20061956 Ver 3_Application_20131113

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STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATTON
PAT MCCRORY
GOVERNOR
US Army Corps of Engineers
Raleigh Regulatory Field Office
Attn: Mr. Andy Williams
3331 Heritage Trade Dr., Ste. 105
Wake Forest, NC 27587
ANTHONY J. TATA
SECRCTARY
November 6, 2013
NC Division of Water Resources
Winston-Salem Regional Office
Attn: Ms. Sue Homewood
585 Waughtown St.
Winston-Salem, NC 27107
R�: Sediment Removal on Westdale Acres Drive, UT to Polecat Creek, Guilford
County; NC DOT Project No. 7.20411B
Dear Mr. Williams and Ms. Homewood:
The North Carolina Depai�tment of Transportation (NC DOT) is proposes to remove
accumulated sediment from a UT to Polecat Creek. The sediment is mostly sand and is
causing a blockage of a tr�iple barrel culvert on Westdale Acres Drive. The accumulated
sand is restricting stream flow which then backs the water up during high storm flows,
threatening to flood the nearby residences. The NC DOT is requesting written
concunence from the US Army Corps of Engineers (USACE) and the N.C. Division of
Water Quality (DWQ) that the activities proposed below may proceed under Nationwide
Permit (NWP) 3& 33 and General Water Quality Ceitifications (GC) 3883 & 3893.
Please contact Mr. Jerry Parker at [phone] if you have any questions or require
additional information.

PROJECT SUMMARY
IMPACT SUMMARY
Attachments:
Pre-construction Notificatiou (PCN) Application Form
USGS Topographic Site Vicinity Map
NRCS Soil Survey Site Vicii�ity Map
Impact Maps (11X17)
Impact Summary Sheet
Cultural Review & Archaeological Review Letters
Sincerely,
�7�/i�
.M, Mills, PE
Divisi n ineer, Division 7
Cc: Barry Harrington, Roadside Environmental Field Operations Engineer
Darrell Ferguson, Dishict 2, District Engineer
Tyler Berrier, Sandy Ridge Maintenance Office, County MaintenTnce Engineer

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Office Use Oniy:
Corps action ID no.
DW� project no.
Form Versian 1.3 Dec 10 2008
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the
Corps: � Section 404 Permit ❑ Section 10 Permit
1b. Specify Nafionwide Permit (NWP) number: 3& 33 or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps? � Yes ❑ No
1d. Type(s) of approval sought from the DWQ (check all that apply):
� 401 Water Quality Certiflcation — Regular ❑ Non-404 Jurisdiclional General Permit
❑ 407 Water Quality Cerlification — Express ❑ Riparian Buffer Aulhorization
1e. Is fhis notification solely for the record For the record only for DWQ 401 For the record only for Corps Permit:
because written approval is not required? Certificafion:
� Yes ❑ No ❑ Yes � No
1f. Is payment into a mitigation bank or in-lieu fee program proposed for mitigation � yes � No
of impacls7 If so, attach the acceptance letter from mitigation bank or in-lieu
fee program.
1g. Is the project located in any of NC's lwenry coastal counties. If yes, answer 1h ❑ Yes � No
below.
1 h. Is the project located within a NC DCM Area of Environmental Concem (AEC)? ❑ Yes � No
2. Project Information
2a. Name of project: Westdale Acrew Dr (SR 3629)
2b. County: GuilFord
2c. Nearest municipality / town: Pleasant Garden
2d. Subdivision name: N/A
2e. NCDOT only, T.I.P. or state �.20411 B
project no:
3. Owner Information
3a. Name(s) on Recorded Deed: NC Department of Transportation
3b. Deed Book and Page No. NIA
3c. Responsible Party (for LLC if N/A
applicable): `
3d. Street address: PO Box 14996
3e. City, state, zip: Greensboro, NC 27415
3f. Telephone no.: [phone]
3g. Fax no.: (336) 3343637
3h. Email address: mmills@ncdotgov
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: NC DOT Highway Division 7
4b. Name: Division Engineer NC DOT Division 7, Mr. Mike Mills, PE
4c. Business name NC DOT
(if applicable):
4d. Streel address: PO Box 14996
4e. City, state, zip: Greensboro, NC 27415
4f. Telephone no.: (336) 3343297
4g. Fax no.: [phone]
4h. Emailaddfess: [e-mail]'note:pleasealsocopyMr.JerryParker,HlghwayDivlslon7Envlronmental
Supervlsor on all correspondence - jparker(afcdot.gov
5. AgentlConsultant Informatfon (if applicable)
5a. Name: Mr. Jerry Parker
5b. Business name NC DOT Highway Division 7, Division Environmental Supervisor
(if applicable):
5c. Street address: PO Box 14996
5d. City, state, zip: Greensboro, NC 27415
5e. Telephone no.: [phone]
5f. Fax no.: [phone]
5g. Email address: [e-mail]
Page 2 of 10

