NCC205542_NOI Application_20201230

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/1/2020 10:39:50 AM (NCG01 NOI Submission)
Approve by Gamble, Aana C 12/1/2020 2:49:21 PM (Review- Construction NOI 37799)
• The task was assigned to Gamble, Aana C by round robin distribution 12/1/2020 10:40 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 3, 2020 5:00
PM 12/1/2020 10:40 AM
Submit by McCoy, Suzanne 12/30/2020 2:32:55 PM (Payment Verification for NCC205542)
* Good Stewards V LLC
• McCoy, Suzanne assigned the task to McCoy, Suzanne 12/30/2020 2:31 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 12, 2021 5:00 PM
12/1/2020 2:49 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 *
Providence Glen
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
24-45
1 c. Parcel ID List all RNs associated w ith this project.
Number(s) (PIN)
2. County* Rockingham
3. Highwayor Street Gold Hill Road
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* New Bethel Township
5. State * NC
6. Zip Code* 27025
7. Latitude* Enter the latitude in decimal degrees
36.3189
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.9329
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*
12/15/2020
Estimated Construction Project Start Rate
10. Date to End *
12/15/2021
Estinated Construction Project End Cate
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Development
12. Acres to be
18.50
disturbed*
(including off -site borrow and waste areas)

13. Total site area 58.73
(acres) *
14. Post- 1.80
construction (Estirreted)
impervious area
(acres) *
NCC Project NCC-ROCKI-2020-Providence Glen
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 Brushy Creek
Waterbody* Narreof waterbody into which storrrwater runoff will discharge
15b. Waterbody 22-32-1
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. ^
Fl rnittee 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 * Good Stewards V, 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 * Harry
IF Corporation, enter Faegistered Agent First Wre
3. Last Name* Rakestraw
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title Managing Member
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-932-0890
Telephone No.*
6. Permittee Mailing Street Address
Address* 283 Foch Farm Road
Address Line 2
City
Reidsville
Postal / Zip Code
27320
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
283 Foch Farm Road
Address Line 2
City
Reidsville
Postal / Zip Code
27320
State / Province / Pegion
NC
Country
USA
State / Province / Faegion
NC
Country
USA
8. Type of Ojvnership 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
Harry
Contact - First
Name *
2. Primary Site
Rakestraw
Contact - Last
Name *
3. Title
Managing Member
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-932-0890
Telephone No.*
6. Organization
Good Strewards V, LLC
Name
7. Site Contact
Street Address
Mailing Address*
283 Foch Farm Road
Address Line 2
City
State / Rovince / Region
Reidsville
NC
Fbstal / Zip Code
Country
27320-9355
us
8. Consultant Name
(Optional)
Stoltzfus Engineering, Inc. Bruce Nooe, PE
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-904-0207
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
Default is legally responsible person e-n-ail (older NCAs rray not populate)
12. Billing (For Annual Fee correspondence)
Telephone Default is legally responsible person telephone (older NCls rray not populate)

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 11/25/2020
Approved *
2. E&SC Plan Project ROCKI-2021-010
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 ROCKI-2021-010_20201125_Approval.pdf 4.88MB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 20 NB)
C1.pdf 1.39MB
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 if necessary.
8. NOI Certification eNO1-ROCKI-2021-010.pdf 1.91VIB
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* Harry Rakestraw
Title Managing Member
Organization Legally Responsible Entity
Good Stewards V, LLC
Date * 12/01 /2020

F. Tracking and COC Info
NOI Tracking No. 37799
NC Reference No.
NCG01-2020-5542
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205542
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5542
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. NCC205542-2020
Invoice Due Date 12/31/2020
Initial Fee $ 100.00
Invoice Status OPEN