20020149 Ver 1_COMPLETE FILE_20020131

O?0 W A T ?RpG
r
4 ^?
Michael F. Easley
Govemor
William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D., Acting Director
Division of Water Quality
February 1, 2002
DWQ# 02-0149
Forsyth County
Thomas C. Hall
Windsor Investments
2311 West Cone Blvd., Suite 245
Greensboro, NC, 27429
APPROVAL of 401 Water Quality Certtficatlon
Dear Mr. Hall:
You have our approval, in accordance with the attached conditions, to impact 0.05 acre of wetlands in order to
construct the Glenn Meadow Storm Sewer project in Forsyth County, as described in application materials received by the
Divss5on of Water Quality on January 31, 2002. After reviewing your application, we have decided that this work is covered
by General Water Quality Certification Number 3288, which can be downloaded from our web site at
httD- o.enr.state.nc.us/ncwetlands . This Cefff=tion mows to use Nationwide Permit Number 12 when the Corps of
Engineers issues iL In addition, you should get any other federal, state or local permits before you go ahead with your
proie"t including (but not limited to) Sediment and Erosion Control, Coastal Stormwater, Non-Discharge and Water Supply
Walershed regulations. Also this approval will expire when the accompanying 404 permit expires unless otherwise
specifed in the General Certification. Please note that any other proposed impacts to wetlands or streams associated with
this satbdivision, such as road crossings and lot fa may also require application to DWO for written approval of 401 Water
Qua tdy Certification.
Ttts approval is only valid for the purpose and design that you described in your application. If you change your
prc*ct, you must notify us in writing and you nay be required to send us a new application for a new certification. If the
proverty is sold, the new owner must be given a copy of the Certification and approval letter and is thereby responsible for
cornafying with all conditions. If total wetland firs for this project (now or in the future) exceed one acre, compensatory
mitiie? may be required as described in 15A NCAC 2H .0506 (h). For this approval to be valid, you must follow the
condi bras listed in the attached certification.
lfi you do not accept any of the conditions of this certi cation, you may ask for an adjudicatory hearing. You must act
vrithin 60 days of the date that you receive this fir. To ask for a hearing, send a written petition which conforms to
Cha:Aw 150B of the North Carolina General StaftCes to the Office of Administrative Hearings, P.O. Box 27447, Raleigh,
N.C. 27511-7447. T his certification and its condtfons are 11kial and binding unless you ask for a hearing.
Thus fetter completes the review of the Divsiim of Waler Quality under Section 401 of the Clean Water Act. If you have
any gtesbons, please telephone Steve Mitchell in our Raheigh Regional Office at 919-571-4700 or Cyndi Karoly at 919-733-
9721_
Sincerely,
ri.Thorpe,p..
cc: C *pis of Engineers Raleigh Regulatory Field Office
Vrrision-Salem DWQ Regional Office
FAe Copy
Central Files
020149
W-xth Carolina Division of Water QuaRy, Aol Wetiards Certification Unit,
1 WA Mail Service Center, Raleigh, NC 21699-1650 ObaTng Address)
2321 Crabtree Blvd., Raleigh. NC 27EC.A-2250 (Lrr_ndr)n)
......._.l__J_/
-+ -,- .100 - T &0, ' ri-.. ___ __ _.„._ __ -

