NC0074772_Permit (Modification)_20160425

AQUA .9
Thomas J.Roberts,President and Chief Operating Officer
0:919.653.5770 • F:919.460.1788 • [e-mail]
April 25, 2016
NC Department of Environmental Quality
Division of Water Resources RECEIVED/NCDEQ/DWR
Water Quality Permitting Section—NPDES
1617 Mail Service Center MAY 0 2 2016
Raleigh, NC 27699-1617
Water Quality
Subject: Application for Permit Modification Permitting Section
Aqua North Carolina, Inc.
Diamond Head WWTP
NPDES No. NC0074772
Iredell County
Gentlemen:
Attached are three(3)copies of the completed application Form D, a location map, a copy of the
sludge management plan and a check for the permit modification application processing fee
($ 260.00). This letter and attachments are our request to modify the subject permit to allow the
introduction of a maximum of 500 gallons per day of wastewater from several existing community
potable well water treatment systems. The existing well water systems are all owned and operated by
Aqua North Carolina, Inc.
Each of these existing community well water systems has existing uranium removal filter systems. In
the past, the wastewaters derived from the backwashing of these systems have been collected in
existing tanks located on the well sites and periodically removed by a licensed commercial hauler
(tanker truck) for disposal at treatment facilities off site. However, the hauler has advised that he will
no longer be able to continue providing this disposal service. Therefore, Aqua North Carolina, Inc. is
requesting that this NPDES permit be modified to allow the collected uranium filter backwash
wastewater to be transported to the existing Diamond Head WWTP and introduced into the influent.
The uranium filter backwash wastewater will be brought to the WWTP by tanker truck, offloaded
into a storage tank and fed slowly at a rate of less than one gallon per minute by means of a manually
operated valve, into the WWTP influent. We have included an analysis of the collected uranium
backwash wastewater in Attachment 1 of the application.
202 MacKenan Court Cary, NC 27511 • AquaAmerica.com

Page Two
April 25,2016
NC Department of Environmental Quality
Diamond Head WWTP
We appreciate your consideration of this request for modification. If you need any additional
information or assistance, please feel free to contact our engineer, Mr. J. Thurman Horne, P.E.,
Horizon Engineering& Consulting, Inc. (704-788-4455.)
Sincere)
Thomas J. Robert
President and C of Operating Officer
cc: Laurie Ison
J. Thurman Home RECEIVED/NCDEQ/DVVR
MAY 0 2 2016
Water Quality
Permitting Section

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to:
N. C. DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit INC0074772
If you are completing this form in computer use the TAB key or the up - down arrows to move from one
field to the next. To check the boxes, click your mouse on top of the box. Otherwise,please print or type.
1. Contact Information:
Owner Name Aqua North Carolina, Inc.
Facility Name Diamond Head WWTP
Mailing Address 202 MacKenan Court
City Cary
State / Zip Code NC/27511 RECEIVED/NCDEQ/DWR
Telephone Number [phone] MAY 0 2 29
Fax Number [phone] Water Quality
e-mail Address [e-mail] Permitting Section
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road 799 Williamson Road
City Mooresville
State / Zip Code NC/28115
County Iredell
3. Operator Information:
Name of the firm, public organization or other entity that operates the facility. (Note that this is not
referring to the Operator in Responsible Charge or ORC)
Name Aqua North Carolina, Inc.
Mailing Address 202 MacKenan Court
City Cary
State / Zip Code NC/27511
Telephone Number [phone]
Fax Number [phone]
e-mail Address [e-mail]
1 of 4 Form-D 11/12

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Facility Generating Wastewater(check all that apply):
Industrial ❑ Number of Employees
Commercial X Number of Employees
Residential X Number of Homes 138
School El Number of Students/Staff
Other ❑ Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Domestic and commercial watewater from 14 commercial and 138 residential connections.
Number of persons served: 345
This application is being submitted for a modification to to allow the existing wastewater treatment
facilities to receive a maximum of 500 gpd of backwash wastewater collected from nearby, existing
private community well water, uranium filtration systems. These existing community well water
systems are owned and operated by the applicant (Aqua North Carolina, Inc.)
The well water, uranium filter backwash wastewaters is collected and held in existing tanks at the well
sytems. This application requests the permission to periodically transport these collected uranium
backwash wastewaters via a tanker truck, to the existing Diamondhead WWTP, where it will be
unloaded into a holding tank on site and introduced into the influent of the WWTP at a rate less than 1
gpm and controlled by a manual vavle.
An analysis of the collected uranium filter backwash wastewaters from each of the existing community
well systems in included in Attachment 1.
5. Type of collection system
X Separate (sanitary sewer only) El Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points 1
Outfall Identification number(s) 001
Is the outfall equipped with a diffuser? ❑ Yes X No
7. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfall):
Lake Norman (Reeds Creek Arm) in the Catawba River Basin
8. Frequency of Discharge: X Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: Duration:
9. Describe the treatment system
List all installed components, including capacities,provide design removal for BOD, TSS, nitrogen and
phosphorus. If the space provided is not sufficient, attach the description of the treatment system in a
separate sheet of paper.
2 of 4 Form-D 11112

