WQ0044958_Mod_Application_(FTSE)_20240125

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Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 10-23 & SUPPORTING DOCUMENTATION
,f M
Application Number: (to be completed by DwR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Town of Pilot Mountain (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ® Municipal ❑ Other
3. Signature authority's name: Michael Boaz/per 15A NCAC 02T .0106(b)
Title: Town Manap-er /
i
4. Applicant's mailing address: 124 West Main Street
City: Pilot Mountain State: NC Zip: 27401-9304
5. Applicant's contact information:
Phone number: [phone] Email Address: mboazkpilotmountainnc.org�
IL PROJECT INFORMATION:
1. Project name: Town of Pilot Mountain Collection System Improvements
2. Application/Project status: ❑ Proposed (New Permit) ® Existing Permit/Project
If a modification, provide the existing permit number: WQ0044958 and issued date: 12/1/2023,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Su _1
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.380078° Longitude:-80.482497'
5. Parcel ID (if applicable): 596618308552 596603214401 596506386900 596506399182, 596618400304 (or Parcel ID to
closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Jack Fitz eg rald' License Number: 040740
Firm: WithersRavenel, Inc.
Mailing address: 424 Gallimore Dairy Road, Suite C
City: Greensboro State: NC Zip: 27409-9545
Phone number: [phone] Email Address: ifitzgeraldna,withersravenel.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION
1. Facility Name: Pilot Mountain WWTPz Permit Number: NCO026646
Owner Name: Town of Pilot Mountain
V. RECEIVING DOWNSTREAM SEW INFORMATION:
1. Permit Number(s): WQCS00112 11-1
2. Downstream (Receiving) Sewer Information: 3 8 inch ® Gravity ® Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCSCS001121
FORM: FTA 10-23 Page I of 6

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State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 10-23 & SUPPORTING DOCUMENTATION
Owner Name(s): Town of Pilot Mountain "
FORM: FTA 10-23 Page 2 of 6

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VI. ' GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑ No ® N/A'
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.01 15(c) been attached?
❑ Yes [—]No ® N/A
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential (Leased) ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater : % Domestic % Commercial % Industrial (See 15A NCAC 02T .0I 03(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes El No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(fl? ❑ Yes ®No
➢ If yes, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow b
No. of Units
Flow
No new wastewater generated
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
GPD
a See 15A NCAC 02T .0114(b(d), L, (1) and (e)(2) for caveats to wastewater design flow rates (i.e. proposed unknown
non-residential development uses; public access facilities located near high public use areas; and residential property
located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 0 GPD (per 15A NCAC 02T .0114 and G.S. 143-215.1)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
® Rehabilitation or replacement of existing sewers with no new flow expected -'
® Other (Explain): Relocatingexisting xisting pump station due to high -risk location in berm, re -using majority of existing 3-inch
force main (partial replacement with new 4-inch force main), re-routing existing gravity sewer to new pump station and away
from high risk aerial lines to be removed, no new customers connected.
FORM: FTA 10-23 Page 3 of 6

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VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
55
PVC
8
1,005
DIP
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Lift Station 18
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.379803' Longitude:-80.481691'
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0_2 millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): 140 gallons per minute (GPM) at 57 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
4
305
PVC /
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01 C.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ® Other (please specify) Cutter
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
® Standby power source or ❑ Standby pump ,
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B):
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 10-23 Page 4 of 6

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IX. ' SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(f) & (g)? ®'Yes ❑ No
15A NCAC 02T.0305(fl contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
ZWater mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
ZWater mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305( or (g), see Section X.I of this application
* 15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications webpaae
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ®'(es ❑ No ❑ N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
i
4. Is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name: ® No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 213.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ®'No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yeses []No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
/
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 10-23 Page 5 of 6

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X. ' CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrently with the approval of the permit and projects requiring a variance approval may be subject to longer
review times For projects requiring two or more variances or where the variance is determined by the Division to be a
siunificant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
I, Jack Fitzgerald , attest that this application for Pilot Mountain Collection System Improvet tKents
(Professional Engineer's name from Application Item II1.1.) (Project Name from Application Item II.1)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering 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 the applicable regulations,
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). 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 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. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
.......................................................................................,
North Carolina Professional Engineer's seal, signature, and date: 1\p CCAggROZ
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1/18/2024
:.........................................................................................
Applicant's Certification per 15A NCAC 02T .0106(b):
I, Michael Boaz , attest that this application for Pilot Mountain Collection System Improvements
(Signature Authority Name from Application Item I.3.) (Project Name from Application Item II.1)
attest that this application 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 are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. 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.
NOTE — In accordance with General Statutes 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.
Docu Signed by: /
Signature: A l b6m, Date:
10DF4F19C47E454...
1/18/2024
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FORM: FTA 10-23 Page 6 of 6

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%0 WithersRavenel
lipOur People. Your Success.
115 MacKenan Drive
Cary, NC 27511
t: 919.469.3340 1 f: 919.467.6008
NCDEQ - Winston-Salem Regional
To: Office - Water Quality Section
450 W. Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
WE ARE SENDING YOU THE FOLLOWING ITEMS:
® Attached ❑ Under Separate Cover Via
❑ Shop Drawings ❑ Prints ❑ Plans
❑ Copy of Letter ❑ Change Order ❑ Disk
Letter of Transmittal
1/19/2024 ' ' • • 02210676.13
Fast Track Sewer Extension Applications Review
Pilot Mountain Collection System SRP Engineering
WR Project No.: 02210676.13
DWI Project No.: SRP-W-0207 / VUR-W-ARP-0024
.,r r%_"nrtmP.nt Of
Environ�mee tea
JAN 2 5 2024
❑ Samples ❑ S I ons
Winstori1016M
El Other Ite$ional Office
COPIES DESCRIPTION
1 Cover Letter
1
Fast Track Application for Modification to Existing Permit WQ0044958
1
Check for $600 Application Modification Fee
1
Existing Permit WQ0044958 Issued December 1, 2023
1
8.5x11 Aerial and USGS Maps (Same as previous application)
THESE ARE TRANSMITTED as checked below:
❑x For approval ❑ Approved as submitted
❑ For your use ❑ Approved as noted
❑ As requested ❑ Returned for corrections
® For review and comment
❑ For bids due
REMARKS:
COPY TO:
❑ Resubmit copies for approval
❑ Submit copies for distribution
❑ Return corrected prints
❑ Other
❑ Prints returned after loan to us
Please contact me at 919-978-3837 or [e-mail] with any questions.
SIGNED: Jack Fitzgerald, PE
If enclosures are not as noted, kindly notify us at once.

WithersRavenel
®r Our People. Your Success.
To:
North Carolina Department of Environmental Quality
Winston Salem Regional Office - Water Quality Section
450 W. Hanes Mill Road, Suite 300
Winston-Salem, North Carolina 27105
Attn: Jenny Graznak
CC:
Michael Boaz, Town Manager
Town of Pilot Mountain, NC
From:
Jack Fitzgerald
Date:
January 19, 2024
Project:
Town of Pilot Mountain Collection System SRP Engineering
Project Number: WR # 02210676.13
DWI Project Number: SRP-W-0207 / VUR-W-ARP-0024
Subject:
Fast Track Sewer Extension Application
N C department of
Environmental Quality
Received
JAN 2 5 2024
e Winston-Salem
Regional Office
On behalf of the Town of Pilot Mountain, WithersRavenel is submitting the attached Fast Track
Sewer Extension Permit modification application for the Town of Pilot Mountain Collection
System Improvements project. The Town has received a letter of intent to fund (LOIF) from the
NCDEQ Department of Water Infrastructure (DWI) indicating that a total of $2,845,000 will be
remitted for the project. The funding source is 50% grant and 50% low -interest loan.
A Fast Track application was previously approved by your office on December 1, 2023, permit
number WQ0044958. The project scope is identical to that of the previous application, except for
quantities, sizes, and materials of the proposed gravity sewer and force main infrastructure,
following a design change. The scope of work described in the previous application and cover
letter is the same, with the following exceptions:
• The proposed force main to re-route flow from the new Lift Station 18 location and tie-in
to the existing 3-inch force main was originally listed as 685 LF of 3-inch pipe. The updated
quantity and size are 305 LF of 4-inch force main.
• The proposed gravity sewer was originally listed as 825 LF of 8-inch PVC and 255 LF of 8-
inch DIP for a total of 1,080 LF. The updated quantities are 55 LF of 8-inch PVC and 1,005
LF of 8-inch DIP for a total of 1,060 LF. The material change was for improved longevity
of the proposed gravity sewer which will be located under an existing road asphalt.
As stated in the original application, the project will re-route existing flow; no additional flow will
be added to the collection system. It is requested that the existing permit be modified and re-
issued for the updated gravity sewer and force main quantities.
115 MacKenan Drive I Cary, NC 27511
t: 919.469,3340 1 f: 919.467.60081 www.withersravenel.com I License No. F-1479
Asheville I Cary I Charlotte I Greensboro I Pittsboro I Raleigh I Southern Pines I Wilmington

