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Home My WebLink About20031361 Ver 1_Application_20031014WETLANDS 1401 GROUP n ^+a A'~ ~~ 4 ~ ~:~ .~~~. STATE OF NORTH CAROLINA DEPARTMENT OF TRANSPORTATION MICHAEL F. EASLEY GOVERNOR October 15, 2003 U.S. Army Corps of Engineers Regulatory Field Office 6508 Falls of the Neuse Road Suite 120 Raleigh, NC 27615 o~~~~~ ATTN: Mr. John Thomas NCDOT Coordinator LYNDO TIPPETT SECRETARY Subject: Nationwide 23 and 33 application. Rockingham County, replacement of Bridge No. 45 over the Dan River on SR 2282, Federal Aid Project No. BRSTP-87(10), State Project No. 8.1511601, TIP Project No. B-3368. The U.S. Army Corps of Engineers (USAGE) issued Nationwide Permits 23 and 33 for the above-mentioned project on December 14, 2001. The tear sheet for these permits is enclosed. These permits expired on February 11, 2002. The purpose of this application is to request a Nationwide Permit 23 and 33 for the construction of a hazardous spill basin in wetlands and construction of a temporary work bridge. A work bridge will be used upstream of the existing bridge to facilitate in the demolition of the existing bridge. Deck drainage will be carried off the bridge and diverted into the proposed hazardous spill catch basin. Please see the attached permit drawings for details regarding the temporary work bridge and the hazardous spill catch basin. Wetland Impacts: Permanent jurisdictional wetland impacts will occur during project construction. Wetland delineations were conducted by NCDOT biologists using the criteria specified in the 1987 Corps of Engineers Wetland Delineation Manual. Due to the small size of the wetland, it was not verified by the USAGE. Wetland impacts are due to the placement of the hazardous spill basin and consist of permanent fill, totaling approximately 0.037 acre. These impacts are identified on Sheet 4 of 6 of the permit drawings. Wetland impacts do not exceed 1/10 of an acre, therefore no wetland mitigation is proposed. Surface Water Impacts: A temporary work bridge will be constructed to aid in the demolition of the existing structure. The work bridge will be approximately 30 ft wide and long enough to span the Dan River. If needed, clean rip rap, at areas of bridge supports, maybe used to level this structure. The resulting temporary fill occurring from the placement of the work bridge bents in the river will be less than 1110 acre. All rip rap will be removed from the streambed to the extent practicable. OCT 1 4 2003 WATER (QUALITY SECTION Temporary Impacts: Construction of the proposed bridge will require the installation of a temporary work bridge. The temporary work bridge will be constructed at the elevation and location as shown in the permit drawings. This work bridge will require the temporary placement of Class II rip rap into 0.1 acre of surface waters of the Dan River. Restoration Plan: The temporary impact will consist of the above mentioned materials. No permanent fill will result from the subject activity. After completion of the permanent bridge, all material used in the construction of the temporary work bridge will be removed. The stream will then be restored to its pre-project contours. The temporary impact area associated with the construction is expected to recover naturally, since the natural streambed and plant material will not be dramatically impacted. The fill will be placed and removed with the appropriate equipment. Schedule: All steps will be taken to minimize impacts to the Dan River. The Contractor will be required to remove the temporary work bridge as soon as is practical, minimizing the time of the temporary impacts to the Dan River. All exposed areas will be stabilized to prevent erosion. Removal and Disposal Plan: The Contractor will be required to submit a reclamation plan for the removal of and disposal of all materials off-site at an upland location. The Contractor will use excavating equipment to remove any materials from the stream. Heavy-duty trucks, dozers, cranes and various other pieces of mechanical equipment necessary for construction of roadways and culverts will be used on site. All material placed in the stream will be removed at that time. The Contractor will have the option of reusing any of the materials that the Engineer deems suitable in the construction of the project. After the temporary work bridge is no longer needed, all materials will become the property of the Contractor. ENVIRONMENTAL COMMITMENTS The existing bridge has a concrete deck, with a concrete closed spandrel arch span over the Dan River. This type of structure makes it difficult to remove the existing structure without the use of explosives. For this reason, a field meeting was held on September 17, 2001 with representatives from the USACE, DWQ and NCDOT to discuss bridge demolition. The following environmental commitments have been agreed upon: - If it is necessary to use explosives during bridge demolition, personnel representing the WRC, USACE and DWQ will be notified of the dates, so that they maybe present. - NCDOT will avoid using explosives during the months of May and June of any year due to fish spawning in the Dan River as well as during periods of high flow in the Dan River. - The surface water intake located approx. 