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (lax PIN or parcel ID): N/A - Sediment Removal
1b. Site coordinates (in decimal degrees): Latitude: 35.9641 Longitude: - 79.7712
. (DD.DDDDDD) (-DD.DDDDDD)
1 c. Property size: N/A - sediment removal acres
2. Surface Waters
2a. Name of nearest body of waler (stream, river, etc.) to UT to Polecat Creek
proposed projeci:
2b. Water Quality Classification of nearest receiving waler: 17-11-(1); WS-III
2c. River basin: Cape Fear River Basin (HUC 03030003)
3. Project Descriptfon
3a. Describe the existing conditions on the site and the general land use in the vicinily of the project at lhe time of this
application:
The surrounding land use consists of single family residenlial neighborhood.
3b. List the total estimated acreage of all existing wetlands on the property:
0
3c. List the total esfimated linear feet of all existing streams (intermittent and perennial) on the property:
- 60 LF of UT to Polecat Creek
3d. Expiain the purpose of the proposed project:
The proposed projecl will involve removing sediment from the upstream and downstream ends of the existing triple-banel
culvert. Currenily, stream flow is restricted due to the "plug" of sediment that has built up in fronl of the pipes, restricting
normal stream flow. This is especially problematic during peak storm Flows as the nearby residences experience flooding
of their properties.
3e. Describe the overall project in detail, including the type of equipment to be used:
The project will involve removing the sedimenl "plug" in front of the existing iriple barrel culverts. Sediment build up is
causing restrictions in stream Flow which lhen backs up water during periods of high rain fall which then threatens to flood
the nearby residences. Atl excavated material will be deposited and maintained in an upland sile. No excavation activity
will extend beyond 200 feet in any direction trom the culvert. Equipment utilized will be a long arm excavator and dump
trucks to haul the sediment away. ' Please no(e - this project was approved in 2006 and 2008 for the same proposed
impacfs.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinalions by the
Corps or Slate been requested or obtained for this property /
project (including all prior phases) in the past? � Yes ❑ No ❑ Unknown
Comments:
4b. If the Corps made the jurisdictional determination, what type � preliminary � Final
of determination was made?
4c. If yes, who delineated the jurisdictional areas? Agency/Consultant Company:
Name (if known): Other:
4d. If yes, lisl the dates of the Corps jurisdictional determinations or State determinalions and atlach documentation.
SAW-2008-02989 dated Oct. 31, 2008
5. Project History
5a. Have permits or certifications been requested or obtained for � Yes ❑ No ❑ Unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help flle° instructions.
Similar proposed impacts were requested and approved in late 2006 and again in Fall of 2008. (see attached approval
dated 10/31/2008 - USAID: SAW-2008-02989)
Page 3 of 10
PCN Form - Version 1.3 December 10, 2008 Version

