SW4080503_Inspection_20211029

514 Edwards Road Phone: [phone]
Pram. co.s.m..' Rural Hall, NC 2704.5 [e-mail]
NC Departure-,t ,f
Environmental QUL'�-;r
Received
OCT 2 9 2332-1
North Carolina Environmental Quality Winston-S_Itim
Department of Energy, Minerals and Land Resources Rc;,ional Cffice
Winston-Salem Regional Office
Attn: Glen White October 22, 2021
450 W. Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
RE: Stormwater Permit No. SW4080503
Annual Summary Report
Primary Care of Mocksville
Davie County
Dear Mr. White,
Please find attached,with our Annual Inspection Checklist and Certification,supporting documentation to complete
the required Annual Summary Report of maintenance and inspection for the BMP's at the Primary Care of
Mocksville. The Annual Summary Report is due on November 1.
The Annual Summary Report supporting documents attached include:
• LPK Annual inspection Checklist and Certification (2021)
• 2020/2021 Monthly Inspection Reports & Periodic Inspection Reports
• 2020/2021 Rainfall Data
Submitted By,
1-
John D. Lipka, PE
LPK Consulting, PA
c. Feodor Birjkersma,WFBMC
Matt Fields, WFBMC
Jay Culler, WFBMC

STORMWATER BMP ANNUAL MAINTENANCE INSPECTION REPORT
Post-Construction Maintenance Report Form
Inspection Date: October 21,2021
NCDENR Permit No. Legal Owner of Record:(Name from County Tax Website or from
the owner if more recently updated):
SW4080603
Wake Forest Baptist Medical Center
Project Name: Legal Owner of Record Address:: (from County Tax Website or
from the owner if more recently updated):
Primary Care of Mocksville, NC
Medical Center Blvd,Winston-Salem, NC 27167
Physical Address/Location of BMP's: Owner Telephone Number:
1188 Yadkinville Road [phone]
Mocksville, NC Davie County
Site Contact Entity: Name of Inspection Company:
Wake Forest Baptist Medical Center LPK Consulting, PA
Department of Environment and Health
Site Contact Person Namerritle: BMP Inspector Name: (a person's name-not a company name)
Jay Culler, LEED Specialist John D. Lipka
Site Contact Entity Mailing Address: Mailing Address of Inspection Company:
Medical Center Boulevard 514 Edwards Rd
Winston-Salem, NC 27157 Rural Hall, NC 27046
Qualification//Credentials of Inspector:
Site Contact Person Telephone Number: Type Name of Entity State #
[phone] Registration: NC Professional Engineer
Site Contact Person e-mail address: Licensure: 026494
[e-mail] BMP Inspector Telephone Number: (336)94"302
BMP Inspector e-mail Address:[e-mail]
The results of this Inspection are as follows:
FAIL
VISUAL INSPECTION FOUND APPARENT PROBLEMS WHICH NEED IMMEDIATE ATTENTION.COMPLETE
THE REPAIR AND/OR MAINTENANCE ITEMS INDICATED:ON THE ATTACHED CHECKLISTS WITHIN 30-DAYS OF THE
DATE OF THIS REPORT.
■ PASSIGERTIFIED
VISUAL INSPECTION FOUND NO APPARENT PROBLEMS
Certification (is o ed is functional and has no outstanding repair or maintenance issues)
I, � as a duly registered Professional in the State of North
Caroli herby state ,to the best of my abilities the sto water best management practice(bmp)device(s)is/are
fully ctioning an perating as designed and intended.
Seal/Signatutb
Inspection by: John D.Lipka °' "'1' Oc Ober 22 2021

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Level Spreader Checklist for Annual BMP Report
BMP Site Name Primary Care of Mocksville Date Oct 21, 2021
Item-b -Item Code Key:
FF Full 1"ctional (No Repafis:Weeded) , Pass for lnspection
PF Partially Functiional(Rep0m.,Needed} Fail the,Inspeehoi�
NF Not Functional(Repairs Needed dad the insp+ ction;.
1V[t3N ;Monitor(Monitor for a penod ofttme perhaps until the next mspechoti)
N. LM App cabi-,
INLET/FLOW SPUTTER DEVICE
Assessment Cod 'Statds,`; Cowmen#s' .
Obstruction: vegetation/debris/sediment N/A
Rip Rap Displacement/Sedimentation N/A
Structural Condition N/A
Other(Describe) NIA No Splitter by Design
POOLING AREA AND LEVEL LIP
Assessment -.. Cod'e sums:` comments;
Sediment/debris accumulation FF
Level lip is cracked , settled, undercut FF
or eroded
Stormwater is by-passing levels reader FF
Woody Vegetation growth in pooling FF
area or on level lip
Grass is maintained as mowed FF
Nuisance Vegetation is Present FF
Other Describe
BYPASS CHANNEL
Assessment: Codetatas.: Comtineats
Bare soil/erosive gullies N/A
Turf Reinforcement condition N/A
Displacement of rip-rap N/A
Other (Describe) N/A No Bypass by Design
FILTER STRIP
Assessment Code Status Comments
Grass length: too short/too ion FF
Bare soil/erosive gullies FF
Sediment accumulation FF
Nuisance vegetation is present FF
Other(Describe)
Level Spreader Checklist
Page 1 of 2

Level Spreader Checklist for Annual BMP Report
BMP Site Name Primary Care of Mocksville Date Oct 21, 2021
item-by-Item Code Key:
FF Fully Functional (No Repairs Needed)=Pass for Inspection
PF Partially Functional (Repairs Needed) = Fail the Inspection
NF Not Functional (Repairs Needed) =Fail the Inspection
MON Monitor(Monitor for a period of time—perhaps until the next inspection)
NIA Not Applicable
MISCELLANEOUS
Assessment Code Status Comments
Trash/debris FF
Access FF
Evidence of routine maintenance being FF
performed?
Other (Describe)
PHOTOGRAPHS
71
Level Spreader & Filter Strip
Level Spreader Checklist
Page 2 of 2

