WQ0000702_More Information (Received)_20211018

wlllcox&mabe
SOIL SOLUTIONS
September 20, 2021
NCDEQ/DWR
Non -Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Attention: Mr. Erick Saunders
Reference: Application for City of Havelock - Residuals Land Application Program
Permit No. WQ0000702
Additional Information Request dated September 17, 2021
Craven County, North Carolina
Willcox & Mabe Soil Solutions, PLLC Project No. 15-23 Ph:02
Dear Mr. Saunders:
Willcox & Mabe Soil Solutions, PLLC (WMSS) is submitting the enclosed Additional
Information Response for the referenced permit application for the City of Havelock
Residuals Land Application Program. Please accept this letter and the attachments as
response to the referenced items within the Additional Information Request from the
North Carolina Department of Environmental Quality (NCDEQ) — Division of Water
Resources (DWR), Non -Discharge Branch (NDB) dated September 17, 2021. WMSS is
providing response to the following items with the request and response given below:
Item D1: The photocopied site maps for all the renewed fields are not clear and legible.
Legible electronic versions of these maps shall be provided that meet the requirements
Iisted in the "Map Guidance for Residuals Land Application Permits" and "Soil
Scientist Evaluation Policy" memorandums..
Response: WMSS has resubmitted the electronic versions of the map in conjunction
with this response. Additionally, two hardcopies will be mailed to NCDEQ to your
attention.
Item D2: There is a habitable residence in the southeast of field NC-PA-03-09 under
separate ownership on parcel 6551587480000 which appears to be within the 200-foot
setback from the application field as required for the subsurface application of residuals.
The 200-foot setback from this residence would extend past the setback provided for the
first drainage ditch, and it is unclear from the map provided whether this is the case. This
setback shall be shown on the resubmitted site map for this field as required by Item
D. L, and any acreage change shall be included in an updated LASC form. Alternatively,
a setback waiver may be executed in accordance with 15A NCAC 02T . I I08(e) to reduce
this setback. This waiver shall be written, notarized, signed by all parties involved, and
recorded with the Pamlico County Register of Deeds.
Response: The habitable residence in the southeast of field NC-PA-3-9 under separate
ownership on parcel 65520277153000 has been now been buffered out of the "net
Willcox & Mabe Soil Solutions, PLLC / 7231 B Summerfield Road/ Surnmerfield, NC 27358 / Rob 336.339.9128 or
Martin 336.312.1396 / www.willcoxmabesoil.com

Application for Bio-Green RLAP WMSS Project No. 21-06
Additional Information Request — Application No. W00038499 September 9 2021
acreage" of the field. This resulted in a net decrease of 0.1 acre. The LASC form has
also been updated and included in the attachements.
Item El: Section III on each of the LOAs submitted for the renewed fields do not specify
whether a re -defined compliance boundary is required for these fields due to a water supply well
inside the compliance boundary as per 15A NCAC 02L .0107(d). Please mark this section in each
LOA to indicate whether a re -defined compliance boundary is needed for every site covered in
the LOA. If so, the affected fields shall be noted in this section in accordance with 15A NCAC
02T .0105(h) with the rationale for the requested re -location of the compliance boundary.
Please note that there appear to be wells within the compliance boundary of the following fields:
a. NC-PA-02-01 (within the boundary of field NC-PA-02-01B, labelled an irrigation well);
b. NC-PA-03-01 (labelled a well); and
c. NC-PA-0 3 -02 (labelled a weIl).
If these wells are not water supply wells, then please reply that these wells would not need to meet
15A NCAC 02L .0107(d), which prohibits the construction and operation of a water supply well
within the compliance boundary of a disposal system.
Response: Revised LOA forms are attached with rationale that the compliance boundary
will remain as indicated in the footnote on Figures 2 & 3 — Buffer Map (Spencer Farms,
Inc.) and Figure 2 — Buffer Map (Jason A. Rice).
WMSS appreciates the opportunity to assist in responding to the Additional Information
Request for the City of Havelock Residuals Land Application Program. If after
reviewing the enclosed information you have any questions or require any additional
information, please contact us at your convenience.
Sincerely,
Willcox & Mabe Soil Solutions, PLLC
Martin E. Mabe
Rob Willcox, L.S.S.
Agronomist
Soil Scientist
Attachments
cc: City of Havelock
SharedlWMSS Projects12015115-23 City of HavelocklPhase 2 - Technical Assistance12021 Permit RenewaMdd Info
Request115-23 Phase 2 City of Havelock Add Info 9-20-21.doc

