WQ0000520_Renewal Application Part 2_20220203

Non -Discharge Branch Upload/Submittal Form
NORTH CAROLINA
EnWrvnmemfal Qualify
Version 2 - Revised June 23, 2020
Initial Review
Reviewer
Thornburg, Nathaniel D
Is this submittal an application? (Excluding additional information.)*
Yes No
Permit Number (IR) * WQ0000520
Applicant/Permittee City of Burlington
Applicant/Permittee Address PO Box 1358 Burlington, NC27216
Is the owner in BIMS? Yes No Is the facility in BIMS? Yes No
Owner Type
Facility Name
County
Fee Category
Is this a complete application?*
Yes No
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Does this need review by the hydrogeologist?*
Regional Office
CO Reviewer
Admin Reviewer
Municipal
City of Burlington Class B Residuals Program
Alamance
Yes No
Fee Amount $395
Complete App Date 02/03/2022
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
Please provide information on the person to be contacted by NDB Staff regarding electronic submittal, confirmation of receipt, and other correspondence.
Name* Robert N Roth
Email Address*
[e-mail]
Project Information
Application/Document Type *
New (Fee Required)
Modification - Major (Fee Required)
Renewal with Major Modification (Fee
Required)
Annual Report
Additional Information
Other
Phone Number*
3364034324
Modification - Minor
Renewal
GW-59, NDMR, NDMLR, NDAR-1,
NDAR-2
Residual Annual Report
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: *
Permit Number: *
Wastewater Irrigation
Other Wastewater
Closed -Loop Recycle
Single -Family Residence Wastewater
Irrigation
WQ0000520
Has Current Existing permit number
Applicant/Permittee* City of Burlington
Applicant/Permittee Address* PO Box 1358 Burlington, NC27216
Facility Name* City of Burlington Class B Residuals Program
Please provide comments/notes on your current submittal below.
Part2of3
High -Rate Infiltration
Reclaimed Water
Residuals
Other
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 Plans, Specifications, Calculations, Etc.)
City of Burlington Renewal WQ0000520_Part2.pdf 239.33MB
Upload only 1 PDF document (less than 250 MB). Multiple documents must be combined into one PDF file unless file is larger
than upload limit.
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 1/31/2022

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, contra ctor, or other permitted entity. Furthermore, I certify that I have read this Agr eement,
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: Ut/ i CA G / % GAQ A.L
Address: k%v,L P/(pf fc N' / egi
City: _clrtw C State:
Phone: 3 3Cv - 0: 7rO d.)'
Ne-
zip:
E-mail address:
Signature: fr14
NORTH CAROLINA, pe\Q t1
I, the undersigned Notary Public do hereby certify tha
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
agth
WITNESS my hand and official sealthis the
day of tC? I
, 20 ea I
Signature and seal: IL04. }
My commission expires: ' aR 5 a (J
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/operatorname:
Address:
City: State: Zip:
Phone: E-mail address:
Signature: Date:
Permittee's Certification:
I certify that I have read this Agrrreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name: �V1Gt, rt
Signature: Date: 1/4/W
FORM: LOA 06-16
Page 3 of 3

Vicinity Map
1 in = 6,000 ft
Site: NC-AM-007; Fields 1-2
Feet
0 4,000 8,000
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1/10/2022
ALA MAN CE
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Site Location
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,Town of Cary, Alamance County,State of North -Carolina DOT, Esri, HERE,
Garmin, INCREMENT P, USGS, METI/NASA, NGA, EPA, USDA
/
City of
URLINGTON
Q.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Budington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspect_,
produce inconsistencies among features represented together on
this map. Neither the City of Burtington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-007; Fields 1-2
ty of
UR(L1INGTON
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
[=Site Boundary
0 Property Line
Application Area
Unsuitable
X — Fence
V/1
S.W.A.
. On Site House
111 Off Site House
ES Outbuildings
On Site Well
-0- Off Site Well
• Streams
Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
Application Area Map
1 in = 350 ft
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Budington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with feld surveys where required, must be consulted
for the verification of the information contained within this map.

January 19, 2022
Owner Name: TEAGUE MICHAEL CARLTON
Aamanae County GIS
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390 - TRAIL
391 - TRAIL
Preliminary Roads

Site: NC-AM-007; Fields 1-2
Soil Map
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GIS Division
Date: 1/10/2022
City of
URLINGTON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

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DENR FORM FSF (12/2006)

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Signature of Land Applier
DENR FORM FSF (12/2006)

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
Nj Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
E Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
11
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: City of Burlington
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)
NC-AM-8-1
No
Fescue
Hay/Pasture
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 landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section 11) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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 Permitter 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.
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, 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)
X 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

X
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 anothermunicipality, 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, and1 do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
x i
Landowner name: � K 44-4/4-d
Address: 11/
City:
Phone:
Signature: 414.0,
NORTH CAROLINA, f '2 on a e.e. COUNTY
6-ret (/t4vr�
371e-t.973
Zip: .2-701,5-3
State:
E-mail address:
Date:
/
(initials:%�) personally
appeared before me this day, and, being duly sworn, stated that in his/her presence ;"'"" "i f 5414' ' %. signed
the attached document and acknowledged the due execution of the foregoing instrument. St % ty
WITNESS my hand and official seal this the 1 3 AIN day of ..1ot et itt ay ,
20 Z2.
Signature and seal: f'
`� ccAA
My commission expires: De � ii "" 2-n 7JA
I, the undersigned Notary Public do hereby certify that ,she ve. 1 4 &k,e
Lessee's/Operator's Certification:
ROBERT N. ROTH
NOTARTPUBLIC
GUILFORn Cni 1NTv
STATE OF NORTH CAROLINA
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
a,Lessee/operatorname:
Address:
City: State: Zip:
Phone: 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 here in.
Signing official name: 5 i'l�'^� �l elc
Signature:` f,� Date: 2-// i
FORM: LOA 06-16
Page 3 of 3

Site: NC-AM-008; Field 1
Vicinity Map
1 in = 6,000 ft
AgtetiN
Feet
4,000 8,000
Legend
® Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
LNi
a '
Cary, Alamance County, State of North Carolina DOT, Esri, HERE,
Garmin, INCREMENT,P, USGS, METI/NASA, NGA, EPA, USDA
II City of
URLINGTON
—- G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-008; Field 1
CIPpmFee
140 280 420 560
CIty of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend ® S.W.A.
QSite Boundary ® On Site House
Q Property Line II Off Site House
4, % Application Area 1 I Outbuildings
V//f Unsuitable \ On Site Well
X — Fence -0- Off Site Well
• Streams
— Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
1 I
Application Area Map
l in = 400 ft
t
Disclaimer
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

c\I
z
coc
Owner Name: STALEY JIMMY RONALD & SANDRA
0
01
Parcels New ID
0
0,
"
0
10
E
0
5 Ft Contours

Site: NC®AM-008; Field 1
Soil Map
1 in = 1,000 ft
HeB EiD
CnC2
CnD2 Val
vaD VaC
HeCVal_
Legend
Q Approved Application Fields
0 Field Numbers
GIS Division
Date: 1 /10/2022
City of
URLINGTON
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Budington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

ANNUAL L
Acres Utilized:
N
kn
CY
WQ Permit #:
City of Burlington
Facility Name:
ten
Acres Perm
00
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N
N
Annual Dry Tons Applied:
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Land Owner:
N
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Predominant Soil Series:
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Crop 2 Max. PAN:
Crop 2 Name:
Crop 1 Max. PAN:
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Ammonia °'
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Mineralizatio
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Volatilization
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10
Signature of Land Applier
DENR FORM FSF

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
1SA NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
Eg, Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: City of Burlington
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)
NC-AM-10-1,3
No
Fescue
Hay/Pasture
NC-AM-10-2
No
Row
Crop/Corn,Sovbeans
Feed
'PI.-
landowner or hts 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the
land application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of
the equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals
land application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final
soil pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for
the specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of
nutrients (e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land
application events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
IL RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land
application site(s) during active use and for the 12-month period following a residuals land application event. Such controls 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.
IILALTERNATIVES FOR WATER SUPPLY WELLS INSIDE TILE 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;
X A re -defined compliance boundary is needed for field(s) ID: 1,2
(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:
residuals land application program; Permit Number WQ:e is currently permitted under another
dge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals and owner land application ereby 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, contra ctor, or other permitted entity. Furthermore, I certify that I have read this Agr eement,
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. n
Landowner name: D�f C' eek
Address: F(rr COC,4961, 1G
City:
I, the undersigned Notary Public do hereby certify that
Litecly
P one: �• j ! 1p Qcf((p
• a ture:
State:
fic
E-mail address:
Zip: 02 7.2 /(f-
NORTH CAROLINA, AIQmwknCOUNTY
C2N.fl -t :2_ ,
Date: --?11 — a'
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the a1 T� l
day of
Signature and seal:
My commission expires: • 3.6 - 'X'?,
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: State:
Phone: E-mail address:
Signature:
Date:
Permittee's Certification:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name: L5l4st c .
Signature:
Date: 576e./el/
FORM: LOA 06-16
Page 3 of 3

