NCC190064_NOI Application_20190417

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/17/2019 9:11:14 PM (NCG01 NOI Submission)
Approve by Lucas, Annette 4/18/2019 9:41:20 AM (Review- Construction NOI 10227)
* Dear Mr. Randall.
Thank you for using our new e-NOI form. Good luck with your project.
Sincerely,
Annette Lucas
• The task was assigned to Lucas, Annette by round robin distribution 4/17/2019 9:11 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 19, 2019 5:00 PM
4/17/2019 9:11 PM
Submit by Lucas, Annette 4/18/2019 9:42:41 AM (Payment Verification - NCG01-2019-0064)
• The task was assigned to Lucas, Annette. The due date is: April 19, 2019 5:00 PM 4/18/2019 9:41 AM

!1i)iTOT:2,11111711MF1Ii(-_TiIa10141
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Testoff Residence
2. County* Guilford
3. Highway or Street 3405 Myrtle Grove Drive
Address * Street narra only is acceptable if no address nurrber assigned yet
4. City or Township* Gibsonville
5. State * NC
6. Zip Code* 27249
7. Latitude * Enter the latitude in decirral degrees
36.1377
8. Longitude * Enter the longitude in decirral degrees (MJSTbe negative)
-79.5733
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*
10. Date to End*
11. SIC (Primary)*
12. Acres to be
disturbed *
13. Total site area
(acres)*
14. Post -
construction
impervious area
(acres) *
04/22/2019
Estirrated Construction Project Start Date
02/28/2020
Estirrated Construction Project End Date
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Developrrant
1.60
(including off -site borrow and waste areas)
Off
0.10

NCC Project NCC-GUILF-2019-Testoff Residence
Tracking ID Assigned autonatically
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. You may
enter up to 3 waterbodies.
15a. Receiving Travis Creek
Waterbody* I\bne of waterbody into which stornvdater runoff will discharge
15b. Waterbody 16-12
Index No. * NCWaterbody Index Ninber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional Haw River
Receiving Waterbody narre
Waterbody
15d. Waterbody 16-(10-5)
Index No. NCWaterbody Index N.anber
15e. Additional Cape Fear River
Receiving Waterbody nane
Waterbody
15f. Waterbody 18-(1.)
Index No. NCWaterbody Index Nlunber
16a. Is this project f• Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Perrrittee Information - Legally Responsible Entity and Individual
.....................................................................................................................................................................
h
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should 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. Organization James Randall General Contractor
Name *
2. First Name*
James
ff Corporation, enter Registered Agent First l\brre
3. Last Name *
Randall
ff Corporation, enter Registered Agent Last Barre
4. Permitee E-mail
[e-mail]
Address*
5. Permittee 336-337-2325
Telephone No.*
6. Permittee Mailing Street Address
Address* 120 W. Vandalia Rd
Address Line 2
City
Greensboro
Fbstal / Zip Code
27406
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
120 W. Vandalia Rd
Address Line 2
City
Greensboro
Postal / Zip Code
27406
State / Province / Region
NC
Country
USA
State / Province / Region
NC
Country
USA

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Individual
Ownership*
2. Primary Site James
Contact - First
Name *
3. Primary Site Randall
Contact - Last
Name *
4. Title Contractor
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 336-337-2325
Telephone No.*
7. Organization
James Randall General Contractor
Name
8. Site Contact
Street Address
Mailing Address*
120 W Vandalia Rd
Address Line 2
aty
Greensboro
Fbstal / Zip Code
27406
State / Province / Region
NC
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 04/11/2019
Approved *
2. E&SC Plan Project 19-04-GCRP-02979
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Guilford County
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application.
5. E&SC Plan Testoff Residence Letter of Approval.pdf 159.65KB
Approval Mist be FDFfornat
letter/documentation
6. NOI Certification Testoff NOI.pdf 270.28KB
Form Mist be RDFfornat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6B (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes 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 deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
rJ 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.
* V 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.
* I7 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* V 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.
* I7 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:* r The Responsible Person named on this Notice of Intent
r Authorized Responsible Person*
Important: The person who signs this Certification above and signs the NOI Certification Form should be the same
person (or authorized responsible person within the same organization) as listed in Section B (Permittee Information)
of this form. *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* James Randall, Jr.
Date * 04/17/2019

F. Tracking and COC Info
NOI Tracking No. 10227
NC Reference No. NCG01-2019-0064
Uses 'count_nunber variable (increrrented by SP)
Certificate of NCC190064
Coverage (COC) Uses'count_nunber'variable (increrrented by SF)
No. *
Count Number 64
Sequential nunber for subrrittal that is increrrented by Stored Procedure
COC Year 2019
Year of date reviewed, used to assign YY digits after "NOC' in OOC no.)