20190062 Ver 2_401 Application_20200220

Staff Review
Does this application have all the attachments needed to accept it into the review process?
r Yes r No
ID#*
20190062
Version* 2
Is this project a public transportation project?* r Yes
r No
Reviewer List:* Sue Homewood:eads\slhomewood
Select Reviewing Office:* Winston-Salem Regional Office - [phone]
Submittal Type:*
401 Application
Does this project require a request for payment to be sent?*
r
Yes
r
No
How much is r $240.00
owed?* r $570.00

Project Submittal Form
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Type: r
New Project
r
New Project w Existing ID
r
Pre -Application Submittal
r
More Information Response
r
Other Agency Comments
r
For the Record Only (Courtesy Copy)
r
Stream or Buffer Appeal
New Project - Please check the new project type if you are trying to submit a new project that needs an official approval
decision.
Pre -Application Submittal - Please check the pre -application submittal if you just want feedback on your submittal and
do not have the expectation that your submittal will be considered a complete application requiring a formal decision.
More Information Response - Please check this type if you are responding to a request for information from staff and
you have and ID# and version for this response.
Other Agency Comments - Please check this if you are submitting comments on an existing project.
Project Contact Information
Name: Perry Isner
VUio is subrritting the inforrration?
Email Address: [e-mail]
Project Information
Existing ID #: Existing Version:
20190062 1
20170001(no dashes)
Project Name: Verona Subdivision
Is this a public transportation project?
r Yes
r No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
r Yes r No r Unknown
County (ies)
Guilford
Please upload all files that need to be submited.
aick the upload button or drag and drop files here to attach document
Verona_NWP12PCN.pdf 1.51 MB
Only pdf or Iv17 files are accepted.
Describe the attachments:

Revised PCN regarding use of NWP 12 regarding temporary impacts for construction of open -cut sanitary
sewer. Crossing was originally designed as directional bore, which was unable to be completed due to
presence of sub -surface rock which was discovered during construction.
P By checking the box and signing box below, I certify that:
• I have given true, accurate, and complete information on this form;
• I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the
"Uniform Electronic Transactions Act")
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the online form."
Signature:
I Y-7 lwk,
Submittal Date: Is filled in auto ratically.

Page 1 of 10
PCN Form – Version 1.4 January 2009

Office Use Only:
Corps action ID no. _____________
DWQ project no. _______________
Form Version 1.4 January 2009
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1a. Type(s) of approval sought from the Corps: Section 404 Permit Section 10 Permit
1b. 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
because written approval is not required?

For the record only for DWQ
401 Certification:
Yes No
For the record only for Corps Permit:

Yes No
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 bank
or in-lieu fee program.
Yes No
1g. Is the project located in any of NC’s twenty coastal counties. If yes, answer 1h
below. Yes No
1h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? Yes No
2. Project Information
2a. Name of project:
2b. County:
2c. Nearest municipality / town:
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state project no:
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:
3f. Telephone no.:
3g. Fax no.:
3h. Email address:
Verona
Guilford
Burlington
Verona
n/a
BURLINGTON ROAD 140 LLC
008229-00487
Erin Christmas
PO Box 489
Colfax, NC 27235
336.500.8668
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Page 2 of 10
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
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:

Perry Isner
Wetlands & Waters, Inc.
328 East Broad Street, Suite D
Statesville, NC 28677
704.773.4239
[e-mail]

Page 3 of 10
PCN Form – Version 1.4 January 2009
B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
1b. Site coordinates (in decimal degrees): Latitude: Longitude:
1c. Property size: acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
2b. Water Quality Classification of nearest receiving water:
2c. River basin:
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:

3b. List the total estimated acreage of all existing wetlands on the property:
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3d. Explain the purpose of the proposed project:

3e. Describe the overall project in detail, including the type of equipment to be used:

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 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 No Unknown
5b. If yes, explain in detail according to “help file” instructions.

6. Future Project Plans
6a. Is this a phased project? Yes No
6b. If yes, explain.

8834763965
-79.55013
46.55
Back Creek
WS-V;NSW
Cape Fear
The site is currently used entirely for agricultural purposes, primarily for cattle pasture with a dilapidated barn also present. An existing home-site is
not part of the project area and is to remain undisturbed. Existing land use in the vicinity of the project includes residential, some commercial, a
municipal park facility, and agricultural.
1.52
The purpose is to construct an open-cut sanitary sewer connection as directional bore was not feasible due to presence of sub-surface rock. All other
plans and impacts from previous verification remain unchanged. No additional impacts are proposed beyond those required for the open-cut sewer.
The project consists of the proposed development and associated infrastructure including roadways, stormwater facilities, and sanitary sewer.
Typical earth-moving equipment will be utilized including but not limited to excavator, pan, dumptruck, bulldozer, etc.
Wetlands & Waters, Inc.
SAW-2018-01856
36.07695
632
Perry Isner / Tamp Bandy
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Page 4 of 10
PCN Form – Version 1.4 January 2009
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
2d.
Forested
2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other)
2f.
Area of
impact
(acres)
W1
W2
W3
W4
W5
W6
2g. Total Wetland Impacts:
2h. Comments:

