NCC193018_NOI Application_20191205

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 12/3/2019 10:27:32 AM(NCG01 NOI Submission)
Approve by Farkas,Jim J 12/3/2019 3:25:08 PM(Review-Construction NOI 19049)
• The task was assigned to Farkas,Jim J by round robin distribution 12/3/2019 10:27 AM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is: December 5,2019 5:00
PM.The priority is: High 12/3/2019 10:27 AM
Submit by McCoy, Suzanne 12/5/2019 7:23:42 AM(Payment Verification for NCC193018)
* Robert Todd Joyce
• McCoy,Suzanne assigned the task to McCoy, Suzanne 12/5/2019 7:23 AM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is:January 14, 2020 5:00 PM.
The priority is: High 12/3/2019 3:25 PM

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1Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System 'D application for•• - .•-under NorthCarolina's
General Permit 1 1111:STORIVWATER DISCHARGES associated with construction activities(or
NORTH CAROLINA
Enrlrnnmenfu�Qr�arlry
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* Kernersville State Veterans Home
2.County* Forsyth
3. Highway or Street Kernersville Medical Parkway
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Kernersville
5.State* NC
6.Zip Code* 27284
7. Latitude* Enter the latitude in decirral degrees
36.0941
8. Longitude* Enter the longitude in decimal degrees(M.ST be negative)
-80.0440
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* 12/09/2019
Estinated Construction Project Start Date
10. Date to End* 03/01/2021
Estirreted Construction Project End Cute
11.SIC(Primary)* Commercial(1542)
Standard Industrial aassification for Development
12.Acres to be 15.79
disturbed* (including off-site borrow and waste areas)
13.Total site area 19.55
(acres)*
14. Post- 8.00
construction (E tir ated)
impervious area
(acres)*
NCC Project NCC-FORSY-2019-Kernersville State Veterans Home
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 West Fork Deep River
Wate rbody* f brre of waterbody into which storrrwater runoff will discharge
15b.Waterbody 17-3-(0.3)
Index No.* NCWaterbody Index N nber
Stormwater V No
discharges will flow r Yes
to additional
wate rs*
16a. Is this project F 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 Rodgers Builders, Inc.
Name*
2. First Name* Todd
ff Corporation,enter Pbegistered Agent First Barre
3. Last Name* Joyce
If Corporation,enter Faegistered Agent Last%rre
3b.Title Sr.Vice President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704.264.7442
Telephone No.*
6. Permittee Mailing Street Address
Address* 5701 N. Sharon Amity Rd.
Address Line 2
PO Box 18446(28218)
City State/Frovince/Region
Charlotte NC
Fostal/Zip Code Country
28215 USA
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 5701 N. Sharon Amity Rd.
Address Line 2
PO Box 18446(28218)
City State/Frovince/Fbgion
Charlotte NC
Fbstal/Zip Code Country
28215 USA

C. Site Contact Information
Part C. ^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1.Type of Government-State
Ownership*
2. Primary Site Myron
Contact-First
Name*
3. Primary Site Albright
Contact-Last
Name*
4.Title Superintendent
5.Site Contact E- [e-mail]
mail Address*
6.Site Contact 910-508-8399
Telephone No.*
7.Organization Rodgers Builders
Name
8.Site Contact Street Address
Mailing Address* 1795 Kernersville Medical Parkway
Address Line 2
City State/Rovince/Fbgion
Kernersville NC
Fbstal/Zip Code Country
28284 USA
9. Consultant Name (Optional)
Lewis Hardee
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant 919-645-5964
Telephone No.

D. E&SC Plan
Part D. ^
Erosion&Sediment Control(E&SC)Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 09/03/2019
Approved*
2. E&SC Plan Project Forsy-2019-035
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* 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 2411 VA Home NCG01 NOI Certification Form.pdf 2.04MB
Approval Wst be RDFforrrat
letter/documentation
6. NOI Certification 2411 VA Home NCG01 NOI Certification Form.pdf 2.04MB
Form Mist be R7Fforrrat
This is an Express f No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6E(i) 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 knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis 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 guiltyofa Class 2 misdemeanor which mayinclude 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
-rekD.raYCrr
Type Name* Todd Joyce
Title Sr.Vice President
Organization Rodgers Builders.com
Date* 12/03/2019

F. Tracking and COC Info
NOI Tracking No. 19049
NC Reference No. NCG01-2019-3018
Uses'count_nurrber'variable(increrrented by SP)
Certificate of NCC193018
Coverage (COC) Uses'count number'variable(increrrented by SP)
No.*
Count Number 3018
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2019
Year of date reviewed(used to assign YY digits after"NOC'in COCno.)