NCC191271_NOI Application_20190808

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/7/2019 12:44:44 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 8/7/2019 3:07:25 PM (Review- Construction NOI 14579)
• The task was assigned to McCoy, Suzanne by round robin distribution 8/7/2019 12:45 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 9, 2019 5:00
PM 8/7/2019 12:45 PM
Submit by Lucas, Annette 8/8/2019 9:14:53 AM (Payment Verification for NCC191271)
• Lucas, Annette assigned the task to Lucas, Annette 8/8/2019 9:14 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: August 21, 2019 5:00 PM
8/7/2019 3:07 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Cultural Center Lake Dam Repair
2. County* Robeson
3. Highway or Street 678 Terry Sanford Drive
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Pembroke
5. State * NC
1 r-i) iTiT 7i) M fiIi (-:To a 10141
6. Zip Code* 28372
7. Latitude * Enter the latitude in decirral degrees
34.7082
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-79.2684
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*
10/01/2019
Estimated Construction Project Start Date
10. Date to End*
05/29/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
25.70
disturbed*
(including off -site borrow and waste areas)
13. Total site area
384.00
(acres)*
14. Post-
0.02
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-ROBES-2019-Cultural Center Lake Dam Repair
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 Lumber River
Waterbody * Nacre of waterbody into which stormuater runoff will discharge
15b. Waterbody 14-(4.5)
Index No. * NCWaterbody Index Nunber
Stormwater r No
discharges will flow rj Yes
to additional
wate rs *
15c. Additional Gum Swamp
Receiving Waterbody narre
Waterbody
15d. Waterbody 14-5
Index No. NCWaterbody Index Ninber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Nunter
Index No.
16a. Is this project r Yes
subject to the NC f 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 Lumbee Tribe of North Carolina
Name *
2. First Name* Freda
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Porter
ff Corporation, enter Registered Agent Last Barre
3b. Title Tribal Administrator
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-522-2187
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box2709
Address Line 2
6984 NC Hwy 711 West
City
Pembroke
Postal / Zip Code
28372
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
PO Box 2709
Address Line 2
6984 NC Hwy 711 West
City
Pembroke
Postal / Zip Code
28372
State / Province / Region
NC
Country
USA
State / Province / Region
NC
Country
USA

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Government - State
Ownership*
2. Primary Site Amy
Contact - First
Name *
3. Primary Site Black
Contact - Last
Name *
4. Title Project Engineer
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 336-996-9974 x 107
Telephone No.*
7.Organization Jewell-LJB
Name
8. Site Contact Street Address
Mailing Address* PO Box2294
Address Line 2
aty
Kernersville
Fbstal / Zip Code
27285
State / Province / Region
NC
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 08/01/2019
Approved *
2. E&SC Plan Project ROBES-2019-004
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 * Fayetteville (FRO)
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 robes2019004apRev. pdf 69.81 KB
Approval Mist be FDFforrrat
letter/documentation
6. NOI Certification scan [e-mail]_20190807_111017.pdf 1.01MB
Form Mist be RDFforrret
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
Type Name * Freda Porter, PhD
Title Tribal Administrator
Organization Lumbee Tribe of North Carolina
Date * 08/07/2019

F. Tracking and COC Info
NOI Tracking No. 14579
NC Reference No. NCG01-2019-1271
Uses 'count_nunber variable (increrrented by SP)
Certificate of NCC191271
Coverage (COC) Uses'count_nunber'variable (incremented by SF)
No. *
Count Number 1271
Sequential nunber for subrrittal that is increrrented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NGC' in OOCno.)