20020514 Ver 1_COMPLETE FILE_20020404

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June 13, 2002
Rutherford County
DWQ Project #: 02-0514
APPROVAL OF 40lQuality Certification with ADDITIONAL CONDITIONS
Blanton and Miller, DDS
363 North Main Street
Rutherfordton, NC 28,139
Dear Sirs:
You have our approval, in accordance with the attached conditions, to place fill in 100 linear feet
of streams for the purpose of constructing a road crossing Blanton and Miller Office Park (Office Park
Street extension) as you described in your application dated April 26, 2002 with a revision received in
DWQ's Asheville Regional Office on May 29, 2002. After reviewing your application, we have
decided that this fill is covered by General Water Quality Certification Number 3375, which may be
viewed on our website at http://h2o.enr.state.nc.us/ncwetlands. This certification allows you to use
General Permit Number 14 when the Corps of Engineers issues it. In addition, you should get any
other federal, state or local permits before you go ahead with your project including (but not limited to)
Sediment and Erosion Control, Coastal Stormwater, Non-Discharge and Water Supply Watershed
regulations. This approval will expire when the accompanying 404 or CAMA permit expires
unless otherwise specified in the General Certification.
This approval is only valid for the purpose and design that you described in your application
except as modified below. If you change your project, you must notify us and you may be required to
send us a new application. If the property is sold, the new owner must be given a copy of this
Certification and approval letter and is thereby responsible for complying with all conditions. If total
wetland fills for this project (now or in the future) exceed one acre, compensatory mitigation may be
required as described in 15A NCAC 2H.0506 (h) (6) and (7). This approval shall expire when the
corresponding Nationwide Permit expires or as otherwise provided in the General Certification. For
this approval to be valid, you must follow the conditions listed in the attached certification and any
additional conditions listed below.
IVIIU lav, 1 . I.-Y, u vm i 1-1
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E., Director
Division of Water Quality
1. Upon completion of the project, the applicant shall complete and return the enclosed
"Certification of Completion Form" to notify DWQ that all the work included in the 401
Certification has been completed. The responsible party shall complete the attached form and
return it to the 401/Wetlands Unit of the Division of Water Quality.
2. Stormwater shall be directed to flow at non-erosive velocities across the entire protected stream
buffers.
3. Deed notifications or similar mechanisms shall be placed on all remaining jurisdictional
wetlands and waters or areas within 50 feet of all streams and ponds to notify the state in order
to assure compliance for future wetland and/or water impact. These mechanisms shall be put
in place within 30 days of the date of this letter or the issuance of the 404 Permit (whichever is
later).
a?I,?
0a NR
N. C. Division of Water Quality, 401 Wetlands Certification Unit,
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
[phone] (phone), 919-733-6893 (fax), (http://h2o.enr.state.nc.us/ncwetlands
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory
hearing. You must act within 60 days of the date that you receive this letter. To ask for a hearing, send
a written petition, which conforms to Chapter 150B of the North Carolina General Statutes to the
Office of Administrative Hearings, P.O. Box 27447, Raleigh, N.C. 27611-7447. This certification and
its conditions are final and binding unless you ask for a hearing.
This letter completes the review of the Division of Water Quality under Section 401 of the Clean
Water Act. If you have any questions, please telephone John Dorney at 919-733-1786 or Roger
Edwards at our Asheville Regional Office at 828-251-6208.
Sincerely,
Attachments

cc: Corps of Engineers Asheville Field Office
Asheville DWQ Regional Office
File copy
Central Files
Jonathan Hollifield; Odom and Associates
Klimek, P.E., ire for
MEMORANDUM
TO: John Dorney Regional Contact: Roger Edwards
Non-Discharge Branch WO Supervisor: Eor est Westall
Date:
SUBJECT: WETLAND STAFF REPORT AND RECOMMENDATIONS
Facility Name Office Park Street Extension
Project Number 02 0514
Recvd From APP
Received Date 4/4/02 Recvd By Region 5/10/2002
Project Type road extension
County Rutherford
County2
Region Asheville
Certificates Stream Stream Impacts (ft.)
Permit Wetland Wetland Wetland Stream Class Acres Feet
Type Type Impact Score Index Prim. Supp. Basin Req. Req.
14 -Stream p Y -@N F__ 9-26 F_C -F_ 30,802. F_ 80.00 F_- r-
Mitigation Wetland
MitigationType Type Acres Feet
Is Wetland Rating Sheet Attached? Q Y 0 N Did you request more info? QQ Y 0 N
Have Project Changes/Conditions Been Discussed With Applicant? Q Y 0 N
Is Mitigation required? Q Y Q N Recommendation: pQ Issue p Issue/Cond O Deny
Provided by Region: Latitude (ddmmss) Longitude (ddmmss)
Comments:
Plans received on May 10 indicated a section of culvert on the south east corner of the project that
was not included in the application. The engineer redesigned (sent to RO on May 29) this area of the
eject to eliminate the culvert (revised plans will be forwared to wetlands unit by cr ourier)_ The
length of culvert on the plans scales to be just over 100 feet, which is under the allowable 150 ft,
cc: Regional Office
Central Office Page Number 1
MEMO
TO: V\IC &/ L &Z
DATE: Z
SUBJECT: 62 O 5