%0 WithersRavenel
00 Our People. Your Success.
This Fast Track Application Package includes the following items:
• Updated Fast Track Application (Form FTA 10-23).
• Check for the $600 application modification fee.
• Existing permit WQ0044958
• Two (2) 8.5x11 site maps showing the location of project features (same as previously
submitted)
Please do not hesitate to contact me at 919-978-3837 or [e-mail] should
you have any questions or concerns.
Sincerely,
WithersRavenel
Jack Fitzgerald, PE
Page 2 of 2

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State of North Carolina
Department of Environmental Quality
Division of Water Resources
4p,
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria (Gravi . Sewer & Pump Stations/Force Mains) and that plans, specifications and supporting documents
have been prepared in accordance with 15A NCAC 02T. 15A NCAC 02T .0300. Division policies, and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be immediately available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPs) or simplex grinder pumps;
➢ Simplex STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an application, 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 requested additional information. Failure to submit all required items will necessitate additional processing and review
time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit one original and one copy of
the application and supporting documentation.
A. One Original and One Copy (second copy may be digital) of Application and Supporting Documents
® Required unless otherwise noted. Signatures on original must be "wet ink" or secure digital signatures.
Please do not submit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description (Required for All Application Packages):
M List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ Include the permit number/status of any other required sewer permits (downstream/upstream)
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Modification Application Packages):
E Submit a check or money order in the amount of $600.00, dated no more than 90 days prior to application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track Application (Required for All Application Packages, Form FTA 10-23):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary of State.
❑ If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of Deeds in
the county of business.
® The Project Name in Item II.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina
licensed Professional En ig neer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b). Per
15A NCAC 02T .0106(c), 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).
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 1 of 3

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E. Flow Tracking/Acceptance Form (Form: FTSE 10-23) (If Applicable):
❑ Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year
prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215.67(a).
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
N Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area,
including the closest surface waters.
➢ General location of the project components (gravity sewer, pump stations, & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
N Include an aerial location map showing general project area (such as street names or latitude/longitude) so that Division staff
can easily locate it in the field.
G. Existing Permit (Application Packages for Modifications to an Existing Permit):
N Submit a copy of the most recently issued existing permit.
N Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to be
added, and/or items to be modified (the application form itself should include only include items to be added/modified). The
narrative should also include whether any previously permitted items have been certified.
N The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
N Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible with
the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed contractor,
stating that "the portable power generation unit or portable, independently -powered pumping units, associated appurtenances
and personnel are available for distribution and operation of this pump station."
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall
be provided in the case of a multiple station power outage. (Required at time of certification)
1. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities
Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
❑ Provide a letter from the North Carolina 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.
Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b). submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 2 of 3

UVI.U01y11 L:IIVt:!1UyC IV. I / JJ
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778-8211
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5095
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
3800 Barrett Drive
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27609
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan, Craven,
Water Quality Section
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Alamance, Alleghany, Ashe, Caswell, Davidson,
Water Quality Section
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 3 of 3

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Michael Boaz, Town Manager
Email: [e-mail]
Town of Pilot Mountain
124 West Main Street
Pilot Mountain, NC 27401-9304
NORTH CAROLINA
Environmental Quality
December 1, 2023
Subject: Permit No. WQ0044958
Town of Pilot Mountain
Town of Pilot Moutain Collection System SRP Engineering
Wastewater Collection System Extension Permit
Surry County
Dear Mr. Boaz:
In accordance with your application received November 22, 2023 we are forwarding herewith Permit No.
WQ0044958 dated December 1, 2023 to the Town of Pilot Mountain (Permittee) for the construction and
operation upon certification of the subject wastewater collection system extension. This permit shall be
effective from the date of issuance until rescinded and shall be subject to the conditions and limitations
as specified therein. This cover letter shall be considered a part of this permit and is therefore
incorporated therein by reference.
Please pay particular attention to the following conditions contained within this permit:
Condition 11.1: This permit shall not be automatically transferable; a request must be made and
approved.
Condition 11.4: Requires that the wastewater collection facilities be properly operated and maintained
in accordance with 15A NCAC 02T .0403 or any individual system -wide collection system
permit issued to the Permittee.
Condition 11.7: Upon completion of construction and prior to operation of these permitted facilities, the
completed Engineering Certification form with checklist attached to this permit shall be
submitted with the required supporting documents to the address provided on the form.
Permit modifications are required for any changes resulting in non-compliance with
this permit, regulations, or the Minimum Design Criteria. [15A NCAC 02T.01161
It shall be the responsibility of the Permittee to ensure that the as -constructed project meets the
appropriate design criteria and rules. Failure to comply may result in penalties in accordance with North
Carolina General Statute §143-215.6A through §143-215.6C, construction of additional or replacement
wastewater collection facilities, and/or referral of the North Carolina -licensed Professional Engineer to
the licensing board.
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
1fF1.;Ni(i_W1
336.776.9800

Town of Pilot Mountain
Permit No. WQ0044958
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing upon written request within 30 days following receipt of this permit. This
request must be in the form of a written petition, conforming to Chapter 150E of North Carolina General
Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC
27699-6714. Unless such demands are made, this permit shall be final and binding.
If you need additional information concerning this matter, please contact Jenny Graznak at (336) 776-
9695 or via e-mail at jenny.�[e-mail].�ov.
Sincerely,
DOCUSigned by:
Je n nx�en JJ",q((ll _AU
OD2D3CEV3F187456...
for Richard E. Rogers, Jr.
Director, Division of Water Resources
by Jennifer F. Graznak, Assistant Regional Supervisor
Water Quality Regional Operations Section
Winston-Salem Regional Office
Division of Water Resources, NCDEQ
cc: Jack Fitzgerald, WithersRavenel, Inc.
Page 2 of 7

NORTH CAROLINA
Environmental Quality
WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations, permission is hereby granted to the
Town of Pilot Mountain
Surry County
forthe construction and operation of approximately 1,080 linear feet of 8-inch gravity sewer; a 140—gallon
per minute pump station (Lift Station 18) with duplex grinder pumps, on -site audible and visual high water
alarms, telemetry, and an onsite permanent generator with an automatic transfer switch; as well as
approximately 685 linear feet of 3-inch force main to serve the residents of Pilot Mountain as part of the
Town of Pilot Mountain Collection System SRP Engineering project, and the discharge of 0* additional
gallons per day of collected domestic wastewater pursuant to the application received November 22, 2023
and in conformity with 15A NCAC 02T; the Division's Gravity Sewer Minimum Design Criteria adopted
February 12, 1996 as applicable; the Division's Minimum Design Criteria for the Fast -Track Permitting of
Pump Stations and Force Mains adopted June 1, 2000 as applicable; and other supporting data
subsequently filed and approved by the Department of Environmental Quality and considered a part of
this permit.
This permit shall be effective from the date of issuance until rescinded and shall be subject to the specified
conditions and limitations contained therein.
*Permitted flow is zero, because the project involves the relocation of an existing pump station.
EDocuSigned b
y:�-2D3CE3F1 B7456...
for Richard E. Rogers, Jr.
Director, Division of Water Resources
By Authority of The Environmental Management Commission
Permit Number: WQ0044958
Permit Issued: December 1, 2023
Page 3 of 7

