NC0037311_Permit Issuance_20020723

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Michael F. Easley, Governor
William G. Ross, Jr., Secretary
Alan W. Klimek, P.E., Director
July 23, 2002
Mr. James M. Cheshire
Research & Analytical Laboratories, Inc.
P.O. Box 473
Kernersville, North Carolina 27285
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NCDENR
NORTH CAROLINA DFIRARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
Subject: Issuance of NPDES Permit NC0037311
Creekside Manor Rest Home WWTP
Forsyth County
Dear Mr. Cheshire:
Division personnel have reviewed and approved your application for renewal of the subject permit.
Accordingly, we are forwarding the attached NPDES discharge permit. This permit is issued pursuant
to the requirements of North Carolina General Statute 143-215.1 and the Memorandum of Agreement
between North Carolina and the U.S. Environmental Protection Agency dated May 9, 1994 (or as
subsequently amended).
Please note that this facility is discharging high amounts of total residual chlorine (TRC). The average
TRC concentration in the effluent should be below 17 µg/L (0.017 mg/L). This facility discharged
concentrations well above 17 µg/L during 2000 and 2001. Unless these concentrations are reduced,
the Division may reopen this permit to include a chlorine limit
If any parts, measurement frequencies or sampling requirements contained in this permit are
unacceptable to you, you have the right to an adjudicatory hearing upon written request within thirty
(30) days following receipt of this letter. This request must be in the form of a written petition,
conforming to Chapter 150B of the North Carolina General Statutes, and filed with the Office of
Administrative Hearings (6714 Mail Service Center, Raleigh, North Carolina 27699-6714). Unless
such demand is made, this decision shall be final and binding.
Please note that this permit is not transferable except after notice to the Division. The Division may
require modification or revocation and reissuance of the permit. This permit does not affect the legal
requirements to obtain other permits which may be required by the Division of Water Quality or
permits required by the Division of Land Resources, the Coastal Area Management Act or any other
Federal or Local governmental permit that may be required.
If you have any questions concerning this permit, please contact Christie Jackson at telephone
number [phone], extension 538.
Sincerely,
O L
SUSANA. iWILSON'
Alan W. Klimek. P.E.
cc: Central Files
Winston-Salem Regional Office/Water Quality Section
NPDES Unit 4
David Bolling, Pierce Management Group
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer VISIT US ON THE INTERNET 0 httpJ/h2o.enr.state.nc.us/NPDES

Permit NCO037311
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIIVIINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended, the
Pierce Management Group
is hereby authorized to discharge wastewater from a facility located at the
Creekside Manor Rest Home
6206 Reidsville Road
Kernersville
Forsyth County
to receiving waters designated as an unnamed tributary to Belews Creek in the
Roanoke River Basin
in accordance with effluent limitations, monitoring requirements, and other
conditions set forth in Parts I, II, III and IV hereof.
This permit shall become effective September 1, 2002.
This permit and authorization to discharge shall expire at midnight on February 28, 2007.
Signed this day July 23, 2002.
ORIGINAL SiGNF-a
SUSAt4 A• WILSON
Alan W. Klimek, P.E. Director
Division of Water Quality
By Authority of the Environmental Management Commission

Permit NCO037311
SUPPLEMENT TO PERMIT COVER SHEET
The Pierce Management Group is hereby authorized to:
1. Continue to operate an existing 0.01 MGD extended aeration wastewater
treatment system with the following components:
♦ Bar screen
♦ Aeration basin
♦ Secondary clarifier
♦ Aerobic digester
♦ Chlorination
The facility is located in Kernersville at Creekside Manor Rest Home at 6206
Reidsville Road in Forsyth County.
2. Discharge from said treatment works at the location specified on the attached
map into an unnamed tributary to Belews Creek, classified C waters in the
Roanoke River Basin.

