WQ0041797_Application (FTSE)_20200707

LATHAM-WALTERS ENGINEERING, INC.
16507-A Northcross Drive Uapari,��ent o`
Huntersville, North Carolina 28078 Environmental Quality
Ph [phone] Fax [phone] Received
[e-mail]
,,.,A• 0 9 zi to
LETTER OF TRANSMITTAL Winston-Salem
Regional Ofnce
To: NCDEO -Division of Water Resources
Winston-Salem Regional Office
Address: 450 W. Hanes Mill Rd., Suite 300
Winston-Salem, NC 27105
Job No.: 2019.28
From: Meredith Hammill
Date: July 7, 2020
Re: Meadowlands — Chestnut Hills Section 2
We are sending you: X attached
via
The following items:
specifications
under separate cover
copy of letter _xsubmittal package
Copies
Date
No.
Description
1
7/l/20
5
Fast Track Sewer Application modification request)
1
7/l/20
1
$480 application fee check payable to NCDE
1
4/15/20
1
Meadowlands Development, LLC Annual Report filed w/ SoS
1
7/l/20
2
FTSE from the City of WS
1
6/3/20
2
FTSE for Meadowlands PS's
1
2020
1
8.5xl l color 7.5 min. USGS To o with site and waterbodies
1
2020
1
8.5x11 street level ma
1
11/22/05
5
CPCN for Meadowlands Development, LLC
1
6/19/20
1
Flow allocation letter from Davidson Co.
1
6/25/20
1
Flow acceptance letter from the City of WS Utilities
1
2/28/05
1
Flow reduction approval letter
THESE ARE TRANSMITTED as checked below:
✓ For approval o Approved as submitted
o For your use o Approved as noted
o As requested o Returned as corrections
o For review and comment o Forms for signatures & submittal
Remarks:
Meadowlands Development, LLC is requesting a permit for "Meadowlands — Chestnut Hills
Section 2". This section consists of 16 lots @ 300 gpd for a total flow of 4800 gpd. The project
is located in Davidson Co. but effluent will be treated at the Archie Elledge WWTP, owned by
Winston / Forsyth Utility Commission. A flow reduction letter for Meadowlands is attached, as
is a flow acceptance letter from the City of WS. A flow allocation from Davidson Co. is also
attached. If you have any questions please do not hesitate to call. [phone] —
Meredith Hammill

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 INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, 15A
NCAC 02T,15A NCAC 02T .0300, Division policies and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that require an environmental assessment in accordance with 15A NCAC 1 C .0100;
➢ Projects that do not meet any part of the minimum design criteria (MDC) document;
➢ Projects that involve a variance from the requirements of 15A NCAC 2T;
➢ Pressure sewer systems utilizing septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General- When submitting an application, please use the following instructions as a checklist in order to ensure all required items
are submitted. Adherence to xhese instructions and checking the provided boxes will help produce a quicker review time and
reduce the amount of requested additional information. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit
one original and one copy of the application and supporting documentation.
A. One Original and One Copy of Application and Supporting Documents
® Required unless otherwise noted
B. Cover Letter (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
® Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
Q
Fast Track (Form: FTA 04-16) Application (Required for All Application Packages):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
® If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary of State.
If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
® The Project Name in Item II.I shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b).
Per 15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is
provided from a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 1 of 3