Site: NC-AM-010; Fields 1-3
Rocky .Rlyer
IICENIpommmom Feet
0 4,000 8,000
Vicinity Map
1 in = 6,000 ft
ALAMANCE
t;t1A1HAM
Town of Cary, Alamance County State of North Carolina DOT, Esri;..HERE,'
Garmin INCREMENT P, US S, METI/NASA, NGA, EPA, USDA
Legend
0 Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1/10/2022
City of
URLINGTON—ly
fat
Disclaimer:
This map was compiled from the GIS resources of the Buffington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with feld surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-010; Fields 1-3
Application Area Map
Feet
3 175 350 525 700
UR%INGTON -)
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Application Area
Unsuitable
X — Fence
Legend
[Site Boundary
Q Property Line
11
V/J
U S.W.A.
il On Site House
1111 Off Site House
Outbuildings
On Site Well
-0- Off Site Well
Streams
— Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
l I
1 In = 500 ft
•
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Prima
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

January 19, 202
Parcels New ID
(75
0
0
E
5 Ft Contours

Site: NC-AM-010; Fields 1-3
CnD2
CnB2'
CnC2
1C2
w
ChA
ChA
GeC2
Chi
0 Feet
750 1,500
Legend
Q Approved Application Fields
OField Numbers
GIS Division
Date: 1/10/2022
Cn02
City of
URLINGTON
G.I.S.
CmB
WyC2
CnC2
HnC
Soil Map
1 in = 1,000 ft
yC2
CnB2
GeB2
GaC
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consuked
for the verification of the information contained within this map.

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .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. Land Owner Agreement (FORM: LOA 06-16):
[, Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
61 Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
tr-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: City of Burlington
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)
NC-AM-14-1,2,3,5,6
No
Fescue
Hay/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 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
H. 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, I5A 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;
X A re -defined compliance boundary is needed for field(s) ID: 1
(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 anothermunicipality, 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: 77aks4e. r ��D✓1�`%�
Address: g-334 $ar h G //
<ge--
Zip:
J r✓ ra n ey 2/6 D 1,11 I . Grin
VSignature: .. Date: 37 7 tO102-
City: C/811 Yl L°i State:
Phone: 336 b 7c 3) 3
E-mail address:
NORTH CAROLINA, fila Clf4 Ce, COUNTY
I, the undersigned Notary Public do hereby certify that 3-Ui Me 5
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the 7
day of /Vial
Signature and seal:
My commission expires: ��% t + ,?„✓)��
,20
— sai}dx3 UoisSiwwon Art
31N `A1Un03 e3UEWeId
3n8nd AMON
Leona W /Wa 1S
Lessee's/Operator's Certification: 1
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/op erator name:
Address:
City: State: Zip:
Phone: 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: 514414e' ech'-"',e/-
Signature: .-- Date: 317/W 2/
FORM: LOA 06-16
Page 3 of 3

Site: NC-AM-014; Fields 1-3, 5
Feet
4,000 8,000
Legend
® Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1/10/2022
Vicinity Map
1 in = 6,000 ft
Alamance County, State of North Carolina DOT, Esri, HERE, Garcnin,
-INCREM.E-NT,P, USGS, METI/NASA, NGA, EPA, USDA
City of
URLINGTON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Budington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primal -
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-014; Field 6
0
Feet
4,000 8,000
Legend
® Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1/10/2022
Vicinity Map
1 in = 6,000 ft
Alarnance County, State of North Carolina DOT, Esri, HERE, Garmin,
INCREMENT P, USGS, METI/NASA, NGA, EPA, USDA
City of
URLINGTON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-014; Fields 1-3, 5
230 460 690
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Feet
920
Legend
DSite Boundary
Q Property Line
1d
Application Area
F71 Unsuitable
X — Fence
® S.W.A.
® On Site House
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— — Streams
— Drains
I i Surface Water
Flood Zones:
AE
; t Floodway (AE) conjunction with field surveys where required, must be consulted
0.2% Annual Chance Flood Hazard for the verification of the information contained within this map.
Application Area Map
1 in = 660 ft
Disclaimer
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Prima
ublic information sources from which this map was compiled, in

Site: NC-AM-014; Field 6
BCity of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
Site Boundary
Q Property Line
1'd
Application Area
Unsuitable
X — Fence
V/1
S.W.A.
On Site House
II Off Site House
Outbuildings
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Application Area Map
1 in = 500 ft
— — Streams Disclaimer.
This map was compiled from the GIS resources of the Burlington
Drains Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
Surface Water different scale, time, origin, definition and accuracy, which aspects
Flood Zones: produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
AE be held liable for any errors in this map or supporting data. Primar
public information sources from which this map was compiled, in
Floodway (AE) conjunction with field surveys where required, must be consulted
0.2% Annual Chance Flood Hazard for the verification of the information contained within this map.
I I

January 19, 2022
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Site: NC-AM-014; Fields 1-3, 5
Soil Map
1 in = 1,000 ft
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Date: 1 /10/2022
City of
URLINGTON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

E.E LI r:,L
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uid Solids Acre
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Permit PAN Limit 1st/2nd Crop
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Signature of Land Applier
DENR FORM FSF

DWR
Division of Water Resourc
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 1 SA NCAC 02T .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
M Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator,
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: City of Burlington
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)
NC-AM-15-1,2,3,4
No
Fescue
Hay/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 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the
land application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of
the equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals
land application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final
soil pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for
the specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of
nutrients (e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land
application events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of this Agreement.
IL RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land
application site(s) during active use and for the 12-month period following a residuals land application event. Such controls 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;
X A re -defined compliance boundary is needed for field(s) ID: 2,3,4
(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.
C. Landowner name: h9, /'C- cI / I
Address: a go ''` ed6ty
City:
&-1i'4�I�
State: Ale
Phone: ail add
Signature: tt IQt(_�
NORTH CAROLINA, tv+o.n.cCI
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
r
Zip:
day of
Signature and seal:
Rd ).J
My commission expires: cq' a 5-d a
Lessee's/Operator's Certification:
,20a
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/op erator name:
Address:
City: State: Zip:
Phone: 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 here in.
Signing official name:
Signature:
S 144 a•e r-
Date: 57;-1/-70 "74
FORM: LOA 06-16
Page 3 of 3

Site: NC-AM-015; Fields 1-4
0
Feet
4,000 8,000
Legend
Q Subject Farm Boundary
Highways Si Street Centerlines
GIS Division
Date: 1/10/2022
Vicinity Map
1 in = 6,000 ft
Alamance County, State ofNorth Carolina` DOT, Esrl HEREEGa'rmin, A"
-INCREMENT P,,USGS, METI/NASA, N,GA, EPA, USDA'
City of
URLINGTON
G I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primar
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-015; Fields 1-4
ity of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
QSite Boundary
Q Property Line
1'd
Application Area
Unsuitable
)( — Fence
V/I
® S.W.A.
® On Site House
▪ Off Site House
Outbuildings
On Site Well
-0- Off Site Well
--- Streams
• — Drains
Surface Water
Flood Zones:
AE
rf,% Floodway (AE)
0.2% Annual Chance
Application Area Map
1 in = 600 ft
Disclaimer:
This map was compiled from the GIS resources of the Buffington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primar
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
Flood Hazard for the verification of the information contained within this map.

January 19, 2022
TT CHARLIE ANDERSON & DONNA
Owner Name
a
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Owner Name:
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January 19, 2022
Owner Name: WYATT CHARLIE A & DON
mance County GIS
Parcels New ID
5 Ft Contours

Site: NC-AM-015; Fields 1-4
Soil Map
1 in = 1,000 ft
Legend
Q Approved Application Fields
OField Numbers
GIS Division
Date: 1 /1012022
City of
URLINGTON
-- G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with feld surveys where required, must be consulted
for the verification of the information contained within this map.

