WQ0024301_Staff Report_20231004

October 4, 2023
To: DWR Central Office — WQ, Non -Discharge Unit
Attn: Leah Parente
From: Caitlin Caudle
Winston-Salem Regional Office
State of North Carolina
Division of Water Resources
Water Quality Regional Operations Section
Staff Report
Application No.: W00024301
Facility name: 152 Hickory Flats Rd SFR
Note: This form has been adapted from the non -discharge facility staff report to document the review of both non -discharge and NPDES permit applications and/or renewals. Please complete all sections as they are applicable.
I. GENERAL AND SITE VISIT INFORMATION
1. Was a site visit conducted? ® Yes or ❑ No
a. Date of site visit: 9/11/2023
b. Site visit conducted by: C. Caudle and K. Potwora
c. Inspection report attached? ® Yes or ❑ No
d. Person contacted: Tim Gilbert and their contact information: (336) 514 - 2378
II. EXISTING FACILITIES: MODIFICATION AND RENEWAL APPLICATIONS
1. Are there appropriately certified Operators in Charge (ORCs) for the facility? ❑ Yes ❑ No ® N/A
2. Are the design, maintenance and operation of the treatment facilities adequate for the type of waste and disposal
system? ® Yes or ❑ No
3. Are the site conditions (e.g., soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? ® Yes or ❑ No
4. Has the site changed in any way that may affect the permit (e.g., drainage added, new wells inside the compliance
boundary, new development, etc.)? ❑ Yes or ® No
5. Are the existing application rates (e.g., hydraulic, nutrient) still acceptable? ® Yes or ❑ No
6. Are there any setback conflicts for existing treatment, storage and disposal sites? ❑ Yes or ® No
7. Is the description of the facilities as written in the existing permit correct? ® Yes or ❑ No
8. Has a review of source facilities compliance history been completed (e.g., CEIs and DMRs)? ® Yes or ❑ No
9. Are there any permit changes needed in order to address ongoing BIMS violations? ❑ Yes or ® No
10. Check all that apply:
® No compliance issues ❑ Current enforcement action(s) ❑ Currently under JOC
❑ Notice(s) of violation ❑ Currently under SOC ❑ Currently under moratorium
Please explain and attach any documents that may help clarify answer/comments (i.e., NOV, NOD, etc.)
If the facility has had compliance problems during the permit cycle, please explain the status. Has the RO been
working with the Permittee? Is a solution underway or in place? See attached inspection report.
Have all compliance dates/conditions in the existing permit been satisfied? ® Yes ❑ No ❑ N/A
11. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit?
❑ Yes ®No❑N/A
FORM: WQROSSR 04-14 Page 1 of 2

III. REGIONAL OFFICE RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes or ® No
2. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office
® Hold, pending review of draft permit by regional office
❑ Issue upon receipt of needed additional information
❑ Issue
❑ Deny (Please state reasons: )
3. Signature of report preparer:
Signature of regional supervisor:
Date: 10/5/2023
L-oti T. 15Md«-
145B49E225C94EA...
See attached easement documents and inspection report.
Tom Gilbert's email needs to be updated under the billing affiliation. t ilbertkcdirad.com is still functioning.
Tim Gilbert needs to be added as the primary contact as he cares for the system. Cell phone: [phone]. Email:
tims ilg [e-mail].
FORM: WQROSSR 04-14 Page 2 of 2

Compliance Inspection Report
Permit: WQ0024301 Effective: 02/01/19 Expiration: 02/29/24 Owner : Thomas J Gilbert
SOC: Effective: Expiration: Facility: 152 Hickory Flats Rd. SFR
County: Caswell 152 Hickory Flats Rd
Region: Winston-Salem
Leasburg NC 27291
Contact Person: Thomas J Gilbert
Title:
Phone:
Directions to Facility:
From Yanceyville, 86 S., left to 119, 2 miles to first hardtop rd. (Griers Ch. Rd.) to end, left at T, 1 mile to Hickory Flats Rd., house on
right
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Inspection Date: 09/11/2023 Entry Time 11:OOAM Exit Time: 12:OOPM
Do Signed by:
Primary Inspector: Caitli CL(±834968199MD...
� uc�Yef�.� I'� Phone: [phone]
Secondary Inspector(s):lti l�D�
Kristen Potwora
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Single -Family Residence Wastewater Irrigation
Facility Status: ❑ Compliant 0 Not Compliant
Question Areas:
Miscellaneous Questions
Disinfection Tablets
General
(See attachment summary)
Septic Tank
Pump Tank
Sand Filter/Treatment Pods
Drip or Irrigation
Page 1 of 4

