WQ0018857_Monitoring - 12-2016_20170203

FORM: NDAR-1 10-13N( ON -DISCHARGE APPLICATION REPORT (NDAR-1) Page / of
Permit No./®4o �
Facility Name:County:
ty:m�bMonth:
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Year:,o/G
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Did irrigation occur
Field Name
Field Name:
Field Name
Field Name:
Area acres
(, )
Area (acres):
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Area (ages)
Area (acres):
at this facility?
Cover.Crop
Cover Crop:Cover
Crop +
Cover Crop:
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❑ YES NO
Hourly Rafe (m)
Hourly Rate (in):
,our Rate (In)
Hourly Rate m :
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F
Annual Rate (m)�
Annual Rate (in):
Anrtual Rate (m) ` `
Annual Rate in
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Weather Freeboard
Fieltl lrn afed? `"
9 r, [] YES ; ❑ �0
Field Irrigated?
❑ YES
❑ No
YE5 �(]iNQ
Feld"Irngateal? „❑ >
Field Irrigated?
YES
❑ No
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FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of
Did the application rates exceed the limits in Attachment B of your permit? Compliant ❑ Non -Compliant
Were adequate measures taken to prevent -effluent ponding in or runoff from the sites? Compliant' ❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? Compliant ❑' Non -Comp liant
Were all setbacks listed in your permit maintained for every application to each permitted site? Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑ Compliant ❑ Non{ompliant
If the facility is non-compliant, please explain in the space below the reason(s) the facility was not in compliance.. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken_ Attach additinnal choatc if nor n..a. ,
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: %f`� Wc31 �lNy�^'
Permittee: D CJ i/1 d ac C
Certification No.:
Signing Official:
Grade: S �e Phone Number:
Signing Official's Title:
/(
Has the ORC changed since the previous NDAR-17f�
❑yes � No
Phone Number•CRa3 permit Exp.:
a —%Z-7—,
7
Signature Date
Signature Date
By this signature, I certify that this report Is accurrale and complete to the best of my knowledge.
I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance
with a system designed to assure that all qualified personnel property gathered and evaluated the information submitted. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the
Information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant
penalties for submitting false information, including the possibility of fines and Imprisonment for knowing violations.
Mail Original,and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh. North Carnlina 97t;gq_1R117