SW4181201_Application_20190115

N5PD
DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
o (S • 4
5015
t1a Vzo
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters
❑ Other WQ Mgmt Plan:
- 2008 ❑ Ph II - Post Construction
❑ Universal Stormwater Management Plan
State of North Carolina P. F r 17 tit
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources DEC 27 2013
STORMWATER MANAGEMENT PERMIT APPLICATION FOR -MR -LAND QUALITY
This form may be photocopied for use as an original STORMWATER PERIVII i TINGv
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.):
Neilson WTP Modernization
2. Location of Project (street address):
5725 Frye Bridge Rd
City: Clemmons County: Forsyth Zip: 27012
3. Directions to project (from nearest major intersection):
From intersection of Clemmons Rd (Hwy 158) and Middlebrook Dr, travel south on Middlebrook Dr.
At stop sign, turn left onto Idols Rd. At stop sign, turn right onto Hampton Rd. After half a mile, turn left
onto Frye Bridge Rd. The Neilson WTP will be on the left.
4. Latitude: 35° 59' 40.8912" N Longitude: -80° 21' 3.4452" W
II. PERMIT INFORMATION:
of the main entrance to the project.
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenezoals zoith modifications also requires SWU-102 - Renezoal Application Form
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number its issue date (if known) , and the status of
construction: ❑Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certification
2. Specify the type of project (check one):
®Low Density ❑High Density ❑Drains to an Offsite Stormwater System ❑Other
3. If this application is being submitted as the result of a previously returned application or a letter from
DEMLR requesting a state stormwater management permit application, list the stormwater project number,
if assigned, and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major ®Sedimentation/Erosion Control: 13 ac of Disturbed Area
❑NPDES Industrial Stormwater 0404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit: Submitted (in progress)
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: http:/Iportal.ncdenr.org/web/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6

III. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization: City of Winston-Salem
Signing Official & Title: Courtney Driver, Director of Utilities
b. Contact information for person listed in item 1a above:
Street Address: 101 North Main St, Suite 357
City: Winston-Salem
Mailing Address (if applicable): P.O. Box 2511
City: Winston-Salem
State: NC
State: N
Zip: 27101
Zip: 27102
Phone: ( 336 ) 747-7315 Fax: (_ 336 ) 727-8432
Email: [e-mail]
c. Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ 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: NOT APPLICABLE
Signing Official &
b. Contact information for person listed in item 2a above:
Street Address: NOT APPLI
City:
Mailing Address (if applicable):
City:_
Phone:
Email:
State: Zi
State: Zi
Fax: ( )
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: Marcus Felton/City of Winston-Salem
Signing Official & Title:
Director of Utilities
b. Contact information for person listed in item 3a above:
Mailing
2511
City: Winston-Salem State: NC Zip: 27102
Phone: ( 336 ) 771-5111 Fax: ( 336 ) 727-8432
Email:—[e-mail]
4. Local jurisdiction for building permits: City of Winston-Salem Inspections Division
Point of Contact: Glenn Tohnson Phone #: ( 336 ) 748-3543
Form SWU-101 Version Oct. 31, 2013 Page 2 of 7

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
This project will utilize vegtated conveyance to the maximum extent possible. Once flow is dispersed into the
vegetated property area from the impervious surfaces, it will travel a minumum of 180 feet across a vegetated
surface prior to reaching the drainage ditch on the north-western corner of the property. The average distance
stormwater will travel across the vegetated surface prior to discharge is roughly 400 feet. Infiltration to the
pervious vegtated surface will be the treatment method for stormwater runoff due to the new built upon area.
Roughly 67,400 square feet of the drainage area are perimeters of lagoons, where flow will be into the lagoon
to be held until infiltrated or evaportated, rather than to the stream.
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW -1995 ❑ Ph II - Post Construction
3. Stormwater runoff from this project drains to the Yadkin Pee -Dee River basin.
4. Total Property Area: 65.5 acres 5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 8.85 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+: 56.65 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 rivers, the area below the Normal High Water (NFRIV) line or Mean High Water
(MHW) line, and coastal wetlands landward front 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 MHW) line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 =
0.24 %
9. How many drainage areas does the project have? 1 (For high densihj, count 1 for each proposed engineered
stormwater BMP. For low densihj and other projects, use 1 for the whole properhj area)
10. Complete the following information for each drainage area identified in Project Information item 9. If there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 7

