WQ0042832_Modification_20221222

Initial Review
Reviewer Thornburg, Nathaniel D
Is this submittal an application? (Excluding additional information.)*
Yes No
Permit Number (IR) * WQ0042832
Applicant/Permittee Town of Holly Springs
Applicant/Permittee Address 128 S Main St. Holly Springs, NC 27540
Is the owner in BIMS? Yes No Is the facility in BIMS?
Owner Type
Facility Name
County
Fee Category RW Distribution Line
Is this a complete application?*
Yes No
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Municipal
Oakview Innovation Park RWDL
Wake
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer
15[ 019
Fee Amount $0
Complete App Date 12/22/2022
Below list any additional email address that need notification about a new project.
... ... ..
Email Address
Comments to be added to email notfication
Comments for Admin
Comments for RO

Comments for Reviewer
Comments for Applicant

Submittal Form
Project Contact Information
Please provide information on the person to be contacted by NDB Staff regarding electronic submittal, confirmation of receipt, and other correspondence.
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Name* Emily Koncz
Email Address*
[e-mail]
Project Information
Application/Document Type*
New (Fee Required)
Modification - Major (Fee Required)
Renewal with Major Modification (Fee
Required)
Annual Report
Additional Information
Other
Phone Number*
9195572933
Modification - Minor
Renewal
GW-59, NDMR, NDMLR, NDAR-1,
N DAR-2
Residual Annual Report
Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
hftps://edocs.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Perm it Type:*
Wastewater Irrigation
High -Rate Infiltration
Other Wastewater
Reclaimed Water
Closed -Loop Recycle
Residuals
Single -Family Residence Wastewater
Other
Irrigation
Permit Number: *
WQ0042832
Has Current Existing permit number
Applicant/Permittee*
Town of Holly Springs
Applicant/Permittee Address*
128 S Main St. Holly Springs, NC 27540
Facility Name*
Oakview Innovation Park RWDL
Please provide comments/notes on your current submittal below.
Reclaimed water modification of existing permit and final certification for Oakview Innovation
Park
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.
(Application Form, Engineering Plans, Specifications, Calculations, Etc.)
Oakview Innovation Park Cert and mod to State.pdf 6.2MB
Upload only 1 PDF document (less than 250 MB). Multiple documents must be combined into one PDF file unless file is larger
than upload limit.
* By checking this box, I acknowledge that I understand the application will not be
accepted for pre -review until the fee (if required) has been received by the Non -
Discharge Branch. Application fees must be submitted by check or money order and
made payable to the North Carolina Department of Environmental Quality (NCDEQ).
I also confirm that the uploaded document is a single PDF with all parts of the
application in correct order (as specified by the application).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature

Submission Date 12/22/2022

DocuSign Envelope ID: 713F213132A-50013-4790-A892-6621 BEB2E4C8
0 0
oa$` THE TOWN OF oily cVpnngs
�O '"f�'NOICfK�A
December 19, 2021
NCDEQ — Division of Water Resources
Water Quality Permitting Section, Non -Discharge Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Re: Holly Springs Reclaimed Water Distribution System Extension Request; Application for Approval
Project: RECLAIMED Water Modification Permit and FINAL Certification —
Oakview Innovation Park RWDL
Dear Sir or Madam:
Please find enclosed the following items in application for a RECLAIMED water extension modification
and FINAL reclaimed certification to the Town of Holly Springs' existing reclaimed water distribution
system:
❑ One copy of the engineer certification
❑ One copy of the original permit WQ0042832
❑ One copy of the plats
❑ One copy of the as builts
Feel free to contact me at 919-577-3150 should you have any questions or need additional information in
order to process this application.
Sincerely,
E
DocuSigned by:
03C05669FC34440...
Kendra D. Parrish, P.E., C.F.M
Executive Director of Utilities and Infrastructure Services
KDP/ek
cc: Project Consultant Engineer, A
Rachel Ingham, Utility Engineer
Drew Johnson, Development Construction Manager
Seann Byrd, Director Public Utilities
Project file/paper/electronic/Correspondence 9
3021
12.19.2022
DS
2�
Rachel Ingham
Utility Engineer
DS
D
Drew Johnson
Development Construction Manager
Utilities and Infrastructure Services
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 • www.hollyspringsnc.gov

