WQ0001800_Renewal Application_1_20210908

Initial Review
Reviewer Thornburg, Nathaniel D
Is this submittal an application? (Excluding additional information.)*
r Yes r No
Permit Number (IR)* WQ0001800
Applicant/Permittee Town of Yadkinville
Applicant/Permittee Address 1620 Fred Hinshaw rd Yadkinville, NC 27055
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 Yadkinville RLAP
County Yadkin
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 $245
Complete App Date 09/08/2021
Below list any additional email address that need notification about a new project.
Email Address
Comments to be added to email notfication
Comments for Admin
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 * Alex Fox
Email Address*
[e-mail]
electronic subnittal, confirmation of receipt, and other correspondence.
Project Information
........ ......... ....................................................................................................................................... .
Application/Document Type* r New (Fee Req ui red)
r Modification - Major (Fee Required)
6- Renewal with Major Modification (Fee
Required)
r Annual Report
r Additional Information
r Other
Phone Number*
17048813429
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:* WQ0001800
Has Current Existing permt number
Applicant/Permittee* Town of Yadkinville
Applicant/Permittee Address* 1620 Fred Hinshawrd Yadkinville, NC 27055
Facility Name * Town of Yadkinville RLAP
Please provide comments/notes on your current submittal below.
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.)
Sharp Copier_ 20210826_101638.pdf 41.07MB
upload only 1 RCF docurrent (less than 250 NS). Matiple documents nest be corrbined into one RJF file 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 8/26/2021

SYNAGRO
AUGUST 26.2021
TO: Nathaniel Thornburg
FROM: Alex Fox, Synagro Central, LLC
RE: Yadkinville Renewal (WQ0001800)
We are submitting this renewal on behalf of the town of Yadkinville. The dry tonnage on the
water plant is being increased to prevent from getting another NOV in the future. We have done
house and property buffers on two sites YK-35 and YK-08. There are two new fields being
added YK-29-2 and YK-33-4. All of the required information is attached in this packet. Let us
know if you need anything else.
I look forward to working with you all on this to ensure a smooth and time efficient process.
Feel free to call or email me with any questions.
T4to
you
Ax
Technical Services Specialist
704-881-3429
[e-mail]
284 Boger Road, Mocksville, NC 27028 • Phone: [phone]. Fax: [phone]

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Description Amount
CKRQ-072221-RTR 245.00
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DATE 07/29/2021
[phone]
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$ ****245.00
PAY Two Hundred Forty -Five Dollars and 001100 Cents
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TO NCDENR-DWR
THE LAND APPLICATION UNIT�..
ORDER 1636 MAIL SERVICE CENTER
RALEIGH NC 27699-1638
United 'States

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*See Other Side For Opening Instructions*
Synagro Technologies, Inc.
435 WilllaMS Court, Ste 100
Ba[t[more MD 21220
[phone]
NCDENR-DWR
LAND APPLICATION UNIT
1638 MAIL SERVICE CENTER
RALEIGH NC 27699-1636
United States

DWR
State of North Carolina
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 co ies of the anylication and
supporting documentation
For more information, visit the Water QtfalityPennitting Section 'sNon-Discharire PernuttinY U)7h
General —This appiicationis for treatment, storage, transport, and/or land application of Class residuals (mayinclude residuals that
are generated from a water treatment plant or other type facilities) on the proposed or currently approved land application site(s) under
15A NCAC 02T .1100,
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-I 6) 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 maybe 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 . An
alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the
criteria in 15ANCAC 02T.0106(b).
® 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 ofproposed facility(ies) for application packages involving new or changes to treatment and storage units.
B. Application Fee (New and Maj orModificat ion Applica tion Packages)
® Submit a check, money order or electronic funds transfer made payable to: North Carolina Department of Environmental
Quality (NCDEQ).
Facility Classification New Permit j Major Modification
Major(landarepennittedfor >300acres) $1,310 $395
Minor (land are permitted for<300 acres) S810 $245
-A ma'ormodification shaUbe defined as any permit modification that: increases the generating facility's residuals dry tonn
age;
nage;
adds additional land application areas notpreviously approved forthat particularprogram [including transferring offield(s) from
one program to another]; adds additional residuals sources; or includes the addition of new treatment or storage units/processes
notpreviously permitted. There is no fee for minor modifications to apermit.
C. Cover Letter (All Application Packages)
® List all items included in the application package, as well as abrief description of therequested permitting action.
D. Environmental Assessments (Maybe Required— See 15A NCAC 1C .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 forprivate systems if any public funds and/or lands
are used for the construction of the subject facilities.
INSTRUCTIONS FOR FORM: RLAP 06-16 Page 1 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 15A NCAC 02T.1 110 and include at 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.
® Inspection plan including the following information;
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 the 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 samplingplan shall account forany foreseen fluctuations in residuals duality 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
yearbut have an anrivalsamp6ngfrequency,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 M1 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 15A NCAC 02T
.110202). Specifically, a residuals land application program is designated as dedicated if any of the following are
applicable:
❑ Any land application site certified for the residuals land application program that receives residuals at rates or frequencie s
greater than agronomic rates.
❑ Any Iand 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 determiningwhetheryourresiduals program
falls underthe dedicated program definitions.
G. Program information
❑ Provide an explanation of why a dedicated system is required instead of a conventionalnon -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 1 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 andfenceswithin 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
❑ 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

L 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 Packagesor Modifications involving increasing thetotaldesign capacity)
❑ Submit a detailed hydrogeologic evaluation in accordance with 15A NCAC 02T .1104(d)(4) and current Division Policy
available at: httl2://www.iacwater.org/Rules Policies and Re lations/.Thedocumentshallbe signed, sealedanddatedby a
qualified professional.
K. Engineering Design 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 . 1104 d 2 . For Modifications, submit an updated
site map specific to the modification(s) only,
❑ The design documentsmust 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 understandingofthe complete process;
❑ Specifications describing materials to be used, method of construction, and means forensuring quality and integrity of the
finished product including Ieaking 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 mappingunits 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 waterbalance in accordance with 15ANCAC 02T-1104(d)(5) and current Division Policy
availableat: httl2://www.newater.orWRuies Policies and Re lations/.
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 casement running with the land specifically indicating the intended use of the property and meeting the requirements
of 15A NCAC 021 .0107 , or
❑ A written notarizedlease agreementsigned by both parties, indicating the intendeduse of theproperty, aswell asa 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]
INSTRUCTIONS FOR FORM: RLAP 06-16 Page 3 of 3

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15ANCAC 02T .1100 —RESIDUALS LAND APPLICATION PROGRAM
FORM: RLAP 06-16
I. APPLICANT INFORMATION:
1. Applicant's name: Town ofYadkarville
Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State ® Municipal ❑ County
Signature authority's name per 15A NCAC 02T .0106:Jacob Swaim Title: Director of Public Works
Applicant's mailing address: PO Box 816
City: Yadkinville State: NC Zip: 27055-
Telephone number: (21J6 403-2444 Emai] Address iswaim@, adkinvillc.org
2. Consultant's name: Alex Fox License Number (for P.E.):
Affiliation: ❑ On Staff ®Retained(Firm: SynagtoLLC.)
Consultant's mailing address: 284 Boger rd
City: Mocksyille State: NC Zip: 27028
Telephone number: 704)981-3429 EmailAddress: afox(a,synagroxom
3. Agronomist's name:
License Number:
Affiliation: ❑ N/A ❑ On Staff
❑ Retained (Firm: )
Agronomist's mailing address:
City: State:
Zip: -
Telephone number: (_)
Email Address:
4. Soil Scientist's name: Chris Murray
License Number: 1284
Affiliation: ® N/A ❑ On Staff
❑ Retained(Finn:
Soil Scientist's mailing address: 216
S. Swing Rd. Suite 1
City; Greensboro State: NC
Zip: 27028
Telephone number: 336) 662-5487
Email Address: chris(cr7 iedmontsoil.com
5. Fee submitted: 245 (See Instruction
B)
H. PERMIT INFORMATION:
1. Application is for(check all thatapply):❑ new, IR modified, ❑ renewed permit
2. 1fthis applicationis being submitted to renew or modify an existing permit, provide the following:
Permit number; W 0001900
Date of most -recently issued permit: 3/13/17
Date of most -recently certified Attachment (if different than the permit):
Date of most -recently certified Attachment (if different than the permit): 9/20/20
FORM: RLAP 06-16 Page 1 of 5

III. RESIDUALS LAND APPLICATION PROGRAM INFORMATION:
1. Residuals Processing Facility's physical address: 1620 Fred HinshawRd
City: YadkinvilIe State: NC Zip: 27055
Coordinates: Latitude: 36OW 01" Longitude: 80137' 32"
Datum: NAD83 Level of accuracy: second
Method of measurement: MAP
2. Countywhere residuals land application program is headquartered: YADKIN
3. List the Operator In Responsible Charge (ORC) and all Back -Up ORCs for the residuals land application program, their
certification numbers, and their affiliationsin thefollowing table:
Designation
Name
Affiliation
Certification Number
ORC
Alex Fox
Synagro LLC
1009594
Back -Up ORC
Mikey Boone
Synagro LLC
987521
Additional Back -Up
ORCs
if a licable)
It an ORC and at least one Back -Up ORC are not currently designated forthis 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:
4. Complete the following tables regarding management of the residuals land application program:
a. Plant Available Nitrogen Summar 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: 250 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
28.77
34,27
8,056
9,596
Five -Year Maximum Adjusted
43.79
49,29
12,262
13,802
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
5.9
IIay
45
Pasture
44.1
Total:
95.0
Methods
Surface
95,0
Incorporation or I nj ection
Total:
95.0
FORM: RLAP 0 6 - t 6 Page 2 of 5

c. Residuals Land A Heation Summary: 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 Acres Required Using Acres Required Using
Application Rate First -Year PAN Concentrations Five -Year Maximum Adjusted PAN
(Ibs PAN/ac yr) Concentrations
Surface Incorporation or Surface Incorporation or
Injection Injection
50 161.1 191.9 242.2 276.0
100 80.6 96.0 122.6 138.0
150 53.7 64.0 81.7 92.0
200 403 48.0 61.3 69.0
6. If applicable, provide a plan anda schedule to resolve anyknown 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.
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.
I R
Land Application Sike
Certification. doc
FORM: RLAP 06-16 Page 3 of 5

Note: Item VI. Applicable to Dedicated Program with fixed irritation system oniy.
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 requires at least one -foot vertical separation between SHWT and
ground surface.
4. Are there any artificial drainage or watermovement 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 to be maintainedormodified:
5. Loading rates recommended by the Soil Scientist Evaluation:
Recommended Recommended
Soil Series Fields within Soil Area Loading Rate Loading Rate
(in/trr) (in/yr)
6. Design loading rates are equalor less than the loading rates recommended by Soil Scientist?
❑ Yes or El No IfNo, explain why 15ANCAC 02T.0505 n is not met:
7. Non -dedicated System Design (fill in the appropriate information foreither a spray or drip irrigation system):
Field /Zane Design Area Number of �Ma;xl�mumlication Design Annual Loading
(ft) Nozzless/hr) Rate (gallons/yr)
Total
Spray Irrigation Design Element Plan Sheet Specification
Number Pa a Number
Wetted diameterof nozzles tfftt2
Wetted area of nozzles Nozz
le capacity
Nozzle manufacturer/ model /
Elevation of highest nozzle I't
FORM: RLAP 06-16
Page 4of5

Applicant's Certification (signing authority must be in compliance with 15A NCAC 02T .0106):
The applicant or any affiliate has not been convicted of an environmental crime, has not abandoned a wastewater facility with out
proper closure, does not have an outstanding civil penalty where all appeals have been exhausted or abandoned, are compliant with
any active compliance schedule, and do not have any overdue annual fees under Rule 15ANCAC 02T.0105.
® Yes ❑ No, Explain;
1, Jacob Swaim Puhlie Works Director
(Signature Authority's Name —PLEASE PRINT) (Title)
attest that this application for Yadkinville WWTP/WTP
(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 technicalreview of this program and approval does not constitute a variance to any rules orstatutes
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
notto exceed $10,000 as well ascivil penalties up to $25,000 per violation.
Signature: Date: S
FORM: RLAP 06-16 Page 5 of 5

DWR
State of North Carolina
Department 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 Apulicant shall submit one original and two covies of the application and
supporting documentation
Formore infonnation, visitthe Water Quality Permitting Section's Non -Discharge Permittj)1Unit
General — This certification provides detailed information of residuals source generating facility and its residuals quality for land
application, distribution, or disposal in accordance with 15A NCAC 02T .1100. 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 supportingdocumentatio n listed
below.
A. Residuals Source Certification (FORM: RSC 11-15):
B.
C.
® Submit the completed and appropriately executed Residuals Source Certification (FORM: RSC 11-15) form. Please do not
make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to th e
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 perm its, submit a separate certification foronly thosefacilities thatare affected by the proposed modification.
® Complete the residuals source facility summary page. List all new, renewed, or modified facilities.
Residuals Source -Generating Facility Information:
For each source facility, attach the following:
® Vicinity map -A vicinity map that shows the location ofthe facility andmeets all of the criteria in the "Ma p Guidance for
Residuals Land AUplication Pennits".
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 permit. 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 €he pla n details how the facility and/or the residua Is are monitored for any applicable pathogen reduction a n d
vector attraction reduction requirements. Note that all sampling and monitoring must be completed on the residuals as
they are to be land applied, distributed, and/ordisposed.
Residuals Quality Information:
® For each source facility, attach the following:
® Laboratory analytical reports and operational data -reports for all laboratory analysesused to complete this certification.
Documentation that the facility complies and/orthe 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 alongwith the description of similarities of the two
facilities.
INSTRUCTIONS FOR FORM: RSC 06-16 Page I of 1

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State of North Carolina
DWR Department of Environmental Quality
Division of Water Resources
Division of Water Resources RESIDUALS SOURCE CERTIFICATION
FORM: RSC 06-16
I. RESIDUALS SOURCE -GENERATING FACILITY INFORMATION (See Instruction B.):
1. Facility Name: Yadkinyille WWTP
2. Facility permit holder is: ❑ Federal, ❑ State, ® LocalGovemment, or ❑ Private.
Facility pen -nit issued by: ® Div. of Water Resources, ❑ Div. ofEnvironmental Health,
or ❑ Other (explain: ).
3. Facility contact personand title: Grant Trivette Plant Super -visor
Complete mailing address: PO BOX 816
City: Yadkinville State: NC Zip: 27055
Telephone number: Q36) 679-2184 E-mail address: [e-mail]
4. Facility physical address: 1620Fred Hinshaw Rd
City: Yadkinville State: NC Zip: 27055-_
Coordinates: Latitude: 36°08'01" Longitude: 900 37'32"
Datum: NAD83 Level of accuracy: Second
Method of measurement: MAP
5. Purpose of the facility:
0 treatment of municipal wastewater, ❑ treatment of 100% domestic wastewater,
❑ treatmentof potable water, ❑ treatment of 100% industrial wastewater,
❑ treatmentof industrial wastewatermixed with domestic wastewater,
(approximate percentages: %industrial and %domestic)
❑ other (explain: ).
6. Does thefacility have an approved pretreatmentprogram : ® Yes ❑ No
7. Facility permitted/design flow: 2_5 MGD and facility average daily flow: 0.75 MGD
8. Average amount of residuals being generated at this facility 40 dry tonsper year.
9. Specify the following regarding treatment and storage volumes available at the facility:
Type and volume of residuals treatment: 350,000 gaNon aerobic digester
Type and volume of residuals storage (i.e., outside of residuals treatment units): 230.000 gallon storage tank
IL RESIDUALS QUALITY INFORMATION (See Instruction C.):
1. Specify if residuals are regulated under:
E 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 under40 CFR Part 257.
2. Specify if residuals are definedunder 15A NCAC 02T.1 102 6 as:
0 Biological ❑ Non -Biological
Note; Biological residuals are residuals that have been generated during the treatment of domestic wastewater, anirnal
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).
FORM: RSC 06-16 Page 1 of 5

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 §261.3 l-§261.33: � yes no.
If yes, list the number(s);
b. Specify whether or not the residuals exhibit any of the characteristics defined by40 CFR §261.21-
261.24; Q yes j 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, andreactivity:
Laboratory: SummitEnvironmental Technolo ies andDateofanalysis: 4/2/21
Passed corrosivity test: OJ yes Q no. PH:7.46 s.u. (2 <ph < 12.5)
Passed ignitability test: yes Qj no. Flashpoint; >140 °F (> 140°F)
Passed reactivity test: yes ]�na. HCN: ND mg/kg (<250) & H25: ND mg/kg (<500)
TCLP Parameter
Limit
09/1)
Result
(mg/1)
TCLP Parameter
Limit
(mg/1)
Result
(Mg/l)
Arsenic
5.0
ND
Hexachlorobenzene
0.13
ND
Barium
100.0
ND
Hexachloro-1,3-Butadiene
0.5
ND
Benzene
Cadmium
Carbon Tetra chloride
0.5
1.0
0.5
ND
ND
ND
Hexachloroethane
Lead
Lindane
3.0
5.0
0.4
ND
ND
ND
Chlordane
0.03
ND
Mercury
0.2
ND
Cblorobenzene
100.0
ND
Methoxychlor
10.0
ND
Chloroform
6.0
ND
Methyl Ethyl Ketone
200.0
ND
Chromium
5.0
ND
Nitrobenzene
2.0
ND
m-Cresol
200.0
ND
Pentachlorophenol
100.0
ND
o-Cresol
200.0
ND
Pyridine
5.0
ND
p-Cresol
200.0
ND
Selenium
1.0
ND
Cresol
200.0
ND
Silver
5.0
ND
2,4-D
10.0
ND
Tetra chloroethylene
0.7
ND
1,4-Dichlorobonzene
7.5
ND
Toxaphene
0.5
ND
1,2-Dichloroethane
0.5
ND
Trichloroethylene
0.5
ND
1,1-Dichloroethylene
0.7
ND
2,4,5-Trichlorophenol
400.0
ND
2,4-D nitrotoluene
0.13
ND
2,4,6-Trichlorophenol
2.0 7
ND
Endrin
Reptachlorand its Hydroxide
0.02
0.008
ND
ND
2,4,5-TP (Silvex)
Vinyl Chloride
1.0
0.2
ND
ND
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 formetalsregulated under 15ANCAC 02T 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) forthe following meta 1parameters:
Laboratory: Pace Analytical and Date of analysis:4/30/21
Parameter
Ceiling
Monthly Average
Result
Concentration Limits
Concentration Limits
(Class, & ClassB)
(Class A Only)
(nzgAg)
(nigAg)
(nzg/kg)
Arsenic
75
41
5.8
Cadmium
8S
39
99
Copper
4,300
1,500
390
Lead
840
300
26
Mercury
57
17
NI}
Molybdenum
75
n/a
7.1
Nickel
420
420
50
Selenium
100
100
8.5
Zinc
7,500
2,800
1804
b, For Sur ace Dis osal Unit Landfill): Fill in the following table with the results of the latest analyses (i.e., on a dry weight
basis) for the following metalparameters:
Laboratory: and Date of
analysis:
Distance from Disposal
Arsenic Chromium=NickelUnit
to Boundary to
Closest Property Line
(meters, clzeckozze(nzg/kg)
(mg4g)
❑ > 0 but<25
30 200
210
❑ > 25 but< 50
34 220
240
❑ > 50 but< 75
39 260
270
❑ > 75 but< 100
46 300
320
❑ > 100 but< 125
53 360
390
❑ > 125
62 450
420
Result (mg/kg)
FORM: RSC 06-16
Page 3of5

5. Nutrient/Micronutrient Determination: Completethefollowing:
a. Totalsolids: 2.79 %.
b. Fill in the following table with the results of the latest analyses (i.c., on a dry weight basis) for the following nutrient and
micronutrient parameters:
Laboratory: PaccAnalytical and Dateof analysis: 4/30/21
Parameter
Result
(mg/kg)
Aluminum
58000
Ammonia -Nitrogen
5500
Calcium
11000
Magnesium
2800
Nitrate -Nitrite Nitrogen
86.3
pH (Standard Unit)
6.9
Phosphorus
25000
Potassium
4200
Sodium
3 000
Tota I Kj oldahl Nitrogen
44000
c. Using the results listed in Item IL 5b. above, calculate the sodium adsorption ration (SAR): 1.10
[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): defaultvalue, or 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 L
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 (I') Year PAN
Five -Year
Maximum Adjusted PAN
(mg/kg)
(mg/kg)
Surface
14,386
21,897
Injection/Incorporation
17,136
24,647
6. Other Pollutants Determination: Specify whetherornot there are any other pollutants of concern in the residuals andprovide
the results of the latest analyses L1
FORM: RSC 06-16 Page 4 of 5

