250029_Rescission Request_20230622

Animal Waste Storage Pond and Lagoon Closure Report Form
(Please type or print all information that does not require a signature)
General Information:
Name of Farm: A,. s �. �n�� �F,,�J`�13f� Facility No
Owner(s) Name: -7Wr p f A
.2S - 04
Mailing Address:_ / 7 Qvave4 �,�� _ — _ Phone No: -2 S1 •,145t7 /10
7 County: a­4�� .- - --
Operation Description(remaining animals only):
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 Stivine No. of Animals
o Wean to Feeder
o Feeder to Finish
o Farrow to Wean
• Farrow to Feeder
o Farrow to Finish
o Gilts
o Boars
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:
Type of Dairy
• Milking
•Dry
o Heifers
o Calves
No. of Animals
Number of Animals:
Will the farm maintain a number of animals greater than the G.S. § 143-215.1 OB threshold? Yes o No p/
Will other lagoons be in operation at this farm after this one closes? Yes o No 6/
How many lagoons are left in use on this farm?: 0
(Name)_ Meet 4.) T- ; Il-r of the Water Quality Regional Operations Section staff in the
Division of '. ter Resources Regional Office (see map on back) was
contacted on 3 -Z 1- 1013 (date) or notification of the pending closure of this pond or lagoon. This notification was
at least 24 hours prior to the start of closure, which began on J-=_-1o_ 1_:n (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): 0
Signature•.2&_0 _ Date: '_�r(r- Zn.13
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 Specialist (Please Print):
Affiliation: LZ S
Address (Agenc fi'A /!7_T`Z _ Phone No.: ,J_S 2 - L 3-7-.2 �;'V7 a�,* 3
Signature: Date: S - / r- �2 0.1 ? .
Return within 15 days following completion of animal water storage pond or lagoon closure to:
N. C. Division of Water Resources qECEPAD
Animal Feeding Operations Branch
1636 Mail Service Center JUN 2 2 2023
NC DEQ/DWR
Central Off g