20041657 Ver 1_COMPLETE FILE_20041013

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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
October 15, 2004
DWQ Project # 04-1657
Forsyth County
Paul ad Margaret Harrell
2405 Buchanan Street
Winston-Salem, NC 27127
Subject Property: Corner of Buchanan Street and West Sprague, Winston-Salem, NC
Approval of 401 Water Quality Certification with Additional Conditions
Dear Mr. & Ms. Harrell:
You have our approval, in accordance with the attached conditions and those listed below, to place fill
within or otherwise impact 140 feet of streams for the purpose of expanding the parking lot at the subject
property, as described within your application dated October 8, 2004 and received by the N.C. Division of
Water Quality (DWQ) on October. 13, 2004. After reviewinj. your application, we have decided that the
impacts are covered by General Water Quality Certification N?mber(s) 3402 (GC3402). The
Certification(s) allows you to use Nationwide Permit(s) 39 whon issued by the US Army Corps of
Engineers (USACE). In addition, you should obtain or otherwise comply with any other required federal,
state or local permits before you go ahead with your project including (but not limited to) Erosion and
Sediment Control, and Non-discharge regulations. Also, this approval to proceed with your proposed
impacts or to conduct impacts to waters as depicted in your application shall expire upon
expiration of the 404 or CAMA Permit.
This approval is for the purpose and design that you described in your application. If you change your
project, you must notify us and you may be required to send us a new application. If the property is sold,
the new owner must be given a copy of this Certification and approval letter and is thereby responsible for
complying with all conditions. If total fills for this project (now or in the future) exceed one acre of
wetland or 150 linear feet of stream, compensatory mitigation may be required as described in 15A
NCAC 2H.0506 (h). This approval requires you to follow the conditions listed in the attached
certification and any additional conditions listed below.
The Additional Conditions of the Certification are:
1. Impacts Approved
The following impacts are hereby approved as long as all of the other specific and general
conditions of this Certification (or Isolated Wetland Permit) are met. No other impacts are
approved including incidental impacts:
Amount Approved Plan Location or Reference.
(Units)
Stream 140 (feet)
401 Wetlands Certification Unit
1650 Mail Service Center, Raleigh, North Carolina 27699-1650
2321 Crabtree Boulevard, Suite 250, Raleigh, North Carolina 27604
Phone: [phone] / FAX [phone] / Internet: htto://h2o.enr.state.nc.us/ncwetiands
None Caroina
Natyra!!ty
Paul & Margaret Harrell
Page 2 of 3
October 15, 2004
2. Erosion & Sediment Control Practices
Erosion and sediment control practices must be in full compliance with all specifications
governing the proper design, installation and operation and maintenance of such Best
Management Practices in order to protect surface waters standards:
a. The erosion and sediment control measures for the project must be designed, installed,
operated, and maintained in accordance with the most recent version of the North Carolina
Sediment and Erosion Control Planning and Design Manual.
b. The design, installation, operation, and maintenance of the sediment and erosion control
measures must be such that they equal, or exceed, the requirements specified in the most
recent version of the North Carolina Sediment and Erosion Control Manual. The devices
shall be maintained on all construction sites, borrow sites, and waste pile (spoil) projects,
including contractor-owned or leased borrow pits associated with the project.
c. For borrow pit sites, the erosion and sediment control measures must be designed, installed,
operated, and maintained in accordance with the most recent version of the North Carolina
Surface Mining Manual.
d. The reclamation measures and implementation must comply with the reclamation in
accordance with the requirements of the Sedimentation Pollution Control Act.
3. No Waste, Spoil, Solids, or Fill of Any Kind i
No waste, spoil, solids, or fill of any kind shall occur \wetlands, waters, or riparian areas beyond
the footprint of the impacts depicted in the Pre-ConstrucAon Notification. All construction
activities, including the design, installation, operation, and maintenance of sediment and erosion
control Best Management Practices, shall. be performed so that no violations of state water quality
standards, statutes, or rules occur.
4. No Sediment & Erosion Control Measures w/n Wetlands or Waters
Sediment and erosion control measures shall not be placed in wetlands or waters to the maximum
extent practicable. If placement of sediment and erosion control devices in wetlands and waters
is unavoidable, they shall be removed and the natural grade restored within six months of the date
that the Division of Land Resources has released the project.
5. Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable
Buffer Rules, and any subsequent modifications, the applicant is required to return the attached
certificate of completion to the 401/Wetlands Unit, North Carolina Division of Water Quality,
1650 Mail Service Center, Raleigh, NC, 27699-1650.
Violations of any condition herein set forth may result in revocation of this Certification and may result in
criminal and/or civil penalties. The authorization to proceed with your proposed impacts or to conduct
