NCG590037_Renewal (Application)_20240503

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May 3, 2024 /7 .CPi
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Division of Water Resources 0�
Water Quality Permitting Section - NPDES NC0 2024
1617 Mail Service Center FQ/C�
Raleigh, North Carolina 27699-1617 R//`/p0
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Re: Application for Permit Renewal
Aqua North Carolina, Inc.
Fleetwood Falls WTP
NPDES No. NCG590037
Ashe County
To Whom It May Concern:
Enclosed are three (3) copies of the completed application Form 2C and Form 1. This
submittal includes the necessary attachments for your office to renew the subject permit.
Should you need any additional information or assistance, please feel free to contact me via
phone[phone])or by email at [e-mail].
Sincerely,
Brent Miltiron
Environmental Compliance Director
Aqua North Carolina, Inc.
Enc: NPDES Application, Form 2C
NPDES Application, Form 1
Fleetwood Falls WTP NPDES Permit
Cc: Shannon Becker, President,Aqua North Carolina
Wesley Dye, Environmental Compliance Specialist 1
202 MacKenan Court,Cary, NC, 27511 • 919.467.8712 • AquaAmerica.com

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
United States Office of Water EPA Form 3510-2C
Environmental Protection Agency Washington,D.C. Revised March 2019
Water Permits Division
EPA 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.

r
DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
Form U.S.Environmental Protection Agency
2C \".EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING,COMMERCIAL,MINING,AND SILVICULTURE OPERATIONS
SECTION 1.OUTFALL LOCATION(40 CFR 122.21(g)(1))
1.1 Provide information on each of the facility's outfalls in the table below.
c Numbelr Receiving Water Name Latitude Longitude
CO
0 001 Rocky Shoal Branch 36° 18' 18" N 3 81° 32' 31" W
ea
O
SECTION 2.LINE DRAWING(40 CFR 122.21(g)(2))
co 2.1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
c 3 balance?(See instructions for drawing requirements.See Exhibit 2C-1 at end of instructions for example.)
c ❑✓ Yes ❑ No
SECTIOII 3.AVERAGE FLOWS AND TREATMENT(40 CFR 122.21(0(3))
3.1 For each outfall identified under Item 1.1,provide average flow and treatment information.Add additional sheets if
necessary.
"Duffel!Number**001
Operations Contributing to Flow
Operation Average Flow
WTP Backwash Discharge 0.0036 mgd
mgd
Co
CD
mgd
y mgd
c Treatment Units
u_
a, Description Code from Final Disposal of Solid or
d (include size,flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than
retention time,etc.) by Discharge
EPA Form 3510-2C(Revised 3-19) Page 1

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
3.1 **OutfaII Number**
cont. Operations Contributing to Flow
Operation Average Flow
mgd
mgd
mgd
mgd
Treatment Units
Description Code from Final Disposal of Solid or
(include size,flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than
retention time,etc.) by Discharge
d
C
0
C
m
E
is
a>
H
c **Outfail Number**
Operations Contributing to Flow
o Operation Average Flow
rn mgd
co
' mgd
mgd
mgd
Description Code from Final Disposal of Solid or
(include size,flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than
retention time,etc.) by Discharge
3.2 Are you applying for an NPDES permit to operate a privately owned treatment works?
d ❑ Yes ❑ No 4 SKIP to Section 4.
cncn
3.3 Have you attached a list that identifies each user of the treatment works?
❑ Yes ❑ No
EPA Form 3510-2C(Revised 3-19) Page 2

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
SECTION 4.INTERMITTENT FLOWS(40 CFR 122.21(g)(4))
4.1 Except for storm runoff,leaks,or spills,are any discharges described in Sections 1 and 3 intermittent or seasonal?
❑� Yes ❑ No 4 SKIP to Section 5.
4.2 Provide information on intermittent or seasonal flows for each applicable outfall.Attach additional pages, if necessary.
Outfall Operation Frectuency Flow Rate
Number (list) Average Average Long-Term Maximum Duration
Days/Week Months/Year Average Daily
WTP Backwash Dischari 7 days/week 12 months/year 0.0036 mgd 0.0036 mgd 134 days
c001 days/week months/year mgd mgd days
u_
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
SECTION 5.PRODUCTION(40 CFR 122.21(g)(5))
5.1 Do any effluent limitation guidelines(ELGs)promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes ❑✓ No 4 SKIP to Section 6.
5.2 Provide the following information on applicable ELGs.
w ELG Category ELG Subcategory Regulatory Citation
d
5.3 Are any of the applicable ELGs expressed in terms of production(or other measure of operation)?
c ❑ Yes ❑✓ No 4 SKIP to Section 6.
5.4 Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
Outfall Operation,Product,or Material Quantity per Day Unit of
-0 Number Measure
fR
co
O
O
EPA Form 3510-2C(Revised 3-19) Page 3

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
SECTION 6.IMPROVEMENTS(40 CFR 122.21(g)(6))
6.1 Are you presently required by any federal,state,or local authority to meet an implementation schedule for constructing,
upgrading,or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
❑ Yes 0 No 4 SKIP to Item 6.3.
6.2 Briefly identify each applicable project in the table below.
dAffected Final Compliance Dates
d Brief Identification and Description of Outfalls Source(s)of
o Project (list outfall Discharge Required Projected
number)
c
CO
w
as
as
0.
a
6.3 Have you attached sheets describing any additional water pollution control programs(or other environmental projects
that may affect your discharges)that you now have underway or planned?(optional item)
❑ Yes ❑ No r❑ Not applicable
SECTION 7.EFFLUENT AND INTAKE CHARACTERISTICS(40 CFR 122.21(g)(7))
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn,the tables you must
complete.Not all applicants need to complete each table.
Table A.Conventional and Non-Conventional Pollutants
7.1 Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
❑r Yes ❑ No 4 SKIP to Item 7.3.
7.2 If yes,indicate the applicable outfalls below.Attach waiver request and other required information to the application.
Outfall Number 001 Outfall Number Outfall Number
O 7.3 Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
y requested and attached the results to this application package?
No;a waiver has been requested from myNPDES
ElYes ❑ permitting authority for all pollutants at all outfalls.
Table B.Toxic Metals,Cyanide,Total Phenols,and Organic Toxic Pollutants
7.4 Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
co
listed in Exhibit 2C-3?(See end of instructions for exhibit.)
❑ Yes No 4 SKIP to Item 7.8.
co
7.5 Have you checked"Testing Required"for all toxic metals,cyanide,and total phenols in Section 1 of Table B?
w ❑ Yes 0 No
7.6 List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s)identified
in Exhibit 2C-3.
Primary Industry Category Required GC/MS Fraction(s)
(Check applicable boxes.)
❑Volatile 0 Acid 0 Base/Neutral 0 Pesticide
❑Volatile 0 Acid ❑ Base/Neutral 0 Pesticide
0 Volatile 0 Acid 0 Base/Neutral 0 Pesticide
EPA Form 3510-2C(Revised 3-19) Page 4

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
7.7 r Have you checked"Testing Required"for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?
❑ Yes ❑✓ No
7.8 Have you checked"Believed Present"or"Believed Absent"for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required?
ElYes ❑ No
7.9 Have you provided(1)quantitative data for those Section 1,Table B,pollutants for which you have indicated testing is
required or(2)quantitative data or other required information for those Section 1,Table B,pollutants that you have
indicated are"Believed Present"in your discharge?
❑ Yes El No
7.10 Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
❑ Yes 4 Note that you qualify at the top of Table B, 0 No
then SKIP to Item 7.12.
7.11 Have you provided(1)quantitative data for those Sections 2 through 5,Table B,pollutants for which you have
c determined testing is required or(2)quantitative data or an explanation for those Sections 2 through 5,Table B,
H pollutants you have indicated are"Believed Present"in your discharge?
❑ Yes ElNo
d Table C.Certain Conventional and Non-Conventional Pollutants
E. 7.12 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed on Table C
r for all outfalls?
c.)
E Yes ❑ No
c 7.13 Have you completed Table C by providing(1)quantitative data for those pollutants that are limited either directly or
indirectly in an ELG and/or(2)quantitative data or an explanation for those pollutants for which you have indicated
10 "Believed Present"?
❑ Yes ❑r No
w Table D.Certain Hazardous Substances and Asbestos
7.14 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed in Table D for
all outfalls?
El Yes ❑ No
7.15 Have you completed Table D by(1)describing the reasons the applicable pollutants are expected to be discharged
and(2)by providing quantitative data,if available?
❑ Yes ❑✓ No
Table E.2,3,7,8-Tetrachlorodibenzo-p-Dioxin(2,3,7,8-TCDD)
7.16 Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions,or do you
know or have reason to believe that TCDD is or may be present in the effluent?
❑ Yes 4 Complete Table E. ❑✓ No 4 SKIP to Section 8.
7.17 Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes ElNo
SECTION 8.USED OR MANUFACTURED TOXICS(40 CFR 122.21(g)(9))
8.1 Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
an intermediate or final product or byproduct?
co
❑ Yes ❑r No 4 SKIP to Section 9.
co
v, 8.2 List the pollutants below.
1. 4. 7.
0
2. 5. 8.
H
3. 6. 9.
EPA Form 3510-2C(Revised 3-19) Page 5

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
SECTION 9.BIO OGICAL TOXICITY TESTS(40 CFR 122.21(g)(11))
9.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on(1)any of your discharges or(2)on a receiving water in relation to your discharge?
�, ❑ Yes ElNo 4 SKIP to Section 10.
9.2 Identify the tests and their Durposes below.
Test(s) Purpose of Test(s) Submitted to NPDES Date Submitted
o Permitting Authority?
I-
ElYes ❑ No
0
—
17D
0
0 ❑ Yes ❑ No
❑ Yes ❑ No
SECTION 10.CONTRACT ANALYSES(40 CFR 122.21(g)(12))
10.1 Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
❑� Yes ❑ No 4 SKIP to Section 11.
10.2 Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1 Laboratory Number 2 Laboratory Number 3
Name of laboratory/firm Water Tech Laboratories Inc
W
Laboratory address 5 Pinewood Plaza Dr
c Granite Falls,NC 28630
co
co
_
Phone number
c.)
[phone]
Pollutant(s)analyzed Total Suspended Solids
SECTION 11.ADDITIONAL INFORMATION(40 CFR 122.21(9)(13))
11.1 Has the NPDES permitting authority requested additional information?
c ❑ Yes ElNo 4 SKIP to Section 12.
E 11.2 List the information requested and attach it to this application.
0
1. 4.
a
0
2. 5.
-o
3. 6.
EPA Form 3510-2C(Revised 3-19) Page 6

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
SECTION 12.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
12.1 In Column 1 below,mark the sections of Form 2C that you have completed and are submitting with your application.
For each section,specify in Column 2 any attachments that you are enclosing to alert the permitting authority.Note
that not all applicants are required to complete all sections or provide attachments.
Column 1 Column 2
❑✓ Section 1:Outfall Location ❑✓ w/attachments
ElSection 2:Line Drawing El w/line drawing ❑ w/additional attachments
Section 3:Average Flows and w/list of each user of
Treatment ❑� w/attachments Elprivately owned treatment
works
❑ Section 4: Intermittent Flows ❑ wl attachments
❑ Section 5:Production ❑ w/attachments
w/optional additional
❑ Section 6: Improvements ❑ wl attachments ❑ sheets describing any
additional pollution control
plans
❑ wl request for a waiver and ❑ w/explanation for identical
supporting information outfalls
wl small business exemption w/other attachments
❑ request ❑
in ❑ Section 7: Effluent and Intake w/Table A ❑✓ w/Table B
Characteristics
0
❑✓ w/Table C ❑✓ w/Table D
wl analytical results as an
❑ wl Table E ❑ attachment
❑ Section 8:Used or Manufactured ❑ wl attachments
Toxics
❑ Section 9: Biological Toxicity ❑ w/attachments
Tests
U
❑ Section 10:Contract Analyses ❑ w/attachments
❑ Section 11:Additional Information El w/attachments
© Section 12:Checklist and ❑ w/attachments
Certification Statement
12.2 Certification Statement
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted.Based on my inquiry of the person or persons who manage the system,or those persons directly
responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true,
accurate, and complete.I am aware that there are significant penalties for submitting false information,including the
possibility of fine and imprisonment for knowing violations.
Name(print or type first and last name) Official title
Brent Milliron Environmental Compliance Director
Signature r—DocuSigned by: Date signed
05/03/2024
\—1742870BB06Bit EF...
EPA Form 3510-2C(Revised 3-19) Page 7

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
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DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590O37 Fleetwood Falls Subdivision-WTP 001 OMB No 2040-0004
TABLE A.CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(iii))1
Effluent Intake
Waiver (Optional)
Pollutant Requested Units Maximum Maximum Long-Term
(specify) Daily Monthly Average Daily Number of Long-Term Number of
(if applicable) Discharge Discharge Discharge Analyses Average Value Analyses
(required) (If available) (if available)
❑ Check here if you have applied to your NPDES permitting authority for a waiver for al/of the pollutants listed on this table for the noted outfall.
Biochemical oxygen demand Concentration
1. (BOD5) ❑ Mass
Chemical oxygen demand Concentration
2. (COD) ❑ Mass
Concentration
3. Total organic carbon(TOC)9 ( ) El
Mass
Concentration
4. Total suspended solids(TSS) El
-
Mass
Concentration
5. Ammonia(as N) ❑r
Mass
6. Flow ❑ Rate gpd 3,600 3,600 134
Temperature(winter) ❑✓ °C °C
7.
Temperature(summer) ❑✓ °C °C
pH(minimum) ❑ Standard units S.U. 6.4 7.4 30
8.
pH(maximum) ❑ Standard units s.u. 8.0 7.4 30
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 9

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
This page intentionally left blank.

