WQ0004166_Application_20200602

Town of Jefferson Water Re4Ot 'Celk
1233 Highway 16 South P.O.
ox 67 g Y Jefferson, NC 28640 336.246.2165
"Protect-IA/to-the,New River$a-}i.&'
May 6, 2020
NC Dept. of Environmental Quality
Division of Water Resources
Water Quality Permitting Section RECERfEo,/kr/CFO tivR
Non-Discharge Permitting Unit
1617 Mail Service Center jUN 0 2 2020
Raleigh, NC 27699-1617 Non-
ATTN: Mr. Nathaniel Thornburg Permit-Li U
nit
SUBJECT: Town of Jefferson RLAP
Permit Renewal Application
Class B Residuals Land Application
WQ0004166 (Non-Dedicated)
Dear Mr. Thornburg:
Please find enclosed the Permit Renewal Application for Land Application of Class B Residuals
(Non-Dedicated) WQ0004166 for the Town of Jefferson, Ashe County. This existing permit
allows for the disposal of 75 dry tons per year on 43 acres of pasture/hay crops. No
modifications or changes are proposed in this renewal request.
The application package contains Form RLAP 06-16, LOA 06-16, RSC 06-16, and LASC 06-16 along
with the supporting documentation requested within each form. Also please find attached a
check in the amount of $810.00 from the Town of Jefferson payable to North Carolina
Department of Environmental Quality (NCDEQ).
If you have questions or require additional information please call me at [phone] or
contact by email at [e-mail]. Thank you for your assistance to the Town of
Jefferson Water Resources and our efforts to protect the waters of the New River Basin.
Respectfully,
Tim Church, Water Resources Director
CC: Cathy Howell, Town Manager
ENCL: Residuals Land Application Program, Residuals Source Certification,
Landowner Agreements, Land Application Site Certification.
Check for$810.00 payable to NCDEQ

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Divislon of Water Resources 15A NCAC 02T.1100—RESIDUALS LAND APPLICATION PROGRAM
FORM: RLAP 06-16
I. APPLICANT INFORMATION:
1. Applicant's name:Town of Jefferson
Applicant type: ❑ Individual ❑ Corporation General Partnership ❑ Privately-Owned Public Utility
❑ Federal ❑ State X Municipal ❑ County
Signature authority's name per 15A NCAC 02T.0106: Tim Church Title: Water Resources Director
Applicant's mailing address: PO Box 67
City:Jefferson State:NC Zip:28640
Telephone number: [phone] Email Address:[e-mail] RECEIVEDINCDEQIDWR
2. Consultant's name:N/A License Number(for P.E.): JUN 0 2 2020
Affiliation: On Staff Retained(Firm: )
Consultant's mailing address: Non-Discharge
Permitting Unit
City: State: Zip:
Telephone number:( Email Address:
3. Agronomist's name:N/A License Number:
Affiliation: N/A On Staff Retained(Firm:
Agronomist's mailing address:
City: State: Zip:
Telephone number:( Email Address:
4. Soil Scientist's name:N/A License Number:
Affiliation: N/A On Staff Retained(Firm:
Soil Scientist's mailing address:
City: State: Zip:
Telephone number:( Email Address:
5. Fee submitted: $810.00
II. PERMIT INFORMATION:
1. Application is for(check all that apply):LEI new, L modified, X renewed permit
2. If this application is being submitted to renew or modify an existing permit,provide the following:
Permit number: WQ0004166
Date of most-recently issued permit: August 25,2015
Date of most-recently certified Attachment A(if different than the permit):n/a
Date of most-recently certified Attachment B(if different than the permit):n/a
FORM: RLAP 06-16 Page 1 of 5

III. RESIDUALS LAND APPLICATION PROGRAM INFORMATION:
1. Residuals Processing Facility's physical address: 1233 NC Highway 16 S
City: Jefferson State:NC Zip: 28640
Coordinates: Latitude: 36°24'37" Longitude: 81°25'37"
Datum: Level of accuracy:
Method of measurement:
2. County where residuals land application program is headquartered: Ashe
3. List the Operator In Responsible Charge (ORC) and all Back-Up ORCs for the residuals land application program, their
certification numbers, and their affiliations in the following table:
Designation Name Affiliation Certification Number
ORC Tim Church Water Resources Director 14736
Back-Up ORC Brandon Patrick West Jefferson 1003070
Additional Back-Up
ORCs
(if applicable)
If an ORC and at least one Back-Up ORC are not currently designated for this residuals land application program,provide the
candidates' names,affiliations,and an estimated time schedule for each candidate's completion of the required training school
and certification test:
4. Complete the following tables regarding management of the residuals land application program:
a.Plant Available Nitrogen Summer: Determine the maximum plant available nitrogen (PAN) generated by all residuals
source-generating facilities as currently certified and proposed for certification with this application and list the results in the
following table:
Maximum amount of residuals to be certified: 75 dry tons per year.
PAN Pounds of PAN per Dry Ton Pounds of PAN per Year
(Weighted Average)
Surface Incorporation Surface Incorporation
or Injection or Injection
First-Year 33.6 1135
Five-Year Maximum Adjusted 37.9 1278
b.Land Application Site Use Summary: Summarize information regarding the land application sites as currently certified and
proposed for certification with this application:
Category Use Acres Comments
Crops Forest or Plantation
Row Crops
Hay 43
Pasture
Total: 43
Methods Surface 43
Incorporation or Injection
Total: 43
FORM: RLAP 06-16 Page 2 of 5

c.Residuals Land Application Summary: Determine the minimum acreage required to land apply the residuals as currently
certified and proposed for certification assuming the scenarios listed in the following table:
Assumed Acres Required Using Acres Required Using
Application Rate First-Year PAN Concentrations Five-Year Maximum Adjusted PAN
(lbs PAN/ac-yr) Concentrations
Surface Incorporation or Surface Incorporation or
Injection Injection
50 22.7 25.5
100 11.3 12.8
150 7.5 8.5
200 5.6 6.4
6. If applicable,provide a plan and a schedule to resolve any known issues that would prevent land application of the proposed
residuals due to the violation of North Carolina Administrative Code(e.g.not enough storage,not enough land,vector reduction
practices not in place,etc.):N/A
7. Specify type of residuals program(See Instruction F): X Non-dedicated ❑ Dedicated
If Dedicated,specify the following(check all that apply):
Residuals program contains any land application site(s)that receives residuals at rates or frequencies greater than agronom is
rates,explain;
Residuals program contains any land application site(s)that is used primarily for residuals disposal, and agricultural crop
production is of secondary importance,explain;
Residuals program contains any land application site(s)that receives residuals through fixed irrigation facilities or irrigation
facilities fed through a fixed supply system,explain;
IV. RESIDUALS SOURCE INFORMATION: (Required for all new,renewed,or modified residuals source)
Complete and submit the following Residuals Source Certification and all associated documentation.
jl 4'
Residuals Source
Certification
V. LAND APPLICATION SITE INFORMATION: (Required for all new,renewed,or modified land application site)
Complete and submit the following Land Applications Site Certification and all associated documentation.
,Ji' I
Land Application Site
Certification.doc
FORM: RLAP 06-16 Page 3 of 5

Note: Item VI. Applicable to Dedicated Program with fixed irrigation system only.
VI. DESIGN INFORMATION FOR FIXED IRRIGATION SYSTEM
1. The irrigation system is: ❑ Spray ❑ Drip
2. Disposal system is: existing ❑ proposed.
3. Minimum depth to mean seasonal high water table(SHWT)within irrigation sites(s)per Soil Scientist's Evaluation: feet
below ground surface.Rules 15A NCAC 02T.0505(p)requires at least one-foot vertical separation between SHWT and ground
surface.
4. Are there any artificial drainage or water movement structures within 200 feet of any irrigation area?
Yes or ❑No If Yes,please explain if the soil scientist report addresses artificial structures and please indicate if
structures are to be maintained or modified:
5. Loading rates recommended by the Soil Scientist Evaluation:
Recommended Recommended
Soil Series Fields within Soil Area Loading Rate Loading Rate
(in/hr) (in/yr)
6. Design loading rates are equal or less than the loading rates recommended by Soil Scientist?
❑ Yes or❑No If No,explain why 15A NCAC 02T.0505(n) is not met:
7. Non-dedicated System Design(fill in the appropriate information for either a spray or drip irrigation system):
Field/Zone Design Area Number of Maximum Application Design Annual Loading
(ft') Nozzles Rate(gallons/hr) Rate(gallons/yr)
Total �.,.
Spray Irrigation Design Element Plan Sheet Specification
Number Page Number
Wetted diameter of nozzles ft
Wetted area of nozzles ft2
Nozzle capacity gpm
Nozzle manufacturer/model /
Elevation of highest nozzle ft
FORM: RLAP 06-16 Page 4 of 5

Applicant's Certification(signing authority must be in compliance with 15A NCAC 02T.0106):
The applicant or any affiliate has not been convicted of an environmental crime,has not abandoned a wastewater facility without proper
closure,does not have an outstanding civil penalty where all appeals have been exhausted or abandoned,are compliant with any active
compliance schedule,and do not have any overdue annual fees under Rule 15A NCAC 02T.0105.
X Yes No, Explain;
1, Cathy Howell Town Manager
(Signature Authority's Name—PLEASE PRINT) (Title)
attest that this application for Town of Jefferson.WWTP
(Facility Name)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that the Division of Water Resources
may not conduct a technical review of this program and approval does not constitute a variance to any rules or statutes unless specifically
granted in the permit. Further,any discharge of residuals to surface waters or the land will result in an immediate enforcement action,
which 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 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 North Carolina General Statutes §143-215.6A and §143-215.6B,any person who knowingly makes any false
statement,representation, or certification in any application 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: Date: " eq9�oZ O
FORM: RLAP 06-16 Page 5 of 5

May 5, 2020
Town of Jefferson Wastewater Treatment Plant
Class B Residuals Permit Number WQ0004166
Operation & Maintenance Plan
Operational functions are dictated by the amount of solids being wasted in order to maintain
an optimum concentration of mixed liquor suspended solids within the WWTP oxidation ditch.
The plant has three aerobic solids handling areas including the sludge basins, a round digester,
and a loading station. Sludge is wasted initially to the basins, then transferred to the round
digester, and finally to the loading station. All three units have dewatering/decanting devices.
Maintaining this flow pattern produces maximum detention time and stabilization.
Sludge wasting rates are determined using information gathered from quality control analyses
of the mixed liquor, including MLSS concentration, sludge settling rate, mixed liquor pH, and
sludge volume index. The WWTP ORC is responsible for conducting the In-Plant Quality Control
process analyses and making operational changes based upon relative data.
Maintenance schedules are followed for the blowers that supply aeration for the sludge
handling units. All tanks have dual blowers for back-up purposes. Pumps used for transferring
sludge from one unit to the next also have back-ups in place. This maintenance is the
responsibility of the plant operator.
The Spill Response Plan is included on the following pages. It is compatible for the Land
Application Program as well as the Sanitary Sewer Collection System.
Inspections of the sludge handling facilities occur daily and are performed by both the ORC and
WWTP operator. The process is continuously monitored for adequate mixing and aeration and
the need to dewater the sludge units and/or transfer sludge accordingly. A log of dewatering
and wasting activity is maintained in the WWTP laboratory. The land application sites are
inspected and evaluated each day when solids application occurs. A checklist is completed each
day noting the site name, weather conditions, precipitation during previous 24 hours, regional
office notification, flagging of buffers, restricted public access signs in place, site secured from
livestock. This inspection is done by both the ORC and the plant operator since the sites are
located on his family farm.
The ORC is Tim Church. The WWTP operator is Fred Walters. They work cooperatively to
ensure that compliance measures are maintained during the application process. The WWTP
operator holds a valid Commercial Drivers' License and is responsible for transporting the
sludge to the application sites. A tally log of each load applied to each site is maintained in the
sludge truck along with a copy of the Land Application Permit and Spill Response Plan.
(See back of this page.)

Sampling and monitoring plan information is included in the Residuals Source Certification
section (RSC 06-16). The unit labeled "Final Digester" on the Process Flow Diagram is the
collection point for sludge sampling because it is the final unit in the process. Grab samples are
collected from each corner and the middle of the tank. Sampling is performed by the ORC, Tim
Church and occurs on an annual basis.
All samples are preserved according to Standard Method procedures and transported by
courier to the commercial laboratory. Samples are collected as early in the year as possible to
verify compliance with permit limits. Samples for pathogen and vector attraction reduction
were collected in January and February, 2020.
Monitoring as required for the existing permit is conducted for:
• %Total Solids, Ammonia nitrogen, TKN, Nitrate/Nitrite, Aluminum, Arsenic
Cadmium, Calcium, Copper, Lead, Magnesium, Mercury, Molybdenum,
Nickel, Phosphorus, Selenium, Sodium, Zinc, and pH.
• Vector Attraction Reduction
• Pathogen Reduction
• TCLP (Attachment A states "Analyses to demonstrate that residuals are non-hazardous
(TCLP, ignitability, reactivity, and corrosivity) as stipulated under permit Condition IV.2.
Provided that the residuals generated from this residuals source-generating facility are
not mixed with any other residuals authorized by this permit, this facility shall be
exempt from complying with the performance standards stipulated in Condition IV.2 as
well as the monitoring and reporting requirements stipulated in Condition IV.2."

Town of Jefferson Wastewater Treatment Plant
Class B Residuals Land Application Program
Permit Number WQ0004166
Spill Prevention and Control Plan
In the event of accidental loss of liquid biosolids from the transport tanker after it has left the
wastewater treatment facility, the driver is to immediately notify the Town of Jefferson Water
Resources Director via the following numbers.
WWTP 336 246-2165
Water Plant 336 982-2828
Cell Phone [phone]
Based on the nature of the event,the following contacts may need to be completed:
NC Division of Water Quality: Winston-Salem Regional Office 336 776-9800
Ashe County Emergency Management Coordinator 336 846-5521
For specific steps to be implemented in the event of a significant spill, refer to the
Spill Response Action Plan that is attached.

