drawing
✓❑ w/ line drawing ❑ w/ additional attachments
Section 3: Average Flows and
0
w/ list of each user of
❑� w/ attachments ❑ privately owned treatment
Treatment
works
❑ Section 4: Intermittent Flows
❑ w/ attachments
❑ Section 5: Production
❑ w/ attachments
w/ optional additional
❑ Section 6: Improvements
❑ wl attachments ❑ sheets describing any
additional pollution control
tans
a w/ request for a waiver and ❑ w/ explanation for identical
supporting information outfalls
w/ small business exemption
❑ ❑ w/ other attachments
d
request
❑ Section 7: Effluent and Intake
❑ w/ Table A ❑✓ w/ Table B
=
Characteristics
❑✓ w/ Table C ❑✓ w/ Table D
❑ w/ Table E El wl analytical results as an
c>
attachment
❑ Section 8: Used or Manufactured
❑ w/ attachments
Toxics
Section 9: Biological Toxicity
ElTests
❑ w/ attachments
U
❑ Section 10: Contract Analyses
❑ w/ attachments
❑ Section 11: Additional Information
❑ w/ attachments
© Section 12: Checklist and
❑ w/ attachments
Certification Statement
12.2
Certification Statement
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 by:
Date signed
�UocuSigned
NY—P(V*K, V'
02/01/2024
9C8BE0980A7649B_.
EPA Form 3510-2C (Revised 3-19) Page 7

This page intentionally left blank.

EPA Identification Number PDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 OMB No. 2040-0004
Effluent Intake
Waiver o tional
Pollutant Requested Units 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.
�'
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
13.2
3.66
109
4.
Total suspended solids (TSS)
0
Mass
Concentration
5.
Ammonia (as N)
Mass
6.
Flow
❑
Rate
mgd
0.0024
0.0024
288
Temperature (winter)
C
°C
7.
Temperature (summer)
C
°C
pH (minimum)
❑
Standard units
S.U.
6.9
7.2
78
8.
pH (maximum)
❑
Standard units
S.U.
7.3
7.2
78
Samolina shall be conducted accordina
to sufficiently sensitive test Drocedures (i.e.. methods) aDoroved under 40 CFR
136 for the analvsis of pollutants or Dollutant 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
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
Ul
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
❑
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
❑
El
Concentration
Concentration
(7440-36-0)
1.2
Arsenic, total
❑
❑
❑
Concentration
Mass
(7440-38-2)
1.3
Beryllium, total
El
❑
El
Concentration
Mass
(7440-41-7)
1.4
Cadmium, total
❑
El
El
Concentration
Concentration
(7440-43-9)
1.5
Chromium, total
El
El
El
Concentration
Concentration
(7440-47-3)
1.6
Copper, total
El
❑
El
Concentration
Concentration
(7440-50-8)
1.7
Lead, total
❑
❑
El
Concentration
Concentration
(7439-92-1)
1.8
Mercury, total
El
❑
El
Concentration
Concentration
(7439-97-6)
1'9
Nickel, total
❑
❑
El
Concentration
Concentration
(7440-02-0)
1.10
Selenium, total
❑
❑
El
Concentration
Concentration
(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
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 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
q
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
ily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
1.12
Thallium, total
D
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
El
El
Concentration
Mass
Section 2.Organic Toxic Pollutants (GC/MS
Fraction
—Volatile Compounds)
2.1
Acrolein
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
El
El
❑
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
❑
El
El
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
El
El
El
Concentration
Mass
(108-90-7)
2.7
Chlorodibromomethane
El
El
Concentration
Mass
(124-48-1)
2.8
Chloroethane
El
❑
❑
Concentration
Mass
(75-00-3)
EPA Form 3510-2C (Revised 3-19) Page 12

EPA Identitication Number NPDES Permit Number Facility Name Outtall Number
NCG590008 NCGS90008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
•
Testing
Required
• • • •
• • •I wk1w,
MMM
Effluent
Intake
(optional)
Presence or Absence
check one
Units
(specify)
Believed
Present
Believed
Absent
Maximum
Daily
Dis�charrge
(reif
Maximum
Monthly
Dischuired) (if arge
Long -Term
Average
Daily
Discharge
available
Number
of
Analyses
Long -
Term
Average
alue
Number
of
Analyses
2.9
2-chloroethylvinyl ether
(110-75-8)
Concentration
Mass
2.10
Chloroform (67-66-3)
R
Concentration
Mass
2.11
Dichlorobromomethane
(75-27-4)
✓
Concentration
Mass
2.12
1,1-dichloroethane
(75-34-3)
1:1
El
✓
Concentration
Mass
2.13
1,2-dichloroethane
(107-06-2)
El
1:1
[a
Concentration
Mass
2.14
1,1-dichloroethylene
(75-35-4)
El
El
0
Concentration
Mass
2.15
1,2-dichloropropane
(78-87-5)
Concentration
Mass
2.16
1,3-dichloropropylene
(542-75-6)
El
El
El
Concentration
Mass
217
Ethylbenzene
(100-41-4)
El
El
ID
Concentration
Mass
2.18
Methyl bromide
(74-83-9)
El
1:1
El
Concentration
Mass
2.19
Methyl chloride
(74-87-3)
El
El
0
Concentration
Mass
2.20
Methylene chloride
(75-09-2)
1:1
El
El
Concentration
Mass
221
1, 1,2,2- tetrachloroethane
(79-34-5)
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 13

tf A Idenbtication Number NF utb rerma Number Facility Name Uuttall Number
NCG590008 NCG590008 I Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
1
I II MA•
• 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
if available
alue
2.22
Tetrachloroethylene
❑
Concentration
Mass
(127-18-4)
2.23
Toluene
❑
El
El
Concentration
Mass
(108-88-3)
224
1,2-trans-dichloroethylene
❑
❑
0
Concentration
Mass
(156-60-5)
225
11,1-trichloroethane
❑
❑
El
Concentration
Mass
(71-55-6)
226
1,1,2-trichloroethane
❑
El
El
Concentration
Mass
(79-00-5)
2.27
Trichloroethylene
❑
❑
❑�
Concentration
Mass
(79-01-6)
2.28
Vinyl chloride
❑
El
O
Concentration
Mass
(75-01-4)
Section 3.Organic Toxic Pollutants (GC/MS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
❑
❑�
Concentration
Mass
(95-57-8)
3.2
2,4-dichlorophenol
❑
❑
Concentration
Mass
(120-83-2)
3.3
2,4-dimethylphenol
❑
El
©
Concentration
Mass
(105-67-9)
3.4
4,6-dinitro-o-cresol
El
ED
El
Concentration
Mass
(534-52-1)
3.5
2,4-dinitrophenol
❑
ElConcentration
Mass
(51-28-5)
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• • 4al
Pollutant/Parameter
(and CAS Number, if available)
•
Testing
Required
• 1 • •
Presence or Absence
(check one
• • • 1
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
le
(if
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)
❑
❑
❑
Concentration
Mass
3.8
p-chloro-m-cresol
(59-50-7)
❑
❑
✓
Concentration
Mass
3.9
Pentachlorophenol
(87-86-5)
❑
E]❑
Concentration
Mass
3.10
Phenol
(108-95-2)
Concentration
Mass
3.11
2,4,6-trich1orophenol
(88-05-2)
El
_j
0
I
on
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)
El
Concentration
Mass
4.4
Benzidine
(92-87-5)
©
Concentration
Mass
4.5
Benzo (a) anthracene
(56-55-3)
❑
El
❑✓
Concentration
Mass
4.6
Benzo (a) pyrene
(50-32-8)
❑
El
Z
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
Testing
Required
Presence or Absence
(check one)
Units
(specify)
Effluent
Intake
(optional)
14.7
Pollutant/Parameter
(and CAS Number, if available)
(and
Believed
Present
Believed
Absent
Maximum
Discharge r
Maximum
Monthly
(if available)
Long -Term
Average
Dailischargey
Discharge
if available
Number
of
Analyses
Lon"
Term
Average
Number
of
Analyses
3,4-benzofluoranthene
(205-99-2)
El
ElConcentration
r
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)
❑
❑
❑
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)
El
❑
21
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
❑
❑
❑�
Concentration
Mass
4.16
2-chloronaphthalene
(91-58-7)
❑
❑
a
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
El
❑
❑
Concentration
Mass
4.18
Chrysene
(218-01-9)
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
❑
❑❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCG590008 NCG590008 I Fox Run Subdivision -Well t#3 WTP 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
q
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
A e
of
(required)
(if
Discharge
Analyses
Value
Analyses
if available
4.20
12-dichlorobenzene
❑
El
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
❑
El
El
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
✓❑
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
❑
21
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
❑
❑
2
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
❑
0
Concentration
Mass
(117-84-0)
4.30
1,2-Dipheny1hydrazine
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
El
1:1
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
❑
❑
a
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

dentification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 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
lee
Daily
of
Average
of
available)
Discharge
Analyses
value
Analyses
if available
4.33
Hexachlorobenzene
❑
❑
❑
Concentration
Mass
(118-74-1)
1
4.34
Hexachlorobutadiene
El
❑
0
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
❑
El
El
Concentration
Mass
(193-39-5)
4.38
Isophorone
El
❑
✓❑
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
❑
❑
✓❑
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
El
✓
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
El
El
Concentration
Mass
(129-00-0)
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number
NCG590008 NCG590008
ame
Fox Run Subdivision -Well #3 WTP
Outfall Number
001
Form Approved 03/05/19
OMB No. 2040-0004
• •
•
• • ••
• •• rin,
NATM)
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long'
(anCAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
D
Daily
of
Average
of
f available)
Discharge
Analyses
Value
Analyses
if available
4.46
1,2,4-trichlorobenzene
El
Concentration
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
✓
Concentration
Mass
(319-84-6)
5.3
R-BHC
El
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
❑
❑
2
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
El
❑
0
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

