SW4080503_CURRENT PERMIT_20091014

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW�mzS��7
DOC TYPE
�DCURRENT PERMIT
ff APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE
�DDq�'�
YYYYMMDD

State Stormwater Permit
Permit No. SW4080503
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of
North Carolina as amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Wake Forest University Baptist Medical Center
Primary Care of Mocksville
1188 Yadkinville Road, Mocksville, North Carolina
Davie County
FOR THE
construction, operation and maintenance of a bioretention basin in compliance with the
provisions of Session Law 2006-246 and 15A NCAC 2H .1000 (hereafter referred to as
the "stormwater rules') and the approved stormwater management plans and
specifications and other supporting data as attached and on file with and approved by
the Division of Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until June 1, 2018, and shall be
subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
1. This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. This stormwater system has been approved for the management of stormwater
runoff as described in Section 1.7 on page 3 of this permit. The stormwater
control has been designed to handle the runoff from 37,880 square feet of
impervious area.
3. The tract will be limited to the amount of built -upon area as indicated in Section
1.7 of this permit, and per the application documents and as shown on the
approved plans.
4. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
5. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
6. The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
Page 1 of 6

State Stormwater Permit
Permit No. SW4080503
7. The following design criteria have been provided in the bioretention basin and
must be maintained at design condition:
a. Drainage Area, acres:
Onsite, ft :
Offsite, ft2:
b. Total Impervious Surfaces, ft2:
Onsite, ft
Offsite, ft
2:
C. Design Storm, inches:
d. Max. Ponded Depth, feet:
e. Seasonal High Water Table, fmsl:
f. Planting Media Depth, feet:
g. Basin Dimensions, feet:
h. Bottom Elevation, fisl:
i. Top Surface Area, ft
j. Permitted Storage Volume, ft3:
k. Bypass / Storage Elevation, fmsl:
I. Predevelopment 1 year 24 hour:
m. Post development 1 year 24 hour.:
n. Drawdown Time, hours:
o. Underdrain Diameter, inches:
P. Total number of plants provided:
q. Receiving Stream/River Basin:
r. Stream Index Number-
s. Classification of Water Body:
II. SCHEDULE OF COMPLIANCE
1.5
57;817
0
36,539
36,539
0
1.0"
9.0"
822.0
2'
95'x58'
833.0
4,543.0
3,109.0
835.75
0.9 ft3/sec
2.62 ft /sec
<48 hours
6" PVC
See Sheet C-5.0
Bear Creek / South Yadkin
12-108-18-(3)
WS-IV
1. The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use prior to the construction of any
built -upon surface.
2. During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
3. The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted stormwater system functions at optimum efficiency. The
approved Operation and Maintenance Plan must be followed in its entirety and
maintenance must occur at the scheduled intervals including, but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and re -vegetation of slopes and the filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
f. Debris removal and unclogging of all drainage structures, level spreader,
filter media, planting media, underdrains, catch basins and piping.
g. Access to the basin and outlet structure must be available at all times.
4. Records of maintenance activities must be kept for each permitted BMP. The
reports will indicate the date, activity, name of person performing the work and
what actions were taken.
5. The permittee shall submit to the Division of Water Quality an annual summary
report of the maintenance and inspection records for each BMP. The report
shall summarize the inspection dates, results of the inspections, and the
maintenance work performed at each inspection.
Page 2 of 6

State Stormwater Permit
Permit No. SW4080503
6. The facilities shall be constructed as shown on the approved plans. This permit
shall become void unless the facilities are constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other
supporting data.
7. Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received
from an appropriate designer for the system installed certifying that the permitted
facility has been installed in accordance with this permit, the approved plans and
specifications, and other supporting documentation. Any deviations from the
approved plans and specifications must be noted on the Certification. A
modification may be required for those deviations.
8. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
9. Access to the stormwater facilities shall be maintained via appropriate recorded
easements at all times.
10. The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval or a CAMA
Major permit was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
11. The permittee shall submit final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
12. A copy of the approved plans and specifications shall be maintained on file by
the Permittee for a minimum of ten years from the date of the completion of
construction.
13. The Director may notify the permittee when the permitted site does not meet one
or more of the minimum requirements of the permit. Within the time frame
specified in the notice, the permittee shall submit a written time schedule to the
Director for modifying the site to meet minimum requirements. The permittee
shall provide copies of revised plans and certification in writing to the Director
that the changes have been made.
III. GENERAL CONDITIONS
1. This permit is not transferable except after notice to and approval by the Director.
In the event of a change of ownership, or a name change, the permittee must
submit a completed Name/Ownership Change form signed by both parties, to the
Division of Water Quality, accompanied by the supporting documentation as
listed on page 2 of the form. The approval of this request will be considered on
its merits and may or may not be approved.
Page 3 of 6