0.2 miles downstream of Bridge Number 45 will be notified prior to the use of any explosives that maybe necessary during bridge demolition. A notice will be placed in the local newspaper alerting nearby residents if explosives are necessary and when they will be used. - All precautions must be used to control the blast and the turbidity from the blast. - Turbidity curtains will be used to contain sediment and debris. All measures will be taken to protect the downstream water intake. - Following bridge demolition, any debris allowed to fall into the Dan River will first be removed by "picking" it out of the channel by boat. Any debris remaining in the river will be removed at the discretion of the regulatory agencies (USACE, DWQ and WRC). It may be necessary for the agencies to meet on-site to determine if the streambed should be dragged to remove the remaining debris. - Best Management Practices for Bridge Demolition & Removal will be implemented. - NCDOT will strictly adhere to "Design Standards in Sensitive Watersheds" (15A NCAC 04B .0024)(High Quality Water Standards) throughout design and construction of this project. - Deck drainage will be carried off the bridge and diverted into the proposed hazardous spill catch basin. Regulatory Approvals Section 404 Permit: This project is being processed by the Federal Highway Administration as a "Categorical Exclusion" in accordance with 23 CFR 771.115(b). Therefore, we do not anticipate requesting an individual permit, but propose to proceed under a Nationwide 23 and 33 as authorized by Nationwide Permits 23 and 33 (FR number 10, pages 2020-2095; January 15, 2002). Section 401 Permit: We anticipate 401 General Certification numbers 3361 and 3366 will apply to this project. In accordance with 15A NCAC 2H .0501(a) we are providing two copies of this application to the North Carolina Department of Environment and Natural Resources, Division of Water Quality, for their records. If you have any questions or need additional information, please contact Matt Haney at (919) 715-1428. Sincerely, ~w- Grego J. Thorpe, Ph.D., Environmental Management Director, Project Development and Environmental Analysis Branch w/attachment Mr. John Dorney, Division of Water Quality (2 copies) Mr. Travis Wilson, NCWRC Mr. Gary Jordan, USFWS Mr. Greg Perfetti, P.E., Structure Design w/o attachment Mr. David Franklin, USACE, Wilmington Mr. Jay Bennett, P.E., Roadway Design Mr. Omar Sultan, Programming and TIl' Ms. Debbie Barbour, P.E., Highway Design Mr. David Chang, P.E., Hydraulics Mr. Mark Staley, Roadside Environmental Mr. J.M. Mills, P.E., Division 7 Engineer Mr. Jerry Parker, Division 7 Environmental Officer ROCKINGHAM COUNTY NORTH CAROLINA _ ~ ~~ e~ ~a a ~. EDE s, ti POP. 1s m ~ Can t r I m Ch r Sx 5 R .S ~'Sp s.. ~ ~ ~x ~• O ~~ ~x 2 RO CT '~ / 2 0 „~.~ ~o 0 E~ ~ sR fl ~ 2?B2 aQ~ ~ '~'FNUF~aY \/ ,, . ~ Vv' 2100 iyd~dNII°Jf°~ 1r`" 11i C.D.O.T. DIVISl011t OF HIGHWAYS ROCKI11iGHAM COU11iTY REPLAG'F.MENT OF BRIDGE N0.45 0111 NC 87 OVER THE DAN RIVER STATE PROJECT#8.1511604 8-3368 SHEET 1 OF ~ PROPOSED BRIDGE 162 158 154 I 150 I EXISTING BRIDGE N0. 45 _ _ _ _ _ _ _ _ _ \ - ~- - . ,` `~ I I I / • I I I I I L5:i ~ I I I / ~ I I I I I I I I I / ~ I I I I I I RIPA RAPI I I I ~ ~, I I _ 1- -1- - ~ ~ J ~ I I I ~ ~--~---- J__ TEMPORARY WORK ~ ~ ~ - - ~ BRIDGE ~ - NORMAL WSEL = 150.40 m 12+60 12+g0 13+00 13+20 13+40 5m 0 20m HORIZONTAL SCALE 5m 0 ~m VERTICAL SCALE 13+60 13+80 14+00 14+20 14+40 DIVISION OF HIGHWAYS ROCgINGHAM COUNTY REPLACEMENT OF BRIDGE NO. ~5 ON NC 87 OVER THE DAN RIVER STATE PROJECT N0.8.1b11601 cB-ab68) ~* 3 ~ ~ MATCHLINE i i i __ ~_~___~__==~-'I ----=EXISTINGIBRIDGE tt45____ I!