NCG021011_Application_20230203

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�'i- l"E9VED
Division of Energy, Mineral, and Land Resources Land Quality Se#*jh 1 12023
National Pollutant Discharge Elimination System
NCGO20000 DEMLR S'oam:aw: , ;'sm
This general permit covers STORMWATER AND/OR WASTEWATER DISCHARGES
associated with activities under SIC (Standard Industrial Classijkation) Code 14
(Mineral Mining Industry) except for: peat mining, coal mining, metal mining,
oil and gas extraction, tourist gem mines, NCOOT borrow pits, in -stream sand
mining, and discharges from mining operations which are intermixed on site
with stormwater from concrete operations. You can find information on the
DEMLR Stormwater Program at deq.nc.gov/SW.
Date
Amount
Directions: Print or type all entries on this application form. Send the original, Permit Assigned to
signed application with all required items listed in Item (9) below to: NCDEMLR
Stormwater Program, 512 N. Salisbury St.,1612 MSC, Raleigh, NC 27699-1612.
The submission of this form does not guarantee coverage under the General Permit. Prior to coverage under this
General Permit a site inspection will be conducted.
1. Owner/Operator (to whom all permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed in Item (10) below:
Donald Bryant Jr
Darold Bryant Jr
Street address:
City:
State and zip code:
195 Rousevllle Lane
Newport
NC 28570
Telephone number:
Email address:
252-723.8873
[e-mail]
2. Industrial Facility (facility being permitted):
Facility name:
Facility environmental contact:
NLR Mine
Street address:
City:
State and zip code:
Newport Loop Rd
Newport
NC 28570
Telephone Number:
Email address:
252-723-8873
[e-mail]
Latitude of entrance: 34.8171
Longitude of entrance:-78.8579
Parcel Identification Number (PIN)
634901255600000
4-digit SIC code:
Facility is:
Date operation is to begin or began:
1440
[]New ❑ Proposed El Existing
2021
Brief description of the types of minerals mined at this facility:
soil
Is this a processing -only facility for materials mined elsewhere?
is this an inactive mine site?
❑ Yes
❑ Yes
El No
El No
Does total area of this mine site include ready -mixed concrete plant and/or asphalt plant areas?
❑ Yes, and has separate NPDES stormwater permits (provide permit numbers):
❑Yes, and does not have separate NPDES stormwater permits
O No
Does this facility already have a valid Mining Permit from DEMLR's Land Quality Section?
DYes (please provide the Mining Permit Number) 1"5
❑ No (please indicate the status of the Mining Permit application)
Page 1 of 8

Are you applying for a discharge permit in the same location as a previously permitted mine?
❑ Yes (please provide permit number and mine name)
El No
If the stormwater discharges to a municipal separate storm sewer system (MS4), name the operator of the MS4:
N/A
3. Consultant (if applicable):
:2
Name of consultant:
Consulting firth:
James IneN
Carolina Geological Services, Inc
Street address:
City:
State and zip code:
PO Box 429
Gamer
NC 27529
Telephone number:
Email address:
919-3024411
[e-mail]
AcuYmes ana Duffers
Mining operation will precede development activities at this site:
❑ Yes
R No
Mine is located within one of the 20 Coastal Counties, and will it add more than 10,000 ft" of impervious surface:
El Yes (to both)
El No, this mine is within one of the 20 Coastal Counties, but will not at more than 10,000 ftz of impervious surface
❑ No, this mine is not within one of the 20 Coastal Counties
Mine is in the Neuse, Tar -Pamlico, or Catawba River Basins, OR in the Randleman or Jordan Water supply Watersheds?
❑r Yes (specify size of stream buffers) no streams w thin permitted area
No
S. Mine Dewatering
Mine dewatering will occur at this site:
El Yes ❑ No (mark N/A for the rest of this section)
Mine dewatering from this facility will be discharged to:
aurface Waters and/or Wetlands
[]Other (specify)
[]Mine will not discharge dewatering to Surface Waters and/or Wetlands; specify how dewatering will occur and where
water will be directed:
[]N/A
Wetlands and/or Surface Waters are within 400' of the mine pit perimeter:
404/401 Certification permits required:
❑Yes (specify distance) iooket
❑Yes (briefly describe)
❑ No
❑ No
❑ N/A
R N/A
Have you been required to obtain a wetland delineation certified by the US Army Corps of Engineers?
DYes (please attach to this application) ❑ No
6. Wastewater Treatment
Will this facility wash mined materials?
❑Yes ❑r No
Will discharges of process wastewater treatment systems occur (including possible recycle system overflows)
❑ Yes (please describe)
Q No
Page 2 of 8

