WQ0000884_Renewal Application_20220325

Non -Discharge Branch Upload/Submittal Form
NORTH CAROLINA
EnvironmentalQuul1ty
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) * WQ0000884
Applicant/Permittee Butterball, LLC
Applicant/Permittee Address 1628 Garner Chapel Road, Mt. Olive, NC 28365
Is the owner in BIMS? Yes No Is the facility in BIMS? Yes No
Owner Type Organization
Facility Name Butterball - Mt. Olive WWTF
County Duplin
Fee Category Major Fee Amount $0
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?* Yes No
Regional Office
CO Reviewer
Admin Reviewer
Complete App Date 03/25/2022
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* Jocelyn Russell
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*
919-746-9627
O Modification - Minor
O Renewal
O GW-59, NDMR, NDMLR, NDAR-1,
NDAR-2
O Residual Annual Report
O 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.deg.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type: *
Permit Number:*
Applicant/Permittee *
• Wastewater Irrigation
Other Wastewater
Closed -Loop Recycle
Single -Family Residence Wastewater
Irrigation
Butterball LLC
WQ0000884
Has Current Existing permit number
Applicant/Permittee Address* 1628 Garner Chapel Road, Mt. Olive, NC 28365
Facility Name* Butterball - Mt. Olive WWTF
Please provide comments/notes on your current submittal below.
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.)
2022.03.25 Butterball LAS Permit Renewal Application
WQ0000884.pdf
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.
27.23MB
* v 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 3/25/2022

Dew berry' Dewberry Engineers Inc. 919.881.9939
�.� 2610 Wycliff Road,Suite 410 919.881.9923 fax
Raleigh, NC 27607 www.dewberry.com
March 25,2022
NC Department of Environmental Quality—Non-discharge Permitting Unit
Attn:Nathaniel Thornburg,Environmental Program Supervisor
Archdale Building
512 N.Salisbury Street
Raleigh,NC 27699
RE: Butterball,LLC—Non-Discharge Permit WQ0000884 Renewal Application
Dear Mr.Thornburg:
Dewberry is pleased to submit the enclosed permit renewal application package on behalf of Butterball,
LLC(Butterball).
Below is a summary of what is included in the permit renewal application.
Document Explanation
Form WWIS-R-o2-21 Sections I-VIII Enclosed
Attachment A-Site Map Enclosed
Attachment B-Signature Authority Delegation Not Applicable
Attachment C-Flow Reduction Not Applicable
Attachment D—Certificate of Public Convenience and Necessity Not Applicable
Attachment E—Operational Agreement Not Applicable
Attachment F—Demonstration of Future Wastewater Treatment Capacities Not Applicable
Attachment G—Easement,Encroachment,And Lease Agreements Not Applicable
Attachment H—Affiliations Enclosed
Attachment I—Compliance Schedules Enclosed
Attachment J—Civil Penalties and Outstanding Violations Not Applicable
Attachment K—Industrial Wastewater Enclosed
Attachment L—Setback Waivers Enclosed
Please feel free to contact me at 919-424-3764 with any questions regarding this application package.
Sincerely,
Leigh-Ann Dudley,PE
Associate,Sr.Project Manager
Page 1 of 1

State of North Carolina
DW R Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02T.0500—WASTEWATER IRRIGATION SYSTEM—RENEWAL
FORM:WWIS-R 02-21
Pursuant to 15A NCAC 02T.0107(b),if the application does not include all required information and the necessary supporting
documentation,the application shall be returned. The application and attachments shall be prepared in accordance with 15A
NCAC 02T .0100, 15A NCAC 02T .0500, and Division Policies. For more information, visit the Water Quality Permitting
Section's Non-Discharge Branch website. The Applicant shall submit an electronic copy of the application and attachments
uploaded as a single Portable Document Format(PDF)file to https://edocs.de i.nc.gov/Forms/NonDischarge-Branch-Submittal-
Form-Ver2,or emailed to Non-Discharge.ReportsAncdenr.gov if less than 20 megabytes(MB).
SECTION I—APPLICANT INFORMATION
1. Applicant: Butterball,LLC-Mt. Olive WWTF
2. Permit No.:WQ0000884
3. Signature authority:Lankford Ruffin Title:Director of Environmental Affairs and Sustainability
Phone number: [phone] Office Email:[e-mail]
4. Mailing address: One Butterball Lane
City: Garner State:NC Zip:27529
5. Contact person: Lankford Ruffin Email: [e-mail]
Primary phone number: [phone] Office Secondary phone number: ( ) - Select
SECTION II—FACILITY INFORMATIO
1. Physical address: 1628 Garner Chapel Road County:Duplin Parcel No.: 352100502850
City: Mt. Olive State:NC Zip:28365
2. Treatment facility coordinates to the sixth decimal degree:
Latitude: 35.142220° Longitude:-77.912938° Method:Unknown
SECTION III—FLOW INFORMATION
1. Permitted flow:2,000,000 GPD(The maximum allowable flow based on what has been permitted)
2. As-built flow: 2,000,000 GPD(The maximum allowable flow based on what has been constructed)
3. Average flow: 1,244,489 GPD(The average of all reported flows on the previous calendar year's NDMRs)
4. Hydraulic capacity: 62%(Divide the average flow in Item 3 by the As-built flow in Item 2)
5. Wastewater composition: Domestic : 8% Industrial: 92% Stormwater: 0%
SECTION IV—BILLING INFORMATION
1. Billing address: One Butterball Lane
City: Garner State:NC Zip: 27529
2. Verify the Applicant does not have any overdue annual fees:
https://deq.nc.gov/about/divisions/water-resources/water-resources-permits/wq-epayments
Pursuant to 15A NCAC 02T .0120(c),permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORM: WWIS-R 02-21 Page 1 of 6

SECTION V—OPERATOR IN RESPONSIBLE CHARGE(ORC)INFORMATION
1. ORC: Josh Tray Batchelor Grade: SI,WW-4 Certification No.: 987940,991798
Mailing address:PO Box 589
City: Mount Olive State:NC Zip: 28365
Phone number: [phone] Cell Email:[e-mail]
2. Back-Up ORC:Jason Conway Murphy Grade: SI,WW-4 Certification No.: 990502,989800
Mailing address:PO Box 589
City: Mount Olive State:NC Zip: 28365
Phone number: ( ) - Email:
3. Back-Up ORC: Glenn Franklin Lane Grade: SI Certification No.: 990500
4. Back-Up ORC: Marcus Shane Martin Grade: SI Certification No.: 987542
5. Back-Up ORC Jefferson Wayne Foy Grade:WW-4 Certification No.: 994317
6. Back-Up ORC Houston Bodell Howard Grade:WW-3 Certification No.: 993627
ECTION VI—OPEN-ATMOSPHERE STRUCTURES
1. List all open-atmosphere treatment and storage structures associated with the renewing permit. Attach additional sheets if
necessary.
Type Parcel No. Volume(gal) Liner Type Freeboard(ft) Latitude Longitude
Treatment 352100502850 13,000,000 Unlined 2 35.146249° -77.913697°
Storage 352100502850 41,000,000 Unlined 2 35.147984° -77.913140°
11.1114 SECTION VII—RELATED PERMITS
1. List all wastewater permits (i.e., sewer, collection system,NPDES, residuals)that have interactions with the renewing permit.
Attach additional sheets if necessary.
Permit Type Permit No. Relationship Type
N/A N/A N/A
SECTION VIII—MONITORING WELLS
1. List all groundwater monitoring wells associated with the renewing permit. Attach additional sheets if necessary.
Well Parcel No. Status Gradient Location Latitude Longitude
Name
MW-21 Permanently Abandoned
MW-22 352100502850 Active Upgradient Outside Compliance Boundary 35.144500° -77.923900°
MW-23 352100152405 Active Downgradient On Review Boundary 35.166100° -77.923900°
MW-24 352100152405 Active Downgradient On Review Boundary 35.163600° -77.920600°
MW-27 352100502850 Active Downgradient Between CB and RB 35.141200° -77.904800°
MW-28 352100502850 Active Upgradient On Review Boundary 35.137700° -77.905100°
MW-29 352100081087 Active Downgradient Between CB and RB 35.167500° -77.927400°
MW-31 Permanently Abandoned
MW-32 Permanently Abandoned
MW-33 Permanently Abandoned
MW-34 352100102850 Active Downgradient Between CB and RB 35.156400° -77.918900°
FORM:WWIS-R 02-21 Page 2 of 6