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From: (/-?Gr l c?,p
STATE a;
North Carolina Department of Environment,
Health, and Natural Resources g? Printed on Recycled Paper
44 QW'n Ndp-..
;4*
MEMORANDUM
TO: John Dorney Regional Contact:
Non-Discharge Branch WQ Supervisor:
Date:
SUBJECT: WETLAND STAFF REPORT AND RECOMMENDATIONS
Facility Name Office Park Street Extension
Project Number 02 0514
Recvd From APP
Received Date 4/4/02 Recvd By Region 5/10/2002
Project Type road extension
County Rutherford
County2
Region Asheville
Certificates Stream Stream Impacts (ft.)
Permit Wetland Wetland Wetland Stream Class Acres Feet
Type Type Impact Score Index Prim. Supp. Basin Req. Req. BE
14 Stream O Y -@)N ?- 9-26 ?? 30,802. F- 80.00 F_ ?-
r__ f?_. o Y O N f -?????__ F- f
Mitigation Wetland
MitigationType Type Acres Feet
F-1 F_
Is Wetland Rating Sheet Attached? 0 Y 0 N Did you request more info? Q Y 0 N
Have Project Changes/Conditions Been Discussed With Applicant? Q Y 0 N
Is Mitigation required? 0 Y O N Recommendation: Q Issue 0 Issue/Cond 0 Deny
Provided by Region: Latitude (ddmmss) Longitude (ddmmss)
Comments:
Plans received on May 10 indicated a section of culvert on the south east corner of the project that
was not included in the application. The engineer redesigned (sent to RO on May 29) this area of the
project to eliminate the culvert (revised plans will be forwared to wetlands unit by courier). The
length of culvert on the plans scales to be just over 100 feet, which is under the allowable 150 ft,
cc: Regional Office
Central Office Page Number 1
Triage Check List
Date: S - o(* - b l-
To: ?RRO Steve Mitchell Project Name 0 i? c - PnIv C t-t?C 1
?FRO Ken Averitte DWQ Project Number O 2L05 1
?WaRO Deborah Sawyer County S&'?pC-CDf CI
?WiRO Joanne Steenhuis
?WSRO Jennifer Frye
ARO Mike Parker
?MRO Pete t:olwell
From:
Telephone (919) 733- ?? uv
The file attached is being forwarded to you for your evaluation. Please call if you need
assistance.
? Stream length impacted
? Stream determination
? Wetland determination and distance to blue-line surface waters on USGW topo maps
? Minimization/avoidance issues
? Buffer Rules (Neuse, Tar-Pamilco, Catawba, Randleman)
? Pond fill
? Mitigation Ratios
? Ditching
? Are the stream and or wetland mitigation sites available and viable?
? Check drawings for accuracy
? Is the application consistent with pre-application meetings?
? Cumulative impact concerns
Comments
5 ?-orrn n ?nh- M(?P ? ??? --
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10 Odom
&Associates
Engineering, Inc.
CERTIFIED MAIL
April 26, 2002
Mr. John Dorney
Division of Water Quality
2321 Crabtree Boulevard
Parkview Building
Suite 250
Raleigh, North Carolina 27604
Dear Mr. Dorney:
020514;
APR g 1, ,
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....?ATE?? G?? P
RE: Blanton & Miller Office Park Corrections
Rutherford County, North Carolina
DWQ # 02-0514
The following responses directly correlate with your letter of April 12, 2002:
1. 7 completed copies of the application are included with this letter
2. 7 copies of the site plan are enclosed with this letter
3. The impervious surface was originally 0.38 acres and will now be 1.27 acres.
Should you have any questions or comments regarding this matter, please do not hesitate
to give me a call.
Sincerely,
(;2r? q2(e?
Jonathan F. Hollifield
152 East Main Street • Forest City, North Carolina 28043 • [phone] • Fax [phone]