State Stormwater Permit
Permit No. SW4080503
2. The permittee is responsible for compliance with all permit conditions until such
time as the Division approves a request to transfer the permit. `
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Water Quality, in
accordance with North Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation
of nuisance conditions, the Permittee shall take immediate corrective action,
including those as may be required by this Division, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants DENR Staff permission to enter the property during normal
business hours for the purpose of inspecting all components'of the permitted
stormwater management facility.
7. The permit issued shall continue in force and effect until revoked or terminated.
The permit may be modified, revoked and reissued or terminated for cause. The
filing of a request for a permit modification, revocation and re -issuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
10. The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Session Law 2006-
246, Title 15A NCAC 2H.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division in writing of any name, ownership or
mailing address changes at least 30 days prior to making such changes.
Permit issued this the 4th day of June 2008.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
(or"Cdleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission
Page 4 of 6

State Stormwater Permit
Permit No. SW4080503
Primary Care of Mocksville
Stormwater Permit No. SW4080503
Davie County
Designer's Certification
I, , as a duly registered in the
State of North Carolina, having been authorized to observe (periodically/ weekly/
full time) the construction of the project,
(Project Name)
for (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
Page 5 of 6

State Stormwater Permit
Permit No. SW4080503
Certification Requirements:
—1. The drainage area to the system contains approximately the permitted
acreage.
_2. The drainage area to the system contains no more than the permitted
amount of built -upon area.
_3. All the built -upon area associated with the project is graded such that the
runoff drains to the system.
_4. , All roof drains are located such that the runoff is directed into the system.
_5. The outlet/bypass structure elevations are per the approved plan.
_6. The outlet structure is located per the approved plans.
_7. Trash rack is provided on the outlet/bypass structure.
8. All slopes are grassed with permanent vegetation, per the vegetation plan.
_9. Vegetated slopes are no steeper than 3:1.
_10. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
_11. The permitted amounts of surface area and/or volume have been
provided.
—12. Required drawdown devices are correctly sized per the approved plans.
_13. All required design depths are provided.
—14. All required parts of the system are provided, such as a vegetated shelf,
and a forebay.
_15. The required system dimensions are provided per the approved plans.
cc: NCDENR-DWQ Regional Office
Davie County Building Inspections
Page 6 of 6

�oy RECEIVED
N.C. Dept of ENR
R ROBINSON & OCT 14 2009
'y S
SAWYER1c9ior,al INC, Region
•.-r - - CONSULTING ENGINEERS & LAND SURVEYORS -EST: 1962
707 E. SECOND AVE. o GASTONIA, NORTH CAROLINA 28054 o PHONE: [phone] o FAX: [phone]
October 13, 2009
NCDENR
Storm Water Permitting
585 Waughtown Street
Winston-Salem, NC 27107-2241
RE: Designer's Certification — Primary Care of Mocksville — High Density
Commercial Bio-Retention Project - Stormwater Permit No. SW4080503 —
Davie County
To Whom It May Concern:
Please find enclosed the Designer's Certification for the above referenced project.
Should you have any questions or need any additional information, please do not
hesitate to call me or e-mail me at dsmith(a�robinson-sawyer.com.
Sincerely,
Robinson & Sawyer, Inc.
Donald D. Smith, PE
President
Cc: T.R. Bowers
Paul Ouellette
Keith Fleming

