NCC221767_Contact Update Record_20240506

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 5/6/2024 3:05:45 PM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC221767
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2022-1767
Original NOI No.* 90518
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Town of Drexel
Project Name Drexel 1 Site
Address 101 Main Street, Drexel, NC
County Burke
Latitude 35.7590
Longitude -81.6050
Date COC Issued* 04/01/2024
Prior Rescission Date This field will populate only if COC has already been rescinded.
Which Contacts Have Billing Only
Changed?* Legally Responsible Individual Only
Site Contact Only
BOTH Legally Responsible Individual and Site Contact
Has Billing Contact Choose'Yes'to revise Billing Contact details.
Changed? Q No
0 Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 828 437-7421
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Sherri Bradshaw
Individual(Previous)
First Name(New)* William
Last Name(New)* Carroll

NEW Legally Reflects any revisions above
Responsible William Carroll
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing PO Box 188, 0, Drexel, NC 28655-3657
Address(Previous)
NEW Permittee Street Address
Mailing Address* P.O. Box 188
Address Line 2
City State/Province/Region
Drexel NC
Postal/Zip Code Country
28619 United States
Permittee Street 202 Church Street,0, Morganton, NC 28655-
Address(Previous) 3657
NEW Permittee Street Street Address
Address* 202 Church Street
Address Line 2
City State/Province/Region
Morganton NC
Postal/Zip Code Country
28655 US
Change Requested William Carroll via Modification request submitted 5/2/2024.(Street address zip
by:* code maintained as 28655/verified by map search for Church St)
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 05/06/2024