20050808 Ver 1_COMPLETE FILE_20050509

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Michael F. Easley, Governor
William G. Ross, Jr., Secretary
Alan W. Klimek, P.E., Director
May 25, 2005
CERTIFIED MAIL
DWQ #: 05-0808
Louise Walker
515 Gash Road
Horse Shoe, NC 28742
t
Dear Ms. Walker:
On 5/9/05, the Division of Water Quality received your application for a 401 Certification in
Henderson County, North Carolina. Please note that beginning January 1, 1999, the N.C. General
Assembly passed legislation requiring payment of a fee for all 401 applications. Your
application is being placed on hold since no payment was received with the package. The fee for
applications is $200 for projects impacting less than an acre of wetland and less than 150 linear
feet of streams. For projects impacting one or more acres of wetland or 150 or more feet of
streams, the fee is $475. In order for DWQ to begin review and process your request, you must
send a check in the appropriate amount made payable to the N.C. Division of Water Quality. You
may attach payment to this letter and return both at your earliest convenience. Please reference
the DWQ project number noted above in all future correspondence.
If you have any questions regarding this letter please do not hesitate to call me at (919)-733-
1786.
Sincerely,
&4-AAL`' Cyndi Karoly
CC: Central Files
PAX'
Wetlands/401 Unit
1650 Mail Service Center, Raleigh, North Carolina 27699-1650 One
2321 Crabtree Boulevard, Suite 250, Raleigh, North Carolina 27604 NofthCarolina
Phone:, 919-733-1786 FAX [phone] / Internet: http:/,h2o.enr.state.nc.us%ncwetlands ,lVaturally

Subject: Re: Withdrawal Letters
From: Kevin Barnett <[e-mail]>
Date: Tue, 06 Jun 2006 15:38:20 -0400
To: Bev Strickland <[e-mail]>
Hi Bev:
20050808, 20041887, and 20041888 were all returned as incomplete.
Thanks,
Kevin
Bev Strickland wrote:
Attached is a list of projects that have been in the on hold drawer for over 3 months. Please review this
spread sheet to see if you have received more information or have sent out a request for additional
information that would keep these projects on hold.
The files I am proposing to withdraw, do not have a letter requesting us to keep the project on hold from the
applicant and I have no copies of additional information requested from the Regional offices. If I do not hear
from you by the end of the week about these projects, I will assume they can be withdrawn and withdrawal
letters will be sent out on these projects.
Please let me know if you have any concerns or questions about any of these projects by June 9, 2006.
Thanks
Bev
Kevin Barnett - [e-mail]
North Carolina Dept. of Environment and Natural Resources
Asheville Regional Office
Division of Water Quality - Water Quality Section
2090 U.S. 70 Highway
Swannanoa, NC 28778
Tel: [phone]
Fax: [phone]
......... _ ..... ....._.
Kevin Barnett <[e-mail]>
NC DF.NR - Asheville Regional Office
Division of Water Quality - Water Quality Section
...... ..... . ......._..._.......... ..._...__..._......._....................._......_.. .......... ......................... ............ ......_.................... _..__..._
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MAY 9 2005
DENR - wAtER QUALITY
WETLANDS AND STORMWATER BRANCH
f f? '

0Spe0a
Pre-Construction Notification (PCN) Application Form
?yF
t .?
? -i
For Section 404 and/or Section 10 Nationwide, Regional and General Permits, Section 401
General Water Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This form is to be used for projects qualifying for any of the U.S. Army Corps of Engineers' (USACE)
Nationwide, Regional or General Permits as required by Section 404 of the Clean Water Act and/or
Section 10 of the Rivers and Harbors Act, and for the North Carolina Division of Water Quality's
(DWQ) associated General 401 Water Quality Certifications. This form is also to be used for any
project requiring approval under any Riparian Buffer Rules implemented by the N.C. Division of Water
Quality. This form should not be used if you are requesting an Individual 404 Permit ("IP") or
Individual 401 Water Quality Certification. The USACE Individual Permit application form is available
online at http://www.saw.usace.arnv.miI/wetlandsiPerin app htm.
The USACE is the lead regulatory agency. To review the requirements for the use of Nationwide,
Regional or General permits, and to determine which pen-nit applies to your project, please go to the
USACE website at http://wivw.saw usace ar-mv.mil/wetlands/reqtour.htm, or contact one of the field
offices listed on page 3 of this application. The website also lists the responsible project manager for
each county in North Carolina and provides additional information regarding the identification and
regulation of wetlands and waters of the U.S.
The DWQ issues a corresponding Certification (General or Individual), and cannot tell the applicant
which 401 Certification will apply until the 404 Permit type has been determined by the USACE.
Applicants are encouraged to visit DWQ's 401/Wetlands Unit webs ite at
http://h2o.enr.state.ne.us/ncwettands to read about current requirements for the 401 Water Quality
Certification Program and to determine whether or not Riparian Buffer Rules are applicable. The
applicant is also advised to read the full text of the General Certification (GC) matching the specific 404
Permit requested. In some cases, written approval for General Certifications is not required, provided
that the applicant adheres to all conditions of the GC. Applicants lacking access to the internet should
contact DWQ's Central Office in Raleigh at [phone].
Trout Waters Coordination - Special coordination with the North Carolina Wildlife Resources
Commission (NCWRC) is required for projects occurring in any of North Carolina's twenty-five
counties that contain trout waters. In such cases, the applicant should contact the appropriate NCWRC
regional coordinator (listed by county on page 4 of this application) prior to submittal of the application.
Page 1 of 12
L
-??s..-??t _'?'... i 1,15 -.?•i y* r - tn` ?:e,._ ,.. cccjr-• 1 n v -,,?-Nonh CarolIr,a
t_i•V.:1`_?a
pr:
. `
..
_:._. cons ., c;,,:.-..es (listed c^ - e acciican_ s ouic contact the `orth Carolina Division of
C: y. `?la.- _ •_ DC`.C; Ctr ?.i1 det_.::in :?i:et - cr sot -117.2 project is within. a desi?z^ated
°a = con ce.__. in . c c??e DCM iii act as tl:e lead perinitting ageney. In such
zaseS. DCNI will r cairn a CA_1La ?e._:.it and will coordinate t e 4C4-`401 Permits.
ci:cac_t pray also chccse to cocrdinate with rise U^.ited Stases Fish and Wildlife Service to ensure
:_.__ ^pesed prof wi11 nave no impact upon arv endar.-7 .ed or threatened species or critical
c.:a: as re_ la_ed b . Endan_ .ed Species Act. and the State Historic Preservation Office, North
C:yoi^a Depa..:e_nt of Cult::.-al Resources to ensure that the proposed project will have no impact upon
an properties listed or e1121ble for lis:ir_g or. tl:e National Register of Historic Places. Compliance with
° ons, is required to be ee _or any Department of the Arm, y permit. The addresses for
?e agencies are listed on page - of this application.
USACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms,
photos. etc. to t<he applicable USACE Regulatory Field Office. Upon receipt of an application, the
US ACE will determine if the application is complete as soon as possible, not to exceed 30 days. This
PC` form is designed for ,he convenience of the applicant to address information needs for all USACE
N--:ior-:wide, Regional or Gene al permits, as well as information required for State authorizations,
cord:::cations, and coordination. Fully providing the information requested on this form will result in a
complete application for any of the USACE -Nationwide, Regional or General permits. To review the
minimum amount of information that must be provided for a complete PCN for each USACE
-Nationwide permit, see Condition 13, 65 Fed. Reg. 12893 (March 9, 2000), available at
-0: "w1 by permit and
"v.saw.usace.armv.miL,wetlands/nwofinalFedReg.pdi. Processing times vary
Gegin. once t; e application has been determined to be complete. Please contact the appropriate
re?uia*.ory Held once for specific answers to permit processing periods.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise
stated as optional. Incomplete applications will be returned. Submit five collated copies of all USACE
Permit materials to the Division of Water Quality, 401/Wetlands Unit, 1650 Mail Service Center,
Raleigh, NC, 27699-16.0. If written approval is required or specifically requested for a 401
Certification, then a non-refiindable application fee is required. In brief, if project impacts include less
than one acre of cumulative wetland water impacts and less than 150 feet cumulative impacts to
streams, then a fee of S200 is required. If either of these thresholds is exceeded, then a fee of S475 is
required. A check made out to the North Carolina Division of Water Quality, with the specific name of
the project or applicant identified, should be attached to the front of the application package. For more
information, see the DWQ website at http://h2o.enr.state.nc.us/newettands/fees.htmi. The fee must
be attached with the application unless the applicant is a federal agency in which case the check may be
issued from a separate office. In such cases, the project must be identifiable on the U.S. Treasury check
so t..at it can be credited to the appropriate project. If written approval is sought solely for Buffer Rules,
.h- application fee dces not apply, and the applicant should clearly state (in a cover letter) that only
Buf_er Rule approval is sought in writing. Wetlands or waters of the U.S. may not be impacted prior to
issuance or waiver of a Section 401 Water Quality Certification. Upon receipt of a complete application
for a 401 Certification, the Division of Water Quality has 60 days to prepare a written response to the
applicant. This may include a 401 Certification, an on-hold letter pending receipt of additional
ecuested information, or denial.
PaQc 2 of 12
US Army Corps Of Engineers Field Offices and County Coverage
sheville Regulatory Field Office

S Army Corps of Engineers Alexander Caldwell Havwood McDowell Swain

51 Patton Avenue
rto
[ Alleehany

Ash
Catawba
Henderson
Mecklenburg Trans
lvania
oom
208 e
Avery Cherokee
Cl Iredell y
Mitchell Union
Asheville,
NC 23301-5006
Telephone: C
( ) 271-7980
Buncombe ay
Cleveland Jackson
Lincoln Polk Watauga
Rowan Yancey

Fax: [phone] Burke

Caba Gaston Macon
Rutherford -
rrus Graham Madison Stanlev
Raleigh Regulatory Field Office
US Army Corps Of Engineers Alamance Franklin Nash
Su
v

6508 Falls of the Neuse Road Caswell Forsyth n
Northampton Vance

Suite 120 Chatham Granville Orange
Wake

Raleigh, NC 27615 Davidson
Davi Guilford Person Warren

Telephone: [phone] e

Du
h
Halifax
Randolph
Wilkes

Fax: [phone] r
am Johnston Rockingham Wilson
Edgecombe Lee
Stokes
Yadkin
Washington Regulatory Field Office
US Army Corps Of En
ineers Beaufort Currituck Jones
Pitt
g
Post Office Box 1000 Bertie
Camden Dare
Gat Lenoir Tyrrell
Washington, NC 27889-1000
Carteret* es
Gr Martin Washington
Telephone: [phone]

F
Chowan een
Hertford Pamlico
Pas
uotank Wayne
ax: [phone] Craven
Hyde q
Perquimans
*Croatan National Forest Only
Wilmington Regulatory Field Office
US Army Corps Of Engineers Anson Duplin Onslow

Post Office Box 1890 Bladen Harnett Perder

Wilmington, NC 28402-1890 Brunswick

Cart Hoke
Richmond

Telephone: [phone] eret
Columbus Montgomery
M Robeson

Fax: [phone]
Cumberland oore
New Hanover Sampson
Scotland
(n North Carolina State Age ncies
ivision of Water Quality
01 Wetlands Unit Division of Water
Quality
State Historic Preservation Office

650 Mail Service Center Wetlands Restoration Program Department Of Cultural Resources

aleigh, NC 27699-1650
[ 1619 Mail Service Center
Raleigh
NC 27699-1619 4617 Mail Service Center
clephone: [phone] ,
Telephone: [phone] Raleigh, NC 7699-4617
Fa
x:[phone]
Fax: [phone] Telephone: [phone]
Fax: [phone]
US Fish and Wildlife Service / National Marine Fisheries Service
US Fish and Wildlife Service
Rale
igh Field Office US Fish and Wildlife Service
National Marine Fisheries Service

Post Office Box 33726 Asheville Field Office

160 Zillicoa Street
Habitat Conservation Division

Raleigh, NC 27636-3726
Telephone: [phone]
Asheville, NC 28801 Pivers Island

Beaufort, NC 8516
?
Telephone: [phone] Telephone: [phone]
Pagc 3 of 12
CA MA and NC Coastal Counties
i:: cn C' Coastal NIuna ..._nt

- Bea ;crt Cho.van
Henford
Pasquotank
5: N[-;
, 711 1c- Cen .er Berne Craven H de Pender
Rd:ei_^L NC _7699-16- 3 Bour.swick Cur:ituck New Hanov:r Pe:auimans
_. ?•.--! :?) C-,Mcen Dare Onsic•.v T,,Tretl
".• -y Fy? ----F;9; Cara.-. Cats Pamlico Washington
NCWRC and NC Trout Counties
LG"-?s-, r ?iec wort R=Ton Cocrdinato, ai'??han. Caldwell atauo
_a
W

isle..,:d-toad
Asne
Mitchell _
Wilkes
tee.. ors: iFle. \C '7?3Y-9F30 r: Stokes
?r oro: ( ?o) 7t 9- Y= 3 Burke
Sum.

