NCC190138_NOI Application_20190430

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/30/2019 12:21:11 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 4/30/2019 1:58:45 PM (Review- Construction NOI 10519)
• The task was assigned to McCoy, Suzanne by round robin distribution 4/30/2019 12:21 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 2, 2019 5:00 PM
4/30/2019 12:21 PM
Submit by McCoy, Suzanne 4/30/2019 1:59:35 PM (Payment Verification - NCG01-2019-0138)
• The task was assigned to McCoy, Suzanne. The due date is: May 1, 2019 5:00 PM 4/30/2019 1:58 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Watkins Landing
2. County* Forsyth
3. Highway or Street Watkins Ford Road
Address * Street narra only is acceptable if no address nurrber assigned yet
4. City or Township* Kernersville
5. State * NC
1r-G)a�T:2,11111711Mfi1if_TiIa10141
6. Zip Code* 27284
7. Latitude * Enter the latitude in decirral degrees
36.0420
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-80.0990
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. Date to End*
11. SIC (Primary)*
12. Acres to be
disturbed *
13. Total site area
(acres)*
14. Post -
construction
impervious area
(acres) *
05/01 /2019
Estirrated Construction Project Start Date
05/01 /2021
Estirrated Construction Project End Date
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Developrrant
13.50
(including off -site borrow and waste areas)
30.41
2.45

NCC Project NCC-FORSY-2019-Watkins Landing
Tracking ID Assigned autorratically
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. You may
enter up to 3 waterbodies.
15a. Receiving Abbotts Creek
Wate rbody* l\bre of waterbody into which stornvwater runoff will discharge
15b. Waterbody 12-119-(1)
Index No. * NCWaterbody Index Ninber
Stormwater fJ No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project F Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act? *

B. Permittee Information
Part B.
Perrrittee Information - Legally Responsible Entity and Individual
.....................................................................................................................................................................
h
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should 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. Organization Shugart Homes
Name *
2. First Name*
Brian
ff Corporation, enter Registered Agent First l\b e
3. Last Name *
Shugart
ff Corporation, enter Registered Agent Last Barre
4. Permitee E-mail
[e-mail]
Address*
5. Permittee 336-231-6802
Telephone No.*
6. Permittee Mailing Street Address
Address* 221 Jonestown Road
Address Line 2
City
Winston-Salem
Fbstal / Zip Code
27104
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
221 Jonestown Road
Address Line 2
City
Winston-Salem
Postal / Zip Code
27104
State / Province / Region
NC
Country
us
State / Province / Region
NC
Country
us

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Greg
Contact - First
Name *
3. Primary Site Garrett
Contact - Last
Name *
4. Title VP of Land Development
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
336-231-6764
Telephone No.*
7. Organization
Shugart Homes
Name
8. Site Contact
Street Address
Mailing Address*
221 Jonestown Road
Address Line 2
oty
Winston-Salem
Rbstal / Zip Code
27104
State / Province / Region
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 04/12/2019
Approved *
2. E&SC Plan Project FORSY-2019-034
Number/ID* Assigned by agency or local program
3. E&SC Plan f• State DEQ Office
Approved by r 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.
5. E&SC Plan NCDEQ Letter of Approval 041219.pdf 183.9KB
Approval Mist be RDFformat
letter/documentation
6. NOI Certification Signed NOI.pdf 66.86KB
Form Mist be RDFformat
This is an Express f• No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.613 (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes 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 deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
rJ 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.
* rJ 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.
* I7 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ 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:* r The Responsible Person named on this Notice of Intent
r Authorized Responsible Person*
Important: The person who signs this Certification above and signs the NOI Certification Form should be the same
person (or authorized responsible person within the same organization) as listed in Section B (Permittee Information)
of this form. *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
,56614 P_ 5641 &&Y
Type Name * Brian D Shugart
Date * 04/30/2019

F. Tracking and COC Info
NOI Tracking No. 10519
NC Reference No. NCG01-2019-0138
Uses 'count_nunber variable (increrrented by SP)
Certificate of NCC190138
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 138
Sequential nunber for subrrittal that is increrrented by Stored Procedure
COC Year 2019
Year of date reviewed, used to assign YY digits after "NOC' in OOC no.)