NCC232244_MODIFICATION Supporting Doc (ADDL LOTS)_20240216

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with$120 check if paying by check)
at:
Division of Energy, Mineral&Land Resources Stormwater Program
512 N.Salisbury Street, 6th Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Per NC Genera!Statute 143-215.6B(I), 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. . . 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(check all boxes to indicate your agreement):
0 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.
0 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.
[r/], I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
LA' If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCG010000 General Permit,I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
FIL{ I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit recuirements for the discharge(s)and is enforceable in the same manner as an
individual permit.
Project Name (must match Ala): \I U(.11n 1C 1 $Uhd V i'S' OM
Specific Lot Numbers(must match Alb): 114 i 1 cy, q `4. r�
Permittee(must match B1): F f'our, W.l e.fs W ,, 5fCLLC- �I`I, 1. ,C.
Legally Responsible Person (must match B2& 83): GhQrt- 1 3o1 I ---
Title of Legally Responsible Person (must match 83h): imJnb-Q( 1i t aJ1 il..., --
Print Name&Title of Signed if Authorized
Individual Differs from r�Legally Responsible Person:
Phone Number: t33(p - 9 ci-- 5-i. (9 9
• a-1 to -4opti
-________Signature of Legally Responsible Person or Authorized Individual Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that awns or eperotes the construction activity,
such as a president,secretary, treasurer,or vice president, or a manager that is authorized in accordance with Part iV,Section 8,
Item(6)of the NCG010000 permit.

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ROY COOPER l'a , ;: `_ i
Governor ,J �
ELIZABETH S.BISER Y Secretary sae`.
WILLIAM E.TOBY VINSON,JR NORTH CAROLINA
Interim Director Environmental Quality
02-1.3-2024
LETTER OF APPROVAL
Dream Builders WS Construction, LLC
8603 N. NC Hwy 150
RE: Project Name: Wynnfall Subdivision Lots 16, 17, 29, 44
Project ID: DAVID-2024-0118
Acres Approved: 3
County: Davidson
City: Lexington
Address: Cricket's Run
River Basin: Yadkin - Pee Dee
Stream Classification: C:Aquatic Life, Secondary Contact Recreation, Fresh water
Submitted By: Robert Wooten
• Date Received by LQS: 2/6/2024 8:45:33 PM
Plan Type: New Plan
Dear Dream Builders WS Construction, LLC,
This office has reviewed the subject erosion and sedimentation control plan. We hereby issue this
Letter of Approval. Any modifications required for approval are listed in the body of the email that
accompanied this attached letter . The enclosed Certificate of Approval must be posted at the job
site. This plan approval shall expire three (3) years following the date of approval, if no land-
disturbing activity has been undertaken, as is required by Title 15A NCAC 4B .0129.
As of April 1, 2019, all new construction activities not explicitly exempt are required to complete
and submit an electronic Notice of Intent (eNOI) form requesting a Certificate of Coverage (COC)
under the NCG010000 Construction General Permit. After the form is reviewed and found to be
complete,you will receive a link with payment instructions for the annual permit fee. After the fee
is processed,you will receive the COC. As the Financially Responsible Party shown on the FRO form
submitted for this project,you MUST obtain the COC prior to commencement of any land disturbing
activity. The eNOI form may be accessed at deq.nc.gov/NCG01.
Q North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
R NOD !!! �JJJ/// 512 North Salisbury Street 11612 Mail Service Center I Raleigh,North Carolina 27699-1612
Department of ironmeemOM r 919.707.9200

Letter of Approval
Dream Builders WS Construction, LLC
02-13-2024
Page 2 of 2
Please direct questions about the eNOI form to the Stormwater Program staff in the Raleigh central
office. If the owner/operator of this project changes in the future, the new responsible party must
obtain a new COC.
Title 15A NCAC 4B .0118(a) and the NCGO1 permit require that the following documentation be
kept on file at the job site:
1. The approved E&SC plan as well as any approved deviation.
2. The NCGO1 permit and the COC, once it is received.
3. Records of inspections made during the previous 12 months.
Also, this letter gives the notice required by G.S. 113A-61.1(a) of our right of periodic inspection to
ensure compliance with the approved plan.
North Carolina's Sedimentation Pollution►Control Act is performance-oriented,requiring protection
of existing natural resources and adjoining properties. If, following the commencement of this
project, the erosion and sedimentation control plan is inadequate to meet the requirements of the
Sedimentation Pollution Control Act of 1973 (North Carolina General Statute 113A-51 through 66),
this office may require revisions to the plan and implementation of the revisions to ensure
compliance with the Act.
Acceptance and approval of this plan is conditioned upon your compliance with Federal and State
water quality laws, regulations, and rules. In addition, local city or county ordinances or rules may
also apply to this land-disturbing activity. This approval does not supersede any other permit or
approval.
Please note that this approval is based in part on the accuracy of the information provided in the
Financial Responsibility Form and on the plan, which you provided. You are requested to file an
amended form if there is any change in the information included on the form.
Your cooperation is appreciated.
Sincerely,
Land Quality Section

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name: Wynnfall Subdivision Lots 16, 17, 29, 44
*If this project involves American Rescue Plan Act(ARPA)funds,list the Project Name below under which
you applied for funding through the Division of Water Infrastructure (DWI).
Is Project ARPA Funded ARPA Project Name ARPA Project#
No
2. Location of land-disturbing activity: County: Davidson City or Township: Lexington
Highway/Street: Cricket's Run Latitude: 35.908225 Longitude:-80.236082
3. Approximate date land-disturbing activity will commence: 1/22/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.00
6. The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount (Example: 8.10-acre application fee is$900).
7. Has an erosion and sediment control plan been filed? Yes-Will be Mailed or Hand-Delivered
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Thomas Hedrick E-mail Address: [e-mail]
Phone: [phone] Mobile: [phone]
9. Landowner(s)of Record:
_Landowner(s) of Record
Name Email Business Phone Mobile Phone
Dream Builders WS Construction, LLC [e-mail]
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
8603 N. NC Hwy Clemmons NC 27012 8603 N. NC Hwy Clemmons NC 27012
150 150

Part B.
1. Company(ies) who are financially responsible for the land-disturbing activity (Provide a comprehensive list of all
responsible parties on accompanied pag�.)If the company is a sole proprietorship or if the landowner(s)is an individual(s), the
name(s)of the owner(s)may be listed as the financially responsible party(ies).
Primary Financially Responsible Party
Company Name _ Email Business Phone Mobile Phone
Dream Builders WS Construction, LLC [e-mail]
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
8603 N. NC Hwy Clemmons NC 27012 8603 N. NC Hwy Clemmons NC 27012
150 150
Additional Financially Responsible Parties
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form the
landowners signed and dated written c nsent for the applicant to submit a draft erosion and sedimentation control
plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Registered Agent Information
Name I Email Business Phone Mobile Phone
Physical Address 1 Mailing Address
Street 1 City State Zip Street 1 City State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent who is registered on the NC Secretary of State business registry:
North Carolina Agent Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
Engineering/Consulting Firm Information
Name Email Business Phone Mobile Phone
Dream Builders WS Construction, LLC [e-mail]
Physical Address Mailing Address
Street 1 City State _ Zip Street 1 City State Zip
8603 N. NC Hwy Clemmons NC 27012 8603 N. NC Hwy Clemmons NC 27012
150 150

Additional Details
1. Stream Classification: C: Aquatic Life, Secondary Contact Recreation, Fresh water
2. Was Express Review Requested: No
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.