20140990 Ver 1_401 Application_20140914

1 $ PAID
Wetland and Natural Resource Consultants
170 Dew Drop Road
Sparta, NC 28675
TRANSMITTAL
Date: September 16, 2014
To: Tasha McCormick
Jennifer Burdette
From: Chris Huysman
RE: Frank Volunteer Fire Department
Plumtree, NC
2 0 1 4 0 9 9 0
RECEIVED
SEP 18 2014
DENR -LAND QUALITY
STOR=ATER PERI01TTING
Enclosed please find a request for a Jurisdictional Determination and authorization for
impacts under Nationwide Permit 39. We are requesting a written 401 Water Quality
Certification.
The Frank Volunteer Fire Department needs to construct a new firehouse because the
existing facilities are unsafe and out of date. Currently, the Department needs to
close the highway in order to back the truck into the station. And, the station is so
close to the highway and so constrained that vehicles can not be safely maintained or
parked at the site. Waste water from the existing Department is pumped and hauled
off site. The old facilities will be demolished.
The new firehouse will be located on a parcel of land that is adjacent to the existing
firehouse. This new parcel was recently acquired and will allow for the new facility to
be located off of the highway and will allow for a septic field. The attached site plans
shows that impacts are needed to access the garage bays. Specifically, a new
driveway will enter from the side of the property and this will impact a small wetland
and a modified stream. The stream is but 1.5 feet wide and less than 1 inch deep; it
is more like a ditch.
The enclosed aerial photographs show that an off line pond behind the firehouse. The
pond was filled and it is presumed to have been non - regulated. The area currently
supports upland vegetation. A small adjacent wetland (200 flag series) appears to be
residual from the decommissioning of the pond.
We would like to request a trout moratorium waiver for this project based on the
absence of trout in the impact areas.
Please call me at 336 / 406 -0906 with any questions that you may have.

Corps StibnAttal-Cover Sheet
Please,provide the following-info:
1. Pi-qJecf Name, - _,, ,
BI&N - ( __ \J
2. Nafhe of Property Owng/Applicant: ,
—MIA
3. Name dCob:Ailtant/Ageht:
*Agent authonzation.needsio be'attached
4. Related/Previous ActionW,number(q):
5. Site Address:
6. SubdivisidnNamet
'7. City:
8. CbVnty:, C�C)�itV� _
9. Lati Lon
�34(09 - 9. _(Decimal,Dqgrges,fkqse)
10. Quadrangle Name:
11. Waterway.
-12. Watershed: FV-071*4CkA
111 Req4ested, Action:
Nationwide Permit 4
General Pemk#
Jurisdictional l?&terminatioxf_k6qiIest
Pre-ApplicationApiquest
The following information will be c6niplbted by Corps office:
•Ir, I I
Prepare File Folder
Assign number Iii ORM
Authorization: Sectioif 10
'Project DescriptionfNature,of Activity/ PidjectTurpose:
Site/W_a&&rs,Name:
Keywords!
Section 404
Begin Date

Sep 68 14 08t2p Frank WI.,Fire Dept
, W Mik MI
Wetland and. NaturaV'Resource Consultants
17©',Dew;DropyRoad,
Sparta,, NC 28675
Department of the -Array
Wilmington District, Corps of Engineers
Attn. Scott- McLendon, Chief, Regulatory`Divlslon
PO"Box`1f890
Wilmington, North Carolina, 28402 -4890
-and-
NC Division of Water Quality, Wetlsnds,.Unit
Aid; KarenrHiggins
2321 Crabtree.,Blvd,
Raleigh,, North•Caroliria,27604 =2260
18287333639 p2
i; the current landowner of the property identified below,, herebylauthorize Wetland and`
Natural Resource, Consultants,to,act on�my behalf regarding the determination of
regulated - limits of waters and'wetiarids and processing of permits to impact Wetlands
and Waters of the US "that,are regulated- byJhwClean Water Act and the FR vers and
HarborS,A& F6d&M.6nd Stateagents,are authorized t6 be on,said property when
accompanied"by Wetland and Natural Resource Consultants ;staff.
Wetland -and Natural Resource Consultants;is authorised 't4'provaie-, supplemental'
information needed for permit pri idessing at•the requestbf,fhe Army Corps -or NC `DWO.
Property-Owner , Applicant; `
Contact Name: -
Street- Address•/ PO;Box: /'°O
City, State,'Zip Code:
Phone/ Fax Number' 733- 953C �_,L 929`- 7B- 363
Project Name: 'Pj_r Ak '44e-
Property Street,Address °�rY'S'`
(street address; city; State, zip)
Owner ,/ Applicant Signature. ITT
Date:

A.
B.
jurisdicdori4l Nitermination Rt-qdest.
PA1tC9L,1NFOfRMAT14jN,
Street, Address:-
City,, State:
Coiintyt,
.Ditedtiohs,
Parcel Index P4urfiber(s).(PIN)
REQUESTOkIWOkMATiON
i?, k Gob2 0 al�
Name-., L V-1)1\-`-
Mai , ling,,Addressf 170, Q SW DOW, V–D
Telephone Number: 711
t-itctron , ic Mail Addrtss'`
Select 6he-
F] I am the current property owner.
I® 1 am an Authorized Agent or Enviiohrnerftd1 Constiltant2
1:1 Interested Buyer -or Under Confra6t to Purchase
❑ Other, please, explain.
C. PROPERTY-OWNER INFORMATION
Name:
Mailing Address:
TeleohQneNjjmbpr: •
Electronic Mail Address':
F%71
U
Proof of Ownership, Attached (e.g: a copy ofDbed, County, Record,data),
si - 1 .1 , — - -, -
GV�'� � � ITO 1'� -Ov k �--
I If' available
available
2
Must attach,completed Agent Authorization Form
3 Ifavailable
Version, December 2013
Page,'

`jurisdictional Determination Request
D. PROPER'T'Y OWNER CER'TIFICATION;4
1, the undersigned; A duly; authorized ,'owrid,of`recordofthe property /properties identified herein;
do,duthorize- representatives of the'Wilmingtori- District; U.S. Army Corps 9f�Engineer5,(Co"j
'to enter upon the property herein, described for the.purpose °of conducting on -site investigations
and,issuing a,detennination_associatedwith Waters:ofdie, U: S._ subjectto'Federal- jucisdictioii
r- �a
under Section 404 of,the Clean Water-Actand/or Section 10 of the Rivers.and Harbors -Act of
1899.
Properfy Owner,(please print) Date
Property Owner Signature
E. JURISDICTIONAL DETERMINATION TYPE,
Select One:
I am requesting that the Corpss provide a;preliminary JD for "the'property identified herein.
This request does include,a;delineafion.
I am requesting'that the Corps - provide a,preliniinary JD for the property, identified "Herein:
`This requesVdoes NOT include a d'e_lineation.
0 I am requestingthat the Corpsjnvestigate the ,property/project,acea,for -the presence or
absence-of WoUSS and provide dn,aporoved JD for "the property identified,herein. This
request does,NOT include a request.for a verifedAblinea'tion,.
F-I I' am' requestingfthat,theGorps °delineate the bouridari6ss f all 'WoUS oh a property /project
area and proyide,an approved JD (this may orlmaynot;include a.survey-plat).
ham requesting;thatthe Corps evaluate =dnd ,,approve,a,delineatioii -of WoUS (conducted
by- others) on a,property/proje&area and provide -an approved JD (may or may not
include a survey plat).
° For kDOT requests,followmg the - current NCDOT /USAGE protocols, skip to Part E
s-W,aters ofthe'United States
,version:,Deceinber-2013 Page 4

