HomeMy WebLinkAboutWQ0002648_Monitoring - 05-2023_20230627Monitoring Report Submittal
Permit Number#*
Name of Facility:*
Month: * May
WQ0002648
Seagrove -Utah Metropolitan
Report Information
Type *
NDMR, NDAR-1, NDAR-2, NDMLR
Confirmation Email Address:
Name of Submitter: *
Signature:
Date of submittal:
Initial Review
Year:* 2023
Upload Document*
5-May 2023 NDMR,NDAR Signed.pdf 2.73MB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
Itchilton128@gmail.com
Larry T. Chilton
v6;t tJ P. 641l-ew
Reviewer: Wanda.Gerald
6/27/2023
This will be filled in automatically
Is the project number correct?* WQ0002648
Is the monitoring report accepted?* Yes No
Regional Office* Winston-Salem
Reviewer: _anonymous
Review Date: 6/27/2023
FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page Y of S-
Permit No.: WQ0002648
Facility Name: Seagrove -Utah Metropolitan
County: Randolph
Month: May
Year: 2023
PPI: 001
Flow Measuring Point: Influent
Parameter Monitoring Point: Effluent
Parameter Code
50050
00310
00940
50060
31616
00610
00625
00620
00600
00400
00665
70300
00530
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24-hr
hrs
GPD
mg/L
mg/L
mg1L
#1100 mL
mg/L
mg/L
mg/L
mg1L
su
mg/L
mg/L
mg/L
1
06:30
8
30,600
1.5
7.1
2
06:30
8
30,000
1.5
7
3
06:00
8
27,800
1.6
7
4
06:30
8
30,600
1.5
6.9
5
06:00
8
28,200
1.4
6.8
6
05:00
8
20,500
2.2
7.1
7
04:00
8
19,200
2
1
7,1
8 1
06:30
8
27,800
1.9
7.1
9
06:00
8
29,500
1.8
7.1
10
06:00
8
25,800
1.8
7.2
11
06:00
8
25,000
1.8
7.1
12
06:00
8
22,100
1.7
7.2
13
04:00
8
18,700
2.2
7.1
14
04:00
8
19,000
1.9
7.1
15
06:00
8
23,100
1.8
7.2
161
06:00
8
25,100
10.5
1.8
<1
55.1
57.1
2.5
59.7
7.1
8.17
9.78
17
06:00
8
27,400
1.7
7.3
18
06:00
8
27,000
1.7
7.3
19
06:00
8
25,800
1.6
7.1
20
04:00
8
1 19,800
0.8
1 7.3
21
04:00
8
18,200
2
1
7.3
22
06:00
8
18,900
1.9
7.2
23
06:00
8
22,100
1.9
7.2
241
06:00
8
19,300
2
7.3
25
06:00
8
21,900
1.8
7.2
26
04:00
8
32,900
1.8
7.1
27
06:00
4
24,500
1.7
7.2
28
06:00
4
57,900
1.7
7.1
29
06:00
8
24,600
0.9
7.2
30
06:00
8
19,600
1.6
7.2
311
06:00
1 8
20,500
1.7
7.1
Average:
25,271
10.50
1.72
1.00
55.10
57.10
2.50
59.70
8.17
9.78
Daily Maximum:
57,900
10.50
2.20
1.00
55.10
57.10
2.50
59.70
7.30
8.17
9.78
Daily Minimum:
18,200
10.50
0.80
1.00
55.10
57.10
2.50
59.70
6.80
8.17
1 9.78
Sampling Type:
Recorder
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Monthly Avg. Limit:
30,000
Daily Limit:
Sample Frequency:
Continuous
Monthly
3 X Year
5 X Week
Monthly
Monthly
Monthly
Monthly
Monthly
5 X Week
Monthly
3 X Year
Monthly
FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR)
Page i of S
Sampling Person(s)
Name: Russell Welch 11 Name: Cameron Testing Services
Name: II Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit?
