NC0023604_fact sheet_20230731

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
FACT SHEET FOR EXPEDITED PERMIT RENEWALS
This form must be completed by Permit Writers for all expedited permits which do not require
full Fact Sheets. Expedited permits are generally simple 100% domestics (e.g., schools, mobile
home parks, etc.) that can be administratively renewed with minor changes but can include
facilities with more complex issues (Special Conditions, 303(d) listed water, toxicity testing,
instream monitoring, compliance concerns).
Basic Information for Expedited Permit Renewals
Permit Writer/Date
Charles H. Weaver — 7/31/2023
Permit Number
NCO023604
Facility Name
Wilderness NC, Inc. Lumber Yard
Basin Name/Sub-basin number
Yadkin -Pee Dee 030704
Receiving Stream
UT to Flat Swamp Creek
Stream Classification in Permit
C
Does permit need Daily Max NH3 limits?
NH3 limits are at BAT for class WW-2
facilities.
Does permit need TRC limits/language?
Already resent
Does permit have toxicity testing?
No
Does permit have Special Conditions?
Biocide condition and High Rock Lake
reo ener
Does permit have instream monitoring?
D.O. & Temperature
Is the stream impaired on 303(d) list)?
No
Any obvious compliance concerns?
No
Any permit mods since lastpermit?
No
New expiration date
May 31, 2028
Changes in Draft Permit?
Updated biocide condition
Updated eDMR text
Changes to final permit?
None
Most Commonly Used Expedited Language:
303(d) language for Draft/Final Cover Letters: "Please note that the receiving stream
is listed as an impaired waterbody on the North Carolina 303(d) Impaired Waters List.
Addressing impaired waters is a high priority with the Division, and instream data will
continue to be evaluated. If there is noncompliance with permitted effluent limits and
stream impairment can be attributed to your facility, then mitigative measures may be
required".
• TRC language for Compliance Level for Cover Letters/Effluent Sheet Footnote:
"The facility shall report all effluent TRC values reported by a NC certified laboratory
including field certified. However, effluent values below 50 ug/1 will be treated as zero
for compliance purposes."

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
70097050 70699348
AFFIDAVIT OF PUBLICATION
STATE OF NORTH CAROLINA LEXINGTON, NC June 15, 2023
DAVIDSON COUNTY
I, Lynn Bowers OF THE DISPATCH, A NEWSPAPER PUBLISHED IN THE CITY OF LEXINGTON, COUNTY AND STATE
AFORESAID, BEING DULY SWORN, SAYS THE FOREGOING LEGAL OF WHICH THE ATTACHED IS A TRUE COPY,
WAS PUBLISHED IN SAID NEWSPAPER ONCE A WEEK FOR 1 WEEK, BEGINNING THE 15th DAY OF June, 2023.
PUBLICATION FEE: $ 103.17
(SEAL)
TO AND SUBSC IBE BEFORE ME, THIS DAY OF
k
p,AM Ali A
MY COMMISSION EXPIRES
Ad Copy:
Public Notice
North Carolina
Environmental
Management
Commission/NPDES Unit
1617 Mail Service
Center
Raleigh, NC 27699-1617
Notice of Intent to Issue a
NPDES Wastewater Permit
NCO023604 Wilderness -NC
Lumber Plant The North
Carolina Environmental
Management Commission
proposes to issue a NPDES
wastewater discharge
permit to the person(s)
listed below. Written
comments regarding the
proposed permit will be
accepted until 30 days after
the publish date of this
notice. The Director of the
INC Division of Wager
Resources (DWR) may hold
a public hearing should
there be a significant
degree of public interest
Please mail comments
and/or information requests
to DWR at the above
address. Interested persons
may visitthe DWR at 512 N.
Salisbury Street, Raleigh,
NC to review information on
rofflml. op
file. Additional information
on NPDES permits and this
notice may be found on our
website:
httr)://deo.nc.00v/about/di
visions/water-
reso u rces/water-reso urces-
nermits/wastewater-
branch/npdes-
wastewater/public-
notices,or by calling (919)
707-3601. Wilderness -NC,
Inc. has applied for renewal
of NPDES permit
NCO023604 for its Lumber
Plant (7578 U.S. Hwy 64,
Lexington) in Davidson
County. This permitted
facility discharges to an
unnamed tributary to Flat
Swamp Creek in the
Yadkin -Pee Dee River
Basin. Currently BOD,
ammonia nitrogen,
dissolved oxygen, fecal
coliform and total residual
chlorine are water quality
limited. This discharge may
affect future allocations in
this portion of the Yadkin -
Pee Dee River Basin.
June 15, 2023
i. ALLISON L MYERS
Notary Public, North Carolina
Davidson County
My Commission Expires
-----------------

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Wilderness- NC, Inc.
Attn: Ronnie Bolt
PO Box 2136
Lexington, NC 27293
Subject: Permit Renewal
Application No. NCO023604
Wilderness -NC Lumber Plant
Davidson County
Dear Applicant:
NORTH CAROLINA
Environmental Quality
January 23, 2023
The Water Quality Permitting Section acknowledges the January 23, 2023, receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150E-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deq nc gov/permits-regulations/permit-g-uidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
ec: WQPS Laserfiche File w/application
DEQ��
Sincerely, (, /
Cynthia Demery 00
Administrative Assistant
Water Quality Permitting Section
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 West Hanes Mill Road, Suite 300 1 Winston-Salem, North Carolina 27105
336176.9800