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
E Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one
year prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-
215.67 a .
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
E Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project
area and closest surface waters.
➢ Location of the project (gravity sewer, pump stations & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
E Include a street level map (aerial) showing general project area so that Division staff can easily locate it in the field.
G. Existing Permit (All Modification Packages):
❑ Submit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible
with the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed
contractor, stating that "the portable power generation unit or portable, independently -powered pumping units, associated
appurtenances and personnel are available for distribution and operation of this pump station."
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump
stations' storage capacities and the rotation schedule of the portable power source or pump, including travel
timeframes, shall be provided in the case of a multiple station power outage. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
E Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by
the sewer extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area or that
franchise approval is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
Home/Properly Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS.
COUNTIES SERVED
Asheville Reaional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Favetteville Regional Office
225 Green Street Suite 714
Anson, $laden, Cumberland, Harnett, Hake,
Water Quality Section
Fayetteville, North Carolina 28301-5094
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Reaional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredelli Lincoln, Mecklenburg, Rowan,
[phone]
Stanly; Union
[phone] Fax
Raletah Realonal.Office
1628 Mail Service Center
.Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27699-1628
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washinaton Reaional Office
943 Washington Square Mall
Beaufort, Bartle, Camden, Chowan, Craven,
Water Quality Section
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans; Pitt, Tyrrell, Washington, Wayne
Wilminaton Reaional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pander
[phone]
[phone] Fax
Winston-Salem Reaional Office
450 W. Hanes Mill Road
Suite 300
Alamance, Allegheny, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Water Quality Section
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR FORM: PTA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 3

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:
(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1.
Applicant's name: Meadowlands Development. LLC (company, municipality, HOA, utility, etc.)
2.
Applicant type: ❑ Individual ® Corporation ❑ General Partnership
❑ Privately-OwnedPublic Utility
❑ Federal ❑ State/County ❑ Municipal
❑ Other
3.
Signature authority's name: C:J. Ram ev per 15A NCAC 02T .0106(b)
f`.;a. Department or'
Title: Managing Partner
Environmental Quality
Received
4.
Applicant's mailing address: P.O. Box 10
City:Bethania State: NC Zip:27010-
':; L d 91
5.
Applicant's contact information:
Winston-Salem
Phone number: M6) 922-4000 Email Address: [e-mail]
Regional Office
H. PROJECT INFORMATION:
1. Project name: Meadowlands - Chestnut Hills Section 2
2. Application/Project status: ED 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: Davidson
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.01069P Longitude:-80.167593'
5. Parcel ID (if applicable): 6852-04-63-5379
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: James L. Walters License Number: 18584
Finn: Latham -Walters Engineering,Inc.
Mailing address: 16507-A Northcross Drive
City: Huntersville State: NC Zip: 28078
Phone number: 704) 895-8484 Email Address: jim[7a,lwengineencom
IV. WASTEWATER TREATMENT FACILITY (W WTF) INFORMATION:
1. Facility Name: Archie Elledee W WTF Permit Number: NC 0037834
Owner Name: Winston-Salem / Forsyth County Utility Commission
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than W WTF):
1. Permit Number(s): W00031015 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS00003
Owner Name(s): Winston-Salem / Forsyth County Utility Commission
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 .0103(20))
►,Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(fl? ®Yes ❑ No
➢ If yes, provide a cony of flow reduction approval letter
7. Summarize wastewater generated by project:
a
Establishment Type (see 02T.01140
Daily Design Flow a,b
No. of Units
Flow
Residential - Single Family
300 gal/unit
16
4800 GPD
gall
GPD
gal
GPD
gal
GPD
gal/
GPD
gal
GPD
Total
4800 GPD
a See 15A NCAC 02T .0114(b), (d),(e)(1and (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-4I.
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.
Wastewater generated by project: 12,M GPD (per ISA 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
1125
PVC
8
90
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
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: _
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) I Length (feet) I 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)(I)(C)'
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry -15A NCAC 02T .0305(h)(1)(C):
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
in the case of a multiple station power outage,
FORM: FTA 04-16 Page 3 of 5

IX. SETBACKS & SEPARATIONS - (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T,0305(f) & (e)
➢ 15A NCAC 02T.0305(fl contains minimum senarations that shall be provided for sewer systems:
0 Yes [-]No
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 drinkingwater
100 feet'
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water or tide elevation and wetlands see item IX.2
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade vertical
36 inches
15A NCAC 02T.0305(u) contains alternatives where separations in 02T.0305 cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications weboaee
➢ If noncompliance with 02T.0305(f) or W. 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)(61(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.04021 "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

