SW4110601_CURRENT PERMIT_20110715

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW 411 o Cv o I _
DOC TYPE
CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE
Z,o I 1 d7 j JS
YYYYMMDD

NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Dr. Prithvi Hanspal
Asheboro Medical Properties, LLC
724 Thomas Street
Asheboro, NC 27203
Coleen H. Sullins
Director
July 15, 2011
RECEIVED
N r , -. "I
AUG 16 2011
�fnI15L::��oidR7
Regionai Oii'ice
Dee Freeman
Secretary
Subject: Stormwater Permit No. SW4110601
Asheboro Medical Properties, LLC (Central Piedmont Surgery Center)
High Density Commercial Infiltration Trench Project
Randolph County
Dear Dr. Hanspal:
The Stormwater Permitting Unit received a complete Stormwater Management Permit
Application for Asheboro Medical Properties, LLC on July 13, 2011. Staff review of the plans
and specifications has determined that the project, as proposed, will comply with the Stormwater
Regulations set forth in Title 15A NCAC 2H.1000 and Session Law 2006-246. We are forwarding
Permit No. SW4110601, dated July 15, 2011, for the construction, operation and maintenance of
the subject project and the stormwater BMPs.
The infiltration trenches were approved, and must be maintained, to provide 2.5x the minimum
required treatment volume (based on the 1.0" design storm) in order to waive the requirement of
providing a bypass and 30, vegetated filter strip.
This permit shall be effective from the date of issuance until July 15, 2021, and shall be subject
to the conditions and limitations as specified therein. Please pay special attention to the
Operation and Maintenance requirements in this permit. Failure to establish an adequate system
for inspection and maintenance of the stormwater management system will result in future
compliance problems.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the
right to request an adjudicatory hearing upon written request est within thirty (30) days following
receipt of this permit. This request must be n the form written petition, conforming to
Chapter 150B of the North Carolina General Statutes, and filed with the Office of Administrative
Hearings, P.O. Drawer 27447, Raleigh, NC 27611-7447. Unless such demands are made this
permit shall be final and binding.
This project will be kept on file at the Winston-Salem Regional Office. If you have any questions,
or need additional information concerning this matter, please contact Robert Patterson at (919)
807-6375; or [e-mail].
Wetlands and Stormwater Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St, Raieigh, North Carolina 27604
Phone: [phone] FAX: [phone] Customer Service:1-877-623-6748
Internet: www,ncwaterquality.org
An Equal Opportunity 4 Affirmative Action Employer
One
NCarolina
mma!!rf

Dr. Prithvi Hanspal
SW4110601 — Asheboro Medical Properties, LLC
July 15, 2011
Sincerely,
for Coleen H. Sullins
cc: H. Mack Summey, Jr., PE — Summey Engineering Associates, PLLC
SW4110601 File
ec: Winston-Salem Regional Office
Y
Page 2 of 2

State Stormwater Permit
Permit No. SW4110601
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of
North Carolina as amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Asheboro Medical Properties, LLC
Asheboro Medical Properties, LLC (Central Piedmont Surgery Center)
724 Thomas St., Asheboro, Randolph County
FOR THE
construction, operation and maintenance of four (4) underground infiltration trenches in
compliance with the provisions of Session Law 2006-246 and 15A NCAC 2H .1000
(hereafter referred to as the "stormwater rules') and the approved stormwater
management plans and specifications and other supporting data as attached and on file
with and approved by the Division of Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until July 15, 2021, and shall be
subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
1. This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. This stormwater system has been approved for the management of stormwater
runoff as described in Section 1.8 of this permit. The stormwater control has been
designed to handle the runoff from 40,618 square feet of impervious area.
3. The trenches were approved, and must be maintained, to provide 2.5x the
minimum required treatment volume (based on the 1.0" design storm) in order to
waive the requirement of providing a bypass and 30' vegetated filter strip.
4. The tract will be limited to the amount of built -upon area indicated in Section 1.8
of this permit, and per approved plans.
5. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
6. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
Page 1 of 7

State Stormwater Permit
Permit No. SW4110601
7
The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent streams.
The following design criteria have been provided in the infiltration trenches and
must be maintained at design condition:
DA1 I DA2 I DA3
a. Drainage Area, acres
Onsite, ft
Offsite, ft2:
b. Total Impervious Sur�aces, ft2:
Onsite, ft :
Offsite, ft2:
c. Design Storm, inches:
d. Trench Length ft:
e. Trench Width, ft:
f. Trench Height, ft:
g. Perforated Pipe Diameter / Length:
h. Bottom Elevation, FMSL:
i. Bypass Weir Elevation, FMSY
j. Permitted Storage Volume, ft
k. Type of Soil:
I. Expected Infiltration Rate, inlhr:
m. Seasonal High Water Table, FMSL
n. Time to Draw Down, days:
o. Receiving Stream/River Basin:
p. Stream Index Number:
q. Classification of Water Body:
II. SCHEDULE OF COMPLIANCE
0.447
0.129
0.143
19,491
5,599
6,227
0
0
0
16,458
4,040
4,987
16,458
4,040
4,987
0
0
0
1.0
1.0
1.0
100.0
75.0
85.0
13.0
7.0
6.0
6.5
4.25
5.08
no pipe
no pipe
no pipe
787.0
791.25
791.42
793.5
795.5
796.5
3,315.7
866.5
1,011.1
clay, saprolite
2.5
1.5
3.5
<783.5
<788.5
1
<788.5
1.3
1.41
0.73
UT to
Vestal Creek 1 Cape Fear
17-22-4
„C„
The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use immediately after the drainage
area is stabilized.
2. During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
3. The permittee shall at all times provide the operation and maintenance
necessary to assure the permitted stormwater system functions at optimum
efficiency. The approved Operation and Maintenance Plan must be followed in
its entirety and maintenance must occur at the scheduled intervals including, but
not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and revegetation of slopes.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans and
specifications.
f. Debris removal and unclogging of overflow structure, trench media and
piping, catch basins, and piping.
g. A clear access path to the overflow structure must be available at all
times.
4. Records of maintenance activities must be kept for each permitted BMP. The
records will indicate the date, activity, name of person performing the work and
what actions were taken.
0.445
19,396
0
13,636
13,636
0
1.0
160.0
7.08
6.25
no pipe
790.25
796.5
2,775.9
3.5
<786.5
0.89
Page 2 of 7

