SW4240907_Application Form_20241015

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑Coastal SW- 1995
CI Coastal SW- 2008 Ph post
(select all that apply) ❑Non-Coastal SW-HQW/p W Waters 0 Universa❑l Stormwater Management
n
❑Other WQ M.►n t Plan: agement Plan
State of North Carolina
Department of Environmental Quality
Division of Energy, Mineral and Land Resources
POST-CONSTRUCTION STORMWATER MANAGEMENT PERMIT APPLIC
This form may be photocopied for use as an original. ATION FORM
I GENERAL INFORMATION
1 Project Name (subdivision, facility, or establishment name-should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.).
Design Master Dis la s Buildin Ex ansion
2. Location of Project(street address): —
5657 Pros ect Street
City:Archdale ----
C
3. Directions to project(from nearest major intersection):oRandolph Zip:27263
0.95 miles South from intersection of US Hw 29 and Pro est Street SR1625
4 Latitude:35° 54' 16" N
Longitude:80e 02' 07" W of the main entrance to the project.
II. PERMIT INFORMATION:
1.a.Specify whether project is (check one): ZNew
tRenewals with modifications a sodreq►a es SWU-10 n RRenewa Application enewal w/ aFor
b.If this application is being submitted as the result of a modification to an existingForm
permit number its issue date (if known) permit. list the existing
construction: ❑Not Started , and the status of
certification ❑Partially Completed" ❑ Completed` *provide a designer's
2. Specify the type of project:
❑Low Density NHigh Density Drains to an Offsite Stormwater System
3. If this application is being submitted as the result of a previously returned application❑ her orta letter
DEMLR requesting a state stormwater management permit application, list the stormwater project
number, if assigned, from
proposed, and the previous name of the project, if different than currently
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 LZSedimentation/Erosion Control: 6.65 ac of Disturbed Area
❑NPDES Industrial Stormwater N 4 0 4/4 0 1 Permit: Proposed Impacts Tem Crossin an
b.If any of these permits have already been acquired please provide the Project Name, Project/Permit d Pipe
1t/Permit Number,
issue date and the type of each permit:
5. Is the project located within 5 miles of a public airport?
ZN
If yes, see S.L. 2012-200, Part VI:http.//portalmcdenror /web/lr/ru es and ❑Yes
requlationc
Form SWU-101 Version July 26,2024
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:Jerry Hardy
Signing Official & Title:Jerry Hardy, Managing Member, H2PRO, LLC
b.Contact information for person listed in item la above:
Street Address:4001 Brambletye Court
City:Greensboro State:NC
Zip:27407
Mailing Address (if applicable):Same as above
City. State
Zip.
Phone: ( ) Fax:
Email:
c.Please check (one) 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)
❑ Developer` (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:H2PRO,LLC
Signing Official & Title:Jerry Hardy. Managing Member
b.Contact information for person listed in item 2a above
Street Address:4001 Brambletye Court
City:Greensboro State:NC
Zip:27407
Mailing Address (if applicable):Same as above
City State:
Zip:
Phone: ( ) Fax:
Email
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:Andrew Christ, PE / FEI Civil Engineers and Land Surveyors
Signing Official &Title:Andrew Christ, PE/ Senior Project Manager
b.Contact information for person listed in item 3a above:
Mailing Address 5818 Traid Drive
City:Colfax State NC
Zip:27235
Phone: (336 ) 544-6438 Fax: (
Email achrist(a�feiconsulting.corn
4. Local jurisdiction for building permits City of Trinity/ Randolph County
Point of Contact: Phone#: l
Email
Form SWU-101 Version July 26,2024 Page 2 of 8