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents for
review. Approval of the request is required prior to submittal of the Fast Track Application and supporting documents
2. Professional Engineer's Certification:
James L. Walters, P.E. attest that this application for
(Professional Engineer's name from Application Item III.1.)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans, specifications,
engineering calculations, and all other supporting documentation to the best of my knowledge. I farther attest that to the best
of my knowledge the proposed design has been prepared in accordance with the applicable regulations, Gravity Sewer
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6E, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
1, C.J. Ramey attest that this application for
(Signature Authority's name & title from Application Item I.3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that any discharge of wastewater from this non -
discharge system to surface waters or the land will result in an immediate enforcement action that may include civil penalties,
injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition
of this permit be violated. I also understand that if all required parts of this application package are not completed and that if
all required supporting information and attachments are not included, this application package will be returned to me as
incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6E, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: - /" Date:
FORM: FTA 04-16 Page 5 of 5

r'r.3` LIMITED LIABILITY COMPANY ANNUAL REPORT ■
INl0V
NAME OF LIMITED LIABILITY COMPANY: Meadowlands Development, LLC
SECRETARY OF STATE ID NUMBER: 0670719
REPORT FOR THE CALENDAR YEAR: 2020
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: RAMEY. C J
2. SIGNATURE OF THE NEW REGISTERED AGENT:
STATE OF FORMATION: NC
E - Filed Annual Report
5/2020 09:45
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
5121 North Causeway Drive 5121 North Causeway Drive
Winston Salem, NC 27106-9695 Forsyth County Winston Salem, NC 27106-9695
SECTION B:
1. DESCRIPTION OF NATURE OF BUSINESS: Real Estate Development
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS 5. PRINCIPAL OFFICE MAILING ADDRESS
5121 North Causeway Drive 5121 North Causeway Drive
Winston Salem, NC 27106-9695 Winston Salem, NC 27106-9695
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: Hubbard Realty of Winston Salem Inc NAME: The Sherwood Company NAME: C J Ramey
TITLE: Manager TITLE: Manager TITLE: Manager
ADDRESS: ADDRESS: ADDRESS:
2110 Cloverdale Ave 5446 University Pkwy 5121 North Causeway Drive
Winston Salem, NC 27103 Winston Salem, NC 27105 Winston Salem, NC 27106
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
C J Ramey 4/15/2020
SIGNATURE DATE
Farm must be signed by Company Official listed under Section C of This form.
CJ Ramey Manager
Printer Type Name of Company Official Print or Type Title of Company Official
This Annual Report has been filed electronically.
MAIL TO: Secretary of State, Business Registration Division, Past Office Box 29525, Raleigh, NO 27626-0525

W�-- # � State of North Carolina
Department of Environmental Quality
v m, Division of Water Resources
Division of Watee ftesomces Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Meadowlands Development, LLC
Project Name for which flow is being requested: 12454,Meadowlands-Chestnut Hills,Sec2
More than one FTSE may be requiredfor a single project if the owner of the WWTP is not responsible far all proup
statlons 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 #: NCO037834
All flotps are in MGD
c.
WWTP facility's permitted flow
30.000000
d.
Estimated obligated flow not yet tributary to the WWTP
2.052116
c.
WWTP facility's actual avg. flow
19.320000
f.
Total flow for this specific request
0.004800
g.
Total actual and obligated flows to the facility
21.376916
h.
Percent of permitted flow used
71.3%
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)
(B)
(C)
(D)=(B+C)
(F)=(A-D)
Design
Obligated,
Pump
Pump
Average
Approx.
Not Yet
Total Current
Station
Station
Firm
Daily Flow**
Current
Tributary
Flow Plus
(Name or
Permit
Capacity, *
(Firm / pt),
Avg. Daily
Daily Flow,
Obligated
Available
Number)
No.
MGD
MGD
Flow, MGD
MGD
Flow
Capacity***
South Fork
14.400000
14.400000
6.733753
0.173144
6.906897
7.493103
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 W WTP by gravity. Therefore, no peaking factor is used when determining design average dally flow.
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow
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 peaking factor
(pl) 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 i of 6
FTSE 10-18

