950008_ENFORCEMENT_20171231

Mitchell, Patrick
From:
Rosebrock, Melissa
Sent:
Tuesday, June 04, 2013 4:04 PM
To:
[e-mail]
Cc:
Mitchell, Patrick
Subject:
FW: J.C. Shore- Flannery Fork and Payne Branch property
Attachments:
Payne Branch 1.pdf; Payne Branch 2.pdf; Payne Branch 3.pdf; Payne Branch 4.pdf; Flannery
Fork 1.pdf; Flannery Fork 2.pdf; Flannery Fork 3.pdf; Flannery Fork 4.pdf; Flannery Fork 5.pdf
Ladonna,
Thanks for your quick response to our requests for addressing the water quality complaint received by our
office. Additionally, we appreciate you sending the photographs depicting your response.
In general, everything looks good. However, I/we still have a couple of questions and I will refer to your
photos from Payne Branch as PB and Flannery Fork as FF. You are welcome to "reply" and then type your
response under each of the questions below if that is easier for you:
PB #1— Silt fencing looks to be installed correctly. Thanks!
PB #2 — Was the silt fence re -installed? When we visited 5/21/2013 the bottom portion was not buried. I will
let Patrick determine if this is critical.
PB #3 and #4 — Looks good.
FF #1— Was the photo taken from the road? Le, is the creek in the foreground of the photo? The vegetation
has really grown!
FF #2 -- As you turn into the property, is this stockpile to the left of the barn?
FF #3 — Much better! Is this area to be seeded to establish permanent vegetation?
FF #4 — In the photo, was silt fencing eventually installed where the track hoe bucket is currently digging?
FF #5 — Is this shot looking towards the road?
Thanks again for your assistance in resolving this issue.
Melissa
Melissa Rosebrock
E-mail Address: melissa.rosebrock(@ncdenr.aov
NCDENR Division of Water Quality
Winston-Salem Regional Office
585 Waughto% n Street, Winston-Salem, NC 27107
[phone]; fax [phone]
www.ncwateraualitv.ore
E-mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Ladonna Shore (maiIto: breooffice0)Xahoo,com]
Sent: Friday, May 31, 2013 1:27 PM
To: Rosebrock, Melissa
Subject: J.C. Shore- Flannery Fork and Payne Branch property

Mitchell, Patrick
From:
Rosebrock, Melissa
Sent:
Wednesday, June 05, 2013 9:28 AM
To:
[e-mail]
Cc:
Mitchell, Patrick
Subject:
J.C. Shore and Flannery Fork and Payne Branch Property
Thanks for the clarification Ladonna. If any further concerns arise, Patrick will contact you. We have not
received any additional complaints. In the future, please let us know if there's anything we can do for you!
Best Regards,
Melissa
Melissa Rosebrock
E-mail Address: [e-mail]
NCDENR Division of Water Quality
Winston-Salem Regional Office
585 Waughtown Street, Winston-Salem, NC 27107
[phone]; fax [phone]
www.ncwaterauality.or�
E-mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Ladonna Shore [mailto:laja286050byahoo.com]
Sent: Tuesday, June 04, 2013 9:56 PM
To: Rosebrock, Melissa
Subject: Fw: J.C. Shore- Flannery Fork and Payne Branch property
----- Forwarded Message -----
From: Ladonna Shore <[e-mail]>
To: Ladonna Shore <brepofficeCa7�yahoo.com>
Sent: Tuesday, June 4, 2013 8:16 PM
Subject: Re: J.C. Shore- Flannery Fork and Payne Branch property
From: Ladonna Shore <brepoffice(ZDVahoo.com>
To: "laia286050yahoo.com" <Iaia28605(q)_yahoo.com>
Sent: Tuesday, June 4, 2013 5:23 PM
Subject: Fw: J.C. Shore- Flannery Fork and Payne Branch property
----- Forwarded Message -----
From: "Rosebrock, Melissa" <melissa.rose brockfc)ncdenr.pov>
To: " brepofficaa-yahoo;com" <brepofficetcDyahoo.com>
Cc: "Mitchell, Patrick" <Patrick.Mitchell(a.NCDENR.gov>