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated
Stormwater pond will be used to ca ture and treat runoff from the BUA.
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 PP
❑ Valid Building Permit Approval Date
❑ Other: Issued Date:
Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordanc
❑ Coastal SW— 1995 El Ph II — Post Construction e with:
3. Stormwater runoff from this project drains to the Yadkin Pee-Dee
4. Total Property Area: 18.73 River basin.
acres 5. Total Coastal Wetlands Area: 0
6. Total Surface Water Area- 0.23 acres
acres
7. Total Property Area (4)—Total Coastal Wetlands Area (5)—Total Surface Water Area (6) = jct
Total Proe
Area+- 18.50 acres
�
+ Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area between the banks
of streams and avers, the area below the Normal High Water(NNW)line or Mean High Water(MHVIq line, and coastal wetlands
landward from the NHW(or MHW)line The resultant project area is used to calculate overall percent built upon area(BUA). Non-
coastal wetlands landward of the NHW(or MH144 line may be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area/Total Project Area)X 100 = 28 0
9. How many drainage areas does the project have?1 (For high density, count 1 for each proposedSCM. For
/o
low density and other projects, use 1 for the whole property area. If there are multiple receiving streams
provide the drainage areas within the project area to each stream.)
10. Complete the following information for each drainage area directed to an SCM or low density area identified
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. in
Basin Information Draina•e Area 1 Draina.a Area 2 Draina•e Area Draina•e Area
Receiving Stream Name
Hunts Fork Hunts Fork 11.11111111.11111.111111111
Stream Index Number
DrIndexe NuArember
r*sf) 12-119-7-3 12-119-7-3
Totalsite Drainage (sf)Area641,964 173,718 11111111111111111111111111111
641,964 173,718 1111111111111111111111111111
Off-site Drainage Area (sf) 0
11111111111111111111111111111
Pro.osed Impervious Area** sf 0 0
96,576 11111111111111111111111111.1
Impervious Area** total 10.7% 0
55.6/o 11111111111111111111111111111
Impervious" Surface Area Drainage Area 1 Drainage Area 2 Drainage Area
Drainage Area
On-site Buildings/Lots (sf) 0
On-site Streets (sf) 22,000
On-site Parking0
(sf) 0 74,576 On site Sidewalks (sf) 0 IIIIIIIIIIIMIIIIIIIIIIIIIM
11111.11111111111.111111111111111111111111
Other on-site (sf) 0
IMIIIIIIIIIMIIIIIIIIIIIIIIIIIIIIIIIIIII
IIMICE
Off-site (sf) 0
1111111111111111.111111111111.11.111111 11111111.11111111111111111111111111111111111
Existing BUA***
(sf) 68,961 41,071
111111111111111111111111111.1
Total (sf): 68,961 137,647
111.11111111111.11111111111
Stream Class and Index Number can be detemuned at.htt s.//www_de .nc. ov/about/divisions/water-resources/water-
tannin /classification-standards/classifications
Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas, sidewalks
gravel areas, etc.
""Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that is to be
removed and which will be replaced by new BUA. See definition 15A NCAC 02H 1002(17).
Form S WU-101 Version July 26,2024
Page 3 of 8

