NCG020313_COMPLETE FILE - HISTORICAL_20151027

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
IV CC2 00 0 3i3
DOC TYPE
0' HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑ C)
YYYYMMDD

Division of Energy, Mineral and Land Resources
Land Quality Section / Stormwater Permitting Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been -
FOR AGfiNCY USE ONLY
Date Received
Year
Monde
na
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
If the name of the facility has changed, or if the ownership of the facility has changed,
do NOT use this form. Instead, you must fill out a Name -Ownership Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual" mean? RECEIVED
The person is either: f ` ED
• the responsible corporate officer (tor a corporation);
• the principle executive officer or ranking elected official (for a municipality, state, a er t r l$lr public
agency); [)EN
• the general partner or proprietor (for a partnership or sole proprietorship); 570R1 R AND ��aLlTy
• or, the duly authorized representative of one of the above. R PERM1771N(3
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
is KM111111
2) Facility Information:
(or) Certificate of Coverage
N C G C) Z d -3 ! 3
Facility name: 7 ,,,,t r,tiq" tA­Cj I_Lj k-e_- &Q _ I t ve__k
Company/Owner Organization: %„tir,a �u� L tAx ewc,,-tA
Facility address: / ,,�e // 7j23 jPrA,5Lvy
Address
G,5 N c_ Z 20-7 1
City State "Lip
To tend the current legally responsible person associated with your permit, go to this website:
http://portal.ncdenr.orz/web/lr/sw-pertnit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: �� K q A F-1 S � t Y­
[.,iy MI Last
4) NEW OWNER. AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: 72 1 GCA WnL
I i t MI Last
Page 1 of 2
SM-OW NEi2AFFIL-25July2o14

.. _ : 3:. - ..
t

PJ
NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Titic
3 v Z_ vl Cr»J,oYcl - P l —
Mailing Address
AJ ; n Lu- 4 IV C- Lg 14 to
Cite State Zip
r 79Y)-63 9-,YP1< l;yao-A,,-tn..lLUr—
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of: ❑ Employee or management change
❑ Inappropriate or incorrect designation before
©-11i&r
If olher please explain: ��, v 9 ��L. /� —js �i/
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, t� , /U /q • 6-40 attest that this application for this change in Owner Affiliation
(person legally responsible for the permit) has been reviewed and is accurate and complete to the best of my
knowledge. 1 understand that if all required parts of this form are not completed, this change may not be
processed.
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call 919-707-9220 or visit the website at:
http//portal.ncdenr.or web/Ir/stormwater
Page 2 of 2
SWU-0WNERAFFIL-25Ju1y2014

0

6oFblu)U
W A rE�QG
�I
February 7, 2005
Hugh A Fisher
Immanuel Lutheran Church
2070 Immanuel Church Rd
Rockwell, NC 28138
Michael F, Easley, Covernor
William C. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P,E, Director
Division orwatcr Quality
Subject: NPDES Stormwater Permit Coverage Renewal
Immanuel Lutheran Church
COC Number NCG020313
Cabarrus County
Dear Permittee:
In response to your renewal application for continued coverage under general permit NCG020000 the Division of Water
Quality (DWQ) is forwarding herewith the reissued stormwater general permit. Please review the new permit to familiarize
yourself with the changes in the reissued permit. The general permit authorizes discharges of stormwater and some types of
wastewater. You must meet the provisions of the permit for the types of discharges present at your facility. This permit is
reissued pursuant to the requirements of North Carolina General Statute 143-215.1 and the Memorandum of Agreement
between the state of North Carolina and the U.S. Environmental Protection Agency, dated December 6, 1983.
The following information is included with your permit package:
+ A new Certificate of Coverage
• A copy of General Stormwater Permit NCG020000
• A copy of a Technical Bulletin for the general permit
• Five copies of Discharge Monitoring Report (DMR) Forms - wastewater and stormwater
• Five copies of Qualitative Monitoring Report Form
Your coverage under this general permit is not transferable except after notice to DWQ. The Division may require modification
or revocation and reissuance of the Certificate of Coverage. This permit does not affect the legal requirements to obtain other
permits which may be required by DENR or relieve the permittee from responsibility for compliance with any other applicable
federal, state, or local law, rule, standard, ordinance, order, judgment, or decree.
If you have any questions regarding this permit package please contact Bethany Georgoulias of the Central Office Stormwater
Permitting Unit at [phone], ext.529.
Sincerelv.
for Alan W. Klimek, P.E.
cc: Central Files
Stormwater & General Permits Unit Files
Mooresville Regional Office
Onc
No hCarolina
�Valurally
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 Phone [phone] Customer Service
Internet: h2o.enr.state.nc.uslsulstormwater.html 512 N. Salisbury St. Raleigh, NC 27604 FAX [phone]
An Equal Opportunity/Affirmative Action Employer — 50% Recycled110% Post Consumer Paper