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
January 17, 2023
NC Department of Environment and Natural Resources
Division of Water Quality /NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject.
To Whom It May Concern:
Wilderness -NC, Inc.
PO Box 2136
Lexington, NC 27293
336-474-2314
Request to Renew Permit
NPDES Permit NC0023604
Wilderness NC, Inc.
Lexington, North Carolina
Davidson County
Wilderness NC, Inc. is requesting renewal of NPDES Permit NC0023604 in
accordance with Federal (40 FR 122.41) and North Carolina (1 SA CCAC 2IL 0105 (e))
regulations. No changes have been made since the issuance of our last permit.
Wilderness NC, Inc. permit expires May 31, 2023.
You will find a renewal package attached with this letter. The following are included.
One signed cover letter requesting renewal of the permit.
Form 1 NPDES, Form 2F NPDES, a recent lab report, the 2019 permit renewal and
the 2019 Draft permit.
I have completed this as best that I can.
If I can be of any assistance, please feel free to call Belinda Milan at 336-474-2314.
RECEIVED
JAN 2 0 2023
NCDEQIDWRINPDES
Sincerely,
//-e i3,, '--r
Ronnie Bolt

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
Tuesday, January 17, 2023 at 11:08:03 Eastern Standard Time
Subject: Re: Renewing NCO023604 Permit
Date: Thursday, December 15, 2022 at 3:30:44 PM Eastern Standard Time
From: Belinda Milan
To: Williams, Paul E
Attachments: image001.png
Do you have an email address, the phone is not going through
1 M I/ : ,l
WILDERNESS NC, INC.
PHONE [phone] ext. 103
FAX [phone]
From: "Williams, Paul E" <[e-mail]>
Date: Thursday, December 15, 2022 at 9:21 AM
To: Belinda Milan <[e-mail]>
Subject: Renewing NCO023604 Permit
Belinda,
NPDES Wastewater permits are not processed out of the regional offices, only through Central Office. I am
attaching individual permit renewal information. If you will require further assistance, I would direct you to
contact the NPDES Permitting Branch at [phone].
Thank you,
Paul Williams
Environmental Assistance Coordinator
Winston Salem Regional Office
North Carolina Department of Environmental Quality
Office: [phone]
[e-mail]
..........
EQ
ti;
NOH 1 H CAHOLNA -�
Department of Environmental Quality
NAC>Y-N.k 1S b a—n c� Y-i
1�- oeS .0 6,-t5"/ nI(ya l .
Email correspondence to and from this address is subject to the North
Carolina Public Records Law and may be disclosed to third parties.
Page 1 of 1

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
Tuesday, January 17, 2023 at 11:26:34 Eastern Standard Time
Subject: RE: [External] Re: Renewing NCO023604 Permit
Date: Thursday, December 15, 2022 at 3:42:11 PM Eastern Standard Time
From: Williams, Paul E
To: Belinda Milan
Attachments: image002.png, image003.png
I do not have any specific individual contact information, for their unit. I did find secondary front desk
number. It is [phone]. + N p 1 0 /2 2.
1
Thank you, � I/ zg
Paul Williams
Environmental Assistance Coordinator
Winston Salem Regional Office
North Carolina Department of Environmental Quality
Office: [phone]
[e-mail]
cc�-��D tj E
hl 1111 I CARouNA
�Aj
Department of Environmental Quality
Email correspondence to and from this address is subject to the North
Carolina Public Records Law and may be disclosed to third parties.
From: Belinda Milan <[e-mail]>
Sent: Thursday, December 15, 2022 3:31 PM
To: Williams, Paul E <[e-mail]>
Subject: [External] Re: Renewing NCO023604 Permit
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to Report Spam.
Do you have an email address, the phone is not going through
BELINDA MILAN
WILDERNESS NC, INC.
PHONE [phone] ext. 103
FAX [phone]
Page 1 of 2

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
From: "Williams, Paul E" <[e-mail]>
Date: Thursday, December 15, 2022 at 9:21 AM
To: Belinda Milan <[e-mail]>
Subject: Renewing NCO023604 Permit
Belinda,
NPDES Wastewater permits are not processed out of the regional offices, only through Central Office. I am
attaching individual permit renewal information. If you will require further assistance, I would direct you to
contact the NPDES Permitting Branch at [phone].
Thank you,
Paul Williams
Environmental Assistance Coordinator
Winston Salem Regional Office
North Carolina Department of Environmental Quality
Office: [phone]
[e-mail]
D- E
�
NORTH CAROLINA C110)
Department of Environmental Quality
Email correspondence to and from this address is subject to the North
Carolina Public Records Law and may be disclosed to third parties.
Page 2 of 2

