20020583 Ver 1_COMPLETE FILE_20020416

Michael F. Easley
Governor
William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Alan W. Klimek, PE, Director
Division of Water Quality
August 7, 2002
Halifax Regional Medical Center
P.O. Box 1089
250 Smith Church Road
Roanoke Rapids, NC 27870
Attn: Mr. Paul Sherwood, Senior Vice President
DWQ Project # 02-0583
Halifax County
Page 1 of 2
Subject Property: Access Drive from Old Farm Rd. to Halifax Regional Medical Center, Roanoke Rapids, NC
Chockoyotte Creek [03-02-08, 23-29, C]
APPROVAL of 401 Water Quality Certification with ADDITIONAL CONDITIONS
Dear Mr. Sherwood:
You have our approval, in accordance with the attached conditions and those listed below, to impact approximately 0.24
acres of wetlands and approximately 120 feet of stream at the subject property to construct the road as described within
your application dated April 10, 2002. After reviewing your application, we have determined that the water impacts are
covered by the Division of Water Quality (DWQ) General Water Quality Certification Number 3375. This Certification
allows you to use the Nationwide Permit No. 14 when issued by the US Army Corps of Engineers (USACE). In addition,
you should get or otherwise comply with any other federal, state and local requirements before you go ahead with your
project including (but not limited to) erosion and sediment control regulations. Also, this approval will expire when the
accompanying 404 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 and additional information
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 is thereby responsible for
complying with all conditions. If total fills for this project (now or in the future) exceed one acre of wetland and/or 150 feet
of stream, compensatory mitigation may be required as described in 15A NCAC 2H .0506 (h). For this approval to be
valid, you must follow the conditions listed in the DWQ General Water Quality Certification No. 3375 and any additional
conditions listed below.
Conditions:
• Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer Rules, and any
subsequent modifications, the applicant is required to return the attached certificate of completion to the 401/Wetlands
Unit, North Carolina Division of Water Quality, 1650 Mail Service Center, Raleigh, NC, 27699-1650.
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
North Carolina 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)
919-733-1786 (phone), 919-733-6893 (fax), http://h2o.enr.state.nc.us/ncwetiands/
Page 2 of 2
Chapter 1508 of the North Carolina General Statutes to the Office of Administrative Hearings, 6714 Mail Service Center,
Raleigh, NC 27699-6714. 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 Mr. Steve Mitchell at [phone] or Mr. Bob Zarzecki at [phone].
Sincerely,
i
??'
Alan W. Klimek, P.E.
NC DWQ, Director
Attachment: General Water Quality Certification No. 3375
Certificate of Completion
Cc: Charlie Hollis, Regulatory Consultant, 128 Green Forest Drive, Wilmington, NC 28409
Steve Mitchell, DWQ Raleigh Regional Office
USACE Raleigh Regulatory Field Office, 6508 Falls of Tar-Pamlico Road, Suite 120, Raleigh, NC 27615
File Copy
Central Files
DWQ 020693
August 7, 2002
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ax Regional Medical Center 020583
Subject: Halifax Regional Medical Center 020583
Date: Fri, 19 Jul 2002 12:25:41 -0400
From: Bob Zarzecki <bob.zarzecki @ncmail.net>
Organization: Division of Water Quality; 401 Certification Unit
To: Steve Mitchell <[e-mail]>,
"Debbie Edwards (RRO)" <[e-mail]>
CC: Cyndi Karoly <[e-mail]>
Steve & Debbie:
I spoke to Charlie Hollis today about this project. We need to
determine if stream impacts need to be accounted for. If so, how many
feet and whether they are perennial or intermittent. If not, then they
are requesting 0.24 acres of wetlands in addition to the 0.25 acres of
previously approved (NW26) impacts. This is not a buffer issue (Roanoke
R.; class C). Charlie said that he sent information to you. Have
either of you gone to the site yet? If not, do you plan to go? If not,
let me know and I'll go. I spoke to Amanda and she's going to follow
our lead as to whether there are any streams. This is not buffered and
not my Regional Office assignment, but I'd be willing to conduct the
site visit since I'm familiar with the project. The earliest I can get
up there is August 6th. Let me know if ya'll need me to go. If so,
give me what Charlie gave you. Anyone that goes should call the
surveyor Louis Burr & Associates [phone].
- Bob
Bob Zarzecki
NC DENR/DWQ 401 Wetlands Certification Unit
919-733-9726
7/19/02 12:26 PN
CHARLIE HOLLIS
Regulatory Consultant
138 Green Forest Drive
Wilmington, NC 28409
Phone/FAX [phone]
MAY - 3 2012
May 1, 2002
Project: Nationwide Permit No. 14 and 401 Certification
Access Drive from Old Farm Road to Hospital
Halifax Regional Medical Center
Roanoke Rapids. Halifax County, N.C.
Corps Action ID 200200621
DWQ # 02-0583
Mr. John Dorney
Water Quality Certification Program
N.C. Division of Water Quality
1650 Mail Service Center
Raleigh, NC 27699-1650

