SW4200702_As-Built Certification_20220421

State Stormwater Management
Permit No. SW4200702 — Major Modification
AS -BUILT PERMITTEE CERTIFICATION
I hereby state that I am the current permittee for the project named above, and I certify by my
signature below, that the project meets the below listed Final Submittal Requirements found in NCAC
02H.1042(4) and the terms, conditions and provisions listed in the permit documents, plans and
specifications on file with or provided to the Division.
Check here if this is a partial certification. Section/phase/SCM #?
Check here if this is partofa Fast Track As -built Package Submi I. ,
Printed Name t A) f i iD nn f�t PLY 1�i5 ; } {, Signature .F�
a Notary Public in the State of t
County of 1;J L do hereby certify that IVIJ I 1 1 f')') k4, /75� Jr
—
personally appeared before me this day of / %' 20 t7
and acknowledge the due execution of this as -built certification. (SEAL)
Witness my hand and official seal AINASTASIA C. HOWARD
NOTARY PUBLIC
Forsyth County
(2L--�tr 4l (. {���%(�. North Carolina
� � J My Commission Expires December 8, 2028
My commission expires �e
Permittee's Certification NCAC .1042(4)
Completed 1
Provided
NIA
A. DEED RESTRICTIONS / BUA RECORDS
1. The deed restrictions and protective covenants have been recorded
Y or N
and contain the necessary language to ensure that the project is
maintained consistent with the stormwater regulations and with the
permit conditions.
2. A copy of the recorded deed restrictions and protective covenants
Y or N
�(
has been provided to the Division.
3. Records which track the BUA on each lot are being kept. (See Note
1
Y or N
B. MAINTENANCE ACCESS
1. The SCMs are accessible for inspection, maintenance and repair.
Y or N
2. The access is a minimum of 10 feet wide.
Y or N
3. The access extends to the nearest public right-of-way.
Y or N
C. EASEMENTS
1. The SCMs and the components of the runoff collection / conveyance
system are located in recorded drainage easements.
Y orN
2. A copy of the recorded plat(s) is provided.
Y or N
D. SINGLE FAMILY RESIDENTIAL LOTS - Plats for residential lots that
have an SCM include the following:
Y or N
X
1. The specific location of the SCM on the lot.
Y or N
2. A typical detail for the SCM.
Y or N
3. A note that the SCM is required to meet Stormwater regulations and
that the lot owner is subject to enforcement action as set forth in
Y N
NCGS 143 Article 21 if the SCM is removed, relocated or altered
or
without prior approval.
E. OPERATION AND MAINTENANCE AGREEMENT
Y or N
1. The O&M Agreement is referenced on the final recorded plat.
Y or N
2. The O&M Agreement is recorded with the Register of Deeds and
Y or N
appears in the chain of title.
F. OPERATION AND MAINTENANCE PLAN - maintenance records are
being kept in a known set location for each SCM and are available for
@or N
review.
G. DESIGNER'S CERTIFICATION FORM - has been provided to the
Division.
Y or N
Page 1 of 6

State Stormwater Management
Permit No. SW4200702 — Maior Modification
Note 1- Acceptable records include ARC approvals, as -built surveys, and county tax records.
Provide an explanation for every requirement that was not met, and for every "N/A" below. Attach
additional sheets as needed.
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Page 2 of 6