EPA Identitication Number NPUES Permit Number Facility Name Outfall Number
NCG590008 NCG590 I Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
TOXICTABLE B. 1E,
Pollutant/Parameter
(and CAS Number, if available)
TOTAL PHENOLS,1
Testing
Required
ORGANIC TOXIC••
Presence or Absence
check one
1
Effluent
Intake
(optional)
Units
(specify)
Believed
Present
Believed
Absent
Maximum
Daily
D(eqtge
if
Maximum
Monthly
D
available)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
5.12
Q-endosulfan
(115-29-7)
❑
❑
❑
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
El
❑
❑
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
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)
❑
0
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
❑
El
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)
❑
❑
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPDE5 Permit Number Facility Name Outtall Number
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
•13 1 • • i k lag•
• • 1in.
TFAIlp
Intake
Presence or Absence
check one
Effluent
(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
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
Toxaphene
5.25
❑
❑
0
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

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG59OOO8 NCG590008 Fox Run Subdivision -Well #3 WTP 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 Analyses
(required) 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
12
10.02
113
Mass
residual
3.
Color
❑
0
Concentration
Mass
4.
Fecal coliform
El
❑✓
Concentration
Mass
5
Fluoride
❑
✓
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
El
ElConcentrationMass
7'
Nitrogen, total
❑
El
Concentration
Concentration
organic (as N)
8.
Oil and grease
El
ElConcentration
Mass
9'
Phosphorus (as
❑
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
✓
❑
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
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 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)
12
Sulfite (as S03)
❑
❑
Concentration
Mass
(1426545-3)
13.
Surfactants
❑
O
Concentration
Mass
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
(7439-89-0)
19
Magnesium, total
❑
❑
Concentration
Mass
(7439-95-4)
Molybdenum,
Concentration
20.
total
❑
(7439-98-7)
Mass
21.
Manganese, total
❑
❑
Concentration
mg/L
0.1
0.04
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
Outfalt Number
Form Approved 03/05/19
NCG59OOO8
NCG590008 Fox Run Subdivision -Well #3 WTP
001
OMB No. 2040-0004
Q=
Elm
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
Value Analyses
(if available)
(if available
24.
Radioactivity
Alpha, total
El�
Concentration
Mass
Beta, total
El�
Concentration
Mass
Radium, total
❑
�
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
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 OMB No. 2040-0004
1 ' 1 • 1 � I �
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
1. Asbestos ❑
2. Acetaldehyde ❑ 0
3.
Allyl alcohol
❑
4.
Allyl chloride
❑
5.
Amyl acetate
❑
❑�
6.
Aniline
❑
❑�
7.
Benzonitrile
❑
❑�
8.
Benzyl chloride
❑
0
9.
Butyl acetate
❑
10.
Butylamine
❑
0
11.
Captan
❑
0
12.
Carbaryl
❑
0
13.
Carbofuran
❑
14.
Carbon disulfide
❑
0
15.
Chlorpyrifos
❑
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
NCG590008 NCG590008 Fox Run Subdivision -Well 43 WTP 001 OMB No. 2040-0004
'�• I • I
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 (214-dichlorophenoxyacetic acid) ❑ ❑r
21. Diazinon ❑
22.
Dicamba
❑
❑�
23.
Dichlobenil
❑
24.
Dichlone
❑
25.
2,2-dichloropropionic acid
❑
❑�
26.
Dichlorvos
❑
❑�
27.
Diethyl amine
❑
0
28.
Dimethyl amine
❑
❑�
29.
Dintrobenzene
❑
❑�
30.
Diquat
❑
❑�
31.
Disulfoton
El
El
32.
Diuron
❑
❑r
33.
Epichlorohydrin
❑
M
34.
Ethion
❑
0
35.
Ethylene diamine
❑
36.
Ethylene dibromide
❑
❑�
37.
Formaldehyde
❑
0
38.
Furfural
❑
ED
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 OMB No. 2040-0004
'1• PEW-11
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
39. Guthion ❑
40. Isoprene ❑
41.
Isopropanolamine
❑
❑�
42.
Kelthane
❑
43.
Kepone
❑
❑�
44.
Malathion
❑
0
45.
Mercaptodimethur
❑
46.
Methoxychlor
❑
47.
Methyl mercaptan
❑
48.
Methyl methacrylate
❑
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 Pen -nit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 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
❑
P
60.
Propargite
❑
El
61.
Propylene oxide
❑
62.
Pyrethrins
❑
❑�
63.
Quinoline
❑
64.
Resorcinol
❑
❑r
65.
Strontium
❑
P
66.
Strychnine
❑
❑�
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)
propanoic acid]
❑
❑
71.
Trichlorofon
❑
0
72.
Triethanolamine
❑
0
73.
Triethylamine
❑
74.
Trimethylamine
❑
❑�
75.
Uranium
❑
P
76.
Vanadium
❑
M
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
NCG590008
NCG590008 Fox Run Subdivision-We"WTP001
OMB No. 2040-0004
1 'I•
1 a 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
❑
0
79.
Xylenol
❑
80.
Zirconium
❑
0
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

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 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
EPA Form 3510-2C (Revised 3-19) Page 33

0
I'M
11
Outfall 001
�/_
C t
h
Aqua North Carolina, Inc. Facility
Fox Run WTP Location
Latitude: 35° 1 P 19" N State Gtid: Gastonia South not to scale
Loneitudo: 81, 09, 25" W Permitted Flow: N/A
ReceivineStream: UT to Crowdets Creek Stream Class: C 7OY+� NPDES Permit No. NCO072061
Drainage Basin: Catawba River Basin Sub -Basin: 03-08-37 North G Gaston County