DocuSign Envelope ID:2AOED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 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
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
Maximum Maximum Long-
(and CAS Number,if available) Required Believed Believed (specify) Daily Monthly Average Number Term Number
Present Absent
D(eeggharge (if availableDisc harge Analyses
Value Average Analyses
(if available)El
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
Antimony,total Concentration
1.1 (7440-36-0) Mass
1.2 Arsenic,total Concentration
(7440-38-2) Mass
1 3 Beryllium,total Concentration
(7440-41-7) ✓ Mass
1.4 Cadmium,total Concentration
(7440-43-9) Mass
1.5 Chromium,total Concentration
(7440-47-3) ✓ Mass
Copper,total Concentration
1.6 (7440-50-8) Mass
1.7 Lead,total Concentration
(7439-92-1) Mass
Mercury,total Concentration
1.8 (7439-97-6) Mass
1.9 Nickel,total Concentration
(7440-02-0) Mass
1 10 Selenium,total Concentration
(7782 49-2) Mass
1.11 Silver,total Concentration
(7440-22-4) Mass
EPA Form 3510-2C(Revised 3-19) Page 11

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Out-fall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))l
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number.if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) (if available) Value
1.12 Thallium,total Concentration
(7440-28-0) ✓ Mass
Zinc,total Concentration
1.13 (7440-66-6) Mass
1.14 Cyanide,total Concentration
0 0
(57-12-5) ✓ Mass
1.15 Phenols,total ❑ 0 CI
Concentration
Mass
Section 2.Organic Toxic Pollutants(GC/MS Fraction—Volatile Compounds)
Acrolein Concentration
2.1 (107-02-8) Mass
Acrylonitrile Concentration
2.2 (107-13-1) ✓ Mass
Benzene Concentration
2.3 0 0(71-43-2) ✓ Mass
2.4 Bromoform Concentration
(75-25-2) Mass
Carbon tetrachloride ❑ Concentration
✓
2.5 (56-23-5) Mass
Chlorobenzene ❑ 0 Concentration
✓
2.6 (108-90-7) Mass
Chlorodibromomethane Concentration
2.7 (124-48-1) ✓ Mass
2 8 Chloroethane ❑ ❑ Concentration
(75-00-3) Mass
EPA Form 3510-2C(Revised 3-19) Page 12

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 Fleetwood Falls Subdivision-WTP
OMB No.2040-0004
NCG590037001
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))+
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term Long-
(and
CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Number
Present Absent Daily Monthly Term
Daily of
of
Discharge Discharge Dischar a An lyses Average Analyses
(requited) (if available) g Value
(if available)
2.9 2-chloroethylvinyl ether ❑ Concentration
(110-75-8) Mass
Concentration
2.10 Chloroform(67-66-3) ❑ ❑ C Mass
2.11 Dichlorobromomethane Concentration
(75-27-4) ✓ Mass
212 1,1-dichloroethane Concentration
(75-34-3) Mass
213 1,2-dichloroethane ❑ ❑ Concentration
(107-06-2) ✓ Mass
214 1,1-dichloroethylene ❑ Concentration
(75-35-4) Mass
215 1,2-dichloropropane ❑ Concentration
(78-87-5) Mass
216 1,3-dichloropropylene ❑ Concentration
(542-75-6) ✓ Mass
217 Ethylbenzene Concentration
(100-41-4) Mass
218 Methyl bromide Concentration
(74-83-9) Mass
2 19 Methyl chloride Concentration
(74-87-3) Mass
2 20 Methylene chloride ❑ 0 Concentration
(75-09-2) Mass
2.21 1,1,2,2-tetrachloroethane ❑ Concentration
(79-34-5) Mass
EPA Form 3510-2C(Revised 3-19) Page 13

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))r
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,iavailable) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Term
Discharge Discharge Daily of Average of
(required) (if available) Discharge Analyses Value Analyses
(if available)
2.22 Tetrachloroethylene ❑ ❑. Concentration
(127-18-4) Mass
Toluene Concentration
2.23 (108-88-3) ❑ 0 ❑ Mass
2.24 12-Vans-dichloroethylene a Concentration
(156-60-5) Mass
225 1,1,1-trichloroethane ❑ ❑ ❑ Concentration
(71-55-6) Mass
2.26 1 1,2-trichloroethane 0 0 ❑ Concentration
(79-00-5) Mass
Trichloroethylene ❑ Concentration
2.27 (79-01-6) Mass
Vinyl chloride CI
2.28 (75-01-4) Mass
Section 3.Organic Toxic Pollutants(GC/MS Fraction—Acid Compounds)
2-chlorophenol Concentration
3.1 (95-57-8) LI 0 Mass
3.2 2,4-dichlorophenol El Concentration
(120-83-2) Mass
2 4-dimethylphenol Concentration
3.3 0 El(105-67-9) El
4,6-dinitro-o-cresol El Concentration
3.4 (534-52-1) Mass
3.5 2,4-dinitrophenol 0 0 El Concentration
(51-28-5) Mass
EPA Form 3510-2C(Revised 3-19) Page 14

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Tenrn gl Number
Present Absent Daily MonthlyDaily D(req ired)e D(ifavailable) Discharge Analyses of Average Analyses
(if available) Value
3.6 2-nitrophenol Concentration
(88-75-5) Mass
3.7 4-nitrophenol Concentration
(100-02-7) ✓ Mass
3.8 p-chloro-m-cresol ElConcentration
0 El
(59-50-7) Mass
3.9 Pentachlorophenol ❑ ❑ Concentration
(87-86-5) Mass
Phenol Concentration
3.10 (108-95-2) Mass
311 2,4,6-trichlorophenol ❑ El
(88-05-2) ✓ Mass
Section 4.Organic Toxic Pollutants(GC/MS Fraction—Base/Neutral Compounds)
4.1 Acenaphthene Concentration
(83-32-9) Mass
Acenaphthylene Concentration
4.2 (208-96-8) Mass
4.3 Anthracene Concentration
(120-12-7) Mass
4.4 Benzidine ElConcentration
(92-87-5) Mass
Benzo(a)anthracene Concentration .
4.5 (56-55-3) Mass
4.6 Benzo(a)pyrene Concentration
(50-32-8) Mass
EPA Form 3510-2C(Revised 3-19) Page 15
I

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
1 TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(9)(7)(v)'
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number.if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly of Tenn
Discharge Discharge DisDcharge Analyses Average Analyses
(required) (if available) Value
(if available)
3 4-benzofluoranthene ❑ Concentration
4.7 (205-99-2) Mass
4.8 Benzo(ghi)perylene Concentration
(191-24-2) Mass
Benzo(k)fluoranthene Concentration
4.9 (207-08-9) ✓ Mass
4.10 Bis(2-chloroethoxy)methane © Concentration
(111-91-1) Mass
4.11 Bis(2-chloroethyl)ether ❑ 0 ❑� Concentration
(111-44-4) Mass
4.12 Bis(2-chloroisopropyl)ether � Concentration
(102-80-1) Mass
4.13 Bis(2-ethylhexyl)phthalate Concentration
(117-81-7) ✓ Mass
4.14 4-bromophenyl phenyl ether Concentration
(101-55-3) Mass
4.15 Butyl benzyl phthalate ❑ Concentration
(85-68-7) Mass
2-chloronaphthalene Concentration
4.16 (91 58 7) ✓ Mass
4-chlorophenyl phenyl ether Concentration
4.17 (7005-72-3) Mass
Chrysene Concentration
4.18 (218-01-9) Mass
Dibenzo(a,h)anthracene ❑ ❑ Concentration
4.19 ✓(53-70-3) Mass
EPA Form 3510-2C(Revised 3-19) Page 16

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCGS90037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Maximum Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Average Number Long-
(and
Present Absent Daily Monthly Term
Daily
of
Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) Value
(if available)
4.20 12-dichlorobenzene � Concentration
(95-50-1) r Mass
1,3-dichlorobenzene Concentration
4.21 (541-73-1) ❑ 0
Mass
4.22 1,4-dichlorobenzene 0 ❑ Concentration
(106-46-7) r Mass
4.23 3,3-dichlorobenzidine ❑ Concentration
(91-94-1) r Mass
4.24 Diethyl phthalate El ❑ ❑ Concentration
(84-66-2) Mass
4.25 Dimethyl phthalate ❑ ❑ Concentration
(131-11-3) r Mass
4.26 Di-n-butyl phthalate IDConcentration
(84-74-2) Mass
4.27 2 4-dinitrotoluene ❑ ❑ Concentration
(121-14-2) r Mass
4.28 2,6-dinitrotoluene ❑ r Concentration
(606-20-2) Mass
4.29 Di-n-octyl phthalate ❑ ❑ Concentration
(117-84-0) Mass
4.30 1,2-Diphenylhydrazine ❑ ❑ Concentration
(as azobenzene)(122-66-7) r Mass
4.31 Fluoranthene © Concentration
El I=1(206-44-0) Mass
Fluorene Concentration
4.32 (86-73-7) Mass
EPA Form 3510-2C(Revised 3-19) Page 17

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05119
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No 2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))r
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long-
(and
Present Absent Daily Monthly Term
Discharge Discharge Daily of Average of
(required) (if available) Discharge Analyses Value Analyses
(if available)
Hexachlorobenzene ❑ ❑ Concentration
4.33 (118 74 1) Mass
Hexachlorobutadiene ❑ Concentration
✓
4.34 (87 68 3) Mass
Hexachlorocyclopentadiene Concentration
4.35 (77-47-4) ✓ Mass
Hexachloroethane Concentration
4.36 (67 72 1) Mass
4.37 Indeno(1,2,3-cd)pyrene ❑ El
(193-39-5) Mass
Isophorone Concentration
4.38 0 CI(78-59-1) ✓ Mass
Naphthalene Concentration
4.39 (91-20-3) Mass
Nitrobenzene Concentration
4.40 (98 95 3) ✓ Mass
4.41 N-nitrosodimethylamine Concentration
(62-75-9) Mass
4.42 N-nitrosodi-n-propylamine Concentration
(621-64-7) Mass
4.43 N-nitrosodiphenylamine Concentration
(86-30-6) Mass
4.44 Phenanthrene Concentration
(85-01-8) Mass
Pyrene Concentration
4.45 0 0(129-00-0) ✓ Mass
EPA Form 3510-2C(Revised 3-19) Page 18

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 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 Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term Average of
Discharge Discharge
(required) (ifavailable) Discharge Analyses Value Analyses
(if available)
1,2,4-trichlorobenzene Concentration
4.46 r(120 82 1) Mass
Section 5.Organic Toxic Pollutants(GC/MS Fraction—Pesticides)
51 Aldrin Concentration
El
(309-00-2) Mass
5.2 a-BHC Concentration
(319-84-6) Mass
)3-BHC Concentration
5.3 (319-85-7) Mass
y-BHC Concentration
5.4 (58-89-9) Mass
6-BHC Concentration
5.5 (319-86-8) Mass
5.6 Chlordane Concentration
(57-74-9) Mass
4,4'-DDT Concentration
5.7 (50-29-3) Mass
5.8 4,4'-DDE 0 0 0 Concentration
(72-55-9) Mass
5.9 4,4'-DDD Concentration
(72-54-8) r Mass
Dieldrin Concentration
5.10 0 0(60-57-1) CI
Mass
5.11 a-endosulfan � Concentration
(115-29-7) r Mass
EPA Form 3510-2C(Revised 3-19) Page 19

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBDB-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCGS90037 NCGS90037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))I
Presence or Absence
check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (�ciy) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Dailyof Term of
Dt eQuired) Drfava ischarablee) Discharge Analysese AValuee Analyses
(if available)
512 13-endosulfan ❑ ❑ ❑ Concentration
(115-29-7) Mass
5.13 Endosulfan sulfate CI ❑ Concentration
(1031-07-8) ✓ Mass
Endrin Concentration
5.14 (72 20 8) ❑ ❑ El
5.15 Endnn aldehyde El ❑ ❑ Concentration
(7421-93-4) Mass
5.16 Heptachlor CI ❑ ❑ Concentration
(76-44-8) Mass
Heptachlor epoxide Concentration
5.17 (1024-57-3) ❑ ❑ 0
Mass
PCB-1242 Concentration
5.18 (53469-21-9) ❑ ❑ E Mass
PCB-1254 Concentration
5.19 (11097-69-1) ❑ ❑ ❑� Mass
PCB-1221 Concentration
5.20 (11104-28-2) ❑ 0 0 Mass
PCB-1232 Concentration
5.21 (11141-16-5) ❑ CI CI
Mass
PCB-1248 Concentration
5.22 (12672-29-6) ❑ ❑ ❑r
Mass
PCB-1260 Concentration
5.23 (11096-82-5) ❑ ❑ ❑ Mass
PCB-1016 Concentration
5.24 (12674-11-2) ❑ ❑ 0
Mass
EPA Form 3510-2C(Revised 3-19) Page 20

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
I EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,ifavailable) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Term
aily of of
Dls�cired) Drfavalablleee) Dicharge Analyses AValuee Analyses
r) (if available) •
Toxaphene Concentration
5.25 (8001-35-2) ❑ 0 0 Mass
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

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
This page intentionally left blank.

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))t
Presence or Absence
(check one) Effluent Intake
(Optional)
Units
Pollutant Maximum Long-Term
Believed Believed (specify) Maximum Daily Monthly Average Daily Number of Long-Term Number of
Present Absent Discharge Discharge Discharge Analyses Average Analyses
(required) (it available) (if available) Value
❑
Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall.You need not complete the"Presence or Absence column of Table C for
each pollutant.
©
Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall.You need not complete the"Presence or Absence"column of Table C for
each pollutant.
1 Bromide ❑ ❑ Concentration
(24959-67-9) Mass
Chlorine,total Concentration
2. residual ❑ ❑ Mass
Concentration
3. Color ❑ ❑ Mass
Concentration
4. Fecal coliform ❑ ❑ Mass
6 Fluoride ❑ ❑ Concentration
(16984-48-8) Mass
Concentration
6 Nitrate-nitrite ❑ ❑ Mass
Nitrogen,total Concentration
7. organic(as N) ❑ 0 Mass
Concentration
8. Oil and grease ❑ ❑ Mass
9 Phosphorus(as ❑ ❑ Concentration
P),total(7723-14-0) Mass
•
10. Sulfate(as SO4) 0 ❑ Concentration
(14808-79-8) Mass
•
Concentration
11. Sulfide(as S) ❑ ❑ Mass
EPA Form 3510-2C(Revised 3-19) Page 23

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCGS90037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))1
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)
12. Sulfite(as SOa) ❑ ❑ Concentration
(14265-45-3) Mass
Concentration
13. Surfactants ❑ ❑ Mass
14. Aluminum,total ❑ ❑ Concentration
(7429-90-5) Mass
15. Barium,total ❑ ❑ Concentration
(7440-39-3) Mass
16. Boron,total ❑ ❑ Concentration
(7440 42-8) Mass
17. Cobalt,total ❑ ❑ Concentration
(7440-8-4) Mass
18. Iron,total ❑ ❑ Concentration
(7439-89-6) Mass
19 Magnesium,total ❑ ❑ Concentration
(7439-90-4) Mass
Molybdenum, Concentration
20. total ❑ ❑ Mass
(7439-98-7)
21. Manganese,total ❑ ❑ Concentration
(7439-96-5) Mass
22 Tin,total ❑ 0 Concentration
(7440-31-5) Mass
•
23 Titanium,total ❑ 0 Concentration
(7440-32-6) Mass
EPA Form 3510-2C(Revised 3-19) Page 24

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))r
Presence or Absence
(check one) Effluent Intake
(Optional)
Units
Pollutant Maximum Long-Term Lon Term
Believed Believed (specify) Maximum Daily Long
-Term
Absent Discharge Monthly Average Daily Number of Average Number of
Discharge Discharge Analyses Analyses
(required) Value
(if available) (it available)
24. Radioactivity
Concentration
Alpha,total 0 ❑ Mass
Concentration
Beta,total ❑ ❑ Mass
•
•
Concentration
Radium,total ❑ ❑ Mass
Concentration
Radium 226,total ❑ ❑ Mass
1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C(Revised 3-19) Page 25

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
This page intentionally left blank.

