SW4110601_HISTORICAL FILE_20130930

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW 4 1 ! d (n I
DOC TYPE
❑ CURRENT PERMIT
❑ APPROVED PLANS
HISTORICAL FILE
DOC DATE
Z co 13 07 2>'o
YYYYMMDD

Taylor -Smith, Aana
From:
Sent:
To:
Cc:
Subject:
Attachments
Dear Ms Taylor -Smith,
Kim McCarty <[e-mail]>
Monday, September 30, 2013 12:45 PM
Taylor -Smith, Aana
Anita Roper; Kim McCarty; Dr. Hanspal
Central Piedmont Surgery Center
NCDENR citation repairs.pdf; CPS - CERT.pdf
Attached is the Engineer Certification for Central Piedmont Surgery Center. Also attached are the repairs made
to meet the recommendations of the Compliance Inspection Report completed by yourself and Ms. White.
If you have any questions or need additional information please do not hesitate to contact me.
Thank you,
Kim
Kim McCarty, 11N SSN
Facility Administrator
Central Piedmont Surgery Center
724 Thomas Street
Asheboro, NC 27203
Office: 336-308-0155
Main: 336-308-0791
Cell:910-639-2597
Fax: '336-610-6615
Email: kmccartyQ),nueterra.orb

ASHEBORO MEDICAL PROPERTIES, LLC
Flu-nC:r.i0 rirnGtiA nnnnnnnnnnnnnnnlA iimcionin
0000016
Our Reference
Number
Your Invoice
Number
Invoice
Date
Invoice
Amount
Amount Paid
Discount .
Net Amount
00000000000000017
STORMWATER
11/19/2010
$505.00
$505.00
$0.00
S505.00
$505.04
$505.00
$O.C)01
$505,00

THE ClIE�Al4Sd!��i
►BUDD
GROUP
www.buddLroup.com
Central Piedmont Surgical Center
724 Thomas St.
Asheboro, NC 27203
September 25, 2013
WORK PERFORMED FOR NCDENR REPAIR FOR
PERMIT #SW4110601
► The Budd Group addressed the following areas to fix issues that were
in the NCDENR citation from August 29, 2013.
We aerated, seeded with a turf type fescue blend at
6lbs/1000sgft. The blend consists of Falcon, "titan. and
Odyssey Tall FeSCues. We fertilized with 18-12-2 at a rate of
200lbs/acre. We applied wheat straw to the areas surrounding
the gravel in all trenches. This was done to get turf established
around trenches.
2. We removed sediment and added gravel to area at inlet and
leveled out gravel in Trench 41.
3. We pulled weeds from rip -rap on all trenches.
4. We removed muddy gravel, added new gravel. and leveled the
gravel with rake in Trenches 4 and 3.
► The Budd Group completed all work on September 20, 2013.

State Stormwater Permit
Permit No. SW4110601
Asheboro Medical Properties, LLC
Stormwater Permit No. SW4110601
Randol h Count
Designer's Certification
as a duly registered _ - )Sto
, Y re 9 <:' err in the
State of North Carolina,' ving been authorized to observe (periodicall' / weekly/ full
time) the construction of the project,
C e^ tRL[ f l`C&(A0n4 S.trJ-er
(Project)
r
for htShe-)a OrA:ct,-1 pre oer ;e (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:
SEAL
Signature t
Registration Numbers
Date
Page 6 of 7

State Stormwater Permit
Permit No. SW4110601
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.
ICU 4. All roof drains are located such that the runoff is directed into the system.
t 5. The overflow structure elevations are per the approved plan.
6. The overflow structure is located per the approved plans.
W.7. The system is functioning as designed and per the approved plans.
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.
+VL. 11. The permitted amounts of surface area and volume have been provided_
1J_12. All required design depths are provided.
+.1 _13. All required parts of the system are provided.
14. The required system dimensions are provided per the approved plans.
Please submit this Designer's Certification to: Winston-Salem Regional Office
Surface Water Protection
585 Waughtown Street
Winston-Salem, NC 27107
Page 7 of 7

Summey Engineering Associates, PLLC
SEA Engineering • Land Planning • Consulting
PLLC P.O. Box 968 — Asheboro, NC 27204
(336) 328-09021 Fax: [phone] / Mack a asheboro.com
Date: July 12, 2011
To
TRANSMITTAL
Attn: Mr. Robert Patterson, PE
NC Division of Water Quality
Stormwater Permitting Unit
1617 Mail Service Center
Raleigh NC .27699-1617
We are sending you attached the following items:
Re:
Central Piedmont Surgery
SEA Job. E-1972
❑
Shop Drawings
❑
Samples
❑ Copy of Letter
❑
Prints
❑
Specifications
❑ Other
®
Plans
❑
Disk
# Copies I
Drawing #
Description
Disposition
2 sets
Plans
1 set
Calculations
�
L'/ 15
1 3
t
2011WATER
QlJAL Sn"Wh
Remarks: Please let me know if anything else is needed.
Thanks,
H. Mack Summey, Jr.
By: /V( A64—
H. Mack Summey, PE
c: File

Summey Engineering Associates, PLLC
Engineering - Land Planning - Consulting
P.O. Box 968
Asheboro, NC 27204
Phone: [phone] - Fax: [phone]
July 11, 2011
Re: Asheboro Medical Properties, LLC
ljormerly Central Piedmont Surgery
Stormwater Project No. S W4110601
Thomas Street - Asheboro, NC
Randolph County, NC
SEA Job No. E-1972
Mr. Robert Patterson, PE
North Carolina Division of Water Quality r=
Stormwater Permitting Unit
1617 Mail Service Center �
Raleigh, North Carolina 27699-1617 JUL 1 3 2011
Dear Mr. Patterson:
We are in receipt of your comment letter dated June 30, 2011 and offer the following
responses below.
Item I
Asheboro Medical Properties, LLC now owns the property that the Central Piedmont
Surgery Center is being constructed on. Under prior submissions, we were told to use the
CPS name but since all property acquisitions have been completed.
Item 2
All supplement forms and calculations have been revised and resubmitted.
Item 3
This item has been revised. There is no place on the supplement form that shows when
the extra volume has been provided and not throw up "red Bags". Meaning that when the
"N , is selected for No, a red lined warning appears. This has been revised to show that
the strip and bypass are not provided.
Item 4
The calculation spread sheet has been revised as well as the chart on C 1.3 to more
accurately reflect dimensions of' the trench. We have now shown on C1.3 a more
accurate and detailed chart to spell out elevations of each section of the trench such as,
top of pea gravel, top of #57 stone, top of Sand and bottom of trench. We left one place
on the chart and detail to reflect the bottom of the trench so the contractor will understand

it better however, the volume of voids in the sand is not considered as part of the
calculation.
Item 5
Per response #4 above elevations have been revised and shown more clearly.
Please note the enclosed revised Soil Scientist Seasonal High Water Table report. The
soil scientist tested the soils deeper than what was provided on the earlier report and said
it was no problem revising his report to reflect slightly deeper trenches. These are
provided for consistency to show the SFIWT elevation is below the bottom of the sand
layer.
Please let me know it' you need anything else to aid or assist in your review of this
project.
Very Truly Yours,
Summey Engineering Associates, PI.hC
-11� d&d z �j
Fl. Mack Summey, Jr., PE
-I MSJlhmsj
Cc: Mr. Jon Campbell, Nueterra Real Estate
File

Scott F. Cole
North Carolina Licensed Soil Scientist
312 Copples Road Ext.
Asheboro, NC 27205-0711
336.460.4554 nnM
Summey Engineering Associates
IJUL
Attn: Mr. Mack Summey 13 2011
1342 E. Salisbury StreetAsheboro, NC 27203
Re: Identification of the seasonal high-water table (SHWT) for storm -water in
Piedmont Surgery Center, Asheboro, NC.
Mr. Summey,
July 11, 2011
vices at Central
Per your request, soil conditions were evaluated within the footprint of each infiltration trench for the above
referenced property. A digital, geo-referenced image of the property was loaded onto a Trimble GPS unit to
ensure soil analysis was conducted within each infiltration trench area. Work was conducted to satisfy
requirements set forth in the North Carolina Division of Winer Quality Stornnvater Best 11anagernent Practices
Manual. All samples were evaluated with a hand auger.
The seasonal high-water table is determined by a field evaluation for soil wetness conditions. Soil wetness
conditions are determined by the presence of colors with a chroma of 2 or less (in Munsell color notation) in
mottles or the horizon matrix. Colors of chroma 2 or less due to relic minerals from the parent material
(underlying rock) are not considered as indicators for soil wetness conditions.
The soils of this site are typical ofthose found within the Georgeville soil series. Georgeville soils are found on
broad ridges and hillsides of Piedmont uplands. Formation of Georgeville soils is from the weathering; of felsic
volcanic rock within the Carolina Slate Belt.
OBSERVATIONS
• In_filtrution 'french # I (Depth: 6.83)
o Top Elevation of trench: 793.5'
o Seasonal high-water table not observed within 120 inches (783.5') of surface.
o Horizon Description:
■ 0-12": Bt (clay)
■ 12"-50": BC 1 CB (clay + saprolite)
• 50"-120": C / CR (saprolite / weathered rock)
• Infiltration Trench # 2 (Depth: 4.58)
o Top Elevation of trench: 795.5' C
o Seasonal high-water table not observed within 84 inches (788.5) of surface.
o Horizon Description:
■ 15"-33": BC 1 CB
■ 33"-84": C / CR

Infiltration Trench 4 3 (Depth: 5.41)
o "I'op Elevation of trench: 796.5'
o Seasonal high-water table not observed within 96 inches (788.5') of surface.
o Horizon Description
■ 0-36": BC / CB
■ 36"-96": C / CR
• Infiltration Trench # 4 (Depth: 6.58)
o Top Elevation of trench: 796.5'
o Seasonal high-water table not observed within 120 inches (786.5') of surface
o Horizon Description
■ 0-24": BC I CB
■ 24"-120": C / CR
The attached map shows the location of each sampling point and its associated horizon data.
With the small size oi'the parcel on which this facility is to be constructed, it is strongly recommended to
implement all protective measures to prevent damage to the infiltration trench areas (i.e. construction fences).
Construction traffic should be directed away from infiltration trench areas as much as possible to prevent soil
compaction. Vegetation and energy dissipation devices should be established and in place prior to the
construction of the infiltration trenches to prevent erosion and subsequent clogging of the trenches.
I am pleased to be of service in this matter and can be contacted at your convenience should you have any
questions with information contained within this report.
"thank you,
6Z(&_.
Scott F. Cole
North Carolina Licensed Soil Scientist
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North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Mr. H. Mack Summey, Jr., PE
Summey Engineering Associates, PLLC
P.O. Box 968
Asheboro, NC 27204
Dear Mr. Summey:
Division of Water Quality
Coleen H. Sullins
Director
June 30, 2011
Subject: Request for Additional Information
Dee Freeman
Secretary
Stormwater Project No. SW4110601
Asheboro Medical Properties, LLC
Previously - Central Piedmont Surgery Center
Randolph County
The Division of Water Quality Central Office received a Stormwater Management Permit Application for
the subject project on June 27, 2011. A preliminary review of that information has determined that the
application is not complete. The following information is needed to continue the stormwater review:
1. The project name shown on SWU-101 now appears as Asheboro Medical Properties, LLC
instead of Central Piedmont Surgery Center. Please verify that you want to officially have this
facility name different than as previously submitted.
2. The supplement form for infiltration trench #1 is inconsistent with the plans and calculations for
impervious area, percent impervious, and minimum volume required.
3. All four of the supplement forms incorrectly show that a vegetated filter strip (VFS) and bypass
are provided. In lieu of providing these, the trenches have been increased in size.
4. The infiltration trench section incorrectly shows the trench design depth dimension. The
infiltration trench depth is shown to include the sand layer on the bottom. As stated in a
previous letter, this layer of sand is not considered part of the trench depth, nor the trench
volume. The bottom elevation should be at the sand and #57 stone interface. Also, based on
the calculations for trench # 1, there is 7' of #57 stone plus an additional 4" of pea gravel. So,
for trench #1, the depth dimension in the corresponding table on C1.3 should be 7.33'
(D = 7' #57 stone + 4" pea gravel = 7.33') (not including the sand layer). The same error
appears for the other three trenches as well.
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.ncwaterguality.org
An Equal Opportunity 1 Affirmative Aclion Employer
Noe Carolina
ahmallry

Mr. 14. Mack Summey, Jr., P.E.
Asheboro Medical Properties, LLC
June 30, 2011
5. Based on comment #4 above, the trench bottom elevations shown in the table and supplement
forms should be 4" deeper (not including the sand layer). Please revise and verify all trench
elevations and depths shown on the table and supplement forms.
Please note that this request for additional information is in response to a preliminary review. The
requested information should be received by this Office prior to August 1, 2011, or the application will be
returned as incomplete. The return of a project will necessitate resubmittaI of all required items, including
the application fee.
If you need additional time to submit the information, please mail or fax your request for a time extension
to the Division at the address and fax number at the bottom of this letter. The request must indicate the date
by which you expect to submit the required information. The Division is allowed 90 days from the
receipt of a completed application to issue the permit.
The construction of any impervious surfaces, other than a construction entrance under an approved
Sedimentation Erosion Control Plan, is a violation of NCGS 143-215.1 and is subject to enforcement
action pursuant to NCGS 143-215.6A.
All revised original signed documents must be returned or new originals must be provided. Copies are not
acceptable. Any revised calculations or plans must be sealed, signed, and dated. Please reference the State
assigned project number SW4110601 on all correspondence. If you have any questions concerning this
matter please feel free to call me at [phone], or at [e-mail].
Sincerely,
Robert D. Patterson, PE
Environmental Engineer
Stormwater Permitting Unit
cc: Dr. Prithvi Hanspal — Asheboro Medical Properties, LLC
SW4110601 File
ec: Corey Basinger -- Winston-Salem Regional Office
Page 2 of 2