ATTACHMENTS

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
S. DANIEL SMITH
Director
THE HONORABLE WILLIAM LEWIS
CITY OF HAVELOCK
POST OFFICE Box 368
HAVELOCK, NORTH CAROLINA 28532
Dear Mayor Lewis:
NORTH CAROLINA
Environmental Quality
September 17, 2021
Subject: Application No. WQ0000702
Additional Information Request
City of Havelock RLAP
Land Application of Class B
Residuals
Craven County
Division of Water Resources' Central and Regional staff has reviewed the application package
received July 1, 2021. However, additional information is required before the review may be completed.
Please address the items on the attached pages no later than the close of business on October 18, 202I.
Please be aware that you are responsible for meeting all requirements set forth in North Carolina
rules and regulations. Any oversights that occurred in the review of the subject application package are
still the Applicant's responsibility. In addition, any omissions made in responding to the outstanding items
in Sections A through E, or failure to provide the additional information on or before the above requested
date may result in your application being returned as incomplete.
Please reference the subject application number when providing the requested information. All
revised and/or additional documentation shall be signed, sealed and dated (where needed), with two paper
copies and one electronic copy submitted to my attention at the address below.
If you have any questions regarding this request, please do not hesitate to contact me at (919) 707-
3659 or [e-mail]. Thank you for your cooperation.
Sincerely,
Erick Saunders, Engineer
Division of Water Resources
cc: Washington Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Martin Mabe — WMSS, PLLC (Electronic Copy)
Permit Application File WQ0000702
D North Carolina Department of Environinental Quality j Division of Water Resources
EQ>
S12 North Salisbury Street 1 1617 Mail Service Center I Raleigh. North Carolina 27699-1617
919.707.9000

Mayor William Lewis
September 17, 2021
Page 2 of 2
A. Residuals Land Application Program(FORM: RLAP 06-16 Application:
I. No comments.
B. O eration and Maintenance Plan O&M Plan):
1. No comments.
C. Residuals Source Certification FORM: RSC 06-16 Application:
1. No comments.
D. Land Application Site Certification (FORM: LASC 06-16) Form:
1. The photocopied site maps for all the renewed fields are not clear and legible. Legible electronic
versions of these maps shall be provided that meet the requirements listed in the "Map Guidance
for Residuals Land Application Permits" and "Soil Scientist Evaluation Policy" memorandums.
2. There is a habitable residence in the southeast of field NC-PA-03-09 under separate ownership on
parcel 6551587480000 which appears to be within the 200-foot setback from the application field
as required for the subsurface application of residuals. The 200-foot setback from this residence
would extend past the setback provided for the first drainage ditch, and the it is unclear from the
map provided whether this is the case. This setback shall be shown on the resubmitted site map for
this field as required by Item D.1., and any acreage change shall be included in an updated LASC
form. Alternatively, a setback waiver may be executed in accordance with 15A NCAC 02T . 1108(e)
to reduce this setback. This waiver shall be written, notarized, signed by all parties involved, and
recorded with the Pamlico County Register of Deeds.
E. Landowner Allreement (FORM: LOA 06-16) Form:
1. Section III on each of the LOAs submitted for the renewed fields do not specify whether a re-
defined compliance boundary is required for these fields due to a water supply well inside the
compliance boundary as per 15A NCAC 02L .0107(d). Please mark this section in each LOA to
indicate whether a re -defined compliance boundary is needed for every site covered in the LOA. If
so, the affected fields shall be noted in this section in accordance with 15A NCAC 02T .0105(h)
with the rationale for the requested re -location of the compliance boundary.
Please note that there appear to be wells within the compliance boundary of the following fields:
a. NC-PA-02-01 (within the boundary of field NC-PA-02-01B, labelled an irrigation well);
b. NC-PA-03-01 (labelled a welI); and
c. NC-PA-03-02(labelled a well).
If these wells are not water supply wells, then please reply that these wells would not need to meet
15A NCAC 02L .0107(d), which prohibits the construction and operation of a water supply well
within the compliance boundary of a disposal system.

