WQ0016247_More Information (Received)_20210930

SYNAGRO
YOUR PARTNER FOR A CLEANER, GREENER WORLD
September 30"', 2021
N.C. Department of Environment and Natural Resources
Division of Water Resources
Water Quality Permitting Section — Non -Discharge Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
ATTENTION: Erick Saunders
REFERENCE: Additional Info - WQ0016247
Synagro Western Piedmont Class B
Mr. Saunders,
Please see the below items in response to a request for additional information received via email
on Friday September 24, 2021:
• Due to recently changed cropping patterns fields CL-21-03 and CL-21-04 will no longer
be requested as transfer fields. Additionally, a redefined compliance boundary is not
needed for the remaining fields. Amended maps for the entire CL-21 site and an update
LASC are included to reflect this request.
• Field LT-32-04 has been amended to include 400-foot offsite house buffers as opposed to
the previously submitted maps. Because of the additional buffers, new maps along with
an updated LASC reflecting the change in acreage is attached.
• A scan of the LOA for site CH- 101 which now includes my signature is attached.
• Additional redefined compliance boundaries were needed for several fields. The note
detailing the location of the needed boundary are below for each field. Also updated LOA
scans are attached which now include the request for each boundary. .
o NC-LT-32-1A,3: A redefined compliance boundary is requested for this site. The
redefined compliance boundary is centrally located between these two fields.
o (NC-CH-60-03) — The redefined compliance boundary shall be located west of
the on -site water supply well located to the east of NC-CH-60-03 and south of
Elmer Moore Rd.
o (NC-CH-60-11) — The redefined compliance boundary on LuAnne Moore's
property is located northwest of the on -site water supply well located to the
southeast of NC-CH-60-11 and east of Barker Rd.
Please let me know if you have further questions or comments concerning the provided
information.
Technical Services Manager

State of North Carolina
DW,tR
Division of Water Resources
Department of Environmental Quality
Division of Water Resources
LAND APPLICATION SITE CERTIFICATION
INSTRUCTIONS FOR FORM: LASC 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 certification provides detailed information of 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 certification for review
without a corresponding application form (FORM: RLAP 06-16 or FORM: SDR 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Application Site Certification (FORM: LASC 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.
® For new or renewed permits, submit the requested information for all land application sites.
® For modified permits, submit the requested information for only those sites that are new, transferred or affected by the
proposed modification.
B. Land Application Site Information:
® The status of the land application site with respect to this residuals land application program must be provided in table I. The
status categories and their corresponding codes are as follows:
♦ New (N) ♦ Renewed (R) ♦ Modified (M) ♦ Transferred (T) ♦ Deleted (D)
® Attach the following in accordance with each status code:
Status Code
Required Item
N
R
T
M
County Board
Notification.doc
W l
TLI✓
✓
✓
Land Owner
Agreement
(If applicable)
w
Setback Waiver
Agreement
An updated vicinity/setback map in accordance with the "Map Guidance
✓
✓
✓
for Residuals Land Application Permits"
A soils and agronomic evaluation in accordance with the "Soil Scientist
✓
Evaluation Policy"
INSTRUCTIONS FOR FORM: LASC 06-16 Page I of 3