State Stormwater Permit
Permit No. SW4080503
Primary Care of Mocksville
Stormwater Permit No. SW4080503
Davie Countv
Designer's Certification
I, �o„�!d !� �.��as a duly registered in the
State of North Carolina, having been authorized to observd weekly/
full time) the construction of the project,
P,- m .e il-,I 6 , e o
lOCZ-�, S !//}// G
(Project Name)
for 01,4 7 /Zwe si (�,�'�✓- 13, PT/s7' (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification-
�/a� o n-�X-2 7-111W /�
t/FG/T�T�D -S�oPE EXc��I�j 3"/ .SLDfE 'C>/la "VOT- /r e( QIT �'�CrO�fSTC' 4(r
SEAL
Signature LW�N ,FARO ,
4 oF� ss�o . lA,y�,,,+
Registration Number IZ493 7 �.Q�, ��'••9
Date ©� _ SEAL _
13037
Page 5 of 6

State Stormwater Permit'
Permit No. SW4080503
Certification Requirements:
1. The drainage area to the system contains approximately the permitted
acreage.
The drainage area to the system contains no more than the permitted
amount of built -upon area.
All the built -upon area associated with the project is graded such that the
runoff drains to the system.
f4. All roof drains are located such that the runoff is directed into the system.
✓5. The outlet/bypass structure elevations are per the approved plan.
6. The outlet structure is located per the approved plans.
Trash rack is provided on the outlet/bypass structure.
All slopes are grassed with permanent vegetation, per the vegetation plan.
G�vffl7ioiS/s . Vegetated slopes are no steeper than 3:1.
'l0. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
11. The permitted amounts of surface area and/or volume have been
provided.
4-"*'1_2. Required drawdown devices are correctly sized per the approved plans.
AII'required design depths are provided.
4. 'All 'regdii-ed parts of the system are provided, such as a vegetated shelf,
and-a,fof6bay.
y.15. ..The required system dimensions are provided per the approved plans.
S
cc: '' NCDENR'-DWQ Regional Office
Davie,Codhty Building Inspections
Page 6 of 6

Ak--
WATF9
0
p
Michael F. Easley, Governor
William G. Ross Jr., Sccrctary
North Carolina Department of Environment and Natural Resources
Coleen 11, Sullins, Director
Division of Water Quality
May 6, 2008 REdEi p
H c Not, of EkR
T. R Bowers MAY Q l 2008
Manager of Capital Projects
r.-cs;on•Salem
Facilities Planning and Construction Regional Office
Medical Center Boulevard
Winston Salem, North Carolina 27157
Subject: Phase II Post -Construction Stormwater Permit Application Return
Primary Care if Mocksville Project
Davie County
Dear Mr. Bowers:
The Division of Water Quality received your Stormwater Management Permit Application for the
subject project on May 5, 2008. After a preliminary review the submittal was found to be
incomplete, and we are returning the submittal application and application fee to you. The
application is incomplete based on the following items:
I . Failure to provide original signatures on the application.
2. Stromwater Controls do not provide 85% removal of TSS. Multiple BMPs may be
placed in series within the same drainage area to combine treatment capabilities. If
multiple BMPs are placed in series, they can utilize the combined volume control
capabilities and increase combined removal efficiency. The volume control capabilities
are additive, however, the pollutant removal rates are not. The overall efficiency (E) for a
given pollutant (TSS, TN or TP) of multiple BMPs in series is computed as shown on
Page 3-18 of the state's BMP Manual (at: http://h2o.enr.state.ne.us/su/bmp_forms.litm).
Please see checklist on our website to help check that your re -submittal includes all necessary
items. It can be downloaded from http://h2o.enr.state.nc.us/su/documents/checklis(rev-1.pdf.
'fhe construction of any impervious surfaces, other than a construction entrance under an
approved Sedimentation Erosion Control Plan, is a violation of NCGS 143-215.1 and is subject to
enforcement action pursuant to NCGS 143-215.6A.
If you have any questions concerning this matter, please contact me at [phone] x 545 or
mike. randall ncmail.net
>k�_
Sincereely,
.
Micheal F. )andall
DWQ Stormwater Permitting Unit
cc: Mr. Mark N. Breen, P.E., Robinson -Sawyer, Inc.
LWinston--Salem Regional'Office
SPU files

