NC0087122_application_20230807

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North Carolina
Department of Environmental Quality
Division of Water Resources
Modified Application Form 2A
Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < 0.1 MGD
and No Pretreatment Program
NPDES Permitting Program
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO075388
COOPER RIIS HEALING FARM
Modified March 2021
Form
NC Department of Environmental Quality - Application for NPDES Permit to Discharge Wastewater
MINOR SEWAGE FACILITIES (Before completing this form, please read the instructions. Failure to follow
NPDES
the instructions may result in denial of the application.)
SECTION•N
INFORMATION FOR i
1.1
Facility name
COOPER RIIS HEALING FARM
Mailing address (street or P.O. box)
PO BOX 600
City or town
State
ZIP code
o
MILL SPRING
INC
28756
r
EContact
name (first and last)
Title
Phone number
Email address
.0
c
TOM WARREN
MANAGER
[phone]
TOM.WARREN@COOPERRIIS.(
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
R
LL-
101 HEALING FARM LANE
City or town
State
ZIP code
MILL SPRING
INC
28756
1.2
Is this application for a facility that has 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 ❑ No SKIP to Item 1.4.
Applicant name
Applicant address (street or P.O. box)
0
o
City or town
State
ZIP code
w
r
Contact name (first and last)
Title
Phone number
Email address
.Q
a
1.4
Is the applicant the facility's owner, operator, or both? (Check only one response.)
❑✓ Owner ❑ Operator ❑ Both
1.5
To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
❑ Facility ❑✓ Applicant ❑ 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.
Existing Environmental Permits
a
✓❑ NPDES (discharges to surface
❑ RCRA (hazardous waste)
❑ UIC (underground injection
R
water)
control)
E
c
NCO075388
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
w
a�
y
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
❑ Other (specify)
w
404)
Page 1

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO075388
COOPER RIIS HEALING FARM
Modified March 2021
1.7
Provide the collections stem information
requested below for the treatment works.
Municipality
Population
Collection System Type
Ownership Status
Served
Served
indicate percentage)
100 % separate sanitary sewer
0 Own 0 Maintain
250
% combined storm and sanitary sewer
❑ Own ❑ Maintain
2-1
CD
❑ Unknown
❑ Own ❑ Maintain
c%
separate sanitary sewer
El Own ❑ Maintain
R
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
a
% separate sanitary sewer
ElOwn ElMaintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
2
% separate sanitary sewer ❑ Own ❑ Maintain
N%
combined storm and sanitary sewer ❑ Own ❑ Maintain
c
❑ Unknown ❑ Own ❑ Maintain
Total
Population 250
�
Served
Separate Sanitary Sewer System Combined Storm and
Sanitary Sewer
Total percentage of each type of
sewer line in miles
0
o /o
100 �0
1.8
Is the treatment works located in Indian Country?
'
0
U
ElYes ✓❑ No
1.9
Does the facility discharge to a receiving water that flows through Indian Country?
c
❑ Yes ❑✓ No
1.10
Provide design and actual flow rates in the designated spaces.
Design Flow Rate
.011 mgd
= N
Annual Average Flow Rates Actual
Two Years Ago
Last Year
This Year
a o
.004 mgd
.0041 mgd
.004 mgd
Maximum Daily Flow Rates Actual
Two Years Ago
Last Year
This Year
o.o11 mgd
oil mgd
oil mgd
1.11
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
oTotal
Number of Effluent Discharge Points b T pe
a Q-
a'
Combined Sewer
Constructed
Treated Effluent
Untreated Effluent
Overflows
Bypasses
Emergency
Overflows
M
G
1
0
0
0
0
Page 2

