WQ0044579_Application (FTSE)_20230713

State of North Carolina
1 Department of Environmental Quality
DWR Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: .' 0�0�k_ q(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Clayton Properties Group, INC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: James W. Derrickson per 15A NCAC 02T .0106(b)
Title: Manager
4. Applicant's mailing address: 221 Jonestown Road
City: Winston Salem State: NC Zip: 27104-
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: Fieldstone Phase 1
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date: ,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Davidson
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.8744' Longitude:-80.2692'
5. Parcel ID (if applicable): 6820-01-26-7593 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
l . Professional Engineer: Brent Nesom License Number: 051642
Firm: FEI
Mailing address: 8518 Triad Drive
City: Colfax State: NC Zip: 27235-
Phone number: (336) 544 - 6421 Email Address: bnesomkfeiconsulting com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Muddy Creek Permit Number:
Owner Name: Winston Salem/Forsyth County Utilities
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
l . Permit Number(s): WQ
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00361
Owner Name(s): Clayton Properties Group
FORM: FTA 06-21 Page 1 of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
[—]Yes [—]No ® N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
® Yes ❑ No ❑ N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
® Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential (Leased) ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ®No
➢ If yes, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow a'"
No. of Units
Flow
Single Family Residential-4 bedroom
320 gal/day
40
12,800 GPD
Townhomes-3 bedroom
240 gal/day
52
12,480 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
25,280 GPD
a See 15A NCAC 02T .0114(b), (d), (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use areas;
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 23700 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 06-21 Page 2 of 5

VI1. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 5,555 PVC
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: 0Longitude: - °
3. Total number of pumps at the pump station:
3. Design flow of the pump station: millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): gallons per minute (GPM) at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.Lb. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B):
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 06-21 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T.0305(f) & (g)? ® Yes [:]No
15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
2Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
2Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(fl or (g), see Section X.1 of this application
* 15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ® Yes ❑ No ❑ N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name: , ® No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes [:]No
➢ This includes Trout Buffered Streams per 15A NCAC 213.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0 I 05(c)(6), directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 06-21 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrently with the approval of the permit, and projects requiring a variance approval may be subject to longer
review times. For projects requiring two or more variances or where the variance is determined by the Division to be a
significant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
I, Brent A. Nesom , attest that this application for Fieldstone Phase 1
(Professional Engineer's name from Application Item lll.l .) (Project Name from Application Item II.I )
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56:0701)
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3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, _James W. Derrickson , attest that this application for Fieldstone Phase 1
(Signature Authority Name from Application Item I.3.) (Project Name from Application Item II.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to `being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: Date:
7�1
FORM: FTA 06-21 Page 5 of 5

.D. WR
Division of Water Re- sources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: 12683- Clayton Properties Group, Inc.
Project Name for which flow is being requested: Fieldstone Phase 1
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Muddy Creek
b. WWTP Facility Permit #: NC0050342
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
21.000000
2.9583400
14.260000
0.0025280
17.220900
82.0
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A)
(B)
Design
Pump Pump
Average
Approx.
Station Station
Firm Daily Flow* *
Current
(Name or Permit
Capacity, * (Firm / p f),
Avg. Daily
Number) No.
MGD MGD
Flow, MGD
(C)
(D)=(B+C) (E)=(A-D)
Obligated,
Not Yet
Total Current
Tributary
Flow Plus
Daily Flow,
Obligated Available
MGD
Flow Capacity***
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Muddy Creek
Downstream Permit Number: WQCS00003
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Courtney Driver, P.E. certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
vZ
'gning fzcial rignature Date
ASPIVI VTIL177CS ®r26C7a12-
Title of Signing Official
Page 2 of 6
FTSE 10-18

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division o; xvatf-; Ret o rccs Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Clayton Properties Group
Project Name for which flow is being requested: Fieldstone
More than one FTSE maybe required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: _
b. WWTP Facility Permit #:
All flows are in MGD
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design
Average Approx. Obligated, Total
Pump Pump Daily Current Not Yet Current Flow
Station Station Firm Flow** Avg. Daily Tributary Plus
(Name or Permit Capacity, * (Firm / pf), Flow, Daily Flow, Obligated Available
Number) No. MGD MGD MGD MGD Flow Capacity***
Frye's WQCS00361 2.304 .921 .230 .183 .413 .508
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Davidson County Sewer
Downstream Permit Number: WQCS00361
Page I of 6
FTSE 10-18

