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Office Use Only:
Corps action ID no.
DWQ project no.
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: 3 or General Permit (GP) number:
1c.
Has the NWP or GP number been verified by the Corps?
❑X Yes ❑ No
1d.
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
1 e.
Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification:
❑ Yes ❑X No
For the record only for Corps Permit:
❑ Yes ❑X 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
1g.
Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
❑ Yes ❑X No
1 h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes ❑X No
2.
Project Information
2a.
Name of project:
Henson Pond ( NC Dam Safety ID: SURRY-057)
2b.
County:
Surry
2c.
Nearest municipality / town:
Lowgap
2d.
Subdivision name:
N/A
2e.
NCDOT only, T.I.P. or state project no:
3.
Owner Information
3a.
Name(s) on Recorded Deed:
James Henson
3b.
Deed Book and Page No.
01387 / 0989
3c.
Responsible Party (for LLC if
applicable):
3d.
Street address:
184 North Wilson Rd.
3e.
City, state, zip:
Lowgap, North Carolina 27024
3f.
Telephone no.:
336.401-3387
3g.
Fax no.:
3h.
Email address:
[e-mail]
Page 1 of 10
PCN Form — Version 1.4 January 2009

4.
Applicant Information (if different from owner)
4a.
Applicant is:
❑ Agent ❑ Other, specify:
4b.
Name:
4c.
Business name
(if applicable):
4d.
Street address:
4e.
City, state, zip:
4f.
Telephone no.:
4g.
Fax no.:
4h.
Email address:
5.
Agent/Consultant Information (if applicable)
5a.
Name:
Chris Huysman
5b.
Business name
(if applicable):
Wetlands and Waters, Inc
5c.
Street address:
170 Dew Drop Rd
5d.
City, state, zip:
Sparta, NC 28675
5e.
Telephone no.:
336.406.0906
5f.
Fax no.:
5g.
Email address:
[e-mail]
Page 2 of 10

B.
Project Information and Prior Project History
1.
Property Identification
1a.
Property identification no. (tax PIN or parcel ID):
405100288454
1 b.
Site coordinates (in decimal degrees):
Latitude: 36.5334 Longitude: 80.8632
1c.
Property size:
59.32 acres
2.
Surface Waters
2a.
Name of nearest body of water to proposed project:
Fisher River
2b.
Water Quality Classification of nearest receiving water:
WS-II;Tr,HQW
2c.
River basin:
Yadkin Pee -Dee
3.
Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
The site is a pond that was constructed on a tributary to the Mitchell River circa 1960. At this time the pond and its embankment are in the midst of
being repaired. The repair work included a forebay in the upper reach of the pond. The repair and rehab of the structure required a pre -construction
notification due to the conditions on the site. The site is located in a rural area in the foot hills of the Blue Ridge Mountains.
3b.
List the total estimated acreage of all existing wetlands on the property: 1
3c.
List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: 0
3d. Explain the purpose of the proposed project:
The purpose of the project is to repair a failing riser pipe and dam structure. See cover letter for additional narrative.
3e. Describe the overall project in detail, including the type of equipment to be used:
The overall project includes the reconstruction of the dam to specifications approved by NC Dam Safety; see attached DEMLR Classification.
4.
Jurisdictional Determinations
4a.
Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (includingall prior phases)in the past?
❑ Yes ❑X No ❑ Unknown
Comments:
4b.
If the Corps made the jurisdictional determination, what type
of determination was made?
❑X Preliminary ❑ Final
4c.
If yes, who delineated the jurisdictional areas?
Name (if known): Chris Huysman
Agency/Consultant Company: Wetlands and Waters, Inc
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
Drained pond area evaluated by USACE and NC DWR during a field evaluation of the unauthorized work
5.
Project History
5a.
Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
❑Yes ❑X No ❑ Unknown
5b. If yes, explain in detail according to "help file" instructions.
The pond was constructed pre 1972 Clean Water Act requirements.
6.
Future Project Plans
6a.
Is this a phased project?
❑ Yes ❑X No
6b.
If yes, explain.
Page 3 of 10
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
❑ Wetlands ❑X Streams — tributaries ❑ Buffers ❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
Wetland impact
number
Permanent (P) or
Temporary T
2b.
Type of impact
2c.
Type of wetland
2d.
Forested
2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other)
2f.
Area of
impact
(acres)
W1
Choose one
Choose one
Yes/No
-
W2
Choose one
Choose one
Yes/No
W3
Choose one
Choose one
Yes/No
W4
Choose one
Choose one
Yes/No
W5
Choose one
Choose one
Yes/No
W6
Choose one
Choose one
Yes/No
2g. Total Wetland Impacts:
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a.
Stream impact
number
Permanent (P) or
Temporary (T)
3b.
Type of impact
3c.
Stream name
3d.
Perennial (PER) or
intermittent (INT)?
3e.
Type of
jurisdiction
3f.
Average
stream
width
(feet)
3g.
Impact
length
(linear
feet)
S1 T
Dam construction
UT Mitchell River
PER
Corps
4
200
S2 P
Dam construction
UT Mitchell River
PER
Corps
4
150
S3 T
Stabilization
UT Mitchell River
PER
Corps
3
250
S4
Choose one
S5
Choose one
S6
Choose one
3h. Total stream and tributary impacts
600
3i. Comments:
Impacts S1 and S2 relate to amounts noted in DWR NOV dated July 29, 2022. Impact S1 is associated with a forebay that will be removed and are
thus deemed temporary. Impact S2 is related to work associated with the reconstruction of the outlet structure. Impact S3 is stabilization of channel
banks with native vegetation- banks will be live staked on TxT spacings and seeded with riparian mixture.
Page 4 of 10
PCN Form — Version 1.4 January 2009

