NCC190668_NOI Application_20190620

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/20/2019 7:40:07 AM (NCG01 NOI Submission)
Approve by Georgoulias, Bethany 6/20/2019 10:28:52 AM (Review- Construction NOI 12632)
* Applicant accidentally uploaded unsigned NOI Certification Form. A corrected form was e-mailed to the
reviewer and will be added to the permit record.
• The task was assigned to Georgoulias, Bethany by round robin distribution 6/20/2019 7:40 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 24, 2019 5:00 PM
6/20/2019 7:40 AM
Submit by Georgoulias, Bethany 6/20/2019 10:29:04 AM (Payment Verification - NCG01-2019-0668)
• The task was assigned to Georgoulias, Bethany. The due date is: June 21, 2019 5:00 PM
6/20/2019 10:28 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Chick-fil-A Restaurant at Carraway Village
2. County* Orange
3. Highway or Street 4500 Carraway Crossing
Address * Street name only is acceptable if no address nurrber assigned yet
4. City or Township* Chapel Hill
5. State * NC
117-8) sT.:2,i) it fiIi f_TiI a 10 141
6. Zip Code* 27516
7. Latitude * Enter the latitude in decirral degrees
35.9700
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-79.0647
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* 08/05/2019
Estimated Construction Project Start Date
10. Date to End* 01 /30/2020
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 1.30
disturbed* (including off -site borrow and waste areas)
13. Total site area
1.50
(acres)*
14. Post-
1.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-ORANG-2019-Chick-fil-A Restaurant at Carraway Village
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 old Field Creek
Waterbody * Nacre of waterbody into which stormuater runoff will discharge
15b. Waterbody 16-41-1-7
Index No. * NCWaterbody Index Nanber
Stormwater r No
discharges will flow rj Yes
to additional
wate rs *
15c. Additional New Hope Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 16-41-1-(0.5)
Index No. NCWaterbody Index Ninber
15e. Additional B. Everett Jordon Lake
Receiving Waterbody narre
Waterbody
15f. Waterbody NCWaterbody Index Nunter
Index No.
16a. Is this project r Yes
subject to the NC f 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 Chick-fil-A, Inc.
Name *
2. First Name* Sandra
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Moody
ff Corporation, enter Registered Agent Last Barre
3b. Title Vice President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 770-363-2863 404-765-8000
Telephone No.*
6. Permittee Mailing Street Address
Address* 5200 Buffington Road
Address Line 2
City
Atlanta
Postal / Zip Code
30349-2998
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
5200 Buffington Road
Address Line 2
City
Atlanta
Rastal / Zip Code
30349-2998
State / Province / Region
GA
Country
us
State / Province / Region
GA
Country
us

C. Site Contact Information
Part C.
Roiect Site Contact hforrration
1. Type of Individual
Ownership*
2. Primary Site Nate
Contact - First
Name *
3. Primary Site Thompson
Contact - Last
Name *
4. Title Chick-fil-A, Development Manager
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact
770-363-2863 or 404-765-8000
Telephone No.*
7. Organization
Chick-fil-A, Inc.
Name
8. Site Contact
Street Address
Mailing Address*
5200 Buffington Rd
Address Line 2
city
Atlanta
Postal / Zip Code
30349-2998
State / Province / Region
GA
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 05/22/2019
Approved *
2. E&SC Plan Project LDP19-0024
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Orange 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 COA Chick-Fil-A Restaurant at Carramay Village. pdf 398.33KB
Approval Mist be RCFformat
letter/documentation
6. NOI Certification 2040-NCG01-eNO1-Certification-Form-20190329-
Form 218.74KB
DEMLR-SW.pdf
NLst be RDF format
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
aeeta e• (owl
Type Name* Sandra Moody
Title Vice President
Organization Chick-fil-A, Inc.
Date * 06/20/2019

F. Tracking and COC Info
NOI Tracking No. 12632
NC Reference No. NCG01-2019-0668
Uses 'count number variable (incremrented by SP)
Certificate of NCC190668
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 668
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.)