Town of Jefferson Water Resou
rces
Response
Spill Action Plan
*Sanitary Sewer Collection System
*Sewer Pump Stations
*Class B Liquid Residuals Land Application Program

In the event of a Sanitary Sewer Overflow it is the responsibility of the Water Resources Director to submit
Form CS-SSO to the NC Division of Water Quality Winston-Salem Regional Office within 5 days of the time
the Town becomes aware of the SSO. This response should be forwarded through the BIMS system. A
call should be placed to the Winston-Salem Regional Office within 24 hours at [phone].
Sanitary Sewer Overflow or Class B Residuals Spill Contact Numbers
NC Division of Water Quality, Winston-Salem Regional Office 1 [phone]
Ashe County Emergency Management Coordinator [phone]
Jefferson Town Manager [phone]
Jefferson Water Resources Director [phone]
Jefferson Maintenance Superintendent [phone]
Also reference the attached list with the "Contingency Plan for Pump Station Failures" to find numbers
for Plumbers, Contract Pump & Haul Trucks, Electricians, and Equipment Contractors.
I. Containment Procedures
A. Upon reaching the SSO the first priority will be to contain the spill and prevent the
material from reaching surface waters. If there is no danger of the spill reaching surface
waters, contain the event to the smallest area possible.
B. Secure the area of the event to prevent any unauthorized persons from entering the
contaminated area. This includes the stream banks of any surface waters the overflow
has reached.
C. Containment may be achieved in a number of ways, including but not limited to the
construction of ditches, dikes, berms, ponds, or dams. In some situations containment
booms used by the Fire Departments and Emergency Management may be effective. The
material captured within these structures shall be pumped back to the sanitary sewer or
transported to the WWTP by pump truck.
D. In the event of a sewer main blockage, a bypass may be accomplished using a trash pump
suction within the overflowing manhole and pumping the flow into the next downstream
manhole until the blockage is removed. At least one employee shall remain on site until
the pumps are no longer required.
II. Blockage Correction Procedures
A) Upon containment of the spill and the establishment of a bypass pumping system,
attempt to eliminate the blockage by checking for problems in the invert of the
overflowing manhole.
B) Utilizing Town or contract equipment eliminate the blockage. Containment structures
and bypass pumping should remain operational until the blockage is removed.
C) Shortly after the S50 is eliminated and clean-up is completed, contact the Water
Resources Director or the Town Manager to discuss and verify the nature and possible
causes of the blockages.

R
Ill. Clean-Up Procedures for Various Spill Events
At the site of any spill there will likely be an assortment of trash/debris littering the area. Remove
all paper, plastic, and any other non-decomposing material from the site. Such material should
be bagged in a container clearly identified as a BIOHAZARD transported to the WWTP.
A. Spills on Asphalt or Concrete
1. Set up containment at or near the storm drain system. Do not allow the spill to enter
the storm drain.
2. Install a highly visible perimeter (warning tape, cones, barricades, etc.) around area.
3. Spread hydrated lime on the spill and sand to a depth of 1 inch. Allow to stand for an
hour and sweep up. If moisture/grease remains repeat the procedure.
4. After removing contaminated material wash down the area with water and household
chlorine bleach. Dispose this material to the sewer system.
5. If this spill goes into the storm drainage system refer to procedure for spills into
streams.
B. Spills into Streams
1) If possible a dam should be constructed near a manhole or at a location which is
accessible to the pump truck. Station two pumps at the dam capable of handling
stream flow. Use the second pump as a backup. Provide a backhoe at the site with
materials sufficient to repair any breech that might occur. At least two workers are
to be onsite during pumping operations. Pump water from the dam into the manhole.
Notify the WWTP operator regarding this procedure. The volume of some streams
may render this response unacceptable.
2) Place warning tape from the spill to the pump site on either side of the stream. In
populated areas restrict any public access to the spill area.
3) Flush the stream with water from a hydrant or fire truck to remove spillage from the
stream. Request the Water Resources department to collect stream samples and
analyze at the Water Plant Laboratory. Sampling should continue at 24 hour intervals
until Fecal coliform results are 500 colonies/100 ml. or less at a point 100 feet below.
4) When riprap is in the stream implement a high pressure washing until there is no
waste residue remaining on or within the riprap structure.
5) If sludge is present in the stream broom the bottom and sides until no residue remains
6) If the stream flows into a body of water used for recreation or drinking notify the
affected county and local health department officials immediately. This procedure
also applies to spills affecting ponds and lakes.
C. Spills into Ponds or Lakes
1) Place warning tape and/or barriers on the shoreline at site of contamination.
2) Request Water Resources operator to collect fecal coliform samples and dissolved
oxygen samples around the entire circumference.
3) If initial fecal coliform samples exceed 8,000 colonies/100 ml contact the Winston-
Salem Regional Office of DWQ for appropriate action.
4) Continue pumping until results of 500 colonies or less are obtained.
5) Continue monitoring until NC DWQ or Regional Health Department no longer requires
monitoring.

D. Open Areas
1) Use warning tape to prevent public access around the spill.
2) Apply lime and till. Repeat. Seed and cover with straw.
3) In undergrowth wash with liberal amounts of water. Push toward containment area
and pump site. Continue until no waste remains. After 12 to 24 hours lime the area.
Avoid liming when heavy precipitation is forecast.
4) When a citizens yard is involved till the area whenever possible. Apply lime, seed, and
straw. If unable to till, apply lime and 2 inches of topsoil mixing thoroughly, Lime,
Town of Jefferson Water Resources Contingency, Staging, & Mobilization
I. Equipment Resources and Storage Locations
A) Standby Portable Generator Maintenance Shop Bucket Truck
B) Portable Trash Pump WWTP Biosolids Building
C) Portable Water Pump WWTP Biosolids Building
D) Portable Mud Pump Maintenance Shop
E) 2 Case Backhoes Maintenance Shop
F) Ford Tractor WWTP Garage
G) New Holland Tractor 4X4. Maintenance Shop
H) Sludge Truck 1800 gallon WWTP Garage
i) Tripod, Harness, Winch Maintenance Shop cage
J) Confined Entry Equipment and Oxygen Meter Maintenance Shop office
K) Personal Protection Equipment Maintenance Shop office
Contractors, Technicians, and Engineering
Blue Ridge Electric Membership 1 800 448-2383
R.L. Electric Service 336 877-7216
David Wright Electrician ......................... 336 977-0873
Potter Electric Service 336 384-1989
Wilkes Electric Motors 336 973-4507
High Country Electric Motors 336 838 4808
Doug Cox Backhoe and Septic Pumping 336 982-8640
Myers Septic Service 336 838 5045
Jefferson Rent-All 336 246-8136
Ernie Carpenter Utilities 336 384-3800
McGill Associates, P.E 828 252 0575
Technical information files for the Pump Stations such as drawings pump curves, installation, and
manufacturing data are located in the brown filing cabinet in the #1 Lab Building at the WWTP at
the Pump Control Panel.

State of North Carolina
"n 161;'` Department of Environmental Quality
Division of Water Resources
Division of Water Resources RESIDUALS SOURCE CERTIFICATION
FORM: RSC 06-16
I. RESIDUALS SOURCE-GENERATING FACILITY INFORMATION(See Instruction B.):
1. Facility Name: Town of Jefferson
2. Facility permit holder is: 1„1 Federal, [l State, X Local Government,or IF? Private.
Facility permit issued by: X Div.of Water Resources, Si Div.of Environmental Health,
or Other(explain:
3. Facility contact person and title: Tim Church, Water Resources Director
Complete mailing address: PO Box 67
City:Jefferson State: NC Zip: 28640
Telephone number:[phone] E-mail address:jeffwns n,centurylink.net
4. Facility physical address: 1233 Hithway 16 S
City:Jefferson State: IBC Zip:28640
Coordinates: Latitude:26°21' ." Longitude:1r 2. '4."
Datum:II. Level of accuracy:MI
Method of measurement:
5. Purpose of the facility:
X treatment of municipal wastewater, ® treatment of 100%domestic wastewater,
❑ treatment of potable water, NI treatment of 100%industrial wastewater,
❑ treatment of industrial wastewater mixed with domestic wastewater,
(approximate percentages:ME%industrial and %domestic)
other(explain:Mil).
6. Does the facility have an approved pretreatment program: X Yes 111 No
7. Facility permitted/design flow:0.600 MGD and facility average daily flow: 0.220 MGD
8. Average amount of residuals being generated at this facility¢Q dry tons per year.
9. Specify the following regarding treatment and storage volumes available at the facility:
Type and volume of residuals treatment: Aerobic digesters with 180,000 gallons capacity
Type and volume of residuals storage(i.e.,outside of residuals treatment units): n/a
II. RESIDUALS QUALITY INFORMATION(See Instruction C.):
I. Specify if residuals are regulated under:
X 40 CFR Part 503 or Li 40 CFR Part 257.
Note: Only residuals that are generated during domestic/municipal wastewater treatment processes are regulated under 40
CFR Part 503,otherwise,the residuals are regulated under 40 CFR Part 257.
2. Specify if residuals are defined under 15A NCAC 02T.1102(6)as:
X Biological 03 Non-Biological
Note: Biological residuals are residuals that have peen generated during the treatment of domestic wastewater, animal
processing wastewater, or the biological treatment of industrial wastewater (biological treatment is a system that utilizes
biological processes including lagoons,activated sludge systems,extended aeration systems,and fixed film systems).
FORM: RSC 06-16 Page 1 of 5

3. Hazardous Waste Determination: Complete the following to demonstrate that the residuals are non-hazardous under
RCRA: (Note - this item does not have to be completed for facilities that are less than 0.5 MGD in design flow that treat
100%non-municipal,domestic wastewater only)
a. Are the residuals listed in 40 CFR §261.31-§261.33: [ yes X no.
If yes, list the number(s) +`"M!`
b. Specify whether or not the residuals exhibit any of the characteristics defined by 40 CFR §261.21-
261.24: 0 yes X no.
Fill in the following tables with the results of the latest toxicity characteristic leaching procedure (TCLP) analysis as
well as those for corrosivity, ignitability, and reactivity:
Laboratory: Meritech,Inc. Date of analysis: 8/23/18
Passed corrosivity test: X yes 0 no. pH: s.u. (2 <pH < 12.5)
Passed ignitability test: X yes 0 no. Flashpoint:> I40°F(> 140°F)
Passed reactivity test: X yes 'di no. HCN:0.54 mg/kg(<250)& H2S: <10. mg/kg(<500)
TCLP Parameter Limit Result TCLP Parameter Limit Result
(mg/1) (mg/1) (mg/I) (mg/I)
Arsenic 5.0 <0.100 Hexachlorobenzene 0.13 <0.100
Barium 100.0 0.196 Hexachloro-1,3-Butadiene 0.5 <0.100
Benzene 0.5 <0.0100 Hexachloroethane 3.0 <0.100
f Cadmium 1.0 <0.020 Lead 5.0 <0.100
Carbon Tetrachloride 0.5 <0.0100 Lindane 0.4 <0.040
Chlordane 0.03 <0.003 Mercury 0.2 <0.02
Chlorobenzene 100.0 <0.0100 Methoxychlor 10.0 <1.00
Chloroform 6.0 <0.0100 Methyl Ethyl Ketone 200.0 <0.100
Chromium 5.0 <0.050 Nitrobenzene 2.0 <0.100
m-Cresol 200.0 <0.200 Pentachlorophenol 100.0 <0.500
o-Cresol 200.0 <0.100 Pyridine 5.0 <0.100
p-Cresol 200.0 <0.200 Selenium 1.0 <0.100
Cresol 200.0 <0.300 Silver 5.0 <0.050
2,4-D 10.0 <1.00 Tetrachloroethylene 0.7 <0.0100
1,4-Dichlorobenzene 7.5 <0.100 Toxaphene 0.5 <0.05
1,2-Dichloroethane 0.5 <0.0100 Trichloroethylene 0.5 <0.0100
1,1-Dichloroethylene 0.7 <0.0100 2,4,5-Trichlorophenol 400.0 <0.100
2,4-Dinitrotoluene 0.13 <0.100 2,4,6-Trichlorophenol 2.0 <0.100
Endrin 0.02 <0.002 2,4,5-TP(Silvex) 1.0 <0.100
Heptachlor and its Hydroxide 0.008 <0.0008 Vinyl Chloride 0.2 <0.0200
FORM: RSC 06-16 Page 2 of 5

4. Metals Determination: Complete one of the following tables (i.e., as applicable) to demonstrate that the residuals do not
violate the ceiling concentrations for metals regulated under 15A NCAC 02T.1105.
a. For Distribution/Land Application: Fill in the following table with the results of the latest analyses (i.e., on a dry weight
basis)for the following metal parameters:
Laboratory: Meritech,Inc. and Date of analysis: 1/15/2020
Parameter Ceiling Monthly Average Result
Concentration Limits Concentration Limits
(ClassA & ClassB) (Class A Only)
(mg/kg) (mg/kg) (mg/kg)
Arsenic 75 41 <4.31
Cadmium 85 39 <0.862
Copper 4,300 1,500 385.
Lead 840 300 10.3
Mercury 57 17 0.302
Molybdenum 75 n/a 5.28
Nickel 420 420 13.9
Selenium 100 100 <4.31
Zinc 7,500 2,800 544.
b. For Surface Disposal Unit(landfill): Fill in the following table with the results of the latest analyses(i.e.,on a dry weight
basis) for the following metal parameters: Iv f k
Laboratory:Iii;1 '' and Date of analysis: it ll
Distance from Disposal Arsenic Chromium Nickel
Unit to Boundary to
Closest Property Line
(meters, check one) (mg/kg) (mg/kg) (mg/kg)
❑ >0 but<25 30 200 210
0 >25 but<50 34 220 240
0 > 50 but<75 39 260 270
0 >75 but < 100 46 300 320
0 > 100 but< 125 53 360 390
0 > 125 62 450 420
Result (mg/kg)
FORM: RSC 06-16 Page 3 of 5

5. Nutrient/Micronutrient Determination: Complete the following:
a. Total solids: 1.16%.
b. Fill in the following table with the results of the latest analyses (i.e., on a dry weight basis) for the following nutrient and
micronutrient parameters:
Laboratory: Meritech.Inc. and Date of analysis: 1/15/2020
Parameter Result
(mg/kg)
Aluminum 5540
Ammonia-Nitrogen <862
Calcium 15400
Magnesium 4600
Nitrate-Nitrite Nitrogen 1460
pH (Standard Unit) 6.0
Phosphorus 18500
Potassium 4940
Sodium 3160
Total Kjeldahl Nitrogen 50700
c. Using the results listed in Item II. 5b. above, calculate the sodium adsorption ration (SAR):
[Note: If residuals contain SAR of 10 or higher, the applicant shall obtain recommendations from the local Cooperative
Extension Office, the Department of Agriculture and Consumer Services, the Natural Resource Conservation Service, a
North Carolina Licensed Soil Scientist, or an agronomist,prior to land application of residuals. The recommendations shall
address the sodium application rate, soil amendments (e.g., gypsum, etc.), or a mechanism for maintaining site integrity
and conditions conducive to crop growth].
d. Specify the mineralization rate to be used in calculating the plant available nitrogen (PAN) of the residuals: MOb %.
This rate is a(check one): default value,or (] actually established.
If the residuals are not generated from the treatment of municipal or domestic wastewater, ex•lain or provide technical
justification as to why the selected default value is appropriate to be applied to these residuals:
e. Calculate the PAN for the residuals(i.e.,on a dry weight basis)and fill the results in the following table:
Application Method First(1")Year PAN Five-Year
Maximum Adjusted PAN
(mg/kg) (mg/kg)
Surface 16,842 18,950
Injection/Incorporation
6. Other Pollutants Determination: S•ecify whether or not there are any other pollutants of concern in the residuals and provide
the results of the latest analyses: 111011,
FORM: RSC 06-16 Page 4 of 5
-

