NCC213684_NOI Application_20210621

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/17/2021 12:07:45 PM (NCGO1 NOI Submission)
App— by Broussard, Brooklyn C 6/18/2021 7:17:24 AM (Review - Construction NOI 56713)
* The task was assigned to Broussard, Brooklyn C by round robin distribution 6/17/2021 12:08 PM
The task was assigned to DEMLR NCGO1 NOI Review Team. The due date is: June 21, 2021 5:00 PM
6/17/2021 12:08 PM
Submit by Selkane, Aziza 6/21/2021 8:50:38 AM (Payment Verification for NCC2113684)
p Patrick IN Sizemore
* Selkane, Aziza assigned the task to Selkane, Aziza 6/21/2021 8:49 AM
The task was assigned to DEMLR NCGOII Payment Team. The due date is: July 30, 2021 5:00 PM
6/18/2021 7:17 AM

NORTH CAROLINA
ErpirironmertW quailly
A. Project Information
Part A.
Project Location and Waterbody Inforrnation
Are you submitting IT No
an N01 that was r Yes
rejected before?
1 a. Project Name * B-5765 WO# 31367824 Gumtree DEP Distribution Relocation
1b. Specific Lot This field rray be used to list specif c lot nunbers.
Numbers
1c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) NA (Public Utility Easement)
2. County * Davidson
3. Highway or Street GumtreeRd
Address* Street narre only is acceptable if no address nunber assigned yet
4. Cityor Township* Winston-Salem
5. State * NC
6. Zip Code* 27107
7. Latitude* Enter the latitude in decirral degrees
35.9746
8. Longitude Enter the longitude in clecirral degrees (MJST be negative)
-80.2222
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
Estirrated 0:)nstruction Project Start Date
10. Date to End
12/01/2021
Estirrated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassif ication for Developnent
12. Acres to be
1.40
disturbed*
(including off -site borrow and waste areas)

13. Total site area 1.40
(acres) *
14. Post- 0.00
construction (Estin-Bted)
impervious area
(acres) *
NCC Project NCC-DAVID-2021-B-5765 WO# 31367824 Gumtree DEP
Tracking ID Distribution Relocation
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 Hartman Branch
Waterbody* %rre of w aterbody into w hich storrrw ater runoff w ill discharge
15b. Waterbody 12-94-13-7-1
Index No. * NCWaterbody Index I\brrber
Stormwater r- No
discharges will flow PF Yes
to additional
wate rs *
15c. Additional Little Brushy Fork
Receiving Waterbody narre
Waterbody
15d. Waterbody 12-119-5-3
Index No. NCV\taterbody Index Nin-ber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index I\brrber
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.
Flarnittee Inforrration - Legally Fbsponsible Entity and Individual
..................................... ­­ ................................................................ ­­­­­­­ ....................................................................................................... ...................
Important: The person Who signs the N01 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 Duke Energy Carolinas, 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 Patrick
If Corporation, enter Pbegistered Agent First %rre
3. Last Name* Sizemore
If Corporation, enter Pegistered Agent Last %rre
3b. Title Senior Engineering Technologist
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-917-2522
Telephone No.*
6. Permittee Mailing Street Address
Address* 526 South Church Street
Address Line 2
City
Charlotte
Flostal / Zip Code
28202
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
500 Utility Drive
Address Line 2
city
Clemmons
Fbstal / Zip Gode
27012
State / Frovince / Fbgion
NC
Country
U. S. A.
State / Frovince / F;bgion
NC
Country
U.S.A
8. Type of ON 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
Patrick
Contact - First
Name *
2. Primary Site
Sizemore
Contact - Last
Name *
3. Title
Senior Engineering Technologist
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-917-2522
Telephone No.
6. Organization
Duke Energy Carolinas, LLC
Name
7. Site Contact
Street Address
Mailing Address
500 Utility Drive
Address Line 2
city
Clemmons
Fbstal / Zip Code
27012
8. Consultant Name
(Optional)
Elizabeth Steffens
First and Last nan-e
9. Consultant E-mail
[e-mail]
This person will be colaied on all correspondence.
10. Consultant
984-232-6795
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
336-917-2522
Default is legally responsible person telephone
State / Frovince / F;bgion
NC
Country
U.S.A.

D. E&SC Plan
Part D.
aosion & Sediment Control (E&SC) Ran Approval Information
........................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 06/10/2021
Approved *
2. E&SC Plan Project DAVID-2021-046
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 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 DAVID-2021-046.pdf
Approval letter or Mist be RDF format
Grading Permit
6. Site Location Map Mist be RDF forn-Bt (linit 20 K/B)
314.93KB
Project Location Map.pdf 1.43MB
Rease do not upload entire set of E&SC plans.
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 B-5765 NOI.pdf 91.41 KB
Form Wst be RDF forn-Bt
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
Type Name* Patrick Sizemore
Title Sir Engineering Tech
Organization Legally Plesponsible Entity
Duke Energy
Date * 06/17/2021

F. Tracking and COC Info
NOI Tracking No. 56713
NC Reference No.
NCGOl-2021-3684
Uses 'count nurrber' variable (increrrented by SP)
Certificate of
NCC213684
Coverage (COC)
Uses 'count—nun-ber' variable (increrrented by SP)
No. *
Count Number 3684
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. NCC213684-2021
Invoice Due Date 7/18/2021
Initial Fee $ 100.00
Invoice Status OPEN