Basin Information
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area _
Receiving Stream Name
Muddy Creek
Stream Class *
C
Stream Index Number *
12-94-(0.5)
Total Drainage Area (sf)
2,855,794
On -site Drainage Area (so
2,855,794
Off -site Drainage Area (so
Proposed Impervious Area** (so
6,884
% Impervious Area** total
0.24 %
Impervious— Surface Area
Drainage Area 1
Drainage Area _
Draina e Area _
Drainage Area _
On -site Buildings/Lots (so
6,884
On -site Streets (sf)
--
On-site Parking (so
--
On-site Sidewalks (so
600
Other on -site (sf)
--
Future (so
--
Off-site (so
--
Existing BUA*** (sf)
382,354
Total (so:
389,838
* Stream Class and Index Number can be determined at: http://portal.ncdenr.org web/zoq/ps/csu/classi cations
Im ervious 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 rentain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. No off -site
impervious area contributes to site runoff.
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 BMP specified for this project. The latest versions of the forms can be downloaded
from http://portal.ncdenr.org/web/wq/ws/su/­­bmp-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
http://portal.ncdenr.org/web/wq/ws/su/statesw/forms docs. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map athttp://portal.ncdenr.org/web/wq/ws/su/mals.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from http://portal.ncdenr.org/web/wq/ws/su/statesw/forms docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. _69��_
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants IVIW
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M A11,4
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to ---
http:/ /www.envhelp.org/pages/onestopexpress.html for information on the Express program
Form SWU-101 Version Oct. 31, 2013 Page 4 of 7

and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor
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/z mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"x11" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DEMLR to verify the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 822 Page No: 406 Q�
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC IV/A`
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item 1a, 2a, and/or 3a per 15A NCAC 2H.1003(e).
The corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
http: / /www.secretary.state.nc.us/­Corl2orations/CSearch.aspx
Form SWU-101 Version Oct. 31, 2013 Page 5 of 7

VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided
as an attachment to the completed and notarized deed restriction form. The appropriate deed restrictions and
protective covenants forms can be downloaded from http://portal.ncdenr.org/web/ir/state-stormwater-
forms docs. Download the latest versions for each submittal.
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and listed
on the forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DEMLR, and that they will be recorded prior to the sale of any lot.
VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
Consulting Engineer: Joseph Ryan y
Consulting Firm: Black & Veatch International Co
Mailing Address: 10715 David Taylor Dr, Suite 240
City:
Charlotte
Phone: ( 704 ) 510-8420
Email: [e-mail]
State: NC Zip: 28262
Fax: ( 704 ) 548-8640
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or hjpe name of person listed in Contact Information, item 2a) NOT APPLICABLE , certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed in Contact Information, itenc 1a) NOT APPLICABLE with (print or hjpe name of organization listed in
Contact Information, item 1a) NOT APPLICABLE to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWU-101 Version Oct. 31, 2013 Page 6 of 7

As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR immediately and .
submit a completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater
treatment facility without a valid permit. I understand that the operation of a stormwater treatment facility
without a valid permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement
action including the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature:
NOT APPLICABLE Date:
a Notary Public for the State of
do hereby certify that
before me this _ day of
County of
personally appeared
and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission
X. APPLICANT'S CERTIFICATION
I, (print or hjpe name of person listed in Contact Information, item 1a) Courtney Driver
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protectiv covenants wil ecorded, and that the proposed project complies with the requirements of the
applicable s r ywater ru es nde 15A NCAC 2H .1000 and any other applicable state stormwater requirements.
Sig ture. �1L1 Date: U
lTke.4`i'l • a Notary Public for th State of y( r�� County of
do hereby
, certify that Y � personally appeared
before me this day of �1,1V' �� b an knowledge the du execution of the application for
a stormwater permit. Witness my hand and official `
GE Y GAF
Q NOTARY
PUBLIC
* My Comm Exp. V
. March 22, 2022 :'_
SEAL
My commission expires wk o-) Z, J ZZ I
Form SWU-101 Version Oct. 31, 2013 Page 7 of 7

