NCC217103_NOI Application_20211222

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/20/2021 3:25:01 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 12/21/2021 7:24:34 AM (Review - Construction NOI 76233)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 12/20/2021 3:25 PM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 22, 2021 5:00
PM 12/20/2021 3:25 PM
Submit by Evans, Shaundra M 12/22/2021 7:59:29 AM (Payment Verification for NCC217103)
P Tyler Beardsley
• Evans, Shaundra M assigned the task to Evans, Shaundra M 12/22/2021 7:59 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 1, 2022 5:00 PM
12/21/2021 7:24 AM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting No
an NOI that was Yes
rejected before?
la. Project Name* Gem Street Extension
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)
00520405, 00520201, 00520224, 00520406, 00520407, 00520408, 00520411,
00520412,00520301,00520302,00520320,00520413,00521225,00521226,
00521246, 00521244, 00521243, 00521240, 00521240, 00521210, 00521299
2. County*
Mecklenburg
3. Highway or Street
School St, Willow St, Gem St, Center St, Meridian St, Kelly St, Oak
Address*
St, Aftonshire Dr
Street name only is acceptable if no address number assigned yet
4. City or Township*
Cornelius
5. State* NC
6. Zip Code* 28031
7. Latitude* Enter the latitude in decimal degrees
35.4799
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-80.8594
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*
01/15/2022
Estimated Construction Project Start Date
10. Date to End*
12/01/2022
Estimated Construction Project End Date
11. SIC (Primary)*
Highway (1611)
Standard Industrial Classification for Development

12. Acres to be 3.90
disturbed* (including off -site borrow and waste areas)
13. Total site area 3.90
(acres) *
14. Post -construction 1.95
impervious area (Estimated)
(acres)*
Project Tracking ID NCC-MECKL-2022-Gem Street Extension
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 McDowell Creek
Waterbody * Name of waterbody into which stormwater runoff will discharge
15b. Waterbody Index 11-115-(1)
No. * NC Waterbody Index Number
Stormwater No
discharges will flow Yes
to additional waters*
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
Town of Cornelius
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* Tyler
If Corporation, enter Registered Agent First Name
3. Last Name* Beardsley
If Corporation, enter Registered Agent Last Name
3b. Title Assistant Town Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-892-6031 ext. 172
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box 399
Address Line 2
City State / Province / Region
Cornelius North Carolina
Postal / Zip Code Country
28031 USA
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
21445 Catawba Avenue
Address Line 2
City
State / Province / Region
Cornelius
North Carolina
Postal / Zip Code
Country
28031
USA
8. Type of
Ownership is only individual if an individual is named in B.1. above.
Ownership*
Government - Municipal

C. Site Contact Information
Part C.
Project Site Contact Information
.................................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Tyler
Contact - First
Name*
2. Primary Site Beardsley
Contact - Last Name*
3. Title Assistant Town Manager
4. Site Contact E-mail [e-mail]
Address*
5. Site Contact 704-892-6031 ext. 172
Telephone No.*
6. Organization Name Town of Cornelius
7. Site Contact Street Address
Mailing Address* P.O. Box 399
Address Line 2
City
Cornelius
Postal / Zip Code
28031
8. Consultant Name (optional)
Ben Crawford
First and Last name
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 919-573-9930
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)
704-892-6031 ext. 172
Default is legally responsible person telephone
State / Province / Region
North Carolina
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC Plan 12/17/2021
Approved *
2. E&SC Plan Project MECKL-2022-023
Number/ID* Assigned by agency or local program
3. E&SC Plan State DEQ Office
Approved by* Local Program
4. State DEQ Office* Mooresville (MRO)
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
GEM-12172021.pdf
4.15MB
Approval letter or
Must be PDF format
Grading Permit
6. Signed FRO
Financial Responsibility/Ownership Form
R015.002_FRO-Form_Signed.pdf
1.29MB
Must be PDF format
7. Site Location Map
Must be PDF format (limit 20 MB)
GEM_REU_EC-01_TSH.pdf
746.31 KB
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.
Begin Project Lat: 35.48137
Begin Project Long:-80.86335
End Project Lat: 35.47991
End Project Long:-80.85939
9. NOI Certification
Gem Certification Form.pdf
59.1 KB
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 F
Type Name* Tyler Beardsley
Title Assistant Town Manager
Organization Legally Responsible Entity
Town of Cornelius
Date * 12/20/2021

F. Tracking and COC Info
NOI Tracking No. 76233
NC Reference No.
NCG01-2021-7103
Uses'count_numb& variable (incremented by SP)
Certificate of
NCC217103
Coverage (COC) No.*
Uses'count_number' variable (incremented by SP)
Count Number
7103
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. NCC217103-2021
Invoice Due Date 1/20/2022
Initial Fee $ 100.00
Invoice Status OPEN