WQ0005910_Modification_1_20201120

Initial Review
Reviewer Thornburg, Nathaniel
Is this submittal an application? (Excluding additional information.)*
r Yes r No
Permit Number (IR)* WQ0005910
Applicant/Permittee Avoca LLC
Applicant/Permittee Address 841 Avoca Farm Road, Merry Hill, Nc 27957
Is the owner in BIMS? r Yes r No Is the facility in BIMS? r Yes r No
Owner Type Organization
Facility Name Avoca - Merry Hill WWTP
County Bertie
Fee Category Major
Is this a complete
application?*
r Yes r No
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Does this need review bythe hydrogeologist?* r Yes r No
Regional Office
CO Reviewer
Admin Reviewer
Fee Amount $0
Complete App Date 11/20/2020
Below list any additional email address that need notification about a new project.
Email Address
Comments to be added to email notfication
Comments for Kendall
Comments for RO

Comments for Reviewer
Comments for Applicant

Submittal Form
Project Contact Information
Rease provide information on the person to be contacted by NDB Staff regarding electibnittal, confirmation of receipt, other
.......................................................... electronic surece, aner correspondence.
_ -
Name * Brian Conner
Email Address*
[e-mail]
Project Information
........ ......... ............................................................................................................................... .
Application/Document Type* r New (Fee Req ui red)
r Modification - Major (Fee Required)
r Renewal with Major Modification (Fee
Required)
r Annual Report
r Additional Information
r Other
Phone Number*
252-482-2133
O Modification - Minor
C Renewal
C GW-59, NDMR, NDMLR, NDAR-1,
NDAR-2
r Residual Annual Report
r Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
https://edocs.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type:* r Wastewater Irrigation r High -Rate Infiltration
r Other Wastewater r Reclaimed Water
r Closed -Loop Recycle r Residuals
r Single -Family Residence Wastewater r Other
Irrigation
Permit Number:* W00005910
Has Current Existing permt nunUer
Applicant/Permittee* Avoca LLC
Applicant/Permittee Address* 841 Avoca Farm Road, Merry Hill, Nc 27957
Facility Name * Avoca - Merry Hill WWTP
Please provide comments/notes on your current submittal below.
This application, and attached documents are being submitted at the request of Mr. Dwight
Randy Sipe, Hydrogeologist, from the Washington Regional Office for a minor permit
modification of Avoca, LLC's permit No. WQ0005910.
Attached is the completed form WWIS 06-16 application for wastewater irrigation systems. I
have also attached the closure documents for monitoring well # MW-4 as well as the
construction records for monitoring wells MW-10 and MW-11.
Due to this application only being for the removal of 1 monitoring well and the addition of 2
monitoring wells, there are no operational, equipment, or other changes being made to the
facility or permit I am only submitting the well forms and general WSIS 06-16 application. I
asked Mr. Sipe for the need of a PE signature on the application , and he said that he did not
think it was necessary for these minor changes.
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.*
(Application Form Engineering Rans, Specifications, Calculations, Rc.)
2020 Permit Mod. App..pdf 1.02MB
upload only 1 FLFdocurrent (less than 250 NB). Witiple docurrents mist be combined into one RDFfile unless file is larger than
upload limt.
* V By checking this box, I acknowledge that I understand the application will not be
accepted for pre -review until the fee (if required) has been received by the Non -
Discharge Branch. Application fees must be submitted by check or money order
and made payable to the North Carolina Department of Environmental Quality
(NCDEQ). I also confirm that the uploaded document is a single PDF with all parts
of the application in correct order (as specified by the application).

Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature *
Submission Date 11/20/2020
Is filled in autorratically once submitted.

ox,Avoca, LLC
The World's Premier- Botanical Extraction Company
October 5, 2020
NCDENR
Division of Water Resources
Water Quality Permitting Section
Non -Discharge Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Avoca, LLC - WWT Permit No. 0005910 Modification
County: Bertie
Minor Permit Modification
Remove Monitoring well # MW-4
Add monitoring wells MW-10 and MW-I I
Dear NCDWR Representative:
Avoca,LLC
Po Box 129
841 Avoca Farm Rd
Merry Hill, NC 27957
Phone: [phone]
t;ax: 252-482-8622
This letter, the attached application, and attached documents are being submitted at the
request of Mr. Dwight Randy Sipe, Hydrogeologist, from the Washington Regional
Office for a minor permit modification of Avoca, LLC's permit No. WQ0005910.
Attached is the completed form WWIS 06-16 application for wastewater irrigation
systems. I have also attached the closure documents for monitoring well 4 MW-4 as well
as the construction records for monitoring wells MW-10 and MW-11.
Due to this application only being for the removal of 1 monitoring well and the addition
of 2 monitoring wells, there are no operational, equipment, or other changes being made
to the facility or permit I am only submitting the well forms and general WSIS 06-16
application. I asked Mr. Sipe for the need of a PE signature on the application, and he
said that he did not think it was necessary for these minor changes. If there is more
information needed please do not hesitate to contact me.
Sincerely,
AM CAn, .O�
Brian Conner
EHS Manager
Avoca, LLC
[phone]

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
15A NCAC 02T .0500 —WASTEWATER IRRIGATION SYSTEMS
Division of Water Resources FORM: WWIS 06-16
I. APPLICANT INFORMATION:
I. Applicant's name. Avoca, LLC
2, Applicant type, ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State ❑ Municipal ❑ County
3. Signature authority's name, Augustinus Gerritsen, per I5A_NCAC 02T,,D-106(Title, President
4. Applicant's mailing address: P O Box 129
City. Merry Hill State, NC Zip: 27957-
5. Applicant's contact information•
Phone number, [phone] Email Address, guus.genitsen mhland coin,
11. FACILITY INFORMATION:
1 Facility name: Avoca, LLC
2. Facility status. Existing
3, Facility type: Major (> 10,000 GPD or > 300 disposal acres)
4 Facility's physical address, 841 Avoca Farm Road
City- Merry Hill State. NC Zip- 27957- County. Bertic
S. Wastewater Treatment Facility Coordinates (Decimal Degrees), Latitude: 36.00025' Longitude. -76 42735'
Datum. Unknown Level of accuracy- Unknown Method of measurement: Map inter ietation b extraction
6. USGS Map Name:
III. CONSULTANT INFORMATION:
1 Professional Engineer- Stan Taylor
License Numbei: Firm- O'Breian & Gere Engineers, Inc
Mailing address-
City- State:
Zip -
Phone number, (_) _-
Email Address.
2 Soil Scientist: John P Williams
License Number. It 13 Firm: Land Management Group, Inc
Mailing address: PO Box 2522
City- Wilminatnn
State- NC Zip, 28402-
Phone number. (910) 452-OOOI
Email Address. ]williamsaftgroup.nct
3. Geologist. Kelly Smith
License Number- 2355 Firm • Groundwater Management Associates, Inc.
Mailing address 4300 Saphire Court. Suite 100
City: Greenville State. NC
Zip- 27834-
Phone numbei. [phone]
Email Address kellyagma-ne.com
4. Agronomist:
Firm.
Mailing address.
City: State.
Zip, -
Phone number. (_)
Email Address
FORM- WWIS 06-16 Page 1 of 12

