WI0400550_DEEMED FILES_20200706

Permit Number WI0400550
Program Category
Deemed Ground Water
Permit Type
Injection Deemed Stormwater Drainage Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Saxon Place Infiltration Trench Building #3
Location Address
3535 Lancelot Ln
Wilmington
Owner
Owner Name
Saxon Place LLC
Dates/Events
NC 28403
Scheduled
Orig Issue
6/3/2020
App Received Draft Initiated Issuance
5/27/2020
Regulated Activities
State Stormwater -Infiltration System
Outfall
Central Files: APS _ SWP __
7/6/2020
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Christopher Buffalino
2918 A Martinsville Rd
Greensboro NC 27408
Public Notice Issue
6/3/2020
Requested /Received Events
Effective
6/3/2020
Expiration
Waterbody Name Streamlndex Number Current Class Subbasin
NORTH CAROLINA DEPAR l'MENT OF ENVIRONMENT AND t-!ATURAL RESOURCES
NOTU'ICA'IlON FOR STORMW ATER DRAINAGE WELLS
Stormwater drainage wells are Class 5 injection wells "permitted hy rule" and do 1101 require an indfr1dual
ilyeclitm well permit wizen constructed in accordo111.:e with the rules oj 15A i\'CAC 02( • .{J2{J(J.
As described 1i1 I 5A NCAC O;C .0127 this applies to rooftop nmojf infiltration SJ'$lems u11d certain other
stormwater infiltration systems implemented as Best !r.fa1Wgeme11t Practices de.,;igned in accordance with State
stormwater regulotio11s or an approved local go\•ernment stormwat~r program. Additio11al guidance is m;ailable
011/ine at httq:llportolncdenr.orglwcbiwa1ap.s.lgwpro/iniection stomnwrter
This notification form shall be submilted within 30 d,~ys of a change of status as described in Purl lJ below.
Print Clearly or 1)pe ln/ormtllion. Illegible SubmittaL~ Will Be Returned As lncomplele.
DATE: ___ M_a----'Cy_8_th ___ ,. 20 2Q PERMIT NO. /;vJ-0 lf 005' SO (to be completed by DWR)
A. STATUS OF WELL OWNER {choose one) RECt"~\/ED
(1)
(2)
(3)
Single Family Residence __
Business/Organizalion ~
Government: State Federal
MAY,,-,~ 1
B.
OENR•LAND OU~LITY
WF.LI, OWNER -For single family residences list the property ownct(s). For all othai.ORMWtrl'E.8fA'JiG MITTfi•.!G
business. organi;r.ation, or g(wemment agency !llil_ person delegated signature authority:
Municipal __ County __
Saxoh Place LLC
Mailing Address: __ 2_9_1_8A_M_a_rt_i_n_sv_i_ll _e _R_o_a_d ____________________ _
Ciry: ___ G_r_ee_n_s_b_o_r_o ___________ _ State: NC Zip Code: __ 274_0_8 __ _
Ph#: ___ 3_3_6._3_89_.9_9_9_2 ____ _ EMAIL: __ m_a_tt_@_e_v-o_lv_e_c_o_s_.c_o_m _________ _
C. WELL FACILITY
(I) Name of Facility: Saxon Place Infiltration Trench Buildimz #3
(2) Physical Address: __ 3_5_2_5_L_a_n_c_e_lo'-'t_L...;.a_;_n...;.e ___________________ _
City: WIimington State :~ Zip Code: __ 2_8_4_03 ____ _
(3) Facility Location Identified By {check one):
(X] Allu\;hctJ fa\;ility :;it!.l nrnp with prop,;ny l>ound11tics, or
{ ] Geographic Coordinates: Latitude: ________ Longitude: _______ _
Reference Datum: _______ Position Accumcy: __________ _
Method of Data Collection: ________________________ _
D. WELL STATUS-indicate the status of the well or well system (choose one):
_X __ Proposed ___ Active ___ lnactive ___ Temporarily Abandoncd_Permanently Abandoned
UIC S1onnna1cr fnje'Cliun Notificatiun Fomt (Rcvised &i'8f1013) RECEIVED
MAY 2 8 2020
NCDEQJOWR
Central Office
rage 1
E. SIGNATURES — The following section is td be completed as required below or by that person's authorized
agent. ISA NC AC 02C .02I 1 i e t requires signatures as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
(c) for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
(d) for all others; by the well owner;
(e) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification that clearly identifies the person, grants them signature
authority, and is signed and dated by the applicant.
"I hereby cert, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appur& names in uew7 lance with the ISA NGAC 02C 0200 Rules. "
Signature of Pro
pplica nt
C6]i/e5-/ePI- Y
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit one copy of the completed notification package to:
DWR — Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone] I Fax: [phone]
1JIC Stormwater Injection Notification Form
(Revised 81S/20131 Page 2