NCC200234_NOI Application_20200205

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/20/2020 4:49:41 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 1/21/2020 8:08:04 AM (Review- Construction NOI 20883)
• The task was assigned to McCoy, Suzanne by round robin distribution 1/20/2020 4:50 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 22, 2020 5:00
PM 1/20/2020 4:50 PM
Submit by McCoy, Suzanne 2/5/2020 7:11:58 AM (Payment Verification for NCC200234)
* Joseph B Millikan
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/5/2020 7:11 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 3, 2020 5:00 PM
1 /21 /2020 8:08 AM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name *
1901665_Bojangles Norwood
2. County*
Stanly
3. Highway or Street
411 N Main Street
Address *
Street narre only is acceptable if no address number assigned yet
4. City or Township* Norwood
5. State * NC
6. Zip Code * 28128
7. Latitude * Enter the latitude in decimal degrees
35.2274
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.1245
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*
02/03/2020
Estimated Construction Project Start Date
10. Date to End*
07/31/2020
Estimated Construction Project End Cute
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
1.56
disturbed*
(including off -site borrow and waste areas)
13. Total site area
1.60
(acres) *
14. Post-
0.93
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-STANL-2020-1901665_Bojangles Norwood
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 Cedar Creek
Waterbody* Ibrre of w aterbody into w hich storrrw ater runoff w ill discharge
15b. Waterbody 13-12-(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. ^
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 Randolph Development Group, LLC
Name *
2. First Name* Joey
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Millikan
If Corporation, enter Registered Agent Last %rre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 336.382.4721
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box841
Address Line 2
city
Randleman
Fbstal / Zip Code
27317
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
PO Box841
Address Line 2
City
Randleman
Fbstal / Zip Code
27317
8. Type of
Non -Government
Ownership*
State / F rovince / Region
NC
Country
Randolph
State / Frovince / Fbgion
NC
Country
Randolph

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Joey
Contact - First
Name *
2. Primary Site
Millikan
Contact - Last
Name *
3. Title
Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336.382.4721
Telephone No.
6. Organization
Randolph Development Group, LLC
Name
7. Site Contact
Street Address
Mailing Address*
PO BOX841
Address Line 2
city
Randleman
Fbstal / Zip Code
23317
8. Consultant Name
(Optional)
Lee Bakely
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
704.565.7071
Telephone No.
State / Rovince / Region
NC
Country
Randolph

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 12/30/2019
Approved *
2. E&SC Plan Project STANL-2020-013
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 * Mooresville (MRO)
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 1901665_Bojangles-Norwood_EC&S Letter of
Approval 1.95MB
Approval & Permit.pdf
letter/documentation
Mist be R7Ffon-rat
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
6. NOI Certification 1901665 NCG01-eNO1-Certification- Form- DEMLR-
Form 317.77KB
SW-signed.pdf
Mist be FDFfornat
This is an Express r 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 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 Atide 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 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
C-A91 rl st
Type Name *
Joey Millikan
Title
Manager
Organization
Randolph Development Group, LLC
Date *
01 /20/2020

F. Tracking and COC Info
NOI Tracking No. 20883
NC Reference No. NCG01-2020-0234
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200234
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 234
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.)