NCC192195_NOI Application_20191010

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/3/2019 1:53:01 PM (NCG01 NOI Submission)
Approve by EADS\Ivgarcia 10/7/2019 8:29:26 AM (Review- Construction NOI 16699)
• The task was assigned to EADS\Ivgarcia by round robin distribution 10/3/2019 1:53 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 7, 2019 5:00
PM 10/3/2019 1:53 PM
Submit by McCoy, Suzanne 10/10/2019 12:37:53 PM (Payment Verification for NCC192195)
* Phoenix Assc. at Brightwood LLC
• McCoy, Suzanne assigned the task to McCoy, Suzanne 10/10/2019 12:37 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 18, 2019 5:00
PM 10/7/2019 8:29 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Brightwood Farms Phase 4A Sect. 2D, 3D & 4D
2. County* Guilford
3. Highway or Street 732 ZZ Breeders Cup Drive
Address * Street name only is acceptable if no address nurrber assigned yet
4. City or Township* Sedalia
5. State * NC
1r-8)a�T7i1)Mfi1i(-_ToIa10141
6. Zip Code* 27048
7. Latitude * Enter the latitude in decirral degrees
36.0717
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-79.5906
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*
10/28/2019
Estimated Construction Project Start Date
10. Date to End*
10/30/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
12. Acres to be
27.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area 27.50
(acres)*
14. Post- 5.00
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-GUILF-2019-Brightwood Farms Phase 4A Sect. 2D, 3D & 4D
Tracking ID Assigned autonatically
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 Rock Creek
Waterbody* Narre of Waterbody into which stornwater runoff will discharge
15b. Waterbody 16-19-3.5-(1)
Index No. * NCWaterbody Index Nunber
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 Phoenix Associates at Brightwood, LLC
Name *
2. First Name* Barry
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Siegal
ff Corporation, enter Registered Agent Last Barre
3b. Title Member
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-587-3633
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 16168
Address Line 2
City
High Point
Postal / Zip Code
27261
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
r Yes
Street Address
4425 Monument Trrace
Address Line 2
City
Greensboro
R bstal / Zip Code
27409
State / Province / Region
NC
Country
Guilford
State / Province / Region
NC
Country
Guilford

C. Site Contact Information
Part C.
Proiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Barry
Contact - First
Name *
3. Primary Site Siegal
Contact - Last
Name *
4. Title Member
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 336-587-3633
Telephone No.*
7. Organization
Phoenix Associates at Brig htwood
Name
8. Site Contact
Street Address
Mailing Address*
Po Box 16168
Address Line 2
city
High Point
Pbstal / Zip Code
27261
9. Consultant Name (optional)
Evans Engineering, Inc
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11.Consultant 336-279-7450
Telephone No.
State / Province / P egion
NC
Country
Guilford

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 10/01/2019
Approved *
2. E&SC Plan Project 19-07-GCRP-06206
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Guilford County
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 Brightwood Farms Phase
Approval 152.79KB
4A Section_2D_3D_4D_Approval Letter.pdf
letter/documentation
Mist be RDF fornat
6. NOI Certification Brightvmod Farms NOI Certification Form.pdf 751.38KB
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
Type Name* Barry Siegal
Title Manager
Organization Phoenix Associates, LLC
Date * 10/03/2019

F. Tracking and COC Info
NOI Tracking No. 16699
NC Reference No. NCG01-2019-2195
Uses 'count number variable (incremrented by SP)
Certificate of NCC192195
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 2195
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.)