NCC214548_NOI Application_20210811

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 8/9/2021 2:34:22 PM(NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 8/10/2021 7:49:15 AM(Review-Construction NOI 61724)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 8/9/2021 2:36 PM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:August 11,2021 5:00
PM 8/9/2021 2:36 PM
Submit by McCoy, Suzanne 8/11/2021 8:06:45 AM(Payment Verification for NCC214548)
* Teramore Development
• McCoy,Suzanne assigned the task to McCoy, Suzanne 8/11/2021 8:06 AM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is: September 21,2021 5:00
PM 8/10/2021 7:50 AM

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1Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Eliminatio em 'D application for•• - .•-under NorthCarolina's
General Permit 1 1111:STORIVWATER DISCHARGES associated with construction acti\Aties(or
NORTH CAROLINA
Enrlrnnmenfu�Qr�arlry
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting f•No
an NOI that was r Yes
rejected before?
1a. Project Name* Dollar General- Pilot Mountain
1 b.Specific Lot This field may be used to list specifc lot numbers.
Numbers
1 c. Parcel ID List all Rios associated w ith this project.
Number(s)(PIN) 5957-04-71-6052
2. County* Surry
3. Highway or Street Cooks School Road
Address* Street name only is acceptable if no address number assigned yet
4.City or Township* Pilot Mountain
5. State* NC
6.Zip Code* 27041
7. Latitude* Enter the latitude in decimal degrees
36.4068
8. Longitude* Enter the longitude in decinal degrees(MJSTbe negative)
-80.5009
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* 11/22/2021
Estimated Construction Project Start Rate
10. Date to End* 04/21/2022
Estimated Construction Project End Date
11.SIC(Primary)* Commercial(1542)
Standard Industrial aassification for Development
12.Acres to be 2.15
disturbed* (including off-site borrow and waste areas)

13.Total site area 3.00
(acres)*
14. Post- 0.77
construction (Estimated)
impervious area
(acres)*
Project Tracking ID NCC-SURRY-2021-Dollar General-Pilot Mountain
Assigned automatically(not used)
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 Toms Creek
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b.Waterbody 12-72-14-(4)
Index No.* NCWaterbody Index Narrber
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. ^
Fternittee 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* Teramore Construction, LLC
It 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* Zach
If Corporation,enter Faegistered Agent First Wre
3. Last Name* Crumley
It Corporation,enter F;bgistered Agent Last%rre
3b.Title Senior Vice President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 229-516-4289
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box6460
Address Line 2
City State/Rovince/Fbgion
Thomasville GA
Fbstal/Zip Code Country
31758 USA
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 165 Big Star Drive
Address Line 2
City State/Frovince/Fbgion
Thomasville GA
Fbstal/Zip Code Country
31757-7708 US
8.Type of Ojvnership 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 Mark
Contact-First
Name*
2. Primary Site Zeiner
Contact-Last
Name*
3.Title
4.Site Contact E- [e-mail]
mail Address*
5.Site Contact 267-261-6972
Telephone No.*
6.Organization Teramore Construction, LLC
Name
7.Site Contact Street Address
Mailing Address* PO Box6460
Address Line 2
City State/Rovince/Region
Thomasville GA
Fbstal/Zip Code Country
31758 USA
8. Consultant Name (Optional)
Jennifer Edwards
First and Last nacre
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 336-844-4088
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 [phone]
Default is legally responsible person telephone

D. E&SC Plan
Part D. ^
Erosion&Sediment Control(E&SC)Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 08/05/2021
Approved*
2. E&SC Plan Project SURRY-2022-006
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 APPROVED_ESC_PERMIT.pdf 5.44MB
Approval letter or Mast beRDFfornat
Grading Permit
6.Site Location Map Wst be RDFfornat(linit 20 NB)
VICINITY_MAP.pdf 20.05KB
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 NOI_CERTIFICATION_FORM.pdf 2.45MB
Form Wst be RDFfornat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66(1) provides that:
Anyperson who knowinglymakes any false statement,representation,or certification in anyapplication,record,report,plan,or other
documentfiled 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 underthis 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 guiltyofa Class 2 misdemeanor which mayinclude 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
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* Zach Crumley
Title Senior Vice President
Organization Legally Pesponsible Entity
Teramore Construction, LLC
Date* 08/09/2021

F. Tracking and COC Info
NOI Tracking No. 61724
NC Reference No. NCG01-2021-4548
Uses'count_nurrber'variable(increrrented by SP)
Certificate of NCC214548
Coverage (COC) Uses'count_nurrber'variable(increrrented by SP)
No.*
Count Number 4548
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. NCC214548-2021
Invoice Due Date 9/9/2021
Initial Fee $ 100.00
Invoice Status OPEN