WQ0003992_Modification_1_20200930

Initial Review
Reviewer Thornburg, Nathaniel
Is this submittal an application? (Excluding additional information.)*
r Yes r No
Permit Number (IR)* WQ0003992
Applicant/Permittee Town of West Jefferson
Applicant/Permittee Address PO Box490 West Jefferson NC 28694
Is the owner in BIMS? r Yes r No Is the facility in BIMS? r Yes r No
Owner Type Municipal
Facility Name Town of West Jefferson RLAP
County Ashe
Fee Category Minor
Is this a complete
application?*
c Yes r No
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Does this need review bythe hydrogeologist?* r Yes r No
Regional Office
CO Reviewer
Admin Reviewer
Fee Amount $0
Complete App Date 09/30/2020
Below list any additional email address that need notification about a new project.
Email Address
Comments to be added to email notfication
Comments for Kendall
Comments for RO

Comments for Reviewer
Comments for Applicant

Submittal Form
Project Contact Information
Rease provide information on the person to be contacted by N B Staff
Name * Brandon Patrick
Email Address*
[e-mail]
electronic subntttal, confirmation of receipt, and other correspondence.
Project Information
........ ......... ..........................................................................................................................................
Application/Document Type* r New (Fee Req ui red)
r Modification - Major (Fee Required)
r Renewal with Major Modification (Fee
Required)
r Annual Report
r Additional Information
r Other
Phone Number*
3369776725
O Modification - Minor
C Renewal
C GW-59, NDMR, NDMLR, NDAR-1,
NDAR-2
r Residual Annual Report
r Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
https://edocs.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type:*
r Wastewater Irrigation
r High -Rate Infiltration
r Other Wastewater
r Reclaimed Water
r Closed -Loop Recycle
r Residuals
r Single -Family Residence Wastewater
r Other
Irrigation
Permit Number:*
WQ0003992
Fbs Current Existing permit number
Applicant/Permittee *
Town of West Jefferson
Applicant/Permittee Address*
PO Box490 West Jefferson NC 28694
Facility Name *
Town of West Jefferson RLAP
Please provide comments/notes
on your current submittal below.
The only change is to add the setback waivers to field DP-2.
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.*
(Application Form Engineering Rans, Spec'rfications, Calculations, Rc.)
Town of West Jefferson Mod.pdf 13.09MB
Cpload only 1 RCFdocurn:nt (less than 250 NS). NLftiple documents nest be corrbined into one RDFfile unless file is larger than
upload limit.
* W By checking this box, I acknowledge that I understand the application will not be
accepted for pre -review until the fee (if required) has been received by the Non -
Discharge Branch. Application fees must be submitted by check or money order
and made payable to the North Carolina Department of Environmental Quality
(NCDEQ). 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).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature *
Submission Date Is filled in automatically once submtted.

September 21, 2020
NCDEQ- Division of Water Resources
Water Quality Permitting Section
Non -discharge Permitting Section
1617 Mail Service Center,
Raleigh, NC 27699-1617
Reference: Modification of Permit No. WQ0003992
Town of West Jefferson Land Application Program
West Jefferson, North Carolina
Town of West Jefferson
Permit Renewal
Table of Contents
Residuals Land Application Program Form
Operation and Maintenance Plan
Residuals Source Certification Form
Facility Vicinity Map
Process Flow Diagram and Narrative
Justification for Residuals Production Rate
Residuals Sampling Plan
Analytical Data
Land Application Site Certification Form
Landowner Agreement Attachments
Site Vicinity and Buffer Maps
Cumulative Pollutant Loading Rates and Soil Metal Data
Soil Maps
Your attention in the review of this application for modification would be greatly appreciated.
The modification consists of lessening of the buffer on field DP-2 with the attachment of set-
back waivers. I have also added Nicholas Walters as Backup ORC on the Operation and
Maintenance Plan. Please contact me if you require additional information or have questions in
the review of the permit application.
Bran Patrick, RC
I
own of West Jefferson
PO Box 490
West Jefferson NC 28694
wwtp 11 townofwj.com 336-977-6725

Residuals Land Application Program Form

r State of North Carolina
DWF
Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02T .1100 — RESIDUALS LAND APPLICATION PROGRAM
INSTRUCTIONS FOR FORM: RLAP 06-16 & SUPPORTING DOCUMENTATION
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted. the Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Pennitthig Unit
General — This application is for treatment, storage, transport, and/or land application of Class B residuals (may include residuals that
are generated from a water treatment plant or other type facilities) on the proposed or currently approved land application site(s) under
I �A NCAC 02T .1 100.
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Residuals Land Application Program (FORM: RLAP 06-16) Application: (All Application Packages):
® Submit the completed and appropriately executed Residuals Land Application Program (FORM: RLAP 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® The Applicant's Certification on Page 5 of this form shall be signed in accordance with 15A NCAC 02T .0106(b). An alternate
person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria in 15A
N('AC 02T .0106 W.
® If this project is for a modification of an existing permit, submit one copy of the existing permit.
® Please submit this application form at least 180 days prior to the expiration date on the existing permit, or 90 days prior to
operation of proposed facility(ics) for application packages involving new or changes to treatment and storage units.
B. Application Fee (New and Major Modification Application Packages)
❑ Submit a check, money order or electronic funds transfer made payable to: North Carolina Department of Environmental
Quality (NCDI Q).
Facility Classification New Permit I Major Modification'
Major (land are permitted for z 300 acres) $1,310 $395
I 3
I
Minor (land are permitted for < 300 acres) $810 $245
' - A major modification shall be defined as any permit modification that: increases the generating facility's residuals dry tonnage;
adds additional land application areas not previously approved for that particular program [including transferring of field(s) from
one program to another[; adds additional residuals sources; or includes the addition of new treatment or storage units/processes not
previously permitted. There is no fee for minor modifications to a permit.
C. Cover Letter (All Application Packages)
N List all items included in the application package, as well as a brief description of the requested permitting action.
D. Environmental Assessments (May be Required — See 15A NCAC 1 C .0300)
❑ Submit a copy of the Findings of No Significant Impact (FONSI) or Environmental Impact Statement (EIS). Also, include
information on any mitigating factor(s) from the Environmental Assessment (EA) that impact the construction of the residuals
treatment and storage facilities. An EA may also be required for private systems if any public funds and/or lands are used for
the construction of the subject facilities.
INSTRUCTIONS FOR FORM: RLAP 06-16 Pagel of 3

E. Operation and Maintenance Plan (New and Renewal Application Packages)
❑ For Modification Application, if there are any changes to the existing plan, submit an updated O&M plan.
❑ Submit the O&M Plan in accordance with I SA NCAC 02T . l l 10 and include at a minimum:
Operational functions; describe the operation of the program to show what operations are necessary for the program to
function and by whom the functions are to be conducted.
Maintenance schedules; may include equipment calibration, maintenance of signs, etc.
Safety measures; may include safety training program, manuals, signs, etc.
Spill response plan; including control, containment, remediation, emergency contact information, etc.
E] Inspection plan including the following information;
Ej Names and titles of personnel responsible for conducting the inspections.
Frequency and location of inspections, including those to be conducted by the ORC, and procedures to assure that the
selected location(s) and inspection frequency are representative of the residuals management program.
® Detailed description of inspection procedures including record keeping and actions to be taken by th inspector in the event
that noncompliance is observed.
Sampling and monitoring plan including the following information;
Names and titles of personnel responsible for conducting the sampling and monitoring.
® Detailed description of monitoring procedures including parameters to be monitored.
® Sampling frequency and procedures to assure that representative samples are being collected. Fluctuation in temperature,
flow, and other operating conditions can affect the quality of the residuals gathered during a particular sampling event. The
sampling plan shall account for any foreseen fluctuations in residuals quality and indicate the most limiting times for
residuals to meet pathogen and vector attraction reduction requirements (e.g. facilities that land apply multiple times per
year but have an annual sampling frequency, may need to sample during winter months when pathogen reduction is most
likely to be negatively affected by cold temperatures.
THE FOLLOWING ADDITIONAL ITEMS G to M ARE REQUIRED FOR DEDICATED PROGRAM ONLY.
F. Program Determination
❑ Dedicated residuals land application programs are ones in which land application sites meet the criteria in ISA NCAC 027
.110202). Specifically, a residuals land application program is designated as dedicated if any of the following are applicable:
El Any land application site certified for the residuals land application program that receives residuals at rates or frequencies
greater than agronomic rates.
E] Any land application site certified for the residuals land application program that is used primarily for residuals disposal,
and agricultural crop production is of secondary importance.
❑ Any land application site certified for the residuals land application program that receives residuals through fixed irrigation
facilities or irrigation facilities fed through a fixed supply system.
❑ Please contact the Non -Discharge Permitting Unit if you need any assistance in determining whether your residuals program
falls under the dedicated program definitions.
G. Program Information
❑ Provide an explanation of why a dedicated system is required instead of a conventional non -dedicated system.
❑ Provide an explanation of the dedicated system and its operation.
H. Detailed Site Maps (All New or Modification Application Packages)
❑ Submit three (3) sets of standard size plans and two (2) sets of l I" by 17" plans (electronic format is acceptable - Adobe PDF
only). For Modifications, submit plans specific to the modification(s) only.
Plans must include the following minimum items:
❑ A general location map, a vicinity map and a topographic map with contours not exceeding 10 feet or 25% of the total site
relief and showing all facility related structures and fences within the land application area.
❑ The location of all wells (including usage and construction details if available), streams (ephemeral, intermittent, and
perennial), springs, lakes, ponds, and other surface drainage features within 500 feet of the land application site(s).
❑ Delineation of the review and compliance boundaries
n Setbacks as required by 15A NCAC 02T .1108
❑ Site property boundaries within 500 feet of all waste treatment, storage, and disposal site(s).
[] A map showing the entire irrigation area with an overlay of the suitable irrigation area depicted by the soil scientist's
evaluation. The irrigation plans shall show each nozzle/emitter and wetted area (when applicable). Clearly label spray
irrigation zones as they will be operated.
❑ Plans must depict a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY, NOT FOR
CONSTRUCTION, etc.) that indicate that they are anything other than final plans. However, the plans may be labeled with
the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION
INSTRUCTIONS FOR FORM: RLAP 06-16 Page 2 of 3

I. Project Evaluation and Receiver Site Management Plan (All New Application Packages or Modifications that include new sites)
❑ Submit a project evaluation and a receiver site management plan (if applicable) with recommendations concerning cover crops
and their ability to accept the proposed application rates.
J. Hydrogeologic Report (All New Application Packages or Modifications involving increasing the total design capacity)
❑ Submit a detailed hydrogeologic evaluation in accordance with 15A NCAC 02T .1104(d)(4) and current Division Policy
available at: 13ttl�ahvtivn_.nc+vater.or�IRules Policies and Regulationsl, The document shall be signed, sealed and dated by a
qualified professional.
K. Engineering Desi;n Documents (All New or Modification Application Packages with fixed irrigation facilities or irrigation
facilities fed through fixed supply system)
❑ Submit engineering design documents that have been signed, sealed, and dated by a NC licensed Professional Engineer and/or
Professional Land Surveyor in accordance with 15A NCAC 02T .I 104 d)(2). For Modifications, submit an updated site map
specific to the modification(s) only.
❑ The design documents must include the following minimum items:
❑ Engineering plans for the facility and equipment except those previously permitted unless they are directly tied into the new
units or are critical to the understanding of the complete process;
❑ Specifications describing materials to be used, method of construction, and means for ensuring quality and integrity of the
finished product including leaking testing; and
❑ Engineering calculations including hydraulic and pollutant loading, sizing criteria, hydraulic profile, total dynamic head
curve analysis for each pump, and irrigation design.
❑ Soil mapping units shown on all disposal sites.
L. Water Balance (All New Application Packages or Modifications that include new sites utilizing fixed irrigation facilities or
irrigation facilities fed through fixed supply systems)
❑ Submit a completed and accurate water balance in accordance with 15A NCAC 02T .1 104(d)(5) and current Division Policy
available at: 1i_tL,://%vivw.ricwater.org/Rules_ Policies and Regulations/.
M. Property Ownership Documentation (All New or Modification Application Packages involving new and/or relocated treatment
or irrigation components)
❑ Property ownership documentation shall consist of one of the following:
❑ Legal documentation of ownership (i.e., GIS, deed or article of incorporation), or
❑ Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
❑ An easement running with the land specifically indicating the intended use of the property and meeting the requirements of
15A NCAC 021- .0107(f), or
❑ A written notarized lease agreement signed by both parties, indicating the intended use of the property, as well as a plat or
survey map,
ONE ORIGINAL AND TWO COPIES OF THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL
SUPPORTING INFORMATION AND MATERIALS, SHALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE PERMITTING UNIT
By U.S. Postal Service:
1617 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1617
TELEPHONE NUMBER: [phone]
By Courier/Special Delivery:
512 N. SALISBURY STREET
RALEIGH, NORTH CAROLINA 27604
FAX NUMBER: [phone]
INSTRUCT[ONS FOR FORM: RLAP 06-16
Page 3 of 3

