SW4110301_CURRENT PERMIT_20110330

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW 41 i 03 O i
DOC TYPE
CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE
z 011 3,30
YYYYMMDD

NCDENR
RECEIVED
N.C. Deot. of RNA
North Carolina Department of Environment and Natural Resources
APR 0 5 2011
Division of Water Quality
Y1ins an 5�
Beverly Eaves Perdue Coleen H. Sullins
p�gion=Gffi-
Dee Freeman
Governor Director
Secretary
March 30, 2011
Mr. Tab Patton
Patton Development
P.O. Box 100
Woodruff, South Carolina 29388
Subject: Stormwater Permit No. SW4110301
Thomasville Road Dollar General
Forsyth County
Dear Mr. Patton:
The Stormwater Permitting Unit received a complete Stormwater Management Permit Application for
Thomasville Road Dollar General on March 30, 2011. Staff review of the plans and specifications has
determined that the project, as 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..SW4110301, dated March 30,
2011, for the construction, operation and maintenance of the subject project and the stormwater BMPs.
This permit shall be effective from the date of issuance until March 29, 2021, 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 must be in the form of a written petition, conforming to Chapter 150B of the North Carolina
General Statutes, 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 Mike Randall at [phone]; or
[e-mail].
Sincerely,
for Coleen H. Sullins
cc: Winston-Salem Regional Office
SPU Files
Wetlands and Stormwater Branch
1617 Mail Service Center, 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
An Equal Opportunity 1 Affirmative Action Employer
Nne
orthCarolina
Aatura!!y

State Stormwater Permit
Permit No. SW4110301
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
Dollar General
Thomasville Road NC-109
Thomasville and Maranda Roads, Forsyth County
FOR THE
construction, operation and maintenance of one biorefe'ntion cell(s) 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 March 29, 2021, 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 application, plans and supporting documents. The
stormwater control has been designed to handle the runoff from 30,056 square
feet of impervious area.
3. The tract will be limited to the amount of built -upon area as indicated in the
application and supporting 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 4

State Stormwater Permit,
Permit No. SW4110301
7. The following design criteria have been provided in the bioretention cell and must
be maintained at design condition:
a. Drainage Area acres:
Onsite, ft :
Offsite, ft2:
b. Total Impervious Surfaces, ft2:
Onsite, ft
Offsite, ft2:
c. Design Storm, inches:
d. Max. Ponded Depth, feet:
e. Seasonal High Water Table, fmsl:
f. Planting Media Depth, feet. -
Cell Dimensions, feet: _
h. Bottom Elevation, fmsl:
i. Bottom Surface Area, ft2:
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. Receiving Stream/River Basin:
q. Stream Index Number:
s. Classification of Water Body:
II. SCHEDULE OF COMPLIANCE
76,230
47,045,
29,185
30,056
30,056
.0
1
1.0
857
2.0
76 by 25 feet
861.00
1,872.0
3,859.0
8£3.00
0.340 ft /sec
0.190 ft3/sec
48 hours
4 in diameter w/1 inch low flow orifice
Swaim Creek /Yadkin Pee -Dee
12-94-13-1
"C"
1. The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use prior to the occupancy.
2. During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired prior to the occupancy.
3. The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted stormwater system functions as approved. 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 cell 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. Upon request the permittee shall submit to the Division of Water Quality a
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 4

Stormwater Permit
Permit No. SW4110301
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. 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 certification in writing to the Director
that the changes have been made.
III. GENERAL CONDITIONS
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 4

State Stormwater Permit
Permit No. SW4110301
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 sy_ste .m. s.
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.
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 30«' day of March, 2011.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
for Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission
Page 4 of 4

State Stormwater Permit
Permit No. SW4110301
Dollar General
Thomasville Road NC-109
Forsyth 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,
Dollar General, Thomasville Road NC-109
(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 1 of 2

State Stormwater Permit
Permit No. SW4110301
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, i
and a forebay.
3
15. The required system dimensions are provided per the approved plans.
cc: NCDENR-DWQ Regional Office
Page 2 of 2

