20100251 Ver 3_Stormwater Info_20120919

!
o� Clayton, Sr., RE, Inc. o - oa,,sI V.3
Civil & Environmental Engineering
LETTER OF TRANSMITTAL
September 19, 2012
Annette Lucas, PE
Wetlands, Buffers and Stormwater Compliance and Permitting Unit
NCDENR -DWQ
512 N. Salisbury Street
Raleigh, NC 27604
RE: Stormwater Management Permit Modification Application
for the development of Lot 4R
Harnett Health Investors, LLC
Skilled Nursing Facility
Brightwater Biotechnology and Medical Complex
Harnett County, NC
(via Hand Delivery)
Ms. Lucas,
PN: 173001
Please find attached the following:
1. One Original and One Copy of Form SWU -101
2. One Original Wet Detention Supplement Form and O &M Agreement for Drainage
Area #1
3. One Original Wet Detention Supplement Form and O &M Agreement for Drainage
Area #2
4. Application Fee of $505 (Check # 12526)
5. Two Narrative Books with Calculations and other required documents.
6. Two Plan Sets
7. NC Secretary of State info on Harnett Health Investors, LLC
8. NC Secretary of State info on Harnett Forward Together Committee
9. Memo from Harnett Forward concerning Harnett Health obtaining approvals
Please call should you need to discuss. We will be more than happy to come to your office to
discuss or review any concerns.
cc: file
46 W. Washington Street - Coats, NC 27521
Phone 910 - 897 -7070 • Fax- 910 - 897 -6767
Offices located in Coats and New Bern, North Carolina
License No C 2570 www.ctclavton corn

DWQ USE ONLY
Date Received
FeeTaid
Permit Number
Applicable Rules: ❑ Coastal SW —1995 ❑ Coastal SW.- 2008 ❑ Ph II - Post Construction
(select all that apply) ❑ Non - Coastal SW- HQW /ORWWaters 'DU niversal Stormwater Management Plan
❑ Other WQ Mgmt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION 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, letters, operation and maintenance agreements, etc.):
Harnett Health Investors, LLC - Skilled Nursine Facilitv
2. Location of Project (street address):
Crested Iris /Red Mulberry
City: Lillington County: Harnett
3. Directions to project (from nearest major intersection):
From intersection of North Main Street (NC 210) and Cornelius Harnet Blvd (US 401/421) west on W
Cornelius Harnett Blvd for 0.8 miles. Turn right. North on Matthews Rd approximately 500 feet Turn right
East on Crested Iris Drive approximately 300 feet. Site is on east side of intersection of Crested Iris Drive and
Red Mulberrry.
4. Latitude:35° 25'31.8" N Longitude:78° 48'43.3" 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 number10 -0251 Ver. 2 , its issue date (if known) March 8, 2011 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: 6 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: Brightwater Medical Complex, 10-0251 Ver. 2, February 3 2011 401
Form SWU -101 Version 07Jun2010 Page 1 of 6
SEP 1 2012
DENR - 11 ATER DD%tL1TY
'effantl. A ov

