NC0061620_Renewal (Application)_20230420

Gr�fe-r bk,rcj
North Carolina
Department of Environmental Quality Modified Application Form 2A
Division of Water Resources Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < o.1 MGD
and No Pretreatment Program
NPDES Permitting Program
RECEIVED
APc� � 0 20�3
NCDEC j[)WRjNPDES
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

NPDES Permit Number I Facility flame Modified Application Forth 2A
CL0 7^lf JrnnModified March 2021
Form NC Department of Environmental Quality - Aoplie6tion for NPDES Permit to Discharge Wastewater
NPDES MINOR SEWAGE FACILITIES (Before completing this form, please read the instructions. Failure to follow
the instructions ma resuk in denial of the a ication.
r r ••
1.1 Facility name , n 1 1 I ,
VU V1J
Mailing address (street or P.O. box
City or town State ZIP code
h� �2 NC,
E , Contact name (first and last) Title Phone number Email address
Rt I (-Goy �u� Cc+m c ee rzl
f Locatio dress (street, route number, or ther specific identifier) ❑ Same as mailing address g r • C-LW1
City or town State ZIP code
1.2 Is this applichtion for a facility that h s yet to commence discharge?
❑ Yes + See instructions on data submission No
requirements for new dischargers.
;> ` 1.3 Is applicant different from entity listed under Item 1,1 above?
❑ Yes L1Q No 4 SKIP to Item 1.4.
Applicant name
c
Applicant address (street or P.O. box)
a
City or town
State
ZIP code
s
Contact name (first and last)
Title
Phone number
Email address
n
1.4
Is the applicant the facility's owner, operator, or troth? (Check only one response.)
VOwner ❑ Operator ❑ Both
1.5
To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
❑ Facility ❑ Applicant Ib Facility and applicant
(they are one and the same)
1.6
Indicate below any existing environmental permits, (Check all that apply and print or type the corresponding permit
°
number for each.
ExietlnitEmrilronmontai Permits' ..:_
NPDES (discharges to surface
e)
❑ RCRA (hazardous waste)
❑ UIC (underground injection
Ewa
_ u1
control)
Q
❑ PSD (air emissions)
❑ Nonadainment program (CAA)
❑ NESHAPs (CAA)
w
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
❑ Other (specify)
j
404)
Page 1

NPDES Permit Numsbler �l G-IT U. Modified Application Form 2A
K� i ri I di D/ %) 11A It r r 0 Modfied March 2021
`.7
V VVv l
Provide the collections stem information requested below for the trealment works.
Municipality
fPopulation
Collection System Type
Served
Sered
indicate percentage)
Ownership Status
�o�W
P�f�
1
%sepa ate sanitary sewer
Own ❑ Maintain
(n�
%combined storm and sanitary sewer
❑ Own ❑ Maintain
tG
❑ Unknown
❑Own ❑ Maintain
c
% separate sanitary sewer
❑ Own ❑ Maintain
Ta
_'�,,
%combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
%separate sanitary sewer
❑ Own ❑ Maintain
a
m%combined
storm and sanitary sewer
❑ Own ❑ Maintain
E
❑ Unknown
❑ Own ❑ Maintain
•=
N%
_ % separate sanitary sewer
❑ Own ❑ Maintain
combined storm and sanitary sewer
❑ Own ❑ Maintain
a
❑ Unknown
❑ Own ❑ Maintain
TOW x
3 on' i
Separate Sanitary Sewer System
Cotttbirted StoymtM
samitary Sewis,
Total percentage of each type of
sewer line in miles
'
1.8
Is the treatment works located in Indian Country?
'a,
El Yes N / No
1.9
Does the facility discharge to a receiving water that flows through Indian Country?
❑ Yes No
1"
1.10
Provide design and actual flow rates in the designated spaces.
Design Ftowlitate
mgd
Annual Average Flow Rates Actual
Two Years Ago
Last Year
This Year
LA mgd
O L)13 i L[ mgd
1, mgd
Maximum Daily Flow Rates Actual
n
Two Years Ago
Last Year
This Year
mgd
O • W l mgd
p. LX>7_$ mgd
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
Bypasses
Constructed
Emergency
�=
Overflows
Overflows
Page 2

