WQ0043099_Application (FTSE)_20211222

C}HILDRESS WINERY, LLC
1000 ChQdrewVLvteyard s, LLC
Ler2vtgto-w, NC 27295
Mr. Alex Lowe
NC DWR
450 West Hanes Mill Road , Suite 300
Winston Salem, NC 27105
Win sin n-Sa le ni
Regional Office
Subject: Delegation of authority for Mr. Steve Hartzog to represent Childress Winery LLC and to sign the
necessary papers for the Fast Track Form (FTA 06-21) for the new waste water line noted in the
application.
Dear Mr. Lowe,
It is my intent that Mr. Hartzog represent Childress Winery LLC with regards to the subject project.
Please allow him to sign in my behalf.
Sincerel
Richard Chil. -ss

KALE ENGINEERING
3550 Vest Mill Road
WINSTON SALEM, N.C. 27103
PROPERTY SURVEYS
CONSTRUCTION SURVEYS
DESIGN OF ROADS AND STREETS
WATER AND SEWAGE SYSTEMS
SUBDIVISION PLANNING & LAYOUT
Mr. Alex Lowe
NCDWR, Winston Salem Office
450 West Hanes Mill Road, Suite 300
Winston Salem, NC 27105
336-768-0250
email kaleengr(a3belisouth..net
December 22, 2021
MEMBERS OF
NATIONAL SOCIETY OF
PROFESSIONAL ENGINEERS
AMERICAN CONGRESS OF
SURVEYING AND MAPPING
Department of
Environrrmentnl Quality
i 2 2821
`ilir istori-:5;TIE in
l c ioiial Office
Subject: Fast Track Application For the Childress Winery LLC located at 1000 Childress Vineyard Road.
References: 1. Fast Track Permit Form SFTA 06-21 is being used for this project. Modified permit from
NCDWQ.
2 Marked up Davidson County GIS photo showing the new sewer line and various buildings
at Childress Winery LLC at 1000 Childress Vineyard Road.
3. Company representative for Childress Winery LLC is Steve Hartzog (336-460-2976).
4. The WWTF Permit Number for pipe placed in 2004 is NC0055786 for City of Lexington
Waste Water Facility.
5. ChildressWinery LLC is registered to do business in NC. See number 0644898 dated
09/10/2002. See Attachments.
6. Letter designating Steve Hartzog as representative. See attachment.
7. NCGS map showing location.
This letter serves as the cover letter for the subject application for the new sewer line to be constructed at
the Childress Winery LLC located at 1000 Childress Road. Given below is a brief narrative for this
project.
This project will consist of constructing 1500'+- of new 4" and 6" Schedule 40 Core Foam Pipe to take
waste water from the san sewer lift station at the winery to the Swearing Creek Outfall. This new pipe is
being installed to replace the pipe placed in 2004 and to eliminate the need for the pump station. This new
pipe being placed will be gravity flow only to Swearing Creek Outfall. Waste water will continue to flow
into the pump station, but will not be pumped out. It will exit the pump station by gravity flow to the
Swearing Creek Outfall. The out fall goes to City of Lexington Waste Water Facility. See the reference 2
marked up GIS Photo. This is an economic decision based on the cost of maintaining the pump station.
The amount of waste water going into the pump station will not be changed. No new buildings are being
added. The amount of waste water shown on the reference 4 form will not be changed. The quantities
shown are the same quantities given earlier.
This new line was permitted by the Davidson County plumbing department and is already under
construction. Thus far 75' +- of 4" line and 125'+- of 6" line has already been installed. This new pipe
was connected to the invert (lowest point) inside the existing pump station with the invert of the new 4"
pipe matching the invert of the lowest pipe that empties into the pump station. The waste water will gravity
flow from the invert of the pump station. The pump station will remain in place, but it will not be used to
pump the wastewater.
The end of the new 6" pipe is located 200'+- from the lift station and the invert elevation of the new pipe is
2' lower than the invert of the lift station and 6'+- below the surface of the ground. The line is also located
12'+- West of the centerline of the existing gravel driveway leaving the lift station and going Northward
from the lift station. The new line placed thus far has been placed on 1/8" per foot, which is 1%.

PROPERTY SURVEYS
CONSTRUCTION SURVEYS
DESIGN OF ROADS AND STREETS
WATER AND SEWAGE SYSTEMS
SUBDIVISION PLANNING & LAYOUT
KALE ENGINEERING
3550 Vest Mill Road
WINSTON SALEM, N.C. 27103
336-768-0250
email kaleengr@bellsouth..net
MEMBERS OF
NATIONAL SOCIETY OF
PROFESSIONAL ENGINEERS
AMERICAN CONGRESS OF
SURVEYING AND MAPPING
I hope this helps explain this project. If you have any questions, please do not hesitate to call me at 336-
768-0250. We are always glad to hear from you.
Sincerely,
andall G. Kale
Kale Engineering
336-768-0250

