20020454 Ver 1_Complete File_20020326

05/03/2002 11:03 1-336-629-7228 ASHEBORO DISTRICT PAGE 02/02
OF W ATFA Michael F. Easley, Governor
Q William G. Ross Jr., Secrete
North Carolina Department of Environment and Natural Resources
> .i Gregory J. Thorpe, Ph.D.
< Acting Director
Division of Water Quality

FILE COPY
April 30, 2002
DWQ # 02-0454
Randolph County
MAY-6
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
R. Thomas McManus, Jr., County Maintenance Engineer
NCDOT
948 Southmont Drive
Asheboro, NC 27203
Dear Mr. McManus: "'^' rl ~----•
INS 7 ?:." },`?,•,? y?ROUP
On March 26, 2002 the. Division of Water Quality (DWQ) was notified by receipt of your
application regarding your plan to fill wetlands for the purpose of a road crossing in Randolph County.
Approval from DWQ is required to disturb these areas. Please provide 7 copies of the following
information and refer to the DWQ # listed above in your reply. In particular as described in 15A NCAC
2B .0502, we will require you to locate all streams and ponds on the property. Please show these on
maps of suitable scale (for instance 1" = 100 feet) so we can begin to determine your projects'
compliance with 15A NCAC 2H.0500.
1. Page 7 of PCN application was missing from your application. Please complete page 7
of the PCN application and return it so we may proceed with the permitting process.
Please telephone me at 919-733-1786 if you have any questions or would require copies of our
rules or procedural materials. This project will remain on hold as incomplete in accordance with 15A
NCAC 2H .0505(c). The processing time for this application will begin when this information is
received. If we do not hear from you by writing within three (3) weeks we will assume you no longer
want to pursue the project and will consider it withdrawn.
Sincerely,
lorney
Quality C Z ation Program
cc: Winston-Salem DWQ Regional Office
Asheville Corps of Engineers
Central Files
File Copy
North Carolina Division of Water Quality, Wetlands/401 Certiflcadon Unit
1650 Mail Service Center, Raleigh, NC 27899-1660 (Melling Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
Ph: (919) 733-178x, Fax: [phone], http://h2o.enr.state.nc us/ncwetlands/
of W ATF9
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13 r
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D.
Acting Director
Division of Water Quality
April 30, 2002
DWQ # 02-0454
Randolph County
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
R. Thomas McManus, Jr., County Maintenance Engineer
?
NCDOT U
948 Southmont Drive Asheboro, NC 27203 VILE Dear Mr. McManus:

