NCDEQ_0002.pdf

NC Department of Environmental Quality

Division of Water Resources, Public Water Supply Section

SITE VISIT REPORT

Entered into SDWIS at RO by :

Name Date

Water System Name: Water System No.: FORT RALEIGH--CAPE HATTERAS NS NC0428415

Site Visit Primary Reason: MM/DD/YYYYDate of Visit:

Sanitary Survey (SNSV)

Sanitary Hazard Investigation (SHAZ)

Compliance Assistance (CMPA)

Water Treatment Plant Site Visit (TRTP)

Training (TRNG)

Emergency Assistance (EMRG)

Engineering Determination/Advice/Plan Review (ENGR)

Investigation (Complaint/Violation/etc)

(INVG)

Laboratory Inspection (LABI)

Informal System Inspection (INFI)

Permit (Qualification/Review/Compliance)

(PRMT)

Sample Collection (SMPL)

Technical Assistance (non-specific) (TECH)

Variance/Exemption Related (VAEX)

Formal Enforcement (FENF)

Follow-up to Formal Enforcement (FUFE)

Informal Enforcement (IENF)

Comprehensive Performance Evaluation

(CPE) (CPEV)

Construction Inspection (CNST)

Operation & Maintenance (OM)

Records Review (RCDR)

Site Inspection (SITE)

Needs Survey (NEED)

Source Water Inspection (SRCE)

Locational Data Collection (LOCD

Wellhead Protection Program (WHPP)

State Revolving Fund (SRF)

Capacity Development Assessment

(CAPD)

Watershed Evaluation (WSHD)

Cross-Connection Inspection/Investigation (XCON)

Public Hearing (PUBH)

PWSS Staff:

New System WS Name Entry Point

Treatment Plant Activity Status Source Activity Status Legal Entity

DEQ 4800 (Revised 11/2017)

State Type Population - affects compliance only

Activity Status (Deactivation, Reactivation)

IMMEDIATE Attention Needed by Data Entry (to record changes as indicated):

Comments From the Last Sanitary Survey (SNSV) (from date above): (comments must not exceed 300 words):

Person(s) Contacted:

If >1 staff member, list primary first.

SNSV 11/29/2018

WHITE, JOEY

TOMMY TWIDDY, MIKE BERRY, ANDY ROGERS

RTCR SAMPLE SITING PLAN NOT AVAILABLE. APPEARS SYSTEM IS ELIGIBLE FOR REDUCED SAMPLE FREQUENCY FOR DBPS. COLLECTING BACTI SAMPLES MONTHLY. REVIEW OF MORS SHOWS SOME WTP FREE CHLORINE RESIDUALS <0.2 MG/L. MIKE BERRY IS NOW ORC FOR WTP & DISTRIBUTION. NOTE UPDATED EMERGENCY CONTACT INFORMATION. WE DISCUSSED PLANNED MAINTENANCE FOR HYDROPNEUMATIC & GROUND STORAGE

TANK. SYSTEM IS NOT CURRENLTY USING GPWMOR APPLICATION.

Public Water Supply Section Page 1 of 22

Water System Name: Water System No.: FORT RALEIGH--CAPE HATTERAS NS NC0428415

Water System Name: Water System No.:

SITE VISIT REPORT ADDENDUM (DEQ 4800B)

Specific Deficiency(ies) or Recommendation(s): (see deficiency checklist for description code and text).

Description:

Severity: Significant; Minor; Recommendation Category: SO; TR; DS; FW; PU; MR; SM; OC;

OT

Date Identified: (MM/DD/YYYY) Water System Notification Date: (MM/DD/YYYY)

WS Facility ID:

Resolved Date: (MM/DD/YYYY)

Comments:

Compliance Schedule: Resolve within how many days:

(30; 60; 90; 120; 150; 180; 360) Due Date:

Specific Deficiency(ies) or Recommendation(s): (see deficiency checklist for description code and text).

Description:

Severity: Significant; Minor; Recommendation Category: SO; TR; DS; FW; PU; MR; SM; OC;

OT

Date Identified: (MM/DD/YYYY) Water System Notification Date: (MM/DD/YYYY)

WS Facility ID:

Resolved Date: (MM/DD/YYYY)

Comments:

Compliance Schedule: Resolve within how many days:

(30; 60; 90; 120; 150; 180; 360) Due Date:

Specific Deficiency(ies) or Recommendation(s): (see deficiency checklist for description code and text).

Description:

Severity: Significant; Minor; Recommendation Category: SO; TR; DS; FW; PU; MR; SM; OC;

OT

Date Identified: (MM/DD/YYYY) Water System Notification Date: (MM/DD/YYYY)

WS Facility ID:

Resolved Date: (MM/DD/YYYY)

Comments:

Compliance Schedule: Resolve within how many days: (30; 60; 90; 120; 150; 180; 360) Due Date:

Public Water Supply Section Page 2 of 22

DEQ 4800B (Revised 11/2017)

Specific Deficiency(ies) or Recommendation(s): (see deficiency checklist for description code and text).

Description:

Severity: Significant; Minor; Recommendation Category: SO; TR; DS; FW; PU; MR; SM; OC;

OT

Date Identified: (MM/DD/YYYY) Water System Notification Date: (MM/DD/YYYY)

WS Facility ID:

Resolved Date: (MM/DD/YYYY)

Comments:

Compliance Schedule: Resolve within how many days:

(30; 60; 90; 120; 150; 180; 360) Due Date:

Specific Deficiency(ies) or Recommendation(s): (see deficiency checklist for description code and text).

Description:

Severity: Significant; Minor; Recommendation Category: SO; TR; DS; FW; PU; MR; SM; OC;

OT

Date Identified: (MM/DD/YYYY) Water System Notification Date: (MM/DD/YYYY)

WS Facility ID:

Resolved Date: (MM/DD/YYYY)

Comments:

Compliance Schedule: Resolve within how many days:

(30; 60; 90; 120; 150; 180; 360) Due Date:

Specific Deficiency(ies) or Recommendation(s): (see deficiency checklist for description code and text).

Description:

Severity: Significant; Minor; Recommendation Category: SO; TR; DS; FW; PU; MR; SM; OC;

OT

Date Identified: (MM/DD/YYYY) Water System Notification Date: (MM/DD/YYYY)

WS Facility ID:

Resolved Date: (MM/DD/YYYY)

Comments:

Public Water Supply Section Page 3 of 22

INVENTORY REPORT

BASIC INFORMATION of the Public Water System

Water System No.: Water System Name:

NC Department of Environmental Quality

Division of Water Resources, Public Water Supply Section

FORT RALEIGH--CAPE HATTERAS NS NC0428415

Local Gov't; Federal Gov't; Mixed (public/private); Private; State Gov't

(Can have more than one Service Area, but one must be Primary)

(Must have one Primary Service Area)Primary:

(Residential; Commercial; Combined; Industrial; Agricultural; Power Production)

(Metered (ME); Unmetered (UM);Metered and Unmetered (MU); Unknown (UN))

(if still in effect, leave End Date blank)

(MM/DD/YYYY)

End Date:

(MM/DD/YYYY)

(Residential; Non-Transient;

Transient; Wholesale)

Effective Begin Date:

(Calculated by SDWIS; uses all population types with blank effective end date(s))

(default AOP is 01/01 - 12/31)

End Month:

Groundwater (GW); Surface Water (SW); Groundwater UDI Surface Water (GU); Purchase Groundwater (GWP); Purchase Surface Water (SWP);

Purchase Groundwater UDI Surface Water (GUP)

Non-Transient Non-Community (NTNC) State Non-Public (STNP)

Non-Community Transient (NC) Adjacent NTNC (ANT)

Federal Primary Source:

None; Abandoned/Discontinued (AB); Duplicated with another PWSID# (DU); Connected to another PWSID# (CN); Not a PWS (UN); NCUC WR Classification (WR); Reactivation (RA);

(MM/DD/YYYY)

Status Date:Active; Inactive; Proposed

Owner Type:

Status Reason Code:

Activity Status:

Federal Type:

Status Reason: (Explanation or if duplicated or connected to another PWSID#, please supply other PWSID# and name.)

