20200508 Ver 1_JD_request_MtZion_revised_20200414

JLIFISdictionai Determination Request
Us Army Baps
ai EnQ1rlNrt
VAnno m aoir,a
This form is intended for use by anyone requesting a jurisdictional determination (JD) from the
U.S. Army Corps of Engineers, Wilmington District (Corps). Please include all supporting
information, as described within each category, with your request. You may submit your request
to the appropriate Corps Field Office (or project manager, if known) via mail, electronic mail, or
facsimile. A current list of county assignments by Field Office and project manager can be
found on-line at: hitp://www.saw,usace.arin%.mil/Missions/ReaulatoryPerinitProgram.M. , by
telephoning: 910-2514633, or by contacting any of the field offices listed below:
ASHEVILLE REGULATORY FIELD OFFICE
US Army Carps or F ngineers
151 Patton Avenue. Room 208
Asheville. North Carolina 28801-5006
General Number: [phone]
Fax Number: [phone]
RALEIGH REGULATORY FIELD OFFICE
U5 Army Corps of Engineers
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
General Nurttber:[phone]
Fax Number: [phone]
WASHIINGTON REGULATORY FIELD OFFICE
U5 Army Corps of Engineers
2407 West Fifth Street
Washington, North Carolina 27889
General Number: [phone]
Fax Number: [phone]
WILMINGTON REGULATORY FIELD OFFICE
U5 Army Corps of Engineers
69 Darlington Avenue
Wilmington. North Carolina 28403
General Number: 910-251-4633
Fax Number. (910) 25t-4025
Version: December 2013 Page 1

Jurisdictional Determination Bequest
INSTRtJCTIONS:
All requestors must complete Parts A, B, C, D, E and F.
NOTE TO CONSULTANTS AND AGENCIES: If you are requesting a JD on behalf ofa
paying client or your agency, please note the specific submittal requirements in Part G.
NOTE ON PART D — PROPERTY OWNER AUTHORIZATION: Please be aware that all JD
requests must include the current property owner authorization for the Corps to proceed with the
determination, which may include inspection of the property when necessary. This form must be
signed by the current property owner to be considered a complete request.
NOTE ON PART D - NCDOT REQUESTS: Property owner authorization notification for JD
requests associated with North Carolina Department of Transportation (NCDOT) projects will be
conducted according to the current NCDOTIUSACE protocols.
NOTE TO USDA PROGRAM PARTICIPANTS. A Corps approved or preliminary JD may not
be valid for the wetland conservation provisions of the Food Security Act of 1985. If you or
your tenant are USDA Program participants, or anticipate participation in USDA programs, you
should also request a certified wetland determination from the local office of the Natural
Resources Conservation Service, prior to starting work.
Version: Decepber 2013 Page 2

A.
Jurisdictional Determination Request
PARCEL INFORMATION
Street Address: 19328 Zion Avenue
City, State: Cornelius, NC
County: Mecklenburg
Directions: From exit 28 on 1.77, heed east for 1 mile on US-21, turn right on Main St. for 0.2 mile, lum
left onto Hickory 5t., then immediately right onto Iron Ave, Head south for 0.5 mile to site.
Parcel Index Number(s) (PIN); 00710123A
00710123E
B. REQUESTOR INFORMATION
Name; Environmental Services. Inc. - Jeff Harbour
Mailing Address: 524 S. New Hope Road, Raleigh, NC 27610
Telephone Number: [phone]
Electronic Mail Address [e-mail]
Select one:
❑ I am the current property owner.
am an Authorized Agent or Environmental Consultant'
❑ Interested Buyer or Under Contract to Purchase
❑ Other, please explain.
C. PROPERTY OWNER INFORMATION
Name: Curry Engineering
Mailing Address: 205 S. Fuquay Ave.
Fuquay-Varina, NC 27526
Telephone Number: [phone] ^
Electronic Mail Address: Info@curryeng,com
❑ Proof of Ownership Attached (e.g. a copy of Deed, County GISIParcel/'fax Record data)
if available
Must attach completed Agent Authorization Form
3 if available
Version: December 2013 Page 3

