NCG590025_Renewal (Application)_20240216

AQUA.
j Essential Utilities Company
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.
Windgate Subdivision Well #1 WTP
NPDES No. NCG590025
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.
We are requesting a waiver of any upstream sampling requirements for the site due to the
inability to collect samples at the location relevant to upstream of the discharge site.
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:
E
a�YY,ili.
9C88E0980A7B49B_.
Lauren Raup-Plummer
Engineering Manager
Aqua North Carolina, Inc.
Enc: NPDES Application, Form 2C
NPDES Application, Form 1
Windgate Subdivision Well #1 WTP NPDES Permit
Cc: Joseph Pearce
Shannon Becker
202 MacKenan Court, Cary, NC, 27511 • 919.467.8712 * AquaAmerica.com

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590025
NCG590025
Windgate Subdivision -Well #1
WTO
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
1
\-EPA
o
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•NPDES
1.1
Applicants Not Required to Submit Form 1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete 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
4 Complete Form 1 No
0 Yes 4 Complete Form ❑ No
a
and Form 2B.
1 and Form 2C.
z
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
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 [E] 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
Q
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
❑ Yes 4 Complete Form 1 �✓ No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
b 15 .
SECTIONDD•
• •
Facility Name
2.1
Windgate Subdivision -Well #1 WTP
0
2.2
EPA Identification Number
o
J
NCG590025
2.3
Facility Contact
Name (first and last)
Title
Phone number
Lauren Raup-Plummer
Engineering Manager
[phone]
Q
c
Email address
[e-mail]
2.4
Facility Mailing Address
ZStreet
or P.O. box
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
NCG590025
NCG590025
Windgate Subdivision -Well #1
OMB No. 2040-0004
y
2.5
Facility Location
wStreet,
route number, or other specific identifier
a 0
Simmons Road
`o
County name
County code (if known)
Surry
0
E _j
City or town
State ZIP code
Z
Mt. Airy
North Carolina 27030
SECTION1
NAICS CODES1
SIC Code(s)
Description (optional)
3.1
4941
Establishments primarily engaged in distributing water for sale for domestic,
N
N
O
0
U
U
Z
-a
3.2
NAICS Code(s)
Description (optional)
R
310
Water Distribution (except irrigation)
L)
M
Name of Operator
4.1
Aqua North Carolina
`0
4.2
Is the name you listed in Item 4.1 also the owner?
cc
�o
c
El Yes ❑ No
w
:
4.3
Operator Status
0
`
❑ Public —federal ElPublic—stateElOther public (specify)
CU
Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
w0
Street or P.O. Box
R
d
202 MacKenan Drive
0
City or town
State
ZIP code
0 o
Cary
North Carolina
27511
� U
a
Email address of operator
O
[e-mail]
SECTIO
5. INDIAN1
1
Is the facility located on Indian Land?
o
5.1
,
c J
❑ Yes ❑ No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590025 NCGS90025 Windgate Subdivision -Well #1 OMB No. 2040-0004
SECTION'• 1
6.1 Existing Environmental Permits (check all that apply and print or type the corresponding permit number for each)
❑✓ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
cwater)
fluids)
0 •Y
> E
NCG59002S
w a
rn
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
w
ElOcean dumping (MPRSA) ElDredge or fill (CWA Section 404) ElOther (specify)
SECTION1
7.1
Have you attached a topographic map containing all required information to this application? (See instructions for
specific requirements.)
El Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 213.)
SECTIONOF
1
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
fR
N
N
C
.y
7
m
O
is
Z
SECTION••
1
9.1
Does your facility use cooling water?
❑ Yes ID 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
a, r
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
oY
NPDES permitting authority to determine what specific information needs to be submitted and when.)
o
U �
SECTION
1 VARIANCE
REQUESTS1 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
when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
L)
R
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
❑r Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05119
NCG590025
NCG590025
Windgate Subdivision -Well #1 OMB No.2040-0004
SECTION•
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
11.1
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2
❑✓ Section 1: Activities Requiring an NPDES Permit
❑✓ w/ attachments
❑r Section 2: Name, Mailing Address, and Location
❑ w/ attachments
❑✓ Section 3: SIC Codes
❑ wl attachments
0 Section 4: Operator Information
❑ w/ attachments
0 Section 5: Indian Land
❑ wl attachments
c
❑✓ Section 6: Existing Environmental Permits
❑ wl attachments
E
❑ Section 7: Map
wl topographic
❑ w/ additional attachments
map
in
`o
❑� Section 8: Nature of Business
❑ w/ attachments
w
❑✓ Section 9: Cooling Water Intake Structures
❑ w/ attachments
-a
❑✓ Section 10: Variance Requests
❑ w/ attachments
c
y
❑✓ Section 11: Checklist and Certification Statement
Elw/ attachments
Y
d
11.2
Certification Statement
L
U
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision
in accordance with a system designed to assure that qualified personnel properly gather and evaluate the
information submitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Lauren Raup-Plummer
Engineering Manager
Signature
Date signed
DocuSigned by:
E"_p"KAtr
02/01/2024
OA7B49B.,
EPA Form 3510-1 (revised 3-19) Page 4

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCGS9( I NCG590025 I Windgate Subdivision -Well #1 1 OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
2C
Application for NPDES Permit to Discharge Wastewater
NPDES
\-/EPA
EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS
SECTIONOUTFALL
LOCATIONi
1.1 Provide information
on each of the facility's outfalls in the table below.
Ouffa
Number
Receiving Water Name
Latitude
Longitude
001
unnamed tributary to Fisher
36° 24' 29" N �
80° 40' 43" W
io
O
SECTION
D• I
cm
2.1
Have you attached a line drawing to this application that shows the water flow through your facility with a water
c 3
balance? (See instructions for drawing requirements. See Exhibit 2C-1 at end of instructions for example.)
J
c
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 o.00i mgd
c
E
mgd
d
mgd
h
mgd
3
0
Treatment
Description
Units
Code from
Final Disposal of Solid or
U_
a,
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
a'
retention time, etc.)
by Dischar e
EPA Form 3510-2C (Revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590025
NCG59002S
Windgate Subdivision -Well #1
OMB No. 2040-0004
3.1
**Outfall Number**
Cont.
Operations
Operation
Average Flow
mgd
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
retention time, etc.)
by Discharge
d
c
0
U
c
m
E
is
d
L
**Outfall Number**
Operations
_0
Operation Average Flow
U_
rn
mgd
d
>
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
retention time, etc.)
by Dischar e
3.2
Are you applying for an NPDES permit to operate a privately owned treatment works?
❑ Yes ❑� No 4 SKIP to Section 4.
N
3.3
Have you attached a list that identifies each user of the treatment works?
❑ Yes ❑ No
EPA Form 3510-2C (Revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 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 -* SKIP to Section 5.
4.2
Provide information
on intermittent or seasonal flows for each applicable outfall.
Attach additional pages, if necessar .
Frequency
Flow
Rate
Outfall
Operation
Duration
Average
Average
Long -Term
Maximum
Number
(list)
Days/Week
MonthsNear
Average
Dail
WTP Backwash Dischari
7 days/week
12 months/year
0.001 mgd
0.001 mgd
176 days
30
001
days/week
months/year
mgd
mgd
days
LL
days/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
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
5.1
❑ Yes ❑� No -* SKIP to Section 6.
5.2
Provide the following information on applicable ELGs.
CD
ELG Category
ELG Subcategory
Regulatory Citation
m
ra
c.�
a
a
Q
5.3
Are any of the applicable ELGs expressed in terms of production (or other measure of operation)?
c
❑ Yes No -* SKIP to Section 6.
0
w
5.4
Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
J
Outfall
Operation, Product, or Material
Quantity per Day
Unit of
a
Number
Measure
h
16
m
C
O
7
O
a
EPA Form 3510-2C (Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG59002S NCG590025 Windgate Subdivision -Well #1 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 ❑v, 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
o
Project
(list outfall
Discharge
Required
Projected
Q
number
E
cc
N
d
�
I
CL
O-
_
6.3
Have you attached sheets describing any additional water pollution control programs (or other environmental projects
that may affect your discharges) that you now have underway or planned? (optional item)
❑ Yes ❑ No Not applicable
SECTIONi
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
complete. Not all applicants need to complete each table.
Table A. Conventional and Non -Conventional Pollutants
7.1
Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
❑✓ Yes ❑ No 4 SKIP to Item 7.3.
7.2
If yes, indicate the applicable outfalls below. Attach waiver request and other required information to the application.
Outfall Number 001 Outfall Number Outfall Number
7.3
Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
y
requested and attached the results to this application package?
No; a waiver has been requested from my NPDES
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.
cc
15
7.5
Have you checked "Testing Required" for all toxic metals, cyanide, and total phenols in Section 1 of Table B?
w
❑ Yes 0 No
7.6
List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s) identified
in Exhibit 2C-3.
Required GC/MS Fraction(s)
Primary Industry Category
Check applicable boxes.
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
EPA Form 3510-2C (Revised 3-19) Page 4

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590O25
NCG590025
Windgate Subdivision -Well #1
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 4 Note that you qualify at the top of Table B, ❑ No
then SKIP to Item 7.12.
'=
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?
y
tYq
❑ Yes El No
W
Table C. Certain Conventional and Non -Conventional Pollutants
M
7.12
Have you indicated whether pollutants are 'Believed Present' or `Believed Absent' for all pollutants listed on Table C
for all outfalls?
Y
Q Yes ❑ No
z
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
d
❑ Yes 0 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 ❑✓ No
Table E. 2,3,7,8-Tetrachlorod ibenzo- -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
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
❑ Yes ❑ No + SKIP to Section 9.
8.2
List the pollutants below.
c_
2 10
1. 4. 7.
0
d
2. 5. 8.
f/J
F3. 6. 9.
EPA Form 3510-2C (Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG59002S NCG590025 Windgate Subdivision -Well #1 OMB No. 2040-0004
SECTION• •TOXICITY
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.
Z.
.5
Purpose of Test(s)
Submitted to NPDES
Submitted
Date Submitted
x
Permitting Authority?
0
R
❑ Yes ❑ No
0
0
in
❑ 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
fR
Laboratory address
5 Pinewood Plaza Dr
c
Granite Falls, NC 28630
a
0
c.�
Phone number
[phone]
Pollutant(s) analyzed Total Suspended Solids
SECTIONDD
• O• • i
Has the NPDES permitting authority requested additional
information?
11.1
❑ Yes
No 4 SKIP to Section 12.
0
11.2
List the information requested and attach it to this application.
E
0
1. 4.
R
c
0
v
2. 5.
a
3. 6.
EPA Form 3510-2C (Revised 3-19) Page 6

