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WELL-06-2021-152177.TIF
North Carolina Division of Public Health Occupational and Environmental Epidemiology Branch, Epidemiology Section BIOLOGICAL ANALYSIS REPORT Private well water information and recommendations County: Catawba Name: Catawba County Sample ID Number: 152177 Location: lake front well, Mountain Creek Park—6562 Little Mountain Rd. Sherrills Ford,NC 28673 Reviewer: Megen McBride Initial Sample X Confirmation Sample: BIOLOGICAL ANALYSIS RESULTS AND RECOMMENDATIONS FOR USES OF YOUR PRIVATE WELL WATER(These recommendations are based on biological analysis only.) X No coliform bacteria were found in your well water. Your water can be used for all purposes including drinking, cooking, washing dishes, bathing and showering. Total coliform bacteria were detected in your water sample. Total Coliform are a group of related bacteria that are(with few exceptions)not harmful to humans. A variety of bacteria, parasites,and viruses, known as pathogens, can potentially cause health problems if humans ingest them. EPA considers total coliforms a useful indicator of other pathogens for drinking water. Total coliforms are used to determine the adequacy of water treatment and the integrity of the distribution system It is recommended that your well water be re-tested to verify that the result is accurate. Fecal coliform bacteria were detected in the sample. Do not use the water for drinking, cooking,washing dishes,bathing or showering. If the re-test shows contamination by bacteria contact your local health department for assistance. There may be a problem with the construction of the well, the groundwater source,or operation of the well. The well needs to be inspected by the local health department or a local well contractor to determine the problem with the well and to give guidance on how to correct the problem. Your well water was tested for biological contaminants(total coliform and fecal coliform bacteria).The results were evaluated using the federal drinking water standards. Drinking water may contain substances that can occur naturally in water or can be introduced into water from man-made sources. Total coliform bacteria are found in soil and fecal coliform bacteria are found in animal and human waste. Total coliform or fecal coliform bacteria in well water indicate that the well may have structural problems or that the well was not properly disinfected. If you have been drinking the well water and are pregnant, nursing, have a child in the household under 5 years of age, or immunocompromised(such as an individual with AIDS, cancer, hepatitis,dialysis or surgical procedures) inform your physician of these results at your next visit. If the contamination continues,you should investigate the possibility of drilling a new well or installing a point-of-entry disinfection unit which can use chlorine, ultraviolet light, or ozone. For further information please contact your county health department or the Occupational and Environmental Epidemiology Branch at 919-707-5900. N 0 R T H C A R 0 L I N A _ Private Well Information and Use Recommendations NC DEPARTMENT OF HEALTH AND HUMAN SERVICES Division of Public Health For Inorganic Chemical Contaminants County: Catawba Name: lake front well, Mountain Creek Park 6562 Little Mountain Rd. Sherrills Ford,NC 28673 Sample ID#: 152177 1 Reviewer: Megen McBride TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for drinking, cooking,washing,cleaning, bathing,and showering based on the inorganic chemical results only. You may have other water sampling results that are not taken into account in this report. 2. ® The following substance(s)exceeded federal drinking water standards or the North Carolina 2L calculated health levels. The North Carolina Division of Public Health recommends that your well water not be used for drinking and cooking, unless you install a water treatment system to remove the circled substance(s). However, it may be used for washing, cleaning, bathing and showering based on the inorganic chemical results only. ❑ Arsenic ❑ Barium El Cadmium El Chromium El Copper ❑ Fluoride El Iron ❑ Lead ❑ Manganese El Mercury ❑Nickel El Nitrate/Nitrite ❑ Selenium El Silver ®Zinc 3.❑ While your lead levels do not exceed federal or state standards,the North Carolina Division of Public Health has concerns with any detection of lead. Should you have any questions please contact the NC Private Well and Health Program at(919) 707-5900. 4. ❑ Re-sample for lead and/or copper. Take a first draw and 30-second flush sample inside the house (preferably the kitchen sink)and a first draw and 4 minutes flush sample at the wellhead to determine the source of lead and/or copper. 5. ® The following substance(s)exceeded aesthetic drinking water standards. Your water can be used for drinking, cooking, washing,cleaning, bathing, and showering based on the inorganic chemical results only, but aesthetic problems such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment system to address aesthetic problems. ❑ Chloride El Copper El Fluoride ❑ Iron ® Manganese ❑ pH El Silver ® Sulfate El Zinc 6. ® a. Sodium levels exceed the U.S. Environmental Protection Agency's(USEPA) Health Advisory level for sodium of 20 mg/l.The North Carolina Division of Public Health recommends that only individuals on no or low sodium-restricted diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on the inoreartic chemical results only. ® b. Your sodium level exceeds 30 mg/I and may pose aesthetic issues such as bad taste,odor, staining of porcelain,etc. 7. ❑ Re-sampling is recommended in months,to reinvestigate For more information regarding your well water results,please call the:'Forth Carolina Division of Public Health at 919-707-5900. Zinc & gy PRIVATE WELLS „.; „I: 1 F t What is zinc? Zinc is a natural element found in rocks deep underground,air,soil,and water.Zinc is found in What level of zinc should I be the environment as zinc compounds joined to other elements like chloride,oxygen and sulfur. concerned about? Zinc is used to produce metals,batteries,and pennies. The NC Department of Environmental Quality Zinc is also used as a metal coating to prevent rust. developed a groundwater standard of 1 milligrams of zinc per liter of water(mg/L).Ground water Zinc compounds are used to make paint,rubber,dyes, standards are developed to protect public health. ointments,and wood preservatives. This standard was developed in 2013. How does zinc get in my The US Environmental Protection Agency private well water? developed an aesthetic standard of 5 mg/L.This standard was developed to prevent metallic taste. Zinc compounds can enter your private well water from erosion of rocks underground.Zinc can also enter How do I test for zinc in groundwater from industrial practices like mining,steel my private well? production,coal burning,and burning of waste. Use