20021557 Ver 1_Complete File_20020927

A ? W A rFRp?
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0 2 ? SS 7 ELANDS/401(3ROUP
DWQ Project No.: _County: ??
Applicant: A/ A-, o T _
Project Name: 4 1
Date of Issuance of 401 Water Quality Certification: 09-30-
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer
Rules, and any subsequent modifications, the applicant is required to return this certificate to the
401/Wetlands Unit, North Carolina Division of Water Quality, 1650 Mail Service Center, Raleigh, NC,
27699-1650. This form may be returned to DWQ by the applicant, the applicant's authorized agent, or
the project engineer. It is not necessary to send certificates from all of these.
Applicant's Certification
I, L. , hereby state that, to the best of my abilities, due care
and diligence was used in the observation of the construction such that the construction was observed to
be built within substantial compliance and intent of the 401 Water Quality Certification and Buffer
Rules, the ap ved pl s?W specifications, and other supporting materials.
Signature: ??Date: 1C) -t3 -©3
Agent's Certification
I. , hereby state that, to the best of my abilities, due care
and diligence was used in the observation of the construction such that the construction was observed to
be built within substantial compliance and intent of the 401 Water Quality Certification and Buffer
Roles, the approved plans and specifications, and other supporting materials.
Signature: Date:
If this project was designed by a Certified Professional
1, , as a duly registered Professional (i.e.,
Engineer, Landscape Architect, Surveyor, etc.) in the State of North Carolina, having been authorized
to observe (periodically, weekly, full time) the construction of the project, for the Permitee hereby state
that, to the best of my abilities, due care and diligence was used in the observation of the construction
such that the construction was observed to be built within substantial compliance and intent of the 401
Water Qualitv Certification and Buffer Rules, the approved plans and specifications, and other
supporting materials.
Signature --Registration No. Date
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
AM
NMENF
North Carolina Division of Water Quality, 401 Wetlands Certification Unit,
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
919-733-1786 (phone), 919-733-6893 (fax), http://h2o.enr.state.nc us/ncwetlands/
WQC #3375
This General Certification is issued in conformity with the requirements of Section 401, Public Laws 92-
500 and 95-217 of the United States and subject to the North Carolina Division of Water Quality (DWQ)
Regulations in 15A NCAC 2H, Section .0500 and 15A NCAC 2B .0200 for the discharge of fill material to waters
and adjacent wetland areas which are above headwaters or to wetland areas that are not a part of the surface
tributary system to interstate waters or navigable waters of the United States (i.e., isolated wetlands) as
described in 33 CFR 330 Appendix A (B) (14) of the Corps of Engineers regulations (Nationwide Permit No. 14
and Regional General Permit 198200031) and for the Riparian Area Protection Rules (Buffer Rules) in 15A
NCAC 2B .0200. The category of activities shall include any fill activity for road crossings and is limited to fill
less than one-third acre in tidal waters and less than one-half acre in non-tidal waters. This Certification replaces
Water Quality Certification Number 2177 issued on November 5, 1987, Water Quality Certification Number 2666
issued on January 21, 1992, Water Quality Certification Number 2732 issued on May 1, 1992, Water Quality
Certification Number 3103 issued on February 11, 1997, and Water Quality Certification Number 3289 issued on
June 1, 2000. This WQC is rescinded when the Corps of Engineers re-authorizes Nationwide Permit 14 or
Regional General Permit 198200031 or when deemed appropriate by the Director of DWQ.
The State of North Carolina certifies that the specified category of activity will not violate applicable
portions of Sections 301, 302, 303, 306 and 307 of the Public Laws 92-500 and 95-217 if conducted in
accordance with the conditions hereinafter set forth.
Conditions of Certification:
1. Enumerating and Reporting of Impacts:
Streams - Impacts to streams as determined by the Division of Water Quality shall be measured as
length of the centerline of the normal flow channel. Permanent and/or temporary stream impacts
shall be enumerated on the entire project for all impacts regardless of which 404 Nationwide Permits
are used. Stream relocations and stream bed and/or bank hardening are considered to be
permanent stream impacts. Any activity that results in a loss of use of stream functions including but
not limited to filling, relocating, flooding, dredging and complete shading shall be considered stream
impacts. Enumeration of impacts to streams shall include streams enclosed by bottomless culverts,
bottomless arches or other spanning structures when a 404 Permit is used anywhere in a project
unless the entire structure (including construction impacts) spans the entire bed and both banks of
the stream, is only used for a road, driveway or path crossing, and is not mitered to follow the stream
pattern. Impacts for dam footprints and flooding will count toward the threshold for stream impacts,
but flooding upstream of the dam will not (as long as no filling, excavation, relocation or other
modification of the existing stream dimension, pattern or profile occurs) count towards mitigation.
Wetlands - Impacts to wetlands as determined by the Division of Water Quality shall be measured as
area. Permanent and/or temporary wetland impacts shall be enumerated on the entire project for all
