NCC221180_NOI Application_20220328

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/22/2022 8:45:40 AM (NCG01 NOI Submission)
Approve by Morman, Alaina 3/25/2022 2:33:29 PM (Review - NOI 84725 Millers Reserve Subdivision)
• The task was assigned to Morman, Alaina by round robin distribution 3/22/2022 8:46 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 25, 2022 5:00 PM
3/22/2022 8:46 AM
by Workflow 3/25/2022 2:33:38 PM (Workflow Start Event)
Submit by EADS\aselkane 3/28/2022 11:46:54 AM (Payment Verification for NCC221180)
* Robert Dischinger
• EADS\aselkane assigned the task to EADS\aselkane 3/28/2022 11:45 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 6, 2022 5:00 PM
3/25/2022 2:33 PM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting No
an NOI that was Yes
rejected before?
la. Project Name* Millers Reserve Subdivision
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
65
1 c. Parcel ID
List all PINs associated with this project.
Number(s) (PIN)
6812-35-7963
2. County*
Forsyth
3. Highway or Street 4540 Ebert Road
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Winston-Salem
5. State* NC
6. Zip Code* 27127
7. Latitude* Enter the latitude in decimal degrees
36.0137
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-80.3029
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*
03/21/2022
Estimated Construction Project Start Date
10. Date to End*
12/29/2022
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial Classification for Development
12. Acres to be
24.50
disturbed *
(including off -site borrow and waste areas)

13. Total site area 51.33
(acres)*
14. Post -construction 3.75
impervious area (Estimated)
(acres) *
Project Tracking ID NCC-FORSY-2022-Millers Reserve Subdivision
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 South Fork Muddy Creek
Waterbody * Name of waterbody into which stormwater runoff will discharge
15b. Waterbody Index 12-94-13
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
Keystone Group, Inc
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* Scott
If Corporation, enter Registered Agent First Name
3. Last Name* Wallace
If Corporation, enter Registered Agent Last Name
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-856-0111
Telephone No.*
6. Permittee Mailing Street Address
Address* 3708 Alliance Drive
Address Line 2
City State / Province / Region
Greensboro NC
Postal / Zip Code Country
27407-2016 US
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address *
3708 Alliance Drive
Address Line 2
City
State / Province / Region
Greensboro
NC
Postal / Zip Code
Country
27407-2016
US
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 Scott
Contact - First
Name*
2. Primary Site Wallace
Contact - Last Name*
3. Title President
4. Site Contact E-mail [e-mail]
Address*
5. Site Contact 336-856-0111
Telephone No.*
6. Organization Name Keystone Group Inc
7. Site Contact Street Address
Mailing Address* 3708 Alliance Drive
Address Line 2
City
Greensboro
Postal / Zip Code
27407-2016
8. Consultant Name (optional)
Lee Bryant
First and Last name
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 336-482-6543
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)
336-856-0111
Default is legally responsible person telephone
State / Province / Region
NC
Country
US

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC Plan 03/11/2021
Approved *
2. E&SC Plan Project EN2000079
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 Approval Letter.pdf 218.34KB
Approval letter or Must be PDF format
Grading Permit
6. Signed FRO Financial Responsibility/Ownership Form
FRO.pdf 160.85KB
Must be PDF format
7. Site Location Map Must be PDF format (limit 20 MB)
site location.pdf 830.17KB
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 Signed NOI.pdf 404.46KB
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* Scott Wallace
Title President
Organization Legally Responsible Entity
Keystone Group, Inc
Date * 03/22/2022

F. Tracking and COC Info
NOI Tracking No. 84725
NC Reference No. NCG01-2022-1180
Indicates NCG01 or NCG25. Uses NOI number until approved, then uses NUMBER incremented by SP (passed
from workflow if eNOI approved)
Certificate of NCC221180
Coverage (COC) No.* Uses NOI number until approved, then uses NUMBER incremented by SIP (formatted and passed from workflow if
eNOI approved)
Initial Invoice No. NCC221180-2022
Invoice Due Date 4/24/2022
Initial Fee $ 100.00
Invoice Status OPEN