a certified lab to test your well water for zinc How can zinc affect my health? every two years,as part of the inorganic panel screen. Contact the private well program at your county Zinc is an essential element,meaning your body health department to assist you with getting your needs it small amounts. It helps with enzyme water tested.Pricing of testing varies from county function,structure,and regulation throughout the to county. body.However,drinking high levels of zinc may cause adverse health effects.You can't smell or see zinc.Zinc may have a detectable taste. What if my zinc levels are high? Drinking high levels of zinc over short periods can You can install a treatment system to reduce the lead to: levels of zinc in your private well.Installing a filtration • Stomach cramps treatment system can reduce the level of zinc in your well water. • Nausea • Vomiting You can also reduce your exposure by using bottled Drinking high levels of zinc over long periods can water or connecting to public water supply,if possible. cause anemia,decreased good cholesterol levels and reduced copper absorption. Percent of Private Wells Tested Exceeding State Standards for Zinc, 2011-2013 L' ■ � iar 146 �--- II.>25%exceeded health standards ` � A 40 -10-25•/exceeded health standards � <10%exceeded health standards .,..�° 0%exceeded health standards Insufficient data(<10 wells tested) Where is zinc found in NC? Where did this information Zinc is found at low levels(0.05-43 mg/L)throughout come from? NC.About 8%of wells sampled for zinc in NC from Agency for Toxic Substances and Disease Registry: 2011 to 2013 exceeded the N.C.Department of www.atsdr.cdc.gov/toxfaqs/tfacts60.pdf Environmental Quality groundwater standard World Health Organization:www.who.int/water (1 mg/L). Yet,there are several areas in NC with at least 10%of wells exceeding state standards.See sanitation health/dwq/chemicals/zinc.pdf map for areas with elevated zinc. National Sanitation Foundation:www.nsforg/ consumer-resources/water-quality/water-filters- Where can I find more testing-treatment/contaminant-reduction- claims-guide information about zinc and my well? King,J.C.The American journal of clinical nutrition Zinc an essential but elusive nutrient Visit the NC Division of Public Health's Private Well 2011:www.ncbi.nlm.nih.gov/pmc/articles/ and Health Program website:http://epi.publichealth. PMC3142737/pdf/ajcn9420679S.pdf nc.gov/oee/programs/wellwater.html. There you can find: • Contacts for your county private well program • Zinc in well water maps • A guide for selecting a treatment system • Other private well resources You can also call the Private Well and Health Program at 919-707-5900. s� '.. NC Department of Health and Human Services•Division of Public Health•Epidemiology Section•Occupational and Environmental • j I Epidemiology Branch•Private Well and Health Program•httos://eoi.oublichealth.nc,gov/oee/orograms/wellwater.html•NCDHHS is an North Catch.o equal opportunity employer and provider.•09/2019 Whhe Ho1Q Exposure to Manganese has the potential to harm your health. Contact with any hazardous substances can cause health effects and the occurrence and nature of the effects depend on how much,how long and how one comes into contact with the substance. What is Manganese is an essential nutrient that occurs naturally in the environment. It occurs in low levels in the air,water, soil, and food,Manganese can be found in Manganese? grains and cereals, and is found in high amounts in other foods,such as tea. People can be exposed to manganese by ingestion or inhalation. How could I be What are the sources? Some people are exposed to eating food or exposed to supplements containing manganese. The way manganese gets into your Manganese? body is by eating food,drinking,swimming or bathing in water or breathing in workplace air contaminated with manganese. Workers in the welding or factory industry may be exposed through air in the workplace. Manganese is used in a variety of products such as fireworks,dry-cell batteries, fertilizer,paints and cosmetics. Manganese is also found in the environment in soil and water after release from the manufacture,use and disposal of manganese based products. What are the health effects of Depending on the concentration, manganese exposure may cause neurological Manganese effects on the most vulnerable populations,which includes infants,children,and Exposure? pregnant women. • Avoid manganese exposure sources. How can I limit • Test your well water on a regular basis. or prevent my • Workers with potential for manganese exposure should remove exposure to • contaminated clothing before getting in car or entering your house. • Weld objects in a well-ventilated area and use an appropriate respirator to Manganese? reduce inhalation of fumes. Is there a Manganese is an essential element in the body so there will always be medical test to some present. Levels can be measured in the blood,hair,feces,and show if I have urine. Increased levels in your in your body may not indicate the health effects experienced from the exposure. been exposed to manganese? Manganese Fact Sheet 1 February 2015 Additional Call the N.C. Department of Health and Human Services, Division of Public Health at(919) 707-5900 for additional information. Information Agency for Toxic Substances&Disease Registry(ATSDR). Manganese. March 2011. Available at: www.atsdr.cdc.gov/substances/toxsubstance.asp?toxid=23 References Agency for Toxic Substances&Disease Registry(ATSDR). Public Health Statement for Manganese. January 2015. Available at: www.atsdr.cdc.gov/phs/phs.asp?id=100&tid=23 Agency for Toxic Substances&Disease Registry(ATSDR). ToxFAQs for Manganese. March 2014. Available at: www.atsdr.cdc.gov/toxfaqs/tf.asp?id=101&tid=23 State of North Carolina•Department of Health and Human Services Division of Public Health www.ncdhhs.gov www.publichealth.nc.gov N.C.DHHS is an equal opportunity employer and provider 2/15. NCIVI nr doparlmont hodlh.d North Carolina Fniman mrvirox Public Health Manganese Fact Sheet 2 February 2015 if 16, Su ate & PRIVATE WELLS What is sulfate? 