WQ0041419_Application (FTSE)_20200114

State of North Carolina
DWR Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: i_o' 1 I III (to be compieted by DWR)
All items nmst be completed or the `a`n`olliiccation will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: The Grand at Union Cross. LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ® Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Chris Parr per 15A NCAC 02T .0106(b)
Title: Manager
NC Department of
4. Applicant's mailing address: P.O Box 10888 Environmental Quality
City: Greensboro State: NC Zip: 27404-Received_
5. Applicant's contact information: JAN 14 2020
Phone number: 3( 36) 382-4523 Email Address: [e-mail] Winston-Salem
II. PROJECT INFORMATION: Regional Office
1. Project name: The Grand at Union Cross
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: W000_ and issued date: _
If new construction but part of a master plan, provide the existing permit number: W000_
3. County where project is located: Forsyth
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.0781' Longitude:-80.1105°
5. Parcel ID (if applicable): 6874-19-6243.00
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Barret Hagen License Number: 30469
Firm: Hagen Engineering, PA
Mailing address: 3859 Battleground Ave Suite 300
City: Greensboro State: NC Zip: 27410-_
Phone number: 3( 36) 286-3350 Email Address: tshaw(a),hagen-eng.com
IV. WASTEWATER TREATMENT FACILITY (W WTF) INFORMATION:
I. Facility Name: Archie Elledge Permit Number: NCO037834
Owner Name: Winston Salem Forsyth County Utility Commission
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ_ Downstream (Receiving) Sewer Size: _ inch
System Wide Collection System Permit Number(s) (if applicable): WQCS_
Owner Name(s):
FORM: FTA 04-16 Pagel of 5

V1. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes [:]No ®N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑No ®N/A
3. If the Applicant is a Home/Property Owners' Association, has an Operational Agreement (FORM: HOA) been attached?
❑ Yes [-]No ®N/A
4. Origin of wastewater: (check all that apply):
❑ Residential Owned ❑ Retail (stores, centers, malls) ❑ Car Wash
® Residential Leased ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ® Swimming Pool /Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic/Commercial % Commercial
_ % Industrial (See 15A NCAC 02T .0I03(20))
"Is there a Pretreatment Program in effect? ❑ Yes ® No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ❑ No
➢ If Yes, provide a cony of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow',b
No. of Units
Flow
1 Bedroom Unit Multi -family
240 gal/day
96
23040 GPD
2 Bedroom Unit Multi -family
240 gal/day
152
36480 GPD
3 Bedroom Unit Multi -family
240 gal/day
24
5760 GPD
Clubhouse Employees
25 gal/day
4
100 GPD
Swimming Pool
10 gal/day/person
50
500 GPD
gal/
GPD
Total
65,880 GPD
a See 15A NCAC 02T .0114(b), (d), (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use areas;
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 65,880 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain): _
FORM: FTA 04-16 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 780 DIP
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirement is not allowed and a violation of the MDC
Vill. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
I. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -
3. Design flow of the pump station: _ millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): _ gallons per minute at _ feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(B).'
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including ravel timeframes, shall be provided
in the case of a multiple station power outage.
FORM: FTA 04-16 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(f) & (g)
D 1 SA MCAC 02T 0105rtl enntnins minimum senarations that shall he nrovided for sewer systems:
. ---------- ------------
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
24 inches
Water mains vertical -water over sewer including in benched trenches
18 inches
Water mains(horizontal)
10 feet
Reclaimed water lines vertical - reclaimed over sewer
18 inches
Reclaimed water lines horizontal - reclaimed over sewer
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water
100 feet
**Waters classified WS (except WS-1 or WS-V), B, SA, ORW, HQW, or SB from normal
high water or tide elevation and wetlands see item IX.2
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade vertical
36 inches
➢ 15A NCAC 02T.0305(e) contains alternatives where separations in 02T.0305(fl cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webuaee
➢ If noncompliance with 02T.0305(f) or (g), see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ❑ Yes ❑ No ®N/A
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes ❑ No ® N/A
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ❑ Yes ® No
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 & Buffer PermittingBranch
ranch
5. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes [-]No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater management plans, etc.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02T.0402, "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ® No ❑ N/A
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and inspections
documented per 15A NCAC 02T.0403(a)(5) or the permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