Certified Laboratories
Co,ry.P l�
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Larry T. Chilton
Permittee: Seagrove/Utah Metropolitan Water District
Certification No.: 2WW-10681 SI-28234
Signing Official: Michael T. Walker
Grade: 2 Phone Number: 2WW-10681 SI-28234
Signing Officials Title: Secretary
Has the ORC changed since the previous NDMR?
Phone Number: 336-873-9055 Permit Expiration: 4/30/2027
Signature Date
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
I certify, under penally of law, that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that all qualified personnel properly gathered and evaluated 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 fines and imprisonment for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDAR-1 05-16 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _d of .S
Permit No.: WQ0002648
Facility Name: Seagrove -Utah Metropolitan Water District WWTP
County: Randolph
Month: May
Year: 2023
Field Name:
1
Field Name:
2
Field Name:
3
Field Name:
4
Did irrigation occur at
Area (acres):
2.1
Area (acres):
2
Area (acres):
2.1
Area (acres):
3.4
this facility?
Cover Crop:
Cover Crop:
Cover Crop:
Cover Crop:
Hourly Rate (in):
Hourly Rate (in):
Hourly Rate (in):
Hourly Rate (in):
Yes
Annual Rate (in):
38.4
Annual Rate (in):
38.4
Annual Rate (in):
38.4
Annual Rate (in):
38.4
Weather
Freeboard
Field Irrigated?
Yes
Field Irrigated?
Yes
Field Irrigated?
Yes
Field Irrigated?
Yes
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°F
in
ft
ft
gal
min
in
in
gal
min
in
in
gal
min
in
in
gal
min
in
in
1
PC
54
0
5'6"
2
PC
48
0
5'1"
6,250
12.5
0.11
0.11
6,250
12.5
0.12
0.12
5,680
11.4
0.10
0.10
9,660
19.3
0.10
0.10
3
PC
44
0
6'2"
4
PC
42
0
51101,
5
PC
46
0
57'
3,750
7.5
0.07
0.07
3,750
7.5
0.07
0.07
3,408
6.8
0.06
0.06
5,796
11.6
0.06
0.06
6 1
C 1
54
0
6'1"
7
PC
53
0
5'10"
8
PC
63
0
57"
9
PC
63
0
5'4"
10
C
57
0
510"
11
PC
52
0
4'9"
6,250
12.5
0.11
0.11
6,250
12.5
0.12
0.12
5.680
11.4
0.10
0.10
9,660
19.3
0.10
0.10
12
PC
57
0
6'2"
13
PC
61
0
5'9"
14
R
68
0.2
57'
15
PC
58
0
5'4"
16
R
61
0.5
5'0"
6,250
12.5
0.11
0.11
6,250
12.5
0.12
0.12
5,680
11.4
0.10
0.10
9,660
19.3
0.10
0.10
17
PC
63
0
6'1"
18
PC
57
0
5'10"
19
R
56
0.5
57'
20
CL
54
0
5'3"
21
CL
64
0
510"
5,000
1 10
0.09
0.09
5,000
10
0.09
0.09
4,545
9
0.08
0.08
7,727
15.4
0.08
0.08
22
PC
54
0
6T.
231
PC
1 55
0
5'9"
24
PC
52
0
5'5"
25
PC
51
0
1 5'3"
5,000
10
0.09
1 0.09
5,000
10
0.09
0.09
4,545
9
1 0.08
0.08
7,727
15.4
0.08
1 0.08
26
PC
56
0
6'3"
27
R
55
0.6
6'0"
28
R
54
1.2
57'
29
CL
1 60
0
4'10"
30
CL
60
0
47'
311
PC
1 61
0
1 6'3"
Monthly Loading:
32,500
0.57
32,500
0.60
29,538
0.52
50,230
0.54
12 Month Floating Total (in):
8.01
8.37
7.47
7.51
FORM: NDAR-1 05-16 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page ;�, of 5"
Did the application rates exceed the limits in Attachment B of your permit? Compliant V
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? Compliant V",_
Was a suitable vegetative cover maintained on all sites as specified in your permit? Compliant'
Were all setbacks listed in your permit maintained for every application to each permitted site? Compliant f
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Larry T. Chilton
Permittee:
Seagrove/Utah Metropolitan Water District
Certification No.: 2WW-10681 SI-28234
Signing Official: Michael T. Walker
Grade: 2 Phone Number: 336-302-3782
Signing Official's Title: Secretary
Has the ORC changed since the previous NDAR-1?
