SW6120304_CURRENT PERMIT_20120502

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW
DOC TYPE
C�, CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE
4/UZA DrJ(i�
YYYYMMDD

A
jar�.wrr
NCDENR
North Carolina Department of Environment and
Beverly Eaves Perdue
Division of Water Quality
Charles IPvakild, P.E.
Governor Director
April 2, 2012
Mr. David T. Sumner
SOUTHEASTERN REGIONAL MEDICAL CENTER
300 W. 27th Street
Lumberton, NC 28358
Subject: Stormwater Permit No. SW6120304
Gray's Creek Medical Building.
High Density Commercial Wet Pond Project
Cumberland County
Dear Mr. Sumner:
MAY tt 1 a;l
Natural Resources ®VVQ
Cee Freeman
Secretary
The Stormwater Permitting Unit received a complete Stormwater Management Permit Application for Gray's
Creek Medical Building on March 30, 2012. Staff review of the plans and specifications has determined that the
project, as proposed, will comply with the Stormwater Regulations set forth in Title 15A NCAC 2H.1000 and
Session Law 2006-246. We are forwarding Permit No. SW6120304, dated April 2, 2012, for the construction,
operation and maintenance of the subject project and the stormwater BM Ps.
This permit shall be effective from the date of issuance until April 2, 2020 and shall be subject to the conditions
and limitations as specified therein, and does not supersede any other agency permit that may be required.
Please pay special attention to the conditions listed in this permit regarding the Operation and Maintenance of
the BMP(s), recordation of deed restrictions, procedures for changes of ownership, transferring the permit,
and renewing the permit. Failure to establish an adequate system for operation and maintenance of the
stormwater management system, to record deed restrictions, to follow the procedures for transfer of the
permit, or to renew the permit, will result in future compliance problems.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing upon written request within thirty (30) days following receipt of this pert -nit,
This request must be in the form of a written petition, conforming to Chapter 150E of the North Carolina
General Statutes, and filed with the Office of Administrative Hearings, P.O. Drawer 27447, Raleigh, NC 27611-
7447. Unless such demands are made this permit shall be final and binding.
This project will be kept on file at the Fayetteville Regional Office. I f you have any questions, or need additional
information concerning this matter, please contact Robert Patterson at [phone]; or
[e-mail].
Sincerely,
for Charles Wakild, P.E.
Wetlands and Stonnwaler Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone [phone] FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer
cc: SW6120304 File
ec: James M. Kizer, Jr., PE — Moorman, Kizer & Reitzel, Inc.
Mike Lawyer— Fayetteville Regional Office
One
NorthCarolina
Natu,rall

State Stormwater Permit
Permit No. SW6120304
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of
North Carolina as amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
SOUTHEASTERN REGIONAL MEDICAL CENTER
Gray's Creek Medical Building
1249 Chicken Foot Rd. (SR2252), Gray's Creek, Cumberland County
FOR THE
construction, operation and maintenance of a wet detention pond in compliance with
the provisions of 15A NCAC 2H .1000 and S.L. 2006-246 (hereafter referred to as the
"stormwater rules') and the approved stormwater management plans and specifications
and other supporting data as attached and on file with and approved by the Division of
Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until April 2, 2020, and shall be
subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
1. This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. This stormwater system has been approved for the management of stormwater
runoff as described in Section 1.6 of this permit. The stormwater control has been
designed to handle the runoff from 71,400 square feet of impervious area.
3. The tract will be limited to the amount of built -upon area indicated in Section 1.6
of this permit, and per approved plans.
4. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
5. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
Page 1 of 6