State Stormwater Permit
Permit No. SW4110601
5. The permittee shall submit to the Division of Water Quality an annual summary
report of the maintenance and inspection records for each BMP. The report
shall summarize the inspection dates, results of the inspections, and the
maintenance work performed at each inspection.
6. The facilities shall be constructed as shown on the approved plans. This permit
shall become voidable unless the facilities are constructed in accordance with
the conditions of this permit, the approved plans and specifications, and other
supporting data.
7. Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received
from an appropriate designer for the system installed certifying that the permitted
facility has been installed in accordance with this permit, the approved plans and
specifications, and other supporting documentation. Any deviations from the
approved plans and specifications must be noted on the Certification. A
modification may be required for those deviations.
8. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
9. Access to the stormwater facilities shall be maintained via appropriate
easements at all times.
10. The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval or a CAMA
Major permit was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
10. The permittee shall submit final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
11. A copy of the approved plans and specifications shall be maintained on file by
the Permittee for a minimum of ten years from the date of the completion of
construction.
12. The Director may notify the permittee when the permitted site does not meet one
or more of the minimum requirements of the permit. Within the time frame
specified in the notice, the permittee shall submit a written time schedule to the
Director for modifying the site to meet minimum requirements. The permittee
shall provide copies of revised plans and certification in writing to the Director
that the changes have been made.
Page 3 of 7

State Stormwater Permit
Permit No. SW4110601
III. GENERAL CONDITIONS
This permit is not transferable to any person or entity except after notice to and
approval by the Director. In the event of a change of ownership, or a name
change, the permittee must submit a completed Name/Ownership Change form
to the Division of Water Quality, signed by both parties, and accompanied by the
supporting documentation as listed on page 2 of the form. The approval of this
request will be considered on its merits and may or may not be approved.
2. The permittee is responsible for compliance with all permit conditions until such
time as the Division approves the transfer request.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Water Quality, in
accordance with North Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation
of nuisance conditions, the Permittee shall take immediate corrective action,
including those as may be required by this Division, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants DENR Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
7. The permit issued shall continue in force and effect until revoked or terminated.
The permit may be modified, revoked and reissued or terminated for cause. The
filing of a request for a permit modification, revocation and reissuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
10. The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Session Law 2006-
246, Title 15A NCAC 2H.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division in writing of any name, ownership or
mailing address changes at least 30 days.
12. The permittee shall submit a renewal request with all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Page 4 of 7

State Stormwater Permit
Permit No. SW4110601
Permit issued this the 151h day of July, 2011.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
for Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission
Page 5 of 7

State Stormwater Permit
Permit No. SW4110601
Asheboro Medical Properties, LLC
Stormwater Permit No. SW4110601
Randolph County
Designer's Certification
I, , as a duly registered in the
State of North Carolina, having been authorized to observe (periodically/ weekly/ full
time) the construction of the project,
(Project)
for (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
Page 6 of 7

State Stormwater Permit
Permit No. SW4110601
Certification Requirements:
1. The drainage area to the system contains approximately the permitted
acreage.
2. The drainage area to the system contains no more than the permitted
amount of built -upon area.
3. All the built -upon area associated with the project is graded such that the
runoff drains to the system.
4. All roof drains are located such that the runoff is directed into the system.
5. The overflow structure elevations are per the approved plan.
6. The overflow structure is located per the approved plans.
7. The system is functioning as designed and per the approved plans.
8. All slopes are grassed with permanent vegetation.
9. Vegetated slopes are no steeper than 3:1.
10. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
11. The permitted amounts of surface area and volume have been provided.
12. All required design depths are provided.
13. All required parts of the system are provided.
14. The required system dimensions are provided per the approved plans.
Please submit this Designer's Certification to: Winston-Salem Regional Office
Surface Water Protection
585 Waughtown Street
Winston-Salem, NC 27107
Page 7 of 7

Permit Number: -5Lt/4T1la'601
(to he provided hY DWQ)
Drainage Area Number:?' f
Infiltration Trench Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will be kept in a
log in a known set Iocation. Any deficient BMP elements noted in the inspection will be
corrected, repaired or replaced immediately. These deficiencies can affect the integrity
of structures, safety of the public, and the removal efficiency of the BMP.
Important maintenance procedures:
— The drainage area of the infiltration trench will be carefully managed to reduce
the sediment load to the sand filter.
— The water Ievel in the monitoring wells will be recorded once a month and after
every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal County).
The infiltration trench will be inspected once a quarter and within 24 hours after every
storm event greater than 1.0 inches (or 1.5 inches if in a Coastal County). Records of
operation and maintenance will be kept in a known set location and will be available
upon request.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element:
Potentialproblem:
How I will remediate theproblem:
The entire BMP
Trash/debris is present.
Remove the trash/debris.
The grass filter strip or
Areas of bare soil and/or
Regrade the soil if necessary to
other pretreatment area
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
one-time fertilizer application.
Sediment has accumulated to
Search for the source of the
a depth of greater than six
sediment and remedy the problem if
inches.
possible. Remove the sediment and
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
The flow diversion
The structure is clogged.
Unclog the conveyance and dispose
structure (if applicable)
of any sediment off -site.
The structure is damaged.
Make any necessary repairs or
replace if damage is too large for
re air.
Pornn SW401-infiltration Trench O&M-Rev.3
Page 1 of"I

