SW8080426_CURRENT PERMIT_20220727

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW8 0g0`\210
DOC TYPE
CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
20220"12-1
YYYYMMDD

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
BRIAN WRENN
Director
Jelly 27, 2022
A & K of Wilmington, LLC
Attn: Kimberly Martin, Member
6419-A Carolina Beach Road
Wilmington, NC 28412
NORTH CAROLINA
Environmental Quality
Subject: Permit Renewal
lost -Construction Stormwater Management Permit No. SW8 080426
Masonboro Family Medicine
New Hanover County
Dear Ms. Martin:
The Division of Energy, Mineral and Land Resources received a complete 8-year Permit Renewal Application for
the subject permit on July 22, 2022. The Division is hereby notifying you that permit SW8080426 has been
renewed, updated, and re -issued on July 27, 2022, as attached. A copy of the current operation and maintenance
agreement is also enclosed. Please be aware that the renewal and re -issuance of this stormwater permit does not
imply that the site is currently in compliance.
This permit shall be effective until December 31, 2029, and does not supersede any other agency permit that may
be required. The project shall be subject to the conditions and limitations as specified therein. This permit does
not impose new or increased stormwater control requirements; it clarifies the rules and requirements of this
program to provide you with a better understanding of your obligations under this permit. Failure to comply with
these requirements will result in future compliance problems. Please note that this permit is not transferable
except after notice to and approval by the Division.
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 and 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.
If you have any questions concerning this permit, please contact Ashley Smith in the Wilmington Regional
Office, at [phone] or [e-mail].
S incerely,
CPU5�tW40
,W" Brian Wrenn, Director
Division of Energy, Mineral and Land Resources
Enclosures: AttachmentC— PermittingHistory
Renewal Application Documents
Copy of the current operation and maintenance agreement
DES/ams: \\\Srormwater\Permits & Projects\2008\080426 HD\2022 07 permit 080426
cc: Wilmington Regional Office Stormwater Pile
D rl Aft � North Carolina Department of Environmental. Quality I Division of Energy, Miner -al and land Resources
�/ '�_l' /p Wilmington Regional Office 1 127 Cardinal Drive Extension I Wilmington, North Carolina 28405
��v� / / 910.796.7215

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Post -Construction Stormwater Management
Permit No. SW8 080426
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL AND LAND RESOURCES
POST -CONSTRUCTION STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
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
A & K of Wilmington, LLC
Masonboro Family Medicine
6419 Carolina Beach Rd., Wilmington, New Hanover County
FOR THE
construction, operation and maintenance of one (1) infiltration trench (hereafter referred to as
infiltration system or stormwater control measure) discharging to Class SA waters in compliance with
the provisions of 15A NCAC 2H .1000 and Session Law 2006-246 (hereafter referred to as the
"stormwater rules') and as outlined in the application, approved stormwater management plans,
supplement, calculations, operation and maintenance agreement, recorded documents,
specifications, and other supporting data (the "approved plans and specifications") as attached and/or
on file with and approved by the Division of Energy. Mineral and Land Resources (the "Division" or
"DEMLR"). The project shall be constructed, operated and maintained in accordance with these
approved plans and specifications. The approved plans and specifications are incorporated by
reference and are enforceable part of this permit.
This permit shall be effective from the date of issuance until December 31, 2029 and shall be subject
to the following specified conditions and limitations. The permit issued shall continue in force and
effect until the permittee files a request with the Division for a permit modification, transfer, renewal, or
rescission; however, these actions do not stay any condition. 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 for cause as allowed by the laws, rules, and regulations contained in Title 15A
NCAC 2H.1000 and NCGS 143-215.1 et.al.
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.
This stormwater system has been approved for the management of stormwater runoff as
described in Section 1.7 of this permit. The runoff from all built -upon area within the permitted
drainage area of this project must be directed into the permitted stormwater control measure.
The stormwater control has been designed to handle the runoff from 52,971 square feet of
impervious area.
3. The maximum built -upon area allowed for the entire project is 52,971 square feet.
4. The drainage area will be limited to the amount of built -upon area indicated in Sections 1.2 and
1.7 of this permit, and per approved plans. This permit does not provide any allocation of built -
upon area for future development.
Page 1 of 5

