NCG590010_Renewal (Application)_20240216

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Lauren Raup-Plummer, PE
Aqua North Carolina Inc
202 Mackenan Ct
Cary, NC 27511
Subject: Permit Renewal
Application No. NCG590010
Oakley Park WTP
Gaston County
Dear Applicant:
NORTH CAROLINA
Environmental Quality
February 19, 2024
Laserfiehe
The Water Quality Permitting Section acknowledges the February 19, 2024 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150E-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https•//deq nc gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
ec: WQPS Laserfiche File w/application
Sincerely,,
Cynthia Demery
Administrative Assistant
Water Quality Permitting Section
North Carolina Department of Environmental Quality I Division of Water Resources
Mooresville Regional Office 1 610 East Center Avenue, Suite 301 1 Mooresville, North Carolina 28115
704.663.1699

AOUA-
An �6 ESsentiat Utilities con
February 1, 2023
NC Department of Environmental Quality
Division of Water Resources
NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
LUJY,i iit—i i%_i
RECEIVED
FEB 16 2024
NCDEQIIDwRINPDES
Subject: Application for Permit Renewal
Aqua North Carolina, Inc.
Oakley Park Well 1 & Well 2 Treatment Plants
NPDES No. NCG590010
Gaston County
To Whom It May Concern:
Attached are the completed application Modification Application Forms 1 and
2C , process flow diagram, and topographic map. This letter and attachments
are Aqua North Carolina's request to renew the subject permit.
We are requesting a waiver of any upstream sampling requirements for both
sites due to the inability to collect samples at the locations relevant to
upstream of the discharge sites.
If you need any additional information or assistance, please feel free to contact
me at [e-mail].
Sincerely,
DocuSigned by:
" -P"Mtr
9C8BE09B0A7B49B_.
Lauren Raup-Plummer
Engineering Manager

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

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
t
\"I 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 0 No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
operation or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
a
production facility?
currently discharging process wastewater?
c❑
Yes 4 Complete Form 1 No
Yes 4 Complete Form ❑ No
z
and Form 2B.
1 and Form 2C.
C
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?
Cr
Yes 4 Complete Form 1 0 No
❑ Yes 4 Complete Form No
cc
H
and Form 2D.
1 and Form 2E.
1.2.5
Is the facility a new or existing facility whose
'—
discharge is composed entirely of stormwater
a
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
❑ Yes 4 Complete Form 1 No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
b (15).
SECTIONDD-
AND LOCATION (40
2.1
Facility Name
Oakle Park Subdivision -Well #1 & #2 WTP
•R`0
2.2
EPA Identification Number
t)
C
J
NCG590010
2.3
Facility Contact
Name (first and last)
Title
Phone number
Q
Lauren Raup-Plummer
Engineering Manager
[phone]
Email address
[e-mail]
d
2.4
Facility Mailing Address
c
Street 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
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1
OMB No. 2040-0004
y
2.5
Facility Location
wStreet,
route number, or other specific identifier
Q 0
U
Well 1 @ 133 Sequoia Dr Well 2 @ Pinto Ln
rn
c
County name
County code (if known)
cc
Gaston
0
E
City or town
State ZIP code
z m
Gastonia
North Carolina 28052
SECTION1
NAICS CODES1
Description (optional)
3.1
SIC Code(s)
4941
Establishments primarily engaged in distributing water for sale for domestic,
U)
d
O
0
U
co
Z
3.2
NAICS Code(s)
Description (optional)
cc
310
Water Distribution (except irrigation)
2
H
Name of Operator
4.1
Aqua North Carolina
0
4.2
Is the name you listed in Item 4.1 also the owner?
cc
0
c
El Yes ❑ No
7
4.3
Operator Status
R
❑ Public —federal ❑ Public —state ❑ Other public (specify)
o❑
Private ElOther (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
0
Street or P.O. Box
M
E 0
202 MacKenan Drive
City or town
State
ZIP code
`O 0
Cary
North Carolina
27511
io
Q
Email address of operator
O
[e-mail]
SECTION1
1
Is the facility located on Indian Land?
5.1
J
❑ Yes 0 No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells 1 OMB No. 2040-0004
SECTION'•
1
all that apply and print or type the corresponding permit number for each)
6.1
Existing Environmental Permits (check
d
❑✓ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
C
water)
fluids)
o w
NCG590010
L a
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
w
El Ocean dumping (MPRSA) El Dredge or fill (CWA Section 404) El Other (specify)
SECTION1
Have you attached a topographic map containing all required information to this application? (See instructions for
7.1
Co
specific requirements.)
❑✓ Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 26.)
SECTIONOF
I
Describe the nature of your business.
8.1
Operating a filter -backwash treatment system employing greensand filter technology to treat groundwater in
support of potable -water production
N
4)
d
C
.y
7
m
O
7
l0
Z
SECTION
••
9.1 Does your facility use cooling water?
❑ Yes ❑r No -* SKIP to Item 10.1.
3
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
a, «
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
W
NPDES permitting authority to determine what specific information needs to be submitted and when.)
O 4)
O td
L) =
SECTIONI
VARIANCE
REQUESTS1 I
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
10.1
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
H
when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
CD
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
❑✓ Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
NCGS90010
NCG590010
Oakley Park Subdivision -Wells 1 OMB No. 2040-0004
SECTION•
CERTIFICATION STATEMENT (40
11.1
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2
❑r Section 1: Activities Requiring an NPDES Permit
✓❑ w/ attachments
El Section 2: Name, Mailing Address, and Location
❑ w/ attachments
El Section 3: SIC Codes
❑ w/ attachments
❑r Section 4: Operator Information
❑ w/ attachments
❑✓ Section 5: Indian Land
❑ w/ attachments
El Section 6: Existing Environmental Permits
❑ w/ attachments
a
ElSection 7: Ma p
w/ topographic
❑ ❑ w/ additional attachments
ma
in
c
El Section 8: Nature of Business
Elw/ attachments
w
❑✓ Section 9: Cooling Water Intake Structures
❑ w/ attachments
d
❑� Section 10: Variance Requests
❑ w/ attachments
�
c
❑ Section 11: Checklist and Certification Statement
❑ wl attachments
_N
Y
s
11.2
Certification Statement
c�
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision
in accordance with a system designed to assure that qualified personnel properly gather and evaluate the
information submitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Lauren Raup-Plummer
Engineering Manager
Signature
Date signed
by:
CDocuSigned
V
02/Ol/2024
7B49B
9C8BE09BOA7849B_.
EPA Form 3510-1 (revised 3-19) Page 4

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

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

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

dentification Number NPDES Permit Number Facility Name Outfall Nu
NCG591 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
TABLE
B. TOXIC METALS, CYANIDE,
TOTAL PHENOLS,
AND ORGANIC TOXIC
POLLUTANTS (40 CFR
122.21(g)(7)(v))'
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Believed
Believed
Units
(specify)
Maximum
Maximum
Long -Term
Average
Number
Long -
Number
Present
Absent
Daily
Discharge
Monthly
Discharge
Daily
of
Term
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
if available
4.7
3,4-benzofluoranthene
✓
Concentration
(205-99-2)
Mass
4.8
Benzo (ghi) perylene
❑
❑
❑�
Concentration
(191-24-2)
Mass
4.9
Benzo (k) fluoranthene
❑
❑
Z
Concentration
Mass
(207-08-9)
4.10
Bis (2-chloroethoxy) methane
❑
©
Concentration
(111-91-1)
Mass
4.11
Bis (2-chloroethyl) ether
❑
Concentration
Mass
(111-44-4)
4.12
Bis (2-chloroisopropyl) ether
❑
❑
❑
Concentration
(102-80-1)
Mass
4.13
Bis (2-ethylhexyl) phthalate
r
Concentration
(117-81-7)
Mass
4.14
4-bromophenyl phenyl ether
El
❑
E
Concentration
Mass
(101-55-3)
4.15
Butyl benzyl phthalate
❑
0
Concentration
(85-68-7)
Mass
4.16
2-chloronaphthalene
❑
❑
❑�
Concentration
Mass
(91-58-7)
4.17
4-chlorophenyl phenyl ether
❑
❑
❑�
Concentration
Mass
(7005-72-3)
4.18
Chrysene
Concentration
Mass
(218-01-9)
4.19
Dibenzo (a,h) anthracene
El
El
Concentration
1 Mass
(53-70-3)
1
EPA Form 3510-2C (Revised 3-19) Page 16

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available )
Testing
Required
q
Presence or Absence
(check one)
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Dail y
Discharge
(required)
Maximum
Monthly
yof
Discharge
(if available)Value
Long -Term
Average
Discharge
if available
Number
Analyses
Long-
Term
Average
Number
Analyses
4.20
12-dichlorobenzene
(95-50-1)
El
El
El
Concentration
Mass
4.21
1,3-dichlorobenzene
(541-73-1)
El
El
El
Concentration
Mass
4.22
1,4-dichlorobenzene
(106-46-7)
❑
✓
Concentration
Mass
4.23
3,3-dichlorobenzidine
(91-94-1)
❑
❑
❑�
Concentration
Mass
4.24
Diethyl phthalate
(84-66-2)
El
❑
El
Concentration
Mass
4.25
Dimethyl phthalate
(131-11-3)
El
❑
❑
Concentration
Mass
4.26
Di-n-butyl phthalate
(84-74-2)
El❑
Concentration
Mass
4.27
2,4-dinitrotoluene
(121-14-2)
El
❑
❑
Concentration
Mass
4.28
2,6-dinitrotoluene
(606-20-2)
El
❑
❑
Concentration
Mass
4.29
Di-n-octyl phthalate
(117-84-0)
El
❑
❑
Concentration
Mass
4.30
1,2-Dipheny1hydrazine
(as azobenzene) (122-66-7)
❑
E
Concentration
Mass
4.31
Fluoranthene
(206-44-0)
❑
©
Concentration
Mass
4.32
Fluorene
(86-73-7)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 17

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

EPA Identification Number NPDES Permit Number
NCG590010 NCG590010
Name
Oakley Park Subdivision -Wells #1
0
Outfall Number
001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
(check one)
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge a
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
e)
if available
4.46 1,2,4-trichlorobenzene
❑
❑
❑
Concentration
Mass
(120-82-1)
Section 5.Organic Toxic Pollutants (GC/MS
Fraction
—Pesticides)
5.1
Aldrin
El
❑
❑
Concentration
Mass
(309-00-2)
5.2
a-BHC
Concentration
Mass
(319-84-6)
5.3
R-BHC
❑
❑
❑
Concentration
Mass
(319-85-7)
5.4
y-BHC
El
El
❑
Concentration
Mass
(58 89 9)
5.5
b-BHC
El
El
El
Concentration
Mass
(319-86-8)
5.6
Chlordane
El
❑
❑
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
❑
El
0
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
❑
❑
❑
Concentration
Mass
(72-55-9)
5 9
4,4'-DDD
❑
❑
❑
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
❑
❑
Concentration
Mass
(60-57-1)
5.11
a-endosulfan
El
❑
❑
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