Sent: Tuesday, June 4, 2013 4:03 PM
Subject: FW: J.C. Shore- Flannery Fork and Payne Branch property
Ladonna,
Thanks for your quick response to our requests for addressing the water quality complaint received by our
office. Additionally, we appreciate you sending the photographs depicting your response.
In general, everything looks good. However, I/we still have a couple of questions and I will refer to your
photos from Payne Branch as PB and Flannery Fork as FF. You are welcome to "reply' and then type your
response under each of the questions below if that is easier for your
PB 41 — Silt fencing looks to be installed correctly. Thanks!
PB #2 — Was the silt fence re -installed? When we visited 5/21/2013 the bottom portion was not buried. I will
let Patrick determine if this is critical.
Silt fence was buried.
PB #3 and #4 — Looks good.
FF #I — Was the photo taken from the road? i.e. is the creek in the foreground of the photo? The vegetation has
really grown!
Yes this was taken from our driveway.
FF 92 — As you turn into the property, is this stockpile to the left of the barn?
This is the only stock pile, it is to the right of the barn standing in our driveway.
FF 43 — Much better! Is this area to be seeded to establish permanent vegetation?
Yes!
FF #4 — In the photo, was silt fencing eventually installed where the track hoe bucket is currently digging?
Trackhoe is not digging, it is parked, silt fence goes past stock pile on both ends.
FF #5 — Is this shot looking towards the road?
Yes
Thanks again for your assistance in resolving this issue.
Melissa
Melissa Rosebrock
C-rnail Address: melissa.rosebrocknncdenr.gov
NCDENR Division of Water Quality
Winston-Salem Regional Office
585 Waughtown Street, Winston-Salem, NC 27107
[phone]: fax [phone]
ww w. n ewa tergua I i ty.ore
E-mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties
From: Ladonna Shore [mailto:brepoffice c,Dyahoo.com]
Sent: Friday, May 31, 2013 1:27 PM
To: Rosebrock, Melissa
Subject: J.C. Shore- Flannery Fork and Payne Branch property

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North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat McCrory Charles Wakild, P, E.
Governor Director
May 24, 2013
Mr. J.C. and Mrs. Ladonna Shore
706 Flannery Fork Road
Blowing Rock, NC 28605
SUBJECT: Complaint Investigation -- Animal Waste Stockpiles
J.C. Shore Farm
Facility No. 95-0007
Watauga County
Dear Mr. and Mrs. Shore:
John E. Skvarla, III
Secretary
This letter is a follow-up to the complaint investigation conducted on May 22, 2013 by the Division of
Water Quality (DWQ). The investigation was conducted by DWQ staff members Mr. Patrick Mitchell and
Ms. Melissa Rosebrock from the Winston-Salem Regional Office, As a reminder, this investigation
occurred in response to an anonymous complaint alleging animal waste (horse manure) runoff from
stockpiles located on your properties located at 706 Flannery Fork Road and Parcel No. 2809918125000
located on Payne Branch Road. A copy of the complaint investigation report is attached for your review.
Site located at 706 Flannery Fork Road:
On the date of our investigation, DWQ staff noted several areas for animal waste to potentially enter
Flannery Fork from stockpiles located along the bank of Flannery Fork (see enclosed Photos Page 1).
Flannery Fork is rated as a Water Supply-Il; Trout, and High Quality waters of the State. Per discussion
and verbal agreement during the investigation, you stated that you would move the animal waste
stockpiles at this site 25 feet or greater from the banks of Flannery Fork and reinstall the silt fencing
properly to contain any runoff. It is our expectation that the buffer area along the entire length of stream
also be seeded and vegetated. NC Administrative Code 02T .1303(a)(3)(B) requires "a vegetative buffer
(separation) of at least 25 feet is maintained from a perennial stream or perennial waterbody" to animal
waste. Also, please be aware that any unpermitted discharge of animal waste into Flannery Fork (even
during rain events) is illegal per NC General Statute 143-215.1(a)(1).
Site located „on Payne Branch Road (Parcel ID2809918125000):
On the date of our investigation, DWQ staff noted areas for animal waste to potentially enter an unnamed
tributary to Flannery Fork (Water Supply-11; Trout, and High Quality waters of the State) from stockpiles
located onsite (see enclosed Photos Page 2). Per discussion and verbal agreement during the investigation,
you stated that you would move the animal waste stockpiles at this site 100 feet or greater from surface
waters (i.e. Neighbors Pond, Unnamed Tributary and the Wetland Area) and reinstall the silt fencing
properly to contain any runoff. It is our expectation that the area where stockpiles were originally located
be seeded and vegetated. Again, be aware that the unpermitted discharge of animal waste into any surface
waters of NC (even during raid events) is illegal per NC General Statute 143-215.1(a)(1). .
Ni 3
585 Waughtown Street, Winston-Salem, North Carolina 27107 Qlle
Phone: [phone] FAX: [phone] North Caroli na
Internet: www,ncwatefgualijy.oLqNaturally
An Equal Opportunity 1 Airmlalive Action Employer

