NCC204193_NOI Application_20200924

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/23/2020 2:24:36 PM (NCG01 NOI Submission)
Approve by Clark, Paul 9/23/2020 3:31:03 PM (Review- Construction NOI 31865)
• The task was assigned to Clark, Paul by round robin distribution 9/23/2020 2:25 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 25, 2020 5:00
PM. The priority is: High 9/23/2020 2:25 PM
Submit by Selkane, Aziza 9/24/2020 9:27:07 AM (Payment Verification for NCC204193)
* Jo Anna K. Reynolds
• Selkane, Aziza assigned the task to Selkane, Aziza 9/24/2020 9:26 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 4, 2020 5:00 PM.
The priority is: High 9/23/2020 3:31 PM

.• SThF� ';
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 * Quail Hollow Club -Tennis Courts
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers 20956101
2. County* Mecklenburg
3. Highway or Street 3700 GLENEAGLES RD
Address* Street narre only is acceptable if no address number assigned yet
4.CityorTownship* Charlotte
5. State * NC
6. Zip Code * 28210
7. Latitude* Enter the latitude in decimal degrees
35.1190
8. Longitude* Enter the longitude in decimal degrees (M.JST be negative)
-80.8470
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*
10/02/2020
Estinated Construction Project Start Date
10. Date to End *
10/02/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Classification for Leveloprrent
12. Acres to be
5.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area 256.00
(acres) *

14. Post- 26.30
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-MECKL-2020-Quail Hollow Club - Tennis Courts
Tracking ID 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 McMullen Creek
Waterbody* %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 11-137-9-5
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. ^
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 * Tom Delozier
IF pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * Tom
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Delozier
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title General Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 7045521727
Telephone No.*
6. Permittee Mailing Street Address
Address* 3700 Gleneagles Rd
Address Line 2
City
Charlotte
Fbstal / Zip Code
28210-4937
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
3700 Gleneagles Rd
Address Line 2
city
Charlotte
Fbstal / Zip Code
28210-4937
8. Type of Non -Government
Ownership *
State / Frovince / Fbgion
NC
Country
us
State / Frovince / Region
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Tom
Contact - First
Name *
2. Primary Site Delozier
Contact - Last
Name *
3. Title General Manager
4. Site Contact E- [e-mail]
mail Address*
5. Site Contact 7045521727
Telephone No.*
6. Organization
Name
7. Site Contact Street Address
Mailing Address* 3700 GLENEAGLES RD
Address Line 2
City
CHARLOTTE
Rbstal / Zip Code
28210
8. Consultant Name (Optional)
First and Last nave
9. Consultant E-mail This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Frovince / Pegion
NC
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 09/23/2020
Approved *
2. E&SC Plan Project LDGPL-2020-00198
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* City of Charlotte
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
Letter of Approval modified April 2019 -Quail Hollow
Approval letter or
27.08KB
Club Tennis Courts.pdf
Grading Permit
Mast be FDFforrrat
6. Site Location Map
Helpful for linear project review
(Optional)
Mast 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
2020-09-22-QHC Tennis Courts- NOI Form -
Form
83.56KB
Signed.pdf
Mast be FDFfornat
This is an Express
f No
Review Project*
F 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 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 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
Type Name* Tom Delozier
Title General Manager
Organization Legally Ibsponsible Entity
Tom Delozier
Date * 09/23/2020

F. Tracking and COC Info
NOI Tracking No. 31865
NC Reference No.
NCG01-2020-4193
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC204193
Coverage (COC)
Uses 'count number' variable (increrrented by SP)
No.*
Count Number 4193
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. NCC204193-2020
Invoice Due Date 10/23/2020
Initial Fee $ 100.00
Invoice Status OPEN