MW-35 352100102850 Active Downgradient Outside Compliance Boundary 35.156400° -77.919400°
MW-36 352100102850 Active Downgradient Outside Compliance Boundary 35.156100° -77.919700°
MW-37 352100081087 Active Downgradient On Review Boundary 35.167500° -77.927800°
MW-38 352100102850 Active Downgradient On Review Boundary 35.152700° -77.906400°
MW-39 352100081087 Active Downgradient Inside Compliance Boundary 35.17145° -77.93006°
(CP-1)
MW-40 352100349992 Active Downgradient Inside Compliance Boundary 35.16242° -77.91725°
(CP-2)
MW-41 352100448348 Active Downgradient Inside Compliance Boundary 35.15961° -77.91324°
(CP-3)
MW-42 351100827571 Active Downgradient Inside Compliance Boundary 35.15626° -77.93453°
(CP-4)
SECTION IX-IRRIGATION FIELDS1.1
1. List all irrigation fields associated with the renewing permit. Attach additional sheets if necessary.
Field County Parcel No. Deeded Owner Area Cover Crop Latitude Longitude
O1A Duplin 352100502850 Butterball,LLC 26.76 Coastal Bermuda 35.151400° -77.908300°
O1B Duplin 352100502850 Butterball,LLC 74.59 Coastal Bermuda 35.153900° -77.913600°
O1C Duplin 352100502850 Butterball,LLC 11.48 Coastal Bermuda 35.153900° -77.908600°
02A Duplin 352100502850 Butterball,LLC 18.61 Coastal Bermuda 35.144200° -77.906100°
02B Duplin 352100502850 Butterball,LLC 10.94 Coastal Bermuda 35.146900° -77.905300°
02C Duplin 352100502850 Butterball,LLC 9.16 Coastal Bermuda 35.149200° -77.903900°
03 Duplin 352100502850 Butterball,LLC 15.66 Coastal Bermuda 35.147200° -77.908300°
05 Duplin 352100502850 Butterball,LLC 18.03 Coastal Bermuda 35.143600° -77.919400°
07 Duplin 352100502850 Butterball,LLC 9.57 Coastal Bermuda 35.140000° -77.905000°
07A Duplin 352100502850 Butterball,LLC 6.12 Coastal Bermuda 35.138300° -77.905800°
Duplin 352100502850 Butterball,LLC 30.38
08A Coastal Bermuda 35.156100° -77.923900°
352100152405
Duplin 352100502850 Butterball,LLC 34.84
08BCoastal Bermuda 31.159200° -77.921700°
352100152405
Duplin 352100502850 Butterball,LLC 10.75
08C 352100152405 Coastal Bermuda 35.161700° -77.920800°
352100360453
09A Duplin 352100152405 Butterball,LLC 30.38 Coastal Bermuda 35.157500° -77.928300°
09B-A1 Duplin 352100152405 Butterball,LLC 4.25 Trees 35.163900° -77.927200°
09B-A2 Duplin 352100152405 Butterball,LLC 3.85 Trees 35.163900° -77.926400°
09B-B1 Duplin 352100152405 Butterball,LLC 1.75 Trees 35.158100° -77.926100°
09B-B2 Duplin 352100152405 Butterball,LLC 11.01 Trees 35.158900° -77.926100°
09C Duplin 352100152405 Butterball,LLC 21.48 Coastal Bermuda 35.165000° -77.927200°
10A Duplin 352100152405 Butterball,LLC 15.19 Coastal Bermuda 35.156400° -77.931100°
10B Duplin 352100152405 Butterball,LLC 31.42 Coastal Bermuda 35.158600° -77.921400°
10C Duplin 352100152405 Butterball,LLC 19.80 Coastal Bermuda 35.163900° -77.929200°
11 Duplin 351100851014 Butterball,LLC 26.13 Coastal Bermuda 35.159700° -77.936900°
FORM:WWIS-R 02-21 Page 3 of 6

Duplin 351100851014 Butterball,LLC 17.78
12 Coastal Bermuda 35.162500° -77.936400°
352100081087
13 Duplin 352100081087 Butterball,LLC 26.62 Coastal Bermuda 35.166400° -77.930300°
14 Duplin 352100081087 Butterball,LLC 12.07 Coastal Bermuda 35.170542° -77.931467°
Duplin 352100448348 Butterball,LLC 18.03
15C Coastal Bermuda 35.157278° -77.912900°
352100502850
16 Duplin 352100110650 Butterball,LLC 12.95 Coastal Bermuda 35.152978° -77.926786°
18 Duplin 352100152405 Butterball,LLC 2.25 Coastal Bermuda 35.157242° -77.932431°
Duplin 352100345301 Butterball,LLC 3.71
15A Coastal Bermuda 35.160769° -77.918903°
352100349992
15B Duplin 352100502850 Butterball,LLC 0.72 Coastal Bermuda 35.161747° -77.917756°
17A Duplin 351100827571 Butterball,LLC 14.95 Coastal Bermuda 35.152997° -77.932161°
Duplin 351100830382 Butterball,LLC 0.36
17B Coastal Bermuda 35.154938° -77.931942°
351100836386
17C Duplin 351100827571 Butterball,LLC 0.72 Coastal Bermuda 35.154122° -77.934578°
17D Duplin 351100732815 Butterball,LLC 4.58 Coastal Bermuda 35.156922° -77.937614°
Total Acreage: 556.88 1.111
ATTACHMENT A-SITE MAP
Was the facility originally permitted or had a major modification issued after September 1,2006?
® Yes-Pursuant to 15A NCAC 02T.0105(d),submit a site map pursuant to the requirements in 15A NCAC 02T.0504(d). These
requirements are:
❑ A scaled map of the site with topographic contour intervals not exceeding 10 feet or 25 percent of total site relief and showing
all facility-related structures and fences within the wastewater treatment, storage, and irrigation areas. Submitted with
previous application
❑ Soil mapping units shown on all irrigation sites. Submitted with previous application
® The location of all wells (including usage and construction details if available), streams (ephemeral, intermittent, and
perennial), springs, lakes,ponds, and other surface drainage features within 500 feet of all wastewater treatment, storage,
and irrigation sites.
® Delineation of the compliance and review boundaries per 15A NCAC 02L .0107 and.0108, and 15A NCAC 02T .0506(c)
if applicable.
Z Setbacks as required by 15A NCAC 02T.0506.
® Site property boundaries within 500 feet of all wastewater treatment,storage,and irrigation sites.
® All habitable residences or places of public assembly within 500 feet of all treatment,storage,and irrigation sites.
❑No-Skip Attachment A.
ATTACHMENT B-SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section I,Item 3 meet the requirements pursuant to 15A NCAC 02T.0106(b)?
®Yes-Skip Attachment B.
❑ No-Submit a delegation letter pursuant to 15A NCAC 02T.0106(c)authorizing the signature authority to sign.
ATTACHMENT C-FLOW REDUCTION
Does the existing permit include an approved flow reduction?
❑ Yes-Submit a copy of the flow reduction approval letter,as well as the measured monthly average amount of wastewater flow
contributed per unit for the 12 months prior to permit renewal. If any of these monthly averages are within 20%of the approved
flow reduction value,the Permittee shall provide a reevaluation of the reduced flow value pursuant to the requirements in 15A
NCAC 02T.0114(f).
® No-Skip Attachment C.
FORM:WWIS-R 02-21 Page 4 of 6

ATTACHMENT D—CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY
Is the Applicant a Privately-Owned Public Utility?
❑ Yes — Pursuant to 15A NCAC 02T .0115(a)(1), submit the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise.
®No—Skip Attachment D.
ATTACHMENT E—OPERATIONAL AGREEMENT
Is the Applicant a Home/Property Owners'Association or Developer of Lots to be Sold?
❑ Yes(Home/Property Owners'Association)—Pursuant to 15A NCAC 02T.0115(a)(2),submit an executed Operational Agreement
(FORM: HOA). Pursuant to 15A NCAC 02T .0115(c), if the applicant is a legally formed Homeowners' or Property Owner's
Association,submit a copy of the Articles of Incorporation,Declarations,and By-laws.
❑ Yes (Developer of Lots to be Sold) — Pursuant to 15A NCAC 02T .0115(a)(2), submit an executed Operational Agreement
(FORM: DEV). Pursuant to 15A NCAC 02T .0115(b), if the applicant is a developer of lots to be sold, submit a copy of the
Articles of Incorporation,Declarations,and By-laws.
®No—Skip Attachment E.
ATTACHMENT F—DEMONSTRATION OF FUTURE WASTEWATER TREATMENT CAPACITIES
Is the applicant a municipality,county,sanitary district,or public utility?
❑ Yes—Proceed to the next question.
® No—Skip Attachment F.
Does the hydraulic capacity in Section III,Item 4 exceed 70%?
❑ Yes(the hydraulic capacity is greater than 70%,but less than 80%)— Pursuant to 15A NCAC 02T.0118(1),prior to exceeding
80 percent of the system's permitted hydraulic capacity(based on the average flow during the last calendar year),the permittee
shall submit an engineering evaluation of their future wastewater treatment,utilization,and disposal needs.This evaluation shall
outline plans for meeting future wastewater treatment,utilization,or disposal needs by either expansion of the existing system,
elimination or reduction of extraneous flows,or water conservation and shall include the source of funding for the improvements.
If expansion is not proposed or is proposed for a later date,a justification shall be made that wastewater treatment needs will be
met based on past growth records and future growth projections, and as appropriate, shall include conservation plans or other
measures to achieve waste flow reductions.
❑ Yes(the hydraulic capacity greater than 80%)—Proceed to the next question.
❑ No—Skip Attachment F.
If answered Yes above,does the hydraulic capacity in Section III,Item 4 exceed 80%?
❑ Yes (the hydraulic capacity is greater than 80%)—Pursuant to 15A NCAC 02T .0118(2),prior to exceeding 90 percent of the
system's permitted hydraulic capacity (based on the average flow during the last calendar year), the permittee shall obtain all
permits needed for the expansion of the wastewater treatment, utilization, or disposal system and, if construction is needed,
submit final plans and specifications for expansion,including a construction schedule.If expansion is not proposed or is proposed
for a later date,a justification shall be made that wastewater treatment needs will be met based on past growth records and future
growth projections, and as appropriate, shall include conservation plans or other specific measures to achieve waste flow
reductions.
❑ No—Skip Attachment F.
ATTACHMENT G—EASEMENT,ENCROACHMENT,AND LEASE AGREEMENTS
Does the Permittee own all of the land associated with the wastewater collection,treatment,conveyance,and irrigation system?
® Yes—Skip Attachment G.
❑ No—Pursuant to 15A NCAC 02T .0116(c),provide a copy of all easements, lease agreements, and encroachment agreements
allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and irrigation system on
property not owned by the Permittee.
FORM:WWIS-R 02-21 Page 5 of 6

