NCC201699_NOI Application_20200612

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/24/2020 2:38:56 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 4/25/2020 3:11:00 PM (Review- Construction NOI 24799)
• Clark, Paul reassigned the task to Morman, Alaina 4/24/2020 3:23 PM
* Alaina, for you.)
• The task was assigned to Clark, Paul by round robin distribution 4/24/2020 2:39 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 28, 2020 5:00 PM
4/24/2020 2:39 PM
Submit by McCoy, Suzanne 6/12/2020 8:01:01 AM (Payment Verification for NCC201699)
* Adam Essink
• McCoy, Suzanne assigned the task to McCoy, Suzanne 6/12/2020 8:00 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: June 8, 2020 5:00 PM
4/25/2020 3:11 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting r No
an NOI that was r Yes
rejected before?
Previous Rejected 24718
NOI No.
Prior Reviewer Alaina Morman
Name
1a. Project Name * Mountain Island Educational State Forest - Education Center
1 b. Specific Lot This field may be used to list spedc lot numbers.
Numbers
2. County* Gaston
3. Highway or Street 528 Killian Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Stanley
5. State * NC
6. Zip Code * 28164
7. Latitude * Enter the latitude in decimal degrees
35.3858
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.9950
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* 07/01/2021
Estimated Construction Project End Cute
11. SIC (Primary) * Other (9999)
Standard Industrial Classification for Ceveloprrent

12. Acres to be 10.60
disturbed* (including off -site borrow and waste areas)
13. Total site area 1,260.00
(acres) *
14. Post- 3.60
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-GASTO-2020-Mountain Island Educational State Forest -
Tracking ID Education Center
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 Catawba River
Wate rbody* N larre of waterbody into which stormwater runoff will discharge
15b. Waterbody 11-(112)
Index No.* NCWaterbody Index Number
Stormwater rJ No
discharges will flow r- Yes
to additional
wate rs *
16a. Is this project r 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
Legally Pesponsible Entity
Name *
NCDA & CS
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Andrew
If Corporation, enter Faegistered Agent First %rre
3. Last Name*
Meier
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Director, NCDA & CS Property and Construction
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-707-3238
Telephone No.*
6. Permittee Mailing Street Address
Address* 1001 Mail Service Center
Address Line 2
city State / Rovince / F;bgion
Raleigh NC
Fbstal / Zip Code Country
27699-1001 us
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
2 West Edenton Street
Address Line 2
city
State / Frovince / Region
Raleigh
NC
Fbstal / Zip Code
Country
27601
us
8. Type of
Government - State
Ownership*

C. Site Contact Information
Part C.
^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site
Don
Contact - First
Name *
2. Primary Site
Shires
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-707-3096
Telephone No.*
6. Organization
North Carolina Department of Agriculture &
Name
Consumer Sciences
7. Site Contact
Street Address
Mailing Address*
1001 Mail Service Center
Address Line 2
City
State / Rovince / Region
Raleigh
NC
Postal / Zip Code
Country
27699-1001
us
8. Consultant Name
(Optional)
Kevin Westra
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
704-496-6297
Telephone No.

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 01/16/2020
Approved *
2. E&SC Plan Project GASTO-2020-003
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 * Mooresville (MRO)
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 Erosion Control Approval Letter - Revised Septic
Approval letter or 55.17KB
Area.pdf
Grading Permit
Mist be FDFforrrat
6. Site Location Map Helpful for linear project review
(Optional) Mast be FDFfornat. Rease do not upload entire set of E&SCplans.
7. Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies for linear projects if necessary.
8. NOI Certification 20200423_NCGOI Notice of Intent (NOI) Certification
Form 445.2KB
Form.pdf
Mast be FDFfornat
This is an Express r 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 * andrew a meier
Title Director
Organization Legally Plesponsible Entity
NCDA & CS
Date * 04/24/2020

F. Tracking and COC Info
NOI Tracking No. 24799
NC Reference No. NCG01-2020-1699
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201699
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1699
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.)