NC0061123_Renewal (Application)_20220707 (2)

North Carolina
Department of Environmental Quality
Division of Water Resources
Modified Application Form 2A
Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < 0.1 MGD
and No Pretreatment Program
NPDES Permitting Program
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

NPDES Permit Number Facility Name
Mou.n-tit 4 in rt-h-ca-l-t
NCOb LQ l (2- 3 Learn i hel Cpn-ler- I,v
Modified Application Form 2A
Modified March 2021
WTI°
Form
NPDES
NC Department of Environmental Quality - Application for NPDES Permit to Discharge Wastewater
MINOR SEWAGE FACILITIES (Before completing this form, please read the instructions. Failure to follow
the instructions ma result in denial of the : L. ication.
SECTION
1. BASIC
APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.21(j)(1) and (9))
1.1
Facility name
MOU,A+01 6e-1i ct q- LTA(ninc CuA-ef- w uiiP
Mailing address (street or P.O. box)
Po fox I2C1Ci
City or town
141 * 1 ands
State
MC
ZIP code
a8-44 i
Contact name (firstsdd last)
3 'cu lo Pr'1d?rA.r1
Title Exert VL
—b1 ctt-ttvt-
Phone number
a/is- 520-5e3K
Email address
A mince Allay
as
Location address (street, route number, or other specific identifier)
3Fs12 Di llarcl )Rc1
•
Same as mailing
address 1
City or town
ghlar, i
State
NC
ZIP code
a8 4
1.2
Is this
•
applicatio
Yes 4 See
requirements
r a facility that has yet to commence discharge?
instructions on data submission V No
for new dischargers.
1.3
Is applicant different from entity listed under Item 1.1 above?
❑ Yes IV. No 4 SKIP to Item 1.4.
Applicant name
c-
Applicant address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
1.4
Is the applicant the facility's owner, operator.
'Owner
•
or both? (Check only one response.)
Operator ❑ Both
1.5
To
•
which entity should the NPDES permitting
Facility
■
authority send correspondence? (Check only one response.)
Applicant �/ Facility and applicant
(they are one and the same)
tit-
1.6
Indicate
number
below any existing environmental
for each.)
permits.
(Check all that apply and print or type the corresponding permit
Existing Environmental Permits
NPDES (discharges to surface
water)
N
PSD (air emissions)
•
Nonattainment program (CAA)
•
NESHAPs (CAA)
•
Ocean dumping (MPRSA)
•
Dredge or fill (CWA Section
404)
•
Other (specify)
Page 1

NPDES Permit Number Facility Name
I\[ C _OD C21 lol 3 Mou,rtt t iv1 rehrect{
Modified Application Form 2A
Leartil Mar h o21A
Collection System and Population Served
1.7
Provide the collection system information requested below for the treatment works.
Municipality
Served
Population
Served
Collection System Type
(indicate percentage)
Ownership Status
t:t el
Tr I VCt4
too % separate sanitary sewer
q/'Own ❑ Maintain
1 < <.KI i
% combined storm and sanitary sewer
0 Own 0 Maintain
rtkriCtf-
-cCtU 1 t1
0 Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own 0 Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
0 Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own 0 Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
❑ Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own 0 Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
❑ Unknown
❑ Own 0 Maintain
Total
Population
Served
SiEntiErril
p wok
Separate Sanitary Sewer System Combined Storm and
Sanitary Sewer
Total percentage of each type of
sewer line (in miles)
1 O 0 70
Indian Country
1.8
Is the
■
treatment works located in Indian
Yes
Country?
E2/ No
1.9
Does
•
the facility discharge to a receiving
Yes
water that flows through Indian Country?
10' No
Design and Actual
Flow Rates
1.10
Provide design and actual flow rates
in the designated spaces.
Design Flow Rate
D • bd(o mgd
Annual Average Flow Rates (Actual)
Two Years Ago
Last Year
This Year
•mgd Y•
10 c 0 L/V mgd
D .ecx.0 w") mgd
Maximum Daily Flow Rates (Actual)
Two Years Ago
Last Year
This Year
� • 1� mgd
(La
I" 10 I0 Vv mgd
11• � fi mgd
charge Points
by Type
1.11
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
Total Number of Effluent Discharge Points by Type
Treated Effluent
Untreated Effluent
Combined Sewer
Overflows
Bypasses
Constructed
Emergency
Overflows
Page 2