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 12221(g)(7)(vii))1
Presence or Absence
Pollutant (check one) Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
1. Asbestos ❑ ❑✓
2. Acetaldehyde ❑ ❑✓
3. Allyl alcohol ❑ ❑r
4. Allyl chloride ❑ ❑e
5. Amyl acetate ❑ ❑r
6. Aniline ❑ ❑✓
7. 8enzonitrile ❑ 0
8. Benzyl chloride ❑ ❑r
9. Butyl acetate ❑ ❑r
10. Butylamine ❑ ❑r
11. Captan ❑ ❑r
12. Carbaryl ❑ ❑s
13. Carbofuran ❑ ❑✓
14. Carbon disulfide 0 ❑✓
15. Chlorpyrifos ❑ ❑r
16. Coumaphos ❑ 0
17. Cresol ❑ ❑r
18. Crotonaldehyde ❑ ❑r
19. Cyclohexane ❑ ❑✓
EPA Form 3510-2C(Revised 3-19) Page 27

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identltication Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 12221(g)(7)(vii))1
Presence or Absence
Pollutant pea one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent _
20. 2,4-D(2,4-dichlorophenoxyacetic acid) ❑ CI
21. Diazinon ❑ CI
22. Dicamba ❑ ❑✓
23. Dichlobenil ❑ El
24. Dichlone ❑ 0
25. 2,2-dichloropropionic acid 0 ❑✓
26. Dichlorvos ❑ ❑✓
27. Diethyl amine ❑ ❑r
28. Dimethyl amine ❑ El
29. Dintrobenzene ❑ ❑
30. Diquat ❑ ❑r
31. Disulfoton ❑ 0
32. Diuron ❑ ❑✓
33. Epichlorohydrin ❑ ❑r
34. Ethion ❑ ❑r
35. Ethylene diamine ❑ 0
36. Ethylene dibromide ❑ ❑.
37. Formaldehyde ❑ CI
38. Furfural ❑ ❑�
EPA Form 3510-2C(Revised 3-19) Page 28

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 001 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))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 0 El
41. Isopropanolamine ❑ ❑r
42. Kelthane ❑ ❑r
43. Kepone ❑ ❑r
44. Malathion ❑ ❑r
45. Mercaptodimethur ❑ ❑r
46. Methoxychlor ❑ ❑r
47. Methyl mercaptan ❑ ❑✓
48. Methyl methacrylate ❑ 0
49. Methyl parathion ❑ ❑✓
50. Mevinphos ❑ Cl
51. Mexacarbate ❑ ❑r
52. Monoethyl amine ❑ El
53. Monomethyl amine ❑ Cl
54. Naled ❑ ❑r
55. Naphthenic acid ❑ ❑✓
56. Nitrotoluene ❑ CI
57. Parathion ❑ ❑✓
EPA Form 3510-2C(Revised 3-19) Page 29

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 12221(g)(7)(vii))1
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
58. Phenolsulfonate ❑ ❑r
59. Phosgene ❑ ❑r
60. Propargite ❑ El
61. Propylene oxide ❑ 12
62. Pyrethrins ❑ ❑s
63. Quinoline ❑ ❑✓
64. Resorcinol ❑ ❑r
65. Strontium ❑ ❑✓
66. Strychnine ❑ 0
67. Styrene ❑ El
68 2,4,5-T(2,4,5-trichlorophenoxyacetic ❑ El
acid)
69. TDE(tetrachlorodiphenyl ethane) 0 D
70. 2,4,5-TP[2-(2,4,5-trichlorophenoxy) ❑ El
propanoic acid]
71. Trichlorofon ❑ ❑r
72. Triethanolamine ❑ ❑r
73. Triethylamine ❑ ❑r
74. Trimethylamine ❑ 0
75. Uranium ❑ ❑r
76. Vanadium ❑ 0
EPA Form 3510-2C(Revised 3-19) Page 30

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))'
Presence or Absence
Pollutant (ch one) Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
77. Vinyl acetate ❑ 0
78. Xylene 0 0
79. Xylenol 0 0
80. Zirconium 0 0
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

DocuSign Envelope ID:2A0ED3A5-7779454C-BBDS-74C3F658E8E6
This page intentionally left blank.

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE E.2,3,7,8 TETRACHLORODIBENZO P DIOXIN(2,3,7,8 TCDD)(40 CFR 122.21(g)(7)(viii))
TCDD Presence or
ICongeners Absence
Pollutant (check one) Results of Screening Procedure
Used or
Manufactured Believed Believed
Present Absent
2.3.7.8-TCDD ❑
EPA Form 3510-2C(Revised 3-19) Page i3

DocuSign Envelope ID: BE3E753E-46E6-457F-BC63-442A4D0328EA
United States Office of Water EPA Form 3510-1
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
.l.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.

DocuSign Envelope ID:BE3E753E-46E6-457F-BC63-442A4D0328EA
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision WTP OMB No.2040-0004
Form U.S.Environmental Protection Agency
1 8 EPA Application for NPDES Permit to Discharge Wastewater
NPDES GENERAL INFORMATION
SECTION 1.ACTIVITIES REQUIRING AN NPDES PERMIT(40 CFR 122.21(f)and(f)(1))
1.1 Applicants Not Required to Submit Form 1
Is the facility a new or existing publicly owned Is the facility a new or existing treatment works
1.1.1 12
treatment works? 1. . treating domestic sewage?
If yes,STOP. Do NOT complete �✓ No If yes,STOP. Do NOT E No
Form 1.Complete Form 2A. complete Form 1.Complete
Form 2S.
1.2 Applicants Required to Submit Form 1
1.2.1 Is the facility a concentrated animal feeding 1.2.2 Is the facility an existing manufacturing,
operation or a concentrated aquatic animal commercial,mining,or silvicultural facility that is
a production facility? currently discharging process wastewater?
o ❑ Yes 4 Complete Form 1 E No 0 Yes 4 Complete Form ❑ No
a and Form 2B. 1 and Form 2C.
R1.2.3 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?
o ❑ Yes 4 Complete Form 1 E No ❑ Yes 4 Complete Form J No
and Form 2D. 1 and Form 2E.
fd
1.2.5 Is the facility a new or existing facility whose
discharge is composed entirely of stormwater
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
El Yes 4 Complete Form 1 �r No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x)or
b 15 .
SECTION 2.NAME, MAILING ADDRESS,AND LOCATION(40 CFR 122.21(f)(2))
2.1 Facility Name
Fleetwood Falls Subdivision-WTP
`0 2.2 EPA Identification Number
co
0
o NCG590037
J
2.3 Facility Contact
Name(first and last) Title Phone number
'D Brent Milliron Environmental Compliance Director [phone]
Email address
[e-mail]
2.4 Facility Mailing Address
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

DocuSign Envelope ID:BE3E753E-46E6-457F-BC63-442A4D0328EA
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision WTP OMB No.2040-0004
d 2.5 Facility Location
wStreet,route number,or other specific identifier
Q 0 Parcel #13198117 by 490 Bear Ridge Trail
rn
c County name County code(if known)
2 II Ashe
o City or town State ZIP code
Fleetwood North Carolina 28626
SECTION 3.SIC AND NAICS CODES(40 CFR 122.21(f)(3))
3.1 SIC Code(s) Description(optional)
4941 Establishments primarily engaged in distributing water for sale for domestic,
In
0
U
co
z 3.2 NAICS Code(s) Description(optional)
-o
coo 310 Water Distribution(except irrigation)
U
N
SECTION 4.OPERATOR INFORMATION(40 CFR 122.21(f)(4))
4.1 Name of Operator
Aqua North Carolina
4.2 Is the name you listed in Item 4.1 also the owner?
❑✓ Yes ❑ No
4.3 Operator Status
❑ Public—federal ❑ Public—state ❑ Other public(specify)
2 Private ❑ Other(specify)
4.4 Phone Number of Operator
[phone]
4.5 Operator Address
w
Street or P.O.Box
R
202 MacKenan Drive
o
c w City or town State ZIP code
o 0 Cary North Carolina 27511
co
Email address of operator
[e-mail]
SECTION 5.INDIAN LAND(40 CFR 122.21(f)(5))
c 5.1 Is the facility located on Indian Land?
co
co
c ❑ Yes ❑ No
EPA Form 3510-1(revised 3-19) Page 2

DocuSign Envelope ID:BE3E753E-46E6-457F-BC63-442A4D0328EA
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision WTP OMB No.2040-0004
SECTION 6.EXISTING ENVIRONMENTAL PERMITS(40 CFR 122.21(f)(6))
6.1 Existing Environmental Permits(check all that apply and print or type the corresponding permit number for each)
d ❑✓ NPDES(discharges to surface ❑ RCRA(hazardous wastes) ❑ UIC(underground injection of
water) fluids)
NCG590037
c
w a ❑ PSD(air emissions) ❑ Nonattainment program(CM) ❑ NESHAPs(CM)
c
w 0 Ocean dumping(MPRSA) ❑ Dredge or fill(CWA Section 404) ❑ Other(specify)
SECTION 7.MAP(40 CFR 122.21(f)(7))
7.1 Have you attached a topographic map containing all required information to this application?(See instructions for
R specific requirements.)
ElYes ❑ No ❑ CAFO—Not Applicable(See requirements in Form 2B.)
SECTION 8.NATURE OF BUSINESS(40 CFR 122.21(f)(8))
8.1 Describe the nature of your business.
Operating a filter-backwash treatment system employing greensand filter technology to treat groundwater in
support of potable-water production
N)
a)
N
y
m
0
O
d
m
Z
SECTION 9.COOLING WATER INTAKE STRUCTURES(40 CFR 122.21(f)(9))
9.1 Does your facility use cooling water?
0 Yes ❑✓ No 4 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
,w 40 CFR 125,Subparts I and J may have additional application requirements at 40 CFR 122.21(r).Consult with your
m NPDES permitting authority to determine what specific information needs to be submitted and when.)
o
O
c
SECTION 10.VARIANCE REQUESTS(40 CFR 122.21(f)(10))
10.1 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)?(Check all that
y apply.Consult with your NPDES permitting authority to determine what information needs to be submitted and
when.)
❑ Fundamentally different factors(CWA ❑ Water quality related effluent limitations(CWA Section
cu
cc Section 301(n)) 302(b)(2))
co ❑ Non-conventional pollutants(CWA ❑ Thermal discharges(CWA Section 316(a))
Section 301(c)and(g))
ElNot applicable
EPA Form 3510-1(revised 3-19) Page 3

DocuSign Envelope ID:BE3E753E-46E6-457F-BC63-442A4D0328EA
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision WTP OMB No.2040-0004
SECTION 11.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
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 El wl attachments
2 Section 3:SIC Codes El w/attachments
ElSection 4:Operator Information ❑ wl attachments
ElSection 5:Indian Land El w/attachments
ElSection 6: Existing Environmental Permits ❑ w/attachments
dI=1Section 7:Mapwl topographic
;a ❑ map ❑ w/additional attachments
co
c ❑r Section 8:Nature of Business Elw/attachments
•R
w El Section 9:Cooling Water Intake Structures El w/attachments
cu
c.) ElSection 10:Variance Requests El w/attachments
-o
co
w 0 Section 11:Checklist and Certification Statement El w/attachments
Y
w 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. 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
Brent Milliron Environmental Compliance Director
Signature Date signed
�DocuSigned by:
r """' o,,,a-_— 05/03/2024
1742670860684EF_.
EPA Form 3510-1(revised 3-19) Page 4

DocuSign Envelope ID:FDB49CFE-F14A-4737-A849-4A36D9F1 F07E
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Fleetwood Falls N
NPDES Permit NCG590037
Receiving Stream: Rocky Shoal Branch Longitude: 81° 32'31" W Facilit
Stream Index: 10-1-20 Latitude: 36° 18' 18" N Location
River Basin: New River Sub-Basin: 05-07-01 SCALE
Stream Class: C+ HUC: 050500010204 1:16,000 Ashe County

41111111110 Fleetwood Falls Subdivision
Sodium NCG590037
Hypochlorite 0 Process Flow Diagram
Day Tank
Raw Water Greensand
Wells 3, 5, Water
MEll Distribution
&g Treatment
Facility
IFilter Backwash
Water:680 GPD
Outfa 11001
MillIMIMMIMINIIIMOINOMMINOMMai
Rocky Shoal Branch

AQUA
Essential
May 3, 2024
Division of Water Resources
Water Quality Permitting Section - NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: Application for Permit Renewal
Aqua North Carolina, Inc.
Fleetwood Falls WTP
NPDES No. NCG59O037
Ashe County
To Whom It May Concern:
Enclosed are three (3) copies of the completed application Form 2C and Form 1. This
submittal includes the necessary attachments for your office to renew the subject permit.
Should you need any additional information or assistance,please feel free to contact me via
phone[phone])or by email at [e-mail].
Sincerely,
6L7F
Brent Milliron
Environmental Compliance Director
Aqua North Carolina, Inc.
Enc: NPDES Application, Form 2C
NPDES Application, Form 1
Fleetwood Falls WTP NPDES Permit
Cc: Shannon Becker, President,Aqua North Carolina
Wesley Dye, Environmental Compliance Specialist 1
202 MacKenan Court,Cary, NC, 27511 • 919.467.8712 • AquaAmerica.com

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
United States Office of Water EPA Form 3510-2C
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
: EPA Application Form 2C
Existing Manufacturing,
Commercial, Mining, and
Si Ivicu Itu ral 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.

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
Form U.S.Environmental Protection Agency
2C 3IEPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING,COMMERCIAL,MINING,AND SILVICULTURE OPERATIONS
SECTION 1.OUTFALL LOCATION(40 CFR 122.21(g)(1))
1.1 Provide information on each of the facility's outfalls in the table below.
c Outfall Receiving Water Name Latitude Longitude
Number
001 Rocky Shoal Branch 36° 18' 18" N 3 81° 32' 31" W 3
0
SECTION 2. LINE DRAWING(40 CFR 122.21(g)(2))
Q, 2.1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
c 3 balance?(See instructions for drawing requirements.See Exhibit 2C-1 at end of instructions for example.)
J o ❑ Yes ❑ No
SECTION 3.AVERAGE FLOWS AND TREATMENT(40 CFR 122.21(c)(3))
3.1 For each outfall identified under Item 1.1,provide average flow and treatment information.Add additional sheets if
necessary.
**Outfall Number**001
Operations Contributing to Flow
Operation Average Flow
WTP Backwash Discharge 0.0036 mgd
mgd
mgd
N mgd
Treatment Units
Description Code from Final Disposal of Solid or
(include size,flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than
retention time,etc.) by Discharge
EPA Form 3510-2C(Revised 3-19) Page 1

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
3.1 **Outfall Number**
cont. Operations Contributing to Flow
Operation Average Flow
mgd
mgd
mgd
mgd
Treatment Units
Description Code from Final Disposal of Solid or
(include size,flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than
retention time,etc.) by Discharge
a)
0
C-
wm E
H
0 **Outfall Number**_
Operations Contributing to Flow
Operation Average Flow
LL
mgd
a' mgd
mgd
mgd
Treatment Units
Description Code from Final Disposal of Solid or
(include size,flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than
retention time,etc.) by Discharge
3.2 Are you applying for an NPDES permit to operate a privately owned treatment works?
d ❑ Yes 0 No 4 SKIP to Section 4.
N3.3 Have you attached a list that identifies each user of the treatment works?
❑ Yes ❑ No
EPA Form 3510-2C(Revised 3-19) Page 2

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
SECTION 4.INTERMITTENT FLOWS(40 CFR 122.21(g)(4))
4.1 Except for storm runoff, leaks,or spills,are any discharges described in Sections 1 and 3 intermittent or seasonal?
❑ Yes ❑ No 4 SKIP to Section 5.
4.2 Provide information on intermittent or seasonal flows for each applicable outfall.Attach additional pages,if necessary.
Outfall Operation Frecuency Flow Rate
Number (list) Average Average Long-Term Maximum Duration
Days/Week Months/Year Average Daily
WTP Backwash Discharj 7 days/week 12 months/year 0.0036 mgd 0.0036 mgd 134 days
c001 days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
CD
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
SECTION 5. PRODUCTION(40 CFR 122.21(g)(5))
5.1 Do any effluent limitation guidelines(ELGs)promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes ❑✓ No 4 SKIP to Section 6.
u, 5.2 Provide the following information on applicable ELGs.
ELG Category ELG Subcategory Regulatory Citation
n
5.3 Are any of the applicable ELGs expressed in terms of production(or other measure of operation)?
u, ❑ Yes ❑ No 4 SKIP to Section 6.
• _
co 5.4 Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
Outfall Operation,Product,or Material Quantity per Day Unit of
Number Measure
W
co
O
O
`
EPA Form 3510-2C(Revised 3-19) Page 3