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Facility Information FacilitJ
.Latitude: 36012'49' Sub -Basin: 03-02-01
Location
Lv :teR •tude: 90'03'49'
Quad Mame: Sefeuo Creek
Stream Cfass: C
Rtteivinq Stream: 41?to'Beftua CreekPierce Management grou - C eckFide Manor7,tstNome
North]x
forsytle County

Permit NC0037311
A. (1.) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS — FINAL
During the period beginning on the effective date of this permit and lasting until
expiration, the Permittee is authorized to discharge from outfall 001. Such discharges
shall be limited and monitored by the Permittee as specified below:
EFFLUENT
CHARACTERISTICS
LIMITS
MONITORING REQUIREMENTS
Monthly
Averse
. Weekly
Averse
Daily
Maximum
Measurement
Frequency
Sample Type
Sample Location
Flow
0.010 MGD
Weekly
Instantaneous
Influent or Effluent
BOD, 5-day (204C)
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
Total Suspended Residue
30.0 mg1L
.0 mg/L'
Weekly
Grab
Effluent
NH3 as N
(April 1 —October 31
2.0 mg/L
l0 rng L
Weekly
Grab
Effluent
NH3 as N
November 1 — March 31
4.0 mg/L
a© _ /L
Weekly
Grab
Effluent
Dissolved Oxygen
Weekly
Grab
Effluent,
Upstream &
Downstream
Fecal Coliform (geometric mean)
200/100 ml
400/100 ml
Weekly
Grab
Effluent
Total Residual Chlorine
21Week
Grab
Effluent
Temperature (C)
Daily
Grab
Effluent
Temperature (QC)
Weekly
Grab
Upstream &
Downstream
pH3
Weekly
Grab
Effluent
Footnotes:
1. Upstream = approximately 100 feet above outfall; Downstream = approximately 300 feet
below outfall.
2. The daily average dissolved oxygen effluent concentration shall not be less than 5.0
mg/L.
3. The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units.
There shall be no discharge of floating solids or visible foam in other than trace amounts

RESEARCh & ANAtYTICAI
Uborzmoniu, INC.
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FACSIMILE MESSAGE
Date;
From:h
Research & Analytical Laboratories, Inc.
Telephone [phone]
Fax [phone]
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Comments:
Pages to Follow: t
Mailing Address:
PO Box 473
Kernersville, ITC 27285
Shipping Address:
106 Short Street
Kernersville, NC 27284

07/03/2002 M27 p1UER31CRRE a 9960326 N0.050 901
Dhersimfe
.A„„IF.0 L,YIN& SPA Y10 tf.
FACSIM IIJIS SSA+GF
Date: July 3, 7002
From: David A. Bolling
To: Christy'Jackson a? 919-733.7019
NCDBNR
CC: Creekside Manor of Forsyth, LLC
Hammonds Management, William Hammonds
R.&.A Laboratories, Dennis Hodge
bf: Creekside Manor
Comments:
Dear Ms. Jackson, please accept this as formal notifi cation and oonflrmation of transfer
of "Owners authorized Agent" from myself to Mr, James Cheshire of Researeb &
Analytical Laboratories, bic, ,for wastewater and community water concerns for
Creekside Manor Rest Home, permit no. NCO037311.1 have spoke with the current
owners/operators and they have agreed to this change as well.
Should you have any questions or need further assistance, please do not hesitate to
contact me.
Sincerely,
S�=
David A, Bolling
770-D Park Centre Drive K'ernersville, NC 27284 (336) 9924173 Fax [phone]
A sUbsfdiary ofAdvo001, Ina.

