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HomeMy WebLinkAboutNCC215493_NOI Application_20211005Action History (UTC-05:00) Eastern Time (US & Canada) Subrrit by Anonymous User 9/30/2021 1:33:44 PM (NCG01 NOI Submission) Approve by Broussard, Brooklyn C 10/4/2021 6:53:40 AM (Review- Construction NOI 67350) • The task was assigned to Broussard, Brooklyn C by round robin distribution 9/30/2021 1:35 PM The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 4, 2021 5:00 PM 9/30/2021 1:35 PM Submit by Evans, Shaundra M 10/5/2021 7:52:56 AM (Payment Verification for NCC215493) * Teramore Development • Evans, Shaundra M assigned the task to Evans, Shaundra M 10/5/2021 7:52 AM The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 15, 2021 5:00 PM 10/4/2021 6:53 AM .• SThF� '; 1 NORTH CAROLINA EnrlronmertW quallly 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 - Wadesboro 1 b. Specific Lot This field nay be used to list specifc lot nunbers. Numbers 1 c. Parcel ID List all Rios associated w ith this project. Number(s) (PIN) 647406382510 2. County* Anson 3. Highway or Street 1179 US Hwy 74 West Address* Street name only is acceptable if no address nunber assigned yet 4. Cityor Township* Wadesboro 5. State * NC 6. Zip Code* 28170 7. Latitude* Enter the latitude in decinal degrees 34.9774 8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative) -80.0910 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* 10/15/2021 Estinated Construction Project Start Rate 10. Date to End * 03/16/2022 Estinated Construction Project End Date 11. SIC (Primary)* Commercial (1542) Standard Industrial aassification for Development 12. Acres to be 1.17 disturbed* (including off -site borrow and waste areas) 13. Total site area 1.09 (acres) * 14. Post- 0.75 construction (Estimated) impervious area (acres) * Project Tracking ID NCC-ANSON-2021-Dollar General - Wadesboro 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 Culpepper Creek Waterbody* Narreof waterbody into which stormwater runoff will discharge 15b. Waterbody 13-20-15-2 Index No. * NCWaterbody Index Number 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 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 Teramore Construction, LLC IF pernittee is an individual, enter first and last narre in this field. Ctherwise, 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 * Zach IF Corporation, enter Faegistered Agent First Wre 3. Last Name* Crumley IF Corporation, enter F;bgistered Agent Last %rre 3b. Title Senior Vice President 4. Permitee E-mail tglass@teramore.net Address* 5. Permittee 229-516-4289 Telephone No.* 6. Permittee Mailing Street Address Address* PO Box6460 Address Line 2 City Thomasville Fbstal / Zip Code 31758 Check box if the street address the same as mailing address 7. Permittee Street Address* F Yes Street Address 165 Big Star Drive Address Line 2 City Thomasville Fbstal / Zip Code 31757-7708 State / Frovince / Pegion GA Country USA State / Frovince / Faegion GA Country 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 Robert Contact - First Name * 2. Primary Site Caldwell Contact - Last Name * 3. Title 4. Site Contact E- tglass@teramore.net 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 Thomasville Fbstal / Zip Code 31758 8. Consultant Name (Optional) Jennifer Edwards First and Last narre 9. Consultant E-mail jennifer@brec.biz This person will be copied on all correspondence. 10. Consultant 336-844-4088 Telephone No. 11. Billing E-mail (For Annual Fee correspondence) tglass@teramore.net Default is legally responsible person e-rrail 12. Billing (For Annual Fee correspondence) Telephone 229-516-4289 Default is legally responsible person telephone State / Rovince / Region GA Country USA D. E&SC Plan Part D. ^ Erosion & Sediment Control (E&SC) Ran Approval Information ...................................................................................................................................................................................................................................................................................................................................... 1. Date E&SC Plan 09/29/2021 Approved * 2. E&SC Plan Project Anson-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 * 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 APPROVED _ESC_LETTER.pdf 803.48KB Approval letter or Mast beRDFformal Grading Permit 6. Signed FRO Financial Pesponsibility/Ojvnership Form F ROF_WADESBORO. pdf 171.93KB Mist be RDFfornal 7. Site Location Map Mast be RDFforrrat (lirrit 20IVB) VICINITY MAP.pdf 17.02KB Rease do not upload entire set of E&SC plans. 8. Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support the application. Include additional w aterbodies if necessary. 9. NOI Certification SIGNED_NOI.pdf 429.08KB Form Mast be RDFforrrat 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 Type Name * Zach Crumley Title Senior Vice President Organization Legally Plesponsible Entity Teramore Construction, LLC Date * 09/30/2021 F. Tracking and COC Info NOI Tracking No. 67350 NC Reference No. NCG01-2021-5493 Uses 'count_nurrber' variable (increrrented by SP) Certificate of NCC215493 Coverage (COC) Uses 'count_nurrber' variable (increrrented by SP) No.* Count Number 5493 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. NCC215493-2021 Invoice Due Date 11/3/2021 Initial Fee $ 100.00 Invoice Status OPEN