WQ0045044_Application_20240104

Initial Review
Reviewer nathaniel.thorn burg
Is this submittal an application? (Excluding additional information.) *
Yes No
Permit Number (IR) * WQ0045044
Applicant/Permittee Town of Holly Springs
Applicant/Permittee Address 128 S Main Street, Holly Springs NC
Is the owner in BIMS? Yes No Is the facility in BIMS?
Owner Type
Facility Name
County
Fee Category RW Distribution Line
Is this a complete application?*
Yes No
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Municipal
Carolina Springs - Phase 2, Sections 6-10 RWDL
Wake
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer
Fee Amount
Complete App Date
01/04/2024
Yes No
$600
Below list any additional email address that need notification about a new project.
Email Address
Comments to be added to email notfication
Comments for Admin
Comments for RO

Comments for Reviewer
Comments for Applicant

Submittal Form
Project Contact Information
Please provide information on the person to be contacted by NDB Staff regarding electronic submittal, confirmation of receipt, and other correspondence.
Name* Emily Koncz
Email Address*
[e-mail]
Project Information
Application/Document Type*
New (Fee Required)
Modification - Major (Fee Required)
Renewal with Major Modification (Fee
Required)
Annual Report
Additional Information
Other
Phone Number*
9195572933
Modification - Minor
Renewal
GW-59, NDMR, NDMLR, NDAR-1,
N DAR-2
Residual Annual Report
Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
https://edoes.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type:*
Wastewater Irrigation
High -Rate Infiltration
Other Wastewater
Reclaimed Water
Closed -Loop Recycle
Residuals
Single -Family Residence Wastewater
Other
Irrigation
Applicant/Permittee*
Town of Holly Springs
Applicant/Permittee Address*
128 S Main Street, Holly Springs NC
Facility Name*
Carolina Springs - Phase 2, Sections 6-10 RWDL
Please provide comments/notes on your current submittal below.
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.
(Application Form, Engineering Plans, Specifications, Calculations, Etc.)
Complete_with_DocuSign_42149_Carolina_Spring.pdf 9.86MB
Upload only 1 PDF document (less than 250 Me). Multiple documents must be combined into one PDF file unless file is larger
than upload limit.
* By checking this box, I acknowledge that I understand the application will not be accepted for pre -review until the fee (if required) has
been received by the Non -Discharge Branch. Application fees must be submitted by check or money order and made payable to the
North Carolina Department of Environmental Quality (NCDEQ). I also confirm that the uploaded document is a single PDF with all parts
of the application in correct order (as specified by the application).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature
sly CIA r'1W-_.z
Submission Date 12/28/2023

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
Hors y
1876...
0 0
oa$` THE TOWN OF OilJpnngs
�O NOICfK�A
December 6, 2023
NCDEQ — Division of Water Resources
Water Quality Permitting Section, Non -Discharge Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Re: Holly Springs Reclaimed Water Distribution System Extension Request; Application for Approval
Project: RECLAIMED Water — Carolina Springs Ph 2 Sections 6-10
Dear Sir or Madam:
Please find enclosed the following items in application for a RECLAIMED water extension permit to the
Town of Holly Springs' existing reclaimed water distribution system:
❑ One copy of the State application
❑ One copy of Instructions
❑ One copy of the locally -required Reclaimed Water Extension Design and Application
Certification (Form 3016)
❑ One copy of the Town Engineering Design and Construction Standards Reclaimed Water
Distribution System Section - to be used for the project in conjunction with the State's extension
standards
❑ One copy of No Impact Letter
❑ One copy of plats
Feel free to contact me at 919-577-3150 should you have any questions or need additional information in
order to process this application.
Sincerely,
E
DocuSigned by:
03C05669FC34440...
Kendra D. Parrish, P.E., C.F.M
Executive Director of Utilities and Infrastructure Services
KDP/ek
cc: Project Consultant Engineer, Curt Blazier
Rachel Jones, Utility Engineer
Catherine Jacobs, Development Engineering Manager
Seann Byrd, Deputy Director of Water Resources
DS
D
Rachel Jones
DSn
CJ
Catherine Jacobs
3017
07.24.23
Utilities and Infrastructure Services
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 • www.hollyspringsnc.gov

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
Hors y
1876...
0 0
oa$` THE TOWN OF OilJpnngs
�O NOICfK�A
Project file/paper/electronic/Correspondence # <next correspondence number>
3017
07.24.23
Utilities and Infrastructure Services
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 • www.hollyspringsnc.gov

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
i■ WithersRavenel
,. Our People. Your Success.
October 23, 2023
NC DEQ
1628 Mail Service Center
Raleigh, NC 27699-1628
RE: Carolina Springs - Phase 2 - Sections 6-10 - Reclaimed Water System
Dear Sir or Madam:
This letter is to serve as a request to permit the reclaimed water system of a project in Holly Springs. The
proposed development consists of approximately 8,865 LF of 6" C900 PVC reclaimed water. Attached
please find revised applications: RWPI 06-16, RWDL 06-16, along with Developer Certification of
Ownership and Reclaimed Water Distribution Extension Design & Application Certification.
If you have any questions or need any additional information, please feel free to contact me at 919-238-
0361.
Sincerely
witnersRavenel
Curt Blazier, P.E.
Director of Engineering, Design + Planning
115 MacKenan Drive I Cary, NC 27511
t: 919.469.3340 1 f: 919.467.6008 1 www.withersravenel.com I License No. C-0832
Cary I Greensboro I Pittsboro I Raleigh I Wilmington