State Stormwater Permit
Permit No. S4"J6120304
6. The following design criteria have been provided in the wet detention pond and
must be maintained at design condition:
a.
Drainage Area, acres:
2.35
Onsite, ft :
92,436
Offsite, ft2:
9,930
b.
Total imperviokis Surfaces, ft2:
71,400
Buildings ft`:
10,361
Roads/Parking, W.
38,284
SidewalP ft :
7,439
Other, ft
380
Future, ft�:
5,006
Offsite, ft2:
9,930
C.
Pond Depth, feet:
3.0
d.
TSS removal efficiency:
90%
e.
Design Storm:
1.0 inch
f.
Permanent Pool Elevation, FMS�:
149.50
g.
Permitted Surface Area @PP ft :
4,547
h.
Permitted Storage Volume, ft�:
5,810 at temporary pool
i.
Storage Elevation, FMSL:
150.48
j.
Controlling Orifice:
1.25" 0 pipe
k.
Permanent Pool Volume, ft3:
9,364
I.
Forebay Volume, ft3:
2,028
m.
Receiving Stream/River Basin:
Grays Creek 1 Cape Fear
n.
Stream Index Number:
18-35-(1)
o.
Classification of Water Body:
"B"
II. SCHEDULE
OF COMPLIANCE
The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use prior to the construction of any
built -upon surface.
2. During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
3. The permittee shall at all times provide the operation and maintenance
necessary to assure the permitted stormwater system functions at optimum
efficiency. The approved Operation and Maintenance Plan must be followed in
its entirety and maintenance must occur at the scheduled intervals including, but
not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and revegetation of slopes and the vegetated filter.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved.plans and
specifications.
f. Debris removal and unclogging of outlet structure, orifice device, flow
spreader, catch basins and piping.
g. Access to the outlet structure must be available at all times.
4. Records of maintenance activities must be kept and made available upon
request to authorized personnel of DWQ. The records will indicate the date,
activity, name of person performing the work and what actions were taken.
5. The stormwater treatment system shall be constructed in accordance with the
approved plans and specifications, the conditions of this permit, and with other
supporting data.
Page 2 of 6

State Stormwater Permit
Permit No. SW6120304
6. Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received
from an appropriate designer for the system installed certifying that the permitted
facility has been installed in accordance with this permit, the approved plans and
specifications, and other supporting documentation. Any deviations from the
approved plans and specifications must be noted on the Certification. A
modification may be required for those deviations.
7. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
8. Access to the stormwater facilities shall be maintained via appropriate
easements at ali times.
9. The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to any item shown on the approved -plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval or a CAMA
Major permit was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
10. The permittee shall submit final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
11. A copy of the approved plans and specifications shall be maintained on file by
the Permittee for a minimum of ten years from the date of the completion of
construction.
12. The Director may notify the permittee when the permitted site does not meet one
or more of the minimum requirements of the permit. Within the time frame
specified in the notice, the permittee shall submit a written time schedule to the
Director for modifying the site to meet minimum requirements. The permittee
shall provide copies of revised plans and certification in writing to the Director
that the changes have been made. I
III. GENERAL CONDITIONS
This permit is not transferable except after notice to and approval by the Director.
In the event of a change of ownership, or a name change, the permittee must
submit a completed Name/Ownership Change form, to the Division of Water
Quality, signed by both parties, and accompanied by supporting documentation
as listed on page 2 of the form. The project must be in good standing with the
Division. The approval of this request will be considered on its merits and may or
may not be approved.
2. The permittee is responsible for compliance with all permit conditions until such
time as the Division approves the transfer request.
Page 3 of 6

State Stormwater Permit
Permit No. SW6120304
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Water Quality, in
accordance with North Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, reguiations, or ordinances, which may be Imposed by
other government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation
of nuisance conditions, the Permittee shall take immediate corrective action,
including those as may be required by this Division, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants DENR Staff permission to enter the properiy during norrrial
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
7. The permit issued shall continue in force and effect until revoked or terminated.
The permit may be modified, revoked and reissued or terminated for cause. The
filing of a request for a permit modification, revocation and re -issuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
10.The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Session Law 2006-
246, Title 15A NCAC 2H.1000, and NCGS 143-215.1 et.al.
11.The permittee shall notify the Division of any name, ownership or mailing
address changes at least 30 days prior to making such changes.
12.The permittee shall submit a renewal request with all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Permit issued this the 2nd day of April, 2012.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
for unanes vvaKiia, v.E., uirector
Division of Water Quality
By Authority of the Environmental Management Commission
Page 4 of 6