impacts to waters as depicted in your application and as authorized by this Certification, shall expire upon
expiration of the 404 or CAMA Permit.
If you do not accept any of the conditions of this Certification (associated with the approved wetland or
stream impacts), you may ask for an adjudicatory hearing. You must act within 60 days of the date that
you receive this letter. To ask for a hearing, send a written petition, which conforms to Chapter 150B of
the North Carolina General Statutes to the Office of Administrative Hearings, 6714 Mail Service Center,
Raleigh, N.C. 27699-6714. This certification and its conditions are final and binding unless you ask for a
hearing.
Paul & Margaret Harrell
Page 3 of 3
October 15, 2004
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water
Act. If you have any questions, please telephone Cyndi Karoly in the Central Office in Raleigh at 919-
733-9721 or Daryl Lamb in the DWQ Winston-Salem Regional Office at 336-771-4600.
Sincerely,
Alan W. Klimek, P.E.
AWKIbs
Enclosures: GC 3402
Certificate of Completion
cc: USACE Raleigh Regulatory Field Office
DWQ Winston-Salem Regional Office
DLR Winston-Salem Regional Office
File Copy
Central Files
Filename: 04-1657 Pauls Cycling and Fitness (Forsyth) 401
W
Paul's Cycling and Fitness W240.1 Buchanan Street
inston-Salem, NC 27127
[phone],
October 8, 2004
Andrea Wade 4Q-j J?i®
Division of Water Quality
2321 Crabtree Blvd. 041657
Suite 250
Raleigh, NC 27604-2260
Dear Ms. Wade:
Paul's Cycling and Fitness on Buchanan Street is planning on expanding our parking area to the rear of
the building. To be able to do this, we need to extend the 60" CMP that begins on our property and then
leads under Buchanan Street. We plan on extending this pipe 140' to allow for the planned additional
gravel parking lot.
Please find seven (7) copies the attached site plan, vicinity map and Preconstruction Notification
Application Form for you use and approval.
The planned land disturbing activity is less than 10,000 square feet, so an erosion control permit is not
required by the City of Winston-Salem's Inspection Division.
Thank you for your attention to this matter and please let us know if you have any questions.
Sin erely,
Paul Harrell, Sr.
- D
c) (: r 3 2004
WETLANDS AND iORMWATERBRANCH
Office Use Only: 041657 Form Version May 2002
USACE Action ID No. DWQ No.
(If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A".)
1. Processing
Check all of the approval(s) requested for this project:
X Section 404 Permit ? Riparian or Watershed Buffer Rules
? Section 10 Permit ? Isolated Wetland Permit from DWQ
X 401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested: NWP 39
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 Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (verify availability with NCWRP 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
1. Owner/Applicant Information
Name: Paul and Margaret Harrell
Mailing Address: 2405 Buchanan Street, Winston-Salem, NC 27127
Telephone Number: [phone] Fax Number: [phone],
E-mail Address: [e-mail]
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:
Page 5 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long 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;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: Paul's Cycling & Fitness Pipe Extension,
2. T.I.P. Project Number or State Project Number (NCDOT Only): N/A
3. Property Identification Number (Tax PIN): 6834-05-0556
4. Location
County: Forsyth Nearest Town: Winston-Salem
Subdivision name (include phase/lot number): N/A
Directions to site (include road numbers, landmarks, etc.): I-40 to exit 192 (Peters Creek
Parkway), turn left on Peters Creek Parkway, turn right on Silas Creek Parkway, turn left on
Buchanan Street, property on the right.
5. Site coordinates, if available (UTM or Lat/Long):Not available
(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.)
6. Property size (acres): 1.44 acres
7. Nearest body of water (stream/river/sound/ocean/lake): Salem Creek
8. River Basin: Yadkin River Basin
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: Commercial property, existing lot developed in front,
overgrown with kudzu in the rear where proposed pipe extension is located
Page 6 of 12
10. Describe the overall project in detail, including the type of equipment to be used: Existing
60" CMP to be extended by 140 feet. Pipe to be installed with backhoe and track hoe. Fill
material to be placed with dump trucks and bulldozer.
11. Explain the purpose of the proposed work: Back section of property is unusable as is. By
extending the pipe, property owner will be able to use area as a gravel lot for employees and
then build a warehouse in the future.
IV. Prior Project History
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.
None anticipated
VI. 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
Provide a written description of the proposed impacts: 140 feet of the Parkway Branch
stream on this property will be piped.
2. Individually list wetland impacts below:
Wetland Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(es/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http://www.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.) Indicate if wetland 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
Site Number
(indicate on ma)
Type of Impact* Length of
Impact
linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
leases eci )
1 Extend Culvert 140' Parkway Branch 20 feet perennial