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then indivi ually list all open water impacts below.
4a.
Open water
impact number
Permanent (P) or
Temporary T
4b.
Name of waterbody
(if applicable)
4c.
Type of impact
4d.
Waterbody
type
4e.
Area of impact (acres)
01
Choose one
Choose
02
Choose one
Choose
03
Choose one
Choose
04
Choose one
Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below.
5a.
Pond ID number
5b.
Proposed use or
purpose of pond
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes ❑X No If yes, permit ID no: SURRY 057
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If any impacts require mitigation, then you MUST fill out Section D of this form.
6a. Project is in which protected basin?
❑ Neuse ❑ Tar -Pamlico ❑ Catawba ❑ Randleman ❑ Other:
6b.
Buffer Impact
number —
Permanent (P) or
Temporary T
6c.
Reason for impact
6d.
Stream name
6e.
Buffer
mitigation
required?
6f.
Zone 1
impact
(square
feet)
6g.
Zone 2
impact
(square
feet
B1
Yes/No
B2
Yes/No
B3
Yes/No
B4
Yes/No
B5
Yes/No
B6
Yes/No
6h. Total Buffer Impacts:
6i. Comments:
Page 5 of 10

D.
Impact Justification and Mitigation
1.
Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
The proposed design includes a 6 inch low -flow cold -water discharge pipe in the riser. The water will fall approximately 12 feet and will thus be
aerated. Work will abide by the trout construction moratorium from October through April.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
The work was being conducted without a PCN when it was determined to be a violation by NC DWR. The owner ceased construction activities and
established ground cover within a few weeks. The ground cover has been maintained and is sufficient to prevent off -site sedimentation. The
proposed low flow structure is intended to minimize impacts to water quality.
2.
Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a.
Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
❑ Yes ❑X No
2b.
If yes, mitigation is required by (check all that apply):
❑ DWQ ❑ Corps
2c.
If yes, which mitigation option will be used for this
project?
❑ Mitigation bank
El Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
3.
Complete if Using a Mitigation Bank
3a.
Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter)
Type: Choose one
Type: Choose one
Type: Choose one
Quantity:
Quantity:
Quantity:
3c. Comments:
4.
Complete if Making a Payment to In -lieu Fee Program
4a. Approval letter from in -lieu fee program is attached.
❑ Yes
4b.
Stream mitigation requested:
linear feet
4c.
If using stream mitigation, stream temperature:
Choose one
4d.
Buffer mitigation requested (DWQ only):
square feet
4e.
Riparian wetland mitigation requested:
acres
4f.
Non -riparian wetland mitigation requested:
acres
4g.
Coastal (tidal) wetland mitigation requested:
acres
4h.
Comments:
5.
Complete if Using a Permittee Responsible Mitigation Plan
5a.
If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form — Version 1.4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
❑ Yes ❑ No
buffer mitigation?
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
6c.
6d.
6e.
Zone
Reason for impact
Total impact
Multiplier
Required mitigation
(square feet)
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund).
6h. Comments:
Page 7 of 10

