NCC212052_Notice of Termination Closeout Documentation_20240411

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, 61h 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.: < <- 2- 0 5 2- . Z a Z3
Name of Project: L V C%0'r Zo /t Al
Per NC General Statute 143-215.6B (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.
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Legally Responsible Organizational Entity: ✓X 11 c"-W L�e4014f-c�
*Legally Responsible Person: rr w /+ 4—e,
Title L al espon . erpon: C U U
*Signature. Date: Z+
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 NCGO10000 permit.

JOHNSTON COUNTY PUBLIC UTILITY DEPARTMENT
SEDIMENTATION INSPECTION REPORT
309 E.MARKET STREET,SMITHFIELD,N C 27577-TELEPHONE[phone]
Ins ection Information
Date: 1/25/2022 Type of Inspection Construction Stage
Date of Inspection: 1/25/2022 ❑ Initial Inspection ❑ Pre-Construction
❑ Routine Site Inspection ❑ Initial Grading
Inspection by: Shannon Stanley ❑ On-Site Meeting ❑ Infrastructure
El Progress Inspection El Site Stabilization
Others Present: Click or tap here to enter
text. © Final Inspection ❑ Vertical
Photos: ❑ Yes ® No ❑ Plat Inspection ® Final Site Stabilization
❑ Spot Check Inspection
Weather and Site Conditions: ❑ Complaint Inspection
Click or tap here to enter text.
Development/Owner Information
Project Name: Beverly(ph3) Project Number: 19-087-P
Project Location: Reedy Creek Rd. This Report Sent To: Greenhawk Development
Email: Click or tap here to enter text.
® File Copy
Land Owner of Record: Person Financially Responsible for Land Disturbing
Insert Land Owner. Activity: ❑ Same as owner
Click or tap here to enter text.
6. Comments/Notes:
The erosion control permit for Johnston County is closed.
7. Corrective Actions:
a.
8. Photos:

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Department of Environmental Duality -- .
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 NCC212052
Coverage (COC) Enter the Certificate of Coverage Number(Use capital letters)
No.*
Information associated with this permit:
Project Name Beverly Subdivision Ph 3
Address 1585 Reed Creek Road, Four Oaks, NC
County Johnston
Latitude 35.4935
Longitude -78.5110
Permittee Listed GHD-Beverly, LLC
Legally Responsible Jeff White
Individual
E&SC Plan ID JC# 19-087-P
Original NOI 49454
Tracking No.*
Date COC Issued* 04/07/2021
Prior Rescission 03/31/2024
Date This field will populate only if COC has already been rescinded.
DO NOT PROCEED with this Notice of Termination. This Certificate of Coverage is no longer active.

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* Unable to submit at this time
Value is required.
Reason for Rescission/Termination Request:
Reason for * Project Closed-Out
Termination of 0 Sale (Another Owner/Operator obtained new COC)
Coverage* 0 Mistake or Invalid Coverage
0 Other
Additional More information about the basis of this request, if needed.
Explanation
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 1/25/2022
Close-out Date*
Erosion Control Plan Upload
Close-out 4-9-24 closeout - Beverly Phase 3 Closeout from ... 530.13KB X
Documentation
Must be PDF format
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 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.

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*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* Jeff White
Title* COO
Organization* GreenHawk Corporation Inc
Date* Date will be captured on form submission
Email for [e-mail]
Confirmation
Contact Telephone* 919-805-8946
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM (click on this link)
(https://www.deq.nc.gov/energy-mineral-and-land-resources/stormwater/npdes-general-permits/ncg01-enot-
certification-form/download) 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* Beverly Phase 3 NOT Signed Form.pdf (blob:http... 822.43KB X
Must be PDF Format
Additional Email
(Optional)
;�i!_�r11i1 Save as Draft

Georgoulias, Bethany
From: Paul Bailey <[e-mail]>
Sent: Thursday, April 11, 2024 1:16 PM
To: Georgoulias, Bethany
Cc: Matt Desvergers
Subject: [External] FW: Scanned image from GreenHawk Corp BEVERLY PHASE 3
Attachments: GreenHawk Scan_20240411_130432.pdf
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the
Report Message button located on your Outlook menu bar on the Home tab.
Bethany, please see signed NOT form for Beverly phase 3. If you need to reach me by phone, my number is 919-805-
8946.
-----Original Message-----
From: [e-mail] <[e-mail]>
Sent:Thursday, April 11, 2024 1:05 PM
To: Paul Bailey<[e-mail]>
Subject: Scanned image from GreenHawk Corp
Reply to: GreenHawk Scan <[e-mail]> Device Name: GreenHawk Corp Device Model: BP-70C45
Location: 1330 Sunday Drive Suite 105 Raleigh NC 27607
File Format: PDF (Medium)
Resolution: 300dpi x 300dpi
Attached file is scanned image in PDF format.
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confidential and/or privileged information and may be legally protected from disclosure. If you are not the intended
recipient of this message or their agent, or if this message has been addressed to you in error, please immediately alert
the sender by reply email and then delete this message and any attachments. If you are not the intended recipient,you
are hereby notified that any use, dissemination, copying, or storage of this message or its attachments is strictly
prohibited.
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