1111) Sulfate is a form of sulfur,a natural element.Sulfate is found in rocks deep underground,mineral deposits and soil.Sulfate is found in the environment joined to other elements like sodium,calcium and magnesium. These form sulfate salts or sulfates. Sulfates are used to produce fertilizers,chemicals, What level of sulfate should dyes,glass,paper,soaps,textiles,pesticides,and I be concerned about? some medical supplies.Sulfates are also used in mining,metal industries,sewage and drinking The US Environmental Protection Agency and water treatment. NC Department of Environmental Quality developed an aesthetic standard of 250 mg/L.This How do sulfate get in standard was developed to prevent a salty taste. my private well water? How do I test for sulfate in Sulfate can enter your private well water from my private well? erosion of rocks and minerals underground.Rain may wash sulfate from soil on the surface to Use a certified lab or purchase test kits at your local groundwater.Sulfate can also enter groundwater home improvement store to measure sulfate in your well from industrial practices. water.Contact the private well program at your county health department to assist you with getting your water How can sulfate affect tested.Pricing of testing varies from county to county. my health? What if my sulfate levels Sulfate is not an essential element,meaning your are high? body does not need it.You can't smell or see sulfate. Sulfate may have a detectable salty taste.Drinking If you are concerned about possible laxative effect high levels of sulfate can have a laxative effect. or the taste of your well water,you can install a treatment system.Treatment systems that reduce the levels of sulfate in your well water include: • Distillation • Reverse Osmosis You can also reduce your exposure by using bottled water or connecting to public water supply,if possible. Private Well Median Concentration of Sulfate, 2011-2013 411111111MviewitnilimaN t fir► t" 4111.414111*.1111111ri igerAillwowak •Ilrwmwikv ->250.1 mglL _ 100.1-250.0 mglL 25.1-100.0 mglL <25.0 mg/L Insufficient data(<10 wells tested) Where is sulfate found in NC? Where did this information Sulfate varies across NC(5-1,800 mg/L),see map for come from? areas with elevated sulfate(>250 mg/L). US Environmental Protection Agency:www.eoa. aov/sites/production/files/2014-09/documents/ Where can I find more support cc1 sulfate healtheffects.pdf information about sulfate World Health Organization:www.who.int/water and my well? sanitation health/dwq/chemicals/sulfate.pdf Visit the NC Division of Public Health's Private Well National Sanitation Foundation:www.nsf.org/ and Health Program website:http://epi.publichealth, consumer-resources/what-is-nsf-certification/ nc.gov/oee/programs/wellwater.html. water-filters-treatment-certification/contaminant- There you can find: reduction-claims-guide • Contacts for your county private well program • Sulfate in well water maps • A guide for selecting a treatment system • Other private well resources You can also call the Private Well and Health Program at 919-707-5900. NC Department of Health and Human Services•Division of Public Health•Epidemiology Section•Occupational and Environmental ,., NCP�fI Epidemiology Branch•Private Well and Health Program•httos://eoi,oubiichealth.nc.aov/oee/oroorams/wellwater.html • NCDHHS is an t.�' N•np c,.oe•� equal opportunity employer and provider.•09/2019 wbhc x•al�h Total Hardness, Calcium, Magnesium & PRIVATE WELLS - �• What are total hardness, calcium, and magnesium? Total hardness is a measurement of the amount of dissolved minerals in your water.Hard water has high levels of calcium, magnesium,and other metals.Hardness is often referred to as the ability of your well water to react with soaps. Magnesium is an essential element,meaning your body needs it.It helps with energy metabolism,protein Calcium and magnesium are natural elements found in synthesis,vascular tone,and insulin sensitivity.You rocks deep underground.They contribute to the hardness can't see or smell magnesium.Magnesium may have a of your well water. detectable taste. • Only people with preexisting kidney problems may How do calcium and magnesium be affected by drinking high levels of magnesium because it can cause diarrhea or laxative effects. get in my private well water? Calcium and magnesium can enter your private well water from erosion of rocks underground. What level of total hardness, calcium, and magnesium How can total hardness, should I be concerned about? calcium, and magnesium The US Environmental Protection Agency or affect my health? NC Department of Environmental Quality have not developed standards for total hardness,calcium, Total hardness is not an essential element,meaning or magnesium. your body does not need it.You can't see or smell total hardness.Total hardness may have a detectable taste. The World Quality Association developed a degree • Total hardness may cause dry,itchy skin and scalp, of hardness standard: Calcium is an essential element,meaning your body Degree of Hardness Milligrams per liter of water(mg/L) needs it.It helps with bone development,kidney function, Soft < 17.0 metabolism,vascular contraction,blood clotting,muscle Slightly Hard 17.1 -60 contraction and nerve transmission.You can't see or smell Moderately Hard 60.1 -120 calcium.Calcium may have a detectable taste. • Only people with preexisting conditions,like Hard 120.1 -180 milk alkali syndrome and hypercalcemia,may be Very Hard > 180 affected by drinking high levels of calcium because Hard water can lead to technical effects in the well such as: it can interfere with the absorption of other • High soap usage essential elements. • Mineral deposits on dishes • Scale build up in sinks,tubs Private Well Total Hardness, 2011-2013 ,,,_, ,, _ . I4.4„. il ,-- \ . • - , ,40.41Liev__, Awl* . _,-- .. J. - • r • _ t ir.:4,_._,_ 44,0 ail , _ .. 0„1‘;41,;114 1. -.p4A•• ir-6.,mbizi_.+.. - - p __,_ _ ... „70-,, 1 0 w im Very Hard . _S >r': — Hard _Moderately Hard ,` El Slightly Hard Soft `41- II — Insufficient data(<10 wells tested) ��. How do I test for total hardness, Where can I find more calcium, and magnesium in my information about total private well? hardness, calcium, and You can use a certified lab or buy test kits at your local magnesium and my well? home improvement store to test for total hardness,calcium, Visit the NC Division of Public Health's Private Well and and magnesium.Contact the private well program at your Health Program website:http://epi.publichealth.nc.gov/ county health department to assist you with getting your oee/programs/wellwater.html. water tested.Pricing of testing varies from county to county. There you can find: • Contacts for your county private well program Where is total hardness, calcium, • Total hardness,calcium,and magnesium in well and magnesium found in NC? water maps • A guide for selecting a treatment system Calcium and magnesium contribute to the total hardness in . Other private well resources your water.Calcium ranges from 1-400 mg/L and magnesium ranges from 1-600 mg/L in private well water throughout You can also call the Private Well and Health Program the state.Total hardness in private well water varies across at 919-707-5900. NC(3-2,600 mg/L),see map for areas with hard water. Where did this information What if my water is hard? come from? If you are concerned about the taste of your well water,you World Health Organization:www,who,int/water can install a treatment system to reduce the levels of total sanitation health/publications/publication hardness,calcium,and magnesium in your private well. 9789241563550/en/ Cation exchange,also known as a Water Softener,is a Water Quality Association:www,wqa.org/learn-about- treatment system that can reduce the levels of total water/perceptible-issues/scale-deposits hardness,calcium,and magnesium in your well water. + , NC Department of Health and Human Services•Division of Public Health•Epidemiology Section•Occupational and Environmental J . 