NCC200575_NOI Application_20200214

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 2/12/2020 8:39:27 AM(NCG01 NOI Submission)
Approve by Morman,Alaina 2/13/2020 1:20:39 PM(Review-Construction NOI 21798)
Reviewer corrected index numbers for receiving waterbodies.
• The task was assigned to Morman,Alaina by round robin distribution 2/12/2020 8:39 AM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is: February 14,2020 5:00
PM 2/12/2020 8:39 AM
Submit by Garcia, Lauren V 2/14/2020 3:29:10 PM(Payment Verification for NCC200575)
* Kelsey Pace
• Garcia, Lauren V assigned the task to Garcia, Lauren V 2/14/2020 3:28 PM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is: March 26,2020 5:00 PM
2/13/2020 1:20 PM

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1Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System 'D application for•• - .•-under NorthCarolina's
General Permit 1 1111:STORIVWATER DISCHARGES associated with construction activities(or
NORTH CAROLINA
Enrlrnnmenfu�Qr�arlry
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* Line 204 Gas Line Relocation Project
2.County* Martin
3. Highway or Street North of Old Ford, east of Bear Grass
Address* Street nacre only is acceptable if no address number assigned yet
4. City or Township* Williamston
5.State* NC
6.Zip Code* 27892
7. Latitude* Enter the latitude in decimal degrees
35.7310
8. Longitude* Enter the longitude in decimal degrees(M.ST be negative)
-77.0778
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* 03/02/2020
Estimated Construction Project Start Date
10. Date to End* 01/29/2021
Estimated Construction Project End Cute
11.SIC(Primary)* Other(0000)
Standard Industrial Classification for Ceveloprrent
12.Acres to be 114.00
disturbed* (including off-site borrow and waste areas)
13.Total site area 114.00
(acres)*
14. Post- 8.13
construction (Estimated)
impervious area
(acres)*
NCC Project NCC-MARTI-2020-Line 204 Gas Line Relocation Project
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 Dog Branch
Waterbody* %rre of waterbody into which storrrwater runoff will discharge
15b.Waterbody 23-50-1-1
Index No.* NCWaterbody Index Number
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs*
15c.Additional Ready Branch
Receiving Waterbody narre
Waterbody
15d.Waterbody 23-50-1
Index No. NCWaterbody Index Nurrber
15e.Additional Gum Swamp
Receiving Waterbody narre
Waterbody
15f.Waterbody 28-103-14-2-1
Index No. NCWaterbody Index Nurrber
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 Piedmont Natural Gas
Name*
2. First Name* Kelsey
ff Corporation,enter Fbgistered Agent First Barre
3. Last Name* Pace
If Corporation,enter Faegistered Agent Last%rre
3b.Title Project Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-731-4705
Telephone No.*
6. Permittee Mailing Street Address
Address* 4720 Piedmont Row Drive
Address Line 2
City State/Frovince/Faegion
Charlotte NC
Fbstal/Zip Code Country
28054 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
28054 us
8.Type of Individual
Ownership*

C. Site Contact Information
Part C. ^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Michael
Contact-First
Name*
2. Primary Site Parham
Contact-Last
Name*
3.Title
4.Site Contact E- [e-mail]
mail Address*
5.Site Contact 865-771-9841
Telephone No.*
6.Organization Piedmont Natural Gas
Name
7.Site Contact Street Address
Mailing Address* 4720 Piedmont Row Drive
Address Line 2
City State/Rovince/Region
Charlotte NC
Fbstal/Zip Code Country
28054 us
8. Consultant Name (Optional)
Suzanne Herron
First and Last narre
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 615-383-6300
Telephone No.

D. E&SC Plan
Part D. ^
Erosion&Sediment Control(E&SC)Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 01/24/2020
Approved*
2. E&SC Plan Project Marti-2020-001
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* Washington (WaRO)
Documentation of E&SC Plan approval and the signed Notice of Intent(NOI)Certification Form is required for a
complete application. For linear projects, please also upload a site map showing the overall extent of the project.
5. E&SC Plan Marti-2020-001 Line 204 Gas Line Relocation
Approval 1.22MB
Project-01242020.pdf
letter/documentation
Mast be R7Fforrrat
Notes(Optional) Frovide any additional information that might help the reviewer better understand how uploaded documents support
the application.
6. NOI Certification NOI Certification Form.pdf 33.97KB
Form IvLst be R7Fforrrat
This is an Express F No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6E(i) provides that:
Anyperson who knowinglymakes any false statement,representation,or certification in anyapplication,record,report,plan,or other
documentfiled 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 underthis 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 guiltyofa Class 2 misdemeanor which mayinclude 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* Kelsey Pace
Title Project Manager
Organization Duke Energy- Piedmont Natural Gas
Date* 02/12/2020

F. Tracking and COC Info
NOI Tracking No. 21798
NC Reference No. NCG01-2020-0575
Uses'count_nurrber'variable(increrrented by SP)
Certificate of NCC200575
Coverage (COC) Uses'count number'variable(increrrented by SP)
No.*
Count Number 575
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed(used to assign YY digits after"NOC'in COCno.)