6. Future Project Plans
6a. Is this a phased project? ❑ Yes � No
6b. If yes, explain.
C. Proposed Impacts Inventory
1. Impacts Summary
1a. Which sec[ions were completed below for your project (check ail that apply):
❑ Wetlands � Streams - lributaries ❑ Buffers
❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If lhere are wettand impacts proposed on the site, fhen complete this question for each wetland area impacted.
2a. 2b. 2c. 2d. 2e. 2F.
WeUand 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, oiher) (acres)
Tem ora T
W� � P� T ❑ Yes ❑ Corps
❑ No ❑ DWQ
2g. Total wetland impacts 0
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including lemporary impacts) proposed on the site, lhen complete this
question for all stream sites impacted.
3a. 3b. 3c. 3d. 3e. 3f. 3g.
Slream impact Type of impact Stream name Perennial Type of jurisdiction Average Impact
number - (PER) or (Corps - 404, 10 slream length
Permanenl (P) or inlermittent DWQ - non-404, width (linear
Temporary (T) (INT)? other) (feet) feet)
S1 ❑ P� T Pump Around UT to Polecat � PER � Corps +�_ � 20
Creek ❑ INT ❑ DWQ
S2 ❑ P� T Sediment Removal UT to Polecal � PER � Corps +�_ � 60
Creek ❑ INT ❑ DWQ
3h. Total stream and tributary impacts 80
3i. Comments: The proposed impacts are temporary in nature. Approximately 60 linear feel of sediment removal will occur at
the upstream and downstream ends (in total); approximately 20 linear feel of temporary impacts will result from lhe utilization
of a pump around during the excavalion of the sediment.
4. Open Water Impacts
If there are proposed impacls to lakes, ponds, esluaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individuall list all o en water im acts below.
4a. 4b. 4c. 4d. 4e.
Open water Name of waterbody
impacl number - (if applicable) Type of impacl Waterbody type Area of impact (acres)
Permanent (P) or
Tem ora T
01 ❑P❑T
4f. Total open water impacts 0
4g. Comments:
Page 4 of 10

5. Pond or Lake Construction
If ond or lake construction ro osed, then com lete the chart below.
5a. 5b. 5c. 5d. 5e.
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID proposed use or purpose of (acres)
number pond Floode
d Filled Excavated Flooded Filled Excavated Flooded
P7
P2
5f. Total
5g. Comments:
5h. Is a dam high hazard permil required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construclion:
6. Buffer Impacts (for DWQ)
If project will impact a protecled riparian buffer, lhen complele the chart below. If yes, lhen individually list all buffer impacts
below. If an im acts re ulre miti aiion, then ou MUST fill out Section D of this form.
6a.
❑ Neuse ❑ Tar-Pamlico ❑ Other:
Project is in which protecled basin7 ❑ 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)
Tem ora T im act re ulred?
B1 ❑P❑T ❑Yes
❑ No
6h. Total buffer impacts 0 0
6i. Comments: This projecl is within the Cape Fear River Basin where there are no riparian buffer fules in effect.
Page 5 of 10

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize lhe proposed impacts in designing project.
The sediment removal is necessary as the stream flow through the culverts is severely restricted which results in Flooding
of the nearby residences during high slorm flows. Impacts will be minimlzed to the extent necessary to remove only the
accumulated sediment. Strict adherence to the Best Management Practices for the proteclion of wetland and surface
waters will be followed. There will be no staging of equipmenl in or adjacent to waters of the US and coordination
(including a pre-conslruction meeting) with lhe Division Environmental Officer (DEO) will further ensure the protection of
surrounding resources.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Impacts will be minimized by strict enforcement of Best Managemenl Practices for lhe proiection of surface waters,
restriclions against the staging of equipment in or adjaceni to waters of ihe US and coordination (including a pre-
construclion meeting) with the Division Environmental Supervisor.
2. Compensatory Mitigatian for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigalion for ❑ Yes � No
impacts to Walers of the U.S. or Walers of the Stale?
2b. If yes, mitigation is required by (check all that apply): ❑ DWQ ❑ Corps
❑ Mitigalion bank
2c. If yes, which mitigation option will be used for this
project? ❑ 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-Ifeu fee program is attached. ❑ Yes
4b. Stream mitigaiion requested: linear
4c. If using stream mitigation, sfream temperature: ❑ warm ❑ cool ❑cold
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian welland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland miiigation requested: acres
4h. Commenis:
5. Complete if Using a Permittee Responsible Mitlgation Plan
5a. If using a permiftee responsible mitigation plan, provide a descriplion of the proposed mifigation plan.
Page 6 of 10
PCN Form — Version 1.3 December 10, 2008 Version

