NCG590029_Renewal (Application)_20240216

AQUA_
1
JEssential Utilities Company LaserrlChe
February 1, 2024
Division of Water Resources
Water Quality Permitting Section —NPDES RECEIVED
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FEB 16 2024
Re: Application for Permit Renewal
Aqua North Carolina, Inc.
Snow Hill Subdivision Well #2 WTP
NPDES No. NCG590029
Surry County
To Whom It May Concern:
NCDEQ/DWR/NPDES
Enclosed are three (3) copies of the completed application Form 2C and Form 1. This
submittal includes the necessary attachments for your office to renew the subject permit.
Should you need any additional information or assistance, please feel free to contact me via
phone [phone]) or by email at [e-mail].
Sincerely,
DocuSigned by:
EP"K�V
9CBBE09BOA7649B_.
Lauren Raup-Plummer
Engineering Manager
Aqua North Carolina, Inc.
Enc: NPDES Application, Form 2C
NPDES Application, Form 1
Snow Hill Subdivision Well #2 WTP NPDES Permit
Cc: Joseph Pearce
Shannon Becker
202 MacKenan Court, Cary, NC, 27511 • 919.467.8712 • AquaAmerica.com

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
NCG590029
NCG590029
Snow Hill Subdivision- Well #2-
IAITD
OMB No. 2040-0004
U.S. Environmental Protection Agency
Form
t
\-/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..
12
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?
w
❑ Yes -+ Complete Form 1 0 No
0 Yes 4 Complete Form No
a
and Form 2B.
1 and Form 2C.
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
commenced to discharge?
discharges only nonprocess wastewater?
❑ Yes 4 Complete Form 1 No
❑ Yes 4 Complete Form No
and Form 2D.
1 and Form 2E.
1.2.5
Is the facility a new or existing facility whose
w
discharge is composed entirely of stormwater
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
Yes 4 Complete Form 1 No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
SECTION
fay- • •
Facility Name
2.1
Snow Hill Subdivision- Well #2 WTP
`0
2.2
EPA Identification Number
U
0
NCG590029
2.3
Facility Contact
Name (first and last)
Title
Phone number
Lauren Raup Plummer
Engineering Manager
[phone]
Q
Email address
c
[e-mail]
2.4
Facility Mailing Address
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
NCG590029
NCG590029
Snow Hill Subdivision- Well #2-
OMB No. 2040-0004
y
2.5
Facility Location
S
Street, route number, or other specific identifier
Q 0
Snow Hill Drive
CM
c
County name
County code (if known)
Surry
E v
City or town
State ZIP code
z A
Dobson
North Carolina 27017
SECTION•D
1
3.1
SIC Code(s)
Description (optional)
4941
Establishments primarily engaged in distributing water for sale for domestic,
V/
d
O
V
N
V
Z
3.2
NAICS Code(s)
Description (optional)
R
310
Water Distribution (except irrigation)
ca
SECTIONOPERATOR
INFORMATION
4.1
Name of Operator
Aqua North Carolina
`0
4.2
Is the name you listed in Item 4.1 also the owner?
w
❑� Yes ❑ No
0
w
z
4.3
Operator Status
A
❑ Public —federal ❑ Public —state ❑ Other public (specify)
o
R Private ❑ Other (specify)
4.4
Phone Number of Operator
(919)6S3-6977
4.5
Operator Address
°
Street or P.O. Box
202 MacKenan Drive
o �
w
City or town
State
ZIP code
0 0
Cary
North Carolina
27511
M
CL
Email address of operator
O
[e-mail]
SECTIONI
5.1
Is the facility located on Indian Land?
e
C J
❑ 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
NCG590029
NCG590029 Snow Hill Subdivision- Well #2- OMB No.2040-0004
SECTION'•
1
all that apply and print or type the corresponding permit number for each)
6.1
Existing Environmental Permits (check
d
❑✓ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
c w
water)
fluids)
0
NCG590029
w a
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
rn
c
w
ElOcean dumping (MPRSA) ElDredge or fill (CWA Section 404) ElOther (specify)
SECTIONI
Have you attached a topographic map containing all required information to this application? (See instructions for
7.1
CL R
specific requirements.)
2
❑'' Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 2B.)
SECTIONOF
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
N
N
C
7
m
O
7
A
Z
SECTION••
1
Does your facility use cooling water?
9.1
d
❑ Yes ❑r No 4 SKIP to Item 10.1.
R w
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
9M .r
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
. N
NPDES permitting authority to determine what specific information needs to be submitted and when.)
O Y
O R
V C
SECTION
1 VARIANCE
REQUESTSI 1
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
10.1
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
H
when.)
d
❑ 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
NCG590029 NCG590029
Snow Hill Subdivision- Well #2- 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
Section 1: Activities Requiring an NPDES Permit
0 w/ attachments
❑✓ Section 2: Name, Mailing Address, and Location
❑ wl attachments
Fv�, Section 3: SIC Codes
❑ wl attachments
[D Section 4: Operator Information
❑ w/ attachments
❑� Section 5: Indian Land
❑ w/ attachments
c
❑� Section 6: Existing Environmental Permits
❑ wl attachments
d
d
Section 7: Map
wl topographic
❑ El w/ additional attachments
map
Cn
c
❑� Section 8: Nature of Business
❑ w/ attachments
o
w
2 Section 9: Cooling Water Intake Structures
❑ w/ attachments
d
❑r Section 10: Variance Requests
❑ w/ attachments
o
v,
❑r Section 11: Checklist and Certification Statement
❑ w/ attachments
�L
d
11.2
Certification Statement
s
U
1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision
in accordance with a system designed to assure that qualified personnel properly gather and evaluate the
information submitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Lauren Raup-Plummer
Engineering Manager
Signature
Date signed
by:
EUocuSigned
1
"—Pam,,-4V
02/01/2024
9C86E09BOA7B4913
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
NCG590029
Form
NPDES 10EPA
NPDES Permit Number I Facility Name Form Approved 03/05/19
NCG590029 Snow Hill Subdivision -Well #2 OMB No.2040-0004
\A/TD
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'
° Numbelr OutfalReceiving Water Name
.R
V
001 unnamed tributary to Cody
O
outfalls in the table below.
Latitude
36' 21' 06" N
o
Longitude
80° 42' 07" W
Q, 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
c
m
E
d
F-
h
3
0
LL Treatment Units
o, Description Code from
(include size, flow rate through each treatment unit, Table 2C-1
a' retention time, etc.
Flow
0.0025 mgd
mgd
mgd
mgd
Final Disposal of Solid or
Liquid Wastes Other Than
EPA Form 3510-2C (Revised 3-19) Page 1

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590029 NCGS90029 Snow Hill Subdivision -Well #2 OMB No. 2040-0004
3.1 **Outfall Number"
cont. Operations,
Operation Average Flow
mgd
mgd
mgd
mgd
Treatment Units
Description 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
.c
0
U
c
m
E
io
m
H
**Outfall Number**
R
Operations
_0 Operation Average Flow
LL
rn mgd
R
d
> mgd
mgd
-- � mgd
Description 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 0 ❑ Yes S 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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 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?
❑r 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.
Frequency
Flow
Rate
Outfall
Operation
Duration
Average
Average
Long -Term
Maximum
Number
(list)
Da sMeek
MonthsNear
Average
Dail
WTP Backwash Dischar
7 days/week
12 months/year
0.0025 mgd
0.0025 mgd
170 days
3c
001
days/week
months/year
mgd
mgd
days
U_
mdays/week
months/year
mgd
mgd
days
E
days/week
months/year
mgd
mgd
days
m
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 0 No 4 SKIP to Section 6.
y
5.2
Provide the following information on applicable ELGs.
w
ELG Category
ELG Subcategory
Regulatory Citation
a�
a
m
Q
c
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
R
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
Number
Measure
m
O
u
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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 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
;z
number
E
c
ra
N
N
.6
CL
C
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?
❑✓ 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
2
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
c
listed in Exhibit 2C-3? (See end of instructions for exhibit.)
❑ Yes ❑ 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 ❑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.
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
NCG590O29
NCG590029
Snow Hill Subdivision -Well #2
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?
0 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 ❑✓ 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, ❑ 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
0
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?
N
fA
❑ Yes El 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
cc
for all outfalls?
❑✓ Yes ❑ No
R
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"?
c
❑ 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 ❑✓ 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. 0 No + SKIP to Section 8.
7.17
Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes ❑✓ 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?
w
t5
❑ Yes 0 No 4 SKIP to Section 9.
3 h
8.2
List the pollutants below.
C 2
r0
1. 4. 7.
0
2. 5. 8.
t/1
D
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
NCG59OO29 NCG59O029 Snow Hill Subdivision -Well #2 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.
y
fA
9.2
Identify the tests and their
ur oses below.
Test(s)
Purpose of Test(s)
Submitted to NPDES
Date Submitted
x
Permitting Authority?
0
R
❑ Yes ❑ No
0
0
Co
❑ Yes ❑ No
❑ Yes ❑ No
SECTIONt
CONTRACT
ANALYSES (40
Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
10.1
❑r 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
0,
Laboratory address
5 Pinewood Plaza Dr
Granite Falls, NC 28630
Q
w
a
c
o
U
Phone number
[phone]
Pollutant(s) analyzed
Total Suspended Solids
SECTIONDD
• •R•
i
information?
11.1
Has the NPDES permitting authority requested additional
0
0
❑ Yes
0 No 4 SKIP to Section 12.
E11.2
List the information requested and attach it to this application.
E
0
1. 4.
c
0
0
2. 5.
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
NCGS90029
NCG590029 Snow Hill Subdivision -Well #2 OMB No.2040-0004
MGM
SECTION
12. CHECKLIST
AND CERTIFICATION STATEMENT
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 com fete all sections or provide attachments.
Column 1
Column 2
❑✓ Section 1: Outfall Location
❑ wl attachments
❑✓ Section 2: Line Drawing
w/ line drawing ❑ w/ additional attachments
❑ Section 3: Average Flows and
wl list of each user of
0 w/ attachments ❑ privately owned treatment
Treatment
works
❑ Section 4: Intermittent Flows
❑ w/ attachments
❑ Section 5: Production
❑ wl attachments
w/ optional additional
❑ Section 6: Improvements
❑ wl attachments ❑ sheets describing any
additional pollution control
tans
❑ wl request for a waiver and ❑ wl explanation for identical
supporting information outfalls
w/ small business exemption
El ❑ w/ other attachments
E
request
❑ Section 7: Effluent and Intake
❑ wl Table A ❑✓ w/ Table B
Characteristics
0
wl Table C ❑✓ wl Table D
r
❑ w/ analytical results as an
El w/ Table E
attachment
Section 8: Used or Manufactured
❑
❑ wl attachments
Toxics
Section 9: Biological Toxicity
❑
El w/ attachments
Tests
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. 1 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
ADocuSfgned
[�/
02/01/2024
9CBBE09BOA7B498_.
EPA Form 3510-2C (Revised 3-19) Page 7

