NCC214733_NOI Application_20210824

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/18/2021 12:19:26 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 8/19/2021 7:16:29 AM (Review- Construction NOI 62435)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 8/18/2021 12:20 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 20, 2021 5:00
PM 8/18/2021 12:20 PM
Submit by Miller, Ariyelle L 8/24/2021 9:50:42 AM (Payment Verification for NCC214733)
* Public Works 3
• Miller, Ariyelle L assigned the task to Miller, Ariyelle L 8/24/2021 9:49 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 30, 2021 5:00
PM 8/19/2021 7:16 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 62368
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name * FY20 Short Water Line Extensions Project PhA
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) Foxwood Lane/Deerwwod Court: 06180087, 06180088, 06180092, 06180091,
06180090, 06180098, 06180094, 06180097
Newtown Road: 06156008F, 06156008K
Winding Lane: 06042067,06042068
Black Oak Lane: 6054115, 6054117, 6054118, 6054119, 6054121, 6054123,
6054126
Turtle Wood Drive; 6054127
Stirrup Court: 06147038, 06147044, 06147046, 06147042, 06147045, 06147039,
06147043
Horseshoe Bend:06120135
Rockridge Pass: 06120075A, 06120095
Greenbrook Parkway: 06120062, 06120061
Gatewood Lane: 06096059
2. County* Union
3. Highway or Street Various locations, see site map attached
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Indian Trail
5. State * NC
6. Zip Code* 28112
7. Latitude* Enter the latitude in decimal degrees
35.0300

8. Longitude * Enter the longitude in decirral degrees (M-STbe negative)
-80.6880
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*
08/23/2021
Estimated Construction Project Start Rate
10. Date to End *
04/04/2022
Estimated Construction Project End Cate
11. SIC (Primary) *
Other (9999)
Standard Industrial aassification for Developrnent
12. Acres to be
4.89
disturbed*
(including off -site borrow and waste areas)
13. Total site area 4.89
(acres) *
14. Post- 0.00
construction (Estirrated)
impervious area
(acres) *
Project Tracking ID NCC-UNION-2021-FY20 Short Water Line Extensions Project PhA
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 McBride Branch
Waterbody* Ibrre of w aterbody into w hich storrrw ater runoff w ill discharge
15b. Waterbody 11-138-3-3
Index No.* NCWaterbody Index Number
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional Little Twelvemile Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 11-138-2-3
Index No. NCWaterbody Index Number
15e. Additional Sixmile Creek
Receiving Waterbody narre
Waterbody
15f. Waterbody 11-138-3
Index No. NCWaterbody Index Number

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 * Union County
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 * Thomas
If Corporation, enter Faegistered Agent First Wre
3. Last Name* Mann
It Corporation, enter F;bgistered Agent Last %rre
3b. Title CIP Program Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-292-2560
Telephone No.*
6. Permittee Mailing Street Address
Address* 500 N. Main St.
Address Line 2
Suite 600
aty
Monroe
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
Fbstal / Zip Code
28112
F Yes
Street Address
500 N. Main St.
Address Line 2
Suite 600
city
Monroe
Fbstal / Zip Code
28112
State / Ffovince / Fbgion
NC
Country
USA
State / Ftovince / Region
NC
Country
USA
8. Type of Ownership is only individual if an individual is naned in B.1. above.
Ownership* Government - County

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Neal
Contact - First
Name *
2. Primary Site
Gaston
Contact - Last
Name *
3. Title
Construction manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
704-363-9168
Telephone No.
6. Organization
Union County Public Works
Name
7. Site Contact
Street Address
Mailing Address*
500 N. Main Street
Address Line 2
Suite 600
city
Monroe
Fbstal / Zip Code
28112
8. Consultant Name
(Optional)
Jake Berkshire
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
704-227-3419
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
704-292-2560
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 02/18/2021
Approved *
2. E&SC Plan Project UNION-2021-041
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 * Mooresville (MRO)
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 2021-02-18 NCDEQ Approval.pdf 164.51 KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 201VB)
FY20 PhA Site Location Map.pdf 1.08MB
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 20210816 NCG01-eNO1-Certification- Form- FY20
Form 820.3KB
Phase 4.pdf
Mast be FDFfon-rat
This is an Express r 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
Type Name* Thomas R Mann
Title CIP Program Manager
Organization Legally Responsible Entity
Union County
Date * 08/18/2021

F. Tracking and COC Info
NOI Tracking No. 62435
NC Reference No.
NCG01-2021-4733
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC214733
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 4733
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. NCC214733-2021
Invoice Due Date 9/18/2021
Initial Fee $ 100.00
Invoice Status OPEN