DocuSign Envelope ID: 713F213132A-50013-4790-A892-6621 BEB2E4C8
Permit No. WQ0042832 Reclaimed Water Distribution
Town of Holly Springs February 17, 2022
Oakview Innovation Park RWDL Wake County
ENGINEERING CERTIFICATION
❑ Partial ® Final
I, Blake Hall , as a duly licensed North Carolina Professional
Engineer, having ❑X periodically / ❑ fully observed the construction of the permitted facilities, do hereby
state to the best of my abilities that the facility was constructed in compliance with G.S. 143-215.1,
Administrative Code Title 15A Subchapter 02U, this permit, and the Division -approved plans and
specifications.
Documentation of any variation to this permit, and the Division -approved plans and specifications, is in the
attached as -built drawings.
Description of variations:
Blake Hall
r
i¢
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t el�aJ 9� f'}} �I
6p
Timmons Group;°°
5410 Trinity Rd, Suite 102
686`i6
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Adde
r
Raleigh
NC
27607
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919-866-4933
blake.hallC timmons.com
THE COMPLETED ENGINEERING CERTIFICATION, INCLUDING ALL SUPPORTING
DOCUMENTATION, SHALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
NON -DISCHARGE BRANCH
By U.S. Postal Service By Courier/Special Deliver
1617 MAIL SERVICE CENTEP, 512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604
WQ0042832 Version 1.0 Sbell Version 200201 Page 6 of 6

DocuSign Envelope ID: 713F213132A-50013-4790-A892-6621 BEB2E4C8
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
February 17, 2022
KENDRA D. PARRISH, PE — EXECUTIVE DIRECTOR OF UTILITIES AND INFRASTRUCTURE SERVICES
TOWN OF HOLLY SPRINGS
128 SOUTH MAIN STREET
HOLLY SPRINGS, NORTH CAROLINA 27540
Subject: Permit No. WQ0042832
Oakview Innovation Park RWDL
Reclaimed Water Distribution
Wake County
Dear Ms. Parrish:
In accordance with your permit application request received September 20, 2021, and subsequent
additional information received December 16, 2021, we are forwarding herewith Permit No. WQ0042832
dated February 17, 2022, to the Town of Holly Springs for the construction only of the subject reclaimed
water distribution facilities.
This permit shall be effective from the date of issuance until rescinded, and shall be subject to the
conditions and limitations therein.
If any parts, requirements, or limitations contained in this permit are unacceptable, the Permittee
has the right to request an adjudicatory hearing upon written request within 30 days following receipt of
this permit. This request shall be in the form of a written petition, conforming to Chapter 150B of the North
Carolina General Statutes, and filed with the Office of Administrative Hearings at 6714 Mail Service
Center, Raleigh, NC 27699-6714. Otherwise, this permit shall be final and binding.
One set of approved plans and specifications is being forwarded to you. If you need additional
information concerning this permit, please contact Lauren Raup-Plummer at [phone] or
Lauren. Plummer&ncdenr. gov.
Sincerely,
S. Daniel Smith, Director
Division of Water Resources
cc: Wake County Health Department (Electronic Copy)
Raleigh Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Blake Hall, PE — Timmons Group (Electronic Copy)
Laserfiche File (Electronic Copy)
Digital Permit Archive (Electronic Copy)
� North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11617 Mail Service Center I Raleigh, North Carolina 27699-1617
NORTH GAROLINA +
919.707.9000

