20180794 Ver 1_401 Application_20180607

Action History (UTC -05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/7/2018 11:38:58 AM (Start Event)
Accept by Montalvo, Sheri A 6/12/2018 10:53:55 AM (Non DOT Initial Review)
• The task was assigned to Montalvo, Sheri A. The due date is: June 12, 2018 5:00 PM
6/7/2018 11:40 AM

DWR
Dfutslon of Water Resources
Pre -Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
January 31, 2018 Ver 2.3
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all mandatory questions are answered.
Also, if at any point you wish to print a copy of the E -PCN, all you need to do is right -click on the document and you can print a copy of the form.
Below is a link to the online help file.
https://edocs. deq. nc.gov/WaterResources/0/edoc/624704/PCN%20Help%20File%202018-1-30. pdf
A. Processing Information
County (or Counties) where the project is located:*
Alamance
Is this project a public transportation project?*
r Yes G No
This is any publicly funded by rrunicipal,state or federal funds road, rail, airport transportation project.
1a. Type(s) of approval sought from the Corps:*
PF Section 404 Permit (wetlands, streams and waters, Clean Water Act)
r Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
1b. What type(s) of permit(s) do you wish to seek authorization?*
r% Nationwide Permit (NWP)
r Regional General Permit (RGP)
r Standard (IP)
This form may be Corps to initiate the standard/individual permit process. Please contact your Corps representative for submittal of standard permits.
All required items that are not provided in the E -PCN and be added to the miscellaneous upload located at the bottom of this form.
Nationwide Permit (NWP) Number: 18 - Minor Discharges
NWP Number Other:
List all WV nun-bers you are applying for not on the drop dow n list.
1c. Type(s) of approval sought from the DWR:*
check all that apply
401 Water Quality Certification - Regular r 401 Water Quality Certification - Express
r Non -404 Jurisdictional General Permit r Riparian Buffer Authorization
r Individual Permit
*
1d. Is this notification solelyfor the record because written approval is not required?

For the record only for DWR 401 Certification:
For the record only for Corps Permit:
G Yes r No
O Yes a No
1e. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
V so, attach the acceptance letter from mitigation bank or in -lieu fee program
r Yes r No
1f. Is the project located in anyof NC's twenty coastal counties?*
r Yes r No
1h. Is the project located in a designated trout watershed?*
r Yes r No
Link to trout information: http://wuwv.saw.usace.army.miI/Missions/Regulatory-Permit-Program/Agency-Coordination/Trout.aspx
B. Applicant Information
1a. Who is the Primary Contact?*
Ashley Bentz of S&ME, Inc.
1b. Primary Contact Email:*
[e-mail]
1c. Primary Contact Phone:*
(XXX)XXX-XXXX
1d. Who is applying for the permit?
r- Owner V Applicant (other than owner) V Agent/Consultant
(Check all that apply)
2. Owner Information
2a. Name(s) on recorded deed:
Whitesell Worth Rhyne Irrevocable Trust
2b. Deed book and page no.:
Book 3177, Page 0514
2c. Responsible party:
(for Corporations)
Cheryl Rhyne Whitesell
2d. Address
Street Address
1844 Old St Marks Church Road
Address Line 2
CRY
Burlington
Fbstal / Zip Code
27215
2e. Telephone Number:
()=)XXX-XXXX
2f. Fax Number:
(X_XX)XM-XXXX
2g. Email Address:*
[e-mail]
/ Ftovince / Plegion
NC
Country

3. Applicant Information (if different from owner)
3a. Applicant is:
f Agent
C Other
If other please specify.
3b. Name:
Brent Narkawicz
3c. Business Name:
(if applicable)
Calamar
3d. Address
Street Address
43 Technology Drive
Address Line 2
aty State / Province / Flegion
Bedford NH
Fbstal / Zip Code Country
03110
3e. Telephone Number:
[phone]
(XXX)XXX-XXXX
Fax Number:
[phone]
(XM)MX-XXM
Email Address:*
[e-mail]
4. Agent/Consultant (if applicable)
4a. Name:
Ashley Bentz
4b. Business Name:
(if applicable)
S&ME, Inc.
4c. Address
Street Address
3201 Spring Forest Road
Address Line 2
City State/ Province/ Fegion
Raleigh NC
F bstal / Zip Code Country
27616
4d. Telephone Number:
[phone]
(xxx)xxx-xxxx
4e. Fax Number:
(XXX)XXX-XXXX