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 I Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
TABLE
A. CONVENTIONAL AND NON•
• •• 1
Effluent
Intake
Pollutant
Waiver
Requested Units
o tional
Maximum
Maximum
Long -Term
(if applicable) (specify)
Daily
Monthly
Average Daily
Number of
Long -Term
Number of
Discharge
Discharge
Discharge
Analyses
Average Value
Analyses
(required)
if available
if available
❑
Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this
table for the noted outfall.
1'
Biochemical oxygen demand
❑
Concentration
Mass
(BOD5)
2'
Chemical oxygen demand
❑
Concentration
Mass
(COD)
Concentration
3.
Total organic carbon (TOC)
❑✓
Mass
Concentration
4.
Total suspended solids (TSS)
❑✓
Mass
Concentration
5.
Ammonia (as N)
❑✓
Mass
6.
Flow
❑
Rate
gpd
2,500
2,500
170
Temperature (winter)
°C
°C
7.
Temperature (summer)
°C
°C
pH (minimum)
❑
Standard units
S.U.
6.8
7.3
138
8.
pH (maximum)
❑
Standard units
s.u.
7.9
7.3
138
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

ENA laentiticatlon Number
NCG590029
Name
NCGS90029 I Snow Hill Subdivision -Well #2 WTP
Outfall Number
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
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Average
(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
Concentration
Mass
(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
❑
O
Concentration
Mass
(7440-43-9)
1.5
Chromium, total
Concentration
Mass
(7440-47-3)
1.6
Copper, total
❑
❑
Concentration
Mass
(7440-50-8)
1.7
Lead, total
El
El
Z
Concentration
Mass
(7439-92-1)
1.8
Mercury, total
❑
❑❑
Concentration
Mass
(7439-97-6)
1'9
Nickel, total
El
El
El
Concentration
Mass
(7440-02-0)
1.10
Selenium, total
El
El
21
Concentration
Mass
(7782-49-2)
1.11
Silver, total
El
El
21
Concentration
Mass
(7440-22-4)
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Identification Number NNUEJ Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• ti
•
• 1 ••
• •• 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
h
le
Daily
of
Average
of
(if available)
Discharge
Analyses
Value
Analyses
if available
1.12
Thallium, total
Concentration
Mass
(7440-28-0)
1.13
Zinc total
Concentration
Mass
(7440-66-6)
1.14
Cyanide, total
El
1:1
R1
Concentration
Mass
(57-12-5)
1.15
Phenols, total
El
El
R]
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
✓j
Concentration
Mass
(71-43-2)
2.4
Bromoform
El
1:1
Z
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
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

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590 I Snow Hill Subdivision -Well #2 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�
(i
Daily
of
Average
of
(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
❑
El
❑
Concentration
Mass
(75-27-4)
212
1,1-dichloroethane
❑
❑
❑
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
❑
❑
21
Concentration
Mass
(542-75-6)
2.17
Ethylbenzene
❑
❑
❑✓
Concentration
Mass
(100-41-4)
2.18
Methyl bromide
❑
❑
Concentration
Mass
(74-83-9)
2.19
Methyl chloride
❑
❑
✓❑
Concentration
Mass
(74-87-3)
2.20
Methylene chloride
Concentration
Mass
(75-09-2)
221
1,1,2,2-tetrachloroethane
❑
21
Concentration
Mass
(79-34-5)
EPA Form 3510-2C (Revised 3-19) Page 13

EPA Identification Number Nruta rermit Number racility Name Uuttall Number
NCG590029 NCG590029 I Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•1111
3k'11111011c"kllr•
'• 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
12.22
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
(required)
(if available)
if available
Value
Tetrachloroethylene
El
❑
❑
Concentration
Mass
(127-18-4)
2.23
Toluene
❑
El
El
Concentration
Mass
(108-88-3)
224
1,2-trans-dichloroethylene
El
❑
❑�
Concentration
Mass
(156-60-5)
2.25
1,1,1-trichloroethane
❑
❑
❑
Concentration
Mass
(71-55-6)
2.26
1 1,2-trichloroethane
❑
❑
0
Concentration
Mass
(79-00-5)
2.27
Trichloroethylene
❑
❑
❑�
Concentration
Mass
(79-01-6)
2.28
Vinyl chloride
❑
El
a
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
El
El
Concentration
Mass
(120-83-2)
3.3
2,4-dimethylphenol
©
Concentration
Mass
(105-67-9)
3.4
4,6-dinitro-o-cresol
El
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 Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 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
3.6
2-nitrophenol
❑
❑
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
El
❑
❑
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
✓
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
❑
❑
a
Concentration
Mass
(87-86-5)
3.10
Phenol
Concentration
Mass
(108-95-2)
3.11
2,4,6-trichlorophenol
❑
❑
0
Concentration
Mass
(88-05-2)
Section 4.Organic Toxic Pollutants (GCIMS
Fraction
—Base /Neutral
Compounds)
4.1
Acenaphthene
❑
❑
O
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
Concentration
Mass
(208-96-8)
4.3
Anthracene
Concentration
Mass
(120-12-7)
4.4
Benzidine
©
Concentration
Mass
(92-87-5)
4.5
Benzo (a) anthracene
❑
❑
0
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
❑
El
0
Concentration
(50-32-8) 1
1Mass
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 I Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
TABLE
B. TOXIC METALS, CYANIDE,
TOTAL PHENOLS,
AND ORGANIC TOXIC
Presence or Absence
POLLUTANTS (40 CFR
122.21(g)(7)(v))'
Intake
check one
Effluent
(optional)
Poll utant/Parameter
(and CAS Number, if available)
Testing
Required
Believed
Believed
Units
(specify)
Maximum
Maximum
Long -Term
Average
Number
Long -
Number
Present
Absent
Daily
Monthly
Daily
of
Term
of
D(eq
(i
Discharge
Analyses
Average
Analyses
i e)
(if available)
if available
Value
4.7
3,4-benzofluoranthene
✓
Concentration
Mass
(205-99-2)
4.8
Benzo (ghi) perylene
El
El
Concentration
Mass
(191-24-2)
4.9
Benzo (k) fluoranthene
✓
Concentration
Mass
(207-08-9)
4.10
Bis (2-chloroethoxy) methane
1:1
El
©
Concentration
Mass
(111-91-1)
4.11
Bis (2-chloroethyl) ether
El
El
ID
Concentration
Mass
(111-44-4)
4.12
Bis (2-chloroisopropyl) ether
✓
Concentration
Mass
(102-80-1)
4.13
Bis (2-ethylhexyl) phthalate
El
El
21
Concentration
Mass
(117-81-7)
4.14
4-bromophenyl phenyl ether
El
El
0
Concentration
Mass
(101-55-3)
4.15
Butyl benzyl phthalate
El
El
✓
Concentration
Mass
(85-68-7)
4.16
2-chloronaphthalene
El
El
r
Concentration
Mass
(91-58-7)
4.17
4-chlorophenyl phenyl ether
1:1
El
El
Concentration
Mass
(7005-72-3)
4.18
Chrysene
✓
Concentration
Mass
(218-01-9)
4.19
Dibenzo (a,h) anthracene
El
1:1
El
Concentration
1 Mass
(53-70-3)
1
1
1
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 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)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
of
Average
of
(required)
(if available)
DisDaily
char a
Analyses
Value
Analyses
if availabllee
4.20
1,2-dichlorobenzene
❑
❑
✓
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
El
❑
✓
Concentration
Mass
(541-73-1)
4.22
1,4-dichlorobenzene
El
❑
❑
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
El
❑
❑
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
El❑
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
❑
❑
❑�
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
El
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
❑
❑
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
❑
❑
�
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
❑
❑�
Concentration
Mass
(117-84-0)
4.30
1,2-Diphenylhydrazine
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
❑
❑
21
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 ••
• •• I lilt UA z 116SE111101
Intake
Presence or Absence
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Lon
(and CAS Number, if available)
(and
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Absentof
Discharge
Discharge
Discharge
Analyses
Average
Analyses
(required)
(if available)Value
if available
4.133
Hexachlorobenzene
❑
❑
Concentration
Mass
(118-74-1)
4.34
Hexachlorobutadiene
❑
❑
Concentration
Mass
(87-68-3)
4.35
Hexachlorocyclopentadiene
❑
❑
❑
Concentration
Mass
(77-47-4)
4.36
Hexachloroethane
❑
El
ID
Concentration
Mass
(67-72-1)
4.37
Indeno (1,2,3-cd) pyrene
❑
❑
❑✓
Concentration
Mass
(193-39-5)
4.38
Isophorone
❑
❑
❑
Concentration
Mass
(78-59-1)
4.39
Naphthalene
❑
❑
❑
Concentration
Mass
(91-20-3)
4.40
Nitrobenzene
❑
✓❑
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
❑
❑
0
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
El
❑
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
❑
❑
21
Concentration
Mass
(86-30-6)
4.44
Phenanthrene
✓
Concentration
Mass
(85-01-8)
4.45
Pyrene
❑
❑
❑
Concentration
Mass
(129-00-0)
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 •' 129•
•• 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
if available
4.46 1,2,4-trichlorobenzene
0
Concentration
Mass
(120-82-1)
Section 5.Organic Toxic Pollutants (GC/MS
Fraction
—Pesticides)
5.1
AldrinEl
0
Concentration
Mass
(309-00-2)
5.2
a-BHC
Concentration
Mass
(319-84-6)
5.3
R-BHC
El
El
Z
Concentration
Mass
(319-85-7)
5.4
y-BHC
❑
El
Concentration
Mass
(58-89-9)
5.5
b-BHC
El
Concentration
Mass
(319-86-8)
5.6
Chlordane
❑
❑
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
El
❑
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
❑
z
Concentration
Mass
(72-55-9)
5.9
4 4'-DDD
❑
❑
0
Concentration
Mass
(72-54-8)
5.10
Dieldrin
Concentration
Mass
(60-57-1)
5.11
a-endosulfan
❑
❑
21
Concentration
(115-29-7)
1
1Mass
EPA Form 3510-2C (Revised 3-19) Page 19