IV. GENERAL REQUIREMENTS — 15A NCAC 02T .0100:
1. Application type, 0 New ❑ Majoi Modification M Minoi Modification
If a modification, provide the existing permit number: WQ0005910 and most recent issuance date: Se tembet 1 2019
2. Application fee, $O -Standard Minor Modification
3 Does this project utilize public monies or lands? ❑ Yes or ® No
If yes, was an Environmental Assessment required under 15A NCAC O1C? ❑ Yes or ® No
If yes, which final environmental document is submitted? ❑ Finding of No Significant Impact or ❑ Record of Decision
Briefly describe any mitigating factors from the Environmental Assessment that may impact this facility:
4. What is the status of the following permits/certifications applicable to the subject facility?
Permit/Certification
Date�Aroved
Submitte
Permit/Certification
Number
Agency Reviewer
Collection System (0> 200,000 GPD)
Dam Safety
Erosion & Sedimentation Control Plan
Nationwide 121 Section 404
Pretreatment
tern
Sewer System
Stormwater Manavement Plan
11/4/19
NCSO00134
Wetlands 401
Other•
5. What is the wastewater type? ❑ Domestic or Industrial (See 15A NCAC 02T .0103(20))
Is there a Pretreatment Program in effect? ❑ Yes or ® No
Has a wastewater chemical analysis been submitted? ❑ Yes or ® No
6 Wastewater flow: 50000 GPD
Limited by. ® Treatment, ❑ Storage, ® Field Hydraulics, ❑ Field Agronomics or ❑ Groundwater Mounding
7. Explain how the wastewater flow was determined- ❑ 15A NCAC 02T .0114 or ® Representative Data
Has a flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes or ® No
Establisbrrrent Type
Daily Design Flow "
No. of Units
Flow
Biological WWTP
50000 gal/day
1
50000 GPD
gall
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
50000 GPD
a See 15A NCAC 02T .0114(b), (d), (c)(1) and (e)(2), for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling, proposed unknown non-residential development uses, public access facilities located near high public use areas;
and iesidentral property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S 42A-4)
FORM: WWIS 06-16 Page 2 of 12

IV. GENERAL REQUIREMENTS— 15A NCAC 02T .0100 (continued):
8. What is the ncalest 100-year flood elevation to the facility? feet mean sea level Source:
Are any treatment, storage of itrigation facilities located within the 100-year flood plain? ❑ Yes or ® No
If yes, which facilities ai c affected and what measures are being taken to protect them against flooding?
If yes, has the Applicant submitted written documentation of compliance with &143 Article 21 Part 6? ❑ Yes or ❑ No
9. Has the Applicant provided documentation of the presence or absence of threatened or endangered aquatic species utilizing
information provided by the Department's Natural Heritage Program? ❑ Yes or ® No
10. Does the facility have a proposed or existing groundwater monitoring well network? ® Yes or ❑ No
If no, provide an explanation as to why a groundwater monitoring well network is not proposed:
If yes, complete the following table (NOTE— Thts table may be expanded for additional wells).
Well Name
Status
Latitude"
Longitude"
Gradient
Location
MW-4
-Perm-anently Abandonec
36,000678'
-76,715433'
Cross Gradient
Outside Compliance Bou
MW-5
Active
36 0043200
-76.4310420
Down Gradient
Inside Review Boundary
MW-6
PermanenLIK Abandonec
35,999034'
-76,720898'
Down Gradient
On Review Boundary
MW-7
Active
35.59376'
-76.432150
Down Gradient
On Review Boundary
MW-8
Active
35 593710
-76.429050
Down Gradient
On Review Boundary
MW-9
Active
35 9989790
-76,721044"
Cross Gradient
Inside Review Boundary
MW-10
Active
35.5930180
-76 4309020
Up Gradient
On Review Boundary
MW-11
Active
36 0004780
-76.717562°
Cross Gradient
Outside Compliance Bou
Select
0-
0Select
Select
Select
0-
Select
Select
a Piovide the following latitude and longitude coordinate determination information.
Datum: Select Level of accuracy- Select Method of measurement, Select
11 If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been submitted?
❑ Yes, ❑No or ®NIA
12. If the Applicant is a Developer of lots to be sold, has a Developer's Opeiational Agreement (FORM: DEV) been submitted?
❑ Yes, ❑No or ®NIA
13. If the Applicant is a Home/Property Owners' Association, has an Association O erational A reement FORM. HOA been
submitted? ❑ Yes, ❑No or NN/A
14 Demonstration of historical consideration for permit approval — 15A NCAC 02T 0120•
Has the Applicant or any parent, subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or G.S. 143-215.6B? ❑ Yes or ® No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ® No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or ® No
d Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or ® No
e. Has unpaid annual fees in accordance with 15A NCAC 02T 0105(e)(2)? ❑ Yes or ® No
FORM. WWIS 06-16 Page 3 of 12