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
0.0731 MGD extended aeration wastewater treatment system consisting of:
Effluent Pump station
Flow splitter
Bar Screen
Flow Equalization basin
Aeration basins
Secondary clarifiers
Sludge holding tank
Chlorine disinfection facilities (tablet)
Dechlorination facilities (tablet)
Post aeration
V-notch weir
Effluent flow recording meter
Standby power
3 of 4 Form-D 11/12

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0.0731 MGD
Annual Average daily flow 0.047 MGD (for the previous 3 years)
Maximum daily flow 0.075 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes X No
12. Effluent Data
NEW APPLICANTS:Provide data for the parameters listed. Fecal Coliform, Temperature and pH shall be grab
samples,for all other parameters 24-hour composite sampling shall be used. If more than one analysis is reported,
report daily maximum and monthly average. If only one analysis is reported, report as daily maximum.
RENEWAL APPLICANTS: Provide the highest single reading(Daily Maximum)and Monthly Average over
the past 36 months for parameters currently in your permit. Mark other parameters "N/A".
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BODS) 12.9 1.0 mg/1
Fecal Coliform 95 3.5 #/100m1
Total Suspended Solids 12.7 5.5 mg/1
Temperature (Summer) 28 23.3 Deg. C
Temperature (Winter) 23 13.7 Deg. C
pH 8.2 7.2 s.u.
13. List all permits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA) Ocean Dumping(MPRSA)
NPDES NC0074772 Dredge or fill (Section 404 or CWA)
PSD (CAA) Other
Non-attainment program (CAA)
14. APPLICANT CERTIFICATION
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
Thomas J. Roberts President & Chief Operating Officer
Printe. . e o Person S';ning Title
ignature of Applic. t Date
North Carolina General S atute 143-215.6 (b)(2) states: Any person who knowingly makes any false statement representation, or certification in any
application, record, report, plan, or other document files or required to be maintained under Article 21 or regulations of the Environmental Management
Commission implementing that Article, or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method
required to be operated or maintained under Article 21 or regulations of the Environmental Management Commission implementing that Article,shall be
guilty of a misdemeanor punishable by a fine not to exceed$25,000,or by imprisonment not to exceed six months,or by both. (18 U.S.C.Section 1001
provides a punishment by a fine of not more than$25,000 or imprisonment not more than 5 years,or both,for a similar offense.)
4 of 4 Form-D 11/12

ANC - Diamond Head WWTP
NPDES Permit No. NC0074772
Application for Permit Modification
Sunset Hills Well System Uranium Filter Backwash
Sample Results
Parameter Concentration Units
Aluminum 4120 ug/I
Iron 12600 ug/I
Manganese 157 ug/I
Copper 57.7 ug/I
Sodium 30500 ug/I
Zinc 35.8 ug/I
TDS 154 mg/I
TSS 11300 mg/I
Total nitrogen 16.6 mg/I
Fluoride ND mg/I
Ammonia nitrogen ND mg/I
Total Kjeldahl nitrogen 7.9 mg/I
Nitrogen, NO2 + NO3 8.7 mg/I
Phosphorous 1.1 mg/I
Chloride 26 mg/I
Gross Alpha 1014 pCi/I
Gross Beta 2.26 pCi/I
Radium-226 0.972 pCi/I
Radium-228 2.38 pCi/I
Strontium-90 0.114 pCi/I
Tritium -57.4 pCi/I
Total uranium 1077 ug/I
pH 7.1 s.u.
TRC 1.2 mg/I