DocuSign Envelope ID: 7BF2BB2A-500B-4790-A892-6621 BEB2E4C8
THIS PAGE BLANK

DocuSign Envelope ID: 713F213132A-50013-4790-A892-6621 BEB2E4C8
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH
RECLAIMED WATER DISTRIBUTION PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Town of Holly Springs
Wake County
FOR THE
construction only of a reclaimed water distribution system extension consisting of
3,441 linear feet (LF) of 8-inch C-900 polyvinyl chloride (PVC) reclaimed water distribution line; and all
associated piping, valves, controls, and appurtenances
to serve the Oakview Innovation Park RWDL, with no discharge of wastes to surface waters, pursuant to
the application received September 20, 2021, subsequent additional information received December 16,
2021, and in conformity with the Division -approved plans and specifications considered a part of this
permit.
This permit shall be effective from the date of issuance until rescinded, and shall be subject to the following
conditions and limitations:
I. SCHEDULES
Upon completion of construction and prior to operation of the permitted distribution facilities, the
Permittee shall submit an engineering certification from a North Carolina licensed Professional
Engineer certifying that the permitted facilities have been constructed in accordance with G.S. 143-
215.1, Administrative Code Title 15A Subchapter 02U, this permit, and the Division -approved plans
and specifications. For phased and partially certified facilities, the Permittee shall retain the
responsibility to track further construction approved under this permit, and shall provide a final
engineering certification upon project completion. Mail the Engineering Certification to the Division
of Water Resources, Non -Discharge Branch, 1617 Mail Service Center, Raleigh, NC 27699-1617, or
Non-Discharge.Reports&ncdenr. og_v. [15A NCAC 02T .0116(a)]
2. The facilities permitted herein are for construction only. The Permittee shall submit the following
documentation as a minor permit modification request:
a. Easements for all the properties on which the distribution line is to be located.
b. A map showing the distribution line and all properties with a table referencing all easements (Deed
Book and Page).
Mail the documentation to the Division of Water Resources, Non -Discharge Branch, 1617 Mail Service
Center, Raleigh, NC 27699-1617, or Non-Discharge.Reports&ncdenr.gov [15A NCAC 02T .0116(a)]
WQ0042832 Version 1.0 Shell Version 200201 Page 1 of 6

DocuSign Envelope ID: 7BF2BB2A-500B-4790-A892-6621 BEB2E4C8
Operation of the reclaimed water distribution facilities shall be contingent upon construction and
operation of permitted reclaimed water distribution lines immediately upstream and downstream of the
reclaimed water distribution facilities permitted herein. Specifications for future upstream and
downstream reclaimed water distribution lines shall include quality assurance testing procedures, which
shall be adhered to prior to operation of the reclaimed water distribution facilities permitted herein.
[G. S. 143-215.1 ]
IL PERFORMANCE STANDARDS
1. The Permittee shall maintain and operate the subject reclaimed water distribution facilities so there is
no discharge to surface waters, nor any contravention of groundwater or surface water standards. In
the event the facilities fail to perform satisfactorily, including the creation of nuisance conditions due
to improper operation and maintenance, the Permittee shall take immediate corrective actions, including
Division required actions, such as the construction of additional or replacement reclaimed water
distribution facilities, or cessation of reclaimed water distribution. [15A NCAC 02T .0108(b)(1)(A)]
2. This permit shall not relieve the Permittee of their responsibility for damages to groundwater or surface
water resulting from the operation of this facility. [15A NCAC 02T .0108(b)(1)(A)]
3. Construction of the reclaimed water distribution facilities permitted herein shall be scheduled as not to
interrupt service of existing utilities. [15A NCAC 02T .0108(b)(1)(A)]
4. All reclaimed water valves, storage facilities, and outlets shall be tagged or labeled to warn the public
or employees that the water is not intended for drinking. [15A NCAC 02U .0403(b)]
5. All reclaimed water piping, valves, outlets, and other appurtenances shall be color -coded, taped, or
otherwise marked to identify the source of the water as being reclaimed water as follows:
a. All reclaimed water piping and appurtenances shall be either colored purple (Pantone 522 or
equivalent) and embossed or integrally stamped or marked "CAUTION: RECLAIMED WATER -
DO NOT DRINK" or be installed with a purple (Pantone 522 or equivalent) identification tape or
polyethylene vinyl wrap. The warning shall be stamped on opposite sides of the pipe and repeated
every three feet or less;
b. Identification tape shall be at least three inches wide and have white or black lettering on purple
(Pantone 522 or equivalent) field stating "CAUTION: RECLAIMED WATER - DO NOT
DRINK". Identification tape shall be installed on top of reclaimed water pipelines, fastened at least
every 10 feet to each pipe length and run continuously the entire length of the pipe; and
c. Existing underground distribution systems retrofitted for the purpose of convey reclaimed water
shall be taped or otherwise identified as noted in IL5.a. and IL5.b. This identification need not
extend the entire length of the distribution system but shall be incorporated within 10 feet of
crossing any potable water supply line or sanitary sewer line.
[15A NCAC 02U .0403(c)]
6. All reclaimed water valves and outlets shall be of a type, or secured in a manner, that permits operation
by personnel authorized by the entity that operates the reclaimed water system. [15A NCAC 02U
.0403(d)]
7. Hose bibs shall be located in locked, below grade vaults that shall be labeled as being of non -potable
quality. As an alternative to the use of locked vaults with standard hose bib services, other locking
mechanisms such as hose bibs that can only be operated by a tool may be placed above ground and
labeled as non -potable water. [15A NCAC 02U .0403(e)]
8. There shall be no direct cross -connections between the reclaimed water and potable water systems,
unless such connection has been approved by the Department pursuant to 15A NCAC 18C .0406. [15A
NCAC 02U .0403(f)]
WQ0042832 Version 1.0 Shell Version 200201 Page 2 of 6