V. WASTEWATER TREATMENT FACILITY DESIGN CRITERIA— 15A NCAC 02T .0505:
1. For the following parameters, provide the estimated influent concentrations and designed effluent concentrations as
determined in the Engineering Calculations, and utilized in the Agionomic Evaluation and Groundwater Modeling (if
applicable).
Parameter
Estimated influent Concentration
Designed Effluent Concentration
u><ontiil avera e
Ammonia Nitrogen (NH3-N)
0 07 mg1L
1.5 mg/L
Biochemical Oxygen Demand (BOD5)
1000 mg/L
1500 mg/L
Fecal Coliforms
NIA per 100 mL
Nitrate Nitrogen (NO3-N)
0 44 mg/L
10 mg/L
Nitrite Nitrogen (NO2-N)
0.04 mg1L
I
m /L
Total Kjeldahl Nitrogen
mg/L
Total Nitrogen
62 mg1L
100 mg/L
Total Phosphorus
19 mg/L
20 mg/L
Total Suspended Solids (TSS)
235 mg/L
250 mg/L
2. is flow equalization of at least 25% of the average daily flow provided? ® Yes or ❑ No
3 Does the treatment facility include any bypass or overflow lines? ❑ Yes or ® No
if yes, describe what treatment units are bypassed, why this is necessary, and where the bypass discharges.
4. Are multiple pumps provided wherever pumps are used? ® Yes or ❑ No
If no, how does the Applicant intend on complying with I SA NCAC 02T 0505 k ?
5 Check the appropriate box describing how power reliability will be provided in accordance with 15A NCAC 02T .0505(D-
® Automatically activated standby power supply onsite capable of powering all essential treatment units; or
❑ Approval from the Director that the facility.
➢ Has a private water supply that automatically shuts off dui ing power failures and does not contain elevated water
storage tanks;
➢ Has sufficient storage capacity that no potential for overflow exists; and
➢ Can tolerate septic wastewater due to prolonged detention.
6 if the wastewater treatment system is located within the 100-year flood plain, are there water -tight seals on all treatment units
or a minimum of two feet protection fiom the I00-year flood plain elevation? ❑ Yes, ❑ No or ® N/A
7. In accordance with 15A NCAC 02T ,0505(Q), how many days of residuals storage are provided? 15+
8 How does the Applicant propose to prohibit public access to the wastewater treatment and storage £acilmes? Facility is
surrounded by a fence with 24/7 guards on duty_
9. If an influent pump station is par t of the proposed facility (i.e., within the wastewater treatment plant boundary), does the
influent pump station meet the design critei is in 15A NCAC 02T .0305(h)? ❑ Yes, ❑ No, ® NIA — To be permitted
separately, or ❑ NIA — Gravity fed
10 If septic tanks are part of the wastewater treatment facility, do the septic tanks adhere to the standards in 15A NCAC 18A
1900? ❑ Yes, ❑ No or ® N/A
FORM. WWIS 06-16 Page 4 of 12

V. WASTEWATER TREATMENT FACILITY RESIGN CRITERIA — I5A NCAC 02T .0505 (continued):
11 Provide the requested treatment unit and mechanical equipment information.
a PRELIMINARY / PRIMARY TREATMENT (i.e., physical removal operations and flow equalization)
Treatment Unit
No. of
Units
Manufacturer or
Material
Dimensions (ft) !
S acin s in
Volume
allons
Plan Sheet
Reference
Specification
Reference
Flow Equalization
2
Concrete with liner
23 5 x 23.5 x 16 5
65500
Dissolved Air Floatatic
1
Stainless Steel
880
Select
Select
Select
b. SECONDARY / TERTIARY TREATMENT (i e , biological and chemical processes to remove organics and nutrients)
Treatment Unit
No. of
Units
Manufacturer or
Material(gallons)
Dimensions (ft)
Volume
Plan Sheet
Reference
Specification
Reference
Aeration Basin
3
Concrete with Liner
23 5 x 23.5 x 16 5
63500
Select
Select
Select
Select
Select
Select
Select
c. DISINFECTION
Treatment Unit
No. of
Manufacturer or
Dimensions (ft)
Volume
Plan Sheet
Specification
I
Units
Material
(gallons)Reference
Reference
Select
Select
➢ If chlorination is the proposed method of disinfection, specify detention time provided, minutes (NOTE-- 30
minutes minimum required), and indicate what treatment unit chloi me contact occurs.
➢ If ultraviolet (UV) light is the proposed method of disinfection, specify the number of banks, , number of lamps
per bank: and maximum disinfection capacity: GPM
d RESIDUAL TREATMENT
Treatment Unit
No. of
Manufacturer or
Dimensions (ft)
Volume
Volume
Plan Sheet
Specification
Units
Material
Reference
Reference
Aerobic Digester
1
Concrete with liner
23,5 x 23.5 x 16 5
68000
Select
FORM: WWIS 06-16 Page 5 of 12

V. WASTEWATER TREATMENT FACILITY DESIGN CRITERIA— 15A NCAC 02T .0505 (continued):
c PUMPS
Location
No. of
Purpose
Manufacturer /
"I'
Capacit
Plan Sheet
Specification
GPM
TDI-I
Pumps
a
Reference
Reference
Equalization
2
Move water from EQ
Goulds
Chambers
to Aeration
DAF
I
Move water through
Goulds
DAF
Digestor
1
Move water in
Goulds
di estor
Move water from
Tertiary Lagoon
1
Tertiary Lagoon to
Goulds
Holding Pond
Move water from
Tertiart Lagoon
I
tertiary laogoon to
Goulds
holding and
Holding Pond
2
Irrigation pumps
Goulds / 3196
350
Holding Pond
2
Irrigation Pumps
Goulds 13196
520
f BLOWERS
Location
No. of
No.
Units Served
Manufacturer /
Type
Capacity
CFM
Plan Sheet
Reference
Specification
Reference
Aeration Chambers
3
Aeration Chambers
and Digester
g. MIXERS
No. of
Manufacturer 1
Power
Plan Sheet
Specification
Location
Mixers
Units Served
Type
h
Reference
Reference
Equalization
Equalization
Chambers
2
Chambers
10
Aeration Chambers
3
Aeration Chambers
25
Sludge Sump
1
Sludge Sump
3
h, RECORDING DEVICES & RELIABILITY
Device
No. of
Location
Manufacturer
Maximum
Plan Sheet
Specification
Units
Capacity
Reference
Reference
In Pipe From
Equaliztion
Effluent Flow Measuring Device
I
chambers to
Rosemont
100 gpm
Aeration
Chambers
Production
Influent Flow Measuring Device
5
lines leading to
Rosemont
100 gpm
Equalization
Chambers
Select
Select
i, EFFLUENT PUMP / FIELD DOSING TANK (IF APPLICABLE).
FORM. WWIS 06-16 Page 6 of 12

Plan Sheet
Reference
Specification
Reference
Internal dimensions (L x W x H or 9 x H)
ft I
ft
Total volume
ft3
gallons
Dosing volume
ft3
gallons
Audible & visual alarms
Equipment to prevent irrigation during rain
events
FORM- WWIS 06-16 Page 7 of 12