Phone Number: 336-873-9055 Permit Exp.: 4/30/27
A —�Xd7R3
2vX G' c. �L.IyC�
Signature Date
Signature Date
By this signature. I certify that this report is accurrale and complete to the best of my knowledge.
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 all qualified personnel property gathered and evaluated 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 fines and imprisonment for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDAR-1 05-16 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 3 of -S-
Permit No.: WQ0002648
Facility Name: Seagrove -Utah Metropolitan Water District WWTP
County: Randolph
Month: May
Year: 2023
Field Name:
5
Field Name:
6
Field Name:
7
Field Name:
8
Did irrigation occur at
Area (acres):
2.2
Area (acres):
2.6
Area (acres):
2.7
Area (acres):
2.4
this facility?
Cover Crop:
Cover Crop:
Cover Crop:
Cover Crop:
Hourly Rate (in):
Hourly Rate (in):
Hourly Rate (in):
Hourly Rate (in):
Yes
Annual Rate (in):
38.4
Annual Rate (in):
38.4
Annual Rate (in):
38.4
Annual Rate (in):
38.4
Weather
Freeboard
Field Irrigated?
Yes
Field Irrigated?
Yes
Field Irrigated?
Yes
Field Irrigated?
No
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in
I't
ft
gal
min
in
in
gal
min
in
in
gal
min
in
in
gal
min
in
in
1
PC
54
0
5'6"
2
PC
48
0
511"
4,540
9.1
0.08
0.08
7,950
15.9
0.11
0.11
9,660
19.3
0.13
0.13
3
PC
44
0
6'2"
4
PC
42
0
5'10"
5
PC
46
0
57'
2,724
5.5
0.05
0.05
4,770
9.6
0.07
0.07
5,796
11.6
0.08
0.08
6
C
54
0
6'1"
7
PC
53
0
5110"
8
PC
63
0
57"
9
PC
63
0
5'4"
10
C
57
0
5'0"
11
PC
52
0
4'9"
4,540
9.1
0.08
0.08
7,950
15.9
0.11
0.11
9,660
19.3
0.13
0.13
12
PC
57
0
67"
13
PC
61
0
5'9"
14
R
68
0.2
57'
15
PC
58
0
5'4"
16
R
61
0.5
5'0"
4,540
9.1
0.08
0.08
7,950
15.9
0.11
0.11
9,660
19.3
0.13
0.13
17
PC
63
0
6'1"
18
PC
57
0
5'10"
19
R
56
0.5
57'
20
CL
54
0
5'3"
21
CL
64
0
5'0"
3,636
7.2
0.06
0.06
6,363
12.7
0.09
0.09
7,727
15.4
0.11
0.11
22
PC
54
0
61"
23
PC
55
0
5'9"
24
PC
52
0
5'5"
25
PC
51
0
5'3"
3,636
7.2
0.06
0.06
6.363
1207
0.09
0.09
7,727
15.4
0,11
0.11
26
PC
56
0
6'3"
27
R
55
0.6
6'0"
28
R
54
1.2
57'
29
CL
60
0
4'10"
30
CL
60
0
47'
31
PC
61
0
6'3"
Monthly Loading:
23,616
0.40
41,346
0.59
50,230
0.69
0
0.00
12 Month Floating Total (in):
5.73
8.24
9.62
FORM: NDAR-1 05-16 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 3 of -�
Did the application rates exceed the limits in Attachment B of your permit? Compliant �=
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? Compliant ---
Were all setbacks listed in your permit maintained for every application to each permitted site? Compliant 4
i
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Larry T. Chilton
Permittee:
Seagrove/Utah Metropolitan Water District
Certification No.: 2WW-10681 SI-28234
Signing Official: Michael T. Walker
Grade: 2 Phone Number: 336-302-3782
Signing Official's Title: Secretary
Flas the ORC changed since the previous NDAR-1?