C. Stormwater Management and Diffuse Flow Plan (required by DWQ), continued
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the project resull in an impacl 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 miiigation. Calculate the
amount of mitigation required.
6c. 6d. 6e.
Zone Reason for impact Total impact Multiplier Required mifigation
(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., paymenl to private mitigafion bank,
permiltee responsible riparian buffer restoration, paymenl into an approved in-lieu fee fund).
6h. Comments: This project takes place in the Cape Fear River Basin which does not have any State mandated buffer rules in
effect. Please note that while Polecat Creek is a tributary of Deep River, it empties into the river below Randleman Lake
and therefore is nol subject to the Randleman Buffer Rules.
Page 7 of 10

C. Stormwater Management and Diffuse Flow Pian (required by DWQ), continued
2. Stormwater Management Plan
2a. Whaf is the overall percent imperviousness of this projecl? %
2b. Does this project require a Stormwater Management Plan? ❑ Yes � No
2c. If this projecl DOES NOT require a Stormwater Management Plan, explain why: This project is only proposing lo remove
the accumulated sediment at the upstream and d6wnstream ends of an existing triple-barrel culvert. No new impervious
surface is being added and therefore, no stormwater managemen( plan is required.
2d. If lhis project DOES require a Stormwaler Management Plan, then provide a brief, narratfve 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 Unii
3. Certified Local Government Stormwater Review
3a. In which local governmenl's jurisdicGon is this projecl?
❑ Phase II
3b. Which of the following locally-implemented stormwa[er 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
atlached?
4. DWQ Stormwater Pro ram Review
❑ Coastal counlies
❑ HQW
4a. Which of the following stale-implemented slormwater 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 submitfal requirements been met? ❑ Yes ❑ No
Page 8 of 10

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1a. Does the projecl involve an expenditure of public (federal/stale/local) funds or the � yes ❑ No
use of public (federallstate) land?
1b. If you answered °yes" to the above, does Ihe project require preparation of an
environmental document pursuant to the requirements of the Nalional 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 House7 (If so, attach a copy of lhe NEPA or SEPA final approval
letter.) ❑ Yes ❑ No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site In violalion o( DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Slandards, ❑ Yes � No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the-fact permit application? ❑ Yes � No
2c. If you answered °yes" to one or bofh of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in � yes � No
additional development, which could impact nearby downstream water qualiiy?
3b. If you answered "yes° to the above, submit a qualilative or quanlitative cumulative impacl analysis in accordance wilh the
mosl recent DWQ policy. If you answered °no," provide a short narrative description.
This proposed project is lo remove accumulated sedimenl that is currently impeding stream flow fhrough existing culvert
pipes. The project is within a developed landscape (i.e. existing residential homes in the vicinity), this is not a road on a
new location and the project drains to a UT to Polecat creek which is Class WS-III waters (i.e. not HWQ or ORW or
303(d) lisled waters). We do not anticipate the need for a qualitative or quanlitative cumulafive impact analysis will be
necessary.
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.
It is noi anticipated that this project will generate any wastewater as il is a sediment removal project.
Page 9 of 10
PCN Form — Version 1.3 December 10, 2008 Version