Post -Construction Stormwater Management
Permit No. SW8 080426
[:a
7
The excess design storm overflow from the infiltration basin must be directed into a 50'
vegetated filter strip and level spreader, designed per Section .1008 (f) of the stormwater
rules.
The built -upon areas associated with this project shall be located at least 30 feet landward of
all perennial and intermittent streams.
The following design criteria have been permitted for the infiltration trench and it must be
provided and maintained at the design condition:
a. Drainage Area, acres:
1.63
Onsite, ft2:
71,003
Offsite, ft2:
None
b. Total Impervious Surfaces, ft2:
52,971
Onsite, ft2:
52,971
Offsite, ft2:
None
G. Design Storm, inches:
3.7
d. Trench Length, feet:
285.7
e. Trench Width, feet:
50
f. Trench Depth, feet:
2
g. Perforated Pipe Diameter x Length:
8" x 522' / 12" x 1,000'
h. Bottom Elevation, FMSL:
32.5
i. Bypass Weir Elevation, FMSL:
34.5
j. Permitted Storage Volume, ft3:
15,538
k. Predevelopment 1 yr-24 hr. discharge rate, cfs:
2.31
I. Type of Soil:
Fine to Medium Sand
M. Expected Infiltration Rate, in/hr:
6.0
n. Seasonal High Water Table, FMSL:
30.5
o. Time to Draw Down, hours:
4.1
p. Receiving Stream/River Basin:
ICWW / Cape Fear
q. Stream Index Number:
18-87-25.5
r. Classification of Water Body:
"SA, ORW"
II. SCHEDULE OF COMPLIANCE
The stormwater management system shall be constructed in its entirety, vegetated and
operational for its intended use prior to the construction of any built -upon surface.
2. During construction, erosion shall be kept to a minimum and any eroded areas of the system
will be repaired immediately. If the stormwater system is used as an Erosion Control device, it
must be restored to design condition prior to operation as a stormwater treatment device, and
prior to occupancy of the facility.
The permittee shall at all times provide the operation and maintenance necessary to assure
that all components of the permitted stormwater system function at design condition. The
approved Operation and Maintenance Agreement is incorporated by reference into this permit
and must be followed in its entirety and maintenance must occur at the scheduled intervals.
Records of maintenance activities must be kept and made available upon request to
authorized personnel of the Division. The records will indicate the date, activity, name of
person performing the work and what actions were taken.
5. The facilities shall be constructed, operated and maintained in accordance with the provisions
of this permit, the approved plans and specifications, and the supporting documents attached
to this permit and on file with the Division.
Page 2 of 5

Post -Construction Stormwater Management
Permit No. SW8 080426
6. 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 system installed certifying that the permitted facility 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.
All stormwater collection and treatment systems must be located in either public rights -of -way,
dedicated common areas or recorded easements. The final plats for the project will be
recorded showing all such rights -of -way, common areas and easements, in accordance with
the approved plans. Access to the stormwater facilities for inspection and maintenance shall
be maintained via appropriate recorded easements at all times.
8. 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.
No person or entity, including the permittee, shall alter any component shown in the approved
plans and specifications. Prior to the construction of any modification to the approved plans,
the permittee shall submit to the Director, and shall have received approval for modified plans,
specifications, and calculations including, but not limited to, those listed below. For changes to
the project or SCM that impact the certifications, a new or updated certification(s), as
applicable, will be required and a copy must be submitted to the appropriate DEQ regional
office upon completion of the modification.
a. Any modification to the approved plans and specifications, regardless of size including
the SCM(s), BUA, details, etc.
b. Redesign or addition to the approved amount of BUA or to the drainage area.
C. Further development, subdivision, acquisition, lease or sale of any, all or part of the
project and/or property area as reported in the approved plans and specifications.
d. Altering, modifying, removing, relocating, redirecting, regrading, or resizing of any
component of the approved SCM(s), the stormwater collection system and/or
vegetative conveyance shown on the approved plan.
e. The construction of any allocated future BUA.
f. The construction of any permeable pavement, #57 stone area, public trails, or
landscaping material to be considered a permeable surface that were not included in
the approved plans and specifications.
g. Other modifications as determined by the Director.
III. GENERAL CONDITIONS
CORRECTIVE ACTIONS REQUIRED. If the facilities fail to perform satisfactorily, the
permittee shall take immediate corrective actions. This includes actions required by this
Division and the stormwater rules such as the construction of additional or replacement on -site
stormwater systems. These additional or replacement measures shall receive a permit from
the Division prior to construction.
2. PERMIT RENEWAL. A permit renewal request must be submitted at least 180 days prior to
the expiration date of this permit. The renewal request must include the appropriate
application, documentation and the processing fee as outlined in Title 15A NCAC
02H.1045(3).
3. CHANGES TO THE PROJECT NAME, PERMITTEE NAME OR CONTACT INFORMATION.
The permittee shall submit a completed Permit Information Update Application Form to the
Division within 30 days to making any one of these changes.
Page 3 of 5

