NCC203310_NOI Application_20200805

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/30/2020 7:05:07 PM (NCG01 NOI Submission)
Approve by Farkas, Jim J 8/3/2020 1:54:14 PM (Review- Construction NOI 29203)
• The task was assigned to Farkas, Jim J by round robin distribution 7/30/2020 7:05 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 3, 2020 5:00
PM 7/30/2020 7:05 PM
Submit by Selkane, Aziza 8/5/2020 1:16:58 PM (Payment Verification for NCC203310)
* Brick Church
• Selkane, Aziza assigned the task to Selkane, Aziza 8/5/2020 1:16 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 14, 2020 5:00
PM 8/3/2020 1:54 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 * Fellowship Hall for Brick Reformed United Church of Christ
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2. County* Guilford
3. Highway or Street 3694 Brick Church Road
Address* Street narre only is acceptable if no address number assigned yet
4.City orTownship* Burlington
5. State * NC
6. Zip Code * 27215
7. Latitude* Enter the latitude in decimal degrees
36.0039
8. Longitude* Enter the longitude in decimal degrees (M.JST be negative)
-79.5592
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*
08/10/2020
Estinated Construction Project Start Date
10. Date to End *
03/12/2021
Estimated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Classification for Developrrent
12. Acres to be
2.60
disturbed*
(including off -site borrow and waste areas)
13. Total site area 10.81
(acres) *

14. Post- 0.70
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-GUILF-2020-Fellowship Hall for Brick Reformed United Church
Tracking ID of Christ
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 Beaver Creek
Waterbody* Ibrre of w aterbody into w hich storrrw ater runoff w ill discharge
15b. Waterbody 16-19-4-(1)
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. ^
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 *
Brick Reformed United Church of Christ
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
William
IF Corporation, enter Registered Agent First %rre
3. Last Name*
Reece
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Consistory President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-449-6034
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box27
Address Line 2
Cty
Whitsett
Fbstal / Zip Code
27277
Check box if the F Yes
street address the
same as mailing
address
State / Rovince / Pbegion
North Carolina
Country
United States
7. Permittee Street
Street Address
Address*
3699 Brick Church Road
Address Line 2
city
State / Ftovince / Region
Burlington
NC
Fbstal / Zip Code
Country
27215
United States
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Charles
Contact - First
Name *
2. Primary Site
O'Bryant
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-202-4132
Telephone No.
6. Organization
Bar Construction Company, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
611-A Industrial Avenue
Address Line 2
city
Greensboro
Fbstal / Zip Code
27406
8. Consultant Name
(Optional)
Keith Broderick
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-402-0308
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 07/27/2020
Approved *
2. E&SC Plan Project 20-06-GCCP-04097
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Guilford 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 Brick Reformed United Church of Christ_LOA_7-27-
Approval letter or 123.46KB
2020.pdf
Grading Permit
Mast be FDFforrrat
6. Site Location Map Helpful for linear project review
(Optional) Mast be PDFfornat. 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 Notice of Intent_ Signed_7-30-2020.pdf 821.97KB
Form Mist be RDFfornat
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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Amide or rules of the
Commission implementing this Atcle 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
rl rr�rr , klr
Type Name* William Reece
Title Consistory President
Organization Legally Ibsponsible Entity
Brick Reformed United Church of Christ
Date * 07/30/2020

F. Tracking and COC Info
NOI Tracking No. 29203
NC Reference No.
NCG01-2020-3310
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC203310
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3310
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. NCC203310-2020
Invoice Due Date 9/2/2020
Initial Fee $ 100.00
Invoice Status OPEN