20091127 Ver 1_401 Application_20091009

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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1a . Type(s) of approval sought from the

Section 404 Permit F] Section 10 Permit
?
Corps:
1 b. Specify Nationwide Permit (NWP) number: or General Permit (GP) number.
1c. Has the NWP or GP number been verified by the Corps? ? Yes ? No
1d. Type(s) of approval sought from the DWQ (check all that apply):
? 401 Water Quality Certification - Regular ? Non-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express ? Riparian Buffer Authorization
1e. Is this notification solely for the record For the record only for DWQ For the record only for Corps Permit:
because written approval is not
required? 401 Certification: }
Yes ? No ? Yes
1f. Is payment into a mitigation bank or in-lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation ? Yes EJNo
bank or in-lieu fee program.
1 g. Is the project located in any of NC's twenty coastal counties. If yes,
1 h b
l
? Yes No
answer
ow.
e
1 h. Is the project located within a NC DCM Area of Environmental Concern
AEC
? Yes ? No
(
)?
2. Project Information
2a. Name of project P uy (-
i _ C_ tiff nc?Vr_ „7?" vT
2b. County: =)GC?,
2c. Nearest municipality / town: , f--
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'

2d. Subdivision name: 0 C
T 9 ? ?nn

2e. NCDOT only, T.I.P. or state
project no: - WATER
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Page 1 of 14
PCN Form - Version 1.3 December 10, 2008 Paper Version
3. Owner Information
3a. Name(s) on Recorded Deed:
3b. Deed.Book and Page No.
3c. Responsible Party (for LLC if
applicable):
3d. Street address:
3e. City, state, zip: c.,a ?,o vc 2 2J_/_?
3f. Telephone no.: ?? ! ct 4t 6? ._ 3 J
3g. Fax no,: < `? (-teG - 43_x"
3h. Email address:
?-cr-
4--y'
4. Applicant Information (if different from owner)
4a. Applicant is: Agent ? Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name:
5b. Business name:
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 14
PCN Form - Version 1.3 December 10, 2008 Paper Version
B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): t,/,+ A,^, J -- J?
Latitude: ?S - ?e?s (DD.DDDD)
1b. Site coordinates (in decimal degrees):
Longitude: - V'? DD.DDDD)
1c. Property size: t0, ?5 -rte ?r>?'r (acres)
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project: e,
2b. Water Quality Classification of nearest receiving
water:
2c. River basin: N yJ?
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
--- - ?yp ti G CE' /` t .r J i AN L> t v c i? ? J /? ?? w q y.

3b. List the total estimated acreage of all existing wetlands on the property: (acres)
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
(linear feet)
3d. Explain the purpose of the proposed project:
N o T Z F-? Ci!'T? d ?.J
iL v !i ???} t'.1 I G?..? C? ?-/l. ?......• /}U-CC. ,S.S-- ? ? ; .l -' ! .I _
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Cj ,?C ?,. _ .nra /M .AR?'TI fk+ 2 /ZG
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3e. Describe the overall project in detail, including the type of equipment to be used:
4 G. ?/???ott f?av'L f'L?/1Zc
/t-¢.)?.?$ .._.- G.?.1..-T'y?sa ? .?-a ?..1-?Gr L ? j C.y c Z.C.... (.? C' ??.lGc? ?-
r?
e' 63 J t ''?-? ?' r'L/' t c...?. ? C., c, J L..J lT rt Pf'L? ? ?\.J r .''? C?tr?}C'W'T ? -? ?

Page 3 of 14
PCN Form - Version 1.3 December 10, 2008 Paper Version
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations
by the Corps or State been requested or obtained for
this property / project (including all prior phases) in the
past?

? Yes 2-No ? Unknown
Comments:

4b. If the Corps made the jurisdictional determination,
what type of determination was made?
? Preliminary ? Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known): Agency/Consultant Company:
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.

5. Project History
5a. Have permits or certifications been requested or
obtained for this project (including all prior phases) in
the past?
? Yes RNo ? Unknown
5b. If yes, explain in detail according to "help file" instructions.