1C ll`I Epidemiology Branch• Private Welland Health Program•Jlttos://eoi.oublichealth.nc.gov/oee/orograms/wellwater.html•NCDHHS is an �* a.�ac•.a„• equal opportunity employer and provider.•09/2019 r.a��xn�a • Sodium & i ; PRIVATE WELLS dip , /it at. What is sodium? '' '1). Sodium is a natural element found in soil,water,and rocks deep underground.Sodium is found in the Higher levels of sodium can cause: environment as salts bound to chloride,carbonate, • Vomiting hypochlorite,and silicate. • Nausea Sodium is used in water softener treatment systems, • Gastrointestinal issues disinfectants,and pH adjustment to produce • Muscular twitch industrial chemicals.Sodium salts are used in • Convulsions snow/ice control and production of paper,glass, Drinking high levels of sodium over long periods may soap,pharmaceuticals,chemical and food. lead to death. Along the coast,seawater can influence the amount of sodium in groundwater.This is known What level of sodium should as saltwater intrusion. I be concerned about? The US Environmental Protection Agency How does sodium get developed a health advisory of 20 milligrams in my private well water? of sodium per liter of water(mg/L).Health Sodium can enter your private well water from advisories are non-enforceable guidance levels erosion of rocks underground.Rain may wash sodium developed to protect public health.This advisory from de-icing salts and industrial activities on the level was developed to protect the development of surface to groundwater.Water softener treatment hypertension for people on restricted sodium in 2003. systems increase the amount of sodium in water. In addition,the US Environmental Protection Agency developed an aesthetic standard of 30-60 mg/L.This How can sodium affect standard was developed to prevent a salty taste. my health? Sodium is an essential element,meaning your body How do I test for sodium needs it in small amounts.It helps with regulation in my private well? of osmolarity and fluids within the body.However, Use a certified lab to test your well water for sodium drinking high levels of sodium may cause adverse every two years,as part of the inorganic panel health effects.You can't see or smell sodium.Sodium screen.Contact the private well program at your may have a detectable taste. county health department to assist you with getting Drinking high levels of sodium over short periods can your water tested.Pricing of testing varies from lead to hypertension. county to county. Percent of Private Wells Tested Exceeding Federal Guidance for Sodium, 2011-2013 4 • APi Fri a 11.1 un IC A.t•I I I 446 • >25%exceeded health guidance 10-25%exceeded health guidance <10%exceeded health guidance :7110A4—+ 0%exceeded health guidance is — Insufticient data(<10 wells tested) Where is sodium found in NC? Where can I find more Sodium is found at varying levels(1-3,900 mg/L) information about sodium throughout NC.About 14%of wells sampled for and my well? sodium in NC from 2011 to 2013 exceeded the Visit the NC Division of Public Health's Private Well federal advisory level(20 mg/L).Yet,there are and Health Program website:http://epi.publichealth. several areas in NC with more than 25%of wells nc.gov/oee/programs/wellwater.html. exceeding the federal guidance.See map for areas with elevated sodium. There you can find: • Contacts for your county private well program • Sodium in well water maps What if my sodium levels • A guide for selecting a treatment system are high? • Other private well resources If you are concerned about the taste of your well You can also call the Private Well and Health Program water or have a preexisting condition,you can install at 919-707-5900. a treatment system to reduce the levels of sodium in your private well.Treatment systems that reduce the Where did this information levels of sodium in your well water include: ? • Distillation come from. • Reverse osmosis World Health Organization:www.who.int/water_ You can also reduce your exposure by using bottled sanitation_health/dwq/chemicals/sodium.pdf water or connecting to public water supply,if possible. US Environmental Protection Agency:www.epa. gov/sites/production/files/2014-09/documents/ support_cc1_sodium_dwreport.pdf US Geological Survey:http://water.usgs.gov/ogw/ gwrp/saltwater/salt.html Gil a iIj,i NC Department of Health and Human Services•Division of Public Health•Epidemiology Section•Occupational and Environmental 11 Epidemiology Branch•Private Well and Health Program•httos://eoi.oublichealth.nc.gov/oee/Drograms/wellwater.html•NCDHHS is an so.a c,.a�., equal opportunity employer and provider.•09/2019 whF.Heath. • MEMORANDUM ��11 Qp /'/� r ��010� • TO: MVO 44 IA Cie e t' -Kr k ', keg. IrDiAf ll n ip/ Date ?k R ! � System Name Responsible Person/Person Contacted I •' " 3 as 307 `7 PD Scsk '3 f79 System Phone e - � Mailing Address NC. tP a I R 0 g l ,N1 P t..A34.a,-t A/C aBetS I ')Water Sys me ' City � / State //Ziipp�C.ode FROM: W eS4D✓1 Y a0J0a-1 • l011-C!�4� ( Lv/ 9 �n� Name . / / Regional Office Phone e • drlaetrecdd//r Public Water Supply Section Regional Office RE: Monitoring Requirements&General Information Transient Non-Community Water Systems • The North Carolina Department of Environmental Quality has determined that your water system is a transient non-community • (TNC) public water system.Transient non-community public water systems are legally defined as a water system which , serves at least 25 people (not necessarily the same people) for sixty or more days each year. It is not necessary that the water system furnish water for drinking, only that the water system is available for drinking, bathing, cooking, dishwashing or oral hygiene. Examples of TNC public water systems include churches, convenience stores, and restaurants.The items listed below were discussed with the above-listed Person Contacted. " . [ ] Testing requirements for TNC systems:what tests, how often and where they should be collected. • Coliform Bacteria: Collected quarterly from faucets such as a kitchen or bathroom sink. • . • • Nitrate:Collected annually from the Entry Point identified below. • Nitrite: Collected one time from the Entry Point identified below. , • • • SAMPLING SITE LOCATION AND CODE Test: Sample Location Code: Location: • Nitrate/Nitrite E 0 1 (Entry Point) ' '/ Q Coliform L 12 L t 1 e•nl • II -0Q2. G✓ a. he.r h. 4L . I) op3 D. Br • SAMPLE SITING PLAN COMMENTS: • If you have further questions, please contact the Regional Office at the phone number listed above. . . White copy-Central Office Yellow copy-Regional Office - Revised 8/2018 Pink