SW5211201_Application Form_20211221 (2)

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
l:C—?_1— Q2i
I 0 O-5 Ckck # 1 35
IWSZII 1
Applicable Rules:
(select all that apply)
❑ Coastal SW -1995 ❑ Coastal SW - 2008 Ph H - Post Construction
❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal tormwater Management Plan
❑ Other WQ Mgmt Plan:
State of North Carolina
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
1. Project Name (subdivision, facility, or establishment name - should fil ect name o` plans;'=,:^
specifications, letters, operation and maintenance agreements, etc.):
Dollar General
2. Location of Project (street address): DNF-LAND duALliY
W. NC Highway 97 STORMWATER PFERMITTING
City:Middlesex County:Nash Zip:27557
3. Directions to project (from nearest major intersection):
The l,rajecl is located 431 feel from the intersectiun of NC Hwy 97 and NC Hwy 231 going eest towards Rich
Lane Street.
4. Latitude:35' 51' 35" N Longitude:78° 10' 37" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New OModification ❑ Renewal w/ Modificationt
tRenewals with modifications also requires SWU 102 - Renewal Application Form
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number , its issue date (if known) , and the status of
construction: QNot Started QPartially 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 QOther
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, 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:1.77 ac of Disturbed Area
❑NPDES Industrial Stormwater n404/401 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:
5. Is the project located within 5 miles of a public airport? []No ®Yes
If yes, see S.L. 2012 200, Part VI: http://portal.ncdenr.org/web/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6

III. 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/ Organization:Glandon Forest Equity, LLC
Signing Official & Title:George Barnes, Jr. - Member Manager
b. Contact information for person listed in item 1a above:
Street Address:3825 Barrett Drive, Suite 100
City:Raleigh State:NC Zip:27609
Mailing Address (if applicable):
City:
State:
'Lip:
Phone: (919 ) 459-2601 Fax: J919- } 459-2604
Email:gbarnes«vanguard L3a.com
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)
❑ DeveIoper* (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:Mor an. Properties, LLC
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:5904 Morgan Road
City:Bailev State:NC Zip:27807
Mailing Address (if applicable):Same
City:
Phone: (252 ) 235-4198
Email:[e-mail]
State:
Fax:
Zip:
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:GIandon Forest Equity, LLC
Signing Official & Title:George Barnes, Jr. - Member/manager
b. Contact information for person listed in item 3a above:
Mailing Address:3825 Barrett Drive Suite 100
City:Raleigh State:NC Zip:27609
Phone: (91.9 ) 459-2601 Fax: (919 } 459-2604
Email:,,-,[e-mail]
4. Local jurisdiction for building permits: Nash County
Point of Contact:Kevin Marks Phone #: (252 ) 459-9808
Fornn SWTJ-101 Version Oct. 31. 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Stormwater runoff from the developed areas of the site will be captured and treated in a stormwater wet
detention pond
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. Storm -water runoff from this project drains to the Neuse River basin.
4. Total Property Area: 2.0 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*: 2.0 acres
Total project area shall be calculated to exclude the followin the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NHW) line or Mean High Water
(MHM line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BLIA). Non -coastal wetlands landward of the NHW (or MHM line ma/
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 44.59 %
9. How many drainage areas does the project have?1 (For high density, count 1 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
Draina e Area
Drainage Area
Dxaina e Area
Receiving Stream Name
Turkey Creek
Stream Class *
QNSW
Stream Index Number
27-86-3-(1.)
Total Drainage Area (sf)
53,402
On -site Drainage Area (so
53,402
Off -site Drainage Area (sf)
0
Proposed Impervious Area** (so
38,890
% Impervious Area** (total)
72.82%
Im ery ous"' Surface Area
Drainage Area 1
Drainage Area _
Drainage` Area
Drainage Area _
On -site Buildings/Lots (sf)
10,640
On -site Streets (sf)
0
On -site Parking (sf)
26,530
On -site Sidewalks (so
1,720
Other on -site (sf)
0
Future (sf)
0
Off -site (sf)
0
Existing BUA*** (sf)
0
Total (sf):
38,890
x Stream Class and Index Number can be determined at: http://portal.ncdenr.org web/wcs/csu/classifications
x hn}�erz�ivus area is defined as the built upon area including, but not litnited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 . Page 3 of 6

'Report only that amount of existing BUA that will remain after development. Do not report any existing BL1A that
is to be removed and which will be replaced by new BLIA.
11. How was the off -site impervious area listed above determined? Provide documentation N/A
Proiects in Union County: Contact DEMLR Central Ojjice staff to check if the project is located within a Threatened &
Endangered Species watershed that maybe subject to more stringent stormwater requirements as per 15A NCAC 02B .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 htty: / /vortal.ncdennore/web/wo /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
hn://portal.ncdenr.org/web/wq/­`­ws/su/statesw/forms_docs. 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 atbgp://12ortal.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.
Initials
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
httv:/ /www.envhely.org/pages/onestol2eLcpress.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.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/management for
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the �W_
receiving stream drains to class SA waters within Y2 mile of the site boundary, include the Y2
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: Q161
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.
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).
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"x11' 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 determimng 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: 2921 Page No: 215-238
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 1a, 2a, and/or 3a per 15A NCAC 21-1.1003(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.
http://www.secretga.state-nc.us/Cprporations/CSearch.gMx
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 hU://portal.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:Matt Lowder, PE
Consulting Firm: Bowman North Carolina, Ltd.
Mailing Address:4004 Barrett Drive, Suite 101
City:Raleigh
Phone: (919 ) 553-6570
Email:[e-mail]
State:NC Zip:27609
Fax: ( 1
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) Morgan Properties, LLC ,certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed in Contact Information, item 1a) George Barnes, fr. with (print or type name of organization listed in
Contact Information, item 1a) Glandon Forest Equity, 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 incluthe assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature: ( Ja"c-,L ©i ar, Dater '
I,/ W �C7A//�C/A� a Notary Public for the State of mil' County of
, do hereby certify thatQGAQX & N _ 60AIt Jftl personally appeared
before me this �c ay of &M-AAAA , gVX , and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official s`��ti.�L�1'J
Barbara W Boykin r
AL
NOTARY PUBLIC
Nash County, NC
My Commission Expires February 12, 202 I
y p/��
M commission expires
to b
n �
r,.
o �
0
X. APPLICANT'S CERTIFICATION ® N
I, (print or type name of person listed in Contact Information, item 1a) Geor e T. Barnes F-y
certify that the information included on this permit application form is, to the best of my knowledo, correct and6
that the project will be constructed in conformance with the approved plans, that the required deRd restrictions =
and protective covenants will be recorded, and that the proposed project complies with the requirements of the
applicable stormwater rules^d%15A NCAC 2H .1000 and any other applicable state stormwater requirement`57
N'k
Date: I t o 2
County of
1'c C��1Y�Cl do hereby certify that �`rcm T o-, cu personally appeared
before me this KP day of acknowledge the due ex 6jfi-o'"n'-'bf the application for
a stormwater permit. Witness my hand and official seal,
a Notary Public for the State of
SEAL
My commission expires (X0 - CS - 23
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6