WQ0004823_Renewal (Application)_20231220

State of North Carolina
Department of Environmental Quality
DWR
Division of Water Resources
Division of Water Resources
15A NCAC 02U — RECLAIMED WATER SYSTEM — RENEWAL
FORM: RWS-R 02-21
Pursuant to 15A NCAC 02T .0107(b), if the application does not include all required information and the necessary supporting
documentation, the application shall be returned. The application and attachments shall be prepared in accordance with 15A
NCAC 02T .0100, 15A NCAC 02U, and Division Policies. For more information, visit the Water Quality Permitting Section's
Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application and attachments uploaded as
a single Portable Document Format (PDF) file to httus://edocs.deci.nc.2ov/Forms/NonDischar2e-Branch-Submittal-Form-Ver2,
or emailed to Non-Dischar2e.Reuorts(dncdenr.2ov if less than 20 megabytes (MB).
SECTION I —
APPLICANT INFORMATION
1.
Applicant: Pine Island Currituck LLC
2.
Permit No.: WQ004823
3.
Signature authority: Rolf Blizzard
Phone number: [phone] Select
Title: Authorized Representative
Email: [e-mail]
4.
Mailing address: 106 York Way, Suite 201
City: Bermuda Run
State: NC Zip: 27006-
5.
Contact person: Rolf Blizzard
Primary phone number: [phone] Select
Email: [e-mail]
Secondary phone number: [phone] Select
SECTION II — FACILITY INFORMATION
1. Physical address: 501 Old Stoney Rd.
City: Corolla
2. Treatment facility coordinates to the sixth decimal degree:
Latitude: 36.278764' Longitude:-75.800175'
County: Currituck
State: NC
Method: Address matching
Parcel No.: 0127000001H0000
Zip: 27927-
SECTION III — FLOW INFORMATION
1.
Permitted flow: 600,000 GPD (The maximum allowable flow based on what has been permitted)
2.
As -built flow: GPD (The maximum allowable flow based on what has been constructed)
3.
Average flow: GPD (The average of all reported flows on the previous calendar year's NDMRs)
4.
Hydraulic capacity: % (Divide the average flow in Item 3 by the As -built flow in Item 2)
5.
Wastewater composition: Domestic : % Industrial: % Stormwater: %
SECTION IV — BILLING INFORMATION
1. Billing address: 106 York Way, Suite 201
City: Bermuda Run State: NC Zip: 27006-
2. Verify the Applicant does not have any overdue annual fees:
https:Hdeq.nc. gov/about/divisions/water-resources/water-resources-permits/wq-cpavments
Pursuant to 15A NCAC 02T .0120(c), permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORM: RWS-R 02-21 Page 1 of 6

SECTION V — OPERATOR IN RESPONSIBLE CHARGE (ORC) INFORMATION
(NOT APPLICABLE FOR CONJUNCTIVE SYSTEMS)
I. ORC: James Bliven
Grade: IV Certification No.: 991879
Mailing address: PO Box 602
City: Wanchese
State: NC Zip: 27981-
Phone number: [phone] Cell
Email: [e-mail]
2. Back -Up ORC: David Robertson
Grade: III Certification No.: 987714
Mailing address: 611 Sealoft Ct
City: Kill Devil Hills
State: NC Zip: 27948-
Phone number: [phone] Cell
Email: [e-mail]
IF SECTION VI — OPEN -ATMOSPHERE STRUCTURES
1. List all open -atmosphere treatment and storage structures associated with the renewing permit. Attach additional sheets if
necessary.
Type
Parcel No.
Volume (gal)
Liner Type
Freeboard (ft)
Latitude
Longitude
Select
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°
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SECTION VII — RELATED PERMITS
1. List all wastewater permits (i.e., sewer, collection system, NPDES, residuals) that have interactions with the renewing permit.
Attach additional sheets if necessary.
Permit Type
Permit No.
Relationship Type
Select
Select
Select
Select
Select
Select
Select
Select
SECTION VIII — MONITORING WELLS
1. List all groundwater monitoring wells associated with the renewing permit. Attach additional sheets if necessary.
Well Name
Parcel No.
Status
Gradient
Location
Latitude
Longitude
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FORM: RWS-R 02-21 Page 2 of 6