NPDES Permit Number Facility Name
ivccoi a3 f40
Modified Application Form 2A
Modified March 2021
Outfalls and Other Discharge or Disposal Methods
Outfails Other Than to Waters of the State of North Carolina
1.12
Does the POTW discharge wastewater to basins, ponds, or other surface impoundments that do not have outlets
for discharge to waters of the State of North Carolina?
■ Yes It2 No 4 SKIP to Item 1.14.
1.13
Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Impoundment Location and Discharge Data
Location
Average Daily Volume
Discharged to Surface
Impoundment
Continuous or Intermittent
(check one}
gpd
❑ Continuous
❑ Intermittent
gpd
0 Continuous
❑ Intermittent
gpd
0 Continuous
0 Intermittent
1.14
Is wastewater applied to land?
V No4SKIPtoItem1.16.
• Yes
1.15
Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
Location
Size
Average Daily Volume
Applied
Continuous or
Intermittent
(check one)
acres
gpd
❑ Continuous
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
1.16
Is effluent transported to another
facility for treatment prior to discharge?
ad No 4 SKIP to Item 1.21.
■ Yes
1.17
Describe the means by which the effluent is transported (e.g., tank truck, pipe).
1.18
Is the effluent transported by
a party other than the annlicant?
, _ No 4 SKIP to Item 1.20.
■ Yes
1.19
Provide information on the transporter below.
Transporter Data
Entity name
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
Page 3

NPDES Permit Number Facility Name
t\fLo7LD1 �a3 M �b'•cIn r
Modified Application Form 2A
Modred March2021
Outfalls and Other Discharge or Disposal Methods Continued
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving facility,
Receiving Facility Data
Facility name
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
NPDES number of receiving facility (if any) ❑ None
Average daily flow rate mgd
1.21
Is the
not
•
wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
have outlets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
Yes No 4 SKIP to Item 1.23.
1.22
Provide information in the table below on these other disposal methods.
Information on Other Disposal Methods
Disposal
Method
Description
Location of
Disposal Site
Size of
Disposal Site
Annual Average
Daily Discharge
Volume
Continuous or Intermittent
(check one)
acres
gp d
Continuous
❑ Intermittent
acresgpd
❑ Continuous
❑ Intermittent
acresgpd
0 Continuous
❑ Intermittent
Variance
Requests
1.23
Do
Consult
Le
you intend to request or renew one or more of the
with your NPDES permitting authority to determine
Discharges into marine waters (CWA
Section 301(h))
Not applicable
•
variances authorized at 40 CFR 122.21(n)? (Check all that apply.
what information needs to be submitted and when.)
Water quality related effluent limitation (CWA Section
302(b)(2))
Contractor Information
1.24
Are any operational or maintenance aspects (related
the re ponsibility of a contractor?
Yes
to
■
wastewater treatment and effluent quality) of the treatment works
No +SKIP to Section 2.
1.25
Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
Contractor Information
Contractor 1
Contractor 2
Contractor 3
Contractor name
(company name)
envirenmenkAl,lhc,
Mailing
street or P.O. box)
P0-6bx C1511
City, state, and ZIP
code
C It\ 1u.ohea. w_atma3
Contact name (first and
last
�(L 1
Phone number
4 _5c66 _
Email address
enij rawf Ott 1
nc_ .cia m
Operational and
maintenance
responsibilities of
contractor
c
opeirafry 3
1—
mGtI R r�Ct tr anLP
Page 4

NPDES Permit Number
Facility Name
1r1
Modified Application Form 2A
Modified March 2021
0)
Design Flow 0
0
N 2. ADDITIONAL INFORMATION (40 CFR 122.21(j)(1) and (2))
OutfaIts to Waters of the State of North Carolina
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
• Yes V No + SKIP to Section 3.
Inflow and Infiltration
2.2
Provide the treatment works' current average daily volume of inflow
Average Daily Volume of inflow and infiltration
and infiltration.
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
Topographic
Map
2.3
Have
specific
■
you attached a topographic map to this application
requirements.)
Yes
•
that contains all the required information? (See instructions for
No
Flow
Diagram
2.4
Have
(See
■
you attached a process flow diagram or schematic
instructions for specific requirements.)
Yes
•
to this application that contains all the required information?
No
Scheduled Improvements and Schedules of Implementation
2.5
Are
■
improvements to the facility scheduled?
Yes
■
No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
1.
2.
3.
4.
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
Scheduled
Improvement
(from above)
Affected
Outfalls
(list mitten
number
Begin
Construction
End
Construction
(MM/DD/YYYY)
Begin
Discharge
(MM/DD/YYYY)
Attainment of
Operational
Level
Level
(MM/DD/YYYY)
2.
3.
4.
2.7
Have
response.
•
appropriate permits/clearances
Yes
concerning other federal/state requirements
■ No
been obtained? Brief
• None required
y explain your
or applicable
Explanation:
Page 5

