NCC200055_NOI Application_20200107

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/6/2020 11:58:06 AM (NCG01 NOI Submission)
Approve by Clark, Paul 1/6/2020 12:29:17 PM (Review- Construction NOI 20236)
• The task was assigned to Clark, Paul by round robin distribution 1/6/2020 11:58 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 8, 2020 5:00
PM 1/6/2020 11:58 AM
Submit by McCoy, Suzanne 1/7/2020 7:31:10 AM (Payment Verification for NCC200055)
* Town of Red Springs
• McCoy, Suzanne assigned the task to McCoy, Suzanne 1/7/2020 7:30 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 17, 2020 5:00
PM 1/6/2020 12:29 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * 2020 USDA Water Distribution System Improvements Contract 2
2. County* Robeson
3. Highway or Street McPhaul Ln, N. Vance St, W. First Ave, Hackett St, Garner St,
Address* Brooks Ave, James St, Jackson St McLean St, ThurlowSt
Street narre only is acceptable if no address number assigned yet
4. City orTownship* Red Springs
5. State * NC
6. Zip Code * 28377
7. Latitude * Enter the latitude in decimal degrees
34.8152
8. Longitude* Enter the longitude in decimal degrees (M.JST be negative)
-79.1831
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*
04/13/2020
Estimated Construction Project Start Date
10. Date to End*
12/15/2020
Estimated Construction Project End Cute
11. SIC (Primary) *
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial Classification for Development
12. Acres to be
1.58
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.58
(acres) *
14. Post- 0.00
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-ROBES-2020-2020 USDA Water Distribution System
Tracking ID Improvements Contract 2
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 Richland Swamp
Waterbody* Narreof waterbody into which stormwater runoff will discharge
15b. Waterbody 14-10-8-(0.5)
Index No. * NCWaterbody Index Number
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional Panther Branch
Receiving Waterbody narre
Waterbody
15d. Waterbody 14-10-8-3-(1)
Index No. NCWaterbody Index Number
15e. Additional Little Raft Swamp
Receiving Waterbody narre
Waterbody
15f. Waterbody 14-10-5
Index No. NCWaterbody Index Number
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. ^
F2rnittee Inforrration - Legally Fbsponsible Entity and Individual
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 Town of Red Springs
Name *
2. First Name* David
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Ashburn
If Corporation, enter Faegistered Agent Last %rre
3b. Title Town Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 9108435241
Telephone No.*
6. Permittee Mailing Street Address
Address* Post Office Box790
Address Line 2
city
Town of Red Springs
Fbstal / Zip Code
28377
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
r Yes
Street Address
217 South Main Street
Address Line 2
City
Town of Red Springs
Fbstal / Zip Code
28377
State / Frovince / Faegion
NC
Country
us
State / Frovince / Fbgion
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Government - Municipal
Ownership *
2. Primary Site
Tim
Contact - First
Name *
3. Primary Site
Mauldin
Contact - Last
Name *
4. Title
Public Works Director
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
9108435241
Telephone No.*
7. Organization
Town of Red Springs
Name
8. Site Contact
Street Address
Mailing Address*
P.O. Box790
Address Line 2
City
Red Springs
Fbstal / Zip Code
28377
9. Consultant Name
(Optional)
JD Freeman
First and Last narre
10. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
11. Consultant
9194693340
Telephone No.
State / Rovince / Fbgion
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 09/24/2019
Approved *
2. E&SC Plan Project ROBES-2020-007
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 * Fayetteville (FRO)
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 robes-2020-007.pdf
Approval Wst be RDFfornat
letter/documentation
6. NOI Certification NOI Certification Form.pdf
Form Mist be R7Ffornat
This is an Express F No
Review Project* r Yes
79.59KB
359.41 KB

E. Certification
North Carolina General Statute 143-215.6E (i) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 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.
* 17 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
f 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 *
David Ashburn
Title
Town Manager
Organization
Town of Red Springs
Date *
01 /06/2020

F. Tracking and COC Info
NOI Tracking No. 20236
NC Reference No. NCG01-2020-0055
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200055
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 55
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)