FAIi9.
NE
NNPDES Permit Number - Fadl;,Na Aaj 1 M lW Application Form 2A
I LD Z Modified March 2021
i�C�dta# �ThatttaWeta offtS oftb*Capilina , _
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 B/ 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 Im
oundment Location and Disch
a Data
Average Daily Volume
Location
Discharged to Surface
Continuous or Interm tteM
ousox
Impoundment
one)
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
gpd
❑ Continuous
f9
❑ Intermittent
1.14
Is wastewater applied to land?
_
❑ Yes L� No 4 SKIP to Item 1.16.
1.15
Provide the land application site and discharge data requested below.
_$
Land Application Site and Discharge Data
Location
Sue
Average Daily Volume
Continuousor
Intermittent
®
Applied
ctieckone
acres
d
gpd
❑ Continuous
_
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
.,o
acres
g�
❑ Continuous
❑ Intermittent
1.16
Is effluent transported to another facility for treatment pn r to discharge?
❑ Yes No 4 SKIP to Item 1.21.
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 applicant?
❑ Yes ❑ No 4 SKIP to Item 1.20.
1.19
Provide information on the transporter below.
Trans 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 1 ' Facility Narrh Modified Application Form 2A
% Modified March 2021
1.20 In the table below, indicate the name, address, contact infonnatioh!NPDES number, and average daily Flow rate of the
receiving facili .
f Receirht f
Facility name
Mailing address (street or P.O. box)
0
C' dY or town
State
ZlPcode
v
Contact name (first and last)
Title
V
Phone number
Email address
NPDES number of receiving facility (if any) ❑ None
Average daily flow rate mgd
5
21
Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
°
®
not have outlets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
v
4,�Q/
❑ Yes No + SKIP to Item 1.23.
1.22
Provide information in the table below on these other disposal methods.
Information on Other Disposal Methods
Disposal
Location of
Size of
Annual Average
Daily Discharge
Continuous or Intermittent
WMethod
Description
Disposal Site
Disposal Site
Volume
(check one)
acres
APd
❑ Continuous
❑ Intermittent
acres
gPd
❑ Continuous
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
'.23
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)? (Check all that apply.
r
Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
6
Discharges into marine waters (CWA Water quality related effluent limitation (CWA Section
a
Section 301 (h)) 302(b)(2))
Not applicable
1,24
Are any operational or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works
the responsibility of a contractor?�0
Yes ❑ 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
C f..
Cattttactor2
Contractor
®
(coa
(company na name)
Mailing address
�°—
n
street or P.O. box
i
o
City, state, and ZIP
A
code
5
Contact name (first and
U
last
Phone number
Email address
Operational and
maintenance
l.lM
responsibilities of
contractor
Page 4

Corn Q
NPDES Permit N�u�m/b'err Fatality Nd me U Modified Application Form 2A
I�X I GrQ.en b ► rd Modified March 2021
(-t,)
SECTION 2. ADDI TONAL INFORMATION (40 CIFIR 122.216)(1) and (2))
to Waters of the State of North Caroline
7{krifa-5
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
o
❑ Yes No SKIP to Section 3.
S
2.2
Provide the treatment works' current average daily volume of inflow
Average DaffVoftmre ofjnflow=d9niilhaf h .
gpd
and infiltration.
z
c
Indicate the steps the facility is taking to minimize inflow and infiltration.
v
c
m
`c
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
q
specific requirements.)
Q®Q�
F
❑ Yes ❑ No
E
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
2
(See instructions for specific requirements.)
0
❑ Yes ❑ No
2.5
Are improvements to the facility scheduled?
❑ Yes ❑ No + SKIP to Section 3.
c,
Briefly list and describe the scheduled improvements.
,a
EE
a
2.
E
D
3.
5
v
4.
�
2.6
Provide scheduled or actual dates of com letior'or im rovenens.
Scheduled
or Actual Dates of com letion for Im rovements
m
Scheduled-
Affected
Ou"Is
Begin
End
Begirt
Attainmeitof
Operational
o
Improvement
{listouffall
Construction
Construction
Discharge
Level
Level
a
g
from above
(' )
number
(MMIDWYYYY'
(MM/DDYYYY)
(MWDDrY"
a
1,
S
a
m
N
2.
3,
4.
2.7
Have appropriate permits/clearances concerning other federallstate requirements been obtained? Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

NPDES Penn Number _ Facility me Modified Application Form 2A
�O Gt �-r-f IV ( Modified Match 2021
SECTION•'
• ON r r
3.1
Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Dutfall Number
Outfafl Number
Gluffall Number
State
KV
4 A
County
Sir
City or town
Distance from shore
ft.
ft.
ft.
0
Depth below surface
ft.
ft.
ft.
Average daily flow rate
mgd
mgd
mgd
Latitude
' a (34
Longitude
3.2
Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
®
❑ Yes nz� No 4 SKIP to Item 3.4.
m
3.3
If so, provide the following information for each applicable oct`ail.
.c
Outfall Number
Outfall Number
Outfalf Number
Number of times per year
discharge occurs
Average duration of each
$ '-
discharge (specify units
R"
Average flow of each
mgd
mgd
mgd
i.
dischar e
w -
Months in which discharge
occurs
3.4
Are any of the ouffalls listed under Item 3.1 equipped with a diffuser?
❑ Yes Gl� No 4 SKIP to Item 3.6.
3.5
Briefly describe the diffuser t pe at each applicable outfall.
®
A
f.
Outfal4Number_
Outfall Number
OuNaHMumyer=
w
G
3.6
Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
one or more discharge points?
Yes ❑ No +SKIP to Section 6.
s*a:
Page 6

