NCC242564_NOI Application_20240826

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 8/20/2024 8:31:11 PM(NCG01 NOI Submission)
Approve by Brooklyn.Broussard 8/21/2024 7:21:43 AM (Review-NOI 213499 Highway 65 Water Line Extension)
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:August 23,2024 5:00 PM.
The priority is: Medium 8/20/2024 8:31:25 PM
• The task was assigned to Brooklyn.Broussard by round robin distribution 8/20/2024 8:31:25 PM
Submit by Tev.Holloman 8/26/2024 10:59:46 AM (Payment Verification for NCC242564)
•Ninette P Diggs
• The task was assigned to DEMLR NCG01 Payment Team.The due date is:October 2,2024 5:00 PM.
The priority is: Medium 8/21/2024 7:22:01 AM
• Tev.Holloman assigned the task to Tev.Holloman 8/26/2024 10:57:10 AM

applicationConstruction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System(NPDES)
General Permit 1 OOOO:STORMWATER DISCHARGES associated with construction activities
NORTH CAROUNA
Environmental Quality
A. Project Information
Part A.
Project Location and Waterbody Information
...................................................................................................................................................................................................................................................................................................................................................................................................
Are you submitting an NOI that was rejected before?
No
Yes
1a.Project Name*
Highway 65 Water Line Extension
1b.Specific Lot Numbers
This field may be used to list specifc lot numbers.
1c.Parcel ID Number(s)(PIN)
List all PINs associated with this project.
6910-99-3704
6921-91-2640
6921-92-1161
6921-70-7652
6921-70-4586
6921-00-1378
6921-10-0292
6920-29-5624
6921-70-1314
6921-60-5140
6921-60-3014
6921-40-4467
6921-71-5239
6920-09-1713
6921-40-2442
6921-93-8463
6931-02-6859
6921-81-6965
2.County*
Forsyth
3.Highway or Street Address*
Highway 65 between Rural Hall and Germanton in Forsyth County
Street name only is acceptable if no address number assigned yet
4.City or Township*
Rural Hall
5.State* NC
6.Zip Code* 27045

7. Latitude* Enter the latitude in decimal degrees
36.2424
8. Longitude* Enter the longitude in decimal degrees(MUST be negative)
-80.2908
If you do not know the latitude and longitude coordinates for this project,you can search the location on this map of North
Carolina. Look for the coordinates in the bottom left corner.
9. Date to Begin* 10/16/2024
Estimated Construction Project Start Date
10. Date to End* 09/05/2025
Estimated Construction Project End Date
11.SIC(Primary)*
Other(9999)
Standard Industrial Classification for Development
12.Acres to be 6.60
disturbed* (including off-site borrow and waste areas)
13.Total site area 6.60
(acres)*
14. Post-construction 0.00
impervious area (Estimated)
(acres)*
Project Tracking ID NCC-FORSY-2024-Highway 65 Water Line Extension
Assigned automatically(not used)
Below you must enter waterbody information for surface waters affected by this project. Please consult
DWR's Surface Water Classifications Map Viewer to find waterbody name and corresponding index number. Please enter
only immediate receiving waterbodies-not waters downstream of those unless the project extends there. You may enter
up to 3 waterbodies if needed.
15a.Receiving Waterbody*
Lucy Branch
Name of waterbody into which stormwater runoff will discharge
15b.Waterbody Index No.
22-25-5-2-1
NC Waterbody Index Number
Stormwater discharges will flow to additional waters*
No
Yes
15c.Additional Receiving Waterbody
Leak Branch
Waterbody name
15d.Waterbody Index No.
22-25-4
NC Waterbody Index Number
15e.Additional Receiving Waterbody
Town Fork Creek
Waterbody name

15f.Waterbody Index No.
22-25
INC Waterbody Index Number
16a.Is this project subject to the NC Sediment Pollution Control Act?*
Yes
No, not subject to NC SPCA
17. Is this project funded with ARPA(American Rescue Plan Act)grant funds?
No
Yes
This question was added to the eNOI on 1/26/2023 and will not be answered in applications submitted prior to that date.
18.ARPA Project Number
Project number assigned by Division of Water Infrastructure(e.g.,SRP-D-ARP-0090)
SRP-D-ARP-0047
CONFIRMED ARPA Project Number
REVIEWER:Confirm DWI Assigned ARPA Project No.(Revise if necessary)
SRP-D-ARP-0047
19. Letter of Intent to Fund(LOIF)ARPA Project
Please upload the Letter of Intent to Fund provided by the N.C.Division of Water Infrastructure(DWI)for this project that references the assigned ARPA
Project number.
Winston-Salem_ARP0047_LOIF_220218.pdf 859.58KB
Must be PDF format