On March 26, 2002 the Division of Water Quality (DWQ) was notified by receipt of your
application regarding your plan to fill wetlands for the purpose of a road crossing in Randolph County.
Approval from DWQ is required to disturb these areas. Please provide 7 copies of the following
information and refer to the DWQ # listed above in your reply. In particular as described in 15A NCAC
213 .0502, we will require you to locate all streams and ponds on the property. Please show these on
maps of suitable scale (for instance 1" = 100 feet) so we can begin to determine your projects'
compliance with 15A NCAC 2H.0500.
Page 7 of PCN application was missing from your application. Please complete page 7
of the PCN application and return it so we may proceed with the permitting process.
Please telephone me at 919-733-1786 if you have any questions or would require copies of our
rules or procedural materials. This project will remain on hold as incomplete in accordance with 15A
NCAC 2H .0505(c). The processing time for this application will begin when this information is
received. If we do not hear from you by writing within three (3) weeks we will assume you no longer
want to pursue the project and will consider it withdrawn.
Sincerely,
cc
Dorney Z Wter Quality C ation Program
Winston-Salem DWQ Regional Office
Asheville Corps of Engineers
Central Files
File Copy
North Carolina Division of Water Quality, Wetlands1401 Certification Unit
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
Ph: [phone], Fax: [phone], http://h2o.enr.state.nc.us/ncwetlands/
*A
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M.
a auw+?STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY P.O. BOX 25201, RALEIGH, N.C. 27611-5201 LYNDO TIPPETT
GOVERNOR SECRETARY
August 28, 2003
NERANDR/ 1 %(k?
North Carolina Division of Water Quality
401/Wetlands Unit
1621Mail Service Center
Raleigh, NC 27699-1621
Reference: DWQ Project No. 020454
NCDOT/SR1123 Randolph County
Dear Sir or Madam:
?P r_r
NATER QUALITY RECTIop
Attached is certification of completion for the work performed under the above
referenced permit. The certification is signed by our field agent. If additional
information is required please advise.
Sincerely,
W. F. Rosser, P.E.
Division Engineer
cc: Jeff Picklesimer, PE, PLS
Randolph Co. Maintenance
Art King
File
DIVISION 8, P. O. BOX 1067, ABERDEEN, NC 28315
Telephone: [phone] Fax: [phone]
OO? WA
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DWQ Project No.: U 70 -154 __ County:
Applicant: W • F. Q SSF?
Project Name: 5R wz-3
Date of Issuance of 401 Water Quality Certification
.c1-U
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, , 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 approved plans and specifications, and other supporting materials.
Signature: Date:
Agenf s qJ ofication
hereby state that, to the best of my abilities, due care
and diligence was used in the observ tion 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 approved plans and specifications, and other supporting materials.
Signature: Date:
If this project was designed by a Certified Professional
I, , 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 Quality Certification and Buffer Rules, the approved plans and specifications, and other
supporting materials.
Signature Registration No. Date
MA
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
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/ncwetiands/
05/03/2002 11:03
o?ot N NA r?9o
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t? t
1-336-629-7228 ASHEBORO DISTRICT PAGE 02/02
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina DepaRment of Environment and Natural Resources
Gregory J. Thorpe, Ph.D.
Acting Director
Division of Water Quality
April 30, 2002
DWQ # 02-0454
FILE COPY Randolph County
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
R. Thomas McManus, Jr., County Maintenance Engineer
NCDOTm_
948 Southmont Drive
Asheboro, NC 27203 MAY - 6
Dear Mr. McManus: >
iTy
On March 26, 2002 the Division of Water Quality (DWQ) was notified by receipt of your
application regarding your plan to fill wetlands for the purpose of a road crossing in Randolph County.
Approval from DWQ is required to disturb these areas. Please provide 7 copies of the following
information and refer to the DWQ # listed above in your reply. In particular as described in 15A NCAC
2B .0502, we will require you to locate all streams and ponds on the property. Please show these on
maps of suitable scale (for instance 1" = 100 feet) so we can begin to determine your projects'
compliance with 15A NCAC 2H.0500.
1. Page 7 of PCN application was missing from your application. Please complete page 7
of the PCN application and return it so we may proceed with the permitting process.
Please telephone me at 919-733-1786 if you have any questions or would require copies of our
rules or procedural materials. This project will remain on hold as incomplete in accordance with 15A
NCAC 2H .0505(c). The processing time for this application will begin when this information is
received. If we do not hear from you by writing within three (3) weeks we will assume you no longer
want to pursue the project and will consider it withdrawn.
Sincerely,
Dorney
r Quality C ifi ation Program
cc: Winston-Salem DWQ Regional Office
Asheville Corps of Engineers
Central Files
File Copy
North Carolina Division of Water Quality, Wetlands/401 Certification Unit
1660 Mail Service Center, Raleigh, NC 27899-1650 (Mslling Address)
2321 Crabtree Bled., Raleigh, NC 27604-2260 (Location)
Ph: [phone], Fax: [phone], http://h2o.anr.state.ne.us/newetlands/
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\O??F W A T FRQG
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O <
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D.
Acting Director
Division of Water Quality
April 30, 2002
DWQ # 02-0454
Randolph County
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
R. Thomas McManus, Jr
NCDOT
948 Southmont Drive
Asheboro, NC 27203
Dear Mr. McManus:
County Maintenance Engineer
FILE COPY
On March 26, 2002 the Division of Water Quality (DWQ) was notified by receipt of your
application regarding your plan to fill wetlands for the purpose of a road crossing in Randolph County.
Approval from DWQ is required to disturb these areas. Please provide 7 copies of the following
information and refer to the DWQ # listed above in your reply. In particular as described in 15A NCAC
213 .0502, we will require you to locate all streams and ponds on the property. Please show these on
maps of suitable scale (for instance 1" = 100 feet) so we can begin to determine your projects'
compliance with 15A NCAC 2H.0500.
Page 7 of PCN application was missing from your application. Please complete page
of the PCN application and return it so we may proceed with the permitting process.
Please telephone me at 919-733-1786 if you have any questions or would require copies of our
rules or procedural materials. This project will remain on hold as incomplete in accordance with 15A
NCAC 2H .0505(c). The processing time for this application will begin when this information is
received. If we do not hear from you by writing within three (3) weeks we will assume you no longer
want to pursue the project and will consider it withdrawn.
Sincerely,
Dorney
W?ter Quality C Z ation Program
cc: Winston-Salem DWQ Regional Office
Asheville Corps of Engineers
Central Files
File Copy
*A
N?DEMR
North Carolina Division of Water Quality, Wetlands/401 Certification Unit
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
Ph: [phone], Fax: [phone], http://h2o.enr.state.nc.us/ncwetlands/
OF wAT?R Michael F. Easley, Governor
William G. Ross Jr., Secretary
\OCI QG North Carolina Department of Environment and Natural Resources
co 7 Alan W. Klimek, P.E. Director
Division of Water Quality
O 'C
June 9, 2002
Randolph County
DWQ Project No. 020454
SR 1123 (King View Road)
APPROVAL of 401 Water Quality Certification with Additional Conditions
Mr. W.F. Rosser, P.E., Division Engineer
NCDOT Division 8
P.O. Box 1067
Aberdeen, NC 28315
Dear Mr. Rosser:
You have our approval, in accordance with the attached conditions and those listed below, to impact 64
linear feet of an unnamed tributary to Little River in order to improve SR 1123 (King View Road) in
Randolph County. The project must be constructed in accordance with your application dated March 18,
2002 with additional information received May 6, 2002. After reviewing your application, we have
decided that this fill is covered by General Water Quality Certification No. 3375, corresponding to the
U.S. Army Corps of Engineers Nationwide Permit Number 14. In addition, you must 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 valid solely for the purpose and design described in your application (unless modified
below). Should your project change, you must notify the DWQ in writing and submit 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 the conditions. If total wetland fills for this project (now or in
the future) exceed one acre, or of total impacts to streams (now or in the future) exceed 150 linear feet,
compensatory mitigation may be required as described in 15A NCAC 2H .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. NCDOT shall implement Best Management Practices for the Protection of Surface Waters (NCDOT
March 1997) and Sedimentation and Erosion Control Guidelines for Sensitive Watersheds (15A
NCAC 4B .0024) prior to any ground-disturbing activities to minimize impacts to downstream
aquatic resources. Temporary or permanent herbaceous vegetation shall be planted on all bare soil
within 10 days of ground-disturbing activities (due to the presence of High Quality Waters) to provide
long term erosion control.
2. NCDOT shall adhere to the requirements for High Quality Waters [15A NCAC 2B .0224].
3. Riparian vegetation must be reestablished within the construction limits of the project by the end of
the growing season following completion of construction.
4. NCDOT is encouraged to use existing on-site vegetation and materials for stream bank stabilization
and to minimize the use of rip rap.
5. The dimension, pattern, and profile of the stream and floodplain above and below each structure shall
not be modified by widening the stream channel or reducing the depth of the stream.
6. All work shall be performed during low flow conditions.
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/
4
1 n
Heavy equipment must be operated from the banks rather than in the stream channel in order to
minimize sedimentation and reduce the likelihood of introducing other pollutants into the stream.
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.
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 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 which 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.
Attachment
Since ely,
KlimekE
cc: Wilmington District Corps of Engineers
Richard Spencer, USACE Wilmington Field Office
NCDWQ Winston-Salem Regional Office
Central Files
File Copy
STME
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY DIVISION OF HIGHWAYS
GOVERNOR
May 3, 2002
Mr. Rob Ridings
Division of Water Quality
401 Wetlands Unit
1650 Mail Service Center
Raleigh, NC 217699-1650
Dear Mr. Ridings:
FILE COPY
LYNDO TIPPETT
SECRI'A ARY
"N" 6 t
WETLAWS (?0 "'---j
"TT ; , O U"-"' Y S
Enclosed is the material you requested to complete the application referenced to DWQ
#02-0454.
If you require any additional information please contact me at the address or phone
numbers shown below.
Sincerely
Art C. King
Division Environmental Officer
P. O. Box 1067, ABERDEEN, NORTii CAROLINA 28315
PHONE [phone] FAX [phone]
yrv i.l
02© ?4
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY
GOVERNOR
DIVISION OF HIGHWAYS
March 18, 2002
Mr. Rob Riding FILE COPY
Division of Water Quality
401 Wetlands Unit
1650 Mail Service Center
Raleigh, North Carolina 27699-1650
Dear Mr. Ridings:
Enclosed is the permit application for the following project:
Description: SR 1123 - Randolph County
Work Order #: 6.572055T
TIP Number: N/A
Fee Category: $200.00
Please submit for automated payment.
Sincerely,
LYNDO TIPPETT
SF('.RFI'ARY
?#
MAR26:70
Yt
W. AI Sl a !' CTIr?j
420454
a'-4 C ,
Art C. King
Division Environmental Officer
PAYMENT
RECEIVED
•a
0
STATE OF North CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY DIVISION OF HIGHWAYS LYNDO TIPPET"r
GOVERNOR SECRETARY
March 15, 2002