~-~== I=====~__-_ EIP v z~ 00~ s~+~ 3 ~, ~ ~ TDE m ~ ~ TDE Ir- ~ ~ ~~ ~ .z,n v W =_ ' ? '~ > ~° ~° ,1 ~ z n 1`~ Q l~IL~N ~~IEW W TDE- +95 33 UPSTREAM TEMPORARY WORK ,' BRIDGE ~ »~WORK BRIDGE MAY BE MOVED BY CONTRACTOR WITHIN ~ EASEMENT AS DEEMED NECESSARY 1~ DIVISION OF HIQHWAYS ROCgINGHAM COUNTY REPLACEMENT OF BRIDGE NO. ~b ON NC 87 OVER THE DAN RIVER STATE PROJECT N0.8.1b11601 (B-E368) D~L7.S D! ~ DATs -/S/N WETLAND PERMIT IMPACT SUMMARY WETLAND IMPACTS SURFACE WATER IM PACTS Site No. Station (From/To) Structure Size /Type Fill In Wetlands (ha) Temp. Fill In Wetlands (ha) Excavation In Wetlands (ha) Mechanized Clearing (Method III) (ha) Fill In SW (Natural) (ha) Fill In SW (Pond) (ha) Temp. Fill In SW (ha) Existing Channel Impacted (m) Natural Stream Design (m) 1 15+17-L-Lt to Hazardous spill catch basin 0.015 15+40-L-Lt 2, 3 Temporary work bridges <0.04 TOTALS : rm Revised 3122/07 0.015 0 0 0 0 0 <0.04 0 0 NCDOT DIVISION OF HIGHWAYS ROCKINGHAM COUNTY PROJECT 8.1511601 (B-3368) BRIDGE NO. 45 OVER THE DAN RIVER ON NC 87 SHEET ~ OF ~ !0/25/2001 U.S. ARMY CORPS OF ENGINEERS WILMINGTON DISTRICT Action ID. 200220355 & 200220356 County Rockingham GENERAL PERMIT (REGIONAL AND NATIONWIDE) VERIFICATION Property Owner/Agent: NCDOT/Bridge No. 45/NC 87/TIP No. B-3368 Address: Attn: Mr. D. William Gilmore, P.E., Manager, Planning & Environmental Branch 1548 Mail Service Center, Raleigh, North Carolina 27699-1548 Telephone No.: (919) 733-3141 Size and Location of project (waterway, road name/number, town, etc.): Bridge No. 45, on NC 87, northwest of SR 2282, in Eden, North Carolina. The project is located adjacent to, and below the headwaters of, the Dan River. Description of Activity Mechanized landclearing, excavation and filling activities, associated with the replacement of Bridge Number 45 with a new bridge and temporary access work pads (bridge) to facilitate construction and demolition. Impacts associated with the bridge will involve the construction of a hazardous spill basin into 0.037 acre of scrub-shrub wetlands adjacent to the river. The temporary work pads will involve the discharge of Class II rip rap into 0.1 acre of surface waters, with all rip rap being removed and the river bottom being restored to pre-project contours following project completion. Traffic will be detoured along existing secondary roads during construction. X Section 404 (Clean Water Act, 33 USC 1344) only. Section 10 (River and Harbor Act of 1899) only. Section 404 and Section 10. 23 & 33 Nationwide General Permits. Any violation of the conditions of the~R.egional General or Nationwide Permit referenced above may subject the permittee to a stop work order, a restoration order, and/or appropriate legal action. This Department of the Army Regional GeneraUNationwide Permit verification does not relieve the undersigned permittee of the responsibility to obtain any other required Federal, State, or local approvals/permits. The permittee may need to contact appropriate State and local agencies before beginning work. Regulatory Project Manager Signature o.n,..~ . ,,L~ Date 14 December 2001 ~ Expiration Date 11 February 2002 SURVEY PLATS, FIELD SKETCH, WETLAND DELINEATION FORM, ETC., MUST BE ATTACHED TO THE FILE COPY OF THIS FORM, IF REQUIRED OR AVAILABLE. Note: When the nationwide permit authorization expires, activities, which have commenced or are under contract to commence, in reliance upon the nationwide permit, will remain authorized. This is provided the activity is completed within twelve months of the date of the nationwide permit's expiration, modification or revocation. Office Use Only: Form Version May 2002 USACE Action ID No. DWQ No. (If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A".) I. Processing 1. Check all of the approval(s) requested for this project: ® Section 404 Permit ^ Riparian or Watershed Buffer Rules ^ Section 10 Permit ^ Isolated Wetland Permit from DWQ ^ 401 Water Quality Certification 2. Nationwide, Regional or General Permit Number(s) Requested: NWP 23, NWP 33 If this notification is solely a courtesy copy because written approval for the 401 Certification is not required, check here: 4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for mitigation of impacts (verify availability with NCWRP prior to submittal of PCN), complete section VIII and check here: ^ 5. If your project is located in any of North Carolina's twenty coastal counties (listed on page 4), and the project is within a North Carolina Division of Coastal Management Area of Environmental Concern (see the top of page 2 for further details), check here: ^ II. Applicant Information Owner/Applicant Information Name: NC Department of Transportation Mailing Address: 1548 Mail Service Center Raleigh, NC 27699-1548 Telephone Number: 919-733-3141 Fax Number: 919-715-1501 E-mail Address: 2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter must be attached if the Agent has signatory authority for the owner/applicant.) Name: N/A Company Affiliation: Mailing Address: Telephone Number: Fax Number: E-mail Address: Page 5 of 13 III. Project Information Attach a vicinity map clearly showing the location of the property with