Community (C) Adjacent Community (ACOM)

State Type:

State Primary Source:

(If mixed water [using only Active Permanent and Active Seasonal sources], use following hierarchy:

Number of Days/Year Serving at least 25 (only needed if different than AOP(s)):

Annual Operating Period (AOP): Begin Month:

Total Calculated Daily Population:

Population:

Type:

Service Connections (#):

Type:

Meter Type:

Service Area(s):

DEQ 4801 (Revised 11/2017)

Federal Gov

Active 06/01/1977

NTNC GW

NTNC

GW

1 12 1 31

Non-Transient

UN

Commercial

PA Yes

05/01/2006

Public Water Supply Section Page 4 of 22

Transient (T) areas:

Other Transient Area (Church, etc.) (OT)

Highway Rest Area (HR)

Restaurant (RS)

Regional Office:County:City:

Geographic Areas

Other Area (OA)Dispenser (DI)Water Bottler (WB)

Recreation Area ("RCOM", etc) (PA)

Retail Employees (RE)

Hotel/Motel (HM)

School (SC)

Other NT Area (ON)

Sanitary Improvement District (SI)

Residential Area (RA)

Municipality (MU)

Homeowners Assoc. (HA)

Other Residential Area (OR)

Institution (IN)

Industrial/Agricultural (IA)

Service Station (SS)

Summer Camp (SK)

Secondary Residence (SR)

Interstate Carrier (IC) Other (O) areas:

Wholesaler (sells water) (WH)

Non-Transient (NT) areas:

Day Care Center (DC)

Medical Facility (MF)

Residential (R) areas:

Subdivision (SU)

Mobile Home Park - Principal Residence (MP)

Groundwater % Groundwater UDI % Surface Water % Total: 100%

(gallons per day)

Average Daily Production:

Total Design Capacity:

Total Emergency Capacity:

Maximum Daily Production:

(gallons per day)

(gallons per day)

(gallons per day)

Flows:

PurchasedNon-Purchased

Source Water Percentages (active permanent and active seasonal sources only)

Seasonal Pressure Status:

Measures:

Approved Number of Connections:

Indicators:

Auxiliary Power: (Yes or No) Date: (MM/DD/YYYY)

DEQ 4801 (Revised 11/2017)

Required MRT Chlorine Tests:

(per week (wk); per month (mo))

Approved System:

Grandfathered System:

Existed Prior to Activation:

BA Audit Performed:

LC Audit Performed:

Approved Reduction of MRT Chlorine Tests:

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

Date:

Date:

Date:

Date:

Date:

Date:

(MM/DD/YYYY)

(Latest Approval Date)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)Date:

(NPAY or

APIO)

NPAY = not pressurized all year

APIO = all pressurized including offseason

MANTEO DARE WASHINGTON

100 0 0 0 0 0

3,729

28,800

57,600

65,410

1 WK

YES

YES 01/21/2011

YES 04/27/2010

Public Water Supply Section Page 5 of 22

Division of Water Resources, Public Water Supply Section

INVENTORY REPORT

Legal Entities

RELATED POINTS of CONTACT of the Public Water

Water System Name: Water System No.: NC0428415FORT RALEIGH--CAPE HATTERAS NS

Physical Location Date Became PL:

Zip:State:City:

Address Line 2:

Address Line 1:

And/Or

Directions:

MANTEO NC 27954

1401 NATIONAL PRK DR

10/21/2008

FT RALEIGH OF US 64 WEST

(MUST be a person! An Individual)

First Name:

Address Line 1:

Address Line 2:

Date Became AC:

Last Name:

City: State: Zip:

MIKE BERRY

1401 NATIONAL PARK DR.

MANTEO NC 27954

06/01/2016Administrative Contact

Phone Numbers:

(MM/DD/YYYY)

252-475-9005 Ext.:Business:

Ext.:Emergency:

252-473-1543 Ext.:Home:

252-475-8325 Ext.:Mobile:

Ext.:Pager:

Ext.:Fax:

Email: mike_berry@nps.gov

If an Individual (IN):

First Name:

Address Line 1:

Address Line 2:

Date Became OW:

Last Name:

City: State: Zip:

1401 NATIONAL PARK DRIVE

ATTN JOHN KOWLOK

MANTEO NC 27954

01/01/1100Owner Contact

Or "a Company" (CM):

Name: NATIONAL PARK SERVICE_0428415

Phone Numbers:

(MM/DD/YYYY)

252-475-9024 Ext.:Business:

Ext.:Emergency:

Ext.:Home:

Ext.:Mobile:

Ext.:Pager:

Ext.:Fax:

Email: John_Kowlok@nps.gov

Public Water Supply Section Page 6 of 22

Name: BERRY, MIKE

Phone Numbers:

10/21/2015Date Became EC:Emergency Contact (MM/DD/YYYY)

252-475-9005 Ext.:Business:

Ext.:Emergency:

252-473-1543 Ext.:Home:

252-475-8325 Ext.:Mobile:

Ext.:Pager:

Ext.:Fax:

Email: mike_berry@nps.gov

Name: ROGERS, JOSEPH "ANDY"

Phone Numbers:

01/01/2017Date Became EC:Emergency Contact (MM/DD/YYYY)

252-475-9005 Ext.:Business:

Ext.:Emergency:

252-802-0353 Ext.:Home:

252-216-5998 Ext.:Mobile:

Ext.:Pager:

Ext.:Fax:

Email: joseph_rogers@nps.gov

DEQ 4802 (Revised 11/2017)

Public Water Supply Section Page 7 of 22

Division of Water Resources, Public Water Supply Section

INVENTORY REPORT

WELL FACILITY

Water System Name:

WSF State Assigned ID: Type:

WSF Name:

Source Treatment Status: Treated; Not Treated

Availability: Permanent; Seasonal; Emergency; Interim; Other (If Seasonal, fill in AOP dates below)

Activity Status: Active; Inactive; Proposed Activity Date: (MM/DD/YYYY)

Activity Status Reason: <None> (default); Abandoned; Decommissioned; Maintained; Low Yield; Contaminated;

Equipment Not Being Used; General Water Quality; Reactivated; Activation (New Well)

Activity Comment:

Water Type: Groundwater; Groundwater UDI Surface Date:

(MM/DD/YYYY)

Annual Operating Period (AOP): (If Seasonal) Begin Month: End Month:

When did this season go into effect?

Begin Date: End Date:

(If still in effect, leave End Date blank)

Sampling Point: In general, if a well flows to treatment, then Sampling Point Type is RW, if no treatment, then Sampling Point Type is EP. (See SOP_SamplingPoints_Creation_Final20060830.doc)

Entry Point Code: Location:

Note 1:

Sampling Point Type:

Activity Status: Active; Inactive; Proposed Status Date:

(MM/DD/YYYY)

Constructed Date: (MM/DD/YYYY)

Directions:

Drilling Method: Drilled; Bored; Other

Pump Type: Submersible; Jet; Vertical Turbine; Centrifugal; Hand Pump; Positive Displacement; Screw

Description:

Water System No.:

(Well)

Raw Water (RW); Entry Point (EP)

FORT RALEIGH--CAPE HATTERAS NS NC0428415

W02 WL

WELL #2

Treated

Permanent

Active 06/01/1977

Groundwater

RW2 RAW WATER

RW

Active 10/01/2009

SOUTH OF THE WTP

Drilled

Jet

STA RITE 1.5 HP

Public Water Supply Section Page 8 of 22

Well Casing:

Casing Type (Plastic; Steel; Concrete; or

Other)

Diameter (inches)

Top Measure (inches)

Top Measure Relative to Surface

(above or below)

Bottom Depth Measure

(feet)

Casing ID

1 3.00 12.00 AB 43.00

Screen:

ID USGS Aquifer Code

USGS Aquifer Name

Depth to Screen Top (feet)

Screen Type (e.g. sand point, slotted, etc.

