NCC214788_NOI Application_20210910

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/20/2021 9:55:56 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 8/20/2021 10:08:29 AM (Review- Construction NOI 62619)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 8/20/2021 9:56 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 24, 2021 5:00
PM. The priority is: High 8/20/2021 9:56 AM
Submit by Selkane, Aziza 9/10/2021 10:22:49 AM (Payment Verification for NCC214788)
* Preston Bell
• Selkane, Aziza assigned the task to Selkane, Aziza 9/10/2021 10:21 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 1, 2021 5:00 PM.
The priority is: High 8/20/2021 10:08 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 62612
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name * Randy Marion Chrysler/Dodge/Jeep/Ram
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers n/a
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 3848815771, 3848900991
2. County* Wilkes
3. Highway or Street 2000 US-421
Address* Street name only is acceptable if no address nunber assigned yet
4. City or Township* Wilkesboro
5. State * NC
6. Zip Code* 28697
7. Latitude* Enter the latitude in decimal degrees
36.1515
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-81.2042
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 Date
10. Date to End * 08/26/2022
Estimated Construction Project End Cate

11. SIC (Primary)* Commercial (1542)
Standard Industrial Classification for Development
12. Acres to be 25.04
disturbed* (including off -site borrow and waste areas)
13. Total site area 25.83
(acres) *
14. Post- 6.00
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-WILKE-2021-Randy Marion Chrysler/Dodge/Jeep/Ram
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 Millers Creek
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 12-36
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.
Fbrnittee 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 must 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. Permittee * Legally Pesponsible Entity
G.L. Wilson Building Company, Inc.
IF pernittee is an individual, enter first and last narre in this field. Otherwise, enter organization/business narre.
Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the
registration here.
2. First Name * Thomas L.
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Wilson
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-872-2411
Telephone No.*
6. Permittee Mailing Street Address
Address* 190 Wilson Park Rd
Address Line 2
City
Statesville
Fbstal / Zip Code
28625
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
190 Wilson Park Rd
Address Line 2
city
Statesville
Fbstal / Zip Code
28625
State / Frovince / Fbgion
NC
Country
United States
State / Frovince / Faegion
NC
Country
United States
8. Type of Ownership 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
Robert
Contact - First
Name *
2. Primary Site
Palmes
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
704-903-3180
Telephone No.
6. Organization
G.L. Wilson Building Company, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
190 Wilson Park Rd
Address Line 2
28625-8506
city
Statesville
Postal / Zip Code
28625
8. Consultant Name
(Optional)
Scott Bell
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
7048800143
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
704-872-2411
Default is legally responsible person telephone
State / Rovince / Region
NC
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 08/19/2021
Approved *
2. E&SC Plan Project Wilke-2022-002
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 LoA-M WILKE-2022-002_20210819_Express.pdf 220.54KB
Approval letter or Mast beRDFformat
Grading Permit
6. Signed FRO Financial Pesponsibility/Ownership Form
Mast be RDFfornat
7. Site Location Map Mast be RDFforrret (lint 201VB)
vici n ity. pdf 89.62KB
Rease do not upload entire set of E&SC plans.
8. Notes (Optional) Provide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
9. NOI Certification 2020-046 NCG01-eNOI-Certification-Form-
Form 522.04KB
20210514-DEMLR-SW. pdf
Mast 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:* 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
1 rr.IW" r e 11�K11OA!
Type Name* Thomas L. Wilson
Title President
Organization Legally Responsible Entity
G. L. Wilson Building Company Inc
Date * 08/20/2021

F. Tracking and COC Info
NOI Tracking No. 62619
NC Reference No.
NCG01-2021-4788
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC214788
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 4788
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. NCC214788-2021
Invoice Due Date 9/19/2021
Initial Fee $ 100.00
Invoice Status OPEN