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HomeMy WebLinkAboutNCC213902_NOI Application_20210701Action History (UTC-05:00) Eastern Time (US & Canada) Subrrit by Anonymous User 6/30/2021 11:23:44 AM (NCG01 NOI Submission) Approve by Broussard, Brooklyn C 6/30/2021 11:27:52 AM (Review- Construction NOI 58007) • The task was assigned to Broussard, Brooklyn C by round robin distribution 6/30/2021 11:24 AM The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: July 2, 2021 5:00 PM. The priority is: High 6/30/2021 11:24 AM Submit by Selkane, Aziza 7/1/2021 12:54:46 PM (Payment Verification for NCC213902) * Bruce Sekaly • Selkane, Aziza assigned the task to Selkane, Aziza 7/1/2021 12:54 PM The task was assigned to DEMLR NCG01 Payment Team. The due date is: August 11, 2021 5:00 PM. The priority is: High 6/30/2021 11:28 AM .• SThF� '; 1 NORTH CAROLINA EnrlronmertW quallly A. Project Information Part A. Project Location and Waterbody Information Are you submitting IT No an NOI that was r Yes rejected before? 1a. Project Name * Rhodes Pond Dam Repair 1 b. Specific Lot This field any be used to list specifc lot numbers. Numbers n/a 1 c. Parcel ID List all Rios associated w ith this project. Number(s) (PIN) 1504-31-3233, 1503-27-9048, 1503-27-5539 2. County* Cumberland 3. Highway or Street 11037 Dunn Rd. Address* Street name only is acceptable if no address number assigned yet 4.CityorTownship* Godwin 5. State * NC 6. Zip Code* 28344 7. Latitude* Enter the latitude in decimal degrees 35.2278 8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative) -78.6479 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* 06/21/2021 Estimated Construction Project Start Late 10. Date to End* 06/21/2022 Estinated Construction Project End Date 11. SIC (Primary) * Other (9999) Standard Industrial C]assification for Development 12. Acres to be 4.99 disturbed* (including off -site borrow and waste areas) 13. Total site area 459.24 (acres) * 14. Post- 0.50 construction (Estirreted) impervious area (acres) * NCC Project NCC-CUMBE-2021-Rhodes Pond Dam Repair Tracking ID Assigned autorratically 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 Black River Waterbody* Narreof waterbody into which storrrwater runoff will discharge 15b. Waterbody 18-68-12-1 Index No. * NCWaterbody Index Nurrber 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. ^ F2rnittee 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 * NC Wildlife Resources Commission 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 * Gary IF Corporation, enter Faegistered Agent First %rre 3. Last Name* Gardner IF Corporation, enter F;bgistered Agent Last %rre 3b. Title Section Chief 4. Permitee E-mail gary.gardner@ncvvildlife.org Address* 5. Permittee 919-707-4091 Telephone No.* 6. Permittee Mailing Street Address Address* 1720 Mail Service Dr. Address Line 2 City Raleigh Fbstal / Zip Code 27699 Check box if the F Yes street address the same as mailing address State / Frovince / Fbgion NC Country us 7. Permittee Street Street Address Address* 1751 Varsity Drive Address Line 2 City State / Frovince / Faegion Raleigh NC Fbstal / Zip Code Country 27606 us 8. Type of Ownership is only individual if an individual is naned in B.1. above. Ownership* Government - State C. Site Contact Information Part C. Roject Site Contact Inforrration .................................................................................................................................................................................................... 1. Primary Site Randall Contact - First Name * 2. Primary Site Chilton Contact - Last Name * 3. Title Project Superintendent 4. Site Contact E- randall@segserv.com mail Address* 5. Site Contact 336 202 2289 Telephone No. 6. Organization Sequoia Services, LLC Name 7. Site Contact Street Address Mailing Address* 7815 National Service Rd. Address Line 2 Suite 606 city Greensboro Postal / Zip Code 27409 8. Consultant Name (Optional) Dori Sabeh, PE, GISP First and Last narre 9. Consultant E-mail dori.sabeh@mcgillassociates.com This person will be copied on all correspondence. 10. Consultant 919 364 3989 Telephone No. 11. Billing E-mail (For Annual Fee correspondence) bruce@segserv.com Default is legally responsible person e-rrail 12. Billing (For Annual Fee correspondence) Telephone 336-906-0022 Default is legally responsible person telephone State / Rovince / Region NC Country USA D. E&SC Plan Part D. ^ Erosion & Sediment Control (E&SC) Ran Approval Information ...................................................................................................................................................................................................................................................................................................................................... 1. Date E&SC Plan 05/15/2020 Approved * 2. E&SC Plan Project CUMBE-2020-159 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 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 cumbe-2020-159mod.pdf 102.34KB Approval letter or Mist beRDFformat Grading Permit 6. Site Location Map Mist be RDFforrret (lint 20 NB) Site Location Map.pdf 596.23KB 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 NCG01_eNO1_Certification Formsigned.pdf 320.22KB Form Must be RDFformat 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:* r 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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of that permit. Signature C_;!T�'/C� ¢r' �/''t Type Name* Gary Gardner Title Section Chief Organization Legally Responsible Entity NC Wildlife Resources Commission Date * 06/30/2021 F. Tracking and COC Info NOI Tracking No. 58007 NC Reference No. NCG01-2021-3902 Uses 'count_nurber' variable (increrrented by SP) Certificate of NCC213902 Coverage (COC) Uses 'count_nurrber' variable (increrrented by SP) No.* Count Number 3902 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. NCC213902-2021 Invoice Due Date 7/30/2021 Initial Fee $ 100.00 Invoice Status OPEN