20181066 Ver 1_401 Application_20180802

DWR
Division 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.govMaterResources/0/edocl6247041PCN%20Help%20File%202018-1-30.pdf
A. Processing Information
County (or Counties) where the project is located:*
Forsyth
Is this project a public transportation project?*
f Yes f• No
This is any publicly funded by nunicipal,state or federal funds road, rail, airport transportation project.
1a. Type (s) of approval sought from the Corps:*
V Section 404 Permit (wetlands, streams and waters, Clean Water Act)
F Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
1b. What type(s) of permit(s) do you wish to seek authorization?*
IJ 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: 29 - Residential Developments
NWP Number Other:
List all IWV nurrbers you are applying for not on the drop down list.
1c. Type(s) of approval sought from the DWR:*
check all that apply
IJ 401 Water Quality Certification - Regular r 401 Water Quality Certification - Express
F Non -404 Jurisdictional General Permit r Riparian Buffer Authorization
r Individual Permit
*
1d. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification:
r Yes C No
For the record only for Corps Permit: C Yes O No

1e. 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
f Yes C No
1f. Is the project located in anyof NC's twentycoastal counties?*
r Yes C No
1h. Is the project located in a designated trout watershed?*
f Yes f• No
Link to trout information: http://vmw.saw.usace.army.mil/Missions/Regulatory-Permit-ProgranVAgency-Coordination/Trout.aspx
B. Applicant Information
1a. Who is the Primary Contact?*
Philip May
1b. Primary Contact Email:*
[e-mail]
1c. Primary Contact Phone:*
(XXX)XXX-XXXX
[phone]
1d. Who is applying for the permit?
❑ Owner r Applicant (other than owner) rJ Agent/Consultant
(Check all that apply)
2. Owner Information
2a. Name(s) on recorded deed:
806 GIBB STREET LLC
2b. Deed book and page no.:
DB 003395, Deed Pages 03020,25,30,35,40,45,48
2c. Responsible party:
(for Corporations)
Justin Mendenhall
2d. Address
Street Address
11 Brookstown Avenue
Address Line 2
city
Winston Salem
Postal / Zip Code
27101
2e. Telephone Number:
(XXX)XXX-XXXX
[phone]
2f. Fax Number:
(XXX)XXX-)O=
2g. Email Address:*
[e-mail]
4. Agent/Consultant (if applicable)
4a. Name:
State/ Province/ Fbgion
NC
Country
USA

Philip May
4b. Business Name:
(if applicable)
Carolina Ecosystems, Inc.
4c. Address
Street Address
P.O. Box 41
Address Line 2
City
Lewisville
Postal / Zip Code
27023
4d. Telephone Number:
[phone]
(xxx)xxx-xxxx
4e. Fax Number:
(XXX)XXX-)O=
4f. Email Address:*
[e-mail]
State/ Province/ Region
NC
Country
USA
Agent Authorization Letter*
Pease provide the Agent Authorization Letter if you are submitting this docurrent.
PheasantRidge-AgAuth.pdf 571.72KB
FILE TYP= M -ST BE PDF
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Pheasant Ridge
1b. Subdivision name:
(if appropriate)
Pheasant Ridge
1c. Nearest municipality / town:
*
Winston Salem
1d. Driving directions*
It it is a new project and can not easily be found in a GPS crapping system Pease provide directions.
From downtown Winston Salem, take Reynolda Road northwest, turn left onto Robinhood Road. Approximately a quarter mile after passing
Shattalon Drive, take a left onto Gibb Street.
2. Project Identification
2a. Property Identification Number:
(tax PN or parcel ID)
6806-55-5433.00, 6806-55-5323.00, 6806-54-4996.00, 6806-64-0893.00,
6806-55-7293.00, 6806-55-9337.00, 6806-55-8602.00
2b. Property size:
(in acres)
19.37
2c. Project Address

Street Address
800 Gibb Street
Address Line 2
City
State/ Province/ Region
Winston Salem
NC
Postal / Zip Code
Country
27106
USA
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 how the 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:* Longitude:*
36.119240 -80.334008
ex: 34.208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
UT to Muddy Creek
3b. Water Resources Classification of nearest receiving water:*
C
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Yadkin-PeeDee
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:*
Existing site conditions include pasture, forest areas, and light residential development. The project vicinity is
generally residential and forest.
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)
(]ick the upload button or drag and drop files here to attach docurrent
PheasantRidge_Fig1_USGS.pdf 1.85MB
File type rrust be pdf
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)
Gick the upload button or drag and drop files here to attach docunent
PheasantRidge_Fig2_NRCS.pdf 5.24MB
File type mist be pdf
4d. List the total estimated acreage of all existing wetlands on the property:
<0.01 - one small wetland adjacent to existing sewer line
4e. List the total estimated linear feet of all existing streams on the property:
(intermittent and perennial)
895 - Streams SA (320' per) and SB (575 int & per)
4f. Explain the purpose of the proposed project:*
To provide single family residential housing in close proximity to major commercial and transportation routes within
the Winston Salem city limits.