SUPPLEMENT TO PERMIT COVER SHEET
Town of Pilot Mountain is hereby authorized to:
Construct, and then operate upon certification the aforementioned wastewater collection extension. The
sewage and wastewater collected by this system shall be treated in the Town of Pilot Mountain's
Wastewater Treatment Facility in accordance with Permit Number NC0026646.
Permitting of this project does not constitute an acceptance of any part of the project that does not meet
15A NCAC 02T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as
applicable; and the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and
Force Mains adopted June 1, 2000 as applicable, unless specifically mentioned herein. Division approval
is based on acceptance of the certification provided by a North Carolina -licensed Professional Engineer in
the application. It shall be the Permittee's responsibility to ensure that the as -constructed project meets
the appropriate design criteria and rules.
Construction and operation is contingent upon compliance with the Standard Conditions and any Special
Conditions identified below.
I. SPECIAL CONDITIONS
1. No flow in excess of the quantity permitted herein, 0 additional GPD, shall be made tributary to the
subject sewer system until an application for permit modification for an increase in flow has been
submitted to and approved by the Division. [15A NCAC 02T.0304(b)]
2. Each pump station shall be clearly and conspicuously posted using a weatherproof sign with a pump
station identifying name/number, 24-Hour Emergency telephone number, and name of the
owner/operator of the sewer system/pump station and instructions to call the number in the event
of alarm activation or other emergency. Simplex pump stations or vacuum sewer pits serving a single-
family residence may have a placard or sticker on the control panel in lieu of a sign. [15A NCAC 02T
.0305(h)(2)]
II. STANDARD CONDITIONS
This permit shall not be transferable. In the event there is a desire for the wastewater collection
facilities to change ownership, or there is a name change of the Permittee, a formal permit request
shall be submitted to the Division accompanied by documentation from the parties involved, and
other supporting materials as may be appropriate. The approval of this request shall be considered
on its merits and may or may not be approved. [15A NCAC 02T.0116; G.S 143-215.1(d3)]
2. This permit shall become voidable unless the wastewater collection facilities are constructed in
accordance with the conditions of this permit; 15A NCAC 02T; the Division's Gravity Sewer Minimum
Design Criteria adopted February 12, 1996 as applicable; the Division's Minimum Design Criteria for
the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable; and
other supporting materials unless specifically mentioned herein. [15A NCAC 02T.0110]
3. This permit shall be effective only with respect to the nature and volume of wastes described in the
application and other supporting data. [15A NCAC 02T .01101
Page 4 of 7

4. The wastewater collection facilities shall be properly maintained and operated at all times. The
Permittee shall maintain compliance with an individual system -wide collection system permit for the
operation and maintenance of these facilities as required by 15A NCAC 02T .0403. If an individual
permit is not required, the following performance criteria shall be met:
The sewer system shall be effectively maintained and operated at all times to prevent discharge
to land or surface waters, and to prevent any contravention of groundwater standards or surface
water standards.
b. A map of the sewer system shall be developed and shall be actively maintained.
An operation and maintenance plan including pump station inspection frequency, preventative
maintenance schedule, spare parts inventory and overflow response has been developed and
implemented.
d. Pump stations that are not connected to a telemetry system shall be inspected every day (i.e. 365
days per year). Pump stations that are connected to a telemetry system shall be inspected at
least once per week.
e. High -priority sewer lines shall be inspected at least once per every six -months and inspections are
documented.
f. A general observation of the entire sewer system shall be conducted at least once per year.
g. Overflows and bypasses shall be reported to the appropriate Division regional office in accordance
with 15A NCAC 2B .0506(a), and public notice shall be provided as required by North Carolina
General Statute §143-215.1C.
h. A Grease Control Program is in place as follows:
For public owned collection systems, the Grease Control Program shall include at least
biannual distribution of educational materials for both commercial and residential users and
the legal means to require grease interceptors at existing establishments. The plan shall also
include legal means for inspections of the grease interceptors, enforcement for violators and
the legal means to control grease entering the system from other public and private satellite
sewer systems.
For privately owned collection systems, the Grease Control Program shall include at least bi-
annual distribution of grease education materials to users of the collection system by the
permittee or its representative.
3. Grease education materials shall be distributed more often than required in Parts (1) and (2)
of this Subparagraph if necessary to prevent grease -related sanitary sewer overflows.
Right-of-ways and easements shall be maintained in the full easement width for personnel and
equipment accessibility.
j. Documentation shall be kept for Subparagraphs (a) through (i) of this Rule for a minimum of three
years with exception of the map, which shall be maintained for the life of the system.
5. The Permittee shall report by telephone to a water resources staff member at the Winston-Salem
Regional Office, telephone number [phone], as soon as possible, but in no case more than 24
hours, following the occurrence or first knowledge of the occurrence of either of the following:
Page 5 of 7

a. Any process unit failure, due to known or unknown reasons, that renders the facility incapable
of adequate wastewater transport, such as mechanical or electrical failures of pumps, line
blockage or breakage, etc.; or
b. Any SSO and/or spill over 1,000 gallons; or
c. Any SSO and/or spill, regardless of volume, that reaches surface water
Voice mail messages or faxed information is permissible, but this shall not be considered as the initial
verbal report. Overflows and spills occurring outside normal business hours may also be reported to
the Division of Emergency Management at telephone number [phone] or [phone].
Persons reporting any of the above occurrences shall file a spill report by completing and submitting
Part I of Form CS-SSO (or the most current Division approved form) within five days following first
knowledge of the occurrence. This report must outline the actions taken or proposed to be taken to
ensure that the problem does not recur. Part II of Form CS-SSO (or the most current Division approved
form) can also be completed to show that the SSO was beyond control. [G.S. 143-215.1C(a1)]
6. Construction of the gravity sewers, pump stations, and force mains shall be scheduled so as not to
interrupt service by the existing utilities nor result in an overflow or bypass discharge of wastewater
to the surface waters of the State. [15A NCAC 02T.0108(b)]
7. Upon completion of construction and prior to operation of these permitted facilities, the completed
Engineering Certification form with checklist attached to this permit shall be submitted with the
required supporting documents to the address provided on the form. A complete certification is one
where the form is fully executed and the supporting documents are provided as applicable. Any
wastewater flow made tributary to the wastewater collection system extension prior to completion
of this Engineer's Certification shall be considered a violation of the permit and shall subject the
Permittee to appropriate enforcement actions.
A complete certification is one where the form is fully executed and the supporting documents are
provided as applicable. Supporting documentation shall include the following:
a. One copy of the project construction record drawings (plan & profile views of sewer lines & force
mains) of the wastewater collection system extension. Final record drawings should be clear on
the plans or on digital media and are defined as the design drawings that are marked up or
annotated with after construction information and show required buffers, separation distances,
material changes, etc.
b. One copy of the supporting applicable design calculations including pipe and pump sizing, velocity,
pump cycle times, and level control settings, pump station buoyancy, wet well storage, surge
protection, detention time in the wet well, and force main, ability to flush low points in force
mains with a pump cycle, and downstream sewer capacity analysis. If a portable power source or
pump is dedicated to multiple stations, an evaluation of all the pump stations' storage capacities
and the rotation schedule of the portable power source or pump, include travel timeframes, shall
be provided.
c. Changes to the project that do not result in non-compliance with this permit, regulations, or the
Minimum Design Criteria should be clearly identified on the record drawings, on the certification
in the space provided, or in written summary form.
Prior to Certification (Final or Partial): Permit modifications are required for any changes resulting
in non-compliance with this permit (including but not limited to pipe length changes of 10% or
Page 6 of 7

