SW4100601_CURRENT PERMIT_20100721

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW +I OU CnO
DOC TYPE
D�'CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE
2b 10 07 z.I
WYYMMDD

RECEIVED
N.C, Dect. of ENR
jFA� AUG2 � zoo '
NC®ENR .
North Carolina Department of Environment and Natural Resour,res Ninsto .Saerr
Regional Office
Division of Water Quality
Beverly Eaves Perdue Coleerf H. Sullins
Governor Director
July 21, 2010
Mr. Joseph S. Sheetz, Executive Vice President
Sheetz Inc.
5700 Sixth Avenue
Altoona, PA 16602
Subject: Stormwater Permit No. SW4100601
Sheetz- Wallburg, NC
High Density Commercial Wet Pond Project
Davidson County
Dear Mr. Sheetz:
Dee Freeman
Secretary
The Stormwater Permitting Unit received a complete Stormwater Management Permit Application for
Sheetz- Wallburg, NC on June 14, 2010. Staff review of the plans and specifications has determined that
the project. �s proposed, will comply with the Stormwater Regulations set forth in Title 15A NCAC 2H.1000
and Session Law 2006-246. We are forwarding Permit No. SW4100601, dated July 20, 2010, for the
constructs-.,-.. operation and maintenance of the subject project and the stormwater BMPs.
This permit shall be effective from the date of issuance until July 20, 2020, and shall be subject to the
conditions and limitations as specified therein. Please pay special attention to the Operation and
Maintenance requirements in this permit. Failure to establish an adequate system for inspection and
maintenance of the stormwater management system will result in future compliance problems.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing upon written request within thirty (30) days following receipt of this permit.
This request most be in the form of a written petition, conforming to Chapter 150B of the North Carolina
General St_,tutes, and filed with the Office of Administrative Hearings, P.O. Drawer 27447, Raleigh, NC
27611-7447. Unless such demands are made this permit shall be final and binding.
This project will be kept on file at the Winston Salem Regional Office. If you have any questions, or need
additional information concerning this matter, please contact Brian Lowther at [phone]; or
brian.lowther,'fDncdenr.gov.
Sincerely,
for Coleen H.:3ullins
cc: Winston Salem Regional Office
Central Files
SPU Files
Wilbur Christmas, PE, Stimmel Associates, PA
Wetlands and Stormwater Branch
1617 Mail Service Cenler, Raleigh, North Carolina 27699.1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone] Customer Service: 1.877-623-6748
Internet: www.ncwaterquality.org
NorthCarolina
Naturally
An Equal Opportunity 1 Affirmative Action Employer

State Stormwater Permit
Permit No.SW4100601
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES----.__
DIVISION OF WATER QUALITY
AUG z 4 2010
STATE STORMWATER MANAGEMENT PERMIT w'nst-; •Sarom
Regrona+ Ica
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
Sheetz Inc.
Sheetz- Wallburg, NC
5519 Gumtree Rd, Winston-Salem, Davidson County
FOR THE
construction, operation and maintenance of a wet detention pond in compliance with
the provisions of 15A NCAC 2H A000 and S.L. 2006-246 (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 July 20, 2020, 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 1.6 on page 2 of this permit. The stormwater
control has been designed to handle the runoff from 23,018 square feet of
impervious area.
3. The tract will be limited to the amount of built -upon area indicated on page 3 of
this permit, and per 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.
Page 1 of 6

State Stormwater Permit
Permit No.SW4100601
6. The following design criteria have been provided in the wet detention pond and
must be maintained at design condition:
a. Drainage Area, ages: 0.77
Onsite, ft : 33,457
Offsite, ft2: 0
L
G.
d.
e.
f.
h.
i.
k.
1.
m
n.
o.
Total lmpervioys Surfaces, ft2:
Buildings ft
Roads/Parking, ft2:
Other, ft2.
Offsite, ft�.
Pond Depth, feet.
TSS removal efficiency:
Design Storm:
Permanent Pool Elevation, FMSL
Permitted Surface Area @PP ft2:
Permitted Storage Volume, ft,:
Storage Elevation, FMSL:
Controlling Orifice:
Permanent Pool Volume, ft3:
Forebay Volume, ft3:
Receiving Stream/River Basin:
Stream Index Number:
Classification of Water Body:
II. SCHEDULE OF COMPLIANCE
23,018
5,017
15,631
2,370 (sidewalks)
3.08
90%
1.0 inch
914.5
3,694
16,230 at temporary pool
915.0
1.0" O pipe
7,145
1,481
South Fork Muddy Creek 1 Yadkin
12-94-13
1,C„
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 times 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 revegetation of slopes and the vegetated filter.
d. Immediate repair of eroded areas.
e. Maintenance of ail slopes in accordance with approved plans and
specifications.
f. Debris removal and .unclogging of outlet structure, orifice device, flow
spreader, catch basins and piping.
g. Access to the outlet structure must be available at all times.
4. Records of maintenance activities must be kept and made available upon
request to authorized personnel of DWQ. The records will indicate the date,
activity, name of person performing the work and what actions were taken.
5. The facilities shall be constructed as shown on the approved plans. This permit
shall become voidable unless the facilities are constructed in accordance with
the conditions of this permit, the approved plans and specifications, and other
supporting data.
Page 2 of 6

State Stormwater Permit
Permit No.SW4100601
6. 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.
7. 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.
a. Access to the stormwater facilities shall be maintained via appropriate
easements at all times.
9. 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 defied as all property owned by the permittee,
for which Sedimentation and Erosion Control'Plan- approvaI or a CAMA
Major permit was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
10. The permittee shall submit final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
11. 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.
12. 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 certificationIin 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, to the Division of Water
Quality, signed by both parties, and accompanied by supporting documentation
as listed on page 2 of the form. The project must be in good standing with the
Division. The approval of this request will be considered on its merits and may or
may not be approved.
2. The permittee is responsible for compliance with all permit conditions until such
time as the Division approves the transfer request.
Page 3 of 6

State Stormwater Perr+iit ,
Permit No.SW4100601
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 of any name, ownership or mailing
address changes at least 30 days prior to making such changes.
12. The permittee shall submit a renewal request with all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Permit issued this the 21th day of July, 2010.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
>0)- �- ,�
for Coleen H. ulliris, Director
Division of Water Quality.
By Authority of the Environmental Management Commission
Page 4 of 6

State Stormwater Permit
Permit No.SW4100601
Sheetz Inc.
Stormwater Permit No. SW4100601
Davidson Countv
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,
Sheetz-Wallburg, NC
(Project)
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.SW4100601
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.
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.
Please submit t-N3 Designer's Certification to: Asheville Regional Office
Surface Water Protection
2090 US Highway 70
Swannanoa, NC 28778
Page 6 of 6
h

