NCC200463_NOI Application_20200206

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/3/2020 9:43:02 AM (NCG01 NOI Submission)
Approve by Farkas, Jim J 2/5/2020 1:20:09 PM (Review- Construction NOI 21419)
• The task was assigned to Farkas, Jim J by round robin distribution 2/3/2020 9:43 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 5, 2020 5:00
PM 2/3/2020 9:43 AM
Submit by McCoy, Suzanne 2/6/2020 10:42:47 AM (Payment Verification for NCC200463)
* Patrica L Cortes
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/6/2020 10:42 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 18, 2020 5:00 PM
2/5/2020 1:20 PM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Revolution Academy
2. County* Guilford
3. Highway or Street 3800 Oak Ridge Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Summerfield
5. State * NC
6. Zip Code * 27358
7. Latitude * Enter the latitude in decimal degrees
36.2050
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-79.9160
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*
02/10/2020
Estimated Construction Project Start Date
10. Date to End*
12/31/2020
Estimated Construction Project End Cute
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
10.50
disturbed*
(including off -site borrow and waste areas)
13. Total site area
28.98
(acres) *
14. Post-
4.14
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-GUILF-2020-Revolution Academy
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 Reedy Fork
Wate rbody* INbrre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 16-11-(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 Revolution Charter Holdings, LLC
Name *
2. First Name* Jason
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name * Guffey
IF Corporation, enter Pegistered Agent Last %rre
3b. Title Project Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 704-956-5822
Telephone No.*
6. Permittee Mailing Street Address
Address* 1613 Daniels Road
Address Line 2
city
Lincolnton
Fbstal / Zip Code
28092-7805
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
r Yes
Street Address
775 West 1200 North
Address Line 2
Suite 100
Cty
Springville
Fbstal / Zip Code
84663
8. Type of Non -Government
Ownership*
State / F rovince / Faegion
NC
Country
US
State / Rovince / F;bgion
UT
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Ryan
Contact - First
Name *
2. Primary Site
Thompson
Contact - Last
Name *
3. Title
Project Engineer
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-784-2000
Telephone No.
6. Organization
Landmark Builders
Name
7. Site Contact
Street Address
Mailing Address*
3520 Triad Court
Address Line 2
City
Winston Salem
Fbstal / Zip Code
27107
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Rovince / Region
NC
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 01/23/2020
Approved *
2. E&SC Plan Project 19-12-SUCP-09381
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Guilford County
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 D00O20320-02032020084120.pdf 833.41KB
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.
Please see attached signed copy of the approval letter from
Guilford County. I have not altered the document, so I apologize for
the blank page.
6. NOI Certification NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form SW.pdf 788.69KB
Mist be FDFfornat
This is an Express F No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) 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 If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit. I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* 17 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* Jason Guffey
Title Project Manager
Organization Revolution Charter Holdings, LLC
Date * 02/03/2020

F. Tracking and COC Info
NOI Tracking No. 21419
NC Reference No. NCG01-2020-0463
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200463
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 463
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.)