greater, increased flow, pump station design capacity design increases of 5% or greater, and
increases in the number/type of connections), regulations, or the Minimum Design Criteria.
Requested modifications or variances to the Minimum Design Criteria will be reviewed on a case -by -
case basis and each on its own merit. Please note that variances to the Minimum Design Criteria
should be requested and approved during the permitting process prior to construction. After -
construction requests are discouraged by the Division and may not be approved, thus requiring
replacement or repair prior to certification & activation. [15A NCAC 02T .0116]
8. Gravity sewers installed greater than ten percent below the minimum required slope per the Division's
Gravity Sewer Minimum Design Criteria shall not be acceptable and shall not be certified until
corrected. If there is an unforeseen obstacle in the field where all viable solutions have been
examined, a slope variance can be requested from the Division with firm supporting documentation.
This shall be done through a permit modification with fee. Such variance requests will be evaluated
on a case -by -case basis. Resolution of such request shall be evident prior to completing and submitting
the construction certification. [ 15A NCAC 02T.0105(n)]
9. A copy of the individual permit and construction record drawings shall be maintained on file by the
Permittee for the life of the wastewater collection facilities. [15A NCAC 02T .0116]
10. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 02T; the
Division's Gravity Sewer Design Criteria adopted February 12, 1996 as applicable; the Division's
Minimum Design Criteria for the Fast -Track Permitting of Pump Station and Force Mains adopted June
1, 2000 as applicable; and other supporting materials may subject the Permittee to an enforcement
action by the Division, in accordance with North Carolina General Statutes §143-215.6A through §143-
215.6C, construction of additional or replacement wastewater collection facilities, and/or referral of
the North Carolina -licensed Professional Engineer to the licensing board. [15A NCAC 02T .0108(b-c)]
11. In the event that the wastewater collection facilities fail to perform satisfactorily, including the
creation of nuisance conditions, the Permittee shall take immediate corrective action, including those
as may be required by this Division, such as the construction of additional or replacement facilities.
[15A NCAC 02T .0110; 15A NCAC 02T .0108(b)]
12. The issuance of this permit shall not exempt the Permittee from complying with any and all statutes,
rules, regulations, or ordinances that may be imposed by the Division any other Federal, State, or Local
government agencies which have jurisdiction or obtaining other permits which may be required by
the Division or any other Federal, State, of Local government agencies. [G.S. 143-215.1(b)]
Page 7 of 7

CERTIFICATION CHECKLIST
To be completed by the certifying engineer prior to operation of the permitted sewers, per 15A NCAC 02T.0116.
Certifying Engineer:
Certification Review Date:
Project: Town of Pilot Mountain Collection System SRP Engineering
Permit No. WQ0044958 Project County: Surry County
1) Has permittee information changed since the permit was issued (or last modified): change of mailing address,
change of ownership, transfer from developer to HOA/POA, etc. ❑ Yes ❑ No
• If yes, please provide either a change of ownership form or new contact information. Note that transfer of
permits from the developer to the HOA/POA must occur with the first certification.
2) Have the as -built drawings have been signed, sealed, and dated by an N.C. PE? ❑ Yes ❑ No
3) Final Engineering certification? ❑ Yes ❑ No
• If Partial Engineering certification, provide detailed narrative including what is being certified in the current
phase, what was previously certified (if applicable), and what is left to be certified.
4) Adequate information related to sewer lines: ❑ Yes ❑ No ❑ N/A
• Three feet minimum cover has been provided for all sewers unless ferrous pipe was installed.
• Minimum diameters for gravity sewers are 8-inches for public lines and 6-inches for private lines.
• Manholes have been installed: At the end of each line, at all changes in grade, size, or alignment, at all
intersections, and at distances not greater than 425 feet; minimum diameter shall be 4 feet (48-inches).
5) Adequate information related to pump stations: ❑ Yes ❑ No ❑ N/A
• Ensure power reliability option was selected per 15A NCAC 02T.0305(h).
6) Was project construction completed in accordance with all of the following: ❑ Yes ❑ No ❑ N/A
• 15A NCAC 02T1 Minimum Design Criteria (MDC) for the permitting of Gravity Sewers (latest version), and MDC
for the Permitting of Pump Stations and Force Mains (latest version)?
If not, a variance approval is required in accordance with 15A NCAC 02T.0105(b), prior to certification and operation.
• Contact the Central Office to discuss the variance to determine a course of action.
• Applicant must submit two copies of the variance request form, plans, specifications, calculations, and any other
pertinent information to the Central Office (one hard copy, one digital copy).
• The central office will review the variance request, and if approvable, specific language regarding the variance
will be incorporated into the permit, either via a special condition or a supplementary letter. A copy of the
reissued permit with variance language or the variance letter must be maintained with the original documents.
7) Does the project contains high priority lines (15A NCAC 02T .0402(2))? ❑ Yes ❑ No
• If yes, ensure that the permit already contains the necessary condition related to high priority lines 15A NCAC
02T.0403 (a)(5). If the permit does not include this language, the Fast Track reviewer will reissue the permit with
the appropriate language.
8) Are Permit modifications are required for any changes resulting in non-compliance with this permit (including but not
limited to pipe length changes of 10% or greater, change in flow, pump station design capacity design change of 5% or
greater, and/or change in the number/type of connections)? ❑ Yes ❑ No
• If yes, a permit modification request must be submitted to the appropriate Regional Office, and a modified
permit with revised certification must be issued prior to certification and operation.
NC DWR— Water Quality Regional Operations Section 450 West Hanes Mill Road, Suite 300, Winston-Salem, NC 27105
Winston-Salem Regional Office Phone: [phone] FAX: [phone]

FAST TRACK SEWER ENGINEERING CERTIFICATION
PERMITTEE: Town of Pilot Mountain
PERMIT M WQ0044958
PROJECT: Town of Pilot Mountain Collection System SRP Engineering
ISSUE DATE: December 1, 2023
COUNTY: Surry County
This project shall not be considered complete nor allowed to operate in accordance with Condition 7 of
this permit until the Division has received this Certification and all required supporting documentation. It
should be submitted in a manner that documents the Division's receipt. Send the required documentation
to the Regional Supervisor, Water Quality Regional Operations Section at the address at the bottom.
Any wastewater flow made tributary to the wastewater collection system extension prior to completion
of this Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions. The Permittee is responsible for tracking all partial certifications up
until a final certification is received. A Final Certification shall be a complete set of record drawings and
design calculations regardless of whether partials have been submitted.
PERMITTEE'S CERTIFICATION
I, the undersigned agent for the Permittee, hereby state that this project has been constructed pursuant
to the applicable standards & requirements, the Professional Engineer below has provided applicable
design/construction information to the Permittee, and the Permittee is prepared to operate & maintain
the wastewater collection system permitted herein or portions thereof.
Printed Name, Title Signature Date
ENGINEERS CERTIFICATION
I, , as a duly registered Professional Engineer in the State of North Carolina,
having been authorized to observe (❑ periodically, ❑ weekly, ❑ full time) the construction of the
project referenced above for the above Permittee, and hereby state that, to the best of my abilities, due
care and diligence was used in the observation of the following construction:
of approximately 1,080 linear feet of 8-inch gravity sewer; a 140—gallon per minute pump station (Lift
Station 18) with duplex grinder pumps, on -site audible and visual high water alarms, telemetry, and an
onsite permanent generator with an automatic transfer switch; as well as approximately 685 linear feet
of 3-inch force main to serve the residents of Pilot Mountain as part of the Town of Pilot Mountain
Collection System SRP Engineering project, and the discharge of 0* additional gallons per day of collected
domestic wastewater pursuant to the application received November 22, 2023; such that the construction
was observed to be built within substantial compliance of this permit;15A NCAC 02T; the Division of Water
Resources' (Division) Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable;
the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains
adopted June 1, 2000 as applicable; and other supporting materials.
.........................................................................
North Carolina Professional Engineer's Seal w/signature & date:
❑ Final ❑ Partial (include description)
Certification Comments/Qualifiers (attach if necessary):
:.......................................................................:
NC DWR — Water Quality Regional Operations Section 450 West Hanes Mill Road, Suite 300, Winston-Salem, NC 27105
Winston-Salem Regional Office Phone: [phone] FAX: [phone]