7. Pathoeen Reduction: Per 15A NCAC 02T.1 106,specify how residuals will meet the pathogen reduction requirements:
a. For Distribution/Land Application of Class A or Equivalent:
A fecal coliform density that is demonstrated to be less than 1,000 MPN per gram of total dry solids,
or
ILI A salmonella sp. density that is demonstration to be less than 3 MPN per 4 grams of total dry solids.
AND one of the followings(except for non-biological residuals):
❑ Alternative 1 [15A NCAC 02T.1106(bx3XA)]-Time/Temperature Compliance.
❑ Alternative 2[15A NCAC 02T.1106(bx3)(B)]-Alkaline Treatment.
❑ Alternative 3 [15A NCAC 02T.1106(bx3XC)]-Prior Testing for Enteric Virus/Viable Helminth Ova.
❑ Alternative 4[15A NCAC 02T.1106(bX3XD)]-No Prior Testing for Enteric VirusNiable Helminth Ova.
❑ Alternative 5 [15A NCAC 02T.1106 . 3)(E)-(K)]-Process to Further Reduce Pathogens(PFRP).
Specify one: Iu 4 composting, i,. heat drying, i heat treatment,
thermophilic aerobic digestion, °"'I beta ray irradiation,
Q gamma ray irradiation, or IM pasteurization.
b. For Land Application of Class B:
X Alternative 1 [15A NCAC 02T.1106(cxl)]-Fecal Coliform Density Demonstration.
IN Alternative 2 [15A NCAC 02T.1106(c)(2 - Process to Si tficantly Reduce Pathogens(PSRP).
Specify one: IN aerobic digestion, f,;'::1 air drying, anaerobic digestion,
tidli composting,or Dii""'' lime stabilization.
c. Far Surface Disposal:
❑ Select One of the Class A or Equivalent Pathogen Reduction Alternatives in Item II.7a. above.
X Select One of the Class B or Equivalent Pathogen Reduction Alternatives in Item II. 7b.above.
❑ Exempt-If Daily Cover Alternative is chosen in Item 1I.8.below [15A NCAC 02T.1106(a)(2)].
Not Applicable-Non-Biological Residuals with NO Domestic Wastewater Contribution.
8. Vector Attraction Reduction(VAR): Per 15A NCAC 02T.1 107,specify how residuals will meet the VAR requirements:
❑ A• lternative 1 [15A NCAC 02T.1107(axl)]-38%Volatile Solids Reduction(Aerobic/Anaerobic Digestion).
❑ Alternative 2 [15A NCAC 02T.1107(a)(2)]-40-Day Bench Scale Test(Anaerobic Digestion).
X Alternative 3 [15A NCAC 02T.1107(ax3)]-30-Day Bench Scale Test(Aerobic Digestion).
Alternative 4 [15A NCAC 02T.1107(a)(4)]-Specific Oxygen Uptake Rate Test(Aerobic Digestion).
❑ Alternative 5 [15A NCAC 02T.1107(a)(5)]- 14-Day Aerobic Processes.
❑ Alternative 6 [15A NCAC 02T.1107(a)(6)]-Alkaline Stabilization.
❑ Alternative 7 [15A NCAC 02T.1107(a)(7)]-Drying of Stabilized Residuals.
❑ Alternative 8[15A NCAC 02T.1107(ax8)]-Drying of Unstabilized Residuals.
❑ Alternative 9 [15A NCAC 02T.1107(ax9)]-Injection.
❑ Alternative 10[15A NCAC 02T.1107(a)(10)]-Incorporation.
❑ A• lternative for Surface Disposal Units Only-Soil/Other Material Cover[15A NCAC 02T.1107(bx2)].
❑ N• ot Applicable-Non-Biological Residuals with NO Domestic Wastewater Contribution.
Note: For animal processing residuals, only alternatives 9 or 10 may be chosen due to the nuisance conditions that typically
occur when these residuals are applied and left on the land surface.
FORM: RSC 06-16 Page 5 of 5

RESIDUALS SOURCE FACILITY SUMMARY
Applicant's name:Town of Jefferson
Status Maximum Dry Tons E'er Year
Codc• Facility Permit Holder Facility Name County Permit Number
Current b Proposed
(t Town of Jefferson Jefferson WWTP Ashe WQ0004166 75 75
'Status Code for source facility are: •N(New) •R(Renewed) •M(Modified) •D(Deleted)
b The amount of residuals currently permitted for distribution,land application,or disposal(i.e,not applicable to new facility).
SUMMARY FOR FORM: RSC 06-16 Page 1

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1000 0 METERS 1000 2000
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MILES
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FEET --_ QUADRANGLE LOCATION
CONTOUR INTERVAL 40 FEET
NATIONAL GEODETIC VERTICAL DATUM OF 1929 1 Park
TO CONVERT FROM FEET TO METERS,MULTIPLY BY 0.3048 1 2 3 2 Grassy Creek
3 Mouth of Wilson
4 Warrensville
4 5 5 Laurel Springs
6 Todd
THIS MAP COMPLIES WITH NATIONAL MAP ACCURACY STANDARDS 7 Glendale Spings
6 7 S 8 Horse Gap
FOR-SALE BY U.S.GEOLOGICAL SURVEY,P.O.BOX 25286,DENVER,COLORADO 80225
A FOLDER DESCRIBING TOPOGRAPHIC MAPS AND SYMBOLS IS AVAILABLE ON REQUEST ADJOINING 7.5'QUADRANGLE NAMES

i
Process Flow Diagram
.., , _- Wastewater & Residuals Processing
Town of Jefferson WWTP ....
`' Headworks Short-Term Monitoring Plan Sample Point 1 wet
Bar Scr
-- well
Cooling for Dryer < „1/
S u.pCrne, I ami .
A A
f I ......
1 N.
Sludge Sludge
• ► Basin Basin
Belt Sludge N,,
Press Dryer Clarifyer
i.-s• #1 ,Y
mp Station
Final Wit',
..._ _._ _ _ Digester .—
'‘'-----ft.---.
G Sample Point 4
Divider Box ' ,' ,e ., `""`..
Digester
C^— ". .... ......9 I
rt. 7 4/.
Y u
Sample Point 3 V
Oxidation Ditch
ri1e-t ry
Fit rS Chlorine. "P.`
Dechlor,
Clarifyer L� Sample Point 2
#2
7

April 30, 2020
Town of Jefferson Wastewater Treatment Plant
Class B Residuals Permit Number WQ0004166
Residuals Sampling Plan and Flow Narrative
Sludge Storage Capacity
Two sludge storage basins 115,000 gallons
Round digester 65,000 gallons
Loading station 25,000 gallons
Total sludge storage capacity 205,000 gallons
II. Sludge Transfer through the Facility
Sludge collected from two final clarifiers enters a pump station where wasting is accomplished
by diverting return activated sludge flow to the dual sludge storage basins. When the basins
are filled, the aerators are turned off allowing solids to settle and a clear supernatant to be
decanted using a telescopic valve in each basin. The supernatant is returned by gravity to the
influent headworks of the WWTP. At the completion of dewatering, aeration is resumed and
the thickened sludge is transferred to the round digester using a submerged pump in each
basin. The round digester has similar dewatering capability. Upon dewatering, the round
digester, sludge is allowed to flow by gravity to the loading station. Supernatant from the
round digester flows to the pump station and is recycled to the Oxidation Ditch. Sludge from
the loading station is transferred to the tank truck and land applied. This plan allows for
maximum detention time and stabilization.
III. Class B Residuals and Sampling Plan
Permit WQ0004166 contains 43 acres for land application, all within a 2 mile radius of the
WWTP. Spreading is done using a tandem axle all-wheel drive truck equipped with a 1,800
gallon tank and spreader bar controlled by a cab-operated pneumatic valve.
Sludge samples are collected at the loading station, the last unit in the digester train. Grab
sampling is done by collecting a sample from each corner of the tank and in the middle. The
permit requires annual sampling.
Pathogen Reduction : 7 samples with a fecal Water Quality Lab, Banner Elk, NC
geometric mean < 2,000,000
Vector Attraction Reduction : 30 day bench Water Quality Lab, Banner Elk, NC
Volatile Solids Reduction < 15 %
Metals, Nutrients, TCLP Meritech Lab, Reidsville, NC
Certificates of Analysis provided in this application

April 30, 2020
Town of Jefferson Wastewater Treatment Plant
Class B Residuals Permit Number WQ0004166
Quantitative Justification of Residuals Production Rate
Year 2017
Volume Land Applied, Gallons 759,600
%Total Solids 1.1 (0.011)
Total Dry Tons 35
Year 2018
Volume Land Applied, Gallons 570,600
%Total Solids 2.8 (0.028)
Total Dry Tons 66
Year 2019
Volume Land Applied, Gallons 761,800
%Total Solids 1.8 (0.018)
Total Dry Tons 57
Using data from the three most recent years and assuming the volume and characteristics of
the flow to the Jefferson WWTP will remain largely unchanged, the Town of Jefferson requests
this permit be renewed at its existing permitted level, 75 dry tons annually.

/
Meritech, Inc.
;, Environmental Laboratory
Laboratory Certification No.165
i
Report Date: 1/30/2020
Client: Town of Jefferson WWTP NPDES #: NC0021709
P.O. Box 67 Project: Sludge
g
Jefferson, NC 28640 Date Sample Rcvd: 1/15/2020
Meritech Work Order# 01152004 Sample: Digester Sludge Grab 1/14/20
Parameters Results Analysis Date Reporting Limit Method
%Total Solids 1.16 % 1/16/2020 0-100 % SM 2540E
Ammonia, Nitrogen <862 mg/kg 1/21/2020 862 mg/kg EPA 350.1
TKN 50700 mg/kg 1/17/2020 0.20 mg/kg EPA 351.1
Nitrate/Nitrite, Nitrogen 1460 mg/kg 1/22/2020 31.3 mg/kg EPA 353.2
Aluminum,total 5540 mg/kg 1/23/2020 2.5 mg/kg EPA 200.7
Arsenic,total <4.31 mg/kg 1/23/2020 4.31 mg/kg EPA 200.7
Cadmium, total <0.862 mg/kg 1/23/2020 0.862 mg/kg EPA 200.7
Calcium,total 15400 mg/kg 1/23/2020 10.0 mg/kg EPA 200.7
Copper,total 385 mg/kg 1/23/2020 1.00 mg/kg EPA 200.7
-- Lead, total 10.3 mg/kg 1/29/2020 0.500 mg/kg EPA 200.7
Magnesium, total 4600 mg/kg 1/23/2020 10.0 mg/kg EPA 200.7
Mercury, total 0.302 mg/kg 1/21/2020 0.100 mg/kg EPA 245.1
Molybdenum,total 5.28 mg/kg 1/23/2020 0.500 mg/kg EPA 200.7
Nickel,total 13.9 mg/kg 1/23/2020 2.0 mg/kg EPA 200.7
Phosphorus, total 18500 mg/kg 1/23/2020 2.00 mg/kg EPA 200.7
Potassium,total 4940 mg/kg 1/23/2020 20.0 mg/kg EPA 200.7
Selenium,total <4.31 mg/kg 1/29/2020 4.31 mg/kg EPA 200.7
Sodium,total 3160 mg/kg 1/23/2020 20.0 mg/kg EPA 200.7
Zinc,total 544 mg/kg 1/23/2020 0.500 mg/kg EPA 200.7
I hereby certify that I have reviewed and approve these data.
abo tory'Representative
642 Tamco Road, Reidsville, North Carolina 27320
tel.[phone] fax.[phone]

�~ = Chain of Custody Record (COC) NPD[Stt: NCJO2I/09
I1/I ERITElient: 1 0Wl� o� L�(i��� r�SO Phone: �Li� - �.,��j-
INC.I • Address: R Q. Li* (I Fax: 3�O 2_1-{(c. - 2..I 6-5-
. ENVIRONMENTAL LABORATORIES �C.0 QXs-a-\j NC, ? 6Lio Email:jC WhS C:Chi'tlry) I .,I]C,f
642 Tamco Rd. Phone: [phone] Project: IuCcek/
Reidsville NC 27320 Fax: [phone] P.O.#:
Email: [e-mail] Attention: Turn Around Times
*RUSH work needs prior approval,
How would you like your report sent? c h,n:e,two Std 10da s) I).� ti 2t '1RIfr�
Circle all that apply: preferred), Fax, Mail �� C -
Sampling Dates Times Person Sample(Sign/Print):
Lab Use Only
Sample Location and/or ID ft Start End
Comp? trof Test(s) Required on Ice? pH OK?
_ Date Time Date Time Grab? Cont. yr's 1 No CI OK?
.Di ester Slurs e, I/1'-I /20 ►3ZS G I Nifrtte,�1\i--r►--eJ N1-h-N T<N (.. L
G I �o Totoit Solids _
. G _ I Aluminum- ArstNc/Gdmlum C.A1riuim
Copper LEtio, Motottya,51an Ako-cury 1
d Ni h o
� Pa Qosllrys ,
o a.ssiurn,, Sr,InnI'ur�1, aodi m� 1
U t
Zinc
Temperature Upon
_Receipt: �) c
Method of •••Dechlorination(<0.5 ppm)of Ammonia,Cyanide,Phenol and TKN samples must be done in the field prior to preservation.••• Y.
$hl ►pent: Comments: Compositor it
p
11-
UPS Jug II
U_] Fed Ex Are thes results for regulatory purposes? / J Received
` by: Date: Time.:
Yes ,-`.3 No U Report results in: mg/I. 0 mg/kg I ug/L (i
�� Relinquished by: f /� Date:/p/ 0Time: /3 r 5
Hand Delivery //�
Li Other Relinquished by: Date: Time: Received by: Date: Time:
Relinquished by: Date: Time: Recei : 1,,,____, i/i cf:lati:::) c Ttimei c L,
I,

SAR for Biosolids or Wastewater S QmP lea: 111 1 ZOZO
Sodium Absorption Ratio Na(Mq/L) Ca(Mq/L) Mq(Mq/L)
Na :Sodium (Mg/L) Equivalent weight: 23 36.6 178.6 53.3
Ca : Calcium (Mg/L) Equivalent weight:20
Mg : Magnesium (Mg/L) Equivalent weight: 12 Na (ME) Ca (ME) Mq (ME
1.591304 8.93 4 44166
Milli Equivalent= Mg/L/Equivalent weight
SAR=Na Milli Equivalent/[0.5 X(Ca Milli Equivalent+Mg Milli equivalent)]0.5 power
GAR -- E; F15425 (From MgIL entered above)
If your lab reports in Milli Equivalents enter Na,Ca,&Mg below:
SAR= #DIV/0! )From ME entered below)
Na (ME) Ca (ME) Mq (ME)
Exchangeable Sodium Percentage(FOR SOIL SAMPLE RESULTS)
ESP= Na (Milli Equivalents)/CEC X 100 The percentage of sodium ions occupying the
Na (ME) CEC
ESP - #DIVru'
Na on NC soil test is expressed as meq.