Jurisdictional 'Detertninati'On,R--6ci,uest
F. ALL REQUESTS'
FV_I,
Map of Propeqyor Project Area (attached). ThisMap miist,cf6arly, depict the,boundaries
of the area of,evaluation.
PeP_*A,lam"
1-14 Size of Property or Project Area acres
I.verify,thaVthecprqpqq
yI(or pyqjgcf) boundaries,have,,reedfitly been surveyed and mark6d
by-ajicehkd OR are otherwise clearly marked or distinguishable.
G. JD REQUESTS FROM CONSULTANTS OR AGENCIES
(1)- Preliminary, JD Requests:
1--J, Cbmpl&ted,and signed Preliminary Jurisdictional Determinationform6.
91 Project Coordinates 340- 6- n-- !-Latitude e? , () 07-2--'s Longitude
Mzips,(po lager than I ]VI) with P -01 ect,BoundaryOverlay:
Large and- small,scale na s,thatdepicti at minimum: streets, intersections; towns
Aerial Photography of the project-area
f
,ograofiic Mdp
If 1 Soil Survey Map
Other Map - , as appro p f iite.( e:g., atfonal We A
lafid Inventor,
a Proposed Site
P la,prev i ous, deline ati on m aps, LIDA , maps; T N - f oodpI ai h-m ap§)
r
See Appendik-kofithisForm From:RegUIat6rVtui8anteLeWe(No OMZ,dked Idne_,26, 2008
Version: December-2013 Page, 5

Jurisdictional Determination Request
Delineation Information (when applicable):
We nds:
Wetland Data Sheets
Tributaries:
USACE Assessment Forms
Upland Data Sheets Other Assessment Forms
(when appropriate)
Landscape Photos, if taken
Field Sketch overlain on legible Map that includes:
• All aquatic resources (for sites with multiple resources, label and identify)
• Locations of wetland data points and /or tributary assessment reaches
• Locations of photo stations
• Approximate acreage /linear footage of aquatic resources
(2) Approved JDs including Verification of a Delineation:
❑ Project Coordinates:
Latitude Longitude
Maps (no larger than l I x 17) with Project Boundary Overlay:
❑ Large and small scale maps that depict, at minimum: streets, intersections, towns
❑ Aerial Photography of the project area
❑ USGS Topographic Map
❑ Soil Survey Map
❑ Other Maps, as appropriate (e.g. National Wetland Inventory Map, Proposed Site Plan,
previous delineation maps)
1987 Manual Regional Supplements and Data forms can be found at:
http: / /www.usace.army.mil/ Missions/ CivilWorks/ RelzuiatoryProizramandPermits /ree suoo.asox
Wetland and Stream Assessment Methodologies can be found at:
http: / /oortal.ncdenr.ofg/c /document library/get file ?uuid= 76f3c58b -dab8- 4960- ba43- 45b7fafo6f4c &grouold =38364 and
http: / /www.saw.usace.army. mil / Portals /59 /dots /regulatory /pubIicnotices /2013 /NCSAM Draft User Manual 130318 pdf
6 Delineation information must include, at minimum, one wetland data sheet for each wetland /community type.
Version: December 2013 Page 6

ATTACHMENT ' A
PRELIMINARY, JURISDICTIONAL` bETJERMINATIOWFORM
BACKGROUND WFLokMATjON
A. 'REPORT d6MPLETION'DATE FOR PRELIMINARY JURISDICTIONAL
btT0Fk91NAT1_0W-(J'D):
B" NAME AND ADDRESS,'OF,PERS0-N REQUESTING PRELIMINARY JI)i
C_- bittRICT-6FFICE, FILE NAME, AND NUMBER:
D;. PROJECT LOCATIONS) AND BACKGROUND INFORMATION:
(USE THE ATTACHED TABLE'TO DOCUMENTMULTIPL-E WATEl!B0d1E$, AT DIFFERENT
,$ITES) ,�A� ca
State: NC County /parish /borough; City:
L
Cbrit&-c6drdinates of site (lat/long in degree.decimal format):
Lat.'s G .1 67 'N _21- * - ON; Long. e-Z. W.
Universal -Transverse Mercator
Name of nearest waterbody:
Identify (estimate) amount, of waters, in the\ reviewafrea:
Non wetland waters:
Jinpar'f6et: -,acres.
,Cowardin Class:
Streaib-Flov%:
Wetlands, v A acres.
CoWardin,'C lass:
Name 6fafiyvatLarlbodies on thb site that have.been' identified as-Se6tion 1D
w6tefs.
Tidjl:
Non-Tidal

E. •REV,IEW'PERFORMED FOR SITE EVALUATION_(CHECK ALL THAT
APPLY -
❑ 'Office (Desky Determination. Date-.
F-1 Field Determihation. Date(s)
-SUPPORTING DATA. Data reviewed for preliminary JD
(check`all that °app`iy - checked items should; be incl'uded'in case file and,
where checked -and requested, approptiately reference sources below):
;❑ Maps,'plans,,plots or.plafisubmitted by or on behalf of'the
applicanii'consultant:
Data `sheets ,prepared /submitted by =grbn behalf of the
app nt/consultani.
Office concurs =with data sheets /delineation report.
Office -does not concurswith _data ,sheets %delineatibn,report.
❑ Data sheets prepared by,the'.Corps
❑, Corps navigable waters' study:- _
❑ U.-S. -Geological Survey, Hydrologic Atlas:
❑ USGS 'NHD data
❑ 'USGS 8.and 12 digit.HUC maps
❑ U.S. Geological Survey map(s). -ite -scale & quad name:.
❑ USDA Natural, Resources,Conseivation Service Soii�SurGey.
Citation.
National wetlands inventory map(s) Cite name:{
State /Local Wetland inventory map(s):
❑- FEMA/FIRM,_maps:
❑, 100 =year Floodplain Elevation is:
(National Geodectic Ve7tical`Datum,of "1929), _
❑ Photographs: Aerial (Name & Date): or
❑ Other (Name & Date)`:
❑ Previous d`e_termination(s)., File no. and date of'response letter-
❑� Other information (please specify):
0A