DocuSign Envelope ID: 80CAAAF2-E399-4EOF-A251-B33BC46D1739
State of North Carolina
r/��� Department of Environmental Quality
DWR��� �l�' ��' `��" Division of Water Resources
�'' a �• FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 10-23 & SUPPORTING DOCUMENTATION
"& 0
Application Number: g5 X(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Town of Pilot Mountain (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: Michael Boaz per 15A NCAC 02T .0106(b)
Title: Town Manager
f
4. Applicant's mailing address: 124 West Main Street
City: Pilot Mountaitf State: NCf Zip: 27401-9304
5. Applicant's contact information:
Phone number: [phone] Email Address: mboazgpilotmountainnc.org
II. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ Other
I. Project name: Town of Pilot Mountain Collection System Improvements
2. Application/Project status: ❑ Proposed (New Permit) ® Existing Permit/Project
If a modification, provide the existing permit number: WQ0044958 and issued date: 12/l/2023,
3
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00
Conn where 1 t d S
ty p o�ec is oca e uny
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.380078' Longitude:-80.4824970
5. Parcel ID (if applicable): 596618308552, 596603214401. 596506386900 596506399182 596618400304 (or Parcel ID to
closest downstream sewer)
III. CONSULTANT INFORMATION:
Professional Engineer: Jack Fitzgerald License Number: 040740
Firm: WithersRavenel, Inc.-'
Mailing address: 424 Gallimore Dairy Road, Suite C
City: Greensboro State: NC Zip: 27409-9545
Phone number: [phone] Email Address: iiitz eg raldp_withersravenel.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
i
1. Facility Name: Pilot Mountain WWTP Permit Number: NC0026646
Owner Name: Town of Pilot Mountain /
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. PermitNumber(s): WQCS00112
2. Downstream (Receiving) Sewer Information: 3 8 inch ® Gravity ® Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCSCS00112
FORM: FTA 10-23 Page 1 of 6

DocuSign Envelope ID: 80CA4AF2-E399-4EOF-A251-B33BC46D1739
DWR
Division of Water Resources
Owner Name(s): Town of Pilot Mountain `
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 10-23 & SUPPORTING DOCUMENTATION
FORM: FTA 10-23 Page 2 of 6

DocuSign Envelope ID: 80CA4AF2-E399-4EOF-A251-B33BC46D1739
VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑ No ® N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑ No ® N/A /
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential (Leased) ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ❑ Church
❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: % Domestic % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(1)? ❑ Yes ® No
➢ If Yes, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow a,b
No. of Units
Flow
No new wastewater generated
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
GPD
a See 15A NCAC 02T .0114(b) (d),(e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e. proposed unknown
non-residential development uses; public access facilities located near high public use areas; and residential property
located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 0 GPD (per 15A NCAC 02T .0114 and G.S. 143-215.1)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
® Rehabilitation or replacement of existing sewers with no new flow expected'
® Other (Explain): Relocating existing pump station due to high -risk location in berm re using majority of existing 3-inch
force main (partial replacement with new 4-inch force main) re-routina existing gravity sewer to new pump station and away,,
from high risk aerial lines to be removed no new customers connected
FORM: FTA 10-23 Page 3 of 6

DocuSign Envelope ID: 80CA4AF2-E399-4EOF-A251-B33BC46D1739
VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
55
PVC
8
1,005
DIP
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED fN THIS PROJECT
1. Pump station number or name: Lift Station 18
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.379803' Longitude:-80.481691'
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0_2 millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): 140 gallons per minute (GPM) at 57 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
4
305
PVC
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01 C.l.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ® Other (please specify) Cutter
Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
® Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B)_
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 10-23 Page 4 of 6

DocuSign Envelope ID: 80CA4AF2-E399-4EOF-A251-B33BC46D1739
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(f)&(g)? ® Yes ❑ No
15A NCAC 02T.0305 contains minimum set3arations that shall be provided for sewers stems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
2Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
2Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
.- it noncompliance with UZ EU3U5(t or (2). see Section X.1 of this application
* 15A NCAC 02T.0305(e) contains alternatives where separations in 02T.0305(f) cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications webnaee
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ® Yes ❑ No ❑ N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name: ® No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 2B.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® ivo
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ®Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 10-23 Page 5 of 6

DocuSign Envelope ID: 80CA4AF2-E399-4EOF-A251-B33BC46D1739
X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting, of Pump Stations
and Force Mains (latest version) and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrently with the approval of the permit and proiects requirine a variance approval may be subject to longer
review times. For proiects reauirine two or more variances or where the variance is determined by the Division to be a
significant portion of the proiect, the full technical review is required
2. Professional Engineer's Certification:
I, Jack Fitzgerald ; attest that this application for Pilot Mountain Collection System Improvements
(Professional Engineer's name from Application Item III.1.) (Project Name from Application Item I1.1)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering 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 the applicable regulations,
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). 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 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. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:gN OARp��
4cw4idnae c
o:
GINE��' �P
1/18/1024
Applicant's Certification per 15A NCAC 02T .0106(b):
I, Michael Boaz , attest that this application for Pilot Mountain Collection System Improvements
(Signature Authority Name from Application Item I.3.) (Project Name from Application Item II.1)
attest that this application 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 are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. 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.
NOTE — In accordance with General Statutes 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.
Zia
lpned by:
Signature: bje Date
10DE4F=47E454...
1/18/2024
FORM: FTA 10-23 Page 6 of 6

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ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Michael Boaz, Town Manager
Email: [e-mail]
Town of Pilot Mountain
124 West Main Street
Pilot Mountain, NC 27401-9304
NORTH CAROLINA
Environmental Quality
December 1, 2023
Subject: Permit No. WQ0044958
Town of Pilot Mountain
Town of Pilot Moutain Collection System SRP Engineering
Wastewater Collection System Extension Permit
Surry County
Dear Mr. Boaz:
In accordance with your application received November 22, 2023 we are forwarding herewith Permit No.
WQ0044958 dated December 1, 2023 to the Town of Pilot Mountain (Permittee) for the construction and
operation upon certification of the subject wastewater collection system extension. This permit shall be
effective from the date of issuance until rescinded and shall be subject to the conditions and limitations
as specified therein. This cover letter shall be considered a part of this permit and is therefore
incorporated therein by reference.
Please pay particular attention to the following conditions contained within this permit:
Condition 11.1: This permit shall not be automatically transferable; a request must be made and
approved.
Condition IIA: Requires that the wastewater collection facilities be properly operated and maintained
in accordance with 15A NCAC 02T .0403 or any individual system -wide collection system
permit issued to the Permittee.
Condition 11.7: Upon completion of construction and prior to operation of these permitted facilities, the
completed Engineering Certification form with checklist attached to this permit shall be
submitted with the required supporting documents to the address provided on the form.
Permit modifications are required for any changes resulting in non-compliance with
this permit, regulations, or the Minimum Design Criteria. [15A NCAC 02T.0116]
It shall be the responsibility of the Permittee to ensure that the as -constructed project meets the
appropriate design criteria and rules. Failure to comply may result in penalties in accordance with North
Carolina General Statute §143-215.6A through §143-215.6C, construction of additional or replacement
wastewater collection facilities, and/or referral of the North Carolina -licensed Professional Engineer to
the licensing board.
D E Q�� North Carolina Department Environmental Quality I Division of Water Resources
ern o, ae nw �
Winston-Salem Regional Office 1 450 West Hanes Mill Road, Suite 300 1 Winston-Salem, North Carolina 27105
1 / 336.77b.9800

Town of Pilot Mountain
Permit No. WQ0044958
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing upon written request within 30 days following receipt of this permit. This
request must be in the form of a written petition, conforming to Chapter 150E of North Carolina General
Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC
27699-6714. Unless such demands are made, this permit shall be final and binding.
If you need additional information concerning this matter, please contact Jenny Graznak at (336) 776-
9695 or via e-mail at [e-mail].
Sincerely,
EDocuSIg d by:
am. 4..��.Q�
OD2D3CE3F187458... C/
for Richard E. Rogers, Jr.
Director, Division of Water Resources
by Jennifer F. Graznak, Assistant Regional Supervisor
Water Quality Regional Operations Section
Winston-Salem Regional Office
Division of Water Resources, NCDEQ
cc: Jack Fitzgerald, WithersRavenel, Inc.
Page 2 of 7