[
..
./
Meritech, Inc.
EnLvabiorroatnomry Cenerttiatil Laboratory
cati. No.i6
5
•
.. . :"
Page 1
Report Date: 9/11/2018
Client: Town of Jefferson VVWTP
P.O.Box 67 Project: Sludge
Jefferson, NC 28640 Date Sample Rcvd: 8/23/2018
4eritech Work Order# 082318132 Sample: Digester Sludge Grab 8/23/18
1311 - TCLP Metals
Parameters Result Analysis Date pet. Limit Reg. Limit Method
Arsenic <0.100 mg/L 8/31/18 0.100 5.0 EPA 200.7
Barium 0.196 mg/L 8/31/18 0.050 100.0 EPA 200.7
Cadmium <0.020 mg/L 8/31/18 0.020 1.0 EPA 200.7
Chromium <0.050 mg/L 8/31/18 0.050 5.0 EPA 200.7
Lead <0.100 mg/L 8/31/18 0.100 5.0 EPA 200.7
Mercury <0.02 mg/L. 9/4/18 0.02 0.2 EPA 245.1
Selenium <0.100 rng/L 8/31/18 0.100 1.0 EPA 200.7
Silver <0.050 mg/L 8/31/18 0.050 5.0 EPA 200.7
TCLP Organics
Parameter Results AnitlY515 Da te Reporting Limit Method
Volatiles 8260 Attached 8/28/18 - 8260
Semi Vol. 8270 Attached 9/6/18 - 8270
Other Tests
Parameter Result Analysis Date Reporting Limit Method
%Total Solids 1.5 % 8/29/18 0-100 % SM 2540B
Corrositivity (pH) 6.4 S.U. 9/4/2018 1.0 - 14.0 S.U. SM 4500 HB
Cyanide,total 0.54 mg/kg 8/24/18 0.500 mg/kg EPA 335.4
lgnitabllity >140 °F 8/24/18 - - EPA 1030
Sulfide,total <10.0 mg/kg 8/24/18 10.0 mg/kg SM 4500 SD
642 Tarnco Road, Reidsville, North Carolina 27320
tel.[phone] fax.[phone]

Meritech, Inc.
Environmental Laboratory
Alli Laboratory Certification No.165
1/4#
Page 2
Report Date: 9/11/2018
Client: Town of Jefferson WWTP
P.O.Box 67 Project: Sludge
(effeison, NC 28640 Date Sample Rcvd: 8/23/2018
Meritech Work Order# 082318132 Sample: Digester Sludge Grab 8/23/18
1311 - TCLP Pesticides & Herbicides
Pesticide- SW-846 808.1A
Parameter Results Analysis Date pet.Limit Reg.Limit Dilution Factor
Endrin <0.002 mg/L 9/5-6/18 0.002 0.02 1
Chlordane <0.003 mg/L 9/5-6/18 0.003 0.03 1
Toxaphene <0.05 mg/L 9/5-6/18 0.05 0.5 1
Methoxychlor <1.00 mg/l. 9/5-6/18 1.00 10.0 1
Heptachlor <0.0008 mg/L 9/5-6/18 0.0008 0.008 1
Lindane <0.040 mg/L 9/5-6/18 0.040 0.4 1
Herbicides -SW-846 8151A
Parameter Results Analysis Date Pet.limit Reg. Limit Pilution Factor
2,4-D <1.00 mg/L 9/5-6/18 1.00 10.0 1
2,4,5-TP (Silvex) <0.100 mg/L 9/5-6/18 0.100 1.0 1
I hereby certify that I have reviewed and approve these data.. , , frdsk 0(1)4 ,
Laborato epresentative
642 Tamco Road,Reidsville, North Carolina 27320
tel.[phone] fax.[phone]

MERITECH, INC.
Environmental Laboratories
1110, Laboratory Certificate#165
Client: Jefferson W W'I'P
Project: Sludge
Client Sample ID: Digester Sludge
Sample Collection: 08/23/18
Meritech Sample ID: 082318132
1311 - TCLP Organics
Volatiles; SW-846 8260
Analysis: 08/28/18 Extraction: 08/27/18
Analyst: VWV Report Date: 09/04/18
Parameter Result Units pet. Limit pee,Limit ,dilution Factor
Benzene <0.0100 mg/L 0.0100 0.50 10
Carbon Tetrachloride <0.0100 mg/L 0.0100 0.50 10
Chlorobcnzcne <0.0100 mg/I, 0.0100 100 10
Chloroform <0.0100 rng/L 0.0100 6.0 10
1,2-Dichloroethane <0.0100 mg/L 0.0100 0.50 10
1,I-Dichloroethene <0.0100 mg/L 0.0100 0.70 10
Methyl Ethyl Ketone <0.100 mg/L 0.100 200 10
Tetrachloroethylenc <0.0100 mg/L 0.0100 0.70 10
Trichloroethene <0.0100 mg/L 0.0100 0.50 10
vinyl Chloride <0.0200 mg/L 0.020 0.20 10
Semi-Volattles:SW-846 8270
Analysis: 09/06/18 Extraction: 08/27/18
Analyst: PM Report Date: 09/10/18
Parameter Result Unit4 Det,Limit Ref. Limit Dilution Factor
I,4-I)ichlorobenzcnc <0.100 mg/L 0.100 7.5 10
Hexachlorobenzene <0.100 mg/L 0.100 0.13 10
llexachloro-1,3-butadiene <0.100 mg/1, 0.100 0.5 10
IlexachIoruethane <0.100 mg/L 0.100 3.00 10
o-cresol <0.100 mg/L 0.100 200 10
m&p-cresol <0.200 mg/L 0.200 200 10
Total cresols <0.300 mg/L 0.300 200 10
Nitrobenzene <0.100 mg/I. 0.100 2.00 10
Pentachlorophenol <0.500 mg/L 0.500 I00 10
Pyridine <0.100 mg/L 0.100 5.0 10
2,4,5-Trichiorophenol <0.100 mg/L 0.100 400 10
2,4,6-Trichlorophenol <0.100 mg1L 0.100 2.00 10
2.4-1)initrotolucne <0.100 mg/L 0.100 0.13 10
I hereby certify that I have reviewed and approve these data. iLit,,�_ a!(/::
Laboratory Representative
642 Tamco Road * Reidsville, NC 27320
[phone] * [e-mail]

,.,.,,:, Chain of Custody Record (COC) NPDES#:
Client:Je S , {�' 'V i OP t Phone: - t
rP M E R IT EC H, INC. Address: U.,L3k to Fax: Z (0' 5
'1 ENVIRONMENTAL LABORATORIES :TP;ge.t-SOnl WC 2.X'.WO Email:'
. 642 Tamco Rd. Phone: [phone] Projec : Shia f/
C, '-- ' Reidsville NC 27320 Fax: [phone] P.O.#:
-
Turn Around Time'
Email: [e-mail] Attention:
'RUSH work needs prior approval.
How would you like your report sent?
www.meritechlabs.com Circle all that apply: Emai preferred), Fax, Mail 5tt5) ;ems 2� r
Sampling Dates & Times Person Taking Sample(Sign/Print): • h/ Tn, �l Lu►tom L Lab Use Only
Sample Location and/or ID# Start End Comp? #of On Ice? Yes pH OK?
Date Time Date Time Grab? Cont. Test(s) Required / No dOK?
es er S k . 8.23.18, 0730 , . Cyr '1 . TC L P +-�
Temperature Upon Receipt:
Method of
'••Dechlorination(<0.5 ppm)of Ammonia,Cyanide,Phenol and TKN samples must be done In the field prior to preservation.••• el PC/
Comments: Compositor#
Shipment:
UPS Jug#l°� Fed Ex Ar ese Its fo regulatory purposes? es No .J Report
Reposults in: metm Li ugh -,..i
Relinquished by: Date:Di une: y7 -
ReliHand Delivery O b 6yt,hed by (.— Date Time Received j ab " /!,Diij: r
r Time: .

- ATTACHMENT A - Approved Residual Sources Certification Date: August 25,2015
Town of Jefferson Permit Number: WQ0004166 Version: 3.0
Residuals Source-Generating Facilities
Monitoring 1
Monitoring Monitoring Approved
Maximum Frequency for
Owner Facility Name County Permit Biological Dry Tons Frequency for Frequency for Pathogen& Mineralization
Number Residuals Per Year, Non-hazardous Metals and Vector Attraction Rate
2
Characteristics Nutrients - 4.c
Reductions
Town of Jefferson Town of Jefferson Wastewater Treatment Plant Ashe NC0021709 Yes 75 Annually Annually Annually 0.30
1. Maximum Dry Tons per Year is the amount of residuals approved for land application from each permitted facility.
2. Analyses to demonstrate that residuals are non-hazardous(i.e.. TCLP, ignitability, reactivity,and corrosivity) as stipulated under permit Condition IV.2. Provided that the residuals generated
from this residuals source-generating facility are not mixed with any other residuals authorized by this permit, this facility shall be exempt from complying with the performance standards
stipulated in Condition IV.2.as well as the monitoring and reporting requirements stipulated in Condition 1V.2. fn.!
3. Testing of metals and nutrients as stipulated under permit Condition IV.3.
4. Analyses of pathogen and vector attraction reductions as stipulated under permit Condition IV.4.
5. Monitoring frequencies are based on the actual dry tons applied per year using the table below,unless specified above.
Dry Tons Generated Monitoring Frequency
(short tons per year) (Established in 40 CFR 503 and 15A NCAC 02T.1111)
<319 1/Year
=>319-<1,650 I/Quarter(4 times per year)
=>1.650-<16.500 1/60 Days(6 times per year)
>16,500 1/month(12 times per year)
If no land application events occur during a required sampling period(e.g. no land application occur during an entire year when annual monitoring is required),then no
sampling data is required during the period of inactivity.The annual report shall include an explanation for missing sampling data.Those required to submit the annual
report to EPA may be required to make up the missed sampling,contact the EPA for additional information and clarification.
WQ0004166 Version 3.0 Attachment A Page 1 of I

7 . U?j)
t ;
WATER QUALITY LAB &OPERATION, INC. PSR p
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
CLIENT: JEFFERSON SLUDGE LOGIN TIME: 9:00 AM
SAMPLER: TIM CHURCH
COLLECTED DATE: 9-Jan-20
REPORTED DATE: 6-Feb-20
I D#:
ANALYSIS ANALYSIS H:UNILTS:;"I:5AMPL1::: ANALYSIS METHOD INT
RESULTS LOCATION COMPLETED CODE
TOTAL SOLIDS 0.88 %
FECAL COLIFORM 29550 1 CFU's 1 10-Jan-20 SM-9222D WPS
REPORTED BY: NC CERTIFIED LAB#544
/C3CLIke
PAUL ISENHOUR, SUPERVISOR
Lo,
DATE CFUs
1. 9 2.0 Z9,550 q. 0
1. 1q W gl ZOO 3. 913g
I. 15. .20 /3, 60/ q. /335
I. 2,I. 2,0 13, 3049 1 iliat
1. 23. 2 7 631
302,5
L 28.20 q 7418 3. 065
1. 29. 20 /3, 4101 LI. 12,71
/8. 3217
y. q 68
Georndri Math II, /3g

S
WATER QU•\L IT`;' SERVICES, INC.
Slucice. P.O. BOX 1102 BANN!ii: PIK, NC. 23604
(828)-89S-6277
fax (828)-S9S-6255
1 of 7 „.„..„ 0,-,:, ,:,, ,,..„.(-,:),.
SAMPLE 1'YPE. \VASTEWA I'ER _ lc: • :c 1 \ •N. . :ON C" )!;:.
LOCATION. • H2SO4, 2 - I itiU:). . • ik.L.
FACILITY 104: Jefferson Wastewater Treatment Plant 4 . NAOH, 3 . NONE. ti • coot !', i.
SAMPLER NAME: Tim Church ; • NA2S203, S • OTI iER r
COMPOSITE SAMPLE; START TIME: , STOP "INIE.
SAMPLE NAME: COL ECTIOt� US lv� _ .. `M_ \.\TIG s , , ' t 2•4`mot' t SAMPLE TYPE PRESER
DAME 1 IE.!E ! E -.. 1 1P E v__...
.�.� . ,__1-. 9, 'L3 CO!,1P F IFd D 4 �.. ._...,�__.. .r..-., _
tUOD INF I I ( 1
ITSS • INF. i __ _
130D • EFT i I I I _�
`:113as �' I T I: ,
; GREASE :,__.—., —. ---
OIL
1 I 1 I
'TOTAL NIT. I I • i ! IL
!TOTAL I HOS. � I
L! ;-
(E%.AL • t1P 720 I I ,l 1 __.��_ __.
IF►- 'A!. • EFF. • if I ,
HARDNESS UPST i
HARDNESS F
! I i r,2 i 1 _
`CUI'PLR ZINC I I I Ird. II I
[Cyanide- I f iL't _____, -.__
I : ----
' LEA') NICKEL. I I i I It ,
iC'Ilk)MIUtMI i 1 I_._i�I _j__ —i— — _.
i .:NC) SHE BY• ! AT •I•„ nt ' :nt .iSII:� , • -
f v
:L!N U!SHED G1 • D.\TE 11 !:,I!- ... ! .. :s11 '
i /; :aril. !.!-...4fa1,,-,-1.-- - 5)-46 06/0- ! .=.1 _2'ts ei(�'0
t '•Latorato reservation is ensured b • addition t%•:tv` •:ri'r - t
D'P ) o o'Jresc r c s , � to sa.
containers leaving the lab. unless other s isc n. e.
Cl.:•1)•::1'• Cht,rtnc check and dechlt,rrnation %erifica::on
:'d;E: ;:RV AT!0'•
() COC)!. 4C: BOO. RESIDUE,CONDUCTIVITY, rMBAS,COLOR, ALKALINITY, trR, TURBID; ;
•. 1 C001. 4C . PH-It-CW-1 : NH3, NO2-NO3, TKN,O^G, IOC. COD. HARDNESS, PHENOLS. TOT Plt.JS
: ) COOL 4C. P11<: HNO3 : METALS except CR. VI
, ) NONE CHLORIDE. PH, FLUORIDE ti SAMPLE DE IAT;O`•
OTHER
, . 4_ ..:S:to) COLIFCRM UA(. :l:R: y

WATER QUALITY LAB &OPERATION, INC.
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
CLIENT: JEFFERSON SLUDGE LOGIN TIME: 11:00 AM
ADDRESS: SAMPLER: TIM CHURCH
CITY: COLLECTED DATE: 14-Jan-20
STATE: REPORTED DATE: 6-Feb-20
I D#:
ANALYSIS ANALYSIS MQL's UNITS SAMPLE ANALYSIS METHOD INT
RESULTS LOCATION COMPLETED CODE
TOTAL SOLIDS 0.9 %
FECAL COLIFORM 8200 1 CFU's 2 15-Jan-20 SM-9222D WPS
REPORTEDppBY: NC CERTIFIED LAB # 544
—
PAUL ISENHOUR, SUPERVISOR