DRAhT NpDES NCO037311
Subject: DRAFT NPDES MCA- 003IM4
Date: Thu, 25 Apr 200216:53:38 -0400
From: Steve Mauney <[e-mail]>
Organization: NC DENR Water Quality
To: Christie Jackson <Christie [e-mail]>
CHRISTIE-I have reviewed the draft for Creekside Manor Rest Home and it
looks good. I also spoke to Dennis Hodge of Research & Analytical Labs
which monitors the plant. He confirmed that David Bolling should be the
name on the permit instead of James Cheshire who signed the application
as an authorized agent. Jim runs R& A Labs and signs the DMR's but
should not have signed the application. Call if any questions. --Steve
Steve Mauney
NC DENR Winston-Salem Regional Office
Division of Water Quality, Water Quality Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone] ext 262
FAX: [phone]
STEVE MAUNEY <Steve.Mauney(.NCMail.net>
ENVIRONMENTAL ENGINEER
DIVISION OF WATER QUALITY
ENVIRONMENT& NATURAL RESOURCES
1 of 1 4/29/0212:01 PM

NO SYTH AROLINA�N'
FO COUNTY
AFFIDAVIT OF PUBLICATION
Before the undersigned, a Notary Public of said County and State, duly
commissioned, qualified, and authorized by law to administer oaths, personally
appeared D.H. Stanfield, who being duly sworn, deposes and says: that he is
Controller of the Winston-Salem Journal, engaged in the publishing of a newspaper
known as Winston-Salem Journal, published, issued and entered as second class mail
in the City of Winston-Salem, in said county and State: that he is authorized to
make this affidavit and sworn statement: that the notice or other legal advertisement,
a true copy of which is attached hereto, was published in �' --• won
the following dates:
March 23, 2002
and that the said newspaper in which such notice, paper document, or legal
advertisement was published was, at the time of each and every such publication, `a
newspaper meeting all the requirements and qualifications of Section 1-597 of the
General Statues of North Carolina and was a qualified newspaper within the meaning
of Section 1-597 of the general statues of North Carolina.
This 25th day of March, 2002
(signature of pers n)naking affidavit)
Sworn to and subscribed before me, this 25th day of h, 2002
Nota ublic
viy Commission expires: September 28, 2005
OFFICIAL SEAL
r
S Notary Public, North Carolina
COUNTY OF R
KIMALEWOI
My Commission Expires
0
H

