790002_Application_20231204

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Animal Feeding Operations Permit Application Form
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
State Individual Permit Existing Animal Waste Operations
1. GENERAL INFORMATION:
L I Facility name: Mmse, Cl- V, V-C'rmS
1.2 Print Land Owner's name: LJ1W(Ana V,. mc(,t.)l1(xm
1.3 Mailing address: 0 tU mcksiq Cy x, to
City, State: V\Ax0IS(n , NC Zip: ,Q1 UaC3
Telephone number (include area code): O 4Aj
1.4 Physical address: JIy M(�q cyrfy— 'GA
City, State: 1MG(,iA4�X1� ML, Zip:
Telephone number (include area code): (?>�
1.5 County where facility is located: flook inghCLM
1.6 Facility location (directions fi-om nearest major highway, using SR numbers for state roads): UZZO N -7 E tynN\tv�1UdC
1.7 Farm Manager's name (if different from Land Owner): C\,) QY)TA &s� 4 LY V4
1.8 Lessee's / Integrator's name (if applicable; circle which type is listed):
1.9 Facility's original start-up date: CA 0\ 1061 Date(s) of facility expansion(s) (if applicable):
2. OPERATION INFORMATION:
2.1 Facility number: R 1ktil oo a
2.2 Operation Description:
Please enter the Design Capacity of the system. The "No. of Animals" should be the maximum number for which the
waste management structures were designed.
Type of Swine No. of Animals Type of Poultry No. of Animals Type of Cattle No. of Animals
❑ Wean to Feeder ❑ Layer ❑ Beef Brood Cow
❑ Feeder to Finish ❑ Non -Layer ❑ Beef Feeder
Farrow to Wean (4 sow) ❑Turkey ❑ Beel' Stocker Calf
❑ Farrow to Feeder (# sow) _ ❑ Turkey I'oults ❑ Dairy Calf
❑ Farrow to Finish (# sow) ❑ Dairy Heifer
❑ Wean to Finish (# sow) ❑ Dry Cow
❑ Gilts ❑ Milk Cow
❑ Boar/Stud
❑ Other Type of Livestock on the farm: No. of Animals:
FORM: AWO-STATE-I-E 1/10/06 Page 1 of 5

2.3 Acreage cleared and available for application (excluding all required buffers and areas not covered by the application
system):1U1 Required Acreage (as listed in the CAWMP):' VD.
^
2,4 Number of lagoons: Total Capacity (cubic feet):' equired Capacity (cubic feet):
Number of Storage Ponds: Total Capacity (Cubic feet): Required Capacity (cubic feet):
2.5 Are subsurface drains present within 100' of any of the application fields? YES or§0 (circle one)
2.6 Are subsurface drains present in the vicinity or under the waste management system? YES orEs�) (circle one)
2.7 Does this facility meet all applicable siting requirements? YE or NO (circle one)
2.8 Brief description of treatment process: ,rZt'►-e_rz 6
3. REQUIRED ITEMS CHECKLIST:
Please indicate that you have included the following required items by signing your initials in the space provided next to each
item.
Applicants Initials
3.1 One completed and signed original and two copies of the application for State individual Permit
- Animal Waste Operations;
3.2 Three copies of a general location map indicating the location of the animal waste facilities and
field locations where animal waste is land applied and a county road map with the location of
the facility indicated;
3.3 Three copies of the entire Certified Animal Waste Management Plan (CAWMP). If the facility
does not have a CA WMP, it must be completed prior to submittal of a permit application for
animal waste operations.
The CAWMP must include the following components. Some of these components oral, not have been required at the time
the facility was certified but should be added to the CAWt14P for permitting purposes:
3.3.1 The Waste Utilization Plan (WUP) must include the amount of Plant Available Nitrogen (PAN) produced and
utilized by the facility
3.3.2 The method by which waste is applied to the disposal fields (e.g. irrigation, injection, etc.)
3.3.3 A map of every field used for land application
3.3.4 The soil series present on every land application field
3.3.5 The crops grown on every land application field
3.3.6 The Realistic Yield Expectation (RYE) for every crop shown in the WUP
3.3.7 The PAN applied to every land application field
3.3.8 The waste application windows for every crop utilized in the WUP
3.3.9 "file required NRCS Standard specifications
3.3,10 A site schematic
3.3.1 1 Emergency Action Plan
3.3.12 Insect Control Checklist with chosen best management practices noted
3.3.13 Odor Control Checklist with chosen best management practices noted
3.3.14 Mortality Control Checklist with the selected method noted
3.3.15 Lagoon/storage pond capacity documentation (design, calculations, etc.); please be sure to include any site
evaluations, wetland determinations, or hazard classifications that may be applicable to your facility
3.3.16 Operation and Maintenance Plan
if your CAWMP includes any components not shown on this list, please include the additional components with your
submittal. (Composting, waste transfers, etc.)
FORM: AWO-STATE-I-E 1/10/06 Page 2 of 5

