20110212 Ver 1_Application_20110304

RECEWED
t
N.C. Not. of ENR
FEB 17 2011
Winston-Salem
Regional Office
201 102 12
Office Use 010y: -- ----- - -
USACE Action 11) No. lDW(Z No.
(If any particular item is not applicable to this project, please entt
). Processing
17 m i Mirch 65
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of Applicable" or
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1. Check all of the approval(s) requested for this project:
? Section. 404 Permit ? Riparian or Waters
? Section 10 Permit ? Isolated Wetland P
? 401 Water Quality Certification ? Express 401 Water
2. Nationwide, Regional or UeneraI Permit Nun.iber(s)
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 Ecosystem Eiihanccrnent Program (NCE:13P) is proposed
for mitigation of impacts, attach the acceptance letter from NCEEP, complete section VIII,
and check liege: ?
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
Environmental Concern (see the top of page 2 for further details), check here: ?
if. Applicant Information
1. Own er/App lic an t. Inform a.tioi
Namc: _ f \ 0, le
Mailing Address: -?? - ---
1'elephoric Fax Number: 3.31e _CR?
i
E-mail Address: ,a-_ - --
__ .cr! l a k1. Rory-? !` ?a t J
2. Agent/Consultant Information (A signed and dated copy of the Agent: Authorization letter
must be attached if the Agent ha's si iatory authority for the owner/appl' _
Name: N -tt
0
Company Affiiiat-ion: _ ------------- D
Mailing Address: - ----------
-------- t__w_•aar?de__$s
- - -----
lclephoilc; Number: /U - - -
-_______
E-mail Address: IiaxNamber:
__-- -----N A ---_.--------------
Page 5 of 12