1nic'-� R0
DWQ USE ONLY
Date Received
Fee Paid Permit Number
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all flirt 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 Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FO
. This fonn may be photocopied for use as an original
I. GENERAL INFORMATION
AUG 2 4 2010
WinSED-Salem
Rc,gional ChTice
1. Project Name (subdivision, facility, or establishment name -should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
SHEETZ- WALLBURG NC
2. Location of Project (street address):
5519 GUMTREE RD.
City:WINSTON-SALEM - County:DAVIDSON Zip:27107
3. Directions to project (from nearest major intersection):
NE Quadrant of intersection of HWY 109 and Gumtree Rd. _
4. Latitude:36' 01' 34" N . Longitude:80* 09' 41" W of the main entrance to the project.
IL' PERMIT INFORMATION:
1.a.Specify whether project is (check one): ®New ❑Modification
b. 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 ®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 DWQ
requesting a state stormwater 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 state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major ®Sedimentation/Erasion Control: 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:
45ue1r3 JeteMtwatS '? sp11eiMM y^-
wna Li3 ft - IdN3CI
�U��1�.Oi0
oloz P I I�nr
Form SWU-101 Version 07July2009 Page 1 of 6 lnrt 0SNR .& A
a w
��0 gI

M
14
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 pr2'ect
Applicant/Organization,SHEETZ INC.
Signing Official & Titlel 1 Joseph S. Sheetz, Executive Vice President
b.Contact information for person fisted in item 1a above:
Street Address:5700 Sixth Avenue
City: AI toona State -.PA Zi p:16602
Mailing Address (if applicable): _
City:
State:
Zip:
Phone: f540 366-9616 Fax: (540 } 366-9501'
Email:
c. PIease 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/
;� k-
b.Contact information for person listed in item 2a above:.
A
Street Address:PO BOX 503
City:Wallburg _ _ State:NC Zip:27373
Mailing Address (ifapplicable): r. 0, t,)oJ 5 0-4
City: W46wer,
Phone: 33.6
State: _NC= - Zip:_ !?9 7� -
Fax: ( }
3. a. (Optional) Print the name and title of another contact such as the projects construction supervisor or other
.person who can answer questions about the project:
Other Contact Person/Organization: Wilbur Christmas / Stimmel Associates, P.A.
Signing Official & Title:Wilbur Christmas, PE
b. Contact information for person listed in item 3a above:
Mailing Address:601 N. Trade St.
City:Winston-Salem State:NC Zip.27101
.k
Phone: 036 } 723-1067 Fax: (336 } 723-1069
Email:[e-mail]
4. Local jurisdiction for building permits: Davidson County Inspections
-
Point of Contact:Ron Triplette Phone #: (336 Z 242-2230 -
Form S WU-101 Version 07July2009 - Page 2 of 6

p IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Runoff will be treated by way of a Wet Detention Basin
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.ldentify 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 Yadkin River basin.
4. Total Property Area: 2.318 acres 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':2.318 acres
* Total project area shall be calculated to exclude the follaruing the uonnal pool of impomuted strtrctrires, tice area
between the banks of streams and rivers, the area before the Nonrral Hi h Water (NHW) line or Mean High Water
W) (MHline, and coastal Wetlands Iand7oard froiti the NHW (or MHX line. The resultant project area rs used to
calculate overall percent built upoiu area (BUA). No)i-coastal ruetlands larrdroard of tlue NHW (orMHM line uruay
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 55.34
9. How many drainage areas does the project have?1 (For high density, count 1 for each proposed engineered
stormwater BMP. For low 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
Draina Area _
Draina a Area
Receiving Stream Name
South Fork
'Muddy
Creek
_
Stream Class *
C
Stream Index Number *
12-94-13
Total Drainage Area (so
33457
On -site Drainage Area (sf)
33457
Off -site Draina e Area (sf)
0
Proposed Im ervious Area (sq
23018
Impervious Area** total
68.8
Impervious- Surface Area
Drainage Are6;1
_Drainag6Area
Drainage Area
Draina a Area
On -site Buildin s/Lots (so
5017
On -site Streets (so
0
On -site Parking (sf)
15631
On -site Sidewalks (so
2370
Other on -site (sf)
0
Future (so
0
Off -site (sf)
0
Existin BUA*** (so
0
Total (sf):
23018
* Stream Class and Index Number can be defennined at: hlf : 2o.cur.state.uc.uu irrus re orts re ortsWB.hhul
Form 5WU-101 Version 07July2009 Page 3 of 6

Iruppenn.ous area is defied as Ilte built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc,
***Report only that aruount 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.
1.1. How was the off -site impervious area listed above determined? Provide documentation. N/A
Projects in Union County: Contact DIVQ Central ice staff to check if the project is located within a Threatened &
Endangered Species ivaler•shed that may be subject to more stringent slornnvater requirements as per NC.4C 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
fromhttp://h2o.enr.state.nc.us/su[bmp forms.htm.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from http://h2o.enr.state.ne.us/su/bmp forms.htm. The complete application
package should be submitted to the appropriate DWQ Office. (The appropriate office may be found by
locating project on the interactive online map at h h2o.enr.state.nc.us su msi ma s.htm.)
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://h2o.enr.state.nc.us/sulbmp forms.htm.
j Initials
1. Original and one copy of the Stormwater Management Permit Application Form.
2. 'Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part V11 below)/
3. Original of the applicable Supplement Forni(s) (sealed, signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR, (For an Express review, refer.to
http://www.envhelp.org/pageslonestopexpress.html for information on the Express program
LJ [J
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�twb pages) describing the stormwater treatment/management
for
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.
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
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 landwaid.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.
m. 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.
n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
Form SWU-101 Version 07July2009 Page 4 of 6

