NCC191878_NOI Application_20190913

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/12/2019 2:05:54 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 9/13/2019 11:22:25 AM (Review- Construction NOI 15857)
• The task was assigned to McCoy, Suzanne by round robin distribution 9/12/2019 2:06 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 16, 2019 5:00
PM 9/12/2019 2:06 PM
Submit by McCoy, Suzanne 9/13/2019 11:26:29 AM (Payment Verification for NCC191878)
* J. Westmoreland Inc
• McCoy, Suzanne assigned the task to McCoy, Suzanne 9/13/2019 11:25 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 25, 2019 5:00 PM
9/13/2019 11:22 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * J Westmoreland, Inc - LCID Landfill
2. County* Forsyth
3. Highway or Street 6250 Walnut Cove Road
Address * Street name only is acceptable if no address nurrber assigned yet
4. City or Township* Walkertown
5. State * NC
117-8) sT.:2,G) M 1-11 (-_TiI a 1010
6. Zip Code* 27051
7. Latitude * Enter the latitude in decirral degrees
36.1964
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-80.1646
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* 09/16/2019
Estimated Construction Project Start Date
10. Date to End* 09/28/2020
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 14.20
disturbed* (including off -site borrow and waste areas)
13. Total site area
38.73
(acres)*
14. Post-
3.20
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-FORSY-2019-J Westmoreland, Inc - LCID Landfill
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 Old Field Creek
Waterbody * Narre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 22-25-11
Index No. * NCWaterbody Index N nber
Stormwater r No
discharges will flow rj Yes
to additional
wate rs *
15c. Additional Waterbody narre
Receiving
Waterbody
15d. Waterbody NC Waterbody Index N nber
Index No.
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NC Waterbody Index N rater
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 J Westmoreland, Inc
Name *
2. First Name* Thomas
If Corporation, enter Registered Agent First l\b e
3. Last Name * Westmoreland
ff Corporation, enter Registered Agent Last Barre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-529-4472
Telephone No.*
6. Permittee Mailing Street Address
Address* 6851 Old Still Trail
Address Line 2
City
Kernersville
Postal / Zip Code
27284
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
6851 Old Still Trail
Address Line 2
City
Kernersville
R bstal / Zip Code
27284
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 Thomas
Contact - First
Name *
3. Primary Site Westmoreland
Contact - Last
Name *
4. Title President
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
336.529.4472
Telephone No.*
7. Organization
J Westmoreland, Inc
Name
8. Site Contact
Street Address
Mailing Address*
6851 Old Still Trail
Address Line 2
aty
Kernersville
Fbstal / Zip Code
27284
9. Consultant Name (optional)
Alex Carter
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant 336.748.0071
Telephone No.
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 09/10/2019
Approved *
2. E&SC Plan Project 43495
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Winston-Salem/Forsyth County
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 AP 43495 Approval Letter.pdf 182.92KB
Approval Mist be PCFfornat
letter/documentation
6. NOI Certification eNO1 Form Signed.pdf 1.84MB
Form Mist be RDFfornet
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6B (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.
* V 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.
* V If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit, I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* I7 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* Thomas Westmoreland
Title President
Organization J Westmoreland, Inc
Date * 09/12/2019

F. Tracking and COC Info
NOI Tracking No. 15857
NC Reference No. NCG01-2019-1878
Uses 'count number variable (incremrented by SP)
Certificate of NCC191878
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 1878
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.)