An updated accounting of the land application site's cumulative
pollutant loading rates CPLRs
Status Code
Required Item N R T M
For previously permitted sites without a soil series name indicated in the
Attachment B, submit County Soil Survey Map (or equivalent) clearly ✓
indicate the location of the land application site and in accordance with
the soil map requirements in the "Soil Scientist Evaluation Polic "
Acknowledgement of field transfer from Land Owner (Fields may not
be permitted to multiple Permittees over the same timeperiod)
* This item may be required for land application site with a status code "M", please contact the Division if you need assistant in
determining attachment requirements.
® Crop Type should include the most likely crop types for the life of the permit (five years).
® Predominant Soils Series Name must be either the name of the soil indicated in Attachment `B" of the existing permit, or
name of the soil series as provided by the licensed soil scientist.
® Predominant Soil Mapping Unit or Representative Slope: Either the Soil Mapping Unit or the representative slope of each
site must be provided. The predominant soil -mapping unit must be consistent with the predominant soil series name. Please
note that the soil mapping units are variable between Counties, so care should be taken in properly identifying the correct
mapping unit. If a representative slope is provided, it must be determined accordingly:
® For sites previously permitted for use, but do not have an established soil mapping unit (the mapping unit provides
information on both the soil series name and the slope of the soil), the Applicant may determine the representative slope
by using the average slope provided in the County Soil Survey (or equivalent). A soil type with a slope range of 4 - 8%
would have a representative slope of 6%.
® New Sites to be permitted must have slopes determined as part of the soils report prepared by a licensed soil scientist.
® Acceptable methods for determining location coordinates (i.e., latitude and longitude) and their corresponding codes are as
follows:
• Address Matching (ADD) • Digital or Raw Photo Extraction (EXT)
• Aerial Photography with Ground Control (AER) • Geodetic Quality GPS Survey (GEO)
• Cadastral Survey (SUR) • LORAN-C Navigation Device (LOR)
• Conversion from Coordinate Plane (CP) • Navigation Quality GPS (GPS)
• Conversion from Township -Section -Range (TSR) • Remote Sensing (RS)
• Conversion from Universal Trans Merc (UTM) • Zip Code Centroid (ZIP)
• Map Interpretation by Digital or Manual Extraction (MAP)
C. Waterbody and Classifications Information: (new sites only)
® Use an 8.5 by 11-inch copy of the portion of a 7.5-minute USGS Topographic Map to identify the location where the
residuals program activities are planned to occur as well as the closest downslope surface waters as clearly as possible. Each
map portion must be labeled with the map name and number, the identified location, and be of clear and reproducible quality.
® Surface water body classifications information may be found at: hiip://deq.nc.p-ov/about/divisions/water-
resources/pllanningJclassification-standards/classifications
® Any questions concerning the waterbody and its classification, please contact the Division's regional offices.
® A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
http•//deq nc aov/contact/regional-offices
® General Instructions: There are 17 river basins in North Carolina. Each basin has associated waterbodies with assigned
subbasins, location descriptions, stream index numbers and established classifications.
1. Identify the project area on a 7.5 minute USGS topographical map (an 8.5 x 11-inch sheet showing the project area
should be submitted with the permit application regardless of whether a Stream classification was completed).
2. Determine the names of all the closest down slope surface waters from the project site. For unnamed tributaries, see
Table 1: Unnamed Tributaries Entering Other States or for Specific Basin Areas. Label any unnamed tributaries as
"UT to stream name" as the waterbody name.
3. Open the link htip•//dea nc gov/about/divisions/water-resources/planning/classification-standards/classifications.
® Stream Classification Process: One of the options below may be used depending on the known initial project information.
® KNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Select proper basin from the List all Waterbodies in Basin sorted report. Sort hydrologically as this will provide
the proper location descriptions if multiple runs.
INSTRUCTIONS FOR FORM: LASC 06-16 Page 2 of 3