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ Mgmt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This fornc may be photocopied for use as an original
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.):
WTP Modernization
2. Location of Project (street address):
5725 Frve Bridge Rd
City: Clemmons
County: Forsyth Zip: 27012
3. Directions to project (from nearest major intersection):
From intersection of Clemmons Rd (Hwy 158) and Middlebrook Dr, travel south on Middlebrook Dr.
At stop sign, turn left onto Idols Rd. At stop sign turn right onto Hampton Rd After half a mile turn left
onto Frye Bridge Rd. The Neilson WTP will be on the left.
4. Latitude: 350 59' 40.8912" N Longitude: -80021' 3.4452" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenezvals zvitlt modifications also requires SWU-102 - Renewal Application Form
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number , its issue date (if known) , and the status of
construction: ❑Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certification
2. Specify the type of project (check one):
®Low Density ❑High Density ❑Drains to an Offsite Stormwater System ❑Other
3. If this application is being submitted as the result of a previously returned application or a letter from
DEMLR requesting a state stormwater management permit application, list the stormwater project number,
if assigned, and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑LAMA Major
❑NPDES Industrial Stormwater
®Sedimentation/Erosion Control: 13 ac of Disturbed Area
❑404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit: Submitted in progress)
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: htt2://12ortal.ncdenr.org/web/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6

III. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc, who owns the project):
Applicant/Organization: City of Winston-Salem
Signing Official & Title: Courtney Driver, Director of Utilities
b. Contact information for person listed in item 1a above:
Street Address: 101 North Main St, Suite 357
City: Winston-Salem State: NC Zip: 27101
Mailing Address (if applicable): P.O. Box 2511
City: Winston-Salem
Phone: ( 336 ) 747-7315
Email: [e-mail]
State: NC Zip: 27102
Fax: ( 336 ) 727-8432
Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ 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: NOT APPLICABLE
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address: NOT APPLICABLE
City:
Mailing Address (if
City:
Phone: ( 1
Email:
State:
State:
Fax:
Zip:
Zip:
3. a. (Optional) Print the name and title of another contact such as the project's construction supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization: Marcus Felton/City of Winston-Salem
Signing Official & Title: Courtney Driver, Director of Utilities
b. Contact information for person listed in item 3a above:
Mailing Address: P.O. Box 2511
City: Winston-Salem State: NC Zip: 27102
Phone: ( 336 ) 771-5111 Fax: ( 336 ) 727-8432
Email: [e-mail]
4. Local jurisdiction for building permits: City of Winston-Salem Inspections Division
Point of Contact: Glenn Johnson Phone #: ( 336 ) 748-3543
Form SWU-101 Version Oct. 31, 2013 Page 2 of 7

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
This project will utilize vegtated conveyance to the maximum extent possible Once flow is dispersed into the
vegetated property area from the impervious surfaces, it will travel a minumum of 180 feet across a vegetated
surface prior to reaching the drainage ditch on the north-western corner of the property. The average distance
stormwater will travel across the vegetated surface prior to discharge is roughly 400 feet Infiltration to the
pervious vegtated surface will be the treatment method for stormwater runoff due to the new built upon area
Roughly 67,400 square feet of the drainage area are perimeters of lagoons where flow will be into the lagoon
to be held until infiltrated or evaportated, rather than to the stream.
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b. If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW -1995 ❑ Ph II - Post Construction
3. Stormwater runoff from this project drains to the Yadkin Pee -Dee River basin.
4. Total Property Area: 65.5 acres 5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 8.85 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+: 56.65 acres
+ Total project area shall be calculated to exclude the follozing: the normal pool of impounded structures, the area
between t1le banks of streams and rivers, the area below tlae Normal High Water (NHW) line or Mean High Water
(MHW) line, and coastal zoetlands landward front the NHW (or A4FIM line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward of the NHW (or MHW) line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 0.24 %
9. How many drainage areas does the project have? 1 (For high densihf, count 1 for each proposed engineered
stormzater BMP. For lozv densihf and other projects, use 1 for file zvliole property area)
10. Complete the following information for each drainage area identified in Project Information item 9. If there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 7