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
SECTION 6.IMPROVEMENTS(40 CFR 122.21(g)(6))
6.1 Are you presently required by any federal,state,or local authority to meet an implementation schedule for constructing,
upgrading,or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
❑ Yes 0 No 4 SKIP to Item 6.3.
6.2 Briefly identify each applicable project in the table below.
cn
Affected Final Compliance Dates
Brief Identification and Description of Outfalls Source(s)of
o Project (list outfall Discharge Required Projected
Enumber)
c
co
w
m
CD
a
6.3 Have you attached sheets describing any additional water pollution control programs(or other environmental projects
that may affect your discharges)that you now have underway or planned?(optional item)
❑ Yes ❑ No r❑ Not applicable
SECTION 7.EFFLUENT AND INTAKE CHARACTERISTICS(40 CFR 122.21(g)(7))
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn,the tables you must
complete.Not all applicants need to complete each table.
Table A.Conventional and Non-Conventional Pollutants
7.1 Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
❑r Yes ❑ No 4 SKIP to Item 7.3.
7.2 If yes,indicate the applicable outfalls below.Attach waiver request and other required information to the application.
Outfall Number o01 Outfall Number Outfall Number
tO
7.3 Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
requested and attached the results to this application package?
❑✓ Yes No;a waiver has been requested from my NPDES
❑ permitting authority for all pollutants at all outfalls.
i Table B.Toxic Metals,Cyanide,Total Phenols,and Organic Toxic Pollutants
47
7.4 Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
listed in Exhibit 2C-3?(See end of instructions for exhibit.)
❑ Yes ElNo 4 SKIP to Item 7.8.
co
7.5 Have you checked"Testing Required"for all toxic metals,cyanide,and total phenols in Section 1 of Table B?
❑ Yes ElNo
7.6 List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s)identified
in Exhibit 2C-3.
Primary Industry Category Required GC/MS Fraction(s)
(Check applicable boxes.)
❑Volatile 0 Acid 0 Base/Neutral 0 Pesticide
❑Volatile 0 Acid 0 Base/Neutral 0 Pesticide
❑Volatile 0 Acid 0 Base/Neutral 0 Pesticide
EPA Form 3510-2C(Revised 3-19) Page 4

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
7.7 Have you checked"Testing Required"for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?
❑ Yes ❑✓ No
7.8 Have you checked"Believed Present"or`Believed Absent"for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required?
O Yes ❑ No
7.9 Have you provided(1)quantitative data for those Section 1,Table B,pollutants for which you have indicated testing is
required or(2)quantitative data or other required information for those Section 1,Table B, pollutants that you have
indicated are"Believed Present"in your discharge?
❑ Yes ❑r No
7.10 Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
El Yes 4 Note that you qualify at the top of Table B, ❑ No
then SKIP to Item 7.12.
7.11 Have you provided(1)quantitative data for those Sections 2 through 5,Table B,pollutants for which you have
c determined testing is required or(2)quantitative data or an explanation for those Sections 2 through 5,Table B,
pollutants you have indicated are"Believed Present"in your discharge?
❑ Yes 0 No
tv• Table C.Certain Conventional and Non-Conventional Pollutants
ra 7.12 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed on Table C
s for all outfalls?
0 Yes ❑ No
• 7.13 Have you completed Table C by providing(1)quantitative data for those pollutants that are limited either directly or
indirectly in an ELG and/or(2)quantitative data or an explanation for those pollutants for which you have indicated
"Believed Present"?
❑ Yes ❑✓ No
w Table D.Certain Hazardous Substances and Asbestos
7.14 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed in Table D for
all outfalls?
El Yes ❑ No
7.15 Have you completed Table D by(1)describing the reasons the applicable pollutants are expected to be discharged
and(2)by providing quantitative data,if available?
❑ Yes E No
Table E.2,3,7,8-Tetrachlorodibenzo-p-Dioxin(2,3,7,8-TCDD)
7.16 Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions,or do you
know or have reason to believe that TCDD is or may be present in the effluent?
❑ Yes-4 Complete Table E. ❑r No 4 SKIP to Section 8.
7.17 Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes ElNo
SECTION 8.USED OR MANUFACTURED TOXICS(40 CFR 122.21(g)(9))
8.1 Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
an intermediate or final product or byproduct?
El Yes ❑r No 4 SKIP to Section 9.
8.2 List the pollutants below.
1. 4. 7.
2. 5. 8.
3. 6. 9.
EPA Form 3510-2C(Revised 3-19) Page 5

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
SECTION 9.BIOLOGICAL TOXICITY TESTS(40 CFR 122.21(g)(11))
9.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on(1)any of your discharges or(2)on a receiving water in relation to your discharge?
❑ Yes ❑✓ No 4 SKIP to Section 10.
9.2 Identify the tests and their)urposes below.
Test(s) Purpose of Test(s) Submitted to NPDES Date Submitted
•I
Permitting Authority?
❑ Yes ❑ No❑ Yes ❑ No
❑ Yes ❑ No
SECTION 10.CONTRACT ANALYSES(40 CFR 122.21(g)(12))
10.1 Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
❑ Yes El No 4 SKIP to Section 11.
10.2 Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1 Laboratory Number 2 Laboratory Number 3
Name of laboratory/firm Water Tech Laboratories Inc
M
Laboratory address 5 Pinewood Plaza Dr
QGranite Falls,NC 28630
co
ea
c
Phone number
[phone]
Pollutant(s)analyzed Total Suspended Solids
SECTION 11.ADDITIONAL INFORMATION(40 CFR 122.21(g)(13))
11.1 Has the NPDES permitting authority requested additional information?
c El Yes E No 4 SKIP to Section 12.
11.2 List the information requested and attach it to this application.
0
1. 4.
2. 5.
3. 6.
EPA Form 3510-2C(Revised 3-19) Page 6

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
SECTION 12.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
12.1 In Column 1 below,mark the sections of Form 2C that you have completed and are submitting with your application.
For each section,specify in Column 2 any attachments that you are enclosing to alert the permitting authority.Note
that not all applicants are required to corn)fete all sections or provide attachments.
Column 1 Column 2
❑✓ Section 1:Outfall Location ❑r w/attachments
❑r Section 2: Line Drawing ❑r w/line drawing ❑ w/additional attachments
Section 3:Average Flows and w/list of each user of
0 Treatment ❑r ❑w/attachments privately owned treatment
works
❑ Section 4: Intermittent Flows ❑ w/attachments
❑ Section 5: Production ❑ w/attachments
w/optional additional
❑ Section 6: Improvements ❑ w/attachments ❑ sheets describing any
additional pollution control
plans
❑ w/request for a waiver and ❑ w/explanation for identical
supporting information outfalls
w/small business exemption w/other attachments
❑ request ❑
O Section 7: Effluent and Intake ❑ w/Table A ❑
Characteristics w/Table B
0
❑✓ w/Table C ❑✓ w/Table D
❑ w/analytical results as an
❑ w/Table E attachment
R ❑ Section 8: Used or Manufactured ❑ w/attachments
Toxics
❑ Section 9: Biological Toxicity ❑ w/attachments
Tests
U
❑ Section 10:Contract Analyses ❑ w/attachments
❑ Section 11:Additional Information El w/attachments
© Section 12:Checklist and ❑ w/attachments
Certification Statement
12.2 Certification Statement
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted.Based on my inquiry of the person or persons who manage the system,or those persons directly
responsible for gathering the information,the information submitted is, to the best of my knowledge and belief, true,
accurate,and complete. I am aware that there are significant penalties for submitting false information,including the
possibility of fine and imprisonment for knowing violations.
Name(print or type first and last name) Official title
Brent Milliron Environmental Compliance Director
Signature p—Docusigned by: Date signed
A— 05/03/2024
174287013B06B'EF...
EPA Form 3510-2C(Revised 3-19) Page 7

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•
DocuSign Envelope ID:2A0ED3A5-7779.454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE A.CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(iii))t
Effluent Intake
Waiver (Optional)
Pollutant Requested Units Maximum Maximum Long-Term
(if applicable) (specify) Daily Monthly Average Daily Number of Long-Term Number of
Discharge Discharge Discharge Analyses Average Value Analyses
(required) (if available) (if available)
❑ Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.
Biochemical oxygen demand Concentration
(BODs) ❑ Mass
Chemical oxygen demand Concentration
2.
(COD) ❑ Mass
Concentration
3. Total organic carbon(TOC) ❑✓
Mass
Concentration
4. Total suspended solids(TSS) ❑�
Mass
Concentration
5. Ammonia(as N) ❑✓
Mass
6. Flow ❑ Rate gpd 3,600 3,600 134
Temperature(winter) E °C °C
7.
Temperature(summer) ❑r °C °C
pH(minimum) ❑ Standard units s.u. 6.4 7.4 30
8.
pH(maximum) ❑ Standard units S.U. 8.0 7.4 30
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

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
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DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))r
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
D(requ edischarge Ddavailablee) Discharge Analyses Average
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
Antimony,total Concentration
1.1 (7440-36-0) Mass
2 Arsenic,total Concentration
1. CI 0
(7440-38-2) ✓ Mass
Beryllium,total Concentration
1.3 0(7440.41-7) Mass
1.4 Cadmium,total ❑ ❑ Concentration
(7440.43-9) r Mass
1.5 Chromium,total CI ❑ Concentration
(7440-47-3) ✓ Mass
Copper,total Concentration
1.6 ✓(7440-50-8) Mass
1.7 Lead,total Concentration
(7439-92-1) r Mass
Mercury,total Concentration
1.8 CI 0 CI
(7439-97-6) Mass
•
1 9 Nickel,total Concentration
CI 0 r
(7440-02-0) Mass
Selenium,total Concentration
1.10 (7782-49-2) Mass
Silver,total Concentration
1.11 (7440-22-4) Mass
EPA Form 3510-2C(Revised 3-19) Page 11

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))t
Presence or Absence Intake
(check one) Effluent
(optional)
Pollutant/Parameter Testing Units Long-Term
Long-
(and CAS Number,d available Required Believed Believed Maximum Maximum) q (specify) Average Number Number
Present Absent Daily Monthly Term
Daily
Discharge Discharge Discharge Analyses Average Analyses
(requited) (if available) (if available) Value
1.12 Thallium,total Concentration
(7440-28-0) ✓ Mass
1.13 Zinc,total Concentration
(7440-66-6) Mass
1.14 Cyanide,total Concentration
(57-12-5) Mass
1.15 Phenols,total ❑ ❑ 0
Concentration
Mass
Section 2.Organic Toxic Pollutants(GC/MS Fraction—Volatile Compounds)
21 Acrolein Concentration
(107-02-8) Mass
Acrylonitrile Concentration
2.2 (107-13-1) Mass
Benzene Concentration
2.3 (71-43-2) Mass
2.4 Bromoform Concentration
(75-25-2) Mass
Carbon tetrachloride � ❑ Concentration
✓
2.5 (56-23-5) Mass
Chlorobenzene Concentration
2.6 (108-90-7) Mass
Chlorodibromomethane 0 ❑ Concentration
✓
2.7 (124-48-1) Mass
Chloroethane Concentration
2.8 (75-00-3) Mass
EPA Form 3510-2C(Revised 3-19) Page 12

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))r
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Term
Daily of of
Discharge Discharge Discharge Analyses Average Analyses
(required) ( (davailable) (ifavailable) Value
2.9 2-chloroethylvinyl ether ❑ ❑ ❑ Concentration
(110-75-8) Mass
Concentration
2.10 Chloroform(67-66-3) ❑ ❑ 0 Mass
2.11 Dichlorobromomethane ❑ 0 ❑ Concentration
(75-27 4) Mass
212 1,1-dichloroethane ❑ 0 ❑ Concentration
(75-34-3) Mass
213 1,2-dichloroethane ❑ ❑ ❑ Concentration
(107-06-2) Mass
214 1,1-dichloroethylene 0 0 ❑ Concentration
(75-35-4) Mass
215 1,2-dichloropropane ❑ 0 ❑ Concentration
(78-87-5) Mass
2.16 13-dichloropropylene El 0 ❑ Concentration
(542-75-6) Mass
217 Ethylbenzene ❑ 0 ❑ Concentration
(100-41-4) Mass
218 Methyl bromide ❑ ❑ ❑ Concentration
(74-83-9) Mass
2.19 Methyl chloride Concentration
0 0
(74-87-3) El Mass
2.20 Methylene chloride ❑ ❑ CIConcentration
(75-09-2) Mass
221 1,1,2,2-tetrachloroethane 0 0 CI
Concentration
(79-34-5) Mass
EPA Form 3510-2C(Revised 3-19) Page 13

DocuSign Envelope ID:2AOED3A5-7779454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))l
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
Maximum Maximum Long-
(and CAS Number,if available) Required Believed Believed (specify) DailyMonthlyAverage Number Term Number
Present Absent
Discharge Discharge Daily of Average of
(required) (if available) Discharge Analyses Analyses
Value
(if available)
2 22 Tetrachloroethylene Concentration
(127-18-4) Mass
2 23 Toluene Concentration
(108-88-3) Mass
1,2-trans-dichloroethylene ❑ Concentration
2.24 (156-60-5) Mass
11,1-trichloroethane ❑ ❑ ❑ Concentration
2.25 (71-55-6) Mass
1 1,2-trichloroethane Concentration
2.26 (79-00-5) Mass
2.27 Trichloroethylene 0 O Concentration
(79-01-6) Mass
2 28 Vinyl chloride 0 Concentration
(75-01-4) Mass
Section 3.Organic Toxic Pollutants(GC/MS Fraction—Acid Compounds)
2-chlorophenol Concentration
3.1 (95-57.8) Mass
3 2 2,4-dichlorophenol El Concentration
(120-83-2) Mass
3.3 2,4-dimethylphenol ElConcentration
(105-67-9) Mass
3.4 4,6-dinitro-o-cresol � 0Concentration
(534-52-1) Mass
2,4-dinitrophenol Concentration
3.5 (51-28-5) Mass
EPA Form 3510-2C(Revised 3-19) Page 14

II
DocuSign Envelope ID:2A0ED3A5-7779454C-BBD8-74C3F658E8E6 I
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 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
check one) Effluent Intake
!optional)
Pollutant/Parameter Testing Units Long-Term _
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long Number
Present Absent Daily Monthly Daily of Term of
Discharge Discharge Average
(required) (if available) Discharge Analyses Value Analyses
(if available)
2-nitrophenol Concentration
3.6 (88-75-5) Mass
4-nitrophenol Concentration
3.7 (100-02-7) Mass
p-chloro-m-cresol Concentration
3.8 (59-50-7) Mass
Pentachlorophenol Concentration
3.9 (87-86-5) Mass
Phenol Concentration
3.10 •
(108-95-2) ❑ ❑ El Mass
2,4,6-trichlorophenol Concentration
3.11 (88-05-2) � 0
Mass
Section 4.Organic Toxic Pollutants(GC/MS Fraction—Base/Neutral Compounds)
Acenaphthene Concentration
4.1 (83-32-9) El ❑ 2
Mass
Acenaphthylene Concentration
4.2 El 0 El
(208-96-8) Mass
4.3 Anthracene Concentration
(120-12-7) Mass
Benzidine Concentration
4.4 (92-87-5) ❑ ❑ © Mass
Benzo(a)anthracene Concentration
4.5 (56-55-3) Mass
4.6 Benzo(a)pyrene 0 ❑ ❑ Concentration
(50-32-8) Mass
EPA Form 3510-2C(Revised 3-19) Page 15