2. Locate the name of the identified waterbody (from General Directions) on the list.
3. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
4. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
® KNOWN COUNTY WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Select the proper county from the List all Waterbodies in county, hydrologically report.
2. Locate the name of the identified waterbody (from General Directions) on the list.
3. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
4. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
® UNKNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Use the Clickable basin map to hydrologically sorted list report.
2. Click on the approximate project location to bring up the hydrologically sorted list.
3. Locate the name of the identified waterbody (from General Directions) on the list.
4. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
5. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
® Notes on index number and unnamed streams:
Unnamed Streams 15A NCAC 02B .03016).
® Any stream which is not named in the schedule of stream classifications carries the same classification as that assigned
to the stream segment to which it is tributary (at the point of entry) except:
(A) unnamed streams specifically described in the schedule of classifications;
(B) unnamed freshwaters tributary to tidal saltwaters will be classified "C"; or
(C) after November 1, 1986, any newly created areas of tidal saltwater which are connected to Class SA waters by
approved dredging projects will be classified "SC" unless case -by -case reclassification proceedings are conducted.
® The following river basins have different policies for unnamed streams entering other states or for specific areas of the
basin:
Unnamed Tributaries Entering Other States or for Specific Basin Areas
Hiwassee River Basin
Streams entering Georgia or Tennessee shall be classified "C Tr."
Little Tennesse River
Basin And Savannah
River Drainage Area
Streams entering Georgia or Tennessee shall be classified "C Tr." Such streams in the Savannah
River drainage area entering South Carolina shall be classified "B Tr."
French Broad River
Basin
Streams entering Tennessee will be classified "B."
Watauga River Basin
Streams entering the State of Tennessee are classified "C."
Broad River Basin
Streams entering South Carolina are classified "C."
New River Basin
Streams entering the State of Tennessee are classified "C."
Catawba River Basin
Streams entering South Carolina are classified "C."
Yadkin -Pee Dee River
Basin
Streams entering Virginia are classified "C," and such streams entering South Carolina are
classified "C."
Lumber River Basin
Streams entering South Carolina are classified "C Sw."
Roanoke River Basin
Streams entering Virginia are classified "C." Except that all backwaters of John H. Kerr
Reservoir and the North Carolina portion of streams tributary thereto not otherwise named or
described shall carry the classification "B," and all backwaters of Lake Gaston and the North
Carolina portion of streams tributary thereto not otherwise named or described shall carry the
classification "C and B."
Chowan River Basin
Streams entering Virginia are classified "C."
Tar -Pamlico River
Basin
All drainage canals not noted in the schedule are classified "C Sw." except the main drainage
canals to Pamlico Sound and its bays which shall be classified "SC."
Pas uotank River Basin
All drainage canals not noted in the schedule are classified "C."
INSTRUCTIONS FOR FORM: LASC 06-16 Page 3 of 3

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GRAPHIC SCALE
1" = 4,000'
4,000' o a,o".a'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
N C-C L-21
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area, All
locations are approximate.
Fields 1,5-9

APPLICATION MAP
4'
L I k
s:
5
F
LEGEND
APPLICATION AREA UNSUITABLE AREA
- — — — — - PRIVATE ROAD C� WATER GRAPHIC SCALE
--'- •- - -- STREAM ONSITE HOUSE 1° = 660'
ssoe sir
-- DRAIN . OFFSITE HOUSE
FENCE ❑ OUTBUILDING
PROPERTY LINE 0 WELL
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within N C-CL-21
in the properly boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate, Fields 5 & 7

APPLICATION MAP
■
LEGEND
APPLICATION AREA UNSUITABLE AREA
- - - - - - PRIVATE ROAD WATER
GRAPHIC SCALE
— - STREAM ONSITE HOUSE
110 = 660'
eao
a s�
- --- DRAIN . OFFSITE HOUSE
FENCE ❑ OUTBUILDING
- PROPERTY LINE 0 WELL
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
N C-CL-21
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area, All
locations are approximate,
Fields 6,8-9

Q
Z
0
SOIL SURVEY
rl'
. 1 ^
-.: AV-
AW /�,4j
Wip v- g V
a
L
GRAPHIC SCALE
1" = 800'
800' a NO,
t
The com>liaace boundary Is established either 250 ft fiom the residuals appliration area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway betv.c on the compliance: boundary and the parinider of the residuals application araa, All
locations are approximate,
NC-CL-21
Fields 5-9

TOPOGRAPHIC MAP
Q
Z
}
GRAPHIC SCALE
V = 800'
!"YT a Rix
The compliance boundary is established either 250 ft from the residuals appliration area or 50 feet within N C-C L-21
in the property boundary, whichever is closest to the application area. The review boundary is establisher]
midway between the compliance: boundary and the porimctor of the residuals application iirea. All
locations are approximate. Fields 5-9

VICINITY MAP
LMt
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Z
UI
y„
G � s
41k.
90,
GRAPHIC SCALE
1" = 2,000'
The compliance boundary is established either 250 fl from the residuals application area or 50 feet within N C—LT-32
in the property 4oundary, whichever is closest to the application area_ The review boundary is established
midway between the compliance boundary and tho perimeter of the residuals applicrition area. All
locations Field 1-4
are approximate.