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: Harnett Health Investors. LLC
Signing Official & Title: Hunter Smith - Vice Chairman Manager
b. Contact information for person listed in item 1a above:
Street Address: 4423 Pheasant Ridge Rd SW, Suite 301
City: Roanoke State: VA Zip: 24014
Mailing Address (if applicable): same
City:
Phone: (540 ) 774 -7762
Email:[e-mail]
State: Zip:
Fax: (540 ) 772 -6470
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 /Organization: Harnett Forward Together Committee
Signing Official & Title: lohnson Tilghman - Chairman
b. Contact information for person listed in item 2a above:
Street Address: 907 S Main St
City: Lillington State: NC Zip: 27546
Mailing Address (if applicable): PO Box 1270
City: Lillingion State: NC Zip: 27546
Phone: (910 ) 893 -7524
Email:
Fax: (910 ) 814 -8298
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: C. T. Clayton, Sr.. PE, Inc.
Signing Official & Title: C. T. Clayton, Ir., P.E., Project Engineer
b. Contact information for person listed in item 3a above:
Mailing Address: 46 W. Washington St.
City: Coats State: NC Zip: 27521
Phone: (910 ) 897 -7070
Email: [e-mail]
Fax: (910 ) 897 -6767
4. Local jurisdiction for building permits: Harnett County
Point of Contact:Ken Slattum Phone #: (910 ) 893 -7525
Form SWU -101 Version 07Jun2010 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
The stormwater from the proposed impervious surfaces will be collected in an underground pipe network
that will discharge to two wet detention ponds. Due to the location of the ponds, the fonds will share an
outlet device.
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 PUDApproval 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 II — Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area: 6.52 acres
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: .01 acres
7. Total Property Area (4) — Total Coastal Wetlands Area (5) — Total Surface Water Area (6) = Total Project Area':
6.51 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 High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BLIA). 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 = 31.67 %
9. How many drainage areas does the project have ?2 (For high density, count 1 for each proposed engineered
stormwater BMP. For low density and other projects, use 1 for the whole property area)
10. Complete the following information for each drainage area identified in Project Information item 9. If there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below.
Basin Information
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area _
Receiving Stream Name
Cape Fear River
Cape Fear River
Stream Class *
WS -IV;CA
WS -IV;CA
Stream Index Number *
18- (16.3)
18- (16.3)
Total Drainage Area (sf)
92,507
53,880
On -site Drainage Area (sf)
92507
53,880
Off -site Drainage Area (sf)
0
0
Proposed Impervious Area ** (sf)
55,023
34,784
% Impervious Area ** (total)
59.5
64.6
Impervious" Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area _
On -site Buildings /Lots (sf)
13,067
39,221
On -site Streets (sf)
0
0
On -site Parking (so
12,280
11,640
On -site Sidewalks (sf)
4,724
1,792
Other on -site (so
4,724
1,792
Future (so
0
0
Off -site (sf)
0
0
Existing BUA * ** (sf) 1
0
0
Total (sf): 1
34,795
54,442
* Stream Class and Index Number can be determined at: http://portal.ncdenr.or /wg eb/w9/ps/csu /classifications
** Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU -101 Version 07Jun2010 Page 3 of 6

* ** Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that is
to be removed and which will be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. N/A
Proiects in Union County: Contact DWQ Central Office 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 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 htW: / /12ortal.ncdenr.org /web /wq /ws /su /bmp- manual.
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 htt2: / /12ortal.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 hW2: / /12ortal.ncdenr.org /web /wq /ws /su /maps.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from http: / /12ortal.ncdenr.org /web /wq /ws /su /statesw /forms does.
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 N E)
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
htt2:// www. envhelp .org/12ages /onestol2exl2ress.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 /management for
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 Vs mile of the site boundary, include the Vz
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.
Form SWU -101 Version 07Jun2010 Page 4 of 6
CT
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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 - mpl
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 verify the SHWT prior
to submittal, (910) 796 - 7378.)
10. A copy of the most current property deed. Deed book: a� Page No: l- l5
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 1a, 2a, and /or 3a per NCAC 21-1.1003(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.
hU://www.secretai:y.state.nc.us/CoQ2orations/CSearch.asl2x
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
htW: / /12ortal.ncdenr.org /web /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:C. Torus Clayton, Tr. P.E.
Consulting Firm: C. T. Clayton Engineering
Mailing Address: 46 W. Washington St.
City: Coats
Phone: (910 ) 897 -7070
Email: [e-mail]
State:NC Zip:27521
Fax: (910 ) 897 -6767
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) Johnson Tilghman 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) Hunter Smith with (print or type name of organization listed in
Contact Information, item 1a) Harnett Health Investors. LLC to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SW-101 Version 07Jun2010 Page 5 of 6

As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and /or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ immediately and submit a
completed Name /Ownership Change 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 violati9Z of NC General Statue 143 -215.1 and may result in appropriate enforcement action including
the assessment enalties to 25,000 per day , pursuant to NCGS 143 - 215.6.
p P Y P-
Date:
I, M-,0101 1 C G . GmA 6.11� a Notary Public for the State of Aor}h Cc-('o1;,no. , County of
Actr nq-�+ do hereby certify that 11. 36,1irvGa^ - Me�brnc'n personally appeared
before me this day of �T.��1a. WIZ , and acknowledge the d - execution of the application for
a stormwater permit. Witness my hand and official seal, )4ceplj
G. G •..
acv � R �
O y'-
Atli B1.�G� �C;
X. APPLICANT'S CERTIFICATION
SEAL
My commission expires 12r;
I, (print or type name of person listed in Contact Information, item 1a) Hunter Smith
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 stormwater rules under 15A NCAC 2H.1000, SL 2006 -246 (Ph. II - Post Construction) or SL 2008 -211.
Signature:
Date: Cp - 7 1 Z
A- `Do Ud / ke 1'1 a Notary Public for the State of V/ Yq/ �'1 / � County of
!,-40 , do hereby certify that _6 -un -fe Y D, 8 M r th personally appeared
before me this day of (Jim! f'. �Z, and knowledge the due execution •• of the application for
a stormwater permit. Witness my hand and official seal' MW �7" y
I CAROL A. DOUDIKEN
NOTARY PUBLIC
I Commonwealth of Virginia
Reg. #226376
My Commiss -)n Expires: 10 -31 -12
SEAL
My commission expires l0 - & /— /Z
Form SWU -101 Version 07Jun2010 Page 6 of 6

