NCC191575_NOI Application_20190828

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/26/2019 8:14:48 AM (NCG01 NOI Submission)
Approve by Georgoulias, Bethany 8/26/2019 8:28:42 AM (Review- Construction NOI 15262)
• The task was assigned to Georgoulias, Bethany by round robin distribution 8/26/2019 8:15 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 28, 2019 5:00
PM 8/26/2019 8:15 AM
Submit by McCoy, Suzanne 8/28/2019 3:24:03 PM (Payment Verification for NCC191575)
* Laura Meadows
• McCoy, Suzanne assigned the task to McCoy, Suzanne 8/28/2019 3:23 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 9, 2019 5:00
PM 8/26/2019 8:28 AM

1 re) fTiT 2,0) M 111 f_T1II a 1010
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Suffolk-Swamp-Winfall 230 kV Rebuild, Swamp-Winfall Phase
2. County* Perquimans
3. Highway or Street 150 Two Mile Desert Road
Address * Street name only is acceptable if no address number assigned yet
4. City or Township* Winfall
5. State * NC
6. Zip Code* 27985
7. Latitude * Enter the latitude in decimal degrees
36.2231
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-76.4610
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*
09/02/2019
Estimated Construction Project Start Date
10. Date to End*
09/30/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
17.05
disturbed*
(including off -site borrow and waste areas)
13. Total site area
50.96
(acres)*
14. Post-
0.05
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-PERQU-2019-Suffolk-Swamp-Winfall 230 kV Rebuild, Swamp -
Tracking ID
Winfall Phase
Assigned automatically

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 Perquimans River
Waterbody* Mirre of waterbody into which stormuater runoff will discharge
15b. Waterbody 30-6-(1)
Index No.* NC Waterbody Index Minter
Stormwater F No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional Mill Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 30-6-5-(2)
Index No. WWaterbody Index Minter
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Minter
Index No.
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.
Rerrrittee 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 Dominion Energy North Carolina
Name *
2. First Name* Mark
ff Corporation, enter Registered Agent First l\brre
3. Last Name * Allen
ff Corporation, enter Registered Agent Last Barre
3b. Title Director, Electric Transmission Lines Project Development &
Execution
4. Permitee E-mail [e-mail]
Address*
5. Permittee (804) 257 - 4711
Telephone No.*
6. Permittee Mailing Street Address
Address* 10900 Nuckols Road, 4th Floor
Address Line 2
City State / Province / Region
Glen Allen VA
Fbstal / Zip Code Country
23060 USA
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 10900 Nuckols Road, 4th Floor
Address Line 2
City
State / Province / Region
Glen Allen
VA
Rastal / Zip Code
Country
23060
USA

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Donald
Contact - First
Name *
3. Primary Site Hoover
Contact - Last
Name *
4. Title MANAGER ELEC TRANSMISSION &
SUBSTATION CONSTRUCTION
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact (804) 257 - 4608
Telephone No.*
7. Organization Dominion Energy North Carolina
Name
8. Site Contact Street Address
Mailing Address* 10900 Nuckols Road, 4th Floor
Address Line 2
aty
Glen Allen
Rxstal / Zip Code
23060
State / Rovince / iegion
VA
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 08/21/2019
Approved *
2. E&SC Plan Project Perqu-2020-001
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 * Washington (WaRO)
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 E&SC Plan Approval - Perqu-2020-001 Suffolk -
Approval 1.2MB
Swamp-Winfall 230 kV Rebuild - 08212019.pdf
letter/documentation
Mist be R7F forrret
6. NOI Certification NOI Certification Form.pdf 476.73KB
Form Mist be RDFfornet
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 4&
Type Name * Mark Allen
Title Authorized Representative
Organization Dominion Energy North Carolina
Date * 08/26/2019

F. Tracking and COC Info
NOI Tracking No. 15262
NC Reference No. NCG01-2019-1575
Uses 'count number variable (incremrented by SP)
Certificate of NCC191575
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 1575
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.)