Will this facility employ chemical additives to flocculate suspended solids?
❑ Yes (specify name/manufacturer/quantity of daily use)
❑� No
Note: please visit: https:Hfiles nc gov/ncdeg/Water+Quality/Environmental+Sciences/ATU/PAM8 30 18 pdf for list of
approved PAMS
Will any of the wastewater treatment facilities at this mine overflow only during rainfall events that exceed the 30-yr, 24-hr
rainfall event?
[I Yes (specify which systems)
E] No
Are wastewater treatment facilities (including recycle systems) planned in the 100-year flood plain?
❑Yes ❑� No
Wastewater Treatment Aitemative Review as required by 15A NCAC 2H.0105(c)(2)
Types of wastewater this mine site will discharge: ❑r Mine Dewaterng ❑Process Wastewater
Types of wastewater considered for this alternative review: r❑ Mine Dewatering []Process Wastewater
Are there existing sewer lines within a one -mile radius?
❑ Yes
❑ Wastewater treatment plant will accept wastewater
❑ Is feasible to connect (explain)
❑ Is not feasible to connect (explain)
[]Wastewater treatment plant will not accept wastewater (please attach letter documenting this)
❑� No
Are you already proposing a closed -loop recycle system (CLRS) that meets design requirements of 15A NCAC 2T .100D0?
[]Yes, for dewatering
❑Yes, for process wastewater
[]Yes, for both
❑ No, this option is technologically feasible (explain)
❑ No, this option is not technologically feasible (explain)
❑ No, this option is otherwise feasible (explain)
ado, this option is otherwise not feasible (explain)
Too smell scale
What is the feasibility of building a CLRS compared to direct surface water discharge?
Surface or subsurface Disposal System
❑ A surface or subsurface disposal system is technologically feasible (explain)
❑ A surface or subsurface disposal system is not technologically feasible (explain)
❑ A surface or subsurface disposal system is otherwise feasible to implement (explain)
❑✓ A surface of subsurface disposal system is not otherwise feasible to implement (explain)
Too small scale
What is the feasibility of employing a subsurface of surface discharge as compared to a direct discharge to surface waters?
Direct Discharge to surface waters is the most environmentally sound alternative to all reasonably cost-effective options
for the wastewaters being considered?
❑Q Yes
❑ No
Page 3 of 8