impacts regardless of which 404 Nationwide Permits are used. Any activity that results in a loss of
use of wetland functions including but not limited to filling, draining, and flooding shall be considered
wetland impacts. Enumeration of impacts to wetlands shall include activities that change the
hydrology of a wetland when a 404 Permit is used anywhere in a project.
Lakes and Ponds - Lake and Pond Impacts Enumeration- Impacts to waters other than streams and
wetlands as determined by the Division of Water Quality shall be measured as area. Permanent
and/or temporary water impacts shall be enumerated on the entire project for all impacts proposed
regardless of which 404 Nationwide Permits are used. Any activity that results in a loss of use of
aquatic functions including but not limited to filling and dredging shall be considered waters impacts;
2. Proposed fill or substantial modification of wetlands or waters (including streams) under this General
Certification requires application to and prior written concurrence from the Division of Water Quality;
GENERAL CERTIFICATION FOR PROJECTS ELIGIBLE FOR CORPS OF ENGINEERS NATIONWIDE
PERMIT NUMBER 14 (ROAD CROSSINGS) AND REGIONAL GENERAL PERMIT 198200031 (WORK
? NJATF Michael F. Easley, Governor
Q R William G. Ross Jr., Secretary
\O? pG North Carolina Department of Environment and Natural Resources
Vj Alan W. Klimek, P.E. Director
y Division of Water Quality
September 30, 2002
Forsyth County
DWQ Project No. 021557
Replacement of Bridge No. 41 on SR 2219 (Dippen Road)
APPROVAL of 401 Water Quality Certification with Additional Conditions
Ms. Diane K. Hampton, P.E., Division Environmental Officer
NCDOT Division 9
2125 Cloverdale Avenue
Winston-Salem, North Carolina 27103
Dear Ms. Hampton:
You have our approval, in accordance with the attached conditions and those listed below, to impact 140
linear feet of Mill Creek in order to replace Bridge No. 41 on SR 2219 (Dippen Road) in Forsyth County.
The project should be constructed in accordance with your application dated September 23, 2002
(received September 27, 2002). After reviewing your application, we have decided that this fill is
covered by General Water Quality Certification Nos. 3366 and 3375 corresponding to the U.S. Army
Corps of Engineers Nationwide Permit Numbers 33 and 14. In addition, you should acquire any other
federal, state or local permits before you proceed with your project including (but not limited to)
Sediment and Erosion Control, Non-Discharge and Water Supply Watershed regulations. This approval
will expire with the accompanying §404 permit unless otherwise specified in the Water Quality
Certification.
This approval is only valid for the purpose and design that you described in your application except as
modified below. If you change your project, you must notify us in writing, and you may be required to
send us a new application. If the property is sold, the new owner must be given a copy of this
Certification and approval letter and is thereby responsible for complying with all conditions. If total
wetland fills for this project (now or in the future) exceed one acre, or if stream impacts exceed 150 linear
feet, compensatory mitigation may be required as described in 15A NCAC 211.0506 (h) (6) and (7). For
this approval to be valid, you must follow the conditions listed in the attached certification and any
additional conditions listed below.
1. The three 120-inch corrugated steel pipes required for this project shall be designed and installed in a
manner that does not initiate a headcut along the streams. NCDOT must submit a plan for written
DWQ approval to address any headcutting that will occur as a result of this project.
2. Storm water shall be directed to buffer areas or retention basins and not routed directly to streams.
3. All work shall be performed during low flow conditions.
4. All mechanized equipment operated near surface waters must be regularly inspected and maintained
to prevent contamination of stream waters from fuels, lubricants, hydraulic fluids, or other toxic
materials.
5. The presence of equipment in the channels must be minimized.
6. Existing vegetated buffers shall not be mowed in order to utilize it for storm water sheet flow.
7. Riparian vegetation must be reestablished within the construction limits of the project by the end of
the growing season following completion of construction.
8. Upon completion of the project, the NCDOT shall complete and return the enclosed
"Certificate of Completion" form to notify NCDWQ when all work included in the §401
North Carolina Division of Water Quality, 401 Wetlands Certification Unit,
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
919-733-1786 (phone), 919-733-6893 (fax), http://h2o.enr.state.nc.us/ncwetlands/
Certification has been completed. The responsible party shall complete the attached form
and return it to the 401/Wetlands Unit of the NC Division of Water Quality upon
completion of the project.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing.
You must act within 60 days of the date that you receive this letter. To ask for a hearing, send a written
petition that conforms to Chapter 150B of the North Carolina General Statutes to the Office of
Administrative Hearings, 6714 Mail Service Center, Raleigh, N.C. 27699-6714. This certification and its
conditions are final and binding unless you ask for a hearing.
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water
Act. If you have any questions, please telephone Ms. Cynthia Van Der Wiele at 919.733.5715 or Ms.
Jennifer Frye of the Winston-Salem Regional Office at 336.771.4600.
Sincerely,
Attachment
#a. limek, P.E.
Pc: Wilmington District Corps of Engineers
Eric Alsmeyer, USACE Raleigh Field Office
NCDWQ Winston-Salem Regional Office
Central Files
File Copy