Phone Number: 336-873-9055 Permit Exp.: 4/30/27
--174
Signature Date
Signature
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
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 all qualified personnel properly gathered and evaluated 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 fines and imprisonment for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDAR-1 05-16 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page °f- of 6-
Permit No.: WQ0002648
Facility Name: Seagrove -Utah Metropolitan Water District WWTP
County: Randolph
Month: May
Year: 2023
Field Name:
9
Field Name:
10
Field Name:
11
Field Name:
12
Did irrigation occur at
Area (acres):
2.3
Area (acres):
2
Area (acres):
2.7
Area (acres):
2
this facility?
Cover Crop:
Cover Crop:
Cover Crop:
Cover Crop:
Hourly Rate (in):
Hourly Rate (in):
Hourly Rate (in):
Hourly Rate (in):
Yes
Annual Rate (in);
38.4
Annual Rate (in):
38.4
Annual Rate (in):
38.4
Annual Rate (in):
38.4
Weather
Freeboard
Field Irrigated?
Yes
Field Irrigated?
Yes
Field Irrigated?
Yes
Field Irrigated?
No
T
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=
°F
in
ft
ft
gal
min
in
in
gal
min
in
in
gal
min
in
in
gal
min
in
in
1
PC
54
0
5'6"
2
PC
48
0
511"
5,110
10.2
0.08
0.08
4,540
9.1
0.08
0.08
8,520
17
0.12
0.12
3
PC
44
0
67'
4
PC
42
0
5110"
5
PC
46
0
57'
3,066
6.1
0.05
0.05
2,724
5.5
0.05
0.05
5,112
10.2
0.07
0.07
6
C
54
0
611"
7
PC
53
0
5'10"
8
PC
63
0
57"
9
PC
63
0
5'4"
10
C
57
0
5.0"
11
PC
52
0
4'9"
5,110
10.2
0.08
0.08
4,540
9.1
0.08
0.08
8,520
17
0.12
0.12
12
PC
57
0
62"
13
PC
61
0
5'9"
14
R
68
0.2
57'
151
PC
1 58
0
5'4"
16
R
61
0.5
5-0"
5,110
10.2
0.08
0.08
4,540
9.1
0.08
0.08
8,520
17
0.12
0.12
17
PC
63
0
6'1"
18
PC
57
0
5110"
19
R
56
0.5
57'
20
CL
54
0
5'3"
21
CL
64
0
5'0"
4,091
8
0.07
0.07
3,636
7.2
0.07
0.07
6,818
13.6
0.09
0.09
22
PC
54
0
6'1"
23
PC
55
0
5'9"
24
PC
52
0
515"
25
PC
51
0
5'3"
4,091
8
0.07
0.07
3,636
7.2
0.07
0.07
6,818
13.6
0.09
0.09
26
PC
56
0
6'3"
27
R
55
0.6
6'0"
28
R
54
1.2
57'
29
CL
60
0
4'10"
30
CL
60
0
47"
311
PC
1 61
1 0
1 6'3"
Monthly Loading:
26,578
0.43
23,616
0.43
44,308
0.60
0
0.00
12 Month Floating Total (in):
1
6.60
6.11
8.48
FORM: NDAR-1 05-16 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page -Y--- Of _-
Did the application rates exceed the limits in Attachment B of your permit? Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Larry T. Chilton
Permittee: Seagrove/Ulah Metropolitan Water District
Certification No.: 2WW-10681 SI-28234
Signing Official: Michael T. Walker
Grade: 2 Phone Number: 336-302-3782
Signing Official's Title: Secretary
Has the ORC changed since the previous NDAR-1?