If this review included all wastewater discharge types, would excluding some types make any of the above non -discharge
options feasible for some the wastewaters?
❑ Yes
❑r No
Outfalls(s) At least one outfall is required to be eligible for coverage.
3-4 digit identifier:
Name of receiving water:
Classification:
[]This water is impaired.
oot
Deem
[]This watershed has a TMDL
Discharge from this outfall is from:
❑ Stormwater ❑✓ Mine Dewatering ❑ Process Wastewater
Discharge occurs from this outfall:
❑ Only during a rainfall event
❑ Intermittently (please indicate how often)
❑� Continuously (please indicate flow in CFS) 0.4
Latitude of outfall: 34.8176
Longitude of outfall:-70.8sea
Brief description of the industrial activities that drain to this outfall:
mhe dmatem,g
Do Vehicle Maintenance Activities occur in the drainage are of this outfall? ❑ Yes r❑ No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier:
Name of receiving water:
Classification:
❑This water is impaired.
❑ This watershed has a TMDL
Discharge from this outfall is from:
❑Stormwater ❑Mine Dewatering ❑ Process Wastewater
Discharge occurs from this outfall:
❑ Only during a rainfall event
❑ Intermittently (please indicate how often)
❑ Continuously (please indicate flow in CFS)
Latitude of outfall:
Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage are of this outfall? ❑ Yes ❑ No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier:
Name of receiving water:
Classification:
❑ This water is impaired.
❑This watershed has a TMDL
Discharge from this outfall is from:
❑ Stormwater []Mine Dewatering ❑ Process Wastewater
Discharge occurs from this outfall:
[]Only during a rainfall event
❑ intermittently (please indicate how often)
❑ Continuously (please indicate flow in CFS)
Latitude of outfall:
Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage are of this outfall? ❑ Yes ❑ No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
Page 4 of 8

All outfalls must be listed and at least one outfall is required. Additional outfalls may be added in the section
"Additional Outfalls" found on the last page of this NC L
8. Other Facility Conditions (check all that apply and explain accordineiv):
9.
❑This facility has any other NPDES permits. If checked, list the permit numbers for all current NPDES permits:
❑This facility has Non -Discharge permits (e.g. recycle permit). If checked, list the permit numbers for all current Non -
Discharge permits:
❑ This facility uses best management practices or structural stormwater control measures.
If checked, briefly describe the practices/measures and show on site diagram:
E]This facility has a Stormwater Pollution Prevention Plan (SWPPP).
If checked, please list date that SWPPP was implemented:
will be prepared upon pemvt approvals
❑This facility stores hazardous waste stored in the 100-year floodplain.
If checked, describe how the area is protected from flooding:
❑ This facility Is a (mark all that apply)
❑Hazardous Waste Generation Facility
❑ Hazardous Waste Treatment Facility
❑ Hazardous Waste Storage Facility
❑ Hazardous Waste Disposal Facility
If checked, indicate:
Kilograms of waste generated each month:
Type(s) of waste:
How material is stored:
Where material is stored:
Number of waste shipments per year:
Name of transport/disposal vendor:
Transport/disposal vendor EPA ID:
Vendor address:
❑ This facility is located on a Brownfield or SUPERFUND site
If checked, briefly describe the site conditions:
❑ Facility provides appropriate secondary containment for bulk storage of liquid materials
If checked, briefly describe these measures:
❑ Site has an active landfill within the mining permit boundary
If checked, please indicate type:
a) ❑ LCID (Land clearing and Inert Debris)
b) []other (specify)
Required Items (Application will be returned unless all of the following items have been included):
❑ Check for $100 made payable to NCDEQ
❑ Copy of most recent Annual Report to the NC Secretary of State
❑This completed application and any supporting documentation
❑ Copy of the approved mining permit or indication of mining permit application status
❑ Copy of US Army Corps— approved wetland delineation (if applicable)
Page 5 of 8

