NCC201246_NOI Application_20200326

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/26/2020 12:06:17 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 3/26/2020 4:01:50 PM (Review- Construction NOI 23677)
• The task was assigned to Morman, Alaina by round robin distribution 3/26/2020 12:07 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 30, 2020 5:00
PM 3/26/2020 12:07 PM
Submit by Lucas, Annette 3/26/2020 4:09:51 PM (Payment Verification for NCC201246)
• Lucas, Annette assigned the task to Lucas, Annette 3/26/2020 4:07 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 7, 2020 5:00 PM
3/26/2020 4:02 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Multi -Tenant Development at HWY 42 and Old Drug Store
1 b. Specific Lot This field any be used to list specifc lot numbers.
Numbers
2. County* Johnston
3. Highway or Street 5771 NC HWY 42
Address* Street name only is acceptable if no address nunber assigned yet
4. CityorTownship* Garner
5. State * NC
6. Zip Code* 27529
7. Latitude* Enter the latitude in decinal degrees
35.6010
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-78.5730
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
Estirrated Construction Project Start Date
10. Date to End*
03/31/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
11.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area 10.03
(acres)*
14. Post- 4.21
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-JOHNS-2020-Multi-Tenant Development at HWY 42 and Old
Tracking ID Drug Store
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 Mill Branch
Waterbody* N3meof waterbody into which stormwater runoff will discharge
15b. Waterbody 27-43-15-12
Index No. * NCWaterbody Index Number
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional Middle Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 27-43-15-(4)
Index No. NCWaterbody Index Number
15e. Additional Swift Creek
Receiving Waterbody narre
Waterbody
15f. Waterbody 27-43-(8)
Index No. NCWaterbody Index Number
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 Triple B #29 ODS, LLC
Name * If perrrittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* James
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Broemer
If Corporation, enter F3egistered Agent Last %rre
3b. Title Partner
4. Permitee E-mail [e-mail]
Address *
5. Permittee 919-379-9288
Telephone No.*
6. Permittee Mailing Street Address
Address* 109 Preston Grande Way
Address Line 2
city State / F rovince / Faegion
Morrisville NC
F ostal / Zip Code Country
27560-7073 United States
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
109 Preston Grande Way
Address Line 2
City
State / Ffovince / Fbgion
Morrisville
NC
Flostal / Zip Code
Country
27560-7073
United States
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Billy
Contact - First
Name *
2. Primary Site
Raynor
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-892-6630
Telephone No.
6. Organization
Wellons Construction
Name
7. Site Contact
Street Address
Mailing Address*
510 North Powell Avenue
Address Line 2
city
Dunn
Fbstal / Zip Code
28334-4538
8. Consultant Name
(Optional)
Wyatt Bone
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-578-9000
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 07/12/2019
Approved *
2. E&SC Plan Project JC#19-006-P
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Johnston 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 or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan
19-006 MultiTenant development Hwy42 Old Drug
Approval letter or
95.42KB
Store ESC appr 7.12.19.pdf
Grading Permit
Mast be RDFforrrat
Site Map (Optional)
Helpful for linear project review
Mast be FDFform3t
Notes (Optional)
Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional waterbodies for linear projects if necessary.
Confirmation of new accepted FRO dated 03/26/2020 on file with
Deed for subject property in Project ID: JC# 19-006-P as confirmed
by Charles Pender.
6. NOI Certification
NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form
144.32KB
SW- Modified 03 26 20 Signed.pdf
Mast be RFfornat
This is an Express
F 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* James Broemer
Title Partner
Organization Triple B #29 ODS, LLC
Date * 03/26/2020

F. Tracking and COC Info
NOI Tracking No. 23677
NC Reference No. NCG01-2020-1246
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201246
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1246
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.)