NCC200776_NOI Application_20200306

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/26/2020 9:01:45 AM (NCG01 NOI Submission)
Approve by Clark, Paul 2/26/2020 9:53:05 AM (Review- Construction NOI 22441)
• The task was assigned to Clark, Paul by round robin distribution 2/26/2020 9:02 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 28, 2020 5:00
PM. The priority is: High 2/26/2020 9:02 AM
Submit by McCoy, Suzanne 3/6/2020 7:08:23 AM (Payment Verification for NCC200776)
* Chad Astle
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/6/2020 7:07 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 8, 2020 5:00 PM. The
priority is: High 2/26/2020 9:53 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name* Creekside Mobile Home Park
1 b. Specific Lot This field any be used to list specifc lot numbers.
Numbers
2. County* Rockingham
3. Highway or Street 400 Stoney Creek Dr
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Reidsville
5. State * NC
6. Zip Code* 27320
7. Latitude* Enter the latitude in decimal degrees
36.3390
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.6330
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*
03/09/2020
Estimated Construction Project Start Date
10. Date to End *
09/07/2020
Estimated Construction Project End Late
11. SIC (Primary) *
Residential, Other
than SFE (1522)
Standard Industrial C]assification for Development
12. Acres to be
14.20
disturbed*
(including off -site borrow and waste areas)
13. Total site area 26.86
(acres) *
14. Post- 5.00
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-ROCKI-2020-Creekside Mobile Home Park
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 Jones Creed
Wate rbody* Nacre of waterbody into which stomwater runoff will discharge
15b. Waterbody 22-50-3
Index No. * NCWaterbody Index Nurrber
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
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 Vineyards Management Group
Name * If perrrittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* Chad
IF Corporation, enter F;bgistered Agent First Barre
3. Last Name* Astle
IF Corporation, enter F3egistered Agent Last Wre
3b. Title Regional Vice President
4. Permitee E-mail [e-mail]
Address *
5. Permittee 801-787-1663
Telephone No.*
6. Permittee Mailing Street Address
Address* 1371 East 2100 South
Address Line 2
city State / Frovince / Region
Salt Lake City UT
Fbstal / Zip Code Country
84105 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
1371 East 2100 South
Address Line 2
city
State / Ffovince / Fbgion
Salt Lake City
UT
Fbstal / Zip Code
Country
84105
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Stephen
Contact - First
Name *
2. Primary Site
Walker
Contact - Last
Name *
3. Title
Owner
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-932-1242
Telephone No.
6. Organization
Stephen Walker Grading and Hauling
Name
7. Site Contact
Street Address
Mailing Address*
1580 Moir Mill Road
Address Line 2
city
Reidsville
Fbstal / Zip Code
27320-8003
8. Consultant Name
(Optional)
Norris Clayton
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
3362759826
Telephone No.
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 01/02/2020
Approved *
2. E&SC Plan Project ROCKI-2020-011
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. For linear projects, please also upload a site map showing the overall extent of the project or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan LETTER OF APPROVAL.pdf 11.46MB
Approval letter or Mast beRDFformat
Grading Permit
Site Map (Optional) Helpful for linear project review
Mast be R7Fform3t
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies for linear projects if necessary.
6. NOI Certification NOI Certificate Signed.pdf 495.59KB
Form Mast be FDFformat
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 Ascle; 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 Ascle 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 * Chad Astle
Title Regional Vice President
Organization Vineyards Management Group
Date * 02/26/2020

F. Tracking and COC Info
NOI Tracking No. 22441
NC Reference No. NCG01-2020-0776
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200776
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 776
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)