20170239 Ver 2_NPDES - 4.12.21 thru 4.18.21_20210506

04/2019 SPPPFORM30
PROJECT LOCATION
LEVEL II SUPERVISOR
CONTRACTOR
INSPECTION RECORD FOR ACTIVITIES UNDER STORMWATER GENERAL PERMIT NCG010000
SELF -INSPECTION RECORD FOR LAND DISTURBING ACTIVITIES PER § 113A-54.1
RESPONSE FOR EROSION CONTROL FORM 1675
TIP/WBS#
COUNTY
All erosion and sedimentation control measures and stormwater discharge outfalls must be inspected once per seven calendar days AND
within 24 hours of a rainfall of 1.0 inch or greater per 24-hour period. Permittee must keep a record of inspections. If using on site rain
gage, complete daily rainfall measurement. If using Multi Precipitation Estimator (MPE), attach rainfall data for weekly period.
Day
Date
Rain
Amt (in)
Notes
M
T
W
Th
F
Sat
Sun
Phase of Grading
(Place a check in the box of the current project phase)
Installation of perimeter erosion and sediment control measures
Clearing and grubbing of existing ground cover
Completion of any phase of grading of slopes or fills
Installation of storm drainage facilities
Completion of construction or development
Establishment of permanent ground cover sufficient to restrain erosion
Has all land disturbing activity been completed? (Y/N)
Has the final permanent ground cover been completed and established? (Y/N)
By this signature, I certify (in accordance with Part IV, Section B, 6(d) of the NCG010000 permit)
that this report is accurate and complete to the best of my knowledge:
Cert. Level II Supervisor
Cert. #
NCDOT Cert. Level II Representative Cert. #
Exceptions to standard monitoring requirements
Idle projects: Idle projects must be inspected once every 14
calendar days and after 1.0" of rain in a 24-hour period. Idle
projects are projects that have not been completed but where no
construction activity occurs for 21 calendar days or more AND
the entire project has been adequately stabilized with temporary
vegetation pursuant to DEMLR guidelines.
Completed projects: Completed projects are those projects
where work has been completed and you're waiting for the
permanent vegetation to establish (i.e. waiting for the grass to
grow). Completed projects must be inspected once every 30
calendar days AND within 24 hours of a rain event 1.0 inch or
greater in 24 hours. The reduced monitoring can begin once
construction has been completed, and erodible slopes have been
sufficiently stabilized to restrain erosion by application of
permanent ground cover varieties and installation of temporary
ground cover to include appropriate erosion control matting
and/or other approved mulch materials.
Form should not be signed until the week is complete and ALL
corrective actions have been completed in the 24 hour and/or 5
day time periods.

04/2019 SPPPFORM30
Stormwater Discharge Outfalls (SDO)
(Required to list each SDO for each inspection)
Visible Sedimentation and Stream
Turbidity
Inspection
Date
Station Number
Corrective Actions Needed
Priority*
Date
Corrected
Other
Pollutants**
Sediment
Deposited***
Stream
Clarity****
* R=Routine, needs
attention within 5
days; U=Urgent,
needs attention
within 24 hrs.
**Is there evidence of other pollutants discharging from
site such as oil sheen, discoloration, cement wastes,
sanitary waste, fertilizers, or fuel or chemical storage
leakage? (Y/N) **If Other Pollutants is marked Yes,
describe extent of discharge and list the corrective actions
taken. Report potential illicit discharges to NCDOT for
confirmation/reporting.
***Is there visible sediment deposited in a stream,
wetland, buffer or adjacent property? (Y/N) Contact
DWR within 24 hours if visible sediment greater than a 5
gallon bucket is deposited in surface waters or wetlands,
and DEMLR if greater than 5 gallon bucket lost off site.
****Is there visible
decrease in stream clarity
(increase turbidity -cloudy)
because of a discharge?
(Y/N)
NOTE: Any erosion control device that is damaged that has the potential to lose sediment and/or pollutants offsite and/or into surface waters should be treated as "URGENT".

04/2019 SPPPFORM30
Stormwater Discharge Outfalls (SDO)
(Required to list each SDO for each inspection)
Visible Sedimentation and Stream
Turbidity
Inspection
Date
Station Number
Corrective Actions Needed
Priority*
Date
Corrected
Other
Pollutants**
Sediment
Deposited***
Stream
Clarity****
* R=Routine, needs
attention within 5
days; U=Urgent,
needs attention
within 24 hrs.
**Is there evidence of other pollutants discharging from
site such as oil sheen, discoloration, cement wastes,
sanitary waste, fertilizers, or fuel or chemical storage
leakage? (Y/N) **If Other Pollutants is marked Yes,
describe extent of discharge and list the corrective actions
taken. Report potential illicit discharges to NCDOT for
confirmation/reporting.
***Is there visible sediment deposited in a stream,
wetland, buffer or adjacent property? (Y/N) Contact
DWR within 24 hours if visible sediment greater than a 5
gallon bucket is deposited in surface waters or wetlands,
and DEMLR if greater than 5 gallon bucket lost off site.
****Is there visible
decrease in stream clarity
(increase turbidity -cloudy)
because of a discharge?
(Y/N)
NOTE: Any erosion control device that is damaged that has the potential to lose sediment and/or pollutants offsite and/or into surface waters should be treated as "URGENT".

