SW4191202_Permit Application_1/2/2020

Mi. 0lVla
Date Received Fee Paid Permit Number
Applicable.Rules:. © Coastal SW -1995: 0 .Coastal.SW —:2608 .0 Ph II - Post Construction
(select.nIllhat apply) 0 Non -Coastal. SW- HQW/ORW Waters ❑ Universal 5tormwater Management Plan
0 Other WQ M t Plan:
State of North Carolina
Deparbrient of Environment and.Natural Resources
Division of. Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photacepied far use as an orighial
I. GENERAL. INFORMATION
1. Project Name(subdivision, facility;.or:establishment name - should be consistent with project name on plans,
specifications, fetters, operation and.maintenance agreements, etc.):
Matcor Metal Fabrication Site Improvements
Location of Project (street address):
835 Salem Road
City. -Welcome
County:Davidson.
3. Directions to project (from nearest major intersection):
Zip:27874
From the intersection of Salem Road (SR 182Z) and OId US HW_Y 52, proceed southeast on Salem Road.
The site is annroximately 1.650 feet from the intersection of Salem Road and Old US HWY 52.
4. Latitude:35° 53' 45" N Longitude:-80 15' .U9" W of the main entrance to the. project.
II.. PERMIT INFORMATION:
1, a. Specify whether project is (check one): NNew ❑Modification ❑ Renewal w/ Modificationi
tRenezuals. zoith inodifications also requires. SWU7102 — Renewal Application Form
U.If .this application is being submitted as the result of a modification to an existing permit, list the existing
permit -number its. issue date (if known). and. the status. of
construction:. ❑Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certification
2. Specify.the type of project (check one):
[]Low Density NHigh 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.states torrnwater management permit application, list the stormwater project number,
if assigned, and the.previous. name of the project, if different than currently
proposed,.
4. a. Additional Project Requirements.. (check applicable blanks, information on required statepermits canoe
obtained by contacting the Customer Service•Center at 1-877-623-6748):
❑CAMA Major NSedimentation/Erosion Control:.3.66 ac of Disturbed Area
❑N.PDDES Industrial 5torrawater ❑404/401 Permit: Proposed Impacts
U:If any of these permits have already been acquired please provide the Project Name, Project/.PermitNumber,
issue date and the type of each permit E&SC Approval.- Matcor Metal Fabrication Site Improvements,
bavid-202Q-014
5. Is the project located within 5 miles of a. public airport? NNo ❑Yes
If yes, see S.L. 2012-200, Part VP http,.//portal.ncdenr.org/web/lrlr.ales=and-regLilations
Form..SWU-10I Version Oct. 31, 20.0 Page i of 6

* * Report only that: rantount of existing. BUA..ilia..t wild: rerttrairr rafter development: Do. not report any existing BUA that
is to be rentoved and.wliich zoild be replaced by crew BUA.
11. How was the off -site impervious area listed above determined? Provide doeumentation..N/A _
Projects in Union County:. ContactDEML'R Central Office staff to. check if the project is located }vithin a 7'hmaienod &
Endangered Species ►watershed that may be subject io tnore stringent scorn:}voter regrrirenrents as per 15A.. NCAC 02B .060.0.
V. SUPPLEMENT AND O&M FORMS
Theapplicablestate stormwater management permit supplement. and operation and.maintenance (O&M) forms
must:be submitted. for each BMP specified for #his .project. The latest versions: ofthe fortes can be downloaded
from htt j lvortal.ncdenr.org/NQb/­yq/­ws/su/­
bmp-manual.
VI.. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed. by the :Division of Energy, Miiieral and.
Land Resources (DEMLR). A complete package includes-allof the. items listed. below. A. detailed application
instruction sheet and BMP checklists are available from
htt .://portaI.ncdenr.6rg 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 atlittIL./_/portal.ncd nr.arg/web"ly Zws suLmaps:)
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 applieatioti package.frorii bttp://portal.ncd6nr;org/web/wg/ws/su/statesw/farms .does.
In, als
1. OriginaI and one copy of the.Stormwater Management:PermitApplicatiori Form.
2. OrfghW and one copy of the signed and notarized Deed -Restrictions & Protective. Covenants _ J►l A
Form. (if required as per Part V11 beloert)
3. Original of:the.applicable Supplement.Form(s) (sealed, signed and dated) and O&M
agreement(s) for. each. BMP.
4. Permit application processing fee of.$505-payabde to NCDENR, (For an.Express review, refer to
http1Lwww.enyhelp.oTg/pages/onestopexpress.htmi for information on..the Express program
and the associated. fees. Contact the appropriate xegional 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/management for
b. A USGS map identifying the site location. If the receiving stream is reported as class SA or the CAL
receiving stream drains to class SA. waters within 1h mile of the site`boundary, include. the ih.
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:
a. Development/Project.name.
1b. 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 delineatingthe normal pool elevation of
impounded structures, the banks of streams:and.rivers, the MHW or N. 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 (orIVHW) 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
.qualified person. Provide document400n.of.qualifications and identify the person who
made the determination on the plans:
n. 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):
Fonn SWU-101 Ve.rsion..Oct. 31., 2013. Page 4 of6