BMP element:
Potentialproblem:
How I will remediate theproblem:
The trench
Water is ponding on the
Remove the accumulated sediment
surface for more than 24
from the infiltration system and
hours after a storm.
dispose in a location that will not
impact a stream or the BMP.
The depth in the trench is
Remove the accumulated sediment
reduced to 75% of the original
from the infiltration system and
design depth.
dispose in a location that will not
impact a stream or the BMP.
Grass or other plants are
Remove the plants, preferably by
growing on the surface of the
hand. If pesticide is used, wipe it on
trench,
the plants rather than spraying.
The observation well(s)
The water table is within one
Contact the DWQ Stormwater Unit
foot of the bottom of the
immediately at 919-733-5083.
system for a period of three
consecutive months.
The outflow pipe is clogged.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
The outflow pi2e is damaged.
Repair or replace the pipe.
The emergency overflow
Erosion or other signs of
The emergency overflow berm will
berm
damage have occurred at the
be repaired or replaced if beyond
outlet
repair,
The receiving water
Erosion or other signs of
Contact the NC Division of Water
damage have occurred at the
Quality 401 Oversight Unit at 919-
outlet.
733-1786.
Form SW40I -Infiltration 'french O&M-Rev.3 Page 2 of")

Permit Number: SW'l i i �GOI
(to be provided bi> 0ff'Q)
acknowledge and agree by my signature below that I am responsible for the
performance of the maintenance procedures listed above. I agree to notify DWQ of any
problems with the system or prior to any changes to the system or responsible party.
Pt-gject name: Asheboro Medical Properties, LLC
BAJP drainage area number: I 2 3 & 4
Print name: Dr. Prithvi Hanspal
Title: Managing Partner
Address: P.O. Box
Phone: [phone]
Signature;. / `
Date: 6 - 2-
Note: The legally responsible party should not be a homeowners association unless more than 50% of
the lots have been sold and a resident of the subdivision has been named the president.
I, � _ �`-1 kr'A a Notary Public for the State of
0orAV\, Cara\'v.e, , County of do hereby certify that
Dle . ?0N �'personally appeared before me this
day of t.�L— , —IZ 1 \ , and acknowledge the due execution of the
forgoing infiltration trench maintenance requirements. Witness my hand and official
SEAT.
My commission expires DO- C.jg-nak
Form SW401-Infiltration Trench O&M-Rev.3
Page 3 o f 3

�t11 t'3r:�,
•✓ �'� � � S •'r' ,
ti � :l � fG-

1 4 it`. t� : � :xDWQjIJSE ONLY
', i w
Pate •ceived
Fee Paid
Permit Number
1: z7 ! r
"LDS
SW �f 110 6 0
Applicabh. Rul s:
(select all that apply)
❑ Coastal SW —1995 ❑ Coastal SW
❑ Non -Coastal SW- HQW/ORW Waters
❑ Other WQ M mt Plan:
— 2008 1�1- h II - Post Construction
❑ Universal Stormwater Management Plan
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for [ise 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.):
Asheboro Medical Properties, LLC
2. Location of Project (street address):
724 Thomas St. SR 2195
City:Asheboro County:Randolph Zip:27203
3. Directions to project (from nearest major intersection):
From intersection of US Highway 64 and US Hwy 220 take 64 East to NC Hwy 42 turn left. Site is 0.50 miles
on right. _
4. Latitude:35° 70' 25" N Longitude:79° 79' 42" W of the main entrance to the project.
[I. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification
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 certificatio►t
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 DWQ
requesting a state stormwater management permit application, list the stormwater project number, if
assigned, N/A _ _ 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: 2.0 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: Land Disturbance Permit was obtained in December 2010.
Project ID number is RANDO - 2011-012
Form SWU-101 Version 07July20U9
Page l of 6

Ili. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who ovens the l2rojeck):
Applicant/Organization:. Asheboro Medical Properties, LLC
Signing Official & Title: Dr. Prithvi Hanspal, Manager _
b.Contact information for person listed in item 1a above:
Street Address: 724 Thomas Street
City:Asheboro State:NC Zip:27203
Mailing Address (if applicable): P.O. Box 519
City:Asheboro State:NC Zip:27204
Phone: (336 } 308-0155 Fax: (336 ) 308-0155
Email: [e-mail]
Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
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: _Asheboro Medical Properties, LL C
Signing Official & Title: Dr. Prithvi Hanspal, Manager
b.Contact information for person listed in item 2a above:
Street Address: 724 Thomas Street
City:Asheboro State:NC Zip:27203
Mailing Address (if applicable): P.O. Box 519
City:Asheboro State:NC Zip:27203
Phone: (336 ) 308-0155 Fax: [phone]
Email: drhanspal«hotmail.com
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:
Signing Official & Title:
b.Contact information for person listed in item 3a above:
Mailing Address:
City: State: Zi
Phone: ( ) Fax: ( }
Email:
4. Local jurisdiction for building permits: City of Asheboro
Point of Contact: Mr. Lar v Trotter Phone #: (336 _) 626-1204x231
Form SWU-10l Version 07July2009 Page 2 ol'7

