NCC200443_NOI Signed Certification_20200206

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6`h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false 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 ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
P� 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.
0 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.
P" I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan 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.
C � I hereby request coverage under the NCGO10000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharges) and is enforceable in the
same manner as an individual permit. /
Name of Project: kl lv- 4r/4 ,. ��'r �'�1���, G� Z �
Legally Responsible Organizational Entity: (-� /44114e (a-7'1
Legally Responsible Person: TT' jo-4v
Title of Legally Responsible Person: L) L J �0-74,
*Signature: �� l� Date:
*Print Name and Title of Signed if Authorized '
Individual Differs from Permittee:
Phone Number: 1 1 h _ <q_3 7;' j
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that 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 NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (5) of the NCGO10000 permit.

NORTH CAROLINA
Environmental Quality
Construction Storrnwater: Notice of Intent
(NOI)
National Pollutant Discharge Elimination System (NPDES) application for coverage under North
Carolina's General Permit NCG010000: STORMWATER DISCHARGES associated with
construction activities (or NCG250000)
A. Project Information
Part A.
Preje: t Lncation and Information
1. Project Name* Arbor Ridge
2. County* Mecklenburg
3. Highway or
15797 Statesville Rd
Street Address *
Street name only is acceptable if no address number assigned yet
4. City or
Huntersville
Township*
5. State*
NC
6. Zip Code*
28078
7. Latitude*
Enter the latitude In decimal degrees
35A290
8. Longitude*
Enter the longitude in decimal degrees (MUST be negative)
-80.8640
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

10. Date to End * 02/28/2021
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial Classification for Development
12. Acres to be 8.74
disturbed * (including off -site borrow and waste areas)
13. Total site area 18.90
(acres) *
14. Post- 3.88
construction (Estimated)
impervious area
(acres)*
Project Tracking ID NCC-MECKL-2020-Arbor Ridge
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 Torrence Creek
Waterbody* dame of waterbody into which stormwater runoff will discharge
15b. Waterbody 11-115-4
Index No.* NC Waterbody Index Number
Stormwater Ili No
discharges will l- I Yes
flow to additional
waters *
16a. Is this project 4 Yes
subject to the NC r , No, not subject to NC SPCA
Sediment Pollution
Control Act?*
Note: Stormwater discharges from construction activities associated with oil and gas exploration,
production, processing, treatment, or transmission facilities are eligible for the exemption from NPDES
permit coverage except in very limited instances. Do not proceed with this application before consulting this
EPA fact sheet and verifying a permit applies.

B. Permittee Information
Permittee Information - Legally Responsible Entity and Individual
Important. The person who signs the N01 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 NCGO10000 General Permit, For
more information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
1. Organization
Name*
2. First Name`
3. Last Name*
3b. Title*
4. Permitee E-mail
Address*
5. Perm ittee
Telephone No.*
6. Permittee
Mailing Address
Arbor Ridge at Huntersville LLC
Matt
If Corporation, enter Registered Agent First Name
Sobota
If Corporation, enter Registered Agent Last Name
Director of Development
[e-mail]
336-993-7555
Street Address
983 Old Winston Road, Suite 118
Address Line 2
City
Kernersville
Postal I Zip Code
27284-6640
Check box if the Il Yes
street address the
same as mailing
address
State f Province I Region
NC
Country
us

7. Permittee Street Street Address
Address` 983 Old Winston Road, Suite 118
Address Line 2
City State / Province 1 Region
Kernersvilie NC
Postal / Zip Code Country
27284-6640 us
8. Type of Non -Government
Ownership`

C. Site Contact information
Part C.
Projoct Site Contact Information
1. Primary Site Matt
Contact - First
Name *
2. Primary Site Sobota
Contact - Last
Name *
3. Title Director of Development
4. Site Contact E- [e-mail]
mail Address* This person will be copied on all correspondence.
S. Site Contact 336-993-7555
Telephone No.*
6. Organization Arbor Ridge at Huntersville LLC
Name
9. Site Contact Street Address
Mailing Address* 983 Old Winston Road, Suite 118
Address Line 2
City State ! Province I Region
Kernersville NC
Postal I Zip Cody; Country
27284-6640 us
10. Consultant (Optional)
Name Jay Henson
First and Last name
11. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
12. Consultant 704-875-1615
Telephone No.

D. E&SC Plan
Part D.
Erosion & Sediment Contrai (E&SC) Plan Approval Information
1. Date E&SC Plan 01/30/2020
Approved *
2. E&SC Plan 393467
Project Assigned by agency or local program
Number/ID*
3. E&SC Plan ! State DEQ Office
Approved by* Local Program
4. Local Program` Town of Huntersville
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 2020-01-10_ Arbor _Ridge_Civil_Plans_Feed... 51.43MB
Approval must be PDF format
letterldocumentation *
Notes (Optional) Provide any additional information that might help the reviewer better understand how uploaded
documents support the application.
6. NOI Certification NOI cert form.pdf 343.27KB
Form * Must be PDF format
YOU MUST MAIL THE ORIGINAL SIGNED NOI CERTIFICATION FORM (click on this link) to The
Stormwater Program at the address on the form for the application to fulfill federal application requirements.
The Certification Form must be signed by the person listed in Section B (Permittee Information) or by an
authorized responsible person within the same organization. NOTE: The person who signs the paper form
must be the same person to electronically certify and sign the eNOL
This is an Express E $ No
Review Project* F` Yes

E. Certification
North Carolina General Statute 143-215.6B (i) provides that:
Any person who knowingly makes any false 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 Article; or who falsities, 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 Article shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
* I"�l 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.
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,
* tl I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* jai If the Erosion and Sediment Control Plan approved by the delegated
program is not compliant with Part it (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.
* tv] I hereby request coverage under the NCGO10000 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 The Responsible Person named on this Notice of Intent
are: * 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's
Type Name* Matt Sobota
Title* Director of Development
Organization* Arbor Ridge at Huntersville
Date * 02/03/2020