HCDENR
Permit No
(to be provided by DWQ)
O�aF W A
TF9QG
o
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
WET DETENTION BASIN SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Part III) must be printed, filled out and submitted along with all of the required information.
I. PROJECT INFORMATION
Project name Brightwater Skilled Nursing Facility
Contact person C Tyrus Clayton, Jr , P E
Phone number (910) 897 -7070
Date 15- Jul -12
Drainage area number 1
II. DESIGN INFORMATION
Site Characteristics
Drainage area
Impervious area, post - development
% impervious
Design rainfall depth
Storage Volume: Non -SA Waters
Minimum volume required
Volume provided
Storage Volume: SA Waters
15" runoff volume
Pre - development 1 -yr, 24 -hr runoff
Post - development 1 -yr, 24 -hr runoff
Minimum volume required
Volume provided
Peak Flow Calculations
Is the pre /post control of the 1 yr 24hr stone peak flow required?
1 -yr, 24 -hr rainfall depth
Rational C, pre-development
Rational C, post-development
Rainfall intensity. 1 -yr, 24 -hr storm
Pre - development 1 -yr, 24 -hr peak flow
Post -development 1 -yr, 24 -hr peak flow
Pre/Post 1 -yr, 24 -hr peak flow control
Elevations
Temporary pool elevation
Permanent pool elevation
SHWT elevation (approx at the pens. 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 then; additional volume stored above the state - required temp pool?
Elevation of the top of the additional volume
66,034 fe
34,795 fe
52.69 %
1.0 in
2,885 ft"
3,565 ft3
OK, volume provided is equal to or in excess of volume required.
ft3
ft3
113
ft3
ft3
N (Y or N)
3.0 in
0.35 (unitless)
0 66 (unitless)
5.15 in/hr OK
2.73 ft3 /sec
5.15 ft3 /sec
2 42 ft3 /sec
16100 fmsl
160 00 fmsl
157.00 fmsl
160 50 fmsl
159.50 fmsl
155.00 fmsl
154.00 fmsl
1.00 ft
N (Y or N)
fmsl
SEAL r
s 0289
G��O e
CLA _ moo
q, rr20'
Form SW401 -Wet Detention Basin -Rev 9- 4118112 Parts I & 11 Design Summary, Page 7 of 3