7. Pathogen Reduction: Per 15A NCAC 02T.1 106, specify how residuals will meet the pathogen reduction requirements:
a. For DistributiaizILatidAj2izlieation o Class A or E uivalent:
❑ A fecalcoliform density that is demonstrated to be less than 1,000 MPN per gram of totaldry 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 1 [15A NCAC 02T.1106(b)(3)(A)] - Time/Temperature Compliance.
❑ Alternative [15A NCAC 02T. I 106(b)(3)(B)] - Alkaline Treatment.
❑ Alternative 3 [15ANCAC 02T.1106(b)(3)(C)] -Prior Testing for Enteric Virus/Viable Helminth Ova.
❑ Alternative 4 [15A NCAC 02T.1 106(b)(3)(13)] - No Prior Testing for Enteric Virus/Viable Hehninth Ova.
❑. Altemative 5 [15A NCAC 02T.1106(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 ClassB.
Alternative l [15A NCAC 02T.1106(c)(1)] -Fecal Colifonn Density Demonstration.
❑ Alternative 2 [15A NCAC 02T.1106(c)(2)] - Process to Significantly Reduce Pathogens (PSRP).
Specify one: ❑ aerobic digestion, ❑. airdrying, ❑ anaerobic digestion,
❑ composting, or [9, lime stabilization.
c. For Sur
aceDisposal.
❑ Select One of the Class A or Equivalent Pathogen Reduction Alternatives in Item 11.7a. above.
❑ Select One of the Class B or Equivalent Pathogen Reduction Alternatives in Item I1.7b. above.
❑ Exempt - If Daily Cover Altemative is chosen in Item II.8. below [15A NCAC 02T.1106(a)(2)].
❑ Not Applicable - Non -Biological Residuals with NO Domestic Wastewater Contribution.
8. Vector Attraction Reduction OAR): Per 15A NCAC 02T.1 107,specify how residuals will meet the VAR requirements:
® Alternative I [15A NCAC 02T.1107(a)(1)] - 38% Volatile Solids Reduction (Aerobic/Anaerobic Digestion).
❑ Alternative 2 [15A NCAC 02T.1107(a)(2)] - 40-Day Bench Scale Test (Anaerobic Digestion).
® Alternative 3 [I5A NCAC 02T.1107(a)(3)] - 30-Day Bench Scale Test (Aerobic Digestion).
® Alternative 4 [15A NCAC 02T.1107(a)(4)] - Specific Oxygen Uptake Rate Test (Aerobic Digestion).
Alternative 5 [15A NCAC 02T.1107(a)(5)] - 14-Day Aerobic Processes.
®, Alternative 6 [15A NCAC 02T.1107(a)(6)] - Alkaline Stabilization.
❑ Alternative 7 [15A NCAC 02T.1107(a)(7)] - Drying of Stabilized Residuals.
❑ Alternative 8 [15A NCAC 02T.1107(a)(8)] - Drying ofUnstabilized Residuals.
® Alternative 9 [I SA 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.1107(b)(2)].
❑ Not Applicable - Non -Biological Residuals with NO Domestic WastewaterContribution.
Note: For animal processing residuals, only alternatives 9 or 10 may be chosen due to the nuisance conditions that typically
occurwhen these residuals areapplied and left on the land surface.
FORM: RSC 06-16 Page 5 of 5

_Quantitative Justification for Residuals Production
Currently, the Town of Yadkinville WWTP is permitted for 250 dry tons of annual production.
There is no request at this time to change this amount. The facility permitted/design flow is 2.5
MGD. The plant currently has a average daily flow of .75MGD. Even if this maximum amount is
reached, we would still be under the permitted 250 dry tons of annual production. The additional
dry tonnage will allow for any future expansions.
Total Dry Tons = gallons of residuals X % solids X 8.34 lbs./ allon
2,000 lbs./ton
(600,000 X 0.025 X 8.34 lbs./gallon)/ 2,000 lbs./ton = —62 dry tons

I
j Residuals Sampling Plan
Synagro Residuals Land Application for WQ0001800
Town of Yadkinville NC
Nutrients and Metals Analysis (WWTP and WTP)
• Sampling Point: Digester
• Sampling Frequency: Annual or Specific Event
• Sample Type: Composite
• Lab: Waypoint Analytical
Pathogen Reduction (Fecal Coliform Density Demonstration) (WWTP only)
• Sampling Point: Digester
• Sampling Frequency: l/yr (Volume Dependent)
• Sample Type: Grab -- Fecal Coliform Demonstration
• Lab: Statesville Analytical Laboratory
Vector Attraction Reduction (38% VSR)
TCLP
• Sampling Point: Digester
• Sampling Frequency: I/yr (Volume Dependent)
• Sample Type: Composite
• Lab: Yadkinville Wastewater Lab
• Sampling Point: Digester
• Sampling Frequency: Annual
• Sample Type: Composite
• Lab: Summit Environmental Technologies, Inc
(

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Town of Yadkinville
WTP and WWTP Vicinity Map
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284 Boger Road, Mocksville, NG 27028
Phone; [phone] 0 Fax: [phone]

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aceAnalytical 0
Report of Analysis
synagro
12701 Lancaster Hwy
Pineville, NC 28134
Attention: Adam Brigman
Project Name: Yadkinville
Lot Number.WD20039
Date Completed:04/3012021
I
05/03/2021 3:36 PM
Approved and released by:
Project Manager II: Lucas Odom
ANSI MISIIIIA-1*9 dnR Said
\e _
ACCA EDI T ED
--—
TESTINGLMORATGRV
The electronic signature above is the equivalent of a handwritten signature.
This report shall not be reproduced, except in its entirety, without the written approval of Pace Analytical services, LLC.
Pace Analytical Services, LLC (formerly Shealy Environmental Services, Inc.)
106 Vantage Point Drive West Columbia, SC 29172
Tel:[phone] Fax:[phone] www.pacelabs.com
Page 1 of 7

PACE ANALYTICAL SERVICES, LLC
SC DHEC No; 32010001 NELAC No: E87653 NC DENR No: 329 NC Fleld Parameters No: 5639
Case Narrative
Synagro
Lot Number: WD20039
This Report of Analysis contains the analytical result(s) for the sample(s) listed on the Sample Summary
following this Case Narrative. The sample receiving date is documented in the header information
associated with each sample.
All results listed in this report relate only to the samples that are contained within this report.
Sample receipt, sample analysis, and data review have been performed in accordance with the most
current approved The NELAC Institute (TNI) standards, the Pace Analytical Services, LLC ("Pace")
Laboratory Quality Manual, standard operating procedures (SOPs), and Pace policies. Any exceptions to
the TNI standards, the Laboratory Quality Manual, SOPs or policies are qualified on the results page or
discussed below.
Where applicable, all soil sample results (including LOQ and DL if requested) are corrected for dry weight
unless flagged with a "W" qualifier.
If you have any questions regarding this report please contact the Pace Project Manager listed on the
cover page.
The pH analysis associated with the sample(s) in this report was/were performed after the method
recommended 15 minute holding time.
Pace Analytical Services, LLC (formerly Shealy Environmelal Services, lno,)
106 Vantage Point Drive West Columbia, SC 29172 [phone] Fax [phone] www.pacelabs.com
Page 2 of 7

Client: Synagro Laboratory ID: WD20039-001
Description, Yadkinvllle WWTP Matrix: Solid
Date Sampled:0411912021 1130 % Solids: 2.79 04/21/2021 0002
Date Received; 0412012021
Inorganic non-metals
Run Prep Method
Analytical Method
Dilution Analysis Date 'Analyst
_
Prep Date
Batch
1
(% Solids) SM 254OG
1 04/21/2021 0002 SJL
89669
1 350.1
(Ammonia - N ) 350.1
5 04/26/2021 1340 DRD
90225
2
(Nitrate - N ) 9056A
1 04/30/2021 1102 AMR
90829
1
(Nitrite - N ) 9056A
1 04/2812021 2338 AMR
90650
1
(Phosphorus) 365.1
25 04/26/2021 1446 DMA
04/24/2021 1139
90119
1
(Soil pH meas) 9045D
1 04/26/2021 2203 NBW
90278
1 351.4
(TKN) 351.2
2 04/26/2021 1263 DMA
04/2412021 1116
90116
CAS Analytical
Parameter
Number Method
Result Q
LOQ
DL
Units
Run
% Solids
SM 25400
2.79
%
1
Ammonia - N (gas diffusion)
350.1
5500
180
93
mglkg
1
Nitrate - N (soluble)
9056A
80
18
3.6
mglkg
2
Nitrite - N (soluble)
9056A
6.3 J
7.2
3.6
mglkg
1
Phosphorus
7723-14.0 365.1
25000
4500
900
mglkg
1
Soil pH measured in water @
18.7 ° C
9045D
6.9
su
1
TKN
351.2
44000
1800
1800
mglkg
1
CVAA
Run Prep Method Analytical Method Dilution Analysis Date Analyst Prep Date Batch
1 7471 B 7471 B 1 04/27/2021 1544 CMS2 04/27/2021 1035 90176
CAS Analytical
Parameter Number Method Result Q LOQ DL Units Run
Mercury 7439-97-6 74716 ND 2.8 0.66 mglkg 1
ICP-AES
Run Prep Method
Analytical Method Dilution Analysis Date Analyst
Prep Date
Batch
1 3050B
6010D 1 04/23/2021 1618 KSH2
04/22/2021 1217
89730
CAS Analytical
Parameter
Number Method
Result Q
LOQ
DL
Units
Run
Aluminum
7429-90-5 6010D
58000
200
74
mglkg
1
Arsenic
7440-36-2 6010D
5.8 J
7.4
2.5
mglkg
1
Cadmium
7440-43.9 6010D
0.99 J
2.5
0.62
mg/kg
1
Calcium
7440.70-2 6010D
11000
2500
310
mglkg
1
Chromium
7440-47-3 6010D
55
4.9
1.2
mglkg
1
Copper
7440-50-8 6010D
390
4.9
2.2
mglkg
1
Iron
7439-89-6 6010D
23000
49
22
mglkg
1
Lead
7439.92.1 6010D
26
4.9
2.2
mglkg
1
Magnesium
7439-95-4 6010D
2800
2600
310
mglkg
1
Manganese
7439-96-5 6010D
3800
7.4
2.9
mglkg
1
Molybdenum
7439-98-7 6010D
7.1 J
20
4.9
mglkg
1
Nickel
7440-02-0 6010D
50
20
5.2
mglkg
1
LOQ = LIM of Quantitation B = Detected In the method blank E = Quantitation of compound exceeded the calibration range DL = Detection Limit Q = Surrogate failure
ND = Not detected at cr above the DL N = Recovery is out of criteria P = The RPD between two GC columns exceeds 40% J = Estimated result < LOQ and > DL L = LCSILCSD failure
H = Out of holding time W = Reporled an wet weight basis 5 = MS/MSD failure
Pace Analytical Services, LLC (formerly Shealy Environmental Services Inc.)
106 Vantage Point Drive West Columbia, 5C 29172 [phone] Fax [phone] www.paceiabs.com
Page 3 of 7

Client: Synagra Laboratory ID: WD20039-001
Description: Yadkinville WWTP Matrix: Solid
Date Sampled:04119/2021 1130 % Solids: 2.79 0412112021 0002
Date Received:04120/2021
ICP-AIES
Run Prep Method
Analytical Method Dilution Analysis Date Analyst
Prep Date
Batch
1 3050B
6010D 1 04/23/2021 1618 KSH2
O4/22/2021 1217
89730
CAS Analytical
Parameter
Number Method
Result Q
LOQ
DL
Units
Run
Potassium
7440-09-7 6010D
4200
2500
310
mglkg
1
Selenium
778249 2 6010D
8.5 J
919
4.0
mglkg
1
Sodium
7440-23.5 6010D
3000
2500
310
mglkg
1
Zinc
7440-66-6 6010D
1800
25
6.2
mglkg
1
LOQ = Limit of Quantitalion B = Detected In the method blank E = Quantitallon of compound exceeded the calibration range DL = Detection Limit Q = Surrogate failure
ND = Not detected at or above the DL N = Recovery is out of criteria P = The RP between two GC columns exceeds 40% J = hstlmaled result a LDQ and a DL L = LCSILCSD failure
H = Out of holding time W = Reported on wet weight basis 8 = MSIMSD failure
Pace Analytical Services, LLC (formerly Shealy Environmental Services, Inc.)
106 Vantage Point Drive West Columbia, SC 29172 [phone] Fax [phone] www.pacolabs.com
Page 4 of 7

Chain of Custody
and
Miscellaneous Documents
Pace Analytical Services, LLC (formerly Shealy Fnvironmenlal Services, Inc.)
106 Vantage Point Drive West Columbia, SC 29172 (803} 791-9700 Fax [phone] www.pacelabs.com
Page 5 of 7

PACE ANALYTICAL SERVICES LLC
UR
Pace Analyticai Services, LLC (formerly Shealy Environmental Services, Inc.)
106 Vantage Point Drive West Columbia, 5C 29172 [phone] Fax (M) 791-9111 www.pacelabs.com
Page 6 of 7

PACE ANALYTICAL SERVICES LLC
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I [, i` wn tum to be PQrf'ot't€ted WtUd oft the CO d
n Yes
No
12. Did all s€im fetes arrivo fa the peeper containers for each Wr And/or in good condidon
(mbroken, lids on, etv-)?
0 Yos71
Nr
13, Was R&quHLo!1WUj)le volume mil�thle?
Yos
9NO
14. Wore all samples teeml),red within 14 the bolding lime or 4a hears, whichever ombs first'?
Yes
,� lac.,
.µ
mmFu (circle samples Not lis[cd on CGC7
15. Were any ssam(zfe:3�uLtraittot'�.missini(ccle
Yes
[�No
-
--
�AIA
� e, -one)
�...T ... mo...
16. Far'VOA and R'SK-17$ swuples* wcrc bulkles m nt' ergsfze" Vi" )
p p (.� 4rfimn�ind'uirn�:lsf'
In any of:lft4 VGA vials?
Yr-
Nt,
OR' E:A
17. Ware a151}Ctl�farlelalsinLLtridtt sn:m Ies mccMd at 4 pH cf �:'d7
Ycs
N aMA
19. Wore all eynnicic sins 1as recolvptl at: a PH > 12 ttnd sttlf de s€tmplm mceived at It pll % �7
Ycs
El No
OItEA
9, Wei a at�jylf�AMe Nl!)fl'i`i�r1 yrrtide,[z 1ea1oU625.1 fr[18.' (=0.' p)J. L samples lr of -
resitlnui ehlorhle?
O Ye.q
❑ NID
A
[Z]NAV.f
fr
211, Wore clioint teniartcsJrrt tt sts �i.c. requcslcd 01hitio€3s, 11+[S(kl81) dosigirtiom, euc...)
earreetly trans00jed frotn the i�OC intro the cnmtllettt section in AIMS`?
- -
Yes Nto1,Fts[he.~rtocnr listed OTT the rttainer lnh kmbG - Ll? l.f- BnOtty i�
Sample Presorya lom (Must be completed fear ally ,>ample(s) Inwrrectly t?Lr:Y6t'vea of with licut race.) -
S€lmplc(s) hA _ .._ ---were were re", ivcd lncotxectlu preserved and ware arjjustcd accordingly
lu ziamp!e receiving, with NA ._ inL of nir4le onto, k3 SO4, ITNO3, HCI, N.101l nsi€ U Sit p NA
Time D(preservatiou NA If more than onto praservatirrc is nmtetl% pleme note In the cammente boloui.
+*tlttt7lt!(1) NA ... SVr�CO lL5'1Ve(1 IVE']l bubblkaC nl.11>i In tiinrrselel',
�.t} NA - ry....— Were recoivod with TRC � 0•5 mg?L (If elf) is sm) aiW were
ACrI le
J,d1rLsted ttccotdtntly in 5€1111ple receiving will). 4ndium [hirmlNe {NaZ'SA03) ruilh Shealy ID;
— --
—
SR lsimwde lak-ls applied by: J)eta D001 0 7wxL .t
Ctatmmnts:
Pace Analytical Services, LLC (formerly Shealy Environmental Services, Inc.)
106 Vantage Point Drive West Cofumbia, SC 29172 [phone] Fax [phone] WWW.pacelabs.com
Page 7 of 7

/ --, � -(--))
, 'k :__�) P�
valablesolds-kis 22M % TOTAL SOURS % VOLATILE SOLIDS
SM 2540 G
Amazed By:
Calculated By:
Date In 103-105 oven: Date In SW furnace:
Tine in 403-106 oven: Time In 550 face:
Time Out 103-105 oven: Tiffne Out 550 fumace: j, 1, JAA_
M
RAS
4NMAL
RAS 2-
—
L4
_77-T
0 r,
VOL
I
0
#
Md.
-7 1)
7 1 La
.wt
6 6
-7
C)
o 66s
% voub
ftmcdm
1p
SIT A
Twk L'SA
fff4AL L)
HoMftTankh -N7
.VOL
t-WL
"6 -T 42
. x
vtg-
-�_ajr
Ll
Wt
!�C -7, __7 -7
)
F5 Lb-�j
W ,L
btry
% ve I MM&e-
hacwn
RAGE:
pVAL
Calcukkion for TS% and VS%: Dry wt. - Dish wt. X loo
smwe Vol.
fer
C,
ci

USE INITIAL AND FINAL AVERAGES OF YOUR % voLATiLE FRACTION TO CALCULATE THE
PERCENT REDUCTION (USE THE VAN KLEECK FORMULA)
yonja2mkHadmogn: lnftW 96 Vol. ftc.
Final % Vol. frac. Xj00'%LN,4"CtI0n
In % VC4. foo, - (initial 94iv—d. fraox Final %V61. frW,----)
( L'I 5-) ) relinLr. L
(x U minus R 0, � 45 1 times A
6, btrad 3 tom
Do multiplication IInsidebefore you: suoa WftoML of
equation.
Cl t
9 76
x too

Analytical Results STATESVILLE
ANALYTICAL
Town of Yadkinvtlle
PO Box 816
Yadkinville, NC 27055
Receive Date: 04/29/2021
Reported: 05/03/2021
For: Holding Tank Fecals
Comments: Geometric Mean: 8364 MPNIg
Sample Number
parameter
Sample ID
Result
Unit
Method
Analyzed
Analyst
210429-10-01
Fecal Coliforms
HT#1
7692
MPN/g
SM92210E-2006
04/29/2021
MD
210429-10-01
Percent Solids
HT#1
2.99
%
SM254CB-2011
04/29/2021
MD
210429-10-02
Fecal Coliforms
HT#2
7667
MPNIg
SM92210E-2oos
04/29/2021
MD
210429-10-02
Percent Solids
HT#2
3.0
%
sM254OB-2011
04/29/2021
MD
210429-10-03
Fecal Coliforms
HT#3
7823
MPNIg
SM92210E-2006
04/29/2021
MD
210429-10-03
Percent Solids
HT#3
2.94
%
SM25406-2011
04/29/2021
MD
210429-10-04
Fecal Coliforms
HT#4
10101
MPN/g
SM92210E-2006
04/29/2021
MD
210429-10-04
Percent Solids
HT#4
2.97
%
SM25406-2011
04/29/2021
MD
210429-10-05
Fecal Coliforms
HT#5
8070
MPNIg
SM92210E-2006
04/29/2021
MD
210429-10-05
Percent Solids
HT#5
2.85
%
SM25409-2011
04/29/2021
MD
210429-10-06
Fecal Coliforms
HT#6
9901
MPN1g
SM02210E-2006
04/29/2021
MD
210429-10-06
Percent Solids
HT#6
3.03
%
SM2540B-2011
04/29/2021
MD
210429-10-07
Fecal Coliforms
HT#7
7692
MPNIg
SM92210E-2006
04/29/2021
MD
210429-10-07
Percent Solids
HT#7
2.99
%
SM25408-2011
04/29/2021
MD
Respectfully submitted,
Melissa Myers
NC Cert #440,
NCDW Cert #37755,
EPA #NC00909
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 4

