NCC212528_NOI Application_20210427

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/26/2021 9:30:19 AM (NCG01 NOI Submission)
Approve by Meloy, Michael K 4/26/2021 10:52:06 AM (Review- Construction NOI 50992)
• Gamble, Aana C reassigned the task to Meloy, Michael K 4/26/2021 9:49 AM
• The task was assigned to Gamble, Aana C by round robin distribution 4/26/2021 9:30 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 28, 2021 5:00 PM.
The priority is: High 4/26/2021 9:30 AM
Submit by Selkane, Aziza 4/27/2021 11:01:34 AM (Payment Verification for NCC212528)
* Matthew Bare
• Selkane, Aziza assigned the task to Selkane, Aziza 4/27/2021 11:00 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: June 7, 2021 5:00 PM. The
priority is: High 4/26/2021 10:52 AM

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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 50835
NOI No.
Prior Reviewer Michael Meloy
Name
1a. Project Name * PNG - Dixie River Extension Open Cut
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 14117101
2. County* Mecklenburg
3. Highway or Street Dixie River Road
Address* Street name only is acceptable if no address nunber assigned yet
4. CityorTownship* Charlotte
5. State * NC
6. Zip Code* 28278
7. Latitude* Enter the latitude in decinal degrees
35.1725
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-80.9858
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* 05/03/2021
Estimated Construction Project Start late
10. Date to End * 06/30/2021
Estinated Construction Project End late

11. SIC (Primary)* Other (9999)
Standard Industrial aasslfication for Development
12. Acres to be 3.20
disturbed* (including off -site borrow and waste areas)
13. Total site area 3.20
(acres) *
14. Post- 0.00
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-MECKL-2021-PNG - Dixie River Extension Open Cut
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 Beaverdam Creek
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 11-126
Index No. * NCWaterbody Index Nurrber
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional Legion Lake and Shoaf Lake
Receiving Waterbody narre
Waterbody
15d. Waterbody 11-126-1
Index No. NCWaterbody Index Nunber
15e. Additional Waterbody name
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Nurrber
Index No.
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 %sponsible Entity
Name * Piedmont Natural Gas Company, Inc.
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 * Corey
IF Corporation, enter Faegistered Agent First Wre
3. Last Name* Dillard
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title Supervisor - Field Operations
4. Permitee E-mail Corey. [e-mail]
Address*
5. Permittee 704.249.5714
Telephone No.*
6. Permittee Mailing Street Address
Address* 4301 Yancey Road
Address Line 2
City
Charlotte
Fbstal / Zip Code
28217
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
4301 Yancey Road
Address Line 2
city
Charlotte
Fbstal / Zip Code
28217
State / Frovince / Fbgion
NC
Country
USA
State / Frovince / Faegion
NC
Country
USA
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
Khalid
Contact - First
Name *
2. Primary Site
Boston
Contact - Last
Name *
3. Title
Distribution Project Specialist
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
704.587.6941
Telephone No.
6. Organization
Piedmont Natural Gas Company, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
4301 Yancey Road
Address Line 2
city
Charlotte
Fbstal / Zip Code
28217
8. Consultant Name
(Optional)
Matthew Bare
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
3364080571
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
704.249.5714
Default is legally responsible person telephone
State / Rovince / Region
North Carolina
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 02/19/2021
Approved *
2. E&SC Plan Project MECKL-2019-027
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 * Mooresville (MRO)
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 0227 PNG Dixie River EC Approval MECKL-
Approval letter or 1.42MB
2019-027.pdf
Grading Permit
Mist be FL7Fforrrat
6. Site Location Map Mist be RDFforrret (lint 201VB)
Location Map.pdf 196.28KB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Provide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
8. NOI Certification NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form SW.pdf 721.38KB
Mast be R7Ffon-rat
This is an Express f No
Review Project* F 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
Type Name * Corey Dillard
Title Supervisor Field Operations
Organization Legally Responsible Entity
Piedmont Natural Gas Company, Inc.
Date * 04/26/2021

F. Tracking and COC Info
NOI Tracking No. 50992
NC Reference No.
NCG01-2021-2528
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC212528
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 2528
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. NCC212528-2021
Invoice Due Date 5/26/2021
Initial Fee $ 100.00
Invoice Status OPEN