KELLY B. SELLARS
F-NGINEER & PLANNER
RECEIVED
N.C. Deot. of ENR
MAY 1 6 �0J
1/� a
May 9, 201 1 Regional O"..a
Mr. Mike Randall
Stormwater & General Permits Unit Division of Water Quality
161.7 Mall Service Center
Raleigh, NC 27699-1617
RE: Thomasville Road — Dollar General, NC
K13S Project No. 10-329 ( Revised 05/02/201 1)
Dear Mr. Randall:
r'
Enclosed for your review is the erosion control submittal for the referenced project.
Included in the package:
• I'wo (2) copies of the revised site construction drawings.
• Stormwater Management Permit Application Form (Revised a minor change)
The revised of the bioretention pond to accommodate the septic drain field, the volume of
the bioretention pond, and elevations remain the same. Therefore, the reconfigured pond
should function exactly as shown on the approved drawings (SW41 10301, March 30,
2011).
Please give me a tali if you have questions or need additional information.
Since
KK;V
r , P>J
Enc.
571 WINDRIDGE CIRCLE
INMAN. SOUTH CAROLINA 29349
C VIP p
LMAY 1 0 2011
- 4'VAT C'. d"0AL
i6 wwIi; & sulumgrAlw $rmxh
TELEPHONE [phone]
FAX [phone]
EMAIL [e-mail]

DWQ USE ONLY
Date Received
Fee Paid
Perrnit Number
Applicable Rules: ❑ Coastal SW —1995 ❑ Coastal SW -- 2008 ❑ I'll II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina RECEIVED
Department of Environment and Natural Resources N'e' Ooot. of KNR
Division of Water Quality MAY 16 2011
STORMWATER MANAGEMENT PERMIT APPLICATION FORM: o,
This form may be photocopied for use as an original "
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Thomasville Road - Dollar General
2. Location of Project (street address):
Thomasville Road NC-10
City: County:Forsyth Zi
3. Directions to project (from nearest major intersection):
Approximate 780' intersection southeast Thomasville road and Maranda Road
4. Latitude:36° 01' 56" N 1,011glhlde:80° 10' 15" W of the plain entrance to the project.
if. 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
Specify the type of project (check one):
❑Low Density ❑High Density ®Drains to an Offsite Stormwater System ®Other
1 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/Erosion Control: 1.8 ac of Disturbed Area
❑NI'DES 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 pet-mit:Submitted to the City of Winston-Salem and Forsyth County inSl2eCtiOn
Fm-M 102011
,VIstvw
Form SWU-I01 Version 07JUn20l0 Page I of 6

III. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization:Patton Development
Signing Official & Title:Tab Patton Owner
b.Contact information for person listed in item la above:
Street Address:PO Box 100
City:Woodruff
State:SC
Zip:29388
Mailing Address (if applicable):332 S. Pearson Street
City:Woodruff State:SC Zip:29388
Phone: [phone] Fax: (864 ) 476-9991
Email: [e-mail]
c. Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
® Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/OrganizationTatton Development
Signing Official & Title:Tab Patton/ Owner _
b.Contact information for person listed in item 2a above:
Street Address:PO Box 100
City:Woodruff State:SC Zip:29388
Mailing Address (if applicable):332 S. Pearson Street
City:Woodruff
Phone: (863 } 476-9990
Ernail:[e-mail]
State:SC
Zip:29388
Fax: (864 ) 476-9991
3.a. (Optional) Print the name and title of another contact such as the project's construction supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization:KB Sellars Engineering
Signing Official & Title:
b.Contact information for person listed in item 3a above:
Mailing Address:571 Windridge Circle
City:Inman State:SC Zip:29349
Phone: (864 ) 699-9512 _
Email:[e-mail]
4. Local jurisdiction for building permits:
Point of Contact:
Fax: [phone]
Phone #:
Form SWU-101 Version 07Jun2010 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Construction site preparation for phase I will be treated with sediment pond. In final contruction site for
phase II will be treated with bio-detention.
2, a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW — 1995 ® Ph lI — Post Construction
3. Stormwater runoff from this project drains to the Yadkin Pee Dee River basin.
4. Total Property Area: 2.7 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': 2.1 acres
Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the j Jorinal High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward of the NHW (or MHW) line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 39 '%
9. I -low many drainage areas does the project have? 2 (For high density, count 7 for each proposed engineered
stort►iwater BMP. For low density and other projects, rise 7 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 in additional sheet with the information for each area
provided in the same format as below.
Basin Information
Drainage Area _
Drainage Area _
Drainage Area _
Drainage Area _
Receiving Stream Name
Swaim Creek
Stream Class *
C
Stream Index Number *
12-94-13-1
Total Drainage Area (sf)
76,230
On -site Drainage Area (sf)
47,045
Off -site Drainage Area (sf)
29,185
Proposed Impervious Area** (sf)
30,056
` ) Impervious Area** (total)
39
Im ervious" Surface Area
Drainage Area _
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
9,100
On -site Streets (sf)
On -site Parking (sf)
19,241
On -site Sidewalks (sf)
1,715
Other on -site (sf)
Future (sf)
Off -site (sf)
0
Existing 13UA*** (sf)
Total (sf):
30,056
Stream Class and Index Number can be determined at: hi"jortal.ncdcnr.vr uv 2 Vss/csu/classifications
** liltperuious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version 07Jun2010 Page 3 of 6

"Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
11. I -low was the off -site impervious area listed above determined? Provide documentation. No off -site
impervious area for the project site
Projects in Union County: Contact DWQ Central Office staff to check if the project is located ii ithin a Threatened &
EndangeredSpecies watershed that malt' be subject to more stringent stornm ate>r regairetnents as per NCAC 02B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from http://portaLncdcnr.ort wcb��/ws/su/bmp-manual.
V1. 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 htt,: ortal.ncdenr.ort web W J/ws/su/statesw/forms does. 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 htt LL: 12ortal.ncdenr.org/wcb/wq/ws/su/maps.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from htt ,://por(ciI.iizdLiir-org/web/­wq/ws/,;uZstatesw/`­..foriiis does.
hlit'�Is
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one cop:/ of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part Vll below)
3. Original of the applicable Supplement Form(s) (sealed signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
littp://www.envhelp.orgLpaves/onestopexpress.1-itm] for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. if the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within 1h mile of the site boundary, include the'h
mile radius on the map.
7. Sealed, signed and dated calculations.
8. Two sets of plans folded to 8.5" x 14" (scaled, 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 NI-1W line of tidal
waters, and any coastal wetlands landward of the MHW or NFIW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MI-IW (or NFIW) 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.
Form SWU-101 Version 07Jun2010 Page 4 of 6
r
1�&

n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated Duffers (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"x1I" 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 verifit the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 1745 Page No: 234
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and /or 3a per NCAC 21-I.1003(e). The
corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
http:/ /www.secretary.state.nc.us/Corporations/CSeardl.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided
as an attachment to the completed and notarized deed restriction form. The appropriate deed restrictions and
protective covenants forms can be downloaded from
http://portal.ncdenr.org/web/wc�vs/su/sta_tes�v/forms does. 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 atl parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC 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:Kelly Sellars, PE —_
Consulting Firm: KB Sellars Engineering
Mailing Address:571 Wind ridge Circle
City:Inman State:SC Zip:29349
Phone: (864 ) 699-9512
[e-mail]
Fax: (864 ) 699-9523
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, iterrr 2 has been filled out, complete this
section)
1, (print or hype name of person listed in Contact Information, item 2a) Patton Developrnent , 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 7a) Tab Patton with (print or type name of organization listed in
Contact Information, item In) Patton Development to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWU-101 Version 07Jun2010 Page 5 of 6

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 Dorm 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 pe�jties 9�f up too $25� day, pursuant to NCGS 143-215.6.
Signature:
I,
1-�' Ste«-46t-s
Da te: .S- 9- /l
a Notary Public for the State of _Zi 7-H CAALV' , County of
ti1�4_ UAL C do hereby certify that , Th� e, -l—N^I personally appeared
k�
before me this cr day of A ]f �� t I , and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires 1 U _� E?_ Zoe 5
X. APPLICANT'S CERTIFICATION 0-1-
1, (print or type natne of person listed in Contact Information, item 1a) / "t
certify that the information included on this permit application form is, to th4 best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protective covenants will be recorded, and that the proposed project complies with the requirements of the
applicable stormwater rules-ynder 15A NCAC 2J00@-, SL 2006-246 (Ph. II - Post Construction) or SL 200$-211.
Signature:
Da te: ✓ ��
a Notary Public for the State of 50J i H CIP�-1-11, County of
sa&AU11_✓11G do hereby certify that 1 AI-T^f personally appeared
before me this day of r�\A i �-`' 1 , and acknowledge the quexec ition of the application for
a stormwater permit. Witness my hand and official seal, e�w
SEAL
My commission expires
o- —yd/S
Form SWU-101 Version 077un2010 Page 6 of 6

A . .