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OF A
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 are requesting an Individual 404 Permit or Individual 401
Water Quality Certification. The USACE Individual Permit application form is available online at
htW://www.saw.usace.army.mil/wetlands/Penn app.htm.
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 hn://www.saw.usace.army.mil/wetlands/regtour.htm, or contact one of the field
offices listed at the end of this application. The website also lists the responsible project manager for
each county in North Carolina and provides additional information 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 the 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/ncwetlands 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 some 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 also 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 the last page of this application).
Page 1 of 12
CAMA Coordination - If the project occurs in any of North Carolina's twenty coastal counties (listed on
the last page of this application) the applicant should also contact the North Carolina Division of Coastal
Management (DCM) at [phone]. DCM will determine whether or not the project involves a
designated Area of Environmental Concern, in which case DCM will act as the lead permitting agency.
In such cases, DCM will require a Coastal Area Management Act (CAMA) Permit and will coordinate
the 404/401 Permits.
USACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms,
photos, etc. to the applicable USACE Regulatory Field Office (addresses are listed at the end of this
application). 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.usace.army.mil/wetlands/nwpfinalFedRegpdf.
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 required 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 fee 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, see the DWQ website at http://h2o.ehnr.state.nc.us/ncwetlands/fees.html. 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
Office Use Only: Form Version April 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.
I. 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: NW 14
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
Owner/Applicant Information
Name: Blanton & Miller DDS
Mailing Address: 363 North Main Street
Rutherfordton, NC 28139
Telephone Number: [phone] Fax Number:
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: Odom & Associates
Company Affiliation: Consulting Engineer
Mailing Address: P.O. Box 1787
Shelby, North Carolina 28152
Telephone Number: [phone] Fax Number: [phone]
E-mail Address: [e-mail]
Page 3 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: Office Park Street Extension
2. T.I.P. Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location
County: Rutherford Nearest Town: Rutherfordton
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.):
Take Highway 221 South from I-40. Project is located directly across from Green Street
immediately before entering the Town of Rutherfordton
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 time of this application:
N/A (open field)
7. Property size (acres): Approximately 3.34 acres
8. Nearest body of water (stream/river/sound/ocean/lake): Cleghorn Creek
9. River Basin: Broad
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/mgps/.)
Page 4 of 12
v
10. Describe the purpose of the proposed work: To build an access road for new development
11. List the type of equipment to be used to construct the project:
Dozer, track hoe, compactor, paving machine, curbing machine
12. Describe the land use in the vicinity of this project:
Commercial
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 additional permit requests anticipated for this project in the future? 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.
Page 5 of 12
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***
N/A

* 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 httn://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 secif )
1 Culvert 80 UT Cleghorn Creek 3 Perennial

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usgs.gov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com,
www.mgpquest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: 80
Page 6 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 ma)
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): ? uplands ? 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: N/A
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 is the only viable access area to this property.
Page 7 of 12

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/strmizide.html.
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.
Page 8 of 12
r

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/wrp/index.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet): 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
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
(Neuse), 15A NCAC 213 .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:
Page 9 of 12

Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3 N/A
2 1.5 N/A
Total N/A
* 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.
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 existing impervious acreage is 0.38 acres and proposed is 1.27 acres. On-site storm water
Systems are proposed and will drain into the creek. During construction, erosion control
Control measures will be in place to reduce sediment entering the stream.
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 wastewater generated by this project will be sent to the Town of Rutherfordton
wastewater treatment 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
Page 10 of 12