J.C. and Ladonna Shore
May 24, 2013
Page 2 of 2
Flannery Fork is a tributary to the South Fork New River, which is rated as class "C:+" waters of the state.
This designation identifies waters that are subject -to a special management strategy specified in 15A
NCAC 213 •.0225 the Outstanding Resource Waters (ORW) rule, in order to protect downstream waters
designated as ORW. ORW classification is intended to protect unique and special waters having excellent
water quality and being of exceptional state or national ecological or recreational significance. Stream
samples were not obtained for either site at the time of investigation. However, there is certainly the
potential for a violation of NC water quality standards during rain events and if conditions are allowed to
deteriorate.
The quantity of animal waste that you are receiving in a given year is currently unknown. It is estimated
that you have greater than 100 tons of animal waste stockpiled at the above described sites. Be aware that
NC Administrative Code 02T .1403(a) requires that:
• Persons accepting or purchasing animal waste at a rate of 100 tons or less per year must apply the
waste at no greater than agronomic rates; and maintain a setback of at least 25 feet from a perennial
stream or waterbody.
• In addition to the above listed requirements, persons accepting or purchasing over 100 tons of
animal waste per year must also do the following: register with DWQ prior to accepting or
purchasing the manure; animal waste shall not be stockpiled within 100 feet of a perennial stream
or waterbody; animal waste shall not be stockpiled uncovered for greater than 15 days; along with
the other requirements contained within section .1403(a)(2).
If you are hauling greater than 100 tons of animal waste per year, please register with the Division
prior to accepting or purchasing any additional manure. The office recommends that you cover the
existing animal waste stock piles.
The Division of Water Quality appreciates your cooperation and efforts thus far in preventing potential
violations and discharges. DWQ requests that you notify this office within thirty (30) days of receipt
of this letter that the proposed corrective actions have been completed. Should you need technical
assistance, we urge you to contact the Watauga County Soil and Water Conservation District/Natural
Resources Conservation Service office at [phone].
Your cooperation in this matter is much appreciated. If you have any questions, please contact Mr. Patrick
Mitchell or me at [phone].
Sincerely,
Sherri V. Knight, P.E.
Regional Supervisor, Aquifer Protection Section
enc: Site photos (Page 1 & 2)
Investigation Report
cc: Watauga County Health Department '
Mr. Brian Chatham, Watauga County SWCDINRCS
DWQ-APS-Confined Animal Feeding Operations Unit / r—WSRO = APS-Files=

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Division of Water Quality
Division of Soil and Water Conservation
❑ Other Agency
Facility Number; 950007 Facility Status: Active Permit: AWD950007 ❑ Denied Access
Inspection Type: Compliance InsQection, _ Inactive or Closed Date:
Reason for Visit: County: Watauga _ _ Region: Winston-Salem
Date of Visit: 05/22/2013 Entry Time: 10:50 AM Exit Time: 12:30 PM Incident #:
Farm Name: J.C. Shore Farm _ „ „ -, , „ „ , Owner Email:
Owner: J C Shore Phone:
Mailing Address: 706 Flannery Fork Rd _____ glowing Rock NC 28605
Physical Address: Blowina Rock NC 28605
Facility Status: ❑ Compliant ■ Not Compliant Integrator:
Location of Farm: Latitude: Longitude:
Hwy 321 toward Bolwing Rock, R onto Payne Branch Rd, L onto Flannery Fork Rd, Farm on Right.
Question Areas:
Dischrge & Stream Impacts Other Issues
Certified Operator: Operator Certification Number:
Secondary OIC(s):
On -Site Representative(s): Name Title Phone
24 hour contact name J.C. Shore Phone: [phone]
On -site representative Ladonna Shore Phone: [phone]
Primary Inspector: Patrick Mitchell
Inspector Signature: _
Secondary Inspector(s):
Melissa Rosebrock
Phone:
Date: 2 3�z i, 1 3
Phone:
Page: 1

