NCC216119_NOI Application_20211104

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/2/2021 11:06:31 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 11/3/2021 8:49:04 AM (Review - Construction NOI 72223)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 11/2/2021 11:06 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 4, 2021 5:00
PM 11/2/2021 11:06 AM
Submit by Evans, Shaundra M 11/4/2021 8:05:45 AM (Payment Verification for NCC216119)
F Michele Ciban
• Evans, Shaundra M assigned the task to Evans, Shaundra M 11/4/2021 8:05 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 15, 2021 5:00
PM 11/3/2021 8:49 AM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
A. Project Information
Part A.
�J
Project Location and Waterbody Information
...............................................................................................................................................................................................................................................................................................................................................................................................
Are you submitting No
an NOI that was • Yes
rejected before?
Previous Rejected 72113
NOI No.
Prior Reviewer Name Brooklyn Broussard
la. Project Name* Grandview Crossing Erosion Control
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers 12-29 53-57 61-66
1 c. Parcel ID List all PINS associated with this project.
Number(s) (PIN) 3438 Eagle Cove Ct (5898-91-7816.000)
3412 Grandview Crossing Ln (5898-91-1705.000)
3484 Grandview Crossing Ln (5898-92-7375.000)
3490 Grandview Crossing Ln (5898-92-8430.000)
3510 Grandview Crossing Ln (5898-92-9327.000)
3534 Grandview Crossing Ln (6808-02-0250.000)
3542 Grandview Crossing Ln (6808-02-0195.000)
3550 Grandview Crossing Ln (6808-02-1049.000)
3558 Grandview Crossing Ln (6808-02-1094.000)
3566 Grandview Crossing Ln (6808-01-2939.000)
3574 Grandview Crossing Ln (6808-01-2983.000)
3582 Grandview Crossing Ln (6808-01-3827.000)
3590 Grandview Crossing Ln (6808-01-3717.000)
4611 Fairway Run Dr (6808-01-4738.000)
4605 Fairway Run Dr (6808-01-5721.000)
4604 Fairway Run Dr (6808-01-5650.000)
4610 Fairway Run Dr (6808-01-4509.000)
4616 Fairway Run Dr (6808-01-3508.000)
3415 Grandview Crossing Ln (5898-91-2647.000)
3533 Grandview Crossing Ln (5898-92-9009.000)
3541 Grandview Crossing Ln (5898-92-9052.000)
3549 Grandview Crossing Ln (6808-01-0906.000)
3559 Grandview Crossing Ln (6808-01-0941.000)
3569 Grandview Crossing Ln (6808-01-0896.000)
4643 Fairway Run Dr (5898-91-9725.000)
3437 Eagle Cove Ct (5898-91-9822.000)
3463 Eagle Cove Ct (5898-91-9903.000)
3490 Eagle Cove Ct (5898-91-8928.000)
3464 Eagle Cove Ct (5898-91-7964.000)

2. County* Forsyth
3. Highway or Street 3438 Eagle Cove Ct
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Winston Salem
5. State* INC
6. Zip Code* 27040
7. Latitude* Enter the latitude in decimal degrees
36.1650
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-80.3560
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*
11/01/2021
Estimated Construction Project Start Date
10. Date to End*
12/31/2022
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial Classification for Development
12. Acres to be
6.83
disturbed*
(including off -site borrow and waste areas)
13. Total site area 8.61
(acres) *
14. Post -construction 2.00
impervious area (Estimated)
(acres)*
Project Tracking ID NCC-FORSY-2021-Grandview Crossing Erosion Control
Assigned automatically (not used)
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 Bashavia Creek
Waterbody * Name of waterbody into which stormwater runoff will discharge
15b. Waterbody Index 12-81
No. * NC Waterbody Index Number
Stormwater No
discharges will flow Yes
to additional waters*
16a. Is this project Yes
subject to the NC No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Permittee Information - Legally Responsible Entity and Individual
........................................................................................................................................................................
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form must 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
1. Permittee* Legally Responsible Entity
Clay Pigeon, LLC
If permittee is an individual, enter first and last name in this field. Otherwise, enter organization/business name.
Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the
registration here. Permittee must be the same entity that is responsible for the land -disturbing activity as listed on the NC
SPCA Financial Responsibility/Ownership (FRO) Form.
2. First Name* Tom
If Corporation, enter Registered Agent First Name
3. Last Name* Quackenbush
If Corporation, enter Registered Agent Last Name
3b. Title Managing Member
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-741-7993
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box90427
Address Line 2
City State / Province / Region
Raleigh Nc
Postal / Zip Code Country
27675 Wake
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
9220 Fairbanks Drive Suite 120
Address Line 2
City
State / Province / Region
Raleigh
NC
Postal / Zip Code
Country
27613
Wake
8. Type of
Ownership is only individual if an individual is
named in B.1. above.
Ownership*
Non -Government