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCGS90025 NCG59002S Windgate Subdivision -Well #1 OMB No.2040-0004
SECTIONMall
• 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
M Section 2: Line Drawing
0 w/ line drawing ❑ w/ additional attachments
Section 3: Average Flows and
wl list of each user of
w/ attachments ❑ privately owned treatment
Treatment
works
❑ Section 4: Intermittent Flows
❑ w/ attachments
❑ Section 5: Production
❑ w/ attachments
wl 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
w/ small business exemption
❑ ❑ wl other attachments
E
request
in
❑ Section 7: Effluent and Intake
❑ w/ Table A ❑✓ w/ Table B
Characteristics
❑✓ w/ Table C ❑✓ w/ Table D
❑ w/ analytical results as an
❑ wl Table E
attachment
Section 8: Used or Manufactured
El
❑ 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
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly
responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true,
accurate, and complete. I am aware that there are significant penalties for submitting false information, including the
possibility of fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Lauren Raup-Plummer
Engineering Manager
Signature oocu3igned by:
Date signed
E"—p"M�
9C8BE0980A7B49B_.
02/01/2024
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
NCG590025 NCG590025 Windgate Subdivision -Well #17
001
OMB No. 2040-0004
Effluent
Intake
Waiver
0 tional
Maximum
Maximum
Long -Term
177
Requested Units
(specify)
Daily
Monthly
Average Daily
Number of
Long -Term
Number of
(if applicable)
Discharge
Discharge
Discharge
Analyses
Average Value
Analyses
(required)
if available
if available
to your NPDES permitting authority
for a waiver for a// 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)
0
Mass
Concentration
4.
Total suspended solids (TSS)
❑✓
Mass
Concentration
5.
Ammonia (as N)
❑✓
Mass
6.
Flow
❑
Rate
gpd
1400
1145.45
176
Temperature (winter)
0
°C
°C
7.
Temperature (summer)
R
°C
°C
pH (minimum)
❑
Standard units
S.U.
6.46
7.0
80
8.
pH (maximum)
❑
Standard units
S.u.
8.21
7.0
80
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 9

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 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
(required)
(if available)
if available
Value
❑ Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.
Section 1. Toxic Metals, Cyanide, and Total Phenols
1.1
Antimony, total
❑
❑
❑
Concentration
Mass
(7440-36-0)
1.2
Arsenic, total
El
❑
❑
Concentration
Mass
(7440-38-2)
1.3
Beryllium, total
❑
❑
Concentration
Mass
(7440-41-7)
1.4
Cadmium, total
El
El
❑
Concentration
Mass
(7440-43-9)
1.5
Chromium, total
❑
❑
❑
Concentration
Mass
(7440-47-3)
1.6
Copper, total
El
❑
El
Concentration
Mass
(7440-50-8)
1.7
Lead, total
❑
El
❑
Concentration
Mass
(7439-92-1)
1.8
Mercury, total
El
El
El
Concentration
Concentration
(7439-97-6)
1.9
Nickel, total
❑
❑
❑
Concentration
Mass
(7440-02-0)
1.10
Selenium, total
❑
El
Concentration
Concentration
Mass
(7782-49-2)
1.11
Silver, total
❑
❑
❑
Concentration
Mass
(7440-22-4)
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 I Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Lon
(and CAS Number, if available)
(and
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Absentof
Discharge
Discharge
DisDcha�ge
Analyses
Average
Analyses
(required)
(if available)Valueif
available
1.12
Thallium, total
El
El
✓
Concentration
Mass
(7440-28-0)
1.13
Zinc total
✓
Concentration
Mass
(7440-66-6)
1.14
Cyanide, total
✓
Concentration
Mass
(57-12-5)
1.15
Phenols, total
El
11
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
✓
Concentration
Mass
(71-43-2)
2.4
Bromoform
Z
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
El
El
Concentration
Mass
(108-90-7)
2.7
Chlorodibromomethane
Concentration
Mass
(124-48-1)
2.8
Chloroethane
✓
Concentration
Mass
(75-00-3)
EPA Form 3510-2C (Revised 3-19) Page 12

aenntication Number NPUES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
amilygovig1
Pollutant/Parameter
(and
(and CAS Number, if available)
•
Testing
Required
• 1 •'
Presence or Absence
check one
• •• 1
Units
(p fy)
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
DisDaily
charge
if available)Value
Number
of
Analyses
Long -
Term
Average
Number
of
Analyses
2'9
2-chloroethylvinyl ether
(110-75-8)
❑
❑
❑
Concentration
Mass
2.10
Chloroform (67-66-3)
ID
Concentration
Mass
2.11
Dichlorobromomethane
(75-27-4)
El
El
El
Concentration
Mass
2.12
1,1-dichloroethane
(75-34-3)
✓
Concentration
Mass
2.13
1,2-dichloroethane
(107-06-2)
El
El
✓
Concentration
Mass
2.14
1,1-dichloroethylene
(75-35-4)
El
1:1
✓
Concentration
Mass
2.15
12-dichloropropane
(78 87 5)
El
✓
Concentration
Mass
2.16
1,3-dichloropropylene
(542-75-6)
El
El
0
Concentration
Mass
217
Ethylbenzene
(100-41-4)
El
11
0
Concentration
Mass
2.18
Methyl bromide
(74-83-9)
21
Concentration
Mass
2.19
Methyl chloride
(74-87-3)
El
El
El
Concentration
Mass
2.20
Methylene chloride
(75-09-2)
z
Concentration
Mass
221
1, 1,2,2- tetrachloroethane
(79-34-5)
1Mass
z
Concentration
EPA Form 3510-2C (Revised 3-19) Page 13

EPA Identification Number NHutS Hermit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1
001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
(and
•
Testing
Required
• 1 •-
Presence or Absence
check one
• •• 1
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absentof
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)Value
Long -Term
Average
Discharge
f available
Number
Analyses
Long -
Term
Average
Number
Analyses
2 22
Tetrachloroethylene
(127-18-4)
❑
Concentration
Mass
2.23
Toluene
(108-88-3)
❑
❑�
Concentration
Mass
224
1,2-trans-dichloroethylene
(156-60-5)
❑
❑
❑✓
Concentration
Mass
2 25
1,1,1-trichloroethane
(71-55-6)
El
❑
❑�
Concentration
Mass
2.26
1,1,2-trichIoroethane
(79-00-5)
El
El
El
Concentration
Mass
2.27
Trichloroethylene
(79-01-6)
❑
El
Concentration
Mass
2.28
Vinyl chloride
(75-01-4)
El
❑
Concentration
Mass
Section 3.Organic Toxic Pollutants (GCIMS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
(95-57-8)
El
El
El
Concentration
Mass
3.2
2,4-dichlorophenol
(120-83-2)
❑
❑
❑
Concentration
Mass
3.3
2,4-dimethylphenol
(105-67-9)
❑
❑
©
Concentration
Mass
3.4
4,6-dinitro-o-cresol
(534-52-1)
El
El
El
Concentration
Mass
3.5
2,4-dinitrophenol
(51-28-5)
El
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No. 2040-0004
• 1
•
• 1 • •
• • • 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
DAve
Dfacg
Daily
Discharge
of
Analyses
e
of
Analyses
(reghed9e
ailable)
if available
Value
3.6
2-nitrophenol
❑
❑
❑
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
El
El
El
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
❑
❑❑
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
El✓
Concentration
Mass
(87-86-5)
3.10
Phenol
El
El
21
Concentration
Mass
(108-95-2)
3.11
2,4,6-trichlorophenol
ncentration
rMass
(88-05-2)
Section 4.Organic Toxic Pollutants (GC/MS
Fraction
—Base /Neutral
Compounds)
4.1
Acenaphthene
❑
❑
0
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
Concentration
Mass
(208-96-8)
4.3
Anthracene
El
11
El
Concentration
Mass
(120-12-7)
4.4
Benzidine
❑
❑
©
Concentration
Mass
(92-87-5)
4.5
Benzo (a) anthracene
El
❑
ID
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
❑
❑
S
Concentration
Mass
(50-32-8)
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Testing
Required
Presence or Absence
check one
Im
Units
(specify)
Effluent
Intake
(optional)
Poll utant/Parameter
(and CAS Number, if available)
Believed
Present
Believed
Absent
Maximum
Daily
D(eq h (required)
Maximum
Monthly
Di
scharge f available)
e)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
4.7
3,4-benzofluoranthene
(205-99-2)
❑
❑
❑
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
El
❑
❑
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
❑
❑
©
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
❑
❑
❑✓
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
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
(91-58-7)
❑
❑
0
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
El
El
✓
Concentration
Mass
4.18
Chrysene
(218-01-9)
El
El
✓
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
❑
❑
✓❑
Concentration
1 Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available)
Required
4
Believed
Believed
(specify)
(p �)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
4.20
1,2-dichlorobenzene
O
Concentration
Mass
(95-50-1)
4.21
13-dichlorobenzene
✓
Concentration
Mass
(541-73-1)
4.22
1,4-dichlorobenzene
1:1
El
✓
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
El
El
El
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
El
El
21
Concentration
Mass
(84-66-2)
4.25
Dim ethyl phthalate
✓
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
0
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
El
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
Z
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
H
Concentration
Mass
(117-84-0)
4.30
1,2-Dipheny1hydrazine
El
El
R
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
El
1:1
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
El
1:1
E
Concentration
Mass
(86-73-7)
1
1
1
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Lon
(and CAS Number, if available)
(and
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Absent
Discharge
Discharge
Daily
Discharge
°f
Analyses
Average
°
Analyses
(required)
(if available)
if available
Value
4.33
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
❑
❑
Concentration
Mass
(67-72-1)
4.37
Indeno (1,2,3-cd) pyrene
❑
❑
❑✓
Concentration
Mass
(193-39-5)
4.38
Isophorone
❑
Concentration
Mass
(78-59-1)
4.39
Naphthalene
❑
❑
❑
Concentration
Mass
(91-20-3)
4.40
Nitrobenzene
❑
El
❑
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
❑
El
❑✓
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
El
El
El
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
❑
❑
F-11
Concentration
Mass
(86-30-6)
4.44
Phenanthrene
❑
❑
❑✓
Concentration
Mass
(85-01-8)
4.45
PyreneEl
El
El
Concentration
Mass
(129-00-0)
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available )
14.461,2,4-trichlorobenzene
Required
q
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
of
Average
of
(required)
(if available)
DisDaily
charge
Analyses
Analyses
if available)Value
Concentration
Mass
(120-82-1)
Section 5.Organic Toxic Pollutants (GC/MS
Fraction
—Pesticides
5.1
Aldrin
❑
❑
H
Concentration
Mass
(309-00-2)
5.2
a-BHC
El❑
Concentration
Mass
(319-84-6)
5.3
R-BHC
El
El
Z
Concentration
Mass
(319-85-7)
5.4
y-BHC
El
1:1
21
Concentration
Mass
(58-89-9)
5.5
b-BHC
El
Concentration
Mass
(319-86-8)
5.6
Chlordane
El
El
El
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
❑
❑
Z
Concentration
Mass
(72-54-8)
5.10
Dieldrin
El
El
21
Concentration
Mass
(60-57-1)
5.11
a-endosulfan
❑
❑
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

