240027_Rescission Request_20240425

APPENDIX 3.1
Animal Waste Storage Pond and Lagoon Closure Report Form
(Please type or print all information that does not require a signature)
General Information:
Name of Farm: John Blosser Swine Farm Facility No: 2 4 -27
Owner(s)Name: John Blosser
Mailing Address:2649 Poley Bridge Road, Phone No: 910-770-2484
Nakina,NC 28455 County: Columbus
Operation Description (remainin, animals only1:
'lease check this box if there will be no animals on this farm after lagoon closure. If there will still be animals on the site
after lagoon closure,please provide the following information on the animals that will remain.
Operation Description:
Type of Swine No. of Animals Type of Poultry No. of Animals Type of Dairy No. of Animals
o Wean to Feeder o Layer o Milking
o Feeder to Finish o Non-Layer o Dry
o Farrow to Wean Type of Beef No. of Animals o Heifers
o Farrow to Feeder o Brood o Calves _
o Farrow to Finish o Feeders
o Gilts o Stockers
o Boars Other Type of Livestock: Number of Animals:
Will the farm maintain a number of animals greater than the 2H.0217 threshold? Yes o NOV
Will other lagoons be in operation at this farm after this one closes? Yes o NOV
How many lagoons are left in use on this farm?: 0
(Name)Chad Coburn of the Water Quality Section's staff in the Division of
Water Quality's Wilmington Regional Office(see map on back) was contacted on 1/30/2024 (date)
for notification of the pending closure of this pond or lagoon. This notification was at least 24 hours prior to the
start of closure,which began on 2/l/2024 (date).
I verify that the above information is correct and complete. I have followed a closure plan,which meets all NRCS
specifications and criteria. I realize that I will be subject to enforcement action per Article 21 of the North
Carolina General Statutes if I fail to properly close out the lagoon.
Name of Land Own (Please Print): John Blosser
Signature: Date: y/Iro— al
The facility has followed a closure plan which meets all requirements set forth in the NRCS Technical Guide
Standard 360. The following items were completed by the owner and verified by me: all waste liquids and
sludges have been removed and land applied at agronomic rate,all input pipes have been removed, all slopes have
been stabilized as necessary,and vegetation established on all disturbed areas.
Name of Technical Specialist(Please Print): Sam Edwards
Affiliation:Ncoaroswc
Address(AgencvL 45Z Phone No.:910-770-2168
Signature: _S Date:-7 "/G r.17
Return within 15 days following completion of animal water storage pond or lagoon closure to:
N. C.Division Of Water Quality RECEIVEM
Animal Feeding Operations Unit
1636 Mail Service Center APR 2 5 2024
Raleigh,NC 27699-1636
NC DEQ/®WR
PLC- 1 March 18,2002 Central Office

SpIv&wA7p,
Swine & Dairy Assistance Program O� �Orys
�i'- Certificate of Completion 10 ! �9
A
r , � For
Agricultural Water Supply Pond
DSWC Contract Number: 24-2024-005 County: Columbus
Landowner/Project Name: John Blosser
Certification of Completion
Upon completion a copy of the as-built survey shall be provided to the Soil and Water Conservation
District Office,the landowner and the Division of Soil and Water Conservation. Certification of
Completion must be completed signed, sealed, and dated by the design engineer and returned to the
district office and uploaded into CS2.
Professional Engineer's Certification
I, Robert Moore having been
(Professional Engineer's name and NC license number)
authorized to observe the construction of the project for strict adherence to the approved plans,
specifications, and other supporting materials. I hereby state that,to the best of my abilities, due
care and diligence was used in the observation of the construction to ensure that the approved plans
and specifications were followed and that the project meets the design standard and AgWRAP policies.
DocuSiLgned by:
4/3/2024
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North Carolina Professional Engineer's seal,signature,and date: =pF Oy
_ :a SEAL
044115 =
-his ite•n l7as been electronically signed -AO
and sealer b}•Pr belt R_Moore,PE,rasing a �F
digital signature.Pri-ted copies of this document /�//111Ri 1NO
are nc�t coisidered signed and sealed and the
SHA al.lthei+ication code must be verified
IF, or,any electronic copies_