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
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 DWQ to verifij t1W SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 636 Page No: 939
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 t\
by the persons listed in Contact Information, item 1a, 2a, and/or 3a per NCAC 2H.1003(e). The v
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.
hU://www.secretar-v.state.nc.us/Corl2orations/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
httn://h2o.enr.state.nc.us/su/bmi) forms.htm#deed restrictions. 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
— -4 under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DWQ, 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:Wilbur Christmas, PE
Consulting Firm: Stimmel Associates, P.A.
Mailing Address:601 N. Trade St.
City: Winston-Salem
Phone: (336 __- ) 723-1067
.Email:wchristmas®stimmel a.com
State:NC Zip:27101
Fax: (336 ) 723-1069
IX. PROPERTY OWNER AUTHORIZATION (if Cmdact Information, item 2 has beets filled out, complete this
section) t,_(P-d n1 or htpe name of person listed in Contact It _ennation,_itenr 2a ^-MAR LEA lkeg g certify that i
own the property identified in this permit application, and thus give permission to (print or type name of person
"listed in Contact Information, item 1a) with (print or type name of organization listed in
Contact Information, item 1b) Slneetz hic. todevelop 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 07.Iuly2009 Page 5 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 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ 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, pursdant to NCGS 143-215.6.
Signature: P4S Date: F-A"o
( I 1. .`I 1 the I e Lb /I V a Notary Public for the State of � C_ County of
DA q L_ 6, do hereby certify that - ULV V iyA 1 ,. 1*CO,; US personally appeared
before me this _Lday of g and acknowledge a due ari�
cution of the application for
a stormwater permit. Witness my hand and official seal,�,Q
SEAL
Y OFFICIAL SEAL
i �4 Notary Public - NmM CarWm
` s I, DAVIDSON COUNTY
�=�'``�•' MICHELLE MINOR I My commission expires �(s
X. APPLIlnitifT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item z) Joseph S. ShFetz
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 nformance with the approved plans, that the required deed restrictions
and protective covenants will be r ed, and that the proposed project complies with the requirements of the
applicable stormwater rules and A NCAC 2H .1000, SL 2006-246 (Ph.11-Post Construction) or SL 2008-211.
Signature: Date:'.S cafe- 1C�
s
a Notary Public for the State of�VfRn lr., County of
do hereby certify that �nh S 1e_F Z_ personally appeared
before me this, day of 1U�1C��(_� C> and acknowledge the due execution of the application for
r� Q a stormwater permit. Witness my hand and official seal,
Notarial Seal
SEAL Jennifer D. Schramke, Notary Public
City Of Altoona, Blair County
My Commission E)pires Apil 7, 2011
Member, Pennsylvania Association of Notaries
My commission expires
Form SWU-101 Version 07Ju1y2009 Page 6 of 6

Permit No.
(to be provided by DWQ)
A�
NCDENR
RECEIVrp ,
i
FAUG 214 2010
Wins:cn•Salem
Regional Office
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
WET DETENTION BASIN SUPPLEMENT
This form must be filled out, printed and submitted
The Required items Checklist (Part fll) must be printed, filled out and submitted along with all of the required information.
I. PROJECT. INFORMATION .
Project name Sheetz - Walburg, NC _
Contact person Sam_ Smith, Rt.A
Phone number 336-723-1067
Date 7/12/2010'
Drainage area number 1
111. DESIGN INFORMATION
Site Ctlaracter€stfcs
Drainage area 34,457 fe
Impervious area, post -development 23,178 ft'
% impervious 67.27 %
Design rainfall depth 1.0 in
Storage Volume: Nan -SA Waters
%linimum volume required
—_Volume provided
Storage Volume: SA Waters
1.5" runoff volume
Pre -development 1-yr, 24-hrrunof
Post -development 1-yr, 24-hrrunoff
Minimum volume required
Volume provided
Peak Flow Calculations
Is the prelpost control of the lyr 24hr storm peak flow required?
.1-yr. 24-hr rainfall depth
Rational C, pre -development
Rational C. post -development
Rainfall intensity: 1-yr, 24-hr storm
Pre -development 1-yr, 24-hr peak flow
Post -development 1-yr, 24-hr peak flow
Pre'Post 1-yr, 24-hr peak Flow control
Elevations
"Temporary pool elevation
Permanent pool elevation
SHWT elevation (appmx. at the perm. pool elevation)
Tof;`t,f 10ft vegetated shelf elevation
Bottom of 1Oft vegetated shelf elevation
Sediment deanout, top elevation (bottom of pond)
Sediment deanout, bottom elevation
Sediment storage provided
Is there additional volume stored above the state -required temp. pool?
E€evadon of the top of the additional volume
1,882 ft3
2,211 ft3
ft3
y (Y or N)
2.8 in
OK
OK; volume provided is equal to or in excess of volume required.
0.72 (unitless)
0.75 (unitless)
0.12 inlhr OK
0.16 f0lsec
0.19 felsec
0,03 ft3lsec
915.00 fmsl
914.50 fmsl
909.11 fmsl
915.00 fmsl
914,00 fmsl
911.00 fmsl
910,00 fmsl
1.00 ft
N (Y or N)
fmsl
Form SW401-Wet Detention Basin-Rev.S-9117109 Parts I. & 11. Design Summary, Page 1 of 2

Permit No.
fto be Provi,4 5. D,W}Q)
El. DESIGN INFORMATION
Surface Areas
Area, temporary pool
5.148 fe
Area REQUIRED, permanent pool
1,330 ft2
SAIDA ratio
3.86 (unitiess)
Area PROVIDED, permanent pool, Apef1,,,,d
3,694 e
OK
Area, bottom of 1Oft vegetated shelf, Ate, ,ho
2,448 to
Area, sediment cleanout, top elevation (bottom of pond), A
1,291 ft'
volumes
Volume, temporary pock
2,211 ft
OK
Volume, permanent pool, Vpd,,,—
7,145 fe
Volume, forebay (sum of forebays if more than one forebay)
1,481 fe
Forebay % of permanent pool volume
20.7% %
OK
SAIDA Table Data
Design TSS removal
90 %
Coastal SAIDA Table Used?
N
(Y or N)
MountainfPiedmont SAIDA Table Used?
Y
(Y or N)
SAIDA ratio
3.86 (unidess)
Average depth (used in SAIDA table):
Calculation option 1 used? (See Figure 10.2b)
N
(Y or N)
Volume, permanent pool, V,, _poc,
7,145 ft3
Area provided, permanent pool, Ap,-,,,
3,694 ft`
Average depth calculated
3.08 ft
OK
Average depth used in SAIDA, d,,,, (Round to nearest 0.5fi)
3.0 it
OK
Calculation option 2 used? (See Figure 10-2b)
Y
(Y or N)
Area provided, permanent pool, Ap,,,,,-poy
3,694 ft
Area, bottom of 100, vegetated shelf, Ab,_
2,448 ff
Area, sediment c!eanout, top elevation (bottom of pond), A,d_,,d
1,291 ft
'Depth' (distance b/w bottom of 10ft shelf and top of sediment)
3,00 ft
Average depth calculated
3.08 ft
OK
Average depth used in SAIDA. d. (Round to nearest 0.5ft)
3.0 ft
OK
Drawdown Calculations
Drawdown through orifice?
Y
(Y or N)
Diameter of orifice (if circular)
1.00 in
Area of orifice (if -non -circular)
in2
Coefficient of discharge (Co)
0.60 (unitless)
Driving head (Ha)
0.15 ft
Drawdown through weir?
N
(Y or N)
Weir type
(unifless)
Coefficient of discharge (C.)
(unitiess)
Length of weir (L)
ft
Driving head (H)
ft
Pre -development 1-yr, 24-hr peak flog
0.07 ft3Isec
Post -development 1-yr, 24-hr peak Flow
0.07 ft3lsec
Storage volume discharge rate (through discharge orifice or weir)
0.01 fP/sec
Storage volume drawdown time
2.49 days
OK, draws down in 2.5 days.
Additional Information
Vegetated side slopes ,
3 :1
OK
Vegetated shelf slope _
10 A
OK
Vegetated shelf width
10.0 ft
OK
Length of flowpath 10 width ratio
2 A
Insufficient flow path to width ratio. Must not short-circuit pond.
Length to width ratio
2.0 :1
OK
Trash rack for overflow & orifice?
N (Y or N)
Trash rack or similar device recommended.
Freeboard provided
1.0 ft
OK
Vegetated filter provided?
N (Y or N)
OK
Rocarded drainage easement provided?
Y (Y or N)
OK
Capures all runoff at ultimate build -out?
Y (Y or N)
OK
Drain mechanism for maintenance or emergencies is:
Drain Plug Within Drawdown Structure
Form SW401-Wel Detention Basin-Rev.a-9117109 Parts I, & 11. Design Summary, Pago 2 of 2