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
Tuesday, January 17, 2023 at 11:09:40 Eastern Standard Time
Subject: waste water permit NCO023604
Date: Monday, January 9, 2023 at 3:00:07 PM Eastern Standard Time
From: Belinda Milan
To: [e-mail]
Joe,
I am trying to renew the waste water permit for Wilderness NC, Inc. I am having difficulties navigating the
forms that need to be filled out. The last renewal that I did was on short form C — minor industrial. I filled
out the forml NPDES and then it tells me to go to form 2S, this form is 23 pages long and I have no clue on
some of the information that is being asked. My number is 336-474-2314. 1 would appreciate your help on
this.
Thank you,
BELINDA MILAN
WILDERNESS NC, INC.
PHONE [phone] ext. 103
FAX [phone]
0 a 1 l' CL. `LA43
NU'i GE{�GiGi�G �/G ice rnQi �S
ct,n caL fo r' In 4- r
91q- 70 7- 3�'7
Page 1 of 1

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
Tuesday, January 17, 2023 at 11:10:13 Eastern Standard Time
Subject: Wilderness Nc Inc permit renewal
Date: Wednesday, January 11, 2023 at 8:59:27 AM Eastern Standard Time
From: Belinda Milan
119191 To: [e-mail], [e-mail], [e-mail],
L e�-k Vow � �o [e-mail], [e-mail], [e-mail],
�ne951= 1�
12zL"R o cv � [e-mail]
1 Attachments: 2019 PERMIT RENEWAL APPLICATION.pdf, CURRENT PERMIT.pdf, FORM 1.pdf, FORM 2F.pdf
qIq• 707 1&16
1 have been trying since the beginning of November to get help with this renewal and have not had any luck
in getting in touch with anyone. I am attaching the last permit renewal, the current permit and for 1 NPDES
and what I have filled out on form 2F NPDES. I am at a loss on how to proceed further
BELINDA MILAN
WILDERNESS NC, INC.
PHONE [phone] ext. 103
FAX [phone]
C� IZ�Sp� asc-
�U � Jv"L CLn�/o r12.
Page 1 of 1

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO023604
OMB No.2040-0004
Form
U.S. Environmental Protection Agency
1
�--.EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
1. ACTIVITIES
REQUIRINGSECTION •r 4i
1.1
Applicants Not Required to Submit Form 1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete 0 No
If yes, STOP. Do NOT No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1,2
Applicants Required to Submit Form 1
=.
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
operation or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
d
o-
production facility?
currently discharging process wastewater?
p[]
Yes 4 Complete Form 1 No
Yes 3 Complete Form 0✓ No
o-
and Form 2B.
1 and Form 2C.
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
c
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
commenced to discharge?
discharges only nonprocess wastewater?
Yes 4 Complete Form 1 ✓] No
[] Yes Complete Form No
and Form 2D.
1 and Form 2E.
N
1.2.5
Is the facility a new or existing facility whose
discharge is composed entirely of stormwater
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
Yes 4 Complete Form 1 j] No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
SECTION
2. NAME,
2.1
MAILING ADDRESS, AND 40
Facility Name
Wilderness NC, Inc.
0
2.2
EPA Identification Number
0
J
m
2.3
Facility Contact
Name (first and last)
Title
Phone number
'a
Ronnie D Bolt
Owner
(3361 474-2314
Email address
[e-mail]
d
2.4
Facility Mailing Address
Street or P.O. box
z
PO Box 2136
City or town
State
ZIP code
Lexington
NC
27293
EPA Form 3510-1 (revised 3-19) Page 1

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identifcation Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO023604
OMB No. 2040-0004
2.5
Facility Location
.a
Street, route number, or other specific identifier
a 0
0
7578 U5 HWY 64 East
co
c
County name
County code (if known)
Davidson
0
o
City or town
State ZIP code
ca
Z 0
Thomasville
INC 27360
SECTION•D
1
SIC Code(s)
Description (optional)
3.1
321912-32113
N
d
a
O
C.i
C0
U
z
3.2
NAILS Code(s)
Description (optional)
c
U
SECTION,
OPERATOR
INFORMATION (40
4.1
Name of Operator .
Ronnie D Bolt
0
4.2
Is the name you listed in Item 4.1 also the owner?
W
r=
® Yes ❑ No
.02
43
0 erator Status
❑ Public —federal ❑ Public —state El Other public (specify)
❑✓ Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
0 eratorAddress
Street or P.O. Box
cc
0
PO Box 2136
y
City or town
State
ZIP code
o v
Lexington
INC
27293
�
Email address of operator
Q
[e-mail]
SECTION•A
5.1
•'0
Is the facility located on Indian Land?
o
—�
❑ Yes ❑✓ No
EPA Form 3510-1(revised 3-19) Page 2