EPA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 •'
• '• 1
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
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
5.12
R-endosulfan
(115-29-7)
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
ElMass
El
Z
Concentration
5.14
Endrin
(72-20-8)
❑
❑
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
El
❑
❑
Concentration
Mass
5.16
Heptachlor
(76-44-8)
❑
❑
❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
El
El
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
❑
0
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
El
El
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
El
El
El
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
El
El
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑
❑El
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
El
❑
El
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
❑
❑
❑✓
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

oenti ication Number NPDES Permit Number Facility Name
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP
Outfall Number
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
(p fY)
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
aily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
�Toxaphene
5.25
❑
El
0
Concentration
Mass
(8001-35-2)
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 21

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG59OO29 NCG590O29 Snow Hill Subdivision -Well #2 WTP 001 OMB No. 2040-0004
Presence or Absence
Intake
check one Effluent
(Optional)
7Units
Pollutant Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
(required) Discharge Discharge Analyses Analyses
Value
if available if available
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
© Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
1.
Bromide
❑
❑
Concentration
Mass
(24959-67-9)
2.
Chlorine, total
❑
❑
Concentration
Mass
residual
3.
Color
❑
El
Concentration
Mass
4.
Fecal coliform
El
El
Concentration
Mass
5
Fluoride
❑
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
❑
ElConcentrationMass
7'
Nitrogen, total
❑
❑
Concentration
Mass
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)
❑
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

JEPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05119
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No.2040-0004
ME
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
(required) Discharge Discharge Analyses Value Analyses
if available if available
12
Sulfite (as S03)
(14265-45-3)
❑
❑
Concentration
Mass
13.
Surfactants
❑
El
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
❑
❑
Concentration
Mass
15.
Barium, total
(7440-39-3)
❑
❑
Concentration
Mass
16.
Boron, total
(744042-8)
❑
❑
Concentration
Mass
17.
Cobalt, total
(74404844)
❑
❑
Concentration
Mass
18
Iron, total
(7439-89-6)
❑
❑
Concentration
Mass
19
Magnesium, total
(7439-95-4)
❑
❑
Concentration
Mass
20.
Molybdenum,
total
7439-98-7
❑
❑
Concentration
Mass
21
Manganese, total
(7439-96-5)
❑
❑
Concentration
Mass
22
Tin, total
(7440-31-5)
❑
❑
Concentration
_
Mass
23.
Titanium, total
(7440-32-6)
El
El
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
NCG59OO29
NCG590029 Snow
Hill Subdivision -Well #2 WTP
001
OMB No. 2040-0004
111111111
Presence or Absence
Intake
check one
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
-
Maximum Long -Term
_ -
Long -Term
Present
Absent
Discharge
MonthlyAverage DailNumber of
gy
Number of
Average
(required)
Discharge Discharge Analyses
Value Analyses
if available if available
24.
Radioactivity
Alpha, total
❑
Concentration
Mass
Concentration
Beta, total
❑
❑
Mass
Radium, total
❑
❑
Concentration
Mass
Concentration
Radium 226, total
❑
❑
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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No. 2040-0004
1 'I• 1 1 1
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
1.
Asbestos
❑
0
2.
Acetaldehyde
❑
Z
3.
Allyl alcohol
❑
0
4.
Allyl chloride
❑
El
5.
Amyl acetate
❑
Z
6.
Aniline
❑
❑�
7.
Benzonitrile
❑
❑�
8.
Benzyl chloride
❑
9.
Butyl acetate
❑
E]
10.
Butylamine
❑
❑r
11.
Captan
❑
z
12.
Carbaryl
❑
13.
Carbofuran
❑
❑�
14.
Carbon disulfide
❑
15.
Chlorpyrifos
❑
16.
Coumaphos
❑
❑r
17.
Cresol
❑
0
18.
Crotonaldehyde
❑
0
19.
Cyclohexane
❑
2
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No. 2040-0004
1 '1• 0,1
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)
❑
Z
21.
Diazinon
❑
FD
22.
Dicamba
❑
23.
Dichlobenil
❑
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
❑�
26.
Dichlorvos
❑
F11
27.
Diethyl amine
❑
❑�
28.
Dimethyl amine
❑
❑r
29.
Dintrobenzene
❑
❑�
30.
Diquat
❑
R
31.
Disulfoton
❑
❑r
32.
Diuron
❑
M
33.
Epichlorohydrin
❑
❑r
34.
Ethion
❑
0
35.
Ethylene diamine
❑
❑r
36.
Ethylene dibromide
❑
❑�
37.
Formaldehyde
❑
ID
38.
Furfural
❑
❑r
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No.2040-0004
1 ' 1• 1 1 I
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge
(specify units)
Present Absent
39.
Guthion
❑
M
40.
Isoprene
❑
❑r
41.
Isopropanolamine
❑
❑�
42.
Kelthane
❑
❑�
43.
Kepone
❑
R
44.
Marathion
❑
❑r
45.
Mercaptodimethur
❑
❑r
46.
Methoxychlor
❑
❑�
47.
Methyl mercaptan
❑
❑�
48.
Methyl methacrylate
❑
0
49.
Methyl parathion
❑
Z
50.
Mevinphos
❑
El
51.
Mexacarbate
❑
0
52.
Monoethyl amine
❑
R
53.
Monomethyl amine
❑
54.
Naled
❑
R
55.
Naphthenic acid
❑
0
56.
Nitrotoluene
❑
0
57.
Parathion
❑
0
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No. 2040-0004
Presence or Absence
rolPollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
58.
Phenolsulfonate
❑
59.
Phosgene
❑
60.
Propargite
❑
R
61.
Propylene oxide
❑
62.
Pyrethrins
❑
ED
63.
Quinoline
❑
❑r
64.
Resorcinol
❑
❑�
65.
Strontium
❑
66.
Strychnine
❑
0
67.
Styrene
❑
❑✓
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetrachlorodiphenyl ethane)
❑
❑�
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
❑
O
71.
Trichlorofon
❑
2
72.
Triethanolamine
❑
R
73.
Triethylamine
❑
0
74.
Trimethylamine
❑
❑r
75.
Uranium
❑
❑�
76.
Vanadium
❑
ID
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
NCG590029
NCG590029 Snow Hill Subdivision -Well #2 WTP 001
OMB No. 2040-0004
Presence or Absence
Pollutant
(check one)
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
77.
Vinyl acetate
❑
78.
Xylene
❑ 0
79.
Xylenol
❑
M
80.
Zirconium
❑
Z
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 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 ❑ ❑ M
EPA Form 3510-2C (Revised 3-19) Page 33

Snow Hill S/D Well #2 WTP
Surry County; Permit No. NCG590029

AOUA%A
An *Essential Utilities Company
February 1, 2024
Division of Water Resources
Water Quality Permitting Section — NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: Application for Permit Renewal
Aqua North Carolina, Inc.
Snow Hill Subdivision Well #2 WTP
NPDES No. NCG590029
Surry County
To Whom It May Concern:
Enclosed are three (3) copies of the completed application Form 2C and Form 1. This
submittal includes the necessary attachments for your office to renew the subject permit.
Should you need any additional information or assistance, please feel free to contact me via
phone [phone]) or by email at [e-mail].
Sincerely,
EDocuSigned by:
au�vt In Ieall�p—Pll,►�u^
9CBBEO9BOA7B4911
Lauren Raup-Plummer
Engineering Manager
Aqua North Carolina, Inc.
Enc: NPDES Application, Form 2C
NPDES Application, Form 1
Snow Hill Subdivision Well #2 WTP NPDES Permit
Cc: Joseph Pearce
Shannon Becker
202 MacKenan Court, Cary, NC, 27511 • 919.467.8712 • AquaAmerica.com

