SW4120101_CURRENT PERMIT_20120222

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW �1201
DOC TYPE
� CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE
IA Dt� Aiq
YYYYMMDD

NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Dr. Grace E. Terrell, CEO
Cornerstone Triad Realty, LLC
237-A N. Fayetteville St.
Asheboro, NC 27203
Division of Water Quality
Charles Wakild, P.E.
Director
February 22, 2012
Subject: Stormwater Permit No. SW4120101
Cornerstone Healthcare of Asheboro
High Density Commercial Sand Filter Project
Randolph County
Dear Dr. Terrell:
Dee Freeman
Secretary
The Stormwater Permitting Unit received a complete Stormwater Management Permit Application for
Cornerstone Healthcare of Asheboro on February 22, 2012. Staff review of the plans and specifications has
determined that the project, as proposed, will comply with the Stormwater Regulations set forth in Title 15A
NCAC 211.10O0 and Session Law 2006-246. We are forwarding Permit No. SW412O101, dated February 22,
2012, for the construction, operation and maintenance of the subject project and the stormwater BM Ps.
This permit shall be effective from the date of issuance until February 22, 2020 and shall be subject to the
conditions and limitations as specified therein, and does not supersede any other agency permit that may be
required. Please pay special attention to the conditions listed in this permit regarding the Operation and
Maintenance of the BMP(s), recordation of deed restrictions, procedures for changes of ownership,
transferring the permit, and renewing the permit. Failure to establish an adequate system for operation and
maintenance of the stormwater management system, to record deed restrictions, to follow the procedures for
transfer of the permit, or to renew the permit, will result in future compliance problems.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing upon written request within thirty (30) days following receipt of this permit.
This request must be in the form of a written petition, conforming to Chapter 15OB of the North Carolina
General Statutes, and filed with the Office of Administrative Hearings, P.O. Drawer 27447, Raleigh, NC 27611-
7447. Unless such demands are made this permit shall be final and binding.
This project will be kept on file at the Winston-Salem Regional Office. If you have any questions, or need
additional information concerning this matter, please contact Robert Patterson at [phone]; or
[e-mail].
Sincerely,
�D 124,
for Charles Wakild; P.E. cc: SW412O101 File
ec: Mack Summey, PE — Summey Engineering
Sue Homewood — Winston-Salem Regional Office
Wetlands and stormwater Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location, 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer
011C
NOrthClrollila
Naturally

State Stormwater Permit
Permit No. SW4120101
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of
North Carolina as amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Cornerstone Triad Realty, LLC
Cornerstone Healthcare of Asheboro
136 S. Park St., Asheboro, Randolph County
FOR THE
construction, operation and maintenance of one (1) sand filter in compliance with the
provisions of Session Law 2006-246 and 15A NCAC 2H .1000 (hereafter referred to as
the "stormwater rules) and the approved stormwater management plans and
specifications and other supporting data as attached and on file with and approved by
the Division of Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until February 22, 2020, and
shall be subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
1. This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. This stormwater system has been approved for the management of stormwater
runoff as described in Section 1.7 of this permit. The stormwater control has been
designed to handle the runoff from 38,745 square feet of impervious area.
3. The tract will be limited to the amount of built -upon area as indicated in Section
1.7 of this permit, and per the application documents and as shown on the
approved plans.
4. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
5. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
6. The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
Page 1 of 6

State Stormwater Permit
Permit No. SW4120101
7
The following design criteria have been provided in the sand filter and must be
maintained at design condition:
a.
Drainage Area, acres:
1.18
Onsite, ft :
51,215
Offsite, ftz:
0
b.
Total Impervioug Surfaces, ft2:
38,745
Onsite, ft :
38,745
Offsite, ftZ:
0
C.
Design Storm, inches:
1.0
d.
Sed. Chamber Bottom Elev., fmsl:
810.5
e.
Top of Sand Elevation, fmsl:
810.5
f.
Seasonal High Water Table, fmsl:
806.0
g.
Sand Depth, feet:
2.0
h.
Bottom of Sand Elevation fmsl:
808.5
i.
Sediment Chamber S1 , ft�:
580
Sand
Sand Chamber SA, ft :
319
k.
Permitted Storage Volume, ft:
8,325
I.
Bypass 1 Storage Elevation, fmsl:
814.5
M.
Drawdown Time, hours:
15.4
n.
Underdrain Diameter, inches:
4.0
o.
Receiving Stream/River Basin:
Cedar Fork Crk. 1 Yadkin - Pee Dee
P.
Stream Index Number:
13-2-3-3-2
q.
Classification of Water Body:
"C"
II. SCHEDULE OF COMPLIANCE
1. The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use prior to the construction of any
built -upon surface.
2. During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
3. The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted stormwater system functions at optimum efficiency. The
approved Operation and Maintenance Plan must be followed in its entirety and
maintenance must occur at the scheduled intervals including, but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and re -vegetation of slopes and the filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
f. Debris removal and unclogging of all drainage structures, level spreader,
filter media, planting media, underdrains, catch basins and piping.
g. Access to the cell and outlet structure must be available at all times.
4. Records of maintenance activities must be kept for each permitted BMP. The
reports will indicate the date, activity, name of person performing the work and
what actions were taken.
5. The permittee shall submit to the Division of Water Quality an annual summary
report of the maintenance and inspection records for each BMP. The report
shall summarize the inspection dates, results of the inspections, and the
maintenance work performed at each inspection.
Page 2 of 6

State Stormwater Permit
Permit No. SW4120101
6. The stormwater treatment system shall be constructed in accordance with the
approved plans and specifications, the conditions of this permit, and with other
supporting data.
7. Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received
from an appropriate designer for the system installed certifying that the permitted
facility has been installed in accordance with this permit, the approved plans and
specifications, and other supporting documentation. Any deviations from the
approved plans and specifications must be noted on the Certification. A
modification may be required for those deviations.
8. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
9. Access to the stormwater facilities shall be maintained via appropriate recorded
easements at all times.
10. The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
c. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval or a CAMA
Major permit was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
11. The permittee shall submit final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
12. A copy of the approved plans and specifications shall be maintained on file by
the Permittee for a minimum of ten years from the date of the completion of
construction.
13. The Director may notify the permittee when the permitted site does not meet one
or more of the minimum requirements of the permit. Within the time frame
specified in the notice, the permittee shall submit a written time schedule to the
Director for modifying the site to meet minimum requirements. The permittee
shall provide copies of revised plans and certification- in writing to the. Director
that the changes have been made.
III. GENERAL CONDITIONS
1. This permit is not transferable except after notice to and approval by the Director.
In the event of a change of ownership, or a name change, the permittee must
submit a completed Name/Ownership Change form signed by both parties, to the
Division of Water Quality, accompanied by the supporting documentation as
listed on page 2 of the form. The approval of this request will be considered on
its merits and may or may not be approved.
Page 3 of 6

State Stormwater Permit
Permit No. SW4120101
2. The permittee is responsible for compliance with all permit conditions until such
time as the Division approves a request to transfer the permit.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Water Quality, in
accordance with North Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation
of nuisance conditions, the Permittee shall take immediate corrective action,
including those as may be required by this Division, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants DENR Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
7. The permit issued shall continue in force and effect until revoked or terminated.
The permit may be modified, revoked and reissued or terminated for cause. The
filing of a request for a permit modification, revocation and re -issuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
10. The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Session Law 2006-
246, Title 15A NCAC 2H.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division in writing of any name, ownership or
mailing address changes at least 30 days prior to making such changes.
12. The permittee shall submit a renewal request with all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Permit issued this the 22nd day of February, 2012.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
for Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission
Page 4 of 6

State Stormwater Permit
Permit No. SW4120101
Cornerstone Healthcare of Asheboro
Stormwater Permit No. SW4120101
Randolph County
Designer's Certification
I, , as a duly registered
State of North Carolina, having been authorized to observe (check one)
❑ periodically ❑ weekly ❑ full time the construction of the project,
(Project Name)
in the
for (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
S EAI_
Page 5of6

State Stormwater Permit
Permit No. SW4120101
Certification Requirements:
1. The drainage area to the system contains approximately the permitted
acreage.
2. The drainage area to the system contains no more than the permitted
amount of built -upon area.
3. All the built -upon area associated with the project is graded such that the
runoff drains to the system.
4. All roof drains are located such that the runoff is directed into the system.
5. The outlet/bypass structure elevations are per the approved plan.
6. The outlet structure is located per the approved plans.
7. Trash rack is provided on the outlet/bypass structure.
8. All slopes are grassed with permanent vegetation, per the vegetation plan
9. Vegetated slopes are no steeper than 3:1.
10. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
11. The permitted amounts of surface area and/or volume have been
provided.
12. Required drawdown devices are correctly sized per the approved plans.
13. All required design depths are provided.
14. All required parts of the system are provided, such as a sediment
chambers, sand chambers, under drains, and outlets.
15. The required system dimensions are provided per the approved plans.
Please submit this Designer's Certification to: Winston-Salem Regional Office
Surface Water Protection
585 Waughtown Street
Winston-Salem, NC 27107
cc: Mr. Larry Trotter — City of Asheboro
Page 6 of 6