EPA Icentiticatlon Number NPDES Permit Number i-acuity Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
•
Pollutant/Parameter
(and CAS Number, if available)
•W111
Testing
Required
1 • 4
Presence or Absence
check one
• ' • 1FroUrAl
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
i availa e
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)
❑
❑
❑
Concentration
Mass
5.14
Endrin
(72-20-8)
❑
❑
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
El
❑
El
Concentration
Concentration
5.16
Heptachlor
(76-44-8)
❑
❑
❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑
'❑
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
❑
El
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
El
❑
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
❑
El
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
El
❑
El
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑
❑
0
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑
El
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
❑
❑
El
Concentration
j Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
.Q. I \A/TD
Form Approved 03/05/19
OMB No. 2040-0004
-
-
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
15.25
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
available)
Discharge
Analyses
alue
Analyses
if available
Toxaphene
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 Forrn Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence Intake
(check one) Effluent
(Optional)
Units - --
Pollutant Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
(required) Discharge Discharge Analyses Value Analyses
if available) if available
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
❑ Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
1
Bromide
❑
❑
Concentration
Mass
(24959-67-9)
2'
Chlorine, total
❑
❑
Concentration
ug/L
10
9.92
109
Mass
residual
3.
Color
❑
❑
Concentration
Mass
4.
Fecal coliform
❑
❑
Concentration
Mass
5
Fluoride
❑
❑
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
❑
Concentration
Mass
7'
Nitrogen, total
❑
❑
Concentration
Mass
organic (as N)
8.
Oil and grease
❑
❑
Concentration
Mass
9.
Phosphorus (as
El
Concentration
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
❑
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
• • • • • '• I
Presence or Absence Intake
check one Effluent
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
(required) Discharge Discharge Analyses Value Analyses
if available if available
12.
Sulfite (as S03)
(14265 45-3)
❑
❑�
Concentration
Mass
13.
Surfactants
❑
0
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
❑
❑
Concentration
Mass
15.
Barium, total
(7440-39-3)
❑
❑
Concentration
Mass
16.
Boron, total
(744042-8)
❑
❑
Concentration
Mass
17
Cobalt, total
(7440484)
❑
❑
Concentration
Mass
18
Iron, total
(7439-89-0)
❑
❑
Concentration
Mass
19.
Magnesium, total
(7439-954)
❑
ElConcentration
Mass
20.
Molybdenum,
total
7439-98-7
❑
E
Concentration
Mass
21
Manganese, total
(7439-96-5)
❑
❑
Concentration
mg/L
1.02
0.37
17
Mass
22
Tin, total
(7440-31-5)
❑
❑
Concentration
Mass
23
Titanium, total
(7440-32-6)
El
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Pennit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park Subdivision -Wells #i1
001
OMB No. 2040-0004
Presence or Absence
Intake
(check
one)
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum
Long -Term
Long -Term
Present
Absent
Discharge
Monthly
Average Daily Number of
Average Number of
(required)
Discharge
Discharge Analyses
Analyses
Value
(if available
if available
24. Radioactivity
Alpha, total
❑
❑
Concentration
Mass
Beta, total
❑
0
Concentration
Mass
Radium, total
❑
El
Concentration
Mass
Radium 226, total
❑
ConcentrationMass
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 Foan 3510-2C (Revised 3-19) Page 25

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

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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Q M•1• • 1
Presence or Absence
Pollutant (check one) Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
140.
Guthion
❑
0
Isoprene
El0
Isopropanolamine
❑
0
42.
Kelthane
❑
0
43.
Kepone
❑
0
44.
Marathion
❑
❑�
45.
Mercaptodimethur
❑
❑�
46.
Methoxychlor
❑
0
47.
Methyl mercaptan
❑
0
48.
Methyl methacrylate
❑
0
49.
Methyl parathion
❑
0
50.
Mevinphos
❑
0
51.
Mexacarbate
❑
0
52.
Monoethyl amine
❑
0
53.
Monomethyl amine
❑
0
54.
Naled
❑
0
55.
Naphthenic acid
❑
0
56.
Nitrotoluene
❑
0
57.
Parathion
❑
0
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence
Pollutant check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
F58Phenolsulfonate
❑
ED
59.
Phosgene
❑
❑r
60.
Propargite
❑
F-1
61.
Propylene oxide
❑El
62.
Pyrethrins
❑
❑r
63.
Quinoline
❑
❑r
64.
Resorcinol
❑
Q
65.
Strontium
❑
❑�
66.
Strychnine
❑
❑�
67.
Styrene
❑
ID
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑�
69.
TDE (tetrachlorodiphenyl ethane)
❑
M
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
❑
El
71.
Trichlorofon
❑
❑r
72.
Triethanolamine
❑
❑✓
73.
Triethylamine
❑
74.
Trimethylamine
❑
❑�
75.
Uranium
❑
❑�
76.
Vanadium
❑
El
EPA Form 3510-2C (Revised 3-19) Page 30

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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells # 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

EPA Identification Number Permit Number Facility Name
Outfall Number
Form Approved 03/05/19
lNPIDES
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1
002
OMB No. 2040-0004
TABLE
A. CONVENTIONAL AND NON
CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(Iii)) 1
Effluent
Intake
Waiver
0 ti- al
Pollutant
Requested Units Maximum Maximum Long -Tenn
(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
r
Concentration
Mass
(BOD5)
2'
Chemical oxygen demand
❑
Concentration
Mass
(COD)
Concentration
3.
Total organic carbon (TOC)
❑r
Mass
Concentration
mg/L
40
9.16
108
4.
Total suspended solids (TSS)
❑r
Mass
Concentration
5.
Ammonia (as N)
❑r
Mass
6.
Flow
❑
Rate
mgd
0.0012
0.0012
282
Temperature (winter)
°C
°C
7.
Temperature (summer)
❑r
°C
°C
pH (minimum)
❑
Standard units
S.I.I.
6.7
7.2
78
8.
pH (maximum)
❑
Standard units
s.u.
s.7
7.2
78
SamDlina shall be conducted according
to sufficiently sensitive test Drocedures (i.e.. methods) aDDroved under 40 CFR
136 for the analvsis of Dollutants or pollutant parameters 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 Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
a
Di(if
if scha rge
Number
of
Analyses
Long-
Term
Average
Value
Number
of
Analyses
❑ Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.
Section 1. Toxic Metals, Cyanide, and Total Phenols
1.1
Antimony, total
(7440-36-0)
El
El
El
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)
El
El
Concentration
Mass
1.5
Chromium, total
(7440-47-3)
El
1:1
El
Concentration
Mass
1.6
Copper, total
(7440-50-8)
❑
❑
❑
Concentration
Mass
1.7
Lead, total
(7439-92-1)
El
1:1
El
Concentration
Mass
1.8
Mercury, total
(7439-97-6)
Concentration
Mass
1.9
Nickel, total
(7440-02-0)
El
❑❑
Concentration
Mass
1.10
Selenium, total
(7782-49-2)
❑
❑
❑
Concentration
Mass
1.11
Silver, total
(7440-22-4)
El
El
El
1
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 11

dentification Number NPDES Permit Number
NCG590010 NCG590010
Name
Oakley Park Subdivision -Wells #1
o,
ill Number
002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
(check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(
( e)
Discharge
Analyses
ee
Analyses
if available
1.12
Thallium, total
Concentration
Mass
(7440-28-0)
1.13
Zinc, total
El
El
21
Concentration
Mass
(7440-66-6)
1.14
Cyanide, total
El
1:1
El
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
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
Concentration
Mass
(107-13-1)
2.3
Benzene
El
Concentration
Mass
(71-43-2)
2.4
Bromoform
El
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
a
Concentration
Mass
(108-90-7)
2.7
Chlorodibromomethane
Concentration
Mass
(124-48-1)
2.8
Chloroethane
El
El
El
Concentration
1Mass
(75-00-3)
1
1
1
EPA Form 3510-2C (Revised 3-19) Page 12

EPA Identification Number NPUES rermlt Number Facility Name Outfall Nu
NCG590010 NCG590010 Oakley Park Subdivision -Wells 41 002
Form Approved 03/05/19
OMB No. 2040-0004
Intake
Presence or Absence
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge)
Daily
of
Avera a
of
(required)
(if
Discharge
Analyses
Analyses
if available
2.9
2-chloroethylvinyl ether
❑
❑
❑
Concentration
Mass
(110-75-8)
2.10
Chloroform (67-66-3)
❑
❑
❑�
Concentration
Mass
2.11
Dichlorobromomethane
❑
El
❑�
Concentration
Mass
(75-27-4)
212
1,1-dichloroethane
❑
❑
❑
Concentration
Mass
(75-34-3)
2.13
1,2-dichloroethane
El
El
Z
Concentration
Mass
(107-06-2)
2.14
1,1-dichloroethylene
❑
❑
Z
Concentration
Mass
(75-35-4)
2.15
1,2-dichloropropane
❑
❑
Z
Concentration
Mass
(78-87-5)
2.16
1,3-dichloropropylene
Concentration
Mass
(542-75-6)
2.17
Ethylbenzene
❑
❑
E
Concentration
Mass
(100-41-4)
218
Methyl bromide
❑
❑❑
Concentration
Mass
(74-83-9)
2 19
Methyl chloride
Concentration
Mass
(74-87-3)
2.20
Methylene chloride
❑
❑❑
Concentration
Mass
(75-09-2)
221
1, 1,2,2- tetrachloroethane
Concentration
Mass
(79-34-5)
EPA Form 3510-2C (Revised 3-19) Page 13

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells N1 002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available )
Required
q
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
2.22
Tetrachloroethylene
1:1
El
❑
Concentration
Mass
(127-18-4)
2.23
Toluene
El
✓
Concentration
Mass
(108-88-3)
224
1,2-trans-dichloroethylene
❑
El
❑✓
Concentration
Mass
(156-60-5)
2.25
1,1, 1 -trichloroethane
❑
❑
El
Concentration
Mass
(71-55-6)
226
1,1,2-trichloroethane
❑
❑
❑✓
Concentration
Mass
(79-00-5)
2.27
Trichloroethylene
❑
El
Concentration
Mass
(79-01-6)
2.28
Vinyl chloride
El
❑
✓
Concentration
Mass
(75-01-4)
Section 3.Organic Toxic Pollutants (GC/MS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
❑
El❑
Concentration
Mass
(95-57-8)
3.2
2,4-dichlorophenol
El
❑
✓
Concentration
Mass
(120-83-2)
3.3
2,4-dimethylphenol
❑
❑
©
Concentration
Mass
(105-67-9)
3.4
4,6-dinitro-o-cresol
❑
❑
Concentration
Mass
(534-52-1)
3.5
2,4-dinitrophenol
El
❑
✓
Concentration
Mass
(51-28-5)
EPA Form 3510-2C (Revised 3-19) Page 14

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

LNA Identification Number NF ULS Hermit Number
NCG590010 NCG590010
Name
Oakley Park Subdivision -Wells #1
0
Outfall Number
002
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
g
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)
El
El
El
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
1:1
z
Concentration
Mass
412
Bis (2-chloroisopropyl) ether
(102-80-1)
❑
❑
❑�
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
❑
❑
Z
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
El
❑
❑
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
❑
❑
❑�
Concentration
Mass
4.16
2-chloronaphthalene
(91-58-7)
❑
❑
❑�
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
✓
Concentration
Mass
4.18
Chrysene
(218-01-9)
❑
❑
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
❑
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

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

EPA Identification Number Nruta vertu¢ Number racmty Name Outtall Number
NCG590010 NCG590 I Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•1 Ell % U: 1:
Z 161 w 1 •'
• '•toll
EMM
Presence or Absence
Intake
(check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
°f
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
4.33
Hexachloro benzene
Concentration
Mass
(118-74-1)
4.34
Hexachlorobutadiene
❑
❑
0
Concentration
Mass
(87-68-3)
4.35
Hexachlorocyclopentadiene
❑
El
El
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
El
El❑
Concentration
Mass
(78-59-1)
4.39
Naphthalene
El
El
✓
Concentration
Mass
(91-20-3)
4.40
Nitrobenzene
El
❑
❑
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
❑
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
El
El
El
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
❑
❑
❑
Concentration
Mass
(86-30-6)
4.44
Phenanthrene
El
❑
✓
Concentration
Mass
(85-01-8)
4.45
Pyrene
❑
❑
❑
Concentration
Mass
(129-00-0)
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells 41 002
Form Approved 03/05/19
OMB No. 2040-0004
TOXICTABLE B. 1E,
TOTAL PHENOLS,1
ORGANIC TOXIC'•
1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
t
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
-
I
if available
4.46
1,2,4-trichlorobenzene
El
❑
❑�
Concentration
Mass
(120-82-1)
Section 5.Organic Toxic Pollutants GC/MS Fraction
—Pesticides
5.1
Aldrin
Concentration
Mass
(309-00-2)
5.2
a-BHC
r
Concentration
Mass
(319-84-6)
5.3
R-BHC
Concentration
Mass
(319-85-7)
5.4
y-BHC
El
El
El
Concentration
Mass
(58-89-9)
5.5
i)-BHC
Concentration
Mass
(319-86-8)
5.6
Chlordane
El
El
El
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
El
1:1
El
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
Concentration
Mass
(72-55-9)
5.9
4,4'-DDD
El
1:1
z
Concentration
Mass
(72-54-8)
5.10
Dieldrin
1:1
El
a
Concentration
Mass
(60-57-1)
5.11
a-endosulfan
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