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO075388
COOPER RIIS HEALING FARM
Modified March 2021
Outfalls Other Than to Waters of the State of North Carolina
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 ❑✓ 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 Discharge Data
Average Daily Volume
Continuous or Intermittent
Location
Discharged to Surface
(check one)
Impoundment
❑ Continuous
gpd
❑ Intermittent
ElContinuous
gpd
❑ Intermittent
gpd
ElContinuous
❑ Intermittent
Z
1.14
Is wastewater applied to land?
❑ Yes ❑✓ No 4 SKIP to Item 1.16.
0
1.15
Provide the land application site and discharge data requested below.
C
Land Application Site and Discharge Data
o
0
Average Daily Volume
Continuous or
a,
Location
Size
Applied
Intermittent
check one
Hacres
d
gpd
❑ Continuous
o
❑ Intermittent
acres
d
gpd
El Continuous
o
ElIntermittent
acres
d
gpd
El Continuous
❑ Intermittent
R
1.16
Is effluent transported to another facility for treatment prior to discharge?
o
ElYes ❑✓ No -* 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.
Transporter 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
Facility Name
Modified Application Form 2A
NCO075388
COOPER RIIS HEALING FARM
Modified March 2021
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving facility.
Receiving F cility Data
-a
Facility name
Mailing address (street or P.O. box)
d
City or town
State
ZIP code
0
U
Contact name (first and last)
Title
0
d
Phone number
Email address
c
NPDES number of receiving facility (if any) ❑ None
Average daily flow rate mgd
0.
0
1.21
Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
0
not have outlets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
Er
❑ Yes ❑✓ No 4 SKIP to Item 1.23.
0
1.22
Provide information in the table below on these other disposal methods.
Information on Other Disposal Methods
o
Disposal
Location of
Size of
Annual Average
Continuous or Intermittent
Method
Disposal Site
Disposal Site
Daily Discharge
(check one)
Description
Volume
.�
acres
gpd
El
❑ Intermittent
acres
gpd
ElContinuous
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
1.23
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)? (Check all that apply.
ti
Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
El El into marine waters (CWA ElWater quality related effluent limitation (CWA Section
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?
❑ Yes ❑✓ No 4SKIP 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
Contractor 1
Contractor 2
Contractor 3
0
Contractor name
R
(companyname
0
Mailing address
street or P.O. box
r
City, state, and ZIP
code
L
o
Contact name (first and
U
last
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
Page 4

NPDES Permit Number Facility Name Modified Application Form 2A
NCO075388 COOPER RIIS HEALING FARM Modified March 2021
SECTION11 • •' • 1
o Outfalls to Waters of the State of North Carolina
a
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
T
c
❑ Yes ❑✓ No 4 SKIP to Section 3.
c
2.2
Provide the treatment works' current average daily volume of inflow
Average Daily Volume of Inflow and Infiltration
;�
w
and infiltration.
gpd
=
Indicate the steps the facility is taking to minimize inflow and infiltration.
3
0
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
g
specific requirements.)
a�
C
0
0
El Yes ❑ No
H
E
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
c M
(See instructions for specific requirements.)
o
❑ Yes ❑ No
2.5
Are improvements to the facility scheduled?
❑ Yes ❑ No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
0
w
d
E
d
CL
2.
E
0
0
y
3.
d
4.
Cn
R
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
E
a)
Scheduled
Affected
Begin
End
Begin
Attainment of
>
o
Improvement
Outfalls
Construction
Construction
Discharge
Operational
CL E
(from above)
(list o number)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
Level
MMIDDIYYYY
1.
5053 0 R
a�
s
2.
3.
4.
2.7
Have appropriate permits/clearances concerning other federal/state requirements been obtained? Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

NPDES Permit Number
Facility Name Modified Application Form 2A
NCO075388
COOPER RIIS HEALING FARM Modified March 2021
SECTION•'
• ON DISCHARGES
3.1
Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number 001
Outfall Number
Outfall Number
State
NORTH CAROLINA
w
r
County
POLK
0
w
City or town
MILL SPRING
0
c
r
Distance from shore
0 ft.
ft.
ft.
n
'i
Depth below surface
3.5 ft.
ft.
ft.
c
Average daily flow rate
.004 mgd
mgd
mgd
Latitude
35° 18' 24" N
Longitude
82' 09' 36" W
"
3.2
Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
R
o
❑ Yes ✓❑ No 4 SKIP to Item 3.4.
a�
3.3
If so, provide the following information for each applicable outfall.
y
Outfall Number
Outfall Number
Outfall Number
0
Number of times per year
L
discharge occurs
a
Average duration of each
o
discharge (specify units
Average flow of each
mgd
mgd
mgd
0
discharge
R
in
Months in which discharge
occurs
3.4
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes ❑✓ No 4 SKIP to Item 3.6.
3.5
Briefly describe the diffuser t pe at each applicable outfall.
CL
Outfall Number
Outfall Number
Outfall Number
d
w
0
vi
3 6
Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
12
one or more discharge points?
3::
❑✓ Yes ❑ No 4SKIP to Section 6.
Page 6