Soil Perk Test
Infiltration Rate Results
For
Central Piedmont Surgery Center
724 Thomas Street
Asheboro, NC 27203
Date Performed: May 5, 2011
Weather: Sunny, approx. 60 degrees, ground moist from earlier 1.19" rain
Employees Performing Test: Mack Summey, Neale Kearns, Mark Thompson
Summar-` -.
Holes were located and drilled with 4" gas powered auger to desired depth in each of the
four(4) trenches. Ground was wet from earlier rainfall. Desired depths were reached and
holes cleaned out with post hole diggers. Holes were filled with water every three (3)
hours all day long from 9:OOam to 6:OOpm on May 51.201 1. At 7:30 am on May 6, 2011
holes were empty and filled with water again. At 11:00 holes were filled with water and
testing began to ensure holes were saturated thoroughly. After 3:00 pm testing, holes
were refilled with water and results taken again at 7:00 pm. See results below.
Results:
Trench
Number
Time Hole
Filled
with Water
3:00 pm
Drawdown
(in inches)
7:00 pm
Drawdown
(in inches)
Calculated
Rates At
3:00 pm
Test
Calculated
Rates At
7:00 pm
"hest
Rate
Used
(In/hr)
l
11:00 am
- 12
- 1 l
3 in/hr
2.75 in/hr
2.5 in/hr
2
11:00 am
- 6
- 6
1.5 in/hr
1.5 in/hr
1.5 in/hr
3
11:00 am
- 15
- 14
3.75 in/hr
3.5 in/hr
3.5 in/hr
4
11:00 am
- 14
- W
3.5 in/hr
3.5 in/hr
3.5 in/hr
Based on our field tests we hereby certify that the above Rate Used in the calculations is
adequate to allow the proposed gravel infiltration trenches to operate efficiently.
Summey Engineering Associates, PLLC
Engineering - Land Planning — Consulting
P.O. Box 968
Asheboro, NC 27204
Phone: [phone]
Mack u,asheboro.com
Q L
264471
Sec GINSE
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Project Narrative
Central Piedmont Surgery Center
Thomas Street
Randolph County - Asheboro, NC
The purpose of this narrative is to briefly describe the development of a new Outpatient Surgery Center
located on a 1.812 acre parcel located near the intersections of "Thomas Street, Dublin Street, Dublin
Square Road and NC Hwy 42 in Asheboro, NC.
This stormwater management plan is the result of the site being Tipped Into the NPDES Phase 11
regulations and as a result must comply with the Post Construction Rules.
The existing 1.812 acre site was originally grassed & wooded. The existing topography slopes from
the Northwest Corner toward the southeast corner of the property toward a channel along the southern
right of way/property line. NC Hwy 42 borders the property along the South. No perennial streams
exist on the property. There is no offsite drainage that flows thru the site.
The proposed development consists of clearing, grubbing & grading approximately 2.4 acres and
placing a building near the eastern edge of the property. There is no existing Built Upon area on the
property.
Due to the large trees located on the site and the owners desire to keep those trees, we propose to use a
series of Infiltration Trenches to capture the stormwater and slow it down around the site. The
trenches are designed to capture the first one inch of runoff and slowly release the flows over time into
the ground (infiltration) and excess will be spread out over grassy area at or below the pre -developed
rates. All Impervious areas on site will flow to these Infiltration Trenches and what doesn't infiltrate
back into the ground will flow over grass areas into grassy channels in the NCDOT right'of ways.
No future development is proposed for the site that would not be treated with the proposed system..
The site has been approved by the City of Asheboro Planning and Engineering Departments and the
NCDENR-Division of hand Quality. Please see the attached plans, calculations and details for more
information.
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Summey Engineering Associates, PLLC
Engineering - Land Planning - Consulting
P.O. Box 968
Asheboro, NC 27204
Phone: [phone] - Fax: [phone]
June 23, 201 1
Re: Central Piedmont Surgery Center
NOV-201 I-CV-0003
Thomas Street - Asheboro, NC
Randolph County, NC
SEA Job No. E-1972
Mr. Bradley Bennett, PIE, Supervisor _
North Carolina Division of Water Quality IDENR
Stormwater Permitting Unit1617 Mail Service Center
Raleigh, North Carolina 27699-1617 .1UN 2 7 2011
Dear Mr. Bennett:dandQa
Brana
We are in receipt of your Notice of Violation letter dated June 7, 2011 and are responding
as required.
As you are aware we were in the process of working with your office to obtain a
stormwater permit for the site. As often occurs, we received the grading; permit and work
started prior to receiving the letter that the stormwater was required. We were under the
assumption that as long as a Stormwater permit was in place prior to final construction,
work could continue. We did however plan for BMP's to be installed on site for
stormwater treatment. As your letter indicates, we had a few submittals to work thru.
The last comment letter from March 29, 2011 required some type of soil testing different
than what we had provided. This took some time to obtain within a reasonable expense.
It was after this time, my office, Summey Engineering, experienced a tremendous surge
in work load and was unable to get the work completed as needed at the time and we
were responsible for the delay in submitting the required information which resulted in
the project package being returned and subsequent NOV issues.
Site clearing began near the end of February 2011 and footings began around March 21,
2011. We have inspected the site every week since clearing began to ensure that the
erosion control measures were in place and functioning properly and have at no time
noticed any environmental damage.
The calculations show the amount of built upon area that is to be installed; however, they
do not show the amount of BUA that had been on the site to begin with. The property
formerly had a residential home, out buildings for storage and gravel parking lots that we
did not include in the calculations and designed the site as if it was brand new. Literally

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speaking, the runoff from the site up to the NOV point is not much different than when
the home place existed.
Since we were on our way to obtaining a permit, just like on most other projects. the
contractor did not stop construction due to a tight completion schedule and the fact the
permit would be in hand long before construction was nearing an end or before the
majority of the impervious surface was placed.
We respectfully request that your office not fine the owners due to the fact we never
intended to do the site without any BMP's and there would be an approved stormwater
plan in place prior to any occupancy or even any BUA other than roof building area
being placed. Simply stated, due to the nature of the project, should a fine be issued, our
office would be expected to pay it and with the economy like it is, there are absolutely no
funds available for this in any amount. There has been no environmental damage
whatsoever and we respectfully request your understanding in this.
The new package is being submitted with this letter along with a new review fee. We
sincerely apologize for the delay and should there be any further comments, we will
respond quickly.
Please let me know if you need anything else to aid or assist in your review of this
proliect.
Very Truly Yours,
Summey Engineering Associates. Plsl_C
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I -I. Mack Summey, Jr., PE
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CDEN
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
June 07, 2011
CERTIFIED MAIL #7003 2260 0005 5382 8441 CERTIFIED MAIL #7003 2260 0005 5382 8458
RETURN RECEIPT REQUESTED RETURN RECEIPT REQUESTED
Mr. Lance T. Sisco M.D. CT Corporation System
Central Piedmont Surgery Center, LLC 150 Fayetteville Street.
138 Dublin Square Rd., Suite #A Box 1011
Asheboro, NC 27203 Raleigh, NC 27601
CERTIFIED MAIL #7003 2260 0005 5382 8465
RETURN RECEIPT REQUESTED
Mr. Lance T. Sisco M.D.
Central Piedmont Surgery Center, LLC
1088 Mountain Valley Drive
Asheboro, NC 27205
Subject: NOTICE OF VIOLATION and Recommendation for Enforcement
NOV-2011-CV-0003
Central Piedmont Surgery Center, LLC
Failure to Obtain State Stormwater Permit
Central Piedmont Surgery Center
Randolph County
Dear Sirs:
In December, 2010, the NC Division of Land Resources issued an approval for an erosion and
sedimentation control plan for 2.0 acres of land disturbance for the construction of Central
Piedmont Surgery Center in Asheboro, Randolph County, NC. According to North Carolina
General Statute 143-214.7 and Session -Law 2006-246, Senate Bill 1566, the subject site is
required to obtain a State Stormwater Management permit for post -construction stormwater.
This permit is to be secured prior to installation or construction of impervious surfaces on
the site.
On February 8, 2011, the Division of Water Quality (DWQ) Stormwater Permitting Unit
received an application for a permit for the Central Piedmont Surgery Center site. Subsequent
requests from DWQ for additional information were sent on February 21, 2011 and March 29,
Wetlands and Siormwater Branch
1617 Mail Service Center, Raleigh, NC 27699-1617
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604 One
Phone: [phone] FAX! 91M07-64921 Customer Service: 1-877-623-6748 NorthCarolina
Internet; wuvw.ncwaierqualiry.org Naturall'y
An Equal Opport-inity 1Afrmative Action Emplaver

Pat;, 2. of I, �
Central Piedmont Surgery Center
Randolph County
2011. To date, all of the requested information has not been received by the required date, so the
application was returned on June 6, 2011. The Division of Land Resources (DLR) Winston-
Salem Regional Office conducted a site visit of the Central Piedmont Surgery Center and
observed that the building and parking lot were already under construction. DWQ file review
revealed that a State Stormwater Management permit for Post -Construction stormwater has not
been issued for the site.
As a result of the site inspection and a file review, the following violations are noted: Failure to
Obtain State Stormwater Permit according to Session -Law 2006-246, Senate Bill 1566.
Required Response
Accordingly, you are directed to respond to this letter in writing within 30 calendar days of
receipt of this Notice. Your response should be sent to this office at the letterhead address and
include the following:
1. Explain when the construction started and why proper permits were not obtained prior to
installation or construction of impervious surfaces on the site.
2. Submit a complete permit application with a completed supplement form, a signed O&M
agreement, sealed calculations, two sets of detailed plants, and other supporting
information along with the processing fee currently set at $505. See the Permit
Application form that can be obtain at
http://Po.rtal.nedenr.org/web/wq/ws/su/statesw/forms does. Please note that a Designer's
Certification is also required upon project completion.
By copy of this letter to the City of Asheboro Building Inspection Office, NCDENR is requesting
that the Building Inspector withhold building permits and Certificates of Occupancy for this
project until this matter is satisfactorily resolved.
Thank you for your attention to this matter. This Office is considering sending a
recommendation for enforcement to the Director of the Division of Water Quality regarding
these issues and any future/continued violations that may be encountered. This office requires
that the violations, as detailed above, be abated immediately and properly resolved.
Environmental damage and/or failure to secure proper authorizations have been documented on
the subject tract as stated above. Your efforts to undertake activities to bring the subject site
back into compliance is not an admission, rather it is an action that must be taken in order to
begin to solve ongoing environmental issues.
Pursuant to G.S. 143-215.6A, these violations and any future violations are subject to a civil
penalty assessment of up to a maximum of $25,000.00 per day for each violation. Your
above -mentioned response to this correspondence, the degree and extent of harm to the
environment and the duration and gravity of the violation(s) will be considered in any civil
penalty assessment process that may occur. Should you have any questions regarding these
matters, please contact Robert Patterson at [phone] or myself at [phone].

1 .age 3 of 3
Central Piedmont Surgery Center
Randolph County
Sincerely,
Bradley Bennett, Supervisor
Stormwater Permitting Unit
cc: SPU Files
Corey Basinger— WSRO SWP Supervisor
Karen Higgins — WBS Compliance & Permits Unit Supervisor, Archdale Building
Katie Merritt — WBS Compliance & Permits Unit, Archdale Building
Division of Land Resources - WSRO
Mack.Summey, Jr., PE — Summey Engineering Associates, PLLC
City of Asheboro Building Inspector
City of Asheboro Planning Department

NCENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Mr. Lance Sisco
Central Piedmont Surgery Center, LLC
138 Dublin Square Rd., Suite #A
Asheboro, NC 27203
Division of Water Quality
Coleen H. Sullins
Director
June 6, 2011
Subject: Stormwater Permit Application Return
Central Piedmont Surgery Center - SW4110201
Application Return #1274
Randolph County
Dear Mr. Sisco:
Dee Freeman
Secretary
A review of your Stormwater Management Permit Application indicates that as of this date,
information requested on March 29, 2011, has not been received in this Office within the stipulated
timeframe. Per DWQ requirements and policies, this Office is hereby returning the subject application
as incomplete. The $505.00 application fee has been forfeited and a new fee will need to be provided
if you choose to resubmit this application in the future. Any original signed documents are enclosed.
Until a State Stormwater Permit is issued for this project, the construction of any impervious surfaces,
other than a construction entrance under an approved Sedimentation Erosion Control Plan, is a
violation of NCGS 143-215.1 and is subject to enforcement action pursuant to NCGS 143-215.6A.
If you have any questions concerning this matter, please contact me at [phone], or
[e-mail].
Sincerely,
kw-
/9
Robert D. Patterson, PE
Environmental Engineer
DWQ Stormwater Permitting Unit
Enclosures
cc: Mr. Mack Summey, Jr., PE - Summey Engineering Associates, PLLC
Winston-Salem Regional Office - Sue Homewood
SPU files
Wetl2nds and Stormwater Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: 9IM07 64941 Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity 1 Aff rmalivo Acton Employer
Aurally
eCarolina

North Ca,—aha Department of Environment and Nature.. Resources
Land Quality Section: 585 Waughtown Street, Winston-Salem, NC 27107 [phone]
County: _Randolph Project: Central Piedmont Surges Center River basin: Cape Fear
Person financially responsible: Carolina Bank Project# RANDO-2011-012
Address: Attn: John Walters 335 S. Fayetteville Street Asheboro, NC 27203
1. Project location: Thomas Street, Asheboro
Pictures: Yes: ❑ No: X Prints: ❑ Slides: ❑ Video: ❑ Digital: ❑
2. Weather and soil conditions: Rain/60's/Wet Soil
Initial inspection: Yes: ❑ No: X
3. Is site currently under notice of violation? Yes: ❑ No: X
4, is the site in compliance with S.P.C.A. and rules? Yes: X No: ❑ If no, check violations below:
5. Violations:.
❑ a. No approved plan, G.S. 113A-57 (4) and 15A N.C.A.CiIB.0107(c)
❑ g. Inadequate buffer zone. G.S. 1 13A-57(l )
❑ b. Failure to follow approved plan, 15A N.C.A.C. 4B.01 13
❑ It. Graded slopes and tills too steep,
❑ c. Failure to submit revised plan, G.S. 1 13A-54.1(b) and
C.S. 1 13A-57(2) or 15A N.C.A.C. 413.0I24(d)
❑ i. Unprotected exposed slopes, G.S. l 13A-57(2)
❑ j. Failure to maintain erosion control measures,
15A N.C.A.C. 413.01 18(a)
l5A N.C.A.C. 411,01 13
❑ d. Failure to provide adequate groundcover, G.S. 113A-57(3) and
❑ k. Failure to self -inspect G.S. 1 13A-54.1(e) and
15A N.C.A.C. 413.0007(b) or 15A N.C.A.C. 413.0124(c)
15A N.C.A.C. 413.0131
❑ e. Insufficient measures to retain sediment on site, G.S. 1 13A-57(3)
❑ I, Other (describe)
❑ f. Failure to lake all reasonable measures, 15A N.C.A.C.4130105
6. Has sedimentation damage occurred since last inspection? Yes: ❑ If yes, where? (check all that apply) No: X
Lake/natural watercourse on the tract: ❑ Lake/natural watercourse off the tract: ❑ Other property: ❑
Description:
Degree of damage: slight: ❑ moderate : ❑ severe: ❑
7. Contact made with (name): Charming Title: Landmark
Inspection report given: ❑ or sent: X to person Financially responsible. Date given scut:�I1 I1't( _
S. Potential NPDES Permit Violation? Yes: ❑ No: X Describe:
9. Corrective actions needed:
❑ Submit an adequate sedimentation and erosion control plan for approval, covering all areas disturbed or to be disturbed.
❑ Install all sedimentation and erosion control measures as shown on the approved plan, including the following locations:
❑ Submit a revised sedimentation and erosion control plan for approval for the following areas:
❑ Provide adequate permanent ground cover on all areas where development has been completed for 15 working or 90
calendar days, whichever is shorter ( 15 working or 60 calendar days, whichever is shorter, in High Quality Waters).
❑ Install erosion and sediment control devices sufficient to retain sediment on the tract.
❑ Install temporary sediment traps, basins and rock dams and associated diversions as shown on the approved plan, including
the following locations:
❑ Install adequate drop inlet protection as shown on the approved plan, including the following locations:
❑ Provide an adequate stream buffer zone of sufficient width to confine visible sedimentation within the 25 % of the buffer
nearer the land disturbance using natural or artificial means (minimum 25-foot width in 'rrout Waters) including the following
areas:
❑ Reduce the angle of graded slopes to an angle on which vegetative ground cover may be established at the following
locations:
❑ Provide adequate temporary or permanent ground cover on all graded slopes where rough or fine grading has been
completed for 21 calendar days, including the following areas:
❑ Maintain all sedimentation and erosion control measures as specified in the approved plan and as required to prevent
sedimentation damage including the following locations
Report By;, Khuck Kirchner (late of inspection: •5-17-2011 Page 1 of 2

