NCC200205_NOI Application_20200117

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/14/2020 4:06:58 PM (NCG01 NOI Submission)
Approve by Farkas, Jim J 1/16/2020 3:16:02 PM (Review- Construction NOI 20674)
• The task was assigned to Farkas, Jim J by round robin distribution 1/14/2020 4:07 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 16, 2020 5:00
PM. The priority is: High 1/14/2020 4:07 PM
Submit by McCoy, Suzanne 1/17/2020 7:23:59 AM (Payment Verification for NCC200205)
* Justin Hall
• McCoy, Suzanne assigned the task to McCoy, Suzanne 1/17/2020 7:23 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 27, 2020 5:00 PM.
The priority is: High 1/16/2020 3:16 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Dormie Club - Phase 1 Cottages
2. County* Moore
3. Highway or Street Beulah Hill Church Rd.
Address * Street narre only is acceptable if no address nunber assigned yet
4. City or Township* West End
5. State * NC
6. Zip Code * 27376
7. Latitude * Enter the latitude in decirral degrees
35.2622
8. Longitude* Enter the longitude in decir al degrees (M. ST be negative)
-79.5060
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*
01/20/2020
Estimated Construction Project Start Date
10. Date to End*
11/20/2020
Estimated Construction Project End Cute
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
2.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area
986.00
(acres) *
14. Post-
3.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-MOORE-2020-Dormie Club - Phase 1 Cottages
Tracking ID
Assignedautorratically

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 Little River (Lower Little River)
Wate rbody* Barre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 18-23-(1)
Index No.* NCWaterbody Index Nirrber
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. ^
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 Sampson Construction Co., Inc.
Name *
2. First Name* Justin
IF Corporation, enter Pegistered Agent First Barre
3. Last Name* Hall
If Corporation, enter Faegistered Agent Last %rre
3b. Title Senior Project Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 402-416-6569
Telephone No.*
6. Permittee Mailing Street Address
Address* 3730 South 14th Street
Address Line 2
city
Lincoln
Fostal / Zip Code
68502
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
3730 South 14th Street
Address Line 2
City
Lincoln
Fbstal / Zip Code
68502
State / Frovince / Region
NE
Country
us
State / Frovince / Fbgion
NE
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
.................................................................................................................................................................................................................
1. Type of
Non -Government
Ownership *
2. Primary Site
Peter
Contact - First
Name *
3. Primary Site
Erickson
Contact - Last
Name *
4. Title
Superintendent
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
402-610-3599
Telephone No.*
7. Organization
Sampson Construction Co., Inc.
Name
8. Site Contact
Street Address
Mailing Address*
6033 Beulah Hill Church Road
Address Line 2
City
State / Rovince / Fbgion
West End
NC
Flostal / Zip Code
Country
27376
us
9. Consultant Name
(Optional)
Philip Picerno
First and Last narre
10. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
11. Consultant
910-420-1437
Telephone No.

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 01/13/2020
Approved *
2. E&SC Plan Project MOORE-2020-029
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 moore029exapDef.pdf
Approval Wst be RDFfornat
letter/documentation
6. NOI Certification Cottages Phase 1 NCG01-eNO1-Certification-
Form Form.pdf
Wst be RDFfornat
This is an Express f No
Review Project* r Yes
76.69KB
1.08MB

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
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
01 71e,f�� Call/
Type Name * Justin J. Hall
Title Senior Project Manager
Organization Sampson Construction Co., Inc.
Date * 01 /14/2020

F. Tracking and COC Info
NOI Tracking No. 20674
NC Reference No. NCG01-2020-0205
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200205
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 205
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.)