WQ0002096_Monitoring - 01-2024_20240220

Monitoring Report Submittal
Permit Number#*
Name of Facility:*
Month: * January
WQ0002096
Ahoskie Assisted Living
Report Information
Type *
NDMR, NDAR-1, NDAR-2, NDMLR
Confirmation Email Address:
Name of Submitter: *
Signature:
Date of submittal:
Initial Review
Year:* 2024
Upload Document*
January 2024 NDMR.pdf 351.3KB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
[e-mail]
Paula G Armstrong
c�nula (,��arJGiary
Reviewer: Wanda.Gerald
2/20/2024
This will be filled in automatically

Is the project number correct?* W00002096
Is the monitoring report accepted?* Yes NO
Regional Office* Washington
Reviewer: _anonymous
Review Date: 3/14/2024

FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) rage of
Permit No.: WQ0002096
Facility Name: Ahoskie Assisted Living
County: Hertford
Month: January
Year: 2024
PPI: 001
Flow Measuring Point: ElInfluent ❑ Effluent ElNo flow generated
Parameter Monitoring Point: ElInfluent Q Effluent ❑Groundwater towering El Surface water
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FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page of
Sampling Person(s) Certified Laboratories
Name: Randy Parker Name: Waypoint Analytical
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? ❑r Compliant ❑ Non -Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
Qualification of lab data: All QC requirements were not met; Total Dissolved Residue- Laboratory control sample exceeded control limits. Blank result exceeded method constant weight criteria.
operator in Responsible Charge (ORC) Certification
Perm ittee Certification
ORC:
Randall Parker
Permittee: Ahoskie Assisted Living
Certification No.: 996843
Signing Official: Paula Armstrong
Grade:
SI Phone Number: 252-287-4153
Signing Officials Title: Administrator
Has the ORC changed since the previous NDMR? ❑ Yes ❑J No
Phone Number: 252-513-8591 Permit Expiration: 4/30/2025
"
Signature Date
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
I certify, under penally of law, that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that all qualified personnel property gathered and evaluated 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 fines and imprisonment for
knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of
Permit No.: WQ0002096
Facility Name: Ahoskie Assisted Living
County: Hertford
Month: January
Year: 2024
Did irrigation occur
Field Name:
sitel
Field Name:
Site 2
Field Name:
Site 3
Field Name:
Site 4
at this facility?
Area (acres):
1.75
Area (acres):
1.33
Area (acres);
1.35
Area (acres):
1.5
Cover Crop:
Trees
Cover Crop:
Trees
Cover Crop:
Trees/Bermuda
Cover Crop:
Bermuda
0 YES ❑ No
Hourly Rate (in):
0.25
Hourly Rate (in):
0.25
Hourly Rate (in);
0.25
Hourly Rate (in):
0.25
Annual Rate (in):
18
Annual Rate (in):
18
Annual Rate (in)-
31.5
Annual Rate (in):
31.5
Weather
Freeboard
Field irrigated?
(� YES ❑ NO '_
Field Irrigated?
i] YES ❑ No
Field Irrigated?
❑ YES NO
Field Irrigated?
❑ YES ❑� NO
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FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of
Did the application rates exceed the limits in Attachment B of your permit? [Z Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? 21 Compliant ❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? ❑✓ Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? E]Compliant ❑Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? D Compliant ❑ Non -Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
ORC: Randall Parker
Certification No.: 996843
Grade: SI Phone Number: 252-287-4153
Has the ORC changed since the previous NDAR-1? ❑ Yes n No
Permittee Certification
Permittee:
Ahoskie Assisted Living
Signing Official: Paula Armstrong
Signing Official's Title: Administrator
Phone Number: 252-513-8591 Permit Exp.: 4/30/25
C� Signature Date Signature J Date
By this signature, I certify that this report is accurrafe and complete to the best of my knowledge. 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 all qualified personnel properly gathered and evaluated 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 fines and imprisonment for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page
Permit No.: W00002096
Facility Name: Ahoskie Assisted Living
County: Hertford
Month: January
Year: 2024
Did irrigation occur
;Field Name:
Site 5
Field Name:
Field Name:
Field Name:
this facility?
Area (acres):
1.94
Area (acres):
Area (acres);
Area (acres):
at
Cover Crop:
P�
Bermuda
Cover P�
Cover p:
CoverCro p:
FD YES ❑ NO
Hourly Rate (in):
0.25
Hourly Rate (in):
Hourly Rate (in);
Hourly Rate (in):
Annual Rate (in):
31,5
Annual Rate (in):
Annual Rate (in);
Annual Rate (in):
Weather
Freeboard
Field Irrigated?
❑ YES [] No
Field Irrigated?
❑ YES ❑ NO
Field Irrigated?
0 YES []-No
Field Irrigated?
❑ YES ❑ No
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FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of
Did the application rates exceed the limits in Attachment B of your permit?
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
Was a suitable vegetative cover maintained on all sites as specified in your permit?
Were all setbacks listed in your permit maintained for every application to each permitted site?
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?
El Compliant ❑ Non -Compliant
❑� Compliant ❑ Non -Compliant
❑r Compliant ❑ Non -Compliant
F21 Compliant ❑ Non -Compliant
Compliant ❑ Non -Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Randall Parker
Permittee:
Ahoskie Assisted Living
Certification No.: 996843
Signing Official: Paula Armstrong
Grade: SI Phone Number: 252-287-4153
Signing Officials Title: Administrator
Has the ORC changed since the previous NDAR-1? ❑ Yes O No
Phone Number: 252-513-8591 Permit Exp.: 4/30/25
Signature Date
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
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 all qualified personnel properly gathered and evaluated 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 fines and imprisonment for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617