SW4170601 - Dollar General - Belews Creek

DEMLR USE ONLY
Date Received
Fee Paid
er
Permit Numb47
r
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ Mgmt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original ��►' 'lJ
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I. GENERAL INFORMATION (
1. Project Name (subdivision, facility, or establishment name - should be consistent with projec na eon
specifications, letters, operation and maintenance agreements, etc.):
Dollar General - Belews Creek NC
2. Location of Project (street address). �w g
0 Belews Creek Road p p C 1V
City:Belews Creek Co ty:Fors th 1N 7�j 2W
3. Directions to project (from nearest major intersectio
DENR-LAND QUALITY
Head North on US 158 take a slight left on to Belews Creek Road. Property is, �,�;RFRM1SY101t4�^3i eft.
You will pass Charity Baptist Church and the property is located at the intersection of HWY 65 & Belews
4. Latitude:36° 24' 224 ' f Longitude: 80° 7 6" W Y.3P-L of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenewals with modifications also requires SWLi-102 - Renewal Application Form
b. If this application is being submitted as the result of a modification to an existing permit, list the existing
permit numberN/A , its issue date (if known) , and the status of
construction: ❑Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certification
Specify the type of project (check one):
®Low Density ❑High Density ❑Drains to an Offsite Stormwater System ❑Other
3. If this application is being submitted as the result of a previously returned application or a letter from
DEMLR requesting a state stormwater management permit application, list the stormwater project number,
if assigned, N/A and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major ®Sedimentation/Erosion Control: 3.45 ac of Disturbed Area
❑NPDES Industrial Stormwater ❑404/401 Permit: Proposed Impacts
b. If any of these permits have already been acquired please provide the Project Name, Project/ Permit Number,
issue date and the type of each permit:Erosion Control applied for with City of Winston Salem/Forsyth
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: http://12ortal.ncdenr.org/web/lr/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6

III.. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization:Teramore Construction, LLC
Signing Official & Title:ieffrey Lang
b. Contact information for person listed in item 1a above:
Street Address:1970 Derita Road
City.Concord State.NC Zip:28027
Mailing Address (if applicable):
City:
Phone: (229 ) 516-4289
Email:[e-mail]
State: Zip:
Fax: (229 ) 516-4229
c. Please check the appropriate box. The applicant listed above is:
❑ The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
® Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/Organization:Carolyn Russell & Dianne Lane
Signing Official & Title Carolyn Russell & Dianne Lane
b. Contact information for person listed in item 2a above:
Street Address:PO Box 553
City:Vanceboro
Mailing Address (if
City.
State -NC
State:
Phone: ( ) N/A Fax:.(N/A )
Email:N/A
Zip:28586
Zip:
3. a. (Optional) Print the name and title of another contact such as the project's construction supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization:BREC, PA
Signing Official & Titlejustin C. Church - Principal Engineer
b. Contact information for person listed in item 3a above:
Mailing Address:126 Executive Drive - Suite 220
City:Wilkesboro
State:NC
Zip:28697
Phone: (336 ) 844-4088 Fax: (336 ) 609-7726
Email:justin®brec.biz
4. Local jurisdiction for building permits: City of Winston Salem/ Forsyth County
Point of Contact:Fred Holbrook Phone #: (336 ) 727-2328
Form S)VU-101 Version Oct. 31, 2013 Page 2 of 6

