NCC240557_Contact Update Record_20250205

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 2/5/2025 10:40:27 AM (Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC240557
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2024-0557
Original NOI No.* 184229
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Davidson Water, Inc.
Project Name Highway 150 16"Waterline Improvements
Address NC Highway 150,Lexington, NC
County Davidson
Latitude 35.7934
Longitude -80.4085
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Prior Rescission Date This field will populate only if COC has already been rescinded.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
C) Yes
Billing Email [e-mail]
Billing Telephone No. 336-731-5561
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Robert Walters
Individual(Previous)
First Name(New)* Ben
Last Name(New)* Palmer
NEW Legally Reflects any revisions above
Responsible Ben Palmer
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 969, 0,Welcome, NC 27295-6096
Address(Previous)
NEW Permittee Street Address
Mailing Address* P.O. Box 969
Address Line 2
City State/Province/Region
Welcome NC
Postal/Zip Code Country
27374 USA
Permittee Street 7040 Old U.S. Highway 52,0, Lexington, NC
Address(Previous) 27295-6096
NEW Permittee Street Street Address
Address* 7040 Old U.S. Highway 52
Address Line 2
City State/Province/Region
Lexington NC
Postal/Zip Code Country
27295-6096 US
Change Requested Ben Palmer(Director of Construction&Engineering)via Modification request
by:* submitted 2/3/2025.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 02/05/2025