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02T .1100 — RESIDUALS LAND APPLICATION PROGRAM
FORM: RLAP 06-16
I. APPLICANT INFORMATION:
1. Applicant's name: Town of West Jefferson
Applicant type: [] Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
Federal [] State ® Municipal ❑ County
Signature authority's name per I5A NCAC 02T .0106: Brantley Price Title: Town Manager
Applicant's mailing address: PO Box 490
City: West Jefferson
State: NC Zip: 28694-
Telephone number: 3L) 2�46-3558
Email Address: wwt Ctownofw'.com
2. Consultant's name: -'' `'
License Number (for RE):
Affiliation: ❑ On Staff ❑ Retained (Firm: }
Consultant's mailing address: `
City:State:
Zip:
Telephone number: ( =
Email Address: .
3. Agronomist's name:.
License Number:
Affiliation: ❑ NIA ❑ On Staff
0 Retained (Firm:)
Agronomist's mailing address:
City: State:
Zip: -
Telephone number: (_) _ .
Email Address:
4. Soil Scientist's name: .T
License Number:
Affiliation: [] NIA Q On Staff
❑ Retained (Firm: " )
Soil Scientist's mailing address:.
City: State:
Zip:
Telephone number: (T) ..
Email Address: T
5. Fee submitted: $0.00 (See Instruction B)
11. PERMIT INFORMATION:
1. Application is for (check all that apply): ❑ new, ® modified, ❑ renewed permit
2. If this application is being submitted to renew or modify an existing permit, provide the following:
Permit number: WQ0003992
Date of most -recently issued permit:O4/22/2019
Date of most -recently certified Attachment A (if different than the permit):
Date of most -recently certified Attachment B (if different than the permit):
FORM: RLAP 06-16 Pagel of 5

Ill. RESIDUALS LAND APPLICATION PROGRAM INFORMATION:
1. Residuals Processing Facility's physical address: 335 Clearwater Drive
City: West Jefferson State: NC Zip: 28694- -:
Coordinates: latitude: 36° 24' 34.37" Longitude: 810 29' 25.73"
Datum: NAD 1983 UTM 17N Level of accuracy: I"
Method of measurement: Map
2. County where residuals land application program is headquartered: Ashe
3. List the Operator In Responsible Charge (ORC) and all Back -Up ORCs for the residuals land application program, their
certification numbers, and their affiliations in the following table:
4.
Designation
ORC
Back -Up ORC
Additional Back -Up
ORCs
(if applicable)
Name
Brandon Patrick
Nicholas Walters
Affiliation
Town of West Jefferson
Town of West Jefferson
Certification Number
1003070
1007912
If an ORC and at least one Back -Up ORC are not currently designated for this residuals land application program, provide the
candidates' names, affiliations, and an estimated time schedule for each candidate's completion of the required training school
and certification test:
Complete the following tables regarding management of the residuals land application program:
a. Plant Available Nitro en Summary: Determine the maximum plant available nitrogen (PAN) generated by all residuals
source -generating facilities as currently certified and proposed for certification with this application and list the results in the
following table:
Maximum amount of residuals to be certified: 180 dry tons per year.
PAN
Pounds of PAN per Dry Ton
(Weighted Average)
Pounds of PAN per Year
Surface
Incorporation
Surface
Incorporation
or Injection
or Injection
First -Year
12.69
2283.48
Five -Year Maximum Adjusted
IS.S6
2854.$
b. LandApplicalion Site Use Summary: Summarize information regarding the land application sites as currently certified and
proposed for certification with this application:
Category
Use
Acres
Comments
Crops
Forest or Plantation
Row Crops
Hay
26.56
Pasture
Total;
26.56
Methods
Surface
26.56
Incorporation or Injection
Total.-
26.56
FORM: RLAP 06-16
Page 2 of 5

Residuals Land Application Summar : Determine the minimum acreage required to land apply the residuals as CUrrently
certified and proposed for certification assuming the scenarios listed in the following table:
Assumed
Application Rate
(16s PAN/ac-yr)
Acres Required Using
First -Year PAN Concentrations
Acres Required Using
Five -Year Maximum Adjusted PAN
Concentrations
Surface
Incorporation or
Surface
Incorporation or
Injection
Injection
50
45.67
57.09
100
22.83
28.54
150
15.22
19.03
200
11.42
14.28
6. If applicable, provide a plan and a schedule to resolve any known issues that would prevent land application of the proposed
residuals due to the violation of North Carolina Administrative Code (e.g. not enough storage, not enough land, vector reduction
practices not in place, etc.):
7. Specify type of residuals program (See Instruction F): ® Non -dedicated ❑ Dedicated
If Dedicated, specify the following (check all that apply):
❑ Residuals program contains any land application site(s) that receives residuals at rates or frequencies greater than agronomic
rates, explain;_
❑ Residuals program contains any land application site(s) that is used primarily for residuals disposal, and agricultural crop
production is of secondary importance, explain;
❑ Residuals program contains any land application site(s) that receives residuals through fixed irrigation facilities or irrigation
facilities fed through a fixed supply system, explain;
IV. RESIDUALS SOURCE INFORMATION: (Required for all new, renewed, or modified residuals source)
Complete and submit the following Residuals Source Certification and all associated documentation.
f-
Residuals Source
Certification
V. LAND APPLICATION SITE INFORMATION: (Required for all new, renewed, or modified land application site)
Complete and submit the following Land Applications Site Certification and all associated documentation.
lJ
Land Application Siite
Certification.doc
FORM: RLAP 06-16 Page 3 of 5

Note: Item V1. Applicable to Dedicated Program with fixed irrigation system only.
VI. DESIGN INFORMATION FOR FIXED IRRIGATION SYSTEM
1. The irrigation system is: ❑ Spray ❑ Drip
2. Disposal system is: ❑ existing ❑ proposed.
3. Minimum depth to mean seasonal high water table (SHWT) within irrigation sites(s) per Soil Scientist's Evaluation: feet
below ground surface. Rules 15A NCAC 02T .0505(p) requires at least one -foot vertical separation between SHWT and ground
surface.
4. Are there any artificial drainage or water movement structures within 200 feet of any irrigation area?
❑ Yes or ❑ No If Yes, please explain if the soil scientist report addresses artificial structures and please indicate if
structures are Lo be maintained or modified:
5. Loading rates recommended by the Soil Scientist Evaluation:
Soil Series
Fields within Soil Area
Recommended
Loading Rate
(k%r)
Recommended
Loading Rate
t
6. Design loading rates are equal or less than the loading rates recommended by Soil Scientist?
❑ Yes or ❑ No If No, explain why 15A NCAC 02T .0505 n is not met:
7. Non -dedicatee System Design (fill in the appropriate information for either a spray or drip irrigation system):
Field / Zone Design Area Number of Maximum Application Design Annual Loading
ft2 Nozzles Rate allons/hr Rate allonsl r
Total
Spray Irrigation Design Element
Plan Sheet
Number
Specification
Page Number
Wetted diameter of nozzles
ft
Wetted area of nozzles
ft'
Nozzle capacity
gpm
Nozzle manufacturer 1 model
1 .
Elevation of highest nozzle
ft
T
'
FORM: RLAP 06-16 Page 4 of 5

Applicant's Certification (signing authority must be in compliance with I5A NCAC 02T .0106):
The applicant or any affiliate has not been convicted of an environmental crime, has not abandoned a wastewater facility without proper
closure, does not have an outstanding civil penalty where all appeals have been exhausted or abandoned, are cor_npliant with any active
compliance schedule, and do not have any overdue annual fees under Rule 15A NCAC 02T .0105.
® Yes ❑ No, Explain;
1, Mr. Brantley Price Town Manauer
(Signature Authority's Name — PLEASE PRINT) (Title)
attest that this application for Town of West Jefferson
(Facility Name)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that the Division of Water Resources
may not conduct a technical review of this program and approval does not constitute a variance to any rules or statutes unless specifically
granted in the permit. Further, any discharge of residuals to surface waters or the land will result in an immediate enforcement action,
which may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water
Resources should a condition of this permit be violated. I also understand that if all required parts of this application are not completed
and that if all required supporting information and attachments are not included, this application package will be returned to me as
incomplete.
Note: In accordance with North Carolina General Statutes § 143-215.6A and § 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation.
q-, /�;,
Signature: Date: zV
FORM: RLAP 06-16 Page 5 of 5

Operation and Maintenance Plan

Operation and Maintenance Plan
Town of West Jefferson
The WWTP ORC (or Backup ORC if ORC is unavailable) shall be in charge of the following items
as it relates to the current land application program:
• Collection of WWTP Samples
o TCLP Samples
o Pathogen Reduction Samples
o Vector Attraction Reduction Samples
o Collection of Nutrient and Metal Analysis
As Preparer for the facility under 40 CFR 503
o Being the individual that is familiar with the routine operation of this facility
includes:
■ Insuring solids are ready for land application
• Insuring solids have undergone proper treatment
■ Proper operation of treatment units
■ Proper maintenance of treatment and storage units
■ Notification of state and land appliers of abnormal conditions
• All inspections and maintenance of facilities at this plant
The Land Applier shall be in charge of:
■ Buffering Land Application Fields
■ Spreading Materials at Rates Given for Field, Crop, and Soil
• Calibrating Spreader
• Inspections and Inspection Log
■ Record Keeping regarding disbursement and Location of material spread
■ Lime Stabilization (if applicable) — collecting pH measurements:
o Initial pH
o Raising the pH to 12
o Monitoring the pH to see that it stays at 12 for 2 hours;
o Making sure it doesn't drop below 11.5 for the next 22 hours
■ Spill Response
• Signage
Both the WWTP ORC and Land Appliers will complete the aforementioned responsibilities
before the commencement of each land applying event. In the event that an area of
noncompliance is observed, the NCDENR office will be contacted. Inspections should be
performed in the field at the beginning of every land application even, with every change in
loading rate, and post application event for run off. An additional inspection will be performed
if rain occurs after the application event and before the residuals had time to desiccate
(typically 3-5 days). Each field will be inspected pre and post with each application event. The
frequency of inspections will depend on the frequency of application events.

Land Application ORC -- Brandon Patrick — 336-246-3558 — 336-977-6725
Land Applier/Backup ORC — Nick Walters -- 336-246-3558 — 336-977-9791
Land Applier - Jody Walters — 336-246-3558 — 336-977-4622

Spill Control Plan
Land Application ORC: Brandon Patrick
Telephone: [phone]
Land Applier/Backup ORC: Nick Waiters
Telephone: [phone]
Land Applier: Jody Walters
Telephone: [phone]
Plant Operator Telephone: [phone]
Local Police, Fire, Emergencies: 911
Carolina Grading
Office Phone: [phone]
NCQENR Regional Office: 336-771-5000
State of NC Warning Point: 800-662-7956

' OWn Of WCS1.leffer10n
I.isWd heh] w ym will fittcl quipMent used for spill respota.,x and their location.
1`i FXI
1, Hand totals
ShoNCIS, flicks, e1 ,
. 11um1 s (traq), etc:.)
4. Owncralar
S. Ainher rvttr`rting lights
G. "1TnkilIC COWS
7. 1: miricades
S. Moral deic"ors
9- TrijWW1 & harricss
M, 11mvcY1, tools, (saws, etc)
11, Safety equipment
12. Tricks (vehivivs)
]3, BlIck-hoe
lit, Trench Hux
Is, Pilv- Plugs
16: PVC Pipe fitting's
17, I ucUle Iron (metal) fittings
18, All pipc (Water & sewer)
1 9.. Radios
20_ Monitor (ga-W"", etc,)
21. Work lights
22. Slurring Equil}r icni
r 1. Grader
.'�4. Bo1x:at
2.5. Weldor
LOCATION
Maimenance Bldg. Hay WI (New)
Maintenanco Bldg. (On Trucks)
Maintenance Bldg, Bay #2 (Old)
Maintenanec Bldg., Cap (Old)
MaintenimWe Bldg, Day #2 (told)
Maintena we 11ld& Day #2 (Old)
Maintalmice Bldg. flay (lot)
,Maintmumc:c Bldg,, Cage (old)
Maintcrtance Bldg, Cage (01d)
14 aintettance Bldg,, Cage (Old)
Assignt%:! to pet nne.]
]4 aintenimev MA& Lot
Maintenance 11ldg. (01(l)
Maintcaance Bldg. Lot
Ma nt.enunor Bldg, Bay (g)cl)
Maintemi nce, Bldg, tiny #l(old)
Mriirrt )AnCt Hitig. L4DJ
Pjj-W 1AA
Assignul to pm.onnel
Maimcmance Bldg, Office
Now Wintenanct, Ald&. Loft (New)
New Main enatrcc Bldg, - Tmiler
New Maintenance Bld#-
Now Mnintensnce 1314g.
Now Maintmanc c Bldg.
Thi-, list will ]rc• updated its new cep P111cnt ii olatai lM andlur M, laccmcnt of old equipment.