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
DO NOT SUBMIT RECLAIMED WATER EXTENSION APPLICATION UNTIL
CONSTRUCTION DRAWINGS HAVE BEEN APPROVED BY STAFF!
RECLAIMED Water Distribution Extension Design & Application
Certification
Note: This form must be submitted with Permits for Extensions to the Town of Holly Springs
RECLAIMED Water System
Project: Carolina Springs Phase 2, Sections 6-10
Design Engineer: WithersRavenel, Inc / Curtis M Blazier, PE
Address: 115 Mackenan Drive, Cary, NC 27511
Phone Number: 919-469-3340 Email: [e-mail]
Date Complete Application Package Received by Town: 12/15/2023
DS �DnS Ds
Date Approved: I�9 (by RJ) r (by KDP) Q" (by CJ)
As design engineer for this project, I certify the following (please check (x) each applicable box):
That the design of the project is in complete conformance with Town of Holly Springs
Engineering Design and Construction Standards and the State of North Carolina NC DEQ.
* That each of the following items are completed and enclosed for submittal to the State for a
RECLAIMED Water Distribution System Permit:
Do One copy of Reclaimed Instructions
09 One copy of a Reclaimed Water extension permit application for the project
w One set of sealed construction drawings, as approved by the Town of Holly Springs. All
comments by the Town of Holly Springs are addressed and reflected on the plans. In
addition, the plans must include all of the information required per Section 15A NCAC
2T.0100 and .0900.
20 Owner Certification Letter
® A check for Town processing fee is enclosed
Do A check to NC DEQ is enclosed
'DocuuSigned by:
Design Engineer's Signature FS b6,ir Date 10/23/2023
D50BEDD2C86D49A...
For your information, a copy of the Town's Engineering Design and Construction Standards
(RECLAIMED Water Distribution System Section 11.00) will be forwarded to the State along with
these plans.
Please contact Emily Koncz at emily.konczkholl. sspringsnc.gov if you have any questions.
3016. Utilities and Infrastructure Services
01.25.21
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 • www.hollyspringsnc.gov

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
DAyiS • MARTIN • POWELL ENGINEERS 8 SURVEYORSdm p
T: 336-886-4821 • F: 336-886-4458 • License: F-0245
6415 Old Plank Road, High Point, NC 27265 • www.dmp-inc.com
Technical Memorandum
CA
Date: May 23, 2022 , N N... • .
�.• F E
Prepared For: Town of Holly Springs
Reclaimed Water Modeling i
S S
Carolina Springs Phase 2 PUD i 024968
t 05/23/2022
Prepared By: Michael Goliber, PE �'•/X N E �� ����•�
Project: DMP 220058 ,,,• �„�nI„O`�,,,
Background
As requested by the Town of Holly Springs (Town), DMP has evaluated the feasibility of adding the proposed
Carolina Springs PUD Phase 2 to the Reclaimed Water System. The proposed project is in the north limits
of the Reclaimed Service Area and is bordered by Woods Creek Road, and Highway 1, and Highway 540
Model Setup
DMP performed the evaluations utilizing the Town's reclaimed water system model in WaterCAD. The
following setup was used for the modeling:
• Reclaimed Model Setup
- Tank Water Elev: 578' (normal low, down 7 ft)
- WRF Pumps off
- SFR Lots at Typical Demand (1.83 gpm/SFR due to average lot size being approximately 15,000 SF)
(assumes 70% of SFR's are connected).
- Sequiris: 550 gpm (includes 400 gpm cooling and 150 gpm irrigation)
- WRF: 360 gpm (NPW uses + 200 gpm for RCW bulk filling)
- Twelve Oaks Pond: 500 gpm
- Ingenco: 53 gpm
- Burt Tract: Full build out active and in service (412 gpm)
— Hensley Tract: Full build out active and in service (214 gpm)
— Twelve Oaks Phase 09: Full build out active and in service (Stephenson) (150 gpm)
— Addison Subdivision: Full build out active and in service (Formerly Harris) (72 gpm)
— New Hill Road Subdivision (52 GPM)
— Carolina Springs PUD Phases 1-5 (296 GPM)
- Model Calculations: All modeling calculations were performed as a Steady State Model. Modeling
as a Steady State Model provides for worst case demand condition, meaning that all demands in
the model are active as part of the Scenario calculation.
• Carolina Springs PUD
Based on CAD drawings and PDF's provided to DMP by the Town of Holly Springs, the proposed Phase
2 area for this development includes three (3) additional areas adding to the Phase 1 area. The CAD
information provided primarily consisted of Phase 2, which is essentially three (3) areas. See attached
Utility Sheet for the layout.
The Phase 2 layout provided to DMP was brought into the model as a backdrop. The reclaimed water
lines and system nodes, with corresponding elevations, were then added to the model. Nodes on the
property range in elevation from approximately 290 ft to 330 ft and are based on the information
provided.

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
Technical Memorandum
DMP 220058
Page 2
The following is a summary of the demand calculation for the Carolina Springs Phase 1 Development:
— 372 units (calculated from drawings received from TOHS)
— QIP = Peak Demand (gpm) = 0.419*A*I*P*C*R/1440
■ A = Lot size in SF (6,400)
■ I = Irrigable Area (50%)
■ N = Number of Lots (372)
■ 0.419 = Irrigation Factor equivalent to 1.0" per week(.133/1.5)*Peaking Factor of 4.7
■ DMP assumed 65% connected for the modeling scenario.
■ Demand = 0.6 GPM/Lot or 225 GPM
Modeling Results:
Carolina Springs Phase 2 PUD was modeled as all 6" RCWL piping with new taps on the proposed 12" RCWL
along Woods Creek Road, which will be extended as part of this project. The third area is extending lines in
the previously approved Phase 1 area. The model assumes that the improvements recommended for full
build out of Phase 1 will be completed prior to the completion of Phase 2. The model also assumed that
the developments proposed and approved prior, as outlined under Reclaimed Model Setup, are active and
in service.
Based on the above described model setup, several scenarios were modeled and are described with their
results summarized as follows:
Scenario 1: Base System (CS PUD Ph 2, all areas)
This Scenario assumes full build out all Sub -phases in Phase 1 and all areas for Phase 2.
— Existing 6" RCWL from New Hill Road to Ivy Arbor Way
— New 12" RCWL installed from Ivy Arbor Way to Ingenco
— Existing 12" RCWL to Twelve Oaks Phase 9 (Stephenson)
— New 12" RCWL to serve Carolina Springs PUD
— Results: Pressures are above 45 psi, which is the target system requirement minimum pressure.
Feasible - Does meet the Project Objectives
Summary
For Carolina Springs PUD Phase 2, the model was setup as described above.
One scenario was modeled and pressures within the Development are satisfactory and meet the
requirements of the Town's RCW System. These results indicate that the proposed project meets the
objectives of the system.
One system component that should be monitored as part of the build -out for Carolina Springs PUD is the
impact on the previously approved Twelve Oaks Phase 09. This system was designed to be installed with
master meters, which require a 70 psi minimum, based on design information supplied to DMP at the time
of review for Twelve Oaks Phase 09. With significant demands being placed on the system adjacent to and
north of these master meters could potentially have impact on the operation of this system.
Attached are the following documents:
Exhibit: Active System
Exhibit: Scenario 1
P: �2022�220058�Technical Memo�220058 Technical Memo for Carolina Springs Phase 2 PUD -FINAL 2022-05-23.docx

