NCC192287_NOI Application_20191011

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/10/2019 9:42:33 AM (NCG01 NOI Submission)
Approve by Clark, Paul 10/10/2019 1:35:45 PM (Review- Construction NOI 16993)
• The task was assigned to Clark, Paul by round robin distribution 10/10/2019 9:43 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 14, 2019 5:00
PM 10/10/2019 9:43 AM
Submit by McCoy, Suzanne 10/11/2019 12:57:37 PM (Payment Verification for NCC192287)
* Wildlands Engineering Inc.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 10/11/2019 12:57 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 21, 2019 5:00
PM 10/10/2019 1:35 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * White Buffalo Mitigation Site
2. County* Surry
3. Highway or Street White Buffalo Rd.
Address * Street narra only is acceptable if no address nurrtrer assigned yet
4. City or Township * Mt. Airy
5. State * NC
117-8) TiT 2,G) M F1Ii f_T1II a 10141
6. Zip Code* 27030
7. Latitude * Enter the latitude in decirral degrees
36.4446
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-80.6843
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*
11/01/2019
Estimated Construction Project Start Date
10. Date to End*
04/01 /2020
Estimated Construction Project End Date
11. SIC (Primary)*
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
21.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area
21.00
(acres)*
14. Post-
0.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-SURRY-2019-White Buffalo Mitigation Site
Tracking ID
Assigned autorratically

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 Jackson Creek
Waterbody* Narre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-63-11
Index No. * NCWaterbody Index Pbnber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional Fisher River
Receiving Waterbody narre
Waterbody
15d. Waterbody 12-63-(9)
Index No. NCWaterbody Index Ninber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index kbrrber
Index No.
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.
Perrrittee Information - Legally Fbsponsible Entity and Individual
.....................................................................................................................................................................
h
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 Wildlands Holdings IV LLC
Name *
2. First Name* Shawn
ff Corporation, enter Fbgistered Agent First l\bm
3. Last Name * Wilkerson
IF Corporation, enter Faegistered Agent Last Barre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-458-1836
Telephone No.*
6. Permittee Mailing Street Address
Address* 1430 South Mint Street
Address Line 2
Suite 104
City
Charlotte
Pastal / Zip Code
28203
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
PF Yes
Street Address
1430 South Mint Street
Address Line 2
Suite 104
City
Charlotte
Pastal / Zip Code
28203
State / Province / Faegion
NC
Country
United States
State / Province / Region
NC
Country
United States

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Individual
Ownership*
2. Primary Site Eric
Contact - First
Name *
3. Primary Site Neuhaus
Contact - Last
Name *
4. Title Water Resources Engineer
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact
[phone]
Telephone No.*
7. Organization
Wildlands Engineering, Inc.
Name
8. Site Contact
Street Address
Mailing Address*
1430 South Mint Street
Address Line 2
Suite 104
aty
Charlotte
Fbstal / Zip Code
28203-4151
9. Consultant Name (optional)
Wildands Engineering, Inc.
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant [phone]
Telephone No.
State / Province / Pegion
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 09/16/2019
Approved *
2. E&SC Plan Project SURRY-2020-010
Number/ID* Assigned by agency or local program
3. E&SC Plan f• State DEQ Office
Approved by r Local Program
4. State DEQ Office * Winston-Salem (WSRO)
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 Letter of Approval.pdf 336.36KB
Approval Mist be RCFformat
letter/documentation
6. NOI Certification NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form 631.96KB
SW —White Buffalo_Signed.pdf
Mist be RCF format
This is an Express f• No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.613 (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
rJ 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.
* I7 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ 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
r 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
�. ��r�rsr.,� �f�'lf�• tJC6�
Type Name * Shawn Wilkerson
Title President
Organization Wildlands Holdings IV LLC
Date * 10/10/2019

F. Tracking and COC Info
NOI Tracking No. 16993
NC Reference No. NCG01-2019-2287
Uses 'count number variable (incremrented by SP)
Certificate of NCC192287
Coverage (COC) Uses'count_nunber'variable (incremrented by SF)
No. *
Count Number 2287
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NGC' in OOCno.)