NC0088854_Renewal (Application)_20240729

AOUAS.
An 4asentlal Utilities Cornpany
_ RECEIVED
July 2, 2024
JUL 2 9 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.
Pine Lakes Subdivision Well #2 WTP
NPDES No. NCO088854
Surry County
To Whom It May Concern:
NCDEOJDWR/NPDES
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 Milliron
Environmental Compliance Director
Aqua North Carolina, Inc.
Enc: NPDES Application, Form 2C
NPDES Application, Form 1
Pine Lakes Subdivision Well #2 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

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO088854
NCO088854
Pine Lakes Subdivision Well 2
IAITQ
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
t
EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•NPDES
1.1
Applicants Not Required to Submit Form 1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete 0 No
If yes, STOP. Do NOT No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
doperation
or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
a
production facility?
currently discharging process wastewater?
oYes
4 Complete Form 1 No
Yes 4 Complete Form ❑ No
a
and Form 213.
1 and Form 2C.
z
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?
CD
❑ Yes 4 Complete Form 1 ❑� No
❑ Yes 4 Complete Form ❑� No
and Form 2D.
1 and Form 2E.
H
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 �r No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
b 15).
SECTIONDD-
• • r
Facility Name
2.1
Pine Lakes Subdivision Well #2 - WTP
`0
2.2
EPA Identification Number
0
NCO088854
a
2.3
Facility Contact
d
2
Name (first and last)
VT,tle
Phone number
Brent Milliron
vironmental Compliance Director
[phone]
a
Email address
[e-mail]
2.4
Facility Mailing Address
ZStreet
or P.O. box
202 MacKenan Drive
City or town
State
ZIP node
Cary
North Carolina
27511
EPA Form 3510-1 (revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO088854
NCO088854
Pine Lakes Subdivision Well 2
OMB No. 2040-0004
U.S. Environmental Protect /D R/NPD
Form
1
\—/EPA
v V
Application for NPDES Permit to Discharge Wastewater LJ
NPDES
GENERAL INFORMATION
SECTION•D
Applicants Not Required to Submit Form 1
1.1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete 0 No
If yes, STOP. Do NOT 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?
oYes
4 Complete Form 1 0 No
0 Yes 4 Complete Form No
a.
and Form 213.
1 and Form 2C.
z
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
of
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
Yes 4 Complete Form No
and Form 2D.
1 and Form 2E.
N)
°'
1.2.5
Is the facility a new or existing facility whose
'—
discharge is composed entirely of stormwater
a
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
❑ Yes 4 Complete Form 1 No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
b 15).
SECTIOND••
2.1
• • i
Facility Name
Pine Lakes Subdivision Well #2 - WTP
0
2.2
EPA Identification Number
J
NCO088854
'O
2.3
Facility Contact
Name (first and last)
Title
Phone number
I Q
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

AQUA,.
S Essential
July 2, 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.
Pine Lakes Subdivision Well #2 WTP
NPDES No. NCO088854
Surry 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 Milliron
Environmental Compliance Director
Aqua North Carolina, Inc.
Enc: NPDES Application, Form 2C
NPDES Application, Form 1
Pine Lakes Subdivision Well #2 WTP NPDES Permit
Cc: Shannon Becker, President, Aqua North Carolina
Wesley Dye, Environmental Compliance Specialist 1
202 MacKenan Court, Cary, INC, 27511 0 919.467.8712 * AquaAmerica.com

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f .
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WIN
Pine Lakes Subdivision - Well #2
NPDES Permit NCO088854
Gloria Road, Mt. Airy 27030
Receiving Stream: UT to Stewarts Creek
Stream Segment: 12-72-9-(4) Stream Class: WS-IV
River Basin: Yadkin -Pee Dee Sub -Basin #: 03-07-03
County: Surry HUC: 030401010804
rr���t�rsi/►i�i� ��I►���1�'�
SCALE
1:24,000 •