Condition of Receipt
Sam le Number 210429-10-01 Temp on Arrival: 5.1
Parameter Schedule: Percent Solids
Received on Ice
Parameter Schedule: Fecal Coliforms
Sodium Thiosulfate Received on Ice
Chemicals in containers, lab
Sample Number 210429-10-02 Temp on Arrival: 5.1
Parameter Schedule: Percent Solids
Received on Ice
Parameter Schedule: Fecal Collforms
Sodium Thiosulfate Received on Ice
Chemicals in containers, lab
Sample Number 210429-10-03 Temp on Arrival: 5.1
Parameter Schedule: Percent Solids
Received on Ice
Parameter Schedule: Fecal Coliforms
Sodium Thiosulfate Received on Ice
Chemicals in containers, lab
Sample Number 210429-10-04 Temp on Arrival: 5.1
Parameter Schedule: Percent Solids
Received on Ice
Parameter Schedule: Fecal Coliforms
Sodium Thiosulfate Received on Ice
Chemicals in containers, lab
Sample Number 210429-10-05 Temp on Arrival: 5.1
Parameter Schedule: Percent Solids
Received on Ice
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 2 of 4

Parameter Schedule: Fecal Coliforms
Sodium Thlosulfate Received on Ice
Chemicals in containers, lab
Sample Number 210429-10-06 Temp on Arrival: 5.1
Parameter Schedule: Percent Solids
Received on Ice
Parameter Schedule: Fecal Coliforms
Sodium Thiosuifate Received on Ice
Chemicals in containers, lab
Sample Number 210429-10-07 Temp on Arrival: 5.1
Parameter Schedule: Percent Solids
Received on Ice
Parameter Schedule: Fecal Coliforms
Sodium Thiosulfate Received on Ice
Chemicals in containers, lab
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 3 of 4

00
N
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PO Box 228 • Statesville, INC 28687 • 704/872/4697
Page 4 of 4

SUMMI,
Summit Envitotrmental Technologies, Ittc.
3310 Win St,
ENVIRONMENTAL TECHNOLOG19S,INC Cuyahoga Falls, Ohio44223
Arnaly0cal Laboratorles TEL: [phone] FIX., [phone]
Website: http://www.settekco
April 02, 2021
Alex Fox
Synagro
284 Boger Rd.
Mocksville, NC 27028
TEL:
FAX:
RE: Yadkinville
Dear Alex Fox:
Order No.: 21031808
Summit Environmental Technologies, Inc. received 2 sample(s) on 3/26/2021 for the
analyses presented in the following report.
There were no problems with the analytical events associated with this report unless noted
in the Case Narrative.
Quality control data is within laboratory defined or method specified acceptance limits
except where noted.
If you have any questions regarding these tests results, please feel free to call the
laboratory.
Sincerely,
� fV r,
Jennifer Woolf
Project Manager
3310 Win St.
Cuyahoga Falls, Ohio 44223
Arkansas 88-0733, Ca€ifomia 2943, Colorado, Connecticut PH-0108, Florida NELAC E87688, Idaho OH00923, Illinois 200061, Indiana C-OH-13, Kansas
E-10347, Kentucky (Underground Storage Tank) 3, Kentucky 90146, Maryland 339, Michigan 9988, Minnesota 1780279, Nevada 011009232020-1, New
Hampshire 29%, New Jersey DH006, New York 11777, North Carolina 39705 and 631, North Dakota R-201, Ohio DW, Ohio VAP CL0052, Oklahoma
2019-155, Oregon OH200001, Pennsyl,,aria 011, Rhode Island LA000317, South Carolina 92016001, Texas T104704466-19-16, Utah OH009232020-12,
Virginia VELAP 10381, West Virginia9957C
Page 1 of 39

SUMMIT
Summit EnvironmentalTechnolnw. Case Narrative
3310will StSt,
ENVIRONMENTAL TEr_HN0L,0GjUS, INC Cuyahoga Falls, Ohio 44223 WO#: 21031808
Analytical LaboralDrlms TEL: [phone] FAX. [phone]
Website. http://www.settek.com Date: 4/2/2021
CLIENT: Synagro
Project: Yadkinville
WorkOrder Narrative:
21031808: This report in its entirety consists of the following documents: Cover Letter, Case Narrative,
Analytical Results, QC Summary Report, Applicable Accreditation Information, Chain -of -Custody,
Cooler Receipt Form, and other applicable forms as necessary. All documents contain the Summit
Environmental Technologies, Inc., Work Order Number assigned to this report.
Summit Environmental Technologies, Inc., holds the accreditation/certifications listed at the bottom of
the cover letter that may or may not pertain to this report. Please refer to the "Accreditation Program
Analytes Report" for accredited analytes list.
The information contained in this analytical report is the sole property of Summit Environmental
Technologies, Inc. and that of the customer. It cannot be reproduced in any form without the consent of
Summit Environmental Technologies, Inc. or the customer for which this report was issued. The results
contained in this report are only representative of the samples received. Conditions can vary at different
times and at different sampling conditions. Summit Environmental Technologies, Inc. is not responsible
for use or interpretation of the data included herein.
All results for Solid Samples are reported on an "as received" or "wet weight" basis unless indicated as
"dry weight" using the "-dry" designation on the reporting units.
This report is believed to meet all of the requirements of the accrediting agency, where applicable. Any
comments or problems with the analytical events associated with this report are noted below.
Analytical Sequence Sample Notes:
21031808-001A TCLP-VOC-MSTR_8260D: Corresponding QC exhibited high recovery for Vinyl
chloride. Sample is ND
21031808-002A TCLP-VOC-MSTR 8260D: Corresponding QC exhibited high recovery for Vinyl
chloride. Sample is ND
Analytical Sequence QC Notes:
Pest CCV 1 500ppb TCLP-SVOC-CPEST(808113): P: RPD between confirmation column is greater
than 40%.
CCV VOC-MSTR NPW(8260): CCV exhibits high recovery for Vinyl chloride. Associated samples
Original
Page 2 of 39

U'� Summit Environmental Technologies, Inc.
3310 Win St. Case Narrative
EiiENVIRONMNYALTMHNOLOGi£s,iNC Cuyahoga Falls, Ohio44223 WOM 21031808
Attalyfleal LafaoratorJss TEL: [phone] FAX.- [phone]
Wehsite; htt ✓1www.settek.com Date: 4/2/2021
CLIENT: Synagro
Project: Yadkinville
are N.D. for this analyte.
LCS-48669 TCLP-VOC-MSTR_TCLP(8260): LCS exhibits high recovery for Vinyl chloride.
Associated samples are N.D. for this analyte. Possible high bias for Vinyl chloride due to high recovery
in CCV.
Original
Page 3 of 39

summ,nt 'Summit Environmental Technologies, In Qualifiers and Acronyms
3310 Win .
Eta RONMENTAL TECHNOI_OGit:&, INC. Cuyahoga Falls, Ohio 442� M1Analytical Ladaratorlos TEL: [phone] FAX.- (330) 253-44E WO#: 21031808
Website: ht ://www.settek.co Date: 4/2/2021
These commonly used Qualifiers and Acronyms may or may not be present in this report.
Qualifiers
U The compound was analyzed for but was not detected.
d The reported value is greater than the Method Detection Limit but less than the Reporting Limit.
H The hold time for sample preparation and/or analysis was exceeded.
D The result is reported from a dilution.
E The result exceeded the linear range of the calibration or is estimated due to interference.
MC The result is below the Minimum Compound Limit.
* The result exceeds the Regulatory Limit or Maximum Contamination Limit.
in Manual integration was used to determine the area response.
d Manual integration in which peak was deleted
N The result is presumptive based on a Mass Spectral library search assuming a 1:1 response.
P The second column confirmation exceeded 25% difference.
C The result has been confirmed by GC/MS.
X The result was not confirmed when GC/MS Analysis was performed.
B/MB+ The analyte was detected in the associated blank.
C. The ICB Or CCB contained reportable amounts of analyte.
QC-/+ The CCV recovery failed low (-) or high (+).
R/QDR The RPD was outside of accepted recovery limits.
QL-/+ The LCS or LCSD recovery failed low (-) or high (+).
QLR The LCS/LCSD RPD was outside of accepted recovery limits.
QM-/+ The MS or MSD recovery tailed low (-) or high (+),
QMR The MS/MSD RPD was outside of accepted recovery limits.
QV-/+ The ICV recovery failed low (-) or high (+).
S The spike result was outside of accepted recovery limits.
Z Deviation; A deviation from the method was performed; Please refer to the Case Narrative for
additional information
Acronyms
ND
Not Detected
RL
Reporting Limit
QC
Quality Control
MDL
Method Detection Limit
MB
Method Blank
LOD
Level of Detection
LCS
Laboratory Control sample
LOQ
Level. of Quantitation
LCSD
Laboratory Control Sample Duplicate
PQL
Practical Quantitation Limit
QCS
Quality Control Sample
CRQL
Contract Required Quantitation Limit
DUP
Duplicate
PL
Permit Linut
MS
Matrix Spike
RegLvl
Regulatory Limit
MSD
Matrix Spike Duplicate
MCL
Maximum Contamination Limit
RPD
Relative Percent Different
MinCL
Minimum Compound Linut
ICV
Initial Calibration Verification
RA
Reanalysis
ICB
Initial Calibration Blank
RE
Reextraction
CCV
Continuing Calibration Verification
TIC
Tentatively Identified Compound
CCB
Continuing Calibration Black
RT
Retention Time
RLC
Reporting Limit Check
CF
Calibration Factor
DF
Dilution Factor
RF
Response Factor
This list of Qualifiers and Acronyms reflects the most commonly utilized Qualifiers and Acronyms for reporting.
Please refer to the Analytical Notes in the Case Narrative for any Qualifiers or Acronyms that do not appear in this
list or for additional information regarding the use of these Qualifiers on reported data.
Original
Page 4 of 39

u'ir Summit Environmental Technologies, Inc.
3310 Win St.
ENVIRONMENTAL TECHNOLOGIeS, INe Cuyahoga Falls, Ohio 44223
Analytical Laboratories TEL: [phone] FAX., [phone]
Website: httoa/www.settek.com
Workorder
Sample Summary
WO#: 21031808
02-Apr-21
CLIENT: Synagro
Project: Yadkinville
Lab SamplelD Client Sample ID Tag No Date Collected Date Received Matrix
21031808-001 Yadkinville WWTP 3/25/2021 9.00:00 AM 3/26/2021 4:00:00 PM Sludge
2I031808-002 Yadkinville WTP 3/25/2021 10:00:00 AM 3/26/2021 4:00:00 PM Sludge
Page 5 of 39

Dry
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SUMMIlt Summit Environmental Technologies, rnt.
3310 Win St_
ffnENVIRONMENTAL TECHMOLgt3 S,Me Cuyahoga Falls, Ohio44223
Analytical Labaratarlas TEL: [phone] FAX: [phone]
Website: htrp:llwww.settek.cam
Analytical Report
(basereporo
WO#: 21031808
Date Reported: 4/2/2021
CLIENT: Synagro
Tag Number:
Matrix: SLUDGE
Collection Date:
3/25/2021 9:00:00 AM
Lab 11): 21031808-OOIA
Project: Yadkinville
Client Sample ID Yadkinville WWTP
Analyses Result
RL
Qual Units
DF Date Analyzed
TCLP METALS, VOC, BNA, PEST, HERB -SOLID
SW7470A
SW7470A Analyst: ERA
TCLP MERCURY ANALYSIS (SW131117470)
TCLP Mercury
ND
0.00200
mg1L
1 412/2021 3:08:00 PM
TCLP METALS, VOC, BNA, PEST, HERB -SOLID
SW6010D
SW3010A Analyst: DNS
TCLP METALS ANALYSIS (SW131116010)
TCLP Arsenic(As)
ND
0.500
mg/L
1 4/2/2021 1:22:23 PM
TCLP Barium(Ba)
ND
5.00
mg/L
1 412/2021 1:22:23 PM
TCLP Cadmium(Cd)
ND
0.100
mg/L
1 4/2/2021 1:22:23 PM
TCLP Chromium(Cr)
N❑
0.200
mg1L
1 412/2021 1:22:23 PM
TCLP Lead(Pb)
N❑
0.500
mg1L
1 412/2021 1:22:23 PM
TCLP Selenium(Se)
ND
0.0500
mg/L
1 4/212021 1:22:23 PM
TCLP Silver(Ag)
ND
0.500
mg1L
1 41212021 1:22:23 PM
TCLP METALS, VOC, BNA, PEST, HERB -SOLID
SW8270
SW3510C Analyst: SFG
TCLP SEMI-VOLATILES ANALYSIS (SW131118270)
1,4-❑ichlorobenzene
ND
0.200
mg1L
2 4/1/2021 7:22:00 PM
2,4,5-Trichlorophenol
ND
0.500
mg1L
2 4/1/2021 7:22:00 PM
2,4,6-Trichlorophenol
ND
0.500
mg1L
2 4/1/2021 7:22:00 PM
2,4-Dinitrotoluene
ND
0.100
mg/L
2 4/1/2021 7:22:00 PM
Cresols, Total
ND
10.0
mg/L
2 4/1/2021 7:22:00 PM
Hexachlore-1,3-butadiene
ND
0.0400
mglL
2 4/1/2021 7:22:00 PM
Hexachlorobenzene
ND
0.100
mg1L
2 4/1/2021 7:22:00 PM
Hexachloroethane
ND
0.200
mg/L
2 4/1/2021 7:22:00 PM
Nitrobenzene
ND
0.200
mg/L
2 41ll2G21 7:22:00 PM
Pentachlorophenol
ND
0.500
mg/L
2 4/1/2021 7.22:00 PM
Pyridine
ND
0.500
mg1L
2 4/1/2021 7:22:00 PM
Surr: 2-Fluorophenol
86.5
10 -157
%Rec
2 4/1/2021 7:22:00 PM
Surr: PhenoW6
91.4
10 -169
%Rec
2 411/2021 7:22:00 PM
Surr: Nitrobenzene-d5
80.0
32.1 - 130
%Rec
2 411/2021 7.22:00 PM
Surr. 2,4,6-Tribromophenol
113
45.4 - 166
%Rec
2 4/112021 7:22:00 PM
Surr: 2-Fluorobiphenyl
79.5
35.7 - 130
%Rec
2 41112021 7:22:00 PM
Surr: p-Terphenyl-d14
112
70 - 145
%Rec
2 411/2021 T22:00 PM
Qualifiers: B
Analyte detected in the associated Method Blank
E
Value above quantitation range
H
Holding times for preparation or analysis exceeded
M
Manual Integration used to determine area response
MC
Value is below Minimum Compound Limit.
N
Tentatively identified compounds
ND
Not Detected
P
Second column confirmation exceeds
PL
Permit Limit
R
RPD outside accepted recovery limits Original
RL
Reporting Detection Limit
U
Samples with Ca[cVal c MDL
Page 7 of 39

r=r.003
Summit EnvironmentalTechnologies,
SU 'T
Analytical Report
3310 Win StSt.
.
Er
ENVIRONMENTAL TfCWN0L0t t;ES,1NC
Cuyahoga Falls, Ohio 44223
(base report)
Analytical Laboralorlat
TEL: [phone] FAX.- [phone]
WO#l: 21031808
Wehsite. ht�p://www.settekCom
Date Reported: 4/2/2021
CLIENT: Synagro
Tag Number:
Matrix: SLUDGE
Collection Date: 3/25/2021 9:00:00 AM
Lab ID: 21031808-OOIA
Project: Yadkinville
Client Sample ID Yadkinville WWTP
Analyses
Result
RL
Qua) Units
DF Date Analyzed
TCLP METALS, VOC, BNA, PEST, HERB -SOLID
SW8081
SW3510C Analyst: CSS
TCLP PESTICIDES ANALYSIS (SW1311/8081)
Chlordane, total
ND
0.0250
mg1L
1
4/1/2021 8:10:00 PM
Toxaphene
ND
0.0500
mg1L
1
4/1/2021 8:10:00 PM
Endrin
ND
0.00250
mg1L
1
4/1/2021 8:10:00 PM
gamma-BHC
ND
0.00250
mglL
1
4/1/2021 8:10:00 PM
Heptachlor
N❑
0.00250
mglL
1
4/1/2021 8:10:00 PM
Heptachlor epoxide
ND
0.00250
mglL
1
4/1/2021 8:10:Oo PM
Methoxychlor
ND
0.00250
mg1L
1
4/1/2021 8:10:00 PM
Surr: TCMX
72.2
10 - 119
%Rec
1
4/1/2021 8:10:00 PM
Surr: DCB
91.1
10 -119
%Rec
1
4/1/2021 8:10:00 PM
TCLP HERBICIDES BY EPA 8321B
SW8321
SW1311M Analyst: TM
2,4-D
ND
0,500
mglL
50
4/112021 11:00:00 PM
2,4,5-TP
ND
0.500
mg1L
50
411/2021 11:00:00 PM
Surr: 2,4-Dichlorophenylacetic aci
72.9
70 - 130
%Rec
50
4/1/2021 11:00:00 PM
TCLP METALS, VOC, BNA, PEST, HERB -SOLID
SW8260
SW1311M
Analyst: MES
TCLP VOLATILES ANALYSIS
IIJ-Dichloroethene
ND
0.250
mglL
50
411120218:51:00PM
1,2-Dichlorcethane
ND
0.250
mglL
50
4/1/2021 8:51:00 PM
MEK
ND
5.00
mglL
50
4/1/2021 8:51:00 PM
Benzene
ND
0.250
mg/L
5C
41l/2021 8:51:00 PM
Carbon tetrachloride
ND
0.250
mg1L
50
411/2021 8:51:00 PM
Chlorobenzene
ND
2-50
mglL
50
4/112021 8:51:00 PM
Chloroform
N❑
0250
mglL
50
4/112021 8:51:00 PM
Tetrachloroethene
ND
0,250
mg1L
50
4/112021 8:51:00 PM
Trichloroethene
ND
0.250
mglL
50
4/1/2021 8:51:00 PM
Vinyl chloride
ND
0.100QC+QL+mgIL
50
4/1/2021 8:51:00 PM
Surr: 4-Bromofluorobenzene
91.6
70 -130
%Rec
50
4/1/2021 8:51,00 PM
Surr: Dibromofluoromethane
99.2
70 -130
%Rec
50
4/1/2021 8:51:00 PM
Sum Toluene-di8
100
70 -130
%Rec
50
4/1/2021 8:51:00 PM
Qualifiers: B
Analyte detected in the associated Method Blank
E
Value above quantitation range
H
Holding times for preparation or analysis exceeded
M
Manual Integration used to determine area response
MC
Value is below Minimum Compound Limit.
N
Tentatively identified compounds
ND
Not Detected
P
Second column confirmation exceeds
PL
Permit Limit
R
RPD outside accepted recovery limits Original
RL
Reporting Detection Limit
D
Samples with CalcVal < MDL
Page 8 of 39

Summit Environmental Technologies, Inc.
UMM'lt
Analytical Report
Pf--
3310 Win St.
ENVIRONMENTAL Tr=CHNOLOtgtEs, INC
Cuyahoga Falls, Ohio 44223
(base report)
Analytleal Laboralortes
TEL: [phone] FAX' [phone]
WOM 21031808
Website: ht :1Avww,settek.com
Date Reported: 4/2/2021
CLIENT: Synagro
Tag Number:
Matrix: SLUDGE
Collection Date:
3/25/2021 9:00:00 AM
Lab ID: 21031808-OOIA
Project: Yadkinville
Client Sample ID Yadkinville WWTP
Analyses
Result RL Qual Units
DF Date Analyzed
RCI
SW9014
Analyst: MS
REACTIVE CYANIDE (901417.3.3.2)-SOLID
Cyanide, Reactive
ND 0.490 mglKg
1 3/31/2021 2:55:00 PM
IGNITABILITY OF SOLIDS (SW-846: 1030)
SW1030
Analyst: KMW
Ignitability nonflammable mm/sec
1 4/112021 11:13:20 AM
RCI
SW9045D
Analyst: ALT
PH (SW9045D)
pH
7.2 s.u.@16.9C
1 3/29/2021 5:36:55 PM
RCI
SW9034
Analyst: MS
REACTIVE SULFIDE (9034)17.3.4.2
Sulfide, Reactive
ND 25.0 mg/Kg
1 3/31/2021 2:55:00 PM
Qualifiers- B Analyte detected in the associated Method Blank
H Holding times for preparation or analysis exceeded
MC Value is below Minimum Compound Limit,
ND Not Detected
PL Permit Limit
RL Reporting Detection Limit
E Value above quantitation range
M Manual Integration used to determine area response
N Tentatively identified compounds
P Second column confirmation exceeds
R RPD outside accepted recovery limits Original
U Samples with CaleVal c MDL
Page 9 of 39