SECTION IX — UTILIZATION FIELDS
1. List all utilization fields associated with the renewing permit. Attach additional sheets if necessary.
Field
County
Parcel No.
Deeded Owner
Area
Cover Crop
Latitude
Longitude
0
O
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total Acreage:
FORM: RWS-R 02-21 Page 3 of 6

ATTACHMENT A — SITE MAP
Was the facility originally permitted or had a major modification issued after September 1, 2006?
❑ Yes — Pursuant to 15A NCAC 02T .0105(d), submit a site map pursuant to the requirements in 15A NCAC 02U .0201(d). These
requirements are:
❑ A scaled map of the site with topographic contour intervals not exceeding 10 feet or 25 percent of total site relief and showing
all facility -related structures and fences within 500 feet of the treatment, storage, and utilization areas.
❑ Soil mapping units shown on all utilization sites.
❑ Delineation of the compliance and review boundaries per 15A NCAC 02U .0501(a)(6).
❑ Setbacks as required by 15A NCAC 02U .0701.
❑ Site property boundaries within 500 feet of all treatment, storage, and utilization sites.
❑ No — Skip Attachment A.
ATTACHMENT B — SIGNATURE AUTHORITY DELEGATION now
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)?
❑ Yes — Skip Attachment B.
❑ No — Submit a delegation letter pursuant to 15A NCAC 02T .0106(c) authorizing the signature authority to sign.
ATTACHMENT C — FLOW REDUCTION
Does the existing permit include an approved flow reduction?
❑ Yes — Submit a copy of the flow reduction approval letter, as well as the measured monthly average amount of wastewater flow
contributed per unit for the 12 months prior to permit renewal. If any of these monthly averages are within 20% of the approved
flow reduction value, the Permittee shall provide a reevaluation of the reduced flow value pursuant to the requirements in 15A
NCAC 02T .0I14(f).
❑ No — Skip Attachment C.
I ATTACHMENT D — CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY
Is the Applicant a Privately -Owned Public Utility?
® Yes — Pursuant to 15A NCAC 02T .0115(a)(1), submit the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise.
❑ No — Skip Attachment D.
I ATTACHMENT E — OPERATIONAL AGREEMENT
Is the Applicant a Home/Property Owners' Association or Developer of Lots to be Sold?
❑ Yes (Home/Property Owners' Association) — Pursuant to 15A NCAC 02T .0115(a)(2), submit an executed Operational Agreement
(FORM: HOA). Pursuant to 15A NCAC 02T .0115(c), if the applicant is a legally formed Homeowners' or Property Owner's
Association, submit a copy of the Articles of Incorporation, Declarations, and By-laws.
❑ Yes (Developer of Lots to be Sold) — Pursuant to 15A NCAC 02T .0115(a)(2), submit an executed Operational Agreement
(FORM: DEW Pursuant to 15A NCAC 02T .0115(b), if the applicant is a developer of lots to be sold, submit a copy of the
Articles of Incorporation, Declarations, and By-laws.
❑ No — Skip Attachment E.
FORM: RWS-R 02-21 Page 4 of 6

