NCC205744_NOI Application_20201214

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/8/2020 5:58:58 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 12/10/2020 1:10:25 PM (Review- Construction NOI 38675)
• Morman, Alaina reassigned the task to Garcia, Lauren V 12/8/2020 6:13 PM
• The task was assigned to Morman, Alaina by round robin distribution 12/8/2020 5:59 PM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 10, 2020 5:00
PM. The priority is: High 12/8/2020 5:59 PM
Submit by Selkane, Aziza 12/14/2020 8:52:18 AM (Payment Verification for NCC205744)
* SME Inc
• Selkane, Aziza assigned the task to Selkane, Aziza 12/14/2020 8:48 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 21, 2021 5:00 PM.
The priority is: High 12/10/2020 1:10 PM

.• SThF� ';
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 36470
NOI No.
Prior Reviewer Lauren Garcia
Name
1a. Project Name * Oxford Road Loop Gas Pipeline Extension
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
1 c. Parcel ID List all PEA associated w ith this project.
Number(s) (PIN)
2. County* Granville
3. Highway or Street Oxford Loop Road near Raleigh Street
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Oxford
5. State * NC
6. Zip Code* 27565
7. Latitude* Enter the latitude in decimal degrees
36.3050
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.5640
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* 11/20/2020
Estimated Construction Project Start Date
10. Date to End* 01/31/2021
Estimated Construction Project End Date

11. SIC (Primary)* Other (9999)
Standard Industrial aassification for Development
12. Acres to be 2.10
disturbed* (including off -site borrow and waste areas)
13. Total site area 2.10
(acres) *
14. Post- 0.00
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-GRANV-2020-Oxford Road Loop Gas Pipeline Extension
Tracking ID Assigned automatically
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 Coon Creek
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 28-11-5
Index No. * NCWaterbody Index Nurrber
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
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. ^
Fbrnittee 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 Responsible Entity
Name * Public Service Company of North Carolina, 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 * Shaun
If Corporation, enter Registered Agent First Wre
3. Last Name* Randall
It Corporation, enter F;bgistered Agent Last %rre
3b. Title Vice President - Gas Operations
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-810-3350
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box 1398
Address Line 2
City
State / Ffovince / Fbgion
Gastonia
NC
Fbstal / Zip Code
Country
28053
us
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
800 Gaston Road
Address Line 2
Building A
City
State / Ftovince / Region
Gastonia
NC
Fbstal / Zip Code
Country
28056-6519
us
8. Type of
ONnership is only individual if an individual
is naned in B.1. above.
Ownership*
Non -Government

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Robert
Contact - First
Name *
2. Primary Site
Schwartz
Contact - Last
Name *
3. Title
Engineer IV
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
803-530-7172
Telephone No.
6. Organization
Dominion Energy North Carolina
Name
7. Site Contact
Street Address
Mailing Address*
220 Operation Way
Address Line 2
MC C221
city
Cayce
Fbstal / Zip Code
29033-3701
8. Consultant Name
(Optional)
Liane R. Morgan, P.E. (S&ME, Inc.)
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
704-523-4726
Telephone No.
State / Rovince / Region
SC
Country
US

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 11/06/2020
Approved *
2. E&SC Plan Project GRANV-2021-003
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 * Raleigh (RRO)
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 GRANV-2021-003_20201106_LOA.pdf 265.94KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 20 NB)
Figure1.pdf 1.03MB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Rovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies for linear projects if necessary.
This is a linear utility project for natural gas pipeline installation.
Project will commence east of the intersection of Oxford Loop Road
and Raleigh Street and will conclude approximately 1,000 feet
northeast of the intersection of Oxford Loop Road and Maluli Drive.
The vast majority of this project will occur within the available
NCDOT roadway right-of-way.
8. NOI Certification NCG01-eNO1-Certification-Form-Oxford Loop -
Form 4.07MB
signed.pdf
NUst be RDFfornat
This is an Express r 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 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 Legally Responsible Person named on this Notice of Intent
f Authorized Responsible Person* (signing on behalf of Legally Responsible
Person named in Part B)
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
�rr?r�r�c rzsrdr�lf
Type Name* Shaun Randall
Title Vice President - Gas Operations
Organization Legally Responsible Entity
Public Service Company of North Carolina, Inc.
Date * 12/08/2020

F. Tracking and COC Info
NOI Tracking No. 38675
NC Reference No.
NCG01-2020-5744
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205744
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5744
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. NCC205744-2020
Invoice Due Date 1/9/2021
Initial Fee $ 100.00
Invoice Status OPEN