CHIPLY DAIRY FARM IREDELL_MISC_20171231

N. C. Department of Natural Resources and Community Development
Office of Water Resources
Facility and'Impoundment Questionnaire
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I.
General Facility Information
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1 } Faci 1 i ty Name
2) Facility Location
3) Facility Mailing Address
4)
5}
6)
Facility Manager
Telephone No.
Facility Contact Telephone No.
Facility Purpose
(a) Standard Industrial Classification (SIC)
Group Name
(b) Four Digit Number
Primary Secondary
1) Number of Impoundments at Facility
II. Impoundment Information
(please complete this section for each impoundment)
1) Pur .semcircle)
Storage Disposal Treatment Other (Specify)
2) Nature or Type of Waste
3) Surface Area, acres
4) Average Influent, gal/day Year of Record
5) Average Effluent, gal/day Year of Record
6 ) Type of Bottom Liner 1.,J 09 J.C�o
7) Years of Service _ to
8) Depth of Impoundment
9) Soil Type in Vicinity of Impoundment (circle)
Sandy Clayey Sand and Clay Other (Specify)
10) Distance from Impoundment to:
(a) Water Supply Wells
(b) Nearest Stream
III. Monitoring Information
1) Number of Monitor Wells
2} Depth of Wells
3) Depth to Water in Wells
4) Include Analysis if Available