DWQ USE ONtLY
at, Received
Fee Paid
1'ermit Number
t r Z-
S'oS' 9.0_
1 S 1✓ /Z d/ a
Applicable Rules: ❑ Coastal SW - 1995 ❑ Coastal SW - 2008 19-Ph Il - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
I. GENERAL INFORMATION
1, Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Cornerstone Healthcare of Asheboro
2. Location of Project (street address):
136 S. Park Street
City:Asheboro County:Randolph %ip:27203
3. Directions to project (from nearest major intersection):
From intersection of US Highway 64 and US Hwy 220, take 64 Last to Park Street, Turn Left.
Site is 1.5 miles on left.
4. Latitude:351,70' 30" N
IL PERMIT INFORMATION:
Longitude:79° 82' 12" W of the main entrance to the project.
1. a. Specify whether project is (check one): ®New ❑Modification
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number , its issue date (if known) , and the status of
construction: Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certification
2. Specify the type of project (check one):
❑Low Density ®High Density ❑Drains to an Offsite Stormwater System ❑Other
3. If this application is being submitted as the result of a previously returned application or a letter from DWQ
requesting a state stormwater management permit application, list the stormwater project number, if
assigned, 4120101 and the previous name of the project, if different than currently
proposed, same
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major ®Sedimentation/Erosion Control: 2.0 ac of Disturbed Area
❑NPDFS Industrial Stormwater ❑404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit: Land Disturbance Permit has been applied for.
Form SWU-101 Version 07Jun2010 Page I of

III. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization: Cornerstone Triad Realty, LLC
Signing Official & Title:Dr. Grace E. Terrell, CEO & Registered Agent
b. Contact information for person listed in item la above:
Street Address:1701 Westchester Drive, Suite 850
City: High Point
State:NC Zip:27262
Mailing Address (if applicable):237-A N. Fayetteville Street
City:Asheboro State:NC Zip:27203
Phone: (336 ) 626-6371
Email:[e-mail]
Fax: (336 ) 629-0436 „
Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/Organization: Cornerstone Triad Realty, LLC
Signing Official & Title: Dr. Grace E. Terrell CEO & Registered Agent
b.Contact information for person listed in item 2a above:
Street Address: 1701 Westchester Drive, Suite 850
City:High Point State:NC Zip:27262
Mailing Address (if applicable):237-A N. Fayetteville Street
City:Asheboro State:NC Zip:27203
Phone: (336 ) 626-6371
Email: craig✓gaccioneOcornerstonehealthcare.com
Fax: [phone]
3. a. (Optional) Print the name and title of another contact such as the project's construction supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization:
Signing Official & Title:
b.Contact information for person listed in item 3a above:
Mailing Ad
City:
State:
Form SWU-101 Version 07Jun2010 Page 2 of 7
Zip:

Phone: ( ) Fax:
Email:
4. Local jurisdiction for building permits: City of Asheboro
Point of Contact:Mr. Larry Trotter
IV. PROJECT INFORMATION
Phone #: (336 ) 626-1204X231
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
All BUA surface area runoff will be directed to a Sand Filter Device as shown on the plans. BMP's are
designed to capture the first inch of runoff from the entire site.
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW - 1995 ® Ph II - Post Construction
3. Stormwater runoff from this project drains to the Yadkin River basin.
4. Total Property Area: 1.4 acres 5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area': 1.4 acres
' Total project area shall be calculated to exclude the following the normal pool of itxppounded structures, the area
between the batiks of streams and rivers, the area below the Normal High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHM Iine. Die resultant project area is used to
calculate overall percept built capon area (BUA), Nat -coastal wetlands landward of the NHW (or MHW) line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 75.65 %
9. How many drainage areas does the project have?1 (For high density, count 1 for each proposed engineered
stormwater BMP. For lozv densihj and other projects, use I for the whole property area)
10. Complete the following information for each drainage area identified in Project Information item 9. If there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below.
Form SWU-101 Version 07Jun2010 Page 3 of 7

Basin Information
Drainage Area _
Drainage Area _
Drainage Area _
Drainage Area _
Receiving Stream Name
Br k
C qr>A4
P V—ic drCK,
Stream Class
C
Stream Index Number *
- - - - -
13 — Z —3
—L
Total Drainage Area (sf)
51,215
On -site Drainage Area (so
51,215
Off -site Drainage Area (sf)
0
Proposed Impervious Area** (SO
38,745
To Impervious Area** total
75.65
Impervious— Surface Area
Draina e Area _
Draina e Area _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
8,786
On -site Streets (so
17,005
On -site Parking (so
12,059
On -site Sidewalks (so
895
Other on -site (so
0
Future (so
0
Off -site (so
0
Existing BUA*** (so
0
Total (so:
38,745
* Stream Class and Index Number can be determined at: littp.Z portal.)lcdelrr.org%u7ebAoa6ps/csri/classifrcations
�* Irrr�err�iocrs area is defined as the built npoat area including, but not limited to, buildings, roads, parking areas,
sideroalks, gravel areas, etc.
** Report only that amount of existing B UA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation, There was no off -site
Impervious Area listed above, there is none going thru site. _
Protects in Union_ County: Contact DTVQ Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that may he subject to more stringent stormwater requirements as per NCAC 02B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from http://portal.ncdenr.org/web/wq/ws/su/bnip-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from http://portal.ncdenr.org/web/wq/ws/su/statesw/forms does. The complete
application package should be submitted to the appropriate DWQ Office. (The appropriate office may be
found by locating project on the interactive online map at http://portal.ncdenr.org/web/wq/ws/su/mans.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from littp://portal,ncdenr.org/web/wq./ws/su/statesw/fornis does.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants tih
Form. (if required as per Part VII be1070)
3. Original of the applicable Supplement Form(s) sealed signed and dated and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to I dl%h - grzvi"'�
http://www.envhelp.org/pages/onestopexpress.html for information on the Express program Scat l�
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
Form SWU-101 Version 07Jun2010 Page 4 of 7

5. A detailed narrative (one to two pages) describing the stormwater treatment/ manage mentfo r
�{
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the
yk5
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the'/z
mile radius on the map.
7. Sealed, signed and dated calculations.
vKS
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:{
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
& Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW Iines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/ project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"x11" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DWQ to verify the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 2213 Page No: 1068
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC VWS
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and/or 3a per NCAC 2H.1003(e). The
corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
hqp://www.secretary.state.nc.us/-LO--rRorations/CSearch,aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided
as an attachment to the completed and notarized deed restriction form, The appropriate deed restrictions and
protective covenants forms can be downloaded from
http://portal.ncdenr.org/web/wq/rvs/su/statesw/forms_docs. Download the latest versions for each submittal.
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and listed
on the forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DWQ and that they will be recorded prior to the sale of any lot.
Form SWU-101 Version 07Jun2010 Page 5 of 7

As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ} immediately and submit a
completed Name/Ownership Change Form within 30 days; otherwise 1 will be operating a stormwater treatment
facility without a valid permit. I understand that the operation of a stormwater treatment facility without a valid
permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement action including
the assessment of ciya Tenalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signatu re:
Date:_ '�) - /-:1-9D1 a
a Notary Public for the State of N . e . , County of
ar�dol_pk _, do hereby certify that G yn-e e 9 1E,n-e' U personally appeared
before me this `3 day of Yua Y- �O lo2_, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
o
H,CO�,,.
X. APPLICANT'S CERTIFICATION
SEAL
My commission expires DJ4-0 5-07!01(p
I, (print or type name of person listed in Contact Information, item 1a) Dr. Crate Gaccione�ju
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protective covenants will be recorded, and that the proposed project complies with the requirements of the
applicable stormwaJq rules under 15,A-NCAC 2H .;000, SL 2006-246 (Ph. II - Post Construction) or SL 2008-211,
Signature:_
Date: Ga- 13-90J,�
11 kur n4- La iA ) C lm�, a Notary Public for the State of C County of
�IC�_4 y, , do hereby certify that of rai e° �E��P. personally appeared
before me this k� day of VebiruQ�� ��2, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, a 1
Y A, '
Aw
"y
SEAL
My commission expires 0/- 0�5- -)o 14
Form SWU-101 Version 07.1un2010 Page 6 of 6

