NCC201629_NOI Application_20200501

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/20/2020 1:55:34 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 4/21/2020 9:29:51 PM (Review- Construction NOI 24587)
• The task was assigned to Morman, Alaina by round robin distribution 4/20/2020 1:56 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 22, 2020 5:00 PM
4/20/2020 1:56 PM
Submit by McCoy, Suzanne 5/1/2020 7:10:25 AM (Payment Verification for NCC201629)
* Timothy J Morris
• McCoy, Suzanne assigned the task to McCoy, Suzanne 5/1/2020 7:09 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: June 2, 2020 5:00 PM
4/21 /2020 9:30 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting IT No
an NOI that was r Yes
rejected before?
1a. Project Name *
Hair Sheep Stream Mitigation Bank
1 b. Specific Lot
This field nay be used to list specifc lot nunbers.
Numbers
PIN:499900764767
PIN: 499900887042
PIN: 499902865621
2. County*
Surry
3. Highway or Street 187 Haystack Road
Address * Street narre only is acceptable if no address nunber assigned yet
4. City or Township * Mount Airy
5. State * NC
6. Zip Code * 27030
7. Latitude * Enter the latitude in decirral degrees
36.4780
8. Longitude* Enter the longitude in decinal degrees (MJSTbe negative)
-80.7070
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*
04/27/2020
Estimated Construction Project Start Cate
10. Date to End*
08/01/2020
Estimated Construction Project End Cute
11. SIC (Primary) *
Other (9999)
Standard Industrial aassification for Ceveloprrent
12. Acres to be
15.87
disturbed*
(including off -site borrow and waste areas)
13. Total site area 15.87
(acres) *

14. Post- 0.00
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-SURRY-2020-Hair Sheep Stream Mitigation Bank
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 Cooks Creek
Wate rbody* %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-63-11-1
Index No.* NCWaterbody Index Number
Stormwater rJ 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
Legally Pesponsible Entity
Name *
KCI Environmental Technologies and Construction Inc.
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Timothy
If Corporation, enter Faegistered Agent First %rre
3. Last Name*
Morris
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Secretary
4. Permitee E-mail [e-mail]
Address*
5. Permittee 9197936886
Telephone No.*
6. Permittee Mailing Street Address
Address* 4505 Falls of Neuse Road
Address Line 2
Suite 400
City
State / Frovince / Region
Raleigh
NC
Pbstal / Zip Code
Country
27609
USA
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
4505 Falls of Neuse Road
Address Line 2
Suite 400
City
State / Province / Region
Raleigh
NC
Postal / Zip Code
Country
27609
USA
8. Type of
Non -Government
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
_......................................................................................................................................
1. Primary Site
Timothy
Contact - First
Name *
2. Primary Site
Morris
Contact - Last
Name *
3. Title
Secretary
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
9197936886
Telephone No.*
6. Organization
KCI Environmental Technologies and
Name
Construction Inc.
7. Site Contact
Street Address
Mailing Address*
4505 Falls of Neuse Road
Address Line 2
Suite 400
city
Raleigh
Fbstal / Zip Code
27609
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
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 03/23/2020
Approved *
2. E&SC Plan Project SURRY-2020-023
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 Land Quality Permit - Hair Sheep.pdf 138.03KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Helpful for linear project review
(Optional) Hai rSheepCreek_Fig07_CurrentConditions_10.pdf 863.66KB
Mast be RDF format. Rease do not upload entire set of E&SC plans.
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.
8. NOI Certification NOI - Hair Sheep.pdf 57.04KB
Form Wst be RDFfornat
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 * Timothy Morris
Title Secretary
Organization Legally Plesponsible Entity
KCI Environmental Technologies and Construction Inc.
Date * 04/20/2020

F. Tracking and COC Info
NOI Tracking No. 24587
NC Reference No. NCG01-2020-1629
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201629
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1629
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.)