NCC205828_NOI Application_20201222

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/16/2020 12:26:14 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 12/16/2020 12:34:47 PM (Review- Construction NOI 39279)
• The task was assigned to Garcia, Lauren V by round robin distribution 12/16/2020 12:26 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 18, 2020 5:00
PM 12/16/2020 12:26 PM
Submit by Selkane, Aziza 12/22/2020 9:24:11 AM (Payment Verification for NCC205828)
* Harvey Montague
• Selkane, Aziza assigned the task to Selkane, Aziza 12/22/2020 9:23 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 27, 2021 5:00 PM
12/16/2020 12:35 PM

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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 * Quail Glen - Phase 4B
1 b. Specific Lot
This field nay be used to list specifc lot nunbers.
Numbers
1 c. Parcel ID
List all Rim associated w ith this project.
Number(s) (PIN)
0652-83-6051.000
0652-82-7927.000
0652-82-8901.000
0652-82-6833.000
0652-82-6761.000
0652-82-6633.000
0652-82-6506.000
0652-82-5488.000
0652-82-8317.000
0652-82-8426.000
0652-82-8563.000
0652-82-8690.000
0652-82-9759.000
0652-82-9879.000
0652-92-0883.000
0652-92-1863.000
0652-93-0190.000
0652-93-0126.000
0652-83-9147.000
0652-83-8148.000
2. County*
Harnett
3. Highway or Street Bella Vita Way
Address* Street name only is acceptable if no address nunber assigned yet
4. City or Township* Black River
5. State * NC
6. Zip Code* 27501
7. Latitude* Enter the latitude in decinal degrees
35.4640

8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-78.8020
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*
06/03/2019
Estinated Construction Project Start Date
10. Date to End*
06/30/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Leveloprrent
12. Acres to be
15.50
disturbed*
(including off -site borrow and waste areas)
13. Total site area 12.25
(acres) *
14. Post- 2.94
construction (Estinated)
impervious area
(acres) *
NCC Project NCC-HARNE-2019-Quail Glen - Phase 4B
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 Neills Creek
Waterbody* Narreof waterbody into which stornwater runoff will discharge
15b. Waterbody 18-16-(0.7)
Index No. * NCWaterbody Index Nunber
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 Pesponsible Entity
Name * Penny Road Developers, LLC
IF 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 * Harvey
If Corporation, enter Faegistered Agent First Wre
3. Last Name* Montague
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title Registered Agent
4. Permitee E-mail [e-mail]
Address*
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* 10305 Penny Road
Address Line 2
City
Raleigh
Fbstal / Zip Code
27606-9107
Check box if the V Yes
street address the
same as mailing
address
State / Frovince / Fbgion
NC
Country
us
7. Permittee Street
Street Address
Address*
10305 Penny Road
Address Line 2
City
State / Frovince / Faegion
Raleigh
NC
Fbstal / Zip Code
Country
27606-9107
us
8. Type of
Ownership 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
Harvey
Contact - First
Name *
2. Primary Site
Montague
Contact - Last
Name *
3. Title
Registered Agent
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-362-5730
Telephone No.*
6. Organization
Penny Road Developers, LLC
Name
7. Site Contact
Street Address
Mailing Address*
10305 Penny Road
Address Line 2
City
State / Rovince / Region
Raleigh
NC
Fbstal / Zip Code
Country
27606-9107
us
8. Consultant Name
(Optional)
Enoch Engineers, PA
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-894-7765
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
Default is legally responsible person e-n-ail (older NOts may not populate)
12. Billing (For Annual Fee correspondence)
Telephone Default is legally responsible person telephone (older NOIs rray not populate)

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 05/10/2019
Approved *
2. E&SC Plan Project HARNE-2019-081
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 * Fayetteville (FRO)
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 harne081apMod.pdf
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 20 NB)
vici n ity. pdf
Rease do not upload entire set of E&SC plans.
79.44KB
17.88KB
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.
8. NOI Certification NCG01-eNO1-Certification-Form-20190801-DEMLR-
Form SW.pdf 442.6KB
Mast be FDFformat
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 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:* IT 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
1�t'kvZ' W"-'-,5 o-
Type Name * Harvey L. Montague
Title Registered Agent
Organization Legally Responsible Entity
Penny Road Developers, LLC
Date * 12/16/2020

F. Tracking and COC Info
NOI Tracking No. 39279
NC Reference No.
NCG01-2020-5828
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205828
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5828
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. NCC205828-2020
Invoice Due Date 1/15/2021
Initial Fee $ 100.00
Invoice Status OPEN