NCC212980_Modification Review_20210729

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/28/2021 2:26:25 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 7/29/2021 7:00:10 AM (Construction COC ADD TO FILE Review -
NCC212980)
• The task was assigned to Georgoulias, Bethany A. The due date is: August 2, 2021 5:00 PM
7/28/2021 2:26 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC212980
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Beaver Creek Phases 2 & 3
Address
0 Claude Lewis Rd, Middlesex, NC
County
Nash
Latitude
35.7718
Longitude
-78.1822
Permittee Listed
Little Bear Creek Properties, LLC
Legally Responsible
David Geiger
Individual
NC Reference No.
NCG01-2021-2980
E&SC Plan ID
NASFI�2021-020
Original NOI
52898
Tracking No.*
Date COC Issued*
05/18/2021
Prior Rescission
This field will populate only if CCChas already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification * r Additional Lots/Outparcels Approved - E&SC Revised
F Other Revision(s) to E&SC Plan
r Legally Responsible Individual and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional Ivbre inforrration (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation We have increased the disturbed area total from 11 acres to 23 acres. The revised
plans have been approved by NCDEQ per the approval letter dated July 23, 2021.
You must upload supporting documentation below. Do not upload E&SC Plans unless specific plan
sheets are the only documentation with approval for revised acres of disturbance, etc. (only upload applicable
sheets).
For changes to the legally responsible individual, you must upload this form.

Supporting Upload Supporting Documentation (Pevised E&SCApproval, nose -Out Doc, etc.)
Documentation NASH-2021-020_20210723_LOA(1).pdf 317.49KB
Mist be FDFfornat
North Carolina General Statute 143-215.6B (i) provides that:
Anyperson who knowinglymakes anyfalse statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Artide or a rule implementing this Artide; or who knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Artide or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto exceed ten thousand
dollars ($10,000).
� I hereby request modification to coverage under the NPDES Stormwater Permit
for the subject project site. I am familiar with the information contained in this
request and to the best of my knowledge and belief such information is true,
complete and accurate.
Specify if you are:* r The Legally Responsible Individual
f Authorized Responsible Person*
*This form must be signed by a responsible corporate officer that 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
ewwt�f
Type Name* David Geiger
Title * Principal
Organization * Little Bear Creek Properties, LLC
Date * 07/28/2021
Email Address* [e-mail]
En -ail for confirnation
Telephone Number* 919-612-5531
Contact nunber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional en -ail for confirnation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 07/29/2021
Rescinded Since
Submitted?

Request Date 20210728
Formatted
Review Date 20210729
Formatted