04/2019 SPPPFORM30
Stormwater Discharge Outfalls (SDO)
(Required to list each SDO for each inspection)
Visible Sedimentation and Stream
Turbidity
Inspection
Date
Station Number
Corrective Actions Needed
Priority*
Date
Corrected
Other
Pollutants**
Sediment
Deposited***
Stream
Clarity****
* R=Routine, needs
attention within 5
days; U=Urgent,
needs attention
within 24 hrs.
**Is there evidence of other pollutants discharging from
site such as oil sheen, discoloration, cement wastes,
sanitary waste, fertilizers, or fuel or chemical storage
leakage? (Y/N) **If Other Pollutants is marked Yes,
describe extent of discharge and list the corrective actions
taken. Report potential illicit discharges to NCDOT for
confirmation/reporting.
***Is there visible sediment deposited in a stream,
wetland, buffer or adjacent property? (Y/N) Contact
DWR within 24 hours if visible sediment greater than a 5
gallon bucket is deposited in surface waters or wetlands,
and DEMLR if greater than 5 gallon bucket lost off site.
****Is there visible
decrease in stream clarity
(increase turbidity -cloudy)
because of a discharge?
(Y/N)
NOTE: Any erosion control device that is damaged that has the potential to lose sediment and/or pollutants offsite and/or into surface waters should be treated as "URGENT".

04/2019 SPPPFORM30
Stormwater Discharge Outfalls (SDO)
(Required to list each SDO for each inspection)
Visible Sedimentation and Stream
Turbidity
Inspection
Date
Station Number
Corrective Actions Needed
Priority*
Date
Corrected
Other
Pollutants**
Sediment
Deposited***
Stream
Clarity****
* R=Routine, needs
attention within 5
days; U=Urgent,
needs attention
within 24 hrs.
**Is there evidence of other pollutants discharging from
site such as oil sheen, discoloration, cement wastes,
sanitary waste, fertilizers, or fuel or chemical storage
leakage? (Y/N) **If Other Pollutants is marked Yes,
describe extent of discharge and list the corrective actions
taken. Report potential illicit discharges to NCDOT for
confirmation/reporting.
***Is there visible sediment deposited in a stream,
wetland, buffer or adjacent property? (Y/N) Contact
DWR within 24 hours if visible sediment greater than a 5
gallon bucket is deposited in surface waters or wetlands,
and DEMLR if greater than 5 gallon bucket lost off site.
****Is there visible
decrease in stream clarity
(increase turbidity -cloudy)
because of a discharge?
(Y/N)
NOTE: Any erosion control device that is damaged that has the potential to lose sediment and/or pollutants offsite and/or into surface waters should be treated as "URGENT".

04/2019 SPPPFORM30
Erosion & Sedimentation Control Devices
(Required to list all devices that need maintenance)
Inspection
Date
Station Number
Corrective Actions Needed
Priority*
Date
Corrected
*R=Routine, needs attention within 5 days; U=Urgent, needs attention within 24 hours.
NOTE: Any erosion control device that is damaged that has the potential to lose sediment and/or pollutants offsite and/or into surface waters should be treated as "URGENT".

04/2019 SPPPFORM30
RESPONSE FOR EROSION CONTROL - INSPECTOR'S DAILY REPORT
SUBSTITUE FORM 1675
Pay Item
Standard/Metric Unit
Quantity
Comments
Temporary Silt Fence
LF M
Special Sediment Control Fence
TN/MTN LF/M
Temporary Mulching
AC HA
Seed - Temporary Seeding
LB KG
Fertilizer - Temporary Seeding
TN MTN
Matting for Erosion Control
SY M2
Coir Fiber Mat
SY M2
Coir Fiber Baffles
LF M
Perm. Soil Reinforcement Mat
SY M2
Seeding and Mulching
AC HA
Seed - Repair Seeding
LB KG
Fertilizer - Repair Seeding
TN MTN
Seed for Supplemental Seeding
LB KG
Fertilizer Topdressing
TN MTN
Response for Erosion Control
EA EA
Safety/Highly Visible Fencing
LF M
We agree that this is the work to be performed.
We agree that this work was performed.
NCDOT Representative:
NCDOT Representative:
Prime Representative:
Prime Representative:
Date
Date