North C:awtina Department of Environment and Natui_ rtesources
Land Quality Section: 585 Waughtown Street, Winston-Salem, NC 27107 [phone]
County; Randolph Project; Central Piedmont Surgery Center Project it RANI O-201 1-012
Sketch and/or measurements:
N/A
9. Corrective actions needed (continued):
NIA
10. Comments:
1. Work on steel structure and roof today. Stone down in parking lot.
2. Continue to stabilize site as discussed in the field. OK to remove traps upon installation of trenches outside of parking lot. Ensure all
disturbed area continues to discharge through or over stone as discussed in the Geld during this transition.
Report by: Chuck Kirchner Others Present;
Date of inspection: 5-17-201 1 Time arriving on site: 12.23„pm Time leaving site. 12:46 pm
cc: J.Waltersfgcnrolinabank.com Page 2 of 2

Patterson, Robert
From: H. Mack Summey, Jr. [[e-mail])
Sent: Monday, May 02, 2011 1:20 PM
To: Patterson, Robert
Subject: RE: SW4110201 - Central Piedmont Surgery Center
Hi Robert
We will get it done this week. We have been swamped and not completed it.
Thanks!
Mack
From: Patterson, Robert [mailto:robert.patterson(a ncdenr.govl
Sent: Friday, April 29, 2011 2:03 PM
To: H. Mack Summey, Jr.
Subject: SW4110201 - Central Piedmont Surgery Center
Mack,
What is the status of the additional information requested for the subject project on 3/29/11?
Thanks.
Robert D. Patterson, PE
Environmental Engineer
NCDENR I DWQ I Stormwater Permitting
1617 Mail Service Center, Raleigh, NC 27699-1617 (Mail)
512 N. Salisbury St, Raleigh, NC 27604 1 91h Floor (Location Rr, Parcels)
[phone] Phone [phone] I,eix I Robert, Patterson a,ncdenr.eov Email
Website: http://portal.ncdenr.org/weblwg/ws/su
h,A Before printing this email, please consider your budget and the environment.
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.

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Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ Coastal SW - 1995 ❑ Coastal SW
- 2008 ❑ Ph 11 - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters
❑ Universal Stormwater Management Plan
❑ Other WQ M2Lat Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
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, Ietters, operation and maintenance agreements, etc.):
Central Piedmont Surgery Center
2. Location of Project (street address):
® intersection of Thomas St. (SR 21951 wLrubhn LS92197) @ NC Hwy 42
City:Asheboro Countv:Randolph _ _ Zip:27203
3. Directions to project (from nearest major intersection):
From intersection of US Highway 64 and US Hwy 220, take 64 East to NC Hwy 42, turn left. Site is 0.50 miles
on right.
4. Latitude:35° 70' 25" N Longitude:79° 79' 42" W of the main entrance to the project.
II. 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, N/A and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑LAMA Major ®Sedimentation/Erosion Control: 2.0 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: Land Disturbance Permit was obtained in December 2010.
Project ID number is RANDO - 2011.012
Form SWU-101 Version 07July2009 Page I of 6

III. CONTACT INFORMATION
I. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the proj_ect): �Dp
Applicant/Organization: Central Piedmont SurgeLy Center , L-L G ff
Signing Official & Title:Mr. Lance Sisco, Manager
b. Contact information for person listed in item la above:
Street Address:138 Dublin Square Road #A
City:Asheboro State:NC Zip:27203
Mailing Address (if applicable):138 Dublin Square Road Suite #A
City:Asheboro State:NC Zip:27203
Phone: (336 ) 626-2688 Fax: (336 ) 6264100
Email:
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/Organization: Central Piedmont Surgery Center, LLC
Signing Official & TitIe:Mr. Lance Sisco, Manager
b. Contact information for person listed in item 2a above:
Street Address:138 Dublin Square Rd Suite #A
City:Asheboro State:NC Zip:27203
Mailing Address (if applicable): Same
City:
Phone: {336 } 626-2688
Email:
State:
Zip:
Fax: (336 _ ) 626-4100
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:
Signing Official &
b. Contact information for person listed in item 3a above:
Mailing Address:
City:
Phone: {
Email:
State:
Fax: (
as
4. Local jurisdiction for building permits: Ci of Asheboro
Point of Contact:Mr; Larry, Trotter Phone #: {336 626-1204x231
Form SWU-101 Version 07July2009 Page 2 of 7

IV. PROJECT' INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
All BUA surface area runoff will be directed to 4 gravel infiltration trenches located around the site to capture
BUA. BMP's are designed to capture the first inch of runoff from the entire site.
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.Identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW -1995 ® Ph II - Post Construction
3. Stormwater runoff from this project drairts to the Cape Fear River basin.
4. Total Property Area: 1.812 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':1.812 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 Normal Higgh Water (Nffm 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 = 52.09 io
9. How many drainage areas does the project have? 4 (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.
a
a
e
Receiving Stream Name
UT to Vestal
Creek
UT to Vestal
Creek
UT to Vestal
Creek
UT to Vestal
Creek
Stream Class *
C
C
C
C
Stream Index Number *
17-22-4
17-22-4
17-22-4
17-224
Total Drainage Area (so
19,620
4,360
5,120
15,105
On -site Drainage Area (so
19,620
4,360
5,120
15,105
Off -site Drainage Area (so
0
0
0
0
Proposed Impervious Area** (so
K,18,751�e
3,917
4,920
13,004
% Impervious Area** total
95.6
89.8
96.1
86.1
On -site Buildings/Lots (sf)
9,710
0
0
0
On -site Streets (so
0
0
0
0
On -site Parking (so
6,022
3,698
4,845
12,179
On -site Sidewalks (so
1,482
219
75
825
Other on -site (so
0
0
0
0
Future (sf)
0
0
0
0
Off -site (sf)
0
0
0
0
Existing BUA*** (sf)
4fff0
0
0
Total (so:
17,98
3,917
4,920
13,004
Stream Class and Index Number can be red at: ht2o.enr.state.nc.uslbimslrfportsIre ortsWB.html
Form SWU-101 Version 07July2009 Page 3 of 7

Im ervious area is defined as the built apon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
*** Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. There was no off -site
Impervious Area listed above, there is none going thru site. _
Projects in Union County: Contact DWQ Central Ojjlce staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater 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
from http://h2o.enrstate.nc.us/su1bmp 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 hgp://h2o.enr.state.nc.usjsu/bmp�forms.htm. The complete application
package should be submitted to the appropriate DWQ Office. (The appropriate office may be found by Iocating
project on the interactive online map at httpl/h2o.enr.state.nc.us/su/msi_maps.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 h!V://h2o.enr.state.nc.us/su/bmp-forms.htm.
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
q's
Form. (if required as per Part VII 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 $505 payable to NCDENR. (For an Express review, refer to
h!!p://wivw.envhelp.org/pages/onestopexpress.hbnl for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor
1A LS
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations.
t►�.$
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. ScaIe.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
Form SWU-101 Version 071u1y2009 Page 4 of 7

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
inade the determination on the plans.
n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify
elevations in addition Eo depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"01" 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 verify the SHWTprior
to submittal, [phone].) _� _
A copy of the most current property deed. Deed book: 2126 Page No: 1522
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 2H.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.
hqv://wv,tw.secretary.state.nc.us/Corporations/CSearch.avx
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
httl2:/Wo.enr.state.nc.us/suibmp 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
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: H. Mack Summe Jr., PE
Consulting Firm: Summey En&eerin Associates, PLLC
Mailing Address: P.O. Box 968
City:Asheboro State:NC Zip:27204
Phone: (336 ) 328-0902
Email: mack®asheboro.com
Fax: (336 ) 328_-0922
Form SWU-101 Version 07July2009 Page 5 of 7

IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or hjpe name of person listed in Contact Information, item 2a) same as above 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) 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.
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, pursuant to NCGS 143-215.6.
Signature:
a Notary Public for the.State of
do hereby certify that
Date:
County of
personally appeared
before me this — day of and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
Form SWU-10I Version 07July2009 Page 6 of 7

X. APPLICANT'S CERTIFICATION
1, (print or hjpe name of person listed in Contact Information, item 2) Dr. Lance Sisco
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protective covenants will be recorded, and that the proposed project complies with the requirements of the
applicable stormwat r rules under 1 1i NCAC 2 .1000, SL 2006-246 {Ph. II - Post Construction or SL/2008-211.
Signature: Date:
r--
I, O a Notary Public for a State of r County of
do hereby cer ' that LcLne' e- S �� % l� personally appeared
}
before me this day of �0 !` , di0 i( , and acknowledge the nxecution o the app 'cation for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires `" 10 r I ?
Form SWU-101 Version 07luly2009 Page 7 of

Summey Engineering Associates, PLLC
Engineering - Land Planning - Consulting
Y.O. Box 968
Asheboro, NC 27204
Phone: [phone] - Fax: [phone]
March 19, 2011
Mr. Robert Patterson, PE
North Carolina Division of Water Quality
Stormwater Permitting Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Dear Mr. Patterson:
Re: Central Piedmont Surgery Center
Thomas Street - Asheboro, NC
Randolph County, NC
SEA Job No. E-1997272n�
Ff
��f�►l!41�
MAR 2 2 2011
We are in receipt of your comment letter dated February 21, 2011 and offer the following
response:
Item 1
The property has now been purchased by the Central Piedmont Surgery Center, LLC
group and attached is a newly signed formed with the updated information on it along
with a copy of the Secretary of State's report listing the names. Also, a new form has
been provided for the O&M Agreements listing all the infiltration trenches on one page.
Item 2
"There are no wetlands or streams on the site of any kind so a note has been placed on the
plan noting such. See note 17 on C 1.0 and Environmental note added to C 1.2.
Item 3
A copy of' the SHWT report is now enclosed as requested. The calculations and
supplement forms have been revised as needed to reflect the revised drawdown time.
Item 4
A revised sequence of construction has been revised on the detail sheet, C2.3.
Item S
A full size plan showing the drainage area is now provided for your review with all the
contours on.
Item 6
"There is an area provided for a small addition in the future where the runoff goes to
DA#1 currently but when the future addition is done runoff will flow to DA#4. This has
been allowed for in the calculations. "Trench #4 will be larger than needed until the future
BUA is done.

Item 7
This has been revised as requested and the trench section has been revised on Sheet C 1.3
for clarity. The pea gravel void ratio used was 25% and this reduction in volume has
been accounted for in the trench sizes. Most of the trenches were ok, one had to be
revised. New calculations and supplements are provided.
Item 8
The volume of the trench without voids or stone has been shown and all calculations and
supplement forms have been revised and provided for your review.
Item 9
No response needed for this item that I know of. Trenches will carry volume from storm.
Erosion should not be a problem
Item 10
Observation wells have been provided in each trench and properly shown in the details.
Item I
A class "A" rip rap channel has been provided to slow the water down prior to entering
trench which will prevent any erosion.
Item 12
The calculations and supplement forms have been revised and match the plans now.
Item 13
This note has been revised. No compaction is to take place under the trenches in any way
shape or form.
Item 14
No landscaping is to be placed in the trenches. The overlap has been removed from the
landscaping plan.
Please let me know if you need anything else to aid or assist in your review of this
project.
Very Truly Yours,
Summey Engineering Associates, PLLC
VAIuLlt'��
H. Mac'k Summey, Jr., PE (1)
-IMSJ/hmsj
Cc: Mr. Jon Campbell, Nucterra Real Estate
File

NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
February 21, 2011
Mr. H. Mack Sununey, Jr., PE
Summey Engineering Associates, PLLC
P.O. Box 968
Asheboro, NC 27204
SLv 1 I D 2— 0 )
Subject: Request for Additional Information
Central Piedmont Surgery Center
Randolph County
Dear Mr. Summey:
Dee Freeman
Secretary
The Division of Water Quality Central Office received a Stormwater Management Permit Application for
the subject project on February 8, 2011. A preliminary review of that information has determined that the
application is not complete. The following information is needed to continue the stormwater review:
Please provide the correct legal name of the applicant, as it appears on the NC Secretary of
State website, on pg. 2 of SWU-101. It appears to bean LLC, and needs to be shown as such
on the application. The signing official's title must also be provided. Since the applicant is a
LLC, a member or member manager listed on the NC Secretary of State website must sign the
application and O&M Agreements. Mr. John Walters is not shown as such. Alternatively, a
person that is listed may submit a letter giving signature authority to Mr. Walters. Note that if
getting the 0&M Agreements resigned, only one is needed to cover all listed infiltration
trenches.
2. Any wetlands and surface waters (intermittent & perennial) must be delineated and shown on
the plans. Otherwise, a note must be provided on the plans stating none exist on the property.
3. A boring and infiltration test within the footprint of each infiltration trench must be performed
to specifically state the estimated SHWT and the infiltration rate. The geotech report provided
does not include this information. The infiltration test should be conducted at the proposed
bottom elevation of each trench. The drawdown calculations and supplement forms will have
to be revised to reflect the results of these infiltration tests.
4. The construction sequence needs to include when the infiltration trenches should be constructed
(after each DA is stabilized so that they do not get clogged). It should include language that
these areas should be protected from compaction during construction.
Wetlands and stormwater Branch
1617 Mail service Center, Ralegh, 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
MfthCarolina
Natma!!y

