WQ0003992_Additional Information Received_20201113

LAND APPLICATION SITE CERTIFICATION
Applicant's name: Town of West Jefferson
Land application sites currently certified: 2656 net acres and Total to be certified: 27.98 net acres.
I. LAND APPLICATION SITE INFORMATION (See Instruction B):
Status
Code'
Site/Field
ID
Landowners
O
Lessees or Operator(s)
O
Net Acres
County
Crop(s) s
PO
Predominant Soil
Series Name
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
N
'Status Code for land application sites are: ♦ N (New) ♦ R (Renewed) ♦ M (Modified) ♦ T (Transferred) ♦ D (Deleted)
b 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)
II. WATERBODY AND CLASSIFICATIONS INFORMATION (See Instruction C):
Site/Field ID
Latitude
Longitude
Location
Datum
Location Method Code
Location Accuracy
Waterbody Subbasin and
Stream Index No.
Current and Proposed
p
Class
_
it a r
NAD 83
ADD
Nearest Second
T
NAD 83
ADD
Nearest Second
NAD 83
ADD
Nearest Second
NAD 83
ADD
Nearest Second
■
NAD 83
ADD
Nearest Second
■
_
.°.
.°..
NAD 83
ADD
Nearest Second
■
_
.°..
.°.
NAD 83
ADD
Nearest Second
■
_
.°..
.°..
NAD 83
ADD
Nearest Second
■
Note: Please keep the site information (L) and waterbody information (II.) of the same field on the same page.
FORM: LASC 06-16 Page 1

III. RESIDUALS LAND APPLICATION PROGRAM INFORMATION:
l . Residuals Processing Facility's physical address: 335 Clearwater Drive
City: West Jefferson State: NC Zip: 28694 11
Coordinates: Latitude: 360 24' 34.37" Longitude: 810 29' 25.73"
Datum: NAD 1983 UTM 17N Level of accuracy: 1I"
Method of measurement: Man
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
Name
Affiliation
Certification Number
ORC
Brandon Patrick
Town of West Jefferson
1003070
Back -Up ORC
Nicholas Walters
Town of West Jefferson
1007912
Additional Back -Up
ORCs,..�,.'',
if applicable)
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: AM
Complete the following tables regarding management of the residuals land application program:
a. Plant Available Nitrogen 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
or Injection
Surface
Incorporation
or Injection
First -Year
12.69
2283.48
Five -Year Maximum Adjusted
15.86
2854.8
b. Land Application 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
Proposed: 27.98
Pasture
Total:
26.56
Proposed: 27.98
Methods
Surface
26.56
Proposed: 27.98
Incorporation or Injection��
;..�
Total:
26.56
Proposed: 27.98
FORM: RLAP 06-16 Page 2 of 5

0519
1418
BK:00519 PG: 1418
FILED Nov 12, 2020 11:39:04 am
BOOK 00519
A — q PAGE 1418 THRU 1419 ASHE COUNTY NC
INST # 05874 DEAETT R. ROTEN
EXCISE TAX (None) REGISTER OF DEEDS
State of North Carolina
Department of Environmental Qu lit ,
Division of Water Resourc
T;
NON -DISCHARGE RESIDUALS SYSTEM
AX-,, A^r NYTv7
AGREEMENT TO WAIVE SETBACKS AS RE-QUIRED BY
15A NCAC 03$11108(e)
1, James Lambert, certify that I am a deeded owne property located at: Address: 464 Smith Dixon Rd.
Parcel No.: 09334162
City: Crumpler State: NC Zip Co '1861 ounty: Ashe
Furthermore, I certify that 1 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*ermit 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 ' ti a consent to a reduced setback from _ feet to _ feet of my
property line, thel allown1W the application of residuals as near as feet from my property
line.
For the pa i bove, I consent to a reduced setback from 400 feet to 100 feet of my
house, here (lowing the application of residuals as near as 100 feet from my house.
Sigre: V,7?221 i' -i-�L Date: _Vi7
FORM: NDWW-17 Page I oft

0519
1419 BK:00519 PG: 1419
1 understand that this agreement must be registered with the Register of Deeds for Asiie 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,h e COUNTY
I,_ ,�(ar lila fUi'1�T r�G , a Notary Public for lqSlz&- County, North Carolina,
do hereby certify that j6aVA +:gin Ltp-" k e,- personally appeared before me this day
and acknowledged the due execution of the foregoing instrument. J
Witness my hand and official seal, this the—L I day of t 1
�•
SEAL
MARSHA L summd
NOTARY PUIWIC
ASNECONNN
NORM CAROLN A
W COMMISSION EXPIRES IV2712023
Signature of Notary Public
�2J-2-1
M nun lion expires tl 7J�
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