NCC202164_NOI Application_20200526

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/20/2020 7:38:29 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 5/21/2020 12:07:00 PM (Review- Construction NOI 25938)
• Clark, Paul reassigned the task to Morman, Alaina 5/21/2020 8:15 AM
* good am ... for you.-)
• The task was assigned to Clark, Paul by round robin distribution 5/20/2020 7:38 PM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 22, 2020 5:00 PM
5/20/2020 7:38 PM
Submit by McCoy, Suzanne 5/26/2020 7:26:25 AM (Payment Verification for NCC202164)
* Seth A Norris
• McCoy, Suzanne assigned the task to McCoy, Suzanne 5/26/2020 7:26 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 2, 2020 5:00 PM
5/21/2020 12:07 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 24855
NOI No.
Prior Reviewer Alaina Morman
Name
1a. Project Name * Perkinsville Baptist Church Beyond Facility - Multi Phased Project
1 b. Specific Lot This field may be used to list specifc lot nunbers.
Numbers Phase 1
2. County* Watauga
3. Highway or Street 274 Jefferson Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Boone
5. State * NC
6. Zip Code * 28607
7. Latitude * Enter the latitude in decirral degrees
36.2212
8. Longitude* Enter the longitude in decinal degrees (MJSTbe negative)
-81.6593
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* 06/01/2020
Estimated Construction Project Start Date
10. Date to End* 09/01/2021
Estimated Construction Project End Cute
11. SIC (Primary) * Other (9999)
Standard Industrial Classification for Ceveloprrent

12. Acres to be 1.38
disturbed* (including off -site borrow and waste areas)
13. Total site area 1.38
(acres) *
14. Post- 1.00
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-WATAU-2020- Perkinsvi Ile Baptist Church Beyond Facility -
Tracking ID Multi Phased Project
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 Perkins Branch
Wate rbody* N larre of waterbody into which stormwater runoff will discharge
15b. Waterbody 10-1-5-1
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 *
Perkinsville Baptist Church, Inc.
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Seth
IF Corporation, enter Faegistered Agent First %rre
3. Last Name*
Norris
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Pastor
4. Permitee E-mail [e-mail]
Address*
5. Permittee 828-264-8605
Telephone No.*
6. Permittee Mailing Street Address
Address* 274 Jefferson Road
Address Line 2
City State / Rovince / F;bgion
Boone NC
Fbstal / Zip Code Country
28607-8811 us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
274 Jefferson Road
Address Line 2
City
State / Frovince / Region
Boone
NC
Fbstal / Zip Code
Country
28607-8811
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Ronnie
Contact - First
Name *
2. Primary Site
Marsh
Contact - Last
Name *
3. Title
Elder
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
828-406-1705
Telephone No.
6. Organization
Perkinsville Baptist Church
Name
7. Site Contact
Street Address
Mailing Address*
274 Jefferson Road
Address Line 2
City
Boone
Postal / Zip Code
28607-8811
8. Consultant Name
(Optional)
Michael P. Trew
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
828-963-0535
Telephone No.
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 04/24/2020
Approved *
2. E&SC Plan Project Z02598-052319
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Town of Boone
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 ZoningPermit_Z02598-
Approval letter or 052319_PerkinsvilleBaptistChurch_04212020 258.44KB
Grading Permit
(1).pdf
4-29-20 Email Explaining Disturbed Area for Phase
1.42MB
1.pdf
Mist be RFfornat
6. Site Location Map Helpful for linear project review
(Optional) Wst be FDFfornat. Rease do not upload entire set of E&SCplans.
7. Notes (Optional) Ffovide 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.
8. NOI Certification NOI - Signed.pdf 45.51 KB
Form Mast be R7Fformat
This is an Express F 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* Seth Norris
Title Pastor
Organization Legally Iesponsible Entity
Perkinsville Baptist church, Inc.
Date * 05/20/2020

F. Tracking and COC Info
NOI Tracking No. 25938
NC Reference No. NCG01-2020-2164
Uses 'count number' variable (incremrented by SP)
Certificate of NCC202164
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2164
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.)