NCC190976_NOT Signed Certification_20201103

11/3/2020
New Submission
NOT Request Form - Construction Stormwater
NCG01 or NCG25
NORTH CAROLINA
This form is to request Notice of Termination (NOT) for a existing coverage under the NC NPDES Stormwater
Environmental Quality
General Permit for Construction Activities
Certificate of NCC190976
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name
Panther Creek Subdivision (Wake County Side)
Address
7810 Mt. Pleasant Rd., Willow Springs, NC
County
Wake
Latitude
35.5662
Longitude
-78.6472
Permittee Listed
Gray Wolf Development
Legally Responsible
Wade Corbett
Individual
NC Reference No.
NCG01-2019-0976
E&SC Plan ID
SEC-018186-2019
Original NOI Tracking
13542
No. *
Date COC Issued *
07/17/2019
Prior Rescission Date
This field will populate only if COG has already been rescinded.
Reason for Rescission/Termination Request:
Reason for Q Project Closed -Out
Termination of Q Sale (Another Owner/Operator will apply for a new COC)
Coverage* Q Mistake or Invalid Coverage
0 Other

11 /3/2020
New Submission
Addional Explanation More information about the basis of this request, if needed.
You must upload supporting documentation of the sale below. The new owner or operator will be
required to obtain a new COC to cover construction activities.
Supporting Upload Supporting Documentation if applicable.
Documentation Upload
Panther Creek - Executed Contract H&H JSJ 0418... 1.21 MB
Must be PDF format
North Carolina General Statute 143-215.6B (i) provides that:
F_4
Any person who knowingly makes any false 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 Article; 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 Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
* I, as an authorized representative, hereby request rescission of coverage under
the NPDES Stormwater Permit for the subject facility. I am familiar with the
information contained in this request and to the best of my knowledge and belief
such information is true, complete and accurate.
*This form must be signed by a responsible corporate officer that 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* x
Type Name* Dennis Peacock
Title* VP of Construction
Organization * Gray Wolf Development, LLC
Date* Date captured on form submission
Email for [e-mail]
Confirmation
Contact Telephone * 9199347788
NOT Certification Upload
Form * Must be PDF Format

11/3/2020
New Submission
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM
(https://files. nc.gov/ncdeq/Energy%20Mineral%20and%2OLand%2OResources/Stormwater/N PDES%2OGeneral%2OPer}nits/N
eNOT-Certification-Form-20190508-DEMLR-SW.pdf) to The Stormwater Program at the address on the form for the
application to fulfill federal requirements.
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