ATTACHMENT F - DEMONSTRATION OF FUTURE WASTEWATER TREATMENT CAPACITIES
Is the applicant a municipality, county, sanitary district, or public utility?
❑ Yes — Proceed to the next question.
❑ No — Skip Attachment F.
Does the hydraulic capacity in Section III, Item 4 exceed 70%?
❑ Yes (the hydraulic capacity is greater than 70%, but less than 80%) — Pursuant to 15A NCAC 02T .0118(1), prior to exceeding
80 percent of the system's permitted hydraulic capacity (based on the average flow during the last calendar year), the permittee
shall submit an engineering evaluation of their future wastewater treatment, utilization, and disposal needs. This evaluation shall
outline plans for meeting future wastewater treatment, utilization, or disposal needs by either expansion of the existing system,
elimination or reduction of extraneous flows, or water conservation and shall include the source of funding for the improvements.
If expansion is not proposed or is proposed for a later date, a justification shall be made that wastewater treatment needs will be
met based on past growth records and future growth projections, and as appropriate, shall include conservation plans or other
measures to achieve waste flow reductions.
❑ Yes (the hydraulic capacity greater than 80%) — Proceed to the next question.
❑ No — Skip Attachment F.
If answered Yes above, does the hydraulic capacity in Section III, Item 4 exceed 80%?
❑ Yes (the hydraulic capacity is greater than 80%) — Pursuant to 15A NCAC 02T .0118(2), prior to exceeding 90 percent of the
system's permitted hydraulic capacity (based on the average flow during the last calendar year), the permittee shall obtain all
permits needed for the expansion of the wastewater treatment, utilization, or disposal system and, if construction is needed,
submit final plans and specifications for expansion, including a construction schedule. If expansion is not proposed or is proposed
for a later date, a justification shall be made that wastewater treatment needs will be met based on past growth records and future
growth projections, and as appropriate, shall include conservation plans or other specific measures to achieve waste flow
reductions.
❑ No — Skip Attachment F.
ACHMENT G - EASEMENT, ENCROACHMENT, AND JEASE A&EEMENTS
Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and utilization system?
❑ Yes — Skip Attachment G.
❑ No — Pursuant to 15A NCAC 02T .0116(c), provide a copy of all easements, lease agreements, and encroachment agreements
allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and utilization system on
property not owned by the Permittee.
= ATTACHMENT H - AFFILIATIONS
Are the Permittee's affiliations of record correct? Check affiliations.
❑ Yes — Skip Attachment H.
❑ No — Provide the corrected affiliations and their contact information.
ATTACHMENT I - COMPLIANCE SCHEDULES
Does the existing permit include any Compliance Schedules? (See Section I of the most recently issued permit)
❑ Yes — Submit documentation that the compliance schedules have been met.
❑ No — Skip Attachment I.
ATTACHMENT J - CIVIL PENALTIES AND OUTSTANDING VIOLATIONS
Does the Permittee have any existing civil penalties or outstanding violations?
❑ Yes (civil penalties) — Submit payment for the civil penalty, or proof of remission request.
❑ Yes (violations) — Submit a copy of your response to the Notice of Violation.
❑ No — Skip Attachment J.
FORM: RWS-R 02-21 Page 5 of 6

ATTACHMENT K— INDUSTRIAL WASTEWATER
Does the wastewater composition in Section III, Item 5 include any industrial wastewater?
❑ Yes — Proceed to the next question.
❑ No — Skip Attachment K.
Has the nature of the industrial wastewater changed since the last permit issuance (i.e., changes in industrial process, introduction of
new materials or chemicals, etc.)?
❑ Yes — Provide a chemical analysis of the wastewater pursuant to the requirements in 15A NCAC 02U .0201(g). Provide an
overview of the manufacturing process; an inventory of all chemical and biological materials used in the manufacturing process;
and an overview of the cleaning and treatment methodology.
❑ No — Provide an overview of the manufacturing process; an inventory of all chemical and biological materials used in the
manufacturing process; and an overview of the cleaning and treatment methodology.
ATTACHMENT L — SETBACK WAIVERS
Does the existing permit include setback waivers?
❑ Yes — Pursuant to 15A NCAC 02T .0701(g), provide setbacks waivers that have been written, notarized, signed by all parties
involved, and recorded with the county Register of Deeds. Waivers involving the compliance boundary shall be in accordance
with 15A NCAC 02L .0107.
❑ No — Skip Attachment L.
APPLICANT'S CERTIFICATION
I O. Rolf Blizzard, It attest that this application
(Signature authority's name as noted in Section I, Item 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application package are not completed, and that if all required supporting information and attachments are not included, this
application package will be returned as incomplete. I further certify pursuant to 15A NCAC 02T .0120(b), that the applicant, or any
parent, subsidiary, or other affiliate of the applicant has: not been convicted of environmental crimes under; not previously abandoned
a wastewater treatment facility without properly closing the facility; not paid a civil penalty; not been compliant with any compliance
schedule in a permit, settlement agreement, or order; not paid an annual fee.
Note: The Applicant's Certification shall be signed pursuant to 15A NCAC 02T .0106(b). An alternate person may be delegated as
the signing official if a letter is provided pursuant to 15A NCAC 02T .0106(c). Pursuant to § 143-215.6A and § 143-215.6B, any
person who knowingly makes any false statement, representation, or certification in any application package shall be guilty of a Class
2 misdemeanor, which may include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: Date:
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-D ischarse.Reuo rts(d ncden r.2ov
Laserfiche Upload:
httn s: //edocs. deci.nc.2ov/Fo rm s/NonDischar2e-Branch-
Submittal-Form-Ver2
FORM: RWS-R 02-21 Page 6 of 6