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usgs.eov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com,
www.mWquest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: 140'
Page 8 of 12
4. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.) below:
Open Water Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Name of Waterbody
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, 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
techniques to be followed during construction to reduce impacts.
Back of Dronertv is verv narrow and is unusable unless stream is Dined. Owner desires extra
parking and future building expansion. All necessary erosion control measures (silt fence and
check dams) will be used and construction will be limited along this 140' long corridor.
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
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as.streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.us/ncwetlands/strmgide.html.
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
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
N/A
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP). Please note it is the applicant's responsibility to contact the NCWRP 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
NCWRP, check the NCWRP website at http://h2o.enr.state.nc.us/wrp/index.htm. If use of
the NCWRP 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):
Page 10 of 12
IX. 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 X
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 213 .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No X 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) Multiplier Required
Mitigation
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; "Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 11 of 12
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or .0260.
XI. Stormwater (required by DWQ)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
Total acreage = 1.44, Exist. Impervious = 0.65, Prop. Impervious = 0.69. Three inlets will lead
directly to culvert, no stormwater controls necessary for such a small increase in impervious area
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.
N/A
XIII. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No X
Is this an after-the-fact permit application?
Yes ? No X
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).
N/A
X - Zoo
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 12 of 12
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Paul's Cycling and Fitness
0UE®
October 8, 2004
Andrea Wade
Division of Water Quality
2321 Crabtree Blvd.
Suite 250
Raleigh, NC 27604-2260
Dear Ms. Wade:
2405 Buchanan Street
Winston-Salem, NC 27127
[phone]
041657
OCT y s 2004
DENR - WATER QUALITY
ILAN S AND STORMW TER BRANCH
Paul's Cycling and Fitness on Buchanan Street is planning on expanding our parking area to the rear of
the building. To be able to do this, we need to extend the 60" CMP that begins on our property and then
leads under Buchanan Street. We plan on extending this pipe 140' to allow for the planned additional
gravel parking lot.
Please find seven (7) copies the attached site plan, vicinity map and Preconstruction Notification
Application Form for you use and approval.
The planned land disturbing activity is less than 10,000 square feet, so an erosion control permit is not
required by the City of Winston-Salem's Inspection Division.
Thank you for your attention to this matter and please let us know if you have any questions.
S71erely,
`+ a.c ?
r
Paul Harrell, Sr.
-W -
Office Use Only: Form Version May 2002
USAGE Action ID No. DWQ No. 041657
ku any parucuiar item is not appucanie to is project, please enter "Not Applicable" or "N/A".)
1. Processing
1. Check all of the approval(s) requested for this project:
X Section 404 Permit ? Riparian or Watershed Buffer Rules
? Section 10 Permit ? Isolated Wetland Permit from DWQ
X 401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested: NWP 39
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 Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (verify availability with NCWRP 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
1. Owner/Applicant Information
Name: Paul and Margaret Harrell
Mailing Address: 2405 Buchanan Street, Winston-Salem, NC 27127
Telephone Number: [phone] Fax Number: [phone]
E-mail Address: [e-mail]
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:
Page 5 of 12

