NCC191244_NOI Application_20190807

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/1/2019 12:46:43 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 8/6/2019 9:52:13 AM (Review- Construction NOI 14405)
• The task was assigned to Morman, Alaina by round robin distribution 8/1/2019 12:46 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 5, 2019 5:00
PM 8/1/2019 12:46 PM
Submit by Lucas, Annette 8/7/2019 8:14:01 AM (Payment Verification for NCC191244)
• Lucas, Annette assigned the task to Lucas, Annette 8/7/2019 8:13 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: August 20, 2019 5:00 PM
8/6/2019 9:52 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Gamble Solar, LLC
2. County* Rutherford
3. Highway or Street 799 Old U.S. Highway 74
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Bostic
5. State * NC
1r-i)iTII1T7i1)MF11(-_TiIa10141
6. Zip Code* 28018
7. Latitude * Enter the latitude in decirral degrees
35.3500
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-81.8190
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* 08/05/2019
Estimated Construction Project Start Date
10. Date to End* 12/31 /2019
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 13.00
disturbed* (including off -site borrow and waste areas)
13. Total site area
29.00
(acres)*
14. Post-
0.10
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-RUTHE-2019-Gamble Solar, LLC
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 Webbs Creek
Waterbody * Nbrre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 9-41-22-(1)
Index No. * NCWaterbody Index Pbnber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional Puzzle Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 9-41-19
Index No. NCWaterbody Index Narrber
15e. Additional Second Broad River
Receiving Waterbody narre
Waterbody
15f. Waterbody 9-41-(12.7)
Index No. NCWaterbody Index Narrber
16a. Is this project r 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 A>ds Energy, Inc
Name *
2. First Name* Jeff
ff Corporation, enter Registered Agent First Nacre
3. Last Name * Filippo
Y Corporation, enter Registered Agent Last Narre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-218-6711
Telephone No.*
6. Permittee Mailing Street Address
Address* 100 Newspaper Way, Suite 105
Address Line 2
City State / Province / Region
Holly Springs NC
Postal / Zip Code Country
27540 us
Check box if the r% Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 100 Newspaper Way, Suite 105
Address Line 2
City
State / Province / Region
Holly Springs
NC
Postal / Zip Code
Country
27540
us

C. Site Contact Information
Part C.
Roiect Site Contact hforrration
1. Type of Individual
Ownership*
2. Primary Site Josh
Contact - First
Name *
3. Primary Site Butler
Contact - Last
Name *
4. Title General Manager
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 919-218-6711
Telephone No.*
7. Organization
Axis Energy, Inc
Name
8. Site Contact
Street Address
Mailing Address*
100 Newspaper Way, Suite 105
Address Line 2
aty
Holly Springs
Fbstal / Zip Code
27540
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 07/30/2019
Approved *
2. E&SC Plan Project RUTHE-2020-002
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 * Asheville (ARO)
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 LOA & COPA 7-30-2019.docx.pdf 113.52KB
Approval Mast be PCFfornat
letter/documentation
6. NOI Certification NCG01 - Signed.pdf 33.87KB
Form Mist be RDFfornat
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
0/��
Type Name * Jeff Filippo
Title President
Organization Axis Energy, Inc
Date * 08/01 /2019

F. Tracking and COC Info
NOI Tracking No. 14405
NC Reference No. NCG01-2019-1244
Uses 'count number variable (incremrented by SP)
Certificate of NCC191244
Coverage (COC) Uses'countnunber'variable (incremrented by SF)
No. *
Count Number 1244
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NGC' in OOCno.)