Dear Mr. Dorney:
Please be advised that we have gathered information requested in your letter on April 18, 2002 and
plan to meet with a representative of your office (probably Steve Mitchell who has not been available yet to
schedule a meeting) on site to determine the extent that existing old ditches may qualify as "steams" under
the state rules. We do intend to pursue appropriate authorization to construct this road since it is necessary
to insure access to the Hospital from an alternate direction (Old Farm Road).
Thank you for any assistance regarding this project.
Charlie Hollis
Cy: Amanda Jones (COE)
Paul Sherwood (HRMC)
\O?GF W ATF9pG
? r
n -r
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 18, 2002
DWQ # 02-0583
Halifax County
CERTIFIED MAIL - RETURN RECEPT REQUESTED
Halifax Regional Medical Center
Attn: Paul Sherwood
P. O. Box 1089
Roanoke Rapids, NC 27870
Dear Mr. Sherwood:
On April 16, 2002 the Divisimz of Water Quality (DWQ) was notified by receipt of your application
regarding your plan to fill wetlands forthe purpose of a road crossing in Halifax 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. Please show the following items on maps of suitable scale (for instance 1" = 100 feet)
so we can begin to determine your pro*ts' compliance with 15A NCAC 2H .0500.
1. Please provide better desilp details for the (3) crossings including fill slopes, inlet/outlet protection
(e.g. rip-rap) and profiles.
2. It appears that areas I & 11have streams running through them. Will any streams be impacted by the
project? If so, what is thr amount of stream length impacted? (The length should be measured in
feet.)
3. Please complete Section X (stormwater) of the PCN form.
Please telephone Bob Zarzeckiat 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.
hn orne
ater Quality Ce ific ion Program
cc: Raleigh DWQ Regional Office
Raleigh Corps of Engineers
Central Files
File Copy
Charlie Hollis
N MENR
North Carolina Division of Vbter Quality, Wetlands/401 Certification Unit
1650 Mail Service Center, ibleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Ralei* NC 27604-2260 (Location)
Ph: [phone], Fax: (91&)733-6893, http://h2o.enr.state.nc.us/ncwetiands/
Michael F. Easley. Governor
William G. Ross Jr.. Secretary
North Carolina Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D.
Actins Director
Division of Water Quality
Division of Water Quality
Department of Environmental and Natural Resources
Wetlands/401 Unit
Street Address: 2321 Crabtree Boulevard, Suite 250
Raleigh, NC 27604-2260
Mailing Address:
Contact Information:
Fax To: NG? ©,.,.s e--5
Company: OL-. Q - Qa-O
1650 Mail Service Center 4
Raleigh, NC 27699-1650a
Phone #: [phone] 'Fax #: [phone]
Fax #: 91ci - 5-'
Date: a15-a3-o2
Number of pages including cover sheet: Z
Notes or special instructions:
OZ-0,562 O'\ L" Xd uAy".- t[ 161OZ
d*?
7DEM
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
J
CHARLIE HOLLIS
Regulatory Consultant
138 Green Forest Drive
Wilmington, NC 28409
Phone/FAX [phone]
April 10, 2002
Project: Nationwide Permit No. 14
Access Drive from Old Farm Road to Hospital
Halifax Regional Medical Center
Halifax County, N.C.
Corps Action ID (Delineation) 200200621
Mr. John R. Dorney
North Carolina Division of Water Quality
Wetlands/401 Unit
1621 Mail Service Center
Raleigh, NC 27669-1621
Dear Mr. Dorney:
? 620
®2U
Enclosed are seven copies of a Pre-Construction Notification Application for the above-cited project.
Enclosed also is a check in the amount of $200.00 for the Water Quality Certification fee.
Si re ,
Charlie Hollis
Encls: Application (7 cys)
Check
Cy: Ed Kinzer
nor -ice-uG U!=1:37A Halifax Regional ADMIN.
MHK- 1 S-H1 11!52 AM

C ?
tr ?L?1446 ?tOI,L]5
Residuary Cuukultpnt

020583 131 f3fm 10r1tt I?rty$
Wal"Ingmn, NC 2A400
,?I,tar.?:? VIA-3yI.08»
TO "OM IT MAY CONCERN- ,
252 535 8466 p.02
P. 02

APR 1 6 ?002
WETI ; , OS GA'0UP
WATER ?.•Yi^' ?rnT!/1Rl
This is to siuthcrtfie Charlie)iollis, Re$utasoq Confultanr, acrid Mitchell A Associates
Inc., Eltvironmental Comultants under. Mr,1[ollis' dimation to act in my (our) bohAlf to
preparing doeurnaRts, Jixw%ings, forms, and other items its may be necessary to secure
Fthral at:ldlur stale permits for tho piojxt identified Wow.
Project Name
t u. r
Location:

r - it
Office Use Only: Form Version October 2001
USACE Action ID No. DWQ No. t1 7 tl Q •?
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
APR 1 6 7.00 J
1. Check all of the approval(s) requested for this project:
Section 404 Permit W
ETtA; h
? Section 10 Permit WATER
Q' 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or Gener.41 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. Applies nt.Inform ation
1. Owner/Applicant Information
Name: Aq L
Mailing Address: ,
-16. 1r t4 1
c v r,
Telephone Number: Z!C -V .. rPts I( 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 signtory authority for the owner/applicant.)
Name: HAM;..t E o Lt, t 5
Company Affiliation:
Mailing Address:
Telephone Number: g ( D - - Q 2 •
E-mail Address: c L.-i 6^11 v c o
Fax Number:_ qt O -
Gom
Page 5 of 12

III. Project Information
Attach -a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of prof
9
2. T.I.P. Project Number or State Project Number (NCDOT Only
3. Property Identification Number (Tax PIN):
4. Location ' I
County: Fd q L I FAIL Nearest Town: 28ANOKL= RAPIDS
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.):
SO U -t tA O F U. S. I O m ?j(g'ST S t D c-?
Site coordinates, if available (UTM or'Lat/Long):
(Note - If project is linear, such as a xoad or utility line,, attach a sheet that separately lists the
'coordinates for each crossing of a distinct waterbody.)
6. Describe the exist' g land use or condition of the site at the time of this application:
7. Property size (acres):
8. Nearest body of water (stream/river/sound/ocean/lake):- CI40CI[ O YoTTE CREEK
River Basin: 1-VlgNOKE
(Note - this must be one of North Carolina's seventeen designated major river basins.
River Basin map is available at hM2://h2o.enr.state.nc.us/admin/maps/.)
Page 6 of 12
The
10, Describe the purpose 9f the proposed work: PQoyi DE, AN Access nie,vE
IV.
11. List the type of equipment to be used to construct the project:
-- @ A n c Tn ?? .? ?-tz ?6it 1?-! e & S
12. Describe the larA use in the vicinity of this proj
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. proiect, alone with

T)
V.
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
Page 7 of 12
Zoozz peaZ.l
Future Project Plans
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***

S
jeelis F:1 L I-
+

f=
ffs
.'Aim 0 e

T t.
L1Jl VQWI aaaaNuLa 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 htjp://www.fema.goy.
*** 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: S
Total area of wetland impact proposed: D ,.Z.!Y 4<4krs
2. Stream Impacts, including all intermittent and perennial streams
Stream Impact
Site Number
indicate o ' ma
Type of Impact* Length of
Impact
linear feet
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
leasespecify)
-

••••,,,.- J..F_. Vay CUM auvauuiy tnaaaporary impacts. impacts mclude, 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 intemet sites also allow direct download and printing of USGS maps (e.g., www.to2gzone.com.
www.maRQuest coin. etc.).
Cumulative impacts (linear distance in feet) to all streams on site:
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 ma
Type of Impact* Area of
Impact

acres
Name ofWaterbody
(if applicable) Type of Waterbody

(lake, pond, estuary, sound,
bay, ocean, etc.