.I

R scvy! Zola/
Permit Number:
(to be provided by DWQ)
of Waifi9
h r
7
NCDENR
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
SAND FILTER SUPPLEMENT ff
This form must be filled out on tine, printed and submitted with all of the required information. FEB 2 2 2012
Make sure to also fill out and submit the Required Items Checklist (Section 111) and the 18M Agreement (Section IV)
L4=4h A I IDENR - WATER QUALITY
II. PROJECT INFORMATION
Project name Cornerstone Healthcare of Asheboro
Contact name H. Mack Summey, , Jr., PE
Phone number 336-328-0902
Date February 14, 2012
Drainage area number 1
II. DESIGN INFORMATION
Site Characteristics
Drainage area (AD)
51,215.00 ft2 OK
Impervious area
38,745.00 ft2
% Impervious (IA)
75 7%
Design rainfall depth (Ro)
1.00 in
Peak Flow Calculations
1-yr, 24-hr runoff depth
2.79
in
1-yr, 24-hr Intensity
0.12
inlhr
Pre -development 1-yr, 24-hr runoff
0.06
ft3lsec
Post -development 1-yr, 24-hr runoff
0.11
ft31sec
Pre/Post 1-yr, 24-hr peak control
0,05
11:3lsec
Storage Volume
Design volume (WOV) 3,116.70 ft'
Adjusted water quality volume (WOVAdi) 2,337.53 ft3
Volume contained in the sedimentation basin and on top of the sand filter 8,325.00 ft'
Top of sand filler/grate elevation 810.5 ft amsl
Weir elevation (between chambers) 813.5 It amsl
Maximum head on the sedimentation basin and sand filter (InMa'Rtg) 4.00 ft
Average head on the sedimentation basin and sand filter (hp) 2.00 ft
Runoff Coefficient (Rv) 0.73 (uniiless)
Type of Sand Filter
Open sand filter? Y
Y or N
SHWT elevation
806.00 ft amsl
Bottom of the sand filter elevation
808,50 ft amsl
Clearance (dsHwr)
2.50
Closed/pre-cast sand filter? N
Y or N
SHWT elevation
It amsl
Bottom of the sand filter elevation
It amsl
Clearance (dsHwr)
If this is a closed, underground closed sand filter. The clearance between
the surface of the sand filter and the bottom of the roof of the underground
ft
structure (dsn,,e)
M
OK
OK
Form SW401-Sand Filter-Rev.5 2009Sept17 Parts I and II. Project Design Summary, Page 1 of 2

Permit Number:
(to be provided by DWQ)
Sedimentation Basin
Surface area of sedimentation basin (As)
Sedimentation basin/chamber depth
Sand Filter
Surface area of sand filter (AF)
Top of sand media filter bed elevation
Bottom of sand media filter bed/drain elevation
Depth of the sand media filter bed (dF)
Coefficient of permeability for the sand filter (k)
Outlet diameter
Outlet dischargelflowrate
Time to drain the sand filter (t)
Time to drain the sand filter (t)
Additional information
Does volume in excess of the design volume bypass the sand filter?
Is an off-line flow -splitting device used?
If draining to SA waters: Does volume in excess of the design volume flow
evenly distributed through a vegetated filter?
What is the length of the vegetated filter?
Does the design use a level spreader to evenly distribute flow?
Is the BMP located at least 30ft from surface waters (50fi if SA waters)?
If not a closed bottom, is BMP located at least 100ft from water supply wells?
Are the vegetated side slopes equal to or less than 3:1
Is the BMP located in a recorded drainage easement with a recorded access
easement to a public Right of Way (ROW)?
What is the width of the sedimentation chamberlforebay (Wsed)?
What is the depth of sand over the outlet pipe (dpipe)?
580.00 ft2 U[N. IVMULa iiluninuin, uur nidy ll=U LtJ uG rnucdacu w
4.00 ft
319.00 ft2 Illk.,Od OB JuI Im.'c dl VC], I I II,`7LYYI II ❑lzw n Ild miz= LI IC
810,50 ft amsl
808,50 ft amsl
200 ft
3.50 (fUday)
4.00 in
0.15 113lsec
15.41 hours OK. Submit drainage calculations.
0,64 days
Y Y or N OK
N Y or N Insufficient flow sputter.
Y Y or N OK
20.00 ft
N
Y or N
Show how flow is evenly distributed.
Y
YorN
OK
Y
YorN
OK
Y
Y or N
OK
Y
Y or N
OK
29.00 ft OK
1,50 ft OK
Form SW401-Sand Filter-Rev,5 2009Septl7 Parts I and II. Project Design Summary, Page 2 of 2

Postal
1
CERTIFIED y RECEIPT
ru
fDomestic Mail Only;
For delivery information
a
visit our website(,
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1enrro1701 Westchester Drive
si.-;Suite 850
..........
or POE
6 AHigh Pont, NC 27262
- -- -
■ Complete items 1, 2, and 3, Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse '
so that we can return the card to you.
• Attach this card to the back of the mailpiece,
or on the front if space permits.
t. Article Addressed to:
Dr. Grace E. Terrell, CEO
Cornerstone Triad Realty, LLC,
1701 Westchester Drive, Suite 850 t
Hi-h Point, NC 27262
I
1 CERTIFIEDru y RECEIPT
LrJ fDomesfic Mail I Coverage Provided)
For delivery
W1 F,FCL USE
.0
rr-1 Postage $ [ � ZJ 1
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{ C1 PosJt'mark I
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Dr. Grace E. Terrell, CEO
m sent Cornerstone Triad Realty, LLC
a gjiiii 1701 Westchester Drive, Suite 850
t4 orpiHigh Point, NC 27262 _----___.
, Ciry i
A. Sipat rent
�j%� ��
XZGai. ' .� Adl(" VP40.4 " WE3 Addressee
B. Received by (Printed Name) C. rate 4 Delivery '
D. Is delivery address different from item 17 ❑ Yes
If YES, enter delivery address below: Q No ;
3. Fertifi,'
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d Mail® ❑Priority Mail Express'
gistered ❑ Return Receipt for Merchandise
❑ insured Mail ❑ Collect on Delivery
g. Restricted Delivery? (Extra Fee) © Yes
7013 1710 0002 1865 7652
PS Form 38111 July 2013 Domestic Return Receipt
01
I

�swE q es �r�
North Carolina Department of ti y��
Environment and Natural Resources
595 Waught0%Vn Street a-PITHEY BOWES
va, atl Winston-Salem, NC 27107-2241 02 1 P $ 006.31 0
p 0003143750 AUG 302013
Land Quality 7012 2920 0000 3656 1479 MAILED FROM ZIP CODE 2 710 7
Dr, Grace E. Terrell, CEO
Cornerstone Triad Reality LLC
237-A North Fayetteville Street
Asheboro, NC27203 1stVIOTi-:3`201
Ni X_7E 774 :E. 1 P@A lAG4411 Lf/1'3
RETURN TO SENDER
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AMMY
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral, and Land Resources
Land Quality Section
Tracy E. Davis, PE, CPM
Director
August 29, 2013
Pat McCrory, Governor
John E. Skvarla, III, Secretary
CERTIFIED MAIL_#7012 2920 0000 3656 J 1523 fZe-Sen+ St1ptcmoer lb
RETURN RECEIPT REQUESTED
Dr. Grace E. Terrell, CEO
Cornerstone Triad Realty, LLC 1`101 westtws�ej Dr•
237-A North Fayetteville Street
Asheboro, NC 27203 She" ;-'IkJ1� P�irr}, NL. 2`l2t.o2
Subject: NOTICE OF INSPECTION
Cornerstone Healthcare of Asheboro (Central Carolina Women's Center)
Permit No. SW4120101
Randolph County
Dear -Dr. Terrell:
On August 28, 2013, Aana Taylor -Smith and Sue White of the Winston-Salem Regional Office of the Division of
Energy, Mineral, and Land Resources (DEMLR) inspected the Cornerstone Healthcare of Asheboro site in
Randolph County to determine compliance with Stormwater Management Permit Number SW4120101 issued on
February 22, 2012. DEMLR site inspection and subsequent file review revealed that the site is not compliant with
the terms and conditions of this permit. The following items were noted during the inspection and file review:
The bank near the inlet pipe needs re -seeding to prevent potential erosion into the sand filter.
Vegetation around the perimeter of the sand filter should be kept between 3-6 inches as per the Sand
Filter Operation and Maintenance Agreement.
Weeds should be removed from the sand filter, including the rip -rap at the inlet and the rock dam. Please
remove weeds by hand if possible, or wipe on pesticide rather than spraying. Please refer to the Sand
Filter Operation and Maintenance Agreement and/or NC DENR Stormwater Best Management Practices
(BMP) Manual for guidance. The BMP Manual can be found at the following website:
httpa/porlal.ncdenr.org/webhvglrvs/su/burp-rttartual
4. Condition 11.7 of Permit Number SW4120101 requires that an engineer's certification must be received
by the Division prior to occupancy of the project. An engineer's certification was not found during the file
review. Please submit an engineer's certification within 30 days of receiving this letter.
All necessary repairs should be conducted within 30 days of receiving this letter. DEMLR staff will conduct a
follow-up inspection at that time. Please find a copy of the completed form entitled "Compliance Inspection
Report" attached to this letter.
Winston-Salem Regional Office
585 Waughtown Street, Winston-Salem, NC 27101 . Phone; 336-771-5000 I FAX: [phone]