Depth to Screen Bottom

(feet)

Flows:

(gallons per day)

(gallons per minute)

(gallons per minute)

(gallons per minute)

Average Daily Production:

Yield:

Approved Pump Capacity:

Actual Pump Capacity:

Measures:

(feet)

(feet)

(feet)

(hp)

(hp)

(feet)

Depth at Completion:

Grout Depth:

Static Water Level:

Approved Pump Horsepower:

Actual Pump Horsepower:

Pump Intake Level:

Indicators:

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

Date:

Date:

Date:

Date:

Date:

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

Auxiliary Power:

Surface Water within 200 feet:

Well Site Approved (C, NTNC):

Well Site Meets 2C Setbacks (NC):

Wellhead Protection Plan Approved:

Locational Information:

Latitude DMS:

Longitude DMS:

AND/OR

Differentially Corrected; GPS; Mapped/Surveyed

Collection Date:

Collection Method:

Latitude Measure:

Longitude Measure:

DEQ 4803 (Revised 11/2017)

(MM/DD/YYYY)

1,865.00

15.00

8.00

1.50

YES 01/01/2001

NO

35 56 00 .21 -75 42 04 .00

35.933392

-75.701112

04/27/2006

Differentially Corrected

Public Water Supply Section Page 9 of 22

WELL FACILITY

Water System Name:

WSF State Assigned ID: Type:

WSF Name:

Source Treatment Status: Treated; Not Treated

Availability: Permanent; Seasonal; Emergency; Interim; Other (If Seasonal, fill in AOP dates below)

Activity Status: Active; Inactive; Proposed Activity Date: (MM/DD/YYYY)

Activity Status Reason: <None> (default); Abandoned; Decommissioned; Maintained; Low Yield; Contaminated;

Equipment Not Being Used; General Water Quality; Reactivated; Activation (New Well)

Activity Comment:

Water Type: Groundwater; Groundwater UDI Surface Date:

(MM/DD/YYYY)

Annual Operating Period (AOP): (If Seasonal) Begin Month: End Month:

When did this season go into effect?

Begin Date: End Date:

(If still in effect, leave End Date blank)

Sampling Point: In general, if a well flows to treatment, then Sampling Point Type is RW, if no treatment, then Sampling Point Type is EP. (See SOP_SamplingPoints_Creation_Final20060830.doc)

Entry Point Code: Location:

Note 1:

Sampling Point Type:

Activity Status: Active; Inactive; Proposed Status Date:

(MM/DD/YYYY)

Constructed Date: (MM/DD/YYYY)

Directions:

Drilling Method: Drilled; Bored; Other

Pump Type: Submersible; Jet; Vertical Turbine; Centrifugal; Hand Pump; Positive Displacement; Screw

Description:

Water System No.:

(Well)

Raw Water (RW); Entry Point (EP)

FORT RALEIGH--CAPE HATTERAS NS NC0428415

W1A WL

WELL 1A

Treated

Permanent

Active 03/01/2011

AC

NEEDS CONCRETE 3FT RADIUS

Groundwater

RW3 RAW WATER

RW

Active 03/01/2011

02/19/2009

NORTH OF WTP

Drilled

Jet

STA RITE 1.5 HP

Public Water Supply Section Page 10 of 22

Casing Type (Plastic; Steel; Concrete; or

Other)

Diameter (inches)

Top Measure (inches)

Top Measure Relative to Surface

(above or below)

Bottom Depth Measure

(feet)

Casing ID

1 PLASTIC 3.00 18.00 AB 45.00

Screen:

ID USGS Aquifer Code

USGS Aquifer Name

Depth to Screen Top (feet)

Screen Type (e.g. sand point, slotted, etc.

Depth to Screen Bottom

(feet)

1 35.00 45.00

Flows:

(gallons per day)

(gallons per minute)

(gallons per minute)

(gallons per minute)

Average Daily Production:

Yield:

Approved Pump Capacity:

Actual Pump Capacity:

Measures:

(feet)

(feet)

(feet)

(hp)

(hp)

(feet)

Depth at Completion:

Grout Depth:

Static Water Level:

Approved Pump Horsepower:

Actual Pump Horsepower:

Pump Intake Level:

Indicators:

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

Date:

Date:

Date:

Date:

Date:

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

Auxiliary Power:

Surface Water within 200 feet:

Well Site Approved (C, NTNC):

Well Site Meets 2C Setbacks (NC):

Wellhead Protection Plan Approved:

Locational Information:

Latitude DMS:

Longitude DMS:

AND/OR

Differentially Corrected; GPS; Mapped/Surveyed

Collection Date:

Collection Method:

Latitude Measure:

Longitude Measure:

DEQ 4803 (Revised 11/2017)

(MM/DD/YYYY)

1,865.00

50.00

8.00 1.50 1.50

YES

NO

35 56 03 .99 -75 42 45 .02

35.934441

-75.712505

11/10/2004

Public Water Supply Section Page 11 of 22

Division of Water Resources, Public Water Supply Section

INVENTORY REPORT

TREATMENT PLANT FACILITY

Water System Name:

WSF State Assigned ID: Type:

WSF Name:

Availability: Permanent (P); Seasonal (S); Emergency (E); Interim (I); Other (O) (If Seasonal, fill in AOP dates below)

Activity Status: Active (A); Inactive (I); Proposed (P) Activity Date: (MM/DD/YYYY)

Activity Status Reason: <None> (default); Abandoned; Decommissioned; Maintained; Equipment Not Being Used;

Equipment Out of Service; Reactivated; Activation (New TP)

Activity Comment:

Water Type: Groundwater (GW); Groundwater UDI Surface (GU); Surface (SW)

Annual Operating Period (AOP): (If Seasonal) Begin Month: End Month:

When did this season go into effect?

Begin Date: End Date:

(If still in effect, leave End Date blank)

Sampling Point: (See SOP_PWS_Flows_Trains_20070625.xls for Flow. )

Sampling Point Code: Location:

Note 1:

Sampling Point Type:

Activity Status: Active (A); Inactive (I); Proposed (P) Status Date:

(MM/DD/YYYY)

Constructed Date: (MM/DD/YYYY)

Directions:

Water System No.:

(Treatment Plant)

Raw Water (RW); Entry Point (EP)

(Prefer 3 digits; max 12)

(default AOP: blank)

Physical Modification Date: (MM/DD/YYYY)

FORT RALEIGH--CAPE HATTERAS NS NC0428415

P01 TP

TREATMENT_PLT_WELL #1 &2

P

A 04/01/2006

GW

002 FT RALEIGH

FINISHED WTR TAP AT HYDRO TANK

EP

A 02/09/2011

SOUTH OF WTP

Public Water Supply Section Page 12 of 22

Flows:

Approved Design Capacity:

Measures:

Required Operator Visits:

Indicators:

Auxiliary Power:

Approved Reduction of Operator Visit Frequency:

Individual Treatment Parameter Rating at Least 10:

(gallons per day)

(per week)

(Yes or No)

(Yes or No)

(Yes or No)

Date:

Date:

Date:

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

Locational Information:

Latitude DMS:

Longitude DMS:

AND/OR

Collection Date:

Collection Method:

Latitude Measure:

Longitude Measure:

Differentially Corrected; GPS; Mapped/Surveyed

(MM/DD/YYYY)

Treatment Unit:

Treatment Objective(s), and the specific process(es) are as follows:

Type: Generic Unit (GU); Distribution System Treatment (DS) (please put "Booster" in the WSF name)

YES

NO

35 56 00 .21 -75 42 04 .00

35.933392 -75.701112

04/27/2006 Differentially Corrected

GU

D DISINFECTION 421 HYPOCHLORINATION, POST

DEQ 4804 (Revised 11/2017)

Public Water Supply Section Page 13 of 22

Division of Water Resources, Public Water Supply Section

INVENTORY REPORT

STORAGE FACILITY

Water System Name:

WSF State Assigned ID: Type:

WSF Name:

Availability: Permanent (P); Seasonal (S); Emergency (E); Interim (I); Other (O) (If Seasonal, fill in AOP dates below)

Activity Status: Active (A); Inactive (I); Proposed (P) Activity Date: (MM/DD/YYYY)

Activity Status Reason: <None> (default); Abandoned; Decommissioned; Maintained; Low Yield; Contaminated;

Equipment Not Being Used; General Water Quality; Reactivated; Activation (New Well)

Activity Comment:

Water Type: Groundwater (GW); Groundwater UDI Surface (GU); Surface (SW)

Annual Operating Period (AOP): (If Seasonal) Begin Month: End Month:

When did this season go into effect?

