NCC193113_NOI Application_20191210

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/5/2019 9:13:42 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 12/9/2019 8:35:08 AM (Review- Construction NOI 19139)
• Georgoulias, Bethany reassigned the task to Garcia, Lauren V 12/9/2019 8:25 AM
* Lauren, these are two of Jim's from last week. He could use some help, too. Thank you!
• The task was assigned to Farkas, Jim J by round robin distribution 12/5/2019 9:14 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 9, 2019 5:00
PM 12/5/2019 9:14 AM
Submit by McCoy, Suzanne 12/10/2019 1:39:45 PM (Payment Verification for NCC193113)
* Laura P Meadows
• McCoy, Suzanne assigned the task to McCoy, Suzanne 12/10/2019 1:39 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 20, 2020 5:00 PM
12/9/2019 8:35 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Suffolk-Swamp-Winfall 230 kV Rebuild, Section 3
2. County* Perquimans
3. Highway or Street North of Swamp Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Winfall
5. State * NC
6. Zip Code * 27944
7. Latitude * Enter the latitude in decimal degrees
36.2773
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-76.4943
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*
01/01/2020
Estimated Construction Project Start Date
10. Date to End*
01/31/2021
Estimated Construction Project End Cute
11. SIC (Primary) *
Other (0000)
Standard Industrial aassification for Ceveloprrent
12. Acres to be
47.20
disturbed*
(including off -site borrow and waste areas)
13. Total site area
150.42
(acres) *
14. Post-
0.05
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-PERQU-2020-Suffolk-Swamp-Winfall 230 kV Rebuild, Section
Tracking ID
3
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 Perquimans River
Waterbody * %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 30-6-(1)
Index No.* NCWaterbody Index N nber
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional Raynor Swamp
Receiving Waterbody narre
Waterbody
15d. Waterbody 25-17-2
Index No. NCWaterbody Index Nanber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Nmber
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. ^
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 Dominion Energy North Carolina
Name *
2. First Name* Mark
If Corporation, enter Registered Agent First f brre
3. Last Name* Allen
If Corporation, enter Fegistered Agent Last %rre
3b. Title Director, Electric Transmission Lines Project Development &
Execution
4. Permitee E-mail [e-mail]
Address*
5. Permittee 804-257-4711
Telephone No.*
6. Permittee Mailing Street Address
Address* 10900 Nuckols Road, 4th Floor
Address Line 2
Cty
Glen Allen
Fbstal / Zip Code
23060
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 10900 Nuckols Road, 4th Floor
Address Line 2
city
Glen Allen
Postal / Zip Code
23060
State / Rovince / Fegion
VA
Country
us
State / Rovince / Faegion
VA
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
...............................................................................................................................
1. Type of Non -Government
Ownership *
2. Primary Site James Eric
Contact - First
Name *
3. Primary Site Clay
Contact - Last
Name *
4. Title
Electric Transmission Construction
Consultant
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
804-335-9534
Telephone No.
7. Organization
Dominion Energy North Carolina
Name
8. Site Contact
Street Address
Mailing Address*
10900 Nuckols Road, 4th Floor
Address Line 2
city
Glen Allen
Fbstal / Zip Code
23060
9. Consultant Name
(Optional)
First and Last nacre
10. Consultant E-
This person will be copied on all correspondence.
mail
11. Consultant
Telephone No.
State / Rovince / Region
VA
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 12/02/2019
Approved *
2. E&SC Plan Project Gates-2020-001
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 * Washington (WaRO)
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 Gates-2020-001 Suffolk-Swamp-Winfall 230 kV
Approval 1.11 MB
Rebuild -Section 3 - 120220.... pdf
letter/documentation
Mist be R7Fforrrat
6. NOI Certification signed eNO1 certification.pdf 548.85KB
Form Mist be PDFfon-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
Type Name *
Mark Allen
Title
Director, Electric Transmission Lines Project Development &
Execution
Organization
Dominion Energy North Carolina
Date *
12/05/2019

F. Tracking and COC Info
NOI Tracking No. 19139
NC Reference No. NCG01-2019-3113
Uses 'count number' variable (incremrented by SP)
Certificate of NCC193113
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 3113
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.)