TTACHMENT H—AFFILIATIONS
Are the Permittee's affiliations of record correct? Check affiliations.
❑ Yes—Skip Attachment H.
® No—Provide the corrected affiliations and their contact information.
ATTACHMENT I—COMPLIANCE SCHEDULE
Does the existing permit include any Compliance Schedules?(See Section I of the most recently issued permit)
® Yes—Submit documentation that the compliance schedules have been met.
El No—Skip Attachment I.
ATTACHMENT J—CIVIL PENALTIES AND OUTSTANDING VIOLATIONS
Does the Permittee have any existing civil penalties or outstanding violations?
El Yes(civil penalties)—Submit payment for the civil penalty,or proof of remission request.
El Yes(violations)—Submit a copy of your response to the Notice of Violation.
® No—Skip Attachment J.
FORM:WWIS-R 02-21 Page 6 of 6

ATTACHMENT K — INDUSTRIAL WASTEWATER
Does the wastewater composition in Section III, Item 5 include any industrial wastewater?
® Yes — Proceed to the next question.
n No — Skip Attachment K.
Has the nature of the industrial wastewater changed since the last permit issuance (i.e., changes in industrial process, introduction of
new materials or chemicals, etc.)?
❑ Yes — Provide a chemical analysis of the wastewater pursuant to the requirements in 15A NCAC 02T .0504(h). Provide an
overview of the manufacturing process; an inventory of all chemical and biological materials used in the manufacturing process;
and an overview of the cleaning and treatment methodology.
No — Provide an overview of the manufacturing process; an inventory of all chemical and biological materials used in the
manufacturing process; and an overview of the cleaning and treatment methodology.
ATTACHMENT L — SETBACK WAIVERS
Does the existing permit include setback waivers?
® Yes — Pursuant to 15A NCAC 02T .0506(d), provide setbacks waivers that have been written, notarized, signed by all parties
involved, and recorded with the county Register of Deeds. Waivers involving the compliance boundary shall be in accordance
with 15A NCAC 02L .0107.
❑ No — Skip Attachment L.
APPLICANT'S CERTIFICATION
I, Lankford Ruffin attest that this application
(Signature authority' s name as noted in Section I, Item 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application package are not completed, and that if all required supporting information and attachments are not included, this
application package will be returned as incomplete. I further certify pursuant to 15A NCAC 02T .0120(b), that the applicant, or any
parent, subsidiary, or other affiliate of the applicant has: not been convicted of environmental crimes under; not previously abandoned
a wastewater treatment facility without properly closing the facility; not paid a civil penalty; not been compliant with any compliance
schedule in a permit, settlement agreement, or order; not paid an annual fee.
Note: The Applicant's Certification shall be signed pursuant to 1 5A NCAC 02T .0106(b). An alternate person may be delegated as
the signing official if a letter is provided pursuant to 15A NCAC 02T .0106(c). Pursuant to § 143-215 .6A and § 143-215.6B, any
person who knowingly makes any false statement, representation, or certification in any application package shall be guilty of a Class
2 misdemeanor, which may include a fine not to exceed $ 10,000 as well as civil penalties up to $25,000 per violation.
3 -
Signature:
or I�---- Date:
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email: Laserfiche Upload:
Non-Discharge.Reports ar,ncdenr. ov https://edocs.deq.nc.gov/Forms/NonDischarge-Branch-
Submittal-Form-Vert
FORM: WWIS-R 02-21 Page 7 of 6

