NCC241662_FRO Submitted_20240611

City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
WII1S191LSIIk 11 Mailing: PO Box 2511,Winston-Salem,NC 27102
Financial Responsibility/Ownership Form
No person may initiate any land-disturbing activity exceeding 20,000 square feet for Single-Family Dwelling construction, 10,000
square feet for any other non-exempt purpose,or part of a larger common plan of development exceeding these thresholds,before this
form and an acceptable Erosion Control Plan have been submitted,reviewed,and approved by the City of Winston-Salem Erosion
Control Division and a Grading/Erosion Control Permit has been issued. Please type or print. Please place"N/A"in the blank space if
not applicable.
Part A
Project Name: Shelton Lake Dam Repair
Grading/Erosion Control Permit i!:
Location of Land-disturbing Activity: 2452 Lake Forest Drive, Winston-Salem, NC 27106
Latitude: 36°08'09" N Longitude: .... .....80° 22' 50"W
Approximate Date that Land-disturbing Activity will Commence: September 2023
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family ❑Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots «Other
Total Site Acreage:....13.63 ac Acreage to be Disturbed: 2.4 ac
Grading/Erosion Control Permit Fee: $ ...1.046
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name:.....Tracy O'Brien Email• tobrien(«obriensouthern.com
Office Phone: [phone] Mobile Phone:...[phone] Fax#'
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN# 5897-21-3737 Tax Block#:....4611 Tax Lot#:....026R
Name- O'Brien Southern Trenching, Inc
Street Address/PO Box: PO Box 849
City/State/Zip Code: Rural Hall, NC 27045
Office Phone:-[phone] Mobile Phone: [phone] Fax#-
Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract:$ City of WS Contractor ID#:
Name of Grading Contractor: NC License#:
Contractor Contact Person: Contact Phone:
Street Address/PO Box: ....
City/State/Zip Code:

Part B
Person(s)or firms who are financially responsible for this land-disturbing activity: (use blank page to list additional
person(s)or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership***
Name of Person or Firm: ....O'Brien Southern Trenching,Inc.,Tracy O'Brien
Street Address/PO Box: ..... PO Box 849
City/State/Zip Code: Rural Hall, NC 27045
Office Phone:.... [phone].... Mobile Phone: [phone] Fax#•
If the financially responsible party is an out-of-state firm,provide information for the in-state registered agent:
Name of Registered Agent'
Street Address/PO Box. -
City/State/Zip Code:
Office Phone: Mobile Phone: Fax#:
If the financially responsible party is a partnership,provide information for each General Partner:
(use blank page to list additional partners if needed)
Name of Registered Agent:
Street Address/PO Box:
City/State/Zip Code:
Office Phone: Mobile Phone: Fax ii:
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath. (This form
must be signed by the financially responsible person, if an individual,or their attorney-in-fact,or if not an individual,by an officer,
director,partner,or registered agent with authority to execute instruments for the financially responsible person.) I agree to provide
corrected information should there be any change in the information provided herein.
Type or Print Name: (�� 2eri.e.,i4;
Title or Authority: ... 'Q
c
.. 7 � .. `J/IG{/z o�
Signature:
Date:
I, 6e.td9 clad.owl
a Notary Public of the Countyof F(jr6\tftj'-
_,2__ ,
State of. l (l,I� tt ff����A /I j/�, ,L --
�, ; " ` ��" y���" , do hereby certify that....l..l.�y�i� +�!'r/� ,appeared
personally before me this day,and being dullysworn,acknowledged that the above form was executed by him/her. Witness my
hand and notarial seal,this J1' " day ofKidA 20
Notary Public Name: r )e �.-.3D (/'� KELSEY GODDARD
Notary Public
Notary Public Signature: Forsyth Co.,North Carolina
J My Commission Expires Feb.23,2025
My commission expires: .�( .V Notary Seal

Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#• 5897-20-7999
Tax Block#: ....4611 Tax Lot#:....025C
Name• Adams, Garland• Adams Vicky
Street Address/PO Box: .....2460 Lake Forest Dr
City/State/Zip Code: ......Winston-Salem NC 27106
5-7
Office Phone:..{336) xxx-xxxx Mobile Phone:...{336)x xx xxxx
Fax#•
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#' 5897-31-0259
Tax Block#: ....4611 Tax Lot#:....026J
Name- Lamour Faith Beata
Street Address/PO Box: .....2440 Lake Forest Dr
City/State/Zip Code: ......Winston-Salem NC 27106..
Office Phone:..(336) xxx xxxx Mobile Phone:...{336) > X 7 ��
Fax#•