VI. EARTHEN IMPOUNDMENT DESIGN CRITERIA— 15A NCAC 02T .0505:
IF MORE THAN ONE IMPOUNDMENT PROVIDE ADDITIONAL COPIES OF THIS PAGE AS NECESSARY,
1. What is the earthen impoundment type? Aerobic Lagoon
2. Storage Impoundment Coordinates (Decimal Degrees) Latitude: 36.005' Longitude. -76 700'
Datum. Unknown Level of accuracy Unknown Method of measurement. Map ititerpretation..by extraction
3. Do any impoundments include a discharge point (pipe, spillway, etc)?[] Yes or ® No
4, Are subsurface drains present beneath or around the impoundment to control groundwater elevation? ❑ Yes or ® No
5. Is the impoundment designed to receive surface runoff? ❑ Yes or ® No
If yes, what is the drainage area? ft2, and was this runoff incorporated into the water balance? ❑ Yes or ❑ No
6 If a liner is present, how will it be protected from wind driven wave action9-
7 Will the earthen impoundment water be placed directly into or in contact with GA classified groundwater? ❑ Yes or ® No
If yes, has the Applicant provided predictive calculations or modeling demonstrating that such placement will not result in a
contravention of GA groundwater standards? ❑ Yes or ❑ No
8. What is the depth to bedrock from the earthen impoundment bottom elevation? ft
If the depth to bedrock is less than four feet, has the Applicant provided a liner with a hydraulic conductivity no greater than
I x 10' cmis? ® Yes, or ❑ NIA
Has the Applicant provided piedictive calculations or modeling demonstrating that surface
water or groundwater standards will not be contravened? ❑ Yes or ❑ No
If the earthen impoundment is excavated into bediock, has the Applicant provided predictive calculations or modeling
demonstrating that surface water or groundwater standaids will not be contravened? ❑ Yes, ❑ No or E NIA
9. If the earthen impoundment is lined and the mean seasonal high water table is higher than the impoundment bottom
elevation, how will the Inver be protected (e g , bubbling, gioundwater infiltration, etc.)?
10 If applicable, provide the specification page references for the liner installation and testing requirements,
1 l . If the earthen impoundment is located within the 100-year flood plain, has a minimum of two feet of protection (i e , top of
embankment elevation to 100-year flood plain elevation) been provided? ❑ Yes or ❑ No
12 Provide the requested earthen impoundment design elements and dimensions.
Earthen Impoundment Design Elements
Earthen Impoundment Dimensions
Liner type:
Cl�y ElS
Top of embankment elevation:
ft
❑ Other ❑Unlinlineed
El Other
Liner hydraulic conductivity
x - cm/s
Freeboaid elevation-
ft
Hazard class-
Not Applicable
Toe of slope elevation:
ft
Designed freeboard:
2 ft
Impoundment bottom elevation-
ft
Total volume-
327940 W
2452997 gallons
Mean seasonal high watei table depth-
8 ft
Effective volume:
2981,2$
ft
230000 gallons
Embankment slope-
4 : 1
Effective stoi age time:
46 days
Top of dam water surface area:
39204 ft2
Plan Sheet Reference•
Freeboard elevation water surface area-
38224 ft2
Specification Section-
Bottom of impoundment surface area-
21122 W
NOTE — The effective volume shall be the volume between the two foot freeboard elevation and the: (1) pump intake pipe
elevation; (2) impoundment bottom elevation or (3) mean seasonal high water table, whichever is closest to the two foot
freeboard elevation.
FORM; W WIS 06-16 Page 8 of 12

VII. IRRIGATION SYSTEM DESIGN CRITERIA— 15A NCAC 02T .0505:
I Provide the minimum depth to the seasonal high water table within the irrigation area: 8 feet average over all fields
NOTE — The vertical separation between the seasonal high water table and the ground surface shall be at least one foot.
2. Are there any artificial drainage or water movement structures (e.g., surface water or groundwater) within 200 feet of the
irrigation area? ❑ Yes or ® No
If yes, were these structures add►essed in the Soil Evaluation and/or Hydrogeologic Report, and are these structures to be
maintained or modified?
3 Soil Evaluation recommended loading rates (NOTE — This table may be expanded for additional soil se► ies):
Fields within
Recommended
Recommended
Annual /Seasonal
If Seasonal, list
Soil Series
Soil Series
Loading Rate
Loading Rate
Loading
appropriate
appropriate
in/hr
r in/
Lynchburg
5-1, 5-3,
26
Annual
5 -4'
Bonneau
4
26
Annual
Select
Select
Select
Select
4 Are the designed loading rates less than or equal to Soil Evaluation recommended loading rates? ® Yes or ❑ No
If no, how does the Applicant intend on complying with 15A NCAC 02T 0505 n ?
5. How does the Applicant propose to prohibit public access to the irrigation system? Signs are posted. The plant area has
guards on duty
6 Has the irrigation system been equipped with a flow meter to accurately determine the volume of effluent applied to each
field as listed in V1I.8.? ® Yes or ❑ No
If no, how does the Applicant intend on complying with 15A NCAC 02T .0505(t)?
7. Provide the required cover crop information and demonstrate the effluent will be applied at or below agronomic rates:
Cover Crop
Soil Series
% Slope
Nitrogen Uptake Rate
Phosphorus Uptake
lbs/ae r
Rate Ibs/ac r
Coastal Bermuda
Lynchburg
158.9928
92
Grass
Fescue
Lynchburg
158.9928
65
Winter Wheat
Lynchburg
a. Specify where the nitrogen and phosphorus uptake rates for each cover crop were obtained: Hand auger samples
obtained from spray fields.
b. Proposed nitrogen mineralization rate•
c Proposed nitrogen volatilization rate.
d Minimum irrigation area frorn the Agronomist Evaluation's nitrogen balance ft2
e Minimum irrigation area from the Agronomist Evaluation's phosphorus balance: ft2
f. Minimum irrigation area from the water balance: ft2
FORM- WWIS 06-16 Page 9 of 12

FORM: WWIS 06-16
Page 10 of 12

VII. IRRIGATION SYSTEM DESIGN CRITERIA —15A NCAC 02T .0505 (continued):
8 Field Information (NOTE — This table may be expanded for additional fields) -
Field
Area
(acres)
Dominant
Soil Series
Designed
Loading
Rate
in/hr
Designed
Loading
Rate
inl r
Latitude "
Longitude"
Wat
Stream Index
Inds
No. b
Classification
4
997
Bonneau
26
36 000107
-76.720816'
25-24
C. NSW
5-1
564
Lynchburg
26
35 990627
-76.7200980
25-25
C: NSW
5-2
5 9
Lynchburg
26
35,990797
-76.7188000
25-25
C• NSW
5-3
564
Lynchburg
26
35.990448
_76 7169260
25-25
C NSW
5-4
5.73
Lynchburg
26
35,999974
-76 715829"
25-25
C. NSW
o
a
0
n
0
0
o
a
q
o
q
o
0
0
0
a
0
0
0
0
0
0
4
D
O
O
O
�
O
O
Total
a Piovide the following latitude and longitude coordinate deteimination information:
Datum. UnknownLevel of accuracy. UnknownMethod of measurement. Man interpretation by extraction
h For assistance determining the wateibody stream index number and its associated classification, instructions may be
downloaded at- http•//deg nc Gov/about/divisions/wate-resources/planning/elassification-standards/classifications
FORM- WWIS 06-16 Page I I of 12