1. The 'Corps of Engineers belkev_ es that there may be jurisdictional_waters o_f,, the
United States,on the subject site, and the peri nitYapplicant- orr,other,affected party
who requested this•preliminary JD'is,hereby advised of his or heroption,to
request and obtain a naappr'oved;jurisdictional determination (JD) for thatsite.
,Nevertheless, the_ permit�applicant•orfother person whb- requested this
preliminary JD has declined to,exercise the option to obtain an approved:JD m
this, instance and atAhis,time.
2. do -any circumstance where a ,permit applicant obtains an individual' permit, or
a Nationwide General- Permit (NWP).oi* other'general permit verification requiring
"pre- construction notification" (PCN), or requests verification for a non'-reporting_
NWP or other general „permit,_ and the permit applicant has'not- requestedran
approved JD`�for the activity; ,the permit applicant is tie -reby'made .,aware,of the
'following: (1) the permit•applicant has elected =to seek'a permit authorization
based'bh a, ,`preliminary” JD; which does not,rnake,•an official determination of
,jurisdictional waters; (2),-that the.applicant hasAhe option to request -an app-roved
JD' before accepting the terms and conditions of the permit authorization, and
that'basing a;permit authorization on an approved JD could possibly result in less
compensatory mitigation being required or different special conditions; ,(3) that
the applicant has the, right "to "request an individual permit rather-than accepting
the terms -and conditions of-the NWP or other-general permit authbrizatiorf; (4)
that.the applicant cam accept a permit,authorization'and, thereby agree-,to, comply
with'all the, terms,and,conditions of that permit, including,whateverKmitigation
-requirements the Corps: has'determined�to bewriecessary ;, (5) thatwundertaking
,any activityin reliance upon the subjectxpermit authorization without requesting
an approved JD constitutes the applicant's acceptance of the use- of the
preliminary JD,, but that either form of JD will'be processed as soon as -is
practicable; (6) accepting, a permit °authorization (e.g., signing a proffered
individual permit) or undertaking any- activity in reliance on any form of Corps
permit'authorizaiion based on a preliminary JD-constitutes agreement =that :all
wetlands and other water, bodies on the site affected`in, any way by that activity
are jurisdictional.waters of the United,States, and precludes any challenge -to
such jurisdiction in -any administrative or judicial compliance or enforcement
s -
'action, or in any administrative appeal or in any, Federadl;bdUrt ;,and, (7),whether
the applicant'elects to use either an approved JD or'a preliminary JD, that J6
will be processed assoon',as' is, practicable. ,Further„ an- approved JD; a proffered.
individual permit-(and� all, terms and conditions contained therein), or, individual
:permit denial can be administrativel'y - appealed pursuant tC 331,
and
that in any administrative- appeal, jurisdictional'issiies can be iaised­(see 33
C.F.R. 331.5(a)(2)). If, during that administrative appeal, it becomes necessary
to make an official determination whether CWA. jurisdiction.exists over a site, or
to provide an official delineation of jurisdictional waters--on the site, the Corps will
provide an approved JD to-accomplish,that result, as soon as.'is practicable.
5

This-preliminary JD finds that there '"may be "'waters of,the United $tates�on the
Subject project site, and identifibt,all aquatic- features 6h,the,site that could be
affected b lheproposed activity, based on<the following' information:
Signature and date of
Regulatory-Project Manager
(REQUIRED)
nature grid date.of
person requesting preliminary JD
,(REQUIRED, unless obtaining
the signature is impracticable)

W AA rF�
P � Y
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Page 1 of 10
PCN Form — Version 1.4 January 2009
Pre - Construction Notification (PCN) Form
A.
Applicant Information
1.
Processing
1 a.
Type(s) of approval sought from the Corps:
❑X Section 404 Permit ❑ Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 39 or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps? ❑ Yes ❑X No
1 d.
Type(s) of approval sought from the DWQ (check all that apply):
❑X 401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
le.
Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification:
❑ Yes ❑ No
For the record only for Corps Permit:
❑ Yes ❑ No
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 X❑ No
1 g.
Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
E] Yes XQ No
1 h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes No
2.
Project Information
2a.
Name of project:
Frank VFD
2b.
County:
Avery
2c.
Nearest municipality / town:
Newland
2d.
Subdivision name:
2e.
NCDOT only, T.I.P. or state project no:
20
3.
Owner Information DENR -L
3a.
Name(s) on Recorded Deed:
Avery County Fire Commission 1 LJNMWATER PERMITTiNG
3b.
Deed Book and Page No.
478, 1220
3c.
Responsible Party (for LLC if
applicable):
3d.
Street address:
749 N US 19E Hwy. PO Box 640
3e.
City, state, zip:
Newland, NC 28657
3f.
Telephone no.:
3g.
Fax no.:
3h.
Email address:
Page 1 of 10
PCN Form — Version 1.4 January 2009

4.
' Appl icant -infortnation`(if'different.from owner)
Sr
4a
Apphcanf is.
❑Agent ❑X Othef,�speafy. Municipality
4b
Name.
Johnny Mathes _
4c
,Business name '
_,(if applicable)_
Frank °Volunteer Fire D6partment
4d
- Street address-
699'N 19E (PO-Box 160 Plumtree)
4e
City, state, zip ,
Newland NC 28657
4f,
Telephone, no
828.7339'336, -
4g,, Fax no:_
828 -Z33 3639
4h
Email-address -
_
5'.
Agent/Consultant 'information "'(if applicable)'
5a, Name_
'Chns,Huysman
56
Business name
„ (f appllca6le)-
WNRConsultants
5c, Street, address-
170bew Diop fO
'5d
0 ity, state, ziq
Sparta, NC 28675
5e. Telephone no.,
(336) 406 -0906 _
5f
Fax no
5g. Email address.
chns'- huysman @wetland- cohsultarits=com, T
Page'2'of110

B. PioJecf lnforrnation.and Prior Project History
1. Propertyldentification
la Property identification no (tax PIN or parcei.ID)
18160021703.6
1 by `Site coordinates pn ;decimal degrees):
Latitude '36.0792: Longdude -82.0023
1 c Property siie _
1 5 acres
,2. Surface Waters
2a Name of- nearest body of water to,proposed project
North To& River
2b ' WaterOua it Classfication of nearest receiving= water=
WS -V; Tr w.
2c River basin:
French Broad
-3. Project Description
3a, Descnbe'the existing conditions on the,sit&and,the general land use.inthe vicinity of the project at the,time.of this
appficatwn_
The site is,the locabonrof,the existing fire department and an abandoned resident4l'dwelling -The landscape waehighly impacted by the pne�nou's
owners An off-line pond has been filled in, it is,presumed,fo have, been riori f uiated The'pFoperly was historically ditched and the ditches have
been inamtained :Orie s iia etland,exists omthe site,and' � is,assumed•to b&related to;the filling of the °pond
3b List the total estimated acreage of all existing wetlands on;the_property 0 01
•3c List the.total estimated linear feet of all,existing streams (intermittent and_ perennial) ori'the property= 440
-3d Explain the_' {purpose of the,proposed project
The,purpose of the protechsSo construct a new fire iabowbecausEPthe existing;fire'hodse',is unsafe and does not have proper septic facilities
3e Describe,theyoverall project in detail, mcluding.the type of'equipmentio'be used.
The, project includes the construction'of a fire house and garage baysJand all appurtenarit infrastructure using convenbonal construction.equiprrrent,
4. .Jurisdictional' beterm ina,tio'ns
46, Have jurisdictional iv6tland or'stream;.deter:minatlons by the
Corps orState`been requested or obtained ifor this property-/
ro ect includin all, prior hoses m the; asi? .
El yes [0-No, ❑Unknown
Comments
-
4b If the Corps1nade the'junsdicbonal determination, what type
of'determination,was made?
❑Preliminary E] Final
4c If `yes, who delineated the,junsdidiona' Far`eas?
Name,(if known): Chns _Huysman
Agency /Corfsultant;Com_pbny MR, Sparta
Other.
4d if yes, list the1'dates of the Corps' jurisdictional deterrniriations or -State determinations and attach documentation
-
- w_
5. 'Projecf;Hisfory.
5a Have. permits;or`,certificabons been requested oe obtained for
this project,(including;all prior phases)'in the•past?
❑!Yes ®No ❑;Unknown
5b If yes, explain in detail according to "help,file °°instructions.
6. Future`Projeat'Plans
;6a is this a phased project?
❑X °Yes ❑, No
,6b- If--'yes, explain
The exisbng fire station will tie'demolished when the new facildi s`aie operable
Page 3 of 10
PCN Form Version 1 4 January 2009

