WQ0019753_Residual Annual Report 2019_20200122

Initial Review
INITIAL REVIEW
Reviewer Williams, Kendall
Is this submittal an application? (Excluding additional information.)*
r Yes r No
If not an application r Annual Report
what is the submittal r Residual Annual Report
type?* r Additional Information
r Other
Annual Report 2019
Year*
Date Paper Copy 1/22/2020
Received:*
Project Number* WQ0019753
Email Notifications
Does this need review by the hydrogeologist?*
r Yes r No
Regional Office
CO Reviewer
Admin Reviewer [e-mail]

Submitted Form
Project Contact Information
Rease provide information on the person to be contacted by MB Staff regarding electronic subnittal, confirmation of receipt, and other issues.
..........................................................................................................................................................................................................................................................................................................................................................................
Name * J. Kevin Yates
Email Address*
[e-mail]
Project Information
.........................................................................................
Submittal Type* r New Permit Application
r Renewal
r Annual Report
r Other
Permit Type * r Wastewater Irrigation
r Other Wastewater
r Closed -Loop Recycle
r Single -Family Residence
Wastewater Irrigation
Is a paper copy of the application being submitted?
r Yes r Nor N/A
Permit Number* WQ0019753
Applicant\Permittee * Town of Madison
Facility Name * Madison Water Plant
Phone Number*
336-427-3971
r Modification (Major or Minor)
r Additional Information
r Residual Annual Report
r High -Rate Infiltration
r Reclaimed Water
r Residuals
r Other
Please provide comments/notes on your current submittal below.
No land application in 2019. We have two lagoons that we plan to land apply in 2020.
Please attach all information required or requested for this submittal to be review here.
Application Form Engineering Rans, Specifications, Calculations, Etc.)
2019 land app.pdf 21.57KB
Upload only 1 R7F document. NL@iple documents must be combined into one R7F file.

For new and modification permit applications, a paper copy may be required. If you have any questions
about what is required, please contactthe reviewer or Tessa Monday. If a paper 2-pol cation is required,
be advised, applications accepted for pre -review until both the paper and elect-c-ii.- --ol:ies have been
received. The paper copy shall include the following:
o Application Form
o All relevant attachments {talcs, soils report, specs, etc.]
o One full-size engineering plan set
o One 11x17" engineering plan set
o One extra set of specifications
o Fee (if required)
Mailine address:
Division of Water Resources ! Division of Water Resources
Non -Discharge Branch I Non -Discharge Branch
1617 Mail Service Center I Att: Nathaniel Thornburg, P Floor, Office #942W
- =
Raleigh, NC 27699-1617 S12 N.5alisburySt.
For questions or problems contact Tessa Monday attessa.monday@)ncdenr.Qov or 919.707.3560.
* rJ By checking this box I acknowledge that I understand the application will not be accepted
for pre -review until the paper copy (if required) and fee (if required) have been received by
the Non -Discharge Branch. I also confirm that the uploaded document is a single PDF with
all parts of the application in correct order (as specified by the application).
Signature
Submission Date 1/27/2020

CLASS A ANNUAL DISTRIBUTION AND MARKETING/ SURFACE DISPOSAL CERTIFICATION AND SUMMARY FORM
WQ PERMIT #: WQ0019753 FACILITY NAME:
Town of Madison WTP
PHONE: [phone] COUNTY: Rockingham OPERATOR: J. Kevin Yates
FACILITY TYPE (please check one): ❑ Surface Disposal (complete Part A (Source(s) and "Residual In" Volume only) and Part C)
0 Distribution and Marketing (complete Parts A, B, and C)
Was the facility in operation during the past calendar year? Yes ❑ No ❑ P If No skip parts A, B, C and certify form below
Part A*:
Part B*:
Month
Sources(s) (include NPDES # if
applicable)
Volume (dry tons)
Recipient Information
Amendment/
Bulking Agent
Residual In
Product Out
Name(s)
Volume (dry tons)
Intended use(s)
January
Did not land apply in 2019
February
March
April
May
June
July
August
September
October
November
December
Total from FORM DMSDF (sup)
Totals:
Annual (dry tons):
0
0
0
0
Amendment(s) used: Bulkin A ent(s) used:
* If more space is required, attach additional information sheets (FORM DMSDF (supp)): Total Number of Form DMSDF (Supp)
Part C:
Facility was compliant during the past calendar year with all conditions of the land application permit ❑ Yes
(including but not limited to items 1-3 below) issued by the Division of Water Resources: ❑ No 0 If No, Explain in Narritive
1. All monitoring was done in accordance with the permit and reported for the year as required and three (3) copies of certified laboratory results are attached.
2. All operation and maintenance requirements were compiled with or, in the case of a deviation, prior authorization was received from the Division of Water Resources.
No contravention of Ground Water Quality Standards occurred at a monitoring well.
"I certify, under penalty of law, that the above information is, to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant
penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
Signature of Permittee
Date Signature of Preparer* *
(if different from Permittee)
**Preparer is defined in 40 CFR Part 503.9(r) and 15A NCAC 2T .1102 (26)
Date
DENR FORM DMSDF (12/2006)