EPA Identification Number NPDES Permit Number
NCG590025 NCG590025
Name
Windgate Subdivision -Well #1
Outfall Number
001
Form Approved 03/05/19
OMB No. 2040-0004
•
1
•
now / •'
Presence or Absence
check one
• '• 1
Units
(specify)
Effluent
Intake
(optional)
Pollutant/Parameter
(and
(and CAS Number, if available)
Testing
Required
Believed
Present
Believed
Absent
Maximum
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Lon
Term
Average
Value
Number
of
Analyses
5.12
R-endosulfan
(115-29-7)
❑
❑
✓
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
Concentration
Mass
5.14
Endrin
(72-20-8)
El
1:1
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
Concentration
Mass
5.16
Heptachlor
(76-44-8)
❑
❑
21
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
❑
E
Concentration
Mass
5.19
PC13-1254
(11097-69-1)
❑
El
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)
❑
❑
H
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
El
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
El
ElEl
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

oentitication Number NPDES Permit Nu
NCG590025 NCG590025
Name
Windgate Subdivision -Well #1
ill 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 CAS Number, if available)
15.25
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
(iischarge
Daily
Discharge
of
Analyses
Average
of
Analyses
i ed
f available)
if available
Toxaphene
Concentration
Mass
(8001-35-2)
t Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG59OO25 NCG59OO25 Windgate Subdivision -Well #1 001 OMB No. 2040-0004
Presence or Absence Intake
check one Effluent (Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
Discharge Discharge Analyses Analyses
(required) Value
if available if available
❑ 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
El
Concentration
Mass
4.
Fecal coliform
El
ElConcentrationMass
5
Fluoride
❑
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
El
El
Concentration
Mass
7'
Nitrogen, total
❑
❑
Concentration
Mass
organic (as N)
8.
Oil and grease
El
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)
❑
ElMassncentration
Co
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590O25 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant
Presence or Absence
check one
Effluent
7
Intake
(Optional)
Units
(specify)Maximum
)
Believed
Present
Believed
Absent
Maximum Daily
Discharge
(required)
Monthly
Discharge
f available
Long -Term
Average Daily
Discharge
if available
Number of
Analyses
Long -Term
Average
Value
Number of
Analyses
12
Sulfite (as S03)
(1426545-3)
❑
❑
Concentration
Mass
13.
Surfactants
❑
❑
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
❑
❑
Concentration
Mass
15.
Barium, total
(7440-39-3)
❑
❑
Concentration
Mass
16.
Boron, total
(744042-8)
❑
❑
Concentration
Mass
17.
Cobalt, total
(7440484)
❑
❑
Concentration
Mass
18
Iron total
(7439-8M)
❑
❑
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)
❑
ElConcentration
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
NCG59O025
NCG590025
Windgate Subdivision -Well #1
001
OMB No. 2040-0004
•
•
• •
• ••
1
Presence or Absence
Intake
check one
Effluent
(Optional)
Pollutant
Believed
Believed
Unitsnce
(specify)
Maximum Daily
Maximum
Long -Term
Long -Term
Present
Absent
Discharge
MonthlyAverage
DailNumber of
gy
Number of
Average
(required)
Discharge
Discharge Analyses
Analyses
if available
if available)Value
24.
Radioactivity
Alpha, total
El
El
Concentration
Mass
Beta, total
❑
�
Concentration
Mass
Radium, total
El
El
Concentration
Mass
Radium 226, total
El
El
Concentration
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No.2040-0004
1 • 1 ,DIXON
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
1. Asbestos ❑ R
2.
Acetaldehyde
❑
0
3.
Allyl alcohol
❑
4.
Ally] chloride
❑
5.
Amyl acetate
❑
6.
Aniline
❑
❑r
7.
Benzonitrile
❑
2
8.
Benzyl chloride
❑
❑r
9.
Butyl acetate
❑
0
10.
Butylamine
❑
❑r
11.
Captan
❑
12.
Carbaryl
❑
El
13.
Carbofuran
❑
Z
14.
Carbon disulfide
❑
E
15.
Chlorpyrifos
❑
ED
16.
Coumaphos
❑
0
17.
Cresol
❑
P,1
18.
Crotonaldehyde
❑
0
19.
Cyclohexane
❑
P,1
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 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
20.
2,4 D (2,4 dichlorophenoxyacetic acid)
❑
0
21.
Diazinon
❑
0
22.
Dicamba
❑
0
23.
Dichlobenil
❑
24.
Dichlone
❑
25.
2,2-dichloropropionic acid
❑
❑�
26.
Dichlorvos
❑
0
27.
Diethyl amine
❑
0
28.
Dimethyl amine
❑
0
29.
Dintrobenzene
❑
0
30.
Diquat
❑
0
31.
Disulfoton
❑
0
32.
Diuron
❑
0
33.
Epichlorohydrin
❑
0
34.
Ethion
❑
35.
Ethylene diamine
❑
❑
36.
Ethylene dibromide
❑
0
37.
Formaldehyde
❑
0
38.
Furfural
❑
0
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No.2040-0004
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
❑
❑✓
41.
Isopropanolamine
❑
❑r
42.
Kelthane
❑
❑�
43.
Kepone
❑
0
44.
Malathion
❑
❑r
45.
Mercaptodimethur
❑
❑r
46.
Methoxychlor
❑
❑r
47.
Methyl mercaptan
❑
E
48.
Methyl methacrylate
❑
❑✓
49.
Methyl parathion
❑
0
50.
Mevinphos
❑
❑✓
51.
Mexacarbate
❑
0
52.
Monoethyl amine
❑
❑✓
53.
Monomethyl amine
❑
54.
Naled
❑
0
55.
Naphthenic acid
❑
0
56.
Nitrotoluene
❑
2
57.
Parathion
❑
ID
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No.2040-0004
I 1
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
58. Phenolsulfonate El 0
59.
Phosgene
El ❑
00.
Propargite
❑ ❑
61.
Propylene oxide
❑ 12
62.
Pyrethrins
❑
f -.11
63.
Quinoline
❑
Z
64.
Resorcinol
❑
65.
Strontium
❑
H
66.
Strychnine
❑
H
67.
Styrene
❑
2
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetrachlorodiphenyl ethane)
❑
0
70.
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
❑
❑
71.
Trichlorofon
❑
Z
72.
Triethanolamine
❑
ED
73.
Triethylamine
❑
❑�
74.
Trimethylamine
❑
75.
Uranium
❑
❑�
76.
Vanadium
❑
0
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
NCG590025
NCG590025 Windgate Subdivision -Well #1 001
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
spedunits)
Present Absent
77.
Vinyl acetate
❑
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 3510-21C (Revised 3-19) Page 31

This page intentionally left blank.

EPA Identification Number
NCG590025
Pollutant
2,3,7,8-TCDD
NCG590025 Windgate Subdivision -Well #1
• P 1 • 1I 1
TCDD Presence or
Congeners Absence
Used or check one
Manufactured Believed Believed
Present Absent
❑ I ❑ I 2_1
001
Results of Screening Procedure
Form Approved 03/05/19
OMB No. 2040-0004
EPA Form 3510-2C (Revised 3-19) Page 33

Aqua North Carolina, Inc. Facility
Windgate Subdivision Well #1 WTP Location
at ittdet 36° 24' 29 N State Grid: Dobson not to -scale
Loagitude: 80' 40' 43" W Permitted Flow: 0.00168 MGD
Beeeivine Strew: UT to Fisher River Stream Class: C North
/O7 *� NPDES Permit No. NC0088609
Drabaate Bain: Yadkin -Pee Dee River Basin Sub -Basin: 03-07-02 L V - 6 Surry County

Windgate S/D Well #1 WTP
Surry County; Permit No. NCG590025

AOUAWA
An AEssential 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.
Windgate Subdivision Well #1 WTP
NPDES No. NCG590025
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.
We are requesting a waiver of any upstream sampling requirements for the site due to the
inability to collect samples at the location relevant to upstream of the discharge site.
Should you need any additional information or assistance, please feel free to contact me via
phone [phone]) or by email at [e-mail].
Sincerely,
CDocuSigned by: I. Y.bI. r4l-r"Mv
9C8BE0980A7B49B...
Lauren Raup-Plummer
Engineering Manager
Aqua North Carolina, Inc.
Enc: NPDES Application, Form 2C
NPDES Application, Form 1
Windgate Subdivision Well #1 WTP NPDES Permit
Cc: Joseph Pearce
Shannon Becker
202 MacKenan Court, Cary, NC, 27511 • 919.467.8712 • AquaAmerica.com

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590025
NCG590025
Windgate Subdivision -Well #1
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
1
\=/EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•NPDES
1.1
Applicants Not Required to Submit Form 1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete 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
4 Complete Form 1 0 No
Yes 4 Complete Form ❑ No
z
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?
a
Yes 4 Complete Form 1 ❑� No
❑ Yes 4 Complete Form No
b)
and Form 2D.
1 and Form 2E.
CD
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 .
SECTIONADDRESS,
• • r
2.1
Facility Name
Windgate Subdivision -Well #1 WTP
0
2.2
EPA Identification Number
R
C
J
NCG590025
13
2.3
Facility Contact
Name (first and last)
Title
Phone number
Q
Lauren Raup-Plummer
Engineering Manager
[phone]
c
Email address
[e-mail]
2.4
Facility Mailing Address
ZStreet
or P.O. box
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
NCG590025
NCG590025
Windgate Subdivision -Well #1
VAITn
OMB No. 2040-0004
v;
2.5
Facility Location
wStreet,
route number, or other specific identifier
Q o
U
Simmons Road
CM
c
County name
County code (if known)
cc
Surry
0
City or town
State ZIP code
Z
Mt. Airy
North Carolina 27030
SECTION•D
1
Description (optional)
3.1
SIC Code(s)
4941
Establishments primarily engaged in distributing water for sale for domestic,
�i a ...a„-; ,1 ,
Nf
N
O
0
U
N
t�
Z
-0
3.2
NAICS Code(s)
Description (optional)
R
310
Water Distribution (except irrigation)
C)
Name of Operator
4.1
Aqua North Carolina
`0_
4.2
Is the name you listed in Item 4.1 also the owner?
0
❑� Yes ❑ No
4.3
Operator Status
0
❑ ❑ Public ❑ Other (specify)
Public —federal —state public
o
Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
w
Street or P.O. Box
cc
202 MacKenan Drive
City or town
State
ZIP code
0 0
Cary
North Carolina
27511
R
n
Email address of operator
O
[e-mail]
SECTIONI
Is the facility located on Indian Land?
5.1
c J
❑ Yes ❑ No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 OMB No.2040-0004
'ECTION 6. EXISTING ENVIRONMENTAL1
m 6.1 Existing Environmental Permits (check all that apply and print or type the corresponding permit number for each)
❑✓ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
o
water)
fluids)
.y
NCG590025
LU a
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
x
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section 404)
❑ Other (specify)
w
h
y
a�
c
.N
m
0
0
m
A
z
7.1 Have you attached a topographic map containing all required information to this application? (See instructions for
specific requirements.)
Z Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 2B.)
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
9.1 1 Does your facility use cooling water?
❑ Yes ❑r No 4 SKIP to Item 10.1.
R 9.2 Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
o, 40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
o Y NPDES permitting authority to determine what specific information needs to be submitted and when.)
o
U c
y 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
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
R❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
R 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
NCG590025
NCG59002S
Windgate Subdivision -Well #1 OMB No.2040-0004
SECTION•
CERTIFICATION
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
11.1
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2
0 Section 1: Activities Requiring an NPDES Permit
❑✓ w/ attachments
Section 2: Name, Mailing Address, and Location
❑ w/ attachments
Section 3: SIC Codes
❑ w/ attachments
❑✓ Section 4: Operator Information
❑ w/ attachments
❑✓ Section 5: Indian Land
❑ wl attachments
❑✓ Section 6: Existing Environmental Permits
❑ w/ attachments
E
❑✓ Section 7: Map
w/ topographic
0 El w/ additional attachments
map
ca
c
❑✓ Section 8: Nature of Business
Elw/ attachments
w
❑� Section 9: Cooling Water Intake Structures
❑ w/ attachments
❑� Section 10: Variance Requests
❑ w/ attachments
c
h
Section 11: Checklist and Certification Statement
❑ w/ attachments
Y
d
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
by:
CDocuSigned
am. �q p.P yt4u/
02/01/2024
9CBBE0980A7B49B_.
EPA Form 3510-1 (revised 3-19) Page 4