C: Proposed Impactsdnventory
'1. Impacts Summary
1 a, Which sections were completed below for your project (check all that- apply)_-
® Wetlands ®;Streams = tnbutanes 0 Buffers ® Open Waters Pond Construction
2. VWetfandi Impacts
If there are wetland impacts proposed on- thessite, then complete,this question for eachhetland area impacted, -
2a
Wetland nnpact
number
Permanent (P)-or
Temporary (T),
2b
Type,of Impact
-
26=
Type of wetland
2d
Forested
26
Type ofjunsdicbon
Cfts,(404,1b) or
DWQ (401, other)
2f
Area of'
impact
(acres)'
W1' P
Fill
Small-Basin Wefland
No
Corps
001
W2 -
Choose one
Choose one
Yes/No
-
W3 -
Choose'one
Choose'ane
Yes/No
-
W4 -
Choose one
, Choose'ane
YeWNo
-
W5 -
Choose -one
Choose one
Yes/ No
-
,W_ 6 -
Choose�one
Choose-one
Yes1N6
-
"2g. Total Wetland1mpacts:
0'01
2h., Comments.
This ;is awe y low quality feature',thaf'wassessed'to have been created during the brea6hmg,of'an,o#4-ine,pond T
3. Stfearn Impacts
If`there are,perenn-40or Inte"nmlttentlstream'Impacts (Including temporary�impacts_) proposed omthe.site,r theimcoinplete this
,question for all stream sites Impacted.
3a -`
'Stream,impact
numbers
Permanent (P)'or
Temporary (�T)
3b.
Type)of Impact
3c
Stream name
3d
Perennlal;(PER) or
intermittent,(INT)?
`3e-
Type of
junsdiction
M
Avefage
stream
width
(feet) _
impact
length
(linear
feet)
S1 P
Culvert
unnarried1rib
PER
Corps
3
80
S2, i P
Stabilization
outlet protechbrijor pipe
PER
Corps
3
-20
S3 -
Choose'ane
'S4 -
Choose one
-
-
S5 -
Choose one,
-
S6 -
Choose'one
-
-
3h. Total stream and triibuta'.'qrr�p
'Acts-j
100
31- Comments
This is a verf low,quality stream It is likely a natuial¢ed�ditch as spoil'piIes,are evident
Page 4 of.10
PCN Form, — Version 14 January,2009

4.. Open • Water Im pacts
If there °are proposed impacts-to,lak_es; ponds, estuanes, tn6utanes; soundsiv'the;Atlantic Ocean,,,or'any othe�'operrwate� of
the.0 S.,' then individual) Ilst' all o` n water im acts,belowi
4a
Open;water
irnpacf number
Permanent.(P),or
Tem ora
4b.
Name,J f waterbody
(if_applica0e) 4
4c
Type of"mpact
4d.
W_ aterbody
type
4e�
Area•of!mpact (acres)
01 P
off-line pond ,(old,air,photos)
-
Fill
Pond
02- -
-
Ch'oose one
Choose
03 - °
Choose one
Choose
04 -
Choose one
Choose
_ - - 4f•Totalopen'Water impacts
4g .Comments. is is presufW to Deq non-repprong,a-cuviry since uie,pona was excavatea in ig ground-
5. 'Pond or Lake.Construction
If pohd or•Iake,constniaUon ro sail, then com rlete the chart below.
5a
,Pond'1D, number
;5b•
Proposed,use or
Purpose of "pond
5c
Wetland{Impacts (acresj,
5d.
Stream Impacts#eet)
5e_
Upland
(acres)
Flooded
Filled
' E_xcavatetl
-'Flooded
Filled
Excayated
P1
Choose,orie.
`
P2
Choose one
_ 5f_ Total:
5g, :Comments:
5h „ Is a,dam high hazard ,,permit required?
0 Yes ❑ ,No If yes; perrnifO no
5i Expect ed;porfd surface•area'(acres)
5j Size of pond,watershed (acres)-
51k, `Method of construction
-
6: Buffer Imp4ets,(forl WO)
If project will impact a protected riparian buffer,,then complete the chart below If yes, then individually bst.all-buffer impacts
below 'Itan Im cts,re uire mite abon, en" you, NiUSTAI out Sectionb -,of this.form:__
6a. Projec is in which protected basin?
❑ Neuse E] Tar - Pamlico '[]',Catawba Randleman ❑ Other
6b - -
'Buffer Impact
number —
`Permanent (P) =or
Tem ora -
6c
Reason,for impact
6d.
Stream name
6e
Buffer
mitigation
required?
6f
Zone1
impact
(square
feet
6g`
Zone 2
Impacf
(`square
feet
131; _
Yes/No,
- -
B2 -
Yes/No
B3
*4j-No
B4 -
--
Yes/No'
B5 -
Yes No
B6 -
YesiNO
6h. Total Buffer Impacts:
61. Comments.
r
Page 5 of 10