STORMWATER BMP ANNUAL MAINTENANCE INSPECTION REPORT
Post -Construction Maintenance Report Form
Inspection Date. October 23, 2012
NCDENR Permit No.
Legal Owner of Record: (Name from County Tax Website or
from the owner if more recently updated):
SW4080503
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 27157
Physical Address/Location of BMP's:
Owner Telephone Number:
1188 Yadkinville Road
( 336) 716-1226
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 NamelTitle:
BMP Inspector Name: (a person's name - not a company name)
L. Celeste Caskey, MS, CSP
John D. Lipka
Site Contact Entity Mailing Address:
Mailing Address of Inspection Company:
Medical Center Boulevard
7750 Seasons Hollow Road
Winston-Salem, NC 27167
Lewisville, NC 27023
QualificationllCredentials 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: [phone]
BMP Inspector e-mail Address: [e-mail]
The results of this inspection are as follows:
F 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.
PASS/CERTIFIED
VISUAL INSPECTION FOUND NO APPARENT PROBLEMS
Certification (is is functional and has no outstanding repair or maintenance issues)
I, , as a duly registered Professional in the State of North
Caro . , h by e e -estpf my abilities the stormwater best management practice (bmp) device(s) islare
ful uncti�►in and 'ng of designed and intended.
Seal/Signatures
Inspection by: John D. Lipka Date: October 25 2012

Level Spreader Checklist for Annual BM P Report
BMP Site Name Primary Care of Mocksville T_ Date Oct 23, 2012
Item- b -l.tem L.Ocle 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
INLET/FLOW SPUTTER DEVICE
Assessment
Code Status
Comments
Obstruction: vegetation/debris/sediment
NIA
Rip Rap Displacement /Sedimentation
NIA
Structural Condition
NIA
Other (Describe)
NIA
No S litter by Design
POOLING AREA AND LEVEL LIP
Assessment 1
Code Status
Comments
Sediment/debris accumulation
FF
Level lip is cracked , settled, undercut
or eroded
FF
Stormwater is by-passing levels reader
FF
Woody Vegetation growth in pooling
area or on level ip.
FF
Grass is maintained as mowed
FF
Nuisance Vegetation is Present
FF
'
Other Describe
BYPASS CHANNEL
Assessment
Code Status
Comments
Bare soil/erosive gullies
NIA
`I'urfReinforcement condition
NIA
Displacement of rip -rap
NIA
Other (Describe)
NIA
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 loft

Bioretention Area Checklist for Annual BMP Report
BMP Site Name Primary Care of Mocksville Date Oct 23, 2012
Item -by -item Code .Kev:
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 I Not Applicable
INFLOW POINTS
Assessment
Code Status
Comments
Obstruction: vegetation/debris/sediment
FF
Eros ion/undercuttin
FF
Structural condition
FF
Displacement /sedimentation of
labric/ri -ra
FF
Other (Describe)
PERIMETER/SIDE SLOPES/EMBANKMENT
Assessment
Code Status
Comments
Sediment/debris accumulation
FF
Bare soil/erosion
FF
Woody vegetation
FF
Turfgrass maintained as mowed
FF
Other (Describe)
PRE-TREATMENT AREA (Forebay. Lyrass swales. & verLyes. eraveh
Assessment
Code Status
Comments
Sediment/debris accumulation
FF
Erosion/gullies present
FF
Invasive vegetation
FF
Recently seeded and stabilized
Flow is by-passing pretreatment
FF
Other (Describe)
Bioretention Area Checklist
Pagel of 4

Bioretention Area Checklist for Annual BMP Report
BMP Site Name Primary Care of Mocksville Date Oct 23, 2012
Item-hv-Item Code Kev:
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 I Not Applicable
BIORETENTION CELL
Assessment
Code Status
Comments
Overgrown vegetation (requires
pruning)
FF
Plants are dead, diseased, or dying
(Replace such planes as necessary per original
approved constructionplans)
I l=
Mulch is decomposed or dis laced
FF
Soils/mulch clogged with sediment
FF
Evidence of lack of proper drainage
(i.e., dead plants, or successional
wetland vegetation)
FF
Bare or eroded areas in grass cells
NA
Other Describe
OUTLET DEVICE
Assessment
Code Status
Comments
Obstruction: vegetation/debris/sediment
FF
Erosion/undercutting
FF
Erosion repairs made
Structural condition
FF
Sediment in pipe
FF
Infiltration repairs made
Joint failure/loss of joint material/soil
i in g
FF
Displacement of fabric/ri -ra
FF
Other (Describe)
MISCELLANEOUS
Assessment
Code Status
Comments
Trash/debris
FF
Access
FF
Evidence of routine maintenance being
performed?
FF
Other Describe
Bioretention Area Checklist
Page 2 of 4