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: (to be completed by DWR)
All items must be completed or the application will be returned
L APPLICANT INFORMATION:
1. Applicant's name: ChildressWinery LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal X Other
3. Signature authority's name: Steve Hartzog per 15A NCAC 02T .0I06(b)
Title: Company Representative
4. Applicant's mailing address: PO Box 398
City: Welcome State: NC Zip: 27374-0398
5. Applicant's contact information:
Phone number: [phone] Email Address: shartzog(Wcrracing.com
II. PROJECT INFORMATION:
I. Project name: Childress Winery
2. Application/Project stank: ❑ Proposed (New Permit) x Existing Permit/Project
If a modification, provide the existing permit number. WQ00 and issued date:
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: W000
3. County where project is located: Davidson
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.84301 ° Longitude: -80..28310°
5. Parcel ID (if applicable): 6719-04-845329 (or Parcel ID to closest downstream sewer)
IIL CONSULTANT INFORMATION:
1. Professional Engineer: Randall G. Kale License Number: 1.0748
Firm: Kale Engineering P.0
Mailing address: 3550 Vest Mill Road
City: Winston Salem State: NC Zip: 27103-
Phone number: (336)768 -0250 Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: City of LexingtonWaste Water Facility Permit Number: NC0055786
Owner Name: City of Lexington
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
L Permit Number(s): WQCS00042
2. Downstream (Receiving) Sewer Information: 15 inch X Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCSCS00042
Owner Name(s): City of Lexington
FORM: FTA 06-21
Page 1 of 5

GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes 0 No X N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes 0 No X N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes 0 No X N/A
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned)
❑ Residential. (Leased)
❑ School / preschool. / day cam
X Food and drink facilities
0 Businesses / offices / factories
❑ Retail (stores, centers, malls)
Retail with food preparation/service
❑ Medical / dental / veterinary facilities
❑ Church
❑ Nursing Home
❑ Car Wash
X Hotel and/or Motels
❑ Swimming Pool/Clubhouse
❑ Swimming Pool/Filter Backwash
X Other (Explain in Attachment)
Winery
5. Nature of wastewater : % Domestic % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? 0 Yes ❑ No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(f)? 0 Yes ❑ No
➢ If yes, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(0)
Daily Design Flow',h
No. of Units
Flow
winery
625 gal/day
1
625 GPD
Winery processing
1,000 gal/day
1
1,000 GPD
Hotel
9,600 gal/day
1
9,600 GPD
Resturant
1,200 gal/day
1
1,200 GPD
gall
GPD
gal/
GPD
Total
GPD
a See 15A NCAC 02T .0114(b) (d) (e)(1) and (e)(2) for caveats to wastewater deign flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use
areas; and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals
as defined in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.0114] shaft
be determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 0 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
if permitted flow is zero, please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: NC0055786 Issuance Date: 10/22/03
X Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 06-21
Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
I. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
4
75
PVC
6
1425
PVCC
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
VIM PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: - . °
3. Total number of pumps at the pump station:
3. Design flow of the pump station: millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): gallons per minute (GPM) at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(I):
❑ Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B);
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the
station.
FORM: FTA 06-21 Page 3 of 5

'➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be
provided as part of this permit application in the case of a multiple station power outage.
FORM: FTA 06-21 Page 4 of 5

jX. `SETBACKS & SEPARATIONS — (02B .0200 & ISA NCAC 02T .0305(f)):
1. Does the project comply with all separations/alternatives found in I5A NCAC 02T .0305(f) & (a)?
15A NCAC 02T.0305(f1 contains minimum separations that shall be provided for sewer systems:
❑ Yes ❑ No
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
2Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
2Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**My other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical) k
36 inches
➢ If noncompliance with 02T.0305(f) or (g) see Section X.I of this application
*15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
2. Does this project comply with the minimum sepaldtion requirements for water mains? ❑ Yes ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(0 for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ❑ Yes ❑ No ❑ N/A
> Please provide supplementary information identifying the areas of non-conformance.
> See the Division's draft separation requirements for situations where separation cannot be met.
> No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name: ❑ No
If yes, does the project comply with setbacks found in the river basin rules per I5A NCAC 02B .0200? ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 26.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ❑ No
or 401 Water Quality Certifications?
> Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ❑ Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ❑ No
Per 1 5A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval
> If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per ISA NCAC 02T.0403(aX5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 06-21 Page 5 of 5

CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria For the Permitting of Pump Stations
and Force Mains (latest version) and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
❑ Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrently with the approval of the permit, and projects requiring a variance approval may be subject to longer
review times. For projects requiring two or more variances or where the variance is determined by the Division to be
a significant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
I, , attest that this application for
(Professional Engineer's name from Application Item [II.1.) (Project Name from Application Item 1I.1)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track
Permitting of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain
portions of this submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this
material and have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the
application information, including failure to disclose any design non-compliance with the applicable Rules and design
criteria, may subject the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:
✓ I
1a/),-1
5®
a QiC? ��"F "p
SEAL
oa
urn
3. Applicant's Certification per 15A NCAC 02T .0106(b): �� /n /
I, attest that this application for �(� .-r (r G It SS W IMe/".yy 7 (-C-
(Signature A mrityN m Application Item I.3.) - (Project Name from Application Itemhf.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that 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 package 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 General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
SignatureI - I Date: /2- 2
FORM: FTA 06-21 Page 6 of 5