UM'T Summit Environmental Technologies, Inc.E:=40PI]S3310 tin St.
ILJENVIRONMENTAL TEEHN[It00JES, INC Cuyahoga Falls, Ohio 44223
Analytical Laboralorla6 TEL: [phone] FAX: [phone]
Website: http://www.settek.com
Analytical Report
(base report)
WO#: 21031808
Date Reported: 4/2/2021
CLIENT: Synagro
Tag Number:
Matrix: SLUDGE
Collection Date:
3/25/2021 10:00:00 AM
Lab ID: 21031908-002A
Project: Yadkinville
Client Sample ID Yadkinville WTP
Analyses
Result
RJ,
Qual Units
DF Date Analyzed
TCLP METALS, VOC, BNA, PEST, HERB -SOLID
SW7470A
SW7470A Analyst: ERA
TCLP MERCURY ANALYSIS (SW131117470)
TCLP Mercury
ND
0.0100
mg/L
1 4/2/2021 3:22:00 PM
TCLP METALS, VOC, BNA, PEST, HERB -SOLID
SW6010D
SW3010A Analyst: DNS
TCLP METALS ANALYSIS (SW131116010)
TCLP Arsenic(As)
ND
0.500
mg/L
1 4/2I2021 1:26:24 PM
TCLP Barium(Ba)
ND
5.00
mg/L
1 4/212021 1:26:24 PM
TCLP Cadmium(Cd)
ND
0.100
mg1L
1 4/2/2021 1:26:24 PM
TCLP Chromium(Cr)
ND
0.200
mg/L
1 4/212021 1:26:24 PM
TCLP Lead(Pb)
ND
0.500
mg1L
1 41212021 1:26:24 PM
TCLP Selenium(Se)
ND
0.0500
mg/L
1 41212021 1:26:24 PM
TCLP Silver(Ag)
ND
0.500
mg/L
1 412/2021 1:26:24 PM
TCLP METALS, VOC, BNA, PEST, HERB -SOLID
SW8270
SW3510C Analyst: SFG
TCLP SEMI-VOLATILES ANALYSIS (SW131118270)
1,4-Dichlorobenzene
ND
0.500
mg/L
5 4/1/2021 7:54:00 PM
2,4,5-Trichlorophenol
ND
1,25
mg1L
5 4/1/2021 7:54:00 PM
2,4,6-Trichlorophenol
ND
1.25
mg1L
5 4/1/2021 7:54:00 PM
2,4-Dinitrotoluene
ND
0.250
mg1L
5 4/1/2021 T54:00 PM
Cresols, Total
ND
25.0
mg1L
5 411/2021 7:64:00 PM
Hexachlcro-1,3-butadiene
ND
0.100
mg/L
5 4/1/2021 7:54:00 PM
Hexachlorobenzene
ND
0.250
mg/L
5 4/1/2021 7:54:00 PM
Hexachloroethane
ND
0.500
mg/L
5 4/l/2021 7:54:00 PM
Nitrobenzene
ND
0.500
mglL
5 4/1/2021 7:54:00 PM
Pentachlorophenol
ND
1.25
mg/L
5 4/1/2021 7:54:00 PM
Pyridine
ND
1.25
mg1L
5 4/1/2021 7:54:00 PM
Surr. 2-Fluorophend
71.6
10 -157
%Rec
5 4/1/2021 7:54:00 PM
Surr: Phenol-d6
85.4
10 -169
%Rec
5 411/2021 7:54:00 PM
Surr: Nitrobenzene-d5
82.2
32.1 -130
%Rec
5 41112021 7:54:00 PM
Surr: 2,4,6-Tribromophenol
104
45.4 - 166
%Rec
5 4/112021 7:54:00 PM
Surr: 2-Fluorobiphenyl
81.8
35.7 - 130
%Rec
5 411/2021 7:54:00 PM
Surr: p-Terphenyl-04
ill
70 -145
%Rec
5 4/112021 7:54:00 PM
Qualifiers: B
Analyte detected in the associated Method Blank
E
Value above quantitation range
H
Holding times for preparation or analysis exceeded
M
Manual Integration used to determine area response
MC
Value is below Minimum Compound Limit,
N
Tentatively identified compounds
ND
Not Detected
P
Second column confirmation exceeds
PL
Permit Limit
R
RPD outside accepted recovery limits Original
RL
Reporting Detection Limit
U
Samples with CalcVal < MDL
Page 10 of 39

SUMMInt
Summit Environmental Technologies, Inc. 3310 Win Sr. Analytical Report
ffl ENVIRONMENTAL TECHNOWGWS, INC Cuyahoga Falls, Ohio 44223 (base report)
Ara/yticat Laboralarles TEL: [phone] FAX.- [phone] WO#: 21031808
Wb'h // k
e srt
e. ttE www.setre .cam Date Reported: 4/2/2021
CLIENT: Synagro Tag Number:
Matrix: SLUDGE Collection Date: 3/25/2021 10:00:00 AM
Lab 1D: 21031808-002A
Project: Yadkinville
Client Sample ID Yadkinville WTP
Analyses
Result
RL
Qua] Units
DF Date Analyzed
TCLP METALS, VOC, BNA, PEST, HERB -SOLID
SW8081
SW3510C Analyst: CSS
TCLP PESTICIDES ANALYSIS (SW131118081)
Chlordane, total
NO
0.0250
mg/L
1 4/1/2021 &32:00 PM
Toxaphene
NO
0.0500
mg/L
1 4/1/2021 &32:00 PM
Endrin
NO
0.00250
mg1L
1 4/1/2021 8:32:00 PM
gamma-BHC
NO
0.00250
mg/L
1 411/2021 8:32:00 PM
Heptachlor
NO
0.00250
mg/L
1 4/1/2021 8:32:00 PM
Heptachlor epoxide
NO
0.00250
mg/L
1 4/1/2021 8:32:00 PM
Methoxychlor
NO
0.00250
mg/L
1 4/1/2021 8:32:00 PM
Surr: TCMX
71.9
10 - 119
%Rec
1 4/1/2021 &32:00 PM
Surr: DCB
80.1
10 -119
%Rec
1 V112021 8:32:00 PM
TCLP HERBICIDES BY EPA 8321B
SW8321
SW1311M Analyst: TM
2,4-D
NO
0.500
mg/L
50 4/1/2021 11:57:00 PM
2,4,5-TP
ND
0.500
mg/L
50 4/112021 11:57:00 PM
Surr 2,4-Dichlorophenylacetic ad
85.4
70 - 130
%Rec
50 4/1/2021 11:57:00 PM
TCLP METALS, VOC, BNA, PEST, HERB
-SOLID
SW8260
SW1311 M Analyst: MES
TCLP VOLATILES ANALYSIS
1,1-Dichloroethene
NO
0.250
mg/L
50 4/1/2021 8:23:00 PM
1,2-Dichloroethane
ND
0.250
mg1L
50 4/1/2021 8:23:00 PM
MEK
NO
5.00
mg/L
50 4/1/2021 8:23:00 PM
Benzene
ND
0.250
mg1L
50 4/1/2021 8:23:00 PM
Carbon tetrachloride
NO
0.250
mg1L
50 4/1/2021 8:23:00 PM
Chlorobenzene
NO
2.50
mg1L
50 4/1/2021 8:23:00 PM
Chloroform
NO
0,250
mg1L
50 411/2021 8:23:00 PM
Tetrachloroethene
NO
0.250
mg1L
50 4/1/2021 8:23:00 PM
Trichloroethene
NO
0.250
mg1L
50 411/2021 8:23:00 PM
Vinyl chloride
NO
0.1000C+QL+mg/L
50 4/112021 8:23:00 PM
Surr: 4-Bromofluorobonzene
92.0
70 -130
%Rec
50 4/1/2021 8:23:00 PM
Surr Dibromofluoromethane
98.0
70 - 130
%Roe
50 4/1/2021 8:23:00 PM
Surr: Toluene-d8
99.1
70 - 130
%Rec
50 4/1/2021 8:23:00 PM
Qualifiers: B Analyze detected in the associated Method Blank
E Value above quantitation range
H Holding times for preparation
or analysis exceeded
M Manual Integration
used to determine area response
MC Value is below Minimum Compound
Limit.
N Tentatively identified
compounds
ND Not Detected
P Second column confirmation exceeds
PL Permit Limit
R RPD outside accepted
recovery limits Original
RL Reporting Detection Limit
U Samples with CalcVal < MDL
Page 11 of 39

.
um1 'y 3310 Win SiSt.
AInsnalytical Report
ENVIR01VlMNTAL TECHNdWQtBS, INC
Cuyahoga Falls, Ohio 44223
(base report)
Analyt(eai Laborarartas TEL: (330)
253-8211 FAX: [phone]
WO#: 21031808
Website: httn://www.settek.co7n
Date Reported: 412/2021
CLIENT: Synagro
Tag Number:
Matrix: SLUDGE
Collection Date:
3/25/2021 10:00:00 AM
Lab ID: 21031808-002A
Project: Yadkinville
Client Sample ID Yadkinville WTP
Analyses Result
RL Qual Units
DF Date Analyzed
RCI
SW9014
Analyst: MS
REACTIVE CYANIDE (901417.3,3.2)-SOLID
Cyanide, Reactive ND
0.476 mg/Kg
1 3/31/2021 2:55:00 PM
IGNITABILITY OF SOLIDS (SW-846: 1030)
SW1030
Analyst: KMW
Ignitabiiity nonflammable
mmisec
1 411/2021 11:13:20 AM
RCI
SW9045D
Analyst: ALT
PH (SW9045D)
pH 6.8
s.u.@a 17.2C
1 3/29/2021 5:36:55 PM
RCI
SW9034
Analyst: MS
REACTIVE SULFIDE (9034)17.3.4.2
Suifide, Reactive ND
25.0 mgli
1 3/31/2021 2:56:00 PM
Qualifiers: B
Analyte detected in the associated Method Blank
H
Holding times for preparation or analysis exceeded
MC
Value is below Minimum Compound Limit.
ND
Not Detected
PL
Permit Limit
RL
Reporting Detection Limit
E Value above quan€itation range
M Manual Integration used to determine area response
N Tentatively identified compounds
P Second column confirmation exceeds
R RPD outside accepted recovery limits Original
U Samples with CalcVal c MDL
Page 12 of 39

r=npn
UM'T SummitEnviranmental Technologies, Etc
Accreditation Program
ENVIRONMENTAL TECtINt}WGIVs..INC
3310 Win St.
Cuyahoga Falls, Ohio44223
Analytes Report
An&lytical LaborworJes
TEL: [phone] FAX.- [phone]
WO#:
21031808
Website.• httP.-11w vw.seuek cons
02 Apr-21
Client: Synagro
State: NW
Project: Yadkinville
Program Name: NC
WW SCM
Sample ID Matrix
Test Name
Analyte
Status
21031808-OOIA Sludge
lgnitability of Solids (SW-846: 1030)
ignitability
A
Sludge
pH (SW9045D)
Hydrogen Ion (pH)
A
Sludge
Reactive Cyanide (9014/7.3.3.2)-Solid
Cyanide, Reactive
U
Sludge
Reactive Sulfide (9034)/7.3.4.2
Sulfide, Reactive
U
Sludge
TCLP Herbicides by EPA 8321 B
2 4 5-TP
A
Sludge
TCLP Herbicides by EPA 8321E
2,4-D
A
Sludge
TCLP Mercury Analysis (SW1311/7470)
Mercury
A
Sludge
TCLP Metals Analysis (SW1311/6010)
Arsenic
A
Sludge
TCLP Metals Analysis (SWi31 116010)
Barium
A
Sludge
TCLP Metals Analysis (SW I311/6010)
Cadmium
A
Sludge
TCLP Metals Analysis (SW1311/6010)
Chromium
A
Sludge
TCLP Metals Analysis (SW 1311/6010)
Lead
A
Sludge
TCLP Metals Analysis (SWI311/6010)
Selenium
A
Sludge
TCLP Metals Analysis (SW1311/6010)
Silver
A
Sludge
TCLP Pesticides Analysis (SW1311/8081)
Chlordane, total
A
Sludge
TCLP Pesticides Analysis (SW131 I/8081)
Endrin
A
Sludge
TCLP Pesticides Analysis (SW1311/8081)
gamma-BliC
A
Sludge
TCLP Pesticides Analysis (SW1311/8081)
Heptachlor
A
Sludge
TCLP Pesticides Analysis (SW1311/9081)
Heptachlor epoxide
A
Sludge
TCLP Pesticides Analysis (SW1311/8081)
Methoxychlor
A
Sludge
TCLP Pesticides Analysis (SW1311/808I)
Toxaphene
A
Sludge
TCLP Semi-Volatiles Analysis (SW 131118270)
1,4-Dichlorobenzene
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
214,5-Trichlorophenol
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
2,4,6-Trichlorophenol
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
2,4-Dinitrotoluene
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
Cresols, Total
A
Sludge
TCLP Semi-Volatiles Analysis (SWI311/8270)
Hcxacblorobenzene
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
Hexachlorobutadiene
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
Hexachloroethane
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
Nitrobenzene
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
Pentachlorophenol
A
Sludge
TCLP Semi-Volatiles Analysis (SW 1311/8270)
Pyridine
A
Key
Key
NC_WW_SCM A Accredited
NC_WW SCM U Unavailable
Original # I
Page 13 of 39

'Er SwmnttEnvironmentalTechnologies,rne. Accreditation Program
Um 3310 Win St. Anal tBS Report
Er ENVIFtONMENTAL TECHNOLOGIES, INC Cuyahoga Falls, Ohio 44223 J p
Analytteal Laberatartes TEL: [phone] FAX.- [phone] Wo#: 21031808
Website: htt :1Avvnv.settek.cont 02-Apr-21
Client: Synagro State: NW
Project: YadkinviIle Program Name: NC WW SCM
Sample ID Matrix
Test Name
Analyte
Status
21031808-001A Sludge
TCLP Volatiles Analysis
1,1-Dichloroethene
A
Sludge
TCLP Volatiles Analysis
1,2-aichloroethane
A
Sludge
TCLP Volatiles Analysis
2-Butanone
A
Sludge
TCLP Volatiles Analysis
Benzene
A
Sludge
TCLP Volatiles Analysis
Carbon tetrachloride
A
Sludge
TCLP Volatiles Analysis
Chlorobenzene
A
Sludge
TCLP Volatiles Analysis
Chloroform
A
Sludge
TCLP Volatiles Analysis
Tetrachlomethene
A
Sludge
TCLP Volatiles Analysis
Trichloroethene
A
Sludge
TCLP Volatiles Analysis
Vinyl chloride
A
21031808-002A Sludge
[gnitability of Solids (SW-846: 1030)
Ignitability
A
Sludge
pH (SW9045D)
Hydrogen [on (PH)
A
Sludge
Reactive Cyanide (901417.3.3.2)-Solid
Cyanide, Reactive
U
Sludge
Reactive Sulfide (9034)I7.3.4.2
Sulfide, Reactive
U
Sludge
TCLP Herbicides by EPA 8321 B
2,4,5-TP
A
Sludge
TCLP Herbicides by EPA 8321 B
2,4-D
A
Sludge
TCLP Mercury Analysis (SW 131117470)
Mercury
A
Sludge
TCLP Metals Analysis (SW1311/6010)
Arsenic
A
Sludge
TCLP Metals Analysis (SW1311/6010)
Barium
A
Sludge
TCLP Metals Analysis (SW131116010)
Cadmium
A
Sludge
TCLP Metals Analysis (SW131116010)
Chromium
A
Sludge
TCLP Metals Analysis (SW 1311160 10)
Lead
A
Sludge
TCLP Metals Analysis (SWI311/6010)
Selenium
A
Sludge
TCLP Metals Analysis (SW131 VOID)
Silver
A
Sludge
TCLP Pesticides Analysis(SWt3I118081)
Chlordane, total
A
Sludge
TCLP Pesticides Analysis (SWI31 I18091)
Endrin
A
Sludge
TCLP Pesticides Analysis (SW 131 1/8081)
gamma-BHC
A
Sludge
TCLP Pesticides Analysis (SW1311/8081)
Heptachlor
A
Sludge
TCLP Pesticides Analysis (SW 1311/908 t)
Heptachlor epoxide
A
Sludge
TCLP Pesticides Analysis (SW I31118081)
Methoxychlor
A
Sludge
TCLP Pesticides Analysis (SW 1311/9081)
Toxaphene
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
1,4-Richlorobenzene
A
Key Key
NC WW SCM A Accredited NC WW SCM U Unavailable
Original #1
Page 14 of 39

m'mt Summit Environmental Technologies, Inc.
331 in
Accreditation Program
4422 .
Ei1VlRBkMENTAL TECHNOLOGIES, INC Cuyahog¢ Falls, Ohia 44223
Ohio
Anal tes Report
Y P
ArtatyUcal Laboratarlas
TEL: [phone] FAX, [phone]
WO#:
21031808
Website: hap:/lwww.settek.com
02-Apt-21
Client: Synagro
State: NW
Project: Yadkinville
Program Name: NC WW SCM
Sample ID Matrix
Test Name
Analyte
Status
21031808-002A SIudge
TCLP Semi-Volatiles Analysis (SW1311/8270)
2,4,5-Trichlorophenol
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
2,4,6-Trichlorophenol
A
Sludge
TCLP Semi-Volatiles Analysis (SW131118270)
2,4-Dinitratoluene
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
Cresols, Total
A
Sludge
TCLP Semi-Volatiles Analysis (SWI311/8270)
Hexachlorobenzene
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
Hexachlorobutadiene
A
Sludge
TCLP Semi-Volatiles Analysis (SW131118270)
Hexachloroethane
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
Nitrobenzene
A
Sludge
TCLP Semi-Volatiles Analysis (SW131118270)
Pentachlorophenol
A
Sludge
TCLP Semi-Volatiles Analysis (SW1311/8270)
Pyridine
A
Sludge
TCLP Volatiles Analysis
1,1-Dichloroethene
A
Sludge
TCLP Volatiles Analysis
1,2-Dichloroethane
A
Sludge
TCLP Volatiles Analysis
2-Butanone
A
Sludge
TCLP Volatiles Analysis
Benzene
A
Sludge
TCLP Volatiles Analysis
Carbon tetrachloride
A
Sludge
TCLP Volatiles Analysis
Chlorobenzene
A
Sludge
TCLP Volatiles Analysis
Chloroform
A
Sludge
TCLP Volatiles Analysis
Tetrachloroethene
A
Sludge
TCLP Volatiles Analysis
Trichlomethene
A
Sludge
TCLP Volatiles Analysis
Vinyl chloride
A
Key Key
NC_WW_SCM A Accredited NC WW SCM U Unavailable
Original # 1
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Page 37 of 39

1��S
U I� Sammif Environmental Technologies, St.
3310 Win Sr.
ENVlfONMENTALTECHNOLpGI S,INC-, GryahogaFalls, Ohio 44223 Sample Log -In Check List
Analytleal Laboratorlac TEL: [phone] FAX, [phone]
Website.- http://`yww.settek cone
Client Name: SYN-NC-27028 Work Order Number: 21031808
RcptNo: 1
Logged by: Christina N. Jager 3/26/2021 4:00:00 PM
Completed By: Jacqueline Rasile 3/28/2021 11:39:11 AM
Reviewed By: Jennifer Woolf 3/29/2021 1,26:08 PM
Chain of Custody — — - —
1 • Is Chain of Custody complete? Yes ❑ No U Not Present ❑
2. How was the sample delivered? UPS
Log In
3. Coolers are present?
Yes
No ❑
NA ❑
4, Shipping container/cooler in good condition?
Yes
No ❑
Custody seals intact on shipping containerlcooler?
Yes ❑
No ❑
Not Present❑
No. Seal Date:
Signed By:
5. Was an attempt made to cool the samples?
Yes ©
No ❑
NA ❑
6. Were all samples received at a temperature of >0° C to 6.0°C
Yes SM
No ❑
NA ❑
7, Sample(s) in proper container(s)?
Yes d❑
No ❑
g• Sufficient sample volume for indicated test(s)?
Yes W1
No ❑
9, Are samples (except VOA and ONG) properly preserved?
Yes ©
No ❑
10. Was preservative added to bottles?
Yes ❑
No i]
NA ❑
I I. Is the headspace in the VOA vials less than 114 inch or 6 mm?
Yes ❑
No ❑
No VOA Vials 0
12. Were any sample containers received broken?
Yes ❑
No
13. Does paperwork match bottle labels?
Yes
No ❑
(Note discrepancies on chain of custody)
14. Are matrices correctly identified on Chain of Custody?
Yes ©
No ❑
15. Is it clear what analyses were requested?
yes ®
No ❑
16. Were all holding times able to be met?
Yes ©
No ❑
(If no, notify customer for authorization.)
Special Handling (if applicable)
17• Was client notified of all discrepancies with this order?
Yes 0
No ❑
NA ❑
Personotifed: Alex Fox Date:
3/2912021
By Whom: Jennifer Woolf Via:
F�V] eMail ❑ Phone ❑ Fax
❑ In Person
Regarding: 9 9: both bottles labeld as WWTP
--
Client Instructions: the Brown one is WTP and the Blacker one is WWTP.
1$. Additional remarks:
the Brown one is WTP and the Blacker one is W WTP.
samples not labeled
both lids labled as WWTP
Cooler Information
Page 38 of 39