NPDES Permit Number
Facility Name
Modified Application Form 2A
Modified March 2021
SECTION 3. INFORMATION
ON EFFLUENT DISCHARGES (40 CFR 122.21(j)(3) to (5))
Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls )
Description of Outfalls
3.1
Outfall Number ODf
Outfall Number
Outfall Number
State
Ncr-th CoxbI Ira
County
rY' acAn
City or town
1 9hltutO
Distance from shore
ft.
ft.
ft.
Depth below surface
ft.
ft.
ft.
Average daily flow rate
mgd
mgd
mgd
Latitude
35° (7 5q " Iv
°
0 '
Longitude
g3 ° 15 ,Lty " YV
Seasonal or Periodic Discharge Data
3.2
Do
•
any of the outfalls described under Item 3.1 have seasona
Yes
or periodic discharges?
l0' No 4 SKIP to Item 3.4.
3.3
If so, provide the following information for each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
Number of times per year
discharge occurs
Average duration of each
discharge (specify units)
Average flow of each
discharge
mgd
mgd
mgd
Months in which discharge
occurs
Diffuser Type
3.4
Are
■
any of the outfalls listed under Item 3.1 equipped with a diffuser?
Yes "No 4 SKIP to Item 3.6.
3.5
Briefly describe the diffuser t pe at each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
Waters of
the U.S.
3.6
Does the treatment works discharge or plan to discharge wastewater
one or more discharge points?
DV Yes
•
to waters of the State of North Carolina from
No 4SKIP to Section 6.
Page 6

NPDES Permit Number Facility Name ��y�
IVfCcnu 1, o�5 H1 l r rQ:1 r C.6+a
Modified Application Form 2A
► Modified March 2021
ReceMng Water Descr!tAion
3.7
Provide the receiving water and related information (if known) for each outfall.
Outfall Numbert b 1
Outfall Number
Outlet l Number
Receiving water name
t Y. es &la..
Name of watershed, river,
or stream system
J. �" tiK�ttiC
vcuc g n
U.S. Soil Conservation
Service 14-digit watershed
code
Name of state
management/river basin
ScVQnnth .
rig tr basin
U.S. Geological Survey
8-digit hydrologic
cataloging unit code
Critical low flow (acute)
cfs
cfs
cfs
Critical low flow (chronic)
cfs
cfs
cfs
Total hardness at critical
low flow
mg/L of
CaCO3
mg/L of
CaCO3
mg/L of
CaCO3
3.8
Provide the following information
describing the treatment provided for discharges from each outfall.
Outfall Number obi
Outfall Number
Outfa l Number
Highest Level of
Treatment (check all that
apply per outfall)
I 'Primary
0 Equivalent to
secondary
❑ Secondary
❑ Advanced
❑ Other (specify)
❑ Primary
0 Equivalent to
secondary
0 Secondary
0 Advanced
0 Other (specify)
0 Primary
0 Equivalent to
secondary
0 Secondary
0 Advanced
0 Other (specify)
Design Removal Rates by
Outfall
BODs or CBODo
TSS
%
%
%
Phosphorus
❑ Not applicable
%
0 Not applicable
%
0 Not applicable
Nitrogen
❑ Not applicable
%
0 Not applicable
0 Not applicable
Other (specify)
0 Not applicable
%
0 Not applicable
%
0 Not applicable
%
Page 7

3.9
NPDES Permit Numba
Modified Application Form 2A
Modified March 2021
Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season, describe below.
Outfall Number COI
OutfaB Number
(Wan Number
Disinfection type
Seasons used
Calcium pod ta- t
`kc v Y(
Dechlorination used?
❑,/ Not applicable
LN Yes
❑ No
❑ Not applicable
❑ Yes
❑ No
❑ Not applicable
❑ Yes
❑ No
3.10
Have you completed monitoring for all Table A parameters and attached the results to the application package?
Yes 0 No
3.11
Have you conducted any WET tests during the 4.5 years prior to the date of the application on any of the facility's
discharges or on any receiving water near the discharge points?
❑ Yes No 4 SKIP to Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outial Number
Outran Number
Outlet! ' Number_
Acute
Chronic
Acute
Chronic
c
Number of tests of discharge
water
Number of tests of receiving
water
3.14
3.15
.Prue c t t
Does the PATWI:Me chlorine disinfection, use chlorine elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
q (es 4 Complete Table B, including chlorine. No 4 Complete Table B, omitting chlorine.
Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
pack e?
Yes ❑ No
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
3.18 attached the results to this application package?
❑ or No additional sampling required by NPDES
Yes permitting authority.
Page 8
Factlity 1,10111U
NCODlo i a3 Y1naniu nrithistIcAt