S ilidet.'
WATER UAL11•Y SERVICES,, INC.
P.O. BOX 1102, BANNER ELK, NC. 2S604
(82S)-898-627;
20 'of 7 fax [phone]
CHAIN OF CUSTODY
SAMPLE TYPE: WASTEWATER •I'RESEE RA'A'I ION Ck)DE.
LOCATION: 1 • H2SO4, 2 • HNO3, 3 - HCL.
FACILITY 1Dk: Jefferson Wastewater Treatment Plant a - NAOH. 5 - NONE. 6 • COOL Il E.
SAMPLER NAME: Tim Church 7 • NA?S203. S • OTHER i
COMPOSITE SAMPLE; START TIME: . STOP :*IMtE
COLLECTION f D I': SAMPLE - .� SEP ,1 !,;;.� I.2•D 1
�,�'tr'LE `A't 1 { 7
DATE i TIME j 1 L I.I.' 1 .1P GKAd CO.'..:r F f li i- 1._1II_ 1. ° 7TszT=`i
L�
TSS • INF. (— I I I �� �
1 I ( 1 I 1
TSS • E:FF. ( — - ! r I. -
•
!OIL & GREASE — L :_. : .. _
ii•1 U'I'.�1. NIT. _1 • .• — i
t WI I
....... �i f:l :11. • UPSIud �1 107 I L7 i i .
FECAL • EFF. J I I I IL7 I I _
CAL • DOWN I i I I i 11_7 I ._- ---- -
[HARDNESS UPS'f• ��_ i I :: 2 � __ -
1
COPPER ZINC I I • i ?
I.EAU NICKEL I i I ! ' I L? __ _. ---_
` SIL\'EIS I i I _. ---_. _. ..-
1 C'r\I)\1IUN1 ( f i ,
r----1 !_
_I.f UISE ED E3Y• DA E Mfr. 2EL1NQUISHED V ;} ti
i 800 ' _I`4 y : _ .0 8JP
::!:LIy LISHED B'': DATE s TIME Pr.Ie I 'Q JISE•Ii:D L 't' :) .•I is •i _
- f/ -ll1�t4
I DOO !
l aQ
_---
••Laboratory preservation is ensured by addition of preservatives prier to sample
containers leaving the lab. unless others%isc n::te
CI.'•!1•C1`' Chlonr.c check and dcchlvrinatton vrnrica.
?RI_ F.I•tVAT10`•
)COO:. -IC : BUD. RESIDUE,CONDUCTIVITY, MBA� is J:.Uk. A:.... ..:'•. I.Y. _R. • ' . '.s::)' : •
. )COO:. 4C . PH,1H2SO4 : NH), NO?•NO3, TKN,O P.G. .-UC.C 0;) i'.:.,. F. S ps:...,..,,.N :.)", . ..
- ) CUUL :C. I'II<"' HNO3 : :.IETALS except CR, VI
( ) NONE CHLORIDE, PH, FLUORIDE s ;;•\MP'..E L!:`:IA1 :;i
OT)IF.k
(-On: a•' 'A2S?03 COLIFOR41 BACTERIA _.__,_______... _..

WATER QUALITY LAB &OPERATION, INC.
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
CLIENT: JEFFERSON SLUDGE LOGIN TIME: 10:50 AM
ADDRESS: SAMPLER: TIM CHURCH
CITY: COLLECTED DATE: 15-Jan-20
STATE: REPORTED DATE: 6-Feb-20
I D#:
ANALYSIS ANALYSIS MQL's UNITS SAMPLE ANALYSIS METHOD INT
RESULTS LOCATION COMPLETED CODE.
TOTAL SOLIDS 0.9r
FECAL COLIFORM 13601 1 CFU's 3 16-Jan-20 SM-9222D WPS
REPORTED BY: NC CERTIFIED LAB # 544
PAUL ISENHOUR, SUPERVISOR

WATER QUALITY SERVICES, INC.
PO. BOX 1102, BANNER ELK, C. 28604
S I Udre (S28)-898-6277
fax (628)-89S-6255
N.,.3 of 7 cHAN OF CLCTODY
SAMPLE TYPE. WASTEWATER .i,i(i sr R\ A ) 1,...),.; (4 jul,
LOCATION:
: • 1-12SO4, 2. • HNO3, 2, - HCL.
FACILITY IN: Jefferson Wastewater Treatment Plant .1 . NAoFt 5 . NONE. 6 . coot It t
SAMPLER NAME: Tim Church 7 . NA2S20.3. S - OTIIER
COMPOSITE SAMPLE; START TIME: . STOP :1ME:
sAN1;)1.1NAM;47.--.
C
I M-7776N DEL I SAMPLEVE— 1-'7; E, PR E-§t.77.-;\177"5 .•_j i.d L2.D•t.t..? t.A i i ', .'.'.•
DATE i TIME 1 TE.."AP TEMP( GA [ CO.'.!P F•37171- D '7.•:.:\ii Thew% YES \O, lD \L
WO • INF,
TS S • INF. . 1 I 1
DOD • EFF. • 1 _1 71,'Tss - EH. ,
! I
„,_„,.....„..___I _
--- 1
LN1-13 as N i IL:
....____ ______
[OIL & GREASE FE
TOTAL NIT.
'-' __—________ .
--....... _h____
TOTAL PROS. !L I i .
FECAL • Siudf, 1.18.2Q, Q7.30 I It_ V ; (4) '.7 '____ --..._ . ....
FECAL . EFF.
I L7 . i
FECAL • DOWN
I IARDNESS UPS' ' • . _. . . .
,____.... _._
HARD .
HARDNESS EFF . — r......—,
i __
1 .. .. ,... ..
,....... . i IL2 I r--T
COPPER ZINC 1 Ild i i 1 .. . ...—,--
,
(Cyanide _
Iii I •
LEAD NICKEL ---1
1T, ; ;
.....1
LSILVER
1 1 • ,
. _ ..... _. .._ .
1 CADMIUM ,
rCIIROMIUM
1 r 1 ;___T____,..................
.... ____
"1 I 1 ____L____,. __..
. __..... _
, ier..iN , ISHE9 BY• 1545 , ,I.P.IF AR.H.:k•:cv.*!SIIF:") !Inv „, . . .. . .:
...--
! IAAAI*- ogio . ...._
......... _ ___. _
ii%EL)NQUISHED BX. DATE TINIE
41410*
la.1,P:( )!Sl?i::)
,),A e144,2144....X li --..-61-6) _/. ' li.•, , .9.444 11. i22.-- -05:4?
U ••Laboratory preservation is ensured by addition of Oresen,atives prior iv sampdc
containers leaving the 13b. unless othermise nate.:
Cl.:•1)-(12- Chlorine check and&chlorination vertlicrwri
PRESERVATION
( ) COOL 4C: BOO. RESIDUE, CONDUCTIVITY, MBAS, COLOR,ALKALINITY,CR, VI, TURIIIDI;
COOL 4C, PH'2H2SO4 : NH3, NO2•1403,TKN,04O, TOC,COD. HARDNESS, PHENOLS, TOT P .)S
( i COOL 4C. Mc-2 HNO3 : METALS except CR, VI
( ) NONE CHLORIDE, Pit, FLUORIDE SAMPLE DE' I
OTHER
, 1 COO: :C •;An203 COLIFORM BACTERIA .....________ .. ....... . ... .
\OTIHCA'r!ir

WATER QUALITY LAB &OPERATION, INC.
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
CLIENT: JEFFERSON SLUDGE LOGIN TIME: 10:30 AM
ADDRESS:
SAMPLER: TIM CHURCH
CITY: COLLECTED DATE: 21-Jan-20
STATE: REPORTED DATE: 6-Feb-20
I D#:
ANALYSIS ANALYSIS MQL's UNITS SAMPLE ANALYSIS METHOD INT
RESULTS LOCATION COMPLETED CODE
TOTAL SOLIDS 0.92"
FECAL COLIFORM 13306 1 CFU's 4 22-Jan-20 SM-9222D WPS
REPORTED BY: NC CERTIFIED LAB #544
PAUL ISENHOUR, SUPERVISOR

WATER QUALITY SERVICES, INC. ,
P.O. BOX 1102, BANNER ELK, NC. 28604
(828)-898-6277
- S Ittdiel LI tii 7 fax [phone]
CHAIN OF CUSTODY
SAMPLE TYPE: WASTEWATER •Hti-s! R\ A ! 1 ON (' )i 11:
LOCATION: I - H2504, : - i iNO:), '.., - HCL.
FACILITY IN: Jefferson Wastewater Treatment Plant 4 . NAQH. 5 . NO -E. 6 . coot. k F.
SAMPLER NAME: Tim Church 7 - NA1S103. S • OTI IER i
COMPOSITE SAMPLE; START TIME: . STOP !1NIE:
COLLECTION D LI I V' SAMPLE" TY PE - PRES ER V 2TION',T7V.5.7.077.7.77:,';i7-c s.:.:'....
SAMPLE IqAME.
DATE I77T E Taw, TEMP GRA COMP F-FIELD ; 1...•!..Ai3 ‘,.•,,!% lES1 \1/4) r. v
. .
BOO • INF. i
TSS - INF. . 1111 .
.
BOD • EFF. , 1 --I •.1.11.111111111
TSS • EFF. f.---4—--'--------- -- .
t••:1-0 as N LI
[OIL & GREASE I 1 - 1 LI 1----, ---T
1 , ,
--............_ ......
TOTAL NIT. . I IL I i
TOTAL PHOS. 1 • .. ILI_i
FECAL • S1iJ.2ttO72.5 A. I Co IL 7
FECAL • EFF. I I • - -
_ _. ...
ICAL • DOWN - ,rIIARDNESS
UPS' ' ""- . I i.L.2 —_ ,..... __ -.•
HARDNESS EFFL. ! , 1
COPPER ZINC iri2 .—
,
--- ----
Cyanide , _____I ILA 1
—• .____ •
LEAD NICKEL 1IL?
• ----•
:-
SILVER 1----- ,
— -• •--- -
CADMIUM
I
o-Twomium 1 1-- ,
1— i _____T____ i
,..__________
ISH -D BY7-1 pi-ylE TIMF PitINQUISHED BY n
i/ 1 07..C.) "„,,--t--si}i,s,,,, -- A. '
RELINQUI,SHED BY , DA TE . . i
! !NH:- krt( ..0I l!SIII-.:) !.Ct,
A41715- CYL4'"--;- '''. -- /-:2I-:2t' LPcff?) lr1141636
j •Laboratory preservation is ensured by addition or pre...cr.:I:Ives Prior ;v s.101;k:
containers leaving the lab, unless others.ise .1.;e..!
CL:•D-CL 2. Chlorine check and dech!ortnation %Trifle:1:4.n
?KISER VAT ION.
) COOL 4C: DOD. RESIDUE,CONDUCTIVITY, MUAS,COLOR. ALi.AL! TY, R. VI,
COOL .IC , Plis1H2SO4 :NH3, NO2-NO3.TKN, 04:G, TOC, COD, HARDNESS. PHENOLS, TOT Pi: 0;
( ) COOL -IC. 1114<2 )4N0.3 : METALS except CR, VI
( ) NONE CHLORIDE, PH, FLUORIDE SAMPLE DEVIATIO\
OTHER
. ) COnt..4C. `:A2S203 COLIFORM BACTERIA
NOTIFICATION
— — —

WATER QUALITY LAB&OPERATION, INC.
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
CLIENT: JEFFERSON SLUDGE LOGIN TIME: 12:00 PM
ADDRESS: SAMPLER: TIM CHURCH
CITY: COLLECTED DATE: 23-Jan-20
STATE: REPORTED DATE: 6-Feb-20
I D#:
ANALYSIS ANALYSIS MQL's UNITS SAMPLE ANALYSIS METHOD INT
RESULTS LOCATION COMPLETED CODE
TOTAL SOLIDS 0.92= 0/0
FECAL COLIFORM 7631 1 CFU's 5 24-Jan-20 SM-9222D WPS
REPORTED BY: NC CERTIFIED LAB# 544
PAUL ISENHOUR, SUPERVISOR

WATER QUALITY SERVICES, INC.
5'''''''''''s
P.Q. BOX 1102, BANNER EG_1 , NC. 28604
S 0 (828)-898-6277
fax (S28)-89S-6255
CHAIN OF CUSTODY
SAMPLE TYPE: WASTEWATER _ •PRESERVATION C'')D!.
LOCATION: I • 1-I2SO4, 2 • HNO3, 3 • HCL.
FACILITY IN: Jefferson Wastewater Treatment Plant .; . NAOH, 3 . NONE. o . coot. K E
SAMPLER NAME: Tim Church 7 . NA2S203, S • OTI IER i
COMPOSITE SAMPLE; START TIME: . STOP :.IME
SAMPLE !v.1!.SE: COLLECTION IDLLIV' SAMPLE 1-'�'i'f'� i• aErt'...1 'Uti •�ZC1.2•D : .tr �.
D--- I TIME-- l E�ti{F'�fl'�tP� GR kD COP F•rli•l.D T 1 •l.AE37..
TSS • INF, I i
DOD • EFF.
TSS - EFF. ; ' T 1- I l ----
—_
NI.13asti' L t ;
OILS GREASE IL I i i ________..... .. .. _
TOTAL SNIT. IL I
FECAL
�SU•� I�Z3/ 0 — ✓ � LL7 __________.-------
FECAL • EFF. i7 I = —_- _
FECAL - DOWN I I I i o!.% +
I IARDNESS UPS'I' I I ' I I
1-HARDNESS EFTL. I I I I I
I I I ! ir,2 I I_
COPPER "ZINC ' 4,) _M
I I T I i + 4
[CyanideI 1 I I I t ' _ --
! L
EAD NICKEL I I I I I i147 —
I. SILVER
i CADVIIUM .
ICI-IROMIU,M 1 1 -________i_
—`I 1 I _ ,�_
i�� T- i I 1 i ? _... .._ . ..
-,{REl. ' UISHED BY: 1 DATEI, TIME . RELINQUISH �,i31' !:-,' F -
1/23/2,0 i On -...#1. 1_22..2 a 5 3./-
i :.ELINQLISHED BY: DATE i TIME RF.LI>:QUI: J !?1 'IF.
••Laboratory preservation is ensured by addition of prescr•.wives prior tv sample
containers leaving the lab. unless °then%isc rt3:e.;
CL_•D•(.2. Chlorine check and dechiorinauon verificv:cft
PRi.S K:'ATIO`.
l ) COOL aC: DOD. RESIDUE,CONDUCTIVITY,MBAS,COLOR. ALKALI •iT't'. CR, '. : ' .RS!:)!
'. )COOL •:C . PH<2H2SO4 :NH), NO2-NO3,T) N, O.:G. TUC, COD. HARDNESS, PHENOLS. 1'OT Pi.. i
t ) COOL :C. PH<2 HNO3 : METALS except CR, VI
( ) NOE ' CHLORIDE, PH, FLUORIDE SAMPLE DEVIATION _
OTHER
•:C •' S203 COI.IFOP`.I I3ACTLRIA --- -- — ---_..__. .
. ) COO;
NOTIFICAT:O`‘:
t

WATER QUALITY LAB & OPERATION, INC.
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
CLIENT: JEFFERSON SLUDGE LOGIN TIME: 11:00 AM
ADDRESS: SAMPLER: TIM CHURCH
CITY: COLLECTED DATE: 28-Jan-20
STATE: REPORTED DATE: 6-Feb-20
ID#:
ANALYSIS ANALYSIS MQL.'s UNITS SAMPLE ANALYSIS METHOD INT
RESULTS LOCATION COMPLETED CODE
TOTAL SOLIDS 0.91—
FECAL COLIFORM 4748 1 Cars 6 29-Jan-20 SM-9222D WPS
REPORTED BY: NC CERTIFIED LAB#544
A21,4 /t,-
PAUL ISENHOUR, SUPERVISOR

