NCC202791_NOI Application_20200702

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/29/2020 6:23:34 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 7/1/2020 2:54:12 PM (Review- Construction NOI 27659)
. The task was assigned to Garcia, Lauren V by round robin distribution 6/29/2020 6:24 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: July 1, 2020 5:00 PM
6/29/2020 6:24 PM
Submit by Selkane, Aziza 7/2/2020 12:10:45 PM (Payment Verification for NCC202791)
* Brunswick County
• Selkane, Aziza assigned the task to Selkane, Aziza 7/2/2020 12:10 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: August 12, 2020 5:00 PM
7/1/2020 2:54 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 * Northwest Water Treatment Plant Concentrate Discharge Pipeline
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2. County* Brunswick
3. Highway or Street Clearwell Drive, Butler Road, Mt. Misery Road, and Hooper Rd
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Northwest Township
5. State * NC
6. Zip Code * 28451
7. Latitude* Enter the latitude in decimal degrees
34.3038
8. Longitude* Enter the longitude in decimal degrees (M.JST be negative)
-78.1057
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*
06/15/2020
Estimated Construction Project Start Date
10. Date to End*
10/31/2021
Estimated Construction Project End Date
11. SIC (Primary) *
Other (9999)
Standard Industrial Classification for Developrrent
12. Acres to be
12.50
disturbed*
(including off -site borrow and waste areas)
13. Total site area 12.50
(acres) *

14. Post- 0.02
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-BRUNS-2020-Northwest Water Treatment Plant Concentrate
Tracking ID Discharge Pipeline
Assigned automatically
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 Hood Creek
Waterbody* Ibrreofwaterbodyinto whichstormwaterrunoff will discharge
15b. Waterbody 18-66
Index No.* NCWaterbody Index Number
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional Bay Branch
Receiving Waterbody narre
Waterbody
15d. Waterbody 18-66-7
Index No. NCWaterbody Index Nurrber
15e. Additional Cape Fear River
Receiving Waterbody narre
Waterbody
15f. Waterbody 18-(63)
Index No. NCWaterbody Index Nurrber
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 *
Brunswick County
IF pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
John
IF Corporation, enter Faegistered Agent First %rre
3. Last Name*
Nichols
IF Corporation, enter F;bgistered Agent Last %ne
3b. Title
Director of Public Utilities
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-253-2657
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box249
Address Line 2
Cty
Bolivia
Fbstal / Zip Code
28422
Check box if the F Yes
street address the
same as mailing
address
State / Rovince / Pbegion
NC
Country
us
7. Permittee Street
Street Address
Address*
250 Grey Water Road
Address Line 2
city
State / Frovince / Region
Supply
NC
Fbstal / Zip Code
Country
28462
us
8. Type of
Government - County
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Bob
Contact - First
Name *
2. Primary Site
Tweedy
Contact - Last
Name *
3. Title
Sr. Utilities Manager - CIP/Infrastructure
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-253-2680
Telephone No.
6. Organization
Brunswick County Public Utilities
Name
7. Site Contact
Street Address
Mailing Address*
PO Box249
Address Line 2
city
Bolivia
Fbstal / Zip Code
28422
8. Consultant Name
(Optional)
Kelly Boone, CDM Smith
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-325-3508
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 10/29/2019
Approved *
2. E&SC Plan Project BRUNS-2020-026
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 * Wilmington (WiRO)
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 BRUNS-2020-026 Approval 10-29-2019.pdf 299.08KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Helpful for linear project review
(Optional) Figure 1 aerial wetlands map.pdf 228.12KB
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.
Project begins at the entrance to the Northwest Water Treatment
Plant at 3954 Clearwell Drive in Leland. The pipeline follows
Clearwell Drive, Butler Road, Mt. Misery Road, and Hooper Road
NE to the Cape Fear River.
8. NOI Certification NCGo1 Notice of Intent - Pipeline.pdf 51.07KB
Form Mast be RDFfornat
This is an Express r 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 * john nichols
Title Director
Organization Legally Plesponsible Entity
Brunswick County
Date * 06/29/2020

F. Tracking and COC Info
NOI Tracking No. 27659
NC Reference No. NCG01-2020-2791
Uses 'count_nunber' variable (increrrented by SP)
Certificate of NCC202791
Coverage (COC) Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 2791
Sequential nunber for subnittal 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. NCC202791-2020
Invoice Due Date 7/31/2020
Initial Fee $ 100.00
Invoice Status OPEN