III: Certification Statement:
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 haVdSRu ate capacity to transport and treat the proposed new wastewater.
Signing
Title ofSikzning-0fficial
Page 2 of 6
Date
FTSE 10-18

1,,
y
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: Meadowlands Development, LLC
Project Name for which flow is being requested: Meadowlands -Chestnut Hills Section 2
More than one FTSE may be required far a single project if the owner of the WWTP is not responsible forall pump
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: _
b. WWTP Facility Permit #:
All flows are in MGD
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
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:
Pump
Pump
Station
Station
(Name or
Permit
Number)
No.
(A)
(B)
Design
Average
Approx.
Daily
Current
Finn Flow*"
Avg. Daily
Capacity, " (Firm / po,
Flow,
MGD MGD
MGD
Main#1 WQ0024206 0.496 0.1984
(C)
(D)=(B+C)
Obligated,
Not Yet
Total Current
Tributary
Flow Plus
Daily Flow,
Obligated
MGD
Flow
(E)=(A-D)
Available
Capacity***
.0086 .0608 0.0694 0.1290
PS #2 WQ0024206 0.202 0.0808 .0030 .0228 0.0258 0.0550
* 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 peaking factor
(pf) 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

Ill. Certification Statement:
James L. Walters, 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 1 and 11 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.
v
Title of Signing
Date
Page 2 of 6
FTSE 10-18

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STATE OF NORTH CAROLINA
UTILITIES COMMISSION
RALEIGH
DOCKET NO. W-1259, SUB 0
BEFORE THE NORTH CAROLINA UTILITIES COMMISSION
In the Matter of
Application by Meadowlands Development, LLC, Post )
Office Box 10, Bethania, North Carolina 27010, fora ) ORDER GRANTING
Certificate of Public Convenience and Necessity to ) FRANCHISE AND
Provide Sewer Utility Service in Meadowlands ) APPROVING RATES
Subdivision in Davidson County, North Carolina, and )
for Approval of Rates }
BY THE COMMISSION: On July 25, 2005, Meadowlands Development, LLC
(Meadowlands or Applicant), filed an application with the Commission seeking a sewer
utility franchise for Meadowlands Subdivision in Davidson County, North Carolina, and for
approval of rates. The Applicant states that no customers are being served, and no other
person or utility seeks to provide the proposed service. The Applicant expects eventually
to serve 170 customers in Meadowlands Subdivision.
On the basis of the verified application and the records of the Commission, the
Commission makes the following
FINDINGS OF FACT
1. Meadowlands is properly before the Commission, seeking a Certificate of
Public Convenience and Necessity pursuant to G.S. 62-110(a) to provide sewer utility
service in Meadowlands Subdivision in Davidson County, North Carolina. This is the first
franchise sought by Meadowlands.
2. The service area covered is shown on the September 23, 2005, map drawn
by COE Forestry & Surveying and filed October 7, 2005. The area includes 170 lots in
various sections of Meadowlands Subdivision, including 42 lots in the Inverness section,
27 lots in the Medinah section, 38 lots in the Wakefield section, and 63 lots in the
Southern Woods section.
3. The Public Staff has recommended that Meadowlands be required to post a
$10,000.00 bond for Meadowlands Subdivision. Meadowlands has filed the required bond.
4. Meadowlands has the technical, managerial, and financial capacity to
provide sewer utility service in this new franchise area.