❑ Une drawing of the water flow through the facility or block flow diagram
❑ Pictorial description of the nature of any sources of water and any collection and treatment measures
❑ A site diagram showing, at a minimum, existing and proposed:
a) outline of drainage areas
b) surface waters
c) stormwater management structures
d) location of stormwater outfalls corresponding to the drainage areas
e) runoff conveyance features
f) areas where materials are stored
g) impervious areas
h) site property lines
❑2 copies of large scale (24"x36" minimum) site plan showing:
a) topographical lines
b) all outfall locations
c) applicable buffers and delineated wetlands
d) receiving waters
e) 100-year flood plain (if applicable)
❑ Copy of county map or USGS quad sheet with the location of the facility clearly marked
If mines site is in one of the 20 Coastal Counties (if applicable)
❑ Applicant has check with the appropriate regional office to verify the need for a Coastal State Stormwater permit.
a) Indicate the Regional office Contact:
❑ Detailed list of:
a) impervious surface areas and percentages
b) sub -drainage areas
c) total drainage area
If mine is dewatering and near wetlands, or may otherwise impact surface waters or groundwater (if
applicable)
❑ 2 copies of large scale (24"x36" minimum) plans delineating areas on the listing acreage including:
a) wetlands
b) ditches
c) well -placements
d) pits
e) borrow areas
f) overburden storage
g) stormwater controls/BMPs
h) vehicle maintenance areas
1) settling basins
j) product process (such as screening, stockpiles, and waste piles)
k) total drainage area
1) impervious surface percentages (if state Stormwater programs apply)
m) applicable buffers
n) access and/or haul roads
❑ Pump dewatering size and information on its specifications
[]Well information (design, depths, maintenance)
❑ Physical monitoring for the wetland areas
❑ Settling pond size information, if applicable
❑ Level spreader design, if applicable
❑ Details about dewatering method
❑ Cone of influence calculations
Page 6 of 8

❑ Description of measures to prevent erosion and flooding
❑ Description and information about 401/404 permits that have been obtained
❑Copy of US Army Corps of Engineers wetlands delineations or approved wetland delineation (if applicable)
❑ 1 have contacted my local regional office about a Pumping Operation and Monitoring (POM) plan
a) Regional Office Contact:
b) Date Contacted:
10. Applicant Certification:
North Carolina General Statute 143-215.68 (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 ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,D00). I hereby request coverage under the referenced General Permit.
Under penalty of law, I certify that:
❑ 1 am the person responsible for the permitted industrial activity, 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 NC302 permit. I 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.
❑ I hereby request coverage under the NCG020000 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.
Printed Name of Person Signing:
Title:
0.1a W U
(Signature of Applicant) (Date Signed)
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
512 N. Salisbury Street, 6`^ floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 7 of 8

Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
NCG020000
This general permit covers STORMWATER AND/OR WASTEWATER DISCHARM
associated with activities under SIC (Standard Industrial ClassUkation) Code 14
[Mineral Mining Industry] except for: peat mining, coal mining, metal mining,
oil and gas extraction, tourist gem mines, NCDOT borrow pits, in -stream sand
mining, and discharges from mining operations which are intermixed on site
with stormwater from concrete operations. You can find information on the
DEMLR Stormwater Program at deq.nc.gov/SW.
Date Received
Year Month Day
Certificate of Coverage
NICIGI
Check # I Amount
Directions: Print or type all entries on this application form. Send the original, Permit Assigned to
signed application with all required items listed in Item (9) below to: NCDEMLR
Stormwater Program, 512 N. Salisbury St.,1612 MSC, Raleigh, NC 27699-1612.
The submission of this form does not guarantee coverage under the General Permit. Prior to coverage under this
General Permit a site inspection will be conducted.
1. Owner/Operator (to whom all permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed in Item (10) below:
Donald Bryant Jr
Donald Bryant Jr
Street address:
City:
State and zip code:
185 Rouseville Lane
Newport
NO 28570
Telephone number:
Email address:
252-723-5873
[e-mail]
2. Industrial Facility (facility being permitted):
Facility name:
Facility environmental contact:
NLR Kne
Street address:
City:
State and zip code:
Newport Loop Rd
Newport
NC 28570
Telephone Number:
Email address:
252-723-8873
[e-mail]
Latitude of entrance: 34.8171
Longitude of entrance:-76.8579
Parcel Identification Number (PIN)
634901255600000
4-digit SIC code:
1
Facility is:
Date operation is to begin or began:
1440
❑ New ❑ Proposed ❑� Existing
2021
Brief description of the types of minerals mined at this facility:
soil
Is this a processing -only facility for materials mined elsewhere?
Is this an inactive mine site?
❑ Yes
❑ Yes
I] No
✓❑ No
Does total area of this mine site include ready -mixed concrete plant and/or asphalt plant areas?
[]Yes, and has separate NPDES stormwater permits (provide permit numbers):
❑ Yes, and does not have separate NPDES stormwater permits
0 No
Does this facility already have a valid Mining Permit from DEMLWs Land Quality Section?
❑� Yes (please provide the Mining Permit Number) 16-85
❑ No (please indicate the status of the Mining Permit application)
Page 1 of 8

