310565_Lagoon Closure Form_20230601

Animal Waste Storage Pond and Lagoon Closure Report Form
(Please type or print all information that does not require a signature)
General Information: ti
Name of Farm: Y�Sy 4 1
Facility No:
Owner(s) Name:
Mailing Address: 1`) Phone No: _52
County:
Operation Description (remaining animals only):
o Please check this box if there will be no animals on this farm after lagoon closure. If there will still be animals on the site after
lagoon closure, please provide the following information on the animals that will remain.
Operation Description:
Type of Swine No. of Animals
o Wean to Feeder
Ito Finish a d
o F;Ivow to Wean
,'arrow to Feeder
o Farrow to Finish
o Gilts
o Boars
Type of Dairy
o Milking
o Dry
o Heifers
o Calves
No. of Animals
Number ofAnimals: m"
Will the farm maintain a number of animals greater than the G.S. § 143-215.1 OB threshold? Yes No o
Will other lagoons be in operation at this farm after this one closes? Yes o--'No 0
How many lagoons are left in use on this farm?: t
(Name) -' - �. ;P of the Water Quality Regional Operations Section staff in the
Division of Water Resources' ti G"on Regional Office (see map on back) was
contacted on t�_(date) for note ication of the pending closure of this pond or lagoon. This notification
was at least 24�rs prior to the start of closure, which began on Q 9 (date).
I verify that the above information is correct and complete. I have followed a closure plan, which meets all NRCS
specifications and criteria. I realize that I will be subject to enforcement action per Article 21 of the North Carolina
General Statutes if I fail to properly close out the lagoon.
Name of Land Owner (Please Print):
Signature:
Type of Poultry No. of Animals
o Layer
o Non -Layer
Type of Beef No. of Animals
o Brood
o Feeders
o Stockers
Other Type of Livestock:
Date: �^
The facility has followed a closure plan which meets all requirements set forth in the NRCS Technical Guide Standard
360. The following items were completed by the owner and verified by me: all waste liquids and sludges have been
removed and land applied at agronomic rate, all input pipes have been removed, all slopes have been stabilized as
necessary, and vegetation established on all disturbed areas.
Name of Technical pecialist (Please Print):
Affiliation:JJC ' 1 V 1 1 0 . )i) 1" aE hi " �
Address (,
Signature:
WIN
e No.: 0 . C 7 -170
Return within 15 days following completion of animal water storage pond or lagoon closure to:
N. C. Division of Water Resources
Animal Feeding Operations Branch
1636 Mail Service Center
Raleigh, NC 27699-1636
PLC - 1 Nov 19, 2013