WQCSD0030_Report_20190812

State of North Carolina
DWR
Department of Environment and Natural Resources
Division of R•'ater Resources
Division of Water Resources Collection System Sanitary Sewer Overflow Reporting Form
Form CS-SSO
PART I:
This form shall be submitted to the appropriate DWR Regional Office within five business days of the first knowledge of the
sanitary sewer overflow (SSO).
WQGSD 0030
Permit Number: (WQCS# if active, otherwise use WQCSD#)
Facility: ToMIi of Woo41Aw4 Incident #: 1 - 1019 Owner: TOwN Of WOOPLAWO
Region: QA1ti51h City: Wo*41Ar►d County:
P
Source of SSO (check applicable): 21 Sanitary Sewer ❑ Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump
Station 6, Manhole at Westall & Bragg Street, etc.):Mmhott *ZS ;a rcu�F��a of✓ Wtanden • F60M t& SkrtaE
Manhole #: a% 4 4n Mp.+Ne1c O3 lsrMe* e F N . Cht4l"At + p,nt40p s 34re.e}
Latitude (degrees/minute/second): Longitude (degrees/minute/second):
Incident Started Dt: Time: 05t00em Incident End Dt: Time: 07:15pm
(mm-dd-yyyy) 06JOS1.1019 (hh:mm)AM/PM (mm-dd-yyyy) 061057/acl9
(hh:mm) AM/PM
Estimated volume of the SSO: 996 gallons Estimated Duration (round to nearest hour): a hour(s)
Describe how the volume was determined: CS3 jr.cL}cot
Weather conditions during the SSO event: Hewvy Rai a 111€01IVED/NCDEA/DWR
� �Illtbtr �' gaabc.
Did the SSO reach surface waters? 711
Ai Yes ❑ No ❑ Unknown -AU13_1 2-2Oj9-
Volume reaching surface waters: $SO gallons Surface water name: Po}ecas, CretK Swo p%r
Water Quatity
Did the SSO result in a fish kill? ❑ Yes ,� No Unknown Permitting Section
If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
;Severe Natural Conditions ❑ Grease ❑Roots r Inflow & Infiltration
LA -❑Pump Station Equipment Failure ❑ Power Outage ❑Vandalism ❑ Debris in line ❑Pipe Failure (Break)
r-,
!Other (Please explain in Part II)
24-hour verbal notification (name of person contacted): Q; c Prict
V7DWR [-]Emergency Management Date (mm-dd-yyy): 02/061 A Time: (hh:mm AM/PM): tt'.1O
Per G.S. 143-215.1C(b), the owner or operator of any wastewater collection system shall:
In the event of a discharge of 1,000 gallons or more of untreated wastewater to the surface waters of the State, issue
a press release to all print and electronic news media that provide general coverage in the county where the
discharge occurred setting out the details of the discharge. The press release shall be issued within 24 hours after
the owner or operator has determined that the discharge has reached surface waters of the State.
In the event of a discharge of 15,000 gallons or more of untreated wastewater to the surface waters of the State,
publish a notice of the discharge in a newspaper having general circulation in the county in which the discharge
occurs and in each county downstream front the point of discharge that is significantly affected by the discharge. The
Regional Office shall determine which counties are significantly affected by the discharge and shall approve the form
and content of the notice and the newspapers in which the notice is published.
WHETHER OF NOT PART II IS COMPLETED A SIGNATURE IS RE_ UQ IRED SEE PAGE 13
Form CS-SSO
Page I

Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule
❑ Yes [K No
❑NA ❑ NE
in any permit that addresses I/I?
Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows this spill location
within the last year? j,iet impair aaA -"%ola rcesir has toter, dor c- k-. Set—c �tnca
Has there been any flow studies to determine 1/1 problems in the
0 Yes ❑ No
DNA ❑ NE
collection system at the SSO location?
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year?
�:<] Yes ❑ No
❑NA ❑ NE
If Yes, when and what actions are necessary and the status of such actions:
Are there 1/1 related projects in your Capital Improvement Plan?
Yes ❑ No
]NA ❑ NE
If Yes, explain: S6ck�rc) 9twr.�a %� lntlp �lienwie (�ro6t�r�1
Have there been any grant or loan applications for 1/1 reduction projects?
® Yes ❑ No
❑NA ❑ NE
If Yes, explain: ya &
Do you suspect any major sources of inflow or cross connections
❑ Yes [ J No
DNA ❑ NE
with storm sewers?
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream
❑ Yes ❑ No
©NA ❑ NE
been inspected recently?
If Yes, explain:
What other corrective actions are planned to prevent future 1/1 related SSOs at this
location? Sca k ���
odra�t. for Stw r
u?�radc .
Comments:
Form CS-SSO Page 6

System Visitation
ORC [�C Yes
Backup Yes
Name: M.E LASSM-0-
Certification Number: d0 49tr - 14 001 -14 too
Date visited: 061 OUl d0l"I
Time visited:
How was the SSO remediated (i./e. Stopped and cleaned up)?
Mar.,Wt #25 { its Vas w&44 OU , CAP -MCA *A41 ltm*.d .
As a -f-my entative for the responsibleoarty, I certiify that the information contained in this report is true and accurate to the
best of m -knowledge.
Person submitting claim: M. c . (,ptss% Vee—
Signature: I',C ;•
Telephone Number: agl - 5 8l -'I I % I
Title:
Date: $'tetlaolQ
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five
business days of first knowledge of the SSO with reference to the incident number (the incident number is only generated
when electronic entry of this form is completed, if used).
Form CS-SSO Page 13