Residuals Sampling Plan
Prior to application, multiple samples are collected from the sludge holding tank. These
samples as grabs are analyzed for fecal coliform. The multiple samples are composited and
submitted for nutrient, metal, and TCLP analysis. Currently, vector attraction reduction is met
by a 30-day additional aerobic test. Beginning in the upcoming year, 2 or 3 fecal samples will be
collected prior to each haul event. The Town of West Jefferson typically has 3 —4 haul events
per year. This will provide the seven fecal samples needed over the year and allow specific
information on each of the separate haul events. Additional methods may be used for vector
attraction reduction alternatives. These include volatile solids reduction, SOUR tests, and
incorporation.
Annually, a composite residual solid sample from each of these sources will be analyzed for:
Arsenic, Cadmium, Copper, Lead, Mercury, Molybdenum, Nickel, Selenium, Zinc, Aluminum,
Ammonia — Nitrogen, Calcium, Nitrate -Nitrite, Nitrogen, Magnesium, % Total Solids, pH,
Phosphorus, Potassium, TKN, and Sodium. The PAN will be calculated from this information.
The Town of West Jefferson requests that TCLP sample frequency remains at once per permit
cycle. The once per permit cycle will be analyzed for the following parameters:
Arscnic
11ex.3chlcrrobcnone
ThIm m
1lexachlovo, 1,3-Buladielie
Rcnxenc
thxAchlormihanr
Cadmium
Carbon Tetrachlondr
Ghlmdanc
C'hk-roticrucar
t:l kwoform
C'WrniunI
+n-CTMI
0-crtsal
P�Cresol
Cris I
2•!�
1,44)7ch1vtob wror
T.xmd
I.indaw
Mercury
Mcthoxychlor
Methyl t+Ayt Kttax
Peniachboruphenol
Pyridine
SelonirEfla
Sitver
1'ctrachi)Trjethykne
Toxapheve
ph far Cormlivity
Jf6&11 pawl f6r igni[xbiiity
Sulfitcc mW Cyarrldirt for reacim v
1. i •11)>iclrinr�cth�kiE�
�;4=©iuitt�inhtrne
Endha
HcptK}alrir and its Hydroxide
Trich%roc*yletw
2,4,54aicb;woP scrum
2,4,6-Trich6rep"A
2,04P (Sihvx)
vinyl ewonide

Residuals Source Certification Form

State of North Carolina
DWFtDepartment of Environmental Quality
Division of Water Resources
Division of Water Resources RESIDUALS SOURCE CERTIFICATION
INSTRUCTIONS FOR FORM: RSC 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted the Applicant shall submit one original and two co ies of the application and
supporting documentation
For more information, visit the Water Quality Permilling Section's Non -Discharge Perrnitliq J Unit
General — This certification provides detailed information of residuals source generating facility and its residuals quality for land
application, distribution, or disposal in accordance with I �A NCAC 02T . l 100. Do not submit this certification for review without
a corresponding application form (FORM: RLAP 11-15, FORM: DCAR 11-15, or FORM: SDR 11-15).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Residuals Source Certification (FORM: RSC 11-15):
® Submit the completed and appropriately executed Residuals Source Certification (FORM: RSC I1-15) form. Please do not
maize any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the
application may be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
® For new or renewed permits, submit a separate certification for each source facility.
❑ For modified permits, submit a separate certification for only those facilities that are affected by the proposed modification.
® Complete the residuals source facility summary page. List all new, renewed, or modified facilities.
B. Residuals Source -Generating Facility Information:
® For each source facility, attach the following:
® Vicinity map - A vicinity map that shows the location of the facility and meets all of the criteria in the "Map Guidance for
Residuals Land Application Permits".
® Process flow diagram and/or narrative - A detailed narrative and/or process flow diagram that describes how the residuals
are to be generated, treated, processed, and stored at the facility.
® Quantitative justification for residuals production rate - A quantitative justification for the value provided in Item I. 8.
Ensure that the amount of residuals listed is the maximum amount expected to be generated by the facility for the life of
the pen -nit. In addition, ensure that this amount is equivalent to that which is actually to be land applied, distributed,
and/or disposed, including any chemicals, amendments, or other additives that are added to the residuals during
processing.
® Sampling plan - A detailed sampling plan for the residuals source -generating facility. Ensure that the plan identifies
sampling points, sampling frequency, sample type, as well as the Division -certified laboratory to be used. In addition,
ensure that the plan details how the facility and/or the residuals are monitored for any applicable pathogen reduction and
vector attraction reduction requirements. Note that all sampling and monitoring must be completed on the residuals as
they are tc be land applied, distributed, and/or disposed.
C. Residuals Quality Information:
® For each source facility, attach the following:
® Laboratory analytical reports and operational data - reports for all laboratory analyses used to complete this certification.
® Documentation that the facility complies and/or the residuals comply with any applicable pathogen reduction and vector
attraction reduction requirements.
❑ For new facility that may have not yet been constructed and analytical results of residuals cannot be obtained, please
attach analytical results of residuals generated from a similar facility along with the description of similarities of the two
facilities.
INSTRUCTIONS FOR FORM: RSC 06-16 Page l of 1

RESIDUALS SOURCE FACILITY SUMMARY
Applicant's name: Town of West Jefferson
Status Maximum Dry Tons Per Year
Code Facility Permit Holder Facility Name County Permit Number
Current" Proposed
M Town of West Jefferson West Jefferson W WTP Ashe WQ0003992 180 180
Status Code for source facility are: ♦ N (New) ♦ R (Renewed) ♦ M (Modified) ♦ D (Deleted)
6 The amount of residuals currently permitted for distribution, land application, or disposal (i.e, not applicable to new facility).
SUMMARY FOR FORM: RSC 06-16 Page 1

II
DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
RESIDUALS SOURCE CERTIFICATION
FORM: RSC 06-16
1. RESIDUALS SOURCE -GENERATING FACILITY INFORMATION (See Instruction B.):
I. Facility Name: Town of West Jefferson
2. Facility permit holder is: Federal, [] State, M Local Government, or Private.
Facility permit issued by: [ Div. of Water Resources, [f Div. of Environmental Health,
or Other (explain:
3. Facility contact person and title: Brandon Patrick
Complete mailing address: PO Box 490
City: West Jefferson State: NC Zip; 28694-
Telephone number: [phone] E-mail address: [e-mail]
4. Facility physical address: 335 Clearwater Drive
City: West Jefferson State: NC Zip: 28694_4L
Coordinates: Latitude: 36' 24' 34.37" Longitude: 81 ° 29' 25.73"
Datum: NAD 1983 UTM 17N Level of accuracy: I"
Method of measurement: Map
5. Purpose of the facility:
treatment of municipal wastewater, [ treatment of 100% domestic wastewater,
[] treatment of potable water, treatment of 100% industrial wastewater,
[] treatment of industrial wastewater mixed with domestic wastewater,
(approximate percentages % industrial and % domestic)
❑ other (explain:. ).
6. Does the facility have an approved pretreatment program:] Yes 0 No
7. Facility pennitted/design flow: 0_5 MGD and facility average daily flow: 0.25 MGD
8. Average amount of residuals being generated at this facility 180 dry tons per year.
9. Specify the following regarding treatment and storage volumes available at the facility:
Type and volume of residuals treatment: 190,000 sludge holding tank
Type and volume of residuals storage (i.e., outside of residuals treatment units): none
RESIDUALS QUALITY INFORMATION (See Instruction C.):
1. Specify if residuals are regulated under:
® 40 CFR Part 503 or ] 40 CFR Part 257.
Note: Only residuals that are generated during domestic/municipal wastewater treatment processes are regulated under 40
CFR Part 503, otherwise, the residuals are regulated under 40 CFR Part 257.
2. Specify if residuals are defined under 1 5A NCAC 02T.1 102(6) as:
® Biological 0 Non -Biological
FORM: RSC 06-16 Page I of 5

Note: Biological residuals are residuals that have been generated during the treatment of domestic wastewater, animal
processing wastewater, or the biological treatment of industrial wastewater (biological treatment is a system that utilizes
biological processes including lagoons, activated sludge systems, extended aeration systems, and fixed film systems).
3. Hazardous Waste Determination: Complete the following to demonstrate that the residuals are non -hazardous under
RCRA: (Note - this item does not have to be completed for facilities that are less than 0.5 MGD in design flow that treat
100% non -municipal, domestic wastewater only)
a. Are the residuals listed in 40 CFR §261.31-§261.33: 0 yes no.
If yes, list the number(s): "-
b. Specify whether or not the residuals exhibit any of the characteristics defined by 40 CFR §261.21-
261,24: ❑ yes 0 no.
Fill in the following tables with the results of the latest toxicity characteristic leaching procedure (TCLP) analysis as
well as those for corrosivity, ignitability, and reactivity:
Laboratory: Summit Environmental Technologies and Date of analysis: 05/21 / 19, 12/ 10/ 19
Passed corrosivity test: N yes ❑ no. pH: s.n. (2 < pH < 12.5)
Passed ignitability test: � yes ❑ no. Flashpoint: °F (> 140°F)
Passed reactivity test: M yes ❑no. HCN: <i .0.0 mg/kg (<250) & HzS: <5.0 mg/kg (<500)
TCLP Parameter
Limit
(mg/1)
Result
(1ng/1)
TCLP Parameter
Limit
(mg/l)
Result
(jrrg/l)
Arsenic
5.0
<0.01
Hexachlorobenzene
0.13
<0.1
Barium
100.0
<12.5
Hexachloro-1,3-Butadiene
0.5
<0.04
Benzene
0.5
<0.005
Hexachloroethane
3.0
<0.2
Cadmium
1.0
<0.25
Lead
5.0
<125
Carbon Tetrachloride
0.5
<0.005
Lindane
0.4
<0.0025
Chlordane
0.03
<0.0125
Mercury
0.2
<0.005
Chlorobenzene
100.0
<5
Methoxychlor
10.0
<0.0025
Chloroform
6.0
<0.005
Methyl Ethyl Ketone
200.0
<10
Chromium
5.0
<0.5
Nitrobenzene
2.0
<0.2
m-Cresol
200.0
<5.0
Pentachlorophenol
100,0
<0.5
o-Cresol
200.0
<5.0
Pyridine
5.0
<0.5
p-Cresol
200.0
<5.0
Selenium
1.0
<0.125
Cresol
200.0
<10
Silver
5.0
<1.25
2,4-D
10.0
<0.5
Tetrachloroethylene
0.7
<0.005
1,4-Dichiorobenzene
7.5
<0.2
Toxaphene
0.5
<0.025
1,2-Dichloroethane
0.5
<0.005
Trichloroethylene
0.5
<0.005
1, 1 -Dichloroethylene
0.7
<0.005
2,4,5-Trichlorophenol
400,0
<0.005
2,4-Dinitrotoltiene
0.13
<0.1
2,4,6-Trichlorophenol
2.0
<0.005
Endrin
0.02
<0.0025
2,4,5-TP (Silvex)
1.0
<0.5
Heptachlor and its Hydroxide
0.008
<0.0025
Vinyl Chloride
0.2
<0.2
FORM: RSC 06-16 Page 2 of 5

4. Metals Determination. Complete one of the following tables (i.e., as applicable) to demonstrate that the residuals do not
violate the ceiling concentrations for metals regulated under l5A NCAC 021'.1105.
a. For Distribution/Land Application Fill in the following table with the results of the latest analyses (i.e., on a dry weight
basis) for the following metal parameters:
Laboratory: Blue Ridge Labs and Date of analysis: 05/21/19 12/10/19
Parameter
Ceiling
Concentration Limits
(ClassA & ClossB)
(mg4g)
Monthly Average
Concentration Limits
(Class A Only)
(mg/kg)
Result
(mg/kg)
Arsenic
75
41
<18,657
Cadmium
85
39
<3.731
Copper
41300
1,500
65,970
Lead
840
300
<18.657
Mercury
57
17
<0.075
Molybdenum
75
n/a
<0.015
Nickel
420
420
5.507
Selenium
100
l00
<1.866
Zinc
7,500
2,800
8.403
b. For Sur ace Disposal Unit (landfill): Fill in the following table with the results of the latest analyses (i.e., on a dry weight
basis) for the following metal parameters:
Laboratory: and Date of analysis. ,
Distance from Disposal
Unit to Boundary to
Closest Property Line
(meters, check one)
Arsenic
(mg/kg)
Chromium
(mg/kg)
Nickel
(mg/kg)
> 0 but < 25
30
200
210
[] > 25 but < 50
34
220
240
(] > 50 but < 75
39
260
270
0 > 75 but < 100
46
300
320
> 100 but < 125
53
360
390
El > 125
62
450
420
Result (mg/kg)
FORM: RSC 06-16 Page 3 of 5

5, Nutrient/Micronutrient Determination: Complete the following:
a. Total solids: 0.67 %.
b. Fill in the following table with the results of the latest analyses (i.e., on a dry weight basis) for the following nutrient and
micronutrient parameters:
Laboratory: Blue Ridge Labs and Date of analysis: 05/21/19, 12/10/19
Parameter
Result
(mg/kg)
Aluminum
753.73
Ammonia -Nitrogen
450.75
Calcium
2716.42
Magnesium
826.87
Nitrate -Nitrite Nitrogen
143,29
PH (Standard Unit)
7.I
Phosphorus
6313.43
Potassium
2134.33
Sodium
4432.84
Total Kjeldahl Nitrogen
174627
c. Using the results listed in Item IL 5b, above, calculate the sodium adsorption ration (SAR): 2.29
.Note: If residuals contain SAR of 10 or higher, the applicant shall obtain recommendations from the local Cooperative
Extension Office, the Department of Agriculture and Consumer Services, the Natural Resource Conservation Service, a
North Carolina Licensed Soil Scientist, or an agronomist, prior to land application of residuals. The recommendations shall
address the sodium application rate, soil amendments (e.g., gypsum, etc.), or a mechanism for maintaining site integrity
and conditions conducive to crop growth].
d. Specify the mineralization rate to be used in calculating the plant available nitrogen (PAN) of the residuals: 30 %. This
rate is a (check one): 0 default value, or 0 actually established.
If the residuals are not generated from the treatment of municipal or domestic wastewater, explain or provide technical
justification as to why the selected default value is appropriate to be applied to these residuals:
e. Calculate the PAN for the residuals (i.e., on a dry weight basis) and fill the results in the following table:
Application Method
First (V) Year PAN
Five -Year
Maximum Adjusted PAN
(mg1kg)
('mg/kg)
Surface
757.313
946.64 E
[njection/lncorporation
6. Other Pollutants Determination: Specify whether or not there are any other pollutants of concern in the residuals and provide
the results of the latest analyses: No
FORM: RSC 06- l6 Page 4 of 5

