NCC192057_NOI Application_20190927

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 9/25/2019 3:44:22 PM(NCG01 NOI Submission)
Approve by Georgoulias, Bethany 9/26/2019 7:46:54 AM(Review-Construction NOI 16298)
• The task was assigned to Georgoulias, Bethany by round robin distribution 9/25/2019 3:44 PM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is: September 27,2019 5:00
PM 9/25/2019 3:44 PM
Submit by McCoy,Suzanne 9/27/2019 7:28:12 AM(Payment Verification for NCC192057)
* Jill Biddle.
• McCoy, Suzanne assigned the task to McCoy,Suzanne 9/27/2019 7:27 AM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is: November 7,2019 5:00
PM 9/26/2019 7:47 AM

1 sees �' � ••. -• i •• i i• i
IY sell
NORTH CAROLINA
Environmental QUII
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* Poplar Wells Subdivision
2. County* Alamance
3. Highway or Street 5533 Kimesville Rd
Address* Street narra only is acceptable if no address nurrber assigned yet
4. City or Township* Liberty
5. State* INC
6.Zip Code* 27298
7. Latitude* Enter the latitude in decirral degrees
35.9773
8. Longitude* Enter the longitude in decirral degrees(MIST be negative)
-79.5290
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* 11/01/2019
Estimated Construction Project Start Date
10. Date to End* 11/01/2020
Estimated Construction Project End Date
11. SIC(Primary)* Residential, Single
Family Houses(SFE)
(1521)
Standard Industrial aassification for Developrrant
12.Acres to be 6.20
disturbed* (including off-site borrow and waste areas)
13.Total site area 25.98
(acres)*
14. Post- 6.00
construction (Estimated)
impervious area
(acres)*

NCC Project NCC-ALAMA-2019-Poplar Wells Subdivision
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. Please
enter only immediate receiving waterbodies-not waters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a.Receiving North Prong Stinking Quarter Creek
Waterbody* %n-e of waterbody into which storrrwater runoff will discharge
15b.Waterbody 16-19-8-1
Index No.* NCWaterbody Index Narrber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs*
15c.Additional South Prong Stinking Quarter Creek
Receiving Waterbody narre
Waterbody
15d.Waterbody 16-19-8-2-(2)
Index No. NCWaterbody Index%nber
15e.Additional Waterbody narre
Receiving
Waterbody
15f.Waterbody NCWaterbody Index Ninber
Index No.
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
.....................................................................................................................................................................
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 Triad Investment Partners, LLC
Name*
2. First Name* Gary
ff Corporation,enter Registered Agent First l\b e
3. Last Name* Berg
ff Corporation,enter Registered Agent Last Barre
3b.Title Member
4. Permitee E-mail [e-mail]
Address*
5. Permittee 3365108606
Telephone No.*
6. Permittee Mailing Street Address
Address* 2515 Penny Rd
Address Line 2
Suite 102
City State/Province/Region
High Point NC
Postal/Zip Code Country
27265 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 2515 Penny Rd
Address Line 2
Suite 102
City State/Province/Region
High Point NC
Pastal/Zip Code Country
27265 us

C. Site Contact Information
Part C.
Project Site Contact Information
....................................................................................................................
1.Type of Non-Government
Ownership*
2. Primary Site Steve
Contact-First
Name*
3.Primary Site Stone
Contact-Last
Name*
4.Title Vice President of Construction
5.Site Contact E- [e-mail]
mail Address*
6.Site Contact 3365108606
Telephone No.*
7.Organization Triad Investment Partners, LLC
Name
8.Site Contact Street Address
Mailing Address* 2515 Penny Road
Address Line 2
Suite 102
City State/Province/Plegion
High Point NC
Fbstal/Zip Code Country
27265 us
9.Consultant Name (optional)
Summey Engineering, PLLC
First and Last narre
10.Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant 3363280902
Telephone No.

D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Ran Approval Information
....................................................................................................................................................................................................................................... .............................................................................................
1. Date E&SC Plan 09/06/2019
Approved*
2. E&SC Plan Project ALAMA-2020-001
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 Approval Letter.pdf 158.6KB
Approval Mist be RDFforrrat
letter/documentation
6. NOI Certification Poplar Wells NOI- 16077.pdf 397.72KB
Form Mist be RJFfornat
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 electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee,that individual must be an authorized responsible
person within the same organization as the Permittee. *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 �1
Type Name* Gary D. Berg
Title Member
Organization Triad Investment Partners, LLC
Date* 09/25/2019

F. Tracking and COC Info
NOI Tracking No. 16298
NC Reference No. NCG01-2019-2057
Uses'count number variable(incremented by SP)
Certificate of NCC192057
Coverage (COC) Uses'count_nunber'variable(increrrented bySP)
No.*
Count Number 2057
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.)