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLEASE MAKE A COPY OF THIS BLANK FO
EN NOT APPLICABLE.
PLACE A "N/A" IN A BLANK OR BOX
Acres Utilized:
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Signature of Land Applier
DENR FORM FSF (12/2006

CO
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City of Burlington
Acres Permitted:
Facility Name:
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Signature of Land Applier
DENR FORM FSF (12/2006)

TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
N
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Signature of Land Applier
DENR FORM FSF (12/2006)

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
O
Acres Utilized:
CY
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
Annual Dry Tons Applied:
Land Owner:
O
Cation Exchange Capacity (non 503):
Predominant Soil Series:
U
1
v
cEe
z
U
U
9J
w
E
z
U
Name of Crop Type
Receiving Residual
Application
I Crop 2
Lime Applied 1
U
Ct
V)
•-,
o
u
0
Vi
.)
CI
PAN Applied
(lbs/acre)
N
P.
O%.
U
Q
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
0
O
O
0
O
0
0
—
o
N
o
ej
,,
,,
.
,,
coo
0
co
0
0
0
0
0
O
0
o
0
co
0
0
0
0
0
0
co
0
o
0
co
0
co
0
O
0
o
0
co
0
0
0
co
0
o
0
co
06
O�
0`0
O
a d ae
h .i co
z z
.�-,
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form): I
rn-7
o
M
p/
Ammonia
Nitrogen E
O
o
2
N
v
r
M
a,
m
a,
m
00
N
ch
N
-Y
0
(92,i0
(/)
N
m
0
O
O
N
N
O
,D
N
O
c,
pp
Mineralizatio
n Rate***
r.
0
N
o
M
0
`,,,°
0
v
"'
Volatilization
Rate**
Ir,
0
m
O
0
°0
N
0
0
N
0
Application
Method*
0
to
x
0
O
0
cA
O
0
N
O
0
In
.-.
N'zr CDN
ir-
m
6
N
M
ripCn
U Q
0.
0.412
7.143
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
U
co)
N
o
N
o
t-
cf-,
co
"G
U
m
0
0
cc
0
-
N
0
V
M
Volume
Applied per
Acre
(Dry Tons/Ac)
O
N
N
m
0.000
O
O
O
O
co
O
O
O
0.000
0.000
O
co
O
O
0.000
0.000
O
co
O
O
0.000
0.000
0.000
m
Q
0.032
N
0
N
m
N
O
,o
m
o o
c
o,
,-„
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit lst/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
195000
co
195000
0
O
u1uo
zoo U
o
0
H
to assure that
N
0
CA
Signature of Land Applier
DENR FORM FSF (12/2006)

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
El Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
/"'"N
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: City of Burlington
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (Le., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field IDLease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-AM-16-1,3
No
Fescue
Hay/Pasture
me an owner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
,ThPermittee 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
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.
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, 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;
X A re -defined compliance boundary is needed for field(s) ID: 1,3
(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:
residuals land application program; Permit Number We , is currently permitted under another
dge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land applicatowner hereby ion 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 anothermunicipality, 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. 7 J
Landowner name: lid 7 111 gm ! / ctdi '2y
Address: s / J
State: 1 V
City: Sr77t3W 11CamP ,)t�
Phone:
Signature: (A/ . n �� , dI
w►arJ
NORTH CAROLINA,
E-mail address:
I, the undersigned Notary Public do hereby certify that
J
COUNTY
/1
zip: a-7 39-7
Ii e h ac1-M ey 6m q
Date: - a 1
personally appeared before me this day and acknowledged the due execution of the forgoing instrum
WITNESS my hand and official sealthis the
day of
by
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
, 20 21/
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/op erator na me:
Address:
City: State: Zip:
Phone: 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 here in.
Signing official name:
Signature:
(44" L t C1 &
Date: P/+pb I2(
FORM: LOA 06-16
Page 3 of 3

Division o
R
ater Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
n
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: City of Burlington
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
(yes/no)
Land Use or
Cropping Patterns
pp g
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-AM-16-
2A,2B,4A,4B,5
No
Fescue
Hay/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 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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
r—N 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.
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, 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;
X A re -defined compliance boundary is needed for field(s) ID: 2A,2B,4A,4B
(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 anothermunicipality,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: /7 2 G J4Q .. /9 1
Address: / C' 8 J /' e , /c'C ' /Z./C.
City: .Sit/eat,/ Ci'4
Phone: 3 6 2/ S� Q 0 g
Signature:
State: "-%'— Zip: 3 9
E-mail ddress:
Date:
NORTH CAROLINA, 41a+in c-P- - COUNTY
I, the undersigned Notary Public do hereby certify that 1 G`tet.z/ lx
personally appeared before me this day and acknowledged the due execution of the forgoing instnzmerit`
WITNESS my hand and official sealthis the
day of
Signature and seal:
a _ 7._ p
,20 1
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: State: Zip:
Phone: 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:
Signature:
Date: fr/,oi
FORM: LOA 06-16
Page 3 of 3

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
gA 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: City of Burlington
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
(yes/no)
Land Use or
Cropping Patterns
pp g
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-AM-16-3
No
Fescue
Hay/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

/'1
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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
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.
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;
X A re -defined compliance boundary is needed for field(s) ID: 3
(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: z 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 anothermunicipality, 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. //��dr p
Landownername: / t e c,J .
Address: 173 /3' L gc,>
City: ,r1 n J & v1A,f State: �!� Zip: 0273J T 9
Phone: ?3 6 (/ E-mail address:
Signature:
NORTH CAROLINA,
lam— COUNTY
I, the undersigned Notary Public do hereby certify that
Date:
ride& P #4-Dcc
personally appeared before me this day and acknowledged the due execution of the forgoing instruttlot.
WITNESS my hand and official sealthis the c�
(134-LisLA40.- 9i-k-c1-0-Zebet
My commission expires: 7- 202--41
day of
Signature and seal:
Lessee's/Operator's Certification:
,20
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: State: Zip:
Phone: E-mail address:
Signature: Date:
Permittee's Certification:
I certify that I have read this Agreement and do hereby ag
ree to abide by the stipulations and restrictions as specified here in.
Signing official name: tgAcirt G Reit ✓t t r'
Signature:
Date: cP/ Pba /
FORM: LOA 06-16
Page 3 of 3

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: City of Burlington
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)
NC-AM-16-6
No
Fescue
Hay/Pasture
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
"—aPermittee 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
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.
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;
X A re -defined compliance boundary is needed for field(s) ID: 6
(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)
D 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. Furthennore, Icertify 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. �rLandownername: !ttJ'i'j Ii I VJ
Address: v1 Ki,bu%(f ,
City: $titrltb&> 1 State: 14l., Zip: a7a15-
Phone: 3Iej 55 f'1 E-mail address: .1�, neal ® W .Q.+ , conk,
1 3 -
Signature: e v� ] Date: / (20 901+
NORTH CAROLINA, G1P'e',GZ." / _ COUNTY
I, the undersigned Notary Public do hereby certify that CA.-4-1,(A Nivrct
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the 4g0
day of VCUNA, LX
Signature and seal:
My commission expires: f11 O?S
Lessee's/Operator's Certification:
, 20 RR
syLE
yr
PUBLIC
I certify that I have read this Agreement and do hereby agree to abide by the Stipulation- ns and restrictions as specified herein.
Lessee/operator name:
Address:
City: State: Zip:
Phone: E-mail address:
Signature: Date:
Permittee's Certification:
I certify that I have read this Agreement and doJJhereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name: S1' erne �f�iTJi-€l
Signature: Date: //267W2 Z— --
FORM: LOA 06-16
Page 3 of 3

Site: NC-AM-016; Fields 1-2, 4, 5
Vicinity Map
1 in = 6,000 ft
aw C
0
Feet
4,000 8,000
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
ALAMANCE
\CHATHAM
Town of Cary;'Alamance County, State of North_Carolina DOT, Esri, HERE,
Garmin, INCREMENT P, USGS, METI/NASA, NGA, EPA, USDA
BURLINGTON�
.. G.I.S.
City of
DNA
Disclaimer:
This map was compiled from the GIS resources of the Budington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-016; Fields 3, 6
Vicinity Map
1 in = 6,000 ft
0
Feet
4,000 8,000
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
Town of Cary, Alamance County, State of North Carolina DOT,Esti, HERE,
—Garinin'IINCREMENT P, USGS, METI/NASA2NGA, EPA, USDA
T City of
V /�RL1NGTO�T
Q.I.S.
DNA
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must he consulted
for the verification of the information contained within this map.

Site: NC-AM-016; Fields 1-2,
Application Area Map
1 in - 2�n ff
City of
URLINGTON
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend 0 S.W.A.
QSite Boundary a On Site House
Q Property Line III Off Site House
c4-1Application Area Outbuildings
Unsuitable \ On Site Well
X — Fence -0- Off Site Well
V71
• Streams
• — Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
( I
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-016; Fields 3, 6
CpilimpimmFeet
230 460 690 920
c ty or
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
QSite Boundary
Q Property Line
4,11
Application Area
Unsuitable
X — Fence
V/1
▪ S.W.A.
® On Site House
▪ Off Site House
Outbuildings
Sc On Site Well
-0- Off Site Well
• Streams
— Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
I I
Application Area Map
tin=660ft
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable far any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.
/
r
7

Owner Name: NEAL CATHY JO HADLEYAS TRSTEE
f
Parcels New ID
5 Ft Contours

Owner Name: HADLEY MICHAEL TODDAS TRUSTEE
Parcels New ID
t©
5 Ft Contours

§
Owner Name: HADLEY MICHAEL TQDD
Parcels New ID
f ❑
5 Ft Contours

Owner Name: HADLEY MICHAEL TODDAS TRUSTEE
Parcels New ID
to
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Owner Name: HADLEY MICHAEL TODDAS TRUSTEE
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Owner Name: HADLEY WILLIAM EARL
t
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Owner Name: HADLEY WILLIAM EARL
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Site:NC-AM-016; Fields 1-2, 4, 5
Soil Map
1 in = 1,000 ft
Legend
0 Approved Application Fields
0 Field Numbers
GIS Division
Date: 1/10/2022
City of
URLINGTON
G.I.S.
ChE2
CrC2
NaB
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time. origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-016; Fields 3, 6
Feet
750 1,500
Legend
Q Approved Application Fields
OField Numbers
GIS Division
Date: 1/10/2022
City of
U Ii9Gf ON
GIS"
Soil Map
tin=1,000ft
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Acres Utilized:
N
N
a
WQ Permit #:
City of Burlington
Acres Permitted:
00
00
r.
Annual Dry Tons Applied:
William Hadley
O
Cation Exchange Capacity (non 503):
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Michael Hadley
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(NPDES #, WQ#,
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East Burlington
East Burlington
East Burlington
I Residuals Appl
0.784 I
m
0
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0.034 I
M
,fir
0
0.187 I
TOTALS:1 01 4290001 I
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
•
•
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0
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v
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Volume
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Signature of Land Applier
DENR FORM FSF

