NCC200663_NOI Application_20200224

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/18/2020 4:30:23 PM (NCG01 NOI Submission)
Approve by Clark, Paul 2/19/2020 9:41:50 AM (Review- Construction NOI 22096)
• The task was assigned to Clark, Paul by round robin distribution 2/18/2020 4:30 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 20, 2020 5:00
PM 2/18/2020 4:30 PM
Submit by McCoy, Suzanne 2/24/2020 11:11:52 AM (Payment Verification for NCC200663)
* Thomas Royse
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/24/2020 11:11 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 1, 2020 5:00 PM
2/19/2020 9:41 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Publix Greensboro Distribution Center
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers
2. County* Guilford
3. Highway or Street 5566 Burlington Rd
Address* Street name only is acceptable if no address nunber assigned yet
4. CityorTownship* Mcleansville
5. State * NC
6. Zip Code* 27301
7. Latitude* Enter the latitude in decinal degrees
36.0845
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-79.6660
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*
02/19/2020
Estimated Construction Project Start Date
10. Date to End *
02/28/2023
Estinated Construction Project End Date
11. SIC (Primary)*
Industrial (1541)
Standard Industrial C]assification for Development
12. Acres to be
234.09
disturbed*
(including off -site borrow and waste areas)
13. Total site area 334.14
(acres)*
14. Post- 113.78
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-GUILF-2020-Publix Greensboro Distribution Center
Tracking ID Assignedautorratically
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 Little Alamance Creek
Wate rbody* %ne of waterbody into which storrrwater runoff will discharge
15b. Waterbody 16-19-3-(0.5)
Index No. * NCWaterbody Index I inber
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
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. ^
Flarnittee 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 Gray Construction
Name *
2. First Name* Jerry
IF Corporation, enter Pegistered Agent First Barre
3. Last Name* Hack
IF Corporation, enter Faegistered Agent Last %rre
3b. Title Senior Project Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 859-281-9272
Telephone No.*
6. Permittee Mailing Street Address
Address* 10 Quality Street
Address Line 2
city
State / Frovince / Region
Lexington
KY
Fbstal / Zip Code
Country
40507-1443
us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
10 Quality Street
Address Line 2
City
State / Frovince / legion
Lexington
KY
F bstal / Zip Code
Country
40507-1443
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Jerry
Contact - First
Name *
2. Primary Site
Hack
Contact - Last
Name *
3. Title
Senior Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
859-281-9272
Telephone No.
6. Organization
Gray Construction
Name
7. Site Contact
Street Address
Mailing Address*
10 Quality Street
Address Line 2
city
Lexington
Fbstal / Zip Code
40507-1443
8. Consultant Name
(Optional)
Jacob Moore
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-478-3348
Telephone No.
State / Rovince / Region
KY
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 02/17/2020
Approved *
2. E&SC Plan Project 19-11-GCCP-08733
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. For linear projects, please also upload a site map showing the overall extent of the project.
5. E&SC Plan PublixDistribution_Approval Letter.pdf 125.76KB
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 Publix NOI.pdf 1.57MB
Form Mast be RDFfon-rat
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* Jerry Hack
Title Senior Project Manager
Organization Gray Construction
Date * 02/18/2020

F. Tracking and COC Info
NOI Tracking No. 22096
NC Reference No. NCG01-2020-0663
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200663
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 663
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.)