State Stormwater Permit
Permit No. StN6120304
Gray's Creek Medical Building
Stormwater Permit No. SW6120304
Cumberland County
Designer's Certification
I, , as a duly registered
in the State of North Carolina, having been authorized to observe (periodically/ weekly/
full time) the construction of the project,
(Project)
for (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
Page 5 of 6

State Stormwater Permit
Permit No. SW6120304
Certification Requirements:
_1. The drainage area to the system contains approximately the permitted
acreage.
2. The drainage area to the system contains no more than the permitted
amount of built -upon area.
_3. All the built -upon area associated with the project is graded such that the
runoff drains to the system.
_4. All roof drains are located such that the runoff is directed into the system.
_5. The outlet/bypass structure elevations are per the approved plan.
_6. The outlet structure is located per the approved plans.
_7. Trash rack is provided on the outlet/bypass structure.
_8. All slopes are grassed with permanent vegetation.
_9. Vegetated slopes are no steeper than 3:1.
_10. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
_11. The permitted amounts of surface area and/or volume have been
provided.
_12. Required drawdown devices are correctly sized per the approved plans.
_13. All required design depths are provided.
_14. All required parts of the system are provided, such as a vegetated shelf,
and a forebay.
_15. The required system dimensions are provided per the approved plans.
Please submit this Designer's Certification to: Fayetteville Regional Office
Surface Water Protection
225 Green Street
Systel Building Suite 714
Fayetteville, NC 28301-5043
Page 6 of 6

DWQ USE ONLY
Date Received
Fee Paid
Permit Number
_ tv a �7 t�
Sim lye 0 3 04
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 h II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This forin may be photocopied for rise as air original
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name -should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Gray's Creek Medical Building
2. Location of Project (street address):
1249 Chicken Foot Road (SR2252)
City:Gray's Creek County:Cumberland Zip: 3'�
3. Directions to project (from nearest major intersection):
Property is approximently 300 yards north of the intersection of Chicken Foot Road and Celebration Drive
4. Latitude:340 92' 66" N Longitude:78° 91' 02" 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, and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major ®Sedimentation/Erosion Control: 2,95 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:CUMBE-2011-223 dated June 1, 2011
Fonn SWU-101 Version 07Jun2010
Page 1 of 6
%7r--,

III. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project): /�
Applicant/Organization: Southeastern Regional Medical Center—yt#.u.Lb �y Aim )e
Signing Official & Title:Davi_d T. Sumner Vice President of Support Services_
b.Contact information for person listed in item 1a above:
Street Address:300 W. 27th
City:Lu mberton State:NC Zip:28358
Mailing Address (if applicable):300 W. 2711, Street
City:Lumberton
State:NC
Phone: [phone] Fax:
Email:
Zip:28358
c. Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer, (This is the
person who owns the property that the project is located on):
Property Owner/Organiza
Signing Official & Title:_
b.Contact information for person listed in item 2a above:
Street Ad
City:
Mailing Address (if applicable):
City:
State: Zip:
State:
Phone: f 1 Fax:
Email:
;Lip:
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 & Title:
b.Contact information for person listed in item 3a above:
Mailing Address:
City: State: Zip:
Phone: ( Fax:
Email:
4. Local jurisdiction for building permits: Cumberland County
Point of Contact: Phone #:
Form SWU-101 Version 07Jun2010 Page 2 of

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Stormwater treatment for this project will be provided by a wet detention pond. _
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW -1995 ❑ Ph I1 - Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area: 3.03 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':3.03 acres
' TotaI project area shall be calculated to exclude the following: the nortnal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NHW) line or Mean High Water
(MHW) line, and coastal zetlands 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 NNW (or MHW) line may
be inclrided in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 54.1
9. How many drainage areas does the project have?1 (For high density, count I for each proposed engineered
storinwater BMP. For low density and other projects, use 1 for the whole property area)
10. Complete the following information for each drainage area identified in Project Information item 9. if there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below-.
Basin Information
Drainage Area A
Drainage Area _
Drainage Area _
Drainage Area
Receiving Stream Name
Grays Creek
Stream Class *
B
Stream Index Number *
18-35-(1)
Total Drainage Area (sf)
102366
On -site Drainage Area (so
92436
Off -site Drainage Area (so
9930
Proposed Impervious Area** (so
71400
% Impervious Area'* total
69.8
Impervious *' Surface Area
Drainage Area A
Drainage Area _
Drainage Area
Drainage Area
On -site Buildings/Lots (so
10361
On -site Streets (so
On -site Parking (sf)
38284
On -site Sidewalks (so
7439
Other on -site (so
380
Future(so
5006
Off -site (so
9930
Existing BUA*** (so
Total (so:
71400
* Streant Class and Index Number can be detertnined at: http.aortalmcdennorg veh/r�r is/csn/classi cations
liltppervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidezvalks, gravel areas, etc.
'Report only that announnt of existing BUA that will retuain after development. Do not report any existing BUA that
is to be removed and which zoill be replaced by new BUA.
Form SWU-101 Version 07Jun2010 Page 3 of 6

