NCC203374_NOI Application_20200811

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/5/2020 5:01:02 PM (NCG01 NOI Submission)
Approve by Farkas, Jim J 8/6/2020 3:42:27 PM (Review- Construction NOI 29523)
. The task was assigned to Farkas, Jim J by round robin distribution 8/5/2020 5:01 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 7, 2020 5:00 PM.
The priority is: High 8/5/2020 5:01 PM
Submit by Selkane, Aziza 8/11/2020 11:49:55 AM (Payment Verification for NCC203374)
* Gemini Construction Company
• Selkane, Aziza assigned the task to Selkane, Aziza 8/11/2020 11:49 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 17, 2020 5:00
PM. The priority is: High 8/6/2020 3:42 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 * Randolph Mall Redevelopment
1 b. Specific Lot This field nay be used to list specifc lot nunbers.
Numbers
2. County* Randolph
3. Highway or Street 1437 East Dixie Drive
Address* Street narre only is acceptable if no address number assigned yet
4.CityorTownship* Asheboro
5. State * NC
6. Zip Code * 27203
7. Latitude* Enter the latitude in decinal degrees
35.7013
8. Longitude* Enter the longitude in decir al degrees (M.JST be negative)
-79.7863
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
Estinated Construction Project Start Date
10. Date to End *
06/28/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Classification for Leveloprrent
12. Acres to be
4.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area 36.72
(acres) *

14. Post- 33.00
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-RANDO-2020-Randolph Mall Redevelopment
Tracking ID Assigned autorretically
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 Gabriels Creek
Waterbody* Klarre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 17-14
Index No.* NCWaterbody Index Number
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project F Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
Fl rnittee 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 *
Asheboro Mall, LLC
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
James
IF Corporation, enter Faegistered Agent First Wre
3. Last Name*
Hull
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
General Partner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 706-855-4031
Telephone No.*
6. Permittee Mailing Street Address
Address* 1190 Interstate Parkway
Address Line 2
City State / Rovince / F;bgion
Augusta GA
Fbstal / Zip Code Country
30909 us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
1190 Interstate Parkway
Address Line 2
City
State / Frovince / Region
Augusta
GA
Fbstal / Zip Code
Country
30909
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Trevor
Contact - First
Name *
2. Primary Site
Huggins
Contact - Last
Name *
3. Title
Project Contact
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
706-434-1781
Telephone No.
6. Organization
Gemini Construction Company, LLC
Name
7. Site Contact
Street Address
Mailing Address*
1190 Interstate Parkway
Address Line 2
city
Augusta
Fbstal / Zip Code
30909
8. Consultant Name
(Optional)
Zachary Gardner
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-328-0902
Telephone No.
State / Rovince / Region
GA
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 06/04/2020
Approved *
2. E&SC Plan Project RANDO-2020-020
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 * Winston-Salem (WSRO)
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 LOA - 2020-06-04 - Randolph Mall.pdf 6.83MB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Helpful for linear project review
(Optional) Mast be FCFfornat. 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 NOI Cert Form - Randolph Mall - Signed.pdf 94.77KB
Form Mist be RDFfornat
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
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 * James M Hull
Title Member Manager
Organization Legally Responsible Entity
Asheboro Mall, LLC
Date * 08/05/2020

F. Tracking and COC Info
NOI Tracking No. 29523
NC Reference No.
NCG01-2020-3374
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC203374
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3374
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. NCC203374-2020
Invoice Due Date 9/5/2020
Initial Fee $ 100.00
Invoice Status OPEN