Bioretention Area Checklist for Annual BMP Report
BMP Site Name Primary Care of Mocksville Date Oct 21, 2021
Item-b -Item Code Key:
FF" Fully:Functional `(l�To Repairs)�teeded) Pass for Inspei�hon.
PF; Psrtiixlly Functional(ReQa 'xi—eiiec) Tail the:Inspectxon
NF Not k'anctional(Repairs Needed) Faxl the inspection
1VIpN Moxiiitor(Monxtori.for a period::,o lime perhaps until tLe ne$t xnspectxox►)
N/A Not Apphc&ble
INFLOW POINTS
Assessment Code:Status 'QM men#s .
Obstruction: vegetation/debris/sediment FF
Erosion/undercutting FF
Structural condition FF
Displacement/sedimentation of FF
fabric/rip-rap
Other(Describe)
PERIMETER/SIDE SLOPES/EMBANKMENT
Asessment.... Code.:Status< Comiie�ats.
Sediment/debris accumulation FF
Bare soil/erosion FF
Woody vegetation FF
Turf ass maintained as mowed FF
Other(Describe)
PRE-TREATMENT AREA (For ebay, grass swales, & verge , ravel
Assessment .: _b od e Status Comments
Sediment/debris accumulation FF
Erosion/gullies present FF
Invasive vegetation FF
Flow is by-passing pretreatment FF
Other(Describe)
Bioretention Area Checklist
Page ] of 3

Bioretention Area Checklist for Annual BMP Report
BMP Site Name Primary Care of Mocksville Date Oct 21, 2021
Item-b -Item Code Key:
Fnlly Fnnehonal .'(No Repairs;Needed) Pass forspec#ian
PF; Partiially Tunetiionsl.(R6pajrs.lYeeded). Fail.the Inpeetion,
Notnnctional{Rpairs Needed) a�l the Jnspe+ctzon
-MO Monitor(Monitor fora-penod of tiu e: perhaps until the next mspectiioi )
NIA No_'A►pplicable
BIORETENTION CELL
Asessnoient . rode Status: .. omaaents'
Overgrown vegetation (requires FF
pruning)
Plants are dead, diseased, or dying FF
(Replace such plants as necessary per original
approved constructionplans)
Mulch is decomposed or displaced FF
Soils/mulch clogged with sediment FF
Evidence of lack of proper drainage MON At appropriate planting season,
(i.e., dead plants, or successional supplement plantings per design
wetland ve etationplant schedule
Bare or eroded areas in grass cells NA
Other(Describe)
OUTLET DEVICE
Assessment 777777
Cade Status:, Comments
Obstruction: vegetation/debris/sediment FF
Erosion/undercutting FF
Structural condition FF
Sediment in pipe FF
Joint failure/loss of joint material/soil FF
piping
Displacement of fabric/rip-rap FF
Other(Describe)
MISCELLANEOUS
A�>aiie�t. Co�e`Status ':Ct�mutents ;..
Trash/debris FF
Access FF
Evidence of routine maintenance being FF
performed.
Other(Describe)
Bioretention Area Checklist
Page 2 of 3

Bioretention Area Checklist for Annual BMP Report
BMP Site Name Primary Care of Mocksville Date Oct 21, 2021
Item-b -Item Code Key:
FF Fully Functional (No Repairs Needed)=Pass for Inspection
PF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional (Repairs Needed)=Fail the Inspection
MON Monitor(Monitor for a period of time—perhaps until the next inspection)
NIA Not Applicable
PHOTOGRAPHS
r�
i'
y '4
'r.
Forebay l Forebay 2
1
t(
31
.w L,
Clean Out Filet Structure & Bio Cell
Bioretention Area Checklist
Page 3 of 3

Daily Rainfall Totals
Oct-201 WFBH Urgent Care- Mocksville
Day Amount of Rainfall Comments
1
2
3
4
5
6
7
8
9
10
11 2.3
12 0.5
13
14
15
16
17
18
19
20
21
22
23
24
25 1.3
26
27
28
29 1.0
30
31 0.3

�,P1 Wake Forest'"
Baptist Health
{ MONTHLY/RAIN EVENT STORMWATER BMP CHECKLIST
The Stormwater BMP Checklist must be performed monthly and when it has rained more than 1 inch
within 24 hours.
BMP Site Name: Medical Pav' ' -Mocksville 1188 Yadkinville Rd.,Mocksville NC
Inspector's Name: YMt
AVE&
BIORETENTION AREA
INFLOW POINTS
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Erosion/undercutting
Structural condition �=
Displacement/sedimentation of fabric/rip-rap
PERIMETER/SIDE SLOPES/EMBANKMENT
Sediment/debris accumulation FF
Bare soil/erosion _
Woody vegetation
Turf ass maintained as mowed
PRE-TREATMENT AREA(For ebay,grass swales,& verges,gravel)
Sediment/debris accumulation PF
Erosion! flies present FF
Invasive vegetation FE
Flow is by-passing pretreatment f
BIORETENTION CELL
Overgrown vegetation (requirespruning) FF
Plants are dead, diseased, or dying (Replace such plants
as necessary per original approved constructionplans)
Mulch is decomposed or displaced
Soils/mulch clogged with sediment
Evidence of lack of proper drainage(i.e., dead plants,
or successional wetland vegetation) F r
Bare or eroded areas in grass cells FF I
OUTLET DEVICE
Obstruction: vegetation/debris/sediment r
Erosion/undercutting F
Structural condition rr
Sediment in pipe EP
Joint failure/loss of joint material/soil piping
Displacement of fabric/rip-rap
F Fully Functional (No Repairs Needed)=Pass for Inspection
OF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)—Fail the Inspection
NIA Not Applicable

