WQ0001800_More Information (Received)_20211206

SYNAGRO
DECEMBER 6, 2021
TO: Nathaniel Thornburg
FROM: Alex Fox, Synagro Central, LLC
RE: Town of Yadkinville major modification WQ0001800
As a follow up to the additional information request dated November 23rd, 2021, for each field
requiring a redefined compliance boundary due to onsite water supply wells.
NC-YK-009-01: A redefined compliance boundary is requested for this site. The redefined
compliance boundary is to the north of this field and shall be located 50 feet from the well located
on the property.
NC-YK-35-01: A redefined compliance boundary is requested for this site. The redefined
compliance boundary is to the south of this field and shall be located 50 feet from the well located
on site.
Thhann�k you,
� v 7�
Alex Fox
Technical Services Specialist
704-881-3429
[e-mail]
284 Boger Road, Mocksville, NC 27028 9 Phone: [phone] Fax: [phone]

OPERATIONS AND MAINTENANCE PLAN
RESIDUALS LAND APPLICATION FOR WQ0001800 (Town of Yadkinville)
Operational Functions
The operational function of this project involves land application of residuals for the Town of
Yadkinville's wastewater treatment plant. This material will be loaded onto tractor trailers or "spreader
trucks" and hauled to land application sites. The residuals will be spread at agronomic rates, as
determined by a recently analyzed nutrients and metals sample. The material will be land applied with a
liquid applicator that will use pressure to achieve a consistent spread pattern. The fields applied will
have a crop, either established or planted soon after application, which is to be utilized for animal
consumption.
Safety Measures
Synagro believes in operating in a safety -conscious manner and has all employees participate in
quarterly online safety courses. These courses are designed to help employees recognize safety issues
and take steps to prevent accidents from occurring. In addition, all Synagro employees have the
authority to stop operations if they think any aspect of the operation could cause environmental or
personal harm.
Maintenance Schedule
Synagro will follow the maintenance schedule specified by their fleet management section for the
equipment necessary to complete the job.

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources LAND APPLICATION SITE CERTIFICATION
INSTRUCTIONS FOR FORM: LASC 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the 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-Discharye PermittiinjZ Unit
General — This certification provides detailed information of 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 certification for review
without a corresponding application form (FORM: RLAP 06-16 or FORM: SDR 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Application Site Certification (FORM: LASC 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. 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.
❑ For new or renewed permits, submit the requested information for all land application sites.
® For modified permits, submit the requested information for only those sites that are new, transferred or affected by the
proposed modification.
B. Land Application Site Information:
® The status of the land application site with respect to this residuals land application program must be provided in table I. The
status categories and their corresponding codes are as follows:
♦ New (N) ♦ Renewed (R) ♦ Modified (M) ♦ Transferred (T) ♦ Deleted (D)
® Attach the following in accordance with each status code:
Status Code
Required Item
N
R
T
M
County Board
Notification. doc
Land Owner
Agreement
(If applicable)
Setback Waiver
Agreement
An updated vicinity/setback map in accordance with the "Map Guidance
for Residuals Land Application Permits"
✓
✓
✓
A soils and agronomic evaluation in accordance with the "Soil Scientist
✓
Evaluation Policy"
INSTRUCTIONS FOR FORM: LASC 06-16 Page 1 of 3