It
Permit Number. sw41IQ1
(to be provided by OWQ)
AI
O�OF W A rFyQG
MA
tIA
NCDENR
STORMWATER MANAGEMENT PERMIT APPLICATION FORM RECEIVED
401 CERTIFICATION APPLICATION FORM N.C. Deot. of ENq
BIORETENTION CELL SUPPLEMENT APR 0 5 2011
This form must be filled out, printed and submitted. winstcr-_-
The Required Items Checklist (Part Ill) must be printed, filled out and submitted along with all of the required information.cria'l
I. PROJECT INFORMATION
Project name Thomasville Road - Dollar General
Contact name Kelly Sellar
Phone number (864)-699-9512
Date March 11,2011
Drainage area number 1
II. DESIGN INFORMATION
Site Characteristics
Drainage area 47,045 ft2
Impervious area 30,056 ft2
Percent imperious 63.9% %
Design rainfall depth 2.8 inch
Peak Flow Calculations
Is pre/post control of the 1-yr, 24-hr peak flow required?
1-yr, 24-hr runoff depth
1-yr, 24-hr intensity
Pre -development 1-yr, 24-hr peak flow
Post -development 1-yr, 24-hr peak flow
Pre/Post 1-yr, 24-hr peak control
Storage Volume: Non -SA Waters
Minimum volume required
Volume provided
Storage Volume: SA Waters
1.5" runoff volume
Pre -development 1-yr, 24-hr runoff
Post -development 1-yr, 24-hr runoff
Minimum volume required
Volume provided
Cell Dimensions
Ponding depth of water
Ponding depth of water
Surface area of the top of the bioretention cell
Length:
Width:
-or- Radius
Media and Soils Summary
Drawdown time, ponded volume
Drawdown time, to 24 inches below surface
Drawdown time, total:
In -situ soil.,
Soil permeability
Planting media soil:
Soil permeability
Soil composition
% Sand (by volume)
% Fines (by volume)
% Organic (by volume)
Phosphorus Index (P-Index) of media
Form SW401-Bioretention-Rev.8
June 25. 2010
y (Y or N)
0.72 in
2.8 in/hr
0, 340 ft'Isec
0.190 ft'/sec
-0150 ft3lseC
3,5.0 ft'
3,859.0 ft' OK
it' �rA,;,t,a,o1ev►Z.l' �e 3G 3S
ff3
W
0 ft 3
ft3
12 inches
OK
1.00 ft
1,872.0 ft2
Insufficient surface area.
76 ft
OK
25 it
OK
10 ft
OK
12 hr OK
36 hr OK
48 hr
1.20 in/hr OK
1.20 inlhr OK
85% OK
10% OK
5% OK
Total: 100%
22 (unitless) OK
Paris I and It. Design Summary, Page 1 of 2

Permit Number: SW'+11 0301_
(to be provided by DWQ)
Basin Elevations
Temporary pool elevation
Type of bioretention cell (answer Y' to only one of the two
following questions).
Is this a grassed cell?
is this a cell with trees/shrubs?
Planting elevation (top of the mulch or grass sod layer)
Depth of mulch
Bottom of the planting media soil
Planting media depth
Depth of washed sand below planting media soil
Are underdrains being installed?
How many clean out pipes are being installed?
What factor of safety is used for sizing the untlerdrains? (See
BMP Manual Section 12.3.6)
Additional distance between the bottom of the planting media and
the bottom of the cell to account for untlerdrains
Bottom of the cell required
SHWT elevation
Distance from bottom to SHWT
Internal Water Storage Zone (IWS)
Does the design include IWS
Elevation of the top of the upturned elbow
Separation of IWS and Surface
Planting Plan
Number of tree species
Number of shrub species
Number of herbaceous groundcover species
Additional Information
Does volume in excess of the design volume bypass the
bioretention cell?
Does volume in excess of the design volume Flow evenly distributed
through a vegetated fitter?
What is the length of the vegetated filter?
Does the design use a level spreader to evenly distribute flow?
is the BMP located at least 30 feet from surface waters (50 feet if
SA waters)?
Is the BMP localed at least 100 feet from water supply weals?
Are the vegetated side slopes equal to or less than 3:1?
Is the BMP located in a proposed drainage easement with access
to a public Right of Way (ROW)?
Inlet velocity (from treatment system)
Is the area surrounding the cell likely to undergo development in
the future?
Are the slopes draining to the bioretention c0 greater than 20%?
Is the drainage area permanently stabilized?
Pretreatment Used
(Indicate Type Used with an "X" in the shaded cell)
Gravel and grass
(81inches gravel followed by 3-5 ft of grass)
Grassed swage
Forebay
Other
864.00 fmsl
Y (YorN) OK 2r &,b-cd — CAS
N (Y or N) I MaA.1t kA�
863 fmsl l
4 inches OK
861 fmsl
2ft
0.33 ft
Y (Y or N)
tr
1 Insufficient number of clean out pipes provided (c1 LF-
3 OK
b�MQC�►�f�Kh
1ft
859.67 fmsl
857 fmsl
2,67 ft OK
Y (Y or N)
fmsl
863 it
0
0
3 OK
Y (Y or N) OK
Y (Y or N) OK
76 ft
N (Y or N) Show how flow is evenly distributed.
Y (Y or N) OK
Y (Y or N) OK
Y (Y or N) OK
Y (Y or N) OK From pu,I�iCG 0� G.
N
ft/sec A.-40-
N (Y or N) OK
N (Y or N) OK
Y (Y or N) OK
#VALUE!
Form SW401-Bioratention-Rev,8
June 25, 2010 Parts I and It. Design Summary, Page 2 of 2