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V. GROUND -WATER DEGRADATION
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III. IMPOUNDMENT DESCRIPTION
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a.'Age of impound
'
c. if answer to I1Lb ie
d. If answer to IIIb is
e. Surface area of impoundment.
f. Surface area of AU impoundments
44
U.S. ENVIRONMENTAL PROTECTION AGENCY
PRESENTLY USED.
1 _ v- -. nrn
SERIAL NUMBER
DATE PREPARED
r,n erre.]
at this site (in acres).
g. Average influent into j(" impoundment (gallons per day and year of record).
SURFACE IMPOUNDMENT ASSESSMENT (SIA)
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OPERATIONAL
FEATURES
OF THE IMPOUNDMENT AND GROUND -WATER CONTAMINATION POTENTIAL
- - - - ,� - are now elle within mile of impoundment.)
-' - - '-- - - - '-- -
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2, Daily S. Quarterly S. Other (Specify in blocks 50 thru 61.)
MONrN
"'
DAY
IMPOUNDMENT DESCRIPTION (Continued)
3. Weekly 6. Semi -Annually
k. TYPE OF BOTTOM LINER (Enter no. from the types listed into blocks 23 and 24.)
SECTION II
1FOR AGRICULL IMPOUNDMENT T GIVE GIVE)
038365 S S
- •IF CLAY LINER NO. 2,3 OR 4 IS SELECTED, GIVE THICKNESS IN INCHES (Enter
in blocks 25 thru 27.)
.
.:.
01. None 04. Chemically Modified Clay
07. Metal
I0. Butyl Rubber Sheeting 13. Chlorinated Polyethylene
AR.
INSTRUCTIONS: This form is
to be com leted for one im oundment r site facilit identified in Section I, Location and Count of Impoundments Form or for one
08. Polyethylene
GALS./DAY
14. Other Membrane type (Specify in blks. 28 - 39.)
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impoundment per site selected via random sampling Procedures. Complete multiple choice questions by entering the code number preceding the appropriate answer.
75 76 77 78
1. Cattle 2. Hogs 3. Sheep
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1. FACILITY IDENTIFICATION
xr:rty;,av:ey ¢Y:.:,u. ', : .::•: ..: x'�i >• t::c r•w . . •x- ,,:,o,:,,.a-,=-
I1. PURPOSE OF IMPOUNDMENT (Enter no. in block 23
A
12. Ethylene Propylene
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IMPOUNDsrt„
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STATE
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CNTY./CITY>' -% PLACE
CATEGORY < SIA
SITE NUMBER *.,
9 �;'6 oxg., ',6`fi. 1. Waste Storage 2. Waste Disposal 3. Waste Treatment (Specify below) 4. Other (Specify below)
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40 - 43
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STATE COPY
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�` SPECIFY_6>T?
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V. GROUND -WATER DEGRADATION
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III. IMPOUNDMENT DESCRIPTION
a.'Age of impound
b. i5 IMPOUNDMENT
c. if answer to I1Lb ie
d. If answer to IIIb is
e. Surface area of impoundment.
f. Surface area of AU impoundments
44
men[ in years.
r
PRESENTLY USED.
1 _ v- -. nrn
'yes', give no. of
- rnfle-
'no', give last year
I nr nne-tion-
r,n erre.]
at this site (in acres).
g. Average influent into j(" impoundment (gallons per day and year of record).
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IV. GROUND -WATER MONITORING
V. GROUND -WATER DEGRADATION
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RECORD
a
oring wells assn-
RECORD
OBSERVED IN ANALYSIS FROM MONITORING WELLS? (If 'yes', explain
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YEAR OF
- - - - - --- - - - - - - - - - - - - - - -
,�
- - - - ,� - are now elle within mile of impoundment.)
-' - - '-- - - - '-- -
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2, Daily S. Quarterly S. Other (Specify in blocks 50 thru 61.)
}
III.
IMPOUNDMENT DESCRIPTION (Continued)
3. Weekly 6. Semi -Annually
k. TYPE OF BOTTOM LINER (Enter no. from the types listed into blocks 23 and 24.)
1FOR AGRICULL IMPOUNDMENT T GIVE GIVE)
AVERAGE DAILY NUMBER
- •IF CLAY LINER NO. 2,3 OR 4 IS SELECTED, GIVE THICKNESS IN INCHES (Enter
in blocks 25 thru 27.)
.
.:.
01. None 04. Chemically Modified Clay
07. Metal
I0. Butyl Rubber Sheeting 13. Chlorinated Polyethylene
`f
�
50 .,,...: -so-..,{
08. Polyethylene
GALS./DAY
14. Other Membrane type (Specify in blks. 28 - 39.)
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1. Cattle 2. Hogs 3. Sheep
a
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ca
09. Plasticized PVC
12. Ethylene Propylene
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111. IMPOUNDMENT DESCRIPTION (Continued)
h. Average effluent for is impoundment (gallons per day and year of record). i. Average daily influent forth impoundments at this facility (gallons per day and year j. Average daily effluent removed from gaimpoundments and discharged to streams, lakes,
_ of record), etc, (gallons per day and year of record).
YEAR OF YEAR OF YEAR OF
GA11 iS./DAY GALS./DAY GALS./ DAY
pox 47 48 49 {c o: 50
IV. GROUND -WATER MONITORING
V. GROUND -WATER DEGRADATION
RECORD
b. FREQUENCY OF GROUND -WATER QUALITY SAMPLING FROM
RECORD
b. HAS THE GROUND -WATER QUALITY OF DRINKING WATER WELLS IN THE
oring wells assn-
RECORD
OBSERVED IN ANALYSIS FROM MONITORING WELLS? (If 'yes', explain
rc .::, .:. s .,,n .. :n
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:.
36
44
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1. None 4. Monthly 7. Yearly
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vestfon V.b.).
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- - - - - --- - - - - - - - - - - - - - - -
,�
- - - - ,� - are now elle within mile of impoundment.)
-' - - '-- - - - '-- -
K� ,.
2, Daily S. Quarterly S. Other (Specify in blocks 50 thru 61.)
EXPLAIN:
III.
IMPOUNDMENT DESCRIPTION (Continued)
3. Weekly 6. Semi -Annually
k. TYPE OF BOTTOM LINER (Enter no. from the types listed into blocks 23 and 24.)
1FOR AGRICULL IMPOUNDMENT T GIVE GIVE)
AVERAGE DAILY NUMBER
- •IF CLAY LINER NO. 2,3 OR 4 IS SELECTED, GIVE THICKNESS IN INCHES (Enter
in blocks 25 thru 27.)
.
dx%L
01. None 04. Chemically Modified Clay
07. Metal
I0. Butyl Rubber Sheeting 13. Chlorinated Polyethylene
UTURARA AND TYPE (inL
(frt blocks 40 OF LIVESTOCK.
02 Clay 05. Concrete
50 .,,...: -so-..,{
08. Polyethylene
11. Hypelon Sheeting
14. Other Membrane type (Specify in blks. 28 - 39.)
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1. Cattle 2. Hogs 3. Sheep
4, Poultry 5. Other
03. Bentonite Modified 06. Asphalt
.>. 9.r
09. Plasticized PVC
12. Ethylene Propylene
1S. Other (Specify in blocks 28 thru 39.)
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IV. GROUND -WATER MONITORING
V. GROUND -WATER DEGRADATION
. Number of moni-
b. FREQUENCY OF GROUND -WATER QUALITY SAMPLING FROM
a. HAVE SIGNIFICANT CHANGES IN GROUND=WATER QUALITY BEEN
b. HAS THE GROUND -WATER QUALITY OF DRINKING WATER WELLS IN THE
oring wells assn-
MONITORING WELLS.
OBSERVED IN ANALYSIS FROM MONITORING WELLS? (If 'yes', explain
rc .::, .:. s .,,n .. :n
:.::::o-.cQ;
:.
AREA BEEN ADVERSELY AFFECTED BY SEEPAGE FROM THIS
iated with this
and describe below how the site was corrected.)
c�c,. a>-t«•s'mt, .:.
IMPOUNDMENT? (Il 'yes', explain below.)
mpoundment (if '0'
VI. RATING OF THE GROUND -WATER CONTAMINATION POTENTIAL (See instruction manual EPA 570/9-78-003)
nter and go to
1. None 4. Monthly 7. Yearly
1. Yea 2- No A. Unknown 4- Not Applicable
STEP i
(Can only
1. Yes 2, Na 3. Unknown 4. Not Applicable (Caonly be used when there
vestfon V.b.).
STEP 4
- - - - - --- - - - - - - - - - - - - - - -
-
- - - - ,� - are now elle within mile of impoundment.)
-' - - '-- - - - '-- -
K� ,.
2, Daily S. Quarterly S. Other (Specify in blocks 50 thru 61.)
EXPLAIN:
G W. CONTAM. HEALTH HAZARD CONFIDENCE
- �.
EXPLAIN. -
3. Weekly 6. Semi -Annually
pox 47 48 49 {c o: 50
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VI. RATING OF THE GROUND -WATER CONTAMINATION POTENTIAL (See instruction manual EPA 570/9-78-003)
NIL WASTE IDENTIFICATQN
N
STEP i
STEP 2 STEP3
STEP 4
STEP 5 STEP 6
MISCELLANEOUS Enter the waste identification number
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UNSAT. ZONE CONFIDENCE G.W. AVAIL.
CONFIDENCE G.W. QUAL. CONFIDENCE WASTE CONFIDENCE
G W. CONTAM. HEALTH HAZARD CONFIDENCE
IDENTIFIERS for Part VI, Step 4.
7
POTENTIAL
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E PA . Form 7500-44A (6-78)
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STATE COPY

