NCC220116_NOI Application_20220126

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/5/2022 1:25:36 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 1/6/2022 7:01:21 AM (Review - Construction NOI 77641)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 1/5/2022 1:25 PM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 7, 2022 5:00 PM
1/5/2022 1:25 PM
Submit by Selkane, Aziza 1/26/2022 12:37:54 PM (Payment Verification for NCC220116)
P Thermal Belt Outreach Ministry, Inc
• Selkane, Aziza assigned the task to Selkane, Aziza 1/26/2022 12:37 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 17, 2022 5:00 PM
1 /6/2022 7:01 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* THERMAL BELT OUTREACH MINISTRY, INC.
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) P-60-162, P60-30
2. County* Polk
3. Highway or Street HOPE VALLEY LANE
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* COLUMBUS
5. State* NC
6. Zip Code* 28722
7. Latitude* Enter the latitude in decimal degrees
35.2503
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-82.2054
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*
01/06/2022
Estimated Construction Project Start Date
10. Date to End*
12/31/2022
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial Classification for Development
12. Acres to be
1.65
disturbed *
(including off -site borrow and waste areas)

13. Total site area 8.99
(acres)*
14. Post -construction 0.74
impervious area (Estimated)
(acres) *
Project Tracking ID NCC-POLK-2022-THERMAL BELT OUTREACH MINISTRY, INC.
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 HORSE CREEK
Waterbody * Name of waterbody into which stormwater runoff will discharge
15b. Waterbody Index 9-55-1-13-(2)
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 INC 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
Thermal Belt Outreach Ministry, Inc.
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* Margot B.
If Corporation, enter Registered Agent First Name
3. Last Name* Carter
If Corporation, enter Registered Agent Last Name
3b. Title executive director
4. Permitee E-mail [e-mail]
Address*
5. Permittee 828-894-0130
Telephone No.*
6. Permittee Mailing Street Address
Address* 134 White Drive
Address Line 2
P.O. Box 834
City
State / Province / Region
Columbus
NC
Postal / Zip Code
Country
28722
USA
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 134 White Drive
Address Line 2
P.O. Box 834
City
State / Province / Region
Columbus
NC
Postal / Zip Code
Country
28722
USA

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 Margot B.
Contact - First
Name*
2. Primary Site Carter
Contact - Last Name*
3. Title Executive Director
4. Site Contact E-mail [e-mail]
Address*
5. Site Contact 828-894-0130
Telephone No.*
6. Organization Name Thermal Belt Outreach Ministry, Inc.
7. Site Contact Street Address
Mailing Address* 134 White Drive
Address Line 2
P.O. Box 834
City
Columbus
Postal / Zip Code
28722
8. Consultant Name (optional)
Jill Graudszus
First and Last name
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 8282474495
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)
828-894-0130
Default is legally responsible person telephone
State / Province / Region
NC
Country
United States

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC Plan 01/03/2022
Approved *
2. E&SC Plan Project POLK-2022-002
Number/ID* Assigned by agency or local program
3. E&SC Plan State DEQ Office
Approved by* Local Program
4. State DEQ Office* Asheville (ARO)
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
D00010422-01042022161042.pdf 523.47KB
Approval letter or
Must be PDF format
Grading Permit
6. Signed FRO
Financial Responsibility/Ownership Form
financial responsibility ownership form.pdf 392.67KB
Must be PDF format
7. Site Location Map
Must be PDF format (limit 20 MB)
Polk County GIS.pdf 490KB
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 notice of intent energy mineral land resources
Form 364.76KB
stormwater program.pdf
Must be PDF format
This is an Express No
Review Project* Yes

E. Certification
North Carolina General Statute 143-215.6113 (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
6/3�dt�rcr,0., (:',"-rt
Type Name* Margot B. Carter
Title executive director
Organization Legally Responsible Entity
Thermal Belt Outreach Ministry, Inc.
Date * 01 /05/2022

F. Tracking and COC Info
NOI Tracking No. 77641
NC Reference No.
NCG01-2022-0116
Uses'count_numb& variable (incremented by SP)
Certificate of
NCC220116
Coverage (COC) No.*
Uses'count_number' variable (incremented by SP)
Count Number
116
Sequential number for submittal that is incremented by Stored Procedure
COC Year
2022
Year of date reviewed (used to assign YY digits after "NCC" in COC no.)
Initial Invoice No. NCC220116-2022
Invoice Due Date 2/5/2022
Initial Fee $ 100.00
Invoice Status OPEN