HL Project Info,-nlation
Attach a vicinity map clearly showing the location of the property with respect: to local
landmarks such as towels, rivers, and roads. Also provide a detailed site plat, showing property
boundaries and development plal)s in relation to surrounding prapc;rtles. Both the vicinity neap
alid site plat] 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 NR.CS 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
USACL requires information to be submitted o17 sheets no larger than 1.1 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 fill-,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 naps are provided,
1. Name of project:_ _ gnok- 1 D 4
2, T.I.T. Project Number or State Project N
J umber (NCDOT Only):---- - IV
3. Property Identification Number (Tax PIN):_ b34 to Q?>
4. Location
County: U (AV .S 6 r?
Subdivision name (include phase/lot number Nearest Town:
U V Q ?? 11 / est dr D<
Directions to site include road numbers/ n nes, landlnarlcs, etc, : J SCZt,? `„ < J
cso .ti. 1 ?J1 --- --
g?1 WOoc1 iT Sou 1,`,nWOec{) 1 ----- -- Ld4
61-
s.
Site coordinates (For linear projects, such as a road or utility line, attach a shee
separately lists the coordinates for each crossing t that
I?eC1111al Degrees (6 digits 1111111111tt111 : of distinct Wa.tGrbo(yd?/ )
6. Proper' , size (acres Q
7. Nance of nearest receiving body of water: ?------^ -`__.-_ -.
8. River Basin: `Ja ri ` . ------
9
Note -- this 1n.u8t be 0110 of North C£lrolin c 1teen designated major river basins. The
River Basin map is available at htt??,//1??o_cri?sta(c.n.c_
I.)escribe the existing conditions on the site an(
at the time of this application: )Zz-
in the vicinity of the project:
Page 6 of 12
•
1.0. Describe the overall. J)"oject in detail, including tile, type ofequipm'nt to be used:
1 I ..t;x Main the pt ?)ose of the proposed work: `----
- ? ? O vL
IV, Prior Project Il'istory
if jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) ill the past, please explain. Include
the USACF Action ID Number, DWQ Project Number, application date, and date omits 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. F'utiire Project PIZns
Are any future pernlit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application.
VI. Proposed Irriparts to Waters of file United States/Waters of the State
It: is t]ie applicant's (or agent's) responsibility to determine, delineate and map all iinpact:s to
wetlands, open water, and stream channels associated with the project. Each impact must be
]fisted separ?tile]y in the tables below (e. g., i•ipi'ap dissipater pads). Be sure to indicate iil?aiitinil acl1isoteni orac ?` Alfed separately from
proposed ipacts,
permanent and temporary, must be listed, and must be labelod and clearly id
entifi ?.ble11oil all
accompanying site plan. All wetlands and waters, and all streams (intermittent and perennial
should be shown oil 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 [lie impact in Section VIII below. If additional
space is needed for listing or descriptor, please attach a separate sheet.
1, Provide a written description of (lie proposed iinpacts: -4-),.- ie
JAI 4
Page 7 of 12
2. Individually list wetland impacts. l'ypes of impacts include, but w,(, not Izmzted to
mechanized clearing, grading, fill, excavation, flooding, ditching/drainage, etc. For darns,
se-paz_atcly list impacts due to both structure and. floodin
Wetland Impact -?.__.______--
Type of Wetland I-.oeated within Distance to Area of
Si to Number Type of Impact (e.g., forested marsh 100-yeal• ]Nearest Impact
(indicate on map) herbaceous, bog, etc.) Floodplain Stream (acres)
Nr???
Total Wetland Impact (acres)
3. List the total acreage (estimated) of all existing wetlands on the property:- _ ? --
4. lndiviclually list all intermittent and perennial stream impacts. Be sure to idezitif temporary
impacts. Stream impacts include, but are not limited to placement of fill or culverts, dam
construction, flooding, relocation, stabilization activities (e.g., cemt walls, rip-rap, crib
walls, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation- is proposed,
plans anal profiles showing the linear footprint for both the original and relocated streams
_ must be included. To calculate acreage, multi ly ten th X width, then divide b 43,560.
Stream Impact '
Nun>bcr Stream Nagle Type of Ict I'elennial or Average Iact Area of
udicate on ma Internuttent? Stream Width th mpact
Before In»act feet) (acres)
-----.------ ---- --,'1 offal Stream impact (by length and acreage)-- --- ------ -
5. Individually list all open wager impacts (including lakes, ponds, estuaries, sounds, ftcd to
Atlantic
Ocean and any other water o.f, the t1.S,), Open water impacts include, but arc not liimite
_ _fi11, excavat__ion, dredging, floodin draina Tc,
Opel Water - -??-' - ?'
bulkheads, etc._
Impact
Site Number Name of ?'Jaterbody - - -- ----
_ (if applicable) Type of Impact 'f ypc of WaterbodY Area of
?1nC11CiltC 071 IIlii) - (lake, poled, estuary, sound, bay, Impact
occall etc.) ---- ------- - ? ? ? ------' - --,-_------ acres I
Total
----- Open Water Impact (acres)
Page 8 01 '12
6. List the cumulative ire']act to all Watei_s of tide U.S. I'Miltinp from the project:
Stream Impact (acres):
ctlatid Impact (ac,res);
_nPe Wafer impact (acres):
Total Impact to Waters of the U.S. acres --' _1 f-b--
Total Strearn Impact (linear feet):
7. Isolated Waters
Do any isolated waters exist on the property? [] Yes (-moo
Describe all impacts to isolated waters, and include the type of water (wetland or stream) and
the size of the proposed impact (acres or linear .feet). Please note that this section only
applies to waters that have specifically been determined to be isolated by the USACE.
8. Pond Creation Al 0
If Construction of a. pond is proposed, associated wetland and stream impacts should be
included above; ill 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): F] uplands
Describe the method of construction (e,gr, U stream (,?] wetlands
, 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,
Current land use in the vicinity of the pond: ___
Size; of watershed draining to pond:__ ---`- -- -
'Expected pond surface a.iea; _
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 SUCK as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attack drawings of altcrriativc, 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 ap Iicable, discuss construction
tCC1111iCIliCS to be followed during construction to rechinc- +_
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 t 150 linear foot of total impacts to
streams. perennial
P,190 9 of 12

iJSACr - In accordance with the Final Notice of Issuance a.nd Modification of Nationwide,
Pern-)its, Published in the Federal Register on Jantlary 15, 2002, mitigation will be required when
necessary to enstire that adverse effects to the aquatic envir•onmont are llllnimal. Factor,,;
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 fiulctions 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 NCEEP 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
11fi4 ://ti2c?.e_ire.;lute;_nc.us/uc??vellatl.cls/stnm?,idG.I-Alli1.
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
anti/or map, if offsi.te), affected stream and. river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or pros crva.tion), 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.
2. Mitigation may also be made by payment into the North Carolina Ecosystem Enhancement
Program (NCEEP), Please note it is the applicant's responsibility to contact the NCEEP at
[phone] to determine availability, and written approval from the NCEEP indicating
that they are will to accept payment for the mitigation must be attached to this form, For
additional information regarding the application process for the WEEP, check the NCELP
websitc at hllE?_/,%112cLpgrLsLz1c,11c.1JS/W.l'p/1iac?ex,h(_If use of the NCLLP is proposed, please
check the appropriate box on page five 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 o1' 12