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
NCG590029
NCG590029
Snow Hill Subdivision- Well #2-
IALTO
OMB No. 2040-0004
U.S. Environmental Protection Agency
Form
I
EPA Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•D
Applicants Not Required to Submit Form 1
1.1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete 0 No
If yes, STOP. Do NOT No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
operation or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
a
production facility?
currently discharging process wastewater?
oYes
-* Complete Form 1 0 No
0 Yes -* Complete Form Ej No
a
and Form 2B.
1 and Form 2C.
a
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
cc
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 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 (15).
SECTIONDD-
• • i
Facility Name
2.1
Snow Hill Subdivision- Well #2 WTP
0
2.2
EPA Identification Number
o
J
NCG590029
'C
2.3
Facility Contact
Name (first and last)
Title
Phone number
Lauren Raup-Plummer
Engineering Manager
[phone]
Q
Email address
[e-mail]
2.4
Facility Mailing Address
zStreet
or P.O. box
202 MacKenan Drive
City or town
State
ZIP node
Cary
North Carolina
27511
EPA Form 3510-1 (revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05119
NCG590029
NCG590029
Snow Hill Subdivision- Well #2-
OMB No. 2040-0004
v;
2.5
Facility Location
Street, route number, or other specific identifier
Q 0
Snow Hill Drive
rn
5 0
County name
County code (if known)
Surry
0
E _j
City or town
State ZIP code
z A
Dobson
North Carolina 27017
SECTION1
NAICS CODES1
3.1
SIC Code(s)
Description (optional)
4941
Establishments primarily engaged in distributing water for sale for domestic,
H
d
O
0
U
N
U
Z
3.2
NAICS Code(s)
Description (optional)
310
Water Distribution (except irrigation)
U
U)
4.1
Name of Operator
Aqua North Carolina
0
4.2
Is the name you listed in Item 4.1 also the owner?
w
R
✓❑ Yes ❑ No
w
z
4.3
Operator Status
❑ Public —federal ❑ Public —state ❑ Other public (specify)
p
❑✓ Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
w
Street or P.O. Box
R
0
202 MacKenan Drive
as
•w
City or town
State
ZIP code
0 0
Cary
North Carolina
27511
R
n
Email address of operator
O
[e-mail]
SECTION1
1 1
A
5.1
Is the facility located on Indian Land?
c
r_ J
❑ Yes ❑r No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590029 NCG590029 Snow Hill Subdivision- Well #2- OMB No.2040-0004
ENVIRONMENTAL1
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
c
water)
fluids)
•2
NCG590029
W a
rn
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
w
w
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section 404)
❑ Other (specify)
7.1 Have you attached a topographic map containing all required information to this application? (See instructions for
specific requirements.)
❑✓ Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 26.)
8.1 Describe the nature of your business.
Operating a filter -backwash treatment system employing greensand filter technology to treat groundwater in
support of potable -water production
U)
U)
N
C
y
7
m
0
O
d
7
ee
Z
9.1 Does your facility use cooling water?
❑ Yes ❑r No + 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
' 40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
01 r
NPDES permitting authority to determine what specific information needs to be submitted and when.)
•� Y
y I10.1 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
m when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
CD
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
NCG590029
NCG590029
Snow Hill Subdivision- Well #2- 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
❑� Section 1: Activities Requiring an NPDES Permit
Z w/ attachments
❑✓ Section 2: Name, Mailing Address, and Location
❑ w/ attachments
❑r Section 3: SIC Codes
❑ w/ attachments
❑r Section 4: Operator Information
❑ w/ attachments
R Section 5: Indian Land
❑ w/ attachments
E Section 6: Existing Environmental Permits
❑ w/ attachments
1=
d
E
❑✓ Section 7: Map
w/ topographic
❑ w/ additional attachments
ma
o
❑✓ Section 8: Nature of Business
❑ w/ attachments
w
❑✓ Section 9: Cooling Water Intake Structures
❑ w/ attachments
❑✓ Section 10: Variance Requests
❑ w/ attachments
in
❑✓ Section 11: Checklist and Certification Statement
❑ w/ attachments
d
11.2
Certification Statement
L
U
1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision
in accordance with a system designed to assure that qualified personnel properly gather and evaluate the
information submitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. / am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Lauren Raup-Plummer
Engineering Manager
Signature
Date signed
by:
EDocuSigned
I .
"—�UA�NWIv
02/01/2024
9C8BE0980A7B498.
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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 OMB No. 2040-0004
Form U.S. Environmental Protection Agency
2C = EPA Application for NPDES Permit to Discharge Wastewater
NPDES ��
EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS
Provide information on each of the facilitv's outfalls in the table below
c Numbelr OutfalReceiving Water Name Latitude Longitude
.�
U
001 unnamed tributary to Cody 36' 21' 06" N 80° 42' 07" W
cc
O
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 `
C3 0 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
E
Treatment Units
3
0
u_
a, Description Code from
(include size, flow rate through each treatment unit, Table 2C-1
> retention time, etc.
Flow
0.0025 mgd
mgd
mgd
mgd
Final Disposal of Solid or
Liquid Wastes Other Than
by Discharae
EPA Form 3510-2C (Revised 3-19) Page 1

dentification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 OMB No.2040-0004
3.1 **Outfall Number**
cont. Operations,
Operation Average Flow
mgd
mgd
mgd
mgd
Treatment Units
Description 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
M
d
H
**Outfall Number**
y Operations Contributing to Flow
0 Operation Average Flow
U_
a, mgd
> mgd
mgd
I I I mgd
Description 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.) I by Discharge
3.2 Are you applying for an NPDES permit to operate a privately owned treatment works?
❑ Yes 0 No 4 SKIP to Section 4.
Cn 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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 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?
[D Yes ❑ No 4 SKIP to Section 5.
4.2
Provide information
on intermittent or seasonal flows for each applicable outfall.
Attach additional pages, if cessary
Frequency
Flow
Rate
Outfall
Operation
Duration
Average
Average
Long -Term
Maximum
Number
(list)
Days/Week
Months/Year
Average
Dail
WTP Backwash Dischar
7 days/week
12 months/year
0.0025 mgd
0.0025 mgd
170 days
N
30
001
days/week
months/year
mgd
mgd
days
U.
days/week
months/year
mgd
mgd
days
mdays/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.
w
ELG Category
ELG Subcategory
Regulatory Citation
d
R
V
.Q
C-
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
5.4
Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
€
Outfall
Operation, Product, or Material
Quantity per Day
Unit of
Number
Measure
d
M
R
m
C
O
.0
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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 OMB No.2040-0004
SECTION'• I
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.
FA
Affected
Final Compliance Dates
E
Brief Identification and Description of
Outfalls
Source(s) of
E
Project
(list outfall
Discharge
Required
Projected
a
number
E
V
c
R
Uf
N
R
c
Cf
G.
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 ✓❑ Not applicable
SECTIONr
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
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.
7.5
Have you checked "Testing Required" for all toxic metals, cyanide, and total phenols in Section 1 of Table B?
w
❑ Yes E] 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
NCG59OO29
NCG59OO29
Snow Hill Subdivision -Well #2
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?
0 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 4 Note that you qualify at the top of Table B, ❑ No
o
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
0
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?
N
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
R
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'?
c
❑ 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?
El 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 H 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?
w
u
❑ Yes ❑ No 4 SKIP to Section 9.
3
8.2
List the pollutants below.
co X
1. 4. 7.
0
2. 5. 8.
W
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
NCG59( I NCGS90029 I Snow Hill Subdivision -Well #2 1 OMB No. 2040-0004
an
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 purposes below.
Tests Purpose of TestSubmitted to NPDES Date Submitted
P (s � PormiHinn An4hnri4v7
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
10.1 Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
0 Yes ❑ No -* SKIP to Section 11.
10.2 I Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1 1 Laboratory Number 2 Laboratory Number 3
Name of laboratory/firm I Water Tech Laboratories Inc
Laboratory address 5 Pinewood Plaza Dr
Granite Falls, NC 28630
Phone number
[phone]
Pollutant(s) analyzed Total Suspended Solids
11.1 Has the NPDES permitting authority requested additional information?
❑ Yes ❑ 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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 OMB No.2040-0004
SECTION•
1
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
✓❑ 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 ❑ wl explanation for identical
supporting information outfalls
w/ small business exemption w/ other attachments
❑ ❑
request
❑ Section 7: Effluent and Intake
❑ w/ Table A ❑✓ w/ Table B
Characteristics
0
w/ Table C ❑✓ w/ Table D
w
❑ w/ analytical results as an
El w/ Table E
attachment
❑ Section 8: Used or Manufactured
❑ w/ attachments
Toxics
Section 9: Biological Toxicity
❑
❑ w/ attachments
''
L
Tests
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
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 by.
Date signed
�DocuS;gned
`p"PA l�
02/01/2024
9CBBE09BOA7B49B.
EPA Form 3510-2C (Revised 3-19) Page 7

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
Effluent
Intake
FOCh7lied
Waiver Units
Requested
0 tional
Maximum
Maximum
Long -Term
(sperm)
Daily
Monthly
Average Daily
Number of
Long -Term
Number of
(if applicable)
Discharge
Discharge
Discharge
Analyses
Average Value
Analyses
(required)
if available
if available
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
4.
Total suspended solids (TSS)
Mass
Concentration
5.
Ammonia (as N)
❑✓
Mass
6.
Flow
❑
Rate
gpd
2,500
2,500
170
Temperature (winter)
0
°C
°C
7.
Temperature (summer)
21
'C
°C
pH (minimum)
❑
Standard units
s.u.
6.8
7.3
138
8.
pH (maximum)
❑
Standard units
s.U.
7.9
7.3
138
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

This page intentionally left blank.

EPA Identification Number
NCG590029
Name
NCG590029 I Snow Hill Subdivision -Well #2 WTP
Outfall Number
001
Form Approved 03/05/19
OMB No. 2040-0004
•
1
•
• A 1 •'
• '• 1
Units
(specify)
0
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
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
of
Analyses
Long"
Term
Average
Value
Number
of
Analyses
❑ Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.
Section 1. Toxic Metals, Cyanide, and Total Phenols
1.1
Antimony, total
(7440-36-0)
El
El
❑
Concentration
Mass
1.2
Arsenic, total
(7440-38-2)
❑
El
ID
Concentration
Mass
1.3
Beryllium, total
(7440-41-7)
❑
❑
Concentration
Mass
1.4
Cadmium, total
(7440-43-9)
El
❑
El
Concentration
Concentration
1.5
Chromium, total
(7440-47-3)
❑
❑
❑
Concentration
Mass
1.6
Copper, total
(7440-50-8)
❑
❑
El
Concentration
Concentration
1.7
Lead, total
(7439-92-1)
El
El
❑
Concentration
Mass
1.8
Mercury, total
(7439-97-6)
El
El
El
Concentration
Mass
1.9
Nickel, total
(7440-02-0)
El
El
El
Concentration
Mass
1.10
Selenium, total
(7782-49-2)
❑
❑
❑
Concentration
Mass
1.11
Silver, total
(7440-22-4)
❑
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 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
Analyses
Value
Analyses
if available
1.12
Thallium, total
❑
❑
❑
Concentration
Mass
(7440-28-0)
1.13
Zinc total
❑
❑
❑
Concentration
Mass
(7440-66-6)
1.14
Cyanide, total
El
❑
❑
Concentration
Mass
(57-12-5)
1.15
Phenols, total
❑
❑
❑�
Concentration
Mass
Section 2.Organic Toxic Pollutants (GC/MS Fraction
—Volatile Compounds)
21
Acrolein
❑
❑
❑
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
Concentration
Mass
(107-13-1)
2.3
Benzene
❑
❑
Concentration
Mass
(71-43-2)
2.4
Bromoform
❑
❑
❑�
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
El
El
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
✓
Concentration
Mass
(108-90-7)
2.7
Chlorodibromomethane
El
El
Concentration
Mass
(124-48-1)
2.8
Chloroethane
El21
Concentration
Mass
(75-00-3)
EPA Form 3510-2C (Revised 3-19) Page 12

oentitication Number NPUL6 Permit Number Facility Name Outfall Nu
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
12.9(110-75-8)
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
g
if available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
2-chloroethylvinyl ether
❑
El
Concentration
Mass
2.10
Chloroform (67-66-3)
❑
❑
�
Concentration
Mass
2.11
Dichlorobromomethane
(75-27-4)
El
El
Concentration
Mass
212
1,1-dichloroethane
(75-34-3)
❑
❑
❑
Concentration
Mass
2.13
1,2-dichloroethane
(107-06-2)
❑
El
Concentration
Mass
2.14
1,1-dichloroethylene
(75-35-4)
❑
El
Concentration
Mass
2.15
1,2-dichloropropane
(78-87-5)
❑
❑
❑
Concentration
Mass
2.16
1,3-dichloropropylene
(542-75-6)
❑
❑
0
Concentration
Mass
217
Ethylbenzene
(100-41-4)
❑
❑
❑
Concentration
Mass
2.18
Methyl bromide
(74-83-9)
❑
❑
❑
Concentration
Mass
2.19
Methyl chloride
(74-87-3)
❑
❑
0
Concentration
Mass
2.20
Methylene chloride
(75-09-2)
❑
❑
El
Concentration
Mass
2.21
1,1,2,2- tetrachloroethane
(79-34-5)
❑
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 13