`•Icl;-=n Region Coordinator B"Mcomhe Henderson Polk
2G330 Mtn. Cherckce Jackson Rutherford
?.4 a:' ;?j11F:e, \C ?S" ?o CI3•: Macon Swain
Te =,hone: (181-3) 4621_25546 Graham Madison Transvlvania
ax: (323) ;52-777'- Hay .voed McDowell Yancey
APPLICATION FORM BEGINS ON PAGE S. PLEASE DO NOT SUBMIT PAGES 1- 4.
PaQc -1 of 12
C
P@[2ud_9=1p
Form Version Febniall X04
DEAIR - WATER QUALITY
,USAGE :action ID No. WETLAN MDSTORMWATERBRA14CH 0 5 0808
DWQ No. (If anv particular item is rot aopiicable to this project, please enter "Not :applicable" or " N A".l
vttice Lse Only:
I.
II
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:
I 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 Ecosystem Enhancement Program (NCEEP) is proposed
for mitigation of impacts (verify availability with NCEEP 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: ?
Applicant Information
O Owner/Appl* ant Information
Name:
Mailing A dress:
Telephone Number: 2 - Fax Number:
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:
Company Affiliation:
Mailing Address:
I elephone Number: Fax Number:
E-mail Address:
Page 5 of 12
III. Project Information
vicinit .:nap clea . e iccaticn c_ ...e ^roce- with resnzct co fccli
:.r=_s sLCd as towr,
.: %,e.s. and reads. Also provide a detailed site plan sho v r:_Q property
.
bc,_,nda._,-s and d2 elopm-_ t plans ?i r°lat:C% :o surrcundtng properties Both the Vict,^.ttV map
?nC SL? Jtr.. rr ar'ow. T;_e _peClitC foot-;,rints of all buildirt_s.
_7er;;C_ 3 =L' Cr Jt e, i«iS: -luO.-d. I' rOSSibie. the maps and plans should
i c:' de -•= appropriate USGS Topozrac;.ic Quad Map and MRCS Soil Survey with the property
be'wndaries outlined. Pla : drativi tgs.or other macs may be included at the applicant's discretion.
so Ions 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;
nowever. DNVQ may accept pipe, ,cork of any size. DWQ prefers full-size construction
drawin°'s tvu er tan a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small seal- suc that the final version is ille-2ible, the applicant will be infor-ned that
?
the project as been placed on hold until decipherable maps are provided.
I. Name of project:
?. T.I.P. Project \umber, `CNL-k or State Project ,umber (NCDOT Only):
3. Proper ; Identification \umber (Tax PIN):
l' Location
Cour. y: i 1 1)
, . Nearest Town RV
Subdivision name (include phase.'lot number):
Directions to site (include road numbers, landmarks, ^etc.)
_Y i
r ')
J
13
?. Site coordinates (Lat/Lona; D;%L S format):.? S Qa,,
(Note - If project is linear, suer. as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
Property size (acres):
D Nearest body of water (stream 'riverrsoundr'ocean/la'.ce):
`J
8. River Basin:
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at hrpa.'h?o.enr.state.nc.usiadmin,'maps%.)
Q9 Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: ? r,,,_L
Pa,e 6 0` t2
IV.
V.
VI.
10. Describe the overall proje
Explain the purpose o
Prior Project History
tail, including the type of equipment to be used:
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.
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.
Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agents) 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.
Page 7 of 12
1. =o`;:de 1 «'=-: CeSCr ?i Cn of the proposed impacts:
:d1:-:da-,- lly lest w_t.`a...^_;
t. Impacts be low:
G"e.==rd =r "-res at Located within Distance to
Sit= \-,.:m her T`.-e of I pact' i. cact 100-year Flccdplain** Nearest Stream I Type of Wetland***
l:r.. icat- on trap) (acres) (ves'no) (linear feet)
List the total acreage (estimated) of all existing wetlands on the property:
Total area of wetland impact proposed:
I InclMdually list all intermittent and perennial stream impacts below:
Stream Imnact Ler: th of I Average Width j Perennial or
Site Number i Type of Impact- ; Impact I Stream Name** of Stream I Intermittent?
(indicate on man) (linear feet) i Before Impact I (please specify)
' List each t:rpact seaara-:Iy a.. .dentif t. perar: impacts. Impacts include, but are not limited to: culverts and associated rip-rap.
darts (separately list impacts due to both stn:cture and Hooding), relocation (include linear feet before and after, and net loss/gain).
st.:biliz:tion activiries (cement wall. rip-ran, crib wall, eabions. VC.), excavation, ditchingistraightening, etc. If stream relocation is
Proposed, plans and profiles show;rg the linear icotcrint for both the original and relocated streams must be included.
Str: a rames c-, be ;curd or. CSGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
-S.._aa .._..._? st.,._... i;ao ..rich a t:o:vs" USGS maps are available threw=h the USGS at 1-300-353-9616, or online at
Several in:e; :et sites also allovv direct download and printing of C:SGS maps (e.g., www.topozone.com,
Curnulatlvze impacts (linear distance in feet) to all streams on site:
Page 8 of 12
?.?• per.: scPWU,:eiv are :c_nnr to Perm impacts. Impacts include, but are rot limited to: mechanized clearing, grading, fill.
es a on t:cccsa -.. - , For cars, separteiy list impacts due to boll structure and flooding.
ICGF= r ."ocd r._ ,....:'-
.?..:_..... rl:e Federal Emeraencv Manazemert .-agency's (FE%La) Flood Insurance Rate Maps
.?-'^.,'a.,.maps. Maps
tFL?.?t),..EMLa--..- roved loc'^. .cc..
blips ...e available though the FENIA NIap Service Center at 1-300-353-9616.
or
... 7. 77:1 -a" zov.
List a - - :.re th:1Z ,.eat ?esc..ces we-land to be impacted (e.g., freshwaterrsaltwater marsh, forested wetland, beaver pond.
C a Say, pcg .?.} I L._a = it xetl ,.d its isoi .ed (de.err ination of isolation to be made by USACE only).

z _.
Jaz
v C.
U-Y
cz?-
() v
4-Z IL
i
All?

IT
i
L/Z t! X010 _
4. Individually list all open water impacts (includin T lakes, pones. estuari;s. sounds, Atlantic
Ocean and any other water of the U.S.) below:
.,...._ ti_.__ r
-I-.. .u ru
Site Number
(indicate on mae)
Type of Impact*
Area of
Impact
(acres)
Name of `waterbody
(if applicable)
Tape of Waterbody
(lake, pond, estuary, sound,
bav_ ocean err 1
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: till, 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.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be 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
were minimized once the desired site plan was developed. If applicable, discuss construction
t chniques to be followed during construction to reduce impacts. (1 , f
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.
Page 9 of 12
Nor-,:,- of ar.c of
C m:i
e R2'?'s:er or N l= : 9. ,!.!.?i r :I} ' ce i when
c : a :c: «-
.,..Cessa ': :o ens1re that aL-;:erse e;:eC:; ;c the aquatic enviroI'ment are minimal. Factors
sln., and Te of proposed !mpac: and tuncron and relative value 'of the impacted
aquati, r_scu:ce .viii be considered in dete.:.ining ac .ep_abili y of appropriat: and practicable
r ;-tgat.on as r roL'osed. Exarnt`les of min,-;or t?a: ma ^ b r)^te
: be a, p,?pra and practicable irch!de.
4:.? .?-arm net to: reducin_ t::e size of --le projzc: establis iinuy and maintaining wetland
a= or upia L ve,er.a:ed bu_.,_ to project open waters such as st%ai:;s; and replacing losses of
aCuatic resource furs:ions arid values by creating. restoring, enhancing, or preserving similar
ancaors and values, preferable in the same watershed.
if ritigation is required for this project, a copy of the mitigation plan must be attached in order
for CS:A.CE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCEEP concurrence shall be placed on hold as incomplete.
applicant may also choose to review the current guidelines for stream restoration in DWQ's
D Technical Guide for Stream Work in North Carolina, available at
--^- '?20- -sta: -nc.W'!"rcwetlands?'strmQide ittml.
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
descript=ion of me current site conditions and proposed method of construction. Please attach
a separa:e s':ee: if more space is needed.
2. Mitigation may also be made by payment into the North Carolina Ecosystem Enhancement
Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at
[phone] 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
NCEEP, check the KEEP website at htto://www.nceep.net . If use of the NCEEP is
proposed, please check the appropriate box on page three and provide the following
information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Paa° 10 of 12
IY. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federaVstate) rands or the use of public
(federal/state) land''
Yes !C] No 71
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 [phone] 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 D`VQ)
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 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )`'
Yes ? No ? If you answered "yes", provide the following information:
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
) Multiplier
(s uare feet /ac Required
res i4litigation
1
I 3
2 I 1.5
Total
y 7- 1 .,...o..,J.. . ?n .
- -- -- r-•r-• ?•? ••u ,, ,,, „?? u„„K uL channel; cone: extends an
additional 20 feet from the edee of Zone 1.
Page I I of 12
. _ . Vim. ora,,cr
Te or =12a:ion is proposed (i.e., D
ra_,e er:t, Ripanar But_er Resrora::on En'narcemn-nt. Preser,,atton of
Pa: ..en. in:c :he C:^ -:an Buffer Rts:orar.on Fund). P'.ease _--aC . all appropr.a:e Information as
15 A CA. 5 .0_4_ ?r.0 2 6 0.
1I. Stormwater (required by DWQ)
Describe Impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stermwater controls proposed in order to protect surface waters and wetlands
dow-as ream'fom the property.
XII. Sewage Disposal (required by DNN'Q)
Clearly derail the ultimate treatment methods and disposition (non-discharge or discharge) of
%vastewater generated from the proposed project, or available capacity of the subject facility.
[III. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ! 1i \o i
Is this an after-the-fact permit application?
Yes I f \o
ZIV. Other Circumstances (Optional):
It is the applicants 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
%vort 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).

Applicant/Agent's Signature Date
(Age:-,:s signature is valid only if an authorization letter from the applicant is provided.)
Page 12 of 12

x
to '
It

5
r
MAY 9 2005
DENR - WATER QUALIl Y
VVEiIANDS AND STORMWATER
050,808
1:: ICY
1 .V-?
Pre-Construction Notification (PCN) Application Form
For Section 404 and/or Section 10 Nationwide, Regional and General Permits, Section 401
General Water Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This form is to be used for projects qualifyinfor any of the U.S. Army Corps of Engineers' (USACE
Nationwide, Regional or General Permits by Section 404 of the Clean Water Act and/or
Section 10 of the Rivers and Harbors Act, and for the North Carolina Division of Water Quality's
(DWQ) associated General 401 Water Qualitv Certifications. This form is also to be used for any
project requiring approval under any Riparian Buffer Rules implemented by the N.C. Division of Water
Quality. This form should not be used if you are requesting an Individual 404 Permit ("IP") or
Individual 401 Water Quality Certification. The USACE Individual Permit application form is available
online at ht ://www.saw.usace.armv.mil/wetlands/Perip a .htm.
The USACE is the lead regulatory agency. To review the requirements for the use of Nationwide,
Regional or General permits, and to determine which pen-nit applies to your project, please go to the
USACE website at http://w, v"v.saw.usace army mil/wetlands/regtour htm, or contact one of the field
offices listed on page 3 of this application. The website also lists the responsible project manager for
each county in North Carolina and provides additional information regarding the identification and
regulation of wetlands and waters of the U.S.
The DWQ issues a corresponding Certification (General or Individual), and cannot tell the applicant
which 401 Certification will apply until the 404 Permit type has been determined by the USACE.
Applicants are encouraged to visit DWQ's 401/Wetlands Unit website at
http://h2o.enr.state.ne.us/ncwetlands to read about current requirements for the 401 Water Quality
Certification Program and to determine whether or not Riparian Buffer Rules are applicable. The
applicant is also advised to read the full text of the General Certification (GC) matching the specific 404
Permit requested. In some cases, written approval for General Certifications is not required, provided
that the applicant adheres to all conditions of the GC. Applicants lacking access to the internet should
contact DWQ's Central Office in Raleigh at [phone].
Trout Waters Coordination - Special coordination with the North Carolina Wildlife Resources
Commission (NCWRC) is required for projects occurring in any of North Carolina's twenty-five
counties that contain trout waters. In such cases, the applicant should contact the appropriate NCWRC
regional coordinator (listed by county on page 4 of this application) prior to submittal of the application.
Page I of 12