021557
STATE OF NORTH CAROLINA

Wz 7,W
?j
DEPARTMENT OF TRANSPORTATION
JAMES B. HUNT JR. P.O. BOX 25201, RALEIGH, N.C. 27611-5201 DAVID MCCOY
GOVF,RNOR SECRF,TARY
September 23, 2002
SUBJECT: Forsyth County - SR 2219 Bridge 41 Dippen Road Work Order Number 5.6252024
Mr. John Dorney B
NC Division of Water Quality
4401 Reedy Creek
Raleigh, NC 27607
Dear Mr. Dorney, FILE COPY
In an effort to obtain the necessary permits for the subject bridge replacement, we are providing
location plans and supporting documentation for the replacement of bridge number 41 in Forsyth County.
There are no wetlands in the project area. We propose to replace the old timber and steel girder bridge with
three 120-inch corrugated steel pies at the same location. The streambed is mostly exposed bedrock.
Pipes wi a placed as low as possible. No endangered species were found on a survey conducted on
9/20/02. We believe this project can be accomplished under Nationwide permit numbers 14 and 33.
By copy of this letter, we are also seeking approval from the NC Wildlife Resources Commission,
the State Historic Preservation Office (through your office), the Corps of Engineers, and US Fish and
Wildlife Service. Therefore, we are submitting the enclosed material to them.
If you have any questions, comments or need additional information after reviewing this material,
please contact our office at [phone]. Thank you for your cooperation in this matter.
Respectfully,
Diane K. Hampton, P.E.
Division Environmental Engineer
Enclosures
CF: Mr. Pat Ivey, P.E., Division Engineer PAYMENT
Mr. George Teague, Bridge Maintenance Superintendent RECEIVED
Mr. Willie Bradwell, Division Business Officer
File
Division of Highways • Division Nine • 2125 Cloverdale Avenue, Winston-Salem, NC 27103
Telephone [phone] • Fax [phone] • Courier Box 13-12-04
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Office Use Only: Form Version April 2001
USACE Action ID No. DWQ No. 021557
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
I. Processing
1. Check all of the approval(s) requested for this project:
® Section 404 Permit
? Section 10 Permit
® 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: NW-14. NW-33
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ?
H. Applicant Information
Owner/Applicant Information
Name: NC Department of Transportation, S.P. Ivey PE, Div. 9 Engineer
Mailing Address: 2125 Cloverdale Ave.
Winston-Salem NC 27055
Telephone Number: 336-761-2613 Fax Number: 336-761-2606
E-mail Address:
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name: Diane Hampton PE, DEO
Company Affiliation: NCDOT - Division 9
Mailing Address: 2125 Cloverdale Ave.
Winston-Salem NC 27055
Telephone Number: 336-761-2613 Fax Number: 336-761-2606
E-mail Address: dkham_pton@a dot state nc us
D'- 'I nr 17

III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: Bridge Replacement SR 2219 Dippen Road
2. T.I.P. Project Number (NCDOT Only): N/A
3. Property Identification Number (Tax PIN): N/A
4. Location
County: Forsyth Nearest Town: Walkertown
Subdivision name (include phase/lot number): N/A
Directions to site (include road numbers, landmarks, etc.): Starting in Walkertown, at US
158, take NC 66 NW for 3.5 miles turn left onto SR 2219 Dippen Road bridge is 0.3 miles
down the road.
5. Site coordinates, if available (UTM or Lat/Long): 36°10'31" N 80°11'45" W
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this application:
Suburban bridge site
7. Property size (acres):
8. Nearest body of water (stream/river/sound/ocean/lake): Mill Creek
9. River Basin: Yadkin
(Note - this must be one of North Carolina's seventeen designated major river basins. The
ans/.)
River Basin map is available at http://h2o.enr.state.nc.us/admin/m
P'.-A nr17
10, Describe the purpose of the proposed work: to replace old bridge with three corrugated
pipes for safety.
11. List the type of equipment to be used to construct the project: standard bridge construction
equipment including a trackhoe
12. Describe the land use in the vicinity of this project: suburban
IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
V. Future Project Plans
Are any additional permit requests anticipated for this project in the future? If so, describe the
anticipated work, and provide justification for the exclusion of this work from the current
application: N/A
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream

mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
1. Wetland Impacts
Wetland Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres Located within
100-year Floodplain**
es/no Distance to
Nearest Stream
linear feet
Type of Wetland***
N/A

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Fmergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at htty://www.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property: none
Total area of wetland impact proposed: none
2. Stream Impacts, including all intermittent and perennial streams
Stream Impact
Site Number
(indicate on ma
Type of Impact* Length of
Impact
(linear feet
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
leasespecify)
1 Pipes and ri ra 140 Mill Creek 20 Perennial

List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usgs.gov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozonle.eom,
www.mapyuest,com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: 140 feet
D.- r -f V)

Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U. S.
Open Water Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres Name of Waterbody
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.
N/A

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation N/A
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
The old timber and steel bridge is being replaced with three 120-inch corrugated steel pipes Rip
rap will be placed along, the banks to protect the pipes from scour caused by floods. All efforts
to maintain the original geometry of the natural stream will be made Bedrock is exposed along
most of the stream area, so pipe burial will not occur, but pipes will be placed as low as possible,
with one higher for flood flow. All efforts to insure erosion control and to minimize the
placement of rip rap will be made Natural materials will be used to stabilize the banks where
possible Construction will be completed in a timely fashion to not upset the natural and human
community.
D.- I -r 1 7
V.
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.us/ncwetiands/strmizide.html.
1. Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
N/A

2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at http://h2o.cnr.statc.nc.us/wrp/indcx.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ® No ?
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No ?
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No ® If you answered "yes", provide the following information:
D.-O..r11
I
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet Multiplier Required
Miti anon
1 3
2 1.5
Total
"Lone 1 extends out 30 feet perpenaicular from near eaRK of cnan=, c.unc L rn«,LuZ? Olt
additional 20 feet from the edge of Zone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
XI. Stormwater (DWQ Only)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
XII. Sewage Disposal (DWQ Only)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
N/A
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No H
Is this an after-the-fact permit application?
Yes ? No H
13-- 10 ..F 11

XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
US Army Corps Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Office Alexander Cherokee Iredell Mitchell
US Army Corps of Engineers Avery Clay Jackson Polk
151 Patton Avenue Buncombe Cleveland Lincoln Rowan
Room 208 Burke Gaston Macon Rutherford
Asheville. NC 28801-5006 Cabarrus Grahani Madison Stanley
Telephone: [phone] Caldwell Haywood McDowell Swain
Fax: [phone] Catawba Henderson Mecklenburg Transylvania
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham
US Army Corps Of Engineers Alleghany Edgecombc Lee Stokes
6508 Falls of the Neuse Road Ashe Franklin Nash Surry
Suite 120 Caswell Forsyth Northampton Vance
Raleigh, NC 27615 Chatham Granville Orange Wake
Telephone: [phone] Davidson Guilford Person Warren
Fax: [phone] Davie Halifax Randolph Wilkes
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare Lenoir
Post Office Box 1000 Camden Gates Martin
Washington. NC 27889-1000 Carteret* Green Pamlico
Telephone: [phone] Chowan Hertford Pasquotank
Fax: [phone] Craven Hyde Perquimans
Wilmington Regulatory Field Office Anson Duplin Onslow
US Army Corps Of Engineers Bladen Harnett Pendcr
Post Office Box 1890 Brunswick Hoke Richmond
Wilmington, NC 28402-1890 Carteret Montgomery Robeson
Telephone: [phone] Columbus Moore Sampson
Fax: [phone] Cumberland New Hanover Scotland
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
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N.C. DEPARTMENT OF TI
tTA RALEIGH, NORTH CARD
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Name: WALKERTOWN Location: 036° 10'22.3" N 080° 11' 48.1" W
Date: 9/20/2002 Caption: SR 2219 Dippen Rd.
Scale: 1 inch equals 2000 feet Forsyth County
Bridge 41
Copyright (C) 1997, Maptach, Inc.
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