6. Future Project Plans
6a. Is this a phased project? ? Yes ??N0
6b. If yes, explain.

Page 4 of 14
PCN Form - Version 1.3 December 10, 2008 Paper Version
C. Proposed Impacts Inventory
1. Impacts Summary
1a. Which sections were completed below for your project (check all that apply):
? Wetlands ? Streams - tributaries ? Buffers
? Open Waters ? Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
Wetland impact
number -
Permanent (P)
or Temporary T 2b.

Type of impact 2c.

Type of wetland
(if known) 2d.

Forested
(Yes or No) 2e.
Type of jurisdiction
(Corps - 404, 10
DWQ - non-404, other) 2f.

Area of impact
(acres)
W1 ? P ? T ? Corps ? DWQ
W2 ? P ? T ? Corps ? DWQ
W3 ? P ? T ? Corps ? DWQ
W4 ? P ? T ? Corps ? DWQ
W5 ? P ? T r ? Corps ? DWQ
W6 ? P ? T ? Corps ? DWQ
W7 ? P ? T ? Corps ? DWQ
W8 ? P ? T ? Corps ? DWQ
2g. Total wetland impacts
2h. Comments: " -J__
7

Page 5 of 14
PCN Form - Version 1.3 December 10, 2008 Paper Version
3. Stream Impacts - If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the
site, then complete this question for all stream sites impacted.
3a.
Stream impact
number -
Permanent (P)
or Temporary (T) 3b.
Type of impact 3c.
Stream name 3d. Perennial
(PER) or
intermittent
(INT)? 3e.
Type of
jurisdiction
(Corps - 404, 10
DWQ - non-404,
other) 3f.
Average
stream
width
(feet) 3g.
Impact
length
(linear
feet)
S1 ? P ? T
S2 ? P ? T
S3El P?T
S4?P?T
S5 ?P ?T
S6El P?T
3h. Total stream and tributary impacts
3i. Comments:

4. Open Water Impacts - If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic
Ocean, or an other open water of the U.S. then individually list all open water impacts below.
4a.
Open water
impact number -
Permanent (P) or
Temporary T 4b.
Name of
waterbody
(if applicable) 4c.

Type of impact 4d.

Waterbody type 4e.

Area of impact (acres)
01 ?P?T
01 ?P?T
01 ? P ? T
01 ?P?T
4f. Total open water impacts
4g. Comments:

Page 6 of 14
PCN Form -Version 1.3 December 10, 2008 Paper Version
5. Pond or Lake Construction - If pond or lake construction proposed, then complete the chart below.
5a

Pond ID 5b.

Proposed use or purpose 5c.
Wetland Impacts (acres) 5d.
Stream Impacts (feet) 5e.
Upland
(acres)
number of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
5f. Total
5g. Comments:
5h. Is a dam high hazard permit required? Yes ? No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction: f'
6. Buffer Impacts (for DWQ) If project will impact a protected roarian bu er, then com lete the chart below. If yes, then
individually list all buffer impacts below. If any impacts require tnitigatio , then you .M ; ' oUt'Section D.

6a. Project is in which protected,bas1`0 Neus?,--_ F] Tar-Pamlico ? Other:
r
? Ca4wba ? Randleman
6b. Buffer impact
number-
Permanent (P) or
Tem orar T 6c. i
Reaso6 for
impact \ 6c.

tre name 60.
Bu it r
t mitig on
i re ud? 6f.
Zone 1 impact
(square feet) 6g.
Zone 2 impact
(square feet)
61 ? P?T
B2 ? P?T
B3? P?T
64 ? P?T
B5 ? P?T
66 ? P?T
6h. Total buffer impacts
6i. Comments:

Page 7 of 14
PCN Form - Version 1.3 December 10, 2008 Paper Version
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
c
c.,s /!"? ?S- : ?' y?? i c. /J"?:c ? sv a ! ?^-? 6'.9?' ?.f .? -2 -
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e'
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9?
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y
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/

1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
G? ?i ?-. Z Ft t c aw e F 1''7 i3?"E ti?.'C a! eW c `- G-/11 -1 --
~a 4c C G-Z-re d h f?rta .°'c s_ d r?.c J
en Z?) C_