Jurisdictional Determination Request
D. PROPERTY OWNER C>E;RTI1FfCATION4
1, the undersigned, a duly authorized owner of record of the property/properties identified h
do authorize representatives of the Wilmington District, U.S. Army Corps of Engineers (Cc
to enter upon the property herein described for the purpose of conducting on -site investigate
and issuing a determination associated with Waters of the U.S. subject to Federal jurisdim
under Section 404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors Act
1899.
Zf0'I) U' 'M /0 -1 7-2e
Property Owner (piease print) Date
Property Owner Signature
E. JURISDICTIONAL DETERMINATION TYPE
Select One;
MI am requesting that the Corps provide a preliminary JD for the property identified herein.
This request does include a delineation-
1 ar i requesting that the Corps provide a preliminary JD for the property identified herein.
This request does NOT include a delineation_
I am requesting that the Corps investigate the p rope rtylproj ect area for the presence or
absence of WoUSs and provide an at3proved_3D for the property identified herein. This
request does NOT include a request for a verified delineation.
I am requesting that the Corps delineate the bowidaries of all WoUS on a property/project
area and provide an approved JD (this may or may not include a survey plat).
F] I am requesting that the Corps evaluate and approve a delineation of WoUS (conducted
by others) on a property project area and provide an approved JD (may or may not
include a survey plat).
For NCDDT requests fallowing the current NCDOT/USACE protocols, skip to Part E.
s Waters of the United States
Version: December 2013 Page 4

JUrisdictional Determination Request
F. ALL REQUESTS
F7Map of Property or Project Area (attached). This Map must clearly depict the boundaries
of the area of evaluation,
✓❑ Size of Property or Project Area 10.5 acres
_❑V _ I verify that the property (or project) boundaries have recently been surveyed and marked
by a licensed land surveyor OR are otherwise clearly marked or distinguishable.
G. JD REQUESTS FROM CONSULTANTS OR AGENCIES
(1) Preliminary JD Requests:
❑� Completed and signed Preliminary Jurisdictional _Determination Form,
14 Project Coordinates: 35.47491 N Latitude 80.84993 W Longitude
Maps (no larger than I Ix17) with Project Boundary Overlay:
W1Large and small scale maps that depict, at minimum: streets. intersections, towns
F7 Aerial Photography of the project area
W1 USGS Topographic Map
0 Soil survey Map
Other Maps. as appropriate (e.g. National Wetland Inventory Map. Proposed Site
Plan, previous delineation maps, LIDAR maps. FEMA floodplain maps)
See Appendix A of this Form. From Regulatory Guidance Letter No_ 48-02, dated June 26, 2008
Version: Decerber 2013 Page 5

Jurisdictional Determination Request
Delineation Information (when applicable):
Wetlands:
❑A Wetland Data Sheets
Tributaries:
USAGE Assessment Forms
Upland Data Sheets 17 Other Assessment Forms
(when appropriate)
Landscape Photos. if taken
10 Field Sketch overlain on legible Map that includes:
■ All aquatic resources (for sites with multiple resources, label and identify)
■ Locations of wetland data points and/or tributary assessment reaches
■ Locations of photo stations
■ Approximate acreage/linear footage of aquatic resources
(2) Approved JDs including Verification of Delineation:
❑ Project Coordinates:
Latitude Longitude
Maps (no larger than l 1x17) with Project Boundary Overlay:
❑ Large and small scale maps that depict, at minimum, streets, intersections, towns
❑ Aerial Photography of the project area
❑ USGS Topographic Map
❑ Soil Survey Map
❑ Other Maps, as appropriate (e.g. National Wetland Inventory Map, Proposed Site Plan,
previous delineation maps)
7 1987 Manual Regional Supplements and Data forms can be found at:
httu://www.usace.army.mil/Missions/LivilWorks/Regina_toryProgfomandpormits/reg supp_aspx
Wetland and Stream Assessment Methodologies can be found at:
http:l/port Lri�.4epit.org/c/document library/get fiie?uuid=76f3c58b-dab8-4960-ba43-45b7fafO6f4c&grpu,pld=38364 and,
htto:/Iwww.saw. usace. army. millPortals/59/dots/rekulatory/pubIicratices/2013/NC5AM Draft User Manual 130318 Pdf
$ Delineation information must include, at minimum, one wetland data sheet for each wetland/community type.
Version: December 2013 Page 6