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0
}
APPLICATION MAP
LEGEND
APPLICATION AREA
UNSUITABLE AREA
— — — — — — PRIVATE ROAD CD
WATER
STREAM
ONSITE HOUSE
DRAIN .
OFFSITE HOUSE
FENCE
OUTBUILDING
PROPERTY LINE 0
WELL
The romplimce boundary is established either 250 ft from the residuals opplimlion wren or 50 feet within
in the property Mindary, whichever Is closest to the application area.
The review boundary is established
midway botwoon the compliana: boundary and the purimetor of the
residuals application area, All
locations are approximate.
GRAPHIC SCALE
1" = 660'
NC-LT-32
Fields 1-4

�'•� �41�-�'Lti
TOPOGRAPHIC MAP
GRAPHIC SCALE
V = 660'
Fi3U' U 6ri(i'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area, All
locations are approximate,
NC-LT-32
Fields 1-4

SOIL SURVEY _
1
r .R
ti. v� �T
r
GRAPHIC SCALE
1" = 660'
The compliance boundary is established either 250 ft from the residuals appliration area or 50 feet wilhin N C-LT-32
in the property boundary, whichever is closest to the applicalion area. The review boundary is establisher)
midway between the compliance boundary and the porimelor of the residuals application aroa, All
locations aro approximalo. Fields 1-4

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources
15A NCAC 02T .1100 —LANDOWNER 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 .1 100. 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: Synagro Western Piedmont RLAP
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:
Site/Field ID
Lease
Land Use or
Intended Use of Crops
Residuals Source
Special note
(no-till/over-seed/
(yes/no)
Cropping Patterns
(optional)
pasture)
NC-CH-101-1
N
Pasture
Grazing
NC-CH-101-2
N
Pasture
Grazing
NC-CH-101-3
N
Pasture
Grazing
NC-CH-101-4
N
Pasture
Grazing
NC-CH-101-5
N
Pasture
Grazing
NC-CH-101-6
N
Pasture
Grazing
NC-CH-101-7
N
Pasture
Grazing
NC-CH-101-8
N
Pasture
Grazing
NC-CH-101-9
N
Pasture
Grazing
NC-CH-101-10
N
Pasture
Grazing
NC-CH-101-11
N
Pasture
Grazing
NC-CH-101-12
N
Pasture
Grazing
FORM: LOA 06-16 Pagel of 3

NC-CH-101-13
N
Pasture
Grazing
NC-CH-101-14
N
Pasture
Grazing
NC-CH-101-15
N
Pasture
Grazing
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 2 of 3

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 Permittee 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 time 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 time 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 of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
H. 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 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 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are 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 are applied shall not be harvested for a 12-month period following a residuals land application event.
M. 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: NC-CH-101-5, 7
(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: NC-CH-10141-15) , is currently permitted under another residuals land
application program; Permit Number WQ: W00007066 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; W00016247
(Name of the new program)
FORM: LOA 06-16 Page 3 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: �,LC 4 � 'mot � cl ge,
P
Address:
City: P -- rr ���r eP��� State: N C Zip:
Phone: o +..��� & /7 (/3 E-mail address: �lcc /'i"► �o�(LILP� Q 1�'� �c �/ C'd "'t
Signature: Date:
NORTH CAROLINA, COUNTY
I, the undersigned Notary Public do hereby certify that a,' n-e_
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the ) 7
day of 16rC�
Signature and seal:
My commission expires: 30 20 Z5
Lessee's/Operator's Certification:
, 20,
* EW 9%M
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:
Address:
City: State: Zip:
Phone: E-mail address:
Signature: Date:
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: �4e C"
Signature:
Date:
FORM: LOA 06-16 Page 4 of 3

