NCC215900_Contact Update Request with Change Forms_20221128

Georgoulias, Bethany
From:
Dennis Gilbert <[e-mail]>
Sent:
Monday, November 28, 2022 12:44 PM
To:
Georgoulias, Bethany
Cc:
'Jennifer Gardner'
Subject:
RE: [External] RE: Construction SW Modification Requests - More received without
Form
Attachments: Preserve @ Lake Upchurch Legally Responsible Individual Change Form.pdf,- Taylors
Creek Legally Responsible Individual Change Form.pdf, Meadows at Roslin Farms
Legally Responsible Individual Change Form.pdf
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Bethany — Attached are the Change of Responsible person forms covering the CoC numbers below provided to me by
H&H. - Dennis
Dennis A. Gilbert
115 Broadfoot Ave.
PO Box 53774
Fayetteville, NC 28305
Phone: [phone]
Fax: [phone]
ENGINEERS
Since
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SUKVkY[]K5
MOORMAN, KIZER & REITZEL, IRCI
From: Georgoulias, Bethany [mailto:[e-mail]]
Sent: Tuesday, November 22, 2022 9:50 AM
To: Dennis Gilbert
Subject: RE: [External] RE: Construction SW Modification Requests - More received without Form
Dennis,
For the other requests that came in earlier (see below), can Leslie fill out a form and just reference all of the affected
COCs / attach a list of numbers?
The Cypress Pointe ones that you attached will cover the 5 requests submitted last week, but I still have these others
outstanding that I cannot process without a signed certification.

NCG01 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible forth e permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead, you must submit a new NCG01 electronic Notice of Intent (eNOI).
Directions:
Print this form, complete, scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6`^ Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 CFR 122.221
Certificate of Coverage (COC) Number: NCC212867 NCC215900
Name of Project: Taylors Creek Phase 1
Legally Responsible Organizational Entity: H & H Constructors of Fayetteville , LLC
PREVIOUS Legally Responsible Individual: Brian Walker
NEW Legally Responsible Individual: Leslie Groves
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6E (i), 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 ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Page 1 of 2

NCG01 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Under penalty of law, I certify that (check all boxes to indicate your agreement):
1A 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.
14 1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
YL If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
91 1 understand that coverage underthis permit will constitute the permit requirements for the
discharge(s) and is enforceable in the same manner as an individual permit.
K This form has been reviewed and is accurate and complete to the best of my knowledge.
Title: Division President
Mailing Address: 3709 Raeford Rd., Suite200, Fayetteville , NC 28304
Street Address: 3709 Raeford Rd., Suite200, Fayetteville , NC 28304
Email Address: [e-mail]
Phone Number: 910-486-4864
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that 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 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.
Page 2 of 2

NCG01 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead, you must submit a new NCG01 electronic Notice of Intent (eNOI).
Directions:
Print this form, complete, scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6'h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Certificate of Coverage (COC) Number: NCC213570, NCC213344, NCC222548
Name of Project: Preserve at Lake Upchurch, Phase 2
Legally Responsible Organizational Entity: H & H Constructors Of FaVetteville , LLC
PREVIOUS Legally Responsible Individual: Brian Walker
NEW Leealiv Responsible Individual: Leslie Groves
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6B (i), 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 ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Page 1 of 2

NCG01 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Under penalty of law, I certify that (check all boxes to indicate your agreement):
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.
�[ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
ik If the approved Erosion and Sediment Control Plan 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 understand that coverage underthis permit will constitute the permit requirements for the
discharge(s) and is enforceable in the same manner as an individual permit.
This form has been reviewed and is accurate and complete to the best of my knowledge.
Date:
Print
Title: Division President
Mailing Address: 3709 Raeford Rd., Suite200, Fayetteville , NC 28304
Street Address: 3709 Raeford Rd., Suite200, Fayetteville , NC 28304
Email Address: [e-mail]
Phone Number: 910-486-4864
*IMPORTANT NOTE: This form must be signed by a responsible corporate officer that 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 NC6010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.
Page 2 of 2

NCG01 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead, you must submit a new NCGO1 electronic Notice of Intent (eNOI).
Directions:
Print this form, complete, scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMUR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6`^ Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Certificate of Coverage (CDC) Number: NCC221284 NCC215864 NCC214780 NCC214173
Name of Project: Meadows at Roslin Farms West, Section 2
Legally Responsible Organizational Entity: H & H Constructors Of Fayetteville , LLC
PREVIOUS Legally Responsible Individual: Brian Walker
NEW Legally Responsible Individual: Leslie Groves
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6E (1), 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 ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Page 1 of 2

