20220210 Ver 1_ORM Form Gallimore Dairy 2022-Jan-28_20220203

Preliminary ORM Data Entry Fields for New Actions
ACTION ID #: SAW- 2021-00395 Begin Date (Date Received):
Prepare file folder ❑ Assign Action ID Number in ORM ❑
1. Project Name [PCN Form A2a]: 415 Gallimore Dairy Site (ECS 49-11545-C)
2. Work Type: ❑✓ Private ❑Institutional ❑Government ❑ Commercial
3. Project Description / Purpose [PCN Form B3d and B3e]:
The applicant proposes to construct four commercial buildings, 126,000-SF, 52,500-SF, 12,000-SF and 10,800-SF in size, on the 415
Gallimore Dairy Road Site, City of Greensboro, North Carolina (36.067648,-79.749464). In addition, site improvements will also
include site access points on Gallimore Dairy Road and Chimney Rock Road, vehicular parking, utility improvements, landscaping,
lighting and stormwater management measures.
4. Property Owner / Applicant [PCN Form A3 or A4]: Koury Corporation
5. Agent / Consultant [PNC Form A5 — or ORM Consultant ID Number]:
Michelle Measday / ECS
6. Related Action ID Number(s) [PCN Form B5b]: NA
7. Project Location —Coordinates, Street Address, and/or Location Description [PCN Form Blb]:
415 Gallimore Dairy Road, City of Greensboro, North Carolina
36.067676,-79.949423
8. Project Location —Tax Parcel ID [PCN Form Bla]: 7814943873
9. Project Location —County [PCN Form A2b]: Guilford County
10. Project Location —Nearest Municipality or Town [PCN Form A2c]: Greensboro, NC
11. Project Information —Nearest Waterbody [PCN Form 132a]: East Fork Deep River
12. Watershed / 8-Digit Hydrologic Unit Code [PCN Form 132c]: Cape Fear / 03030003
Authorization: Section 10 ❑ Section 404 ✓❑
Regulatory Action Type:
Standard Permit
✓ Nationwide Permit # 39
Regional General Permit #
Jurisdictional Determination Request
Section 10 and 404 ❑
Pre -Application Request
Unauthorized Activity
Compliance
No Permit Required
Revised 20150602