List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
NIA IIp 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.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
/JJ N1412 ki AIQ£q$, ?F ?LgnLOS "t-'o I11?r11w112Er
naGY- S
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Page 9 of 12

USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
htlp:Hh2o.enr.state.nc.us/ncwetiands/strmgide.htm1.
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.
JloNE Rabp_Qs=rrp
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 no.tified:early in the review process by the 40OWetlands'Unit if payment into the
NCWRP is available as anoption,,,. For additional information regarding the application
process for the NCWRP, check the NCWRP website at httn://h2o.ent.st?ie nc'us/mrm/index htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):_
Amount of Non-riparian wetland mitigation requested (acres
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No [ V?
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No ?
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No ?
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion. ?-
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Require ents), or other (please identify )?
Yes ? No If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
*
Zone Impact
(square feet
Multiplier Required
Mitigation
1 3
2 1.5
Total
i
i.one i vaenas out sv teet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 11 of 12

If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
XI. Stormwater (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.
.i
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 E] 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).
Page 12 of 12
L µ L\,.(Agent's signature is valid only if an authorization letter from the applicant is provided.)
SUMMARY OF HETLAND AREAS
HITHIW THE;PROPOSED..ACCESS DRIVE
FROM OLD FARM ROAD
MARK AREA
AREA 1 8,eH9-Sr
AREA 11 4,082
AREA 111 .2,889

TOTAL
10,660 SF
Z'T 'gGJ
C
v ? ....? y V YMIM
fl St;
IV
O
=ad
1 ?
?, AREA 111
2744 F4
2745 "
6E d?
CYEq Oq O ,? .
'? uy )as
4
a??? S I a ` `O 's? NELDON
6 ti? T ?' ?bP
tof 'ra ?
? ha
k ,moo
V/
1 0 C A T! O N M A P
SCALE: may
2746 rs I
(
ORJGINAL HALIF T ) I
FLAG NU4BERS AS l
AX MEMORIAL HO / FIELD HARKED By OTHERS
/N N 1
DEED BOOK 733, PAG£ 31 PI TAL PROPERTY 1 N i I
830. 01 • - - - ?> Lanz
( l
N !7124'2W
32,11 ( 2164-2632) ) ^=- Di r HAL IFAX
REGIONAL £R b ?' s3a;Dy: t
FORMERLY MA
MEDICAL CENT s7o1 o g,) d,4?
NN
DEED BOOK 1329, I NG LANDS R.s39.25' A=iSB. B4' l
DEED BOO)( 1691, X291 Z= a b N 55150'3E'W
B7 A-53.82' d'o 158.27' CHORD-TOTAL I
R=539.25• b? 'i?;? AREA II `z465'2484)
,;BV I
R=539.25' A=53.82' l
N 61'25' 2!'W ? 7706 C/
53.80' CHORD `)
(2985-2802) 1 = 1
?I
ti60
1 P 1
?IN 60' PROJECTED DISTURBANCE ?i
p, 1 PRQ"OSED ACCESS DRIVE ?lN
i N 1
• 8 R:2674.55' A-199.911
"i
Q 1 Vr N 62108.291w N
0 1; ?1 `199.86' CHORD-TOTAL -Cl
L('qµ F_-. FK s? Iis N (1424-1925) y/l
?: ? F &TI kLl to
FLAG NUHBERS AS----ti ?l
FIELD MARKED BY OTHERS ?y0 A a •? AREA 1
'r? 1M1 a ? 17719 AS
'C ?y 7797
D? I
R-2674. 55' A-26. 2e' 2720 A6
1
N 60'16' 53' W 7771 A7 l
26. 28' CHORD
(1424-2800)
7777 AB _ 189. 9B'
1 1 ' ??•' S 30.00'07'W?
1 1 2774 A! l
2725 ASO I
----- I I I
w
I ------T g'. I 2776 AU l }V7 4t .? I
I s '? !v ?? I
I I Z? 1 ?,?' $JN ?(u I
I PROPOSED CLINIC SITE I I I .I;
f?c
l
PLAT CAB 6, SLIDE BO-S I 1 m ?s l
1 . 4
I EIP 31,e.
L i I
OLD FARM ROAD 100' R/H 249.02'
<--- TO NC ROUTE 125 TO US HNY ise --->
--------------------------------------
NATIONWIDE PERMIT NO. 14
ACCESS DRIVE FROM OLD FARM ROAD TO HOSPITAL
HALIFAX REGIONAL MEDICAL CENTER
SCALE: 1" = 200' 250 SMITH CHURCH ROAD
P.O. BOX 1089
ROANOKE RAPIDS, NC 27870

Office Use Only: Form Version October 2001
USACE Action ID No. DWQ No. 020583-
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
i ,a
?2 J .
I. Processing
g
4 APR >002
1. Check all of the approval(s) requested for this project:
Section 404 Permit , .
? Section 10 Permit
Y 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 re4uired, 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: ?
U. Applicant. Information • .
1. Owner/Applicant Information
Name: N,q L
Mailing Address: ,
ko vs
N qv >c/2tJe.?t? r0
Telephone Number: ZC7 MA I 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 sign tory authority or the owner/applicant.)
Name: EfAI' Iw E O LL t S
Company Affiliation:
Mailing Address: 1.3 8 ekQP A-M -F::arp,CC-r .n"
Telephone Number: 1 •
E-mail Address: & rl? In.
Fax Number:__ !} I D _
c.o M
Page 5 of 12

III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project:
2. T.I.P. Project Number or State Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location ?ALIEAT (?
County: Nearest Town: ROANOWE RAPIDS
Subdivision name (include phase/lot number):
Directions to site (inc`l?ude road numbers, landmarks, etc.):
So u-r
9
Site coordinates, if available (UTM or+Lat/Long):
(Note - If project is linear, such as a xoad or utility line,, attach a sheet that separately
"coordinates for each crossing of a distinct waterbody.)
lists the
6. Describe the exist' g land use or condition of the site at the time of this application:
7. Property size (acres):
8. Nearest body of water (stream/river/sound/ocean/lake): C1?OCK D YD't`r? CY2L Ek
River Basin: 111 ANDKE
(Note - this must be one of North Carolina's seventeen designated major river basins.
River Basin map is available at hM?://h2o.enr.state.nc.us/admin/mal2s/.)
Page 6 of 12
The

10. Describe the purpose 9f the proposed work: PQavlDF qN 14CGME55 72t2tvE
IV.
11. List the type of equipment to be used to construct the project:
Q A DER S ti u eL s !!M q.?l t1e 15 S
12. Describe the lag use in the vicinity of this proj
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. nroiect_ along with

X)
V.
VI.
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:
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
Future Project Plans zoozz..nC9 Z.1

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***
4126 0.
-A tip

* r : ,.t..
.._.,..,N,... ,.,=ya?L b"paraw,y ai,u iucamy 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 htlp://www.fema,gov.
*** List a wetland type that best describes wedand 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: / S
Total area of wetland impact proposed: D ? 7-i j dQ<*K!r
2. Stream Impacts, •including all intermittent and perennial streams
Stream Impact
Site Number
indicate o i ma
Type of Impact* Length of
Impact
linear feet
Stream Name** Average Width
of Stream
Before Impact .. , . Perennial or
Intermittent?
leasespecify)