E.
Stormwater Management and Diffuse Flow Plan (required by DWQ)
1.
Diffuse Flow Plan
1 a.
Does the project include or is it adjacent to protected riparian buffers identified
❑ Yes ❑X No
within one of the NC Riparian Buffer Protection Rules?
1 b.
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?
1
2b.
Does this project require a Stormwater Management Plan?
❑ Yes ❑X No
2c.
If this project DOES NOT require a Stormwater Management Plan, explain why:
The work does not increase impervious area.
2d.
If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e.
Who will be responsible for the review of the Stormwater Management Plan?
3.
Certified Local Government Stormwater Review
3a.
In which localgovernment's jurisdiction is thisproject?
❑ Phase II
❑ 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)
1 a.
Does the project involve an expenditure of public (federal/state/local) funds or the
❑ Yes
0 No
use of public (federal/state) land?
1 b.
If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State
❑Yes
❑ No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c.
If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.)
❑ Yes
❑ No
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,
DYes
❑ No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b.
Is this an after -the -fact permit application?
DYes
❑ No
2c.
If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
See
attached cover letter for additional narrative. The land owner commenced repairs on a failing metal riser structure in 2015.
The project grew in
scope due to the age of the metal and the conditions of the outlet structure which were in excess of 50 years old. The work was more complex than
the owner had thought it would be and due to some health complications it did not proceed in a timely manner. The owner hired a grading contractor
to complete the work.
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.
N/A.
The property has a single family residence with a septic system.
Page 9 of 10
PCN Form — Version 1.4 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 ❑X No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
❑ Yes ❑X 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?
Based on a review of PAC: Site is outside known range for small anthered bittercress. No suitable habitat for Schweinitz's sunflower within the work
area. No tree removal is necessary for the embankment repairs. No bog turtle habitat in drained pond. MANLA determination appropriate.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
❑ Yes ❑X 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 ❑X 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?
SHPO GIS data shows no proximate sites or structures. All work areas previously impacted by construction.
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain?
❑ Yes ❑X No
8b. If yes, explain how project meets FEMA requirements:
Resource maps include a FEMA figure
8c. What source(s) did you use to make the floodplain determination?
FEMA Floodplain mapper.
James Henson
Applicant/Agent's Printed Name
Date
Applicant/Agent's Signature
(Agent's signature is valid only if an authorization
letter from the applicant isprovided.)
Page 10 of 10

To: To Whom It May Concern
Date: 15 July 23
Re: Lowe Dam Surry — 057 — L
From: James Henson
I offer the following response for not being able to complete this project in a reasonable time
frame. In correspondence dated 20 December 12 from N.C. department of Environment and Natural
Resources, it stated "the subject dam is exempt from the law and any future work on the dam does not
require approval from this division". This is a grandfather clause. No time limit placed on the exemption.
In earlier correspondence it was recommended that the trees and bushes growing on the dam be
removed and the emergency spillway be repaired as there was erosion and tree growth in the spillway.
After a visual dam inspection in May of 2013. 1 started work on 19 June 13 with four pieces of
equipment, 318 Cat Excavator, 450 John Deere, 50D John Deere Excavator, and a John Deere Skid Steer
Loader. I have continued to work on this project as my health permitted. There have been delays due to
excess amounts of rain, labor issues, COVID, equipment break downs, parts delay, and my health issues,
the project was never abandoned. It was my understanding and belief that I could
repair/restore/refurbish the dam and continue on until the project was complete. Since the dam was
exempt, I had the right without further authority to proceed with the recommended repairs and that I
could do so until finished. As of 15 July 23, the project is not complete. My intention was and still is to
repair damage and restore the dam to the original specifications. However, when I inspected the
primary spillway in May of 2013, 1 determined that the 15" pipe had rusted and partially collapsed and
not repairable. At this junction I decided to replace the 15" pipe with a 24" pipe. Since the primary
spillway is an essential part of the dam construction that needed to be replaced, I do not understand
why a dam permit is being asked for seven years after the project started. The project of restoring,
repairing and refurbishing has been on going since July 2013. 1 had almost no control over the numerous
delays that spanned about seven years.
Initially the plan was to do the recommended repairs to the emergency spillway and remove the
trees and bushes from the face of the dam but the scope of repairs got expanded due to having to dig
out and replace the 15" pipe. The emergency spillway had eroded to a depth of about 25' and
approximately 80' in length. It came to about 12'-15' of eroding into the dam itself. That could cause a
dam failure if not fixed. This erosion required filling the hole and removing dirt from the hillside. That
process was started in 2013, with the removal of the 15" pipe and to prevent any down stream erosion
from upstream, I installed a sediment pond in the backside of the original dam about 4' high.
I used my own equipment and a few rented pieces for this project and self -performed with
occasional help. Things were moving toward completion until a NOV on the 28 July 22 was received.
Since then, the project has been on hold an exempt status to me means exempt! I thought that I could
do legally and without conflict the necessary and related items and activities to repair and restore the
dam to its original specs without getting entangled with the bureaucracy. I still believe that. It was not
my intention to violate any regulations or law then or now. If I have, I sincerely apologize.
As previously noted, the dam had some issues that needed timely attention and I was to the best
of my abilities endeavoring to correct those issues in order to protect the integrity and longevity of the
structure. It might survive another seventy -plus years.