Pace Analytical Services,Inc.
6 9800 Kincey Ave. Suite 100
aceAnalytical Huntersville,NC 28078
www.pacelabs.com [phone]
April 08, 2016
Michael Melton
Aqua America
RE: Project: Sunset Hills Backwash
Pace Project No.: 92290529
Dear Michael Melton:
Enclosed are the analytical results for sample(s) received by the laboratory on March 17, 2016. The
results relate only to the samples included in this report. Results reported herein conform to the
most current TNI standards and the laboratory's Quality Assurance Manual, where applicable, unless
otherwise noted in the body of the report.
Analyses were performed at the Pace Analytical Services location indicated on the sample analyte
page for analysis unless otherwise footnoted.
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
Taylor Ezell
[e-mail]
Project Manager
Enclosures
cc: Ms.Debbie Dycus,Aqua North Carolina
Ms.Debbie Gentry,Aqua North Carolina
A-*4'
`` REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
without the written consent of Pace Analytical Services,Inc.. Page 1 of 11

Pace Analytical Services,Inc.
9800 Kincey Ave. Suite 100
aceAnalytical Huntersville.NC 28078
wwwpacelabs.com [phone]
CERTIFICATIONS
Project: Sunset Hills Backwash
Pace Project No.: 92290529
Pennsylvania Certification IDs
Georgia Certification#:C040 Montana Certification#:Cert 0082
1638 Roseytown Rd Suites 2,3&4,Greensburg,PA 15601 Nebraska Certification#:NE-05-29-14
L-A-B DOD-ELAP Accreditation#:L2417 Nevada Certification#:PA014572015-1
Alabama Certification#:41590 New Hampshire/TNI Certification#:2976
Arizona Certification#:AZ0734 New Jersey/TNI Certification#:PA 051
Arkansas Certification New Mexico Certification#:PA01457
California Certification#:04222CA New York/TNI Certification#: 10888
Colorado Certification North Carolina Certification#:42706
Connecticut Certification#:PH-0694 North Dakota Certification#:R-190
Delaware Certification Oregon/TNI Certification#:PA200002
Florida/TNI Certification#:E87683 Pennsylvania/TNI Certification#:65-00282
Georgia Certification#:C040 Puerto Rico Certification#:PA01457
Guam Certification Rhode Island Certification#:65-00282
Hawaii Certification South Dakota Certification
Idaho Certification Tennessee Certification#:TN2867
Illinois Certification Texas/TNI Certification#:Ti 04704188-14-8
Indiana Certification Utah/TNI Certification#:PA014572015-5
Iowa Certification#:391 USDA Soil Permit#:P330-14-00213
KansaslTNl Certification#:E-10358 Vermont Dept.of Health:ID#VT-0282
Kentucky Certification#:90133 Virgin Island/PADEP Certification
Louisiana DHH/TNI Certification#:LA140008 VirginiaNELAP Certification#:460198
Louisiana DEQ/TNI Certification#:4086 Washington Certification#:C868
Maine Certification#:PA00091 West Virginia DEP Certification#: 143
Maryland Certification#:308 West Virginia DHHR Certification#:9964C
Massachusetts Certification#:M-PA1457 Wisconsin Certification
Michigan/PADEP Certification Wyoming Certification#:8TMS-L
Missouri Certification#:235
Asheville Certification IDs
2225 Riverside Drive,Asheville,NC 28804 North Carolina Wastewater Certification#:40
Florida/NELAP Certification#:E87648 South Carolina Certification#:99030001
Massachusetts Certification#:M-NC030 VirginiaNELAP Certification#:460222
North Carolina Drinking Water Certification#:37712
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
without the written consent of Pace Analytical Services,Inc.. Page 2 of 11

Pace Analytical Services,Inc.
® 9800 Kincey Ave. Suite 100
aceAnalytical Huntersville,NC 28078
www.pacelabs.com [phone]
SAMPLE ANALYTE COUNT
Project: Sunset Hills Backwash
Pace Project No.: 92290529
Analytes
Lab ID Sample ID Method Analysts Reported Laboratory
92290529001 Sunset Hills Backwash EPA900.0 NEG 1 PASI-PA
EPA 300.0 MDW 1 PASI-A
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services,Inc.. Page 3 of 11