11. How was the off -site impervious area listed above determined? Provide documentation.
Existing Survey
Proiects in Union County: Contact UIVQ Central Office stuff to check if the project is located within a Threatened R
Endangered Species watershed that maY be subject to more stringent stortnivater requirements as per NCAC 02B . 0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from http://portal.ncdenr.org/web/wq/ws/su/bml2-manua1.
V1. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from http://pprtal.ncdenr.org/web/wq/ws/su/statesw/forms does. The complete
application package should be submitted to the appropriate DWQ Office. (The appropriate office may be
found by locating project on the interactive online map at ht ortal.ncdennor web w /ws/su ma s.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from http://portal.ncdenr.org/web/wq/ws/su/statesw/forms_docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. -/Zlkj
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part VII belortt)
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
http//www.envhelp.org/pages/onestopexpress.html for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/ managementfor
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the'/z
mile radius on the map.
7. Sealed, signed and dated calculations.
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands 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.
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
lzr-)
r.-
Form SWU-101 Version 07Jun2010 Page 4 of 6

1
9 Copy of any applicable soils report with the associated SHWT elevations (Please identify Agi
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"x11" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DWQ to verifij the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 08557 Page No: 0125 3��3
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and/or 3a per NCAC 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.
http://www.secretary,state.nc.us/Corporatiotis/CSearch.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided
as an attachment to the completed and notarized deed restriction form. The appropriate deed restrictions and
protective covenants forms can be downloaded from
http://12ortal.ncdenr;orglweb/wq/ws/su/statesw/forms.._docs. 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: ames M. Kizer,Jr. PE
Consulting Firm: Moorman, Kizer & Reitzel, Inc.
Mailing Address:115 Broadfoot A
City: Fayettev i Ile _
Phone: (910 ) 484-5191
Email:ikizerirOmkrinc.com
State:NC
Zip:28305
Fax: (910 ) 484-0388
IX. PROPERTY OWNER AUTHORIZATION (if Corr tact Information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) , certify that I
own the property identified in this permit application, and thus give permission to (print or type natne of person
listed in Contact Inforrrration, itenn In) with (print or type mule of organization listed in
Contact Information, item 1a) 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.
Fonn SWU-101 Version 07Jun2010 Page 5 of

As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ immediately and submit a
completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater treatment
facility without a valid permit. I understand that the operation of a stormwater treatment facility without a valid
permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement action including
the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature: Date:
I, , a Notary Public for the State of
do hereby certify that
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
X. APPLICANT'S CERTIFICATION
1, (print or type nanze of person listed in Contact Information, itenz 1a) David T. Sumner
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 stor�Iater rulesaun-qer 15A NCAC 2H .1000, SL 2006-246 (Ph. II - Post Construction) or SL 2008-211.
Signatu
Date: d / 16 /14
a Notary Public for the State of &'-f4 mLC` L�f �r� County of
�p ,y5on do hereby certify that DAUk -T personally appeared
before me this L day of I ola, , and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires Ma-r & �� 16f.3
Form SWU-101 Version 07Jun2010
Page 6 of 6