••==F"v a lra=away a<lu iuouuiy tctttporaryimpacts. impacts mciude, 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 foe 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.mapques o etc.).
Cumulative impacts (linear distance in feet) to all streams on site:
Page 8 of 12
n
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S.
Open Water Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres Name of Waterbody
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ean, etc.
p

L' U
Est eac 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.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
A Li ew Mar r OFD' PYa o Posae-D POAD 1414S BEEN PLV%e.iF r)
114 N 1412 eo w A 12Fq 5 l= y??-L p? t?I p S 't"b 11"! i N I wl 12 ?'
#M naGT S
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Page 9 of 12

USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
htt-o://h2o.enr.state.nc.us/ncwetlands/strrngide.htm1.
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.
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
wi-11 be notified:early in the review process by the 40ftetlands'Unit if payment into the
NCWIZP is available as an option.; For additional information regarding the application
process for the NCWRP, check the NCWRP website at http://h2o.ent.stdie nc°uawrp/index htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):_
Amount of Non-riparian wetland mitigation requested (acres
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
I
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 Q?
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. I
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requi?r?e} ents), or other (please identify )?
Yes ? No [J If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.

Zone* Im act
s u are feet
Multiplier
Mitiquai red
tion
1 3
2 1.5
Total
cone t extends out su teet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 11 of 12

If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
Xl. 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 gener?ed from the proposed project, or available capacity of the subject facility,
Al ^
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 pplication?
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).
Page 12 of 12
LGtIG
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
SUMMARY OF NETLMD AREAS
HITHIN7THE:.PROPOSED..ACCESS
FROM OLD FARM ROAD
MARK AREA
AREA I 3,BB9-SF
TOTAL 10, 860 Sr IY . .
AREA I I ,, 062
AREA 111 .2,869 /
DRI
?
W
Us is,
k ??`'? b oe i? 1 NELDON
P
y 4 as f.T Ly7 S A? ?-_?
by
,of ire ?
eha
k ?o
1 0 C A T 1 O N M A P
SCALE: 799 3746 r6 I

ORIGINAL F ' 4 ( I
HAL l FAX I ?' T FLAG NUMBERS AS
MEMORIAL y ?o / IELD HARKED BY OTHERS I
OE£O BOOK 733, PqG£ OSPJTAL PROPERTY ' N i I
830. 02 H?5?3l, ?B' E _?> ?3 ' I I ??
68.11' TOTAL
??I l I
7'24'20'N=? I.
N4
HAL I F 32.11' (2484-26 DITCH
AX REGIONAL MEDICAL 4 `'' s3H' °y- _ I
FORMERLY CENTER 17"1 °7 G S `"?
DEED gOpK MANNING LANDS R=539.25' A=159.84' 'I
DEED 8D 'Z!• 2!2 17°1 ak?,ya 9' N 55'SO'3B'N
-TOTAL
694, PAGE 87 R=539825' ''66.? i5B.2T (42 BSD-2!B!) I
. ( RREA 11 I
R=539.25' A=53. 81'. 2m 66 . ?1 y I
N 61'25'24'71 t ?Vv
53.80' CHORD
!2485-2602) ?-
,°'P. oI
6&W ECTED DISTURBANCE n
PACCESS DRIVE `o
I
?
' •t t a Id
b
R=2674. SS' A=199. 91' ^ I
N 62'08'29'N
o &? ; M 199.86' CHORD-TOTAL I
EaL.„?_.. ?R G ? ?Ik? ? f14z1-llzs) NI
N
FLAG NUMBERS AS
FIELD MARKED BY OTHERS ?y?' ?+ P •? AREA I
12719 A
R=2674. 55' A=26.28' 3720 A? I
N 60'16'53'W I 2711 A7 I
26.28' CHORD
(4424-2800) _ 189.98'
I 2711 NB
i \7 S 30'00'0771
2721 R9
I EfP 314'• I
n3s ,uo •
t------------- ' f I I
T g ?. I 2736 A" I ?. w I
? y1
PROPOSED CLINIC SITE I I ,./; w
I PLAT CAB 6, SLIDE 80-S I I;! Ji 9I
it h O Q I
I3090'
f I
EiP 3?4'• .----------?----------w 30'00'00,W
JI,
I - - -
OLD FARM ROAD 100' RiN • 149. oz'
<--- TO NC ROUTE 125 TO US HNY 1S8 ---> 1
644f- vv?'
?P-

NATIONWIDE PERMIT NO. 14
ACCESS DRIVE FROM OLD FARM ROAD TO HOSPITAL
HALIFAX REGIONAL MEDICAL CENTER
SCALE: 1" = 200' 250 SMITH CHURCH ROAD
P.O. BOX 1089
ROANOKE RAPIDS, NC 27870
i?
i
a
H?
O
i

Office Use Only: Form Version October 2001
USACE Action ID No. DWQ No. 020583
If any particular item is not applicable to this project, please enter "Not Applic' eo N r he than
leaving the space blank. --- it a ?y
I. Processing APR I
f-
s
1. Check all of the approval(s) requested for this project: RIFT',
`-
Section 404 Permit wE ?"
? Section 10 Permit
Y 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: I Al
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not re4uired, 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 Inforgmation
Name: N I L
ffilelpr?gMailing Address:
? DS *'
N qvL LJer?A _ ? r?_
Telephone Number= 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 sign tory authori or the owner/applicant.)
Name: ifAnt..t E o Li-t S
Company Affiliation:
Mailing Address: !38 G1REL-N T?,oreas-r a7A- i.i?
Telephone Number: q 1 n `3 Q Z -6933 Fax Number: !R[0-3- Z?-G S33
E-mail Address: (o111s M rd srt . Gown
Page 5 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project:
2. T.I.P. Project Number or State Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location I'
County: M q (,l FAY Nearest Town: ?DIANoKL W PJDS
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.):
SoutA cV,- II. S..1 CA. A11 WW-V"r ,.. ?
5. Site coordinates, if available (UTM orlat/Long):
(Note - If project is linear, such as a xoad or utility line,, attach a sheet that separately lists the
'coordinates for each crossing of a distinct waterbody.)
6. Describe the existipg
7. Property size (acres):
land use or condition of the site at the time of this application:
9
8. Nearest body of water (stream/river/sound/ocean/lake): 040c w 9 YO TTE CeFerk
River Basin: M014 N w
(Note - this must be one of North Carolina's seventeen designated major river basins.
River Basin map is available at httn://h2o.enr.state.ne.us/admin/maps/.)
The
Page 6 of 12
10. Describe the purpose gf the proposed work: a6VI DE AN r4cc ys 5 r2g tvE
11. List the type of equipment to be used to construct the project:
eop" QApelt S ti uueS ??? tjaLcS .
12. Describe the lard use in the vicinity of this proj
IV. Prior Project History
V. Future Project Plans
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
ZOOZ.Z.o42.1
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
VI.
Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
L-)