Cca_._r. _-%_ea Nlana`?"--..mot Azt IC %(.k' : ; ord;nat :c --I 'te r e cc-_:.,r3 a -v ..
c ..? in nv c \ortl. Ca.
?c :ai ccnn:.es ('.fisted cr ca__ .::e applicarr scculd conaac: the North Carolina Div;siun of
`.I (-'C%['. 'CN v*' 11 cr not project is within a designated
ir{',=ental CCr_....... in wnlc- Case D)CM1 `:vi:i Zia as ..:? leaf: pen ining agency. In such
Z-Z _.._. D-CM recuir„ a CA_tiI_a ?ti--. _ and :vili coordinate the -G 401 Permits
__._ _cant La also caecse :o ccerdirate with the United States Fis'h . and titi'ildlife Service to ensure
reposed projec, will have no impact upon anv endanered or threatened species or critical
as r?zia_
b,.• the E ndargLred Species Act, and the State Historic Preservation Office, North
C rcli: a Deo -m. -nt of Culrrral Resources to ensure that the proposed project will have no impact upon
any preLerties listed or eligible for':is:in(z on the National Revister of Historic Places. Compliance with
cr .s is -eaur?-d to b?: eliible or any Department of the Arn y permit. The addresses for
cC-_. a` z:
L-n _r listed or pa e . o =is application.
U S ACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms,
"'no, s. etc. to the applicable USACE Regulatory Field Office. Upon receipt of an application, the
'S ACE will deter*nine if the application is complete as soon as possible, not to exceed 30 days. This
PC\ for u is desig* ed for the convenience of the applicant to address information needs for all USACE
Nationwide, Regional or General permits, as well as information required for State authorizations,
cenifications, -nd coord ma=tiaa. Fully providing the information requested on this form will result in a
complete application for any of the USACE -Nationwide, Regional or General permits. To review the
minimum amount of information that must be provided for a complete PCN for each USACE
\anomvide permit, see Cor_dition 13, 65 Fed. Reg. 12893 (March 9, 2000), available at
i zz -,,:,?'%v1.w.saw.usace.army.miL,.vetlandsrnwofinalFedRea.t)df. Processing times vary by permit and
begirt once the application has been determined to be complete. Please contact the appropriate
rozulato; i field office for specific answers to permit processing periods.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise
stated as optional. Incomplete applications will be returned. Submit five collated copies of all USACE
Permit materials to the Division of Water Quality, 401,Wetlands Unit, 1650 Mail Service Center,
Raleigh, \C, 27699-1650. If written approval is required or specifically requested for a 401
Certification, then a non-refundable application fee is required. In brief, if project impacts include less
than one acre of cumulative wetland water impacts and less than 150 feet cumulative impacts to
streams, then a fee of S200 is required. If either of these thresholds is exceeded, then a fee of S475 is
required. A check made out to the North Carolina Division of Water Quality, with the specific name of
the project or applicant identified, should be attached to the front of the application package. For more
information, see the DWQ website at httn://h2o.enr.state.nc.us/ncNvetlands/fees.htmi. The fee must
be attached with the application unless the applicant is a federal agency in which case the check may be
issued from a separate office. In such cases, the project must be identifiable on the U.S. Treasury check
so that it can be credited to the appropriate project. If written approval is sought solely for Buffer Rules,
the application fee does not apply, and the applicant should clearly state (in a cover letter) that only
Buffer Rule approval is sought in writing. Wetlands or waters of the U.S. may not be impacted prior to
issuance or waiver of a Section 401 Water Quality Certification. Upon receipt of a complete application
or a 401 Certification, the Division of Water Quality has 60 days to prepare a written response to the
arolica t. T;tis may include a 401 Certi ieation, an on-hold letter pending receipt of additional
quested information, or denial.
Pave 2 of 12

Asheville Regulatory Field Office
US Army Corps of Engineers
151 Patton Avenue
Room 208
Asheville, NC 23301-5006
Telephone: [phone]
Fax: [phone]
Raleigh Regulatory Field Office
US Army Corps Of Engineers
6508 Falls of the Neuse Road
Suite 120
Raleigh, NC 27615
Telephone: [phone]
Fax: [phone]
Washington Regulatory Field Office
US Army Corps Of Engineers
Post Office Box 1000
Washington, NC 27889-I000
Telephone: [phone]
Fax: [phone]
Wilmington Regulatory Field Office
US Army Corps Of Engineers
Post Office Box 1890
Wilmington, NC 28402-1890
Telephone: [phone]
Fax: [phone]
-0
r401 ivision of Water Quality
Wetlands Unit
650 Mail Service Center
aleigh, NC 27699-1650
elephone: [phone]
Fax: [phone]
Alexander Caldwell Haywood McDowell Swain
Aileghany Catawba Henderson Mecklenburg Transylvania
Ashe Cherokee Iredell Mitchell Union
Avery Clay Jackson Polk Watauga
Buncombe Cleveland Lincoln Rowan Yancey
Burke Gaston Macon Rutherford
Cabarrus Graham Madison Stanley
Alamance Franklin Nash Surry
Caswell Forsyth Northampton Vance
Chatham Granville Orange Wake
Davidson Guilford Person Warren
Davie Halifax Randolph Wilkes
Durham Johnston Rockingham Wilson
Edgecombe Lee Stokes Yadkin
Beaufort Currituck Jones Pitt
Bertie Dare Lenoir Tyrrell
Camden Gates Martin Washington
Carteret* Green Pamlico Wayne
Chowan Hertford Pasquotank
Craven Hyde Perquimans *Croatan National Forest Only
Anson Duplin Onslow
Bladen Harnett Pender
Brunswick Hoke Richmond
Carteret Montgomery Robeson
Columbus Moore Sampson
Cumberland New Hanover Scotland
North Carolina State Agencies
Division of Water Quality
Wetlands Restoration Program
1619 Mail Service Center
Raleigh, NC 27699-1619
Telephone: [phone]
Fax: [phone]
State Historic Preservation Office
Department Of Cultural Resources
4617 Mail Service Center
Raleigh, NC 27699-4617
Telephone: [phone]
Fax: [phone]
US Fish and Wildlife Service / National Marine Fisheries Service
US Fish and Wildlife Service US Fish and Wildlife Service National Marine Fisheries Service
Raleigh Field Office Asheville Field Office Habitat Conservation Division
Post Office Box 33726 160 Zillicoa Street
Raleigh, NC 27636-3726 Fivers Island
Asheville, NC 28301 Beaufort, NC 23516
Telephone: [phone] Telephone: [phone]
Telephone: [phone]
US Army Corps Of Engineers Field Offices and County Coverage
Page 3 of 12
C_01_a and NC Coastal Counties

•? 3.au,crt Chowan
F;:-,T ".- ra
Pas
uotanic
l»_z `faii - is e Ce.--=r 3e.^,ie Craver H de ?
Ponder
..ns .c Car.tu,:k New Harov-.r Per uimnans
T . _. !9:9) -- ----- C,mc zm Dare Orslow Tyrrell
'a-''fy:yr7 --l'95 Carteret Gates Pamlico Washin-on
NC'WRC and NC Trout Counties
?.e... art 3e_ c.^^. C crc.ratcr a:ie?ha Caldxell Watau,a
-' I??e•?i.d Road _
A31--- Mitchell «ilk- S
n
e s.il:e.\C ?,??= 9150 3•.erv Stokes
Te shore: [phone] Burke
Sum;
c
\f
tai : Roman Coordiratcr Buncombe Henderson Polk
Gress Sm-ok'_ Mz . 1-:t-ress;c•av Cherokee Jackson Rutherford
`aa.restia:e. NC ?S7?6 Clav Macon Swain
Graratn ?(adison Transylvania
ax: (S-S) '=--1 1
UZ Har,.eed McDowell Yancey
APPLICATION FORA BEGINS ON PAGE 5. PLEASE DO NOT SUBMIT PAGES 1- 4.
Paac » of 12
RIE& p
MAY 2005
vtirce Lse Only:
IVE asANDSTOP^ATERMCH
Version February 2004 i
_0tb808
USAGE Action ID No. DWQ No.
(If any particular item is not appacable to this project, please onrer "Not Applicable" or
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:_
3. 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 Ecosystem Enhancement Program (NCEEP) is proposed
for mitigation of impacts (verify availability with NCEEP 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
O Owner/Appl' ant Information
Name:
iVlailing A dress: -
Telephone Number: ,a - Fax Number:
E-mail Address:
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
trust be attached if the Agent has signatory authority for the owner/applicant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
Pa.-c 5 of 12
M. Project Information
v2Cl:lltti' mil clear=. S:' t;v _ r
44.. p o r.= -^z <ccat:ca o nrcpe? ?v,.h respect to local
such as 10W7-15. rivers, and roa 's. Also provide a detailed site plan sho?.vir:? propz^ :
et nda..es and developrnen, plans ;z relation to surrcundins proper:ie171 Both the vicinity map
C si ..
. plan must include a seal- and noi_.. arow. T-e -peC1:iC footprints of all buildln?s.
`leas sur bees. or other :acilit1CS must be included. i` possible. the ma a ?
' •- ps and plans sl:uill4
apprcp r-:e liSGS , po-aphic Quad Map and vRCS Soil Survey with the proper -y
bc` dames outlined. Plan drasvin`s. or ot;.er maps may be included at the applicant's discretion.
so 'lo as the proce.y is clearIv defined. For administrative and distribution purposes, the
t;SACE rewires irlfo.-marlon to be submitted on sheets no larger than 11 by 17-inch format:
o`.vever. DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawi-:gs rather than a sequentiai sheet version of the full-size plans. If full-size plans are
reduced to a Small scab such that the final version is illegible, the applicant will be informed that
l Project has been placed on hold until decipherable maps are provided.
1. `a^:e of project:
2. T.I.P. Project Number, _ CIL-k or State Project Number (vCDOT Only):
3. Property Ideraification Number (Tax PIN):
T Location
r ?
County: r1-1,,_4?? Nearest Town
Subdivision n e (include pheilot number):
Direc Eons to site (include road numbers, landma lcs,
t t? - 1 ! t7 -L/?^? T r
QNr
5. Site coordinates (Lat/Long; DIAL'S format):
(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.)
Property size (acres): <z ?? ?Yli?
D Nearest body of water (stream river,,'soundiocean/lake): /"`? u?.QlLc ? ! h
S. River Basin:
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at htto:,,`h2o.enr.state. nc.ils/admin/maps/.)
U Describe tr.- existing conditions on the site and general land use in the vicinity of the project
at the time of this application:_' i-,Lc ?, . ,L7
Pa.,e 6 of 12
IV.
V.
VI.1
ODescribe the overall pro.
Explain the Purpose of the
Prior Project History
including the type
of equipment to be used:
ed,work:
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.
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.
Proposed Impacts to Waters of the United States/Waters of the State
It is the applicants (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.
Page 7 of 12
of he Yrccesed impacts:
%vet an c i_ ts ?elc.v:
catzn within Distance to
Sitz me:: T_-z of L pact' im2act 100-}ear Fioodplain- Nearest Stream i T}pe of wztland*"*
i r.:yc or mao) (acres) (yes/no) (linear feet) I
-..::pc:.:epam:e:v a.,U tt g temnenrr tr: pacs. I :pacts include, but are not limited to: mechanized clearing, grading, till,
excavanoz, ':ccc di: cr _ina,° e:c. For'arns, separately list impacts due to both structure and fl v
oodim
,
ICC- ear f_cc' gins are denht:ed th oualt the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
f FL?? f?, e: F.?{ -apo:oved local tlcodplain raps. Maps a e available through the FENL4L Map Service Center at 1-800-353-9616, or
a %e:--I n ?.a. bwt desc.^:bes =.vetla:.d to be impacted freshwa:erisaltwater marsh, forested wetland, beaver pond,
Cw,..:na Ba}•, Cc2 .c_) L?a.,.? . if •.ietla:.d is isci..,ed (de.,.t........:ion o isoiaticn to be made by USACE only).
List the total acreage (estimated) of all existing wetlands on the property:
Total area of wetland impact proposed:
3. Individually list all intermittent and perennial stream impacts below:
Stream I pact Le nath of Average Width i Perennial or
Site Nurn'I, T}Tc of Imp act` lr-ract Stream Name`* of Stream Inte ?
rmittent
(Indic-%: cn map) (linear t °t) Before Imt act (please specify)
i
E I I
t i I
I
Lis; _..ca , pact sz '_=iV .-... _, ccr i^ cts. G cs include. but are riot limited to: culverts and associated rip-rap,
da .s (Sep--a-,ell list i. cts cue to Goth sm-cr :rz and flooding),relocation (include linear feet before and after, and net loss gain).
stabiiiz-;on ac;ivit zs (cen ;ent ,,.all, zip-rac. c b ?aa. zab ons. C.c.), excavation, ditchingtsuaightening, etc. If stream relocation is
prcpo_ed_ plars an les showing -.he lin-ar tootprt::t :br both the original and relocated streams must be included.
S :e_ . n=es can be fc;:nd on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
da.: :: eat
named s:rar into ..C is it 'logs. USGS maps are available through the USGS at 1-300-353-9616, or online at
_ _ .^v. Seve:a intz rzt sites also allow direct download and printing of USGS maps (e.g., www.toPozone.com,
CurnuIative impacts (linear distance in feet) to all streams on site:
Page 8 of 12
a_sl-ok?l ?? ?-
I?
t
- - . ??` /

L
cir
?Z?