Permit No
II. DESIGN INFORMATION
Surface Areas
Area, temporary pool
3 .1
3,565 ft2
Vegetated shelf slope
Area REQUIRED, permanent pool
OK
2,311 ft?
100 ft
SAIDA ratio
Length of flowpath to width ratio
3.50 (unitless)
OK
Area PROVIDED, permanent pool, Ap._p d
30 1
2,612 11:2
OK
Area, bottom of 1 Oft vegetated shelf, Amt shelf
OK
1,669 ft'
1.0 ft
Area, sediment cleanout, top elevation (bottom of pond), Anwt_d
Vegetated filter provided?
306 f'
OK
Volumes
Y (Y or N)
OK
Capures all runoff at ultimate build -out?
Volume, temporary pool
OK
3,565 ft3
OK
Volume, permanent pool, Vce, -"
5,420 ft3
Volume, forebay (sum of forebays if more than one forebay)
1,119 ft3
Foeebay % of permanent pool volume
206% %
OK
SAIDA Table Data
Design TSS removal
90 %
Coastal SAIDA Table Used?
N
(Y or N)
Mountain/Piedmont SAIDA Table Used?
Y
(Y or N)
SAIDA ratio
3.50 (unitless)
Average depth (used in SAIDA table)
Calculation option 1 used? (See Figure 10 -2b)
N
(Y or N)
Volume, permanent pool, V,-,,,,,,
5,420 ft3
Area provided, permanent pool, A,,,,,,,
2,612 ft'
Average depth calculated
307 ft
OK
Average depth used in SAIDA, dev, (Round to nearest 0 5ft)
3.0 ft
OK
Calculation option 2 used? (See Figure 10 -2b)
Y
(Y or N)
Area provided, permanent pool, Ate, w
2,612 ft2
Area, bottom of 1 Oft vegetated shelf, Abot Shen
1,669 ft'
Area, sediment cleanout, top elevation (bottom of pond), Aboi-pond
306 fe
"Depth" (distance b/w bottom of 1 Oft shelf and top of sediment)
4 50 ft
Average depth calculated
3 07 ft
OK
Average depth used in SAIDA, d.„ (Round to down to nearest 0 5ft)
3.0 ft
OK
Drawdown Calculations
Drawdown through orifice?
Y
(Y or N)
Diameter of orifice (d circular)
100 in
Area of orifice (if- non -circular)
in
Coefficient of discharge (CD)
0.60 (unitless)
Driving head (Ho)
0.33 ft
Drawdown through weir?
N
(Y or N)
Weir type
(unitless)
Coefficient of discharge (Cw)
(unitless)
Length of weir (L)
ft
Driving head (H)
0 333 ft
Pre - development 1 -yr, 24 -hr peak flow
2,73 ft3 /sec
Post-development 1 -yr, 24 -hr peak flow
515 ft3 /sec
Storage volume discharge rate (through discharge orifice or weir)
0.03 ft3 /sec
Storage volume drawdown time
3.72 days
OK, draws down in 2 -5 days.
Additional Information
(to be provided by DWQ)
Vegetated side slopes
3 .1
OK
Vegetated shelf slope
10 1
OK
Vegetated shelf width
100 ft
OK
Length of flowpath to width ratio
3 :1
OK
Length to width ratio
30 1
OK
Trash rack for overflow & orifice?
Y (Y or N)
OK
Freeboard provided
1.0 ft
OK
Vegetated filter provided?
N (Y or N)
OK
Recorded drainage easement provided?
Y (Y or N)
OK
Capures all runoff at ultimate build -out?
Y (Y or N)
OK
Drain mechanism for maintenance or emergencies Is-
Outlet valve and portable pump for complete dewatering
Form SW401 -Wet Detention Basin -Rev 9- 4/18/12 Parts 18 11 Design Summary, Page 2 of 3

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.
Page/ Plan
Initials Sheet No.
005
1. Plans (1" - 50' or larger) of the entire site showing:
LSoa
- Design at ultimate build -out,
C50 1
- 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.
C C 50l
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.
C 50 t 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.
C"fC G 46" "C%N. 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.
C1� 7n
Go k-3 5. A table of elevations, areas, incremental volumes & accumulated volumes for overall pond and for forebay,
to verify volume provided.
cic 0-5 6D 6. A construction sequence that shows how the wet detention basin will be protected from sediment until the
entire drainage area is stabilized.
144fmtie %ak 7, The supporting calculations.
c4o7
C7 r-k 8. A copy of the signed and notarized operation and maintenance (0 &M) agreement.
_ 9. A copy of the deed restrictions (if required).
C14 t644htie 10. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. County
6OK soil maps are not an acceptable source of soils information.
Form SW401 -Wet Detention Basin -Rev 9- 4/18/12 Part III. Required Items Checklist, Page 3 of 3

Permit Number:
(to be provided by DWQ)
Drainage Area Number: 1
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 R does not
This system (check one):
❑ does N does not
incorporate a vegetated filter at the outlet.
incorporate pretreatment other than a forebay.
Important maintenance procedures:
- Immediately after the wet detention basin is established, the plants on the
vegetated shelf and perimeter of the basin should be watered twice weekly if
needed, until the plants become established (commonly six weeks).
- No portion of the wet detention pond should be fertilized after the first initial
fertilization that is required to establish the plants on the vegetated shelf.
- Stable groundcover should be maintained in the drainage area to reduce the
sediment load to the wet detention basin.
- If the basin must be drained for an emergency or to perform maintenance, the
flushing of sediment through the emergency drain should be m;n;m;zed 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:
Potential problem:
How I will remediate the problem:
The entire BMP
Trash /debris is present.
Remove the trash/ debris.
The perimeter of the wet
detention basin
Areas of bare soil and /or
erosive gullies have formed.
Regrade the soil if necessary to
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
I
Maintain vegetation at a height of
long.
approximately six inches.
Form SW401 -Wet Detention Basin O &M -Rev.4 Page 1 of 4

