NCC191927_NOI Application_20190918

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/17/2019 11:15:27 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 9/17/2019 12:28:55 PM (Review- Construction NOI 15982)
• The task was assigned to Garcia, Lauren V by round robin distribution 9/17/2019 11:15 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 19, 2019 5:00
PM. The priority is: High 9/17/2019 11:15 AM
Submit by McCoy, Suzanne 9/18/2019 7:54:42 AM (Payment Verification for NCC191927)
* Anne Frasier Mullen
• McCoy, Suzanne assigned the task to McCoy, Suzanne 9/18/2019 7:54 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 29, 2019 5:00 PM.
The priority is: High 9/17/2019 12:29 PM

1r-i)iTiT7i)ilf1Iif_T1IIa10141
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Mockingbird and Scout Sites
2. County* Davie
3. Highway or Street Spillman Road
Address * Street name only is acceptable if no address number assigned yet
4. City or Township* Mocksville
5. State * NC
6. Zip Code* 27028
7. Latitude * Enter the latitude in decimal degrees
36.0333
8. Longitude * Enter the longitude in decimal degrees (MUST be negative)
-80.5172
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*
09/23/2019
Estimated Construction Project Start Date
10. Date to End*
12/16/2019
Estimated Construction Project End Date
11. SIC (Primary)*
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
41.20
disturbed*
(including off -site borrow and waste areas)
13. Total site area
41.00
(acres)*
14. Post-
0.80
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-DAVIE-201 9-Mocking bird and Scout Sites
Tracking ID
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. Please
enter only immediate receiving waterbodies - not waters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a. Receiving Hauser Creek
Wate rbody* Barre of waterbody into which stormuater runoff will discharge
15b. Waterbody 12-86
Index No.* NC Waterbody Index Narrber
Stormwater W No
discharges will flow F Yes
to additional
wate rs *
16a. Is this project F 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 RES
Name *
2. First Name* David
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Godley
If Corporation, enter Registered Agent Last Barre
3b. Title Operations Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 9197238350
Telephone No.*
6. Permittee Mailing Street Address
Address* 302 Jefferson Street
Address Line 2
Suite 110
City
raleigh
Postal / Zip Code
27605
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
302 Jefferson Street
Address Line 2
Suite 110
City
raleigh
Rastal / Zip Code
27605
State / Province / Region
nc
Country
United States
State / Province / Region
nc
Country
United States

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Brian
Contact - First
Name *
3. Primary Site Hockett
Contact - Last
Name *
4. Title Construction Project Manager
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact
3366013246
Telephone No.*
7.Organization
RES
Name
8. Site Contact
Street Address
Mailing Address*
302 jefferson st
Address Line 2
Suite 110
City
raleigh
Fbstal/ Zip Code
27605
9. Consultant Name (optional)
Frasier Mullen
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant 9194123866
Telephone No.
State / Rovince / Plegion
nc
Country
United States

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 09/12/2019
Approved *
2. E&SC Plan Project Davie-2020-003
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 * Winston-Salem (WSRO)
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 2019-09-
Approval 592.11 KB
12_NCDEQ_ESC_PERMIT_APPROVAL. pdf
lette r/docume ntation
Mist be RDF forrrat
6. NOI Certification 2019-09-17_NCG01_Signed.pdf 510.54KB
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 electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized responsible
person within the same organization as the Permittee. *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
pavi�
Type Name *
David Godley
Title
Operations Manager
Organization
RES
Date *
09/17/2019

F. Tracking and COC Info
NOI Tracking No. 15982
NC Reference No. NCG01-2019-1927
Uses 'count number variable (incremented by SP)
Certificate of NCC191927
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 1927
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.)