NORTH CAROLINA
Environmental Quality
WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations, permission is hereby granted to the
Town of Pilot Mountain
Surry County
for the construction and operation of approximately 1,080 linear feet of 8-inch gravity sewer; a 140—gallon
per minute pump station (Lift Station 18) with duplex grinder pumps, on -site audible and visual high water
alarms, telemetry, and an onsite permanent generator with an automatic transfer switch; as well as
approximately 685 linear feet of 3-inch force main to serve the residents of Pilot Mountain as part of the
Town of Pilot Mountain Collection System SRP Engineering project, and the discharge of 0* additional
gallons per day of collected domestic wastewater pursuant to the application received November 22, 2023
and in conformity with 15A NCAC 02T; the Division's Gravity Sewer Minimum Design Criteria adopted
February 12, 1996 as applicable; the Division's Minimum Design Criteria for the Fast -Track Permitting of
Pump Stations and Force Mains adopted June 1, 2000 as applicable; and other supporting data
subsequently filed and approved by the Department of Environmental Quality and considered a part of
this permit.
This permit shall be effective from the date of issuance until rescinded and shall be subject to the specified
conditions and limitations contained therein.
*Permitted flow is zero, because the project involves the relocation of an existing pump station.
EDocuSigned by:
am. 4..�.
OD2D3CE3F1B7458... (l
for Richard E. Rogers, Jr.
Director, Division of Water Resources
By Authority of The Environmental Management Commission
Permit Number: WQ0044958
Permit Issued: December 1, 2023
Page 3 of 7

SUPPLEMENT TO PERMIT COVER SHEET
Town of Pilot Mountain is hereby authorized to:
Construct, and then operate upon certification the aforementioned wastewater collection extension. The
sewage and wastewater collected by this system shall be treated in the Town of Pilot Mountain's
Wastewater Treatment Facility in accordance with Permit Number NC0026646.
Permitting of this project does not constitute an acceptance of any part of the project that does not meet
15A NCAC 02T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as
applicable; and the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and
Force Mains adopted June 1, 2000 as applicable, unless specifically mentioned herein. Division approval
is based on acceptance of the certification provided by a North Carolina -licensed Professional Engineer in
the application. It shall be the Permittee's responsibility to ensure that the as -constructed project meets
the appropriate design criteria and rules.
Construction and operation is contingent upon compliance with the Standard Conditions and any Special
Conditions identified below.
I. SPECIAL CONDITIONS
1. No flow in excess of the quantity permitted herein, 0 additional GPD, shall be made tributary to the
subject sewer system until an application for permit modification for an increase in flow has been
submitted to and approved by the Division. [15A NCAC 02T.0304(b)]
Each pump station shall be clearly and conspicuously posted using a weatherproof sign with a pump
station identifying name/number, 24-Hour Emergency telephone number, and name of the
owner/operator of the sewer system/pump station and instructions to call the number in the event
of alarm activation or other emergency. Simplex pump stations orvacuum sewer pits serving a single-
family residence may have a placard or sticker on the control panel in lieu of a sign. [15A NCAC 02T
.0305(h)(2)]
II. STANDARD CONDITIONS
1. This permit shall not be transferable. In the event there is a desire for the wastewater collection
facilities to change ownership, or there is a name change of the Permittee, a formal permit request
shall be submitted to the Division accompanied by documentation from the parties involved, and
other supporting materials as may be appropriate. The approval of this request shall be considered
on its merits and may or may not be approved. [15A NCAC 02T.0116; G.S 143-215.1(d3)]
This permit shall become voidable unless the wastewater collection facilities are constructed in
accordance with the conditions of this permit; 15A NCAC 02T; the Division's Gravity Sewer Minimum
Design Criteria adopted February 12, 1996 as applicable; the Division's Minimum Design Criteria for
the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable; and
other supporting materials unless specifically mentioned herein. [15A NCAC 02T.0110]
3. This permit shall be effective only with respect to the nature and volume of wastes described in the
application and other supporting data. [15A NCAC 02T .0110]
Page 4 of 7

4. The wastewater collection facilities shall be properly maintained and operated at all times. The
Permittee shall maintain compliance with an individual system -wide collection system permit for the
operation and maintenance of these facilities as required by 15A NCAC 02T .0403. If an individual
permit is not required, the following performance criteria shall be met:
a. The sewer system shall be effectively maintained and operated at all times to prevent discharge
to land or surface waters, and to prevent any contravention of groundwater standards or surface
water standards.
b. A map of the sewer system shall be developed and shall be actively maintained.
c. An operation and maintenance plan including pump station inspection frequency, preventative
maintenance schedule, spare parts inventory and overflow response has been developed and
implemented.
d. Pump stations that are not connected to a telemetry system shall be inspected every day (i.e. 365
days per year). Pump stations that are connected to a telemetry system shall be inspected at
least once per week.
e. High -priority sewer lines shall be inspected at least once per every six -months and inspections are
documented.
f. A general observation of the entire sewer system shall be conducted at least once per year.
g. Overflows and bypasses shall be reported to the appropriate Division regional office in accordance
with 15A NCAC 2B .0506(a), and public notice shall be provided as required by North Carolina
General Statute §143-215.1C.
h. A Grease Control Program is in place as follows:
1. For public owned collection systems, the Grease Control Program shall include at least
biannual distribution of educational materials for both commercial and residential users and
the legal means to require grease interceptors at existing establishments. The plan shall also
include legal means for inspections of the grease interceptors, enforcement for violators and
the legal means to control grease entering the system from other public and private satellite
sewer systems.
2. For privately owned collection systems, the Grease Control Program shall include at least bi-
annual distribution of grease education materials to users of the collection system by the
permittee or its representative.
3. Grease education materials shall be distributed more often than required in Parts (1) and (2)
of this Subparagraph if necessary to prevent grease -related sanitary sewer overflows.
Right-of-ways and easements shall be maintained in the full easement width for personnel and
equipment accessibility.
j. Documentation shall be kept for Subparagraphs (a) through (i) of this Rule fora minimum of three
years with exception of the map, which shall be maintained for the life of the system.
5. The Permittee shall report by telephone to a water resources staff member at the Winston-Salem
Regional Office, telephone number [phone], as soon as possible, but in no case more than 24
hours, following the occurrence or first knowledge of the occurrence of either of the following:
Page 5 of 7