Mr. H. Mack Summey, Jr., P.E. J
Central Piedmont Surgery Center N
February 21, 2011
The drainage area (DA) map needs to on a frill -size plan sheet. It should also show the
proposed contours.
6. The DA map appears to show a portion of ground area in front of the north side of the building
included in the DA 41 delineation. However, the grading plan shows that area draining to DA
#4.
7. The infiltration trench depth is shown to include the sand layer on the bottom. This layer of
sand is not considered part of the trench depth, nor the trench volume. The bottom elevation is
at the sand and gravel interface. Also, the calculations correctly include the pea gravel on the
top, but this layer likely has a void ratio less than the 0.4 used for the #57 stone. Please revise
the depth and volume calculations.
8. The volume provided (Vp) should the full storage capacity of the trench; what is shown in the
calculations as "Volume of trench provided", not the lesser "Water Quality Volume Provided"
shown in the calculations. Please revise the calculations and supplement forms to show the
actual volume provided.
9. InfItration devices must have a bypass all storms in excess of the 1" design storm to a properly
designed vegetated filter strip (VFS) with a level spreader. In order to waive the bypass and
VFS requirements, the Vmin must be multiplied by 2.5; or demonstrate that the I0-yr storm will
be infiltrated without any overflow (see 16.3.9 in the BMP Manual). All of the infiltration
trenches proposed have overflow devices (not bypasses) and no proper VFS. However, this
additional treatment volume (2.5x) has already been provided in the BMPs based on the
"Volume of trench provided" value in the calculations.
10. An observation well needs to be provided and shown on the plans and infiltration trench cross -
sections.
11. Some form of energy dissipation needs to be provided at the flume outlets to avoid erosion of
the vegetation and potential clogging of the infiltration trenches.
12. The calculations and supplement form for infiltration trench 41 show the width as 12', but the
plans show it as 12.5'. Please make all consistent.
13. The note on the infiltration trench section on C1.3 says to compact in -situ soil. Compaction
must be avoided beneath the trenches. Please revise.
14. Please show the infiltration trenches on the landscape plan. It appears to show trees and shrubs
on top of the trenches. No vegetation should be on top of the infiltration trenches.
Please call me at your earliest convenience to discuss these items. Note that this request for additional
information is in response to a preliminary review. The requested information should be received by this
Office prior to March 23, 2011, or the application will be returned as incomplete. The return of a project
will necessitate resubmittal of all required items, including the application fee.
If you need additional time to submit the information, please mail or fax your request for a time extension
to the Division at the address and fax number at the bottom of this letter. The request must indicate the date
by which you expect to submit the required information. The Division is allowed 90 days from the
receipt of a completed application to issue the permit.
Page 2 of 3

} Mr. 14. Mack Summey, Jr., P.1J.
Central Piedmont Surgery Center
February 21, 2011
The construction of any impervious surfaces, other than a construction entrance under an approved
Sedimentation Erosion Control Plan, is a violation of NCGS 143-215.1 and is subject to enforcement
action pursuant to NCGS 143-215.6A.
All revised original signed documents must be returned or new originals must be provided. Copies are not
acceptable. Any revised calculations or plans must be sealed, signed, and dated. If you have any questions
concerning this matter please feel free to call me at [phone], or at [e-mail].
Sincerely, j�
;" /1� 4�
Robert D. Patterson, PE
Environmental Engineer
Stormwater Permitting Unit
cc: Mr. John Walters — CENTRAL PIEDMONT SURGERY CENTER, LLC
Corey Basinger — Winston-Salem Regional Office
Project File
Page 3 of 3

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NCDENR
North Carolina Department of Environment and Natura
Division of Water Quality
Beverly Eaves Perdue
Governor
Mr. H. Mack Summey, Jr., PE
Summey Engineering Associates, PLLC
P.O. Box 968
Asheboro, NC 27204
Dear Mr. Summey:
Coleen H. Sullins
Director
February 21, 2011
Resources
Subject: Request for Additional Information
Central Piedmont Surgery Center
Randolph County
Dee Freeman
Secretary
The Division of Water Quality Central Office received a Stormwater Management Permit Application for
the subject project on February 8, 2011. A preliminary review of that information has determined that the
application is not complete. The following information is needed to continue the stormwater review:
1. Please provide the correct legal name of the applicant, as it appears on the NC Secretary of
State website, on pg. 2 of SWU-101. It appears to bean LLC, and needs to be shown as such
on the application. The signing official's title must also be provided. Since the applicant is a
LLC, a member or member manager listed on the NC Secretary of State website must sign the
application and O&M Agreements. Mr. John Walters is not shown as such. Alternatively, a
person that is listed may submit a letter giving signature authority to Mr. Walters. Note that if
getting the O&M Agreements resigned, only one is needed to cover all listed infiltration
trenches.
2. Any wetlands and surface waters (intermittent & perennial) must be delineated and shown on
the plans. Otherwise, a note must be provided on the plans stating none exist on the property.
A boring and infiltration test within the footprint of each infiltration trench must be performed
to specifically state the estimated SHWT and the infiltration rate. The geotech report provided
does not include this information. The infiltration test should be conducted at the proposed
bottom elevation of each trench. The drawdown calculations and supplement forms will have
to be revised to reflect the results of these infiltration tests.
4. The construction sequence needs to include when the infiltration trenches should be constructed
(after each DA is stabilized so that they do not get clogged). It should include language that
these areas should be protected from compaction during construction.
Wetlands and Stormwater Branch
1617 Mail Service Center, Ralegh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Ralegh, North Carolina 27604
Phone: [phone] FAX: 91U07-64941 Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.or9
Nne
orthCarohna
A74(rally
An Equal Opportunity 1 Affirmative Action Employer

f i Mr. H. Mack Summey, Jr., P.E. . R
Central Piedmont Surgery Center '
February 21, 2011
5. The drainage area (DA) map needs to on a full-size plan sheet. It should also show the
proposed contours.
6. The DA map appears to show a portion of ground area in front of the north side of the building
included in the DA #1 delineation. However, the grading plan shows that area draining to DA
#4.
7. The infiltration trench depth is shown to include the sand layer on the bottom. This layer of
sand is not considered part of the trench depth, nor the trench volume. The bottom elevation is
at the sand and gravel interface. Also, the calculations correctly include the pea gravel on the
top, but this layer likely has a void ratio less than the 0.4 used for the #57 stone. Please revise
the depth and volume calculations.
8. The volume provided (Vp) should the full storage capacity of the trench; what is shown in the
calculations as "Volume of trench provided", not the lesser "Water Quality Volume Provided"
shown in the calculations. Please revise the calculations and supplement forms to show the
actual volume provided.
9. Infiltration devices must have a bypass all storms in excess of the 1" design storm to a properly
designed vegetated filter strip (VFS) with a level spreader. In order to waive the bypass and
VFS requirements, the Vmin must be multiplied by 2.5, or demonstrate that the 10-yr storm will
be infiltrated without any overflow (see 16.3.9 in the BMP Manual). All of the infiltration
trenches proposed have overflow devices (not bypasses) and no proper VFS. However, this
additional treatment volume (2.5x) has already been provided in the BMPs based on the
"Volume of trench provided" value in the calculations.
10. An observation well needs to be provided and shown on the plans and infiltration trench cross -
sections.
11. Some form of energy dissipation needs to be provided at the flume outlets to avoid erosion of
the vegetation and potential clogging of the infiltration trenches.
12. The calculations and supplement form for infiltration trench #1 show the width as 12', but the
plans show it as 12.5'. Please make all consistent.
13. The note on the infiltration trench section on C 1.3 says to compact in -situ soil. Compaction
must be avoided beneath the trenches. Please revise.
14. Please show the infiltration trenches on the landscape plan. It appears to show trees and shrubs
on top of the trenches. No vegetation should be on top of the infiltration trenches.
Please call me at your earliest convenience to discuss these items. Note that this request for additional
information is in response to a preliminary review. The requested information should be received by this
Office prior to March 23, 2011, or the application will be returned as incomplete. The return of a project
will necessitate resubmittal of all required items, including the application fee.
If you need additional time to submit the information, please mail or fax your request for a time extension €
to the Division at the address and fax number at the bottom of this letter. The request must indicate the date
by which you expect to submit the required information. The Division is allowed 90 days from the
receipt of a completed application to issue the permit.
Page 2 of 3

Mr. 1-1. Mack Summey, Jr., P.E.
' Central Piedmont Surgery Center
February 21, 2011
The construction of any impervious surfaces, other than a construction entrance under an approved
Sedimentation Erosion Control Plan, is a violation of NCGS 143-215.1 and is subject to enforcement
action pursuant to NCGS 143-215.6A.
All revised original signed documents must be returned or new originals must be provided. Copies are not
acceptable. Any revised calculations or plans must be sealed, signed, and dated. If you have any questions
concerning this matter please feel free to call me at [phone], or at Robert. [e-mail].
Sincerely,
ye� wl
Robert D. Patterson, PE
Environmental Engineer
Stormwater Permitting Unit
cc: Mr. John Walters — CENTRAL PIEDMONT SURGERY CENTER, LLC
Corey Basinger — Winston-Salem Regional Office
Project File
Page 3 of 3

Summey Engineering Associates, PLLC
SEA Engineering • Land Planning • Consulting
PLLC P.O. Sox 968 — Asheboro, NC 27204
[phone] / Fax: [phone] / [e-mail]
Date: February 3, 2011
To
TRANSMITTAL
NCDENR-DWO
Stormwater Permitting Unit
Post Construction Application
1617 Mail Service Center
Raleigh, NC 27699-1617
Attn.: Bill Diuguid___
We are sending you attached the following items:
❑
Shop Drawings
❑
Samples
❑
Prints
❑
Specifications
®
Plans
❑
Disk
Re
Central Piedmont Surgery Center
Civil/Site Construction Plans
Post Construction Permitting
SEA Job No. E-1972
❑ Copy of Letter
❑ Other
# Copies
Drawin #
I Description
Disposition
2 sets
Civil Site Plans showing Underground Detent.
1 set
Calculations
1 ea.
$505 Review Fee
1 Ea.
Application & Package
Remarks
c: File
Bill, enclosed are plans for this project. We are providing permanent underground
detention to treat all the stormwater from the site. If you need anything else please let
me know.
Thanks!
Mack
By:
ae//—
H. Ma k Summey, PE

Summey Engineering Associates, PLLC
Engineering • Land Planning • Consulting
P.O. Box 968
Asheboro, NC 27204
Phone: [phone] • Fax: [phone]
February 2, 2011
Mr. Bill Diuguid, AICP
North Carolina Division of Water Quality
Stormwater Permitting Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: Central Piedmont Surgery Center
Thomas Street - Asheboro, NC
Randolph County, NC
SEA Job No. E-1972
Dear Bill:
Enclosed is the revised package for this project. We have revised the underground
detention to Gravel Infiltration Trenches in accordance with the BMP manual.
Please let me know if you need anything else to aid or assist in your review of this
project.
Very Truly Yours,
Summey Engineering Associates, PLLC
14
H. Mack Summey, Jr., PE
FIMSJ/hmsj
Cc: Mr. Jon Campbell, Nueterra Real Estate
File

AQ;=
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Division of Water Duality
Coleen H. Sullins
Director
January 10, 2011
Mr. Mack Summey
Summey Engineering Associates, PLLC
P.O. Box 968
Asheboro, NC 27204
_�i-�Yuu(2-N /VD . i 2_6 1
Subject: Phase II Post -Construction Stormwater Permit Application Return
Central Piedmont Surclery Center
Randolph County
Dear Mr. Summey:
Dee Freeman
Secretary
The Division of Water Quality (DWQ) Central Office, Raleigh, reviewed your Stormwater Management
Permit Application for the Central Piedmont Surgery Center project the week of January 3, 2010.
After a preliminary review, the submittal was found to be incomplete. Per DWQ requirements and
policies, this Office is hereby returning the subject application package as incomplete.
The application is incomplete based on the following items:
The proposed stormwater management plan does not meet the requirements of the Phase II
post -construction stormwater requirements and will need to be redesigned.
The proposed plan does incorporate stormwater volume control, but does not provide for any
stormwater treatment.
Until a State Stormwater Permit is issued for this project, the construction of any impervious surfaces,
other than a construction entrance under an approved Sedimentation Erosion Control Plan, is a
violation of NCGS 143-215.1 and is subject to enforcement action pursuant to NCGS 143-215.6A.
Please prepare the missing information and return the revised, entire package to me at the DWQ
Central Office, Raleigh, 1617 Mail Service Center, 27699-1617.
If you have any questions, please contact Robert Patterson, P.E., at [phone], or email:
robert.patterson(a ncdenr.gov. Mr. Patterson has a copy of your site plan if you wish to discuss
changes with him.
ejly,
/ �" /
Bill Diuguid, AICP
Staff Planner
DWQ Stormwater Permitting Unit
Wetlands and Stormwater Branch 011e
1617 Mail Service Center, Raleigh, North Carolina 27E.99-1617 1
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604 Noah Caro] i n a
Phone: [phone] FAX: 919-a07-6t941 Cust0niEr Service: 1.877-623-6748 Naturally
InlerneL www.nmaterquality.org
An Equal Oopoounity'. Altamative Achon Emoloyer

