SW3191205_Application_20191231

DEMLR USE ONLY
Date Received Fee Paid Permit Number
M.131 I26tt e46.2422 # Sae, Su-) 31°1 t 2 oc,
Applicable Rules: 0 Coastal SW-1995 0 Coastal SW-2008 ❑Ph II-Post Construction Me0
(select all that apply) 0 Non-Coastal SW-HQW/ORW Waters 0 Universal Stormwater Management Plan
❑Other WQ Mgmt Plan:
State of North Carolina RECEIVED
Department of Environment and Natural Resources
Division of Energy,Mineral and Land Resources EEC 31 2019
STORMWATER MANAGEMENT PERMIT APPLICATION FOUR-LAND QUALITY
This form may be photocopied for use as an original STORMWATER PERMITTING
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.):
Windsong Subdivision
2. Location of Project(street address):
Fairview Road (NC HWY 218)
City: N/A County: Union Zip:
3. Directions to project(from nearest major intersection):
From the intersection of Interstate 485 & Fairview Road (NC 218), East on Fairview
for approx. 2.5 miles. Site is on the left (North)
4. Latitude: 35° 09' 55 " N Longitude: 80° 35 ' 29"W of the main entrance to the project.
II. PERMIT INFORMATION:
1.a.Specify whether project is(check one): ElNew [Modification ❑Renewal w/ Modificationt
tRenewals with 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: DNot Started DPartially Completed* ❑Completed* *provide a designer's certification
2. Specify the type of project(check one):
❑Low Density ®High Density ODrains 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):
DCAMA Major ®Sedimentation/Erosion Control: 18.24 ac of Disturbed Area
❑NPDES Industrial Stormwater ®404/401 Permit:Proposed Impacts 141 LF &0.03 AC
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: (404) Windsong Development-SAW-2019-00553-9/1 1/201 9
5. Is the project located within 5 miles of a public airport? No ❑Yes
If yes,see S.L.2012-200,Part VI:http://portal.ncdenr.org/web/lr/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: Wellspring Carolina Investments LLC
Signing Official&Title: Mark Boyce
b.Contact information for person listed in item la above:
Street Address: 2133 Garden View Lane
City:Matthews, State: NC Zip: 28104
Mailing Address(if applicable):
City: State:
Zip:
Phone: 980 ) 269-6609 Fax: ( 704 ) 919 5099
Email: [e-mail]
c.Please check the appropriate box.The applicant listed above is:
❑The property owner(Skip to Contact Information,item 3a)
0 0 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: Wellspring Carolina Investments LLC
Signing Official&Title: Mark Boyce
b.Contact information for person listed in item 2a above:
Street Address: 2133 Garden View Lane
City:Matthews, State: NC Zip: 28104
Mailing Address(if applicable):
City: State:
Zip:
Phone: 980 ) 269-6609 Fax: f 704 ) 919-5099
Email: [e-mail]
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: Henson Foley Design
Signing Official&Title: Tim Foley
b.Contact information for person listed in item 3a above:
Mailing Address:8712 Lindholm Dr#202A
City: Huntersville, State: NC Zip: 28078
Phone: ( 704 ) 875- 1615 Fax: (
Email: [e-mail]
4. Local jurisdiction for building permits: Union County
Point of Contact: Lee Jenson Phone#. ( 704 283 3564
Form SWU-101 Version Oct.31,2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below,bri�fly summarize how the stormwater runoff will be treated.
The entire built upon area will be either piped or swaled to a SCM with a sand filter
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
❑ Valid Building Permit Approval Date:
Other: Issued Date:
Date:
b.If claiming vested rights,identify the regulation(s)the project has been designed in accordance with:
❑Coastal SW-1995 0 Ph II-Post Construction
3. Stormwater runoff from this project drains to the Yadkin Pee-Dee
4. Total Property Area: 53.70 River basin.
acres 5. Total Coastal Wetlands Area: N/A
6. Total Surface Water Area: 13.17 acres
7. Total Property Area(4)-Total Coastal Wetlands Area(5)-Total Surface Water Area(6)=Total Project acres
Area+: 40.53 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(NHW
(MHW)line,and coastal wetlands landward from the NHW(or MHiresultant
line or Mean High Water
calculate overall percent built upon area(BU . Non-coastal etlands landward N W(or MI-1 is usedn to
be included in the total project area. of HW(or MHV1�line may
8. Project percent of impervious area: (Total Impervious Area/Total Project Area)X 100 = 14.41 %
9. How many drainage areas does the project have? 3
count 1
stormwater BMP. For low density and other projects, use 1 for thetwhole pr perty area)or each proposed engineered
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.
Basin Information Draina•e Area 1 Draina•e Area 2 Draina•e Area 3 Draina•e Area
Receiving Stream Name Duck Creek Duck Creek —
Stream Class * Duck Creek
C C C
Stream Index Number* 13-17-18-3 13-17-18-3
Total Drainage Area 1 0 3
g (s� 665,596 331,056 267,022
On-site Drainage Area(sf) 661,222 287,140
Off-site Drainage Area246,760
2
g (sf) 4,374 43,916 20, 62
Pro.osed Impervious Area** s 135,617 70,310
48,640
%Impervious Area** total) 20.37 % 21.23 % 18.21 %
Im•ervious Surface Area Drainage Area 1
+
OM On-site Buildings/Lots(sf) 104,000 56,000 40,0Drainage Area 3 Drainage Area
On-site Streets (sf) 00
31,617 14,3108,640
On-site Parking (sf) 0 0
On-site Sidewalks (sf) 0 0
0 0
Other on-site (sf)
0 0 0
Future(sf) 0 0
Off-site (sf) 0
0 0 0
Existing BUA***(sf) 0
0 0 111111
Total (sf): 135,617 70,310
* Stream Class and Index Number can be determined at: ht 48,640
classi cations
** Impervious area is defined as the built upon area including,but not limited to,r.or buildings,roadss,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.
Form SWU-101 Version Oct.31,2013
Page 3 of 6