Fox Run Well #3 WTP
Gaston County; Permit No. NCG590008

DocuSign
Certificate Of Completion
Envelope Id: B8CA3964B22C4E7391028862DC92BOC2
Status: Completed
Subject: Here is your signed document: Fox Run_NCG590008_WTP renewal permit.pdf
Source Envelope:
Document Pages: 42
Signatures: 3
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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Timestamp
Lauren Raup-Plummer
by:
Sent: 2/2/2024 2:20:[e-mail]
ED—SIgned
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Viewed: 2/2/2024 2:21:08 PM
Engineering Manager
9C8BE09B0A7B48B_
Signed: 2/2/2024 2:21:59 PM
Aqua North Carolina, Inc.
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AOUA,.
�'-ssertia
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.
Fox Run Water Treatment Plant
NPDES No. NCG590008
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.
If you need any additional information or assistance, please feel free to contact
me at [e-mail].
Sincerely,
DocuSigned by:
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
NCG590008
NCG590008
Fox Run Subdivision -Well #3
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
/EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•D
t
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,
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
Yes 4 Complete Form ❑ No
a
and Form 2B.
1 and Form 2C.
z
0
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 4 Complete Form 1 0 No
❑ Yes 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).
SECTION•••
• • t
Facility Name
2.1
Fox Run Subdivision -Well #3 WTP
0
•R
2.2
EPA Identification Number
U
O
J
NCG590008
2.3
Facility Contact
Name (first and last)
Title
Phone number
Lauren Raup Plummer
Engineering Manager
[phone]
a
Email address
:m
[e-mail]
2.4
Facility Mailing Address
E
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
NCG590008
NCG590008
Fox Run Subdivision -Well #3
MTO
OMB No. 2040-0004
y
2.5
Facility Location
sStreet,
route number, or other specific identifier
Q 0
U
Coachwood Lane
rn
0
County name
County code (if known)
Gaston
0
E
City or town
State ZIP code
z R
Gastonia
North Carolina 28056
SECTION1
NAICS CODES1
3.1
SIC Code(s)
Description (optional)
4941
Establishments primarily engaged in distributing water for sale for domestic,
N
O
U
N
U
z
3.2
NAICS Code(s)
Description (optional)
-a
310
Water Distribution (except irrigation)
U
4.1
Name of Operator
Aqua North Carolina
0
4.2
Is the name you listed in Item 4.1 also the owner?
R
€
❑✓ Yes ❑ No
z
4.3
Operator Status
S
❑ Public —federal ❑ Public —state ❑ Other public (specify)
o
D Private El Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
w
Street or P.O. Box
R
202 MacKenan Drive
0
c
City or town
State
ZIP code
0 0
Cary
North Carolina
27511
�v
Q
Email address of operator
O
[e-mail]
SECTION1
1 1
0
5.1
Is the facility located on Indian Land?
c
c �
❑Yes ❑ No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number
NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590008
NCG590008 Fox Run Subdivision -Well #3 OMB No.2040-0004
SECTION'•
1 CFR 122.211(fI(6))
all that apply and print or type the corresponding permit number for each)
6.1
Existing Environmental Permits (check
a
❑✓ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
c
water)
fluids)
w
o •-
NCG590008
E
w a
rn
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
w
ElOcean dumping (MPRSA) ElDredge or fill (CWA Section 404) ElOther (specify)
SECTION1
Have you attached a topographic map containing all required information to this application? (See instructions for
7.1
specific requirements.)
0 Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 26.)
SECTIONOF
I CFR 122.21(fll(8))
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
y
N
tv
C
.y
7
O
L
R
Z
SECTION••
I
9.1 Does your facility use cooling water?
d
❑ Yes 0 No 4 SKIP to Item 10.1.
E
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
a, w
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 °7
O Y
U +°
c
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
y
U)
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
NCG590008
NCG590008
Fox Run Subdivision -Well #3 WTP OMB No.2040-0004
SECTION
11. CHECKLIST
1 I
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
❑✓ Section 1: Activities Requiring an NPDES Permit
❑✓ w/ attachments
❑✓ Section 2: Name, Mailing Address, and Location
❑ w/ attachments
0 Section 3: SIC Codes
❑ w/ attachments
❑� Section 4: Operator Information
❑ w/ attachments
❑✓ Section 5: Indian Land
❑ w/ attachments
c
❑✓ Section 6: Existing Environmental Permits
❑ w/ attachments
d
d❑✓
Section 7: Ma p
w/ topographic
❑ Elma w/ additional attachments
•o
fN
c
❑✓ Section 8: Nature of Business
❑ w/ attachments
❑✓ Section 9: Cooling Water Intake Structures
❑ w/ attachments
CD
.a
Section 10: Variance Requests
q
w/ attachments
c
Cn
Section 11: Checklist and Certification Statement
❑ w/ attachments
Y
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
DocuSigned by:
C
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
EPA Application Form 2C
Existing Manufacturing,
Commercial, Mining, and
Si Ivicu ltu ral 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 Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP OMB No, 2040-0004
Form U.S. Environmental Protection Agency
2C \i EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS
'ECTION 1. OUTFALL LOCATION
1.1 Provide information on each of the facility's outfalls in the table below.
Outfa
Nu ber Receiving Water Name Latitude Longitude
0
001 unnamed tributary to Crow( 35° 11' 19" N E] 81° 9' 25" W
� I
a, 2.1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
.3 balance? (See instructions for drawing requirements. See Exhibit 2C-1 at end of instructions for example.)
J `
o Yes ❑ No
3.1 For each outfall identified under Item 1.1, provide average flow and treatment information. Add additional sheets if
necessary.
"Outfall Number** 001
WTP Backwash Discharge
� I
m
E
is
F-
R
U)
3
0 Treatment Units
U_
a, Description Code from
(include size, flow rate through each treatment unit, Table from
> retention time, etc.
Flow
0.0024 mgd
mgd
mgd
mgd
Final Disposal of Solid or
Liquid Wastes Other Than
by Discharae
EPA Form 3510-2C (Revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590008
NCG590008
Fox Run Subdivision -Well #3 WTP
OMB No. 2040-0004
3.1
"Outfall Number"
Cont.
Operations
Operation Average Flow
mgd
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
retention time, etc.)
by Dischar e
d
0
c
0
U
c
a>
E
iv
a!
H
a
"Outfall Number"
c
N
Operations
o
Operation Average Flow
LL
CDs
mgd
a
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
retention time, etc.)
by Dischar e
3.2
Are you applying for an NPDES permit to operate a privately owned treatment works?
d
❑ Yes ❑✓ No 4 SKIP to Section 4.
N
3.3
Have you attached a list that identifies each user of the treatment works?
❑ Yes ❑ No
EPA Form 3510-2C (Revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG59o008 NCG590008 Fox Run Subdivision -Well #3 WTP OMB No. 2040-0004
SECTIONFLOWS
4.1 Except for storm runoff, leaks, or spills, are any discharges described in Sections 1 and 3 intermittent or seasonal?
❑✓ Yes ❑ No -* SKIP to Section 5.
4.2
Provide information
on intermittent or seasonal flows for each applicable outfall.
Attach additional pages, if n cessary.
Outfall
Operation
Frequency
Flow
Rate
Average
Average
Long -Term
Maximum
Number
(list)
Duration
Days/Week
Months/Year
Average
Dail
WTP Backwash Discharl
4 days/week
12 months/year
0.0024 mgd
0.0024 mgd
288 days
fp
c
001
days/week
months/year
mgd
mgd
days
U_
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
c
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week months/year mgd mgd days
SECTION"•1
• I
5.1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes ❑ No 4 SKIP to Section 6.
5.2
Provide the following information on applicable ELGs.
w
ELG Category
ELG Subcategory
Regulatory Citation
d
R
t)
.Q
C
Q
5.3
Are any of the applicable ELGs expressed in terms of production (or other measure of operation)?
❑ Yes 0 No -* SKIP to Section 6.
0
5.4
Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
J
Outfall
Operation, Product, or Material
Quantity per Day
Unit of
-a
Number
Measure
d
V!
W
m
C
O
t1
7
0
O
a
EPA Form 3510-2C (Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP OMB No. 2040-0004
SECTION'• 1
6.1 Are you presently required by any federal, state, or local authority to meet an implementation schedule for constructing,
upgrading, or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
❑ Yes ❑v No -* SKIP to Item 6.3.
6.2
Briefly identify each applicable project in the table below.
Affected
Final Compliance Dates
E
Brief Identification and Description of
Outfalls
Source(s) of
c
Project
(list outfall
Discharge
Required
Projected
Q
number
E
c
N
d
f6
CL
Q
6.3 Have you attached sheets describing any additional water pollution control programs (or other environmental projects
that may affect your discharges) that you now have underway or planned? (optional item)
❑ Yes ❑ No El Not applicable
SECTIONi
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
complete. Not all applicants need to complete each table.
Table A. Conventional and Non -Conventional Pollutants
7.1
Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
❑✓ Yes ❑ No 4 SKIP to Item 7.3.
7.2
If yes, indicate the applicable outfalls below. Attach waiver request and other required information to the application.
Outfall Number 001 Outfall Number Outfall Number
7.3
Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
y
requested and attached the results to this application package?
No; a waiver has been requested from my NPDES
0 Yes ❑permitting
authority for all pollutants at all outfalls.
Table B.
Toxic Metals, Cyanide, Total Phenols, and Organic Toxic Pollutants
°1
7.4
Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
listed in Exhibit 2C-3? (See end of instructions for exhibit.)
❑ Yes 0 No -* SKIP to Item 7.8.
7.5
Have you checked "Testing Required" for all toxic metals, cyanide, and total phenols in Section 1 of Table B?
w
❑ Yes 0 No
7.6
List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s) identified
in Exhibit 2C-3.
Required GC/MS Fraction(s)
Primary Industry Category
Check applicable boxes.
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
EPA Form 3510-2C (Revised 3-19) Page 4

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590008
NCG590008
Fox Run Subdivision -Well #3 WTP
OMB No. 2040-0004
7.7
Have you checked 'Testing Required" for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?
❑ Yes ❑✓ No
7.8
Have you checked `Believed Present' or "Believed Absent' for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required?
❑✓ Yes ❑ No
7.9
Have you provided (1) quantitative data for those Section 1, Table B, pollutants for which you have indicated testing is
required or (2) quantitative data or other required information for those Section 1, Table B, pollutants that you have
indicated are "Believed Present' in your discharge?
❑ Yes (a No
7.10
Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
❑ Yes 4 Note that you qualify at the top of Table B, ❑ No
then SKIP to Item 7.12.
a�
7.11
Have you provided (1) quantitative data for those Sections 2 through 5, Table B, pollutants for which you have
c
determined testing is required or (2) quantitative data or an explanation for those Sections 2 through 5, Table B,
pollutants you have indicated are 'Believed Present' in your discharge?
H
y
❑ Yes ❑✓ No
d
Table C. Certain Conventional and Non -Conventional Pollutants
7.12
Have you indicated whether pollutants are "Believed Present' or "Believed Absent' for all pollutants listed on Table C
for all outfalls?
Y
❑� Yes ❑ No
o
7.13
Have you completed Table C by providing (1) quantitative data for those pollutants that are limited either directly or
indirectly in an ELG and/or (2) quantitative data or an explanation for those pollutants for which you have indicated
'Believed Present'?
0 Yes ❑ No
w
Table D.
Certain Hazardous Substances and Asbestos
7.14
Have you indicated whether pollutants are "Believed Present' or 'Believed Absent' for all pollutants listed in Table D for
all outfalls?
0 Yes ❑ No
7.15
Have you completed Table D by (1) describing the reasons the applicable pollutants are expected to be discharged
and (2) by providing quantitative data, if available?
❑ Yes 0 No
Table E. 2,3,7,8-Tetrachlorodibenzo- -Dioxin 2,3,7,8-TCDD
7.16
Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions, or do you
know or have reason to believe that TCDD is or may be present in the effluent?
❑ Yes + Complete Table E. ❑✓ No 4 SKIP to Section 8.
7.17
Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes ❑r No
SECTION 8. USED
OR MANUFACTURED TOXICSr
8.1
Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
an intermediate or final product or byproduct?
❑ Yes ❑ No 4 SKIP to Section 9.
4
8.2
List the pollutants below.
c _
1. 4. 7.
0
2. 5. 8.
CD
3. 6. 9.
EPA Form 3510-2C (Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590OO8 NCG59OOO8 Fox Run Subdivision -Well #3 WTP OMB No.2040-0004
CTION 9. BIOLOGICAL• 1
9.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on (1) any of your discharges or (2) on a receiving water in relation to your discharge?
�, ❑ Yes ❑✓ No -* SKIP to Section 10.
y
9.2 Identify the tests and their Durposes below.
.5 Test(s) Purpose of Test(s) Submitted to NPDES Date Submitted
X Permitting Authority?
0
H
❑ Yes ❑ No
0
o
•m ElYes ElNo
❑ Yes ❑ No
10.1 Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
0 Yes ❑ No 4 SKIP to Section 11.
10.2 Provide information for each contract laboratory or consulting firm below.
��Laboratory Number 1 Laboratory Number 2 Laboratory Number 3
Name of laboratory/firm I Water Tech Laboratories Inc
Laboratory address 5 Pinewood Plaza Dr
Granite Falls, INC 28630
Phone number
[phone]
Pollutant(s) analyzed Total Suspended Solids,
Turbidity, Manganese,
Hardness
11.1 Has the NPDES permitting authority requested additional information?
❑ Yes 0 No 4 SKIP to Section 12.
11.2 List the information requested and attach it to this application.
1. 4.
2. 5.
3. 6.
EPA Form 3510-2C (Revised 3-19) Page 6