7. Pathogen Reduction: Per 15A NCAC 02T.1 106, specify how residuals will meet the pathogen reduction requirements:
a. For DisfributionlL and Application of Class A or Eguivalent:
❑ A fecal coliform density that is demonstrated to be less than 1,000 MPN per gram of total dry solids,
or
❑ A salmonella sp. density that is demonstration to be less than 3 MPN per 4 grams of total dry solids.
AND one of the followings (except for non -biological residuals):
❑ Alternative I [ 15A NCAC 02T.I 106(b)(3)(A)] - Time/Temperature Compliance.
Alternative 2 [15A NCAC 02T.1106(b)(3)(B)] -Alkaline Treatment.
❑ Alternative 3 [15A NCAC 02T. 1106(b)(3)(C)] - Prior Testing for Enteric Virus/Viable Helminth Ova.
❑ Alternative 4 [15A NCAC 02T.1 106(b)(3)(D)] - No Prior Testing for Enteric Virus/Viable Helminth Ova.
❑ Alternative 5 [15A NCAC 02T.I 106(b)(3)(E)-(K)] - Process to Further Reduce Pathogens (PFRP).
Specify one: ❑ composting, ❑ heat drying, [` heat treatment,
❑ thermophilic aerobic digestion, ❑ beta ray irradiation,
❑ gamma ray irradiation, or ❑ pasteurization.
b. For Land Application of Class B:
® Alternative 1 [ 15A NCAC 02T. l 106(c)(1)] - Fecal Coliform Density Demonstration.
❑ Alternative 2 [15A NCAC 02T. 1106(c)(2)] - Process to Significantly Reduce Pathogens (PSRP).
Specify one: ❑ aerobic digestion, ❑ air drying, [] anaerobic digestion,
d composting, or ❑ time stabilization.
c. For Surface Disposal:
❑ Select One of the Class A or Equivalent Pathogen Reduction Alternatives in Item I1. 7a. above.
[� Select One of the Class B or Equivalent Pathogen Reduction Alternatives in Item 11. 7b. above.
Exempt - If Daily Cover Alternative is chosen in Item 11.8. below [ 15A NCAC 02T. 1106(a)(2)].
Not Applicable - Non -Biological Residuals with NO Domestic Wastewater Contribution.
8. Vector Attraction Reduction (VAR): Per 15A NCAC 02T.1107, specify how residuals will meet the VAR requirements:
® Alternative I [ 15A NCAC 02T. I 107(a)(1)] - 38% Volatile Solids Reduction (Aerobic/Anaerobic Digestion).
❑ Alternative 2 [15A NCAC 02T.1 107(a)(2)1- 40-Day Bench Scale Test (Anaerobic Digestion).
® Alternative 3 [15A NCAC 02T. 1107(a)(3)] - 30-Day Bench Scale Test (Aerobic Digestion).
® Alternative 4 [15A NCAC 02T.1 107(a)(4)] -Specific Oxygen Uptake Rate Test (Aerobic Digestion).
❑ Alternative 5 [15A NCAC 02T.1 107(a)(5)] - 14-Day Aerobic Processes.
® Alternative 6 [15A NCAC 02T.1 107(a)(6)] -Alkaline Stabilization.
❑ Alternative 7 [15A NCAC 02T.] 107(a)(7)] -Drying of Stabilized Residuals.
❑ Alternative 8 [15A NCAC 02T.I 107(a)(8)] - Drying of Unstabilized Residuals.
❑ Alternative 9 [15A NCAC 02T.1 107(a)(9)] - Injection.
❑ Alternative 10 [15A NCAC 02T.1 107(a)(10)] - Incorporation.
❑ Alternative for Surface Disposal Units Only- Soil/Other Material Cover [15A NCAC 02T.1 107(b)(2)].
❑ Not Applicable - Non -Biological Residuals with NO Domestic Wastewater Contribution.
Note: For animal processing residuals, only alternatives 9 or 10 may be chosen due to the nuisance conditions that typically
occur when these residuals are applied and left on the land surface.
FORM: RSC 06- l6 Page 5 of 5

Facility Vicinity Map

..
Wileyell-
s
yoog
s
MorphCD
G
y
Ur .,O
�ota�``
,y Willi
is 1 kgdC,teeK
88 88
4
O
1 0L
�o
�Ia4fey o
,o Brgak:�
�oJ.
21
CL
;?e ass
_.'
�b4rh
asf
;�aa0e
,xoeclom
4as, Tgw11
ofWW Mfei<sO WvYT
w 8Tti
Xti
7N
r
Wafer
;
oo/
l �'
uprirl
gBare Park
��
-
5y�
D
Harriett
:�J
11� o
rjY
f
SCALE: V = 1,500'
Town of West Jefferson
site
RTB
Land Application Program
Location
CHECKED BY:
Wastewater Treatment Plant
Map
RTB
DRAWN BY:
�BRANCrH
�)�''
RESIDUALS
DATE: July 2014
& S OI LS, LLC
._..
2014-109

Process Flow Diagram and Narrative

WASTEWATER TREATMENT PLANT PROCESS
Town of West Jefferson operates a 0.5 million gallon capacity aerobic wastewater treatment plant.
After bar screening and grit collection, the influent goes from the 500,000 gallon oxidation ditch to
one of two 130,000 gallon clarifiers. Return sludge is sent back to the oxidation ditch from the
clarifiers. Decant from the clarifiers are sent to tertiary sand filters on to an ultraviolet disinfection
process prior to discharge.
Solids are sent to a 190,000 gallon aerobic digester that serves as a sludge holding tank. In this
tank, sludge is generally aerated but also allowed to settle without air to allow decanting and
thickening. Liquids generated from the thickening are sent to the head of the plant. Once the
storage limit is approached, the land appliers of the WWTP perform a land application event.

Wastewater Treatment Plant Process for the Town of West Jefferson

Justification for Residuals Production Rate

Justification For Residuals Production Rate
Over the past several years, the dry ton production has averaged less than half of the current
production rate, which has been set at 180 dry tons per year. Current production is expected to
remain the same for this permit.

Residuals Sampling Plan

Residuals Sampling Plan
Prior to application, multiple samples are collected from the sludge holding tank. These
samples as grabs are analyzed for fecal coliform. The multiple samples are composited and
submitted for nutrient, metal, and TCLP analysis. Currently, vector attraction reduction is met
by a 30-day additional aerobic test. Beginning in the upcoming year, 2 or 3 fecal samples will be
collected prior to each haul event. The Town of West Jefferson typically has 3 --- 4 haul events
per year. This will provide the seven fecal samples needed over the year and allow specific
information on each of the separate haul events. Additional methods may be used for vector
attraction reduction alternatives. These include volatile solids reduction, SOUR tests, and
incorporation.
Annually, a composite residual solid sample from each of these sources will be analyzed for:
Arsenic, Cadmium, Copper, Lead, Mercury, Molybdenum, Nickel, Selenium, Zinc, Aluminum,
Ammonia — Nitrogen, Calcium, Nitrate -Nitrite, Nitrogen, Magnesium, % Total Solids, pH,
Phosphorus, Potassium, TKN, and Sodium. The PAN will be calculated from this information.
The Town of West Jefferson requests that TCLP sample frequency remains at once per permit
cycle. The once per permit cycle will be analyzed for the following parameters:
Anmmic
Cvii
li pow br %piftbuily
Cich�iuru
l
Carbon Tc"chkri&
#fie
$WAd" ati gAWd t 0x WWdVky
chl"d1w
MWMY
1,2-DWwoodow
Ch)ombftu
MV&"Ydi"
1.1A
chl mkm
irk EW Kebw
2.4-DWOODhme
0-04a1
0-COMI
p),
ilk
"" ad ift
Tt
PCMWI
39koks
"dow
2,4,$-TrA r~
CM01
sow
2,4kTijabWt*pbwd
2�44D
T
2,4�T? Wm?
1.4-1[a►iihiorobadan e
V*4

Analytical Data
TCLP, Nutrient, and Metals

WATER QUALITY LAB &OPERATIONS, INC.
LAB No. 544
30 DAY BENCH SCALE VAR OPTION 3
SM 2540 E
ANALYST: START DATE: � -S 2� _
DIGESTER VOLUME: C 000 _
VOLUME
SCRAPED
VOLITILE SOLIDS REDUCTION: . 2 7Q

CLIENT:
ADDRESS:
CITY:
STATE:
I D#:
WATER QUALITY LAB & OPERATION, INC.
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
WEST JEFFERSON
WEST JEFFERSON
NC
SAMPLER: BRANDON PATRICK
COLLECTED DATE: 4-Feb-20
REPORTED DATE: 10-Mar-20
::
ANAL YSIS
MQL's:
::UNITS
I SMOKE,
:-ANALYSIS.
' INT
R88ULTS
LOCATION
ICOMPLETEbl
30 DAY BENCH SCALE
START
VOLITILE SOLIDS
79.90
0.1
%
SLUDGE
7-Feb-20
PI
END
VOLITILE SOLIDS
77.70
0.1
%
SLUDGE
10-Mar-20
PI
VOLITILE SOLIDS REDUCTION:
REPORTED BY: NC CERTIFIED LAB # 544
I 1 /
PAUL ISENHOUR, SUPERVISOR
2.20%

WATER QUALITY LAB & OPERATIONS, INC.
PO BOX 1167, BANNER ELK, NC 28604
8288986277
30 Dn Bn h S 1 FAX [phone]
.iv vay viceM.%,a c '
SAMPLE TYPE:
LOCATION:
FACILITY ID#:
SAMPLER NAME:
WASTEWATER
WEST JEFFERSON
NCO020451
CHARLES CALL
COMPOSITE SAMPLE: START DATE:
CHAIN OF CUSTODY
START TIME:
*PRESERVATION CODE
1- H2SO4, 2 - HNO3, 3 - HCL,
4 -- NAOH, 5 - NONE, 6 - COOL ICE
7 - NA2S203, 8 -- OTHER
STOP DATE: STOP TIME:
SAMPLE
NAME:
COLLECTION
DELIV
TEMP
SAMPLE
TYPE:
PRESERVATION*
PH
verify
CL2-D-
CL2
LAB
SAMPLE
ID
NUMBER
DATE
TIME
TEMP
GRAB
COMP
F-FIELD
L-LAB
YES
NO
30 Day Bench
Scale
02/04/2020
0 Srog
1.5
G
RELINQUISHED BY:
DATE
TIME
RECEIVED BY:
DATE
TIME
RELINQUISHED BY:
DATE
TIME
REC IVED BY:
DATE:
TIME
} F tf
/000
�) `Laboratory preservation is ensured by addition of preservatives prior to sample
containers leaving the lab, unless otherwise noted,
C1-2-D-CL2 = Chlorine check and dechlorination verification. pH: 5 1 t
PRESERVATION: Temp; `t, 5'
,] COOL 4°C: BOD, RESIDUE, CONDUCTIVITY, MBAS, COLOR, ALKALINITY, CR, VI, TURBIDITY Cond: I I L�
} COOL 4°C, PH<2 1-12SO4: NH3, NO2-NO3, TKN, O&G, TOC, COD, HARDNESS, PHENOLS, TOT PHOS.
j COOL 4°C, PH<2 HNO3: METALS EXCEPT CR, VI
] NONE: CHLORIDE, PH, 1=-UORIDE

SAR for Biosolids or Wastewater
Sodium Absorption Ratio Na_.jMg;L Ca1hi 11q( 1g;'L]
Na Sodium (Mg/L) Equivalent weight:23 297 182 55.4
Ca: Calcium(Mg/L) Equivalent weight:20
Mg: Magnesium (Mg/L) Equivalent weight- l2 ±ii.`T'% CI.:
MiiIi Equivalent = Mg/L / Equivalent weight
SAR-Na Milli Equivalent/(0.5 X (Ca Milli Equivalent +Mg Milli equivaIent)]0.5 power
If your lab reports In Milli Equivalents enter Na, Ca, & Mg below:
-_I ..
Na it:1E1 ce '1{ lE] rY1ir ihiEj
Exchangeable Sodium Percentage (FOR SOIL SAMPLE RESULTS)
The amount of exchangeable sodium ions versus the
amount of exchangeable calcium & magnesium ions in a given material.
Permit Limit is 10. CONTACT REGIONAL OFFICE
ESP =Na(IVIHN Equivalents)/CECX100 The percentage ofsodiumions occupying the cation exchange complex o{soils
Ni [ME} GEC
_- - - Should beiessthan15%(15-20%)
Na on NC soil test is expressed as meq.