Page 7 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***

S
912 6 AS Qj moo!
'AND -rff-

* T nY o ..t. _i_ _ J
.._?• Cac== ....Fact sepa.aw,y Attu iuenury 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 htIR://www.fcma.jzo v.
*** 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: / S
Total area of wetland impact proposed: D,, 7_41 cis
2. Stream Impacts, -including all intermittent and perennial streams
Stream Impact
Site Number
indicate cLn ma
Type of Impact* Length of
Impact
linear feet
Stream Name** Average Width
of Stream
Before Impact .. , . 'Perennial or
Intermittent?
leasespecify)
Rhq

- - • - r»?• ?r»' a=?=7 w=u =ucuu> y Lim wrary Tmpads. impacts mctuae, but are not 11mlted 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 fof 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,tonozone.com
www mapquest com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site:
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 ma
Type of Impact* Area of
Impact
acres
Name of Waterbody
(if applicable) Type of Waterbody
(lake, pond, estuary, sound
bay, ocean, etc.
p
-1 A1 I

* T or -l, ..? ..t_ _A iv__._-
4.
- °• -- 1- .,..Fw w,y a,u ?u'Ituly ?cinpurary Impacts. impacts tnctuae, 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.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
/!J NAT2f2?ki QgtmAS Ap WEMLqMDS -t-o MINIM)7-C
P14GT 5
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Page 9 of 12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.us/ncwetlands/strmgide.html.
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.
ME Prznpos
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 40ftetlands'Urrit if payment into the
NCWRP is available as anoption,,. For 'addition'al information regarding the application
process for the NCWRP, check the NCWRP website at http://h2o.eni.state.nc.us/m rm index htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes E] No [g'
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. I,-
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Req ents), or other (please identify )?
Yes ? Nouire ? If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* (square feet Multiplier Required
Mitigation
1 3
2 1.5
Total
Zone I extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 11 of 12
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
XI. Stormwater (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 gener?ed from the proposed project, or available capacity of the subject facility.
A / /1
XIH. 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).
Page 12 of 12
1.J0.LG
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
SUMMARY OF HETLAND AREAS
HITHI,N-THE:PROPOSED..ACCESS DRIVE
FROM OLD FARM ROAD --
MARK AREA
AREA 1 3,089 -Sr
AREA 11 }, 082
AREA III . 2, 889

TOTAL
10,860 SF
z1J'q'
C
p
t 81
=,O S
i
1 °
0
IC
?(*, AREA 111
rM r4

WELDON
vC i : n?sn •L 0 C A T 1 ON MAP
13 qu• 90 4 / It ; rs?s n $c4f: may R ',? /
ORIGINAL HALIFAX H /"'/o?FLAS I
ENORIA( HOSP / T=79 OTHERS EEo BOOK 733. PAGE I TAL PROPERTY • I , I
32 N :
_ - N 35'31.18'$ I I
830.02' -->?368. SST=TAL` ' l
N 17'24'20'!
HAL I FAX 32.11• (2181-2632) .y "? pI tG, -- .? I
REGI ANAL MEDICAL CF ve 097
FORMERLY MANNING NTER 37°3 ° `0'
DEED BOOK 1311. LANDS R-S39. 2S' A-1S8.84' I
DEED BOOM 169,212 2761 F
?{a 6' PACE 87 R=539.25' •lrbl 4r 1SB. 27' CHDRDD-21BTOTAL
I
. AREA 11 I
R-S39.2S' A=S3.82'I
N 61•2S'21'W r ? 2706 W
53.80' CHORD _
(2485-2802) 1 2 : pI
1 P P ? ti
i1N --6- ' PROJECTED DISTURBANCE In?
P i PROPOSED ACCESS DRIVE COI'?
Nil
• 7 _/' R=2671. S$' A:199. 91' NI
yr N 62'08'29'W N
i 199.86' CHORD-TOTAL ,•
(1121-1425) yI
RL4V
FLAG NUMBERS AS-?ti
FIELD MARKED BY OTHERS ?y P AREA I I
?p
e4 ?0?1 2729 AS
161 I
R=2671.55' R:26.28' 2720 A6
N 60'16'S31W 2721 47 1
26.28' CHORD 1
11429-2800)
- 189. 99•
2722
1? +-S _30•00'07'W-
2n4 As
I EIP 3/9" I
n2s ,uo •
t-------------' it
I I
I 1 g I 5726 Ail I >ti 6t :1 I
I I gl$ ? ? ?? ?? a? I
I I ZI ? ? $?" ?2 ?? I
PROPOSED CLINIC SITE I I I 03 ' Qca I
PLAT CAB 6, SLIDE Do-S I j S I
I 130'?30'I
I. ZIP 3i4" I
------- T
w,5 30.00'00'! ? •-• - - -? -
OLD FARM ROAD 100' R/H z99. oz'
C--- TO NC ROUTE 12S TO US H11Y 158 --->
.------------T--------------------------
NATIONWIDE PERMIT NO. 14
ACCESS DRIVE FROM OLD FARM ROAD TO HOSPITAL
HALIFAX REGIONAL MEDICAL CENTER
SCALE: 1" = 200' 250 SMITH CHURCH ROAD
P.O. BOX 1089
ROANOKE RAPIDS, NC 27870

Office Use Only: Form Version October 2001
USACE Action ID No. DWQ No. 020583
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
I.
H.
Processing r (? [ Q d
1. Check all of the approval(s) requested for this project: APR # 6 20n?
Q? Section 404 Permit
? Section 10 Permit
MIANOS ;:
401 Water Quality Certification "'" _~jJ T_Y
E] Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: f
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not re4uired, 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: ?
Applicant -Information t• .
1. Owner/Applicant Information
Name: ' AA L JA-6014 9
Mailing Address:
O Df
217 R_ r
v c r
Telephone Number: ' ;P I .. 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 sign tory authority or the owner/applicant.)
Name: ?tfAn;_1 E t-tol-1-IS
Company Affiliation:
Mailing Address: !'38 .,9--- -':.*o iy4F
Telephone Number:
E-mail Address: e
Fax Number:
Go wl
Page 5 of 12