An updated accounting of the land application site's cumulative
7
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pollutant loading rates (CPLRs)
Status Code
Required Item
N
F R
T
M
For previously permitted sites without a soil series name indicated in the
Attachment B, submit County Soil Survey Map (or equivalent) clearly
indicate the location of the land application site and in accordance with
the soil map requirements in the "Soil Scientist Evaluation Policy"
Acknowledgement of field transfer from Land Owner (Fields may not
be permitted to multiple Permittees over the same timeperiod)
* This item may be required for land application site with a status code "M", please contact the Division if you need assistant in
determining attachment requirements.
® Crop Type should include the most likely crop types for the life of the permit (five years).
® Predominant Soils Series Name must be either the name of the soil indicated in Attachment `B" of the existing permit, or
name of the soil series as provided by the licensed soil scientist.
® Predominant Soil Mapping Unit or Representative Slope: Either the Soil Mapping Unit or the representative slope of each
site must be provided. The predominant soil -mapping unit must be consistent with the predominant soil series name. Please
note that the soil mapping units are variable between Counties, so care should be taken in properly identifying the correct
mapping unit. If a representative slope is provided, it must be determined accordingly:
❑ For sites previously permitted for use, but do not have an established soil mapping unit (the mapping unit provides
information on both the soil series name and the slope of the soil), the Applicant may determine the representative slope
by using the average slope provided in the County Soil Survey (or equivalent). A soil type with a slope range of 4 - 8%
would have a representative slope of 6%.
® New Sites to be permitted must have slopes determined as part of the soils report prepared by a licensed soil scientist.
® Acceptable methods for determining location coordinates (i.e., latitude and longitude) and their corresponding codes are as
follows:
• Address Matching (ADD) • Digital or Raw Photo Extraction (EXT)
• Aerial Photography with Ground Control (AER) • Geodetic Quality GPS Survey (GEO)
• Cadastral Survey (SUR) • LORAN-C Navigation Device (LOR)
• Conversion from Coordinate Plane (CP) • Navigation Quality GPS (GPS)
• Conversion from Township -Section -Range (TSR) • Remote Sensing (RS)
• Conversion from Universal Trans Mere (UTM) • Zip Code Centroid (ZIP)
• Map Interpretation by Digital or Manual Extraction (MAP)
C. Waterbody and Classifications Information: (new sites only)
® Use an 8.5 by 11-inch copy of the portion of a 7.5-minute USGS Topographic Map to identify the location where the
residuals program activities are planned to occur as well as the closest downslope surface waters as clearly as possible. Each
map portion must be labeled with the map name and number, the identified location, and be of clear and reproducible quality.
® Surface water body classifications information may be found at: hU://deg.nc.gov/about/divisions/water-
re source s/planning/classification-standards/classifications
❑ Any questions concerning the waterbody and its classification, please contact the Division's regional offices.
❑ A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
hLtp://deg.nc.gov/contact/regional-offices
❑ General Instructions: There are 17 river basins in North Carolina. Each basin has associated waterbodies with assigned
subbasins, location descriptions, stream index numbers and established classifications.
1. Identify the project area on a 7.5 minute USGS topographical map (an 8.5 x 11-inch sheet showing the project area
should be submitted with the permit application regardless of whether a Stream classification was completed).
2. Determine the names of all the closest down slope surface waters from the project site. For unnamed tributaries, see
Table 1: Unnamed Tributaries Entering Other States or for Specific Basin Areas. Label any unnamed tributaries as
"UT to stream name" as the waterbody name.
3. Open the link http://deg.nc.gov/about/divisions/water-resources/planning/classification-standards/classifications.
❑ Stream Classification Process: One of the options below may be used depending on the known initial project information.
❑ KNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Select proper basin from the List all Waterbodies in Basin sorted report. Sort hydrologically as this will provide
the proper location descriptions if multiple runs.
INSTRUCTIONS FOR FORM: LASC 06-16 Page 2 of 3