���'� Summit Environmental Technologies, Inc.
3310 Win St.
EENIRONMEFJ7AL YECHPit3t ACitEs INC Cuyahoga Falls, Ohio 44223
Analytical Laboralorles TEL: [phone] FAX• [phone] Sample Log -in Check List
Website: ht ://`vww.setiek.can
Client Name: SYN-NC-27028 Work Order Number: 21031808
RcplNo: 1
Cooler No Tom °C Condition �Soalact Seal No Seal Date 1 Signed By
2_6 Goodssent,
Page 39 of 39

DWR
State of North Carolina
Department 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 otalityPer)nitting Seetion 'sNoir-Dischar e Permittin Urzit
General — This certification provides detailed information of residuals source generating facility and its residuals quality for land
application, distribution, or disposal in accordance with 15A NCAC 02T 1100. 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 appheation and supporting docum enta tio n listed
below.
A. Residuals Source Certification (FORM: RSC 11-15):
Submit the completed and appropriately executed Residuals Source Certification (FORM: RSC 11-15) form. Please do not
makeanyunauthorizedcontentchangestothisform. If necessary for clarityordue tospacerestrictions, a tta chm en t s t o the
appfie a tion may be ma de, a s long a s the a ttachments are numbered to correspond to th a 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 Guidanee for
Residuals Land Anplication 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. S.
Ensure that the amount of residuals listed is the maximum amount expected to be generated by the facility for the life of
the permit. 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 howthe facility and/ortheresiduals 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 to be land applied, distributed, and/ordisposed.
C. Residuals Quality Information:
® For each source facility, attach the following:
® Laboratory analytical reports and operationa I data -reports for all laboratory analyses used to complete this certification,
® Documentation that the facility complies and/orthe 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 1 of 1

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State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources RESIDUALS SOURCE CERTIFICATION
FORM: RSC 06-16
I. RESIDUALS SOURCE -GENERATING FACILITY INFORMATION (See Instruction R.):
L Facility Name: Yadkinville WTP
2. Facility permit holder is: ❑ Federal, ❑ State, ® Local Government, or ❑ Private.
Facility permit issued by: ❑ Div. of Water Resources, ® Div_ of Environmental Health,
or ❑ Other (explain: ).
3. Facility contact person and title: Joel Hands Plant Supervisor
Complete mailing address: PO BOX 816
City: Yadkinville State: NC Zip: 27055
Telephone number:[phone] E-mail address: jharrisrnr_,yadkinville.org
4. Facility physical address: 2820 South 601
City: Yadkinville State: NC Zip: 27055-
Coordinates: Latitude:36°06'23" Longitude: 80' 39'24"
Datum: NAD83 Level of accuracy: second
Method of measurement: MAP
5. Purpose of the facility:
❑ treatment of municipa I wastewater, ❑ treatment of 100% domestic wastewater,
® treatment of potable water, ❑ treatment of100%industrial wastewater,
❑ treatment of industrial wastewatermixed with domestic wastewater,
(approximate percentages: % industria I and %domestic)
❑ other (explain: ).
6. Does the facility have an approved pretreatment program: ❑ Yes ® No
7. Facility permitted/design flow: 1_6 MGD andfacility averagedaily flow:.086 MGD
8. Average amount of residuals being generatedatthis facility 18 dry tonsper. year.
9. Specify the following regarding treatment and storage volumes available at the facility:
Type and volume of residuals treatment: Four75.600yallon settlingbasins,One 112,8002allondecantbasin
Type and volume of residuals storage (i.e., outside ofresiduals trea tment units) : Two 14,500 gallon drying basins
II. RESIDUALS QUALITY INFORMATION (See Instruction C.):
1. Specify if residuals are regulated under:
❑ 40 CFR Part 503 or ER 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 under40 CFR Part 257,
2. Specify if residuals are definedunder l 5A NCAC 02T.1 102(6) as:
❑ Biological 0 Non -Biological
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, andfixedfilm systems).
FORM: RSC 06-16 Page 1 of 5

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-municipa I, domestic wastewater only)
a. Are the residuals listed in 40 CFR §261.31-§261.33:]� yes P4no.
If yes, list thenumber(s):
b. Specify whether or not the residuals exhibit any of the characteristics defined by40 CFR §261.21-
261.24: Q yes P
_I 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 EnvinmentalTechn to i s and Date of analysis: 4/2/21
Passed corrosivity test: yes no. pH: 6.35 s.u. (2 < pH < 12.5)
Passed ignitability test: yes no. Flashpoint: >140 °F (> 140°F)
Passed reactivity test: yesno. HCN: ND mg/kg {<250} & HzS: ND mg/kg (<500)
TCLP Parameter
Limit
(mg/1)
Result
(m9/1)
TCLP Parameter
Limit
(Mg/1)
Result
(mg/1)
Arsenic
5.0
ND
Hexachlorobenzene
0.13
ND
Barium
100.0
ND
Hexachloro-1,3-Butadiene
0.5
ND
Benzene
Cadmium
0.5
1.0
1 ND
ND
Hexa chlo ro ethane
Lead
3.0
5.0
ND
ND
Carbon Tetrachloride
Chlordane
0.5
0.03
ND
ND
Lindane
Mercury
0.4
0.2
ND
ND
Chlorobenzene
Chloroform
100.0
6.0
ND
ND
Methoxychlor
Methyl Ethyl Ketone
10.0
200.0
ND
ND
Chromium
m-Cresol
5,o
200.0
ND
ND
Nitrobenzene
Pentachlorophenol
2.0
100.0
ND
ND
0-Cresol
200,0
ND
Pyridine
5.0
ND
p-Cresol
200.0
ND
Selenium
1.0
ND
Cresol
200.0
ND
,Silver
5,0
ND
2,4-D
10.0
ND
Tetrachloroethylene
0.7
ND
1,4-Dichlorobeuzene
1,2-Dichlorocthane
7.5
0.5
ND
ND
Toxaphene
Trichloroethylene
0.5
0.5
ND
ND
1,1-Dichloroethylene
0.7
ND
2,4,5-Trichlor.phenol
400.0
ND
2,4-Dinitrotoluene
O.I3
ND
2,4,6-Trichlorophenol
2.0
ND
Endrin
0.02
ND
2,4,5-TP (Sitvex)
1.0
ND
rEHeptachlorandits Hydroxide
o.008
ND
Vinyl Chloride
0.2
ND
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 15A NCAC 02T .1 105.
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: Pace Analytical and Date of analysis:4/7/21
Parameter
Ceiling
Concentration Limits
(ClassA & ClassB)
(ing4g)
Monthly Average
Concentration Limits
(Class A Only)
(mg/kg)
Result
(nag/kg)
Arsenic
75
41
14
Cadmium
85
39
1000
Copper
4,300
11500
40
Lead
840
300
33
Mercury
57
17
ND
Molybdenum
75
n/a
ND
Nickel
420
420
18
Selenium
100
100
910
Zinc
7,500
2,800
160
b. For Surface 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 meta Iparameters:
Laboratory: and Date of analysis: _
Distance from Disposal
Unit to Boundary to
Closest Property Line
(meters, checkone)
Arsenic
(mg4g)
Chromium
(mg/kg)
Nickel
(mg/kg)
❑ > 0 but< 25
30
200
210
❑ > 25 but< 50
34
220
240
❑ >_ 50 but< 75
39
260
270
❑ >_ 75 but< 100
46
300
320
❑ > 100 but< I25
53
360
390
❑ >125
62
450
420
Result (mg/kg)
FORM: RSC 06-16 Page 3 of 5

5, Nutrient/Micro nutrint Determination: Complete the following:
a. Totalsolids: 1.65 %,
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: Pace Analytical and Date of analysis: 4l7l21
Parameter
Result
(mg1kg)
Aluminum
161,000
Ammonia -Nitrogen
40
Calcium
1000
Magnesium
1000
Nitrate -Nitrite Nitrogen
44
PH (Standard Unit)
6.6
Phosphorus
1200
Potassium
770
Sodium
910
Total ICjcldahl Nitrogen
4600
C. using the results listed in Item II, 5b. above, calculate the sodium adsorption ration (SAR): 1.10
[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, oran agronomist, priorto 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): l defauhvalue,or - 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., onadry weight basis) and fill the results in thefnllnurna t�hl—
Application Method
First (Ist) Year PAN
Five -Year
(mg�l�g}
Maximum Adjusted PAN
(mg/kg)
Surface
1432
2322
Injection/Incorporation
1452
2342
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.
FORM: RSC 06-16
Page 4of5

7, Patho en Reduction: Per15ANCAC 02T.1106,specify how residuals will meet the pathogen reduction requirements:
a. For Distribution/LandApplication o C1assAorE uivalent:
❑ A fecalcoliform density that is demonstrated to be less than 1,000MPN 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 fornon-biological residuals):
❑ Alternative 1 [15A NCAC 02T.1106(b)(3)(A)] - Time/Temperature Compliance.
❑ Alternative 2 [15A NCAC 02T.I 106(b)(3)(B)] - Alkaline Treatment.
❑ Alternative 3 [15A NCAC 02T.]106(b)(3)(C)] -Prior Testing for Enteric Virus/Viable Helm inth 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.1106(b)(3)(E)-(K)] - Process to Further Reduce Pathogens (PFRP).
Specify one: ❑ composting, ❑ heatdryiag, ❑ Beat treatment,
❑ thermophilic aerobic digestion, ❑ beta ray irradiation,
❑. gamma ray irradiation, or ❑ pasteurization.
b. For Land Application of Class B:
❑ Alternative 1 [15A NCAC 02T.1106(c)(1)]-Fecal Coliform Density Demonstration.
❑ Alternative 2 (15A NCAC 02T.1106(c)(2)j -Process to Significantly Reduce Pathogens (PSRP).
Specify one: ❑❑ aerobic digestion, El airdrying, ❑ anaerobic digestion,
composting, or ❑ lime stabilization.
c. For Surface Disposal:
❑ Select One of the Class A or Equivalent Pathogen Reduction Alternatives in Item 11. 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 II.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.1 107, specify howresiduals will meet the VAR requirements:
❑ Alternative 1 [15A NCAC 02T.I 107(a)(1)] - 38% Volatile Solids Reduction (Aerobic/Anaerobic Digestion).
❑ Alternative 2 [15A NCAC 02T.1107(a)(2)] - 40-Day Bench Scale Test (Anaerobic Digestion).
❑ Alternative 3 [15A NCAC 02T.I 107(a)(3)] - 30-Day Bench Scale Test (Aerobic Digestion).
❑ Alternative 4 [15A NCAC 02T.] I07(a)(4)] - Specific Oxygen Uptake Rate Test (Aerobic Digestion).
❑, Alternative 5 [15A NCAC 02T.1107(a)(5)] - l4-Day Aerobic Processes.
❑ Alternative 6 [15A NCAC 02T.1107(a)(6)] - Alkaline Stabilization.
❑ Alternative 7 [15A NCAC 02T.1107(a)(7)] - Drying of Stabilized Residuals.
❑ Alternative 8 [15A NCAC 02T.1107(a)(8)] -Drying ofUnstabilized Residuals.
❑ Altemative 9 [I5A NCAC 02T.1 107(a)(9)] - Injection.
❑ Alternative 10 [15A NCAC 02T.1107(a)(10)1- Incorporation.
❑, Alternative for Surface Disposal Units Only - Soil/Other Material Cover [15A NCAC 02T.I 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 andleft on the land surface.
FORM: RSC 06-16 Page 5 of 5

w4s
4.IiiY
frl�+f
W

Quantitative Justification for Residuals Production
Currently, the Town of Yadkinville WTP is permitted for 30 dry tons of annual production. We
are proposing to increase this to 150 dry tons per year. This is to allow for further expansion of
the plant and to ensure we do not exceed the permitted dry tonnage again life we did in 2020.
2017-6.98 dry tons
2018- 27 dry tons
2019- 12.95 dry tons
2020- 78 dry tons

(: ;acmnalytical''
Report of Analysis
Synagro
12701 Lancaster Hwy
Pineville, NC 28134
Attention: Alex Fox
Project Name: Yadkinville WTP
Lot Number:WC26085
Date Completed:04/0712021
04/08/2021 11:44 AM
Approved and released by:
Project Manager II: Lucas Odom
ANSI HRllonel AccreNlelrvR 8oud
A C C R E O I T E O
TESTING LAEORATORY
The electronic signature above is the equivalent of a handwritten signature.
This report shall not be reproduced, except in its entirety, without the written approval of Pace Analytical Services, LLC,
Pace Analytical Services, LLC (formerly Shealy Environmental Services, Inc.)
106 Vantage Point Drive West Columbia, SC 29172
Tel:[phone] Fax:[phone] www.pacelabs.com
Page I of 7

PACE ANALYTICAL SERVICES, LLC
SC DHEC No: 32010001 NELAC No: E87653 NC DENR No: 329 NC Field Parameters No: 5639
Case Narrative
Synagra
Lot Number: WC26085
This Report of Analysis contains the analytical result(s) for the sample(s) listed on the Sample Summary
fallowing this Case Narrative. The sample receiving date is documented in the header information
associated with each sample.
All results listed in this report relate only to the samples that are contained within this report.
Sample receipt, sample analysis, and data review have been performed in accordance with the most
current approved The NELAC Institute (TNI) standards, the Pace Analytical Services, LLC ("Pace")
Laboratory Quality Manual, standard operating procedures (SOPs), and Pace policies. Any exceptions to
the TNI standards, the Laboratory Quality Manual, SOPs or policies are qualified on the results page or
discussed below.
Where applicable, all soil sample results (including LOQ and DL if requested) are corrected for dry weight
unless flagged with a "W" qualifier.
If you have any questions regarding this report please contact the Pace Project Manager listed on the
cover page.
The pH analysis associated with the sample(s) in this report was/were performed after the method
recommended 15 minute holding time.
Pace Analytical Services, l.l.0 (formerly Shealy ✓=nvironmetal Services, lncj
106 Vantage Point Drive west Columbia, SC 29172 [phone] Fax [phone] www.pacelabs.com
Page 2 of 7

Cllent:Synagro
Description: Yadkinviile WTP
Date Sampled:03/25/2021 1000
Date Received:03/2612021
Laboratory ID: WC26085.001
Matrix: Solid
% Solids: 1.65 03/27/2021 1535
Inorganic non-metals
Run Prep Method
1
Analytical Method
Dilution Analysis Date Analyst
Prep Date
Batch
(% Solids) SM 254OG
1 03/27/2021 1535 AAB
87070
1 350.1
(Ammonla - N ) 350.1
1 04/01/2021 1404 KFE
87697
1
(Nitrate - N ) 9056A
1 03/31/2021 0319 AMR
87625
1
(Nitrite - N ) 9056A
1 03/31/2021 0319 AMR
87626
1
(Phosphorus) 365.1
1 03/30/2021 1242 DMA
03/27/2021 0820
87068
1
(Soil pH meas) 90450
1 03/31/2021 1339 NBW
87485
3 351.4
(TKN) 361.2
1 04/06/2021 1623 MSG
04/03/2021 0859
87839
Parameter
CAS Analytical
%Solids
Number Method
Result Q
LOQ
DL
Units
Run
Ammonia - N (gas diffusion)
SM 254OG
1.65
%
1350.1
Nitrate - N (soluble)
40 J
61
32
mglkg
1
Nitrite - N (soluble)
9056A
44
30
6.1
mglkg
1
Phosphorus
9056A
7723-14.0 365.1
ND
1200
12
6.1
mglkg
1
Soil pH measured in water @
19.9 ° C
300
61
mglkg
1
TKN
9045D
6,g
su
1
351.2
4600
1500
1500
mg/kg
3
CVAA
Run Prep Method Analytical Method Dilution Analysis Date Analyst Prep Date Batch
1 7471B 7471B 1 04/01/2021 1817 CMS2 04/01/2021 1540 87571
Parameter
CAS Analytical
Number Method Result Q LOQ DL Units Run
Mercury 7439-97-6 7471E ND 4.7
1.1 mglkg 1
ICP-AES
Run Prep Method
1
Analytical Method Dilution Analysis Date Analyst
Prep Date
Batch
3050B
6010D 1 03131/2021 1502 KSH2
03/30/2021 1157
87144
Parameter
CAS Analytical
Aluminum
Number Method
Result Q
LOQ
DL
Units
Run
Arsenic
7429-90-5 6010D 20000o
370
140
mglkg
1
Cadmium
7440-38-2 6010D
6.7 J
14
4.6
mglkg
1
Calcium
7440-43-9 601 OD
ND
4.6
1.2
mglkg
1
Chromium
7440-70-2 6010D
1000 J
4600
580
mg/kg
1
Copper
7440-47-3 6010D
42
9.2
2.3
mglkg
1
Iron
7440.50-8 601OD
40
9.2
4.2
mglkg
1
Lead
7439-89-6 6010D
29000
92
42
mglkg
1
Magnesium
7439-92-1 6010D
33
9.2
4.2
n lkg
1
Manganese
7439-95-4 6010D
1000 J
4600
580
mgJkg
1
Molybdenum
7439-96-5 6010D
3800
14
5.5
mg/kg
1
Nickel
7439-98 7 6010D
ND
37
9.2
mgJkg
1
7440-02.0 6010D
18 J
37
9.7
mg/kg
1
LOQ = Limit of Quantitatlon B = Detected in the method blank E = Quani tation of compound exceeded the caiibratfon range DL = Detection Limit ND = Not detected at or shove the OL N = Recover is out of criteria Q =Surrogate failure
Y P =The nPD between two GC columns exceeds 40% J =Estimated result < LOQ and > =
H = Out of holding time W =Reported on wet weight basis -
OL L LCSILCSD failure
=
Pace Analytical Services, LLC (formerly Shealy Environmental Services, Inc.) S MSIMSD failure
106 Vantage Point Drive West COlUmbla, SC 29172 [phone] Fax [phone] www.pacelabs,com
Page 3 of 7

Client: Synagro
Description: Yadkinvllie WTP
Data Sampled:0312512021 1000
Date Received:03/2612021
IMAE5
Laboratory ID: WC26085-001
Matrix: Solid
% Solids: 1.65 03/27/2021 1535
Run Prep Method
1
Analytical Method Dilution Analysis Date Analyst
Prep Date
Batch
3050B
601OD 1 03/31/2021 1502 KSH2
O3/30/2021 1157
87144
\
Parameter
CAS Analytical
Potassium
Number Method
Result Q
LOQ
DL
Units
Run
Selenium
7440-09.7 6010D
770 J
4600
580
mglkg
1
Sodium
7782,49-2 601OD
8.5 J
18
7.5
mglkg
1
Zinc
7440.23-5 6010D
910 J
4600
580
mglkg
1
7440-66-6 6010D
160
46
12
mglkg
1
LOQ = Limit of Quantitalion 3 = Detected in the method blank E = Quantltalior of compound exceeded the calibration range DL = Detection Limit Na = Nat detected at or above the DL N = RecoveryIs out of criteria Q Surrogate failure
P = The RPD between we GC columns exceeds 40% J =Estimated result < LOQ and > DL
H = Out of holding time W =Reported on wet weight basis _ L = LCSlLCSD (allure
=
Pace Analytical Services, LLC (formerly Shealy Environmental Services, Inc.) S MSIMSD failure
106 Vantage Polnl Drive West Columbia, SC 29172 [phone] Fax [phone] www.pacelabs.com
Page 4 of 7

Chain of Custody
and
Miscellaneous Documents
Pace Analytical Services, UC (formerly Shealy Environmental Ser&as, Inc.)
106 Vantage Point Drive West Columbia, SC 29172 [phone] Fax [phone] www.pacelabs,com
Page 5 of 7

