NCC200427_NOI Application_20200226

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/3/2020 2:03:58 PM (NCG01 NOI Submission)
Approve by Clark, Paul 2/3/2020 2:33:13 PM (Review- Construction NOI 21445)
• The task was assigned to Clark, Paul by round robin distribution 2/3/2020 2:04 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 5, 2020 5:00
PM 2/3/2020 2:04 PM
Submit by McCoy, Suzanne 2/26/2020 12:02:54 PM (Payment Verification for NCC200427)
* Garner White Oak NW MOB LLC
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/26/2020 12:02 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 16, 2020 5:00 PM
2/3/2020 2:33 PM

d� #
NORTH CAROLINA
Ernvlronmental qualily
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * White Oak Northwest Subdivision - Medical Office Building
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
2. County* Wake
3. Highway or Street Cabela Drive
Address* Street name only is acceptable if no address nunber assigned yet
4. City or Township* Garner
5. State * NC
6. Zip Code* 27529
7. Latitude* Enter the latitude in decimal degrees
35.6988
8. Longitude * Enter the longitude in decimal degrees (MJST be negative)
-78.5866
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*
04/22/2020
Estimated Construction Project Start Rate
10. Date to End *
01 /01 /2021
Estinated Construction Project End Cate
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
5.20
disturbed*
(including off -site borrow and waste areas)
13. Total site area 6.62
(acres) *
14. Post- 2.97
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-WAKE-2020-White Oak Northwest Subdivision - Medical Office
Tracking ID Building
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 Mahlers Creek
Wate rbody* Nacre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 27-43-9
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. ^
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 Garner White Oak NW MOB, LLC
Name *
2. First Name* Joshua
If Corporation, enter Pegistered Agent First Barre
3. Last Name* Teague
If Corporation, enter Faegistered Agent Last %rre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 704-618-1153
Telephone No.*
6. Permittee Mailing Street Address
Address* 9113 Cameron Wood Drive
Address Line 2
city State / Frovince / Region
Charlotte NC
Fbstal / Zip Code Country
28210-7939 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
9113 Cameron Wood Drive
Address Line 2
City
State / Frovince / Fbgion
Charlotte
NC
Fbstal / Zip Code
Country
28210-7939
us
8. Type of
Individual
Ownership*

C. Site Contact Information
Part C.
Project Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Brad
Contact - First
Name *
2. Primary Site Connolly
Contact - Last
Name *
3. Title
4. Site Contact E- [e-mail]
mail Address*
5. Site Contact 919-578-6769
Telephone No.*
6. Organization
Burton Engineering Associates, PC
Name
7. Site Contact
Street Address
Mailing Address*
130 Partlo Street
Address Line 2
city
Garner
Pbstal / Zip Code
27529
8. Consultant Name (Optional)
First and Last nave
9. Consultant E-mail This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Province / Region
27
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 11/25/2019
Approved *
2. E&SC Plan Project SEC-027696-2019
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Wake 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 SEC-027696-2019_Approval-
Approval S&EConstructionPlan ReviewChecklist-V.2 WM 11- 280.04KB
letter/documentation
25-19.pdf
Financial Responsibility Form.pdf 387.48KB
Mast be R7Ffon-rat
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
6. NOI Certification NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form 753.22KB
SW-= Teague_signed_012120.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
Type Name* Joshua Teague
Title Manager
Organization Garner White Oak NW MOB, LLC
Date * 02/03/2020

F. Tracking and COC Info
NOI Tracking No. 21445
NC Reference No. NCG01-2020-0427
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200427
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 427
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.)