NCC201779_NOT Supporting Documents (2)_20230524

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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(COC)will be rescinded.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 INCC201779
Coverage (COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
Information associated with this permit:
Project Name Watkins Borrow Pit
Address Dawson Cabin Rd, Stump Sound, NC
County Onslow
Latitude 34.6800
Longitude -77.4800
Permittee Listed C M Mitchell Construction
Legally Responsible Charles Mitchell
Individual
E&SC Plan ID ONSLO-2020-035
Original NOI Tracking 25002
No.*
Date COC Issued* 05/11/2020
Prior Rescission Date
This field will populate only if COC has already been rescinded.
Reason for Rescission/Termination Request:
Reason for 0 Project Closed-Out
Termination of 0 Sale (Another Owner/Operator obtained new COC)
Coverage* 0 Mistake or Invalid Coverage
O® Other C. M. Mitchell helped the owner obtain all licenses and permits anc
Additional More information about the basis of this request,if needed.
Explanation

Supporting Upload Supporting Documentation if applicable.
Documentation Upload
Must be PDF format
North Carolina General Statute 143-215.6B (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).
* se 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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6)of that permit.
Signature* 7i J'7 i l t LI4
Type Name* Charles M. Mitchell
Title* President
Organization* C. M. Mitchell Construction Co. Inc.
Date* Date will be captured on form submission
Email for [e-mail]
Confirmation*
Contact Telephone* 9103272907
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM (click on this link)
(https://files.nc.govincdeq/Energy%20Mineral%20and%20Land%20Resources/Stormwater/NPDES%20General%20Permits/N
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 Upload
Form* Must be PDF Format
Additional Email [e-mail]
(Optional)
I'm not a robot
reCAPTCHA
Privacy-Terms

NCGO1 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.: NCC201779
Name of Project: Watkins Borrow Pit
Per NC General Statute 143-215.68(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: C. M. Mitchell Construction CO. Inc.
*Legally Responsible Person: Charles M. Mitchell
Title of Legally Responsible Person: President
*Signature: 07 74q 7rbJC V Date: 6-17-22
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 NCG010000 permit.
For more information on signatory requirements,see Part IV, Section B, Item (6)of the NCG010000 permit.

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OeparUnent of Envlronmenta tlty i\C L L ' l., ! C 1.waits f 'For �,f t I �.t�.L I: .� -ro t.e)V.::.i. t; ,i` o(.s,i,
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 NCC201779
Coverage (COC) Enter the Certificate of Coverage Number(Use capital letters)
No.*
Information associated with this permit:
Project Name Watkins Borrow Pit
Address Dawson Cabin Rd, Stump Sound, NC
County Onslow
Latitude 34.6800
Longitude -77.4800
Permittee Listed C M Mitchell Construction
Legally Responsible Charles Mitchell
Individual
E&SC Plan ID ONSLO-2020-035
Original NOI 25002
Tracking No.*
Date COC Issued* 05/11/2020
Prior Rescission This field will populate only if COC has already been rescinded.
Date
Reason for Rescission/Termination Request:
Reason for p Project Closed-Out
Termination of 0) Sale (Another Owner/Operator obtained new COC)
Coverage* C) Mistake or Invalid Coverage
C7 Other C. M. Mitchell No Longer Involved in the Project

Additional More information about the basis of this request,if needed.
Explanation C. M. Mitchell helped Gary Watkins with necessary paperwork and steps to obtain
the permits, with the understanding Mitchell would be doing excavation and using
the pit. Unfortunately after the permits were obtained, Mr. Watkins severed ties
with C. M. Mitchell.
Supporting Upload Supporting Documentation if applicable.
Documentation Must be PDF format
North Carolina General Statute 143-215.6B (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).
* („ 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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature*
if. ifftelteff
Type Name* Charles M. Mitchell
Title* Owner/President
Organization* C. M. Mitchell Construction Co. Inc.
Date* 06/20/2022
Email for [e-mail]
Confirmation*
Contact Telephone* 910-327-2907

YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM (click on this link) 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 Notice of Termination.pdf 643.88KB
Form* Must be PDF Format
Additional Email [e-mail]
(Optional)