State Stormwater Management
Permit No. S 20 7 2 - Major Modification
AS -BUILT DESIGNER'S CERTIFICATION GENERAL MDC
I hereby state that I am a licensed the
and I certify by my signature and seal below, that I
have observed the construction of the project named above to the best of my abilities with all due care
and diligence, and that the project meets the below listed General MDC found in NCAC 02H.1050 in
accordance with the permit documents, plans and specifications on file with or provided to the
Division, except as noted on the "AS -BUILT" drawings, such that the intent of the stormwater rules
and statutes has been preserved.
Check here if this is a partial certification. Section/phase/SCM #?
Check here if this Is a part of a Fast -Track As -Built Package Submittal per .1044(3).
Check here if the designer did not observe the construction, but is certifying the project.
Check here if pictures of the SCM are provided.
Printed SDSSPR i4 GJtuoa.
Name Signature_ Jn
NC Registration
Number 3gS73 Date_ 2lxeiaz
SEAL: Ary
SEAL
38573 =
'>, N A G P
1111111.1111!!\1.
Consultant's Mailing Address:
l64x V. R419 QY tTCUT 4"r8 136
City/State/ZIP G,2ry AWOORo, mt. Z7401
Phone Number 336.47P.33916
Consultant's Email address:
A,daM. &Wtvil e t'MMOns. eOM
O Circle N if the as -built value differs from the Plan. If N is circled, provide an explanation on Page 2.
ON/E = not evaluated (provide explanation on page 2) ON/A = not applicable to this SCM or project.
Consultant's Certification NCAC .1003((3) & General MDC
.1050
TAs-built
ON/E
ON/A
A. TREATMENT REQUIREMENTS
1. The SCM achieves runoff treatment.
or N
2, The SCM achieves runoff volume match..
or N
3, Runoff from offsite areas and/or existing B A is
or N
b assed.
. unoff from offsite areas an /or ex! stingBUA i1-3 rected
Y or N
into the permitted SCM and is accounted for at the full
X
build -out potential.
5. The project controls runoff through an offsite permitted
Y or N
SCM that meets the re uirements of the MDC.
X
6. The net area of new BUA increase for an existing project
Y or N
has been accounted for at the appropriate design storm
K
level.
7. T e SCM(s) meets all the specific minimum design
or N
criteria.
B. VEGETATED SETBACKS / BUA
1. The width oft the vegetated setback has een measured
Y or N
from the normal pool of impounded waters, the MHW
line of tidal waters, or the top of bank of each side of
X
rivers or streams.
2. The vegetated set ac is maintained in grass or other
Y or N
ve etation.
k
3: BUA that meets the requirements of N GS 143-2 4.7
Y or N
X
b2 2 is located in the setback.
Paqe 3 of 6

State Stormwater Management
Permit No S)N4200702 — Maior Modification
4. BUA that does not meet the requirements of NCGS 143-
Y or N
214.7 (b2)(2) is located within the setback and is limited
to:
a. Publicly funded linear projects (road, greenway
sidewalk)
X
b. Water -dependent structures
c. Minimal footprint uses (utility poles, signs, security
lightingyand appurtenances)
5. Stormwater that is not treated in an SGM is released at
Y or N
the edge of the setback and allowed to flow through the
X
setback as dispersed flow.
OAs-built
ON/E
ON/A
C. STORMWATER VUT ET — the outlet handles the peak
or N
flow from the 10 ear storm with no downslo a erosion.
D. VARIATIONS
1. A variation (alternative) from the stormwater rule
rovisions has been im lemented,
Y or N
a(
2. The variation provides equal or better stormwater control
and a ual or better rotection of surface waters.
Y or N
x
LI NCE WITH ER REGULATORY PROGRAMS
has been met.
©or N
F. SIZINd -the volume of the SCM takes the runoff from all
surfaces into account and is sufficient to handle the required
0 or N
storm de
CONTAMINATED
G. AMI ILS — infiltrating M"s are not
Y or N
x
located in or on areas with contaminated soils.
H. SIDE SLOPES
1. Vegetated side slopes are no steeper than 31­1:1 V.
or N
2. Side slopes include retaining walls, gabion walls, or
Y or N
other surfaces that are stee er than 3H:1 V.
k
3. Vegetated side slopes are steeper than 3H:1 V (provide
Y or N
supporting documents for soils and ve etation .
k
I. EROSION PROTECTION
1. The inlets do not cause erosion in the SCM.
CYJ or N
2, The outlet does not cause erosion downslope of the
or N
discharge point during the peak flow from the 10 year
storm.
XC SS FLOWS — An overflow / bypass has been
N
provided.
or
K. DEW ' RI G - A method to drawdown standing water has
or N
been provided to facilitate maintenance and inspection.
L. ULUNOUT AFTER C-0—NMUCTION—t the SCM has been
or N
cleaned out and converted to its approved design state.
M. MAINTENANCE ACCESS
1. The SCM is accessible for maintenance and repair.
or N
2. The access does not include latera or incline slopes
or N
>3:1.
N. DESIGNER IF[CATIONS (FAST -TRACK PERMIT)—
The designer is licensed under Chapters 89A, 89C, 89E, or
Y or N
X
89F of the General Statutes.
Provide an explanation for every MDC that was not met, and for every item marked "N/A" or "WE",
below. Attach additional pages as needed:
Page 4 of 6