Phone Number: 336-873-9055 Permit Exp.: 4/30/27
Signature Date
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
I certify, under penally of law, that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that all qualified personnel properly gathered and evaluated 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 fines and imprisonment for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDAR-1 05-16 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 5- of 6-
Permit No.: WQ0002648
Facility Name: Seagrove -Utah Metropolitan Water District WWTP
County: Randolph
Month: May
Year: 2023
Field Name:
13
Field Name:
14
Field Name:
15
Field Name:
16
Did irrigation occur at
Area (acres):
2.2
Area (acres):
2.1
Area (acres):
3.4
Area (acres):
3.8
this facility?
Cover Crop:
Cover Crop:
Cover Crop:
Cover Crop:
Hourly Rate (in):
Hourly Rate (in):
Hourly Rate (in):
Hourly Rate (in):
Yes
Annual Rate (in):
38.4
Annual Rate (in):
38.4
Annual Rate (in):
38.4
Annual Rate (in):
38.4
Weather
Freeboard
Field Irrigated?
Yes
Field Irrigated?
Yes
Field Irrigated?
Yes
Field Irrigated?
Yes
>
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rn
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x
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x T
3
i
°F
in
ft
ft
gal
min
in
in
gal
min
in
in
gal
min
In
in
gal
min
in
in
1
PC
54
0
5'6"
2
PC
48
0
5'1"
4,540
9.1
0.08
0.08
4,540
9.1
0.08
0.08
10,790
21.6
0.12
0.12
11,930
23.9
0.12
0.12
3
PC
44
0
6'2"
4
PC
42
0
5110"
5
PC
46
0
57'
2,724
5.5
0.05
0.05
2.724
5.5
0.05
0.05
6,474
13
0.07
0.07
7,158
14.3
0.07
0.07
6
C
54
0
6-1"
7
PC
53
0
5110"
8
PC
63
0
1 57"
9
PC
63
0
5'4"
10
C
57
0
5'0"
11
PC
52
0
4'9"
4,540
9.1
0.08
0.08
4,540
9.1
0.08
0.08
10,790
21.6
0.12
0,12
11,930
23.9
0.12
0.12
12
PC
57
0
67'
13
PC
61
0
5'9"
14
R
68
0.2
57'15
PC
58
0
5'4"
16
R
61
0.5
5'0"
4,540
9.1
0.08
0.08
4,540
9.1
0.08
0.08
10,790
21.6
0.12
0.12
11,930
23.9
0.12
0.12
17
PC
63
0
6'1"
18
PC
57
0
5'10"
19
R
56
0.5
57'
20
CL
54
0
5'3"
21
CL
64
0
5'0"
3,636
7.2
0.06
0.06
3,636
7.2
0.06
0.06
8,636
17.2
0,09
0.09
9,545
19.1
0.09
0.09
22
PC
54
0
6'1"
23
PC
55
0
5'9"
24
PC
52
0
5'5"
25
PC
51
0
5'3"
3,636
7.2
0.06
0.06
3,636
7.2
0.06
0.06
8,636
17.2
0.09
0.09
9,545
19.1
0.09
0.09
26
PC
1 56
0
6'3"
27
R
55
0.6
60"
28
R
54
1.2
5'7"
29
CL
60
0
4'10"
30
CL
60
0
47'
31
PC
61
0
6'3"
Monthly Loading:
23,616
0.40
23,616
0.41
56,116
0.61
62,038
0.60
12 Month Floating Total (in):
5.55
5.80
8.47
8.45
FORM: NDAR-1 05-16 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page .Y of S
Did the application rates exceed the limits in Attachment B of your permit? Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? Compliant ✓
Was a suitable vegetative cover maintained on all sites as specified in your permit? Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? Compliant t�
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Larry T. Chilton
Permittee:
Seagrove/Utah Metropolitan Water District
Certification No.: 2WW-10681 SI-28234
Signing official: Michael T. Walker
Grade: 2 Phone Number: 336-302-3782
Signing Official's Title: Secretary
Has the ORC changed since the previous NDAR-1?
Phone Number: 336-873-9055 Permit Exp.: 4/30/27
J �� l0 cif it �ir[i i;�
✓..i 1. (�('.-r K.:�• � � � -�
Signature Date
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
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 all qualified personnel properly gathered and evaluated 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 fines and imprisonment for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617