Blue Ridge Labs
PO Box 2940
Lenoir, NC 28645
828-728-0149
blueridgela bsleno it ftma il.com
Client
Wiitff {, Uallt), Lams
P. 0. Rox i 107
Hanner I-:lh. NC 28014
Atlention:
eft.1'.Isetlltclu1'
date Received:
12- Dec- 19
Report Date:
09-Jail-20
Sample Date:
10-DL:c-19
BRLr1;
13RL-2019-1010
Lab Sninple 11):
LSID-2019-0391?
Clieitl Sample 11):
Wes[ Jefferson 5lmhn
Analysis AIi711}'Sis
Paraillcm.
IZCSIiI(
ry)QL
Unit
IN101110t1
Tirnc t)rllc
Analvst
If, by Cold Vapor AAS *
0.005
mod
7470A 1994
12/23/2019
Sutllnlit
t_ LP I:mractim Metals c.�iracled
SW-846-1-i 1 f
Summit
mE!"I
SW-846-6010
12`'3"2()10
Sunlulit
N11'-S-16-601{+
E==+.'ili`
Srilllltil!
[3:1
12.E
Ilrz I
S\V-846.6010
12:23.201i)
5uiruull
t =1
x
0.25
1
SW-8�16-6010
12 23'201L)
Sllrn{llii
C
0.5
{tlO
SW-846-6010
1123,2019
Siilltstl€I
I'll
'
1.25
11rgi1
SW-846-6010
12:_'_-? _iJ 19
5ulnnrit
Se
0.125
1mg,/I
SW-846-6010
12/23/2019
;tnl,nlit
Repro tell 11%
5, ,1, tnson, D.R. Wessinger
Cmice0ralion4 arc below Miuiinurn Quantification Lirnit e\ccllt where lrlttert.
NC Laboratory Ccrtifiicate No. 275
Page 12 of 18

Blue Ridge Labs
PO Box 2940
Lenoir, NC 28645
8207280149
blueridgelabsienoMgmadvom
Client: W,Ttet- QW11ity Labs
Bnoncr Elk, NC 28604
Attentiow Mr. P. Isenhour
Date Received: 12-17cc-19
Report Date: 09-Jan-20
Sarnple Date: IO-Uec-19
IML 4: 13RL-2019-1010
Imb s Itllllls ID: LSI€ OO190391�
Client Sample Ill: West Jefferson 51udL-e
Analysis Analysis
Parameter Iles€llt
YiQL
Unh
Whod
lime Bate
AnMyss
tCLPSemi-VOCExuauhn e LMOed
SW-8-16-1311
"mIIIIIII
Cresols (Tom!)
If)
mg I
SW-M6-3270
I :' --21)1'1
S.........
Dichloroben4ene, IA *
0.2
In;I1
5W-846-8270
12'02019
S[nTllnll
D) ili(M[UhICnC.14- ;
0.1
1
SW•846-8270
12-27,20F)
511nllTlll
Il,:michlilrll-1-3-Buladle°ne
O.Od
IIIE l
SkV-8,16-8270
1" 272019
jllkllilll€
Ilexachlorobenzene
M
mgI
SW-846-8270
12 27,2019
511n111111
Ile,xachlorosimne
f1.2
m A
Si4 8448270
12 77 2W
S,Ilnmit
tiitrabenzene
0.2
11ig!I
SW-8-t6-8270
12 27 MP
5m"mi!
Pentachlorophenol
0.5
mg l
SW-8-I6-8270
IM THQ
Siin,mit
Pyndke
00
tug I
SAXd&82%
_ ' ' T HO
Sl[ Mnit
IhhkTroOw al.2AY
0.00(
uigr l
S-846-8270
12172019
Sl,n:nl l
Kith{uru4k!Icnn1. 2,4.6-
0.001
illz-;-1
SW-S-16-8?70
, 2 2' min
St;n ill
Reported 13�
S. J. J lslsll, v,R. NVt:ssinbcr
Coneen nHms are below iIdA nlum Quantification Limit except v here Tlumd,
NC: Labol-atory C:ertiticate No. 275,

Blue Ridge Labs
PO Box 2940
Lenoir, ,NC 28645
828-728-0149 [e-mail]
Client :
Water QL1a1it} Labs
1'. U. 13ox 1 167
Manner Klk, NC 29604
Atietltion:
Mr. P, Isenhour
Date Received:
12-Dec-19
ltcltort slate:
09-.Ian--20
S;€,nj,1V 141L':
10-Dcc-19
BIt1,it;
13RI 2019-1010
Lab Sample ID:
E_,SID-2019-03914
Client Sample ID:
West-1CrterS0JI S11€clge
Analy5iS Atialvsk
Para€nCie r
Rrsult
141QL
Unit
Method
Time Hate
AnaI st
i{_LP LI1L Volatiles Fxtracl ion v?.Iiacik:d
SW-946 1311
5111111Ili[
13c:n/Lmc
0 00
11121
SW846-9260
1' '3 OIL)
SsI111r1111
l -idlk € lc]hloridC
0.00i
!11`_' �I
,W3,16-8260
1 -1 ' i �t111)
i........1)
C'hhwobcucnc
*
j
ingil
SW8.16-8260
17 2322011)
St11»tltil
Chlctrofttrm
*
0.005
mg/1
SW846-8260
12r'23f2019
SUMInit
Dichloroctlime, 1,2-
*
0.005
mg/1
SW846-8260
12i2 3/2.019
Sun1111it
Dichloroelhene, t,l-
0,003
,ngjl
SW846-8260
12/23 2f111)
Stul»€tit
MEK
10
moll
SW846-8260
12l23-2019
Sunlrni€
ictr.,c'rllurul€henc
0.001
mL, 1
SW816-s260
12 23 �.11't
S11€» sni€
Il601101nith''€le
0.005
m u'I
SW&16-8260
I? ?; ?01Ci
5t1n,111i1
Vim i ( 0ori'.!`
0.2
1M,,il
SIU d6-8260
flI'i
Reported By:
: a5�!son,)R��
Wessinger
* Cmicentratioas €ire below Minitntin, Qt€a€ltilicat€or€ Limit except where t€oted.
NC Laboratory Certificate No, 275
11 llue W of IS

0
Blue Ridge Labs
Pt? L'o-r 2940
Lenoir, NC 28645
828-728-0149 [e-mail]
Client :
Water QUalit} Labs
11. 0. Box 1 167
Barincr Ells, NC 2860-1
Attention:
Mr, P, ISealhcltlr
Date leeched:
12-Dec-19
Report 1):tte:
09-.hm-20
Sample Date:
I O-Dec- 19
nRLM
BR1,-2019-1010
Lab Staanple 11);
1_SID-2019-03915
('laent Skanaple JD-
West JeFFersott Slli�l�e
AfInI Siti AII;Iksis
Punmeter
kc,"1llt
mQ1.
Unit
,NIQIIt4€[I
I rnli' l) 1tl
:\n:tlti l
10.111;ottr VQC'L.mraction
SW-846-131I
SW-846-808t)
I? 2; �titl)
tins€nnsir
2.4.5 "1I'(Silveaj
0.5
mill
SW-846-8080
I?r'?}" Oi9
tiuntaltit
2.44)
S W-S'l6-8080
€ 2 . ; 'fi i)
5a ntln it
chlordane
0,0125
rngrl
SW-846.8080
12 31 _'1'N
ytltttaallt
I €lCil'€n
0 002)
SW-546-8080
12: ; l-'[11'1
SLan mil
Flcptacltlor
*
0.0025
rtt':I
SW-846-8090
12' 1
SLIM nIit
Hcptachlor t_poxide
0.0025
SW-846-8080
11 31 2011)
St€€nfttit
I,i€tda€te
CW02�
m '1
5N 8 tG $08(i
{?:`31 :'Cs19
Sc€ntmit
NI�1!1kI\%ChIUf
0.002>
€n,,'I
SW-846-8080
f= =I talil
tilflslrtr€t
-l-oxaphelle
0.025
€s€e.f
Sw-8=16-8080
1'.;I 2011)
Su€€I€tlit
Reported By:
S.iJ Jolmsun, 17.R. Wessinger
Cnncentratiwis tire helots Nlinitnuan Quantification Limit e.reept wlacre (toted.
!�'C' t.:aharrutr€rt C'er-Olic:ate No. 275
18

R
Blue Ridge Labs
PO Ro.r 2940
Lenoir, NC 28645
828-728-0149
Client
.Mention:
I "Ite €iecuked:
Report D ilk';
Sample Datc:
RIIL N:
Lab Sample ID:
Client Sample ID
P-.ir:smeti,r
�'
IKN
Water Quality L ibs
P.O. Box 1 167
BaImcv f:Ik, N!C' ]X004
1r. N. Isenhcsur
12. Dec- 19
10-Dec-19
BRL-2019-1010
LS€D-2019-03916
West Jefferson SludLve
[e-mail]
'IQI• Unit NIelhnd
o.US sire l SNt I').! tip -N
OI 5 nte;l SM I9 4500-N
Xitlilysis AIIill�Sk
i,irttc Date AIlaI%st
Reported By:
S..1. Jo son, D,R. Wessinger
C oncentratiti;s% are helim Nfilltmmil Onhntifivolioll 1,6161 csmp; 101cre noted
NC Laboaalkart CertificateNo. 275
t ao.c 16 of 18

Blice Ridge Labs
PO Borr 2940
Lettoir, NC 28645
828-728-0149
Client :
Water Quality Labs
P.O. Box 1 167
Banner Elk, NC 28604
Attention:
Mr. P. Isenhour
Date Received:
06-Jun-19
Report Date:
20-,Tun-19
Sample Date:
04-Jun-19
BRL #:
BRL-2019-0429
Lab Sample ID:
LSID-2019-Ot657
Client Sample ID:
West Jefferson
Parameter
Result MQL
Cu
* O.aa t
[e-mail]
Analysis
Unit Method Time
mg/l 200.7 1994 14:46
Analysis
Date Analyst
6/ 19/2019 KCJ
Reported By:
S. J. ohnson, D.R. Wessinger `
{ Concentrations are below Minimum Quantification Limit except where noted.
NC Laboratory Certificate No. 275
Page 4 of 13

Blue .Ridge Labs
p0 Bar 2940
Lenoir, NC 28645
828-728-0149
Client ; Water Quality Labs
P. 0. Box 1 167
Banner Ells, NC 28604
Attention:
Mr. P. Isenhour
Date Received:
23-May-19
Report Date:
02-Jul-19
Sample Date:
21-1v1ay-19
BIRL 9:
BRL-2019-0382
Lab Sample ID:
LSID-2019-01480
Client Sample ID:
West Jefferson Sludge
Parameter
Total Phosphorus
Al by ICP-AES
As by ICP-AES
Ca by ICP-AES
Cd by 1CP-AES
by ICP-AES
Cu by 1CP-AES
K by ICP-AES
Mg by ICP-AES
NIL) by ICP-AES
Na by ICP-AES
Ni by ICP-AES
Pb b\ ICI'-AES
Se by ICP-AES
Zn by ICP-AES
11- by Cold Vapor AAS
Result
NIQL
423
0.02
50.5
0.005
*
0.01
182
0.025
0.0489
0.0002
0.087
0.001
4.42
0.001
143
49.5
55A
0.005
*
0.001
297
49.5
0.369
0.001
*
0.01
0.061
0.01
0.563
OA01
0.0008
0.0003
[e-mail]
Analysis
Unit
Method
Time
nigil
200.7 1994
15 :2 8
mg/t
200.71994
15:28
mg/1
200.7 1994
15:28
mg/1
200.7 1994
15:28
mg/1
200.7 1994
15:28
mg/l
200,7 1994
15:28
mg/1
200.7 1994
15:28
mg/1
200.71994
3:48
mg/1
200.7 1994
15:28
nig/1
200.7 1994
15:28
mg/1
200.71994
3AS
mgil
200.7 1994
15:28
mg/1
200.7 1994
15:28
mal/1
200.7 1994
15:23
mg/l
200.7 1994
15:28
mb/l
7470A 1994
11:30
Reported by: 77'-
hnson, D.1t. Wessinger
* Concentrations are below Minimum Quantification Limit except where noted,
NC Laboratory Certificate No. 275
Page 1 of 4
Analysis
Date
61'19 2019
6+ 19/2019
6119/2019
6/19/2019
6!19/2019
6!19/2019
6/ 19,'2019
611 112019
6/19/2019
6/19.'2019
6/1 1!2019
6;19r2019
6.11912019
& 9,''019
0 1912019
611712019
Analyst
KC.i
KCJ
KCJ
KCJ
KCJ
KCJ
KCJ
Surnniit
KCJ
KCJ
Stua� m it
KCJ
KCJ
KCJ
KCJ
KC.1

Blue Ridge Labs
PO Bov 2940
Lenoir, NC 28645
828-728-0149
[e-mail]
Client:
Water Quality Cabs
P. O) Box 1 167
Banner balk, NC: 28604
Attention:
Mr. P. Isenhour
Bate Received:
23-May- 19
Report Date:
02-Jul-I9
Sample Date:
21-May-19
ML 0:
BR1,-2019-0382
Lab Sample ID:
I,SID-2019-01481
Client Sample ill:
West Jefferson Sludge
Analysis
Parameter
Result MQL Unit Method 'rime
Ammoma Nitrogen
30.2 Q.5 mg/I SM4500 I99 l -.00
Analysis
Date Analyst
6/7/2019 KCJ
Reported By.
%�-"
t�
S ohnson, D.R. Wessinger
* Concentrations are below Minimum Quantification Limit except where noted.
NC Laboratory Certificate No. 275
Page 2 of 4

Blue Ridge Lahs
PO Box 2940
Lenoir, NC 28645
828-728-0149 [e-mail]
Client:
Water Quality Labs
P.O. Box 1 167
Banner Elk, NC 28604
Attention:
Mr. P. Isenhour
Date Received:
23-May-19
Report Date:
02-Jul-19
Sample Date:
21-May-19
BRL 4:
BRL-2019-0382
Lab Sample ID:
ISID-2019-01482
Client Sample ID:
West Jefferson Sludge
Parameter
Result MQL
—
qo Solids
0.67 0.1
lw-niwbiiity
Not Ignitable 70
Corrosivity as pH
7.1 0.1
Analysis
Analysis
Unit Method
Time
Date
Analyst
% % Solids
16A5
5/24,2019
KCJ
Deg, K 1030 SW-846
11:02
5/24,'2019
KCJ
su 9045C SW-8
16:10
5/23/2019
KCJ
ot
Reported By:
hnson, D.R. Wessinger
"Cuncentratiuns are below Minimum Quantification Limit except where noted.
IBC Laboratory Certificate No. 275
Page 3 of 4

Blue Ridge Labs
PO Box 2940
Lenoir, NC 28645
828-728-0149 [e-mail]
Client :
Water Quality Labs
P. 0. Box 1167
Banner Elk, NC 28604
Attention;
Mr. P. Isenhour
Date Received:
23-May-19
Report Date:
024111-19
Sample Date:
21-May-19
BRL 9:
BRL-2019-0382
Lab Sample Ill:
LSID-2019-01483
Client Sample ID:
West .lef'ferson Sludge
Analysis Analvsis
h.inuueter
Result MQL
Unit Method Time Date Analyst
Iteactivii\ as CN
* 1
mg/l SW-846-7.3.3 16:10 5130/2019 KCJ
lke:tcti%ir� as Sulfide
* 5
mg/l SW-846-7.3.3 14:10 5/3012019 KCJ
Reported By: - - tSXfo
-_
hnson, D.R. Wessinger
* Concentrations are below Minimum Quantification Limit except where noted.
NC Laboratory Certificate No. 275
Page 4 of 4