opo.
_ i Dewberry®
, . . ... _
\ ____
\. r y
.. ,, - - MONITORING WELL INFORMATION TABLE EX. FIELD INFORMATION TABLE
/ - ` I \\\\ i •`' • /� FIELD NO. LATITUDE LONGITUDE NET ACREAGE Dewberry Engineers Inc.
\i , / / k,, f r ,� Monitoring Well Boundary Type Location 2610 WYCLIFF ROAD
SUITE 410
`\ \ \ i •�, •
{ MW-21 Not Applicable Upgradient 01 A 35.151400° 77.908300° 26.75 AC RALEIGH, NC 27607
^ " �' \ \\\ �� �..� r^. • PHONE: [phone]
i \ \ j' ,.fir' -''* MW-22 Not Applicable Upgradient 01 B 35.153900° -77.913600' 74.59 AC FAX [phone]
\ \ \ NCBELS#F-0929
• \ r /-., • \ MW-23 Review Downgradient 01 C 35.153900 77.908600° 1 1 .48 AC
' FIELD GlczycRFORMERLY �. ,: I - , `� MW-24 Review Downgradient 02A 35.1 44200° -77.9061 00° 18.61 AC
I I CAROLINA TURKEYS
- I 94 I IAI 'n0081087 --' \ MW-27 Review Downgradient 02B 35.146900° -77.905300° 10.94 AC
I CP-1 • I k �< 40, ti
/ / -:4. ., _- - ' i/ i i`� /--- - • . .... MW-28 Not Applicable Upgradient 02C 35.149200° -77.903900° 9.16 AC
\ '
/% r•_ ' /' '� _ ._ . • MW-29 Compliance Downgradient 03 35.147200° 77.908300° 15.66 AC
• / / MW-31 Review Downgradient 05 35.143600° 77.919400° 18.03 AC
FORMERLY I • \/ �. s r j/ ` �:b / - ••'•` y ' ifa
HERRING,PHYLUS GARNEr.: " •
IK/ FORMERLY ilk I i ,
PIN 3511008871181 - / - / /' / r, i.• l
WHITFIELD, MARTHAANN -I /\� 1 k• / :.. r M W-32 Review Downgradient 07 35.1 40000° -77.905000° 9.57 AC
\ OBI 351100880164 I 1 i / I % -z /, ./,-; :y «
r / 'l' / `' MW-33 Review Downgradient
/ - 07A 35.138300° -77.905800° 6.12 AC
/ >
- I I ' ' / jo �o�- FORMERLY i /: --t• - MW-34 Review Downgradient
L� / BUTTERBALL, ,,, ,.A < 08A 35.156100° -77.923900° 30.38 AC
\ I / / R 352100W6823 /, e "�
-
/ i' •., 4; MW-35 Compliance Downgradient
/ I MW-29L / / \ 08B 35.159200° -77.921700' 34.84 AC
I I-; i ' / • " / + �. MW-36 Compliance Downgradient
:j I/ MAW-37 I_ -* /. ,/*
j/ _ _% ;�, r •
- E ` • 08C 35.1 61700° -77.920800° 1 0.75 AC
• i • J, ;-1. M W-37 Review Downgradient
/ .' 09A 35.157500° -77.928300° 30.38 AC
(<ICRFORMERLY ; / , .� ' \ i' �/ / r,,% ; \ :�..- MW-38 Review Downgradient - -
WHITFIELD,MARTHAANN .,
I 351100773810 Kan ''' \--- M ) 09B Al 35.163900 77.927200 4.25 AC
MW-23 . / / / W-39 (CP-1 Review Downgradient
\ �\ / �� \ -, .,\ / %' / --., A - ;" r' , ' - - 09B-A2 35.1 63900° -77.926400° 3.85 AC
\ •\ / _ _ �; \ *./.
/ / / « '' MW-40 (CP-2) Compliance Downgradient
• / / ,/ % /' 09B B1 35.158100° 77.926100° 1 .75 AC
,.:....
' \\ .�* / ' // \ y:. / ,x,si- I': (' MW-41 (CP-3) Review Downgradient
•
,•
\ / = MW-42 (CP-4) Compliance Downgradient
\ •� ',/ // %" i ��\ \ /IACdltl4NlF�S? / % `iO, 09B-B2 35.1 58900° -77.9261 00° 1 1 .01 AC
�,�. ,/ / CAROLINA TURKEYS \ ''` ..' �s�
�`'/ . - / �''� \\ \ /� GIg352100360453 / � I -,�-'• � . y `' y �- -� 09C 35.165000° -77.927200° 21 .48 AC
// '//r l \ \ ti ' �` ;�' ;/ / jV'` * Note: Wells MW-39, MW-40, MW-41, and MW-42 were renamed in 2018
, / / � I � - 11- .J.f.‘.,-.......11...,,,.*:"Iti......-'._.:-.
•� �,' � 10A 35.156400° 77.931 1 00° 15.19 AC
Aidoilo
FIELD ^r/ . to be consistent with the site s namin convention. The former names are
�/ i1 __ --- I 09C _ \ / o[ FORMERLY �- \.-\ t� ��:- ' ;. :/ g+� I1 I �_ \ BUTTERBALL 1 / g* - ;' „E. "- ` ' p '' also provided in the table. 10B 35.158600° -77.931400° 31 .42 AC
I \ // RE 3521003695'13 % \ �' � � 7 .y,_- II \. .-
.a[�.( .]-(;\WIFE ROSE,DEBORAH W. • ' // i' ' i �.. ` - 1 , 10C 35.163900° 77.929200° 19.80 AC
: : ,
PIN351100675777 , / -. _%' v'� -7/ -------� ij • _�\ . / \ � �� # z ' ~: c `+� 1 35.1 59700° -77.936900° 26.13 AC Z
/ �0 ) i i / / ,/ / \\ 1 .� .r �e� `� Y ,4? +crs* ih , * I ;{.� 2 35.1 62500° -77.936400° 17.78 AC J J
cam tlm �`� % - t'/ i In
/ / / / %, \\\ \\, �` / 1 • .• le-'"L , ,`1 , 4 r f.. 1 3 35.166400° 77.930300' 26,62 AC Z J J 0 N. W
II':
CHERRY, / / .. MUM '
PIw3511oo6r / / o o- FORMERLY / � � v {` .. °¢. a'' O N d
/ �' v / / CAROLINA TURKEYS - / / / \\ \ / \ . lrUl�l'��J ,, eK�''c -`/ �+ +'. . �� �rar� 1 J M
F / -�_ 1 / / 4 35.170542 -77.931467 12.07 AC
/ • OBI 352100152405 �/ / / ' \ \i \ ,r \ 9� \ .., e.
%/ + l Il r-_ �� ' �< • //r;. I ► IO D) II / -- \\ . . ' � ;\, •..0,- •�'A f ' 111x.-4,!4' �'ky.►. 1 5C 35.157278° 77.91 2900° 1 8.03 AC Q m Z LL O
/ I I FIELD I ------ may .� I I / \ ' ' , . . �,�`' mcc Q o
/ _.o ' !+ I 108C / \ / .•rZ FORMERLY ' �•.`, �, ^'r' ^ O
i / I I ` i'-,"'� „� t 1 I ,'. ,� ��,IM 453429 \ \ ;•`' -•+ `'tl'� 'r r�AZ 1 6 35.152978° -77.926786* 1 2.95 AC
/ III O I Y` •- -' "• 1 i / \ , RBA�L,L�C �� i- r rs.�" °£ ��g.. W
i / 1 ` �� w� '': `'` .�'t , \\ _ r ,\ I ' - .4•-x` r -;" 1,4';. 18 35.157242' -77.932431 2.25 AC I- 0 Z a
011.
// \ \ \ `(' * r :;`'. 'j�/ / -' I'' ` CP_2 .\ �,, ;. •-ar,, �,':+�. Y•;-3,'.4,;9. 1 O.
li Z
/ • !� iliii �s,_ TOTAL CURRENT IRRIGABLE ACREAGE 531.84 AC a <
/
�'.,t .- .\ , / I .,,_ ' A FORMERLY
NOW UR FORMERL\ // i / ..ft , �s �\\\/ ,. I ''�
CAROLINATURK-,, / _., - / '\RY 1 / \ 0 0
�jQ'�.,400851( . '-' / / 14 RUMOR TTERB FORMERLY /� FUTURE FIELD INFORMATION TABLE
::-,
\ / / / BUTTERBALL,O ''�
\ / , F I E L D �c j G�J 352100349992 '\/ \ �!., = i.
�> \ / ,/ / (AREAS b 110 '� 90 o D _,--' /. .-FUTU `// / \ \.\ C � , 1.-:
- �,� � / 4,�, /- '' ► �,-� ai, d. ` FIELD NO. LATITUDE LONGITUDE NET ACREAGE\ j ,�ef"� 74"
� .+ ti .�. FUTURE 15A 35.160769° -77.918903' 3.71 AC
/ / I ; ' HELD 1 / CP-3 - '? - �' s r-. y,a� ,
,. . / / I I Y ,t 08'B • I ,' % ''- . • +.�r:�4 FUTURE 15B 35.1 61747° -77.917756° 0.72 AC
% / I TRV#2 �OELD Ir' IAMCI1 FORMERLY \\ \ •1" „, .r 11*•.. !"'•
BUTTERBALL,II1 $
\ FUTURE 1 7A 35.1 52997° -77.9321 61° 14.95 AC
\` / / i lirz gm352100345301 o- FORMERLY \ �, ( _ ,:�i { �!#" . ry�_y-ti .� ,rt' a
,.. ;
\ j / / 1 BUTTERBALL,II \ n • �r
G�J 352100448348 \ ; '
.,` / / �,J 7 7 ,' i• �• • FUTURE 17B 35.154983° -77.931942° 0.36 AC
\, / / / r \ TRV#1 ,� \\ =; �` '; :,4 ,�. yY x• ':,, �> ,
\ / 1 • \ ' I ' t' s�'ti �''"t'°y' ! '> r FUTURE 17C 35.154122° -77.934578° 0.72 AC
- . \ / / I 1 (A �CQFOORMERLY i C'•�, � r� / 1 1.,. \ em s a• GAC4 ` �f �.Y . �rt �- + t
/ \ BUTTERBALL,O ' 1 \ \ , s .."� R- •
\ I RA352100342043 / �.\ 9g I ^�.,•a. .. ,'' „,, P.,.. . '� ; FUTURE 17D 35.156922° -77.93761 4° 4.58 AC
FUTURE \ 1 FIELD' . / I \ mod,, �: ,� s � �
di FIEL-D I 18 MW-33 A / . - I I \ ,�, cr ; \
\ ( I ; •. .�s„o, , f TOTAL ADDITIONAL IRRIGABLE ACREAGE 25.04 AC
\ M -32 A4 . -. - �. ,,C--
I 1 BOLD ( / / _-� ,.,-• ,:,.,�.s3 .>- ,�,, FIELDS HAVE BEEN PERMITTED, BUT HAVE NOT BEEN
Gro.E FORMERLY I I 1 1 / / , ' !� �[. ry` �
CAROL INA3 / I \ I - - - 09A �1 / ------ CONSTRUCTED TO DATE.
PIA 351100732815 ; '- I.
M, -34 M -3'6 / / -,� `•,` � a _
41 \ 1MW 35 i ,-
-�1., - NOW,OR FORMERLV • -_ - \ / - \_,_______ ____
- / - - ---. •
SEAL
GOSSMIAN,F JOSEPH,BISHO_ ROMAN CATHOLIC DIOCESE RALE, y/1I O HELD) \ •
/ --. - \ \ t` -- -
1 /• PIN 351100836386 \\ , IJ� 1 / , \\ \ // _ ,'\• -__ wYM
� y ---__ - ..7 _ IRRIGABLE ACREAGE
o I12n
O CR FORMt i"N \ Emu) Oj 8A I s •
CAROLINATURKL'J, FIELD /'-� \ - j k, ELECTRICAL I " // // \\`\ \\�\� �'_, - 2. ' '�'' `�' -
PE 351100830382 - / -/ \ \ • _ I \ / \ s' 1. !A
17Biii \ ., I / \ / ` SUMMARY TAB L E
POWER , / / / \ '\ ,
CP-4 --- \� \\ \\ \\ B'UOdDOG / / L�OELD 1 r \ ` 4;
/ \, \ D / / \ . 1 ---', "{ TOTAL CURRENT IRRIGABLE ACREAGE 531.84 AC
�. \\\ .. �`\ \ / / / / l�J i© 0 1 :'fir ;,{,4 -
/ ` \ // / • 1 '\ ' `o 1 TOTAL ADDITIONAL IRRIGABLE ACREAGE 25.04 AC
1 MW-2-11 \ \` // \ \ \\ // / /'' - I. I I TOTAL IRRIGABLE ACREAGE 556.88 AC
\ \ .// \ \\ I \ \ - ' / I 1 GCRFORMERLY
4\.7
FUTURE \ \\I \ - / CAROLINA / - .�, 4 . .
\ \ FIELD \ \� `-'� I RA352100502850 \ SEAL
ARE ��. \ I \\,�
It .
\�OELD I, 1-7A /�/ \\ FIELD I • I011E3 \\\M`�38 \•,\
9� / 90 \ Ii FWD)
Cj . •\
Yj10 Yoh- FORMERLY
,\ I \
CAROLINATURKEYS TRAILER PARK • / ;, \\ 1� , \ \ \`\ \
O 35110082.7571 \I / \
\ KARIoM- FORMERLY \ Q =R.• \ \ \
\ • CAROL INA TURKEYS �I ,, �'- .Ora-0..• r7 \ \\ \\ \ /
. ., \ \ \
'oo�' FORMERLY t \ \ .>/ . _
/ \ I
SASSER, GOODSON,� /� 1 .. Inv__
`� \ / • \ \ I \
Gla 351100720335 / \ \ / / s ` \ \\ I I KEY PLAN
/ a - JOW CR FORMERLY \ \ / \ \ 1 �'`
, • ill? TRACE WHITFIELC \�'�\\-'i / ; ` �;� \ `\\ / HOLD i I /�I---_
1 ••.... '�.4 .
100916215 �x _'' \ V. \ \ i 1 /.\ I \ \r;
6 i�\ Gil CR FORMERLY \\\ ' / ? V U/n1 / / �-_----- �\ \,
- - 0,, ,, ,
, �/ GARNER,LOTTIE,O II CRFORMERLY \\\ - '�/ \ .k\• /l l / �i ��\\ \
/ ' - _ OE352100117320 GARNER,THESIAOTRUST �,. ��� / R \ / \
j �F O 352100311475 // -\ 1 \\ ' % / / // -
. , "ii
y 4 / /
NOW OR.FORMERLY I' - •- \///
� I •
�1 �� L \' <\ - / / / -
BRITT HELEN WHITFIELD r •- _ - _ . `
,.
Pw35n NOWHITFI NOW OR FOR ERLY �- .I / e �'' .r. \ - �,� / / _
CARTER,GRADE "HITFIELD l / /�� \ ` N. '� // 1 I FIELD. • ,
02C
• .. \\' „l j SCALE
, �' '3 't, l �, 1 NOW OR FORMERLY
II
NOW ORFORMERLY I - 'lr ,k- G�i, /. ri --r�,U__-!.• . , } / !-_�1 JAKEIPRI321 OSO6s62.rit
M'�GEORGETHOMAS&M(o]�$o aROSE8.WIFE� �.,'- 1 ` �;`�r � l /[phone] I / / I F � r { t< l l 0 200 400 600
OIL :�,i\ / / / ( lo oCR' FORMERLY / l NOW •OR FORMERLY ■ • - Feet
' \` BUTTERBALL,O ik,. 41 MG \ / GG�C�7DGub�
oiii
/ /: .j / / / •�• - -- '! �3524 00 80524 6
�, / / A O�'+I 352100207684 LAG OO N - / i
, ,,� l I \\•
/ / % .,�' �\ / I LEGEND:I /•.\'\ / j / I://
, � / , I1 inch = 400 feet
` ' ..,,\. / // j' ://
}!+•f //> I1 GL-�II Fi?'�i,M�Ey:R},yL,Y� PROPERTY LINE
_ r_��a,. �_ / \'\ % / • %' ,t � , , - l % / �352000893968
f�. _ / _ 'Rr' IOwC>3FORMERLY /' `�� / / •"' / / �� APPLICATION AREA
S '�+~ 4ir - - -��- - vRNER, _ll�l '\ •,% % , /' '- _�• :a✓ % / FIELD , >'
* �` 351000884593 /'\, \ - / /T'� / o o FORMERLY \ / y -' _ % j / Qj yiB
r--_ dote. �,.`'� �; CAARROLINAu�r �\:`' \ t _ _ // in GO / / / /' • 125' REVIEW BOUNDARY
14�; +. \ 352100110650 / `,\ I: ,�. l`. / \\ \, / I NE-Lib) / /
. ,- • y - i \ LAGOON I o / I
I /
NQWaR FQRMERV\ ' q�/,7CR FORMERLY �. `" Al*., / 250' COMPLIANCE BOUNDARY
6EST$JOHN MARK 8 \ ,
., ._
r / PIN351000998816 , / GARNER,THERON( \
GUG�3520001 ( r \ P O • ..I
ealzmnroninlill
\ � _ I , / (50 FROM ADJACENT RIGHT-OF-WAY
riE HRs \ < �. r I I
• NOW ORF IY ,.4. 1.12itr4
'
{ T' `� _ °96'0' y':` !� \ • -us ulna AND NON-BUTTERBALL PROPERTY
GARNERI
, , • ��.-._-.. •--•- ` PIN 352000...vti62 - \ \ `' y•t _ I 1' / /
%/q ' `� \3, II \ r'l' . . . . , „�,� '�`` � • /40.0 ••�. BOUNDARIES)
iki , \ \ •,,_ I . r--E .,,,,,,,,,--\
.r
3.-.. / N°W oR % \ \ \� ► i' -/ . 1 HELD I 3 r" / / / / G+S n7CR FORMERLY
• �\ - `� I I I EFFLUENT \ \ /10r / / MONITORING WELL
,i PIN•351000998490 � ./' - / 1 I I I ` \ / 1.� PRICEO`I FARM, (MONITORING WELLS DENOTED
/ NOW OR FORMERLY �' \ \ C° / PUMPING \ /
rri'• ' ,',• ' x PATE, '� \ O CRFORMERLY '�• rr \ / / yam, \ \ ; / , FIELD Nki352000891230 WITH (A) HAVE BEEN ABANDONED)
.r pm351000995482 '\GARNER, o i• `•- \ /
\, �'� \ u - - _ ,; \ / STATION �`�. \ \\ // / I �1. - \ / oj�off- FORMERLY 1 r��' I ILFRME \ \ Opp 352000191176 i• • ' \ / - t11 - \ / 1/ M ® \ \ / \ ICONTROL POINT A
`-r \` / '.- Go3510009980277 _-A \ T''\ ►cam \ \ / ,r. '� __ / 1.-\: �! / / rumFORMERLLY �, \ \\ / / r ' G ` / I��, / oO off- FORMERLY GARNER, J kI �i \ / / l'lf PACKATGED/ / \ \ m352000097008 \. r �� \ \ NOTES,� .� YE 51 0098894NTHONY� \ \ ./ ` / .. �, / // ,i . x'. WWTP /i,;�« ) \ \ 11106(iirrorrM
/• / ! 1 -""\ \ -i ,, \ F `"� '� III.: \ \\ 1. LOCATION OF MONITORING WELLS, EXCEPT CP-1
THROUGH CP-4 IS BASED ON A SURVEY PERFORMED BY
/ / ownoff- FORMERLYi • • -.� / \ :iDEWBERRY ENGINEERS INC. FROM AUGUST 24, 2015 TO
NOWyRFD / OCR FORMERLY YE�ZER,ANTHONYd, , \ / •. '`�• -
/ GARNER, RUSSELL GOG�351000989623 ` •
/ \�-i� I r +-a^ • +- rrl� , ;j( \ \\\ -• N ' _ //
GkIffi9000883503 =� '' I • �v�`, 1:F \ \,- _- , ,r.-'' OCTOBER 23, 2015.
N.
\ >A r •'hiR "49 `T' r r+� t `�-__��� No. DATE BY Description
1jo LK FORMERLY \ • , ' •' , ` �;,;, _� , .� alit 2. LOCATION OF MONITORING WELLS CP-1 THROUGH CP-4
_ IS BASED ON A SURVEY PERFORMED BY DEWBERRY
WALKER,SANDY \ _ .. _ �. - � + ,,M ' '417, • ;0� , 4 �1- �* /+ s .
REVISIONS
Waal_FORMERLY - � - ,J ••
G2�ICL3 0=�1352000080209 1 ' � ' � .. __ � :. ` 'e.•.�*"S;':n. . .�.. 1��j s� ! - ����
SIMPSON,CORAZONrL4o I »'� 4218-• �,,,: _ _ ( "M,, �'+'• _ Y
I IRE 351000982265 ,_ .... - _ 'mod 7 . 1t�+k. ' '�`�. ,,, + --
.�» t „ 2pfq MW-z O \ ENGINEERS INC. DATED DECEMBER 11, 2017,
/' ti•..,�,, 4,i. - - '''0, / \ -----� � -• ' • )r " t # �1' �' ,, t i // - ----------------i 1 DRAWN BY
NOW ORQa I 'r ., -' . - �: ,,,,�,. ; ►• i / / 1 \ r r 3. HORIZONTAL CONTROL (NAD83) AND VERTICAL APPROVED BY
, CHERRd', m 1 _
m351000879907 o Y1�off,- FORMERLY I \ ' / %
\ t `� , ,� ;�4 i / CONTROL (NAVD88) ESTABLISHED BY GPS
• • / / I NOW OR�FORMERLY
1' / /• �. ' e A kiNKLOM� `\ '� '// = . 4,A- '`t. / / 1, I / BLIZZARDo OBSERVATIONS AND COMPUTED USING NORTH CHECKED BY
/ /imy-• •/' /,- \ -��-kt 1 RN F2000071910 .\` ,f , n y ;,,i / i , �/ PIN352000872940 CAROLINA GEODETIC SOCIETY VIRTUAL REFERENCE DATE 03/03/2020
/ /�.. \�� - _� (< No�Q' FORMERLY % 4 i *. y , w. / % r�f12f1 I1 ,
1 - - ` GARNER, I DIXON jar O'j - • / ; IrUIKIhI�J / STATION SERVICE (VRS). CONTROL POINTS ARE AS
/`\ -/� /' IIPI' \ \ - gm 3520002,70666 :.r• id: ,,..//%' / i / ' '' I FOLLOWS: TITLE
/ NOW OR,FORMERLY i'
S MPSON,CORAZON NGO - % r i
// '\,/' /• \ y PIN351000974483 \ 1.�/Z i - ' /'� �4. ' -/- / ''
ar,
/ ti \ \;` ` '�; /�%%'.. '/'/ o ,/ `\ / ..�''' TRV#1 TRV#2
/ ' o�j'FORMERLLY OCR FORMERLY . .�y�' '„� s/ .-. /
.-"','"/
' / \ CHERRY, j MAXWELL FOODS,O • �" �� ode • / /
G1I6Qo�' FORMERLY v „�" is J / % LAT: 35.158095 LAT: 35.158795
it--/' ' CHERRY GIg351000971405 \ •
1 (i 352000059678 / _ r�ls. �s NOW OR FORMERLY "5 N / ' j10 off- FORMERLY
G�I351000877225 \ l,, '� / \ LONG: -77.932035 LONG: -77.932615 ATTACHMENT A
NOW OR,FORMERLY •• / .. /�/ \, �352000575205 - / MOZ'INGO,ALBERT DOUGLAS
_ , '/ /- A /
SIMPSON,CORAZON� \ \ ., . •1 '1 �„/ W \ '/
/ \ 352000875425
PIN•351000762572 / - _ . .
\ J \^ ~ N
` I�OELD \ NOWOR_.SHAREIV 4. NORTH ARROW IS GRID NORTH AND ALL DISTANCES ARE
�/ `� '1 •1 - .- _ __ /.'. ♦\ �\ \ PI NLIMA00016 9ELLC
\ \ - .` OCR FORMERLY
1 \ �7/.\ GROUND DISTANCES.
- \ _„• '� BUTTERBALL,I `A \ ,
•� AA '" \ Q oCQ' FORMERLr \ ,/ •^,� \' 1 ` 1 `\� ' - "'-' OBI 352000469782 � \
of off- FORMERLY SIMPSON,CORAZON eo\ y \ \, -/-'` o �o�' FORMERLY -` �� 5. PROPERTY OWNERS PRESENTED HEREIN ARE BASED ON PROJECT N0.50126777
GIG13510008E'O55 / , MEJERRY1,PRICEFAMILY� INFORMATION OBTAINED FROM DUPLIN COUNTY GIS
SIMPSON,CORAZON� ` �'\ � -/'
• Got 351000763488 " �1 ' N
• \ ^` { ` --/ -'- 352000365385 v +�I►,. �� MW-2�8
NOW OR FORMERLY
ACCESSED ON SEPTEMBER 26, 2016. DOCUMENTATION
DUPLIN•COUNT AOF
'' .' Ilir \ 4 ` E AMERON� `` -/-- ' PIN352000861664
MN351000965696 \ _< 7^ CRFORMERLY �; WAS PROVIDED TO NC DEPARTMENT OF
c.i.,' \ j 1 .�` ,i U(}IQJERRYdPRICE FAMILY0� �p - _` �_ -
352000653871 ENVIRONMENTAL QUALITY ON MARCH 3, 2017 WITHIN
•, '' THE PERMIT MODIFICATION APPLICATION WHICH
\ , NOW OR FORMERLY •, '\� -/' / N./ !�, \. oQ''I Ili VIZU lam, MARGARET e. / \
ark ,` i / 351000857203 `�� r NOW OR FORMERLY N
• - M/iXWELn;O�DS-1LTLC / N '
- PI"352`°" `- DEMONSTRATES PARCELS IDENTIFIED BY DUPLIN
COUNTY GIS AS OWNED BY CAROLINA TURKEYS ARE
OWNED BY BUTTERBALL. SHEET NO.