Health Issues:
Lost eye sight in right eye (blind)
Several back issues that required treatment
Mild stroke that required hospital stay-2018
Pulse rate down to mid-30's with A fib
Irregular heart beat
Passed out in doctor's office at Baptist Hospital (Code Blue)
Passed out twice in Sunday School
Surgery on left hand
Had heart monitor implanted in chest
Several tests ordered by four different cardiologists since 2014
Still under cardio care
Adverse effects due to heart medications (could not operate equipment)
Knee problems —walking with a cane
I just turned 83 years old

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Energy. Mineral
and Land Resources
ENVIRONMENTAL QUALITY
Jurisdictional Determination/Hazard Classification Request
To evaluate if a dam is governed by the Dam Safety Law of 1967 (as amended)
If it is your desire to have the Land Quality Section's Dam Safety Program staff determine if your dam
is governed by the Dam Safety Law of 1967 (as amended) (General Statute § 143-215.23-37),
Please complete this form in its entirety, if applicable, and return one hardcopy and one softcopy to:
State Dam Safety Engineer (DamSafetv`d.ncdenr.kov)
North Carolina Department of Environmental Quality
Division of Energy, Mineral, and Land Resources
Land Quality Section
1612 Mail Service Center
Raleigh, NC 27699-1612
1. Describe any potential hazards for loss of life and environmental or structural property damage to
existing and/or potential future downstream developments (i.e. buildings, houses, roads, bridges,
major utility lines, etc.): NA
2. Please attach a vicinity map of the dam (Preferably aerial and/or topographic contour map, which
shows the premise as well as the concerned downstream areas) and provide a brief description of
the location/nearest physical street address: 184 North Wilson RD LowQaa
Stare or North Carolina I Enviranaterasl Quality' Energy, Mineral and Land Resources
1612 Mail Serviea Center 1 512 N. Salisbury St. I Raleigh, NC 27699
919 707 9220 T

Page 2 of 4
3. General Summary of the Dam:
a. Name of Owner: lames G Henson
b. Address: 184 North Wilson Rd
c. City: Lowuaa State: NC Zip: 27024
d. Phone No.: 336-352-5174 Email: jth5174(20otmail.com
Dam Name (STATE- ID, if assigned):
Lowe Dam
Latitude:
Longitude:
80051'46" W
36031'S8" N
Nearest State Road Number/Name:
(SR #) 1601
County:
Surry
River/Stream:
Tributary of Fisher River
Drainage Area (acres):
550
Dam Height (from the highest point on the top of dam to the
lowest point on the downstream toe of dam in feet):
25.9'
Dam Crest Elevation (ft.) (NAVD88):
1395'
Dam Toe Elevation (ft.) (NAVD88):
1370'
Depth of Water at Normal Pool (ft.):
20'
Depth of Water at Top of Dam (ft.):
26'
Impoundment Surface Area at Normal Pool (acres):
2.2
Impoundment Surface Area at Top of Dam (acres):
2.8
Storage Capacity at Normal Pool (acre-feet):
18.5
Maximum Storage Capacity at Top of Dam (acre-feet):
22.8
e. Please provide any additional engineering documents to validate your assessment (historical
records, design drawing plans, rating curves, etc.)
4. General Summary of the Downstream Area(s) [check all boxes that apply]:
a. Primary Downstream Land Use:
® WOODLAND ® AGRICULTURAL[-] RESIDENTIAL ❑ INDUSTRIAL/COMMERCIAL
Dsgovern.frm (revised 04/D5/I8)

Page 3 of 4
b. Existing and/or Future Downstream Developments/Improvements:
❑ DWELLINGS ❑ BUILDINGS ❑ ROADS ❑ UTILITIES ❑ "OTHER" None within 3,277' of the dam.
Existing and/or Future Downstream Development/Improvement(s) Data:
Downstream
Hazard/Improvement
Type
Distance
Downstream
from Dam
Floodplain
Width
Elevation
Relative
to
Floodplain
Channel
Slope
Breach Flood
Wave
Elevation
Culvert/Bridge
Dimensions
Traffic
Count
Sight
Distance
In accordance with 15A NCAC 02K .0I05,1 am providing the following proposed hazard classification:
RECOMMENDED HAZARD CLASSIFICATION: ® LOW INTERMEDIATE HIGH
I agree that this form will be used to initiate the Jurisdictional Determination process and/or determine its Hazard
Classification based on the current submittal and additionally requested documents, as needed.
NAME OF OWNER/REPRESENTATIVE or PROFESSIONAL
ENGINEER-. ame-s i'-letnscstn

Page 4 of 4
SIGNATURE.. P.E. SEAL:
DATE: ;I � 2 2.
osgovern.frm (revised 04/05/16)