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO075388
COOPER RIIS HEALING FARM
Modified March 2021
3.7
Provide the receiving water and related information if known for each outfall.
Outfall Number 001
Outfall Number
Outfall Number
Receiving water name
CANAL CREEK
Name of watershed, river,
0
or stream system
BROAD RIVER BRP
•L
U.S. Soil Conservation
N
Service 14-digit watershed
03050105150010
o
code
L
Name of state
a�
management/river basin
BROAD
U.S. Geological Survey
8-digit hydrologic
03050105
cataloging unit code
Critical low flow (acute)
cfs
cfs
cfs
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
3.8
Provide the following information
describing the treatment pr vided for discharges from each outfall.
Outfall Number 001
Outfall Number
Outfall Number
Highest Level of
0 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)
0
Q
Design Removal Rates by
Outfall
d
BOD5 or CBOD5
85 %
%
%
c
d
E
acci
L
TSS
85 %
%
%
0 Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
%
%
%
0 Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
%
%
%
Other (specify)
0 Not applicable
❑ Not applicable
❑ Not applicable
Page 7

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO075388
COOPER RIIS HEALING FARM
Modified March 2021
3.9
Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season, describe below.
d
0
U
Outfall Number 001
Outfall Number
Outfall Number
0CL
r
Disinfection type
ULTRAVIOLET
tp
N
G
Seasons used
ALL
y
E
r
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?
✓❑ 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 ✓❑ No 4 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
R
Number of tests of discharge
a,
water
Number of tests of receiving
water
d
w
LU
w
3.14
Does the POTW use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
❑ Yes 4 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 ❑ No additional sampling required by NPDES
permitting authority.
Page 8

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO075388
COOPER RIIS HEALING FARM
Modified March 2021
3.19
Has the POTW conducted either (1) minimum of four quarterly WET tests for one year preceding this permit application
or (2) at least four annual WET tests in the past 4.5 years?
❑ Yes ❑ No + Complete tests and Table E and SKIP to
Item 3.26.
3.20
Have you previously submitted the results of the above tests to your NPDES permitting authority?
❑ Yes ❑ No 4 Provide results in Table E and SKIP to
Item 3.26.
3.21
Indicate the dates the data were submitted to our NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
Summary of Results
MM/DD/YYYY
m
c
0
3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
o
toxicity?
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
d
w
L
w
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

NPDES Permit Number
Facility Name Modified Application Form 2A
NCO075388
COOPER RIIS HEALING FARM Modified March 2021
SECTION.
CHECKLIST
AND 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 applicants are required to provide attachments.
Column 1
Column 2
Section 1: Basic Application
w/ variance requestEl wl additional attachments
ElInformation
for All A licants
Section 2: Additional
❑ w/ topographic map ❑ wl process flow diagram
Information
❑ w/ additional attachments
❑✓ w/ Table A ❑ wl Table D
Section 3: Information on
❑ w/ Table B ❑ wl additional attachments
Effluent Discharges
E
❑ w/ Table C
d
ca
w.
`o
Section 4: Not Applicable
c
0
Section 5: Not Applicable
d
U
Section 6: Checklist and
❑
0 wl attachments
w
Certification Statement
Y
6.2
Certification Statement
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 properly 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 imprisonment for knowing violations.
Name (print or type first and last name)
Official title
THOMAS A WARREN, JR
CHIEF ADMIN OFFICER
Signature
Date signed
Page 10

NPDES Permit Number
Facility Name
Outfall Number
NCO075388
COOPER RIIS HEALING FARM
Modified Application Form 2A
Modified March 2021
Maximum Daily Discharge
Average Daily Discharge
Analytical ML or MDL
Value
Units
Number of
Pollutant
Value Units
Methods Include units
( )
Samples
Biochemical oxygen demand
o BOD5 or ❑ CBOD5
29.64
MG/L
17.2
MG/L
52
5210E MG/L El MDMI L
(report one)❑
Fecal coliform
9
CFLI/100MLS
6
CFU/100MLS
52
9222D CFLI/100K/ 17 ML
❑ MDL
Design flow rate
.011
MGD
.004
MGD
365
pH (minimum)
6.0
SU
pH (maximum)
7.5
SU
Temperature (winter)
14.4
C
10.2
C
130
Temperature (summer)
25.8
C
16.9
C
131
Total suspended solids (TSS)
15.9
MG/L
10.6
MG/L
52
2540D MG/L 17 ML
❑ MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 11

NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NCO075388 COOPER RIIS HEALING FARM
Modified March 2021
�� • •
•1111111 1111111311•
Maximum Dail Discharge Average Dail Discharge
Pollutant
Analytical ML or MDL
Number
(list)
�
Value
Units Value
Units
d Metho(include units)
Samples
s
❑� No additional sampling is required by NPDES permitting authority.
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or required
under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 18