SW3170901_CURRENT PERMIT_20180220

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
DOC TYPE CURRENT PERMIT
APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE���
YYYYMMDD

State Stormwater Permit
Permit No. SW3170901
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT QUALITY
STATE STORMWATER MANAGEMENT PERMIT
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
Teramore Construction, LLC
o �
for Dolla; General — #18434 0� 0;, of
120 Grace Church Road, Salisbury NC
Rowan County ago P
FOR THE
construction, operation and maintenance of the 1 Stormwater Control Measures (SCM) in
compliance with the provisions of 15A NCAC 2H .1000 (hereafter referred to as the
"stormwater rules') and the approved stormwater management plans, specifications and
other supporting data as on file with and approved by the, State and considered a part of
this permit.
This permit shall be effective from the date of issuance until October 31, 2025, and shall be
subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. The SCM is approved for the management of stormwater runoff as described in the
application documents and as shown on the approved plans.
3. 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.
4. The runoff from all built -upon area within the permitted drainage area of this project
must be directed into the SCM.
5. The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
II. SCHEDULE OF COMPLIANCE
During construction, erosion shall be kept to a minimum and any eroded areas of the
system will be repaired immediately.
2. The permittee shall at all time provide the operation and maintenance necessary to
assure every SCM functions at optimum efficiency. The approved Operation and
Maintenance Plan must be followed in its entirety and maintenance must occur at
Page 1 of 4

State Stormwater Permit
Permit No. SW3170901
the scheduled intervals including, but not limited to
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and re -vegetation of slopes and the filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
f. Debris removal and unclogging of all drainage structures, level spreader, filter
media, planting media, underdrains, catch basins and piping.
q. Access to the cell and outlet structure must be available at all times.
3. Records of maintenance activities must be kept for the SCM. The reports will
indicate the date, activity, name of person performing the work and what actions
were taken.
4. The permittee shall submit an annual summary report of the maintenance and
inspection records for the SCM. The report shall summarize the inspection dates,
results of the inspections, and the maintenance work performed at each inspection.
5. The SCM shall be constructed in accordance with the approved plans and
specifications, the conditions of this permit, and with other supporting data.
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 SCM certifying that it 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.
SCMs impacted by sedimentation and erosion control during the construction phase
shall be cleaned out and converted to its approved design state.
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 was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
9. A copy of the approved plans and specifications shall be maintained on file by the
Permittee for a minimum of eight years from the date of the completion of
construction.
10. 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
Page 2 of 4

State Stormwater Permit
Permit No. SW3170901
have been made.
11. SCMs that allow stormwater to infiltrate shall not be located on or in areas with
contaminated soils.
12. Plats for residential lots that contain SCMs shall include: the specific location of the
SCM on the lot; a typical detail for SCM to be used; and a note that the SCM on the
property has been required to meet stormwater regulations and that the property
owner may be subject to enforcement procedures as set forth in G.S. 143, Article 21
if the SCM is removed, relocated, or altered without prior approval.
13. The O&M Agreement shall be referenced on the final plat and shall be recorded with
the county Register of Deeds upon final plat approval. If no subdivision plat is
recorded for the site, then the O&M Agreement shall be recorded with the county
Register of Deeds so as to appear in the chain of title of all subsequent purchasers.
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 signed by both parties, to the State,
accompanied by the supporting documentation. 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 a request to transfer the permit.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the State, 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, regulations, 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 DEQ Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
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.
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.
Approved plans and specifications for this project are incorporated by reference and
are enforceable parts of the permit.
Page 3 of 4

State Stormwater Permit
Permit No. SW3170901
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 in writing 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 31 th day of October 2017.
0%4,w d Q' wa 4 R"axd Z Rcdde, Pi,
or Tracy E. Davis, P.E., CPM
Director Division of Energy, Mineral, and Land Resources
Page 4 of 4

State Stormwater Permit
Permit No. SW3170901
Dollar General-#18434
120 Grace Church Road, Salisbury NC
Rowan 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 Name)
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.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
cc: NCDEQ-DEMLR Regional Office
Page 1 of 1