Parcel Number :
Pin Id :
Owner :
Property Address:
Township:
Building Value:
Land Value:
Assessed Value:
Randal! G Kole-
1000 Childress Vineyard Rd Ka Ie i neel ! Na
.33 7 8- ©moo
1133100000039
6716-04-94-6192
CHILDRESS WINERY LLC
P O BOX 398
WELCOME NC 27374-0398
1000 CHILDRESS VINEYARD RD
11
Land Units: 16.01 AP
Deed Book: I505 Pg: 0209
Deed Date:
Account Number:
Exempt Code:
$6,053,260 Other Building Value:
$700,440 Market Value:
S6,933,980 Deferred Value:
03/10/2004
9073866
$180,280
$6,933,980
S0

Red sn
• File an Annual Report/Amend an Annual Report • Upload a PDF Filing • Order a Document Online •
Add Entity to My Email Notification List • View Filings • Print a Pre -Populated Annual Report form • Print
an Amended a Annual Report form
Limited Liability Company
Legal Name
Childress Winery, LLC
Information
Sosld: 0644898
Status: Current -Active O
Date Formed: 9/10/2002
Citizenship: Domestic
Annual Report Due Date: April 15th
CurrentAnnual Report Status:
Registered Agent: Childress, Richard R.
Addresses
Mailing Principal Office Reg Office
1000 Childress Vinyard Rd 1000 Childress Vinyard Rd 1000 Childress Vinyard Rd
Lexington, NC 27295 Lexington, NC 27295 Lexington, NC 27295
Reg Mailing
1000 Childress Vinyard Rd
Lexington, NC 27295
Company Officials
AA LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20.
Manager/Member
Richard R Childress
9160 Hampton Rd
Lexington NC 27295

CA202114101590
'LIMITED LIABILITY COMPANY ANNUAL REPORT
�otm»
NAME OF LIMITED LIABILITY COMPANY: Childress Vineyards, LLC
SECRETARY OF STATE ID NUMBER 0644697 STATE OF FORMATION: NC
REPORT FOR THE CALENDAR YEAR: 2021
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: Richard R. Childress
2. SIGNATURE OF THE NEW REGISTERED AGENT:
fie-r J 13
SOSID: 0644897
Date Filed: 5121l2021
Elaine F. Marshall
North Carolina Secretary of State
CA2021 141 01590
SIGNATURE CONSTITUTES CONSENT MINE APPOP1TNENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
9160 Hampton Road PO Box 129
Lexington, NC 27295 Davidson Clemmons, NC 27012 Forsyth
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Cultivation of Grapes
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL
Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS 5. PRINCIPAL OFFICE MAILING ADDRESS
9160 Hampton Road ' PO Box 129
Lexington, NC 27295 Davidson Clemmons, NC 27012 Forsyth
6. Select one of the fallowing if applicable. (Optional see instructions)
❑ The company is a veteran -owned small business
❑ The ccrnpany is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: Richard R Childress
TITLE: Manager
ADDRESS:
9160 Hampton Rd
Po=mustbe
NAME:
TITLE:
NAME:
TITLE:
ADDRESS: ADDRESS:
Section D must be completed in its entirety by a person/business entity.
Oland gated under Section C er Tres rem.
Mpy LS, 202%
DATE
RiCttMk9 R CIAR_DRESS MANA GER
PritoTypeName ofCompanyOfficial - Rid crTipe Tie&Company OWnial
SUBMIT THIS ANNUAL REPORT WITH THE REQUIRED FILING FEE OF $200
MALTYk Secretary of State, Business Registration Division, Peat to eras 29525. Rated, NC 7I11260525

tl
triti
e
41. 1` .#: a - .I- ' t 0
.ffi at ii ii„ • 0 .
) ir.t
_. --
.,. .:ita4a -C
----- .
0
• ' a) # ,----.-
....-----'e”
•
•
li- • -"... ii.....--.--, - -,'-'7. • . ..,_. r
..r. , .. 4 ..N •
---.f.:„t_-----.-q.
.. E :-•',*1a:I.-' t
-r;;L
.
i1c3
.., t,,,_
it . -.4:-:. C)
, -
I.. , a )
at -. it V v' f ,4 e A t
-:-., • a 4 at- lif
a -r.
• 01
*--",:' F.,:sa-1 4 ii:
, - ci
ch"
•
ij
a f,
tt C--e
• onice. a
cy.
4. *
.er
`Is L