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCGS90037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))r
Presence or Absence Intake
(check one) Effluent
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly of Term of
aily
Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) Value
(if available)
3,4-benzofluoranthene Concentration
4.7 (205-99-2) Mass
4.8 Benzo(ghi)perylene Concentration
(191-24-2) Mass
Benzo(k)fluoranthene Concentration
4.9 (207-08-9) Mass
Bis(2-chloroethoxy)methane Concentration
4.10 (111-91-1) ❑ ❑ El
4 11 Bis(2-chloroethyl)ether ❑ ❑ Concentration
(111-44-4) ✓ Mass
4 12 Bis(2-chloroisopropyl)ether Concentration
(102-80-1) Mass
4.13 Bis(2-ethylhexyl)phthalate Concentration
(117-81-7) ✓ Mass
4.14 4-bromophenyl phenyl ether Concentration
(101-55-3) Mass
4.15 Butyl benzyl phthalate ❑ Concentration
(85-68-7) Mass
416 2-chloronaphthalene 0 0 Concentration
(91-58-7) Mass
4.17 4-chlorophenyl phenyl ether Concentration
(7005-72-3) ✓ Mass
418 Chrysene Concentration
(218-01-9) Mass
4.19
Dibenzo(a,h)anthracene Concentration
53-70-3
( ) Mass
EPA Form 3510-2C(Revised 3-19) Page 16

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPOES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))l
Presence or Absence Intake
(check one) Effluent
loplionao
Pollutant/Parameter Testing Units Maximum Maximum Long-Term Long-
(and CAS Number,if available) Required Believed Believed (specify) Number
Daily Monthly Average Number Term
Present Absent Daily of of
Discharge Discharge Average
(required) (if available) Discharge Analyses Value Analyses
(if available)
4.20 1,2-dichlorobenzene ❑ Concentration
(95-50-1) r Mass
1,3-dichlorobenzene Concentration
4.21 (541-73-1) ❑ ❑ 0 -
Mass
1,4-dichlorobenzene Concentration
4.22 (106-46-7) ❑ D 0
Mass
4.23 3,3-dichlorobenzidine ❑ Concentration
(91-94-1) r Mass
Diethyl phthalate Concentration
4.24 (84-66-2) Mass
4.25 Dimethyl phthalate 0 Concentration
(131-11-3) r Mass
4.26 Di-n-butyl phthalate 0 Concentration
(84-74-2) r Mass
4.27 2,4-dinitrotoluene ❑ 0 Concentration
(121-14-2) r Mass
2,6-dinitrotoluene Concentration
4.28 r(606-20-2) Mass
4.29 Di-n-octyl phthalate Concentration
(117-84-0) Mass
4.30 1,2-Diphenylhydrazine ❑ Concentration
(as azobenzene)(122-66-7) r Mass
Fluoranthene Concentration
4.31 0 0(206-44-0) El
4.32 Fluorene Concentration
0 0
(86-73-7) r Mass
EPA Form 3510-2C(Revised 3-19) Page"?

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 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
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
Discharge Discharge Average
(required) (if available) Discharge Analyses Value Analyses
(if available)
Hexachlorobenzene Concentration
4.33 (118 74 1) ✓ Mass
Hexachlorobutadiene � ✓
Concentration
4.34 (87-68-3) Mass
Hexachlorocyclopentadiene ❑ ✓
Concentration
4.35 (77-47-4) Mass
Hexachloroethane ❑ Concentration
4.36 (67 72 1) Mass
4.37 Indeno(1,2,3-cd)pyrene Concentration
(193-39-5) Mass
Isophorone Concentration
4.38 (78 59 1) ✓ Mass
4.39 Naphthalene Concentration
(91-20-3) ✓ Mass
Nitrobenzene Concentration
4.40 (98 95 3) ✓ Mass
N-nitrosodimethylamine � ❑ Concentration
4.41 (62.75-9) Mass
N-nitrosodi-n-propylamine Concentration
4.42 (621-64-7) ✓ Mass
N-nitrosodiphenylamine ❑ ✓
Concentration
4.43 (86-30-6) Mass
Phenanthrene ❑ ✓
Concentration
4.44 (85 01 8) Mass
4.45 Pyrene Concentration
(129-00-0) Mass
EPA Form 3510-2C(Revised 3-19) Page 18

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))r
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
Maximum Maximum Long-
(and CAS Number,if available) Required Believed Believed (specify) Average Number Term Number
Present Absent Daily Monthly Daily of of
Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) Value
_ (if available)
1,2,4-trichlorobenzene Concentration
4.46 •
(120-82-1) Mass
Section 5.Organic Toxic Pollutants(GCIMS Fraction—Pesticides)
5.1 Aldrin Concentration
El 0
(309-00-2) ✓ Mass
a-BHC Concentration
5.2 (319-84-6) Mass
13-BHC Concentration
5.3 (319-85-7) Mass
y-BHC Concentration
5.4 1=1 0 0(58.89-9) Mass
5.5 6-BHC Concentration
(319-86-8) Mass
Chlordane Concentration
5.6 EI 0 0(57-74-9) Mass
5.7 4 4'-DDT Concentration
(50-29-3) Mass
4,4'-DDE Concentration
5.8 (72-55-9) Mass
5.9 4,4'-DDD Concentration
0 0
(72-54-8) ✓ Mass
5.10 Dieldrin Concentration
El 0
(60-57-1) ✓ Mass
5.11 a-endosulfan Concentration
(115-29-7) ✓ Mass
EPA Form 3510-2C(Revised 3-19) Page 19

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WIP 001 OMB No,2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(9)(7)(v)),
Presence or Absence Intake
(check one) Effluent
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long-
Number
Present Absent Daily Monthly Daily of
Average Term of
Discharge Discharge
(required) (ifavailable) Discharge Analyses Value Analyses
(if available)
512 R-endosulfan ❑ ❑ ❑ Concentration
(115-29-7) Mass
Endosulfan sulfate Concentration
5.13 (1031-07-8) ❑ 0 ❑ Mass
5.14 Endrin ❑ 0
© Concentration
(72-20-8) Mass
5.15 Endrin aldehyde El ❑ ❑ Concentration
(7421-93-4) Mass
5.16 Heptachlor El ❑ ❑ Concentration
(76-44-8) Mass
Heptachlor epoxide Concentration
5.17 (1024-57-3) ❑ ❑ 0 Mass
PCB-1242 Concentration
5.18 (53469-21-9) ❑ ❑ 0
Mass
PCB-1254 Concentration
5.19 (11097-69-1) ❑ ❑ 0 Mass
PCB-1221 Concentration
i 5.20 (11104-28-2) ❑ 0 0
Mass
PCB-1232 Concentration
5.21 (11141-16-5) ❑ 0 0 Mass
PCB-1248 Concentration
5.22 (12672-29-6) 0 ❑ 0
Mass
PCB-1260 Concentration
5.23 (11096-82-5) 0 0 0 Mass
PCB-1016 Concentration
5.24 (12674-11-2) ❑ ❑ 0
Mass
EPA Form 3510-2C(Revised 3-19) Page 20

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Duffel!Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence e
Intak
(check one) Effluent (optional)
Pollutant/Parameter Testing Units Long-Term -Long
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Number
Present Absent Daily Monthly Daily of Term of
Discharge Discharge Average
Discharge Analyses Analyses
(required) (if available) (if available) Value
Toxaphene e Concentration
5.25 (8001-35-2) 0 0
Mass
I Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C(Revised 3-19) Page 21

DocuSign Envelope ID:2AOED3A5-7779-454C-BBD8-74C3F658E8E6
This page intentionally left blank.

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))r
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
Discharge Discharge Analyses Analyses
(required) Value
(if available) (if available)
❑
Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall.You need not complete the"Presence or Absence"column of Table C for
each pollutant.
©
Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall.You need not complete the"Presence or Absence"column of Table C for
each pollutant.
1. Bromide ❑ ❑ Concentration
(24959-67-9) Mass
2 Chlorine,total ❑ ❑ Concentration
residual Mass
3. Color ❑ ❑ Concentration
Mass
Concentration
4. Fecal coliform ❑ ❑ Mass
6 Fluoride ❑ ❑ Concentration
(1698448-8) Mass
Concentration
6 Nitrate-nitrite ❑ ❑ Mass
7 Nitrogen,total El ❑ Concentration
organic(as N) Mass
Concentration
8. Oil and grease ❑ ❑ Mass
Phosphorus(as Concentration
9. P),total(7723-14-0) ❑ ❑ Mass
10 Sulfate(as SOa) ❑ ❑ Concentration
(14808-79-8) Mass
Concentration
11. Sulfide(as S) ❑ ❑ Mass
EPA Form 3510-2C(Revised 3-19) Page 23

DocuSign Envelope ID:2A0ED3A5-7779454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
NCG590037 001
TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))r
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
Discharge Discharge Analyses Analyses
(required) (if available) (if available) Value
Sulfite(as S03) CI CI Concentration
12. (14265-45-3)
Mass
13. Surfactants CI
Concentration
Mass
.14. Aluminum,total ❑ ❑ Concentration
(7429-90-5) Mass
15.
Barium,total Concentration
(7440-39-3) CI CI Concentration
Boron,total CI CI Concentration
16. (744042-8)
Mass
17 Cobalt,total ❑ ❑ Concentration
(7440-484) Mass
Iron'total CI Concentration
18. (7439-89-6)
Mass
•
Magnesium,total Concentration
19. ❑ ❑
(7439-954) Mass
Molybdenum, Concentration
20.
total ❑ ❑
(7439-98-7) Mass
Manganese,total ❑ CI Concentration
21. (7439-96-5)
Mass
22 Tin,total CI ❑ Concentration
(7440-31-5) Mass
Titanium,total CI CI Concentration 23. (7440-32-6)
Mass
EPA Form 3510-2C(Revised 3-19) Page 24

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))r
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) Value
(if available) Cif available)
24. Radioactivity
Concentration
Alpha,total ❑ ❑ Mass
•
Concentration
Beta,total ❑ ❑ Mass
Concentration
Radium,total ❑ ❑ Mass
Concentration
Radium 226,total ❑ ❑ Mass
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

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
This page intentionally left blank.

DocuSign Envelope ID:2AOED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))'
Presence or Absence
Pollutant (check one) Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
1. Asbestos ❑ 0
2. Acetaldehyde ❑ ❑r
3. Allyl alcohol ❑ ❑r
4. Allyl chloride ❑ CI
5. Amyl acetate ❑ CI
6. Aniline ❑ ❑✓
7. Benzonitrile ❑ ❑r
8. Benzyl chloride ❑ ❑r
9. Butyl acetate ❑ ❑✓
10. Butylamine ❑ ❑✓
11. Captan ❑ ❑e
12. Carbaryl ❑ El
13. Carbofuran ❑ ❑r
14. Carbon disulfide ❑ ❑r
15. Chlorpyrifos ❑ ❑✓
16. Coumaphos ❑ ❑r
17. Cresol ❑ ❑r
18. Crotonaldehyde ❑ ❑r
19. Cyclohexane ❑ 0
EPA Form 3510-2C(Revised 3-19) Page 27

DocuSign Envelope ID:2A0E03A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))r
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. Diazinon ❑ 0
22. Dicamba ❑ Cl
23. Dichlobenil ❑
24. Dichlone ❑ 0
25. 2,2-dichloropropionic acid ❑ 0
26. Dichlorvos ❑ Cl
27. Diethyl amine ❑ 0
28. Dimethyl amine ❑ 0
29. Dintrobenzene ❑ 0
30. Diquat ❑ 0
31. Disulfoton ❑ ❑r
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

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))r
Presence or Absence 1
Pollutant (check one) Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent _
39. Guthion ❑ 0
40. Isoprene 0 0
41. Isopropanolamine ❑ 0
42. Kelthane ❑ 0
43. Kepone ❑ 0
44. Malathion ❑ 0
45. Mercaptodimethur ❑ 0
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 0
54. Naled ❑ 0
55. Naphthenic acid ❑ 0
56. Nitrotoluene ❑ 0
57. Parathion ❑ 0
EPA Form 3510-2C(Revised 3-19) Page 29

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))1
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
58. Phenolsulfonate ❑ ❑r
59. Phosgene ❑ 0
60. Propargite ❑ ❑r
61. Propylene oxide ❑ El
62. Pyrethrins ❑ 0
63. Quinoline ❑ ❑✓
64. Resorcinol ❑ ❑✓
65. Strontium ❑ ❑✓
66. Strychnine ❑ 0
67. Styrene ❑ ❑✓
68. 2,4,5-T(2,4,5-trichlorophenoxyacetic ❑ ❑
acid)
69. TDE(tetrachlorodiphenyl ethane) ❑ ❑,.
70 2,4,5-TP[2-(2,4,5-trichlorophenoxy) ❑ ❑
propanoic acid]
71. Trichlorofon ❑ CI
72. Triethanolamine ❑ ❑✓
73. Triethylamine ❑ 0
74. Trimethylamine ❑ CI
75. Uranium ❑ ❑r
76. Vanadium 0 ❑r
EPA Form 3510-2C(Revised 3-19) Page 30

r —
DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))'
Presence or Absence
Pollutant (check one) Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
77. Vinyl acetate ❑ El
78. Xylene ❑ ❑�
79. Xylenol ❑
80. Zirconium ❑ ❑r
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

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
This page intentionally left blank.

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE E.2,3,7,8 TETRACHLORODIBENZO P DIOXIN(2,3,7,8 TCDD)(40 CFR 122.21(g)(7)(viii))
TCDD Presence or
Congeners Absence
Pollutant Used or (check one) Results of Screening Procedure
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD ❑ �r
EPA Form 3510-2C(Revised 3-19) Page 33

DocuSign Envelope ID: BE3E753E-46E6-457F-BC63-442A4D0328EA
United States Office of Water EPA Form 3510-1
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
..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.