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO088854
NCO088854
Pine Lakes Subdivision Well 2
OMB No. 2040-0004
y
2.5
Facility Location
Street, route number, or other specific identifier
Q o
Gloria Road
rnv
`o
County name
County code (if known)
Surry
0
E _j
City or town
State ZIP code
z cc
Mt Airy
North Carolina 27030
SECTIONI
NAICS CODES1
SIC Code(s)
Description (optional)
3.1
4941
Establishments primarily engaged in distributing water for sale for domestic,
,i a ,..a­..,,1 ,
vi
m
0
0
N
U
Z
-a
3.2
NAICS Code(s)
Description (optional)
cc
310
Water Distribution (except irrigation)
Name of Opemtor
4.1
Aqua North Carolina
`0
4.2
Is the name you listed in Item 4.1 also the owner?
cc
c
0 Yes ❑ No
w
4.3
Operator Status
0
❑ Public —federal ❑ Public —state ❑ Other public (specify)
C
ID Private ElOther (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
w
Street or P.O. Box
E
202 MacKenan Drive
City or town
State
ZIP code
o 0
Cary
North Carolina
27511
cv
Q
Email address of operator
O
[e-mail]
SECTION•
1 1
Is the facility located on Indian Land?
5.1
J
❑ Yes ❑ No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number
NPDES Permit Number Facility Name Form Approved 03/05/19
NCO088854
NCO088854 Pine Lakes Subdivision Well 2 OMB No. 2040-0004
SECTION•
1
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
cw
water)
fluids)
•—
NCO088854
w a
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
rn
c
K
❑ Ocean dumping (MPRSA) ❑ Dredge or fill (CWA Section 404) ❑ Other (specify)
w
SECTIONI
Have you attached a topographic map containing all required information to this application? (See instructions for
7.1
specific requirements.)
❑✓ Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 213.)
SECTIONOF
1
Describe the nature of your business.
8.1
Operating a filter -backwash treatment system employing greensand filter technology to treat groundwater in
support of potable -water production
N/
H
6>
C
N
7
m
O
CD
3
lC
Z
SECTION••
1
Does your facility use cooling water?
9.1
d
❑ Yes ❑r No 4 SKIP to Item 10.1.
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
�
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
r `o
NPDES permitting authority to determine what specific information needs to be submitted and when.)
O Y
O ip
V =
SECTION
1 VARIANCE
REQUESTS1 1
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
10.1
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
N
d
when.)
d
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
ac
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
❑✓ Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
NC00888S4
NC00888S4
Pine Lakes Subdivision Well 2 OMB No.2040-0004
SECTION•
CERTIFICATION STATEMENT (40
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
11.1
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2
❑r Section 1: Activities Requiring an NPDES Permit
❑r w/ attachments
❑✓ Section 2: Name, Mailing Address, and Location
❑ w/ attachments
❑✓ Section 3: SIC Codes
❑ w/ attachments
❑r Section 4: Operator Information
❑ w/ attachments
❑✓ Section 5: Indian Land
❑ w/ attachments
c
B Section 6: Existing Environmental Permits
❑ w/ attachments
d
R
Section 7: Ma
❑ p
w/ topographic
Elma w/ additional attachments
N
`o
S Section 8: Nature of Business
❑ w/ attachments
Section 9: Cooling Water Intake Structures
❑ w/ attachments
❑✓ Section 10: Variance Requests
❑ w/ attachments
v
c
Mn❑✓
Section 11: Checklist and Certification Statement
❑ w/ attachments
Y
d
11.2
Certification Statement
s
c.�
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision
in accordance with a system designed to assure that qualified personnel properly gather and evaluate the
information submitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. l 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
07/02/2024
RECEIVED—
JUL 2 9 1024
NCDEQ/DWR/NPDE%
EPA Form 3510-1(revised 3--9) Page 4

United States Office of Water EPA Form 3510-2C
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
�E�► Application Form 2C
Existing Manufacturing,
Commercial, Mining, and
S i lvicu ltu 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.