LEVEL SPREADER
INLET/FLOW SPLITTER DEVICE
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment FP
Rip Rap Displacement/Sedimentation -
Structural Condition
POOLING AREA AND LEVEL LIP
Sediment/debris accumulation FF
Level lip is cracked, settled,undercut or eroded
Stormwater is by-passing levels reader
Woody Vegetation growth in pooling area or on level
lip
Grass is maintained as mowed
Nuisance Vegetation is Present
FILTER STRIP
Grass length: too short/too long)
Bare soil/erosive gullies
Sediment accumulation
Nuisance vegetation is present
MISCELLANEOUS
Trash/debris
Access
Evidence of routine maintenance being performed?
ADDITIONAL COMMENTS
Date of Inspection
Time of Inspection 1P PM
Weather at time of Inspection
Inspection Type: Monthly or Rain
Event
Rain Event Amount ~J'
PAS� r FAIL (Circle One)
FIT Fully Functional (No Repairs Needed)=Pass for Inspection
PF Partially Functional(Repairs Needed)=Fail the Inspection ti
NF Not Functional(Repairs Needed)=Fail the Inspection
N/A Not Applicable

��rt Wake Forest'"
Baptist Health
( MONTHLY/RAIN EVENT STORMWATER BMP CHECKLIST
The Stormwater BMP Checklist must be performed monthly and when it has rained more than 1 inch
within 24 hours.
BMP Site Name: Medical Pavilion-M ocksville, 1188 Yadkinville Rd.,Mocksville,NC
Inspector's Name: ovy ( &)
BIORETENTION AREA
INFLOW POINTS
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment y
Erosion/undercutting
Structural condition
Displacement/sedimentation of fabric/ri -ra
PERIMETER/SIDE SLOPES/EMBANKMENT
Sediment/debris accumulation
fir
Bare soil/erosion
Woody vegetation
Turf ass maintained as mowed
PRE-TREATMENT AREA(Fore bay, grass swales,& verges, ravel
Sediment/debris accumulation
Erosion/gullies present
Invasive vegetation
Flow is by-passing retreatment
BIORETENTION CELL
Overgrown vegetation (requires pruning) ,.-
Plants are dead, diseased, or dying (Replace such plants
as necessaw per original approved constructionplans) '
Mulch is decomposed or displaced ri
Soils/mulch clogged with sediment
Evidence of lack of proper drainage(i.e., dead plants,
or successional wetland vegetation)
Bare or eroded areas in grass cells
OUTLET DEVICE
Obstruction: vegetation/debris/sediment
Erosion/undercutting
Structural condition
Sediment in pipe
Joint failure/loss of joint material/soil piping r
Displacement of fabric/rip-rap
Fully Functional (No Repairs Needed)=Pass for Inspection
rB Partially Functional(Repairs Needed)=Fall the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
NIA Not Applicable

LEVELSPREADER
INLET/FLOW SPLITTER DEVICE
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Rip Rap Displacement/Sedimentation {
Structural Condition
POOLING AREA AND LEVEL LIP
Sediment/debris accumulation
Level lip is cracked , settled, undercut or eroded
Stormwater is by-passing levels reader
Woody Vegetation growth in pooling area or on level
lip
Grass is maintained as mowed
Nuisance Vegetation is Present
FILTER STRIP
Grass length: too short/too long)
Bare soil/erosive gullies
Sediment accumulation (�
Nuisance vegetation is present
MISCELLANEOUS
Trash/debris
Access
Evidence of routine maintenance being erformed?
ADDITIONAL COMMENTS
Date of Inspection -t..0
Time of Inspection V
Weather at time of inspection ' 0
Inspection Type: Monthly or Rain t
Event f�\V t1�'`
Rain Event Amount
PASS r FAIL (Circle One)
Jj
FF Fully Functional (No Repairs Needed)—Pass for Inspection
PF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fall the Inspection
NIA Not Applicable

Daily Rainfall Totals
r
Nov-201 WFBH Urgent Care-Mocksville
Day Amount of Rainfall Comments
1
2
3
4
5
6
7
8
9
10
11
12 4.5
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30 2.1

XXXX. Wake Forest'"
Baptist Health
�r MONTHLY/RAIN EVENT STORMWATER BMP CHECKLIST
The Stormwater BMP Checklist must be performed monthly and when it has rained more than 1 inch
within 24 hours.
BMP Site Name: Medical Pavilion-Mocksville, 1188 Yadkinville Rd.,Mocksville,NC
Inspector's Name: M,t W,-I�
BIORETENTION AREA
INFLOW POINTS
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment EP
Erosion/undercutting
Structural condition
Displacement/sedimentation of fabric/rip-rap
PERIMETER/SIDE SLOPES/EMBANKMENT
Sediment/debris accumulation
Bare soil/erosion
Woody vegetation
Turf ass maintained as mowed
PRE-TREATMENT AREA oreba ,grass swales, & verges, ravel
Sediment/debris accumulation
Erosion/gullies present
Invasive vegetation
Flow is by-passing pretreatment
BIORETENTION CELL
Overgrown vegetation (requires pruning) FF
Plants are dead, diseased, or dying (Replace such plants
cis necesvaiv per ofiginal approved constructionplans)
Mulch is decomposed or displaced
Soils/mulch clogged with sediment
Evidence of lack of proper drainage(i.e., dead plants,
or successional wetland vegetation)
Bare or eroded areas in grass cells E/
OUTLET DEVICE
Obstruction: vegetation/debris/sediment
Erosion/undercuttingr
Structural condition
Sediment in pipe
Joint failure/loss of joint material/soil piping
Displacement of fabric/rip-rap
Fully Functional (No Repairs Needed)—Pass for Inspection
rF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)—Fail the Inspection
N/A Not Applicable