p. Vegetated buffers (where: required).
10..A copy of the most current property deed. Deed book .1930 Page No; 1728
11, For corporations and limited liabiI'ity 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 Ia, 2a, and/or 3a per. 15A.NCAC 21-1.1003(e).
The. corporation or 1 LC must be listed as an active corporation in good standing with the. NC
Secretary of State, otherwise the:applicatian will he returned.
http: / /www.secretary.state.ne.us/Corporations/CSearch.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
9. Copy of any applicable soils report with.the associated SHWT elevations. (Please identify
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"x1V' copy of the NRCS County. Soils .map with the
project areaclearly delineated. For projects with infiltration SMPs; the reportshould.also
include the. soil type, expected..infiltration.rate, and the method of determining the infiltration: rate
(Infiltration Devices submi Red to,WIRO:'.ScJ2edide n.site visit far DEMLR to verify fire SHWr prior
to srbinitfnl;. t910) 796-7378.)
1--l7wo .
.For.aI]: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 Iot number,.lot size, and the allowable built -upon area must be
provided as:awattachnient to the completed and notarized deed restriction. form. The appropriate :deed
restrictions and. protective.covenants forrns:canbe downloaded. from http://portal.ncdenr.orgJwebllrlstate-
stormwater=forms .docs..Download the latest versions for each submittal.
In the instances where the applicantis 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 signatures) below, the permit holder(s) certify that the recordedproperty restrictions. and
protective covenants for this project, if required, shall include all. the items.required in the permitand listed..
on the forms available on the website, tliat. 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 DEML,R, 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 Engineer:L. Allan :.Hill -PE
Consulting Firm: Triad Design Group, PC
Mailing Address:4807-C Koger Boulevard
City: Greensboro State:NC Zip:27407
Phone: f336j 218-828 _ -- Fax: (336 ] 218-8010
Ema.il:ahfll@iriad-degignSiou'p.com
Sioup.com
IN. PROPERTY .OWNER AUTHORIZATION(if Contact.Inforination, ifein 2 has.beenflled out,.contplefe this
section)
l) (Print or type if ante of person listed. in Contact Information 'tent 1a) certify that I.
.own. the property identified in.this permit application, and thus give permission to (print or hype name of person.
listed infonfsct hiforrrurtion, item lawith (print.or type name of organization.listed:.in.
Contact hiforanation, iten0a) to develop the project as. currently proposed. A copy of
the leasengreement 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 SWU7101 Version Oct: 31,1013 Page 5 of

III. CONTACT INFORMATION
1. a. Print Applicant / Rg ]ng Official's name and title (specifically the developer, .property owner, lessee,
designated government. official, individual, etc. who owns the. Project :
Applicant/Organization:Matcor Metal Fabrication Inc.
Signing Official & Title:TgDy Coomer/Director of Operations
b. Contactiin.formation. for person. listed in item la above:
Street Address:835.Salem Road
City:Welcome State -NC Zip:27374
Mailing Address (if applicable):P. O: Box .729
City: Welcome
Phone: [phone]
Email:.ibogoje@mate ormetalfab. com
State:NC Zip;27374
.Fax: f 1 -
c. Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact liiformatibn; item 3a)
❑ Lessee* (Attach a copy of the. lease. agreement and complete. Contact Information, item 2a and 2b below)
Fj 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 O:wner'sname and title below, if you :are the lessee, purchaser or developer. (This isthe:
Person who owns. the property that the project is located on):
Property Owner/Organza
Signing Official & Title:_
b .Contact. information for person listed in item 2a above:
Street Address:
City:.
.Mailing Address .(if applicable):
State:
Zip::
City: State: Zip:
Phone: f ] Pax:
Email:
3. a. (Optional) Print the naive and title: of another contact such as the projeces construction supervisor or other
person who can answer questions about the project:
Other Contact:Person/Organization:Tony Coomer/Matcor.Metal Fabrication
Signing Official & Title.:Ton Coomer Director of Operations
b. Contact informationfor person listed in item 3a above:
Mailing Address:835 Salem.Road
City:Welcome State:NC Zip:27374
Phone: Q36 ) 731-5783 Fax: { )
Email:[e-mail]
4. Local jurisdiction for building permits:. Davidson County
Point of Contact:Tod Hancock Phone ##; 336 242-2807
Form S WU-101 Version Oct 31, M 3. Page 2 of 4