LHA wentitication Nt
NCG590010
NF'UL6 Permit Number
NCG590010
Facility
Oakley Park Subdivision -Wells #1
Outfall Number
002
Form Approved 03/05/19
OMB No. 2040-0004
1
1 • '
' • 1
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)
Average
Number
Term
Number
Present
Absent
Monthly
Daily
°f
of
Discharge
Discharge
Discharge
Analyses
Average
Analyses
(required)
(if available)
if available
Value
5.12
R-endosulfan
El
El
❑
Concentration
Mass
(115-29-7)
5.13
Endosulfan sulfate
El
❑
❑
Concentration
Mass
(1031-07-8)
5.14
Endrin
❑
❑
©
Concentration
Mass
(72-20-8)
5.15
Endrin aldehyde
El
El
Concentration
Mass
(7421-93-4)
5.16
Heptachlor
El❑
Concentration
Mass
(76-44-8)
Heptachlor epoxide
Concentration
5.17
(1024-57-3)
Mass
5.18
PCB-1242
❑
Concentration
Mass
(53469-21-9)
5.19
PCB-1254
El
El
Concentration
Mass
(11097-69-1)
5.20
PCB-1221
❑
0
Concentration
Mass
(11104-28-2)
PCB-1232
Concentration
5.21
(11141-16-5)
❑
El
Mass
5.22
PCB-1248
❑
El
Concentration
Mass
(12672-29-6)
PCB-1260
Concentration
5.23
(11096-82-5)
❑
❑
El
Mass
5.24
PCB-1016
El❑
El
Concentration
Mass
(12674-11-2)
EPA Form 3510-2C (Revised 3-19) Page 20

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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
Presence or Absence
check one Effluent Intake
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
(required) Discharge Discharge Analyses Analyses
Value
if available if available
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
© Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the 'Presence or Absence' column of Table C for
each pollutant.
1
Bromide
❑
❑
Concentration
Mass
(24959-67-9)
2'
Chlorine, total
❑
❑
Concentration
ug/L
10
9.91
114
Mass
residual
3.
Color
El�
Concentration
Mass
4.
Fecal coliform
El
�
Concentration
Mass
5
Fluoride
❑
0
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
❑
H
Concentration
Mass
7'
Nitrogen, total
❑
❑
Concentration
Mass
organic (as N)
8.
Oil and grease
❑
0
Concentration
Mass
9.
Phosphorus (as
❑
❑
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
0
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
❑
0
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
• • • • • '• 1
JEPA
Presence or Absence Intake
(check one) Effluent (Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Discharge Discharge Analyses Average Analyses
(required) Value
if available) (if available)
12
Sulfite (as S03)
(14265-45-3)
❑
✓
Concentration
Mass
13.
Surfactants
❑
0
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
❑
✓
Concentration
Mass
15.
Barium, total
(7440-39-3)
❑
❑
Concentration
Mass
16.
Boron total
(7440-42-8)
El
✓
Concentration
Mass
17
Cobalt, total
(7440-08-4)
El
❑
Concentration
Mass
18
Iron, total
(7439-89-0)
❑
✓
Concentration
Mass
19
Magnesium, total
(7439-95-4)
El
Z
Concentration
Mass
20.
Molybdenum,
total
(7439-98-7)
Z
Concentration
Mass
21
Manganese, total
(7439-96-5)
Concentration
mg/L
4.64
1.26
16
Mass
22
Tin, total
(7440-31-5)
Concentration
Mass
23
Titanium, total
(7440-32-6)
El
21
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park Subdivision -Wells
#1 002
OMB No. 2040-0004
Presence or Absence
check
one
Effluent
Intake
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum Long -Term
Long -Term
Present
Absent
Discharge
Monthly Average Daily Number of
Average Number of
(required)
Discharge Discharge Analyses
Value Analyses
if available if available
24. Radioactivity
Alpha, total
El
0
Concentration
Mass
Beta, total
❑
0
Concentration
Mass
Radium, total
❑
El
Concentration
Mass
Radium 226, total
❑
�
Concentration
Mass
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 25

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

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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
I '1� 11TIV11:11*2 [IM 1111812
Presence or Absence
Pollutant check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
39.
Guthion
❑
0
40.
Isoprene
❑
❑�
41.
Isopropanolamine
❑
0
42.
Kelthane
❑
❑�
43.
Kepone
❑
0
44.
Marathion
❑
❑r
45.
Mercaptodimethur
❑
M
46.
Methoxychlor
❑
ID
47.
Methyl mercaptan
❑
❑r
48.
Methyl methacrylate
❑
0
49.
Methyl parathion
❑
❑r
50.
Mevinphos
❑
❑�
51.
Mexacarbate
❑
52.
Monoethyl amine
❑
53.
Monomethyl amine
❑
0
54.
Naled
❑
❑�
55.
Naphthenic acid
❑
❑�
56.
Nitrotoluene
❑
❑�
57.
Parathion
❑
❑�
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
1 1 • 1 • 1
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
F58Phenolsulfonate
❑
ED
59.
Phosgene
❑
ID
60.
Propargite
❑
Q
61.
Propylene oxide
❑10
62.
Pyrethrins
❑
El
63.
Quinoline
❑
0
64.
Resorcinol
❑
0
65.
Strontium
❑
66.
Strychnine
❑
❑�
67.
Styrene
❑
ID
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetra chlorodiphenyl ethane)
❑
❑�
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
propanoic acid]
❑
❑
71.
Trichlorofon
❑
Z
72.
Triethanolamine
❑
❑�
73.
Triethylamine
❑
❑�
74.
Trimethylamine
❑
ID
75.
Uranium
❑
❑�
76.
Vanadium
❑
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park Subdivision -Wells #1 002
OMB No. 2040-0004
1 'I•
• 1
Presence or Absence
Pollutant
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
77.
Vinyl acetate
❑ 21
78.
Xylene
❑
0
79.
Xylenol
❑
M
80.
Zirconium
❑
21
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 ��? OMB No. 2040-0004
7Used
11 �1 TCDD Presence orCongeners Absence
Pollutant or check one Results of Screening Procedure
Us
Believed Believed
Present Absent
2,3,7,8-TCDD ❑ ❑ 0
EPA Form 3510-2C (Revised 3-19) Page 33

OF61 N raw:fill MbTA ISAY1,10 I OFORMA Flit KnOWFAUTA I w
Raw
Raw
Water
Water
Well #1
Well #2
Greensand Greensand
Water Chlorine Distribution Chlorine Water
Treatment nfection Disinfection Treatment
I.L
Facility Facility
Outfall 001 Outfall 002
McGill Branch; Catawba McGill Branch; Catawba
River Basin River Basin

Aqua North Carolina, Inc.
Oaldey Park Subdivision Wells #1, #2 WTP
Latitude: 35° IT 32" (001) State Grid: Gastonia, North
35° 1 1' 50" (002) Perndttcd Flow: N/A
Longitude: 81° 16' 02" (001) StreatuClnss: C
81* IS' 40" (001) Drainaec Basin: Catawba River Bas' i
RecelyimStrmun: Mc Ciill Branch Sub -Basin: 03-08-37
Facility
Location
'i�i �ili:'fi �;s �-:�I• �_;y7tiirt�-y'
scalenot to t•:.
T 7 NPDES Permit No. NC0086142
Y 1 O rth- Gaston County

DocuSign
Certificate Of Completion
Envelope Id: 2FC710DOCOE142F6B9EOF2BB32A44E45
Status: Completed
Subject: Here is your signed document: Oakley Park_NCG90010_Permit renewal 2.3.2024.pdf
Source Envelope:
Document Pages: 54
Signatures: 2
Envelope Originator:
Certificate Pages: 1
Initials: 0
Lauren Raup-Plummer
AutoNav: Disabled
[e-mail]
Envelopeld Stamping: Disabled
IP Address: 144.202.188.252
Time Zone: (UTC-05:00) Eastern Time (US & Canada)
Record Tracking
Status: Original
Holder: Lauren Raup-Plummer
Location: DocuSign
2/2/2024 2:22:46 PM
[e-mail]
Signer Events
Signature
Timestamp
Raup-Plummer
Ey:Lauren
ent: 2/2/20 4 4:[e-mail]
ED—SIgned
w c.w "-P(.W Mw
Viewed: 2/2/2024 2:24:43 PM
Engineering Manager
BC8BEo8BOA]B4sB_
Signed: 2/2/2024 2:26:39 PM
Aqua North Carolina, Inc.
Freeform Signing
Security Level: Email, Account Authentication
Signature Adoption: Pre -selected Style
(None)
Using IP Address: 144.202.188.252
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer Events
Signature
Timestamp
Editor Delivery Events
Status
Timestamp
Agent Delivery Events
Status
Timestamp
Intermediary Delivery Events
Status
Timestamp
Certified Delivery Events
Status
Timestamp
Carbon Copy Events
Status
Timestamp
COPIED Sent: 2/2/2024 2.26:44 PM
[e-mail] Viewed: 2/2/2024 3:38:59 PM
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Witness Events
Signature
Timestamp
Notary Events
Signature
Timestamp
Envelope Summary Events
Status
Timestamps
Envelope Sent
Hashed/Encrypted
2/2/2024 2:24:31 PM
Certified Delivered
Security Checked
2/2/2024 2:24:43 PM
Signing Complete
Security Checked
2/2/2024 2:26:39 PM
Completed
Security Checked
2/2/2024 2:26:44 PM
Payment Events
Status
Timestamps

