NCC201171_NOI Application_20200324

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/22/2020 8:02:02 AM (NCG01 NOI Submission)
Approve by Clark, Paul 3/23/2020 9:31:00 AM (Review- Construction NOI 23351)
• Georgoulias, Bethany reassigned the task to Clark, Paul 3/23/2020 7:26 AM
• The task was assigned to Morman, Alaina by round robin distribution 3/22/2020 8:02 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 25, 2020 5:00
PM 3/22/2020 8:02 AM
Submit by McCoy, Suzanne 3/24/2020 7:45:08 AM (Payment Verification for NCC201171)
* E Brent Blair
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/24/2020 7:44 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 4, 2020 5:00 PM
3/23/2020 9:31 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name*
Brooke Ridge
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
Township 16, Map 347, Tax Lot 45
Davidson County
2. County*
Davidson
3. Highway or Street Fisher FerryRoad
Address* Street name only is acceptable if no address number assigned yet
4. Cityor Township* Thomasville
5. State * NC
6. Zip Code * 27360
7. Latitude* Enter the latitude in decimal degrees
35.8450
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.0900
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*
04/01/2020
Estimated Construction Project Start Date
10. Date to End *
09/30/2020
Estimated Construction Project End Cate
11. SIC (Primary) *
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
12. Acres to be
6.24
disturbed*
(including off -site borrow and waste areas)
13. Total site area 18.50
(acres)*

14. Post- 1.48
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-DAVID-2020-Brooke Ridge
Tracking ID Assignedautorraticaly
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
Waterbody * %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 12-119-7-4
Index No.* NCWaterbody Index Nunber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional Yadkin Pee -Dee River Basin
Receiving Waterbody narre
Waterbody
15d. Waterbody 12-(1)
Index No. NCWaterbody Index Narrber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index N nber
Index No.
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 Blair Appraisal Service, Inc.
Name * If pernittee is an individual (i.e., organization does not apply), enter first and last nave in this field.
2. First Name* Brent
IF Corporation, enter Plegistered Agent First Barre
3. Last Name* Blair
If Corporation, enter Faegistered Agent Last Wre
3b. Title President
4. Permitee E-mail [e-mail]
Address *
5. Permittee 336-476-8410
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 1261
Address Line 2
city
Thomasville
Fostal / Zip Code
27361-1261
Check box if the r Yes
street address the
same as mailing
address
State / Frovince / Faegion
NC
Country
U.S.
7. Permittee Street
Street Address
Address*
1152 Randolph Street
Address Line 2
City
State / Ffovince / Fbgion
Thomasville
NC
Flostal / Zip Code
Country
27360
U.S.
8. Type of
Individual
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Brent
Contact - First
Name *
2. Primary Site
Blair
Contact - Last
Name *
3. Title
President/Developer
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-476-8410
Telephone No.
6. Organization
Blair Appraisal Service, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
PO Box 1261
Address Line 2
city
Thomasville
Fbstal / Zip Code
27361-1261
8. Consultant Name
(Optional)
Paul Stimpson
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
704-560-8514
Telephone No.
State / Rovince / Region
NC
Country
U.S.

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 03/13/2020
Approved *
2. E&SC Plan Project DAVID-2020-027
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 or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan
Approval letter or
Grading Permit
Site Map (Optional)
SCAN0436_000.pdf
Mist be FDFfornat
Helpful for linear project review
Mast be FDFform3t
152.49KB
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 SCAN0438_000.pdf 70.26KB
Form Mast be FDFformat
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 * E. Brent Blair
Title President
Organization Blair Appraisal Service, Inc.
Date * 03/22/2020

F. Tracking and COC Info
NOI Tracking No. 23351
NC Reference No. NCG01-2020-1171
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201171
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1171
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.)