NCC213403_NOI Application_20210604

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/3/2021 8:20:48 AM (NCG01 NOI Submission)
Approve by EADS\bcbroussard 6/3/2021 11:21:44 AM (Review- Construction NOI 54691)
. The task was assigned to EADS\bcbroussard by round robin distribution 6/3/2021 8:21 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 7, 2021 5:00 PM.
The priority is: High 6/3/2021 8:21 AM
Submit by Selkane, Aziza 6/4/2021 10:12:06 AM (Payment Verification for NCC213403)
* James Lester Collins
• Selkane, Aziza assigned the task to Selkane, Aziza 6/4/2021 10:11 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 15, 2021 5:00 PM. The
priority is: High 6/3/2021 11:22 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 54508
NOI No.
Prior Reviewer Michael Meloy
Name
1a. Project Name * Shamrock Valley Phase 4
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) 8873328657, 8873239224, 8873239224
2. County* Alamance
3. Highway or Street Kaney Drive, Whelen Street
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Graham
5. State * NC
6. Zip Code* 27253
7. Latitude* Enter the latitude in decimal degrees
36.0363
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.4281
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* 07/01/2021
Estimated Construction Project Start Date
10. Date to End* 07/01/2022
Estinated Construction Project End Date

11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Development
12. Acres to be 11.00
disturbed* (including off -site borrow and waste areas)
13. Total site area 60.36
(acres) *
14. Post- 3.10
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-ALAMA-2021-Shamrock Valley Phase 4
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 Little Alamance Creek
Waterbody* %rreof waterbody into which stormwater runoff will discharge
15b. Waterbody 16-19-11
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. ^
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 Pesponsible Entity
Name * Concept Builders, Incorporated
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 * James
IF Corporation, enter Faegistered Agent First Wre
3. Last Name* Collins
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-228-0490
Telephone No.*
6. Permittee Mailing Street Address
Address* 236 North Mebane Street
Address Line 2
City
Burlington
Fbstal / Zip Code
27217-3966
Check box if the V Yes
street address the
same as mailing
address
State / Frovince / Fbgion
NC
Country
us
7. Permittee Street
Street Address
Address*
236 North Mebane Street
Address Line 2
City
State / Frovince / Faegion
Burlington
NC
Fbstal / Zip Code
Country
27217-3966
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
James
Contact - First
Name *
2. Primary Site
Collins
Contact - Last
Name *
3. Title
President
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-228-0490
Telephone No.
6. Organization
Concept Builders, Incorporated
Name
7. Site Contact
Street Address
Mailing Address*
236 North Mebane Street
Address Line 2
city
Burlington
Fbstal / Zip Code
27217-3966
8. Consultant Name
(Optional)
Ravindra Bissram
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-544-6426
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
336-228-0490
Default is legally responsible person telephone
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 05/19/2021
Approved *
2. E&SC Plan Project ALAMA-2021-053
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. 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 ALAMA-2021-053_20210519_Approval_Express.pdf 4.37MB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 20 NB)
Vici n ity. pdf 208.19KB
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 Certification-signed.pdf 366.5KB
Form Wst be RDF format
This is an Express f 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�11111V tt c1
Type Name * James Collins
Title President
Organization Legally Plesponsible Entity
Concept Builders, Incorporated
Date * 06/03/2021

F. Tracking and COC Info
NOI Tracking No. 54691
NC Reference No.
NCG01-2021-3403
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC213403
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3403
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. NCC213403-2021
Invoice Due Date 7/3/2021
Initial Fee $ 100.00
Invoice Status OPEN