5. Meadowlands has filed all exhibits required with the application.
6. Davidson Water Company, Inc. (Davidson Water), a nonprofit membership or
consumer -owned corporation exempt from Commission regulation, will provide water
service in the Meadowlands Subdivision. Davidson Water will handle Meadowlands'
sewer billing services. Meadowlands intends to eventually turn the sewer system over to
the Homeowners Association.
7. The Meadowlands will purchase bulk wastewater treatment service from the
City of Winston-Salem.
S. On August 11, 2004, the NC Department of Environment and Natural
Resources, Division of Water Quality (DWQ), issued a Wastewater Collection System
Extension Permit No. WQ0024206 approving an eight (8) inch gravity sewer of
approximately 10,450 feet, and two (2) pump stations to serve 170 single-family
residences.
9. The $42.00 flat monthly sewer rate proposed by Meadowlands is reasonable
and should be approved.
10. Meadowlands proposed a flat monthly residential sewer rate of $42.00, a
reconnection charge of $50.00, and a tap -on fee of $500.00.
11. The $50.00 reconnection charge proposed by Meadowlands exceeds the
$15.00 reconnection charge set forth in Commission Rule R10-16(e). Meadowlands has
not proved cost justification for a reconnection charge in excess of $15.00 and has agreed
to accept the $15.00 connection charge.
12. The cost of the sewer system is being entirely recovered through the sale of
lots. Meadowlands withdrew the request for a tap -on fee.
Based upon the foregoing, the Commission is of the opinion that the $10,000 bond
and surety filed by Meadowlands should be accepted and approved, that the sewer utility
franchise requested by Meadowlands for Meadowlands Subdivision should be approved,
and that the recommended rates should be approved.
IT IS, THEREFORE, ORDERED as follows:
1: That the letter of credit filed in this proceeding, as surety for the bond in the
amount of $10,000 required by the Commission, is hereby accepted and approved.
2. That Meadowlands Development, LLC, is granted a certificate of public
convenience and necessity to provide sewer utility service in Meadowlands Subdivision, in
Davidson County, North Carolina. The franchise service area covers 170 lots shown on
the map filed with the Commission on October 7, 2005.

3. That Appendix A constitutes the Certificate of Public Convenience and
Necessity.
4. That the Schedule of Rates attached hereto as Appendix B is approved, and
deemed filed with the Commission pursuant to G.S. 62-138.
5. That Meadowlands shall maintain its books and records so that all
information required in the prescribed annual report to the Commission will be readily
identified from its books and records.
V12105.02
ISSUED BY ORDER OF THE COMMISSION.
This the 22nd day of November, 2005.
NORTH CAROLINA UTILITIES COMMISSION
/
fl" da-
Patricia Swenson, Deputy Clerk
3

STATE OF NORTH CAROLINA
UTILITIES COMMISSION
RALEIGH
Vaaq,1U1EI_\
DOCKET NO. W-1259, SUB 0
BEFORE THE NORTH CAROLINA UTILITIES COMMISSION
MEADOWLANDS DEVELOPMENT, L LC
is granted this
CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY
to provide sewer utility service
i
in
i
MEADOWLANDS SUBDIVISION
(including the following sections)
SECTION LOTS
Inverness 42
Medinah 27
Wakefield 38
Southern Woods 63
Davidson County, North Carolina
subject to any orders, rules, regulations,
and conditions now or hereafter lawfully made
by the North Carolina Utilities Commission.
ISSUED BY ORDER OF THE COMMISSION.
This the 22nd day of November, 2005.
NORTH CAROLINA UTILITIES COMMISSION
Patricia Swenson, Deputy Clerk

APPENDIX B
SCHEDULE OF RATES
for
MEADOWLANDS DEVELOPMENT. LLC
for providing sewer service in
MEADOWLANDS SUBDIVISION
Davidson County, North Carolina
Sewer Utility Service:
Flat monthly residential rate $42.00
Reconnection Charges:
If sewer service is cutoff by utility for good cause $15.00
If sewer service cut off by utility at customer's request $15.00
Bills Due: On billing date
Return Check Fee: $25.00
Bills Past Due: 15 days after billing date
Billing Freauencv: Shall be monthly for service in arrears
Finance Charge for Late Payment: 1 % per month will be applied to the unpaid
balance of all bills still past due 25 days after the
billing date
Issued inAccordance with Authority Granted by the North Carolina Utilities Commission in
Docket No. W-1259, Sub 0, on this the 22nd day of November, 2005.