Cornerstone Healthcare of Asheboro
August 29, 2013
Page 2 of 2
Please be advised that you are required to comply with the terms, conditions and limitations of your Stormwater
Management Permit under Title 15A North Carolina Administrative Code 2H .1003 and North Carolina General
Statute 143-214.7, including operation and maintenance of your permitted stormwater system.
If the project has changed name, ownership or mailing address, a formal change of name/ownership form must be
submitted to DEMLR within 30 calendar days detailing the change. Please provide the name, mailing address and
phone number of the person or entity that is now responsible for this permit.
Thank you for your assistance and cooperation during this inspection. Please be advised that violations of the
Stormwater Management Permit may be subject to a civil penalty assessment of up to $25,000.00 per day
for each violation. If you have any questions, comments, or need assistance with understanding any aspect of
your permit, please do not hesitate to contact Aana Taylor -Smith, Sue White, or me at [phone].
Sincerely,
Matthew E. antt, PE e--'—
Regional Engineer
Land Qttalit_y Section
■ Complete items 1, 2, and 3. Also complete A. 5 1r�-S
item 4 if Restricted Delivery is desired. )agent
■ Print your name and address on the reverse _Addra
so that we can return the card to you. B Recei (Prr ame) Ca o
e Attach this card to the back of the mailpiece,
or on the front if space permits. r
D. Is deiiv address different from Item 1? Ye
1. Article Add"* to: If YES, enter delivery address below: 1] No
— ---, m _ - -- _ — —_ , 71
.Dr, Grace F_ Terrell, CFO
1701 Westchester Drive
Suite 850
High Pont, NC 27262
f
13. §Certified
ice Type
iMail® 0 Priority Mail Express"egistered ❑ Return Receipt for Merchandise
© Insured Mall ❑ CoUect on Delivery
4. Restricted Delivery? (Extra Fee) p Yes
7012 2920 0000 3656 1523 ,�d�ekC`o•
PS Form 3811, July 2013 -ay•13 Domestic Return Receipt
Enclosure: Compliance Inspection Report
cc: WSRO Files
DWR Central Files
t-11 L. UtO

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral, and Land Resources
Land Quality Section
Tracy E. Davis, PE, CPM
Director
August 29, 2013
CERTIFIED MAIL #7012 2920 0000 3656 1479
RETURN RECEIPT REQUESTED
Dr. Grace E. Terrell, CEO
Cornerstone Triad Realty, LLC
237-A North Fayetteville Street
Asheboro, NC 27203
Pat McCrory, Governor
John E. Skvarla, 111, Secretary
Subject: NOTICE OF INSPECTION
Cornerstone Healthcare of Asheboro (Central Carolina Women's Center)
Permit No. SW4120101
Randolph County
Dear Dr. Terrell:
On August 28, 2013, Aana Taylor -Smith and Sue White of the Winston-Salem Regional Office of the Division of
Energy, Mineral, and Land Resources (DEMLR) inspected the Cornerstone Healthcare of Asheboro site in
Randolph County to determine compliance with Stormwater Management Permit Number SW4120101 issued on
February 22, 2012. DEMLR site inspection and subsequent file review revealed that the site is not compliant with
the terms and conditions of this permit. The following items were noted during the inspection and file review:
The bank near the inlet pipe needs re -seeding to prevent potential erosion into the sand filter.
Vegetation around the perimeter of the sand filter should be kept between 3-6 inches as per the Sand
Filter Operation and Maintenance Agreement.
Weeds should be removed from the sand filter, including the rip -rap at the inlet and the rock dam. Please
remove weeds by hand if possible, or wipe on pesticide rather than spraying. Please refer to the Sand
Filter Operation and Maintenance Agreement and/or NC DENR Stormwater Best Management Practices
(BMP) Manual for guidance. The BMP Manual can be found at the following website:
lli tt30portal.ncdenr.ori4/web/wq/ws/su/bmp-manual
4. Condition II.7 of Permit Number SW4120101 requires that an engineer's certification must be received
by the Division prior to occupancy of the project. An engineer's certification was not found during the file
review. Please submit air engineer's certification within 30 days of receiving this letter.
All necessary repairs should be conducted within 30 days of receiving this letter. DEMLR staff will conduct a
follow-up inspection at that time. Please find a copy of the completed form entitled "Compliance Inspection
Report" attached to this letter.
Winston-Salem Regional Office
585 Waughtown Street, Winston-Salem, NC 27101 . Phone: [phone] / FAX: [phone]

Cornerstone Healthcare of Asheboro
August 29, 2013
Page 2 of 2
Please be advised that you are required to comply with the terms, conditions and limitations of your Stormwater
Management Permit under Title I SA North Carolina Administrative Code 214 .1003 and North Carolina General
Statute 143-214.7, including operation and maintenance of your permitted stormwater system.
If the project has changed name, ownership or mailing address, a formal change of name/ownership form must be
submitted to DEMLR within 30 calendar days detailing the change, Please provide the name, mailing address and
phone number of the person or entity that is now responsible for this permit.
Thank you for your assistance and cooperation during this inspection. Please be advised that violations of the
Stormwater Management Permit may be subject to a civil penalty assessment of up to $25,000.00 per day
for each violation. If you have any questions, comments, or need assistance with understanding any aspect of
your permit, please do not hesitate to contact Aana Taylor -Smith, Sue White, or me at (336) 771-A00,
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
1 ■ Print your name and address on the reverse
so that we can return the card to you.
1 ■ Attach this card to The back of the mailpiece,
or on the front if space permits.
1. Article Addressed to
Dr. Grace E. Terrell, CEO
I
Cornerstone Triad Reality LLC
237-A North Fayetteville Street
D Asheboro, NC 27203
1
7
Sincerely,
Matthew E. antt, PE "
Regional Engineer
Land QualitySection__
A. Signature
X ❑ Agent
❑ Addressee
B. Received by ( Printed Name) C. Date of Delivery Y
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. S��iceType
13 Qerdfied Mail
('Registered
❑ Insured Mail
© Express Mall
❑ Return Receipt for Merchandise
❑ C.O.D.
4. Restricted Delivery? (Extra Fee)
2r 7012 2920 0000 3656 1479
PS Form 3811, February 2004V-q-t34- estic Return
Enclosure: Compliance Inspection Report
cc: WSRO Files
DWR Central Files
❑ Yes
102595-02-M-1 W

Compliance Inspection Report
Permit: SW4120101 Effective: 02/22/12 Expiration: 02/22/20 Owner: Cornerstone Healthcare of Asheboro
County: Randolph Project: Cornerstone Healthcare of Asheboro
Region: Winston-Salem 136 S Park St
Contact Person: Craig Gaccione
Title:
Directions to Project:
Type of Project: State Stormwater - HD - Sand filters
Drain Areas: 001 - (Cedar Fork Creek) (03-07-09) ( C)
On -Site Representative(s):
Related Permits:
Inspection Date: 0812812013
Entry Time: 09:30 AM
Primary Inspector: Aana Taylor -Smith
Secondary lnspector(s):
Sue White
Reason for Inspection. Routine
Permit Inspection Type: State Stormwater
Facility Status: Cl Compliant ■ Not Compliant
Question Areas:
State Stormwater
(See attachment summary)
Asheboro NC 27203
Exit Time: 10:15 AM
Phone: [phone]
Phone: [phone]
Phone;
inspection Type: Compliance Evaluation
Er- (Domestic Mail Only; No Insurance Coverage ProrjiLk�)
rq
-a I OF O I L USE
f ��� 5 � Z
r1'{ Po5Eage $ f
a
Certified Fee U 16
0 Return Recelpt Fee Postmark
0 (Endorsement Required) Here
i3
Restricted Delivery Fee
Q (Fndorsemem Required)
rU
Q' Total Fos'
ru Dr. Grace E. Terrell, CEO
ru "` ° Cornerstone Triad Reaky LLC
srteai,Api: 237-A North Fayetteville Street
r or PO BOX Asheboro, NC 27203 ......
"snare,
Page: 1

e
Permit: Sw4120101 Owner - Project: Cornerstone Healthcare of Asheboro
Inspection Date: 08128/2013 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
Please submit a signed copy of the Engineer's certification as required by Condition 11.7 of the Permit.
Bank near inlet pipe needs re -seeding. Vegetation around perimeter of sand filter needs maintenance - should be kept
between 3-6 inches. Weeds should be removed from the sand filter, including the rip -rap at the inlet and the rock dam.
Please remove weeds by hand if possible, or wipe on pesticide rather than spraying, in accordance with the Sand Filter
Operation and Maintenance Agreement.
Page: 2

Permit: 5W4120101 Owner - Project: Cornerstone Healthcare of Asheboro
Inspection Date: 08/28/2013 Inspection Type: Compliance Evaluation Reason for Visit: Routine
File Review Yes No NA NE
Is the permit active?
Signed copy of the Engineer's certification is in the file?
Signed copy of the Operation & Maintenance Agreement is in the file?
Copy of the recorded deed restrictions is in the file?
Comment: Please submit a signed copy of the Engineer's certification as required by
Condition 11.7 of the Permit.
Built Upon Area
Is the site BUA constructed as per the permit and approval plans?
Is the drainage area as per the permit and approved plans?
Is the BUA (as permitted) graded such that the runoff drains to the system?
Comment:
Are the SW measures constructed as per the approved plans?
Are the inlets located per the approved plans?
Are the outlet structures located per the approved plans?
Yes No NA NE
■ ❑ ❑ ❑
■ ❑ ❑ ❑
■ ❑ ❑ ❑
Yes No NA NE
■❑❑❑
■ ❑ ❑ ❑
■ ❑ ❑ ❑
Comment:
Operation and Maintenance Yes No NA NE
Are the SW measures being maintained and operated as per the permit requirements? ❑ ■ ❑ ❑
Are the SW BMP inspection and maintenance records complete and available for review or provided to DWQ ❑ ❑ ❑ ■
upon request?
Comment: Bank near inlet pipe needs re -seeding. Vegetation around perimeter of
sand filter needs maintenance - should be kept between 3-6 inches. Weeds should be
removed from the sand filter, including the rip -rap at the inlet and the rock dam. Please
remove weeds by hand if possible, or wipe on pesticide rather than spraying, in
accordance with the Sand Filter Operation and Maintenance Agreement.
Other Permit Conditions
Is the site compliant with other conditions of the permit?
Comment:
Other WO Issues
Is the site compliant with other water quality issues as noted during the inspection?
Comment:
Yes No NA NE
■ ❑ ❑ ❑
Yes No NA NE
■ ❑ ❑ ❑
Page: 3

