WQ0040421_Application (FTSE)_20181205

-FU9rd1T1 craLUqUry
Status project Type
Non -discharge
In review New Project -
Permit hype
Version Permit Classification
Gravity Sewer Extension, Pump Stations; & Pressure Sewer Extensions
A Individual
Primary Reviewer
Permit Contact Affiliation
dean.hunkele
Coastal SRule
Permitted Flow
_
�y
Facility Marne
Major/Minor Region
Circle K at Ridge Road Private Pump Station
Minor Wilmington
Location Address
County
Onslow
Facility Contact Affiliation
��wne r
Dates1vents
Raleigh
NC 27606 .�
Scheduled
Or�ig.lssue: App tReie Drat Initiated Issuance
Public Notice Issue Effective
E ai� ti
pin
11 /9/2018
e �y
is € _
Request Rec i� e Events
Additional information requested
_..- _ _.. '

ex a
HURVED/NMENR/DWR
TIMMONS GROUP
YOUR VISION ACHIEVED THROUGH OURS.
TRANSMITTAL
TO: NCDEQ — Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC, 28405
ATT N :
❑ ENCLOSED PLEASE FIND:
❑ WE ARE SENDING UNDER SEPARATE COVER:
Nov
0 9 2018
Water Quality Regional
Operations Section
Wlirningon Regional Office
Date: 11 /08/2018 Job #: 37630.021
Project: Circle K NTI Ridge Road
Reference:
Copies Sent To:
COPIES
DATE
NUMBER
DESCRIPTION
2
11/08/18
FTA 04-16 & Supporting Documentation
1
11/08/18
$480.00 Application Fee
1
11/08/18
Document Certifying Company is Registered with the State
1
11/08/18
Site Ma
1
11/08/18
Street Ma
1
11/08/18
Power Reliability Plan
1
11/08/18
Letter of Agreement with Blue Creek Utilities
THESE ITEMS ARE TRANSMITTED:
If enclosures are not as noted, please notify us at once.
COMMENTS: The Circle K NTI Ridge Road Project Pump station is to be a packaged pump station that connects
down -stream via forcemain into a private sewer collection system owned by Blue Creek Utilities. Circle K Stores Inc.
will retain ownership of the portion of on -site forcemain, approximately 320 L.F. Blue Creek Utilities will have ownership o
the approximate 130 L. F of forcemain within the NCDOT right-of-way. The pumping rate of this packaged pump station
is going to be 1500 gallons per day and will only serve this Circle K site.
Proposed store #: 2704589 .
Feel free to contact me with any questions at 919-532-3234 or [e-mail]
Thank you,
Chris Petree
Sr. Project Manager
SIGNED: --
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• File an Annual Report/Amend an Annual Report e Upload a PDF Filing • Order a Document Online •
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Pre -Populated Annual Report form
Business Corporation
Legal Name
Circle K Stores Inc.
Prev Legal Name
Circle K Convenience Stores, Inc.
Prev Legal Name
The Circle K Corporation
Information
Sosld: 0176043
Status: Current -Active
Annual Report Status: Current
Citizenship: Foreign
Date Formed: 10/25/1985
Fiscal Month: April
State of Incorporation:
TX
Registered Agent: Corporation Service Company
Addresses
Mailing
1130 West Warner Road, Building B
Tempe, AZ 85284-2816
Reg Office
2626 Glenwood Avenue, Suite 550
Raleigh, NC 27608-1370
Officers
Principal Office
1130 West Warner Road, Building 6
Tempe, AZ 85284-2816
Reg Mailing
2626 Glenwood Avenue, Suite 550
Raleigh, NC 27608-1370