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area wilh federaliy protected species or
habital? ❑ Yes � No
5b. Have you checked with the USFWS concerning Endangered Species Act � Yes
impacts? � No
❑ Raleigh
5c. If yes, indicate the USFWS Field Office you have contacted.
❑ Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Crilical
Habitat?
This project has been reviewed and approved by ihe USACE twice before. This issue was not deemed to be a probtem
in previous permit requests and we therefore do not anticipate it to be an issue now.
6. Essential Fish Habitat (Corps Requirement)
6a. Will lhis 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?
This bridge �eplacement project takes ptace in Guilford County which is not near any coastal or tidal habiiat that would
support EFH (i.e. salt marshes, oyster reefs, efc.).
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this projecl occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservalion � Yes � No
status (e.g., National Historic Trusl designation or properties significant in
Norlh Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
This project has been reviewed and approved by the USACE lwice before. This issue was not deemed to be a problem
in previous permit requesls and we therefore do not anticipate it to be an issue now.
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:
Sc. Whal source(s) did you use to make the floodplain determination? http:llfloodmaps.nc.gov/fmislMap.aspx?FIPS=081
Mr. Mike Mills, PE _/7 J �,� ��/�L/�
lY / �t
ApplicanVAgenPs Printed Name App icanUAgenl's Signature Date
(AgenPs signalure is valid only if an authorizalion letler from ihe applicant
Is rovided.
Page 10 of 10

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U.S. ARMY CORPS OF ENGINEERS -� `�- '� �
WII.MINGTON DISTRICT
Action ID. SAW-2008-02989 County: Guilford USGS Quad: Pleasant Garden
GENERAI, PERMIT (REGIONAL AND NATIONWIDE) VERIFICATION
Property Owner / Authorized Agent J.M. Mills, P.E. Division Eneineer Division 7
Address: P.O. Box 14996
Greensboro, North Carolina 27415-4996
Telephone No.: 336-334-3192
Size and locafion ofproperty (water body, road name/number, town, etc.): 0.1 acre (approximatelvl; The site is located
at Westdale Acres Drive immediatelv soutL of Lancelot Drive, in Pleasant Garden, GuilTord Countv, North
Carolina.
Descriprion of projects area and activity: This anthorization is for the temporarv discharee of clean fill material
within 20 linear feet of a iurisdictional stream. Other imuacts associated with this authorization include the
removal of accumulated sediment within 601inear feet of the same iurisdictional stream. The proiect must be
conducted in accordance with the application and drawinas submitted on September 17, 2008.
Applicable Law: � Secrion 404 (Clean Water Act, 33 USC 1344)
❑ Section 10 (Rivers and Haibois Act, 33 USC 403)
Authoiization: Regional General Pemrit Number: _
Narionwide Pemut Numbec: 33
Your work is authorized by the above ieferenced pernut ptovided it is accomplished in strict accordance with the attached
conditions and your submitted plans. Any violation of the attached condirions or deviarion from your submitted plans may subject the
permittee to a stop work ocder, a cestoiaHon order and/or appropriate legal action.
Tlus verification will remain valid until the expirarion date identified below unless the nationwide authorizarion is modified,
suspended or revoked. If, prior to the expuation date idenrified below, the narionwide permit authorizarion is reissued and/or
modified, this verificarion wiil remain valid until the expuarion date idenrified below, piovided it complies with all requuements of
the modified nafionwide permit. If the narionwide pemut authorization expires oi is suspended, revoked, or is modified, sucb that the
acrivity would no longer comply with the terms and conditions of the nafionwide pemut, acKvities w]uch have commenced (i.e., are
under conshucHon) or are under cont�act to commence in reliance upon the nationwide pemut, will remain authorized provided the
activity is completed within twelve months of the date of We natiomvide permiYs expuation, modificarion or revocarion, unless
discrerionary authoriry has been exercised on a case-by-case basis to modify, suspend or xevoke the authorization.
Acrivifies subject to Secrion 404 (as indicated above) may also iequire an individual Secfion 401 Water Quality Cerlificarion. You
shouid coniact the NC Division of �Vater �uality (telephone [phone]) to determine Section 401 iequuements.
For activities occurring witttin the iwenty coastal counfies subject to regulation under the Coastal Area Management Act (CAMA),
prior to beginning work you must contact the N.C. Division of Coastal Management .
This Department of the Army verificarion does not relieve the pernuttee of the responsibility to obtain any other requued Federal,
State or local approvals/permits.
If there are any quesrions regaiding tlus verification, any of the condirions of the Permit, or the Corps of Engineers regulatory
piogram, please contact Andrew Williams at telephone number 919-554-4884 extension 26.
Corps Regulatory Official �s+�.�kJ G��%���•d
Expiration Date of Verification: October 31, 2010
Date: October 31, 2008
The Wilwington District is committed to providing the ]ughest level of support to the public. To help us ensuie we continue to do so,
please complete the Cl�stomer Saqsfacrion Survey located at our website at htto:l/ree�latory.usacesurvey.com/ to complete the survey
online.
Page 1 ot 3