C. Site Contact Information
Part C.
Project Site Contact Information
1. Primary Site Chad
Contact - First
Name*
2. Primary Site Knapik
Contact - Last Name*
3. Title VP of Construction
4. Site Contact E-mail [e-mail]
Address*
5. Site Contact 919-605-8502
Telephone No.*
6. Organization Name
7. Site Contact
Street Address
Mailing Address*
PO Box 90427
Address Line 2
City
Raleigh
Postal / Zip Code
27675
8. Consultant Name
(optional)
First and Last name
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 e-mail
12. Billing Telephone
(For Annual Fee correspondence)
919-741-7993
Default is legally responsible person telephone
State / Province / Region
NC
Country
Wake

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC Plan 10/25/2021
Approved *
2. E&SC Plan Project EN2100137
Number/ID* Assigned by agency or local program
3. E&SC Plan State DEQ Office
Approved by* Local Program
4. Local Program* Winston-Salem/Forsyth County
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 GVC Erosion Approval Letter PDF.pdf 79.17KB
Approval letter or Must be PDF format
Grading Permit
6. Signed FRO Financial Responsibility/Ownership Form
GVC Erosion Control FRO Form.pdf 148.71 KB
Must be PDF format
7. Site Location Map Must be PDF format (limit 20 MB)
Grandview.pdf 376.13KB
Please do not upload entire set of E&SC plans.
8. Notes (Optional) Provide any additional information that might help the reviewer better understand how uploaded documents
support the application. Include additional waterbodies if necessary.
9. NOI Certification NOI Grandview Crossing Erosion Control.pdf 75.12KB
Form Must be PDF format
This is an Express • No
Review Project* Yes

E. Certification
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false 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 Article; 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 Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
* 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.
* 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.
* I will abide by all conditions of the NCG010000 General Permit and the approved
Erosion and Sediment Control Plan.
* If the Erosion and Sediment Control Plan approved by the delegated program is not
compliant with Part II (Stormwater Pollution Prevention Plan) of the NCG010000
General Permit, I will nonetheless ensure that all conditions of Part II of the permit are
met on the project at all times.
* 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:* The Legally Responsible Person named on this Notice of Intent
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* Tom Quackenbush
Title Managing Member
Organization Legally Responsible Entity
Clay Pigeon, LLC
Date * 11 /02/2021

F. Tracking and COC Info
NOI Tracking No. 72223
NC Reference No.
NCG01-2021-6119
Uses'count_numb& variable (incremented by SP)
Certificate of
NCC216119
Coverage (COC) No.*
Uses'count_number' variable (incremented by SP)
Count Number
6119
Sequential number for submittal that is incremented by Stored Procedure
COC Year
2021
Year of date reviewed (used to assign YY digits after "NCC" in COC no.)
Initial Invoice No. NCC216119-2021
Invoice Due Date 12/3/2021
Initial Fee $ 100.00
Invoice Status OPEN