Pace Analytical Services,Inc.
2eAnalytical a 9800 Kincey Ave. Suite 100
/fiHuntersville,NC 28078
ww.v.pacelabs.com [phone]
ANALYTICAL RESULTS
Project: Sunset Hills Backwash
Pace Project No.: 92290529
Sample: Sunset Hills Backwash Lab ID: 92290529001 Collected: 03/16/16 00:00 Received: 03/17/16 15:35 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
300.0 IC Anions 28 Days Analytical Method:EPA 300.0
Fluoride ND mg/L 0.25 1 03/22/16 18:22 16984-48-8
REPORT OF LABORATORY ANALYSIS
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Date:04/08/2016 04:59 PM without the written consent of Pace Analytical Services,Inc.. Page 4 of 11

Pace Analytical Services,Inc.
® 9800 Kincey Ave. Suite 100
aceAnalytical Huntersville,NC 28078
wwwpacelabs.com [phone]
QUALITY CONTROL DATA
Project: Sunset Hills Backwash
Pace Project No.: 92290529
QC Batch: WETA/26866 Analysis Method: EPA 300.0
QC Batch Method: EPA 300.0 Analysis Description: 300.0 IC Anions
Associated Lab Samples: 92290529001
METHOD BLANK: 1691015 Matrix: Water
Associated Lab Samples: 92290529001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Fluoride mg/L ND 0.25 03/22/16 14:14
LABORATORY CONTROL SAMPLE: 1691016
Spike LCS LCS %Rec
Parameter Units Conc. Result %Rec Limits Qualifiers
Fluoride mg/L 2.5 2.4 96 90-110
MATRIX SPIKE&MATRIX SPIKE DUPLICATE: 1691017 1691018
MS MSD
92290258001 Spike Spike MS MSD MS MSD %Rec
Parameter Units Result Conc. Conc. Result Result %Rec %Rec Limits RPD Qual
Fluoride mg/L ND 2.5 2.5 6.8 6.9 70 73 90-110 D3,M6
Results presented on this page are in the units Indicated by the"Units"column except where an alternate unit Is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
Date:04/08/2016 04:59 PM without the written consent of Pace Analytical Services,Inc.. Page 5 of 11

Pace Analytical Services,Inc.
® 9800 Kincey Ave. Suite 100
aceAnalytical Huntersville,NC 28078
www.paceIabs.com [phone]
ANALYTICAL RESULTS -RADIOCHEMISTRY
Project: Sunset Hills Backwash
Pace Project No.: 92290529
Sample: Sunset Hills Backwash Lab ID: 92290529001 Collected: 03/16/16 00:00 Received: 03/17/16 15:35 Matrix: Water
PWS: Site ID: Sample Type:
Parameters Method Act±Unc(MDC)Carr Trac Units Analyzed CAS No. Qual
Gross Beta EPA 900.0 2.26±1.12 (1.84) pCi/L 03/30/16 06:33 12587-47-2
C:NA T:NA
REPORT OF LABORATORY ANALYSIS
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Pace Analytical Services,Inc.
9800 Kincey Ave. Suite 100
,,b
aceAnalytical Huntersville,NC 28078
www.pacelabs.com [phone]
QUALITY CONTROL-RADIOCHEMISTRY
Project: Sunset Hills Backwash
Pace Project No.: 92290529
QC Batch: RADC/28648 Analysis Method: EPA 900.0
QC Batch Method: EPA 900.0 Analysis Description: 900.0 Gross Alpha/Beta
Associated Lab Samples: 92290529001
METHOD BLANK: 1048752 Matrix: Water
Associated Lab Samples:
Parameter Act t Unc(MDC)Carr Trac Units Analyzed Qualifiers
Gross Beta 0.028±0.663 (1.65)C:NA T:NA pCi/L 03/30/16 06:16
Results presented on this page are in the units indicated by the"Units"column except where an alternate unit is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services,Inc.. Page 7 of 11

