NCC203358_NOI Application_20200806

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/4/2020 11:17:44 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 8/5/2020 3:30:18 PM (Review- Construction NOI 29418)
• Clark, Paul reassigned the task to Garcia, Lauren V 8/4/2020 11:22 AM
* another for you. thx.
• The task was assigned to Clark, Paul by round robin distribution 8/4/2020 11:18 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 6, 2020 5:00
PM 8/4/2020 11:18 AM
Subnut by Selkane, Aziza 8/6/2020 8:05:59 AM (Payment Verification for NCC203358)
* Erik HartWck
• Selkane, Aziza assigned the task to Selkane, Aziza 8/6/2020 8:05 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 16, 2020 5:00
PM 8/5/2020 3:31 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 29186
NOI No.
Prior Reviewer Lauren Garcia
Name
1a. Project Name * Rutledge Gas Pipeline Extension
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
2. County* Wake
3. Highway or Street 8313 Poole Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Knightdale
5. State * NC
6. Zip Code * 27545
7. Latitude * Enter the latitude in decimal degrees
35.7510
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-78.4840
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* 02/10/2020
Estirrated Construction Project Start Cate
10. Date to End* 10/02/2020
Estimated Construction Project End Cute
11. SIC (Primary) * Other (9999)
Standard Industrial Classification for Ceveloprrent

12. Acres to be 3.30
disturbed* (including off -site borrow and waste areas)
13. Total site area 3.30
(acres) *
14. Post- 0.00
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-WAKE-2020-Rutledge Gas Pipeline Extension
Tracking ID 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 Poplar Creek
Wate rbody* %rre of waterbody into which stormwater runoff will discharge
15b. Waterbody 27-35
Index No.* NCWaterbody Index Nunber
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 * Public Service Company of North Carolina, Inc.
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name * M. Shaun
IF Corporation, enter Registered Agent First %rre
3. Last Name* Randall
It Corporation, enter F;bgistered Agent Last %ne
3b. Title Vice President - Gas Operations
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-810-3350
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 1398
Address Line 2
Cty
Gastonia
Fbstal / Zip Code
28053
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*
800 Gaston Road
Address Line 2
Building A
City
State / Ftovince / Region
Gastonia
NC
Fbstal / Zip Code
Country
28053
us
8. Type of
Non -Government
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Robert
Contact - First
Name *
2. Primary Site
Schwartz
Contact - Last
Name *
3. Title
Engineer IV
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
803-217-7112
Telephone No.
6. Organization
Dominion Energy North Carolina
Name
7. Site Contact
Street Address
Mailing Address*
220 Operation Way
Address Line 2
City
Cayce
Postal / Zip Code
29033
8. Consultant Name
(Optional)
Erik L. Hartwick
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
704-523-4723, Ext. 11607
Telephone No.
State / Province / Region
South Carolina
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 02/06/2020
Approved *
2. E&SC Plan Project WAKE-2020-052
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 * Raleigh (RRO)
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 WAKE-2020-052 LOA 20200206.pdf 379.88KB
Approval letter or WAKE-2020-052_20200513_LOA_revised.pdf 318.99KB
Grading Permit
WAKE-2020-052_20200724_LOA revised.pdf 381.33KB
Mast be RFformat
6. Site Location Map Helpful for linear project review
(Optional) SiteLocationMap_Lat_Long.pdf 4.27MB
Mast be R7F format. Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Ffovide any additional information that might help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies for linear projects if necessary.
There was an incorrect interpretation of 40 CFR 122.26(c)(1)(iii).
This submission is subsequent to learning of the error and is
intended to correct the error.
The proposed disturbance acreage has increased as other permits
from USACE and DWR were approved.
02/06/2020 LOA = 3.3 acres
05/13/2020 LOA = 4.3 acres
07/24/2020 LOA = 4.4 acres
8. NOI Certification Rutledge NOI.pdf 1.42MB
Form Mast be FDFfon-rat
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
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
Type Name * M. Shaun Randall
Title Vice President - Gas Operations
Organization Legally Responsible Entity
Dominion Energy North Carolina
Date * 08/04/2020

F. Tracking and COC Info
NOI Tracking No. 29418
NC Reference No.
NCG01-2020-3358
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC203358
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3358
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. NCC203358-2020
Invoice Due Date 9/4/2020
Initial Fee $ 100.00
Invoice Status OPEN