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCO088854 NCO088854 Pine Lakes Subdivision Well #2 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
I I
Provide information on each of the facilitds outfalls in the table below.
Numbelr Receiving Water Name Latitude Longitude
U
0 001 Unnamed tributary to Stews 36' 30' 25" N 80° 40' 55" W
O -
a, 1 2.1 1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
balance? (See instructions for drawing requirements. See Exhibit 2C-1 at end of instructions for example.)
J 16
o Yes ❑ No
3.1 For each outfall identified under Item 1.1, provide average flow and treatment information. Add additional sheets if
necessary.
**Outfall Number" 001
Operation
WTP Backwash Discharge
c
E
3
0
U-
Description
(include size, flow rate through each treatment unit,
> retention time, etc.)
Green sand filter (3 vessels); backwash flow rate is 15gpm
Average Flow
o.o015 mgd
mgd
mgd
mgd
Final Disposal of Solid or
Code from Liquid Wastes Other Than
Table 2C-1 by Discharge
No sludge is treated on site.
EPA Form 3510-2C (Revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO088854
NCO088854
Pine Lakes Subdivision Well #2
OMB No.2040-0004
3.1
**Outfall Number** _
cont.
Operations,
Operation
Average Flow
--- -
mgd
— _ mgd
mgd
mgd
Treatment
Description
Units
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 Dischar e
d
c
c
0
c.�
c
a•
E
is
m
N
**Outfall Number**
Operations Contributing to Flow
o
Operation Average Flow
LL
mgd
d
a'
mgd
mgd
mgd
Treatment
Description
Units
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 Dischar e
3.2
Are you applying for an NPDES permit to operate a privately owned treatment works?
d
❑ Yes ❑ No + SKIP to Section 4.
y3.3
Have you attached a list that identifies each user of the treatment works?
❑ Yes ❑ No
EPA Form 3510-2C (Revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCO088854 NCO088854 Pine Lakes Subdivision Well #2 OMB No. 2040-0004
SECTION•
1
Except for storm runoff, leaks, or spills, are any discharges described in Sections 1 and 3 intermittent or seasonal?
4.1
❑r Yes ❑ No 4 SKIP to Section 5.
4.2
Provide information
on intermittent or seasonal flows for each applicable outfall.
Attach additional pages, if n cessary.
Frequency
Flow
Rate
Outfall
Operation
Duration
Average
Average
Long -Term
Maximum
Number
(list)
Days/Week
Months/Year
Average
Dail
WTP Backwash Dischari
1 days/week
12 months/year
0.0015 mgd
0.0020 mgd
263 days
c
001
days/week
monthslyear
mgd
mgd
days
c
days/week
months/year
mgd
mgd
days
m
E
days/week
months/year
mgd
mgd
days
m
c
days/week
monthslyear
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
monthslyear
mgd
mgd
days
days/week months/year mgd mgd days
SECTION•••D
• r
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
5.1
❑ Yes ❑✓ No 4 SKIP to Section 6.
U)
5.2
Provide the following information on applicable ELGs.
CD
ELG Category
ELG Subcategory
Regulatory Citation
m
m
Q
c-
Q
5.3
Are any of the applicable ELGs expressed in terms of production (or other measure of operation)?
❑ Yes 0 No 4 SKIP to Section 6.
0
5.4
Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
J
Outfall
Number
Operation, Product, or Material
Quantity per Day
Unit of
Measure
0
U)
W
m
C
O
Z
7
O
d
EPA Form 3510-2C (Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCO088854 NC0088854 Pine Lakes Subdivision Well #2 OMB No. 2040-0004
SECTION••
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 + SKIP to Item 6.3.
6.2
Briefly identify each applicable project in the table below.
Affected
Final Compliance Dates
E
Brief Identification and Description of
Outfalls
Source(s) of
c
Project
(list outfall
Discharge
Required
Projected
c.
number
E
a
c
ea
h
47
lC
C!
Q
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
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?
0 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
PA
7.3
Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
h
requested and attached the results to this application package?
No; a waiver has been requested from m NPDES
0 Yes ❑ q
R
permitting authority for allpollutants at all outfalls.
Table B.
Toxic Metals, Cyanide, Total Phenols, and Organic Toxic Pollutants
c
7.4
Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
c
listed in Exhibit 2C-3? (See end of instructions for exhibit.)
❑ Yes ❑ No 4 SKIP to Item 7.8.
7.5
Have you checked "Testing Required" for all toxic metals, cyanide, and total phenols in Section 1 of Table B?
w
❑ Yes El 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 GCIMS Fraction(s)
Check applicable boxes.
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
EPA Form 3510-2C (Revised 3-19) Page 4

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCOO88854
NCOO88854
Pine Lakes Subdivision Well tit
IAITD
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?
S 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?
❑ Yes -* 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,
N
pollutants you have indicated are "Believed Present' in your discharge?
`—'
.N
❑ Yes No
d
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
s
for all outfalls?
U
Y
0 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
'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?
❑r 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 [D No
Table E. 2,3,7,8-Tetrachlorodibenzo- -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 -* Complete Table E. ❑ No -* SKIP to Section 8.
7.17
Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes 0 No
SECTION•
OR MANUFACTURED TOXICS
Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
8.1
an intermediate or final product or byproduct?
w
❑ Yes No SKIP to Section 9.
2 FA
8.2
List the pollutants below.
r- •-
1. 4. 7.
0
2. 5. 8.
3. 6. 9.
EPA Form 3510-2C (Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCO088854 NCO0888 I Pine Lakes Subdivision Well #2 1 OMB No. 2040-0004
fA
d
0
cc
CO
0
0
o
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 purposes below.
Submitted to NPDES
Test(s) Purpose of Test(s) A.4k 4-1 Date Submitted
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
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 I Water Tech Laboratories Inc
Laboratory address 5 Pinewood Plaza Dr
Granite Falls, INC 28630
Phone number
[phone]
Pollutant(s) analyzed Total Suspended Solids, zinc
11.1 Has the NPDES permitting authority requested additional information?
❑ Yes No 4 SKIP to Section 12.
11.2 List the information requested and attach it to this application.
1. 4.
2. 5.
3. 6.
EPA Form 3510-2C (Revised 3-19) Page 6

EPA Identification Number
NPDES Permit Number Facility Name Form Approved 03/05/19
NC0088854
NCO088854 Pine Lakes Subdivision Well #2 OMB No.2040-0004
SECTION•
i
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 lete all sections or provide attachments.
Column 1
Column 2
❑✓ Section 1: Outfall Location
0 w/ attachments
❑� Section 2: Line Drawing
✓❑ w/ line drawing ❑ w/ additional attachments
w/ list of each user of
Section 3: Average Flows and
0
w/ attachments ❑ privately owned treatment
Treatment
works
❑✓ Section 4: Intermittent Flows
❑ w/ attachments
❑✓ Section 5: Production
❑ w/ attachments
w/ optional additional
0 Section 6: Improvements
❑ w/ attachments ❑ sheets describing any
additional pollution control
tans
❑ w/ request for a waiver and ❑ w/ explanation for identical
supporting information outfalls
w/ small business exemption
❑ w/ other attachments
E
request
N
a Section 7: Effluent and Intake
0 w/ Table A w/ Table B
Characteristics
❑✓ w/ Table C w/ Table D
V
w/ analytical results as an
E] w/ Table E
ca)
attachment
8: Used or Manufactured
El
E]w/attachments
E]
Toxics
-Nc❑
Section 9: Biological Toxicity
❑ w/ attachments
s
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
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. l 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
07/02/2024
EPA Form 3510-2C (Revised 3-19) Page 7