,
HAZARD CLASSIFICATION DATA FORM FOkI` DAMS DS-1
DAM NAME CoLrhlT �� KMFR ©�7
RIVER/STREAM, ?•y/` f"����/' /�/vet QUADRANGLE
DAM HEIGHT Z S, % SURFACE AREA (ACRES) Z. Z STORAGE CAPACITY(ACRE FT.) Z Z, 6F
PRIMARY DOWNSTREAM LARD OSE:
QWOODLAND ® AGRICULTURAL RESIDERT'IAL INDOSTRIAL/COIMEBCIAL
DOWNSTREAM IMPROVEMENTS
aDWELLIRGS a BUILDINGS ROADS UTILITIES
DOWNSTREAM IMPROVEMENT DATA:
TYPE
WROVMM
DISTANCE
DOWNSTREAM
FLOODPLLIN
wnm
CHANNEL
SLOPE
ELEVATION ABOVE
F D"LAIN
BREACH WAVE
ELEVATION
CULVERT/BRIDGE
DIKEtNSIONS
TRAFFIC
COUNT
SIGHT
DISTANCE
CHANNEL
FL00 DWAY
DECK 9'�6�
RA L�
ROAD//' kl,
SPAN J� `
11I DTH 30 '
PI PE
LEFT
ao '
RIGHT
DESCRIBE POTEFML FOR LOSS OF LIFE AIM STRUCIURE OR DWIRONHE.KPAI, DAMAGE TO ECG OR POTE87M FVPURE
DOWRSTREAM IMPROVEMENTS: /i. "P e
0" aI�d7Gh-Yv
✓eh+jwi`n G d@SGroi� pa^+ Si1��� 1(y��iOw�i_n�» Oh 1-16-11 - ---
D CLbSSIFICATION* .&LOW
ppT
BY
CONCURRED BY
Dh%RMFJIATE n-1 v a HIGH 1-4 -
_f`, q g
TI-aE ,���� DATE DATE ✓?
TT1I,E G�iy G 4/
�' I - Zo -qa

A a
RCDENR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral, and Land Resources
Land Quality Section
Tracy Davis, PE, CPM
Director
Notice of Inspection
December 20, 2012
James Henson
184 N. Wilson Road
Low Gap, NC 27024
RE: Lowe Dam
Surry County
State Dam ID: Surry-057-L
Size: 25.9 feet, 22.8 acre-feet
Hazard Classification: Low Hazard
Dear Owner:
Beverly Eaves Perdue, Governor
Dee Freeman, Secretary
The "Dam Safety Law of 1967," as amended, provides for the certification and inspection of
dams in the interest of public health, safety, and welfare, in order to reduce the risk of failure of
such dams; to prevent injuries to persons, damage to property; and to insure the maintenance of
stream flows.
Our records indicate you are the owner of the referenced dam. The downstream hazard for this
dam was evaluated on December 20, 2012 by personnel of the Land Quality Section. We
investigated the potential for property damage and loss of life in the event your dam fails. This
investigation determined that failure of your dam poses no significant threat to human life or
property downstream. Therefore, based on current downstream development, we have
determined your dam to be classified as "Low Hazard".
Effective July 1, 2011, the North Carolina Dam Safety Law of 1967 (Law) was amended by
increasing the minimum size criteria for low and intermediate hazard jurisdictional dams from 15
feet in height and 10 acre-feet in impoundment capacity to 25 feet in height and 50 acre-feet in
impoundment capacity. As a result of this, the subject dam, which is currently classified as low
hazard, is exempt from the Law and any future work on the dam does not require approval from
this Division.
However, you should note that your dam's jurisdictional status may change based on
modifications to the dam affecting its height and/or impoundment capacity or as a result of
development in the area downstream of the dam, which can affect hazard classification. It is
therefore recommended that you contact our office for guidance prior to making modifications to
your dam or if you suspect the hazard classification of your dam may have changed due to
downstream development.
585 Waughtown Street, Winston-Salem, North Carolina 27107-2241
Phone: [phone] \ FAX: [phone]
AN EQUAL OPPORTUNITY \ AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED / 10% POST CONSUMER PAPER

Lowe Dam
Notice of Inspection/Exemption
December 20, 2012
Page 2 of 2
Dams and their spillways and conduits, even if well -constructed, will deteriorate over time
without proper maintenance and timely repairs. Therefore, it is recommended you regularly
inspect your dam and notify your engineer if you suspect any problems or changes with your
dam. Due to your dam's exemption from the Law, regular inspections of your dam by this
Division will be discontinued.
Your cooperation and consideration in maintaining a safe dam is appreciated. If ownership of
the dam has changed, or if you are not responsible for the dam, please notify us so that we can
update our records. Should you have any questions concerning our inspection, please contact me
at [phone].
Sincerely,
Matthew E. Gantt, P.E.
Regional Engineer
Land Quality Section
cc: WSRO file

