20011734 Ver 1_COMPLETE FILE_20011126

J. MICHAEL LEMON
1101 WARF ROAD r?
LEXINGTON, NC 27292
North Carolina Division of Water Quality
Ms. Cindi Bell -? 5s G
4401 Reedy Creek Road
Raleigh, NC 27607 August 21, 2001
Dear Ms. Bell:
I have been direct by Yadkin, Inc. to contact your office for permission to remove
sediment from the shoreline surrounding my property and the property of my neighbor,
Mr. Douglas Hill. Mr. Hill and I are filling jointly for this permit. Would you please
direct me on the proper procedure for obtaining your permission? Our property is located
in Lexington, NC on High Rock Lake.
Thank you for your assistance.
incerely,
J. chael Lemon
F WATF Michael F. Easley, Governor
O RpG William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
co ? Gregory J. Thorpe, Ph.D.
> Acting Director
O Division of Water Quality
December 10, 2001
DWQ # 01-1734
Davidson County
J. Michael Lemon and Olin Douglas Hill
1101 Warf Road
Lexington, NC 27292
APPROVAL of 401 Water Quality Certification and Additional Conditions
Dear Sirs:
You have our approval, in accordance vrith ine attached conditions, to dredge the area in front of Feezor Flats
subdivision, Lots C and D, High Rock Lake. DarK Dn County, as described in your application materials received by the
Division of Water Quality on November 26, 2001. After reviewing your application, we have decided that this activity is
covered by General Water Quality Certification ?4umber 3280, which can be downloaded from our web site at
http://h2o.enr.state.nc.us/ncwetlands. This Ce7JFrabDn allows the use Regional Permit Number 198200030 when the US
Army Corps of Engineers (USACE) issues it. In addi;:?on, you should get any other federal, state or local permits before you
go ahead with your project including (tut not limited to) Sediment and Erosion Control, Coastal Stormwater, Non-Discharge,
State Stormwater and Water Supply Wa:?e-slrec roulations. Also this approval will expire when the accompanying 404
permit expires unless otherwise specific-d in the Gane-al Certification.
This approval is only valid for the purpose and design that you described in your application. If you change your
project, you must notify us in writing, arc you r..--y he required to send us a new application for a new certification. If the
property is sold, the new owner must t-- ciwen a cDay of the Certification and approval letter and is thereby responsible for
complying with all conditions. If total vwr-ffznd fill for this project (now or in the future) exceed one acre, compensatory
mitigation may be required as descry in 15A NCAC 2H .0506 (h). For this approval to be valid, you must follow the
conditions listed in the attached certification and any additional conditions listed below.
1. All spoil material must be plac=ed in upland arms and properly stabilized.
2. This Certification does not arias far the d-edairg of any wetlands.
If you do not accept any of the oo diticns of this certification, you may ask for an adjudicatory hearing. You must act
within 60 days of the date that you retsive his Ietr?r_ To ask for a hearing, send a written petition which conforms to
Chapter 1506 of the North Carolina Gera l Statutes to the Office of Administrative Hearings, 6714 Mail Service Center,
Raleigh, NC 27699-6714. This cert fcaticn zinc its oo-, dtions are final and binding unless you ask for a hearing.
This letter completes the review of. tip Division &I Water Quality under Section 401 of the Clean Water Act. If you have
any questions, please telephone Jenn-rer" in t` e? DDWQ Winston-Salem Regional Office at 336-771-4600 or Todd St.
John at 919-733-1786.
Attachment
cc: USACE Raleigh Regulatory Field OffxaF
in ely,
?r
g . Thorpe, h.D.
tin irector
i
Winston-Salem DWQ Regional Office 01-1734
File Copy
Central Files
NCDENR
N. C. Division of Water Quality 1650 Mad PAvit.-_ grit- Pdeo, NC 27699-1650 [phone] Customer Service
1 800 623-7748
John Michael Lemon
1 10 1 Warf Road
Lexington, NC 27292
Raleigh Regulatory Field Office
U. S. Army Corps of Engineers
6508 Falls of the Neuse Road
Suite 120
Raleigh, NC 27615
Cc: Division of Water Quality
To whom it may concern:
NOV '2"6 pnnl
011734
01 %% 0E® November 23, 2001
Our proposed project is to remove a build up of silt from the bottom of the cove where
our boat docks are located. Mr. Robbie Cole of Alcoa, who monitors High Rock Lake,
told me that 2 to 3 feet of silt has built up in my cove since my home was built in 1994.
Our water access has been unusable after early July of the last two years.
The silt will be loaded onto dump trucks and brought across town where fill is needed in
a residential area. Access to the lake will be via driveway on my property at 1101 Warf
Rd. Lexington, NC.
The silt removal will be graded so as to prevent any ponding affect. A gradual slop to the
channel of Abbott's creek will be made in accordance with the regulations governing silt
removal.
Thank you for your consideration,
J. Michael Lemon
PAYATNT
RIT"" af)
Office Use Only: 01173 F Version October 2001
?'
USACE Action ID No. DWQ No.
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
1.
Processing
1. Check all of the approval(s) requested for this project:
® Section 404 Permit
? Section 10 Permit
® 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
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 Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ?
II. Applicant Information
1. Owner/Applicant Information
Name: •S : OnaAA?-A_Y-npyi w,-%a 0 V%
Mailing Address: 1 r. 3
I elepnone 1-4umDer:
E-mail Address: %V,
CiiX LVUIIIVCI. JJ ?D - ( 10• J ? l V
2. Agent 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: N / Ik
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
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: r ao? vnQ Vkoaur-r Oa-LA's - 2 ?' o p x??t? 5
2. T.I.P. Project Number or State Project Number (NCDOT Only):
bb - 02%.1-G -00 q - O ok, -q
3. Property Identification Number (Tax PIN): _0 G - 0 2.4- b - CEO R • 003
4. Location wt? ?-?.
County: .yM-,J S on Nearest Town: er' kaYl &OV L Oo S?i p
Subdivision name (include phase/lot number): ?a.?.zor 'La s • l.C?t C ,t h
Directions to site (include road numbers, landmarks, etc.):
5. Site coordinates, if available (UTM or Lat/Long):
(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. Describe the existing, land use or condition of the site at the Vme of this
IV
7. Property size (acres): Z. a
8. Nearest body of water (stream/river/sound/ocean/lake): R.D\:)0-y5 C%-4 Mict?) ?OUC
9. River Basin: 1 0.0,& `'R
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.ear,state.nc.us/admin/maps,?.)
10. Describe the purpose of the proposed work: ?Jex-o.? 80.C?`rrsal??
\c% Waf'
11. List the type of equipment to be used to construct the project: %kkl zu-. d D
12. Describe the land use in the vicinity of this project: Res pnol .
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:
/A
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.
1. Wetland Impacts
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-%16, 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.)
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stream Impacts, including all intermittent and perennial streams
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 specify)
IWA