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).
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
US Army Corps Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Office Alexander Cherokee Iredell Mitchell
US Army Corps of Engineers Avery Clay Jackson Polk
151 Patton Avenue Buncombe Cleveland Lincoln Rowan
Room 208 Burke Gaston Macon Rutherford
Asheville, NC 28801-5006 Cabarrus Graham Madison Stanley
Telephone: [phone] Caldwell Haywood McDowell Swain
Fax: [phone] Catawba Henderson Mecklenburg Transylvania
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham
US Army Corps Of Engineers Alleghany Edgecombe Lee Stokes
6508 Falls of the Neuse Road Ashe Franklin Nash Surry
Suite 120 Caswell Forsyth Northampton Vance
Raleigh, NC 27615 Chatham Granville Orange Wake
Telephone: [phone] Davidson Guilford Person Warren
Fax: [phone] Davie Halifax Randolph Wilkes
Washington Regulatory Field Office
US Army Corps Of Engineers
Post Office Box 1000
Washington, NC 27889-1000
Telephone: [phone]
Fax: [phone]
Beaufort Currituck Jones
Bertie Dare Lenoir
Camden Gates Martin
Carteret* Green Pamlico
Chowan Hertford Pasquotank
Craven Hyde Perquimans
Wilmington Regulatory Field Office Anson Duplin Onslow
US Army Corps Of Engineers Bladen Harnett Pender
Post Office Box 1890 Brunswick Hoke Richmond
Wilmington, NC 28402-1890 Carteret Montgomery Robeson
Telephone: [phone] Columbus Moore Sampson
Fax: [phone] Cumberland New Hanover Scotland
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
Page 11 of 12
S
A
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]
North Carolina State Agencies
Division of Water Quality
401 Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
Telephone: [phone]
Fax: [phone]
Division of Water Quality
Wetlands Restoration Program
1619 Mail Service Center
Raleigh, NC 27699-1619
Telephone: [phone]
Fax: [phone]
State Historic Preservation Office
Department Of Cultural Resources
4617 Mail Service Center
Raleigh, NC 27699-4617
Telephone: [phone]
Fax: [phone]
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 Ashe 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
Page 12 of 12
\O?oF w A r?q
r
O -?
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D.
Acting Director
Division of Water Quality
April 12, 2002
DWQ # 02-0514
Rutherford County
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
Blanton & Miller, DDS
363 North Main Street
Rutherfordton, NC 28139
Dear Sirs:
On April 4, 2002 the Division of Water Quality (DWQ) was notified by receipt of your application
regarding your plan to fill wetlands for the purpose of a road extension in Rutherford County. Approval from
DWQ is required to disturb these areas. Please provide 7 copies of the following information and refer to the
DWQ # listed above in your reply. In particular as described in 15A NCAC 2B .0502, we will require you to
locate all streams and ponds on the property. Please show these on maps of suitable scale (for instance V = 100
feet) so we can begin to determine your projects' compliance with 15A NCAC 2H .0500.
Complete section IX, X, XI and XIII of the PCN form especially section (XI) concerning
stormwater.
Provide a site plan with all proposed buildings, parking areas and other impervious surfaces in
relation to impacted streams and wetlands.
What is the impervious surface area proposed on this site?
Please telephone me at 919-733-1786 if you have any questions or would require copies of our rules or
procedural materials. This project will remain on hold as incomplete in accordance with 15A NCAC 2H
.0505(c). The processing time for this application will begin when this information is received. If we do not
hear from you by writing within three (3) weeks we will assume you no longer want to pursue the project and
will consider it withdrawn.
Sincerely,
cc: Asheville DWQ Regional Office
Asheville Corps of Engineers
Central Files
File Copy
Odom & Associates
t
hn Domey
ater Quality <eri-ti cation Program
V
N5EM1R
North Carolina Division of Water Quality. Wetlands/401 Certification Unit
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
Ph: [phone], Fax: [phone], http://h2o.enr.state.nc.uslncwetiands/
' l1,tITYStc.1? ..
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 are requesting an Individual 404 Permit or Individual 401
Water Quality Certification. The USACE Individual Permit application form is available online at
http://www.saw.usace.anny.mil/wetlands/Perm app.htm.
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 hM://www.saw.usace.army.mil/wetlands/reglour.htin, or contact one of the field
offices listed at the end of this application. The website also lists the responsible project manager for
each county in North Carolina and provides additional information 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 the 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/ncwetlands 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 some 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 also 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 the last page of this application).
Page 1 of 1
CAMA Coordination - If the project occurs in any of North Carolina's twenty coastal counties (listed on
the last page of this application) the applicant should also contact the North Carolina Division of Coastal
Management (DCM) at [phone]. DCM will determine whether or not the project involves a
designated Area of Environmental Concern, in which case DCM will act as the lead permitting agency.
In such cases, DCM will require a Coastal Area Management Act (CAMA) Permit and will coordinate
the 404/401 Permits.
USACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms,
photos, etc. to the applicable USACE Regulatory Field Office (addresses are listed at the end of this
application). 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 hqp://www.saw.usace.army.mil/wetlands/nwpfmalFedReg;ndf.
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 required 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 fee 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, see the DWQ website at ho://h2o.ehnr.state.nc.us/ncwetlands/f`ees.html. 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 2
Office Use Only: Form Version April 2001
USAGE 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.
I. 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: ?
H. Applicant Information
1. Owner/Applicant Information
Name: Blanton & Miller DDS
Mailing Address: 363 North Main Street
Rutherfordton. NC 28139
Telephone Number: [phone] Fax Number:
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: Odom & Associates
Company Affiliation: Consulting Engineer
Mailing Address: P.O. Box 1787
Shelby, North Carolina 28152
Telephone Number: [phone] Fax Number: [phone]
E-mail Address: [e-mail]
Page 3 of 3
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: Office Park Street Extension
2. T.I.P. Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location
County: Rutherford Nearest Town: Rutherfordton
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.):
Take Highway 221 South from I-40. Project is located directly across from Green Street
immediately before entering the Town of Rutherfordton
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 time of this application:
N/A (open field)
7. Property size (acres): Approximately 2.5 acres
8. Nearest body of water (stream/river/sound/ocean/lake): Cleghorn Creek
9. River Basin: Broad
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at hlW://h2o.enr.state.nc.us/admin/mVs/.)
Page 4 of 4
10. Describe the purpose of the proposed work: To build an access road for new development
11. List the type of equipment to be used to construct the project:
Dozer, track hoe, compactor, paving machine, curbing machine
12. Describe the land use in the vicinity of this project:
Commercial
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 additional permit requests anticipated for this project in the future? 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 5 of 5
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***
N/A