Post -Construction Stormwater Management
Permit No. SW8 080426
4. TRANSFER. This permit is not transferable to any person or entity except after notice to and
approval by the Director. Neither the sale of the project and/or property, in whole or in part, nor
the conveyance of common area to a third party constitutes an approved transfer of the permit.
TRANSFER REQUEST. The transfer request must include the appropriate application,
documentation and the processing fee as outlined in 15A NCAC 02H.1045(2). This
request must be submitted within 90 days of the permit holder meeting one or more of
the following:
i. A natural person who is deceased;
ii. A partnership, limited liability corporation, corporation, or any other business
association that has been dissolved;
iii. A person or entity who has been lawfully and finally divested of title to the
property on which the permitted activity is occurring or will occur through
foreclosure, bankruptcy, or other legal proceeding.
iv. A person or entity who has sold the property, in whole or in part, on which the
permitted activity is occurring or will occur,
V. The assignment of declarant rights to another individual or entity;
vi. The sale or conveyance of the common areas to a Homeowner's or Property
Owner's Association, subject to the requirements of NCGS 143-214.7(c2);
b. TRANSFER INSPECTION. Prior to transfer of the permit, a file review and site
inspection will be conducted by Division personnel to ensure the permit conditions
have been met and that the project and the on -site stormwater system complies with
the permit conditions. Records of maintenance activities performed to date may be
requested. Projects not in compliance with the permit will not be transferred until all
permit and/or general statute conditions are met.
5. COMPLIANCE. The permittee is responsible for compliance with the terms and conditions of
this permit until the Division approves the transfer request.
a. APPROVED PLANS AND SPECIFICATIONS. A copy of this permit, approved plans,
application, supplement, operation and maintenance agreement, all applicable
recorded documents, and specifications shall be maintained on file by the permittee at
all times.
b. DIVISION ACCESS. The permittee grants Division Staff permission to enter the
property during normal business hours to inspect all components of the permitted
project.
C. ENFORCEMENT. Any individual or entity found to be in noncompliance with the
provisions of a stormwater management permit or the requirements of the stormwater
rules is subject to enforcement procedures as set forth in NCGS 143 Article 21.
d. ANNUAL CERTIFICATION. The permittee shall electronically submit to the Division an
annual certification completed by either the permittee or their designee confirming the
projects conformance with permit conditions
e. OBTAINING COMPLIANCE. 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 modified plans and certification in writing to the Director that the
changes have been made.
Page 4 of 5

Post -Construction Stormwater Management
Permit No. SW8 080426
OTHER PERMITS. The issuance of this permit does not preclude the permittee from
complying with and obtaining any other permits or approvals that are required for this
development to take place, as required by any statutes, rules, regulations, or
ordinances, which may be imposed by any other Local. State or Federal government
agency having jurisdiction. Any activities undertaken at this site that cause a water
quality violation or undertaken prior to receipt of the necessary permits or approvals to
do so are considered violations of NCGS 143-215.1, and subject to enforcement
procedures pursuant to NCGS 143-215.6.
Permit renewed, updated and reissued this the 27th day of July 2022.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
Cy►�� A
f77 ria n, Directo
Division of Energy, Mineral and Land Resources
By Authority of the Environmental Management Commission
Permit Number SW8 080426
Page 5 of 5

Attachment C - Permitting History
Masonboro family Medicine
Permit No. SW8 080426
Approval
Date
Permit
Action
BIMS
Version
Description of the Changes
5/28/2008
Original
Approval
1.0
1/27/2016
Correction
_
Clarifying the set of rules the permit
was issued under
7/27/2022
Renewal
2.0
Expires December 30, 2029