North Carolina Department of Environmental Quality
Division of Water Resources
Permit Number: WQ0000884
Permit Type: Wastewater Irrigation
Facility Name: Butterball - Mt. Olive WWTF
Facility Addressl: 1628 Garner Chapel Rd
Facility Address2:
City, State&Zip: Mount Olive, NC 28365
Owner Information Details:
MUST submit a Change of Name/Ownership form to DWR to make any changes to this Owner information.
(Click here for "Change of Name/Ownership"form)
Owner Name: Butterball LLC
Owner Type: Non-Government Owner Type Group: Organization
*** Legally Responsible for Permit ***
(Responsible corporate officer/principle executive officer or ranking elected official/general partner or proprietor;
or any other person with delegated signatory authority from the legally responsible person.)
Owner Affiliation: Lankford Ruffin Title: Director of Environmental
Addressl: PO Dox 2309 One Butterball Lane Affairs and Sustainability
Address2:
City, State&Zip: Garner, NC 27529-2389
Work Phone: [phone] Fax: [phone]
Email Address: [e-mail]
*** Permit Annual Fee Billing ***
Billing Month: December
Invoice Number Invoice Date Invoice Due Date Invoice Amount Invoice Status
Owner Contact Person(s)
Contact Name Title Address Phone Fax Email
Bill Folk Vice President One Butterball 919-921-9273 [e-mail]
of Operations Lane, Garner, NC
27529
Facility Contact Person(s)
Contact Name Title Address Phone Fax Email
Permit Contact Person(s)
Contact Name Title Address Phone Fax Email
Joshua Batchelor Wastewater Manager 1628 Garner Chapel Rd, Mount Olive, 919-658-6743 [e-mail]
NC 28365 m
Permit Billing Contact Person(s)
Contact Name Title Address Phone Fax Email
Butterball LLC PO Box 589, Mount Olive, NC 919-658-6743 919-658-5865
28365-0589
3/11/2022 Page 1

