NCC192832_NOI Application_20191121

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/18/2019 4:49:13 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 11/19/2019 10:31:36 AM (Review- Construction NOI 18607)
• The task was assigned to Morman, Alaina by round robin distribution 11/18/2019 4:49 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 20, 2019 5:00
PM 11/18/2019 4:49 PM
Submit by McCoy, Suzanne 11/21/2019 7:30:33 AM (Payment Verification for NCC192832)
* Brunswick County
• McCoy, Suzanne assigned the task to McCoy, Suzanne 11/21/2019 7:30 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 31, 2019 5:00
PM 11/19/2019 10:31 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Northeast Brunswick Wastewater System Force Main Improvements
2. County* Brunswick
3. Highway or Street Mt Misery Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Leland
5. State * NC
6. Zip Code * 28451
7. Latitude * Enter the latitude in decimal degrees
34.2716
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-78.0487
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*
11/22/2019
Estimated Construction Project Start Date
10. Date to End*
06/30/2020
Estimated Construction Project End Cute
11. SIC (Primary) *
Other (0000)
Standard Industrial classification for Ceveloprrent
12. Acres to be
17.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area
17.00
(acres) *
14. Post-
0.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC- BRUNS-201 9- Northeast Brunswick Wastewater System Force
Tracking ID
Main Improvements
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 cape fear
Waterbody * %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 18-(71)
Index No.* NCWaterbody Index Number
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional rowell branch
Receiving Waterbody narre
Waterbody
15d. Waterbody 18-77-1-1-1
Index No. NCWaterbody Index Nurrber
15e. Additional cartwheel branch
Receiving Waterbody narre
Waterbody
15f. Waterbody 18-72
Index No. NCWaterbody Index Nurrber
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 Brunswick County
Name *
2. First Name* John
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Nichols
IF Corporation, enter Faegistered Agent Last %rre
3b. Title public utilities director
4. Permitee E-mail [e-mail]
Address *
5. Permittee 9102532657
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box249
Address Line 2
city
Bolivia
Fbstal / Zip Code
28422
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
r Yes
Street Address
250 Grey Water Road
Address Line 2
City
Supply
Fbstal / Zip Code
28462
State / F rovince / Faegion
NC
Country
us
State / Frovince / Fbgion
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Government - County
Ownership *
2. Primary Site
Brent
Contact - First
Name *
3. Primary Site
Lockamy
Contact - Last
Name *
4. Title
Project Manager
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
9102532460
Telephone No.*
7. Organization
Brunswick Bounty
Name
8. Site Contact
Street Address
Mailing Address*
Po box249
Address Line 2
City
bolivia
Fbstal / Zip Code
28422
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 08/01/2019
Approved *
2. E&SC Plan Project Bruns-2020-003
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. State DEQ Office * Wilmington (WiRO)
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 BRUNS-2020-003 Approval 8-1-2019.pdf 287.56KB
Approval Mist be RDFfornal
letter/documentation
6. NOI Certification NOI signed form.pdf 58.95KB
Form Mist be R7Ffon-rat
This is an Express F No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6E (i) 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 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
01 7"Off (�1i�Oell/
Type Name * John Nichols
Title Director of Public Utilities
Organization Brunswick County
Date * 11 /18/2019

F. Tracking and COC Info
NOI Tracking No. 18607
NC Reference No. NCG01-2019-2832
Uses 'count number' variable (incremrented by SP)
Certificate of NCC192832
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2832
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.)