PC__-f ue.,J -b P4- t-4-_FAJ49 s 0 W
p rz c k f-f- ?3 M 5
G First Submittal M Re-su
Development/Project Name:
Receiving stream name
ApplicatjQn Completeness Review
cA �_ 1y
r�ittal e Received: B 1+ Date Reviewed: �D
5
ass ification:
For post -construction requirements, a program will be deemed compliant for the areas where it is
implementing any of the following programs: WS-I,,WS-ll, WS-III, WS-IV, HOW, ORW, Neuse River Basin
NSW, Tar -Pamlico River Basin NSW, and the Randleman Lake Water Supply Watershed Nutrient
Management Strategy.
High Density Projects that require a 401/404 within an NSW require 85% TSS, 30% TN and 30% TP removal.
T&E Species (Goose Creek,
Latitude and Longitude:
Project Address:
Engineer name and firm:
Waxhaw Creek or Six Mile Creek Water Sheds):
Jurisdiction
Low Density (no curb and gutter) ❑ Low Density with curb and gutter outlets ❑ High Density ❑ Other
401/404 impacts to surface waters, wetlands, and buffers (add language to cover letter and/or addinfo letter)
Ci BUA
• Check for $505.00 included
• Original signature (not photocopy) on application
❑ Legal signature (Corporation-VP/higher, Partnership -General Partnerlhigher, LLC-memberlmanager, Agent).
Check spelling, capitalization, punctuation: http://www.secretary.state.nc.us/corporittions/thepage.aspx
If an agent signs the application, a signed letter of authorization from the applicant must be provided which
includes the name, title, mailing address and phone number of the person signing the letter.
❑ For subdivided projects, a signed and notarized deed restriction statement
,556'aled, signed & dated calculations
Correct supplement and 0&M provided for each BMP on site (check all that were provided & number of each)
U Bioretention
Ci Dry Detention Basin
❑ Filter Strip
o Grass Swale
❑ rifiltration Basin
tir Infiltration Trench
❑ Level Spreader
❑ Permeable Pavement
❑ Restored Riparian Buffer
❑ Rooftop Runoff Management
❑ Sand Filter
❑ Stormwater Wetland
❑ Wet Detention Basin
❑ Low Density
❑ Curb Outlet
❑ Off -Site
❑ NCDOT Linear Road
ci Two sets of sealed, signed & dated layout & finish grading plans with appropriate details
Narrative Description of stormwater management provided
❑ Soils report provided
Wetlands delineated or a note on the plans that none exist on site and/or adjacent property
❑ Details for the roads, parking area, cul-de-sac radii, sidewalk widths, curb and gutter;
❑ Dimensions & slopes provided
❑ Drainage areas delineated ❑ Pervious and impervious reported for each ❑ Areas of high density
U spection and maintenance agreements provided
❑/ Application complete ❑ Application Incomplete Returned:
Comments
(Date)
February 9, 2009 Revision

SL 2006-246 Section 9 Post Construction Requirements for Non -Coastal Counties
Low-densitv oroiects
❑ No more than two dwelling units per acre or 24% built -upon area;
❑ Vegetated conveyances to the maximum extent practicable;
❑ Built -upon areas at least 30 feet landward of perennial and intermittent surface waters;
• Deed restrictions, protective covenants, and/or other restrictive language/measures.
High density projects
❑ Control and treat runoff from the first one -inch of rain.
❑ Runoff volume drawdown time must be a minimum of 48 hours, but not more than 120 hours;
❑ Discharge the storage volume at a rate equal to or less than the predevelopment discharge rate for the
one-year, 24-hour storm.
❑ Achieve 85% average annual removal of total suspended solids.
❑ For BMPs that require a separation from the seasonal high-water table (SHWT), the separation shall include
at least 12 inches of naturally occurring soil above the SHWT.
❑ Stormwater management measures must comply with the General Engineering Design Criteria For All
Projects requirements listed in 15A NCAC 2H .1008(c);
❑ All built -upon areas are at least 30 feet landward of perennial and intermittent surface waters;
❑ Deed restrictions, protective covenants, and/or other restrictive language/measures
❑ Provide a mechanism to require long-term operation and maintenance of Best Management Practices
Goose Creek, Six Mile Creek and Waxhaw Creek Watersheds
Buffer Requirements
❑ Undisturbed riparian buffers within 200 feet of water bodies within the 100-Year Floodplain and within 100 feet
of water bodies that are not within the 100-Year Floodplain. Exceptions to the undisturbed buffer
requirements are set forth in 15A NCAC 02B .0607
Stormwater Controls as required by 15A NCAC 02B .0602
❑ Control and treat the difference between the pre -development and post -development conditions for the one-
year, 24-hour storm with structural controls.
❑ Development and redevelopment shall implement stormwater management measures that promote infiltration
of flows and ground water recharge for the purpose of maintaining stream base flow.
❑ 85% average annual removal of total suspended solids.
❑ Draw down the treatment volume no faster than 48 hours, but no slower than 120 hours, for detention ponds.
❑ Discharge the storage volume at a rate equal or less than the pre -development discharge rate for the one-
year, 24-hour storm.
0 Meet design or stormwater management measures set forth in 15A NCAC 2H A 008,
High Density Projects that require a 4011404 within an NSW
❑ 85% TSS
CI 30% TN
❑ 30% TP
February 9, 2009 Revision

Application Completeness Review
d First Submittal ❑ Re -submittal Date Received: o Date Reviewed: 6 I By (�
Development/Project Name: (',g,, Y P�� r,��u
Receiving stream name 41 4-o4-o t C k classification: 1 , 6.,+ P,>•N'
For post -construction requtr ments, a program will be deemed compliant for the areas where it is
implementing any of the following programs: WS-I, WS-11, WS-III, WS-IV, HOW, ORW, Neuse River Basin
NSW, Tar -Pamlico River Basin NSW, and the Randleman Lake Water Supply Watershed Nutrient
Management Strategy.
High Density Projects that require a 401/404 within an NSW require 85% TSS, 30% TN and 30% TP removal.
T&E Species (Goose Creek, Waxhaw Creek or Six Mile Creek Water Sheds): %/ a
Latitude and Longitude: 3 -41 r 7T 179 'tZ w Jurisdiction o . IZ d C.a t
Project Address: &V I, Z�x .rG'-,o se Z/9 - 61 sK-21 AlCOW Y i�_Z%
Engineer name and firm: I-f. MACk s winm F_ - S (t m M 9— ' -5 rs.lc
33a16Z s,nC�K(d)VikGSC/to .Carr►
El Low Density (no curb and gutter) ❑ Low Density with curb and gutter outletstir
-gh Den;ad)iinfo
❑ Other
D 4011404 impacts to surface waters, wetlands, and buffers (add language to cover an or letter)
(.-(' BUA ._5- 2. 0 9 Z
�rCheck for $505.00 included
Original signature not photocopy on application 7rvA 5 VP
�� Legal signatur (Corporation-VPlr,±er, Partnership -General Partner igher, LLC-membertmanager, Agent),
Check spelling, capitalization, punctuation: Ili p://%V\VW.sccrctary.state.nc.usicorporationsiihcpagc,aspx
If an agent signs the application, a signed letter of authorization from the applicant must be provided which
includes the name, title, mailing address and phone number of the person signing the letter.
❑ For subdivided projects, a signed and notarized deed restriction statement
:w' Sealed, signed & dated calculations
1 ` Correct supplement and O&M provided for each BMP on site (check all that were provided &number of each)
Bioretention
J Dry Detention Basin
D Filter Strip
u Grass Swale
Infiltration Basin r
Infiltration Trench Cry► D d t r�J)
u Level Spreader
• Permeable Pavement
U Restored Riparian Buffer
❑ Rooftop Runoff Management
❑ Sand Filter
❑ Stnrmwater vvefland
❑ Wet Detention Basin
❑ Low Density
❑ Curb Outlet
❑ Off -Site
❑ NCDOT Linear Road
'r Two sets of sealed, signed & dated layout & finish grading plans with appropriate details
sir'/Narrative Description of stormwater management provided
Soils report provided
mZ Wetlands delineated or a note on the plans that none exist on site and/or adjacent property
7' Details for the roads, parking area, cul-de-sac radii, sidewalk widths, curb and gutter;
G!l"' Dimensions & slopes provided
V /Drainage areas delineated ❑ Pervious and impervious reported for each ❑ Areas of high density
� Inspection and maintenance agreEpents provided
❑ Application complete Gl Application Incomplete Returned: (Date)
Comments
:# A)
Q S
February 9, 2009 Revision

Summey Engineering Associates, PLLC
Engineering - Land Planning - Consulting
P.O. Box 968
Asheboro, NC 27204
Phone: [phone] - Fax: [phone]
February 2, 2011
Mr. Bill Diuguid, AICP
North Carolina Division of Water Quality
Stormwater Permitting Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: Central Piedmont Surgery Center
Thomas Street - Asheboro, NC
Randolph County, NC
SEA Job No. E-1972
ti R��VR'%
. y� 11
Dear Bill: 4'��1�lly
Enclosed is the revised package for this project. We have revised the underground
detention to Gravel Infiltration Trenches in accordance with the BMP manual.
Please let me know if you need anything else to aid or assist in your review of this
project.
Very Truly Yours,
Summey Engineering Associates, PLLC
Mold—
H. Mack Summey, Jr., PE
HMSJ/hmsj
Cc: Mr. Jon Campbell, Nueterra Real Estate
File

9/2
11100000Lr3um e:10IL023LS1:0048S9911ill'
ASHEBORO MEDICAL PROPERTIES, LLC
NCDENR NCDENR 00000000000000016 1111912010
0000016
ray­­Invoice­"'
voice
4
Arfi6untic
rel_l�g;--'
*�M'm'-ou- nt' Paid
"'.*ujj'
jj 4'Discbu'nO�
t-,-Net'
00000000000000017
STORMWATER
1111912010
$505.00
$505.001
$505,00
$505.00
$0.00
$0.00
$505.00
$505.00

RANDOLPN COUNTY AEG STER OF DEEDS -UNOFFICIAL RECORD Pape 1 of 9
cIL a Kri.ta n
Ri�fpprt�rrgol Mr1• v,tlolRl, fa,NC
fC R..l E�1�li C: f~I�e le,Op
21*04424 f 024 TRIe
Bk:RE2126 P9:1722
04114,Mg ff:55:17 M Ila
11111111111111111IIM11 1l1
21IM42400MIG" Ila
Prepared by: Barden W. Cooke, Attorney
Excise Tax: $2,010.00
Grantee's Address: 2604 Lawndale Drive, Greensboro, NC 27408
NORTH CAROLINA ((P�U 1 � y_ o
_0
\p(COr)
RANDOLPH COUNTY
THIS DEED, Made on this the 23rd day of April, 2009,
by and between BARDEN W. COOKS, Substitute Trustee, of Guil-
ford County, North Carolina, hereinafter called 'Grantor,' and
CAROLINA nAN1t, hereinafter called 'Grantee";
W I T N E S S E T H:
WHEREAS, Alvah L. Skeen and wife, Louise W. Skeen, executed
to Daniel D. Hornfeck, Trustee, and Carolina Bank, Beneficiary,
a Real Estate Deed of Trust dated December 29, 2006, recorded in
Book 2006, Page 378 in the Office of the Register of Deeds of
Randolph County, N.C., to secure a promissory note in the origi-
nal principal amount of $1,400,000.00, executed by Alvah G. Skeen
and Louise W. Skeen in favor of Carolina Bank, hereinafter re-
ferred to as the 'Deed of Trust'; and
WHEREAS, the Deed of Trust conveyed to the Trustee the prem-
ises described below; and
WHEREAS, by a Substitution of Trustee recorded in Book 2111
Page 139 in the Randolph County Registry, the original Trustee
under the Deed of Trust was removed, and Gary R. wolf was ap-
pointed to serve as Substitute Trustee; and

t 1
It
RANDOLPH COUNTY REGISTER OF DEEDS • UNOFFICIAL RECORD Page 2 ol9
M103 111111I111
RUIN Ian 201
WHEREAS, the parties liable on said promissory note failed
to pay the same according to its terms; and the holder thereof
demanded that Gary R, wolf, as substitute Trustee, foreclose the
Deed of Trust for the purpose of satisfying the obligation evi-
denced by said promissory note; and
WHEREAS, Gary R. Wolf, as Substitute Trustee, instituted a
special proceeding (see File No. 09 SP 15) before the Clerk of
the Superior Court of Randolph County, N.C., for authority to
foreclose under the terms of the Deed of Trust; and
WHEREAS, after the commencement of said special proceeding,
Gary R. Wolf was removed; and Barden W. Cooke was appointed to
serve as Substitute Trustee by a Substitution of Trustee recorded
in Book 2117, Page 1340 in the Randolph County Registry; and
WHEREAS, following a hearing conducted on February 25, 2009,
said Clerk entered an Order authorizing Grantor, as Substitute
Trustee, to proceed with the foreclosure of the Deed of Trust;
and
WHEREAS, pursuant to said order and after due and legal
advertisement as required by law and the terms of the Deed of
Trust, Grantor offered the real property described below for sale
at public auction, for cash, at the front door of the Randolph
County Courthouse in Asheboro, North Carolina, at 11;30 A.H. on
Wednesday, the Sth day of April, 2009; and
WHEREAS, Grantor offered the tracts described in the Deed
of Trust for sale as follows; Tracts Nos. 1, 2 and 3 as a group;
Tract No. 4 separately; Tract No. 5 separately; Tract No. 6
separately; and Tracts Nos. 7 and B as a group; and Grantee was
the highest bidder for each of said sales, and the total amount
of its bids for all of the sales was $1,005,000.00; and
- 2 -

c
RANDOLPH COUNTY REGISTER OF DEEDS - UNOFFIC$AL RECORD Page 3 al 9
I 2'a6�tlitl71111111111I I I l l 6
RMN 1634 319
WHEREAS, each of said sales was duly reported to the Clerk
of the Superior Court of Randolph County, N.C., by a Report of
Foreclosure Sale filed on April B, 2009; and each of said sales
remained open for the ten (10) day period following the filing of
said report, and during said period, no upset bid was made to any
of said sales; and
WHEREAS, Grantee has complied with the terms of said sale
by paying to Grantor the purchase price for all of said tracts;
NOW, THEREFORE, Grantor, for and in consideration of the
premises and the sum of 51,005,000,00, paid to Grantor by
Grantee, the receipt of which is hereby acknowledged, Grantor
has given, granted, bargained, sold and conveyed, and by these
presents does give, grant, bargain, sell, convey and confirm unto
Grantee, its successors and assigns, those tracts of real prop-
erty that are located in Randolph County, North Carolina, and art,
described on Exhibit A, which in attached hereto and incorporated
herein.
TO HAVE AND TO HOLD said real property, together with all
privileges and appurtenances thereunto belonging or in anywise
appertaining, unto Grantee, its successors and assigns, forever,
in as full and ample manner as Grantor is authorized to convey
the same.
IN WITNESS WHEREOF, Grantor, as Substitute Trustee, has
hereunto set his hand and seal on the day and year first above
written.
(SEAL)
Harden W. Cooke, Substitute Trustee
- 3 -

RANDOLPH COUNTY REGISTER OF DEEDS - UNOFFICIAL RECORD Page 4 of 9
1311 0«1II1m3I i
WE?Iae 1676 4,,
NORTH CAROLINA
GUILFORD COUNTY
1, _- Gail T. Ezell , a Notary Public of said
County and State do hereby certify that RARDEN W. COOKE, Substi-
tute Trustee, personally appeared before me this day and acknowl-
edged the due execution of the foregoing Deed.
WITNESS my hand and notarial seal, this the 2,�rdday of
April, 2009.
�pTAR},
1� Notary PubY4c
My Commission Expires: ,30 ai
April 22, 2Q10
- 4 -