Determination of Jurisdiction:
❑ Based on pxeliminary information, theie appeai to be waters of the US including wetlands within the above described pioject area.
Tlus pieluninary determination is not an appealable action undec the Regulatory Program Administrative Appeal Pcocess
( Reference 33 CFR Part 331).
❑ There aze Navigable Waters of the United States within the above described project area subject to the pemvt iequirements of
Section 10 of the Rivers and Haibors Act and Section 404 of the Clean Water Act. Unless there is a change in the law or our
published regulations, fhis determination may be zelied upon for a period not to exceed five yeais from the date of this
notification.
� There aie waters of the US and/oi wetlands witbin the above described pioj ect area subject to the permit requirements of Section
404 of the Clean Water Act (CV4A)(33 USC § 1344). Unless there is a change in the law or our published regulafions, tivs
determination may be relied upon for a period not to exceed five yeais from the date of Uris no6ficarion.
� The jurisdicfional axeas witliin the above described project area have been idenrified under a previous action. Please reference
juiisdicfional determinarion issued _ Acrion ID_
Basis of 7urisdictional Determination: The stream is a relativelv permanent water (RPW) and an unnamed tributarv to Polecat
and the destruction of terrestrial veeetation.
This iurisdictional determination is onlv for the waters proposed for imnncts associated with this Nationwide Permit and does
not include anv other waters/wetlands that mav be lacated on the propertv.
Appeals InfoYmation (This information applies only to approved jurisdictional determinations.)
Attached to flils verificarion is an approved jurisdicrional determinaHon. If you are not in agreement with that approved jurisdictional
determination, you can make an administ�ative appeal under 33 CFR 331. Enclosed you will find a NoHficarion of Appeal Process
(1VAP) fact sheet and request for appeal (RFA) form. If you request to appea] tlils determination you must submit a completed RFA
form to the following address:
Distdct Engineer, Wilmington Regulatory Division
Attn: Andrew Williams, Pcoject Manager,
Raleigh Regulatory Field Office
U.S Acmy Corps ofEngineers
3331 Heritage Txade Drive, Suite 105
Wake Forest, North Carolina 2�587
In oider for an RFA ro be accepted by the Coxps, the Coips must deteimine that it is complete, that it meets the criteria for appeal
under 33 CFR part 331.5, and that it has been ieceived by the Disirict Office within 60 days of the date of the NAP. Should you
decide to submit an RFA form, it must be ieceived at the above add�ess by December 29. 2008.
*�It is not necessary to submit an RFA form to the Dishict Office if you do not object to the determination in tlus correspondence.**
Coips Regulatory OfficiaL• {`C/!2�-�+� G!/a��-L6�"�
Date October 31, 2008
Page 2 of 3
ExpuationDate October 31, 2013