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 OMB No. 2040-0004
Form U.S. Environmental Protection Agency
2C V-/EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS
SECTIONOUTFALL LOCATION
1.1 Provide information on each of the facility's outfalls in the table below.
Outfa
Number Receiving Water Name Latitude Longitude
V
001 unnamed tributary to Fisher 36' 24' 29" N � 80° 40' 43" W
R
4! o n o n
7
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 `
o ❑� Yes ❑ No
ECTION 3. AVERAGE FLOWSi
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
�o
d
-o
U)
3
0
U_
o, Description
(include size, flow rate through each treatment unit,
> retention time, etc.
Average Flow
o.00i mgd
mgd
mgd
mgd
Code from Final Disposal of Solid or
Table 2C-1 Liquid Wastes Other Than
by Discharge
EPA Form 3510-2C (Revised 2-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590025
NCG590025
Windgate Subdivision -Well #1
OMB No. 2040-0004
3.1
**Outfall Number**
cont.
Operations ,
Operation Average Flow
mgd
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than i
retention time, etc.)
by Discharge
a
d
c
0
U
c
m
E
is
m
F-
**Outfall Number**
Operations Contributing
to Flow
0
Operation
Average Flow
U_
a,
mgd
a
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
retention time, etc.)
by Dischar e
3.2
Are you applying for an NPDES permit to operate a privately owned treatment works?
W d
❑ Yes 0 No 4 SKIP to Section 4.
(n Zn
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
NCG590025 NCG590025 Windgate Subdivision -Well #1 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.
Freq
uency
Flow
Rate
Outfall
Operation
Duration
Average
Average
Long -Term
Maximum
Number
(list)
Days/Week
MonthsNear
Average
Dail
WTP Backwash Dischar
7 days/week
12 months/year
0.001 mgd
0.001 mgd
176 days
W
30
001
days/week
months/year
mgd
mgd
days
LL
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
c
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week months/year mgd mgd days
SECTION"•1
• 1
5.1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes ❑r No 4 SKIP to Section 6.
H
5.2
Provide the following information on applicable ELGs.
w
ELG Category
ELG Subcategory
Regulatory Citation
d
R
.Q
CL
a
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
;g
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
U)
R
m
C
O
V
3
V
O
a
EPA Form 3510-2C (Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 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.
Affected
Final Compliance Dates
E
Brief Identification and Description of
Outfalls
Source(s) of
c
Project
(list outfall
Discharge
Required
Projected
fl-
number
E
M
R
d
-o
L
aL
a
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 E] Not applicable
SECTIONt
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
complete. Not all applicants need to complete each table.
Table A. Conventional and Non -Conventional Pollutants
7.1
Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
❑✓ Yes ❑ No 4 SKIP to Item 7.3.
7.2
If yes, indicate the applicable outfalls below. Attach waiver request and other required information to the application.
Outfall Number 001 Outfall Number Outfall Number
7.3
Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
y
requested and attached the results to this application package?
No; a waiver has been requested from my NPDES
❑✓ Yes ❑permitting
authority for all pollutants at all outfalls.
Table B.
Toxic Metals, Cyanide, Total Phenols, and Organic Toxic Pollutants
7.4
Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
listed in Exhibit 2C-3? (See end of instructions for exhibit.)
❑ Yes ❑ No 4 SKIP to Item 7.8.
3
7.5
Have you checked "Testing Required" for all toxic metals, cyanide, and total phenols in Section 1 of Table B?
w
❑ Yes No
7.6
List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s) identified
in Exhibit 2C-3.
Primary Industry Category
Required GC/MS Fraction(s)
Check applicable boxes.
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
EPA Form 3510-2C (Revised 3-19) Page 4

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590025
NCG590025
Windgate Subdivision -Well #1
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?
El 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 E] No
7.10
Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
❑ Yes 4 Note that you qualify at the top of Table B, ❑ No
then SKIP to Item 7.12.
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,
H
pollutants you have indicated are "Believed Present" in your discharge?
"
N
❑ Yes 0 No
4)
Table C. Certain Conventional and Non -Conventional Pollutants
12
7.12
Have you indicated whether pollutants are 'Believed Present' or 'Believed Absent' for all pollutants listed on Table C
for all outfalls?
0 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'?
c
d
❑ 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 4 Complete Table E. ❑ No 4 SKIP to Section 8.
7.17
Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes ID No
SECTIONOR
MANUFACTURED TOXICSi
Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
8.1
an intermediate or final product or byproduct?
❑ Yes ❑ No 4 SKIP to Section 9.
! U)
8.2
List the pollutants below.
ccc
X
1. 4. 7.
0
2. 5. 8.
NJ
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
NCG590025 NCG590025 Windgate Subdivision -Well #1 OMB No.2040-0004
SECTION• • • I
9.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on (1) any of your discharges or (2) on a receiving water in relation to your discharge?
❑ Yes ❑✓ No -* SKIP to Section 10.
VJ
9.2
Identify the tests and their
ur oses below.
w
Test(s)
Purpose of Test(s)
Submitted to NPDES
Date Submitted
x
Permitting Authority?
0
cc
❑ Yes ❑ No
0
m
❑ Yes ❑ No
❑ Yes ❑ No
SECTIONi
CONTRACT
ANALYSES (40
Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
10.1
❑✓ Yes ❑ No 4 SKIP to Section 11.
10.2
Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1
Laboratory Number 2
Laboratory Number 3
Name of laboratory/firm
Water Tech Laboratories Inc
H
d
U,
Laboratory address
5 Pinewood Plaza Dr
=
Granite Falls, NC 28630
Q
ea
c
0
U
Phone number
[phone]
Pollutant(s) analyzed Total Suspended Solids
SECTIONDD
• •• • i
Has the NPDES permitting authority requested additional
information?
11.1
c
❑ Yes
❑✓ No 4 SKIP to Section 12.
0
E
11.2
List the information requested and attach it to this application.
E
0
c
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
NCG590025
NCG590025 Windgate Subdivision -Well #1 OMB No. 2040-0004
SECTION1
CERTIFICATION STATEMENT (40
12.1
In Column 1 below, mark the sections of Form 2C that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to com lete all sections or provide attachments.
Column 1
Column 2
Section 1: Outfall Location
❑✓ w/ attachments
❑✓ Section 2: Line Drawing
0 w/ line drawing ❑ w/ additional attachments
Section 3: Average Flows and
0
wl list of each user of
❑✓ 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
❑ w/ request for a waiver and ❑ wl explanation for identical
supporting information outfalls
w/ small business exemption
El E] w/ other attachments
E
request
❑ Section 7: Effluent and Intake
❑ w/ Table A ❑✓ w/ Table B
Characteristics
w/ Table C ❑✓ wl Table D
E] w/ Table E ❑ w/ analytical results as an
attachment
❑ Section 8: Used or Manufactured
E] w/ attachments
y
Toxics
Section 9: Biological Toxicity
❑
❑ w/ attachments
�'
L
Tests
U
❑ Section 10: Contract Analyses
❑ w/ attachments
❑ Section 11: Additional Information
❑ wl attachments
© Section 12: Checklist and
❑ w/ attachments
Certification Statement
12.2
Certification Statement
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 oocuSigned by:
Date signed
EK'ay—PILWMV
scasEossoA�B4se
02/01/2024
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
Il NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No. 2040-0004
\�/TA
Effluent Intake
Waiver 0 tional
Pollutant Requested Units Maximum Maximum Long -Term
(specify) Daily Monthly Average Daily Number of Long -Term Number of
(if applicable)
Discharge Discharge Discharge Analyses Average Value Analyses
(required) if available if available
❑
Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.
1'
Biochemical oxygen demand
❑
Concentration
Mass
(BOD5)
2'
Chemical oxygen demand
❑
Concentration
(COD)
Mass
Concentration
3.
Total organic carbon (TOC)
❑✓
Mass
Concentration
4.
Total suspended solids (TSS)
0
Mass
Concentration
5.
Ammonia (as N)
❑✓
Mass
6.
Flow
❑
Rate
gpd
1400
1145.45
176
Temperature (winter)
°C
°C
7.
Temperature (summer)
°C
°C
pH (minimum)
❑
Standard units
S.U.
6.46
7.0
80
8.
pH (maximum)
❑
Standard units
S.U.
8.21
7.0
80
SamDlino shall be conducted according
to sufficiently sensitive test Drocedures li.e.. methodsl gDDroved under 40 CFR
136 for the analvsis, of nolliitants nr nnllutant narameters nr
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
NCG590025 NCG590025
Name
Windgate Subdivision -Well #1
Outfall Number
001
Form Approved 03/05/19
OMB No. 2040-0004
In. TM
Presence or Absence
Intake
check one
Effluent
(optional)
PollutantlParameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and
(and CAS Number, if available)
1El
Required
Believed
Believed
(specify)
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Average
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.
Section 1. Toxic Metals, Cyanide, and Total Phenols
1.1
Antimony, total
El
El
21
Concentration
Mass
(7440-36-0)
1.2
Arsenic, total
El
El
2
Concentration
Mass
(7440-38-2)
1.3
Beryllium, total
❑
❑
❑
Concentration
Mass
(7440-41-7)
1.4
Cadmium, total
El
El
Concentration
Mass
(7440-43-9)
1.5
Chromium, total
El
11
El
Concentration
Mass
(7440-47-3)
1.6
Copper, total
El
❑
❑
Concentration
Mass
(7440-50-8)
1.7
Lead, total
❑
Concentration
Mass
(7439-92-1)
1.8
Mercury, total
El
1:1
El
Concentration
Mass
(7439-97-6)
1.9
Nickel, total
Concentration
Mass
(7440-02-0)
1.10
Selenium, total
El
11
El
Concentration
Mass
(7782-49-2)
1.11
Silver, totalEl
El
[D
Concentration
Mass
(7440-22-4)
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Identitication Number NFUtb rermit Number Facility Name Outtall Number
NCG590025 NCG590 I Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
MUM
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
s
(recaredre))
Daily
Discharge
of
Analyses
Average
of
Analyses
(if available)
if available
Value
1.12
Thallium, total
❑
Concentration
Mass
(7440-28-0)
1.13
Zinc total
El
El
✓
Concentration
Mass
(7440-66-6)
1.14
Cyanide, total
❑
❑
❑
Concentration
Mass
(57-12-5)
1.15
Phenols, total
❑
❑
El
Concentration
Mass
Section 2.Organic Toxic Pollutants (GC/MS
Fraction
—Volatile Compounds)
2.1
Acrolein
1:1
El
✓
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
El
El
El
Concentration
Mass
(107-13-1)
2.3
Benzene
❑
❑
❑✓
Concentration
Mass
(71-43-2)
2.4
Bromoform
❑✓
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
El
El
❑
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
❑
❑
✓❑
Concentration
Mass
(108-90-7)
2.7
Chlorodibromomethane
✓
Concentration
Mass
(124-48-1)
2.8
Chloroethane
El
❑
❑
Concentration
Mass
(75-00-3)
EPA Form 3510-2C (Revised 3-19) Page 12

Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
(required)
(if available)
Discharge
chare
Analyses
Value
Analyses
if available
2'9
2-chloroethylvinyl ether
El
El
Concentration
Mass
(110-75-8)
2.10
Chloroform (67-66-3)
El
Concentration
Mass
2.11
Dichlorobromomethane
El
1:1
✓
Concentration
Mass
(75-27-4)
2.12
1,1-dichloroethane
El
1:1
✓
Concentration
Mass
(75-34-3)
2.13
1,2-dichloroethane
✓
Concentration
Mass
(107-06-2)1:1
2.14
1,1-dichloroethylene
El
El
✓
Concentration
Mass
(75-35-4)
2.15
1,2-dichloropropane
El
1:1
✓
Concentration
Mass
(78 87 5)
2.16
1,3-dichloropropylene
El
El
✓
Concentration
Mass
(542-75-6)
217
Ethylbenzene
Concentration
Mass
(100-41-4)
2.18
Methyl bromide
El
1:1
El
Concentration
Mass
(74-83-9)
2.19
Methyl chloride
1:1
El
E
Concentration
Mass
(74-87-3)
2.20
Methylene chloride
El
El
Concentration
Mass
(75-09-2)
2.21
1,1,2 2- tetrachloroethane
El
Concentration
Mass
(79-34-5)
EPA Form 3510-2C (Revised 3-19) Page 13

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1
001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•1U111
Testing
Required
• '
Presence or Absence
check one
• ' • 1
Units
(specify)
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Believed
Present
Believed
Absent
Maximum
Daily
Dischaischarge
(requ� ed a
Maximum
Monthly
D
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
2.22
Tetrachloroethylene
(127-18-4)
El
1:1
✓
Concentration
Mass
2.23
Toluene
(108-88-3)
Concentration
Mass
2.24
1,2-trans-dichloroethylene
(156-60-5)
El
El
2
Concentration
Mass
225
1,1,1-trichloroethane
(71-55-6)
✓
Concentration
Mass
2.26
1,1,2-trichloroethane
(79-00-5)
El
El
El
Concentration
Mass
2.27
Trichloroethylene
(79-01-6)
0
Concentration
Mass
2.28
Vinyl chloride
(75-01-4)
El
El
Z
Concentration
Mass
Section 3.Organic Toxic Pollutants (GC/MS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
(95-57-8)
ElConcentration
Mass
3.2
2,4-dichlorophenol
(120-83-2)
El
El
El
Concentration
Mass
3.3
2 4-dimethylphenol
(105-67-9)
1:1
El
©
Concentration
Mass
3.4
4,6-dinitro-o-cresol
(534-52-1)
El
El
El
Concentration
Mass
3.5
2,4-dinitrophenol
(51-28-5)
0
El
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
•13 1 ••
• •• 1
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)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
D
Daily
of
of
(requied)
(if available)
Discharge
Analyses
Valuee
Analyses
if available
3.6
2-nitrophenol
El
❑
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
El
El
El
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
El
❑
0
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
❑
❑✓
Concentration
Mass
(87-86-5)
3.10
Phenol
✓
Concentration
Mass
(108-95-2)
3.11
2,4,6-trichlorophenol
❑
El
Concentration
Mass
(88 05 2)
Section 4.Organic Toxic Pollutants (GC/MS
Fraction
—Base /Neutral
Compounds)
4.1
Acenaphthene
❑
El
❑✓
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
❑
El
❑
Concentration
Mass
(208-96-8)
4.3
Anthracene
El
11
✓
Concentration
Mass
(120-12-7)
4.4
Benzidine
El
11
©
Concentration
Mass
(92-87-5)
4.5
Benzo (a) anthracene
❑
❑
❑✓
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
El
Concentration
1 Mass
(50-32-8)
1
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 I Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
•
Testing
Required
• 1 #11 :1011 k, 11142
Presence or Absence
check one
• -• 1
Effluent
Intake
(optional)
Units
(specify)
Believed
Present
Believed
Absent
Maximum
Daily
D( equi ed a
Maximum
Monthly
(if available)
Long -Term
Average
Dailischargey
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Number
of
Analyses
4.7
3,4-benzofluoranthene
(205-99-2)
El
El
El
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
©
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
El
El
✓
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
El
1:1
21
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
El
El
El
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
El
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
0
Concentration
Mass
4.16
2-chloronaphthalene
(91-58-7)
El
El
✓
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
1:1
El
El
Concentration
Mass
4.18
Chrysene
(218-01-9)
El
1:1
✓
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
El
El
✓
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Poll utant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
if available
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
❑
❑
0
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
❑
❑
El
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
El
1:1
El
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
❑
❑
z
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
❑
El
❑�
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
❑
❑�
Concentration
Mass
(117-84-0)
4.30
1,2-Dipheny1hydrazine
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
❑
❑
El
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

dentification Number NFUt5 Hermit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 • :1 A 0 1•
• • 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long'
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
(required)
(if available)
if available
Value
4.33
Hexachlorobenzene
❑
❑
✓
Concentration
Mass
(118-74-1)
4.34
Hexachlorobutadiene
❑
❑
El
Concentration
Mass
(87-68-3)
4.35
Hexachlorocyclopentadiene
Concentration
Mass
(77-47-4)
4.36
Hexachloroethane
❑
❑
❑
Concentration
Mass
(67-72-1)
4.37
Indeno (112,3-cd) pyrene
❑
21
Concentration
Mass
(193-39-5)
4.38
Isophorone
❑
❑✓
Concentration
Mass
(78-59-1)
4.39
Naphthalene
❑
❑
❑✓
Concentration
Mass
(91-20-3)
4.40
Nitrobenzene
❑
O
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
❑
❑
z
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
❑
❑
❑✓
Concentration
Mass
(86-30-6)
4.44
Phenanthrene
✓
Concentration
Mass
(85-01-8)
4.45
Pyrene
❑
El
ElConcentration
Mass
(129-00-0)
EPA Form 3510-2C (Revised 3-19) Page 18

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 I Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 •' fag•
'• IImIrAw
Intake
Presence or Absence
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
1
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
.46 1,2,4-trichlorobenzene
4.461
El
El
0
Concentration
1 Mass
(120-82-1)
1
1
1
Section 5.Organic Toxic Pollutants GCIMS
Fraction
—Pesticides)
5.1
Aldrin
El
El
ID
Concentration
Mass
(309-00-2)
5.2
a-BHC
El
❑
❑
Concentration
Mass
(319-84-6)
5.3
Q-BHC
❑
❑
❑
Concentration
Mass
(319-85-7)
5.4
y-BHC
❑
El
El
Concentration
Mass
(58-89-9)
5.5
b-BHC
❑
El
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
❑
El
IDConcentration
Mass
(72-55-9)
5.9
4 4'-DDD
❑
El
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
El
❑
Concentration
Mass
(60-57-1)
5.11
o-endosulfan
❑
El
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1
001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
•
Testing
Required
• 1 •'4
Presence or Absence
check one
• '• IIIIIIIIIIINUARN1
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
DisDaily
chr a
if schaarge
Number
of
Analyses
Long-
Term
Average
Value
Number
of
Analyses
5.12
R-endosulfan
(115-29-7)
El
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
El
El
✓
Concentration
Mass
5.14
Endrin
(72-20-8)
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
El
El
El
Concentration
Mass
5.16
Heptachlor
(76-44-8)
El
1:1
✓
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
El
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
El
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
El
0
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
El
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
El
El
El
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
El
El
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
NCG59OO25 NCG59OO25 Windgate Subdivision -Well #1 001
\A/T fl
Form Approved 03/05/19
OMB No. 2040-0004
1 -zlcfill
0 11
SK4111111041I
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
if available
alue
Toxaphene
Concentration
5.25 (8O01-35-2)El
Z
Mass
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
;EPA
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No. 2040-0004
WTID
Presence or Absence Intake
check one Effluent (Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
Discharge Discharge Analyses Analyses
(required) if available if available Value
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
© Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
1
Bromide
❑
❑
Concentration
Mass
(24959-67-9)
2'
Chlorine, total
El
❑
Concentration
Mass
residual
3.
Color
❑
❑
Concentration
Mass
4.
Fecal coliform
El
El
Concentration
Mass
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
❑
❑
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)
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No.2040-0004
J;EPAIdentification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
Presence or Absence
check one Effluent Intake
(Optional)
Pollutant Units 7 Term
Believed Believed (specify) Maximum Daily Maximum Long 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
❑
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
El
❑
Concentration
Mass
15.
Barium, total
(7440-39-3)
Concentration
Mass
16.
Boron, total
(744042-8)
❑
❑
Concentration
Mass
17.
Cobalt, total
(7440-484)
El
Concentration
Mass
18
Iron total
(7439-89-6)
El
El
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)
El
El
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
NCG590025
NCG590025
Windgate Subdivision -Well #1
001
OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum Long -Term
Long -Term
Present
Absent
Discharge
MonthlyAverage DailNumber of
gy
Number of
Average
(required)
Discharge Discharge Analyses
Analyses
if available if available)Value
24.
Radioactivity
Alpha, total
ElConcentration
Mass
Beta, total
❑
�
Concentration
Mass
Radium, total
El
❑
Concentration
Mass
Radium 226, total
Concentration
Mass
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 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
Fi�sbestos
❑
0
2.
Acetaldehyde
❑
3.
Allyl alcohol
❑
4.
Allyl chloride
❑
5.
Amyl acetate
❑
H
6.
Aniline
❑
7.
Benzonitrile
❑
❑r
8.
Benzyl chloride
❑
S
9.
Butyl acetate
❑
❑�
10.
Butylamine
❑
❑�
11.
Captan
❑
0
12.
Carbaryl
❑
13.
Carbofuran
❑
14.
Carbon disulfide
❑
0
15.
Chlorpyrifos
❑
❑�
16.
Coumaphos
❑
2
17.
Cresol
❑
0
18.
Crotonaldehyde
❑
El
19.
Cyclohexane
❑
0
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No. 2040-0004
UITO
IR�1 '1w 1 • I
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge
(specify units)
Present Absent
20.
2,4-D (2,4-dichlorophenoxyacetic acid)
❑
0
21.
Diazinon
❑
❑�
22.
Dicamba
❑
❑�
23.
Dichlobenil
❑
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
❑r
26.
Dichlorvos
❑
❑�
27.
Diethyl amine
❑
H
28.
Dimethyl amine
❑
❑�
29.
Dintrobenzene
❑
30.
Diquat
❑
31.
Disulfoton
❑
0
32.
Diuron
❑
33.
Epichlorohydrin
❑
❑�
34.
Ethion
❑
0
35.
Ethylene diamine
❑
❑�
36.
Ethylene dibromide
❑
37.
Formaldehyde
❑
❑�
38.
Furfural
❑
❑�
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPDES
NCG590025 NCG590025
Pollutant
Permit Number
Windgate
Presence or Absence
check one
Facility Name Outfall Number
Subdivision -Well #1 001
0
Reason Pollutant Believed Present in Discharge
Form Approved 03/05/19
OMB No. 2040-0004
Available Quantitative Data
(specify units)
Believed
Present
Believed
Absent
39.
Guthion
❑
0
40.
Isoprene
❑
0
41.
Isopropanolamine
❑
42.
Kelthane
❑
43.
Kepone
❑
❑�
44.
Malathion
❑
45.
Mercaptodimethur
❑
46.
Methoxychlor
❑
47.
Methyl mercaptan
❑
Q
48.
Methyl methacrylate
❑
49.
Methyl parathion
❑
ID
50.
Mevinphos
❑
F1
51.
Mexacarbate
❑
H
52.
Monoethyl amine
❑
0
53.
Monomethyl amine
❑
0
54.
Naled
❑
55.
Naphthenic acid
❑
0
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
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No. 2040-0004
1 1 • 1 • 1
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
1Phenolsulfonate
58.
❑
59.
Phosgene
❑
❑�
60.
Propargite
❑
❑r
61.
Propylene oxide
❑12
62.
Pyrethrins
❑
❑r
63.
Quinoline
❑
21
64.
Resorcinol
❑
Z
65.
Strontium
❑
2
66.
Strychnine
❑
❑r
67.
Styrene
❑
0
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetrachlorodiphenyl ethane)
❑
❑✓
70.
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
❑
O
71.
Trichlorofon
❑
Z
72.
Triethanolamine
❑
❑r
73.
Triethylamine
❑
❑r
74.
Trimethylamine
❑
75.
Uranium
❑
❑�
76.
Vanadium
❑
0
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
NCG590O25
NCG590025 Windgate Subdivision Well #1 001
OMB No. 2040-0004
'1•
1 61Presence
or Absence
Pollutant
F77Vinyla',cetate
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
❑ M
78.
Xylene
❑ ❑r
79.
Xylenol
❑
0
80.
Zirconium
❑
❑r
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No. 2040-0004
•'��11-1:044112111 11 I
TCDD Presence or
Congeners Absence
Pollutant Used or check one Results of Screening Procedure
Manufactured Believed Believed
Present Absent
2,3.7,8-TCDD
EPA Form 3510-2C (Revised 3-19) Page 33