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03105119
NCO023604 OMB No, 2040-0004
SECTION'• 41
6.1 Existing Environmental Permits (check all that apply and print or type the corresponding permit number for each
u m NPDES (discharges to surface ❑ RCRA (hazardous wastes) ❑ UIC (underground injection of
r- water) fluids)
Lo
8 A NCG210295
Lu n
ElPSD (air emissions)
ElNonattainment program (CAA)
❑ NESHAPs (CAA)
x
❑ Ocean dumping (MPRSA) ElDredge or fill (CWA Section 404) ❑✓ Other (specify)
LU
Air permit 02916R24
SECTIONA'
7.1
41
Have you attached a topographic map containing all required information to this application? (See instructions for
specific requirements.)
❑✓ Yes []No ❑ CAFO—Not Applicable (See requirements in Form 2B.)
SECTIONF
OF 41
Describe the nature of your business.
8.1
Green lumber is brought to Wilderness NC, Inc by different vendors to be kiln dried. The lumber will run through the
stacker line where it is put on sticks and counted. It is tagged with the name of customer, the type, grade, thickness
y
cand
species of lumber. The lumber is then placed in the kiln to dry. When taken out of the kiln the lumber is taken
to
off sticks graded and repacked according to species, grade and length. We then store the lumber until it ships.
m
0
d
w
N
SECTION
9. COOLING
WATER INTAKE STRUCTURES 41 '
Does your facility use cooling water?
9.1
w
❑ Yes ❑✓ No 4 SKIP to Item 10A.
2
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
40 CFR 126, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
NPDES permitting authority to determine what specific information needs to be submitted and when.)
6.2
o ,a
U c
SECTION
1 VARIANCE40
10.1
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122,21(m)? (Check all that
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
N
when.)
Cr❑
Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
a
Section 301(n)) 302(b)(2))
[J Non -conventional pollutants (CWA rl Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
✓❑ Not applicable
Page 3
EPA Form 3510-1 (revised 3-19)

P DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number NPDES Permit Number
Facility Name Form Approved 03/05/19
NC0023604
OMB No. 2040-0004
SECTION,
11.1
• 40
In Column 1 below, mark the sections of Form 1 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 9
Column 2
❑ Section 1: Activities Requiring an NPDES Permit
❑ wl attachments
❑ Section 2: Name, Mailing Address, and Location
❑ wl attachments
❑ Section 3: SIC Codes
❑ w/ attachments
❑ Section 4: Operator Information
❑ w/ attachments
❑ Section 5: Indian Land
❑ w/ attachments
❑ Section 6: Existing Environmental Permits
❑ w/ attachments
G
d
❑ Section 7: Map
w/ topographic
❑ El w/ additional attachments
map
o
❑ Section 8: Nature of Business
❑ w/ attachments
❑ Section 9: Cooling Water Intake Structures
❑ wl attachments
❑ Section 10: Variance Requests
❑ w/ attachments
a
c
y
❑ Section 11: Checklist and Certification Statement
❑ w/ attachments
�L
d
11.2
Certification Statement
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
Ut�X' ems.
Signature
Date signed
I1/l 7/13
RECEIVED
JAN 2 0 2023
4CDEQ1DWR/NPDES
EPA Form 3510-1 (revised 3-19) Page 4

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCO023604 Wilderness NC, Inc OMB No.2040-0004
Form U.S Environmental Protection Agency
2F =,.EPA Application for NPDES Permit to Discharge Wastewater
NPDES STORMWATER DISCHARGES ASSOCIATED WITH INDUSTRIAL ACTIVITY
SECTIONOUTFALL LOCATION
1.1 Provide information on each of the facility's outfalIs in the table below
Outfall Receiving Water Name Latitude Longitude
Number
001 UT to Flat Swamp Creek 35 46' 39" 80' 07' 12
c
0
002 UT to Flat Swamp Creek 35' 46' 31 80' 07' 13
0
so
.r
0 o
o
SECTION
-•
2.1 Are you presently required by any federal, state, or local authority to meet an implementation schedule for constructing,
upgrading, or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
❑ Yes ❑✓ No 4 SKIP to Section 3.
2.2 Briefly identify each applicable project in the table below.
Brief Identification and Affected Outfalls Final Compliance Dates
Description of Project (list outfall numbers) Source(s) of Discharge
Required Projected
w
c
W
E
m
0
n.
E
2.3 Have you attached sheets describing any additional water pollution control programs (or other environmental projects
that may affect your discharges) that you now have underway or planned? (Optional Item)
❑ Yes ❑✓ No
EPA Form 3510-2F (Revised 3-19) Page 1

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05119
NCO023604 Wilderness NC, Inc OMB No.2040-0004
SECTIONDRAINAGE MAP 1
v� 3.1 Have you attached a site drainage map containing all required information to this application? (See instructions for
c; W C specific guidance.)
o ® Yes ❑ No
SECTIONPOLLUTANT SOURCES
4.1 Provide information on the facility's pollutant sources in the table below.
Outfall
Impervious Surface Area
Total Surface Area Drained
Number
(within a mile radius of the facility)
(within a mile radius of the facility)
specify units
specify units
001
specify units
specify units
002
specify units
specify units
specify units
specify units
specify units
specify units
specify units
specify units
4.2
Provide a narrative description of the facility's significant material in the space below. (See instructions for content
requirements.)
y
d
7
O
47
C
�o
7
O
a
4.3
Provide the location and a description of existing structural and non-structural control measures to reduce pollutants in
stormwater runoff. See instructions forspecificguidance.)
Stormwater Treatment
Codes
Outfall
from
Number
Control Measures and Treatment
Exhibit
2F-1
list
EPA Form 3510-2F (Revised 3-19) Page 2