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCO088854 NCO088854 Pine Lakes Subdivision Well k2 001 OMB No.2040-0004
TABLE A. CONVENTIONAL AND NON
CONVENTIONAL•
r
Effluent
Intake
(Opt al
Waiver
Units
Maximum
Maximum
Long -Term
Pollutant
Requested
(specify)
Daily
Monthly
Average Daily
Number of
Long -Term
Number of
(if applicable)
Discharge
Discharge
Discharge
Analyses
Average Value
Analyses
(requiI
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
1
❑
Concentration
Mass
(BOD5)
Chemical oxygen demand
2'
❑
Concentration
Mass
(COD)
Concentration
3. Total organic carbon (TOC)
❑✓
Mass
Concentration
4. Total suspended solids (TSS)
❑✓
Mass
Concentration
5.
Ammonia (as N)
❑✓
Mass
6.
Flow
❑
Rate
gpd
2,000
1522.8
263
Temperature (winter)
❑✓
°C
°C
7.
Temperature (summer)
❑✓
°C
°C
pH (minimum)
❑
Standard units
S.U.
6.7
7.8
111
8.
pH (maximum)
❑
Standard units
S.U.
8.9
7.8
111
r Sampling shall be conducted according to sufficiently sensitive test proceaures (i.e., metnoas) approveo unaer 4u Ut-K rsa Tor me analysis or pollutants or ponutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 9

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NC0088854 NCO088854 Pine lakes Subdivision Well #2 001 OMB No.204M004
TOXICTABLE B.
•E,
TOTAL PHENOLS,AND
ORGANIC TOXICPOLLUTANTSr
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
(andCAS Number, rfavailable)
Testing
Required
Believed
Believed
Units
(Specify)
Maximum
Maximum
Long -Term
Average
Number
Long-
Term
Number
Present
Absent
Daily
Discharge
Monthly
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
A
nalyses
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
1.1
Antimony, total
El
El
r
Concentration
Mass
(7440.36.0)
1.2
Arsenic, total
❑
❑
Concentration
Mass
(7440-38-2)
1.3
Beryllium, total
Concentration
Mass
(744041-7)
1.4
Cadmium total
El
El
ID
Concentration
Mass
(7440-43-9)
1.5
Chromium, total
El
El
El
Concentration
Mass
(7440-47-3)
1.6
Copper, total
11
❑
❑
Concentration
Mass
(7440-50-8)
1.7
Lead total
❑
❑
❑
Concentration
Mass
(7439-92-1)
1.8
Mercury, total
El
El
El
Concentration
Mass
(7439-97-6)
1.9
Nickel, total
El
El
El
Concentration
Mass
(7440-02-0)
1.10
Selenium, total
Concentration
Mass
(778249-2)
1.11
Silver, total
El
El
H
Concentration
Mass
(7440-224)
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCO088854 NCO088854 Pine Lakes Subdivision Well N2 001 OMB No.2040-0004
• 1
•
• • • '
• • • 1
Presence or Absence
Intake
check one
Effluent
(optbnal)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, davailable)
Required
Believed
Believed
(specify)
Daily
ay
ony
Monthly
Average
Number
Term
Number
Present
Absent
Discharge(equired)(if
Daily
of
Average
of
available)
Discharge
Analyses
Analyses
if available
1.12
Thallium, total
Concentration
Mass
(7440-28-0)
1.13
Zinc total
❑
a
❑
Concentration
ug/L
1400.0
45.8
49
Mass
(7440-66-6)
1.14
Cyanide, total
El
❑
❑
Concentration
Mass
(57-12-5)
1.15
Phenols, total
Z
ConcentrationMass
Section 2.Organic Toxic Pollutants (GCIMS Fraction —Volatile Compounds)
2.1
Acrolein
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
❑
❑
R1
Concentration
Mass
(107-13-1)
2.3
Benzene
❑
❑
ID
Concentration
Mass
(71.43-2)
2.4
Bromoform
❑
❑
0
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
El
El
E
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
Concentration
Mass
(108-90-7)
2.7
Chlorodibromomethane
El
1:1
ID
Concentration
Mass
(124-48-1)
2.8
Chloroethane
Concentration
1 Mass
(75-00-3)
EPA Form 3510-2C (Revised 3-19) Page 12