LV
0
180
NC0025526
WALNUT COVE, TOWN OF - WWTP
WSRO
STOKES
$1,323.00
LV
99
549
NC0028011
STONEVILLE, TOWN OF - WWTP
WSRO
ROCKINGHAM
$1,573.00
LV
99
581
NC0028011
STONEVILLE, TOWN OF - WWTP
WSRO
ROCKINGHAM
$1,073.00
LV
98
43
NC0029777
NC DOC - STOKES CORRECTIONAL
WSRO
STOKES
$303.30
LV
99
185
NG0029777
NC DOC - STOKES CORRECTIONAL
WSRO
STOKES
$3,078.00
LV
99
231
NC0029777
NC DOC - STOKES CORRECTIONAL
WSRO
STOKES
$1,571.00
LV
1
49
NC0035173
KOBE COPPER PRODUCTS, INC.
WSRO
STOKES
$1,579.00
Le°
99
133
NG0037311
CREEKSIDE MANOR REST HOME
WSRO
FORSYTH
$1,060.00'
TX
1
31
NG0040011
Yanceyvi Ile WWTP
WSRO
Caswell
$1,056.24
LV
1
177
NC0044954
STOKES CO SCH/SOUTH STOKES HS
WSRO
STOKES
$1,823.00
LV
1
87
NC0044962
STOKES CO SCH/NORTH STOKES HS
WSRO
STOKES
$1,073.00
LV
1
492
NC0044962
North Stokes High School
WSRO
Stokes
$829.00
LM
98
12
NC0050954
DOLLY MADISON MOTEL
WSRO
ROCKINGHAM
$199.00
LV
1
290
NC0050954
Dolly Madison Motel
WSRO
Rockingham
$2,580.00
LV
1
494
NG0056791
Horizons Residential Care Ctr
WSRO
Forsyth
$326.00
LM
98
14
NC0057720
TWIN LAKES MHP / SSB., INC.
WSRO
STOKES
$3,549.00
LV
98
106
NC0057720
TWIN LAKES MHP / SSB., INC.
WSRO
STOKES
$1,049.00
LV
0
178
NC0057720
TWIN LAKES MHP / SSB., INC.
WSRO
STOKES
$1,073.00
LV
98
268
NC0060461
CWS - ABINGTON
WSRO
FORSYTH
$1,060.00
LV
99
50
NC0060461
CWS - ABINGTON
WSRO
FORSYTH
$1,560.00
LV
0
432
NC0060542
GOLD HILL MOBILE HOME PARK
WSRO
ROCKINGHAM
$1,073.00
LV
97
27
NC0060623
STONE HIGHWAY MHP
WSRO
ROCKINGHAM
$13,098.26
LV
98
66
NC0075027
CAINS WAY MOBILE HOME PARK.
WSRO
FORSYTH
$1,040.00
LV
98
113
NG0075027
CAINS WAY MOBILE HOME PARK.
WSRO
FORSYTH
$1,290.00
LM
1
11
NC0075027
CAINS WAY MOBILE HOME PARK.
WSRO
FORSYTH
$526.00
LM
99
83
NC0077135
CURL MOD. HOMES/HIDDEN VALLEY
WSRO
ROCKINGHAM
$1,723.00
LV
0
9
NC0077135
CURL MOD. HOMES/HIDDEN VALLEY
WSRO
ROCKINGHAM
$312.00
LV
1
125
NC0077135
CURL MOD. HOMES/HIDDEN VALLEY
WSRO
ROCKINGHAM
$1,323.00
LV
1
176
NG0077135
CURL MOD. HOMES/HIDDEN VALLEY
WSRO
ROCKINGHAM
$1,323.00
LV
96
36
NC0078115
AQUASOURCE, INC. GREYSTONE SUB
WSRO
FORSYTH
$5,579.96
LV
98
121
NC0078115
AQUASOURCE, INC. GREYSTONE SUB
WSRO
FORSYTH
$2,640.00
LV
98
183
NC0078115
AQUASOURCE, INC. GREYSTONE SUB
WSRO
FORSYTH
$2,190.00
LV
98
219
NC0078115
AQUASOURCE, INC. GREYSTONE SUB
WSRO
FORSYTH
$1,540.00
LV
98
269
NC0078115
AQUASOURCE, INC. GREYSTONE SUB
WSRO
FORSYTH
$560.00
LV
99
138
NC0078115
AQUASOURCE, INC. GREYSTONE SUB
WSRO
FORSYTH
$1,310.00
LV
99
249
NC0078115
AQUASOURCE, INC. GREYSTONE SUB
WSRO
FORSYTH
$310.00
LV
0
314
NC0078115
AQUASOURCE, INC. GREYSTONE SUB
WSRO
FORSYTH
$345.00

Residual Chlorine and Ammonia Toxicity Assessment
Residual Chlorine
Ammonia as NH3
(summer)
s7Q10 (CFS)
0
s7Q10 (CFS)
0
DESIGN FLOW (MGD)
0.01
DESIGN FLOW (MGD)
0.01
DESIGN FLOW (CFS)
0.0155
DESIGN FLOW (CFS)
0.0155
STREAM STD (UG/L)
17.0
STREAM STD (MG/L)
1.0
UPS BACKGROUND LEVEL (
0
UPS BACKGROUND LEVEL
0.22
WC (%)
100.00
IWC (%)
100.00
Allowable Concentration (ug
17.00
Allowable Concentration (rr
1.00
Ammonia as NH3
(winter)
w7010 (CFS)
0.06
Fecal Limit
200/100ml
DESIGN FLOW (MGD)
0.01
Ratio of 0.0 :1
DESIGN FLOW (CFS)
0.0155
STREAM STD (MG/L)
1.8
UPS BACKGROUND LEVEL
0.22
IWC (%)
20.53
Allowable Concentration (rr
7.92
3/8/02
CRJ NC003731 1