D. Impact Justification'and "Mitigation
1. Avoidance and Minimization
1a Speofically_descnbe�measures °taken ;to -avoid'or minimize the proposed impacts in designing protect
Thieis�the only'locattori suitable for the fire location No other parcels are for sale and this parcel is adjacent to the, emsting'faabties
and wdrensdri4safe'and consistent piotection for ihe`residence served by.the department Further avoidance,is not possible to-achieve
a's`afe fire'deparbnent
lb Specifically,descnbe 'measures,taken to- avoidor minimize the proposed-impaaf s through,coristruchon•techniques
The,stabon has been located on'tFie'property away fiomFthe 3l).fool stream- buffer-to,avoid'impada The small,impacts10 the" wetlands aie necessary
fdf I:W,tuming,radius of the iubk to allow them into the'garage jgays;and the access driveway'is, necessary to allow truck to park.without dosing
ttie state `htghway'to traffic The site ts,confined'by the stream,buffers,and the proposed septtc field
2: rCom ensato - , Mitigation for Im actii10 Waters,&4he U.S.,or Waters of'the.State
2a Does the project require Compensatory Mitigation for
impacts to,Waters of the U E or Waters of the•State?
❑ yes ® No,
2b If yes, mitigation is required by (check all that,apply)
Q DWQ ❑ Corps
2c If,yes, which mitigatiomoption;vvill be_used4or'this
protect?
❑ Mitigation bank,
❑ Payment to,irhL,lieu fee program
❑ Permittee,Responsible Mitigation
r3: Com olete,if•Usin a Miti ation.Bank�
3a Name_of Mttlgatlon;Bank--
3b Credits Purchased (attach receiptirand ',letter)
Type• Choose one
Type. ,Choose one
Type Choose-one
Quantity
Quantity
.Quantity
3c Comments
4. Complete if Makin a�Pa ment lio=n -lieu Fee Pro ram
4a Approval,"letter- fromyin- lieutfee,programPis{attached,
❑ Yes
4b Stream,miilgat bn,requested-
linear feet
4c Ifusno'strearn mitigation, stream temperature-
Chbbse one
4d Buffer mitigation requested (DWQ only).
square feet
4e Riparian wet!and,mitigation °requested_
acres
4 Non- ripanamwetland'mitigation requested.
acres
4g Coastal,(tidalyWetland,mitigation requestedµ
acres'
,4h Comments:
S. 'Complete if Using a Permit-too Responsible Mitigation Plan
5a If, using a,permittee responsible Mitigation, plan, provide a description ofthe, proposed mitigation plan.
Page°6 of X10
PCN`Form — Version 1, ,4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWO
6a Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation?
❑ Yes ❑ No
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
Zone
6c
Reason for impact
6d
Total impact
(square feet)
Multiplier
6e
Required mitigation
(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

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1.
Diffuse Flow Plan
la
Does the project include or is 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
2.
Stormwater Management Plan
2a
What is the overall percent imperviousness of this project?
15
2b
Does this project require a Stormwater Management Plan?
❑ Yes ® No
2c
if this project DOES NOT require a Stormwater Management Plan, explain why -
The site does not exceed 24% impervious when the old facilities are demolished and the disturbed area is less than 10 acres
2d
If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan
The
site is presumed to not require a stormwater management plan
2e
Who will be responsible for the review of the Stormwater Management Plan?
3.
Certified Local Government Stormwater Review
3a.
In which local government's jurisdiction is this project?
no local tunsduiction
❑ Phase 11
❑ NSW
3b
Which of the following locally - implemented stormwater management programs
❑ 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
❑ Yes ❑ No
attached?
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 4 January 2009

F. Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
la
Does the project involve an expenditure of public (federal /state/local) funds or the
® Yes
❑ 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)9
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,
❑Yes
QX No
or Riparian Buffer Rules (15A NCAC 28 0200)?
2b
Is this an after - the -fact permit application?
❑ Yes
® No
2c
If you answered "yes" to one or both 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
0 No
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
The
site will have its own well and septic The septic permits will be issued by Avery County The proposed septic field is to be
located
between the front of the budding and the state highway
Page 9 of 10
PCN Form —Version 14 January 2009

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a Will this project occur in or near an area with federally protected species or
Yes ® No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
El Yes 0 No
impacts?
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?
The site is mostly cleared
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
(� Yes ❑ No
status (e g , National Historic Trust designation or properties significant In
North Carolina history and archaeology)?
7b What data sources did you use to determine whether your site would impact historic or archeological resources?
No reviews conducted
8. Flood Zone Designation (Corps Requirement)
8a Will this project occur in a FEMA- designated 100 -year floodplain?
1-:1 Yes ❑ No
8b If yes, explain how project meets FEMA requirements
8c What source(s) did you use to make the floodplain determination?
S(Agent's
Ap lcant/Agent's (gnat re
Applicant/Agent's Printed Name
Date
signature is valid only if an authorization
letter from the applicant is provided
Page 10 of 10

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z Parcel 181600217036
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North Toe River
Classification: WS-V; Tr
Qerp
749 N US 19E Hwy.
47! PO Box 640
Newland, NC 28657
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91`4=4 A,eryCounty, NC Print Map
Avery County, NC
Disclaimer: The information contained on this page is taken from aerial mapping, tax Wrapping, and public records and is NOTto be construed or
used as a survey or'legal description'. Only a licensed professional land surveyor can legally determine precise locations, elevations, length and
direction of a line, and areas.
Parcel Number: 1 81 60021 7036
Account Number: 62712
Deed Date: 20130917
Acreage: 1.490AC
Owner Name: AVERY COUNTY FRECOMML13SION
Additional Info: 749 N US 19E HWY
Mailing Addr2: P O BOX 640
Parcels
Mailing City: NEWLAND
Mailing State: NC
Mailing Zip: 28657
House Number: 749
Street Name: US 19E
Street Type: HWY
Bldg Value: 59900
Land Value: 11200
Total Value: 71100
Athibutlee at Wnt K 861146, E: 1112824
Census Tracts (2000) Townships
STCNTRBG °370119903 5 Township: Roaring Creek
htto://www.webuis net Anderson & Associates. Inc. htto Ilwww.andassoc.com
init: start
init. done
Approved By: 8
Year Built: 1949
Rre Department: 8
Township Code: 6
M NBH Nu m be r: 800
Deed Book: 478
Deed Page: 1220
Size: 1.49
Units: Acres
Acres (measured): 1.404
ht ip: / /arcgis.webgis.net/nc/aver�printable.asp 1/1

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Soil Map--Avery County, North Carolina
Map Unit Legend
—AyeryZounti, N" Carolina, Coll
Map Unif
Ctc
Cullasaja cobbly loam, 8 to 15
01
8.0%
Percent slopes, extremely
bou Idery
i DeB
Dellwood cobbly sandy loam, 1
06
354%
to 5 percent slopes,
,
occasionally flooded
NkA
Nikwasi loam, 0 to 3 percent
1.0
565%
slopes, frequently flooded
SaC
Saunook loam, 8 to 15 percent
slopes
01%
Totals for Area of Interest 1
1.71
100.0%
USDA Natural Resources Web Soil Survey 911612014
2iM Conservation Service National Cooperative Soil Survey Page 3 of 3