III. Project Information
Attach a. vicinity :map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long.:as the property is clearly defined. For administrative and distribution purposes, the
USACe i6quires 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 proj
2. T.I.P. Project Number or State Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location ('?
county:_ Fd q (,l F'RI Nearest Town:PonmoKE 1APIDS
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.):
Site coordinates, if available (UTM orlLat/Long):
(Note - If project is linear, such as a xoad 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:
7. Property size (acres):
8. Nearest body of water (stream/river/sound/ocean/lake): 040c-x D Vo 7TE CRES-k
River Basin: 1-SV lq m twe
(Note - this must be one of North Carolina's seventeen designated major river basins.
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
The
Page 6 of 12
10. Describe the purpose gf the proposed work: PLO M M A t4 q.cc.L S 5 T ie t vE
IV.
V.
VI.
11. List the type of equipment to be used to construct the project:
RA DER S !M e e S T`L ILL
12. Describe the lag use in the vicinity of this proj
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, alona with
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:
b uTt? E W am- N O a? sny Q 3 AN s/ S
au'r/c1PA &p
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.
J
D
Page 7 of 12
ZOOZZ-ado 2.1
Future Project Plans
1. Wetland Impacts ;
Wetland Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres Located YAthin
100-year Floodplain**
es/no Distance to
Nearest Stream
linear feet
Type of Wetland***
_A26 ts /2 d)0.1#
'A IUD Is-

# T :ter a ..1.: _.
L- each impact separately anu 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 httu://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: / S
Total area of wetland impact proposed:-. D Z.4 AAw- !r
2. Stream Impacts, including all intermittent and perennial streams'
Stream Impact
Site Number
indicate o ma
Type of Impact* ..Length of,
Impact
linear feet
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
leasespecify)

- - • ••r.?• avraaa«a? a„u ruclurry rornpurary rmpacTs. impacts mcluae, 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 intemet sites also allow direct download and printing of USGS maps (e.g., www.tonozone.cor&
www.mapguest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site:
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 ma
Type of Impact* Area of
Impact
acres
Name Wate)
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ean, etc.

* List each impact separately and identify temporary impacts. Impacts include, but are not limited td: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation
Nl p If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be-created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
IN h114r2RDLc? A12£a5 ?? 1?tt?TLlp?I?t?s "t"o rniNrwt?zL
#M Paw--r s
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Page 9 of 12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
hiip:Hh2o.enr.state.nc.us/ncwetlands/strmgide.htmi.
Provide a-brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
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 uotiffied:early in the review process by the 40ftetlands'`Urrit 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.ent.stife nc'us/wrp/index htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No [Yr
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. I
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Require ents), or other (please identify )?
Yes ? No V If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet Multiplier Required
Mifl ation
1 3
2 1.5
Total
Luiiu 1 uxtcnas out su ieet perpenarcutar trom near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 11 of 12
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B.0242 or.0260.
XI. Stormwater (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.
I/ /'A
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 pplication?
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).
Page 12 of 12
LQlG
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
'SUMMARY OF WETLAND'AREAS
WITHW THE :.PROPOSED..ACCESS DRIVE
FROM OLD FARM ROAD
MARK AREA
AREA I 9,689-SF
AREA It }.082
AREA III .2,889
TOTAL 10,060 SF zli ?GJ

ip
soil
PN
=o?
?i
AREA 111
nm re
kv?
It i i 374TH I L OCA T 1 ON MAP
0 9; II Z71b IS
acu1: Kpf
/
OR1 G1 NAL t
, ?
HALIFAX MEMO I M FLAG NUMBERS AS 1
RIAL HOSP FIELD MARKED BY OTHERS I
D£ID BOOK 733, PAGE 32 I TAL PROPERTY " ` ry i I
830.02'Y?S?3??8•?"->?368. 11? I l I
TOTAL ( .6)
N 97.29'20'x °' ?- I
HALIF 32.11 (2989-2632) q "?D)TCH_-?-
AX REGIONAL MEDICA g O v 53e: Oy _ _ I
FORMERLY 11,4 L CENTER r'01 ° S: P? MvI
DEED BOpr 1311, NG LANDS Rz539.25' A=158. 99' I
DIED BOOK 1691, ' E 212 3702 64 d' N 55.50'38'x
PAGE 87 Rz539825' yb?? 158. Y!' (2485-2484)
8I
.: ARE
A 11 I
Rz539.25' Az53.82'
I
N 61'25'2.1'7! - .• 2706 n
53.80' CHORD
( 2985-2802) , _ 1 I
?iIN 60' PROJECTED DISTURBANCE Hln
e~, PROPOSED ACCESS DRIVE 01
yl
,? n } Rz2674.55' A-199.911
ItQp4 nl
NI
lir N 4OR -2
1999..8686' ' (1424145)
.
f RUV ?. ?•? NI ?2-2 yl
FLAG NUMBERS AS --??1? ?I
FIELD MARKED BY OTHERS ?q? ••? AREA I
12719 AS
A 3770 As I
Rz2674.55' Az26.28' 1
N 60'16'53'7! i 37S A7 I
26. 26' CHORD
(1921-2800)
I 3733 A9 ??? _s 189. 9H'
i : I?----30'00'07'x-l
1 1 M4 A9 I
tI ( E!P 319" I
37. A10
r------------' I ?? I
8'. I 2736 AL( I }y Z' I
%
ag?
?~ I
PROPOSED CLINIC SITE j
PLAT CAB 6, SLIDE 80-5 I I I INy ?g
I
? 130'?3o•I. ? ?
I. ZIP 3i4„ I
OLD FARM ROAD 100' RiW 299.02
<--- TO NC ROUTE 125 TO US HNY 158 --->
---------------------
------------------
NATIONWIDE PERMIT NO. 14
ACCESS DRIVE FROM OLD FARM ROAD TO HOSPITAL
HALIFAX REGIONAL MEDICAL CENTER
SCALE: 1" = 200' 250 SMITH CHURCH ROAD
P.O. BOX 1089
ROANOKE RAPIDS, NC 27870
er d?
W?
gee , 14ELDON
of
a ..
Office Use Only: Form Version October 2001
USACE Action ID No. DWQ No 02-0583
If any particular item is not applicable to this project, please enter "Not Appl c l1 71 1
r her than
leaving the space blank.
?e
1. Processing APR 16 2002
1. Check all of the approval(s) requested for this project: WETLANDS GROUP
,. ?d,?i'Ei? OUACInr SECTtO?+R
9 Section 404 Permit
? Section 10 Permit
401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: f
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not re4uired, 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 Info
Name:
Mailing Address:
Telephone Number:' V'Z - an I( 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 sign tory authority or the owner/applicant.)
Name: ?ffAnw E o tc. t S
Company Affiliation:
Mailing Address: I I a ('?*= sx-m -; A' rp c.f- _ns, %, =*
Telephone Number: _g I n- 3 4 Z •6933 Fax Number:_ 4 l C)- 3ai?Z -6833
E-mail Address: c t w hnik i -c ® w? Sri . Go rn
Page 5 of 12
.. 0.
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project:
2. T.I.P. Project Number or State Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location / f
County: hd A Ll FAI Nearest Town: ?p1gA014 W PIDS
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.):
So v-r A o ra f J. 5.. 1 CA - A i1 L/ICC-r - - G`
9
5. Site coordinates', if available (UTM orlat/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 exist' g land use or condition of the site at the time of this application:
IW_ - - - --
7. Property size (acres):
8. Nearest body of water (stream/river/sound/ocean/lake): C40CW OVOTTE 012LEK
River Basin: I'towt4 aKLr.-
(Note - this must be one of North Carolina's seventeen designated major river basins.
River Basin map is available at hM2://h2o.enr.state.nc.us/admin/maps/.)
Page 6 of 12
The
10. Describe-the purpose 9f the proposed work: PPaui ME A" r4cc 5 5 z2R t VK
11. List the type of equipment to be used to construct the project:
t e Q A DEW ` e !M Lj e ic .t `TTY 16is1?}?e &
IV.
V.
VI.
12. Describe the lax use in the vicinity of this proj
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. nroiect_ alnnv with
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:
r /_ - - _ _
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.

