WQ0002648_Application_20200228

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 01-20
This form is for renewal without modification for all non -discharge system permits, except Residuals Management and Single -
Family Residence Wastewater Irrignilon System permits.
For more irr%rrttation, visit the lVater• Quality Permitting Section's Nora-Ulscharce Brunch Wehsile,
1. PERMITTEE INFORMATION:
1. Permittee: WQ0002648
2. Signature authority's name: Michael T. Walker per 15A NCAC 02T .0106(b) Title: Secretary of the Board
Primary Telephone number: 336 465-1460 cell Secondary number: (_) _- Select . -
Email Address: lmccaskill2atriad.rr.com
3. Permittee's mailing address: PO Box 370
City: Seagrove State: NC Zip: 27341-
4. Billing address (if different from above):
City: State: Zip: -.
5. Contact person's name (if different from signature authority): Larry Chilton Title: ORC
Primary Telephone number: 3( 36) 302-3782 Select Secondary number: Q 36) 215-3835 Select
Email Address: Itchilton l28(&Mail.com
II. PERMIT INFORMATION:
1. Existing permit number: WQ0002648
2. Has the facility been constructed? ® Yes or ❑ No
If yes, has the facility been constructed in accordance with the permit and the Division -approved plans and specifications?
115A NCAC 02T .01 10] ® Yes or ❑ No
If no, a formal permit modification request shall be submitted to the Division.
3. Has any of the property ownership within the facility and/or disposal area changed from what is indicated in the current permit
(Attachment B — disposal field owner/lessee)? ❑ Yes or ® No
Has the Permittee had a name change or has the permit changed ownership? ❑ Yes or ® No
If yes to either, a permit modification request shall be submitted to the Division. [ 15A NCAC 02T .01051
4. Is this facility a Privately -Owned Public Utility? ❑ Yes or ® No
If yes, provide two copies of the Certificate of Public Convenience and Necessity from the North Carolina Utilities Commission
demonstrating the Applicant is authorized to hold the utility franchise. [ 15A NCAC 02T .01 I5 a I ]
5. Is the Permittee a Home/Property Owners' Associations or Developers of lots to be sold? ❑ Yes or ® No
If yes, provide the following:
• For Home/Property Owners' Associations — Operational Agreement (FORM: HOA) and a copy of the proposed or
approved Articles of Incorporation, Declarations, and By-laws [ i 5A NCAC 02T ,01 15(c)]
• For Developers of lots to be sold — Operational Agreement (FORM: DEV) [15A NCAC 02T .0115(b)1
FORM: NDSR 01-20 Page 1 of 5

DWR
Division of Water Resources
6. Does the facility treat and dispose of industrial wastcwnter?
if yes, complete items below. if no, skip to the next section.
Indicate the approximate percentage of wastewater makeup:
industrial:5% Domestic:90% Slormwater:5%
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL.
FORM: NDSR 0 1 -20
For all industrial wastewater sources (excluding those permitted under a pretreatment permit), provide a detailed industrial
process description including:
• An overview of the manufacturing process Plastic Molds
• An inventory of all materials used for manufacture, including chemicals and biological matter
• An overview of cleaning and treatment methodology, including an inventory of treatment materials and compounds
Has the nature of wastes (e.g., change in industrial processes, introduction of new materials or chemicals, etc.) described in the
approved permit application(s) changed? ❑ Yes or ® No
If yes, a permit modification request shall be submitted to the Division. G.S. 141-215. I d
Ill. SITE MAP:
i . Provide an updated site map in accordance with 15A NCAC 02T .0105 d that shows the following (if applicable):
The site map is not required to be signed or sealed by a Professional Engineer. However, the map must indicate the source of
information. For example, parcel lines taken from a county GIS map should reference the GIS website.
® Legend, north arrow, and scale
® Topographic contours on all disposal sites
® Soil mapping units on all disposal sites
® All facility -related structures and fences within the treatment, storage, and disposal areas
® All habitable residences and places of assembly within 500 feet of all treatment, storage, and irrigations sites
® Location of all wells, streams (ephemeral, intermittent, and perennial), springs, lakes, ponds, ditches, and other surface
drainage features within 500 feet of all waste treatment, storage, and disposal site(s)
® Latitude and longitude coordinates of all monitoring wells (decimal degrees to 6 digits)
® Location and identification of major components of the waste disposal system
® The wetted perimeter of all irrigation fields with field names (named according to the approved permit)
® Location and ownership of property boundaries within 500 feet of the disposal area (including road/rail right-of-ways)
® The delineation of compliance and review boundaries
® Distance measurements verifying all setbacks are being met
® Stormwater drainage controls
® 100-year floodplain
❑ For reclaimed water eneration ermits, provide a separate map showing all distribution lines and utilization permit
locations that are connected to the water generation facility and are permitted by the Non -Discharge Branch (excludes
Local Program permitted facilities). Include all reclaimed water distribution line and reclaimed water utilization permit
numbers.
Page 2 of 5
FORM: NDSR 0 1 -20