Permit Number:
(to be provided by DWQ)
Drainage Area Number: 1
BMP element:
Potential problem:
How I will remediate the problem:
The inlet device: pipe or
The pipe is clogged.
Unclog the pipe. Dispose of the
swale
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged.
Erosion is occurring in the
Regrade the swale if necessary to
swale.
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
The forebay
Sediment has accumulated to
Search for the source of the
a depth greater than the
sediment and remedy the problem if
original design depth for
possible. Remove the sediment and
sediment storage.
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Erosion has occurred.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Weeds are present.
Remove the weeds, preferably by
hand. If pesticide is used, wipe it on
the plants rather than spraying.
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 4

Permit Number:
(to be provided by DWQ)
Drainage Area Number: 'I
BMP element:
Potential problem:
How I will remediate the problem:
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 Se 0 feet in the main pond, the
sediment shall be removed.
When the permanent pool depth reads 0 feet in the forebay, the sediment
shall be removed.
Sediment Removal
Bottom
BASIN DIAGRAM
ill in the blanks)
Permanent Pool Elevation 166,0
15 v fPeanen Pool
- - - - - - - - - - - - - - ume Sediment Removal Elevation �S a Volume
L1 in.--------------------------------- - - - - -- I--- ement Bottom Elevation 15q b 1 -ft
Storage Sedimer
Storage
FOREBAY MAIN POND
Form SW401 -Wet Detention Basin O &M -Rev.4 Page 3 of 4

Permit Number:
(to be provided by DWQ)
I acknowledge and agree by my signature below that I am responsible for the
performance of the maintenance procedures listed above. I agree to notify DWQ of any
problems with the system or prior to any changes to the system or responsible party.
Project name: Brightwater Skilled Nursing Facility
BMP drainage area number:
Print name: Harnett Health Investors, LLC - Hunter Smith
Title:Vice Chairman Manager
Address:4423 Pheasant Ridge Rd Ste 301, Roanoke, VA 24014
Phone: [phone]
Signature: / l-
b
ate: 7 -1 Z
Note: The legally responsible party should not be a homeowners association unless more than 50% of
the lots have been sold and a resident of the subdivision has been named the president.
I, CA r O I A • Do v d � k e h , a Notary Public for the State of
V( ra I Y, 1 av , County of R O Q Y1 U k e- , do hereby certify that
4 V h -f-ey- D, S m'i t h personally appeared before me this 7 -A
day of J V h r— , ZO Z, and acknowledge the due execution of the
forgoing wet detention basin maintenarrkc-e requirements. Witness my hand and official
seal, d au_t � c�9�' e&;a_ -�
CAROL A. DOUDIKEN
NOTARY PUBLIC
Commonwealth of Virginia g
My Comm s p alon Ex 3es 10 -31 -12
SEAL
My commission expires (1> '0/- /Z.,
Form SW401 -Wet Detention Basin O &M -Rev.4 Page 4 of 4

A,
NCDENR
Permit No
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
WET DETENTION BASIN SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Part 111) must be printed, filled out and submitted along with all of the required information.
I. PROJECT INFORMATION
Project name Brightwater Skilled Nursing Facullty
Contact person C Tyrus Clayton, Jr , P E
Phone number (910) 897 -7070
Date 15- Jul -12
Drainage area number 2
(to be provided by DWQ)
OHO'( W A L, 9pq
> r
o
II. DESIGN INFORMATION
Site Characteristics
N (Y or N)
Drainage area
95,394 ft
Impervious area, post-development
34,784 ft
% Impervious
3646%
Design rainfall depth
1.0 In
Storage Volume: Non -SA Waters
Minimum volume required 3,006 ft3
Volume provided 4,435 ft3
OK, volurr
Storage Volume: SA Waters
15" runoff volume ft3
Pre - development 1 -yr, 24 -hr runoff ft3
Post - development 1 -yr, 24 -hr runoff ft3
Minimum volume required ft3
Volume provided ft3
Peak Flow Calculations
Is the pre /post control of the lyr 24hr storm peak flow required?
N (Y or N)
1 -yr, 24 -hr rainfall depth
3.0 In
Rational C, pre - development
0.35 (umtless)
Rational C, post-development
0.69 (unitless)
Rainfall intensity 1 -yr, 24 -hr storm
5.15 In/hr OK
Pre - development 1 -yr, 24 -hr peak flow
3.95 g3 /sec
Post - development 1 -yr, 24 -hr peak flow
7.78 ft3 /sec
Pre/Post 1 -yr, 24 -hr peak flow control
; - 3.83 ft3 /sec
Elevations
Temporary pool elevation
16100 fmsl
Permanent pool elevation
160.00 fmsl
SHWT elevation (approx at the perm. pool elevation)
157 00 fmsl
Top of 1Oft vegetated shelf elevation
160.50 fmsl
Bottom of 10ft vegetated shelf elevation
159.50 fmsl
Sediment cleanout, top elevation (bottom of pond)
155.00 fmsl
Sediment cleanout, bottom elevation
154 00 hsl
Sediment storage provided
1.00 ft
Is there additional volume stored above the state - required temp. pool?
N (Y or N)
Elevation of the top of the additional volume
fmsl
uRG/Ngl
red
11
�� •?
•t.
CRR` -., 0
Form SW401 -Wet Detention Basin -Rev 9- 4/18/12
Parts 18 11 Design Summary, Page 1 of 3