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STORMWATER BMP ANNUAL MAINTENANCE INSPECTION REPORT
Post -Construction Maintenance Report Form
Inspection Date: October 10, 2012
NCDENR Permit No.
Legal Owner of Record: (Name from County Tax Website or
from the owner if more recently updated):
SW4080503
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 27157
Physical Address/Location of BMP's:
Owner Telephone Number:
1188 Yadkinville Road
{ 336) 716-1226
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)
L. Celeste Caskey, MS, CSP
John D. Lipka
Site Contact Entity Mailing Address:
Mailing Address of Inspection Company:
Medical Center Boulevard
7750 Seasons Hollow Road
Winston-Salem, NC 27157
Lewisville, NC 27023
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: [phone]
BMP Inspector e-mail Address: [e-mail]
he results of this inspection are as follows:
Mr FAIL J�L Id�tr/Iz
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.
PASSICERTIFIED
VISUAL INSPECTION FOUND NO APPARENT PROBLEMS
Certification (is 9MI performed when BMP is functional and has no outstanding repair or maintenance issues)
I, as a duly registered Professional in the State of North
Carolina, herby state that, to the best of my abilities the stornwater best management practice (bmp) device(s) islare
fully functioning and operating as designed and intended.
Seal/Signature
Inspection by: Date:

Level Spreader Checklist for Annual BMP Report
BM P Site Name Primary Care of Mocksville Date Oct 10, 2012
Item-bv-Item (_:ode 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
INLET/FLOW SPUTTER DEVICE
Assessment
Code Status
Comments
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
Code Status
Comments
Sediment/debris accumulation
FF
Level lip is cracked , settled, undercut
or eroded
FF
Stormwater is by-passing levels reader
PF
Woody Vegetation growth in pooling
area or on level lip
FF
Grass is maintained as mowed
FF
Nuisance Vegetation is Present
FF
Other Describe
BYPASS CHANNEL
Assessment
Code Status
Comments
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 lon
FF
Bare soil/erosive gullies
FF
Sediment accumulation
FF
Nuisance vegetation is present
FF
Other (Describe)
Level Spreader Checklist
Page 1 of 2

•�Y•r�' J, ',�r
Y..

Bioretention Area Checklist for Annual BM P Report
BMP Site Name Primary Care of Mocksville Date Oct 10, 2012
item-bv-Item t;oae Kev:
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
INFLOW POINTS
Assessment
Code Status
Comments
Obstruction: vegetation/debris/sediment
FF
Erosion/undercutting
FF
Structural condition
FF
Displacement /sedimentation of
fabric/rip-rap
FF
Other Describe
PERIMETER/SIDE SLOPES/EMBANKMENT
Assessment
Code Status
Comments
Sediment/debris accumulation
FF
Bare soil/erosion
FF
Woody vegetation
FF
Turfgrass maintained as mowed
FF
Other (Describe)
PRE-TREATMENT AREA (Forebay. grass swales. & verges. gravel)
Assessment
Code Status
Comments
Sediment/debris accumulation
FF
Erosion/gullies present
FF
Invasive vegetation
FF
Recently seeded and stabilized
Flow is by-passing pretreatment
FF
Other (Describe
Bioretention Area Checklist
Page I of 3

Bioretention Area Checklist for Annual BM P Report
BM P Site Name Primary Care of Mocksville Date Oct 10, 2012
Item-bv-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 I Not Applicable
BIORETENTION CELL
Assessment
Code Status
Comments
Overgrown vegetation (requires
runin
FF
Plants are dead, diseased, or dying
(Replace such plants as necessary per original
approved constructionplans)
FF
Mulch is decomposed or displaced
FF
Soils mulch clogged with sediment
FF
Evidence of lack of proper drainage
(i.e., dead plants, or successional
wetland vegetation)
FF
Bare or eroded areas in grass cells
NA
Other (Describe)
OUTLET DEVICE
Assessment
Code Status
Comments
Obstruction: vegetation/debris/sediment
FF
Erosion/undercuttin�
PF
Erosion at exterior of structure
Structural condition
FF
Sediment in pipe
PF
Silt in pipe requires further
investigation
Joint failure/loss of joint material/soil
piping
FF
Displacement of fabric/rip-rap
FF
Other (Describe)
MISCELLANEOUS
Assessment
Code Status
Comments
Trash/debris
FF
Access
FF
Evidence of routine maintenance being
performed?
FF
Other (Describe)
Bioretention Area Checklist
Page 2 of 3

