WQ0019753_2023 Residual Annual Report_20240220 (2)

Initial Review
Reviewer
nathaniel.thorn burg
Is this submittal an application? (Excluding additional information.) *
Yes No
If not an application what is the submittal type?* Annual Report
Residual Annual Report
Additional Information
Other
Annual Report Year* 2023
Permit Number (IR) * W00019753
Applicant/Permittee Town of Madison
Email Notifications
Does this need review by the hydrogeologist? * Yes U No
Regional Office Winston-Salem
CO Reviewer
Admin Reviewer Wanda Gerald

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* Kevin Yates
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*
3364273971
Modification - Minor
Renewal
GW-59, NDMR, NDMLR, NDAR-1,
N DAR-2
Residual Annual Report
Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
https://edoes.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type:*
Wastewater Irrigation
High -Rate Infiltration
Other Wastewater
Reclaimed Water
Closed -Loop Recycle
Residuals
Single -Family Residence Wastewater
Other
Irrigation
Permit Number:*
WQ0019753
Has Current Existing permit number
Applicant/Permittee Address*
403 Lindsey Bridge Rd.
Facility Name*
Town of Madison Class A Residuals Program
Please provide comments/notes on your current submittal below.
No Land application in 2023. We have two lagoons that were land applied in 2021 and dont have the need to land apply in the near future.
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.)
2023 Madison Land Residuals Form.pdf 40.49KB
Upload only 1 PDF document (less than 250 MB). Multiple documents must be combined into one PDF file unless file is larger
than upload limit.
* By checking this box, I acknowledge that I understand the application will not be accepted for pre -review until the fee (if required) has
been received by the Non -Discharge Branch. Application fees must be submitted by check or money order and made payable to the
North Carolina Department of Environmental Quality (NCDEQ). I also confirm that the uploaded document is a single PDF with all parts
of the application in correct order (as specified by the application).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature
Submission Date 2/20/2024

CLASS A ANNUAL DISTRIBUTION AND MARKETING/ SURFACE DISPOSAL CERTIFICATION AND SUMMARY FORM
WQ PERMIT #: WQ0019753 FACILITY NAME:
Town of Madison WTP
PHONE: [phone] COUNTY: Rockingham OPERATOR: J. Kevin Yates
FACILITY TYPE (please check one): Surface Disposal (complete Part A (Source(s) and "Residual In" Volume only) and Part C)
-- Distribution and Marketing (complete Parts A, B, and C)
Was the facility in operation during the past calendar year? Yes hd No _ _ P If No skip parts A, B, C and certify form below
Part A*:
Part B*:
Month
Sources(s) (include NPDES # if
applicable)
Volume (dry tons)
Recipient Information
Amendment/
Bulking Agent
Residual In
Product Out
Name(s)
Volume (dry tons)
Intended use(s)
January
Did not Land Apply in 2023
February
March
April
May
June
July
August
September
October
November
December
Total from FORM DMSDF (sup)
Totals:
Annual (dry tons):
0
0
0
0
Amendment(s) used: I I Bulking Agent(s) used:
* If more space is required, attach additional information sheets (FORM DMSDF (supp)): Total Number of Form DMSDF (Supp)
Part C:
Facility was compliant during the past calendar year with all conditions of the land application permit __ Yes
(including but not limited to items 1-3 below) issued by the Division of Water Resources: No o If No, Explain in Narritive
1. All monitoring was done in accordance with the permit and reported for the year as required and three (3) copies of certified laboratory results are attached.
2. All operation and maintenance requirements were compiled with or, in the case of a deviation, prior authorization was received from the Division of Water Resources.
No contravention of Ground Water Quality Standards occurred at a monitoring well.
"I certify, under penalty of law, that the above information is, to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant
penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
Signature of Permittee
Date Signature of Preparer**
(if different from Permittee)
**Preparer is defined in 40 CFR Part 503.9(r) and 15A NCAC 2T .1102 (26)
Date
DENR FORM DMSDF (12/2006)