II. DESIGN INFORMATION
Surface Areas
Area, temporary pool
Area REQUIRED, permanent pool
SAIDA ratio
Area PROVIDED, permanent pool, Ap,,._pw
Area, bottom of 1 Oft vegetated shelf, Abot oeff
Area, sediment cleanout, top elevation (bottom of pond), Abt_p d
Volumes
Volume, temporary pool
Volume, permanent pool, Vp--"
Volume, forebay (sum of forebays If more than one forebay)
Forebay % of permanent pool volume
SAIDA Table Data
Design TSS removal
Coastal SAIDA Table Used?
Mountain/Piedmont SAIDA Table Used?
SAIDA ratio
Average depth (used in SAIDA table):
Calculation option 1 used? (See Figure 10 -2b)
Volume, permanent pool, Vce,,,_,w
Area provided, permanent pool, A,,,,,w
Average depth calculated
Average depth used in SAIDA, da,,, (Round to nearest 0.51t)
Calculation option 2 used? (See Figure 10 -2b)
Area provided, permanent pool, A�rr.yci
Area, bottom of 10ft vegetated shelf, Abot S,at
Area, sediment cleanout, top elevation (bottom of pond), Ayot_p,,,d
5,168 fe
3,339 fe
3 50 (undless)
3,345 ffz OK
2,214 ft'
462 ft2
4,435 ft3 OK
7,364 ft3
1,579 ft3
21.4%% OK
90%
N (Y or N)
Y (Y or N)
3 50 ( unitless)
N (Y or N)
7,364 ft3
3,345 ft2
ft Need 3 ft min
It
Y (Y or N)
3,345 fl?
2,214 ft3
462 ft2
"Depth" (distance b/w bottom of 1 Oft shelf and top of sediment) 4.50 ft
Average depth calculated 3.14 ft
Average depth used in SAIDA, d.„ (Round to down to nearest 0 5ft) 3 0 It
Drawdown Calculations
Drawdown through orifice?
Diameter of orifice (If circular)
Area of orifice (If- non - circular)
Coefficient of discharge (Co)
Driving head (Ho)
Drawdown through weir?
Weir type
Coefficient of discharge (C.)
Length of weir (L)
Driving head (H)
Pre - development 1 -yr, 24 -hr peak flow
Post - development 1 -yr, 24 -hr peak flow
Storage volume discharge rate (through discharge orifice or weir)
Storage volume drawdown time
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.
Y (Y or N)
150 in
in
060 ( unitless)
0.33 It
N (Y or N)
( unitless)
(unitless)
ft
ft
3 95 ft3 /sec
7 78 ft3
/sec
0.01 ft3 /sec
3.72 days
OK
OK
OK, draws down In 2 -5 days
Permit No
(to be provided by DWQ)
3 :1
OK
10 1
OK
10 0 ft
OK
3-1
OK
3.0 •1
OK
Y (Y or N)
OK
10 ft
OK
N (Y or N)
OK
Y (Y or N)
OK
Y (Y or N)
OK
Outlet valve and portable pump for complete dewatering
Form SW401 -Wet Detention Basin -Rev 9- 4/18/12 Parts I & 11 Design Summary, Page 2 of 3

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.lf a
requirement has not been met, attach justification.
Pagel Plan
Initials Sheet No.
C1405
1. Plans (1" - 50' or larger) of the entire site showing:
L500
- Design at ultimate build -out,
G So t
- 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 (ROM,
- Overflow device, and
- Boundaries of drainage easement.
C C 5ol
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.
C661
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.
C"lC G 464 4 GSoD4. 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.
CI CV 7h Caj4S 5. A table of elevations, areas, incremental volumes & accumulated volumes for overall pond and for forebay,
to verify volume provided.
C 1 C 0-50 6. A construction sequence that shows how the wet detention basin will be protected from sediment until the
entire drainage area is stabilized.
Nor&k 7. The supporting calculations.
0
8. A copy of the signed and notarized operation and maintenance (0 &M) agreement.
_ 9. A copy of the deed restrictions (if required).
C14 NorrahLc 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 9- 4/18/12 Part III Required Items Checklist, Page 3 of 3