? t

?OF W q TFRQ
`O G
? r
1
?L?A 1?
O
Pre-Construction Notification (PCN) Application Form
For Section 404 and/or Section 10 Nationwide, Regional and General Permits, Section 401
General Water Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This form is to be used for projects qualifying for any of the U.S. Army Corps of Engineers' (USACE)
Nationwide, Regional or General Permits as required by Section 404 of the Clean Water Act and/or
Section 10 of the Rivers and Harbors Act, and for the North Carolina Division of Water Quality's
(DWQ) associated General 401 Water Quality Certifications. This form is also to be used for any
project requiring approval under any Riparian Buffer Rules implemented by the N.C. Division of Water
Quality. This form should not be used if you arc requesting an Individual 404 Permit or Individual 401
Water Quality Certification. The USACE Individual Pen-nit application form is available online at
http://www.saw.usace.at-iiiy.iiiiI/wetlands/Perlll app.httll.
The USACE is the lead regulatory agency. To review the requirements for the use of Nationwide,
Regional or General permits, and to determine which permit applies to your project, please go to the
USACE website at littt)://www.stw.tisacc.ariiiy.iiiiI/wetlatids/re2toui-.litiii, or contact one of the field
offices listed on page 3 of this application. The website also lists the responsible project manager for
each county in North Carolina and provides additional infonnation regarding the identification and
regulation of wetlands and waters of the U.S.
The DWQ issues a corresponding Certification (General or Individual), and cannot tell tine applicant
which 401 Certification will apply until the 404 Permit type has been determined by the USACE.
Applicants are encouraged to visit DWQ's 401/Wetlands Unit website at
http://h2o.enr.state.nc.us/ncwetIands to read about current requirements for the 401 Water Quality
Certification Program and to determine whether or not Riparian Buffer Rules are applicable. The
applicant is also advised to read the full text of the General Certification (GC) matching the specific 404
Permit requested. In some cases, written approval for General Certifications is not required, provided
that the applicant adheres to all conditions of the GC. Applicants lacking access to the internet should
contact DWQ's Central Office in Raleigh at [phone].
Trout Waters Coordination - Special coordination with the North Carolina Wildlife Resources
Commission (NCWRC) is required for projects occurring in any of North Carolina's twenty-five
counties that contain trout waters. In such cases, the applicant should contact the appropriate NCWRC
regional coordinator (listed by county on page 4 of this application).
Page 1 of 12
Coastal Area Management Act (LAMA) Coordination - If the project occurs in any of North Carolina's
twenty coastal counties (listed on page 4) the applicant should contact the North Carolina Division of
Coastal Management (DCM). DCM will determine whether or not the project is within a designated
Area of Environmental Concern, in which case DCM will act as the lead permitting agency, In such
cases, DCM will require a LAMA Permit and will coordinate the 404/401 Permits.
The applicant may also choose to coordinate with the United States Fish and Wildlife Service to ensure
that the proposed project will have no impact upon any endangered or threatened species or critical
habitat as regulated by the Endangered Species Act, and the State Historic Preservation Office, North
Carolina Department of Cultural Resources to ensure that the proposed project will have no impact upon
any properties listed or eligible for listing on the National Register of Historic Places. Compliance with
these regulations is required to be eligible for any Department of the Army permit. The addresses for
both agencies are listed on page 3 of this application.
USACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms,
photos, etc. to the applicable USACE Regulatory Field Office. Upon receipt of an application, the
USACE will determine if the application is complete as soon as possible, not to exceed 30 days. This
PCN form is designed for the convenience of the applicant to address information needs for all USACE