Permit Number: '5 L)5yaDUl�
(to be provided by DWQ)
Drainage Area Number:
Filter Strip, Restored Riparian Buffer and Level Spreader
Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will 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 removal efficiency of the BMP.
Important maintenance procedures:
— Immediately after the filter strip is established, any newly planted vegetation
will be watered twice weekly if needed until the plants become established
(commonly six weeks).
— Once a year, the filter strip will be reseeded to maintain a dense growth of
vegetation
— Stable groundcover will be maintained in the drainage area to reduce the
sediment load to the vegetation.
— Two to three times a year, grass filter strips will be mowed and the clippings
harvested to promote the growth of thick vegetation with optimum pollutant
removal efficiency. Turf grass should not be cut shorter than 3 to 5 inches and
may be allowed to grow as tall as 12 inches depending on aesthetic requirements
(NI PC,1993). Forested filter strips do not require this type of maintenance.
— Once a year, the soil will be aerated if necessary.
— Once a year, soil pH will be tested and lime will be added if necessary.
After the filter strip is established, it will be inspected quarterly and within 24 hours
after every storm event greater than 1.0 inch (or 1.5 inches if in a Coastal County).
Records of operation and maintenance will be kept in a known set location and will be
available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element
Potentialproblem:
How I will rentediate theproblem:
The entire filter strip
Trash/debris is present.
Remove the trash/debris.
system
The flow splitter device
The Flow splitter device is
Unclog the conveyance and dispose
(if applicable)
clogged.
of any sediment off -site.
The flow splitter device is
Make any necessary repairs or
damaged.
replace if damage is too large for
repair.
Form SWU401-Level Spreader, Filter Strip, Restored Riparian Buffer O&M-Rev.3 Page I of 3

BMP element:
Potentialproblem:
How 1 will remediate theproblem:
The swale and the level
The swale is clogged with
Remove the sediment and dispose
lip
sediment.
of it off -site.
The level lip is cracked,
Repair or replace lip.
settled, undercut, eroded or
otherwise damaged.
There is erosion around the
Regrade the soil to create a berm
end of the level spreader that
that is higher than the level lip, and
shows stormwater has
then plant a ground cover and
bypassed it.
water until it is established. Provide
lime and a one-time fertilizer
application.
Trees or shrubs have begun
Remove them.
to grow on the swale or just
downslo a of the level lip.
The bypass channel
Areas of bare soil and/or
Regrade the soil if necessary to
erosive gullies have formed.
remove the gully, and then
reestablish proper erosion control.
Turf reinforcement is
Study the site to see if a larger
damaged or ripap is rolling
bypass channel is needed (enlarge if
downhill.
necessary). After this, reestablish
the erosion control material.
The filter strip
Grass is too short or too long
Maintain grass at a height of
if applicable).
approximately three to six inches.
Areas of bare soil and/or
Regrade the soil if necessary to
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
one-time fertilizer application.
Sediment is building up on
Remove the sediment and
the filter strip.
restabilize the soil with vegetation if
necessary. Provide time and a one-
time fertilizer application.
Plants are desiccated.
Provide additional irrigation and
fertilizer as needed.
Plants are dead, diseased or
Determine the source of the
dying.
problem: soils, hydrology, disease,
etc. Remedy the problem and
replace plants. Provide a one-time
fertilizer application.
Nuisance vegetation is
Remove vegetation by hand if
choking out desirable species.
possible. If pesticide is used, do not
allow it to get into the receiving
water.
The receiving water
Erosion or other signs of
Contact the NC Division of Water
damage have occurred at the
Quality local Regional Office, or the
outlet.
401 Oversight Unit at 919-733-1786.
Form SWU401-Level Spreader, Filter Strip, Restored Riparian Buffer O&M-Rev.3 Page 2 of 3

Permit Number:
(to be provided by D { Q)
I acknowledge and agree by my signature below that 1 am responsible for the
performance of the maintenance procedures listed above. I agree to notify DWQ of any
problems with the system or prior to any changes to the system or responsible party.
Project name:Masonboro Family Medicine
BMP drainage area number:
Print name:Kimberly J. Martin
Title:Member Manager
Address:A&K of Wilmington, LLC, 6132-8 Carolina Beach Rd., Wilmington, NC 28412
Note: The legally responsible party should not be a homeowners association unless more than 50% of
the lots have been sold and a resident of the subdivision has been named the president.
Public for the State of
do hereby certify that
t/
appeared before me this 2
ie due execution of the
forgoing filter strip, riparian buffer, and/or level spreader maintenance requirements.
Witness my hand and official seal,
r 7TAAR o
•' Y
2�
Go OOo al IEV1 Q
SEAL
My commission expires /1)'a'9- a0/
Form SWU401-1-evel Spreader, Filter Strip, Restored Riparian Buffer O&M-Rev.3 Page 3 of 3

