NCC216206_NOI Application_20211108

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/5/2021 8:43:51 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 11/5/2021 9:02:57 AM (Review - Construction NOI 72520)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 11/5/2021 8:44 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 9, 2021 5:00
PM. The priority is: High 11/5/2021 8:44 AM
Submit by Evans, Shaundra M 11/8/2021 8:22:32 AM (Payment Verification for NCC216206)
F Johnathan C Gates
• Evans, Shaundra M assigned the task to Evans, Shaundra M 11/8/2021 8:22 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 17, 2021 5:00 PM.
The priority is: High 11/5/2021 9:03 AM

NORTH CAROLINA
RrwY mrlm&tral Qualrly
A. Project Information
Part A.
Project Location and Waterbody Information
...............................................................................................................................................................................................................................................................................................................................................................................................
Are you submitting No
an NOI that was • Yes
rejected before?
Previous Rejected 70210
NOI No.
Prior Reviewer Name Brooklyn Broussard
la. Project Name* M121 Western Boulevard Replacement 2021
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers
1 c. Parcel ID List all PINs associated with this project.
Number(s) (PIN) NA. All work in road right of ways with no PIN
2. County* Wake
3. Highway or Street Western Blvd and Blue Ridge Rd
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Raleigh
5. State* NC
6. Zip Code* 27606
7. Latitude* Enter the latitude in decimal degrees
35.7857
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-78.7190
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*
11/01/2021
Estimated Construction Project Start Date
10. Date to End*
09/30/2022
Estimated Construction Project End Date
11. SIC (Primary) *
Other (9999)
Standard Industrial Classification for Development

12. Acres to be 6.10
disturbed* (including off -site borrow and waste areas)
13. Total site area 6.10
(acres) *
14. Post -construction 6.10
impervious area (Estimated)
(acres)*
Project Tracking ID NCC-WAKE-2021-M121 Western Boulevard Replacement 2021
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 SIMMONS BRANCH
Waterbody * Name of waterbody into which stormwater runoff will discharge
15b. Waterbody Index 27-34-2
No. * NC Waterbody Index Number
Stormwater No
discharges will flow Yes
to additional waters*
15c. Additional BUSHY CREEK
Receiving Waterbody Waterbody name
15d. Waterbody Index 27-34-3
No. NC Waterbody Index Number
15e. Additional Waterbody name
Receiving Waterbody
15f. Waterbody Index NC Waterbody Index Number
No.
16a. Is this project Yes
subject to the NC No, not subject to NC SPCA
Sediment Pollution
Control Act?*

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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
1. Permittee* Legally Responsible Entity
PUBLIC SERVICE COMPANY OF NORTH CAROLINA
If permittee is an individual, enter first and last name in this field. Otherwise, enter organization/business name.
Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the
registration here. Permittee must be the same entity that is responsible for the land -disturbing activity as listed on the NC
SPCA Financial Responsibility/Ownership (FRO) Form.
2. First Name* Andrew
If Corporation, enter Registered Agent First Name
3. Last Name* Moore
If Corporation, enter Registered Agent Last Name
3b. Title Director - Engineering & Construction
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-810-3259
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box 1398
Address Line 2
City State / Province / Region
Gastonia NC
Postal / Zip Code Country
28053 US
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address * 800 Gaston Road
Address Line 2
Building A
City
State / Province / Region
Gastonia
NC
Postal / Zip Code
Country
28056-6519
US

8. Type of Ownership is only individual if an individual is named in B.A. above.
Ownership* Non -Government

C. Site Contact Information
Part C.
Project Site Contact Information
.................................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Robert
Contact - First
Name*
2. Primary Site Ley
Contact - Last Name*
3. Title Environmental Specialist
4. Site Contact E-mail [e-mail]
Address*
5. Site Contact [phone]
Telephone No.*
6. Organization Name PUBLIC SERVICE COMPANY OF NORTH
CAROLINA, INCORPORATED
7. Site Contact Street Address
Mailing Address* 160 Mine Lake Ct
Address Line 2
Ste 200
City
Raleigh
Postal / Zip Code
27615-6417
8. Consultant Name (Optional)
Nathan Willkom
First and Last name
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 3033239799
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-mail
12. Billing Telephone (For Annual Fee correspondence)
704-810-3259
Default is legally responsible person telephone
State / Province / Region
NC
Country
US

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC Plan 10/06/2021
Approved *
2. E&SC Plan Project WAKE-2022-027
Number/ID* Assigned by agency or local program
3. E&SC Plan State DEQ Office
Approved by* Local Program
4. State DEQ Office* Raleigh (RRO)
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 WAKE-2022-027_20211006_LOAwM.pdf 322.75KB
Approval letter or Must be PDF format
Grading Permit
6. Signed FRO Financial Responsibility/Ownership Form
DENC M121 Western Blvd 2021 - Express FROF.pdf 158.08KB
Must be PDF format
7. Site Location Map Must be PDF format (limit 20 MB)
DENC-M121-USGS Quad Map.pdf 737.02KB
Please do not upload entire set of E&SC 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 M121 NOI 131550.pdf 604.15KB
Form Must be PDF format
This is an Express No
Review Project* Yes

E. Certification
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false 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 Article; 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 Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
* 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.
* 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.
* I will abide by all conditions of the NCG010000 General Permit and the approved
Erosion and Sediment Control Plan.
* 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:* The Legally Responsible Person named on this Notice of Intent
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
*c &
Type Name* Andrew Moore
Title Director - Engineering and Construction
Organization Legally Responsible Entity
Public Service Company of North Carolina, Inc.
Date * 11 /05/2021

F. Tracking and COC Info
NOI Tracking No. 72520
NC Reference No.
NCG01-2021-6206
Uses'count_numb& variable (incremented by SP)
Certificate of
NCC216206
Coverage (COC) No.*
Uses'count_number' variable (incremented by SP)
Count Number
6206
Sequential number for submittal that is incremented by Stored Procedure
COC Year
2021
Year of date reviewed (used to assign YY digits after "NCC" in COC no.)
Initial Invoice No. NCC216206-2021
Invoice Due Date 12/5/2021
Initial Fee $ 100.00
Invoice Status OPEN