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NC0088854 NCO088854 Pine Lakes Subdivision Well fit 001 OMB No.2040-0004
e
�•
Presence or Absence
check one
•� .r
Units
(specify)
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
('rfavailable)
Long -Term
Average
Dail
Discharge
g
rf available
Number
of
Analyses
Long'
Term
Average
Value
Number
of
Analyses
2.9
2-chloroethylvinyl ether
(110-75-8)
❑
❑
❑
Concentration
Mass
2.10
Chloroform (67 66-3)
El
El21
Concentration
Mass
2.11
Dichlorobromomethane
(75-274)
❑
❑
❑
Concentration
Mass
212
11-dichloroethane
(75-34-3)
❑
❑
Concentration
Mass
2.13
12-dichloroethane
(107-06-2)
❑
ElMass
ID
Concentration
214
11-dichloroethylene
(75-35.4)
❑
❑
❑�
Concentration
Mass
215
12-dichloropropane
(78.87-5)
❑
❑
❑
Concentration
Mass
216
13-dichloropropylene
(542-75-6)
❑
❑
S
Concentration
Mass
2.17
Ethylbenzene
(100-414)
❑
❑
ID
Concentration
Concentration
2 18
Methyl bromide
(74-83-9)
❑
❑
❑�
Concentration
Mass
219
Methyl chloride
(74-87-3)
❑
❑
Concentration
Mass
2.20
Methylene chloride
(75-09-2)
❑
❑
Concentration
Mass
2.21
1 12 2- tetrachloroethane
(79-34-5)
❑
ElMass
El
Concentration
EPA Form 3510.2C (Revised 3-19) Page 13