Tempe AR 85284 TEMPE AZ 85284 Waycross GA 31501
Assistant Secretary Assistant Secretary Vice President
John Little Sarah Longwell Matt Mccure
305 Gregson Drive 495 E Rincon, suite 150 2440 Whitehall Park Drive Suite 800
Cary NC 27511 Corona CA 92879 Charlotte NC 28273
Vice President Vice President Vice President
Kelly Mcguire Alex Miller David G Morgan
807 42nd Avenue SE Suite 1 1130 West Warner Road Building B 12911 N Telecom Parkway
Calgary, Alberta. T2G 1Y8 Tempe AZ 85284 Tampa FL 33637
Vice President Senior Vice President
Mark Ostoits Mark Ostoits
2550 West Tyvola road Suite 200 2550 West Tyvola road Suite 200
Charlotte NC 28217 Charlotte NC 28217
Senior Vice President Assistant Secretary Assistant Secretary
Mark Ostoits Patrick Panzarella Tim Peters
2550 West Tyvola road Suite 200 19500 Bulverde Road 3001 Gateway Dr Suite 130
Charlotte NC 28217 San Antonio TX 78259 Irving TX 75063
Assistant Secretary Vice President Vice President
Kyle Poyer Meredith Will Rice , Jr. Paul Rodriguez
25 W Cedar St Suite 100 1100 Situs Court Suite 100 1130 West Warner Road, Building B
Pensacola FL 28273 Raleigh NC 27606 Tempe AZ 85284
Vice President Assistant Secretary
Dag Rog Roger Scott J. Stevenson
2440 Whitehall Park Dr Suite 800 1130 West Warner Road, Building B
Charlotte NC 28273 Tempe AZ 85284
Vice President Vice President Assistant Secretary
Mark Tate Dennis Tewell Peter Uhlich
5500 S Quebec St. Suite 100 1130 West Warner Road, Building B 12911 N. Telecom Parkway
Greenwood Village CO 80111 Tempe AZ 85284 Tampa FL 33637

Application Number: LA-6wHoqv-` (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Circle K Stores Inc. (company, municipality, HOA, utility, etc.)
2. Applicant type: El Individual
E Corporation ❑General Partnership
El Federal
❑State/County ❑Municipal
3. Signature authority's name: Meredith Will Rice, Jr. per 15A NCAC 02T .0106(b)
Title: Vice Pesident
4. Applicant's mailing address: 1100 Situs Court, Suite 100
City: Raleigh State: NC
Zip: 27606-4295
5. Applicants contact information:
Phone number: [phone]
Email Address: N/A
II. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ Other
1. Project name: Circle K - NTI Ride Road fvez�, 9,0-41 %4 `�
2. Application/Project status: Z Proposed (New Permit) ❑Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date:
If new construction but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Onslow
4. Approximate Coordinates (Decimal Degrees): Latitude: 34.757804° Longitude:-77.480426°
5. Parcel ID (if applicable): 435719606255
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Chris Petree License Number: 041935
Firm: Timmons Group
Mailing address: 5410 Trinity Road Suite 102
City: Ralei h State: NC Zip: 27607-6003
Phone number: [phone] Email Address: chris.petreektimmons.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Blue Creek WWTP Permit Number: NCO056952
Owner Name: Blue Creek Utilites
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: inch
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s):
E
OV 0 9 2018
FORM: FTA 04-16 Page 1 of 5

VI.
GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
El Yes ❑No EN/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement FORM: Dbeen attached?
El Yes [—]No EN/A
3. If the Applicant is a Home/Property Owners' Association, has an Operational Agreement FORM: HOAR been attached?
❑ Yes ❑No EN/A
4. Origin of wastewater: (check all that apply):
❑ Residential Owned E Retail (stares, centers, malls) ❑Car Wash
❑ Residential Leased ❑Retail with food preparation/service El 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 El Nursing Home ❑Other (Explain in Attachment)
5. Nature of wastewater: %Domestic/Commercial 100 %Commercial
%Industrial (See 15A NCAC 02T .0103(20))
)o-Is there a Pretreatment Program in effect? ❑Yes E No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(f)? El Yes ® No
➢ If yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(fl)
Daily Design Flow a,b
No. of Units
Flow
Service Stations, Gas Stations
250 gal/Plumbing Fixture
6
1500 GPD
gal/
GPD
gal/
GPD
-
gal/
GPD
gal/
GPD
gal/
GPD
Total
1500 GPD
a See 15A NCAC 02T .0114(b), (d)(e)(1) and(e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; 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: 1500 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
FORM: FTA 04-16 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
6 200 SCH 40 PVC
➢ 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 requirement is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Circle K NTI Ridge Road Pump Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 34.758172' Longitude:-77.480272'
3. Design flow of the pump station: 0.0015 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 14 gallons per minute at 12 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2
317
SDR 21 PVC
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or pump with 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
Or if the pump station has an average daily flow less than 15,000 gallons per day:
® Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
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
in the case of a multiple station power outage.
FORM: FTA 04-16 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T.0305(f) &W E Yes [:]No
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below vertical
24 inches
Water mains vertical -water over sewer including in benched trenches
18 inches
Water 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
100 feet
"Waters Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water or tide elevation and wetlands see item IX.2
50 feet
"Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
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
➢ 15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ "Stream Stream classifications can be identified using the Division's NC Surface Water Classifications web -page
➢ If noncompliance with 02T.0305(f) or .g), see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) E Yes [:]No ❑ N/A
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? Yes [:] No, ❑ N/A
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ❑Yes No
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? Z Yes [:]No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications are 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.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02T.0402, "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
[:]Yes [:]No Z N/A
➢ 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 permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