Permit No, SW40UL
(to be assigned by DWQ)
I 11:11 REQU I RE01 ITEMS CHECK111!IS
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
Shee No.
&3 /q
Bio— rii " �% l
iM W � �
"� .
PSS�cf S�► A,.
1. Plans (1' - 50' or larger) of the entire site showing:
Design at ultimate build -out,
' Off -site drainage (if applicable),
J_ Delineated drainage basins (include Rational C coefficient per basin),
i Cell dimensions, (]j 1 2 0)
Pretreatment system, {`�►nl�'�t��
- High flow bypass system,
✓- Maintenance access, °K Row +'
Recorded drainage easement and public right of way (ROW), N/A
!- Clean out pipe locations, t
/- Overflow device, and br r 56'L
Boundaries of drainage easement.
2. Plan details (1' = 30' or Iprger) for tq bioretention cell showing:
VCelt dimensions
,.pretreatment system,
High flow bypass system,
E Maintenance access, B O
Recorded drainage easement and public right of way (ROW),
VDesign at ultimate build -out,
/Off -site drainage (if applicable),
%Clean out pipe locations,
Overflow device, and
Boundaries of drainage easement.
Indicate the P-Index between 10 and 30
3. Section view of the bioretention cell (1" = 20' or larger) showing:
/- Side slopes, 3:1 or lower
Underdrain system (if applicable), and
Bioretention cell layers [ground level and slope, pre-treatment, pending depth, mulch depth, fill media
depth, washed sand, filter fabric (or choking stone if applicable), #57 stone, underdrains (if applicable),
SHWT level(s), and overflow structure]
4. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. The
results of the soils report must be verified in the field by DWO, by completing & submitting the soils
investigation request form. County soil maps are not an acceptable source of soils information. All
elevations shall be in feet mean sea level (fmsl). Results of soils tests of both the planting soil and the in
situ soil must include:
Soil permeability,
Z k �. Soil composition (% sand, % fines, % organic), and
P'Idx
A5.
A detailed planting plan (1' = 20' or larger) prepared by a qualified individual showing:
/^+
A variety of suitable species,
l.T
Sizes, spacing and locations of plantings,
kA- JI
Total quantity of each type of plant specified,
A planting detail,
The source nursery for the plants, and
e3 f
Fertilizer and watering requirements to establish vegetation,
ah
fi. A construction sequence that shows how the bioretention cell will be protected from sediment until the
entire drainage area is stabilized.
7. The supporting calculations (including underdrain calculations, if applicable).
8. A copy of the signed and notarized inspection and maintenance (I&M) agreement.
9. A copy of the deed restriction.
Form SW441-Bioretention-Rev.7
Part III, Page 1 of t

Permit Number:
(10 be prouidcd bye DWQ)
Drainage Area Number:
Bioretention Operation and Maintenance Agreement
I will keep a maintenance 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.
Important operation and maintenance procedures:
Immediately after the bioretention cell is established, the plants will be watered
twice weekly if needed until the plants become established (commonly six
weeks).
Snow, mulch or any other material will NEVER be piled on the surface of the
bioretention cell.
— Heavy equipment will [NEVER be driven over the bioretention cell.
— Special care will be taken to prevent sediment from entering the bioretention cell.
— Once a year, a soil test of the soil media will be conducted.
After the bioretention cell is established, I will inspect it 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 will be kept in a known set location
and will be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element:
Potentialproblems:
How I will remediate theproblem:
The entire BMP
Trash/debris is present.
Remove the trash/debris.
The perimeter of the
Areas of bare soil and/or
Regrade the soil if necessary to
bioretention cell
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.
The inlet device: pipe,
The pipe is clogged (if
Unclog the pipe. Dispose of the
stone verge or swale
applicable).
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged (if
applicable).
Erosion is occurring in the
Regrade the swale if necessary to
swale (if applicable).
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
Stone verge is clogged or
Remove sediment and clogged
covered in sediment (if
stone and replace with clean stone.
applicable).
Form SW401-Bioretention O&M-Kev3 Page 1 of 4