Begin Date: End Date:

(If still in effect, leave End Date blank)

Sampling Point:

Sampling Point Code: Location:

Note 1:

Sampling Point Type:

Activity Status: Active (A); Inactive (I); Proposed (P) Status Date:

(MM/DD/YYYY)

Constructed Date: (MM/DD/YYYY)

Directions:

Type: Bladder; Elevated; Ground; Hydropneumatic; Reservoir; Standpipe; Underground; Clear Well; Unknown

Construction Material:

Water System No.:

(Storage)

Raw Water (RW); Entry Point (EP)

(Prefer 3 digits; max 12)

(default AOP: blank)

Physical Modification Date: (MM/DD/YYYY)

Coating Type:

Comments:

Asbestos cement; Asphalt; Concrete; Copper; Earth; Fiberglass; Plastic; Steel; Wood

Approved paint (AP); Epoxy resin (ER); Fiberglass (FG); Glass-lined steel (GS); Greased;

Not approved paint (NP); Plastic; Unlined (UN)

FORT RALEIGH--CAPE HATTERAS NS NC0428415

G01

STORAGE_GROUND_1

ST

P

A 06/01/1977

GW

GR

CC

PL

CLEANED IN 2012

Public Water Supply Section Page 14 of 22

Approved Design Capacity:

Actual Capacity:

Effective Volume:

Indicators:

Auxiliary Power:

(gallons)

(gallons)

(Yes or No) Date: (MM/DD/YYYY)

DEQ 4805 (Revised 11/2017)

100,000

NO

Public Water Supply Section Page 15 of 22

STORAGE FACILITY

Water System Name:

WSF State Assigned ID: Type:

WSF Name:

Availability: Permanent (P); Seasonal (S); Emergency (E); Interim (I); Other (O) (If Seasonal, fill in AOP dates below)

Activity Status: Active (A); Inactive (I); Proposed (P) Activity Date: (MM/DD/YYYY)

Activity Status Reason: <None> (default); Abandoned; Decommissioned; Maintained; Low Yield; Contaminated;

Equipment Not Being Used; General Water Quality; Reactivated; Activation (New Well)

Activity Comment:

Water Type: Groundwater (GW); Groundwater UDI Surface (GU); Surface (SW)

Annual Operating Period (AOP): (If Seasonal) Begin Month: End Month:

When did this season go into effect?

Begin Date: End Date:

(If still in effect, leave End Date blank)

Sampling Point:

Sampling Point Code: Location:

Note 1:

Sampling Point Type:

Activity Status: Active (A); Inactive (I); Proposed (P) Status Date:

(MM/DD/YYYY)

Constructed Date: (MM/DD/YYYY)

Directions:

Type: Bladder; Elevated; Ground; Hydropneumatic; Reservoir; Standpipe; Underground; Clear Well; Unknown

Construction Material:

Water System No.:

(Storage)

Raw Water (RW); Entry Point (EP)

(Prefer 3 digits; max 12)

(default AOP: blank)

Physical Modification Date: (MM/DD/YYYY)

Coating Type:

Comments:

Asbestos cement; Asphalt; Concrete; Copper; Earth; Fiberglass; Plastic; Steel; Wood

Approved paint (AP); Epoxy resin (ER); Fiberglass (FG); Glass-lined steel (GS); Greased;

Not approved paint (NP); Plastic; Unlined (UN)

FORT RALEIGH--CAPE HATTERAS NS NC0428415

H01

STORAGE_HYDRO

ST

P

A 06/01/1977

GW

HD

ST

Public Water Supply Section Page 16 of 22

Approved Design Capacity:

Actual Capacity:

Effective Volume:

Indicators:

Auxiliary Power:

(gallons)

(gallons)

(Yes or No) Date: (MM/DD/YYYY)

DEQ 4805 (Revised 11/2017)

3,000

NO

Public Water Supply Section Page 17 of 22

Division of Water Resources, Public Water Supply Section

INVENTORY REPORT

COMMON HEADER FACILITY

Water System Name:

WSF State Assigned ID: Type:

WSF Name:

Availability: Permanent (P); Seasonal (S); Emergency (E); Interim (I); Other (O) (If Seasonal, fill in AOP dates below)

Activity Status: Active (A); Inactive (I); Proposed (P) Activity Date: (MM/DD/YYYY)

Activity Status Reason: <None> (default); Activation; Reactivation

Activity Comment:

Water Type: Groundwater (GW); Groundwater UDI Surface (GU); Surface (SW)

Annual Operating Period (AOP): (If Seasonal) Begin Month: End Month:

When did this season go into effect?

Begin Date: End Date:

(If still in effect, leave End Date blank)

Sampling Point(s):

Sampling Point Code: Location:

Note 1:

Sampling Point Type:

Activity Status: Active (A); Inactive (I); Proposed (P) Status Date:

(MM/DD/YYYY)

Water System No.:

(Common Header)

Raw Water (RW); Entry Point (EP)

(Prefer 3 digits; max 12)

(default AOP: blank)

DEQ 4806 (Revised 11/2017)

FORT RALEIGH--CAPE HATTERAS NS NC0428415

CH1 CH

COMMON HEADER_WELLS# 1A-2

P

A 02/09/2011

GW

Public Water Supply Section Page 18 of 22

Division of Water Resources, Public Water Supply Section

INVENTORY REPORT

WATER SYSTEMS FACILITIES (WSF) SUMMARY

Water System Name: Water System No:FORT RALEIGH--CAPE HATTERAS NS NC0428415

WSF ID WSF Name WSF Type Activity Status Availability

G01 STORAGE_GROUND_1 ST A P

H01 STORAGE_HYDRO ST A P

W01_INACTIVEWELL #1 WL I P

D01 DISTRIBUTION SYSTEM DS A P

P01 TREATMENT_PLT_WELL #1 &2 TP A P

CH1 COMMON HEADER_WELLS# 1A-2 CH A P

W02 WELL #2 WL A P

W1A WELL 1A WL A P

DEQ 4811 (Revised 11/2017)

Public Water Supply Section Page 19 of 22

Division of Water Resources, Public Water Supply Section

INVENTORY REPORT

WATER SYSTEM FACILITIES (WSF) FLOW SUMMARY

Water System Name:

NameTypeWSFID*NameTypeSequenceTrain

Receiving Facility

Water System No:

Supplying Facility

NC0428415FORT RALEIGH--CAPE HATTERAS NS

T1 A1 WL WELL #2 CHCH1 COMMON HEADER_WELLS# 1A-2

T1 A2 WL WELL 1A CHCH1 COMMON HEADER_WELLS# 1A-2

T1 B CH COMMON HEADER_WELLS# 1A-2 TPP01 TREATMENT_PLT_WELL #1 &2

T1 C TP TREATMENT_PLT_WELL #1 &2 DSD01 DISTRIBUTION SYSTEM

*-facility ID is the receiving facility ID on the treatment train, not supplying facility ID

Public Water Supply Section Page 20 of 22

Division of Water Resources, Public Water Supply Section

INVENTORY REPORT

RTCR SPECIAL MONITORING EVALUATION

Water System Name: Water System No.: County:

Federal Type (C, NC, NTNC, NP): Source Type: Population:

Current Coliform Monitoring Schedule (Number of Samples / Period): Current Schedule Type:

FORT RALEIGH--CAPE HATTERAS NS NC0428415 DARE

Based on review during the Sanitary Survey, is there any reason to change the water system's monitoring schedule?

Based on review during the Sanitary Survey, was there any reason to change the water system's Sampling Plan?

