WQCS00003_Application_20201201

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0400 — SYSTEM -WIDE WASTERWATER COLLECTION SYSTEMS
INSTRUCTIONS FOR FORM CSA 04-16 & SUPPORTING DOCUMENTATION
Documents shall be prepared in accordance with 15A NCAC 02T .0100, 15A NCAC 02T .0400, and all relevant
Division Policies. Failure to submit all required items will necessitate additional processing and review time.
For more information, visit the System -wide Collection System Permitting website:
General — When submitting an application to the Pretreatment, Emergency Response, & Collection Systems (PERCS) Unit,
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 requested
additional information.
The Applicant shall submit one original and one copy of the application and supporting documentation.
A. Cover Letter
❑ Submit a cover letter listing all items and attachments included in the permit application package
B. No Application Fee Required
➢ No application fee is necessary. The permittee will be billed an annual fee upon issuance of the permit
➢ The appropriate annual fee for systemwide wastewater collection system permits may be found at:
➢ Annual Non -Discharge Fees
C. System -Wide Wastewater Collection System (FORM: CSA 04-16) Application:
❑ Submit the completed and appropriately executed System -wide Wastewater Collection System (FORM: CSA 04-
16) application. Any unauthorized content changes to this form shall result in the application package being
returned. 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.
❑ If the Applicant Type in Section L3 is a Privately -Owned Public Utility, provide the Certificate of Public
Convenience and Necessity (CPCN) from the North Carolina Utilities Commission demonstrating the Applicant is
authorized to hold the utility franchise for the area to be served by the wastewater collection system, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area
or that franchise approval is expected.
❑ If the Applicant Type in Section L3 is a corporation or company, provide documentation if it is registered for
business with the North Carolina Secretary of State.
D. General Information:
➢ The Authorized signing official listed in Section L4 should match with that of the Applicant certification page in
accordance with 15A NCAC 02T .0106(b). Per 15A NCAC 02T .0106(c), 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 NCAC 02T
.0106(b).
➢ NOTE - Public Works Director's are not authorized to sign this permit application according to the rule
unless they are delegated.
INSTRUCTIONS FOR APPLICATION CSA 04-16 & SUPPORTING DOCUMENTATION Page 1 of 5

E. Summary of Attachments Required:
❑ Instruction A:
❑ Instruction C:
❑ Instruction C:
❑ Instruction D:
❑ Section IV.3
❑ Section IV.4
❑ Section V.4
❑ Section V.6
❑ Section VI.2
❑ Section VL4
❑ Section VL6
❑ Section VII
Cover Letter
Application
Ownership Documentation (i.e. CPCN) (If necessary)
Delegation Letter (If necessary for signing official)
Pump Station List
High Priority Lines List
Annual Budget for Collection System (Updated and Approved)
Capital Improvement Plan (Updated and Approved)
Response Action Plan
Contingency Plan
Comprehensive Collection System Map
Note Any Potential Compliance Issues
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO:
NCDEQ-DWR
Water Quality Permitting Section
PERCS UNIT
By U.S. Postal Service:
Attn: PERCS Unit Supervisor
1617 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1617
TELEPHONE NUMBER: [phone]
By Courier/Special Delivery:
512 N. SALISBURY ST. Suite 925
RALEIGH, NORTH CAROLINA 27604
INSTRUCTIONS FOR APPLICATION CSA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 5

I. APPLICANT INFORMATION:
1. Applicant's name (Municipality, Public Utility, etc): Winston-Salem/Forsyth County Utilities
2. Facility Information: Name: Wastewater Collection System Permit No.: WQCS00003
3. Applicant type: ® Municipal ❑ State ❑ Privately -Owned Public Utility
❑ County ❑ Other:
4. Signature authority's name: Courtney Driver per 15A NCAC 02T .0106(b)
Title: Utilities Director
5. Applicant's mailing address: Utilities Administration P.O. Box 2511
City: Winston-Salem State: NC Zip: 27102-
6. Applicant's contact information:
Phone number: [phone] Fax number: [phone] Email address: [e-mail]
II. CONTACT/CONSULTANT INFORMATION:
1. Contact Name:
2. Title/Affiliation:
3. Contact's mailing address:
4. City: State: Zip: 5. Contact's information:
Phone number: ( ) - Fax number: ( ) - Email address:
III. GENERAL REQUIREMENTS:
1. New Permit or Permit Renewal? ❑ New ® Renewal
2. County System is located in: Forsyth County
3. Owner & Name of Wastewater Treatment Facility(ies) receiving wastewater from this collection system:
Owner(s) & Name(s): City of Winston-Salem Archie Elledge WWTP & Muddy Creek WWTP
4. WWTF Permit Number(s): NC0037834 (Elledge); NC005342 Muddy Creek)
5. What is the wastewater type? 98.8 % Domestic or .60 % Industrial (See 15A NCAC 02T .0103(20))
Is there a Pretreatment Program in effect? ® Yes or ❑ No
6. Wastewater flow: 36.68 MGD (Current average flow of wastewater generated by collection system)
7. Combined permitted flow of all treatment plants: 51 MGD
8. Explain how the wastewater flow was determined: ❑ 15A NCAC 02T .0114 or ® Representative Data
9. Population served by the collection system: 299.808
IV. COLLECTION SYSTEM INFORMATION:
1. Line Lengths for Collection System:
Sewer Line Description
Length
Gravity Sewer
1,782 (miles)
Force Main
31.9 (miles)
Vacuum Sewer
0 (miles)
Pressure Sewer
0 (miles)
APPLICATION CSA 04-16 Page 3 of
5