Nationwide, Regional or General permits, as well as information required for State authorizations,
certifications, and coordination. Fully providing the information requested on this form will result in a
complete application for any of the USACE Nationwide, Regional or General permits. To review the
minimum amount of information that must be provided for a complete PCN for each USACE
Nationwide permit, see Condition 13, 65 Fed. Reg. 12893 (March 9, 2000), available at
http://www.saw.usacc.army.mil/wetlan(is/nwpfinalFcdRe,-.i)(it Processing times vary by permit and
begin once the application has been determined to be complete. Please contact the appropriate
regulatory field office for specific answers to permit processing periods.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise stated
as optional. Incomplete applications will be returned. Submit seven collated copies of all USACE
Permit materials to the Division of Water Quality, 401/Wetlands Unit, 1650 Mail Service Center,
Raleigh, NC, 27699-1650. If written approval is rcquircd or specifically requested for a 401
Certification, then a non-refundable application fee is required. In brief, if project impacts include less
than one acre of cumulative wetland/water impacts and less than 150 feet cumulative impacts to
streams, then a fee of $200 is required. If either of these thresholds is exceeded, then a fce of $475 is
required. A check made out to the North Carolina Division of Water Quality, with the specific name of
the project or applicant identified, should be stapled to the front of the application package. For more
information, sec the DWQ website at http://li2o.ehnr.state.nc.us/ncwctlan(is/fccs.litml. The fee must be
attached with the application unless the applicant is a federal agency in which case the check may be
issued from a separate office. In such cases, the project must be identifiable on the U.S. Treasury check
so that it can be credited to the appropriate project. If written approval is sought solely for Buffer Rules,
the application fee does not apply, and the applicant should clearly state (in a cover letter) that only
Buffer Rule approval is sought in writing. Wetlands or waters of the U.S. may not be impacted prior to
issuance or waiver of a Section 401 Water Quality Certification. Upon receipt of a complete application
for a 401 Certification, the Division of Water Quality has 60 days to prepare a written response to the
applicant. This may include a 401 Certification, an on-hold letter pending receipt of additional
requested information, or denial.
Page 2 of'12
US Army Corps Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Office Alexander Caldwell Haywood McDowell
US Army Corps of Engineers Alleghany Catawba Henderson Mecklenburg
151 Patton Avenue Ashe Cherokee Iredell Mitchell
Room 208 Avery Clay Jackson Polk
Asheville, NC 28801-5006 Buncombe Cleveland Lincoln Rowan
Telephone: [phone] Burke Gaston Macon Rutherford
Fax: [phone] Cabarrus Graham Madison Stanley
?- Raleigh Regulatory Field Office Alamance Franklin Nash Surry
US Army Corps Of Engineers Caswell Forsyth Northampton Vance
6508 Falls of the Neuse Road Chatham Granville Orange Wake
Suite 120 Davidson Guilford Person Warren
Raleigh, NC 27615 Davie Halifax Randolph Wilkes
Telephone: [phone] Durham Johnston Rockingham Wilson
Fax: [phone] Edgecombe Lee Stokes Yadkin
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare Lenoir
Post Office Box 1000 Camden Gates Martin
Washington, NC 27889-1000 Carteret* Green Pamlico
Telephone: [phone] Chowan I Icrtford Pasquotank
Fax: [phone] Craven I lyric Perquimans
Wilmington Regulatory Field Office
US Army Corps Of Engineers
Post Office Box 1890
Wilmington, NC 28402-1890
Telephone: [phone]
Fax: [phone]
Division of Water Quality
401 Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
Telephone: [phone]
Fax: [phone]
Anson Duplin Onslow
Bladen I Iarnett Pender
Brunswick Hoke Richmond
Carteret Montgomery Robeson
Columbus Moore Sampson
Cumberland New Hanover Scotland
North Carolina State Agencies
Division of Water Quality
Wetlands Restoration Program
1619 Mail Service Center
Raleigh, NC 27699-1619
'T'elephone: [phone]
Fax: [phone]
Pitt
Tyrrell
Washington
Wayne
Swain
Transylvania
Union
Watauga
Yancey
*Croatan National Forest Only
