SW4170601_CURRENT PERMIT_20170725

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
Sw 41Z�j
DOC TYPE
CURRENT PERMIT
APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE�`"�U�a�
YYYYMMDD

Energy, Mineral &
Land Resources
ENVIRONMENTAL QUALITY
Mr. Jeffery Lang
Teramore Construction, LLC
1970 Derita Road
Concord, North Carolina 28027
June 16, 2017
Subject: Stormwater Permit No. SW4170601
Dollar General, Belews Creek, NC, Forsyth County
Dear Mr. Lang:
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
TRACY DAVIS
Director
N C Department of
Environmental Quality
Received
JUL 2 5 2017
Winston-Salem
Regional Office
The Division of Energy, Mineral, and Land Resources (DELMR), received a complete Stormwater
Management Permit Application for the subject project on July 20, 2017. Staff review of the plans and
specifications has determined that the project, as proposed, will comply with the Stormwater Regulations
set forth in Title 15A Section NCAC 2H.1000. We are forwarding Permit No. SW4170601, dated July 21,
2017, for the construction, operation and maintenance of the subject project and the stormwater system.
This permit shall be effective from the date of issuance until July 20, 2025, or until rescinded and shall be
subject to the conditions and limitations as specified therein, and does not supersede any other agency
permit that may be required.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing by filing a written petition with the Office of Administrative Hearings
(OAH). The written petition must conform to Chapter 150B of the North Carolina General Statutes. Per
NCGS 143-215(e) the petition must be filed with the OAH within thirty (30) days of receipt of this
permit. You should contact the OAH with all questions regarding the filing fee (if a filing fee is required)
and/or the details of the filing process at 6714 Mail Service Center, Raleigh, NC 27699-6714, or via
telephone at 919-431-3000, or visit their website at www.NCOAH.com. Unless such demands are made
this permit shall be final and binding.
This project will be kept on file at the Winston-Salem Regional Office. If you have any questions, or
need additional information concerning this matter, please contact Mike Randall at [phone]; or
[e-mail].
Sincerely, 1i
for Tracy E. Davis, PE, CPM, Director
cc: SW4170601 File, Winston-Salem Regional Office
cc: Justin Church, BREC, PA
Nothing Compares�
SState of North Carolina I Environmental Quality I Energy, Mineral and land Resources
512 N. Salisbury Street 11612 Mail Service Center I Raleigh, North Carolina 27699-1612
919 707 9200

State Stormwater Permit
Permit No. SW4170601
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
Dollar General, Belews Creek, North Carolina
Forsyth County
FOR THE
construction, operation and maintenance of a Sand Filter 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 June 15, 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 Sand Filter 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 within a 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 Sand Filter.
5. The built -upon areas associated with this project shall be located at least 30 feet landward of
all perennial and intermittent surface waters.
6. The inlets shall be designed to protect the Sand Filter from erosion resulting from stormwater
discharges. The outlets of the Sand Filter shall be designed so that they do not cause
erosion immediately downslope of the discharge point during the peak flow from the 10-year
storm event as shown by engineering calculations.
It. SCHEDULE OF COMPLIANCE
During construction, erosion shall be kept to a minimum and any eroded areas of the system
will be repaired immediately.
2. SCMs that allow stormwater to infiltrate shall not be located on or in areas with contaminated
soils.
Page 1 of 4

State Stormwater Permit
Permit No. SW4170601 '
3. 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 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.
4. The Sand Filter shall be maintained in a manner that results in a drawdown of at least two
inches per hour at the sand surface. When the filtering capacity has diminished below this
level, then remedial actions shall be taken.
5. Records of maintenance activities must be kept for the Sand Filter. The reports will indicate
the date, activity, name of person performing the work and what actions were taken. The
owner shall keep maintenance records and these shall be available upon request by the
party responsible for enforcing the stormwater program under which the SCMs were
approved.
6. The permittee shall submit an annual summary report of the maintenance and inspection
records for the Sand Filter. The report shall summarize the inspection dates, results of the
inspections, and the maintenance work performed at each inspection.
7. The Sand Filter shall be constructed in accordance with the approved plans and
specifications, the conditions of this permit, and with other supporting data.
8. 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 Sand Filter 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.
9. SCMs impacted by sedimentation and erosion control during the construction phase shall be
cleaned out and converted to its approved design state.
10. 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.
Page 2 of 4

