NCC202987_NOI Application_20200715

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 7/13/2020 10:33:37 AM(NCG01 NOI Submission)
Approve by Garcia, Lauren V 7/15/2020 8:20:45 AM(Review-Construction NOI 28164)
• The task was assigned to Garcia, Lauren V by round robin distribution 7/13/2020 10:34 AM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:July 15,2020 5:00 PM.
The priority is: High 7/13/2020 10:34 AM
Submit by Selkane,Aziza 7/15/2020 9:18:49 AM(Payment Verification for NCC202987)
* Stocks Engineering, P.A.
• Selkane,Aziza assigned the task to Selkane,Aziza 7/15/2020 9:17 AM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is:August 26, 2020 5:00 PM.
The priority is: High 7/15/2020 8:21 AM

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1Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System 'D application for•• - .•-under NorthCarolina's
General Permit 1 1111:STORIMATER DISCHARGES associated with construction activities(or
NORTH CAROLINA
Enrlrnnmenfu�Qr�arlry
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 27860
NOI No.
Prior Reviewer Paul Clark
Name
1a. Project Name* Gander Lake Phase 6
1 b.Specific Lot This field may be used to list specifc lot nunbers.
Numbers 115-171
2.County* Wayne
3. Highway or Street Princeton-Pikeville Road
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Princeton
5.State* NC
6.Zip Code* 27569
7. Latitude* Enter the latitude in decimal degrees
35.4868
8. Longitude* Enter the longitude in decimal degrees(M.ST be negative)
-78.1121
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* 07/15/2020
Estinated Construction Project Start Date
10. Date to End* 07/16/2021
Estirreted Construction Project End Cute
11.SIC(Primary)* Residential, Single Family Houses(SFE)(1521)
Standard Industrial aassification for Development

12.Acres to be 8.05
disturbed* (including off-site borrow and waste areas)
13.Total site area 119.94
(acres)*
14. Post- 5.50
construction (Estimated)
impervious area
(acres)*
NCC Project NCC-WAYNE-2020-Gander Lake Phase 6
Tracking ID Assignedautoratically
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 Dennis Branch
Wate rbody* %rre of waterbody into which stormwater runoff will discharge
15b.Waterbody 27-57-20.5
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. ^
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* Gander Lake Development, LLC
It 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* Richard
It Corporation,enter F;bgistered Agent Last Iona
3b.Title Owner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-550-7711
Telephone No.*
6. Permittee Mailing Street Address
Address* 5215 Hwy 70 Bus West
Address Line 2
City State/Rovince/F;bgion
Clayton NC
Fbstal/Zip Code Country
27520 us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 5215 Hwy 70 Bus West
Address Line 2
City State/Frovince/Region
Clayton NC
Fbstal/Zip Code Country
27520 us
8.Type of Non-Government
Ownership*

C. Site Contact Information
Part C. ^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Cary
Contact-First
Name*
2. Primary Site Chandler
Contact-Last
Name*
3.Title
4.Site Contact E- [e-mail]
mail Address*
5.Site Contact 919-550-7711
Telephone No.*
6.Organization RRT Development
Name
7.Site Contact Street Address
Mailing Address* 5212 Hwy 70 BUS West
Address Line 2
City State/Rovince/Region
Clayton NC
Fbstal/Zip Code Country
27520 US
8. Consultant Name (Optional)
Kevin Varnell
First and Last narre
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 2524598196
Telephone No.

D. E&SC Plan
Part D. ^
Erosion&Sediment Control(E&SC)Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 07/01/2020
Approved*
2. E&SC Plan Project Wayne-2020-027
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* Washington (WaRO)
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 Wayne-2020-027 Gander Lake Phase 6-07012020
Approval letter or 839.38KB
(EXP).pdf
Grading Permit
Mist be FDFforrrat
6.Site Location Map Helpful for linear project review
(Optional) Mist be FDFfornat.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 NCG01-eNO1-Certification-Form-Signed.pdf 130.54KB
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:
Anyperson who knowinglymakes any false statement,representation,or certification in anyapplication,record,report,plan,or other
documentfiled 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 underthis 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 guiltyofa Class 2 misdemeanor which mayinclude 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
r 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
owo
Type Name* John Richard
Title Owner
Organization Legally Pesponsible Entity
Gander Lake Development, LLC
Date* 07/13/2020

F. Tracking and COC Info
NOI Tracking No. 28164
NC Reference No. NCG01-2020-2987
Uses'count_nurrber'variable(increrrented by SP)
Certificate of NCC202987
Coverage (COC) Uses'count_nurrber'variable(increrrented by SP)
No.*
Count Number 2987
Sequential nurrber for subrrittal 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. NCC202987-2020
Invoice Due Date 8/14/2020
Initial Fee $ 100.00
Invoice Status OPEN