NCG020019 DMR WW

PROCESS/MINE DEWATERING WASTEWATER DISCHARGE MONITORING REPORT (DMR)
Please Mail Original And One Copy To Mailing Address Below
GENERAL PERMIT NO. NCG020000
Part A: Facility Information
Samples Collected In Quarters Q 3Q 40 (all samples shall be reported within 30 days following monitoring period)
(Circle one)
Certificate Of Coverage No. NCG02 06>) 9 County of Facility
Facility Name m\ i4 Name of Laboratory
Facility Contact ;1 L%.V 'fi DOLL Lab Certification #
Facility Contact Phone No.
Part B: Process Wastewater and Mine Dewatering Wastewater Monitoring Requirements
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Outfall lteceivin Stream Name 5 i
Number g amble G�ollected Tbailr itlow pH Total Siispend�d Solidsurbtdity 3 SetiiealRle Salids ,;
Inaid
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1 Measured continuously using a Flow measuring device or estimated using manufacturer's pump curves and pump logs.
Part C: Certification
"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 fines and imprisonment for knowing violation '
(Signature 4P fernuftte'
(Date)
Part D: Mailing Address
Attn: Central Files, DENR, N.C. Division of Water Quality, 1617 Mail Service Center, Raleigh, NC 27699-1617
SWU-244-012005