,1. PPLICANjT+;RTWICATION:
e
(Land Owner's naive listed in question 1.2), attest that
this application for /C__✓�.S (Facility name listed in question 1.1)
has been reviewed by me and is ccurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information and attachments are not included, this application
package will be re red e as it mplete.
Signature Date Z
5.
MANAGER'S CERTIFICATION: (complete only if different from the Land Owner)
a.
(Nana er's name lisle 'n uestion 1 6) attest that this
application for
has been reviewed by me and is accurate and co tr
application are not completed and that if all required s
package will be returned as incomplete.
Signature.
6.
g q
(Facility name listed in question 1.1)
y-nowledge. I understand that if all required parts of this
information and attachments are not included, this application
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING INFORMATION AND MATERIALS,
SHOULD BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DIVISION OF WATER RESOURCES
WATER QUALITY REGIONAL OPERATIONS SECTION
ANIMAL FEEDING OPERATIONS PROGRAM
1636 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
TELEPHONE NUMBER: [phone]
FAX NUMBER: [phone]
SURFACE WATER CLASSIFICATION:
FORM: AWO-STATE-I-E 1/10/06 Page 3 of 5

This form must be completed by the appropriate DWR regional office and included as a part of the
project submittal information.
INSTRUCTIONS TO NC PROFESSIONALS:
The classification of the downslope surface waters (the surface waters that any overflow from the facility would flow toward) in
which this animal waste management system will be operated must be determined by the appropriate DWR regional office.
Therefore, you are required, prior to submittal of the application package, to submit this form, with items 1 through 6
completed, to the appropriate Division of Water Resources, Water Quality Regional Operations Supervisor (see page 6 of 10).
At a minimum, you must include an 8.5" by 11" copy of the portion of a 7.5 minute USGS Topographic Map which shows the
location of this animal waste application system and the downslope surface waters in which they will be located. Identify the
closest downslope surface waters on the attached map copy. Once the regional office has completed the classification,
reincorporate this completed page and the topographic map into the complete application form and submit the
application package.
6.1 Farm Name: \
6.2 Name & complete address of engineering firm:
Telephone number: ( ) -
6.3 Name of closest downslope surface waters:
6.4 County(ies) where the animal waste management system and surface waters are located
6.5 Map name and date:
6.6 NC Professional's Seal (if appropriate), Signature, and Date:
TO: WQROS SUPERVISOR
Please provide me with the classification of the watershed where this animal waste management facility will be or has been
constructed or field located, as identified on the attached map segment(s):
Name of surface waters:
Classification (as established by the Environmental Management Commission):
Proposed classification, if applicable:
Signature of regional office personnel:
(All attachments must be signed)
Date:
FORM: AWO-STATE-I-E 1/10/06 Page 4 of 5

DIVISION OF WATER RESOURCES REGIONAL OFFICES (9/05)
Asheville Regional WQROS Supervisor
Washington Regional WQROS Supervisor
Raleigh Regional WQROS Supervisor
2090 U.S. Highway 70
943 Washington Square Nall
1628 Mail Service Center
Swannanoa, NC 28778
Washington, NC 27889
Raleigh, NC 27699-1628
[phone]
[phone]
[phone]
Fax [phone]
Fax [phone]
Fax [phone]
Avery Macon
Beaufort Jones
Chatham Nash
Buncombe Madison
Bertie Lenoir
Durham Northampton
Burke McDowell
Camden Martin
Edgecombe Orange
Caldwell Mitchell
Chowan Pamlico
Franklin Person
Cherokee Polk
Craven Pasquotank
Granville Vance
Clay Rutherford
Currituck Perquimans
Halifax Wake
Graham S\N'ain
Dare Pitt
Johnston Warren
Haywood Transylvania
Gates Tyrell
Lee Wilson
Henderson Yancey
Greene Washington
Jackson
Hertford Wayne
Hyde
Fayetteville Regional WQROS SupervisorMooresville Regional WQROS Supervisor
Wilmington Region WQROS Supervisor
225 Green Street, Suite 714
610 East Center Avenue
127 Cardinal Drive Extension
Fayetteville, NC 28301-5094
Mooresville, NC 28115
Wilmington, NC 28405-3845
[phone]
[phone]
[phone]
Fax [phone]
Fax [phone]
Fax [phone]
Anson Moore
Alexander Lincoln
Brunswick New Hanover
Bladen Richmond
Cabarrus Mecklenburg
Carteret Onslow
Cumberland Robeson
Catawba Rowan
Columbus Pender
Harnett Sampson
Cleveland Stanly
Duplin
Hoke Scotland
Gaston Union
Montgomery
Iredell
Winston-Salem Regional WQROS Supervisor
450 Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
Phone [phone]
Fax [phone]
Alamance
Rockingham
Alleghany
Randolph
Ashe
Stokes
Caswell
Surry
Davidson
Watauga
Davie
Wilkes
Forsyth
Yadkin
Guilford
FORM: AWO-STATE-1-E 1/10/06 Page 5 of 5