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
All BUA surface area runoff will be directed to 4 gravel infiltration trenches located around the site to capture
BUA. BMP's are designed to capture the first inch of runoff from the entire site.
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.Identify the regulations) the project has been designed in accordance with:
❑ Coastal SW - "1995 ® Ph 11 - Post Construction
3. Stormwater runoff frorn this project drains to the Cape Fear River basin.
4. Total Property Area: 1.812 acres
5. Total Coastal Wetlands Area: 0 acres
6. "Total Surface Water Area: 0 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) -Total Surface Water Area (6) = Total Project
Area*:1.812 acres
Total project area shall be calculated to exclude the following the normal pool of impounded structures, the area
between the hanks of streams and rivers, the area below the Normal High Water (NHW) lime or Mean High Water
(MHW) lime, and coastal wetlands latidWard frorn the NHW (or MHIline. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward c f 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 = 51.40
9. How many drainage areas does the project have? 4 (For high density, count 1 for each proposed
engineered stormwater BMP. For low density and other projects, use 1 for the whole 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.
Basin Information
Drainage Area 1
Drraina a -Area 2
Draina a Area 3
_
Drainage Area 4
Receiving Stream Name
UT to Vestal
Creek
UT to Vestal
Creek
UT to Vestal
Creek
UT to Vestal
Creek
Stream Class
C
C
C
C
Stream Index Number *
17-22-4
17-22-4
17-22-4
"17-22-4
Total Drainage Area (sf)
5599
6227
19396
On -site Drainage Area (so
—1414W
5599
6227
19396
Off -site Drainage Area (sf)
0
0
0
0
Proposed Impervious Area** s
,-r�,� l6
4,040
4,987
13,636
% Impervious Area** total
85.7
1 72.8
80.10
70.3
Impervious— Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area 3
Drainage Area 4
On -site Buildings/l.ots (so
8,663f
0
0
0
On -site Streets (so
0
0
0
0
On -site Parking (so
6384)
3825
4910
12635
On -site Sidewalks (so
591 I
215
77
966
Other on -site (so
860
0
0
0
Future (so
1457
0
0
0
Off -site (sf)
0
0
0
0
Existing BUA*** (so
0
, r 0
0
0
Total (so:
1795&-
4040
4987
13636
5trearrr Class and Index Number can be determined at: itttp://h2o.enr.state.lrc.us/buns/re>ports/reportsWB.htnrl
Form SWU-101 Version 07July2009 Page 3 of 7

lrrrpervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
"W Report only that amount Of existing BUA that will rennin after development. Do riot 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. There was no off -site
impervious Area listed above, there is none going thru site.
Projects in Union County: Contact DWQ Central Office stuff to check if the project is located ir-ithin a 771reatened &
Endangered Species i%vtershed that may he subject to more stringent storinvvater requirements as per 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://li2o.enr.statC.nc.L]S/su/bmp forms.htm.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from htt ]n2o.etnr.state.nc.us su bmi2 forms.htm. The complete application package
should be submitted to the appropriate DWQ Office. (The appropriate office may be found by locating project
on the interactive online map at htt h2o.enr.state.ttc.us su msi ma s.htm.)
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 htQ2://h2o.enr.state.nc.us/su/bmp forms.htm.
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part Vtl below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDI.NR. (For an Express review, refer to
http://www.etivhelp.org/12ages/onestol2exl2ress.litmt 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/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 ii mile of the site boundary, include the'1h
mile radius on the map.
7. Sealed, signed and dated calculations.
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 tidai 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.
Initials
-� 4
�uS
Form SWU-101 Version 47July2(109 Page 4 47

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).
Copy of any applicable soils report with the associated SHWT elevations (Please identify rr1S
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 Kith 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: Schedi de a site visit for DWQ to verify the SHWT prior
to 20-ift-1 19101796-7378.1
rt5
L
A copy of the most current property deed. Deed book: 2126 Page No: 1522
For corporations and limited liability corporations (LLC): Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and/or 3a per 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/CorporationsZCSearcii.asl2x
VIL 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:ILh2o.enr.st,ite.nC.us/SLI/binl2 forms.]Ztm#deed restrictions. 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 DWQ, 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: H. Mack Summey, fr., PE
Consulting Firm: Summey Engineering Associates, PLLC
Mailing Address: P.O. Box 968
City:Asheboro State:NC Zip:27204
Phone: (236 ) 328-0902
Email: mack@,islieboro.com
Fax: (336 ) 328-0922 _
Forni SWU-101 Version 07July2009 Page 5 of 7

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) sorne as above 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, item 1a) with (print or type name of organization listed in
Contact Information, item 1b) 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.
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 DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ 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:
Da te:
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 fora
stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
Form SWU-101 Version 07Rily2009 Page 6 ol'7

X. APPLICANT'S CERTIFICATION
1, (print or type name of person listed in Contact Information, item 2) Dr. PrithVi Hanspal
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 cove an tll be recorded, and that the proposed project complies with the requirements of the
applicable stormwaterfi es under 15A N�;AC 2H .1000, SL 2006-246 (Ph. II — Post Construction) or SL 2008-211.
Signa
Date: �' Z
I, Q�D Si• �El_�� Z — a Notary Public for the State of r f-6 County of
do hereby certify that L� Pr tv: Gn5 personally appeared
before me this day of �J11� , and acknow ge the due execution of the application fora
stormwater permit. Witness my hand and official seal,
T,1414-
Pp
-40
10
SEAL
My commission expires Q_ %Jd
Form SWU-101 Version 07JUly2009 Page 7 of 7

21
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral, and Land Resources
Land Quality Section
Tracy E. Davis, PE, CPM
Director
August 29, 2013
CER"11FIED MAIL #7012 2920 0000 3656 1462
RETURN RECEIPT REQUESTED
Dr. Prithvi Hanspal
Asheboro Medical Properties, LLC
724 Thomas Street
Asheboro, NC 27203
Pat McCrory, Governor
John E. Skvarla, III, Secretary
Subject: NOTICE OF INSPECTION
Asheboro Medical Properties, LLC (Central Piedmont Surgery Center)
Permit No. SW4110601
Randolph County
Dear Dr. Hanspal:
On August 28, 2013, Aana Taylor -Smith and Sue White of the Winston-Salem Regional Office of the Division of
Energy, Mineral, and Land Resources (DEMLR) inspected the Central Piedmont Surgery Center site in Randolph
County to determine compliance with Stormwater Management Permit Number SW4110601 issued on July 13,
2011. DEMLR site inspection and subsequent file review revealed that the site is not compliant with the terms and
conditions of this permit. The following items were noted during the inspection and file review:
1. Grass perimeters for all infiltration trenches need re -seeding to address bare patches that could lead to
erosion.
2. Trench # 1 needs attention at the inlet where there is some sediment accumulation below the gravel
causing slight ponding.
3. Inlets for Trench 42 and Trench #3 need maintenance to remove vegetation and accumulated sediment
from rip -rap.
4. Trench #4 may need a small amount of gravel replaced at the corner closest to the parking lot entrance.
5. Condition 11.7 of Permit Number SW4110601 requires that an engineer's certification must be received
by the Division prior to occupancy of the project. An engineer's certification was not found during the file
review. Please submit an engineer's certification within 30 days of receiving this letter.
All necessary repairs should be conducted within 30 days of receiving this letter. DEMLR staff will conduct a
follow-up inspection at that time. Please find a copy of the completed form entitled "Compliance Inspection
Report" attached to this letter.
Please be advised that you are required to comply with the terms, conditions and limitations of your Stormwater
Management Permit under Title 15A North Carolina Administrative Code 2H .1003 and North Carolina General
Statute 143-214.7, including operation and maintenance of your permitted stormwater system.
Winston-Salem Regional Office
585 Waughtown Street, Winston-Salem, NC 27101 a Phone: [phone] FAX: [phone]