Permit No,
(to be provided by D WQ)
Fill —REQUIRED ITEMS CHECKLIST '
5
Please indicate the page or plan sheet numbers where the supporting documentation can be found, An incomplete submittal package will
result in a request for additional information. This will delay final review and approval of the project. Initial in the space provided to
indicate the following design requirements have been met, If the applicant has designated an agent, the agent may initial below. If a
requirement has not been met, attach justification.
Page/ Plan
Initials Sheet No.
KB C-1.0,__
1. Plans (1' - 50' or larger) of the entire site showing:
C-3.1 ,
Design at ultimate build -out,
SWM
Off -site drainage (if applicable),
Delineated drainage basins (include Rational C coefficient per basin),
Report
Basin dimensions,
Pretreatment system,
High flow bypass system,
Maintenance access,
Proposed drainage easement and public right of way (ROW),
Overflow device, and
Boundaries of drainage easement.
KB C-3.1_,_
2. Partial plan (1'.= 30' or larger) and details for the wet detention basin showing:
C-3.3,
Outlet structure with trash rack or similar,'
L-1-G'
Maintenance access,
Permanent pool dimensions,
Forebay and main pond with hardened emergency spillway,
Basin cross-section,
Vegetation specification for planting shelf, and
- Filter strip.
KB C-3.1
3. Section view of the wet detention basin (1" = 20' or larger) showing:
Side slopes, 3:1 or lower,
Pretreatment and treatment areas, and
- Inlet and outlet structures.
KB NIA G. If the basin is used for sediment and erosion control during construction, clean out of the basin is specified
on the plans prior to use as a wet detention basin.
KB SW Report 5• A table of elevations, areas, incremental volumes & accumulated volumes for overall pond and for forebay,.
to verify volume provided.
KB C-_4.G' 6. A construction sequence that shows how the wet detention basin will be protected from,sediment until the
entire drainage area is stabilized.
KB SWM_RepOrt 7. The supporting calculations.
Orig.Srtbmittal
KB 8, A copy of the signed and notarized operation,and maintenance (O&M)'agreement.
KB NIA 9, A copy of the deed restrictions (if required).
KB Orig.Submittalt0. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. County
soil maps are not an acceptable source of soils information.
Form SW401-Wet Detention Basin-Rev.8-9117I09 Part III. Required Items Checklist, Page 1 or 1

Nn
Permit Numher;
(Io &e provided
Draina re Area Number:
AUG 2 4 2010
Y1ir5Co n-SalO"I UWQ)Regional Cfrice
C----..
Wet Detention Basin Operation and Maintenance Agreement
I will keep a taintenance record on this BMP. This maintenance record will be kept in a
log in a known set location. Any deficient BMP elements noted in the inspection will be
corrected, repaired or replaced immediately. These deficiencies can affect the integrity
of structures, safety of the public, and the removal efficiency of the BMP.
The wet detention basin system is defined as the wet detention basin,
pretreatment including forebays and the vegetated filter if one is provided,
This system (check one):
does X does not incorporate a vegetated filter at the outlet.
This system (check one):
[] does Z does not incorporate pretreatment other than a forebay.
Important maintenance procedures:
Immediately after the wet detention basin is established, the plants on the
vegetated shelf and perimeter of the basin should be watered twice weekly if
needed, until the plants become established (commonly six weeks).
— No portion of the wet detention pond should be fertilized after the first initial
fertilization that is required to establish the plants on the vegetated shelf.
Stable groundcover should be maintained in the drainage area to reduce the
sediment load to the wet detention basin.
If the basin must be drained for an emergency or to perform maintenance, the
flushing of sediment through the emergency drain should be minimized to the
maximum extent practical.
Once a year, a dam safety expert should inspect the embankment.
After the wet detention pond is established, it should be inspected once a month and
within 24 hours after every storm event greater than 1.0 inches (or 1.5 inches if in a
Coastal County). Records of operation and maintenance should be kept in a known set
location and must be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element:
Potentialproblem:
How l will remediate the problem
The entire BMP
Trash debris is present.
Remove the trash/debris.
The perimeter of the wet
Areas of bare soil and/or
Regrade the soil if necessary to
detention basin
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
one-time fertilizer application.
Vegetation is too short or too
Maintain vegetation at a height of
long.
approximately six inches.
Form SW401-Wet Detention Basin O&M-Rev.4 Page 1 of 4

Permit Ntnnber:___
(to be provided by DWQ)
Drainage Area Number:
BMP element:
Potentialproblem:
How I will remediate theproblem:
The inlet device: pipe or
The pipe is clogged.
Unclog the pipe. Dispose of the
Swale
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged.
Erosion is occurring in the
Regrade the Swale if necessary to
Swale.
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
The forebay
Sediment has accumulated to
Search for the source of the
a depth greater than the
sediment and remedy the problem if
original design depth for
possible. Remove the sediment and
sediment storage.
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Erosion has occurred.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
revent future erosion problems.
Weeds are present.
Remove the weeds, preferably by
hand. If pesticide is used, wipe it on
the plants rather than spray .
The vegetated shelf
Best professional practices
Prune according to best professional
show that pruning is needed
practices
to maintain optimal plant
health.
Plants are dead, diseased or
Determine the source of the
dying.
problem: soils, hydrology, disease,
etc. Remedy the problem and
replace plants. Provide a one-time
fertilizer application to establish the
ground cover if a soil test indicates
it is necessary.
Weeds are present.
Remove the weeds, preferably by
hand. If pesticide is used, wipe it on
the plants rather than spraying.
The main treatment area
Sediment has accumulated to
Search for the source of the
a depth greater than the
sediment and remedy the problem if
original design sediment
possible. Remove the sediment and
storage depth.
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Algal growth covers over
Consult a professional to remove
50% of the area.
and control the algal growth.
Cattails, phragmites or other
Remove the plants by wiping them
invasive plants cover 50% of
with pesticide (do not spray).
the basin surface.
Form SW40I-Wet Detention Basin O&M-Rev.4 Paget off