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCO088854 NCO088854 Pine Lakes Subdivision Well #2 001 OMB No, 204NO04
TOXICTABLE B. 1E,
TOTAL PHENOLS,AND
ORGANIC TOXIC•
• I
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available 1
Required
q
Believed
Believed
l p tv)
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(rfavailable)
Discharge
Analyses
Value
Analyses
rfavailable
2.22
Tetrachloroethylene
❑
❑
❑
Concentration
Mass
(127-18-4)
2.23
Toluene
❑
❑
0
Concentration
Mass
(108-88-3)
2.24
1,2-trans-dichloroethylene
❑
❑
❑
Concentration
Mass
(156-60-5)
2.25
1,1,1-trichloroethane
❑
1-1
ID
Concentration
Mass
(71-55-6)
226
1,1,2-trichloroethane
❑
El
❑�
Concentration
Mass
(79-00-5)
2 27
Trichloroethylene
❑
❑
O
Concentration
Mass
(79.01-6)
228
Vinyl chloride
❑
❑
Concentration
Mass
(75-014)
Section 3.Organic Toxic Pollutants GC/MS Fraction —Acid Compounds
31
2-chlorophenol
❑
❑
ID
Concentration
Mass
(95.57.8)
3.2
2,4-dichlorophenol
El
El
E
Concentration
Mass
(120-83-2)
3.3
2,4-dimethylphenol
❑
❑
©
Concentration
Mass
(105-67-9)
3.4
4,6-dinitro-o-cresol
❑
❑
❑
Concentration
Mass
(534-52-1)
3.5
2,4-dinitrophenol
❑
❑
r2l
Concentration
Mass
(51-28-5)
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCO088854 NCO088854 Pine Lakes Subdivision Well #2 001 OMB No.2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, rfavailable)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Diss�chaarrge
Discharge
aily
Discharge
of
Analyses
Average
of
Analyses
ifavailable
Value
3.6
2-nitrophenol
❑
❑
❑
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
❑
El
❑
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
❑
❑
❑
Concentration
Mass
(87-86-5)
3.10
Phenol
Concentration
Mass
(108 95-2)
3.11
2 4,6-trichlorophenol
❑
❑
❑
Concentration
Mass
(88.05-2)
Section 4.Organic Toxic Pollutants GC/MS Fraction —Base /Neutral Coml
wunds)
41
Acenaphthene
El
El
❑
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
❑
0
Concentration
Mass
(208-96-8)
4.3
Anthracene
❑
❑
❑
Concentration
Mass
(120-12-7)
4.4
Benzidine
❑
❑
©
Concentration
Mass
(92.87-5)
4.5
Benzo (a) anthracene
El
El
21
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
El
El
2
Concentration
Mass
(50-32-8)
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Oudall Number Form Approved 03/05/19
NCO088854 NCO088854 Pine Lakes Subdivision Well N2 001 OMB No.2040-0004
• •
Pollutant]Parameter
(and CAS Number, bavailable)
•
Testing
Required
• 1 • •
Presence or Absence
heck one
• • • • IIfflom
Units
(spec4)
Effluent
Intake
,crtone,j
Believed
Present
Believed
Absent
Maximum
Dail y
Discharge
(required) )
Maximum
� Monthly
y
Discharge
( )
Long -Term
Average
DisDcharge
rfavailable
Number
Analyses
Long -
Term
Average
Number
of
Analyses
4.7
3,4-benzofluoranthene
(205-99-2)
El
❑
ID
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
❑
El
❑
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
El
S
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
©
Concentration
Mass
411
Bis (2-chloroethyl) ether
(1114144)
121
Concentration
Mass
412
Bis (2-chloroisopropyl) ether
(102-80-1)
❑
❑
❑�
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
El
11
El
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
❑
❑
S
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
❑
❑
O
Concentration
Mass
4.16
2-chloronaphthalene
(91-58-7)
11
El
10
Concentration
Mass
417
4-chlorophenyl phenyl ether
(7005-72-3)
❑
11
B
Concentration
Mass
418
Chrysene
(218-01-9)
11
El
S
Concentration
Mass
419
Dibenzo (a,h) anthracene
(53-70-3)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NC0088854 NCO0888S4 Pine Lakes Subdivision Well #2 001 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
Maximum
Maximum
Long -Tenn
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
(required)
(ifavailable)
if available
Value
4.20
12-dichlorobenzene
❑
❑
Concentration
Mass
(95-50-1)
4.2 1
1 3-dichlorobenzene
El
S
Concentration
Mass
(541-73-1)
422
14-dichlorobenzene
❑
❑
Concentration
Mass
(106-46-7)
4.23
3 3-dichlorobenzidine
El
❑
r
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
Concentration
Mass
(84.66-2)
4.25
Dimethyl phthalate
El
11
El
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
r
Concentration
Mass
(84-74-2)
4.27
2 4-dinitrotoluene
❑
❑
❑
Concentration
Mass
(121-14-2)
4.28
2,6-dindrotoluene
El
El
21
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑r
Concentration
Mass
(117-84-0)
4.30
1,2-Diphenylhydrazine
❑
Concentration
Mass
(as azobenzene)(122-66-7)
4.31
Fluoranthene
El
❑
©
Concentration
Mass
(206-44-0)
4.32
Fluorene
El
El
r
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCO088854 NC0088854 Pine Lakes Subdivision Well #2 001 OMB No.2040-0004
Pollutant/Parameter
available)
(and CAS Number. if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
ifavailable
Number
of
Analyses
Long-
Term
Average
Value
Number
of
Analyses
4.33
Hexachlorobenzene
(118 74 1)
Concentration
Mass
4.34
Hexachlorobutadiene
(87-68-3)
❑
O
Concentration
Mass
4.35
Hexachlorocyclopentadiene
(77-47-4)
❑
❑
R
Concentration
Mass
4.36
Hexachloroethane
(67-72-1)
❑
❑
❑�
Concentration
Mass
4.37
Indeno (1,2,3-cd) pyrene