..-? ? - :???- ?- ? -f--?-, ?-?- ? . •???1'?:.?' -?-?-?. - ? __ rte.,
y •
`?"?.-,
i ?
_ ?o`? ct ?V ?c?E'X • ;/ ?C ` l ?,z„ 'tom
z
?? c J z
4. Individually list all open water impacts (including lakes, pone, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.) below:
Open Water Impact
Site dumber
(indicate on man)
I
Type of Impact*
Area of Ty
dame of pe of `Vaterbody
Impact I waterbodv
(if applicable) (lake, pond, estuarv, sound,
(acres} i bav. ocean, etc.)
List each impact separately and identify temporary impacts. Impacts include, but are not limited to: till, excavation, dredaina.
floodine, 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.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII Impact Justification (.avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
i 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
were minimized once the desired site plan was developed. If applicable, discuss construction
t chniques to be followed during construction to reduce impacts.
1-k 1 11
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.
Pale 9 of 12
S - , : ce e Firal ?,:ot Ce of L a?r ce and M? ii . .
r? ? :.• •? od - of ? -?,r ,
ce?em! R'.z's:... on Nl'a. ! a. ,CCA". *1 i!?
m..t: a.IC= <'v _ b t . :rCC when
'10 c.S .o !1,e
^' - ••-L- -? e- ? agt?ariC e.^.?virCnIi:ent are minimal. Factors
i :..adi g Sig„ and t-.-.- of proposed ir. ract nc n;:et.en and relative value of the impacted
acua? .Ce will_ be considered in de._,., ninQ acceptabilit: of appropriate anal practicable
r? t._aticr. as -ropesed. Exam.cles of rnicgationr z at ma: be approp *at: and practicable inch:de.
bur arr.. nor ?ii: _vd .o: reducing the sig., -z° of t
-e project; establishing and maintain:n_Q wetland
-::d or upla^C `."e_°tated bui?erS to protect oce.^1 waters such as St:caITS; and - losses of
replaci
m-,
ac'satic re-Sou:--e :unctions and values by creating. restoring, enhancing, or preserving similar
ft::.C.ions and values, preferable in the same watershed.
i , -. Ligation is r quirt d for this proiect, a copy of the mitigation plan must be attached in order
for "SACE or DVVQ to consider the application complete for processing. Any application:
lacking a recuired mitigation plan or \CEEP concurrence shall be placed on hold as incomplete.
:fin applicant may also choose to review the current guidelines for stream restoration in DWQ's
Dra Technical Guide for Stream `York in North Carolina, available at
L?2o.enr.sr---.nc.us` cwetlandsfstrmQide html.
1. Provide a beef description of the proposed mitigation plan. The description should provide
as much information as possible. including, but not limited to: site location (attach directions
ard:'or map, if offsite), atiected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view.
preservation mechanism 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.
2. Mitigation may also be made by payment into the Forth Carolina Ecosystem Enhancement
Program (\CEEP). Please note it is the applicant's responsibility to contact the NCEEP at
(919) 733--5208 to determine availability and to request written approval of mitigation prior
to submittal of a PC\. For additional information regarding the application process for the
\CEEP, check the \CEEP website at htto://'www•.nceer).net . If use of the NCEEP is
proposed, please check the appropriate box on page three and provide the following
information:
amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):-
Amoua of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
I-`t. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federal/state) funds or the use of public
(fedeml/state) land?
Yes ±? No i J
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 [phone] 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
(Ni euse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )`'
Yes ? No ? If you answered "yes", provide the following information:
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* I Impact ?[ultiplier Required
(square feet /acres) V;ti-t;-
` i 3
2 1.5
Total i I
* Zone l extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page I I of 12
T _Rr_c is . ?u e^s disc ?;s .v` at ,.pe of m: i2?t1 0n is proposed Dora-c,
cf?= .e^:_ Ccnse a_ic E e...?._t. R a an Buffer Restoration »' E^:.arcerrert. P-ese: i ,
+at.0i: Lr
a" ?^ 7 :Zetit0=at10n Furd). TO lease
,. all aprropr:ate In-O0=11 1 r! as
..... ?ti_ ?.. '.i ?.L. 1?`'C3C .B .t'_t_ Or .O:Ct).
II. Stormwater (required by DNN'Q)
Describe i.Lper•V ions acreage (both existing and proposed) versus total acreage on the site.
Discuss srer,-nwater controls proposed in order to protect surface waters and wetlands
dov.ms earn f7cm the prope:z .
III. 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.
VIII. Violations (required by DNN'Q)
Is this site in violation of DWQ %V---hard Rules (15A `CAC 2H.0500) or any Buffer Rules?
Yes i No
Is this an after-the-fact permit application?
Yes ' ti o i
IIV. Other Circumstances (Optional):
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-dawn schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
r: r
Applicantlagent's Signature Date
(?.gent's signature is %alid only if an authorization letter from the applicant is provided.)
Pa?-,e 12 of 12

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p@1ROW12 09
MAY 9 2005
D?NR -WATER QUALITY
VYETLANDS ANO STORMWATER BRANCH
ti f. r
i
'Dul
Pre-Construction Notification (PCN) Application Form
For Section 404 and/or Section 10 Nationwide, Regional and General Permits, Section 401
General Water Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This form is to be used for projects qualifying for any of the U.S. Arm, Corps of Engineers' (USACE)
Nationwide, Regional or General Permits as required by Section 404 of the Clean Water Act and/or
Section 10 of the Rivers and Harbors Act, and for the North Carolina Division of Water Quality's
(DWQ) associated General 401 Water Quality Certifications. This form is also to be used for any
project requiring approval under any Riparian Buffer Rules implemented by the N.C. Division of Water
Quality. This form should not be used if you are requesting an Individual 404 Permit ("IP") or
Individual 401 Water Quality Certification. The USACE Individual Permit application form is available
online at http://www.saw.usace.army:mil/wetlands/Penn ap htm.
The USACE is the lead regulatory agency. To review the requirements for the use of Nationwide,
Regional or General permits, and to determine which pen-nit applies to your project, please go to the
USACE website at http://www.saw.usace.arm.V.miI/wetlands/reqtour.htm, or contact one of the field
offices listed on page 3 of this application. The website also lists the responsible project manager for
each county in North Carolina and provides additional information regarding the identification and
regulation of wetlands and waters of the U.S. `
The DWQ issues a corresponding Certification (General or Individual), and cannot tell the applicant
which 401 Certification will apply until the 404 Permit type has been determined by the USACE.
Applicants are encouraged to visit DWQ's 401/Wetlands Unit webs' ite at
http://h2o.enr.state.ne-us/nervetiands to read about current requirements for the 401 Water Quality
Certification Program and to determine whether or not Riparian Buffer Rules are applicable. The
applicant is also advised to read the full text of the General Certification (GC) matching the specific 404
Pen-nit requested. In some cases, written approval for General Certifications is not required, provided
that the applicant adheres to all conditions of the GC. Applicants lacking access to the internet should
contact DWQ's Central Office in Raleigh at [phone].
Trout Waters Coordination - Special coordination with the North Carolina Wildlife Resources
Commission (NCWRC) is required for projects occurring in any of North Carolina's twenty-five
counties that contain trout waters. In such cases, the applicant should contact the appropriate NCWRC
regional coordinator (listed by county on page 4 of this application) prior to submittal of the application.
Page I of 12

Coz_,::a 1 A-r-ea M=a` t .°.^.t c: `ccrd! at.cn - It the Cr,-`iec.t cc urn in a -,v of Nol'1: carolina':
.ye_ _ CC.--S:ai Ci.L'n .es (11s:ed cr a..::e applicant s:.oulc c_-niac: the Norh Carolina Division c?r
?. la.. .._. L. t 'iC,.l JCS 1 i i -.:_.:. 1 :y of e: Cr not .. Project :s wit111P. a C'eSIgnate
'-:T.` nr_:..nwl Cel_ce--- in '.v:' C,..SC LC.M will ac, as the lean perrmitzing agency. In such
.....:.._. DCM will , ulra- a CA-N I_a 'e...__. Ind Will coora:n ate t: e -04.401 Permits.
a:tr%;canr m my cheese to cccrdi ate with t'.7e United States Fish and Wildlife Service to ensure
. roCOSed 1N-qje... will have no im-,act upon ar_v endan_ered or threatened species or critical,
. Historic Preservation Office, North
.__. _I.at as .e ,later by the End--a-,red SoeCies Act, and the State
Ca.-oiina Dena.-u ent of Cultural Resources to ensure that the proposed project will have no impact upon
an%- =oner:ies listed or eligible for I's:ina on the National Reaister of Historic Places. Compliance with
:rose ref. Iat10 rz, is re.^L'IreQ to be ellaicle for any Depa:urient of the Arniv permit. The addresses for
es a:e S-1e pac° .. 0 -as app11cat10n. ,
USACE Permits - Submit one Copy of this form, along with supporting narratives, maps, data forms,
2:.oros, etc. to the applicable USACE Regulatory Field Office. Upon receipt of an application, the
USACE will determine if the application is complete as soon as possible, not to exceed 30 days. This
PCN fora is designed for the convenience of the applicant to address information needs for all USACE
Nationwide, Regional or General permits, as well as information required for State authorizations,
ce ications, and coordination. Fullv providing the information requested on this form will result in a
Complete application for any of the U S ACE Nationwide, Regional or General permits. To review the
minimum amount of information that must be provided for a complete PCN for each USACE
Nationwide permit, see Condition 13, 65 Fed. Reg. 12893 (4larch 9, 2000), available at
Attn:,'/w?titiv-saw.usace.armv.miUwetlandsinwofinalFedRea.pdf. Processing times vary by permit and
begin once the application has been determined to be complete. Please contact the appropriate
regulatory field office for specific answers to permit processing periods.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise
stated as optional. Incomplete applications will be returned. Submit five collated copies of all USACE
Permit materials to the Division of Water Quality, 401/Wetlands Unit, 1650 iVlail Service Center,
Raleigh, NC, 27699-1650. If written approval is required or specifically requested for a 401
Certification, then a non-refundable application fee is required. In brief, if project impacts include less
than one acre of cumulative wetland/water impacts and less than 150 feet cumulative impacts to
streams, then a fee of 5200 is required. If either of these thresholds is exceeded, then a fee of 5475 is
required. A check made out to the North Carolina Division of Water Quality, with the specific name of
the project or applicant identified, should be attached to the front of the application package. For more
information, see the DWQ website at http://h2o.enr.state.ne.usinc?vetlands/fees.htmi. The fee must
be attached with the application unless the applicant is a federal agency in which case the check may be
issued from a separate office. In such cases, the project must be identifiable on the U.S. Treasury check
so that it can be credited to the appropriate project. If written approval is sought solely for Buffer Rules,
the application fee does not apply, and the applicant should clearly state (in a cover letter) that only
Butner Rule approval is sought in writing. Wetlands or waters of the U.S. may not be impacted prior to
issuance or waiver of a Section =401 Water Quality Certification. Upon receipt of a complete application
fora '01 Certification, the Division of Water Quality has 60 days to prepare a written response to the
a pllcan,. This may Include a 401 Certification, an on-hold letter pending receipt of additional
cuested information, or denial.
Page 2 of 12
US Army Corps Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Off
ce
S Army Corps of Engineers Alexander Caldwell Havwood McDowell Swain

51 Patton Avenue Alleghanv
sh Catawba Henderson Mecklenburg
Transvlvania
203 e
Ave Cherokee Iredell Mitchell Union
NC 28301-5006 ry
Buncombe Clay
Clev
l
d Jackson Polk Watauga

Telephone: [phone]
Burke e
an
Gast Lincoln Rowan Yancey
Fax: [phone]
Cabarrus on
Grah %(acon Rutherford
am Madison Stanley
Raleigh Regulatory Field Office
US Army Corps Of En
ineers Alamance Franklin Nash
Sutty
g
6508 Falls of the Neuse Road Caswell Forsyth Northampton Vance

Suite 120 Chatham Granville Orange Wake
Raleigh, NC 27615 Davidson Guilford Person Warren
Telephone: [phone] Davie Halifax Randolph Wilkes

Fax: [phone] Durham Johnston Rockingham Wilson
Edgecombe Lee
Stokes
Yadkin
Washington Regulatory Field Office Beaufort Currituck J

US Army Corps Of Engineers
Berti ones Pitt

Post Office Box 1000
ox e

Camden Dare

Gat
Lenoir
Tyrrell
Washington,
27389-1000
t*
Cart es Martin Washington
Telephone: [phone] ere
Chow Green Pamlico Wayne

Far: [phone] an
Cra Hertford Pasquotank
ven Hvde
Perquimans
*Croatan National Forest Only
Wilmington Regulatory Field Office Anson Duplin Onslow
US Army Corps Of Engineers Bladen Harnett Pende

Post Office Box 1890
Wilmington, NC 28402-1390
Brunswick
Hoke r
Richmond

Telephone: [phone] Carteret Montgomery Robeson

Fax: [phone] Columbus Moore
Sampson
Cumberland New Hanover Scotland
North Carolina State Agencies
F ivision of Water Quality Division of Water
01 Wetlands Unit Quality State Historic Preservation Office
Wetlands Restoration Program Department Of Cultural Resources
650 Mail Service Center 1619 Mail Service Center 4617 Mail Service Center
aleigh, NC 27699-1650 Raleigh, NC 27699-1619 Raleigh, NC 27699-4617
Telephone: [phone]-=1617
Telephone: [phone] Telephone: [phone]
Fax:[phone] Fax: [phone]
Fax: [phone]
US Fish and Wildlife Service / National -Marine Fisheries Service
US Fish and Wildlife Service
Raleigh Field Office US Fish and Wildlife Service National Marine Fisheries Service

