NCC193134_NOI Application_20191211

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/6/2019 1:59:23 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 12/10/2019 2:41:58 PM (Review- Construction NOI 19228)
• The task was assigned to McCoy, Suzanne by round robin distribution 12/6/2019 1:59 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 10, 2019 5:00
PM 12/6/2019 1:59 PM
Submit by McCoy, Suzanne 12/11/2019 7:52:11 AM (Payment Verification for NCC193134)
* Cidney Joe//e Jones.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 12/11/2019 7:51 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 21, 2020 5:00 PM
12/10/2019 2:42 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Red Barn Mitigation Bank
2. County* Surry
3. Highway or Street Timeless Trail
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Mount Airy
5. State * NC
6. Zip Code * 27030
7. Latitude * Enter the latitude in decimal degrees
36.4918
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.6392
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*
12/13/2019
Estimated Construction Project Start Date
10. Date to End*
03/13/2020
Estimated Construction Project End Cute
11. SIC (Primary) *
Other (0000)
Standard Industrial classification for Ceveloprrent
12. Acres to be
32.70
disturbed*
(including off -site borrow and waste areas)
13. Total site area
34.00
(acres) *
14. Post-
0.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-SURRY-2019-Red Barn Mitigation Bank
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 Stewarts Creek
Wate rbody* Barre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-72-9-(8)
Index No.* NCWaterbody Index Ninber
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 Ecosystem Planning and Restoration
Name *
2. First Name* Kevin
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Tweedy
If Corporation, enter F3egistered Agent Last %rre
3b. Title Vice President
4. Permitee E-mail [e-mail]
Address *
5. Permittee 919-388-0787
Telephone No.*
6. Permittee Mailing Street Address
Address* 1150 Southeast Maynard Road
Address Line 2
Suite 140
Qty State / Ftovince / Faegion
Cary NC
F ostal / Zip Code Country
27511 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 1150 Southeast Maynard Road
Address Line 2
Suite 140
C7ty
State / Frovince / Fbgion
Cary
NC
Fbstal / Zip Code
Country
27511
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Non -Government
Ownership *
2. Primary Site
Cidney
Contact - First
Name *
3. Primary Site
Jones
Contact - Last
Name *
4. Title
Project Manager
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
9193880787
Telephone No.*
7. Organization
Ecosystem Planning and Restoration
Name
8. Site Contact
Street Address
Mailing Address*
1150 SE Maynard Rd, Suite 140
Address Line 2
Suite 140
Cty
Cary
Fbstal / Zip Code
27511
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
United States

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/24/2019
Approved *
2. E&SC Plan Project SURRY-2020-015
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 Letter of Approval_20191024.pdf 660.48KB
Approval Wst be RDFfornat
letter/documentation
6. NOI Certification RB_NOI.pdf 428.12KB
Form Mist be RDFfornat
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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle 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 * Kevin Tweedy
Title Vice President
Organization Ecosystem Planning and Restoration
Date * 12/06/2019

F. Tracking and COC Info
NOI Tracking No. 19228
NC Reference No. NCG01-2019-3134
Uses 'count number' variable (incremrented by SP)
Certificate of NCC193134
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 3134
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.)