IV. PROJECT INFORMATION
L In the space -provided below, briefly summarize how the storinwater-runoff will be treated.
The. proposed new built -upon area. and a_portion of the_existigggbuilt-upon area will be directed to the
proposed wet detention pond by it series of proposed storm drains. Thepond will be designed per the
current NCDEO Stormwater Manual.
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.xights, identify the regulations) the project. has been designed in accordance with:
❑ Coastal SW 1995 ❑ Ph IT - Post Construction
3. Stormwater runoff from this project drains to the Yadkin Pee -Dee River:basin,
4.. Total Property.Area: 32.11 acres: 5. Total Coastal Wetlands .Area 0.00 acres
6. Total Surface Water Area: 0.00 acres
7. Total Property Area.(4) -Total Coastal Wetlands. Area. (5) - Total Surface Water Area (b) = Total Project.
Area:' 32.11 acres
Total project area shall be calculated to eachide the followtaig: the norinal pool .af ini ppunded stnlctures, the area
between the batiks of streams and rivers, the area:below the Nornial High Wafer (NH.M Tine. or Mean: High Water
(MHM line, and coastal ivetlands lgndivard front the NHW (or MHM litre, The. resultant project area is. used to
calcidate. merM percent built upa.n:area (BETA ). Nan=coastal zvetlairds landivard of the NHW.(or:A4 Wj lisle nzay
be included in the total project area;
8. Project percent:of impervious area:.(`1.'otal Iinperviaus Area Total Project Area) X 100 = 31.36. 'o
9. How many drainage areas does the project slave?1. (For.l;igh densihj, count 1 for eiaclt proposed engineered
stovnyi) rter BMP. For lore densihj and -other pr*cts, itse 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.:.
Draina e: Area l:.,
:Drama e::P;:rea`;:::L
-Drama e;Area: ;: L>
Draina e:"P
Receiving Stream Name
Easter Creek
Stream Class*
C
Stream Index Number *
12-119-84-1
Total Drainage:Area.(sf}
147233
On -site Draina e Area (so
147233
Off -site Drainage Area (sf)
0
Proposed Impervious Area s
108464.
% Impervious Area'* total
73:67
Ixri "ervious :Surface Area::. :...::.Drama
tea: ::..
rains g tea:_ :<
.; rains tea;::::.
= : xartta e.
On -site Buildings/ Lots (so
0
Ori=site Streets (SO
0
On -site Parking (so
29185
On -site. Sidewalks (sD
0
Other on -site. [sf)
0
Future so
0
Off -site (so
0
Existing BUA**' (sf).
79279
Total (sf):
109464
* .Stream Class and Index Malnber can be.deterinined at:. ht!p,*brtril.arcdenreb/rvr� ,org1 /ns�csu/classificrrtians
I71Ipen11O1[s area Is def ned as the beat upon. area including, but not limited to, buildings, roads, parking areas,
sideroalks,.gravel areas, etc..
Form.SWU-101 Version Oct..31,,2013 Page of

As. the legal property owner I acknowledge, understand, and.agree by my signature below,that if my designated.
agent (entity listed in Contact Information, item!) 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 rne,. the property owner, .As the property owner, itis myresponsibility to.notify DEMLR imriiediately and
submit a completed..Narne/Cwnexsltip<Change. Form within M days; otherwise I will be. operating a stormwater:
treatment. facility without a v4lid permit. 1.. understand -that the operation of a star mwater treatment.facility
without a valid permit is a violation of NC General Statue`143-.215:1 and may, resultin appropriate' enforcement.
action including the assessment.of civil penalties of:up to $25,000 per day, pursuant to. MCGS 143m-215.6.
Signa
a Nofary.Public fox 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 expires
3G APPLICANT'S CERTIFICATION
nt or hype Warne. of persdn lWed.f i CMtact Information, item 1a) Tonv CoorrierlDirectdr of OperationslMate r Met
certify that Elie 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 b ord and that the proposed project complies with the requirements of the.
applicable storsnruater reFlps d 1 CAC 3H.1000 and any other applicable state storrmwateer requirements.
5igriature:
Date:. I 2_[ Zal L
I, _ .C� �� , an ___ a Notary Public for the State of �_ 1✓�.. rCL • County of
,� ui d _c� � , do hereby certify .that _TMI U C b nD,.Q_r __ Personally appeared.
before..me this 4 day of
a stormwater permit. Witness. my hand and
y0000111111IF!!F!!Fl,,
,=
r
Jaf.4�d PJ L LJo�!"IES�~yL��4oe.
arF@d;:dill i�i%iSE9R4
,and ackno ledge the due executiQn of the a plication for
official seal,.
SEAL
My commission expires u 3 ! 11 JZ 0
Form.SVM-101 Version Oct. 31,.2033 Page 6 of