EPA Identification Number Nrut=a rermit Numoer racmty Name Uuttall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
Intake
Presence or Absence
check one
Effluent
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Believed
Believed
Units
(specify)
Maximum
Maximum
Long -Term
Average
Number
Long -
Number
Present
Absent
Daily
Discharge
Monthly
Discharge
Daily
of
Term
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)
225
1,1,1-trichloroethane
❑
❑
❑
Concentration
Mass
(71-55-6)
226
11,2-trichloroethane
❑
❑
✓
Concentration
Mass
(79-00-5)
2.27
Trichloroethylene
❑
0
R
Concentration
Mass
(79-01-6)
2.28
Vinyl chloride
❑
❑
❑
Concentration
1 Mass
(75-01-4)
Section 3.Organic Toxic Pollutants (GC/MS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
El
El
El
Concentration
Mass
(95-57-8)
3.2
2 4-dichlorophenol
El
1:1
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
❑
❑
✓
Concentration
Mass
(51-28-5)
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
PollutantlParameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Long -
Term
Average
Value
Number
of
Analyses
3.6
2-nitrophenol
(88-75-5)
El
❑
Concentration
Mass
3.7
4-nitrophenol
(100-02-7)
El
❑
✓
Concentration
Mass
3.8
p-chloro-m-cresol
(59-50-7)
El
El
El
Concentration
Mass
3.9
Pentachlorophenol
(87-86-5)
El
El
El
Concentration
Mass
3.10
Phenol
(108-95-2)
❑
❑
❑
Concentration
Mass
3.11
2 4,6-trichlorophenol
(88 05 2)
El
El
❑
Concentration
Mass
Section 4.Organic Toxic Pollutants (GCIMS
Fraction
—Base /Neutral
Compounds)
4.1
Acenaphthene
(83-32-9)
❑
Concentration
Mass
4.2
Acenaphthylene
(208-96-8)
❑
Concentration
Mass
4.3
Anthracene
(120-12-7)
✓
Concentration
Mass
4.4
Benzidine
(92-87-5)
❑
©
Concentration
Mass
4.5
Benzo (a) anthracene
(56-55-3)
❑
❑
0
Concentration
Mass
4.6
Benzo (a) pyrene
(50-32-8)
❑
❑
0Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
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
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Long-
Term
Average
Value
Number
of
Analyses
4.7
3,4-benzofluoranthene
(205 99 2)
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
0
El
✓
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
El
13
✓
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
El
❑
©
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
❑
El
❑✓
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
❑
❑
❑✓
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
❑
z
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
❑
❑
❑
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
❑
❑
0
Concentration
Mass
4.16
2-chloronaphthalene
(91-58-7)
El
❑
ID
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
El
El❑
Concentration
Mass
4.18
Chrysene
(218-01-9)
❑
El
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
El❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
•Y4 [01 ky, 1:1111 r-11 4:91iff-11 1Z I 1111141
IWTAG•
1 ••
sm 14429111
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
if available
4.20
1,2-dichlorobenzene
El
❑
❑
Concentration
Mass
(95-50-1)
4.21
1 3-dichlorobenzene
❑
❑
❑�
Concentration
Mass
(541-73-1)
4.22
1,4-dichlorobenzene
❑
❑
❑�
Concentration
Mass
(106-46-7)
4.23
3 3-dichlorobenzidine
❑
El
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
21
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
El
❑
O
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
❑
El
21
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
❑
❑
0
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
Q
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
❑
E
Concentration
Mass
(117-84-0)
4.30
1,2-Dipheny1hydrazine
El
El
ID
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
0
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
Owl 111111011WK614:11
Testing
Required
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
aily
Discharge
f available
Number
of
Analyses
Long-
Term
Average
Value
Number
of
Analyses
4.33
Hexachlorobenzene
(118-74-1)
❑
❑
2
Concentration
Mass
4.34
Hexachlorobutadiene
(87-68-3)
❑
El
F-11
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
El
Concentration
Mass
4.38
Isophorone
(78-59-1)
El
❑
❑
Concentration
Mass
4.39
Naphthalene
(91-20-3)
❑
El
El
Concentration
Mass
4.40
Nitrobenzene
(98-95-3)
El
❑
❑
Concentration
Mass
4.41
N-nitrosodimethylamine
(62 75 9)
El
El
Concentration
Mass
4.42
N-nitrosodi-n-propylamine
(621-64-7)
El
El
Concentration
Mass
4.43
N-nitrosodiphenylamine
(86-30-6)
El
ElConcentration
El
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
NCG590029 NCG590029 I Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
Intake
Presence or Absence
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
I
(required)if
available
alue
1,2,4-trichlorobenzene
4.46
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
21
Concentration
Mass
(319-84-6)
5.3
R-BHC
Concentration
Mass
(319-85-7)
5.4
y-BHC
El
11
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
❑
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-endosWan
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

EPA Identification Number NPUES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)Value
Long -Term
Average
aily
Discharge
if available
Number
of
Analyses
Long -
Termof
Average
Number
Analyses
5.12
R-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)
❑
❑
O
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑
E
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
❑
0
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
❑
❑r
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
❑
El
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
❑
El
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑
❑
El
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑
0
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
❑
❑
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

LPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 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
Analyses
Value
Analyses
if available
Concentration
�Toxaphene
5.25 (8001-35-2)
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 21

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG59OO29 NCG59OO29 Snow Hill Subdivision -Well #2 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)
if available if available)Value
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
© Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
1'
Bromide
El
El
Concentration
Concentration
(24959-67-9)
2'
Chlorine, total
❑
❑
Concentration
Mass
residual
3.
Color
El
El
Concentration
Mass
4.
Fecal coliform
❑
❑
Concentration
Mass
5
Fluoride
❑
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
El
❑
Concentration
Mass
7'
Nitrogen, total
El
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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No. 2040-0004
Presence or Absence
check one Effluent Intake
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
(required) Discharge Discharge Analyses Value Analyses
(if available) (if available)
12
Sulfite (as S03)
(14265-45-3)
❑
❑
Concentration
Mass
13.
Surfactants
❑
❑
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
❑
❑
Concentration
Mass
15.
Barium, total
(7440-39-3)
❑
❑
Concentration
Mass
16.
Boron total
(744042-8)
❑
ElConcentration
Mass
17.
Cobalt, total
(7440484)
❑
❑
Concentration
Mass
18
Iron total
(7439-89-6)
❑
❑
Concentration
Mass
19
Magnesium, total
(7439-954)
❑
❑
Concentration
Mass
20.
Molybdenum,
total
7439-98-7
❑
❑
Concentration
Mass
21
Manganese, total
(7439-96-5)
❑
❑
Concentration
Mass
22
Tin, total
(7440-31-5)
❑
❑
Concentration
Mass
23
Titanium, total
(7440-32-6)
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG59OO29
NCG59OO29 Snow
Hill Subdivision -Well #2 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
Average Number of
(required)
Discharge Discharge Analyses
Analyses
Value
if available if available)
24.
Radioactivity
Alpha, total
El
❑
Concentration
Mass
Beta, total
❑
❑
Concentration
Mass
Radium, total
❑
El
Concentration
Mass
Radium 226, total
El
ElConcentrationMass
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