State Historic Preservation Office
Department Of Cultural Resources
4617 Mail Service Center
Raleigh, NC 27699-4617
Telephone: [phone]
Fax: [phone]
US Fish and Wildlife Service / National Marine Fisheries Service
US Fish and Wildlife Service US Fish and Wildlife Service National Marine Fisheries Service
Raleigh Field Office Asheville Field Office Habitat Conservation Division
Post Office Box 33726 160 Zillicoa Street Pivers Island
Raleigh, NC 27636-3726 Asheville, NC 28801 Beaufort, NC 28516
Telephone: [phone] Telephone: [phone] Telephone: [phone]
Page 3 of 12
CAMA and NC Coastal Counties
Division of Coastal Management Beaufort Chowan Hertford Pasquotank
1638 Mail Service Center Bertie Craven Hyde Pender
Raleigh, NC 27699-1638 Brunswick Currituck New Hanover Perquimans
Telephone: [phone] Camden Dare Onslow Tyrrell
Fax: [phone] Carteret Gates Pamlico Washington
NCWRC and NC Trout Counties
Western Piedmont Region Coordinator Alleghany Caldwell Watauga
3855 Idlewild Road Ashc Mitchell Wilkes
Kernersville, NC 27284-9180 Avery Stokes
Telephone: [phone] Burke Surry
Mountain Region Coordinator Buncombe Henderson Polk
20830 Great Smoky Mtn. Expressway Cherokee Jackson Rutherford
Waynesville, NC 28786 Clay Macon Swain
Telephone: [phone] Graham Madison "Transylvania
Fax: [phone] Haywood McDowell Yancey
APPLICATION FORM BEGINS ON PAGE 5. PLEASE, DO NOT SUBMIT PAGES 1 - 4.
Page 4 of 12
Office Use Only: Form 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 , E C' .? -.??aa I TTE
D
Check all of the approval(s) requested for this project:
© Section 404 Permit JAN 2 8 2002
Section 10 Permit
® 401 Water Quality Certification f:1,ATOR) F1l i,D 01"" 1(1.1
? 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: Windsor Investments
Mailing Address: 2311 West Cone Boulevard, Suite 245, Northwestern Business
Greensboro, North Carolina 27429
Telephone Number: [phone] Fax Number: [phone]
E-mail Address:
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/A
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
Page 5 of 12
111111. 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 II 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 arc
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 Glenn Meadow
2. T.I.P. Project Number or State Project Number (NCDOT Only): N/A
3. Property Identification Number (Tax PIN): B ock 5622 - Lot 103, 104, 105, & 106
4. Location
County: Forsyth Nearest Town: Abbotts Creek
Subdivision name (include phase/lot number): Glenn Meadow Phase 3
Directions to site (include road numbers, landmarks, etc.): The site is located on
Glenn Hi Road (SR 2678) 1.25 miles west of the intersection of Glenn Hi
Road (SR 2678) and Union Cross Road.
5. Site coordinates, if available (UTM or Lat/Long): N/A
(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 time of this application:
Single Family Housing
7. Property size (acres): 43.136 Acres
8. Nearest body of water (stream/river/sound/ocean/lake): Swaim Urc,ek
9. 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://li20.ciii-.state.nC.Lls/a(imin/maps/.)
Pagc 0 of, 12
10. Describe the purpose of the proposed work: Install storm sewer for roadway crossing
11. List the type of equipment to be used to construct the project: Digging and trenching
egiii pmanf
12. Describe the land use in the vicinity of this project: single family housing;
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:
N/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.
Page 7 of 12
1. Wetland Impacts
Wetland Impact
Site Number
(indicate on map)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(yes/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***
1 drainage .004 Yes 19 forested wetland
2 Fill(roadway) .016 No 76 forested wetland
3 drainage .005 No 329 forested wetland
4 clearing 007 No 392 forested wetland
5 drainage .005 No 490 forested wetland
6 clearing .005 No 565 forested wetland
7 fill .008 No 647, forested 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 bttl2:///www.feina.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: - 15 Ac.
Total area of wetland impact proposed: .05 Ac
2. Stream Impacts, including all intermittent and perennial streams
Stream Impact
Site Number
(indicate on map)
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
(please specify)
N/A