DEMLRUSE ONLY
D4 Re
ived
Pc it Number
Applicable Rules:
❑ Coastal SW -1995 11 Coastal SW - 2008 ❑ Ph 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 pi Jd
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
I. GENERAL INFORMATION t
1. Project Name (subdivision, facility, or establishment name - should be consistent with project name on
specifications, letters, operation and maintenance agreements, etc.): o < C` IL s�
oD
Dollar General - Salisbury, NC 0,�d
2. Location of Project (street address):
City:Salisbury County:Rowan AJ.lyo-n n,"v"IRK
pl 4
3. Directions to project (from nearest major intersection):
O
�O
4. Latitude:35° 36' 55" N Longitud/e:80° 32' 10�"yW� of the main entrant to the project.
II. PERMIT INFORMATION: 35 , I 51 J V
1. a. Specify whether project is (check one): ® ew ❑Modification ❑ Renewal w Modification+
iRenewals with modifications also requires SIIVU-102 - Renemnl Application Fonn
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit numberN/A , 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
DEMLR requesting a state stormwater management permit application, list the Stormwater project number,
if assigned, N/A and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major ®Sedimentation/Erosion Control: 1.50 ac of Disturbed Area
❑NPDES Industrial Stormwater ❑404/401 Permit: Proposed Impacts
b.lf any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit:Erosion Control applied for with Rowan County.
5. Is the project located within 5 miles of a public airport? [�gNo "Ye
If yes, see S.L. 2012-200, Part Vl: htto://12ortal.ncdenr.org/web/Ir/rules-and-regulations
Fonn SWU-101 Version Oct. 31, 2013 Page I of

ill. CONTACT INFORMATION
I. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization:Teramore Construction, LLC
Signing Official & Titlejeffrey Lang_
b. Contact information for person listed in item 1 a above:
Street Address:1970 Derita Road
City:Concord
Mailing Address (if applicable):
City:
Phone: (229 ) 516-4289
Email:ilanQflteramo re.net
State:NC Zip:28027
Fax: (229 ) 516-4229
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/Organ izahon:Teramore Development, LLC
Signing Official & Title:losh Hufstetler
b.Contact information for person listed in item 2a above:
Street Address:165 Big Star Drive
City:Thomasville State:GA Zip:31757
Mailing Address (if applicable):PO Box 6460
City:Thomasville
Phone: (229 ) 516-4289
Email:[e-mail]
State:GA Zip:31758
Fax: (229 ) 516-4229
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: BREC, PA
Signing Official & Title:iustin C. Church - Principal Engineer
b. Contact information for person listed in item 3a above:
Mailing Address:126 Executive Drive - Suite 220
City:Wilkesboro State:NC Zip:28697
Phone: (336 ) 844-4088 Fax: (336 ) 609-7726
Eniail:[e-mail]
4. Local jurisdiction for building permits: Rowan County
Point of Contact:Thomas O'Kelly Phone #: (704 ) 216-8619
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

JV. PROJ$CT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
An above ground sand filter will be used to treat runoff from all impervious surfaces of a proposed
9,100 sq. ft. Dollar General store.
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 II - Post Construction
3. Stormwater runoff from this project drains to the Yadkin Pee Dee River basin.
4. Total Property Area: 1.47 acres
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+:1.47 acres
Total project area shall be calculated to exclude the followiug the normal pool of impounded structures, the area
between the banks of streanns and rivers, the area below the Nonual High Water (NHW) line or Meat High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward of tlue NHW (or MHW) lithe may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 51.7
9. How many drainage areas does the project have?1 (For high density, count I 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
Drainage Area _
Drainage Area _
Receiving Stream Name
Grants Creek
Stream Class *
C
Stream Index Number *
12-110
Total Drainage Area (so
66213
On -site Drainage Area (sf)
50580
Off -site Drainage Area (sf)
15633
Proposed Impervious Area** s
33095
Impervious Area** (total)
50
Impervious** Surface Area
Drainage Area 7
Drainage Area
Drainage Area
Drainage Area _
On -site Buildings/Lots (so
9301
_
On -site Streets (so
0
On -site Parking (so
22270
On -site Sidewalks (so
1524
Other on -site (so
0
Future (so
0
Off -site (sf)
0
Existing BUA*** (so
0
Total (so:
33095
Strewn Class and Index Number can be determined at: httq://portaLucdetnr.or veb uq/ps/cstu/classiftrntiotts
Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Report only that amount of existing BUA dust will remain after development. Do not report sty existing BUA dint
is to be removed and which eoill be replaced by new BUA.
Form S WU-101 Version Oct. 31, 2013 Page 3 of 6

11. How was the off -site impervious area listed above determined? Provide documentation. Field Survey
Pro iects in Union County: Contact DEMLR Central Office sta fto check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements as per I5A NCAC 0213.0600.
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 httv://oortal.ncdenr.ore/web/wa/ws/su/bmo-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
http://portal.ncdenr.org/web/wq/ws/su/statesw/forms does. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map athttp://portal.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://portal.ncdenr.org/web/wq/ws/su/statesw/forms_docs.
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
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
http:/ /www.envlielp.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 lh
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
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.
I. 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).
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