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No. 2040-0004
I •I• 1 1 I
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
1. Asbestos ❑ 0
2. Acetaldehyde ❑ 0
3.
Allyl alcohol
❑
H
4.
Allyl chloride
❑
M
5.
Amyl acetate
❑
0
6.
Aniline
❑
El
7.
Benzonitrile
❑
❑�
8.
Benzyl chloride
❑
0
9.
Butyl acetate
❑
❑r
10.
Butylamine
❑
ED
11.
Captan
❑
0
12.
Carbaryl
❑
0
13.
Carbofuran
❑
14.
Carbon disulfide
❑
15.
Chlorpyrifos
❑
El
16.
Coumaphos
❑
0
17.
Cresol
❑
❑r
18.
Crotonaldehyde
❑
M
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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No.2040-0004
•1• 1 � 1 �
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge
(specify units)
rPresent Absent
20. 2,4-D (2,4-dichlorophenoxyacetic acid) ❑ 0
21.
Diazinon
❑
21
22.
Dicamba
❑
H
23.
Dichlobenil
❑
24.
Dichlone
❑
F-1
25.
2,2-dichloropropionic acid
❑
❑r
26.
Dichlorvos
❑
❑r
27.
Diethyl amine
❑
❑r
28.
Dimethyl amine
❑
❑r
29.
Dintrobenzene
❑
❑r
30.
Dicluat
❑
31.
Disulfoton
❑
E
32.
Diuron
❑
R
33.
Epichlorohydrin
❑
34.
Ethion
❑
R
35.
Ethylene diamine
❑
R
36.
Ethylene dibromide
❑
❑r
37.
Formaldehyde
❑
❑r
38.
Furfural
❑
Z
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No. 2040-0004
r1 I 1
Presence or Absence
Pollutant (check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
39. Guthion ❑ 0
40. Isoprene ❑ Z
41.
Isopropanolamine
❑
H
42.
Kelthane
❑
43.
Kepone
❑
❑�
44.
Malathion
❑
45.
Mercaptodimethur
❑
46.
Methoxychlor
❑
R
47.
Methyl mercaptan
❑
❑r
48.
Methyl methacrylate
❑
R
49.
Methyl parathion
❑
R
50.
Mevinphos
❑
51.
Mexacarbate
❑
52.
Monoethyl amine
❑
0
53.
Monomethyl amine
❑
0
54.
Naled
❑
0
55.
Naphthenic acid
❑
56.
Nitrotoluene
❑
57.
Parathion
❑
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No.2040-0004
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
58.
Phenolsulfonate
❑
Z
59.
Phosgene
❑
60.
Propargite
❑
61.
Propylene oxide
❑
62.
Pyrethrins
❑
R
63.
Quinoline
❑
❑r
64.
Resorcinol
❑
0
65.
Strontium
❑
❑Q
66.
Strychnine
❑
❑r
67.
Styrene
❑
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetrachlorodiphenyl ethane)
❑
❑�
70.
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
El
Q
71.
Trichlorofon
❑
Z
72.
Triethanolamine
❑
0
73.
Triethylamine
❑
❑r
74.
Trimethylamine
❑
❑r
75.
Uranium
❑
R
76.
Vanadium
❑
❑r
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
NCG59OO29
NCG59OO29 Snow Hill Subdivision -Well #2 WTP 001
OMB No. 2040-0004
1 •1•
1 0 I
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
❑
❑�
79.
Xylenol
❑
❑✓
80.
Zirconium
❑
❑r
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG59OO29 NCG59O029 Snow Hill Subdivision -Well #2 WTP 001 OMB No. 2040-0004
•'�I I ' I 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

Snow Hill S/D Well #2 WTP
Surry County; Permit No. NCG590029

AOUA9A
An iEssential Utilities Company
February 1, 2024
Division of Water Resources
Water Quality Permitting Section — NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: Application for Permit Renewal
Aqua North Carolina, Inc.
Snow Hill Subdivision Well #2 WTP
NPDES No. NCG590029
Surry County
To Whom It May Concern:
Enclosed are three (3) copies of the completed application Form 2C and Form 1. This
submittal includes the necessary attachments for your office to renew the subject permit.
Should you need any additional information or assistance, please feel free to contact me via
phone [phone]) or by email at [e-mail].
Sincerely,
DocuSigned by:
9CBBE09BOA7B498...
Lauren Raup-Plummer
Engineering Manager
Aqua North Carolina, Inc.
Enc: NPDES Application, Form 2C
NPDES Application, Form 1
Snow Hill Subdivision Well #2 WTP NPDES Permit
Cc: Joseph Pearce
Shannon Becker
202 MacKenan Court, Cary, NC, 27511 • 919.467.8712 9 AquaAmerica.com

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, 21), 2E, or 2F. To determine the specific forms you must complete, consult the
"General Instructions" for this form.

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590029
NCG590029
Snow Hill Subdivision Well #2
OMB No.2040-0004
U.S. Environmental Protection Agency
Form
t
C�/`1
`OEPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•
•D
Applicants Not Required to Submit Form 1
1.1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete 0 No
If yes, STOP. Do NOT No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
..
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
operation or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
a
production facility?
currently discharging process wastewater?
o❑
Yes 4 Complete Form 1 No
Yes -+ Complete Form No
a
and Form 2B.
1 and Form 2C.
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
commenced to discharge?
discharges only nonprocess wastewater?
d
❑ Yes 4 Complete Form 1 No
❑ Yes 4 Complete Form 0 No
and Form 2D.
1 and Form 2E.
y
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 n✓ No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
SECTION
D•• • • i
Facility Name
2.1
Snow Hill Subdivision- Well #2 WTP
0
2.2
EPA Identification Number
o
J
NCG590029
2.3
Facility Contact
d
Name (first and last)
Title
Phone number
0
Lauren Raup Plummer
Engineering Manager
[phone]
Q
Email address
[e-mail]
a
2.4
Facility Mailing Address
W
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
NCG590029
NCG590029
Snow Hill Subdivision- Well #2
MITO
OMB No. 2040-0004
2.5
Facility Location
.w
Street, route number, or other specific identifier
Q U
Snow Hill Drive
rn
o
County name
County code (if known)
M
Surry
E
City or town
State ZIP code
z m
Dobson
North Carolina 27017
SECTION•1
I
3.1
SIC Code(s)
Description (optional)
4941
Establishments primarily engaged in distributing water for sale for domestic,
N
N
0
O
U
Cl)
U
z
3.2
NAICS Code(s)
Description (optional)
R
310
Water Distribution (except irrigation)
U
U)
SECTIONOPERATOR
INFORMATION
4.1
Name of 0 erator
Aqua North Carolina
`o_
4.2
Is the name you listed in Item 4.1 also the owner?
E
`
0 Yes ElNo
o
w
4.3
Operator Status
❑ Public —federal ❑ Public —state ❑ Other public (specify)
o
0 Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
w
Street or P.O. Box
M
E
202 MacKenan Drive
o M
City or town
State
ZIP code
o 0
R
Cary
North Carolina
77511
CL
Email address of operator
O
[e-mail]
SECTIONti
I 1
R
5.1
Is the facility located on Indian Land?
J
❑ 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
NCG590029
NCG590029 Snow Hill Subdivision- Well #2- OMB No.2040-0004
SECTION'•
I CFR 122.21ffi(6))
m
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
cU)water)
fluids)
'=
NCG590029
w a
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
x
❑ Ocean dumping (MPRSA) ❑ Dredge or fill (CWA Section 404) ❑ Other (specify)
W
SECTION1
7.1
Have you attached a topographic map containing all required information to this application? (See instructions for
A
specific requirements.)
❑✓ Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 2B.)
SECTIONOF
8.1
Describe the nature of your business.
Operating a filter -backwash treatment system employing greensand filter technology to treat groundwater in
support of potable -water production
U)
U)
d
C
N
7
Co
O
7
is
Z
SECTION••
I
9.1
Does your facility use cooling water?
d
❑ Yes ❑ No 4 SKIP to Item 10.1.
5
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
Of r
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
c
NPDES permitting authority to determine what specific information needs to be submitted and when.)
Y
O
V w
C
SECTION1
VARIANCE
REQUESTSI 1
10.1
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
h
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
d
when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
❑✓ Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
NCG590029
NCG590029
Snow Hill Subdivision- Well #2- OMB No. 2040-0004
'--
SECTION
11. CHECKLIST
AND 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
❑� Section 1: Activities Requiring an NPDES Permit
w/ attachments
0 Section 2: Name, Mailing Address, and Location
❑ wl attachments
❑✓ Section 3: SIC Codes
❑ wl attachments
0 Section 4: Operator Information
❑ wl attachments
❑✓ Section 5: Indian Land
❑ w/ attachments
CD
❑� Section 6: Existing Environmental Permits
❑ wl attachments
d
❑✓ Section 7: Map
wl topographic
Elw/ additional attachments
map
Cn
o
❑� Section 8: Nature of Business
❑ w/ attachments
w
❑✓ Section 9: Cooling Water Intake Structures
❑ w/ attachments
�'
❑� Section 10: Variance Requests
❑ wl attachments
N_
❑� Section 11: Checklist and Certification Statement
❑ wl attachments
Y
11.2
Certification Statement
U
1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision
in accordance with a system designed to assure that qualified personnel properly gather and evaluate the
information submitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Lauren Raup-Plummer
Engineering Manager
Signature
Date signed
DocuSgned by:
"—PUWii%t '
02/01/2024
9c88E09B0A7B496_.
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
�!EPp► 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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 OMB No. 2040-0004
Form U.S. Environmental Protection Agency
2C "EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS
SECTIONOUTFALL LOCATIONt
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 Cody 36' 21' 06 N E] 80° 42' 07" W Ej
is
O
SECTION1' I
o, 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 Cc
o [E] Yes ❑ No
SECTION• i
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 0.0025 mgd
w
c
E mgd
cv
d
mgd
-a
c
H mgd
Treatment Units
0
U_
o, Description Code from Final Disposal of Solid or
d
(include size, flow rate through each treatment unit, Liquid Wastes Other Than
> retention time, etc. Table 2C-1 by Discharge
a
EPA Form 3510-2C (Revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590029
NCG590029
Snow Hill Subdivision -Well #2
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
retention time, etc.
by Dischar e
•a
d
c
c
0
tU
c
d
E
M
m
H
**Outfall Number**
c
U)
Operations Contributing to Flow
o
Operation Average Flow
LL
rn
mgd
R
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.
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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 OMB No. 2040-0004
• • 1
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
Freq
uency
Flow
Rate
Average
Average
Long -Term
Maximum
Number
(list)
Duration
Da sfWeek
MonthslYear
Average
Dail
WTP Backwash Dischar
7 days/week
12 months/year
0.0025 mgd
0.0025 mgd
170 days
30
001
days/week
months/year
mgd
mgd
days
U_
days/week
months/year
mgd
mgd
days
E
`m
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•••ti
• r
5.1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes ❑ No -* SKIP to Section 6.
5.2
Provide the following information on applicable ELGs.
w
ELG Category
ELG Subcategory
Regulatory Citation
d
R
.Q
o-
a
5.3
Are any of the applicable ELGs expressed in terms of production (or other measure of operation)?
U)
❑ Yes ElNo 4 SKIP to Section 6.
0
5.4
Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
E
_j
Outfall
Operation, Product, or Material
Quantity per Day
Unit of
Number
Measure
d
cc
l6
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
NCGS90029 NCG590029 Snow Hill Subdivision -Well #2 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
a
number
E
R
CD
16
CL
C
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 ✓❑ 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?
❑ 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
w
requested and attached the results to this application package?
d
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
R
7.4
Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
c
listed in Exhibit 2C-3? (See end of instructions for exhibit.)
❑ Yes 0 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 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.
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 03/05119
NCG590029
NCG59O029
Snow Hill Subdivision -Well #2
WTD
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?
[21 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 El 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, ❑ No
o
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
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?
`—'
.y
❑ Yes ❑✓ No
r;
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
t
for all outfalls?
U
2] Yes ❑ No
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'?
❑ 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 ❑✓ 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 -* SKIP to Section 8.
7.17
Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes ❑✓ No
SECTIONra
OR 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?
w
❑ Yes 0 No 4 SKIP to Section 9.
U)
8.2
List the pollutants below.
1. 4. 7.
0
2. 5. 8.
N
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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 OMB No. 2040-0004
ALT-0-
SECTION 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 4 SKIP to Section 10.
N
9.2
Identify the tests and their
ur oses below.
Test(s)
Purpose of Test(s)
Submitted to NPDES
Date Submitted
x
Permitting Authority?
0
R
❑ Yes ❑ No
0
0
ca
❑ Yes ❑ No
❑ Yes ❑ No
SECTIONt
CONTRACT
ANALYSES (40
Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
10.1
❑r 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
UN
CD
U,
Laboratory address
5 Pinewood Plaza Dr
=
Granite Falls, NC 28630
Q
w
a
c
0
U
Phone number
[phone]
Pollutant(s) analyzed Total Suspended Solids
SECTIONera
• •- • r
Has the NPDES permitting authority requested additional information?
11.1
0
❑ Yes No 4 SKIP to Section 12.
0
11.2
List the information requested and attach it to this application.
E
`o
1. 4.
R
c
0
2. 5.
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
NCG590029 NCGS90029 Snow Hill Subdivision -Well #2 OMB No.2040-0004
SECTION
12. CHECKLIST
AND CERTIFICATION STATEMENT 1
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 0 w/ attachments El owned treatment
Treatment
works
❑ Section 4: Intermittent Flows
❑ w/ attachments
❑ Section 5: Production
❑ wl 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
15
wl small business exemption
❑ ❑ wl other attachments
E
request
N
❑ Section 7: Effluent and Intake
0 wl Table A 0 wl Table B
Characteristics
❑✓ w/ Table C ❑✓ w/ Table D
❑ w/ Table E ❑ w/ analytical results as an
attachment
❑ Section 8: Used or Manufactured
❑ w/ attachments
Toxics
❑ Section 9: Biological Toxicity
❑ w/ attachments
Tests
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
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. 1 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
�DocuSigned
"—p"KIV
02/01/2024
9CBBE09BOA7B496...
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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No. 2040-0004
Effluent Intake
Waiver o tional
Pollutant Requested Units Maximum Maximum Long -Term
(S►eciM 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)
❑r
Mass
Concentration
4.
Total suspended solids (TSS)
0
Mass
Concentration
5.
Ammonia (as N)
❑✓
Mass
6.
Flow
❑
Rate
gpd
2,500
2,500
170
Temperature (winter)
°C
°C
7.
Temperature (summer)
°C
°C
pH (minimum)
❑
Standard units
S.u.
6.8
7.3
138
8.
pH (maximum)
❑
Standard units
s.u.
7.9
7.3
138
Samolino shall be conducted accordina
to sufficiently sensitive test procedures li.e.. methods) aonroved under 40 CFR
136 for the analvsis of nollutants or nnlhdant naramaters 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
NCG590029 NCG590029 I Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
(P fY)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
Analyses
Lon
Term
Average
Value
Number
of
Analyses
❑ Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.
Section 1. Toxic Metals, Cyanide, and Total Phenols
1.1
Antimony, total
(7440-36-0)
Concentration
Mass
1.2
Arsenic, total
(7440-38-2)
El
El
Concentration
Mass
1.3
Beryllium, total
(7440-41-7)
El
El
El
Concentration
Mass
1.4
Cadmium, total
(7440-43-9)
Concentration
Mass
1.5
Chromium, total
(7440-47-3)
El
El
El
Concentration
Mass
1.6
Copper, total
(7440-50-8)
❑
✓
Concentration
Mass
1.7
Lead, total
(7439-92-1)
El
❑
✓
Concentration
Mass
1.8
Mercury, total
(7439-97-6)
Concentration
Mass
1'9
Nickel, total
(7440-02-0)
Concentration
Mass
1.10
Selenium, total
(7782-49-2)
Concentration
Mass
1.11
Silver, total
(7440-22-4)
1:1Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
•] '3kill][91�4C 0410
• • r
,
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and
(and CAS Number, if available)
Required
Believed
Believed
(p �)
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absentof
Discharge
Discharge
Daily
Average
(required)
(if available)
Di harge
Analyses
Value
Analyses
if available
1.12
Thallium, total
El
1:1
v
Concentration
Mass
(7440-28-0)
1.13
Zinc total
Concentration
Mass
(7440-66-6)
1.14
Cyanide, total
❑
❑
O
Concentration
Mass
(57-12-5)
1.15
Phenols, total
❑
117
❑✓
Concentration
Mass
1
Section 2.Organic Toxic Pollutants (GC/MS
Fraction
—Volatile Compounds)
2.1
Acrolein
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
El
El
El
Concentration
Mass
(107-13-1)
2.3
Benzene
El
El
Concentration
Mass
(71-43-2)
2.4
Bromoform
❑
El
❑�
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
El
❑
❑
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
❑
❑
Concentration
Mass
(108-90-7)
2.7
Chlorodibromomethane
El
El
2
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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 • •
• • • 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
1(110-75-8)
(and
(and CAS Number, if available
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
(required)
(if available)
if available
Value
2 9
2-chloroethylvinyl ether
❑
❑
Concentration
Mass
2.10
Chloroform (67-66-3)
El
❑
ID
Concentration
Mass
2.11
Dichlorobromomethane
❑
ID
Concentration
Mass
(75-27-4)
212
1,1-dichloroethane
❑
❑
✓
Concentration
Mass
(75-34-3)
213
1,2-dichloroethane
❑
❑
E
Concentration
Mass
(107-06-2)
2.14
11-dichloroethylene
❑
❑
❑
Concentration
Mass
(75-35-4)
2.15
1,2-dichloropropane
❑
❑
0
Concentration
Mass
(78-87-5)
2.16
1,3-dichloropropylene
❑
E
Concentration
Mass
(542-75-6)
2.17
Ethylbenzene
❑
❑
Z
Concentration
Mass
(100-41-4)
2.18
Methyl bromide
❑
❑
0
Concentration
Mass
(74-83-9)
2.19
Methyl chloride
❑❑
Concentration
Mass
(74-87-3)
2.20
Methylene chloride
❑
El
El
Concentration
Mass
(75-09-2)
2.21
1 1,2,2- tetrachloroethane
❑
❑
❑
Concentration
Mass
(79-34-5)
EPA Form 3510-2C (Revised 3-19) Page 13