/�
■--
f fir+' .l • . �t � r ,
'" •J �all
ri• � rlilr1� •.J
r r
fit Vt
t iC
�J
OJAI
\ /ro
I0 I
_ r `.-
�.;.� Outfa11001 F'
%�'
11 ;+✓ _% p '• %� `� i
Aqua North Carolina, Inc. Facility
Windgate Subdivision Well #1 WTP Location
atittdet 36° 24'29" N State Grid: Dobson notto_scale _
Loagitude: 80' 40' 43" W Permitted Flow: 0.00168 MGD
Beeeivine Strew: UT to Fisher River Stream Class: C North I NPDES Permit No. NC0088609
Drabaate Bain: Yadkin -Pee Dee River Basin Sub -Basin: 03-07-02 Surry County

Windgate S/D Well #1 WTP
Surry County; Permit No. NCG590025

AQUARA
An AEssential 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.
Windgate Subdivision Well #1 WTP
NPDES No. NCG590025
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.
We are requesting a waiver of any upstream sampling requirements for the site due to the
inability to collect samples at the location relevant to upstream of the discharge site.
Should you need any additional information or assistance, please feel free to contact me via
phone [phone]) or by email at [e-mail].
Sincerely,
CDocuSigned by:
�a.uvt,ta, JEatY—r(kAJ%K1tr
9C8BE09BOA7B49B...
Lauren Raup-Plummer
Engineering Manager
Aqua North Carolina, Inc.
Enc: NPDES Application, Form 2C
NPDES Application, Form 1
Windgate Subdivision Well #1 WTP NPDES Permit
Cc: Joseph Pearce
Shannon Becker
202 MacKenan Court, Cary, NC, 27511 • 919.467.8712 9 AquaAmerica.com

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590025
NCG590025
Windgate Subdivision -Well #1
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
t
\-/EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•
•Di
1.1
Applicants Not Required to Submit Form 1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete 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?
c❑
Yes 4 Complete Form 1 No
Yes 4 Complete Form ❑ No
a-
and Form 2B.
1 and Form 2C.
R
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
M
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
AE
commenced to discharge?
discharges only nonprocess wastewater?
d❑
Yes 4 Complete Form 1 ❑� No
❑ Yes 4 Complete Form ❑� No
and Form 2D.
1 and Form 2E.
1.2.5
Is the facility a new or existing facility whose
w
discharge is composed entirely of stormwater
a
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater9
❑ Yes -* Complete Form 1 No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
b 15).
SECTIONADDRESS,
AND LOCATIONt
2.1
Facility Name
Windgate Subdivision -Well #1 WTP
0
2.2
EPA Identification Number
0
C
J
NCG590025
-C
2.3
Facility Contact
Name (first and last)
Title
Phone number
Lauren Raup-Plummer
Engineering Manager
[phone]
a
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 03/05/19
NCG590025
NCG590025
Windgate Subdivision -Well #1
OMB No.2040-0004
y
2.5
Facility Location
Street, route number, or other specific identifier
Q 0
Simmons Road
rn
c
County name
County code (if known)
Surry
E _j
City or town
State ZIP code
z A
Mt. Airy
North Carolina 27030
SECTION1
NAICS CODES1
3.1
SIC Code(s)
Description (optional)
4941
Establishments primarily engaged in distributing water for sale for domestic,
fq
N
0
O
U
Cn
V
Z
3.2
NAICS Code(s)
Description (optional)
-a
R
310
Water Distribution (except irrigation)
V
N
4.1
Name of Operator
Aqua North Carolina
`o_
4.2
Is the name you listed in Item 4.1 also the owner?
c
El Yes ❑ No
w
7
4.3
Operator Status
S
;o
❑ Public —federal ❑ Public —state ❑ Other public (specify)
o
❑✓ Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
w
Street or P.O. Box
cc
m
202 MacKenan Drive
0 3
City or town
State
ZIP code
o v
Cary
North Carolina
27511
R
a
Email address of operator
O
[e-mail]
SECTION1
1 I
5.1
Is the facility located on Indian Land?
c
J
❑Yes ❑ No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well 41 OMB No.2040-0004
' • 1 ,
6.1 Existing Environmental Permits (check all that apply and print or type the corresponding permit number for each)
❑✓ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
c
water)
fluids)
w
L •—
>
NCG590025
E
w
rn
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
x
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section 404)
❑ Other (specify)
LU
N
N
N
C
.y
7
m
w
O
N
is
Z
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 28.)
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
9.1 1 Does your facility use cooling water?
El Yes ❑ No > SKIP to Item 10.1.
5 Z 9.2 Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
tm w 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.)
O Y
U
N I10.1 I 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
when.)
d ❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
0: Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
❑r Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
NCGS9002S
NCGS90025
Windgate Subdivision -Well #1 OMB No.2040-0004
SECTION1
CERTIFICATION STATEMENT (40
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
11.1
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2
❑✓ Section 1: Activities Requiring an NPDES Permit
w/ attachments
Section 2: Name, Mailing Address, and Location
❑ w/ attachments
F-11 Section 3: SIC Codes
❑ w/ attachments
❑✓ Section 4: Operator Information
❑ w/ attachments
❑✓ Section 5: Indian Land
❑ w/ attachments
c
❑� Section 6: Existing Environmental Permits
❑ w/ attachments
d
❑✓ Section 7: Map
w/ topographic
0 Elw/ additional attachments
M
ma
W
`o
Section 8: Nature of Business
Elw/ attachments
❑✓ Section 9: Cooling Water Intake Structures
❑ w/ attachments
-a
❑✓ Section 10: Variance Requests
❑ w/ attachments
c
H
❑✓ Section 11: Checklist and Certification Statement
❑ w/ attachments
Y
d
11.2
Certification Statement
L
U
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision
in accordance with a system designed to assure that qualified personnel properly gather and evaluate the
information submitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Lauren Raup-Plummer
Engineering Manager
Signature
Date signed
by:
EDocuSipned
"—p"KA .V�
02/01/2024
9c6BE0900AM49B...
EPA Form 3510-1 (revised 3-19) Page 4

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590025 NCGS9002S Windgate Subdivision -Well #1 OMB No. 2040-0004
Form U.S. Environmental Protection Agency
2C V-/EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS
SECTIONOUTFALL LOCATION
1.1 Provide information on each of the facility's outfalls in the table below.
Numbelr Receiving Water Name Latitude Longitude
001 unnamed tributary to Fisher 36' 24' 29" N F-1 80° 40' 43" W
is
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0
O
SECTIOND• 1
M 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 R
c Yes ❑ No
SECTION• r
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 0.001 mgd
c
E mgd
is
d
mgd
-o
y mgd
Treatment Units
0
U_
o, Description Code from Final Disposal of Solid or
d (include size, flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than
a' retention time, etc.) by Dischar e
EPA Form 3510-2C (Revised 3-19) Page 1

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG59002S NCG590025 Windgate Subdivision -Well #1 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
is
m
H
a **Outfall Number**
_
y Operations Contributing to Flow
o Operation Average Flow
LL
a, 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?
E ❑ Yes 0 No 4 SKIP to Section 4.
N3.3 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
NCG590025 NCG590025 Windgate Subdivision -Well #1 OMB No.2040-0004
SECTION• I
4.1 Except for storm runoff, leaks, or spills, are any discharges described in Sections 1 and 3 intermittent or seasonal?
❑ 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.
Freq
uency
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
0.001 mgd
0.001 mgd
176 days
c001
days/week
months/year
mgd
mgd
days
i_
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
c
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week monthslyear mgd mgd days
SECTION''•1
• 1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
5.1
❑ Yes ❑ No 4 SKIP to Section 6.
5.2
Provide the following information on applicable ELGs.
ELG Category
ELG Subcategory
Regulatory Citation
w
d
Q
o-
Q
5.3
Are any of the applicable ELGs expressed in terms of production (or other measure of operation)?
c
❑ Yes 0 No 4 SKIP to Section 6.
0
is
5.4
Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
J
Outfall
Operation, Product, or Material
Quantity per Day
Unit of
a
Number
Measure
d
cc
c6
m
C
O
7
.a
O
a
EPA Form 3510-2C (Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 OMB No.2040-0004
A LT-0-
• ' • 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 0 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
CL
number
E
c
so
H
N
'O
l3
CL
O.
6.3
Have you attached sheets describing any additional water pollution control programs (or other environmental projects
that may affect your discharges) that you now have underway or planned? (optional item)
❑ Yes ❑ No ❑� Not applicable
SECTIONi
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
complete. Not all applicants need to complete each table.
Table A. Conventional and Non -Conventional Pollutants
7.1
Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
❑ Yes ❑ No 4 SKIP to Item 7.3.
7.2
If yes, indicate the applicable outfalls below. Attach waiver request and other required information to the application.
Outfall Number 001 Outfall Number Outfall Number
7.3
Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
rn
requested and attached the results to this application package?
No; a waiver has been requested from my NPDES
❑✓ Yes ❑permitting
authority for all pollutants at all outfalls.
Table B.
Toxic Metals, Cyanide, Total Phenols, and Organic Toxic Pollutants
7.4
Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
listed in Exhibit 2C-3? (See end of instructions for exhibit.)
❑ Yes ❑ No 4 SKIP to Item 7.8.
d
7.5
Have you checked "Testing Required" for all toxic metals, cyanide, and total phenols in Section 1 of Table B?
w
❑ Yes ❑r No
7.6
List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s) identified
in Exhibit 2C-3.
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
NCG590O2S
NCG59O025
Windgate Subdivision -Well #1
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 S 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?
El Yes ❑ No
7.9
Have you provided (1) quantitative data for those Section 1, Table B, pollutants for which you have indicated testing is
required or (2) quantitative data or other required information for those Section 1, Table B, pollutants that you have
indicated are 'Believed Present' in your discharge?
❑ Yes 0 No
7.10
Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
❑ Yes 4 Note that you qualify at the top of Table B, ❑ No
13
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,
V
pollutants you have indicated are "Believed Present' in your discharge?
fN
`—'
•y
❑ Yes 0 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
A
15
7.13
Have you completed Table C by providing (1) quantitative data for those pollutants that are limited either directly or
c
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 4 Complete Table E. ❑✓ No 4 SKIP to Section 8.
7.17
Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes ❑✓ No
SECTION•
8.1
OR MANUFACTURED TOXICSi
Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
an intermediate or final product or byproduct?
❑ Yes ❑ No 4 SKIP to Section 9.
! U)
8.2
List the pollutants below.
c 2
1. 4. 7.
0
2. 5. 8.
Nl
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
NCGS9OO25 NCG59OO2S Windgate Subdivision -Well #1 OMB No. 2040-0004
SECTION• BIOLOGICAL TOXICITYI -
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
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
❑ Yes ❑ No
0
0
co
❑ Yes ❑ No
❑ Yes ❑ No
SECTIONi
CONTRACT
ANALYSES (40
Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
10.1
❑ Yes ❑ No 4 SKIP to Section 11.
10.2
Provide information for each contract laboratory or consulting
firm below.
Laboratory Number 1
Laboratory Number 2
Laboratory Number 3
Name of laboratory/firm
Water Tech Laboratories Inc
H
M
Z.
Laboratory address
5 Pinewood Plaza Dr
c
Granite Falls, NC 28630
Q
is
�a
L
C
o
U
Phone number
[phone]
Pollutant(s) analyzed Total Suspended Solids
SECTIONDD
• •• • t
Has the NPDES permitting authority requested additional
information?
11.1
0
❑ Yes
❑✓ No SKIP to Section 12.
E11.2
List the information requested and attach it to this application.
L
0
1. 4.
c
0
2. 5.
•a
a
3. 6.
EPA Form 3510-2C (Revised 3-19) Page 6