Basin Information
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area
Receiving Stream Name
Muddy Creek
_
Stream Class *
C
Stream Index Number *
12-94-(0.5)
Total Drainage Area (so
2,855,794
On -site Drainage Area (so
2,855,794
Off -site Drainage Area (so
Proposed Impervious Area** so
6,884
% Impervious Area** (total)
0.24%
Impervious— Surface Area
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area
On -site Buildings/Lots (so
6,884
_
On -site Streets (so
--
On-site Parking (so
--
On-site Sidewalks (so
600
Other on -site (so
--
Future (so
--
Off-site (so
--
Existing BUA*** (so
382,354
Total (so:
389,838
Stream Class and Index Number can be determined at: littp.aortal.ticdeiir.or /zveb/zvq&s/csu/classi cations
Impervious area is defined as the built upon area including, brit not limited to, buildings, roads, parking areas,
sidezvalks, gravel areas, etc.
*** Report only that amount of existing BUA that zvill reruain after development. Do not report any existing BUA that
is to be removed and zoldch zvill be replaced by nezv BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. No off -site
impervious area contributes to site runoff.
Projects in Union Countv: Contact DEAfLR Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent storrrnvater requirements as per 15A NCAC 03B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from http://Portal.ncdenr.orR/web/wq/ws/su/bmi)-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
hgp://portal.ncdenr.org/web/wq/`/ws/su/statesw/forms does. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map at htW://portal.ncdenr.org/web/wQ/ws/su/maps.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from http://portal.ncdenr.org/web/wci/ws/su/statesw/forms does.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. ogeti__�
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants A11,4
Form. (if required as per Part VII belozv)
3. Original of the applicable Supplement Form(s) (sealed, sib Lied and dated) and O&M oVI,4
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
http://www.envhelp.org/pages/onestopexpress.htnil for information on the Express program
Form SWU-101 Version Oct. 31, 2013 Page 4 of 7

and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor
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 ? z mile of the site boundary, include the lh
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify_
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"x11" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Scliedule a site visit for DEMLR to verify the SHWT prior
to subinittal, [phone].)
10. A copy of the most current property deed. Deed book: 822 Page No: 406
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC Nl,+
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item 1a, 2a, and/or 3a per 15A NCAC 2H.1003(e).
The corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
http: / /www.secretary.state.nc.us/Corporations/­­CSearch.aspx
Form SWU-101 Version Oct. 31, 2013 Page 5 of 7

VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided
as an attachment to the completed and notarized deed restriction form. The appropriate deed restrictions and
protective covenants forms can be downloaded from http://portal.ncdenr.org/web/lr/state-stormwater-
forms dots. Download the latest versions for each submittal.
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signatures) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and listed
on the forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DEMLR, and that they will be recorded prior to the sale of any lot.
VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
Consulting Engineer:Toseph Ryan Shy
Consulting Firm: Black & Veatch International Company
Mailing Address: 10715 David Taylor Dr Suite 240
City: Charlotte
Phone: ( 704 510-8420
Email: ShyTRCbv.com
State: NC
Fax: ( 704 ) 548-8640
28262
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) NOT APPLICABLE , certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed in Contact Inforntatioti, itettt 1a) NOT APPLICABLE with (print or hjpe natne of organization listed in
Contact Information, item 1a) NOT APPLICABLE to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWU-101 Version Oct. 31, 2013 Page 6 of 7