N
Acres Utilized:
CA
N
h
3
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
oro
Annual Dry Tons Applied:
Michael Hadley
Land Owner:
O
tro
too
cot
Predominant Soil Series:
Michael Hadley
0
E
5
z
U
Name of Crop Type
Receiving Residual
Application
N
0
• v
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S1
P
U
U
w
U
cc
w
U
co,
w
U
w
U
w
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0
v
Q
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(lbs/acre)
N
0
d
z
z
z
z
z
z
z
d'
z
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z
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o0
O
O
0
O
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O
o
O
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0
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0
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O
0
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O
0
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N
N
en
N
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00
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0
0
©
0
©
0
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0
0
0
0
0
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01
"~
Nitrate
TKN o°o o and
° Nitrite
mg/kg mg/kg mg/kg
o N
CA
N©
coy
N
CA
4-4
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form): 1
py
00
N
44
M
0
O
0
0
O
0
0
O
0
0
O
0
0
O
0
o
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0
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N
v,
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r
N
N
ao
O
O
O
M
O
O
O
M
O
O
O
M
O
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O
M
O
O
O
O
0
O
r/]
N
O
©
+-+
©
O
N
©
cc
Mineralizatio
n Rate***
cn
0
M
0
en
0
en
0
�'
0
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0
Z
N
o
0
N
V
m
Volatilization
Rate**
v,
O
to
O
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O
v,
O
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O
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O
en
N
O
O
N
O
N
O
vo
N
N
O
Application
Method*
rn
cn
cn
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0
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0
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0
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a, x '2
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V
V
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N
c
Q
Dry
No
o
4.240 I
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
East Burlington
East Burlington
East Burlington
Mackintosh
Mackintosh
M
O
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00
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0
0
N
N
t
N
N
N
N
N
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00
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
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0. 0
u
N
.-7
z •
v
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
97500
182000
O
O
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O
O
L
o0
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O
00
CO
O
5330001
0
7 T
'1�UOTAI
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N
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N
00
N
00
N
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N
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N
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0
a)
CO
Signature of Land Applier
DENR FORM FSF (12/2006)

Acres Utilized:
To
N
WQ Permit #:
City of Burlington
st
N
Acres Permitted:
Annual Dry Tons Applied:
Cation Exchange Capacity (non 503):
`:Ng'
Predominant Soil Series:
Michael Hadley
Y.i
U
O
E
z
iOr
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6)
Lw
0.4
Name of Crop Type
Receiving Residual
Application
Crop 2
Lime Applied
Date lbs/ac
U
a)
9)
w
o
w
w
PAN Applied
( lbs/acre)
N
a,
0 c
0
z
0
z
O
0
o
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
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o-F00000000000N
o
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a,
h
g
O
0
co
0
O
0
o
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
N
c'
N
Y Nitrate
TKN g and
Oti
CD Nitrite
mg/kg mg/kg mg/kg
O
O
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form): 1
p
N
m
V
0
0
0
0
N
co-
ch
N
-
O°
N
aL�..
O
O
M
o
O
M
~O
0
0
0
Mineralizatio
n Rate***
M
o
,„
o
Z
o
o
0
o�
0
"?
0
M
Volatilization
Rate**
v,
o
o
o
o
O
a,
O
o,
O
Application
Method*
up
CA
,
x
0
o
0
o
r.
a c. L
2 ccvd x e
a w
in
V.
in
V.
...CD
py
O
o
M
0
W
M
0
N
N
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3 "'
Cn a mar
L.)Q /
a
TT
L
a
n
O
O
N
I�
N
2.798
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
East Burlington
vM
cr,
N
O
,r)
vC
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O
0
0
0
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0
0
0
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0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0.000 1
0
O
O
O
As
0.010
O
O
O
36
O
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n
N
N
N
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit 1st/2nd Crop
"1 rartif., ran1f-....4r 1...., �.
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
32500
0
0
O
O
0
O
a
o
O
cti
2_
q uoJA
N
N
N
0
Q i
N
N
N
Signature of Land Applier
DENR FORM FSF (12/2006

Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
Annual Dry Tons Applied:
Land Owner:
0
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Michael Hadley
is
CVO
E
N
er
ens
z
0.1
Name of Crop Type
Receiving Residual
Application
N
4a
o
-
d
z
U
k.
a
O
Q
PAN Applied
( lbs/acre)
N
R.
O
U
<
z
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
O
0
O
O
*-4
-
N
"-'
CL
CN
v"
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0
0
0
O
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0,
C
Nitrate
TKN v8 o and
CD Nitrite
mg/kg mg/kg mg/kg
N
ications totals on FORM FSF supp ( attach FORM FSF supp to this form): I
a
1.449 1 22.540 f
Prior Years Cumulative lbs/ac 0.13 0.108 6.655 2.726 0.377 0.015 0.179 0.501 0.169 17.916
Current Cumulative lbs/ac 0.146 0.124 7.032 2.839 0.393 0.016 0.195 0.517 0.185 19.365
Permitted C. P. L. R.**** 36 34 1338 267 15 374 89 2498
Permit PAN Limit lst/2nd Crop f
CD
CD
rn
rn
l0
Mineralizatio
n Rate***
,-.-,
O
Volatilization
Rate**
v,
O
p
`c
o
Application
Method*
,
x
o
.0 N N co
fax
«'i
V.
wo
cn U 6 a.
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
Residuals Appl
_
N
-71
N U
a� Q
) � o�
o.
> n '
0
‘c
0
o
o
0
0
0
0
0
0
0
0
0
0
0
0
0.000
0.000
0
0
0
0
o
o
0.000 I
0.000
0
o
0
C-
o
0
rn
Orip
Annual lbs/acre
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
o
o
11-1
r`
o
0
0
R
0
0
zo a;sQ
OC
TOTALS:I
Signature of Land Applier
DENR FORM FSF (12/2006)

Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
Annual Dry Tons Applied:
Russell Hadley Trust
Land Owner:
0
Cation Exchange Capacity (non 503):
u
Predominant Soil Series:
Michael Hadley
00
cr
Fescue -Pasture
E
C4
z
Name of Crop Type
Receiving Residual
Application
N
0,
O
C�
Lime Applied
Q
cC
cia
0
L)
U
w
v
w
6Oi
w
v
w
U
w
c0.>
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U
w
UN
w
//c�'+�
PAN Applied
(lbs/acre)
sa-
(
z
z
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z
Z
---
z
z
z
Z
0
o
O
0
co
O
0
o
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0
O
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o
o
O
o
0
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vs-
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00
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N
N
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N
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4
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O
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co
0
N
D1
0) Y cn
0 i, 3,
:0 cc3 z Z E
N
N
O
O
00
00
c-1
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form): I
Qi
M..571
—
Ammonia Y
Nitrogen E
co
d;
o
o
co
0
o8,
0
o
0
ti
co
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N
`M
CNO
Q;
N.
•
N
00
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N
Permit PAN Limit lst/2nd Crop
Z 0)o
Y
L E
0
M
M
0
0
M
M
0
0
M
M
0
O.
m
M
0
0
n
0
0
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0
0
N•
0
0
r--i
4%
C/j
M-
0
O
O
o
N
O
p�
co
Mineralizatio
n Rate***
M
O
M
C
m
O
M
O
'Cr
O
v-
O
O
v
O
Z
,Nn
o
ooO
6
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v
M
Volatilization
Rate**
.n
O
kn
O
kr,
O
kn
O
v,
0
kn
0
,,,
0
,,,
0
O
m
o
0
0
""
0
00
N
N
0
Application
Method*
hi
x
o
o
No
0
N
0
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a s `rri c
V-
V
h
V
v.)4'1
V
V
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N
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A
T
A
A
T
A
A
T
A
T
Q
C.)u�,
0.435
M
CO
o�,
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
East Burlington
East Burlington
East Burlington
Mackintosh
Mackintosh
Mackintosh
Mackintosh
U
V
O
d'
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N
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0.644
0.467
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0.647
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O
0
O
O
0
O
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0
O
O
0
O
O
0
O
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O
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0.143 I
vn
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O
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O
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N
N
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N
h
N
N
M
N
m
I"-h
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
78000
26000
188500
136500
123500
149500
123500
O
o
01
O
9165001
0
0
'RAM'
zoa1�Q
N
N
00
N
M
0
N
..-4-
i"
N
N
,m_,•
00
N
00
N
N
00
N
N
0
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0
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r... G..O y
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a
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0
cr
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„:S CL
Signature of Land Applier
DENR FORM FSF