Bioretention Area Checklist for Annual BMP Report
BM P Site Name Primary Care of Mocksville Date Oct 10, 2012
iteln-uv-11Le111 %-"Uc nev:
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
Forebay 1 Stabilization Forebay 2
Erosion at exterior of structure Silt in outlet pipe
Bioretention Area Checklist
Page 3 of 3

V Q __ lzo1 t 1 o324--
Compliance Inspection Report
Permit: SW4080503 Effective: 06/04/08 Expiration: 06/01/18 Owner: Wake Forest University Baptist Medical Center
Project: Primary Care of Mocksville
County: Davie 1188 Yadkinville Rd
Region: Winston-Salem
Contact Person: Mark N Breen Title:
Directions to Project:
Type of Project: State Stormwater - HD - Other
Drain Areas: 1 -
On -Site Representative(s):
Related Permits:
Inspection Date: 05119/2011 Entry Time: 01:00 PM
Primary Inspector: Sue L Homewood
Secondary inspector(s):
Reason for Inspection: Routine
Permit Inspection Type: State Stormwater
Facility Status: 0 Compliant ® Not Compliant
Question Areas:
® State Stormwater
(See attachment summary)
Mocksville NC 27028
Phone: [phone]
Exit Time: 01:30 PM
Phone: [phone]
Inspection Type: Compliance Evaluation
Page: 1

Permit: SW4080503 Owner - Project: Wake Forest University Baptist Medical Center
Inspection Date: 05/19/2011 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
File Review
Is the permit active?
Signed copy of the Engineer's certification is in the file?
Signed copy of the Operation & Maintenance Agreement is in the file?
Copy of the recorded deed restrictions is in the file?
Comment:
Built Upon Area
Is the site BUA constructed as per the permit and approval plans?
Is the drainage area as per the permit and approved plans?
Is the BUA (as permitted) graded such that the runoff drains to the system?
Comment:
Yes NO NA NE
Yes
No
NA
NE
Ip❑❑❑
■nnn
■nnn
Yes
No
NA
NE
Are the SW measures constructed as per the approved plans?
n
®
n
n
Are the inlets located per the approved plans?
■
❑
❑
n
Are the outlet structures located per the approved plans?
❑
®❑
n
Comment: filter strip not sized in accordance with plans
level spreader has holes to allow drainage, causing erosion
Operation and Maintenance
Yes
No
NA
NE
Are the SW measures being maintained and operated as per the permit requirements?
❑
■
❑
❑
Are the SW BMP inspection and maintenance records complete and available for review or provided to DWQ
n
n
n
upon request?
Comment: no apparent maintenance
Other Permit Conditions
Yes
No
NA
NE
Is the site compliant with other conditions of the permit?
®
n
❑
❑
Comment:
Other WQ Issues Yes NO NA N
Is the site compliant with other water quality issues as noted during the inspection? ®❑ n n
Comment:
Page: 2

Compliance Inspection Report
Permit: SW4080503 Effective: 06/04/08 Expiration: 06/01/18 Owner: Wake Forest University Baptist Medical Center
Project: Primary Care of Mocksvifle
County: Davie 1188 Yadkinville Rd
Region: Winston-Salem
Contact Person: Mark N Breen Title:
Directions to Project:
Type of Project: State Stormwater - HD - Other
Drain Areas: 1 -
On -Site Representative(s):
Related Permits:
Inspection Date: 12119/2011 Entry Time: 11:00 AM
Primary Inspector: Sue L Homewood
Secondary Inspector(s):
Robert D Patterson
Brian Lowther
Reason for Inspection: Follow-up
Permit Inspection Type: State Stormwater
Facility Status: 0 Compliant fl Not Compliant
Question Areas:
® State Stormwater
(See attachment summary)
Mocksville NC 27028
Phone: [phone]
Exit Time: 11:15 AM
Phone: [phone]
Phone:
Phone:
Inspection Type: Compliance Evaluation
Page: 1

