NCC200455_NOI Application_20200206

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/4/2020 10:51:27 AM (NCG01 NOI Submission)
Approve by Morman, Alaina 2/5/2020 10:58:49 AM (Review- Construction NOI 21488)
• The task was assigned to Morman, Alaina by round robin distribution 2/4/2020 10:52 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 6, 2020 5:00
PM. The priority is: High 2/4/2020 10:52 AM
Submit by McCoy, Suzanne 2/6/2020 10:44:25 AM (Payment Verification for NCC200455)
* Alicia De Palma
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/6/2020 10:43 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 18, 2020 5:00 PM.
The priority is: High 2/5/2020 10:59 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * PING Line 328 Relocation A
2. County* Forsyth
3. Highway or Street White Rock Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Winston-Salem
5. State * NC
6. Zip Code * 27105
7. Latitude * Enter the latitude in decimal degrees
36.1785
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.2157
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*
02/06/2020
Estirrated Construction Project Start Cate
10. Date to End*
04/30/2020
Estimated Construction Project End Cute
11. SIC (Primary)*
Other (0000)
Standard Industrial Classification for Ceveloprrent
12. Acres to be
8.60
disturbed*
(including off -site borrow and waste areas)
13. Total site area
8.60
(acres) *
14. Post-
0.02
construction
(Estirrated)
impervious area
(acres) *
NCC Project
NCC-FORSY-2020-PNG Line 328 Relocation A
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 Mill Creek
Wate rbody* Barre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-94-7
Index No.* NCWaterbody Index Number
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 Piedmont Natural Gas
Name *
2. First Name* Sanu
If Corporation, enter Pbegistered Agent First Barre
3. Last Name* Odugbesan
If Corporation, enter Faegistered Agent Last %rre
3b. Title Project Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 704-731-4246
Telephone No.*
6. Permittee Mailing Street Address
Address* 4720 Piedmont Row Drive
Address Line 2
city State / Frovince / Region
Charlotte NC
Fbstal / Zip Code Country
28210 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
4720 Piedmont Row Drive
Address Line 2
City
State / Frovince / Fbgion
Charlotte
NC
Fbstal / Zip Code
Country
28210
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Dennis
Contact - First
Name *
2. Primary Site
Robertson
Contact - Last
Name *
3. Title
Implementation Superintendent
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
803-917-6577
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
4720 Piedmont Row Drive
Address Line 2
City
Charlotte
Fbstal / Zip Code
28210
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
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 12/04/2019
Approved *
2. E&SC Plan Project FORSY-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 * 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 Permit Approval DOC120419-12042019111711.pdf 11.07MB
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.
6. NOI Certification NOI form signed.pdf 49.73KB
Form Mast be RDFforrrat
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 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
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
Type Name *
Sanu Odugbesan
Title
Project Manager
Organization
Piedmont Natural Gas
Date *
02/04/2020

F. Tracking and COC Info
NOI Tracking No. 21488
NC Reference No. NCG01-2020-0455
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200455
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 455
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.)