respect to local landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property boundaries and development plans in relation to surrounding properties. Both the vicinity map and site plan must include a scale and north arrow. The specific footprints of all buildings, impervious surfaces, or other facilities must be included. If possible, the maps and plans should include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion, so long as the property is clearly defined. For administrative and distribution purposes, the USACE requires information to be submitted on sheets no larger than 11 by 17-inch format; however, DWQ may accept paperwork of any size. DWQ prefers full-size construction drawings rather than a sequential sheet version of the full-size plans. If full-size plans are reduced to a small scale such that the final version is illegible, the applicant will be informed that the project has been placed on hold until decipherable maps are provided. 1. Name of project: Replacement of Bridge No. 45 over Dan River 2. T.I.P. Project Number or State Project Number (NCDOT Only): B-3368 3. Property Identification Number (Tax PIN): N/A 4. Location County: Rockingham Nearest Town: Eden Subdivision name (include phase/lot number): N/A Directions to site (include road numbers, landmarks, etc.): Bridge No. 45 on SR 2282 over the Dan River, located in the southwestern Hart of Eden 5. Site coordinates, if available (UTM or Lat/Long):36°30'/79°45' (approx.) (Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the coordinates for each crossing of a distinct waterbody.) 6. Property size (acres): N/A 7. Nearest body of water (stream/river/sound/ocean/lake) Dan River 8. River Basin: Roanoke (Note -this must be one of North Carolina's seventeen designated major river basins. The River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.) 9. Describe the existing conditions on the site and general land use in the vicinity of the project at the time of this application: urban and residential Page 6 of 13 10. Describe the overall project in detail, including the type of equipment to be used: The proposed project will consist of replacing the existing bridge with a new bridge east (downstream~of the existing bride. Traffic will be maintained on the existing bride during construction. Construction equipment will consist of heavy duty trucks, earth moving equipment and cranes etc. 11. Explain the purpose of the proposed work: Replace substandard bridge over Dan River resulting in safer and more efficient traffic operations. IV. Prior Project History If jurisdictional determinations and/or permits have been requested and/or obtained for this project (including all prior phases of the same subdivision) in the past, please explain. Include the USACE Action ID Number, DWQ Project Number, application date, and date permits and certifications were issued or withdrawn. Provide photocopies of previously issued permits, certifications or other useful information. Describe previously approved wetland, stream and buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project, list and describe permits issued for prior segments of the same T.I.P. project, along with construction schedules. A Nationwide Permit 23 & 33 was issued for this project on December 14, 2001 (Action ID 200220355 & 2002203561. V. Future Project Plans Are any future permit requests anticipated for this project? If so, describe the anticipated work, and provide justification for the exclusion of this work from the current application. VI. Proposed Impacts to Waters of the United States/Waters of the State Page 7 of 13 It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to wetlands, open water, and stream channels associated with the project. The applicant must also provide justification for these impacts in Section VII below. All proposed impacts, permanent and temporary, must be listed herein, and must be clearly identifiable on an accompanying site plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a delineation map, whether or not impacts are proposed to these systems. Wetland and stream evaluation and delineation forms should be included as appropriate. Photographs may be included at the applicant's discretion. If this proposed impact is strictly for wetland or stream mitigation, list and describe the impact in Section VIII below. If additional space is needed for listing or description, please attach a separate sheet. 1. Provide a written description of the proposed impacts: There will be permanent wetland impacts to approximately 0.037 acres of iurisdictional wetlands. There will be temporary stream impacts to approximately 0.1 acres of jurisdictional stream. 