LEVEL SPREADER
INLET/FLOW SPLIT17ER DEVICE
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Rip Rap Displacement/Sedimentation _
Structural Condition %
POOLING AREA AND LEVEL LIP
Sediment/debris accumulation
Level lip is cracked , settled, undercut or eroded
Stormwater is by-passing levels reader
Woody Vegetation growth in pooling area or on level
lip
Grass is maintained as mowed
Nuisance Vegetation is Present
FILTER STRIP
Grass length: too short/too long)
Bare soil/erosive gullies 1'
Sediment accumulation
Nuisance vegetation is present
MISCELLANEOUS
Trash/debris it
Access it
Evidence of routine maintenance being erformed?
ADDITIONAL COMMENTS
l
Date of Inspection 15 1-4
Time of Inspection 3
Weather at time of Inspection 4 N r r)
Inspection Type:Monthly or Rain �� Q
Event
Rain Event Amount '' k
PASS pr FAIL (Circle One)
FIT Fully Functional (No Repairs Needed)=Pass for Inspection
PF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
N/A Not Applicable

Daily Rainfall Totals
Dec-201 WFBH Urgent Care- Mocksville
Day Amount of Rainfall Comments
1
2
3
4
5 0.8
6
7
8
9
10
11
12
13
14 1.5
15
16 1.0
17
18
19
20
21
22
23
24 0.8
25 0.2
26
27
28
29
30
31

X �N Wake Forest"
Baptist Health
f MONTHLY/RAIN EVENT STORMWATER BMP CHECKLIST
The Stormwater BMP Checklist must be performed monthly and when it has rained more than 1 inch
within 24 hours.
BMP Site Name: Medical Pavilli*o'n-Mocksville, 1188 Yadkinville Rd.,Mocksville,NC
Inspector's Name: RA
BIORETENTION AREA
INFLOW POINTS
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment r&d4ed 0-r(4,'N -f
Erosion/undercutting ;eJ hv gre e..
Structural condition
Displacement/sedimentation of fabric/rip-rap
PERIMETER/SIDE SLOPES/E ANKMENT
Sediment/debris accumulation
Bare soil/erosion -�
Woody vegetation
Turfgrass maintained as mowed r
PRE-TREATMENT AREA oreba ,grass swales,&verges, ravel
Sediment/debris accumulation
Erosion/gullies present .�
Invasive vegetation
Flow is by-passing pretreatment ��
BIORETENTION CELL
Overgrown vegetation(requirespruning)
Plants are dead, diseased, or dying (Replace such plants
as necessa> >per original approved construction tans)
Mulch is decomposed or displaced
Soils/mulch clogged with sediment
Evidence of lack of proper drainage(i.e., dead plants, �.
or successional wetland vegetation)
Bare or eroded areas in grass cells
OUTLET DEVIC
Obstruction: vegetation/debris/sediment -�
Erosion/undercutting
Structural condition
Sediment in pipe
Joint failure/loss of joint material/soil piping
Displacement of fabric/rip-rap
Fully Functional (No Repairs Needed)=Pass for Inspection
rF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
N/A Not Applicable

LEVEL SPREADER
INLET/FLOW SPLITTER DEVICE
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Rip Rap Displacement/Sedimentation
Structural Condition
POOLING AREA AND LEVEL LIP
Sediment/debris accumulation
Level lip is cracked , settled, undercut or eroded
Stormwater is by-passing levels reader
Woody Vegetation growth in pooling area or on level
lip
Grass is maintained as mowed
Nuisance Vegetation is Present
FILTER STRIP
Grass length: too short/too long)
Bare soil/erosive gullies
Sediment accumulation
Nuisance vegetation is present r .
MISCELLANEOUS
Trash/debris
Access '
Evidence of routine maintenance being erformed?
ADDITIONAL COMMENTS
Date of Inspection , 2
Time of Inspection
Weather at time of Inspection r t!
Inspection Type: Monthly or Rain o N
Event
Rain Event Amount
TAS..8 Or FAIL (Circle One)
11-1-.'"
FF Fully Functional (No Repairs Needed)=Pass for Inspection
PF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
N/A Not Applicable

Daily Rainfall Totals
- Jan-211 WFBH Urgent Care-Mocksville
Day Amount of Rainfall Comments
1
2
3
4 1.5
5
6
7
8
9 0.5
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 1.0
26
27
28 1.0
29
30
31 0.8

X `X Wake Forest"
Baptist Health
MONTHLY/RAIN EVENT STORMWATER BMP CHECKLIST
The Stormwater BMP Checklist must be performed monthly and when it has rained more than 1 inch
within 24 hours.
BMP Site Name: Medical Pavilion-Mocksville, 1188 Yadkinville Rd., Mocksville,NC
Inspector's Name: d> � �� pj{+ ,
BIORETENTION AREA
INFLOW POINTS
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment 5}Q0d;r) (� Q W
Erosion/undercutting of e`ks
Structural condition
Dis lacement/sedimentation of fabric/rip-rap
PERIMETER/SIDE SLOPES/EMBANKMENT
Sediment/debris accumulation '
Bare soil/erosion (-
Woody vegetation
Turf ass maintained as mowed '
PRE-TREATMENT AREA oreba , grass swales,& verges,gravel)
Sediment/debris accumulation
Erosion/gullies present
Invasive vegetation C.
Flow is by-passing pretreatment C
BIORETENTION CELL
Overgrown vegetation(re uirespruning)
Plants are dead, diseased, or dying(Replace such plants C
as necessar per original approved constructionplans) �
Mulch is decomposed or displaced
Soils/mulch clogged with sediment
Evidence of lack of proper drainage(i.e., dead plants, A P
or successional wetland vegetation) VT
Bare or eroded areas in grass cells
OUTLET DEVICE
Obstruction: vegetation/debris/sediment
Erosion/undercutting -�
Structural condition
Sediment in pipe
Joint failure/loss of joint material/soil piping
Displacement of fabric/rip-rap
Fully Functional (No Repairs Needed)=Pass for Inspection
.r Partially Functional(Repairs Needed)a Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
NIA Not Applicable

