NCC230299_NOI Application_20230202

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/31/2023 9:59:39 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 2/1/2023 8:04:16 AM (Review - NOI 125486 KLRWS 20 mgd Water Treatment
Plant Improvements)
IN Applicant provided ARPA Project Number as "WIF 1920; H-SRP-D-17-0131; H-SF-D17-0152; 2019
Consulted DWI staff (R. Riddle) who confirmed this project is associated with the following:
WIF 1920 —Drinking Water SRF Project
H-SRP-D-17-0131 -Drinking Water SRP Project
H-SRF-D-0152 (H-SF-D17-0152) —Warren Co, Drinking Water, SRP Project
WIF 2019 — City of Oxford, Drinking Water, Kerr Lake Regional Water Treatment Plant
All of which are joined to the ARPA Project # SRP-D-ARP-0194.
• The task was assigned to Broussard, Brooklyn C by round robin distribution 1/31/2023 10:00 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 3, 2023 5:00
PM 1 /31 /2023 10:00 AM
by Workflow 2/1/2023 8:04:25 AM (Workflow Start Event)
Submit by Holloman, Tevye L 2/2/2023 12:28:27 PM (Payment Verification for NCC230299)
IP Casey Byrd
• Holloman, Tevye L assigned the task to Holloman, Tevye L 2/2/2023 12:26 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 15, 2023 5:00 PM
2/1/2023 8:04 AM

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NORTH CAROLINA,
Enri--tn! C2-1;ly
A. Project Information
Part A.
Project Location and Waterbody Information
................................................................................................................... .
Are you submitting an NOI that was rejected before?
No
Yes
la. Project Name*
KLRWS 20 mgd Water Treatment Plant Improvements
1b. Specific Lot Numbers
This field may be used to list specifc lot numbers.
N/A
1c. Parcel ID Number(s) (PIN)
List all PINS associated with this project.
059201009
2. County*
Vance
3. Highway or Street Address
280 Regional Water Lane
Street name only is acceptable if no address number assigned yet
4. City or Township*
Middleburg Township
5. State* NC
6. Zip Code* 27537
7. Latitude* Enter the latitude in decimal degrees
36.4350
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-78.3540
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* 01/30/2023
Estimated Construction Project Start Date
10. Date to End* 03/31/2025
Estimated Construction Project End Date

11. SIC (Primary)*
Other(9999)
Standard Industrial Classification for Development
12. Acres to be 17.20
disturbed* (including off -site borrow and waste areas)
13. Total site area 38.47
(acres) *
14. Post -construction 3.59
impervious area (Estimated)
(acres)*
Project Tracking ID NCC-VANCE-2023-KLRWS 20 mgd Water Treatment Plant
Improvements
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 Waterbody*
Anderson Swamp Creek
Name of waterbody into which stormwater runoff will discharge
15b. Waterbody Index No.*
23-8-6-(1.5)
NC Waterbody Index Number
Stormwater discharges will flow to additional waters*
No
Yes
16a. Is this project subject to the NC Sediment Pollution Control Act?*
Yes
No, not subject to NC SPCA
17. Is this project funded with ARPA (American Rescue Plan Act) grant funds?
No
Yes
This question was added to the eNOI on 1 /26/2023 and will not be answered in applications submitted prior to that date. Reviewer may update if status is
known.
18. ARPA Project Number
Project number assigned by Division of Water Infrastructure (e.g., SRP-D-ARP-0090)
SRP-D-ARP-0194

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
City of Henderson
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* E. Terrell
If Corporation, enter Registered Agent First Name
3. Last Name* Blackmon
If Corporation, enter Registered Agent Last Name
3b. Title City Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 252-430-5701
Telephone No.*
6. Permittee Mailing Street Address
Address* 134 Rose Avenue
Address Line 2
City
State / Province / Region
Henderson
NC
Postal / Zip Code
Country
27536
USA
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
134 Rose Avenue
Address Line 2
City
State / Province / Region
Henderson
NC
Postal / Zip Code
Country
27536
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 Casey
Contact - First
Name*
2. Primary Site Byrd
Contact - Last Name*
3. Title Project Manager
4. Site Contact E-mail [e-mail]
Address*
5. Site Contact 803-530-8675
Telephone No.*
6. Organization Name CDM Smith
7. Site Contact Street Address
Mailing Address* 1441 Main Street
Address Line 2
Suite 1000
City
Columbia
Postal / Zip Code
29201
8. Consultant Name (optional)
Kelly Boone, CDM Smith
First and Last name
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 919-325-3508
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)
803-530-8675
Default is legally responsible person telephone
State / Province / Region
Sc
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC Plan 01/27/2023
Approved *
2. E&SC Plan Project VANCE-2023-600
Number/ID* Assigned by agency or local program
3. E&SC Plan State DEQ Office
Approved by* Local Program
4. State DEQ Office* Raleigh (RRO)
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 VANCE-2023-600_20230127_LOA.pdf 775.49KB
Approval letter or Must be PDF format
Grading Permit
6. Signed FRO Financial Responsibility/Ownership Form
FRO Form Signed UPDATED.pdf 612.07KB
Must be PDF format
7. Site Location Map Must be PDF format (limit 20 MB)
Kerr Lake Erosion Control Figure.pdf 2.11 MB
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 NCG01-eNOI-Certification-Form-20210917-DEMLR-
Form 798.48KB
SW (002).pdf
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
C�t p.�l�.S�rPrr+rorr
Type Name* E. Terrell Blackmon
Title City Manager
Organization Legally Responsible Entity
City of Henderson
Date * 01 /31 /2023

F. Tracking and COC Info
NOI Tracking No. 125486
NC Reference No. NCG01-2023-0299
Indicates NCG01 or NCG25. Uses NOI number until approved, then uses NUMBER incremented by SP (passed
from workflow if eNOI approved)
Certificate of NCC230299
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. NCC230299-2023
Invoice Due Date 3/3/2023
Initial Fee $ 100.00
Invoice Status OPEN