NCC201280_NOI Application_20200331

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/30/2020 9:04:58 AM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 3/30/2020 10:15:16 AM (Review- Construction NOI 23765)
. The task was assigned to McCoy, Suzanne by round robin distribution 3/30/2020 9:05 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 1, 2020 5:00 PM
3/30/2020 9:05 AM
Submit by McCoy, Suzanne 3/31/2020 8:36:42 AM (Payment Verification for NCC201280)
* Isaiah Koonce
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/31/2020 8:36 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 11, 2020 5:00 PM
3/30/2020 10:15 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Pope 12" Water Main Replacement
1 b. Specific Lot This field any be used to list specifc lot numbers.
Numbers
2. County* Cumberland
3. Highway or Street Reilly Rd
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Fort Bragg
5. State * NC
6. Zip Code* 28307
7. Latitude* Enter the latitude in decimal degrees
35.1740
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.0170
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*
05/31/2020
Estimated Construction Project Start Date
10. Date to End*
01/01/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Industrial (1541)
Standard Industrial C]assification for Development
12. Acres to be
1.51
disturbed*
(including off -site borrow and waste areas)
13. Total site area 2.02
(acres)*
14. Post- 0.04
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-CUMBE-2020-Pope 12" Water Main Replacement
Tracking ID Assigned autoaatically
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 Tank Creek
Wate rbody* Barre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 18-23-27
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 American States Utility Services, Inc.
Name * If perrrittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* Timothy
It Corporation, enter Fbgistered Agent First Barre
3. Last Name* Loughman
If Corporation, enter Faegistered Agent Last Wre
3b. Title Utility Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 9102378717
Telephone No.*
6. Permittee Mailing Street Address
Address* 2941 Logistics Street, Building N-6307
Address Line 2
city State / Ftovince / Faegion
Fort Bragg NC
Fostal / Zip Code Country
28310-0001 United States
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
2941 Logistics Street, Building N-6307
Address Line 2
City
State / Ffovince / Plegion
Fort Bragg
NC
Fbstal / Zip Code
Country
28310-0001
United States
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Jeremy
Contact - First
Name *
2. Primary Site
George
Contact - Last
Name *
3. Title
Capital Projects Supervisor
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
9104898862
Telephone No.
6. Organization
American States Utility Services, Inc
Name
7. Site Contact
Street Address
Mailing Address*
2941 Logistics Street, Building N-6307
Address Line 2
city
Fort Bragg
Fbstal / Zip Code
28310-0001
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Rovince / Region
NC
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 03/25/2020
Approved *
2. E&SC Plan Project CUMBE-2020-128
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 NCDEQ Letter of Approval.pdf 78.72KB
Approval letter or Mast beRDFformat
Grading Permit
Site Map (Optional) Helpful for linear project review
Mast be RDFform3t
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 NCG01-eNO1-Certification- Form- DEMLR-Pope 12-
Form 297.99KB
Inch Water Main Replacement —SIG NED.pdf
Wst be FDFfornat
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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle 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
Fw#y 44X bk j�
Type Name *
Timothy Adam Loughman
Title
Utility Manager
Organization
Old North Utility Services Inc.
Date *
03/30/2020

F. Tracking and COC Info
NOI Tracking No. 23765
NC Reference No. NCG01-2020-1280
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201280
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1280
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.)