11. How was the off-site impervious area listed above determined?Provide documentation. NIA
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 htt : ortal.ncdenr ore/web/wa/ws/su/bm 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
htt : ortal.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 httn://portal.ncdenr.or /web/wa/ws/su/ma s.)
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 htt : ortal.ncdenr.or web w ws su statesw forms does.
1. Original and one copy of the Stormwater Management Permit Application Form. is
2. Original and one copy of the signed and notarized Deed Restrictions&Protective Covenants
Form. (if required as per Part VII below) 1t:.�)
3. Original of the applicable Supplement Form(s)(sealed,signed and datedl and O&M
agreement(s)for each BMP.
4. Permit application processing fee of$505 payable to NCDENR. (For an Express review,refer to
htt : www.envhel .or a es onesto ex ress.html for information on the Express program
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 1/2 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.
I. 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).
Form SWU-101 Version Oct.31,2013
Page 4 of 6

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: 720713
11. For corporations and limited liability corporations(LLC):Provide d cumge ntaN tion from
4:01
Secretary of State or other official documentation,which supports the titlesand positions held Igrr
by the persons listed in Contact Information,item la,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.
h www.secretary state nc us/Coroorations/CSearch.asvx
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 httn://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: Tim Foley
Consulting Firm: Henson Foley Design
Mailing Address: 8712 Lindholm Dr#202A
City: Huntersville,
State: NC Zip: 28078
Phone: 704 875 - 1615
Fax: j
Email: [e-mail]
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)
certify that
own the property identified in this permit application,and thus give permission to(print or type name of pe son I
listed in Contact Information, item 1a)
with(print or type name of organization listed in
Contact Information, item la) to develop the project as currently proposed. copy of
the lease agreement or pending property sales contract has been provided with the submittal,which ndcat indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWU-101 Version Oct.31,2013
Page 5 of 6

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: -I y /
I, r �- t.� _ , _ ^ Date: j p - �J
t_ ,a Notary Public for the State of / �( �0.
County
of
1)l/1 ,do hereby certify that
l 1 personally appeared
before me this ay of 1�,19-}Q,Vy VOA ,20i9,and a,cknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
J7
\Weil
QPV�A J.Ro
y SEAL
�OTARy ;
My Comm.Exp. __
Ti 11/6/2022
ss
G J'IBLIC c� My commission expires ) I — .Q2Z
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information,item 1a)
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 protective covenants will be recorded,and that the proposed project complies with the requirements of the
applicable stormwater rules under 15A NCAC 2H.1000 and any other applicable state stormwater requirements.
Signature:
Date:
I, ,a Notary Public for the State of
County of
,do hereby certify that
personally appeared
before me this_day of , .and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
Form SWU-101 Version Oct.31,2013 Page 6 of 6

North Carolina Secretary of State Search Results Page 1 of 1
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an Amended a Annual Report form
Limited Liability Company
Legal Name
WELLSPRING CAROLINA INVESTMENTS, LLC
Information
Sosld: 1080574
Status: Current-Active
Annual Report Status: Current
Citizenship: Domestic
Date Formed: 1/23/2009
Registered Agent: Hinson, Wesley S.
Addresses
Mailing Principal Office Reg Office
2133 Garden View Lane 2133 Garden View Lane 309 Post Office Drive
Matthews, NC 28104-8062 Matthews, NC 28104-8062 Indian Trail, NC 28079-7671
Reg Mailing
309 Post Office Drive
Indian Trail, NC 28079-7671
Company Officials
All LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20.
Manager
Mark W. Boyce
2133 Garden View Lane
Matthews NC 28104
https://www.sosnc.gov/onlineservices/search/Business Registration Results 1/9/2020