BMP element:
Potentialproblems:
How I will remediate theproblem:
The pretreatment area
Flow is bypassing
Regrade if necessary to route all
pretreatment area and/or
flow to the pretreatment area.
allies have formed.
Restabilize the area after grading.
Sediment has accumulated to
Search for the source of the
a depth greater than three
sediment and remedy the problem if
inches.
possible. Remove the sediment and
restabilize the pretreatment area.
Erosion has occurred.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Weeds are present.
Remove the weeds, preferably by
hand.
The bioretention cell:
Best professional practices
Prune according to best professional
vegetation
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.
Tree stakes/wires are present
Remove tree stake/wires (which
six months after planting.
can kill the tree if not removed).
The bioretention cell:
Mulch is breaking down or
Spot mulch if there are only random
soils and mulch
has floated away.
void areas. Replace whole mulch
layer if necessary. Remove the
remaining much and replace with
triple shredded hard wood mulch at
a maximum depth of three inches.
Soils and/or mulch are
Determine the extent of the clogging
clogged with sediment.
- remove and replace either just the
top layers or the entire media as
needed. Dispose of the spoil in an
appropriate off -site location. Use
triple shredded hard wood mulch at
a maximum depth of three inches.
Search for the source of the
sediment and remedy the problem if
possible.
An annual soil test shows that
Dolomitic lime shall be applied as
pH has dropped or heavy
recommended per the soil test and
metals have accumulated in
toxic soils shall be removed,
the soil media.
disposed of properly and replaced
with new elanting media.
Form SW401-Bioretention O&M-Rev.3 Page 2 of 4

BMP element:
Potentialproblems:
How I will remediate theproblem:
The underdrain system
Clogging has occurred.
Wash out the underdrain system.
(if applicable)
The drop inlet
Clogging has occurred.
Clean out the drop inlet. Dispose of
the sediment off -site.
The drop inlet is damaged
Repair or replace the drop inlet.
The receiving water
Erosion or other signs of
Contact the NC Division of Water
damage have occurred at the
Quality 401 Oversight Unit at 9'19-
outlet.
733-1786.
Form 5W401-Bioretention O&M-Rev3 Page 3 of 4

Permit Number:
(to he pro vkW by DWQ)
I acknowledge and agree by my signature below that I am responsible for the
performance of the maintenance procedures listed above. I agree to notify DWQ of any
problems with the system or prior to any changes to the system or responsible party.
Project name:Thomasville Road - Dollar General
BMP drainage area number:
Print nameTatton
Title:Owner/ Developer
Address:PO Box 100 Woodruff, SC 29388
Phone:(8b4
Signature: Ml-
Date: 31�' /—
Note: The legally responsible party should not be a homeowners association unless more than 50% of
the lots have been sold and a resident of the subdivision has been named the president.
I, :e,4N X 0. SCLLgp-s , a Notary Public for the State of'
SD,I i }I C4iUL 4 .J A County of SjAtL A,� 60IL6 , do hereby certify that
,B personally appeared before me this I I tH
day of 3' kACLC,j , -2o l 1 and acknowledge the due execution of the
forgoing bioretention maintenance requirements. Witness my hand and official seal,
My commission expires
Form SW401-Bioretention I&M-Rev. 2 Page 4 of'4

State Stormwater Inspection Report
General
Project Name: il1e 1u1- T>C.�1 Al
Permit No: SW 4tI03D 1
Expiration Date: 3I Z-1 /21
Contact Person: •Tq 6 pA �I-Dy-)
Phone Number:8,q-
Inspection Type: Ce 1
Inspection Date: it/ tIS
Time In: 1oy5
Time Out: I t p 5
Current Weather: j I y,t a rt , L_p pS
Recent Rain (Date)?
Rain — in
Location
Facility Address / Location: TV)U lSV1Jlf 1ZC,,-d % NG— 1tr1
City: jYIS 1�Y� -SA 1 �v1 Zip: 2J1 1 D1 County: IFDrSt - Lat: "N Long. - W
Permit Information
Rule Subject to (circle one): 1988 Coastal Rule 1995 Coastal Rule
Goose Creek High Quality Water;
Density (circle one): High (H Low (LD)
Stormmwater Best Management Practices (BM Ps) (insert numbet- of eoch):
Wet Ponds Infiltration Basins Infiltration Trenches
Dry Ponds y Bioretention Permeable Pavement
Cistern Level Spreader/Filter Strip Other (vpecif):
File Review
2008 Coastal Rule Session Law 2006-246
Outstanding RCSOurce Waters
LD Swales Stormwater Wetlands
Sand filters (circle one) Open Closed
Yes No NIA NIE
1. Is the permit active?
t/
2 Signed Ert ineer's Certification on file?
✓
3. Signed Operation and Maintenance agreement on file?
t/
4. Recorded Deed Restrictions on file?
✓
Site Visit: Ri ilt Unnn Area (BUA1
Yes No NIA NIE
5. BUA is constructed and consistent with the permit requirements?
6. BUA (aspermitted) is graded such that the runoff drains to the system? (high density only
7. Drainage area is consistent withpermit? i.e. no un ermitted draina17e to the SW BMPs
8. Drainage area is stabilized? (to reduce risk of sedimentation to the SW BMPs
Site Visit: Stormwater BMPs
Yes No NIA NIE
9. Stormwater BMI's are located per the approvedplans?
LZ
10. Stormwater BMPs have dimensions (eg. length, width, area) matching the approvedplans?
11. Stormwater BM Ps are constructed perthe approvedplans?
Site Visit: Oneratinn and Maintenance
Yes No NIA NIE
12. Access points to the site are clear and well maintained?
✓
13. Trash has been removed as needed?
14. Excessive landscape debris (grass clippings, leaves, etc) is controlled?
t/
15. Stormwater BMPs being operated and maintained as per the permit requirements?
16, Inspection and Maintenance records are available for inspection? (hi17h density only, 1995 — present only)
Site Visit: Other Permit Conditions Yes No NIA NIE
17. Is the site compliant with other conditions of the omit?
Site Visit: Other Water Quality Issues Yes No NIA NIE
I8. Is the site compliant with other water quality issues as noted during the inspection?
State Stormwater ]nspeetion Report, Version 3.0_3-09 Page t of 2