SURFACE IMPOUNDMENT ASSESSMENT
EVALUA 7ON SYSTEM WORKSHEE r (c,
L
S FE 1. RATING OF = UNSATURATED ZONE
A. Thickness of unsaturated zone f %Q �' ,3&eters.
B. Earth Material;
Description of Material Thickness (meters)
AS S� to dm
Earth Material Category;
D. Score for Step 1;
STEP 2. RATING THE GROUND -WATER AV AI LA BILI TY
A. Thickness of saturated zone �> S3_�^ meters.
B. Earth Material of the saturated zone:
Material
Earth Material Category:77—t�
C. Score for Step 2: 2
Thickness (meters)

-2 -
STEP 3. RATING THE GROUND -WATER QUALITY
A. Is ground water presently used as a drinking water source?
YES NO
B. Total dissolved solids content of ground water
C. Score for Step 3:
STEP 4. RATING OF THE WASTE HAZARD POTENTIAL
A. CLassification of Impoundment User by Standard Industrial
Classification: 27 or
B. Waste Type (Give I. D. Number); / 7 D 2-
C. Score for Step 4:
let-
STEP
e —
mg/1.
STEP 5. RATING THE OVERALL GROUND -WATER POLLUTION "
POTENTIAL
Step I + Step 2 + Step 3 + Step 4 - Step 5
+ z1�: + + = 1

•
GR0UNDi1ATER POLLUTION SOURCE
RANKING CRITERIA
THREAT TO GROUNDWATER
Probability of Groundwater Violations
3 Violations documented or highly probable
aDefault
1 Violations unlikely
Extent of Groundwater Contamination
. 3 Mappable, migrating plume
0 Default
I Insignificant contamination expected
Seriousness of Groundwater Threat
3 One of most serious in DEM region
2 Default
Ol Not considered a serious problem
FEASIBILITY FOR TAKING ACTION
Feasibility for Remedial Action
3 Remedial action both feasible and desirable
2 Default
'tJ No remedial action recommended
Desirability of Remedial Action
3 One of top regional office priorities
2 Default
01 Not a priority incident
THREAT TO PEOPLE OR ECONOMY
How Hazardous to Health/Economy
3 People or business advised of contamination
2 Default
1� No expected impacts on people or business
Number of People at Risk
3 4 or more family units, or $10,000 loss
ODefault
1 No people or other interests at risk
Seriousness of People Threat
3 Strong DEM concern over threat to people
2 Default
ONo threat to people or economy
4 FEASIBILITY OF RECLASSIFYING GROUNDWATER
Need to Reclassifv Croundwater
3 Groundwater should be relassified RS or GC
2 Default
l� No reclass. nor remedial action recommended
Desirability of Reclassification
3 One of top reclassification priorities
2 Default
0 Not a priority incident
EVALUATION
�— THREAT OF POLLUTANTS
How Toxic are Pollutants (use Sax)
3 High value
2 Mod value
Low or hone value
Quantity -of Pollutants in Ground
3 Reportable quantity of hazardous material
(CERCLA def.) or quantity of real concern
2 Default
P) Not of concern to regional office
Seriousness of Pollutant Threat
3 One of most serious in DEM region
nDefault
1 Not a serious threat
RANK SCORE:
Source Name:
Control Number: (o
County:
Ranker:
Date :