EPA Identification Number
NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590008
NCG590008 Fox Run Subdivision -Well #3 WTP OMB No. 2040-0004
SECTION•
1
In Column 1 below, mark the sections of Form 2C that you have completed and are submitting with your application.
12.1
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 complete all sections or provide attachments.
Column 1
Column 2
❑� Section 1: Outfall Location
❑✓ w/ attachments
❑✓ Section 2: Line Drawing
w/ line drawing ❑ w/ additional attachments
Section 3: Average Flows and
w/ list of each user of
❑� w/ attachments ❑ privately owned treatment
Treatment
works
❑ Section 4: Intermittent Flows
❑ w/ attachments
❑ Section 5: Production
❑ w/ attachments
w/ optional additional
❑ Section 6: Improvements
❑ w/ attachments ❑ sheets describing any
additional pollution control
tans
❑ w/ request for a waiver and ❑ w/ explanation for identical
supporting information outfalls
d
w/ small business exemption w/ other attachments
❑ El
d
request
U'
❑ Section 7: Effluent and Intake
❑ w/ Table A ❑✓ w/ Table B
c
Characteristics
0
❑� w/ Table C ❑✓ w/ Table D
_2
d
❑ w/ Table E ❑ w/ analytical results as an
c�
attachment
❑ Section 8: Used or Manufactured
❑ wl attachments
MnToxlcs
-19
0
Section 9: Biological Toxicity
❑
❑ w/ attachments
r
Tests
U
❑ Section 10: Contract Analyses
❑ w/ attachments
❑ Section 11: Additional Information
❑ wl attachments
Section 12: Checklist and
©
❑ w/ attachments
Certification Statement
12.2
Certification Statement
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 DocuSigned by:
Date signed
ENY—P"M V'
02/01/2024
9C8BE0980A7B49B_.
EPA Form 3510-2C (Revised 3-19) Page 7

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
Effluent
Intake
Waiver Units
0 tional
Maximum
Maximum
Long -Term
Pollutant
Requested
(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)
❑
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
Concentration
Mass
(BODs)
2'
Chemical oxygen demand
❑
Concentration
Mass
(COD)
Concentration
3.
Total organic carbon (TOC)
❑✓
Mass
Concentration
mg/L
13.2
3.66
109
4.
Total suspended solids (TSS)
❑✓
Mass
Concentration
5.
Ammonia (as N)
❑✓
Mass
6.
Flow
❑
Rate
mgd
0.0024
0.0024
288
Temperature (winter)
❑✓
°C
°C
7.
Temperature (summer)
❑✓
°C
°C
pH (minimum)
❑
Standard units
S.U.
6.9
7.2
78
8.
rpH (maximum)
❑
Standard units
S.U.
7.3
7.2
78
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 9

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 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
of
Average
of
(required)
(if available)
Discharge
g
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
El
Concentration
Mass
(7440-36-0)
1.2
Arsenic, total
Concentration
Mass
(7440-38-2)
1.3
Beryllium, total
❑
❑
❑
Concentration
Mass
(7440-41-7)
1.4
Cadmium, total
El
Concentration
Mass
(7440-43-9)
1.5
Chromium, total
11
El
El
Concentration
Mass
(7440-47-3)
1.6
Copper, total
0
El
Concentration
Mass
(7440-50-8)
1.7
Lead, total
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
Concentration
Mass
(7440-22-4)
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 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-
11.12
(and CAS Number, if available )
Required
q
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
Thallium, total
El
❑
ElConcentration
Mass
(7440-28-0)
1.13
Zinc, total
El
El
El
Concentration
Mass
(7440-66-6)
1.14
Cyanide, total
❑
❑
❑
Concentration
Mass
(57-12-5)
1.15
Phenols, total
❑
❑
r❑
Concentration
Mass
Section 2.Organic Toxic Pollutants (GC/MS
Fraction
—Volatile Compounds)
2.1
Acrolein
El
❑
El
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
❑
❑
❑
Concentration
Mass
(107-13-1)
2.3
Benzene
El
❑
❑
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
El
❑
❑
Concentration
Mass
(124-48-1)
2.8
Chloroethane
❑
❑
❑
Concentration
Mass
(75-00-3)
EPA Form 3510-2C (Revised 3-19) Page 12

dentification Number NPDES Permit Number Facility Name Uuttall Number
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
•
1
•0111111111OWL6
1 •-
• •• 1
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
D
Daily
of
Average
of
(requ red)
if available)
Discharge
Analyses
Value
Analyses
if available
2.9
2-chloroethylvinyl ether
❑
❑
Concentration
Mass
(110-75-8)
2.10
Chloroform (67-66-3)
❑
❑
❑✓
Concentration
Mass
2.11
Dichlorobromomethane
❑
❑
❑
Concentration
Mass
(75-27-4)
212
1,1-dichloroethane
El
❑
❑
Concentration
Mass
(75-34-3)
2.13
1,2-dichloroethane
❑
❑
❑
Concentration
Mass
(107-06-2)
2.14
1,1-dichloroethylene
❑
❑
❑
Concentration
Mass
(75-35-4)
2.15
12-dichloropropane
❑
Concentration
Mass
(78-87-5)
2.16
1,3-dichloropropylene
❑
❑
❑
Concentration
Mass
(542-75-6)
217
Ethylbenzene
❑
Concentration
Mass
(100-41-4)
2.18
Methyl bromide
❑
❑
❑
Concentration
Mass
(74-83-9)
Methyl chloride
Concentration
Mass
(74-87-3)
L.19
Methylene chloride
Concentration
Mass
(75-09-2)
221
1, 1,2,2- tetrachloroethane
r
Concentration
Mass
(79-34-5)
EPA Form 3510-2C (Revised 3-19) Page 13

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 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
q
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
2122
Tetra chloroethylene
❑
❑
ID
Concentration
Mass
(127-18-4)
2.23
Toluene
El
El
El
Concentration
Mass
(108-88-3)
2.24
1,2-trans-dichloroethylene
El
El
El
Concentration
Mass
(156-60-5)
225
1,1,1-trichloroethane
❑
Concentration
Mass
(71-55-6)
2.26
1,1,2-trichloroethane
✓
Concentration
Mass
(79-00-5)
2.27
Trichloroethylene
El
❑
El
Concentration
Mass
(79-01-6)
2.28
Vinyl chloride
El
El❑
Concentration
Mass
(75-01-4)
Section 3.Organic Toxic Pollutants (GCIMS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
El
El
Concentration
Mass
(95-57-8)
3.2
2,4-dichlorophenol
El
El
El
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
El
Concentration
Mass
(51-28-5)
EPA Form 3510-2C (Revised 3-19) Page 14

Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590008 NCG590008 I Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
13.62-nitrophenol
Pollutant/Parameter
(and CAS Number, if available)
Units
(specify)
Effluent
Intake
(optional)
Testing
Required
Presence or Absence
(check one)
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
(88-75-5)
El
El❑
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)
El
❑
❑
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)
❑
❑
El
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)
El
1:1
❑✓
Concentration
Mass
4.6
Benzo (a) pyrene
(50-32-8)
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available
•
Testing
Required
1 1 a 02
Presence or Absence
(check one
• '• 1
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
aily
Discharge a
g
if available
Number
of
Analyses
Lon
Term
Average
Value
Number
of
Analyses
4.7
3,4-benzofluoranthene
(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)
❑
❑
O
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
❑
0
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
El
Concentration
Mass
4.18
Chrysene
(218-01-9)
El
El❑
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

Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
•ELM 0 =ZA k 10421
• '• 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
Discharge
of
Analyses
Average
of
Analyses
e)Discharge
f available)
e)
if available
Value
4.20
1,2-dichlorobenzene
❑
El
El
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
Concentration
Mass
(541-73-1)
4.22
1,4-dichlorobenzene
❑
❑
O
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
❑
❑
O
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
❑
❑
0
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
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 Nu
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
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
Dail y
Discharge
(required)
Maximum
Monthly
y
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)
El
❑
❑
Concentration
Mass
4.34
Hexachlorobutadiene
(87 68 3)
El
El
El
Concentration
Mass
4.35
Hexachlorocyclopentadiene
(77-47-4)
❑
✓
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)
El
El
Concentration
Mass
4.40
Nitrobenzene
(98 95 3)
❑
❑
Concentration
Mass
4.41
N-nitrosodimethylamine
(62-75-9)
El
El
El
Concentration
Mass
4.42
N-nitrosodi-n-propylamine
(621-64-7)
❑
✓
Concentration
Mass
4.43
N-nitrosodiphenylamine
(86-30-6)
El
El
El
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 Uuttall Number
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
•
1
•
• 1 •'029
0A 1911126141
Intake
Presence or Absence
(check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
14.46
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
Discharge
g
of
Analyses
Average
of
Analyses
(required)
(if available)
if available
Value
1,2,4-trichlorobenzene
✓
Concentration
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
El
R
Concentration
Mass
(319-84-6)
5.3
R-BHC
El
21
Concentration
Mass
(319-85-7)
5.4
y-BHC
El
El
El
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
✓
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
_F7
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