LEVEL SPREADER
INLET/FLOW SPUTTER DEVICE
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Rip Rap Displacement/Sedimentation
Structural Condition
POOLING AREA AND LEVEL LIP
Sediment/debris accumulation Q"
Level lip is cracked, settled, undercut or eroded (f
Stormwater is by-passing levels reader 1
Woody Vegetation growth in pooling area or on level
lipf
Grass is maintained as mowed ` ~
Nuisance Vegetation is Present
FILTER STRIP
Grass len h: too short/too long)
Bare soil/erosive gullies
Sediment accumulation
Nuisance vegetation is present
MISCELLANEOUS
Trash/debris
Access
Evidence of routine maintenance being performed?
ADDITIONAL COMMENTS
r
Date of Inspection
Time of Inspection 01
Weather at time of inspection
Inspection Type: Monthly or Rain
Event
Rain Event Amount t"
PASS or n
(Circle One)
FF Fully Functional (No Repairs Needed)=Pass for Inspection
PF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
NIA Not Applicable

Daily Rainfall Totals
r
Feb-21 WFBH urgent Care-Mocksville
Day Amount of Rainfall Comments
1 0.1
2
3
4
5
6
7
8 0.9
9
10
11
12 1.1
13
14 1.5
15 0.5
16 1.3
17
18 0.5
19 0.2
20
21
22
23
24
25
26
27
28 0.8
29

Wake Forest-
Baptist Health
' MONTHLY/RAIN EVENT STORMWATER BMP CHECKLIST
The Stormwater BMP Checklist must be performed monthly and when it has rained more than 1 inch
within 24 hours.
BMP Site Name: Medical Pavilion-Mocksville, 1188 Yadkinville Rd.,Mocksville,_NC
Inspector's Name: rj,6� I S
BIORETENTION AREA
INFLOW POINTS
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment fj)1,e 4j.7 r k c e e r a j
Erosion/undercutting t , 1-s jr Y)e e e a« j
Structural condition
Displacement/sedimentation of fabric/rip-
PERIMETER/SIDE SLOPES/EMBANKMENT
Sediment/debris accumulation
Bare soil/erosion
Woody vegetation
Turf ass maintained as mowed
PRE-TREATMENT AREA (Fore bay,grass swales & verges,gravel)
-Sediment/debris accumulation
Erosion/gullies present 'P
Invasive vegetation
Flow is by-passing pretreatment
BIORETENTION CELL
Overgrown vegetation (requires pruning)
Plants are dead, diseased, or dying(Replace such plants �i f
as necessary per original approved constructionplans) r t
Mulch is decomposed or displaced
Soils/mulch clogged with sediment
Evidence of lack of proper drainage(i.e., dead plants, �r
or successional wetland vegetation) 1"
Bare or eroded areas in grass cells
OUTLET DEVICE
Obstruction: vegetation/debris/sediment
Erosion/undercutting
Structural condition
Sediment in pipe f
Joint failure/loss of joint material/soil piping ;-
Displacement of fabric/rip-rap
Fully Functional (No Repairs Needed)=Pass for Inspection
eF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
N/A Not Applicable

LEVELSPREADER
INLET/FLOW SPLITTER DEVICE
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Rip Rap Displacement/Sedimentation
Structural Condition ,
POOLING AREA AND LEVEL LIP
Sediment/debris accumulation -
Level lip is cracked , settled,undercut or eroded f -
Stormwater is by-passing levels reader
Woody Vegetation growth in pooling area or on level
lip
Grass is maintained as mowed
Nuisance Vegetation is Present
FILTER STRIP
Grass length: too short/too long) =
Bare soil/erosive gullies tt
Sediment accumulation *;
Nuisance vegetation is present
MISCELLANEOUS
Trash/debris `
Access
Evidence of routine maintenance being performed? a_,;.
ADDITIONAL COMMENTS
1 �
Date of Inspection \
Time of Inspection
Weather at time of Inspection ,
Inspection Type:Monthly or Rain
Event
Rain Event Amount
PASS or FAIL (Circle One)
FF Fully Functional (No Repairs Needed)=Pass for Inspection
PF Partially Functional(Repairs Needed)=Fail the Inspection 1..
NF Not Functional(Repairs Needed)=Fail the Inspection
N/A Not Applicable

X `)-Wake Forest'"
Baptist Health
( MONTHLY/RAIN EVENT STORMWATER BMP CHECKLIST
The Stormwater BMP Checklist must be performed monthly and when it has rained more than 1 inch
within 24 hours.
BMP Site Name: Medical Pavilion-Mocksville 1188 Yadkinville Rd.,Mocksville NC
Inspector's Name: :-
BIORETENTION AREA
INFLOW POINTS
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Erosion/undercuttin
Structural condition
Displacement/sedimentation of fabric/rip-rap
PERIMETER/SIDE SLOPES/EMBANKMENT
Sediment/debris accumulation
Bare soil/erosion ff
Woody vegetation r`r
Turf ass maintained as mowed Fr
PRE-TREATMENT AREA(For ebay,grass swales,& verges, ravel)
Sediment/debris accumulation EE
Erosion/gullies present
Invasive vegetation
Flow is by-passing pretreatment FF
BIORETENTION CELL
Overgrown vegetation(requirespruning)
Plants are dead, diseased, or dying(Replace such plants
as necessa> >per original approved constructionplans)
Mulch is decomposed or displaced out
Soils/mulch clogged with sediment
Evidence of lack of proper drainage(i.e., dead plants,
or successional wetland vegetation)
Bare or eroded areas in grass cells
OUTLET DEVICE
Obstruction: vegetation/debris/sediment
Erosion/undercuttingf
Structural condition
Sediment in pie '
Joint failure/loss of joint material/soil pipingF
Displacement of fabric/rip-rap
Fully Functional (No Repairs Needed)=Pass for Inspection
r Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
N/A Not Applicable