Permit Number: SWbl2 o3o'f
(to be provided by DWQ)
Drainage Area Number: A
Wet Detention Basin Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will be kept in a
log in a known set location. Any deficient BMP elements noted in the inspection will be
corrected, repaired or replaced immediately. These deficiencies can affect the integrity
of structures, safety of the public, and the removal efficiency of the BMP.
The wet detention basin system is defined as the wet detention basin,
pretreatment including forebays and the vegetated filter if one is provided.
This system (check one):
❑ does ® does not incorporate a vegetated filter at the outlet.
This system (check one):
❑ does ® does not incorporate pretreatment other than a forebay.
Important maintenance procedures:
— Immediately after the wet detention basin is established, the plants on the
vegetated shelf and perimeter of the basin should be watered twice weekly if
needed, until the plants become established (commonly six weeks).
— No portion of the wet detention pond should be fertilized after the first initial
fertilization that is required to establish the plants on the vegetated shelf.
— Stable groundcover should be maintained in the drainage area to reduce the
sediment Ioad to the wet detention basin.
-- If the basin must be drained for an emergency or to perform maintenance, the
flushing of sediment through the emergency drain should be minimized to the
maximum extent practical.
— Once a year, a dam safety expert should inspect the embankment.
After the wet detention pond is established, it should be inspected once a month and
within 24 hours after every storm event greater than 1.0 inches (or 1.5 inches if in a
Coastal County). Records of operation and maintenance should be kept in a known set
location and must be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element:
Potentialproblem:
How 1 will remediate theproblem:
The entire BMP
'Trash debris is present.
Remove the trash debris.
The perimeter of the wet
Areas of bare soil and/or
Regrade the soil if necessary to
detention basin
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
one-time fertilizer application.
Vegetation is too short or too
Maintain vegetation at a height of
long.
approximatel six inches.
Form SW401-Wet Detention Basin O&M-Rev.4
Page 1 of 4

Permit Number: S; 412, 03 DV
(to be provided by DWQ)
Drainage Area Number:
BMP element:
Potentialproblem:
How I will remediate theproblem:
The inlet device: pipe or
The pipe is clogged.
Unclog the pipe. Dispose of the
swale
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged.
Erosion is occurring in the
Regrade the Swale if necessary to
Swale,
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future eroblems with erosion.
The forebay
Sediment has accumulated to
Search for the source of the
a depth greater than the
sediment and remedy the problem if
original design depth for
possible. Remove the sediment and
sediment storage.
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Erosion has occurred.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Weeds are present.
Remove the weeds, preferably by
hand. If pesticide is used, wipe it on
the plants rather than s ra yin ._
The vegetated shelf
Best professional practices
Prune according to best professional
show that pruning is needed
practices
to maintain optimal plant
health.
Plants are dead, diseased or
Determine the source of the
dying.
problem: soils, hydrology, disease,
etc. Remedy the problem and
replace plants. Provide a one-time
fertilizer application to establish the
ground cover if a soil test indicates
it is necessary.
Weeds are present.
Remove the weeds, preferably by
hand. If pesticide is used, wipe it on
the plants rather than spraying.
The main treatment area
Sediment has accumulated to
Search for the source of the
a depth greater than the
sediment and remedy the problem if
original design sediment
possible. Remove the sediment and
storage depth.
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Algal growth covers over
Consult a professional to remove
50% of the area.
and control the algal growth,
Cattails, phragmites or other
Remove the plants by wiping them
invasive plants cover 50% of
with pesticide (do not spray).
the basin surface.
Form SW401-Wet Detention Basin O&M-Rev.4 Page 2 of.