* 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.uses.eov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozonexom,
www.mapguest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: N/A
Page 8 of 12
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 map)
Type of Impact* Area of
Impact
(acres)
Name Wat)
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)
N/A

* 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): 0 uplands F] stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.): N/A
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.): N/A
Size of watershed draining to pond: N/A 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.
This impact must take place in order to access the remaining property. The
only way to get to the remaining property is to cross the stream.
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 deterniining 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.eiii*.state.nc.us/iicwetlands/sti-mgide.htin1.
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.
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 htt2://112o.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): N/A
Amount of buffer mitigation requested (square feet): N/A
Amount of Riparian wetland mitigation requested (acres): N/A
Amount of Non-riparian wetland mitigation requested (acres): N/A
Amount of Coastal wetland mitigation requested (acres): N/A
Page 10 of 12
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes F] No Fx]
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 F] No n
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 F1 No x
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
(Neuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes F-] 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.
lone* Impact
(square feet) Multiplier Required
Mitigation
1 3
2 1.5
Total
Gone I extends out 30 teet perpendicular trom near bank of channel; Lone 2 extends an
additional 20 feet from the edge of Zone I .
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 213.0242 or.0260.
N/A
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.
The density of this site is 2.78 Units/Ac which gives an impervious surface
of 28.3%.
XII. Sewage Disposal (DWQ Only)
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.
The sewer connects into public sewer (City of Winston-Salem).
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).
N/A
c hhU n
?
Applicant/Agent's Signature J Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 12 of 12
?Y
?O
?a
o?
oa
?F s
boo ??
o ?
?o?o w
v
n " O
m Z
CIA ? a o
O ?o
o ? y c?
co i
O
?O
m
rri
r
m
IK
N
C7
2
O
O
r
O
D
O
UI-
0
?o
o?nHO 3&0
a '8 ?d0
d 08 H
O
O
12
O
O
UNION CRO SS ROA
pc-pp"'. i?Ip? Aitf;RaS ii 11 ? !1i ad "pig
q AR 11 s6 Qc ? x
a <? AA 111111 1111
• I"
1101 fill
##44 ? a? N I till
Alit SS11 ?S a 19 p I ----- I y
a r I ?, fig) I
pp qq
1 -4:
m --- - ??)
Q6 O I I \ ; I; N
g g jj 1 N x
510
Cie
y g P I? ? a
' ? ?( T
-T-
'
?& w o s^?. I ?a 4 a N Ph 992
, I I I I I
W `N)
/ r 1 I I I I I
???? m n b ava anon oe (eD I f t-;
I z I p pEB VaUean
Lane
I I I Pa ?? ®I I / ?;
I 1 I- - _l
--L7
`l)
I I y\?.- %. -, 1 1 1 I; ( 1 I I ?4ha etr? I I I I
e/a onend ?.09p (?LDez 'as) (( O1 I 1 j O' I - - -- 1111"'Ir?'_-__ _ _ .=?? I L-L -
-
..................... 7' L:L
I
=_---O_? T-
11 f---------,- I I I e I
I I € '?==Q J '1111 I ?O , O t i? 1I I ?J i I I (? TI J-- 1? ' II ??
J=_ ___
--
a If 11 N ( O 1iilit I f I ---,
--- ! _
... o I , i 1 1 ti_ ?- L _) I a 11 -L----- I I L --O I I; ?- -
pill 1 1 I r----------
Z r r 1
S r?- a I III I I O I i O I li 1 I 0 1 I ab i l j + 9L
I r
II I a at G ---
7 ? t I-
7V Cr1 I I ---_= 1 1 1 fl I f 0? I I N- I I, 1 I Q ? I ® I 0?1 o`i I -- 1 r
..., 1 b Od 00 DDD - - 1 ?' I I N I I i ~ ,1 1 1' ti r O 1 ' o O' __ I; r L?
Z Ns `- _ `Y--' i O I I N I I I I m _ r
if I
I v- I I
I I?O I pip I ,?O II U II ?i11ii 1, m ? ---
I c` I I €i '11 ?I I`--1 --
vpi?
I I ?? ''------ r l
:N1 fill
L- -- f I pip I p p? I ;r 1 I K- y
I ,II _
co end
(DLOZ
NN I I
5311
xN
$ vo
m

ftm
4
ti O n n O
O Sn
ti
?
?
Q)
a =z o^,? tioo `z)
m
^^ U
' 00 \
rn
c0? av3? 001 xoaddr
W 3r>oz
n /
ssV13 3sn
all,
.553NNp1 £Z.1
p.OSP .9t•M
S\
1N37 ?-? .