Spray Irrigation Design Elements
Drip Irrigation Design Elements
Nozzle wetted diameter:
86 ft
Emitter wetted area-
ft2
Nozzle wetted area:
5873 R2
Distance between laterals:
ft
Nozzle capacity:
12.1 GPM
Distance between emitters.
ft
Nozzle manufacturer/model-
Senninger / 7075RD-IEFF
Emitter capacity:
GPH
Elevation of highest nozzle:
6 ft
Emitter manufacturer/model:
/
Specification Section:
5-1
Elevation of highest emitter,
ft
Specification Section:
VIII. SETBACKS —15A NCAC 02T .0506:
I Does the project comply with all setbacks found in the river basin rules (15A NCAC 02B .0200)? ® Yes or ❑ No
If no, list non -compliant setbacks.
2 Have any setback waivers been obtained in order to comply with 15A NCAC 02T 506(a) and .0506 b ? ❑ Yes or ® No
If yes, have these waivers been written, notarized and signed by all parties involved and recorded with the County Register of
Deeds? ❑ Yes or ❑ No
3. Provide the minimum field observed distances (ft) for each setback parameter to the irrigation system and treatment/storage
units (NOTE -- Distances greater than 500 feet may be marked NIA):
Setback Parameter
Irrigation
System
Treatment /
torn a Units
Any habitable residence or place of assembly under separate ownership or not to be
maintained as pan of the pr9ject site
465
NIA
Any habitable residence or place of assembly owned by the Permittee to be maintained as
art of the r9ject site
N/A
Any private or public water supply source
140
N/A
Surface waters (streams -- intermittent and perennial, perennial waterbodies, and wetlands)
N/A
NIA
Groundwater lowering ditches (where the bottom of the ditch intersects the SHWT)
N/A
Subsurface groundwater lowering drainage systems
N/A
Surface water diversions (ephemeral streams, waterways, ditches)
N/A
Any well with exception of monitoring wells
NIA
Any property line
150
Top of slope of embankments or cuts of two feet or more in vertical height
90
Any water line from a disposal system
NIA
Any swimming pool
NIA
Public right of way
150
Nitrification field
N/A
Any building foundation or basement
377
Impounded public water supplies
N/A
Public shallow groundwater supply (less than 50 feet deep)
N/A
4. Does the Applicant intend on complying with 15A NCAC 02T .0506(c) in order to have reduced irrigation setbacks to
property lines? ❑ Yes or ® No
If yes, complete the following table by providing the required concentrations as determined in the Engineei ing Calculations:
FORM. WWIS 06-16 Page 12 of 12

Estimated Influent
Designed Effluent
Designed i✓ftluent
Parameter
Concentration
Concentration
Concentration
(monthly averse(daily
maximum
Ammonia Nitrogen (NH3-N)
mg/L
mg/L
mg/L
Biochemical Oxygen Demand
mg/L
mg/L
mg/L
BODS
Fecal Coliforms
per 100 mL
per 100 ml.
Total Suspended Solids (TSS)
mg/L
+
mg/L
mg/L
Turbidity -+
NTU
FORM: WWIS 06-16 Page 13 of 12

IX. COASTAL WASTE TREATMENT DISPOSAL REQUIREMENTS — 15A NCAC 02H .0400:
1. Is this facility located in a Coastal Area as defined per 15A NCAC 02H .0403? ❑ Yes of ® No
For assistance determining if the facility is located within the Coastal Area, a reference map may be downloaded at- Coastal
Areas Boundary.
2. Is this an Interim Treatment and Disposal Facility per 15A NCAC 02H .0404 v ❑ Yes or Z No
NOTE — Interim facilities do not include County and Municipal area -wide collection and treatment systems.
IF ANSWERED YES TO ITEMS IX.1. AND IX.2., THEN COMPLETE ITEMS IX.3. THROUGH IX.17.
3. Is equalization of at least 25% of the average daily flow provided? ❑ Yes or ❑ No
4 How will noise and odor be controlled?
5. Is an automatically activated standby power source provided? ❑ Yes or ❑ No
6. Are all essential treatment units provided in duplicate? ❑ Yes or ❑ No
NOTE --- Per 15A NCAC 02T..0.103(16), essential treatment units are defined as any unit associated with the wastewater
treatment process whose loss would likely render the facility incapable of meeting the required performance ciiteria, including
aeration units or other main treatment units, clarification equipment, filters, disinfection equipment, pumps and blowers.
7 Are the disposal units (i.e., irrigation fields) provided in duplicate (e g , more than one field) ❑ Yes or ❑ No
8 Is there an impounded public surface water supply within 500 feet of the wetted area? ❑ Yes or ❑ No
9. Is there a public shallow groundwater supply (less than 50 feet deep) within 500 feet of the wetted area? ❑ Yes or ❑ No
10. Is there a private groundwater supply within 100 feet of the wetted area? ❑ Yes or ❑ No
11, Aie there any SA classified watei s within 100 feet of the wetted area? ❑ Yes or ❑ No
12. Aie there any non -SA classified waters within 50 feet of the wetted area? ❑ Yes or ❑ No
13 Are there any surface watei diversions (Le , drainage ditches) within 25 feet of the wetted area? ❑ Yes or ❑ No
14 Per the requirements in 15A NCAC 02H .0404(a)(7), how much green area is provided? — ft2
15. Is the green Mica clearly delineated on the plans9 ❑ Yes or ❑ No
lb. Is the spray irrigation wetted area within 200 feet of any adjoining propertiesh ❑ Yes, ❑ No or ❑ NIA (i,e., drip irrigation)
17. Does the designed annual loading rate exceed 91 inches? ❑ Yes or ❑ No
FORM. W W IS 06-16 Page 14 of 12

Professional Engineer's Certification:
1, attest that this application for
(Professional Engineer's name from Application Item 111.1.)
(Facility name from Application Item II,1.)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans, specifications, engineering
calculations, and all other supporting documentation to the best of my knowledge. I further attest that to the best of my knowledge the
proposed design has been prepared in accordance with this application package and its instructions, as well as all applicable regulations
and statutes. Although other professionals may have developed certain portions of this submittal package, inclusion of these materials
under my signature and seal signifies that I have reviewed this material and have judged it to be consistent with the proposed design.
NOTE -- In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000, as well as civil penalties up to $25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date:
Applicant's
(Signature Authority's name & title from Application Item I.3.)
, LL C.
(Facility name from Application Item 1I.1.)
that this application for
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that any discharge of wastewater
from this non -discharge system to surface waters or the land will result in an immediate enforcement action that may include civil
penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition
of this permit be violated. I also understand that if all required parts of this application package are not completed and that if all required
supporting information and attachments are not included, this application package will be returned to me as incomplete. I further certify
that 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 per 15A NCAC_02T .0105(e).
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 eivil.pgn�ilties�_p to $25,000 per violation.
Signature: /A/ /J4— Date: ` 0 ~ 9 _ C�2_0
FORM: WWIS 06-16 Page 15 of 12