a. Any process unit failure, due to known or unknown reasons, that renders the facility incapable
of adequate wastewater transport, such as mechanical or electrical failures of pumps, line
blockage or breakage, etc.; or
b. Any SSO and/or spill over 1,000 gallons; or
c. Any SSO and/or spill, regardless of volume, that reaches surface water
Voice mail messages or faxed information is permissible, but this shall not be considered as the initial
verbal report. Overflows and spills occurring outside normal business hours may also be reported to
the Division of Emergency Management at telephone number [phone] or [phone].
Persons reporting any of the above occurrences shall file a spill report by completing and submitting
Part I of Form CS-SSO (or the most current Division approved form) within five days following first
knowledge of the occurrence. This report must outline the actions taken or proposed to be taken to
ensure that the problem does not recur. Part II of Form CS-SSO (orthe most current Division approved
form) can also be completed to show that the SSO was beyond control. [G.S. 143-215.1C(a1)]
6. Construction of the gravity sewers, pump stations, and force mains shall be scheduled so as not to
interrupt service by the existing utilities nor result in an overflow or bypass discharge of wastewater
to the surface waters of the State. [15A NCAC 02T.0108(b)]
Upon completion of construction and prior to operation of these permitted facilities, the completed
Engineering Certification form with checklist attached to this permit shall be submitted with the
required supporting documents to the address provided on the form. A complete certification is one
where the form is fully executed and the supporting documents are provided as applicable. Any
wastewater flow made tributary to the wastewater collection system extension prior to completion
of this Engineer's Certification shall be considered a violation of the permit and shall subject the
Permittee to appropriate enforcement actions.
A complete certification is one where the form is fully executed and the supporting documents are
provided as applicable. Supporting documentation shall include the following:
One copy of the project construction record drawings (plan & profile views of sewer lines & force
mains) of the wastewater collection system extension. Final record drawings should be clear on
the plans or on digital media and are defined as the design drawings that are marked up or
annotated with after construction information and show required buffers, separation distances,
material changes, etc.
b. One copy of the supporting applicable design calculations including pipe and pump sizing, velocity,
pump cycle times, and level control settings, pump station buoyancy, wet well storage, surge
protection, detention time in the wet well, and force main, ability to flush low points in force
mains with a pump cycle, and downstream sewer capacity analysis. If a portable power source or
pump is dedicated to multiple stations, an evaluation of all the pump stations' storage capacities
and the rotation schedule of the portable power source or pump, include travel timeframes, shall
be provided.
c. Changes to the project that do not result in non-compliance with this permit, regulations, or the
Minimum Design Criteria should be clearly identified on the record drawings, on the certification
in the space provided, or in written summary form.
Prior to Certification (Final or Partial): Permit modifications are required for any changes resulting
in non-compliance with this permit (including but not limited to pipe length changes of 10% or
Page 6 of 7

greater, increased flow, pump station design capacity design increases of 5% or greater, and
increases in the number/type of connections), regulations, or the Minimum Design Criteria.
Requested modifications or variances to the Minimum Design Criteria will be reviewed on a case -by -
case basis and each on its own merit. Please note that variances to the Minimum Design Criteria
should be requested and approved during the permitting process prior to construction. After -
construction requests are discouraged by the Division and may not be approved, thus requiring
replacement or repair prior to certification & activation. [15A NCAC 02T .0116]
8. Gravity sewers installed greaterthan ten percent below the minimum required slope perthe Division's
Gravity Sewer Minimum Design Criteria shall not be acceptable and shall not be certified until
corrected. If there is an unforeseen obstacle in the field where all viable solutions have been.
examined, a slope variance can be requested from the Division with firm supporting documentation.
This shall be done through a permit modification with fee. Such variance requests will be evaluated
on a case -by -case basis. Resolution of such request shall be evident priorto completing and submitting
the construction certification. [ 15A NCAC 02T.0105(n)]
9. A copy of the individual permit and construction record drawings shall be maintained on file by the
Permittee for the life of the wastewater collection facilities. [15A NCAC 02T .0116]
10. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 02T; the
Division's Gravity Sewer Design Criteria adopted February 12, 1996 as applicable; the Division's
Minimum Design Criteria for the Fast -Track Permitting of Pump Station and Force Mains adopted June
1, 2000 as applicable; and other supporting materials may subject the Permittee to an enforcement
action by the Division, in accordance with North Carolina General Statutes §143-215.6A through §143-
215.6C, construction of additional or replacement wastewater collection facilities, and/or referral of
the North Carolina -licensed Professional Engineer to the licensing board. [15A NCAC 02T .0108(b-c)]
11. In the event that the wastewater collection facilities fail to perform satisfactorily, including the
creation of nuisance conditions, the Permittee shall take immediate corrective action, including those
as may be required by this Division, such as the construction of additional or replacement facilities.
[15A NCAC 02T .0110; 15A NCAC 02T .0108(b)]
12. The issuance of this permit shall not exempt the Permittee from complying with any and all statutes,
rules, regulations, or ordinances that may be imposed by the Division any other Federal, State, or Local
government agencies which have jurisdiction or obtaining other permits which may be required by
the Division or any other Federal, State, of Local government agencies. [G.S. 143-215.1(b)]
Page 7 of 7

CERTIFICATION CHECKLIST
To be completed by the certifying engineer prior to operation of the permitted sewers, per 15A NCAC 02T.0116.
Certifying Engineer:
Certification Review Date:
Project: Town of Pilot Mountain Collection System SRP Engineering
Permit No. WQ0044958 Project County: Surry County
1) Has permittee information changed since the permit was issued (or last modified): change of mailing address,
change of ownership, transfer from developer to HOA/POA, etc. ❑ Yes ❑ No
• If yes, please provide either a change of ownership form or new contact information. Note that transfer of
permits from the developer to the HOA/POA must occur with the first certification.
2) Have the as -built drawings have been signed, sealed, and dated by an N.C. PE? ❑ Yes ❑ No
3) Final Engineering certification? ❑ Yes ❑ No
• If Partial Engineering certification, provide detailed narrative including what is being certified in the current
phase, what was previously certified (if applicable), and what is left to be certified.
4) Adequate information related to sewer lines: ❑ Yes ❑ No ❑ N/A
• Three feet minimum cover has been provided for all sewers unless ferrous pipe was installed.
• Minimum diameters for gravity sewers are 8-inches for public lines and 6-inches for private lines.
• Manholes have been installed: At the end of each line, at all changes in grade, size, or alignment, at all
intersections, and at distances not greater than 425 feet; minimum diameter shall be 4 feet (48-inches).
5) Adequate information related to pump stations: ❑ Yes ❑ No ❑ N/A
• Ensure power reliability option was selected per 15A NCAC 02T.0305(h).
6) Was project construction completed in accordance with all of the following: ❑ Yes ❑ No ❑ N/A
• 15A NCAC 02T, Minimum Design Criteria (MDC) for the permitting of Gravity Sewers (latest version), and MDC
for the Permitting of Pump Stations and Force Mains (latest version)?
If not, a variance approval is required in accordance with 15A NCAC 02T.0105(b), prior to certification and operation.
• Contact the Central Office to discuss the variance to determine a course of action.
• Applicant must submit two copies of the variance request form, plans, specifications, calculations, and any other
pertinent information to the Central Office (one hard copy, one digital copy).
• The central office will review the variance request, and if approvable, specific language regarding the variance
will be incorporated into the permit, either via a special condition or a supplementary letter. A copy of the
reissued permit with variance language or the variance letter must be maintained with the original documents.
7) Does the project contains high priority lines (15A NCAC 02T .0402(2))? ❑ Yes ❑ No
• If yes, ensure that the permit already contains the necessary condition related to high priority lines 15A NCAC
02T.0403 (a)(5). If the permit does not include this language, the Fast Track reviewer will reissue the permit with
the appropriate language.
8) Are Permit modifications are required for any changes resulting in non-compliance with this permit (including but not
limited to pipe length changes of 10% or greater, change in flow, pump station design capacity design change of 5% or
greater, and/or change in the number/type of connections)? ❑ Yes ❑ No
• If yes, a permit modification request must be submitted to the appropriate Regional Office, and a modified
permit with revised certification must be issued prior to certification and operation.
NC DWR —Water Quality Regional Operations Section 450 West Hanes Mill Road, Suite 300, Winston-Salem, NC 27105
Winston-Salem Regional Office Phone: [phone] FAX: [phone]