copy-Water System - . . . . .. .. .. ' • . • TRANSIENT, NON-COMMUNITY WATER SYSTEM REFERENCE SHEET CERTIFIED LABORATORIES AND SAMPLE REPORTING: It will be necessary for you to contract with one of the North Carolina State certified laboratories on this website, https://slphreporting.ncpublichealth.com/Certification/CertifiedLaboratory.asp,to perform the required analyses.The selected laboratory will send you a sample collection bottle (sample kit)and a form, which you must complete each time a sample is taken.The water system number(either printed on the reverse side of this memorandum or it will be furnished later),type of sample, date collected and time collected must be included on the laboratory report form.Additionally, the sample location and location code (from the SAMPLING SITE LOCATION AND CODE section on the reverse side of this memorandum) must be included on the form as well. Contaminated samples will require additional testing. Your laboratory will send results of water sample analyses to the state and to you for your permanent records. Records of bacteriological analyses must be kept on-site for at least 5 years while Nitrate/Nitrite test results must be kept on-site for at least 10 years. Questions concerning testing procedures, contracts or forms should be directed to your laboratory. SAMPLING TIPS: • Follow the instructions provided by your laboratory and only use sample containers they provide. • Collect samples only from designated sampling sites. Sample taps should be clean and in good working order. • Remove strainers, aerators, vacuum breakers or hoses from the sample spigot prior to sample collection. Bacteriological Samples • Disinfection of the sample spigot with chlorine and/or alcohol is recommended. • Open cold-water valve and allow water to run freely for 5 minutes.Then adjust the flow until there is a slow, gentle and steady stream. • Handle the sample container and lid with care. Never touch the inside of the bottle or lid and do not allow water to splatter or splash into either. • Do not rinse out the container. Slowly fill the container to or slightly above the 100-milliliter mark and carefully replace the cap. • Sample analysis must begin at the laboratory within 30 hours. Nitrate/Nitrite Samples • Open sample spigot an allow water to run freely for 5 minutes. Then adjust the flow until there is a slow, gentle and steady stream. • Fill sample container and immediately store on ice. • Nitrite samples must be processed by the laboratory within 48 hours. Nitrate samples must be processed by the laboratory within 48 hours, or within 14 days for chlorinated water systems. WELL HEAD DETAIL: 1.Sanitary well Seal (required) DRILLED WELL 2. Insect-proof Casing Vent(downward opening&screened) 3.Check Valve . 4.Sample spigot(with vacuum breaker if threaded)** Z\ 3 4/ 5.Concrete slab extending 3 feet in all directions from well y casing** **These items are required for systems that were installed After July 1, 1993 and are inspected by your local Health Department for food grade or lodging purposes. 1 Note: Detail is for a submersible pump setup and your well pump setup may be different.Your local Health 5 Department may have additional requirements. White copy-Central Office Yellow copy-Regional Office Revised 8/2018 Pink copy-Water System .n,,� NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY Public Water Supply Section €C oy • PP Y ;_ . yd COMPLIANCE INSPECTION REPORT �t�n ." .t - I 'I + d ' n� I.. . . f� 1 ,R r.. , System Name: Irl/trr M�4'c, Cite' L. £ L. � 1 (CA� PWS ID#: NC (90) B Da I Owner: ( a /GI 4) 4 l O u - � #of Connections:~, ' Address/Phone#: et. So , 3 AleWipr,, Ne cpc, Population: 4S"" • Source: o Surface'.} Ground ❑Purchase Type of System:• o Community o Non-Transient,Non-Community • ` Transient o Adjacent Responsible Person: 1\n�� ! to I l gr R-4 O- '�677 Address/Phone A531` L! e /N.+,1 /G,t/! u'�, Skit //S £ Ale t�t$��73 DEFICIENCIES/VIOLATIONS: Each item below is a deficiency/violation of the NCAC Title I5A Subchapter I 8C, Rules Governing Public Water Systems. Rule ,/ Specifics I / * N9ty ) 51L V • • ACTION REQUIRED: • You are required to take all necessary steps to comply with applicable laws and regulations. The following corrective actions must b taken wi in the time frame lis.{tgd below: Traci ;n� v eai onvAult eL Ors /�iiat Ire t/ C efitntM &r4e / i 41 el �' .r �1, "'m / Artfr,$e its, aer'e -/!pm . fh GOs• 11 . 7,, , - ( n /rr* � /SMtP '/eveP AL.1L ,' i 'tefit ✓'/,► j --,1 ar (rto// ?..,t i • A written response must be filed with the Regional Office once these violations are corrected. NOTICE is given that this and any further violations may result in enforcement actions, including civil penalties. RECOMMENDATIO�/�S/COMMENTS: pp j /� 11) /rah-,'�[(1� tto/ 0 / f cr-f 'II to eyLwci < 5`Ieco+ ; A a II /�i`,Pr /ri,Y? < I 'f �.,w ' to /Be-�� qa'ita c lc rPrt5✓0/IIPo ✓on, St ! an p , H / /Gat (w a4 t C.!'rr. e . ame and Signature f System epresentative: Date: lime: Name of inspector: Agency/Office Region: /9/oo,eg-all/•' EVALUATION SUMMARY: "'� / —7 ❑ Significant Deficiency(ies) • ew MSoti Telephone:. `�' 0 Ij_ S — "/�/� ❑ Minor Deficiency(ies) On-site action taken:I „R. j -." ..��{{��'' f t Recommendation(s) Made literheel,el /`D s' "l ' M5'4 r r' No Deficiencies/Recomendattons • . Regional Files(white/original copy) Central Files(yellow copy). Owner(pink copy) Recipient(goldenrod copy) CIR-101 ?l: Rev.8/IS • RULES GOVERNING PUBLIC WATER SYSTEMS ❑ .0201 - Surface Supplies ❑ .0203 -Public Well Water Supplies - Site Approval ❑ .0305 - Contracting or Constructing before Authorization to Construct ❑ .0306 - Deviation from Approved Plans or Specifications ❑ .0309 - Operation Prior to Final Approval ❑ .0402 - Improper Well Construction ❑ .0403 - Surface Source Deficiencies ❑ .0404 - Water Treatment Facilities Construction ❑ .0405 - Storage of Finished Water ❑ .0406/.0900 - Distribution Systems ❑ .0407 - Electrical Systems ❑ .0409 - Service Connections ❑ .0502 - Design for Source Under the Direct Influence ❑ .0600 - Raw Surface Water Treatment ❑ .0700 - Surface Water Treatment ❑ .0800 - Hydropneumatic Storage Tanks ❑ .1000 - Disinfection ❑ .1200 -Protection of Filtered Supplies • .1300 - Operation of Public Water Supplies ❑ .1400 - Fluoridation ❑ .1500 - Water Quality Standards ❑ . 1600 - Variances & Exemptions ❑ .1900 - Administrative Penalties ❑ .2000 - Filtration/Disinfection SWTR ❑ .2100 - Operating Permits ❑ .2200 - Ground Water Systems NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY �" 'a} Public Water Supply Section • COMPLIANCE INSPECTION REPORT System Name: tyl n a it‘1 A , n L..C et, L ficr L L ( !D11 .... PWS ID#: i J C ' j0 I SS r2) Owner: ink fQ 44-',64 C O y1 - #of Connections: / 1 Address/Phone#: PO /J'�© 3 Ive u-/oH jv C cyo c r' p Population: Source: o Surface XGround o Purchase Type of System: o Community o Non-Transient,Non-Community Q �� Transient ❑Adjacent Responsible Person: Ida VI / 1, `, ( jtis `\ cod 53.. 