NCC193000_NOI Application_20191204

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/26/2019 4:45:19 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 12/2/2019 4:07:57 PM (Review- Construction NOI 18931)
• Morman, Alaina reassigned the task to Garcia, Lauren V 12/2/2019 4:03 PM
* Muchas Gracias!!!!!!
• The task was assigned to Morman, Alaina by round robin distribution 11/26/2019 4:45 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 28, 2019 5:00
PM 11/26/2019 4:45 PM
Submit by McCoy, Suzanne 12/4/2019 7:37:22 AM (Payment Verification for NCC193000)
* Chris Parr
• McCoy, Suzanne assigned the task to McCoy, Suzanne 12/4/2019 7:36 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 13, 2020 5:00 PM
12/2/2019 4:08 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Grand at Union Cross
2. County* Forsyth
3. Highway or Street Pecan Lane
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Winston Salem
5. State * NC
6. Zip Code * 27404
7. Latitude * Enter the latitude in decimal degrees
36.0781
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.1105
If you do not know the latitude and longitude coordinates for this project, you can search the location on this map of
North Carolina. Look for the coordinates in the bottom left corner.
9. Date to Begin*
12/02/2019
Estimated Construction Project Start Date
10. Date to End*
12/01/2021
Estimated Construction Project End Cute
11. SIC (Primary) *
Residential, Other
than SFE (1522)
Standard Industrial aassification for Ceveloprrent
12. Acres to be
13.22
disturbed*
(including off -site borrow and waste areas)
13. Total site area
13.46
(acres) *
14. Post-
7.29
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-FORSY-2019-Grand at Union Cross
Tracking ID
Assigned automatically

Below you must enter waterbody information for surface waters affected by this project. Please consult
DWR's Surface Water Classifications Map Viewer to find waterbody name and corresponding index number. Please
enter only immediate receiving waterbodies - not waters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a. Receiving Fiddler's Creek
Wate rbody* %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-94-13-3
Index No.* NCWaterbody Index Number
Stormwater rJ No
discharges will flow r- Yes
to additional
wate rs *
16a. Is this project r Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
F2rnittee Inforrration - Legally Fbsponsible Entity and Individual
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should be the same person as listed in THIS SECTION, or an authorized responsible individual within the same
organization. That person must be a responsible corporate officer who owns or operates the construction activity, such
as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV,
Section B, Item (6) of the NCG010000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1. Organization The Grand at Union Cross, LLC
Name *
2. First Name* Chris
IF Corporation, enter Pegistered Agent First Barre
3. Last Name* Parr
If Corporation, enter Faegistered Agent Last %rre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 336-382-4523
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 10888
Address Line 2
city
Greensboro
Fbstal / Zip Code
27404
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
r Yes
Street Address
1813 Pembroke Rd
Address Line 2
City
Greensboro
Fbstal / Zip Code
27408-7916
State / Frovince / Faegion
NC
Country
United States
State / Frovince / Plegion
NC
Country
US

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Non -Government
Ownership *
2. Primary Site
Paul
Contact - First
Name *
3. Primary Site
Newton
Contact - Last
Name *
4. Title
Project Manager
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
704-426-9998
Telephone No.*
7. Organization
Charles D. Lowder, Inc.
Name
8. Site Contact
Street Address
Mailing Address*
2810 Griffith Road
Address Line 2
City
Winston Salem
Fbstal / Zip Code
27103-6420
9. Consultant Name
(Optional)
First and Last narre
10. Consultant E-
This person will be copied on all correspondence.
mail
11. Consultant
Telephone No.
State / Rovince / Fbgion
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 11/19/2019
Approved *
2. E&SC Plan Project EN1900074
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Winston-Salem/Forsyth County
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application.
5. E&SC Plan Erosion Control Approval Letter.pdf 253.54KB
Approval Wst be RDFfornat
letter/documentation
6. NOI Certification NCG01-eNO1-Certification-Form-20190507-DEMLR-
Form 987.82KB
SW_Signed.pdf
Wst be RDFfornat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Artcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
Commission implementing this Artcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 I am the person responsible for the construction activities of this project, for
satisfying the requirements of this permit, and for any civil or criminal penalties
incurred due to violations of this permit.
rJ The information submitted in this NOI is, to the best of my knowledge and belief,
true, accurate, and complete based on my inquiry of the person or persons who
manage the system, or those persons directly responsible for gathering the
information.
* 17 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit. I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* 17 I hereby request coverage under the NCG010000 General Permit and
understand that coverage under this permit will constitute the permit
requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Specify if you are:* r The Responsible Person named on this Notice of Intent
f Authorized Responsible Person*
Important: The person who electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized responsible
person within the same organization as the Permittee. *An authorized individual is a responsible corporate officer who
owns or operates the construction activity, such as a president, secretary, treasurer, or vice president, or a manager
that is authorized in accordance with Part IV, Section B, Item (6) of the NCG010000 General Permit. For more
information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature
(f-" frtJ r��/l t t
Type Name* Chris Parr
Title Manager
Organization The Grand at Union Cross, LLC
Date * 11 /26/2019

F. Tracking and COC Info
NOI Tracking No. 18931
NC Reference No. NCG01-2019-3000
Uses 'count number' variable (incremrented by SP)
Certificate of NCC193000
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 3000
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)