•t.
Jv9�'1.7�i
Control Number
County Number
GROUNDWATER POLLUTION SOURCE INVENTORY
O
me
Source Name
00
Private
2 Municipal
Source Addrets lkf
3 County
4 State
City
iL
County
Region
5 Federal
6 Military
Owner peratar
# Quad Name
PultipTe Sources.at 51te
Source Us
YES NO
lCounty
POTENTIAL SOURCE OF GROUNDWATER POLLUTION
LOCATION
OPERATION TYPE
TYPE OF WASTE
DISPOSAL FACILITY
OTHER SOURCE
0 Facility
1 Municipal
1 Gasoline/diesel
O Lagoon, etc.
1
Agricultural Activity
2 Highway
2 Industrial
2 Other oil
2 Landfill-contro.
'2
Salt water intrusion
3 Railroad
(f) Agricultural
3 Solvents
3 Landfill-uncont.
3
Chemical stock pile
4 Waterway
4 Oil and gas
4 Corrosives
4 Land application
4
River infiltration
5 Pipeline
5 Mining
5 Other chemical
5 Abandoned site
5
Mine drainage
6 Dumpsite
6 Other Source
6)Sewage/septage
6 Sewer system
6
Intentional dump
7 Other
7 Sludge
7 Septic tank
7
Spill
8 Leachate
8 Injection well
8
Leak --above ground
9 Other solids
9 Disposal well
9
Leak --underground
In use
10 Gas
WASTE:
STATUS OF SOURCE: 2 Inactive
11 Pest/herbicides
3 Other
12 Fertilizers
POLLUTION STATUS AND
CROSS-REFERENCES
GROUNDWATER POLLUTION
FACILITY PERMITTED:
Yes No
1 Confirmed IG Rank
1 NPDES
6 Mining
Potential 2 Tabulate
No:
2 DEM Nondischarge
No:
7 Hazardous
Waste (RCRA)
MONITORING WELLS
No:
No:
1 No monitoring
2 State has data
3 Well Construction
8 Solid Waste
(Landfill)
3 Data at facility
No:
No:
4 Status unknown
4 Capacity Use
9 Oil Terminal
Registration
DATABASE CROSS-REFERENCE
No:
No:
1 ERRIS (CERCLA) list
5 UIC
0 Air Quality
ID:
No:
No:
2 Surface Impoundment (SIA)
Comments
ID:
3 GW Pollution Source Inv.
Date:
4 Other DEM investigation
Date:
Compiler:
Date:

FORM APPROVED
OMB NO. 158--578004
DATE PREPARED
SERIAL NUMBER
U.S. ENVIRONMENTAL PROTECTION AGENCY
wti
MONTH DAY YEAR #'
SURFACE IMPOUNDMENT ASSESSMENT (SIA)
j
q
LOCATION AND COUNT OF IMPOUNDMENTS
T04 6 ..+ h'
SECTION 1
76 79 8D �'
75 77 78
FACILITY IDENTIFICATION How many impoundments are
-$
STATE IDENTIFICATION NO. (Optional)
-_.Ys� STATE GNTY./CITY PLACE CATEGORY SIA SITE NUMBER -- located at this site.
1 2
3 - 5 fi - 10 it .. 13 14 - 18 --ra;;a. 22 23 - 25 '
26 - 37
STANDARD INDUSTRIAL SITE LOCATION
NPDES NUMBER
CLASSIFICATION (SIC Code) $:xD DEGREES MINUTES SECONDS n# o A a DEGREES MINUTES SFCONDS
e
l'
kZ
"� LATITUDE—�
LONGITUDE---P-
ONGITUDE—P-
01,;1
Y R
38 46 2 01( 47 s °'
—r
— _ ahj
n s 51 52 53 54 55 56
OWNER
NAME OF OWNER
zI
N1
Ei
P (
DI(I
I I El
IL.
-ITIA1
$.:
22 59
OWNER'S MAILING ADDRESS (Street No. or P.O. Box)
I
161n1X1
22 59
CITY OR TOWN
STATE
ZIP CODE
a_S�"
r
UT
n��_2.1911
4
711
` 22 — 52
53 54
55 59
OPERATOR
NAME OF OPERATOR
5_
�'
22
OPERATOR'S MAILING ADDRESS (Street No. or P.O. Box)
6<
#:
t,
22 59
CITY OR TOWN
STATE
ZIP CODE
, 7
`< 22 — 52
5354
55 — 5.9
EPA Form 7500-44 (6-78) STATE COPY