(193-39-5)
❑
El
❑�
Concentration
Mass
4.38
Isophorone
(78-59-1)
❑
El
R]
Concentration
Mass
4.39
Naphthalene
(91.20.3)
❑
❑
❑
Concentration
Mass
4.40
Nitrobenzene
(98-95-3)
El
11
✓
Concentration
Mass
4.41
N-nitrosodimethylamine
(62-75-9)
Concentration
Mass
4.42
N-nkrosodi-n-propylamine
(621-64-7)
❑
❑
❑
Concentration
Mass
4.43
N-nitrosodiphenylamine
(86-30-6)
❑
❑
[a
Concentration
Mass
4.44
Phenanthrene
(85-01-8)
El
El
H
Concentration
Mass
4.45
Pyrene
(129-00-0)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCO088854 NCO088854 Pine Lakes Subdivision Well N2 001 OMB No.2040-0004
•
•
•
• 1 •-
Presence or Absence
• ••1
Intake
check one
Effluent
(optional)
Pollutant/Parameter
(and CAS Number, if available)
(and
Testing
Required
Believed
Believed
Units
Ispeciry)
Maximum
Long -Term
Average
Number
Long -
9
Term
Number
Present
Absent
Daily
Discharge
Monthly
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
d available
1,2,4-bichlorobenzene
4.46
El
❑
❑
Concentration
Mass
(120-82-1)
Section 5. Organic Toxic Pollutants GGMS Fraction —Pesticides)
51
Aldrin
❑
❑
❑
Concentration
Mass
(309-00-2)
5.2
a-BHC
El
21
Concentration
Mass
(319-84-6)
5.3
R-BHC
El
El
ID
Concentration
Mass
(319-85-7)
5.4
y-BHC8-8
❑
❑
El
Concentration
Concentration
(59-9)
5.5
b-BHC
❑
ElMass
Concentration
(319-86-8)
5.6
Chlordane
❑
❑
❑
Concentration
Mass
(57-74-9)
5.7
4 4'-DDT
❑
❑
❑
Concentration
Mass
(50-29-3)
5.8
4 4'-DDE
❑
❑
ID
Concentration
Mass
(72-55-9)
5.9
4 4'-DDD
❑
❑
❑
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
❑
Concentration
Mass
(60.57-1)
511
a-endosulfan
❑
❑
❑
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCO088854 NCO088854 Pine Lakes Subdivision Well N2 001 OMB No.2040-0004
Pollutant/Parameter
(and CAS Number, rf available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
ff available
Number
of
Analyses
Lang -
Term
Average
Value
Number
of
Analyses
512
a-endosulfan
(115-29-7)
❑
❑
❑
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
❑
❑
O
Concentration
Mass
5.14
Endrin
(72 20 8)
❑
©
Concentration
Mass
5.15
Endrin aldehyde
(7421-934)
❑
✓
Concentration
Mass
5.16
Heptachlor
(76-44-8)
❑
❑
❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑
❑
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
❑
❑r
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
❑
❑
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
❑
❑�
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
❑
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑
❑
❑
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑
❑
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
❑
❑
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NC0088854 NCO088854 Pine Lakes Subdivision Well #2 001 OMB No.2040-0004
rr
1
�
rr � • •
Presence or Absence
� ' rr r
Intake
check one
Effluent
(optional)
PollutantlParameter
(and CAS Number, if available)
Testing
Required
Believed
Believed
Units
(specify)
Maximum
Maximum
Long -Term
Average
Number
-
Long -
Lon
Term
Number
Present
Absent
Daily
Discharge
Monthly
Discharge
Daily
of
Average
of
(required)
(davailable)
Discharge
Analyses
Value
Analyses
ifavailable
Toxaphene
❑
❑
S
Concentration
Mass
5.25 (8001-35-2)
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 GFR 136 for the analysis of pollutants or pollutant parameters of
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NCO088854 NC0088854 Pine Lakes Subdivision Well N2 001 OMB No.2040-0004
Presence or Absence
Intake
check one
Effluent
(Optional)
Believed
Believed
Pollutant
Units
(specify)
Maximum Daily
Maximum
Monthly
Long -Term
Average Daily
Number of
Long -Term
Number of
Present
Absent
Discharge
Discharge
Discharge
Analyses
Average
Analyses
(required)
if available
if available)Value
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
El
each pollutant.
each
© 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.
Bromide
❑
❑
Concentration
Mass
(24959-67-9)
2
Chlorine, total
❑
❑
Concentration
Mass
residual
3.
Color
❑
❑
Concentration
Mass
4.
Fecal coliform
El
❑
ConcentrationMass
5
Fluoride
El(1698"8-8)
❑
Concentration
Mass
6
Nitrate -nitrite
El❑
ConcentrationMass
7.
Nitrogen, total
❑
❑
Concentration
Mass
organic (as N)
8.
Oil and grease
❑
❑
Concentration
Mass
9
Phosphorus (as
❑
❑
Concentration
Mass
P), total (7723-14-0)
10
Sulfate (as SO4)
❑
Concentration
Mass
(14908.7M)
11.
Sulfide (as S)
❑
El
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NC0O88854 NC0088854 Pine Lakes Subdivision Well N2 001 OMB No.2040-0004
7P.
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(Opel)
Believed
Present
Believed
Absent
Maximum Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average Daily
Discharge
6available
Number of
Analyses
Long -Term
Average
Value
Number of
Analyses
12 Sulfite (as S03)
(14265A5-3)
❑
❑
Concentration
Mass
13. Surfactants
El
El
Concentration
14 Aluminum, total
(7429-90-5)
❑
❑
Concentration
Mass
15 Barium, total
(7440-39-3)
❑
❑
Concentration
Mass
16 Boron total
(744042-8)
El
ElConcentration
Mass
17 Cobalt total
(744048A)
ElConcentration
El
Mass
18 Iron total
(7439.89.6)
❑
❑
Concentration
Mass
Magnesium, total