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
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Sources: Esri, HERE, DeLorme, TomTom, Intermap, increment P Corp., GEBCO, OSGS, FAO, NPS, NRCAK Geo Base, IGN, Kadaste,r,NL, Ordnance Survey, Egri
Japan, METI, Esri China (Hong Kong);'sv5isstopo, Maprriylndia, ©OpenStreetMap„contributors, and the GIS User Community -
Document Path: P:\2022\220058\GIS\Carolina Springs PUD Ph 2 - 1st Review Analysis Map -Active System Exhibit.mxd Hydraulic Analysis Map for Feet
Carolina Springs PUD Phase 2 - 1st Review 1,500 750 0 1,500 3,000 4,500
Active System 1 inch = 1,907 feet

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
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Sources: Esri, HERE, Del-orme, TomTom,
Intermap, increment P Corp., GEBCO, USGS, FAO, NPS, NRCAN, GeoBase, IGN, Kadaster NL, Ordnance Survey, Esri
Japan, METI, Esri China (Hong Kong), swisstopo, Mapmylndia, © OpenStreetMap contributors, and the GIS User Community
Document Path: P:\2022\220058\GIS\Carolina Springs PUD Ph 2 - 1st Review Analysis Map - Scenario 1 Exhibit.mxd Hydraulic Analysis Map
for Carolina Springs Phase 2 PUD - 1st Review
Scenario 1
500 250 0 500 1,000
1 inch = 500 feet
= Feet
1,500

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
I. Hearthstone, Inc.
HEARTHS BONE
America's Prceminent Investor in Residential Development
(developer/landowner), certify that I aril the owner of the
property upon which the proposed Carolina Springs -Phase 2, Sections 6-10 (subdivision/development) is
planned as shown on Project 421-MAS-06 (TOHS Site Plan #), including all offsite
easements required for the extension of public reclaimed water lines. Ownership of said
property and easements is evidenced in the following recorded deeds: PIN 0730347376
r
Deed Book 019450 Pages 02580-02583 and a portion of PIN 0730439848, Deed Book 019450
es 02561-02564
I hereby request that the Town of Holly Springs apply for a Reclaimed Water Distribution Line
permit on my behalf for construction of the reclaimed water distribution lines.
I certify that upon complete installation of the reclaimed water extensions and subsequent
approval and acceptance by the Torn of Holly Springs, the sul7ject reclaimed waterlines and
easements are hereby dedicated to the Town of Holly Springs.
D1ocuSigned by:
Sign :Stec, �bV
88F13FB9851140C...
11/7/2023
Date:

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
State of North Carolina
nlwAllp Department of Environmental Quality
Division of Water Resources
' 15A NCAC 02U — RECLAIMED WATER SYSTEMS — DISTRIBUTION LINES
Division of Water Resources INSTRUCTIONS FOR FORM: RWDL 06-16 & SUPPORTING DOCUMENTATION
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application.
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit website
General — This application is for projects involving the construction of reclaimed water distribution lines that will supply reclaimed
water for conjunctive use activities. Unless otherwise noted, the Applicant shall submit one original and two copies of
the application and supporting documentation.
Do not submit this application without an associated Reclaimed Water Project Information (FORM: RWPI) form.
A. Reclaimed Water Distribution Lines (FORM: RWDL 06-16) Application (All application packages):
® Submit the completed and appropriately executed Reclaimed Water Distribution Lines (FORM: RWDL 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® The system name in Item II.1. shall be consistent with the user name on the plans, specifications, agreements, etc.
® The Professional Engineer's Certification on Page 5 of this form shall be signed, sealed and dated by a North Carolina licensed
Professional Engineer.
® The Applicant's Certification on Page 5 of this form shall be signed in accordance with 15A NCAC 02T .0106(b). The
application must be signed by a principal executive officer of at least the level of vice-president or his authorized representative
for a corporation; by a general partner for a partnership or limited partnership; by the proprietor for a sole proprietorship;
and by either an executive officer, an elected official in the highest level of elected office, or other authorized employee for a
municipal, state, or other public entity. An alternate person may be designated as the signing official if a delegation letter is
provided from a person who meets the criteria in 15A NCAC 02T .0106(b).
B. Property Ownership Documentation (All Application Packages):
® Per 15A NCAC 02U .0201(e) or 15A NCAC 02U .0202(f), the Applicant shall demonstrate that they are the owner of the
property where the reclaimed water lines will be installed. Documentation shall consist of one of the following (or a
combination of):
® Legal documentation of ownership (i.e., GIS, deed or article of incorporation), or
❑ Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
❑ An easement specifically indicating the intended use of the property and meeting the requirements of 15A NCAC 02L
.0107 , (i.e. municipality right of way) or
❑ A written notarized lease agreement signed by both parties, indicating the intended use of the property, as well as a plat
or survey map.
INSTRUCTIONS FOR FORM: RWDL 06-16 & SUPPORTING DOCUMENTATION Page 1 of 2