State Stormwater Management
Permit No, 284200702 — Major Modification
AS -BUILT DESIGNER'S CERTIFICATION FOR BIORETENTION CELL PROJECT
I hereby state that 1 am a licensed professional and 1 certify by my signature and seal below, that I
have observed the construction of the project named above to the best of my abilities with all due care
and diligence, and that the project meets all of the MDC found in NCAC 02H.1056, In accordance with
the permit documents, plans and specifications on file with or provided to the Division, except as
noted on the "AS -BUILT" drawings, such that the intent of the stormwater rules and the general
statutes has been preserved,
Check here if this is a partial certification. Section/phase/SCM #?
Check here if this is part of a Fast -Track As -Built Package Submittal per .1044(3).
Check here if the Designer did not observe the construction, but is certifying the project,
Check here if pictures of the SCM are provided, tt
Printed Name ,104SPN A z4Xaott Signature
NO Registration Number 3f1S73 Date 312011ZZ
SEAL: tsyfinnurrrt,,rr
.� CAP ..
_ SEAL
38573
<" 3.29- v
�Fp NC) H NEB ••Rp ; g
A. C is \\'
��rf�frrriir+r''�\
Consultant's Mailing Address:
f;642 IW, AAXKIY SrXsET, twr8 rib
City/State/ZIP a2EE+yS401E0, Nt aYao4
Phone Number 336, 0410'.3346
Consultant's Email address:
AdAM C*Vnll6� rarnont. ua,
O Circle N if the as -built value differs from the Plan/permit. If N is circled, provide an explanation on
paggMe 2
E = not evaluated (provide explanation on page 2) ©N/A = not applicable to this project or'SCM.
This Certification must be completed in conjunction with the General MDC certification under NCAC
02H.1050
Consultant's Certification (MDC .1056)
OAs-built
OO N/E
(3)N/A
A. Volume / Elevations
, The lowest point of the bioretention cell Is a minimum of two
® N
feet above the SHWT.
or
2. If separation from the SHWT is between one and two feet a
hydrogeological evaluation has been prepared by a licensed
Y or N
X
professional.
3, The surface area and depth of the bioretention cell is
consistent with the approved cans.
or N
4. 1 he planting surface elevation of th-6-15loretention cell fs
®or N
consistent with the a roved plans,
. The ponding depth, forthe design volume is consistent with
or N
the approved plans and a maximum of 12 Inches above the
plantinq surface.
S. If applicable, the pon ing epth tof t e peak attenuation
Q9 or N
volume is consistent with the approved plans and a
maximum of 24 inches above the planting surface.
7. applicable, the peak attenuation outlet invert is consistent
or N
with the approved plans and a maximum of 18 inches above
the lantin surface.
8. B oretention call with IW — n under rain system with IWS
has been provided, The top of the IWS zone is consistent
O N
with the approved plans and a minimum of 18 inches below
or
the planting surface.
9. Bioretention cell without IWS -- he n-situ so inf ttratlon rate
is at least two inches per hour immediately prior to the initial
[Y:or N
1)C
Placement of media.
Page 5 of 6

State Stormwater Management
Permit No SW420a7O2 — Major Modification
10. At least one capped clean -out pipe has been provided at the
or N
lowpoint of each underdrain.
B. Media
1. The depth of the media is consistent with the approved plans
and specs and is a minimum of...
- 36 inches for cells with trees & shrubs.
® or N
- 30 inches for cells without trees & shrubs and IWS.
- 24 inches for cells without trees & shrubs and no IWS.
2. The media Is consistent with the approved plans and specs
and is a homogeneous soil mixture consisting of...
- 75 — 85 percent by volume medium to coarse washed sand.
n or N
- 8 —15 percent by volume fines.
ercent by volume organic matter.
3. he media has a phosphorous index (P-index) that does not
exceed...
- 30 in Nutrient Sensitive Waters (NSW).
or N
- 50 elsewhere.
4. The media has not been mechanical)
com acted.
or N
5. The media provides a minimum drawdown of one inch per
O or N
hour at the lantIn surface.
C. Landsca a/Plantin Plan
1 . Bioretention cell with sod — The sod is a non -clumping, deep-
or N
rooted s ecies.
2. Bioretention cell with veggetat on other than sod — The
Y or N
k
roved landscaping tan has been followed.
approve
1ioretention cell with vegetation other than sod — Triple
shredded hardwood mulch is placed two to four inches deep
Y or N
X
in the portion of the Bioretention cell that will be inundated.
rroviae an explanation for every MOO that was not met, or for every deviation from the permitted
condition below:
Page 6 of 6