NCC205639_NOI Application_20201216

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/l/2020 2:46:09 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 12/7/2020 5:10:09 PM (Review- Construction NOI 37842)
• The task was assigned to Morman, Alaina by round robin distribution 12/l/2020 2:47 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 3, 2020 5:00
PM 12/l/2020 2:47 PM
Submit by Selkane, Aziza 12/16/2020 8:52:58 AM (Payment Verification for NCC205639)
* Town of Elizabethtown
• Selkane, Aziza assigned the task to Selkane, Aziza 12/16/2020 8:52 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 18, 2021 5:00 PM
12/7/2020 5:10 PM

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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 * Utility Extensions at Elizabethtown Industrial Park
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
1 c. Parcel ID List all Ait associated w ith this project.
Number(s) (PIN)
2. County* Bladen
3. Highway or Street Executive Drive
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Elizabethtown
5. State * NC
6. Zip Code* 28337
7. Latitude* Enter the latitude in decimal degrees
34.5999
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.5855
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*
12/01/2020
Estimated Construction Project Start Rate
10. Date to End*
03/31/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Industrial (1541)
Standard Industrial aassification for Development
12. Acres to be
1.65
disturbed*
(including off -site borrow and waste areas)

13. Total site area 130.00
(acres) *
14. Post- 0.00
construction (Estirreted)
impervious area
(acres) *
NCC Project NCC-BLADE-2020-Utility Extensions at Elizabethtown Industrial Park
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 Plum Branch
Waterbody* Narreof waterbody into which storrrwater runoff will discharge
15b. Waterbody 18-50-2
Index No. * NCWaterbody Index Nurrber
Stormwater V 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. ^
Fternittee 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 * Town of Elizabethtown
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * Eddie
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Madden
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Town Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-862-2066
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box716
Address Line 2
City
Elizabethtown
Fbstal / Zip Code
28337
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
305 W. Swanzy Street
Address Line 2
City
Elizabethtown
Fbstal / Zip Code
28337
State / Ffovince / i egion
NC
Country
us
State / Frovince / Region
NC
Country
us
8. Type of Ojvnership is only individual if an individual is naned in B.1. above.
Ownership* Government- Municipal

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Hugh
Contact - First
Name *
2. Primary Site
Bledsoe
Contact - Last
Name *
3. Title
Director of Public Services
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-862-2035
Telephone No.
6. Organization
Town of Elizabethtown Public Services
Name
Department
7. Site Contact
Street Address
Mailing Address*
401 W. Swanzy Street
Address Line 2
City
Elizabethtown
Fbstal / Zip Code
28337
8. Consultant Name
(Optional)
Larry Anderson
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
910-608-2808
Telephone No.
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/26/2020
Approved *
2. E&SC Plan Project BLADE-2021-006
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 * Fayetteville (FRO)
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 E-town SS_EC_Approval_BLADE-2021-006.pdf 1.93MB
Approval letter or Mast beRDFformal
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 20 NB)
Location map.pdf 3.16MB
Rease do not upload entire set of E&SC plans.
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 NCG01_eNO1-Certification Form_Signed.pdf 356.05KB
Form Wst be RDFforrret
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) 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 Legally Responsible Person named on this Notice of Intent
f Authorized Responsible Person* (signing on behalf of Legally Responsible
Person named in Part B)
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
Vr41 "eye
Type Name * Eddie Madden
Title Town Manager
Organization Legally Plesponsible Entity
Town of Elizabethtown
Date * 12/01 /2020

F. Tracking and COC Info
NOI Tracking No. 37842
NC Reference No.
NCG01-2020-5639
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205639
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5639
Sequential nurrber for subrrittal 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. NCC205639-2020
Invoice Due Date 1/6/2021
Initial Fee $ 100.00
Invoice Status OPEN