D
Page 7 of 12
Future Project Plans ZOOZ29P14Z.1
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***
412 La S ffs

»?•_ .==•ruv? n Fina"viy auu iueamy Lcmporary impacts. impacts mctude, 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 athtip://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: _/
S
Total area of wetland impact proposed: D z.4 I<*E.v
2. Stream Impacts, including all intermittent and perennial streams'
Stream Impact .
Site Number
indicate o ma
'type of Impact* Length of,
Impact
linear feet
Stream Name** Average Width
of Stream
Before Impact .. , . Perennial or
Intermittent?
leasespecify)

- •••=ru- ?..ra,away cu,u ,uciaury Vcmporary impacts. impacts mctude, 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.topgzone.corn,
www.mapquest.com , etc.).
Cumulative impacts (linear distance in feet) to all streams on site:
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 ma
T e of Im act*
yp p Area of
Im act
aces
Name Waterbody
(if applicable) Type of Waterbody

(lake,b pond,
eanaryc sound,
q

List each impact separately and identity temporary impacts. impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
f?p 4. Pond Creation
/Y If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be-created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
LGlJma-wT- aW E!YZOPoswD Roko 11145 SEEM R-ACED
/N N1412ROLct ia12£gS ?P y?gj'L14t?LtDS '7"'b I71iNIw1f2L?
PEiGT S
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Page 9 of 12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
hLip://h2o.enr.state.nc.us/ncwetiands/strmgide.htm1.
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 40 ftetlands `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.staie nc:us/wrprndex htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No 12?
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No ?
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No ?
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion. ?
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requ ents), or other (please identify )?
Yes ? . No ire ? If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone" s Impact
feet
Multiplier
Required
Mitigation
1 3
2 1.5
Total
Lone i extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 11 of 12
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or. 0260.
XI. Stormwater (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.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 211.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit pplication?
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).
Page 12 of 12
LkIV
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
SUMMARY OF WETLAND`AREAS
W I THIN JHE : PROPOSED..ACCESS DRIVE
FROM OLD FARM ROAD
MARK AREA
AREA I 9, 889-Sr
AREA I1 1,062
AREA 111 2,889
TOTAL 10, 860 SF 'Z ?GJ
?? ?'••/ y
? u
i

/ Fn
I4 '
1I
t 06
Hi
i. ?
NZ?Q?
'Q$
J01
?+ AREA 111
2744 r4
2745 r5

0
WELDON
F
•L 0 C A T 1 ON MAP
6CAL ) NW
27461* 1
r }
ORIGINAL HALIF I FLAG NUMBERS AS
AX MEMORIAL I/OSPIT AL 1?( FIELD MARKED BY OTHERS I
Deep BOOK 733, PAGE 32 PROPERTY r N i I
830. 02' J•?'??8• £ . ?> Z36D. Zl' TOTAL l / I
N 47'24'20'7! ° ---
HAL IFAX 32.11 (2464-2632) ' q --- Z D)TCH I
REGIONAL
FO ,?p d 538:09' ??
RHERLY MANN MEDICAL CENTER 7701 °rq` y°I'?
DEED BopK "Zr." I NG LANDS 8-539.2S' A=158.8•!' I
DEED BOOK 1694, 212 2702 a 4+ N 55'50'36'7!
B7 R-
A-S3. 82' 539.25' r C 1581 ' (2465-2484)
5I
e .. RREA 11 I
82539.5' A-53.82' I
N 61'5'24"N ? 7706 6s _
53.80' CHORD - I
(2485-2002) r`
7 O
I P P i ~
SIN 60' PROJECTED DISTURBANCE V
uP? r PROPOSED ACCESS DRIVEL
I `! I hl e
0 4`S t'I
N I
7 n } ! R-2674. 55' As199. 91'
Q I v(' N 62'06' 291W
r`
o I ; gr S 199.86' CHORD-TOTAL .~I
E` RCVV'I (1424-1425) yI
•? I M lI
FLAG N)HBERS AS
FIELD HARKED BY OTHERS ?? a •? AREA I
'p ,e?7n ?tie? I ?271s A\
4?+- 2797
?6 I
Rs 2674, 55' A-26.281 2720 A6
1
N 60'16'S31W( 2721 A7 I
26. 20' CHORD
(1424-2800) 2722 A ???--------- _ 189. 99'
I I ' 1i - S 30'00'07"N?
1 I 2724 A9
I I I EIP 314•• I
na A1o •
1 1 I y A I
g'. I 2776 ALS I >'. (7 4?j ? I
I Jti
8
OIN ? ? •
Z? 11A 8 ?w I
PROPOSED CLINIC SITE I I .ly Ix I
PLAT CAB 6, SLIDE 80-5 I r Ij ?s - I
I30•?90'i
I
EJP 8i4" I
--- -•=s 30.00'o0•hd - -----?---
OLD FARM ROAD 100' R/W 249• oz•
<--- TO NC ROUTE 125 TO US MY 156 --->
------------- -I.--------------------------
NATIONWIDE PERMIT NO. 14
ACCESS DRIVE FROM OLD FARM ROAD TO HOSPITAL
HALIFAX REGIONAL MEDICAL CENTER
SCALE: 1" = 200' 250 SMITH CHURCH ROAD
P.O. BOX 1089
ROANOKE RAPIDS, NC 27870
J y
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.
f,
1. Processing -
.
1. Check all of the approval(s) requested for this project: APR 1 6
[1/r Section 404 Permit
? Section 10 Permit 0,n WETtANDs ?pUP
[v]' 401 Water Quality Certification` UAtlTY S??Tt^"!
? 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 re4uired, 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 Info ation
Name: N.,A L
Mailing Address: Inn a," 1^ 920
,
c as
qv L W?A »
i elepnone Number: 7 K:2 .. ?? 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 sign tory authority or the owner/applicant.)
Name: t-WAMLI E o Lc- t S
Company Affiliation:
-,q U
Mailing Address:U
CT die y E
-
Telephone Number:__q 1 U _ ?3Q 2 -
E-mail Address- ^- r. i 4,..11. A-
Fax Number: 4 I n - 34x7 -
Page 5 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so 1 g2a as he property is clearly defined. For administrative and distribution purposes, the
US requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings 'rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project:
2. T.I.P. Project Number or State Project Number (NCDOT Only):
Property Identification Number (Tax PIN):
4. Location
County: fed q U FAI Nearest Town: ICDI4N014F_ R1AP1DS
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.):
9
i. Site coordinates', if available (UTM orlat/Long):I
(Note - If project is linear, such as a xoad 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:
7. Property size (acres):
8. Nearest body of water (stream/river/sound/ocean/lake): (? ApCk O y T TE 0- Lre x
River Basin:__ 1_?PAMOKE
(Note - this must be one of North Carolina's seventeen designated major river basins.
River Basin map is available at hgp://h2o.enr.state.nc.us/admin/maps/.)
Page 6 of 12
The
10. Describe the purpose 9f the proposed work: r ovi DF AN r4CCREs 5 Vj2 tvE
IV.
11. List the type of equipment to be used to construct the project:
ea e A pry c? :rM u e.e s n:M Iq a x .- 14a 9 s
12. Describe the lard use in the vicinity of this proj
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