State Stormwater Inspection Report
)mments
'�k If PC6 r Y)eox
j2 e,�n by e xCc sS seal i p ►� t c ZA
Ins ectlon Pictures (some of the pictures taken during the site visit)
Compliance Status 0 Compliant Y Non -Compliant
Letter Sent (circle one) Ye No Letter type: CEI NOV NOVRE Other
Date Sen
Reference Number:
Inspector Name and Signature: AA WA T4.tA1AY s`p1
Date: t N i tM
State Stor neater Inspection Report, Version 3.0_3-09
Page 2 of'2

I N
BIORETENTION CELL: O & M Inspection Checklist
INLET and PERIMETER
1. Inlet and Perimeter are free of erosive gullies and bare soil areas: ❑ EV ❑ ❑
2. Inlet device (swale, pipe, stone verge) is free of erosion, damage or clogs:
❑
U/
❑
❑
3. Weir heights appear to match approved plans:
❑
❑
PRETREATMENT
4. Flow is entering pretreatment area (not being bypassed):
ID/
❑
❑
❑
5. Pretreatment area is free of erosion:
❑
[r'
❑
❑
6. Pretreatment area is free of excessive sediment or clogs:
❑
12/
❑
❑
MAIN TREATMENT AREA
7. Side slopes are 3:1 or less:
E
❑
❑
❑
8. The under drain system is free flowing and free of clogs (if applicable):
V
❑
❑
❑
9. Cleanout(s) and cap is provided for the under drain as per the approved plans:
D/
❑
❑
❑
10. Heavy equipment has not been driven into the cell:
L!d
❑
❑
❑
11. Surface is free of piles of heavy materials (piles of mulch, etc):
[/
❑
❑
❑
12. Ponding depth is 9-12 inches after rain:
V/
❑
❑
❑
13. All dimensions are >=10ft.:
2
❑
❑
❑
SOIL/MULCH and VEGETATION
14. Plants are healthy and being maintained:
->'
R'
❑
❑
15. The proper amount and type of vegetation is present in the cell:
❑
Lld
❑
❑
16. Mulch is in good condition (has not broken down or floated/migrated towards the outlet):
U
❑
❑
❑
17. Surface if free of excessive sediment and clogs:
❑
[D/
❑
❑
18. Trees are free of stakes/wires > 6 months after planting:
U/
❑
❑
❑
19. The annual soil test shows the proper pH and absence of heavy metal accumulation:
❑
❑
❑
0
OUTLET
20. Outlet is free of evidence of improper drainage (no standing water, cattails, etc.):
❑
[D/
❑
❑
21. Outlet device (drop inlet, weir, etc.) is free of damage or clogs:
❑
U'
❑
❑
22. Orifice size matches approved plans:
d
❑
❑
❑
23. Outlet is free of damage, clogs, or erosion:
❑
-\ff
❑
❑
24. Relative elevations match approved plans:
Q/
❑
❑
❑
V3.3_09

