NCC202407_NOI Application_20200611

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/8/2020 2:28:55 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 6/9/2020 3:10:46 PM (Review- Construction NOI 26684)
. The task was assigned to Garcia, Lauren V by round robin distribution 6/8/2020 2:29 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 10, 2020 5:00 PM
6/8/2020 2:29 PM
Submit by McCoy, Suzanne 6/11/2020 8:08:42 AM (Payment Verification for NCC202407)
* William Goodson
• McCoy, Suzanne assigned the task to McCoy, Suzanne 6/11/2020 8:08 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 21, 2020 5:00 PM
6/9/2020 3:11 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 * Wake Forest Crossing - Lot 7
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
2. County* Wake
3. Highway or Street 12612 Capital Blvd
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Town of Wake Forest
5. State * NC
6. Zip Code * 27587
7. Latitude* Enter the latitude in decinal degrees
35.9889
8. Longitude* Enter the longitude in decir al degrees (M.JST be negative)
-78.5309
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*
07/01/2020
Estinated Construction Project Start Date
10. Date to End*
12/31/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Classification for Developrrent
12. Acres to be
1.08
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.15
(acres) *

14. Post- 0.81
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-WAKE-2020-Wake Forest Crossing - Lot 7
Tracking ID Assigned autorraticaly
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 Richland Creek
Waterbody* Ibrre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 27-21-(1.5)
Index No.* NCWaterbody Index Number
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project F Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
Fbrnittee 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 * CHI - Wake Forest, LLC
IF pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name * Britt
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Goodson
IF Corporation, enter Fbgistered Agent Last %ne
3b. Title Member
4. Permitee E-mail [e-mail]
Address*
5. Permittee 8642720088
Telephone No.*
6. Permittee Mailing Street Address
Address* 40 West Broad Street
Address Line 2
aty
Greenville
Fbstal / Zip Code
29601
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address *
V Yes
Street Address
40 West Broad Street
Address Line 2
city
Greenville
Fbstal / Zip Code
29601
8. Type of Non -Government
Ownership*
State / Rovince / F;bgion
SC
Country
us
State / province / Faegion
SC
Country
us

C. Site Contact Information
Part C.
^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site
Britt
Contact - First
Name *
2. Primary Site
Goodson
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
8642720088
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
40 West Broad Street
Address Line 2
City
State / Rovince / Region
Greenville
SC
Fbstal / Zip Code
Country
29601
US
8. Consultant Name (Optional)
Kimley-Horn and Associates (John Holcomb)
First and Last name
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 704-954-7480
Telephone No.

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 05/28/2020
Approved *
2. E&SC Plan Project 2020-00001004
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 Wake Forest
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
Wake Forest Crossing #7 Letter of Approval.pdf 88.31 KB
Approval letter or
Mast beRDFformat
Grading Permit
6. Site Location Map
Helpful for linear project review
(Optional)
Site Location Map.pdf 2.63MB
Mast be RDFformat. Rease do not upload entire set of E&SCplans.
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 Notice of Intent Cerification Form (5-28-20).pdf 932.12KB
Form Wst be RDF formal
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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle 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
IT 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
lt"C-71�lle
Type Name* Britt Goodson
Title Authorized Member
Organization Legally Iesponsible Entity
CHI - Wake Forest, LLC
Date * 06/08/2020

F. Tracking and COC Info
NOI Tracking No. 26684
NC Reference No. NCG01-2020-2407
Uses 'count number' variable (incremrented by SP)
Certificate of NCC202407
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2407
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.)