NCC204932_NOI Application_20201102

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/29/2020 3:48:54 PM (NCG01 NOI Submission)
Approve by Clark, Paul 10/30/2020 9:38:17 AM (Review- Construction NOI 34558)
• The task was assigned to Clark, Paul by round robin distribution 10/29/2020 3:49 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 2, 2020 5:00
PM 10/29/2020 3:49 PM
Submit by Selkane, Aziza 11/2/2020 10:12:53 AM (Payment Verification for NCC204932)
* Claude D Morgan IV
• Selkane, Aziza assigned the task to Selkane, Aziza 11/2/2020 10:11 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 11, 2020 5:00
PM 10/30/2020 9:38 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 * WynnWorth LLC - Mundy Road
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2. County* Lincoln
3. Highway or Street Mundy Road
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Denver
5. State * NC
6. Zip Code * 28037
7. Latitude* Enter the latitude in decimal degrees
35.5405
8. Longitude* Enter the longitude in decimal degrees (MJST be negative)
-81.0477
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*
11/15/2020
Estimated Construction Project Start Date
10. Date to End*
12/31/2021
Estimated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Classification for Developrrent
12. Acres to be
7.42
disturbed*
(including off -site borrow and waste areas)
13. Total site area 11.00
(acres) *

14. Post- 3.25
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-LINCO-2020-WynnWorth LLC - Mundy Road
Tracking ID Assignedautorratically
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 Killian Creek
Waterbody * %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 11-119-2-(0.5)
Index No.* NCWaterbody Index Nunber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional Killian Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 11-119-2-(4)
Index No. NCWaterbody Index Minber
15e. Additional Dutchmans Creek
Receiving Waterbody narre
Waterbody
15f. Waterbody 11-119-(0.5)
Index No. NCWaterbody Index Nurrber
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. ^
Fternittee 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 * WynnWorth LLC
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 * Claude D'Val "Sam"
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Morgan IV
It Corporation, enter F;bgistered Agent Last %rre
3b. Title President/Owner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 9104432771
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box 1167
Address Line 2
City State / Frovince / Fbgion
Denver NC
Fbstal / Zip Code Country
28037 United States
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
7473a Hagers Hollow Drive
Address Line 2
City
State / Frovince / Region
Denver
NC
Fbstal / Zip Code
Country
28037
United States
8. Type of
Non -Government
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Claude D. "Sam"
Contact - First
Name *
2. Primary Site
Morgan IV
Contact - Last
Name *
3. Title
President/Owner
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-443-2771
Telephone No.
6. Organization
WynnWorth LLC
Name
7. Site Contact
Street Address
Mailing Address*
P.O. Box 1167
Address Line 2
city
Denver
Fbstal / Zip Code
28307
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Rovince / Region
NC
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/28/2020
Approved *
2. E&SC Plan Project 19-COM-16
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Lincoln 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 WynnWorthLLC_MundyRoad_E&SC_LetterOfAppr... 992.45KB
Approval letter or Mist beRFformat
Grading Permit
6. Site Location Map Helpful for linear project review
(Optional) WynnWorthLLC_MundyRoad_E&SC_SitePlans. pdf 6.38MB
Mast be RDFformat. Rease do not upload entire set of E&SCplans.
7. Notes (Optional) Rovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional waterbodies for linear projects if necessary.
8. NOI Certification WynnWorthLLC_MundyRoad_E&SC_NoticeOflnten... 172.74KB
Form Wst be RDF format
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 Atide 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
(`}ld#re�r 6 r"zr fa'k'2`
Type Name* Claude D'Val Morgan IV
Title President
Organization Legally Iesponsible Entity
WynnWorth LLC
Date * 10/29/2020

F. Tracking and COC Info
NOI Tracking No. 34558
NC Reference No.
NCG01-2020-4932
Uses 'count_nunber' variable (increrrented by SP)
Certificate of
NCC204932
Coverage (COC)
Uses 'count nurrber' variable (increrrented by SP)
No.*
Count Number 4932
Sequential nunber for subnittal 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. NCC204932-2020
Invoice Due Date 11/29/2020
Initial Fee $ 100.00
Invoice Status OPEN