NCG020895 Template WW Annual DMR to CO

ANNUAL SUMMARY DISCHARGE MONITORING
REPORT (DMR) —WASTEWATER
SUBMIT TO CENTRAL OFFICE*
General Permit No. NCG020000
Calendar Year
*Report ALL WASTEWATER monitoring data on this form (include "No Flow"/"No Discharge" and Limit Violations) from
the previous calendar year to the DEQ by MARCH 1 of each year.
Certificate of Coverage No. NCG020895
Facility Name:
County:
Phone Number: ()
Certified Laboratory
Lab #
Lab #
Total no. of outfalls monitored
Wastewater (WW) Discharge Outfall No.
Does this outfall discharge WW to SA waters? Yes ❑ No ❑
Does this outfall discharge WW to SB or PNA waters? Yes ❑ No ❑
Does this outfall discharge WW to HQW or ORW waters? Yes ❑ No ❑
If so, what is the 7Q10 flow rate? or Tidally influenced waters, 7Q10 not available ❑
Does this outfall discharge WW to Trout jr) designated waters? Yes ❑ No ❑
Were there any limit violations in the calendar year? Yes ❑ No ❑
Outfall No.
Daily Flow
Rate, cfs
pH,
SU
TSS,
mg/I
SS,
MIA
ifapplicable
Discharge
Turbidity,
NTU
Upstream
(U) Turbidity,
NTU
Downstream
(D) Turbidity,
NTU
Total
Hardness,
mg/I
Effluent
Limitations
Mo. Ave / Daily Max.
HQW or ORIN
50% of
7Q10
Indicate NO FLOW
if applicable
freshwater
6.0-9.1
saltwater
6.8-8.5
20/30
HQW or ORIN
and Tr or PNA
10/15
HQW, ORIN,
SA, SB, PNA,
or any Trout
0.1/0.2
No Limit
Circle Water
Quality that appl esard
50/25/10
N/A
Water Quality
Standard applies
N/A
Water Quality
Standard applies
N/A
Date Sample
Collected,
mo/dd/yr
Permit Date 5/31/17 — 9/30/2020
Revised 5/31/17 for Additional Monitoring Specific to this COC

Outfall No.
continued
Effluent
Limitations
Date Sample
Collected,
mo/dd/vr
Outfall No.
Effluent
Limitations
Date Sample
Collected,
mo/dd/vr
Certificate of Coverage No. NCG020895
Supplemental parameters:
Iron,Total Ni, Total Zn, Total Sb, Total As, Total Be, Total Cd, Total Cu,
mg/I mg/
I mg/I mg/I mg/I mg/I mg/I mg/I
1.0/2.0 1 N/A I N/A I N/A I N/A I N/A I N/A I N/A
Total Pb, Total Hg, Total Se, Total Ag,
mg/I mg/I mg/I mg/I
NA I N/A I N/A I N/A
Permit Date 5/31/17 — 9/30/2020
Revised 5/31/17 for Additional Monitoring Specific to this COC

Certificate of Coverage No. NCG020895
Additional Outfall Attachment (make copies as needed for additional outfalls)
Wastewater (WW) Discharge Outfall No.
Does this outfall discharge WW to SA waters? Yes ❑ No ❑
Does this outfall discharge WW to SB or PNA waters? Yes ❑ No ❑
Does this outfall discharge WW to HQW or ORW waters? Yes ❑ No ❑
If so, what is the 7Q10 flow rate? or Tidally influenced waters, 7Q10 not available ❑
Does this outfall discharge WW to Trout jr) designated waters? Yes ❑ No ❑
Were there any limit violations in the calendar year reported? Yes ❑ No ❑
Outfall No.
Daily Flow
Rate, cfs
pH,
SU
TSS,
mg/I
SS,
MIA
ifapplicable
Discharge
Turbidity,
NTU
Upstream
(U) Turbidity,
NTU
Downstream
(D) Turbidity,
NTU
Total
Hardness,
mg/I
Effluent
Limitations
Mo. Ave / Daily Max.
Date Sample
Collected,
mo/dd/yr
HQW or ORW
50% of
7Q10
Indicate NO FLOW
if applicable
freshwater
6.0-9.0
saltwater
6.8-8.5
Industrial Sand
25/45
HQW orORW
20/30
HQW or ORW
and Tr or PNA
10/15
HQW, ORW,
SA, SB, PNA,
or any Trout
0.1/0.2
No Limit
Circle Water
Quality that applies: esard
50/25/10
N/A
Water Quality
Standard applies
N/A
Water Quality N/A
Standard applies
Permit Date 5/31/17 — 9/30/2020
Revised 5/31/17 for Additional Monitoring Specific to this COC

Outfall No.
continued
Effluent
Limitations
Date Sample
Collected,
mo/dd/vr
Outfall No.
Effluent
Limitations
Date Sample
Collected,
mo/dd/vr
Certificate of Coverage No. NCG020895
Supplemental parameters:
Iron,Total Ni, Total Zn, Total Sb, Total As, Total Be, Total Cd, Total Cu,
mg/I mg/
I mg/I mg/I mg/I mg/I mg/I mg/I
1.0/2.0 1 N/A I N/A I N/A I N/A I N/A I N/A I N/A
Total Pb, Total Hg, Total Se, Total Ag,
mg/I mg/I mg/I mg/I
NA I N/A I N/A I N/A
Permit Date 5/31/17 — 9/30/2020
Revised 5/31/17 for Additional Monitoring Specific to this COC

Certificate of Coverage No. NCG020895
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 violations."
[Required by 40 CFR §122.22]
Signature
Date
Mail Annual Summary Wastewater DMR to the NCDEQ Central Office:
Note the address is correct — Central Files is housed in DWR (not DEMLR)
N.C. Department of Environmental Quality (DEQ)
Attn: DWR Central Files
512 N. Salisbury St.
1617 Mail Service Center
Raleigh, NC 27699-1617
Central Files Telephone [phone]
Questions? Contact DEMLR Stormwater Program Staff in the Central Office at:
[phone]
Permit Date 5/31/17 — 9/30/2020
Revised 5/31/17 for Additional Monitoring Specific to this COC