RANDOLPH COONTv REGISTER OF DEEDS - UNOFFICIAL RECORD Page 5 of 9
1YItC41 1011111111111111111
RE2126 1,,. .
TRACE l:
Errant Township; Randolph County Tax Pawl lden>rfrcation: 7770432999
One of throe tracts mak[ny up that S2.17 mat: am
Stan Road i+2602; Deed Refetenea 191312487
BEE NfNING at a point in the centerline of Old Buffalo Ford Read
(N.CS.R, 2306), said paint being located 1576.17 foot east of the
intasccbon of the ceoterlina of N.C. Highway 42 with the centaline of
Old Buffalo Ford Road (N.C.S.R_ 2306); thence with the cettertine of Old
Buffalo Ford Read (N.CSR 2306) South 93 degrees 23 minutes 30
P=nds East 27.75 fine to a point and North 91 degrees 27 tnimttes 54
seconds East 16.91 feet to a polot; thence kavirtg the ccmtallae of Old
Buffalo Ford Road (N.CS.R. 2306) and through the Amdn Hancock
property found rocarded in Book 1210, Page 666, Randolph Canty
Regi>sr'y, South 29 degroes 16 minutes 22 seconds Ferri 214,14 tea to a
new iron rod is the Roy Smith property found recorded in Book 484, Page
31, Randolph County Registry; thence with the Smith property lime South
43 degmes 32 mimtlea 46 seconds West 95.00 fat to an etdsdag Unn pipe
in the K=yon L Davidson, it, property found rtx>orded in Book IIRZ
Page 476, Randolph County Registry; thmm with the Davidson line North
33 degrm 19 mi-, 37 semnds West 15E.10 feet to m odsting iron
pipe; thence North 01 degree 32 taiD, 06 seconds East 124.30 feet to
the point and place of the Beginning and containing 0.490 eats, more or
less according to a survey by Henley Surveying and Mapping Co., Inc.
dared May 5, 1997 and =tW "Survey for Leslie R. Smith`,
TRACT 2;
Orsal Township; Randolph Caney Tax Parcel ldemifiesrion: 7770432999
Second ofram taw making op that $117 acre tract
State Road i2602; Deed Rafemoc t 9MA87
BEONNINO at a new iron rod located in the Northern right-of-way line
of NC kfighway 42 at its Intersection with the W tatsn lime of the Barbara
Diane Owens property as destrihod in it deed rocorded is Book 1331, Page
1727, in the Randolph County Registy (RCR"); running tbemce from the
raid Beginning point, South 06 degrees 33 min, 03 seconds West
(crossing a paint in the Southern right-05way, line of NC Fligbway 42 at
100.45 fat) It 1.71 feet to a point; thane North 71 dcV= I t mint a 17
WOOD s West 9E.93 feet to a point in the South= right of way litre of NC
Highway, 42; thence oaatimumg along that line within the right of way of
NC Highway 42. North 71 degrees I mimmns 17 seconds Wart 516.99
feet to a point within the right of way of NC Highway 42; the = slang a
new line. crossing the right of way of NC Fnghway 42, North 27 degr=

RANDOLPH COUNTY REGISTER OF DEEDS - UNOFFICIAL REOOR❑ Pape 6 of 9
1210e21111I11�1I1111N0
07 minutes 26 seconds Past (and crouittg the Northern right of way line of
SIC Highway 42 at 71,31 fad) 37955 feat to a new Iron rod; thence
continuing along a new line, North 61 degrees 45 minutes 07 seconds
West 472.66 feet to a new iron rod in the line of the Kenyon i-. Dgvidwn.
Jr. propraty deKdbed in the deed morded in Book 1192, Page 476, RCR;
cheat* along the line of Davidson North 06 ftmes 59 minutes 29 seconds
East 100 feet to an ceisting iron pipe, a common carnet with Davidson in
the orfoW line of Lucille Smith Estate property; thence coatlnuirtg along
the line of Davidson, Nash 47 degrees 13 minutes 18 s000nds West
459.39 feet to an existing iron pipe and North 32 ekgmes 31 minutes 09
seconds West 358.20 feet to an mristing iron pipe, a canner of the Austin
H=Dck property demlbed in the deed recorded in Book 1210. Page 666.
RCR; Ihcocc along the lion of Austin Haonock North 41 degrees 44
minutes 41 seconds East (crossing an existing iroo rod at 95,01 fat)
395.27 feet to an axle in the line of the Glomrie H. Huzock property
described in the deed recorded in Boole 87g, Page 309, RCR; thence along
the line of Hancock South 84 deF= 45 minutes 48 seconds Fat 136.55
feet to an existing iron pipe, a ooraer of the Stanton V. Kennedy property
described in the deed recorded is Book 1132, Page 308, RCR; thence
along the line of Stanke Kennedy the following courses and dlstutcea:
South 84 degree 42 minters 04 seconds Eon 300.79 feet to a white flint,
North 01 degmm 19 minuaes 33 socondi Fast 190.01 feet to an existing
iron pipe and North 01 degrees 14 rotates 22 seconds East 229.11 feet to
an existing iron pipe, a comer with the Sue Richardson property described
in the deed recorded in Book 1090, Page 139, RCR; then- along the line
of Richardson, the following courses end distances: South 81 degees 33
men 13 s*6*nds East 329.59 fed to an cdsting iron pipe, North 08
degree 38 minutes 30 seconds Feat 34.77 feet to an adsting iroo pipe,
North 03 dgpea 52 minus 05 swonds East 480.75 fact to an existing
iron pipe, South 86 degrees 41 mince 23 roconds Eau 58.45 feet to an
exiting icon pipe, North 04 degrees 08 minutes 49 seconds Fast 539.49
feet to an existing iron pipe, North 03 deg= 49 minutes 23 seconds Flat
2004 feet to an existing inn md, North 03 degree 43 minutes 44
seconds Fat 645 fat to an existing iron pipe, and North 03 degrees 55
mimtts 05 woonds Feu 399.50 fed to an existing iron pipe and stony in
the line of the C.C. Hoover property described in the deed recorded in
Book 703. Page 323. RCR; thence along the line of Hoover, South 85
degrees 49 minutes 56 aeoonds Fit 353.77 fed to an existing iron pipe
end alone, a cornet with the property of Phillip T. Smith described In the
deed rcoordad in Book 1441, Page 709, RCR; thimm along the line of
Smith. South 04 degrees 06 mimic 54 s*cands West 304.80 fed to an
existing iron rod, a coma with the 0. C. Bndy. Jr. property described in
the deed recorded in Book 734. Page 214. RCR thence along the lire of
Brady the following courses and distimcm: South 02 degrece s 26 minutes
02 reconda West 159.09 fat to to existing iron rod, South 06 degrees 08
minutes 54 seconds West 130.44 feet to an existing iron rod, South 04

RANDOLPH COUNTY REGISTER OF DEEDS - UNOFFICIAL RECORD Page 7 of 9
dl 1 NIIIIIlIIYIIIIIIIIIfQ
venue is" Ier in
drgrcu 07 rtarmues 46 swAm& West 314.97 fat to an existing iron rod,
South 04 degrees 07 minus 46 seooneis Wet 140.06 fed to an uisting
iron rod, South 03 degrtca 57 mimaea 15 taoonds Wen 217.84 fen to an
oxiathsg iram rod, Sash 04 degrees 10 minus 04 seconds Web 359.29
feet to an existing iron pipe, South 04 ftmes 06 minuses 58 seconds West
105.39 tut to an existing iron rod. South 04 dogrecs 04 minutes 46
seeooda West 483.23 fat to an existing boa pipe and South 04 degrees 14
minutes 25 soceods West 460,15 feel to an existing bm pipe, it comer of
the Paul D. Stout property described in the dad recorded In Book 1220,
Page 1533, RCR, thence doing the line of Stout in poet and the line of the
property of Robert FL Nichols described in the dad recorded in Book
1142, Page 330, RCR, in pert, South 04 degrees 01 minute 16 seconds
West 875.27 feet to an exIstlog inoo pipe, a corner of Nichols; thence
•Moe A'. 1;— nr N:.1...1. Q—k 74 A-- AA 10 .--A. V

°'f+., North Carolina
Elaine F. Marshall DEPARTMENT °h
Secretary ECRETARY OF STATE
PO Box?,962?, R�leic�h, NC 2762.6-�?6?.2, (919.007-2.00C
N Y+•1
Date: 6/15/2011
Click here to:
View Document Filings I Sign Up for E-Notifications
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Corporation Names
Name Name Type
NC ASHEBORO MEDICAL LEGAL
PROPERTIES, LLC
Limited Liability Company Information
SO SI D:
1143959
Status:
Current -Active
Effective Date:
4/14/2010
Dissolution Date:
Annual Report Due Date:
Citizenship:
DOMESTIC
State of Inc.:
NC
Duration:
PERPETUAL
Annual Report Status:
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Registered Agent
Agent Name: CT CORPORATION SYSTEM
Office Address: 150 FAYETTEVILLE ST„ BOX 1011
RALEIGH NC 27601
Mailing Address: 150 FAYETTEVILLE ST., BOX 1011
RALEIGH NC 27601
Principal Office
Office Address: NUETERRA REAL ESTATE ATTN: G WOODY 11221 ROE AVE.
SUITE 1A
LEAWOOD KS 66211
Mailing Address: NUETERRA REAL ESTATE ATTN: G WOODY 11221 ROE AVE.
SUITE 1A
LEAWOOD KS 66211
Officers
Title: MANAGER
Name: DANIEL J SAALE
Business Address: 11221 ROE AVENUE, SUITE 1 A
LEAWOOD KS 66211
Title:
Name:
Business Address:
Title:
MANAGER
DAVID GIMENEZ MD
171 MACARTHUR
ASHEBORO NC 27203
MANAGER

Name:
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ASHEBORO NC 27205
of the Secretary of State KngAAedge Base (SOSKB) system. Version: 230

Summey Engineering Associates, PLLC
Engineering • Land Planning • Consulting
P.O. Box 968
Asheboro, NC 27204
Phone: [phone] • Fax: [phone]
June 23, 2011
Re: Central Piedmont Surgery Center
Stormwater Project No. SW41 10201
Thomas Street - Asheboro, NC
Randolph County, NC
SEA Job'No. I -1972
Mr. Robert Patterson, PE rJU
j� jj�j �g
North Carolina Division of Water Quality '�'� {.1i5
Stormwater Permitting Unit 1617Mail Service Center 9 "7 2Q11
Raleigh, North Carolina 27699-1617
Dear Mr. Patterson
We are in receipt of your comment letter dated March 29, 2011 and offer the following
responses below. We understand the project has been returned and requires the new
application and associated fee which will be included via separate submittal this date.
We offer these responses in hopes they will assist in your review being that you have
reviewed the project in great detail and these will address your last comments made prior
to the project being returned. Below are our responses to your comments:
Item 1
As previously discusses with Mr. Robert Patterson via emails, enclosed is a summary
report of actual field infiltration tests taken by our office, signed and sealed. Also
enclosed are revised calculations and supplemental forms showing such revisions.
Item 2
Sheet C2.3 now shows a revised Sequence of Construction reflecting a construction order
as required for trenches to be constructed once all areas are stabilized including paving of
site. The revised sequence shows that no compaction is to take place in trench areas.
Item 3
"Three copies of a full size plan sheet are enclosed showing a detailed breakdown of the
Drainage Basin Delineation Map.
Item 4
The future expansion is now shown in the `'Future"' row on the form as requested.
Numbers have been double checked and revised as necessary.
Item 5
The Required Treatment Volume for each device has been multiplied by 2.5 in order to
increase the volume for treatment since site constraints do not allow a properly designed
vegetated filter strip to be put in place. Once the trenches fill up, water will flow from

trench areas thru grass. There is no need for velocity reduction due to the low flows and
wide width of flow out of the trench.
Item 6
From what we understand the calculations to be, the volumes provided meet the volume
requirements per the State BMP manual. The calculation spreadsheet shows the volume
of trench without considering the stone void ratio as well as the treatment volume
provided in the #57 layer and the pea gravel layer individually. These two together make
up the required treatment volume. Also, the minimum volume required has been
multiplied by 2.5 times to get the volume required for being able to do away with the
filter length requirement.
Thank you for your assistance with this project and we apologize for the delay. A new
review fee is included as well as the completed application package.
Please let me know if you need anything else to aid or assist in your review of this
project.
Very Truly Yours,
Summey Engineering Associates, PLLC
fi�� —
I I. Mack Summey, Jr., PE �!
7
HMSJ/hmsj
Cc: Mr. Jon Campbell, Nueterra Real Estate
File

' F
" ®
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Mr. H. Mack Summey, Jr., PE
Summey Engineering Associates, PLLC
P.O. Box 968
Asheboro, NC 27204
Dear Mr. Summey:
Division of Water Quality
Coleen H. Sullins
Director
March 29, 2011
Subject: Request for Additional Information
Stormwater Project No. SW4110201
Central Piedmont Surgery Center
Randolph County
Dee Freeman
Secretary
The Division of Water Quality Central Office received a Stormwater Management Permit Application for
the subject project on February 8, 2011; with additional information on March 22, 2011. A preliminary
review of that information has determined that the application is not complete. The following information
is needed to continue the stormwater review:
1. Only an estimation of infiltration rates were provided. Actual infiltration tests within the
footprint of each infiltration trench must be performed to determine the infiltration rate.
Estimations based on soil types and soil surveys are not aceptable. The infiltration test should
be conducted at the proposed bottom elevation of each trench. The dfawdown calculations and
supplement forms will have to be revised to reflect the results of these infiltration tests.
2. Sheet C2.3 has not been revised as stated in the additional information reply letter to address
item 4 (from the previous add. info. request). The construction sequence needs to include when
the infiltration trenches should be constructed (after each DA is stabilized so that they do not
get clogged). It should include language that these areas should be protected from compaction
during construction.
3. The drainage area (DA) map revision to address previous item S was not able to be located in
the additional information submitted. It should be on a full-size plan sheet and also show the
proposed contours.
4. The information for previous item 6 in the reply letter does not correspond to the BUA
information in IV.10. on SUW-101. The future expansion should be shown in the row labeled
"Future" under the appropriate DA. The BUA for DA l in the table does not add up or match.
Please re -check.
Wettands and Stormwater Branch One
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604 NorthCarolina
Phone: [phone] FAX: 91U07-64941 Customer Service: 1-877-623-6748 �atural�r�
Internet: www.ncwaterquality.org
An Equal Opportunity 1 Afrmalive Action Employer