State of North Carolina
Department of Natural Resources and Community Development
Winston-Salem Regional Office
James G. Mat -tin, Governor S. Thomas Rhodes, Secretary
DIVISION OF LAND RESOURCES
April 26, 1988
Mr. Richard T. Lowe
299 Midland Drive
Asheville, NC 28804
Dear Mr. Lowe:
RE: Lowe Dam, 86-057-L
Surry County
The "Dam Safety Law of 196711, as amended, provided for the
certification and inspection of dams in the interest of
public health, safety, and welfare, in order to reduce the
risk of failure of such dams; to prevent injuries to
persons, damage to property; and to insure the maintenance
of stream flows.
Our records indicate you are owner of the referenced dam
which was inspected by personnel of the Land Quality Section
on February 25, 1988. This inspection found the conditions
listed below.
1. Trees and bushes are growing on the dam. This type of
growth can cause problems and even failure of the dam
by creating holes when trees are uprooted due to wind
or ice; by leaving possible seepage holes when trees
die and their roots decay; and by causing erosion of
the dam around this growth should the dam overtop
during heavy rains. Therefore, we recommend that this
type of growth be removed and a good grass cover
established on the dam. Any growth greater than six
inches in diameter must also have the root system
excavated and the excavated area refilled and compacted
with a suitable soil material.
802` North Point Boulevard, Suite 100, Winston-Salem, N.C. 27106-3295 • Telephone [phone]
An Equal Opportunity Affirmative Action Employer

Mr. Richard T. Lowe
Page 2
April 26, 1988
2. Trees and bushes are growing in the emergency spillway.
This type of growth restricts the capacity of the
emergency spillway to carry water during rains. As a
result, the dam itself may overtop during heavy rains.
Overtopping can cause failure of the dam due to
erosion. We recommend that the this growth be removed
from the emergency spillway and a good grass cover
established to prevent erosion.
3. Erosion is occurring in the emergency spillway.
Erosion is usually progressive in nature and if allowed
to continue may even erode into the dam itself.
Therefore, we recommend that the eroded areas be
repaired and a good grass cover established to prevent
further erosion.
During this inspection we also investigated the potential
for property damage and loss of life in the event your dam
fails. This investigation determined that failure of your
dam could result in minor property damage downstream.
Therefore, we are listing your dam in the "Low Hazard"
category.
Your cooperation and consideration in maintaining a safe dam
is appreciated. Should you have any questions concerning
our inspection, please contact me.
Sincerely,
L,i/f dY M, Leonard
Engineering Technician
Land Quality Section
adw

(-DAM SAFETY INSPECTION REPORT)
NAME
COUNTY
NO.
BY
DATE
0mt"
1f�5_7
JINSPECTED
4,- IJ &JA- to e6Ae
42- 0, r - 86
OWNER
LC)
CAJ C_
XURR E
PHONE
Vic - 2,3 2) 0
TYPE DAM [3C0ncatqgratify [3C*ncnftgCh 13 oilher
TYPE INSPECTION 13 Pam*
SITE CONDITIONS
[3 wet
M4,'bw*mr,t 13C,=W,bMm OSIDMmssonary
044� 13 Followup 13 Other
61JW' 0 Sriowwver 13 Other
HAZARD DESCRIPTION
HAZARD LASS
[I intermediate (a)
B-Lw (A)
13 High (C)
REMARKS
ACTION
C3 None
RECC#AMENDATIONS, 13 Inspection by DSE
ninspectlon letter 13 Darn safety order
C3 maimanatwe
[3 Monitoring
L3 Deficiency letter 13
0 RE notice 13
Enforcement
Periodic reinspection
[3 Minor repsk
C) Engineering study C3otw
reinspection
0 Engineering
0 Inspedon by RE
AREA
PROBLEMS
COMMENTS-:*
[3 1.None
[31 I.Displaced rip rap
COVER: GMegswtion (3 Rip rap Oconcrets, OAsphaft 13Other
ul
[3 2.Trees
[312.Cmcks
"'.;Ilgh bushes
1313.Undermining
UJI❑
4.Burrows
[]14.Holes
06
10'
.j
[3 5.Wave erosion
[315.Spalling
rn
E3 6.Livestock damage
[316.Displaced Joints
4C
0 7.Slides
[317.Deteriorated 10IMS
4E.
0 B.Deprossions
[318.Exposed reinforcement
E3 9.8w9es
131 9.0ther
[3 1 O.Sparse rip rap
Cg/1-None
[31 I.Cracks
COVER: ffr=von 0 Gravel (3concrete E3 Asphalt [3 Other
(3 2.Trees 012.Spolling
E3 3.High bushes
1313.Detefiorated joints
[3 4.8urrom
❑1 4.Displaced Joints
0.
13 s. Ruts
[315.Exposed reinforcement
IL
0..:.:.
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[316-Ottw
0:*
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Eli omas overtopped!
,q
13
13ii-S"page
COVER: 97.udi. 13 Riprap, (3concrete 0 Other
Vweej
nne
Tr a 1312.8olis
[3�13�
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0.
..1
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X
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131s.011splacedloints
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[3 8.13spowssions
0 1 S.Exposed r011100009111011t
0 9-Bulges
[119.0ther
[310.Weiness
0 7'
13 11 - S99M*
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r
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13 lacracke
9 4 8
(3 4.6,10w$
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0
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0 1 S. Exposed reinforcement
[3 9.8ulges
[319.UnderminIng
(31 ovetness
[320.other