Pace Analytical Services,Inc.
w
/.2 Pace
9800 Kincey Ave. Suite 100
Huntersville,NC 28078
www.pacelabs.com [phone]
QUALIFIERS
Project: Sunset Hills Backwash
Pace Project No.: 92290529
DEFINITIONS
DF-Dilution Factor.if reported,represents the factor applied to the reported data due to dilution of the sample aliquot.
ND-Not Detected at or above adjusted reporting limit.
J-Estimated concentration above the adjusted method detection limit and below the adjusted reporting limit.
MDL-Adjusted Method Detection Limit.
PQL-Practical Quantitation Limit.
RL-Reporting Limit.
S-Surrogate
1,2-Diphenylhydrazine decomposes to and cannot be separated from Azobenzene using Method 8270.The result for each analyte is
a combined concentration.
Consistent with EPA guidelines,unrounded data are displayed and have been used to calculate%recovery and RPD values.
LCS(D)-Laboratory Control Sample(Duplicate)
MS(D)-Matrix Spike(Duplicate)
DUP-Sample Duplicate
RPD-Relative Percent Difference
NC-Not Calculable.
SG-Silica Gel-Clean-Up
U-Indicates the compound was analyzed for,but not detected.
Acid preservation may not be appropriate for 2 Chloroethylvinyl ether,Styrene,and Vinyl chloride.
A separate vial preserved to a pH of 4-5 is recommended in SW846 Chapter 4 for the analysis of Acrolein and Acrylonitrile by EPA
Method 8260.
N-Nitrosodiphenylamine decomposes and cannot be separated from Diphenylamine using Method 8270. The result reported for
each analyte is a combined concentration.
Act-Activity
Unc-Uncertainty:SDWA=1.96 sigma count uncertainty,all other matrices=Expanded Uncertainty(95%confidence interval).
Gamma Spec=Expanded Uncertainty(95.4%Confidence Interval)
(MDC)-Minimum Detectable Concentration
Trac-Tracer Recovery(%)
Carr-Carrier Recovery(%)
Pace Analytical is TNI accredited.Contact your Pace PM for the current list of accredited analytes.
TNI-The NELAC Institute.
LABORATORIES
PAST-A Pace Analytical Services-Asheville
PAST-PA Pace Analytical Services-Greensburg
ANALYTE QUALIFIERS
D3 Sample was diluted due to the presence of high levels of non-target analytes or other matrix interference.
M6 Matrix spike and Matrix spike duplicate recovery not evaluated against control limits due to sample dilution.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
Date:04/08/2016 04:59 PM without the written consent of Pace Analytical Services,Inc.. Page 8 of 11

Pace Analytical Services,Inc.
aceAllalytical® 9800Kincey Hunte sv le,NC Suite 100
28078
www.pacefabs.t.om [phone]
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: Sunset Hills Backwash
Pace Project No.: 92290529
Analytical
Lab ID Sample ID QC Batch Method QC Batch Analytical Method Batch
92290529001 Sunset Hills Backwash EPA 900.0 RADC/28648
92290529001 Sunset Hills Backwash EPA 300.0 WETA/26866
REPORT OF LABORATORY ANALYSIS
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Date:04/08/2016 04:59 PM without the written consent of Pace Analytical Services,Inc.. Page 9 of 11