Permit
(to be provided by DWQ)
Drainage Area Number: _
BMP element:
Potentialproblem:
How I will remediate theproblem;
The embankment
Shrubs have started to grow
Remove shrubs immediately.
on the embankment.
Evidence of muskrat or
Use traps to remove muskrats and
beaver activity is present.
consult a professional to remove
beavers.
A tree has started to grow on
Consult a dam safety specialist to
the embankment.
remove the tree.
An annual inspection by an
Blake all needed repairs,
appropriate professional
shows that the embankment
needs repair. if applicable)
The outlet device
Clogging has occurred.
Clean out the outlet device. Dispose
of the sediment off -site.
The outlet device is damaged
Re air or replace the outlet device.
The receiving water
Erosion or other signs of
Contact the local NC Division of
damage have occurred at the
Water Quality Regional Office, or
outlet.
the 401 Oversight Unit at 919-733-
1786.
The measuring device used to determine the sediment elevation shall be such
that it will give an accurate depth reading and not readily penetrate into
accumulated sediments.
When the permanent pool depth reads 3.5 feet in the main pond, the sediment
shall be removed.
When the permanent pool depth reads 3.5 feet in the forebay, the sediment
shall be removed.
BASIN DIAGRAM
Till in the blanks)
Sediment Removal F-. 911 1 Pe manenN
\�---�Sed
---------------- Volume
Bottom Elevatii0_(} Min.
iment
Storage
t<OREBAY
Permanent Pool Elevation 914.5
Pool
Sediment Rentoval Elevation 21 Volume
------------------------------j
Bottom Elevation
MAIN POND
Form SW401-Wet Detention Basin 0&'vl-Rev,4 Page 3 of4
L- J n.
Sediment
Storage

Permit Number:
(it) he pnmi(led fiv DirO)
I acknowledge and agree by my signature below that I ani responslblc for the
performance of the maintenance procedures listed above. 1 agree to notify DWQ of any
problems with the system or prior to any changes to the system or responsible party.
Project narne:Sheetz - Md
BUT' th-ainage area numher: I
Print panic: Joseph S. Sheetz
Title: Executive vase President
Address: 5700 Sixth Avenue, Altoona, PA 16602
Phone: (814) 94A-3Al l
Sil;naturc:
Date: ' i Wo-
Note: The legally responsible party should not be a homeowners association unless more than 50% of
tine lots have been sold and a resident of the subdivision has bcen named the president.
a Notary Public for the State of
County of r,,;r' do hereby certify that
personally appeared before me this �gu
day of r. t , ' 'C) , and acknowledge the due execution of the
forgoing wet detcrition basin maintenance regUirements. Witness my hand and official
C4MMONWrAL_m of PLNNSYLVANIA
Notarial Seal
Jennifer 1). SdImmke, Notary Public
City Of f&xria. Llair County
My Cornmission 3--)#res Apnl 7. 2011
Mlember, Penrmlvanio Assoc'Ial,on of Notaries
S IAA L
MY Commission expires
Dorm SW40I-Wei Detention Basin O&M-Rev.4 Page 4 Of4

Compliance Inspection Report
Permit: SW4100601 Effective: 07/21/10 Expiration: 07/20/20 Owner: Sheetz Incorporated
Project: Sheetz - Walburg NC
County: Davidson 5519 Gumtree Rd
Region: Winston-Salem
Contact Person: Wilbur E Christmas Title:
Directions to Project:
Type of Project: State Stormwater - HD - Detention Pond
Drain Areas: 001 - (South Fork Muddy Creek) (03-07-04) ( C)
On -Site Representative(s):
Related Permits:
Inspection Date: 07107/2011 Entry Time: 02:30 PM
Primary Inspector: Sue L Homewood
Secondary Inspector(s):
Reason for Inspection: Routine
Permit Inspection Type: State Stormwater
Facility Status: ® Compliant ❑ Not Compliant
Question Areas:
E State Stormwater
(See attachment summary)
Winston Salem NC 27107
Phone: [phone]
Exit Time: 02:45 PM
Phone: [phone]
Inspection Type: Compliance Evaluation
Page: 1

Permit: SW4100601 Owner - Project: Sheetz Incorporated
Inspection Date: 07/07/2011 inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
File Review Yes No NA NE
Is the permit active? ■ n n n
Signed copy of the Engineer's certification is in the file? n ■ n n
Signed copy of the Operation & Maintenance Agreement is in the file? m n n n
Copy of the recorded deed restrictions is in the isle? n n n N
Comment: contacted engineer for cent.
Built Upon Area
Yes
No
NA
NE
Is the site BUA constructed as per the permit and approval plans?
e
n
n
n
Is the drainage area as per the permit and approved plans?
®
n
n
n
Is the BUA (as permitted) graded such that the runoff drains to the system?
®
n
n
n
Comment:
SW Measures
Yes
No
NA
NE
Are the SW measures constructed as per the approved plans?
®❑
❑
❑
Are the inlets located per the approved plans?
®
n
n
n
Are the outlet structures located per the approved plans?
®
n
n
n
Comment:
Operation and Maintenance
Yes
No
NA
NE
Are the SW measures being maintained and operated as per the permit requirements?
®
n
n
n
Are the SW BMP inspection and maintenance records complete and available for review or provided to DWQ
n
n
n
upon request?
Comment:
Other Permit Conditions
Yes
No
NA
NE
Is the site compliant with other conditions of the permit?
m
n
n
Cl
Comment. -
Other WQ Issues
Is the site compliant with other water quality issues as noted during the inspection?
Comment:
Yes No NA NE
a n n n
Page: 2

Homewood, Sue
From:
Wilbur Christmas [[e-mail]]
Sent:
Thursday, July 21, 2011 2:30 PM
To:
Homewood, Sue
Cc:
Kim R. Lilly, PLS; Sam Smith
Subject:
RE: Wallburg Sheetz - SW4100601
Attachments:
2011-7-15_Trashguard Fix.pdf
Hi Sue,
Yes, last week we created a detail (copy attached) for repairing the water quality orifice to the owner and he is in the
process of getting a contractor to make the repair.
They will let us know when the repair is complete, we will make a final inspection and then be able to certify the pond.
Thanks,
Wilbur
Wilbur E. Christmas, P.E.
wchristmas(@stimmelpa. com
Stimmel Associates, P.A.
601 N. Trade St. Suite 200
Winston-Salem, NC 27101
v: 336,723.1067 ext.109
f: 336,723.1069
www.stimmelpa.com
5tlmmel Associates. F.A. E-mail Disclaimer
From: Homewood, Sue[mailto:[e-mail]]
Sent: Thursday, July 21, 2011 2:19 PM
To: Wilbur Christmas
Subject: RE: Wallburg Sheetz - SW4100601
Hello Wilbur,
Were you able to get an update on this project/certification? Thank you.
Sue Homewood
NC DENR Winston-Salem Regional Office
Division of Water Quality
585 Waughtown Street
Winston-Salem, NC 27107
voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Homewood, Sue
Sent: Thursday, July 07, 2011 4:27 PM
To: 'Wilbur Christmas'
Subject: RE: Wallburg Sheetz - SW4100601
Thank you.