To: City of Winston-Salem
1;
I(we), ,fr: 5 L , Property Owner(s)at
(--1/4 C kj JL 'LT (•• PIN:_5897-20-7999 give
permission to and will allow O'Brien Southern Trenching Inc.,access to my property and further
to perform the site construction activities as identified and delineated on plan sheet document
prepared by LPK Consulting,PA entitled Shelton Lake Dam Repair dated March 7, 2024..
Name:
)1,
/i/VL
Date: (;)
Signature:
Name: F....) A ttl ' t,kt ,
Date:
Signature: IX gt.
State:
County: tD-ry'rk
Z eell" (Notary Public) do hereby certify that
frqr-• A-"0-f 013 personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal / this day of / , 20-
LANE EVERHART Official Notary Signature
Public
Forsyth Co.,North Carolina
My Commission Expires Aug.29,2027 7-
Printed Notary Name
) )
My Commission Expires '

To: City ofJ Winston-Salem
iC1 t
') /2/ Vi / ;Property Owner(s)at
2460 Lake Forest Dr Winston-Sale NC 27106
r'PIN: 5897-20-7999 give
permission to and will allow O'Brien Southern Trenching Inc., access to my property and further
to perform the site construction activities as identified and delineated on plan sheet document
prepared by LPK Consulting,PA entitled Shelton Lake Dam Repair dated March 7, 2024..
•
Name: r'E Date:
Signature .� ` .�G. Cy-
.f ,
;- ,
Name:• ; :-- t .. _
a t t f' f % } _. Date: �v 3 aa7--
Signature ,
State: NC
•
County: FOr S,p
L \e xCX aCV-2y (Notary Public)do hereby certify that
c as) \/icky
ersona
acknowledged the due execution of the foregoing instrume ly appeared before me this day and,
Witness my hand and official seal 8r8, this day of Mai 20
� dW
ALEXA MACKEY
Notary Public
Forsyth Co.,North Carolina
My Commission Expires Nov.20,2028
Official Notary Signature
f�itpxa Uac Veq
Printed Notary Name
My Commission Expires awl ,g
Twit_ !!� ..►

North Carolina Department of Environmental Quality Dam Safety Program
Division of Energy, Mineral,and Land Resources
APPLICATION FOR REVIEW BY NORTH CAROLINA DAM SAFETY
NOTE: All applications are reviewed on a first come,first served basis. Expedited reviews may be made on a case-by-
case basis based on exceptional need. You can view your position in the queue by accessing the"NC Dam Applications
Review Queue" located here. Modifications, repairs, decommission/removal/breach, and new construction are
considered"Engineering Plans"and should be combined into a single group for the purposes of assessing your position
in the queue. All other types of applications have separate queues.
Applications should be made in general accordance with the Dam Safety Law of 1967 and the North Carolina
Administrative Code(NCAC) Title 15A,Subchapter 2K-Dam Safety.
Applications need only contain supporting documentation, e.g. calculation packages, technical specifications, etc.,
pertinent to scope of work being proposed. For example, plans to repair only a slough need slope stability calculations,
but no hydrology and hydraulics (H&H) calculations. Should the reviewing engineer identify potential deficiencies with
the dam, beyond those addressed in this application,they may request additional supporting material to address those
deficiencies on a case-by-case basis. Approval to conduct the work proposed herein may be conditional upon submitting
a plan to address additional deficiencies as identified by the reviewing engineer.
Dam Name: Shelton Lake Dam Repair State ID: FORSY-004
Application type(check as applicable):
Application Fee Required No Application Fee Required
8 Modification/Repair ❑ Jurisdictional Determination/Hazard Classification
❑ Decommission/Removal/Breach ❑ Emergency Action Plan(EAP)
❑ New Construction El Operations&Maintenance Plan(O&M)
O As-Built ❑ Change of Engineer of Record
Have you mailed your applicable fee following the ❑ Change of Dam Owner
APPLICATION PROCESS instructions?
❑ Extension Request
B Yes
❑ Withdrawal Request
❑ No
Per§143-215.28(A1)(1),your application will be
considered incomplete until your fee is received.
Incomplete applications are not added to the
application review queue. - ._
October 2023
Rev. 1 Page 1 of 7