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

Permit Number:
(to be provided by DWQ)
Drainage Area Number: ;Z.
BMP element:
Potential problem:
How I will remediate the problem:
The inlet device: pipe or
The pipe is clogged.
Unclog the pipe. Dispose of the
swale
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged.
Erosion is occurring in the
Regrade the swale if necessary to
swale.
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
The forebay
Sediment has accumulated to
Search for the source of the
a depth greater than the
sediment and remedy the problem if
original design depth for
possible. Remove the sediment and
sediment storage.
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Erosion has occurred.
Provide additional erosion
protection such as reinforced turf .
matting or riprap if needed to
prevent future erosion problems.
Weeds are present.
Remove the weeds, preferably by
hand. If pesticide is used, wipe it on
the plants rather than spraying.
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 spray mi .
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 4

Permit Number:
(to be provided by DWQ)
Drainage Area Number:
BMP element:
Potential problem:
How I will remediate the problem:
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 S b feet in the main pond, the
sediment shall be removed.
When the permanent pool depth reads 4. D feet in the forebay, the sediment
shall be removed.
Sediment Removal
Bottom Elevatio I SS, 6 iifi
BASIN DIAGRAM
ill in the blanks)
Permanent Pool Elevation I L&L)
'e anen Pool
Volume - - - - -- Sediment Removal Elevation I'S S.0 --- - - - - -- Volume
-ft Min.
Sediment Bottom Elevation 154,o 1 -ft n
Storage Sedimei
Storage
FOREBAY
MAIN POND
Form SW401 -Wet Detention Basin O &M -Rev.4 Page 3 of 4

Permit Number:
(to be provided by DWQ)
I acknowledge and agree by my signature below that I am responsible for the
performance of the maintenance procedures listed above. I agree to notify DWQ of any
problems with the system or prior to any changes to the system or responsible party.
Project name: Brightwater Skilled Nursing g acility
BMP drainage area number:
Print name: Harnett Health Investors, LLC - Hunter Smith
Title:Vice Chairman Manager
Address:4423 Pheasant Ridge Rd Ste 301, Roanoke, VA 24014
Phone: [phone]
Signature:
Date: &- 7 - I Z
Note: The legally responsible party should not be a homeowners association unless more than 50% of
the lots have been sold and a resident of the subdivision has been named the president.
I,
Lo, ro ( A . DD U c; k c h , a Notary Public for the State of
V lrq 14 I a-- , County of l 0 0-n D k if— , do hereby certify that
40 h +e, r D, S m; "h1 personally appeared before me this "l t6
day of J U n e , 1- 01 Z , and acknowledge the due execution of the
forgoing wet detention basin maintenance requirements. Witness my hand and official
seal, 44"-01 J�C_ Zak_A'k&_k_I
CAROL A. DOUDIKEN
NOTARY PUBLIC
Commonwealth of Virginia
Reg. #226376
a ;.,.. FYniras: 10.31 -12
SEAL
My commission expires to -3/ — /Zv
Form SW401 -Wet Detention Basin O &M -Rev.4 Page 4 of 4

9/19/12
North Carolina Secretary of State
North Carolina
Elaine F. Marshall DEPARTMENTOF THE
L - Secretary SECRETARY OF STATE
PO Box 29622 Raleigh, NC 27626-0622 (919 )807 -2000
Date: 9/19/2012
here to:
u Document Filings
PLLC, LP and Non -Profit entities are not required to file annual reports.
'Doration Names
Name Name Type
NC HARNETT FORWARD LEGAL
TOGETHER COMMITTEE
NC HARNETT COUNTY COMMITTEE PREV LEGAL
OF 100
NC HARNETT ECONOMIC PREV LEGAL
DEVELOPMENT CORPORATION
Non - Profit Corporation Information
SOSID:
0341489
Status:
Current - Active
Effective Date:
3/30/1994
Annual Report Due Date:
Citizenship:
DOMESTIC
State of Inc.:
NC
Duration:
PERPETUAL
gistered Agent
Agent Name: MEECE JR, THOMAS E
Office Address: 27 E HARNETT ST
LILLINGTON NC 27546
Mailing Address: PO BOX 1270
LILLINGTON NC 27546
Principal Office
Office Address: NO ADDRESS
Mailing Address: 27 E HARNETT ST
LILLINGTON NC 27546
This website is provided to the public as a part of the Secretary of State Knowledge Base (SOSKB) system. Version:
3457
www. secretary. state. nc. us / corporations /Corp.aspx7PbmId= 4595338 V1