uocurnent Ivame: vu[umem nevraeu.aorcozvio
Sample Condition Upon Receipt(SCUR) Page 1 of 2
aeeAnalytleal Document No.: Issuing Authority:
F-CHR-CS-003-rev.18 Pace Huntersville Quality Office
Page 2 of 2 for Internal I Ica nna v
SaFn IeCo tliion Ian
Client dame: ■rw 92290529
�Rec pt.;��,,at !, tr I � , Project#
Courier: EFed Ex i L] UPS Other: ❑Client 111111 1111
11111111 111
❑Commercial t`Pace
92290529
Custody Seal Present? ❑Yes QNo Seals Intact? Dyes RIND ? .',° f'.•I i
Date/Initials Person Examining Contents; Jl i ) 1"-'1' '�it)
Packing Material: QB�ubbble Wrap ❑Bubble Bags ❑None DOther: r-, r.
Thermometer: E'I 1505 El Type of Ice: � et Delue :None nSamples on Ice,cooling process has begun
Correction Factor:0.0°C Cooler Temp Corrected(°C): O Biological Tissue Frozen? ❑Yes ONo ON-/A
Tenip should be above freezing to 6°C
USDA Regulated Soil(❑N/A,water sample)
Did samples riginate in a quarantine zone within the United States:CA,NY,or SC(check maps)? Did samples originate from a foreign source(internationally,
OYes LIN() including Hawaii and Puerto Rico)?❑Yes ONo"
COMMENTS:
Chain of Custody Present? Y s ONo ON/A 1.
Chain of Custody Filled Out? Ores ONo ON/A 2.
Chain of Custody Relinquished? DieFs ONo ON/A 3.
Sampler Name and/or Signature on COC? :ryes :No ON/A 4.
Samples Arrived within Hold Time? Mies ❑No ON/A 5.
Short Hold Time Analysis(<72 hr.)? Oyes [,Tn]No ON/A 6.
Rush Turn Around Time Requested? Dyes ©No ON/A 7.
Sufficient Volume? [¢Yes El No ON/A 8.
Correct Containers Used? [ Yes ONo ON/A 9.
_ -Pace Containers Used? Des ONo ON/A
Containers Intact? [) s ONo ON/A 10.
Filtered Volume Received for Dissolved Tests? Oyes ❑No [3ta/A 11. Note if sediment is visible in the dissolved container
Sample Labels Match COC? !]Yes ❑No ON/A 12.
-Includes Date/Time/ID/Analysis Matrix:\i\ _
All containers needing acid/base preservation have been ,�' 13
checked? QYes Orb ON/A
All containers needing preservation are found to be in
compliance with EPA recommendation?
(HNOS,H2SO4,HCI<2;NaOH>9 Sulfide,NaOH>12 Cyanide) all'es ❑No ON/A
Exceptions:VOA,Coliform,TOC,Oil and Grease,
DRO/5015(water)DOC,LLHg ❑Yes ONo ON/A
Samples checked for dechlorination Oyes ONo Df/A 14.
Headspace In VOA Vials(>5-6mm)? Ores ONo JN/A 15.
Trip Blank Present? Dyes ONo BOA 16.
Trip Blank Custody Seals Present? ❑Yes ❑No1�N/A
Pace Trip Blank Lot if(if purchased):
CLIENT NOTIFICATION/RESOLUTION Field Data Required? pies ❑No
Person Contacted: Date/Time:
Comments/Resolution:
Project Manager SCURF Review: Date: //I
Project Manager SRF Review: (FJ Date: `'lit
Note: Whenever there is a discrepancy affecting North Carolina compliance samples,a copy of this form will be sent to the North Carolina DEHNR Certification Office(i.e.
Out of hold,Incorrect preservative,out of temp,incorrect containers)
Page 10of11

CHAIN-OF-CUSTODY /Analytical Request Document -P3ceA1111;1.:21
The Chain-of-Custody is a LEGAL DOCUMENT.All relevant fields must be completed accurately. 5
Section A Section B Section C N
Required Client Information: Required Project Information: Invoice Information: Page: 1 Of 1 to
t
Company: Aqua North Carolina ,Report To. d
q Po Laurie!son Attention:
Address: 4163 Sinclair St Copy To. Company Name:
Denver.NC 28037Address: Regulatory Agency
_
Email: Purchase Order#: Pace Quote:
Phone: 'fax Prated Name: Sunset Hills Backwash Pace Project Manager [e-mail], State I Location
IRequested Due Date: !Project e: !Pace Profile It 4521-3 NC
Requested Analysis Filtered(YIN)
_ a 2
urRix cos o COLLECTED Preservatives >-
Conking Weer OW U g
Wale. W r-
w
Waste Wa!er WW = Q 2
Predud P U O el }
SAMPLE ID S;IV$etld o� 6 START END ti tm—
One Character per box. Wipe we y a w CO o
w z a al
(A-Z,0-9/r-) Air AR Oo c F Q a a —
1* Me. OT 2 M a
Sample Ids must be unique Tissue TS K Cu w 0 m v ON c o co
K S e. V m O '' 2 N e1 t :2 r^ v
IllF s 4 Q C N cn 2 U O NCJ 0 t Q o
y DATE TIME DATE TIME N M 2 2 2 Z 2 a O ti !rJ
1 Sunset Hills Backwash WT X X
2
3
4
5
6
7
a
9
10•
11
12
ADDITIONAL COMMENTS - REUNQUISHED BY I AFFIUAT1ON DATE TIMECCEPTED I AFF�IATION - DATE TIME SAMPLE CONDITIONS
1 rte' i� t
<---C-...---- .47 ,---
L �yt� (J c-4,___ /7 l��� 1 i"' T n1... 24,-'1\H dl'ff- i tel` 3 t.' �,' `l4 �;
SAMPLER NAME AND SIGNATURE
o 6
P NT't�ams SA PLER:
_ ii 11t: t.' Sa _ a m
SI LOIRg of�A{JIP ER: t/ . = I DATE Signed: m 3 Z o? .m?