State Stormwater Permit
Permit No. SW4170601
11. 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.
12. The Director may notify the permittee when the permitted site does not meet one or more of
the minimum requirements of the permit. Within the time frame specified in the notice, the
permittee shall submit a written time schedule to the Director for modifying the site to meet
minimum requirements. The permittee shall provide copies of revised plans and certification
in writing to the Director that the changes have been made.
13. All SCMs and associated maintenance accesses on privately owned land shall be in
permanent recorded easements. The Sand Filter shall be shown and labeled within the
easement. These easements shall be granted in favor of the party responsible for enforcing
the stormwater program under which the Sand Filter was approved. The Sand Filter must
have access and maintenance easements to provide the legal authority for inspections,
maintenance personnel and equipment. The entire footprint of the Sand Filter must be
included in the access and maintenance easement, plus an additional ten or more feet
around the Sand Filter to provide enough room to complete maintenance tasks. This SCM
system includes the side slopes, forebay, riser structure, SCM device, and basin outlet, dam
embankment, outlet, and emergency spillway.
14. 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. , I I. • , .
III. GENERAL CONDITIONS
This permit is not transferable except after notice to and approval by the Director. In the
event of a change of ownership, or a name change, the permittee must submit a completed
Name/Ownership Change form 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.
1
2. The permittee is responsible for compliance with all permit conditions until 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 all statutes,
rules, regulations, or ordinances, which may be imposed by other government agencies
(local, state, and federal) having jurisdiction.
5. In the event the Sand Filter fails 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 to inspect 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.
Page 3 of 4

State Stormwater Permit
Permit No. SW4170601
Unless specified elsewhere, permanent seeding requirements for the stormwater control
must follow the guidelines established in the North Carolina Erosion and Sediment Control
Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference and are
enforceable parts of the permit.
10. The issuance of this permit does not prohibit the Director from reopening and modifying the
permit, revoking and reissuing the permit, or terminating the permit as allowed by the laws,
rules and regulations contained in Session Law 2006-246, Title 15A NCAC 2H.1000, and
NCGS 143-215.1 et.al.
11. The permittee shall notify the Division 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 211h day of July, 2017.
for Tracy E. Davis, P. ff., CPM
Director Division of Energy, Mineral, and Land Resources
Page 4 of 4

State Stormwater Permit
Permit No. SW4170601
Teramore Construction, LLC
Dollar General, Belews Creek, North Carolina
Forsyth County
Designer's Certification
I, , as a duly registered
North Carolina, having been authorized to observe (periodically/ weekly/
full time) the construction of the project,
(Project Name)
in the State of
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 Winston-Salem Regional Office
Page 1 of 1

DEMLR USE ONLY
Date Received
Fee Paid,
Permit Number
_.
i
I
Applicable Ru es:I
Coastal SW -1995 ❑ 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:
14L Uepdr UrlenL OI
State of North Carolina Environmental Quality
Received
Department of Environment and Natural Resources JUL 2 5 2017
Division of Energy, Mineral and Land Resources
L^rtrston-Salem
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This forru may be photocopied for use as an original Regional Gt--t``;
I. GENERAL INFORMATION
t
1. Project Name (subdivision, facility, or establishment name - should be consistent with projec�na e on r'
specifications, letters, operation and maintenance agreements, etc.):
Dollar General - Belews Creek, NC
2. Location of Project (street address):
City:Belews Creek
A
3. Directions to project (from nearest major intersectioh�
DENR•LAND QUALITY
Head North on US 158, take a slight left on to Belews Creek Road. Property israp �xy 4ples:P"iy LU9eft.
—�. r it
You will pass Charity Baptist Church and the property is located at the intersection of HWY 65 & Belews
4.
of the main entrance to the project.
it. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tReneu,als zoilh modifications also requires SWU-102 - Renetoal Application Forur
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/Eros ion Control: 3.45 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:Erosion Control applied for with City of Winston Salem/Forsvth
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VL httl2://12ortal.ncdenr.org/web/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page I of 6

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/Organ ization:Teramore Construction LLC
Signing Official & Title:leffrey Lang
b.Contact information for person listed in item la above:
Street Address:1970 Derita Road
City:Concord State:NC Zip:28027
Mailing Address (if applicable):
Phone: (229 ) 516-4289
Email:ilang©teramore.net
State: Zip:
Fax: (229 ) 5164229
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:Carolyn Russell & Dianne Lane
Signing Official & Title:Carolyn Russell & Dianne Lane
b.Contact information for person listed in item 2a above:
Street Address:PO Box 553
City:Vanceboro State:NC Zip:28586
Mailing Address (if applicable):
City:
Phone: ( ) N
Email:N/A
Fax: (N/A )
3. a. (Optional) Print the name and title of another contact such as the projects construction supervisor or other
person who can answer questions about the project:
Other Contact Person/ Organ ization:BREC. PA
Signing Official & Titleaustin 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
Email:[e-mail]
Fax: (336 ) 609-7726
4. Local jurisdiction for building permits: City of Winston Salem/Forsyth County
Point of Contact:Fred Holbrook Phone #: (336 ) 727-2328
Form SWU-101 Version Oct. 31, 2013 Paget of