Permit: AWD950007 Owner - Facility: J C Shore Facility Number: 950007
inspection Data: 05122/2013 inspection Typo: Compliance Inspection Reason for Visit: Complaint
Inspection Summary:
On May 22, 2013 WSRO staff members Patrick Mitchell and Melissa Rosebrock conducted site visits at two locations (a 46.35 acre
tract located on Payne Branch Road (Parcel ID 2809918125000]; and at address 706 Flannery Fork Road), both in Blowing Rock).
Both of these properties are owned and operated by J.C. and Ladonna Shore. The site visits occurred as result of an anonymous
complaint received by the WSRO concerning improper placement of horse manure stockpiles and potential impact to surface waters.
The subsequent investigation revealed the following details for each site:
Parcel ID 2809918125000:
A mixture of horse manure, bedding materials (sawdust & straw) and wood chip mulch was present onsite in two separate stock pile
areas. One large stockpile being adjacent to Payne Branch Road on the shoulder slope and the other large stockpile being at the toe
slope next to an unnamed tributary to Flannery Fork (Tributary to South Fork New River), see attached photos. The stockpile next to
the unnamed tributary was approximately 60 to 70 feet from the stream and a freshwater pond on the neighboring property to the
north. There was also a wetland area present between the stream and the subject stockpile that drained into the neighboring
freshwater pond; the distance between the wetland area and the stockpile was less than 30 feet. It should be noted that the owner
had placed silt fencing downslope of the stockpiles in an effort to contain any runoff. However, the silt fencing was not properly
installed and there was evidence of runoff flowing under the silt fencing. Recommended stockpiles be moved back further away from
the wetland area and that the silt fencing be reinstalled properly.
706 Flannery Fork Road:
A large amount of stockpiles of horse manure and bedding materials (sawdust & straw) mix was present onsite in several areas
adjacent to Flannery Fork (Tributary to South Fork New River). These stockpiles were placed as close as stream bank from Flannery
Fork (see attached photos). It should be noted that the owner had placed silt fencing downslope of the stockpiles in an effort to contain
any runoff. Again, the silt fencing was not properly installed and evidence of runoff flowing under the silt fencing was observed.
Recommended stockpiles be moved back further away from Flannery Fork and that the silt fencing be reinstalled properly.
The horse manure and bedding mix for each site was received from Blowing Rock Equestrian Preserve. NC Administrative Code 02T
.1303(a)(3)(B) requires that "a vegetative buffer (separation) of at least 25 feet is maintained from a perennial stream or perennial
waterbody" to animal waste. This office recommends establising a vegetative cover after moving the stockpiles. While surface water
samples were not taken on the date of our complaint investigation, there is certainly the potential for a violation of NC water quality
standards, if the present conditions at each of the subject sites are not corrected. DWO to send a Notice of Deficiency to the owner of
the subject properties requesting that corrective action be taken.
Page: 2

Permit: AWD950007 Owner -Facility: J C Shore
Faclllty Number: 950007
Inspection Date: 05/22/2013 Inspection Type: Compliance Inspection Reason for Visit: Complaint
Regulated Operations Design Capacity Current Population
Other Animals
❑ Animals Other
Total Design Capacity:
Total SSLW:
Page: 3