PACE ANALYTICAL SERVICES LLC
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106 Vantage Point drive West Columbia, SC 29172 [phone] Fax [phone] www.pacalaa,s.com
Page 6 of 7

PACE ANALYTICAL SERVICES LLC
samplim Reoelwt Checklist (Srtcl IMEDo7 mis) RevlsidW2W2020
Issifing Authority: Pare FNV - WWI- Page's of a
Sample Receipt Clteeldist (SRC)
Client: '5V1119re C013 tnsl>,ectad I,yl(late" rEtaz 1 nMaGM11 1 at . ticrtxaaass
t I'OC{1115t; ara� r'tlelit UL�S I vdEix Other:
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be wnplat4tl for ony VaIttl3te(5) 111Correctly prmarved or with hcaldspilim)
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is Ktirlple lu aiving%%,U_ MA �,ml, air ed and; H2 44,1iNDa, ll [, Nl1f]ll using pit 4 MA
3i11C of pr+rsCrratlUlt .i4h lFli1C11Y: tllatl $liES preSerYatEY9 IS naedeld,, plq 1,^,St n01e lit t11c COL111news�below.
$apiplt (s) NA.-,--_—__ viele raceivelttilrM bubbles>6 m;n in diameter.
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adjusted accordiltKly In ;sumplr, remeiui.tig wilh snelhlnt thloslllft (Naa5a0,0 with Shealy ID. MA
$,R 1Yorcode latae is applied bl, jKU2 1)Mte; 41i1b1702 t
orrstnenls:
Pace Analytical Services, LLC (formerly Shealy Environmental Services, lnc.J
106 Vantage Point Drive West Columbia, SC 29172 [phone] Fax [phone] vmw.pacelabs.com
Page 7 of 7

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
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 A licant shall submit one on final and two co ies of the a lication and
su ortin documentation
Formore information, visitthe Water Quality Permitting Section'sNonNon-Discharge Unit
General — This certification provides detailed information of receiving sites for land application of Class B residuals fmay include
water treatment plant or other type residuals) in accordance with 15A NCAC 02T .l 100. Do notsubmit 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 docum enta tio n 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. Pleasc
do not make any unauthorized content changes to this form. Ifnecessary for clarity or due to space restrictions, attachment s
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 iandapplication site with respect to this residuals landapplication program must be provided in table 1. 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:
Required Item Status Code
N R T M
'J
County Board
Notification, doc
w
Land Owner ✓ ✓ ✓
Agreement
(If applicable)
Pr 16
Setback Waiver
✓ ✓ ✓ ✓
Agreement
An updated vicinity/setback map in accordance with the "Ma (iuida,�ce
fur Residuals Land Anplicatiun Permits" ✓ ✓
A soils and agronomic evaluation in accordance with the "5uil Scicntis,
l:vrtivatr�m pc}�icv'° ✓ :�
INSTRUCTIONS FOR FORM: LASC 06-16
Page Iof3

inns nem may tie 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 mostlikely crop typesfor the life of thepermit (five years).
® Predominant Soils Series Name must be either the name of the soil indicated bn Attachment "B" of the existing pennit, or
nameofthe soil series asprovided 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
mappingunit. 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 haven representative slope of 6%.
® New Sites to be permitted must have slopes determined aspart 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 areas
follows:
• Address Matching (ADD) . Digital or Raw Photo Extraction (EXT)
• Aerial Photography with Ground Control (AER) • Geodetic Quality GPS Survey (GEO)
• Cadastra I Survey (SUR) • LORAN-C Navigation Device (LOR)
• Conversion from Coordinate Plane (CP) • Navigation Quality GPS (GPS)
• Conversion from Township -Section -Range (TSR) e Remote Sensing (RS)
• Conversion from Universal Trans Mere (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; htt :/a /deg.nc.gov/about/divisions/water-
resources/ lannin classification-standards/classifications
❑ Any questions concerning the waterbody and its classification, please contact the Division's regional offices.
❑ A fist of the Division's regional offices, their county coverage, and their contact information may he downloaded at:
http;//de .nc, ov/contact/regional-offices
❑ General Instructions: There are 17 river basins in North Carolina. Each basin has associated waterbodies with assigned
subbasins, location descriptions, stream index numbersand established classifications.
1. Identify the project area on a 7.5 minute USGS topographical map (an 8.5 x If -inch sheet showing the project area
should be submitted with the perm it application regardless ofwhether a Stream elassificationwas completed).
2. Determine the names of all the closest down slope surface waters from the project site. Forunnamed tributaries, see
Table 1: Unnamed Tributaries Entering Other States or for Specific Basin Areas. Label any unnamed tributaries as
"UT to stream name" asthe waterbodyname.
3. Open the link htt ://de .nc. ov/about/divisions/water-resources/ lannin classification-standards/classifications.
❑ Stream Classification Process: One of the optionsbelow maybe used depending on theknown initial project information.
❑ KNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Select proper basin from the List all Waterbodies in Basin sorted report. Sort hydrologically as this willprovide
the proper location descriptions if multiple runs.
INSTRUCTIONS FOR FORM: LASC 06-16 Page 2 of 3

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,hydrologicafy 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" hi 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 hydrologica Hy sorted list report.
2. Click on the approxim ate proj ect 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 tetra
"source" in the description means the beginning of the waterbody segment (most upstream point).
5.Record all Basins, Stream Index Numbers and Classifications applicable tothe project.
❑ Notes on index number and unnamed streams:
Unnamed Streams 15ANCAC 02B .0301i0.
❑ Any stream which is not named in the schedule of stream classifications carries the same classification asthatassigned
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 sattwaters 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 projectswill 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:
INSTRUCTIONS FOR FORM: LASC 06-16 Page 3 of 3

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State of North Carolina
DWR 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 Applicant shall submit one on final and two cies of the application and
supporting documentation o
For more information, visit the Water Quality Permitting Section's Non-Dischar e Permittirr Unit
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
CIass B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .I100. 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. LaV Owner Agreement (FORM: LOA 06-16):
Rr 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
[Pppiication may be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
repare a separate agreement for each set of land application sites that are owned or operated by an enti other th AApplicant. ty an the
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 re resentative hereby permits:
Applicant's name �c� ��(�7✓f� f
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 1D Lease Land Use or Residuals Source Special note
(yesino) Cropping Patterns Intended Use of Crops (no-till/over-seed/
no eed/
(optional)
pasture)
-� tp An 4, , t F-44
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
Pagel of 3

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 II) 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 Iandowner shall give a notice to the new landowner that gives full details of the residuals applied at the
Iand application site(s).
6. The Per alttee 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 Pemittee 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 Ieachate, surface water, groundwater, or soil samduring the
terns of, and 12 months after termination of, this Agreement. es
II. RESTRICTIONS:
I. 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 acid for the 12-month period following a residuals land application event. Such posting of signs that indicate the activities being conducted at the land application site(s). controls may include the
2. Animals shall not be grazed on the land applica
application eveents. tion site(s) for a 30-day period following a residuals land application event . Land application
sites that arc be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land
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 I4-
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 Iand 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 Iand
application cvent 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.
IILALTERNATIVES 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, l5A NCAC 02T .0I05 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 marls 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)
re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID:
residuals land application program; Permit Number WQ: is currently permitted under another
The [Find owner hereby
agreement, he/she is requesting that the field(s) be removed from the previously permitted residualsand applicat oacknown program dge that by signing
andtransfr transferred
into the new program;
(Name of the new program)
FORM; LOA 46-16
Page 2 of 3

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 13 `' �l
name: J
Address: {_{{��' LSr� IT% j2
((
City: 0L et1 State:
Zip: �7fJ.s
Phone: Mb l 6q U E-mail address:
1
Signature:
Date:
NORTH CAROLINA, [t
COUNTY
I, the undersigned Notary Public do hereby certify that
personally appeared before me this day and acknowledged
the due execution of the forgoing instrument,
WITNESS my hand and official seal this the
day of
20
Signature and seal;
My commission expires: G +
Os�
BL►G * Q Z
,�• Z�
�i 11COI�N;
Lessee's/Operator's Certification:
I 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:
State:
E-mail
Date:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name: ��� o�
Signature: Date:p���,2 l
FORM: LOA 06-I6
Page 3 of 3

FILED
YADKIN COUNTY NC
ARIC WILHELM
REGISTER OF DEEDS
FILED Aug 25, 2021
AT 03:31:41 pm
BOOK 01330
START PAGE
0706
END PAGE
0707
INSTRUMENT #
03941
EXCISE TAX
(None)
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE RESIDUALS MANAGEMENT PROGRAM WAIVER
FOR THE APPLICATION OF CLASS B RESIDUALS
AGREEMENT TO WANE SETBACKS PURSUANT TO
15A NCAC 02T .1108(c)
I
,L. hrn� :51Y--c f 5 , certify that I am a deeded owner of the property located at:
Address: 'L l 46� C "r t ,� 12 t 13 (0 0 3
ParcelNa.: (1�Uo 3o� 131po3�
City: t� � h fn V, �I-L, State: -NC -Zip Code: 770 S3- County:ld r
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.
0 For the parcel identified above, I consent to a reduced setback from 50 feet to 0 feet, thereby
,allowing the application of Class )3 residuals as near as 0 feet from my propertyline.
ror the parcel identified above, I consent to a reduced setback from 400 feet to 100 feet,
thereby Allowing the application of Class B residuals as near as 100 feet from my residence.
"THIS WAIVER SHALL BE TERMINATED UPON CHANGE OF OWNERSHIP OF ANY PARTIES INVOLVED**
�--2 f
FORM: NDRMPW-LAS I 1-I8 Page I of 2

Permittee:. Ou.A Ot� Cr��n✓� 1+G
4 62 a i=ru 44wa � >2 b
Address: Permit No.: V OL Q 0 c t% aJ
City: `1 w l''+1 4tate:Al(-- Zip Code:'17°5'�'County:
NORTHCAROLINA, L��K�� COUNTY
a Notary Public for ��e ce County, North Carolina,
do hereby certify that ��fri S�Y.Lr personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
r
Witness my hand and official seal, this the Y day of
Wf F'('�,�id�+
SEAL ~ = (.✓
'o-MV? p
puavmcy Z Signature of Notary Public
�ii Q •,.�..w o�� My commission expires 0 u ZZ a0
®®�° lsr�io+)�°�,,
Once notarized, this form shall be recorded at the Register of Deeds in the county or
counties in which the described properties are located. A copy of the recorded waiver
shall be sent to the following address:
Division of Water Resources
Non -Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDRMPW-LAS 11-18 Page 2 of

FILED
YADKIN COUNTY NC
ARIC WILHELM
REGISTER OF DEEDS
FILED Aug 25, 2021
AT 03:30:05 Pm
BOOK 01330
START PAGE
0704
END PAGE
0705
INSTRUMENT #
03940
EXCISE TAX
(None)
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE RESIDUALS MANAGEMENT PROGRAM WAIVER
FOR THE APPLICATION OF CLASS B RESIDUALS
AGREEMENT TO WANE SETBACKS PURSUANT TO
ram. 15A NCAC 02T .1108(c)
"r`�� , certify that I am a deeded owner of the pro e located at:
Address:
214� lam
l "A� �t p rty
I / Parcel No.: 3� o l
City: State: NC Zip Code: Z70�5 County: �
Furthermore, I certify that I am authorized to snake decisions regarding this property, and that I do hereby
agree that the setback distances cited below be granted to the Applicant/Permittee Iisted on the following
page.
/
[E] For the parcel identified above, I consent to a reduced setback from 50 feet to 0 feet, thereby
allowing the application of Class B residuals as near as 0 feet from my propertyline.
For the parcel identified above, I consent to a reduced setback from 400 feet to 100 feet,
thereby allowing the application of Class B residuals as near as 100 feet from my residence.
**THIS WAIVER SHALL BE TERMINATED UPON CHANGE OF OWNERSHIP OF ANY PARTIES INVOLVED**
I1
S
FORM: NDRMPW-I,AS 11-18
Page] of 2

Permittee: TOO, "A dar�-
1620 rK4-, r-�-
Addjr�ess(: Permit No.: ti✓Q DDD t TO
CityState: AIL- Zip Coda;? 7051�—County:
NOR CAROLINA, �W C COUNTY
I ` f K- a Notar Public for L``
f , } �� c l County, North Carolina,
t do hereby certify that �r t7i'+NY '`' (1 personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the % day of Aw
®00111111/
ate° ' 4Qto'.Snifi
y�®pr�e�aandll�-ftl
009ties "ThM
tea; sh l b6i
x10
Ile
e3�Bcil�4
Signature of Notary Public
My commission expires DL 2 Zp 222- p
this form shall be recorded at the Register of Deeds in the county or
h the described properties are located. A copy of the recorded waiver
he following address:
Division of Water Resources
Non -Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDRMPW-LAS 11-IS Page 2 of 2

State of North Carolina
DWR
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 Applicant shall submit one original and two copies of the application and
Supporting documentation
For more information, visit the Water Quality Permitting Section's_ NonNon�e Permitting 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. La ,q& wner 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
implication 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
pplicant.
Lid 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 repress
Applicant's name: 1 cJ ✓h t-)
by permits:
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
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
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 Page 1 of 3

I. STIPULATIONS:
I. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the sites) 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 patty 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 sitc(s) to anew
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 Permittce 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 Iand
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 sarnples during the
term of and 12 months after termination of, this Agreement.
It. 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 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 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.
III. 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 marls one of the following;
❑ A re -defined compliance boundary is needed for field(s) ID:
(Please include the rationale for the requested re-Iocation of the compliance boundary and attach a map showing the newly proposed
corr�pliance boundary to the application package)
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 moaram:
(Name of the new program)
FORM: L,OA 06-16
Page 2 of 3

Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application sites) 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, 1 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:
2
City: `1 6JG State: _ Zip
Phone: �5� L% [ ' �S�i E-mail address:
Signature: Date:
t %
NORTH CAROLINA, �lRC';,Vhl, COUNTY
—7--f2- 2(
I, the undersigned Notary Public do hereby certify that W try
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the
day of U
Signature and sea]:%
My commission expires:
Lessee's/Operator's Certification:
I certify that 1 have read this Agreement and do hereby
Lessee/operator name: 1J 11y 071-1 f
Address:
2�
City: 41A."Iur 11{ State:
Pk
t%J01ui,
* W _F
,20 �
U:
� b
fe�1%111t11\\\\
to abide by the stipulations and restrictions as specified herein.
Phone: 13% ` I1 6 I- E-mail address:
Signature: a Date:
Permittee's Certification:
Zip: 9 7D53
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name:
Signature: Date: _1 ;� T1q=
FORM: LOA 06-16 Page 3 of 3

APPLICATION MAP
w.
,+$Y :mac`' ,� � `' &' -• • 1
i ram'}j 4.R ice; a �1
'-f
Ln
�.
()14 t,
IMERTME RD
LEGEND
177-77
APPLICATION AREA
PRIVATE ROAD
STREAM
DRAIN
* x FENCE
PROPERTY LINE
UNSUITABLE AREA
WATER
ONSITE HOUSE
OFFSITE HOUSE
OUTBUILDING
WELL
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary. whichever is closest to the application area. The review boundary is established
midway hetween the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
GRAPHIC SCALE
1" = 660'
669 0 660`
NC-YK-08
Fields 146

SOIL SURVEY
GRAPHIC SCALE
1" = 660'
660, 0 660,
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
ocations are approximate.
N C-YK-08
Fields 146

VICINITY MAP
GRAPHIC SCALE
V = 2,000'
2,c00' 0 2,000'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area, The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-YK-08
Fields 146

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•

State of North Carolina
DWR
Department of Environment and Natural Resources
Division of Water Resources
Mvlslon 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 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 Permitting Unit
General — This document is an agreement between the AppIicant 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 .l 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. La 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
7plicant.
opy 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
Applicant's name: 1 0 _✓&
itative hereby permits:
k1oV,I t„
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 tb
Lease
esino
(Y )
Land Use or
Cropping Patterns
PP� g
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-tilliover-seedl
pasture)
+
^ 1
f i
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 Page l of

1. STIPULATIONS:
I. 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 1I) are met.
A. 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
tern of, and 12 months after termination of, this Agreement.
II. 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 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 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. rood crops with harvested pants 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 Iand
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.
III. 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, 1.5A NCAC 02T .0105(h) aliows 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)
DIAomre-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)
FORM: LOA 06- l 6 Page 2 of 3

Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application sitc(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 Pennittee to land apply residuals to the land application site(s) as specified
herein. Landowner name: OOAJ� �4��w�
Address: V, D
City. �Y�, State: ,dc, Zip: Ol
Phone; , 5� E-mail address:
Signature: ✓ Dater
NORTH CAROLINA, G (�� �y� COUNTY
I, the undersigned Notary Public do hereby certify that gyp} . �,JAM,3
♦%% SX w �
personally appeared before me this day and acknowledged the due execution of the forgoing instrum p` 0+
WITNESS my hand and official seal this the ] rl a10TAe_
day of -TW. [ 2q '
Signature and seal:V—Viv �r W,
My commission expires: O."'Val 'go ��/I6COV
Lessee's/Operator's Certification:
I 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:
State:
E-mail address:
Date:
9M
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name:
Signature: Date: . Y/a T LI I
FORM: LOA 06-16 Page 3 of

APPLICATION MAP
un
a .
s R s
r :��� r • sY.E.
'a
b
UMMERTME
.0
d
0
}
. o
7
APPLICATION AREA
UNSUITABLE AREA
— —�—n— — — PRIVATE ROAD
�W
WATER
— — — — STREAM
■
ONSITE HOUSE
— DRAIN
.
OFFSITE HOUSE
X xX FENCE
OUTBUILDING
PROPERTY LINE
0
WELL
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
GRAPHIC SCALE
1 " = 660'
660' 0 660,
NC-YK-09
Field 1

SOIL SURVEY
GRAPHIC SCALP
1 " = 660'
660' 0 660,
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-YK-09
Field 1

2
V
TOPOGRAPHIr. NAAP
GRAPHIC SCALE
1 If
= 800'
800, 0 800,
The compliance boundary is estabiished either 250 ft from the residuals application area or 50 feet within n r
in the property boundary, whichever is closest to the application area. The review boundary is established I V C- r\/
K-09
midway between the compliance boundary and the perimeter of the residuals application area. M
locations are approximate. Field I

VICINITY MAP
t:
a r�
J
pQ
4
Si! RTGyfRO ���i
.�BrF�[7l
Lakc
u
i
1
GRAPHIC SCALE
1" = 2,000'
2,000- 0 2,000-
�
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
N C-YK-0 9
Field 1

State of North Carolina
DWR
Department of Environment and Natural Resources
Division of Water Resources
Divlsion 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 Applicant shall submit one on inal and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non-Dischar.2e Permitting Unit
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class S 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. LaOwner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Residuals Source Certification (FORM: LASC 06-16) form. PIease 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.
repare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
pplicant.
L 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
Applicant's name:
here�by permits:
l
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 Ill
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
pwm All
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 Page 1 of 3

L 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 II) 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.
11. RESTRICTIONS:
1. Appropriate measures must be taken by the Permittec 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 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.
III.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 compliancc 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 fields) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

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 sites) on behalf of other deeded Iandowners 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: rr}} -avkn ` ,
Address:
City: • n dr IL State: OIL- Zip:
Phone: t1(p — 7 ),�7 7 E-mail address:
Signature: Date:
NORTH CAROLINA, �tv� COUNTY
I, the undersigned Notary Public do hereby certify that [IC
personally appeared before me this day and acknowledged the due execution of the forgoing instrument %,���Ix IW '
WITNESS my hand and official seal this the 191��-���
day of �' �-
1t , 20 2� ~
Signature and seal: f ��
My commission expires:
Lessee's/Operator's Certification:
WIA %L%G I:
MI
I 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:
State:
E-mail
Date:
0
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name: ��,,c d►J�:,. ,
Signature: Date:.�i /a2�1 oz l
FORM: LOA 06-16 Page 3 of 3

UkVkVN r<:, vi i -
r.
LEGEND
www�
4� d APPLICATION AREA
G� n n rl UNSUITABLE AREA
- — — — — - PRIVATE ROAD � WATER
- - - --- STREAM
GRAPHIC SCALE
ONSITE HOUSE
9 _ 660
DRAIN sso,
o sso
OFFSITE HOUSE
- -X x FENCE
OUTBUILDING
PROPERTY LINE
�. SOIL BORING 0 WELL
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
t� I Ce V2-7 K_
I V [ I
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
Field 1