X)
V.
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
Page 7 of 12
2oozz.aG 2.1
Future Project Plans
I. 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***

_ ?
•• .... FZCL ocPa.a-ly auu Tucnuty 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 hM://www.fema.eov.
*** 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: / S
Total area of wetland impact proposed:- D 7_4 <Abc!r
2. Stream Impacts, including all intermittent and perennial streams'
Stream Impact :
Site Number
indicate o ma
'type of Impact* Length of
Impact
linear feet
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
leasespecify)
RM

List ea h 1
c impact separate y 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 fot'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 intemet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com,
www.mapQuest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site:
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 ma
Type of Impact* Area of
Impact

acres
(if Name p Waterbody
applicable) Type of Waterbody

(lake, pond, estuary, sound,
bay, ean, etc.

List each impact separately and identity temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation
NIA
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be-created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
it tw relic--r s
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Page 9 of 12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
hM:Hh2o.enr.state.nc.us/ncwetiands/strmLyide.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.
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 40 ftetlands 'Unit if payment into the
NCWIZP is available as an option.,, For additional information regarding the application
process for the NCWRP, check the NCWRP website at httn://h2o.ent.staie nc'u's/wrp/index htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No 21,
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. I
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 Require ents), or other (please identify )?
Yes ? No [ If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* s nimact ape feet Multiplier Required
Mitigation
1 3
2 1.5
Total
Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 11 of 12
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
XI. Stormwater (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 genertd from the proposed project, or available capacity of the subject facility.
./ n
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 211.0500) or any Buffer Rules?
Yes ? No [?r
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).
Page 12 of 12
LdLG
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
`SUMMARY OF WETLAND AREAS
WITHIN•THE RROPOSED..ACCESS DRIVE
FROM OLD FARM ROAD
MARK AREA
AREA 1 31 889 -Sr
AREA It 1,062
AREA 111 . 2, 889 C
TOTAL 10, 660 SF zli R.)
F?
H
n Q?
I?Q
?c
S*c, AREA III
b 2717 ?
/ 2711 -

aF ?`
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`i ua Jas g?

y e WELDON
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i
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o ?

k ?.

_IlVt ?k '1 ?nurs I L 0CA T ! ON MAP
Q says n f SCALE. wcw
.-Imul It
ORIGINAL HALIFAX / FLAG NUMBERS As I
M£MORIA o FIELD MARKED BY OTHERS I
Df£D BOOK 733. PAGE ?SPITAL PROPERTY ' `N ; I
630. 02'- - _ ?'__> 1368.11?T0_TA= J l I.
N 17.21'20'1)
HALIFAX 32.11' (2181-2632) "?p)TCN I
REGIONAL d 538.09' `?
FORMERLY MANN MEDICAL CENTER r'01 ° le.
D- ZED BMW 1321, I'I NG LANDS 8.539.25' As156. 81' I
DEED BOOK 169 AG£ PAGE 212 G4,y N 55•50'38,W A-S3. 82' 156.
87 R=539.25' •?61 _ C 27 (21 D85-2184 I
.1 AREA II I
R=539.25' A=53.82' I
N 61'25'21'x) G, -
53.80' CHORD 1 I
(2185-2802) 1 2 I' A
1 ? 1 ti
??N ?--- 60' PROJECTEDACCESSDISTURBANCE ?In
pl',` 1 DRIVE
?I2,
A I ? 1 I!
1?10 g? ? r ti? I"I
.? R+2671.55' A=199. 91' y
TI I N 62'08'29'1/
o I ; 1199.86' CHORD-TOTAL .N
?•_'? F iI (1421-1125) yI
.? ll
FIELD AMARKEDD By or ERs a •? AREA I I
'ele??1?tie ???\ /p
R=2671.55' R=26.28' 2770 J16
?
N 60.16153'W 7771 A7 1
26.26' CHORD I
(1121-2800)
I 7777 J!6 _ 189. 9B'
I ? I 1? ?•'S 30'00'07"N?
I I 7721 A9 I
EJP 3,1'• I
I na Juo I •
r--------------1 t I
i 1 g'. 7776 ?( I
ay ca
s~ I
/W L
ti w
PROPOSED CLINIC SITE I• I 1 IH.
I I y Q 3 I
PLAT CAB 6, SLIDE 60-S I
I 130'30'
"ip I
41.
I
1 I --4 3.
•.._._-----.?----------- -ALT
OLD FARM ROAD 100' RiW 219.02•
(--- TO NC ROUTE 125 TO US HNY is& --->
•------------
NATIONWIDE PERMIT NO. 14
ACCESS DRIVE FROM OLD FARM ROAD TO HOSPITAL
HALIFAX REGIONAL MEDICAL CENTER
SCALE: 1" = 200' 250 SMITH CHURCH ROAD
P.O. BOX 1089
ROANOKE RAPIDS, NC 27870