1 IV.. PROJECT INFORMATION
1. In the space provided below, hiLefly summarize how the stormwater runoff will be treated.
An above ground sand filter will be used to treat runoff from all impervious surfaces of a proposed
9,100 sq ft Dollar General store.
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b. If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW -1995 ❑ Ph II - Post Construction
3. Stormwater runoff from this project drains to the Roanoke
4 Total Property Area: 3.1 acres
River basin.
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+: 3.1 acres
+ Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
betzoeen the banks of streams and rivers, the area below the Normal High Water (NHW) line or Mean High Water
(MHW) line, and coastal zvetlands landzvard from the NHW (or MH[M lune. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal zvetlands landzvard of the NHW (or MHW) line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = .67/3.1=23.0 %
9. How many drainage areas does the project have?1 (For high density, count 1 for each proposed engineered
stormzoater BMP. For lozv density and other projects, use 1 for the whole property area)
10. Complete the following information for each drainage area identified in Project Information item 9. If there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below.
Basin Information
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area
Receiving Stream Name
West Belews
Creek
18,155
On-site Sidewalks (so
1,873
Stream Class
C
Future (sf)
0
Off-site (so
Stream Index Number *
22-27-9-(3)
0
Total (so:
31,039
Total Drainage Area (so
57,719
On-site Drainage Area (so
55,975
Off-site Drainage Area (sf)
1,744
Proposed Impervious Area** s
31,039
Impervious Area** (total)
23.0
Impervious- Surface Area
Drainage Area 1 Drainage Area _ Drainage Area _ Drainage Area
On-site Buildmgs/Lots (so
9,301
On-site Streets (so
0
On-site Parking (so
18,155
On-site Sidewalks (so
1,873
Other on-site (so
0
Future (sf)
0
Off-site (so
1,710
Existing BUA*** (sf)
0
Total (so:
31,039
Stream Class and Index Number can be determined at: http.Y&ortal.ncdenr.orhvg eb1zvq&s/csu/classi cations
Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

**Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
11. How was the off-site impervious area listed above determined? Provide documentation. Field Survey
Proiects in Union County: Contact DEMLR Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that maybe subject to more stringent stormwater requirements as per 15A NCAC 02B. 0600
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from hft://portal.ncdenr.org/web/wq/WS/-SU/bmp-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
htlp.//portal.ncdenr.org/web/wq/ws/su/statesw/forms docs. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map at hqp.//portal.ncdenr.org/web/wq/­`ws/­su/maps.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from http:/ /portal ncdenr.org/web/wq/ws/su/statesw/forms docs.
'ti is
1. Original and one copy of the Stormwater Management Permit Application Form. v
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M nfc
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
hft://www.envhelp.org/pages/onestopexpress.html for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting)
5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including: L
a. Development/ Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/ project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
in. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

in. Existing drainage (including off-site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required). ^
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify 4j
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"x11" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DEMLR to venfij the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: Page No:
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item 1a, 2a, and/or 3a per 15A NCAC 21-1.1003(e).
The corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
hgp://www.secretaly.state.nc.us/Corporations/CSearch.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided
as an attachment to the completed and notarized deed restriction form. The appropriate deed restrictions and
protective covenants forms can be downloaded from http://12ortal.ncdenr.org/web/lr/state-stormwater-
forms docs. Download the latest versions for each submittal.
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and listed
on the forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DEMLR, and that they will be recorded prior to the sale of any lot.
VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
Consulting Engineerjustin C. Church
Consulting Firm: BREL PA
Mailing Address:126 Executive Drive - Suite 220
City: Wilkesboro
Phone: (336 ) 844-4088
Email:[e-mail]
State:NC
Zip:28697
Fax: (336 ) 609-7726
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) Carolyn Russell & Dianne Lane , certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed to Contact Information, item 1a) jeBrett Lang with (print or hjpe name of organization listed in
Contact Information, item 1a) Teramore Construction, LLC to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWU-101 Version Oct. 31, 2013 Page 5 of 6

, " " A�, the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
ag;nt (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR immediately and
submit a completed Name/ Ownership Change Form within 30 days; otherwise I will be operating a stormwater
treatment facility without a valid permit. I understand that the operation of a stormwater treatment facility
without a valid permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement
action including the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature: Date:
I, a Notary Public for the State of County of
, do hereby certify that personally appeared
before me this _ day of and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item 1a) Teramore Constncction LLC - Teffrey Lang
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protective covenants will be recorded, and that the proposed project complies with the requirements of the
applicable stormwater rules under 15A NCAC 21-1.1000 and any other applicable state stormwater requirements.
Signature:
I,
a Notary Public for the State of
do hereby certify that
before me this _ day of
Date:
County of
personally appeared
, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission
Form SWW-101 Version Oct. 31, 2013 Page 6 of 6

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