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HomeMy WebLinkAbout#5228_2021_0226_MC_FINAL September 10, 2021 5228 Mr. Mark Haver Carolina Water Service Inc. - Charlotte Region P.O. Box 240908 Charlotte, NC 28224- Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Haver: Enclosed is a report for the inspection performed on February 26, 2021 by Michael Cumbus. I apologize for the delay in getting this report to you. Where Finding(s) are cited in this report, a response is required. Within thirty days, please supply this office with a written item for item description of how these Finding(s) were corrected. Please describe the steps taken to prevent recurrence and include an implementation date for each corrective action. If the Finding(s) cited in the enclosed report are not corrected, enforcement actions may be recommended. For Certification maintenance, your laboratory must continue to carry out the requirements set forth in 15A NCAC 2H .0800. A copy of the laboratory’s Certified Parameter List at the time of the audit is attached. This list will reflect any changes made during the audit. Copies of the checklists completed during the inspection may be requested from this office. Thank you for your cooperation during the inspection. If you have questions or need additional information, please contact me at (919) 733- 3908 Ext. 259. Sincerely, Beth Swanson Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Todd Crawford, Michael Cumbus On-Site Inspection Report I. INTRODUCTION: This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) program to verify its compliance with the requirements of 15A NCAC 02H .0800 for the analysis of compliance monitoring samples. II. GENERAL COMMENTS: The inspection was performed remotely due to the coronavirus pandemic. The laboratory submitted requested documentation and pictures of their consumables and instruments electronically. The inspection was performed via phone and email. Staff was forthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples for the 2021 PT Calendar Year have not yet been analyzed. The laboratory is reminded that results must be received by this office directly from the vendor by September 30, 2021. The laboratory submitted their Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) in advance of the inspection. These documents were reviewed, and editorial and substantive revision requirements and recommendations were made by this program outside of this formal report process. Although subsequent revisions were not requested to be submitted, they must be completed by February 28, 2022. The laboratory is reminded that any time changes are made to laboratory procedures, the laboratory must update the QA/SOP document(s) and inform relevant staff. Any changes made in response to the pre- audit review or to Findings, Recommendations or Comments listed in this report must be incorporated to insure the method is being performed as stated, references to methods are accurate, and the QA and/or SOP document(s) is in agreement with each approved practice, test, analysis, measurement, monitoring LABORATORY NAME: Carolina Water Service, Inc. – Charlotte Region NPDES PERMIT #: NC0035041, NC0060461, NC0060755, NC0062383, NC0064734, NC0071242, NC0084565, NC0086592, NC0086606 ADDRESS: 7803 Idlewild Rd. Indian Trail, NC 28079 CERTIFICATE #: 5228 DATE OF INSPECTION: February 26, 2021 TYPE OF INSPECTION: Field Commercial Maintenance AUDITOR: Michael Cumbus LOCAL PERSON(S) CONTACTED: Brent Milliron Page 3 #5228 Carolina Water Service, Inc. – Charlotte Region procedure or regulatory requirement being used in the laboratory. In some instances, the laboratory may need to create an SOP to document how new functions or policies will be implemented. The laboratory is also reminded that SOPs are required to be reviewed at least every two years and are intended to describe procedures exactly as they are to be performed. Use of the word “should” is not appropriate when describing requirements (e.g., Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPs for the proper use of the word “should”. Contracted analyses are performed by K & W Laboratories (Certification #559) and Waypoint Analytical – Charlotte (Certification #402). Approved Procedure documents for the analysis of the facility’s currently certified Field Parameters were provided at the time of the inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation Recommendation: It is recommended that the laboratory standardize the laboratory benchsheet template for all facilities, entering pertinent data such as site information and instrument information prior to printing. Recommendation: It is recommended that the laboratory combine the pH calibration log and the pH benchsheet in order to reduce paperwork and aid in data review. Recommendation: It is recommended that the laboratory reduce redundancy of where data is recorded in order to facilitate data retrieval and review, and reduce the possibility of transcription errors. A. Finding: Error corrections are not properly performed. Requirement: All documentation errors shall be corrected by drawing a single line through the error so that the original entry remains legible. Entries shall not be obliterated by erasures or markings. Wite-Out®, correction tape, or similar products designed to obliterate documentation are not to be used; instead the correction shall be written adjacent to the error. The correction shall be initialed by the responsible individual and the date of change documented. Ref: 15A NCAC 02H .0805 (g) (1). Comment: Multiple instances of data corrections lacking date and/or initials were noted. Multiple instances of data being obliterated by marking were also noted. B. Finding: A temperature-measuring device (serial number 1245902) without a valid NIST certificate or verification was used to analyze compliance samples. Requirement: All analytical records, including original observations and information necessary to facilitate historical reconstruction of the calculated results, shall be maintained for five years. All analytical data and records pertinent to each certified analysis shall be available for inspection upon request. Ref: 15A NCAC 02H .0805 (g) (1). Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Page 4 #5228 Carolina Water Service, Inc. – Charlotte Region Requirement: All compliance temperature-measuring devices without a valid NIST certificate must be checked initially and every 12 months against an NIST traceable temperature- measuring device and the process documented. Documentation must include the serial number of the device being checked. The serial number, stated accuracy and expiration date of the NIST traceable temperature-measuring device used in the comparison must also be documented. Verification data must be kept on file and be available for inspection for 5 years. (NOTE: Vendors or other Certified laboratories may provide assistance in meeting this requirement. When a vendor or other Certified laboratory provides this assistance, they must provide a copy of their NIST Certificate or the serial number, accuracy and calibration expiration date.) Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Comment: From November 4, 2020 – November 10, 2020, Bradfield Farms measured temperature for compliance purposes with their Reference Temperature-Measuring Device (serial number #1245902). The calibration due date according to the manufacturer’s certificate was September 12, 2015. No documentation regarding calibration or annual verification for this thermometer was provided. The laboratory is reminded that Reference Temperature- Measuring Devices are not to be used for anything other than verification of other temperature- measuring devices. C. Finding: The Reference Temperature-Measuring Device (serial number 1245902) used to check other thermometers and/or temperature sensors was not recalibrated in accordance with the manufacturer’s recalibration date. Requirement: Reference Temperature-Measuring Devices shall meet National Institute of Standards and Technology (NIST) specifications for accuracy and shall be recalibrated in accordance with the manufacturer's recalibration date. If no recalibration date is given, the Reference Temperature-Measuring Device shall be recalibrated every five years. Ref: 15A NCAC 02H .0805 (g) (9) (A). Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: All NIST traceable temperature-measuring devices must have a stated accuracy of at least ± 0.5°C and be within their expiration date. Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Comment: The Reference Temperature-Measuring Device (serial number 1245902) certificate expired on September 12, 2015. This temperature-measuring device was used to perform the verification of the compliance temperature-measuring devices for Hemby Acres and Bradfield Farms in 2019. D. Finding: Documentation of the compliance temperature-measuring device calibration verification does not include the stated accuracy or the expiration date of the Reference Temperature-Measuring Device used in the comparison. This is considered pertinent data. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: All compliance temperature-measuring devices without a valid NIST certificate must be checked initially and every 12 months against an NIST traceable temperature- measuring device and the process documented. Documentation must include the serial number of the device being checked. The serial number, stated accuracy and expiration date of the NIST traceable temperature-measuring device used in the comparison must also be documented. Verification data must be kept on file and be available for inspection for 5 years. Page 5 #5228 Carolina Water Service, Inc. – Charlotte Region (NOTE: Vendors or other Certified laboratories may provide assistance in meeting this requirement. When a vendor or other Certified laboratory provides this assistance, they must provide a copy of their NIST Certificate or the serial number, accuracy and calibration expiration date.) Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Requirement: All NIST traceable temperature-measuring devices must have a stated accuracy of at least ± 0.5°C and be within their expiration date. Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Comment: This Finding applies to verifications performed by the laboratory as well as those performed by K & W Laboratories (Certificate #559). E. Finding: The laboratory benchsheet is sometimes lacking required documentation: Facility name or permit number, sample site (ID or location), and the instrument identification. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the instrument identification; sample identification. Each item shall be recorded each time samples are analyzed. Analyses shall conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (2) (C) and (I). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Facility name or permit number. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The following documentation requirement deficiencies were noted but may not be all inclusive: • The April and November 2020 Total Residual Chlorine Logs for Abington are lacking the site ID. • The April and November 2020 laboratory benchsheets for pH and DO for Abington are lacking the site ID. • The April and November 2020 laboratory benchsheets for Bradfield Farms is lacking the site ID. • The September 2020 pH, dissolved oxygen and TRC laboratory benchsheets for The Pointe/The Harbour are lacking the site ID. • The November 2020 pH calibration log for The Pointe/The Harbour is lacking the site ID. • The April, September and November 2020 Hemby Acres laboratory benchsheets for pH and TRC are lacking site ID. • The September 2020 Queen’s Harbor laboratory benchsheets for pH and TRC analysis are lacking site ID. • The November 2020 Queen’s Harbor laboratory benchsheets for TRC and pH are lacking facility name or permit number, site ID, and instrument ID. F. Finding: The units of measure are not consistently documented on the benchsheets. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the proper units of measure. Each item shall be recorded each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (L). Comment: The Total Residual Chlorine (TRC) benchsheets for Abington (NPDES permit # NC0060461), Queens Harbor (NPDES permit # NC0062383) and Saddlewood (NPDES Page 6 #5228 Carolina Water Service, Inc. – Charlotte Region permit # NC0060755) instruct the analyst to circle one of two units of measure (i.e., µg/L or mg/L), but this is not being done. Comment: The pH calibration log for The Pointe/The Harbour (NPDES Permit numbers NC0086592, NC0084565, NC0086606) lacks units for the post analysis check buffer. G. Finding: The laboratory is not documenting all traceability information for purchased materials, reagents and standards. Requirement: 15A NCAC 02H .0805 (a)(7)(K) and (g)(7) requires laboratories to have a documented system of traceability for the purchase, preparation, and use of all chemicals, reagents, standards, and consumables. That system must include documentation of the following information: Date received, Date Opened (in use), Vendor, Lot Number, and Expiration Date (where specified). This information as well as the vendor and/or manufacturer, lot number, and expiration date must be retained for primary standards, chemicals, reagents, and materials used for a period of five years. Consumable materials such as pH buffers are included in this requirement. Ref: NC WW/GW LC Policy. Comment: Only Hemby Acres and Bradfield Farms have a traceability log, according to a phone interview. Of the logs submitted, only the pH buffers were documented. DPD powder was not listed. It was discussed during the phone interview that if the materials are all stored in a central place, that separate logs for each site would not be necessary. However, any containers that reagents such as pH buffers are placed into for daily use in the field will need accompanying traceability information. Comment: The laboratory benchsheets for The Pointe and The Harbour list an incorrect lot number for the gel-type standards being analyzed for TRC. This needs to be updated with the correct lot number for the current set of standards being used. H. Finding: The laboratory is not documenting the true value and percent recovery of TRC QC standards on laboratory benchsheets. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the quality control assessments. Each item shall be recorded each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (O). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: True Value of the Daily Check Standard and percent recovery. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The true value of QC standards and percent recovery obtained must be documented on the benchsheet and evaluated against established acceptance criteria to demonstrate that the analyst was aware of any out-of-control situation. The corrective actions taken must be documented. Any samples not meeting the acceptance criteria must be reanalyzed, if possible. If this is not possible, the data must be flagged on the laboratory reports as all QC requirements not met. I. Finding: Sample analysis time is not consistently documented. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the time of sample analyses (when required to document a required holding time or when time-critical steps are Page 7 #5228 Carolina Water Service, Inc. – Charlotte Region imposed by the method, a federal regulation, or this Rule). Ref: 15A NCAC 02H .0805 (g) (2) (G) and (g) (2) (H). Comment: Some versions of the laboratory benchsheets have pH calibration logs separate from the benchsheet where sample analysis is recorded. These sample analysis sheets often do not record the sample analysis time, especially when multiple permitted sites are included on the same benchsheet. Comment: The laboratory benchsheet for Hemby Acres was lacking analysis time for TRC on November 2 and 10, 2020. J. Finding: Documentation does not demonstrate the gel-type standard was analyzed three times to obtain an average concentration. Requirement: All analytical records, including original observations and information necessary to facilitate historical reconstruction of the calculated results, shall be maintained for five years. All analytical data and records pertinent to each certified analysis shall be available for inspection upon request. Ref: 15A NCAC 02H .0805 (g) (1). Requirement: To assign a true value to the gel-type or sealed liquid standard: 1. Zero the instrument with the calibration blank. 2. Read and record gel standard values. 3. Repeat steps 1 and 2 at least two more times. 4. Assign the average value as the true value. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: Data were reviewed for 8 evaluations of gel-type standards from 4 permitted sites. Of these 8 evaluations, none were found to demonstrate that the gel-type standard had been analyzed three times. Comment: The laboratory is subcontracting this to K & W Laboratories (Certificate #559). K. Finding: The laboratory is lacking a documented training program. Requirement: Each laboratory shall develop and implement a documented training program that includes documentation that: (i) staff have the education, training, experience, or demonstrated skills needed to generate quality control results within method-specified limits and meet the requirements of these Rules; (ii) staff have read the laboratory quality assurance manual and applicable Standard Operating Procedures; and (iii) staff have obtained acceptable results on Proficiency Testing Samples pursuant to Rule .0803(1) of this Section or other demonstrations of proficiency (e.g. side-by-side comparison with a trained analyst, acceptable results on a single-blind performance evaluation sample, an initial demonstration of capability study prescribed by the method). Ref: 15A NCAC 02H .0805 (g) (5). Proficiency Testing L. Finding: PT Samples are not being analyzed in the same manner as routine Compliance Samples. Requirement: Laboratories are required to analyze an appropriate PT Sample by each parameter method on the laboratory’s CPL. The same PT Sample may be analyzed by one or more methods. Laboratories shall conduct the analyses in accordance with their routine testing, calibration and reporting procedures, unless otherwise specified in the instructions supplied by the Accredited PT Sample Provider. This means that they are to be logged in and analyzed using the same staff, sample tracking systems, standard operating procedures Page 8 #5228 Carolina Water Service, Inc. – Charlotte Region including the same equipment, reagents, calibration techniques, analytical methods, preparatory techniques (e.g., digestions, distillations and extractions) and the same quality control acceptance criteria. PT Samples shall not be analyzed with additional quality control. They are not to be replicated beyond what is routine for Compliance Sample analysis. Although, it may be routine to spike Compliance Samples, it is neither required, nor recommended, for PT Samples. PT sample results from multiple analyses (when this is the routine procedure) must be calculated in the same manner as routine Compliance Samples. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Comment: The PT Sample for Total Residual Chlorine was analyzed in duplicate in 2020. M. Finding: The laboratory is not documenting the preparation of PT Samples. Requirement: PT Samples received as ampules are diluted according to the Accredited PT Sample Provider’s instructions. It is important to remember to document the preparation of PT Samples in a traceable log or other traceable format. The diluted PT Sample then becomes a routine Compliance Sample and is added to a routine sample batch for analysis. No documentation is needed for whole volume PT Samples which require no preparation, however the instructions must be maintained. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Comment: Dating and initialing the instruction sheet for each prepared PT Sample would satisfy the documentation requirement. N. Finding: The laboratory is not documenting PT Sample analyses in the same manner as routine Compliance Samples. Requirement: All PT Sample analyses must be recorded in the daily analysis records as for any Compliance Sample. This serves as the permanent laboratory record. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Requirement: The laboratory shall retain all records necessary to facilitate historical reconstruction of the analysis and reporting of analytical results for PT Samples. This means the laboratory must have available and retain for five years [pursuant to 15A NCAC 02H .0805 (a) (7) (E) and (g) (1)] all of the raw data, including benchsheets, instrument printouts and calibration data, for all PT Sample analyses and the associated QC analyses conducted by all parameter methods. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 4.0. Comment: The laboratory benchsheet for the 2020 PT Sample lists a value different from the value submitted to the PT vendor. The value on the benchsheet is the same as the Assigned Value, as stated on the PT report. It may appear to a third-party observer that the benchsheet was filled out after the PT report was made public and back-dated. O. Finding: The laboratory does not have a documented plan for PT procedures. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. A copy of each analytical method or Approved Procedure and Standard Operating Procedure shall be available to each analyst and available for review upon request by the State Laboratory. Standard Operating Procedure documentation shall state the effective date of the document and shall be reviewed every two years and updated if changes in procedures are made. Each laboratory shall have a formal process to track and document review dates and any revisions made in all Standard Operating Procedure documents. Supporting Records Page 9 #5228 Carolina Water Service, Inc. – Charlotte Region shall be maintained as evidence that these practices are implemented. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Laboratories must have a documented plan [this is usually detailed in the laboratory’s Quality Assurance Manual or may be a separate Standard Operating Procedure (SOP)] of how they intend to cover the applicable program requirements for Proficiency Testing per their scope of accreditation. This plan shall cover any commercially available PT Samples and any inter-laboratory organized studies, as applicable. The laboratory must also be able to explain when PT Sample analysis is not possible for certain methods and provide a description of what the laboratory is doing in lieu of Proficiency Testing. This shall be detailed in the plan. The plan must also address the laboratory’s process for submission of PT Sample results and related Corrective Action Reports (CARs). Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.0. QA/QC P. Finding: Accuracy of QC results are not consistently evaluated to demonstrate the analytical process is in control and the established acceptance criteria are met. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the quality control assessments. Ref: 15A NCAC 02H .0805 (g) (2) (O). Requirement: If quality control results fall outside established limits or indicate an analytical problem, the laboratory shall identify the Root Cause of the failure. The problem shall be resolved through corrective action, the corrective action process documented, and any samples involved shall be reanalyzed, if possible. If the sample cannot be reanalyzed, or if the quality control results continue to fall outside established limits or indicate an analytical problem, the results shall be qualified as such. Ref: 15A NCAC 02H .0805 (g) (8). Comment: For the month of November 2020, the TRC analysis for Saddlewood used a gel- type standard (Lot #A8087) with an assigned true value of 206 µg/L, as noted in the verification performed on November 12, 2020 by K & W Laboratories. However, the laboratory benchsheet lists an outdated lot number (#AR807A) and acceptance range (162-198 µg/L). Therefore, it appears that the acceptance criteria for the November data were not met and due to the lack of quality control assessment, no corrective action (i.e., determining that the gel-type standard and values had not been updated) was performed. Applying the correct gel- type standard assigned value demonstrates that the acceptance criteria was actually met. The fact that the observed value of the standard and the acceptance range were handwritten each time and the observed value was not within the acceptance range should have been obvious to the analyst. It is concerning that this did not seem to be the case based on lack of corrective action. Recommendation: It is recommended that the laboratory institute a system of peer review. Q. Finding: An inconsistency was noted between the SOP and laboratory practice as follows: Personnel were not following procedures as stated in the Laboratory’s SOP. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. A copy of each analytical method or Approved Procedure and Standard Operating Procedure shall be available to each analyst and available for review upon request by the State Laboratory. Standard Operating Procedure documentation shall state the effective date of the document and shall be reviewed every two years and updated if changes in procedures are made. Each laboratory shall have a formal process to track and document review dates and Page 10 #5228 Carolina Water Service, Inc. – Charlotte Region any revisions made in all Standard Operating Procedure documents. Supporting Records shall be maintained as evidence that these practices are implemented. Ref: 15A NCAC 02H .0805 (g) (4). Comment: The laboratory SOP for TRC states “Analyze duplicate samples once per week”. The laboratory SOP for pH states “A duplicate sample (split sample) will be analyzed per batch of 20 samples or less.” Duplicates are not being analyzed for either parameter. Recommendation: Duplicates are not a required QC element for Field Parameters. It is recommended that the SOPs be updated to remove the duplicate requirement. Reporting R. Finding: The laboratory does not report results of all tests on the characteristics of the effluent when multiple sample analyses are performed. Requirement: The results of all tests on the characteristics of the effluent, including but not limited to NPDES permit monitoring requirements, shall be reported on the monthly report forms. Ref: 15A NCAC 2B .0506 (b) (3) (J). Comment: The laboratory subcontracted Saddlewood’s BOD analyses for November 2020 to both K & W Laboratories and Waypoint Analytical. The laboratory did not report both sets of data. The laboratory may choose to either average the values or report the value that is closest to the bounds of the permit limit in the daily cell and report the other value in the comment section. Comment: The laboratory records sample temperatures during analysis of pH and DO for Riverpointe, Bradfield Farms, Hemby Acres and Saddlewood WWTP. Only the reading from the DO meter is reported. The laboratory may choose to either average the values or report the value that is closest to the bounds of the permit limit in the daily cell and report the other value in the comment section. Chlorine, Total Residual – Standard Methods, 4500 Cl G-2011 S. Finding: The laboratory does not appear to be waiting the minimum 3-minute development time after adding the color reagents before starting analysis. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Daily Sample Analysis Procedure: • Add DPD/buffer within 15 minutes of collection • Wait 3 - 6 minutes • Read sample result • Document required information Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Requirement: Some examples of the allowed types of changes, provided the requirements of this section are met include: (xiii) The use of prepackaged reagents. As such, the proper procedure for using the packaged reagents would then be determined by the manufacturer’s instructions. Ref: Code of Federal Regulations, Title 40, Part 136; Federal Register Vol. 77, No. 97, May 18, 2012; 136.6. (b) (4). Page 11 #5228 Carolina Water Service, Inc. – Charlotte Region Requirement: For successful testing, especially in treated effluents, strict adherence to the development time is necessary. Three to six minutes of development time are sufficient to resolve all chloramine forms without significant error from competing reactions. Ref: Hach Company, “Current Technology of Chlorine Analysis for Water and Wastewater”, 2002. Comment: Some, but not all, benchsheets have a box that may be checked when the 3- minute color development time requirement has been met. Documenting the 3-minute color development time is not required. However, having a space on the benchsheet for documentation that is not consistently filled out gives the perception that the required color development time is not being observed. T. Finding: The laboratory is not evaluating whether the Factory-set Calibration Curve Verification standards are within the acceptable recovery range. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Annual Factory-set Calibration Curve Verification: This type of calibration curve verification must be performed initially, at least every 12 months and any time the instrument optics are serviced. Zero the instrument with a Calibration Blank and then analyze a Method Blank and a series of five standards (do not use gel or sealed liquid standards for this purpose). The calibration standard values obtained must not vary by more than ±10% from the known value for standard concentrations greater than or equal to 50 μg/L and must not vary by more than ±25% from the known value for standard concentrations less than 50 μg/L. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The laboratory verification performed on October 15, 2019 did not pass the lowest standard recovery criteria for the Queen’s Harbor TRC meter (serial number 1179277). The laboratory submitted a passing calibration verification which was performed on January 12, 2021. U. Finding: The laboratory is not consistently verifying the instrument’s Factory-set Calibration Curve every 12 months. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Annual Factory-set Calibration Curve Verification: This type of calibration curve verification must be performed initially, at least every 12 months and any time the instrument optics are serviced. Zero the instrument with a Calibration Blank and then analyze a Method Blank and a series of five standards (do not use gel or sealed liquid standards for this purpose). The calibration standard values obtained must not vary by more than ±10% from the known value for standard concentrations greater than or equal to 50 μg/L and must not vary by more than ±25% from the known value for standard concentrations less than 50 μg/L. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The spectrophotometer for Queen’s Harbor (serial number 1179277) had a verification performed on October 15, 2019. The next verification was performed on January 12, 2021. V. Finding: The laboratory failed to perform corrective action when the verification of the TRC meter at Queen’s Harbor was outside the recovery acceptance criteria. Page 12 #5228 Carolina Water Service, Inc. – Charlotte Region Requirement: If quality control results fall outside established limits or indicate an analytical problem, the laboratory shall identify the Root Cause of the failure. The problem shall be resolved through corrective action, the corrective action process documented, and any samples involved shall be reanalyzed, if possible. If the sample cannot be reanalyzed, or if the quality control results continue to fall outside established limits or indicate an analytical problem, the results shall be qualified as such. Ref: 15A NCAC 02H .0805 (g) (8). Requirement: If the factory-set readings vary by more than the stated acceptance criteria, the stored calibration program must not be used for compliance monitoring until troubleshooting is carried out to determine and correct the source of error. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: Possible corrective actions include: re-zeroing the meter; ensuring glassware is clean and not scratched; preparing fresh calibration standards; having the meter serviced, etc. Comment: The Queen’s Harbor spectrophotometer (serial number 1179277) continued to be used after failing a low-level standard verification in 2019. The 10 µg/L standard had 130% recovery in 2019. The spectrophotometer passed the most recent curve verification in January 2021, with the 10 µg/L standard having a recovery of 80%. W. Finding: The Factory-set Calibration Curve is not consistently verified with a Daily Check Standard each day that samples are analyzed. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: When an annual five-standard Factory-set Calibration Curve verification is used, the laboratory must check the calibration curve each analysis day. To do this, the laboratory must zero the instrument with a Calibration Blank and analyze a Daily Check Standard (gel-type standards are most widely used for these purposes). The value obtained for the Daily Check Standard must read within ±10% of the true value of the Daily Check Standard for standards ≥50 μg/L and within ±25% of its true value for standards <50 μg/L. If the obtained value is outside of the acceptance limits, corrective action must be taken. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The Hemby Acres spectrophotometer (serial number 1154192) was not verified with a Daily Check Standard on November 2 and 10, 2020. X. Finding: Values less than the established reporting limit are being reported on the DMR. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: For all calibration options, the range of standard concentrations must bracket the permitted discharge limit concentration, the range of sample concentrations to be analyzed and anticipated PT Sample concentrations. One of the standards must have a concentration less than the permitted Daily Maximum Limit. The lower reporting limit concentration is equal to the lowest standard concentration. Sample concentrations that are less than the lower reporting limit must be reported as a less-than value. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G- 2011). Page 13 #5228 Carolina Water Service, Inc. – Charlotte Region Comment: The laboratory established a lower reporting limit of 10 µg/L for Queen’s Harbor by verifying that concentration against the latest calibration curve. Values with concentrations less than that must be reported as < 10 µg/L on the DMR. The laboratory recorded and reported a value of 2 µg/L on April 13, 2020. Dissolved Oxygen – Standard Methods, 4500 O G-2011 (Aqueous) Recommendation: It is recommended that the laboratory remove the “in situ” language from Comment 2 on the Saddlewood benchsheet since the time sampled and time analyzed for November 2020 were different. Y. Finding: Documentation of the calibration variables for the DO meter does not include all pertinent data. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Calibration variables (temperature, elevation or barometric pressure [in mmHg], and salinity). Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO). Comment: The SOP states that the salinity is input as zero. This must be documented on the benchsheet. Comment: The DO calibration log for The Pointe and The Harbour lists elevation as 800 ft. However, DO calibration logs for the other permitted sites do not include an elevation. Z. Finding: When analyses are performed at multiple sample sites, the laboratory is not calibrating at each sample site or performing a Post-Analysis Calibration Verification at the end of the run. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: When performing analyses at multiple sample sites, the meter must be calibrated at each sample site prior to analysis or a post-analysis calibration verification must be performed at the end of the run, regardless of meter type. The calculated theoretical DO value must verify the meter reading within ±0.5 mg/L. If the meter verification does not read within ±0.5 mg/L of the theoretical DO, corrective action must be taken. If the meter is not calibrated at each sample site, it is recommended that a mid-day calibration be performed when samples are extended over an extended period of time. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO). pH – Standard Methods, 4500 H+ B-2011 (Aqueous) Comment: The temperature sensor is being verified on the pH meters. If the laboratory does not use pH meters for temperature compliance monitoring, then this does not need to be performed. NC WW/GW LC does not require Automatic Temperature Compensation probe checks for pH analyses. AA. Finding: The instrument is not being calibrated prior to analysis of samples each day compliance monitoring is performed. Page 14 #5228 Carolina Water Service, Inc. – Charlotte Region Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Instruments are to be calibrated according to the manufacturer’s calibration procedure prior to analysis of samples each day compliance monitoring is performed. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH. Comment: The pH meter at Hemby Acres is calibrated on a weekly basis. However, pH analyses usually occur more frequently. Data from April, September and November, 2020 show 16 instances where the pH meter was not calibrated prior to sample analysis. BB. Finding: Values are being reported that exceed the method specified accuracy of 0.1 units. Requirement: By careful use of a laboratory pH meter with good electrodes, a precision of ±0.02 unit and an accuracy of ±0.05 unit can be achieved. However, ± 0.1 pH unit represents the limit of accuracy under normal conditions, especially for measurement of water and poorly buffered solutions. For this reason, report pH values to the nearest 0.1 pH unit. Ref: Standard Methods, 4500 H+ B-2011. (6). Comment: Per PT Vendor instructions, the PT Sample results should be reported to two decimal places. Comment: The laboratory reported a pH of 6.17 S.U. for Hemby Acres Effluent on April 28, 2020. Temperature – Standard Methods, 2550 B-2010 (Aqueous) Recommendation: It is recommended that the laboratory report temperatures in whole numbers. CC. Finding: The annual temperature-measuring device check procedure is not consistently performed correctly. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: To check a compliance temperature-measuring device, compare readings at two temperatures that bracket the range of compliance samples routinely analyzed against a National Institute of Standards and Technology (NIST) traceable temperature-measuring device and record all four readings. The readings from both devices must agree within 0.5 ºC. Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Please submit an updated temperature verification for each applicable compliance temperature- measuring device bracketing the range of compliance samples analyzed with the report reply. Comment: The Saddlewood DO meter, which is used for compliance monitoring purposes, was verified at a single temperature in 2019, but was correctly verified in 2020. The verifications were performed by K & W Laboratories (Certificate #559). Comment: The laboratory verified the temperature measuring device for Bradfield Farms and Hemby Acres at a single temperature in 2019. The DO meter for Bradfield Farms was verified by the laboratory at a single temperature in 2020. The Pointe’s temperature measuring device was verified at a single temperature by K & W Laboratories in 2019 and 2020. The temperature-sensing device check of the Hemby Acres pH meter performed by K&W Laboratories in 2019 did not bracket the upper range of the compliance sample Page 15 #5228 Carolina Water Service, Inc. – Charlotte Region temperatures routinely encountered. The highest temperature checked was 21°C and routine compliance temperatures in July 2020 exceeded 25°C. The DO meter for Bradfield Farms, also used for compliance monitoring, was verified by K & W Laboratories at two temperatures on November 17, 2020, but data from April 28, 2020 shows a temperature of 10.2°C, which is below the lower verified temperature of 13.5°C. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract laboratory reports to DMRs submitted to the North Carolina Division of Water Resources. Data were reviewed for Hemby Acres WWTP (NPDES permit # NC0035041), Abington WWTP (NPDES permit # NC0060461), Queen’s Harbor WWTP (NPDES permit # NC0062383), Bradfield Farms WWTP (NPDES permit # NC0064734), Riverpointe WWTP (NPDES permit # NC0071242), Saddlewood WWTP (NPDES permit # NC0060755), The Pointe Well #1 WTP (NPDES permit # NC0086592), The Harbour Well #4 WTP (NPDES permit # NC0086606) for April, September and November 2020. The following errors were noted: Date Parameter Location Value on Benchsheet *Contract Laboratory Data Value on DMR 11/17/2020 Temperature Abington Downstream 18.9°C 18.5°C 11/19/2020 pH Abington Effluent 7.3 S.U. 7.5 S.U. 11/24/2020 pH Abington Effluent 6.3 S.U. 7.3 S.U. 4/14/2020 pH Queen’s Harbor Effluent 7 S.U. 7.1 S.U. 11/10/2020 Temperature Queen’s Harbor Effluent 20.5°C 20.6°C 11/18/2020 Chlorine, Total Residual Queen’s Harbor Effluent <10 µg/L Not Reported 4/30/2020 Temperature RiverPointe Effluent 26.5°C Not Reported 4/30/2020 Dissolved Oxygen RiverPointe Effluent 6.4 mg/L Not Reported 4/28/2020 Temperature Hemby Acres Upstream 15.1°C 15.5°C 4/28/2020 Temperature Hemby Acres Downstream 15.5°C 15.1°C 4/26/2020 pH Hemby Acres Effluent 6.7 S.U. Not Reported 11/3/2020 BOD Saddlewood Effluent 2.1 mg/L* 2 mg/L 11/10/2020 BOD Saddlewood Effluent <2 mg/L* 2 mg/L 11/19/2020 BOD Saddlewood Effluent 2.8 mg/L* 2.4 mg/L 11/24/2020 BOD Saddlewood Effluent 3.3 mg/L* 2.6 mg/L Page 16 #5228 Carolina Water Service, Inc. – Charlotte Region 4/13/2020 Dissolved Oxygen Bradfield Farms Effluent 7.54 mg/L 7.51 mg/L 4/28/2020 Temperature Bradfield Farms Effluent 10.2°C 20.2°C 11/02/2020 Dissolved Oxygen Bradfield Farms Effluent 7.74 mg/L Not Reported 11/06/2020 Temperature Bradfield Farms Effluent 19.4°C 19.1°C 11/13/2020 Temperature Bradfield Farms Effluent 21.9°C 21°C 11/23/2020 Temperature Bradfield Farms Effluent 19.8°C 19°C 11/23/2020 Dissolved Oxygen Bradfield Farms Effluent 19.8 mg/L Not Reported 11/24/2020 Dissolved Oxygen Bradfield Farms Effluent 19.2 mg/L 5.89 mg/L 11/25/2020 Dissolved Oxygen Bradfield Farms Effluent 20.5 mg/L 6.21 mg/L 11/26/2020 Dissolved Oxygen Bradfield Farms Effluent 20.6 mg/L 6.21 mg/L 11/27/2020 Dissolved Oxygen Bradfield Farms Effluent 20.9 mg/L 6.51 mg/L 11/30/2020 Dissolved Oxygen Bradfield Farms Effluent 19.9 mg/L 5.17 mg/L To avoid a possible monitoring frequency violation, it is recommended that you contact the appropriate Regional Office for guidance as to whether an amended DMR(s) will be required. A copy of this report will be made available to the Regional Office. To avoid questions of legality, it is recommended that you submit an amended report(s) to your client(s). A copy of this report will be made available to the Regional Office. V. CONCLUSIONS: We are concerned about the number of Findings, transcription errors and apparent lack of QA/QC oversight. It is strongly recommended that the laboratory institute a practice of periodic internal audits, and/or review of a certain percentage of the data, for each permitted site in order to ensure a high standard of quality data and increased legal defensibility. Correcting the above-cited Findings and implementing the Recommendations will help this laboratory to produce quality data and meet Certification requirements. The inspector would like to thank the staff for their assistance during the inspection and data review process. Please respond to all Findings and include supporting documentation, implementation dates and steps taken to prevent recurrence for each corrective action. Report prepared by: Michael Cumbus Date: May 10, 2021 Report reviewed by: Tonja Springer Date: May 11, 2021 Certificate Number:5228 Effective Date:1/1/2021 Expiration Date:12/31/2021 Lab Name:Carolina Water Service Inc. - Charlotte Region Address:7803 Idlewild Rd Indian Trail, NC 28079 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:4/17/2018 The above named laboratory, having duly met the requirements of 15A NCAC 2H.0800, is hereby certified for the measurement of the parameters listed below. CERTIFIED PARAMETERS INORGANIC CHLORINE, TOTAL RESIDUAL SM 4500 Cl G-2011 (Aqueous) DISSOLVED OXYGEN SM 4500 O G-2011 (Aqueous) pH SM 4500 H+B-2011 (Aqueous) TEMPERATURE SM 2550 B-2010 (Aqueous) This certification requires maintance of an acceptable quality assurance program, use of approved methodology, and satisfactory performance on evaluation samples. Laboratories are subject to civil penalties and/or decertification for infractions as set forth in 15A NCAC 2H.0807.