DocuSign Envelope ID: 7BF2BB2A-500B-4790-A892-6621 BEB2E4C8
9. Reclaimed water distribution lines shall be located at least 5 feet horizontally from and 18 inches below
any water line if practicable. If these separation distances cannot be met, the piping and integrity testing
procedures shall meet water main standards in accordance with 15A NCAC 18C. [15A NCAC 02U
.0403(h)]
10. Reclaimed water distribution lines shall not be less than 50 feet from a well unless the piping and
integrity testing procedures meet water main standards in accordance with 15A NCAC 18C, but in no
case shall they be less than 25 feet from a private well. [15A NCAC 02U .0403(i)]
11. Reclaimed water distribution lines shall meet the separation distances to sewer lines in accordance with
15A NCAC 02T .0305. [15A NCAC 02U .04030)]
III. OPERATION AND MAINTENANCE REQUIREMENTS
The Permittee shall operate and maintain the subject facilities as anon -discharge system. [15A NCAC
02U .0101]
2. The Permittee shall maintain an Operation and Maintenance Plan, which shall include:
a. A description of the operation of the system in detail to show what operations are necessary for the
system to function and by whom the operations are to be conducted;
b. A sampling and monitoring plan to evaluate quality of reclaimed water within the distribution
system to provide quality assurance at the time of reuse, and specify actions to be taken in response
to unsatisfactory monitoring results;
c. A map of all reclaimed water distribution lines;
d. A description of anticipated maintenance of the system;
e. Provisions for safety measures, including restriction of access to the site and equipment; and
f. Spill control provisions that include response to upsets and bypasses, including control,
containment, and remediation, and contact information for personnel, emergency responders, and
regulatory agencies.
[15A NCAC 02U .0801(a)]
3. Only reclaimed water generated from the Utley Creek WWTP Reclaimed Water System (Permit No.
WQ0032289) shall be conveyed in the reclaimed water distribution facilities permitted herein. [15A
NCAC 02U.0101]
WQ0042832 Version 1.0 Shell Version 200201 Page 3 of 6

DocuSign Envelope ID: 7BF2BB2A-500B-4790-A892-6621 BEB2E4C8
IV. MONITORING AND REPORTING REQUIREMENTS
The Permittee shall conduct and report any Division required monitoring necessary to evaluate this
facility's impact on groundwater and surface water. [15A NCAC 02T .0108(c)]
2. Noncompliance Notification:
The Permittee shall report to the Raleigh Regional Office, telephone number [phone], within
24 hours of first knowledge of the following:
a. Any failure rendering the reclaimed water distribution facilities incapable of adequately conveying
the reclaimed water (e.g., mechanical or electrical failures, line blockages or breaks, etc.).
b. Any failure resulting in a discharge to surface waters.
c. Any discharge to land surface greater than or equal to 5,000 gallons. The Permittee shall document
discharges less than 5,000 gallons to land surface, but do not require Regional Office notification.
Emergencies requiring reporting outside normal business hours shall call the Division's Emergency
Response personnel at telephone number [phone], [phone], or [phone]. All
noncompliance notifications shall file a written report to the Raleigh Regional Office within five days
of first knowledge of the occurrence, and this report shall outline the actions proposed or taken to ensure
the problem does not recur. [15A NCAC 02T .0108(b)(1)(A)]
V. INSPECTIONS
1. The Permittee shall perform inspections and maintenance to ensure proper operation of the reclaimed
water distribution facilities. [15A NCAC 02U .0801(i)]
2. The Permittee shall inspect the reclaimed water distribution facilities to prevent malfunctions, facility
deterioration, and operator errors that may result in discharges of wastes to the environment, threats to
human health, or public nuisances. The Permittee shall maintain an inspection log that includes the
date and time of inspection, observations made, and maintenance, repairs, or corrective actions taken.
The Permittee shall maintain this inspection log for a period of five years from the date of the inspection,
and this log shall be made available to the Division upon request. [15A NCAC 02U .0801(h), 02U
.0801(1)]
Division authorized representatives may, upon presentation of credentials, enter and inspect any
property, premises, or place related to the reclaimed water distribution facilities permitted herein at any
reasonable time for determining compliance with this permit. Division authorized representatives may
inspect or copy records maintained under the terms and conditions of this permit, and may collect
groundwater, surface water, or leachate samples. [G.S. 143-215.3(a)(2)]
WQ0042832 Version 1.0 Shell Version 200201 Page 4 of 6

