NCC191737_NOI Application_20190906

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/5/2019 2:35:44 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 9/5/2019 3:52:59 PM (Review- Construction NOI 15600)
• The task was assigned to Garcia, Lauren V by round robin distribution 9/5/2019 2:36 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 9, 2019 5:00
PM. The priority is: High 9/5/2019 2:36 PM
Submit by McCoy, Suzanne 9/6/2019 10:49:30 AM (Payment Verification for NCC191737)
* Jennifer Johnson.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 9/6/2019 10:49 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 5, 2019 5:00 PM.
The priority is: High 9/5/2019 3:53 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * West Albemarle DP: Line 2131
2. County* Chowan
3. Highway or Street 120 Substation Road
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Edenton
5. State * NC
1 r-i) iTiT 7i) M fiIi f_T1II a 10141
6. Zip Code* 27932
7. Latitude * Enter the latitude in decirral degrees
36.0942
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-76.5772
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*
01 /31 /2020
Estimated Construction Project End Date
11. SIC (Primary)*
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
1.56
disturbed*
(including off -site borrow and waste areas)
13. Total site area
2.45
(acres)*
14. Post-
0.01
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-CHOWA-2019-West Albemarle DP: Line 2131
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 Queen Anne Creek
Wate rbody* Nacre of waterbody into which stormuater runoff will discharge
15b. Waterbody 26-1-2
Index No. * NCWaterbody Index Number
Stormwater V 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
.....................................................................................................................................................................
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 Virginia Electric & Power Company d/b/a Dominion Energy North
Name * Carolina
2. First Name* Mark
ff Corporation, enter Registered Agent First Nacre
3. Last Name * Allen
ff Corporation, enter Registered Agent Last Narre
3b. Title Director ET Project Development & Execution
4. Permitee E-mail [e-mail]
Address*
5. Permittee 757-636-5047
Telephone No.*
6. Permittee Mailing Street Address
Address* 10900 Nuckols Road
Address Line 2
4th Floor
City
Glen Allen
Rxstal / Zip Code
23060
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
10900 Nuckols Road
Address Line 2
4th Floor
City
Glen Allen
Postal / Zip Code
23060
State / Province / Region
Virginia
Country
USA
State / Province / Region
Virginia
Country
USA

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Eric
Contact - First
Name *
3. Primary Site Clay
Contact - Last
Name *
4. Title Environmental Compliance Coordinator
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 804-335-9534
Telephone No.*
7. Organization
Dominion Energy North Carolina
Name
8. Site Contact
Street Address
Mailing Address*
10900 Nuckols Road
Address Line 2
4th Floor
City
Glen Allen
Fbstal/ Zip Code
23060
9. Consultant Name (optional)
First and Last nacre
10. Consultant E- This person will be copied on all correspondence.
mail
11. Consultant
Telephone No.
State / Ravine / Pegion
Virginia
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
............................................................................................................................................................
1. Date E&SC Plan 08/27/2019
Approved *
2. E&SC Plan Project CHOWA-2020-001
Number/ID * Assigned by agency or local program
3. E&SC Plan r 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 Chowa-2020-001 West Albemarle DP Line 2131
Approval 1.14MB
08272019 (EXP)_rev.pdf
letter/documentation
Mist be RDF format
6. NOI Certification noi_signed.pdf 357.09KB
Form NLst be RJFformat
This is an Express r No
Review Project* r Yes
h

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
t 6'01'
Type Name *
Mark S. Allen
Title
Director Project Development & Execution
Organization
Dominion Energy
Date *
09/05/2019

F. Tracking and COC Info
NOI Tracking No. 15600
NC Reference No. NCG01-2019-1737
Uses 'count number variable (incremrented by SP)
Certificate of NCC191737
Coverage (COC) Uses'count_nunber'variable (incremented by SF)
No. *
Count Number 1737
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.)