X. CERTIFICATIONS:
Does the submitted system comply with 1. �ik the 1\41 I'll' [VIL4 DI.Ucsi o n C.'ri[,.2ria I'Or thc !-�crrnildnt2 of Purno statiuns
"j.11d iM.aill-, Hmi._,si version.). and the Scikcr IM11,11illull) UI,iler -I dah,S[ vcn,,tiion.) as applicable?
Yes ❑ No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and SUpportinor dOCUments for
9 C-1
review. Anproval of the, -re(juest is reguired pf-ioi- to subinittal of Hie Fast 'rrack Applicalimi andsup Lorthig documents.
2. Professionq�Encrineej`s Certification,,
Z__
attest that this application for
(rofessional Engineer's name from Application Item 111. 1.)
Nc-ts been revie�xued by rne and is aCCUrate, ciornplete and consistent with the Information. SUPPIled In the plans, specifications,
encrineering calk- u ladons. and all other SUPP01-ting documentation to the best of im, knoNvledae. I further attest that to the best
I -rn has been prepared in accordance with the applicable regulations. Gravity Sewer
of my knowledcre the proposed design I.-
t� C, z:1 -
Minimumf Design Criteria f6r Gravity Se�..�,trs (latest version), and the MIMMUM De­s`hyri Critena It"Or the Fast -Track Permitting
of Pump Stablon:-;. and F'orce Mains version), AlthOUgh other professlona],, maN.. have de�!eioped certain portions of this
submittal pitckage. ol" theske, aiaterials under my signature and seal diftiat I have revleweddl L-his- rnaterlat and
have -1 -Ludged 11 to tic consistent wick the propw,-ed desi(m.
NOTE - In ;_,Wcordance_ with General Statutes 143-'215.6A and 143-215_61i� an- Person vvho iii,-iakes any Use
'u". .1 in at-ioy applical, -1, packag hc ufilvy ot, a clazss �vhich may
;A C I f '2 110., as Wel f" s i`v* I Penalties tip to R" Pc - }, io 1 -IF
Noftli Carob na-_a Profession -al Eii(xitteer"s sea[, shrnature, and date:
15;Al N('_"AC %).42T W()Nb),-
I I
Vi �Le_
nalme & Ime from Applicc-11tion Ttenrl 1.3")
, uV -
ftk�,�t Onat. lhi-"• Jpnlicatlon 41"01"
Kcts been by n-le and iS 'l-OC, 11 F"a tC 4.111d ColflplcuC to the best of.m-f�e I und1_,r.,,-,t_,1Md 't-hat ifafll frequipeA parts
of
this application are not cmiiplet,%-,`df aid that if all requirod supporting arld arI 2 not included. this
-ctu -1 Lis incomplete. I Lfflder,-,tand " aL 1--oni this non-
appiku-ation 1 ackauc is �uhject to beim), i rj,iei_ I H! dll-,dhw=�� ".-`L1SU-2*\Aatcr i
d' i 11 L t 1 S I/N t e I P1 t 0 > L I I * fa,;, c waters or t i laiid �ev, 111 re�,ult In ail liunnitdlcat� clif m-cernerA action - it uk uldo civil Pen
injunkcLivil- rehict'. PR),�-;CCUOOFI. I will make no claim acyain�t the id_'Watt.�r -hould a conditi011
permit he vi()Iated. I al',C) LH1dC1--:*.1Land th"all: If all reqUiNd -PNIOS Ofthisapplicatlon packuTL, not ck)mpletcd and that If
I 0ITMAIDI)n and attachmcnts anu- not. Included, tfii� appliCatioll packaanf �vfll be ri-Jumcd to mt: as
all required sttppot-Ling
NOTE - to accordance v.,Ith General Statutes 1 and any person who knowingly nizal,..-cs any fak;e
staternunt, representati011 W' certi'l I'hcat'un in any application pac je .hall bi-, gu'lty ilf - Clas- nisdemc�anor. which may
k ag
Include a fine not to ex\ceed S I U.(..)00 a,: as r'lVil penalties Lip tt) $1215.000 per violanoll,
e!5- 7V
sto,nati.ffe
FORIN+ F-TA 04-16 Page 5 of 5
Z:

State of North Carolina
Department of Environmental Quality
Division of Water Resources
1. Complete this section only if you are the owner of the wastewater treatment plant,
a. WWTP Facility Name: BLUE CRJEEK WWTP
b. WWTP Facility Permit NC005695`2
A 11,46®r ws'a re Jr,.!I6,TGD1V
c. WWTP facility's pennitted flow
U1101
d. Estiniated obligated flow not yet tributary to the, 'W_"WTP 0
e. WWTT facility's actual avg. flow
f Total flow for this specific request
0.00115
g. Total actual and obligated flows to the facility
ow01465­­__­_­_­----
h. Percent of permitted flow used
45%
11. Complete this section for each pump station you are responsible for along the route of this
proposed wastewater flow .
List pump stations located between the project connection point and the WWTP:
(A) (B)
(C) (D)=(B+Q (E)=(A-JD)
Design
Obligated,
Pump Average Daily Approx.
Not yet Total Current
Station Firm Flow" Current Avg.
Tributary Flow Plus
(Name or Capacity, (Fim / pf), Daily Flow,
Daily Flow, Obligated Available
Nuniber) MGD MGIB MGD
MGD Flow Capacity * * *
Blue 0,288 0.115 0,017
0 0.017 0.098
The llim­­. -Capacity of any pump station is defined as the maximum pump&f h6w'-Iiii
can be aebleved with the largeo pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking
factor (pf) not less than 2.5.
*** A Planning Asmssment Addendum shall be attached for each pump station located
between the p 'ect connection point and the WWT? where the Available Capacity 418 , < 0
r0i am
Wownstrcam Facility Name (Sewer): Blue Crock Road SPS
Downsm= Permit Number:

111. Certification Statement:
1 B. T. POLLARDcertify to the best of nay knowledge that the addition of
thy-Qume of wuastewat�er to be permitted in this project has been evaluated along the route to the
receiving wastewater treatment facility and that the flow from this project is not .anticipated to
cause any capacity related sanitary sewer overflows or overburden any downstream pump station
en route to the receiving treatment plant under normal circumstances, given the implementation
of the planned improvements identified in the planning assessment where applicable. This
analysis has been performed in accordance with local established policies and procedures using
the best available data. This certification applies to those items listed above in Sections I and I1
plus all attached planning assessment addendums for which I am the responsible party.
Signature of this form indicates acceptance of this wastewater flow,
r �f
f IL
ng � al ignature ,POLLARD, President Date
Page 2 of 6

Blue Creek Utilities, Inc.
2965 Richlands Hwy
Jacksonville, NC 28540
March 21, 2018
To Whom It May Concern:
This letter certifies that Blue Creek Utilities, Incorporation owns and operates a
sewer collection and treatment system. The company has been granted a
Certificate of Public Necessity and Convenience by the North Carolina Utilities
Commission to provide sewer utility services Jonathon Popkins address
Intersection of Hwy 258/Ridge Road, which is located in Jacksonville NC 28540.
The North Carolina Department of Environment, Health, and Natural Resources
has issued NPDES sewer permit number NC0056952. The company is in
compliance with all State and Federal Laws regarding the same.
If you have any questions, or need additional information, please do not
hesitate to contact me.
Sincerely,
Allison Everett
Office Manager

Map.s 0.
34045'28.1 "N 77028'49.5"W
Map data ©2018 Google 200 ft L.
r
11/13/2018