" 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
-wx%w.usos.eov. Several internet sites also allow direct download and printing of USGS maps (e.g., ww\ti.topozone.coni,
lxlucst.cow, etc.).
Cumulative impacts (linear distance in feet) to all streams on site:
Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U. S.
Open Water Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Name of Waterbody

?plicable)
a
( Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean etc
Vwtztr V143 t- . S y
?
Rb?00 t `?g
%Noe-c, - tos *D

' List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. 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): E] uplands C] stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.): IV / R
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.
No akuy-n aJ? vt.s 0'Q 06' l02k)l .
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.
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/strmp-ide.htmi.
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.
lQ /A
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at http://h2o.enr.state.nc.us/Nvrp/index.hti . 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):. IV f {?
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):
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No 1
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 Butlers (DWQ Only)
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* I Im?ot ,. I Multiplier I Required
1.5
Total I I I
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.
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 (DWQ Only)
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.
XU. Sewage Disposal (DWQ Only)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastew#ter generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? 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).
'V?r„a? - Ei;oh Rick ?n?[a kc s • AoLnv-% \oka _
X/Z
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
??/12i/c
John Michael Lemon FILE COPY
1101 Warf Road
Lexington, NC 27292
Raleigh Regulatory Field Office
U. S. Army Corps of Engineers 6508 Falls of the Neuse Road 011734
Suite 120
Raleigh, NC 27615
Cc: Division of Water Quality
401 ISSUED
To whom it may concern:

November 23, 2001
Our proposed project is to remove a build up of silt from the bottom of the cove where
our boat docks are located. Mr. Robbie Cole of Alcoa, who monitors High Rock Lake,
told me that 2 to 3 feet of silt has built up in my cove since my home was built in 1994.
Our water access has been unusable after early July of the last two years.
The silt will be loaded onto dump trucks and brought across town where fill is needed in
a residential area. Access to the lake will be via driveway on my property at 1101 Warf
Rd. Lexington, NC.
The silt removal will be graded so as to prevent any ponding affect. A gradual slop to the
channel of Abbott's creek will be made in accordance with the regulations governing silt
removal.
Thank you for your consideration,
J. Michael Lemon
PAYM `NT
RECEIVED
T
Office Use Only: Form Version October 2001
USACE Action ID No. DWQ No.O 1 1734
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
1. Processing
1. Check all of the approval(s) requested for this project:
® Section 404 Permit
? Section 10 Permit
® 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
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 Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ?
II. Applicant Information
1. Owner/Applicant
Name: =. `n1:
Mailing Address:_
Telephone Number:, 31-77 IS -!JStnt Fax Number: .33 (o - 219 - 31-7 O
E-mail Address: k%_s& or„„r,r_ . r rt
2. Agent 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: N / 1k
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
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:
2 Dror??
2. T.I.P. Project Number or State Project Number (NCDOT Only):
ob - 02%.J-C3-004 - ook-q
3. Property Identification Number (Tax PIN): 0& - O24 b - OoA - 003
4. Location
County: wsmJ?ClSOn Nearest Town: C`\?oY1 aMV TOw S p
Subdivision name (include phase/lot number): r- F^La+s - Lot Gw h-
Directions to site (include road numbers, landmarks, etc.):
5. Site coordinates, if available (UTM or Lat/Long): N3/ R
(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. Describe the existing.land use ee or condition of the site att he
7. Property size (acres): tVZ. 0.O-V-4,
8. Nearest body of water (stream/river/sound/ocean/lake): 1P1"'.1Z-'o o`KVs Cx- n Rock
9. River Basin:
(Note - this must be one of North Carolina's seventeen designated major river basins, The
River Basin map is available at http://Llo.enr.state.nc.us/admin/maps/.)
10. Describe the purpose of the proposed work: 5exv Q ZL&"naM?
11. List the type of equipment to be used to construct the project: 6sa%X d -r-Ly- A Mf??z- \
12. Describe the land use in the vicinity of this project: ItLs ?darr'?iQJ V ?1..Ca-L41?c?ha?? .
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:
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.
1. Wetland Impacts
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:/AN,%w.feiua.aov.
•'• List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stream Impacts, including all intermittent and perennial streams
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?
lease specify)

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
NNANw-llsgs.Qov. Several internet sites also allow direct download and printing of USGS maps (e.g., %%%"k.topozone.coni,
%«v%.ntalxluest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site:
3, Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U. S.
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.
kr Al a ?- O . S I?bbo`tt'a G- Cr-
0?b?k

• List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. 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 r] stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc,): N/ R
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.
%)o o?l?u?-n ate: vas o.yai to 14_ .
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.
USACE - In accordance with the Final Notice of Issuance and Modifipation 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/strmizide. htH.
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.
?Q /A
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at http://l12o.eiir.statc,nc.us/wa?index.litin. 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): N f {?
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):
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
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 (DWQ Only)
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* I "npa' Multiplier I Required
1.5
Total I I I
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.
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 (DWQ Only)
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.
XU. Sewage Disposal (DWQ Only)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wasN?tteer generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? 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).
\k:oh Rt?cs_e l,ok. ? c Ac%inr \oA<a

//1?i11-
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
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