4f. Email Address:*
[e-mail]
Agent Authorization Letter*
Reese provide the Agent Authorization Letter if you are submitting this document.
Revised Calamar Agent Authorization Form (USACE).pdf 35.77KB
RLETYFEM-STBEREF
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Calamar Burlington Proposed Senior Living Facility
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality / town:
*
Burlington
1d. Driving directions*
If it is a new project and can not easily be found in a GPS mapping system Rease provide directions.
From Raleigh, take 1-540 W from US -1 N/ Capital Blvd. Take Eat 1-A toward Durham on 1-40W. Take exit 141 off 1-40W for Huffman Mill Road.
Turn left on Huffman Mill Road. Turn right into Old Saint Marks Church Road/ St Marks Church Road. Site will be on the left (1844 Old Saint
Marks Church Road in Burlington, NC).
2. Project Identification
2a. Property Identification Number:
(tax RN or parcel ID)
8854-02-1159,8854-02-0414,8844-92-8018
2b. Property size:
(in acres)
9.43
2c. Project Address
Street Address
1844 Old Saint Marks Church Road
Address Line 2
City State / Province/ Region
Burlington NC
Fbstal / Zip Code Country
27215
2d. Site coordinates in decimal degrees
Please collect site coordinates in decimal degrees. Use between 4-6 digits (unless you are using a survey -grade GPS device) after the decimal place as
appropriate, based on howthe location was determined. (For example, most mobile phones with GPS provide locational precision in decimal degrees to
map coordinates to 5 or 6 digits after the decimal place.)
Latitude:*
36.062823
ex: 34.208504
Longitude:*
-79.507267
-77.796371

3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
UT- Back Creek
3b. Water Resources Classification of nearest receiving water:*
WS -V: NSW
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Cape Fear
River Basin Lookup
4. Project Description
4a. 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 property is currently developed with a single family home. Also present on site is a pond approximately 0.67
acres. The majority of the undeveloped portion of the site is herbaceous, with some forested areas. General land
use in the vicinity of the site is mixed, with a variety of institutional, residential, industrial, and commercial uses.
4b. Attach an 8 1/2 X 11 excerpt from the most recent version of the USGS topographic map indicating the location of the project site. (for
DWR)
nick the upload button or drag and drop files here to attach docurent
USGS.pdf
File type rust be pdf
772.31 KB
4c. Attach an 8 1/2 X 11 excerpt from the most recent version of the published County NRCS Soil Survey map depicting the project site.
(for DWR)
Click the upload button or drag and drop files here to attach docurrent
SOIL.pdf 1.63MB
File type rust be pdf
4d. List the total estimated acreage of all existing wetlands on the property:
0.74 ac
4e. List the total estimated linear feet of all existing streams on the property:
(intermittent and perennial)
0 linear feet
4f. Explain the purpose of the proposed project:*
The purpose of this project is to construct an independent living facility for those aged 55 or older. This nursing
home will have 140 one and two bedroom units and is designed for active senior residents.
4g. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:
The site consists of three contiguous tax parcels (Alamance Co. Parcel ID Nos.112471, 112472, 107161) totaling
approximately 9.43 acres. Current plans are to construct a three-story independent living facility with associated
paved parking to the west, south, and east of the structure. Four single -car garage buildings are planned on the
eastern or western sides of the parking areas. A stormwater basin is also proposed in the southwest corner of the
property to treat stormwater resulting from the project. Construction will be performed by standard commercial
construction equipment. No specialized equipment not regularly seen on commercial projects is anticipated.
4h. Please upload project drawings for the proposed project.
nick the upload button or drag and drop files here to attach docurrent
Wetland impact exhibit.pdf 340.69KB
Wetland site exhibit.pdf 376.05KB
File type rust be pdf
5. Jurisdictional Determinations

5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
r Yes r No r Unknown
Comments:
Delineation performed by Ashley Bentz of S&ME
5b. If the Corps made a jurisdictional determination, what type of determination was made?
r Preliminary r Approved r Unknown r WA
Corps AID Number:
Exarrple: SAW2017-99999
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Other:
Ashley Bentz
S&ME, Inc.
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
PJD Request submitted to the USACE on 11/28/17. On 1/12/18 a site visit was conducted with Mr. David Bailey of the USACE, who verified
the delineation as correct as depicted within the PJD request. The PJD will be issued concurrently with the NWP.
5d1. Jurisdictional determination upload
Click the upload button or drag and drop files here to attach docurrent
USACE Verification Email.pdf 79.23KB
File type rrust be FDF
6. Project History
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?*
r Yes C No r Unknown
7. Future Project Plans
7a. Is this a phased project?*
C Yes f• No
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the
proposed project or related activity? This includes other separate and distant crossing for linear projects that require Department of the
Army authorization but don't require pre -construction notification.
No other NWPs, regional general permits, or individual permits are intended
to be used.
D. Proposed Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
17 Wetlands r Streams -tributaries r Buffers
m Open Waters r Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.