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

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

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
1
4S/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
CD
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.
c
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
'=
commenced to discharge?
discharges only nonprocess wastewater?
d
❑ Yes 4 Complete Form 1 0 No
❑ Yes 4 Complete Form 0 No
and Form 2D.
1 and Form 2E.
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,
• •
Facility Name
2.1
Oakle Park Subdivision -Well #1 & #2 WTP
0
2.2
EPA Identification Number
w
A
o
J
NCG590010
.0
2.3
Facility Contact
Name (first and last)
Title
Phone number
v
Lauren Raup-Plummer
Engineering Manager
[phone]
Q
Email address
[e-mail]
d
2.4
Facility Mailing Address
zStreet
or P.O. box
202 MacKenan Drive
City or town
State
ZIP code
Cary
North Carolina
27511
EPA Form 3510-1 (revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1
OMB No. 2040-0004
H
2.5
Facility Location
wStreet,
route number, or other specific identifier
Q 0
Well 1 @ 133 Sequoia Dr Well 2 @ Pinto Ln
a�
c
County name
County code (if known)
M 0
Gaston
0
E
City or town
State ZIP code
Z cc
Gastonia
North Carolina 28052
SECTION1
NAICS CODES1
3.1
SIC Code(s)
Description (optional)
4941
Establishments primarily engaged in distributing water for sale for domestic,
w
m
0
U
co
U
z
3.2
NAICS Code(s)
Description (optional)
310
Water Distribution (except irrigation)
U
N
4.1
Name of 0 erator
Aqua North Carolina
`0
4.2
Is the name you listed in Item 4.1 also the owner?
cc
0
0
0 Yes ❑ No
a
7
4.3
Operator Status
o
❑ Public —federal ❑ Public —state ❑ Other public (specify)
p❑
Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
w0
Street or P.O. Box
M
E
202 MacKenan Drive
City or town
State
ZIP code
o 0
ea
Cary
North Carolina
27511
CL
Email address of operator
O
[e-mail]
SECTION1
1
5.1
Is the facility located on Indian Land?
0
E _
❑ Yes 0 No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells 1 OMB No. 2040-0004
SECTION'•
1
all that apply and print or type the corresponding permit number for each)
6.1
Existing Environmental Permits (check
❑✓ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
cw
water)
fluids)
•—
NCG590010
U
ElPSD (air emissions)
❑ Nonattainment program (CAA)
ElNESHAPs (CAA)
li
c
❑ Ocean dumping (MPRSA) ElDredge or fill (CWA Section 404) ElOther (specify)
Lx
SECTIO
1
Have you attached a topographic map containing all required information to this application? (See instructions for
7.1
R
specific requirements.)
0 Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 2I3.)
SECTIONOF
1
Describe the nature of your business.
8.1
Operating a filter -backwash treatment system employing greensand filter technology to treat groundwater in
support of potable -water production
N
N
N
C
y
7
m
O
7
A
Z
SECTION••
9.1 Does your facility use cooling water?
❑ Yes 0 No 4 SKIP to Item 10.1.
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
a, 2
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
rn
NPDES permitting authority to determine what specific information needs to be submitted and when.)
O Y
O �p
L) w
c
SECTION
1 VARIANCE
REQUESTS1 1
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
10.1
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
y
when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
0 Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1 OMB No. 2040-0004
SECTIO
11. CHECKLIST
AND CERTIFICATION STATEMENT (40
11.1
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2
❑✓ Section 1: Activities Requiring an NPDES Permit
El w/ attachments
Section 2: Name, Mailing Address, and Location
❑ w/ attachments
0 Section 3: SIC Codes
❑ w/ attachments
❑r Section 4: Operator Information
❑ w/ attachments
❑✓ Section 5: Indian Land
❑ wl attachments
0 Section 6: Existing Environmental Permits
❑ wl attachments
2
0 Section 7: Map
wl topographic
Ela wl additional attachments
ma
Cn
0
0 Section 8: Nature of Business
❑ w/ attachments
✓❑ Section 9: Cooling Water Intake Structures
❑ w/ attachments
r
U
0 Section 10: Variance Requests
❑ w/ attachments
❑✓ Section 11: Checklist and Certification Statement
❑ w/ attachments
Y
s
11.2
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
Date signed
DocuSigned by:
E—P(, KAt r
02/01/2024
9C86E0980A7B49B..
EPA Form 3510-1 (revised 3-19) Page 4

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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 I Oakley Park Subdivision -Wells #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
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
2.22
Tetra chIoroethylene
El❑
Concentration
Mass
(127-18-4)
2.23
Toluene
Concentration
Mass
(108-88-3)
2.24
1,2-trans-dichloroethylene
El
El
✓
Concentration
Mass
(156-60-5)
225
1, 1, 1 -trichloroethane
❑
Concentration
Mass
(71-55-6)
2.26
1,1,2-trichloroethane
❑
✓
Concentration
Mass
(79-00-5)
2.27
Trichloroethylene
Concentration
Mass
(79-01-6)
2.28
Vinyl chloride
Concentration
Mass
(75-01-4)
Section 3.Organic Toxic Pollutants[GC/MS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
El
El❑
Concentration
Mass
(95-57-8)
3.2
2,4-dichlorophenol
✓
Concentration
Mass
(120-83-2)
3.3
2,4-dimethyl phenol
El
El
©
Concentration
Mass
(105-67-9)
3.4
4,6-dinitro-o-cresol
❑
El
Concentration
Mass
(534-52-1)
3.5
2,4-dinitrophenol
❑
1:1❑
Concentration
Mass
(51-28-5)
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 I Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
TOXICTABLE B. 1E,
TOTAL PHENOLS,1
ORGANIC TOXIC•
• 1
Intake
Presence or Absence
(check one)
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
(required)
(if available)
if available
3.6
2-nitrophenol
❑
❑
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
El
El
✓
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
✓
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
El
21
Concentration
Mass
(87-86-5)
3.10
Phenol
✓
Concentration
Mass
(108-95-2)
3.11
2,4,6-trichlorophenol
❑
✓❑
Concentration
Mass
(88-05-2)
Section 4.Organic Toxic Pollutants (GC/MS
Fraction
—Base /Neutral
Compounds)
4.1
Acenaphthene
❑
❑✓
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
✓
Concentration
Mass
(208-96-8)
4.3
Anthracene
✓
Concentration
Mass
(120-12-7)
4.4
Benzidine
❑
❑
©
Concentration
Mass
(92-87-5)
4.5
Benzo (a) anthracene
❑
❑
El
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
❑
❑✓
Concentration
Mass
(50-32-8)
EPA Form 3510-2C (Revised 3-19) Page 15

Identification Number NPDES Permit Number Facility Name Outfall Nu
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and
(and CAS Number, if available)
_A61%
Testing
Required
ling
Presence or Absence
check one
Units
(specify)
(p ty)
ON
Effluent
Intake
(optional)
Believed
Present
Believed
Absentof
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
available)
Long -Term
Average
Discharge
if available)Value
Number
Analyses
Lon
Term
Average
Number
Analyses
4.7
3,4-benzofluoranthene
(205-99-2)
El
El
21
Concentration
Mass
4.8
Benzo (ghi) per lene
(191-24-2)
❑
❑
ElConcentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
❑
❑
©
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
❑
❑
❑�
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
❑
❑
El
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
❑
❑
21
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
❑
❑
❑�
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
❑
❑
❑�
Concentration
Mass
4.16
2-chloronaphthalene
(91-58 7)
❑
El
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
El
❑❑
Concentration
Mass
4.18
Chrysene
(218-01-9)
El
El
El
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3) 1
El
1
El
1
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

bemincatlon Number NHDES Permit Number Facility Name Uuttall Number
NCG590010 NCG590 I Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
TABLE
B. TOXIC METALS, CYANIDE,
TOTAL PHENOLS,
AND ORGANIC TOXIC
POLLUTANTS (40 CFR
122.21(g)(7)(v))'
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
D'se�charrge
Discharge
charg
Daily
of
Average
of
Discharge
Analyses
Analyses
if available
4.20
12-dichlorobenzene
❑
❑
❑
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
❑
❑
Q
Concentration
Mass
(541-73-1)
422
1,4-dichlorobenzene
El
❑
El
Concentration
Mass
(106-46-7)
4.23
3 3-dichlorobenzidine
❑
❑
❑
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
❑✓
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
❑
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
❑
❑
❑
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
El
Concentration
Mass
(117-84-0)
4.30
1,2-Dipheny1hydrazine
✓
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
❑
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
El
El
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
4:11111111110.41
•
• CRT, 1 rerzrt%•
' • 1
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
4.33
Hexachlorobenzene
❑
❑
❑�
Concentration
Mass
(118-74-1)
4.34
Hexachlorobutadiene
❑
❑
❑�
Concentration
Mass
(87-68-3)
4.35
Hexachlorocyclopentadiene
❑
❑
El
Concentration
Mass
(77-47-4)
4.36
Hexachloroethane
❑
❑
0
Concentration
Mass
(67-72-1)
4.37
Indeno (1,2,3-cd) pyrene
El
Concentration
Mass
(193-39-5)
4.38
Isophorone
El
❑
❑�
Concentration
Mass
(78-59-1)
4.39
Naphthalene
❑
❑
❑�
Concentration
Mass
(91-20-3)
4.40
Nitrobenzene
❑
❑
❑�
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
❑
❑
❑�
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
❑
❑�
Concentration
Mass
(621-64-7)
4.43
N-nitrosod iphenyla mine
❑
❑
❑�
Concentration
Mass
(86-30-6)
4.44
Phenanthrene
❑
❑
a
Concentration
Mass
(85-01-8)
4.45
Pyrene
❑
❑
❑
Concentration
Mass
(129-00-0)
EPA Form 3510-2C (Revised 3-19) Page 18

dentification Number NPULS Hermit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
O. 7 1A/TOE
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1.1 k, I 11111111 '
• ' • 1
Presence or Absence
Intake
(check one)
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
ong-
(and CAS Number, if available)
14.461,2,4-trichlorobenzene
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
erm
Number
Present
Absent
Discharge
Discharge
Daily
of
[Ave
of
�
acailablge)
Discharge
Analyses
luee
Analyses
if available
❑❑❑Concentration
Mass
(120-82-1)
Section 5.Organic Toxic Pollutants (GC/MS
Fraction
—Pesticides)
5.1
Aldrin
❑
❑
El
Concentration
Concentration
(309-00-2)
5.2
a-BHC
Concentration
Mass
(319-84-6)
5.3
Q-BHC
❑
❑
El
Concentration
Concentration
(319-85-7)
5.4
y-BHC
❑
El
❑
Concentration
Mass
(58 89 9)
5.5
6-BHC
❑
❑
❑
Concentration
Mass
(319-86-8)
5.6
Chlordane
❑
❑
❑
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
❑
❑
✓
❑
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
❑
❑
❑
Concentration
Mass
(72-55-9)
5.9
4,4'-DDD
❑
❑
❑
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
❑
El
Concentration
Concentration
(60-57-1)
5.11
a-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
NCG590010 NCG590010 Oakley Park Subdivision -Wells 41 001
Form Approved 03/05/19
OMB No. 2040-0004
•
Pollutant/Parameter
(and CAS Number, if available)
•
• 1 • •
Presence or Absence
check one
• • • 1
Units
(specify)
,
Effluent
Intake
(optional)
Testing
Required
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Long-
Term
Average
Value
Number
of
Analyses
5.12
R-endosulfan
(115-29-7)
�
�
✓
�
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)
❑
Concentration
Mass
5.16
Heptachlor
(76-44-8)
❑
❑
❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑
El
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
ElEl
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
0
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
ElEl
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identitication Number NPuts Term¢ Number Facility Name Outfall Nu
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•L[61
101111s]". A 0111•
' • 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long'
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
alue
Analyses
if available
�Toxaphene
5.25
Concentration
Mass
(8001-35-2)
Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
• • I • • • '• 1
Presence or Absence Intake
(check one) Effluent (Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
Discharge Discharge Analyses Analyses
(required)
(if available if available)Value
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
❑ Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
1
Bromide
❑
✓
❑
Concentration
Mass
(24959-67-9)
2'
Chlorine, total
❑
❑
Concentration
ug/L
10
9.92
109
Mass
residual
3.
Color
❑
Concentration
Mass
4.
Fecal coliform
❑
❑
Concentration
Mass
5
Fluoride
❑
✓
❑
Concentration
Mass
(1698448-8)
6
Nitrate -nitrite
❑
E
Concentration
Mass
7'
Nitrogen, total
❑
❑
Concentration
Mass
organic (as N)
8.
Oil and grease
❑
Concentration
Mass
9'
Phosphorus (as
❑
❑
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
❑
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
El
�
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number FormApproved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence
check one Effluent Intake
(Optional)
Units
Pollutant Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
(required) Discharge Discharge Analyses value Analyses
if available if available
12
Sulfite (as S03)
(1426545-3)
❑
✓
❑
Concentration
Mass
13.
Surfactants
El0
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
(744048-4)
❑
❑
Concentration
Mass
18
Iron total
(7439-89-6)
❑
❑
Concentration
Mass
19
Magnesium, total
(7439-95-4)
❑
❑
Concentration
Mass
20.
Molybdenum,
total
7439-98-7
❑
ID
Concentration
Mass
21
Manganese, total
(7439-96-5)
❑
❑
Concentration
mg/L
1.02
0.37
17
Mass
22
Tin, total
(7440-31-5)
❑
❑
Concentration
Mass
23
Titanium, total
(7440-32-6)
❑
✓
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG59OO1O
NCG590010 Oakley Park Subdivision -Wells #1
001
OMB No. 2040-0004
Presence or Absence
Intake
(check
one)
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum
Long -Term
Long -Term
Present
Absent
Discharge
Monthly
Average Daily Number of
Average Number of
(required)
Discharge
Discharge Analyses
Analyses
Value
(if available
if available)
24. Radioactivity
Alpha, total
El�
Concentration
Mass
Beta, total
❑
21
Concentration
Mass
Radium, total
❑
0
Concentration
Mass
Radium 226, total
❑
0
Concentration
Mass
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