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCO023604 Wilderness INC, Inc OMB No.2040-0004
SECTION• •' 1
5.1 I certify under penalty of law that the outfall(s) covered by this application have been tested or evaluated for the
presence of non-stormwater discharges. Moreover, I certify that the outfalls identified as having non-stormwater
discharges are described in either an accompanying NPDES Form 2C, 2D, or 2E application.
Name (print or type first and last name) Official title
Signature Date signed
y
a> 5.2 Provide the testing information requested in the table below.
cc
Onsite Drainage Points
Outfall
�+ Description of Testing Method Used Date(s) of Testing Directly Observed
o Number During Test
cc
d
�J
3
E
L
O
0
Z
SECTION • '
6.1 Describe any significant leaks or spills of toxic or hazardous pollutants in the last three years.
0
none Q
0
Y
R
d
J
C
N
:z
N
SECTION'' •' • 1
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
o com fete. Not all applicants need to complete each table.
E7.1 Is this a new source or new discharge?
,o ❑ Yes 4 See instructions regarding submission of ❑ No 4 See instructions regarding submission of
d
estimated data. actual data.
C Tables A, B, C, and D
cc
N 7.2 Have you completed Table A for each outfall?
C ❑ Yes ❑ No
EPA Form 3510-21F (Revised 3-19) Page 3

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO023604
Wilderness INC, Inc
OMB No.2040-0004
7.3
Is the facility subject to an effluent limitation guideline (ELG) or effluent limitations in an NPDES permit for its process
wastewater?
0 Yes ❑ No 4 SKIP to Item 7.5.
7.4
Have you completed Table B by providing quantitative data for those pollutants that are (1) limited either directly or
indirectly in an ELG and/or (2) subject to effluent limitations in an NPDES permit for the facility's process wastewater?
❑ Yes ❑ No
7.5
Do you know or have reason to believe any pollutants in Exhibit 2F-2 are present in the discharge?
❑ Yes ✓❑ No 4 SKIP to Item 7.7.
7.6
Have you listed all pollutants in Exhibit 2F-2 that you know or have reason to believe are present in the discharge and
provided quantitative data or an explanation for those pollutants in Table C?
❑ Yes ❑ No
7.7
Do you qualify for a small business exemption under the criteria specified in the Instructions?
❑ Yes +SKIP to Item 7.18. ✓❑ No
7.8
Do you know or have reason to believe any pollutants in Exhibit 2F-3 are present in the discharge?
❑ Yes ❑✓ No 4 SKIP to Item 7.10.
7.9
Have you listed all pollutants in Exhibit 2F-3 that you know or have reason to believe are present in the discharge in
C
Table C?
w
c
o
❑ Yes ❑ No
U
0
7.10
Do you expect any of the pollutants in Exhibit 2F-3 to be discharged in concentrations of 10 ppb or greater?
E
❑ Yes ❑✓ No 4 SKIP to Item 7.12.
0
7.11
Have you provided quantitative data in Table C for those pollutants in Exhibit 2F-3 that you expect to be discharged in
CO
concentrations of 10 ppb or greater?
co
w
❑ Yes ❑ No
7.12
Do you expect acrolein, acrylonitrile, 2,4-dinitrophenol, or 2-methyl-4,6-dinitrophenol to be discharged in concentrations
of 100 ppb or greater?
❑ Yes ❑✓ No 4 SKIP to Item 7.14.
7.13
Have you provided quantitative data in Table C for the pollutants identified in Item 7.12 that you expect to be
discharged in concentrations of 100 ppb or greater?
❑ Yes ❑ No
7.14
Have you provided quantitative data or an explanation in Table C for pollutants you expect to be present in the
discharge at concentrations less than 10 ppb (or less than 100 ppb for the pollutants identified in Item 7.12)?
❑ Yes ❑ No
7.15
Do you know or have reason to believe any pollutants in Exhibit 2F4 are present in the discharge?
❑ Yes ❑✓ No -* SKIP to Item 7.17.
7.16
Have you listed pollutants in Exhibit 2F4 that you know or believe to be present in the discharge and provided an
explanation in Table C?
❑ Yes ❑ No
7.17
Have you provided information for the storm event(s) sampled in Table D?
❑ Yes ❑ No
EPA Form 3510-2F (Revised 3-19) Page 4

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682 Pace Analytical Services, LLC
1377 South Park Drive
,11-7aceAnalytical Kernersville, NC 27284
www.pacelabs.com [phone]
Page 1 of 1
Laboratory Report
Accounts Payable
Report Date: 01/11/2023
Wilderness NC, Inc.
Date Received: 01/04/2023
P.O. Box 2136
Lexington, NC 27292
Project: Wilderness NC
Pace Project No.: 92644854
Sample: Effluent Lab ID: 92644854001 Collected: 01/04/23 09:00 Matrix: Water
Method Parameters
Results Units
Report Limit Analyzed Qualifiers
SM 2540D-2015 Total Suspended Solids
ND mg/L
2.5 01/06/23 09:02
EPA 350.1 Rev 2.0 1993 Nitrogen, Ammonia
ND mg/L
0.10 01/09/23 13:00
SM 521OB-2016 BOD, 5 day
ND mg/L
2.0 01/10/23 14:46 B2
Colilert-18 Fecal Coliforms
1.0 MPN/100ml-
1.0 01/05/23 10:17
ANALYTE QUALIFIERS
B2 Oxygen usage is less than 2.0 for all dilutions set.
The reported value is an estimated less than value and is calculated
for the dilution using the most amount of sample.
Reviewed by:
Stephanie Knott
704-977-0981
[e-mail]
Pace Analytical Services Eden
205 East Meadow Road Suite A, Eden, NC 27288 North Carolina Wastewater Certification #: 633
North Carolina Drinking Water Certification #: 37738 Virginia/VELAP Certification #: 460025
Page 1 of 4

