NCC201110_NOI Application_20200330

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/17/2020 11:06:57 AM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 3/19/2020 1:31:00 PM (Review- Construction NOI 23159)
• The task was assigned to McCoy, Suzanne by round robin distribution 3/17/2020 11:07 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 19, 2020 5:00
PM 3/17/2020 11:07 AM
Submit by Garcia, Lauren V 3/30/2020 10:26:03 AM (Payment Verification for NCC201110)
* Meadowlands Development LLC
• Garcia, Lauren V assigned the task to Garcia, Lauren V 3/30/2020 10:24 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 30, 2020 5:00 PM
3/19/2020 1:31 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Meadowlands Subdivision - Inverness Park
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers 65
2. County* Davidson
3. Highway or Street Inverness Dr.
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Winston-Salem
5. State * NC
6. Zip Code* 27107
7. Latitude* Enter the latitude in decimal degrees
36.0076
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.1630
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*
05/01/2020
Estimated Construction Project Start Date
10. Date to End *
05/15/2021
Estimated Construction Project End Late
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial Classification for Development
12. Acres to be
19.81
disturbed*
(including off -site borrow and waste areas)
13. Total site area 25.06
(acres)*

14. Post- 5.81
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-DAVID-2020-Meadowlands Subdivision - Inverness Park
Tracking ID Assignedautorratically
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 Long Branch
Waterbody* Klarre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-119-5-2
Index No.* NCWaterbody Index Number
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
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. ^
F2rnittee Inforrration - Legally Fbsponsible 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 Meadowlands Development, LLC
Name * If perrrittee is an individual (i.e., organization does not apply), enter first and last nave in this field.
2. First Name* Russ
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Willard
IF Corporation, enter Faegistered Agent Last %rre
3b. Title Project Mgr.
4. Permitee E-mail [e-mail]
Address *
5. Permittee 336.922.4000 &336.655.7339 (M)
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box 10
Address Line 2
city
Bethania
F ostal / Zip Code
27010
Check box if the r Yes
street address the
same as mailing
address
State / F rovince / Faegion
NC
Country
United States
7. Permittee Street
Street Address
Address*
5121 N. Causeway Dr.
Address Line 2
City
State / Ffovince / Fbgion
Winston-Salem
NC
Flostal / Zip Code
Country
27106
UnitedStates
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Russ
Contact - First
Name *
2. Primary Site Willard
Contact - Last
Name *
3. Title Project Mgr.
4. Site Contact E- [e-mail]
mail Address*
5. Site Contact 336.655.7339
Telephone No.*
6. Organization Meadowlands Development, LLC
Name
7. Site Contact Street Address
Mailing Address* P.O. Box 10
Address Line 2
city
Bethania
Fbstal / Zip Code
27010
8. Consultant Name (Optional)
First and Last nave
9. Consultant E-mail This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Frovince / Pegion
NC
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................................................................................................__
1. Date E&SC Plan 03/05/2020
Approved *
2. E&SC Plan Project DAVID - 2020-031
Number/ID * Assigned by agency or local program
3. E&SC Plan r 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. For linear projects, please also upload a site map showing the overall extent of the project or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan Meadowlands Inverness EC Approval.pdf 7.11 MB
Approval letter or Mast beRDFforml
Grading Permit
Site Map (Optional) Helpful for linear project review
Mast be RDFform3t
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies for linear projects if necessary.
6. NOI Certification Meadowlands Inverness Park NOI Form.pdf 930KB
Form Mast be RDFformat
This is an Express F No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6E (i) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 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.
* 17 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
f 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
Type Name *
Russ Willard
Title
Project Manager
Organization
Meadowlands Development LLC
Date *
03/17/2020

F. Tracking and COC Info
NOI Tracking No. 23159
NC Reference No. NCG01-2020-1110
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201110
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1110
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)