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ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
DOUGLAS R. ANSEL
Interim Director
December 7, 2022
James G. Henson
184 North Wilson Rd.
Lowgap, North Carolina 27024
RE: Notice of Exemption
Lowe Dam
Surry County
State Dam ID: SURRY-057
To the Dam Owner:
NORTH CAROLINA
Environmental Quality
This is in response to your latest submission dated September 19, 2022 and received on October 26, 2022 of
a request for a jurisdictional determination and hazard classification of the proposed subject dam. Personnel
from the North Carolina Department of Environmental Quality's Division of Energy, Mineral, and Land
Resources (DEMLR) reviewed the submitted materials and performed independent analyses to evaluate the
subject dam's hazard potential. The proposed dam height and maximum storage capacity are 25.9 feet and
22.8 acre-feet, respectively.
Based on our reviews, analyses and inspections, DEMLR has determined that a Class-B, Intermediate Hazard
classification is presently warranted due to the presence of woodlands and roads downstream from the dam
within the potential breach inundation zone(s). Class B includes dams located where failure may damage
highways or secondary railroads, cause interruption of use or service of public utilities, cause minor damage to
isolated homes, or cause minor damage to commercial and industrial buildings.
In order for a dam to be subject to the Dam Safety Law of 1967 (NCGS 143-215.23), the impoundment must be
both 25 feet in height or taller and impound 50 acre-feet or more or be located where failure will likely cause
loss of life or serious damage to homes, industrial and commercial buildings, important public utilities, primary
highways or major railroads. Since this structure is less than the required maximum storage capacity, and there
is no apparent severe potential damage to downstream areas, the subject dam as proposed is exempt from
requirements of the Dam Safety Law of 1967.
Nevertheless, the following comments are offered:
Our office encourages the owner of any dam to construct their dam using the same standards as would be
applied if it were under thejurisdiction of the Dam Safety Law of 1967.
2. If the dam is modified such that it is 25 feet in height or greater as measured from the highest point on the
crest of the dam to the lowest point on the downstream toe and will impound 50 acre-feet or more at the
highest point on the crestof the dam, this dam will no longer be considered exempt. In this case, engineering
certification, alongwith record drawings and specifications will be required as well as application processing
fees.
D WV North Carolina Department of Environmental Quality I Division of Energy, Mineral and Land Resources
512 North Salisbury Street 1 1612 Mail Service Center I Raleigh, North Carolina 27699-1612
NORTH CAROLA
oe�nu�me�.ro�memaioar� / 919.707.9200

James G. Henson
Notice of Exemption
December 7, 2022
Page 2of2
Lowe Dam
SU R RY-057
3. If future downstream development occurs which would be impacted by a failure of the dam, then the hazard
classification may be reassessed and may change from Intermediate to High Hazard classification. Please
note that in accordance with NCGS 143-215.25A(a)(6), dams which are determined to be high hazard are
subject to the provisions of the Dam Safety Law of 1967 regardless of height or impoundment capacity.
The Army Corps of Engineers and the Division of Water Resources of this Department should be contacted to
determine if additional permits are required. Also, the erosion and sediment control program having
jurisdiction should be contacted to determine plan approval requirements. In any case, sediment must be
prevented from entering the waters of the state or flowing onto neighboring property.
Should the subject dam change ownership, a "Change of Ownership of a Dam" form must be completed by the
new owner of the dam at the time of transfer in order to ensure the new owner receives important information
concerning the subject dam, and the former owner be released from liability. The form may be located on the
Dam Safety website at https://deg.nc.goy/about/divisions/energy-mineral-and-land-resources/dam-
safety/application-forms. The completed form must be submitted via email to [e-mail] listing
the change of ownership for the subject dam with its applicable state ID in the subject line.
There are additional guidance and resources available on the Dam Safety website at:
https://deq. nc.gov/a bout/d ivis i ons/en e rgy-m in era I -la nd-resou rces/e ne rgy-m in era 1-land-perm its/da m-safety
Also, to assist dam owners through outreach and education, the Association of State Dam Safety Officials'
Owner Outreach Committee has developed three educational videos as a free resource for owners on critical
basics of operating and maintaining a dam safely. The videos are 1) dam inspections, 2) spillways and outlet
works, and 3) operation and maintenance plans. All the videos are available at: https://damsafety.org/dam-
owners. These videos are the first in a series specific to owner education called the 'Dam Owner Academy.'
For assistance, you may contact Ms. Tamera Eplin, PE, CPESC, Regional Engineer, Land Quality Section, 450
Hanes Mill Road, Suite 300, Winston-Salem, North Carolina 27105, telephone number [phone]
or the Dam Safety Program in the Raleigh Central Office at telephone number [phone] should you
have questions concerning this matter.
Sincerely,
o Colley, PE
tate Dam Safety Engineer
JC/jas
cc: Ms. Tamera Eplin, PE, CPESC, Land Quality Regional Engineer, WSRO (via email)
James G. Henson, Dam Owner ([e-mail])
File name: SURRY-057 20221207 NOE Lowe Dam

