NCC200368_Notice of Termination_20210105

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/5/2021 11:03:55 AM (NOT Submittal)
Approve by Morman, Alaina 1/6/2021 1:04:17 PM (NOT Request Review- NCC200368)
• The task was assigned to Morman, Alaina. The due date is: January 8, 2021 5:00 PM
1 /5/2021 11:04 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200368
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
K/hy be blank (if not yet billed).
Information associated
with this permit:
Project Name
The Gables at Bridgton Place Sec VII
Address
Mariners Drive, Winston Salem, NC
County
Forsyth
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
Wellspring Carolina Investments, LLC
Legally Responsible
Mark Boyce
Individual
NC Reference No.
NCG01-2020-0368
E&SC Plan ID
EN1900156
Original NOI
21204
Tracking No.
Date COC Issued
1/30/2020
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
F Sale (Another Owner/Operator will apply for a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other
Addional IVbre information about the basis of this request, if needed.
Explanation

Supporting upload Supporting Documentation if applicable.
Documentation FC ROD DB3508-PG3161.pdf
Mast be FDFformat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mast beFDFforrrat
Approval
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
163.36KB
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Artide or a rule implementing this Artide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Artide or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
fJ I, as an authorized representative, hereby request rescission of coverage under
the NPDES Stormwater Permit for the subject facility. I am familiar with the
information contained in this request and to the best of my knowledge and
belief such information is true, complete and accurate.
*This form must be signed by a responsible corporate officer that 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
'-w '"
Type Name* Mark Boyce
Title * Member -Manager
Organization* Wellspring Carolina Investments, LLC
Date * 01 /05/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7049369624
NOT Certification NCG01-eNOT-Certification-Form-20201215-
Form 893.16KB
DEMLR-SW-executed by Mark Boyce.pdf
Mast be FDF Format
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Emails
(Optional) [e-mail]

Original Permittee CCdonNotificationBmils
Email [e-mail]
Original Site Contact GCd on Notificaiton B-mils
Email [e-mail]