NCC216223_NOT Supporting Documents_20230323

9/21/22,`3:31 PM
New Submission
E Q�� Notice of Termination (NOT) Request - NPDES
T ;-A N ,�, � } err >i�vdteu ir�ert���i for Construction Activities
Use this form to submit a Notice of Termination (NOT) request for a project covered under the N.C. NPDES
General Permit for Construction Activities NCG010000 (or NCG250000). If approved, the Certificate of Coverage
(COC) will be rescinded.
Certificate of NCC216223
Coverage (COC) No. * Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name res Subdivision Section 3 t
Address Windcrest Rd, Asheboro, NC
County Randolph
Latitude 35.7457
Longitude-79.7950
Permittee Listed Davidson Land Development, LLC
Legally Responsible Christopher Reid
Individual
E&SC Plan ID RANDO-2022-001
Original NOI Tracking 72560
No.
Date COC Issued` 11/12/2021
Prior Rescission Date
This field will populate only if COC has already been rescinded.
Reason for Rescission/Termination Request:
Reason for QQ Project Closed -Out
Termination of O Sale (Another Owner/Operator obtained new COC)
Coverage* Q Mistake or Invalid Coverage
O Other
https://edocs.deq.nc.gov/Forms/NCGO1-Termination 1 /3

9/21/22, `3:31 PM
New Submission
Additional
Explanation
More information about the basis of this request, if needed.
For Project Close-out, you must provide documentation below. Please note, a Certificate of Occupancy
is not sufficient close-out documentation. You must provide a final inspection report or correspondence
from the authority that approved the Erosion and Sediment Control (E&SC) Plan.
Erosion Control Plan 7/25/2022i
Close-out Date
Erosion Control Plan Upload
Close-out NCC216223 Notice of Termination Certification for ... 59.49KB X
Documentation
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).
* Q I, as an authorized representative, hereby request rescission of coverage under the
NPDES Stormwater Permit for the subject facility. 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.
Important: The person who electronically signs this Certification must be the same person who signs the paper NOT
Certification Form (uploaded below). 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.
*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* x
Type Name* Christopher Reid
Title Registered Agent
Organization* Davidson Land Development LLC
Date* Date will be captured on form submission
hftps:fedocs.deq.nc.gov/Forms/NCGO1-Termination 2/3

9/21/22, 3:31 PM
New Submission
Email for
Confirmation
Contact Telephone*
be[[e-mail]
336-250-0483
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM (click on this link)
(https://files.nc.gov/ncdeq/Energy%20Mineral%20and%20Land%20Resources/Stormwater/N PDES%20General%20P
eNOT-Certification-Form-20210514-DEMLR-SW.pdf) to The Stormwater Program at the address on the form for the
application to fulfill federal requirements. You must also upload a copy of that completed below:
NOT Certification
Form
Additional Email
(Optional)
I'm not a robot
Upload
Must be PDF Format
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Save as Draft
https://edocs.deq.nc.gov/Forms/NCG01-Termination 3/3

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NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: N G C a 1(ed A 3
Name of Project: W ind C res f Acres Subollvls Sec + 3
Per NC General Statute 143-215.6E (i), 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 ... 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, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
the subject facility. 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.
Legally Responsible Organizational Entity: J)G)Vtd 50n Lcl nd -D itvelo pmen + L 1- C
*Legally Responsible Person: Chomp R6r —Rezi 1J
Title of Legally Respons
*Signature:
red IAq e
Date: q•ao'aa
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* IMPORTANT NOTE. 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 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6t' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.6E (i), 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 ... 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 (check all boxes to indicate your agreement):
® 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.
M If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
M I hereby request coverage under the NCGO10000 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.
Name of Project: Windcrest Acres Subdivision Section 3
Legally Responsible Organizational Entity:
* Legally Responsible Person
Title of Legally Responsible
Signature:
Davidson Land Development, LLC
Christopher Reid
Date: I / 1 L(
* IMPORTANT NOTE: 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 NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.

s
Belinda Covington
From: [e-mail]
Sent: Wednesday, November 10, 2021 5:37 PM
To: Belinda Covington
Subject: Payment Confirmation
Thank you for your recent payment to NC DEQ Stormwater.
Payment Application: NC DEQ Stormwater ePayment Payment Status: Payment completed successfully.
Confirmation Number: 21111076793405
Payment Date: 11/10/2021
Billing Address: Davidson Land Development LLC
5794 East Old US Highway 64
Lexington, NC 27292
3362500483
Account Number: x0971
Routing Number: 064008637
Account Type: Checking
Payment Amount: 100.00 USD
Total Amount: 100.00 USD
- -Do we need Tb
do q close ot.4-
Reference Information: NCC216223-2021,NCC216223,Windcrest Acres Subdivision Section 3,Davidson Land
Development LLC,$100.00
DO NOT REPLY DIRECTLY TO THIS EMAIL.
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