Permit: SW4080503 Owner - Project: Wake Forest University Baptist Medical Center
Inspection hate: 12/19/2011 Inspection Type: Compliance Evaluation Reason for Visit: Follow-up
Inspection Summary:
SW Measures
Yes
No
NA
NE
Are the SW measures constructed as per the approved plans?
■
❑
n
n
Are the inlets located per the approved plans?
®
n
n
ri
Are the outlet structures located per the approved plans?
®
n
n
n
Comment:
Other WQ Issues
Yes
No
NA
NE
Is the site compliant with other water quality issues as noted during the inspection?
e
n
n
n
Comment: repairs to the system in response to NOV are superb. Site looks great
Page: 2

Compliance Inspection Report
Permit: SW4080503 Effective: 06/04/08 Expiration: 12/27/21 Owner: Wake Forest University Baptist Medical Center
Project: Primary Care of Mocksville
County: Davie 1188 Yadkinville Rd
Region: Winston-Salem
Contact Person: Mark N Breen Title:
Directions to Project:
Type of Project: State Stormwater - HD - Other
Drain Areas: 1 -
On -Site Representative(s):
Related Permits:
Inspection Date: 06/0312013 EntryTime: 11:15 AM
Primary Inspector: Sue L Homewood
Secondary Inspector(s):
Reason for Inspection: Routine
Permit Inspection Type: State Stormwater
Facility Status: ■ Compliant ❑ Not Compliant
Question Areas:
■ State Stormwater
(See attachment summary)
Mocksville NC 27028
Phone: [phone]
Exit Time: 11:25 AM
Phone: [phone]
Inspection Type: Compliance Evaluation
l

Permit: SW4080503 Owner - Project: Waite Forest University Baptist Medical Center
Inspection bate: 06/03/2013 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
Operation and Maintenance Yes No NA NE
Are the SW measures being maintained and operated as per the permit requirements? ■ ❑ ❑ 0
Are the SW BMP inspection and maintenance records complete and available for review or provided to DWo ❑ Q ❑ ■
upon request?
Comment:
Other Permit rnnefitinnc Yes No NA NE
Is the site compliant with other conditions of the permit?
Comment:
Other WQ Issues
Is the site compliant with other water quality issues as noted during the inspection?
Comment:.
■ n n n
Yes No NA NE
■ ❑ El 0
Page: 2