Acres Utilized:
vl
WQ Permit #:
City of Burlington
Facility Name:
trk
Acres Permitted:
Annual Dry Tons Applied:
Michael Hadley
Land Owner:
0
Predominant Soil Series:
Michael Hadley
Crop 2 Max. P
Crop 2 Name:
00
Crop 1 Max. PAN:
Fescue -Pasture
Crop 1 Name:
N
a
U
Ammonia °1
Nitrogen
m
Mineralizatio
n Rate***
Volatilization
Rate**
Application
Method*
L
0
0
U E
a 0.y E o
it3 rn 49, q X X
W cc; 0.l
Q w
x � 00
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0
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w
z
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r
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0
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0
0
0
O
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0
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0
0
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U
w
U
w
z
z
0
O
O
O
O
0
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0
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0
0
0
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O
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O
O
O
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0
0
0
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0
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0
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O
0
O
O
O
O
O
0
O
O
0
0
O
0
O
O
O
0
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O
0
0
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O
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0
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O
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O
O
O
O
0
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O
O
O
O
0
O
0
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O
0
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CO
O
00
00
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a 'a
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0
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0
0
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00
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rn
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Annual lbs/acre
a
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O
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N
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cal o "O it
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f. y F-7
a) 1 15
0 a U a
Signature of Land Applier
DENR FORM FSF

Acres Utilized:
CD
N
0
3
WQ Permit #:
City of Burlington
Facility Name:
*41
Acres Permitted:
00
Annual Dry Tons Applied:
Russell Hadley Trust
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Michael Hadley
E
0)
U
U
Name of Crop Type
Receiving Residual
Application
1 Crop 2
0
a
o
"
lbs/ac
=
U
U
w
U
w
U
w
v
a
a)
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PAN Applied
(lbs/acre)
N
t4
o
L)
.
z
Q
z
<4
z
0
o
o
o
0
0
o
0
0
0
0
0
0
o
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
o
0
0
0
0
0
0
0
0
0
0
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0
`D
M
N
sr!
en
z-
Cr,
coo
0
O
O
0
O
O
o
0
O
O
O
O
O
O
o
O
O
O
o
O
O
O
o
O
O
O
coo
O
O
O
O
O
O
co
O
O
O
in
O
-
N
Z a Nitrate
TKN and
Nitrite
mg/kg mg/kg mg/kg
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form): 1
0
O;
o
O,
O
o,
O
Cr,N
h
N
M
N
o0
N
N
N
!Permit 1'AN Limit 1st/2nd Crop
0
"n
M
0
to
M
0
In
M
C/]
o
o
O
w
O
of
O
Mineralizatio
n Rate***
M
o
en
0
r
o
Z
0
000
v
kn
,o
,
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Volatilization
rate**
'n
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0
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0
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N
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Method*
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Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
East Burlington
East Burlington
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Annual lbs/acre
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Volume applied
(enter one) Solids/
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Cu. Yds I Gallons
84500
143000
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Signature of Land Applier
DENR FORM FSF (12/2006)

DWR
Division of Water Resource±
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
E 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: City of Burlington
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-tilUover-seed/
pasture)
NC-AM-18-1,2,3
No
Fescue
Hay/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 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the
land application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of
the equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals
land application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final
soil pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for
the specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of
nutrients (e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land
application events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
IL RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land
application site(s) during active use and for the 12-month period following a residuals land application event. Such controls 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;
X A re -defined compliance boundary is needed for field(s) ID: 2
(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: 4(Lg- f //s
Address: Ro 17 ` t e aLt)3 44 Dr
City: ur a n 4 7"D:/1 State: J"C Zip:
Phone:
cJ gy6,-' cry 1 0-, E-mailE-wait address: 4:1 Date: -� ' "►1 A
Signature:
NORTH CAROLINA, 1k`0.�i na .IN COUNTY
I, the undersigned Notary Public do hereby certify that N.1 l+_ Y'4_ 19
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the
day of
Signature and se
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:
State:
Zip:
Phone: 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 here in.
Signing official name: _��G� f i Greki__ `
Signature: Date: -4f/ 72/
FORM: LOA 06-16
Page 3 of 3

Site: NC-AM-018; Fields 1-3
0
Feet
4,000 8,000
Legend
Q Subject Farm Boundary
-- Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
City of
URLINGTON
G
Vicinity Map
1 in = 6,000 ft
ounty; Stateof North Caralna DOT, Esri, HERE, Garmin,
(INCREMENT P,,USGS, ME'Tt/NASA, NGA, EPA, USDA''
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Budington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primer
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC- AM - 018; Fields
Application Area Map
1 in = 600 ft
City of
ITRLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
QSite Boundary
Q Property Line
•VIApplication Area
Unsuitable
X — Fence
111 S.W.A.
® On Site House
II Off Site House
/ Outbuildings
On Site Well
-0- Off Site Well
• Streams
— Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

January 1Q.2O22
0
Parcels New ID
5FtContours

Site: NC -AM - 018; Fields 1® 3
Soil Map
1 in = 1,000 ft
Legend
Q Approved Application Fields
0 Field Numbers
GIS Division
Date: 1 /10/2022
City of
T■ 7j �j�j
�J RLI TON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Budington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Budington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
z
064
W
F
•
O
F
EN NOT APPLICABLE.
Acres Utilized:
N
a
WQ Permit #:
City of Burlington
z
Acres Permitted:
00
0,
Annual Dry Tons Applied:
Albert Mills
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Albert Mills
a
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South Burlington
East Burlington
South Burlington
East Burlington
South Burlington
U
0.030
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Volume applied Volume
° (enter one) Solids/ % Applied per
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Cu. Yds I Gallons (Dry Tons/Ac)
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Annual lbs/acre
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Permit PAN Limit lst/2nd Crop
26000 I
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Signature of Land Applier
DENR FORM FSF (12/2006)

Acres Utilized:
Acres Permitted:
00
WQ Permit #:
City of Burlington
Facility Name:
Annual Dry Tons Applied:
Predominant Soil Series:
EA EA
d d
Land Owner:
Crop 2 Max. PAN:
Crop 2 Name:
a
N
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O
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0
O
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0
O
O
O
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O
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0
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O
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Crop 1 Max. PAN:
Fescue -Pasture
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N
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44
Signature of Land Applier
DENR FORM FSF

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: City of Burlington
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)
NC-AM-35-1,2,3,4,5,6
No
Fescue
Hay/Pasture
NC-AM-55-5
No
Fescue
Hay/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

/""N
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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
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.
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, 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;
X A re -defined compliance boundary is needed for field(s) ID: AM-35-06
(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

s P'^'SS
WA-
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 anothermunicipality, 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: r7 7 © c3 f'ht i CUcu C A ��JrL i
City: &l u.of �Cj t-/) State:
Phone: E-mail address:
1 NORTH CAROLINA,
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
Zip: X 73tt
day of
LIT
goddb .
My commission expires: a- 3
Signature and seal:
Lessee's/Operator's Certification:
2 0
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operatorname:
Address:
City: State: Zip:
Phone: E-mail address:
Signature: Date:
Permittee's Certification:
I certify that I have read this A
greement and do herebyagreeto abide by the stipulations and restrictions as specified here in.
Signing official name: J144 we
Signature: St )% Date:
FORM: LOA 06-16 Page 3 of 3

Site: NC-AM-035 ; Fields 1-5
0
v� I
Feet
4,000 8,000
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
Vicinity Map
1 in = 6,000 ft
ral
LNI
Town of Cary, Alamance County, State of North Carolina DOT, Esri, HERE,
Garmin, INCREMENT P,'l,USGS, METI%NASA; NGA EPAUSDA
City of
URLINGTON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-035 ; Field 6
0
Feet
4,000 8,000
Legend
® Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
Vicinity Map
1 in = 6,000 ft
-1
LNi
ALAMANCE
"HAT HAM
Town of Gary, Alamance County, State of North Carolina DOT Esri, HERE,'
Garmin, INCREMENT P, USGS, METI/NASA, NGA,:EPA, USDA
of City City of
B
URLIN.GTON
g)
GI.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-035 ; Fields 11 -5
Application Area Map
1 in = 650 ft
BCity of
URLINGTON
G.I.S.
GIS Division
Date: 1/11/2022
*Note: Acreage calculated in GIS
Legend
=Site Boundary
= Property Line
4,1 Application Area
Unsuitable
X — Fence
VA
S.W.A.
Ltj On Site House
III Off Site House
Outbuildings
On Site Well
-0- Off Site Well
• Streams
— Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
I I
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held Gable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-035 ; Field
Application Area Map
City of
URLINGTON
G.I.S.. L
GIS Division
Date: 1 /11 /2022
Legend S.W.A.
QSite Boundary ® On Site House
Q Property Line III Off Site House
Application Area F`Outbuildings
Unsuitable \ On Site Well
`Note: Acreage calculated in GIS X — Fence -0- Off Site Well
V/1
— • Streams
— Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
I
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, In
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

