NCC200424_NOI Application_20200203

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/3/2020 10:24:13 AM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 2/3/2020 2:21:41 PM (Review- Construction NOI 21428)
• The task was assigned to McCoy, Suzanne by round robin distribution 2/3/2020 10:24 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 5, 2020 5:00
PM 2/3/2020 10:24 AM
Submit by McCoy, Suzanne 2/3/2020 2:22:53 PM (Payment Verification for NCC200424)
* Koonce Noble and Associates
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/3/2020 2:22 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 16, 2020 5:00 PM
2/3/2020 2:21 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Robeson County County -Wide Water System, Water Main
Extensions 2019-2
2. County* Robeson
3. Highway or Street Rev. Bill Road
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Lumberton
5. State * NC
6. Zip Code* 28358
7. Latitude* Enter the latitude in decimal degrees
34.7939
8. Longitude * Enter the longitude in decimal degrees (MJST be negative)
-79.2817
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*
02/05/2020
Estimated Construction Project Start Date
10. Date to End *
04/07/2020
Estimated Construction Project End Date
11. SIC (Primary) *
Other (0000)
Standard Industrial cassification for Development
12. Acres to be
1.32
disturbed*
(including off -site borrow and waste areas)
13. Total site area 12.90
(acres) *
14. Post- 4.30
construction (Estirated)
impervious area
(acres) *

NCC Project NCC-ROBES-2020-Robeson County County -Wide Water System,
Tracking ID Water Main Extensions 2019-2
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 Gum Swamp
Waterbody* N3rreof waterbody into which storrrwater runoff will discharge
15b. Waterbody 14-5
Index No. * NCWaterbody Index Narrber
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional Richland Swamp
Receiving Waterbody narre
Waterbody
15d. Waterbody 14-10-8 (2.5)
Index No. NCWaterbody Index Narrber
15e. Additional Big Swamp
Receiving Waterbody narre
Waterbody
15f. Waterbody 14-22
Index No. NCWaterbody Index Narrber
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 County of Robeson
Name *
2. First Name* Kellie
IF Corporation, enter Pegistered Agent First Barre
3. Last Name* Blue
If Corporation, enter Faegistered Agent Last %rre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 910-671-3022
Telephone No.*
6. Permittee Mailing Street Address
Address* 701 North Elm Street
Address Line 2
city
Lumberton
Fbstal / Zip Code
28358-4891
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
701 North Elm Street
Address Line 2
City
Lumberton
Fbstal / Zip Code
28358-4891
8. Type of Government - County
Ownership*
State / Frovince / Faegion
NC
Country
us
State / Frovince / ilegion
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Kenny
Contact - First
Name *
2. Primary Site
Meares
Contact - Last
Name *
3. Title
Construction Observer
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-738-9376
Telephone No.
6. Organization
Koonce, Noble and Associates, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
208 East 5th Street
Address Line 2
city
Lumberton
Fbstal / Zip Code
28358-5576
8. Consultant Name
(Optional)
Sam Noble, Jr.
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
910-738-9376
Telephone No.
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 09/18/2019
Approved *
2. E&SC Plan Project ROBES-2020-004
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 Bill Road.pdf 993.2KB
Approval Wst be FDFfornat
letter/documentation
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
The proposed water main extensions are located at four different
locations:
Lat. Lon. Acres Disturbed
Rev. Bill Road 34.7939-79.2817 0.31
Zadie Dirve 34.7227-79.2579 0.16
Buies's Mill Road 34.7388-79.1434 0.55
Singletary Chruch Rd. 34.5712-78.9027 0.30
Total Area Distrubed = 1.32 Acres
6. NOI Certification NCG01 NOI.pdf 361.88KB
Form Mast be R7Ffon-rat
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
Type Name *
Kellie Hunt Blue
Title
County Manager
Organization
Robeson County
Date *
02/03/2020

F. Tracking and COC Info
NOI Tracking No. 21428
NC Reference No. NCG01-2020-0424
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200424
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 424
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.)