2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State? ? Yes ? No
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps
2c. If yes, which mitigation option will be used for this
project? r] Mitigation bank
? Payment to in-lieu fee program
? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type: Quantity:
3c. Comments:

4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: (linear feet)
4c. If using stream mitigation, stream temperature: ? warm ? cool ?cold
4d. Buffer mitigation requested (DWQ only): (square feet)
4e. Riparian wetland mitigation requested: (acres)
Page 8 of 14
PCN Form - Version 1.3 December 10, 2008 Paper Version
4f. Non-riparian wetland mitigation requested: (acres)
4g. Coastal (tidal) wetland mitigation requested: (acres)
4h. Comments:

5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that
requires buffer mitigation?

Yes El No
El
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate
the amount of mitigation required.

Zone 6c.
Reason for impact 6d.
Total impact
(square feet)
Multiplier 6e.
Required mitigation
(square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).

6h. Comments:

Page 9 of 14
PCN Form - Version 1.3 December 10, 2008 Paper Version
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules? Yes ? No
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
Comments:

? Yes ? No
'- /

2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? r "i='s" ate-- "t-- 4' %
2b. Does this project require a Stormwater Management Plan? ? Yes No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
- / ,! S ?/^'? off' GG.. d C.v ,AQ f Ems' Gt'.T rte. r'"'

2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:

2e. Who will be responsible for the review of the Stormwater
Management Plan? ? Certified Local Government
? DWQ Stormwater Program
? DWQ 401 Unit
Page 10 of 14
PCN Form - Version 1.3 December 10, 2008 Version
C. Stormwater Management and Diffuse Flow Plan (required by DWQ), continued
3. Certified Local Government Stormwater Review

3a. In which local government's jurisdiction is this project? r
' Phase If
NSW
3b. Which of the following locally-implemented stormwater F1 US
management programs apply (check all that apply):
ater Supply Watershed
? Other:
3c. Has the approved Stormwater Management Plan with proof
of a
roval been attached?
? Yes ? No J
v
pp
4. DWQ Stormwater Program Review
? Coastal counties
4a. Which of the following state-implemented stormwater
t
l
h ? HQW
? ORW
managemen
programs app
y (c
eck all that apply):
? Session Law 2006-246
? Other:
4b. Has the approved Stormwater Management Plan with proof ? Yes ? No
of approval been attached?
S. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? ? Yes ? No
5b, Have all of the 401 Unit submittal requirements been met? ? Yes ? No
Page 11 of 14
PCN Form - Version 1.3 December 10, 2008 Paper Version
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1a. Does the project involve an expenditure of public (federal/state/local) funds or
the use of public (federal/state) land? Yes ? No
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
? Yes No
1c. If you answered "yes" to the above, has the document review been finalized by
the State Clearing House? (If so, attach a copy of the NEPA or SEPA final
approval letter.)
Comments:

Yes ? No

2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H.1300), DWQ Surface Water or Wetland
Standards, or Riparian Buffer Rules (15A NCAC 2B.0200)?
? Yes ? No
2b. Is this an after-the-fact permit application? Yes Nom
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):

3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts)
result in additional development, which could impact nearby downstream water
quality? _
E ]Yes ?No
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance
with the most recent DWQ policy. If you answered "no," provide a short narrative description.

Page 12 of 14
PCN Form -Version 1.3 December 10, 2008 Version
4. Sewage Disposal (DWQ Requirement)
4a. 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.

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species
or habitat?
1-1 Yes ? No
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts?
? Yes []-No

5c. If yes, indicate the USFWS Field Office you have contacted. ? Raleigh

? Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated
Critical Habitat?

6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish
habitat?
F1 Yes R_
No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?

Page 13 of 14
PCN Form -- Version 1.3 December 10, 2008 Paper Version
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
Yes No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?

8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? E]Yes OrNo
8b. If yes, explain how project meets FEMA requirements:

8c, What source(s) did you use to make the floodplain determination?

13
Applicant/Agent's Printed Name ` Applicant/Agent's Signature
(Agent's signature is valid only if an authorization letter from the
a licant is rovided. Date
Page 14 of 14
PCN Form -Version 1.3 December 10, 2008 Paper Version
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