'U G,) Nm o
M4e
ti? 113
wo??
Co y b
co
y?
to
0
r-?
p
Z
M
F,

0
0
N
0 h-?-I
11
V 1
N
O >

14
i
? i g qyg^
/ / 000 20 / \\
??dd g00 ?/ \\
•XOdd 00 ? \
00
L CY) `
00 \` p0
>
00 p
? ? \ ? 9g Ox gg ?n
o g \
CJ)
/
J I I
1
It
O
I
I W
I O
I
I
I
I
_J
I
I
I
I
I
I
I
2
°
00 [Y \
N C JI

,GL'03s1(313N 1l6 sl 3115
I W103s 4Mtl/1 NZ39901 d,418
30N0 0 -
/ IAl,,
99u pLB LL9 ?Q
? I I
9L9 ?? \ I
? \ OL9 4LH ? OD? I 1\?I?j 1
1 I `
I I
j HL9 I I
'lH
+ -?-_J
00+

A A
V ??N In? I
I
o
/ N u??o
g ? I
C
4
g
m
N
J `
I
A
II
"
I
00
N q
1 . t?o J I
00 I
III
m Lz

/ Q
i
I
I
I
I
L
I
I I 11 II
I
cjl
11
I II II
I , II II I
? I ? \ 11 I II
l ? 1 11
II II
II II
11

\
1 II
11 I II
II II
11 II
I

I
11 if
if if
u
If

1 N
\ n II
I 11 I I
/

_ II n
?7JII II II I

II II
11
I II II 1I\
11 I
?

1\
\? II
- ?_
n II
I 11 I
u
11

---_ ___ - II
_ I 11 II
--
{I 11 II

\

\ I
II II
II I II
11 II
I 11 11
11 II
II
if
n II
II II

\
l
1
\ II I II
11 II
I 11 II
11 II
?
-_ -_-- - 11 II
- I 11 II
_IJI 11 If
11 II

N
0 022

?
I
? II
"
N\ ?{yrn?I??Im??W ?yN ?,A 7

?O-1
C ?•:o. o?
N N

4 ?mrz?m
y?? p[7a
= TI O

?
g
OOZ O
? o M z
??? t3? I--
Z
?
o ? h

m C)