DocuSign Envelope ID:BE3E753E-46E6-457F-BC63-442A4D0328EA
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision WTP OMB No.2040-0004
Form U.S.Environmental Protection Agency
\- EPA Application for NPDES Permit to Discharge Wastewater
NPDES GENERAL INFORMATION
SECTION 1.ACTIVITIES REQUIRING AN NPDES PERMIT(40 CFR 122.21(f)and(f)(1))
1.1 Applicants Not Required to Submit Form 1
Is the facility a new or existing publicly owned Is the facility a new or existing treatment works
1.1.1 12
treatment works? 1. . treating domestic sewage?
If yes,STOP. Do NOT complete 0 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?
Yes 4 Complete Form 1 0 No E Yes 4 Complete Form ❑ No
a and Form 2B. 1 and Form 2C.
c1.2.3 Is the facility a new manufacturing,commercial, 1.2.4 Is the facility a new or existing manufacturing,
C mining,or silvicultural facility that has not yet commercial,mining,or silvicultural facility that
commenced to discharge? discharges only nonprocess wastewater?
❑ Yes 4 Complete Form 1 No D Yes 4 Complete Form 0 No
and Form 2D. 1 and Form 2E.
F. 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 E No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x)or
b 15 .
SECTION 2.NAME,MAILING ADDRESS,AND LOCATION(40 CFR 122.21(f)(2))
2.1 Facility Name
Fleetwood Falls Subdivision-WTP
O 2.2 EPA Identification Number
U
O NCG590037
J
-a
2.3 Facility Contact
d Name(first and last) Title Phone number
-a Brent Milliron Environmental Compliance Director [phone]
c Email address
[e-mail]
2
• 2.4 Facility Mailing Address
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

DocuSign Envelope ID:BE3E753E-46E6-457F-BC63-442A4D0328EA
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision WTP OMB No.2040-0004
2.5 Facility Location
Street,route number,or other specific identifier
0 Parcel #13198117 by 490 Bear Ridge Trail
DI U
c `o County name County code(if known)
2 Ashe
vCity or town State ZIP code
z R Fleetwood North Carolina 28626
SECTION 3.SIC AND NAICS CODES(40 CFR 122.21(f)(3))
3.1 SIC Code(s) Description(optional)
4941 Establishments primarily engaged in distributing water for sale for domestic,
0
0>
0
O
V
N
U
3.2 NAICS Code(s) Description(optional)
310 Water Distribution(except irrigation)
U
N
SECTION 4.OPERATOR INFORMATION(40 CFR 122.21(f)(4))
4.1 Name of Operator
Aqua North Carolina
0 4.2 Is the name you listed in Item 4.1 also the owner?
0
0 Yes El No
4.3 Operator Status
S
❑ Public—federal ❑ Public—state ❑ Other public(specify)co
o El Private ❑ Other(specify) _
4.4 Phone Number of Operator
[phone]
4.5 Operator Address
Street or P.O.Box
E 0 202 MacKenan Drive
0 3
City or town State ZIP code
i C
o V Cary North Carolina 27511
a Email address of operator
[e-mail]
SECTION 5.INDIAN LAND(40 CFR 122.21(f)(5))
0 5.1 Is the facility located on Indian Land?
co
= J El Yes El No
EPA Form 3510-1(revised 3-19) Page 2

DocuSign Envelope ID:BE3E753E-46E6-457F-BC63-442A4D0328EA
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision WTP OMB No.2040-0004
SECTION 6.EXISTING ENVIRONMENTAL PERMITS(40 CFR 122.21(f)(6))
@ 6.1 Existing Environmental Permits(check all that apply and print or type the corresponding permit number for each)
d ❑✓ NPDES(discharges to surface ❑ RCRA(hazardous wastes) ❑ UIC(underground injection of
c w water) fluids)
•— NCG590037
+ a ❑ PSD(air emissions) ❑ Nonattainment program(CM) ❑ NESHAPs(CAA)
rn
w ❑ Ocean dumping(MPRSA) ❑ Dredge or fill(CWA Section 404) ❑ Other(specify)
SECTION 7.MAP(40 CFR 122.21(f)(7))
7.1 Have you attached a topographic map containing all required information to this application?(See instructions for
specific requirements.)
❑� Yes ❑ No ❑ CAFO—Not Applicable(See requirements in Form 2B.)
SECTION 8.NATURE OF BUSINESS(40 CFR 122.21(f)(8))
8.1 Describe the nature of your business.
Operating a filter-backwash treatment system employing greensand filter technology to treat groundwater in
support of potable-water production
U,
H
c
.y
3
m
O
iv
Z
SECTION 9.COOLING WATER INTAKE STRUCTURES(40 CFR 122.21(f)(9))
9.1 Does your facility use cooling water?
❑ Yes ❑ No 4 SKIP to Item 10.1.
R a 9.2 Identify the source of cooling water.(Note that facilities that use a cooling water intake structure as described at
cn 40 CFR 125,Subparts I and J may have additional application requirements at 40 CFR 122.21(r).Consult with your
c rn NPDES permitting authority to determine what specific information needs to be submitted and when.)
e
G
c.) c
SECTION 10.VARIANCE REQUESTS(40 CFR 122.21(f)(10))
10.1 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)?(Check all that
apply.Consult with your NPDES permitting authority to determine what information needs to be submitted and
when.)
c ❑ 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

DocuSign Envelope ID:BE3E753E-46E6-457F-BC63-442A4D0328EA
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision WTP OMB No.2040-0004
SECTION 11.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
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
0 Section 1:Activities Requiring an NPDES Permit wl attachments
El Section 2:Name, Mailing Address,and Location El w/attachments
❑✓ Section 3:SIC Codes ❑ wl attachments
ElSection 4:Operator Information El wl attachments
ElSection 5:Indian Land ❑ w/attachments
ElSection 6:Existing Environmental Permits El w/attachments
d ElSection 7:Map ,, w/topographic
❑ map ❑ w/additional attachments
in
c ElSection 8:Nature of Business Elw/attachments
El Section 9:Cooling Water Intake Structures El w/attachments
CD
❑r Section 10:Variance Requests
q El w/attachments
ElSection 11:Checklist and Certification Statement El w/attachments
Y
L 11.2 Certification Statement
c)
1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision
in accordance with a system designed to assure that qualified personnel properly gather and evaluate the
information submitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the information submitted is,to the best of my knowledge and
belief,true,accurate,and complete. lam 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
Brent Milliron Environmental Compliance Director
Signature Date signed
/—DocuSigned by:
05/03/2024
'-1742870BB0684EF...
EPA Form 3510-1(revised 3-19) Page 4

DocuSign Envelope ID:FDB49CFE-F14A-4737-A849-4A36D9F1F07E
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Fleetwood Falls N
NPDES Permit NCG590037
Receiving Stream: Rocky Shoal Branch Longitude: 81° 32'31" W FacilitY
Stream Index: 10-1-20 Latitude: 36° 18' 18" N Location
River Basin:New River Sub-Basin: 05-07-01 SCALE
Stream Class: C+ HUC: 050500010204 1:16,000 Ashe County

9.
twood Falls Subdivision
Sodium NCG590037
Hypochlorite rocess Flow Diagram
Day Tank
Raw Water Greensand
Wells 3, 5, =111MWater
Distribution
&g Treatment
Facility
Filter Backwash
Water:680 GPD
Outfa 11001
Rocky Shoal Branch

..
AO U A
$Essential
May 3, 2024
Division of Water Resources
Water Quality Permitting Section - NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: Application for Permit Renewal
Aqua North Carolina, Inc.
Fleetwood Falls WTP
NPDES No. NCG590037
Ashe County
To Whom It May Concern:
Enclosed are three (3) copies of the completed application Form 2C and Form 1. This
submittal includes the necessary attachments for your office to renew the subject permit.
Should you need any additional information or assistance, please feel free to contact me via
phone[phone])or by email at [e-mail].
Sincerely,
4-1(
Brent Milliron
Environmental Compliance Director
Aqua North Carolina, Inc.
Enc: NPDES Application, Form 2C
NPDES Application, Form 1
Fleetwood Falls WTP NPDES Permit
Cc: Shannon Becker, President,Aqua North Carolina
Wesley Dye, Environmental Compliance Specialist 1
202 MacKenan Court, Cary, NC, 27511 • 919.467.8712 • AquaAmerica.com

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
United States Office of Water EPA Form 3510-2C
Environmental Protection Agency Washington,D.C. Revised March 2019
Water Permits Division
EPA 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.

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
Form U.S.Environmental Protection Agency
2C \S EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING,COMMERCIAL,MINING,AND SILVICULTURE OPERATIONS
SECTION 1.OUTFALL LOCATION(40 CFR 122.21(g)(1)) 1
1.1 Provide information on each of the facility's outfalls in the table below.
c Numbelr Receiving Water Name Latitude Longitude
-.c.
co
3 001 Rocky Shoal Branch 36° 18' 18" N 3 81" 32' 31" W 3
c.
3
0
SECTION 2. LINE DRAWING(40 CFR 122.21(g)(2))
2.1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
c •c balance?(See instructions for drawing requirements.See Exhibit 2C-1 at end of instructions for example.)
J c ❑r Yes ❑ No
SECTION 3.AVERAGE FLOWS AND TREATMENT(40 CFR 122.21(0(3))
3.1 For each outfall identified under Item 1.1,provide average flow and treatment information.Add additional sheets if
necessary.
"Duffel!Number**001
Operations Contibuting to Flow
Operation Average Flow
WTP Backwash Discharge 0.0036 mgd 1
c
E mgd
0
it mgd
c
CO mgd
c Treatment Units
u.
m Description Final Disposal of Solid or
CA L (include size,flow rate through each treatment unit, Code from Liquid Wastes Other Than
aretention time,etc.) Table 2C-1 by Discharge
EPA Form 3510-2C(Revised 3-19) Page 1

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
3.1 *"Outfall Number**
cont. Operations Contributing to Flow
Operation Average Flow
mgd
mgd
mgd
mgd
Treatment Units
Description Code from Final Disposal of Solid or
(include size,flow rate through each treatment unit, Table Liquid Wastes Other Than
retention time,etc.) by Discharge
c
0
U
c
m
E
iv
as
H
**Outfall Number**
Operations Contributing to Flow
c Operation Average Flow
L
rn mgd
co
>
' mgd
mgd
mgd
Treatment Units
Description Code from Final Disposal of Solid or
(include size,flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than
retention time,etc.) by Discharge
3.2 Are you applying for an NPDES permit to operate a privately owned treatment works?
d cn
d ❑ Yes ❑✓ No 4 SKIP to Section 4.
e.p= 3.3 Have you attached a list that identifies each user of the treatment works?
❑ Yes ❑ No
EPA Form 3510-2C(Revised 3-19) Page 2

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
SECTION 4.INTERMITTENT FLOWS(40 CFR 122.21(g)(4))
4.1 Except for storm runoff,leaks,or spills,are any discharges described in Sections 1 and 3 intermittent or seasonal?
E Yes ❑ No 4 SKIP to Section 5.
4.2 Provide information on intermittent or seasonal flows for each applicable outfall.Attach additional pages,if necessary.
Outfall Operation FreSuency Flow Rate
Number (list) Average Average Long-Term Maximum Duration
Days/Week Months/Year Average Daily
WTP Backwash Dischari 7 days/week 12 months/year 0.0036 mgd 0.0036 mgd 134 days
001 days/week months/year mgd mgd days
u_
days/week months/year mgd mgd days
as
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
SECTION 5.PRODUCTION(40 CFR 122.21(g)(5))
5.1 Do any effluent limitation guidelines(ELGs)promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes ❑✓ No 4 SKIP to Section 6.
rn 5.2 Provide the following information on applicable ELGs.
w ELG Category ELG Subcategory Regulatory Citation
CO
CO
0-
Q
5.3 Are any of the applicable ELGs expressed in terms of production(or other measure of operation)?
c ❑ Yes E No 4 SKIP to Section 6.
0
co 5.4 Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
Outfall Operation,Product,or Material Quantity per Day Unit of
Number Measure
O
O
L
d
EPA Form 3510-2C(Revised 3-19) Page 3

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EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
SECTION 6.IMPROVEMENTS(40 CFR 122.21(g)(6))
6.1 Are you presently required by any federal,state,or local authority to meet an implementation schedule for constructing,
upgrading,or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
❑ Yes ❑ No 4 SKIP to Item 6.3.
6.2 Briefly identify each applicable project in the table below.
Affected Final Compliance Dates
d Brief Identification and Description of Outfalls Source(s)of
c Project (list outfall Discharge Required Projected
number)
co
u
w
CO
C1
C.
6.3 Have you attached sheets describing any additional water pollution control programs(or other environmental projects
that may affect your discharges)that you now have underway or planned?(optional item)
❑ Yes ❑ No ✓❑ Not applicable
SECTION 7.EFFLUENT AND INTAKE CHARACTERISTICS(40 CFR 122.21(g)(7))
See the instructions to determine the pollutants and parameters you are required to monitor and,in turn,the tables you must
complete. Not all applicants need to complete each table.
Table A.Conventional and Non-Conventional Pollutants
7.1 Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
❑r Yes ❑ No 4 SKIP to Item 7.3.
7.2 If yes,indicate the applicable outfalls below.Attach waiver request and other required information to the application.
Outfall Number 001 Outfall Number Outfall Number
O 7.3 Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
requested and attached the results to this application package?
No;a waiver has been requested from my NPDES
co
❑� Yes ❑ permitting authority for all pollutants at all outfalls.
5 Table B.Toxic Metals,Cyanide,Total Phenols,and Organic Toxic Pollutants
7.4 Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
listed in Exhibit 2C-3?(See end of instructions for exhibit.)
❑ Yes ElNo 4 SKIP to Item 7.8.
CCS
7.5 Have you checked"Testing Required"for all toxic metals,cyanide,and total phenols in Section 1 of Table B?
w ❑ Yes ❑r No
7.6 List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s)identified
in Exhibit 2C-3.
Primary Industry Category Required GC/MS Fraction(s)
(Check applicable boxes.)
❑Volatile 0 Acid 0 Base/Neutral 0 Pesticide
❑Volatile 0 Acid 0 Base/Neutral 0 Pesticide
0 Volatile 0 Acid 0 Base/Neutral 0 Pesticide
EPA Form 3510-2C(Revised 3-19) Page 4

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EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
7.7 Have you checked"Testing Required"for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?
❑ Yes ElNo
7.8 Have you checked"Believed Present"or"Believed Absent"for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required?
El Yes ❑ No
7.9 Have you provided(1)quantitative data for those Section 1,Table B,pollutants for which you have indicated testing is
required or(2)quantitative data or other required information for those Section 1,Table B, pollutants that you have
indicated are"Believed Present"in your discharge?
❑ Yes ❑✓ No
7.10 Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
❑ Yes 4 Note that you qualify at the top of Table B, 0 No
then SKIP to Item 7.12.
7.11 Have you provided(1)quantitative data for those Sections 2 through 5,Table B,pollutants for which you have
o determined testing is required or(2)quantitative data or an explanation for those Sections 2 through 5,Table B,
pollutants you have indicated are"Believed Present"in your discharge?
cn
7) ❑ Yes ❑r No
w Table C.Certain Conventional and Non-Conventional Pollutants
7.12 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed on Table C
$ for all outfalls?
U
El Yes ❑ No
7.13 Have you completed Table C by providing(1)quantitative data for those pollutants that are limited either directly or
indirectly in an ELG and/or(2)quantitative data or an explanation for those pollutants for which you have indicated
"Believed Present"?
El Yes ❑✓ No
w Table D.Certain Hazardous Substances and Asbestos
7.14 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed in Table D for
all outfalls?
❑✓ Yes ❑ No
7.15 Have you completed Table D by(1)describing the reasons the applicable pollutants are expected to be discharged
and(2)by providing quantitative data,if available?
❑ Yes ❑r No
Table E.2,3,7,8-Tetrachlorodibenzo-p-Dioxin(2,3,7,8-TCDD)
7.16 Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions,or do you
know or have reason to believe that TCDD is or may be present in the effluent?
❑ Yes 4 Complete Table E. ❑✓ No 4 SKIP to Section 8.
7.17 Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes El No
SECTION 8.USED OR MANUFACTURED TOXICS(40 CFR 122.21(g)(9))
8.1 Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
an intermediate or final product or byproduct?
❑ Yes ❑r No 4 SKIP to Section 9.
N 8.2 List the pollutants below.
U
1. 4. 7.
0
2. 5. 8.
cn
3. 6. 9.
EPA Form 3510-2C(Revised 3-19) Page 5

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NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
SECTION 9.BIOLOGICAL TOXICITY TESTS(40 CFR 122.21(g)(11))
9.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on(1)any of your discharges or(2)on a receiving water in relation to your discharge?
❑ Yes ❑✓ No 4 SKIP to Section 10.
VJ
9.2 Identify the tests and their Durposes below.
Test(s) Purpose of Test(s) Submitted to NPDES Date Submitted
0 Permitting Authority?
I
❑ Yes ❑ No❑ Yes ❑ No
❑ Yes ❑ No
SECTION 10.CONTRACT ANALYSES(40 CFR 122.21(g)(12))
10.1 Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
❑� Yes ❑ No 4 SKIP to Section 11.
10.2 Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1 Laboratory Number 2 Laboratory Number 3
Name of laboratory/firm Water Tech Laboratories Inc
y
Laboratory address 5 Pinewood Plaza Dr
QGranite Falls,NC 28630
c
c.�
Phone number
[phone]
Pollutant(s)analyzed Total Suspended Solids
SECTION 11.ADDITIONAL INFORMATION(40 CFR 122.21(g)(13))
11.1 Has the NPDES permitting authority requested additional information?
c ❑ Yes E No 4 SKIP to Section 12.
11.2 List the information requested and attach it to this application.
0
1. 4.
2. 5.
3. 6.
EPA Form 3510-2C(Revised 3-19) Page 6

