NCC192025_NOI Application_20191002

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/23/2019 2:59:33 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 9/24/2019 9:55:57 AM (Review- Construction NOI 16194)
• The task was assigned to Garcia, Lauren V by round robin distribution 9/23/2019 2:59 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 25, 2019 5:00
PM 9/23/2019 2:59 PM
Submit by McCoy, Suzanne 10/2/2019 1:20:53 PM (Payment Verification for NCC192025)
* JWM57 LLC
• McCoy, Suzanne assigned the task to McCoy, Suzanne 10/2/2019 1:20 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 5, 2019 5:00
PM 9/24/2019 9:56 AM

1r-i)iTII1T7G)MFali(-_ToIa10141
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Meadow Bluffs Phases 3-7
2. County* Wake
3. Highway or Street 6021 Johnson Pond Rd
Address * Street name only is acceptable if no address nurrber assigned yet
4. City or Township* Fuquay-Varina
5. State * NC
6. Zip Code* 27526
7. Latitude * Enter the latitude in decirral degrees
35.6194
8. Longitude * Enter the longitude in decirral degrees (MJSTbe negative)
-78.7536
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*
10/01/2019
Estimated Construction Project Start Date
10. Date to End*
11 /01 /2020
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
12. Acres to be
23.69
disturbed*
(including off -site borrow and waste areas)
13. Total site area 92.99
(acres)*
14. Post- 24.47
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-WAKE-2019-Meadow Bluffs Phases 3-7
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. 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 Terrible Creek
Waterbody* Narre of waterbody into which stornwater runoff will discharge
15b. Waterbody 27-43-15-8-2
Index No. * NCWaterbody Index Nurrber
Stormwater fJ No
discharges will flow r 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 JWM57, Ilc
Name *
2. First Name* J Wayne
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Massengill
ff Corporation, enter Registered Agent Last Barre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-614-2909
Telephone No.*
6. Permittee Mailing Street Address
Address* 6600 Brookshire Drive
Address Line 2
City
Fuquay-Varina
Postal / Zip Code
27526-9006
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
6600 Brookshire Drive
Address Line 2
City
Fuquay-Varina
Postal / Zip Code
27526-9006
State / Province / Region
NC
Country
us
State / Province / Region
NC
Country
us

C. Site Contact Information
Part C.
Roiect Site Contact hforrration
1. Type of Individual
Ownership*
2. Primary Site J Wayne
Contact - First
Name *
3. Primary Site Massengill
Contact - Last
Name *
4. Title manager
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
919-614-2909
Telephone No.*
7. Organization
jwm57, Ilc
Name
8. Site Contact
Street Address
Mailing Address*
6600 Brookshire Drive
Address Line 2
city
Fuquay-Varina
Pbstal/ Zip Code
27526-9006
9. Consultant Name (optional)
Don Curry
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11.Consultant 919-552-0849
Telephone No.
State / Province / Region
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 11/20/2018
Approved *
2. E&SC Plan Project SUB-CD-2018-09
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Town of Fuquay-Varina
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 EC Approval_Meadow Bluffs Ph 3-7_11-20-18.pdf 77.07KB
Approval Mast be PCFfornat
letter/documentation
6. NOI Certification NOI Certification Form - signed.pdf 82.26KB
Form Mist be RDFfornat
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 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
��ff�rPx�Ylr' �%l�Crrlri��r�
Type Name* J Wayne Massengill
Title manager
Organization jwm57, Ilc
Date * 09/23/2019

F. Tracking and COC Info
NOI Tracking No. 16194
NC Reference No. NCG01-2019-2025
Uses 'count number variable (incremrented by SP)
Certificate of NCC192025
Coverage (COC) Uses 'count nunber variable (increrrentedbySP)
No. *
Count Number 2025
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.)