No

Yes

NTNC GW 40

1 / Quarter

Annual Operating Period:

1 1 12 31 --/ /

Routine

Yes

No

Seasonal Pressure Status*:

Regional Office Evaluation

Date*:

If yes, explain:

If yes, explain:

(Contact Central Office RTCR staff about needed monitoring changes)

*Not applicable if annual operating period is 1/1 - 12/31.

Appropriate number of samples?

Monitoring at appropriate locations?

Seasonal system monitoring during appropriate designated time period?

Yes No

NoYes

NoYes N/A

DEQ 4900 (Revised 11/2017)

Public Water Supply Section Page 21 of 22

Division of Water Resources, Water Treatment Facilities Operators Certification Board

INVENTORY REPORT

OPERATOR INFORMATION

Cross Connection Control Operator Required? (Yes/No) (Cross connection certified operator required if system has 5 or more testable cross connection control devices)

Distribution Operator Required? (Yes/No)

Water System Name: Water System No.:

FORT RALEIGH--CAPE HATTERAS NS NC0428415

Certified Operator: (New or Existing)

Last Name:

Work Phone: Home Phone:

Operator Grade and Type: Operator Certification No.:

Address 1:

City: State: Zip Code:

Address 2:

System Grade and Type:

C-Well

First Name:TWIDDY THOMAS

POST OFFICE BOX 40

MANNS HARBOR NC 27953

2524805514

C-Well 976149

Please send this form directly to Operators Certification Board Or fax to (919) 715-2726 (Do Not Send If Information Not Changed)

DEQ 5800 (Revised 11/2017)

Public Water Supply Section Page 22 of 22

Division of Water Resources, Public Water Supply Section

SITE VISIT REPORT

Entered into SDWIS at RO by :

Name Date

Water System Name: Water System No.: FRISCO CAMPGROUND NC0428422

Site Visit Primary Reason: MM/DD/YYYYDate of Visit:

Sanitary Survey (SNSV)

Sanitary Hazard Investigation (SHAZ)

Compliance Assistance (CMPA)

Water Treatment Plant Site Visit (TRTP)

Training (TRNG)

Emergency Assistance (EMRG)

Engineering Determination/Advice/Plan

Review (ENGR)

Investigation (Complaint/Violation/etc)

(INVG)

Laboratory Inspection (LABI)

Informal System Inspection (INFI)

Permit (Qualification/Review/Compliance)

(PRMT)

Sample Collection (SMPL)

Technical Assistance (non-specific) (TECH)

Variance/Exemption Related (VAEX)

Formal Enforcement (FENF)

Follow-up to Formal Enforcement (FUFE)

Informal Enforcement (IENF)

Comprehensive Performance Evaluation

(CPE) (CPEV)

Construction Inspection (CNST)

Operation & Maintenance (OM)

Records Review (RCDR)

Site Inspection (SITE)

Needs Survey (NEED)

Source Water Inspection (SRCE)

Locational Data Collection (LOCD

Wellhead Protection Program (WHPP)

State Revolving Fund (SRF)

Capacity Development Assessment

(CAPD)

Watershed Evaluation (WSHD)

Cross-Connection

Inspection/Investigation (XCON)

Public Hearing (PUBH)

PWSS Staff:

New System

WS Name

Entry Point

Treatment Plant Activity Status

Source Activity Status

Legal Entity

DEQ 4800 (Revised 11/2017)

State Type

Population - affects compliance only

Activity Status (Deactivation, Reactivation)

IMMEDIATE Attention Needed by Data Entry (to record changes as indicated):

Comments From the Last Sanitary Survey (SNSV) (from date above): (comments must not exceed 300 words):

Person(s) Contacted:

If >1 staff member, list primary first.

SNSV 05/22/2017

MIDGETTE, JAMIE

SHELLY ROLLINSON, ORC

CAMP MAY STAY OPEN THROUGH THANKSGIVING HOLIDAY. SHELLY WILL NOTIFY US WHEN THE DECISION IS

FINAL. WELLS ARE OPERATED MANUALLY, ONE PER DAY. PORTABLE GENERATOR AVAILABLE. IF BACKUP IS

UNAVAILABLE, THE CAMP CLOSES THE SHOWERS TO CONSERVE WATER. SHELLY COMPLETED AND SUBMITTED

START UP FORM FOR RTCR. SEASONAL SYSTEM.

Public Water Supply Section Page 1 of 24

Water System Name: Water System No.: FRISCO CAMPGROUND NC0428422

Water System Name: Water System No.:

SITE VISIT REPORT ADDENDUM (DEQ 4800B)

Specific Deficiency(ies) or Recommendation(s): (see deficiency checklist for description code and text).

Description:

Severity: Significant; Minor; Recommendation Category: SO; TR; DS; FW; PU; MR; SM; OC;

OT

Date Identified: (MM/DD/YYYY) Water System Notification Date: (MM/DD/YYYY)

WS Facility ID:

Resolved Date: (MM/DD/YYYY)

Comments:

Compliance Schedule: Resolve within how many days:

(30; 60; 90; 120; 150; 180; 360) Due Date:

Specific Deficiency(ies) or Recommendation(s): (see deficiency checklist for description code and text).

Description:

Severity: Significant; Minor; Recommendation Category: SO; TR; DS; FW; PU; MR; SM; OC;

OT

Date Identified: (MM/DD/YYYY) Water System Notification Date: (MM/DD/YYYY)

WS Facility ID:

Resolved Date: (MM/DD/YYYY)

Comments:

Compliance Schedule: Resolve within how many days:

(30; 60; 90; 120; 150; 180; 360) Due Date:

Specific Deficiency(ies) or Recommendation(s): (see deficiency checklist for description code and text).

Description:

Severity: Significant; Minor; Recommendation Category: SO; TR; DS; FW; PU; MR; SM; OC;

OT

Date Identified: (MM/DD/YYYY) Water System Notification Date: (MM/DD/YYYY)

WS Facility ID:

Resolved Date: (MM/DD/YYYY)

Comments:

Public Water Supply Section Page 2 of 24

DEQ 4800B (Revised 11/2017)

Specific Deficiency(ies) or Recommendation(s): (see deficiency checklist for description code and text).

Description:

Severity: Significant; Minor; Recommendation Category: SO; TR; DS; FW; PU; MR; SM; OC;

OT

Date Identified: (MM/DD/YYYY) Water System Notification Date: (MM/DD/YYYY)

WS Facility ID:

Resolved Date: (MM/DD/YYYY)

Comments:

Compliance Schedule: Resolve within how many days:

(30; 60; 90; 120; 150; 180; 360) Due Date:

Specific Deficiency(ies) or Recommendation(s): (see deficiency checklist for description code and text).

Description:

Severity: Significant; Minor; Recommendation Category: SO; TR; DS; FW; PU; MR; SM; OC;

OT

Date Identified: (MM/DD/YYYY) Water System Notification Date: (MM/DD/YYYY)

WS Facility ID:

Resolved Date: (MM/DD/YYYY)

Comments:

Compliance Schedule: Resolve within how many days:

(30; 60; 90; 120; 150; 180; 360) Due Date:

Specific Deficiency(ies) or Recommendation(s): (see deficiency checklist for description code and text).