4g. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:
Standard construction equipment will be used to clear and grade the portions of the site to be developed. Erosion
and sediment control measures will be installed. The proposed culvert will be built in the dry using temporary coffer
dams and a bypass pipe to maintain downstream flows.
4h. Please upload project drawings for the proposed project.
nick the upload button or drag and drop files here to attach docurreN
Pheasant Ridge Plans.pdf 1.54MB
File type mast be pdf
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
r Yes r No r Unknown
Comments:
Prelim JD Request attached to this application
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
r Preliminary r Approved C Unknown r N/A
Corps AID Number:
Exanple: SAW -2017-99999
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Other:
Philip May
Carolina Ecosystems, Inc.
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5dl. Jurisdictional determination upload
Click the upload button or drag and drop files here to attach docurrent
Pheasant Ridge PJD Form.pdf 112.91 KB
PhesantRidge_Forms.pdf 5.04MB
Pheasant Ridge Creek Crossing Overall Exhibit_PJD Labels.pdf 786.27KB
File type mast 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 r No r Unknown
7. Future Project Plans
7a. Is this a phased project?*
r Yes r 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 permits are used or intended to be used for this project.
D. Proposed Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):

❑ Wetlands V Streams -tributaries ❑ Buffers
❑ Open Waters r- Pond Construction
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. Reason for impact*3b.lmpact 3c. Type of impact *3d. Stream name* 3e. Stream 3f. Type of 3g. Stream 3h. Impact
type* Type* Jurisdiction* width* length*
S1 Road Crossing P Culvert SA (UT M uddy Cr) Perennial Both 5 106
Nbp label (e.g. Road Grossing Fern -anent (P) or Perennial (FEP� or Average (linear feet)
1) Tenporary (T) intermittent (INT) (feet)
S2 Road Crossing T Bank SA (UT M uddy Cr) Perennial Both
Nbp label (e.g. Road Grossing F2rrranent (F� or Stabilization Fbrennial (F6:� or
1) Temporary (T) intermttent (INT)
* Al Perennial or Intermittent streams must be verified by DWR or delegated local government.
3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
106
3i. Total temporary stream impacts:
42
31. Total stream and tributary impacts:
148
3j. Comments:
Perpendicular crossing of stream SA avoiding "s" curve. Temporary impacts include stabilization after construction
and coffer dam dewatering during construction.
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:*
A small tributary stream (intermittent and perennial) beginning near the eastern side of the property has been
avoided by realigning the road to the north and using a retaining wall at the cost of several potential lots. The only
proposed stream crossing has been minimized as much as practicable while maintaining required slope on the
roadway, and has also been shifted away from a distinct "s" curve in the channel to avoid additional stream impact
and the only wetland on site. Utilities will be located within proposed roads including at the stream crossing.
5 42 2
Average (linear feet) 1
(fes) n
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Erosion control measures in compliance with North Carolina regulations will be installed and maintained on the site
during construction. The stream crossing will be built using coffer dams and a bypass pipe as shown in the
attached plans.
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?
f Yes C No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
Stream impacts are under 150 linear feet. Owner has made expenditures (including retaining wall and loss of lot potential with road
realignment) to avoid stream SB channel.
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?
f Yes r No
For a list of options to meet the diffuse flow requirements, click here.
If no, explain why:
Yadkin River basin does not have riparian buffer rules.
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?*
r Yes
G No
Hnt: projects that have vested rights, exemptions, or grandfathering from state or locally implerremted storrrwater programs or projects that satisfy state or locally-irrplerrented storrrwater programs
through use of corrrrunity in -lieu prograrrs 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*
fJ Phase II
r- NSW
r- USMP
r Water Supply
Please identifywhich local government stormwater program you are using.*
Winston Salem
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)?*
f Yes r No
2b. Is this an after -the -fact permit application?*
f 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?*
f Yes r No
3b. If you answered "no," provide a short narrative description.
The surrounding area is already relatively built out with residential and commercial development.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
r Yes f 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.
Sewage will be transported through an existing sewer line on site to the Winston-Salem Muddy Creek Plant.
Adequate capacity has been confirmed with the City.
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 r No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
f• Yes r No
5c. If yes, indicate the USFWS Field Office you have contacted.
Asheville
5d. Is another Federal agency involved?*
r Yes C No r Unknown
5e. Is this a DOT project located within Division's 1-8?*
r Yes C No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?
6 Yes r No
5g. Does this project involve bridge maintenance or removal?
r Yes f• No
Link to the NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-31}17-signed_NLEB-SLOPES&apps.pdf
5h. Does this project involve the construction/installation of a wind turbine(s)?*
r Yes r No
5i. 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 C No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
Current Natural Heritage Program Element Occurrence data, reviewof site habitats, and review of USFWS
Asheville office guidance and GIS data on location of known northern long-eared bat.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
r Yes r No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
NOAA EFH Mapper