u

Permit Numbers w 9_' 4
(to be provided by DWQ)
Drainage Area Number:
Infiltration Trench Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will 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 removal efficiency of the BMP.
Important maintenance procedures:
— The drainage area of the infiltration trench will be carefully managed to reduce
the sediment load to the sand filter.
— The water level in the monitoring wells will be recorded once a month and after
every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal County).
The infiltration trench will be inspected once a quarter and within 24 hours after every
storm event greater than 1.0 inches (or 1.5 inches if in a Coastal County). Records of
operation and maintenance will be kept in a known set location and will be available
upon request.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element:
Potentialproblem:
How I will remediate theproblem:
The entire BMP
Trash debris is present.
Remove the trash debris.
The grass filter strip or
other pretreatment area
Areas of bare soil and/or
erosive gullies have formed.
Regrade the soil if necessary to
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
one-time fertilizer application.
Sediment has accumulated to
Search for the source of the
a depth of greater than six
sediment and remedy the problem if
inches.
possible. Remove the sediment and
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
The flow diversion
The structure is clogged.
Unclog the conveyance and dispose
structure (if applicable)
of any sediment off -site.
The structure is damaged.
Make any necessary repairs or
replace if damage is too large for
repair.
Form SW401-Infiltration Trench O&M-Rev.3
Page I of 3

BMP element:
Potentialproblem:
How I will remediate theproblem:
The trench
Water is ponding on the
Remove the accumulated sediment
surface for more than 24
from the infiltration system and
hours after a storm.
dispose in a location that will not
impact a stream or the BMP.
The depth in the trench is
Remove the accumulated sediment
reduced to 75% of the original
from the infiltration system and
design depth.
dispose in a location that will not
im pact a stream or the BMP.
Grass or other plants are
Remove the plants, preferably by
growing on the surface of the
hand. If pesticide is used, wipe it on
trench.
the plants rather than spraying.
The observation well(s)
The water table is within one
Contact the DWQ Stormwater Unit
foot of the bottom of the
immediately at 919-733-5083.
system for a period of three
consecutive months.
The outflow pipe is clogged.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
The outflow pipe is damaged.
Repair or replace the pipe.
The emergency overflow
Erosion or other signs of
The emergency overflow berm will
berm
damage have occurred at the
be repaired or replaced if beyond
outlet.
repair.
The receiving water
Erosion or other signs of
Contact the NC Division of Water
damage have occurred at the
Quality 401 Oversight Unit at 919-
outlet.
733-1786.
Pone SW401-Infiltration Trench O&M-Rev.3 Page 2 of 3

Permit Number: 5w o OYGQlo�
(to be provided by UIVQ)
I acknowledge and agree by my signature below that I am responsible for the
performance of the maintenance procedures listed above. 1 agree to notify D WQ of any
problems with the system or prior to any changes to the system or responsible party.
Project name:Masonboro Family Medicine
BMP drainage area number:
Print name:K\p%'1'\\I <) 6wAr n
Title:Member Manager
Address:A & K of Wilmington LLC 6132-8 Carolina Beach Rd, Wilmington, NC 28412
Note: The legally responsible party should not be a homeowners association unless more than 50% of
the lots have been sold and a resident of the subdivision has been named the president.
a Notary Public for the State of
/VOrf/7 County of /W f/Q/IOdGr , do hereby certify that
/� th
A'l-mh4r& (-Y /� /ry� C rh' q personally appeared before me this �tJ
day of va / / ODff, , and acknowledge the due execution of the
forgoing infiltration trench maintenance requirements. Witness my hand and official
seal,
ptpfllllllldpp/9
®pO�Ntc CUMy�,
*oTARr
A . 13
goy•., pUt3L1� :i203
aiy'• , o�
.41Vo uE0001 4,`9
SEAL
My commission expires /U-a q a o//
Form SW401-infiltration french O&M-Rev.3 Page 3 of 3

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,)' :' ,I )

STATE STORMWATER:
PERMIT INFORMATION UPDATE APPLICATION FORM
There is NO FEE for updating project name or permittee information.
This form is to only to be used by the current permittee to notify the Division of.
1) changes to the Point of Contact (signing official) for the current permittee (LLC, Corporation,
HOA or POA);
2) changes to the mailing address, phone number or email address of the current permittee;
3) changes to the name of the project, and
4) changes to the legal corporate name as documented by a Name Change or Merger filed
with the NCSOS.
A. NEW PERMIT INFORMATION
State Stormwater Permit Number: SW8 080426
Are you updating
(check all that apply):
If so, please provide the updated information:
Project name
Masonboro Family Medicine
Corporation Name'
A &K of Wilmington, LLC
Permit Contact Namez.3
Kimberly Martin
Permit Contact Title
Member
Mailing Address3
6419-A Carolina Beach Rd Wilmington NC 28412
Phone number
910-790-3660
Email address
Mason [e-mail]
' Provide documentation such as a Name Change / Merger filed with the NCSOS.
2 Provide supporting documentation such as NCSOS filing. The permit contact's position
must be in accordance with 15A NCAC 02H .1040(1).
3 If more than one point of contact or mailing address is being changed, please ttach a., _
separate sheet.
B. CERTIFICATION OF PERMITTEE JUL 2 2 2022
making the cha ge
to the permit infprR
Signature:
tad it I , the current permittee, hereby notify DEMLR that I am
sted in Section A above. I further attest that this application for an update
currently on file is accurate and complete to the best of my knowledge. /
FL. Date:
I, c , a Notary Public for the State of
ILA— ,
County of do hereby certify that