Description:

Severity: Significant; Minor; Recommendation Category: SO; TR; DS; FW; PU; MR; SM; OC;

OT

Date Identified: (MM/DD/YYYY) Water System Notification Date: (MM/DD/YYYY)

WS Facility ID:

Resolved Date: (MM/DD/YYYY)

Comments:

Public Water Supply Section Page 3 of 24

INVENTORY REPORT

BASIC INFORMATION of the Public Water System

Water System No.: Water System Name:

NC Department of Environmental Quality

Division of Water Resources, Public Water Supply Section

FRISCO CAMPGROUND NC0428422

Local Gov't; Federal Gov't; Mixed (public/private); Private; State Gov't

(Can have more than one Service Area, but one must be Primary)

(Must have one Primary Service Area)Primary:

(Residential; Commercial; Combined; Industrial; Agricultural; Power Production)

(Metered (ME); Unmetered (UM);Metered and Unmetered (MU); Unknown (UN))

(if still in effect, leave End Date blank)

(MM/DD/YYYY)

End Date:

(MM/DD/YYYY)

(Residential; Non-Transient;

Transient; Wholesale)

Effective Begin Date:

(Calculated by SDWIS; uses all population types with blank effective end date(s))

(default AOP is 01/01 - 12/31)

End Month:

Groundwater (GW); Surface Water (SW); Groundwater UDI Surface Water

(GU); Purchase Groundwater (GWP); Purchase Surface Water (SWP);

Purchase Groundwater UDI Surface Water (GUP)

Non-Transient Non-Community (NTNC)

State Non-Public (STNP) Non-Community Transient (NC)

Adjacent NTNC (ANT)

Federal Primary Source:

None; Abandoned/Discontinued (AB); Duplicated with another PWSID# (DU); Connected to another PWSID# (CN); Not a PWS (UN); NCUC WR Classification (WR); Reactivation (RA);

(MM/DD/YYYY)

Status Date:Active; Inactive; Proposed

Owner Type:

Status Reason Code:

Activity Status:

Federal Type:

Status Reason: (Explanation or if duplicated or connected to another PWSID#, please supply other PWSID# and name.)

Community (C)

Adjacent Community (ACOM)

State Type:

State Primary Source:

(If mixed water [using only Active Permanent and Active Seasonal sources], use following hierarchy:

Number of Days/Year Serving at least 25 (only needed if different than AOP(s)):

Annual Operating Period (AOP): Begin Month:

Total Calculated Daily Population:

Population:

Type:

Service Connections (#):

Type:

Meter Type:

Service Area(s):

DEQ 4801 (Revised 11/2017)

Federal Gov

Active 03/01/1983

NC GW

NC

GW

1 10 1 31

Transient

UN

Commercial

PA Yes

05/01/2017

Public Water Supply Section Page 4 of 24

Transient (T) areas:

Other Transient Area (Church, etc.) (OT)

Highway Rest Area (HR)

Restaurant (RS)

Regional Office:County:City:

Geographic Areas

Other Area (OA)Dispenser (DI)Water Bottler (WB)

Recreation Area ("RCOM", etc) (PA)

Retail Employees (RE)

Hotel/Motel (HM)

School (SC)

Other NT Area (ON)

Sanitary Improvement District (SI)

Residential Area (RA)

Municipality (MU)

Homeowners Assoc. (HA)

Other Residential Area (OR)

Institution (IN)

Industrial/Agricultural (IA)

Service Station (SS)

Summer Camp (SK)

Secondary Residence (SR)

Interstate Carrier (IC) Other (O) areas:

Wholesaler (sells water) (WH)

Non-Transient (NT) areas:

Day Care Center (DC)

Medical Facility (MF)

Residential (R) areas:

Subdivision (SU)

Mobile Home Park - Principal Residence (MP)

Groundwater %

Groundwater UDI %

Surface Water %

Total:

(gallons per day)

Average Daily Production:

Total Design Capacity:

Total Emergency Capacity:

Maximum Daily Production:

(gallons per day)

(gallons per day)

(gallons per day)

Flows:

PurchasedNon-Purchased

Source Water Percentages (active permanent and active seasonal sources only)

Seasonal Pressure Status:

Measures:

Approved Number of Connections:

Indicators:

Auxiliary Power: (Yes or No) Date: (MM/DD/YYYY)

DEQ 4801 (Revised 11/2017)

Required MRT Chlorine Tests:

(per week (wk); per month (mo))

Approved System:

Grandfathered System:

Existed Prior to Activation:

BA Audit Performed:

LC Audit Performed:

Approved Reduction of MRT Chlorine Tests:

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

Date:

Date:

Date:

Date:

Date:

Date:

(MM/DD/YYYY)

(Latest Approval Date)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)Date:

(NPAY or

APIO)

NPAY = not pressurized all year

APIO = all pressurized including offseason

FRISCO DARE WASHINGTON

100 0

0 0

0 0

1,900

32,400

13,200

YES

YES 01/31/2012

NPAY 12/07/2015

Public Water Supply Section Page 5 of 24

Division of Water Resources, Public Water Supply Section

INVENTORY REPORT

Legal Entities

RELATED POINTS of CONTACT of the Public Water

Water System Name: Water System No.: NC0428422FRISCO CAMPGROUND

Physical Location Date Became PL:

Zip:State:City:

Address Line 2:

Address Line 1:

And/Or

Directions:

FRISCO NC 27936

10/21/2008

EAST END OF BILLY MITCHELL RD

(MUST be a person! An Individual)

First Name:

Address Line 1:

Address Line 2:

Date Became AC:

Last Name:

City: State: Zip:

SHELLY ROLLINSON

PO BOX 190

CAPE HATTERAS NAT'L SEASHORE

BUXTON NC 27920

01/01/1100Administrative Contact

Phone Numbers:

(MM/DD/YYYY)

252-475-9605 Ext.:Business:

Ext.:Emergency:

252-995-4639 Ext.:Home:

252-475-8318 Ext.: VRIZMobile:

Ext.:Pager:

252-995-3974 Ext.:Fax:

Email: shelly_rollinson@nps.gov

If an Individual (IN):

First Name:

Address Line 1:

Address Line 2:

Date Became OW:

Last Name:

City: State: Zip:

PO BOX 190

SHELLY ROLLINSON SUPERVISOR

BUXTON NC 27920

01/01/1100Owner Contact

Or "a Company" (CM):

Name: CAPE HATTERAS NATL SEASHORE_0428416

Phone Numbers:

(MM/DD/YYYY)

252-475-9506 Ext.:Business:

Ext.:Emergency:

252-995-4639 Ext.:Home:

252-475-8318 Ext.:Mobile:

Ext.:Pager:

252-995-3974 Ext.:Fax:

Email:

Public Water Supply Section Page 6 of 24

Name: ROLLINSON, SHELLY

Phone Numbers:

06/02/2011Date Became EC:Emergency Contact (MM/DD/YYYY)

252-475-9605 Ext.:Business:

Ext.:Emergency:

252-995-4639 Ext.:Home:

252-475-8318 Ext.: VRIZMobile:

Ext.:Pager:

252-995-3974 Ext.:Fax:

Email: shelly_rollinson@nps.gov

DEQ 4802 (Revised 11/2017)

Public Water Supply Section Page 7 of 24

Division of Water Resources, Public Water Supply Section

INVENTORY REPORT

WELL FACILITY

Water System Name:

WSF State Assigned ID: Type:

WSF Name:

Source Treatment Status: Treated; Not Treated

Availability: Permanent; Seasonal; Emergency; Interim; Other (If Seasonal, fill in AOP dates below)

Activity Status: Active; Inactive; Proposed Activity Date: (MM/DD/YYYY)

Activity Status Reason: <None> (default); Abandoned; Decommissioned; Maintained; Low Yield; Contaminated;

Equipment Not Being Used; General Water Quality; Reactivated; Activation (New Well)

Activity Comment:

Water Type: Groundwater; Groundwater UDI Surface Date:

(MM/DD/YYYY)

Annual Operating Period (AOP): (If Seasonal) Begin Month: End Month:

When did this season go into effect?