ID NWP / GP
#
os- N�,p 33
Watei ac)
v Permanent
ofthe U.S.
acts and
Permanent
Total Loss of
iuired Stream
Permanent Temporary Pemianent
20
0 20 0
s oftheU.S. (lfl 0
Additional Remarks and/or Special Permit Conditions: 60 linear feet of stream will also be impacted by the removal of
accumulated sediment.
SURVEY PLATS, FIELD SKETCH, WETLAND DELINEATION FORMS, PROJECT PLANS, ETC., MUST BE
ATTACHED TO THE FILE COPY OF THIS FORM, IF REQUIRED OR AVAILABLE.
Copy Furnished:
SueHomewood
North Cazolina Deparhnent of Natural Resources
Division of Water Quality
585 Waughtown Street
Winston-Salem, NC 27107
Jerry Parker
North Carolina Deparhnent ofTransportation
Division Environmental Officer
P.O. Box 14996
Greensboro, North Carolina 27415-4996
Page 3 of 3

Action ID Number:SAW-2008-02989
Permittee: NCDOT: J.M. Mills
Date Verification Issued: 31 October 2008
ProjectManager: Andrew Williams
County:Guilford
Upon completion of the activity authorized by this permit and any mitigation required by the permit,
sign this certification and return it to the following address:
US ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
RAI.EIGH REGULATORY FIELD OFFICE
3331 I.�RITAGE TF 4I�E DRIVE, SUITE 1Q5
WAI� FOREST, NORTH CAROLINA 27587
Please note that your permitted activity is subject to a compliance inspection by a U. S. Army Corps of
Engineers representative. If you fail to comply with this permit you are subject to permit suspension,
modification, or revocation.
I hereby certify that the work authorized by the above referenced permit has been completed in
accordance with the terms and condition of the said permit, and required mitigation was completed in
accordance with the permit conditions.
Signature of Permittee Date

A: INITIAL PROFFERED PERMIT: You may accept or object to the permit. i
• ACCEPT: If you received a Standard Pemut, you may sign the permit document and return it to the district engineer for final
authorizarion. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your signahue
on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all rights to appeal the
pemut, including its terms and conditions, and approved jurisdictional deternvnafions associated with the pemut.
• OB7ECT: If you object to the pemut (Standard oi LOP) because of certain terms and condirions thetein, you may request that the
permit be modified accordingly. You must complete Secrion II of tlus form and cehun the form to the disYrict eugineer. Your
objecrions must be received by the district engineer within 60 days of the date of tlus norice, oi you will fodeit your iight to appeal
the permit in the future. Upon receipt of youi letter, the dist�ict engineer will evaluate youc objecrions and may: (a) modify the
permit to address all of your concems, (b) modify the pemtit to address some of youc objecrions, or (c) not modify the pemut
having determined tl�at the pemut should be issued as pieviously written. Aftec evaluating your objections, the dishict engineer
wil] send you a pioffered pemvt for youc reconsiderafion, as indicated in SecHon B below.
B: PROFFERED PERMIT: You may accept or appeal the permit
• ACCEPT: If you received a Standard Permit, you may sign the permit document and retum it to the district engineer for fmal
authorizarion. If you received a Letter of Pemussion (LOP), you may accept the LOP and your woik is authorized. Youc signature
on the Standard Peimit or acceptance of the LOP means that you accept the perntit in its entuety, and waive all rights to appeal the
permit, including its terms and condifions, and appcoved jurisdictional determinarions associated with tbe permit.
. APPEAL: If you choose to decline the proffered permit (Standard or LOP) because of certain terms and condirions therein, you
may appeal the declined pernut undei the Coips of Engineers Adminislrarive Appeal Process by completing Secrion II of tlus fomi
and sending the form to the division engineer. Tlils form must be received by the division engineer within 60 days of the date of
Uus notice.
C: PERMIT DENIAL: You may appeal the denial of a permit under the Corps of Engineers Adminisuative Appeal Process by
wmpleting Section II of this form and sending the form to the division engineer. Tlus form must be received by ffie division engineer
witbin 60 days of the date of tlus notice.
D: APPROVED JURiSDICTIONAL DETERMINATION: You may accept ar appeal the approved JD or
provide new information. .
• ACCEPT: You do not need to norify the Corps to accept an appioved ID. Failure to norify the Corps within 60 days of the date of
tlus norice, means that you accept the approved JD in its entuety, and waive all rights to appeal the approved JD.
. APPEAL: If you disagree with the approved JD, you may appeal the approved JD under the Corps of Engineeis Adminisuative
Appeal Process by completing Section II of tlus form and sending the form to the district engineer. Tlris form must be received by
the division engineer within 60 days of the date of this norice.