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Site: NC-AM-035 ; Fields 1-5
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Fee
750 1,500
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Soil Map
1 in = 1 nnn ft
Legend
Q Approved Application Fields
OField Numbers
GIS Division
Date: 1/10/2022
City of
URLINGTON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-035 ; Field 6
Feet
750 1,500
Legend
Q Approved Application Fields
0 Field Numbers
GIS Division
Date: 1/10/2022
City of
URLINGTON
—�' G.I.S.
Soil Map
1 in = 1,000 ft
Disclaimer:
This map was compiled from the GIS resources of the Budington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Budington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

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NC-AM-00035-0-0001-
Report Date/Time: 1/25/2022 3:00:16 PM

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DENR FORM FSF (12/2006)

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DENR FORM FSF (12/2006)

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NC-AM-00035-0-0004-
Report Date/Time: 1/25/2022 3:00:35 PM

tri
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0
co
O
v)
0
O
O
Mineralizatio
n Rate***
O
rn
O
Volatilization
Rate**
©
0
0
Application
Method*
CID
0
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0
0
O
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N
0
O
0
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0
0
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0
O
0
0
0
N
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©
0
O
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©
O
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0
O
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0
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0
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0
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0
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0
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0
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ry
00
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00
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N
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0
Signature of Land Applier
DENR FORM FSF (12/2006)

Acres Utilized:
Grr
N
h
a
WQ Permit #:
City of Burlington
Facility Name:
N
Acres Permitted:
'r)
M
(0>
Lin
Annual Dry Tons Applied:
Land Owner:
Predominant Soil Series:
0
124
U
ti
a
00
ca
0
U
U
ai
z
0
0
U
0
U
w
0
U
w
0
U
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N
0)
a'up (y 1114a1. 1 tii\
PAN Applied
( lbs/acre)
Crop 2
I NA I
NA
z
NA
O
o
0.000
0.000
00
0
0
0
00
0
00
o
I MA) 0
000•0
000•0
0
U
N
•
r+
N
V1
N
N
0
0
O
0
0
O
0
0
O
00
0
O
00
0
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0
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0
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00
0
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00
0
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.-'
N
' m
z z E
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.o
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vo
Ammonia m
Nitrogen E°
0
0
0
O°
0
RM FSF supp to this I
s"
N
N
rr
N
O
w
N
o
D
aa
0,
N
Permit PAN Limit lst/2nd Crop
661 nnrl;far .. A....
0
0
0
0
0
0
0
0
0
V)H
o
O
0
O
0
O
pip
Mineralizatio
n Rate***
rn
o
rn
c
r>
o
a.
o
Residuals Applications totals on FORM FSF supp ( attach FO
Z
-_,
o
0
0
0
"'
Volatilization
Rate**
v
o
v
0
„
0
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0
'5
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0
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0
0
Application
Method*
'-'
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1.032 0.242 I
0
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
East Burlington
East Burlington
East Burlington
o
U
00
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QG
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0
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rrior Years Cumulative lbs/ac I
Volume applied
(enter one) Solids/
Liquid
Cu. Yds 1 Gallons
26000
78000
0
0
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ors
45500
0
240500
©
O
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Current Cumulati)
Permitted C. P. L.
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Signature of Land Applier
DENR FORM FSF (12/2006)

Site: NC-AM-055 ; Field 5
Vicinity Map
1 in = 6,000 ft
E Elk!
,)W Ca
0
Feet
4,000 8,000
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
Licit , Cr
i tl.1'AN C•E
'HATHAM
Town of Cary, Alaman ce County, State of North Carolina DOT, Esri, HERE,
Garrnin, INCREMENT P, USGS, METI/NASA, NGA, EPA, USDA
City of
URLINGTON
I ��
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-055 ; Field 5
RCity of
URLINGTON�
1-- ` G.I.S.
GIS Division
Date: 1/11/2022
'Note: Acreage calculated in GIS
Legend
Q Site Boundary
QI Property Line
1
Application Area
Unsuitable
X — Fence
V/J
▪ S.W.A.
On Site House
▪ Off Site House
Outbuildings
On Site Well
-0- Off Site Well
- -- Streams
- — Drains
TT Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
Application Area Map
1 in = 400 ft
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-055 ; Field 5
Soil Map
1 in = 1,000 ft
Legend
Q Approved Application Fields
0 Field Numbers
GIS Division
Date: 1 /10/2022
City of
URLINGTON
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
kn
Acres Permitted:
kn
w
74 71
cy
0
CY
WQ Permit #:
City of Burlington
Facility Name:
Annual Dry Tons Applied:
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
GL
0
00
Fescue -Pasture
E
Naive of Crop Type
Receiving Residual
Application
Crop 2 I
Lime Applied
U
o
U
U
N
N
PAN Applied
( lbs/acre)
N
s3.
cc
Q
z
O
o
o
0
O
0
0
0
Cr
0
o
0
O
o
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
o
0
O
0
0
0
O
0
0
0
O
0
0
0
CC
~
o
0
c'
M
o
o
O
O
0
0
O
O
0
0
O
O
0
0
O
O
0
o
O
O
0
0
O
O
0
0
O
O
0
0
O
O
0
0
O
O
0
0
Cr
O
0
0
O
0
0
O
O
o
M
0 o m
� 0 Y m
z E
M
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form): I
Ammonia Y
Nitrogen E
o
o
N
N
M
•cQ
n°
•M
°O
rn
•N
Y
H E
o
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N
0
O
0
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N
0
01
n Rate***
M
o
N
o
Mv
,-'
rnMineralizatio
NZ
"'
Volatilization
Rate**
, v
o
o
0
m
0
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Method*
-'
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0
0
0
0
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,in Na,
.- N y a).
s t
,-, c0 G
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N
N
0)
= .� N
clp U-
L
q
A
Cj
0.207
00
co
00
h
00
00
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
U
O
Cn
0o
00
Cr,
M
O
M
O
N
00
en
.vt
U
N
Cr
O
HM
en
O
enM
O
Volume
Applied per
Acre
(Dry Tons/Ac)
0000©
kn
cS
0.000
0.000
0.000
0.000
O
o
O
O
0
0.000
O
O
0
O
O
0
Cr
O
0
O
0
O
O
0
cn
N
O
0
0
0.168
,•o
M
O
0 0
00
,-vj
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit 1 st/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
227500
O
227500
0
0
tpuoj
TO MaN
a
H
p
H
0)
cr.
4.4
4.
4.
co
it
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cr
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N
Q
Signature of Land Applier
DENR FORM FSF (12/2006)

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
[Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
efer.
E(r
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
(A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: City of Burlington
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 tt
Intended Use of Crops
Intended
Residuals Source
o
(optional)
Special note
(no-till/over-seed/
pasture)
NC-AM-73-1,2
No
Fescue
Hay/Pasture
NC-AM-110-1
No
Fescue
Hay/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 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
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.
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;
X A re -defined compliance boundary is needed for field(s) ID: AM-110-1
(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 anothermunicipality, 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: (.-Celt L J NLw
Address: F%3‘., uA) ?7 6
City: D(.ti -ctrYI (9 State: ©�1
Phon 659 57G �'�� % E-mail address:
iature: . ,-e-0J �.li.,�.� 2 7.�ccJu'k Date: f {
NORTH CAROLINA, kaXY\°Jr%C. COUNTY
I, the undersigned Notary Public do hereby certify that �.0 t11 GLQS ► " Q13.�
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the
day of
Signature and seal:
Zip:. / 3 49'
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: State: Zip:
Phone: 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 a s specified here in.
Signing official name:
Signature:
Date:
(o//ro/Z/
FORM: LOA 06-16
Page3 of 3

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: City of Burlington
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)
NC-AM-73-3
Yes
Fescue
Hay/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.
/"N,
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

Tom.
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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
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.
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, 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;
X A re -defined compliance boundary is needed for field(s) ID: 3
(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)
'' 0 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 attomey 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 pennitted entity. Furthermore, I certify that 1 have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer,,and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein. ® j
Landowner name: Alt) &1Mij ltil/rt1[> ✓A rr
Address: �r 7 a:A(r x/y /4,1/ A-c
City: Yiv c' State: 7/IC Zip: ` ,_ 7 3,X lF
Phone: ft / 6 -2-1 7E-mail address:
Vjgnature: ?fl14Ly)'"
Date:
NORTH CAROLINA, I f % /14 x e COUNTY
I, the undersigned Notary Public do hereby certify that IC2©C f\ ,v e1A)n
red before me this da and acknowledged the due execu ion of the forgoing instrument.
personally appea Y _
WITNESS my hand and official sealthis the
day of Signature and seal: P Q \ • ( 1�ava-
My commission expires: �' a� "
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipula _ • • . . strictions as specified herein.
Lessee/operator name:/ / r d"S Q-t.4 t v\ }
Address: e9 7 , Ate, G d W l/ 77
City: 5t/2 &— � ri+-ink State: IV C. Zip: 3 /
Phone: 3 36' 37(4 - 3 33 i E-mail address:
,20a1
Signature: r;f-.�Gc�7�t1Ln Date: ll' 742
Permittee's Certification:
I certify that I have read this Agreement and do hereby a(gree to abide by the stipulations and restrictions as specified here in.
`
Q G C TL
Signing official name:
Signature:
Date: ,p/,Z492
FORM: LOA 06-16
Page 3 of 3

Vicinity Map
1 in = 6,000 ft
Site: NC-AM-073; Fields 1-3
Feet
0 4,000 8,000
Legend
0 Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
ALAMAMCE
GH +7hAM
Town of Cary, Alamance County, State of North CarolinaEsri,�HERE,=�-
Garmin, INCREMENT P, IUSGS, METI/NASA, NGA, EPA, USDA
City of
URLINGTON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primal
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-073; Fields 1-3
City of
RURLINGTON
G.I.S. t.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
Site Boundary
Q Property Line
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Surface Water
Flood Zones:
AE
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Application Area Map
1 in = 550 ft
Disclaimer.
This map was compiled from the GIS resources of the Budington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primal
public information sources from which this map was compiled, in
Floodway (AE) conjunction with field surveys where required, must be consulted
0.2% Annual Chance Flood Hazard for the verification of the information contained within this map.