2. Locate the name of the identified waterbody (from General Directions) on the list.
3. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
4. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
❑ KNOWN COUNTY WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Select the proper county from the List all Waterbodies in county, hydrologically report.
2. Locate the name of the identified waterbody (from General Directions) on the list.
3. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
4. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
❑ UNKNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Use the Clickable basin map to hydrologically sorted list report.
2. Click on the approximate project location to bring up the hydrologically sorted list.
3. Locate the name of the identified waterbody (from General Directions) on the list.
4. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
5. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
❑ Notes on index number and unnamed streams:
Unnamed Streams 15A NCAC 02B .0301(i).
❑ Any stream which is not named in the schedule of stream classifications carries the same classification as that assigned
to the stream segment to which it is tributary (at the point of entry) except:
(A) unnamed streams specifically described in the schedule of classifications;
(B) unnamed freshwaters tributary to tidal saltwaters will be classified "C"; or
(C) after November 1, 1986, any newly created areas of tidal saltwater which are connected to Class SA waters by
approved dredging projects will be classified "SC" unless case -by -case reclassification proceedings are conducted.
❑ The following river basins have different policies for unnamed streams entering other states or for specific areas of the
basin:
Unnamed Tributaries Entering Other States or for Specific Basin Areas
Hiwassee River Basin
Streams entering Georgia or Tennessee shall be classified "C Tr."
Little Tennesse River
Basin And Savannah
River Drainage Area
Streams entering Georgia or Tennessee shall be classified "C Tr." Such streams in the Savannah
River drainage area entering South Carolina shall be classified 'B Tr."
French Broad River
Basin
Streams entering Tennessee will be classified 'B."
Watauga River Basin
Streams entering the State of Tennessee are classified "C."
Broad River Basin
Streams entering South Carolina are classified "C."
New River Basin
Streams entering the State of Tennessee are classified "C."
Catawba River Basin
Streams entering South Carolina are classified "C."
Yadkin -Pee Dee River
Basin
Streams entering Virginia are classified "C," and such streams entering South Carolina are
classified "C."
Lumber River Basin
Streams entering South Carolina are classified "C Sw."
Roanoke River Basin
Streams entering Virginia are classified "C." Except that all backwaters of John H. Kerr
Reservoir and the North Carolina portion of streams tributary thereto not otherwise named or
described shall carry the classification 'B," and all backwaters of Lake Gaston and the North
Carolina portion of streams tributary thereto not otherwise named or described shall carry the
classification "C and B."
Chowan River Basin
Streams entering Virginia are classified "C."
Tar -Pamlico River
Basin
All drainage canals not noted in the schedule are classified "C Sw." except the main drainage
canals to Pamlico Sound and its bays which shall be classified "SC."
Pas uotank River Basin
All drainage canals not noted in the schedule are classified "C."
INSTRUCTIONS FOR FORM: LASC 06-16 Page 3 of 3

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State of North Carolina
PWR
Department of Environment and Natural Resources
Division of Water Resources
Dlvlslon of Water Resources LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted the Applicant shall submit one on final and two copies of the application and
supp rting 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. La90Owner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Residuals Source Certification (FORM: LASC 06-16) form. Please do not
make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the
application may be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
Prepare a separate agreement for each set of Iand application sites that are owned or operated by an entity other than the
ZAplicant.
copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his
Applicant's name:
0 .✓ fL
native hereby permits:
4,NW110V,Ifle,
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ics) 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)
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 a]I of the site restrictions (under Section II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1636
Mail Service Center, Raleigh, NC 27699-1636.
5, The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the
land application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of
the equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals
land application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6,0 or greater, sufficient amounts of lime shall be applied to achieve a final
soil pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for
the specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Pennittee 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 Pennittee 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 sites) 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 terns and conditions of the pennit; 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 retrain 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
bou ary provided the groundwater standards can be met at the newly -established compliance boundary. Please marls one of the following;
A re -defined compliance boundary is needed for field(s) ID: '- 0 9
(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 oroeram:
(Name of the new program)
FORM: IAA 06-16 Page 2 of 3

Landowner's Certification:
1 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: �OaAffi 9¢ ` A.X,
Address:
City: a � �Y� State: �N C Zip: -7 o i
Phone: 3 3 E-mail address:
Signature: ✓ Dater
NORTH CAROLINA, i�t(�h. �Y1 COUNTY
I, the undersigned Notary Public do hereby certify that _ p��tt11f11�t
personally appeared before me this day and acknowledged the due execution of the forgoing instrum`a Q` Q
WITNESS my hand and official steal this the r S
day of f 20 c + 9
Signature and seal:co
My commission expires: �� {— 011 pt 0 tX "`i ��I #....
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name:
Address:
City:
Phone:
Signature:
Permittee's Certification:
State:
E-mail address:
Date:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name: ,.,
Signature: Date:
FORM: LOA 06-16 Page 3 of 3

