NCC205575_NOI Application_20201223

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/2/2020 12:05:31 PM (NCG01 NOI Submission)
Approve by Meloy, Michael 12/3/2020 8:15:29 AM (Review- Construction NOI 37929)
• The task was assigned to Meloy, Michael by round robin distribution 12/2/2020 12:05 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 4, 2020 5:00
PM 12/2/2020 12:05 PM
Submit by Selkane, Aziza 12/23/2020 11:10:54 AM (Payment Verification for NCC205575)
* Timothy Morris
• Selkane, Aziza assigned the task to Selkane, Aziza 12/23/2020 11:10 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 14, 2021 5:00 PM
12/3/2020 8:15 AM

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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 * Hip Bone Creek Restoration Site
1 b. Specific Lot This field nay be used to list specifc lot numbers.
Numbers Chatham County Parcel ID - 0014903
1 c. Parcel ID List all R h associated w ith this project.
Number(s) (PIN)
2. County* Chatham
3. Highway or Street 865 Carter Brooks Road
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Siler City
5. State * NC
6. Zip Code* 27202
7. Latitude* Enter the latitude in decimal degrees
35.6837
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.4050
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*
01/15/2021
Estimated Construction Project Start Rate
10. Date to End *
06/15/2021
Estinated Construction Project End Date
11. SIC (Primary) *
Other (9999)
Standard Industrial aassification for Development
12. Acres to be
19.19
disturbed*
(including off -site borrow and waste areas)

13. Total site area 24.00
(acres) *
14. Post- 0.00
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-CHATH-2021-Hip Bone Creek Restoration Site
Tracking ID Assigned autorratically
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 Tick Creek
Waterbody* %neof waterbody into which storrrwater runoff will discharge
15b. Waterbody 17-43-13
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 * KCI Environmental Technologies and Construction 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 * Timothy
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Morris
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Senior Associate
4. Permitee E-mail [e-mail]
Address*
5. Permittee 9197936886
Telephone No.*
6. Permittee Mailing Street Address
Address* 4505 Falls of Neuse Road, Suite 400
Address Line 2
City
Raleigh
Fbstal / Zip Code
27609-2512
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*
4505 Falls of Neuse Road, Suite 400
Address Line 2
city
State / Frovince / Faegion
Raleigh
NC
Fbstal / Zip Code
Country
27609-2512
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
Timothy
Contact - First
Name *
2. Primary Site
Morris
Contact - Last
Name *
3. Title
Senior Associate
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
9197936886
Telephone No.*
6. Organization
KCI Environmental Technologies and
Name
Construction Inc.
7. Site Contact
Street Address
Mailing Address*
4505 Falls of Neuse Road
Address Line 2
Suite 400
Oty
State / Rovince / Region
Raleigh
NC
Fbstal / Zip Code
Country
27609-2512
us
8. Consultant Name
(Optional)
Adam Spiller
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-475-3696
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 06/12/2020
Approved *
2. E&SC Plan Project CHATF-1-2020-013
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 Land Quality Permit.pdf
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 201VB)
276.38KB
HipBoneCreek Fig01_Vicinity_Map_v2.pdf 1.14MB
Rease do not upload entire set of E&SC plans.
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 NCG01 NOI Form.pdf 50.87KB
Form Wst be RDFforrret
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:* 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
Type Name* Timothy J. Morris
Title Senior Associate
Organization Legally Plesponsible Entity
KCI Environmental Technologies and Construction Inc.
Date * 12/02/2020

F. Tracking and COC Info
NOI Tracking No. 37929
NC Reference No.
NCG01-2020-5575
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205575
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5575
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. NCC205575-2020
Invoice Due Date 1/2/2021
Initial Fee $ 100.00
Invoice Status OPEN