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 I Snow Hill Subdivision -Well #2 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
Discharge
of
Analyses
Average
of
Analyses
(required)
(if available)
if available
2.22
Tetrachloroethylene
ID
Concentration
Mass
(127-18-4)
2.23
Toluene
1:1
El
El
Concentration
Mass
(108-88-3)
2.24
1,2-trans-dichloroethylene
Concentration
Mass
(156-60-5)
225
1, 1, 1 -trichloroethane
El
El
El
Concentration
Mass
(71-55-6)
2.26
1,1,2-trichloroethane
El
El
✓
Concentration
Mass
(79-00-5)
2.27
Trichloroethylene
✓
Concentration
Mass
(79-01-6)
2.28
Vinyl chloride
El
1:1
✓
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
1:1
©
Concentration
Mass
(105-67-9)
3.4
4,6-dinitro-o-cresol
El
El
El
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

LNA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
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
°f
Analyses
Long-
Term
Average
Value
Number
of
Analyses
3.6
2-nitrophenol
(88_75 5)
✓
Concentration
Mass
3.7
4-nitrophenol
(100-02-7)
ED
El
✓
Concentration
Mass
3.8
p-chloro-m-cresol
(59-50-7)
✓
Concentration
Mass
3.9
PentachlorophenolEl
(87-86-5)
o
✓
Concentration
Mass
3.10
Phenol
(108-95-2)
El
El
✓
Concentration
Mass
3.11
2,4,6-trichlorophenol
(88-05-2)
El
El
El
j Concentration
1 Mass
Section 4.Organic Toxic Pollutants (GC/MS Fraction
—Base /Neutral
Compounds)
4.1
Acenaphthene
(83-32-9)
1:1
El
✓
Concentration
Mass
4.2
Acenaphthylene
(208-96-8)
El
El
✓
Concentration
Mass
4.3
Anthracene
(120-12-7)
El
El
✓
Concentration
Mass
4.4
Benzidine
(92-87-5)
©
Concentration
Mass
4.5
Benzo (a) anthracene
(56-55-3)
21
Concentration
Mass
4.6
Benzo (a) pyrene
(50-32-8)
21
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 15