Permit Number: S W C 12 b3 0 tt
(to be provided by DWQ)
Drainage Area Number: A
BMP element:
Potentialproblem:
How I will remediate the roblem:
The embankment
Shrubs have started to grow
Remove shrubs immediately.
on the embankment.
Evidence of muskrat or
Use traps to remove muskrats and
beaver activity is present.
consult a professional to remove
beavers.
A tree has started to grow on
Consult a dam safety specialist to
the embankment.
remove the tree.
An annual inspection by an
Make all needed repairs.
appropriate professional
shows that the embankment
needs repair. if applicable)
The outlet device
Clogging has occurred.
Clean out the outlet device. Dispose
of the sediment off -site.
The outlet device is damaged
Repair or replace the outlet device.
The receiving water
Erosion or other signs of
Contact the local NC Division of
damage have occurred at the
Water Quality Regional Office, or
outlet.
the 401 Oversight Unit at 919-733-
1786.
The measuring device used to determine the sediment elevation shall be such
that it will give an accurate depth reading and not readily penetrate into
accumulated sediments.
When the permanent pool depth reads 4.5 feet in the main pond, the sediment
shall be removed.
When the permanent pool depth reads 4.5 feet in the forebay, the sediment
shall be removed.
BASIN DIAGRAM
(fill in the blanks)
V Permanent Pool Elevation 149.5
Sediment Removal 145 Pe anen Pool
------------ -- Volume Sediment Removal Elevation 145 Volume
Bottom Elevatio 144 -ft Min. ------------------------------ ------------ ------
Sediment Bottom Elevation 144 1-ftn.
Storage Sediment
Storage
FOREBAY MAIN POND
Form SW401-Wet Detention Basin O&M-Rev.4 Page 3 of 4

Permit Number: S'✓6 J 2o3OG/
(to be provided by DWQ)
1 acknowledge and agree by my signature below that I am responsible for the
performance of the maintenance procedures listed above. I agree to notify DWQ of -'any
problems with the system or prior to any changes to the system or responsible party.
Project name:Gray's Creek Medical Building
BMP drainage area number:A
Print name:David T. Sumner
Title:Vice President of Support Services
Address:300 W. 27`h Street, Lumberton, NC 28358
PI
6441
Note: The legally responsible party should not be a homeowners association unless more than 50% of
the lots have been sold and a resident of the subdivision has been named the president.
f6 on T , a Notary Public for the State of
County of J�{�s��, , do hereby certify that
Vadid_ `r SP,r,r„_r- personally appeared before me this 101
dayof ��rU� J a la. , and acknowledge the due execution of the
forgoing wet detention basin maintenance requirements. Witness my hand and official
seal, - 7�a�b� Lp. G1„r,�4�0�-✓, I44-2,_rY kbl;
SEAL
My commission expires to i (Uh c 13
Form SW401-Wet Detention Basin O&M-Rev.4
Page 4 of 4

Permit No. _Pl glZ0,309'-
(to be provided by DINO)
OF WATER
9
NCDENR
p
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFVCATION APPLICATION FORM
WET DETENTION BASIN SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Part 111) must be printed, filled out and submitted along with all of the required information.
f. PROJECT INFORMATION
Project name
Gray's Creek Medical Building
Contact person
James M. Kizer, Jr., PE
Phone number
[phone]
Date
1 /2612012
Drainage area number
Basin A
II. DESIGN INFORMATION
Site Characteristics
Drainage area
102,366 h2
Impervious area, post -development
71,400 {tz
% impervious
69.75 %
Design rainfall depth
1.0 in
Storage Volume: Non -SA Waters
Minimum volume required
Volume provided
Storage Volume: SA Waters
1.5' runoff votume
Pre -development 1-yr, 24-hr runoff
Post-developmeN 1-yr, 24-hr runoff
Minimum volume required
Volume provided
Peak Flow Calculations
Is the pre/post control of the lyr 24hr storm peak flow required?
1-yr, 24-hr rainfall depth
Rational C, pre -development
Rational C, post -development
Rainfall intensity: 1-yr, 24-hrstorm
Pre -development 1-yr, 24-hr peak Flow
Post -development 1-yr, 24-hr peak flow
Pre/Post 1-yr, 24-hr peak flow control
Elevations
Temporary pool elevation
Permanent pool elevation
SHWT elevation (approx. at the perm. pool elevation)
Top of 1 Oft vegetated shelf elevation
Bottom of 1 Oft vegetated shelf elevation
Sediment cleanout, top elevation (bottom of pond?
Sediment cleanout, bottom elevation
Sediment storage provided
Is there additionat volume stored above the state -required temp. pool?
Elevation of the top of the additional volume
5,8)4 ft3 OK
5,810 ft3
OK, volume provided is equal to or in excess of volume required.
ft3
ft3
ft3
ft3
ft3
(Y or N)
3.1 in
0.40 (unitless)
0.65 (unitless)
3.00 Whir OK
2.a2 ft3lsec
4.58 ft3lsec
1.76 ft3/sec
150,48 fmsl
149,50 fmsl
149.00 fmsl
15000 fmsl
149,00 fmsl
145,00 fmsl
144.00 fmsl
1,00 ft
(Y or N)
150.5 fmsl OK
,,y�lfiff/l�I ' CA ,, '.
Form SW401-Wet Detention Basin -Rev ,8-9117109 Parts I. & II. Design Summary, Page 1 of 2