Permit: WQ0024301 Owner - Facility: Thomas J Gilbert
Inspection Date: 09/11/2023 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
On September 11, 2023, Division of Water Resources staff Caitlin Caudle and Kristen Potwora conducted a routine
compliance inspection of the 152 Hickory Flats Road SFR. Tim Gilbert was present during the entire inspection. A review of
treatment facilities was completed. This review mostly reflected compliance with the subject permit. The following items of
concern were noted:
A. At the time of inspection, an inspection log was not available. Per Permit Condition V.2, the Permittee shall maintain
and inspection log that includes the date and time of inspection, observations made, and maintenance, repairs, or corrective
actions taken. Permit Condition 111.12 list specific inspection frequencies for individual treatment units. Moving forward, begin
maintaining an inspection log as described above.
B. At the time of inspection, the fencing around the irrigation site was damaged in several places. Per Permit Condition
111.8, the Permittee shall prohibit public access to the irrigation facility through fencing around the irrigation site. Please repair
the fence as soon as possible.
C. Two of the four spray heads were surrounded by vegetation. Vegetation around the spray heads can cause concentrated
flow and impede the spray pattern. One of the four spray heads was not operating properly. Per Permit Condition V.1, the
Permittee shall perform inspections and maintenance to ensure proper operation of the wastewater treatment and irrigation
facilities. Please remove the vegetation surrounding the spray heads and repair the malfunctioning spray head.
Other observations:
• One person lives in the house. The septic tank was last pumped 5 years ago. There are no concerns for solids build up
in the septic tank.
• Mr. Gilbert stated that the septic tank will be checked when his septic tank is pumped within the next few months.
• Chlorine tablets were not in the chlorinator tubes and the tablet container was damaged. Mr. Gilbert stated he will be
purchasing more tablets.
• The forcemain to the irrigation site was not reviewed.
• The alarm is located at the storage tank. It was operational.
Page 2 of 4

Permit: WQ0024301 Owner - Facility: Thomas J Gilbert
Inspection Date: 09/11/2023 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Septic Tank
Yes No NA NE
*** The septic tank and filters should be checked annually and pumped/cleaned as needed. **
Is all wastewater from the home connected to the septic tank? ❑ ❑ ❑
# Does the permittee/resident know where the septic tank is located? ❑ ❑ ❑
Has the septic tank been pumped in the last 5 years? ❑ ❑ ❑
If YES, describe if known and proof (include date pumped):
See summary.
# Does the septic tank have an EFFLUENT FILTER or SANITARY T? ❑ ❑ ❑
If FILTER, when was the filter cleaned and by who? 2019
Comment: See summary.
Sand Filter/Treatment Pods Yes No NA NE
*** Accessible sand filter surfaces shall be raked/leveled every 6 months and vegetative growth shall be
removed manually. ***
# Is system something other than a sand filter? ❑ 0 ❑ ❑
# If YES, what kind? (examples - Peat, Textile or brand name - Advantex, etc.)
# Does the permittee know where the sandfilter is located? ❑ ❑ ❑
Does the sandfilter require maintenance? ❑ ❑ ❑
If maintenace is required, explain:
Comment: See summary.
Disinfection Tablets Yes No NA NE
*** Tablet chlorinator unit shall be checked weekly to ensure continuous and proper operation. ***
Does the permittee have the correct chlorine tablets? (If none, mark No) ❑ ❑ ❑
# Does the Permittee know the location of the chlorinator? ❑ ❑ ❑
Were chlorine tablets observed in the chlorinator? ❑ ❑ ❑
Are tablets contacting water? (If possible, poke them to determine.) ❑ ❑ ❑
Comment: See summary.
Pump Tank Yes No NA NE
*** All pump and alarm sytems shall be inspected monthly. (Non -Discharge) ***
Is the pump working? ❑ ❑ ❑
Is the audible and visual high water alarm operational? ❑ ❑ ❑
# Does the permittee know how to check the pump & high water alarm? ❑ ❑ ❑
# Last functional test: 9/11/2023
Comment:
Drip or Irrigation Yes No NA NE
Page 3 of 4