January 20, 2022
Owner Name: NEWLIN LEONIDAS B
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Date: 1/10/2022
City of
URLINGTON
Disclaimer:
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Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

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Report Date/Time: 1/25/2022 3:06:09 PM

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Signature of Land Applier
DENR FORM FSF (12/2006

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
14. Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
6. Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
16, 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: City of Burlington
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)
NC-AM-100-1,2
No
Fescue
Hay/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 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the
land application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of
the equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals
land application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final
soil pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for
the specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of
nutrients (e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land
application events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
IL RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land
application site(s) during active use and for the 12-month period following a residuals land application event. Such controls 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.
HLALTERNATIVES 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;
X A re -defined compliance boundary is needed for field(s) ID: I
(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)
0 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: f-e:Pe P ` /so i
Address: t ao7 77GrGirabid Or -
city: bra l4 ei State: TIC, Zip: o 7)'6*--3
Phone: `lic'- v `147 E-m. address:
1
�ignature: � � � - Date:
NORTH CAROLINA, 4 I a $A a k Ce— COUNTY
I, the undersigned Notary Public do hereby certify that �eXr C.( M-C Pktnioo n
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the a -1
day of , 20_a I
Signature and seal: �
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: State: Zip:
Phone: 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 here in.
Signing official name:
Signature:
Date:
J /ice/Aez-%
FORM: LOA 06-16 Page 3 of 3

Site: NC-AM-100; Fields 1-2
Vicinity Map
1 in = 6,000 ft
0
ALAMANCE
\cliATHAM
Feet
4,000 8,000
Town of Cary, Alamance County, Orange County, NC, State of North
Carolina DOT, Esri, HERE, Garmin, INCREMENT .P,USGS, METI/NASA,
" `NGA, EPA, USDA
tek
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
City of
URLINGTON
G.I.S.,:.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-100; Fields 1-2
BCity of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
`Note: Acreage calculated in GIS
Legend
Site Boundary
Q Property Line
1'd
Application Area
Unsuitable
X — Fence
V/1
® S.W.A.
® On Site House
III Off Site House
=_ Outbuildings
On Site Well
-0- Off Site Well
— - Streams
— Drains
TT Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
Application Area Map
1 in = 550 ft
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primar
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

January 20, 2022
Owner Name: MCPHERSON TERRY G & LYNN C
A
2
/
0
I
Alamance County GIS
Parcels New ID
5 Ft Contours

January 20, 2022
Owner Name: MCPHERSON TERRY GENE & LYNN C
A
0
C
1
Namanc© County GIS
Parcels New ID
0
5 Ft Contours

Legend
Q Approved Application Fields
OField Numbers
GIS Division
Date: 1 /10/2022
City of
URLINGTON
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

N
Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
N
N
Acres Permitted:
Annual Dry Tons Applied:
Terry McPherson
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Terry McPherson
ct
z
5
ca
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lbs/ac
Name of Crop Type
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(C
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( lbs/acre)
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py
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South Burlington
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Annual lbs/acre
Prior Years Cumulative lbs/ac
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Permit PAN Limit 1st/2nd Crop
Volume applied
(enter one) Solids/
Q Liquid
Cu. Yds I Gallons
0
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143000 I
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Signature of Land Applier
DENR FORM FSF (12/2006)

Acres Utilized:
N
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
0
N
Annual Dry Tons Applied:
Terry McPherson
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Terry McPherson
E
z
CL
U
N
z
4.4
U
Name of Crop Type
Receiving Residual
Application
Crop 2
A lied
lbs/ac
1280
I Date
1 CEC
.-.
S0
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a
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PAN Applied
(lbs/acre)
N
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U
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(enter one) Solids/ % Applied per
Q� Liquid Solids Acre
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• Annual lbs/acre
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78000
0
78000
0
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Signature of Land Applier
DENR FORM FSF (12/2006)

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
g. Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
k 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: City of Burlington
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (Le., 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(optional)
Intended Use of Crops
Residuals Source
Special note
(no-till/over-seed/
pasture)
NC-AM-109-1,2
Yes
Fescue
Hay/Pasture
1 t►e 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 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
t•.-", 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
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.
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, 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)
X 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.
Landownername: (. Iia We (P(L LG 4(,
Address: /do). (r, l(Qwbro
City:
Phone:
V. Signature:
NORTH CAROLINA,
State: /VG'
E-mail a ess:
/�
^ Date:
A(10-flan Ice_
I, the undersigned Notary Public do hereby certify that
COUNTY
Chap Re D een
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
28
WITNESS my hand and official sealthis the
day of
Signature and seal:
0 -(
My commission expires: 3' 5 2
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by
Lessee/opera tor name:: (j /la s2.-..
)?/e,r
Address:''( t.,cl.Ya
KIMBERLY M PEGG
NOTARY PUBLIC
ALAMANCE COUNTY, NC
ExPires—
the stipulations and restrictions as specified herein.
City: C..1 .4f'( 4114 State: C Zip: Z. T 2 5-3
Phone: 33 Z Co 6 S E-mail address:
Signature: Date:
Permittee's Certification:
zo _i
I certify that I have read this Agreement and do hereby a ee to abide by the stipulations and restrictions as specified here in.
Signing official name: „c144et e
Signature:
Date: eGy ei/?. -/
FORM: LOA 06-16
Page 3 of 3

Site: NC-AM-109; Fields 1-2
now Cane
0
4,000
Feet
8,000
Vicinity Map
1 in = 6,000 fl
Town of Cary, Alamance County, State of North Carolina DOT E. ri, HERE,
Garnain, INCREMENTP, USGS, METI/NASA, NGA, EP/,USDA
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
City of
URLINGTON
�.. G.I.S. 1
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-109; Fields -2
Application Area Map
175 350 525 700
BC;cy oe
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
cm Site Boundary
Q Property Line
Application Area
Unsuitable
DC — Fence
V/1
▪ S.W.A.
On Site House
▪ Off Site House
[.1 Outbuildings
On Site Well
-0- Off Site Well
--- Streams
— Drains
I Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
1In=500ft
Disclaimer
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primar
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained Within this map.

Owner Name: MCQUEEN FARMS OF GRAHAM LLC
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Site: NC-AM-109; Fields 1-2
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Legend
0 Approved Application Fields
0 Field Numbers
GIS Division
Date: 1 /10/2022
It City of
URLINGTON
Soil Map
1 in = 1,000 fi
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

0,
Acres Utilized:
Acres Permitted:
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WQ Permit #:
City of Burlington
Facility Name:
Annual Dry Tons Applied:
Chapman McQueen
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Lonnie Thompson
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(enter one) Solids/
Liquid
Cu. Yds Gallons
130000
26000
195000
123500
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Signature of Land Applier
DENR FORM FSF

Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
Annual Dry Tons Applied:
Chapman McQueen
Land Owner:
Predominant Soil Series:
Lonnie Thompson
Crop 2 Name:
Crop 1 Max. PAN:
U
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Crop 1 Name:
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Mineralizatio
n Rate***
O
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0
Volatilization
Rate**
0
Application
Method*
0
0
o
00
East Burlington
O
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0
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Signature of Land Applier
DENR FORM FSF (12/2006)

D R
Division of
ater Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: City of Burlington
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
(yes/no)
Land Use or
Cropping Patterns
pp g
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-AM-110-2
Yes
Fescue
Hay/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

E—\
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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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 Pennittee 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.
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.
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)
X 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
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, Icertify 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: 7I l /3TQh/Ur /
Address: (f� 2/4 ail 4'/» P`¢G
City: k St/State: We
Phone: 1 " � ' a
��%% /n E-mail address:
ature: / 0A , /3'1 C(,{lrjlk/L/
Zip: c2f'f%7f
6r6._AtAcr rQazAv-
NORTH CAROLINA, M InNajaGQr COUNTY
I, the undersigned Notary Public do hereby certify that
Date: 1 -51
& cu; l ?) nef
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the
day of `J �?�.QJ�t\�a�t1�l , 20 Oa i
Signature and seal:
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/operatorname: l,dnl
Address: (574, 3 Aic 1-141/I. 77 cS &
City: Sow✓ Ca 04p / State:
Phone: 33 tP - 37 to - 3 3 3 / E-mail address:
Signature: ram`.-c-.
�pt9V 4
Permittee's Certification:
Date:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name:
Signature:
Date:
FORM: LOA 06-16
Page 3 of 3