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
C. Engineering Plans (All Application Packages):
® Per 15A NCAC 02U .0201(c)(1) or .0202(c), submit standard size and 11 x 17-inch plan sets that have been signed, sealed and
dated by a North Carolina licensed Professional Engineer. At a minimum, the engineering plans shall include the following
items:
® Table of contents.
® A general location map with at least two geographic references and a vicinity map.
® Plan and profile views of all pump stations and reclaimed water line extensions as well as the proximity of the reclaimed
water line extensions to other utilities and natural features.
® Depict minimum separation distances required by 15A NCAC 02U .0403(h). (i), and 15A NCAC 02T .0305).
® Minimum cover in accordance with 15A NCAC 02T .0305(g)(4).
® Location and details of all pump stations.
❑ All labeling and color coding requirements per 15A NCAC 02U .0403.
® Plans shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY, NOT
FOR CONSTRUCTION, etc.) that indicate they are anything other than final specifications. However, the plans may be
labeled with the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION.
D. Specifications (All Application Packages):
® Per 15A NCAC 02U .0201(c) or .0202(c), submit specifications that have been signed, sealed and dated by a North Carolina
licensed Professional Engineer. At a minimum, the specifications shall include the following items:
® Specifications for standard equipment may be omitted for municipalities with approved standard specifications. Use of
standard specifications must be noted on each page of the plans.
® Table of contents with each section/page numbered.
® Detailed specifications for each reclaimed water line and pump station (as applicable).
® Site Work (i.e., earthwork, clearing, grubbing, excavation, trenching, backfilling, compacting, fencing, seeding, etc.)
® Materials (i.e., concrete, masonry, steel, painting, method of construction, etc.)
® Electrical (i.e., control panels)
® All labeling and color coding requirements per 15A NCAC 02U .0403.
® Specifications shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY,
NOT FOR CONSTRUCTION, etc.) that indicate they are anything other than final specifications. However, the
specifications may be labeled with the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION.
E. Engineering Calculations (All Application Packages):
® Per 15A NCAC 02U .0201(c) or .0202(c), submit calculations that have been signed, sealed and dated by a North Carolina
licensed Professional Engineer. At a minimum, the calculations shall include the following items:
® Provide justification for the required pipe capacity, and details for how pipe sizes were determined.
® Minimum velocities to be maintained in the reclaimed water line.
❑ Friction/total dynamic head calculations and system curve analysis for each pump used.
❑ Pump selection information including pump curves, manufacturer's information, and recommended installation guidelines.
® Detailed specifications for each reclaimed water line and pump station (as applicable).
❑ Floatation calculations for any pump stations entirely or partially below grade.
❑ For connection to a pump station, submit an evaluation of the existing pump station's ability to handle peak flows. Provide
calculations to detail how peak flows were determined.
❑ For connection to a force main, submit an evaluation of the existing force main based on peak flows to the proposed project
and peak flows already tributary to the existing force main.
ONE ORIGINAL AND TWO COPIES OF THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION
SHALL BE SUBMITTED TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE PERMITTING UNIT
By U.S. Postal Service:
1617 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1617
TELEPHONE NUMBER: [phone]
By Courier/Special Delivery:
512 N. SALISBURY STREET
RALEIGH, NORTH CAROLINA 27604
FAX NUMBER: [phone]
INSTRUCTIONS FOR FORM: RWDL 06-16 & SUPPORTING DOCUMENTATION Page 2 of 2

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02U — RECLAIMED WATER SYSTEMS — DISTRIBUTION LINES
FORM: RWDL 06-16
L CONTACT INFORMATION:
1. Applicant's name: Town of Holly Springs
Mailing address: 128 South Main Street
City: Holly Springs State: NC Zip: 27540-
Telephone number: [phone] Email Address: emily.konczghollysspringsnc.gov
2. Signature authority's name: Kendra Parrish (per 15A NCAC 02T .0106) Title: Executive Director of Utilities
3. and Infrastructure
4. Consulting Engineer's name: Curt Blazier License Number: 033840 Firm: WithersRavenel
Mailing address: 115 MacKenan Drive
City: Caa State: NC Zip: 27511-
Telephone number: [phone] Email Address: cblazierg-withersravenel.com
IL DISTRIBUTION SYSTEM INFORMATION
1. Distribution system project name (name of subdivision, shopping center, etc.): Carolina Springs - Phase 2, Sections 6-10
2. Project county: Wake
3. USGS map name: New Hill
4. Owner of reclaimed water generating facility: Utley Creek Water Reclamation Facility
5. Permit number of reclaimed water generating facility: W00032289
6. List the owner(s) of any intermediate reclaimed water lines if different from the applicant, or the generating facility. n/a
7. Permit number for reclaimed waterline immediately upstream: W00042791.
8. Pipe diameter for for reclaimed water line immediately upstream: 6" and 12"
9. Specify the proposed destination of the reclaimed water: Recalaimed water will be used for irrigation and similar uses on
single family lots.
10. Capacity of proposed distribution system: 0 gallons per day
11. Explanation of how capacity was determined: NA
III. DISTRIBUTION LINE DESIGN INFORMATION
1. Complete the table below for by providing the required information on the proposed distribution lines:
Diameter (inches)
Length
(linear feet)
Pipe Material
High Elevation
00
Discharge Elevation
00
6
8,865
C900 PVC
342.5'
278.5'
2. Station location of air release valves: ARVs not required for this project
Note: Air release valves must be provided at all high points along the line where the elevation difference exceeds 10 ft.
FORM: RWDL 06-16 Page 1 of 5