i
22 228 5112
SOSID: 0341489
Date Filed: 81191200212:06 PM
Elaine F. Marshall
North Carolina Secretary of State
State of North Carolina
;L Depatrtp�ent ;ntlie;Stetary��,Sts�e ,,,
.L^n. F , `ts-4 :t. :,K `y '�. �� �'`�vf'�,•+.::• ,; �.ri
ARTICLES OF AMENDMENT
NONPROFIT CORPORATION
Pursuant to §55A -10 -05 of the General Statutes of North Carolina, the undersigned corporation hereby
submits the following Articles of Amendment for the purpose of amending its Articles of Incorporation.
1. The name of the corporation is: Harnett Forward Together Committee
2. The text of each amendment adopted is as follows (state below or attach):
SEE ATTACHMENT
3. The date of adoption of each amendment was as follows:
August 2, 2002
4. (Check a, b, and/or c, as applicable)
a X The amendment(s) was (were) approved by a sufficient vote of the board of directors or
incorporators, and member approval was not required because (set forth a brief explanation of why
member approval was notrequir+ed) Member approval was not required
because there are no members.
b. The amendment(s) was ( were) approved by the members as required by Chapter 55A.
C. Approval of the amendment(s) by some person or persons other than the members, the
board, or the incorporators was required pursuant to N.C.G.S. §55A- 10 -30, and such approval was
obtained.
Revised January 2000 Form N -02
CORPORATIONS DIVISION P. O. BOX 29622 RALEIGH, NC 27626 -0622

5. These articles will be effective upon filing, unless a date and/or time is specked:
This the /2711dayof August Y 20--92—
HARNETT FORWARD GETHER COMMITTEE
� Name o a�ation7
Johnson Tilghman,--esident
Type or Print Name and Title
Notes:
1. Filing fee is $25. This document and one exact or conformed copy of these articles mast be filed with the
Secretary of State.
Revised January 2000 Form N -02
CORPORATIONS DIVISION P. O. BOX 29622 RALEIGH, NC 27626 -0622

Attachment to Articles of Amendment - Harnett Forward Together Committee
A. The provisions of Article III in the original Articles of Incorporation filed on March 30,1994
are hereby amended as follows:
d) this corporation is organized exclusively for charitable purposes within the meaning
of section 501(c)(3) of the Internal Revenue Code.
(e) notwithstanding any other provision of these Articles, the corporation shall not carry
on any other activities not permitted to be carried on (a)by the corporation exempt
from Federal income tax under section 501(c)(3) of the Internal Revenue Code of
1986 (or the corresponding provisions of any future United States Internal Revenue
law) or (b) by a corporation contributions to which are deductible under section 170
(c)(2) of the Internal Revenue Code of 1986 (or the corresponding provision of any
future United States Internal Revenue Law).
B. The provisions of Article VI which was last amended in those Articles of Amendment filed
on February 19, 2002 are hereby deleted and in lieu thereof insert the following:
Upon winding up and dissolution of this corporation, after paying or adequately providing
for the debts and obligations of the corporation, the remaining assets shall be distributed to a non-
profit fund, foundation, or corporation which is organized and operated exclusively for charitable,
educational, religious, and or scientific purposes and which has established its tax exempt status
under section 501(c)(3) of the Internal Revenue Code.

August 9, 2012
To all Regulatory Agencies:
RE: Brightwater Lot 4
Permission to obtain approvals
Harnett Health Investors, LLC (Skilled Nursing Facility)
To whom this may concern:
Harnett Health Investors, LLC has the right and our approval to pursue and obtain
regulatory approvals for the proposed Skilled Nursing Facility as depicted on the
drawings issued by C. T. Clayton, Sr., PE, Inc. and Jones & Jones Associates,
Architects, PC.
Sincerely,
nson Tilghman, Cha
Harnett Forward Togetl
P.O. Box 1270
907 S. Main Street
Lillington, NC 27546
phone: [phone]
fax: [phone]
Owner of Record