Analytical Report
CO
O'luo 1422
C4 I
WC 19000231
6"] 21-2019
N T
Blue Ricive Labs, fric.
2 1 21) 11)
Project:
143 [211416,1480
Lab I D:
19000231-003
Matrix:
StAl)(A
Cliens Sainple ID
-- ---- ..... -
1480
Result PQl'
Qual [-nits
D F Dare . to 1) rcrl
MSTAUS AMNIVVS
(90ion),
einrcn sn
Leh nn
405
fnq. Kg
I , 2 Ci 1 .13 4 P, 15 P IM
Sodium(Na)
2W 495
nlglKq
1 611 112o19 3 43A5 Pm
Qualifiers:
',D Not Ni-w.
RI Rqmng bm:l
PI Vern,.: I muc
W ti a Mvflc c--a'vtr 111"PlIIII le �' 110 of Ju I,

WATER QUALITY LAB & OPERATION,
INC.
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
CLIENT: WEST JEFFERSON (1)
LOGIN TIME:
11:00 AM
ADDRESS:
SAMPLER:
CITY:
COLLECTED DATE:
10-Mar-20
STATE.
REPORTED DATE:
9-Apr-20
I D#:
ANALYSIS.
ANALYSIS
MQL's
UN1T$ .::BAMPL>E
ANALYST.
MI=THOd :: ' ' : TNT :;
rysuLrs
LOCATION
tO .LETl »
TOTAL SOLIDS
1.8
%
DIG
FECAL COLIFORM
25300
1
MPN
#2
11-Mar-20
SM-9222D
WPS
REPORTED BY: NC CERTIFIED
LAB # 544
PAUL ISENHOUR, SUPERVISOR

CLIENT: WEST JEFFERSON (1)
ADDRESS:
CITY:
STATE:
I D#:
WATER QUALITY LAB & OPERATION, INC.
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
LOGIN TIME: 9:30 AM
SAMPLER:
COLLECTED DATE: 3-Mar-20
REPORTED DATE: 9-Apr-20
ANALYSfB: ANiALY515 MgL's UNITS.. -, SAMPLE ANALYST;
i SUL'CS: LOCA'TIDN C:OMPLETI
TOTAL SOLIDS 1.7
FECAL COLIFORM 44200 1 MPN E 4-Mar-20
REPORTED BY: NC CERTIFIED LAB # 544
PAUL ISENHOUR, SUPERVISOR
METHOD I INT...
CODE
SM--9222D 1 WPS

WATER QUALITY LAB & OPERATION, INC.
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
CLIENT: WEST JEFFERSON (1) LOGIN TIME: 11:40 AM
SLUDGE SAMPLER:
COLLECTED DATE: 11-Jun-18
REPORTED DATE: 14-Jun-18
I D#:
ANALYSIS
ANALYSIS
MQL's
-UNITS ::
SAMPLE j:
ANALYSIS
' METH D :.
!NT'
RESULTS
:: . .::
LOCATION
C.QMO ETED
coo
DIG
TOTAL SOLIDS
1.6
1.0
%
#3
14-Jun-18
SM-5220B
PI
CFU's
DIG
FECAL COLIFORM
72159
1
1100 MIS
#3
12-Jun-08
SM-92220
PI
REPORTED BY: NC CERTIFIED LAB # 544
PAUL ISENHOUR, SUPERVISOR
� � 7

WATER QUALITY LAB & OPERATION, INC.
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
CLIENT: WEST JEFFERSON (1) LOGIN TIME: 10:00 AM
SAMPLER:
COLLECTED DATE: 12-Jun-18
REPORTED DATE: 14-Jun-18
i D#:
ANALYSIS
ANALYSIS
.MQL'$
UNITS
SAMPLE
. ANALYSIS.
METHOD
INT .. '
RESULTS
LOCATION
COMPLETED
CODE
DIG
TOTAL SOLIDS
1.6
2.0
MG/L
#3
14-Jun-18
SM-52206
WPS
CFU's
FECAL COLIFORM
51802
1
/100 mIs
E
13-Jun-18
L SM-9222D
WPS
REPORTED BY: NC CERTIFIED LAB # 544
PAUL ISENHOUR, SUPERVISOR

Analytical Results STATESVILLE
,:L ANALYTICAL
Town of West Jefferson
PO Box 490
335 Clearwater Drive
West Jefferson, NC 28694
Receive Date: 08/17/2020
Reported: 08/28/2020
For:
Comments:
Sample Number Parameter Sample ID Result Unit Method Analyzed Analyst
200817-01-01
BOD
Inf
117
mg/L
sM521oB-2011
08/17/2020
MD
200817-01-01
TSS
Inf
49
mg/L
sM25400-2011
08/21/2020
CJE
200817-01-02
Ammonia Nitrogen
Eff
<0.5
mg/L
8M450ONH3C.2o11
08/17/2020
CJE
200817-01-02
BOD
Eff
8.5
mg/L
SM521OB-2011
08/17/2020
MD
200817-01-02
Fecal Coliforms
Eff
<1
MPN/100 ml
IoEXXCofilert 18 MPN
08/17/2020
WC
200817-01-02
Nitrate/Nitrite
Eff
2.3
mg/L
SM450OF-2011
0$11812020
CL
200817-01-02
T. Phosphorous
Eff
0.8
mg/L
SM450OPE-2011
0$/18/2020
CL
200817-01-02
TKN
Eff
0.56
mg/L
SM4500NorgB-2o11
08/26/2020
CL
200817-01-02
TSS
Eff
<2.778
mg/L
SM25400-2011
08/21/2020
CJE
200817.01-03
'Fecal Coliforms
Fecal MPN
<32
MPN/g I
SM92210E-2006
08/17/2020
WC
200817-01-03
Percent Solids
Fecal MPN
0.63
%
SM254OB-2011
08/17/2020
WC
Respectfully submitted,
Dena Myers
NC Cert #440,
NCDW Cert #37755,
EPA #NC00909
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 3

Clieni: i- (�
Af-4A Y' i It�Ai_
I zz C;xw slrect - r.a. B(?x _z>< ,
Statesville, NC 2M97
E 7tw y 87'_-sry7
Chain of
Custody Record
Address:
Contact Person: Phone # FAX#
3 VD14 t-395 5!
PO {% Requisitioned try: ITimB
Customer Tlme Sampled
5ample IDk Lab -ID s
{tamp pntyy
Dale Sampled —MatrrK Paromeiera rcy.caed for
(Grab Only} Mudge w 'NW
arteiys's
—
—...-- --�
I S Sn
F
✓
-1--
3,
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Analytical Results �e s'rATESVILi-F
ANALYTICAL
A4
Town of West Jefferson
PO Box 490
335 Clearwater Drive
West Jefferson, NC 28694
Receive Date: 08/24/2020
Reported: 08/31/2020
For: WWTP
Comments:
Sample Number Parameter Sample ID Result Unit Method Analyzed Analyst
200824-01-01
BOD
Inf
76.9
mg/L
SM521OB-2011
08/24/2020
CJE
200824-01-01
TSS
Inf
37.27
mg/L
SM2540D-2011
08/28/2020
CJE
200824-01-02
Ammonia Nitrogen
Eff
<0.5
mg/L
SM4500NH3C-2011
08/24/2020
CJE
200824-01-02
BOD
Eff
<2
mg/L
SM521OB-2011
08/24/2020
CJE
200824-01-02
Fecal Coliforms
Eff
3.1
MPN/100 ml iDEXXCoweri 18MPN
08/24/2020
MD
200824-01-02
TSS
Eff
10.46
mg/L
SM25400-2011
08/28/2020
CJE
200824-01-03
Fecal Coliforms
MPN .
c328
MPN/g"
SM92210E-2006
08/24/2020
MD
200824-01.03
Percent Solids
MPN
0.61
%
sM254OB-2011
08/24/2020
MD
Respectfully submitted,
Dena Myers
NC Cert #440,
NCDW Cert #37755,
EPA #NC00909
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 3

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Analytical Results STATESVIUF
ANALYTICAL
Town of West Jefferson ,.
PO Box 490
335 Clearwater Drive
West Jefferson, NC 28694
Receive Date: 09/01 /2020
Reported: 09/09/2020
For:
Comments:
Sample Number
parameter
Sample ID
Result
Unit
Method
Analyzed
Analyst
200901-14.01
BOD
Inf
409
mg/L
sM521OB-2011
09/02/2020
MD
200901-14-01
TSS
Inf
343.3
mg/L
SM254OD-2011
09/04/2020
CJE
200901-14-02
Ammonia Nitrogen
Elf
<0.5
mg/L
SM4500NH3C-2011
09/08/2020
CJE
200901-14-02
BOD
Eff
<2
mg/L
SM521OB-2011
09/02/2020
MD
200901-14-02
Copper
Eff
0.008
mg/L
EPA2W.7
09/08/2020
MD
200901-14-02
Fecal Coliforms
Eff
<1
MPN/100ml IDEXXColden18MPN
09/01/2020
WC
200901.14-02
TSS
Eff
<2.778
mg/L
SM254OD-2011
09/04/2020
CJE
200901-14-03
Fecal Coliforms
Fecal MPN
-�3279
Mpldlg
` SM92210E-2006
09/01/2020
WC
200901-14-03
Percent Solids
Fecal MPN
0.61
%
SM254OB-2011
09/01/2020
WC
Respectfully submitted,
Dena Myers
NC Cert #440,
NCDW Cert #37755,
EPA #NC00909
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 3

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Land Application Site Certification Form

State of North Carolina
Department of Environmental Quality
nWR Division of Water Resources
Division of Water Resources LAND APPLICATION SITE CERTIFICATION
INSTRUCTIONS FOR FORM: LASC 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted. the Applicant shall submit one original and two conies of the application and
supporting documentation
For more information, visit the Water Quality Pet -milling Section's Non -Discharge Permitting Unit
General — This certification provides detailed information of receiving sites for land application of Class B residuals (may include
water treatment plant or other type residuals) in accordance with 15A NCAC 02T . 1100. Do not submit this certification for review
without a corresponding application form (FORM: RLAP 06-16 or FORM: SDR 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Application Site Certification (FORM: LASC 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
❑ For new or renewed permits, submit the requested information for all land application sites.
® For modified permits, submit the requested information for only those sites that are new, transferred or affected by the
proposed modification.
B. Land Application Site Information:
® The status of the land application site with respect to this residuals land application program must be provided in table I. The
status categories and their corresponding codes are as follows:
♦ New (N) ♦ Renewed (R) ♦ Modified (M) ♦ Transferred (T) ♦ Deleted (D)
® Attach the following in accordance with each status code:
Status Code
Required Item
N
R
T
M
County Board
Notif !cation. doc
f�
Land Owner
Agreement
(If applicable)
Setback Waiver
Agreement
An updated vicinity/setback map in accordance with the "Map Guidance
1'nr Resid,ials Land A pili:at ion Permits"
✓
✓
✓
A soils and agronomic evaluation in accordance with the "Soil Scientist
✓
r
INSTRUCTIONS FOR FORM: LASC 06-16 Page 1 of 3

An updated accounting of the land application site's cumulative
pollutant loading rates CPLRs
Required Item Status Code
N R T M
For previously permitted sites without a soil series name indicated in the
Attachment B, submit County Soil Survey Map (or equivalent) clearly ✓
indicate the location of the land application site and in accordance with
the soil ma re uirements in the "Soil Scientist Evaluation Police"
Acknowledgement of field transfer from Land Owner (Fields may not
be permitted to multiple Permittees over the same time period)
This item may be required for land application site with a status code "M", please contact the Division if you need assistant in
determining attachment requirements.
® Crop Type should include the most likely crop types for the life of the permit (five years).
® Predominant Soils Series Name must be either the name of the soil indicated in Attachment "B" of the existing permit, or
name of the soil series as provided by the licensed soil scientist.
® Predominant Soil Mapping Unit or Representative Slope: Either the Soil Mapping Unit or the representative slope of each
site must be provided. The predominant soil -mapping unit must be consistent with the predominant soil series name. Please
note that the soil mapping units are variable between Counties, so care should be taken in properly identifying the correct
mapping unit. If a representative slope is provided, it must be determined accordingly:
® For sites previously permitted for use, but do not have an established soil mapping unit (the mapping unit provides
information on both the soil series name and the slope of the soil), the Applicant may determine the representative slope
by using the average slope provided in the County Soil Survey (or equivalent). A soil type with a slope range of 4 - 8%
would have a representative slope of 6%.
❑ New Sites to be permitted must have slopes determined as part of the soils report prepared by a licensed soil scientist.
® Acceptable methods for determining location coordinates (i.e., latitude and longitude) and their corresponding codes are as
follows:
• Address Matching (ADD) • Digital or Raw Photo Extraction (EXT)
• Aerial Photography with Ground Control (AER) • Geodetic Quality GPS Survey (GEO)
• Cadastral Survey (SUR) • LORAN-C Navigation Device (LOR)
• Conversion from Coordinate Plane (CP) • Navigation Quality GPS (GPS)
• Conversion from Township -Section -Range (TSR) • Remote Sensing (RS)
• Conversion from Universal Trans Merc (UTM) • Zip Code Centroid (ZIP)
• Map Interpretation by Digital or Manual Extraction (MAP)
C. Waterbody and Classifications Information: (new sites only)
❑ Use an 8.5 by 11-inch copy of the portion of a 7.5-minute USGS Topographic Map to identify the location where the
residuals program activities are planned to occur as well as the closest downslope surface waters as clearly as possible. Each
map portion must be labeled with the map name and number, the identified location, and be of clear and reproducible quality.
❑ Surface water body classifications information may be found at: htlpa ded.nc.�oviaboutr'divisiorts; waler-
mo urces/121annincg lassification-s€andardsiclassitications
❑ Any questions concerning the waterbody and its classification, please contact the Division's regional offices.
❑ A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
htt ):i'/dec .nc.uov/corttact/re gional-offices
❑ General Instructions: There are 17 river basins in North Carolina, Each basin has associated waterbodies with assigned
subbasins, location descriptions, stream index numbers and established classifications.
I. Identify the project area on a 7.5 minute USGS topographical map (an 8.5 x 1 ]-inch sheet showing the project area
should be submitted with the permit application regardless of whether a Stream classification was completed).
2. Determine the names of all the closest down slope surface waters from the project site. For unnamed tributaries, see
Table 1: Unnamed Tributaries Entering Other States or for Specific Basin Areas. Label any unnamed tributaries as
"UT to stream naive" as the Waterbody name.
3. Open the link http://deg.nc.govlabotit,divisional%vater-resourcesiplanning'classiticatiott-standarcls'classifications.
❑ Stream Classification Process: One of the options below may be used depending on the known initial project information.
❑ KNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
INSTRUCTIONS FOR FORM: LASC 06-16 Page 2 of 3