VICINITY MAP
Z
''.
`I
t
ram—
_
1 �
r
L 1 B
E It T y
1 R o K
I
GRAPHIC SCALE
1" = 4,000'
4,000' 0 4,000'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
N C-YK-27
Field 1

SOIL SURVEY
GRAPHIC SCALE
1" = 800'
800' 0 B00'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
N C-YK-27
Field 1

TOPOGRAPHIC MAP
GRAPHIC SCALE
1" = 1,000'
1.000, 0 1,000-
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
In the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-YK-27
Field 1

DW-R
Division of Water Resources
State of North Carolina
Department of Environment and Natural 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 Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Nan -Discharge Permitting 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. Lan caner 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.
dPrepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
/A'copy
plicant.
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 re resentative hereby permits:
Applicant's name: •✓!1�, 1I
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
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
)
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-I6 Page 1 of 3

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 II) 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 Iandowner 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 sites) 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 pennitted 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 neat 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.
It. 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 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 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 Iand 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 Iess 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.
III. 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)
DA 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 nroaram:
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

Landowner's Certification:
i certify that I am a deeded landowner of the above -referenced land application sites) and am authorized to make decisions
regarding the use of the land application sitc(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 sites) 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. Furthennore, 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 Pennittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name:
Address: 2 0 U 0, A,,-)& 2 71 Co
City: State: NC zip: rjOSS
Phone: 3 �' D E-mail address: j 15",Ptwi Me , o f
Signature: I� Date: 1
NORTH CAROLINA, �G C k�(>ti COUNTY
I, the undersigned Notary Public do hereby certify that [Lq� .5Wa"
personally appeared before me this day and acknowledged the due execution of the forgoing instrument. t j%% ltrtttt
WITNESS my ha and official seal this the 2
day of 20 2 /
[ T�
Signature and seal: / G,/ •- U
My commission expires: f 2 z 202 ,r�Q
i
�y A \
Lessee's/Operator's Certification: 11t
I 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:
State:
E-mail address:
Date:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name:
Signature: Date:aS�a l
FORM: LOA 06-16 Page 3 of 3

APPI IrATIONI AAAD
l
LLVClVU
APPLICATION AREA
02
UNSUITABLE AREA
— — — — — —
PRIVATE ROAD
C:D
WATER
— — — —
STREAK
_
DRAIN
ONSITE HOUSE
— ——
FENCE
OFFSITE HOUSE
PROPERTY LINE
❑
OUTBUiLDING
Q
SOIL BORING
WELL
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area, The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. AI
locations are approximate.
GRAPHIC SCALE
1 " = 660'
ssao ssa
NC-YK-29
Field I

VICINITY MAP
i
- r�
d
zr ! ih4V
4
`s
17
Art
�C_ D (E� Elli P• 'G'-'�R E -- -�,'! - _ ! ' I. F' i r.-• per, E " `4 r t
• 1�. I� I� _ 1 � L y1 L! � I
a
'o r 11
GRAPHIC SCALE
1" = 4,000'
4,000- a 4,000'
Tho compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area, The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
N C-YK-29
Field 1

/ �.A
CL
a
z
ILA
SOIL SURVEY
GRAPHIC SCALE
1" = 800'
800' 0 Boo
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. Tihe review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
N G-YK-29
Field 1

..(
cels1` 1 1
r i
■
r
TOPOGRAPHIC MAP
GRAPHIC SCALE
1" = 1,000'
1,aooo �,oco
The compliance boundary Is established either 250 R from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-YK-29
Field 1

a

CeB3
Cac
CaC
FaD
'��
e
SmE
CrA
SOIL MAP
The compliance boundary is established at
either 250 feet from the residuals application
area or 50 feet within the property boundary,
whichever is closest to the application area.
The review boundary is established midway
between the compliance boundary and the
perimeter of the residuals application area.
All locations are approximate.
FdD2
CcC2
DhA
11- DhA
0 0.0375 0.075 0.15 Miles
NC-YK-29
Field-2

TOPOGRAPHY MAP
So _
ER
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NC-YK-29-2 0 0.125 0.25 0.5 Miles

VICINITY MAP
N C-YK-29-2 0 0.15 0.3 0,6 Miles

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Waypoint.
ANALYTICAL
8/17/2021
Synagro Central LLC/ Yadkinville
Mary Brewer
284 Boger Road
Mocksville, NC, 27028
Ref: Analytical Testing
Report Number: 21-222-0006
Project Description: Town of Yadkinville
7621 Whitepine Road, Richmond, VA 23237
Main 804-743-9401 0 Fax [phone]
www.waypointanalytical.com
Dear Mary Brewer:
Waypoint Analytical Virginia, Inc, received sample(s) on 8/10/2021 for the analyses presented in the following
report.
The above referenced project has been analyzed per your instructions. The analyses were performed in
accordance with the applicable analytical method. Sub -contracted testing is noted on the Sample Summary Table
if applicable.
The analytical data has been validated using standard quality control measures performed as required by the
analytical method. Quality Assurance, method validations, instrumentation maintenance and calibration for all
parameters (NELAP and non-NELAP) were performed in accordance with guidelines established by the USEPA
(including 40 CFR 136 Method Update Rule May 2012) and NELAC unless otherwise indicated.
Certain parameters (chlorine, pH, dissolved oxygen, sulfite...) are required to be analyzed within 15 minutes of
sampling. Usually, but not always, any field parameter analyzed at the laboratory is outside of this holding time.
Refer to sample analysis time for confirmation of holding time compliance.
The results are shown on the attached Report of Analysis(s). Results for solid matrices are reported on an as -
received basis unless otherwise indicated. This report shall not be reproduced except in full and relates only to
the samples included in this report.
Please do not hesitate to contact me or client services if you have any questions or need additional information.
Sincerely,
Tp.WIT MC (rlvarr
Pauric McGroary
Agronomist
Laboratory's liability in any claim relating to analyses performed shall be limited to, at laboratory's option, repeating the
analysis in question at laboratory's expense, or the refund of the charges paid for performance of said analysis.
Page 1 of 5

(2)Waypoint, 7621 Whitepine Road, Richmond, VA 23237
Main 804-743-9401 ° Fax [phone]
ANALYTICAL www.waypointan al ytica 1. cow
Sample Summary Table
Report Number: 21-222-0006
Client Project Description: Town of Yadkinville
Lab No Client Sample ID Matrix Date Collected Date Received Method Lab ID
77414 2 Solids 08/10/2021 SW-7471B WP MTN
WP MTN - Memphis, TN: Waypoint Analytical - TN, Memphis, TN
Page 2 of 5

Waypoint,Q)
ANALYTICAL
46507
Synagro Central LLC/ Yadkinviile Project
Mary Brewer
284 Boger Road Information
Mocksville , NC 27028
Report Number : 21-222-0006
Lab No : 77414
Sample ID : 2
Test Results
Mercury 0.0397
7621 Whitepine Road, Richmond, VA 23237
Main 804-743-9401 0 Fax [phone]
www.waypointanalVtical.com
Town of Yadkinville
REPORT OF ANAL YSIS
Units MOL
mg/Kg 0.0147
Report Date: 08/17/2021
Received : 08/10/2021
1OJUIC t fie.'-Oa4"
Pauric Mc Groary Ph.D., CPA
Agronomist
Matrix: Solids
Sampled:
DF Date 1 Time By Analytical
Analyzed Method
1 08117/2111:43 TJS SW-7471B
Qualifiers/ *
Definitions
Outside QC Limit
B
Anal e detected in blank
yt
C
GCMS Confirmation Analysis
E
Result above cal range
9
GGA Outside QC Limits
H
Beyond holding time
J
Estimated value
M
Minimum value
NA
Not on Scope of Accreditation
NC
Not confirmed
Q
RPD >40% dual column results
T
Sample exhibits toxicity
Page 3 of 5

• (2)
Waypoint
ANALYTICAL
7621 Whitepine Road, Richmond, VA 23237
Main 804-743-9401 1 Fax [phone]
www.waypointanalvtical.com
Shipment Receipt Form
Customer Number: 46507
Customer Name: Synagro Central LLCI Yadklnville
Report Number: 21-222-0006
Shipping Method
0 Fed Ex 0 US Postal 0 Lab
0 UPS 0 Client 0 Courier
0 Other:
Thermometer ID:
�—
Shipping container/cooler uncompromised?
# Yes
No
Number of coolers/boxes received
r 1
Custody seals intact on shipping container/cooler?
0 Yes
0 No
Not Present
Custody seals intact on sample bottles?
0 Yes
0 No
0 Not Present
Chain of Custody (COO) present?
0 Yes
(D No
COC agrees with sample label(s)?
# Yes
0 No
COG properly completed
# Yes
0 No
Samples in proper containers?
# Yes
0 No
Sample containers intact?
# Yes
0 No
Sufficient sample volume for indicated test(s)?
Yes
0 No
All samples received within holding time?
Yes
0 No
Cooler temperature in compliance?
0 Yes
0 No
Cooler/Samples arrived at the laboratory on ice.
Samples were considered acceptable as cooling
process had begun.
0 Yes
No
Water - Sample containers properly preserved
0 Yes
0 No
# NIA
Water - VOA vials free of headspace
0 Yes
0 No
0 NIA
Trip Blanks received with VOAs
0 Yes
0 No
0 NIA
Soil VOA method 5035 — compliance criteria met
0 Yes
0 No
# NIA
High concentration container (48 hr)
v High concentration pre -weighed (methanol -14 d)
Low concentration EnCore samplers (48 hr)
F_ Low conc pre -weighed vials (Sod Bis -14 d)
Special precautions or instructions included?
0 Yes
# No
Comments:
Signature: Brandi Watson Date & Time: ;08/10/2021 10:02:54
Page 4 of 5

P'i
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Page 5 of 5

SYNAGRO, YADKINVILLE PERMIT
WQ 0001800
SOIL SCIENTIST CERTIFICATION
This is to certify that soil profile evaluations were conducted on the proposed application
sites for the Synagro Yadkinville project by Piedmont Environmental Associates, P.A. on
behalf of Synagro Central, LLC. The evaluations consisted of hand auger borings and
descriptions of the soils on the application sites. All hand auger borings included in this
package were either performed by me or under my direct supervision. All other work
performed for this permit application was conducted by Synagro Central, LLC.
For each application field site, representative soil borings were conducted to confirm the
soil series designation provided on the USDAINRCS soil survey data. It was assumed
that areas unsuitable to slope or a seasonally high-water table are not included in the
application area for any of these fields.
Table t lists the dominant soil series mapped for each of the fields in this submittal, as
well as the soil series determined:
Table 1. - Soil Profile Descriptions Data, Yadkinville, Permit WQ
0001800
Field NRCS Mapped Series Field Identified Series
YK 29-2 Clifford Clifford
YK 33-4 Clifford Clifford

Sincerely,
G. Christopher Murray, L.S.S.
No. 1284
Synagro, Lincolnton Permit, Various Fields

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State of North Carolina
DWR 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 Applicant shall submit one on inal and two copies of the a lication and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permittin 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. La 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
pplication may be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
P epare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
pplicant.
A copy of the completed and appropriately executed agreement must be provided to the Iandowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his
Applicant's name: 1 p J
hereby permits:
L, 11
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
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
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
Page 1 of 3

I. STIPULATIONS:
1. The Iandowner 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 I1) are met,
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCD) NR-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 sitc(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.
II. RESTRICTIONS:
I. Appropriate measures must be taken by the Permittec 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 Iand 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 drops shall not be harvested for a 30-day period following a residuals land application event.
4, rood crops with harvested pants 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 3$-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 shail not be harvested for a 12-month period following a residuals land application event.
III, ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please cheep one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T .0105(b} 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)
FORM: LOA 06-16 Page 2 of 3

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: �) CV k
Address: `1-1 11 ILI
2 L
City: I,S Jtn p� State: Zip: C t7 t
Phone: (5 "S� - �+� l 2'�SGf� � E-mail address:
X Signature: -D U� a Date: r.-T -2 � 4L�
NORTH CAROLINA, l ay(t.N COUNTY
I, the undersigned Notary Public do hereby certify that
personally appeared before me this day and acknowledged the due execution of the forgoing instrumen ,1%J11ii11I!/
WITNESS my hand and official seal this the t 6'�Z'
+day of ` 20 2
Signature and seal: _
ff � �/I9or, . U
My commission expires: aL 7- �0 D3►,i ����(+,_ __,.•_.t+���
Lessee's/Operator's Certification: '•1Nf111
I 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: E,,,J State: ;��. Zip: %DID
Phone: ���.' - '7 6 - 41, b t( E-mail address:
Signature: Date: 2 (- Z
Permittee's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name:
Signature: f Date:
FORM: LOA 06-16
Page 3 of 3

State of North Carolina
DWR
Department of Environment and Natural Resources
Division of Water Resources
Divislon 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 Applicant shall submit one original and two co ies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge 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 .1 100. 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. Lan caner Agreement (FORM: LOA 06-16):
tA 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
plication 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
pplicant.
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: ©
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 Special note
Intended Use of Crops Residuals Source
(yes/no) Cropping Patterns p (optional) (no-tiNlover-seed/
f( pasture)
x.xe ,auuuwner 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
Page 1 of 3

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 sites) 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 II) 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.
11. 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 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 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.
III. 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 .0I05(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)
L1A 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)
FORM: LOA 06-16 Page 2 of 3

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. 1 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 Pennittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name:`
Address:
City: State:
• Zip:
Phone: E-mail address:
f Signature:
Date: '� _ a t 1 _ _1), l
1 j
NORTH CAROLINA, C h 4, , COUNTY
1, the undersigned Notary Public do hereby certify that �t k r
personally appeared before me this day and acknowledged the due execution of the forgoing instrumFOB.
.�
WITNESS my hand and official sea[ this the
day of \ ) J
U► { , 20 2
G
Signature and seal: jr y✓ L f�
My commission expires:. �C:f 0� i�FL L co—,
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name: R m� 5 �1p�Or
Address:
F ,J
City: 5� 1- 61 C _ State: L Zip: ,2 7ot
Phone:E-mail address: ll
Signature:T Date:
Permittee's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name:
Signature: Date: $
U
Z
FORM: LOA 06-I6
Page 3 of 3

State of North Carolina
Department of Environment and Natural Resources
D-W, R
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 Applicant shall submit one on inal and two Copies of the application and
supporting documentation
For mare information, visit the Water Quality Permitting Section's Nora -Discharge Permitting Unit
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class S residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T A 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. La Owner Agreement (FORM: LOA 06-16):
b4 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
plication may be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
10 Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
pplicant.
A copy of the completed and appropriately executed agreement must be provided to the landowner and the Iessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: f o - ✓fx Iw , y�
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:
Lease Land Use or Special note
Site/Field IA Intended Use of Crops Residuals Source
(yes/no) Cropping Patterns p (optional) (no-till/over-seed/
pasture)
��j �J a f`U✓ to l��t,;++a
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
Pagel of 3

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 II) 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 Permittec.
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.
& 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 time 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 Permittec 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,
II. 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 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 laud 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,
III. 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 marls 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)
U4re-defined compliance boundary is not needed for this site.
IV. ACI'LNOWLEDGEMENT 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 froze the previously permitted residuals land application program and transferred
into the new uroj�ram;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

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.
Landownername: p�� ^'BLS �5, 1_0yy
Address: � � (� J0, K-C.
City: 5�'Y�C 1 State: I`N`C- Zip: -7Dt<(
Phone: h " E-mail address:
Signature: Date:
NORTH CAROLINA, �� �!n COUNTY
I, the undersigned Notary Public do hereby certify that _5� V4 o'�o���°,l�tW'
personally appeared before me this day and acknowledged the due
execution of the forgoing instruflion ter
WITNESS my band and official seal this the
day of L4 , 20
Signature and seal: Lj. +� 4 O��°��
My commission expires:��`
Lessee's/Operator's Certification:
I 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:
State:
E-mail address:
Date:
Zip:
i certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name: J44013 ���.•-
Signature: Date: Fla-g' d-k
FORM: LOA 06-16 Page 3 of 3

State of North Carolina
DWR
Department of Environment and Natural Resources
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. Unless otherwise noted the Applicant shall submit one on inal and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non-Dischar e Pernaittin Unit
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class S 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. La 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 Iong 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.
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: Qd` +y�
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:
S l id R
Lease Land Use or Residuals Source Special note
Site/Field ID Intended Use of Crops n P
(yes/no) Cropping Patterns {optional) { o-tilllover-seed/
pasture)
i ne ianaowner or nis 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
Page 1 of 3

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 II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1636
Mail Service Center, Ralelgh, 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.
S. 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 wlll 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.
II. 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 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 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.
1:1I.A.LTERNATIVES 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-cstablished 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)
IA 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)
FORM: LOA 06-16
Page 2 of 3

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 Iand 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. i I I _ ,
Landowner name:
Address: 2 7v c) �-,m L,_
City: ad-� �`kiv State: JV Zip: -7d[
Phone: 3 - (AL, E-mail address:
Signature: KDate: _ r a l— 2 4
NORTH CAROLINA, 6i h COUNTY
I, the undersigned Notary Public do hereby certify that 6n/ -Ak !-t,oyJ A %%lilt I Itito"r,
personally appeared before me this day and acknowledged the due execution of the forgoing instrumerr�
WITNESS my hand and official seal this the OT r
day of y 120 1 t
Signature and seal: W
My commission expires;
Lessee's/Operator's Certification:
;�tll
co
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name: t Ivy
Address:�A4 ,._
City: ��S(n �� _ State: !� _ zip:' l
CK
Phone: - LlP ` E-mail address:
Signature: Date: _
Permittee's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name: 1a C"t 6 ! :
Signature: Date:
FORM: LOA 06- l6 Page 3 of 3

Q
Z
APPLICATION MAP
Legend
APPLICATION AREA ■ ONSITE HOUSE
PROPERTY LINE OFFSITE HOUSE
WATER SOIL DESCRIPTION
DRAIN ® UNSUITABLE AREA
1 inch = 660 feet
Fe et
0 155330 660 990 1,320
SOL-
The compliance boundary is established at
either 250 feet from the residuals application
area or 50 feet within the property boundary,
whichever is closest to the application area.
The review boundary is established midway
between the compliance boundary and the
perimeter of the residuals application area.
All locations are approximate,
NC-YK-33
Fields 1-3

x
NC-Yf<-33
Fields 1-3
SO�L SURVEY
1 inch � 5oo feet
D 130 260 520 780 1,040
Feet
All locations are approximate.

NCW 1 K-33
Fields 1-3
1 'inch = 667 feet
Feet
0162.S25 650 975 1,300
Ail locations are approximate.