_ .,. . .
WATER QUAL! IN SFR\ICE'S, INC.
P.O. BOX 1102, B.ANNIER ELK, NC 2860-
(828)-898-6277
fax [phone]
,..,, Sluil3to 60 of 7
SAMPLE TYPE: WASTEWATER •PRI: Elt% A I DON C,Mk
LOCATION: I • 1-12SO4, 2 . HNO3, ; - FICL.
FACILITY ID#: Jefferson Wastewater Treatment Plant . NAOH, 5 . NONE, 6 . COOl
SAMPLER NAME: Tim Church 7 • N.A/S203, 8 • OTHER
COMPOSITE SAMPLE; START TIME STOP ....IN,11::
SAN!PLE NAME. COLLECTION (:)E,,fv1sAy•tPLE 'IM,' 'JE . PRESEr'..,A I',0„,)N• -•, h2L2L.)- : .: : -,:t ', •
DATE F...TIME T .,tp TEMPEORAB I CO",',P , F•FIFIA; L•LAB 1,c,- •:71 %'EST,,.:)..,:!: .s;„ ,.:: 1
bT1---ci. ,r---F: -
I 1 i 1 ;1 ,
,.
Tss • INF. , I I i —1-1---
BOD • EFF i
[ i 1
'!'.SS • EH'. i 1 ' I
.........1_........: _ I ?".".. .7.... ....-....-- .---... .
NIL, as N 7 i 1 I
• • - •
IOU, & GREASE I f f
1 i
II.", n
ToTAL NIT. 1-7-
.
TOTAL PHOS. r---.7 IL:
--
AL . 2 ne1 • 1 it _ii
...
...... ________.., . .
1
tiAt. .14.615egjIF 112812-di-Q7la
....... .. ...................... .... . ..
DOWN
I
I 1 i . 1 ;1.7
1 ri-F-FCAI •
i • ' - It ---,I
!I IARDNESS I.:psi' i I ' I __4_ I 1 iL,2
___
.-- - _a. ...a_ ..
. HARI)NESS !TEL i I i , . 1
t 1 1
, t
COPPER ZINC I I 1----1-- ;, ,,?
_. ._._ ___________.
I.F.AI) NICKEL 7 I i ii — ---1
t..;:)
— __._... ._
s 1 t..v 1,...R 7-7 I • I -. --i- — ;1 . ...
, . .
_. .._
1,- (.1 tRomtum i 1 i 1 i---i ;
r
I j------ 1 —7 ,--.
,.. .... .___ — —2—
_______ - • , . • . ' •
. -,. 1.; ' 4„.Th:4-1 !) BY , )AT :.. If%IF
...t..., R!.:.:-...):,Y .I.SIIr.:' .'1
...0 7.50 *Iffy
, •
, I;o:::....NouisHED ': 1 DATE TIME RIII.INQUHE LI ISD
(s
44 tyin.v--,
14,41/20
'•Lraiory prorry3tion is cnsurrd b) 4cidition of protr.,,g!vcs ;:r,,,): to ,:,:tpli:
cot:liners loving the lab, unkss ocher, ••,
al :•i'•••1 Chloone chn:k an,": tidth.4,1:,12,.):1
'.'Ki."... ..'.'A
, ) ( ......)1,. 4C UUD. RESIDUE,CONDUCI I VITY.ME,A L'-)1.0k. AL•*.•:••"•-•%• :.: ,.k, . • -**•:J.:)J' ; '
• 0,X:4 -C , PH:2H2SO4 : NH3, NO2-NO3. TKI^:.04:G. :''fiC, (20[,,, "f,I.,. R.!:',,!,,ESS. PH.F. -_,',...s, li,')T 1,,, ••:.
', ) JCL 4C. PH<2 HNO) : METALS caxcpt CR, vt
CliLORIOE, PH, FLUORIDE ::.,.'li.),PL': ',....1.V:A:
(.)rHER
NA2S:.'tX COLIFORM UAL ri:K;
'.UT:r.CA'..`r,,,',
1

WATER QUALITY LAB & OPERATION, INC.
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
CLIENT: JEFFERSON SLUDGE LOGIN TIME: 11:00 AM
ADDRESS: SAMPLER: TIM CHURCH
CITY: COLLECTED DATE: 29-Jan-20
STATE: REPORTED DATE: 6-Feb-20
I D#:
ANALYSIS ANALYSIS MQL.'s UNITS SAMPLE ANALYSIS METHOD INT
RESULTS LOCATION COMPLETED CODE
TOTAL SOLIDS 0.9-
FECAL COLIFORM 13401 1 CFU's 7 30-Jan-20 SM-9222D WPS
REPORTED BY: NC CERTIFIED LAB #544
PCILAJt7t4A,'
PAUL ISENHOUR, SUPERVISOR

a
WATER Qt.,:.\!_i IV SI.:RVICIS, INC.
P O. BOX I 10'' BAXN!'il,', ';-'1.K, NC
dude 7 of 7 (628)-898-0277
fax (S28)-898-6255
( -i \1 's: OF CL:ST(..)DY
SAMPLE TYPE. WASTEWATER •PRESLIO;A I R." C' JITh
LOCATION: I • H2SO4, 2 • HNO3, 3 • HCL.
FACILITY IN: Jefferson Wastewater Treatment H 2.ant. 4 5 • NONE, 6 - COOL ICE
SAMPLER NAME: Tim Church 7 • NA2S203. S • OTIIER i
COMPOSITE SAMPLE; START TIME: STOP :NE.
COLL EC'TIC. IDL-I" •*%.'.471)LE "r•':'E i PP..t.'SE;•;"..ATII'D,••• : :..• ii:l....t•C'.• LI : '..:• " '•"
SAMPLE NI`•IE:
DATE f TIME Tamp TD,IP.1 GRAB 1 COMP 1 F4'I,I:I.D. . ___I.,1:.....‘ilj.,..LIESsi : ,... ,, ''. _ ' ••
Tr1T
TSS • INF. I
, ...._
DOD . EH I I 1 i 1 -i-------__
I -,--
Tss • LII I I 1 r _1 i r .
f. -.• . -.- .... .-
H.3 as N r ,
!op_ & GREASE I i „
-I
-.- 1 IL _
LIDTAL NIT. I
if qI0S. r_ n_______;_
, 1...1
__.. _ ,.......
(Ti c A L • Stale, 1.a 207 i 7 7---7 6p !...7
1 , .
IECAL • EFF. J • I L7 I i i
FECAL • DOWN
I IAIWNESS UPST
r T • 1
1 i
I i
' i 1.7
1,, ,-,... -.---.-
'11ARDNESS EFFL. 1 i I I I
I i i f _,. r i
........._ _________
75-iiTTF71k i ) 7 — --
i ,1,2-- —.._FC:ialiide 1 I 1----
LEAD NICKEL
7 _______
sII.vrR i 1.---7 ---r
r _ .. .. . . •
cimitum i 1 . : ,
iciimimium ; i 1 -
I 1- .
1
r 1
,I
1 I ,-
1 i
•----
. -- --- - .,.pr•Lti L.,'ISIE- D BY• r y E 11'.1. -. !,rt ,....-. --
10% -) :.-.- 1
_.-
. • ......- • ..........
LeF.LIN:QSHED__23::Q i DATE 'FI
--
I/ -d', -1-6 ns /7-6 I / /-2 7.Q.., _ 1100
-------
L ••Laboratory preservation is eured by addition of preservatives prior to s;— c
containers leaving the lab, unless otherwise n:Ited
2°. :•i/41,!. Chlorine check and drchl(:rination vcrificat;on
,dki.'SFi.IVATIO,•
)COOL 4C boo, RESIDUE, CONDUCTIVITY. MLA , (:',.):.t..)k, A Lt.A L,•'•:I i. '-R. • ..
) COC,',.. 4C , " H2SO4 : NH3, NO2-NO3. TKN, 04:G, IOC. ("....•:) Ili,IM ,ESS, PII.E .',. .. 'Co 7 P!• ,!:
" COOL C. lqi<1. HNO3 , METALS except CR, VI
t ) NONE. CHLORIDE, PH. FLUORIDE 6•\.'•I i'l.F. I.-L.':A*I :"..:•".
OTHER
..._.. .
„I c0,`r.. ::: \.%2S:0:$ COLIFC)RM ii•\(...TER:A ....... _______..
07. TIY.CA-!1',,'

WATER QUALITY LAB & OPERATION, INC.
P.O. BOX 1167,BANNER ELK, NC 28604
[phone]
CLIENT: JEFFERSON
ADDRESS: SAMPLER: TIM CHURCH
CITY: JEFFERSON COLLECTED DATE: 3-Feb-20
STATE: NC REPORTED DATE: 10-Mar-20
I D#:
ANALYSIS ANALYSIS- MQL's UNITS SAMPLE ANALYSIS INT
RESULTS LOCATION COMPLETED
30 DAY BENCH SCALE
START
VOLITILE SOLIDS 76.00 0.1 % SLUDGE 7-Feb-20 PI
END
VOLITILE SOLIDS 74.40 0.1 % SLUDGE 10-Mar-20 PI
VOLITILE SOLIDS REDUCTION: 1.60%
I t AC+ 15 to V cth r Reluc,kitm
1(Y1t+hod._ C.f3cLe, SM - 25zi0
REPORTED BY: NC CERTIFIED LAB #544
PrtifiX>1-711(atv
PAUL ISENHOUR, SUPERVISOR

♦
Jell- y5"" WATER QUALITY LAB &OPERATIONS, INC.
LAB No. 544
30 DAY BENCH SCALE VAR OPTION 3
SM 2540 E
ANALYST: G / START DATE: 2- r 2 0
DIGESTER VOLUME: f 000,415
DAY TIME VOLUME SCRAPED TEMP DO TARE VVET DRY ASH RESULT
CONFIRMED SOLIDS
Start Zcis' v ✓ !A, , Z. 13 7o.K93 'ft 7, ?22 7 7I. -1(4 70 72) 2. o-ilr.,/�14. 70
1 Z� ✓ ✓ /b 4to
2 `�� L. v ,! f- 3 '1,o(
3
4
5 fro(' ✓ 17. 1 3.fl
6 0_30 t✓ L.--V 15.3 3.P1
- 7 r or, n L r5,Z 3.0-r7o.(2 q 167 / 73 -71. 00rc7o-z 7Y o.�jr./'
8 /2 ;.Q ,.- 1`1.3 `1.94
9 10.,,-) Ic,3 ).&7
10 3
11
12 4)9 c.- v 1',3 3,YZ —
13 too v (1.2. ) 7t:
- 14 KJ.. -- I7./ 3.7-7 12_K41( , 645•5-3o7 7) `.] 44 72- (SJ I.Qr. 14Z
15 t oi, I S.x. 7 7 5-
16 (qoc (cI, 3 Po - - —
17
18 _.____
19 te,” L - _. 14.3 3.6L
20 rOlt r?..3 3 .Go
21 [o)o v S.3 3- 'IC- 72.74) 1 16 t.sy l6 '73.7Iw1 7Z.71 at ►.or'/ 7Y.a
22 I01S' .. � 0.4 3. 5o
23 ((01 v ['VI 7. q�
24 j
25 i26 ct 3', v v [5.4r Z.. 7
28 (9�y� v 1y 2.`I L
29 Ioi5 ' ( .S' 2, 73
30 (\' (.- (4).‘ L62. 72 ur 1(9.&01b 73. 1-67V73.1ort 1.17o/ 7NM%
VOLITILE SOLIDS REDUCTION: 1 . 47.

I
\I, • .I_ti_ )1 • :' •. '[ '
,
`'2 ' Vec: of 4fac on Reductiorn f
,+.. Sio3e,
lax`(S?S )-S9S 6255y I
t'' ':)'• Vo1.Solids Redu cdi �~ ""o
ohs �J � t
S..-kMPl.f T' PE \YAS'I !•:\\'.\ ; L (
!_OC':\.IIUN: . . :.)I,.. • : ,,.[:. . ..
! .•\CILI'I Y I1)4: JefIerson \Vastc'w uer Tre'atillent P1:i it , . \.,\,CQ}., , • c .13l.,:
SAMPLER NAME: Tim Church .°A1S203, S • .:)TiIi 'r\
C UMPUSITE SAMPLE; START TIME: ti '',«� , ''1' r;
DATE I TIME. I tl ;,III rt .`,1Pr ,) i C,r•Y .. ,
.�..- ....�.._ �_�=Wiz:._,._...-„T...«
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!.`•: 1
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%r . 4-4—i74:".7:1•1€4.0.77,1-74. .... .•A_. -7) :;?•-1,- . L: t /''
' �c y, r.. ,� . - :� �At /fa0 ' z1r31Zo . ! t
(71 •l.3.orMry prC$Crrt:rcmt, ,S Csa.:Jrr! h� . -,..:,,. . 4... ,.. . .
con!3intrs Ica.'.n, Ihr Izt. ,.,:lcs. ,.�:hc:-•. . , ..
: ..'- Cn:,,nnc:'rc snL' L C!*.?i r. .41:. ; ,c r,. ..
•'r:- :V \ ;(1 •
)L U L ,C t)UD -JSlt)UE. CONDUC i'IVr' , •Ibis.? ';.'.°.-,ln •\: .. . .: .
_i\, ,
f
C )Cil_ .:'` . P}{ I- 2SO: :113, NO?.tio), 1"},..N.O ;ii. I U_. - ',) H. .,• ?.SS r:... ..., '. '
C .J!. ,. 1'}r•: }:r:03 t.tC1'At.::, excl : CI:.. \'t
,•;' :1.LOR':25E .'11. 'L'_'U ,1'.:L . '.'
_ .
1