EPA Identification Number NPDES Permit Number
_F
NCG590010 NCG590010 Oakley Park
'1• M e[fill
Presence or Absence
Pollutant (check one)
Believed Believed
Present Absent
Facility Name Outfall Number Form Approved 03105/19
Subdivision -Wells #1 001 OMB No. 2040-0004
2.1 IAITD,
Reason Pollutant Believed Present in Discharge Available Quantitative Data
(specify units)
1.
Asbestos
❑
0
2.
Acetaldehyde
❑
0
3.
Allyl alcohol
❑
0
4.
Allyl chloride
❑
0
5.
Amyl acetate
❑
❑✓
6.
7.
Aniline
Benzonitrile
❑
❑
0
0
8.
Benzyl chloride
❑
0
9.
Butyl acetate
❑
❑�
I
10.
Butylamine
❑
0
11.
Captain
❑
0
12.
Carbaryl
❑
0
13.
Carbofuran
❑
0
14.
Carbon disulfide
❑
15.
Chlorpyrifos
❑
❑�
16.
Coumaphos
❑
17.
Cresol
❑
0
18.
Crotonaldehyde
❑
0
19.
Cyclohexane
❑
0
EPA Form 3510-2C (Revised 3-19) Page 27,

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
I '1• 1 • 1
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge
(specify units)
Present Absent
20.
2,4-D (2,4-dichlorophenoxyacetic acid)
❑
❑r
21.
Diazin0
❑
❑�
22.
Dicamba
❑
❑�
23.
Dichlobenil
❑
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
0
26.
Dichlorvos
❑
❑r
27.
Diethyl amine
❑
F-11
28.
Dimethyl amine
❑
❑r
29.
Dintrobenzene
❑
R
30.
Diquat
❑
❑r
31.
Disulfoton
❑
❑r
32.
Diuron
❑
❑r
33.
Epichlorohydrin
❑
El
34.
Ethion
❑
ID
35.
Ethylene diamine
❑
❑�
36.
Ethylene dibromide
❑
❑r
37.
Formaldehyde
❑
❑r
38.
rFurfural
❑
❑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
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
a I
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
39.
Guthion
❑
0
40.
41.
42.
Isoprene
Isopropanolamine
Kelthane
❑
❑
❑
F
0
43.
44.
Kepone
Marathion
❑
❑
0
0
45.
Mercaptodimethur
❑
0
46.
Methoxychlor
❑
FD
47.
Methyl mercaptan
❑
0
48.
Methyl methacrylate
❑
El
49.
Methyl parathion
❑
50.
Mevinphos
❑
51.
Mexacarbate
❑
0
52.
Monoethyl amine
❑
❑✓
53.
Monomethyl amine
❑
❑�
54.
Naled
❑
55.
Naphthenic acid
❑
D
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
NCG590010 NCG590010 Oakley Park Subdivision -Wells 91 001 OMB No. 2040-0004
1 N 1 1
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
58.
Phenolsulfonate
❑
59.
Phosgene
❑
0
60.
Propargite
❑
61.
Propylene oxide
❑
62,
Pyrethrins
❑
63.
Quinoline
❑
64.
Resorcinol
❑
0
65.
Strontium
❑
❑�
66.
Strychnine
❑
❑�
67.
Styrene
❑
H
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
❑
❑
71.
Trichlorofon
❑
0
72.
Triethanolamine
❑
❑�
73.
Triethylamine
❑
❑�
74.
Trimethylamine
❑
❑�
75.
Uranium
❑
76.
Vanadium
❑
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number NPDES Pennit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 I rurr_conn, in I Oaklev Park Subdivision -Wells #1 1 nni OMB No.2040-0004
Presence or Absence
(check one)
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(specify units)
Pollutant
Believed
Present
Believed
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 3510-2C (Revised 3-19) Page 31

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No.2040-0004
t►'�1 � 1 � tf1 1 �
TCDD Presence or
Congeners Absence
Pollutant Used or check one) Results of Screening Procedure
Manufactured Believed Believed
7
Present Absent
2,3,7,8-TCDD ❑ ❑ R
EPA Form 3510-2C (Revised 3-19) Page 33

EPA Identification Number
NCG590010
IR911 9
NCG590010
Facility Name
Oakley Park Subdivision -Wells #1
4 1 \AITD
Outfall Number
002
Form Approved 03/05/19
OMB No. 2040-0004
TABLE
Effluent
Intake
Waiver
0 tional
Maximum
Maximum
Long -Term
Pollutant
Requested Units
(if applicable) (specify)
Daily
Monthly
Average Daily
Number of
Long -Term
Number of
Discharge
Discharge
Discharge
Analyses
Average Value
Analyses
(required)
if available
if available
❑
Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.
1'
Biochemical oxygen demand
❑
Concentration
Mass
(BOD5)
2'
Chemical oxygen demand
❑
Concentration
Mass
(COD)
Concentration
3.
Total organic carbon (TOC)
❑✓
Mass
Concentration
mg/L
40
9.16
108
4.
Total suspended solids (TSS)
❑✓
Mass
Concentration
5.
Ammonia (as N)
❑✓
Mass
6.
Flow
❑
Rate
mgd
0.0012
0.0012
282
Temperature (winter)
❑✓
°C
°C
7.
Temperature (summer)
✓❑
°C
°C
pH (minimum)
❑
Standard units
S.U.
6.7
7.2
78
8.
pH (maximum)
❑
Standard units
S.U.
8.7
7.2
78
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 9

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
WE •
I • 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
Dail
of
Average
of
(required)
(if available)
Discharge
Analyses
Analyses
if available)Value
Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.
Section 1. Toxic Metals, Cyanide, and Total Phenols
1.1
Antimony, total
✓
Concentration
Mass
(7440-36-0)
1.2
Arsenic, total
✓
Concentration
Mass
(7440-38-2)
1.3
Beryllium, total
Concentration
Mass
(7440-41-7)
1.4
Cadmium, total
✓
Concentration
Mass
(7440-43-9)
1.5
Chromium, total
El
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
El
✓
Concentration
Mass
(7439-97-6)
1'9
Nickel, total
Concentration
Mass
(7440-02-0)
1.10
Selenium, total
El
El
Concentration
Mass
(7782-49-2)
1.11
Silver, total
El
1:1
El
Concentration
Mass
(7440-22-4)
EPA Form 3510-2C (Revised 3-19) Page 11

dentification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
1 •'
• '• 11
Intake
Presence or Absence
check one)
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long'
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
D(eq hrer
Discharge
Daily
of
e
of
(required)
f available)
(if
Discharge
Analyses
Value
Analyses
if available
1.12
Thallium, total
r
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
❑✓
Concentration
Mass
Section 2.Organic Toxic Pollutants (GC/MS
Fraction
—Volatile Compounds)
21
Acrolein
❑
❑
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
1:1Concentration
Mass
(107-13-1)
2.3
Benzene
❑
El
❑�
Concentration
Mass
(71-43-2)
2.4
Bromoform
❑
❑
R
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
❑
El❑
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
El
El
El
Concentration
Mass
(108-90-7)
2.7
Chlorodibromomethane
Concentration
Mass
(124-48-1)
2.8
Chloroethane
El
11
ElConcentration
1 Mass
(75-00-3)
1
EPA Form 3510-2C (Revised 3-19) Page 12

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available )
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Testing
Required
q
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long-
Term
Average
Value
Number
of
Analyses
2.9
2-chloroethylvinyl ether
(110-75-8)
✓
Concentration
Mass
2.10
Chloroform (67-66-3)
❑
21
Concentration
Mass
2.11
Dichlorobromomethane
(75-27-4)
❑
H
Concentration
Mass
2.12
1,1-dichloroethane
(75-34-3)
El
❑
❑
Concentration
Mass
2.13
1,2-dichloroethane
(107-06-2)
❑
El
Concentration
Mass
2.14
1,1-dichloroethylene
(75-35-4)
El❑
Concentration
Mass
2.15
1,2-dichloropropane
(78-87-5)
❑
❑
Q
Concentration
Mass
216
1,3-dichloropropylene
(542-75-6)
❑
❑
0
Concentration
Mass
217
Ethylbenzene
(100-41-4)
❑
❑
H
Concentration
Mass
2.18
Methyl bromide
(74-83-9)
❑
Concentration
Mass
2.19
Methyl chloride
(74-87-3)
❑
❑
Concentration
Mass
2.20
Methylene chloride
(75-09-2)
❑❑
Concentration
Mass
221
1,1,2,2-tetrachloroethane
(79-34-5)
❑
❑
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 13

EPA Identification Number
NCG590010
Permit Number
ame
NCG590010 I Oakley Park Subdivision -Wells #1 I 002
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Effluent
Intake
(optional)
Units
(specify)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)Value
Long -Term
Average
aily
Discharge
if available
Number
of
Analyses
Long -
Termof
Average
Number
Analyses
2.22
Tetrachloroethylene
(127-18-4)
❑
❑
R
Concentration
Mass
2.23
Toluene
(108-88-3)
❑
❑
❑
Concentration
Mass
224
1,2-trans-dichloroethylene
(156-60-5)
❑
El
Concentration
Mass
2.25
1 1, 1 -trichloroethane
(71-55-6)
❑
❑�
Concentration
Mass
226
1,1,2-trichloroethane
(79-00-5)
11
El
❑�
Concentration
Mass
2.27
Trichloroethylene
(79-01-6)
❑
E
Concentration
Mass
2.28
Vinyl chloride
(75-01-4)
El
El
Concentration
Mass
Section 3.Organic Toxic Pollutants (GCIMS
Fraction
—Acid Compounds)
3.1
2-chlorophenol
(95-57-8)
El
❑
❑
Concentration
Mass
3.2
2 4-dichlorophenol
(120-83-2)
El
❑
❑
Concentration
Mass
3.3
2,4-dimethylphenol
(105-67-9)
El
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)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 4

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

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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available )
Required
q
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
4.20
1,2-dichlorobenzene
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
❑
El
❑�
Concentration
Mass
(541-73-1)
4.22
1,4-dichlorobenzene
❑
❑
❑�
Concentration
Mass
(10646-7)
4.23
3,3-dichlorobenzidine
❑
❑
O
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
✓❑
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
❑
✓❑
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
❑
El
✓l
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
❑
❑❑
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
El
El
Z
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
❑
❑
❑�
Concentration
Mass
(86-73-7)
1
1
1
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number Nruto rermit Number racnity Name UUttall NU
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
•
1
•
1 1 • '
Presence or Absence
• ' • 1
Intake
(check one)
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
hscharge
Daily
of
Average
of
(egrerd)
ifavailable)
Discharge
Analyses
Value
Analyses
if available
4.33
Hexachlorobenzene
❑
Concentration
Mass
(118-74-1)
4.34
Hexachlorobutadiene
❑
❑
21
Concentration
Mass
(87-68-3)
4.35
Hexachlorocyclopentadiene
❑
❑
21
Concentration
Mass
(77-47-4)
4.36
Hexachloroethane
❑
❑
Concentration
Mass
(67-72-1)
4.37
Indeno (1,2,3-cd) pyrene
El
El
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
❑
❑
❑
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
❑
❑
❑✓
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
❑
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
El
El
Concentration
Mass
(86-30-6)
4.44
Phenanthrene
❑
❑
❑✓
Concentration
Mass
(85-01-8)
4.45
Pyrene
ID
Mass
Mass
(129-00-0)
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• Me
• '• 111M, 0111 UIILOI11A
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
Tenn
Number
Present
Absentof
Discharge
Discharge
Discharge a
g
Analyses
Average
Analyses
(required)
(if available)
if available
Value
El
El
OConcentration
1 Mass
(120-82-1)
1
1
1
Section 5.Organic Toxic Pollutants(GC/MS Fraction
—Pesticides
5.1
Aldrin
❑
0
Concentration
Mass
(309-00-2)
5.2
a-BHC
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
1:1
El
Concentration
Mass
(319-86-8)
5.6
Chlordane
El
El
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
❑
El
El
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
❑
E
Concentration
Mass
(72-55-9)
5.9
4,4'-DDD
❑
❑
E
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
❑
0
Concentration
Mass
(60-57-1)
5.11
o-endosulfan
El
21
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

