NCC191649_NOI Signed Certification_20190830

NCG101 Notice of Intient (NOI) CerfificatIon Form
Print this form, cornplete, scan and upload to the electronic INOL
Then, mail the original: form to the NC DEMLR Storm,water Program at:
Division of Energy, Mineral & Land Resourcetormwater Pro rare
512, N , Salisbury Street, 61�1 Floor
1612 Mail Service Center
Rail eigh, INIC 27699-1612
P,erNCGeneraI$tatute 143-215X8 (i), anyperson who knowingly makes o,nyfolse statement, representation,
W(Vctftatidn hi arry application, record, report, plon, or other docurnentfifed or required to be mointoined
under tWAdkk or a rule kt�pl�menting this Artkle. . —shaft be guilty, of, o Class 2 misdemeanor which moy
Mc*j* olMe not to exceed tm thousand dollars ($10,000).
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