mm
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D

WETLAND DETERMINATION DATA FORM — Eastern Mountains and Piedmont Region
�1 l �t
Protect /Sole.1— t/ City /County Sampling Date Q 11
Applicant/Owner t�1t State M- Sampling Point -
Investigator(s) 6N�Srn0"� -L S� Section, Township, Range
Landform (hillslope, terrace etc). ,)Lo_cal relief (concave, convex, none)- naY'� Slope ( %)
Subregion (LRR or MLRA) Lat- S6 - a79 Long ' 921-60 Datum
Sod Map Unit Name NWI classification. None
Are climatic 1 hydrologic conditions on the site typical for this time of year? Yes No C� (If no, explain in Remarks) '/ / /� /'
Are Vegetation" sod=, or Hydrology �� significantly disturbed? , t - Are - Normal Circumstances' present? Yes I � I No
Are Vegetation= Soil =, or Hydrology ❑ naturally problematic? ✓� (It needed, explain any answers in Remarks.)
SUMMARY OF FINDINGS — Attach site map showing sampling point locations, transects, important features, etc.
Hydrophytic Vegetation Present? Yes= No is the Sampled Area rr-'''� j
Hydnc Soil Present? Yes = No within a Wetland? Yes u No L_—t
Weiland Hydrology Present? Yes ❑ No
Remarks
t
I
HYDROLOGY
Wetland Hydrology Indicators:
Secondary Indicators (minimum of two required)
Primary Indicators (minimum of one is required check all that apply)
D Surface Sod Cracks (86)
L] Surface Water (Al)
❑ True Aquatic Plants (B14)
❑ Sparsely Vegetated Concave Surface (88)
❑ High Water Table (A2)
[❑ Hydrogen Sulfide Odor (Ci)
❑ Drainage Patterns (B10)
❑ Saturation (A3)
❑ Oxidized Rhizospheres on Living Roots (C3)
❑ Moss Trim Lines (816)
❑ Water Marks (81)
❑ Presence of Reduced Iron (C4)
❑ Dry- Season Water Table (G2)
❑ Sediment Deposits (B2)
❑ Recent Iron Reduction in Tilled Sods (C6)
❑ Crayfish Burrows (CB)
❑ Drift Deposits (83)
❑ Thin Muck Surface (C7)
❑ Saturation Visible on Aerial Imagery (C9)
❑ Algal -Mat or Crust (84)
❑ Other (Explain in Remarks)
❑ Stunted or Stressed Plants (D1)
❑ iron Deposits (85)
❑ Geomorphic Position (132)
❑ Inundation Visible on Aerial Imagery (87)
❑ Shallow Aqwtard (D3)
❑ Water - Stained Leaves (89)
❑ Microtopographic Relief (D4)
nAquatic Fauna (Bt 3)
❑ FAG - Neutral Test (D5)
Field Observations:
Surface Water Present? Yes ❑ No
Depth (inchesy
Water Table Present? Yes ® No
Depth (inches):
F_]
Saturation Present) Yes ❑ No
Depth (inches)-
Wetland
Hydrology Present? Yes No
Includes rapillary fringe)
Describe Recorded Data (stream gauge, monitoring well, aerial photos, previous inspections), it available
Remarks
f
j
I
jI
I
i
V
-
t
;
I
_

VEGETATION (Five Strata) — Use scientific names of plants. Sampling Point. Lip
' Absolute Dominant Indicator Dominance Test worksheet:
Tree tratum (Plot size ) % Cover S s? Status Number of Dominant Species
That Are OBL, FACW, or FAC (A)
2-
Total Number of Dominant
3' Species Across All Strata (B)
4- A
Percent of Dominant Species
5. p j
That Are 08L, FACW, or FAG. (AB)
50% of total cover
Sapling Stratum (Plot size. )
1
5
50% of total cover
Shrub Stratum (Plot size:
1-
2
3
/y = Total Cover Prevalence Index worksheet:
of total cover
2096 Total % Cover of. Multiply by
`>
OBL species x 1 =
FACW species Y2=
FAG species x3=
FACU species x4=
UPL species x 5 =
Column Totals (A) (B)
Prevalence Index = B/A =
= Total Cover Hydrophytic Vegetation indicators:
_ 20% of total cover ❑ 1 - Rapid Test for Hydrophytic Vegetation
❑ 2 - Dominance Test is X50%
E] 3 - Prevalence Index is 53.o'
❑ 4 - Morphological Adaptations' (Provide supporting
data in Remarks or on a separate sheet)
Problematic Hydrophytic Vegetation' (Explain)
'Indicators of hydnc soil and wetland hydrology must
6 be present, unless disturbed or problematic.
= Total Cover Definitions of Five Vegetation Strata_
t 50% of total cover 20% of total cover
Herb tratum (Plot size_ }
2
3
4
5
6
7.
8
9
10
11
= Total Cover //��
50% of total cover 20% of total cover /61
Woody Vine Stratum (Plot size. )
1
2
3
4
5
Tree - Woody plants, excluding woody vines,
approximately 20 ft (6 m) or more in height and 3 in
(7 6 cm) or larger in diameter at breast height (DBH)
Sapling — Woody plants, excluding woody vines,
approximately 20 ft (6 m) or more in height and less
than 3 in (7.6 cm) DBH-
Shrub — Woody plants, excluding woody vines,
approximately 3 to 20 ft (1 to 6 m) in height
Herb — All herbaceous (non - woody) plants, including
herbaceous vines, regardless of size, and woody
plants, except woody vines, less than approximately 3
ft (1 m) in height
Woody vine — All woody vines, regardless of height
Hydrophytic
= Total Cover Vegetation
50% of total cover- 20% of total cover Present? Yes No
irs here or on a separate sheet )

SOIL
Sampling Point:
Profile Description: (Describe to the depth needed to document the indicator or confirm the absence of indicators.)
Depth Matrix
(inches) Color (moist) — %
0 V",
Redox Features
Color (moist) % Type" Loc'
Texture Remarks
) r— /00
f Q Yr4 �Z6 /00
p
'Type C--Concentration, D=Deplebon, RM=Reduced Matrix, MS=Masked Sand Grains.
"Location PL=Pore Lining, M=Matnx
";el
Hydric Soil Indicators:
❑Indicators
H,,tosol
for Problematic Hydric Sow
(Al)
❑ Dark Surface (S7)
C1, 2 cm Muck (A10) (MLIII. -
Hislic Epipedon (A2)
❑ Polyvalue Below surface (S8) (MLRA 147,148) ❑ Coast Prairie Redox (Al 6)
❑ Black Histic (A3)
❑ Thin Dark Surface ( S9) (M LRA 147,148)
(MLRA 147,148)
❑ Hydrogen Sulfide (A4)
❑ Loamy Gleyed Matrix (F2)
Piedmont RoodpJain Soils (F19)
❑ Stratified Layers (A5)
❑ Depleted Matrix (F3)
(MLRA 136,147)
❑ 2 cm Muck (Al 0) (LRR N)
❑ Redox Dark Surface (F6)
❑ Very Shallow Dark Surface (TFl 2)
Below Dark Surface (All)
❑ Depleted Dark Surface (F7)
❑ Other (Explain in Remarks)
❑Depleted
Thick Dark Surface (Al2)
❑ Redox Depressions (FS)
❑ Sandy Mucky Mineral (S1) (LRR N,
❑ Iron-Manganese Masses (F12) (LRR N,
MLRA 147,148)
MLRA 136)
❑ Sandy Geyed matrix (S4)
❑ Umbnc Surface (Ft 3) (MLRA 136,122)
3 Indicators of hydrophytic vegetation and
❑ Sandy Redox (S5)
❑ Piedmont Roodplain Soils (Fi 9) (IMILRA 148) wetland hydrology must be present,
❑ Stripped Matrix (S6)
❑ Red Parent Material (F21) (MLRA 127,147) unless disturbed or problematic.
Restrictive Layer (it observed):
Type
Depth (inches)
Hydric Soil Present? Yes Li No
Remarks