State Stormwater Inspection Report
General
Project Name: CC, rWj S-tZ�,rZ "eedt �tLyr✓ _ ��
Permit No: SW 41 Z OI D i
Expiration Date: 2' 22 Zn Zo
Contact Person: D h- &I ra Cp Lc . Te-y re l (+ LC D
Phone Number:
Inspection Type: C C- I
Inspection Date: Z B 13
Time In: oqqs
Time Out:
Current Weather: 5 U t r I� t,Lrvt.i
Recent Rain (Date)?
Rain - in
Location
Facility Address / Location:
City: Sl�.�t�?'b
Zip 2-7- 03
County: jLpr1.1 D
Lat: "N
Long: - o "W
Permit Information
Rule Subject to (circle one): 1988 Coastal Rule 1995 Coastal Rule
Goose Creek High Quality Water
Density (circle one): ligh (HD} Low (LD)
Stormwater Best Management Practices (BMPs) (insert number of each):
Wet Ponds Infiltration Basins Infiltration Trenches
Dry Ponds Bioretention Permeable Pavement
Cistern Level Spreader/Filter Strip Other (specify):
File Review
2008 Coastal Rule Session Law 2006-246
Outstanding Resource Waters
LD Swales Stormwater Wetlands
Sand filters (circle one) en Closed
Yes No NIA NIE
1. Is the permit active?
4
2. Signed Engineer's Certification on file?
3. Signed Operation and Maintenance agreement on file?
4. Recorded Deed Restrictions on file?
Rita Visit- Built tJnnn Area (RUAI
Yps Nn NIA NIE
5. BUA is constructed and consistent with the permit requirements?
6. BUA aspermitted) is graded such that the runoff drains to the system? high density only)
7. Drainage area is consistent withpermit? i.e. no un ermitted drainage to the SW BMPs
8. Drainage area is stabilized? (to reduce risk of sedimentation to the SW BMPs)
Site Visit: Stormwater BMPs
Yes No NIA N/E
9. Stormwater BMPs are located per the approvedplans?
10. Stormwater BMPs have dimensions (e . length, width, area) matching the approvedplans?
11. Stormwater BMPs are constructed per the approvedplans?
Sitp Visit- OnpraNnn and Maintenanr_e
Yps Nn NIA NIE
12. Access points to the site are clear and well maintained?
13. Trash has been removed as needed?
�(
14. Excessive landscape debris (grass clippings, leaves, etc) is controlled?
15. Stormwater BMPs being operated and maintained as per the permit requirements?
1D
16. Inspection and Maintenance records are available for inspection? (high density only, 1995 - present only)
Site Visit: Other Permit Conditions Yes No NIA NIE
17. Is the site compliant with other conditions of thepermit?
Site Visit: Other Water Quality Issues Yes No NIA N1E
18. Is the site compliant with other water quality issues as noted during the inspection? I \0
State Stormwater Inspection Report, Version 3.0_3-09 Page I oi'2

State Stormwater Inspection Report
InS ectlon PICtUreS (some of the pictures taken during the site visit)
Compliance Status ❑ Compliant ❑ Non -Compliant
Letter Sent (circle one): Yes No Letter type: CEI NOV NOVRE Other
Date Sent: Reference Number:
Inspector Name and Signature: Date:
State Stormwater Inspection Report, Version 3.0_3-09 Page 2 of 2

SAND FILTERS, OPEN & CLOSED BASINS: O & M Inspection Checklist
FLOW SPLITTER/BYPAS5 i
1. The adjacent pavement is free of sediment: K] ❑ ❑ ❑
2. Inlet device (swale or pipe, if applicable) is free of damage, clogs or erosion: IX ❑ ❑ ❑
3. Weir heights match approved plans:
®
❑
❑
❑
PERIMETER
4. Perimeter is free of bare soil, erosion and gullies: --YtS-reoj hpKYt�(- r1Q0U-
❑
[
❑
❑
ot.c�Ct��
5. Vegetation at the perimeter is maintained at 3 to 6 inches:
❑
❑
❑
❑
� �now7
6. Vegetated side slopes is 3:1 or less:
CP
❑
❑
❑
MAIN TREATMENT'
7. Main treatment area is free of sediment accumulation of more than 6 inches:]
❑
❑
❑
8. Sediment chamber is free of erosion:
t[
❑
❑
❑
9. Sediment chamber is free of weeds: V-,pM0'V't V,�-eeO�S -"M tlb-c* ,
❑
❑
❑
10. Sand Chamber surface is free of clogs: v I, p v0.P , vo(%d m
❑
❑
❑
11. Main treatment area has drained and is free from ponding 24 hours after rain:]
❑
❑
❑
12, Media has been replaced as needed:
❑
❑
❑
OUTLETS
13. Outflow spillway is free of shrubs or trees:
[ 9
❑
❑
❑
14, Outflow pipe is free of damage or clogs:
❑
❑
❑
15. Orifice size matches approved plans:
❑
❑
❑
16. Relative elevations match approved plans:
❑
❑
❑
V3.3-D9

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral, and Land Resources
Land Quality Section
Tracy E. Davis, PE, CPM Pat McCrory, Governor
Director John E. Skvarla, 111, Secretary
November 8, 2013
CERTIFIED MAIL 47013 1710 0002 1865 7652
RETURN RECEIPT REQUESTED
Dr. Grace E.'Terrell, CEO
Cornerstone Triad Realty, LLC
1701 Westchester Drive Suite 850
High Point, NC 27262
Subject: NOTICE OF INSPECTION
Cornerstone Healthcare of Asheboro (Central Carolina Women's Center)
Permit No. SW4120101
Randolph County
Dear Dr. Terrell:
On November 6, 2013, Aana Taylor -Smith of the Winston-Salem Regional Office of the Division of Energy, Mineral, and
Land Resources (DEMLR) inspected the Cornerstone Healthcare of Asheboro site in Randolph County to determine
compliance with Stormwater Management Permit SW4120101 issued on February 22, 2012. This inspection was
conducted as a follow-up to the previous inspection on August 28, 2013. DEMLR File review and site inspection revealed
that the site is compliant with the terms and conditions of this permit and all repairs have been completed as requested.
Please find a copy of the completed form entitled "Stormwater Inspection Report" attached to this letter.
Please be advised that you are required to comply with the terms, conditions and limitations of your Stormwater
Management Permit under Title 15A North Carolina Administrative Code 2H .1003 and North Carolina General Statute
143-214.7, including operation and maintenance of your permitted stormwater system.
Thank you for your assistance and cooperation during this inspection. Your commitment to compliance with the
Stormwater Management Permit is greatly appreciated. If you have any questions, comments, or need assistance with
understanding any aspect of your permit, please do not hesitate to contact Aana Taylor -Smith or me at [phone].
Sincerely,
Matthew E. Gantt, PE
Regional Engineer
Land Quality Section
Enclosure: Compliance Inspection Report
cc: WSRO Files
DWR Central Files
Winston-Salem Regional Office
585 Waughtown Street, Winston-Salem, NC 27101 e Phone: [phone] FAX: [phone]

Compliance Inspection Report
Permit: SW4120101 Effective: 02/22/12 Expiration: 02/22/20 Owner: Cornerstone Healthcare of Asheboro
Project: Cornerstone Healthcare of Asheboro
County: Randolph 136 S Park St
Region: Winston-Salem
Contact Person: Craig Gaccione Title:
Directions to Project:
Type of Project: State Stormwater - HD - Sand filters
Drain Areas: 001 - (Cedar Fork Creek) (03-07-09) { C)
On -Site Representative(s):
Related Permits:
Inspection Date: 11106/2013 Entry Time: 09:25 AM
Primary Inspector: Aana Taylor -Smith
Secondary Inspector(s):
Reason for Inspection: Fallow -up
Permit Inspection Type: State Stormwater
Facility Status: ® Compliant ❑ Not Compliant
Question Areas:
® State Stormwater
(See attachment summary)
Asheboro NC 27203
Phone: [phone]
Exit Time: 09:40 AM
Phone: [phone]
Inspection Type: Compliance Evaluation
Page: 1