47_ . n]7 Address/Phone#: ( [ DEFICIENCIES/VIOLATIONS: Each item below is a deficiency/violation of the NCAC Title 15A Subchapter 18C, Rules Governing Public Water Systems. Rule Specifics AN) -�.?ks1p01V ua r r '4:xrl A ACTION REQUIRED: You are required to take all necessary steps to comply with applicable laws and regulations. The following corrective actions must bg taken wi in the time frame list d below: `j 1 J ;.'Iti r� ( rrr.) vv.,eN : 0htifcT_ sale-,- /y ��p>� ,i ryn," 1M Teri CJn "1 1� ro.M e r l,-,/le//�•--1 s :'P'ff7 • 2 /r9 rf ylLiu ii,'Ti'4 ,� / r . /P_y- y . 1 h t L-(J P I I 1 = / A r( di4 /,MP P ( s , fie. v �Ii �'4,AA 7Ae a,,ie / a / A written response must be filed with the Regional Office once these violations are corrected. NOTICE is given that this and any further violations may result in enforcement actions, including civil penalties. RECOMMENDATIO S/COMMENTS: 1 6 ell- ("ir I ,?tA d < ___)--s e co 1 , •k ..-R I/ t, to rl t�ii /p' /f2, # 9'5♦ ,r i S I PC t�,/►1 PO1,077, y/ �, i.y T.Iiii tt,Ael < C",(7-., 17/L6,"../f tame and Signature¢t System Representative: Date: Time: 4 Name of inspector: Agency/Office Region: /,p0/t' l„< '//e, EVALUATION SUMMARY: El Significant Deficiency(ies) We:5-4oZATcicphonc: �. A � 7 (/ s 76- Fql, ❑ Minor Deficiency(ies) On-site action taken: yRecommendation(s) Made /1 �p / 5 / 7 --)/ *--- ll-r r , Gt.' 0 No Deficiencies/Recomendations Regional Files(white/original copy) Central Files(yellow copy) Owner(pink copy) Recipient(goldenrod copy) CIR-l01 Rev.8/18 RULES GOVERNING PUBLIC WATER SYSTEVIS M201 - Surthee Supplies .0203 - Public Well Water Supplies - Site Approval ,03Wi t. oritracting or Constructing before Authorization to Consnucl .0306 - I kv iation Iron Approved Plans Or Specifications .0309 - Operation Prior to Final i‘pproval .0402 - Improper Well Construction .0403 - Surface. Source Deficiencies ,0404 - Water Treatment Facilities Construction .0405 Storage of Finished 'Water ' .0406/.0900 - Distribution Siystems .0407 Electrical Systems LI .0409 - Service Connections !i! .0502. - Design for Source I. ndcr the Direct Influence .0600 - Raw Surlace Water Treat tnent .0700 - Surface Water Treatment .0800 - I lvdropneumatic Storage Tanks .1000 - Disinfection . 1200 - Protect ion of Filtered Supplies .1300 - Operation of Public Water Supplies .1400 - Fluoridation . 1500 Water Quality Standards 1600 - Variances & Exemptions . 1900 - Administrative Penalties Li .2000 - Filtration/Disinfection SWTR Li .2100 - Operating. Permits .2200 - Ground Water Systems MEMORANDUM r � - 090gR nn// 14 j // �/ � ) Date —C(' it?) System Name Responsible Person/Person Contacted ystem Ph ne Nc cg D i os 0 y Mailing Address Water tt City �lTt State Zip Code WFROM: PS D✓1 111AS�`'1 G^ Name , / Regional Office Phone e ab es ' /r' Public Water Supply Section Regional Office RE: Monitoring Requirements&General Information Transient Non-Community Water Systems The North Carolina Department of Environmental Quality has determined that your water system is a transient non-community (TNC) public water system.Transient non-community public water systems are legally defined as a water system which serves at least 25 people (not necessarily the same people) for sixty or more days each year. It is not necessary that the water system furnish water for drinking, only that the water system is available for drinking, bathing, cooking, dishwashing or oral hygiene. Examples of TNC public water systems include churches, convenience stores, and restaurants.The items listed below were discussed with the above-listed Person Contacted. [ ] Testing requirements for TNC systems:what tests, how often and where they should be collected. • Coliform Bacteria: Collected quarterly from faucets such as a kitchen or bathroom sink. • Nitrate:Collected annually from the Entry Point identified below. • Nitrite: Collected one time from the Entry Point identified below. SAMPLING SITE LOCATION AND CODE Test: Sample Location Code: Location: Nitrate/Nitrite E 0 1 (Entry Point) ' 4, 0 Coliform L . L I idgr Il .C� 22_ No Jar a.�t SAMPLE SITING PLAN COMMENTS: If you have further questions, please contact the Regional Office at the phone number listed above. White copy-Central Office Yellow copy-Regional Office Revised 8/2018 Pink copy-Water System TRANSIENT, NON-COMMUNITY WATER SYSTEM REFERENCE SHEET CERTIFIED LABORATORIES AND SAMPLE REPORTING: It will be necessary for you to contract with one of the North Carolina State certified laboratories on this website, https://slphreporting.ncpublichealth.com/Certification/CertifiedLaboratory.asp,to perform the required analyses.The selected laboratory will send you a sample collection bottle (sample kit) and a form, which you must complete each time a sample is taken.The water system number(either printed on the reverse side of this memorandum or it will be furnished later),type of sample, date collected and time collected must be included on the laboratory report form.Additionally,the sample location and location code(from the SAMPLING SITE LOCATION AND CODE section on the reverse side of this memorandum) must be included on the form as well. Contaminated samples will require additional testing. Your laboratory will send results of water sample analyses to the state and to you for your permanent records. Records of bacteriological analyses must be kept on-site for at least 5 years while Nitrate/Nitrite test results must be kept on-site for at least 10 years. Questions concerning testing procedures, contracts or forms should be directed to your laboratory. SAMPLING TIPS: • Follow the instructions provided by your laboratory and only use sample containers they provide. • Collect samples only from designated sampling sites. Sample taps should be clean and in good working order. • Remove strainers, aerators, vacuum breakers or hoses from the sample spigot prior to sample collection. Bacteriological Samples • Disinfection of the sample spigot with chlorine and/or alcohol is recommended. • Open cold-water valve and allow water to run freely for 5 minutes.Then adjust the flow until there is a slow,gentle and steady stream. • Handle the sample container and lid with care. Never touch the inside of the bottle or lid and do not allow water to splatter or splash into either. • Do not rinse out the container.Slowly fill the container to or slightly above the 100-milliliter mark and carefully replace the cap. • Sample analysis must begin at the laboratory within 30 hours. Nitrate/Nitrite Samples • Open sample spigot an allow water to run freely for 5 minutes. Then adjust the flow until there is a slow, gentle and steady stream. • Fill sample container and immediately store on ice. • Nitrite samples must be processed by the laboratory within 48 hours. Nitrate samples must be processed by the laboratory within 48 hours, or within 14 days for chlorinated water systems. WELL HEAD DETAIL: 1.Sanitary well Seal(required) DRILLED WELL 2. Insect-proof Casing Vent(downward opening&screened) 3. Check Valve 4. Sample spigot(with vacuum breaker if threaded)** 2N I I 3 4 5.Concrete slab extending 3 feet in all directions from well casing** **These items are required for systems that were installed I After July 1, 1993 and are inspected by your local HealthII\ Department for food grade or lodging purposes. 