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 OMB No.2040-0004
SECTIONI
CERTIFICATION STATEMENT (40
12.1
In Column 1 below, mark the sections of Form 2C that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to complete all sections or provide attachments.
Column 1
Column 2
❑✓ Section 1: Outfall Location
0 w/ attachments
Q Section 2: Line Drawing
0 w/ line drawing ❑ w/ additional attachments
Section 3: Average Flows and
❑✓
w/ list of each user of
❑✓ wl attachments ❑ privately owned treatment
Treatment
works
❑ Section 4: Intermittent Flows
❑ wl attachments
❑ Section 5: Production
❑ wl attachments
w/ optional additional
❑ Section 6: Improvements
❑ w/ attachments ❑ sheets describing any
additional pollution control
tans
❑ wl request for a waiver and ❑ w/ explanation for identical
supporting information outfalls
d
wl small business exemption
❑ Elwl other attachments
d
request
N
❑ Section 7: Effluent and Intake
❑ w/ Table A ❑✓ wl Table B
Characteristics
0
❑✓ w/ Table C ❑✓ w/ Table D
d
❑ w/ Table E ❑ w/ analytical results as an
U
attachment
❑ Section 8: Used or Manufactured
❑ w/ attachments
y
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
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly
responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true,
accurate, and complete. I am aware that there are significant penalties for submitting false information, including the
possibility of fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Lauren Raup-Plummer
Engineering Manager
Signature by:
Date signed
gUocuSlgned
E "1P�KAV
9C80E09BOA7B49B...
02/01/2024
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
NCG590025 Wind ate Subdivision -Well #1 OMB No.2040-0004
NCG590025 g 001
\A/TD
Effluent Intake
Waiver 0 tional
ollutant Requested Units Maximum Maximum Long -Term
17,f
(specify) Daily Monthly Average Daily Number of Long -Term Number of
(if applicable)
Discharge Discharge Discharge Analyses Average Value Analyses
(required) if available if available
you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.
1
Biochemical oxygen demand
El
Concentration
Mass
(BOD5)
2.
Chemical oxygen demand
❑
Concentration
Mass
(COD)
Concentration
3.
Total organic carbon (TOC)
0
Mass
Concentration
4.
Total suspended solids (TSS)
0
Mass
Concentration
5.
Ammonia (as N)
0
Mass
6.
Flow
❑
Rate
gpd
1400
1145.45
176
Temperature (winter)
°C
°C
7.
Temperature (summer)
0
°C
°C
pH (minimum)
❑
Standard units
S.U.
6.46
7.0
80
8.
pH (maximum)
❑
Standard units
S.U.
8.21
7.0
80
SamDlina shall be conducted according
to sufficiently sensitive test Drocedures (i.e.. methods) aDDroved under 40 CFR
136 for the analvsis of Dollutants or Dollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 9

EPA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCG590O25 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
WE •
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
g
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)
Concentration
Mass
1.2
Arsenic, total
(7440-38-2)
❑
❑
❑
Concentration
Mass
1.3
Beryllium, total
(7440-41-7)
❑
❑
Concentration
Mass
1.4
Cadmium, total
(7440-43-9)
✓
Concentration
Mass
1.5
Chromium, total
(7440-47-3)
❑
❑
El
Concentration
Mass
1.6
Copper, total
(7440-50-8)
El
11
✓
Concentration
Mass
1.7
Lead, total
(7439-92-1)
✓
Concentration
Mass
1.8
Mercury, total
(7439-97-6)
El
El
✓
Concentration
Mass
1'9
Nickel, total
(7440-02-0)
El
1:1
El
Concentration
Mass
1.10
Selenium, total
(7782-49-2)
El
1:1
✓
Concentration
Mass
1.11
Silver, total
(7440-22-4)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Ioentitication Number NPUES Hermit Number Facility Name Outfall Nu
NCG590025 NCG590025 Windgate Subdivision -Well #1
001
Form Approved 03/05/19
OMB No. 2040-0004
Poll utantlParameter
(and CAS Number, if available)
11.12(7440-28-0)
Testing
Required
Presence or Absence
check one
Units
(specify)Maximum
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Dail y
Discharge
(required)
Maximum
Monthly
Discharge (if
Long -Term
Average
aily
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Number
of
Analyses
Thallium, total
❑
Concentration
Mass
1.13
Zinc, total
(7440-66-6)
El
❑
❑
Concentration
Mass
1.14
Cyanide, total
(57-12-5)
El
❑
❑
Concentration
Mass
1.15
Phenols, total
❑
❑✓
Concentration
Mass
Section 2.Organic Toxic Pollutants (GCIMS
Fraction
—Volatile Compounds)
2.1
Acrolein
(107-02-8)
El
El
Concentration
Mass
2.2
Acrylonitrile
(107-13-1)
El
El
❑
Concentration
Mass
2.3
Benzene
(71-43-2)
❑
El❑
Concentration
Mass
2.4
Bromoform
(75-25-2)
❑
❑
❑
Concentration
Mass
2.5
Carbon tetrachloride
(56-23-5)
El
El
Concentration
Mass
2.6
Chlorobenzene
(108-90-7)
❑
❑
❑
Concentration
Mass
2.7
Chlorodibromomethane
(124-48-1)
El
El
Concentration
Mass
2.8
Chloroethane
(75-00-3)
El
El
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 12

EPA Identification Number NF'UL6 Permit Number Faculty Name Uuttall Nu
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
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 -
Term
Number
Present
Absent
Daily
Discharge
Monthly
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
2.9
2-chloroethylvinyl ether
❑
ID
Concentration
(110-75-8)
Mass
2.10
Chloroform (67-66-3)
❑
❑✓
Concentration
Mass
2.11
Dichlorobromomethane
❑
❑
Concentration
(75-27-4)
Mass
212
1,1-dichloroethane
❑
1:1Concentration
✓
Mass
(75-34-3)
2.13
1,2-dichloroethane
❑
❑
❑
Concentration
Mass
(107-06-2)
2.14
1,1-dichloroethylene
❑
11
❑✓
Concentration
(75-35-4)
Mass
2.15
12-dichloropropane
❑
❑
❑
Concentration
Mass
(78-87-5)
2.16
1,3-dichloropropylene
❑
❑
❑
Concentration
Mass
(542-75-6)
2.17
Ethylbenzene
1:1
El
✓
Concentration
(100-41-4)
Mass
2.18
Methyl bromide
❑
✓❑
Concentration
Mass
(74-83-9)
2.19
Methyl chloride
❑
0
Concentration
Mass
(74-87-3)
2.20
Methylene chloride
El
Concentration
Mass
(75-09-2)
221
1,1,2,2- tetra chloroethane
❑
❑
❑
Concentration
Mass
(79-34-5)
EPA Form 3510-2C (Revised 3-19) Page 13

EPA Identification Number
NCG590025
Number
NCG590025
Name
Windgate Subdivision -Well #1
Outfall Nu
001
Form Approved 03/05/19
OMB No. 2040-0004
•r0oij, 1:11
l[firgea.
Testing
Required
ull1 •'
Presence or Absence
check one
• '• I
Units
(specify)
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
(and
Believed
Present
Believed
Absent
Maximum
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
D
Discharge
if available
Number
Analyses
Long -
Term
Average
Value
Number
Analyses
2.22
Tetra chloroethylene
(127-18-4)
❑
❑
Concentration
Mass
2.23
Toluene
(108-88-3)
El
El
Concentration
Mass
2.24
1,2-trans-dichloroethylene
(156-60-5)
0
❑
❑
Concentration
Mass
2.25
1,1,1-trichloroethane
(71-55-6)
❑
❑
❑
Concentration
Mass
2.26
1,1,2-trichloroethane
(79-00-5)
❑
❑
❑
Concentration
Mass
2.27
Trichloroethylene
(79-01-6)
❑
0
❑
Concentration
Mass
2.28
Vinyl chloride
(75-01-4)
❑
❑
❑
Concentration
Mass
Section 3.Organic Toxic Pollutants (GC/MS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
(95-57-8)
❑
❑
21
Concentration
Mass
3.2
2,4-dichlorophenol
(120-83-2)
0
El
El
Concentration
Mass
3.3
2,4-dimethylphenol
(105-67-9)
El
1:1
©
Concentration
Mass
3.4
4 6-dinitro-o-cresol
(534-52-1)
Concentration
Mass
3.5
2,4-dinitrophenol
(51-28-5)
El
El
1
a
1
Concentration
1 Mass
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 I Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and
(and CAS Number, if available)
Required
Believed
Believed
(specify)
(p �)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
ischarge
Daily
of
Average
of
(if available)
Discharge
Analyses
Analyses
if available
3.6
2-nitrophenol
�
�
✓�
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
✓
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
El
11
✓
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
Concentration
Mass
(87-86-5)
3.10
Phenol
El
✓
Concentration
Mass
(108-95-2)
3.11
2,4,6-trichlorophenol
Concentration
Mass
(88-05-2)
Section 4.Organic Toxic Pollutants (GC/MS Fraction
—Base /Neutral
Compounds)
41
Acenaphthene
El
0
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
El
El
21
Concentration
Mass
(208-96-8)
4.3
Anthracene
Concentration
Mass
(120-12-7)
4.4
Benzidine
Fj
El
©
Concentration
Mass
(92-87-5)
4.5
Benzo (a) anthracene
El
1:1
El
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
El
Concentration
(50-32-8)
1
1
1Mass
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Nu
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
•
•Owar-Hol
Testing
Required
1.1 ki 11111141:40-11•
Presence or Absence
check one
• •4 1111 rj z 1 161c, 1
Units
(specify)
,
Effluent
Intake
(optional)
Pollutant/Parameter
(and
(and CAS Number, if available)
Believed
Present
Believed
Absent
Maximum
Discharge
(required)
Maximum
Monthly
Discharge
(if available)Value
Long -Term
Average
Discharge
if available
Number
Analyses
Long -
Term
Average
Number
Analyses
4.7
3,4-benzofluoranthene
(205-99-2)
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
El
El
✓
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
El
✓
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
❑
©
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
❑
El
❑✓
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
0
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
❑
❑✓
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
El
El
El
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
El
El
El
Concentration
Mass
4.16
2-chloronaphthalene
(91-58-7)
El
1:1
❑
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
El
El
❑
Concentration
Mass
4.18
Chrysene
(218-01-9)
❑
❑
✓
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
El
El
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name I Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 •-
• •• 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
f available
4.20
1,2-dichlorobenzene
Concentration
Mass
(95-50-1)
4.21
13-dichlorobenzene
El
Concentration
Mass
(541-73-1)
4.22
1,4-dichlorobenzene
❑
❑
✓❑
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
El
❑
✓❑
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
✓❑
Concentration
Mass
(84-66-2)
4.25
Dirnethyl phthalate
❑
❑
✓❑
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
❑
❑
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
❑
R]
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
❑
❑
0
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
❑✓
Concentration
Mass
(117-84-0)
4.30
1,2-Diphenylhydrazine
✓
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
❑
❑
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
❑
❑
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number Nf ULS Permit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and
(and CAS Number, if available)
•
Testing
Required
1 1 • '
Presence or Absence
check one
• ' • I
Units
(specify)
Effluent
Intake
(optional)
Believed
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Lon
Term
Average
Value
Number
of
Analyses
4.33
HexachIorobenzene
(118-74-1)
❑
❑
❑
Concentration
Mass
4.34
Hexachlorobutadiene
(87-68-3)
❑
El
Concentration
Mass
4.35
Hexachlorocyclopentadiene
(77-47-4)
Concentration
Mass
4.36
Hexachloroethane
(67-72-1)
✓
Concentration
Mass
4.37
Indeno (1,2,3-cd) pyrene
(193-39-5)
❑
❑
❑�
Concentration
Mass
4.38
Isophorone
(78-59-1)
❑
❑
0
Concentration
Mass
4.39
Naphthalene
(91-20-3)
❑
❑
❑�
Concentration
Mass
4.40
Nitrobenzene
(98-95-3)
❑
El
❑�
Concentration
Mass
4.41
N-nitrosodimethylamine
(62-75-9)
❑
a
Concentration
Mass
4.42
N-nitrosodi-n-propylamine
(621-64-7)
❑
❑
O
Concentration
Mass
4.43
N-nitrosodiphenylamine
(86-30-6)
El
El
❑
Concentration
Mass
4.44
Phenanthrene
(85-01-8)
❑
❑
21
Concentration
Mass
4.45
Pyrene
(129-00-0)
❑
El
ElConcentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 18

