NCC202487_NOI Application_20200625

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/12/2020 8:46:23 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 6/12/2020 4:52:31 PM (Review- Construction NOI 26936)
• The task was assigned to Garcia, Lauren V by round robin distribution 6/12/2020 8:47 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 16, 2020 5:00 PM.
The priority is: High 6/12/2020 8:47 AM
Submit by Selkane, Aziza 6/25/2020 3:26:13 PM (Payment Verification for NCC202487)
* Maser Consulting
• Selkane, Aziza assigned the task to Selkane, Aziza 6/25/2020 3:23 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 24, 2020 5:00 PM. The
priority is: High 6/12/2020 4:53 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 * Line 44 Retirement
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
2. County* Anson
3. Highway or Street Stanback Ferry Ice Plant Road
Address* Street narre only is acceptable if no address number assigned yet
4.CityorTownship* Wadesboro
5. State * NC
6. Zip Code * 28170
7. Latitude* Enter the latitude in decimal degrees
34.9712
8. Longitude* Enter the longitude in decir al degrees (M.JST be negative)
-80.0549
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*
06/29/2020
Estimated Construction Project Start Date
10. Date to End*
08/31/2020
Estimated Construction Project End Date
11. SIC (Primary) *
Other (9999)
Standard Industrial Cassification for Developrrent
12. Acres to be
5.75
disturbed*
(including off -site borrow and waste areas)
13. Total site area 5.75
(acres) *

14. Post- 0.00
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-ANSON-2020-Line 44 Retirement
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 Brush Fork
Waterbody* Klarre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 13-42-1-3-1
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. ^
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 %sponsible Entity
Name *
Piedmont Natural Gas
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Randy
If Corporation, enter Faegistered Agent First %rre
3. Last Name*
Webb
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Operation Supervisor
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-419-7215
Telephone No.*
6. Permittee Mailing Street Address
Address* 185 Enterprise Drive
Address Line 2
Cty
Rockingham
Fbstal / Zip Code
28379
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address *
V Yes
Street Address
185 Enterprise Drive
Address Line 2
city
Rockingham
Fbstal / Zip Code
28379
8. Type of Non -Government
Ownership*
State / Rovince / F;bgion
NC
Country
us
State / Frovince / Faegion
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Matthew
Contact - First
Name *
2. Primary Site
McCort
Contact - Last
Name *
3. Title
Environmental Inspector
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
609-618-0315
Telephone No.
6. Organization
Maser Consulting
Name
7. Site Contact
Street Address
Mailing Address*
5275 Parkway Plaza Boulevard
Address Line 2
Suite 100
city
Charlotte
Fbstal / Zip Code
28217
8. Consultant Name
(Optional)
Matthew McCort
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
980-245-3161
Telephone No.
State / Rovince / Region
NORTH CAROLINA
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 04/17/2020
Approved *
2. E&SC Plan Project ANSON-2020-006
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
NCDEQ Certificate.pdf 176.54KB
Approval letter or
Mast beRDFformat
Grading Permit
6. Site Location Map
Helpful for linear project review
(Optional)
100 Year Flood plain Map_19005836A Revised.pdf 3.77MB
Mast be RDF format. Rease do not upload entire set of E&SCplans.
7. Notes (Optional) Rovide 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 NCDOT Randy Wells.pdf 3.57MB
Form Wst be RDFfornat
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
Type Name * Randy Webb
Title Operation Supervisor
Organization Legally Responsible Entity
Piedmont Natural Gas
Date * 06/12/2020

F. Tracking and COC Info
NOI Tracking No. 26936
NC Reference No. NCG01-2020-2487
Uses 'count number' variable (incremrented by SP)
Certificate of NCC202487
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2487
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.)