1 Note: Detail is for a submersible pump setup and your well pump setup may be different.Your local Health 5 Department may have additional requirements. White copy—Central Office Yellow copy—Regional Office Revised 8/2018 Pink copy—Water System RECEIVED WATER SYSTEM NUMBER: NC2018021/CATAWBA County Environmental Health MOUNTAIN CREEK PARK LAKE FRONT PHELPS, ROBBIE PO BOX 389 25 GOVERNMENT DRIVE NEWTON, NC 28658 % p;5r nr �y ROY COOPER - Governor ? i V ELIZABETH S.BISER ` ,,:,.,�� �R rw „µ..+o• R"' Secretary `t,v •,,. RICHARD E.ROGERS,JR. NORTH CAROLINA Director Environmental Quality NC2016021_20231031_RTCR_LV 1_20230CT_D01.pdf October 31, 2023 TO: CATAWBA COUNTY RE: MOUNTAIN CREEK PARK LAKE FRONT ATTN: JOHN CAMERON WATER SYSTEM NUMBER: NC2018021 PO BOX 389 COUNTY: CATAWBA NEWTON, NC 28658 RTCR—LEVEL 1 ASSESSMENT REQUIRED MOUNTAIN CREEK PARK LAKE FRONT exceeded a treatment technique trigger under the Revised Total Coliform Rule (RTCR)on October 26,2023 (trigger date). [See 15A NCAC 18C .1539(§141.859)]. Therefore,CATAWBA COUNTY is required to conduct a Level 1 Assessment within 30 days of the trigger date indicated in the first paragraph as follows: 1. Conduct a Level 1 Assessment and Perform Necessary Corrective Actions:As soon as practical, review and evaluate each of the listed elements on the attached assessment form and perform corrective actions for the issues and/or sanitary defects identified. The Level 1 Assessment can be conducted by a water system representative, but you are encouraged to contact the Public Water Supply Section's regional supervisor Clinton Cook, P.E., at(704)235-2140 or by email at Clinton.Cooktdep.nc.gov for assistance. 2. Complete the Level 1 Assessment Form and Certification: Document your findings and actions on the assessment form. Be sure to identify and describe any potential causes of contamination,sanitary defects detected,corrective actions completed, and a proposed timetable for any corrective actions not already completed. Provide additional information to support your findings, as necessary. Complete the assessment certification block. Be sure to include your signature and date the assessment was completed. 3. Submit a CODY of your completed Level 1 Assessment Form (including the Certification)to the Public Water Supply Section: Immediately after you have completed the assessment and corrective actions, mail a signed copy of the completed form to the RTCR Rule Manager at 1634 Mail Service Center, Raleigh, NC 27699-1634 or email a copy to: pwss.rtcrCa).ncdenr.aov. The completed assessment form must be submitted to the Public Water Supply Section within 30 days of the trigger date. Retain a copy of these documents for your files. Should events or conditions beyond your control prevent you from completing any corrective actions within the 30-day period,you must notify the Rule Manager noted below immediately,in writing(mail or email). You must describe in detail the reason for the delay and get State-approval for an extended compliance schedule. Failure to conduct the required assessment or corrective actions within 30 days or within an extended timeframe approved by the State will result in your system receiving a Tier 2 Treatment Technique violation that requires 30-day public notification. ADDITIONAL INFORMATION I Please include your water system's name and number on all correspondence. The assessment form is also available on the Public Water Supply Section's website at: http://www.ncwater.orq/pws Compliance Services—0 Revised Total Coliform Rule. Our website contains links to"Sampling Status"which allows systems to view their current monitoring schedules for each contaminant group and to"Drinking Water Watch"which allows systems to view their monitoring results and other system information. Copies of North Carolina's Rules Governing Public Water Systems can also be found on our website at wyniv.ncwater.org/pws. CONTACT INFORMATION If you have questions or need assistance regarding this notice, contact Travis Brooks at(919) 707-9080 or by email at Travis.Brooks( dea.nc.gov. Sincerely, %u x.� 3269A Travis Brooks Total Coliform Team Leader Enclosure: Level 1 Assessment Form Public Water Supply Section cc: MOORESVILLE REGIONAL OFFICE Division of Water Resources, NCDEQ Q D North512North CadineSeli pep Street to nt of11634 FsviMail ice ronmattel purity I DIiviaon d Water Reacurcee abExy ServCerda I Raldgh,North Cadina27699-1634 E bewro."'" 919.707.9100 em d E�Mn,"+,IM D.wtr North Carolina Department of Environmental Quality DEW Division of Water Resources,Public Water Supply Section Level 1 Assessment Form for the Revised Total Coliform Rule (Complete entire form and submit to the Public Water Supply Section's Rule Manager within 30 days of the Level 1 Assessment Trigger Date) Water System Name: Water System Number: County: Trigger Event [Check the box(es)below that apply] Level 1 Assessment Trigger Date ❑ For systems taking fewer than 40 samples per month: System has two or more total coliform-positive samples In the same month Sample Analysis end date: ❑ For systems taking 40 or more samples per month: Greater than 5%of samples are total coliform-positive Sample Analysis end date: Routine sample analysis end date+24 hours(unless extension ❑ Failure to take every required repeat sample after any single total coliform-positive sample approved by the Rule Manager): Section A-Review and evaluate each of the listed elements below that typically relate to a water system. Check(V)"Yes"if any potential causes of contamination were identified,or check(V)"No"if none were identified,or check(Y)"N/A"if the element is not applicable to this water system.(Note: Deficiencies and RTCR Sanitary Defects are denoted below with applicable codes,for example,(D112).] 