99

00 \ 1
I J UI I
I
L- I
I
1 -
00
00
I N J ?
I I
I I
I
L---°--
co -
(? 1
00
J co
I I
1 I
I I
L------------ J
1 I
0
x-gym
00+0
I - (L
I
e69
t
N
P 0)
P (A
I 9 / \
I I
co cle
80
I co 0 ; 1 I , - - • co L------------J I T 1 1 I 1 ?? CD
I i 1 00 (C)
Q i CA ?I (D 11
I I NO I I \\ w i
+ r------- ?-------J I I I `?
° ; o) ; d --- L--- - ------- 6g
I I Z69
F I ( a' cfl 469
L---------_
r
i d © 0 ???? -------? ------
1 0 I or?? I 1 I I --?
I I I I (9 I I ( -/
I I I I 0 J I I J /
0I I 00 N CD
? cc
I
I CD (? I
N ? I
b
I ? I co
ncy)
I I J ___+
1 00
00
O I
I I 1 / /
I
R
2+00+45
u I II
? \ u II
`? I II I
II II
If
u
II
11
11 II
II I I
11 II
I 1 II II
\ V I 11 II
n II
II II
11 If
- II II
11 I II
® ?? \ 11 II
1 II I,
11
I tl II
u ,1
II II _
? ?R ?N \?? I 11 II
n I I
I II II
II II
If
?VV I1
11 I p ?3 / I n
` 11 II
1 11 I I I
II II
I I
____ I II If
i •51\J _-•??1 ? ? • •• _..•• I:-?_/•... ? L ? ?• • • • ? I IV. i I i t, / l ? I -, r / .', ' I i '. __' \ off' ?'
\ -fib' (?,1' ?'-•,
?,y • • • • t• (( I A ?? ?? I V
I fill,
?;.••'? ?,_ ?)l ? ??... 1. ?? ? ?%?l>' _' ??V ' i . ?-•,'vv;, l,?t`..o;?'? ?'%' i. ? / r' .?j?jG??dLe ? ?? :??? ??1 ??? ? 1 - ? \;?
?L?i `r ;? ?r ` _ ?? •? v a`eo ?_ V ! t:F=FZ?? ??Ck roe BM
VY (?? 111 ??' (Y,h 935 i?
ll?t \ i? ?? ?.99
"
4'????? ?? \J 1 u II ' _?'
HMS
0 /1• R0AO 4
n ?? I ? ICC "L 933 1 ? ? _? - (/J 1 •1 i, ?-}? ii 1 ? ? ?i - op
\ 7i
9 5 ,? • .., ???????1?ro?/??? ??i ?v'??? ?? •?\ V. o???o RI???? 92 ?? ii A/ '? ?v
ah?/? r' _ ??J? I? ??? U ??v II • ??" . I Radar Sig rt?l .• ?, 111( w? (II d
r s0
5 / ( 1, ,I ?ll? i .I Z c
??_? u • ? 1? ? ? Station r
It I?- ??'? i ?? •? it ii /('\ i('. /., -'Y? ?U
el?
[45
?o
,
' ? ? oil ??/ .??'?'_?,?, >. , 1 ? i `?o' • i--" / f
't 64
-\ asc'-?11? _?: ,n11 I ? ?n ??, )' • - ? V' `? ? ? °O _.-.?? ? _? /, f-?A ? 85 ?0 _?? ? ?
J
???11?1 .?-? - HOo?
.A I 'x(11 1 ?? ?m(? ?•. 1f? %?'? ?? ( wil,
'?,?,??
IPA
a
V 1111 p O
50-
769 8741
° 855 I ?? +t? c _ % j . ° : ! I ?.__? ?? i n'•
• S•vo VA IIj e ', ? ??,. ??`1• ? 1-? C- ?\•t??` r t /I ? °• n?. _ • Y
aoo J
_1
P
»
111 , ,. - ??l ??t _ - ? ; ((i ,?, ?? ?J ? ,,, !• ,) V?( _,?I? - I ? ., .}l°._ ..t 1 , -? ?,???.
? ?rr
• ??? `,3 I ' 1
11' I
l
?1 ??-;?// ?1r?,} ??:1, Uhl('"??? ?? . •II;? ??1/
n ?. > -Q I) ?I •? ?????AI?vII? (???) ?? ?.A?L °•????•I( ??--f VA \? (? - - 1•?e 9 8? _. U?????
(
f /