d`�c�Ory C�6
oP 2<
SST V ^0NN
9d<ISHED
DAVIDSON COUNTY PLANNING DEPARTMENT
GOVERNMENTAL CENTER
913 GREENSBORO STREET
POST OFFICE BOX 1067.
LEXINGTON, NORTH CAROLINA 27293-I067
GUY L. CORNMAN, III
PLANNING DIRECTOR
Tune 19, 2020
James L. Walters, PE
Latham -Walters Engineering, Inc.
16507-A Northcross Drive
Huntersville, NC 28078
Re: Flow Allocation, Meadowlands —Chestnut Hills, Section 2
Mr. Walters:
PHONE NUMBER: 336-242-2220
In response to your request for sewer allocation for Section 2 of Chestnut Hills in the
Meadowlands, please accept this letter as confirmation that Davidson County will allocate
4,800 gallons per day from the original 216,000 gpd allocated for the Meadowlands. Chestnut
Hills Section 2 will contain 16 lots with a flow of 300 gpd each, totaling 4,800. Davidson County
will continue to monitor the overall allocation for the Meadowlands to insure the total does not
exceed 216,000gallons per day.
If you have any questions regarding this letter or its content, please contact me through this
office by calling 336-242-2229.
Sincerely,
Scott Leonard
Davidson County Planner

Winston-Salem /Forsyth County
Utilities
Water •Wastewater •Solid Waste
Administration, P.O.. Box2511, Winston-Salem, NC 27102
0: 336-727-8000, F: 336-727.8432, wskutilities.org
June 25, 2020
Mr. Scott Leonard
913 Greensboro Street
Lexington, NC 27293
In Re: Meadowlands — Chestnut Hills Flow Acceptance
Dear Mr. Leonard:
This letter is to confirm that the City/County Utility Commission will accept the sewerage from
Meadowlands -Chestnut Hills.
We are currently treating 844,425 gallons per day. Our contract with Davidson County has a maximum
discharge of 1,500,000 gallons per day; therefore, we should encounter no problems in treating an
additional 4,800 gallons per day. This sewerage will be treated at our Archie Elledge Wastewater
Treatment Plant (NC0037834). The wastewater collection system serving this area is properly sized and
maintained for this service.
If you have any questions concerning this subject, please give me a call at [phone].
Sincerely,
UTILITIES
TII� S ADMINISTRATION
Todd Lewis, P.E.
Senior Civil Engineer
Winston-Salem/Forsyth County Utilities
Clly Ceundl: Mayor Allen Joined; Vivian H. Burke, Mayor Pro Tampons, Northeast Ward; Denise D. Adams, North Ward; Dan Besse, Southwest Ward; Rohert C. Clark,
Gmagnm West Ward; John C. Larson, South Ward; Jeff Macintosh, Northwest Ward; Annette Sclpplo, East Ward; lames Taylor, Jr., Southeast Wad; City Manager: Lee D. Garrity
Cauntp Commissioners: David R. Plyler, Chair, Don Martin, Vice Chair; Fleming El -Amin; Ted Kaplan; Richard V. Unvllle; Tonya McDaniel; Gloria D. Whlsenhunt; County
Call 311or336.727.8000 Manager: Dudley Watts, Jr.
Winston-Salem/Forsyth County Utility Commission: Randall S. Tuttle, Chair; L. Wesley Curtis, Jr., Vice Chair, Harold E. Day; Tom Griffin; Yvonne H. Hines; Duane Long;
[e-mail] Hugh W. Jernigan; Chris Parker, lames Ruffin; Donald R. Stewart, Allan Younger