Post Office Box 33726 Asheville Field Office

160 Zillicoa Street
Habitat Conservation Division

Raleigh, NC 27636-3736
Telephone: [phone]
Asheville, NC 28801 Pivers Island
Beaufort, NC 28516
Telephone: [phone]
Telephone: [phone]
Pa-e 3 of 12
CAA and `C Coastal Counties
:-: : - - as:al fa:.
` Bta fcrt Choxar.
Hertfor
Pas4uotanic
. r. `
Se- icy Cn.er 3-rt,* Craven H de Perder
3r nsw;ck C?xrituck New Hanover Perauimans
,.Z. 9, 7,z
--
C.1-dc-1
Dare
Onslow
Tvrrell
Careret Gates Pamlico Wash in;:on
\C«RC and \C Tr out Counties
• es:..r ?:e Y: •o, . Re_ : C, erdira:ar Al'.ezhan•. Caldwell Watauga
--== Road ashe Mitchell Wilkes
K_'r e s.itte. \L 2713;-910 Aver; Stokes
Te - 1- on e: t=-o) -69-94-- Burke Surrv

Mc--n , i. Renton Ccorinator
Bu;:comce
Henderson
Polk
-' `-3 G.-e= Smoky ? f•1. 3cP ess.:ay Cherokee Jackson Rutherford
NC 'S'S Clay Macon Swain
f32S) T-=_'=Td Graham ?laduon Transvivania
Ha,?,.vocd McDowell Yancey
APPLICATION FORM BEGINS ON PAGE S. PLEASE DO NOT SUBMIT PAGES 1 - 4.
Pace 4 of 12
Rff,@P,0Wrqr, p
MAY 9 2005
Office Use Only:
Form Version Frbruary2004 i
DENR-WATER QUALITY 050808
WETLANDS AND STORMWATER BRANCH USACE Action ID No. DtiVQ No
(If any particular item is not appiicable to this project, please enter "Not Applicable" or "NiA".)
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:
3. 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 Ecosystem Enhancement Program (NCEEP) is proposed
for mitigation of impacts (verify availability with NCEEP prior to submittal of PCN),
complete section VIII and check here: [1
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
0 Owner/Appl' ant Information
Name:
Mailing A dress:
Telephone Number: Fax Number:
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: y
Company Affiliation:
i?lailing Address:
I eleptione Number: Fax Number:
E-mail Address:
Page 5 of 12
III. Project Information
_tiltit tti' map clear'. r:_ the lcca::cn of proper"v with respect i0 local
suc as -0%vns. rivers. and . roads. Also provide a detailed site plan srLos
virg property
bot:: da..es and de, elopr ent plans in relatior to surrourdir., propertied Both the vic p
i..ity ma
site p,an must ircli:ce a ;ca!_ a-:. nn
- and nor-nn -,r-ow. The specific footprints of all buildings.
-- ?e^ leas su :aces. cr ot`te. Lacilities must be included. If possible. the maps and plans should
incl?d? e approp Late L:SGS Topographic Quad Map and MRCS Soil Survey with the property
ou'*.li-:-d. Plan drazvu-tgs. or of e. maps may be included at the applicant's discretion.
so "".o as tl:e Drape; v is clearly defined. For administrative and distribution purposes, the
USACE rewires inforration to be submitted on sheets no larger than It by 17-inch format;
c_osvever. DWQ may accept paperwork of any size. DWQ prefers full-size construction
cra7.v1i.=5 muter than a se-uenrial sheet version of the full-size plans. If full-size plans are
redeced to : =„=all scale such that the final version is illegible, the applicant will be informed that
?;e project aas been placed on hold until decipherable maps are provided.
I. Nam- of project:
_'. T.I.P. Project \umber, NC;%Lk or State Project Number (NCDOT Only):
3. Propert`,- Identification Number (Tax PIN):
Location I/ 1
Courts: r(-Z,?'? Nearest Town.c ,n
f
Subdivision name (include phase/lot number):
Directions to site (include road numbers. landma ks, etc.: MMLLLa iti
7 7;
`J
5. Site coordinates (Lat{Long; Di?%US format):
(Vote - 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.)
D Property size (acres):
b
D Nearest body of water (streami'riverisoundiocear.;lake):
_ U
S. River Basin:
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http:--h'o.enr.state.nc.us/admin'maps!.)
V Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: Page 6 of 12

IV.
V:
VI:
Describe the overall pro
Explain the purpose of(? the
'Ct X,1977r
Prior Project History
tail, including the type of equipment to be used:
osed work:
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.
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.
Proposed Impacts to Waters of the United States/Waters of the State
It is the applicants (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 applicants 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.
Page 7 of 12
1. ?.-ov-de 1 `.v__:_, .. '?Cr:Nt:•?% of Zhe ^,rcpcsed impacts:
:`:C_ : aI,- _1 lL'°via i. tt:. ac:s ?elcw:
`'? - = rd t. -- ea ?; ?ccated within, Distance to
Si e N ....,.. T,?e of I lac. I.? t 100-ve r Fioodplain"* Nearest Stream I Tvpe of Wetland`*
t.ndizate or aD) (acres) 1ves.71"o) (linear feet)

= Lis: tzz_ _ c: ser merely and idear,iy tempcrr: it . ac tanacts include, but are rot limited to: mechanized clearing, grad -
in„ till,
^rd r Fir d-
=x ava==on.: CcLn._- cit..'-=. dams, scoarately list irroacs due to both structure and tloodin;.
GGY:ar ; eo u s _ leer-:i-? t ra-a . _ Federal ETer2eacy Mana_emert .aeerev's (FEMA) Flood Insurance Rate Maps
(FLRUM). cr FE?L?-- - ,ed local r -. %I-:;s W., available through the FEN-L-k Map Service Center at 1-800-353-9616, or
e - :v ac=.
List a _ ne .at '_-et desc- _es wz-land to b_ is sacred freshwatensaltw-ater marsh, forested wetland, beaver pond,
C. 3a-, bca .c_) if .cetl?ad is isc .ed (determir..:ion of isolation to be made by OSACE only).
List tine total acreage (estimated) of all existing wetlands on the property:
Total area of wetland impact proposed:
3. Individually list all intermittent and perennial stream impacts below:
Stream Impact Le n=h of Averaee Width Perennial or
Site \u-0111 T, pe of Impact' 1=act Stream \a-eI of Stream intermit
tent?
(indicate or. -,..a:)) (iirear feet) I Before Impact (please specify)
' List c ., s11
- per° , it ..ts. Impacs include, but are not limited to: culverts and associated rip-rap,
d--7.s (_e, %-.l•. !is., cts du.. to seta st. ..._ and "oodmg), relocation (include linear feet before and after, and net loss/-ain).
stabit: - n a.,,vities (c_ ::eat wall, rip-rap. crib well. gabions, excavation, ditching;'straightening, etc. If stream relocation is
proposed, plans and pro iles showing zhe linzar tbotpriia for both d•:e original and relocated streams must be included.
Strea :, as :.es =1 be ,-,.;.-.d on I:SGS topographic mcps. If a stream has no name, list as UT (unnamed tributary) to the nearest
dc.vns r_am named str_..... into ....ch !t t',ovos. USGS maps are available thrcueh the USES at 1-800-333-9616, or online at
irtert e: sites also allow direct download and priding of USGS maps (e.g., www.topozone.com,
Cumulative impacts (linea: distance in feet) to all streams on site:
Page 8 of 12

- `z-
-? t6
? r
lz?
L
!? ?? "ZG Z c ?o
:
i
J
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c'

`•'?'y?L? frZ?l?
-? ?'? • mac'-?-?r? ? J _ ??' ? ? ?=-?rL ?'
t--LcL'
1
A ,
t
=1. Individually list all open water impacts (including lakes, pone-, estuaries. sounds, Atlantic
Ocean and any other water of the U.S.) below:
Open Water Impact i Area of
Site Number Type of Impact" Impact i Name or Waterbody I Type of ?Vaterbody
tj (lake, pond, estuary, sound,
(indicate on man) (acres) (if applicable) bav, ocean, etc.)
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: till, excavation, dredeine.
Hooding, 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 0 stream C wetlands
Describe the method of construction dam/embankment, excavation, installation of
draw-down valve or spillway, etc.): y
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII Impact Justification (.Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be 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
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts. ` ?I
,^,.n

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.
Page 9 of 12
Firal Notice of issu-lnc,'. and ?iJci_icatlon Cf ?+a'iomvide
a =t= --- =1 r Ze'?'st--. on March 9. 2"X,0. m t:Jaticn will be of .alr.'ll whe^
.._...'.SSa to ^._...? r.-a: et_ectj to tie acuauc environment are minimal. Factors
..i:Li.^._ slzL, and t of Gropos--d impact and function and relative value of tllZ impacted
.°_SC'rCe '.vtbe constC.cred to dote m. tna iii . accep,?ab`-rv ?r?
of appropr .ia.., and practicable
.i0:. -as Ey"r lpies of mit'.2--on :1a: may be a^propPat-e and tic? -ab
prac ?le include.
dt cir` s,?e of n e proiec,: establishing and maintaining wetland
a.-,d Or uDla: z°:a:ed brli:erS to protect open '.eaters such as slreanis; and replacing losses OI
aquatic resource ii:ncrions and values by creating. restoring, enhancing, or preserving similar
=c ors and values, preferable in the same watershed.
If tridgaticr. is required for this project, a copy of the mitigation plan must be attached in order
or L S ACE c: DMZ Q to consider the application complete for processing. Any application
a re,u-ed rririganon plan or \CEEP concurrence shall be placed on hold as incomplete.
Aa applicant rrav also choose to review the current guidelines for stream restoration in DWQ's
Draft Tec .nical Guide for Stream Wore in North Carolina, available at
ititto: -h2o.;-ar.state.nc.u ,ncwetland&'strmQide html.
Provide a brief description of the proposed mitigation plan. The description should provide
as much inforrrarion 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 deed -zstrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate shut if more space is needed.
2. Mitigation may also be made by payment into the North Carolina Ecosystem Enhancement
Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at
(919) 733-208 to determine availability and to request written approval of mitigation prior
to submittal of a PCN. For additional information reLyarding the application process for the
\CEEP, check the NCEEP website at htto://www.nceeo.net . If use of the NCEEP is
proposed, please check the appropriate box on page three and provide the following
information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian %-,-land mitigation requested (acres):_
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Pae° 10 of 12
i
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 [phone] to review current thresholds for environmental documentation.
Yes f7 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 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )`'
Yes ? No ? If you answered "yes' provide the following information:
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 /acres)
Multiplier Require
d
iViitigation
t
3
2 1.5
Total
* --
-- - • - ?« P-P-uicuiar from near oanK or charnel; Zone'_ extends an
additional 20 feet from the edge of Zone 1.
Page I l of 12
I: ,C__?. i_'tion is requL.-? ?fa_e discuss what ice ofmi i?a.ion is proposed
ci . _CLe ^:. Co. se^'a:ioIt ?3 e^, enr. Ripa an Buffer Restoration E , green °1*.. °:ese: vatior. e
to Ri .an Ju:71,tsior t:01 i ui.C). i :e'??e ,,ac.: ,:1! appCOCr:l:e iniQrli ?ltiJn as
15- `:CAC _3 .01,= or .0=ci).
XI. Stormwater (required by DWQ)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stcrmL water controls proposed in order to protect surface waters and wetlands
d3vvms :ea: trom the proper:.
XII. Selvage 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.
XIIl. `violations (required by DNN'Q)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes F-1 `o i
Is this an after-the-fact permit application?
Yes i 7 No !"
XIV. Other Circumstances (Optional):
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).
?7 ? ? n
Applicant/Agent's Signature Date
(A?ent J sI? :azure is valid only if an authorization letter from the applicant is provided.)
Paee 12 of i'_