III. Certification Statement:
I Casey Smith certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
— (��" '0";' -
Signing Jjfcial Signature Date
Title of Signing
Page 2 of 6
FTSE 10-18

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Q�QF �QQG Michael F. Easley, Governor
William G. Ross Jr., Secretary
CO r North Carolina Department of Environment and Natural Resources
p Alan W. Klimek, P.E., Director
Division of Water Quality
July 28, 2005
Ron Hargrove, PE, Deputy Utilities Director
City/County Utilities
Utilities Administration
PO Box 2511
Winston-Salem, NC 27102
- -Subject. - - -City of Winston-Salem
Residential Flow Reduction Approval
Forsyth County
Dear Mr. Hargrove:
On June 29, 2005, the Division of Water Quality received a flow reduction request for residences
connecting to the Winston-Salem collection system. The letter requests an allowable flow rate of 240 GPD per
single-family residential unit (three bedroom) based on the evaluated data for the current service area. As you
are aware, the issue of an approved flow reduction has been outstanding for quite some time. We appreciate
your assistance and patience in the matter and are pleased to offer a resolution.
The methodology and data evaluated for this request was discussed with you and your staff, regional
office staff and central office staff during a meeting on June 14, 2005. The evaluation included data collection
from tax records (age and bedrooms) and utility billing (water consumption) and DMR records for the treatment
plants. Based upon this data and with concurrence from our Winston-Salem Regional Office, the Division
hereby approves the use of 240 GPD per single-family residential unit (up to three bedrooms) in all applicable
non -discharge permit applications whether issued by the Division or through your delegated sewer extension
permit program. This value shall be incremented by 80 gpd per additional bedroom above three.
Regardless of the adjusted design daily wastewater flow rate, at no time shall the wastewater flows
exceed the effluent limits defined in the NPDES permits for the treatment facilities or exceed the capacity of the
sewers downstream of any new sewer extension or service connection(s).
If you have any questions or comments regarding this matter, please contact Marie Doklovic at
[phone] ext. 371.
Sincerely,
�lan W. Klimek, P.E.
d
cc: Steve Tedder, Winston-Salem Regional Office
Charles Weaver, NPDES West Program
PERCS Flow Reduction File
One 1 1 Pretreatment, Emergency Response and Collection Systems Unit Internet http://h2o.enr.nc.state.us/ndpu
Noft CarOhna 1617 Mail Service Center, Raleigh, NC 27699-1617 An Equal Opportunity Action Employer
a'aturia//' / Telephone [phone] Fax [phone]% recycled/10% post -consumer paper

FEI
Wednesday, July 12, 2023
DWR
450 W. Hanes Mill Road
Suite 300
Winston Salem, NC 27015
336-776-9800
RE: Fieldstone Phase 1- Sanitary Sewer FTA
N� pepartmQnt � ity.
Env►ro Rece�vae`�u�
j�L 2 IT2 1
Winston-Salem
pwOOna1 ott ce
This letter and application are for the proposed Fieldstone Subdivision, Phase 1 located in
Davidson County. There are 92 units (40 Single Family, and 52 Town Home Units) for this phase.
The flow allocation required is based on the 75 GPD per bedroom threshold and total for the
Phase 1 plans as 21,700 GPD.
Please find attached in this submittal package the following items.
1. FTA Application
2. Application Fee ($480, payable to NCDEQ)
3. Developer Agreement Form
4. Appropriate FTSE Form from Davidson County
5. Provide Maps
a. USGS Historical map (marked with location of site)
b. General Utility Map
c. Aerial map with location
Please let me know if additional information is required.
Thank you,
Brent Nesom, PE
Project Manager
FEI
CIVIL ENGINEERS AND LAND SURVEYORS
8518 Triad Drive
Colfax, NC 27235
!!:rA FEI
Civil Engineers and Land Surveyors