NCC213463_NOI Application_20210609

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/4/2021 1:23:49 PM (NCG01 NOI Submission)
Approve by EADS\bcbroussard 6/7/2021 7:34:45 AM (Review- Construction NOI 54890)
• The task was assigned to EADS\bcbroussard by round robin distribution 6/4/2021 1:25 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 8, 2021 5:00 PM
6/4/2021 1:25 PM
Submit by McCoy, Suzanne 6/9/2021 1:41:29 PM (Payment Verification for NCC213463)
* RPM Partners
• McCoy, Suzanne assigned the task to McCoy, Suzanne 6/9/2021 1:40 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 19, 2021 5:00 PM
6/7/2021 7:35 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting r No
an NOI that was r Yes
rejected before?
Previous Rejected 54848
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name * Holy Cross Orthodox Church
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 6875-57-7718
2. County* Forsyth
3. Highway or Street 1320 Masten Drive
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Kernersville
5. State * NC
6. Zip Code* 27284
7. Latitude* Enter the latitude in decimal degrees
36.1021
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.0972
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* 07/12/2021
Estimated Construction Project Start Date
10. Date to End* 07/31/2024
Estimated Construction Project End Date

11. SIC (Primary)* Other (9999)
Standard Industrial aasslfication for Development
12. Acres to be 1.80
disturbed* (including off -site borrow and waste areas)
13. Total site area 1.98
(acres) *
14. Post- 0.84
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-FORSY-2021-Holy Cross Orthodox Church
Tracking ID 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 Smith Creek
Waterbody* %rreof waterbody into which stormwater runoff will discharge
15b. Waterbody 12-94-12-2-1
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. ^
Fternittee 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 Legally Pesponsible Entity
Name * Holy Cross Orthodox Church
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * Christopher
If Corporation, enter Faegistered Agent First Wre
3. Last Name* Foley
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Priest -In -Charge
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-688-9920
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 1726
Address Line 2
City
Kernersville
Fbstal / Zip Code
27285
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
1320 Masten Drive
Address Line 2
city
Kernersville
Fbstal / Zip Code
27284
State / Frovince / Fbgion
NC
Country
United States of America
State / Frovince / Faegion
NC
Country
US
8. Type of Ownership is only individual if an individual is naned in B.1. above.
Ownership* Non -Government

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Andrew
Contact - First
Name *
2. Primary Site
Wells
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
3369962000
Telephone No.
6. Organization
RPM Partners
Name
7. Site Contact
Street Address
Mailing Address*
1314 E Mountain Street
Address Line 2
city
Kernersville
Fbstal / Zip Code
27284
8. Consultant Name
(Optional)
Garrett Neal
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-819-5279
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
336-688-9920
Default is legally responsible person telephone
State / Rovince / Region
NC
Country
United States of America

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 02/03/2021
Approved *
2. E&SC Plan Project FORSY-2021-018
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. Please also upload a site map showing the overall extent of the project (for linear projects, can
include the beginning point and end point coordinates in the "Notes" box below).
5. E&SC Plan Holy Cross Orthodox Church - NCDEQ Approval
Approval letter or 864.17KB
Letter.pdf
Grading Permit
Mast be FDFforrrat
6. Site Location Map Mist be RDFforrret (lint 201VB)
C2.1 SITE PLAN.pdf 801.02KB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
8. NOI Certification HCOC NOI_signed_210505.pdf 79.52KB
Form Mist be RDFforrret
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) 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:* IT The Legally Responsible Person named on this Notice of Intent
f Authorized Responsible Person* (signing on behalf of Legally Responsible
Person named in Part B)
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* Father Christopher Foley
Title Priest -in -Charge
Organization Legally Plesponsible Entity
Holy Cross Orthodox Church
Date * 06/04/2021

F. Tracking and COC Info
NOI Tracking No. 54890
NC Reference No.
NCG01-2021-3463
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC213463
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3463
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2021
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC213463-2021
Invoice Due Date 7/7/2021
Initial Fee $ 100.00
Invoice Status OPEN