NCC221724_NOI Application_20220504

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/3/2022 8:57:02 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 5/3/2022 9:05:33 AM (Review - NOI 90316 Springside Culvert Replacement)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 5/3/2022 8:57 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 6, 2022 5:00 PM
5/3/2022 8:57 AM
by Workflow 5/3/2022 9:05:42 AM (Workflow Start Event)
Submit by Selkane, Aziza 5/4/2022 11:42:18 AM (Payment Verification for NCC221724)
F Michael L Gunnell
• Selkane, Aziza assigned the task to Selkane, Aziza 5/4/2022 11:41 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: June 14, 2022 5:00 PM
5/3/2022 9:05 AM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
A. Project Information
Part A.
Project Location and Waterbody Information
...............................................................................................................................................................................................................................................................................................................................................................................................
Are you submitting No
an NOI that was • Yes
rejected before?
Previous Rejected 89220
NOI No.
Prior Reviewer Name Brooklyn Broussard
la. Project Name* Springside Culvert Replacement
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers Lot 005, Block 4264 - 3211 Springside (Clemmons) / Lot 004, Block 4264 - Vacant
lot (Crews) / Lot 102, Block 4264 - pond (Rhodes & Frye)
1 c. Parcel ID List all PINS associated with this project.
Number(s) (PIN) 5893-45-0111, 5893-45-0212, 5893-35-7356
2. County* Forsyth
3. Highway or Street 3211 Springside Drive
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Village of Clem mons
5. State* NC
6. Zip Code* 27012
7. Latitude* Enter the latitude in decimal degrees
36.0371
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-80.3736
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* 05/03/2022
Estimated Construction Project Start Date
10. Date to End* 04/14/2023
Estimated Construction Project End Date

11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521)
Standard Industrial Classification for Development
12. Acres to be 2.00
disturbed* (including off -site borrow and waste areas)
13. Total site area 2.00
(acres)*
14. Post -construction 0.00
impervious area (Estimated)
(acres) *
Project Tracking ID NCC-FORSY-2022-Springside Culvert Replacement
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 Muddy Creek
Waterbody * Name of waterbody into which stormwater runoff will discharge
15b. Waterbody Index 12-94-(0.5)
No. * NC Waterbody Index Number
Stormwater No
discharges will flow Yes
to additional waters*
16a. Is this project Yes
subject to the NC No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Permittee Information - Legally Responsible Entity and Individual
........................................................................................................................................................................
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form must 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
1. Permittee* Legally Responsible Entity
Village of Clemmons
If permittee is an individual, enter first and last name in this field. Otherwise, enter organization/business name.
Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the
registration here. Permittee must be the same entity that is responsible for the land -disturbing activity as listed on the NC
SPCA Financial Responsibility/Ownership (FRO) Form.
2. First Name* Mike
If Corporation, enter Registered Agent First Name
3. Last Name* Gunnell
If Corporation, enter Registered Agent Last Name
3b. Title Village Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-439-5187
Telephone No.*
6. Permittee Mailing Street Address
Address* 3715 Clemmons Road
Address Line 2
City State / Province / Region
Clemmons NC
Postal / Zip Code Country
27012 USA
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address *
3715 Clemmons Road
Address Line 2
City
State / Province / Region
Clemmons
NC
Postal / Zip Code
Country
27012
USA
8. Type of
Ownership is only individual if an individual is named in B.1. above.
Ownership*
Government - Municipal

C. Site Contact Information
Part C.
Project Site Contact Information
.................................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Mike
Contact - First
Name*
2. Primary Site Gunnell
Contact - Last Name*
3. Title Village Manager
4. Site Contact E-mail [e-mail]
Address*
5. Site Contact 336-439-5187
Telephone No.*
6. Organization Name Village of Clemmons
7. Site Contact Street Address
Mailing Address* 3715 Clemmons Road
Address Line 2
City
Clemmons
Postal / Zip Code
27012
8. Consultant Name (optional)
Amy Black, PE
First and Last name
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 336-686-7647
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-mail
12. Billing Telephone (For Annual Fee correspondence)
336-439-5187
Default is legally responsible person telephone
State / Province / Region
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC Plan 06/25/2021
Approved *
2. E&SC Plan Project FORSY-2021-045
Number/ID* Assigned by agency or local program
3. E&SC Plan State DEQ Office
Approved by* 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. 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 15005 ESC_Approval.pdf 4.54MB
Approval letter or Must be PDF format
Grading Permit
6. Signed FRO Financial Responsibility/Ownership Form
Financial-Responsibility-Springside.pdf 211.8KB
Must be PDF format
7. Site Location Map Must be PDF format (limit 20 MB)
Springside_PCN_USGS_Map.pdf 666.49KB
Please do not upload entire set of E&SC plans.
8. Notes (Optional) Provide any additional information that might help the reviewer better understand how uploaded documents
support the application. Include additional waterbodies if necessary.
9. NOI Certification NOI(SIGNED).pdf 50.84KB
Form Must be PDF format
This is an Express • No
Review Project* Yes

E. Certification
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false 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 Article; 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 Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
* 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.
* 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.
* I will abide by all conditions of the NCG010000 General Permit and the approved
Erosion and Sediment Control Plan.
* 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:* The Legally Responsible Person named on this Notice of Intent
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
Type Name* Michael L Gunnell
Title Village Manager
Organization Legally Responsible Entity
Village of Clemmons
Date * 05/03/2022

F. Tracking and COC Info
NOI Tracking No. 90316
NC Reference No. NCG01-2022-1724
Indicates NCG01 or NCG25. Uses NOI number until approved, then uses NUMBER incremented by SP (passed
from workflow if eNOI approved)
Certificate of NCC221724
Coverage (COC) No.* Uses NOI number until approved, then uses NUMBER incremented by SIP (formatted and passed from workflow if
eNOI approved)
Initial Invoice No. NCC221724-2022
Invoice Due Date 6/2/2022
Initial Fee $ 100.00
Invoice Status OPEN