r s AM
Y CDE ` R
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, 111, Secretary
March 5, 2014
CERTIFIED MAIL ##70 i 3 1710 0002 1865 7676
RETURN RECEIPT REQUESTED
Mr. Khristopher Reina, Managing Member
DG Winston-Salem, LLC
710 Amsterdam Avenue, No. I -A
New York, NY 10025
Subject; NOTICE OF INSPECTION
Thomasville Road Dollar General
Permit No. SW4110301
Forsyth County
Dear Mr. Reina:
On March 5, 2014, Aana Taylor -Smith of the Winston-Salem Regional Office of the Division of Energy, Mineral,
and Land Resources (DEMLR) inspected the Thomasville Road Dollar General site in Forsyth County to determine
compliance with Stormwater Management Permit Number SW41 10301 issued March 30, 2011. A Notice of
Violation (NOV-2014-PC-0020) was issued for this site on January 31, 2014. This follow-up site inspection and
rile review revealed that all repairs have been completed as required and the site is now compliant with the terms
and conditions of this permit.
Please be advised that you are required to comply with the terms, conditions and limitations of your Stormwater
Management Permit under Title 15A North Carolina Administrative Code 21-1 .1003 and North Carolina General
Statute 143-214.7, including operation and maintenance of your permitted stormwater system.
Thank you for your assistance and dedication to compliance with the Stormwater Management Permit. No further
action is required at this time. If you have any questions, comments, or need assistance with understanding any
aspect of your permit, please do not hesitate to contact Aana Taylor -Smith or me at [phone].
Sincerely,
Matthew E. Gantt, PE
Regional Engineer
Land Quality Section
Enclosure: Compliance Inspection Report
cc: Mr. Lee Pierce, West Point Construction (via email: [e-mail])
DWR Central Files
WSRO Files
Winston-Salem Regional Office
585 Waughtown Street, Winston-Salem, NC 27101 a Phone: [phone] # FAX: [phone]

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Mr. Khristopher Reina
DG Winston-Salem, LLC
710 Amsterdam Avenue, No. 1-A
i New York, NY 10025
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P5 Form 3811, July 2013 Domestic Return Receipt 3 . r

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Compliance Inspection Report
Permit: SW4110301 Effective: 03/20/11 Expiration: 03/19/21 Owner: Dg Winston-Salem LLC
Project: Dollar General - Thomasville Road
County: Forsyth Thomasville Rd NC 109
Region: Winston-Salem
Winston Salem NC 27107
Contact Person: Tab Patton Title: Phone: [phone]
Directions to Project:
Type of Project: State Stormwater - General Permit
Drain Areas:
On -Site Representative(s):
Related Permits:
Inspection Date: 03/05/2014 Entry Time: 09:30 AM
Primary Inspector: Aana Taylor -Smith
Secondary Inspector(s):
Reason for Inspection: Follow-up
Permit Inspection Type: State Stormwater
Facility Status: ® Compliant I] Not Compliant
Question Areas:
® State Stormwater
(See attachment summary)
Exit Time: 09:45 AM
Phone: [phone]
Inspection Type: Compliance Evaluation
Page: 1

Permit: SVV4110301 Owner - Project: Dg Winston-Salem LLC
Inspection Bate: 03/06/2014 Inspection Type: Compliance Evaluation Reason for Visit: Follow-up
Inspection Summary:
This inspection was conducted as a follow-up to NOV # NOV-2014-PC-0020 dated 1/31/14. All repairs have been
completed as required and site is in compliance at this time.
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
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®nnn
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®❑0D
Yes No NA NE
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Yes No NA NE
Are the SW measures constructed as per the approved plans?
® Q
❑
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?
®
Cl
n n
Are the SW SMP inspection and maintenance records complete and available for review or provided to DWQ ®
D
n n
upon request?
Comment: Lee Pierce with West Point Construction completed repairs 2/28/14 as
required in NOV-2014-PC-0020. Records of maintenance have been kept. Site is in
compliance at this time.
Other Permit Conditions
Yes
No
NA NE
Is the site compliant with other conditions of the permit?
®❑
n D
Comment:
Other WQ Issues
Yes
No
NA NE
Is the site compliant with other water quality issues as noted during the inspection?
®
n
n n
Comment:
Page: 2

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Taylor -Smith, Aana
From: Lee <[e-mail]>
Sent: Monday, March 03, 2014 8:27 AM
To: Taylor -Smith, Aana
Subject: RE: Dollar General Thomasville Rd Winston Salem
Sounds great....Please update me on inspection so I can continue to communicate progress with corporate.
Thank you.
Lee Pierce
West Point Construction LLC
919-901-4444
From: Taylor -Smith, Aana [mailto:[e-mail]]
Sent: Monday, March 3, 2014 7:38 AM
To: Lee Pierce
Subject: RE: Dollar General Thomasville Rd Winston Salem
Thanks, Lee! These all look great. I'll be sure to inspect the site soon so we can close the NOV.
Take care,
Aana Taylor -Smith
Land Quality Section
Division of Energy, Mineral, and Land Resources
NC DENR Winston-Salem Regional Office
Phone: [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: Lee Pierce [mailto:lee wpcservicegroup.com]
Sent: Friday, February 28, 2014 5:14 PM
To: Taylor -Smith, Aana
Subject: Dollar General Thomasville Rd Winston Salem
Hi Anna,
Thought you might like to view the after pics of the retention pond.
Thank you, enjoy the weekend.
Lee
919-901-4444
1