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1
001
Form Approved 03/05/19
OMB No. 2040-0004
WE • 1
•
• 1 •"
GK4111010611111LIJUIZ111 &ZE111114g:1
Presence or Absence
Intake
check one
Effluent
(optional)
PollutantlParameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and
(and CAS Number, if available)
14.461,2,4-trichlorobenzene
Required
Believed
Believed
(specify)
(p �)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Average
of
(required)
favailable)
Discharge
Analyses
Analyses
if available
ElElElConcentration
1 Mass
(120-82-1)
1
Section 5.Organic Toxic Pollutants(GC/MS
Fraction
—Pesticides
51
Aldrin
❑
❑
0
Concentration
Mass
(309-00-2)
5.2
a-BHC
El
❑
❑
Concentration
Mass
(319-84-6)
5.3
R-BHC
❑
El
❑
Concentration
Mass
(319-85-7)
5.4
V-BHC
❑
❑
❑
Concentration
Mass
(58-89-9)
5.5
b-BHC
❑
❑
El
Concentration
Mass
(319-86-8)
5.6
Chlordane
❑
❑
❑
Concentration
Mass
(57-74-9)
57
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-endosulfan
❑
❑
❑
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

dentification Number NPDES Permit Number Facility Name UuUall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Effluent
Intake
(optional)
Poll utant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Believed
Present
Believed
Absent
Maximum
Daily
h
D(egedd)
Maximum
Monthly
(if available)
Long -Term
Average
Daily
Discharge
Of available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
5.12
10-endosulfan
(115-29-7)
❑
❑
❑
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
❑
❑
❑
Concentration
Mass
5.14
Endrin
(72-20-8)
❑
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
❑
❑
❑
Concentration
Mass
5.16
Heptachlor
(76-44-8)
❑
❑
❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
❑
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
❑
❑✓
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
❑
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
❑
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑
❑
El
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑
El
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
❑
❑
Elj
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPDES Permit Number I Facility Name Outfall Number
NCG590025 NCG590025 Windgate Subdivision -Well #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and
(and CAS Number, if available)
Required
Believed
Believed
(specify)
(p ty)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
Toxaphene
5.25
El
Concentration
Mass
(8001-35-2)
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG59OO25 NCG590025 Windgate Subdivision -Well #1 001 OMB No.2040-0004
• • • • • '• 1
Presence or Absence
Intake
check one Effluent
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
Discharge Discharge Analyses Analyses
(required) rf available if available Value
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
© Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
1
Bromide
❑
❑
Concentration
Mass
(24959-67-9)
2'
Chlorine, total
El
El
Concentration
Concentration
residual
3.
Color
El
El
Concentration
Mass
4.
Fecal coliform
El
❑
Concentration
Mass
5
Fluoride
❑
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
❑
11
ConcentrationMass
7.
Nitrogen, total
❑
El
Concentration
Concentration
organic (as N)
8.
Oil and grease
El
ElConcentrationMass
9'
Phosphorus (as
❑
❑
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
❑
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
El❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No. 2040-0004
XA
Presence or Absence
Intake
(check one Effluent
(Optional)
Pollutant Units Maximum Long Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Discharge Discharge Analyses Average Analyses
(required) Value
if available if available
12
Sulfite (as S03)
Concentration
Mass
(1426545-3)
13.
Surfactants
El
�
Concentration
Mass
14.
Aluminum, total
❑
El
Concentration
Mass
(7429-90-5)
15.
Barium, total
❑
❑
Concentration
Mass
(7440-39-3)
16.
Boron, total
❑
❑
Concentration
Mass
(744042-8)
17.
Cobalt, total
El
El
Concentration
Mass
(7440-484)
18
Iron, total
❑
❑
Concentration
Mass
(7439-89-6)
19
Magnesium, total
El
❑
Concentration
Mass
(7439-954)
Molybdenum,
Concentration
20.
total
❑
❑
7439-98-7
Mass
21
Manganese, total
Concentration
Mass
(7439-96-5)
22
Tin, total
❑
Concentration
Mass
(7440-31-5)
23
Titanium, total
Concentration
Mass
(7440-32-6)
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG590025
NCG590025
Windgate Subdivision -Well #1
WTQ
001
OMB No. 2040-0004
Presence or Absence
7==
Intake
(check one
Effluent
(Optional)
Pollutant
Believed Believed
Units
(specify)
Maximum Daily
Maximum Long -Term
Long -Term
Present Absent
Discharge
Monthly Average Daily Number of
Number of
Average
(required)
Discharge Discharge Analyses
Value Analyses
if available if available
24.
Radioactivity
Alpha, total
❑
�
Concentration
Mass
Beta, total
❑
❑
Concentration
Mass
Radium, total
El
�
Concentration
Mass
Radium 226, total
❑
❑
Concentration
Mass
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No.2040-0004
'160 1
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge
(specify units)
Present Absent
1. Asbestos
7 ❑ 0
2.
Acetaldehyde
❑
0
3.
Allyl alcohol
❑
0
4.
Allyl chloride
❑
❑�
5.
Amyl acetate
❑
6.
Aniline
❑
0
7.
Benzonitrile
❑
❑Q
8.
Benzyl chloride
❑
9.
Butyl acetate
❑
❑�
10.
Butylamine
❑
❑r
11.
Captan
❑
0
12.
Carbaryl
❑
0
13.
Carbofuran
❑
ED
14.
Carbon disulfide
❑
0
15.
Chlorpyrifos
❑
0
16.
Coumaphos
❑
0
17.
Cresol
❑
0
18.
Crotonaldehyde
❑
0
19.
Cyclohexane
❑
0
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 TWindgate Subdivision -Well #1 001 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
20.
2,4-D (2,4-dichlorophenoxyacetic acid)
❑
rl�
21.
Diazinon
❑
❑�
22.
Dicamba
❑
23.
Dichlobenil
❑
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
❑✓
26.
Dichlorvos
❑
R
27.
Diethyl amine
❑
❑�
28.
Dimethyl amine
❑
ID
29.
Dintrobenzene
❑
E
30.
Dicluat
❑
FD
31.
Disulfoton
❑
M
32.
Diuron
❑
0
33.
Epichlorohydrin
❑
M
34.
Ethion
❑
❑r
35.
Ethylene diamine
❑
Z
36.
Ethylene dibromide
❑
H
37.
Formaldehyde
❑
21
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
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 OMB No. 2040-0004
Presence or Absence
Pollutant (check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
39.
1Guthion ❑
40.
Isoprene
❑
Z
41.
Isopropanolamine
❑
❑r
42.
Kelthane
❑
0
43.
Kepone
❑
H
44.
Malathion
❑
❑r
45.
Mercaptodimethur
❑
46.
Methoxychlor
❑
0
47.
Methyl mercaptan
❑
R
48.
Methyl methacrylate
❑
0
49.
Methyl parathion
❑
FD
50.
Mevinphos
❑
0
51.
Mexacarbate
❑
0
52.
Monoethyl amine
❑
Z
53.
Monomethyl amine
❑
R
54.
Naled
❑
0
55.
Naphthenic acid
❑
❑r
56.
Nitrotoluene
❑
Z
57.
Parathion
❑
❑r
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590025 NCG590025 Windgate Subdivision -Well #1 001 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
❑
0
59.
Phosgene
El
60.
Propargite
❑
0
61.
Propylene oxide
❑
10
62.
Pyrethrins
❑
❑r
63.
Quinoline
❑
64.
Resorcinol
❑
0
65.
Strontium
❑
0
66.
Strychnine
❑
❑�
67.
Styrene
❑
0
68
2,4 5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetrachlorodiphenyl ethane)
❑
El
70.
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
❑
❑
71.
Trichlorofon
❑
❑�
72.
Triethanolamine
❑
73.
Triethylamine
❑
❑�
74.
Trimethylamine
❑
75.
Uranium
❑
❑�
76.
Vanadium
❑
Z
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
NCG590O25
NCG590025 Windgate Subdivision -Well #1 001
OMB No. 2040-0004
1 1.
1 1
Presence or Absence
Pollutant
check one Pollutant Believed Present in Discharge
Reason
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
77.
Vinyl acetate
❑
78.
Xylene
❑
❑✓
79.
Xylenol
❑
80.
Zirconium
❑
❑�
Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05119
NCG59OO25 NCG590025 Windgate Subdivision -Well #1 001 OMB No.2040-0004
TCDD Presence or
Congeners Absence
Pollutant Used or check one Results of Screening Procedure
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD 0
EPA Form 3510-2C (Revised 3-19) Page 33

N`
ISO
fff t
/71
�'r' • ' , `, Ji' ��; - J j ,r • t � f , ice_.
t
{' ' OF
�` L -
`� Outfall 001
INV
'•. • r.
If
Aqua North Carolina, Inc. Facility
Windgate Subdivision Well #1 WTP Location
at ittdet 36° 24' 29" N State Grid: Dobson not to -scale
Loaciitude: 80' 40' 43" W Permitted Flow: 0.00168 MGD
Beeeivine Strew: UT to Fisher River Stream Class: C North
I NPDES Permit No. NCO088609
Drabaate Bain: Yadkin -Pee Dee River Basin Sub -Basin: 03-07-02 L V 6 Surry County

Windgate S/D Well #1 WTP
Surry County; Permit No. NCG590025