PW!
personally appeared before me this the 48 day of T 20 y2—
and acknowledge the due execution of the forgoing instrument. Witne s my hand and official seal,
(Notary Seal)
Notary Signature 4�"�—
My commission expires
w C.'�s'
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AVQLtG .'

�ao6( Say= SuOK o�acfa(o
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER:
PERMIT RENEWAL APPLICATION FORM
In accordance with 15A NCAC 2H.1045(3), the current permit holder shall renew their high
density permit 180 days prior to its expiration. Renewed permits are valid for a period of 8
years per Session Law 2011-398 (SB 781) Section 60.(c). This application form is for
permit renewals only.
A. PROJECT INFORMATION
• State Stormwater Permit Number: SW8 080426
• Project name: Masonboro Family Medicine
• Project street address:
6419 Carolina Beach Rd
City: Wilmington County: New Hanover
• What, if any, changes have been made to the project as permitted? None
If the project has changed from the original approved plans, please complete
SWU-101 for a Major Modification or Minor Modification Application form available
at: https://deg.nc.gov/about/divisions/energy-mineral-land-resources/energv-
mineral-land-rules/stormwater-prop ram/post-construction.
B. PERMITTEE INFORMATION
If changes to the permittee or project name have been made, please complete either
the Permit Update form or the Permit Transfer form available at:
automatically
property.
• Current Permit Holder's Company Name/Organization:
A & K of Wilmington. LLC
• Signing Official's Name:
Kimberly Martin
• Signing Official's Title:
Member
• Mailing Address:
6419-A Carolina Beach Rd
City: Wilmington
State: NC ZIP: 28412
• Street Address:
• 6419-A Carolina Beach Rd
City: Wilmington
State: NC ZIP: 28412
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JUL 2 2 2022
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• Phone: (910 ) 790-3660 Email: Masonborofam(cDgmail. com

C.
SUBMITTAL REQUIREMENTS
Submit the application package to the appropriate DEMLR Regional Office (Coastal, SA
Waters) or DEMLR Central Office (Urbanizing Areas Ph 2, USMP, Non -Coastal
HQW/ORW). Only applications packages that include all required items listed below will
be accepted and reviewed.
Initial each item below to indicate that the required information is provided in the
application package:
1. A permit application processing fee of $505.00 payable to NCDEQ.
2. One original signed hard copy and one electronic copy of this completed
form. The signing official named on this application to represent the current
permittee must meet one of the following:
a. Corporation — a principle executive officer of at least the level of vice-
president;
b. Limited Liability Company (LLC) — a manager or company official as
those terms are defined in G.S. 57D "North Carolina Limited
Liability Company Act;"
c. Public Entity — a principal executive officer, ranking official, or other
duly authorized employee;
d. Partnership or limited partnership — the general partner;
e. Sole proprietor; or
f. Letter of authorization signed by one of the signatories noted in a — e
above authorizing the signature of another entity.
3. One hard copy and one electronic copy of recorded documents required by
the original permit that have not yet been received by DEMLR, including:
deed restrictions, protective covenants, condominium/planned community
declaration and easements. If the project has been built, include
documentation that the maximum BUA per lot or maximum total BUA has
not been exceeded. If the project has not been built, include a signed
agreement that the final recorded deed restrictions and protective
covenants will be submitted at a later date.
4. O&M Agreements, Please select one:
I have a copy of the current recorded O&M Agreement for all SCMs, and
I will continue to keep this on file with the permit; or
I do not have a copy of the current recorded O&M Agreement for all
SCMs and am requesting a copy be sent to me. I agree to keep this
on file with the permit.
5. Designer Certifications, Please select one:
A copy of the certification(s) confirming that the project was built in
accordance with the approved plans have been previously provided
to the Division; or
A copy of the certification(s) confirming that the project was built in
accordance with the approved plans are enclosed; or
The project has not yet been built.
6. (IF APPLICABLE] If the project has been built, one original hard copy and
one electronic copy of a signed, sealed, and dated letter from a licensed
professional stating that the SCMs have been inspected, and that they have
been built and maintained in accordance with the permit.
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7. [IF APPLICABLE] When the permittee is a corporation or a limited liability
corporation (LLC): Provide one hard copy and one electronic copy of
documentation from the NC Secretary of State, or other official
documentation, which supports the titles and positions held by the persons
listed in Section C.2 per 15A NCAC 2H. 1043(3)(b).
https://www.sosnc.gov/online services/search/by title!
Business Registration
rd