1. Select proper basin from the List all Waterbodies in Basin sorted report. Sort hydrologically as this will provide
the proper location descriptions if multiple runs.
2. Locate the name of the identified waterbody (from General Directions) on the list.
3. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
4. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
❑ KNOWN COUNTY WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Select the proper county from the List all Waterbodies in county, hydrologically report.
2. Locate the name of the identified waterbody (from General Directions) on the list.
3. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
4. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
❑ UNKNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Use the Clickable basin map to hydrologically sorted list report.
2. Click on the approximate project location to bring up the hydrologically sorted list.
3. Locate the name of the identified waterbody (from General Directions) on the list.
4. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
5. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
❑ Notes on index number and unnamed streams:
Unnamed Streams 15A NCAC 02B .0301(i).
❑ Any stream which is not named in the schedule of stream classifications carries the same classification as that assigned
to the stream segment to which it is tributary (at the point of entry) except:
(A) unnamed streams specifically described in the schedule of classifications;
(B) unnamed freshwaters tributary to tidal saltwaters will be classified "C; or
(C) after November 1, 1986, any newly created areas of tidal saltwater which are connected to Class SA waters by
approved dredging projects will be classified "SC" unless case -by -case reclassification proceedings are conducted.
❑ The following river basins have different policies for unnamed streams entering other states or for specific areas of the
basin:
Unnamed Tributaries Entering Other States or for Specific Basin Areas
Hiwassee River Basin
Streams entering Georgia or Tennessee shall be classified "C Tr."
Little Tennesse River
Basin And Savannah
River Drainage Area
Streams entering Georgia or Tennessee shall be classified "C Tr." Such streams in the Savannah
River drainage area entering South Carolina shall be classified "B Tr."
French Broad River
Basin
Streams entering Tennessee will be classified "B."
Watauga River Basin
Streams entering the State of Tennessee are classified "C."
Broad River Basin
Streams entering South Carolina are classified "C."
New River Basin
Streams entering the State of Tennessee are classified "C."
Catawba River Basin
Streams entering South Carolina are classified "C."
Yadkin -Pee Dee River
Basin
Streams entering Virginia are classified "C," and such streams entering South Carolina are
classified "C."
Lumber River Basin
Streams entering South Carolina are classified "C Sw."
Roanoke River Basin
Streams entering Virginia are classified "C." Except that all backwaters of John H. Kerr
Reservoir and the North Carolina portion of streams tributary thereto not otherwise named or
described shall carry the classification "B," and all backwaters of Lake Gaston and the North
Carolina portion of streams tributary thereto not otherwise named or described shall carry the
classification "C and B."
Chowan River Basin
Streams entering Virginia are classified "C."
Tar -Pamlico River
Basin
All drainage canals not noted in the schedule are classified "C Sw." except the main drainage
canals to Pamlico Sound and its bays which shall be classified "SC."
Pas uotank River Basin
All drainage canals not noted in the schedule are classified "C."
INSTRUCTIONS FOR FORM: LASC 06-16 Page 3 of 3

LAND APPLICATION SITE CERTIFICATION
Applicant's name: Town of West Jefferson
Land application sites currently certified: 5251 net acres and Total to be certified: 34.61 net acres.
1. LAND APPLICATION SITE INFORMATION (See Instruction B):
Status
Code
Site/Field
ID
Landowner(s)
Lessee(s) or Operator(s)
Net Acres
County
h
s
Crop(s)
pO
Predominant Soil
Series Nameb
Mapping Unit
or Rep. Slope
R
DP-1
Dennis Pennington
7.36
Ashe
Fescue
Clifton
CfD
M
DP-2
Dennis Pennington
10-53
Ashe
Fescue
Clifton
CfD
R
KP-1
Keith Phillips
10.09
Ashe
Fescue
Clifton
CfD
N
N
N
N
„..
Sratus Code for iann application sites are: ♦ N (New) ♦ x (Renewed) ♦ M (Modified) ♦ f (1-ransterred) ♦ D (Deleted)
'Soil Series Name (i.e. Appling, Cecil, etc.)
`Mapping Unit must be consistent with those used in the County Soil Survey (i.e. for a 2-8% slope Cecil in Anson County the mapping unit is CeB2)
11. WATERBODY AND CLASSIFICATIONS INFORMATION (See Instruction C):
Site/Field ID
Latitude
Longitude
g
Location
Location Method Code
Location Accuracy
Waterbody Subbasin and
Current and Proposed
p
Datum
Stream Index No.
Class
NAD 83
ADD
Nearest Second
NAD 83
ADD
Nearest Second
NAD 83
ADD
Nearest Second
NAD 83
ADD
Nearest Second
,._,._.,.
»4 °
NAD 83
ADD
Nearest Second
-
p
NAD 83
ADD
Nearest Second
NAD 83
ADD
Nearest Seconds
-
NAD 83
ADD
Nearest Second
Note: Please keep the site information U.) and waterbody information (It.) of the same field on the same page.
FORM: LASC 06-16 Page 1

Landowner Agreement Attachment

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Division of Water Resources LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the ARaUC&RLaW submit one on 'nal and o co ies of the application and
su in documentation
For more information, visit the Water Quality Permitting Section's Non-Discha a Perrnittin Unit
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .I 100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Residuals Source Certification (FORM: LASC 06-16) form. Please do not
make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the
application may be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Town of West Jefferson
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field ID Lease Land Use or Residuals Source Special note
(yes/no) Cropping patterns Intended Use of Crops {no-till/over-seed/
(optional)
pasture)
DP-1 No Fescue Hay/Pasture Animal Feed West Jefferson WWTP
Fescue Hay/pasture Animal heed West Je#%rson WWTP
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16
a PA op I of Z

1. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (und-r Section 11) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1636
Mail Service Center, Raleigh, NC 27699-1636,
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the
land application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of
the equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals
land application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final
soil pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for
the specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of
nutrients (e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land
application events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect'any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
IL RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land
application site(s) during active use and for the 12-month period following a residuals land application event. Such controls miy include the
posting of signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land
application events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for a 14-
month period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land
application event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38-month period following a residuals land
application event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
I 11. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC' 02T .0105(h) allows the
compliance boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance
boundary provided the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
❑ A re -defined compliance boundary is needed for field(s) ID:
(Please include the rationale for the requested re -location of the compliance boundary and attach a map showing the newly proposed
compliance boundary to the application package)
® A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID: , is currently permitted under another
residuals land application program; Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name ot'the new program)

Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decisions
regarding the use of the land application site(s) on behalf of other deeded landowners OR that I am otherwise authorized, through
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(s) on behalf of the
deeded landowners. I certify that the above -referenced land application site(s) are not included in any waste disposal contract or
agreement with another municipality, contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do -hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name:
Address:
City: C t—���.n,.� State:Zip: co
Phone: "5N E-mail address: Z� �_4V
Signature:
Date: _7—/�3/?a
NORTH CAROLINA, COUNTY
c
1, the undersigned Notary Public do hereby certify that s L V1A15 G! y�
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS m ,hand and official seal this the. 3
day of
Zo
Signature and seal: `'�'GGA
My commission expires: -. q z �,�4i; " �OTAR r ti s
Lessee's/Operator's Certification:
G
I certify that I have read this Agreement and do hereby agree to abide
Lessee/operator name:
Address:
City: State:
Phone:
Signature:
Permittee's Certification:
Ismail address:
Date:
and restrictions as specified herein.
Zip:
i certify that I have read this Agreement and do hereby agree to abide by the stipulations and re fictions as specified herein.
Signing official name: z7�,
Signature:
Date:
C1-NDIe. i r • nr i i

State of North Carolina
Department of Environment and Natural Resources
Dr.--, -%t ".
WF
Division of Water Resources
Divlslon of Water Resources LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
Permit application. Euless therwise no ed he Applicant sha 1 submit one original and . o ca i t e 'c tin and
u ortin o amentstion
For more information, visit the Water Quality Permitting Section's Note-Disclrar Per»titfin Unit
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Residuals Source Certification (FORM: LASC 06-16) form. Please do not
make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the
application may be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
® Prepare a sepzrate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Town of West Jefferson
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e,, see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field la Lease Land Use or lZesiduals Source Special note
(yes/no) Cropping Patterns Intended Use of Crops (no.tiWover-seed/
(optional}
pasture)
KP-1 _ No Fescue Hay/pasture Animal Feed West Jefferson WWTP
The landowner or his representative receives, in consideration, fall use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such t ime as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16
PA aP I of 2

I. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section 11) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1636
Mail Service Center, Raleigh, NC 27699-1636.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
Iandowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the
land.application site(s).
6. The,Permittee has provided the landowner or his representative with information and data concerning the residuals lane. application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of
the equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals
land application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final
soil pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for
the specified crop.'
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of
nutrients (e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land
application events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that. must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or s:)ii samples during the
term of, and 12 months after termination of, this Agreement.
H. RESTRICTIONS:
I. Appropriate measures must be taken by the Penmittee and/or the landowner or his representative to control public access to the land
application site(s) during active use and for the 12-month period following a residuals land application event. Such controls may include the
posting of signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period following a residuals land application event. land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land
application events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuaWsoil mixture and are totally above the land surface shall not he harvested for a 14-
month period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land
application event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38-month period following a residuals land
application event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land zpplication event.
I If. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02I' .0105(h) allows the
compliance boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance
boundary provided the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
❑ A re -defined compliance boundary is needed for field(s) ID:
(Please include the rationale for the requested re -location of the compliance boundary and attach a map showing the newly proposed
compliance boundary to the application package)
® A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID: _.___ is currently permitted under another
residuals land application program; Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name of the new program)

Landowner's Certificatiion:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decisions
regarding the use of the land application site(s) on behalf of other deeded landowners OR that I am otherwise authorized, through
a power of attorney or other legal delegation, to matte decisions regarding the use of the land application site(s) on behalf of the
deeded landowners. I certify that the above -referenced land application site(s) are not included in any waste disposal contract or
agreement with another municipality, contractor, or other permitted entity. Furthermore, I certify that 1 have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site PIP as specified
herein. I I E\ \ f l \ M 5 �7 f 1' jj{AQ,�IyVS
Landowner name:
Address:
3
q�
City: 6� _ State: Zip:
Phone: C E-mail address:
Signature:
D te:
NORTH CAROLINA, M-15n COUNTY
1, the undersigned Notary Public do hereby certify that 1,� t_ l �� Pal �� ips - —
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the 1.3 th
A
day of� rf" u 1
Signature and seal. Jt_.s.-x-
My commission expires, 10—
Lessee's/Operator's Certification:
certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name: _
Address:
City:
Phone:
Signature:
Permittee's Certification*
certi fy that l have read
Signing official lame: _
t
Signature:
State: Zip:
E-mail address:
Date:
and do hereby a to abide by the stipulations and restrictions as specified herein.
Date: Zr4719 —
Pa
FORM: LOA 06-16 Page 3 of 3

Setback Waiver Agreement Attachment

State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE RESIDUALS SYSTENIM-A,LVER"
AGREEMENT TO WAIVE SETBACKwit$
I�Htli7?fM#lt7e �A!
15A NCAC 02T .1108 eT------
1. James Lambert, certify that I am a deeded owner of the property located at: Address: 464 Smith Dixon Rd.
Parcel No.: 09334162
City: Crumpler State:_NC Zip Code: 28617 County:
Furthermore, I certify that I am authorized to make decisions regarding this property, and that I do hereby
agree that the setback distances cited below be granted to the Applicant/Permittee listed on the following
page until the expiration of Permit Number WQ0003992 or until the property of either the
Applicant/Permittee is sold or until my property is sold, whichever event comes first. I understand the
setback requirements set forth in 15A NCAC 02T .1 108(e).
❑ For the parcel identified above, I consent to a reduced setback from _ feet to feet of my
property line, thereby allowing the application of residuals as near as
line. feet from my property
For the parcel identified above, I consent to a reduced setback from 400 feet to 100 feet of my
house, thereby allowing the an�lication of residuals as near as 100 feet from my house.
1-1��"�/
Signature:
FORM: NDW 0 03-'l 7
Date: 4/�
Page 1 of 2

I understand that this agreement must be registered with the Register of Deeds forAk j County.
Applicant/Permittee: Town of West Jefferson
Address: 1 South Jefferson Ave. Parcel No.: 19223001073
City: West Jefferson State: NC Zip Code: 28694 County:
NORTH CAROLINA, COUNTY
I, , a Notary Public for County, North Carolina,
rr -- rt personally appeared before me this day
do hereby certify that ��G1yVLl?S �L:�vY1bC p Y Pl'
y �
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the ay of a prt, .
SEAL
MARSHA L. 8UNTING
li1QRI�Y�IC
IIM�CIRR0�M1A
Signature of Notary Public
My commission expires 2
A copy of the recorded, notarized waiver shall be sent to the following address:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDWSW 03-17 Page 2 of 2