1
Asheboro Medical Properties, LLC
August 29, 2013
Page 2 of 2
If the project has changed name, ownership or mailing address, a formal change of name/ownership form must be
submitted to DEMLR within 30 calendar days detailing the change. Please provide the name, mailing address and
phone number of the person or entity that is now responsible for this permit.
Thank you for your assistance and cooperation during this inspection. Please he advised that violations of the
Stormwater Management Permit may be subject to a civil penalty assessment of up to $25,000.00 per day
for each violation. If you have any questions, comments, or need assistance with understanding any aspect of
your permit, please do not hesitate to contact Aana Taylor -Smith, Sue White, or me at [phone].
■ Complete items 1r:2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
�_Dr. Prithvi Hanspal
Asheboro Medical Properties LLC
724 Thomas Street
Asheboro, NC 27203
Sincerely,
_'�4
Matthew E. Gantt, PE
Regional Engineer
Land Quality Section
❑ Agent
X ❑ Addressee
B. Receiv r by (Printed Name) C. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes ;
If YES, enter delivery address below: ❑ No
3. S Ice Type
TC rtdled Mail ❑ Express Mail
1 E Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
7012 2920 1111 3656 1462• n.
0_0_-Dow-e's-tic Return
U.S. Postal Service3M �'
rLJ
CERTIFIED MAILTM RECEIPT ate%
(Domestic Mai! Only; No Insurance Coverage Provided)
For deiivery infor3rtation visit our website at www.usps.com�,
OFFICIAL
U�I�
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Enclosure: Stormwater Inspection Report
o
certilledFee
SW U 1Pos VLOO1
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Restricted Delivery Fee
DWR Central Files
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(Endorsement Required)
ll`J
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Total Por:7-- " ----: ¢ -
Dr. Prithvi Hanspal
ruF
Asheboro Medical Properties LLC
0
Ga17-'Asheboro,
724 Thomas Street -----
NC 27203 -

Compliance Inspection Report
Permit: SW4110601 Effective: 07/15/11 Expiration: 07/15/21 Owner: Asheboro Medical Properties LLC
Project: Asheboro Medical Properties LLC
County: Randolph 724 Thomas St Sr2195
Region: Winston-Salem
Contact Person: Prithvi Hanspal Title:
Directions to Project:
Type of Project: State Stormwater - HD - Infiltration
Drain Areas: 001 - (Vestal Creek) (03-06-09 } ( C)
002 - (Vestal Creek) (03-06-09 } ( C)
003 - (Vestal Creek) (03-06-09) ( C)
004 - (Vestal Creek) (03-06-09) ( C)
On -Site Representative(s):
Related Permits:
Inspection Date: 08/2812013 EntryTime: 10:00 AM
Primary Inspector: Aana Taylor -Smith
Secondary Inspector(s):
Sue White
Reason for Inspection: Routine
Permit Inspection Type: State Stormwater
Facility Status: 0 Compliant ■ Not Compliant
Question Areas:
0 State Stormwater
(See attachment summary)
Asheboro NC 27203
Phone: [phone]
Exit Time: 10:40 AM
Phone: [phone]
Phone:
Inspection Type: Compliance Evaluation
Page: 1

Permit: SW4110601 Owner - Project: Asheboro Medical Properties LLC
Inspection Date: 08128/2013 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
Please submit signed Engineer's Certification as required by Condition 11.7 of the Permit
Grass perimeters for all trenches need re -seeding to address bare patches, which may lead to erosion. Trench #1 needs
attention at the inlet where there is some sediment accumulation below the gravel causing slight ponding. Inlets for
Trench #2 and Trench #3 need maintenance to remove vegetation and accumulated sediment from rip -rap. Trench #4
may need a small amount of gravel replaced at the corner closest to the parking lot entrance.
Page: 2

Permit: SW4110601 Owner - Project: Asheboro Medical Properties LLC
Inspection Date: 08128/2013 Inspection Type: Compliance Evaluation Reason for Visit: Routine
File Review Yes No NA NE
Is the permit active? ■ ❑ ❑ ❑
Signed copy of the Engineer's certification is in the file? ❑ ■ ❑ ❑
Signed copy of the Operation & Maintenance Agreement is in the file? ■ ❑ ❑ ❑
Copy of the recorded deed restrictions is in the file? ■ ❑ ❑ ❑
Comment: Please submit signed Engineer's Certification as required by Condition 11.7
of the Permit.
Built Upon Area
Yes No
NA
NE
Is the site BUA constructed as per the permit and approval plans?
■ ❑
❑
❑
Is the drainage area as per the permit and approved plans?
■ ❑
❑
❑
Is the BUA (as permitted) graded such that the runoff drains to the system?
■ ❑
❑
❑
Comment:
SW Measures Yes No NA NE
Are the SW measures constructed as per the approved plans? ■ ❑ ❑ ❑
Are the inlets located per the approved plans? ■ ❑ Cl ❑
Are the outlet structures located per the approved plans? ■ ❑ ❑ ❑
Comment:
Operation and Maintenance Yes No NA NE
Are the SW measures being maintained and operated as per the permit requirements? ❑ ■ ❑ ❑
Are the SW BMP inspection and maintenance records complete and available for review or provided to DWO ❑ ❑ ❑ ■
upon request?
Comment: Grass perimeters for all trenches need re -seeding to address bare patches,
which may lead to erosion. Trench #1 needs attention at the inlet where there is some
sediment accumulation below the gravel causing slight ponding. Inlets for Trench #2
and Trench #3 need maintenance to remove vegetation and accumulated sediment
from rip -rap. Trench #4 may need a small amount of gravel replaced at the corner
closest to the parking lot entrance.
Other Permit Conditions
Yes No
NA
NE
Is the site compliant with other conditions of the permit?
❑ ❑
❑
❑
Comment:
Other WQ Issues
Yes No
NA
NE
Is the site compliant with other water quality issues as noted during the inspection?
❑ ❑
❑
❑
Comment:
Page: 3