2. Individually list wetland impacts below: Wetland Impact Site Number (indicate on ma) Type of Impact* Area of Impact (acres) Located within 100-year Floodplain** (yes/no) Distance to Nearest Stream (linear feet) Type of Wetland*** 1 Permanent fill 0.037 Yes Approx. 500 ft Linear scrub-shrub * List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill, excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding. ** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps (FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or online at http://www.fema.eov. *** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond, Carolina Bay, bog, etc.) Indicate if wetland is isolated (determination of isolation to be made by USACE only). List the total acreage (estimated) of all existing wetlands on the property: 0.05 ac Total area of wetland impact proposed: 0.037 ac 3. Individually list all intermittent and perennial stream impacts below: Stream Impact Site Number (indicate on map) Type of Impact* Length of Impact (linear feet) Stream Name** Average Width of Stream Before Impact Perennial or Intermittent? (please specify) N/A Page 8 of 13 * List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap, dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain), stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included. ** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at www.uss.=s.~ov. Several Internet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com, www.mapquest.com, etc.). Cumulative impacts (linear distance in feet) to all streams on site: 4. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic Ocean and any other water of the U.S.) below: Open Water Impact Site Number (indicate on ma) Type of Impact* Area of Impact (acres) Name of Waterbod y (if applicable) Type of Waterbody (lake, pond, estuary, sound, bay, ocean, etc.) 3 Temporary fill 0.1 ac Dan River river * List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging, flooding, drainage, bulkheads, etc. 5. Pond Creation If construction of a pond is proposed, associated wetland and stream impacts should be included above in the wetland and stream impact sections. Also, the proposed pond should be described here and illustrated on any maps included with this application. Pond to be created in (check all that apply): ^ uplands ^ stream ^ wetlands Describe the method of construction (e.g., dam/embankment, excavation, installation of draw-down valve or spillway, etc.): N/A Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond, local stormwater requirement, etc.): N/A Size of watershed draining to pond: N/A Expected pond surface area: N/A VII. Impact Justification (Avoidance and Minimization) Specifically describe measures taken to avoid the proposed impacts. It maybe useful to provide information related to site constraints such as topography, building ordinances, accessibility, and financial viability of the project. The applicant may attach drawings of alternative, lower-impact site layouts, and explain why these design options were not feasible. Also discuss how impacts Page 9 of 13 were minimized once the desired site plan was developed. If applicable, discuss construction techniques to be followed during construction to reduce impacts. The existing structure will be replaced with a 796 ft long bridge east (downstream) of the existing bridge. Traffic will be maintained during construction on the existing_bridge. VIII. Mitigation DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC Division of Water Quality for projects involving greater than or equal to one acre of impacts to freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial streams. USAGE - In accordance with the Final Notice of Issuance and Modification of Nationwide Permits, published in the Federal Register on March 9, 2000, mitigation will be required when necessary to ensure that adverse effects to the aquatic environment are minimal. Factors including size and type of proposed impact and function and relative value of the impacted aquatic resource will be considered in determining acceptability of appropriate and practicable mitigation as proposed. Examples of mitigation that may be appropriate and practicable include, but are not limited to: reducing the size of the project; establishing and maintaining wetland and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of aquatic resource functions and values by creating, restoring, enhancing, or preserving similar functions and values, preferable in the same watershed. If mitigation is required for this project, a copy of the mitigation plan must be attached in order for USAGE or DWQ to consider the application complete for processing. Any application lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as incomplete. An applicant may also choose to review the current guidelines for stream restoration in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at http://h2o. enr.state.nc.us/ncwetlands/strmgide.html. 1. Provide a brief description of the proposed mitigation plan. The description should provide as much information as possible, including, but not limited to: site location (attach directions and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet) of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view, preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a description of the current site conditions and proposed method of construction. Please attach a separate sheet if more space is needed. N/A Page 10 of 13 2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration Program (NCWRP). Please note it is the applicant's responsibility to contact the NCWRP at (919) 733-5208 to determine availability and to request written approval of mitigation prior to submittal of a PCN. For additional information regarding the application process for the NCWRP, check the NCWRP website at http://h2o.enr.state.nc.us/wrp/index.htm. If use of the NCWRP is proposed, please check the appropriate box on page three and provide the following information: Amount of stream mitigation requested (linear feet): N/A Amount of buffer mitigation requested (square feet): N/A Amount of Riparian wetland mitigation requested (acres): N/A Amount ofNon-riparian wetland mitigation requested (acres): N/A Amount of Coastal wetland mitigation requested (acres): N/A IX. Environmental Documentation (required by DWQ) Does the project involve an expenditure of public (federal/state) funds or the use of public (federal/state) land? Yes ® No ^ If yes, does the project require preparation of an environmental document pursuant to the requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)? Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA coordinator at (919) 733-5083 to review current thresholds for environmental documentation. Yes ® No ^ If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a copy of the NEPA or SEPA final approval letter. Yes ® No ^ X. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ) It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to required state and local buffers associated with the project. The applicant must also provide justification for these impacts in Section VII above. All proposed impacts must be listed herein, and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ Regional Office may be included as appropriate. Photographs may also be included at the applicant's discretion. Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233 (Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC ZB .0250 (Randleman Rules and Water Supply Buffer Requirements), or other (please identify )? Yes ^ No ® If you answered "yes", provide the following information: Page 11 of 13 Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer mitigation is required calculate the required amount of mitigation by applying the buffer multipliers. Zone* Impact (s uare feet) Multiplier Required Mitigation I 3 2 1.5 Total * Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an additional 20 feet from the edge of Zone I . If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation of Property, Conservation Easement, Riparian Buffer Restoration /Enhancement, Preservation or Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as identified within 15A NCAC 2B .0242 or .0260. No mitigation required. XI. Stormwater (required by DWQ) Describe impervious acreage (both existing and proposed) versus total acreage on the site. Discuss stormwater controls proposed in order to protect surface waters and wetlands downstream from the property. XII. Sewage Disposal (required by DWQ) 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. XIII. Violations (required by DWQ) Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules? Yes ^ No Is this anafter-the-fact permit application? Yes ® No ^ XIV. Other Circumstances (Optional): Page 12 of 13 It is the applicant's responsibility to submit the application sufficiently in advance of desired construction dates to allow processing time for these permits. However, an applicant may choose to list constraints associated with construction or sequencing that may impose limits on work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and Threatened Species, accessibility problems, or other issues outside of the applicant's control). N/A Applicant/Agent's Signature Date (Agent's signature is valid only if an authorization letter from the applicant is provided.) Page 13 of 13