DocuSign Envelope ID: 713F213132A-50013-4790-A892-6621 BEB2E4C8
VI. GENERAL CONDITIONS
1. Failure to comply with the conditions and limitations contained herein may subject the Permittee to a
Division enforcement action. [G.S. 143-215.6A, 143-215.613, 143-215.6C]
2. This permit is effective only with respect to the nature and volume of wastes described in the permit
application, and Division -approved plans and specifications. [G.S. 143-215.1(d)]
3. Unless specifically requested and approved in this permit, there are no variances to administrative codes
or general statutes governing the construction or operation of the facilities permitted herein. [15A
NCAC 02T .0105(n)]
4. The issuance of this permit does not exempt the Permittee from complying with all statutes, rules,
regulations, or ordinances that other jurisdictional government agencies (e.g., local, state, and federal)
may require. [15A NCAC 02T .0105(c)(6)]
5. If the permitted facilities change ownership, or the Penmittee changes their name, the Permittee shall
submit a permit modification request on Division -approved forms. The Permittee shall comply with
all terms and conditions of this permit until the permit is transferred to the successor -owner. [G.S. 143-
215.1(d3)]
6. The Permittee shall retain a set of Division -approved plans and specifications for the life of the facilities
permitted herein. [15A NCAC 02T .0105(o)]
7. This permit is subject to revocation or modification upon 60-day notice from the Division Director, in
whole or part for:
a. violation of any terms or conditions of this permit or Administrative Code Title 15A Subchapter
02U;
b. obtaining a permit by misrepresentation or failure to disclose all relevant facts;
c. the Permittee's refusal to allow authorized Department employees upon presentation of credentials:
I. to enter the Permittee's premises where a system is located or where any records are required
to be kept;
ii. to have access to any permit required documents and records;
iii. to inspect any monitoring equipment or method as required in this permit; or
iv. to sample any pollutants; or
d. a Division determination that the conditions of this permit are in conflict with North Carolina
Administrative Code or General Statutes.
[15A NCAC 02T .0110]
Permit issued this the 17t' day of February 2022
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
S. Daniel Smith, Director
Division of Water Resources
By Authority of the Environmental Management Commission
Permit Number WQ0042832
WQ0042832 Version 1.0 Shell Version 200201 Page 5 of 6