+E '
Please be aware that the Stormwater permits have standard language that require that all stormwater BMPs be certified
prior_to occupancy. We have been issuing Notices of Violations for sites that occupy their building without engineer's
certifications so please be sure that this client, and future clients are aware of this constraint to opening their
buildings/sites/projects.
I'll await your update on Monday. Have a good evening.
Sue Homewood
NC DENR Winston-Salem Regional Office
Division of Water Quality
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Wilbur Christmas[mailto:[e-mail]]
Sent: Thursday, July 07, 2011 4:19 PM
To: Homewood, Sue
Cc: Sam Smith, Ken Binkley
Subject: RE: Wallburg Sheetz - SW4100601
Sue,
The last issue I am aware of holding up the certification was the water quality orifice.
The contractor had filled above the bottom of the trash guard. We requested that he remove the fill to at least 6" below the
trash guard.
Ken Binkley in our office has been conducting the construction inspections but is on vacation this week. I will check with
him Monday to see if the orifice work has been done and verify all construction is per plan.
I will let you know the status Monday.
Thanks,
Wilbur
Wilbur E. Christmas, P.E.
wchristmas @sfimmelpa.com
Stimmel Associates, P.A.
601 N. Trade St. Suite 200
Winston-Salem, NC 27101
w 336.723.1067 ext.109
f: 336.723.1069
www.stimmelpa.com
Stimmel Associates P.A. E-mail Disclaimer
From: Homewood, Sue [mailto:[e-mail]]
Sent: Thursday, July 07, 2011 3:06 PM
To: Wilbur Christmas
Subject: Wallburg Sheetz - SW4100601
Hello Wilbur,

I am currently reviewing OWQ Post Construction Permit Files. This project does not seem to have an engineer's
certification on file as required by Condition 11.6. of the permit. The Certification is required prior to occupancy of the
facility which appears to have occurred. Are you the person who would have conducted the construction inspections for
the stormwater bmp?
Sue Homewood
NC DENR Winston-Salem Regional Office
Division of Water Quality
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.

Stimmel
Landscape Architecture
Civil Engineering
Stimmel Associates, PA Land Planning
601 N. Trade Street date: 7-15-11 jab #: 09-148
Suite 200
Winston Salem, NC prO ect: SHEETZ WALLBURG
27101-2916
Scale: NIA sheet 1 of 1
P: 336.723.1067
F: 336.723.1069 description: TRASH GUARD FIX
NOTE: CONTRACTOR MAY HAVE TO USE POND DRAWDOWN VALVE TO LOWER POND LEVEL TO PERFORM WORK
)c 6v 0 I �OOG 6jc— f
—_ h0000c: _/�000-
�ooa�00000_
1 S' RCP OUTLET PIPE
AFFIX ALUMINUM
HARCNVARE WIRE WITH
J"XJ" OPENINGS TO TOP OF
TRASH GUARD WITH
GALVANIZED SCREWS.
REMOVE EARTH 5' MIN
FROM TRASH GUARD AND
REPLACE WITH 7'-X CLEAN
STONE
AFFD(ALUMINLAA
HARDWARE WI RE WITH
I" X J" OPENINGS TO TOP OF
TRASH GUARD WFFH
GALVANIZED SCREWS.
REMOVE EARTH 6" MIN
FROM TRASH GUARD AND
REPLACE W FFH 7'�" CLEAN
STONE
- BOTTOM DRAIN INV: 911.00

State Storrnwater Permit
Permit No.SW4100601
Sheetz Inc.
Stormwater Permit No. SW4100601
Davidson County
Designer's Certification
v.C. Dcot. of ENR
AUG 0 4 2011
Wlnoton•saldra
Regicnal office
I Wilbur E . Christmas , as a duly registered Professional Engineer
in the State of North Carolina, having been authorized to observe eriodicallyl eeklyl
full time) the construction of the project,
Sheetz-Wallburg, NC
(Project)
for Sheetz Inc. (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:
-Modified Trash Guard with stone underneath and wire guard on top
to account for pond side slope conflict at outlet structure
-Some side slopes appear slightly steeper than 3:1 due to grade tie to
parking lot, but slopes are fully vegetated at this time and highly
maintained by regular landscape crew. SEAL
Signature `a►�r+�iu+r�1,,��r
Registration Number NC PE # 23552 �`��.�q��
SEAL.
Date
8-4-11
-
C0 52co
_
,,
E5
���Itllltlwo"
Page 5 of 6

State Storrnwater Permit
Permit No.SW4100t)0'
Certification Requirements:
X 1. The drainage area to the system contains approximately the permitted
acreage.
X 2. The drainage area to the system contains no more than. the permitted
amount of built -upon area.
X 3_ All the built -upon area associated with the project is graded such that the
runoff drains to the system.
X 4. All roof drains are located such that the runoff is directed into the system.
X 5. The outlet/bypass structure elevations are per the approved plan.
X 6. The outlet structure is located per the approved plans.
X 7. Trash rack is provided on the outlet/bypass structure.
X 8. All slopes ixe grassed with permanent vegetation.
9. Vegetated slopes are no steeper than 3:1.
X 10. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
X 11. The permitted amounts of surface area and/or volume have been
provided.
X 12. Required .drawdown devices are correctly sized per the approved plans.
X 13. All required design depths are provided.
X 14. All required parts of the system are provided, such as a vegetated shelf,
and a foreb ,y.
X 15. The required system dimensions are provided per the approved plans.
Please submit this Desigr ":.,r's Certification to: Asheville Regional Office
Surface Water Protection
2090 US Highway 70
Swannanoa, NC 28778
Page 6 of 6