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

3f.
Average
stream
width
(feet)
3g.
Impact
length
(linear
feet)
S1
S2
S3
S4
S5
S6
3h. Total stream and tributary impacts
3i. Comments:

Excavation Headwater Wetland No Corps 0.005
Yes/No -
Yes/No -
Yes/No -
Yes/No -
Yes/No -
0.005
Following temporary impacts for purposes of open-cut sanitary sewer installation previous contours will be restored with stockpiled materials and
immediately stabilized per the specifications of the erosion control plan.
Sewer Open-cut UT to Back Creek INT Corps 3 20
20
Following temporary impacts for purposes of open-cut sanitary sewer installation, stream bed and banks will be restored to original contours and
immediately stabilized per the specifications of the erosion control plan.
T
-
-
-
-
-
Choose one
Choose one
Choose one
Choose one
Choose one
Choose one
Choose one
Choose one
Choose one
Choose one
T
-
-
-
-
-
Choose one
Choose one
Choose one
Choose one
Choose one
-
-
-
-
-
-
-
-
-
-
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Page 5 of 10
4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any 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)
O1
O2
O3
O4
4f. Total open water impacts
4g. Comments:

5. Pond or Lake Construction
If pond or lake construction proposed, then complete the chart below.
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(acres)
5a.
Pond ID number
5b.
Proposed use or
purpose of pond
Flooded Filled Excavated Flooded Filled Excavated
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:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If any impacts require mitigation, then you MUST fill out Section D of this form.
6a. Project is in which protected basin? Neuse Tar-Pamlico Catawba Randleman Other:
6b.
Buffer Impact
number –
Permanent (P) or
Temporary (T)
6c.
Reason for impact
6d.
Stream name
6e.
Buffer
mitigation
required?
6f.
Zone 1
impact
(square
feet)
6g.
Zone 2
impact
(square
feet)
B1
B2
B3
B4
B5
B6
6h. Total Buffer Impacts:
6i. Comments:

Choose one Choose
Choose one
Sewer open-cut UT to Back Creek No 1371 817
1371 817
-
-
-
-
Choose one
Choose one
Choose one
Choose
Choose
Choose
Choose one
Jordan
T
-
-
-
-
-
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
)
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Page 6 of 10
PCN Form – Version 1.4 January 2009

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.

1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.

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?
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:
Type:
Type:
Quantity:
Quantity:
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:
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
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.

Impacts are necessary from inability to complete jack-and-bore due to sub-surface rock. Impacts are minimized by crossing at a perpendicular
direction, and coffer-dam and pump around will be utilized in order to maintain downstream aquatic function. Following construction the riparian
buffer will be temporarily maintained.
Project will be constructed under an approved sediment and erosion control plan such that materials incidental to construction activities are not
transported into downstream receiving waters.
Choose one
Choose one
Choose one
Choose one
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Page 7 of 10
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 No
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:

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Page 8 of 10
PCN Form – Version 1.4 January 2009
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
1b. If yes, then is a diffuse flow plan included? If no, explain why.

Yes No
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? %
2b. Does this project require a Stormwater Management Plan? Yes No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:

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?
3. Certified Local Government Stormwater Review
3a. In which local government’s jurisdiction is this project?
3b. Which of the following locally-implemented stormwater management programs
apply (check all that apply):
Phase II
NSW
USMP
Water Supply Watershed
Other:
3c. Has the approved Stormwater Management Plan with proof of approval been
attached? Yes No
4. DWQ Stormwater Program Review
4a. Which of the following state-implemented stormwater management programs apply
(check all that apply):
Coastal counties
HQW
ORW
Session Law 2006-246
Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
attached? Yes No
5. 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

0
Residential project includes construction of a large, permanent stormwater BMP as shown on the attached plan which will adhere to Phase II
specifications.
Burlington
Burlington
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Page 9 of 10
PCN Form – Version 1.4 January 2009

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
1b. 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 No
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? 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.

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.

Project includes construction of sanitary sewer to tie into existing off-site system.
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Page 10 of 10
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? 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.
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? Yes No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?

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? Yes No
8b. If yes, explain how project meets FEMA requirements:

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

Applicant/Agent's Printed Name

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

Date

-
Query of the NC Natural Heritage Program; report is included with previous determination.
NC SHPO Web GIS service. Project is near listed Andrew Gibson Farm, HPO Site ID GF0585, which will be left completely undisturbed.
FEMA National Flood Hazard Layer
Erin Christmas 2/17/2020
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Approximate Wetlandlimits within proposedopen-cut~0.005 acres1,371 sf408 sf409 sf