WQ0007026_Monitoring - 08-2016_20161004 (3)

NON -DISCHARGE APPLICATION REPORT Page .3 of
SPRAY IRRIGATION SITE(S)
THERE ARE TWO APPLICATION FIELDS PER PAGE. USE ADDITIONAL PAGES AS NEEDED.
PERMIT NUMBER: WQ0007026 MONTH: August YEAR: 2016
FACILITY NAME: Sanford Health 8r Rehabilitation COUNTY: Lee
Formulas:
Daily Loading (inches) = [Volume Applied (gallons) x 0.1336 (cubic feet/gallon) x 12 (inches/foot)] / [Area Sprayed (acres) x 43,560 (square feet/acre)] OR
= Volume Applied (gallons) / [Area Sprayed (acres) x 27,152 (gallons/acre-Inch)]
Maximum Hourly Loading (inches) =Daily Loading (inches) /[rime Irrigated (minutes) /60 (minutes/hour)] Monthly Loading (inches) = Sum of Daily Loadings (inches)
12 Month Floating Total (inches) = Sum of this month's Monthly Loading (inches) and previous 11 month's Monthly Loadings (inches)
Weather Codes: C -clear, PC -partly cloudy, CI-cloudv, R -rain, Sn-snow, SI -sleet
Spray Irrigation Operator in Responsible Charge (ORC): Randall Jarrell Phase: 919-210-2500
ORC Certification Number: 7937 / 23925 Check Box if ORC Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
ATTN: Non -Discharge Compliance Unit
DENR /
Division of Water Quality (SIGNATURE OF OPERATOR IN RESPONSIBLE CHARGE)
1617 Mail Service Center BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE AND COMPLETE
RALEIGH, NC 27699-1617 TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDAR-1 (5/2003)
Average vveeKIY Loaamg pricnes) = [montnry Loaamg (Incnes/montn) / Ivumoer of says m the montrn (days/montn)]x t (aays/weeK)
Did Irrigation Occur At This Facility:
Yes: n No:
❑
Did Irrigation Occur On This Field:
Yes: 0 No: ❑
Did Irrigation Occur On This Field:
Yes: ❑ No: ❑
----
FIELD NUMBER: 1
AREA SPRAYED (acres): 1 8
COVER CROP: I Fescue
PERMITTED HOURLY RATE (inches): 0.25
FIELD NUMBER:
AREA SPRAYED (acres):
COVER CROP:
PERMITTED HOURLY RATE (inches):
D
A
T
E
WEATHER CONDITIONS
Temper-
Weather
Code* ature at Preclplta-
application tion
Storage
Lagoon
Free-
board
PERMITTED YEARLY RATE (inches):
Volume Time Dail Y
Applied Irrigated Loading
30.11
Maximum
Hourly
Y
Loading
PERMITTED YEARLY RATE (inches):
Volume Time Dail Y
Applied Irrigated Loading
Maximum
Hourly
Y
Loading
rF)
inches
feet
gallons minutes
inches
inches
gallons minutes Inches
Inches
1
CL
77
0.15
1 316"
37500 300
0.17
0.03
12 -Month Floating Total (inches)
2
NA
3
NA
4
CL
89
3'4"
37500 300
0.17
0.03
5
NA
s
NA'
7
NA
8
CL
75
2.27
32"
37500 300
0.17
0.03
9
NA
10
NA
11
CL
92
3'6"
37500 300
0.17
0.03
12
NA
13
NA
1 a
NA
15
CL
74
1.53
3'6"
37500 300
0.17
0.03
1 s
NA
17
NA
1a
CL
90
1 3'4"
37500 300
0.17 1
0.03
Weather Codes: C -clear, PC -partly cloudy, CI-cloudv, R -rain, Sn-snow, SI -sleet
Spray Irrigation Operator in Responsible Charge (ORC): Randall Jarrell Phase: 919-210-2500
ORC Certification Number: 7937 / 23925 Check Box if ORC Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
ATTN: Non -Discharge Compliance Unit
DENR /
Division of Water Quality (SIGNATURE OF OPERATOR IN RESPONSIBLE CHARGE)
1617 Mail Service Center BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE AND COMPLETE
RALEIGH, NC 27699-1617 TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDAR-1 (5/2003)
----
Total Gallons/Monthly Loading (inches) 11ST, �so
12 -Month Floating Total (inches)
Weather Codes: C -clear, PC -partly cloudy, CI-cloudv, R -rain, Sn-snow, SI -sleet
Spray Irrigation Operator in Responsible Charge (ORC): Randall Jarrell Phase: 919-210-2500
ORC Certification Number: 7937 / 23925 Check Box if ORC Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
ATTN: Non -Discharge Compliance Unit
DENR /
Division of Water Quality (SIGNATURE OF OPERATOR IN RESPONSIBLE CHARGE)
1617 Mail Service Center BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE AND COMPLETE
RALEIGH, NC 27699-1617 TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDAR-1 (5/2003)

NON -DISCHARGE APPLICATION REPORT Page t of S�
J
SPRAY IRRIGATION SITE(S)
Facility Status:
Please indicate ( by inserting Y(es) or N(o) in the appropriate box ) whether the facility has been compliant
with the following permit requirements: (Note: if a requirement does not apply to your facility put (NA) in the
compliant box. )
specified in the permit.
If the facility is non-compliant, please explain in the space below the reason(s) the facility was not in compliance with its
permit. Provide in your explanation the date(s) of the non-compliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
"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 all qualified personnel properly gathered and evaluated 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 violations."
zl"
(Signature of Per ittee)* Date
Sanford Health & Rehabilitation
(Permittee -Please print or type)
2702 Farrell Road
Sanford, N.C. 27330
(Permittee Address)
Randall Jarrell
(Name of Signing Official -Please print or type)
ORC
(Position or Title)
919-210-2500 5/31/2015
(Phone Number) (Permit Exp. Date)
* If signed by other than the permittee, delegation of signatory authority must be on file with the state per 15A NCAC 26.0506 (b)(2)(D).
DENR FORM NDAR-1 (5/2003)
Com liant (Y,N)
1. The application rate(s) did not exceed the limit(s) specified in the permit.
Y
2. Adequate measures were taken to prevent wastewater runoff from the site(s).
YO
3. A suitable vegetative cover was maintained on the site(s) in accordance with the permit.
Y�
4. All buffer zones as specified in the permit were maintained during each application.
I J
5. The freeboard in the treatment and/or storage lagoon(s) was not less than the limit(s)
I�
specified in the permit.
If the facility is non-compliant, please explain in the space below the reason(s) the facility was not in compliance with its
permit. Provide in your explanation the date(s) of the non-compliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
"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 all qualified personnel properly gathered and evaluated 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 violations."
zl"
(Signature of Per ittee)* Date
Sanford Health & Rehabilitation
(Permittee -Please print or type)
2702 Farrell Road
Sanford, N.C. 27330
(Permittee Address)
Randall Jarrell
(Name of Signing Official -Please print or type)
ORC
(Position or Title)
919-210-2500 5/31/2015
(Phone Number) (Permit Exp. Date)
* If signed by other than the permittee, delegation of signatory authority must be on file with the state per 15A NCAC 26.0506 (b)(2)(D).
DENR FORM NDAR-1 (5/2003)