Ij5_)(o 2ece i'VCA 1/Zk /Z.o
x CERTIFICATIONS,
1. Does the su mitted system comply with 1 A N AC
and Fon_.Mains ( lei"-stversion) atad thew
® Yes
2.
If No, c
review.
has been
submittal
■
for
that this application for
d by me and is accurate, complete and consistent with the information supplied in the plans, specifications,
ladon% and all other supporting documentation to the best of my knowledge. I further attest that to the best
p the proposed design has been prepared in accordance with the applicable regulations, Gravity Sewer
Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track permitting
and Force Mains (latest version). Although other professionals may have developed certain portions of this
e, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
he consistent with the proposed design.
NOTE - In accordance with General Statutes 143-215.6A and 143-215.6B,
statement, ;representation, or certification in any application package shall be
include a fine not to exceed S10,000, as Well as civil penalties up to $25,000 pe
North Carolina Professional Engineer's seal, signature, and date,
3. AppliMt!s
1,
02T A106(b):
has been reviewed by me and is accurate and complete to the best
this application are not completed and that if all required suppae
application package is subject to being returned as incomplete. I
discharge system to surface waters or the land will result in an iml
injunctive relief, and/or criminal prosecution. 1 will make no clam
of this pennit be violated. 1 also understated that if all requited pt
all requited supporting information and attachments are not knt
incomplete.
tes -21 and 14 -21 .6N any pets°n who knowingly makes any faks8
any application package shall be guilty of a Class 2 misdemeanor, which may
as civil penalties up to $2$,000 per violation.
who knowingly makes any false
2 misdemeanor, which may
Fje,Glt oo`O
rRF7' A.
that this application for
NOTE - in accordance with General State
statement, representation, or certification in
include a fine not to exceed $10,000 as well
FORM: FTA 04.16
I understand that if all required parts of
and attachmems are not included, this
be retuned to me as
page 5 of 5

HAGEN 3859 Battleground Ave, Suite 300 Phone: [phone]
ENGINEERING, PA Greensboro, NC 27410 [e-mail]
Winston Salem Regional Office
Water Quality Section
450 W. Hanes Mill Road, Suite 300
Winston Salem NC 27105
336-776-9800
RE: The Grand at Union Cross Apartments
Fast Track Sewer Extension
Private Sewer Permit
Cover Letter
January 6, 2020
NC Department of
Environmental Quality
Received
BAN 14 2020
Winston-Salem
Regional Office
The purpose of this cover letter is to outline the contents of this Private Sewer Permit
application package as well as to provide of a summary of the project to which is pertains. This
Grand at Union Cross development is a 272 unit multifamily complex, with a pool, clubhouse,
and cabana, which will require an estimated peak flow of 65,880 GPD for utility consumption. In
terms of private sewer mains, this project will be comprised of 780 LF of 8" DIP. Within this
submittal package you will find the following items:
1) $480 check made payable to NCDEQ
2) Two copies of the North Carolina Secretary of State Documentation
3) One completed & one copy of the DWR Fast Track Sewer System Extension application
4) Two 8.5 x 11" USGS Topo Map
5) Two street level map (aerial)
6) Two copies of Flow Tracking Form
Thank you,
Tim Shaw, EIT
Hagen Engineering, PA
336-286-3350

Division of water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: The Grand at Union Cross LLC
Project Name for which flow is being requested: 12429 The Grand at Union Cross
More that one FTSE pray be rerlydred for a single project if the owner of the WWTP is not responsible for all primp
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: ARCHIE ELLEDGE
b. WWTP Facility Permit #: NC0037834
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
30.000000
1.929939
19.660000
0.065880
21.655819,
72.2%
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A)
Design
Pump
Pump
Average
Station
Station
Finn
Daily Flow**
(Name or
Permit
Capacity, *
(Firm / pt),
Number)
No.
MGD
MOD
South Fork
14.400000
14.400000
(B)
(C)
(D)=(B+C)
Obligated,
Approx.
Not Yet
Total Current
Current
Tributary
Flow Plus
Avg. Daily
Daily Flow,
Obligated
Flow, MGD
MGD
Flow
6.733753
0.192494
6.926247
(E)=(A-D)
Available
Capacity***
7.473753
4 The South Fork Lift Station operates as a basin transfer station. Staff is capable of allowing peak flows to bypass the station and flow to the Lower
Muddy Creek WWTP by gravity. Therefore, no peaking factor is used when determining design average daily flow.
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped now
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a pealing factor
(pi) not less than 2.5, per Section 2,02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is <0.
Downstream Facility Name (Sewer): Archie Elledge
Downstream Permit Number: WQCS00003
Page 1 of 6
FTSE 10-18