Are you applying for a discharge permit in the same location as a previously
❑Yes (please provide permit number and mine name)
If the stormwater discharges to a municipal separate storm sewer system (MS4), name the operator of the MS4:
El N/A
3. Consuttant (if applicable):
4.
Name of consultant:
Consulting firm:
James hell
Carolina Geological Services, Inc
Street address:
City:
State and zip code:
PO Boz 429
Gamer
NC 27529
Telephone number:
Email address:
919302-411
[e-mail]
ACtiVnieS ana tsurTers
Mining operation will precede development activities at this site:
❑ Yes
!IVIT.
Mine is located within one of the 20 Coastal Counties, and will it add more than 10,000 ft2 of impervious surface:
❑ Yes (to both)
✓❑ No, this mine is within one of the 20 Coastal Counties, but will not at more than 10,000 ft2 of impervious surface
n No. this mine is not within one of the 20 Coastal Counties
Mine is in the Neuse, Tar -Pamlico, or Catawba River Basins, OR in the Randleman or Jordan Water supply Watersheds?
Ej Yes (specify size of stream buffers) no streams within permlttec area
❑ No
S. Mine Dewatering
Mine dewatering will occur at this site:
✓❑ Yes ❑ No (mark N/A for the rest of this section)
Mine dewatering from this facility will be discharged to:
Outface Waters and/or Wetlands
❑Other (specify)
[]Mine will not discharge dewatering to Surface Waters and/or Wetlands; specify how dewatering will occur and where
water will be directed:
❑N/A
Wetlands and/or Surface Waters are within 400' of the mine pit perimeter:
404/401 Certification permits required:
EjYes (specify distance) loofeet
[]Yes (briefly describe)
❑ No
❑ No
❑ N/A
✓ N/A
Have you been required to obtain a wetland delineation certified by the US Army Corps of Engineers?
❑✓ Yes (please attach to this application) ❑ No
6. Wastewater Treatment
Will this facility wash mined materials?
❑Yes ❑✓ No
Will discharges of process wastewater treatment systems occur (including possible recycle system overflows)
❑Yes (please describe)
ONO
Page 2 of 8

Will this facility employ chemical additives to flocculate suspended solids?
❑Yes (specify name/manufacturer/quantity of daily use)
EjNo
Note: please visit: https://files.nc.gov/ncdeQ/Water+Quality/Environmental+Sciences/ATU/PAM8 30 18.pdf for list of
approved PAMS
Will any of the wastewater treatment facilities at this mine overflow only during rainfall events that exceed the 10-yr, 24-hr
rainfall event?
[:]Yes (specify which systems)
r❑ No
Are wastewater treatment facilities (including recycle systems) planned in the 100-year flood plain?
[I Yes ElNo
Wastewater Treatment Alternative Review as required by 15A NCAC 2H.0105(c)(2
Types of wastewater this mine site will discharge: Ej Mine Dewatering ❑ Process Wastewater
Types of wastewater considered for this alternative review: o❑ Mine Dewatering ❑ Process Wastewater
Are there existing sewer lines within a one -mile radius?
❑ Yes
❑ Wastewater treatment plant will accept wastewater
❑ Is feasible to conned (explain)
❑ Is not feasible to conned (explain)
[]Wastewater treatment plant will not accept wastewater (please attach letter documenting this)
❑� No
Are you already proposing a dosed -loop recycle system (CLRS) that meets design requirements of 1SA NCAC 2T .10000?
❑Yes, for dewatering
❑ Yes, for process wastewater
[]Yes, for both
❑ No, this option is technologically feasible (explain)
❑ No, this option is not technologically feasible (explain)
❑ No, this option is otherwise feasible (explain)
E)No, this option is otherwise not feasible (explain)
Too email Scale
What is the feasibility of building a CLRS compared to direct surface water discharge?
Surface or Subsurface Disposal System
❑ A surface or subsurface disposal system is technologically feasible (explain)
❑ A surface or subsurface disposal system is not technologically feasible (explain)
❑ A surface or subsurface disposal system is otherwise feasible to implement (explain)
❑� A surface of subsurface disposal system is not otherwise feasible to implement (explain)
Too small scale
What is the feasibility of employing a subsurface of surface discharge as compared to a direct discharge to surface waters?
Direct Discharge to surface waters is the most environmentally sound alternative to all reasonably cost-effective options
for the wastewaters being considered?
❑� Yes
El No
Page 3 of 8