State Stormwater Inspection Report
General
Project Name: AsVLv bo+D AdaC6(A .s trtr
Permit No: SW4I I tO to0 I
Expiration Date: —7 / 1 5 12o2I
Contact Person: Dr. pri 11vt Hnns5p l
Phone Number:
Inspection Type: Cc— t
Inspection Date: I2er 13
Time In: \p i5
Time Out:
Current Weather: LI bVt
Recent Rain (Date)?
Rain — in
Location
Facility Address / Location: z� I 'T]•lc, rt s Si-.
City: 1�SYte bOYv Zip: 21 Z03 County: 12.ArN� Lat: "N Long: - ° "W
Permit Information
Rule Subject to (circle one): 1988 Coastal Rule 1995 Coastal Rule 2008 Coastal Rule Session Law 2006-246
Goose Creek High Quality Waters Outstanding Resource Waters
Density (circle one): High (H Low (LD)
Stormwater Best Management Practices (BMPs) (insert number of each):
Wet Ponds Infiltration Basins J'±_Infiltration Trenches
Dry Ponds Bioretention Permeable Pavement
Cistern Level Spreader/Filter Strip Other (specify):
File Review
LD Swales Stormwater Wetlands
Sand filters (circle one) Open Closed
Yes No NIA NIE
1. Is the permit active?
2. Si ned Engineer's Certification on file?
X
3. Signed Operation and Maintenance agreement on file?
4. Recorded Deed Restrictions on file?
Site Visit- Ruilt llnnn Area IRIIAI
Yes No NIA NIE
5. BUA is constructed and consistent with the permit requirements?
tiG
6. BUA aspermitted) is graded such that the runoff drains to the system? (high density only)
7. Drainage area is consistent withpermit? i.e, no un ermitted drainage to the SW BMPs
8. Drainage area is stabilized? to reduce risk of sedimentation to the SW BMPs
Site Visit: Stormwater BMPs Yes No N/A NIE
9. Stormwater BMPs are located per the approvedplans?
V-
10. Stormwater BMPs have dimensions e . length, width, area) matching the approvedplans?
Y,
11. Stormwater BMPs are constructed per the approvedplans?
x
Site Visit- Oneratinn and Maintenance
Yes No NIA NIE
12. Access points to the site are clear and well maintained?
�G
13. Trash has been removed as needed?
14. Excessive landscape debris (grass clippings, leaves, etc is controlled?
15. Stormwater BMPs being operated and maintained as per the permit requirements?
16. Inspection and Maintenance records are available for inspection? (high density only, 1995 — present only)
Site Visit: Other Permit Conditions Yes No NIA NIE
17. Is the site compliant with other conditions of thepermit?
Site Visit: Other Water Quality Issues Yes No NIA NIE
18. Is the site compliant with other water quality issues as noted during the inspection?
State Stormwater Inspection Report, Version 3.0_3-09 Page I of 2
y ..

State Stormwater Inspection Report
of the pictures taken during the site
Compliance Status ❑ Compliant ❑ Non -Compliant
Letter Sent (circle one): Yes No Letter type: CEI NOV NOVRE Other
Date Sent: Reference Number:
Inspector Name and Signature:
Date:
State Stormwater Inspection Report, Version 3.0_3-09 Page 2 of 2