WELL ABANDONMENT RECORD
I. Well Contractor Information,
Stuart Spruill
%Pell Conulictot Mmic (or Nrll u%%ner per<uudIN abandonu,c %Nell vn I,n'lieI propen) i
2193-A
N( NVe I It onrr actor Ccrtif Ldlsin Nwi*@r
SGI
Cumplily me
2. Well Construction Pertnit N:
Iistscllapptcahlri,'alltonstlnerianPC' mItc(ir VIC Cumin' Sfnre 1'arlanv e etc)ilAltnan
3. 1N ell use (check %+ell use):
Water Supple Well:
C.Agncullura)
O'NNnICIpal, pobbC
UGcotherrital (He.tung'Coolmg Suppls)
GR, timdeutial %Pater Suplty (cingic)
C hsdustnal,'(Coninielcial
❑Residcnwil 11 alcr Supply (shared)
Mirrigalion
Non -Water Supply Well.
PINIonitonng
GRecovery
Injection Well•
PAquifer Retliarge
❑Gruund%%atcr Remediation
©Aatuif" Stotage and Recovery
ClSahntty Bart ici
FllAgmtcr Test
?Stonuwater Drainage
❑Evpcirunental Tctlinologv
MSubstdcnce C nntml
0Gcollicimal (Closed Loop)
Cs rraeer
176tolhclitial (I-icanngfiooling Relum)
001ber Ie%P),un undo 7g)
4, pate well(sl abandoned: 08107/2020
5a. Well locationi
Ashland, LLC
l;ttirli[y/Osoncr yante iacilety IDA, (11aplibcable)
841 Acoca Farm Road, Merry Hill 27957
1`11s' tal Address, C'il), and lip
Bertie
Covinty
Parcel Identirtcatton No (PI\)
ib, Latitude and longitude in degrees/minuceslseconds at decimal degrees:
(it Nell treld one lattlong to auffmcw)
36.000678 N 76.715433 NNI
CC)NSTRUCTION DF.TAILS.t)1: WEI I (S) R IN'12 ABANDON- I)
drtrrthirell cnrlSnr4coonretutd(s)1latarldhle formalrip.'errPeCk"rinrrioii-r,a'<veyiffi,telk
DAf.I' wrls the inrrir cnra%tnrcnon'ah.enitannicnt um r cen urhner one tn+rn
6a, Well IDN: MW-4
6b. Total %%ell depth: 20 (ft.)
6r. Borrbole dinmrfer. N/A _(ill.)
6d, Water level below ground surface: NIA
For h,Ecn, sl L,e OM }
\8TI Is AItANDt]NIIFNT U; .I1.S
7a. For Geoptobe/DPl' or Closed -Loop Geothermal Welli ha%,mg tilt sarric
wcil construction/depth, only I (;W-30 is needed lodicaie T01 AL NUMBER of
€veils abandoned
7b, Approxini.tte %olume of %vales iemaining In s%cll[s): (gal.)
t'C)R NVA`1 ER SUPPLY WELI S ONLY:
7c. I ype of distnfectant used:
7d. Amount of disinfectant used:
7e. Seating materials used (clieck all that apply):
* `'eat Cement Grout
A Bentuntte Chips or Pellets
to Sand Cement Grist%
Ll DrN Clay
91 ('ontrek, Clrout
Ci DriII Cut un6a
© Special(),(Irow
7 (irdyel
C Beniomte Slurry
L3 Other (explain under 7g)
71'. For each material selected abme, provide amount of materials used:
15 lb bentonite
5 lb concrete
7g Provide a brier description of the abandonment procedure:
Poured bentonite chips to three ft from land surface.
Top 3 ft concrete. Did not remove 2 ft stick,
but filled stick up with concrete
S. Certificatlun.
_ [ 08/07/2020
Signature of Cenitictlll e onir.�,r, R'eIl ONner�atc
Rv v ning this form. I herehv eemty that the xe11(3) ttac fitete) abandoned in
accotdunve mth 13,t .`rC1C 02( 0106 or 'C 0200 JFell Cortstrvclum Standen&
rand chat a cop% of rho terotd lurs 1?eeo provided fo the b ell owner
9. Site diagiam or additional %Nell details:
You may use the baLk of this pate to providt additional well site details or well
abandonnicnt dclails You ntay also attach additional pages if accessary
SIIISt1Il ITAL INSTRUCTION
10a Far All NVeils: Submit :l,ls fonll within 30 days of completion or well
abandoninenl to lb,: Inllowing.
Dt%ision of water Resources, Ittfoi oration Processing Gait,
1617 Mail Set %tee Center, Raleigh, NC 27699-1617
IUb For Iniection \Veils• In addittuii to cctidim, die finnu to the addres5 In 10a
ahove, also xihnut one cop, tit thtc firm u•Ithin 30 days tit complown of well
abandonment to the following
DiNtsion of Water Resources. Under ground Injection Control Program,
1636 flail Service Centel-, Raleigh, NC 27699-1636
6e. t)utei casing length (if kno%vri): _(ft,) We. Foi Water Supplti & Injection Welly In addition to seriding the forin to the
nddre]a(eA) above, also subFivi one copy of tilts forin within 30 days of complelton
of well abandoninew to the couritr health department of the county where
6f. Inner casing/tubing length (if known)- 5 (ft.) abandoned
Cig Screen length (if kno%%tt): 10 (ft }
Fnrn, C.\l'-ln ',onh CarotIna D) partmcM of I nv;ronnxntaI QnnIi;y i)i%I,iiw of IS aicr R0u ktr« Rc, twit 2-22.2016