DocuSign Envelope ID: 713F213132A-50013-4790-A892-6621 BEB2E4C8
Permit No. WQ0042832 Reclaimed Water Distribution
Town of Holly Springs February 17, 2022
Oakview Innovation Park RWDL Wake County
ENGINEERING CERTIFICATION
❑ Partial ❑ Final
I, , as a duly licensed North Carolina Professional
Engineer, having ❑ periodically / ❑ fully observed the construction of the permitted facilities, do hereby
state to the best of my abilities that the facility was constructed in compliance with G.S. 143-215.1,
Administrative Code Title 15A Subchapter 02U, this permit, and the Division -approved plans and
specifications.
Documentation of any variation to this permit, and the Division -approved plans and specifications, is in the
attached as -built drawings.
Description of variations:
Professional Engineer's Name
Firm Name
Firm No.
Address
City JL
State
Zip Code
Telephone
Email
Seal, Signature, and Date
THE COMPLETED ENGINEERING CERTIFICATION, INCLUDING ALL SUPPORTING
DOCUMENTATION, SHALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
NON -DISCHARGE BRANCH
By U.S. Postal Service By Courier/Special DelivM
1617 MAIL SERVICE CENTER 512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604
WQ0042832 Version 1.0 Shell Version 200201
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DocuSign
Certificate Of Completion
Envelope Id: 7BF2BB2A500B4790A8926621BEB2E4C8
Subject: Complete with DocuSign: Oakview Innovation RWDL
Source Envelope:
Document Pages: 17 Signatures: 1
Certificate Pages: 5 Initials: 2
AutoNav: Enabled
Envelopeld Stamping: Enabled
Time Zone: (UTC-05:00) Eastern Time (US & Canada)
Record Tracking
Status: Original
12/16/2022 12:45:02 PM
Signer Events
Rachel Ingham
[e-mail]
Utility Engineer
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 11/16/2020 9:41:26 AM
ID: 0c7f672d-8bab-496f-91f1-115266328d46
Company Name: Town of Holly Springs
Drew Johnson
[e-mail]
Development Construction Manager
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 12/22/2022 11:43:13 AM
ID:a20aO551-7314-4a41-8b6d-040683aO949f
Company Name: Town of Holly Springs
Kendra Parrish
[e-mail]
Exec Director of Utilities and Infrastructure
Holly Springs
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 4/6/2021 7:18:46 PM
ID:6cbf2406-2f8d-46a2-8e81-c6f600daf744
Company Name: Town of Holly Springs
In Person Signer Events
Editor Delivery Events
Agent Delivery Events
Intermediary Delivery Events
Holder: Emily Koncz
[e-mail]
Signature
E�
Signature Adoption: Pre -selected Style
Using IPAddress: 65.191.132.203
[ID
Signature Adoption: Pre -selected Style
Using IPAddress: 174.203.250.168
Signed using mobile
EDocu by:
�CO6B69FC34449...
Signature Adoption: Drawn on Device
Using IPAddress: 64.98.124.55
Signed using mobile
Signature
Status
Status
Status
Status: Completed
Envelope Originator:
Emily Koncz
PO Box 8
Holly Springs, NC 27540
[e-mail]
IP Address: 204.84.166.2
Location: DocuSign
Timestamp
Sent: 12/16/2022 12:47:12 PM
Resent: 12/22/2022 8:47:23 AM
Viewed: 12/22/2022 11:36:06 AM
Signed: 12/22/2022 11:42:04 AM
Sent: 12/22/2022 11:42:09 AM
Viewed: 12/22/2022 11:43:13 AM
Signed: 12/22/2022 11:43:46 AM
Sent: 12/22/2022 11:43:51 AM
Viewed: 12/22/2022 12:46:44 PM
Signed: 12/22/2022 12:46:56 PM
Timestamp
Timestamp
Timestamp
Timestamp

Certified Delivery Events
Status
Timestamp
Carbon Copy Events
Status
Timestamp
Witness Events
Signature
Timestamp
Notary Events
Signature
Timestamp
Envelope Summary Events
Status
Timestamps
Envelope Sent
Hashed/Encrypted
12/16/2022 12:47:12 PM
Envelope Updated
Security Checked
12/19/2022 8:38:25 AM
Envelope Updated
Security Checked
12/19/2022 8:38:25 AM
Envelope Updated
Security Checked
12/19/2022 8:38:25 AM
Envelope Updated
Security Checked
12/19/2022 8:38:25 AM
Envelope Updated
Security Checked
12/19/2022 2:24:35 PM
Certified Delivered
Security Checked
12/22/2022 12:46:44 PM
Signing Complete
Security Checked
12/22/2022 12:46:56 PM
Completed
Security Checked
12/22/2022 12:46:56 PM
Payment Events Status Timestamps
Electronic Record and Signature Disclosure