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/hpoweb/
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)?*
f Yes r No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
NCHPO HPOWeb Mapping Program.
7c. Historic or Prehistoric Information Upload
Click the upload button or drag and drop files here to attach docurent
PheasantRidge_HPOWeb_080118.pdf 360.52KB
File rust 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 FEMXdesignated 100 -year floodplain?*
f Yes r No
8c. What source(s) did you use to make the floodplain determination?*
NC Flood Mapping Program
Miscellaneous
Miscellaneous attachments not previously requested.
Click the upload button or drag and drop files here to attach docurent
File rust be FDF or KNE
Signature
V By checking the box and signing below, I certify that:
■ 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:*
Philip May
Signature
c`clya
Date Submitted:
8/2/2018
Initial Review
Is this project a public transportation project?*(?)
f Yes r No
Change only if needed.

Has this project met the requirements for acceptance in to the review process?*
f• Yes
r No
BIMS # Assigned
20181066
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
f Fee needed - send electronic notification

CAROLINA
ECOSYSTEMS, INC.
PROPERTY ACCESS AND AGENT AUTHORIZATION FORM
Property Information
PO Box 41; Lewisville, NC 27023
P:919-6064065 — 17:919-585-5570
Property Address
and/or Description Gibb Street — Pheasant Ridge development
Parcel Identification
Number(s) (PIN) 6806640893000, 6806544996000, 6806555323000, 6806555433000, 6806558602000,
6806559337000
City: Winston Salem State: NC County
Property Owner Information
Owner: ® Authorized Agent*: ❑
Name: 806 Gibb Street LLC —NAME
Title:
TITLE
Street Address:
11 Brookstown Avenue
City: Winston Salem
Forsyth Property Size (Acres)
State: NC
*Written proof of authorization from owner required.
Authorization
Zip Code:27101
19.4
1, the undersigned, a duly authorized owner of record of the property/properties identified herein, do authorize
representatives of the Wihnington District, U.S. Arany Corps of Engineers (Corps) to enter upon the property herein
described for the purpose of conducting on-site investigations and issuing a determination associated with Waters of the
U.S. subject to Federal jurisdiction under Section 404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors
Act of 1899.
Additionally, I hereby grant Carolina Ecosystems, Inc. (CEI) staff, their designated contractors and representatives, as
well as other Federal, State or local authorities access to the above referenced property when necessary for the proposes of
conducting on-site environmental consulting services. I also grant CEI the authority to act as authorized agent on behalf of
the owner of the above listed property for the communication, submission, and/or application to relevant government
entities, including local, state, and federal authorities, for the review, acceptance, concurrence, and/or approval of
environmental information, documents, and/or pen -nit requests concerning the above listed property. These services may
include regulatory determinations of environmental features on my property such as issuing a determination associated
with streams and wetlands. I certify that I am the legal owner or authorized agent of the legal owner of the above property
and have authority to grant such access. I have made CEI aware of, and supplied all available records related to, previous
environmental investigations on the subject property of which I have knowledge.
Owner/Agent
(signature)

CAROLINA PO Box 41; Lewisville, NC 27023
ECOSYSTEMS, INC. P:919-6064065 — F:919-585-5570

August 2018 Figure 1: USGS Map
Pheasant RidgeForsyth Countyy, NC
0 1,000500Feet³Rural Hall and Winston Salem West (2013)USGS 1:24K Quadrangle Map
Study Area
State of North Carolina DOT, Esri, HERE, Garmin, INCREMENT P, NGA, USGS
GIBB STREETlineback av
e
n
u
e
SAMUEL WOODS RUNGILBERT CREEK DRIVEBEULAH VIEW DRIVE
lineback avenueMONROE FLATS DRIVElineback avenue
ROBI
N
H
OOD R
OAD
P OW ELLMARTINDAVIS
E N G I N E E R S & S U R V E Y O R S
6415 OLD PLANK RD, HIGH POINT, NC 27265
[phone] | WWW.DMP-INC.COM | LICENSE: F-0245
PHEASANT RIDGE SUBDIVISION
lINEBACK AVENUE OVERALL CREEK CROSSING
IMPACT MAP
WINSTON TOWNSHIP, FORSYTH COUNTY
WINSTON SALEM, NORTH CAROLINA
August 2018 Figure 2: NRCS Map
Pheasant RidgeForsyth County, NC
0 400200Feet³Forsyth County NRCS Soil SurveyMaps 22 and 29
Study Area