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Division of Water Resources
State of North Carolina
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 PermittinZ 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 .I 100. 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) a 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
r v=
Land Owner
✓
VI
✓
Agreement
(If applicable)
It l!'2
✓
✓
✓
✓
Setback Wanner
Agreement
An updated vicinity/setback map in accordance with the "i\-lap Guidance
Ibr ResiCllials Land Ai)i licatilm Permits"
✓
✓
✓
A soils and agronomic evaluation in accordance with the "Soil Scientist
ky' lualioll PUIic%"
INSTRUCTIONS FOR FORM: LASC 06-16Page 1 of
3

An updated accounting of the land application site's cumulative pollutant
✓
loading rates CPLRs)
Required Item
Status Code
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 Scicntisl I valuaticm I'olic� "
Acknowledgement of field transfer from Land Owner (Fields may not be
permitted to multiple Pennittees 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)
• Cadastrat 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 Mere (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 I 1-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: http:I/deq.nc..ov/about/divisions/water-
resourceslplann in./classification- 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:l/deq_ne. gov/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 http://deq.nc.gov/about/divisions/water-resources/planninJciassification-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
I. 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 06-16Page 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 tern
"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 I5A NCAC 02B .0301 i .
❑ 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 ate 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 ate 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 06-16Page 3 of
3

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IN

State of North Carolina
y N
Department of Environment and Natural Resources
Division of Water 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 cores of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non-Dischar e Permitten Unit
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed 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 time 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: City of Havelock
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Lease Land Use or Residuals Source Special note
Site/Field IA (yes/no) Cropping Patterns Intended Use of Crops (no-till/over-seed/
(�' ) PP� to (optional)
pasture)
,vim P•�� -- 3 J p j
C O
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 l 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 11) 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.
II. RESTRICTIONS:
1. Appropriate measures must be taken by the Petmittee 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: FIELD I14 WILL HAVE AN ALTERNATIVE COMPLIANCE BOUNDARY
OF 50' FROM EACH WATER SUPPLY WELLTHAT IS LOCATED WITHIN 250' OF THE RESIDUAL LAND APPLICATION AREA
THAT IS ALSO NOT WITHHIN 50' OF THE PROPERTY BOUNDARY
(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

Landot+rfaarh owtftlattm
I brat I am a deedal budOwaar of die above -tee Ind W iw6m di*) ad am =Mmimd to mdoe dedidoas
RMft @m ws of die h2d sPpiiCI&n dte(@) an bdu f of odw 6mobd hadowmat gg daY I em odwrisa admind da+e *
a paw of amwm ar odrer iedd ddeP*m, b mdoe daddoas rc pr ft dw om o! dr had !.-- she an beWof ie
deeded lamdoattas. i ibi ie d*wofimwW bmd VVU=fim &Wa) cos Gat i mbW in OW wale dhpadd , 0 - , t or
�� for • Fw&mmwv, lad* dW I have red deb Apm=K
ftd dDbft'd9 fiW P b dm Permimee I� b iasb d m c to iatae bound►, admo�rk k at
aPp$► rorddt�t be lapel ttppBcxtiott db(t)az qerified
LaWwoner comer
Adtlee:s:
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I, the rm I=Aped w*w do hetaby ead$r dzm4./'t tic �•- i S *,�
Pam!► aPP b hm me ibis day Gad jwbo dgod #ise do emo nim of dm f aft b*umeat.
VAMM my hind and afScid OW NJ dw Z $ ` i.
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t►dj'coaadaioaa:¢= z z _ _ ..�,..,�.sio�'►C*'°�`'
t cad$+ & t I hM seat! ft Agmemmt and do hmby ague to abide by tm adtatiatiam Gad rampiedons as spedf ad Detain.
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�OIS�: LM ( -Z6

State of North Carolina
DWR
Department of Environment and Natural Resources
Division of Water 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 Dischar e Permittine Unit
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed 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.
® 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: City of Havelock
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Lease Land Use or Residuals Source Special note
Site/Field Ill es/no Cropping Patterns Intended Use of Crops (no-tilllover-seed/
{Y ) PP� g {optional)
pasture)
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-I636.
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.
II. 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.
11LALTERNATI'VES 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) 113: FIELD 3-1 & 3-2 WILL HAVE AN ALTERNATIVE COMPLIANCE
BOUNDARY OF 50' FROM EACH WATER SUPPLY WELLTHAT IS LOCATED WITHIN 250, OF THE RESIDUAL LAND
APPLICATION AREA THAT IS ALSO NOT WITHIN 50' OF THE PROPERTY BOUNDARY.
(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 boundaryis 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 orouram:
(Name of the new program)
FORM, LOA 06- l6
Page 2 of 3

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