WQ0041516_Application (FTSE)_20200302

State of North Carolina
Department of Environmental Quality
IDWRI.O. Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: V,) QM "I If5)(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Davie County Water System (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ® State/County ❑ Municipal ❑ Other
3. Signature authority's name: Johnny Lambert per 15A NCAC 02T .0106(b)
Title: Utilities Director N C Department of
Environmental Quality4. Applicant's mailingaddress: 298 East Depot SReceived
City: Mocksville State: NC Zip: 27028- MAR 0 2 2020
5. Applicant's contact information:
Phone number: (2M) 753-6090 Email Address: ilambertadaviecountyWinston-Salemnc.gov Regional Office
II. PROJECT INFORMATION:
1. Project name: Tanglewood Sewer
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: W000 and issued date:
If new construction but part of a master plan, provide the existing permit number: W000_
3. County where project is located: Davie
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.004490' Longitude:-80.4487'
5. Parcel ID (if applicable):
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: John Grey
Firm: Grey Enaineerine.Inc.
Mailing address: P.O. Box 9
City: Mocksville State: NC
Phone number: (IM) 978-3222
License Number: 015407
Zip: 27028-
Email Address: iarev(��reveneineerin¢.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Muddy Creek Permit Number: NCO050342
Owner Name: CCUC/Winston Salem
V. RECEIVING DOWNSTREAM'SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): W00035664 Downstream (Receiving) Sewer Size: 18 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s):
FORM: FTA 04-16 Page I of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑No NN/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes [—]No NN/A
3. If the Applicant is a Home/Property Owners' Association has an Operational Agreement (FORM: HOA) been attached?
❑ Yes ❑No NN/A
4. Origin of wastewater: (check all that apply):
N Residential Owned N Retail (stores, centers, malls) ❑ Car Wash
❑ Residential Leased ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool /Clubhouse
N Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic/Commercial % Commercial
% Industrial (See 15A NCAC 02T .0103(20))
"Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f) ❑ Yes N No
➢ If yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(fl1
Daily Design Flow "b
No. of Units
Flow
This is a pump station removal.
gal/
GPD
No additional W W is generated
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
GPD
a See 15A NCAC 02T .0114(b), (d). (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use
areas; and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals
as defined in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall
be determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 0 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new flow expected
N Other (Explain): Removal of existing pump station and replacement by gravity outfall.
FORM: ETA 04-16 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 1890 PVC
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirement is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: - °
3. Design flow of the pump station: millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): gallons per minute at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(B)_
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be
provided in the case of a multiple station power outage.
FORM: FTA 04-16 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T.0305(f) & (g)
➢ 15A NCAC 02T.0305(f) contains minimum senarations that shall be provided for sewer systems:
®,Yes ❑ No
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
24 inches
Water mains vertical -water over sewer including in benched trenches
18 inches
Water mains horizontal
10 feet
Reclaimed water lines vertical - reclaimed over sewer
18 inches
Reclaimed water lines horizontal - reclaimed over sewer
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water
100 feet
"Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands see item IX.2
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade vertical
36 inches
➢ 15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications weboage
➢ If noncompliance with 02T.0305(f) or (g), see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes ❑ No ❑ N/A
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes ❑ No ❑ N/A
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ❑ Yes ® No
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater management plans, etc.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02T.0402 "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ® No ❑ N/A
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with .15A:NCAC t)2T. the Minlrttc
and Force Maim (law version), and the QleYity Sower Minim II Dee
®yes ❑No
If No, complete and submit the Variance/Altemative Design Request application (VADC 10.14) and supporting
for review. Approval of the request is required prior to submittal of the Fast Track Application and i
documents.
2. Professional Engineer's Certification:
that this application for
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans, specifications,
engineering calculations, and all other supporting documentation to the best of my knowledge. I further attest that to the best
of my knowledge the proposed design has been prepared in accordance with the applicable regulations, Gravity Sewer
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track
Permitting of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain
portions of this submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this
material and have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 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.
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
1, JOEUUVY Lf.wt''A=,X:T f�LZ=-dz:J*C L'C r1WTI�5 attest that this application for
(Signature Authority's name & title from Application Item 1.3.)
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 are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that any discharge of wastewater from this non -
discharge system to surface waters or the land will result in an immediate enforcement action that may include civil penalties,
injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a
condition of this permit be violated. I also 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 to
me as incomplete.
NOTE — In accordance with General Statutes 143-215. and 143-2154B. 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.
Signature: y, \ /'cw..tA7r' Date: c2522 ` 26 Z�
FORM: PTA 04-16 Page 5 of 5