III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long 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;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps' are provided.
1. Name of project: Paul's Cycling & Fitness Pipe Extension
2. T.I.P. Project Number or State Project Number (NCDOT Only): N/A
3. Property Identification Number (Tax PIN): 6834-05-0556
4. Location
County: Forsyth Nearest Town: Winston-Salem
Subdivision name (include phase/lot number): N/A
Directions to site (include road numbers, landmarks, etc.): I-40 to exit 192 (Peters Creek
Parkway), turn left on Peters Creek Parkway, turn right on Silas Creek Parkway, turn left on
Buchanan Street, property on the right.
5. Site coordinates, if available (UTM or Lat/Long):Not available
(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.)
6. Property size (acres): 1.44 acres
7. Nearest body of water (stream/river/sound/ocean/lake): Salem Creek,
8. River Basin: Yadkin River Basin
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at hllp:Hh2o.enr.state.nc.us/admin/mMs/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: Commercial property, existing lot developed in front,
overgrown with kudzu in the rear where proposed pipe extension is located
Page 6 of 12
10. Describe the overall project in detail, including the type of equipment to be used: Existing
60" CMP to be extended by 140 feet. Pipe to be installed with backhoe and track hoe. Fill
material to be placed with dump trucks and bulldozer.
11. Explain the purpose of the proposed work: Back section of property is unusable as is. By
extending the pipe, property owner will be able to use area as a gravel lot for employees and
then build a warehouse in the future.
IV. Prior Project History
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.
N/A
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.
None anticipated
VI. 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
Provide a written description of the proposed impacts: 140 feet of the Parkway Branch
stream on this property will be piped.
2. Individually list wetland impacts below:
Wetland Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(yes/no Distance to
Nearest Stream
(linear feet
Type of Wetland***

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http://www.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.) Indicate if wetland 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
Site Number
indicate on ma
Type of Impact* Length of
Impact
linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
(please secify)
1 Extend Culvert 140' Parkway Branch 20 feet perennial

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditchingistraightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usgs.eov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com,
www.mWguest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: 140'
Page 8 of 12
4. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.) below:
Open Water Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres)
Name Water)
(if applicable) Type of Waterbody
(lake, and estuary,
bay, ocean, etc) sound,

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, 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
techniques to be followed during construction to reduce impacts.
Back of monertv is verv narrow and is unusable unless stream is Dined. Owner desires extra
parking and future building expansion. All necessary erosion control measures (silt fence and
check dams) will be used and construction will be limited along this 140' long corridor.
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
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.us/ncwetlands/strmaide.html.
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
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
N/A
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP). Please note it is the applicant's responsibility to contact the NCWRP 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
NCWRP, check the NCWRP website at http://h2o.enr.state.nc.us/wrp/index.litm. If use of
the NCWRP 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):
Page 10 of 12
IX. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federaUstate) funds or the use of public
(federal/state) land?
Yes ? No X
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 X 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 Multiplier Required
Mitigation
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 11 of 12
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or .0260.
XI. Stormwater (required by DWQ)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
Total acreage = 1.44, Exist. Impervious = 0.65, Prop. Impervious = 0.69. Three inlets will lead
directly to culvert, no stormwater controls necessary for such a small increase in impervious area
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.
N/A
XIII. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No X
Is this an after-the-fact permit application?
Yes ? No X
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).
N/A

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