Permit: AWD950007 Owner - Facility: J C Shore Facility Number: 950007
Inspection Date: 05/22/2013 Inspection Type: Compliance Inspection Reason for Visit: Complaint
Discharges & Stream Impacts Yes No NA NE
1. Is any discharge observed from any part of the operation? ❑ ■ ❑ ❑
Discharge originated at:
Structure ❑
Application Field ❑
Other ❑
a. Was conveyance man-made? ❑ ❑ ■ ❑
b. Did discharge reach Waters of the State? (if yes, notify DWQ) ❑ ❑ ■ ❑
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (if yes, notify DWQ) ❑ ❑ ■ ❑
2. Is there evidence of a past discharge from any part of the operation? ■ ❑ ❑ ❑
3. Were there any observable adverse impacts or potential adverse impacts to Waters of the State other than ❑ ■ ❑ ❑
from a discharge?
Otherlssues Yes No
NA
NE
28. Did the facility fail to properly dispose of dead animals within 24 hours and/or document and report
❑ ❑
■
❑
mortality rates that exceed normal rates?
29, At the time of the inspection did the facility pose an odor or air quality concern? If yes, contact a regional
❑ ❑
■
❑
Air Quality representative immediately,
30. Did the facility fail to notify regional DWQ of emergency situations as required by Permit? (i.e., discharge,
❑ ❑
■
❑
freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility?
❑ ❑
■
❑
If yes, check the appropriate box below.
Application Field ❑
Lagoon / Storage Pond ❑
Other ❑
If Other, please specify
32. Were any additional problems noted which cause non-oompliance of the Permit or CAWMP? ■ ❑ ❑ ❑
33. Did the Reviewerllnspector fail to discuss reviewlinspection with on -site representative? ❑ ■ ❑ ❑
34. Does the facility require a follow-up visit by same agency? 1 ■ ❑ ❑ ❑
Page: 4

Watauga County, NC
Page 1 of 1
Summary
Profile
Owner
Sales
Resldenbal
Commercial
OBY
Land
Sketch
Full Legal
Agncuitural
Map
Para l Troe
Values
(:6rSinlf'.1119
PAR10:2808591066000
SR 1541 FLANNERY ROCK RD
Parcel
ParID
Tax Year
S1TUS Addess
City, State, Zip
Unit #
Unit Description
NBHD
Class
Land Use Code
Living Units
CAMA Acres
Zoning
Map #
Jan 1 Values
Land Value.
Building Value
Appraisal Total
Exemptions or Exclusions
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Owner Mailing
Tax Year
Sequence Number
Owner Number
Owner
Malting Address
City, State, Zip
Legal Description
Township
City Code
]unsdiction (Tax Code District)
Unit Desc
Unit #
Book
Page
Legal Desc 1
Deeded Acres
Sala Date Book
05-JUL-05 018
I CONTACTUS I HELP
Watauga County Home
0 Property Records
-..-.,_ ...............................
Owner Address Parcel ID Advanced Map Search
SHORE, J C
706 PLANNeRY FORK RD
CURRENT RECORD
N 4 34of81 �► N
2808591066000
Return to Search Results
2013
706 FLANNERY FORK RD
REPORTS
Property Record Card
0390 - DECK HILUPAYNE BRANCH RD AREA
i
.v.W...-�_...w. m,
AG - AGRICULTURAL
R01 - RESIDENTIAL 1 FAMILY
35.91
2808-59-1066.000
46,900
77,800
124,700 as
124,700 as
2013
0
1511030
SHORE, I C
706 FLANNERY FORK RD
BLOWING ROCK NC 28605
03 - BLOWING ROCK
F12 - BLOWING ROCK
P01B
307
SR 1541 FLANNERY ROCK RD
35.91
Page Sale Pricy Grantor
307
Grantee
Data Copyright Watauga County, NC [Privacy Polley) Last Updated: 05/23/2013
Site Design Copyright 1999-2009 Akanda Group LLC. All rights reserved.
IQ Printable Summary
Printable Version
http://www.wataugacounty.org/ias/Datalets/Datalet.aspx?sIndex=8&idx=34 5/23/2013