NPDES Permit Number Facility Name
IV C. CD U) l l 33 ftilisuil'CAM E-
Modified Application Form 2A
Modified March 2021
3.19
Has the POTW conducted either (1) minimum of four quarterly WET tests for one year preceding this permit application
or (2) at least four annual WET tests in the past 4.5 years?
V Yes J Jo 4 Complete tests and Table E and SKIP to
Item 3.26.
3.20
Have you previously submitted the results of the
VYes
above tests to your NPDES permitting
No 4 Provide
authority?
results in Table E and SKIP to
■
Item 3.26.
3.21
Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
Summary of Results
December aolts
;
3.22
Regardless of
9
toxicity?
howyouprovidedyour WET testingdata to the NPDES permittingauthorit did anyof the tests result in
Y�
No 4 SKIP to Item 3.26.
• Yes
3.23
Describe the cause(s) of the toxicity:
3.24
Has the treatment
works conducted a toxicity reduction evaluation?
No 4 SKIP to Item 3.26.
• Yes
3.25
Provide details of any toxicity reduction evaluations conducted.
3.26
Have you completed
Table E for all applicable outfalls and attached the results to the application package?
Not applicable because previously submitted
IN Yes
information to the NPDES .ermittin. authorit .
Page 9

DocuSign Envelope ID: 1C2281DC-3A75-46A7-BC3F-3885D148410C
SECTION 6. CH
6.
NPDES Permit Number
NJC Oz) I
0
Fcfltv Name
Modified Application Form 2A
Modified March 2021
KLI ANI 1 I : T ' 'N• (40 122. (a) and Op
In Column 1 below, mark the sections of Form 2A that you have completed and are
each section, specify in Column 2 any attachments that you are enclosing to alert the
all applicants are required to provide attachments.
submitting with your application. For
permitting authority Note that not
hivtile4.kift' 6i:;14,,,i*,,44 ''.4.:47,43411.
Section 1: Basic Application
Information for Ail Applicants
- - 47,V- ,,i''' rt :65r;d4ir:',7 ,/,'-7 iiiAC47
• wl variance request(s) • wf additional attachments
VSection 2: Additional
Information
0 w/ topographic map NI wr process flow diagram
0 viii additional attachments
F2/.. Section 3: information on
Effluent Discharges
tier' wl Table A
0 wl Table B
0 wil Table D
D tril additional attachments
• w/ Table C
Section 4: Not Applicable
Section 5: Not Applicable
/Section 6: Checklist and
Certification Statement
III wl attachments
Certification Statement
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted, Based on my inquiry of the person or persons who manage the system, or those persons directly responsible
for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and
complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine
and imprisonment for knowing violations,
Name (print or type first and last name)
Stephanie Anderson- mountain Retreat & Learning CentWcutive
Official title
Di rector
Signature
,DocuSipned ,,,,
Shitzunii.. giuttytm- IkthwA,lwiik, filvulf g,, lkiunAiil CuAlt_
s.—oraz g,,,nr.iqr
Date signed
7/7/2022
Page 1 0

E
z
08
a
NPDES Permit
3
0
�.J
2
ML or MDL
(include units)
❑ ML
0 ML
itilaibL
J
.3
0
(i
. 2
V
` O
T. u
-
Average Daily Discharge
Number of
Samples
1
.1
•
2
Jrr
i
p
b
r l
V
J
i
O -
OV
1.1 %.
73"? �+
Value Units
3,-a mg _
e
F21
0
2
t
o
'
J
43-
g•
0
gE _..
Z.9
cl
�_CI
11)
W
H
UJ
g
a
a
H
z
W
-J
LL
LL
W
Q
UJ
J
CO
Q
H
Pollutant
[OrDCBOD
ical oxygen demand
5
[-Pollutant
Fecal coliform
Design flow rate
pH (minimum)
pH (maximum)
Temperature (winter)
Temperature (summer)
Total suspended solids (TSS)