Permit Number: WQ0000884
Permit Type: Wastewater Irrigation
Facility Name: Butterball - Mt. Olive WWTF
Facility Addressl: 1628 Garner Chapel Rd
Facility Address2:
City, State&Zip: Mount Olive, NC 28365
Persons with Signatory Authormi
ity
Type Contact Name Title Address Phone Fax Email
Permit Craig Leviner Complex Manager 1628 Garner Chapel Rd,Mount 919-921-9021 [e-mail]
Olive,NC 28365
Permit Steve Swan Plant Manager 1628 Garner Chapel Rd, Mount 919-658-6743 [e-mail]
Olive, NC 28365
Permit Joshua Batchelor Wastewater 1628 Garner Chapel Rd, Mount 919-658-6743 [e-mail]
Manager Olive, NC 28365 m
Owner Bill Folk Vice President of Operations One Butterball Lane,Garner,NC 919-921-9273 [e-mail]
27529
Permit Jeffry Shamblin Plant Engineering Manager 252-671-3201 [e-mail]
—
Designated Operators
If the designated operators listed below are incorrect or no longer associated with the collection system,the information can be updated by su
a completed"Operator Designation Form"(Click Here for ORC Designation Form). Please provide specific details as to the changes requested,,
the addition/removal of designated operators. For all other operator questions or issues,please call 919-807-6351
Facility Classification: SI
Operator Name Role Cert Type Cert Status Cert# Effective Date
Joshua Tray Batchelor ORC SI Active 987940 2/21/2011
Glenn Franklin Lane Backup SI Active 990500 2/15/2011
Marcus Shane Martin Backup SI Active 987542 2/15/2011
Jason Conway Murphy Backup SI Active 990502 2/15/2011
Jason Conway Murphy Backup SI Active 990502 2/15/2011
Facility Classification: WW3.
Operator Name Role Cert Type Cert Status Cert# Effective Date
Joshua Tray Batchelor ORC WW-4. Active 991798 2/21/2011
Jefferson Wayne Foy Backup WW-4 Active 994317 2/14/2011
Houston Bodell Howard Backup WW-3 Active 993627 2/15/2011
Jason Conway Murphy Backup WW-4. Active 989800 2/15/2011
3/11/2022 Page 2

Attachment I-Compliance Scheduled
Butterball's land application permit, last issued on May 11, 2018, includes an annual
reporting requirement for groundwater exceedances in Section I. Item 6 of permit WQ0000884: "The
Permittee shall submit an annual report to the Wilmington Regional Office, along with the GW-59s
summarizing any exceedances of permitted monitoring well limits and corrective action taken."
Per discussions with DEQ in 2019, the annual report is to be submitted by April 30 each year for the
previous calendar year. Butterball has met the required compliance schedule.
Reporting Year Compliance Report Submittal Date
2018 Annual Groundwater Report February 27, 2019
2019 Annual Groundwater Report March 5, 2020
2020 Annual Groundwater Report February 16, 2021
2021 Annual Groundwater Report February 7, 2022

Attachment K-Industrial Wastewater
Butterball operates a turkey first processing facility.The cleaning/treatment methodology consists of
spraying and wiping down equipment and the surrounding area to ensure the production area is
properly sanitized.
Inventory of Chemical Materials:
1. Antifoam 1500 (LAF103A-275)
2. Biorem CD-20 (LEP1A-5L)
3. D7 Part I (LS300A-DS-250)
4. D7 Part 2 (LS301A-DS-250)
5. D7 Part 3 (LS302A-05-05)
6. Enzyfoam (LEP2A-05)
7. No Foam DT(LGS17A-55)
8. Q Guard (QBL2A-CS)
9. Saniox (LPA13Z-53)
10. Smart Step (GCP108A-360)
11. Zanitize (LS1D-275)
12. Super Force (LOC15A-275)
13. Microtox Plus—(LPA22A-318)
14. Handisan—(LS9A-275)
15. Sodium Chloride
16. All White Granulated Sugars (Sucrose)
17. Carfosel 996 (sodium tripolyphosphate)
18. Carfosel 1000i (sodium tripolyphosphate)