JL11'iSdiCti011a1 Determination RegUest
Delineation Information (when applicable):
Wetlands:
Wetland Data Sheets9
10
❑�
;-I
Upland Data Sheets
Landscape Photos, if taken
Tributaries:
USAGE Assessment Forms
Field Sketch overlain on legible Map that includes:
Other Assessment Farms
(when appropriate)
• All aquatic resources (for sites with multiple resources, label and identify)
+ Locations of wetland data points and/or tributary assessment reaches
• Locations of photo stations
• Approximate acreage/linear footage of aquatic resources
Supporting Jurisdictional Information (for Approved JDs only)
u Approved Jurisdictional Determination Form(s) (also known as "Rapanos
Forms)")
Map(s) depicting the potential (or lack of potential) hydrologic connection(s),
adjacency, etc. to navigable waters.
9 Delineation information must include, at minimum, one wetland data sheet for each wetland/community type.
Version. December 2013 gage 7

Jurisdictional Determination Request
I. REQUESTS FOR CORPS APPROVAL OF SURVEY PLAT
Prior to final production of a Plat, the Wilmington District recommends that the Land
Surveyor electronically submit a draft of a Survey Plat to the Corps project manager for
review,
Due to storage limitations of our administrative records, the Corps requires that all hard -
copy submittals include at least one original Plat to scale that is no larger than 11"x17"
(the use of match lines for larger tracts acceptable). Additional copies of a plat, including
those larger than 11"xl7", may also be submitted for Corps signature as needed. The
Corps also accepts electronic submittals of plats, such as those transmitted as a Portable
Document Format (PDF) file. Upon verification, the Corps can electronically sign these
plats and return them via e-mail to the requestor.
(11.) PLATS SUBMITTED FOR APPROVAL
QMust be sealed and signed by a licensed professional land surveyor
Must be to scale (all maps must include both a graphic scale and a verbal scale)
Must be legible
1-1 Must include a North Arrow, Scale(s), Title, Property Information
Must include a legible WoUS Delineation Table of distances and bearings/metes
and bounds/GPS coordinates of all surveyed delineation points
Must clearly depict surveyed property or project boundaries
❑ Must clearly identify the known surveyed point(s) used as reference (e.g. property
corner, USGS monument)
When wetlands are depicted:
• Must include acreage (or square footage) of wetland polygons
+ Must identify each wetland polygon using an alphanumeric system
Version: December 2013 Page 8

JUrisdictional Determination Request
When tributaries are depicted:
Must include either a surveyed, approximate centerline of tributary with
approximate width of tributary OR surveyed Ordinary High Water Marks
(OHWM) of tributary
• Must identify each tributary using an alphanumeric system
• Must include linear footage of tributaries and calculated area (using approximate
widths or surveyed OHWM)
Must include name of tributary (based on the most recent USGS topographic
map) or, when no USGS name exists, identify as "unnamed tributary"
all depicted WoUS (wetland polygons and tributary lines) must intersect or tie -to
surveyed project/property boundaries
Must include the location of wetland data points and/or tributary assessment
reaches
Must include, label accordingly, and depict acreage of all waters not currently
subject to the requirements of the CWA (e.g. "isolated wetlands". "non -
jurisdictional waters"). NOTE: An approved JD must be conducted in order to
make an official Corps determination that a particular waterbody or wetland is not
jurisdictional.
❑ Must include and survey all existing conveyances (pipes, culverts, etc.) that
transport WoUS
Version: Decefrnber 2013 page 9