If this review included all wastewater discharge types, would excluding some types make any of the above non -discharge
options feasible for some the wastewaters?
❑ Yes
El No
7. Outfalls(s) At least one outfall is required to be eligible for coverage.
3-4 digit identifier:
Name of receiving water:
Classification:
❑ This water is impaired.
Oat 1
Deep Crash
❑This watershed has a TMDL
Discharge from this outfall is from:
❑Stormwater r❑ Mine Dewatering ❑Process Wastewater
Discharge occurs from this outfall:
❑ Only during a rainfall event
❑ Intermittently (please indicate how often)
Continuously (please indicate flow in CFS) 0.4
Latitude of outfall: 34.8176
Longitude of outfall: ae.asog
Brief description of the industrial activities that drain to this outfall:
mirm de atedng
Do Vehicle Maintenance Activities occur in the drainage are of this outfall? ❑ Yes ❑� No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier:
Name of receiving water:
Classification:
[]This water is impaired.
❑ This watershed has a TMDL
Discharge from this outfall is from:
❑Stormwater []Mine Dewatering ❑ Process Wastewater
Discharge occurs from this outfall:
❑ Only during a rainfall event
[]Intermittently (please indicate how often)
❑ Continuously (please indicate flow in CFS)
Latitude of outfall:
Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage are of this outfall? ❑ Yes ❑ No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier:
Name of receiving water:
Classification:
❑ This water is impaired.
❑This watershed has a TMDL.
Discharge from this outfall is from:
❑ Storrnwater El Mine Dewatering ❑ Process Wastewater
Discharge occurs from this outfall:
❑ Only during a rainfall event
❑ Intermittently (please indicate how often)
❑ Continuously (please indicate flow in CFS)
Latitude of outfall:
Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage are of this outfall? ❑ Yes ❑ No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
Page 4 of 8