dentification Number NPDES Permit Number Facility Name Outfall Nu
NCG590008 NCG590008 I Fox Run Subdivision -Well #3 WTP 1 001
Form Approved 03/05/19
OMB No. 2040-0004
•
1
•
• 1 • •
Presence or Absence
(check one
• • • 1
Units
(specify)
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
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
5.12
R-endosulfan
(115-29-7)
El
R
El
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)
El
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑
0
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
El
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)
El
❑
0
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
0
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
❑
El
0
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 •-=IUl
Intake
Presence or Absence
(check one)
Effluent
(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
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
Toxaphene
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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCGS9OOO8 NCGS90OO8 Fox Run Subdivision -Well #3 WTP 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 Analyses
(required) 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
12
10.02
113
Mass
residual
3.
Color
❑
❑
Concentration
Mass
4.
Fecal coliform
❑
0
ConcentrationMass
5
Fluoride
❑
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
El0
ConcentrationMass
7'
Nitrogen, total
❑
✓
❑
Concentration
Mass
organic (as N)
8.
Oil and grease
❑
0
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)
❑
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

dentification Number NF'UE6 Permit Number Facility Name Outfall Number
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant
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
12
Sulfite (as S03)
(14265-45-3)
❑
✓
❑
Concentration
Mass
13.
Surfactants
❑
0
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
El
R1
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
(7439-89-6)
❑
❑
Concentration
Mass
19
Magnesium, total
(7439-95-4)
❑
0
Concentration
Mass
20.
Molybdenum,
total
(7439-98-7)
❑
❑✓
Concentration
Mass
21
Manganese, total
(7439-96-5)
21
❑
Concentration
mg/L
0.1
0.04
16
Mass
22.
Tin, total
(7440-31-5)
ElConcentration
ID
Mass
23
Titanium, total
(7440-32-6)
❑
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
NCG590008
NCG590O08 Fox Run Subdivision -Well #3 WTP
001
OMB No.2040-0004
gaull"Kell,
•
• •
• '•
1
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
0
Concentration
Mass
Beta, total
El
ID
Concentration
Mass
Radium, total
El
Concentration
Mass
Radium 226, total
❑
[D
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
NCG590008
1 'I•
Pollutant
Asbestos
Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590008 Fox Run Subdivision -Well #3 WTP 001 OMB No. 2040-0004
I • 1
Presence or Absence
(check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
❑ 0
❑ 0
❑ 0
❑ 0
1.
2.
Acetaldehyde
3.
Allyl alcohol
4.
Allyl chloride
5.
Amyl acetate
❑
0
6.
Aniline
❑
❑�
7.
Benzonitrile
❑
❑�
8.
Benzyl chloride
❑
❑�
9.
Butyl acetate
❑
10.
Butylamine
❑
11.
Captan
❑
❑�
12.
Carbaryl
❑
13.
Carbofuran
❑
14.
Carbon disulfide
❑
❑�
15.
Chlorpyrifos
❑
0
16.
Coumaphos
❑
0
17.
Cresol
❑
El
18.
Crotonaldehyde
❑
El
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
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 OMB No. 2040-0004
I '�• 1 • 1 I
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)
❑
P
21.
Diazinon
❑
22.
Dicamba
❑
23.
Dichlobenil
❑
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
0
26.
Dichlorvos
❑
0
27.
Diethyl amine
❑
0
28.
Dimethyl amine
❑
29.
Dintrobenzene
❑
0
30.
Diquat
❑
31.
Disulfoton
❑
0
32.
Diuron
❑
33.
Epichlorohydrin
❑
34.
Ethion
❑
0
35.
Ethylene diamine
❑
36.
Ethylene dibromide
❑
37.
Formaldehyde
❑
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
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 OMB No 2040-0004
� MM
Presence or Absence
Pollutant (check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
7GUthiorn
39. ❑
40.
Isoprene
❑
41.
Isopropanolamine
❑
42.
Kelthane
❑
❑�
43.
Kepone
❑
El
44.
Malathion
❑
❑�
45.
Mercaptodimethur
❑
46.
Methoxychlor
❑
47.
Methyl mercaptan
❑
El
48.
Methyl methacrylate
❑
49.
Methyl parathion
❑
50.
Mevinphos
❑
0
51.
Mexacarbate
❑
0
52.
Monoethyl amine
❑
0
53.
Monomethyl amine
❑
54.
Naled
❑
0
55.
Naphthenic acid
❑
El
56.
Nitrotoluene
❑
57.
Parathion
❑
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Ou(fall Number Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 OMB No. 2040-0004
1 '1• I • 1 �
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
58. Phenolsulfonate ❑ El
59.
Phosgene
❑
0
60.
Propargite
❑
0
61.
Propylene oxide
❑
12
62.
Pyrethrins
❑
❑�
63.
Quinoline
❑
❑�
64.
Resorcinol
❑
65.
Strontium
❑
66.
Strychnine
❑
❑�
67.
Styrene
❑
0
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetra chlorodiphenyl ethane)
❑
70
2,4,5-TP (2-(2,4,5-trichlorophenoxy)
propanoic acid]
❑
❑
71.
Trichlorofon
❑
❑�
72.
Triethanolamine
❑
73.
Triethylamine
❑
❑r
74.
Trimethylamine
❑
❑�
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
NCG590008
NCG590008 Fox Run Subdivision -Well #3 WTP 001
OMB No. 2040-0004
I • I •
I • 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
❑
0
79.
Xylenol
❑
0
80.
Zirconium
❑
0
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

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG59OOO8 NCG59OOO8 Fox Run Subdivision Well #3 WTP 001 OMB No. 2040-0004
•'•1 • 1 • WMANAL 11 �1
TCDD Presence or
Congeners Absence
Pollutant Used or check one Results of Screening Procedure
7
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD
EPA Form 3510-2C (Revised 3-19) Page 33

I 100
RIM
J'7
won
Y Y
tit/.�o i � � • •:ll
AROLE
u
Outfall 001 1
•
•
Aqua North Carolina, Inc. Facility
Fox Run WTP Location
Latitude: 35' 11' 19" N StateGtid: Gastonia South not to scale
Loneitude: 81.09' 25" W Permitted Clow: N/A
ReceiAneSlream: UT to Crowdeis Creek Stream Class: C Worth
NPDES Permit No. NCO072061
Urminaec Basin: Catawba R.ivet Basin Sub -Basin: 03-08-37 `�l Gaston COUllty

Fox Run Well #3 WTP
Gaston County; Permit No. NCG590008

DocuSign
Certificate Of Completion
Envelope Id: B8CA3964B22C4E7391028862DC92BOC2
Status: Completed
Subject: Here is your signed document: Fox Run_NCG590008_WTP renewal permit.pdf
Source Envelope:
Document Pages: 42
Signatures: 3
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 2:19:22 PM
[e-mail]
Signer Events
Signature
Timestamp
Raup-Plummer
by:Lauren
Sent: 2/2/2024 2:20:41 [e-mail]
EDOCUSIgnel
^�^+—P�W+,w�tY
Viewed: 2/2/2024 2:21:08 PM
Engineering Manager
9C9BEo9BOA7B49B_
Signed: 2/2/2024 2:21:59 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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Timestamps

AQUA,.
6 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
Aqua North Carolina, Inc.
Fox Run Water Treatment Plant
NPDES No. NCG590008
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.
If you need any additional information or assistance, please feel free to contact
me at [e-mail].
Sincerely,
UDocuSigned by:
,cUtiYt In "—Pl uw,MV
9CBBE09BOA7849B...
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
NCG590008
NCG590008
Fox Run Subdivision -Well #3
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
I
\-.EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•
•Di
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,
€
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
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?
Cr
❑ Yes -* Complete Form 1 ❑� No
❑ Yes 4 Complete Form � No
d
W
and Form 2D.
1 and Form 2E.
U)
°'
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).
SECTION•D•
2.1
AND LOCATION (40
Facility Name
Fox Run Subdivision -Well #3 WTP
0
2.2
EPA Identification Number
w
0
C
J
NCG590008
-O
2.3
Facility Contact
d
Name (first and last)
Title
Phone number
v
v
Lauren Raup-Plummer
Engineering Manager
[phone]
Q
Email address
[e-mail]
d
2.4
Facility Mailing Address
zStreet
or P.O. box
202 MacKenan Drive
City or town
FNoh
ZIP code
Cary
arolina
27511
EPA Form 3510-1 (revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590008
NCG590008
Fox Run Subdivision -Well #3
OMB No. 2040-0004
y
2.5
Facility Location
Street, route number, or other specific identifier
Q 0
U
Coachwood Lane
�
0
County name
County code (if known)
f° io
U
Gaston
E
City or town
State ZIP code
z M
Gastonia
North Carolina 28056
SECTIONI
3.1
NAICS CODES1
SIC Code(s)
Description (optional)
4941
Establishments primarily engaged in distributing water for sale for domestic,
,i a;
N
O
U
N
U
z
3.2
NAICS Code(s)
Description (optional)
R
310
Water Distribution (except irrigation)
U
4.1
Name of Operator
Aqua North Carolina
0
4.2
Is the name you listed in Item 4.1 also the owner?
cc
`o
❑� Yes ❑ No
w
7
4.3
Operator Status
❑ Public —federal ❑ Public —state ❑ Other public (specify)
C
❑� Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
Street or P.O. Box
E
202 MacKenan Drive
w
City or town
State
ZIP code
o v
Cary
North Carolina
27511
m
Q
Email address of operator
O
[e-mail]
SECTIONI
1 1
0
5.1
Is the facility located on Indian Land?
_ c
r_ _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
NCG590008 NCG590008 Fox Run Subdivision -Well #3 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
cc
d
❑✓ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
C y
water)
fluids)
'=
NCG590008
L €
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
rn
c
w
ElOcean dumping (MPRSA) ElDredge or fill (CWA Section 404) ElOther (specify)
SECTION1
Have you attached a topographic map containing all required information to this application? (See instructions for
7.1
Co
specific requirements.)
❑✓ Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 2B.)
SECTIONOF
I
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
U)
am
C
N
7
Co
O
7
10
Z
SECTION••
1
Does your facility use cooling water?
9.1
❑ Yes ❑r No 4 SKIP to Item 10.1.
M s
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
NPDES permitting authority to determine what specific information needs to be submitted and when.)
O Y
O la
U �
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
d
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
cc
Section 301(c) and (g))
0 Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
NCG590008
NCG590008
Fox Run Subdivision -Well #3 WTP 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
E Section 1: Activities Requiring an NPDES Permit
❑r w/ attachments
[D Section 2: Name, Mailing Address, and Location
❑ w/ attachments
❑� Section 3: SIC Codes
❑ w/ attachments
❑✓ Section 4: Operator Information
❑ w/ attachments
0 Section 5: Indian Land
❑ w/ attachments
❑✓ Section 6: Existing Environmental Permits
❑ wl attachments
d
d
Section 7: Map
w/ topographic
❑ ❑ w/ additional attachments
ma
c
❑✓ Section 8: Nature of Business
❑ w/ attachments
0 Section 9: Cooling Water Intake Structures
❑ w/ attachments
d
Section 10: Variance Requests
❑ wl attachments
❑� Section 11: Checklist and Certification Statement
❑ w/ attachments
_y
Y
s
11.2
Certification Statement
v
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
DocuSipned by:
ALIYi,IA "—p"itAv
E
02/01/2024
9C8BE09BOA7B498_.
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
NCG590008
Form
N 2CE 4r8oEPA
NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590008 Fox Run Subdivision -Well #3 WTP OMB No. 2040-0004
U.S. Environmental Protection Agency
Application for NPDES Permit to Discharge Wastewater
EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS
Provide information on each of the facility'
o Numbe
�� r Receiving Water Name
I I
U
001 unnamed tributary to Crow(
is
O
outfalls in the table below.
Latitude
35° 11' 19" N a
Longitude
81° 91 25" W E]
a, 2.1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
.3 balance? (See instructions for drawing requirements. See Exhibit 2C-1 at end of instructions for example.)
J `
o [E] Yes ❑ No
3.1 For each outfall identified under Item 1.1, provide average flow and treatment information. Add additional sheets if
necessary.
**Outfall Number" 001
WTP Backwash Discharge
Description
(include size, flow rate through each treatment unit,
retention time. etc.)
Flow
0.0024 mgd
mgd
mgd
mgd
Code from Final Disposal of Solid or
Table 2C-1 Liquid Wastes Other Than
- -- — - --by Dischargje
EPA Form 3510-2C (Revised 3-19) Paae

