NCC242563_FRO Submitted_20240826

MODIFIED FIRST PAGE
OF FR/O FORM PER
NCDEQ- DEMLR- LQS
INSTRUCTIONS
FOR
E & SC PERMIT
MODIFICATION
( COVER LETTER
ENCLOSED FOR
REFERENCE )

H
Hazen and Sawyer
620 Green Valley Road,Suite 101
azeii Greensboro,NC 27408 336.292.7490
February 14, 2024
Ms. Nichole Chiles
NCDEQ—Division of Energy, Mineral and Land Resources
450 West Hanes Mill Road,Suite 300
Winston-Salem, NC 27105
Re: Fiddlers Creek Outfall Replacement Project(FORSY-2023-001)
Request for Permit Modification
Dear Ms. Chiles,
Winston-Salem/ Forsyth County Utilities (WSFCU) has elected to proceed with the abandonment of the
existing manholes along the parallel segment of the south outfall adjacent to the referenced project (see
MHs in red on DWG G7; i.e.the (30) MHs with the 'OPT-' prefix). Per preliminary discussions with
NCDEQ this work will require a permit modification such that additional disturbed area,which includes
the proposed work, can be incorporated into the project(see red LOD boundaries on DWG G7).The
following materials, described below, have been enclosed for your review and approval for the request
to amend the existing erosion and sedimentation control permit:
• One (1) copy of revised first page of the FR/0 Form, indicating that the disturbed area associated
with this permit will increase from 19.3 AC±to 25.6 AC±.
• One (1) check made payable to NCDEQ, in the amount of [6.3 AC Additional LOD— (20 AC—19.3
AC permitted LOD) = 5.6 AC± (Net) Disturbed x$100/whole AC=] $600.00
• One (1)full size (24"x36") and one (1) half size (11"x17", NTS) of the following revised drawings:
o DWG G7 (with background aerial imagery) —shows the existing (30) MHs (in red) along
the south outfall to be abandoned ('OPT-' prefix), and additional disturbed area (in red)
to be incorporated into the permit to perform the work. The proposed additional
disturbed area consists of the existing 30-ft permanent utility easement dedicated to the
south outfall, as it will be needed as contingency to cover incidental land disturbances in
moving equipment from one MH to another.
o DWG G7 (without background aerial imagery)—same as above but with no imagery.
o DWG G8—unchanged, included for reference
o DWG D8 — Detail 3/D8 shows a typical detail for localized erosion control measures
around each manhole to be abandoned along the south outfall,to be installed as needed.
Please do not hesitate to contact me if you have any questions or need additional information.Thank
you for your time and assistance in reviewing this application.
Sincerely,
cc: Corbin Willard, Derek Stroud, WSFCU
File (32550-000)
hazenandsawyer.com

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Fiddlers Creek Outfall Replacement (FORSY-2023-001)
2. Location of land-disturbing activity: County Forsyth City or Township Winston-Salem
N/A 36.03433(N) -80.21583(W)
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: February 2023 (ongoing)
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
Utilities (Sanitary Sewer)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):25.6 AC +\-
6. Amount of fee enclosed: $600.00 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brad Bennett, PE E-mail Address [e-mail]
Phone: Office# 336.478.3367 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached 'Property Owner Table'
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. _ Page No. Provide a copy of the most current deed.

ORIGINAL FR/O FORM

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Fiddlers Creek Outfall Replacement
2. Location of land-disturbing activity: County Forsyth City or Township Winston-Salem
36.03433(N) -80.21583(W)
Highway/Street N/A Latitude(declmal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: February 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Utilities (Sanitary Sewer)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 19.3 AC +\-
6. Amount of fee enclosed: $2'000 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed ❑x No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brad Bennett, PE E-mail Address bbennett©hazenandsawyer.com
Phone: office# 336.478.3367 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached 'Landowners of Record' List
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Winston-Salem/Forsyth County Utilities Commission [e-mail]
Company Name E-mail Address
P.O. Box 2511 101 N. Main St.
Current Mailing Address Current Street Address
Winston-Salem, NC 27102 Winston-Salem, NC 27101
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Michael Stover, PE Deputy Utilities Director
Type or ri na Title or Authority
7701 /207;z--
ignature Date
I, ( +rc ..r. qr Glemn , a Notary Public of the County of t:St.,,VI
State of North Carolina, hereby certify that A ,(}-)C, ) . appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this da f , 20 .,:, � •
\k--)
Notary
• Qt,..0' ,... '•,, ''.:Tle•. My commission expires IV) ' -o��.
NOTARY %
PUBLIC
.• My Comm.Exp,
April 10, 027
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