WELL CONSTRUCTION RECORD (MV-1 )
1. Well Contrmlui Wrol Illation
Stuart Spruill
Pn ]ntcnlal t
14.%VAlERZO
"-'—_
11'�II Co„naclP, Name l
2193
N( \Veil t'Inlydpot C Mf,.ali'M Nun Ebro
SGI I
PROW Trj
�""
--
ft
11. OU l ER CAI
rRom TC
I )nlp'lly Name
2, Well Conitrucnon Pernllt #'
It,lulluppfiahl,u,llunEanr.uonArrant,raa f1C tmint, Sex, 1'vrruE., ,r,l
3 Well C w (cheep is ell use).
16 INNER CAA
FRCI\I if,
3 rill 10
ft'
Water Supply Well,
DAE,€Icultural
DSluniclpal Public
❑Creothemial (Healing Cooling Supply)
LjR,+l&lltlal \\'atcl Supply [,nl Icl
Dllndu,ulal Commercial
17Re,ldentr,d Witer Supply [,Il�ied)
131m arum
❑W01, - I 0 00O GPD
Non-Waler Supply Well,
('N oni [itri np,
L] R ecovety
Rejection Well.
rlAqulfer Rediarye
E:Ground'sater Remect Ilion
0AqulfcrStnravcand Re�nlcn'
CSAmil) Banter
CtAqutler 1 est
rSlormtlaler Drainace
OMpenniewil Technology
C\ubvtsC11cc omr"I
L U adiernial (Coned Loup)
E I racer
❑Ciectliennal (He,rling,CrR1hng Retuni I
EOiliet (e,,plaln under =121 Rcmar{ sl
J, Date Well(,) Completed: 9/ 13/19 „ell I IM M W 10
5a Well Location:
Avoca Farms
Fa,llin 05 t rier Nanse Fa,dlh I€ la i tr ot,RE ,.,hie1
841 Avoca Farm Rd,, Merry Hill, NC
Fbs.lcal Address, C,it irli �Ip
Berle
,e 0 11
ni,t RfPI 11\
1G r n1u1r1-cased µell OR 1,11;ER (if i IkcdU
M ILMI'I1R THl(
in,
E
sIG r1 Tt;tit,'{i (�euthr nt:,k t:l,tsed�luup�_ _
nlisl F.1FR TIHECr:\E.Si 11l
j2 'nSCH40 IPV
Ill,
Ill i\ri_FIR Si..tTl,l/F TRtCK-,ISC
10 ft• 20 ft, 2 n � 10 ISCH40 i C
H. 10 tt. iII
p n, I2
2 tt 110
Cement Poured
Bentomite _ Poured
10 f' 20 ' 1#2 Gravel jPoured I �I
rt I It I
FRu\I TO
0 1t `2
2 rr: S
8 rr. 10__.___
10 (' 15
15 H 117
17 fr. 120
Spanry l'a,c[I Lit,,ofienoon 1p tPINI
5b, Latitude and longitude bi dcgrce,fnlillutci/seconds of dcctntal degrees
idwell field, one Iat long I, wffittcnt} 22, Certification
35.991725° , 76.719269°
6. IS(nrc) the Iicll(s), t"Verinauenl of CtTenipof af-N
7, Is tltts a repa i 16 an c\littug dell. EA cs ur JNn
Iflhnlr,il,rart 1111olainmvl,,,1,ontuu,lh,lE+nh�rnaunnat,fr,�v;nrt�Ilnnalrrr,pld,,
Iej4urww,r -Irem am4d ".r-o"wnnthe hr,{nJdvrkor+I
5. Foe Geopi abelDPT or Ctased-Loop Geothermal \\ ells having Illc 4anle
cunstruction only i OW -I is needed lndicilc TOTAL N11,N1BCR of well+
drilled _
9 Total s+ell depth beloss land surface 20 (fl }
Fe, rrrulnpl, uc11, !rs! rat! d,prh, EJ d,fl,', cni r, tan ph i,4200 and : 10u1',
ill. Static Hater le4'el belnm lop of eairllg' (ft j
!I),art, 1c1e1 a rlho,r ulsatg, uae r
11 Boi choic diameter' 5 5 (in }
12 Well conittucttnumetliod,Auger
it a aug,r, rolm, ,al•Ic duet, pu<h, tic I
FOR 1v `t'l rR SL'PPI,1' \1 FIA.S ONLY,
13a, Yield (gpni) Method of test'
136 iiisinfcctinrr €rpN \Inonot
Drk Brwn,©rganic Soil
Brwn F-M'Sandy SILT
Lt Brwn F-M Sandy SILT
LLt Bfwn Silty F-M SAND
jTan Sllty F-M SAND
(Gray Sl1ty F,M SAND
_ 9/1312019
Sig laauu Ili C e wiw,1 1 nnwlct,�r 1?ate
Bv,,r{nn,g dr., f„nr, 1 n, e hi , roll rhal (be v a, ru, nr , nrr+lru, red rrI a ,.nrrknn r "fill
1i( W (r 02( 1,M0or °4 1't (C 117C 0200 ti,li 6, 0E,Efm,iSf,,idv<is,w(Char,t,sps
„t rirn re "d in, hr�n 1E, , E,i-d rn If',, a,-11 ns' n r
23, Site dia#jrant or a dutanal ,e ell detp is
Yuu may use the hacl of thl, pe,c to pro%i& additional %Nell consti udion Inl„
(ddd °Ste fli er' III Rem i Boni You m,tV oko ,rti,l�- h adthlirul<Il P,tj_reN If ncCc„aty
,
24, SLIBMII TkL 1\ I RUC I lO\S
Submit this GNk-i ssi tun all da1'c orsseli completion per the follo kng:
last Fill 111 1Sells, Vllgiu.,l form io Dmslon of Water Resou -es (DWR1,
Information PruLIeNSUI UniE, 107 hiSC, Raleigh itiC 276119-1617
2411 For lu ection \\ ells, l Gp} to DWR, Undergmund Inlectn,n o€ltrol OUC1
Pregrarn, l f,16 'N1t , aleigh, N1( 27699- I b36
24c. For Water Su 13 and Upeo-Lonp Geothet trial Return C op, to the
county cmirvnrtunlai ie,tllh department of the county where u1statit
Nd. I or \1 ater li ell i producing user, to' AII(I GPf]. Copy to D1\ R, r CITUA
Pefrilil PrrocrIi-1 It,li F(-, R<ticq�l,M 'il,yrl-kh1I
Form (,W-I \,)rib Caro:mi Depnr(n,,nt of Lm aonnE,ntal Qdahty DI' ,5E0a p; 1t. kr i(,,,,llr„! R+Esed 6-6-2111 h
0