State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON-DISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FORM ivL4 Y BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Resources will not consider this form complete unless all instructions are followed. Failure
to follow instructions or to submit all required items will lead to additional processing and review time.
For more information or for an electronic version of this form, visit our web site at:
blip: portal.ncdenr.orQhvebriva/aps/laruapplications.
INSTRUCTIONS TO THE APPLICANT:
V Do not submit this form for review without a corresponding Non-Discharge Permitting Unit application form.
✓ Any changes to this form will result in the application package being returned.
V Any other setbacks required by I 5A NCAC Subchapter 02T other than those referenced below, cannot be waived
through execution of this form.
✓ A copy of the completed and appropriately executed form must be provided to the property owner.
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T.0506(a),.0506(b),.0606(a),.0706(a)and.1006(a)
The undersigned property owner(s)hereby permits:
Applicant's name: Butterball, LLC
Complete mailing address of applicant: PO Box 589
City: Mount Olive State: NC Zip: 28365
Telephone number: (919 ) 658-6743 Facsimile number: (919 ) 658-4419
Hereinafter referred to as the Permittee,to(check all that apply):
El Non-Discharge disposal of wastewater effluent within 100 feet of the property line,
❑ Non-Discharge disposal of wastewater effluent within feet of the identified residence,
❑ Construct treatment and storage units within feet of the property line,
❑ Construct treatment and storage units within feet of the identified residence.
FORM:NDWSW 10-16 Page 1 of 2

The waived setbacks apply as shown on the attached map and located at the following:
Location address of property: 296 Willie Best Road (PIN 351100732815)
City: Mount Olive State: NC Zip: 28365
I certify that I am a deeded property owner of above-referenced property and am authorized to make decisions
•••���"` regarding this property on behalf of other deeded property owners. Furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to dispose of wastewater effluent or
construct wastewater treatment units as specified herein. I further agree that I will record this waiver form with the
appropriate Register of Deeds and provide the Permittee and Division of Water Resources with documentation of
such. II
Property owner(s)�name(s): � :S5 O r& "on - 6% 11 4e et h II 1-L C-
Signature: r( _/ e Date: l �-d[ l 7
Signature: ((( Date:
NORTH CAROLINA, a, COUNTY
1, , a Notary Public for County,North Carolina,
do hereby certify that `d U.), &.J �, personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal this the c0ay of q),�,ii' , 0.2D/'J .
SEAL
Signature of Notary Public
My commission expires e� DUI
FORM:NDWSW 10-16 Page 2 of 2

State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON-DISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FORM NIA P BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Resources will not consider this form complete unless all instructions are followed. Failure
to follow instructions or to submit all required items will lead to additional processing and review time.
For more information or for an electronic version of this form, visit our web site at:
http: %por1aLncdenr.org/web;ira,aps/lau'applications.
INSTRUCTIONS TO THE APPLICANT:
✓ Do not submit this form for review without a corresponding Non-Discharge Permitting Unit application form.
✓ Any changes to this form will result in the application package being returned.
V Any other setbacks required by 15A NCAC Subchapter 02T other than those referenced below, cannot be waived
through execution of this form.
✓ A copy of the completed and appropriately executed form must be provided to the property owner.
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T.0506(a),.0506(b),.0606(a),.0706(a)and.1006(a)
The undersigned property owner(s)hereby permits:
Applicant's name: Butterball, LLC
Complete mailing address of applicant: PO Box 589
City: Mount Olive State: NC ZiP' 28365
Telephone number: (919 ) 658-6743 Facsimile number: (919 ) 658-4419
Hereinafter referred to as the Permittee,to(check all that apply):
0 Non-Discharge disposal of wastewater effluent within 100 feet of the property line,
❑ Non-Discharge disposal of wastewater effluent within feet of the identified residence,
❑ Construct treatment and storage units within feet of the property line,
❑ Construct treatment and storage units within feet of the identified residence.
FORM:NDWSW 10-16 Page 1 of 2

The waived setbacks apply as shown on the attached map and located at the following:
Location address of property: 1528 Whitfield Road (PIN 351100830382)
City: Mount Olive State: NC Zip: 28365
gI certify that I am a deeded property owner of above-referenced property and am authorized to make decisions
regarding this property on behalf of other deeded property owners. Furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to dispose of wastewater effluent or
construct wastewater treatment units as specified herein. I further agree that I will record this waiver form with the
appropriate Register of Deeds and provide the Permittee and Division of Water Resources with documentation of
such.
Property owner(s)name(s): / li a l r�� V C Ql'a `co-/ &1 4-e S
Signature: L'el. �'-€-1; r Date: 2 2.0 [ 7
Signature: Date:
NORTH CAROLINA, A_Je.P 1. COUNTY
I, r.n•
.?.ral. ,a Notary Public for � �-J County,North Carolina,
do hereby certify that `i -J.JO j ,(1�� personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal this the Q u-day of .
SEAL I
Signature of Notary Public
My commission expires cw � LO/3
FORM:NDWSW 10-16 Page 2 of 2

State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON-DISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FORM AM Y BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Resources will not consider this form complete unless all instructions are followed. Failure
to follow instructions or to submit all required items will lead to additional processing and review time.
For more information or,for an electronic version of this form, visit our web site at:
httn:'portal.ncdenr.or:web irctlaps-lauapplications.
INSTRUCTIONS TO THE APPLICANT: •
✓ Do not submit this form for review without a corresponding Non-Discharge Permitting Unit application form.
✓ Any changes to this form will result in the application package being returned.
✓ Any other setbacks required by I 5A NCAC Subchapter 02T other than those referenced below, cannot be waived
through execution of this form.
✓ A copy of the completed and appropriately executed form must be provided to the property owner.
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T.0506(a),.0506(b),.0606(a),.0706(a)and.1006(a)
The undersigned property owner(s)hereby permits:
Applicant's name: Butterball, LLC
Complete mailing address of applicant: PO Box 589
City: Mount Olive State: NC zip: 28365
Telephone number: (919 ) 658-6743 Facsimile number:(919 ) 658-4419
Hereinafter referred to as the Permittee,to(check all that apply):
El Non-Discharge disposal of wastewater effluent within 100 feet of the property line,
LI Non-Discharge disposal of wastewater effluent within feet of the identified residence,
❑ Construct treatment and storage units within feet of the property line,
❑ Construct treatment and storage units within feet of the identified residence.
FORM:NDWSW 10-16 Page 1 of2

The waived setbacks apply as shown on the attached map and located at the following: •
Location address of property: 1528 Whitfield (PIN 352100152405)
City: Mount Olive State: NC zip: 28365
jgI certify that I am a deeded property owner of above-referenced property and am authorized to make decisions
regarding this property on behalf of other deeded property owners. Furthermore; I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to dispose of wastewater effluent or
construct wastewater treatment units as specified herein. I further agree that I will record this waiver form with the
appropriate Register of Deeds and provide the Permittee and Division of Water Resources with documentation of
such. rr t II Q
Property owner(s)name(s): �t:Lr �l ,S I� a P(G T d�s - I t rb c,If
Signature: • «'r-� 2 /' © J 7
o ��/� Date: / � / t
Signature: ((( Date:
NORTH CAROLINA, A. COUNTY
7-1'l - J ,a Notary Public for � County,North Carolina,
do hereby certify that Lin-c.c,e-a..,J < . )dj., personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal this the (.261.- clay of , ZL)/7 .
SEAL . e2A
Signature of Notary Public
My commission expires >s .) .. . Z o2C r I C
FORM:NDWSW 10-16 Page 2 of 2

•
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON-DISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Resources will not consider this form complete unless all instructions are followed. Failure
to follow instructions or to submit all required items will lead to additional processing and review time.
For more information or for an electronic version of this form, visit our web site at:
http:Uportal.ncdem'_o, u'eb,"n'c.'aps,lau applications.
INSTRUCTIONS TO THE APPLICANT:
✓ Do not submit this form for review without a corresponding Non-Discharge Permitting Unit application form.
✓ Any changes to this form will result in the application package being returned.
✓ Any other setbacks required by I 5A NCAC Subchapter 02T other than those referenced below, cannot be waived
through execution of this form.
V A copy of the completed and appropriately executed form must be provided to the property owner.
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T.0506(a),.0506(b),.0606(a),.0706(a) and.1006(a)
The undersigned property owner(s)hereby permits:
Applicant's name: Butterball, LLC
Complete mailing address of applicant: PO Box 589
City: Mount Olive State: NC Zip: 28365
Telephone number: (919 ) 658-6743 Facsimile number:(919 ) 658-4419
Hereinafter referred to as the Permittee,to(check all that apply):
FA Non-Discharge disposal of wastewater effluent within 100 feet of the property line,
❑ Non-Discharge disposal of wastewater effluent within feet of the identified residence,
❑ Construct treatment and storage units within feet of the property line,
❑ Construct treatment and storage units within feet of the identified residence.
FORM:NDWSW 10-16 Page 1 of 2