LNA Idenbhcatlon Number NHULS rerrnit Number Facnity Name Uuttall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
o � %eiTn,
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
Absent
Maximum
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
(if available
Number
°f
Analyses
Long -
Term
Average
Value
Number
°
Analyses
5.12
R-endosulfan
(115-29-7)
❑
❑
El
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
❑
❑
El
Concentration
Concentration
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)
❑
❑
El
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
❑
0
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
❑
El
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑
❑
El
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑
Z
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
❑
❑
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1
002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available )
Required
q
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
of
Availy
erage
of
(required)
(if available)
Discharge a
le
Analyses
Value
Analyses
if available
�Toxaphene
5.25
Concentration
Mass
(g001-35-2)
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
NCG59O010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
@�_1114WIRFM
Presence or Absence
check one Effluent Intake
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
(required) Discharge Discharge Analyses Analyses
Value
if available if available
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
© Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
1'
Bromide
❑
❑✓
Concentration
Mass
(24959-67-9)
2'
Chlorine, total
❑
❑
Concentration
ug/L
10
9.91
114
Mass
residual
3.
Color
❑
El
Concentration
Mass
4.
Fecal coliform
❑
El
Concentration
Mass
5
Fluoride
❑
❑
Concentration
Mass
(1698448-8)
6
Nitrate -nitrite
❑
IDConcentration
Mass
7'
Nitrogen, total
❑
❑
Concentration
Mass
organic (as N)
8.
Oil and grease
El
ElConcentrationMass
9
Phosphorus (as
❑
❑
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
❑
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
❑
❑✓
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
HYPI � I I RJUTAIFA� I Blasi
Presence or Absence
Intake
(check one) Effluent
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
Discharge Discharge Analyses Analyses
(required) Value
(if available) (if available)
12
Sulfite (as S03)
❑
✓
❑
Concentration
Mass
(14265-45-3)
13.
Surfactants
❑
0
Concentration
Mass
14.
Aluminum, total
❑
❑
Concentration
Mass
(7429-90-5)
15.
Barium, total
❑
❑
Concentration
Mass
(7440-39-3)
16.
Boron, total
❑
❑
Concentration
Mass
(7440-42-8)
17
Cobalt, total
❑
❑
Concentration
Mass
(7440-484)
18'
Iron total
El
El
Concentration
Mass
(7439-89-0)
19
Magnesium, total
❑
0
Concentration
Mass
(7439-95-4)
Molybdenum,
Concentration
20.
total
❑
ID
(7439-98-7)
Mass
21
Manganese, total
❑
❑
Concentration
mg/L
4.64
1.26
16
Mass
(7439-96-5)
22
Tin, total
❑
❑
Concentration
Mass
(7440-31-5)
23.
Titanium, total
❑
❑
Concentration
Mass
(7440-32-6)
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
NCG59001O
NCG590010 Oakley Park Subdivision -Wells #1
002
OMB No. 2040-0004
Presence or Absence
Intake
(check
one
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum Long -Term
Long -Term
Present
Absent
Discharge
Monthly Average Daily Number of
Average Number of
(required)
Discharge Discharge Analyses
Value Analyses
f available if available
24.
Radioactivity
Alpha, total
❑
0
Concentration
Mass
Beta, total
El
0
Concentration
Mass
Radium, total
❑
Concentration
Mass
Radium 226, total
Concentration
Mass
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

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

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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
I ' 1 • 1 � 1 �
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
39.
Guthion
❑
❑r
40.
Isoprene
❑
ED
41.
Isopropanolamine
❑
H
42.
Kelthane
❑
43.
Kepone
❑
0
44.
Marathion
❑
45.
Mercaptodimethur
❑
46.
Methoxychlor
❑
47.
Methyl mercaptan
❑
48.
Methyl methacrylate
❑
49.
Methyl parathion
❑
0
50.
Mevinphos
❑
❑r
51.
Mexacarbate
❑
F-11
52.
Monoethyl amine
❑
M
53.
Monomethyl amine
❑
F-11
54.
Naled
❑
ID
55.
Naphthenic acid
❑
❑r
56.
Nitrotoluene
❑
0
57.
Parathion
❑
0
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
1 '1• 1 • 1 �
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
58. Phenolsulfonate ❑ 21
59.
Phosgene
❑
❑�
60.
Propargite
❑
❑r
61.
Propylene oxide
❑
El
62.
Pyrethrins
❑
❑�
63.
Quinoline
❑
❑�
64.
Resorcinol
❑
❑�
65.
Strontium
❑
❑r
66.
Strychnine
❑
❑r
Styrene
❑
❑�2,4,5-T
r
(2,4,5-trichlorophenoxyaceticacid
TDE (tetrachlorodiphenyl ethane)
❑2,4,5-TP
[2-(2,4,5-trichlorophenoxy)
propanoic acid
❑
❑
71.
Trichlorofon
❑
❑�
72.
Triethanolamine
❑
❑r
73.
Triethylamine
❑
0
74.
Trimethylamine
❑
75.
Uranium
❑
76.
Vanadium
❑
❑�
EPA Form 3510-2C (Revised 3-19) Page 30

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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
•'•1 • 1 • Mug =-11111ruixeclak
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

spa17C:VlNEm7.7I�ATIVI] I0 1won iF1we.EE PANTII :
Raw
Raw
Water
Water
Well #1
Well #2
Greenland
---I Greenland
IffWater Chlorine
Chlorine Water
Distribution
Treatment Disinfection
Disin fection Treatment
_ Facility
Facility _
Outfall 001 Outfall 002
McGill Branch; Catawba McGill Branch; Catawba
River Basin River Basin

Aqua North Carolina, Inc.
Oaldey Park Subdivision Wells #1, #2 WTP
Latitude: 35° 12' 32" (001) State Grid: Gastonia, North
35° 11' 50" (002) Permitted Flow: N/A
Longitude. 81` 16' 02" (001) Stream Class: C
81* 15' 40" (001) Drainage Basin: Catawba River Basin
RecohringStream: Mc Gill Branch Sub-]lnsin: 03-08-37
Facility
Location
not to scale
NPIa)✓S Permit No. NC0086142
1VMascot, County - --

DocuSign
Certificate Of Completion
Envelope Id: 2FC710DOCOE142F6B9EOF2BB32A44E45
Status: Completed
Subject: Here is your signed document: Oakley Park_NCG90010_Permit
renewal 2.3.2024.pdf
Source Envelope:
Document Pages: 54
Signatures: 2
Envelope Originator:
Certificate Pages: 1
Initials: 0
Lauren Raup-Plummer
AutoNav: Disabled
[e-mail]
Envelopeld Stamping: Disabled
IP Address: 144.202.188.252
Time Zone: (UTC-05:00) Eastern Time (US & Canada)
Record Tracking
Status: Original
Holder: Lauren Raup-Plummer
Location: DocuSign
2/2/2024 2:22:46 PM
[e-mail]
Signer Events
Signature
Timestamp
Lauren Raup-Plummer
ey:
Sent: 2/2/2024 2:24:31 P
[e-mail]
ED—SIgned
aUYtitn—P�Ux+w�t V
Viewed: 2/2/2024 2:24:43 PM
Engineering Manager
9c9gE09B0A1B498
Signed: 2/2/2024 2:26:39 PM
Aqua North Carolina, Inc.
Signature Adoption: Pre selected Style
Freeform Signing
Security Level: Email, Account Authentication
(None)
Using IP Address: 144.202.188.252
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer Events
Signature
Timestamp
Editor Delivery Events
Status
Timestamp
Agent Delivery Events
Status
Timestamp
Intermediary Delivery Events
Status
Timestamp
Certified Delivery Events
Status
Timestamp
Carbon Copy Events
Status
Timestamp
COPIED Sent: 2/2/2024 2:26:44 PM
[e-mail] Viewed: 2/2/2024 3:38:59 PM
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Witness Events
Signature
Timestamp
Notary Events
Signature
Timestamp
Envelope Summary Events
Status
Timestamps
Envelope Sent
Hashed/Encrypted
2/2/2024 2:24:31 PM
Certified Delivered
Security Checked
2/2/2024 2:24:43 PM
Signing Complete
Security Checked
2/2/2024 2:26:39 PM
Completed
Security Checked
2/2/2024 2:26:44 PM
Payment Events
Status
Timestamps

AOUA,.
�=ssennai
February 1, 2023
NC Department of Environmental Quality
Division of Water Resources
NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Application for Permit Renewal
Aqua North Carolina, Inc.
Oakley Park Well 1 & Well 2 Treatment Plants
NPDES No. NCG590010
Gaston County
To Whom It May Concern:
Attached are the completed application Modification Application Forms 1 and
2C , process flow diagram, and topographic map. This letter and attachments
are Aqua North Carolina's request to renew the subject permit.
We are requesting a waiver of any upstream sampling requirements for both
sites due to the inability to collect samples at the locations relevant to
upstream of the discharge sites.
If you need any additional information or assistance, please feel free to contact
me at [e-mail].
Sincerely,
EDOCUSigned by:
9CBBE09BOA7B498_.
Lauren Raup-Plummer
Engineering Manager

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

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

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1
OMB No. 2040-0004
2.5
Facility Location
D w
Street, route number, or other specific identifier
Q 0
Well 1 @ 133 Sequoia Dr Well 2 @ Pinto Ln
11M
0
County name
County code (if known)
Gaston
E _j
City or town
State ZIP code
z WO
Gastonia
North Carolina 280S2
3. SIC
CODESSECTION
AND NAICS
3.1
SIC Code(s)
Description (optional)
4941
Establishments primarily engaged in distributing water for sale for domestic,
N
01
O
U
N
U
z
3.2
NAICS Code(s)
Description (optional)
-a
m
310
Water Distribution (except irrigation)
U
N
SECTION
4. OPERATOR
INFORMATION (40
4.1
Name of Operator
Aqua North Carolina
0
4.2
Is the name you listed in Item 4.1 also the owner?
A
€
0 Yes ❑ No
4.3
Operator Status
S
❑ Public —federal El Public —state El Other public (specify)
0
0 Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
Street or P.O. Box
cc
�v
E
202 MacKenan Drive
5 w
City or town
State
ZIP code
w v
co
Cary
North Carolina
27511
n
Email address of operator
O
[e-mail]
SECTION•r
5.1
Is the facility located on Indian Land?
@ c
❑ Yes 0 No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number
NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park Subdivision Wells 1 OMB No. 2040-0004
SECTION•
1 CFR 1122.211(fflfi))
all that apply and print or type the corresponding permit number for each)
6.1
Existing Environmental Permits (check
_
d
NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
c
water)
fluids)
NCG590010
U a
ElPSD (air emissions)
❑ Nonattainment program (CAA)
ElNESHAPs (CAA)
c
w
❑ Ocean dumping (MPRSA) ElDredge or fill (CWA Section 404) ❑ Other (specify)
SECTIONi
7.1
CFR 1122.21(ffl7))
Have you attached a topographic map containing all required information to this application? (See instructions for
C
specific requirements.)
❑r Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 213.)
SECTIONOF
t CFR 122.21(ffl8))
Describe the nature of your business.
8.1
Operating a filter -backwash treatment system employing greensand filter technology to treat groundwater in
support of potable -water production
N
N
d
C
y
3
m
O
d
Ca
Z
SECTION
••
1
Does your facility use cooling water?
9.1
c
❑ Yes 0 No 4 SKIP to Item 10.1.
w
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
aU
,
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
NPDES permitting authority to determine what specific information needs to be submitted and when.)
O Y
U f6
c
SECTION1
VARIANCE
REQUESTS1 1
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
10.1
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
y
when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
❑✓ Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCG590010
NCG590010
Oakley Park Subdivision -Wells 1
OMB No.2040-0004
SECTION
11. CHECKLIST
AND 1
11.1
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2
✓❑ Section 1: Activities Requiring an NPDES Permit
✓❑ w/ attachments
0 Section 2: Name, Mailing Address, and Location
❑ wl attachments
El Section 3: SIC Codes
❑ w/ attachments
❑r Section 4: Operator Information
❑ w/ attachments
❑r Section 5: Indian Land
❑ w/ attachments
_
❑r Section 6: Existing Environmental Permits
❑ w/ attachments
El Section 7: Ma
w/ topographic
ElSection
❑ w/ additional attachments
map
0
0 Section 8: Nature of Business
❑ w/ attachments
❑✓ Section 9: Cooling Water Intake Structures
❑ w/ attachments
W
d
❑✓ Section 10: Variance Requests
❑ w/ attachments
M
❑ Section 11: Checklist and Certification Statement
❑ w/ attachments
Y
s
11.2
Certification Statement
U
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision
in accordance with a system designed to assure that qualified personnel properly gather and evaluate the
information submitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. / am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Lauren Raup-Plummer
Engineering Manager
Signature
Date signed
by:
EDocuSigned
I'
"-P"Kiv
02/01/2024
9CBBE0980A7649B..
EPA Form 3510-1 (revised 3-19) Page 4