WR
Envision of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Davie County Water System
Project Name for which flow is being requested: Tanglewood Sewer
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Muddy Creek
b. WWTP Facility Permit #: NC0050342
Al[fTows are in MGD
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
Pump
Pump
Station
Station
Firm
(Name or
Permit
Capacity,
Number)
No.
MGD
Smith
0-11
WQ0036294
1.44
Yadkin
WQ0036294
1.85
(A)
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Design
Average
Approx.
Obligated,
Daily
Current
Not Yet
Total Current
Flow**
Avg. Daily
Tributary
Flow Plus
(Firm / pf),
Flow,
Daily Flow,
Obligated
Available
MGD
MGD
MGD
Flow
Capacity***
0.576
.20.
0
0.20
0.376
0.740
.30
0
0.30
0.40
* The Firm Capacity (design Dow) of any pump station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): CCUC Tanglewod Pump Station
Downstream Permit Number:
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Johnny Lambert certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the
receiving wastewater treatment facility and that the flow from this project is not anticipated to cause any
capacity related sanitary sewer overflows or overburden any downstream pump station en route to the
receiving treatment plant under normal circumstances, given the implementation of the planned
improvements identified in the planning assessment where applicable. This analysis has been performed
in accordance with local established policies and procedures using the best available data. This
certification applies to those items listed above in Sections I and II plus all attached planning assessment
addendums for which I am the responsible party. Signature of this form certifies that the receiving
collection system or treatment works has adequate capacity to transport and treat the proposed new
wastewater.
Signature
of Signing
-2�
Date
Page 2 of 6
FTSE 10-18

State of North Carolina
Department of Environmental Quality
Division of Water Resources
t)ivhion oE'"J.ttc: i.c-uni, -s
Entity Requesting Allocation: Davie
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Project Name for which flow is being requested: 12436 Tanglewood Sewer
More than one FTSE may be required for a single project f the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name:
b. WWTP Facility Permit
MUDDY CREEK
: NCO050342
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
21.000000
2.671600
16.620000
19.291600
91.9
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design
Average Approx. Obligated, Total
Pump Daily Current Not Yet Current
Pump Station Station Firm Flow** Avg. Daily Tributary Flow Plus
(Name or Permit Capacity, * (Firm / pfl, Flow, Daily Flow, Obligated Available
Number) No. MOD MOD MOD MOD Flow Capacity***
Tanglewood 4 4,46000 1.784000 1.33521 0.033380 1.368591 0,415409
The Firm Capacity (design flow) of any pump station is defined as the maximum pumped now
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a pealdng factor
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Muddy Creek
Downstream Permit Number: WQCS00003
Page 1 of 6
FTSE 10-18

Ill. Certification Statement:
I Courtney Driver, P.E. certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station on route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Signing Of Signature Date
of Signing
Page 2 of 6
FTSE 10-18

NAD83 COORDINATES
LAT= 36.0044900075
LONG=—80.4487051770
07
r $�
• • •
USGS QUADS 0 1000 2000
TOP = CLEMMONS 36080—A4
BOTTOM = ADVANCE 35080-1-14 SCALE: 1"= 1000' CONTOURS AT 10'
I '
_ �. I\ �� �/ri� '�� V seL jPa'Q ,n Jai.,"I✓/�
_Tanglewd usgs SS permit
GREY ENGINEERING, iNc. DAVI E COUNTY UTILITIES
Civil Design and Surveying
P.O. Box 9 Mocksville, N.C. 27028
greyengineering.com [phone] TANGLEWOOD SHOPPING CENTER 1
DRAWN BY: G. BULLARD PROJ. NO.: 202.131.GE SEWER EXTENSION ON USGS MAP 1
DESIGN BY: G. BULLARD DATE: 02/25/20

