NCC200545_NOI Application_20200225

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/11/2020 10:15:25 AM (NCG01 NOI Submission)
Approve by Clark, Paul 2/11/2020 11:39:38 AM (Review- Construction NOI 21744)
• The task was assigned to Clark, Paul by round robin distribution 2/11/2020 10:17 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 13, 2020 5:00
PM 2/11/2020 10:17 AM
Submit by McCoy, Suzanne 2/25/2020 1:24:32 PM (Payment Verification for NCC200545)
* CLH Design PA
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/25/2020 1:23 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 24, 2020 5:00 PM
2/11/2020 11:40 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Lewisville Middle School
1 b. Specific Lot This field any be used to list specifc lot numbers.
Numbers
2. County* Forsyth
3. Highway or Street 1115 Lewisville -Vienna Road
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Lewisville
5. State * NC
6. Zip Code* 27023
7. Latitude* Enter the latitude in decimal degrees
36.1192
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.3976
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*
02/03/2020
Estirrated Construction Project Start late
10. Date to End *
06/30/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
30.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area 66.21
(acres)*
14. Post- 8.77
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-FORSY-2020-Lewisville Middle School
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 Mill Creek
Wate rbody* %rne of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-82
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. ^
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 Winston-Salem / Forsyth County Schools
Name *
2. First Name* Colon
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Moore
If Corporation, enter Faegistered Agent Last %rre
3b. Title Construction School Planning Director
4. Permitee E-mail [e-mail]
Address *
5. Permittee 336-727-2533 Ext. 34916
Telephone No.*
6. Permittee Mailing Street Address
Address* 475 Corporate Square Drive
Address Line 2
City
State / Frovince / Faegion
Winston-Salem
NC
Fbstal / Zip Code
Country
27105-9100
us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
475 Corporate Square Drive
Address Line 2
City
State / Frovince / Fbgion
Winston-Salem
NC
Fbstal / Zip Code
Country
27105-9100
us
8. Type of
Government - State
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
.........................................................................................................................................................................................................
1. Primary Site
Colon
Contact - First
Name *
2. Primary Site
Moore
Contact - Last
Name *
3. Title
Construction School Planning Direction
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-727-2533 Ext.
Telephone No.
6. Organization
Winston-Salem / Forsyth County Schools
Name
7. Site Contact
Street Address
Mailing Address*
475 Corporate Square Drive
Address Line 2
city
Winston-Salem
Fbstal / Zip Code
27105-9100
8. Consultant Name
(Optional)
Lauren Dickson
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-319-6716
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 11/05/2019
Approved *
2. E&SC Plan Project FORSY-2020-009
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 2019-11-6- LMS NCDEQ Erosion Control
Approval 11.06MB
Approval.pdf
letter/documentation
down loadattach ment. ashx. pdf 11.06MB
Mist be RDFfornat
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application.
6. NOI Certification NCG01.pdf 486.55KB
Form Mist be RDFfornat
This is an Express r 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 * Colon Moore
Title Director Construction Planning
Organization Winston-Salem/Forsyth County Schools
Date * 02/11 /2020

F. Tracking and COC Info
NOI Tracking No. 21744
NC Reference No. NCG01-2020-0545
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200545
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 545
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.)