NCC221116_Modification Review_20220613

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/13/2022 10:15:07 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 6/13/2022 11:17:59 AM (Construction COC ADD TO FILE Review - NCC221116)
• The task was assigned to Georgoulias, Bethany A. The due date is: June 16, 2022 5:00 PM
6/13/2022 10:15 AM

Certificate of NCC221116
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name Samaritan's Purse Inn
Address 118 White Pine Street, North Wilkesboro, NC
County Wilkes
Latitude 36.1860
Longitude-81.1385
Permittee Listed Samaritan's Purse
Legally Responsible Ronald Wilcox
Individual
NC Reference No. NCG01-2022-1116
E&SC Plan ID WILKE-2021-010
Original NOI Tracking 84327
No. *
Date COC Issued* 03/22/2022
Prior Rescission Date This field will populate only if COC has already been rescinded.
Modification Information:
Reason for Closed -Out Lots/Outparcels in E&SC Plan
Modification* Additional Lots/Outparcels Approved - E&SC Revised
• Other Revision(s) to E&SC Plan
Legally Responsible Individual and/or Site Contact Has Changed
Multiple Reasons (List)
Addional Explanation More information (e.g., new Site Contact details). If lots are being added, please include specific lot numbers
Expanded the limits of disturbance on the existing parcel to included previously
noted undisturbed open space.
You must upload supporting documentation below. Do not upload E&SC Plans unless specific plan
sheets are the only documentation with approval for revised acres of disturbance, etc. (only upload
applicable sheets).
For changes to the legally responsible individual, you must upload this form.

Supporting Upload Supporting Documentation (Revised E&SC Approval, Close -Out Doc, etc.)
Documentation CoA WILKE-2021-010.pdf 204.18KB
WILKE-2021-010_20220610 - Revised.pdf 253.23KB
Must be PDF format
North Carolina General Statute 143-215.613 (1) 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).
* I hereby request modification to coverage under the NPDES Stormwater Permit for the
subject project site. I am familiar with the information contained in this request and to
the best of my knowledge and belief such information is true, complete and accurate.
Specify if you are:* • The Legally Responsible Individual
Authorized Responsible Person*
*This form must be signed by a responsible corporate officer that 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.
Signature
Type Name* Ronald Wilcox
Title* Chief Operating Officer
Organization * Samaritan's Purse
Date * 06/13/2022
Email Address* [e-mail]
Email for confirmation
Telephone Number* 828-278-1511
Contact number if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional email for confirmation
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 06/13/2022
Rescinded Since
Submitted?