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Watauga County, NC
Page 1 of I
Summary
Profile
Owner
Sales
Residential
Commercial
OBY
Land
Sketch
Fu€i Legal
Agricultural
Map
Parr"nl Tree
va€aa5
Comments
PARID:2809918125000
FLAT TOP RD
Parcel
ParlD
Tax Year
SIfUS Addess
City, State, Zip
Unit #
Unit Description
NBHD
Class
Land Use Code
Uving Unit$
CAMA Acres
Zoning
Map #
Jan i Values
Land Value.
Building Value
Appraisal Total Ce9Ona6=
Exemptions or Exclusions
Taxable Total
Owner Mailing
Tax Year
Sequence Number
Owner Number
Owner
Mailing Address
City, State, Zip
Legal Description
Township
City Code
Jurlsdlctlon (Tax Code District)
Unit Desc
Unit #
Book
Page
Legal Desc 1
Deeded Acres
Sale Date Book
15-NOV-04 1026
Property Records
Owner Address Parcel ID Advanced Map Search
SHORE, ZELMA VERLEE .ZELMA VERLEE SHORE
REVOCABLE LIVING TRU
2291 PAYNE BRANCH RD
2809918125000
2013
2291 PAYNE BRANCH RD
11
0390 - DECK HILL/PAYNE BRANCH RD AREA
AG - AGRICULTURAL
RO1 - RESIDENTIAL 1 FAMILY
46.35
2809-91-8125-000
289,500
94,500
384,000a
m m ......
384,000
2013
0
1603919
SHORE, ZELMA VERLEE
.ZELMA VERLEE SHORE REVOCABLE LIVING TRU
2269 PAYNE BRANCH RD
BLOWING ROCK NC 28605
03 - BLOWING ROCK
F02 - BOONE FIRE SERVICE DISTRICT
1026
266
FLAT TOP RD
46.35
Page Sale Price Grantor
266 0
Grantee
Data Copyright Watauga County, NC [Privacy Policy] Last Updated: 05/23/2013
7 Site Design Copyright IM-2009 Aldsnda Group LLC. All rights reserved.
I CONTACTUS I HELP
Watauga County Home
CURRENT RECORD
lafI I
Return to Search Results
REPORTS
Property Record Card
I
Printable Summary
Printable Version
http://www.wataugacounty.org/ias/Datalets/Datalet.aspx?slndex=9&idx=1 5/23/2013

Incident/Complaint Investigation Sheet r re- A�b` 950007
---------------------------
Project Description/Name: I,L-15r11ti1 .
Time of Arrival: 0- Date: S- Z2_ z 01 3
On -site Person(s) and contact info:
Weather Conditions/Air Temperature: �
Details (conversations, descriptions, surface waters, eta): �'�o- �ti �y� �4 (fJ Z_L:. �S�t'S its GCr/p%c
71 4 lU, 33yW 31Uyp,'y19,.�> Lp�dry, •`� p a
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❑ Check if -Additional information is recorded on reverse ofpage.
Sample Information
Sample Site Description/Name & #
DO
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% DO
Saturation
Conductivity
S/m
Temperature
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pH
Other(s)
GPS:
Collection
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Additional Comments
(stream bottom, odors, clarity,
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Collector Names
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PHONE LOG
❑ Call Received AMessage Received
❑ Call Returned ❑ CalI Made
El Left Message
Call Purpose
Xcomplaint ❑ Inspection ❑ Non-compliance Reporting ❑ Info Request
Caller Information
Name of Caller/Facility: *XQA I ek 6 ks
Telephone Number(s): Nk
Remain Anonymous? OWS ❑ No ❑ NA
Mailing Address: NA
Date & Time Received:. S!) 71 z-o r 3 ® B 1 519 am
Subject Information
County: Wa�o�
Facility &/or Responsible Person(s):.
Telephone Number(s):
Mailing Address:
Wescription (directions, address/location, source of pollution, nature of incident, surface water body &/or wells
' impacted, amount spilled, when did it start/fmish, etc.):—D J kola a!! l,,_
"rile- a P-14,
(Additional information can be recorded an reverse if needed)
Referred by: Ad,V-, . Z
DWO Information
Action Taken or Referred to:
Received by: P. Mitchell

PHONE LOG
❑ Call Received ❑ Message Received
❑ Call Returned ❑ Call Made ❑ Left Message
Call PuMose
❑ Complaint ❑ Inspection ❑ Non-compliance Reporting ❑ Info Request
Caller Information
Name of Caller/Facility-
Telephone Number(s):
Remain Anonymous? ❑ Yes ❑ No ❑ NA
Mailing Address:
Date & Time Received:
Subject Information
County: ..__
Facility &/or Responsible Person(s):
Telephone Number(s);
Mailing Address: ,
Description (directions, address/location, source of pollution, nature of incident, surface water body &/or wells *-i
impacted, amount spilled, when did it start/finish, etc.):
(Additional information can be recorded on reverse ifneeded)
Referred by:
DWQ Information
Action Taken or Referred to:
Received by: P. Mitchell