2a. Site # - Reason for impact* 2b. Impact type * 2c. Type of wetland*
Wetland Impact W2 P Headwater Forest
IVhp label (e.g. Fbad Grossing 1 - Culvert, Fbrmanent (P) or
dewatering, etc) Temporary (T)
2g. Total Temporary Wetland Impact
0.000
2g. Total Permanent Wetland Impact
0.020
2g. Total Wetland Impact
0.020
2d. Wetland name *2e. 2f. Type of 2g. Impact
Forested* Jurisdicition* area*
W2 No Corps 0.020
(404, 10) or D✓VR(401, (acres)
other)
2h. Comments:
Wetland impacts are limited to 0.02 acres of permanent impacts to an emergent wetland. The wetland will be filled
to allow for the grading for the required driveway, sidewalk, and stormwater basin. See avoidance and minimization
section for additional information on the wetland impact.
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 individually list
all open water impacts below.
4a. Site # - Reason for 4b. Impact type * 4c. Name of waterbody*
impact*
Pond Impact OW1 T OW1
Nbp label (e.g. Road Crossing 1) Fern -anent (F� or (if applicable)
Temporary (T)
4g. Total temporary open water Impacts:
0.01
4g. Total permanent open water impacts:
0.00
4g. Total open water impacts:
0.01
4d. Activity type * 4e. Waterbody type *4f. Impact
area
Fill Pond 0.01
(acres)
4h. Comments:
Open Water impacts will be limited to 0.01 acre of temporary impacts to allow for the installation of a new outlet
structure for the pond. All disturbed areas will be returned to original contour after installation of the outlet
structure is complete. The existing outlet is not functional and has been damaged since it was originally installed.
E. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*

While the project was being designed, NCDOT required that the entrance and driveway would need to access Old
St. Marks Church Road at the location depicted on the attached Site Exhibit. NCDOT also required that the
proposed access road be widened from the existing 10 -12 -foot width to 24 -feet wide, resulting in an increased
impact width and the need for additional grading. Due to the required location of the proposed driveway entrance,
impacts to either the open water pond or wetland W2 would be necessary. The project engineer designed the
improved access road to avoid additional impacts to the jurisdictional open water pond by shifting the grading
required for the voider access road east to impact W2, which results in a smaller impact due to the perpendicular
nature of W2. The proposed stormwater basin, which was required by the City of Burlington to comply Wth local
and state stormwater ordinances, was located in the southwestern location depicted on the attached Site Exhibit
due to required setbacks and in order to avoid more significant impacts to wetland W1 in the western portion of the
site. The grading for the embankment of the proposed stormwater basin is necessary to ensure the pond is built in
a stable, safe, and well -constructed manner. The City of Burlington has also required the installation of a sidewalk
along Old St. Marks Church Road, which also requires grading which will impact wetland W2. Appropriate sediment
and erosion control practices equaling those outlined in the most recent version of the "North Carolina Sediment
and Erosion Control Planning and Design Manual" will be used to minimize impacts to the open water pond.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Specific attention will be paid to ensure grading is only performed to the extent needed for the proposed project
and all grading not required will be avoided. Additional impacts to the pond will be avoided through the use of
appropriate sediment and erosion control devices.
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?
r Yes F No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
The project will impact less than 0.10 acres of wetlands.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
...................
*** Recent changes to the stormwater rules have required updates to this section .***
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection
Rules?
r Yes r No
For a list of options to meet the diffuse flow requirements, click here.
If no, explain why:
There are no buffered features on site as confirmed by NC DEQ in a Stream Determination Letter dated January 17, 2018.
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
r Yes r No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)?
r Yes
r No
To look up low density requirement click here 15A NCAC 02H .1003(2).
2c. Does this project have a stormwater management plan (SMP) reviewed and approved under a state stormwater program or state -
approved local government stormwater program?*
t: Yes
r No
Fint: projects that have vested rights, exemptions, or grandfathering from state or locally irrplerrented storrrvater prograrrs or projects that satisfy state or locally-inlAerrented storrrwater prograrrs
through use of comrunity in -lieu programs should answer no to this question.

2d. Which of the following stormwater management program(s) apply (check all that apply):*
rJ Local Government
F State
Local Government Stormwater Programs*
V Phase II
F- NSW
r- USMP
r Water Supply
Please identify which local government stormwater program you are using.*
City of Burlington
G. Supplementary Information
1. Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?*
r Yes r No
2. Violations (DWR Requirement)
2a. Is the site in violation of DWR Water Quality Certification Rules (15A NCAC 2H .0500), Isolated Wetland Rules (15A NCAC 2H .1300), or
DWR Surface Water or Wetland Standards or Riparian Buffer Rules (15A NCAC 2B .0200)? *
r Yes r No
2b. Is this an after -the -fact permit application?*
r Yes r No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in additional development, which could impact
nearby downstream water quality?*
r Yes F No
3b. If you answered "no," provide a short narrative description.
This project is a standalone project and no additional development is anticipated as a result of this project.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
r Yes r Nor N/A
4b. Describe, in detail, the treatment methods and dispositions (non -discharge or discharge) of wastewater generated from the
proposed project. If the wastewater will be treated at a treatment plant, list the capacity available at that plant.
Wastewater generated as a result of this project will be treated at the East Burlington Wastewater Treatment Plant
with a capacity of 12 million gallons per day (MGD) or the South Burlington Wastewater Treatment Plant with a
capacity of 12 MGD.
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or habitat?*
r Yes F No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*