<, IV..". PROJECT 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 Roanoke River basin.
4. Total Property Area: 3.1 acres
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area':3.1 acres
Total project area shall be calculated to exclude the follozving the normal pool of innpounded structures, the area
between the banks of streams and rivers, the area below the Nornol High Water (NM line or Mean High Water
(MHW) line, and coastal zoetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BLIA). Non -coastal zoetlands landward of tlne NHW (or MHW) lime limy
be included in the total project area. Q 11 -2 5 1-
8. Project percent of impervious area: (total Impervious Area / Total Project Area) X 100 = 3.1=23.0 %
9. How many drainage areas does the project have?1 (For high density, count 1 for each proposed engineered
stormzater BMP. For lozv density and other projects, use 7 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
Draina >e Area 1
Drainage Area _
Drainalze Area _
Drainage Area _
Receiving Stream Name
West Belews
Creek
Stream Class *
C
Stream Index Number *
22-27-9-(3)
Total Drainage Area (sf)
57,719
On -site Drainage Area (sf)
55,975
Off -site Drainage Area (sf)
1,744
Proposed Impervious Area'* s
37,039
% Impervious Area** total
23.0
Impervious- Surface Area
Draina e Area 1
Draina e Area _
Draina e Area _
Draina e Area _
On -site Buildings/Lots (sf)
9,301
On -site Streets (so
0
On -site Parking (sl)
18,155
On -site Sidewalks (sO
1,873
Other on -site (so
0
Future (so
0
Off -site (so
1,710
Existing BUA*** (so
0
Total (so:
31,039
' Stream Class and Index Number can be determined at: ham://portal.acdenr.or hoq�eblzoq&s/csu/classiflcations
" In ervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
si pezvalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 of

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 neeo BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. Field Survey
Projects in Union Countv: Contact DEMLR CentralOffrce 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 t 5A NCAC 028.0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from http://vortal.ncdetir.ore/web/wu/ws/su/bmv-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 dots. 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 at http://portal.ncdennorg/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/wg/ws/su/statesw/forms does.
iti Is
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 Vll 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.envhelp.org/pages/onestopexpress.htmI 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.) n
5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor �( `p
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 VLJC.
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the 1/2
mile radius 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.
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.
I. 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.
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

h. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify / C
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 subrmittal, [phone].1 c
10. A copy of the most current property deed. Deed book: I 7'q Page No: 5'
ation from the NC
nd positions held
NCAC 21-1.1003(e).
ing with the NC
11. For corporations and limited liability corporations (LLC): Provide document
Secretary of State or other official documentation, which supports the titles a
by the persons listed in Contact Information, item la, 2a, and/or 3a per 15A
The corporation or LLC must be listed as an active corporation in good stand
Secretary of State, otherwise the application will be returned.
htto:/ /www.secretarv.state.nc.us/Corporations/CSearch.aspx
VIL DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided
as an attachment to the completed and notarized deed restriction form. The appropriate deed restrictions and
protective covenants forms can be downloaded from http'//12ortal.ncdenr.org/web/Ir/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.
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:Justin C. Church
Consulting
Mailing Address:126 Executive Drive - Suite 220
City:Wilkesboro State:NC Zip:28697
Phone: (336 ) 8444088
Email:[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 hype nmue of person listed in Contact Information, itenn 2a) Carol lit Russell & Dianne Lane , certify that I
own the property identified in this permit application, and thus give permission to (print or type naive of person
listed in Contact Information, item la) Jeffrey Lang with (print or type name of organization listed in
Contact Information, item la) Teranmre 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 permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement
action including the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Date:
1, a Notary Public for the State of County of
do hereby certify that personally appeared
before me this _ day of
and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expi
X. APPLICANT'S CERTIFICATION
I, (print or type mate of person listed in Contact Information, item 1 a) Termeore Construction LLC - le rey 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.
Da
a Notary Public for the State of . County of
do hereby certify that
before me this _ day of
personally appeared
, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6