WELL CONSTRUCTION' RECO111) (G1i'-I)
1,1vell(onllaelor lnforinalltin:
Stuart Spruill
t;rell CConlra�lryt haute
2193-A
�CiS'cn Cornrtctor C tfljhsallnn \mnbci
SGI
compan) Vaine
2, Well Construction I errnit 4.
1 w di apph rrhle t,df u,>+unrc udu frrnirR (I r t'!r r Dunn' Srul, t urrun, e r & J
3, 1Nell V',eOlieel.well nx).
ales SUPPIrISell.
AgtnOWT-,)l \lnmtipa#r`i'uhhc
l,eothenna€ I Ele,tun=ltonlrng'+apple I [ 1Rt idential Water Sllpl>h (singlet
InduUnailCommerctat [3IGemde%tlal Wnler Surpl} l%hrared)
6Non-Water `iupp1% NNeII-
x Nlmnuxmg [)Ruo%,r)
Aquifer Recharge
AclUtfer Storage and Re,vver�
AgUit'er Tc it
F%po imental rechnalargt
C,eolhenwl(Clo%ed Loup)
Geotbennal (Heaung—lCuohng
E)(3F0u11dt%a1Cr ReMWJIAWM
oSalrnlo RalrICT
QStonomiler Dr,kiltapc
[3Subsidence Control
Tracer
ul tinder 421
d. irate Wei(5) (otopleted 06l0512020 W011 ll)g mw-11
,t a. Well Loelidon.
Ashland LLG
#`ngfif)1OwnCr Nan f .3tdihr IDa (I fapph, rhlet
841 Avoca Farm Road Merry Hill 27957
Ph"cnl Address, C sty, and Lp
Be_rtie
Counh i'arcei Ideniificatton Ai, INN,)
Sb. I ;itllude anrd longitude In degreetlnmuteslseconds or dccttnal degrees,
rlf,cctl field nne lau)nng is su€fmcn1)
36.000478 N 76, 717562
6. Is(ale) the %%ell(s)ox Permanent or [31 emporari
'. Is (tits a repair to art e.5€sting %tell: Dies or lflo
It rLn rc n rrrmr, jd1 "d An,nin a ell „,o uc ion 01117+rnelaar4 011,E, I pr,Ior lfrr 1,10- r1f rhr
rep,rlr raider , 21 remark% wi Irmr or un the hock nt rhit lnrm
s I'nr' Geoprobe/DP 1 or ( lased-T oop (,colhcr coal Wells hat mg the same
t(Inctruclion, onl) I GIB--1 13 needed Indmak 1 Ul Al NNUL113LR of'%%ells
drilled
9. Iolal xell dcp(h bcims land surface. 22
J ar nnrbiple w1A hw aft ,kprhs +i def rent 6 rampFe. j ly 20) wnl hadw)')
Print form
70calul IiSc (}nd)
la, U ATER ZO1 r-S
IRMI
TO
DEsCRIPIIOS
ff,
f1
fr,
ft,
15, OV MR. CASING; I for could -case) nelta OR LL,'�L:R(if si1 livable)
F ELU51
TO DtAt{FTCR TNf4i�\ESS i ttATCit1%I
ft
fl, In
16 USNER CASING OR
9-UBING entherinat closed-w I
Illy M1l 10
UTA ME FFR Ili It R1FCS
I MATFRI
+3 it 7 fl
2 Scfl 40
PVC
fi sl.
1t5
I7- SCREEN
IRO%1
TO I
DIA%t(TFR
I St.OTS17r,
I rrncksrrs
I mATFRIAI.
7 It
22 ft,
2
10
sCh 40
PVC
fl.
ft,
in
IS. GROUT
PROM
it 7
%IAIk. AI
L"P1 A( FSIF„ST,1lLt110D,C A,Stbl'11
3 fr.
5 fr.
bentonitr
poured
0 f:
3 ft
concrete
poured
fc.
sa-
19, sANarGRAVEL PAC K iru liable
i RO%!
1 TO
1 AIAUR1AI
Ltk Pi ACFNr\7 trFTROD
5 it,
22 f'
#2 sand
poured
fr.
h
20, DRILLING
LOG [attach addid(m-1 sheets Ifneccssa
FREM
w
nCSCRIPTIR1(rnlor, hwIntm so,unrrk , ra4—hw,cm
0 fr
3 f'
Br clayey sandy! silt
3 ii.
11? fr.
br silt F-M sand
13 r`
Red brown sandy sift
13 ri
22 11
It brow silty fine sand
ft,
fr.
ft
r1.
1`4
it
21. REMARKS
22 Cerhf(catlon•
06/08122
Sienlluc ef( crdi le C1l nrra,w Paie
Hi ,n mrl'fln, 1,rn, I hereny cerwt drr the r-elMi uaor ero rornrrucled IrrprcgrrlIMV
a ah ! s, Vi 4( 1).(- 6100 of l 14 %( 41 02( 10A) Wet; (nnifrtn rt,rn Arruriar,h dm! drat a
al um n'I "I'01ul he , n f rnti lrkd f0 Tilt ft of l m, rr. r
23, Sile (Itagrain of Rddltmaat xell delolI,:
)'Oil may Use lh1 bdc1, ai Ibis page io prat ide aJdilional ,sell she doaik or uelf
consinicuon delalls Von mat alto altach aI Idlttonal pages if netessan,
S,tBmt7-f V INSTRI-(•i'1ON
24a For All Wcbs: S,ib,m( This torn! wnlnn V) dais of completion of %tell
tonatrttctlon to the rollo%%wg
10. Static water le%el bolo» tup of using, (ft 7 DIVISIO0 of 15 ater RcsaUrM, IFtforomIion ProcetSntg I nit,
!1l,we? lr+e1 n nGd+e „ntrrp, ire 1617 ,\lail Serf ice Center, Raleigh, NC 2?699-1617
11 borehole diameter, 81 /4 (in ] 24h, I -or lnj.gsqin.%VvlI . In iddi:ion to tiunding, the form to the addresS In 24a
Auer ,tt:ove, al5n auhmil one cope of thl% form within 30 days of completion of %%ell
12, Well consti nttlon method' _- constr rct%ot%to the 611lousna
c auger roram, cable, direst push et, )
Dn rtlon of L1 ater Resom ces. f nderg,r onnd 1 njeetion Control Pt ogt arn,
FOR WATER SL PPLY WELLS ONLY: t436 Mail lcniee Ccntei, € atviLh, \C 21699.1016
13a, Yield (kpm) Method of (eal: 24c. ),or !later t+rr t )I% sC Tit ectlon 1%oils: In dddluon to scnduig the loan to
the,, addte{s(csl above also soma one cop) of this lone \xithm 30 days sit
13h, nklrfeetion 1)pe: !mount compleuon of :%ell construction to the county health department of the county
%there tunstntcted
Forino%% I h`oir6(srnhniDcpanrn,nt ,ftmironmenolQoala}-Dw9 wrtOlt%aterRe,nurc,r% Re,ned222.2u16

A SURVEY AND SXf7CH S40AW0 GROUNDWATER M6WRORING
WEL. E47A AND AS'OMMO CONIROL NaWtWX
AWC4 WC.
MERRY HILL TOWNSHIP — BMPE COLWIY — NORTH CAROLIM
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