NCC205843_NOI Application_20201222

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/15/2020 10:14:38 AM (NCG01 NOI Submission)
Approve by Morman, Alaina 12/16/2020 4:28:47 PM (Review- Construction NOI 39172)
• Gamble, Aana C reassigned the task to Morman, Alaina 12/15/2020 10:44 AM
• The task was assigned to Gamble, Aana C by round robin distribution 12/15/2020 10:15 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 17, 2020 5:00
PM 12/15/2020 10:15 AM
Submit by Selkane, Aziza 12/22/2020 9:33:23 AM (Payment Verification for NCC205843)
* Brittany McMurry
• Selkane, Aziza assigned the task to Selkane, Aziza 12/22/2020 9:32 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 27, 2021 5:00 PM
12/16/2020 4:29 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 38717
NOI No.
Prior Reviewer Alaina Morman
Name
1a. Project Name * WMC - Johnson Street Construction
1 b. Specific Lot This field may be used to list spedc lot numbers.
Numbers
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 2910-70-6917-000, 2910-70-7453-000
2. County* Watauga
3. Highway or Street Johnson Street
Address* Street name only is acceptable if no address nunber assigned yet
4. CityorTownship* Boone
5. State * NC
6. Zip Code* 28607
7. Latitude* Enter the latitude in decinal degrees
36.1974
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-81.6516
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* 12/16/2020
Estirrated Construction Project Start Date
10. Date to End * 05/28/2021
Estinated Construction Project End Date

11. SIC (Primary)* Other (9999)
Standard Industrial aasslfication for Development
12. Acres to be 1.70
disturbed* (including off -site borrow and waste areas)
13. Total site area 2.06
(acres) *
14. Post- 0.79
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-WATAU-2020-WMC - Johnson Street Construction
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 Middle Fork South Fork New River
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 10-1-2-(14)
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. ^
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 * Watauga Medical Center Inc.
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 * Maran
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Sigmon
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title Vice President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 8282624177
Telephone No.*
6. Permittee Mailing Street Address
Address* 336 Deerfield Road
Address Line 2
City
Boone
Fbstal / Zip Code
28607-5008
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
336 Deerfield Road
Address Line 2
City
Boone
Fbstal / Zip Code
28607-5008
State / Frovince / Pegion
NC
Country
us
State / Frovince / Faegion
NC
Country
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
Rob
Contact - First
Name *
2. Primary Site
Trotter
Contact - Last
Name *
3. Title
Superintendent
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
7046076019
Telephone No.
6. Organization
Vannoy Construction
Name
7. Site Contact
Street Address
Mailing Address*
4024 Barringer Drive
Address Line 2
City
State / Rovince / Region
Charlotte
NC
Fbstal / Zip Code
Country
28217-1508
us
8. Consultant Name
(Optional)
James Peltier
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
6147754363
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
Default is legally responsible person e-n-ail (older NOIs 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 11/23/2020
Approved *
2. E&SC Plan Project Z03957-061020
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Town of Boone
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 ZoningPermit_Z03957-
Approval letter or 258.87KB
061020_WMC_NewStreet_11232020. pdf
Grading Permit
Mist be RDFfon-rat
6. Site Location Map Mist be RDFforrret (lint 201VB)
site map - Johnson Street.pdf 157.56KB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Provide 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 2020-12-09 - WMC - Johnson Street - NCDEQ eNO1
Form 1.67MB
-signed.pdf
Mast be PDFfon-rat
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 Amide 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 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
�lrflF.6t �SL��9T�!
Type Name* Maran Sigmon
Title Vice President
Organization Legally Ibsponsible Entity
Watauga Medical Center Inc.
Date * 12/15/2020

F. Tracking and COC Info
NOI Tracking No. 39172
NC Reference No.
NCG01-2020-5843
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205843
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5843
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. NCC205843-2020
Invoice Due Date 1/15/2021
Initial Fee $ 100.00
Invoice Status OPEN