D. PER MITTEE'S CERTIFICATION
I, k1 m b trik il r (� `�(.v � t yl , the person legally responsible for the
permit, certify that I have a copy of the Permit and O&M Agreement on site (or I will obtain
a copy and it will be kept on site), that I am responsible for the performance of the
maintenance procedures, and the site has been and will be maintained according to the
O&M Agreement and approved plans. I agree to notify DEMLR of any problems with the
SCMs or built -upon area and to submit the proper forms to modify or transfer the permit
prior to any changeyto the project, SCMs, or ownership. All information provided on this
permit renewal ap lic i��n is, to the best of my knowledge, correct and complete.
Signature: jjftA Date:-7-IW2z
NOTARIZATION:
I #VPte.1 C L-45"-1 (--rt , a
Notary Public for the State of N C County of
4lti f/A_70"'1 , do hereby certify that
V22L4G ,yJai%^I personally
appeared before me this the day of
Jai 20 yZ, and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature:`�—
My commission expires
��ttfQ�O N�0 C.
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JUL 21 ?021

•
Permit No.� to ) '�Q OQ �i 1p
(to be provided by DWQ)
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NCDENR
STORMWATER MANAGEMENT PERMIT APPLICATION FORM ��€
401 CERTIFICATION APPLICATION FORM
INFILTRATION TRENCH SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items
Checklist (Part 1/1) must be printed, filled out and submitted along with all of the required information.
I. PROJECT INFORMATION
Project name
Masonbom Family Medicine
Contact person
Charles Cazier, P.E.
Phone number
910-763-5100
Date
412912008
Drainage area number
1
II. DESIGN INFORMATION
Site Characteristics
Drainage area
71,003.00 ft3
Impervious area
52,971.00 ft3
Percent impervious
74.6% %
Design rainfall depth
3.70 in
Peak Flow Calculations
1-yr, 24-hr runoff depth
1-yr, 24-hr Intensity
Pre -development 1-yr, 24-hr peak flow
Post -development 1-yr, 24-hr peak flow
Pre/Post 1-yr, 24-hr peak flow control
Storage Volume: Non -SR Waters
Minimum volume required
Volume provided
Storage Volume: SR Waters
1-yr, 24-hr rainfall depth
Pre -development 1-yr, 24-hr runoff
Post -development 1-yr, 24-hr runoff
Minimum volume required
Volume provided
Solis Report Summary
Soil type
Infiltration rate
SHWT elevation
Trench Design Parameters
Drawdown time
Perforated pipe diameter
Perforated pipe length
Number of laterals
Slone type (if used)
Stone void ratio
Stone is free of fines?
3.70
in
5.67
in/hr
2.31
ft3/sec
7.21
ft'/sec
4.90
ft3/sec
ft3
ft3
3.70 in
1,095.00 ft3
15,793.00 ft3
14,698.00 ft3
15,538.00 ff
Fine to Medium Sand
6.00 inthr
30.50 fmsl
0.17 days OK
8" / 12" in
1,000' 1522' It
n/a
#57 crushed granite
0.4
Y (Y or N) OK
Form SW401-Infiltration Trench-Rev.2 Parts I. & If. Design Summary, Page 1 of 2

1
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Permit No. 5 LA_J 00 -'O (a
(to be provided by O )
Trench Elevations
Bottom elevation
32.50
fmsl
OK
Storage/overflow elevation
34.50
fmsl
Top elevation
34.50
fmsl
Trench Dimensions
Length (long dimension)
285.70
it
Width (short dimension)
50.00
it
Height (depth)
2.00
ft
OK
Additional Information
Total runoff volume captured by trench
3.78
ac-in
Maximum of 2 acre -inches allowed
Length of vegetative filter for overflow
60.00
ft
OK
Number of observation wells
2
OK
Distance to structure
ft
Distance from surface waters
3,000.00
it
OK
Distance from water supply well(s)
n/a
ft
OK
Separation from impervious soil layer
n/a
ft
OK
Depth of naturally occurring soil above SHWT
It
Bottom covered with 4-in of clean sand?
Y
(Y or N)
OK
Proposed drainage easement provided?
Y
(Y or N)
OK
Capures all runoff at ultimate build -out?
Y
(Y or N)
OK
Bypass provided for larger storms?
Y
(Y or N)
OK
Trench wrapped with geotextile fabric?
Y
(Y or N)
OK
Pretreatment device provided
Sediment basin in each inlet
Forth SW401-Ineltratlon Trench-Rev,2 Parts I. d 11. Design Summary, Page 2 of 2