All outfalls must be listed and at least one outfall is required. Additional outfalis may be added in the section
"Additional Outfalls" found on the last page of this N01.
8. Other Facility Conditions (check all that apply and explain accordingly):
9.
❑This facility has any other NPDES permits. If checked, list the permit numbers for all current NPDES permits:
❑ This facility has Non -Discharge permits (e g. recycle permit). If checked, list the permit numbers for all current Non -
Discharge permits:
❑ This facility uses best management practices or structural stormwater control measures.
If checked, briefly describe the practices/measures and show on site diagram:
❑" This facility has a Stormwater Pollution Prevention Plan (SWPPP).
If checked, please list date that SWPPP was implemented:
wdl be prepared upon pemtil approvals
❑ This facility stores hazardous waste stored in the 100-year floodplain.
If checked, describe how the area is protected from flooding:
❑ This facility is a (mark all that apply)
❑Hazardous Waste Generation Facility
❑ Hazardous Waste Treatment Facility
❑ Hazardous Waste Storage Facility
❑ Hazardous Waste Disposal Facility
If checked, indicate:
Kilograms of waste generated each month:
Type(s) of waste:
How material is stored:
Where material is stored:
Number of waste shipments per year:
Name of transport/disposal vendor:
Transport/disposal vendor EPA ID:
Vendor address:
❑ This facility is located on a Brownfield or SUPERFUND site
If checked, briefly describe the site conditions:
❑ Facility provides appropriate secondary containment for bulk storage of liquid materials
If checked, briefly describe these measures:
❑Site has an active landfill within the mining permit boundary
If checked, please indicate type:
a) ❑ LCID (Land clearing and Inert Debris)
b) ❑other(specify)
Required Items (Application will be returned unless all of the following items have been included):
❑ Check for $100 made payable to NCDEQ
❑ Copy of most recent Annual Report to the NC Secretary of State
❑This completed application and any supporting documentation
❑ Copy of the approved mining permit or indication of mining permit application status
❑ Copy of US Army Corps — approved wetland delineation (if applicable)
Page 5 of 8

❑ Une drawing of the water flow through the facility or block flow diagram
❑ Pictorial description of the nature of any sources of water and any collection and treatment measures
❑ A site diagram showing, at a minimum, existing and proposed:
a) outline of drainage areas
b) surface waters
c) stormwater management structures
d) location of stormwater outfalls corresponding to the drainage areas
e) runoff conveyance features
f) areas where materials are stored
g) impervious areas
h) site property lines
❑2 copies of large scale (24"06" minimum) site plan showing:
a) topographical lines
b) all outfall locations
c) applicable buffers and delineated wetlands
d) receiving waters
e) 300-year flood plain (if applicable)
❑ Copy of county map or USGS quad sheet with the location of the facility clearly marked
If mines site is in one of the 20 Coastal Counties (ff applicable)
❑ Applicant has check with the appropriate regional office to verify the need for a Coastal State Stormwater permit.
a) Indicate the Regional Office Contact:
❑ Detailed list of:
a) impervious surface areas and percentages
b) sub -drainage areas
c) total drainage area
If mine is dewatering and near wetlands, or may otherwise impact surface waters or groundwater (if
applicable)
❑ 2 copies of large scale (24"x36" minimum) plans delineating areas on the listing acreage including:
a) wetlands
b) ditches
c) well -placements
d) pits
e) borrow areas
0 overburden storage
g) stormwater controls/BMPs
h) vehicle maintenance areas
1) settling basins
j) product process (such as screening, stockpiles, and waste piles)
k) total drainage area
1) impervious surface percentages (if state Stormwater programs apply)
m) applicable buffers
n) access and/or haul roads
❑ Pump dewatering size and information on its specifications
[]Well information (design, depths, maintenance)
❑ Physical monitoring for the wetland areas
[]settling pond size information, if applicable
❑ Level spreader design, if applicable
❑ Details about dewatering method
❑ Cone of influence calculations
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❑ Description of measures to prevent erosion and flooding
❑ Description and information about 401/404 permits that have been obtained
[]Copy of US Army Corps of Engineers wetlands delineations or approved wetland delineation (if applicable)
❑ 1 have contacted my local regional office about a Pumping Operation and Monitoring (POM) plan
a) Regional Office Contact:
b) Date Contacted:
10. Applicant Certification:
North Carolina General Statute 143-215.68 (1) 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 ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,000). 1 hereby request coverage under the referenced General Permit.
Under penalty of law, I certify that:
❑ I am the person responsible for the permitted industrial activity, 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 NO1 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 NCG02 permit. I 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.
❑ I hereby request coverage under the NCG020000 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.
Printed Name of Person Signing:
Title:
N'z
(Signature of Applicant) (Date Signed)
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
512 N. Salisbury Street, 611 floor
1612 Mail Service Center
Raleigh, NC 27699-1612
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