NCC215237_NOI Application (Original Copy Recovery)_20210920

NORTH CAROLINA
EltOMFkMomral Qualrly
A. Project Information
Part A.
Proiect Location and Waterbodv Information
Are you submitting G No
an NOI that was r Yes
rejected before?
1 a. Project Name * Ostwalt Amity Area Water System Expansion
1 b. Specific Lot This field may be used to list specifc lot nun-bers.
Numbers N/A
1 c. Parcel ID List all Rids associated with this project.
Number(s) (PIN)* PIN4761-36-7058, PIN4761-44-6978, PIN4761-13-9636, NCDOT Right-of-way
2. County* Iredell
3. Highway or Street Bethesda (SR2359), Ostwalt Amity(SR1001), Overcash(SR2378),
Address* Weathers Creek(SR2379), Shinnville(SR2383), Brawley(SR2382)
Rds.
Street narre only is acceptable if no address nun tier assigned yet
4. Cityor Township* Troutman/Statesville
5. State * NC
6. Zip Code * 28687
7. Latitude* Enter the latitude in decimal degrees
35.7012
8. Longitude* Enter the longitude in decimal degrees (NL&Fbe negative)
-80.8030
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*
11/01/2020
Estimated Construction Project Start Date
10. Date to End*
12/01/2021
Estimated Construction Project End Date
11. SIC (Primary) *
Other (9999)
Standard Industrial Classification for Developrrent
12. Acres to be
36.00
disturbed*
(including off -site borrow and waste areas)
LJ

13. Total site area 36.00
(acres) *
14. Post- 0.50
construction (Estimated)
impervious area
(acres) *
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 Weathers Creek
Wate rbody* Nbrre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-108-21-3-1
Index No.* NCWaterbody Index Nin-ber
Stormwater PF 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?*
Note: Stormwater discharges from construction activities associated with oil and gas exploration, production,
processing, treatment, or transmission facilities are eligible for the exemption from NPDES permit coverage except
in very limited instances. Do not proceed with this application before consulting this EPA fact sheet and verifying a
permit applies.

B. Permittee Information
Part B.
Permittee Information - Legally Responsible 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.
C * Legally Pesponsible Entity
Iredell Water Corporation
IF permittee is an individual, enter first and last narre in this field. Ctherw ise, 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* Keith
IF Corporation, enter Pegistered Agent First Ibrre
3. Last Name* Snoddy
IF Corporation, enter Pegistered Agent Last Ibrre
3b. Title * General Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-876-0672
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box711
Address Line 2
aty
Statesville
Postal / Zip Code
28687
Check box if the Yes
street address the
same as mailing
address
State / Province / REgion
NC
Country
us
7. Permittee Street
Street Address
Address*
571 Jennings Road
Address Line 2
aty
State / Province / Pegion
Statesville
NC
Postal / Zip Code
Country
28625-9505
us
8. Type of
Ownership is only individual if an individual is narrad in 13.1. above.
Ownership*
Non -Government

C. Site Contact information
Part C.
Project Site Contact Information
................................................................................................................................................................................................................................................................................................................................
1. Primary Site Matthew
Contact - First
Name *
2. Primary Site Grant
Contact - Last
Name *
3. Title Resident Project Representative
4. Site Contact E- [e-mail]
mail Address* This person will be copied on all correspondence.
5. Site Contact 704-928-7919
Telephone No.*
6. Organization
Jordan Grant & Associates
Name
7. Site Contact
Street Address
Mailing Address*
2351 Simonton Road
Address Line 2
aty
Statesville
Postal / Zip Code
28625-8246
8. Consultant Name (Optional)
Kyle Pohle (WithersRavenel)
First and Last narre
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 804-426-9984
Telephone No.
11. Billing E-mail* ( For Annual Fee correspondence)
[e-mail]
Wault is legally responsible person e-mail
12. Billing ( For Annual Fee correspondence)
Telephone* 704-876-0672
Wault is legally responsible person telephone
State / Province / Pegion
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
....................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 02/17/2020
Approved *
2. E&SC Plan Project IREDE-2020-064
Number/I D * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. Local Program* Iredell County
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 Approval documentation only! DO NOT upload entire set(s) of E&SCRans
Approval letter or LOA Oswalt Amity Area WSE 2-17-20.pdf 55.94KB
Grading Permit* Mist beFDFformat
6. Signed FRO* Financial Responsibility/Cwnership Form
Signed FRO Form.pdf 54.62KB
Mast be FDFformat
7. Site Location Mast be FDFforrrat (limit 20 IVB)
Map* Location and USGS Exhibits.pdf 14.54MB
Pease do not upload entire set of ESaSC plans.
8. Notes (Optional) Provide any additional information that might help the reviewer better understand how uploaded documents support
the application. Include additional waterbodies if necessary.
9. NOI Certification IWC_Signed NOI Form_09-05-2021.pdf 1.33MB
Form* Mast be FDFforrrat
YOU MUST MAIL THE ORIGINAL SIGNED NOI CERTIFICATION FORM (click on this link) to The Stormwater Program
at the address on the form for the application to fulfill federal application requirements. The Certification Form must be
signed by the person listed in Section B (Permittee Information) or by an authorized responsible person within the same
organization. NOTE: The person who signs the paper form must be the same person to electronically certify
and sign the eNOI.
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in anyapplication, 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 Article; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyof a Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that
* rJ 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.
* rJ I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit, I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* 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 *
Type Name*
Keith A Snoddy
Title *
General Manager
Organization*
Legally Plesponsible Entity
Iredell Water Corporation
Date *
09/16/2021

F. Tracking and COC Info
NOI Tracking No. 64967
NC Reference No.
NCG01-2021-5237
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC215237
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5237
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. NCC215237-2021
Invoice Due Date 10/16/2021
Initial Fee $ 100.00
Invoice Status OPEN