Permit No. cs t'k— L1y Oo Y R ("
(to be provided by DWQ)
Ill. REQUIRED ITEMS'CHECKGST tF�a ` '� "' t' ' " ' , • 't �' " ,
Please indicate the page or plan sheet numbers where the supporting documentation can be found. An incomplete submittal package
will result in a request for additional information. This will delay final review and approval of the project Initial in the space
provided to indicate the following design requirements have been met. If the applicant has designated an agent, the agent may initial
below. II a requirement has not been met, attach justification.
Pagel Plan
Initials
Sheet No.
_CV&
�_
1. Plans (1° - 50' or larger) of the entire site showing:
- Design at ultimate build -out,
- Off -site drainage (if applicable),
- Delineated drainage basins (include Rational C coefficient per basin),
- Trench dimensions,
- Pretreatment system,
- High flow bypass system,
- Maintenance access,
- Proposed drainage easement and public right of way (ROW),
- Overflow device, and
- Boundaries of drainage easement.
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2. Partial plan (1' = 30' or larger) and details for the infiltration trench showing:
- Bypass structure,
- Maintenance access,
- Basin bottom dimensions,
- Basin cross-section with benchmark for sediment cleanout,
- Flow distribution detail for inflow,
- Vegetated filter, and
- Pretreatment device.
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3. Section view, of the infiltration basin (10 = 20' or larger) showing:
- Pretreatment and treatment areas, and
- Inlet and outlet structures.
4. A table of elevations, areas, incremental volumes & accumulated volumes to verify the volume provided.
Sr" *'r',W. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. The
results of the soils report must be verified in the field by DWQ, by completing & submitting the soils
investigation request form. County soil maps are not an acceptable source of soils information.
Ct- 6. A construction sequence that shows how the infiltration basin will be protected from sediment until the
entire drainage area is stabilized.
_JAX CAUWOVA7. The supporting calculations.
f ANC' t 8. A copy of the signed and notarized operation and maintenance (0&M) agreement.
nl- P`"44 9. A copy of the deed restrictions (if required).
Form SW401-Infinmtion Trench-Rev2 Part III. Required Items Checklist, Page 1 of 1

SEP 17,2009 11:39A Tripp Engineering 9107635631 page 2
TE 07083
State Stormwater Management Systems
Permit No. SW8 080426
Masonboro Family Medicine
Stormwater Project No, SW8 080426
New Hanover County
Engineer's Certification
I, Phillip G. Tripp , as a duly registered Professional Engineer in the
State of North Carolina, having been authorized to observe (periodically/week4y9444
time) the construction of the project,
Masonboro Family Medicine
(Project)
for A & K of Wilmington LLC (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.
The checklist of items on page 2 of this form is Included in the Certification.
Noted deviationsfrom approved plans and specifications:
Signature
Registration Numoer l f 9r4
Date 9 • 1F~1
IQJ-m� Jf"'AX'\F't'i" i5i
SEP 1 7 2009
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SEP 17,2009 11:39A Tripp Engineering 9107635631 page 3
State Stormwater Management Systems
Permit No. SW8 080426
Certification Requirements. Page 2 of 2
ki. The drainage area to the system contains approximately the permitted
acreage.
� 2. The drainage area to the system contains no more than the permitted
amount of built -upon area.
,-3. All the built -upon area associated with the project is graded such that the
runoff drains to the system.
_4. All roof drains are located such that the runoff is directed into the system.
i
5. The bypass structure elevations are per the approved plan. reL
Ig;2I _6. The bypass structure is located per the approved plans.
7. A trash rack is provided on the outlet/bypass structure.
8. All slopes are grassed with permanent vegetation.
fflL9. Vegetated slopes are no steeper than 3:1.
� 10. The inlets are located per the approved plans and do not cause short-
circuiting of the system. �A�mA1AF� lW-M {I RO
v0 LAw1A��
�11. The permitted amounts of surf AcceobaFrea and/or volume have been
provided.
i
�12. Required drawdown devices are correctly sized per the approved plans.
13. All required design depths are provided.
j� 14. All required parts of the system are provided.
15. The! required system dimensions are provided, per the approved plan.