NCC210499_NOI Application_20210128

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/27/2021 11:16:53 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 1/27/2021 1:25:20 PM (Review- Construction NOI 41940)
• The task was assigned to Garcia, Lauren V by round robin distribution 1/27/2021 11:17 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 29, 2021 5:00
PM 1/27/2021 11:17 AM
Submit by Selkane, Aziza 1/28/2021 9:03:36 AM (Payment Verification for NCC210499)
* Public Works 1
• Selkane, Aziza assigned the task to Selkane, Aziza 1/28/2021 8:58 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 10, 2021 5:00 PM
1/27/2021 1:25 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting
F No
an NOI that was
r Yes
rejected before?
1a. Project Name *
Yadkin Regional Water Supply Project
1 b. Specific Lot
This field rray be used to list specifc lot nunbers.
Numbers

1 c. Parcel ID List all RNIs associated w ith this project.
Number(s) (PIN) 655301096797
655301198504
655403309847
655403403228
655403407468
655403407468
655404508592
655404603783
655404606409
655404608695
655404701699
655404716684
655404815386
655404819238
655404911333
655404914523
655404916546
655404919310
656403012081
656403004991
656403026051
656403016271
656403110241
656403112256
656403114200
656403116172
656403119223
656403210420
656403211419
656403335435
656403212295
656403323289
656403328932
656403440174
656403444410
656403435371
656403439373
656404532219
656404534618
656404539051
656404732414
656404822157
657403022453
656404902885
657403110117
657403110086
657403111221
657403112138
657403112662
2. County* Union
3. Highway or Street 465 Bay Shore Drive
Address * Street narre only is acceptable if no address nun ber assigned yet
4. City or Township* Norwood
5. State * NC

6. Zip Code* 28128
7. Latitude* Enter the latitude in decimal degrees
35.2339
8. Longitude* Enter the longitude in decimal degrees (M-ST be negative)
-80.0984
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*
02/01/2021
Estimated Construction Project Start Rate
10. Date to End*
11 /22/2023
Estimated Construction Project End Cate
11. SIC (Primary) *
Other (9999)
Standard Industrial aassification for Development
12. Acres to be
40.90
disturbed*
(including off -site borrow and waste areas)
13. Total site area 40.90
(acres) *
14. Post- 0.43
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-UNION-2021-Yadkin Regional Water Supply Project
Tracking ID Assigned automatically
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 PEE DEE RIVER (including Lake Tillery
Waterbody* below normal operating levels)
I brre of waterbody into w hich stormwater runoff w ill discharge
15b. Waterbody 13-(1)
Index No.* NCWaterbody Index Number
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional Cedar Creek
Receiving Waterbody name
Waterbody
15d. Waterbody 13-12-(1)
Index No. NCWaterbody Index Number
15e. Additional Waterbody nacre
Receiving
Waterbody

15f. Waterbody
Index No.
NC Waterbody Index N.irrber
16a. Is this project
subject to the NC
Sediment Pollution
Control Act?*
r Yes
r No, not subject to NC SPCA

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 * Union County
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 * John
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Shutak
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Engineering Division Director
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-283-3651
Telephone No.*
6. Permittee Mailing Street Address
Address* 500 N Main St
Address Line 2
Suite 600
aty
Monroe
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
Fbstal / Zip Code
28112-4728
V Yes
Street Address
500 N Main St
Address Line 2
Suite 600
city
Monroe
Fbstal / Zip Code
28112-4728
State / Ffovince / Fbgion
NC
Country
US
State / Ftovince / Region
NC
Country
US
8. Type of Ownership is only individual if an individual is naned in B.1. above.
Ownership* Government - County

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
...........................................................................................................................................................................................................................................................................
1. Primary Site
Kyle
Contact - First
Name *
2. Primary Site
Anderson
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
316-833-6632
Telephone No.*
6. Organization
Garney Companies, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
620 Allenton Street
Address Line 2
City
State / Rovince / Region
Norwood
NC
Fbstal / Zip Code
Country
28128
us
8. Consultant Name
(Optional)
Jay Jackson
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person a-rrail (older NOIs rray not populate)
12. Billing
(For Annual Fee correspondence)
Telephone
704-283-3651
Default is legally responsible person telephone (older NOLs rray not populate)

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 01/26/2021
Approved *
2. E&SC Plan Project UNION-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 * Mooresville (MRO)
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. Please also upload a site map showing the overall extent of the project (for linear projects, can
include the beginning point and end point coordinates in the "Notes" box below).
5. E&SC Plan Yadkin Regional Water Supply Project (UNION
Approval letter or 344.28KB
2021-006) approval w mods.pdf
Grading Permit
Mast be FDFfon-rat
6. Site Location Map Mist be RDFforrret (lint 201VB)
Figure 1-Vicinity Map First 5 Miles.pdf 598.87KB
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 if necessary.
8. NOI Certification 20210127_eNO1_CertificationForm_Union2021-
Form 1.81 MB
006_Executed.pdf
Mast be FCFfon-rat
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 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:* IT 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
J)& 1l kw
Type Name * John Shutak
Title Engineering Division Director
Organization Legally Responsible Entity
Union County
Date * 01 /27/2021

F. Tracking and COC Info
NOI Tracking No. 41940
NC Reference No.
NCG01-2021-0499
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC210499
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 499
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2021
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC210499-2021
Invoice Due Date 2/26/2021
Initial Fee $ 100.00
Invoice Status OPEN