NCC200726_NOI Application_20200225

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/21/2020 1:33:34 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 2/24/2020 8:25:56 AM (Review- Construction NOI 22257)
• The task was assigned to McCoy, Suzanne by round robin distribution 2/21/2020 1:34 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 25, 2020 5:00
PM 2/21/2020 1:34 PM
Submit by McCoy, Suzanne 2/25/2020 10:16:18 AM (Payment Verification for NCC200726)
* Robert Walters -Davidson
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/25/2020 10:15 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 6, 2020 5:00 PM
2/24/2020 8:26 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Old 109 Water Mains
1 b. Specific Lot This field may be used to list specifc lot nunbers.
Numbers
2. County* Davidson
3. Highway or Street E Holly Grove Road
Address* Street name only is acceptable if no address nunber assigned yet
4. City or Township* Thomasville
5. State * NC
6. Zip Code* 27360
7. Latitude* Enter the latitude in decinal degrees
35.8407
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-80.0918
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
Estirrated Construction Project Start Date
10. Date to End*
03/01/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Industrial (1541)
Standard Industrial Classification for Development
12. Acres to be
18.75
disturbed*
(including off -site borrow and waste areas)
13. Total site area 18.75
(acres)*
14. Post- 0.00
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-DAVID-2020-01d 109 Water Mains
Tracking ID Assignedautonatically
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 Hamby Creek
Wate rbody* f\brre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-119-7-4
Index No. * NCWaterbody Index Minter
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. ^
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 Davidson Water, Inc.
Name *
2. First Name* Robert
IF Corporation, enter Pegistered Agent First Barre
3. Last Name* Walters
IF Corporation, enter Faegistered Agent Last %rre
3b. Title Vice President of Construction & Engineering
4. Permitee E-mail [e-mail]
Address *
5. Permittee 336-731-5526
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box969
Address Line 2
city
Welcome
Fbstal / Zip Code
27374-0969
Check box if the r Yes
street address the
same as mailing
address
State / Frovince / Faegion
NC
Country
USA
7. Permittee Street
Street Address
Address*
7040 Old U.S Highway 52
Address Line 2
City
State / Frovince / Pegion
Lexington
NC
Fbstal / Zip Code
Country
27295
USA
8. Type of
Individual
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
......................................................................................................................................................................................................................
1. Primary Site
Robert
Contact - First
Name *
2. Primary Site
Walters
Contact - Last
Name *
3. Title
Vice President of Construction & Engineering
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-731-5526
Telephone No.*
6. Organization
Davidson Water, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
7040 Old U.S Highway 52
Address Line 2
City
State / Rovince / Region
Lexington
NC
Fbstal / Zip Code
Country
27295
USA
8. Consultant Name
(Optional)
Michael Benchich
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
704-941-6058
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 DAVID-2020-024
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 * Winston-Salem (WSRO)
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 D00012420-01242020160223.pdf 6.94MB
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 DWI NOI Signed.pdf 71.14KB
Form Mast be RDFforrrat
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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle 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 * Robert Walters
Title Vice President, Construction and Engineering
Organization Davidson Water, Inc.
Date * 02/21 /2020

F. Tracking and COC Info
NOI Tracking No. 22257
NC Reference No. NCG01-2020-0726
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200726
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 726
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.)