NCC200166_NOI Application_20200123

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/9/2020 10:53:47 AM (NCG01 NOI Submission)
Approve by Farkas, Jim J 1/14/2020 3:42:01 PM (Review- Construction NOI 20394)
• The task was assigned to Farkas, Jim J by round robin distribution 1/9/2020 10:54 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 13, 2020 5:00
PM 1/9/2020 10:54 AM
Submit by McCoy, Suzanne 1/23/2020 7:39:42 AM (Payment Verification for NCC200166)
* Water and land solutions LLc
• McCoy, Suzanne assigned the task to McCoy, Suzanne 1/23/2020 7:39 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 25, 2020 5:00
PM 1/14/2020 3:42 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Horne Creek Tributaries Mitigation Project
2. County* Surry
3. Highway or Street Kiger Rd.
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Pinnacle
5. State * NC
6. Zip Code * 27043
7. Latitude * Enter the latitude in decimal degrees
36.2852
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.5032
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*
01/13/2020
Estimated Construction Project Start Date
10. Date to End*
06/30/2020
Estimated Construction Project End Cute
11. SIC (Primary) *
Other (0000)
Standard Industrial aassification for Ceveloprrent
12. Acres to be
17.30
disturbed*
(including off -site borrow and waste areas)
13. Total site area
11.82
(acres) *
14. Post-
0.10
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-SURRY-2020-Horne Creek Tributaries Mitigation Project
Tracking ID
Assigned autorratically

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 Horne Creek
Wate rbody* Barre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-75
Index No.* NCWaterbody Index Ninber
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 Water and Land Solutions
Name *
2. First Name* Kayne
If Corporation, enter Fbgistered Agent First Barre
3. Last Name* Van Stell
If Corporation, enter Faegistered Agent Last %rre
3b. Title Vice President, Ecosystem Design Services
4. Permitee E-mail [e-mail]
Address *
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* 7721 Six Forks Road
Address Line 2
Suite 130
city
Raleigh
Fostal / Zip Code
27615
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
7721 Six Forks Road
Address Line 2
Suite 130
aty
Raleigh
Fbstal / Zip Code
27615
State / Ftovince / Region
NC
Country
us
State / Frovince / Fbgion
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Individual
Ownership *
2. Primary Site
Nick
Contact - First
Name *
3. Primary Site
Childs
Contact - Last
Name *
4. Title
Restoration Designer
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
[phone]
Telephone No.*
7. Organization
Water and Land Solutions
Name
8. Site Contact
Street Address
Mailing Address*
7721 Six Forks Road
Address Line 2
Suite 130
aty
Raleigh
Fbstal / Zip Code
27615
9. Consultant Name
(Optional)
First and Last narre
10. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
11. Consultant
[phone]
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 09/04/2019
Approved *
2. E&SC Plan Project SURRY-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 * Winston-Salem (WSRO)
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 LQ ESC Letter of approval_ID SURRY-2020-007.pdf 336.45KB
Approval Wst be RDFfornat
letter/documentation
6. NOI Certification NOI Certification Form_HorneCrTribs.pdf 48.12KB
Form Mist be R7Ffornat
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
ILAYAX VAV 5M-L
Type Name * Kayne Van Stell
Title Vice President, Ecosystem Design Services
Organization Water and Land Solutions
Date * 01 /09/2020

F. Tracking and COC Info
NOI Tracking No. 20394
NC Reference No. NCG01-2020-0166
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200166
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 166
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.)