North Carolina Department of Environmental Quality Dam Safety Program
Division of Energy,Mineral,and Land Resources
APPLICATION FEES
A nonrefundable application processing and compliance fee in the amount of two and one-quarter percent(2.25%)of the
actual cost of construction,repair,alteration, breach,or removal of the applicable dam shall be paid for the processing of
applications for approvals to construct a new dam or modify, repair, decommission, remove, breach an existing dam as
follows:
1. An initial fee of five hundred dollars ($500.00) or one-half of the processing and compliance fee based on the
engineer's estimated cost of construction,whichever amount is greater,shall be submitted with the application.
2. The remainder of the processing and compliance fee based on the engineer's actual cost of construction (minus
the initial fee paid), shall be paid when the as-built plans are submitted. The maximum fee shall not exceed fifty
thousand dollars($50,000).
For purposes of determining the actual cost of construction, the cost shall (i) include all labor and materials costs
associated with the project for the applicable dam and(ii)not include the costs associated with acquisition of land or right-
of-way,design,quality control, electrical generating machinery,or constructing a roadway across the dam.
Fee type:
Initial Fee ❑ Final Fee(as-builts only)
(A)Estimated Construction Cost: $ 213,958.00 (A)Actual Construction Cost: $
(B) Estimated Total Fee: $ 5°849.00 (B)Actual Total Fee: $
(2.25%of A) (2.25%of A)
(C) Initial Fee: *,97400 I (C)Initial Fee Paid: $
{greater of 50%of B,or$500)
(D) Final Fee Mfa
(B minus C)
r _ ,
'� }f arrnattt �regarding application few can be found in 1 .215,2. *'A ll) t p >ti
44,A#AL, " gatiffVfiti + me wi hout the subrr)lssion of`a complet 'S*3�Cll �wG wool
October 2023
Rev. 1 Page2of7

North Carolina Department of Environmental Quality
Division of Energy,Mineral,and Land Resources Dam Safety Program
15A NCAC 02K .0203 —PROFESSIONAL ENGINEER REQUIREMENTS
154 NCAC 021e.0203— The design,preparation of the plans and specifications, inspection of the construction of or on the
dam, and certification that the dam was constructed, repaired, altered, or removed according to the plans approved by
the Director and that the dam or its remains are safe shall be done by a legally qualified engineer and shall bear their
professional seal unless exempted under the provisions of G.S.89C-25.
Change of Engineer of Record, Change of Dam Owner, and Extension Requests are not required to be prepared by a
registered professional engineer licensed to practice in the State of North Carolina (NC PE). Jurisdictional
Determination/Hazard Classification requests are not required to be prepared by an NC PE,if prepared by the Dam Owner.
In addition, per § 143.215.31.(2)d., a downstream inundation map prepared for an Emergency Action Plan does not
require preparation by an NC PE or a person under the responsible charge of an NC PE unless the dam is associated with
a coal combustion residuals surface impoundment,as defined by G.S.130A-309.201. All other types of applications must
be prepared by a NC PE and shall bear their professional seal.
Check as applicable:
❑ My application is not required to be prepared by a registered professional engineer licensed to practice in the
State of North Carolina
RI My application/s required to be prepared by a registered professional engineer licensed to practice in the State
of North Carolina. See signed statement below.
ENGINEER'S STATEMENT
I am a registered Professional Engineer licensed to practice in the State of North Carolina, I am qualified in the technical
fields pertinent to the scope of work proposed herein. This application was prepared by me, or under my supervision.
The information submitted as part of this application is, to the best of my knowledge and belief, true, accurate, and
complete,
Date: December 13,2023 Firm: LPK Consulting,PA
Name: John D.Lipka Phone Number: 336.945.0302
, tio " 'Ri,,,,, Email Address: JLipka@LPK_Cor ulting.com
Affix Seal: 140 ►.,
`,`i
:916' Mailing Address: 514 Edwards Rd
Rural Hall,NC 27045
6494
`,t12. t3.zozi, I
,�� h_oitief '���.�?`�/
oh -\Q
October 2023
Rev.1
Page 3 of 7