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
III. DISTRIBUTION LINE DESIGN INFORMATION (Continued)
3. Complete the table below by providing the location of each design criteria in the specification and/or plans in accordance with
15A NCAC 02U .0403. Items that are not applicable shall be marked N/A.
Design Criteria
Page Number in Plans
Page Number in Specifications
Labeling on reclaimed water piping, valves, storage
C3.00-C3.06
N/A
facilities, and outlets
Color coding on reclaimed water piping, valves, etc.
C9.05
N/A
Method of securing valves and outlet for operation by
C9.05
N/A
authorized personnel only
Locking mechanism for hose bibs
C9.05
N/A
Cross connection control devices
C9.05
N/A
IV. SETBACKS (15A NCAC 02U .0701)
1. Provide the actual minimum distance (in feet) from any reclaimed water storage units and/or pump station within the
distribution system to each item listed (distances greater than 500 feet may be marked N/A):
Setback Parameter
Pump stations within
Reclaimed Water
distribution system
Storage Units
Required
Actual
Required
Actual
Any private or public water supply source
N/A
100
N/A
Any property line
N/A:]1
50
N/A
Any well with exception of monitoring wells
100
N/A
100
N/A
Surface waters (streams — intermittent and perennial,
100
N/A
50
N/A
perennial waterbodies, and wetlands) classified as SA
Surface waters (streams — intermittent and perennial,
25
N/A
50
N/A
perennial waterbodies, and wetlands) classified as SA
2. Do the pump stations and storage units comply with all setbacks found in the river basin rules (15A NCAC 2B .0200)?
❑Yes or❑No
✓ If no, list non -compliant setbacks:
3. Are any setback waivers required in order to comply with 15A NCAC 02U .0701? ❑ Yes or ❑ No
✓ If yes, have these waivers been written, notarized, signed by all parties involved and recorded with the County Register of
Deeds? ❑ Yes or ❑ No
✓ If yes, have the required Non -Discharge Wastewater System Waiver (FORM: NDWSW) forms been included with this
application package? ❑ Yes or ❑ No
FORM: RWDL 06-16 Page 2 of 5

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
V. SEPARATION DISTANCES
1. Provide the actual minimum separation distance (in feet) from the reclaimed water distribution system to each item listed in
accordance with 15A NCAC 02U .0403(h), (i), and (j):
Separation Parameter
Horizontal
Vertical
Required
Actual
Required
Actual
Any water line (feet)
10
10
1.5
1.5
Any well
50
N/A
N/A
Sewer lines (reclaimed over sewer)
2
5
1.5
1.5
Final earth grade
N/A
3
3
2. Are the separation requirements listed above met? ® Yes or ❑ No
✓ If No, has documentation been provided to show that piping and integrity testing procedures meet water main standards in
accordance with 15A NCAC 18C? ❑ Yes or ❑ No
Note: In no case shall reclaimed water lines be closer than 25 feet to a private well.
VI. PUMP STATION INFORMATION
IF MORE THAN ONE PUMP STATION, PROVIDE ADDITIONAL COPIES OF THIS PAGE AS NECESSARY.
1. Are there any reclaimed water pump stations proposed as part of the distribution system? ❑ Yes or ® No
✓ If no, then skip the remaining items in Section VI.
2. Complete the table below by providing the required information regarding the reclaimed water pump station(s)
Pump Station Design
Plan Sheet
Number
Specification
Page Number
Internal dimensions (L x W x H or (p x H)
ft
ft
ft
Volume
gallons
Inlet Elevation
ft
Outlet Elevation
ft
Number of pumps
Pump capacity
GPM
Lead pump on elevation
ft
Lag pump on elevation
ft
Lead pump off elevation
ft
Lag pump off elevation
ft
High water elevation
ft
Audible/Visual high water alarm
3. What is the 100-year flood elevation? (ft)
4. Precautions to be taken to protect the pump station from flooding: (ft)
FORM: RWDL 06-16 Page 3 of 5

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
VILSTORAGE TANK INFORMATION
IF MORE THAN ONE STORAGE TANK, PROVIDE ADDITIONAL COPIES OF THIS PAGE AS NECESSARY.
1. Are there any reclaimed water storage tanks proposed as part of the distribution system? ❑ Yes or ® No
✓ If no, then skip the remaining items in Section VII.
2. Complete the table below by providing the required information regarding the reclaimed water storage tank(s)
Storage Tank Design
Plan Sheet
Number
Specification
Page Number
Type of storage tank
Select
Internal dimensions (L x W x H or (p x H)
ft
ft
ft
Storage Volume
gallons
Inlet Elevation
ft
Outlet Elevation
ft
High water elevation
ft
Audible/Visual high water alarm
3. What measures will be taken to reduce the risk of overflow?
FORM: RWDL 06-16 Page 4 of 5

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
Professional Engineer's Certification:
Curtis M. Blazier
attest that this application for Carolina Springs - Phase 2, Sections 6-10
has been reviewed by me and is accurate, complete and
consistent with the information supplied in the engineering plans, calculations, and all other supporting documentation to the best of my
knowledge. I further attest that to the best of my knowledge the proposed design has been prepared in accordance with this application
package and its instructions as well as all applicable regulations and statutes. Although other professionals may have developed certain
portions of this submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design. Note: In accordance with NC General Statutes 143-215.6A and 143-215.613,
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.
North Carolina Professional Engineer's seal, signature, and date:
o°Q000a0000aaoo
CAR
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033840
°�NG IN
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DocuSigne&b% IS ° M °g\Jl Vo°o°°
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Applicant's Certification (signing authority must be in compliance with 15A NCAC 02T .0106):
I, Kendra D. Parrish, PE Executive Director of
Utilities & Infrastructure
(signing authority name — PLEASE PRINT) (title)
attest that this application for
Carolina Springs -Phase 2, Sections 6-10
(facility name)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that any discharge of wastewater from
this non -discharge system to surface waters or the land will result in an immediate enforcement action that may include civil penalties,
injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition of this
permit be violated. I also 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 to me as incomplete. I further certify
that the applicant or any affiliate has not been convicted of an environmental crime, has not abandoned a wastewater facility without proper
closure, does not have an outstanding civil penalty where all appeals have been exhausted or abandoned, are compliant with any active
compliance schedule, and do not have any overdue annual fees under Rule 15A NCAC 02U .0105. Note: In accordance with NC General
Statutes 143-215.6A and 143-215.613, 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 EFA
104a6enbr:
Signature: �bvxs Date: 12/15/2023
FORM: RWDL 06-16 Page 5 of 5