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
CHAIN -OF -CUSTODY / Analytical Regifp-,t nnriimant
1-�-P �e The Chain -of -Custody is a LEGAL DOCUMENT. All releva �0# 92644854
Submitting a sample via this chain of custody constitutes acknowledgment and acceptance of the Pace Terms and Conditions found at
Section A Section B Section C
Required Client Information: Required Project Information: Invoice Information:
Wilderness NC, Inc. eport To David Perdue ttention.
ddress 313 New Cut Road opy To ompany Name. 926448554
exington, NC 27292 ddress:
[Ompany.
mail- belinda wildernesslumber. corn urchase Order #. ace Quote
hone IFaxi
reject Name. Weeky Bottles
ace Project Manager: stephante.knottngpacelabs com,
State / Location
equested Due Date.
Iroject #
ace Profile #: TBD
NC
Requested
Anai
sis
Filtered
YIN
o
COLLECTED
Z
Preservatives
MATRIX CODE
Dnnkug Water OW
Waier WT
u
V
U
m
O
H
U
Waste Water WW
ProduG P
SAMPLE ID p1,VSdiE CIL
m
�
O
_
START
END
O
r
n
rA
{�
Y
m
c
One Character per box. r,,,Pe a P
w
w
a
z
@
g`
(A-Z, 0-9 f, -) other oT
T'u18 Ts
y
w
a
m
re
>.
U
Sample Ids must be unique
w
w
p
°1
ON
c
2
W
W
a
<
¢
u
O
ar
a
O
Z
U
x
O.
m
f0
m
-,
L
°
o
O
E
E
121
v
a
2
rn
DATE
TIME
DATE
TIME
cn
tt
O
=
_
=
Z
z
O
07
t-
m
"-
1
Effluent
WT
1
t-10
2
3
4
P61
7
8
9
90
99
92
ADDITIONAL COMMENTS
RELINQUISHED BY f AFFII IATION
RELINQUISHED
DATE
TIME
ACCEPTED BY
DATE
TIME
SAMPLE cONOITIONS
;i z
i i
;
ry
tp 'AMPLER NAME AND SIGNATURE
m
o
c
(D
N PRINT" Name of SAMPLER: -. ( i _
,
c
y
n
o t Cj /t"_t
A SIGNATURE of SAMPLE DATE Signed:
a
w
y ?
"
o I,
°o Z
z _
n

DocuSion Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
Effactive Cate:
Laboratory receiving samples:
Asheville 17 Eden Greenwood n Huntersville
Ralehr,�—J N1ech3nicsvi!!e:] A-111'371 Kerriersville'll
1` Client .3-na:
CcurFer: LJ F .2 -' E i r—I u P S
M Ccrrr,-,e-c;al ffpa:e
Carrier Tracking Number:
Cus':;d-i 5e3l Present? Seals In'3C? Elyes P"iz-
Pack'r.-N13tarial:
Of 22.7� E?71 c n❑
Thermometer: n IR Gun 10: 12- - F 0 0 Type of Ic-: (awe- F-1 2;ua
Cooler Temp (*C): 1�f- / -.2
Correction Fa=r-,.A-4J / SLt. ,3--t ('C)
Corractad Cooler Tamp ('C): 3-9
USDA Re,-jla2cl Soil ( [YN/A, Water sample}
Cid sarrp!La originate in ; qu3rarVre zone within the Unit2d Stl'-25: CA, NY, cr SC (she,--k ma::S�
17Y-2s MNO I ?
Ed
V'i I I � e y Y) 2 S I
Cate/lnidals Person Examinin., Contents:
RiCiC.-i.C31 Tissue Frozen?
❑Yas ONo Ori/A
0 Nona
Tamp should be above freeing to 6-C
EIE37r,Ples cut of t-27,p cr:tar;a. Samples cn ice, coolir& przzces�
has tegun
Cid sample-t cr'g;nata fir-ri a fora:gn
IT'L.L;tVg `ial-vsii arc PUE!= RXOj? L IY?s
Comments; Ciscr=_?ancv: �
Chain cfCustod,/ Present?
2"fin
On
Mt,/A
II
5.ir'.Oles Arrived within Hcld Time?
ay's
r7r 10
L7'1"'
1 S;,,or' PcId-7me Analysis (<72 hr.)?
3.
Rush Turn Around Time
Oy�!s
a--jo
C] -II/A
4
Fs—.-, i c i-c -, t V c I U m 2 ?
a?-
0
F-1 %,A
5.
Correct Containers used?
ff'(es
0
C1 tl/A
16.
-Pace C:x1:iiners Used?
(des
ylo
r-
Containers Intact?
-5
eeS
ON3
0: !,'A
—
7.
Dis-"lved an3!'151s: Sar-.;Iez F:e!d
[],(-!s
C140
7'1'i!A
8,
Sample Latels klat--h COO
Byes
Cl ' i:)
El ra,'A
9.
1 -IncludesDa*e/i-ime!10/Analysis Matrix:
w -r
Ve3dscace in VOA Vials (>5-5mm)?
Fve-zs
C:(ia
1-71�%,A
110.
Trip Blank Present?
Clyes
Otto
Z, 4,,A
11.
Frio Blank Cu=dv Seals Present?
Eyes
Otic
(Z5 . ti"'A
Z)MMENT S/SAMPLE DISCREPANCY
Temp Lcg; Temp must be maintained
at <5 C during login, record temp
every 20 minutes.
Time opened: I Temp:
Time: %4 0 put in cooler
Time: Tamp:
Person Contacted:
Project Manager SCURF Review:
Project Manager SRF Review:
Quallrax Document ID: 70677
-- -La nequireae Ljy25 (_(No
Lot 11) of slit containers:
Date/Time:
Data:
Date:
Page 1 of 2
Page 3 of 4

