NCC200086_NOI Application_20200109

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/8/2020 7:47:28 AM (NCG01 NOI Submission)
Approve by Clark, Paul 1/8/2020 10:33:28 AM (Review- Construction NOI 20321)
• The task was assigned to Clark, Paul by round robin distribution 1/8/2020 7:47 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 10, 2020 5:00
PM. The priority is: High 1/8/2020 7:47 AM
Submit by McCoy, Suzanne 1/9/2020 7:47:28 AM (Payment Verification for NCC200086)
* Jeff Hosack
• McCoy, Suzanne assigned the task to McCoy, Suzanne 1/9/2020 7:47 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 19, 2020 5:00 PM.
The priority is: High 1/8/2020 10:33 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Proposed Development Boylston Highway
2. County* Henderson
3. Highway or Street Boylston Highway
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Mills River
5. State * NC
6. Zip Code * 28759
7. Latitude * Enter the latitude in decimal degrees
35.4170
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-82.5478
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*
06/01 /2020
Estimated Construction Project End Cute
11. SIC (Primary)*
Industrial (1541)
Standard Industrial Classification for Developrrent
12. Acres to be
18.17
disturbed*
(including off -site borrow and waste areas)
13. Total site area
29.43
(acres) *
14. Post-
12.70
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-HENDE-2020-Proposed Development Boylston Highway
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 McDowell Creek
Waterbody * %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 6-58
Index No.* NCWaterbody Index Nunber
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional French Broad
Receiving Waterbody narre
Waterbody
15d. Waterbody 6-54.75
Index No. NCWaterbody Index Nunber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody jhosack@sametcorp.c
Index No. om
NCWaterbody Index Nunber
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. ^
Fternittee 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 Samet Corporation
Name *
2. First Name* Jeff
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name * Hosack
If Corporation, enter F3egistered Agent Last %rre
3b. Title Project Executive
4. Permitee E-mail [e-mail]
Address *
5. Permittee 704.794.8474
Telephone No.*
6. Permittee Mailing Street Address
Address* 5605 Carnegie Boulevard
Address Line 2
Suite 220
city
Charlotte
Fbstal / Zip Code
28209
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
5605 Carnegie Boulevard
Address Line 2
Suite 220
Cty
Charlotte
Fbstal / Zip Code
28209
State / Ftovince / Faegion
NC
Country
us
State / Frovince / Fbgion
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Non -Government
Ownership *
2. Primary Site
Jeff
Contact - First
Name *
3. Primary Site
Hosack
Contact - Last
Name *
4. Title
Project Executive
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
7047948474
Telephone No.*
7. Organization
Samet Corporation
Name
8. Site Contact
Street Address
Mailing Address*
5605 Carnegie Boulevard
Address Line 2
Suite 220
Cty
Charlotte
Fbstal / Zip Code
28209
9. Consultant Name
(Optional)
Lee Bakley RE
First and Last narre
10. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
11. Consultant
704.565.7071
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 12/18/2019
Approved *
2. E&SC Plan Project HENDE 2020-07
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 * Asheville (ARO)
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 Grading Permit - LOAwM COPA 12-18-2019.pdf 119.77KB
Approval Wst be RDFfornat
letter/documentation
6. NOI Certification NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form 371.12KB
SW signed.pdf
Wst be RDFfornat
This is an Express f No
Review Project* r Yes

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 Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Artcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
Commission implementing this Artcle 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
#Mack
Type Name *
Jeff Hosack
Title
Project Executive
Organization
Samet Corporation
Date *
01 /08/2020

F. Tracking and COC Info
NOI Tracking No. 20321
NC Reference No. NCG01-2020-0086
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200086
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 86
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.)