20091188 Ver 1_401 Application_20091109

WA L"
ag- 1 88
Office Use Only.
Corps action ID no.
DWQ project no.
Form Version 13 Dec 10 2008
Pre-Construction Notification PC Form
A. Applicant Information
1. Processing
1a. Type(s) of approval sought from the
Corps. 'Section 404 Permit ? Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number a or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps? Ayes ? No
1d. Type(s) of approval sought from the DWQ (check all that apply):
N01 Water Quality Certification - Regular ? Non-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express ? Riparian Buffer Authorization
1 e. Is this notification solely for the record
because written approval is not required? For the record only for DWQ 401
Certification-
? Yes 1!?4qo For the record only for Corps Permit:

? Yes XNo
1f Is payment into a mitigation bank or in-lieu fee program proposed for mitigation
of impacts? If so, attach the acceptance letter from mitigation bank or in-lieu
fee program ? Yes XNo
1g Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ? Yes No
1h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes XNo
2. Project Information
2a. Name of project tj,Q/J ?,rfs A
2b. County.
2c Nearest municipality/ town- ul?? n
2d. Subdivision name: TU'.t2cN?'K'ATF J 01
2e project oDOT?only, T.I.P. or state ?r d$"%i?R°yCt!
3. Owner Information
3a. Name(s) on Recorded Deed-
3b. Deed Book and Page No.
3c Responsible Party (for LLC if
applicable).
3d. Street address- a aa? ! S ?? l
3e City, state, zip. G C ?? ?? ?$ jp?7
3f. Telephone no.. ? .- ?. ?g?--
3g Fax no
3h. Email address-
l
Page 1 of 10
PCN Form -Version 1.3 December 10, 2008 Version
4. Applicant information (if different from owner)
4a. Applicant is ? Agent ? Other, specify-
4b. Name-
4c. Business name
(if applicable):
4d. Street address
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.
4h. Email address-
5. Agent/Consultant Information (if applicable)
5a Name:
5b. Business name
(if applicable):
5c. Street address-
5d. City, state, zip.
5e. Telephone no
5f. Fax no.:
5g. Email address:
Page 2 of 10
PCN Form - Version 13 December 10, 2008 Version

B. Project Information and Prior Project History
1. Property Identification
1a Property identification no (tax PIN or parcel ID)-
1 b. Site coordinates (in decimal degrees)* Latitude- Longitude: -
(DD DDDDDD) (-DD DDDDDD)
1 c Property size acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project- KeA-Y- D RXfS.1/V per'
2b. Water Quality Classification of nearest receiving water: V•?cjr ??
2c. River basin A -?
3. Project Description
3a Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
appliic?ation-
CL' E f __ /vt4 i LE't P?9 L 7f-r?21? ) t mill / /?¢G
3b List the total estimated acreage of all existing wetlands on the property.
3c List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
`, P
3d Explain the purpose of the proposed project:
2l vawl;, aec ,.s A v -r
3e. _ Describe a overall project in detail, including the type of equipment to be used-
<5'J E ?- ke/ 'rt"J 4
4. Jurisdictional Determinations
4a Have junsdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
Comments-
Yes ? No ? Unknown
4b. If the Corps made the jurisdictional determination, what type
of determination was made? ? Preliminary ? Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known) Agency/Consultant Company:
Other. 6,V-- -
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past? ? Yes )RrNo ? Unknown
5b If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a Is this a phased project? ? Yes No
6b. If yes, explain
Page 3 of 10
PCN Form -Version 13 December 10, 2008 Version
U Proposed Impacts Inventory
1. Impacts Summary
1a. Which sections were completed below for your project (check all that apply):
? Wetlands Streams - tributaries ? Buffers
? Open Waters ? Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a 2b 2c. 2d. 2e. 2f.
Wetland impact Type of jurisdiction
number- Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ - non-404, other) (acres)
Temporary T
W1 ? P ? T ? Yes ? Corps
? No ? DWQ
W2 ? P ? T ? Yes ? Corps
? No ? DWQ
W3 ? P ? T ? Yes ? Corps
? No ? DWQ
W4 ? P ? T ? Yes ? Corps
? No ? DWQ
W5 ? P ? T ? Yes ? Corps
? No ? DWQ
W6 ? P ? T ? Yes ? Corps
? No ? DWQ
2g. Total wetland impacts
2h Comments-
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a. 3b. 3c. 3d. 3e. 3f. 3g.
Stream impact Type of impact Stream name Perennial Type of jurisdiction Average Impact
number - (PER) or (Corps - 404, 10 stream length
Permanent (P) or intermittent DWQ - non-404, width (linear
Temporary (T) ([N-O? other) (feet) feet)
S1 NfP ? T C.? C ?j?,t-'-?' j'( -fl 1C?? ?r
S?aiE' PER
? INT Corps
C&DWQ
I p
6 T9
S2 ? P ? T ? PER ? Corps
? INT ? DWQ
S3 ? P ? T ? PER ? Corps
? INT ? DWQ
S4 ? P ? T ? PER ? Corps
? INT ? DWQ
S5 ? P ? T ? PER ? Corps
? INT ? DWQ
S6 ? P ? T ? PER ? Corps
? INT ? DWQ
3h. Total stream and tributary impacts
31. Comments:
Page 4of10
PCN Form - Version 1.3 December 10, 2008 Version
4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U S. then individually list all open water impacts below.
4a 4b 4c. 4d. 4e.
Open water Name of waterbody
impact number- (if applicable) Type of impact Waterbody type Area of impact (acres)
Permanent (P) or
Temporary T

01 ?P?T
02 ?P?T
03 ?P?T
04 ?P?T
4f. Total open water impacts
4g Comments.

