NCC190952_NOI Application_20190715

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 7/15/2019 10:18:57 AM(NCG01 NOI Submission)
Approve by McCoy,Suzanne 7/15/2019 11:08:07 AM(Review-Construction NOI 13436)
• The task was assigned to McCoy, Suzanne by round robin distribution 7/15/2019 10:19 AM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:July 17,2019 5:00 PM
7/15/2019 10:19 AM
Submit by McCoy,Suzanne 7/15/2019 11:09:23 AM(Payment Verification-NCG01-2019-0952)
• The task was assigned to McCoy, Suzanne.The due date is:July 16,2019 5:00 PM
7/15/2019 11:08 AM

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* New Hill(62068)High Pressure Main
2. County* Wake
3. Highway or Street New Hill Olive CHI Road
Address* Street narra only is acceptable if no address nurrber assigned yet
4. City or Township* Apex
5. State* NC
6.Zip Code* 27502
7. Latitude* Enter the latitude in decirral degrees
35.7050
8. Longitude* Enter the longitude in decirral degrees(MUST be negative)
-78.9420
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* 07/15/2019
Estimated Construction Project Start Date
10. Date to End* 01/31/2020
Estimated Construction Project End Date
11. SIC(Primary)* Other(0000)
Standard Industrial aassification for Developrrent
12.Acres to be 11.80
disturbed* (including off-site borrow and waste areas)
13.Total site area 11.80
(acres)*
14. Post- 0.00
construction (Estimated)
impervious area
(acres)*
NCC Project NCC-WAKE-2019-New Hill(62068)High Pressure Main
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 Beaver Creek
Wate rbody* Nhrre of waterbody into which stormuater runoff will discharge
15b.Waterbody 16-41-10-(0.5)
Index No.* NCWaterbody Index Nanber
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 Public Service Company of North Carolina, Inc.
Name*
2. First Name* Shaun
ff Corporation,enter Registered Agent First l\brre
3. Last Name* Randall
ff Corporation,enter Registered Agent Last Barre
3b.Title Vice President-Gas Operations
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-810-3350
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 1398
Address Line 2
City State/Province/Region
Gastonia NC
Postal/Zip Code Country
28053 United States
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 800 Gaston Road
Address Line 2
Building A
City State/Province/Region
Gastonia NC
Pastal/Zip Code Country
28056 US

C. Site Contact Information
Part C.
Roject Site Contact Information
....................................................................................................................
1.Type of Non-Government
Ownership*
2. Primary Site Robert
Contact-First
Name*
3.Primary Site Schwartz
Contact-Last
Name*
4.Title Engineer IV
5.Site Contact E- [e-mail]
mail Address*
6.Site Contact 803-217-7112
Telephone No.*
7.Organization Dominion Energy Southeast Services
Name
8.Site Contact Street Address
Mailing Address* 220 Operation Way
Address Line 2
MC C221
City State/Rovince/Region
Cayce South Carolina
Rbstal/Zip Code Country
29033 United States

D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Ran Approval Information
....................................................................................................................................................................................................................................... .............................................................................................
1. Date E&SC Plan 06/26/2019
Approved*
2. E&SC Plan Project WAKE-2018-087
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* Raleigh (RRO)
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 WAKE-2018-087 LOA MOD 20190626 revised.pdf 83.75KB
Approval Mist be FDFforrrat
letter/documentation
6. NOI Certification scannedimage121909.pdf 485.6KB
Form Mist be RDFforrrat
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
'�//a. �rrr�r rt�r rrtf
Type Name* Shaun Randall
Title Vice President-Gas Operations
Organization PSNC
Date* 07/15/2019

F. Tracking and COC Info
NOI Tracking No. 13436
NC Reference No. NCG01-2019-0952
Uses'count number variable(incremented by SP)
Certificate of NCC190952
Coverage (COC) Uses'count number variable(increrrentedbySP)
No.*
Count Number 952
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.)