RESEARCh & ANA[yTICA1
LABORATORIES, INC.
Analytical/Process Consultations
December 10, 2001
Charles H. Weaver, Jr.
NPDES Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, NC 27699-1617
RE: Renewal of NPDES Discharge Permit No. NCO037311
Creekside Manor W WTP
Forsyth County
Dear Mr. Weaver:
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Please renew NPDES Permit No. NCO037311 for the wastewater treatment plant at
Creekside Manor Rest Home. The signed application form in triplicate, a description of the
method of sludge disposal and a map of the location of the discharge are all attached.
Sincerely,
RESEARCH & ANALYTICAL LABORATORIES
P" -, � ?;; /' -
James M. Cheshire
Authorized Agent
JMC/ch
cc. David A. Bollings, Creekside Manor
P.O. Box 473 • 106 Short Street • Kernersville, North Carolina 27284 • 336-996-2841 • Fax [phone]

SLUDGE MANAGEMENT PLAN
CREEKSIDE MANOR WASTEWATER TREATMENT PLANT
NPDES PERMIT NO. NC0037311
Sludge from the Creekside Manor wastewater treatment plant are disposed of in the following
way:
Solids are collected in the sludge holding tank and digested
aerobically. The excess solids are periodically pumped and havled
by a licensed septic pumper contractor and disposed of at the City
of Greensboro wastewater treatment plant.

NPDES PERMIT APPLICATION - SHORT FORM D
To be filed only by dischargers of 100% domestic wastewater (<1 MGD flow)
N. C. Department of Environment and Natural Resources
Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
North Carolina NPDES Permit Number INCO037311
(if known)
Please print or type
1. Mailing address of applicant/permittee:
Facility Name Creekside Manor Rest Home
Owner Name pierce Management Group
Street Address 6206 Reidsville Road
City Kernersville
State NC
ZIP Code 27284
Telephone Number ( 336 ) 992-0173
Fax Number ( )
e-mail Address
2. Location of facility producing discharge:
Name (If different from above)
Facility Contact Person
Street Address or State Road
City / Zip Code
County
Telephone Number
3. Reason for application:
David A.
Kernersville, NC 27284
( 336 ) 992-0173 i
Expansion/Modification * Existing Unpermitted Discharge
Renewal x New Facility
. Please provide a description of the expansion/modification:
Extended aeration activated sludge plant with aerobic digestor and chlorine
4. Description of the existing treatment facilities (list all installed components with
capacities):
Page 1 of 2 Version 1112000

NPDES PERMIT APPLICATION - SHORT FORM D
To be filed only by dischargers of 100% domestic wastewater (<1 MGD flow)
5. Description of wastewater (check all that apply):
Type of Facility Generating Wastewater
Industrial Number of Employees
Commercial Number of Employees
Residential Number of Homes
School Number of Students/Staff
Other X
Describe the source(s) of wastewater (example: subdivision, mobile home park, etc.):
Rest Home
6. Number of separate wastewater discharge pipes (wastewater outfalls):
One
7. If the facility has multiple discharge outfalls, record the source(s) of wastewater for each
outfall:
N/A
S. Name of receiving stream(s) (Provide a map showing the exact location of each outfall):
Unamed tributary to Belews Creek
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
,lames M. Cheshire
Printed Name of Person Signing
Authorized Agent
Title _
of Applicant
12/10/01
Date Signed
Norffi Carolina General Statute 143-215.6B (i) provides that: Any person who knowingly makes any false statement representation, or
certification in any application, record, report, plan, or other document files or required to be maintained under Article 21 or regulations of the
Environmental Management Commission implementing that Article, or who falsifies, tampers with, or knowingly renders inaccurate any
recording or monitoring device or method required to be operated or maintained under Article 21 or regulations of the Environmental
Management Commission implementing that Article, shall be guilty of a misdemeanor punishable by a fine not to exceed $10,000, or by
imprisonment not to exceed six months, or by both. (18 U.S.C. Section 1001 provides a punishment by a fine of not more than $10,000 or
imprisonment not more than 5 years, or both for a similar offense.)
Page 2 of 2 Version 1112000