p. Vegetated buffers (where required). I
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify
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"xll" 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 DEMLR to verify the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 1287 Page No: 444,447,449
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 15A 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.
hU://www.secretaly.state.nc.us/Corporations/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 htto://portal.ncdenr.org/web/lr/state-stormwater-
forms does. 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 DEMLR, and that they will be recorded prior to the sale of any lot.
Vill. 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 Engineeraustin C. Church
Consulting Firm: BREC, PA
Mailing Address:126 Executive Drive - Suite 220
City:Wilkesboro State:NC Zip:28697
Phone: (336 ) 844-4088
[e-mail]
Fax: (336 ) 609-7726
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) Josh Hufstetler , certify that I
own the property identified in this permit application, and thus give permission to (print or type nave of person
listed in Contact Information, items 1 a) Teffreu Lang with (print or hype name of organization listed in
Contact Information, item 1a) Terarmre Construction, 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 SWU-101 Version Oct. 31, 2013 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 DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR 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 per it.is a vi lation of NC General Statue 143-215.1 and may result in appropriate enforcement
action including t e ss ssm of ci it penalties of up to $25,000 per day, pursuant to NOSS 143-215.6.
Signature: Date:
I,� nip tU� a Notary Public for the State of
i(;{ County of
Ii1t5YVtQ do hereby certify that Tnd1 personally appeared
before me this 3l day, of 1 1, and acknowledge the due execution of the application for
a stormwater permit. Witness m hand and official s ill,w
SEAL,p
Mycorn miSSiQ]lr�XF��g�+` I1-1Z-
X. APPLICANT'S CERTIFICATION
1, (print or hjpe name of person listed in Contact hifornmh'on, iteni la) Termnore Construction LLC - leffrey Lang ,
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 and any other applicable state stormwater requirements.
Signatu
Date:
1, a Notary Public for the State of County of
I Y I)AMS , do hereby certify that tIJ personally appeared
before me this 31 day of US� .moot land ackno d e the du execution of the application for
a stormwater permit. Witness my hand and official %Qaf" t
My commi5rslQrlek4*W 11— 1S —
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6

B/31M17
Corporations Division
North Carolina
Elaine F. Marshall DEPARTMENT OFTIAE
Secretary SECRETARY OF STATE
.a „�s. PO Box 29622 Raleigh,NC 27626-0622 [phone] Account
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Corporate Names
Legal: Teramore Construction, LLC
Limited Liability Company Information
Sosld:
1493493
Status:
Current -Active
Annual Report Status:
Current
Citizenship:
Domestic
Date Formed:
1/26/2016
Fiscal Month:
December
Registered Agent:
RUSSLAW, LLC
Corporate Addresses
Principal Office: 1970 Derita Road
Concord, NC 28027-3355
Reg Office: 2235 Gateway Access Point, Suite 201
Raleigh, NC 27607-3076
Reg Mailing: 2235 Gateway Access Point, Suite 201
Raleigh, NC 27607-3076
Mailing: P.O. Box 6460
Thomasville, GA 31758-6460
Company Officials
All LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20.
Manager: Jeff Lang
P.O. Box 6460
Thomasville GA 31758
Member: Teramore Development, LLC
P.O. Box 6460
Thomasville GA 31758
httpsJ/www.sasnc.gov/SeardVprofcorp/11973792 1/1

Project Name:IDollar General Belews Creek
Project Location: INC Hwy 65 Belews Creek; NC
Cover Page
'Maintenance records shall be kept on the following BMP(s). This maintenance record shall 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 pollutant removal efficiency of the BMP(s).
The BMP(s) on this project include (check all that apply
Bioretention Cell Qua
Dry Detention Basin
Grassed Swale
Green Roof
Infiltration Basin
Infiltration Trench
Level SpreaderNFS
PermeablePavement.
Proprietary System
Rainwater Harvesting
Sand Filter
St&mwater Wetland
Wet Detention Basin
Disconnected Impervious Area
User Defined BMP
Quantity:
Quantity:
I111111111orm
O&M tables will be added automaticall
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location
Location
Location(s
Location(s)*
Location(s):
Location(s):
Location(s)
Locations)
Location(s)
acknowledge and agree by my signature below that I am responsible for the performance of the maintenance procedures listed
for each BMP above, and attached O&M tables. I agree to notify NCDENR of any problems with the system orprior 'to any
changes to the system or responsible party.
' Responsible Party:
Title & Organization:
Street address
City, state, zip:
Phone number(s):
Email:
Signature:
Jeff LangT.-
Member, Teramore Construction, LLC
> z1
1970 Derita Road
v.
Concord, NC28027
229.516.4289
o t
[e-mail]
County of I Vi t7Vt/I <k.�
personally appeared before me this
acknowledge the due execution of the Operations and Maih1
Witness my hand and. official seal,
IZ O EXPIRES
CEORCr
commission expires
Date: . 9--'2-
a Notary Public for the State of
do hearbycertify that
y
day of �Q O Y/j %4C nd
9/51201;