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Dt:NR?STEF? WARAFiAP6GM
050848
t
i t
v +` v
Pre-Construction Notification (PCN) Application Form
For Section 404 and/or Section 10 Nationwide, Regional and General Permits, Section 401
General Water Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This form is to be used for projects qualifying for any of the U.S. Army Corps of Engineers' (USACE)
Nationwide, Regional or General Permits as required by Section 404 of the Clean Water Act and/or
Section 10 of the Rivers and Harbors Act, and for the North Carolina Division of Water Qualitys
(DWQ) associated General 401 Water Quality Certifications. This form is also to be used for any
project requiring approval under any Riparian Buffer Rules implemented by the N.C. Division of Water
Quality. This form should not be used if you are requesting an Individual 404 Permit ("IP") or
Individual 401 Water Quality Certification. The USACE Individual Permit application form is available
online at http://www.saw.usace.armv.miI/wetlands/Perin app htm.
The USACE is the lead regulatory agency. To review the requirements for the use of Nationwide,
Regional or General permits, and to determine which pen-nit applies to your project, please go to the
USACE website at http://w?vw.saw.usace.arrnv.mil/wetlands/re?-rtour.htm, or contact one of the field
offices listed on page 3 of this application. The website also lists the responsible project manager for
each county in North Carolina and provides additional information regarding the identification and
regulation of wetlands and waters of the U.S.
The DWQ issues a corresponding Certification (General or Individual), and cannot tell the applicant
which 401 Certification will apply until the 404 Permit type has been determined by the USACE.
Applicants are encouraged to visit DWQ's 401/Wetlands Unit website at
http:/7h2o.enr.state-ne.us/nc ?vetlands to read about current requirements for the 401 Water Quality
Certification Program and to determine whether or not Riparian Buffer Rules are applicable. The
applicant is also advised to read the full text of the General Certification (GC) matching the specific 404
Permit requested. In some cases, written approval for General Certifications is not required, provided
that the applicant adheres to all conditions of the GC. Applicants lacking access to the internet should
contact DWQ's Central Office in Raleigh at [phone].
Trout Waters Coordination - Special coordination with the North Carolina Wildlife Resources
Commission (NCWRC) is required for projects occurring in any of North Carolina's twenty-five
counties that contain trout waters. In such cases, the applicant should contact the appropriate NCWRC
regional coordinator (listed by county on page 4 of this application) prior to submittal of the application.
Page I of 12

r.
Cc : ;:i i A .-ea ?1:.:.1_??: e^_t Act {C ?.?i.-tii :•.it;r:;^- Ii :^: Cl'C•,:rS In a;i_V of NOrtl; C.lrOli:^.Ll?•
"aS_ai CvL:....3 ;:ISt. Cn .fie _ acolicaaz sr.o. .c ccniac: t:. NVor:a Carolina Div;Sicn c
,DC1 r.,. .'DCNI `.•v_li '.v e,. cr not t'.c project is within a les1!T^ated
-yea c: E :ircns;.:ntzl Cer_ce.__. in ca,.e DCM .vii', -act as il:e d permitting "- 1.ea --riaina agency. In such
..._.,Zz. DCM will require a CA_\,L-? ?e._.:i: and will coordinate the 2'04401 Permits.
ct::cant :<? . `i
.Lt rna`% also c _ccse to cacr..ci:I:.:L:° ? i•h t'.e i.'^.ited Sta-.e? u?- F and Wildlife Service to ensure
r-rocesed proiec: will have no irn=act upon any z- dal_' .'red or threatened species or critical
:a: _ 'la ?d th ?: da^_ered Suedes Act, and tie State Historic Preservation Otice, North
Carolina Dena:L-rent or Cultural Resources to ensure that the proposed project will have no impact upon
an•: nroce:nes listed or eligible for lis:inn on the National Register of Historic Places. Compliance with
..^.eSe r°zzlaticns is required to be eligible for any Department of the A... y permit. The addresses for
--e a2°ycies ar, listed on page 3 of tl is application.
I:SACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms,
p'r_ows, etc. to the applicable USACE Regulatory Field Office. Upon receipt of an application, the
L:SACE will determine if the application is complete as soon as possible, not to exceed 30 days. This
PCN form is desiared for the convenience of the applicant to address information needs for all USACE
Nationwide, Regional or General permits, as well as information required for State authorizations,
certifications, and coordmi ation. Fully providing the information requested on this form will result in a
complete application for any of the USACE Nationwide, Regional or General permits. To review the
m :^.irrum amount of information that must be provided for a complete PCN for each USACE
Nationwide permit, see Condition 13, 65 Fed. Rea. 12893 (March 9, 2000), available at
z.sa,z.usace.armti.miL'wetlands;'nwofina1FedRea.pd£ Processing times vary by permit and
begin once the application has been determined to be complete. Please contact the appropriate
regulatory field office for specific answers to permit processing periods.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise
stated as optional. Incomplete applications will be returned. Submit five collated copies of all USACE
Permit materials to the Division of Water Quality, 401/Wetlands Unit, 1650 Mail Service Center,
Raieiah, NC, 27699-1650. If written approval is required or specifically requested for a 401
Certification, then a non-refundable application fee is required. In brief, if project impacts include less
than one acre of cumulative wetland/water impacts and less than 150 feet cumulative impacts to
streams, then a fee of 5200 is required. If either of these thresholds is exceeded, then a fee of S475 is
required. A check made out to the North Carolina Division of Water Quality, with the specific name of
the project or applicant identified, should be attached to the front of the application package. For more
information, see the DWQ website at http://h2o.enr.state.nc.us/ncwetlands/fees.htmi. The fee must
be attached with the application unless the applicant is a federal agency in which case the check may be
issued from a separate office. In such cases, the project must be identifiable on the U.S. Treasury check
so that it can be credited to the appropriate project. If written approval is sought solely for Buffer Rules,
the application fee does not apply, and the applicant should clearly state (in a cover letter) that only
Buffer Rule approval is sought in writing. Wetlands or waters of the U.S. may not be impacted prior to
issuance or waiver of a Section 401 Water Quality Certification. Upon receipt of a complete application
for a 401 Certification, the Division of Water Quality has 60 days to prepare a written response to the
applicant. This may include a 401 Certification, an on-hold letter pending receipt of additional
requested information, or denial.
Pa,e 2 of 12
US Army Corps Of Engineers Field Offices a
d C
n
ou nty Coverage
Asheville Regulatory Field Office

US Army Corps of Engineers Alexander Caldwell Haywood McDowell Swain

131 Patton Avenue
tto Alle,hany

Ash
Catawba
Henderson
Mecklenburg Transylvania
Room
208 e
Ave Cherokee Iredell Mitchell
Union
Asheville, NC 23301-5006 ry
Buncombe Clay"
Clev
l
d Jackson Polk Watauga

Telephone: [phone]
Burke e
an
Ga
t Lincoln Rowan Yancey"
Fax: [phone]
Cabarrus s
on
Graham Macon
Madison Rutherford
Stanlev
Raleigh Regulatory Field Office
US Army Corps Of En
ineers Alamance Franklin Nash
S
v
g
6503 Falls of the Neuse Road Caswell Forsyth Northampto an
n Vance

Suite 120 Chatham Granville Orange Wake

Raleigh, NC '7615 Davidson
Guilford
Person
Warren
Telephone: [phone] Davie Halifax Randolph Wilkes

Fax: [phone] Durham Johnston Rockingham Wilson
'
Edgecombe Lee tokes
Stokes Yadkin
Washington Regulatory Field Office
US Army Corps Of Engineers Beaufort Currituck Jones
Pitt
Post Office Box 1000 Bertie
Camden Dare
Gat Lenoir Tyrrell

Washington, NC 27889-1000
Ca
t
* es Martin Washington

Telephone: [phone] r
eret
Chowan Green
Hertf
d Pamlico Wayne

Fax: [phone]
Craven or
Hyde Pasquotank
Perquimans
*Croatan National Forest Only
Wilmington Regulatory Field Office Anson
US Army Corps Of Engineers Bladen Harnett Pender
ender
Post Office Box 1890
Wilmington
NC 28402-1390 Brunswick Hoke
Richmond
,
Telephone: [phone] Carteret Montgomery Robeson

Fax: [phone] Columbus Moore Sampson

i Cumberland New Hanover Scotland
(n
aF North Carolina State Age ncies
Division of Water Quality
401 Wetlands Unit Division of Water
Quality
State Historic Preservation Office

1650 Mail Service Center Wetlands Restoration Program Department Of Cultural Resources

Raleigh
NC 27699-1650 1619 Mail Service Center 4617 Mail Service Center
,
Telephone: [phone] Raleigh, NC 27699-1619
Raleigh, NC 27699-4617

Fax: [phone] Telephone: [phone] Telephone: [phone]
Fax: [phone]
Fax: [phone]
US Fish and Wildlife Service / National Marine Fisheries Service
US Fish and Wildlife Service US Fish and Wildlife Service National Marine Fisheries Service
Raleigh Field Office Asheville Field Office Habitat Conservation Division
Post Office Box 33726 160 Zillicoa Street
Raleigh, NC 27636-3726 Pivers Island
Asheville, NC 28801 Beaufort, NC 28516
Telephone: [phone] Telephone: [phone]
Telephone: (252
??..) 723.5090
Pagc 3 of 12
CAM A and `C Coastal Counties
Chowan Fertf r Pasquotank
-;S _ i Se. ;cc Ce.._... Be tie Craven Hvde Pender
Z s _ NC _- 9_I _ 3 Br?:swv ck C,riu:ck Ne•.v Hanov;:, Pe imans
+9;9j _--__-- Can dea Darc Onslow Tvr:il
a7 Can's Pamlico tiZ ashinc:on
NCWRC and NC Trout Counties
es.e^ P:ed sort Rem on Coordinator Allezhanv Caldwell Watauga
co 1d e,,tiad
Road
she
Mitchell
Wilkes
R' cer,.il':e. NC 2'7-S--9,S0 verv Stokes
769-945, Burke Sum
`
NNI C l
ain 1egior. Ccordinator Buncombe Henderson Polk
:!,'S-'O Great Jmoti 1It.._ -Expressway Ch.-roke„ Jackson Rutherford
.b a ,tsvil , \C ZS 7 So Clay Macon Swain
Te.eLhore: (323) 45-1-2-546 Graham Madison Transvlvania
(S:8) 45-2-777-1 Haywood McDowell Yancey
APPLICATION FORM BEGINS ON PAGE 5. PLEASE DO NOT SUBMIT PAGES 1- 4.
Page 4 of 12

Office Use Only:
hl?;11
Form Version February 2004
i
DENR • WATt:P ;u [Y
11 USACE Action ID No. WETLMMJDSTORWATERBRMW
DWQ No. 0508o8
(Ifany particular item is not appiicable to this project, please enter "Not .applicable" or "N/A".)
I. Processing
Check all of the approval(s) requested for this project:
? Section 404 Permit 7 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:
3. 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 Ecosystem Enhancement Program (NCEEP) is proposed
for mitigation of impacts (verify availability with NCEEP 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
i
1O Owner/Apph ant Information
Name:
Mailing A dress:L?-
Telephone Number: 'a - Fax Number:
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:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Pasc 5 of 12
III. Project Information
w . a vici?fit?i ea' _
riap c. _ , : ;oWir - -^e .ccat:cn of -!-e propeYy with respect to Iocal,
such as to%vns, and roads. Also provide a detailed ?,i
site plan shov,r:s Prope. .
icu da rtes and dev,. elCpI ; '
'^ PlanS L'1 re!at.Ci'. t0 sllr'Cll GL'1g properti en Both the vici. ?iti ..? man
?, .,
site p mu t i^cluce a sca__ a C nor' a.:ow. T,-. e speci.ic footprints of all buildings
pe^ icier su:Thces. or t'aciilire-
' i.ast ce nc1uced. l: Possible. the maps and plans should
include tine appropriate C SCS Topo• rap' is Quad %lap and NRCS Soil Survey with the property
bou daries outlined. Platt drawirigs. or other maps may be included at the applicants discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
US ACE requires inforration to be submitted on sheets no larger than 1 I by 17-inch format:
1-1o%vevtrr. DWQ may accent Pape:-,: ork of any size. DWQ prefers full-size construction
cr`'•:in-as ia--"-e- t: ^. a sequennal s Beet version of the full-size plans. If full-size plans are
recuced to a small scale suc t` at the nal version is illegible, the applicant will be informed that
:?-.e Project has been placed ',old until decipherable maps are provided.
I. Name ofprojeet:
2. T.I.P. Project Number, NCNL-, or State Project Number (NCDOT Only):
3. Prctae,?? Identification Number (Tax PIN):
0 Location -,?
County: i
Ll-?'Yti, Narest Town-
e Subdivision, name (include phaser'lot number):
Directions to site (include road numbers, landma ks, etc.:
% A
5• Site coordinates (Lat'Long; D,AL S format):
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossina of a distinct waterbody.)
Property size (acres):
D ,
Nearest body of water (stream river;'sourd.iocearv`la!ce):
S. River Basin:
(Noe - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at htto:'. n2o.enr.state.nc.us/admin/maps/.)
Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application:;-?-,L?
Pa,-,e 6 of 12
ODescribe the overall proj
Explain the purpose o
A
IV. Prior Project History
n etaiI, including the typz of equipment to be used:
work:
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.
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 `Paters of the United States/Waters of the State
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.
Page 7 of 12
-- :.^di:idual! v lis: weti_,.^_l: ir::c=5'Celow:
`etiar_c : Ar;.a of ?cca,_-. within Distance to
Si.e N?.. er of T:Te I-- It- ct 100-near Flcodplain` Nearest Stream Type of Wetland*"*
(:ndic_ e :)l (ac zs) i':e&n o) (linear : et) i
I I
=p_=. _epa and ;de,..ir: _..ocrs+ ir_ cs. Impacs .: c!ude, but are not limited to: mechanized clearing, grading, till,
enc. ?_cn, flu. dW? c _ _- -- For d=.s, eparately list it: oats due to both structure and [looting.
IGG-Y r •.cec :_ s -._ :de,. a:_, .._ro _ t e F -derl E; _ :cy Management Agency's (FENL-k) Flood Insurance Rate daps
(FLL?I), e: FEJLa- :o: is l t:codpgain p;. ?IaNs are available t<hroush the FENLL Nlap Service Center at 1-300-353-9616, or
online atF:? :u-.t :v t-eTa-^ov.
List a '.et?ard ge that best desc bes wetla.d to be in;pacted (e.g., treshwaten-saltwater marsh, forested wetland, beaver pond,
Carotin a Bay, bee, e.c.) Indica:e ii .?etland is isolated (determination of isolation to be made by USACE only).
List the total acreage (estimated) of all existing wetlands on the property:
Total area of wetland impact proposed:
3_ Individually- list all intermittent and perennial stream impacts below:
Stream Impact j Length of Average Width j Perennial or
j Site Number ( T}ce of Impact* I Impact 1 Stream 'Name' of Stream Intermittent?
1 (indicate on mao) ( (linear feet) 1 Before Impact (please specify)
1 ?
' List each impact separately and ide nnr•r temporary imacs. lmpacts include, but are not limited to: culvers and associated rip-rap,
dams (separa:cly list trnca_s cue to both stmt-ure and Ioodimz), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cc,-,=.t wal"•.::p-rap, crib eabio :s. etc.), excavation, ditching,/straightening, etc. If stream relocation is
proposed. pans and o ass showi g a e linear footprint for both the original and relocated streams must be included.
_? Srer r c r. b :_-_.-d en USGS topo?• aphic m,.os. If a stream has no name, list as UT (unnamed tributary) to the nearest
rss_a n c:c s::-_.n into . nich it tlo:rs. USGS .. os are availablc t rcu_ the USGS at 1-800-358-9616,
or online at
sites also a:!ow dSc do'w^_'.oad and printing of USGS maps (e.g., w:v:v.tol+ozone.com,
Cumulative impacts (linear distance in f et) to all streams on site:
Page 8 of 12