19' (7439-95-4)
❑
❑
Concentration
Mass
Molybdenum,
20. total
7439-9&7
❑
❑
Concentration
Mass
21 Manganese, total
(7439-96-5)
❑
❑
Concentration
Mass
22
Tin total
(7440-31-5)
❑
ElConcentration
Mass
23 Titanium, total
(7440-32-6)
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05119
NCO088854 NCO088854 fine Lakes Subdivision Well #2 001 OMB No.2040-0004
•
•
1 • •
• •
1
Intake
Presence or Absence
(check one
Effluent
(Optional)
Believed
Believed
Pollutant
Units
(specify)
Maximum Daily
Maximum
Monthly
Long -Term
AverageverageDaily
Number of
Long -Terre
Number of
Present
Absent
Discharge
Discharge
Discharge
Analyses
Average
Analyses
(required)
rfavailable
(if available)
Value
24 Radioactivity
Alpha, total
El
El
Concentration
Mass
Beta, total
El
El
Concentration
Mass
Radium, total
El
Concentration
Mass
Radium 226, total
❑
❑
Concentration
Mass
Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 GFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NC0088854 NC0088854 Pine Lakes Subdivision Well #2 001 OMB No.2040-0004
Presence or Absence
(check one)
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(specify units)
Pollutant
rAsbestos
Believed
Present
Believed
Absent
❑
2.
Acetaldehyde
❑
ID
3.
Allyl alcohol
❑
❑r
4.
My chloride
❑
❑✓
5.
Amyl acetate
❑
❑
6.
Aniline
❑
❑v
7.
Benzonitrile
❑
❑✓
8.
Benzyl chloride
❑
❑r
9.
Butyl acetate
❑
❑r
10.
Butylamine
❑
0
11.
Captan
❑
El
12.
Carbaryl
❑
❑✓
13.
Carbofuran
❑
14.
Carbon disulfide
❑
❑✓
15.
Chlorpyrifos
❑
❑✓
16.
Coumaphos
❑
17.
Cresol
❑
❑�
18.
Crotonaldehyde
❑
19.
Cyclohexane
❑
0
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outtall Number Form Approved 03/05/19
NCO088854 NCO088854 Pine Lakes Subdivision Well #2 001 OMB No.2040-0004
•9•
1 rrI
Presence or Absence
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(spealyunits)
Pollutant
r2,4D
Believed
Present
Believed
Absent
orophenoxyacetic acid)
❑
0
21.
Diazinon
❑
❑✓
22.
Dicamba
❑
ID
23.
Dichlobenil
❑
24.
Dichlone
❑
0
25.
2,2-dichloropropionic acid
❑
E
26.
Dichlorvos
❑
ID
27.
Diethyl amine
❑
❑r
28.
Dimethyl amine
❑
❑r
29.
Dintrobenzene
❑
❑�
30.
Diquat
❑
31.
Disulfoton
❑
32.
Diuron
❑
❑✓
33.
Epichlorohydrin
❑
❑✓
34.
Ethion
❑
B
35.
Ethylene diamine
❑
❑�
36.
Ethylene dibromide
❑
21
37. Formaldehyde
❑
❑✓
38. Furfural
❑
❑r
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPOES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NC0088854 NCO088854 Pine Lakes Subdivision Well #2 001 OMB No.2040-0004
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(specify units)
Pollutant
Presence or Absence
check one
Believed
Present
Believed
Absent
39. Guthion
❑
0
40. Isoprene
❑
❑r
41. Isopropanolamine
❑
❑✓
42. Kelthane
❑
43. Kepone
❑
44. Malathion
❑
R
45. Mercaptodimethur
❑
❑�
46. Methoxychlor
❑
❑✓
47. Methyl mercaptan
❑
❑r
48. Methyl methacrylate
❑
❑✓
49. Methyl parathion
❑
❑�
50. Mevinphos
❑
❑r
51. Mexacarbate
❑
0
52. Monoethyl amine
❑
❑✓
53. Monomethyl amine
❑
❑r
54. Naled
❑
❑r
55. Naphthenic acid
❑
❑✓
56. Nitrotoluene
❑
❑✓
57. Parathion
❑
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05119
NCOO88854 NCOO88854 Pine Lakes Subdivision Well M2 001 OMB No.2040-0004
Pollutant
FPhe,=,oIs.lfonate
Presence or Absence
chiec 0ne
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(specify units)
Believed
Present
Believed
Absent
❑
0
59. Phosgene
❑
0
60. Propargile
❑
❑r
61. Propylene oxide
❑
62. Pyrethrins
❑
0
63. Quinoline
❑
0
64. Resorcinol
❑
El
65. Strontium
❑
❑✓
66. Strychnine
❑
❑�
67. Styrene
❑
❑�
68 2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
0
69. TDE (tetrachlorodiphenyl ethane)
❑
❑r
70 2,4,5-TP 12-(2,4,5-tdchlorophenoxy)
roanoic acid
❑
❑
71. Trichlorofon
❑
0
72. Triethanolamine
❑
❑✓
73. Triethylamine
❑
0
74. Trimethylamine
❑
0
75. Uranium
❑
0
76. Vanadium
❑
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number NPDES Permit Number
NCO088854 NCO088854
Facility Name Outlall Number Form Approved 03/05/19
Pine Lakes Subdivision Well k2 001 OMB No.2040-0004
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(specify units)
Pollutant
Presence or Absence
check one
Believed
Present
Believed
Absent
77.
Vinyl acetate
❑
78.
Xylene
❑
❑✓
79.
Xylenol
❑
❑✓
80.
Zirconium
❑
❑✓
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 31

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
NC0088854 NCOO88854 Pine Lakes Subdivision Well #2 001 OMB No.2040-0004
Presence or
TCDD
tant
Congeners
Absence
check one Results of Screening Procedure
Used or
Believed Believed
r2,3,71,18-TCDD
Manufactured
Present Absent
❑
❑
EPA Form 3510-2C (Revised 3-19) Page 33

Greensand
Raw Water Water
Well 2 Treatment
Facility
Filter Backwash
Water: 2000 GPD

I rnvempe IL7: MUD -I 11o0.7r V
Gloria Rd 'cam
@n,'
-rim'
1
®utfall 001? ,
N (ice � � J
'Gngtori Dr °� Stewart Creek
�n j F
���
� u
wa er� orth Surrq
F 3 as _ Cem
Pine Lakes Subdivision - Well #2
NPDES Permit NCO088854
Gloria Road, Mt. Airy 27030
Receiving Stream: UT to Stewarts Creek
Stream Segment: 12-72-9-(4) Stream Class: WS-IV
River Basin: Yadkin -Pee Dee Sub -Basin #: 03-07-03
County: Surry HUC: 030401010804
UT to Stewarts Creek
1 :1 6;
Quad:SCALE
2bed f