NCC201346_NOI Application_20200416

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/30/2020 4:33:14 PM (NCG01 NOI Submission)
Approve by Farkas, Jim J 4/2/2020 3:29:00 PM (Review- Construction NOI 23788)
. The task was assigned to Farkas, Jim J by round robin distribution 3/30/2020 4:33 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 1, 2020 5:00 PM
3/30/2020 4:33 PM
Submit by McCoy, Suzanne 4/16/2020 7:20:14 AM (Payment Verification for NCC201346)
* S Scott Summerlin
• McCoy, Suzanne assigned the task to McCoy, Suzanne 4/16/2020 7:19 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 14, 2020 5:00 PM
4/2/2020 3:29 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting r No
an NOI that was r Yes
rejected before?
Previous Rejected
NOI No.
Prior Reviewer
Name
1a. Project Name * Town of Warsaw- Contract 43 - Gravity Sewer Rehabilitation
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers West College St, North Cross St, South Gum
St, East John, St, East Best St
2. County* Duplin
3. Highway or Street 384 East Best Street
Address* Street narre only is acceptable if no address number assigned yet
4.CityorTownship* Warsaw
5. State * NC
6. Zip Code * 28398
7. Latitude * Enter the latitude in decimal degrees
34.9929
8. Longitude* Enter the longitude in decimal degrees (KUSTbe negative)
-78.0803
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* 04/30/2020
Estimated Construction Project Start Cate
10. Date to End* 04/30/2021
Estimated Construction Project End Cute
11. SIC (Primary) * 0000
Standard Industrial Classification for lkveloprrent

12. Acres to be 2.99
disturbed* (including off -site borrow and waste areas)
13. Total site area 2.99
(acres) *
14. Post- 2.99
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-DUPLI-2020-Town of Warsaw- Contract 43 - Gravity Sewer
Tracking ID Rehabilitation
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 Stewarts Creek
Waterbody* N larre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 18-68-2-10
Index No.* NCWaterbody Index Number
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional Buckhall Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 18-68-2-10-1
Index No. NCWaterbody Index Nurrber
15e. Additional Grove Creek
Receiving Waterbody narre
Waterbody
15f. Waterbody 18-74-21
Index No. NCWaterbody Index Nurrber
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. ^
Fl rnittee 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
Legally Responsible Entity
Name *
Town of Warsaw
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
A. J.
If Corporation, enter Fegistered Agent First %rre
3. Last Name*
Connors
It Corporation, enter Registered Agent Last %ne
3b. Title
Mayor
4. Permitee E-mail [e-mail]
Address*
5. Permittee 9286533430
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box464
Address Line 2
Cty
Warsaw
Pbstal / Zip Code
28398
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
121 S. Front Street
Address Line 2
city
Warsaw
Postal / Zip Code
28398
8. Type of
Government - Municipal
Ownership*
State / Frovince / Fbgion
NC
Country
Duplin
State / Province / Fegion
NC
Country
Duplin

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Scotty
Contact - First
Name *
2. Primary Site
Summerlin
Contact - Last
Name *
3. Title
Town Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
9103856710
Telephone No.
6. Organization
Town of Cloumbia
Name
7. Site Contact
Street Address
Mailing Address*
PO Box464
Address Line 2
city
Warsaw
Fbstal / Zip Code
28398
8. Consultant Name
(Optional)
Cecil Madden, McDavid Associates, Inc
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
9197367360
Telephone No.
State / Rovince / Region
NC
Country
Duplin

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/17/2019
Approved *
2. E&SC Plan Project DUPLI-2020-011
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 * Wilmington (WiRO)
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 WarsawCN43 S&EC.pdf
Approval letter or Mist beRDFformat
Grading Permit
6. Site Location Map Helpful for linear project review
(Optional) Mast be FCFfornat. Rease do not upload entire set of E&SCplans.
372.07KB
7. 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.
Work is associated with removal and replacement of sewers on
various streets in town. There should be no change in impermeable
area.
8. NOI Certification cn 43 stormwater noi.pdf 604.45KB
Form Mist be RFfornat
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 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 * A. J. Connors
Title Mayor
Organization Legally Plesponsible Entity
Town of Warsaw
Date * 03/30/2020

F. Tracking and COC Info
NOI Tracking No. 23788
NC Reference No. NCG01-2020-1346
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201346
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1346
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.)