NCC190375_NOI Application_20190524

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 5/24/2019 12:31:07 PM(NCG01 NOI Submission)
Approve by Lucas,Annette 5/24/2019 2:14:55 PM(Review-Construction NOI 11386)
In Good luck with your project. Please be certain to send in the original NOI Certification Form with
original signature.
• The task was assigned to Lucas,Annette by round robin distribution 5/24/2019 12:31 PM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is: May 28,2019 5:00 PM
5/24/2019 12:31 PM
Submit by Lucas,Annette 5/24/2019 2:28:18 PM(Payment Verification-NCG01-2019-0375)
• The task was assigned to Lucas,Annette.The due date is: May 27, 2019 5:00 PM 5/24/2019 2:15 PM

E, • 1 • • 1 III • 1
1 sees �' � ••. -• i •• i i• i
IY sell
NORTH CAROLINA
Environmental QUII
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* Former Dicey Mills
2. County* Cleveland
3. Highway or Street 430 Neisler Street
Address* Street narre only is acceptable if no address nurrber assigned yet
4. City or Township* Shelby
5. State* NC
6.Zip Code* 28152
7. Latitude* Enter the latitude in decirral degrees
35.2880
8. Longitude* Enter the longitude in decirral degrees(MUST be negative)
-81.5690
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* 05/06/2019
Estimated Construction Project Start Date
10. Date to End* 06/28/2019
Estimated Construction Project End Date
11. SIC(Primary)* Other(0000)
Standard Industrial aassification for Developrrent
12.Acres to be 3.40
disturbed* (including off-site borrow and waste areas)
13.Total site area 21.98
(acres)*
14. Post- 0.00
construction (Estimated)
impervious area
(acres)*
NCC Project NCC-CLEVE-2019-Former Dicey Mills
Tracking ID Assigned autorratically

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 First Broad River
Wate rbody* Nacre of waterbody into which stormuater runoff will discharge
15b.Waterbody 9-50-(28)
Index No.* NCWaterbody Index Nunber
Stormwater rJ No
discharges will flow r Yes
to additional
wate rs*
16a.Is this project r 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
.....................................................................................................................................................................
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 Dicey Mills, Inc.
Name*
2. First Name* David
If Corporation,enter Registered Agent First l\brre
3. Last Name* Neisler
If Corporation,enter Registered Agent Last Barre
3b.Title Secretary
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-734-5418
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 1090
Address Line 2
City State/Province/Region
Shelby NC
Postal/Zip Code Country
28151 United States
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 430 Neisler Street
Address Line 2
City State/Province/Region
Shelby NC
Pastal/Zip Code Country
28152 USA

C. Site Contact Information
Part C.
Project Site Contact Inforrration
.............................................................................................
1.Type of Individual
Ownership*
2. Primary Site Brett
Contact-First
Name*
3.Primary Site Lawrence
Contact-Last
Name*
4.Title Project Geologist
5.Site Contact E- [e-mail]
mail Address*
6.Site Contact 704-400-5467
Telephone No.*
7.Organization Hart&Hickman, PC
Name
8.Site Contact Street Address
Mailing Address* 2923 South Tryon St
Address Line 2
Suite 100
City State/Province/Plegion
Charlotte NC
Fbstal/Zip Code Country
28203 United States

D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Ran Approval Information
....................................................................................................................................................................................................................................... .............................................................................................
1. Date E&SC Plan 04/29/2019
Approved*
2. E&SC Plan Project CLEVE-2019-015
Number/ID* Assigned by agency or local program
3. E&SC Plan f•State DEQ Office
Approved by r Local Program
4.State DEQ Office* Mooresville(MRO)
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 Approval Letter 2019-04-26.pdf 1.9MB
Approval Mist be RDFforrrat
letter/documentation
6. NOI Certification NOI Certification Form(signed).pdf 1.37MB
Form Mist be RDFfornat
This is an Express f•No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.613(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.
* rJ 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.
* rJ 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* David C. Neisler
Title Secretary
Organization Dicey Mills Inc.
Date* 05/24/2019

F. Tracking and COC Info
NOI Tracking No. 11386
NC Reference No. NCG01-2019-0375
Uses'count number variable(incremented by SP)
Certificate of NCC190375
Coverage (COC) Uses'count_nunber'variable(increrrented bySP)
No.*
Count Number 375
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed(used to assign YY digits after"NGC'in OOCno.)