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Roy Cooper, Governor
■ ■■■
r ■■ ■ INC DEPARTMENT OF
■■,■i NATURAL AND CULTURAL RESOURCES
■ ■■
July 11, 2023
Drew Lucas
Wetlands & Waters, Inc.
328 East Broad Street
Statesville, NC 28677
RE: North Wilson Road
Dear Drew Lucas:
❑. Reid Wilson, Secretary
Misty Buchanan
Deputy Director, Natural Heritage Program
NCNHDE-22587
The North Carolina Natural Heritage Program (NCNHP) appreciates the opportunity to provide
information about natural heritage resources for the project referenced above.
Based on the project area mapped with your request, a query of the NCNHP database indicates that
there are no records for rare species, important natural communities, natural areas, and/or
conservation/managed areas within the proposed project boundary. Please note that although there
may be no documentation of natural heritage elements within the project boundary, it does not
imply or confirm their absence; the area may not have been surveyed. The results of this query
should not be substituted for field surveys where suitable habitat exists. In the event that rare
species are found within the project area, please contact the NCNHP so that we may update our
records.
The attached `Potential Occurrences' table summarizes rare species and natural communities that
have been documented within a one -mile radius of the property boundary. The proximity of these
records suggests that these natural heritage elements may potentially be present in the project area
if suitable habitat exists. Tables of natural areas and conservation/managed areas within a one -mile
radius of the project area, if any, are also included in this report.
If a Federally -listed species is found within the project area or is indicated within a one -mile radius of
the project area, the NCNHP recommends contacting the US Fish and Wildlife Service (USFWS) for
guidance. Contact information for USFWS offices in North Carolina is found here:
httr)s://www.fws.gov/offices/Directory/ListOffices.cfm?statecode=37.
Please note that natural heritage element data are maintained for the purposes of conservation
planning, project review, and scientific research, and are not intended for use as the primary criteria
for regulatory decisions. Information provided by the NCNHP database may not be published
without prior written notification to the NCNHP, and the NCNHP must be credited as an information
source in these publications. Maps of NCNHP data may not be redistributed without permission.
The NC Natural Heritage Program may follow this letter with additional correspondence if a
Dedicated Nature Preserve, Registered Heritage Area, Land and Water Fund easement, or Federally -
listed species are documented near the project area.
If you have questions regarding the information provided in this letter or need additional assistance,
please contact Rodney A. Butler at rod ney.butler�ncdcr.gov or 919-707-8603.
Sincerely,
NC Natural Heritage Program
DEPAR7HEN7 OF NATURAL AND CULTURAL RESOURCES
121 W. JONES STREET. RALEIGH. NC 27603 • 1691 MAIL SERVICE CENTER. RALEIGH. NC 27609
OFC 919.707.9120 • FAX [phone]

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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 ❑X No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
❑ Yes 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?
Based on a review of PAC: Site is outside known range for small anthered bittercress. No suitable habitat for Schweinitz's sunflower within the work
area. No tree removal is necessary for the embankment repairs. No bog turtle habitat in drained pond. MANIA determination appropriate.
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?
SHPO GIS data shows no proximate sites or structures. All work areas previously impacted by construction.
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 1 00-year floodplain?
❑ Yes X❑ No
8b. if yes, explain how project meets FEMA requirements:
Resource maps include a FEMA figure
8c. What source(s) did you use to make the floodplain determination?
FEMA Floodplain mapper.
James Henson
j 9 but X3
ApplicantlAgent's Printed Name
Date
Applicant/Agent's Signature
(Agent's signature is valid only if an authorization
letter from the applicant isprovided,)
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