As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR immediately and .
submit a completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater
treatment facility without a valid permit. I understand that the operation of a stormwater treatment facility
without a valid permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement
action including the assessment of civil penalties of up to$25,000 per day, pursuant to NCGS 143-215.6.
I,
NOT APPLICABLE
a Notary Public for the State of
do hereby certify that
before me this _ day of
Date:
County of
personally appeared
_, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Inforniation, itein 1a) Courtneil Driver
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protectiv covenants wil ecorded, and that the proposed project complies with the requirements of the
applicablere: s nwater ru es nde 15A NCAC 2H .1000 and any other applicable state stormwater requirements.
}
Date:
I, 113A—YI(Aw CA e.4"n , a Notary Public for th State of .�.> County of
do hereby certify that Y it _personally appeared
before me this day of l �V ` � b an knowledge the du leexeeccu_tion of the application for
a stormwater permit. Witness my hand and official
Y GZF ,
NOTARY
PUBLIC
My comm. Exp.
. March 22, 2022
SEAL
My commission expires 14 Vck 3 �-e � Z. Z
Form SWU-101 Version Oct. 31, 2013 Page 7 of 7

r�
40f;
NORTH CAROLINA )
FORSYTH COUNTY H!'. 1A dEP;TCZAFIE WOMBL RLYM SANUU { 6L
ill -
THIS DEED, made this the day of '
1961, by Eva Robertson Scott, widow; Emily Scott C a�er
and husband, Wilburn Crater, all of Forsyth County, North
Carolina, and Pauline Scott Jenkins and husband, James T.
Jenkins, of Norfolk, Virginia, parties of the first part,
to the City of Winston-Salem, a municipal corporation of
Forsyth County, North Carolina, party of the second part;
W I T N E S S E T H:
That the said parties of the first part, in con-
sideration of One Hundred Dollars ($100.00) to them paid
by the said party of the second part, the receipt of
which is hereby acknowledged, have bargained and sold
and by these presents do bargain, sell and convey unto
the said party of the second part, its successors and
assigns, a tract or parcel of land in the County of
Forsyth and State of North Carolina, in Winston Town-
ship, and described as follows:
BEGINNING at a stone, John E. Scottis
southwest corner and a corner of C. P.
Shelton; thence with Shelton's line, North
1 deg. 18 min. East 90.0 feet to a new cor-
ner in Shelton's line; thence with a new
line of John E. Scott the following two
courses: East 60.0 feet, and South 32
deg. 00 min. East 109.3 feet to a new
corner in C. P. Shelton's line; thence
with Shelton's line, North 88 deg. 42
min. West 120.0 feet to the beginning,
containing 0.19 acres, and as shown on
plat dated May 1960,'entitled "Site of
Proposed Water Treatment Plant" prepared
by Piatt & Davis and Associates from sur-
veys made in May and June 1959. Bearings
of the above description refer to the true
meridian as determined from solar observa-
tions. Being the southwest portion of that
real estate described in Deed Book 136 at
Page 82 in the Office of the Register of
Deeds of Forsyth County, North Carolina.
TO HAVE AND TO HOLD the aforesaid tract or par-
cel of land and all privileges and appurtenances thereun-
to belonging to the said party of the second part, its
successors and assigns, forever.

406
AND THE SAID parties of the first part do cove-
nant that they are seized of said premises in fee and have
the right to convey the same in fee simple; that the same
are free from encumbrances; and that they will warrant and
defend the said title to the same against the claims of all
persons whatsoever.
IN TESTIMONY WHEREOF, the said parties of the
first part have hereunto set their hands and seals.
rV_ Raolc� ( SEAL)
Eva Ro er son co , ow
��-�- ( SEAL)
Sri y ' co ra er
NORTH CAROLINA
FORSYTH COUNTY
of Forsyth un Notary Public
y jv—
a: or a na, o ere y certify that
Eva Robertson Scott, widow, and Em ly Scott Crater and
husband, Wilburn Crater, each personally appeared before
-me this day and acknowledged the due execution of the
foregoing deed of'conveyapee.
Witness my hand and notarial seal, this the
day of 1961.
My commission expires:
Ab %ion

PERMIT APPLICATION DOCUMENTS
Neilson Water Treatment Plant Modernization
1 Stormwater Management Permit Application Form
2 Property Deed
Pr
DEAR -LAND QUALITY
STOWAIATER PERMITTING
0 BLACK&VEATCH