NCDA&CS Agronomic Division Phone: [phone] Website: www.ncagr.gov/agronomi/ Report No. FY20-SL006884
Client: Town of Jefferson Advisor Ashe CES-House
Predictive 302 East Main St/PO Box 67 700 Sussex/134
I�''_ ;1' `7± -' Jefferson,NC 28640 Government Circle Suite
'!;,.1',c
: _:'y SoiI Report Mehlich-3 Extraction
202
y` ,yv 1 Sampled County:Ashe Jefferson, NC 28640
-- -: Links to Helpful Information
Client ID: 88367 Advisor ID: 396894
Sampled: 09/25/2019 Received: 09/27/2019 completed: 10/08/2019 Farm:
Sample ID: FWALT Recommendations: Lime Nutrients(lb/acre) More
Crop (tonslacre) N P2O5 K2O Mg S Mn Zn Cu B Information
Lime History: 1 -Fescue/OGrass/Tim, E 0.0 50-70 0 50 0 0 pH$ 0 0 0 Note: 12 Note: $
2-Fescue/OGrass/Tim, E 0.0 50-70 0 50 0 0 pH$ 0 0 0 Note: 12 Note: $
Test Results[units-WN in g/cnt3;CEC and Na in meq/100 crag;NO3-N in mgldni3]: Soil Class: Mineral
HM% WN CEC BS% Ac pH P-I K-I Ca% Mg% S-I Mn-I Mn-All Mn-AI2 Zn-I Zn-Al Cu-1 Na ESP SS-I NO3-N
0.36 1.03 15.5 93 1.0 6.8 223 25 63 30 67 187 117 117 1393 1393 659 0.1 1
Sample ID: BWALT Recommendations: Lime Nutrients(lb/acre) More
Crop (tonslacre) N P2Os K2O Mg S Mn Zn Cu B Information
Lime History: 1 -Fescue/OGrass/Tim, E 0.0 50-70 0 40 0 0 pH$ 0 0 0 Note: 12 Note: $
2-Fescue/OGrass/Tim,E 0.0 50-70 0 40 0 0 pH$ 0 0 0 Note: 12 Note: $
Test Results[units-WN in g/cni3;CEC and Na in meq/100 cm3; NO3-N in mg/dn' ]: Soil Class: Mineral
HM% WN CEC BS% Ac pH P-I K-I Ca% Mg% S-i Mn-I Mn All Mn-Al2 Zn-1 Zn-Al Cu-I Na ESP SS-I NO3-N
0.36 0.96 14.5 91 1.3 6.8 103 31 59 31 43 321 198 198 554 554 349 0.1 1
Sample ID: JWALT Recommendations: Lime Nutrients(lb/acre) More
Crop (tons/acre) N P2O5 K2O Mg S Mn Zn Cu B Information
Lime History: 1 -Fescue/OGrass/Tim, E 1.4 50-70 50 0 0 0 0 0 0 0 Note: 12
2-Fescue/OGrass/Tim, E 0.0 50-70 50 0 0 0 0 0 0 0 Note: 12
Test Results[units-WN in g/cm3;CEC and Na in meg1100 cni3; NO3-N in mg/dnt3j: Soil Class: Mineral
HM% WN CEC BS% Ac pH P-I K-1 Ca% Mg% S-I Mn-I Mn All Mn-Al2 Zn-1 Zn-Al Cu-I Na ESP SS-I NO3-N
0.56 0.95 12.3 86 1.8 6.2 47 49 57 26 50 628 386 386 244 244 203 0.1 1
4 North Ca I(la Reprogramming of the laboratory-information-management system that makes this report possible is being funded
�{ ....._ .._ ...,M__.___._ through a grant from the North Carolina Tobacco Trust Fund Commission.
/,
lsjliir Thank you for using agronomic services to manage nutrients and safeguard environmental quality.
i ti
Steve Troxler, Commissioner Agriculture
of
p culture
t`

LAND APPLICATION SITE CERTIFICATION
Applicant's name: Town of Jefferson
Land application sites currently certified: 43 net acres and Total to be certified: 43 net acres.
I. LAND APPLICATION SITE INFORMATION(See Instruction B):
Predominant Soil
Status Site/Field Landowner(s) Lessee(s)or Operator(s) Net Acres County Crop(s) n Mapping Unit
Code ID Series Name
or Rep.Slope°
R Site#1 Fred Walters Town of Jefferson 26 Ashe Fescue Watauga
R Site#3 Fred Walters Town of Jefferson 8 Ashe Fescue Watauga
R Site#5 Johnny Walters Town of Jefferson 9 Ashe Fescue Watauga
N
N
N
N
N
a Status Code for land application sites are: •N(New) ♦R(Renewed) ♦M(Modified) •T(Transferred) •D(Deleted)
b Soil Series Name(i.e.Appling,Cecil,etc.)
Mapping Unit must be consistent with those used in the County Soil Survey(i.e.for a 2-8%slope Cecil in Anson County the mapping unit is CeB2)
II. WATERBODY AND CLASSIFICATIONS INFORMATION(See Instruction C): N/A
Site/Field ID Latitude Longitude Location Location Method Code Location Accuracy Waterbody Subbasin and Current and Proposed
Datum Stream Index No. Class
O ' " ° NAD 83 ADD Nearest Second
O PP ° NAD 83 ADD Nearest Second
o ' " " NAD 83 ADD Nearest Second
° NAD 83 ADD Nearest Second
0 ' " NAD 83 ADD Nearest Second
o ' " ° ' " NAD 83 ADD Nearest Second
° ' " NAD 83 ADD Nearest Second
° NAD 83 ADD Nearest Second
Note:Please keep the site information(I.)and waterbody information(II.)of the same field on the same page.
FORM: LASC 06-16 Page 1

th Cl
DWRDepartment of EnvironmeStateofNornta Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02T.1100—LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality,Permitting Section's Non-Discharge Permitting Unit.
General—This document is an agreement between the Applicant and land owner(s)of residuals receiving sites for land application of
Class B residuals(may include water treatment plant or other type residuals)in accordance with 15A NCAC 02T.1100.Do not submit
this agreement for review without a corresponding application form(FORM: RLAP 06-16).
Unless otherwise noted,the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement(FORM:LOA 06-16):
❑ Submit the completed and appropriately executed Land Application Site Certification(FORM: LASC 06-16)form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
❑ Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
El A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Town of Jefferson
hereinafter referred to as the Permittee, to land apply residuals from the following fa ility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Lease Land Use or Residuals Source Special note
Site/Field ID (yes/no) Cropping Patterns Intended Use of Crops (optional) (no-till/over-seed/
pasture)
Fred Walters#I no Hay and Pasture Hay and Pasture feed NC0021 709
Bower Walters#3 no Hay and Pasture Hay and Pasture feed NC0021709
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives,in consideration,the use of the land application site(s)described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification,given 30 calendar days in advance,modifies or cancels this Agreement.
FORM: LOA 06-16 Page 1 of 3

, I. STIPULATIONS:
• I. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s)specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application sites)to a third part•,the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions(under Section II)are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DW R,Non-Discharge Permitting Unit. 1617 Mail
Service Center.Raleigh.NC 27699-1617.
5. The Pcrmittec must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a ncvw
landowner in addition,the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application sites)
6 The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program.
including an analy srs of constituents of the residuals,residuals application methods.schedules for typical cropping patterns.a description of the
equipment used bs the Permittec.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
)( lithe soil pH of the land application site(s)is not maintained at 6.0 or greater,sufficient amounts of lime shall be applied to achieve a final soil
pH of at least 6.0. unless an agronomist provides information indicating that the pH of the soil,residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns.results of
soil samples,and the permitted application limits.
10.The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nutrients
(e.g..fertilizer,unregulated animal waste.etc.)that have been applied to the land application site(s).
I I Thc landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s)prior to each planting season to enable the Pennittee to amend this Agreement and schedule residuals land application
ev ents ai appropriate periods
12 Specific residuals land application area boundanes shall be clearly marked on the land application sites)by the Permittee.the landowner.or
his representative prior to and during a residuals land application event.
13.The landowner or his representative hereby authorizes the Pcrmiuce,local officials,and State officials or their representatives to:enter and
inspect any property. premises,or place on or related to the land application sites) at any reasonable time for the purpose of determining
compliance with the permit;establish monitoring facilities on or near the land application sites)as required by the permit:copy any records
that must be kept under the terms and conditions of the permit:take necessary'lcachatc,surface water,groundwater.or soil samples during the
term of.and 12 months after termination of.this Agreement.
II. RESTRICTIONS:
I Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public'access to the land application
sites)during active use and for the 12-month period following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s)for a 30-day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land application
events
3 Food crops,feed crops.and fiber crops shall not be harvested for a 30day.period following a residuals land application event.
4 Food crops with harvested parts that touch the residuals/soil mixture and arc totally above the land surface shall not be harvested for a 14-month
period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6 Food crops with harvested parts below the surface of the land shall not be harested for a 38-month period following a residuals land application
went when the residuals remain on the land surface for less than four months prior to incorporation into the soil
7 'Turf grown on land where residuals arc applied shall not be han cstcd for a 12-month period following a residuals land application event
lll1.ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:(please check one)
i SA NCAC 02L.0107(d)prohibits water supply wells within the compliance boundary.However. I SA NCAC 02T 0103(h)allows the compliance
boundary to be placed closer to the waste disposal area,such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly-established compliance boundary. Please mark one of the following;
❑ A re-defined compliance boundary is needed for field(s)ID: ._--
(Please include the rationale for the requested re-location of the compliance boundary and attach a map showing the newly proposed compliance
boundary to the application package)
❑ A re-defined compliance boundary is not needed for this site.
IV.ACKNOWLEDGEMENT OF FIELD TRANSFER:(if needed)
❑ The land application field(s)ID: • is currently permitted under another
residuals land application program.Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement.heishe is requesting that the field(s)be removed from the previously permitted residuals land application program and transferred
into the new program._-
(Name of the new program)
FORM LOA 06-I6 Page 2 of 3

• Landowner's Certification:
I certify that I am a deeded landowner of the above-referenced land application site(s) and am authorized to make decisions
regarding the use of the land application site(s)on behalf of other deeded landowners OR that I am otherwise authorized,through
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(s) on behalf of the
deeded landowners. I certify that the above-referenced land application site(s) are not included in any waste disposal contract or
agreement with another municipality, contractor,or other permitted entity. Furthermore, I certify that I have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name: Fred Walters
Address: 767 Don Walters Road
City: Jefferson State: NC Zip: 28640
Phone: [phone] `n E-mail address:
Signature: _ Date: •S �/ vZO
NORTH CAROLINA, '-- he COUNTY
I,the undersigned Notary Public do hereby certify that Fr r A \NILti4 a
personally appeared before the this day and acknowledged the due execution of the forgoing instruments .""'""
W INE �,,`�
WITNESS my hand and official seal this the �� 0\, 0 ARy 'QC t
to
day of ITV:ty ,20 a(..-) V My Comm.ExP•
Signature and seal. C !e` \N 1.siNa,<<Z c
My commission expires: �!(71 ,-1Cs' �`yF t:UU� y'''�,
I"Il l„,,,,,,
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name: Tim Church
Address: PO Box 67
City: ,,ll Jefferson State: NC (� Zip: 28640
Phone: Z'V 16 E-mail address: 'QTT W(1S eciAi f II11k . net
Signature: Date: 5t2g12 ?
Permittee's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official n e: Tim C urch
Signature: (/r}� . Date: 1 lq / 20
FORM: LOA 06-16 Page 3 of 3

State of North Carolina
• Department of Environmental Quality
Division of Water Resources
DW R
Division of Water Resources 15A NCAC 02T.1100—LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non Discharge Permitting Unit.
General—This document is an agreement between the Applicant and land owner(s)of residuals receiving sites for land application of
Class B residuals(may include water treatment plant or other type residuals)in accordance with 15A NCAC 02T.1100.Do not submit
this agreement for review without a corresponding application form(FORM: RLAP 06-16).
Unless otherwise noted,the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement(FORM:LOA 06-16):
❑ Submit the completed and appropriately executed Land Application Site Certification(FORM:LASC 06-16)form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
❑ Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
❑ A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Town of Jefferson
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Lease Land Use or Residuals Source Special note
Site/Field ID (yes/no) Cropping Patterns Intended Use of Crops (optional) (no-till/over-seed/
pasture)
John Walters#5 no Hay and Pasture Hay and Pasture feed NC0021709
The landowner or his representative receives, in consideration,full use of the nutrient value of the applied residuals while the
Permittee receives,in consideration,the use of the land application site(s)described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification,given 30 calendar days in advance,modifies or cancels this Agreement.
FORM:LOA 06-16 Page 1 of 3

y
I. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s)specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s)to a third party,the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions(under Section iI)are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR,Non-Discharge Permitting Unit,1617 Mail
Service Center,Raleigh,NC 27699-1617.
5. The Penmittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner.in addition,the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals,residuals application methods,schedules for typical cropping patterns.a description of the
equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s)is not maintained at 6.0 or greater,sufficient amounts of lime shall be applied to achieve a final soil
pH of at least 6.0,unless an agronomist provides information indicating that the pH of the soil,residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns,results of
soil samples,and the permitted application limits.
10.The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nutrients
(e.g.,fertilizer,unregulated animal waste,etc.)that have been applied to the land application site(s).
11.The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s)prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land application
events at appropriate periods.
12.Specific residuals land application area boundaries shall be clearly marked on the land application site(s)by the Permittee,the landowner,or
his representative prior to and during a residuals land application event.
13.The landowner or his representative hereby authorizes the Permittee,local officials,and State officials or their representatives to:enter and
inspect any property,premises,or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit;establish monitoring facilities on or near the land application site(s)as required by the permit;copy any records
that must be kept under the terms and conditions ot'the permit:take necessary leachate,surface water,groundwater.or soil samples during the
term of.and 12 months after termination of,this Agreement.
IL RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land application
site(s)during active use and for the 12-month period following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s)for a 30-day period following a residuals land application event. Land application
sites that arc to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land application
events.
3. Food crops.feed crops,and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and arc totally above the land surface shall not be harvested for a 14-month
period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38-month period following a residuals land application
event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals arc applied shall not be harvested for a 12-month period following a residuals land application event.
iII.ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:(please check one)
15A NCAC 02L.0107(d)prohibits water supply wells within the compliance boundary.However, 15A NCAC 02T.0105(h)allows the compliance
boundary to be placed closer to the waste disposal area,such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly-established compliance boundary. Please mark one of the following;
❑ A re-defined compliance boundary is needed for field(s)ID.
(Please include the rationale for the requested re-location of the compliance boundary and attach a map showing the newly proposed compliance
eAA
undary to the application package)
re-defined compliance boundary is not needed for this site.
iV.ACKNOWLEDGEMENT OF FIELD TRANSFER:(if needed) ,V
/44
❑ The land application field(s)ID: _ _.,. _ , is currently permitted under another
residuals land application program:Permit Number WO: . The land owner hereby acknowledge that by signing this
agreement.he/she is requesting that the field(s)be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

' Landowner's Certification:
I certify that I am a deeded landowner of the above-referenced land application site(s) and am authorized to make decisions
regarding the use of the land application site(s)on behalf of other deeded landowners OR that I am otherwise authorized,through
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(s)on behalf of the
deeded landowners. 1 certify that the above-referenced land application site(s) are not included in any waste disposal contract or
agreement with another municipality, contractor,or other permitted entity. Furthermore, I certify that I have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name: Johnny Walters
Address: 1044 Island Ford Road
City: Crumpler State: NC Zip: 28617
Phone: (336)9 - 637 E-mail address:
Signatur . ./t/life , Date: 'oo —.?OHO
NORTH CAROLINA, c\,,hF COUNTY
I,the undersigned Notary Public do hereby certify that —3-o h -„ro ( 1'.c`t L}r'( 5
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the ,"Zir.l a.0"""�y-.j�"""my,
day of t°I .\4 ,20 T CW.' ,.-''�C�i\'�y0I.Ai4y 'Q(?
Signature and seal: �J(N.r,� C.o `�,i`,, ; ;Y\;,X'_3(\ c My Comm.Exp• j0
My commission expires: U / / 7 i . (1 =3- ;yd,a``G �G
Lessee's/Operator's Certification: ,/�Rf "`C���uN,,,, ,`
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name: Tim Church
Address: PO Box 67
City: JeffersonJ State: NC r{ Zip: 28640
V
Phone: w..- ( 1 „) 2416- Z/(5 E-mail address: tei't`WhS & Ce \+U11(V�c • ne%
Signature:�tANN,-e-I1.4.(4, Date: 5/29/2O26
Permittee's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name: Tim Church p /
Signature: �W" f' Date: 51 2-CI R620
FORM: LOA 06-16 Page 3 of 3