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
State of North Carolina
Department of Environmental Quality
nwVRDivision of Water Resources
15A NCAC 02U — RECLAIMED WATER SYSTEMS — PROJECT INFORMATION
Division of Water Resources INSTRUCTIONS FOR FORM: RWPI 06-16 & SUPPORTING DOCUMENTATION
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application.
For more information, visit the Water Quality Permitting Section Non -Discharge Permitting Unit website.
General —This form is required for all projects involving the generation, utilization, and or distribution of reclaimed water. At least one
of the following forms must also be included in the application package. However, multiple forms may be applicable. Unless
otherwise noted, the Applicant shall submit one original and two copies of the application and supporting
documentation. Please check the boxes below as appropriate to indicate which additional forms are included in the
application package:
❑ Reclaimed Water Generation (FORM: RWG) — for wastewater treatment facilities producing reclaimed water.
❑ Non -Conjunctive Utilization (FORM: RWNC) — for reclaimed water utilization activities, when the reclaimed water
utilization activity is required in order to meet the wastewater disposal needs of the facility.
❑ Conjunctive Utilization (FORM: RWCU) — for reclaimed water utilization activities, when the reclaimed water option is
not necessary to meet the wastewater disposal needs of the facility and other wastewater utilization/disposal methods are
available.
❑ Bulk Distribution (FORM: RWBD) — for distribution of reclaimed water in a bulk manner.
® Distribution Lines (FORM: RWDL) — for construction of reclaimed water distribution lines.
❑ Wetland Augmentation (FORM: RWWA) — for projects seeking to utilize reclaimed water for the purpose of wetland
augmentation.
❑ Local Program Approval (FORM: RWLPA) — for projects seeking permitting delegation for reclaimed water users.
A. Cover Letter (All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
B. Application Fee (All New and Major Modification Application Packages):
® Submit a check, money order or electronic funds transfer made payable to: North Carolina Department of Environmental
Quality (NCDEQ) according to the following fee schedules:
® STANDARD REVIEW —Submit the appropriate fee for all new and major modification applications as listed in the table
below.
Facility Classification
New Permit
Major Modification'
Major Generator/User (ADF > 10,000 gallons per day)
FS1,310
$395
Minor Generator/User (ADF < 10,000 gallons per day)
$810 $245
Reclaimed Water Distribution Lines
7$480 N/A
' A major modification shall be defined as any permit modification that: increases the generating facility's
average daily flow (ADF); increases the utilization area acreage; adds additional utilization areas not
previously approved; or includes the addition of new treatment units/processes not previously permitted.
There is no fee for minor permit modifications.
INSTRUCTIONS FOR FORM: RWPI 06-16 & SUPPORTING DOCUMENTATION Page 1 of 2

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
C. Reclaimed Water Project Information Form (FORM: RWPI 06-16) (All application packages):
® Submit the completed and appropriately executed Reclaimed Water Project Information (FORM: RWPI 06-16) form. Please
do not make any unauthorized content changes to this form.
® The applicant name in Item I.1. shall be consistent with the applicant name on the plans, specifications, agreements, etc.
® The Applicant's Certification on Page 3 of this form shall be signed in accordance with 15A NCAC 02T .0106(b). The
application must be signed by a principal executive officer of at least the level of vice-president or his authorized representative
for a corporation; by a general partner for a partnership or limited partnership; by the proprietor for a sole proprietorship;
and by either an executive officer, an elected official in the highest level of elected office, or other authorized employee for a
municipal, state, or other public entity. An alternate person may be designated as the signing official if a delegation letter is
provided from a person who meets the criteria in 15A NCAC 02T .0106(b).
❑ If this project is for a renewal without modification, use the Non -Discharge System Renewal (FORM: NDSR) application.
There is no fee for permit renewal without modification.
D. Existing Permit: (All Modification Packages):
❑ Submit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit modification
(i.e., compliance schedules, permit description, monitoring, permit conditions, etc.).
ONE ORIGIANL AND TWO COPIES OF THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION
SHALL BE SUBMITTED TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE PERMITTING UNIT
By U.S. Postal Service:
1617 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1617
TELEPHONE NUMBER: [phone]
By Courier/Special Delivery:
512 N. SALISBURY STREET
RALEIGH, NORTH CAROLINA 27604
FAX NUMBER: [phone]
INSTRUCTIONS FOR FORM: RWPI 06-16 & SUPPORTING DOCUMENTATION Page 2 of 2

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02U — RECLAIMED WATER SYSTEMS — PROJECT INFORMATION
FORM: RWPI 06-16
L GENERAL INFORMATION:
1. Applicant's name: Town of Holly Springs
Mailing address: 128 South Main Street
City: Holly Springs State: NC Zip: 27540-
Telephone number: [phone] Email Address:
2. Signature authority's name: Kendra Parrish (per 15A NCAC 2U .0106)Title: Executive Director of Utilities & Infrastructure
3. Applicant type (check all that apply):
❑X Government ❑ Federal ❑ State ® Municipal ❑ County
❑ Individual
❑ Corporation
✓ For new permits, submit documentation that the company is registered for business with the NC Secretary of State.
❑ General Partnership
✓ For new permits, submit a copy of the certificate filed with the Register of Deeds in the county of business.
❑ Privately Owned Public Utility
✓ For new permits, submit a Certificate of Public Convenience and Necessity from the NC Utilities Commission, or a
letter from the NC Utilities Commission's Water and Sewer Division Public Staff stating an application for a
franchise has been received and that the service area is contiguous to an existing franchised area or that franchise
approval is expected.
❑ Home Owners Association
✓ For new permits, submit a properly executed Operational Agreement (FORM: HOA); and proposed or approved
Articles of Incorporation, Declarations and By-laws.
❑ Developer (where residential lots are to be sold)
✓ For new permits, submit a properly executed Operational Agreement (FORM: DEV)
4. Demonstration of historical consideration for permit approval:
Has the Applicant or any parent, subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or G.S. 143-215.6B? ❑ Yes or ® No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ® No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or ® No
d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or ® No
e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(e)(2)? ❑ Yes or ® No
FORM: RWPI 06-16 Page 1 of 3