AIWQW�
nii®
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
July 21, 2011
CERTIFIED MAIL 7010 2780 0001 4221 6146
RETURN RECEIPT REQUESTED
Mr. Joseph S. Sheetz, Executive Vice President
Sheetz, Inc.
5700 Sixth Avenue
Altoona, PA 16602
Subject: Stormwater Permit No. SW4100601
Sheetz-Wallburg, NC
Inspection Report
Davidson County
Dear Mr. Sheetz:
On July 21, 2010 the Division of Water Quality (Division) issued a High Density Commercial Property
Stormwater Permit for the proposed Sheetz in Wallburg, NC in Davidson County. On July 7, 2011, Sue
Homewood from this Division conducted a routine inspection of the approved Wet Detention Pond. The
following items were noted during their inspection:
• An engineer's certification has not been received by the Division prior to occupancy of the project as
required by Condition II.6 of Permit No. SW4100601. Communication with the design engineering firm
Stimmel Associates indicates that repairs are required to the water quality orifice to ensure that the wet
detention pond is constructed in accordance with the approved plans and specifications.
To address the items noted during the site inspection, please provide the following information within 30 days
of receipt of this letter:
• Engineer's Certification in accordance with Condition 11.6 of Permit No. SW4100601
• Per Condition 11.5 of Permit No. SW4100601 "The facilities shall be constructed as shown on the
approved plans." Please modify the outlet structure to comply with the approved plans and provide an
engineer's certification that the corrections have been made.
Please also note that Condition 1I.3 of Permit No. SW4100201 requires routine inspection, operation and
maintenance of the wet detention pond and records of maintenance activities must be kept and made available
upon future request.
North Carolina Division of Water Quality, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone. [phone] FAX: [phone] Customer Service. 1.877-623-6748
Internet: www,ncwaterquality.org
An Equal opportunity 1 Affirmative Action Employer
One
NorthCarolina
Naturally

Mr. Sheetz
July 21, 2011
Page 2 of 2
Thank you for your attention to this matter. Should you have any questions regarding these matters, please
contact Sue Homewood at this office at 336-771-4964 or [e-mail].
Sincerely,
W. Corey Basinger
Water Quality Regional Supervisor
Winston Salem Regional Office
cc: Wilbur Christmas, PE, Stimmel Associates, PA
DWQ WSRO
• Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and'address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
Mr. loseph.S. Sheetz, Executive VP
Sheetz, inc.
5700 Sixth Avenue
Altoona, PA 16602
A. Sianature„'
X^ (-Agent
❑ Addressee
Received y ( Print Name) C. Date of Delivery
J Gcfl 1a rrrt
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Sa� a Type
I Certified Mall ❑ Express Mall I
❑ Registered ❑ Return Receipt for Merchandise `
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2._Article Numher i
7010 .780 .0001 4221 6146, �,Y 7 co I SOT' l
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-W154e

fil� Mj®
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral, and Land Resources
Land Quality Section
Tracy E. Davis, PE, CPM Pat McCrory, Governor
Director John E. Skvarla, lll, Secretary
November 1, 2013
CERTIFIED MAIL #7013 1710 0002 1865 7638
RETURN RECEIPT REQUESTED
Mr. Joseph S. Sheetz, Executive Vice President
Sheetz, Inc.
5700 Sixth Avenue
Altoona; PA 16602
Subject: NOTICE OF 1AISPECTION
Sheetz — Wallburg, NC
Permit No. SW4100601
Davidson County
Dear Mr. Sheetz:
On November 1, 2013, Aana Taylor -Smith of the Winston-Salem Regional Office of the Division of Energy, Mineral, and
Land Resources (DEMLR) inspected the Sheetz — Wallburg site in Davidson County to determine compliance with
Stormwater Management Permit Number SW4100601 issued on July 20, 2010. DEMLR file review and site inspection
revealed that the site is compliant with the terms and conditions of this permit. Please find a copy of the completed form
entitled "Stormwater Inspection Report' attached to this letter.
Please be advised that you are required to comply with the terms, conditions and limitations of your Stormwater Management
Permit under Title 1 SA North Carolina Administrative Code 21-1 .1003 and North Carolina General Statute 143-214.7,
including operation and maintenance of your permitted stormwater system.
If the project has changed name, ownership or mailing address, a formal change of name/ownership form must be submitted
to DEMLR within 30 calendar days detailing the change. Please provide the name, mailing address and phone number of the
person or entity that is now responsible for this permit.
Thank you for your assistance and cooperation during this inspection. Please be advised that violations of the Stormwater
Management Permit may be subject to a civil penalty assessment of up to S25,000.00 per day for each violation. If you
have any questions, comments, or need assistance with understanding any aspect of your permit, please do not hesitate to
contact Ms. Taylor -Smith or me at [phone].
Sincerely,
Matthew E. Gantt, PE
Regional Engineer
Land Quality Section
Enclosure: Stormwater Inspection Report
cc: WSRO Files
DWR Central Files
Winston-Salem Regional Office
585 Waughtown Street, Winston-Salem, NC 27101 . Phone: [phone] I FAX: [phone]

■ Complete items 1, 2, and �.'Ago complete . A. 3&94i�y
item 4 if Restricted DellviN i6Wgired. l9 Agent
■ Print your name and address on the reverse X ❑ Addressee ;
so that we can return the card to you. B. Receive b (Printed me) C. Date of Delive
■ Attach this card to the back of the mailpiece, f
or on the front If space permits.
1. Article Addressed to:
Mr. Joseph S.'Sheetz
ISheetz Inc.
�5700 Sixth Avenue
Altoona, PA 16602
D. Is delivery add different from item 1? 0 Yes
If YES, enter delivery address below: ❑ No r
c
3. Service Type
05^8ed Mail ❑ Express Mail
is Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O._D.
4. Restricted Delivery? (Extra Fee) ❑ Ye
L ; '; 170131 17110 i 0002 j1865"'7638 � .h/0:�.1 SWLI.I UU(cD
PS Form 38111 February 2004 Domestic Return Receipt 102595-02-M-1540,
vR_■ 4 1 u 7`v ■■.�■r.IM . t—— . tm V —
(Domestic Mall Only; No Insurance Coverage Provided)
For delivery Information visit olur website at www.usps.come
C.i
1
:. 1:
----- " �-- - - - . ' - - - -- - .
Total P &. - _ -
r-9
Mr. Joseph S. Sheetz
m
entToSheetz Inc.
a
c3
3freet,i5700 Sixth Avenue
171"
or PO
PA 16602 i------
cv-Altoona,
I

Compliance Inspection Report
Permit: SW4100601 Effective: 07/21/10 Expiration: 12/30/21 Owner: Sheetz Inc
Project: Sheetz - Walburg NC
County: Davidson 5519 Gumtree Rd
Region: Winston-Salem
Winston Salem NC 27107
Contact Person: Wilbur E Christmas Title: Phone: [phone]
Directions to Project:
Type of Project: State Stormwater -Fib - Detention Pond
Drain Areas: 001 - (South Fork Muddy Creek) (03-07-04) ( C)
On -Site Representative(s):
Related Permits:
Inspection Date: 11101/2013 Entry Time: 11:06 AM
Primary Inspector: Aana Taylor -Smith
Secondary lnspector(s):
Reason for Inspection: Routine
Permit Inspection Type: State Stormwater
Facility Status: ® Compliant fl Not Compliant
Question Areas:
® State Stormwater
(See attachment summary)
Exit Time: 11:25 AM
Phone: [phone]
Inspection Type: Compliance Evaluation
Page: 1

