NCC190490_NOI Application_20190605

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/5/2019 10:30:17 AM (NCG01 NOI Submission)
Approve by Georgoulias, Bethany 6/5/2019 12:05:22 PM (Review- Construction NOI 11766)
• The task was assigned to Georgoulias, Bethany by round robin distribution 6/5/2019 10:30 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 7, 2019 5:00 PM
6/5/2019 10:30 AM
Submit by Georgoulias, Bethany 6/5/2019 12:05:34 PM (Payment Verification - NCG01-2019-0490)
• The task was assigned to Georgoulias, Bethany. The due date is: June 6, 2019 5:00 PM
6/5/2019 12:05 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Westchester County Day School
2. County* Davidson
3. Highway or Street 2045 N. Old Greensboro Road
Address * Street name only is acceptable if no address number assigned yet
4. City or Township* Hlgh Point
5. State * NC
1 r-i) iTiT 7i1) M fiIi f_TiI a 10141
6. Zip Code* 27265
7. Latitude * Enter the latitude in decimal degrees
35.9735
8. Longitude * Enter the longitude in decimal degrees (MIST be negative)
-80.0898
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* 05/13/2019
Estimated Construction Project Start Date
10. Date to End* 08/16/2019
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 14.30
disturbed* (including off -site borrow and waste areas)
13. Total site area
49.32
(acres)*
14. Post-
11.40
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-DAVID-2019-Westchester County Day School
Tracking ID
Assigned automatically

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. You may
enter up to 3 waterbodies.
15a. Receiving Abbotts Creek
Wate rbody* Narre of waterbody into which stormuater runoff will discharge
15b. Waterbody 12-119-(1)
Index No. * NCWaterbody Index Number
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project r Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Perrrittee Information - Legally Responsible Entity and Individual
.....................................................................................................................................................................
h
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should 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 NCG010000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1. Organization Westchester County Day School
Name *
2. First Name* Cobb
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Atkinson
ff Corporation, enter Registered Agent Last Barre
3b. Title Head of School
4. Permitee E-mail [e-mail]
Address*
5. Permittee 3368692128
Telephone No.*
6. Permittee Mailing Street Address
Address* 2045 N. Old Greensboro Road
Address Line 2
City State / Province / Region
High Point NC
Pbstal / Zip Code Country
27265 USA
Check box if the r% Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 2045 N. Old Greensboro Road
Address Line 2
City
State / Province / Region
High Point
NC
Pastal / Zip Code
Country
27265
USA

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Bill
Contact - First
Name *
3. Primary Site Monroe
Contact - Last
Name *
4. Title
President
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
7042483250
Telephone No.*
7. Organization
WGM Design
Name
8. Site Contact
Street Address
Mailing Address*
2907 Providence Road
Address Line 2
Ste. 304
City
Charlotte
Fbstal / Zip Code
28211
State / Province / Fbgion
NC
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 04/29/2019
Approved *
2. E&SC Plan Project DAVID-2019-022
Number/ID* Assigned by agency or local program
3. E&SC Plan f• State DEQ Office
Approved by r 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.
5. E&SC Plan E&SC Plan Approval Letter.pdf 162.28KB
Approval Mist be RDFformat
letter/documentation
6. NOI Certification NOI Certification Form.pdf 332.06KB
Form Mist be R7Fformat
This is an Express f• No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.613 (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes 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 deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
rJ 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.
* rJ 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.
* I7 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ 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:* r The Responsible Person named on this Notice of Intent
r Authorized Responsible Person*
Important: The person who signs this Certification above and signs the NOI Certification Form should be the same
person (or authorized responsible person within the same organization) as listed in Section B (Permittee Information)
of this form. *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,111 .-41 4►'-40Ar
Type Name * Cobb Atkinson
Title Head of School
Organization Westchester Country Day School
Date * 06/05/2019

F. Tracking and COC Info
NOI Tracking No. 11766
NC Reference No. NCG01-2019-0490
Uses 'count number variable (incremrented by SP)
Certificate of NCC190490
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 490
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NGC' in OOCno.)