SWG040139_Application Form_20220610

N.C. DIVISION OF WATER QUALITY
SURFACE WATER PROTECTION SECTION
STATE STORMWATER NOTICE OF INTENT (NO])
SWG040000 - GENERAL PERMIT TO CONSTRUCT A LINEAR UTILITY LINE
AND ASSOCIATED INCIDENTAL BUILT -UPON AREA
State Stormwater Management Application Notice of Intent for coverage under the General Stormwater Management
Permit to construct a utility line and incidental built -upon area associated with a linear utility project including water,
sewer, gas, telephone, and electric.
For the construction, operation and maintenance of incidental impervious areas associated with the construction of a
linear utility line. Incidental built -upon area associated with the utility project includes small, single pump stations,
access roads which minimize their built -upon area, concrete pads, manhole covers, etc.
(Please print or type)
1. Mailing address of owner/developer: (The address to which all permit correspondence will be mailed.)
Owner/Developer Name Carolina Water Services, Inc. of North Carolina
Street Address 4944 Parkway Plaza Boulevard, Suite 375
City Charlotte State NC ZIP Code 28217
Telephone No. [phone] Fax )
2. Proposed Project Information:
Project Name
Street Address
of the Project
City
Bradfield Farms - Silverton Water Interconnect
3822 Tea Royal Court
Charlotte State NC ZIP Code 28215
County Cabarrus
Contact Person Travis Dupree
Mailing Address 4944 Parkway Plaza Boulevard Suite 375
City Charlotte State NC ZIP Code 28217
Telephone No. 704 319-0518 Fax ( )
3. Physical Location Information:
Please provide the street address of the project and describe how to get to the project, using street names,
state road numbers, and the distance and direction from the nearest major intersection:
3822 Tea Royal Court, Charlotte, NC 28215, 4236 Fellows Lane, Charlotte, NC 28215
verton
4. What is the name of the receiving stream?
5. River Basin Yadkin Pee Dee
McKee Creek
Receiving Stream Classification C
6. This Certificate of Coverage is being submitted as a result of:
® New or proposed project ❑ Modification to an existing project
Existing COC or Permit Number:
Date project is scheduled to begin construction July 1, 2022
7. What is the total project area above mean high water? 85,363 fe
8. What is the total amount of built -upon area proposed at this site? 4,185 fe
(Please include all manhole covers, pump stations, concrete pads, and gravel access roads)
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9. What type of utility project will be constructed?
® Water ❑ Sewer ❑ Gas ❑ Telephone ❑ Electric ❑ Other
10. Has the built -upon area been minimized to the extent practicable?
® YES ❑ NO
11. Is the runoff from the built -upon area outside the vegetative buffer directed away from surface waters, to the
extent practicable?
® YES ❑ NO
12. Is the project within 575' of the Mean High Water line of class ORW waters?
❑ YES (Please show the 575' AEC line on plans) ® NO
(if yes, total built -upon area must be less than or equal to 25% of the total project area within the AEC above mean high water.)
13. Are there any wetlands on the site? ❑ YES (please delineate on the plans) ® NO
Name and affiliation of person making this determination: Ron Johson, ECS Southeast, LLP
14. Please list all Best Management Practices employed at this site:
None
15. 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 $10,000. (18 U.S.C. Section 1001 provides a punishment by a fine of not more than
$10,000 or imprisonment of not more than 5 years, or both, for a similar offense.)
I hereby request coverage under the referenced General Permit. I understand that coverage under this permit will
constitute the permit requirement for the project and is enforceable in the same manner as an individual permit.
I certify that I am familiar with the information contained in the application and that to the best of my knowledge and
belief such information is true, complete, and accurate.
Printed name of person signing: Travis Dupree
Title: Vice President. Proiect Management and Engineering
(Signature of Applic t) (Date s gned)
A check or money order must accompany this Notice of Intent for $505.00, made payable to: NCDENR.
Your application will be returned unprocessed unless all of the following items are submitted:
® This completed form
® Two sets of site and grading plans
® A check for $505.00
® A USGS map with the project clearly located on it.
Mail the entire package to: NCDENR Division of Water Quality
Surface Water Protection Section — Stormwater
at the Appropriate Contact Address (see the following page)
Note: The submission of this document does not guarantee the issuance of a Certificate of Coverage under the
General Permit.
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For questions, please contact the DWO Central Office or Regional Office for your area.
DWO Regional Office Contact Information:
2090 US Highway 70
Swannanoa, NC 28778
[phone]
HOW & ORW Projects in Counties Above
3800 Barrett Drive
Raleigh, NC 27609
[phone]
HOW & ORW Projects in Counties Above
585 Waughtown Street
Winston-Salem, NC 27107
[phone]
N & ORW Proiects in Counties Above
225 Green Street 610 East Center AvenuelSuite 301
Systel Building Suite 714 Mooresville, NC 28115
Fayetteville, NC 28301-5043 [phone]
[phone] HOW & ORW Projects in Counties Above
?W & ORW Proiects in Counties Above
943 Washington Square Mall
Washington, NC 27889
[phone]
Coastal Stormwater, HOW & ORW Projects in Counties
Above
1617 Mail Service Center
Raleigh, NC 27699-1617
[phone]
Phase 2 Post -Construction Projects not covered
by local government
127 Cardinal Drive Extension
Wilmington, NC 28405-2845
[phone]
Coastal Stormwater, HOW & ORW Projects in
Counties Above
"%preserve, protect
end enhance
North Carolina's tvaler... ":
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