NCC201758_NOI Signed Certification_20200501

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#AWe5_1
FORTH CAROLINA
Envhwum fat Qua ft
Construction Stormwater: Notice of
Intent (NOI)
National Pollutant Discharge Elimination System (NPDES) application for coverage
under North Carolina's General Permit NCGO10000: STORMWATER DISCHARGES
associated with construction activities (or NCG250000)
A. Project Information
Part A.
Project Location and Information
Are you Q No
submitting an O Yes
NOI that was
rejected before?
1a. Project Watkins Landing
Name *
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers
2. County* Forsyth
3. Highway or Watkins Ford Road
Street Address * Street name only is acceptable if no address number assigned yet
4. City or Kernersville
Township*
5. State* NC
6. Zip Code* 27284
7. Latitude* Enter the latitude in decimal degrees
36.0435
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8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-80.0970
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 * 04/22/2020
Estimated Construction Project Start Date
10. Date to End * 06/22/2020
Estimated Construction Project End Date
11. SIC (Primary) Residential, Single Family Houses (SFE) (1521)
* Standard Industrial Classification for Development
12. Acres to be 13.50
disturbed* (including off -site borrow and waste areas)
13. Total site area 30.40
(acres) *
14. Post- 2.83
construction (Estimated)
impervious area
(acres) *
Project Tracking NCC-FORSY-2020-Watkins Landing
ID 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 abbotts creek
Waterbody * Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 12-119-(1)
Index No.* NC Waterbody Index Number
Stormwater ❑./ No
discharges will ❑ Yes
flow to additional
waters *
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16a. Is this Q Yes
project subject to O No, not subject to NC SPCA
the NC Sediment
Pollution Control
Act? *
Note: Stormwater discharges from construction activities associated with oil and gas
exploration, production, processing, treatment, or transmission facilities are eligible for the
exemption from NPDES permit coverage except in very limited instances. Do not proceed with this
application before consulting this EPA fact sheet and verifying a permit applies.
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B. Permittee Information
._a :
Permittee Information - Legally Responsible 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 * Shugart Homes
If permittee is an individual (i.e., organization does not apply), enter first and last name in this
field
2. First Name* Ken
If Corporation, enter Registered Agent First Name
3. Last Name* Capron
If Corporation, enter Registered Agent Last Name
3b. Title* Market Vice President
4. Permitee [e-mail]
E-mail Address*
5. Permittee 3362316743
Telephone No.*
6. Permittee Street Address
Mailing Address* 221 Jonestown Road
Address Line 2
City State / Province / Region
Winston-Salem NC
Postal / Zip Code Country
27104 United States
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Check box if the ❑./ Yes
street address
the same as
mailing address
7. Permittee Street Address
Street Address* 221 Jonestown Road
Address Line 2
City
Winston-Salem
Postal / Zip Code
27104
8. Type of Non -Government
Ownership *
State / Province / Region
NC
Country
United States
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C. Site Contact information
Part C.
Project Site Contact Information
1. Primary Site Keith
Contact - First
Name *
2. Primary Site Nelson
Contact - Last
Name *
3. Title
4. Site Contact [e-mail]
E-mail Address* This person will be copied on all correspondence.
5. Site Contact 3364621070
Telephone No.*
6. Organization
Name
7. Site Contact Street Address
Mailing Address*
221 Jonestown Road
Address Line 2
City
State / Province / Region
Winston-Salem
NC
Postal / Zip Code
Country
27104
United States
8. Consultant
(Optional)
Name
First and Last name
9. Consultant
This person will be copied on all correspondence.
E-mail
10. Consultant
Telephone No.
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D. E&SC Plan
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC
Plan Approved*
2. E&SC Plan
Project
Number/ID
04/13/2020
Forsy-2019-034
Assigned by agency or local program
3. E&SC Plan Q State DEQ Office
Approved by* Q Local Program
4. State DEQ Winston-Salem Regional Office
Office* (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*
6. Site Location
Map (Optional)
7. Notes
(Optional)
8. NOI
Certification
Form *
scan0001.pdf 689.52KB
Must be PDF format
Helpful for linear project review.
Must be PDF format Please do not upload entire set of E&SC plans
Provide any additional information that might help the reviewer better understand how
uploaded documents support the application Include additional waterbodies for linear projects
if necessary
scan0003.pdf
Must be PDF format
C:10^10W➢JO R
YOU MUST MAIL THE ORIGINAL SIGNED NOI CERTIFICATION FORM (click on this link) to The
Stormwater Program at the address on the form for the application to fulfill federal application
requirements. The Certification Form must be signed by the person listed in Section B (Permittee
Information) or by an authorized responsible person within the same organization. NOTE: The
person who signs the paper form must be the same person to electronically certify and sign
the eNOI.
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This is an DQ No
Express Review 0 Yes
Project *
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E. Certification
North Carolina General Statute 143-215.613 (1) provides that:
Any person who knowingly makes any false 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 Article; 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 Article shall be guilty of a Class 2
misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
❑.o 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.
❑./ 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.
* ❑./ I will abide by all conditions of the NCG010000 General Permit and
the approved Erosion and Sediment Control Plan.
* ❑./ 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 Q The Responsible Person named on this Notice of Intent
are: * Q 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 *
Kw
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Type Name* Ken Capron
Title * Market VP
Organization* Legally Responsible Entity
Shugart Homes
Date * 04/16/2020
https://edocs.deq.nc.govIForms/Form/showfonnsubmissionl5429c9ea-4b9e-48l b-8ccd-be3... 4/16/2020