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
Matrix
rD
/�-
0
ro
N
-i
v
ns
O
m
-
ro
o
n
�O
r<D
ti
2
O
c
j
n
C
to
D
a
/
=
a
O
Oa
C
n
p
O
o
�
�
d
�
°
7
D
G
d
CL
O
3
f7
m
�
G1
ro
'p
A
ro
ro
�
v
tof
-
=
O
N
;
on
d
a
°
N
�:
ro
O
3
3
ro
ro
2"
a ti
N
O
D
N to
"
tL
2-
0
M
a
7
3
N
>
3
O
A
n
°
c
�
o
^
°
a
a
to
a v
O
ro
°- ro
m
=
ro
-
A
:l
r
/
M
O
�
n
r
o
� to
as
N
iD
(D
A
O_
A
of `°1 °°( -I -( -I -I (�
rJ i+
ItemH
BP4U-125 ml. Plastic Unpreserved (N/A) (Cl-)
BP3U-250 ml Plastic Unpreserved (N/A)
BP2U-500 mL Plastic Unpreserved (N/A)
BP1U-1 liter Plastic Unpreserved (N/A)
BP4S-125 mL Plastic II2SO4 (pl I < 2) (Cl-)
BP3N-250 mL plastic I IN03 (plI <2)
BP4Z-125 ml. Plastic ZN Acetate & NaOlI (>9)
8P4B-125 mL Plastic NaOI l (pit > 12) (Cl-)
N1GM-Wide-mouthed Glass jar Unpreserved
AG1U-1 liter Amber Unpreserved (N/A) (CI )
AGII1-1 liter Amber IICI (pl I < 2)
AG3U-250 mL Amber Unpreserved (N/A) (Cl-)
AG1S-1 liter Amber 112SO4 (pI I < 2)
AG35-250 ml Amber II2SO4 (pl I < 2)
AG3A(DG3A)-250 ml. Amber NI14CI (N/A)(CI-)
DG911-40 mL VOA IICI (N/A)
VG9T-40 mL von Na2S203 (N/A)
VG9U-40 mL VOA Unpreserved (N/A)
DG9P-40 mL VOA 113PO4 (N/A)
VOAK (3 vials per kit)-5035 kit (N/A)
V/GK (3 vials per kit)-VPII/Gas kit (N/A)
SP5T-121 mL Sterile Plastic (N/A — lab)
SP2T-250 mL Sterile Plastic (N/A — lah)
BP3A-2SO ml. Plastic (NI12)2SO4 (9.3-9.7)
AGOU-I00 ml. Amber Unpreserved vials (N/A)
VSGU-20 mL Scintillation vials (N/A)
DG9U-40 mL Amber Unpreserved vials (N/A)
* m rr <
* n tD n
O ? 1. ru
ED
n_
O N CL
tv
r a
w }' 2 7c'
O nrr , O
O 3 :3 ai
x 'r _
vi O tD O
r n Cu -,.
O 0 n Cr
n O
N• ro
(Llu
R -M
C l
to nEII
S
ro ry
w
R
0 � 5 `.
o tj UD O
1
0 o ro
to N 1
N �.
c7 m
n ^ O-
O O
„
1
(D
n
It:
CL
--7
I-

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO023604
Wilderness INC, Inc
OMB No.2040-0004
Used or Manufactured Toxics
7.18
Is any pollutant listed on Exhibits 2F-2 through 2F-4 a substance or a component of a substance used or
manufactured as an intermediate or final product or byproduct?
0
❑ Yes ❑✓ No 4 SKIP to Section 8.
a
0
co
7.19
List the pollutants below, including TCDD if applicable.
E
L
0
1. 4. 7.
d
CD
2. 5. 8.
0
3. 6. 9.
SECTION
8. BIOLOGICAL
8.1
TOXICITY TESTING DATA (40 CIFIR 122.21(g)(1 1))
Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made on
any of your discharges or on a receiving water in relation to your discharge within the last three years?
0
❑ Yes ❑✓ No 4 SKIP to Section 9.
r
8.2
Identify the tests and their purposes below.
v
X
Test(s)
Purpose of Test(s)
Submitted to NPDES
PermittingAuthority?
Date Submitted
0
`-
❑ Yes ❑ No
0
❑ Yes ❑ No
0
m
❑ Yes ❑ No
SECTION•
9.1
-• •- •
Were any of the analyses reported in Section 7 (on Tables A through C) performed by a contract laboratory or
consulting firm?
❑ Yes ❑ No 4 SKIP to Section 10.
9.2
Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1
Laboratory Number 2
Laboratory Number 3
Name of laboratory/firm
c
0
E
L0
N
Laboratory address
.N
T
CO
C
Q
V
R
L
o
Phone number
U
Pollutant(s) analyzed
EPA Form 3510-2F (Revised 3-19) Page 5