III. Certification Statement:
Fot2
I Courtney Driver, P.E. certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Title of Signing Official
Page 2 of 6
/OlZa2c�
Date
FTSE 10-18

-70
Z1 J
�OF W ATF9Q - Michael F. Easley, Governor
`O G Wilfiam G. Ross Jr., Secretary
ai r North Carolina Department of Environment and Natural Resources
O � Alan W. Klimek, P.E., Director
Division of Water Quality
July 28, 2005
Ron Hargrove, PE, Deputy Utilities Director
City/County Utilities
Utilities Administration
PO Box 2511
Winston-Salem, NC 27102
- — - -- -
-" Stibjeoti - - City of Winston-Salem
Residential Flow Reduction Approval
Forsyth County
Dear Mr. Hargrove:
On June 29, 2005, the Division of Water Quality received a flow reduction request for residences
connecting to the Winston-Salem collection system. The letter requests an allowable flow rate of 240 GPD per
single-family residential unit (three bedroom) based on the evaluated data for the current service area. As you
are aware, the issue of an approved flow reduction has been outstanding for quite some time. We appreciate
your assistance and patience in the matter and are pleased to offer a resolution.
The methodology and data evaluated for this request was discussed with you and your staff, regional
office staff and central office staff during a meeting on June 14, 2005. The evaluation included data collection
from tax records (age and bedrooms) and utility billing (water consumption) and DMR records for the treatment
plants. Based upon this data and with concurrence from our Winston-Salem Regional Office, the Division
hereby approves the use of 240 GPD per single-family residential unit (up to three bedrooms) in all applicable
non -discharge permit applications whether issued by the Division or through your delegated sewer extension
permit program. This value shall be incremented by 80 gpd per additional bedroom above three.
Regardless of the adjusted design daily wastewater flow rate at no time shall the wastewater flows
exceed the effluent limits defined in the NPDES permits for the treatment facilities or exceed the cWaclty of the
sewers downstream of any new sewer extension or service connectioni
if you have any questions or comments regarding this matter, please contact Marie Doklovic at
[phone] ext. 371.
Sincerely,
�
(-Alan
tan W. Klimek, P.E.
T,
cc: Steve Tedder, Winston-Salem Regional Office
Charles Weaver,NPDES West Program
PERCS Flow Reduction File
One L� Pretreatment, Emergency Response and Collection Systems Unit Internet hltpINo.encncstalemandpu
NO llCarohna 1617 Mail Service Center, Raleigh, NC 27699-1617 An Equal Opportunity Acton Employer
n��y��//� Telephone [phone] Fax [phone]%recycled/10% post -consumer paper

0%' `i.'5 AMENDED LIMITED LIABILITY COMPANY ANNUAL REPORT
■
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NAME OF LIMITED LIABILITY COMPANY: The Grand at Union Cross, LLC
SECRETARY OF STATE ID NUMBER: 1282318
REPORT FOR THE CALENDAR YEAR: 2019
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: Chris Parr
STATE OF FORMATION: NC
❑j
2. SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
1813 Pembroke Rd Suite F
1813 Pembroke Rd Suite F
Greensboro, NC 27408-7916 Guilford Greensboro, NC 27408-7916 Guilford
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Apartment Rentals
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL:
4. PRINCIPAL OFFICE STREET ADDRESS 5. PRINCIPAL OFFICE MAILING ADDRESS '0
o..
1813 Pembroke Rd Suite F 1813 Pembroke Rd Suite F
Greensboro, NC 27404-0888 Guilford Greensboro, NC 27404-0888 Guilford
6. Select one of the following if applicable. (Optional see instructions)
❑ The company is a veteran -owned small business
❑ The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: Chris Parr NAME:
TITLE: Member TITLE:
ADDRESS:
1813 Pembroke Suite F
Greensboro, NC 27408 Guilford
ADDRESS:
NAME:
TITLE:
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT, Section D must be completed in its entirety by a person/business entity.
SIGNATURE
Form must be signed by a Company Official listed under Section C of This form.
Print or Type Name of Company
Print or Type Title of Company Official
SUBMIT THIS ANNUAL REPORT WITH THE REQUIRED FILING FEE OF $10.00
MAIL TO: Secretary of Stale, Business Registration Division, Post Office Box 29525, Raleigh, NC 27525-0525

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