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
II. PROJECT INFORMATION
1. Application type: Select (See Instruction B) Fee Submitted (See Instruction B)
2. For modifications, provide the existing permit number: WQ00 and most recent issuance date:
3. Provide a brief description of the activities proposed for permitting: Installation of Reclaimed water mains and services for
single family homes for irrigation and similar uses.
4. What is the status of the following associated permits and/or certifications ? (if not applicable, please mark as N/A)
Permit/Certification
Date Submitted
Date Approved
Permit/Certification No.
Agency Reviewer
Collection System (Q >
200,000 GPD
N/A
Dam Safety
N/A
Erosion & Sedimentation
Control Plan
N/A
Nationwide 12 /Section 404
6/27/22
9/7/22
SAW-2017-01322
(NWP 29 and 14)
George Lyle Phillips
III
Pretreatment
N/A
Sewer System
3/13/23
Stormwater Management Plan
N/A
Other: NCDEQ 401 WQC
6/27/22
8/26/22
WQC005127
Scott Vinson
✓ For any of the permits and certifications listed above that will directly impact the construction of the proposed reclaimed
water project, please provide documentation of permit approval or final certification. Note: This application may be
considered incomplete, or the resulting permit may be issued conditionally if a pending issuance of any of the related
permits/certifications directly impacts the proposed facility.
5. Documentation of the presence or absence of threatened or endangered aquatic species at the project site utilizing information
provided by the Department's Natural Heritage Program is required for construction of all new WWTP projects and/or non -
conjunctive utilization sites, and for any project involving expansion of a WWTP and/or non -conjunctive utilization site in
accordance with 15A NCAC 02T .0105(c)(10). Provide the location in application package where this documentation is
located: ; or explain why this item is N/A.
6. Does this project utilize public monies or lands? ❑ Yes or ❑ No
✓ If yes, was an Environmental Assessment required under 15A NCAC QIC?
Yes ❑ No
Include one of the following final environmental documents with this submittal:
❑ Finding of No Significant Impact, or ❑ Record of Decision
Describe any mitigating factors from the Environmental Assessment that impact the design and/or construction of the
reclaimed water project:
7. Is any portion of the proposed project (reclaimed water treatment units, storage units, distribution lines, or utilization areas)
located within the 100 year flood plain? ❑ Yes or ® No
✓ If yes, specify which portion(s) of the project are affected?
✓ If yes, has the Applicant submitted written documentation of compliance with § 143 Article 21 Part 6? ❑ Yes or ❑ No
Documentation should consist of a letter from the local authority (i.e., county/municipality) stating that the project
complies with any local floodplain ordinance that may apply.
FORM: RWPI 06-16 Page 2 of 3

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
FORM: RWPI 06-16 Page 2 of 3

DocuSign Envelope ID: 5068A9F4-910D-4D3A-A682-7E9B10942ECD
Applicant's Certification (signing authority must be in compliance with 15A NCAC 02U .0106):
I, Kendra D Parrish, PE Executive Utilities & Infrastructure
(signing authority name — PLEASE PRINT) (title)
attest that this application for Carolina Springs — Phase 2, Sections 6-10
(facility name)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that any discharge of wastewater
from this non -discharge system to surface waters or the land will result in an immediate enforcement action that may include civil
penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a
condition of this permit be violated. I also 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 to me as incomplete.
I further certify that the applicant or any affiliate has not been convicted of an environmental crime, has not abandoned a wastewater
facility without proper closure, does not have an outstanding civil penalty where all appeals have been exhausted or abandoned, are
compliant with any active compliance schedule, and do not have any overdue annual fees under Rule 15A NCAC 02U .0105. Note:
In accordance with NC General Statutes 143-215.6A and 143-215.613, 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 $10,000rrKVIAMos�^iayil penalties up to $25,000 per violation.
Signature: � J6w-S Date: 12/15/2023
4BBAA6079AA4450...
FORM: RWPI 06-16 Page 3 of 3

DocuSign
Certificate Of Completion
Envelope Id: 5068A9F491OD4D3AA6827E9B10942ECD Status: Completed
Subject: Complete with DocuSign: 42149 Carolina Springs Ph 2 Reclaimed Permit Application.doc, 220058 Te...
Source Envelope:
Document Pages: 22 Signatures: 3 Envelope Originator:
Certificate Pages: 5 Initials: 5 Emily Koncz
AutoNav: Enabled PO Box 8
Envelopeld Stamping: Enabled Holly Springs, NC 27540
Time Zone: (UTC-05:00) Eastern Time (US & Canada) [e-mail]
IP Address: 204.84.166.2
Record Tracking
Status: Original
Holder: Emily Koncz
Location: DocuSign
12/6/2023 2:42:29 PM
[e-mail]
Signer Events
Signature
Timestamp
Rachel Jones
Doc��Sigg�edby:
Sent: 12/6/2023 2:56:50 PM
[e-mail]
,,OIat,S
Er4BBAA6079AA4450
Viewed: 12/15/2023 9:15:49 AM
Utility Engineer
Signed: 12/15/2023 9:20:47 AM
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre -selected Style
Using IPAddress: 64.98.114.214
Electronic Record and Signature Disclosure:
Accepted: 5/17/2021 2:39:29 PM
ID:126bfa6d-c99c-4b40-be28-00aa263b860b
Company Name: Town of Holly Springs
Catherine Jacobs EDSSent: 12/15/2023 9:20:50 AM
[e-mail] Viewed: 12/20/2023 1:07:15 PM
Engineering Manager Signed: 12/20/2023 1:15:39 PM
Security Level: Email, Account Authentication
(None) Signature Adoption: Pre -selected Style
Using IPAddress: 204.84.166.2
Electronic Record and Signature Disclosure:
Accepted: 12/20/2023 1:07:15 PM
ID:ce09aO43-lb6b-4fd9-a919-b3Od95ff8da4
Company Name: Town of Holly Springs
Kendra Parrish
[e-mail]
IJ,DocuSignedby:
`��
Sent: 12/20/2023 1:15:43 PM
Viewed: 12/20/2023 1:36:19 PM
Exec Director of Utilities and Infrastructure
03c05B69Fc34440
Signed: 12/20/2023 1:36:28 PM
Holly Springs
Security Level: Email, Account Authentication
Signature Adoption: Drawn on Device
(None)
Using IPAddress: 204.84.166.2
Signed using mobile
Electronic Record and Signature Disclosure:
Accepted: 4/6/2021 7:18:46 PM
ID:6cbf2406-2f8d-46a2-8e81-c6f600daf744
Company Name: Town of Holly Springs
In Person Signer Events
Signature
Timestamp
Editor Delivery Events
Status
Timestamp
Agent Delivery Events
Status
Timestamp
Intermediary Delivery Events
Status
Timestamp

Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted 12/6/2023 2:56:50 PM
Certified Delivered Security Checked 12/20/2023 1:36:19 PM
Signing Complete Security Checked 12/20/2023 1:36:28 PM
Completed Security Checked 12/20/2023 1:36:28 PM
Payment Events Status Timestamps
Electronic Record and Signature Disclosure

Electronic Record and Signature Disclosure created on: 11/12/2020 9:42:57 PM
Parties agreed to: Rachel Jones, Catherine Jacobs, Kendra Parrish
ELECTRONIC RECORD AND SIGNATURE DISCLOSURE
From time to time, Town of Holly Springs (we, us or Company) may be required by law to
provide to you certain written notices or disclosures. Described below are the terms and
conditions for providing to you such notices and disclosures electronically through the DocuSign
system. Please read the information below carefully and thoroughly, and if you can access this
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Disclosure (ERSD), please confirm your agreement by selecting the check -box next to `I agree to
use electronic records and signatures' before clicking `CONTINUE' within the DocuSign
system.
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At any time, you may request from us a paper copy of any record provided or made available
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only in paper format. How you must inform us of your decision to receive future notices and
disclosure in paper format and withdraw your consent to receive notices and disclosures
electronically is described below.
Consequences of changing your mind
If you elect to receive required notices and disclosures only in paper format, it will slow the
speed at which we can complete certain steps in transactions with you and delivering services to
you because we will need first to send the required notices or disclosures to you in paper format,
and then wait until we receive back from you your acknowledgment of your receipt of such
paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to
receive required notices and consents electronically from us or to sign electronically documents
from us.
All notices and disclosures will be sent to you electronically

Unless you tell us otherwise in accordance with the procedures described herein, we will provide
electronically to you through the DocuSign system all required notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided or made
available to you during the course of our relationship with you. To reduce the chance of you
inadvertently not receiving any notice or disclosure, we prefer to provide all of the required
notices and disclosures to you by the same method and to the same address that you have given
us. Thus, you can receive all the disclosures and notices electronically or in paper format through
the paper mail delivery system. If you do not agree with this process, please let us know as
described below. Please also see the paragraph immediately above that describes the
consequences of your electing not to receive delivery of the notices and disclosures
electronically from us.
How to contact Town of Holly Springs:
You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: [e-mail]
To advise Town of Holly Springs of your new email address
To let us know of a change in your email address where we should send notices and disclosures
electronically to you, you must send an email message to us at [e-mail]
and in the body of such request you must state: your previous email address, your new email
address. We do not require any other information from you to change your email address.
If you created a DocuSign account, you may update it with your new email address through your
account preferences.
To request paper copies from Town of Holly Springs
To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an email to [e-mail] and in
the body of such request you must state your email address, full name, mailing address, and
telephone number. We will bill you for any fees at that time, if any.
To withdraw your consent with Town of Holly Springs
To inform us that you no longer wish to receive future notices and disclosures in electronic
format you may:

i. decline to sign a document from within your signing session, and on the subsequent page,
select the check -box indicating you wish to withdraw your consent, or you may;
ii. send us an email to [e-mail] and in the body of such request you must
state your email, full name, mailing address, and telephone number. We do not need any other
information from you to withdraw consent.. The consequences of your withdrawing consent for
online documents will be that transactions may take a longer time to process..
Required hardware and software
The minimum system requirements for using the DocuSign system may change over time. The
current system requirements are found here: hitps://sU]2ort.docusign.com/guides/signer-guide-
si fining -system -requirements.
Acknowledging your access and consent to receive and sign documents electronically
To confirm to us that you can access this information electronically, which will be similar to
other electronic notices and disclosures that we will provide to you, please confirm that you have
read this ERSD, and (i) that you are able to print on paper or electronically save this ERSD for
your future reference and access; or (ii) that you are able to email this ERSD to an email address
where you will be able to print on paper or save it for your future reference and access. Further,
if you consent to receiving notices and disclosures exclusively in electronic format as described
herein, then select the check -box next to `I agree to use electronic records and signatures' before
clicking `CONTINUE' within the DocuSign system.
By selecting the check -box next to `I agree to use electronic records and signatures', you confirm
that:
You can access and read this Electronic Record and Signature Disclosure; and
You can print on paper this Electronic Record and Signature Disclosure, or save or send
this Electronic Record and Disclosure to a location where you can print it, for future
reference and access; and
Until or unless you notify Town of Holly Springs as described above, you consent to
receive exclusively through electronic means all notices, disclosures, authorizations,
acknowledgements, and other documents that are required to be provided or made
available to you by Town of Holly Springs during the course of your relationship with
Town of Holly Springs.