NCC201266_NOI Application_20200401

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/27/2020 8:05:02 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 3/27/2020 10:54:40 AM (Review- Construction NOI 23712)
• The task was assigned to Garcia, Lauren V by round robin distribution 3/27/2020 8:05 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 31, 2020 5:00
PM 3/27/2020 8:05 AM
Submit by Garcia, Lauren V 4/1/2020 11:24:56 AM (Payment Verification for NCC201266)
* City of Greensboro
• Garcia, Lauren V assigned the task to Garcia, Lauren V 4/1/2020 11:23 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 8, 2020 5:00 PM
3/27/2020 10:54 AM

d� #
NORTH CAROLINA
Ernvlronmental qualily
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Bunker Hill Road Water Line Extension
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
2. County* Guilford
3. Highway or Street Bunker Hill Road, Gray Wilson Road
Address* Street name only is acceptable if no address nunber assigned yet
4. City or Township* Greensboro
5. State * NC
6. Zip Code* 27409
7. Latitude* Enter the latitude in decimal degrees
36.1080
8. Longitude* Enter the longitude in decimal degrees (M-IST be negative)
-80.0150
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*
01/01/2021
Estirrated Construction Project Start Rate
10. Date to End*
12/31 /2021
Estirrated Construction Project End Cate
11. SIC (Primary) *
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
1.30
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.30
(acres) *
14. Post- 0.00
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-GUILF-2021-Bunker Hill Road Water Line Extension
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 West Fork Deep River
Wate rbody* Narre cf waterbody into which storrrwater runoff w ill discharge
15b. Waterbody 17-3-(0.3)
Index No. * NC Waterbody 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. ^
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 City of Greensboro
Name * If pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* Michael
If Corporation, enter Fbgistered Agent First Barre
3. Last Name* Borchers
If Corporation, enter Faegistered Agent Last %rre
3b. Title Water Resources Director
4. Permitee E-mail [e-mail]
Address *
5. Permittee 336-373-2494
Telephone No.*
6. Permittee Mailing Street Address
Address* 2602 South Elm -Eugene Street
Address Line 2
City State / Ftovince / Faegion
Greensboro NC
Fbstal / Zip Code Country
27406-3623 us
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
2602 South Elm -Eugene Street
Address Line 2
PO Box 3136
City
State / Rovince / Fbgion
Greensboro
NC
Fbstal / Zip Code
Country
27406-3623
us
8. Type of
Government - Municipal
Ownership*

C. Site Contact Information
Part C.
^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site
Brian
Contact - First
Name *
2. Primary Site
Boyd
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-373-2055
Telephone No.*
6. Organization
City of Greensboro Water Resources Dept.
Name
7. Site Contact
Street Address
Mailing Address*
2602 South Elm -Eugene Street
Address Line 2
PO Box 3136
City
State / Rovince / Region
Greensboro
NC
Postal / Zip Code
Country
27406-3623
us
8. Consultant Name
(Optional)
Eric Tweed
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-256-5464
Telephone No.

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 02/19/2020
Approved *
2. E&SC Plan Project GUILF-2020-022
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)
_Approved ESC. pdf
Mast be RDFfornat
Helpful for linear project review
Mast be FDFform3t
611.57KB
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 Cert- Signed- Bunker Hill.pdf 599.91KB
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 * Michael M. Borchers
Title Director of Water Resources
Organization City of Greensboro
Date * 03/27/2020

F. Tracking and COC Info
NOI Tracking No. 23712
NC Reference No. NCG01-2020-1266
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201266
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1266
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.)