Mr. Rob Ridings
Divsion of Water Quality
401 Wetlands Unit 020454
1650 Mail Service Center
Raleigh, North Carolina 27699-1650
Dear Mr. Ridings:
Subject: Randolph County - SR 1123 King View Road
In an effort to obtain the permits needed for pipe replacement on SR 1123 from SR 1127 to End
of Survey (sta46+13.90) in Randolph County, we are providing the pre construction notification
application and the supporting materials.
A survey for the presence of Schweinitz's Sunflower (Helianthus Schweinitz) was conducted by
Mary Frazer and myself as part of the required minimum criteria check. No Schwienitz
Sunflowers were found within the road's right of way.
To our knowledge there are No High Quality Waters or Outstanding Water Resources occurring
in the project area. We anticipate that these activities will be authorized under Nationwide Permit
Number 14. Any detours required for this project will be done off site.
This letter and a copy of the application materials will be submitted to N.C. Division of Water
Quality, U.S. Fish and Wildlife Service, and U.S. Army Corps. of Engineers for approval.
If you have any questions or comments, or need additional information, please contact our office
at [phone]. Thank you for your cooperation in this matter.
Sincerely,
av_e.A?44-
Art C. King
Division Environmental Officer
P.O. BOX 1067, ABERDEEN, NoRTH CARoLNA 28315
PHONE [phone] FAx [phone]
401 1113SUFi?
Office Use Only: O O A Form Version October 2001
USACE Action ID No. DWQ No. ?i
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
1. Processing FILE COPY r
1. Check all of the approval(s) requested for this project: 2 s ,
® Section 404 Permit
? Section 10 Permit
® 401 Water Quality Certification WW UP
WATE QU t S CTION
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: Nationwide #14
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: ?
II. Applicant Information
Owner/Applicant Information
Name: North Carolina Department of Transportation
Mailing Address: W. F. Rosser, P.E., Division Engineer
North Carolina Department of Transportation Division 8
P.O. Box 1067
Aberdeen North Carolina 28315
Telephone Number: 910-944-2344 Fax Number: 910-944-5623
E-mail Address: [e-mail]
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: R. Thomas McManus, Jr., County Maintenance Engineer
Company Affiliation: NC Department of Transportation
Mailing Address: 948 Southmont Drive
Asheboro, NC 27203
Telephone Number: [phone] Fax Number: 336-625-0146
E-mail Address: tmcmanuskdot. state. nc. us
Page 5 of 12