Permit: WQ0024301 Owner - Facility: Thomas J Gilbert
Inspection Date: 09/11/2023 Inspection Type: Compliance Evaluation Reason for Visit: Routine
*** Irrigation sysetm shall be inspected monthly to ensure system is free of leaks and equipment is operating
as designed. ***
# Type of system (DRIP or IRRIGATION):
# If IRRIGATION, number of sprinkler heads:
Are buffers and setbacks adequate?
Is the site free of ponding and runoff?
Does the application equipment appear to be working properly?
Is there a minimum two wire fence surrounding the entire irrigation area?
Comment: See summary.
# Are the treatment units locked and/or secured?
# Has resident had any sewage problems?
If YES, explain:
N/A
Does the system match the permit description?
If NO, explain:
N/A
Is the system compliant?
Is the system failing? (If yes, take pictures if possible)
If system is failing, describe any exposures to people/animals or environmental risks.
N/A
Comment: See summary.
Irrigation
4
Yes No NA NE
■❑❑❑
Page 4 of 4

on nor 09 2004 of C12:48:25 PM
by: DELORES S. DAPfli0N
REGISTER OF DEEDS
BOOK 166 PAGE 120
NORTH CAROLINA DECLARATION OF SEWER EASEMENT
CASWELL COUNTY
THIS DECLARATION OF SEWER EASEMENT made this the -Zt-h day of November, 2004, by Timothy
Scott Gilbert, and Wife, Tammy Stewart Gilbert, their heirs, successors and assigns, hereinafter referred to as
"parties of the first part"; their heirs, successors and assigns in Title to any part of the lands hereinafter described,
hereinafter referred to as "parties of the second part";
WITNESSETH:
THAT WHEREAS the parties of the first part are seized in fee simple absolute and are presently in
possession of two (2) tracts of land lying and being in Leasburg Township, Caswell County, North Carolina, which
tracts of land adjoin each other and one tract of land being more particularly described in Deed duly recorded in
Deed Book 298 on Page 706 of the Caswell County, N.C. Registry hereinafter referred to as Tract 1, containing
26.06 acres ± and the other tract of land tieing more particularly described in Deed duly recorded in Deed Book 415
on Page 78 of the Caswell County, N.C. Registry hereinafter referred to as Tract 2, containing 8.53 acres ±;
AND WHEREAS, the parties of the first part intend to convey Tract 2 and hereby agree to dedicate and
establish a permanent and perpetual sewer easement of right of way across a portion of Tract 1 for the benefit of
Tract 2, by providing off site sewer for Tract 2;
NOW, THEREFORE, in order that Tract 2 may be conveyed and used for residential purposes with off site
sewer, the parties of the first part hereby dedicate and establish a permanent and perpetual sewer easement of right of
way for the purposes of constructing, repairing and maintaining a sanitary septic tank and/or sewer system over and
upon Tract 1 for the benefit of Tract 2 with said sewer easements being described as follows;
Being that permanent and perpetual twenty foot (20') sewer easement of right of way and that 0.32
acres± sewer easement of right of way, running with the land to serve Tract 2 for the purposes of
constructing, repairing and maintaining a sanitary septic sand and/or sewer system. Said sewer
easements extends over and upon Tract 1, that is located in Leasburg Township, Caswell County, N. C.
and being situated to the east of and adjoining Tract 2. Said sewer easements are more particularly
described and depicted on plat of'survey entitled "Plat of Survey for Harold D. Goff', dated June 21,
2004 made William Conway Moorefield, P.L.S., Said plat duly recorded in the Caswell County, N.C.
Registry in Plat Book /S on Page 415$ is incorporated herein and made an integral part of this
description by express reference thereto.
IN TESTIMONY WHEREOF, said parties have hereunto set their hand and seals the day wherein first
above written.
(SEAL)
TIN40TW SCOTT GILBERT
(SEAL)
TAMMY T'EWART GILBERT

