NCC210561_NOI Application_20210201

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/28/2021 8:52:39 AM (NCG01 NOI Submission)
Approve by Clark, Paul 1/28/2021 3:15:36 PM (Review- Construction NOI 42021)
• Garcia, Lauren V reassigned the task to Clark, Paul 1/28/2021 11:28 AM
. The task was assigned to Garcia, Lauren V by round robin distribution 1/28/2021 8:53 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 1, 2021 5:00
PM 1/28/2021 8:53 AM
Submit by Selkane, Aziza 2/1/2021 1:53:20 PM (Payment Verification for NCC210561)
* Century Complete
• Selkane, Aziza assigned the task to Selkane, Aziza 2/1/2021 1:52 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 11, 2021 5:00 PM
1/28/2021 3:16 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 41784
NOI No.
Prior Reviewer Paul Clark
Name
1a. Project Name * Williams Grove Phase 1
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 336514-336532
2. County* Nash
3. Highway or Street Intersection of West Homes Church Road and Stoney Hill Church
Address* Road
Street name only is acceptable if no address number assigned yet
4. City or Township* Bailey
5. State * NC
6. Zip Code* 27807
7. Latitude* Enter the latitude in decimal degrees
35.8113
8. Longitude * Enter the longitude in decimal degrees (MBTbe negative)
-78.0579
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* 03/01/2021
Estimated Construction Project Start Date
10. Date to End* 12/31/2021
Estimated Construction Project End Cate

11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Development
12. Acres to be 14.00
disturbed* (including off -site borrow and waste areas)
13. Total site area 58.20
(acres) *
14. Post- 1.20
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-NASH-2021-Williams Grove Phase 1
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 Toisnot Swamp
Waterbody* %rreof waterbody into which stormwater runoff will discharge
15b. Waterbody 27-86-11-(1)
Index No. * NCWaterbody Index Nunber
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. ^
Fbrnittee 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 * WJH LLC
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 * Dave
If Corporation, enter Registered Agent First Wre
3. Last Name* Hodgman
It Corporation, enter F;bgistered Agent Last %rre
3b. Title Regional President
4. Permitee E-mail [e-mail]
Address*
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* 1225 Eastchester Drive
Address Line 2
Suite 107
City
High Point
Fbstal / Zip Code
27265
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
1225 Eastchester Drive
Address Line 2
Suite 107
city
High Point
Fbstal / Zip Code
27265
State / Ffovince / Fbgion
NC
Country
us
State / Frovince / Region
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
Alan
Contact - First
Name *
2. Primary Site
Mooring
Contact - Last
Name *
3. Title
Division Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
[phone]
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
3091 Governors Lake Drive
Address Line 2
Suite 300
city
Norcross
Postal / Zip Code
30071
8. Consultant Name
(Optional)
George Retschle, P.E.
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
[phone]
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person a-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
[phone]
Default is legally responsible person telephone
State / Rovince / Region
GA
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 01/09/2021
Approved *
2. E&SC Plan Project NASH-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 * Raleigh (RRO)
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 2021-01-09 NCDEQ EC Permit - Williams Grove.pdf 266.22KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Wst be RDFforrret (lint 20 NB)
_G0001-Cover- Williams Grove.pdf 397.96KB
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.
8. NOI Certification eNO1 Williams Grove.pdf 67.69KB
Form Wst be RDFforrral
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:* IT 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
0,?1 , ' YW'4?'Wae
Type Name * Dave Hodgman
Title Regional President
Organization Legally Plesponsible Entity
WJH LLC
Date * 01 /28/2021

F. Tracking and COC Info
NOI Tracking No. 42021
NC Reference No. NCG01-2021-0561
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of NCC210561
Coverage (COC) Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 561
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. NCC210561-2021
Invoice Due Date 2/27/2021
Initial Fee $ 100.00
Invoice Status OPEN