BIORETENTION CELL: O & M Inspection Checklist
1. Inlet and Perimeter are free of erosive gullies and bare soil areas: ❑ ❑ ❑
2. Inlet device (swale, pipe, stone verge) is free of erosion, damage or clogs: ❑ ❑ ❑
3. Weir heights appear to match approved plans: ':9, ❑ ❑ ❑
} y,k .w. a{ -s- Yi-Y, t f." " G � 4P t 70' ih �T' _d}. F s f r. r- V3.�- k n.n?i1 r, f,t ,• r, ie
.. _... _ .. .. ' i .�i... s:.� � .� �E�?"N r,.... •� ,Cs,F .! �_ ..: _.. � >� f,€�i:�.L3'•L, ,+ -a t!" � 1�'�.�.'-Y��✓�f,� `�d :,1
4. Flow is entering pretreatment area (not being bypassed): ❑ ❑ ❑
5. Pretreatment area is free of erosion: j ❑ ❑ ❑
6. Pretreatment area is free of excessive sediment or clogs: &,� , f ��`` �d ❑ ❑ ❑
__ -- — - .....ry•.. V _ks%': y�5°2 K��. u, . t rffi: ' �': '+1`i �"���•li � %�(�}t,. `•=syr^.^q�+: 1 d �"r 'G, wti• ,�{ ,,..:�,� � U .i
MAIN YTREATMENT?AREA a N'4 a� � tii�' f,: iF
1 n:: r• r7 nR ,... s: $an.V .. ` r ik fr..sf _
7. Side slopes are 3:1 or less: f
aEl El El8. The under drain system is free flowing and free ofgs (if applicable): EQ ❑ ❑ ❑
9. Cleanout(s) and cap is provided for the under drain as per the approved plans: 'Z ❑ ❑ ❑
10, Heavy equipment has not been driven into the cell: `_0 ❑ ❑ ❑
11. Surface is free of piles of heavy materials (piles of mulch, etc): ❑ 9 ❑ ❑
12. Ponding depth is 9-12 inches after rain: ❑ ❑ ❑
13. All dimensions are >=10ft.: 9 ❑ ❑ ❑
S 1L MULCH ancl;„VEGETATIONS r x
I. .i 'rusey; F�h��. a-.W�+�i+`��n �.+'�i.•:4:k��`�.,P�u.r'a_��.c.�rft:�'.�Y'��'F. ��:-,..�. 4 tra"'J.: Ln.:xt'r �i'kV�t. .;7
14. Plants are healthy and being maintained: ❑ ❑ ❑
15. The proper amount and type of vegetation is present in the cell: ���''� uJe��S ❑ ❑ ❑
16. Mulch is in good condition (has not broken down or floated/migrated towards the outlet): ❑ ❑ ❑
17, Surface if free of excessive sediment and clogs: ❑ ❑ ❑
18. Trees are free of stakes/wires > 6 months after planting: ❑ ❑ KI ❑
19. The annual soil test shows the proper pH and absence of heavy metal accumulation: ❑ ❑ ❑]
�_._ �-f? si R'. y r ,., . .,fiy ;Y.fs .}2. i.�..t.•a••. Si "s k--.T 4 „fc�r 7^. u. f 'c', f.. 'd l r1
ry. t� 3s�,��� � rs F{ � 5 '• i' i+�p'w+.,y w�µ�L��'
tOUTLETa<{# �s��'�g � �i;i a.�, �+�`�!ii,+�€3•,..,� .4 .i.s .fir ,.ifi,' zi:..X t: F.ca�S�,.:.li"7sr4 sn t..:h.��"l.T;e �J.: ,�.:i�,r�'^r�i �. ,xi4"i. _,:, i� �'E,
20. Outlet is free of evidence of improper drainage (no standing water, cattails, etc.): 'R ❑ ❑ ❑
21. Outlet device (drop inlet, weir, etc.) is free of damage or clogs: 19 ❑ ❑ ❑
22. Orifice size matches approved plans: ❑ ❑ ❑
23. Outlet is free of damage, clogs, or erosion: ®, ❑ ❑ ❑
24. Relative elevations match approved plans: ❑ ❑ ❑
V3.3_09

LEVEL SPREADERS, FILTER STRIPS AND RESTORED RIPARIAN BUFFERS
O & M Inspection Report
1.
The flow splitter device is free of clogs or damage:
L5
L
LJ
LJ
2.
Stormwater bypass is installed:
®
❑
❑
❑
3.
Orifice size/weir heights match approved plans:
❑
❑
❑
,(EC
4.
Turf reinforcement and rip rap are in good condition and the correct location:
❑
❑
❑
5.
Bypass channel is free of bare areas and erosion:
❑
❑
❑
Filter Strip/ Level Lip
6.
Level lip is in good condition (has not settled, been undercut, or eroded):
*'�'.
El❑
7.
Filter Strip/ Level Lip is free of areas of bare soil, erosion or ullies:
❑
❑
❑
8.
Filter Strip is free of excessive sediment accumulation:
�K
❑
❑
❑
9.
Swale is free of excessive (covers grass, —4in. or more) sediment accumulation:
E�
❑
❑
❑
10.
Level spreader is located as per the approved plans and is the correct length:
❑
❑
❑
Vegetation
11.
Filter strip is densely vegetated:
❑
E�
❑
❑
12.
Filter strip grass is maintained at a height of 3 to 6 inches:
❑
❑
❑
13.
Plants are healthy and are being maintained:
❑
❑
❑
14.
Down -slope area of the level lip is free of trees or shrubs:
iK
❑
❑
❑
15.
Nuisance or invasive vegetation has been properly removed:
❑
❑
❑
Outlet
16.
Outlet is free of erosion, clogs or damage:
,�,
Ff
❑
❑
❑
17.
Level spreader end is free of,erosicnm
�a� y
❑
,L
❑
❑
V3.3_09