•
Ir •L� �� '
.' •fir �,` h �

Permit No.
fro be Provided by DINO)
IL DESIGN INFORMATION
Surface Areas
Area, temporary pool 6,766 ft?
Area REQUIRED, permanent pool 4,081 ft2
SAIDA ratio 3.99 (unitless)
Area PROVIDED, permanent pool, Ap, Pw 4,547 ft` OK
Area, bottom of 1Off vegetated shelf, Ab,, a,e 2,749 ft�
Area, sediment cieanout, top elevation (bottom of pond), Abay� d 790 ft`
Volumes
Volume, temporary pool
5.810 ft3
OK
Volume, permanent pool, V,,,, vCd
9,364 ft3
Volume, forebay (sum of forebays if more than one forebay)
2,028 ft3
Forebay % of permanent pool volume
21.7% %
OK
SAIDA Table Data
Design TSS removal
90 %
Coastal SAlDA Table Used?
N
(Y or N)
MountainlPiedmont SA1DA Table Used?
Y
(Y or N)
SAIDA ratio
3.99 (unitless)
Average depth (used in SAIDA table):
Calculation option 1 used? (See Figure 10-2b)
N
(Y or N)
Volume, permanent pool, Vim, P,
9,364 ft'
Area provided, permanent pool, Apes ped
4,547 ft`
Average depth calculated
ft
Need 3 ft min.
Average depth used in SAIDA, d., (Round to nearest 0.5ft)
ft
Calculation option 2 used? (See Figure 10-24)
Y
(Y or N)
Area provided, permanent pool, Ap . _pw
4,547 ft'
Area, bottom of 10ft vegetated shelf, Ab� �,n
2,749 ft`
Area, sediment cleanout, top elevation (bottom of pond), A601-pan4
790 ftZ
"Depth" (distance b/w bottom of 1Oft shelf and top of sediment)
4.00 ft
Average depth calculated
2.98 ft
Need 3 ft min.
Average depth used in SAIDA, d.. (Round to nearest 0.5ft)
3.0 ft
OK
Drawdown Calculations
Drawdown through orifice?
Y
(Y or N)
Diameter of orifice (if circular)
1.25 in
Area of orifice (if -non -circular)
in
Coefficient of discharge (Co)
0.60 (unitless)
Driving head (Ho)
0,98 ft
Drawdown through weir?
N
(Y or N)
Weir type
(unitless)
Coefficient of discharge (C.)
(unitless)
Length of weir (L)
ft
Driving head (H)
ft
Pre -development 1-yr, 24-hr peak flow
2.82 ft3lsec
Post -development 1-yr, 24-hr peak flow
4.58 ft/sec
Storage volume discharge rate (through discharge orifice or weir)
0.02 ft3lsec
Storage volume drawdown time
2,85 days
OK, draws down in 2-5 days.
Additional Information
Vegetated side slopes
Vegetated shelf slope
Vegetated shelf width
Length of flowpath to width ratio
Length to width ratio
Trash rack for overflow & orifice?
Freeboard provided
Vegetated filter provided?
Recorded drainage easement provided?
Capures all runoff at ultimate build -out?
Drain mechanism for maintenance or emergencies is:
3 :1
OK
10 :1
OK
10.0 ft
OK
3 :1
OK
3,0 :1
OK
Y (Y or N)
OK
1T ft
OK
N (Y or N)
OK
Y (Y or N)
OK
Y (Y or N)
OK
Gravity discharge and Pump
Form SW401-Wet Detention Basin-Rev.8-9717109 Parts I. & II. Design Summary, Page 2 of 2