LEVELSPREADER
INLET/FLOW SPLITTER DEVICE
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Rip Rap Displacement/Sedimentation
Structural Condition
POOLING AREA AND LEVEL LIP
Sediment/debris accumulation ff
Level lip is cracked , settled, undercut or eroded VF
Stormwater is by-passing levels reader IFF
Woody Vegetation growth in pooling area or on level
lip
Grass is maintained as mowed
Nuisance Vegetation is Present
FILTER STRIP
Grass length: too short/too long)
Bare soil/erosive gullies
Sediment accumulation
Nuisance vegetation is present 77r
MISCELLANEOUS
Trash/debris
Access
Evidence of routine maintenance being erformed?
ADDITIONAL COM TS L
Date of Inspection
Time of Inspection f 1 c A
Weather at time of Inspection �.
Inspection Type:Monthly or Rain
Event l tj
Rai_qFZAknt Amount } !l
AS►� OP FAIL (Circle One)
FF Fully Functional (No Repairs Needed)=Pass for Inspection
PF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
N/A Not Applicable

Daily Rainfall Totals
Mar-21 WFBH Urgent Care- Mocksville
Day Amount of Rainfall Comments
1 0.3
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 0.2
26 2.3
27 1.0
28 0.5
29
30
31

Daily Rainfall Totals
Apr-21T WFBH Urgent Care- Mocksville
Day Amount of Rainfall Comments
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

�. � Wake Forest'"
Baptist Health
{ MONTHLY/RAIN EVENT STORMWATER BMP CHECKLIST
The Stormwater BMP Checklist must be performed monthly and when it has rained more than 1 inch
within 24 hours.
BMP Site Name: Medical Pavilion-MocksviRe .1188 Yadkinville Rd., Mocksville NC
Inspector's Name: b
BIORETENTION AREA
INFLOW POINTS
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Erosion/undercutting
Structural condition
Displacement/sedimentation of fabric/rip-rap
PERIMETER/SIDE SLOPES/EMBANKMENT
Sediment/debris accumulation FE
Bare soil/erosion
Woody vegetation FF
Turf ass maintained as mowed VE
PRE-TREATMENT AREA (For ebay,grass swales, &verges,gravel)
:Sediment/debris accumulation
Erosion/gullies present
Invasive vegetation
Flow is by-passing pretreatment
BIORETENTION CELL
Overgrown vegetation(requires pruning)
Plants are dead, diseased, or dying (Replace such plants
cis necessary per original a roved construction loins)
Mulch is decomposed or displaced
Soils/mulch clogged with sediment F
Evidence of lack of proper drainage(i.e., dead plants,
or successional wetland vegetation)
Bare or eroded areas in grass cells
OUTLET DEVICE
Obstruction: vegetation/debris/sediment
Erosion/undercutting
Structural condition Ee
Sediment in pipe
Joint failure/loss of joint material/soil piping
Dis lacement of fabric/rip-rap
Fully Functional (No Repairs Needed)=Pass for Inspection
r Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
N/A Not Applicable

LEVELSPREADER
INLET/FLOW SPLITTER DEVICE
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Rip Rap Dis lacemenVSedimentation
Structural Condition
POOLING AREA AND LEVEL LIP
Sediment/debris accumulation
Level lip is cracked , settled, undercut or eroded
Stonnwater is by-passing levels reader
Woody Vegetation growth in pooling area or on level
lip
Grass is maintained as mowed
Nuisance Vegetation is Present
FILTER STRfP
Grass length: too short/too long)
Bare soil/erosive gullies
Sediment accumulation
Nuisance vegetation is present
MISCELLANEOUS
Trash/debris
Access
Evidence of routine maintenance being performed?
ADDITIONAL COMMENTS
Date of Inspection
Time of Inspection i
Weather at time of Inspection
Inspection Type:Monthly or Rain
Event a 6
Rain Event Amount 6 `
S� r FAIL (Circle One)
FF Fully Functional (No Repairs Needed)=Pass for Inspection _
PF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
NIA Not Applicable

Daily Rainfall Totals
May-21 WFBH Urgent Care-Mocksville
Day Amount of Rainfall Comments
1
2
3 1.5
4
5
6
7
8
9
10
11
12 0.9
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30 1.3
31

Wake Forest'"
Baptist Health
MONTHLY/RAIN EVENT STORMWATER BMP CHECKLIST
The Stormwater BMP Checklist must be performed monthly and when it has rained more than 1 inch
within 24 hours.
BMP Site Name: Medical Pavilion-Mocksville, 1188 Yadkinville Rd.,Mocksville, NC
Inspector's Name:A ele-r6
BIORETENTION AREA
INFLOW POINTS
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment ta-
Erosion/undercutting
Structural condition
Displacement/sedimentation of fabric/rip-rapi
PERIMETER/SIDE SLOPE (EMBANKMENT
Sediment/debris accumulation j
Bare soil/erosion r
Woody vegetation rr�
irfgrass maintained as mowed
PRE-TREATMENT AREA (Foreba ,grass swales,& verges, ravel)
Sediment/debris accumulation f
Erosion/gullies present f .-
Invasive vegetation et
Flow is by-passing pretreatment
BIORETENTION CELL
Overgrown vegetation (requirespruning)
Plants are dead, diseased, or dying (Replace.such plants �f,
as necessary per original approved construction tans) t
Mulch is decomposed or displaced
Soils/mulch clogged with sediment
Evidence of lack of proper drainage(i.e., dead plants,
or successional wetland vegetation) t'
Bare or eroded areas in grass cells
OUTLET DEVICE
Obstruction: vegetation/debris/sediment /
Erosion/undercutting
Structural condition
Sediment in pipe
Joint failure/loss of joint material/soil piping /
Displacement of fabric/rip-rap
.r Fully Functional (No Repairs Needed)=Pass for Inspection
PF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
NIA Not Applicable