Begin Date: End Date:

(If still in effect, leave End Date blank)

Sampling Point: In general, if a well flows to treatment, then Sampling Point Type is RW, if no treatment, then Sampling

Point Type is EP. (See SOP_SamplingPoints_Creation_Final20060830.doc)

Entry Point Code: Location:

Note 1:

Sampling Point Type:

Activity Status: Active; Inactive; Proposed Status Date:

(MM/DD/YYYY)

Constructed Date: (MM/DD/YYYY)

Directions:

Drilling Method: Drilled; Bored; Other

Pump Type: Submersible; Jet; Vertical Turbine; Centrifugal; Hand Pump; Positive Displacement; Screw

Description:

Water System No.:

(Well)

Raw Water (RW); Entry Point (EP)

FRISCO CAMPGROUND NC0428422

W01 WL

WELL #1

Treated

Permanent

Active 03/01/1983

Groundwater

RW1 RAW WATER

RW

Active 10/01/2009

100 SW OF TREATMENT PLANT

Drilled

Jet

Public Water Supply Section Page 8 of 24

Casing Type (Plastic; Steel; Concrete; or

Other)

Diameter (inches)

Top Measure (inches)

Top Measure

Relative to Surface (above or below)

Bottom Depth

Measure (feet)

Casing ID

1 PLASTIC 2.00 12.00 AB 50.00

Screen:

ID USGS Aquifer

Code

USGS Aquifer

Name

Depth to Screen

Top (feet)

Screen Type (e.g. sand point, slotted, etc.

Depth to Screen

Bottom (feet)

Flows:

(gallons per day)

(gallons per minute)

(gallons per minute)

(gallons per minute)

Average Daily Production:

Yield:

Approved Pump Capacity:

Actual Pump Capacity:

Measures:

(feet)

(feet)

(feet)

(hp)

(hp)

(feet)

Depth at Completion:

Grout Depth:

Static Water Level:

Approved Pump Horsepower:

Actual Pump Horsepower:

Pump Intake Level:

Indicators:

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

Date:

Date:

Date:

Date:

Date:

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

Auxiliary Power:

Surface Water within 200 feet:

Well Site Approved (C, NTNC):

Well Site Meets 2C Setbacks (NC):

Wellhead Protection Plan Approved:

Locational Information:

Latitude DMS:

Longitude DMS:

AND/OR

Differentially Corrected; GPS; Mapped/Surveyed

Collection Date:

Collection Method:

Latitude Measure:

Longitude Measure:

DEQ 4803 (Revised 11/2017)

(MM/DD/YYYY)

2,336.00

42.00

1.00

NO

35 14 30 .15

-75 35 08 .59

35.24

-75.59

05/19/2004

Public Water Supply Section Page 9 of 24

Water System Name:

WSF State Assigned ID: Type:

WSF Name:

Source Treatment Status: Treated; Not Treated

Availability: Permanent; Seasonal; Emergency; Interim; Other (If Seasonal, fill in AOP dates below)

Activity Status: Active; Inactive; Proposed Activity Date: (MM/DD/YYYY)

Activity Status Reason: <None> (default); Abandoned; Decommissioned; Maintained; Low Yield; Contaminated;

Equipment Not Being Used; General Water Quality; Reactivated; Activation (New Well)

Activity Comment:

Water Type: Groundwater; Groundwater UDI Surface Date:

(MM/DD/YYYY)

Annual Operating Period (AOP): (If Seasonal) Begin Month: End Month:

When did this season go into effect?

Begin Date: End Date:

(If still in effect, leave End Date blank)

Sampling Point: In general, if a well flows to treatment, then Sampling Point Type is RW, if no treatment, then Sampling

Point Type is EP. (See SOP_SamplingPoints_Creation_Final20060830.doc)

Entry Point Code: Location:

Note 1:

Sampling Point Type:

Activity Status: Active; Inactive; Proposed Status Date:

(MM/DD/YYYY)

Constructed Date: (MM/DD/YYYY)

Directions:

Drilling Method: Drilled; Bored; Other

Pump Type: Submersible; Jet; Vertical Turbine; Centrifugal; Hand Pump; Positive Displacement; Screw

Description:

Water System No.:

(Well)

Raw Water (RW); Entry Point (EP)

FRISCO CAMPGROUND NC0428422

W02 WL

WELL #2

Treated

Permanent

Active 03/01/1983

Groundwater

RW2 RAW WATER

RW

Active 10/01/2009

100' W OF TREATMENT PLANT

Drilled

Jet

GOULDS

Public Water Supply Section Page 10 of 24

Casing Type (Plastic; Steel; Concrete; or

Other)

Diameter (inches)

Top Measure (inches)

Top Measure

Relative to Surface (above or below)

Bottom Depth

Measure (feet)

Casing ID

1 PLASTIC 2.00 12.00 AB 50.00

Screen:

ID USGS Aquifer

Code

USGS Aquifer

Name

Depth to Screen

Top (feet)

Screen Type (e.g. sand point, slotted, etc.

Depth to Screen

Bottom (feet)

Flows:

(gallons per day)

(gallons per minute)

(gallons per minute)

(gallons per minute)

Average Daily Production:

Yield:

Approved Pump Capacity:

Actual Pump Capacity:

Measures:

(feet)

(feet)

(feet)

(hp)

(hp)

(feet)

Depth at Completion:

Grout Depth:

Static Water Level:

Approved Pump Horsepower:

Actual Pump Horsepower:

Pump Intake Level:

Indicators:

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

Date:

Date:

Date:

Date:

Date:

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

Auxiliary Power:

Surface Water within 200 feet:

Well Site Approved (C, NTNC):

Well Site Meets 2C Setbacks (NC):

Wellhead Protection Plan Approved:

Locational Information:

Latitude DMS:

Longitude DMS:

AND/OR

Differentially Corrected; GPS; Mapped/Surveyed

Collection Date:

Collection Method:

Latitude Measure:

Longitude Measure:

DEQ 4803 (Revised 11/2017)

(MM/DD/YYYY)

2,336.00

42.00

1.00

NO

35 14 29 .32

-75 35 07 .43

35.24

-75.59

05/19/2004

Public Water Supply Section Page 11 of 24

Water System Name:

WSF State Assigned ID: Type:

WSF Name:

Source Treatment Status: Treated; Not Treated

Availability: Permanent; Seasonal; Emergency; Interim; Other (If Seasonal, fill in AOP dates below)

Activity Status: Active; Inactive; Proposed Activity Date: (MM/DD/YYYY)

Activity Status Reason: <None> (default); Abandoned; Decommissioned; Maintained; Low Yield; Contaminated;

Equipment Not Being Used; General Water Quality; Reactivated; Activation (New Well)

Activity Comment:

Water Type: Groundwater; Groundwater UDI Surface Date:

(MM/DD/YYYY)

Annual Operating Period (AOP): (If Seasonal) Begin Month: End Month:

When did this season go into effect?

Begin Date: End Date:

(If still in effect, leave End Date blank)

Sampling Point: In general, if a well flows to treatment, then Sampling Point Type is RW, if no treatment, then Sampling

Point Type is EP. (See SOP_SamplingPoints_Creation_Final20060830.doc)

Entry Point Code: Location:

Note 1:

Sampling Point Type:

Activity Status: Active; Inactive; Proposed Status Date:

(MM/DD/YYYY)

Constructed Date: (MM/DD/YYYY)

Directions:

Drilling Method: Drilled; Bored; Other

Pump Type: Submersible; Jet; Vertical Turbine; Centrifugal; Hand Pump; Positive Displacement; Screw

Description:

Water System No.:

(Well)

Raw Water (RW); Entry Point (EP)

FRISCO CAMPGROUND NC0428422

W03 WL

WELL #3

Treated

Permanent

Active 03/01/1983

Groundwater

RW3 RAW WATER

RW

Active 10/01/2009

100' NW OF TREATMENT PLANT

Drilled

Jet

GOULDS

Public Water Supply Section Page 12 of 24

Casing Type (Plastic; Steel; Concrete; or

Other)

Diameter (inches)

Top Measure (inches)

Top Measure

Relative to Surface (above or below)

Bottom Depth

Measure (feet)

Casing ID

1 PLASTIC 2.00 12.00 AB 50.00

Screen:

ID USGS Aquifer

Code

USGS Aquifer

Name

Depth to Screen

Top (feet)

Screen Type (e.g. sand point, slotted, etc.