Mr. H. Mack Summey, Jr., P.E.
SW4110201 - Central Piedmont Surgery Center
March 29, 2011
Based on the revised calculations: Infiltration devices must have a bypass all storms in excess
of the 1" design storm to a properly designed vegetated filter strip (VFS) with a level spreader.
In order to waive the bypass and VFS requirements, the Vmin must be multiplied by 2.5, or
demonstrate that the 10-yr storm will be infiltrated without any overflow (see 16.3.9 in the
BMP Manual), All of the infiltration trenches proposed have overflow devices (not bypasses)
and no proper VFS. Please increase the volume provided.
6. The revised calculations do not appear to even provide the minimum required volume based on
the simple method. The volume shown in the calculations for the 457 stone appears to use the
full trench depth instead of the portion between the 4" layer of pea gravel and the 4" layer of
sand. This is over -calculating the volume actually provided in the #57 stone alone. Please
verify.
Note that this request for additional information is in response to a preliminary review. The requested
information should be received by this Office prior to April 12, 2011, or the application will be returned
as incomplete. The return of a project will necessitate resubmittal of all required items, including the
application fee.
If you need additional time to submit the information, please mail or fax your request for a time extension
to the Division at the address and fax number at the bottom of this letter. The request must indicate the date
by which you expect to submit the required information. The Division is allowed 90 days from the
receipt of a completed application to issue the permit.
The construction of any impervious surfaces, other than a construction entrance under an approved
Sedimentation Erosion Control Plan, is a violation of NCGS 143-215.1 and is subject to enforcement
action pursuant to NCGS 143-215.6A.
All revised original signed documents must be returned or new originals must be provided. Copies are not
acceptable. Any revised calculations or plans must be sealed, signed, and dated. Please reference the State
assigned project number SW4110201.on all correspondence. If you have any questions concerning this
matter please feel free to call me at [phone], or at [e-mail].
Sinnccer�ely, 2j -
Z9
Robert D. Patterson, PE
Environmental Engineer
Stormwater Permitting Unit
cc; Dr. Lance Sisco — CENTRAL PIEDMONT SURGERY CENTER, LLC
Corey Basinger — Winston-Salem Regional Office
S W4110201 File
Page 2 of 2

OwnerlDeveloper
Mr. Jon Campbell
Nueterra Real Estate
11221 Roe Avenue, Suite 1A
Leawood, KS 66211
Contact: Mr. Jon Campbell
Phone: [phone]
Prepared By:
SUMMEY ENGINEERING ASSOCIATES, PLLC
ENGINEERING • LAND PLANNING • CONSULTING
P.Q. BOX 968
ASHEBORO, NC 27204
Phone: [phone] / Fax: [phone]
E-mail: [e-mail]
May 5, 2011
,,,\,•111 nl J �Irr�O�f�'''�f
-
2�
\ Glhl�C�

p
t--I0rKv %Ir- CA LLV LJA11 O N
SUMMEY ENGINEERING ►ASSOciATES, PLLC I Project: _ C_ V' I Job No: _ E - !q l z
1342 E. Salisbury St. 336-328-0902
Asheboro, NC 27203 fax [phone] Subject: jDate: —1
[e-mail] VcLI�°Ai; Sheet: I of
.�I-�FlL�tzl�t�[it71-4 �R-k��H �u
-oTAL v0L., NiIECDC-D 'Tc: 5rcZ TP-O- VT z 13i5.-536 tf
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Der"
"
UN
)T� k
jCTAL 'vCLWf- �1c��'uDiN E �c i ids `� S(u�•i
tC-iAL v ATf -- *V&L. S-fcr A& iN �'�/� C yll - 1 cf x 2`7 = to 7, z5
1r11 i7)1'�i —

INFILTRATION TRENCH No.
1
Project: Central Piedmont Surgery Center
Engineer: H. Mack Summey, Jr.
Impervious Area (la)=
0.3778
ac.
Da (contributing drainage area) =
0.4475
ac.
Volume of trench required (includes .4 Porosity) =
3288.9
cu. ft.
Length of trench provided =
100.0
ft.
Width of Trench Provided =
13
ft.
Depth of trench provided (Pea Gravel + #57) =
6.5
ft.
Pea Gravel Depth (4")
0.33
ft.
Depth of #57 stone provided
6.17
#57 Stone Layer - Void Ratio
0.4
Pea Gravel Layer - 4" - Void Ratio
U5
Treatment Volume in Pea Gravel Layer Provided =
107.25
cf
Treatment Volume in #57 Stone Provided =
3208.4
cf
Treatment Volume in Sand Not Considered
Soil type =
Clay & Saprolite
Volume of trench (Pea Gravel + #57 + Sand) =
9308
CF
Water Quality Volume Provided: JJMM3315.7
CF
Infiltration Rate (Determined By Field Testing) =
2.5
In/hour
Rd = Design Rainfall =
1
Inch
la = BUAIDa
0.844
Rv = .05+0.9 x la
0.810
Volume of Runoff to Treat = 3630 x Rd x Rv x Da
1315.563
CF
Volume to Treat with no Filter Strip = 2.5 x Vol. Regd
3288.906
CF
Actual Drawdown Time in Trench =
31.200
Hours
Actual Drawdown Time in Trench =
1.300
Days
16458 sf
19491 sf
(Depth of Trench - 4" Pea Gravel Depth)
Total Excavation
Includes 2.5 x Vol Req'd.
Due to no Bypass nor Filter Strip
Impervious % 84.44%

Permit No
(to be provided by DWQ)
of A F WaT*A
FR
�� OG
h Y
r
NCDENR STORMWATER MANAGEMENT PERMIT APPLICATION FORM Y
401 CERTIFICATION APPLICATION FORM
INFILTRATION TRENCH SUPPLEMENT
This form most be filled out, printed and submitted.
The Required Items Checklist (Part fit) must be printed, filled out and submitted along with all of the required information.
I. PROJECT INFORMATION
Project name
Central Piedmont Surgery Center
Contact person
H. Mack Summey, Jr., PE
Phone number
336.328.0902
Date
7/11/2011
Drainage area number
1
II. DESIGN INFORMATION
Site Characteristics
Drainage area
19,491.00 h2
Impervious area
16,458.00 h2
Percent impervious
84.4% %
Design rainfall depth
1.00 in
Peak Flow Calculations
1-yr, 24-hr rainfall depth
1-yr, 24-hr intensity
Pre -development 1-yr, 24-hr discharge
Post -development 1-yr, 24-hr discharge
Pre/Post 1-yr, 24-hr peak flow control
Storage Volume: Nan -SA Waters
Minimum volume required
Volume provided
Storage Volume: SA Waters
1.5" runoff volume
Pre -development 1-yr, 24-hr runoff volume
Post -development 1-yr, 24-hr runoff volume
Minimum volume required
Volume provided
Soils Report Summary
Soil type
Infiltration rate
SHWT elevation
Trench Design Parameters
Drawdown time
Perforated pipe diameter
Perforated pipe length
Number of laterals
Stone type (if used)
Stone void ratio
Stone is free of fines?
2.79 in
0.12 inlhr
0.02 ft'/sec
0.05 f Isec
0.03 0sec
3,288.90 ns
3,315.70 h3
ff3
ff3
�3
OK for non -SR waters
Clay, Saprolite
2.50 inlhr 'epP
485-09. fmsl ?0- S
1.30 days OK
0.00 in
0.00 ft
0
57
n4
y (Y or N) OK
Form SW401-Infiltralion Trench-Rev.4 Parts I, & If. Design Summary, Page 1 of 2

f Permit No.
� U (to be provided by DWQ)
Trench Elevations
7. 0
Bottom elevation
—787-50
imsl OK
Storage/overflow elevation
494.00
fmsl ) 9 3.5
Top elevation
-794-N
fmsl `) 3. S
Trench Dimensions
Length (long dimension)
100.00
ft
Width (short dimension)
13.00
ft
Height (depth)
6.50
ft OK
Additional Information
Maximum volume to each inlet into the trench?
0.08
ac-in OK
Length of vegetative filter for overflow
0.00
ft Filter is too short, must be > 30-ft �'< "'� 2 sx WOV
Number of observation wells
1
OK
Distance to structure
15.00
ft OK
Distance from surface waters
30.00
ft OK for non -SA waters
Distance from water supply well(s)
1,000.00
ft OK
Separation from impervious soil layer
2.00
It OK
Depth of naturally occuring soil above SHWT
9.00
ft OK
Bottom covered with 4-in of clean sand?
Yr (Y or N) OK
Proposed drainage easement provided?
y
(Y or N) OK
Capures all runoff at ultimate build -out?
y
(Y or N) OK
w%Z s w Qv
Bypass provided for larger storms?
n
(Y or N) Must provide bypass for larger flows ° t` x
Trench wrapped with geotextile fabric?
y
(Y or N) OK
Pretreatment device provided
Stone
Form SW401-infiltration Trench•Rov.4 Paris I. & II. Design Summary, Page 2 of 2

Permit No
(to be provided by OWQ)
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.
Pagel Plan
Initials Sheet No.
�.1.3 1. Plans (1" 50' or larger) of the entire site showing:
Design at ultimate build -out,
Off -site drainage (if applicable),
Delineated drainage basins (include Rational C coefficient per basin),
Trench 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.
rA5 Ck.5 2. Partial plan (1" = 30' or larger) and details for the infiltration trench showing:
Bypass structure,
Maintenance access,
Basin bottom dimensions,
Basin cross-section with benchmark for sediment cleanout,
Flow distribution detail for inflow,
Vegetated filter, and
Pretreatment device.
CX-3 3. Section view of the infiltration trench (1" = 20' or larger) showing:
01 Pretreatment and treatment areas, and
- Inlet and outlet structures.
i- Msq Ck • 4. A table of elevations, areas, incremental volumes & accumulated volumes to verify the volume provided.
a��a 5. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. The
v results of the soils report must be verified in the field by DWQ, by completing & submitting the soils
investigation request form. County soil maps are not an acceptable source of soils information.
CA •3 6. A construction sequence that shows how the infitlration basin will be protected from sediment until the
entire drainage area is stabilized.
0AaAA-a 7. The supporting calculations.
8. A copy of the signed and notarized operation and maintenance (0&M) agreement.
M� to A 9. A copy of the deed restrictions (if required).
Form SW401-Infiltration Trench-Rev.4 Part III. Required Items Checklist, Page 1 of 1

INFILTRATION TRENCH No.
2
Project: Central Piedmont Surgery Center
Engineer: H. Mack Summey, Jr.
Impervious Area (la)=
0.0927
ac.
Da (contributing drainage area) =
0.1285
ac.
Volume of trench required (includes .4 Porosity) =
815.8
cu. ft.
Length of trench provided =
75.0
ft.
Width of Trench Provided =
7
ft.
Depth of trench provided (Pea Gravel + #57) =
4.25
ft.
Pea Gravel Depth (4")
0.33
ft.
Depth of #57 stone provided
3.92
#57 Stone Layer - Void Ratio
0.4
Pea Gravel Layer - 4" - Void Ratio
0.25
Treatment Volume in Pea Gravel Layer Provided =
43.31
cf
Treatment Volume in #57 Stone Provided =
823.2
cf
Treatment Volume in Sand Not Considered
Soil type =
Clay & Saprolite
Volume of trench (Pea Gravel + 457 + Sand) =
2577.75
CF
Water Quality Volume Provided:
866.5
CF
Infiltration Rate (Determined By Field Testing) =
1.5
In/hour
Rd = Design Rainfall =
1
Inch
la = BUA/Da
0.722
R v=. 05+0.9 x la
0.699
Volume of Runoff to Treat = 3630 x Rd x Rv x Da
326.329
CF
Volume to Treat with no Filter Strip = 2.5 x Vol. Regd
815.823
CF
Actual Drawdown Time in Trench =
34.000
Hours
Actual Drawdown Time in Trench =
1.417
Days
4040 sf
5599 sf
(Depth of Trench - 4" Pea Gravel Depth)
Total Excavation
Includes 2.5 x Vol Req'd.
Due to no Bypass nor Filter Strip
Impervious % 72.16%

Permit
(to be provided by DWO)
FWAof "'n rEq
pG
���jjj h v
NCNC DENR STORMWATER MANAGEMENT PERMIT APPLICATION FORM Q Y
401 CERTIFICATION APPLICATION FORM
INFILTRATION TRENCH SUPPLEMENT
This form must be filled out, printed and submitted,
The Required Items Checklist (Part Ill) must be printed, filled out and submitted along with all of the required information.
I. PROJECT INFORMATION
Project name
Central Piedmont Surgery Center
Contact person
H. Mack Summey, Jr., PE
Phone number
336-328.0902
Date
7/11/2011
Drainage area number
2
II. DESIGN INFORMATION
Site Characteristics
Drainage area
5,599,00 ftz
Impervious area
4,040.00 ft2
Percent impervious
72.2% %
Design rainiall depth
1.00 in
Peak Flow Calculations
f-yr, 24-hr rainfall depth
1-yr, 24-hr intensity
Pre -development 1-yr, 24-hr discharge
Post -development 1-yr, 24-hr discharge
Pre/Post t-yr, 24-hr peak flow 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 volume
Post -development 1-yr, 24-hr runoff volume
Minimum volume required
Volume provided
Soils Report Summary
Soil type
Infiltration rate
SHWT elevation
Trench Design Parameters
Drawdown time
Perforated pipe diameter
Perforated pipe length
Number of laterals
Stone type (it used)
Stone void ratio
Stone is free of fines?
2.19 In
0.12 inihr
0.01 ft3/sec
0.01 ft3lsec
0.01 ft3lsec
326,32 ft3
866.50 ft3
ft3
ft3
ft3
ft3
ft3
OK for non -SR waters
Clay & Saprolite
1.50 in/hr
788.99 fmsl
1.41 days OK
0.00 in
0.00 ft
0
57
0.4
y (Y or N) OK
Form SW401-Inlillration Trench-Rev.4 Parts I. & II. Design Summary, Page 1 of 2

Permit No.
(to be provided by DINO)
Trench Elevations
Bottom elevation
Storage/overflow elevation
Top elevation
Trench Dimensions
Length (long dimension)
Width (short dimension)
Height (depth)
Additional Information
Maximum volume to each inlet into the trench?
Length of vegetative filter for overflow
Number of observation wells
Distance to structure
Distance from surface waters
Distance from water supply well(s)
Separation from impervious soil layer
Depth of naturally occuring soil above SHWT
Bottom covered with 4-in of clean sand?
Proposed drainage easement provided?
Capures all runoff at ultimate build -out?
Bypass provided for larger storms?
Trench wrapped with geotexlile fabric?
Pretreatment device provided
791.25
fmsl OK
795.50
fmsl
795.50
fmsl
75.00
ft
7.00
ft
4.25
ft OK
0,02
ac4n
OK
0.00
ft
Filter is too short, must be> 30-ft
1
OK
15.00
ft
OK
30.00
ft
OK for non -SA waters
1,000.00
ft
OK
6.00
ft
OK
6.00
ft
OK
y
(Y or N)
OK
y
(Y or N)
OK
y
(Y or N)
OK
n
(Y or N)
Must provide bypass for larger flows
y
(Y or N)
OK
stone
Form SW401-Infiltration Trench-Rev.4 Parts I, & II. Design Summary, Page 2 of 2