VICINITY MAP
c
.. , ' $ . Far•er silavtl � - �I :Nsr - —.... --
9�a fn
w
C�I�IM�eon�l
Ria, If
-011 Fl.,sur*• �
i.`tr.52 F'Id
Giti2 "�eQfl'7
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n
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r
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sr
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i -
n,
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hfr
rc,
h
- ' - - ~fie A�• - _
4 r Sources: Esri HER , Garmin, OSGS, Intermap, INCREMENT P,
NRCan, Esri Japan, METI, Esri China (Hong Kong), Esri Korea,
Esri (Thatland), NGCC, © OpenStreeffap contiibutorsr and the
GIS UserCammunity
1 inch — 3,333 feet
N C-Y K-3 3 Feet
0 80[L,600 3,200 4,800 6,400
Fields 1-3
All locations are approximate_

KFERSHID MAP
NT
` '' s I 1 r• �'t � If a r' � . 1 -t S
f�\L��� • -i �� 3 i...; ! ' '-�d t-""yam
ir �' �-',, �. "y ' w, '. •$, ' ;y �� r''�,� ,5 � ter. j T�
�c•.�d Imo.+" ;(± w �
NC-YK-33
Fields 1-3
Q
1 inch = 2,000 feet
Feet
0 485970 1,940 2,910 3,880
All locations are approximate.

a

a
z
a
APPLICATION MAP
The compliance boundary is established at
either 250 feet from the residuals application
area or 50 feet within the property boundary,
whichever is closest to the application area.
The review boundary is established midway
between the compliance boundary and the
perimeter of the residuals application area.
All locations are approximate.
0 0.0275 0.055 0.11 Miles
Legend I —I I I ii —I
—h
O Soil
d A A Application Area
® Residential Buffer/ Property Line Buffer
® Onsite
■ Offsite
® well
Property Boundary
NC-YK-33
Field-4

YJ
SOIL MAP
The compliance boundary is established at
either 250 feet from the residuals application
area or 50 feet within the property boundary,
whichever is closest to the application area.
The review boundary is established midway
between the compliance boundary and the
perimeter of the residuals application area.
All locations are approximate.
6 0.0225 0.045 0.09 Miles
NC-YK-33
Field-4

. j
U
TOPOGRAPHY MAP
}
f r!�
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• i
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• I'I
t���
f
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F
NC-YK-33-4 0 0.075 0.15 0.3 Miles

VICINITY MAP
NC-YK-33-4 0 0.175 0.35 0.7 Miles

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Waypoint.0
ANALYTICAL
8/17/2021
Synagro Central LLC/ Yadkinville
Mary Brewer
284 Boger Road
Mocksville, NC, 27028
Ref: Analytical Testing
Report Number: 21-222-0005
Project Description: James Hobson
7621 Whitepine Road, Richmond, VA 23237
Main 804-743-9401 ° Pax 804-271-6446
www.waypointanalytical.com
Dear Mary Brewer:
Waypoint Analytical Virginia, Inc, received sample(s) on 8/10/2021 for the analyses presented in the following
report.
The above referenced project has been analyzed per your instructions. The analyses were performed in
accordance with the applicable analytical method. Sub -contracted testing is noted on the Sample Summary Table
if applicable.
The analytical data has been validated using standard quality control measures performed as required by the
analytical method. Quality Assurance, method validations, instrumentation maintenance and calibration for all
parameters (NELAP and non-NELAP) were performed in accordance with guidelines established by the USEPA
(including 40 CFR 136 Method Update Rule May 2012) and NELAC unless otherwise indicated.
Certain parameters (chlorine, pH, dissolved oxygen, sulfite...) are required to be analyzed within 15 minutes of
sampling. Usually, but not always, any field parameter analyzed at the laboratory is outside of this holding time.
Refer to sample analysis time for confirmation of holding time compliance.
The results are shown on the attached Report of Analysis(s). Results for solid matrices are reported on an as -
received basis unless otherwise indicated. This report shall not be reproduced except in full and relates only to
the samples included in this report.
Please do not hesitate to contact me or client services if you have any questions or need additional information
Sincerely,
TOLW,'c Mt �f"O"r
Pauric McGroary
Agronomist
Laboratory's liability in any claim relating to analyses performed shall be limited to, at laboratory's option, repeating the
analysis in question at laboratory's expense, or the refund of the charges paid for performance of said analysis_
Page 1 of 5

Waypoint.0
ANALYTICAL
7621 Whitepine Road, Richmond, VA 23237
Main 804-743-9401 ° Fax [phone]
www,waypointanalytical.com
Sample Summary Table
Report Number: 21-222-0005
Client Project Description: lames Hobson
Lab No Client Sample ID
Matrix Date Collected Date Received Method Lab ID
77413 4 Solids 08/10/2021 SW-7471B WP MTN
WP MTN - Memphis, TN: Waypoint Analytical - TN, Memphis, TN
Page 2 of 5

Waypoeint(D
ANALYTICAL
46507
Synagro Central LLC/ Yadkinville Project
Mary Brewer
284 Boger Road Information
Mocksville , NC 27028
Report Number : 21-222-0005
Lab No : 77413
Sample ID : 4
Test
Mercury
7621 Whitepine Road, Richmond, VA 23237
Main $04-743-9401 ° Fax [phone]
www.waypointanalytical.com
James Hobson
REPORT OPANAL YSIS
Results Units MOL
0.0747 mg/Kg 0.0135
Report Date : 08/17/2021
Received : 08/10/2021
Q
Pauric Mc Groary Ph.D., CPA
Agronomist
Matrix: Solids
Sampled:
DF Date / Time By Analytical
Analyzed Method
1 06/16/2117:01 TJS SW-7471B
Qualifiers/
Outside QC Limit
B
Analyte detected in blank
Definitions C
GCMS Confirmation Analysis
B
Result above cal range
g
GGA Outside QC Limits
H
Beyond holding time
J
Estimated value
M
Minimum value
NA
Not on Scope of Accreditation
NC
Not confirmed
Q
RPD >40% dual column results
T
Sample exhibits toxicity
Page 3 of 5

s G
Waypoint
ANALYTICAL
7621 Whitepine (toad, Richmond, VA 23237
Main 804-743-9401 ° Fax [phone]
www.waypo inta n alytica Isom
Shipment Receipt Form
Customer Number: 46507
Customer Name: Synagro Central LLCI Yadkinvilie
Report Number: 21-222-0005
Shipping Method
0 Fed Ex 0 US Postal 0 Lab
UPS 0 Client 0 Courier
j Other:
Thermometer ID:
Shipping container/cooler uncompromised?
0 Yes
0 No
Number of coolers/boxes received
F 1
Custody seals intact on shipping container/cooler?
0 Yes
0 No
Not Present
Custody seals intact on sample bottles?
0 Yes
0 No
Not Present
Chain of Custody (COC) present?
Yes
0 No
COC agrees with sample label(s)?
Yes
0 No
COC properly completed
Yes
0 No
Samples in proper containers?
Yes
0 No
Sample containers intact?
0 Yes
0 No
Sufficient sample volume for indicated test(s)?
Yes
0 No
All samples received within holding time?
Yes
0 No
Cooler temperature in compliance?
0 Yes
No
Cooler/Samples arrived at the laboratory on ice.
Samples were considered acceptable as cooling
process had begun.
0 Yes
No
Water - Sample containers properly preserved
0 Yes
0 No
N/A
Water - VOA vials free of headspace
0 Yes
0 No
# NIA
Trip Blanks received with VOAs
Soil VOA method 5035 —compliance criteria met
High concentration container (48 hr)
High concentration pre -weighed (methanol -14 d)
Special precautions or instructions included?
Comments:
0 Yes 0 No 0 NIA
0 Yes 0 No N/A
Low concentration EnCore samplers (48 hr)
Low conc pre -weighed vials (Sod Bis -14 d)
0 Yes n No
Signature: Brand! Watson date & Time: 08/10/2021 10:10:27
Page 4 of 5

Zro O7
Cr
6A
ID
cr
RC
Im
0
0
0
Mm
MF
�w
Page 5 of 5

State of North Carolina
DWR
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 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 Permitting 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 A 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. La_yd 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.
repare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
pplicant.
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 rep
Applicant's name: _ 7-y ti/s1
herebypermits:its:
Lkh-r'n✓l1le-
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
es/no
(Y }
Land Use or
Cropping Patterns
PP� g
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
�!
Y! '
r
f 1'e
4
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 Pagel of 3

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 sites) 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 NCDFNR-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 time 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 sitc(s) prior to each planting season to enable the Permittec 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; talce necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
II. 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 fallowing a residuals laud 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 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 laud
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-mouth period following a residuals land application event.
III, 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 fields) 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)
Its° r'e-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)
FORM; LOA 06-16 Page 2 of 3

Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced Iand 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: / 6,;2, % C f- h G 04 1-- h,
City: J_-' 4, .� t- 0 GA d State:
W G
Zip:%d/k
Phone: 3 ,34/- '% ��s �+ E-mail address:
Signature: if-, Date: �` d
NORTH CAROLINA, 4�r4 A, -­1 COUNTY
I, the undersigned Notary Public do hereby certify that 'rt` DAVV
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the �� ♦���,,'`Wt I
day of 120.
Signature and seal:
ff
My commission expires: 9�L �k 19J4
Lessee's/Operator's Certification: "f 111
I 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:
State:
E-mail
Date:
W
1 certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name: a.eo r .7e-+h%
Signature: Date --
FORM: LOA 06-16 Page 3 of

FILED
YADKIN COUNTY NC
ARIC WILHELM
REGISTER OF DEEDS
FILED
Aug 25, 2021
AT
03:32:08 pm
BOOK
01330
START PAGE
0708
END PAGE
0709
INSTRUMENT # 03942
EXCISE TAX
(None)
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE RESIDUALS MANAGEMENT PROGRAM WAIVER
FOR THE APPLICATION OF CLASS D RESIDUALS
AGREEMENT TO WAIVE SETBACKS PURSUANT TO
15A NCAC 02T .1108(c)
1, -69%)
4,
7 % A464�if�yrthafl am a deeded owner of the property located at:
Address: '-/ i 21 ) Parcel No.: 1S6 9 '14 VD\
City: F,HTT 6, State: NC Zip Code: 01 S Colmty: jL
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 Applicani/Permittee listed on the following
page.
I1 or the parcel identified above, I consent to a reduced setback from 50 feet to 0 feet, thereby
allowing the application of Class B residuals as near as 0 feet from my property line.
I{ar the parcel identified above, I consent to a reduced setback from 400 feet to 100 feet,
thereby allowing the application of Class B residuals as near as 100 feet from my residence.
**TINS WAIVER SHALL BE TERMINATED UPON CHANGE OF OWNERSHIP OF ANY PARTIES INVOLVED**
Signature:
FORM: NDRMPW-LAS 11-18 Page I of 2

Permittee
1690
Address:
r.,^ J X 14,14
xe- V
Permit No.: a aoi)riot
CityukL✓�� tate: ✓V�— Zip Code:7_7vCounty:
NORTH CAROLINA, �& J'(` n COUNTY
I, A, —,a Notary Public for �r� �� 1 f County, North Carolina,
do hereby certify that /L4 L e o i � IINS personally appeared before me this day
and aclmowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the -7 day of L r L Z t,,_.
%l10
lilllll
SEAL
00r,r
rsf�IfIIN
Signature of Notary Public
My commission expires 0 CJ ZZ, 2w_q
Once notarized, this form shall be recorded at the Register of Deeds in the county or
counties in which the described properties are located. A copy of the recorded waiver
shall be sent to the following address:
Division of Water Resources
Non -Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDRMPW-LAS 11-18 Page 2 of 2

FILED
YADKIN COUNTY NC
ARIC WILHELM
REGISTER OF DEEDS
FILED Aug 26, 2021
AT 03:33:02 pm
BOOK 01330
START PAGE 0710
END PAGE 0711
INSTRUMENT # 03943
EXCISE TAX (None)
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE RESIDUALS MANAGEMENT PROGRAM WAIVER
FOR THE APPLICATION OF CLASS D RESIDUALS
AGREEMENT TO WAIVE SETBACKS PURSUANT TO
15A NCAC 02T .1108(c)
I,� ��/ �i��fil S vT LF. , , certify that I am a deeded owner of the property located at:
Address: Y5 2_7 /7'"ir-� ParcelNo.: I S6Q-7O
City: 'aJ i State: NC Zip Code: County: ��/'irf
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.
For the parcel identified above, I consent to a reduced setback from 50 feet to 0 feet, thereby
allowing the application of Class B residuals as near as 0 feet from my property line.
For the parcel identified above, I consent to a reduced setback from 400 feet to 100 feet,
thereby allowing the application of Class B residuals as near as 100 feet from my residence.
**THIS WAIVER SHALL BE TERMINATED UPON CHANGE OF OWNERSHIP OF ANY PARTIES INVOLVED"
S
FORM: NDRMPW-LAS 11-18 Page 1 of:2

Permittee: O 4✓n ©�
Address Fia rr„� wPermit No.: `✓C7,Qpo l$no
City: gJklhak�tate: AID' Zip Code: 21a'_SCounty: �A l k1v\
NOR H CAROLINA, i y Grn COUNTY
1-1
f, �� tj Yn ^4 , a Notary Public forr,. �f County, North Carolina,
do hereby certify that. t"" 5 4 �P'spersonally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the -7 dayof
0911111°°
W PO °err
SEAL ,��*� Q- o.• �,.
1 �
PU
°°1114 111101%
Signature of Notary Public
My commission expires --a Ll
Once notarized, this form shall be recorded at the Register of Deeds in the county or
counties in which the described properties are located. A copy of the recorded waiver
shall be sent to the following address:
Division of Water Resources
Non -Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDRMPW-LAS 11-18 Page 2 of

APPLICATION MAP
Lend
The compliance boundary is established at
APPLICATION AREA
ONSITE HOUSE
either 250 feet from the residuals application
PROPERTY LINE
OFFSlTE HOUSE
area or 50 feet within the property boundary,
whichever is closest to the application area.
WATER
WELL
The review boundary is established midway
!•-�- STREAM
O
SOIL DESCRIPTION
between
between the compliance boundary and the
-- DRAIN
®
UNSUITABLE AREA
of the residuals application area.
All locations are approximate.
1 inch = 660 feet
NC-YK-35
Feet
0 165 330 660
990
1,320
Fields 1-2

TOPOGRAPHIC MAP
I inch - 667 feet
NC-YK-35 Feet
Fields 1-20162,925 650 975 1,300
All locations are appraxiMate.

9
VICINITY MAP
AV. r
S g c
ra
m
', t GG a Yti a
n t CiO"J
� 6
z i _
`br---.r3rec-rnIr-
_� o
! � a
East Bend
-_E NC G7"'Qhv.aY
t
E i O aaf
It _.
+ ! O
i —
n
A
eret y -. l Rtl
C {1
9
O ,
O
A
iiO _
4
£ v
O
" FAAIH.
`L¢
_ _ O
Sources: Esri, HERE, Garmin, USGS, intermap, INCREMENT P,
NRCan, Esri Japan, METI, Esri China (Hong Kong), Esri Karea,
_ Esri (Thailagd), NGCC, Q OpenStreetMap contributors, and the
H sr GIS UserCoanmunity
� I �._Y K-3 5 1 inchFeet '083 Feet
f �! 0 50Q,000 2,000 3,000 4,000
Fields 1-z
All locations are approximate.

WATERSHED MAP
rim
s
Q � i f • " :sue,! �/f f' -� 'i i � s� � s /` `,`�
k+ r-! ?;�-.. i,�-'I - "'t ems � z,`• •� t�-" �
999.•.•
3 Ok
I it
NNZ
1'
0
1� � � t•I''i [:.�.�. -�'�! � ., �', ��', �r -y' ;fir• -
-f 5�• v;j
n �i ! t �'✓I3 � J�� ♦ l�� - I 3 e I i�`�- �+'ir4.,,��rr-Y,�L�j'� - ���.�' s ,f �, _
✓) y ! f % ~- .fit Sal "a, - - ;� F• 4 a �:2
.
_�� ,. �^ �`rC, �- �.�, +� �� ;� •� f Co�p�fugth# 2Q�3..�ational�GeographieS-oc�ety,
1 inch = 2,000 feet
NC- I K-35 Feet
Fields 1-2 0 485970 1,940 2,910 3,880
All locations are approximate.

a
z
V7
APPLICATION MAP
The compliance boundary is established at
either 250 feet from the residuals application
area or 50 feet within the property boundary,
whichever is closest to the application area.
The review boundary is established midway
between the compliance boundary and the
perimeter of the residuals application area.
All locations are approximate.
Legend 0 0.0375 0.075 0.15 Miles
Streams Property Boundary
C� Soil ® Onsite
A —AA Application Area
■ offsite
® Well
® Residential/ Property Line Buffer & Unsuitable Area
NC-YK-29
Field-2

U R
'Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
COUNTY BOARD NOTIFICATION
INSTRUCTIONS FOR FORM: CBN 06-16
Please use the following instructions as a checldist 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 other 'se noted the Ap licant shall submit one on -a and o cop!
sues of the a lira 'on and
supporting documentation
For more information, vlsittheWater Quality Permitting Section's Non-Disclaar ePerarytiltin Unit
General — This notification is intended to provide the county board in which the land application site is proposed to be located with
general information on the size, location and type of residuals land application proposed to occur in their county, and to give them an
opportunity to comment on the pending permitting request as stipulated in Session Law 2013-340. Notification is not required for
fields deemed permitted to receive Class A residuals under l5A NCAC 02T .1100. Do not submit this document for review
without a corresponding residuals program application form (FORM: RLAP 11-15),
Unless otherwise noted,the Applicant shall submit one original and two copies ofthe application and supporting documenta tio n listed
below,
A. County Board Notification (FORM. CBN 11-15):
® Submit the completed and appropriately executed County Board Notification(FORM: CBN11-15). Pleasedonotmalceany
unauthorized content changesto this form, If necessary for clarity orducto spa ev restrictions, attachmentstothe form may
be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
® Prepare a separate County Board Notification (FORM: CBN 11-15) for each county in which the proposed land application
sites are located.
B. Critical Watershed Areas Information:
® Under l5A NCAC.' 02B .0212, no new permitted sites for land application of residuals are allowed within critical watershed
areas. It is the Applicant's responsibility to ensure that the proposed land application sites are not located within these a yeas.
® For more information regarding Water Supply Watershed Protection Program, please visit the Division website at:
htt s://de .nc. ov/about/divisions/water-resources/water-resources-niles/wa---ply-watershed- rotection- ro ni
❑ If uncertain about whether the proposed sites are located within the critical areas, contact the Division or call [phone].
C. Notification Package Submission:
® Complete and mail the notification letter, source facility summary, land application site summary, and site location maps to
the appropriate County Board by certified mad with a return receipt requested. It is recommended that a copy of the
notificationpackagealso be sent to the County Manager.
® The most current publication of the Directo1y of State and County Officials may be downloaded at:
httDs:/Iwww.sostic. ov/ ublications/dii,ect.as x
® A list of the Division's regional offices, their county coverage, and their contact information may he downloaded at:
htt>://de .rrc. ov/contact/re 'Dual -offices,
The source facility summary shall include: facility name; county where it is located; and the proposed annual dry tonnage
(i.e., a copy of"Residuals Source Facility Summary" is adequate but not required).
The land application site summary shall include: field ID; acreage; county where it is located; latitude and longitude (i.e., a
copy of"Land Application Site Certification" is adequatebut not required),
D. Proof of Submission:
® Attach an 8.5 by I I -inch copy of the return receipt to the back of this attachment rior to submission of the applica tion to the
Division for review.
INSTRUCTIONS FOR FORM: CBN 06-16
Page I of I

North Carolina Department of Environmental Quality
Pat McCrory
Governor Donald R. van der Vaart
Secretary
Date: 8/19/21
To: Name of Chairman to the Board of County Commissioners; Kevin Austin
Complete mailing address: 2100 Hoots rd
City: Yadkinville State: NC Zip: 27055
County where land application sites are located: Yadkin
From: Applicant's name: Town of Yadkinville Submitted by Synagro (on behalf of the Division of Water Resources in
accordance with Session Law 2013-340)
Contact person and title: Alex Fox TSS Synagro LLC.
Complete mailing address: 284 Boger Rd
City: Mocksville State: NC Zip: 27028
Telephone number: (704-881-3429) E-mail address: afoxpsynagro.com
Subject: Notification of residual land application site proposal
This is to notify you that the Applicant listed above will be submitting an application to the Division of Water
Resources for the land application of residual solids to site(s) located in your county, During this review, the Division
will ensure that all federal and state regulations are enforced. Attached to this form is information regarding residuals -
generating sources and locations of the proposed land application sites. Please forward this letter and its associated
attachments to the appropriate Department within your County (i.e., Health or Environmental Health Department and
Planning Department) if applicable.
More information of the land application sites included in this application will be available at the following
Division of Water Resources Regional Office:
Name of appropriate regional office: Winston Regional office
Complete mailing address: 215 N Main strect
City: Winston-Salem State: NC Zip: 27155
Telephone number: (EDO) 827-1000
Expected date of application submission: 8/26/21
Should you desire to comment on this application, please do so no later than 3 0 calendar days fo Mowing the
expected application submission date. If you have any questions or comments about this notification, or if you would like
more information, please contact the appropriate regional office at the telephone number provided above. Thank you in
advance for your attention to this matter.
Enclosures: Source Facility Summary
Land Application Site Summary
Maps
Non-Dischargo Permitting Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Phone [phone]tiIrleinet:ht :JJorlal,ncdenr.ar hvebhx
Are Equal Opportunity 1 Atf rma live Action Employer —Made in p art %%flh recycled paper
FORM: CBN 06-16

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Proof of Delivery
Dear Customer,
This notice serves as proof of delivery for the shipment listed below.
Tracking Number
1Z51F78W2210006718
Service
UPS Next Day Air/UPS Express
Delivered On
08/23/2021 9:20 A.M.
Delivered To
YADKINVILLE, NC, US
Received By
ASHER
Left At
Inside Delivery
Thank you for giving us this opportunity to serve you. Details are only available for shipments delivered within
the last 120 days. Please print for your records if you require this information after 120 days.
Sincerely,
UPS
Tracking results provided by UPS: 08/24/2021 9; 47 A.M. EST