NAD83 COORDINATES
LAT= 36.0044900075
LONG—80.4487051770
0 1000
SCALE: 1"= 1000'
2000
GREY ENGINEERING, INC.
Civil Design and Surveying
P.O. Box 9 Mocksville, N.C. 27028
greyenglneering.com [phone]
DRAWN BY: G. BULLARD PROJ. NO.: 202.131.GE
DESIGN BY: G. BULLARD DATE: 02/25/20
_Tanglewd aerial SS
DAVIE COUNTY UTILITIES
TANGLEWOOD SHOPPING CENTER
SEWER EXTENSION ON AERIAL MAP
r

OAIG.
GREY
ENGINEERING, INC.
2/25/20
NC Department of
Environmental Quality
Winston Salem Regional Office Received
Water Quality Section {NAIL 0 2 2020
450 Hanes Mill Rd, Suite 300
Winston-Salem, NC 27105 Winston-Salem
Regional Office
Re: Davie County Tanglewood Sewer Fast Track Permit Application
The Davie County Water System proposes to remove its Tanglewood wastewater pump
station from service and allow approximately 4,000gpd to flow by gravity to the County's
existing 18" interceptor in Smith Creek where it is conveyed through the Smith Creek
Pump station, the Yadkin River pump station, and CCUC's Tanglewood pump station to
treatment and disposal at the Muddy Creek WWTP.
No additional flow will be generated by the project. Maintenance expenses and risk will
be avoided.
Enclosed please find one original and one copy of the following:
1. A $480.00 check to NCDEQ — Water Quality for permit fees.
2. Executed form FTA 04-16 and supporting documentation.
3. Executed form FTSE 10-18 for intermediate sewers in Davie County.
4. Executed form FTSE 10-18 for Intermediate sewers and treatment in Forsyth
County.
5. 8.5X11" USGS topo map of project area.
6. 8.5X11" aerial photomap of the project area.
Thank you,
Grey Engineering, Inc.
John Grey,
President
Cc: Johnny Lambert
P.O. Box 9 • Mocksville, NC 27028 • Phone: [phone] • Fax: [phone] • www.greyengineering.com

Henderson, Justin L
From:
John Grey <[e-mail]>
Sent:
Tuesday, March 3, 2020 6:33 PM
To:
Henderson, Justin L
Subject:
[External] Re: Davie Tanglewood Sewer FTA
Attachments:
Davie Tanglewood FTA pg 5.pdf
Justin,
Please see the attached FTA Page 5 of 5 as requested.
Also, for your convenience, here is a repeat of the flow explanation previously provided:
To clarify, the Davie County Tanglewood pump station serves the Tanglewood Shopping Center in Davie County.
It's flow is currently pumped to Davie's Yadkin River Pump Station which goes to Winston's Tanglewood pump
station. After the project, Davie's Tanglewood station will be removed and it's flow will go by gravity to Davie's
Smith Creek station and then to Davie's Yadkin River station then to Winston's Tanglewood station. There will be
no net difference in either Davie's Yadkin River Station nor in Winston's Tanglewood station.
The names are confusing. Hope this helps.
On Mar 3, 2020, at 1:57 PM, Henderson, Justin L <[e-mail]> wrote:
John,
I am reviewing a Fast Track application for the subject sewer extension, and the following information is
being requested:
1. Please submit a revised/completed p. 5 of 5 that includes a selection of yes or no for Section X.
#1. Attached.
2. Is the flow of 4,000 GPD proposed to be removed from the Tanglewood P/S and redirected via
the proposed gravity sewer currently tributary to each of the pump stations listed in the brief
narrative and on the FTSE forms?
Your application will be placed on hold until the above requested information is received by this office.
Feel free to contact me with any questions you have regarding this inquiry. Thanks.
Justin Henderson
Environmental Specialist II
Winston Salem Regional Office
Division of Water Resources