LEVELSPREADER
INLET/FLOW SPUTTER DEVICE
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Rip Rap Displacement/Sedimentation i
Structural Condition
POOLING AREA AND LEVEL LIP
Sediment/debris accumulation /Gj'
Level lip is cracked , settled,undercut or eroded (�-
Stormwater is by-passing levels reader (�fr
Woody Vegetation growth in pooling area or on level 'rC—
lip
Grass is maintained as mowed �^
Nuisance Vegetation is Present
FILTER STRIP
Grass length: (too short/too long)
Bare soil/erosive gullies fi'
Sediment accumulation Lt
Nuisance vegetation is present ry
MISCELLANEOUS
Trash/debris
Access F
Evidence of routine maintenance being erformed?
ADDITIONAL COMMENTS
Date of Inspection '2i
Time of Inspection 16S,
Weather at time of Inspection
Inspection Type: Monthly or Rain
Event
Rain Event Amount
AS or FAIL (Circle One)
FF Fully Functional (No Repairs Needed)=Pass for Inspection
PF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
NIA Not Applicable

Daily Rainfall Totals
Jun-21 WFBH Urgent Care-Mocksville
Day Amount of Rainfall Comments
1
2
3
4
5
6
7
8 0.9
9
10
11
12 0.8
13 0.1
14
15
16
17
18
19
20 0.5
21
22
23
24
25
26
27
28
29
30 0.3

X `X- Wake Forrest-
Baptist Health
cti MONTHLY/RAIN EVENT STORMWATER BMP CHECKLIST
The Stormwater BMP Checklist must be performed monthly and when it has rained more than 1 inch
within 24 hours.
BMP Site Name: Medical Pavilion-Mocksville 1188 Yadkinville Rd., MocksviUe NC
Inspector's Name:
BIORETENTION AREA
INFLOW POINTS
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment rr
Erosion/undercutting
Structural condition
Displacement/sedimentation of fabric/rip-rap
PERIMETER/SIDE SLOPES/EMBANKMENT
Sediment/debris accumulation rr
Bare soil/erosion
Woody vegetation
Turfgrass maintained as mowed
PRE-TREATMENT AREA oreba ,grass swales,& verges, ravel
pediment/debris accumulation
Erosion/gullies present
Invasive vegetation
Flow is by-passing pretreatment FF
BIORETENTION CELL
Overgrown vegetation (requires pruning)
Plants are dead, diseased, or dying (Replace such plants
as necessa> >per original a roved constructionplans) FE
Mulch is decomposed or displaced P
Soils/mulch clogged with sediment Fr
Evidence of lack of proper drainage(i.e., dead plants,
or successional wetland vegetation)
Bare or eroded areas in grass cells
OUTLET DEVICE
Obstruction: vegetation/debris/sediment
Erosion/undercutting Er
Structural condition
Sediment in pipe
Joint failure/loss of joint material/soil i ing
Dis lacement of fabric/rip-rap
Fully Functional (No Repairs Needed)=Pass for Inspection
.. Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
N/A Not Applicable

LEVELSPREADER
INLET/FLOW SPLITTER DEVICE
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Rip Rap Displacement/Sedimentation
Structural Condition
POOLING AREA AND LEVEL LIP
Sediment/debris accumulation
Level lip is cracked ,settled, undercut or eroded
Stormwater is by-passing levels reader
Woody Vegetation growth in pooling area or on level
lip
Grass is maintained as mowed f=
Nuisance Vegetation is Present
FILTER STRIP
Grass length: too short/too long)
Bare soil/erosive gullies
Sediment accumulation
Nuisance vegetation is present
MISCELLANEOUS
Trash/debris
Access F
Evidence of routine maintenance being performed?
ADDITIONAL COMMENTS
Date of Inspection
Time of Inspection phl
Weather at time of Inspection
Inspection Type:Monthly or Rain
Event
Rain Event Amount
�Apr FAIL (Circle One)
FF Fully Functional (No Repairs Needed)=Pass for Inspection -�
PF Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
N/A Not Applicable

�. Wake Forest"
Baptist Health
MONTHLY/RAIN EVENT STORMWATER BMP CHECKLIST
The Stormwater BMP Checklist must be performed monthly and when it has rained more than 1 inch
within 24 hours.
BMP Site Name: Medical Pavilion-Mocksville 1188 Yadkinville Rd.,Mocksviile NC
Inspector's Name:
BIORETENTION AREA
- ..: S }T�. {'�I�•�,1:190,N.: i .Q�?.� "1?';,yp.�a;-` ��1 }�"7n'���+v��'6y� r'"-4'^.. K '�*��k�s�c'7`r_•.'c,�f "'�"y�r":s,
Assessment � �^tatu �
Obstruction: vegeta "Idebris/sediment
Erosion/undercutting
Structural condition FF
Displacement/sedimentation of fabric/rip-man
. <'P>;I�IMETERISID► :SI�OP.ES�
Sediment/
debris accumulation G ` ��'
_ ., V
Bare soil/erosion
Woody vegetation
irfgrass maintained as mowed F
PRE-TREATMENT:AREA
Sediment/debris accumulation
Erosion/ Ilies resent
Invasive vegetation «t,
Flow is by-passing pretreatment
d T7I
�ENTIOIV��O,.,1.%ill7�+jF,n Overgrown vegetation(re wires pruning)
Plants are dead, diseased, or dying (Replace such plants
as necessary er original approved construction plaps}
Mulch is decomposed or displaced
Soils/mulch clogged with sediment
Evidence of lack of proper drainagedead plants,
or successional wetland vegetation)
Bare or eroded areas in grass cells
OUTLET:DEYICE
Obstruction: vegetation/debris/sediment
Erosion/undercuttin
Structural condition
Sediment in pipe
Joint failure/loss of'oint material/soil pining
Displacement of fabrichi -ra J✓
Fully Functional (No Repairs Needed)=Pass for Inspection
r Partially Functional{Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
N/A Not Applicable
i.