O Yes r No
5c. If yes, indicate the USFWS Field Office you have contacted.
Raleigh
5d. Is another Federal agency involved?*
f Yes r No
5e. Is this a DOT project located within Division's 1-8?*
r Yes r No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?
r Yes r No
5g. Does this project involve bridge maintenance or removal?
r Yes r No
r Unknown
Link to the NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf
5h. Does this project involve the construction/installation of a wind turbine(s)?*
r Yes r No
51. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers,
mechanized pile drivers, etc.?
r Yes r No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
An official species list for any species which is listed or proposed to be listed which may be present in the area of
the proposed action was requested from the USFWS via their Information for Planning and Consultation (IPaC)
system. This species list did not identify any protected species which might be present within the area of the
proposed action. A search of the NC Natural Heritage Program (NCNHP) elemental occurrence database did not
identify any state or federally protected species within one mile of the project area. The Endangered Species,
Threatened Species, Federal Species of Concern, and Candidate Species List for Alamance County, NC identified
a single protected species within the county, the Cape Fear Shiner. According to the NC Wildlife Resources
Commission website (http://ncwildlife.org/Learning/Species/Fish/Cape-Fear-Shi ner#2513696-deta iled-information),
the Cape Fear Shiner is commonly found in shallow, rocky shoals within main river channels. In winter months,
these fish migrate into smaller tributary streams. While there is a pond on site, there is no stream flowing into or
out of the pond, making it unsuitable as habitat for the Cape Fear Shiner. There are no streams on site.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
f Yes r No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
The USFWS website hftp:wwv.fws.gov/Raleigh including IPaC, NC Natural Heritage Program's online database,
GIS data of Elemental Occurrences and Significant Natural Heritage Areas (March 2018) for the project area
downloaded from the North Carolina Center for Geographic Information and Analysis website, NCOneMap.com,
and the Essential Fish Habitat Mapper on the NOAA Habitat Conservation Website.
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to the State Historic Preservation Office Historic Properties Map (does not include archaeological data: http://gis.ncdcr.gov/hpovveb/
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 status (e.g., National Historic Trust designation or properties significant in North Carolina history and archaeology)?*
r Yes r No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*

Review of the historic properties on the North Carolina State Historic Preservation Office Geographic Information
Systems (GIS) Virtual Workroom (Http:Hgis.ncdcr.gov/hpovveb/) did not reveal any historic properties within the or
its immediate vicinity. See the attached NCSHPO historic resources summary for additional information on historic
resources identified within a one -mile search radius of the site.
7c. Historic or Prehistoric Information Upload
pick the upload button or drag and drop files here to attach docurrent
NCSHPO Historic Resource Summary.pdf
File crust be FDF
8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https://msc.fema.gov/portal/search
8a. Will this project occur in a FEMA -designated 100 -year floodplain?*
r Yes
C No
3.02MB
8c. What source(s) did you use to make the floodplain determination?*
Available FEMA mapping (Map Panels 3710885400K and 3710884400L, effective 11/17/17) and the Project
Engineer.
Miscellaneous
Miscellaneous attachments not previously requested.
pick the upload button or drag and drop files here to attach docurrent
NCNHP Report 5-24-18.pdf
Species List_ Raleigh Ecological Services Field Office.pdf
Calamar Burlington PJD Request.pdf
St Marks Church Rd - Calamar - Stream Determination Letter.pdf
2018.04.25--Calamar Burlington Water quality design.pdf
2018-04-25--Calamar Burlington Stormwater Management Plan.pdf
File crust be FDF or KW
Signature
W By checking the box and signing below, I certify that:
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■ I have given true, accurate, and complete information on this form;
■ I agree that submission of this PCN form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic
Transactions Act');
■ I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic
Transactions Act');
■ I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature; AND
■ I intend to electronically sign and submit the PCN form.
Full Name:*
Ashley Steele Bentz
Signature
Date Submitted:
6/7/2018
Initial Review

Is this project a public transportation project?*(?
r Yes r No
Change only it needed.
Has this project met the requirements for acceptance in to the review process?*
r Yes
r No
BIMS # Assigned *
20180794
Version#*
Reviewing Office*
Winston-Salem Regional Office - [phone]
Select Project Reviewer*
Sue Homewood:eads\slhomewood
Is a payment required for this project?*
r No payment required
f Fee received
C Fee needed - send electronic notification