NCG020721 DMR WW (4)

RECEIVED
MAR 2 3 2015
CENTRAL FILES
DwR ECTION
PROCESSIMINE DEWATERING WASTEWATER DISCHARGE MONITORING REPORT (DMR)
Please Mail:0riginal And One Copy To Mailing Address Below
GENERAL PERMIT NO. NCGO20000
Part A: FaciliV Information
Samples Collected In Quarter: 1 Z 3 4 (all samples'slitdl be reported within 30 days
following monitoring period)
Certificate Of Coverage No. NCG02-Q:zzCounty
Facility Name i ' {L°
of Facility
Name of Laboratory
Facility: Contact lr
Facility Contact Phone No. -
Lab Certification #1
OF t --AB
Part B: Process Wastewater and Mine Dewatering Wastewater Monitoring Requirements
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I Meaimed continuously using a Dow meowing devico or estimated using manufaenaws pump naves and pump logs.
Part C. Certification
"I certify; ander penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure thafgaalided 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 U, 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 imprlsonmeat for knowing violatio
(Signature o e e) (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
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{ �. RecefvtogStrmmName xr Sample Collected.: DailyFlowt` ;pH TotalSnspendedSollds Turbidity Setiteable;Sotlds'
Numtier
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I Meaimed continuously using a Dow meowing devico or estimated using manufaenaws pump naves and pump logs.
Part C. Certification
"I certify; ander penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure thafgaalided 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 U, 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 imprlsonmeat for knowing violatio
(Signature o e e) (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