NCC230420_NOI Application_20230214

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/13/2023 3:28:04 PM (NCG01 NOI Submission)
Approve by Brooklyn. Broussard 2/14/2023 7:52:05 AM (Review - NOI 127128 GUERRANT SPRINGS ROAD
WATERLINE)
• The task was assigned to Brooklyn. Broussard by round robin distribution 2/13/2023 3:28 PM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 16, 2023 5:00
PM 2/13/2023 3:28 PM
by Workflow 2/14/2023 7:52:14 AM (Workflow Start Event)
Submit by Tev.Holloman 2/14/2023 10:19:07 AM (Payment Verification for NCC230420)
* DAN RIVER WATER INC
• Tev.Holloman assigned the task to Tev.Holloman 2/14/2023 10:18 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 28, 2023 5:00 PM
2/14/2023 7:52 AM

�a
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*
GUERRANT SPRINGS ROAD WATERLINE
1b. Specific Lot Numbers
This field may be used to list specifc lot numbers.
N/A -WORK CONFINED TO NCDOT R/W
1c. Parcel ID Number(s) (PIN)
List all PINS associated with this project.
N/A -WORK CONFINED TO NCDOT R/W
2. County*
Rockingham
3. Highway or Street Address
GUERRANT SPRINGS ROAD
Street name only is acceptable if no address number assigned yet
4. City or Township*
RUFFIN
5. State* NC
6. Zip Code* 27326
7. Latitude* Enter the latitude in decimal degrees
36.4842
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-79.5579
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* 03/01/2023
Estimated Construction Project Start Date
10. Date to End* 06/29/2023
Estimated Construction Project End Date

11. SIC (Primary)*
Other(9999)
Standard Industrial Classification for Development
12. Acres to be 3.00
disturbed* (including off -site borrow and waste areas)
13. Total site area 3.00
(acres) *
14. Post -construction 0.00
impervious area (Estimated)
(acres)*
Project Tracking ID NCC-ROCKI-2023-GUERRANT SPRINGS ROAD WATERLINE
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*
BIRCH FORK CREEK
Name of waterbody into which stormwater runoff will discharge
15b. Waterbody Index No.*
22-48-4
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 eN01 on 1 /26/2023 and will not be answered in applications submitted prior to that date. Reviewer may update if status is
known.

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
DAN RIVER WATER INC
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* LEMONS
If Corporation, enter Registered Agent Last Name
3b. Title MANAGER
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-623-2526
Telephone No.*
6. Permittee Mailing Street Address
Address* 610 PATRICK ST
Address Line 2
City
State / Province / Region
EDEN
NC
Postal / Zip Code
Country
27288
USA
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address *
610 PATRICK ST
Address Line 2
City
State / Province / Region
EDEN
NC
Postal / Zip Code
Country
27288
USA
8. Type of
Ownership is only individual if an individual is named in B.1. above.
Ownership*
Non -Government

C. Site Contact Information
Part C.
Project Site Contact Information
1. Primary Site MIKE
Contact - First
Name*
2. Primary Site LEMONS
Contact - Last Name*
3. Title MANAGER
4. Site Contact E-mail [e-mail]
Address*
5. Site Contact 336-623-2526
Telephone No.*
6. Organization Name DAN RIVER WATER
7. Site Contact
Street Address
Mailing Address*
610 PATRICK ST
Address Line 2
City
EDEN
Postal / Zip Code
27288
8. Consultant Name
(optional)
First and Last name
9. Consultant 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 e-mail
12. Billing Telephone
(For Annual Fee correspondence)
336-623-2526
Default is legally responsible person telephone
State / Province / Region
NC
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC Plan 02/01/2023
Approved *
2. E&SC Plan Project ROCKI-2023- 018
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 Scan0020 (1).pdf 1.131VIB
Approval letter or Must be PDF format
Grading Permit
6. Signed FRO Financial Responsibility/Ownership Form
Scan0025.pdf 880.07KB
Must be PDF format
7. Site Location Map Must be PDF format (limit 20 MB)
Scan0023 (3).pdf 396.11 KB
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 Scan0024 (1).pdf 422.26KB
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
Mc ZCAOAl.S
Type Name* MIKE LEMONS
Title MANAGER
Organization Legally Responsible Entity
DAN RIVER WATER, INC.
Date * 02/13/2023

F. Tracking and COC Info
NOI Tracking No. 127128
NC Reference No. NCG01-2023-0420
Indicates NCG01 or NCG25. Uses NOI number until approved, then uses NUMBER incremented by SP (passed
from workflow if eNOI approved)
Certificate of NCC230420
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. NCC230420-2023
Invoice Due Date 3/16/2023
Initial Fee $ 100.00
Invoice Status OPEN