Permit: SW4120101 Owner - Project: Cornerstone Healthcare of Asheboro
Inspection Date: 11/06/2013 Inspection Type: Compliance Evaluation Reason for Visit: Follow-up
Inspection Summary:
Please refer to attached inspection letter.
File Review
Yes
No
NA
NE
Is the permit active?
®n
n
Signed copy of the Engineer's certification is in the file?
®❑
0
11
Signed copy of the Operation & Maintenance Agreement is in the file?
®❑
❑
11
Copy of the recorded deed restrictions is in the file?
®
O
n
n
Comment:
Built Upon Area
Yes
No
NA
NE
Is the site BUA constructed as per the permit and approval plans?
®
Q
Q
D
Is the drainage area as per the permit and approved plans?
®�
n
Is the BUA (as permitted) graded such that the runoff drains to the system?
®
Q
0
Q
Comment:
SW Measures
Yes
No
NA
NE
Are the SW measures constructed as per the approved plans?
M
0
0
Are the inlets located per the approved plans?
®
n
Q
❑
Are the outlet structures located per the approved plans?
®❑
❑
D
Comment:
Operation and Maintenance
Yes
No
NA
NE
Are the SW measures being maintained and operated as per the permit requirements?
®❑
Q
Are the SW BMP inspection and maintenance records complete and available for review or provided to ©WQ ®❑
❑
❑
upon request?
Comment: Repairs have been completed as requested.
Other Permit Conditions
Yes
No
NA
NE
Is the site compliant with other conditions of the permit? ®❑ Q n
Comment:
Other WQ Issues Yes No NA NE
Is the site compliant with other water quality issues as noted during the inspections? 0 0 0
Comment:
Page: 2

State Stormwater Inspection Report
General
Project Name: CDVyA6 S:fbr',RMAtVeare g46,-v_bm
Permit No: SW4ilDjb1
Expiration Date: Z/22'2D
Contact Person: D Y. bwce G .TerYeil t GFb
Phone Number:
Inspection 'Type: Cel T-1i.tltM
up
Inspection Date: i 1 l0 1 2j
Time In: �5
Time Out: Cif 4p
Current Weather: C«Qyt dW UOS
Recent Rain (Date)?
Rain-- in
Location
Facility Address 1 Location: I ;lp S. P x-u S+.
City:.PtSVU')0DV-Z> 7_ip:2-12D3 County: "VVA Lat: N Long: - 0 `:W
Permit information
Rule Subject to (circle one): 1988 Coastal Rule
1995 Coastal Rule
2008 Coastal Rule Session Law 2006-246
Goose Creek
High Quality Waters
Outstanding Resource Waters .
Density (cii-cle one):
igh (HD) Low (LD)
Stormwater Best Management Practices (BMPs) (insert
number of each):
Wet Ponds
Infiltration Basins
Infiltration Trenches
LD Swales St water Wetlands
Dry'Ponds
Bioretention
Permeable Pavement
—Sand filters (circle are) Closed
Cistern
Level Spreader/Filter Strip
Other (specify):
File Review
Yes No NIA N1F
1. Is the permit active?
2. Signed Engineer's Certification on file?
3. Signed Operation and Maintenance agreement on file?
4. Recorded Deed Restrictions on file?
Site Visit- Ridit llnnn Area IRl1A1 Yes Nn NIA NIP
5. BUA is constructed and consistent with the permit requirements?
6. BUA aspermitted) is graded such that the runoff drains to the system? (high density on]
7. Drainage area is consistent withpermit? i.e. no un ermitted drainage to the SW BMPs
8. Drainage area is stabilized? to reduce risk of sedimentation to the SW BMPs
Site Visit: Stormwater BMPs Yes No NIA NIE
9. Stormwater BMPs are located per the approvedplans?
10. Stormwater BMPs have dimensions a g. length, width, area) matching the approvedplans?
1 I . Stormwater BMPs are constructed per the approvedplans?
Site Visit: Operation and Maintenance Yes No N/A NIE
12, Access points to the site are clear and well maintained?
13. Trash has been removed as needed?
14. Excessive landscape debris grass clippings, leaves, etc) is controlled?
15. Stormwater BM Ps being operated and maintained as per the permit requirements?
16. Inspection and Maintenance records are available for inspection? (high density only, 1995 — present only)
Site Visit: Other Permit Conditions Yes No NIA NIE
17. Is the site compliant with other conditions of thepermit?
Site Visit: Other Water Quality Issues Yes No NIA ME
18. Is the site compliant with other water aualitv issues as noted during the inspection? '/
State Stormwater Inspection Report, Version 3.0_3-09 Page 1 01`2

State Stormwater Inspection Report
loll eictures (some of the pictures taken during the site
Compliance Status a Compliant Cl Non -Compliant
Letter Sent (circle one): Yes No Letter type: CEI NOV NOVRE Other
Date Sent: Reference Number:
Inspector Name and Signature:
Date:
0
State Stormwater Inspection Report, Version 3.0_3-09 Page 2 of 2

SAND FILTERS, OPEN & CLOSED BASINS: O & M Inspection Checklist
{ FLOW SPLITTER%BYPASS {
1. The adjacent pavement is free of sediment:
i
❑�
R
❑
❑
❑
2. Inlet device (swale or pipe, if applicable) is free of damage, clogs or erosion:
0"
❑
❑
❑
3. Weir heights match approved plans:
i
❑✓
❑
❑
❑
PERIMETER
4. Perimeter is free of bare soil, erosion and gullies: ''pAy�S b V-o
0
❑
❑
❑
5. Vegetation at the perimeter is maintained at 3 to 6 inches: Wv�j-tj
0/'
❑
❑
❑
6. Vegetated side slopes is 3:1 or less:
12
❑
❑
❑
MAIN TREATMENT
7. Main treatment area is free of sediment accumulation of more than 6 inches:
[�']�
❑
❑
❑
8. Sediment chamber is free of erosion:
0�
❑
❑
❑
9. Sediment chamber is free of weeds: Mcr,-l1�
V
❑
❑
❑
10. Sand Chamber surface is free of clogs:
2"'
❑
❑
❑
11. Main treatment area has drained and is free from ponding 24 hours after rain:
0'
❑
❑
❑
12. Media has been replaced as needed:
❑/
❑
❑
❑
OUTLETS
13. Outflow spillway is free of shrubs or trees:
(yam
❑
❑
❑
14. Outflow pipe is free of damage or clogs:
2"'
❑
❑
❑
15. Orifice size matches approved plans:
0 i❑
❑
❑
16. Relative elevations match approved plans:
(/
❑
❑
❑
V3.3-09

Summey Engineering Associates, PLLC
Engineering - Land Planning - Consulting
P.O. Box 968
Asheboro, NC 27204
Phone: [phone] - Fax: [phone]
February 14, 2012
Re: Cornerstone Healthcare of Asheboro
136 Park Street - Asheboro, NC
Randolph County, NC
Stormwater Project No. SW4120101
SEA Job No. E-1972
Mr. Robert Patterson, PE
North Carolina Division of Water Quality
Stormwater Permitting Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
RP.c�12od[2�
FEB 2 2 2012
DENR-WATER QUALITY
WETLANDS AND STORMWATER VMCH
Dear Mr. Patterson:
We are in receipt of your comment letter dated January 13, 2012 and offer the
following responses in Bold:
,,-1. An old version of SWU-101 was submitted. Please be sure to always
use the most recent version of any forms. A revised updated form
has been provided.
2. The blank field for the applicant's name was left blank on Sections IX.
and X. of SWU-101. This has been corrected.
,/ 3. Please provide the correct legal name of the applicant in Ill.1.a. of
SWU-101. The name provided, Cornerstone Healthcare of Asheboro,
is not shown as a valid entity on the NC Secretary of State (SOS)
website. The correct name and registrant has now been provided.
4. The person signing for applicant and owner must have the proper
signature authority to do so as per 15A NCAC 02H .1003(e) and V1.11.
of SWU-101. Dr. Craig Gaccione is not listed as a member/manager
of Cornerstone Triad Realty, LLC on the NC SOS website. Also, his
title was not provided in 111.1.a. and 111.2.a. of SWU-101. Although
V1.11. was initialed on SWU-101, the supporting documentation was
not found in the submitted application package. This has been
corrected.
5. The NC SOS shows that a letter, dated December 9, 2011, was sent to
the owner stating the possible administrative dissolution of
Cornerstone Triad Realty, LLC. Please provide information as to

whether this was resolved. DWQ cannot issue a permit to a company
not in good standing with the NC SOS. Cornerstone Triad Realty
has not been(-- �>t ss o L' V WI>
i6. There is concern with the potential for erosion into the sand filter from
along the un-curbed edge of the pavement just upslope of the BMP.
Rip Rap has been provided to disperse runoff and no erosion
should occur.
✓ 7. The supplement form shows the top elevation of the sediment
chamber berm at 313.5', but the plans show it at 315.0. The berm on
the plans needs to be lowered to below the emergency spillway
elevation. Lowering it to the elevation stated on the supplement would
accomplish this. The berm on the plans has been lowered as
recommended.
I/8. The sediment chamber area (AS) shown on the supplement form
appears to be too small, and not consistent with the plans and
calculations. Please clarify. This has been revised.
1/9. The Hmax on the supplement form shows 3', but the plans show a
max head of 4' (814.5-810.5=4). Please clarify. This has been
revised.
✓10. Please show the supporting calculations for the drawdown time
provided. Provided.
✓ 11. Please show a stage -storage table that supports the stated provided
volume of 8,366 cf. Provided.
�12.Although it is stated no offsite flow drains to the proposed BMP, it
appears from the grading plan that a portion of Park St. will drain into
the site. Please verify and revise as needed. Grading plan has been
revised to direct water away from site by adding a concrete apron
at entrance that will allow water to flow down existing gutter line
as it was before.
Please let me know if you need anything else to aid or assist in your review of
this project.
Very Truly Yours,
Summey Engin ring Associ es, PLLC
H. Mack Summey, Jr., KE
HMSJlhmsj
Cc: Mr. Brian Lathrop, Architect
File