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EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP OMB No.2040-0004
SECTION 12.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
12.1 In Column 1 below,mark the sections of Form 2C that you have completed and are submitting with your application.
For each section,specify in Column 2 any attachments that you are enclosing to alert the permitting authority.Note
that not all applicants are required to com Mete all sections or provide attachments.
Column 1 Column 2
I Section 1:Outfall Location ❑✓ w/attachments
❑r Section 2:Line Drawing ✓❑ wl line drawing ❑ wl additional attachments
Section 3:Average Flows and w/list of each user of
Treatment ❑� w/attachments 0 privately owned treatment
works
❑ Section 4:Intermittent Flows ❑ w/attachments
❑ Section 5:Production ❑ w/attachments
w/optional additional
❑ Section 6:Improvements ❑ w/attachments ❑ sheets describing any
additional pollution control
plans
❑ w/request for a waiver and ❑ wl explanation for identical
supporting information outfalls
w/small business exemption❑ request w/other attachments❑
❑ Section 7:Effluent and Intake
�' ❑ w/Table A ❑✓ w/Table B
Characteristics
0
❑✓ w/Table C ❑✓ w/Table D
❑ w/analytical results as an
❑ w/Table E attachment
❑ Section 8:Used or Manufactured ❑ wl attachments
y• Toxics
d ❑ Section 9: Biological Toxicity El w/attachments
Tests
U
❑ Section 10:Contract Analyses ❑ w/attachments
❑ Section 11:Additional Information ❑ w/attachments
© Section 12:Checklist and ❑ w/attachments
Certification Statement
12.2 Certification Statement
1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted.Based on my inquiry of the person or persons who manage the system,or those persons directly
responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true,
accurate,and complete. 1 am aware that there are significant penalties for submitting false information,including the
possibility of fine and imprisonment for knowing violations.
Name(print or type first and last name) Official title
Brent Milliron Environmental Compliance Director
Signature —DacuSigned by: Date signed
05/03/2024
\-1742870B806BAEc..
EPA Form 3510-2C(Revised 3-19) Page 7

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DocuSign Envelope ID:2A0ED3A5-7779-454C-B8D8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE A.CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(iii))'
Effluent Intake
Waiver (Optional)
Pollutant Requested Units Maximum Maximum Long-Term
Of aPustle) (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
(BOD5) Mass
Chemical oxygen demand Concentration
2. ❑
(COD) Mass
Concentration
3. Total organic carbon(TOC) ❑✓
Mass
Concentration
4. Total suspended solids(TSS) ❑r
Mass
Concentration
5. Ammonia(as N) ❑r
Mass
6. Flow ❑ Rate gpd 3,600 3,600 134
Temperature(winter) ❑r °C °C
7.
Temperature(summer) ❑o °C °C
pH(minimum) ❑ Standard units S.U. 6.4 7.4 30
8.
pH(maximum) ❑ Standard units S.U. 8.0 7.4 30
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

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DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Dutfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))r
Presence or Absence
(check one) Effluent Intake
lopuonali
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 Daily of of
Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) Value
(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
Antimony,total Concentration I
11 (7440-36-0) Mass
Arsenic,total Concentration
1.2 (7440-38-2) El ❑ ❑� Mass
1 3 Beryllium,total ❑ ❑ Concentration
(7440-41-7) Mass
Cadmium,total Concentration
1.4 (7440-43-9) ❑ ❑ ❑ Mass
1.5 Chromium,total Concentration
(7440-47-3) ✓ Mass
1 6 Copper,total Concentration
(7440-50-8) Mass
1.7 Lead,total Concentration
(7439-92-1) ✓ Mass
1 8 Mercury,total ❑ ❑ Concentration
(7439-97-6) Mass
1.9 Nickel,total Concentration
0 El El
(7440-02-0) Mass
Selenium,total Concentration
1.10 (7782-49-2) ❑ ❑ ❑� Mass
1.11 Silver,total Concentration
(7440-22-4) 0 Mass
EPA Form 3510-2C(Revised 3-19) Page 1''

DocuSign Envelope ID:2A0ED3A5-7779454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))r
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
Long-
(and CAS Number,if available Required Believed BelievedMaximum Maximum) q (specify) Average Number Number
Present Absent Daily Monthly Term
D(equim of
ischad a (ifavalabllee( DischargeD Analyses Averageaily of eValue Analyses
(if available)
Thallium,total Concentration
1.12 (7440-28-0) Mass
1.13 Zinc,total Concentration
(7440-66-6) Mass
1.14 Cyanide,total Concentration
(57-12-5) Mass
Concentration
1.15 Phenols,total ❑ ❑ 0 Mass
Section 2.Organic Toxic Pollutants(GC/MS Fraction—Volatile Compounds)
Acrolein Concentration
2.1 (107-02-8) Mass
2.2 Acrylonitrile Concentration
(107-13-1) Mass
Benzene Concentration
2.3 (71-43-2) ✓ Mass
2 4 Bromoform Concentration
(75-25-2) Mass
2.5 Carbon tetrachloride ❑ 0Concentration
(56-23-5) Mass
Chlorobenzene Concentration
2.6 (108-90-7) Mass
Chlorodibromomethane Concentration
2.7 (124-48-1) Mass
Chloroethane Concentration
2.8 (75-00-3) Mass
EPA Form 3510-2C(Revised 3-19) Page 12

DocuSign Envelope ID:2A0ED3A5-7779-454C-B8138-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))r
Presence or Absence Intake
(check one) Effluent (optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,ifavailable) Required Believed Believed (specify) Maximum Maximum Average Number Long-
Number
Present Absent Daily Monthly Daily of Term of
Dharischare
(requiredge Drfavailabe) Discharge Analyses AverageValue Analyses
(if available)
2.9 2-chloroethylvinyl ether ❑ ❑ ❑ Concentration
(110-75-8) Mass
Concentration
2.10 Chloroform(67-66-3) ❑ ❑ 0 Mass
211 Dichlorobromomethane ❑ ❑ ❑ Concentration
(75-27-4) Mass
212 11-dichloroethane ❑ ❑ ❑ Concentration
(75-34-3) Mass
2.13 1 2-dichloroethane ❑ 0 Concentration
(107-06-2) ✓ Mass
214 1,1-dichloroethylene ❑ ❑ ❑ Concentration
(75-35-4) Mass
215 1,2-dichloropropane 0 0 ❑ Concentration
(78-87-5) Mass
216 1,3-dichloropropylene ❑ ❑ ❑ Concentration
(542-75-6) Mass
217 Ethylbenzene ❑ ❑ ❑ Concentration
(100-41-4) Mass
2.18 Methyl bromide ❑ ❑ ❑ Concentration
(74-83-9) Mass
2.19 Methyl chloride ❑ ❑ Concentration
(74-87-3) ✓ Mass
2.20 Methylene chloride ❑ ❑ ❑ Concentration
(75-09-2) Mass
221 1,1,2,2-tetrachloroethane ❑ ❑ ❑ Concentration
(79-34-5) Mass
EPA Form 3510-2C(Revised 3-19) Page 13

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence Intake
(check one) Effluent (opbonal)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
Discharge Discharge Average
(required) (if available) Discharge Analyses Value Analyses
(4 available)
2.22 Tetrachloroethylene ❑ Concentration
(127-18-4) ✓ Mass
Toluene Concentration
2.23 (108-88-3) Mass
2.24 1,2-trans-dichloroethylene Concentration
(156-60-5) Mass
2.25 1,1,1-trichloroethane Concentration
(71-55-6) Mass
2.26 1,1,2-trichloroethane Concentration
El El El
(79-00-5) Mass
2.27 Trichloroethylene ElConcentration
El E
(79-01-6) Mass
2 28 Vinyl chloride Concentration
(75-01-4) ✓ Mass
Section 3.Organic Toxic Pollutants(GC/MS Fraction—Acid Compounds)
3.1 2-chlorophenol Concentration
El El El
(95-57-8) Mass
3.2 2,4-dichlorophenol ElConcentration
(120-83-2) Mass
3.3 2,4-dimethylphenol ❑ ❑ © Concentration
(105-67-9) Mass
4,6-dinitro-o-cresol Concentration
3.4 El El E
(534-52-1)
Mass
3.5 2,4-dinitrophenol Concentration
El El El
(51-28-5) Mass
EPA Form 3510-2C(Revised 3-19) Page 14

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Farm Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 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
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long-
Number
Present Absent Daily Monthly TDail A
of very of
D( hard) Drfava labllee) Discharge Analyses Valuee I Analyses
(if available)
3.6 2-nitrophenol Concentration
(88-75-5) ✓ Mass
4-nitrophenol Concentration
3.7 (100-02-7) Mass
3.8 p-chloro-m-cresol Concentration
(59-50-7) Mass
Pentachlorophenol El � ❑ Concentration
3.9 (87.86-5) Mass
3.10 Phenol Concentration
El El ID
(108-95-2) Mass
311 2,4,6-trichlorophenol 0 Concentration
(88-05-2) Mass
Section 4.Organic Toxic Pollutants(GC/MS Fraction—Base/Neutral Compounds)
41 Acenaphthene Concentration
0 0
(83-32-9) r
Mass
4.2 Acenaphthylene ❑ Concentration
l=l(208-96-8) ✓ Mass
4.3 Anthracene Concentration
(120-12-7) ✓ Mass
4.4 Benzidine ElConcentration
(92-87-5) Mass
Benzo(a)anthracene Concentration
4.5 (56-55-3) Mass
Benzo(a)pyrene Concentration
4.6 (50-32-8) Mass
EPA Form 3510-2C(Revised 3-19) Page 15

DocuSign Envelope ID:2A0E03A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))r
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specifY) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Dailyof Term of
Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) (if available) Value
3,4-benzofluoranthene Concentration
4.7 (205-99-2) Mass
Benzo(ghi)perylene Concentration
4.8 (191-24-2) Mass
Benzo(k)fluoranthene Concentration
4.9 (207-08-9) Mass
4.10 Bis(2-chloroethoxy)methane ❑ ElConcentration
(111-91-1) Mass
4.11 Bis(2-chloroethyl)ether a Concentration
El 0(111-44-4) Mass
4 12 Bis(2-chloroisopropyl)ether Concentration
(102-80-1) ✓ Mass
4.13 Bis(2-ethylhexyl)phthalate Concentration
(117-81-7) Mass
4.14 4-bromophenyl phenyl ether Concentration
(101-55-3) Mass
4.15 Butyl benzyl phthalate Concentration
(85-68-7) Mass
4.16 2-chloronaphthalene Concentration
(91-58-7) ✓ Mass
4-chlorophenyl phenyl ether Concentration
4.17 (7005-72-3) Mass
Chrysene Concentration
4.18 (218-01-9) Mass
4.19 Dibenzo(a,h)anthracene ElConcentration
1:3 El
(53-70-3) Mass
EPA Form 3510-2C(Revised 3-19) Page 16

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))r
Presence or Absence Intake
_ (check one) Effluent (Intake
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) (if available) Value
4.20 1,2-dichlorobenzene ❑ CI Concentration
(95-50-1) ✓ Mass
4.21 13-dichlorobenzene CI Concentration
CI E
(541-73-1) Mass
4.22 1,4-dichlorobenzene CI Concentration
El
(106-46-7) ✓ Mass
4.23 3,3-dichlorobenzidine 0 Concentration
(91-94-1) ✓ Mass
4.24 Diethyl phthalate CI CIConcentration
(84-66-2) Mass
4.25 Dimethyl phthalate CI CIConcentration
(131-11-3) Mass
4.26 Di-n-butyl phthalate Concentration
(84-74-2) Mass
4.27 2,4-dinitrotoluene Concentration
(121-14-2) Mass
4 28 2,6-dinitrotoluene a Concentration
(606-20-2) Mass
4 29 Di-n-octyl phthalate ❑ ❑ E Concentration
(117-84-0) Mass
4.30 1,2-Diphenylhydrazine El El
(as azobenzene)(122-66-7) ✓ Mass
Fluoranthene Concentration
4.31 CI CI(206-44-0) El
4.32 Fluorene Concentration
(86-73-7) Mass
EPA Form 3510-2C(Revised 3-19) Page 17

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number ' Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 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 Long-Term _
(and CAS Number,davailable) Required Believed Believed (specify) Maximum Maximum Average Number Long Number
Present Absent Daily Monthly Term
Dischargeaily of of
red) Drfavalabllee e) Discharge Analyses AverageValue Analyses
(if available)
4.33 Hexachlorobenzene Concentration
(118-74-1) ✓ Mass
4.34 Hexachlorobutadiene Concentration
r
(87-68-3) Mass
4.35 Hexachlorocyclopentadiene 0 Concentration
(77-47-4) Mass
4.36 Hexachloroethane 0 Concentration
(67-72-1) Mass
4.37 Indeno(1,2,3-cd)pyrene � Concentration
(193-39-5) Mass
4.38 Isophorone Concentration
(78-59-1) Mass
4.39 Naphthalene Concentration
(91-20-3) ✓ Mass
4.40 Nitrobenzene Concentration
(98-95-3) Mass
4.41 N-nitrosodimethylamine Concentration
(62-75-9) ✓ Mass
4.42 N-nitrosodi-n-propylamine 0 D Concentration
(621-64-7) ✓ Mass
N-nitrosodiphenylamine Concentration
4.43 (86-30-6) Mass
4.44 Phenanthrene Concentration
(85-01-8) ✓ Mass
Pyrene Concentration
4.45 (129-00-0) Mass
EPA Form 3510-2C(Revised 3-19) Page 18

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence
1.cne::k one[ Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,davailable) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) Value
(if available)
4.46 1,2,4-trichlorobenzene 0 Concentration
(120.82-1) Mass jI
Section 5.Organic Toxic Pollutants(GC/MS Fraction—Pesticides) _
51 Aldrin Concentration
(309-00-2) ✓ Mass
a-BHC Concentration
5.2 (319-84-6) � � Mass
p-BHC Concentration
5.3 (319-85-7) � Mass
y-BHC Concentration
5.4 0 El r(58 89 9) Mass
5.5 o-BHC Concentration
(319-86-8) Mass
5.6 Chlordane Concentration
(57-74-9) Mass
5 7 4,4'-DDT Concentration
0 0 r
(50-29-3) Mass
4,4'-DDE Concentration
5.8 (72-55-9) Mass
5.9 4,4'-DDD Concentration
(72-54-8) ✓ Mass
Dieldrin Concentration
5.10 (60-57-1) Mass
a-endosulfan Concentration
5.11 (115-29-7) Mass
EPA Form 3510-2C(Revised 3-19) Page 19

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCGS90037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))t
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,ifavailable) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
Discharge� Drfavaillable) Darge ischarge Analyses AverageValue Analyses
(if available)
512 R-endosu)fan ❑ ❑ 0 Concentration
(115-29-7) Mass
Endosulfan sulfate Concentration
5.13 (1031-07-8) ❑ ❑ ElMass
Endrin Concentration
5.14 (72-20-8) ❑ 0 ElMass
5 15 Endrin aldehyde Concentration
❑ ❑ El
7421-93-4 Mass
516 Heptachlor ❑ ❑ ❑ Concentration
(76-44-8) Mass
Heptachlor epoxide Concentration
5.17 (1024-57-3) ❑ 0 CI
Mass
PCB-1242 Concentration
5.18 53469-21-9 ❑ ❑ ✓❑
( ) Mass
PCB-1254 Concentration
5.19 (11097-69-1) ❑ ❑ ❑r
Mass
PCB-1221 Concentration
5.20 (11104-28-2) ❑ ❑ LI Mass
PCB-1232 Concentration
5.21 (11141-16-5) ❑ ❑ El
Mass
PCB-1248 Concentration
5.22 (12672-29-6) ❑ ❑ E
Mass
PCB-1260 Concentration
5.23 (11096-82-5) ❑ ❑ ❑�
Mass
PCB-1016 Concentration
5.24 (12674-11-2) ❑ ❑ 0 Mass
EPA Form 3510-2C(Revised 3-19) Page 20

