NCC200631_NOI Application_20200218

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/17/2020 2:17:46 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 2/17/2020 3:32:37 PM (Review- Construction NOI 22008)
• The task was assigned to Garcia, Lauren V by round robin distribution 2/17/2020 2:18 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 19, 2020 5:00
PM 2/17/2020 2:18 PM
Submit by McCoy, Suzanne 2/18/2020 7:35:02 AM (Payment Verification for NCC200631)
* Hunter Oglesby
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/18/2020 7:34 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 30, 2020 5:00 PM
2/17/2020 3:33 PM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Shops 3 and 02 Fitness
2. County* Guilford
3. Highway or Street 4109-4113 Brian Jordan Place
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* High Point
5. State * NC
6. Zip Code * 27265
7. Latitude * Enter the latitude in decimal degrees
36.0346
8. Longitude* Enter the longitude in decimal degrees (MJSTbe negative)
-79.9574
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*
03/01/2021
Estimated Construction Project End Cute
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
2.56
disturbed*
(including off -site borrow and waste areas)
13. Total site area
3.23
(acres) *
14. Post-
2.49
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-GUILF-2020-Shops 3 and 02 Fitness
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 East Fork Deep River
Wate rbody* Barre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 17-2-(0.3)
Index No.* NCWaterbody Index Ninber
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. ^
Fternittee 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 West Wendover Land Development, LLC
Name *
2. First Name* Christopher
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Dunbar
If Corporation, enter Pegistered Agent Last %rre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* 5826 Samet Drive
Address Line 2
Suite 105
City
State / Ftovince / Region
High Point
NC
Postal / Zip Code
Country
27265
us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
5826 Samet Drive
Address Line 2
Suite 105
City
State / Frovince / Fbgion
High Point
NC
Fbstal / Zip Code
Country
27265
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Ryan
Contact - First
Name *
2. Primary Site
Mosser
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
[phone]
Telephone No.
6.Organization
Collett
Name
7. Site Contact
Street Address
Mailing Address*
1111 Metropolitan Avenue
Address Line 2
Suite 700
city
Charlotte
Postal / Zip Code
28204
8. Consultant Name
(Optional)
Steve Webb, P.E.
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
[phone] ext. 310
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 02/14/2020
Approved *
2. E&SC Plan Project EN2000152296
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* City of High Point
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 LOA EN200015226 02-14-2020 Shops 3 & 02
Approval 3.94MB
Fitness.pdf
letter/documentation
Mist be R7Fforrrat
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
6. NOI Certification NOI Certification Form - Shops 3 and 02 Fitness 2-
Form 450.31 KB
17-20.pdf
Mist be FDFfornat
This is an Express r 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
C"ka T i%G[II. i�
Type Name* Christopher T. Dunbar
Title Manager
Organization West Wendover Land Development, LLC
Date * 02/17/2020

F. Tracking and COC Info
NOI Tracking No. 22008
NC Reference No. NCG01-2020-0631
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200631
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 631
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.)