Permit Nwnber: -5k/ I f Z 0 f o!
Oo he provided hY DIVQ)
Drainage Area Number:
Sand Filter Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. "Phis maintenance record will be kept in a log in a
known set location. Any deficient BMP elements noted in the inspection will be corrected, repaired or
replaced immediately. These deficiencies can affect the integrity of structures, safety of the public, and
the removal efficiency of the BMP.
Important maintenance procedures:
— The drainage area will be carefully managed to reduce the sediment load to the sand filter.
— The sedimentation chamber or forebay will be cleaned out whenever sediment depth exceeds
six inches.
— Once a year, sand media will be skimmed.
— The sand filter media will be replaced whenever it fails to function properly after maintenance.
The sand filter will be inspected quarterly and within 24 hours after every storm event greater than
1.0 inches (or 1.5 inches if in a Coastal County). Records of operation and maintenance will be kept in
a known set location and will be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall be repaired
immediately.
BMP elemenE:
Potential rablern:
How I will remediate the roblem:
Entire BMP
Trash/debris is resent.
Remove the trash/debris.
Adjacent pavement (if
Sediment is present on the
Sweep or vacuum the sediment as soon as
applicable)
avement surface.
ossible.
Perimeter of sand filter
Areas of bare soil and/or erosive
Regrade the soil if necessary to remove the
gullies have formed.
gully, and then plant a ground cover and
water until it is established. Provide lime
and a one-time fertilizer application.
Vegetation is too short or too long.
Maintain vegetation at an appropriate
height.
Flow diversion structure
The structure is clogged.
Unclog the conveyance and dispose of any
sediment offsite.
The structure is damaged.
Make any necessary repairs or replace if
damage is too large for repair.
Forebay or pretreatment area
Sediment has accumulated to a
Search for the source of the sediment and
depth of greater than six inches.
remedy the problem if possible. Remove
the sediment and stabilize or dispose of it
in a location where it will not cause
impacts to streams or the BMP.
Erosion has occurred.
Provide additional erosion protection such
as reinforced turf matting or riprap if
needed to prevent future erosion
problems.
Weeds are present.
Remove the weeds, preferably by hand. If
a pesticide is used, wipe it on the plants
rather than spraying.
Form SW401-Sand Filter 4R M-Rev.4 2009Sept 17 Page I of 3

BMP element:.
Potential roblem:,
How .I,will remediate th&vroblem:
Filter bed and underdrain
Water is ponding on the surface for
Check to see if the collector system is
collection system
more than 24 hours after a storm.
clogged and flush if necessary. If rater
still ponds, remove the top few inches of
filter bed media and replace. If water -still
ands, then consult an expert.
Outlet device
Clogging has occurred.
Clean out the outlet device. Dispose of the
sediment offsito,
The outlet device is damaged
Repair or replace the outlet device.
Receiving water
Erosion or other Signs of damage
Contact the NC Division of Water Quality
have occurred at the outlet.
401 Oversight Unit at 919-733-1781
Form SW401-Sand Filter O&M-Rev.4 2009Sept 17 Page 2 oI")

Permit Number: -Stv f 1 Zo/D/
(Io he provided by UItV)
I acknowledge and agree by my signature below that I am responsible for the performance of the
maintenance procedures listed above. I agree to notify DWQ of any problems with the system or prior
to any changes to the system or responsible party.
Project name: Cornerstone Healthcare of Asheboro
BMP clrainage area number:
Print name: Dr. Crain Gaccion
Title: Managing Partner
Address: 237-A N. Fayetteville S
Phone:[phone]
Signature: l
Date: , .7-
Note: The legally responsible party should not be a homeowners association unless more than 50% of the lots have been
sold and a resident of the subdivision has been named the president.
I, a Notary Public for the State of'
County of do hereby certify that
personally appeared before me this 13w' day of
and acknowledge the due execution of the forgoing sand filter
maintenance requirements. Witness my hand and official seal,
SEA1,
My commission expires ag
Form SW40I-Sand Filter 0&_M-Rev.4 2004Sept17 Page 3 of 3

DWQ USE ONLY
Date Received
Fee Paid Permit Number
1 6 i2
5,-k-1auz ►aD1vI
Applicable ales: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 RTh II - Post Construction
(select all that apphl) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name -should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Cornerstone Healthcare of Asheboro
2. Location of Project (street address):
134 N. Park Street
City:Asheboro County:Randolph Zip:27203
3. Directions to project (from nearest major intersection):
From intersection of US Highway 64 and US Hwy 220, take 64 East to Park Street, Turn Left.
Site is 1.5 miles on left.
4. Latitude:350 70' 30" N Longitude:790 82' 12" W of the main entrance to the project.
IL PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number , its issue date (if known) , and the status of
construction: ®Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certification
2. Specify the type of project (check one):
❑Low Density ®High Density ❑Drains to an Offsite Stormwater System ❑Other
3. If this application is being submitted as the result of a previously returned application or a letter from DWQ
requesting a state stormwater management permit application, list the stormwater project number, if
assigned, N/ A and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major ®Sedimentation/Erosion Control: 2.0 ac of Disturbed Area
❑NPDES Industrial Stormwater ❑404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit: Land Disturbance Permit has been applied for.
Form SWU-101 Version 071uly2009 Page 1 of 6

Ill. CONTACT INFORMATION
'La. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization: Cornerstone Healthcare of Asheboro
Signing Official & Title:Dr. Craig Gaccione
b. Contact information for person listed in item la above:
Street Address:237-A N. Fayetteville Street
City:Asheboro State:NC Zip:27203
Mailing Address (if applicable):237-A_ N. _Fayetteville Street _
City:Asheboro State:NC Zip:27203
Phone: (336 _ - }_ 626-6371 Fax: [phone]
Email:[e-mail]
Please check the appropriate box. The applicant Iisted above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/Organization:Cornerstone Triad Realty LLC_
Signing Official & Title:Dr. Craig Gaccione
b.Contact information for person listed in item 2a above:
Street Address:237-A N. Fayetteville Street_
City:Asheboro State:NC Zip:27203
Mailing Address (if applicable):Same
City:
Phone: ( )
Email:
State: Zip:
Fax: ( )
3. a. (Optional) Print the name and title of another contact such as the project's construction supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization:
Signing Official & Title:
b.Contact information for person listed in item 3a above:
Mailing Address:
City: State: Zip:
Phone: ( L_ -- Fax:,.,. —
Email:
4. Local jurisdiction for building permits: City of Asheboro_
Point of Contact: Mr. Larry Trotter Phone #: (336 } 626-1204x231
Form SWU-101 Version 07July2009 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
All BUA surface area runoff will be directed to a Sand Filter Device as shown on the plans. BMP's are
designed to capture the first inch of runoff from the entire site.
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b.Identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW -1995 ® Ph II - Post Construction
3. Stormwater runoff from this project drains to the Yadkin River basin.
4. Total Property Area: 1.4 acres 5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area*: 1.4 acres
* Total project area slialI be calculated to exclude thefollowing., the normal pool of impounded structures, the area
between the batiks of streams and rivers, the area belozo the Normal High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landward froth the NHW (or MHW) litre. Tire resultant project area is rrsed to
calculate overall percent built upon area (13I.1A). Non -coastal wetlands landward of the NHW (or MHW) line pray
be included in the total project area.
S. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 W 75.65 %
9. I -low many drainage areas does the project have? 1 (For high density, count 1 for each proposed engineered
stormwater BMP. For low density and other projects, use 1 for the whole property area)
10. Complete the following information for each drainage area identified in Project Information item 9. If there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below.
Basin Information
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area _
Receiving Stream Name
UT to Long
BranchCreek
Stream Class *
C
Stream Index Number *
13-2-3-3-2-1
Total Drainage Area (so
51,215
On -site Drainage Area (so
51,215
Off -site Drainage Area (so
0
Proposed Impervious Area** (so
38,745
% Im ervious Area** total
75.65
impervious- Surface Area
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (so
8,786
On -site Streets (so
17,005
On -site Parking (so
12,059
On -site Sidewalks (so
895
Other on -site (so
0
Future (so
0
Off -site (so
0
Existing BUA*** (so
0
Total (so:
38,745
Streant Class and Index Number can be determined at: http.11h2o.enr.state.tic.us/bittts/reports/reportsW8.Itttul
Form SWU-101 Version 07July2009 Page 3 of 7

* Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
'Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
11. How was the off -site impervious area Iisted above determined? Provide documentation. There was no off -site
Impervious Area listed above, there is none going thru site.
Proiects in Union Count. Contact DWQ Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that maybe subject to more stringent stormwater requirements as per NCAC 02B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from ht!p://h2o.erLr.state.nc.us/su/bmp—forms.htm.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from htt2:/(h2o.enr.state.nc.us/su/bmp forms.htm. The complete application
package should be submitted to the appropriate DWQ Office. (The appropriate office may be found by
locating project on the interactive online map at http://h2o.enr.state.nc.us/su/msi maps.htm.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from http://h2o.enr.state.nc.us/su/bmp_forms.htm.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. Li MS
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants A4S
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M S
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
hn://www.envhelp.org/paizes/onestopexpress.html for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/management for
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the kAU5
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations.
8. Two sets of plans folded to 8.5" x 1.4" (sealed, signed, & dated), including:
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
I. Details of roads, drainage features, collection systems, and stormwater control measures.
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
Form SWU-101 Version 07July2009 Page 4 of 6

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n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
Copy of any applicable soils report with the associated SH WT elevations (Please identifyJ�
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"01" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DWQ to verify the SHINT prior
to submittal, [phone].)
A copy of the most current property deed. Deed book: 2213 Page No.1068 lZC S
For corporations and limited liability corporations (LLC): Provide documentation from the NC #M'Sa
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and/or 3a per NCAC 2H.1003(e). The
corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
http:/ /www.secretary.state.nc.us/Corporations/CSearch.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any Iot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be
provided as an attachment to the completed and notarized deed restriction form. The appropriate deed
restrictions and protective covenants forms can be downloaded from
httD://h2o.enr.state.nc.us/su/bmo forms.htm#deed restrictions. Download the latest versions for each submittal.
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and listed
on the forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DWQ, and that they will be recorded prior to the sale of any lot.
VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
Consulting Engineer: H. Mack Summey, Jr., PE
Consulting Firm: Summey Engineering Associates, PLLC
Mailing Address: P.O. Box 968
City:Asheboro
Phone: (336 } 328-0902
Email: [e-mail]
State:NC Zip:27204
Fax:.(336 } 328-0922
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or hype name of person listed in Contact Information, item 2a) same as above , certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed in Contact Information, item 7a) with (print or hype name of organization listed in
Contact Information, item 1b) to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWU-101 Version 07July2009 Page 5 of 6

As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ immediately and submit a
completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater treatment
facility without a valid permit. I understand that the operation of a stormwater treatment facility without a valid
permit is a violation of NC General Statue 143;2,15.1 and may result in appropriate enforcement action including
the assessment of civil penalties of p 3; 0 per day, pursuant to NCCS 143-215.6.
Signature: Date: y %%
r J .
11 L - a Notary Public for the State of Yo LG2ttt , County of
do ffereby certify that &aieA o0ace-,(-ck-,-- personally appeared
before me this -L Sy of ,9011 and acknowledge the due execution of the application for
a stormwater pernliL Witness my knd and official seal,
SEAL
My commission expires (}4-45-o2.0/ 0
X. APPLICANT'S CERTIFICATION
I, (print or hfpe name of person listed in Contact Information, item 2) _P9. Cf-M G 6.4 e.e i o�J
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protective covenants will be recorded and that the proposed project complies with the requirements of the
applicable stormwater rules un4e�,15AC 2H .1000, SL 2006-246 (Ph. 11- Post Construction) or SL 2008-211.
Date: _ -? f%:2 Z/i
I, t_ a41't,� a Notary Public for the State of /V 0p2#1 daK� County of
do hereby certify that Zk personally appeared
before me this LfJay of 9,011 and acknowledge the due execution of the application for
a stormwater permit. Witness my and and official seal,
SEAL
My commission expires D 14 — D
Form SWU-101 Version 07July2009 Page 6 of 6

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Application Completeness Review
ar/ First Submittal ❑ Re -submittal Date Received: +p 2- Date Reviewed: 9 /z- By Bill Diuguid�
Development/Project Name: C 2 e v�' / rA a bo
Receiving stream name U4- -1 o #./c j, Ceg F_IG Classification: ____. G
Ziver Basin:
For post-constvGction requirements, a program will be deemed compliant for the areas where it is
implementing any of the following programs: WS-1, WS-II, WS-III, WS-IV, HQW, ORW, Neuse River Basin
NSW, Tar -Pamlico River Basin NSW, and the Randleman Lake Water Supply Watershed Nutrient
Management Strategy.
High Density Projects that require a 401/404 within an NSW require 85% TSS, 30% TN and 30% TP removal.
T&E Species (Goose Creek, Waxhaw Creek or Six Mile Creek Water Sheds): 6�IA
Latitude and Longitude: 35 2d _I
Latitude -79 �Z /Z k/ J u ri sd icti o n,4 s/yF g re P reAA/peLM
Project Address: /341- ,Al. E RR S`I`iCEF T__ _
Engineer name and firm: -5,
Phone: 33 -3ZB - 0902, Email: AWA c. _ _5Hf-Bono, Com
Is the project confirmed to be in the State MSI Stormwater Permit jurisdiction? 2'Yes
❑ Low Density (no curb and gutter) ❑ Low Density with curb and gutter outlets �an�d
❑ Other
�f A � 401/404 impacts to surface waters, wetlands, and buffers (add language to cover 4letternfo letter)
�/'BUA Z5, °7o
Check for $505.00 included
riginal signature (not photocopy) on application
Legal signature (Corporation-VP/higher, Partnership -General Partner/nigher, LLC-member/manager, Agent).
Check spelling, capitalization, punctuation: littp://%vww.secretary.state.nc.us/corporations/thepage.aspx
If an agent signs the application, a signed letter of authorization from the applicant must be provided which
includes the name, title, mailing address and phone number of the person signing the letter.
❑ or subdivided projects, a signed and notarized deed restriction statement
Baled, signed & dated calculations
Correct supplement and O&M provided for each BMP on site (check all that were provided & number of each)
❑ Bioretention
❑ Dry Detention Basin
Filter Strip
❑ Grass Swale
❑ Infiltration Basin
❑ Infiltration Trench
❑ Level Spreader
❑ Permeable Pavement
❑ Restored Riparian Buffer
❑ Rooftop Runoff Management
Ui'Sand Filter
❑ Stormwater Wetland
❑ Wet Detention Basin
❑ Low Density
❑ Curb Outlet
❑ Off -Site
❑ NCDOT Linear Road
Two sets of sealed, signed & dated layout & finish grading plans with appropriate details
r►" Narrative Description of stormwater management provided
&(� Soils report provided
Npdi� a- Wetlands delineated or a note on the plans or in the accompanying documents that none exist on site and/or
h,rpl,ltulf adjacent property
V' Details for the roads, parking area, cul-de-sac radii, sidewalk widths, curb and gutter;
Dimensions & slopes provided
Vrainage areas delineated ❑ Pervious and impervious reported for each ❑ Areas of high density
MP operation and maintenance agreements provided
V,-'Application complete ❑ Application Incomplete Returned: (Date)
Comments
May 5, 2011 Revision, Bill Diuguid

SL 2006-246 Section 9 Post Construction Requirements for Non -Coastal Counties
Low-densitv oroiects
❑ No more than two dwelling units per acre or 24% built -upon area;
❑ Vegetated conveyances to the maximum extent practicable;
❑ Built -upon areas at least 30 feet landward of perennial and intermittent surface waters;
❑ Deed restrictions, protective covenants, and/or other restrictive language/measures.
Hiqh density protects
❑ Control and treat runoff from the first one -inch of rain.
❑ Runoff volume drawdown time must be a minimum of 48 hours, but not more than 120 hours;
❑ Discharge the storage volume at a rate equal to or less than the predevelopment discharge rate for the
one-year, 24-hour storm.
❑ Achieve 85% average annual removal of total suspended solids.
❑ For BMPs that require a separation from the seasonal high-water table (SHWT), the separation shall include
at least 12 inches of naturally occurring soil above the SHWT.
❑ Stormwater management measures must comply with the General Engineering Design Criteria For All
Projects requirements listed in 15A NCAC 2H .1008(c);
❑ All built -upon areas are at least 30 feet landward of perennial and intermittent surface waters;
❑ Deed restrictions, protective covenants, and/or other restrictive language/measures
❑ Provide a mechanism to require long-term operation and maintenance of Best Management Practices
Goose Creek, Six Mile Creek and Waxhaw Creek Watersheds
Buffer Requirements
❑ Undisturbed riparian buffers within 200 feet of water bodies within the 100-Year Floodplain and within 100 feet
of water bodies that are not within the 100-Year Floodplain. Exceptions to the undisturbed buffer
requirements are set forth in 15A NCAC 02B .0607
Stormwater Controls as required by 15A NCAC 02B .0602
❑ Control and treat the difference between the pre -development and post -development conditions for the one-
year, 24-hour storm with structural controls.
❑ Development and redevelopment shall implement stormwater management measures that promote infiltration
of flows and ground water recharge for the purpose of maintaining stream base flow.
❑ 85% average annual removal of total suspended solids.
❑ Draw down the treatment volume no faster than 48 hours, but no slower than 120 hours, for detention ponds.
❑ Discharge the storage volume at a rate equal or less than the pre -development discharge rate for the one-
year, 24-hour storm.
❑ Meet design or stormwater management measures set forth in 15A NCAC 2H .1008.
High Density Projects that require a 401/404 within an NSW
❑ 85% TSS
❑ 30% TN
❑ 30% TP
May 5, 2011 Revision, Bill Diuguid