NCG01 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Under penalty of law, I certify that (check all boxes to indicate your agreement):
IX I am the person responsible forthe 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.
6tl 1 will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
14 If the approved Erosion and Sediment Control Plan 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 understand that coverage underthis permit will constitute the permit requirements for the
discharge(s) and is enforceable in the same manner as an individual permit.
This form has been reviewed and is accurate and complete to the best of my knowledge.
Date:
Print
Title: Division President
Mailing Address: 3709 Raeford Rd., Suite200, Fayetteville, NC 28304
Street Address: 3709 Raeford Rd., Suite200, Fayetteville , NC 28304
Email Address: [e-mail]
Phone Number: 910-486-4864
* IMPORTANT NOTE. This form must be signed by a responsible corporate officer that 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 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.
Page 2 of 2

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Best regards,
Construction COC ADD TO FI LE Review - NCC221284 - Draft
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Bethany Georgoulias (she/her)
Environmental Engineer
Stormwater Program, Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: httl2://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwatgr
Q E Q:
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Email correspondence to and from this address is subject to the North
Carolina Public Records Law and may be disclosed to third parties-
2

From: Dennis Gilbert <[e-mail]>
Sent: Monday, November 21, 2022 11:57 AM
To: Georgoulias, Bethany<[e-mail]>; [e-mail]
Cc: [e-mail]; 'Jennifer Gardner' <[e-mail]>
Subject: [External] RE: Construction SW Modification Requests - More received without Form
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Bethany— Here are the change in responsible person forms for H&H Constructors of Fayetteville, LLC on 5 of their
Cypress Pointe projects.
When filling out the online modification form, I could not find the place to attach the "change of responsible person
form". Do we place them where it asks for the Revised Approval?
H&H filled these out and sent them to me to help take care of, but did not find the place to attach and they have
multitude of projects under the previous responsible person and cannot track all of them.
We have to address them as the issue comes up with each project. - Dennis
Dennis A. Gilbert
115 Broadfoot Ave.
PO Box 53774
Fayetteville, NC 28305
Phone: [phone]
Fax: [phone]
] ] EWINEER$1WM
S 1 J T; PLANNERSAN dLdLAL
SURVEYORS
NMRMAML KIZER & REITZEL. INC
From: Georgoulias, Bethany[maiIto: bethanyaeoraouliasCa)ncdenr.Qov]
Sent: Monday, November 21, 2022 11:37 AM
To: IesliearovesCa)hhhomes. com
Cc: [e-mail]; [e-mail]
Subject: RE: Construction SW Modification Requests - More received without Form
Importance: High
Good morning,
We received several more modification requests like the one below to update legally responsible person for multiple
Construction Stormwater COCs. However, the attached form was still not completed and uploaded for any of them (see
below screenshot). We had reached out about the same thing on November 9" for another group submitted earlier this
month (see attached email).
If it makes it easier, and all of these permits used to have the same person previously, you can complete just one form
and attached the list of COCs with project names that need updating. Then I'll be able to process these requests for
updates. Otherwise I'll have to reject the Modification request and have you resubmit each of them.
Please get us that form as soon as possible so we can update the information for all of these and ensure communication
goes out to the most up to date contacts. Otherwise we will have to reject the modification requests.
Thank you!

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Construction COC ADD TO FILE Review - NCC213344 - i
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Bethany Georgoulias (she/her)
Environmental Engineer
Stormwater Program, Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
4

512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Depmr&W1 a Emlrmwn flml owi�q
Email correspondence to and from this address is subject to the t+lorth
Carolina Public Records Law and may be disclosed to third parties_
From: [e-mail] <[e-mail]>
Sent: Friday, November 18, 2022 8:10 AM
To: [e-mail]
Cc: [e-mail]; [e-mail]
Subject: Construction SW Modification Request Received
Thank you for submitting a Modification request for Cypress Pointe - Lots 3-15 in Cumberland County,
Certificate of Coverage (COC) no. NCC214587.
Modification Reason: Legally Responsible Individual and/or Site Contact Has Changed
Additional Details (fprovided): The Legally responsible person changed from Brian Walker to Leslie Groves
If your submittal is accepted, you will receive e-mail confirmation. You will also be notified if additional
information is needed or if the modification request or documents cannot be accepted.
If you have any questions, please contact bethany_geor og uliasgncdenr.gov.
Be sure to add [e-mail] to your contacts to avoid future e-mails about this application from
going into Spam filters.
The NC DEMLR Stormwater Program
512 N. Salisbury Street, Archdale Building 6th Floor, 1612 Mail Service Center, Raleigh, NC 27699-1612
This email was automatically generated by Laserfiche. Please do not respond to this email address, as
responses are not monitored.