12MI dfii•t^..
(to be provided by OWQ)
.:
rll RE urAggg �IlS cff�c�rir�T= �"' � fF , ;;. f�F= �
-��- �...[JL .�.
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.
wj5S co
1. Plans (1" - 50' or larger) of the entire site showing:
Design at ultimate build -out,
Off -site drainage (if applicable),
Delineated drainage basins (include Rational C coefficient per basin),
Trench 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.
w�33 C.%
2. Partial plan (1" = 30' or larger) and details for the infiltration trench showing:
- Bypass structure,
- Maintenance access,
Basin bottom dimensions,
Basin cross-section with benchmark for sediment cleanout,
Flow distribution detail for inflow,
- Vegetated filter, and
Pretreatment device.
wk9 C 1. 3
3. Section view of the infiltration trench 0" = 20' or larger) showing:
Pretreatment and treatment areas, and
Inlet and outlet structures.
"A '
4. A table of elevations, areas, incremental volumes & accumulated volumes to verify the volume provided.
VAr-6 AA4*&tJ
5. 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 DWQ, by completing & submitting the soils
investigation request form. County soil maps are not an acceptable source of soils information.
C.'Z� �J
6. A construction sequence that shows how the infitlration basin will be protected from sediment until the
entire drainage area is stabilized.
N
7. The supporting calculations.
t�
8, A copy of the signed and notarized operation and maintenance (0&M) agreement.
"+tea
9. A copy of the deed restrictions (if required).
Form SW40I-infiltration Trench-Rev.4 Part #W Required Items Checklist, Page 1 of 1

INFILTRATION TRENCH No.
3
Project: Central Piedmont Surgery Center
Engineer: H. Mack Summey, Jr.
Impervious Area (la)=
0.1145
ac.
Da (contributing drainage area) =
0.1430
ac.
Volume of trench required (includes .4 Porosity) =
999.9
cu. ft.
Length of trench provided =
85.0
ft.
Width of Trench Provided =
6
ft.
Depth of trench provided (Pea Gravel + #57) =
5.08
ft,
Pea Gravel Depth (4")
0.33
ft.
Depth of #57 stone provided
4.75
#57 Stone Layer - Void Ratio
0.4
Pea Gravel Layer - 4" - Void Ratio
0.25
Treatment Volume in Pea Gravel Layer Provided =
42.08
cf
Treatment Volume in #57 Stone Provided =
969
cf
Treatment Volume in Sand Not Considered
Soil type =
Clay & Saprolite
Volume of trench (Pea Gravel + #57 t Sand) =
2927.4
CF
Water Quality Volume Provided:
1011.1
CF
Infiltration Rate (Determined By Field Testing) =
3.5
In/hour
Rd = Design Rainfall =
1
Inch
la = BUA/Da
0.801
Rv = .05+0.9 x la
0.771
Volume of Runoff to Treat = 3630 x Rd x Rv x Da
399.971
CF
Volume to Treat with no Filter Strip = 2.5 x Vol. Regd
999.927
CF
Actual Drawdown Time in Trench =
17.417
Hours
Actual Drawdown Time in Trench =
0.726
Days
4987 sf
6227 sf
(Depth of Trench - 4" Pea Gravel Depth)
Total Excavation
Includes 2.5 x Vol Req'd.
Due to no Bypass nor Filter Strip
Impervious % 80.09%

Permit No.
(to be provided by DWQ)
of ydaT�9
AWoa Oq
_
NCDENR STORMWATER MANAGEMENT PERMIT APPLICATION FORM °
401 CERTIFICATION APPLICATION FORM
INFILTRATION TRENCH SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Part Ill) must be printed, filled out and submitted along with all of the required information.
I. PROJECT INFORMATION
Project name Central Piedmont Surgery Center _
Contact person H. Mack Summey, Jr., PE
Phone number 336-328.0902
Date 7/111201 t - ---
Drainage area number 3
II. DESIGN INFORMATION
Site Characteristics
Drainage area
6,227.00 {�
Impervious area
4,987.00 ft2
Percent impervious
80.1% %
Design rainfall depth
1.00 in
Peak Flow Calculations
1-yr, 24-hr rainfall depth
2.79
in
1-yr, 24-hr intensity
0.12
inlhr
Pre -development 1-yr,24-hr6scharge
0.01
fe/sec
Post -development 1-yr, 24-hr discharge
0.01
ft3lsec
Pre/Post 1-yr, 24-hr peak flow control
0.01
ft3lsec
Storage Volume: Non -SA Waters
Minimum volume required
399.00
ff3
Volume provided
1,011.10
ff3
Storage Volume: SA Waters
151 runoff volume
ff3
Pre -development 1-yr, 24-hr runoff volume
ff3
Post -development 1-yr, 24-hr runoff volume
ff3
Minimum volume required
ff3
Volume provided
ff3
Soils Report Summary
Soil type
Infiltration rate
SHWT elevation
Trench Design Parameters
Drawdown time
Perforated pipe diameter
Perforated pipe length
Number of laterals
Stone type (if used)
Stone void ratio
Stone is free of fines?
OK for non -SR waters
Clay & Saprotite
3.50 inlhr 1
-789.%— fmsl Wt.�
0.73
days OK
0.00
in
0.00
f1
0
57
0.4
y
(Y or N) OK
Form SW401-Infiltration Trench-Rev.4 Paris I, & II. Design Summary, Page 1 of 2

Permit No.
(to be provided by DINO)
Trench Elevations
Bottom elevation
Storage/overflow elevation
Top elevation
Trench Dimensions
Length (long dimension)
Width (short dimension)
Height (depth)
Additional Information
Maximum volume to each inlet into the trench?
Length of vegetative filter for overflow
Number of observation wells
Distance to structure
Distance from surface waters
Distance from water supply well(s)
Separation from impervious soil layer
Depth of naturally occuring soil above SHWT
Bottom covered with 4-in of clean sand?
Proposed drainage easement provided?
Capures all runoff at ultimate build -out?
Bypass provided for larger storms?
Trench wrapped with geolexiile fabric?
Pretreatment device provided
791.42 tmsl OK
796.50 fmsl
796.50 fmsl
85.00 ft
6.00 ft
5.08 ft OK
0.02
ac-in
OK
0.00
ft
Filter is too short, must be > 30-ft
1
OK
15.00
ft
OK
30.00
ft
OK for non -SA waters
1,000.00
ft
OK
6.00
it
OK
6.00
ft
OK
y
(Y or N)
OK
y
(Y or N)
OK
y (Y or N)
OK
n
(Y or N)
Must provide bypass for larger flows
y
(Y or N)
OK
stone
Form SW401-Infiltration Trench-Rev,4 Parts I. & II. Design Summary, Page 2 of 2

Permit
(to be provided by DWQ)
T_6-AJcH # 3
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 wilt 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.
Hi1. Plans (1" 50' or larger) of the entire site showing:
Design at ultimate build -out.
Off -site drainage (if applicable),
Delineated drainage basins (include Rational C coefficient per basin),
Trench 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.
HMSJ C W 2. Partial plan (1" = 30' or larger) and details for the infiltration trench showing:
Bypass structure,
Maintenance access,
Basin bottom dimensions,
Basin cross-section with benchmark for sediment cleanout,
Flow distribution detail for inflow,
Vegetated filter, and
Pretreatment device.
MSl 3. Section view of the infiltration trench (1" = 20' or larger) showing:
Pretreatment and treatment areas, and
Inlet and outlet structures.
_RAJJ ('1-3 4. A table of elevations, areas, incremental volumes & accumulated volumes to verify the volume provided.
MAW a 5. 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 DWQ, by completing & submitting the soils
investigation request form. County soil maps are not an acceptable source of soils information.
_ C �•3 6. A construction sequence that shows how the infitlration basin will be protected from sediment until the
entire drainage area is stabilized.
3� A44&&!J 7. The supporting calculations.
A[W 8. A copy of the signed and notarized operation and maintenance (0&M) agreement.
1NS •� I} 9. A copy of the deed restrictions (if required).
Form SW401-Infiltration Trench-Rev.4 Part III. Required Items Checklist, Page 1 of 1

INFILTRATION TRENCH No.
0
Project: Central Piedmont Surgery Center
Engineer: H. Mack Summey, Jr.
Impervious Area (la)=
0.31 30
ac.
Da (contributing drainage area) =
0.4453
ac.
Volume of trench required (includes .4 Porosity) =
2758.8
cu. ft.
Length of trench provided =
160.0
ft.
Width of Trench Provided =
7.08
ft.
Depth of trench provided (Pea Gravel + #57) =
6.25
ft.
Pea Gravel Depth (4")
0.33
ft.
Depth of #57 stone provided
5.92
#57 Stone Layer - Void Ratio
0.4
Pea Gravel Layer - 4" - Void Ratio
0.25
Treatment Volume in Pea Gravel Layer Provided =
93.46
cf
Treatment Volume in #57 Stone Provided =
2682.4704
cf
Treatment Volume in Sand Not Considered
Soii type =
Clay & Saprolite
Volume of trench (Pea Gravel + #57 + Sand) =
7827.648
CF
Water Quality Volume Provided:
2775.9
CF
Infiltration Rate (Determined By Field Testing) _
Rd = Design Rainfall =
la = BUA/Da
Rv = .05+0.9 x la
Volume of Runoff to Treat = 3630 x Rd x Rv x Da
Volume to Treat with no Filter Strip = 2.5 x Vol. Regd
Actual Drawdown Time in Trench =
Actual Drawdown Time in Trench =
13636 sf
19396 sf
(Depth of Trench - 4" Pea Gravel Depth)
Total Excavation
Includes 2.5 x Vol Req'd.
Due to no Bypass nor Filter Strip
3.5
In/hour
1
Inch
0.703
Impervious %
0.683
1103.517
CF
2758.792
CF
21.429
Hours
0.893
Days
70.30%

Permit No.
(to be provided by DW0)
� FwnrF90
A�
� r
NCDENR STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
INFILTRATION TRENCH SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Part lll) must be printed, filled out and submitted along with all of the required information.
I. PROJECT INFORMATION
Project name Central Piedmont Surgery Center
Contact person H. Mack Summey, Jr., PE
Phone number 336-328-0902
Date 7/11/2011
Drainage area number 4
II. DESIGN INFORMATION
Site Characteristics
Drainage area 19,396.00 ft2
Impervious area 13,636.00 ftz
Percent impervious 70.3% %
Design rainfall depth 1.00 in
Peak Flow Calculations
1-yr, 24-hr rainfall depth
1-yr, 24-hr intensity
Pre -development 1-yr, 24-hr discharge
Post -development 1-yr, 24-hr discharge
PrelPost 1-yr, 24-hr peak flow 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 volume
Post -development 1-yr, 24-hr runoff volume
Minimum volume required
Volume provided
Soils Report Summary
Soil type
Infiltration rate
SHWT elevation
Trench Design Parameters
Drawdown time
Perforated pipe diameter
Perforated pipe length
Number of laterals
Stone type (if used)
Stone void ratio
Stone is free of fines?
2.79 in
0.12 inlhr
0.02 ft3/sec
0.05 ft3/sec
0.03 ft3/sec
1,103.00 ft3
2,775.90 ft3
ft3
ft3
ft3
ft3
ft3
OK for non -SR waters
Clay & Saprolite
3.50 inihr
­78;-922^ fmsi
0.89
days OK
0.00
in
0.00
ft
0
57
0.4
y
(Y or N) OK
Form SW401-Infiltration Trench-Rev.4 Parts I. & il. Design Summary, Page 1 of 2

Permit No
(to be provided by DWa)
Trench Elevations
Bottom elevation
Siorageloverflow elevation
Top elevation
Trench Dimensions
Length (long dimension)
Width (short dimension}
Height (depth)
Additional Information
Maximum volume to each inlet into the trench?
Length of vegetative filter for overflow
Number of observation wells
Distance to structure
Distance from surface waters
Distance from water supply well(s)
Separation from impervious soil layer
Depth of naturally occuring soil above SHWT
Bottom covered with 4-in of clean sand?
Proposed drainage easement provided?
Gapures all runoff at ultimate build -out?
Bypass provided for larger storms?
Trench wrapped with geotextile fabric?
Pretreatment device provided
790.25 imsl OK
796.50 fmsl
796.50 fmsl
160.00 ft
7.08 ft
6.25 ft OK
U6
ac-in
OK
0.00
ft
Filter is too short, must be > 30-ft
1
OK
15.00
ft
OK
30.00
ft
OK for non -SA waters
1,000.00
ft
OK
9.00
It
OK
9.00
ft
OK
y
(Y or N)
OK
y
(Y or N)
OK
y
(Y or N)
OK
n
(Y or N)
Must provide bypass for larger flows
y
(Y of N)
OK
stone
Form SW401-Infiltration Trench-Rev.4 Parts I. & II. Design Summary, Page 2 of 2

Permit No
(to be provided by DWQ)
ct�v_N --U-- 4-
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.
yk 5 G
HMJ) G!
Plans (i" - 50' or larger) of the entire site showing:
Design at ultimate build -out,
Off -site drainage (if applicable),
Delineated drainage basins (include Rational C coefficient per basin),
Trench 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.
2. Partial plan (1" = 30' or larger) and details for the infiltration trench showing:
- Bypass structure,
Maintenance access,
- Basin bottom dimensions,
Basin cross-section with benchmark for sediment cleanout,
Flow distribution detail for inflow,
- Vegetated filter, and
Pretreatment device.
Insi G`' 3. Section view of the infiltration trench 0" = 20' or larger) showing:
Pretreatment and treatment areas, and
Inlet and outlet structures.
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NM61 g&'l`eP
N N eA -L
gns,rj
U,F 5)
wf%s)
4. A table of elevations, areas, incremental volumes & accumulated volumes to verify the volume provided.
5. 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 DWQ, by completing & submitting the soils
investigation request form. County soil maps are not an acceptable source of soils information.
6. A construction sequence that shows how the infitlration basin will be protected from sediment until the
entire drainage area is stabilized.
7. The supporting calculations.
8. A copy of the signed and notarized operation and maintenance (0&M) agreement.
9. A copy of the deed restrictions (if required).
Form SW401-Infiltration Trench-Rev.4 Part tti. Required Items Checklist, Page 1 of 1