LEVEL SPREADER
INLET/FLOW SPUTTER DEVICE
Assessment Code Status Comments
Obstruction: vegetation/debris/sediment
Ri Ra Dis lacement/Sedimentation
Structural Condition
POOLING AREA AND LEVEL LIP
Sediment/debris accumulation
Level li is cracked, settled, undercut or eroded
Stormwater is by- assin level s reader
Woody Vegetation growth in pooling area or on levels
Grass is maintained as mowed
Nuisance Vegetation is Present
FILTER STRIP
Grass len h: too short/too Ion
Bare soil/erosive llies
Sediment accumulation
Nuisance ve etation is resent MISCELLANEOUS
Trash/debris r
Access
Evidence of routine maintenaEEEnce bein erformed?
ADDITIONAL COMMENTS
ry by
Date of Inspection f�
Time of Inspection 3d >n
Weather at time of inspection
Inspection Type:Monthly or Rain
Event
Rain Event Amount 1.
PASS Or FAIL (Circle One)
s
FF any Functional (No Repairs Needed)=Pass for Inspection
PF Partially Functional(Repairs Needed)=Fall the Inspection
NF Not Functional(Repairs Needed)-Fall the Inspection
NIA Not Applicable

k Mocksidle July 2021 Rainfall Data
WRain
is
IC?
41,
G!26 0 Q-, 0

Daily Rainfall Totals
i
Aug-21 WFBH Urgent Care-Mocksville
Day Amount of Rainfall Comments
1 0.3
2
3
4
5
6
7 0.3
8
9
10
11 0.3
12
13
14
15
16 0.5
17 0.8
18
19
20
21
22 0.2
23
24
25
26
27
28
29
30
31 0.2

Wake Forest"
Baptist Health
( MONTHLY/RAIN EVENT STORMWATER BMP CHECKLIST
The Stormwater BMP Checklist must be performed monthly and when it has rained more than 1 inch
within 24 hours.
BMP Site Name: Medical Pavilion-Mocksville 1188 Yadkinville Rd.,Mocksville NC
Inspector's Name:
BIORETENTION AREA
Assessment
CofiR�S>as F,, ammenis " '� `Obstruction: vegetation/debris/sediment -
Erosion/undercutting L a
Structural condition r
Dis lacement/sedimentation of fabric/ri -ra
.< ".;PERIMETERISID
ESLOPES�EItxBANKI♦%IL'IT '
Sediment/debris accumulation
Bare soil/erosion
Woody vegetation
ass maintained as mowed
PRE=TREATMENTAREA ; oreba', asgrsw�Ies`'"&, ►er es,,; ` aveI'<Sediment/deb ri 1 accumulation
Erosion/gullies resent
Invasive vegetation
Flow is b -passing pretreatment '/
• (f
BIORETElYIC}NGE,TsI ' er
CJvergrown vegetation(requires Tuning)
Plants are dead, diseased, or dying(Replace such plants
as necessary Per on inal a roved construction
Mulch is decomposed or displaced P
Soils/mulch clogged with sediment
r;
Evidence of lack of proper drainage(i.e., dead plants,
or successional wetland vegetation)
Bare or eroded areas in grass cellsr
P
Obstruction: vegetation/debris/sediment OUTLET.DEVIGE
Erosion/undercutting
Structural condition
Sediment in pie
Joint failure/loss of'oint materiaUsoil i ing �l
Qs placement of fabric/ri -ra
� a�
Fully Functional {No Repairs Needed)=Pass for Inspection
Partially Functional(Repairs Needed)=Fail the Inspection
NF Not Functional(Repairs Needed)=Fall the Inspection
NIA Not Applicable
r

LEVELSPREADER
INLET/FLOW SPLITTER DEVICE
Code Status Comments
Assessment � _
Obstruction: ve etation/debris/sediment
Ri Ra Dis lacemendSedimentation
Structural Condition
POOLING AREA AND LEVEL LIP
Sediment/debris accumulation
Level lip is cracked, settled,undercut or eroded
Stormwater is b - assin levels reader
Woody Vegetation growth in pooling area or on level
h
Grass is maintained as mowed I
Nuisance Ve etation is Present
FILTER STRIP
Grass iength: too short/too long)
Bare soil/erosive gullies
Sediment accumulation
Nuisance ve etation is resent MISCELLANEOUS
Trash/debris y�
Access
Evidence of routine maintenance being performed?
ADDITIONAL COMMENTS �..
te. a .Ole
LIP
vee
Gr t r < t
Date of Inspection
Time of inspection
� y
Weather at time of inspection l¢
Inspection Type:Monthly or Rain � /
Event
Rain Event Amount
PASS r FAI (Circle One)
t
s
EN/AFF Fully Functional (No Repairs Needed)=Pass for Inspection
pF Partially Functional(Repairs Needed) Fall the Inspection
NF Not Functional(Repairs Needed)=Fail the Inspection
Not Applicable

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