INFILTRATION BASIN O & M Inspection Report
Inlets and Pretreatment .
1. Drainage area is managed to reduce the sediment load to the basin: �E ❑ El-
2.
Bypass structure / Vegetated filter is free of erosion and obstructions:
❑
❑
❑
3.
Inlet device is free of erosion, damage or clogs:
❑
'M
❑
❑
4.
Pretreatment area free of excessive sediment:
❑
❑
❑
5.
Pretreatment area is free of erosion:
❑
❑
[
❑
6.
Rip rap (if used) is in correctly placed:
❑
❑
❑
Perimeter`
7.
Perimeter of the infiltration basin is free of bare soil or erosion:
❑
❑
❑
8.
Vegetation around the basin is maintained at N6 inches height:
❑
[
❑
❑
9.
Slopes and bottom are free of erosion and woody vegetation (trees or shrubs):
❑
❑
❑
Main Treatment Area
10.
Main treatment area is free of weeds:
❑
❑
❑
11.
Vegetation in the basin is maintained at —6 inches height:
❑
❑
❑
12.
Main treatment area is free of excessive sediment:
❑
❑
❑
13.
Main treatment surface area is free of clogs:'r {V)CA-)-r-epla-�^e� Y,Uv I
❑
[
❑
❑
14.
(SM
Basin is drained and it has been more than 5 days since last rain:a;
❑
❑
❑
Device
15. Outlet device is free of erosion, clogs or damage:
16. Orifice size matches approved plans:
17.
18.
Relative elevations match approved plans:
Outlet device draining properly — (free of standing water, cattails, etc.):
QYGIZLr
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral, and Land Resources
Land Quality Section
Tracy E. Davis, PE, CPM Pat McCrory, Governor
Director John E. Skvarla, 111, Secretary
October 16, 2013
CERTIFIED MAIL #7013 1710 0002 1865 7546
RETURN RECEIPT REQUESTED
Dr. Prithvi Hanspal
Asheboro Medical Properties, LLC
724 Thomas Street
Asheboro, NC 27203
Subject: NOTICE OF INSPECTION
Asheboro Medical Properties, LLC (Central Piedmont Surgery Center)
Permit No. SW4110601
Randolph County
Dear Dr. Hanspal:
On October 16, 2013, Aana Taylor -Smith of the Winston-Salem Regional Office of the Division of Energy, Mineral, and
Land Resources (DEMLR) inspected the Central Piedmont Surgery Center site in Randolph County to determine
compliance with Stormwater Management Permit SW4110601 issued on July 13, 2011. This inspection was conducted as
a follow-up inspection to the previous inspection on August 28, 2013. DEMLR file review and site inspection revealed
that the site is compliant with the terms and conditions of this permit and all repairs have been completed as requested.
Please find a copy of the completed form entitled "Stormwater Inspection Report" attached to this letter.
Please be advised that you are required to comply with the terms, conditions and limitations of your Stormwater
Management Permit under Title 15A North Carolina Administrative Code 2H .1003 and North Carolina General Statute
143-214.7, including operation and maintenance of your permitted stormwater system.
Thank you for your assistance and cooperation during this inspection. Your commitment to compliance with the
Stormwater Management Permit is greatly appreciated. If you have any questions, comments, or need assistance with
understanding any aspect of your permit, please do not hesitate to contact Aana Taylor -Smith or me at [phone].
Sincerely,
Matthew E. Gantt, PE
Regional Engineer
Land Quality Section
Enclosure: Stormwater Inspection Report
cc: WSRO Files
DWR Central Files
Winston-Salem Regional Office
585 Waughtown Street, Winston-Salem, NC 27101 e Phone: [phone] FAX: [phone]

0 Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
M Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
Dr. Prithvi Hanspal-�
Asheboro Medical'Properties, LLC
724 Thomas Stre t
❑ Agent
B. P66eived by (Printed Name) C. Date of Delivery
Jo- IS,, (3
D. Is delivery address different from item 1? 0 Yes
If YES, enter delivery address be)ow: 0 No
e
Asheboro, NC 27203 s. s Ice Type
M�ortified Mail* ❑ Priority Mail Express'"
I �l Registered 0 Return Receipt for Merchandise
❑ Insured Mail ❑ Collect on Delivery
4. Restricted Delivery? (Extra Fee) ❑ Yes
tv —ar-13 r
1710 0002 1865 7546 A/0r U
PS Form 3811, July 2013 Domestic Return Receipt Ole ♦rt ,
it ►
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Certified Fee
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Postmark
Here
2 .S�
©
Restricted Delivery Fee
(Endorsement Required)
r-i
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Dr. Prithvi Hanspal
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San
Asheboro Medical Properties,
LLC
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o.F 724 Thomas Street
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c;ry Asheboro, NC 27203
••-•--------

Compliance Inspection Report
Permit: SW4110601 Effective: 07/15/11 Expiration: 07/15/21 owner: Asheboro Medical Properties LLC
County: Randolph
Region: Winston-Salem
Contact Person: Prithvi Hanspal
Directions to Project:
Title:
Type of Project: State Stormwater - HD - Infiltration
Drain Areas: 001 - (Vestal Creek) (03-06-09 ) ( C)
002 - (Vestal Creek) (03-06-09 ) ( C)
003 - (Vestal Creek) (03-06-09 ) ( C)
004 - (Vestal Creek) (03-06-09 ) ( C)
On -Site Representative(s):
On -site representative Kim McCarty
Related Permits:
Inspection Date: 1011612013 Entry Time: 09A0 AM
Primary Inspector: Aana Taylor -Smith
Secondary Inspector(s):
Reason for Inspection: Follow-up
Permit Inspection Type: State Stormwater
Facility Status: IN Compliant ❑ Not Compliant
Question Areas:
State Stormwater
(See attachment summary)
Project: Asheboro Medical Properties LLC
724 Thomas St Sr2195
Asheboro NC 27203
Phone: [phone]
Exit Time: 10:00 AM
Phone:
Phone: [phone]
Inspection Type: Compliance Evaluation
Page: 1

Permit: SW4110601 Owner - Project: Asheboro Medical Properties LLC
Inspection Date: 10/16/2013 Inspection Type: Compliance Evaluation Reason for Visit: Follow-up
Inspection Summary:
Please refer to inspection summary letter.
File ReyleW
Yes
No
NA NE
Is the permit active?
■
Cl
❑ ❑
Signed copy of the Engineer's certification is in the file?
■
❑
❑ ❑
Signed copy of the Operation & Maintenance Agreement is in the file?
■
❑
❑ ❑
Copy of the recorded deed restrictions is in the file?
■
❑
Cl ❑
Comment: Engineer's certification received 9/30/13.
Built Upon Area Yes No NA NE
Is the site BUA constructed as per the permit and approval plans? ■ ❑ ❑ ❑
Is the drainage area as per the permit and approved plans? ■ ❑ ❑ ❑
Is the BUA (as permitted) graded such that the runoff drains to the system? ■ ❑ ❑ 0
Comment:
SW Measures Yes No NA NE
Are the SW measures constructed as per the approved plans? ■ ❑ ❑ ❑
Are the inlets located per the approved plans? ■ ❑ ❑ ❑
Are the outlet structures located per the approved plans? ■ ❑ ❑ ❑
Comment:
Operation and Maintenance Yes No NA NE
Are the SW measures being maintained and operated as per the permit requirements? ■ ❑ ❑ ❑
Are the SW BMP inspection and maintenance records complete and available for review or provided to DWQ ■ ❑ ❑ ❑
upon request?
Comment: All repairs have been completed as requested. Vegetation has been
re-established and is thriving. Gravel has been replenished. Rip -rap at inlets has been
cleaned out. Overall, all four infiltration trenches are in excellent condition. Records of
maintenance received 9/30/13.
Other Permit Conditions Yes No NA NE
Is the site.compliant with other conditions of the permit? ■ ❑ ❑ ❑
Comment:
Other WQ Issues Yes No NA NE
Is the site compliant with other water quality issues as noted during the inspection? ■ ❑ ❑ ❑
Comment:
Page: 2

State Stormwater Inspection Report
General
Project Name: -ASho)OCWD ic6.4 4LX—
GLI `
Permit No: SW LA 1i btpp }Expiration1
Date: 15 j 2D21
Contact Person: (y Spat 1 V im "C_CeL T, A
Phone Number:l� Mckss
Inspection Type:
Inspection Date: 101 113
Time In: D,-, LA O
Time Out: 1 O
Current Weather: �Vo'S, _ oL� o i CAC)"q
Recent Rain (Date)?
Rain -- in
Location
Facility Address/ Location: -124 -Tl/)t)lVW S S+
City: hSy1eAp1c>r,p Zip: 2-12C3 County: YzPri�1D Lat: 0"N Long: - 6 "W
Permit Information
Rule Subject to (circle one): 1988 Coastal Rule 1995 Coastal Rule
Goose Creek High Quality Water!
Density (circle one): ' h HD Low (LD)
Stormwater Best Management Practices (BMPs) (insert number of each):
Wet Ponds Infiltration Basins _ _]nfiltration Trenches
Dry Ponds Bioretention Permeable Pavement
Cistern Level Spreader/Filter Strip Other (specify):
File Review
2008 Coastal Rule Session Law 2006-246
Outstanding Resource Waters
LD Swales Stormwater Wetlands
Sand filters (circle one) Open Closed
Yes No NIA NIF
1. Is the permit active?
2. Signed En ineer's Certification on file?
,/
3. Signed Operation and Maintenance agreement on file?
t/
4. Recorded Deed Restrictions on file?
t/
Site Visit: Built Unon Area MUM
5. BUA is constructed and consistent with the permit requirements?
6. BUA aspermitted) is graded such that the runoff drains to the system? (high density only)
7. Drainage area is consistent withpermit? i.e. no un ermitted drainage to the SW BMPs
8. Drainage area is stabilized? to reduce risk of sedimentation to the SW BMPs
Site Visit: Stormwater BMPs
Yes No NIA N/E
9. Stormwater BMPs are located per the approvedplans?
10. Stormwater BMPs have dimensions (e . length, width, area) matching the approvedplans?
11. Stormwater BMPs are constructed per the approvedplans?
Site Visit: Operation and Maintenance
Yes No NIA NIE
12. Access points to the site are clear and well maintained?
13. Trash has been removed as needed?
14. Excessive landscape debris (grass clippings, leaves, etc) is controlled?
15, Stormwater BMPs being operated and maintained as per the permit requirements?
16. Inspection and Maintenance records are available for inspection? (high density only, 1995 —present only)
_t
Site Visit: Other Permit Conditions Yes No NIA NIE
17. Is the site com liant with other conditions of the ermit? V/
Site Visit: Other Water Quality Issues Yes No NIA NIE
18. Is the site compliant with other water quality issues as noted during the inspection?
State Stormwater Inspection Report, Version 3.0_3-09 Page I of 2

State Stormwater Inspection Report
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Nt� .-Q. +r� S i o►�
y.gDrt0_A-i0y OVA StopTs Y�-eS liS�-red djrow�rte� tae.l�
Inspection Pictures (some of the pictures taken during the site visit)
Compliance Status 9 Compliant ❑ Non -Compliant
Letter Sent (circle one)::Yes No Letter typ : CEI NOV NOVRE Other
Date Sent: Reference Number:
Inspector Name and Signature: 4Date: o IQ 13
State StorTnwater Inspection Reporl, Version 3.0 3-09 Page 2 of 2

INFILTRATION BASIN O & M Inspection Report
9 -A-V�UVV � - all c�o�cD
Inlets and Pretreatment
1. Drainage area is managed to reduce the sediment load to the basin: 12r ❑ ❑ ❑
2.
Bypass structure / Vegetated filter is free of erosion and obstructions:
[J
❑
❑
❑
3.
Inlet device is free of erosion, damage or clogs:
ET
❑
❑
❑
4.
Pretreatment area free of excessive sediment:
19/
❑
❑
❑
5.
Pretreatment area is free of erosion:
EY
❑
❑
❑
6.
Rip rap (if used) is in correctly placed:
❑
❑
❑
Perimeter
7.
Perimeter of the infiltration basin is free of bare soil or erosion:
a
❑,
❑
❑
8.
Vegetation around the basin is maintained at —6 inches height:
a
❑
❑
❑
9.
Slopes and bottom are free of erosion and woody vegetation (trees or shrubs):
13-",
❑
❑
❑
Main Treatment Area
10.
Main treatment area is free of weeds:
❑'
❑
❑
❑
11.
Vegetation in the basin is maintained at —6 inches height:
[
❑
❑
❑
12.
Main treatment area is free of excessive sediment:
19'
❑
❑
❑
13.
Main treatment surface area is free of clogs:
[3
❑
❑
❑
14.
Basin is drained and it has been more than 5 days since last rain:
[
❑
❑
❑
Outlet Device
15.
Outlet device is free of erosion, clogs or damage:
Kr
❑
❑ -
❑
16.
Orifice size matches approved plans:
❑"
❑
❑
❑
17.
Relative elevations match approved plans:
IT
❑
❑
❑
18.
Outlet device draining properly — (free of standing water, cattails, etc.):
C3-
❑
❑
❑
V3.3_09