NCC202506_NOI Application_20200629

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/11/2020 11:36:13 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 6/15/2020 1:29:14 PM (Review- Construction NOI 26886)
• The task was assigned to Garcia, Lauren V by round robin distribution 6/11/2020 11:37 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 15, 2020 5:00 PM
6/11/2020 11:37 AM
Submit by Selkane, Aziza 6/29/2020 3:32:35 PM (Payment Verification for NCC202506)
* Catherine Greenberg
• Selkane, Aziza assigned the task to Selkane, Aziza 6/29/2020 3:31 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 27, 2020 5:00 PM
6/15/2020 1:29 PM

.• SThF� ';
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 26751
NOI No.
Prior Reviewer Lauren Garcia
Name
1a. Project Name *
Lake Forest Church
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
3694925380/93243
2. County*
Lincoln
3. Highway or Street 2204 St James Church Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Denver
5. State * NC
6. Zip Code * 28037
7. Latitude * Enter the latitude in decimal degrees
35.4975
8. Longitude* Enter the longitude in decimal degrees (MJSTbe negative)
-81.0191
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* 06/25/2021
Estimated Construction Project End Cute
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Developrrent

12. Acres to be 8.84
disturbed* (including off -site borrow and waste areas)
13. Total site area 39.55
(acres) *
14. Post- 3.20
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-LINCO-2020-Lake Forest Church
Tracking ID Assignedautorraticaly
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 Forney Creek
Waterbody * %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 11-119-2-3
Index No.* NCWaterbody Index Ninber
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional Killian Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 11-119-2-(0.5)
Index No. NCWaterbody Index Nanber
15e. Additional Dutchmans Creek
Receiving Waterbody narre
Waterbody
15f. Waterbody 11-119-(0.5)
Index No. NCWaterbody Index Nunber
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. ^
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 Responsible Entity
Name * Lake Forest Church, Evangelical Presbyterian Church
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name * Mitchell
IF Corporation, enter Registered Agent First %rre
3. Last Name* White
It Corporation, enter F;bgistered Agent Last %ne
3b. Title Treasurer. Executive Pastor
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-948-3232
Telephone No.*
6. Permittee Mailing Street Address
Address* 8519 Gilead Road
Address Line 2
city State / Rovince / F;bgion
Huntersville North Carolina
Fbstal / Zip Code Country
28078 United States
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
8519 Gilead Road
Address Line 2
city
State / Ftovince / Region
Huntersville
North Carolina
Fbstal / Zip Code
Country
28078
United States
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Jeff
Contact - First
Name *
2. Primary Site
London
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
704-361-5846
Telephone No.
6. Organization
Edifice, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
4111 SOUTH BLVD.
Address Line 2
city
CHARLOTTE
Fbstal / Zip Code
28209
8. Consultant Name
(Optional)
Sean Coldren
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
704-849-1500
Telephone No.
State / Rovince / Region
North Carolina
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 06/02/2020
Approved *
2. E&SC Plan Project 20-COM-02
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Lincoln County
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
SE & SC Letter from Lincoln County - Revised 6-10-
Approval letter or
20.pdf 613.5KB
Grading Permit
Mast be RDFforrrat
6. Site Location Map
Helpful for linear project review
(Optional)
Lake Forest Location Map.pdf 233.59KB
Mast be RDFfornat. Rease do not upload entire set of E&SCplans.
7. Notes (Optional)
Provide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional waterbodies for linear projects if necessary.
8. NOI Certification
NOICertification.pdf 433.37KB
Form
Mast be RDF format
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 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
01ncwoa- L W% 77
Type Name* Mitchell White
Title Treasurer, Executive Pastor
Organization Legally Ibsponsible Entity
Lake Forest Church, Evangelical Presbyterian Church
Date * 06/11 /2020

F. Tracking and COC Info
NOI Tracking No. 26886
NC Reference No. NCG01-2020-2506
Uses 'count number' variable (incremrented by SP)
Certificate of NCC202506
Coverage (COC) Uses 'count number' variable (incremented by SF)
No.*
Count Number 2506
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.)
Initial Invoice No.
Invoice Due Date
Initial Fee $
Invoice Status