?• o• '978' \ \ I1' 8 Ldke ))\. C
f k,
}I
gas •fo)? ?1?J t V
? ? 1 ??? .1111 ? ? n' ? t •1?` ?.,I( l ? l (\y , (? 19' , ?? ? 1 ? +'' ? ? ??? ? ? ??
\ I < i,
l/ 1
??(? _•? s
1 ( Ir
\ \ \ ` „I ,, I \-r- , ----•l?l I? r -? ? I I 1? ?h--r- - ? ' /` 111 ? ---? 1 ?? / I ? ?? i ?///,? C ?\ ? ; l t I / ? ??? ? <
V ?I? 1 '???? / ??1 ? ??? ? ? ? ?1?• I i. I ' ?1 ? ' to l ? ?? 1???v?(' ,:•!? ? I I ,t?? ? 1 ? I
964' . ?? `V,
? 9/5 ? ii a,?/•?'?° ??' ? ?? ??? 1Z%?????5? ,- h ? ?.? ?
u '? j I h 1 n<? % ?t_I . o 1
_ 19 BM
9
V ?\ :_?- %1 ?o. • ?? ??i, ?7' - sae I "''? / ! v 923
o? J ors If / ?? 1 ?? ??
Mt ve-
.h71)934'• ?? ???L?I \1 _?I tVAv_ ?? Ill ?))?, ??¢i??111t??•,?? / ?? ti
1 ?- J
87
`I, A-
\I1 I I\/
111 \\ ` ??
A -6,
L?A\Y ??????(???)?I?? ??• it, u?
1 I ? f? 0 c ?it ?? d ????' rlf ?'?r?' ?• /pJ?{J
906
9.1 9
`.• - ? ? ? ,•?A?..r\1 •'Ift. 1?? (I ? ? ?B?l 1 pO?I ??( L. ? ?) ?? ? ? ? ? ?
/?. _i.? 404'-
9 ?, ?1 ??? d ri I (C yl-? t ?:? / (????? •.1
_1S ? ?? ?? O S ? i .-? ??Sr?? / ???? ??f i_ ? ? ??? -Il?% l ? , I ? ?? ! ? j _(-?? hll???( _ _ ? ? )? ??? ? ?l //(? • ? ,.>?0
?
1 Q
_?_?. 4._ _1111 ??1 11?1?11I . _ .ll 1?. L,_ (??[?__ _L. ?_[ ?, ?Il_f_ ; 1 (_,1?. ??_ 1 • ^-, ,'r .
l.? 1673 (ELLE .
aI I 1574
4966 I NW 10, 576 • RI rE RIOR -UEOI OC CAL SURVEY WASH1 N°tON n I I M/.I
80° 7'
IIif WA W11 1I I 7 Ml.
518MOIR.E.
Pr
SCALE 1 24000 ROAD CLASSIFICATION
MII h Co
Heav ' I A NF 6 L ,1NF
-1 ? :_ ?: -- - - - = - I Y-duty__.o ? L- ight duty -- an(
uou ?uoo --
3000 - noon oa Doan uuo IF1I Medium-dot rn,va le cANl_
---------------
- - 1 A -? y Unimproved dirt Tol
5 0 1 Kul ()Mt I I I+ W
U. S. Route O State Route
No
CONTOUR INTERVAL 10 FEET 10
(La
DATUM IS MEAN SEA LEVEL
CO PLIES WITH NATIONAL MAP ACCURACY STANDARDS
Y U. . GEOLOGICAL SURVEY, WASHINGTON, D. C. 20242
NG T POGRAPHIC MAPS AND SYMBOLS IS AVAII AHI E ON REQUEST
WINSTON-SALEM EAST, N. C o
N3600-W8007.5/7.5 col
I for
1950 I Sul
AMS 4956 II SW-SERIES V842 Re(
Fin,
EVANS ENGINEERING, INC.
ENGINEERS, PLANNERS, SURVEYORS
4609 DUNDAS DRIVE
GREENSBORO, NORTH CAROLINA 27407
PHONE: [phone] FAX: [phone]
DATE: /- Z9 - O Z

A.M.
CLIENT: J z 3 P.M.
PROJECT: Noi
020
TO: I u l i o Aj OF t'--Vl Tf K OL) A I i 7 q
FROM: CNzIJ !£?T EZ
TO BE DELIVERED [ ] TO BE MAILED [ VJ TO BE PICKED UP [ ]
WORLDWIDE EXPRESS [ ] FEDERAL EXPRESS [ ]
COMMENTS: GLFNS ")o?J L)-5ACE T ?T ,yF?, d?
C f/C" C4