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590008
NCG590008
Fox Run Subdivision -Well #3 WTP
OMB No. 2040-0004
3.1
**Outfall Number**
cont.
Operations
Operation
Average Flow
mgd
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
retention time, etc.
by Dischar e
v
d
3
C
-C
O
U
c
ar
E
is
m
h—
c
**Outfall Number**
Operations
o
Operation Average Flow
LL
rn
mgd
CD
CD
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
retention time, etc.)
by Discharge
3.2
Are you applying for an NPDES permit to operate a privately owned treatment works?
d Le❑
Yes ❑✓ No 4 SKIP to Section 4.
M
3.3
Have you attached a list that identifies each user of the treatment works?
❑ Yes ❑ No
EPA Form 3510-2C (Revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP OMB No. 2040-0004
SECTION• I
4.1 Except for storm runoff, leaks, or spills, are any discharges described in Sections 1 and 3 intermittent or seasonal?
0 Yes ❑ No 4 SKIP to Section 5.
4.2
Provide information
on intermittent or seasonal flows for each applicable outfall. Attach additional pages, if n cessary.
Outfall
Operation
Frequency
Flow
Rate
Average
Average
Long -Term
Maximum
Number
(list)
Duration
Days/Week
MonthsNear
Average
Dail
WTP Backwash Dischar
4 days/week
12 months/year
0.0024 mgd
0.0024 mgd
288 days
c
001
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
c
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week months/year mgd mgd days
SECTION•'•1
• 1
5.1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes ❑r No 4 SKIP to Section 6.
v,
5.2
Provide the following information on applicable ELGs.
LU
ELG Category
ELG Subcategory
Regulatory Citation
a
o
.n
n
a
5.3
Are any of the applicable ELGs expressed in terms of production (or other measure of operation)?
H
❑ Yes 0 No 4 SKIP to Section 6.
c
0
5.4
Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
J
Outfall
Operation, Product, or Material
Quantity per Day
Unit of
-0
Number
Measure
d
W
cc
m
C
O
7
O
d
EPA Form 3510-2C (Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP OMB No. 2040-0004
SECTION• • 1
6.1 Are you presently required by any federal, state, or local authority to meet an implementation schedule for constructing,
upgrading, or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
❑ Yes ❑ No 4 SKIP to Item 6.3.
6.2
Briefly identify each applicable project in the table below.
Affected
Final Compliance Dates
E
Brief Identification and Description of
Outfalls
Source(s) of
c
Project
(list outfall
Discharge
Required
Projected
o.
number
E
-o
v
N
d
'O
N
07
O.
6.3
Have you attached sheets describing any additional water pollution control programs (or other environmental projects
that may affect your discharges) that you now have underway or planned? (optional item)
❑ Yes ❑ No 0 Not applicable
SECTION
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
complete. Not all applicants need to complete each table.
Table A. Conventional and Non -Conventional Pollutants
7.1
Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
0 Yes ❑ No 4 SKIP to Item 7.3.
7.2
If yes, indicate the applicable outfalls below. Attach waiver request and other required information to the application.
Outfall Number 001 Outfall Number Outfall Number
7.3
Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
rn
requested and attached the results to this application package?
No; a waiver has been requested from my NPDES
❑ Yes ❑permitting
authority for all pollutants at all outfalls.
Table B.
Toxic Metals, Cyanide, Total Phenols, and Organic Toxic Pollutants
7.4
Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
=
listed in Exhibit 2C-3? (See end of instructions for exhibit.)
❑ Yes ❑� No 4 SKIP to Item 7.8.
d
7.5
Have you checked "Testing Required" for all toxic metals, cyanide, and total phenols in Section 1 of Table B?
w
❑ Yes ❑r No
7.6
List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s) identified
in Exhibit 2C-3.
Primary Industry Category
Required GC/MS Fraction(s)
Check applicable boxes.
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
EPA Form 3510-2C (Revised 3-19) Page 4

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590008
NCG590008
Fox Run Subdivision -Well #3 WTP
OMB No. 2040-0004
7.7
Have you checked `Testing Required" for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?
❑ Yes 0 No
7.8
Have you checked "Believed Present" or "Believed Absent' for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required?
❑r Yes ❑ No
7.9
Have you provided (1) quantitative data for those Section 1, Table B, pollutants for which you have indicated testing is
required or (2) quantitative data or other required information for those Section 1, Table B, pollutants that you have
indicated are "Believed Present' in your discharge?
❑ Yes 0 No
7.10
Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
❑ Yes 4 Note that you qualify at the top of Table B, ❑ No
a
then SKIP to Item 7.12.
d
7.11
Have you provided (1) quantitative data for those Sections 2 through 5, Table B, pollutants for which you have
!
determined testing is required or (2) quantitative data or an explanation for those Sections 2 through 5, Table B,
c)
pollutants you have indicated are 'Believed Present' in your discharge?
tll
`—'
.y
❑ Yes ❑✓ No
Table C. Certain Conventional and Non -Conventional Pollutants
7.12
Have you indicated whether pollutants are "Believed Present' or "Believed Absent' for all pollutants listed on Table C
for all outfalls?
❑✓ Yes ❑ No
c
7.13
Have you completed Table C by providing (1) quantitative data for those pollutants that are limited either directly or
V
indirectly in an ELG and/or (2) quantitative data or an explanation for those pollutants for which you have indicated
"Believed Present'?
0 Yes ❑ No
w
Table D.
Certain Hazardous Substances and Asbestos
7.14
Have you indicated whether pollutants are `Believed Present' or 'Believed Absent' for all pollutants listed in Table D for
all outfalls?
E] Yes ❑ No
7.15
Have you completed Table D by (1) describing the reasons the applicable pollutants are expected to be discharged
and (2) by providing quantitative data, if available?
❑ Yes ❑r No
Table E. 2,3,7,8-Tetrachlorodibenzo- -Dioxin 2,3,7,8-TCDD
7.16
Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions, or do you
know or have reason to believe that TCDD is or may be present in the effluent?
❑ Yes 4 Complete Table E. ❑✓ No 4 SKIP to Section 8.
7.17
Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes 0 No
SECTIONOR
MANUFACTURED TOXICSi
8.1
Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
an intermediate or final product or byproduct?
❑ Yes ❑ No 4 SKIP to Section 9.
2 u,
8.2
List the pollutants below.
c •—
t0
1. 4. 7.
0
d
2. 5. 8.
ui
3. 6. 9.
EPA Form 3510-2C (Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG59O008 NCG59O0O8 Fox Run Subdivision -Well #3 WTP OMB No. 2040-0004
SECTION• • • 1
9.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on (1) any of your discharges or (2) on a receiving water in relation to your discharge?
❑ Yes ❑✓ No + SKIP to Section 10.
h
w
Nl
9.2
Identify the tests and their
ur oses below.
Test(s)
Purpose of Test(s)
Submitted to NPDES
Date Submitted
K
Permitting Authority?
0
R
❑ Yes ❑ No
0
0
m
❑ Yes ❑ No
❑ Yes ❑ No
SECTION•
i
Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
10.1
0 Yes ❑ No 4 SKIP to Section 11.
10.2
Provide information for each contract laboratory or consulting
firm below.
Laboratory Number 1
Laboratory Number 2
Laboratory Number 3
Name of laboratory/firm
Water Tech Laboratories Inc
h
Z,
Laboratory address
5 Pinewood Plaza Dr
=
Granite Falls, NC 28630
Q
c�
R
C
Phone number
[phone]
Pollutant(s) analyzed Total Suspended Solids,
Turbidity, Manganese,
Hardness
SECTIONDD
• •R• 1
Has the NPDES permitting authority requested additional
information?
11.1
❑ Yes
No 4 SKIP to Section 12.
0
E11.2
List the information requested and attach it to this application.
E
0
c
1. 4.
c
0
2. 5.
a
3. 6.
EPA Form 3510-2C (Revised 3-19) Page 6