DWR
DlvNlon of WAIrt Krsourt@*
IV. t:ROUNI)WATER MONITORING WELLS
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1. I )jn:b the facility have a proposed Or existing groundwater monitoring well nctwe ? 0 Yes or ❑ wj
If no, skip to next section.
If yes, complete the following table (NOTE — This table may be expanded for add6onal weilisy
Well Name
Status
Latitude'
LongitudeGradient
L case-
MVN 1
Active
35.533300°
-79.77p6{N1' Up GTadiettl
OtAside Qmy i; cc
Sa1T- dM-•
MW2
Active
35,5289000
-79.763300°
Down Gradient
Iside
Bout.
MW3
Active
35.5308000
-79.764000
Down Gradient
Ipside Corm!mwr
Sos�
Select
°
- 0Selea
Select
Select
°
- 0Select
Select
Select
°
- °
Seketx
Select
Select
°
-
Select
Select
Select
°
- °
Select
Select
Select
°
- °
Select
Select
Select
°
-
Select
Select
a. Coordinates must be in NAD83 and have 6 decimal degrees
V. SETBACK WAIVERS, EASEMENTS, AND LEASES:
1. Does the permit have any setback waivers, easements, or leases? ❑ Yes or ® No
If yes, provide copies of all documents and complete the table below:
Document
Grantor or
Grantee
Expiration
County
Deed
Deedg a
Document
Type
Parcel No.
Date
Register
Book
De-cri tion'
Select
Select
Select
Select
Select
Select
Select
a. The document description shall list any reduced setbacks with distance, etc.
2. For reclaimed water utilization permits;
Is reclaimed water utilized on property not controlled by the generator? ❑ Yes or ® No
A lease, easement, or agreement must be provided allowing for the utilization of reclaimed water on the property or within the
facility. For irrigation of reclaimed water, an easement is required per 15A NCAC 02U .0501(6). All documents shall be listed
in the table above.
FORM: NDSR 0 1 -20 Page 3 of 5

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
Division of Water Resources FORM: NDSR 01-20
VI. RELATED PERMITS
1. If this permit has interactions with other wastewater permits (collection systems, NPDES, etc.), complete the table below
(provide additional pages if necessary);
Permit Type Permit No. Description
2. Does the facility have an approved flow reduction [15A NCAC 02T .01 14 ? ❑ Yes or ® No
If yes, attach the measured monthly average amount of wastewater flow contributed per unit for the 12 months prior to permit
renewal. If any of these monthly averages are within 20% of the approved value, the Permittee shall provide a reevaluation of
the reduced flow value using the methodology applied to the original flow reduction application. Also, attach a copy of the
flow reduction approval letter.
APPLICANT'S CERTIFICATION 15A NCAC 02T .0106(b)
1, Michael T. Walker, attest that this renewal application has been reviewed by me, and is accurate and complete to the best of my
knowledge. I understand that any unauthorized discharge of wastewater from this non -discharge system to surface waters or the land
may result in an enforcement action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim
against the Division of Water Resources should a condition of this permit be violated. 1 also understand that if all required parts of this
application are not completed, this application may be returned to me as incomplete. I further certify that the Applicant or any parent,
subsidiary, or other affiliate of the Applicant 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 does not have any overdue annual fees.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation. The Applicant's Certification shall be signed in accordance with
15A NCAC 02T .0106(b). Per 15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation
letter is provided fr a person who meets the criteria in 15A NCAC 02T .0106(b)
Signature:
Date;
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO: 91
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE BRANCH
By U.S. Postal Service:
Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
By Courier:
Non -Discharge Branch — Archdale 942W
512 N. Salisbury St.
Raleigh, NC 27604
TELEPHONE NUMBER: [phone]
By Email:
Non-Discharee. Reports(@,,ncdenr.+_ov
FORM: NDSR 01-20
Page 4 of 5

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Disclaimer: This map was compiled from recorded deeds, plats, and other public records Map Scale
and data. Users of this data are hereby notified that the aforementioned public information 1 inch = 667 feet
2/21 /2020
sources should be consulted for verification of the information. Randolph County, its
agents and employees make no warranty as to the accuracy ojthe information on this map.
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Disclaimer: This ma was corn iled rom recorded deeds, plats, and other public records
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and data. Users of this data are hereby notified that the c forementioned public information 1 inch = 667 feet
qln
sources should be consulted for verification of the information. Randolph County, its 2/21/2020
p"" agents and employees make no warranty as to the accuracy of the information on this map.