Depth to Screen

Bottom (feet)

Flows:

(gallons per day)

(gallons per minute)

(gallons per minute)

(gallons per minute)

Average Daily Production:

Yield:

Approved Pump Capacity:

Actual Pump Capacity:

Measures:

(feet)

(feet)

(feet)

(hp)

(hp)

(feet)

Depth at Completion:

Grout Depth:

Static Water Level:

Approved Pump Horsepower:

Actual Pump Horsepower:

Pump Intake Level:

Indicators:

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

Date:

Date:

Date:

Date:

Date:

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

(Yes or No)

Auxiliary Power:

Surface Water within 200 feet:

Well Site Approved (C, NTNC):

Well Site Meets 2C Setbacks (NC):

Wellhead Protection Plan Approved:

Locational Information:

Latitude DMS:

Longitude DMS:

AND/OR

Differentially Corrected; GPS; Mapped/Surveyed

Collection Date:

Collection Method:

Latitude Measure:

Longitude Measure:

DEQ 4803 (Revised 11/2017)

(MM/DD/YYYY)

2,336.00

42.00

1.00

NO

35 14 28 .31

-75 35 05 .36

35.24

-75.58

05/19/2004

Public Water Supply Section Page 13 of 24

Division of Water Resources, Public Water Supply Section

INVENTORY REPORT

TREATMENT PLANT FACILITY

Water System Name:

WSF State Assigned ID: Type:

WSF Name:

Availability: Permanent (P); Seasonal (S); Emergency (E); Interim (I); Other (O) (If Seasonal, fill in AOP dates below)

Activity Status: Active (A); Inactive (I); Proposed (P) Activity Date: (MM/DD/YYYY)

Activity Status Reason: <None> (default); Abandoned; Decommissioned; Maintained; Equipment Not Being Used;

Equipment Out of Service; Reactivated; Activation (New TP)

Activity Comment:

Water Type: Groundwater (GW); Groundwater UDI Surface (GU); Surface (SW)

Annual Operating Period (AOP): (If Seasonal) Begin Month: End Month:

When did this season go into effect?

Begin Date: End Date:

(If still in effect, leave End Date blank)

Sampling Point: (See SOP_PWS_Flows_Trains_20070625.xls for Flow. )

Sampling Point Code: Location:

Note 1:

Sampling Point Type:

Activity Status: Active (A); Inactive (I); Proposed (P) Status Date:

(MM/DD/YYYY)

Constructed Date: (MM/DD/YYYY)

Directions:

Water System No.:

(Treatment Plant)

Raw Water (RW); Entry Point (EP)

(Prefer 3 digits; max 12)

(default AOP: blank)

Physical Modification Date: (MM/DD/YYYY)

FRISCO CAMPGROUND NC0428422

P01 TP

TREATMENT_PLT_WELL 1-3

P

A 06/01/1977

GW

E01 WELL #1 PUMP RM

EP

A 03/01/1983

Public Water Supply Section Page 14 of 24

Approved Design Capacity:

Measures:

Required Operator Visits:

Indicators:

Auxiliary Power:

Approved Reduction of Operator Visit Frequency:

Individual Treatment Parameter Rating at Least 10:

(gallons per day)

(per week)

(Yes or No)

(Yes or No)

(Yes or No)

Date:

Date:

Date:

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

Locational Information:

Latitude DMS:

Longitude DMS:

AND/OR

Collection Date:

Collection Method:

Latitude Measure:

Longitude Measure:

Differentially Corrected; GPS; Mapped/Surveyed

(MM/DD/YYYY)

Treatment Unit:

Treatment Objective(s), and the specific process(es) are as follows:

Type: Generic Unit (GU); Distribution System Treatment (DS) (please put "Booster" in the WSF name)

NO

35 14 30 .15

-75 35 08 .59

35.24

-75.59

05/19/2004

Differentially Corrected

GU

D DISINFECTION 421 HYPOCHLORINATION, POST

DEQ 4804 (Revised 11/2017)

Public Water Supply Section Page 15 of 24

Division of Water Resources, Public Water Supply Section

INVENTORY REPORT

STORAGE FACILITY

Water System Name:

WSF State Assigned ID: Type:

WSF Name:

Availability: Permanent (P); Seasonal (S); Emergency (E); Interim (I); Other (O) (If Seasonal, fill in AOP dates below)

Activity Status: Active (A); Inactive (I); Proposed (P) Activity Date: (MM/DD/YYYY)

Activity Status Reason: <None> (default); Abandoned; Decommissioned; Maintained; Low Yield; Contaminated;

Equipment Not Being Used; General Water Quality; Reactivated; Activation (New Well)

Activity Comment:

Water Type: Groundwater (GW); Groundwater UDI Surface (GU); Surface (SW)

Annual Operating Period (AOP): (If Seasonal) Begin Month: End Month:

When did this season go into effect?

Begin Date: End Date:

(If still in effect, leave End Date blank)

Sampling Point:

Sampling Point Code: Location:

Note 1:

Sampling Point Type:

Activity Status: Active (A); Inactive (I); Proposed (P) Status Date:

(MM/DD/YYYY)

Constructed Date: (MM/DD/YYYY)

Directions:

Type: Bladder; Elevated; Ground; Hydropneumatic; Reservoir; Standpipe; Underground; Clear Well; Unknown

Construction Material:

Water System No.:

(Storage)

Raw Water (RW); Entry Point (EP)

(Prefer 3 digits; max 12)

(default AOP: blank)

Physical Modification Date: (MM/DD/YYYY)

Coating Type:

Comments:

Asbestos cement; Asphalt; Concrete; Copper; Earth; Fiberglass; Plastic; Steel; Wood

Approved paint (AP); Epoxy resin (ER); Fiberglass (FG); Glass-lined steel (GS); Greased;

Not approved paint (NP); Plastic; Unlined (UN)

FRISCO CAMPGROUND NC0428422

B04

STORAGE_BLADDER_4

ST

P

A 03/01/1983

GW

BL

ST

4 BLADDER TANKS

Public Water Supply Section Page 16 of 24

Approved Design Capacity:

Actual Capacity:

Effective Volume:

Indicators:

Auxiliary Power:

(gallons)

(gallons)

(Yes or No) Date: (MM/DD/YYYY)

DEQ 4805 (Revised 11/2017)

1,056

YES

Public Water Supply Section Page 17 of 24

STORAGE FACILITY

Water System Name:

WSF State Assigned ID: Type:

WSF Name:

Availability: Permanent (P); Seasonal (S); Emergency (E); Interim (I); Other (O) (If Seasonal, fill in AOP dates below)

Activity Status: Active (A); Inactive (I); Proposed (P) Activity Date: (MM/DD/YYYY)

Activity Status Reason: <None> (default); Abandoned; Decommissioned; Maintained; Low Yield; Contaminated;

Equipment Not Being Used; General Water Quality; Reactivated; Activation (New Well)

Activity Comment:

Water Type: Groundwater (GW); Groundwater UDI Surface (GU); Surface (SW)

Annual Operating Period (AOP): (If Seasonal) Begin Month: End Month:

When did this season go into effect?

Begin Date: End Date:

(If still in effect, leave End Date blank)

Sampling Point:

Sampling Point Code: Location:

Note 1:

Sampling Point Type:

Activity Status: Active (A); Inactive (I); Proposed (P) Status Date:

(MM/DD/YYYY)

Constructed Date: (MM/DD/YYYY)

Directions:

Type: Bladder; Elevated; Ground; Hydropneumatic; Reservoir; Standpipe; Underground; Clear Well; Unknown

Construction Material:

Water System No.:

(Storage)

Raw Water (RW); Entry Point (EP)

(Prefer 3 digits; max 12)

(default AOP: blank)

Physical Modification Date: (MM/DD/YYYY)

Coating Type:

Comments:

Asbestos cement; Asphalt; Concrete; Copper; Earth; Fiberglass; Plastic; Steel; Wood

Approved paint (AP); Epoxy resin (ER); Fiberglass (FG); Glass-lined steel (GS); Greased;

Not approved paint (NP); Plastic; Unlined (UN)

FRISCO CAMPGROUND NC0428422

G01

STORAGE_GROUND_1

ST

P

A 03/01/1983

GW

GR

CC

INTERIOR CLEANING MARCH 2012

Public Water Supply Section Page 18 of 24

Approved Design Capacity:

Actual Capacity:

Effective…