State of North Carolina
Department of Environmental Quality
Division of Water Resources,._ .� __
NON -DISCHARGE RESIDUALS SYSTEM
+U12y�*,a
AGREEMENT TO WAIVE SETBACKS AS RFr}Q- U-JIRED BY `''_...�..'.' ".. � j
15A NCAC 02T .1108(e)
1, James Lambert, certify that I am a deeded owner of the property located at: Address: 464 Smith Dixon Rd.
Parcel No.: 093M4162
City: Crumpler State: NC Zip Code: 28617 County: MM
Furthermore, I certify that I am authorized to make decisions regarding this property, and that I do hereby
agree that the setback distances cited below be granted to the Applicant/Permittee fisted on the following
page until the expiration of Permit Number WQ0091M or until the property of either the
Applicant/Permittee is sold or until my property is sold, whichever event comes first. I understand the
setback requirements set forth in 15A NCAC 02T .1 108(e).
❑ For the parcel identified above, I consent to a reduced setback from feet to _ feet of my
property line, thereby allowing the application of residuals as near as feet from my property
line.
For the parcel identified above, I consent to a reduced setback from 400 feet to 100 feet of my
house, thereby allowing the application of residuals as near as 100 feet from my house.
Signat
FORM: NDWSV(0_ 17
Date: _ /J7
Page 1 of 2

i understand that this agreement must be registered with the Register of Deeds for Ashe County.
Applicant/Permittee: Town of West Jefferson
Address: 1 South Jefferson Ave. Parcel No.: 19223001073
City: West Jefferson State: NC Zip Code: 28694 County:
NORTH CAROLINA,j��CO _COUNTY
I, L&eSkjaL , a Notary Public for ke_ County, North Carolina,
do hereby certify that d" ✓ personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the_) 7"day of t I , .
SEAL
IIR7
Nsc3rm
W C0111 MION EXtm312fT11m
r
Signature of Notary Public
My commission expires Z�
A copy of the recorded, notarized waiver shall be sent to the following address:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDWSW 03- f 7 Page 2 of 2

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Cumulative Pollutant Loading Rates

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Facility Name: Town of West Jefferson WQ Permit #: WQ0003992 Field #: 1
Acres utilized: 7.36
Land Owner: Dennis Pennington Annual Dry Tons Applied: 5.8113 Site #: DP-1 Acres Permitted: 7.36
Operator: Brandon Patrick Predominant Soil Series: Cation Exchange Capacity (non 503):
Crop 1 Name: Fescue Crop I Max. PAN: 202 Crop 2 Name: Crop 2 Max. PAN:
L
o Volume applied (enter
Volume
Residual Sources
Sotl
Precip. >
<
o
�
z a Nitrate
aj %
0 one) Solids/ Liquid
Applied per
pp p
(NPDES #, WQ4,
Cond.
T
Past 24 0
-
°»
a
m
-
3 KN
PAN Applied
Name of Crop Type
e Solids
p
Acre
Fert., Animal
(Dry,
-
Hrs, o
=
ro ? and
{Ibs/acpre)
Receiving Residual
Cu. Yds Gallons
Waste. etc)
Wet,
o v
N'
y
= w Nitrite
Application
pp cation
Apri I 6000 0.67
(Dry
Moist
inches
mg/kg mg/kg mg/kg
Crap I Crop 2
Crop)
Crop 2
May 46000 0.67
0.023
NCO020451
Dry
0 S
0.5
0.3
7.463 450.7 1,194
0.004 NA
Fescue
July 62000 0.67
0.175
0.235
NC00 00451
NCO020451
Dry
0 S
0.5
0.3
7.463 450.7 1.194
0.033 NA
Fescue
Fescue
Dry 0 S 0.5 0.3 7,463 450.7 1,194 0.044 NA
Septembet 94000 0.67 0-357 NC002045[ pry -0-S
o.o0a
0.5
0.3
7.463 450.7 [.194
0.067 NA
Fescue
0.000 0.000
0.000
0.000
0.000 0.000
0.000
0.000 0.000
0.000
0.000 0,000
0.000
0.000 0,000
0.000 0.000 0.000
0-000
0.000 0.000
Residuals Applications totals on FORM FSF supp ( attach FORM
0.000 0.000
TOTALS a zos000 : ::::
As
Cd Cu
FSF supp to this form):
_
•
Lime A lied
Cr Pb HZ Mo Nj Se Zn P 0.148 0.000
Annuallbs/acre 0.000
Prior Years Cumulative lbs/ac
0.001 0.I04
0.002
0.004 0.000
0.000
0.009
0.001 O.OI3 9.975
Date ]bs/ac
Current Cumulative Ibs/ac
0.125
0.029 1.I17
0.091
0.233 0.004
0.066
0.479
0.121 2.861
Permitted C. P. L. R.****
0.125
0.030 1-221
0.093
0.233 0.004
0-066
0.488
0.122 2.874
Permit PAN Limit 1 st/2nd Crop
36
34 [338
2677
267 15
N/A
374
89 2498
"I certify, under penalty of law, that
this document
Personnel properly gathered and evaluated
was prepared
under my direction or supervision
in accordance with a system designed to assure that
qualified
the information submitted.
possibility of fines and imprisonment for
I am aware that there are significant
penalties for submitting
false information,
including the
knowing
violations."
*Application Method: S - Surface, IN - Injection, INC - Incorporation
**Volatilization Rate: Surface - 0.5, Injection/Incorporation - 1.0
Signature of Land Applier Date *** Mineralization Rates. Compost -0.1, anaerobially digested -0.2, aerobically
digested -0.3, raw sludge -0.4
****C.P.L.R.: Cumulative Pollutant Loading Rate
DFNR FrnRM 1=SF r1 91900Ft

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOY WHEN NOT APPLICABLE.
Facility Name: Town of West Jefferson
WQ Permit #: WQ0003992
Field #: I Acres Utilized: 10.53
Land Owner: Dennis Pennington
Annual Dry Tons Applied: 4.2467
Site #: DP-2 Acres Permitted: 10.53
Operator: Brandon Patrick
Predominant Soil Series:
Cation Exchange Capacity (non 503):
Crop I Name: Fescue
Crop 1 Max. PAN: 202
Crop 2 Name- Crop 2 Max. PAN:
o s Volume applied (enter Volume
c a/o
Soil
Residual Sources Precip• >
Cond.
o 3 Nitrate Name of Crop Type
v PAN Applied
Applied per
o one) Solids/ Liquid pP p
(NPDES ##. WQ#, Past 24 s
v rKN o and Receiving Residual
Ca Solids Acre
D o
Fen.. Animal ( ry' Ears. o v
ro M ( Ibs/acre)
.. �• Nitrite Application
Cu. Yds Gallons (Dry TorslAc)
Wet, * o
Waste. etc)
Moist inches
o' o'
mg/kg mg/kg mg/kg Crop I Crop 2 Crop I Crop 2
June 54000 0.67 0.143
NCO020451 Dry 0 S
0.5 0.3 7,463 450.7 1.194 0.027 NA Fescue
July 14000 0.67 0.037
NCO020451 pry 0 S
0.5 0.3 7.463 450.7 1.194 0.007 NA Fescue
September 74000 0.67 0.196
NCO020451 Dry 0 S
0.5 0.3 7.463 450.7 1.194 0.037 NA Fescue
October 10000 0.67 0.027
NCO020451 Dry 0 S
0.5 0.3 7,463 450.7 1.194 0.005 NA Fescue
0.000
0.000 0.000
0.000
0.000 0.000
0.000
0.000 0.000
0.000
0.000 0.000
0.000
0.000 0.000
0.000
0.000 0.000
0.000
0,000 0.000
0.000
0,000 0.000
Residunis Applications totals on FORM FSF supp ( attach FORM FSF supp to this form): 1
TOTALS: 0 l sz000 ::::: =: As
Cd Cu Cr Pb H
Mo Ni Se zn P 0.075 0.000 Lime A • lied'
Annuallbs/acre 0.000
Prior Years Cumulative lbs/ac
0.001 0.053 0.001 0.000 0.000
0.000 0.004 0.001 0.007 5.089 Date lbs/ac
0.684
0.126 9.278 0.667 0,952 0.274
0.802 0.74 0.481 10.812
Current Cumulative lbs/ac 0.684
0,127 9.331 0.668 0.952 0,274
0.802 0.744 0.482 10.819
Permitted C. P. L. R.**** 36
34 1338 2677 267 15
NIA 374 89 2498
Permit PAN Limit 1sU2nd Crop
202
"I certify, under penalty of law, that this document
was prepared under my direction or supervision in accordance with a system designed to assure that qualified
personnel properly gathered and evaluated the information submitted. I am aware that there are significant penalties for submitting false information, including the
possibility of fines and imprisonment for knowing violations."
*Application Method: S - Surface, IN - Injection, INC - Incorporation
**Volatilization Elate: Surface - 0.5, Iniection/Incorporation - 1.0
Signature of Land Applier
Date
** Mineralization Rates: Compost -0.1, anaerobially digested -0.2, aerobically
digested -0.3, raw sludge -0.4
****C.P.L.R.: Cumulative Pollutant Loading Rate
DENR FORM FSF M 212006 1

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Facility Name: Town of West Jefferson
WQ Permit #• W 0003992
' Q
Field #
1
Acres Utilized:
10,09
Land Owner: Bryan Anthony Phillips
Annual Dry Tons Applied: 3.9673
Site #:
KP-1
Operator: Brandon Patrick
Predominant Soil Series:
Acres Permitted:
Cation
10.09
Exchange Capacity (non 503):
Crop 1 Name: Fescue
Crop I Max. PAN: 202
Crop 2 Name:
Fescue Crop 2 Max. PAN:
202
Volumes lied enter
applied {
Volume
Residua] Sources
Soil
Cond.
Preci p.
o
a
�_
Nitrate
Name of Crop Type
P p
o
ce
one) Solids/ Liquid
%
Applied per
(NPDFS # WQ4
_
Past 24
, -u
w `�°
iv
TKN
o o
and
PAN Applied
Receiving Residual
p
Solids
Acre
Fert., Animal
D
(Dry.
Wet.
Hrs.
-.
Q. o
E5
2.
Nitrite
( lbs/acre)
Application
Cu, Yds
Gallons
p
(Dry Tons/Ac)
Waste- etc)
Moist
inches
°
mg/kg
m /k
g g
m /k
g g
Crop I
Crop 2
Crop 1
Crop 2
October
70000
0.67
0.194
NCO020451
Dry
0
S
0.5
0.3
7.463
450.7
1.194
0.036
NA
Fescue
Novembe
72000
0.67
0.199
NC0024451
Dry
0
S
0.5
0.3
7.463
450.7
1.194
0.037
NA
Fescue
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0
0.000
0.000
0.000
0.000
0..000 000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
•:..-:•
= :
Residuals Applications totals on FORM FSF
supp ( attach
FORM
FSF
4.000
4.000
TOTALS;
0
142000
:.:
As
Cd
Cu
Cr
Pb
Hg
Mo
Ni
supp
to this form):
_
• .lied...
Annual[bs/acre
Se
Zn
P
0.074
0-000
Lime A
Prior Years Cumulative lbs/ac
0,000
0.001
0.052
0.001
0,000
0.000
0.000
0,004
0.001
0-007
4.962
Date
Ibs/ac
Current Cumulative lbs/ac
0.202
0.054
2.027
0.165
0.335
0.007
0,123
0.645
0.194
4.321
-
8/02/18
2227.9
Permitted C. P. L. R.****
0.202
0.055
2.479
O.166
0335
0-007
0
0.123
0.649
' Pernlit PAN Limit I st/2nd Crop
36
34
1338
2677
267
NIA
374
�0.1954-328
98
"I certify, under penalty of law, that this document
was prepared under my direction or supervision
in accordance with a system designed to assure that
personnel properly gathered and evaluated the information
submitted. I am aware that there
are significant
qualified
for submitting false
possibility of fines and imprisonment for knowing violations."
penalties information,
including the
*Application Method: S - Surface, IN - Injection, INC - Incorporation
**Volatilization Rate: Surface - 0.5, Iniection/Incorvoration - 1.0
Signature of Land Applier Date "*" Mineralization Rates: Compost -0.1, anaerobially digested -0.2, aerobically
digested -0.3, raw sludge -0.4
****C.P.L.R.: Cumulative Pollutant Loadin_ Rate
riPNR Ff1RRA FCF

Soil Maps

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Land Application

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I
Jeffe so
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Lap
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N
41 ;.
Uarl Ho
L1 -
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Willard LittIe',,
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Albertine /jn'
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Tommy Barlow
St„� ey
Dennis Pennington
'IGG1
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o
21
SCALE: = 1,500'
Town of West Jefferson
:HECKEDHY: ��$
Land Application Program
Site
ltTB
DRAWN BY:
BRANCH
RESIDUA
Farm Locations
Vicinity
Map
DATZ: July 2014
& SOILS, LLC
Ffoject N. 2014-109
1

0
� G to o�Q� ti
_gown of est Jefferson R'tiVTP
G` 1/efferson
West Jeffers -an -
I
�\ 88
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ro
too
163
1 Nerf@� r' Hea`�a� Greek
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Keith Phillips
T:.
CI
so ,
SCALE: 1" = 1,500' Town of West Jefferson n
CHECKED BY: RTB Land Application Program
RTB .� BRANCH Farm Locations
DRAWN BY: [�.SIDUALS
n.Are:
July 2014 8� SOILS, LLC 2014-109
Bob
Beaver Ch `
Site
Vicinity
Map
2