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP OMB No. 2040-0004
SECTION1
CERTIFICATION STATEMENT (40
12.1
In Column 1 below, mark the sections of Form 2C 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 complete all sections or provide attachments.
Column 1
Column 2
❑✓ Section 1: Outfall Location
❑✓ w/ attachments
❑✓ Section 2: Line Drawing
✓❑ wl line drawing ❑ w/ additional attachments
Section 3: Average Flows and
w/ list of each user of
wl attachments ❑ privately owned treatment
Treatment
works
❑ Section 4: Intermittent Flows
❑ w/ attachments
❑ Section 5: Production
❑ w/ attachments
w/ optional additional
❑ Section 6: Improvements
❑ w/ attachments ❑ sheets describing any
additional pollution control
tans
❑ w/ request for a waiver and ❑ w/ explanation for identical
supporting information outfalls
CD
w/ small business exemption
❑ ❑ w/ other attachments
d
request
Section 7: Effluent and Intake
❑ w/ Table A ❑✓ w/ Table B
=
Characteristics
0
w/ Table C ❑✓ w/ Table D
w
❑w/ Table E w/ analytical results as an
❑
attachment
❑ Section 8: Used or Manufactured
❑ w/ attachments
Toxics
Section 9: Biological Toxicity
❑
❑ w/ attachments
°'
Tests
v
❑ Section 10: Contract Analyses
❑ w/ attachments
❑ Section 11: Additional Information
❑ w/ attachments
Section 12: Checklist and
©
El w/ attachments
Certification Statement
12.2
Certification Statement
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 by:
Date signed
j �UocuSigned
9C88E0980A7B49B_.
EPA Form 3510-2C (Revised 3-19) Page 7

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name
Outfall Number
Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP
001
OMB No. 2040-0004
Effluent
Intake
Waiver
0 tional
Maximum
Maximum
Long -Term
17
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
❑
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
❑
Concentration
Mass
(BOD5)
2'
Chemical oxygen demand
❑
Concentration
Mass
(COD)
Concentration
3.
Total organic carbon (TOC)
Mass
Concentration
mg/L
13.2
3.66
109
4.
Total suspended solids (TSS)
✓❑
Mass
Concentration
5.
Ammonia (as N)
✓❑
Mass
6.
Flow
❑
Rate
mgd
0.0024
0.0024
288
Temperature (winter)
E
°C
°C
7.
Temperature (summer)
❑r
°C
°C
pH (minimum)
❑
Standard units
S.U.
6.9
7.2
78
8.
pH (maximum)
❑
Standard units
s.u.
1 7.3
7.2
1 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 Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 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
e)
Discharge
Analyses
alue
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
❑
❑
❑
Concentration
Mass
(7440-36-0)
1.2
Arsenic, total
El
❑
❑
Concentration
Mass
(7440-38-2)
1.3
Beryllium, total
❑
❑
❑
Concentration
Mass
(7440-41-7)
1.4
Cadmium, total
❑
❑
El
Concentration
Concentration
(7440-43-9)
1.5
Chromium, total
❑
❑
❑
Concentration
Mass
(744047-3)
1.6
Copper, total
El
El
El
Concentration
Concentration
(7440-50-8)
1.7
Lead, total
❑
❑
El
Concentration
Concentration
(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
❑
El
El
Concentration
Concentration
(7782-49-2)
1.11
Silver, total
❑
El
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
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
TOXICTABLE B.
1E,
TOTAL PHENOLS,AND
ORGANIC TOXIC•
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
11.12Thallium,
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
(if available
total
❑
❑
IDConcentration
Mass
(7440-28-0)
1.13
Zinc total
El
1:1
✓
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
✓
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
El
El
✓
Concentration
Mass
(107-13-1)
2.3
Benzene
❑
✓❑
Concentration
Mass
(71-43-2)
2.4
Bromoform
❑
❑
0
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
❑
El
El
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
❑
✓
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 Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
•L1101
Testing
Required
L, I • • •
• • • 1
Units
(specify)
Effluent
Intake
(optional)
Presence or Absence
check one
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
2'9
2-chloroethylvinyl ether
(110-75-8)
❑
El
ID
Concentration
Mass
2.10
Chloroform (67-66-3)
El
El
El
Concentration
Mass
2.11
Dichlorobromomethane
(75-27-4)
✓
Concentration
Mass
212
1,1-dichloroethane
(75-34-3)
El
El
0
Concentration
Mass
2.13
1,2-dichloroethane
(107-06-2)
El
El
0
Concentration
Mass
2.14
1,1-dichloroethylene
(75-35-4)
IDConcentration
Mass
2.15
1,2-dichloropropane
(78-87-5)
Concentration
Mass
2.16
1,3-dichloropropylene
(542-75-6)
1:1
El
0
Concentration
Mass
217
Ethylbenzene
(100-41-4)
21
Concentration
Mass
2.18
Methyl bromide
(74-83-9)
0
Concentration
Mass
2.19
Methyl chloride
(74-87-3)
Concentration
Mass
2.20
Methylene chloride
(75-09-2)
El
El
0
Concentration
Mass
221
1, 1,2,2- tetrachloroethane
(79-34-5)
El
El
El
Concentration
1 Mass
EPA Form 3510-2C (Revised 3-19) Page 13

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590008 NCG590008 I Fox Run Subdivision -Well #3 WTP 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
of
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
if available
2.22
Tetrachloroethylene
❑
❑
❑
Concentration
Mass
(127-18-4)
2.23
Toluene
❑
❑
Concentration
Mass
(108-88-3)
2.24
1,2-trans-dichloroethylene
Concentration
Mass
(156-60-5)
2.25
1, 1, 1 -trichloroethane
❑
El
El
Concentration
Mass
(71-55-6)
226
1,1,2-trichloroethane
❑
El
✓❑
Concentration
Mass
(79-00-5)
2.27
Trichloroethylene
11
❑
Z
Concentration
Mass
(79-01-6)
2.28
Vinyl chloride
❑
❑
❑✓
Concentration
Mass
(75-01-4)
Section 3.Organic Toxic Pollutants (GC/MS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
✓
Concentration
Mass
(95-57-8)
3.2
2,4-dichlorophenol
El
1:1
El
Concentration
Mass
(120-83-2)
3.3
2,4-dimethylphenol
El
El
©
Concentration
Mass
(105-67-9)
3.4
4,6-dinitro-o-cresol
❑
El
El
Concentration
Mass
(534-52-1)
3.5
2,4-dinitrophenol
❑
❑
✓❑
Concentration
Mass
(51-28-5)
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCG590008 NCG590008 I Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available )
Testing
Required
q
• 1 •'
Presence or Absence
check one
• •• 1
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-
Tenn
Average
Value
Number
of
Analyses
3.6
2-nitrophenol
(88-75-5)
El
❑
❑
Concentration
Mass
3.7
4-nitrophenol
(100-02-7)
❑
El
El
Concentration
Mass
3.8
p-chloro-m-cresol
(59-50-7)
❑
❑
❑
Concentration
Mass
3.9
Pentachlorophenol
(87-86-5)
❑
❑
El
Concentration
Mass
3.10
Phenol
(108-95-2)
El
❑
Concentration
Mass
3.11
2,4,6-trichlorophenol
(88 05 2)
❑
El
El
Concentration
Mass
Section 4.Organic Toxic Pollutants (GC/MS
Fraction
—Base /Neutral
Compounds)
4.1
Acenaphthene
(83-32-9)
13
El
Concentration
Mass
4.2
Acenaphthylene
(208-96-8)
Concentration
Mass
4.3
Anthracene
(120-12-7)
Concentration
Mass
4.4
Benzidine
(92-87-5)
❑
El
©
Concentration
Mass
4.5
Benzo (a) anthracene
(56-55-3)
El
El
❑�
Concentration
Mass
4.6
Benzo (a) pyrene
(50-32-8)
❑
El
❑�
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 15

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590008 NCG590008 I Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
UQ 1 • •L, III
suletaGIRIL11, will
Effluent
Intake
(optional)
Testing
Required
Presence or Absence
check one
Units
(specify)
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-benzofluoranthene
(205-99-2)
❑
21
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
El
El
El
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
❑
❑
❑
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
El
1:1
©
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)
❑
❑
ID
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
❑
❑
✓❑
Concentration
Mass
4.16
2-chloronaphthalene
(91-58-7)
❑
El
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)
11
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