WETLAND DETERMINATION DATA FORM — Eastern Mountains and Piedmont Region
ProlecUSite l k V1 O City /County Averx Sampling Date-
Applicant/Owner State
Sampling Point 2-6©
Investigator(s) rt7kr\ }' i7 Section, Township, Range.
Landform (hillsfope, terrace, etc)- Local relief (concave, convex, none) 041'-KV4- Slope
Subregion (LRR or MLRA) / as Lat _ ytP- xq � it Long 6 "12- 166 Datum
Sal Map Unit Name Alzf , NWI classfication_ None
Are climatic / hydrologic conditions on the site typical for this time of year? Yes No (If no, explain in Remarks)
Are Vegetation" Sa1I �, or Hydrology significantly disturbed? Are -Normal Circumstances` present? Yes= No =
�j
Are Vegetation= Soil �, or Hydrology u naturally problematic? / 4) (ft needed, explain any answers in Remarks.)
SUMMARY OF FINDINGS — Attach site map showing sampling point locations, transects, important features, etc.
Hydrophyhc Vegetation Present? Yes No = Is the Sampled Area (�'�
Hydnc Soil Present? Yes No= within a Wetland? Yes !� No
Wetland Hydrology Present? Yes = No
Remarks
HYDROLOGY
Wetland Hydrology Indicators:
Secondary Indicators (minimum of two reouirern
Pnmary Indicators iminimurn of one is renuired. check all that a 1
0 Surface Soil Cracks.(B6)
9Surf Water (At)
High Water Table
❑ True Aquatic Plants (BI 4)
❑ Hydrogen
Sparsely Vegetated Concave Surface (Ba)
(A2)
Sulfide Odor (CI)
❑ Drainage Patterns (Bio)
❑ Saturation (A3)
[+�dized Rhizospheres on Living Roots (C3)
❑ Moss Trim Lines (B16)
❑ Water Marks (Bi)
❑ Presence of Reduced Iron (C4)
❑ Dry- Season Water Table (G2)
❑ Sediment Deposits (1212)
❑ Recent Iron Reduction in rifled Soils C6
( )
❑Crayfish Burrows (Ca)
❑ Dnft Deposits (B3)
❑ Thin Muck Surface (C7)
❑ Saturation Visible on Aerial Imagery (G9)
❑ Algal Mat or Crust (B4)
❑ Other (Explain in Remarks)
❑ Stunted or Stressed Plants (D1)
❑ Iron Deposits (1215)
❑ Geomorphic Position (D2)
❑ Inundation Visible on Aerial Imagery (B7)
❑ Shallow Aquitard (D3)
Water - Stained Leaves (Bg)
❑ Microtopographic Relief (D4)
Aquatic Fauna (613)
D FAG - Neutral Test (D5)
Field Observations:
Surface Water Present? Yes No
Depth (inches) 0 it4
Water Table Present? Yes No
Depth (inches)
Saturation Present? Yes= No
Depth (inches)
Wetland
Hydrology Present? Yes NoLl
includes capillary fringe)
Descnbe Recorded Data (stream gauge, monitoring well, aerial photos, previous inspections), it available
Remarks

VEGETATION (Five Strata) — Use scientific names of plants. Sampling Point: 141_ .7,©U
50% of total cover
Sapling Stratum (Plot size. )
1
2
3
4
5
6
60% of total cover
Shrub Stratum (Plot size -
1
2
3
4
5
= Total Cover Prevalence Index worksheet:
Total % Cover of Multiply by
20% of total cover. OBL species x 1 =
FACW species X2=
FAG species x3=
FACU species x4=
UPL species x5=
Column Totals (A) (B)
= Total Cover
20% of total cover
Total Cover
�l 50% of total cover 20% of total cover
�� /1
Herb tratum (Plot size U"1- )aU
2 j✓vic ✓5 2 ✓S !�
4 Y Aa vl 513
5
7.
8.
9-
10
{ it
I
Woody Vine Stratum (Plot size:
1.
3
4
5
Total Cover
50% of total cover. !/" 20% of total cover,
= Total Cover
50% of total cover 2(r% of total cover
photo numbers here or on a separate sheet )
Prevalence Index = B/A =
IJ 2 - Rapid Test for Hydrophyhc Vegetation
- Dominance Test is X50%
❑ 3 - Prevalence Index is s3 0'
❑ 4 - Morphological Adaptations' (Provide supporting
data in Remarks or-on a separate sheet)
Problematic Hydrophytic Vegetation' (Explain)
'Indicators of hydnc soil and wetland hydrology must
be present, unless disturbed or problematic
Definitions of Five Vegetation Strata:
Tree — Woody plants. excluding woody vines,
approximately 20 ft (6 m) or more in height and 3 in
(7'6 cm) or larger in diameter at breast height (DBH).
Sapling — Woody plants, excluding woody vines,
approximately 20 It (6 m) or more in height and less
than 3 in (7.6 cm) DBH.
Shrub — Woody plants, excluding woody vines,
approximately 3 to 20 It (f to 6 m) in height
Herb — All herbaceous (non- woody) plants, including
herbaceous vines, regardless of size, and woody
plants, except woody vines, less than approximately 3
ft (1 m) in height
Woody vine — All woody vines, regardless of height
Hydrophytic
Vegetation
Present? Yes tdo�
Absolute Dominant Indicator
Dominance Test worksheet:
Tree Stratum (Plot size
) e Cover es? Status
Number of Dominant Species
1
That Are OBL, FACW, or FAG-
(A)
2
3.
Total Number of Dominant
Species Across All Strata
(B)
'4
5
Percent of Dominant Species
`
That Are OBL, FACW, or FAC-
(AB)
6
50% of total cover
Sapling Stratum (Plot size. )
1
2
3
4
5
6
60% of total cover
Shrub Stratum (Plot size -
1
2
3
4
5
= Total Cover Prevalence Index worksheet:
Total % Cover of Multiply by
20% of total cover. OBL species x 1 =
FACW species X2=
FAG species x3=
FACU species x4=
UPL species x5=
Column Totals (A) (B)
= Total Cover
20% of total cover
Total Cover
�l 50% of total cover 20% of total cover
�� /1
Herb tratum (Plot size U"1- )aU
2 j✓vic ✓5 2 ✓S !�
4 Y Aa vl 513
5
7.
8.
9-
10
{ it
I
Woody Vine Stratum (Plot size:
1.
3
4
5
Total Cover
50% of total cover. !/" 20% of total cover,
= Total Cover
50% of total cover 2(r% of total cover
photo numbers here or on a separate sheet )
Prevalence Index = B/A =
IJ 2 - Rapid Test for Hydrophyhc Vegetation
- Dominance Test is X50%
❑ 3 - Prevalence Index is s3 0'
❑ 4 - Morphological Adaptations' (Provide supporting
data in Remarks or-on a separate sheet)
Problematic Hydrophytic Vegetation' (Explain)
'Indicators of hydnc soil and wetland hydrology must
be present, unless disturbed or problematic
Definitions of Five Vegetation Strata:
Tree — Woody plants. excluding woody vines,
approximately 20 ft (6 m) or more in height and 3 in
(7'6 cm) or larger in diameter at breast height (DBH).
Sapling — Woody plants, excluding woody vines,
approximately 20 It (6 m) or more in height and less
than 3 in (7.6 cm) DBH.
Shrub — Woody plants, excluding woody vines,
approximately 3 to 20 It (f to 6 m) in height
Herb — All herbaceous (non- woody) plants, including
herbaceous vines, regardless of size, and woody
plants, except woody vines, less than approximately 3
ft (1 m) in height
Woody vine — All woody vines, regardless of height
Hydrophytic
Vegetation
Present? Yes tdo�

SOIL
Sampling Point i" )l'2-0,z)
Profile Description: (Describe to the depth needed to document the indicator or confirm the absence of indicators)
Depth Matrix Redox Features
(inches) Color moist % Color (moist) % Type' Locz Texture Remarks
b--41 (v P- 3A /dy �-
9 /0' Y t; ?,-) Y� � 1 3 p D .M Tit.
'Type C= Concentration, D= Depletion RM =Reduced Matrix MS= Masked Sand Grains Location PL =Pore Lining, M =Matrix
Hydric Soil Indicators-
Histosol (Ai)
L] Dark Surface (S7)
Indicators for Problematic Hydric Sods':
11 2 cm Muck (A10) (MLRA 147)
❑ Htstic Epipedon (A2)
❑ Polyvalue Below Surface (S8) (MLRA 147, 148)
❑ Coast Prairie Redox (A16)
❑ Black Histic (A3)
❑ Thin Dark Surface (S9) (MLRA 147,148)
(MLRA 147, 148)
❑ Hydrogen Sulfide (A4)
❑ Stratified Layers (A5)
❑ Loamy Gleyed Matrix (F2)
101Depleted Matrix (F3)
0 Piedmont Floodplam Sods (F19)
❑ 2 cm Muck (A10) (LRR N)
❑ Redox Dark Surface (F6)
(MLRA 136, 147)
❑ Very Shallow Dark Surface (TF12)
❑ Depleted Below Dark Surface (At 1)
❑ Depleted Dark Surface (F7)
❑ Other (Explain in Remarks)
❑ Thick Dark Surface (Al2)
❑ Redox Depressions (F8)
Sandy Mucky Mineral (S1) (LRR N,
Eb Iron- Manganese Masses (F12) (LRR N,
MLRA 147, 148)
MLRA 136)
® Sandy Gleyed Matrix (S4)
Umbnc Surface (F13) (MLRA 136,122)
31ndicators of hydrophytic vegetation and
❑ Sandy Redox (S5)
® Piedmont Floodplam Sods (F19) (MLRA 148)
wetland hydrology must be present,
❑ Stripped Matrix (S6)
❑ Red Parent Material (F21) (MLRA 127,147)
unless disturbed or problematic
Restrictive Layer (if observed):
Type
Depth (inches)
Hydric Soil Present? Yes � No

USACE AID# DWQ # Site # (indicate on attached map) j
;,o,; STREAM QUALITY ASSESSMENT WORKSHEET w
Provide the following information for the stream reach under assessment:
1. Applicant's name ` 2. Evaluator's name:,,\►�`�$�l
3. Date of evaluation- ' �c %71 4. Time of evaluation. \0%
5. Name of stream- UT .- 1�ioiaZy V° 6. River basin:_
7. Approximate drainage area. C) 8. Stream order
9. Length of reach evaluated. 6� 10. County: M "l
11. Site coordinates (if known), prefer in decimal degrees
Latitude (ex 34 872312). a(--, e 0-1 e525
Method location determined (circle) 1
13. Location of � reach under evalual
�yv Jpll�-W�ljc
14. Proposed channel work (if any)
15. Recent weather conditions
12. Subdivision name (if any).
Longitude (ex -77 556611 ).
Topo Sheet Ortho (Aerial) Photo /GiS Other GIS Other
to nearb roads and landmarks and attach map identifying stream(s) location)
16. Site conditions at time of visit. � ' `�
17. Identify any special waterway classifications known: _Section 10 _Tidal Waters _Essential Fisheries Habitat
" Trout Waters _Outstanding Resource Waters _ Nutrient Sensitive Waters _Water Supply Watershed Y (I -IV)
18. Is there a pond or lake located upstream of the evaluation pomt9 YE NO If yes, estimate the water surface area
19. Does channel appear on USGS quad map) YES 20. Does channel appear on USDA Soil Survey9 YES NO
21. Estimated watershed land use: !S' 0/6 Residential % Commercial _% Industrial _% Agricultural
0160/0 Forested b % Cleared / Logged _% Other (
i i
22. Bankfull width-. - - \ .S 23. Bank height (from bed to top of bank)
24. Channel slope down center of stream %Flat (0 to 2 %) _Gentle (2 to 4 %) _Moderate (4 to 10 %) _Steep ( >10 %)
25. Channel sinuosity is Straight _Occasional bends _Frequent meander _Very sinuous _Braided channel
Instructions for completion of worksheet (located on page 2): Begin by determining the most appropriate ecoregion based on
location, terrain, vegetation, stream classification, etc Every characteristic must be scored using the same ecoregion Assign points
to each characteristic within the range shown for the ecoregion. Page 3 provides a brief description of how to review the
characteristics identified in the worksheet Scores should reflect an overall assessment of the stream reach under evaluation If a
characteristic cannot be evaluated due to site or weather conditions, enter 0 in the scoring box and provide an explanation in the
comment section Where there are obvious changes in the character of a stream under review (e g., the stream flows from a pasture
into a forest), the stream may be divided into smaller reaches that display more continuity, and a separate form used to evaluate each
reach The total score assigned to a stream reach must range between 0 and 100, with a score of 100 representing a stream of the
highest quality.
Score (fr99m reverse
Evaluator's Signature V\,,) V \/\J <3— Date 1 X) - W Y!J=
This channel evalu
hk
tion f rm is int tided to be used only as I guide to assist landowners and environmental professionals in
gathering the data required by the United States Army Corps of Engineers to make a preliminary assessment of stream
quality. The total score resulting from the completion of this form is subject to USACE approval and does not imply a
particular mitigation ratio or requirement. Form subject to change - version 06103. To Comment, please call 919- 876 -8441 x 26.

STREAM QUALITY ASSESSMENT WORKSHEET
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