NCC200074_NOI Application_20200109

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/6/2020 5:11:04 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 1/7/2020 10:56:43 AM (Review- Construction NOI 20269)
• The task was assigned to McCoy, Suzanne by round robin distribution 1/6/2020 5:11 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 8, 2020 5:00
PM 1/6/2020 5:11 PM
Submit by McCoy, Suzanne 1/9/2020 7:45:01 AM (Payment Verification for NCC200074)
* Richard Baker
• McCoy, Suzanne assigned the task to McCoy, Suzanne 1/9/2020 7:43 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 18, 2020 5:00
PM 1/7/2020 10:56 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * CIRCLE K - R&R 2723188
2. County* Forsyth
3. Highway or Street 1065 BETHANIA-RURAL HALL ROAD
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* RURAL HALL
5. State * NC
6. Zip Code * 27045
7. Latitude * Enter the latitude in decimal degrees
36.2118
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.3020
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*
01/10/2020
Estimated Construction Project Start Cate
10. Date to End*
01 /07/2022
Estimated Construction Project End Cute
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
1.40
disturbed*
(including off -site borrow and waste areas)
13. Total site area
1.25
(acres) *
14. Post-
0.99
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-FORSY-2020-CIRCLE K - R&R 2723188
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 GRASSY CREEK
Wate rbody* Barre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-94-7-3
Index No.* NCWaterbody Index Number
Stormwater V 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. ^
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 CIRCLE K STORES, INC
Name *
2. First Name* WILL
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* RICE, JR
IF Corporation, enter F3egistered Agent Last %rre
3b. Title VICE PRESIDENT
4. Permitee E-mail [e-mail]
Address *
5. Permittee 9197746700
Telephone No.*
6. Permittee Mailing Street Address
Address* 1100 SITUS COURT, STE 100
Address Line 2
city
RALEIGH
Fbstal / Zip Code
17606
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 1100 SITUS COURT, STE 100
Address Line 2
City
RALEIGH
Fbstal / Zip Code
17606
State / Frovince / Faegion
NC
Country
USA
State / Frovince / Fbgion
NC
Country
USA

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
_......................................................................................................................................................
1. Type of
Non -Government
Ownership *
2. Primary Site
Wes
Contact - First
Name *
3. Primary Site
Williams
Contact - Last
Name *
4. Title
Construction Manager
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
919.995.0843
Telephone No.*
7. Organization
CIRCLE K STORES, INC
Name
8. Site Contact
Street Address
Mailing Address*
1100 SITUS COURT, STE 100
Address Line 2
City
RALEIGH
Fbstal / Zip Code
27606
9. Consultant Name
(Optional)
BRIAN DOWNS
First and Last narre
10. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
11. Consultant
9198664504
Telephone No.
State / Rovince / Fbgion
NC
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 12/18/2019
Approved *
2. E&SC Plan Project EN1900168
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Winston-Salem/Forsyth 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 2019-12-18 Winston Salem Erosion Control
Approval 181.96KB
Approval.pdf
letter/documentation
Mist be RDFforrrat
6. NOI Certification 37630.025 - NCG01-eNO1-Certification-Form-
Form 20190507-DEMLR-SW (1) - SIGNED.pdf 73.94KB
Mist be RDFfornat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) 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 Amide 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 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.
* 17 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* Will Rice, Jr
Title Vice President
Organization Circle K Stores, Inc
Date * 01 /06/2020

F. Tracking and COC Info
NOI Tracking No. 20269
NC Reference No. NCG01-2020-0074
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200074
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 74
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.)