5. Pond or Lake Construction
If 22nd or lake construction proposed, the n complete the chart below.
5a. 5b. 5c. 5d. 5e
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID Proposed use or purpose (acres)
number of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
5f. Total
5g Comments,
5h. Is a dam high hazard permit required?
? Yes ? No if yes, permit ID no:
5i Expected pond surface area (acres)
5j. Size of pond watershed (acres).
5k. Method of construction.
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If an impacts require mitigation, then you MUST fill out Section D of this form.
6a.
? Neuse ?Tar-Pamlico ? Other
Project is in which protected basin? ? Catawba ? Randleman
6b 6c 6d 6e. 6f. 6g
Buffer impact
number - Reason Buffer Zone 1 impact Zone 2 impact
Permanent (P) or for Stream name mitigation (square feet) (square feet)
Temporary impact required?
B1 ?P?T ?Yes
? No
B2 ?P?T ?Yes
? No
B3 ?P?T ?Yes
? No
6h. Total buffer impacts
61. Comments
Page 5 of 10
PCN Form -Version 1.3 December 10, 2008 Version
D. Impact Justification and Mitigation
-- 1. Avoidance and Minimization
i a. lipecitically describe measures taken to avoid or minimize th r d
Zber vG w4 _ VF0 0 75 -V opose impacts in designing project
1 b. Specifically des be measures taken to avoid or minimize the proposed impacts through construction techniques
1 2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a Does the project require Compensatory Mitigation for
impacts to Waters of the U S or Waters of the State? ? Yes (?No
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps

2c If yes, which mitigation option will be used for this
projects ? Mitigation bank

El Payment to in-lieu fee program
? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank-
3b. Credits Purchased (attach receipt and letter) Type Quantity
3c. Comments.
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached ? Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature- ? warm ? cool ?cold
4d. Buffer mitigation requested (DWQ only): square feet
4e Riparian wetland mitigation requested- acres
4f. Non-riparian wetland mitigation requested. acres
4g. Coastal (tidal) wetland mitigation requested- acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form - Version 1.3 December 10, 2008 Version
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by DWQ
6a Will the project result in an impact within a protected riparian buffer that requires ? Yes ? No
buffer mitigation?
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required
6c. 6d 6e.
Zone Reason for impact Total impact Multiplier Required mitigation
(square feet) (square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1 5
6f. Total buffer mitigation required:
6g If buffer mitigation is required, discuss what type of mitigation is proposed (e g , payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
6h. Comments-
Page 7 of 10
PCN Form - Version 1.3 December 10, 2008 Version
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1a. Does the project include or 3s it adjacent to protected riparian buffers identified ? Yes ?No
within one of the NC Riparian Buffer Protection Rules?
lb If yes, then is a diffuse flow plan included? If no, explain why.
? Yes ? No
Comments*
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
2b. Does this project require a Stormwater Management Plan? ? Yes KNo
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. if this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
? Certified Local Government
2e. Who will be responsible for the review of the Stormwater Management Plan? ? DWQ Stormwater Program
? DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
? Phase 11
3b Which of the following locally-implemented stormwater management programs ? NSW
? USMP
apply (check all that apply). ? Water Supply Watershed
? Other:
3c. Has the approved Stormwater Management Plan with proof of approval been ? Yes ? No
attached?
4. DWQ Stormwater Program Review
? Coastal counties
? HQW
4a. Which of the following state-implemented stormwater management programs apply ? ORW
(check all that apply)'
? Session Law 2006-246
? Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
attached? ? Yes ? No
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? ? Yes ? No
5b. Have all of the 401 Unit submittal requirements been met? ? Yes ? No
Page 8 of 10
PCN Form - Version 1.3 December 10, 2008 Version
I
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the ? Yes tM?No
use of public (federal/state) land?
lb If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State ? Yes ? No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
? Yes ? No
letter )
Comments
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H.0500), Isolated
Wetland Rules (15A NCAC 2H 1300), DWQ Surface Water or Wetland Standards, 3XYes ? No
or Riparian Buffer Rules (15A NCAC 2B 0200)?
2b. Is this an after-the-fact permit applicabon? XYes ? No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):7pt
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in ? YesNo
additional development, which could impact nearby downstream water quality?
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4. Sewage Disposal (DWQ Requirement)
4a. 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.
G
Page 9 of 10
PCN Form - Version 13 December 10, 2008 Version
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
habitat? ? Yes ? No
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts? ? Yes ? No
5c. If yes, indicate the USFWS Field Office you have contacted.
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ? Yes ? No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
? Yes ? No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? ? Yes ? No
8b. If yes, explain how project meets FEMA requirements:
8c What source(s) did you use to make the floodplain determination?

Applicant/Agent's Printed Name Applicant/Agents Signature
(Agents signature is valid only if an authorization
letter from the applicant is provided.) Date
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