NCC202497_NOI Application_20200616

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/15/2020 10:45:50 AM (NCG01 NOI Submission)
Approve by Clark, Paul 6/15/2020 11:34:41 AM (Review- Construction NOI 26986)
• The task was assigned to Clark, Paul by round robin distribution 6/15/2020 10:45 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 17, 2020 5:00 PM
6/15/2020 10:45 AM
Submit by McCoy, Suzanne 6/16/2020 7:12:05 AM (Payment Verification for NCC202497)
* Theodore C Sea/ey
• McCoy, Suzanne assigned the task to McCoy, Suzanne 6/16/2020 7:11 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 27, 2020 5:00 PM
6/15/2020 11:34 AM

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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 * Blakefield Subdivision, Phase 6 Lots 3, 4 & 22-24
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2. County* Cumberland
3. Highway or Street Croft Drive
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Cedar Creek Township
5. State * NC
6. Zip Code * 28312
7. Latitude* Enter the latitude in decimal degrees
35.0308
8. Longitude* Enter the longitude in decimal degrees (M.JST be negative)
-78.7638
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*
06/11/2020
Estimated Construction Project Start Date
10. Date to End *
07/29/2022
Estinated Construction Project End Date
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial Classification for Developrrent
12. Acres to be
1.16
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.21
(acres) *

14. Post- 0.43
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-CUMBE-2020-Blakefield Subdivision, Phase 6 Lots 3, 4 & 22-
Tracking ID 24
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 Sandy Creek
Wate rbody* %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 18-68-12-6
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. ^
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 Pesponsible Entity
Name * JW Sealey & Associates, Inc.
IF pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name * Theodore
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Sealey
IF Corporation, enter F;bgistered Agent Last %ne
3b. Title President/Owner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-897-4210
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box99
Address Line 2
Cty
Wade
Fbstal / Zip Code
28395
Check box if the F Yes
street address the
same as mailing
address
State / Rovince / Pbegion
NC
Country
USA
7. Permittee Street
Street Address
Address*
4520 Bent Grass Drive
Address Line 2
City
State / Frovince / Region
Fayetteville
NC
Postal / Zip Code
Country
28312-9121
USA
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Sara
Contact - First
Name *
2. Primary Site
Sealey
Contact - Last
Name *
3. Title
Secretary
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-322-3670
Telephone No.
6. Organization
JW Sealey & Associates, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
P.O. Box99
Address Line 2
city
Wade
Fbstal / Zip Code
28395
8. Consultant Name
(Optional)
Dennis A. Gilbert
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
910-484-5191
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 06/11/2020
Approved *
2. E&SC Plan Project CUMBE-2020-187
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 * Fayetteville (FRO)
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-CUMBE-2020-187.pdf 83.34KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Helpful for linear project review
(Optional) EC-Blakefield-Lots 3, 4 & 22-24-Approved Plan-
1000.89KB
p1.pdf
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 documents support
the application. Include additional w aterbodies for linear projects if necessary.
8. NOI Certification NOI Certificate - Blakefield.pdf 502.31 KB
Form Mast be FDFfon-rat
This is an Express F 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
7420010r-a C sel5kv
Type Name * Theodore C. Sealey
Title President/Owner
Organization Legally Plesponsible Entity
JW Sealey & Associates, Inc.
Date * 06/15/2020

F. Tracking and COC Info
NOI Tracking No. 26986
NC Reference No. NCG01-2020-2497
Uses 'count number' variable (incremrented by SP)
Certificate of NCC202497
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2497
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.)