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

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

LNA Identitication Number W'ut5 Tenn¢ Number racility Name Outfall Nu
NCG590010 NCG590010 I Oakley Park Subdivision -Wells #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 _
13.62-nitrophenol
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
°f
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
El
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
1:1
El
El
Concentration
Mass
(87-86-5)
3.10
Phenol
Concentration
Mass
(108-95-2)
3.11
2,4,6-trichlorophenol
0
Concentration
Mass
(88-05-2)
Section 4.Organic Toxic Pollutants (GC/MS
Fraction
—Base /Neutral
Compounds)
4.1
Acenaphthene
El
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
El
1:1
El
Concentration
Mass
(208-96-8)
4.3
Anthracene
Concentration
Mass
(120-12-7)1:1
4.4
Benzidine
El
El
©
Concentration
Mass
(92-87-5)
4.5
Benzo (a) anthracene
2
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
R]
Concentration
Mass
(50-32-8)
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells 41 001
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available
(and
Testing
Required
Presence or Absence
check one
Units
(p �v)
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
i availa
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)
✓
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)
❑
❑
0
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
❑
❑✓
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
❑
❑
❑✓
Concentration
Mass
4.16
2-chloronaphthalene
(91-58-7)
❑
❑
✓❑
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
El
El
✓
Concentration
Mass
4.18
Chrysene
(218-01-9)
El
1:1
El
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
❑
❑
❑
Concentration
1 Mass
EPA Form 3510-2C (Revised 3-19) Page 16

dentification Number NPDES Permit Number Facility Name Outfall Nu
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
o , ,e,—
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-
14.2012-dichlorobenzene
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Average
Number
Term
Number
Present
Absent
Daily
Monthly
Daily
°f
of
Discharge
Discharge
Discharge
Analyses
Average
Analyses
(required)
(if available)
if available
Value
El
❑❑
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
❑
❑❑
Concentration
Mass
(541-73-1)
422
1,4-dichlorobenzene
El
❑
❑�
Concentration
Mass
(106-46-7)
4.23
3 3-dichlorobenzidine
❑
El
El
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
✓❑
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
El
❑
El
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
El
El
El
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
El
El
Concentration
Mass
(121-14-2)
4.28
2 6-dinitrotoluene
El
❑
❑
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
✓
Concentration
Mass
(117-84-0)
4.30
1,2-Diphenylhydrazine
❑
❑
0
Concentration
Mass
(as azobenzene)(122-66-7)
4.31
Fluoranthene
❑
El
ElConcentration
Mass
(206-44-0)
4.32
Fluorene
El
El
❑
Concentration
(86-73-7)
1Mass
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number N Ut5 Hermit Number Facility Name Outfall Nu
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001
o,
Form Approved 03/05/19
OMB No. 2040-0004
1
1 4'
Presence or Absence
•
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Lon
(and
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Absent
Discharge
Discharge
Daily
°t
Average
o
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
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
❑
❑
❑
Concentration
Mass
(67-72-1)
4.37
Indeno (1,2,3-cd) pyrene
❑
❑
❑✓
Concentration
Mass
(193-39-5)
4.38
Isophorone
❑
❑
✓
Concentration
Mass
(78-59-1)
4.39
Naphthalene
❑
❑
❑
Concentration
Mass
(91-20-3)
4.40
Nitrobenzene
❑
El
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
❑
❑
❑
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
❑
El
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
❑
❑
❑✓
Concentration
Mass
(86-30-6)
4.44
Phenanthrene
❑
❑
Concentration
Mass
(85-01-8)
4.45
Pyrene
✓
Concentration
Mass
(129-00-0)
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 I Oakley Park Subdivision -Wells #1 001
O 1 %Al -
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
Lon
(and
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Absent
Discharge
Discharge
Daily
°f
Average
°
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
4.46 1,2,4-trichlorobenzene
El
❑
❑
Concentration
Mass
(120-82-1)
Section 5.Organic Toxic Pollutants (GC/MS
Fraction
—Pesticides)
5.1
Aldrin
El
❑
❑
Concentration
Mass
(309-00-2)
5.2
a-BHC
❑
❑
El
Concentration
Mass
(319-84-6)
5.3
R-BHC
❑
El
El
Concentration
Concentration
(319-85-7)
5.4
y-BHC
❑
❑
El
Concentration
Concentration
(58 89 9)
5.5
b-BHC
El
❑
El
Concentration
Concentration
(319-86-8)
5.6
Chlordane
❑
❑
❑
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
El
El
El
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
❑
❑
❑
Concentration
Mass
(72-55-9)
5.9
4 4'-DDD
❑
❑
❑
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

oentiticanon Number NPDES Permit Number Facility Name I Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1
001
Form Approved 03/05/19
OMB No. 2040-0004
• 1
Pollutant/Parameter
(and CAS Number, if available)
• F-11 0 a a, I
Testing
Required
I Lei w 1 •' WTIM-•
Presence or Absence
check one
111M, 071:1111@12:1
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge e)
Maximum
Monthly
(if availabllee)
Long -Term
Average
Daily
Discharge
if available
Number
Analyses
Long-
Term
Average
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)
1:1
El
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
Concentration
Mass
5.16
Heptachlor
(76-44-8)
❑
❑❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑
0
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
ElEl
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
❑
El
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
0
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
0
Concentration
Mass
5.24 1
PCB-1016
(12674-11-2)
❑
❑
0
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

uummuauuri rvumuer Nv ,uta remni[ Numoer Facility Name Outfall Nu
NCG590010 NCG590010 Oakley Park Subdivision -Wells #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)
15.25
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
D
hrerdge
Discharge
aily
of
Average
of
(eq
f available)
Discharge
Analyses
Analyses
if available
Toxaphene
Concentration
Mass
(g001-35-2)
Sampling shall be conducted according to sutticiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence
(check one) Effluent Intake
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
Discharge Discharge Analyses Analyses
(required)
(if available) (if available)Value
Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
1
Bromide
El
✓
Concentration
Mass
(24959-67-9)
2'
Chlorine, total
Concentration
ug/L
10
9.92
109
Mass
residual
3.
Color
El
R
Concentration
Mass
4.
Fecal coliform
Concentration
Mass
5
Fluoride
El
R
Concentration
Mass
(1698448-8)
6
Nitrate -nitrite
❑
El
Concentration
Mass
7'
Nitrogen, total
Concentration
Mass
organic (as N)
8.
Oil and grease
Concentration
Mass
9'
Phosphorus (as
✓
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
El
E
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
El
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence Intake
check one Effluent (Optional)
Units
Pollutant Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
Discharge Discharge Analyses Analyses
(required) Value
if available if available
12
Sulfite (as S03)
❑
❑✓
Concentration
Mass
(14265-45-3)
13.
Surfactants
❑
El
Concentration
Mass
14.
Aluminum, total
✓
Concentration
Mass
(7429-90-5)
15.
Barium, total
❑
❑
Concentration
Mass
(7440-39-3)
16.
Boron, total
❑
Concentration
Mass
(744042-8)
17.
Cobalt, total
✓
Concentration
Mass
(7440484)
18
Iron, total
❑
❑
Concentration
Mass
(7439-89-6)
19
Magnesium, total
❑
❑✓
Concentration
Mass
(7439-954)
Molybdenum,
Concentration
20.
total
❑
El
7439-98-7
Mass
21
Manganese, total
Concentration
mg/L
1.02
0.37
17
Mass
(7439-96-5)
22
Tin, total
❑
✓
Concentration
Mass
(7440-31-5)
23
Titanium, total
❑
✓
Concentration
Mass
(7440-32-6)
EPA Form 3510-2C (Revised 3-19) Page 24

Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
;EPA;Identification
G590010
NCG590010
Oakley Park Subdivision -Wells #1
001
OMB No. 2040-0004
Presence or Absence
check
one
Effluent
Intake
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum
Long -Term
Long -Term
Present
Absent
Discharge
Monthly
Average Daily Number of
Average Number of
(required)
Discharge
Discharge Analyses
Value Analyses
if available
if available
24. Radioactivity
Alpha, total
El0
Concentration
Mass
Beta, total
❑
Concentration
Mass
Radium, total
❑
Concentration
Mass
Radium 226, total
❑
0
Concentration
Mass
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
1.
Asbestos
El
2.
Acetaldehyde
❑
0
3.
Allyl alcohol
❑
0
4.
Allyl chloride
❑
0
5.
Amyl acetate
❑
0
6.
Aniline
❑
❑r
7.
Benzonitrile
❑
8.
Benzyl chloride
❑
El
9.
Butyl acetate
❑
R
10.
Butylamine
❑
R
11.
Captan
❑
12.
Carbaryl
❑
0
13.
Carbofuran
❑
❑r
14.
Carbon disulfide
❑
15.
Chlorpyrifos
❑
16.
Coumaphos
❑
17.
Cresol
❑
❑r
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
NCG590010 NCG590010 Oakley Park Subdivision -Wells # 1 001 OMB No. 2040-0004
1 '1• 1 • 1MUM
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
❑
R
22.
Dicamba
❑
0
23.
Dichlobenil
❑
24.
Dichlone
❑
25.
2,2-dichloropropionic acid
❑
0
26.
Dlchlorvos
❑
❑�
27.
Diethyl amine
❑
❑�
28.
Dimethyl amine
❑
❑Q
29.
Dintrobenzene
❑
❑�
30.
Diquat
❑
E
31.
Disulfoton
❑
❑r
32.
Diuron
❑
❑r
33.
Epichlorohydrin
❑
❑r
34.
Ethion
❑
❑r
35.
Ethylene diamine
❑
R
36.
Ethylene dibromide
❑
❑✓
37.
Formaldehyde
❑
0
38.
Furfural
❑
EPA Form 3510-2C (Revised 3-19) Page 28

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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 001 OMB No. 2040-0004
1 '1• 1 • 1
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge
(specify units)
Present Absent
58.
Phenolsulfonate
❑
El
59.
Phosgene
❑
El
60.
Propargite
❑
❑r
61.
Propylene oxide
❑
El
62.
Pyrethrins
❑
El
63.
Quinoline
❑
❑�
64.
Resorcinol
❑
65.
Strontium
❑
❑r
66.
Strychnine
❑
❑r
67.
Styrene
❑
0
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetra chlorodiphenyl ethane)
❑
❑�
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
El
71.
Trichlorofon
❑
21
72.
Triethanolamine
❑
❑r
73.
Triethylamine
❑
H
74.
Trimethylamine
❑
❑r
75.
Uranium
❑
El
76.
Vanadium
❑
❑r
EPA Form 3510-2C (Revised 3-19) Page 30

