NCC205214_NOI Application_20201113

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/11/2020 6:13:31 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 11/12/2020 5:02:05 PM (Review- Construction NOI 35836)
• Morman, Alaina reassigned the task to Morman, Alaina 11/12/2020 8:02 AM
• The task was assigned to Gamble, Aana C by round robin distribution 11/11/2020 6:14 PM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 13, 2020 5:00
PM. The priority is: High 11/11/2020 6:14 PM
Submit by Selkane, Aziza 11/13/2020 9:40:01 AM (Payment Verification for NCC205214)
* Connie Ader
• Selkane, Aziza assigned the task to Selkane, Aziza 11/13/2020 9:39 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 24, 2020 5:00
PM. The priority is: High 11/12/2020 5:02 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting r No
an NOI that was r Yes
rejected before?
Previous Rejected 35828
NOI No.
Prior Reviewer Alaina Morman
Name
1a. Project Name* Arcadia Ridge
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
2. County* Davidson
3. Highway or Street Central Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Clemmons
5. State * NC
6. Zip Code * 27012
7. Latitude * Enter the latitude in decimal degrees
35.9850
8. Longitude* Enter the longitude in decinal degrees (M. ST be negative)
-80.2988
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* 11/10/2020
Estinated Construction Project Start Date
10. Date to End* 02/26/2021
Estimated Construction Project End Cute
11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Developrrent

12. Acres to be 1.84
disturbed* (including off -site borrow and waste areas)
13. Total site area 1.84
(acres) *
14. Post- 0.33
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-DAVID-2020-Arcadia Ridge
Tracking ID Assignedautonatically
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 Fryes Creek
Waterbody * %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 12-94-15
Index No.* NCWaterbody Index Nunber
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional Millers Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 12-94-14
Index No. NCWaterbody Index Nunber
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 * Clayton Properties Group Inc
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 * Ken
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Capron
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Asst. Secretary
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-765-9661
Telephone No.*
6. Permittee Mailing Street Address
Address* 221 Jonestown Road
Address Line 2
City
Winston-Salem
Fbstal / Zip Code
27104-4618
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
221 Jonestown Road
Address Line 2
City
Winston-Salem
Fbstal / Zip Code
27104-4618
8. Type of Non -Government
Ownership *
State / Frovince / Pegion
NC
Country
us
State / Frovince / Region
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Steve
Contact - First
Name *
2. Primary Site
Kimel
Contact - Last
Name *
3. Title
Builder
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-972-6372
Telephone No.
6. Organization
Shugart Homes
Name
7. Site Contact
Street Address
Mailing Address*
221 Jonestown Road
Address Line 2
city
Winston-Salem
Postal / Zip Code
27104-4618
8. Consultant Name
(Optional)
First and Last nacre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
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 11/03/2020
Approved *
2. E&SC Plan Project DAVID-2021-016
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
Arcadia Approval DAVID-2021-016_20201103_A-
Approval letter or
6.47MB
M_Express.pdf
Grading Permit
Mist be RDFforrrat
6. Site Location Map
Helpful for linear project review
(Optional)
Mast be PDFfornat. 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
Arcadia Ridge a NOI New.pdf 96.83KB
Form
Wst 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
Aa &Yul'
Type Name * Ken Capron
Title Asst. Secretary
Organization Legally Responsible Entity
Clayton Properties Group, Inc
Date * 11 /11 /2020

F. Tracking and COC Info
NOI Tracking No. 35836
NC Reference No.
NCG01-2020-5214
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205214
Coverage (COC)
Uses 'count number' variable (increrrented by SP)
No.*
Count Number 5214
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. NCC205214-2020
Invoice Due Date 12/12/2020
Initial Fee $ 100.00
Invoice Status OPEN