JUrisdictloIlca1 Determination Request
(2) CERTIFICATION LANGUAGE
When the entire actual Jurisdictional Boundary i�picted:
include the following Corps Certification language:
"This certifies that this copy of this plot accurately depicts the boundary of the Jurisdiction
of Section 404 of the Clean Woter Act as determined by the undersigned on this date.
Unless there is a change in the law or our published regulations, the determination of
Section 404 jurisdiction may be relied upon for a period not to exceed five (5) years from
this date. The undersigned completed this determination utilizing the appropriate Regional
Supplement to the 1987 U.S. Army Carps of Engineers Wetlands Delineation Manual."
Regulatory Official:
Title:
Date:
USACE Action ID No.:
When uplands may be present within a depicted Jurisdictional Boundar :
include the following Corps Certification language:
"This certifies that this copy of this plat identifies all areas of waters of the United States
regulated pursuant to Section 404 of the Clean Water Act as determined by the
undersigned on this dote. Unless there is change in the law or our published regulations,
this determination of Section 404 jurisdiction may be relied upon for a period not to exceed
five years from this dote. The undersigned completed this determination utilizing the
appropriate Regional Supplement to the 1987 U,S. Army Corps of Engineers Wetlands
Delineation Manual."
Regulatory Official:
Title:
Date:
USACEAction 10 No.:
Version: December 2013 Page 10

Jurisdictional Determination Request
(3) GPS SURVEYS
For Surveys prepared using a Global Positioning System (GPS), the Survey must include
all of the above, as well as:
be at sub -meter accuracy at each survey point.
❑ include an accuracy verification:
One or more known points (property corner, monument) shall be located with the
GPS and cross-referenced with the existing traditional property survey (metes and
bounds),
❑ include a brief description of the GPS equipment utilized.
Version: December 2013 Page 11

ATTACHMENT
PRELIMINARY JURISDICTIONAL DETERMINATION FORM
BACKGROUND INFORMATION
A. REPORT COMPLETION DATE FOR PRELIMINARY JURISDICTIONAL
DETERMINATION (JD):
B. NAME AND ADDRESS OF PERSON REQUESTING PRELIMINARY JD:
C. DISTRICT OFFICE, FILE NAME, AND NUMBER:
D. PROJECT LOCATION(S) AND BACKGROUND INFORMATION:
(USE THE ATTACHED TABLE TO DOCUMENT MULTIPLE WATERBODIES AT DIFFERENT
SITES)
State: NC County/parish/borough: Mecklenburg
City: Cornelius
Center coordinates of site (lat/long in degree decimal format)-
Lat. 35.47491 ON; Long. 80.84986
M
0W.
Universal Transverse Mercator: 17S 513621 3925721
Name of nearest waterbody: South Prong West Branch Rocky River
Identify (estimate) amount of waters in the review area:
Non -wetland waters:
1,521 linearfeet: 2.5-4 width (ft) and/or acres.
Cowardin Class: Riverine
Stream Flow: S1 perennial, S2 and S3 seasonal
Wetlands: 0.17 —acres.
Cowardin Class: PFO
Name of any water bodies on the site that have been identified as Section 10
waters:
Tidal:
Non -Tidal:
V

