20180862 Ver 1_401 Application_20180621

Water Rcsuurcc,
Em u'uumcnml [lu:dm
����od��
����� G 1 ����8
�ENk.WqTERRE$pURCES
TRANSPORTATICIN GERMI7TING UNR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02H .0506�b)�4) Water Quality Certifitation,
Notification of Work in Trout Watersheds
FORM: TroutW511-2017
Notification of Work in Trout Watersheds Form
A. Applicant Information
1. Processing
1a. Specify Nationwide Permit (NWP) number: � or General Permit (GP) numbe :
16. Has the NWP or GP number been verified by the Corps? Yes ❑ No
1c. Does the project meet all the Conditions of the applicable Water Quality ��
Certifica[ion Yes � No
Please note that your project may be subject to the Sediment and Erosion Control Program andlor Trout Buffers
implemented by the Division of Energy, Mineral, and Land Resources. Find more info at:
https:/ldeq.nc.gov/abo uGdivisions/energy-mineral-la n d-resources/erosion-sediment-control
2. Project Information
2a. Name of project:
2b. County:
2c. Nearest municipality / town:
3. Owner Information
3a. Name(s) on Recorded Deed:
3b. Responsible Party (for LLC if
3c. Street address:
3d. City, state, zip:
3e. Telephone no.: �
3f. Email address: �-1
4. Agent/Consultant Information (if
4a. Name: �"
46. Business name
,;
7
4c. Telephone no.: S � S_
4d_ Emailaddress: ^m�/an ��d
B. Project Information
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID)
7
�' `, �: „ �� � � _
il�./�zE� '�
�LI %— �' C � �iC �
F ,, u; .,
� � l � l,�
' `���5-�{/�)>�- '�� �''' ��-� )�
�
' �=��5!`[17// ��="�
`'��-� ���> � � rnan�l�a ��,
1 b. Site coordinates (in decimal degrees): -� � � Latitude:
"�� l��i��� �_�'� �. .-ll'o[
2. Pro�ect Descnption
2a. Explain the purpose of the proposed project �cont�nue on back):
2. f� � � r- N,
�
Longitude: -

2b. Describe the overall project in detail, including the rype of equipment to be used:
�e�pr� �r � 1�bo � I�,�oS i n, r� s 1 a p�-, m� ��' n�
� e S s-�l� �� � o ��'-� . � k�- h d�
C. Stream Impacts: Please Ifst all proposed impaets to the stream
1a. Stream Name:
1b.
1 c.
Type of impact
Bank Stabilization - Sloping and Revegetating
ank Stabilization - Sloping and Riprap/Armoring
Bank Stabiliza6on - Gabion Baskets / Retaining Wall
Culvert Installation Culvert Diameter:
Temporery Impacts for required dewatering activities
Other(describe):
/�6N9 �1 / �/� f � I �
Owner/AgenPs Printed Name
Average stream
width (linear feet)
��1�,1�n�,��
,-" -
ner AgenY Sig a re
(AgenPs signature ia valid only H an authorization letter from the owner is
0
Impad length
(linear feet)
6�y ��
Date

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 6/21/2018 2:38:22 PM (Message Start Event)
Accept by Carpenter,Kristi 6/21/2018 2:40:13 PM (DOT project)
. The task was assigned to Carpenter,Kristi. The due date is: June 26, 2018 5:00 PM
6/21 /2018 2:38 PM

Staff Review
i�#*
20180862
Version* �
Is this project a public transportation project? *
Is this a DOT F Yes f No
project?*
Reviewer List:*
Select Reviewing Office:*
Submittal Type:*
401 Application
C•' Yes
�' No
Dave Wanucha:eads\djwanucha
Winston-Salem Regional Office - [phone]
Does this project require a request for payment to be sent? *
r
Yes
r•
No
Water Resources
ENVIRONMENTAL �UPLITV

Project Submittal Dated 6/21/2018
*
Please note: fields marked with a red asterisk beloware required. You will not be able to submit the form until all
mandatory questions are ans�red.
Project Type:* �' New Project
C' Pre-Application Submittal
C' More Information Response
r Other Agency Comments
l•' For the Record Only (Courtesy Copy)
New Project - Please check the new project type if you are trying to submit a new project that needs an official approval
decision.
Pre-Application Submittal - Please check the pre-application submittal if you just want feedback on your submittal and
do not have the e�ectation that your submittal will be considered a complete application requiring a formal decision.
More Information Response - Please check this type if you are responding to a request for information from staff and
you have and ID# and version for this response.
Other Agency Comments - Please check this if you are submitting comments on an ebsting project.
Project Contact Information
Name: Kristi Lynn Carpenter for Amanda Jones
Who is subrritting the irrforrration?
Email Address:* [e-mail]
Project Information
Project Name:* Henson Creek Bank Stabilization
Is this a public transportation project? *
C•' Yes
C' No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?*
C' Ye�" No �' Unknown
TI P#: WBS#:
(Applies to DOT projects only)
County (ies) *
Avery
Please upload all files that need to be submited.
Qick the upload button or drag and drop files here to attach docurrent
Henson Creek Bank Stabilization.pdf 617.75KB
Only pdf or Ivre files are accepted.
Describe the attachments:
Original is paper.
* rJ By checking the box and signing box below, I certify that:
o I have given true, accurate, and complete information on this form;
o I agree that submission of this form is a"transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the

"Uniform Electronic Transactions AcY')
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions AcY');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the online form."
Signature:
f� �/tr �j�'N �' }� �f-r�trf
Submittal Date: