NCC213459_NOI Application_20210614

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/4/2021 12:59:49 PM (NCG01 NOI Submission)
Approve by EADS\bcbroussard 6/7/2021 7:16:20 AM (Review- Construction NOI 54883)
. The task was assigned to EADS\bcbroussard by round robin distribution 6/4/2021 1:00 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 8, 2021 5:00 PM
6/4/2021 1:00 PM
Submit by McCoy, Suzanne 6/14/2021 9:05:20 AM (Payment Verification for NCC213459)
* Allied Land Surveying Co., PA
• McCoy, Suzanne assigned the task to McCoy, Suzanne 6/14/2021 9:04 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 19, 2021 5:00 PM
6/7/2021 7:16 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 54851
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name* David Hickman Brookberry
1 b. Specific Lot This field any be used to list specifc lot numbers.
Numbers Lots:423,424,426,427,428,429
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) PIN: 5896-63-8921, 5896-63-8960, 5896-63-8824, 5896-63-8874, 5896-73-0706,
5896-63-9790
2. County* Forsyth
3. Highway or Street 1562 Autumn Park CIR,1568 Autumn Park CIR,1547 Autumn Park
Address*
CIR,1451 Autumn Park CIR,1574 Autumn Park CIR,1445 Autumn
Park CIR
Street name only is acceptable if no address number assigned yet
4. City or Township*
Winston-Salem
5. State *
NC
6. Zip Code*
27106
7. Latitude* Enter the latitude in decimal degrees
36.1156
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.3644
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* 06/01/2021
Estimated Construction Project Start late

10. Date to End *
08/01 /2021
Estimated Construction Project End Cate
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Development
12. Acres to be
0.44
disturbed*
(including off -site borrow and waste areas)
13. Total site area 0.51
(acres) *
14. Post- 0.30
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-FORSY-2021-David Hickman Brookberry
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 Tomahawk Creek
Wate rbody* %rre of waterbody into which stormwater runoff will discharge
15b. Waterbody 12-94-9-1
Index No.* NCWaterbody Index Number
Stormwater rJ 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 Legally Pesponsible Entity
Name * David Hickman
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 * David
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Hickman
It Corporation, enter Pbegistered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-345-0768
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 1787
Address Line 2
City
Clemmons
Fbstal / Zip Code
27012
Check box if the F Yes
street address the
same as mailing
address
State / Frovince / Pegion
NC
Country
USA
7. Permittee Street
Street Address
Address*
2855 Country Club Road
Address Line 2
City
State / Frovince / Faegion
Winston-Salem
NC
Fbstal / Zip Code
Country
27104
USA
8. Type of
Ownership is only individual if an individual
is naned in B.1. above.
Ownership*
Individual

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
David
Contact - First
Name *
2. Primary Site
Hickman
Contact - Last
Name *
3. Title
President
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-345-0768
Telephone No.
6. Organization
Westphalia Construction Company
Name
7. Site Contact
Street Address
Mailing Address*
PO Box 1787
Address Line 2
City
Clemmons
Fbstal / Zip Code
27012
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person a-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
336-345-0768
Default is legally responsible person telephone
State / Rovince / Region
NC
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 05/24/2021
Approved *
2. E&SC Plan Project 552597
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 13-564(2).pdf 121.12KB
Approval letter or Mast beRDFformal
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 20 NB)
13-564(1).pdf 2.91VIB
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 Xerox Scan_ 06042021085521.PDF 400.82KB
Form Wst be RDFforrrat
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 * David Hickman
Title President
Organization Legally Pesponsible Entity
Westphalia Construction Company
Date * 06/04/2021

F. Tracking and COC Info
NOI Tracking No. 54883
NC Reference No.
NCG01-2021-3459
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC213459
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3459
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. NCC213459-2021
Invoice Due Date 7/7/2021
Initial Fee $ 100.00
Invoice Status OPEN