NCC210048_NOI Application_20210107

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/4/2021 9:29:55 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 1/5/2021 2:11:39 PM (Review- Construction NOI 40310)
• The task was assigned to Garcia, Lauren V by round robin distribution 1/4/2021 9:30 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 6, 2021 5:00
PM 1/4/2021 9:30 AM
Submit by Selkane, Aziza 1/7/2021 12:39:21 PM (Payment Verification for NCC210048)
* Elizabeth Scheer
• Selkane, Aziza assigned the task to Selkane, Aziza 1/7/2021 12:38 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 16, 2021 5:00
PM 1/5/2021 2:11 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 39943
NOI No.
Prior Reviewer Not Sure or Not Listed
Name
1a. Project Name * Long Creek Village
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
71-76, 111-115
1 c. Parcel ID
List all R% associated w ith this project.
Number(s) (PIN)
6809-84-6588.000
6809-84-7578.000
6809-84-9528.000
6809-94-0507.000
6809-84-4332.000
6809-84-3269.000
6809-84-2287.000
6809-84-1286.000
6809-84-1207.000
2. County*
Forsyth
3. Highway or Street 5704, 5712, 5713, 5726, 5734, 5724, 5683, 5677, 5671, 5665
Address* Beaver Pond Trail
Street name only is acceptable if no address number assigned yet
4. City or Township* City of Winston-Salem
5. State * NC
6. Zip Code* 27040
7. Latitude* Enter the latitude in decimal degrees
36.2007
8. Longitude * Enter the longitude in decimal degrees (NALSTbe negative)
-80.3262
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*
12/31/2020
Estimated Construction Roject Start Rate
10. Date to End*
12/31 /2021
Estirrated Construction Project End Cate
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Developrnent
12. Acres to be
1.62
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.62
(acres) *
14. Post- 0.00
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-FORSY-2020-1-ong Creek Village
Tracking ID Assignedautorraticaly
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 Muddy Creek
Wate rbody* %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-94-(0.5)
Index No.* NCWaterbody Index Number
Stormwater rJ 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 * Glenwood Homes 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 * Tom
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Quackenbush
IF Corporation, enter Pbegistered Agent Last %rre
3b. Title Elizabeth Scheer
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-741-7993
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box90427
Address Line 2
City State / Ffovince / Fbgion
Raleigh North Carolina
Fbstal / Zip Code Country
27675 United States
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
9220 Fairbanks Drive
Address Line 2
Ste 102
City
State / F rovince / Region
27
North Carolina
Fbstal / Zip Code
Country
27613
United States
8. Type of
ONnership 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
Tom
Contact - First
Name *
2. Primary Site
Quackenbush
Contact - Last
Name *
3. Title
Managing Member
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-741-7993
Telephone No.*
6. Organization
Glenwood Homes LLC
Name
7. Site Contact
Street Address
Mailing Address*
PO Box90427
Address Line 2
City
State / Rovince / Region
Raleigh
North Carolina
Fbstal / Zip Code
Country
27675
United States
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
[e-mail]
Defauft is legally responsible person a-rrail (older NOIs may not populate)
12. Billing (For Annual Fee correspondence)
Telephone [phone]
Defauft 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 12/28/2020
Approved *
2. E&SC Plan Project EN2000208
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Winston-Salem/Forsyth County
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. Please also upload a site map showing the overall extent of the project (for linear projects, can
include the beginning point and end point coordinates in the "Notes" box below).
5. E&SC Plan erosion control approval email.pdf 54.79KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map NUst be RDFforrret (lint 201VB)
2020-22-EC PLAN 71-76-20201223 - approved.pdf 82.25KB
2020-22-EC PLAN 111-115-20201223 -
76.3KB
approved.pdf
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 if necessary.
I was told by Erosion Control department in Forsyth County that the
email of the approval would suffice for these purposes because
they will not upload my permit card until I get the COC from your
Department uploaded to their portal.
8. NOI Certification NOI Certification form.pdf 91.09KB
Form Mist be RDF formal
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
Type Name* Tom Quackenbush
Title Managing Member
Organization Legally Ibsponsible Entity
Glenwood Homes LLC
Date * 01 /04/2021

F. Tracking and COC Info
NOI Tracking No. 40310
NC Reference No.
NCG01-2021-0048
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC210048
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 48
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2021
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC210048-2021
Invoice Due Date 2/4/2021
Initial Fee $ 100.00
Invoice Status OPEN