North Carolina Department of Environmental Quality
Division of Energy,Mineral,and Land Resources Dam Safety Program
OWNER INFORMATION
Owners Full Name: O'Brien Southern Trenching, Inc. (Tracy O'Brien)
Address: 4794 Pfaff Lane Pfafftown NC 27040
Street or PO Box
City State ZipCode
Phone Number: 336 45.2041
EmailAddress: [e-mail]
Owners Full Name:
Address:
Street or PO Box
City State Zip Code
Phone Number: Email Address:
Owners Full Name:
Address:
Street or PO Box City
State Zip Code
Phone Number:
Email Address:
Owners Full Name:
Address:
Street or PO Box
City State Zip Code
Phone Number: Email Address:
NOTE: If there are additional owners, use the additional information sheet to provide the required contact information.
October 2023
Rev. 1
Page 4 of 7

North Carolina Department of Environmental Quality
Division of Energy,Mineral, and Land Resources Dam Safety Program
DAM INFORMATION
Dam Name: Shelton Lake Dam
State ID: FORSY-004
Current hazard classification(check one):
High(Class C) El Intermediate(Class B)
❑ Low(Class A)
Size classification(check one)—refer to 15A NCAC 02K.0205:
B Small ❑ Medium ❑ Large
❑ Very Large
Location Information
Latitude(yy.yyyy): 36.13604 Longitude{-xx.xxxx): -80.38056
Physical Dam Information
Type of Dam: Earth Fill
Concrete,earth fill,rockfili,masonry,zoned,homogeneous,gravity,arch,etc.
Structural Height(ft): 33.8 Crest Elevation(ft NAVD88): 862.8
from the highest point on the top
of dam to the lowest point on the
downstream toe of the darn
Crest Length(ft): 800 Crest Width(ft): 15
Upstream Slope: 3 :
' Bottom Drain(Y/N): Y
H V
Downstream Slope: 3 ; 1
Date Bottom Drain Last
H v Exercised: Proposed
Year of Construction: Initial - 1955
Impoundment Information
Drainage Area(ac); 112
Normal Pool Elevation(ft NAVD88): 859.0 Maximum Pool Elevation(ft NAVD88): 862.1
Surface Area at Normal Pool(ac-ft): 8.4 ac Surface Area at Maximum Pool (ac-ft): 10.9 ac
Impounding Capacity at Normal Pool(ac-ft): 61.3 Impounding Capacity at Maximum Pool(ac-ft): 91.2
Maximum Impounding Capacity at Crest of Dam (ac-ft): 99.0
Freeboard at Normal Pool(ft): 3.8 Freeboard at Maximum Pool(ft): 0.7
October 2023
Rev, 1
Page5of7

North Carolina Department of Environmental Quality
Division of Energy,Mineral, and Land Resources Dam Safety Program
Spillway Information
Principal Spillway Auxiliary/Emergency Spillway
if a livable
Spillway Type: 48" Dia Riser / 16" barrel Vegetated Emergency Spillway
Construction Material: Concrete riser/ductile barrel
grass lined
length(ft): N/A N/A
Width(ft): N/A N/A
Inlet Invert Elevation(ft NAVD88): 859.0 (riser elev.) Crest Elev. 861 .8
Outlet Invert Elevation(ft NAVD88): 829.0 N/A
Flow Capacity(cfs): 1 8.5 120
NOTE: If there are additional spillways, use the additional information sheet to provide the required information.
PROJECT DESCRIPTION
Provide a brief description of your proposed project.
Replacement of the primary spillway structure/device with analysis to the existing surface spillway to
function as the emergency spillway. Narrowing the existing 30' embankment width to 15'. Utilizing
existing earthen material to flatten downstream slope to 3:1. Addition of siphon bottom drain.
October 2023
Rev. 1
Page 6 of 7

North Carolina Department of Environmental Quality
Division of Energy, Mineral, and Land Resources Dam Safety Program
ADDITIONAL INFORMATION
I
October 2023
Rev. 1
Page 7 of 7