NCC204424_NOI Application_20201008

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/1/2020 10:01:00 AM (NCG01 NOI Submission)
Approve by Clark, Paul 10/2/2020 11:03:09 AM (Review- Construction NOI 32372)
• Georgoulias, Bethany reassigned the task to Clark, Paul 10/2/2020 10:34 AM
• The task was assigned to Garcia, Lauren V by round robin distribution 10/1/2020 10:01 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 5, 2020 5:00
PM 10/1/2020 10:01 AM
Submit by Selkane, Aziza 10/8/2020 2:15:16 PM (Payment Verification for NCC204424)
* Carolina Green Corp.
• Selkane, Aziza assigned the task to Selkane, Aziza 10/8/2020 2:14 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 13, 2020 5:00
PM 10/2/2020 11:03 AM

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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 * Lee Park Baptist Church Soccer Field Renovation
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2. County* Union
3. Highway or Street 2505 Morgan Mill Road
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Monroe
5. State * NC
6. Zip Code * 28110
7. Latitude* Enter the latitude in decimal degrees
35.0080
8. Longitude* Enter the longitude in decimal degrees (M.JST be negative)
-80.5216
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*
10/05/2020
Estimated Construction Project Start Date
10. Date to End *
09/30/2021
Estinated Construction Project End Date
11. SIC (Primary) *
Other (9999)
Standard Industrial Cassification for Developrrent
12. Acres to be
2.69
disturbed*
(including off -site borrow and waste areas)
13. Total site area 33.88
(acres) *

14. Post- 0.00
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-UNION-2020-Lee Park Baptist Church Soccer Field
Tracking ID Renovation
Assigned autonatically
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 Stewarts Creek
Waterbody* %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 13-17-36-9-(1)
Index No.* NCWaterbody Index Nunber
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional Stewarts Creek (Lake Twitty (Lake Stewart))
Receiving Waterbody narre
Waterbody
15d. Waterbody 13-17-36-9-(4.5)
Index No. NCWaterbody Index Nurrber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Nunber
Index No.
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 * Carolina Green Corp.
It 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 * Chad
IF Corporation, enter Faegistered Agent First Wre
3. Last Name* Price
It Corporation, enter F;bgistered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-363-8011
Telephone No.*
6. Permittee Mailing Street Address
Address* 10108 Indian Trail Fairview Road
Address Line 2
City State / Frovince / Region
Indian Trail NC
Fbstal / Zip Code Country
28079-7764 us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
10108 Indian Trail Fairview Road
Address Line 2
City
State / Frovince / Region
Indian Trail
NC
Postal / Zip Code
Country
28079-7764
us
8. Type of
Individual
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Russ
Contact - First
Name *
2. Primary Site
Baucom
Contact - Last
Name *
3. Title
Superintendent
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
704-989-0031
Telephone No.
6. Organization
Carolina Green Corp.
Name
7. Site Contact
Street Address
Mailing Address*
10108 Indian Trail Fairview Road
Address Line 2
city
Indian Trail
Fbstal / Zip Code
28079-7764
8. Consultant Name
(Optional)
Trenda Herring
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
704-363-9528
Telephone No.
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 09/30/2020
Approved *
2. E&SC Plan Project Union-2021-012
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 * Mooresville (MRO)
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
Lee Park Baptist Church Soccer Field Renovation
Approval letter or
1.1MB
(UNION-2021-012) approval wmods.pdf
Grading Permit
Mast be FL7Ffon-rat
6. Site Location Map
Helpful for linear project review
(Optional)
Site Location 2053 Lee Park Soccer Plans
838.24KB
09.29.2020-Rev 3.pdf
Mast be R7F format. Rease do not upload entire set of E&SC plans.
7. Notes (Optional)
Frovide 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.
8. NOI Certification
NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form
358.6KB
SW.pdf
Wst be FDFformat
This is an Express
r 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 * Chad D. Price
Title President
Organization Legally Plesponsible Entity
Carolina Green Corp.
Date * 10/01 /2020

F. Tracking and COC Info
NOI Tracking No. 32372
NC Reference No.
NCG01-2020-4424
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC204424
Coverage (COC)
Uses 'count number' variable (increrrented by SP)
No.*
Count Number 4424
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. NCC204424-2020
Invoice Due Date 11/1/2020
Initial Fee $ 100.00
Invoice Status OPEN