B. Permittee Information
Part B.
Permittee Information-Legally Responsible Entity and Individual
......................................................................................................................................................................
Important:The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form must be the same person as listed in THIS SECTION,or an authorized responsible individual within the same
organization. That person must be a responsible corporate officer who 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.
1. Permittee*
Legally Responsible Entity
Winston-Salem/Forsyth County Utilities
If permittee is an individual,enter first and last name in this field.Otherwise,enter organization/business name.
Note: If the permittee is a business,the business must be registered with the INC Secretary of State.You can verify the
registration here. Permittee must be the same entity that is responsible for the land-disturbing activity as listed on the NC
SPCA Financial Responsibility/Ownership(FRO)Form.
2. First Name* Michael
If Corporation,enter Registered Agent First Name
3. Last Name* Stover
If Corporation,enter Registered Agent Last Name
3b.Title Deputy Utilities Director
4. Permitee E-mail Address*
[e-mail]
5. Permittee Telephone No.*
336-747-6840
6. Permittee Mailing Address*
Street Address
PO Box 2511
Address Line 2
City State/Province/Region
Winston-Salem INC
Postal/Zip Code Country
27102 us
Check box if the street address the same as mailing address
Yes
7. Permittee Street Address*
Street Address
100 East First Street
Address Line 2
City State/Province/Region
Winston-Salem NC
Postal/Zip Code Country
27101 us

B.Type of Ownership*
Ownership is only individual if an individual is named in B.1.above.
Government-Municipal

C. Site Contact Information
Part C.
Project Site Contact Information
................................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Contact-First Name*
Brad
2. Primary Site Contact-Last Name*
Bennett
3.Title
Associate
4.Site Contact E-mail Address*
[e-mail]
5.Site Contact Telephone No.*
[phone]
6.Organization Name
Hazen&Sawyer
7.Site Contact Mailing Address*
Street Address
620 Green Valley Road
Address Line 2
Suite 101
City State/Province/Region
Greensboro NC
Postal/Zip Code Country
27408-7729 us
8.Consultant Name
(Optional)
Hazen&Sawyer
First and Last name
9.Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10.Consultant Telephone No.
[phone]
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-mail
12. Billing Telephone
(For Annual Fee correspondence)
336-747-6840
Default is legally responsible person telephone

D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Plan Approval Information
......................................................................................................................................................................
1. Date E&SC Plan 05/06/2024
Approved*
2. E&SC Plan Project FORSY-2024-0118
Number/ID* Assigned by agency or local program
3. E&SC Plan State DEQ Office
Approved by* Local Program
4.State DEQ Office* Winston-Salem(WSRO)
Documentation of E&SC Plan approval and the signed Notice of Intent(NOI)Certification Form is required for a
complete application. Please also upload a site map showing the overall extent of the project(for linear projects,can
include the beginning point and end point coordinates in the"Notes"box below).
5. E&SC Plan E&SC Permit.pdf 1.06MB
Approval letter or Must be PDF format
Grading Permit
6.Signed FRO Financial Responsibility/Ownership Form
FRO.pdf 2.85MB
Must be PDF format
7.Site Location Map Must be PDF format(limit 20 MB)
Vicinity Map.pdf 4.45MB
Please do not upload entire set of E&SC plans.
8. Notes(Optional) Provide any additional information that might help the reviewer better understand how uploaded documents
support the application.Include additional waterbodies if necessary.
The project runs along Highway 65 in Forsyth County between Rural
Hall and Germanton.
Permit application was done using the online application portal;
therefore,the FR/O was issued with the letter of approval.
9. NOI Certification NCG01 Permit 082024.pdf 1.17MB
Form Must be PDF format
This is an Express No
Review Project* Yes

E. Certification
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).
Under penalty of law, I certify that:
* 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.
* I hereby request coverage under the NCG010000 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.
Specify if you are:* The Legally Responsible Person named on this Notice of Intent
Authorized Responsible Person'(signing on behalf of Legally Responsible Person
named in Part B)
Important:The person who electronically signs this Certification above must be the same person who signs the NOI
Certification Form. 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.
'An authorized individual is a responsible corporate officer who 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
Type Name* Michael Stover
Title Deputy Utilities Director
Organization Legally Responsible Entity
Winston Salem/Forsyth County Utilities
Date* 08/20/2024

F. Tracking and COC Info
NOI Tracking No. 213499
NC Reference No. NCG01-2024-2564
Indicates NCG01 or NCG25.Uses NOI number until approved,then uses NUMBER incremented by SIP(passed
from workflow if eNOI approved)
Certificate of NCC242564
Coverage(COC) No.* Uses NOI number until approved,then uses NUMBER incremented by SIP(formatted and passed from workflow if
eNOI approved)
Initial Invoice No. NCC242564-2024
Invoice Due Date 9/20/2024
Initial Fee $ 120.00
Fee increased to$120,effective October 3,2023
Invoice Status OPEN