11. How was the off-site impervious area listed the Section IV, 10 Tables determined? Provide documentation
GIS-Public Information
Projects in Union County: Contact DEMLR Central Office staff to check if the project is located within a
Threatened& Endangered Species watershed that may be 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 SCM specified for this project. The latest versions of the forms can be downloaded
from htt s://www.de .nc. ov/about/divisions/ener -mineral-and-land-resources/stormwater/stormwater-
rogram/stormwater-design manual_ For SCMs subject to older design standards or offsite projects, the archived
supplement can be found from hops://www.deq.nc.gov/about/divisions/energv mineral and land
suresources/stormwater/stormwater ro ram/stormwater-desi n-manual/archived-stormwater-desi n-manual-
pple me ntal-forms
VI. CHECKLIST OF SUBMITTAL REQUIREMENTS FOR AN ADMINISTRATIVELY COMPLETE
APPLICATION PACKAGE PER 15A NCAC 02H .1042(2)
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). An administratively complete application package includes all of the items
listed below. A detailed application instruction sheet and SCM checklists are available from
htt s://www.de nc. ov/about/divisions/ener -mineral-and-land-resources/stormwater/ ost-construction-
rroogram/new-permits-permit modifications. The complete application package should be submitted to the
appropriate DEMLR Office. (The appropriate office may be found by locating
rject on the
map at htt s://www.de .nc ov/about/divisions/ener -mineral-and-land-resourpes/stormwater/stormtwaternline
program/post construction-program )
Please indicate that the followin re uired information have been rovided b initialin 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 https://www.deg nc qov/about/divisions/energv mineral
and-land-resources/stormwater/stormwater ro ram.
1. Original and one copy of the Stormwater Management Permit Application Form. Initials
2. Original and one copy of the signed and notarized Deed Restrictions & Protective
Covenants Form or, for major modifications. a copy of the recorded deed restrictions and
protective covenants limiting the built-upon area so that it does not exceed the capacity of
the SCM(s) or the BUA thresholds. (if required as per Part VII below)
Deed book: Page No: Relevant section:
3. Original of the applicable Supplement Form(s) and
dated an
agreement(s) for each SCM. (please refer to Section V fors more nforma on) d O&M -�
4. Appropriate permit application processing fee per NCGS 143-215.3D(e)(2)payable to
NCDEQ.
A full list of fee adjustments is available on the DEQ website
https://www deq.nc goy/accessdeq/permit fees 2023 updates
(For an Express review, refer to: htt psl/www.de .nc qov/accessdeq/express permitting for
information on the Express program and the associated fees. Contact the appropriate
Coastal 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
the project. This is required in addition to the brief summary provided in the Project
Information, item 1
6 A USGS map identifying the site location. If the receiving stream is reported as class SA
or the receiving stream drains to class SA waters within 1/2 mile of the site boundary, include
the 1/2 mile radius on the map.
fer--
7 Sealed, signed, and dated calculations (one copy).
Form SWU-101 Version July 26,2024
Page 4 of 8

8. Two sets of plans folded to 8.5"x 14" (sealed, signed, & dated), including:
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 setback landward from the normal pool elevation of
structures, the banks of streams or rivers, and the MHW(or NHW) of tidal waters.
i. Dimensioned property/project boundary with bearings & distances. impounded
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
I. Details of roads. drainage features. collection systems. and stormwater control measures
(including any applicable SCM planting plans).
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated b a
qualified person, identify the person who made the determination on the plans. y
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 .
9. Copy of any applicable soils report with the associated SHWT elev ations (Please identi ) -
elevations in addition to depths) as well as a map of the boring locations with the existingf=
elevations and boring logs. Include an 8.5"x11" co
project area clearly delineated. For projects with infiltration SCMs, the report should also
include the soil type, expected infiltration rate, and the ofy met the NRCS County Soils map with the
of determining
(Infiltration Devices submitted to WiRO: Schedule a s tehd voisit for DEMLR to the
verify'thetSH rate.
Prior to submittal. [phone].) lNT
10. A copy of the most current property deed Deed book 2110
11. For corporations and limited liability corporations (LLC): Provide age No. n40
Secretary of State or other official documentation, which supports from ���
by the persons listed in Contact Information, item 1a, 2a, and/or 3a per 15A NCAC 2H 10NC _
the titles and positions held
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. 40(1).
htt ://www.secreta .state.nc.us/Cor orations/CSearch.as x
12. If the applicant is not the property owner, a copy of a lease agreement. affidavit, or other
document showing that the applicant has obtained legal rights to submit a stormwater permit
application within the proposed project area
13. If applicable, a copy of any recorded drainage, maintenance, or operation and maintenance
easements demonstrating ownership interest sufficient to operate the SW system.
Deed book; ��
Page No
14 If a modification to an existingPaRelevant section
permit:
a. The applicant/permit holder will remain the same and permit has not and will
not expire within the next 180 days.
b_ Signed, sealed & dated Designer Certification Forms
c Copies of the following documents recorded with the County Register of Deeds __&i41._
i. Deed restrictions and protective covenants limiting the BUA
does not exceed the capacity of the SCM(s) or the BUA thresholds. it N
ii. Drainage easements, when applicable.
ni. Operation & Maintenance Agreement
iv. Final subdivision plat referencing the Operation & Maintenance Agreement / -
Form SWU-101 Version July 26,2024
Page 5 of 8