1. ATYPICAL EVENTS YES NO NA YES NO NA a.Weather-Recent heavy precipitation/flooding/snowmelt/drought(MA10) 0 0 0 d. Signs of vandalism/tampering/forced entry at water system assets(MA13) ❑ ❑ ❑ b.Power loss(MA31) 0 0 0 e. Changes in plant operation(TA2)/flow rates(TA3)/maintenance/ 0 0 0 construction(TA4) c.Fire-fighting event(MA12) 0 0 0 f. Other(MA1): ❑ ❑ El 2. DISTRIBUTION SYSTEM MAINTENANCE&OPERATION YES NO NA YES NO NA a. Temporary pressure loss/low or negative pressure(DA2) ❑ ❑ ❑ i. Unprotected/unapproved cross-connection(D004) 0 ❑ ❑ b. Pressure loss/inadequate pressure(D105 or D107) 0 0 ❑ j. Hydrants-Sheared,damaged or improperly used hydrants(DA5) ❑ ❑ ❑ c. Main or service lines—new installation(DA3)/leaks/breaks/repairs 0 0 0 k. Pumps-Improper operation or failure of pumps/repairs(PA2) [0 ❑ ❑ (DD2) Mains improperlysized toprovide adequatepressure 0102 or D103) I. Valves-Improper operation of valves/valve breakage(DA6)/leaking air- d. q I 0 0 ❑ ❑ 0 0 relief/air-vacuum valves(DA7) e. Water main/line placed in service without satisfactory bacteriological p ❑ ❑ m.Improper surge control(DA8) 0 0 0 tests(D120) f. Dead end mains do not have hydrant or flushing valve with aboveground n. Low residual disinfectant concentration(<0.2 mg/L free chlorine residual discharge,protected from contamination(0112) ❑ ❑ ❑ or<1.0 mg/L total chlorine residual)at total coliform sampling sites(DD4) ❑ 0 CI g. Flushing activity/fire hydrants and/or blow-offs(DM) 0 0 0 0.Known bio-film accumulation(DA9) 0 0 0 h. Improper disinfection of distribution system after flushing and/or leak p. Other(DA1): 0 0 0 0 0 0 testing(0119) 08/2016 Page 1 Water System Name: Water System Number: 3. STORAGE YES NO NA YES NO NA a. Tank-Not disinfected properly(F004)/elevation not adequate to e. Inadequate cleaning and maintenance practices(FA7)-Visibly unsanitary provide required pressure in distribution system(F115)/hydropneumatic ❑ ❑ ❑ conditions-presence of debris/animals/insects/birds/bats etc.in tank El ❑ ❑ tank capacity not adequate to provide required pressure in distribution or near openings(FD2)/Deterioration,rust,holes,etc.in vent,overflow system(F116) pipe,access hatch,screens,ladders,etc.(FD3) b. High water age/low disinfectant residual(FA6) ❑ ❑ ❑ f. Hatch not sealed properly(FD4) n ❑ ❑ c. Recent maintenance/observed leaks/repair on tank(FA2) ❑ ❑ ❑ g. Improper operation of level control valves,altitude valves,and related ❑ ❑ D appurtenances(FA9) d.Vandalism/tampering observed(FA4) ❑ ❑ ❑ h. Other(FA1): ❑ ❑ ❑ 4. SOURCES-GROUNDWATER YES NO NA YES NO NA a. Source-Unapproved/changed/new source added(SA2) ❑ D ❑ i. Threaded hose bibs are not equipped with anti-siphon devices(S110) D D ❑ b. Heavy rainfall or flooding(5A3) ❑ ❑ ❑ j. Potential cross-connections exist at well site(5501) ❑ El ❑ c. Well pit with standing water or evidence of flooding/run-off inundation (SD2) ❑ ❑ D k. Inadequate concrete slab or well house concrete floor(S108) ❑ ❑ El d. Operational changes/changes in static/pumping levels(5A4) ❑ ❑ ❑ I. Unprotected opening in pump/pump assembly(SA5) ❑ ❑ ❑ e. Inadequate or damaged well components-well cap/well seal/well casing/grout seal/pitless adaptor(SD3) D ❑ D m.New,repaired or reconditioned well was not properly cleaned and disinfected and/or representative bacteriological samples were not found ❑ ❑ ❑ f. Upper terminal of well casing not sealed watertight,with exception of D D D to be free of contamination(5120) vent pipe(5106) g. Vent-damaged/unscreened vent(504) 0 0 ❑ n. Other(SA1): ❑ ❑ ❑ h. Vent pipe or vent tube not downward-directed and screened(5107) ❑ ❑ ❑ 5. SOURCES-SURFACE WATER SOURCES YES NO NA YES NO NA a. Source-Change in source/intake/new source added(SA8) ❑ ❑ ❑ d. Recent maintenance activity(SA11) ❑ ❑ D b. Heavy rainfall or flooding/high raw turbidity measurements(SA9) ❑ ❑ ❑ e. Other(SA1): ❑ ❑ El c. Changes in source water quality(lake turnover,algal blooms,etc.)(SA10) ❑ ❑ ❑ 6. TREATMENT YES NO NA YES NO NA a. Treatment malfunction or interruption(TD2) D D D d. Detectable residual disinfection concentration at water system MRT site ❑ El ❑ not maintained as required(T139) b. Disinfection equipment not provided as specified in approved plans and ❑ 0 ❑ e. Clogging of filters/media(TA5) ❑ ❑ ❑ specifications. Stand-by disinfection equipment is not provided(T110) c. Minimum residual disinfection concentration at Entry Point not ❑ ❑ D f. Other(TA1): ❑ ❑ El maintained as required(T138) 7. SAMPLING YES NO NA YES NO NA a. Visibly unsanitary sampling site/tap(MA2) ❑ ❑ ❑ f. Sample tap not disinfected(MA7) ❑ ❑ El b. Infrequently used sample tap(MA3) ❑ ❑ ❑ g. Aerator was not removed(MA8) ❑ ❑ ❑ c. Threads on inside of tap(MA4) ❑ ❑ 0 h. Inadequate tap flushing(MA9) ❑ ❑ 0 d.Treatment device in use after service connection[Point of Entry(POE)or ❑ ❑ D Point of Use)POU))(MA5) i. Other(MA1): D ❑ ❑ e. Recent maintenance activity(MA6) ❑ 0 ❑ 08/2016 Page 2 Water System Name: Water System Number: Section B-Description of Occurrence-Provide an explanation of any issues that were identified and provide additional Information that supports your findings(i.e.water quality and pressure monitoring data). Include corresponding dates with your findings. If no issues were identified above,provide an explanation of any other factors that may have caused total coliform-positive sample results. Section C-Corrective Action-Describe corrective actions taken or proposed corrective actions for each issue identified in Section B and provide corresponding completion dates for each action item. Note: Drinking water sample(s)with results"absent"of total coliform bacteria are required to demonstrate completion of corrective actions. ❑Check box If ALL corrective actions have been completed O Check box if drinking water samples were collected upon completion of corrective actions and the results were"absent"of total coliform bacteria(required to demonstrate completion of corrective actions) EXAMPLES:(TD2)-Treatment malfunction-Corrective Action taken: Replaced chlorinator;Date Completed: 04/30/2016 (S110)—Threaded hose bibs are not equipped with anti-siphon devices-Corrective Action proposed:Install anti-siphon devices;Date to be Completed: 05/15/2016 08/2016 Page 3 Level 1 Assessment Water System Name: Water System Number: Depending on the Person Responsible for Conducting and Documenting the Assessment, Select Option A,B or C below 0 Option A: Assessment Conducted and 0 Option B: Assessment Conducted by Water System 0 Option C: Assessment Conducted and Documented by Water System Representative Representative(must be Owner,or PE)and Documented by Documented by Public Water Supply Section (must be Owner,Operator or PE) Public Water Supply Section Representative Representative [Complete Section 1 Only] [Complete Both Sections 1 and 2] [Complete Section 2 Only] Section 1: Water System Representative Information(must be Owner,Operator or PE)Operator Name: Title: Date of On-site Assessment: Assessment Completion Date: Signature(Not Required for Option B): Phone Number: Email: Section 2: Public Water Supply Section Representative Information Name: Regional Office: Date of On-site Assessment: Assessment Completion Date: Signature: Phone Number: Email: Date copy of assessment was sent to owner via❑Email or❑Mail: Comments: Please return this form to the Public Water Supply Section at the address below within 30 days of the Level 1 Assessment Trigger Date 1634 Mail Service Center,Raleigh,North Carolina 27699-1634 Attention:Total Coliform Rule Manager OR Email form to pwss.rtcr@ncdenr.gov 08/2016 Page4