NCC200835_NOI Application_20200304

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/28/2020 4:06:28 PM (NCG01 NOI Submission)
Approve by Clark, Paul 3/2/2020 10:53:58 AM (Review- Construction NOI 22616)
• The task was assigned to Clark, Paul by round robin distribution 2/28/2020 4:06 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 3, 2020 5:00 PM
2/28/2020 4:06 PM
Submit by McCoy, Suzanne 3/4/2020 1:08:07 PM (Payment Verification for NCC200835)
* Bethel Christian Building
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/4/2020 1:07 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 13, 2020 5:00 PM
3/2/2020 10:54 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Bethel Christian Assembly Church Development
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers
2. County* Cumberland
3. Highway or Street 1065 Progress Street
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Fayetteville
5. State * NC
6. Zip Code* 28306
7. Latitude* Enter the latitude in decimal degrees
35.0297
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.8935
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*
03/26/2020
Estimated Construction Project Start Date
10. Date to End *
03/26/2021
Estinated Construction Project End Cate
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
4.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area 5.74
(acres)*
14. Post- 1.88
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-CUMBE-2020-Bethel Christian Assembly Church Development
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 Blounts Creek
Waterbody* %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 18-27-5
Index No. * NC Waterbody Index N n ber
Stormwater rJ 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 Bethel Christian Assembly
Name * If pernittee is an individual (i.e., organization does not apply), enter first and last nave in this field.
2. First Name* Jerry
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Swinney
If Corporation, enter FZegistered Agent Last Wre
3b. Title Pastor
4. Permitee E-mail [e-mail]
Address *
5. Permittee 910-484-8321
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box64007
Address Line 2
city
Fayetteville
Festal / Zip Code
28306
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
r Yes
Street Address
1065 Progress Street
Address Line 2
City
Fayetteville
Fbstal / Zip Code
28306-1827
8. Type of Non -Government
Ownership*
State / Frovince / Faegion
NC
Country
us
State / Ffovince / Pegion
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
..........................................................................................................................................................................................................
1. Primary Site
Jerry
Contact - First
Name *
2. Primary Site
SWnney
Contact - Last
Name *
3. Title
Pastor
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-484-8321
Telephone No.
6. Organization
Bethel Christian Assembly
Name
7. Site Contact
Street Address
Mailing Address*
1065 Progress Street
Address Line 2
city
Fayetteville
Postal / Zip Code
28306-1827
8. Consultant Name
(Optional)
Del Crawford, Crawford Design Company
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
910-221-0033
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 02/14/2020
Approved *
2. E&SC Plan Project CUMBE-2020-090
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 * Fayetteville (FRO)
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 or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan cumbe-2020-090 Approval.pdf 85.6KB
Approval letter or Mist beRDFformat
Grading Permit
Site Map (Optional) Helpful for linear project review
Mast be R7Fform3t
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies for linear projects if necessary.
6. NOI Certification NOI Signed 02.26.2020.pdf 1.09MB
Form Mast be FDFfon-rat
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
1� f
Type Name * Jerry Swinney
Title Pastor
Organization Bethel Christian Assembly
Date * 02/28/2020

F. Tracking and COC Info
NOI Tracking No. 22616
NC Reference No. NCG01-2020-0835
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200835
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 835
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.)