LHA IoentITIcanon Number NHULS Hermit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
4:11111014
Pollutant/Parameter
(and CAS Number, if available)
I Lei•
Testing
Required
1 •'
Presence or Absence
check one
• •• 1
AMA
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
DisDchr a
if sch arge
available)
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
4.7
3,4-benzofluoranthene
(205-99-2)
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
El
1:1
El
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
El
El
El
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
❑
El©
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
El
❑
❑
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
❑
❑
El
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
❑
El
El
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
❑
❑
✓
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
El
❑
❑
Concentration
Mass
4.16
2-chloronaphthalene
(9158-7)
El
❑
❑
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
El
El
El
Concentration
Mass
4.18
Chrysene
(218-01-9)
El
0
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
El
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• • ••
• •• 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
ischarge
D(iifavailable)
Daily
of
e
of
(requied)
Discharge
Analyses
Value
Analyses
if available
4.20
1,2-dichlorobenzene
❑
❑
❑
Concentration
Mass
(95-50-1)
4.21
13-dichlorobenzene
El
El
El
Concentration
Mass
(541-73-1)
4.22
1,4-dichlorobenzene
❑
El
❑
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
El
❑
❑
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
21
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
❑
❑
❑
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
❑
❑
❑
Concentration
Mass
(84-74-2)
4.27
2 4-dinitrotoluene
El
❑
❑
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
✓
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
Concentration
Mass
(117-84-0)
4.30
1,2-Dipheny1hydrazine
El
El
ID
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
❑
❑
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
❑
❑
❑
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number
NCG590029
Name
NCG590029 I Snow Hill Subdivision -Well #2 WTP
Uunall Number
001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
1 1 • '
• ' • 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
if available
4.33
Hexachlorobenzene
El
El
✓
Concentration
Mass
(118-74-1)
4.34
Hexachlorobutadiene
Concentration
Mass
(87-68-3)
4.35
Hexachlorocyclopentadiene
❑
❑
❑
Concentration
Mass
(77-47-4)
4.36
Hexachloroethane
❑
El
✓
Concentration
Mass
(67-72-1)
4.37
Indeno (1,2,3-cd) pyrene
❑
❑
❑
Concentration
Mass
(193-39-5)
4.38
Isophorone
❑
❑
❑
Concentration
Mass
(78-59-1)
4.39
Naphthalene
❑
El
El
Concentration
Mass
(91-20-3)
4.40
Nitrobenzene
❑
❑
❑
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
❑
❑
✓
ncentration
rMua
(62-75-9)ss
4.42
N-nitrosodi-n-propylamine
❑
El
❑✓
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
❑
❑
El
Concentration
Mass
(86-30-6)
4.44
Phenanthrene
❑
El
❑✓
Concentration
Mass
(85-01-8)
4.45
Pyrene
El
El
El
Concentration
(129-00-0)
1
1Mass
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 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)
14.461,2,4-trichlorobenzene
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
(required)
(if available)
chare
Discharge
Analyses
Value
Analyses
if available
El
❑
❑�
Concentration
1 Mass
(120-82-1)
Section 5.Organic Toxic Pollutants (GC/MS
Fraction
—Pesticides
5.1
Aldrin
❑
El❑
Concentration
Mass
(309-00-2)
5.2
a-BHC
❑
r
Concentration
Mass
(319-84-6)
5.3
(i-BHC
El
El
✓
Concentration
Mass
(319-85-7)
5.4
y-BHC
El
✓
Concentration
Mass
(58 89 9)
5.5
b-BHC
El
Concentration
Mass
(319-86-8)
5.6
Chlordane
El
21
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
El
El
✓
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
El
✓
Concentration
Mass
(72-55-9)
5.9
4 4'-DDD
El
1:1
E
Concentration
Mass
(72-54-8)
5.10
Dieldrin
El
13
Z
Concentration
Mass
(60-57-1)
5.11
o-endosulfan
El
Concentration
(115-29-7)
1Mass
EPA Form 3510-2C (Revised 3-19) Page 19

bl'A ioentincation rvumoer NPDES Permit Number Facility Name Outfall Number
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
15.12
3:11111111010OW,1
Pollutant/Parameter
(and CAS Number, if available )
•
Testing
Required
q
• 1 • -
Presence or Absence
check one
• • • IMINIM
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge h edge
Maximum
Monthly
Discharge available)
Long -Term
Average
g
aily
Discharge harge
if available
Number
of
Analyses
Long-
Term
Average
Number
of
Analyses
R-endosulfan
(115-29-7)
❑
El
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)
El
❑
❑
Concentration
Mass
5.16
Heptachlor
(76-44-8)
El
❑
❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑
R
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
❑
El
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
❑
0
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)
❑
❑
El
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑
0
Concentration
Mass
5.24
PCB-1016
(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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001
Form Approved 03/05/19
OMB No. 2040-0004
WE •
1
• r-11111111101:
M011116111110, L110101".1cf-AL111•
•• 1in.
Tul
Intake
Presence or Absence
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long'
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge a
Dischuired)
Daily
Discharge
of
Analyses
Average
of
Analyses
(if arge)
if available
Toxaphene
Concentration
T::�
5.25 (8001-35-2)
0
Mass
I
I
I
I
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

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG59OO29 NCG59OO29 Snow Hill Subdivision -Well #2 WTP 001 OMB No.2040-0004
Presence or Absence Intake
check one Effluent (Optional)
Units
Pollutant Maximum Long -Term Lon Term
Believed Believed (specify) Max7imum Daily Long-Term
Monthly Average Daily Number of Number of
e
Absent Discharge Average
Discharge Discharge Analyses Analyses
(required) if available if available Value
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
© Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
1
Bromide
❑
❑
Concentration
(24959-67-9)
Mass
2
Chlorine, total
❑
❑
Concentration
Mass
residual
3.
Color
El
El
Concentration
Mass
4.
Fecal coliform
El
❑
ConcentrationMass
5
Fluoride
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
❑
❑
ConcentrationMass
7.
Nitrogen, total
El
El
Concentration
Concentration
organic (as N)
8.
Oil and grease
El
❑
Concentration
Mass
9'
Phosphorus (as
El
❑
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
❑
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
❑
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590029 NCGS90029 Snow Hill Subdivision -Well #2 WTP 001 OMB No. 2040-0004
Presence or Absence
check one Effluent Intake
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
Discharge Discharge Analyses Analyses
(required) (if available) (if available Value
12
Sulfite (as S03)
(14265.45-3)
❑
❑
Concentration
Mass
13.
Surfactants
❑
❑
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
❑
❑
Concentration
Mass
15.
Barium, total
(7440-39-3)
Concentration
Mass
16.
Boron total
(744042-8)
❑
❑
Concentration
Mass
17.
Cobalt, total
(7440-484)
❑
Concentration
Mass
18
Iron, total
(7439-89-6)
❑
Concentration
Mass
19
Magnesium, total
(7439-95-4)
❑
Concentration
Mass
20.
Molybdenum,
total
7439-98-7
❑
Concentration
Mass
21
Manganese, total
(7439-96-5)
❑
❑
Concentration
Mass
22
Tin, total
(7440-31-5)
11
❑
Concentration
Mass
23
Titanium, total
(7440-32-6)
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG590029
NCG590029 Snow Hill Subdivision -Well #2 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
Average Number of
irequired)
Discharge Discharge Analyses
Value Analyses
if available if available
24
Radioactivity
Alpha, total
❑
❑
Concentration
Mass
Beta, total
❑
❑
Concentration
Mass
Radium, total
El
El
Concentration
Mass
ConcentrationMass
Radium 226, total
El
❑
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

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No, 2040-0004
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge
(specify units)
Present Absent
1.
Asbestos
❑
2.
Acetaldehyde
❑
❑r
3.
Allyl alcohol
❑
❑r
4.
Allyl chloride
❑
5.
Amyl acetate
❑
6.
Aniline
❑
❑r
7.
Benzonitrile
❑
ED
8.
Benzyl chloride
❑
9.
Butyl acetate
❑
0
10.
Butylamine
❑
11.
Captan
❑
0
12.
Carbaryl
❑
21
13.
Carbofuran
❑
0
14.
Carbon disulfide
❑
❑✓
15.
Chlorpyrifos
❑
0
16.
Coumaphos
❑
0
17.
Cresol
❑
0
18.
Crotonaldehyde
❑
19.
Cyclohexane
❑
E
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No. 2040-0004
Presence or Absence
1 1• 1 • I
Pollutant check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
73-Present Absent
20.
2,4-D (2,4-dichlorophenoxyacetic acid)
❑
0
21.
Diazinon
❑
rv�
22.
Dicamba
❑
❑r
23.
Dichlobenil
❑
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
26.
Dichlorvos
❑
27.
Diethyl amine
❑
❑r
28.
Dimethyl amine
❑
0
29.
Dintrobenzene
❑
0
30.
Diquat
❑
❑r
31.
Disulfoton
❑
H
32.
Diuron
❑
E
33.
Epichlorohydrin
❑
0
34.
Ethion
❑
0
35.
Ethylene diamine
❑
0
36.
Ethylene dibromide
❑
❑✓
37.
Formaldehyde
❑
R
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
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No.2040-0004
'1• 1 • I �
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
rPresent Absent
39. Guthion ❑ 0
40. Isoprene ❑ 0
41.
Isopropanolamine
❑
0
42.
Kelthane
❑
M
43.
Kepone
❑
0
44.
Marathion
❑
0
45.
Mercaptodimethur
❑
B
46.
Methoxychlor
❑
E
47.
Methyl mercaptan
❑
48.
Methyl methacrylate
❑
49.
Methyl parathion
❑
0
50.
Mevinphos
❑
51.
Mexacarbate
❑
52.
Monoethyl amine
❑
53.
Monomethyl amine
❑
54.
Naled
❑
0
55.
Naphthenic acid
❑
0
56.
Nitrotoluene
❑
0
57.
Parathion
❑
0
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590029 NCG590029 Snow Hill Subdivision -Well #2 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 uniis)
Present Absent
58. Phenolsulfonate ❑
59.
Phosgene
❑
60.
Propargite
❑
0
61.
Propylene oxide
❑
62.
Pyrethrins
❑
❑�
63.
Quinoline
❑
❑✓
64.
Resorcinol
❑
0
65.
Strontium
❑
66.
Strychnine
❑
❑�
67.
Styrene
❑
0
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
O
69.
TDE (tetrachlorodiphenyl ethane)
❑
FD
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
❑
❑
71.
Trichlorofon
❑
❑�
72.
Triethanolamine
❑
Z
73.
Triethylamine
❑
2
74.
Trimethylamine
❑
0
75.
Uranium
❑
H
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
NCG59OO29
NCG59O029 Snow Hill Subdivision -Well #2 WTP 001
OMB No.2040-0004
1 'I•
1 / 1
Presence or Absence
Pollutant
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
77.
Vinyl acetate
❑ 0
78.
Xylene
❑ 0
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 03105/19
NCG59OO29 NCG590029 Snow Hill Subdivision -Well #2 WTP 001 OMB No.2040-0004
•'•I • 1 • 11 �1 �
TCDD Presence or
Congeners Absence
Pollutant Used or cnecl one Results of Screening Procedure
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD ❑❑
EPA Form 3510-2C (Revised 3-19) Page 33

Snow Hill S/D Well #2 WTP
Surry County; Permit No. NCG590029