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG020000
CERTIFICATE OF COVERAGE No. NCG020313
STORMWATER AND PROCESS WASTEWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and
the Federal Water Pollution Control Act, as amended,
Immanuel Lutheran Church
is hereby authorized to discharge stormwater and to operate treatment systems and discharges associated
with mine dewatering wastewater and process wastewater from a facility located at.
Immanuel Lutheran Church
Klutz Mine 11703 Sansbury
Gold Hill
Cabarrus County
to receiving waters designated as Little Buffalo Creek, a class C stream in the Yadkin -Pee Dee River Basin
in accordance with the effluent limitations, monitoring requirements, and other conditions set forth in Parts I,
II, Ifl, IV, V, and VI of General Permit No. NCG020000 as attached.
This certificate of coverage shall become effective February 7, 2005.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day February 7, 2005
for Alan W. Klimek, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission

.State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Bill Holman, Secretary
Kerr T. Stevens, Director
December 17, 1999
HUGH A. FISHER
IMMANUEL LUTHERAN CHUUCH
2070 IMMANUEL CHURCH ROAD
ROCKWELL, NC 28138
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
Subject: Reissue - NPDES Stormwater Permit
Immanuel Lutheran Chruch
COC Number NCG020313
Cabarrus County
Dear Permittee:
In response to your renewal application for continued coverage under general permit NCG020000, the Division of
Water Quality (DWQ) is forwarding herewith the reissued stormwater general permit. This permit is reissued
Pursuant to the requirements of North Carolina General Statute 143-215.1 and the Memorandum of Agreement
between the state of North Carolina and the U.S. Environmental Protection Agency, dated December 6, 1983.
The following information is included with your permit package:
* A copy of general stormwater permit NCG020000
* Five copies of the Analytical Monitoring form and five copies of the Qualitative Monitoring form
* A copy of a Technical Bulletin on this permit which outlines permit components and
addresses frequently asked questions
* A Certificate of Coverage for your facility
* DWQ fee schedule
Your coverage under this general permit is not transferable except after notice to DWQ. The Division may require
modification or revocation and reissuance of the Certificate of Coverage. This permit does not affect the legal
requirements to obtain other permits which may be required by DENR or relieve the permittee from responsibility
for compliance with any other applicable federal, state, or local law rule, standard, ordinance, order, judgment, or
decree.
Please note that in 1998 Senate Bill 1366 established changes to the permit fee structure for DWQ permits effective
January I, 1999. This change requires that you pay an annual fee to assure continued coverage under this permit.
You will be invoiced for this fee beginning next year. A copy of the current fee schedule is included with this letter.
If you have any questions regarding this permit package please contact Tony Evans of the Central Office Stormwater
and General Permits Unit at [phone], ext. 584
Sincerely,
for Kerr T. Stevens
Director, Division of Water Quality
cc: Central Files
Mooresville Regional Office
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post -consumer paper

.i
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG020000
CERTIFICATE OF COVERAGE No. NCG020313
STORMWATER AND PROCESS WASTEWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215,1. other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and the
Federal Water Pollution Control Act, as amended,
IMMANUEL LUTHERAN CHRUCH
is hereby authorized to discharge stormwater and to operate or continue operation of treatment systems and
discharges associated with mine dewatering and process wastewater from a facility located at
IMMANUEL LUTHERAN CHRUCH
KLUTZ MINE/11703 SANSBURY RD.
GOLD HILL
CABARRUS COUNTY
to receiving waters designated as Little Buffalo Creek in the Yadkin - Pee Dee River Basin in accordance with the
effluent limitations, monitoring requirements, and other conditions set forth in Parts I,11, III, IV, V, and VI of
General Permit No. NCG020000 as attached.
This certificate of coverage shall become effective December 17, 1999.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day December 17, 1999.
for Kerr T. Stevens, Director
Division of Water Quality
By Authority of the Environmental Management Commission