FAST TRACK SEWER ENGINEERING CERTIFICATION
PERMITTEE: Town of Pilot Mountain
PERMIT #: WQ0044958
PROJECT: Town of Pilot Mountain Collection System SRP Engineering
ISSUE DATE: December 1, 2023
COUNTY: Surry County
This project shall not be considered complete nor allowed to operate in accordance with Condition 7 of
this permit until the Division has received this Certification and all required supporting documentation. It
should be submitted in a manner that documents the Division's receipt. Send the required documentation
to the Regional Supervisor, Water Quality Regional Operations Section at the address at the bottom.
Any wastewater flow made tributary to the wastewater collection system extension prior to completion
of this Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions. The Permittee is responsible for tracking all partial certifications up
until a final certification is received. A Final Certification shall be a complete set of record drawings and
design calculations regardless of whether partials have been submitted.
PERMITTEE'S CERTIFICATION
I, the undersigned agent for the Permittee, hereby state that this project has been constructed pursuant
to the applicable standards & requirements, the Professional Engineer below has provided applicable
design/construction information to the Permittee, and the Permittee is prepared to operate & maintain
the wastewater collection system permitted herein or portions thereof.
Printed Name, Title Signature Date
ENGINEERS CERTIFICATION
1, . as a dul registered Professional En sneer in the State of North Carolina,
having been authorized to observe (periodically, ❑ weekly, [] full time) the construction of the
project referenced above for the above Permittee, and hereby state that, to the best of my abilities, due
care and diligence was used in the observation of the following construction:
of approximately 1,080 linear feet of 8-inch gravity sewer; a 140—gallon per minute pump station (Lift
Station 18) with duplex grinder pumps, on -site audible and visual high water alarms, telemetry, and an
onsite permanent generator with an automatic transfer switch; as well as approximately 685 linear feet
of 3-inch force main to serve the residents of Pilot Mountain as part of the Town of Pilot Mountain
Collection System SRP Engineering project, and the discharge of 0* additional gallons per day of collected
domestic wastewater pursuant to the application received November 22, 2023; such that the construction
was observed to be built within substantial compliance of this permit;15A NCAC 02T; the Division of Water
Resources' (Division) Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable;
the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains
adopted June 1, 2000 as applicable; and other supporting materials.
North Carolina Professional Engineer's Seal w/signature & date:
❑ Final ❑ Partial (include description)
Certification Comments/Qualifiers (attach if necessary):
NC DWR — Water Quality Regional Operations Section 450 West Hanes Mill Road, Suite 300, Winston-Salem, NC 27105
Winston-Salem Regional Office Phone: [phone] FAX: [phone]

00 WithersRavenel
NOOur People. Your Success.
To: North Carolina Department of Environmental Quality
Winston Salem Regional Office - Water Quality Section
450 W. Hanes Mill Road, Suite 300
Winston-Salem, North Carolina 27105
Attn: Jenny Graznak
CC: Michael Boaz, Town Manager
Town of Pilot Mountain, NC
From: Jack Fitzgerald
Date: January 19, 2024
Project: Town of Pilot Mountain Collection System SRP Engineering
Project Number: WR # 02210676.13
DWI Project Number: SRP-W-0207 / VUR-W-ARP-0024
Subject: Fast Track Sewer Extension Application
On behalf of the Town of Pilot Mountain, WithersRavenel is submitting the attached Fast Track
Sewer Extension Permit modification application for the Town of Pilot Mountain Collection
System Improvements project. The Town has received a letter of intent to fund (LOIF) from the
NCDEQ Department of Water Infrastructure (DWI) indicating that a total of $2,845,000 will be
remitted for the project. The funding source is 50% grant and 50% low -interest loan.
A Fast Track application was previously approved by your office on December 1, 2023, permit
number WQ0044958. The project scope is identical to that of the previous application, except for
quantities, sizes, and materials of the proposed gravity sewer and force main infrastructure,
following a design change. The scope of work described in the previous application and cover
letter is the same, with the following exceptions:
• The proposed force main to re-route flow from the new Lift Station 18 location and tie-in
to the existing 3-inch force main was originally listed as 685 LF of 3-inch pipe. The updated
quantity and size are 305 LF of 4-inch force main.
• The proposed gravity sewer was originally listed as 825 LF of 8-inch PVC and 255 LF of 8-
inch DIP for a total of 1,080 LF. The updated quantities are 55 LF of 8-inch PVC and 1,005
LF of 8-inch DIP for a total of 1,060 LF. The material change was for improved longevity
of the proposed gravity sewer which will be located under an existing road asphalt.
As stated in the original application, the project will re-route existing flow; no additional flow will
be added to the collection system. It is requested that the existing permit be modified and re-
issued for the updated gravity sewer and force main quantities.
115 MacKenan Drive I Cary, NC 27511
t: 919.469.3340 1 f: 919.467.6008 1 www.withersravenel.com I License No. F-1479
Asheville I Cary I Charlotte I Greensboro I Pittsboro I Raleigh I Southern Pines I Wilmington

1% WithersRavenet
Our PeOPle. Your Success.
This Fast Track Application Package includes the following items:
• Updated Fast Track Application (Form FTA 10-23).
• Check for the $600 application modification fee.
• Existing permit WQ0044958
• Two (2) 8.5x11 site maps showing the location of project features (same as previously
submitted)
Please do not hesitate to contact me at 919-978-3837 or [e-mail] should
you have any questions or concerns.
Sincerely,
WithersRavenet
Jack Fitzgerald, PE
Page 2 of 2

POO WithersRavenel
0 Our Peopte. Your Success.
Check Request
1 /18/2024
Date Requested Date Needed
Erin Spencer
Requested By
Parker Colbath
Approved By
CHECK INSTRUCTIONS
Amount $600.00
Payee Name NCDEQ - Fast Track Plan Review
Payee Address 450 W. Hanes Mill Road, Suite 300
Winston Salem, NC 27105
ATT N
8 Mail check to ❑ Give check
Delivery vendor to
PRO]ECT INFORMATION
Practice Area Utilities
Project Number
Project Name
Explanation/Purpose
1 /19/2024
02210676.13 Task/Subtask Number 00005
Pilot Mountain Collection System SRP Engineering
Fast Track Re -Application Fee
CODING (Accounting Use Only)
Account
Amount
Check Request
Rev. 12/2022 Page 1 of 1

DocuSign Envelope ID: 80CA4AF2-E399-4EOF-A251-B33BC46D1739
State of North Carolina
DWR
Division of Water Resources
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria (Gravity Sewer & Pump Stations/Force Mains) and that plans, specifications and supporting documents
have been prepared in accordance with 15A NCAC 02T. 15A NCAC 02T .0300. Division policies, and good engineering uractices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be immediately available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPs) or simplex grinder pumps;
➢ Simplex STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an application, 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 requested additional information. Failure to submit all required items will necessitate additional processing and review
time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit one original and one copy of
the application and supporting documentation.
A. One Original and One Copy (second copy may be digital) of Application and Supporting Documents
® Required unless otherwise noted. Signatures on original must be "wet ink" or secure digital signatures.
Please do not submit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ Include the permit number/status of any other required sewer permits (downstream/upstream)
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Modification Application Packages):
® Submit a check or money order in the amount of $600.00, dated no more than 90 days prior to application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track Application (Required for All Application Packages, Form FTA 10-23):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary of State.
❑ If the Applicant Type in Item 1.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of Deeds in
the county of business.
® The Project Name in Item II.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina
licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b). Per
15A NCAC 02T .0106(c), 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).
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 1 of 3

DocuSign Envelope ID: 80CA4AF2-E399-4EOF-A251-B33BC46D1739
E. Flow Tracking/Acceptance Form (Form: FTSE 10-23) (If Applicable):
❑ Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year
prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215.67(a).
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area,
including the closest surface waters.
➢ General location of the project components (gravity sewer, pump stations, & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
® Include an aerial location map showing general project area (such as street names or latitude/longitude) so that Division staff
can easily locate it in the field.
G. Existing Permit (Application Packages for Modifications to an Existing Permit):
® Submit a copy of the most recently issued existing permit.
® Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to be
added, and/or items to be modified (the application form itself should include only include items to be added/modified). The
narrative should also include whether any previously permitted items have been certified.
® The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
® Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible with
the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed contractor,
stating that "the portable power generation unit or portable, independently -powered pumping units, associated appurtenances
and personnel are available for distribution and operation of this pump station."
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall
be provided in the case of a multiple station power outage. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities
Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
❑ Provide a letter from the North Carolina 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.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV)_
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 2 of 3

DocuSign Envelope ID: 80CA4AF2-E399-4EOF-A251-B33BC46D1739
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778-8211
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Favetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5095
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
3800 Barrett Drive
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27609
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan, Craven,
Water Quality Section
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Alamance, Alleghany, Ashe, Caswell, Davidson,
Water Quality Section
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 3 of 3