NCC200812_NOI Application_20200303

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/27/2020 5:09:21 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 2/28/2020 7:28:26 AM (Review- Construction NOI 22549)
. The task was assigned to McCoy, Suzanne by round robin distribution 2/27/2020 5:09 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 2, 2020 5:00 PM
2/27/2020 5:09 PM
Submit by McCoy, Suzanne 3/3/2020 1:37:32 PM (Payment Verification for NCC200812)
* LKC Engineering
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/3/2020 1:37 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 10, 2020 5:00 PM
2/28/2020 7:28 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name *
Morganton Park Lot 4
1 b. Specific Lot
This field rray be used to list specffc lot numbers.
Numbers
Lot 4
2. County*
Moore
3. Highway or Street Morganton Road
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Southern Pines
5. State * NC
6. Zip Code* 28387
7. Latitude* Enter the latitude in decimal degrees
35.1768
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.4160
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*
03/05/2020
Estimated Construction Project Start Date
10. Date to End *
08/03/2020
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
11.75
disturbed*
(including off -site borrow and waste areas)
13. Total site area 14.00
(acres)*
14. Post- 11.00
construction (Estirated)
impervious area
(acres) *

NCC Project NCC-MOORE-2020-Morganton Park Lot 4
Tracking ID Assignedautorratically
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 Unnamed Tributary at Southern Pines
Wate rbody* %ram of waterbody into which storrrwater runoff will discharge
15b. Waterbody 14-2-11-2-2-(1)
Index No. * NCWaterbody Index Minter
Stormwater V 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 Pinehurst Surgical Clinic Realty, LLC
Name * If perrrittee is an individual (i.e., organization does not apply), enter first and last nave in this field.
2. First Name* Charles
IF Corporation, enter Pbegistered Agent First Barre
3. Last Name* Gregg
If Corporation, enter Faegistered Agent Last Wre
3b. Title Member
4. Permitee E-mail [e-mail]
Address *
5. Permittee 910-235-2993
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box2000
Address Line 2
city
Pinehurst
Fbstal / Zip Code
27374
Check box if the r Yes
street address the
same as mailing
address
State / Ftovince / Faegion
NC
Country
us
7. Permittee Street
Street Address
Address*
5 First Village Drive
Address Line 2
City
State / Ffovince / Plegion
Pinehurst
NC
Flostal / Zip Code
Country
27374
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Charles
Contact - First
Name *
2. Primary Site
Gregg
Contact - Last
Name *
3. Title
Member
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-235-2993
Telephone No.
6. Organization
Pinehurst Surgical Clinic Realty, LLC
Name
7. Site Contact
Street Address
Mailing Address*
PO Box2000
Address Line 2
city
Pinehurst
Fbstal / Zip Code
28374
8. Consultant Name
(Optional)
Tim Carpenter
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
910-420-1437
Telephone No.
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 02/24/2020
Approved *
2. E&SC Plan Project ZP-03-20
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Town of Southern Pines
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. For linear projects, please also upload a site map showing the overall extent of the project or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan ESC Letter of Approval.pdf 548.8KB
Approval letter or Mast beRDFforml
Grading Permit
Site Map (Optional) Helpful for linear project review
Mast be R7Fform3t
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies for linear projects if necessary.
6. NOI Certification NCGO1 NOI Certification 2.27.20.pdf 118.18KB
Form Mast be RDFfon-rat
This is an Express F 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
Type Name* Charles Gregg
Title Member
Organization Pinehurst Surgical Clinic Realty, LLC
Date * 02/27/2020

F. Tracking and COC Info
NOI Tracking No. 22549
NC Reference No. NCG01-2020-0812
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200812
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 812
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)