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCO590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 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
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term _
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long Number
Present Absent Daily Monthly Term
(required) of of
Discharg
ischare
ifavailablee) DisDcharge Analyses AverageValue Analyses
(if available)
Toxaphene Concentration
5.25 (8001-35-2) ❑ ❑ 0
Mass
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),subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C(Revised 3-19) Page 21

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
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DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))'
Presence or Absence
(check one) Effluent Intake
• (Optional)
Units
Pollutant Maximum Long-Term
Believed Believed (specify) Maximum Daily Monthly Average Daily Number of Long-Term Number of
Present Absent Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) (if available) Value
❑
Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall.You need not complete the"Presence or Absence"column of Table C for
each pollutant.
©
Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall.You need not complete the"Presence or Absence"column of Table C for
each pollutant.
1 Bromide ❑ ❑ Concentration
(24959-67-9) Mass
Chlorine,total Concentration
2 residual CI ❑ Mass
3. Color 0 CI
Concentration
Mass
4. Fecal coliform Concentration
CI CI
Mass
Fluoride Concentration
5. 0 ❑
(1698448-8) Mass
Concentration
6 Nitrate-nitrite ❑ 0 Mass
7 Nitrogen,total CI CI
organic(as N) Mass
Concentration
8. Oil and grease ❑ ❑ Mass
Phosphorus(as Concentration
9. P),total(7723-14-0) ❑ CIMass
10 Sulfate(as SO4) ❑ ❑ Concentration
(14808-79-8) Mass
Concentration
11. Sulfide(as S) 0 0 Mass
EPA Form 3510-2C(Revised 3-19) Page 23

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))r
Presence or Absence
(check one) Effluent Intake
(Optional)
Pollutant Units Maximum Long-Term
Believed Believed (specify) Maximum Daily Monthly Average DailyNumber of Long-Term
Number of
Present Absent Discharge Average
Discharge Discharge Analyses Analyses
(required)
(if available) (if available) Value
12 Sulfite(as SOS) ❑ ❑ Concentration
(14265-45-3) Mass
• Concentration
13. Surfactants ❑ ❑ Mass
14. Aluminum,total ❑ ❑ Concentration
(7429-90-5) Mass
15. Barium,total ❑ ❑ Concentration
(7440-39-3) Mass
16. Boron,total ❑ 0 Concentration
(7440-42-8) Mass
17. Cobalt,total ❑ ❑ Concentration
(744048-4) Mass
18 Iron,total ❑ ❑ Concentration
(7439-89-6) Mass
19 Magnesium,total 0 ❑ Concentration
(7439-95-4) Mass
Molybdenum, Concentration
20. total ❑ ❑ Mass
(7439-98-7)
21 Manganese,total ❑ ❑ Concentration
(7439-96-5) Mass
22 Tin,total 0 0 Concentration
(7440-31-5) Mass
Titanium,total ❑ El Concentration
23. (7440-32-6)
Mass
EPA Form 3510-2C(Revised 3-19) Page 24

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))'
Presence or Absence
(check one) Effluent Intake
(Optional)
Pollutant Units Maximum Long-Term
Believed Believed (specify) Maximum DailyLong-Term
Monthly Average Daily Number of Number of
Present Absent Discharged Discharge Discharge Analyses AValuee Analyses
ui (if available) (if available)
24. Radioactivity
Alpha,total ❑ ❑ Concentration •
Mass
Concentration
Beta,total ❑ ❑ Mass
Concentration
Radium,total ❑ ❑ Mass
Concentration
Radium 226,total ❑ 0 Mass
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

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
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DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS t40 CFR 12221(g)(7)(vii))1
Presence or Absence
Pollutant (check one) Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
1. Asbestos ❑ 0
2. Acetaldehyde ❑ 0
3. Allyl alcohol ❑ 0
4. Allyl chloride ❑ 0
5. Amyl acetate 0 0
6. Aniline 0 0
7. Benzonitrile ❑ 0
8. Benzyl chloride ❑ 0
9. Butyl acetate 0 0
10. Butylamine ❑ 0
11. Caplan 0 0
12. Carbaryl ❑ 0
13. Carbofuran ❑ 0
14. Carbon disulfide ❑ 0
15. Chlorpyrifos 0 0
16. Coumaphos 0 0
17. Cresol 0 0
18. Crotonaldehyde 0 0
19. Cyclohexane ❑ 0
EPA Form 3510-2C(Revised 3-19) Page 27

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))'
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) ❑ El
21. Diazinon ❑ ❑
22. Dicamba ❑ CI
23. Dichlobenil ❑
24. Dichlone ❑ 0
25. 2,2-dichloropropionic acid ❑ El
26. Dichlorvos ❑ ❑✓
27. Diethyl amine ❑ El
28. Dimethyl amine ❑ 0
29. Dintrobenzene ❑ CI
30. Diquat ❑ El
31. Disulfoton ❑ 0
32. Diuron ❑ 0
33. Epichlorohydrin ❑ CI
34. Ethion ❑ El
35. Ethylene diamine ❑ ❑✓
36. Ethylene dibromide ❑ ❑✓
37. Formaldehyde ❑ El
38. Furfural ❑ 0
EPA Form 3510-2C(Revised 3-19) Page 28

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 12221(g)(7)(vii))1
Presence or Absence
Pollutant _ (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
39. Guthion ❑ E
40. Isoprene ❑ 0
41. Isopropanolamine ❑ ❑r
42. Kelthane ❑ 0
43. Kepone ❑ El
44. Malathion ❑ 0
45. Mercaptodimethur ❑ 0
46. Methoxychlor ❑ ❑r
47. Methyl mercaptan 0 ❑r
48. Methyl methacrylate ❑ ❑r
49. Methyl parathion ❑ ❑✓
50. Mevinphos ❑ ❑r
51. Mexacarbate ❑ ❑✓
52. Monoethyl amine ❑ ❑r
53. Monomethyl amine ❑ 0
54. Naled ❑ 0
55. Naphthenic acid ❑ ❑✓
56. Nitrotoluene ❑
57. Parathion ❑
EPA Form 3510-2C(Revised 3-19) Page 29

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 12221(g)(7)(vii))1
Presence or Absence
Pollutant (check one) Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
58. Phenolsulfonate ❑ ❑r
59. Phosgene ❑ ❑r
60. Propargite ❑ ❑r
61. Propylene oxide ❑
62. Pyrethrins ❑ ❑r
63. Quinoline ❑ ❑r
64. Resorcinol 0 ❑✓
65. Strontium ❑ El
66. Strychnine ❑ 0
67. Styrene ❑ 0
68. 2,4,5-T(2,4,5-trichlorophenoxyacetic 0 0
acid)
69. TDE(tetrachlorodiphenyl ethane) 0 El
70 2,4,5-TP(2-(2,4,5-trichlorophenoxy) ❑ ❑
propanoic acid]
71. Trichlorofon ❑ CI
72. Triethanolamine ❑ CI
73. Triethylamine ❑ El
74. Trimethylamine ❑ ❑✓
75. Uranium ❑ El
76. Vanadium ❑ 0
EPA Form 3510-2C(Revised 3-19) Page 30

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPOES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))r
Presence or Absence
Pollutant neck 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 ❑ ❑r
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 Nor 0.See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C(Revised 3-19) Page 31

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
This page intentionally left blank.

DocuSign Envelope ID:2A0ED3A5-7779-454C-BBD8-74C3F658E8E6
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision-WTP 001 OMB No.2040-0004
TABLE E.2,3,7,8 TETRACHLORODIBENZO P DIOXIN(2,3,7,8 TCDD)(40 CFR 122.21(g)(7)(viii))
TCDD Presence or
Congeners Absence
Pollutant (check one) Results of Screening Procedure
Used or
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD ❑ ❑
EPA Form 3510-2C(Revised 3-19) Page 33

DocuSign Envelope ID: BE3E753E-46E6-457F-BC63-442A4D0328EA
United States Office of Water EPA Form 3510-1
Environmental Protection Agency Washington,D.C. Revised March 2019
Water Permits Division
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.

DocuSign Envelope ID:BE3E753E-46E6-457F-BC63-442A4D0328EA
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision WTP OMB No.2040-0004
Form U.S.Environmental Protection Agency
1 \`/EPA Application for NPDES Permit to Discharge Wastewater
NPDES GENERAL INFORMATION
SECTION 1.ACTIVITIES REQUIRING AN NPDES PERMIT(40 CFR 122.21(f)and(f)(1))
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 E 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
n- production facility? currently discharging process wastewater?
o ❑ Yes 4 Complete Form 1 0 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?
0 ❑ Yes 4 Complete Form 1 ❑ No ❑ Yes 4 Complete Form El No
ce and Form 2D. 1 and Form 2E.
cn
1.2.5 Is the facility a new or existing facility whose
' discharge is composed entirely of stormwater
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
Yes 4 Complete Form 1 No
El Yes p
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x)or
b 15 .
SECTION 2.NAME, MAILING ADDRESS,AND LOCATION(40 CFR 122.21(f)(2))
2.1 Facility Name
Fleetwood Falls Subdivision-WTP
0 2.2 EPA Identification Number
0
0 NCG590037
-o
2.3 Facility Contact
Name(first and last) Title Phone number
45 Brent Milliron Environmental Compliance Director [phone]
Email address
[e-mail]
2.4 Facility Mailing Address
zStreet or P.O.box
202 MacKenan Drive
City or town State ZIP code
Cary North Carolina 27511
EPA Form 3510-1(revised 3-19) Page 1

DocuSign Envelope ID:BE3E753E-46E6-457F-BC63-442A4D0328EA
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision WTP OMB No.2040-0004
N d 2.5 Facility Location
a .. Street,route number,or other specific identifier
Q 0 Parcel #13198117 by 490 Bear Ridge Trail
rn(
c County name County code(if known)
7 Ashe
o
E City or town State ZIP code
z Fleetwood North Carolina 28626
SECTION 3.SIC AND NAICS CODES(40 CFR 122.21(f)(3))
3.1 SIC Code(s) Description(optional)
4941 Establishments primarily engaged in distributing water for sale for domestic,
N
O
0
O
U
N
3.2 NAICS Code(s) Description(optional)
310 Water Distribution(except irrigation)
U
F
SECTION 4.OPERATOR INFORMATION(40 CFR 122.21(f)(4))
4.1 Name of Operator
Aqua North Carolina
4.2 Is the name you listed in Item 4.1 also the owner?
0 Yes ❑ No
4.3 Operator Status
73 ❑ Public—federal ❑ Public—state ❑ Other public(specify)
0 Private ❑ Other(specify)
4.4 Phone Number of Operator
[phone]
4.5 Operator Address
w Street or P.O.Box
E m 202 MacKenan Drive
`o
42 City or town State ZIP code
`o 0 Cary North Carolina 27511
m _
a Email address of operator
[e-mail]
SECTION 5.INDIAN LAND(40 CFR 122.21(f)(5))
5.1 Is the facility located on Indian Land?
❑Yes 0 No
EPA Form 3510-1(revised 3-19) Page 2

DocuSign Envelope ID:BE3E753E-46E6-457F-BC63-442A4D0328EA
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision WTP OMB No.2040-0004
SECTION 6.EXISTING ENVIRONMENTAL PERMITS(40 CFR 122.21(f)(6))
6.1 Existing Environmental Permits(check all that apply and print or type the corresponding permit number for each)
❑✓ NPDES(discharges to surface ❑ RCRA(hazardous wastes) ❑ UIC(underground injection of
water) fluids)
NCG590037
W € ❑ PSD(air emissions) ❑ Nonattainment program(CM) ❑ NESHAPs(CM)
rn
0 Ocean dumping(MPRSA) 0 Dredge or fill(CWA Section 404) 0 Other(specify)
SECTION 7.MAP(40 CFR 122.21(f)(7))
7.1 Have you attached a topographic map containing all required information to this application?(See instructions for
co specific requirements.)
2
Yes 0 No ❑ CAFO—Not Applicable(See requirements in Form 2B.)
SECTION 8.NATURE OF BUSINESS(40 CFR 122.21(f)(8))
8.1 Describe the nature of your business.
Operating a filter-backwash treatment system employing greensand filter technology to treat groundwater in
support of potable-water production
ea
ea
.N
O
N
iv
Z
SECTION 9.COOLING WATER INTAKE STRUCTURES(40 CFR 122.21(f)(9))
9.1 Does your facility use cooling water?
cn d El Yes 0 No 4 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
o,2 40 CFR 125,Subparts I and J may have additional application requirements at 40 CFR 122.21(r).Consult with your
c co NPDES permitting authority to determine what specific information needs to be submitted and when.)
O Y
O co
(..)
SECTION 10.VPRIANCE REQUESTS(40 CFR 122.21(f)(10))
10.1 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)?(Check all that
apply.Consult with your NPDES permitting authority to determine what information needs to be submitted and
when.)
Cr ❑ Fundamentally different factors(CWA ❑ Water quality related effluent limitations(CWA Section
Section 301(n)) 302(b)(2))
CD
❑ Non-conventional pollutants(CWA ❑ Thermal discharges(CWA Section 316(a))
co
co Section 301(c)and(g))
❑✓ Not applicable
EPA Form 3510-1(revised 3-19) Page 3

DocuSign Envelope ID:BE3E753E-46E6-457F-BC63-442A4D0328EA
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCG590037 NCG590037 Fleetwood Falls Subdivision WTP OMB No.2040-0004
SECTION 11.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
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
O Section 1:Activities Requiring an NPDES Permit ❑✓ w/attachments
❑✓ Section 2:Name, Mailing Address,and Location ❑ w/attachments
ID Section 3:SIC Codes ❑ wl attachments
El Section 4:Operator Information ❑ w/attachments
❑✓ Section 5: Indian Land ❑ w/attachments
❑ Section 6: Existing Environmental Permits D w/attachments
a)
❑✓ Section 7:Map w/topographic
co ❑ map ❑ w/additional attachments
co
o ❑� Section 8:Nature of Business ❑ w/attachments
❑✓ Section 9:Cooling Water Intake Structures 0 w/attachments
r
d
0 0 Section 10:Variance Requests ❑ w/attachments
c
y 0Section 11:Checklist and Certification Statement 0 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. 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
Brent Milliron Environmental Compliance Director
Signature Date signed
DocuSigned by:
A.J- ii
— 05/03/2024
17426706B06B4EF...
EPA Form 3510-1(revised 3-19) Page 4

DocuSign Envelope ID:FDB49CFE-F14A-4737-A849-4A36D9F1 F07E
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Receiving Stream: Rocky Shoal Branch Longitude: 81° 32'31" W Facility -
Stream Index: 10-1-20 Latitude: 36° 18' 18" N Location
River Basin: New River Sub-Basin: 05-07-01 SCALE
Stream Class: C+ HUC: 050500010204 1:16.000 Ashe County

Fleetwood Falls Subdivision
Sodium NCG590037
Hypochlorite Process Flow Diagram
Day Tank
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Wells 3, 5, MEIMWater
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Treatment Distribution
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Water:680 GPD
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