NCC200705_NOI Application_20200224

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/20/2020 12:29:18 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 2/20/2020 12:35:13 PM (Review- Construction NOI 22205)
• The task was assigned to Garcia, Lauren V by round robin distribution 2/20/2020 12:29 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 24, 2020 5:00
PM. The priority is: High 2/20/2020 12:29 PM
Submit by McCoy, Suzanne 2/24/2020 11:12:37 AM (Payment Verification for NCC200705)
* Lane Elizabeth Carr
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/24/2020 11:12 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 2, 2020 5:00 PM. The
priority is: High 2/20/2020 12:35 PM

d� #
NORTH CAROLINA
Ernvlronmental qualily
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name* 2020 Pole Replacement
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers
2. County* Halifax
3. Highway or Street multiple Ridgecrest Rd. (start) - W. Battleboro Ave. (end)
Address* Street name only is acceptable if no address nunber assigned yet
4. City or Township * multiple - Halifax
5. State * NC
6. Zip Code* 27839
7. Latitude* Enter the latitude in decimal degrees
36.3304
8. Longitude * Enter the longitude in decimal degrees (MJST be negative)
-77.6742
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
Estinated Construction Project Start Rate
10. Date to End*
07/31 /2020
Estirrated Construction Project End Cate
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
4.67
disturbed*
(including off -site borrow and waste areas)
13. Total site area 46.80
(acres) *
14. Post- 0.01
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-HALIF-2020-2020 Pole Replacement
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 Marsh Swamp
Waterbody* %rreof waterbody into which storrrwater runoff will discharge
15b. Waterbody 28-79-30-1
Index No. * NCWaterbody Index Nurrber
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional Beaverdam Swamp
Receiving Waterbody narre
Waterbody
15d. Waterbody 28-79-30-1-1
Index No. NCWaterbody Index Number
15e. Additional Burnt Coal Swamp
Receiving Waterbody narre
Waterbody
15f. Waterbody 28-79-30-2
Index No. NCWaterbody Index Number
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 Dominion Energy North Carolina
Name *
2. First Name* Mark
If Corporation, enter Registered Agent First f brre
3. Last Name* Allen
If Corporation, enter Fegistered Agent Last %rre
3b. Title Director, Electric Transmission Lines Project Development &
Execution
4. Permitee E-mail [e-mail]
Address*
5. Permittee 8047714061
Telephone No.*
6. Permittee Mailing Street Address
Address* 10900 Nuckols Rd, 4th Floor
Address Line 2
City State / Rovince / Fegion
Glen Allen VA
Fbstal / Zip Code Country
23060 us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
10900 Nuckols Rd, 4th Floor
Address Line 2
City
State / Rovince / Faegion
Glen Allen
VA
Postal / Zip Code
Country
23060
us
8. Type of
Non -Government
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Eric
Contact - First
Name *
2. Primary Site
Clay
Contact - Last
Name *
3. Title
Construction Consultant
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
8043359534
Telephone No.
6. Organization
Dominion Energy North Carolina
Name
7. Site Contact
Street Address
Mailing Address*
10900 Nuckols Rd 4th Floor,
Address Line 2
city
Glen Allen
Postal / Zip Code
23060
8. Consultant Name
(Optional)
First and Last nacre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Rovince / Region
VA
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 02/07/2020
Approved *
2. E&SC Plan Project HALIF-2020-010
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 * Raleigh (RRO)
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 Approval Letter HALIF-2020-010 LOA 20200207.pdf 380.21 KB
Approval Site Map NCDENR Application Compiled_Express
letter/documentation 919.68KB
Review.pdf
Mist be RDFfornat
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application.
Fourth impacted waterbody is Swift Creek [28-78-(2.5)]
6. NOI Certification NCG01-eNO1 Certification Form.pdf 408.13KB
Form Wst be RDFfornat
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 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 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 *
Mark Allen
Title
Director, Electric Transmission Lines Project Development &
Execution
Organization
Dominion Energy North Carolina
Date *
02/20/2020

F. Tracking and COC Info
NOI Tracking No. 22205
NC Reference No. NCG01-2020-0705
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200705
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 705
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.)