Ix.
X.
,arvit orrtr>acrital b?octrrrrc?rttatiorA (i egtrired by DWQ)
1. Does the proicct involve an expenditure of public (federal/state/local) funds or the t..ise of
public (federal/state) laical? Yes D No Gl?
2. If yes, does the project rcclt.tire preparation of an environmental document pursuant to the
requirements of the National or North Carolina E.nvii-oninental Policy Act (NEPA/SE:PA)?
Note; If you are not sure whether a NEPA/SLPA document is required, call the SEPA.
coordinator at [phone] to review current thresholds for environmental documentation.
Yes 0 No [•f-?
3. If yes, has the document review been finalized by the State Clearingliouse? If s please
attach a copy of the Nl: PA or SEPA final approval letter. Yes [] No ?
Proposed ?-111Pacts on Ripat Han and Watershed Buffers (required by I3WQ)
It is the applicant's (or agent's) responsibility to determine, delineate and map a.11 impacts to
!Vgt.t.ired sl:atc 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
reap, whether or not impacts are proposed to the buffers. Correspondence from the D WQ
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
(Neese), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 02B .0243 (Catawba) 15A NCAC
2B .0250 (Randleman Rules and Water Supply Buf(or Requirements), or other (please
identify - ------ --- --- )? Yes ? No P
2. If "yes", identify the square feet and acreage of impact to each zone of the riparian buffers.
I^1' buffer mitigation is required calculate the required amount of mitigation by applying the
buffer multipliers.
Impact Required
s uric fbet) Multiplier
-----._-_-_ ----•--•--- - -??.?_ ? ., .-- ?------ --------- Miti anon
-- - 1 ----- - ---- --_-._ 3 (2 f'or Catawba) Jl/ n -
_ Total
" ZOnC 1 extends out 30 feet perpendicular 1,1,0111 the top of the nea, bank of chaunel;L,onr 2 extends an
additional 20 feet from the edge of Zone 1.
3. If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e.,
Donation of Property, Riparian Buffer Restoration / Enhancement, or Payment into the
Riparian Buffer Restoration Fund). Please attach all appro mate information as identified
within 15A. NCAC 213.0242 or.0244, or.0260. __.__/V )q
Page l 1 of U
1
X1. Storxnwater (required by DWQ)
Describe impervious acreage (existing; and propose(l) versus total acreage on the site. Discuss
stormwater controls proposed in order to protect surface waters and wetlands downstream from
the property. If percent impervious surfacc exceeds 20%, please provide calculations
derrlonstrating total proposed impervious level.--
X11. Sewage Disposal; (required by DWQ)
Clearly detail the ultimate treatment methods and disposition (non-discharge or cischarge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
X111. Violations (required by DWQ)
Is this site in. violation of .DWQ Wetland Rules (15A NCAC 214.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application? Yes ? No [ZJ-?
XIV. Cumulative Impacts (required by DWQ)
Will this project (based on past and reasonably anticipated future impacts) result in additional
development, which could impact nearby down.strealn water quality? Yes ? No [-]---
If yes, please submit a qualitative or quantitative cumulative impact analysis in accordance with
the most recent North Carolina Division of Water Quality policy posted on our website at
httl7 //h2o.cr?r.suite :nc u.s/nn Wg lncLs. If no, please provide a short narrative description:- _
XV. Othel- Circumstances (Optional):
It is the applicant's respol.1sibility to submit the application sufficiently in advance of desire(]
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, elates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
& 10
Applicant/Agent's Sigr><ature `??_---------------?I
Date
(Agent's signature is valid only if an authorization letter from the applicant
provided.)
?licant its Pap 12 of 12

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