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: City of Burlington
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (Le., 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)
NC-AM-110-2
Yes
Fescue
Hay/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 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
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.
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)
X A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
r—..\ ❑ The land application field(s) ID:
residuals land application program; Permit Number Wowner , is currently permitted under another
dge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application ereby 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:
&,il Ct lL ,-Pclr/
Address: /1- 7/(' , Pr/e,S ,r- 4vL
City: t4 47tCrs-V/. G e State:
Phone: / / 1— 2 / /
ature:
NC- Zip: .2 7CP
E-mail address:
NORTH CAROLINA, k10..a"4-12,m,
I, the undersigned Notary Public do hereby certify that
4 an C_ (6, 4 Pr'- (cL.. l i jv < it t 7--
Date:
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the
day of
Signature and seal:
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 re r. i specified herein.
Lessee/operatoorrname: Lev4 t' d c,,l W e/
Address: c 6 34 M /17 cc'�
State: N e--- Zip: off 7 3 ti
3 3 (v - -3 74 - 3 33 I E-mail address:
Signature: / ?,�
Date: 79-- —' J t
City: 6";? sw ( p
Phone:
Permittee's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name:
Signature: Date:
FORM: LOA 06-16
Page 3 of 3

Site: NC-AM-110; Fields 1-2
Vicinity Map
1 in = 6,000 ft
0
Feet
4,000 8,000
Legend
Q Subject Farm Boundary
- Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
own of Cary, Alamance County, State of North Carolina DOT, Esri, HERE,
Garmn, INCREMENT P, USGS, METI/NASA, NGA, EPA USDA
City of
URLINGTON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Budington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

ite: NC-AM-110; Fields 1-2
Feet
0 160 320 480
Bmy of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
=Site Boundary
Q Property Line
Application Area
Unsuitable
X — Fence
V4J
S.W.A.
® On Site House
1. Off Site House
Outbuildings
On Site Well
-0- Off Site Well
Application Area Map
J-u1= 450 ft
— — Streams
- — Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
I I
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any ercors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

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Site® NC AM 110 Fields 1-2
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GIS Division
Date: 1/10/2022
City of
URII1 I O
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ai
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with Feld surveys where required, must be consulted
for the verifcation of the information contained within this map.

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Signature of Land Applier
DENR FORM FSF (12/2006)

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Facility Name:
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Signature of Land Applier
DENR FORM FSF (12/2006)

DWR
Division of Water Resource
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — 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 Permuting Unit.
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
Lam& 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: City of Burlington
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
(yes/no)
Land Use or
Cropping Patterns
pp g
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-AM-116-
3,5,7,9,11,13
Yes
Row
Crop/Corn,Sovbeans
Feed
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 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
H. 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.
HLALTERNATIVES 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;
X A re -defined compliance boundary is needed for field(s) ID: 7,9,11,13
(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

pok,kk 4
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 anothermunicipality, contractor, orother pennitted 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, pnd do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name:
h e tin AP..71` \�; Y t-tf'
Address: O d5 I S V CAVt P-d
City:
State: 1 v C a Zip: cR.--) -t g
Phone: 31 L,(/3j ?0 - f a Co E-mail address: h:.e IN. d ,: Ke v-k 14 �c� �jrn 1 , L c >>--1
/) Signature: .-c.--c la R.„f - Date: L/ `ad �oZ1
NORTH CAROLINA, T/14inte.r►Ge. ////COUNTY
I, the undersigned Notary Public do hereby certify that kent 2 4 n• Ryerf
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
It
day of / %f ! , 20 2 / :+ Q� O�co �
Signature and seal: 41/2/4.,44,-e" 4 /py / &/P xxoTARJ„-
i.
rn �BIZG- =02
9
°CeS, Ni`
#11111/14
11ifIN1
WITNESS my hand and official seal this the
Signature:
2.2nc�
My commission expires: ,e a5, .2E..f
Lessee's/Operator's Certification:
i r
I certify that I have read this e and dolerer a to abide by the stipulations and restrictions as specified herein.
Lessee/operator name: 1�d
Address:
City: State: Zip:
Phone: E-mail address:
Signature: Date:
Permittee's Certification:
I certify that I have read this Agreementjand /do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing officialname: SYlgc,,L i nde iG
C
Date: .../11F/A9Z-/
FORM: LOA 06-16
Page 3 of 3

p,t4k-Nk
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 anothermunicipality, 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: ( Q I/ v� ea- 0 !L a 4—
Address: a 9 ' "/c r t" ` Fa-) f'
City: u/ / ) 9 vi State( NC Zip: .2 i S
Phone: — E-mail address: a r �Ct tr 1 , r e . C ©IN -,—
Signature:
Can
NORTH CAROLINA, L¢x -a Y L— COUNTY
KA,,e. £ • e•An Aol t`l
I, the undersigned Notary Public do hereby certify that
Date:
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and officialsealthis the
dayof
Signature and seal: '�- •
My commission expires:
Lessee's/Operator's Certification:
I certify that I have read this
Lessee/operator name:
as
u,x7�JV/
eby afee
abide by the stipulations and restrictions as specified herein.
Address:
City: State: Zip:
Phone: E-mail address:
Signature: Date:
Permittee's Certification:
I certify that I have read this Agreement and dohereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name:
Signature: c Date:
r--/i.P/va
FORM: LOA 06-16
Page 3 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: /19/4- 9eJ gt5cn �G�
Y
Address: 01-915 7,'#- DJ-ive.
City: 8 v rl,n� tdr�
ce
Phone: 33(j-5 35e8 33 �1; •ya.z�!
Signature: "sZa
State: A/.C. Zip: 7 aZS"
E-mail address: /hA,pc/ . lain. rfoconn
A 6=3 014A1 (
Date: y 02-3.Z/
NORTH CAROLINA, CO Y
I, the undersigned Notary Public do hereby certify that t (11A4 I 1 V,411S©IJyrd
personally appeared before me this day and acknowledged thd e/executionoftheforgoinginstrument. `,`i�`t/fii/J/jj`
WITNESS my hand and officialsealthis the 2 (� ♦t,_4`›,r6 EDiy.,,
day ofAtOril21 ,1de
-z .
...
Signature and seal: �'�.„.-_ ( ��ea
..
, ...
ea
My commission expires:oZ
3
— co� i•
"
I ;Ate
•
Lessee's/Operator's Certification: // /�.• t�JJ///till%
I certify that I have read this Age
Lessee/operatorname:
Address:
City:
ee to abide by the stipulations and restrictions as specified herein.
State:
Zip:
Phone: 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.
getc
Signature: g� Date: 500, ,JZ/
Signing official name:
FORM: LOA 06-16 Page 3 of 3

Site: NC-AM-116; Fields 3, 5, 7
Vicinity Map
1 in = 6,000 ft
0
Feet
4,000 8,000
ALAM
\C,' H A,
Town of Cary, Alamance County, State of North Carolina DOT, Esri, HERE,
Garmin, INCREMENT P, USGS, METI/NASA, NGA, EPA, USDA
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
City of
URLINGTON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-116; Fields 9, 11, 13
Vicinity Map
1 in = 6,000 ft
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1/10/2022
Town of Cary{Alamance CoJunty, State of North Carolina DOT, Esri, HERE,
armin, INCREMENT P, USGS, METI/NASA, NGA, EPA, USDA,
' ro .
City of
URLINGTON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-116; Fields 9, 11, 13
city of
URLINGTON
,d_A?
—otogre- G.I.S.J
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
=Site Boundary
= Property Line
4, 4 IApplication Area
171 Unsuitable
X — Fence
▪ S.W.A.
® On Site House
• Off Site House
Outbuildings
On Site Well
-0- Off Site Well
— — Streams
— Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
Application Area Map
1 in = 650 ft
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-116; Fields 3, 5,
City of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
Site Boundary
IQII Property Line
+r , Il
Application Area
Unsuitable
X — Fence
VA
▪ S.W.A.
® On Site House
El Off Site House
Outbuildings
On Site Well
-0- Off Site Well
—• •- Streams
— Drains
Surface Water
Flood Zones:
AE
Application Area Map
1 in = 500 ft
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public Information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Prima
public information sources from which this map was compiled, in
Floodway (AE) conjunction with field surveys where required, must be consulted
0.2% Annual Chance Flood Hazard for the verification of the information contained within this map.

Site: NC- =��/1;i1-_ !, 6); Fields 3.
7
Application Area Map
1 in = 550 ft
City of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
`Note: Acreage calculated in GIS
Legend
Site Boundary
Q Property Line
1'd
Application Area
177] Unsuitable
X — Fence
1111 S.W.A.
® On Site House
▪ Off Site House
MIE Outbuildings
On Site Well
-0- Off Site Well
Streams
• — Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.