2. Pump Stations for Collection System:
Pump Station Type
Number
Simplex Pump Stations (Serving Single Building)
0
Simplex Pump Stations (Serving Multiple Buildings)
0
Duplex Pump Stations
47
3. Submit a list of all major (i.e. not simplex pump station serving a single family home) pump stations. Include the following
information:
➢ Pump Station Name
➢ Physical Location
➢ Alarm Type (i.e. audible, visual, telemetry, SCADA)
➢ Pump Reliability (Can convey peak hourly wastewater flow with largest single pump out of service)
➢ Reliability Source (permanent/portable generator, portable pumps)
➢ Capacity of Station (Pump Station Capacity in GPM)
4. Submit a list of all high priority lines according per 15A NCAC 02T .0402 (2) known to exist in the collection system. Head
the list with "Attachment A for Condition V(4)" and include the system name.
➢ Use the same line identification regularly used by the applicant
➢ Indicate type of high priority line (i.e. aerial), material and general location
V. COLLECTION SYSTEM ADMINISTRATION:
1. Provide a brief description of the organizational structure that is responsible for management, operation and maintenance of
the collection system.
See attached organizational chart.
2. Indicate the current designated collection system operators for the collection system per 15A NCAC 08G.0201
Main ORC Name: Antonio Martinez
Certification Number: 1005510
Back -Up ORC Name: Kenny Atkins
Certification Number: 1009450
See the "WQCS Contacts and ORC Report" for a current listing of the ORC(s) the Division has on file for WQCS permit
3. Approximate annual budget for collection system only: $ 6.767m
4. Submit a copy of your current annual budget.
5. Approximate capital improvement budget for the collection system only: $ 18.25M
6. Submit a copy of your current capital improvement plan.
7. Is this collection system currently a satellite system ❑ Yes or ® No
8. Do any satellite systems discharge to this collection system ® Yes or ❑ No (If yes complete table below)
Satellite System
Contact Information (Name, Address, Phone Number)
City of King 0.60 MGD
Superintendant: Pettitt 229 S. Main St. P.O. Box 1132 King, NC 27021
[phone]
Davidson County 0.16 MGD
Landfill ISW Director: Charlie Brushwood 1242 Old Highway 29
Thomasville, NC 27360 [phone]
Davie County 0.36 MGD
Utilities Director: Johnny Lambert 298 E Depot St., Suite 200
Mocksville, NC 27028 [phone]
Complete for Satellite Systems that have a flow or capacity greater than 200,000 GPD (Average daily flow)
9. List any agreements or ordinances currently in place to address flows from satellite systems:
Intergovemmental agreements between City of King, Davidson County, and Davie County and the Winston-Salem/Forsyth
County Utility Commission.
APPLICATION CSA 04-16
5
Page 4 of

VI. COLLECTION SYSTEM COMPLIANCE:
1. Is a Response Action Plan currently in place ® Yes or ❑ No
2. If Yes, submit a copy of the Response Action Plan or see table 6 below.
3. Is a pump station contingency plan currently in place? ® Yes or ❑ No
4. If Yes, submit a copy of the pump station contingency plan or see table 6 below.
5. Is a comprehensive collection system map currently in place? ® Yes or ❑ No
6. Submit a submit a copy of the collection system map (CD or hardcopy) or indicate a schedule for completion
7. Thoroughly read and review the System -Wide Collection System Permit Conditions. Typically compliance schedules
are only offered to NEW permit applicants and NOT permit renewals. Any compliance dates must be included within
the permit prior to issuance or the permit holder will be found in violation upon inspection.
Permit Condition
Current
Compliance?
If no, Indicate a
Compliance
Date
Typical
Compliance
Schedule
I(4) — Grease ordinance with legal authority to inspect/enforce
/1 Yes ❑ No
12 — 18 mo.
I(5) — Grease inspection and enforcement program
/1 Yes ❑ No
12 — 18 mo.
I(6) — Three to five year current Capital Improvement Plan.
/1 Yes ❑ No
12 — 18 mo.
I(8) — Pump station contingency plan
/1 Yes ❑ No
3 mo.
I(9) — Pump station identification signs.
/1 Yes ❑ No
3 mo.
I(11) — Functional and conspicuous audible and visual alarms.
/1 Yes ❑ No
3 — 6 mo.
II(5) — Spare pumps for any station where one pump cannot
handle peak flows alone (in a duplex station, the 2' pump is
the spare if pump reliability is met).
6 — 9 mo.
/1 Yes ❑ No
II(7) — Accessible right-of-ways and easements.
/1 Yes ❑ No
6 — 12 mo.
II(9) — Response action plan with Items 9 (a — h).
/1 Yes ❑ No
3 mo.
III(3) — Comprehensive collection system map
/1 Yes ❑ No
10% per year
For conditions not listed, compliance dates are not typically offered. List any permit conditions that may be difficult for the
applicant to meet (attach clarification if needed):
VII. APPLICANT'S CERTIFICATION per 15A NCAC 02T .0106(b):
I Courtney Driver, Utilities Director attest that this application for Winston-Salem/Forsyth County Utilities
(Signature Authority's Name & Title from Item L4) (Facility name from Item L1)
has been reviewed by me and is accurate and complete to the best of my knowledge. I 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 NC General Statutes 143-215.6A and, 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.
Signature: Date:
APPLICATION CSA 04-16
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Page 5 of