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

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

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

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

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

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

EPA Ioenbtication Number Nruta rermrt Number Facility Name Uuttall Number
NCG590010 NCG590010 I Oakley Park Subdivision -Wells #1 002
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 -Tenn
Long'
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
D(sgcharrge
arge
Dischuired)
Daily
Discharge
of
Analyses
Average
of
Analyses
(if
if available
alue
2.22
Tetrachloroethylene
Concentration
Mass
(127-18-4)
2.23
Toluene
❑
❑
❑
Concentration
Mass
(108-88-3)
2.24
1 2-trans-dichloroethylene
Concentration
Mass
(156-60-5)
2.25
1, 1, 1-trichloroethane
❑
✓
Concentration
Mass
(71-55-6)
2.26
1,1,2-trichloroethane
❑
❑
0
Concentration
Mass
(79-00-5)
2.27
Trichloroethylene
❑
❑✓
Concentration
Mass
(79-01-6)
2.28
Vinyl chloride
❑
❑
❑✓
Concentration
Mass
(75-01-4)
Section 3.Organic Toxic Pollutants (GC/MS Fraction
—Acid Compounds)
3.1
2-chlorophenol
❑
✓
Concentration
Mass
(95-57-8)
3.2
2,4-dichlorophenol
El
11
✓
Concentration
Mass
(120-83-2)
3.3
2,4-dimethylphenol
©
Concentration
Mass
(105-67-9)
3.4
4,6-dinitro-o-cresol
El
Concentration
Mass
(534-52-1)
3.5
2,4-dinitrophenol
❑
❑
❑
Concentration
Mass
(51-28-5)
EPA Form 3510-2C (Revised 3-19) Page 14

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

dentification Number NPDES Permit Number
NCG590010 NCG590010
Name
Oakley Park Subdivision -Wells #1
Outfall Number
002
Form Approved 03/05/19
OMB No. 2040-0004
•
Pollutant/Parameter
(and CAS Number, if available
•
Testing
Required
• ••
Presence or Absence
check one
• -•
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°t
Analyses
Lon
Term
Average
Value
Number
of
Analyses
4.7
3 4-benzofluoranthene
(205-99-2)
✓
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
El
✓
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
El
1:1
✓
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
El
❑
©
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
❑
❑✓
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
❑
❑
0
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
❑
❑
F-11
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
El
El
Concentration
Mass
4.15El
Butyl benzyl phthalate
(85-68-7)
❑
✓
Concentration
Mass
4.16
2-chloronaphthalene
(91 58 7)
✓
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
❑
❑
❑
Concentration
Mass
4.18
Chrysene
(218-01-9)
❑
✓
ncentration
�Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
El❑
Concentration
1 Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
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
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
4.20
1,2-dichlorobenzene
El
�
�
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
❑
❑
El
Concentration
Mass
(541-73-1)
422
1,4-dichlorobenzene
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
❑
❑
❑�
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
❑�
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
❑
❑
❑✓
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
❑
❑
21
Concentration
Mass
(121-14-2)
4.28
2,6-dinitrotoluene
❑
Z
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
El
Z
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
El
❑
❑
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number
NCG590010
NPDES Permit
NCG590010
ame
Oakley Park Subdivision -Wells #1
Outfall Number
002
Form Approved 03/05/19
OMB No. 2040-0004
TOXICTABLE B. 1E,
TOTAL PHENOLS,1
ORGANIC TOXIC'
• 1
Presence or Absence
Intake
(check one)
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
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
4.133
Hexachlorobenzene
❑
El
El
Concentration
Mass
(118-74-1)
4.34
Hexachlorobutadiene
❑
❑
✓
Concentration
Mass
(87-68-3)
4.35
Hexachlorocyclopentadiene
❑
El
❑✓
Concentration
Mass
(77-47-4)
4.36
Hexachloroethane
❑
Concentration
Mass
(67-72-1)
4.37
Indeno (1,2,3-cd) pyrene
El
❑
❑✓
Concentration
Mass
(193-39-5)
4.38
Isophorone
❑✓
Concentration
Mass
(78-59-1)
4.39
Naphthalene
❑
❑
❑✓
Concentration
Mass
(91-20-3)
4.40
Nitrobenzene
❑
❑✓
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
❑
❑✓
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
ElEl❑
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
❑
El
❑✓
Concentration
Mass
(86-30-6)
4.44
Phenanthrene
❑
❑
❑
Concentration
Mass
(85-01-8)
4.45
Pyrene
El
❑
Concentration
Mass
(129-00-0)
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
• 1
•
• 1 •'
• •• 1
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)
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Average
(required)
(if available)
DisDchr a
schaarge
Analyses
Value
Analyses
if
4.46 1,2,4-trichlorobenzene
❑
❑
❑✓
Concentration
Mass
(120-82-1)
Section 5.Organic Toxic Pollutants GC/MS
Fraction
—Pesticides
5.1
Aldrin
El
❑
❑
Concentration
Mass
(309-00-2)
5.2
a-BHC
❑
❑
❑
Concentration
Mass
(319-84-6)
5.3
Q-BHC
❑
El❑
Concentration
Mass
(319-85-7)
5.4
y-BHC
[I
El❑
Concentration
Mass
(58 89 9)
5.5
b-BHC
❑
El❑
Concentration
Mass
(319-86-8)
5.6
Chlordane
❑
❑
❑✓
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
❑
❑
❑
Concentration
Mass
(72-55-9)
5.9
4,4'-DDD
❑
❑
0
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
❑
❑✓
Concentration
Mass
(60-57-1)
5.11
a-endosulfan
El❑
❑
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
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)
✓
Concentration
Mass
5.14
Endrin
(72-20-8)
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
1:1
El
✓
Concentration
Mass
5.16
Heptachlor
(76-44-8)
El
El
✓
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)
El
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
El
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
El
El
Z
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
El
El
El
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
El
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Lon
(and
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Absent
Discharge
Discharge
Daily
°f
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
�Toxaphene
5.25
El
11
Z
Concentration
Mass
(g001-35-2)
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

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

JEPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 OMB No. 2040-0004
002
Presence or Absence Intake
(check one) Effluent (Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
Discharge Discharge Analyses Analyses
(required) if available if available Value
12
Sulfite (as S03)
(14265-45-3)
❑
❑
Concentration
Mass
13.
Surfactants
❑
❑
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
❑
❑
Concentration
Mass
15.
Barium, total
(7440-39-3)
El
❑✓
Concentration
Mass
16.
Boron, total
(7440-42-8)
❑
❑
Concentration
Mass
17
Cobalt, total
(7440-48-4)
❑
✓
❑
Concentration
Mass
18.
Iron total
(7439-89-0)
El
Concentration
Mass
19
Magnesium, total
(7439-954)
❑
❑
Concentration
Mass
20.
Molybdenum,
total
(7439-98-7)
❑
0
Concentration
Mass
21.
Manganese, total
(7439-96-5)
❑
❑
Concentration
mg/L
4.64
1.26
16
Mass
22.
Tin, total
(7440-31-5)
❑
0Concentration
Mass
23.
Titanium, total
(7440-32-0)
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

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

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

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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
Presence or Absence
Pollutant (check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
F39Guthion
❑
40.
Isoprene
❑
41.
Isopropanolamine
❑
42.
Kelthane
❑
43.
Kepone
❑
44.
Malathion
❑
Z
45.
Mercaptodimethur
❑
❑�
46.
Methoxychlor
❑
0
47.
Methyl mercaptan
❑
0
48.
Methyl methacrylate
❑
49.
Methyl parathion
❑
0
50.
Mevinphos
❑
0
51.
Mexacarbate
❑
❑r
52.
Monoethyl amine
❑
❑�
53.
Monomethyl amine
❑
54.
Naled
❑
Z
55.
Naphthenic acid
❑
❑r
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
NCG590010 NCG590010 Oakley Park Subdivision -Wells #1 002 OMB No. 2040-0004
1 'I• 1 • 1 �
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
58. Pheno Ifonate ❑
59.
Phosgene
❑
R
60.
Propargite
❑
0
61.
Propylene oxide
❑
12
62.
Pyrethrins
❑
❑r
63.
Quinoline
❑
Z
64.
Resorcinol
❑
65.
Strontium
❑
❑�
66.
Strychnine
❑
❑�
67.
Styrene
❑
❑�
68
2,4 5-T (2,4,5-trichlorophenoxyacetic
acid
❑
a
69.
TDE (tetra chlorodiphenyl ethane)
❑
H
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
propanoic acid]
❑
❑
71.
Trichlorofon
❑
❑r
72.
Triethanolamine
❑
❑�
73.
Triethylamine
❑
❑�
74.
Trimethylamine
❑
0
75.
Uranium
❑
E
76.
Vanadium
❑
Z
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
NCG590010
NCG590010 Oakley Park Subdivision -Wells #1 002
OMB No. 2040-0004
1111:81MAN
1 • 1
Presence or Absence
Pollutant
check one Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
77.
Vinyl acetate
❑
El
78.
Xylene
❑
El
79.
Xylenol
❑
80.
Zirconium
❑
0
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

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

0 Fo I � ram M LTA DAYNm LqF:a Frare E mmm VANTA r 90
Raw Raw
Water Water
Well #1 Well #2
Greensand M Greensand
Water Chlorine Distribution Chlorine Water
Treatment Disinfection Disinfection Treatment
FacilityL2 Facility _
Outfall 001 Outfall 002
McGill Branch; Catawba McGill Branch; Catawba
River Basin River Basin

Aqua North Carolina, Inc.
Oaldey Park Subdivision Wells #1 , #2 WTP
Latitude; 35° 12' 32" (001) State Grid: Gastonia, North
35° 1 I' 50" (002) Perndtted Flow: N/A
Longitude: 81° 16' 02" (001) Stream Class: C
81° IS' 40" (001) Drainaee Basin: Catawba River Basi:i
jtecetvineStrewm Me Gill Branch Sub-ilaSin: 03-08-37
Facility
:� •�� t t' 1 i�if'
Location
not • Scale;l.
Permit No. NCO086142
.Nc) rNPDES.th Gaston County

DocuSign
Certificate Of Completion
Envelope Id: 2FC710DOCOE142F6B9EOF2BB32A44E45
Status: Completed
Subject: Here is your signed document: Oakley Park_NCG90010_Permit
renewal 2.3.2024.pdf
Source Envelope:
Document Pages: 54
Signatures: 2
Envelope Originator:
Certificate Pages: 1
Initials: 0
Lauren Raup-Plummer
AutoNav: Disabled
[e-mail]
Envelopeld Stamping: Disabled
IP Address: 144.202.188.252
Time Zone: (UTC-05:00) Eastern Time (US & Canada)
Record Tracking
Status: Original
Holder: Lauren Raup-Plummer
Location: DocuSign
2/2/2024 2:22:46 PM
[e-mail]
Signer Events
Signature
Timestamp
Raup-Plummer
by:Lauren
Sent: 2/2/2024 2:24:31 [e-mail]
ED—SIgned
Ou w� (�aU�—P�.�w+w�v
Viewed: 2/2/2024 2:24:43 PM
Engineering Manager
9G8BE09B0A7B49B
Signed: 2/2/2024 2:26:39 PM
Aqua North Carolina, Inc.
Freeform Signing
Signature Adoption: Pre -selected Style
Security Level: Email, Account Authentication
(None)
Using IP Address: 144.202.188.252
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer Events
Signature
Timestamp
Editor Delivery Events
Status
Timestamp
Agent Delivery Events
Status
Timestamp
Intermediary Delivery Events
Status
Timestamp
Certified Delivery Events
Status
Timestamp
Carbon Copy Events
Status
Timestamp
COPIED Sent: 2/2/2024 2:26:44 PM
[e-mail] Viewed: 2/2/2024 3:38:59 PM
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Witness Events
Signature
Timestamp
Notary Events
Signature
Timestamp
Envelope Summary Events
Status
Timestamps
Envelope Sent
Hashed/Encrypted
2/2/2024 2:24:31 PM
Certified Delivered
Security Checked
2/2/2024 2:24:43 PM
Signing Complete
Security Checked
2/2/2024 2:26:39 PM
Completed
Security Checked
2/2/2024 2:26:44 PM
Payment Events
Status
Timestamps