E: PRELIMINARY JURISDICTIONAL DETERMINATION: You do not need to respond to the Corps
regarding the preliminary 7D. The Preliminary 7D is not appealable. If you wish, you may request an approved
JD (which may be appealed), by contacting the Coxps district for further inshuction. Also you may provide new
information for further consideration by the Corps to reevaluate the 7D.
%� 9.r`.'S,� �� ����� ..,f"r ��-,�µ.m r,� �a -J���� 'i�r ��� �s�:�� `' ��t�� p;� a�'.,7� �� �-�i ,�u�
.._z ,3€:,rt;.�
SECTIOI�-:IIh,RREQTJESTiFQRAP�EA?I�ozOBJECTIO�IS_TOAN:INITIA`T,P�OF��I�DT'ERIVII�' K,� �_
REASONS FOR APPEAL OR OB7ECTIONS: (Describe your reasons for appealing the decision or your
objections to an initial proffered permit in clear concise statements. You may attach additional information to
tlus form to clarify where your reasons or objections are addressed 'm the administrative record.)
ADDITIONAL INFORMATION: The appeal is limited to a review of the administrative record, the Corps
memorandum for the record of the appeal conference or meeting, and any supplemental information that the
review officer has determined is needed to clarify the administrative record. Neither the appellant nor the Corps
may add new information or analyses to the record. However, you may provide additional information to clarify
the location of information that is already in the administrative record:
��a�r-�o�y�o�,�`���.�� _ �sTro�s ox�o��zb � �� �,� �� - �;
If you have questions regarding this decision If you only have questions regarding the appeal process you
and/or the appeal process you may contact: may also contact:
Andrew Williams, Regulatory Project Manager Mr. Mike Bell, Administrative Appeal Review Officer
Raleigh Regulatory Field Office CESAD-ET-CO-R
U.S. Army Corps of Engineers U.S. Army Corps of Engineers, South Atlantic Division
3331 Heritage Trade Drive, Suite 105 60 Forsyth Street, Room 9M15
Wake Forest, North Carolina 27587 Atlanta, Georgia 30303-8801
RIGHT OF ENTRY: Your signature below grants the right of entry to Corps of Engineers personnel, and any
government consultants, to conduct investigations of the project site during the course of the appeal process. You
will be provided a 15 day notice of any site investigation, and will have the opportunity to participate in all site
investigations.
Date: Telephone number:
Signature of appellant or agent.
For appeals on Initial Proffered Permits and approved Jurisdictional Determinations send this form to:
District Engineer, Wilmington Regulatory Division, Attn:Andrew Williams, Project Manager, Raleigh
Regulatory I+Yeld Of£ce, 3331 Heritage Trade Drive, Suite 105, Wake Forest, North Carolina 27587
For Permit denials and Proffered Permits send this form to:
Division Engineer, Commander, U.S. Army Engineer Division, South Atlantic, Attn: Mr. Mike Bell,
Administrative Appeal Officer, CESAD-ET-CO-R, 60 Forsyth Street, Room 9M15, Atlanta, Georgia
30303-8801