Station
Address
City
GPM Per
Pump
Average
Flow (GPD)
Capacity
Abbotts Creek
7435
Watkins Ford Rd
Kernersville
2,620
850,000
37,728,000
Allison Drive
460
Allison Ave
Winston-Salem
67
16,500
96,480
August Dr
6931
August Drive
Clemmons
750
25,000
1,080,000
Avalee
3100
Avalee St.
Walkertown
140
54,000
201,600
Belews Creek
800
Whispering Brook Dr.
Kernersville
1000
240,000
1,440,000
Broad Street
7391
Broad Street
Rural Hall
70
10,000
100,800
Broad View
3262
Broad View Drive
Pfaffiown
350
0
504,000
Brookhaven
500
Brookhaven Drive
Winston-Salem
30
1,000
43,200
Browndale
177
Browndale Ave
Winston-Salem
150
19,000
216,000
Browns Run
1028
Gregory Way Drive
Kernersville
200
25,000
288,000
Clemmons #1
1498
Peace Haven Rd.
Clemmons
325
180,000
468,000
Clemmons #2
7601
Lasater Road
Clemmons
50
40,000
72,000
Clemmons #3
7717
Lasater Road
Clemmons
23
4,000
33,120
Clemmons #4
3542
North Lakeshore Dr.
Clemmons
23
7,000
33,120
Clemmons #5
3638
North Lakeshore Dr.
Clemmons
300
70,000
432,000
Commerce Court
5402
Commerce Court
Winston-Salem
125
2,500
180,000
Crooked Run
780
Crooked Run
Rural Hall
150
3,000
216,000
Deep River
852
Twin Creek Road
Kernersville
1150
240,000
1,656,000
Duke Power
500
Utility Drive
Clemmons
150
13,000
216,000
Eagle Ridge
1407
Pleasant Fork Church
Winston-Salem
65
12,000
93,600
Fair Oaks
3798
Peony Way
Winston-Salem
750
300,000
1,080,000
Foxdale
5460
Foxdale Drive
Winston-Salem
30
2,000
43,200
Friendship Circle
357
Friendship Circle
Winston-Salem
65
1,200
93,600
Griffith Road
2729
Griffith Road
Winston-Salem
700
24,000
1,008,000
Harper Road
2642
Harper Road
Clemmons
1400
135,000
2,016,000
Kaplins
1310
Lewisville-Clemmons
Lewisville
125
10,000
180,000
Kerners Mill
4855
Bellwest Drive
Winston-Salem
4400
1,505,000
6,336,000
Lewisville
421
Williams Road
Lewisville
60
5,000
86,400
Linville Springs
199
Rockford Rd Suite 101
Kernersville
85
40,000
122,400
Lowery Street
3201
Lowery Street
Winston-Salem
700
340,000
1,008,000
Lyons Street
2000
Lyons Street
Winston-Salem
76
1,000
109,440
Mallard Lakes
1790
Mallard Lakes Dr
Winston-Salem
500
1000
720,000
Martin Mill
5880
Reidsville Rd
Winston-Salem
180
70,000
259,200
Montroyal
580
Montroyal Road
Rural Hall
230
12,000
331,200
North Lake
987
La Plata Drive
Kernersville
72
24,000
103,680
Piney Grove
1500
Piney Grove Road
Kernersville
42
6,000
60,480
Plum Street
3271
Plum Street
Winston-Salem
700
90,000
1,008,000
Reedy Fork
275
Lake view Drive
Kernersville
1300
290,000
1,872,000
Somerset Crossing
1180
Old Salem Road
Winston-Salem
215
60,000
309,600
South Fork
4690
Ebert Road
Winston-Salem
3,500
7,500,000
5,040,000
Southview
129
Southview Drive
Winston-Salem
75
4,000
108,000
Tanglewood
Steeple Chase Rd #271
Clemmons
3200
1,300,000
4,608,000
Traid Park
1865
Pleasant View Trail
Kernersville
100
8,200
144,000
Village Club
349
Craver Point Drive
Clemmons
50
6,000
72,000
Walnut Hollow
311
Walnut Hollow Court
Winston-Salem
24
2,000
34,560
West Clemmonsville
2061
Claxton Drive
Winston-Salem
60
2,000
86,400
Winterbrook
147
Winterbrook Court
Winston-Salem
146
2,000
210,240