NORTH CAROLINA
CASWELL COUNTY
BOOK 466 PAGE 121
I, le,/_ a Notary Public for said County and State, do hereby certify
that moH? i Pd- personally appeared before me this day
and acknowled ed the due execution of the foregoing instrument.
Witness my hand and official seal, this thelt' day of November, 2004.
otary Public
I, 4kLr dn; l , a Notary Public for said County and State, do hereby certify
that Tammy 6plt 5�eWaH personally appeared before me this day
ie execution of the foregoing instrument.
and official seal, this theg--�' day of Novemb , 2004.
q-1D-,96 /tJ
'-�otAry Public
The foregoing certificate(s) of_ Karen W. Daniel
Notary Public of Caswell County, North Carolina is certified to be correct. Filed for :registration in
the Caswell County Register of Deeds Office at 2:48:25amL/p,m. on the 8th day ofNov. ,
2004, and recorded in Deed Book 466 Page { O .
Delores S. Dameron
REGISTER OF DEEDS Caswell County
BY: �J )
Tammy W. Riggs — Assistant
HADocumentAREALP Wilbert Easement.doc

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by: DELORES S. DAt1ERON
REGISTER OF DEEDS
BOOK 15 PAGE 458
FINAL MAP
LEASBURG TWSP.
CASWELL,COUNTY, NC
PLAT OF SURVEY FOR
HAROLD D. GOFF
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CARL R. ANDERSON
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STATE OF NORTH CAROLINA
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THIS SURVEY HAS BEEN PREPARED WITHOUT
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AND ODES NOT THEREFORE NECESSARILY INDICATE THIS PLAT WAS DRAWN UNDER W SUPERVISION FROM AN ACTUAL
ALL ENCUMBRANCE ON SAID PROPERTY. ff„�l.+f� SURVEY MADE UNDER MY SUPERVISION (DEED DESCRIP-
% TION RECORDED IN BOOK __y@B--,PAGE _M____ ETC.)
(OTHER): THAT THE BOUNDARIES NOT SURVEYED ARE CLEARLY
INDICATED AS DRAWN FOR INFORMATION FOUND IN BOOK
-------,PAGE ------- :THAT THE RATIO OF PRECISION AS CALCULATED
IS 1/10000+;THAT THIS PLAT WAS PREPARED IN ACCORDANCE
WITH G.S. 47-30 AS AMENDED.WITNESS MY ORIGINAL
SIGNTURE,REGISTRATION NUMBER AND SEAL THIS
DAY OF J✓w<_, A. D. �•p_I�__.
NORTH CAROL INA, CASWELL COUNTY
Filed for registration in the office of Register of Deeds of
of M. 0n the day of
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I,W.C.MOOREFIELD DO CERTIFY THAT THIS MAP IS ONE OF THE
FOLLOWING,AS INDICATED.
(A) THIS SURVEY DOES CREATE A SUBDIVISION AS DEFINEDBY COUNTY ORDINANCE:
(8) THIS PARCEL IS LOCATED IN A UNREGULATED PORTION OF COUNTY ORMUNICIPALITY:
( C) THIS SURVEY IS OF AN EXISTING PARCEL OR PARCELS OF LAND;
(D) THIS SURVEY IS ONE OF THE FOLLOWING;
I RECOMBINATION OF EXISTING PARCELS,
_ 2 A COURT -ORDERED SURVEY,
_ ✓ 3 OTHER EXCEPTION TO THE DEFINITION OF SUBDIVISION ESEWER EASEMENT]
(E) I AM UNABLE TO MAKE A DETERMINATION TO THE BEST OF MY PROFESSIONAL
ABILITY AS TO PROVISIONS CONTAINED IN (A) THROUGH (D) ABOVE.