State of North Carolina
DWR
Department of Environment and Natural Resources
Division of Water Resources
Dlvlslon of Water Resources LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted the Applicant shall submit one on inal and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T A 100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. La Owner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Residuals Source Certification (FORM. LASC 06-16) form. Please do not
make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the
R/pplication 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
Zpplicant.
A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his
Applicant's name:
`ative hereby permits:
V. �,heivIle,
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:
SitelField ID
Lease
(yes/no)
(Y )
Land Use or
Cropping Patterns
PP �
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
r�
)s—
I
I
4
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals laud application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16 Pagel of3

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 pen -nit 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, 1636
Mail Service Center, Raleigh, NC 27699-1636.
5. The Pennittee 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:
I. Appropriate measures must be taken by the Pernittee 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.
IfLALTERNATIVES 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(hallows the
compliance boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance
boo dart' provided the groundwater standards can be met at the newly- s ablished compliance boundary. Please mark one of the following;
(U/ A re -defined compliance boundary is needed for field(s) ID: M, 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: is currently permitted under another
residuals land application program; Pen -nit 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 Droaram:
(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:
Address: / G4 7 I 'C- h r� G Ct 1- w
City: L a 5 f 0 C,A � State:
jJ/ G
Zip: '? % 1�_, / k
Phone: 3`- / j%,�, cil Vi E-mail address:
Signature:-- rev Date: %
NORTH CAROLINA, COUNTY I, the undersigned Notary Public do hereby certify that RVvS
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the t��W 'FO,����i
day of �� , 20
Signature and seal: - V
My commission expires: � 90
Lessee's/0 erator's Certification: fill
CO
'�
,,o�`��`
I}
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:
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 herein.
Signing official name: c�•• oc.,ya_+
Signature: Date:
FORM: LOA 06-16 Page 3 of 3

Vicinity Map
c�
a
z
in
0 0.0375 0.075
The compliance boundary is established at
either 250 feet from the residuals application
area or 50 feet within the property boundary,
whichever is closest to the application area.
The review boundary is established midway
between the compliance boundary and the
perimeter of the residuals application area.
All locations are approximate.
0.15 Miles
Legend
Property Boundary
0
Well
Offsite House
A A
Application Area
0
Onsite House
0
Soil Bore
®
Unsuitable Area
—
Stream/Ditch
NC-YK-33-4

Soil Map
L�
0 0.0375 0.075 0.15 Miles
The compliance boundary is established at
either 250 feet from the residuals application
area or 50 feet within the property boundary,
whichever is closest to the application area.
The review boundary is established midway
between the compliance boundary and the
perimeter of the residuals application area.
All locations are approximate.
Legend
— Property Boundary
Offsite House
0 Onsite House
Unsuitable Area
0 Well
A A Application Area
0 Soil Bore
Stream/Ditch
NC-YK-33-4

SITE SUMMARY
Town of Yadkinville
Site ID:
YK-33
Owners Name:
James Hobson
Kenneth Hobson
Dan Hobson
Address:
3541 Apperson Rd
2700 Linda Ln
4117 Holly Springs Rd
East Bend, NC 27018
East Bend, NC
East Bend, NC
Phone:
33-416-6898
336-699-3704
336-699-8661
Operator:
James and Kenneth
Applicable Predominant Latitude &
FfPlriG ArrP_C rrnn10 RVF QnH Q.A— 1 —„4-1-
1
7.6
Fescue Hay
216
CaB Clifford
36 24' 65" N
80 58' 49" W
2
6.4
Fescue Hay
202
CaC Clifford
36 24' 79"
80 58' 83"
3
C-9�
.,51-
Soybean, Wheat
179,111
CaC Clifford
36 24' 71" N
80 58, 58" W
Total 19.9
Date: 10/03/18

FIR
- -4i

SOIL SURVEY
a
z
y
1 inch = 500 feet
N C-Y K-33 0 130 260 520 790 1,040
Flelds 1-3 Feet
All locations are approximate.

d
z
TOPOGRAPHIC MAP
1 inch � 667 feet
Feet
0162.S25 650 975 1,300
Fields 1--3
All locations are approximate.