Permit: SW4100601 Owner - Project: Sheetz Inc
Inspection date: 11101/2013 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
Site is very well maintained and compliant with all aspects of stormwater management permit.
File Review
Yes
No
NA
NE
Is the permit active?
®n
n
n
Signed copy of the Engineer's certification is in the file?
®n
n
❑
Signed copy of the Operation & Maintenance Agreement is in the file?
®.
n
n
❑
Copy of the recorded deed restrictions is in the file?
®❑
❑
❑
Comment:
Built Upon Area
Yes
No
NA
NE
Is the site BUA constructed as per the permit and approval plans?
®n
❑
❑
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?
®n
n
n
Comment:
CIAI l4A...,......,..
Yoc
Nn
NA
NF
Are the SW measures constructed as per the approved plans? ® n 0 ❑
Are the inlets located per the approved plans? ® Q n ❑
Are the outlet structures located per the approved plans? ®n ❑ n
Comment:
Operation and Maintenance Yes No NA NE
Are the SW measures being maintained and operated as per the permit requirements? ® D ❑ ❑
Are the SW BIVIP inspection and maintenance records complete and available for review or provided to DWQ ❑ ❑ ❑
upon request?
Comment: Measures are very well maintained.
Other Permit Conditions 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:
M 0 0 0
Yes No NA NE
®nn❑
Page: 2

r. A
State Stormwater Inspection Report
General
Project Name: SVEeM—\M(,UtjbLty ) Me
Permit No: SW410DLPD1
Expirat ionDate: •71za/'2D
Contact Person: �j �hUY (,ttr1Y1STYYIAS t C7E
Phone Number: -j23—tULD-1
Inspection Type: LE t
Inspection Date: t I r l 3
Time In: k j 0
Time Out:
Current Weather: �jGtyl� ►��iv� t �p�
Recent Rain (Date)?
Rain— in
Location
Facility Address / Location: 55 iq
City: W!nSiU-n`<-fAvem Lip: 2'1 10-1 County:-bA\jjCjSp Lat: 0 "N Long: - 0 "W
Permit Information
Rule Subject to (circle one): 1988 Coastal Rule 1995 Coastal RUle 2008 Coastal Rule Session Law 2006-246
Goose Creek High Quality Waters Outstanding Resource Waters
Density (circle one): High (HD) Low (LD)
Stormwater Best Management Practices (BMPs) (inse;-1 number of each):
XWet Ponds Infiltration Basins In Filtration Trenches
Dry Ponds Bioretention Permeable Pavement
Cistern Level Spreader/Filter Strip Other (specifi)!
File Review
LID Swales Stormwater Wetlands
Sand filters (circle nne) Open Closed
Yes ' No NIA NIE
I. Is the permit active?
2 Signed Engineer's Certification on file?
3. Signed Operation and Maintenance agreement on file?
4. Recorded Deed Restrictions on file?
Site Visit: Built Upon Area (BUA) Yes No NIA NIE
5. BUA is constructed and consistent with the permit requirements?
6. BUA (aspermitted) is Traded such that the runoff drains to the system? (high density only)
7. Drainage area is consistent with err -nit? (i.e. no un ermitted draina�e to the SW BMPs)✓
8. Drainage area is stabilized? to reduce risk of sedimentation to the SW BMPs)
Sites Visit- Stnrmwater RMPS
Yes Nn NIA NIF
9. Stormwater BMPs are located per the approvedplans?
t/
W. Stormwater BMPs have dimensions (e g. length, width, area) matching the aeprovedplans?
11. Storm -water BMPs are constructed per the approvedplans?
Site Visit: Oneratinn and Maintenanre
Yes No NIA NIE
12. Access points to the site are clear and well maintained?
t/
0. Trash has been removed as needed?
14. Eixcessive landscape debris (grass clippings, leaves, etc) is controlled?
15. Stormwater BMPs being operated and maintained as per the permit requirements?
16. Inspection and Maintenance records are available for inspection? (high density only, 1995 — present only)
✓
Site Visit: Other Permit Conditions Yes No NIA NIE
17. Is the site compliant with other conditions of thepermit?
Site Visit: Other Water Quality Issues Yes No NIA NIE
18. Is the site compliant with other water quality issues as noted during the inspection? ;/
State 5tornmater Inspection Report, Version 3.0 3-09 Page I of 2

State Stormwater Inspection Report-
)mments
M- osuuy,e s min-GXCC—W--_ MT 60 ru i fifi � rl
Inspection Pictures (some of the pictures taken during the site visit)
Compliance Status IX Compliant I] Non -Compliant
Letter Sent (circle one es No
t
Date Sent:
Letter types NOV
Reference Number:
NOVRE Other
Inspector Name and Signature: v)A Tc.ui.bXtC�pndn Date: t t `3
State Slomt„'ater Inspection Report. Version 3.0_3-09 Page 2 of'2

WET DETENTION O & M Inspection Checklist
INLETS and FOREBAY
1. Inlets are located per the approved plans: ❑
F
❑
❑
2. Inlet device (swale or pipe) is free of damage, clogs or erosion:
©
❑
❑
❑
3. Forebay berm is in place and without erosion:
Er
❑
❑
❑
4. Forebay is free of excessive sediment:
©'
❑
❑
❑
SIDE SLOPES AND BANKS
5. Vegetated slopes are 3:1 or less:
Er
❑
❑
❑
6. Banks are stable and free of erosion or bare soil:
❑'
❑
❑
❑
7. Slopes or berms are free of woody vegetation:
U
❑
❑
❑
8. Free of muskrats or beaver activity:
1vr
❑
❑
❑
9. Grass is being maintained and mowed (not scalped) as required:
12'
❑
❑
❑
PERIMETER AND MAIN BAY
10. Vegetated shelf is 6:1 or 10:1 as permitted and properly vegetated:
Er
❑
❑
❑
11. Algal growth covers less 50% of the area:
ER'
❑
❑
❑
12. Cattails, phragmites or other invasive plants cover less than 50% of the basin surface:
ER'
❑
❑
❑
13. Main treatment area is free from excess sediment accumulation:
D/
❑
❑
❑
OUTLETS
14. Swale or emergency outlet bypass is in the correct place and is in good condition:
EY
❑
❑
❑
15. Drawdown device is correctly sized free of damage or clogging:
2
❑
❑
❑
16. Orifice size matches the approved plans
a
❑
❑
❑
17. Outlet is free of erosion or other signs of damage:
[-
❑
❑
❑
18. Trash rack is installed
❑,'
❑
❑
❑
19. Vegetated filter is in place (if applicable)
[DI
❑
❑
❑
20. Relative elevations match approved plans
a
❑
❑
❑
21. Fountain pump (if permitted) is less than or equal to the maximum allowable size:
❑
❑
0�
❑
V3.3_09