Electronic Record and Signature Disclosure created on: 11/12/2020 9:42:57 PM
Parties agreed to: Rachel Ingham, Drew Johnson, Kendra Parrish
ELECTRONIC RECORD AND SIGNATURE DISCLOSURE
From time to time, Town of Holly Springs (we, us or Company) may be required by law to
provide to you certain written notices or disclosures. Described below are the terms and
conditions for providing to you such notices and disclosures electronically through the DocuSign
system. Please read the information below carefully and thoroughly, and if you can access this
information electronically to your satisfaction and agree to this Electronic Record and Signature
Disclosure (ERSD), please confirm your agreement by selecting the check -box next to `I agree to
use electronic records and signatures' before clicking `CONTINUE' within the DocuSign
system.
Getting paper copies
At any time, you may request from us a paper copy of any record provided or made available
electronically to you by us. You will have the ability to download and print documents we send
to you through the DocuSign system during and immediately after the signing session and, if you
elect to create a DocuSign account, you may access the documents for a limited period of time
(usually 30 days) after such documents are first sent to you. After such time, if you wish for us to
send you paper copies of any such documents from our office to you, you will be charged a
$0.00 per -page fee. You may request delivery of such paper copies from us by following the
procedure described below.
Withdrawing your consent
If you decide to receive notices and disclosures from us electronically, you may at any time
change your mind and tell us that thereafter you want to receive required notices and disclosures
only in paper format. How you must inform us of your decision to receive future notices and
disclosure in paper format and withdraw your consent to receive notices and disclosures
electronically is described below.
Consequences of changing your mind
If you elect to receive required notices and disclosures only in paper format, it will slow the
speed at which we can complete certain steps in transactions with you and delivering services to
you because we will need first to send the required notices or disclosures to you in paper format,
and then wait until we receive back from you your acknowledgment of your receipt of such
paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to
receive required notices and consents electronically from us or to sign electronically documents
from us.
All notices and disclosures will be sent to you electronically

Unless you tell us otherwise in accordance with the procedures described herein, we will provide
electronically to you through the DocuSign system all required notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided or made
available to you during the course of our relationship with you. To reduce the chance of you
inadvertently not receiving any notice or disclosure, we prefer to provide all of the required
notices and disclosures to you by the same method and to the same address that you have given
us. Thus, you can receive all the disclosures and notices electronically or in paper format through
the paper mail delivery system. If you do not agree with this process, please let us know as
described below. Please also see the paragraph immediately above that describes the
consequences of your electing not to receive delivery of the notices and disclosures
electronically from us.
How to contact Town of Holly Springs:
You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: [e-mail]
To advise Town of Holly Springs of your new email address
To let us know of a change in your email address where we should send notices and disclosures
electronically to you, you must send an email message to us at [e-mail]
and in the body of such request you must state: your previous email address, your new email
address. We do not require any other information from you to change your email address.
If you created a DocuSign account, you may update it with your new email address through your
account preferences.
To request paper copies from Town of Holly Springs
To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an email to [e-mail] and in
the body of such request you must state your email address, full name, mailing address, and
telephone number. We will bill you for any fees at that time, if any.
To withdraw your consent with Town of Holly Springs
To inform us that you no longer wish to receive future notices and disclosures in electronic
format you may:

i. decline to sign a document from within your signing session, and on the subsequent page,
select the check -box indicating you wish to withdraw your consent, or you may;
ii. send us an email to [e-mail] and in the body of such request you must
state your email, full name, mailing address, and telephone number. We do not need any other
information from you to withdraw consent.. The consequences of your withdrawing consent for
online documents will be that transactions may take a longer time to process..
Required hardware and software
The minimum system requirements for using the DocuSign system may change over time. The
current system requirements are found here: hitps://sU]2ort.docusign.com/guides/signer-guide-
si fining -system -requirements.
Acknowledging your access and consent to receive and sign documents electronically
To confirm to us that you can access this information electronically, which will be similar to
other electronic notices and disclosures that we will provide to you, please confirm that you have
read this ERSD, and (i) that you are able to print on paper or electronically save this ERSD for
your future reference and access; or (ii) that you are able to email this ERSD to an email address
where you will be able to print on paper or save it for your future reference and access. Further,
if you consent to receiving notices and disclosures exclusively in electronic format as described
herein, then select the check -box next to `I agree to use electronic records and signatures' before
clicking `CONTINUE' within the DocuSign system.
By selecting the check -box next to `I agree to use electronic records and signatures', you confirm
that:
You can access and read this Electronic Record and Signature Disclosure; and
You can print on paper this Electronic Record and Signature Disclosure, or save or send
this Electronic Record and Disclosure to a location where you can print it, for future
reference and access; and
Until or unless you notify Town of Holly Springs as described above, you consent to
receive exclusively through electronic means all notices, disclosures, authorizations,
acknowledgements, and other documents that are required to be provided or made
available to you by Town of Holly Springs during the course of your relationship with
Town of Holly Springs.