NCC192498_NOI Application_20191025

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/24/2019 10:11:57 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 10/24/2019 10:19:40 AM (Review- Construction NOI 17623)
• The task was assigned to Garcia, Lauren V by round robin distribution 10/24/2019 10:12 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 28, 2019 5:00
PM 10/24/2019 10:12 AM
Submit by McCoy, Suzanne 10/25/2019 8:17:22 AM (Payment Verification for NCC192498)
* Rebekah Robinson
• McCoy, Suzanne assigned the task to McCoy, Suzanne 10/25/2019 8:16 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 5, 2019 5:00
PM 10/24/2019 10:19 AM

1 re) fTiT 7i) M f i1i f_T1II a 1010
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * MOUTH OF MUD CREEK FLOODPLAIN RESTORATION
2. County* Henderson
3. Highway or Street BUTLER BRIDGE ROAD
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township * MILLS RIVER
5. State * NC
6. Zip Code* 28732
7. Latitude * Enter the latitude in decirral degrees
35.4030
8. Longitude * Enter the longitude in decirral degrees (MUST be negative)
-82.5315
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 *
01 /02/2020
Estimated Construction Project Start Date
10. Date to End*
09/30/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
47.86
disturbed*
(including off -site borrow and waste areas)
13. Total site area
100.00
(acres)*
14. Post-
0.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-HENDE-2020-MOUTH OF MUD CREEK FLOODPLAIN
Tracking ID
RESTORATION
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 French Broad River
Waterbody* Nbrre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 6-(54.75)
Index No. * NC Waterbody Index Narrber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional Mud Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 6-55
Index No. NCWaterbody Index Ninber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody [e-mail]
Index No. m
NC Waterbody Index Ninber
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 Responsible 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 Conserving Carolina
Name *
2. First Name* Kieran
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Roe
ff Corporation, enter Registered Agent Last Barre
3b. Title Executive Director
4. Permitee E-mail [e-mail]
Address*
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* 847 Case Street
Address Line 2
City
State / Province / Region
Hendersonville
NC
Postal / Zip Code
Country
28792
USA
Check box if the r% Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 847 Case Street
Address Line 2
City
State / Province / Region
Hendersonville
NC
Rastal / Zip Code
Country
28792
USA

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site David
Contact - First
Name *
3. Primary Site Lee
Contact - Last
Name *
4. Title Project Manager
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
[phone]
Telephone No.*
7. Organization
Conserving Carolina
Name
8. Site Contact
Street Address
Mailing Address*
847 Case Street
Address Line 2
city
Hendersonville
Fbstal/ Zip Code
28792
9. Consultant Name (optional)
Greg Jennings
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 / Region
NC
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 10/21/2019
Approved *
2. E&SC Plan Project HENDE 2020-003
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 * Asheville (ARO)
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 LOAwM & COPA 10-21-2019.docx.pdf 111.88KB
Approval Mast be FDF format
letter/documentation
6. NOI Certification 20191024102339779.pdf 546.78KB
Form Mist be RDFformat
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
err trl�r,_��
Type Name * Kieran Roe
Title Executive Director
Organization Conserving Carolina
Date * 10/24/2019

F. Tracking and COC Info
NOI Tracking No. 17623
NC Reference No. NCG01-2019-2498
Uses 'count number variable (incremrented by SP)
Certificate of NCC192498
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 2498
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.)