NCC214103_NOI Application_20210720

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 7/13/2021 11:34:16 AM(NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 7/13/2021 11:50:35 AM(Review-Construction NOI 58912)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 7/13/2021 11:34 AM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:July 15,2021 5:00 PM
7/13/2021 11:34 AM
Submit by McCoy, Suzanne 7/20/2021 3:06:52 PM(Payment Verification for NCC214103)
* Cleveland County Water
• McCoy,Suzanne assigned the task to McCoy, Suzanne 7/20/2021 3:06 PM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is:August 24, 2021 5:00 PM
7/13/2021 11:50 AM

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1Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Eliminatio em 'D application for•• - .•-under NorthCarolina's
General Permit 1 1111:STORIMATER DISCHARGES associated with construction activities(or
NORTH CAROLINA
Enrlrnnmenfu�Qr�arlry
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* Clearwell, High Service Pump Station and Water Line
1 b.Specific Lot This field may be used to list specifc lot numbers.
Numbers
1 c. Parcel ID List all Ris associated w ith this project.
Number(s)(PIN) 2632712363,2632614796
2. County* Cleveland
3. Highway or Street Casar-Lawndale Road
Address* Street name only is acceptable if no address number assigned yet
4.City or Township* Lawndale
5. State* NC
6.Zip Code* 28090
7. Latitude* Enter the latitude in decimal degrees
35.4334
8. Longitude* Enter the longitude in decinal degrees(MJSTbe negative)
-81.5638
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* 07/26/2021
Estimated Construction Project Start Late
10. Date to End* 04/01/2023
Estimated Construction Project End Date
11.SIC(Primary)* Other(9999)
Standard Industrial aassification for Development
12.Acres to be 5.00
disturbed* (including off-site borrow and waste areas)

13.Total site area 5.00
(acres)*
14. Post- 0.00
construction (Estimated)
impervious area
(acres)*
Project Tracking ID NCC-CLEVE-2021-Clearwell, High Service Pump Station and Water
Line
Assigned automatically(not used)
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 First Broad River
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b.Waterbody 9-50-(18.5)
Index No.* NCWaterbody Index Number
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. ^
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* Cleveland County Water
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* Brad
If Corporation,enter Faegistered Agent First%rre
3. Last Name* Cornwell
It Corporation,enter F;bgistered Agent Last%rre
3b.Title General Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704.538.9033
Telephone No.*
6. Permittee Mailing Street Address
Address* 439 Casar Lawndale Road
Address Line 2
City State/Frovince/Fbgion
Lawndale NC
Fbstal/Zip Code Country
28090 USA
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 439 Casar Lawndale Road
Address Line 2
City State/Frovince/Faegion
Lawndale NC
Fbstal/Zip Code Country
28090 USA
8.Type of Ojvnership is only individual if an individual is naned in B.1.above.
Ownership* Non-Government

C. Site Contact Information
Part C. ^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Martin
Contact-First
Name*
2. Primary Site Scanlon
Contact-Last
Name*
3.Title Project Manager
4.Site Contact E- [e-mail]
mail Address*
5.Site Contact 704.993.1110
Telephone No.*
6.Organization Dellinger, Inc.
Name
7.Site Contact Street Address
Mailing Address* Post Office Box929
Address Line 2
City State/Rovince/Region
Monroe NC
Fbstal/Zip Code Country
28111 USA
8. Consultant Name (Optional)
Greg Wells
First and Last nacre
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 704.338.4662
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
[e-mail]
Default is legally responsible person a-rmil
12. Billing (For Annual Fee correspondence)
Telephone [phone]
Default is legally responsible person telephone

D. E&SC Plan
Part D. ^
Erosion&Sediment Control(E&SC)Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 07/23/2020
Approved*
2. E&SC Plan Project CLEVE-2021-001
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 LQS Approval 23 Jul 20.pdf 1.98MB
Approval letter or Mast beRDFformat
Grading Permit
6.Site Location Map Mist be RDFfornat(linit 20 NB)
Site Map.pdf 90.41 KB
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 Clearwell Notice of Intent NOI signed 07.13.21.pdf 378.82KB
Form Wst be RDFfornat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66(1) provides that:
Anyperson who knowinglymakes any false statement,representation,or certification in anyapplication,record,report,plan,or other
documentfiled 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 underthis 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 guiltyofa Class 2 misdemeanor which mayinclude 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
'0tfll .�l - Olatlr �f
Type Name* Brad R. Cornwell
Title General Manager
Organization Legally Pesponsible Entity
Cleveland County Water
Date* 07/13/2021

F. Tracking and COC Info
NOI Tracking No. 58912
NC Reference No. NCG01-2021-4103
Uses'count_nurrber'variable(increrrented by SP)
Certificate of NCC214103
Coverage (COC) Uses'count_nurrber'variable(increrrented by SP)
No.*
Count Number 4103
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. NCC214103-2021
Invoice Due Date 8/12/2021
Initial Fee $ 100.00
Invoice Status OPEN