NCC215506_NOI Application_20211005

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/1/2021 9:30:24 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 10/4/2021 8:43:14 AM (Review- Construction NOI 67642)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 10/1/2021 9:31 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 5, 2021 5:00
PM. The priority is: High 10/1/2021 9:31 AM
Submit by Evans, Shaundra M 10/5/2021 10:38:55 AM (Payment Verification for NCC215506)
* Jonathan Powers
• Evans, Shaundra M assigned the task to Evans, Shaundra M 10/5/2021 10:37 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 15, 2021 5:00
PM. The priority is: High 10/4/2021 8:43 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting
IT No
an NOI that was
r Yes
rejected before?
1a. Project Name *
Drill Test Site (Project Carolina Belle, LLC)
1 b. Specific Lot
This field may be used to list specffc lot numbers.
Numbers
1 c. Parcel ID List all Rios associated w ith this project.
Number(s) (PIN) 757600097131,756600599059,756600549781,756600795116,756600770504
2. County* Montgomery
3. Highway or Street Gold Mine Rd
Address* Street name only is acceptable if no address number assigned yet
4.CityorTownship* Candor
5. State * NC
6. Zip Code* 27229
7. Latitude* Enter the latitude in decimal degrees
35.3103
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.7830
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*
10/05/2021
Estimated Construction Project Start Late
10. Date to End *
10/04/2022
Estimated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
5.00
disturbed*
(including off -site borrow and waste areas)

13. Total site area 220.00
(acres) *
14. Post- 0.00
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-MONTG-2021-Drill Test Site (Project Carolina Belle, LLC)
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 Reedy Fork
Waterbody* Narreof waterbody into which stormwater runoff will discharge
15b. Waterbody 13-25-22-1
Index No. * NCWaterbody Index Namber
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional Gold Branch
Receiving Waterbody narre
Waterbody
15d. Waterbody 13-25-22-2
Index No. NCWaterbody Index Namber
15e. Additional Bridgers Creek
Receiving WaterbWynarre
Waterbody
15f. Waterbody 13-25-24
Index No. NCWaterbody Index Namber
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.
F2rnittee 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
Project Carolina Belle, LLC
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 * Jonathan
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Powers
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title Registered Agent
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-650-1158
Telephone No.*
6. Permittee Mailing Street Address
Address* 204 Bernard Purvis Road
Address Line 2
City
Bennett
Fbstal / Zip Code
27208
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
204 Bernard Purvis Road
Address Line 2
City
Bennett
Fbstal / Zip Code
27208
State / Frovince / Pegion
NC
Country
us
State / Frovince / Faegion
NC
Country
us
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
Jonathan
Contact - First
Name *
2. Primary Site
Powers
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-650-1158
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
204 Bernard Purvis Road
Address Line 2
City
Bennett
Postal / Zip Code
27208
8. Consultant Name
(Optional)
Christian Vestal
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-328-0902
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person a-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
919-650-1158
Default is legally responsible person telephone
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 09/30/2021
Approved *
2. E&SC Plan Project MONTG-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 * 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 montg-2022-006exap.pdf 784.44KB
Approval letter or Mast beRDFformat
Grading Permit
6. Signed FRO Financial Pesponsibility/Ojvnership Form
Angus Realty Corp FRO.pdf 128.09KB
Mast be RDFfornal
7. Site Location Map Mast be RDFforrrat (lirrit 20IVB)
Site Map.pdf 268.94KB
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 NCG01-eNOI-Certification-Form-20190507-DEMLR-
Form 377.82KB
SW (signed).pdf
Mast be FDFfornat
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:* 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* Jonathan Powers
Title Registered Agent
Organization Legally Responsible Entity
Project Carolina Belle, LLC
Date * 10/01 /2021

F. Tracking and COC Info
NOI Tracking No. 67642
NC Reference No.
NCG01-2021-5506
Uses 'count_nunber' variable (increrrented by SP)
Certificate of
NCC215506
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5506
Sequential nunber for subnittal 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. NCC215506-2021
Invoice Due Date 11/3/2021
Initial Fee $ 100.00
Invoice Status OPEN