DW-R
_
Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
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 A 100. 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):
EY'S'ubmit the completed and appropriately executed Residuals Source 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.
repare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
plicant.
AA 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
fhe undersigned landowner or his representative herebyKr
mits:
Applicant's name: SS(AaA I'o t-4M441n
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:
Site/Field ID
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
,/Vo
I%
n.!
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:
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, 1636
Mail Service Center, Raleigh, NC 27699-1636.
5. The Permittee 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 of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
1I. 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 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 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are 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 are 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: L"r-32 - I A . 1;1-- 37- — 3
(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)
re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if n ded)
l"The land application field(s) ID: j► �" 3 �� �� 3,T is currently permitted under another
residuals land application program; Permit Number WQ: 040 XS' R The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed frgpi the previously permitted residuals land application program and transferred
into the new program; $ T��d Vt6 peon V'/'� -" I- -/k Go
(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
j 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:
Address: S- L
City: 1.� i�i C� �, {'l%, �1'v / State: �� ' Zip:
Phone: Q 7 7 E-mail address:
Signature: Date:
NORTH CAROLINA, L t ylCa r1 COUNTY
I, the undersigned Notary Public do hereby certify that N A!SS
0'
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the l O Pk 46,
day of "ge r ) , 20
Signature and seal: UW U
My commission expires: Cam— ZT�,^-�� D'a c.R �o�;
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:
Address:
City:
Phone:
Signature:
Permittee's Certification:
State:
E-mail
Date:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing off
Signature:
FORM: LOA 06-16 Page 3 of 3

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources
15A NCAC 02T .1100 —LANDOWNER 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 .1 100. 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: Synagro Western Piedmont RLAP
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:
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.
Special note
Site/Field ID
Lease
Land Use or
Intended Use of Crops
Residuals Source
(no-till/over-seed/
(yes/no)
Cropping Patterns
(optional)
pasture)
NC-CH-60-1
N
Pasture
Animal Feed
NC-CH-60-2
N
Pasture
Animal Feed
NC-CH-60-3
N
Pasture
Animal Feed
NC-CH-60-4
N
Pasture
Animal Feed
NC-CH-60-6
N
Pasture
Animal Feed
NC-CH-60-7
N
Pasture
Animal Feed
NC-CH-60-11
N
Pasture
Animal Feed
NC-CH-60-12
N
Pasture
Animal Feed
FORM: LOA 06-16 Pagel of 3

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 Permittee 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 time 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 of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
H. 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 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 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are 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 are 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: NC-CH-60-2, NC-CH-60-3, NC-CH-60-11
(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, 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. 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 Pennittee to land apply residuals to the land application site(s) as specified
herein.
l�°ram
Landowner name: -1—udd5.�II,,�
Address: 5-5-6�K �w� ks l2
City. �' l �r State:
NL
Phone: E-mail address:
Signature: Date: 1,51 Za 2'
NORTH CAROLINA, COUNTY
oGE� S_ �.c7Ure.
I, the undersigned Notary Public do hereby certify that
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the
day of
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
q h30 / 20 2.S
, 20
*Q3k2=
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:
Address:
City:
Phone:
Signature:
Permittee's Certification:
State:
E-mail address:
Date:
Zip:
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:
Signature:
Date:
FORM: LOA 06-16 Page 3 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 pennitted 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 Pennittee to land apply residuals to the land application site(s) as specified
herein. i
Landowner name: � " t\ C1►1-C-- I V t)� I -{e a
Address: �G C>nfl� AQ21_6?�,
Cityy�3� �►-��� State: Zip: ,=D-��" 7
Phone: 1 -�� g E-mail address: 01 i �/
Q
Signa re: t,�L- /*-x� -c, � � p • 2� Date: s — --a
NORTH CAROLINA,
I, the undersigned Notary Public do hereby certify that
COUNTY
1-L'7 ""o'e' t4Oare_
personally appeared before me this day and acknowledged the clue execution of the forgoing instrument.
WITNESS my hand and official seal this the Z5
day of jVM 20 2-1
1 rjSignature and seal: C•
My commission expires: 3 2-LNO" PUBUC
F Wake ftft NO
Lessee's/Operator's Certification: WCOMMjNIM EVINAug *30s 2M
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:
Address:
City:
Phone:
Signature:
Permittee's Certification:
State:
E-mail address:
Date:
Zip:
I certify that I have read this Agreement anddohereby agree to abide by the stipulations and restrictions as specified herein.
Signing official na e: �YJef lU E
Signature: �� '�� Date: Alz_l
FORM: LOA 06-16 Page 3 of 3