Statepf North Carolina
Department of Environment,
Health and Natural Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
September 22, 1995
Immanuel Lutheran Chruch
2070 Immanuel Chruch Rd
Rockwell, NC 28138
MI.WMA
I'T
A&4
�J dd
I DEHNR
Subject: General Permit No. NCG020000
Immanuel Lutheran Chruch
COC NCG020313
Cabarrus County
Dear:
In accordance with your application for discharge permit received on August 9, 1995, we are
forwarding herewith the subject certificate of coverage to discharge under the subject state - NPDES general
permit. This permit is issued pursuant to the requirements of North Carolina General Statute 143-215 .1 and
the Memorandum of Agreement between North Carolina and the US Environmental Protection agency dated
December 6, 1983.
If any parts, measurement frequencies or sampling requirements contained in this permit are
unacceptable to you, you have the right to request an individual permit by submitting an individual permit
application. Unless such demand is made, this certificate of coverage shall be final and binding.
Please take notice that this certificate of coverage is not transferable except after notice to the Division
of Environmental Management. The Division of Environmental Management may require modification or
revocation and reissuance of the certificate of coverage.
This permit does not affect the legal requirements to obtain other permits which may be required by the
Division of Environmental Management or permits required by the Division of Land Resources, Coastal
Area Management Act or any other Federal or Local governmental permit that may be required.
If you have any question concerning this permit, please contact MS. AISHA LAU at telephone number
919/733-5083.
cc: Mooresville Regional Office
P.O. Box 29535, Raleigh, North Carolina 27626-0535
An Equat Opporlunity Affirmative Action Employer
Sincerely,
Original Signed By
Coleen H. Sullins
A. Preston Howard, Jr. P.E.
Telephone [phone] FAX [phone]
50% recycled/ 10% post -consumer paper

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
DIVISION OF ENVIRONMENTAL MANAGEMENT
GENERAL PERMIT NO, NCG020000
CERTIFICATE OF COVERAGE No. NCG020313
STORMWATER, MINE DEWATERING, AND/OR OVERFLOW FROM
PROCESS WATER RECYCLE SYSTEMS DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and the
Federal Water Pollution Control Act, as amended,
Immanuel Lutheran Church
is hereby authorized to discharge stormwater from a facility located at
Kluttz Mine
11703 Sansbury Rd,
Gold Hill
Cabarrus County
to receiving waters designated as Little Buffalo Creek, a class C stream in the Yadkin -Pee Dee River Basin
in accordance with the effluent limitations, monitoring requirements, and other conditions set forth in Parts 1, II, III
and IV of General Permit No. NCGO20000 as attached.
This Certificate of Coverage shall become effective September 22, 1995.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day September 22, 1995.
Original Signed By
Coleen K Suilitls
A. Preston Howard, Jr., P.E„ Director
Division of Environmental Management
By Authority of the Environmental Management Commission

- NORTH CAROLINA #.\
7.5 MINUTE SERIES (TOPOORAPHIC)
NW/4 MOUNT PLEASANT 15' QUADRANGLE \CP
555 1590000 FEET J BV2'3(r
35-30'
5
A
J
A
X
243
1 4
J
Pll
—1-J
f5o:D
aiTi
n.
so
,750-
0
c-,
OF A7 t)
/i V
III"
-op
'IV- � ,r. % QI ���
��"� O V 1�
� � � i (�
'� ,� �
tip,'"6,ii
r
�/.���� �� /i�� �i �,\\"�/
� � `�I �LJ '
� 65a� �� sob 11 �
„�
,��c} ,� r
V
28
*27
'26
530000., 1 1
FEE-r
3925
1924
27'3(Y -4
3123

FACILITY
Kluttz Mine
COUNTY
Cabarrus
NPDES
NCG020313
MAP# F17NW
DSN FLOW
NA
SUB BASIN
03-07-12
LATTITUDE
350 28' 38"
LONGITUDE
800 22' 45"
RCVNG. STREAM
Little Buffalo Creek
STREAM CLASS
C
DSCHRG: CLASS
Stormwater
EXP. DATE
8/31/97