The waived setbacks apply as shown on the attached map and located at the following:
Location address of property: 1528 Whitfield Road (PIN 352100349992)
City: Mount Olive State: NC zip: 28365
gI certify that I am a deeded property owner of above-referenced property and am authorized to make decisions
regarding this property on behalf of other deeded property owners. Furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to dispose of wastewater effluent or
construct wastewater treatment units as specified herein. I further agree that I will record this waiver form with the
appropriate Register of Deeds and provide the Permittee and Division of Water Resources with documentation of
such. Al �
Property owner(s)name(s): /�I II A ,'Ssl P ( E.(`a�'o,,,) 1 c. tie r-b�.1/, L.L-C
Signature: ��-CP - Date: 2/ 2.42//7
Signature: Date:
NORTH CAROLINA, i` ia,_.
, COUNTY
l,r- ). ?- ia , a Notary Public for /t_J/. -1---)
County,North Carolina,
do hereby certify that ,-,.. -( 0. )r personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal this the �a°A—day of 45/d -- . , c ?O//7
SEAL 6 r> c �
Signature o Notary Public
My commission expires `��- a 0_0/9
l
FORM:NDWSW 10-16 Page 2 of 2

State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON-DISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FORM MAYBE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Resources will not consider this form complete unless all instructions are followed. Failure
to follow instructions or to submit all required items will lead to additional processing and review time.
For more information or for an electronic version of this form, visit our web site at:
http:/portal.ncdenr.orr/web,-ivct/aps'lau'applications.
INSTRUCTIONS TO THE APPLICANT:
✓ Do not submit this form for review without a corresponding Non-Discharge Permitting Unit application form.
✓ Any changes to this form will result in the application package being returned.
✓ Any other setbacks required by I 5A NCAC Subchapter 02T other than those referenced below, cannot be waived
through execution of this form.
V A copy of the completed and appropriately executed form must be provided to the property owner.
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T.0506(a),.0506(b),.0606(a),.0706(a)and.1006(a)
The undersigned property owner(s)hereby permits:
Applicant's name: Bufterball, LLC
Complete mailing address of applicant: PO Box 589
City: Mount Olive State: NC zip: 28365
Telephone number: (919 ) 658-6743 Facsimile number:(919 ) 658-4419
Hereinafter referred to as the Permittee,to(check all that apply):
• Non-Discharge disposal of wastewater effluent within 100 feet of the property line,
❑ Non-Discharge disposal of wastewater effluent within feet of the identified residence,
❑ Construct treatment and storage units within feet of the property line,
❑ Construct treatment and storage units within feet of the identified residence.
FORM:NDWSW 10-16 Page 1 of 2

The waived setbacks apply as shown on the attached map and located at the following:
Location address of property: 1529 Whitfield Road (PIN 352100360453)
City: Mount Olive State: NC Zip: 28365
Rf I certify that I am a deeded property owner of above-referenced property and am authorized to make decisions
regarding this property on behalf of other deeded property owners. Furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to dispose of wastewater effluent or
construct wastewater treatment units as specified herein. I further aaree that I will record this waiver form with the
appropriate Register of Deeds and provide the Permittee and Division of Water Resources with documentation of
such. II ,/ 1 I
Property owner(s)name(s): ,'C h%�i 12s 5 V P off(k-/ Q►o n) p cJT�Pripu l
Signature: Date: 2/2—©/ l 7
Signature: Date:
NORTH_CAROLINA, , COUNTY
, a Notary Public for ,i a-- -� County,North Carolina,
do hereby certify that `T -- rL /0, personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal this the old V"' day of f , oLO 117 .
SEAL U/'}'> , G+.� f
Signature of Notary Public �1
My commission expirescc� . �U `i
1
FORM:NDWSW 10-16 Page 2 of 2

State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON-DISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FORA]ildAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Resources will not consider this form complete unless all instructions are followed. Failure
to follow instructions or to submit all required items will lead to additional processing and review time.
For more information or for an electronic version of this form, visit our web site at:
help:,:,portal.ncdeim org.-iveb✓wo'apsdau;applications.
INSTRUCTIONS TO THE APPLICANT:
✓ Do not submit this form for review without a corresponding Non-Discharge Permitting Unit application form.
✓ Any changes to this form will result in the application package being returned.
✓ Any other setbacks required by I 5A NCAC Subchapter 02T other than those referenced below, cannot be waived
through execution of this form.
✓ A copy of the completed and appropriately executed form must be provided to the property owner.
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T.0506(a),.0506(b),.0606(a),.0706(a)and.1006(a)
The undersigned property owner(s) hereby permits:
Applicant's name: Butterball, LLC
Complete mailing address of applicant: PO Box 589
City: Mount Olive State: NC Zip: 28365
Telephone number: (919 ) 658-6743 Facsimile nmber: (919 ) 658-4419
Hereinafter referred to as the Permittee,to(check all that apply):
El Non-Discharge disposal of wastewater effluent within 100 feet of the property line,
❑ Non-Discharge disposal of wastewater effluent within feet of the identified residence,
❑ Construct treatment and storage units within feet of the property line,
❑ Construct treatment and storage units within feet of the identified residence.
FORM:NDWSW 10-16 Page I of 2

The waived setbacks apply as shown on the attached map and located at the following:
Location address of property: 1528 Whitfield Road (PIN 352100368454)
City: Mount Olive State: NC Zip: 28365
I certify that I am a deeded property owner of above-referenced property and am authorized to make decisions
regarding this property on behalf of other deeded property owners. Furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to dispose of wastewater effluent or
construct wastewater treatment units as specified herein. I further agree that I will record this waiver form with the
appropriate Register of Deeds and provide the Permittee and Division of Water Resources with documentation of
such.Property owner(s)name(s): iC�kafI I+s3 i/n orerq 1✓i f E0.44,,I/
"` _ C
Signature: " "f 1 Date: 17-c j 1 7
Signature: • Date:
NORTH CAROLINA, COUNTY
I, ,•y am • 2 J , a Notary Public for 0.,.._,7,0_4,'_—•=, County,North Carolina,
do hereby certify that ) -/tires d L. J personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal this the o?0K"day of \---la , b2O 1'0 .
SEAL 6--- (riq • Zc j
Signature of otary Public
My commission expires `n I) , 0..O /9_
FORM:NDWSW 10-16 Page 2 of 2

State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON-DISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Resources will not consider this form complete unless all instructions are followed. Failure
to follow instructions or to submit all required items will lead to additional processing and review time.
For more information or for an electronic version of this form, visit our web site at:
htip:;;portal ncdenr,org,ireb.trq'ups luu applications.
INSTRUCTIONS TO THE APPLICANT:
✓ Do not submit this form for review without a corresponding Non-Discharge Permitting Unit application form.
✓ Any changes to this form will result in the application package being returned.
✓ Any other setbacks required by 15A NCAC Subchapter 02T other than those referenced below, cannot be waived
through execution of this form.
✓ A copy of the completed and appropriately executed form must be provided to the property owner.
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T.0506(a),.0506(b),.0606(a),.0706(a) and.1006(a)
The undersigned property owner(s)hereby permits:
Applicant's name: Butterball, LLC
Complete mailing address of applicant: PO Box 589
City: Mount Olive State: NC Zip: 28365
Telephone number: (919 ) 658-6743 Facsimile number: (91.9 ) 658-4419
Hereinafter referred to as the Permittee,to(check all that apply):
O Non-Discharge disposal of wastewater effluent within 100 feet of the property line,
❑ Non-Discharge disposal of wastewater effluent within feet of the identified residence,
❑ Construct treatment and storage units within feet of the property line,
❑ Construct treatment and storage units within feet of the identified residence.
FORM:NDWSW 10-16 Page 1 of 2

The waived setbacks apply as shown on the attached map and located at the following:
Location address of property: 1501 Whitfield Road (PIN 352100448348)
City: Mount Olive State: NC Zip: 28365
,(I certify that I am a deeded property owner of above-referenced property and am authorized to make decisions
regarding this property on behalf of other deeded property owners. Furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to dispose of wastewater effluent or
construct wastewater treatment units as specified herein. I further agree that I will record this waiver form with the
appropriate Register of Deeds and provide the Permittee and Division of Water Resources with documentation of
such.
Property owner(s)name(s): ill/a e.,( /-s$ VP dDre-lA✓'S' — 6J er e,7/ L L
Signature: (2-� J� � Date: 4- J2
0
i (7
Signature:
g Date:
NORTH CAROLINA, J Q - COUNTY
a . 2 d� , a Notary Public for L im � County,North Carolina,
I, C .�y
do hereby certify that eil I O. ' personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal this the orb 'day of p L..6-- , aO/7
SEAL (-- `3 11 .-) 4I—«�c:4
Signature o Notary Public
My commission expires a:-cJ a o14/ 9
`i(_
FORM:NDWSW 10-16 Page 2 of 2