H
Provide the receivinq water and related information
Outfall Number
Receiving water name UGV15e6 ee
wilily Name Modified Application Form 2A
` 1Vr 1- f Modified Mamh 2021
e outfall.
Outfall Number Outfall Number "
Name of watershed, river,
(-,14H 40 TWn/-55
or stream system
P TY6'
U.S. Soil Conservation
Service 14-digit watershed
code
Name of state
management/Over basin
-S I h
U.S. Geological Survey
8-digdhydrologic
cataloging unit code
OLOb>♦ootoa
Critical low flow (acute)
cfs
cfs
cis
Critical low flow (chronic)
cfs
cfs
cfs
Total hardness at critical
mg/L of
mg/L of
mg/L of
low flow
CaCO3
CaCO3
CaCO3
Provide the following informal
on describin the treatment rovided for discharges from each outfall.
Outfalf Number_
Outfall Number_
Outfalf Number_
Highest Level of
Primary
❑
Primary
❑
Primary
Treatment (check all that
❑ Equivalent to
❑
Equivalent to
❑
Equivalent to
apply per outfall)
secondary
secondary
secondary
❑ Secondary
❑
Secondary
❑
Secondary
❑ Advanced
❑
Advanced
❑
Advanced
❑ Other (specify)
❑
Other (specify)
❑
Other (specify)
Design Removal Rates by
Outfall
BODa or CBODe
%
%
%
TSS
%
%
%
❑ Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
%
%
%
❑ Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
%
%
%
Other (specify)
❑ Not applicable
❑ Not applicable
❑ Not applicable
RECEIVED
APR 2 0 2D23
Page 7
NCDEQ/DWR/NPDES

CGrnp.
NPDES Pend Number Facdity ame ified Application Forn 2A
l r� u T Modified March 2021
3.9 Describe the type of disinfection used for the effluent from each outfalIA the table below. If disinfection varies by
season, describe below.
0
_
c
0
U
o
a
Autfialf NumberO
Outfall Number_
OutfOU Numbs"
Disinfection type
ra IC I Wn
cPO
ch I Ln
Seasons used
!1
1
�� n,
_p
Dechlorination used?
❑ Not applicable
❑ Not applicable
❑ Not applicable
Yes
❑ Yes
❑ Yes
❑ No
❑ No
❑ No
3.10
Have you completed monitoring for all Table A parameters and attached the results to the application package?
VW Yes ❑ 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 [1 No + 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,
Outfall Number
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
m
.
Number of tests of discharge
_
a
water
Number of tests of receiving
water
rk unk lr
3.14
Does theFQ4WUse chlorine for di nfection, use chlorine elsewhere in the treatment process, or otherwise have
reaspnable potential to discharge chlorine in is effluent?
Yes + Complete Table B, including chlorine. ❑ No 4 Complete Table B, omitting chlorine.
3.15
Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
❑ 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?
❑ Yes L� No additional sampling required by NPDES
permitting authority.
Page 8

Mal"O
NPDES Permit Number FacilitMarne
Modified AppIcation Fomr 2A
r„�
Modred March 2021
3.19
Has the POTWIco�ndaot/eldJeither (1) minimum of four quartedy WET tests for one year p eceding this pe mit appliation
vim,
or (2) at least four annual WET tests in the past 4.5 years?
/ No 4 Complete tests and Table E and SKIP to
El Yes 4t
J
Item 3.26.
3.20
Have you previously submitted the results of the above tests to your NPDES permitting authority?
r
No + Provide results in Table E and SKIP to
❑ Yes ❑
Item 3.26.
3.21
Indicate the dates the data were submitted to our NPDES pern-ittinq authority and provide a summary of the results.
DaWs) Submitted
Suimimary of Results
MM16DrYYYY
za .
ru
3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
toxicity?
c '
❑ Yes ❑ No SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
m
3.24
Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes ❑ No 4 SKIP to Item 3.26.
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?
"
❑ Yes Not applicable because previously submitted
information to the NPDES permitting authority.
Page 9

NPOES Permit Number Facility Name otlified Application Form 2A
Modified March 2021
I eat
SECTIONAND
CERTIFICATION STATEMENT (40
6.1
In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not
all a licants are required to provide attachments.
,JzOlumn 1 .'.
Column 2
ZySection 1: Basic Application
w Information for All Applicants
❑ wl variance request(s) ❑ wl additional attachments
Section 2: Additional
❑ wl topographic map ❑ wl process Flow diagram
Information
❑ w/ additional attachments
Section 3: Information on
Kr wl Table A ❑ w/ Table D
❑
Effluent Discharges
wi Table 6 ❑ w/add tional attachments
❑ wiTable C
c
Section 4: Not Applicable
a
Section 5: Not Applicable
m;
Section 6: Checklist and
wl attachments
Certification Statement
�r
6.2
Certification Statement
v _
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 property 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 im risonment for knowing violations.
Name (print or type first and last name)
Official We
0 L')
we
Signature
Data signed
3 �6 �3
Page 10

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