NCC243228_NOI Signed Certification_20241021

NCGO1 Notice of Intent (NCI)) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NOI.
Then,mail the original form to the NC DEMLR Stormwater Program(with$120 check if paying by check)
at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N.Salisbury Street,6th Floor(Office 640K)
1612 Mail Service Center
Raleigh,NC 27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.221
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(check all boxes to indicate your agreement):
E 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.
[]✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
0 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.
Project Name(must match Ala): The Proximity Blue Clay, LLC
Specific Lot Numbers(must match Alb):
Permittee(must match B1): The Proximity Blue Clay, LLC
Legally Responsible Person(must match 82&83): Calvin Wells, Jr.
Title of Legally Responsible Person(must match 83b): Manager
Print Name&Title of Signed if Authorized
individual Differs from Lega y Respo le Person:
Phone Number: 910- 1 2
/o/ ii h
Signature of le Ily ponsible Person or Authorized Individual Date
* 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 8,
Item(6)of the NCGO10000 permit.

STATE OF NORTH CAROLINA
ROUTE SR 1318(Blue Clay Rd) PROJECT The Proximity Blue Clay,LLC COUNTY OF New Hanover
DEPARTMENT OF TRANSPORTATION THREE PARTY RIGHT OF WAY
AND- ENCROACHMENT AGREEMENT ON
The Proximity elue Clay.U-C 9to-3e41002 PRIMARY AND SECONDARY SYSTEM
102 Autumn Halt Dr..Suite 210 Wilm.,NC 28403
-AND-
Cape Fear Public Utility Authority 910-332-6629
235 Government Center Dr Wilmington,NC 28403
THIS AGREEMENT,made and entered into this the day of 20 ,by and between the Department
of Transportation,party of the first part,and The Proximity Blue Clay,LLC
party of the second part,and
Cape Fear Public Utility Authority party of the third part,
WITNESSETH
THAT WHEREAS,the party of the second part desires to encroach on the right of way of the public road designated as
Route(s) SR 1318(Blue Clay Rd) ,located -1 4 miles North from the intersection of SR 1322
(N Kerr Ave.)and SR 1318(Blue Clay Rd)toward North
with the construction and/or erection of -60 LF of 10'waterline within the right-of-way Installed by jack&bore&-57 LF of 6'SSFM
within the right-of-way instated by jack&bore
WHEREAS,it is to the material advantage of the party of the second part to effect this encroachment,and the party of
the first part in the exercise of authority conferred upon it by statute,is willing to permit the encroachment within the limits of the
right of way as indicated,subject to the conditions of th's agreement;
NOW,THEREFORE,IT IS AGREED that the party of the first part hereby grants to the party of the second part the right
and privilege to make this encroachment as shown on attached plan sheet(s),specifications and special provisions which are
made a part hereof upon the following cond Lions,to wit.
That the installation operation and maintenance of the above described facility will be accomplished in accordance with the party of
the first part's latest UTILITIES ACCOMMODATIONS MANUAL and such revisions and amendments thereto as may be in effect at the
date of this agreement. Information as to these policies and procedures may be obtained fr::m the Division Engineer or Stale Utilities
Manager of the party of the first pan
That the sad party of the second part binds and obilgales himself to install and maintain the encroaching facility in such safe and proper
condition that it will not Interfere with or endanger travel upon said highway,nor obstruct nor interfere with the proper maintenance
thereof to reimburse the party of the first part for the cost incurred for any repairs or maintenance to its roadways and structures
necessary due to installation and existence of the lac lilies of the party of the second part,and if at any time the party of the first part shall
require the removal of or changes in the location of the said facilities that the sad party of the second part binds himself,his successors
and assgns,to promptly remove or alter the said facilities in order to conform to the said requirement,without any cost to the party of the
first part.
That the party of the second part agrees to provide during construction and any subsequent maintenance proper signs,signal lights
flagmen and other warning devices for the protection of traffic in conformance with the latest Manual on Uniform Traffic Control Devices
for Streets and Highways and Amendments or Supplements thereto Information as to the above rules and regulations may be obtained
from the Division Engineer of the party of the first
That the party of the second part hereby agrees to indemnify and save harmless the party of the first part from all damages and
claims for damage that may arise by reason of the.nsta lation and maintenance of this encroachment.
That the party of the second part agrees to restore all areas disturbed during installation and maintenance to the satisfaction of the
Division Engineer of the party of the first part The party of the second part agrees to exercise every reasonable precaution during
construction and maintenance to prevent eroding of soil,silting or pollution of rivers,streams,takes reservoirs,other water
impoundments,ground surfaces or other property,or pollution of the air There shat be compliance wilh applicable rules and regulations
of the North Carolina Division of Environmental Management North Carol na Sedimentation Control Commission,and with ordinances
and regulations of various counties municipa ities and other official agencies relating to pollution prevention and control. When any
installation or maintenance operation disturbs the ground surface and existing ground cover,the party of the second part agrees to
remove and replace the sod or otherwise reestablish the grass cover to meet the satisfaction of the Division Engineer of the party of the
first part.
Thal the party of the second part agrees to assume the actual cost of any inspection of the work considered to be necessary by the
Division Engineer of the party of the first part
That the party of the second part agrees to have available at the construction site,at all times during construction,a copy of this
agreement showing evidence of approval by the party of the first part The party of the first part reserves the right to stop all work unless
evidence of approval can be shown.
Provided the work contained in this agreement is being performed on a completed highway open to traffic;the party of the second part
agrees to give written notice to the Division Engineer of the party of the first part when all work contained herein has been completed
Unless specifically requested by the party of the first part,written notice of completion of work on highway projects under construction will
not be required.
That in the case of noncompliance with the terms of this agreement by the party of the second part,the party of the first part reserves
the right to stop all work until the facility has been brought into compliance or removed from the right of way at no cost to the party of the
first part.
That it is agreed by both parties that this agreement shall become void if actua construction of the work contemplated herein Is not
begun within one(I)year from the date of authorization by the party of the first part unless written waiver is secured by the party of the
second part from the party of the first part.
FORM RIW 16.6
Rev.February 2021