- M? nn
r
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: SR 1123 King View Road
2. T.I.P. Project Number or State Project Number (NCDOT Only): 6.572055T
3. Property Identification Number (Tax PIN):
4. Location
County: Randolph Nearest Town: Seagrove
Subdivision name (include phase/lot number): N/A
Directions to site (include road numbers, landmarks, etc.): From Asheboro take Highway
220 South 4.7 miles, take Highway 134 South 4.3 miles, turn left on Burney Road SR 1127)
4.3 miles, turn right on King View Road (SR 1123)
5. Site coordinates, if available (UTM or Lat/Long): See attached sheet
(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:
Unpaved Secondary Road Pipe Crossing
7. Property size (acres): N/A Roadway
8. Nearest body of water (stream/river/sound/ocean/lake): Little River
9. River Basin: Cape Fear River Basin
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h-o.enr.state.nc.us/admin/map .)
Page 6 of 12
10. Describe the purpose of the proposed work: Pipe replacement and upgrade in conjunction
with Secondary Road Improvement Project: Grade Drain Base Pave and Erosion Control
on King View Road (SR 1123) from SR 1127 to End of Survey (sta 46+13.90)
11. List the type of equipment to be used to construct the project: Trackhoe, dozer, ppan, Backhoe, compactor, and motor grader.
12. Describe the land use in the vicinity of this project: Private homes
IV. Prior Project History MAY -
If jurisdictional determinations and/or permits have been requested and/or obtained f65 this
project (including all prior phases of the same subdivision) in the past, p i Pft' R&T Include
the USACE Action ID Number, DWQ Project Number, application date, and dafe'permrts 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 future permit requests anticipated for this project? 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.
Page 7 of 12
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***
None

* 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 Emergency 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 http://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:
Total area of wetland impact proposed:
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)
P 64 UT of Little River 2'-3' I

* 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
N%-%,.-%v.usQs.cov. Several intemet sites also allow direct download and printing of USGS maps (e.g., wwwjopozone.com,
www.mapquest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: 64'
Page 8 of 12
3. 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
(if Name p Waterbody
applicable) Type of Waterbody

(lake, pond, estuary, sound,
bay, ocean, etc.
None

List each impact separately and identity temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation
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.): N/A
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.
Erosion control devices will be installed prior to and during construction
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.
Page 9 of 12
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/ncwetlands/strm-gide.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 tittn://h2o.enr.state.nc.us?NiTp/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):
Page 10 of 12
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:
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*
(sImpact quare feet
Multiplier
Required
1 3
2 1.5
Total
' Lone 1 extends out A teet perpenchcular from near bank of channel; Lone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 1 I of 12
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.
XM. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? No
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).
- 0 - 3 15 120 o Z,
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 12 of 12
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