y003•Ga
\o�OF WA TF�4G Michael F. Easley, Governor
W _ y William G. Ross Jr., Secretary
t_ North Carolina Department of Environment and Natural Resources
-i
O < Alan W. Minsk, P.E., Director
Division of Water Quality
February 28, 2005
Mr. Pete Ramey, Managing Partner
Meadowlands Development, LLC
P.O. Box 410
Bethania, North Carolina 27010
Subject: Meadowlands Subdivision
WQ0024206
Flow Reduction Approval
Davidson County
Dear Mr. Ramey:
On January 11, 2005, the Division of Water Quality received a flow reduction request via your
consulting engineer, Mr. Jim Walters, for the subject project consisting of 170 3-bedroom residences.
The letter requests an allowable flow rate of 240 GPD per dwelling based on the evaluated data for a
similar existing subdivision: The flow reduction will allow for a smaller pump in the development
which will eliminate some possible surcharging in the line as modeled by receiving utility.
Information was provided by Winston -Salem -Forsyth County City/County Utilities that
summarized the water usage data for 64 lots in the Whitmore Subdivision between April 2003 and
February 2004 (ten months). The homes in this subdivision range from 2 — 5 bedrooms. The peak
month selected to evaluate was taken from the Winston-Salem Archie Elledge wastewater treatment
plant DMR reports over 2003 and 2004. April 2003 was the highest average flow month for the plant.
The average flow per home based on water usage records for the entire flow evaluation period is 220
GPD based on 3.8 bedrooms average and assuming 100% water/sewer ratio. For the peak month,
water usage averaged 236 gpd per 3.8 bedrooms (note that there was one lot with zero consumption
that was included in the calculation. Removing that and using 63 values, the average is 240 gpd;).
There is one swimming pool that was not included in the calculations.
The Whitmore subdivision and its collection basin is not currently built out and is fairly new. It
is assumed that inflow/infiltration is not a significant factor in the collection system and that any
irrigation accounted for in the water consumption values will balance out. However, 15A NCAC 2H
.0219(I)(3) requires that the top 10% actual daily values be averaged. Since the data provided was
not actual daily readings, additional conservativeness is necessary. Downstream capacity is of issue
in our state, the Division does not wish to promote capacity issues by granting flow reductions that
allow additional growth based on data that is not in complete accordance with 15A NCAC 2H
0219(1)(3). Measured daily values, whether on water usage or wastewater flows, are critical to our
decisions on flow reductions. Due to unknown actual daily readings, the Division will apply 1.25
safety factor to the flow rate desired which equates to 300 gallons per day per single family
residence. When discussed with your engineer, he proposed that value for single family homes and
240 gpd for the townhomes and villas, which most are expected to be two bedrooms.
One Pretreatment, Emergency Response and Collection Systems Unit Internet http,,//h2o.enr.nostato.ustndpu
NorthCarolina 1617 Mail service Center, Raleigh, Nc 27699.1617 An Equal Opportunity Action Employer
Naturally Telephone [phone] Fax [phone]%recycled/100/6 post -consumer paper

Mr. Ramey
February 28, 2005
Page 2
The Division hereby approves the use of 300 GPD per single family home and 240 GPD for
the multi -family units in all applicable non -discharge permit applications for only the Meadowlands
Subdivision. Regardless of the adiusted design daily wastewater flow rate, at no time shall the
wastewater flows exceed the effluent limits defined in the NPDES permit for the treatment facility or
exceed the capacity of the sewers downstream of any new sewer extension or service connection(s).
A permit modification and fee is required to apply this flow reduction to any existing permits where
flows have been allocated.
If you have any questions or comments regarding this matter, please contact Marie Doklovic
at [phone] ext. 371.
Sincerely,
Ian W. Klimek, P.E.
cc: Steve Mauney, Winston-Salem Regional Office
Jim Walters, PE, Latham -Walters Engineering (16507-A Northaoss Drive, HuntemAlle, NC 28078)
PERCS Flow Reduction File