VICINITY MAP
fate - -
c
�f
i us
�46 _
'rr
s
x
Rrlvnonrl '
lid1 HAW
"O'h II
—'--
River 8ilann, tO
c
�o
vJ
sNauy Gale CSlurr.0 Fb
tele '?tl
F>Seri�'�
r
r,
Q�alf kogo;v.4.n n ��r
�n -
;� �a ° Sources: Esri;yHERE, Garrnin,-USES, lntermap, INCREMENT P,
a a NRCan, Esri Japan, METI, Esri China (Hong Korig), Esd Korea,
Esri (Thailand), NGCC, O OpenStreetMap contributors; and the
GIS User Community
NC-YK-33 z inch et,333 feet
0 80a,600 3,200 4,800 6,400
Fields 1--3
All locations are approximate.

WATERSHED MAP
Av j P f I
f
V
NC-YK-33
Fields 1-3
-
hto
1 inch = 2,000 feet
Feet
0 485970 1,940 2,910 3,880
All locations are approximate.

FILED
YADKIN COUNTY NC
ARIC WILHELM
REGISTER OF DEEDS
FILED Dec 03, 2021
AT 11:43:44 am
BOOK 01341
START PAGE 0437
END PAGE 0438
INSTRUMENT # 05786
EXCISE TAX (None)
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE RESIDUALS MANAGEMENT PROGRAM WAIVER
FOR THE APPLICATION OF CLASS B RESIDUALS
AGREEMENT TO WANE SETBACKS PURSUANT TO
15A NCAC 02T .1108(c)
r�rr,, ))
)y Cl ' _ �, certify that I am a deeded owner of the property located at:
Address: Ir J r }(,� Parcel No.: 1145_6 0
City: � � f „ ,State: NC Zip Code: D 70IT County: ` n &f\
Furthermore, I certify that I am authorized to make decisions regarding this property, and that I do hereby
agree that the setback distances cited below be granted to the Applicant/Pennittee listed on the following
page.
•E5"Fbr the parcel identified above, I consent to a reduced setback from 50 feet to 0 feet, thereby
allowing the application of Class B residuals as near as 0 feet from my propertyline.
For the parcel identified above, II: consent to a reduced setback from 400 feet to 100 feet,
thereby allowing the application of Class B residuals as near as 100 feet from my residence.
**THIS WAIVER SHALL BE TERMINATED UPON CHANGE OF OWNERSHIP OF ANY PARTIES INVOLVED**
Signature:
F Vr, 2
FORM: NDRMPW-L,AS 11-18 Page 1 of

Permittee: TO w� 0
Address: Pori -nit No.:
V4 ��"fl'/" /��
-LID, 0DOITad
City:? �6"'ktate: //C' Zip Code:z7o��_County: /mil-_G
NORTH CAROLING A, --/(," COUNTY
1, Pie),, ��! /d, „_„Q , a Notary Public for fry 4. ! I County, North Carolina,
do hereby certify that Af * 06 Lr personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the I�� day of ) � / �L i
X "W
SEAL
�fths ou �o►*��
40-. L� C7_�.
Signature of Notary Public
My commission expires OL �
Once notarized, this form ,shall be recorded at the Register of Deeds in the county or
counties in which the described properties are located. A copy of the recorded waiver
shall be sent to the following address:
Division of Water Resources
Non -Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: N©RMPW-LAS 11-18 Page 2 of 2

Yadkin County, NC
Receipt For: SYNAGRO
Instrument Type : AGMT Receipt # : 2021-104761
Instrument # ; 05785 Date: 12/03/2021 11:43:44am
Book/Page : 01341 / 0437-00438 Pages : 2 Document: 1 of 1
1st Grantor: MARTY OSBORNE
Description:
Description Qty Unit Cost Extended
General Inst - first 15 pages 1 26.00 26.00
Document 1 26.00
Grand Total 26.00
Voucher -26.00
Balance 0.00
Customer Copy