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCO023604 Wilderness NC, Inc OMB No.2040-0004
SECTION1
CHECKLIST
AND CERTIFICATION1
In Column 1 below, mark the sections of Form 2F that you have completed and are submitting with your application. For
10.1
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 com fete all sections or provide attachments.
Column 1
Column 2
❑ Section 1
❑ w/ attachments (e.g., responses for additional outfalls)
❑ Section 2
❑ w/ attachments
❑ Section 3
❑ w/ site drainage map
❑ Section 4
❑ w/ attachments
❑ Section 5
❑ w/ attachments
+.
❑ Section 6
❑ w/ attachments
c
w
❑ Section 7
❑ Table A ❑ w/ small business exemption request
rn
c
❑ Table B ❑ w/ analytical results as an attachment
0
cc
w
❑ Table C ❑ Table D
❑ Section 8
❑ w/attachments
-c
c
y❑
Section 9
❑ w/attachments (e.g., responses for additional contact laboratories or firms)
d
❑ Section 10
❑
s
U
10.2
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
�v✓lr1l� � !JU l-�
6(.�r1� i�
Signature
Date signed
EPA Form 3510-2F (Revised 3-19) Page 6

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number I NPDES Permit Number
NCO023604
Facility Name
Wilderness NC, Inc
Outfall Number
Form Approved 03/05/19
OMB No. 2040-0004
TABLE A. CONVENTIONAL AND NON CONVENTIONAL PARAMETERS (40 CFR 122.26(c)(1)(i)(E)(3))1
You must provide the results of at least one anal sis for every pollutant in this table. Complete one table for each outfall. See instructions for additional details and requirements.
Pollutant or Parameter
Maximum Daily Discharge
(specify units)
Average Daily Discharge
(specify units)
Number of Storm
Events Sampled
Source of
Information
(new source/new
dischargers only; use
codes in instructions)
Grab Sample Taken
During First
30 Minutes
Flow-Weighted
Composite
Grab Sample Taken
During First
30 Minutes
Flow -Weighted
Composite
1.
Oil and grease
2.
Biochemical oxygen demand (BOD5)
3.
Chemical oxygen demand (COD)
4.
Total suspended solids (TSS)
5.
Total phosphorus
6.
Total Kjeldahl nitrogen (TKN)
7.
Total nitrogen (as N)
8.
pH (minimum)
pH (maximum)
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).
EPA Form 3510-21F (Revised 3-19) Page 7

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number NPDES Permit Number Facility Name
NCO023604 Wilderness NC, Inc
Outfall Number
Form Approved 03/05/19
OMB No. 2040-0004
TABLE• •NAL AND NON CONVENTIONAL•• 1 and 40 • '
List each pollutant that is limited in an effluent limitation guideline (ELG) that the facility is subject to or any pollutant listed in the facility's NPDES permit for its process wastewater (if the
facility is operating under an existing NPDES permit). Complete one table for each outfall. See the instructions for additional details and requirements.
Pollutant and CAS Number (if available)
Maximum Daily Discharge
(specify units)
Average Daily Discharge
(speci units)
Number of Storm
Events Sampled
Source of
Information
(new source/new
dischargers only; use
codes in instructions)
Grab Sample Taken
During First
30 Minutes
Flow -Weighted
Composite
Grab Sample Taken
During First
30 Minutes
Flow -Weighted
Composite
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).
EPA Form 3510-217 (Revised 3-19) Page 9

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number I NPDES Permit Number Facility Name
NCO023604 Wilderness NC, Inc
Outfall Number
Form Approved 03/05/19
OMB No. 2040-0004
TABLE• POLLUTANTS,•RD• • 1 CIFIR 122.26(c)(1)(i)(E)(4)and 40 • and
List each pollutant shown in Exhibits 2F-2, 2F-3, and 2F4 that you know or have reason to believe is present. Complete one table for each outfall. See the instructions for additional
details and requirements.
Pollutant and CAS Number (if available)
Maximum Daily Discharge
s eci units
Average Daily Discharge
s eci units
Number of Storm
Events Sampled
Source of
Information
(new source/new
dischargers only; use
codes in instructions)
Grab Sample Taken
During First
30 Minutes
Flow -Weighted
Composite
Grab Sample Taken
During First
30 Minutes
Flow -Weighted
Composite
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).
EPA Form 3510-2F (Revised 3-19) Page 11

DocuSign Envelope ID: 767DCB15-2785-47A2-94EE-63F4DEBCE682
EPA Identification Number NPDES Permit Number Facility name Outfall Number Form Approved 03/05/19
NCO023604 Wilderness NC, Inc OMB No. 2040-0004
TABLE•' •' • 1
Provide data for the storm event(s) that resulted in the maximum daily discharges for the flow -weighted composite sample.
Number of Hours Between
Total Rainfall During Maximum Flow Rate
Duration of Storm Event Beginning of Storm Measured and Total Flow from Rain Event
Date of Storm Event (in hours) Storm Event End of Previous Measurable Rain During Rain Event (in gallons or specify units)
(in inches) Event (in gpm or specify units)
Provide a description of the method of flow measurement or estimate.
EPA Form 3510-2F (Revised 3-19) Page 13