_? -gin . - -- -- _ -
? L -
• -cam,
--! -- __ l CA__ ,
,
-?? a c^
?--? L? ??
17 -1-1-C
r
1 2,11
ell
< V - - - G?7 - - - - -- - -- -
J
tti Lam=- ?>-- ?'YY
LAS
ILI CJ ?-, 0-"Z, n?j?-
? ? ? . ???-?-?rL ?-:!?1?? - ?C c•=mar.,. ? ?? J g '+ C,?zG?.
a
LIZ
s
41. Individually list all open water impacts (ircludin2 lakes, ponc_. estuaries, sounds, Atlantic
Ocea r and any other water ofthe U.S.) below:
Open Water Impact I Area of
Site dumber s Name of `,Vaterbodv ; T pe of `."aterbody
Type of Impact* Impact
(indicate on mao) , (if acr licable) (lake, pond, estuary, sound
(acres)
bay, ocean, etc.)
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: till, 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.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII Impact Justification (avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be 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
were minimized once the desired site plan was developed. If applicable, discuss construction
t chniques to be followed during construction to reduce impacts.
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.

Page 9 of 12
??z A CE - r. ce W1;'1. the Firal Notice of lssuarce and "Iodi -ication of - a* onwide
ins. Cu*--!-,--,
.__ a_. .:e Feces: ?eJi-
on Ma-c! 9. 2cc (`, miti anon w:b a
e when
cessa?: t, ensare t at adver_e effects to *.he aquatic environment are minimal. Factors
sizz? ^d r;pe of _ roposed Irr.pact a.-tc: n:nctlon and relat:ve value of the impacted
:a_ c scu:ce •.vi:: be considered it de_"_,rinina acceptabilit<< of appropriate and practicable
=,pt on as ,opcsed. E 1'.j t ^i t7a ?n -4 a.
ma.
_ ??r c o • - _ .? . be appropria?e : and practicable include.
rOt 1Lm. _e1 t0: reCl:%Irg Szl'e Ot 'n e prcie :Stabl:Sian'g, and maintaining wetland
ardor u p 1 a n veg_=,.:d buffers ro prole." open waters suL r as St'ean'iSi and replacing IOSSeS OI
aquatic reSOu-C.tUnc%ons and values by creating. restoring, enhancing, or preserving similar
:unctions and values, preferable in the same watershed.
if rritigation is required for this project, a copy of the mitigation plan must be attached in order
for LAS ACE or DV,,Q to consider the application complete for processing. Any application
1--can j a required L-nirlgaD`ior. P
plan or \CEE_ concurrence shall be placed on hold as incomplete.
applicanr r- v also choose to review the current guidelines for stream restoration in DWQ's
Dra -L Te-ca ical Guide for Stream Work in North Carolina, available at
rti_t2o.er r.state.rc.usircw'etl8nds strmvide html.
I. Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, ircludina, 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.
2. Mitigation may also be made by payment into the North Carolina Ecosystem Enhancement
Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at
[phone] 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
NCEEP, check the NCEEP website at htto:/,.ww•w.nceep.net . If use of the NCEEP is
proposed, please check the appropriate box on page three and provide the following
information:
amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):_
Amount of Non-riparian wetland mitigation requested (acres):
Arnount of Coastal wetland mitigation requested (acres):
Pa2z! 10 of 12
IY. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federal/state) funds or the use of public
(federaUstate) land"
Yes ? No j
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 [phone] 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 D`VQ)
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 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No ? If you answered "yes", provide the following information:
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
(square feet /acres) Multiplier 7R-cquired
ation
1 I I
3

'- 1 E
1.5
Total
--
?u? ?v iu" pccpcnuicutar rrom near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 1 t of 12
I
Tt prase 11scuss %vhat ty?fm::ig n ) '? r:
pe ?•. `?.,o is prcp? s: { i.e., Dona::
C.7 0 re Cc.:ser:ao:. rase^ enc. zipa, an Buffer Restoration Er,- arc went. °resetvat:or: or
?a on: ...:c R, :a^ 3Zest; -atior_ P;ease ..:;ac:. al acpropr: ae Info=:0r. as
%Via.n I` _ '_X __1LC _J .C_ _ Cr .0_,60.
XI. Stor- nwaIer (required by DWQ)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stcrmvater cortrols proposed in order to protect surface waters and wetlands
dow-rstrea^: Lem the prope^
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.
XlU. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules? 7-1
Yes 1 !! No
Is this an after-the-fact permit application?
Yes i No
YIV. Other Circumstances (Optional):
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
xvort 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).
_ I .r r
Applicant/Agent's Signature Date
(age^t's signature is valid only if an authorization letter from the applicant is provided.)
Page 12 of 12

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Pre-Construction Notification (PCN) Application Form
For Section 404 and/or Section 10 Nationwide, Regional and General Permits, Section 401
General `Pater Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This form is to be used for projects qualifying for any of the U.S. Army Corps of Engineers' (USACE)
Nationwide, Regional or General Permits as required by Section 404 of the Clean Water Act and/or
Section 10 of the Rivers and Harbors Act, and for the North Carolina Division of Water Quality's
(DWQ) associated General 401 Water Quality Certifications. This form is also to be used for anv
project requiring approval under any Riparian Buffer Rules implemented by the N.C. Division of Water
Quality. This form should not be used if you are requesting an Individual 404 Permit ("IP") or
Individual 401 Water Quality Certification. The USACE Individual Permit application form is available
online at htt ://www.saw.usace.armv.mil/wetlands/Perm apg htm.
The USACE is the lead regulatory agency. To review the requirements for the use of Nationwide,
Regional or General permits, and to determine which permit applies to your project, please go to the
USACE website at http://wwxv.saw usace armv mil/wetlands/regtour htm, or contact one of the field
offices listed on page 3 of this application. The website also lists the responsible project manager for
each county in North Carolina and provides additional information regarding the identification and
regulation of wetlands and waters of the U.S.
The DWQ issues a corresponding Certification (General or Individual), and cannot tell the applicant
which 401 Certification will apply until the 404 Permit type has been determined by the USACE.
Applicants are encouraged to visit DWQ's 401/Wetlands Unit website at
http://h2o.enr.state.nc.us/ncwetlands to read about current requirements for the 401 Water Quality
Certification Program and to determine whether or not Riparian Buffer Rules are applicable. The
applicant is also advised to read the full test of the General Certification (GC) matching the specific 404
Permit requested. In some cases, written approval for General Certifications is not required, provided
that the applicant adheres to all conditions of the GC. Applicants lacking access to the internet should
contact DWQ's Central Office in Raleigh at [phone].
Trout Waters Coordination - Special coordination with the North Carolina Wildlife Resources
Commission (NCWRC) is required for projects occurring in any of North Carolina's twenty-five
counties that contain trout waters. In such cases, the applicant should contact the appropriate NCWRC
regional coordinator (listed by county on page 4 of this application) prior to submittal of the application.
Page 1 of 12

Cc »_.._, A--ea M=aa , nt Zkc, i C _%!- IF t::.' ^C `iC cc._....rs IP. aav o Non h Caroi;,a
.....-.tal cou ,.es !hsted cn ^a__ 1 .:1 e =clic :Z: snC!i!C C::.^.:act L^.? `or Carolina Division c,
('`.C`.f;. Dl `I `AL de:e.:.1ne '.wnerner cr not project is wilii'n a des*'.z a:.,
0: =._:.r C.:. nC i L o%Ce._,. in %vm-C' C_-e DCM wi:i act as t: e lead Permitting agency. In sucn
DC'NI will require a CA -%LA. °e. nir and will coordinate the -'04' .0 Permits.
^1:i:.:::t r"i.av arso c::CCSe to CCCC"Ii:ate '.w, h t ",e 1. n'zed Sta'_es Fish and `V tldli:. Service to ensure
Yrcpcs, prof= ` "111 have no impact ucor. anv endarn:eyed or tl:reat- d species or critical
-
a _ '1 ::eC ,rs __., E :da^.Vered J^e res Act, and the State Hisiorlc Preservation Office, North
Carolina Dep a_-_.:ent of Cultural Resources to ensure that the proposed project will have no impact upon
a_nv mpenies listed or eligible for listir_g on the National Register of Historic Places. Compliance with
..__.te rezulatlcrs is required to be eligible for any Department of the Army Permit. The addresses for
bat_ agencies are listed on page 3 of t.-ds application.
L: SACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms.
Photos, ex. to t1e applicable US ACE Regulatory Field Office. Upon receipt of an application, the
S ACE will detertni e if the application is complete as soon as possible, not to exceed 30 days. This
PCN orrn is desigr:ed for the convenience of the applicant to address information needs for all USACE
Nat:on,w:de. Regional or General permits, as well as information required for State authorizations.,
ce l_ cauor , and coordination. Fully providing the information requested on this form will result in a
commlet;, application for any of the USACE Nationwide, Regional or General permits. To review the
minimum amount of information that must be provided for a complete PCN for each USACE
Nationwide permit, see Condition 13, 66 Fed. Reg. 12893 (March 9, 2000), available at
:-n-' %,?tiw:v.?aw_usace.arlnv.niil'wetlards,'nwofinalFedRe1 .pdf. Processing times vary by permit and
?eg:n once the application has been determined to be complete. Please contact the appropriate
regul.=-orn field office for specific answers to permit processing periods.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise
stated as optional. Incomplete applications will be returned. Submit five collated copies of all USACE
Permit materials to the Division of Water Quality, 401/Wetlands Unit, 1660 iVlail Service Center,
Raleigh, NC, 27699-1660. If written approval is required or specifically requested for a 401
Certification, then a non-refundable application fee is required. In brief, if project impacts include less
than one acre of cumulative wetlandj'water impacts and less than 160 feet cumulative impacts to
streams, then a fee of S200 is required. If either of these thresholds is exceeded, then a fee of 5475 is
required. A check made out to the North Carolina Division of Water Quality, with the specific name of
the project or applicant identified, should be attached to the front of the application package. For more
information, see the DWQ website at httn://h2o.enr.state.nc.us/ncNvettands/fees.html. The fee must
be attached with the application unless the applicant is a federal agency in which case the check may be
issued from a separate office. In such cases, the project must be identifiable on the U.S. Treasury check
So : at it can be credited to the appropriate project. If written approval is sought solely for Buffer Rules,
t e application fee does not apply, and the applicant should clearly state (in a cover letter) that only
Buffer Rule approval is sought in writing. Wetlands or waters of the U.S. may not be impacted prior to
iSsua^.ce or waiver of a Section 401 %Vater Quality Certification. Upon receipt of a complete application
fora 40 L Certification, the Division of Water Quality has 60 days to prepare a written response to the
applicant. This may include a 401 Certi ication, an on-hold letter pending receipt of additional
.,cuested information, or denial.
Page 2 of 12
US Army Corps Of Enginee rs Field Offices and Count
Cov
y
erage
Asheville Regulatory Field Offi
ce
S Army Corps of Engineers
S Alexander Caldwell Havwood McDowell Swain

151
Patton Avenue
rto Alleg
hang
Ash
Catawba
Henderson
Mecklenburg Transylvania
e
Averv Cherokee
Cl Iredell Mitchell
Union
sheville, NC 23301-5006
Buncombe av
Clevel
d Jackson Polk Watauga

Telephone: [phone]
Burke an

Gast Lincoln Rowan
Yancey
Fax: [phone]
Cabarrus on
Grah Macon Rutherford
am Madison Stanley
Raleigh Regulatory Field Office

US Army Corps Of Engineers Alamance Franklin Nash
Surry

6503 Falls of the Neuse Road Caswell Forsyth Northampton Vance

Suite 120 Chatham Granville Orange Wake
Raleigh, NC 27615 Davidson
Davi Guilford Person Warren
Telephone: [phone] e Halifax Randolph Wilkes

Fax: [phone] Durham Johnston Rockingham Wilson
Edgecombe Lee
Stokes
Yadkin
Washington Regulatory Field Office
US Army Corps Of Engineers Beaufort
rrituck
Jones
Pitt
Post Office Box 1000
Po
x Bertie
Camd Dare Lenoir Tyrrell
2
shin ton, o
g 7889-1000 en
Cart
* Gates Martin Washington

