NCC201856_NOI Application_20200707

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/5/2020 6:14:08 PM (NCG01 NOI Submission)
Approve by Clark, Paul 5/6/2020 10:09:06 AM (Review- Construction NOI 25186)
• The task was assigned to Clark, Paul by round robin distribution 5/5/2020 6:14 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 7, 2020 5:00 PM
5/5/2020 6:14 PM
Submit by Selkane, Aziza 7/7/2020 7:52:20 AM (Payment Verification for NCC201856)
* Brian Boyd
• Selkane, Aziza assigned the task to Selkane, Aziza 7/7/2020 7:51 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: June 17, 2020 5:00 PM
5/6/2020 10:09 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting IT No
an NOI that was r Yes
rejected before?
1a. Project Name * City of Greensboro - Hicone Rd & Huffine Mill Rd Water Line
Extensions
1 b. Specific Lot This field mmy be used to list specifc lot numbers.
Numbers
2. County* Guilford
3. Highway or Street Hicone Road and Huffine Mill Road
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Greensboro
5. State * NC
6. Zip Code * 27405
7. Latitude* Enter the latitude in decimal degrees
36.1500
8. Longitude * Enter the longitude in decimal degrees (MJST be negative)
-79.7400
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*
09/01 /2020
Estimated Construction Project Start Date
10. Date to End*
09/01/2021
Estinated Construction Project End Cate
11. SIC (Primary) *
Other (9999)
Standard Industrial C]assification for Development
12. Acres to be
4.85
disturbed*
(including off -site borrow and waste areas)
13. Total site area 4.85
(acres) *

14. Post- 0.00
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-GUILF-2020-City of Greensboro - Hicone Rd & Huffine Mill Rd
Tracking ID Water Line Extensions
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 Unnamed Tributary at Camp Herman
Waterbody* Ibrre of w aterbody into w hich storrrw ater runoff w ill discharge
15b. Waterbody 16-11-10-(2)
Index No.* NCWaterbody Index Ninber
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional North Buffalo Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 16-11-14-1
Index No. NCWaterbody Index Nurrber
15e. Additional South Buffalo Creek
Receiving Waterbody narre
Waterbody
15f. Waterbody 16-11-14-2
Index No. NCWaterbody Index Nurrber
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 *
City of Greensboro
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Michael
IF Corporation, enter Faegistered Agent First %rre
3. Last Name*
Borchers
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Director of Water Resources
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-373-2494
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box3136
Address Line 2
City
State / Rovince / F;bgion
Greensboro
NC
Fbstal / Zip Code
Country
27402-3136
USA
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
2602 South Elm -Eugene Street
Address Line 2
City
State / Frovince / Faegion
Greensboro
NC
Fbstal / Zip Code
Country
27406
USA
8. Type of
Government - Municipal
Ownership*

C. Site Contact Information
Part C.
^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site
Virginia
Contact - First
Name *
2. Primary Site
Spillman
Contact - Last
Name *
3. Title
Engineering Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-373-3260
Telephone No.*
6. Organization
City of Greensboro Water Resources Dept.
Name
7. Site Contact
Street Address
Mailing Address*
P.O. Box3136
Address Line 2
City
State / Rovince / Region
Greensboro
NC
Postal / Zip Code
Country
27402-3136
USA
8. Consultant Name
(Optional)
Andy Larrick
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-886-4821
Telephone No.

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 04/29/2020
Approved *
2. E&SC Plan Project GUILF-2020-036
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
Hicone Rd and Huff ine Mill Rd Water Lines Erosion
Approval letter or
2.39MB
Control Letter of Approval_2020-04-29.pdf
Grading Permit
Mast be RDFforrrat
6. Site Location Map
Helpful for linear project review
(Optional)
02 Hicone Rd Huffine Mill Rd Water Lines Index
1.92MB
Sheet 2.pdf
Mast be R7F format. Rease do not upload entire set of E&SC plans.
7. Notes (Optional)
Frovide any additional information that might help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies for linear projects if necessary.
8. NOI Certification
NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form
1.15MB
SW.pdf
Wst be FDFformat
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 Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Artcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
Commission implementing this Artcle 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 * Michael M. Borchers
Title Director of Water Resources
Organization Legally Plesponsible Entity
City of Greensboro
Date * 05/05/2020

F. Tracking and COC Info
NOI Tracking No. 25186
NC Reference No. NCG01-2020-1856
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201856
Coverage (COC) Uses 'count number' variable (incremented by SF)
No.*
Count Number 1856
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.)
Initial Invoice No.
Invoice Due Date
Initial Fee $
Invoice Status