* 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 hap://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?
leasespecify)
1 Culvert 80 ITT Cleghorn Creek 3 Perennial

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.uFgs¢ov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com
www.manauest.com etc.).
Cumulative impacts (linear distance in feet) to all streams on site: 80
Page 6 of 6
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)
(if Name p Waterbody
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 ap lication.
Pond to be created in (check all that apply): ? uplands [stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.): 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: N/A
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 is the only viable access area to this property.
Page 7 of 7
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
hqp://h2o.enr.state.nc.us/ncwetlands/stnngide.html.
1. Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
N/A
Page 8 of 8
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 b-M:/&20.enr.state.nc.us/wrp/indexltm. 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
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/statellocal)
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 El 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
(Neuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Suppl Buffer Requirements), or other (please identify,
)?
Yes] No ? If you answered "yes", provide the following information:
Page 9 of 9
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* (s cafinpact re feet) Multiplier Mitigation
i
3
2 1.5
Total
' Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
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.
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.
X11L 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 ?
Page 10 of 10
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

071-
H
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
US Army Corps Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Office Alexander Cherokee Iredell Mitchell
US Army Corps of Engineers Avery Clay Jackson Polk
151 Patton Avenue Buncombe Cleveland Lincoln Rowan
Room 208 Burke Gaston Macon Rutherford
Asheville, NC 28801-5006 Cabamrs Graham Madison Stanley
Telephone: [phone] Caldwell Haywood McDowell Swain
Fax: [phone] Catawba Henderson Mecklenburg Transylvania
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham
US Army Corps Of Engineers Alleghany Edgecombe Lee Stokes
6508 Falls of the Neuse Road Ashe Franklin Nash Surry
Suite 120 Caswell Forsyth Northampton Vance
Raleigh, NC 27615 Chatham Granville Orange Wake
Telephone: [phone] Davidson Guilford Person Warren
Fax: [phone] Davie Halifax Randolph Wilkes
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 Hertford Pasquotank
Fax: [phone] Craven Hyde Perquimans
Wilmington Regulatory Field Office Anson Duplin Onslow
US Army Corps Of Engineers Bladen Harnett Pender
Post Office Box 1890 Brunswick Hoke Richmond
Wilmington, NC 28402-1890 Carteret Montgomery Robeson
Telephone: [phone] Columbus Moore Sampson
Fax: [phone] Cumberland New Hanover Scotland
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
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US Fisl
US Fish and Wildlife Service
Raleigh Field Office
Post Office Box 33726
Raleigh, NC 27636-3726
Telephone: [phone]
i and Wildlife Service / National Marine Fisheries Service
US Fish and Wildlife Service National Marine Fisheries Service
Asheville Field Office Habitat Conservation Division
160 Zillicoa Street Pivers Island
Asheville, NC 28801 Beaufort, NC 28516
Telephone: [phone] Telephone: [phone]
North Carolina State Agencies
Division of Water Quality
401 Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
Telephone: [phone]
Fax: [phone]
Division of Water Quality
Wetlands Restoration Program
1619 Mail Service Center
Raleigh, NC 27699-1619
Telephone: [phone]
Fax: [phone]
State Historic Preservation Office
Department Of Cultural Resources
4617 Mail Service Center
Raleigh, NC 27699-4617
Telephone: [phone]
Fax: [phone]
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 Perquinum
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 Ashe Mitchell Wilkes
Kernersville, NC 272849180 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
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