State of North Carolina
, DW R Department of Environmental Quality
Division of Water Resources
Division of Water Resources SETBACK WAIVER AGREEMENT(FOR RESIDUALS PROGRAM)
FORM: SWA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non-Discharge Permitting Unit
General —This document is an agreement between the Applicant and the owner(s) of the property adjacent to the land application
site(s) to allow setback reduction for habitable residences or place of public assembly not owned by the permittee or not to be
maintained as part of project site(s) in accordance with 15A NCAC 02T .1 I08(b)(2)[for habitable residences or place of public
assembly only]. Do not submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
A. Setback Waiver Agreement:
❑ Submit the completed and appropriately executed Setback Waiver Agreement (FORM: SWA 06-16) form. Please do not
make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the
application may be made,as long as the attachments are numbered to correspond to the section and item to which they refer.
❑ Prepare a separate agreement for each property from which a waiver is being sought.
❑ Any other setbacks required by 15A NCAC 02T .1108, other than those referenced above, cannot be waived through
execution of this agreement.
❑ A copy of the completed and executed agreement must be provided to the property owner.
AGREEMENT TO WAIVE THE SETBACK REQUIRED BY 15A NCAC 02T.1108(b)(2)(habitable residences)
The undersigned property owner hereby permits:
Applicants name: Town of Jefferson WWTP
Applicable Field ID:Bower Walters#3
hereinafter referred to as the Permittee, to land apply residuals within 100 feet (i.e., cannot be less than 100 feet) of the
residence or place of public assembly located at the following:
Location address of property: 451 Don Walters Road
City: Jefferson State: NC Zip: 28640
This Agreement shall remain in effect for the length of the Division of Water Resources' (Division) permit for the residuals
land application program and shall be renewed each time this permit is renewed. In addition, this Agreement shall only
remain in effect for as long as the undersigned property owner owns the property described herein.
The undersigned property owner agrees to abide by this Agreement until such time as written notification,given 30 calendar
days in advance,modifies or cancels this Agreement.
[l 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 land apply residuals to land application site(s)as specified herein.
Property owner name: Richard Blackburn
Signature: i e��. fot- ?'`r'tAA.J Date: X— 0? 3 — 2 0
I
FORM: SWA 06-16 Page 1 of 1

State of North Carolina
DWR Department of Environmental Quality
Division of Water Resources
Division of Water Resources SETBACK WAIVER AGREEMENT(FOR RESIDUALS PROGRAM)
FORM: SWA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non Discharge Permitting Unit
General — This document is an agreement between the Applicant and the owner(s) of the property adjacent to the land application
site(s) to allow setback reduction for habitable residences or place of public assembly not owned by the permittee or not to be
maintained as part of project site(s) in accordance with 15A NCAC 02T .1108(b)(2)lfor habitable residences or place of public
assembly only]. Do not submit this agreement for review without a corresponding application form(FORM: RLAP 06-16).
A. Setback Waiver Agreement:
❑ Submit the completed and appropriately executed Setback Waiver Agreement (FORM: SWA 06-16) form. Please do not
make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the
application may be made,as long as the attachments are numbered to correspond to the section and item to which they refer.
❑ Prepare a separate agreement for each property from which a waiver is being sought.
❑ Any other setbacks required by 15A NCAC 02T .1108, other than those referenced above, cannot be waived through
execution of this agreement.
❑ A copy of the completed and executed agreement must be provided to the property owner.
AGREEMENT TO WAIVE THE SETBACK REQUIRED BY 15A NCAC 02T.1108(bX2)(habitable residences)
The undersigned property owner hereby permits:
Applicant's name: Town of Jefferson WWTP
Applicable Field ID:Bower Walters#3
hereinafter referred to as the Permittee, to land apply residuals within 100 feet (i.e., cannot be less than 100 feet) of the
residence or place of public assembly located at the following:
Location address of property: 497 Don Walters Road
City: Jefferson State: NC Zip: 28640
This Agreement shall remain in effect for the length of the Division of Water Resources' (Division) permit for the residuals
land application program and shall be renewed each time this permit is renewed. In addition, this Agreement shall only
remain in effect for as long as the undersigned property owner owns the property described herein.
The undersigned property owner agrees to abide by this Agreement until such time as written notification,given 30 calendar
days in advance,modifies or cancels this Agreement.
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 land apply residuals to land application site(s)as specified herein.
Property own eff name: Day' Blackburn
Signature: A od.,i �i�a vv✓� Date: ` %T Ao
FORM: SWA 06-16 Page 1 of I

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Date 4:30,2015 Johnny Walters Site 5 WQ0004166
1 inch=300 feet

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Facility Name: Town of Jefferson WWTP WQ Permit#: WQ0004166 Field#: 1 Acres Utilized: 26
Land Owner: Fred Walters Annual Dry Tons Applied: 36.7494 Site#: Fred Walters Acres Permitted: 26
Operator: Tim Church Predominant Soil Series: Watauga Cation Exchange Capacity(non 503): 15.5
Crop 1 Name: Fescue hay Crop I Max.PAN: 155 Crop 2 Name: Crop 2 Max.PAN:
Volume applied Volume Residual Sources Soil Precip. . o Z Nitrate Name of Crop Tape
L (enter one)Solids/ % PAN hed
J � Applied per (NPDES#,WQ*. Cond. Past 24 3� � � � � TKN � o and (Ibs/acre) Receiving Residual
c ( His. 4. m : r E. Nitrite Application
Liquid Solids Acre Fen Animal
r�s �i r n�
C•Z Cu.Yds Gallons (Dry Tona/Ac) Waste.etc) Moist) inches r ' > r a rng/k9 mdka fnliikti Crop 1 Crop 2 Crop 1 Crop 2
January 16.200 1.8 0.047 NC0021709 dry 0 s 0.5 30% 86.200 529 614 2.486 NA fescue
March 90.000 1.8 0.260 NC0021709 dry 0 s 0.5 30% 86,200 529 614 13.812 NA fescue
April 63,000 18 0.182 NC0021709 dry 0 s 0.5 3(o"„ 86.200 529 614 9.668 NA fescue
May 52,200 1.8 _ 0.151 NC0021709 dry 0 s 0.5 30 ". 86.200 529 614 8.011 NA fescue
June 43200 1.8 0.125 NC0021709 dry 0 s 0.5 30% 86.200 529 614 6.630 NA fescue
August 82.800 1.8 0.239 NC0021709 dry" 0 s 0.5 30% 86.200 529 614 12.707 NA fescue
Sept. 28.800 1.8 0.083 NC0021709 dry 0 s 0.5 30% 86,200 529 614 4.420 NA fescue
Oct. 21.600 1.8 0.062 NC0021709 dry 0 s 0.5 30% 86,200 529 614 3.315 NA fescue
Nov. 84.600 1.8 0.244 NC0021709 dry 0 s 0.5 30% 86,200 529 614 12.983 NA fescue
Dec. _ 7200 1.8 0.021 NC0021709 dry 0 s 0.5 30% 86.200 529 614 1.105 NA fescue
0.000 0.000 0.000
0.000 0.000 0.000
roTALs I 0 4896th)
` Residuals Applications totals on FORM FSF supp(attach FORM FSF supp to this form):
As Cd Cu Cr Pb Hg Mo Ni Se Zn P 75.138 0.000 Lime Applied
Annual lbs/acre 0.007 0.004 1.674 #######I 0.065 0.001 0.014 0.052 0.007 2.520 49.560 Date lbs/ac
Prior Years Cumulative lbs/ac 0.68 0.141 25.565 na 1.539 0.031 0.714 1.308 1.062 82.675
Current Cumulative lbs/ac 0.687 0.145 27.239 ####### 1.604 0.032 0.728 1.360 1.069 85.195
Permitted C. P. L. R.**** 36 34 1338 na 267 13 na 374 89 2498
Permit PAN Limit 1 st/2nd Crop 155
"I certify,under penalty of law,that this document was prepared under my direction or supervision in accordance with a system designed to assure that
qualified personnel properly gathered and evaluated the information submitted. I am aware that there are significant penalties for submitting false
information, including the possibility of fines and imprisonment for knowing violations." 1
/������ � � L� �/� *Application Method:S-Surface,IN-Injection,INC.Incorporation
IL/T& Cif t,„ 2/�7 i2oz **Volatilization Rate:Surface-0.5,Injection/Incorporation- 1.0
Signature of Land Applier Date *** Mineralization Rates:Compost-0.1,anaerobially digested-0.2,
aerobically digested-03,raw sludge-0.4
****C.P.L.R.:Cumulative Pollutant Loading Rate

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Facility Name: Town of Jefferson WWTP WQ Permit#: WQ0004166 Field#: 3 Acres Utilized: 8
Land Owner: Fred Walters Annual Dry Tons Applied: 3.9181 Site#: Bower Walters Acres Permitted: 8
Operator: Tim Church Predominant Soil Series: Watauga Cation Exchange Capacity(non 503): 13.4
Crop I Name: Fescue hay Crop 1 Max. PAN: 155 Crop 2 Name: Crop 2 Max.PAN:
Volume applied Volume Residual Sources Soil Precip. . o z > Nitrate Name of Crop Type
(enter one)Solids! Cond. 3A PAN Applied
o Applied per (NPDES#,WQ#. Past 24 o 1 6 0 y TKN w c and pp Receiving Residual
Liquid Solids Acre Fen..Animal (Dr}' Hrs. 9 ; . * c, a (lbs/acre)
Wet t = ;, Nitrite Application
Waste,etc) " 3 0
Cu.Yds Gallons (Dry Tons/Ac) Moist) incheso o mg/kg mg/kg mg/kg Crop 1 Crop 2 Crop 1 Crop 2
AprIl 32.400 1.8 0.304 NC0021709 dry 0 s 0.5 30% 86,200 529 614 16.160 NA fescue
June 19,800 1.8 0.186 NC0021709 dry 0 s 0.5 30% 86.200 529 614 9.876 NA fescue
0.000 0.000 0.000
0.000 0.000 0.000
0.000 0.000 0.000
0.000 _ 0.000 0.000
-
0.000 _ 0.000 0.000
0.000 0.000 0.0(X)
0.000 0.000 0.000
0.000 _ _ 0.000 0.000_
0.000 0.000 0.000
0.000 _ 0.000 0.000
-
Residuals Applications totals on FORM FSF supp(attach FORM FSF supp to this form):
)'r,�t.s o 522a> As Cd Cu Cr Pb Hg Mo Ni Se Zn P 26.036 0.000 Lime Applied
,nnual Ibs%acre 0.002 0.001 0.574 ##400# 0.022 0.000 0.005 0.018 0.003 0.864 I6.992 Date lbslac
rior Years Cumulative lbs/ac 0.406 0.128 21.797 na 1.256 0.031 0.712 1.191 0.86 79.483
'urrent Cumulative lbs/ac 0.408 0.129 22.371 ####### 1.278 0.031 0.717 1.209 0.863 80.347
ermitted C. P. L. R.**** 36 34 1338 na 267 13 na 374 89 2498
ermit PAN Limit I sU2nd Crop 155
I certify, under penalty of law,that this document was prepared under my direction or supervision in accordance with a system designed to assure that
ualified personnel properly gathered and evaluated the information submitted. I am aware that there are significant penalties for submitting false
'formation, including the possibility of fines and imprisonment for knowing violations."
/ . *Application Method:S-Surface,IN-Injection,INC-Incorporation
( � 2i/3/2020 **Volatilization Rate:Surface-0.5.Injection/Incorporation- 1.0
Signature of Land Applier Date *** Mineralization Rates: Compost-0.1,anaerobially digested-0.2,
aerobically digested-0.3,raw sludge-0.4
****C.P.L.R.:Cumulative Pollutant Loading Rate

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A"N/A"IN A BLANK OR BOX WHEN NOT APPLICABLE.
Facility Name: Town of Jefferson WWTP WQ Permit#: WQ0004166 Field#: 5 Acres Utilized: 9
Land Owner: Johnny Walters Annual Dry Tons Applied: 16.4832 Site#: Johnny Walter. ' Acres Permitted: 9
Operator: Tim Church Predominant Son Series: Watauga Cation Exchange Capacity(non 503): 12.5
Crop 1 Name: Fescue Hay Crop I Max. PAN: 155 Crop 2 Name: Crop 2 Max.PAN:
Volume applied Volume Residual Sources Soil Precip. c .. Nitrate Name of Crop Type
c -S (enter one)Solids/ % lied Cond. et'� ,„ 9 PAN Applied
iv aApplied P� (NPDES#,WQ#, Past 24 b �,° �° TKN c and Receiving Residual
Q0 Liquid Solids Acre Fert.,Animal (DIY Hrs. a : 5 E. Nitrite (lbs/acre) Application
Cu.Yds Gallons (Dry Tons/Ac) Waste.etc) Moist) inches ' r
o Ingikti ka run/kg Crop 1 Crop 2 Crop I Crop 2
July 111,600 1.8 0.931 NC0021709 dry 0 S 0.5 30% 86200 529 614 49.478 NA fescue
Sept. 108,000 1.8 0.901 NC0021709 dry 0 S 0.5 30°A, 86200 529 614 47.882 NA fescue
0.000 _ 0.000 0.000
0.000 0.000 0.000
0.000 36 0.000 0.000
0.000 0.000 0.000
_
0.000 0.000 0.000
0.000 _ 0.000 0.000
0.000 0.000 0.000
0.000 0.000 0.000
0.000 0.000 0.000
0.000 0.000 0.000
r Residuals Applications totals on FORM FSF supp(attach FORM FSF supp to this form):
DIALS:_ 0 219600 As Cd Cu Cr Pb Hg Mo Ni Se Zn P 97.360 _. 0.000 Lime Applied
.nnual lbs/acre 0.009 0.005 2.153 #######_ 0.084 0.002 _ 0.018 v 0.067_ 0.010 3.240 63.720 Date lbs/ac
rior Years Cumulative lbs/ac 0.438 0.021 7.955 na 0.499 0.003 0.017 0.291 0.366 12.531
'urrent Cumulative lbs/ac 0.447 0.026 10.108 ####### 0.583 0.005 0.035 0.358 0.376 15.771
ermined C. P. L. R.**** 36 34 1338 na 267 I3 na 374 89 2498
ermit PAN Limit lst/2nd Crop 155
I certify,under penalty of law,that this document was prepared under my direction or supervision in accordance with a system designed to assure that
ualified personnel properly gathered and evaluated the information submitted. I am aware that there are significant penalties for submitting false
'formation,including the possibility of fines and imprisonment for knowing violations."
//3 4?- *6210 Application Method: S-Surface,IN- Injection,INC- Incorporation
-iti;evt., CAVALL Z **Volatilization Rate: Surface-0.5,Injection/Incorporation- 1.0
Signature of Land Applier Date
*** Mineralization Rates: Compost-0.1,anaerobially digested-0.2,
aerobically digested-0.3,raw sludge-0.4
****CP.I..12.: Cumulative Pollutant Loading Rate