LNA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCGS90008 NCGS90008 Fox Run Subdivision -Well #3 WTP 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)
Average
Number
Term
Number
Present
Absent
Daily
Monthly
Dail
of
of
Discharge
Discharge
Discharge
g
Analyses
Average
Analyses
(required)
(if available)
if available
Value
4.20
1,2-dichlorobenzene
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
El
El
❑
Concentration
Mass
(541-73-1)
4.22
1,4-dichlorobenzene
✓
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
❑
El
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
1:1Mass
Concentration
(84-74-2)
4.27
2,4-dinitrotoluene
❑
❑
El
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
❑
❑
E
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
❑
0
Concentration
Mass
(117-84-0)
4.30
1,2-Dipheny1hydrazine
El
21
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 Nu
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
Testing
Required
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Presence or Absence
check one
Units
(specify)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if )
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Number
of
Analyses
4.33
Hexachlorobenzene
(118-74-1)
❑
❑
❑
Concentration
Mass
4.34
Hexachlorobutadiene
(87-68-3)
El
❑
❑✓
Concentration
Mass
4.35
Hexachlorocyclopentadiene
(77-47-4)
❑
❑
❑✓
Concentration
Mass
4.36
Hexachloroethane
(67-72-1)
13
❑
❑
Concentration
Mass
4.37
Indeno (1,2,3-cd) pyrene
(193-39-5)
❑
❑
0
Concentration
Mass
4.38
Isophorone
(78-59-1)
❑
❑
❑✓
Concentration
Mass
4.39
Naphthalene
(91-20-3)
El
❑
0
Concentration
Mass
4.40
Nitrobenzene
(98-95-3)
❑
❑
❑✓
Concentration
Mass
4.41
N-nitrosodimethylamine
(62 75 9)
El
❑
❑
Concentration
Mass
4.42
N-nitrosodi-n-propylamine
(621-64-7)
Concentration
Mass
4.43
N-nitrosodiphenylamine
(86-30-6)
El
El❑
Concentration
Mass
4.44
Phenanthrene
(85-01-8)
❑
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
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 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
Daily
of
Average
of
(reghrerd)
(if available)
e)
Discharge
Analyses
Value
Analyses
if available
4.46 1,2,4-trichlorobenzene
❑
El
ElConcentration
Mass
(120-82-1)
Section 5.Organic Toxic Pollutants (GC/MS
Fraction
—Pesticides)
5.1
Aldrin
El
El
Concentration
Mass
(309-00-2)
5.2
a-BHC
❑
❑
❑
Concentration
Mass
(319-84-6)
5.3
R-BHC
❑
❑
El
Concentration
Concentration
(319-85-7)
5.4
y-BHC
El
El
El
Concentration
Concentration
(58 89 9)
5.5
b-BHC
❑
❑
El
Concentration
Concentration
(319-86-8)
5.6
Chlordane
❑
❑
❑
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
❑
❑
0
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
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
NCG590008 NCG590 I Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
15.12P-endosulfan
• 1
Pollutant/Parameter
(and
(and CAS Number, if available)
•
Testing
Required
§1161011 •'
Presence or Absence
(check one)
• '• 1
Units
(specify)
(p ty)
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
(115-29-7)
El
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
El
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
R
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)
H
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
El
El
0
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
P
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
1 (12674-11-2)
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590008 NCG590008 I Fox Run Subdivision -Well #3 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• •
•
• 1 • '
• ' • 1RIM
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
available)
Discharge
Analyses
Analyses
if available
Toxaphene
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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 OMB No. 2040-0004
Presence or Absence Intake
(check one) Effluent
(Optional)
7s, 7
Pollutant Maximum Long -Term
Believed Believed (specfyMaximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
Discharge Discharge Analyses Analyses
(required) 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
❑
0
Concentration
Mass
(24959-67-9)
2
Chlorine, total
a
❑
Concentration
ug/r
12
10.02
113
Mass
residual
3.
Color
ElMass
Concentration
4.
Fecal coliform
❑
0
Concentration
Mass
5
Fluoride
❑
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
❑
F-1
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)
El
0
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

JEPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 OMB No. 2040-0004
Presence or Absence
check one) Effluent Intake
(Optional)
Units
Pollutant -Term
Believed Believed (specify) Maximum Daily Maximum Long Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Discharge Discharge Analyses Average Analyses
(required) Value
(if available) (if available)
12
Sulfite (as S03)
(14265-45-3)
Concentration
Mass
13.
Surfactants
❑
E
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
El
❑
Concentration
Mass
15.
Barium, total
(7440-39-3)
✓
Concentration
Mass
16.
Boron, total
(7440-42-8)
❑
❑
Concentration
Mass
17.
Cobalt, total
(7440-48-4)
❑
❑
Concentration
Mass
18
Iron, total
(7439-89-6)
✓
Concentration
Mass
19
Magnesium, total
(7439-95-4)
El
21
Concentration
Mass
20.
Molybdenum,
total
(7439-98-7)
El
Concentration
Mass
21.
Manganese, total
(7439-96-5)
Concentration
mg/L
0.1
0.04
16
Mass
22
Tin, total
(7440-31-5)
[D
Concentration
Mass
23]
Titanium, total
(7440-32-6)
El
R
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
NCG590008
NCG590008 Fox Run Subdivision -Well #3 WTP
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
❑
�
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 3510-2C (Revised 3-19) Page 25

EPA Identification Number NPDES
NCG590008 NCG590008
1 'I•
Pollutant
Permit Number
Fox Run Subdivision
1 • 1
Presence or Absence
(check one)
Facility Name Outfall Number
-Well #3 WTP 001
�
Reason Pollutant Believed Present in Discharge
Form Approved 03/05/19
OMB No. 2040-0004
Available Quantitative Data
(specify units)
--- -
j
Believed
Present
Believed
Absent
1.
Asbestos
❑
2.
Acetaldehyde
❑
Q
3.
Allyl alcohol
❑
0
4.
Allyl chloride
❑
0
5.
Amyl acetate
❑
6.
Aniline
❑
0
7.
Benzonitrile
❑
F-11
8.
Benzyl chloride
❑
H
9.
Butyl acetate
❑
10.
Butylamine
❑
❑�
11.
Captan
❑
12.
Carbaryl
❑
0
13.
Carbofuran
❑
El
14.
Carbon disulfide
❑
15.
Chlorpyrifos
❑
16.
Coumaphos
❑
0
17.
Cresol
❑
❑r
18.
Crotonaldehyde
❑
0
19.
Cyclohexane
❑
21
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 OMB No. 2040-0004
I 'I• 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)
❑
R
21.
Diazinon
❑
0
22.
Dicamba
❑
❑�
23.
Dichlobenil
❑
24.
Dichlone
❑
E]
25.
2,2-dichloropropionic acid
❑
❑�
26.
Dichlorvos
❑
0
27.
Diethyl amine
❑
❑�
28.
Dimethyl amine
❑
❑�
29.
Dintrobenzene
❑
0
30.
Diquat
❑
0
31.
Disulfoton
❑
32.
Diuron
❑
❑�
33.
Epichlorohydrin
❑
34.
Ethion
❑
❑�
35.
Ethylene diamine
❑
36.
Ethylene dibromide
❑
❑r
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
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 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
❑
0
40.
Isoprene
❑
❑r
41.
Isopropanolamine
❑
0
42.
Kelthane
❑
❑r
43.
Kepone
❑
❑r
44.
Malathion
❑
❑�
45.
Mercaptodimethur
❑
❑r
46.
Methoxychlor
❑
0
47.
Methyl mercaptan
❑
El
48.
Methyl methacrylate
❑
21
49.
Methyl parathion
❑
El
50.
Mevinphos
❑
❑�
51.
Mexacarbate
❑
0
52.
Monoethyl amine
❑
❑r
53.
Monomethyl amine
❑
5-11
54.
Naled
❑
❑�
55.
Naphthenic acid
❑
0
56.
Nitrotoluene
❑
El
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
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 OMB No.2040-0004
1 ��• 1 I 1111figAIMPI
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
159.
Phenolsulfonate
El
❑rPhosgene
El0
Propargite
El
❑�1.
Propylene oxide
❑
62.
Pyrethrins
❑
M
63.
Quinoline
❑
❑�
64.
Resorcinol
❑
0
65.
Strontium
❑
El
66.
Strychnine
❑
F-1
67.
Styrene
❑
0
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetrachlorodiphenyl ethane)
❑
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
propanoic acid]
❑
❑
71.
Trichlorofon
❑
❑�
72.
Triethanolamine
❑
73.
Triethylamine
❑
Z
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
NCG590008
NCG590008 Fox Run Subdivision -Well #3 WTP 001
OMB No. 2040-0004
1•
o
Presence or Absence
r'
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
❑
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

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590008 NCG590008 Fox Run Subdivision -Well #3 WTP 001 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 El ❑ 0
EPA Form 3510-2C (Revised 3-19) Page 33

__71 6
Outfall 001
R
'j •�
Aqua North Carolina, Inc. Facility
Fox Run WTP Location
Utitude: 35' 11' 19" N State Grid: Gastonia South not to scale
Loneitude: Sl° 09' 25" W Permitted Clow: N/A
Recei17nCStrealn: UTto Crowdeis Creek Stream Class: C NPDESPermitNo.NC0072061
UralnaCe[3asin: Catawba River Basin Sub -Basin: 03-09-37 North Gaston County

Fox Run Well #3 WTP
Gaston County; Permit No. NCG590008
L-Htor 4d-Af-1/tAl �SIPi
I
3PD

Certificate Of Completion
Envelope Id: B8CA3964B22C4E7391028862DC92BOC2
Subject: Here is your signed document: Fox Run_NCG590008_WTP
renewal permit.pdf
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Holder: Lauren Raup-Plummer
2/2/2024 2:19.22 PM
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Lauren Raup-Plummer
Oocu5lgned by:
[e-mail]
'Awl't& "—plt,"Kiv
Engineering Manager
9C 8BE09BOA7B49B
Aqua North Carolina, Inc.
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