During the performance of this contract,the second party.for tee f,its assignees and successors in interest(hereinafter referred to as
the'contractor),agrees as follows
a. Compliance with Regulations: The contractor shall comply with the Regulations relative to nondiscrimination in Federally
assisted programs of the U S.Department of Transportation,Title 49,Code of Federal Regulations,Part 21,as they may be
amended from time to time (hereinafter referred to as the Regulations),which are herein incorporated by reference and
made a part of this contract
b. Nondiscrimination: The contractor with regard to the work performed by it during the contract,shall not discriminate on the
grounds of race,color,or national origin in the selection and retention of subcontractors,Including procurements of materia s
and leases of equipment The contractor sha not participate either directly or indirectly in the discrimination prohibited by
Section 21.5 of the Regulations,including employment practices when the contract covers a program set forth'n Appendix B
of the Regulations.
c. Solicitations for$yrbcontracts.including ProCeremenls Of Materials and Equipment- In al solicitations either by competitive
bidding or negotiation made by the contractor for work to be performed under a subcontract,including procurements of
materials or leases of equipment,each potential subcontractor or supplier shall be notified by the contractor of the
contractor's obligations under this contract and the Regulations relative to nondiscrimination on the grounds of race,color,or
national origin.
d. Information and Reports. The contractor shall provide all information and reports required by the Regulations or directives
Issued pursuant thereto,and shall permit access to its books,records,accounts.other sources of information and its
facilities as may be determined by the Department of Transportation or the Federal Highway Administration to be pertinent
to ascertain Compliance with such Regulations or d rectives. Where any information required of a contractor is in the
exclusive possession of another who fails or refuses to furnish this information,the contractor shall so Certify to the
Department of Transportation or the Federal Highway Administration as appropr ale,and shall set forth what efforts it has
made to obtain the information.
e. Sanctions for Noncompliance In the event of the contractors noncomplance with the nondiscrimination provisions of this
contract,the Department of Transportation shall impose such contract sanctions as it or the Federa Highway Administration
may determine to be appropriate.including but not lim ted to
(1)withholding of payments to the contractor under the contract unti the contractor complies,and/or
(2) cancellation,termination or suspension of the contract,in whole or in part
f. Incorporation of Provisions. The contractor shall nclude the provisions of paragraphs'a'through'} it every subcontract
including procurements of materials and leases of equipment unless exempt by the Regulations or directives issued
pursuant thereto. The contractor shall take such action with respect to any subcontract or procurement as the Department
of Transportation or the Federal Highway Admin stration may direct as a means of enforcing such provisions ncluding
sanctions for noncompliance Provided however,that in the event a contractor becomes involved in or is threatened with
litigation with a subcontractor Or supplier as a resu t of such direction the contractor may request the Department of
Transportation to enter into such litigation to protect the interests of the State and,in addition,the contractor may request
the United States to enter into such litigation to protect the interests of the United States.
That when title to the subject that constitutes the aforesaid encroachment passes from the party of the second part
and vests in the party of the third part,the party of the third part agrees to assume all responsibilities and rights and to
perform all obligations as agreed to herein by the party of the second part.
RM!(166):Party of the Second Part certifies that this agreement is true and accurate copy of the form
RAN(166)incorporating all revisions to date.
IN WITNESS WHEREOF,each of the parties to this agreement has caused the same to be executed the day and
year first above written.
DEPARTMENT OF TRANSPORTATION
BY:
ISION ENGINEER
WITNESS:
Grp tC4 4_ ove- L t.C- —. __ Calvin e s, Jr., Manager
(A.1„4_,n.n•-k, Wc4rI The Proximity Blue Clay, LLC
102 Autumn Hall Dr.,Suite 210
Wilm., NC 28403 Second Party 910-344-1002
WITNESS:
Donna S.Pope,Clerk to the Board Gary McSmith, Asst Engineering Director
Cape Fear Public Utility Authority Cape Fear Public Utility Authority
235 Government Center Dr. Wilm.,NC 28403 235 Government Center Dr. Wilm.,NC 28403
910-332-6660 910-332-6629 Third Party