NCC213332_NOI Application_20210621

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/11/20211 1:30:47 PM (NCGO1 NOI Submission)
App— by Clark, Paul B 6/1/2021 4:49:09 PM (Review - Construction NOI 54498)
* The task was assigned to Clark, Paul B by round robin distribution 6/1/2021 1:31 PM
The task was assigned to DEMLR NCGOII NOI Review Team. The due date is: June 3, 2021 5:00 PM
6/11/20211 1:31 PM
Submit by McCoy, Suzanne 6/21/2021 8:28:18 AM (Payment Verification for NCC213332)
p 401 Sand Company LLc
e McCoy, Suzanne assigned the task to McCoy, Suzanne 6/21/2021 8:27 AM
The task was assigned to DEMLR NCGOII Payment Team. The due date is: July 13, 2021 5:00 PM
6/11/20211 4:49 PM

NORTH CAROLINA
ErpirironmertW quailly
A. Project Information
Part A.
Project Location and Waterbody Inforn-ation
Are you submitting
IT No
an N01 that was
r Yes
rejected before?
1 a. Project Name *
401 Sand LCID
1b. Specific Lot
This field any be used to list specifc lot nunbers.
Numbers
N/A
1c. Parcel ID
List all R% associated w ith this project.
Number(s) (PIN)
494460001015
494460001013
2. County
Hoke
3. Highway or Street DocBrownRoad
Address* Street narne only is acceptable if no address nunber assigned yet
4. City or Township* Raeford
5. State * NC
6. Zip Code* 28376
7. Latitude* Enter the latitude in decirnal degrees
35.0388
8. Longitude Enter the longitude in clecirral degrees (K4JST be negative)
-79.1750
If you do not know the latitude and longitude coordinates for this project, you can search the location on this map of
NorthCarolina. Look for the coordinates in the bottom left corner.
9. Date to Begin*
04/12/2021
Estirruted Construction Project Start Date
10. Date to End
09/30/2021
Estirrated Construction Project End Date
11. SIC (Primary)*
Industrial (1541)
Standard Industrial aassif ication for Developrrent
12. Acres to be
5.00
d istu rbe d *
(including off -site borrow and waste areas)

13. Total site area 5.00
(acres) *
14. Post- 0.00
construction (Estin-Bted)
impervious area
(acres) *
NCC Project NCC-HOKE-2021-401 Sand LCID
Tracking ID Assigned autorratically
Below you must enter waterbody information for surface waters affected by this project. Pleaseconsult
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 Beaver Creek
Waterbody* Nbn-e of w aterbody into w hich storrrw ater runoff w ill discharge
15b. Waterbody 1-52-30-(l)
Index No. * NCWaterbody Index I\brrber
Stormwater V No
discharges will flow F- 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.
FbrniUee 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 ovvns 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 NCGO1 0000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1. Organization Legally Pesponsible Entity
Name 401 Sand Company 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 John A.
If Corporation, enter Pbegistered Agent First Wre
3. Last Name* Lindsay
If Corporation, enter F;bgistered Agent Last %rre
3b. Title O\&ner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910 875-2108
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box 122
Address Line 2
City
Raeford
Flostal / Zip Code
28376
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
3029 Fayetteville Road
Address Line 2
city
Raeford
Fbstal / Zip Gode
28376
State / Frovince / Fbgion
NC
Country
us
State / Frovince / Pbegion
NC
Country
us
8. Type of Ojv nership is only individual if an individual is nan-ed in B. 1. above.
Ownership Non -Government

C. Site Contact Information
Part C.
Roject Ste Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
John A.
Contact - First
Name *
2. Primary Site
Lindsay
Contact - Last
Name *
3. Title
Owner
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910 875-2108
Telephone No.
6. Organization
401 Sand Company
Name
7. Site Contact
Street Address
Mailing Address
P.O. Box 122
Address Line 2
city
Raeford
Fbstal / Zip Code
28376
8. Consultant Name
(Optional)
Sean M. McClean PE RWK, PA
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be ccoed on all correspondence.
10. Consultant
919 779-4854
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
910 875-2108
Default is legally responsible person telephone
State / Frovince / Pbegion
NC
Country
us

D. E&SC Plan
Part D.
aosion & Sediment Control (E&SC) Ran Approval Information
........................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 08/13/2020
Approved *
2. E&SC Plan Project HOKE-2021-004
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 * Fayetteville (FRO)
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 shoWng 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 HOKE-2021-004.pdf
Approval letter or Mist be RDF format
Grading Permit
6. Site Location Map Mist be RDF forn-Bt (limit 20 K/B)
Site Vicinity on Quad Sheet.pdf
Rease do not upload entire set of E&SC plans.
46.08KB
709.85KB
7. Notes (Optional) Frovide any additional inf ormation that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
8. NOI Certification NCG011 Notice of Intent (NOI) Certification Form.pdf 453.3KB
Form Must be RDF formal
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.613 (1) provides that:
Any person who knoWngly 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 knoWngly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle shall be guilty of a Class 2 misdemeanor which may include a fine not to e)ceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
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.
PF 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.
I will abide by all conditions of the NCGO10000 General Permit and the
approved Erosion and Sediment Control Plan.
PF I hereby request coverage under the NCGO1 0000 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
r 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 NCGO10000 General Permit. For more
information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature 7�
Type Nanri John A. Lindsay
Title Owner
Organization Legally Plesponsible Entity
401 Sand Compay LLC
Date * 06/01/2021

F. Tracking and COC Info
NOI Tracking No. 54498
NC Reference No.
NCGOl-2021-3332
Uses 'count nurrber' variable (increrrented by SP)
Certificate of
NCC213332
Coverage (COC)
Uses 'count—nun-ber' variable (increrrented by SP)
No. *
Count Number 3332
Sequential nurrber for subrrittal that is incren-ented by Stored Frocedure
COC Year 2021
Yearof clatereviewed (used to assign YY digits after "NOMnODCno.)
Initial Invoice No. NCC213332-2021
Invoice Due Date 7/1/2021
Initial Fee $ 100.00
Invoice Status OPEN