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
protective covenants forms can be downloaded from htt s://www_de .nc. ov/about/divisions/ener -mineral and-
land-resources/stormwater/stormwater- ro ram/ ost-construction- ro ram/ ostcostru deed restrictions and
the latest versions for each submittal, d cti�n-forms. Download
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 p p rty
By the notarized signature(s) below, the permit holder(s) certify that the recorded property
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 a restrictionsdpersons
claiming under them, that they will run with the land, that the required covenants cannot be changed
deleted without concurrence from the NC DEMLR, and that they will be recorded prior to the sale of
lot. g or
any
VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such
consulting engineer and/or firm) so that they may provide information on your behalf for this project(such as
addressing requests for additional information). as a
Consulting Engineer:Andr�hrist. PE
Consulting Firm: FEI Civil En ineers and Land Surve ors
Mailing Address:8518 Triad Drive
City:Colfax
Phone: (336 State:NC Zip:27235
544-6438
Email:achnst(u�feiconsultinq.com — Fax: (_
Form SWU-101 Version July 26,2024
Page 6 of 8

IX. PROPERTY OWNER AUTHORIZATION (if Contact information, item 2 has been filled
section)
out, complete this
I, (print or type name of person listed in Contact Information, item 2a) Jer Hard
own the property identified in this permit application, and thus give permission toV
listed in Contact information, item 9a)Jer Hard � certify that I
Coed in Contact
Information,
itemm 9a, Jerry Hardy (print or typef o name off/person
with thep projectc type name of organization copysted inf
the lease agreement or pending property sales contract has been provided with the submittal,
to develop as currently proposed. A of
party responsible for the operation and maintenance of the stormwater system.
As the legal property owner I acknowledge, understand, and agree bymy which indicates the
agent(entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults
lease agreement, or pending sale, responsibility for compliance with the DEMLR
below, that if my designated
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR immediatelyan their
a completed Name/Ownership Change Form within 30 days; otherwise I will be operating stormwater permit reverts back
facility without a valid permit. I understand that the operation of a stormwater treatment facility
and submit
permit is a violatio f NC General Sta n 1 3 215.1 and may result in appropriate operating a stormwater treatment
the assessment ivil penalties of up o -21per day, yle without i valid
13- enforcement action including
pursuant to NCGS 143-215.6.
Signature: .4/ i y„
�' 1\D'ate: 7/.,t_ s___.9 Ze)e:"7
i
Count of ` , , a Notary Public for the State of I`I�� '^r f1
y ( '� do hereby certify that ,� I( I ��
personally appeared before me this day of 1I�I �l( �i�C'�`
r 1-4- , �. and acknowledge the
due execution of the application fora stormwater permit. Witriess my y hand and official seal,
��J '
ASHTON CARTER
Notary Public-North Carolina
Guilford County
My Comm;ssion Expires August 12,2026
SEAL
My commission expires k /Li I,!C 1 Z 2(� L- '
� ,t
Form S WU-101 Version July 26,2024
Page 7 of 8

X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item la) Jer Hard
certify that the information included on this permit application form is, to the best of my knowledge, correct
that the project will be constructed in nformance with the approved plans, that the required deed restrictions
and protective c enants will be rec rd and that the proposed project complies with the requirementsg ect and
he
applicable sto ater rules under 5
CAC 2H .1000 and any other applicable state storm ater requirements.
Signature, I t ' C-
1 (7 Date: GYG�Zei �%
, a Notary Pic for the St to of
County of I)'Th I r.
do hereby certify that L LI ( t
personally appeared before me this L�+ I_ day of
due execution of the application for a stormwater permit. Witness r �l- and acknowledge the
V1 ss myhand and official seal,
C Cy`�--
ASHTON CARTER
Notary Public-North Carolina
Guilford County
My Comrr sin Exp rr.„s,lust 12,2026
SEAL
My commission expires �C
Form SWU-101 Version July 26,2024
Page 8 of 8