Permit No
(to be provided by DWQ)
III. REQUIRED ITEMS CHECKLIST
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. 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),
Basin dimensions,
Pretreatment system,
High flow bypass system,
Maintenance access,
Proposed drainage easement and public right of way (ROW),
Overflow device, and
Boundaries of drainage easement.
6
2. Partial plan (1" = 30' or larger) and details for the wet detention basin showing:
Outlet structure with trash rack or similar,
Maintenance access,
Permanent pool dimensions,
Forebay and main pond with hardened emergency spillway,
Basin cross-section,
Vegetation specification for planting shelf, and
Filter strip.
dU)
�1L
3. Section view of the wet detention basin (1" = 20' or larger) showing:
Side slopes, 3:1 or lower,
Pretreatment and treatment areas, and
Inlet and outlet structures.
i? 12-
4. If the basin is used for sediment and erosion control during construction, clean out of the basin is specified
on the plans prior to use as a wet detention basin.
��JJP
12
5. A table of elevations, areas, incremental volumes & accumulated volumes for overall pond and for Forebay,
to verify volume provided.
moo=
6. A construction sequence that shows how the wet detention basin will be protected from sediment until the
entire drainage area is stabilized.
�n7
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),
a(� 10. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. County
soil maps are not an acceptable source of soils information.
Form SW401-Wet Detention Basin-Rev.8-9l17109
Part ill. Required Items Checklist, Page 1 of 1

R.E -�u Rat/ 10 /\ G � "+ 9Dp �+E1t- S a�/
Application Completeness Review
t' First Submittal ❑ Re -submittal Date Received
Development/Project Name: G E -
Receiving stream name s Ce
River Basin: F- ircA..
Date Reviewed:By Bill Diuguid
Class
TVW_T_­�
For post -construction requirements, 9 program will be deemed compliant for the aTeg-s where it is
implementing any of the following programs: WS-I, WS-II, WS-III, WS-IV, HQW, ORW, Neuse River Basin
NSW, Tar -Pamlico River Basin NSW, and the Randleman take 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): AIIA
Latitude and Longitude: Jurisdiction Cu ,es
Project Address: I Z , ck o e 5R 75Z C,�E
Engineer name and firm: 7it fs m, :r oa R , F ,c, Z6/ 'r-4.1c
Phone: Email: ikizam Ir fo Co
Is the project confirmed to be in the State MSI Stormwater Permit jurisdiction? Yes or 0 No
❑ Low Density (no curb and gutter) ❑ Low Density with curb and gutter outlets E�igh Density ❑ Other
11 401/404 impacts to surface waters, wetlands, and buffers (add language to cover letter and/or add info letter)
5K B U A
q/ Check for $505.00 included
&k,' Original signature (not photocopy) on application
,y/ Legal signature (Corporation-VP/higher, Partnership -General Partner/higher, LLC-member/manager, Agent).
Check spelling, capitalization, punctuation: http://www.sccrctary.statc.nc.us/corporations/thepage.,isps
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.
a For subdivided projects, a signed and notarized deed restriction statement
W%Sealed, signed & dated calculations
4/correct supplement and 0&M provided for each BMP on site (check all that were provided & number of each)
❑ Bioretention
Li Dry Detention Basin
ii Filter Strip
Ei Grass Swale
❑ Infiltration Basin
• Infiltration Trench
a Level Spreader
ci Permeable Pavement
D Restored Riparian Buffer
❑ Rooftop Runoff Management
❑ Sand Filter
❑ Stormwater Wetland
vd vet Detention Basin
❑ Low Density
❑ Curb Outlet
❑ Off -Site
❑ NCDOT Linear Road
,/ Two sets of sealed, signed & dated layout & finish grading plans with appropriate details
. Narrative Description of stormwater management provided
Soils report provided
d Wetlands delineated or a note on the plans or in the accompanying documents that none exist on site and/or
adjacent property
etails 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
rs/ BMP operation and maintenance agreements provided
[9'Application complete ❑ Application Incomplete Returned: (Date)
Comments
May 5, 2011 Revision, Bill Diuguid