NCC240203_NOI Application_20240123

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 1/22/2024 10:10:27 AM (NCG01 NOI Submission)
Approve by Brooklyn.Broussard 1/22/2024 10:16:25 AM (Review-NOI 178606 Bluestone Subdivision)
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:January 25,2024 5:00
PM 1/22/2024 10:10:35 AM
• The task was assigned to Brooklyn.Broussard by round robin distribution 1/22/2024 10:10:35 AM
Submit by Tev.Holloman 1/23/2024 9:35:50 AM (Payment Verification for NCC240203)
0 Chloe Plaut
• The task was assigned to DEMLR NCG01 Payment Team.The due date is: March 4,2024 5:00 PM
1/22/2024 10:16:40 AM
• Tev.Holloman assigned the task to Tev.Holloman 1/23/2024 9:34:44 AM

applicationConstruction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System(NPDES)
General Permit 1 OOOO:STORMWATER DISCHARGES associated with construction activities
NORTH CAROUNA
Environmental Quality
A. Project Information
Part A.
Project Location and Waterbody Information
...................................................................................................................................................................................................................................................................................................................................................................................................
Are you submitting an NOI that was rejected before?
No
Yes
Previous Rejected NOI No.
178598
Prior Reviewer Name
Brooklyn Broussard
1a. Project Name*
Bluestone Subdivision
1b.Specific Lot Numbers
This field may be used to list specifc lot numbers.
Lot 18
1c.Parcel ID Number(s)(PIN)
List all PINS associated with this project.
5892-23-3294.000
2.County*
Forsyth
3.Highway or Street Address*
6411 Bluestone Park Drive
Street name only is acceptable if no address number assigned yet
4.City or Township*
Village of Clemmons
5.State* NC
6.Zip Code* 27012
7. Latitude* Enter the latitude in decimal degrees
36.0042
8. Longitude* Enter the longitude in decimal degrees(MUST be negative)
-80.3780
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* 01/29/2024
Estimated Construction Project Start Date
10. Date to End* 06/24/2024
Estimated Construction Project End Date
11.SIC(Primary)*
Residential,Single Family Houses(SFE)(1521)
Standard Industrial Classification for Development
12.Acres to be 0.07
disturbed* (including off-site borrow and waste areas)
13.Total site area 0.20
(acres)*
14. Post-construction 0.07
impervious area (Estimated)
(acres)*
Project Tracking ID NCC-FORSY-2024-Bluestone 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 Waterbody*
Johnson Creek
Name of waterbody into which stormwater runoff will discharge
15b.Waterbody Index No.*
12-91
NC Waterbody Index Number
Stormwater discharges will flow to additional waters
No
Yes
16a.Is this project subject to the NC Sediment Pollution Control Act?*
Yes
No, not subject to NC SPCA
17. Is this project funded with ARPA(American Rescue Plan Act)grant funds?
No
Yes
This question was added to the eNOI on 1/26/2023 and will not be answered in applications submitted prior to that date.

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 NCG010000 General Permit. For more information on signatory requirements,see Part IV,Section B,
Item(6)of that permit.
1. Permittee*
Legally Responsible Entity
Nova Triad Partners, 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 INC 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* Andrew
If Corporation,enter Registered Agent First Name
3. Last Name* Dreyfuss
If Corporation,enter Registered Agent Last Name
3b.Title Managing Partner
4. Permitee E-mail Address*
[e-mail]
5. Permittee Telephone No.*
[phone]
6. Permittee Mailing Address*
Street Address
206 North Spruce Street
Address Line 2
Suite 2B
City State/Province/Region
Winston-Salem INC
Postal/Zip Code Country
27101-2747 us
Check box if the street address the same as mailing address
Yes

7.Permittee Street Address
Street Address
206 North Spruce Street
Address Line 2
Suite 2B
City State/Province/Region
Winston-Salem NC
Postal/Zip Code Country
27101-2747 us
8.Type of Ownership*
Ownership is only individual if an individual is named in B.1.above.
Non-Government

C. Site Contact Information
Part C.
Project Site Contact Information
................................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Contact-First Name*
Anshul
2. Primary Site Contact-Last Name*
Patel
3.Title
Site Superintendant
4.Site Contact E-mail Address*
[e-mail]
5.Site Contact Telephone No.*
[phone]
6.Organization Name
Nova Triad Partners, LLC
7.Site Contact Mailing Address*
Street Address
206 N Spruce St
Address Line 2
Suite 213
City State/Province/Region
Winston-Salem NC
Postal/Zip Code Country
27101-2747 us
8.Consultant Name
(Optional)
Aden Stoltzfus
First and Last name
9.Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10.Consultant Telephone No.
[phone]
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-mail
12. Billing Telephone
(For Annual Fee correspondence)
[phone]
Default is legally responsible person telephone

D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Plan Approval Information
......................................................................................................................................................................
1. Date E&SC Plan 01/17/2024
Approved*
2. E&SC Plan Project EN2400002
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 Review Completed-Bluestone Lot 18-Erosion
Approval letter or 202.46KB
Control.pdf
Grading Permit
Must be PDF format
6.Signed FRO Financial Responsibility/Ownership Form
Financial Responsibility Ownership Form.pdf 685.37KB
Must be PDF format
7.Site Location Map Must be PDF format(limit 20 MB)
Bluestone Lot 18 Site Map.pdf 817.85KB
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 Bluestone Lot 18 NCG01 Signed.pdf 347.5KB
Form Must be PDF format
This is an Express No
Review Project* Yes

E. Certification
North Carolina General Statute 143-215.613(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;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
(�j///ftl7t
Type Name* Andrew Dreyfuss
Title Managing Partner
Organization Legally Responsible Entity
Nova Triad Partners, LLC
Date* 01/22/2024

F. Tracking and COC Info
NOI Tracking No. 178606
NC Reference No. NCG01-2024-0203
Indicates NCG01 or NCG25.Uses NOI number until approved,then uses NUMBER incremented by SP(passed
from workflow if eNOI approved)
Certificate of NCC240203
Coverage(COC)No.* Uses NOI number until approved,then uses NUMBER incremented by SP(formatted and passed from workflow if
eNOI approved)
Initial Invoice No. NCC240203-2024
Invoice Due Date 2/21/2024
Initial Fee $ 120.00
Fee increased to$120,effective October 3,2023
Invoice Status OPEN