NCC201366_NOI Application_20200403

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/3/2020 10:04:45 AM (NCG01 NOI Submission)
Approve by Clark, Paul 4/3/2020 10:28:10 AM (Review- Construction NOI 23965)
. The task was assigned to Clark, Paul by round robin distribution 4/3/2020 10:05 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 7, 2020 5:00 PM
4/3/2020 10:05 AM
Submit by McCoy, Suzanne 4/3/2020 1:13:16 PM (Payment Verification for NCC201366)
* David R Morgan
• McCoy, Suzanne assigned the task to McCoy, Suzanne 4/3/2020 1:12 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 15, 2020 5:00 PM
4/3/2020 10:28 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name *
Clemmons Town Center Outparcel 1
1 b. Specific Lot
This field rray be used to list specffc lot numbers.
Numbers
Outparcel 1, Laydown Outparcel 2
2. County*
Forsyth
3. Highway or Street Gentry Lane
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Clemmons
5. State * NC
6. Zip Code* 27012
7. Latitude* Enter the latitude in decimal degrees
36.0356
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.3862
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*
04/03/2020
Estimated Construction Project Start Rate
10. Date to End *
10/30/2020
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
1.71
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.56
(acres)*
14. Post- 0.85
construction (Estirated)
impervious area
(acres) *

NCC Project NCC-FORSY-2020-Clemmons Town Center Outparcel 1
Tracking ID Assigned autorratically
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 Johnson Creek
Wate rbody* Barre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-91
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 KJEM, LLC
Name * If pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* David
IF Corporation, enter Plegistered Agent First Barre
3. Last Name* Morgan
If Corporation, enter Faegistered Agent Last %rre
3b. Title Member/Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 336-414-1111
Telephone No.*
6. Permittee Mailing Street Address
Address* 4400 Silas Creek Parkway
Address Line 2
City State / Ftovince / Faegion
Winston-Salem NC
Fbstal / Zip Code Country
27104 us
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
4400 Silas Creek Parkway
Address Line 2
City
State / Ffovince / legion
Winston-Salem
NC
Flostal / Zip Code
Country
27104
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Steven
Contact - First
Name *
2. Primary Site
Hankins
Contact - Last
Name *
3. Title
President
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
[phone]
Telephone No.
6. Organization
Hankins Companies, LLC
Name
7. Site Contact
Street Address
Mailing Address*
PO Box 1584
Address Line 2
City
Cornelius
Fbstal / Zip Code
28031
8. Consultant Name
(Optional)
Kenneth Binkley
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-723-1067
Telephone No.
State / Rovince / Region
NC
Country
Mecklenburg

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/16/2019
Approved *
2. E&SC Plan Project EN1900065
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Winston-Salem/Forsyth 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 Email Plan Approval- 16-260.pdf 221.89KB
Approval letter or Mist beRDFformat
Grading Permit
Site Map (Optional) Helpful for linear project review
Site Plan_Optional_C-4.1.pdf 732.15KB
Mast be RDFfornat
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies for linear projects if necessary.
6. NOI Certification 04-2020 NCG01 Notice Of Intent KJEM OP#1.pdf 417.18KB
Form Wst be RDFfornal
This is an Express r 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* David R. Morgan
Title Member/Manager
Organization KJEM Enterprises, LLC
Date * 04/03/2020

F. Tracking and COC Info
NOI Tracking No. 23965
NC Reference No. NCG01-2020-1366
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201366
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1366
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.)