Telephone: [phone] eret
Chow Green Pamlico Wayne

Fax: [phone] an Hertford Pasquotank
Craven
Hyde
Perquimans
*Croatan National Forest Only
Wilmington Regulatory Field Office Anson
US Army Corps Of Engineers
Post Office Box 1890

ox Bladen Harnet
Harnett
Pender
ender
Wilmington,
28402-1390 Brunswick Hoke Richmond

Telephone: [phone] Carteret Montgomery Robeson

Fax: (910) 25t-4025 Columbus Moore Sampson
Cumberland New Hanover Scotland
(n North Carol ina State Age ncies
ivision of Water Quality
01 Wetlands Unit Division of Water
Quality
State Historic Preservation Office

650 Mail Service Center
[ Wetlands Restoration Program Department Of Cultural Resources
Ralei-h,
NC 27699-1650 1619 Mail Service Center

Raleigh
NC 27699-1619
4617 Mail Service Center
elephone: [phone] ,
Telephone: [phone] Raleigh, NC 27699-4617

ax:[phone]
Fax: [phone] Telephone: [phone]
Fax: [phone]
US Fish and Wildlife Service / National Marine Fisheries Service
US Fish and Wildlife Service
Raleigh Field Office US Fish and Wildlife Service National Marine Fisheries Service

Post Office Box 33726 Asheville Field Office

160 Ziilicoa Street
Habitat Conservation Division

Raleigh, NC 27636-3726
Telephone: [phone]
Asheville, NC 28801 Pivers Island
,
Beaufort, IBC 285(6
Telephone: [phone] Telephone: [phone]
Page 3 of 12.
CAM A and NC Coastal Counties
3eaL;;crt Chowan
He tforc
Pas
uotank
' 17; . t. ; : - ° Ce
_.. e ;c .er 3crtie Craver, H
de ?
P--rd,
Ralei_z. `C 27699-15-3.8 3rurs-,cick C;rin c y
N'e,.v Hanover Perauimans
T e ?h?re. ; 9 i9) 7__-_---
'
Cu^:ce^.
Dare
Ors!ow
Tyr, ell
Cates Pamlico Washincy-on
NCWRC and NC Trout Counties
??"es:e n?:ed :_ort ReTon Cocrdinator a!leghanv Caldwell Watauga
-35.. iLle:c;',d Road Ashe Mitchell Wilkes
tee.. >iile. \C 27-284-9',S-0 Avery Stokes
3ur<a Scrr:
\
' ` c ?
ai : Region ccordi: .or 3imco^?ae Henderson Polk
-j?, ??0 Grea:Smc:: tt?..31? ess..a• Chercke '
Jacso n Rutherford
,?a• es?iil:.tiC 2SzS5 Clay Macon Swain
Telechore: iS?3 ???-?? ,5
-) - -
Graham
Madison
Transylvania
rax:(t"_s)>?'--%,-72 Hay;voed McDowell Yancey
APPLICATION FORM BEGINS ON PAGE 5. PLEASE DO NOT SUBMIT PAGES 1- 4.
Page 4 of 12
R[R=@1901&9D
MAY 9 2005
Office Use Only: WETLANDS AND STORMWATER BRkXH Form Version February 2004
USACE Action ID No. DWQ No. 6-$0808
(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:
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
i
4. If payment into the North Carolina Ecosystem Enhancement Program (NCEEP) is proposed
for mitigation of impacts (verify availability with NCEEP prior to submittal of PCN),
complete section VIII and check here: n
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
0 Owner/Appl* ant Information
Name:
Mailing A dress: ='-"?,c7-
Telephone Number: .a - Fax Number:
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:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
Pa?-c 5 of 12
r
Ill. Project information
:oWin- -c lcca :C
t r, Gf ^r Oper:V V'vlt?
r_ respect [0 1001
` ""'" ?L'C = as t0 •? ^?...vers. and roads. Also provide a detailed site plan showing property
Counda_.es and develo0Men M, °iau; ,i•-,` ?
.:u r o% t0 SIIt:CU^..t .. pr,,p :..n Both the Vicinity map
d -i -z plan muse:- ;:de --c n no- a The ? i
r - h rrow. ',-its of
pec --c footpr all buildir. s.
Wiper::ct:s sun aces. or otl er facilities must be included. If possible. the maps and plans should
include : ` anoroprate L-SCS Topographic Quad Map and MRCS Soil Survey with the property
bcu :dares outlined. Plan drawings. or other maps may be included at the applicant So discretion.
so long as the property is clearly defined. For administrative and distribution purposes. the
USACB requires information to be submitted on sheets no larger than 11 by 17-inch format;
=otc'ever. DWQ t, .ay accept paper::ork of any size. DWQ prefers full-size construction
dra--t= Js mt e t: r.^ a sequential sheet version of the full-size plans. If full-size plans are
recuced to a -..all scale such that t:.e final version is illegible, the applicant will be informed that
t: e project has been placed on hold until decipherable maps are provided.
1. Name of project:
T.I.P. Project 'umber, -NC_NL-)L or State Project -Number (vCDOT Only):
3. PrcDeTtY Identification'umber (Tax PD;):
Y Location
County: • y Nearest Town
Subdivision name (include phase/lot number):
Directions to site (include road numbers. .landmarks, etc.. ' ` ? i `,,z, c Y
Sa
r
5- Site coordinates (Lat/Long; DIALS format):
(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.)
Property size (acres): C G??-? ?y 1 its
d
D Nearest body of water (stream-riverr'sound,,ocear.ilalce):
J
8_ River Basin:
(Note - this must be one of Nosh Carolina's seventeen designated major river basins. The
River Basin map is available at htto:%ih2o.enr.state.nc.us/admin;'mansi.)
(9) Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application:;^?.??
Pa`,e 6 of 12
IV.
V.
VI.
ODescribe the overall proje
Explain the purpose o
A _
Prior Project History
tail, including the typ.z of equipment to be used:
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.
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.
Proposed Impacts to Waters of the United States/Waters of the State
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.
Page 7 of 12
1. ??r1t dO t:5 ;2n 4-?SZ:'- 'Cn o rrenc_ed impacts:
2. End; vidual Iv Ist A'etiand imc.acts below:
'A ettarc : a :. _o::...od within Distance to
T-,--e of I00-cear Ficodplain- Nearest Stream T,.-De of Wetland*"
fi- ate mao) (acres) 4ve& no) (linear; et)
j
' -is: xc: s-r '1_ "d =d-••-iP% ocr in.PZCs_ I ::pacs i,.c;ude, out a:e not limited to: mechanized clearing, ;radin2, till,
=C=" c= c; car c_. _'c yi ,e, e:c. rer n u , secamteiy list i rpacs due to both stru rrre and Yloocin',.
" 1C; Y.;..r tioodplai s are ;d ntif"Cd t:-rough the Federal Emergency I Iaaeemert :agency's (FEAR) Flood Insurance Rate %laps
(FURM", or FENLA approved !cc--I cod-plain maps. Maps are available through the FENLA Map Service Center at 1-800-353-9616, or
on!.._,. at n"'^ ti`.i'cV.teT1.HOV.
Lis: s w-_,!and type *hat bet describes wetland to be impacted (e.g., freshwatensaltwater marsh, forested wetland, beaver pond,
Carolina, Bay, beg °.c) sdicate if %, c-dand is isolated (determination of isolation to be made by USACE only).
List the total acreage (estirpared) of all existing wetlands on the property:
Total area of wetland impact proposed:
3. Individually list all intermittent and perennial stream impacts below:
Stream Impact j Length of average Width I Perennial or
Site Nt:mber , Tyre of Impact' i Impact Stream Name"' of Stream Intermittent?
(indicate on mho) (linear feet) Before Imt;act (please specify)

' List each impact seta rah; ly -:-.d idenrt;: temccrary impacts. Impacs include, but are not limited to: culverts and associated rip-rap,
(_:na:a:el • Est i acts d::e to beta sr-.:cr -- and tlooding), relocation (include liner feet before and after, and net loss/gain).
_ abifizcon ,ties (c,,...-....call, rip-rap. c ,-.b ..all. _"bioas. VC.), excavation, ditchin?straighter.it _ etc. If stream relocation is
pr pos d. ar.d prc, !es showing 'he lin a ?O:pr : -:jr bold :Ire original and relocated streams must be included.
St art _ es a b_ . ..c en L SGS r; o_ is ,. ps. if a s's y rt has no name, list as UT (unnamed tributary) to the nearest
do..rs:: an named Stream. ism ..hich it t'.o•,vs. USES aps availaolc t;-rcu•_; the USES at 1-300-333-9616, or online at
• .v. _ ;o v. Several in.?...et sites also allow direct do-. nload and printing of USGS snaps (e.g ww
„ v.topozor,e.com,
•.?-rv.r^1^c?esrcom, etc).
Cumulative impacts (linear distance in feet) to all streams on site:
Page 8 of 12
?J
i
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ck?
.
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- - -r D
41-
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-4
CL-a
j ?L? ??} e C r? ( 0-7
\ v

- ---- -- - ----
rl ?
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- ;?L -? l?-
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C? ct i?LTcz? .c??'X ??Y G ?C3
41

I. Individually list all open water impacts (includint7 lakes, ponc__ estuaries. sounds, Atlantic
Ocea , and any other water of the U.S.) below:
Open Water Impact Area of
Site Number Type of Impact* Impact game of waterbody Type of .Vaterbody
(lake, pond, estuary, sound,
(indicate on map) i (acres) I (if applicable)
bay. ocean. etc.)
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: till, excavation, dredaine.
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.):
i
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be 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
were minimized once the desired site plan was developed. If applicable, discuss construction
Thniques to be followed during construction to reduce impacts. l (? l
'' ' a
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the INC
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.

Page 9 of 12
Final Noi co of Ijsu.l.nco and Modiitl'arion \,1- t;orwiC'e
=11S. in t :C FCde 1i sie. on -Mar l 9. _'UTO. mitigation will bZ r? i1rCC ?Vhc^
CCS=.. - io ensure t.^.a; acve._ eff`cts io uhe aqu'aiic Z.n irons ent are minimal. Factors
........ L.",'? -'+? and of proposed it pact xxid funct.on and relative value of the impacted
be conic.-.-, it d: t.'._ai..^Lng aCCe C(h? f of appropriate and practicable
i:_1' 1?= l0i'. ?? r reposer.. rxan CIeS OI I;:lt'gation th= may be appropriate and practicable mC '
li de.
i re not liP:'ited to: reducing the size of t:.e project; establishing and maintaining wetland
an cL er upi=d ve_etated buffers to protect open waters such as streams; and repiacirg losses or
a:'1at1C resource fL rctions and valises by creating. restoring, enhancing, or preserving similar
r1ctions and values, preferable in the same watershed.
I_ ir-'i gatior_ is required for ibis project, a copy of the mitigation plan must be attached in order
r -SACS or D WQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCEEP concurrence shall be placed on hold as incomplete.
applicant my also choose to review the current guidelines for stream restoration in DWQ's
Dray Technical Guide for Stream Work in North Carolina, available at
ht.p:.h?o ezr.state.nc.us ncwetlands;'strmUide html.
I. Provide a brief description of the proposed mitigation plan. The description should provide
as muca uiforr ation as possible, including, but not limited to: site location (attach directions
a:-d;'or snap, it 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.
2. Mitigation may also be made by payment into the North Carolina Ecosystem Enhancement
Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at
[phone] 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
NCEEP, check the \CEEP website at htto: ;%v.nceep.net . If use of the NCEEP is
proposed, phase check the appropriate box on page three and provide the following
information: v
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Arnount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12

IX. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federaVstate) 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 [phone] 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 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify
Yes ? No ? If you answered "yes", provide the following information:
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
) Multiplier
(s uare feet /ac
e Required
r
s Mitigation
1 I
3
2 1.5 I
Total
* 7- i _-_I,
?„ .
- - -- r-•r ..?.??,?, ......u+ vL cnanr1cl; cone : extends an
additional 20 feet from the edge of Zone 1.
Page I I of 12
?5 r II:r:r p'-sif discuss `.what `.L'' O m
t i'i?atiOn is proposed (Le.,
r Dona:.cn
c: _ . pz^ Geiser, a_ic . Ea eM:en7. Riparian Buffer Restoration En har:cement. Preser.atior. or
?=. •• ---'• -0 - D'l::..- ,Z?siCrata)n '!T-d', a ac al! apprvpr:at, 1ni0ii%atiOP. as
0 16 0.
1I. Stortnwater (required by DWQ)
Describe imper-.ious acreage (both existing and proposed) versus total acreage on the site.
Discus, stcrrnwatcr controls proposed in order to protect surface waters and wetlands
l.v??iJ?ea: LUlal trio p:operty_
XII. Sewage Disposal (required by D«WQ)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
:stewater zenerased uom the proposed project, or available capacity of the subject facility.
VIII. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A tiCAC 2H.0500) or any Buffer Rules?
Yes ' i \o
Is *_his an after-the-fact permit application?
Yes \o i?
XIV. Other Circumstances (Optional):
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
c nose to list constraints associated with construction or sequencing that may impose limits on
«or'.? schedules draw--down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).

ApplicantiAgent's Signature Date
(?.?e^t's signature is valid only if an authorization letter from the applicant is provided.)
Pa,-,e 12 of 12
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