of Forsyth County, State of North Cerolinn,;�•�i�>a_ot the Boat ysst, to. _C..,
Jane C. Neal
;ouity..
State of North Carolina, partd Pa of the wand'part; Witneasetb That tba--said par!_S2S_ of the first p4rC in tun-
'aideration of (j IO. Cn A- oVi: Ten ➢ Mara a_nd other valuable considerations to
them paid by the said pew s of the cecond part, the receipt of wbicli is hereby acknowledged,baqftave '
bargained and sold, and by these presents do_ bargain,'seS and convey onto; the said I art i es of.,the, second
. part and their heirs a tract or parcel of land in the County of Forsyth and State of North Carolina, in
Pelet+s Creek Township, adjoinins'the landsof
-d others, and bounded as follows:
Lot No. Y6 as shown on the Plat of the property of the
J. G. Neal Estate (Sec. 1), recorded in .Plat Book 17,
page 195, office of Register d Deeds, Forsyth County,
Atorth Carolina.
The above land was conveyed to acantoe bTheirS of J. G. Neal See Hook bt-LE pans 116. L-
TO RAVE AND TO HOLD the afonrid tract or parcel of taod ad W Fdvil"aa and apPDAeata<n thaemte bdangina to tb Wd
pay* t -F. of the second an and rdgoe feeavet.
And the Wd D•w ie5 0[ tio- SnL Dart M mvemnt tha. they viv/an aeixed d add ptm3aes In fee and
t':aVe the dgbt Yo comer the acme to fee ample; that the tame are Sva from Ine®betem; and that thev
will warrant and defend the We tale to the mme'agatmt.the cLima of all peeam vd atameer.
IN TESTIMONY WREitEOF the Wd D if e ° of the fM n-- have h ate.
— a9d eat
Seal
-re
.�3'T�'X--":..
F"NOAT I U'Lli1}�IS Fonith Gary
I' a Noto> PabHo of Forsyth Comty, Noeth Cnolim, do bepby a -WY
T^l-SrvyP'.^,j?e11' ad ht. w;fe Neva L. Neal
aaekC, rahaagy ap9eared before me thie day and achnawledged the esecatlan of the foregoing dud d wniayaee
E . • it, j b aotniol coat W. the /O !L day his" i456
-_j!y eummbaioa izp 195 Netay pabik
9•
. &E,pF',NORTH CAROIINA—Fao>tb Cemty
I, • etar> Pabik of Fonytb Cooaty,`No tbCaroifm, do hereby c dfy
. that and hie wife
gnntore, eaele W.Aally a9Mared bdon me thh day aad aclmowledgW the eseeeda. of the feragdm.deed of emvganea.
Witeex to, had and aoaadal .1 Oda the day of ro
N to.hod.n 19 Paws"
STATE OF NORTH CAROLINA Cn y
The fangolnr "rdloata a t Notary,P.M. of Foeytb'CmAy. .
North Groom,
h (�0!0}�0t-e.0ood9d to ha correct Let tho rid &kd and r41ia4 b j_✓/
Gy hand this A- a.y 14` .
'PrvMa'A. Sac paid - Ck* Roamk. o:t
No
FOed for ngtabatlw
aW ddy r .dW to tba ono 9 tba Raghter d-Daada at Vw ri f;odt," N.'C.'�m DaW`

- Operation & Maintenance Aqreement
Project Name: I Dollar General Belews Creek :. Environmental Quality
Rnroivo,i
Project Location: INC Hwy 65 Belews Creek, NC II II 9 5 9n17
Maintenance records shall be kept on the following BMI'(s). I his maintenance record shall be Kept in a loggin_ail<nownsel
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 & corresponding O&M tables wil
Bioretention Cell Quantity:
Dry Detention Basin Quantity:
Grassed Swale Quantity:
Green Roof Quantity:
Infiltration Basin Quantity:
Infiltration Trench Quantity:
Level Spreader/VFS Quantity:
Permeable Pavement Quantity:
Proprietary System Quantity:
Rainwater Harvesting Quantity:
Sand Filter Quantity:
Stormwater Wetland Quantity:
Wet Detention Basin Quantity:
Disconnected Impervious Area Present:
User Defined BMP Present:
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s),
Location(s):
Location(s):
1
0
No
No
I 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 or prior to any
changes to the system or responsible party.
Responsible Party:
Title & Organization:
Street address:
City, state, zip:
Phone number(s):
Email:
Jeff Lan
Member, Teramore Construction, LLC
1970 Derita Road
Concord, NC 28027
229.516.4289
[e-mail]
County of
personally appeared before me this
acknowledge the due execution of
Witness my hand and official seal,
a
do
dad
—, t0.(-t
Maintenance Agreement.
N
EXPIRES
GEnRGIA
MNRLH 16. 2021
Version 1.4
My commission expires 6/16/2017
"„n WD 1 20 Page l of 3

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