A
REVIEW PERFORMED FOR SITE EVALUATION (CHECK ALL THAT
APPLY):
F]Office (Desk) Determination. Date:
1-1 Field Determination. Date(s):
SUPPORTING DATA. Data reviewed for preliminary JD
(check all that apply - checked items should be included in case file and,
where checked and requested, appropriately reference sources below):
IV-/] Maps, plans, plots or plat submitted by or on behalf of the
applicant/consultant- Figure 3 - Jurisdictional Areas
W-1 Data sheets prepared/submitted by or on behalf of the
applicant/consultant.
F-1 Office concurs with data sheets/delineation report.
F] Office does not concur with data sheets/delineation report.
❑ Data sheets prepared by the Corps:
1-1 Corps navigable waters' study:
F-1 U.S. Geological Survey Hydrologic Atlas:
F1 USGS NHD data
I
USGS 8 and 12 digit HUC maps
U.S. Geological Survey map(s). Cite scale & quad name: 1:24,000 Cornelius
USDA Natural Resources Conservation Service Soil Survey.
Citation: Soil Survey of Mecklenburg County, NC
National wetlands inventory map(s). Cite name: USFWS NWI online wetlands mapper
❑ State/Local wetland inventory map(s):
F-1 FEMA/FIRM maps:
F-1 100-year Floodplain Elevation is:
(National Geodectic Vertical Datum of 1929)
Photographs: 1:1 Aerial (Name & Date):
ZOther (Name & Date): Site photographs, 8/19/14
❑ Previous determination(s). File no. and date of response letter:
F-1 Other information (please specify)-
1�1
n

1. The Corps of Engineers believes that there may be jurisdictional waters of the
United States on the subject site, and the permit applicant or other affected party
who requested this preliminary JD is hereby advised of his or her option to
request and obtain an approved jurisdictional determination (JD) for that site.
Nevertheless, the permit applicant or other person who requested this
preliminary JD has declined to exercise the option to obtain an approved JD in
this instance and at this time.
2. In any circumstance where a permit applicant obtains an individual permit, or
a Nationwide General Permit (NWP) or other general permit verification requiring
"pre -construction notification" (PCN), or requests verification for a non -reporting
NWP or other general permit, and the permit applicant has not requested an
approved JD for the activity, the permit applicant is hereby made aware of the
following: (1) the permit applicant has elected to seek a permit authorization
based on a preliminary JD, which does not make an official determination of
jurisdictional waters; (2) that the applicant has the option to request an approved
JD before accepting the terms and conditions of the permit authorization, and
that basing a permit authorization on an approved JD could possibly result in less
compensatory mitigation being required or different special conditions; (3) that
the applicant has the right to request an individual permit rather than accepting
the terms and conditions of the NWP or other general permit authorization; (4)
that the applicant can accept a permit authorization and thereby agree to comply
with all the terms and conditions of that permit, including whatever mitigation
requirements the Corps has determined to be necessary; (5) that undertaking
any activity in reliance upon the subject permit authorization without requesting
an approved JD constitutes the applicant's acceptance of the use of the
preliminary JD, but that either form of JD will be processed as soon as is
practicable; (6) accepting a permit authorization (e.g., signing a proffered
individual permit) or undertaking any activity in reliance on any form of Corps
permit authorization based on a preliminary JD constitutes agreement that all
wetlands and other water bodies on the site affected in any way by that activity
are jurisdictional waters of the United States, and precludes any challenge to
such jurisdiction in any administrative or.judicial compliance or enforcement
action, or in any administrative appeal or in any Federal court; and (7) whether
the applicant elects to use either an approved JD or a preliminary JD, that JD
will be processed as soon as is practicable. Further, an approved JD, a proffered
individual permit (and all terms and conditions contained therein), or individual
permit denial can be administratively appealed pursuant to 33 C.F.R. Part 331,
and that in any administrative appeal, jurisdictional issues can be raised (see 33
C.F.R. 331.5(a)(2)). If, during that administrative appeal, it becomes necessary
to make an official determination whether CWA jurisdiction exists over a site, or
to provide an official delineation of jurisdictional waters on the site, the Corps will
provide an approved JD to accomplish that result, as soon as is practicable.
U

This preliminary JD finds that there "may be" waters of the United States on the
subject project site, and identifies all aquatic features on the site that could be
affected' by the proposed activity, based on the following information:
IMPORTANT NOTE: The information recorded on this form has not
necessarily been verified by the Corps and should not be relied upon for
later iurisdictional determinations.
Signature and date of
Regulatory Project Manager
(REQUIRED)
71 4
H�rb,xjr-
Si a nd d f
person requesting preliminary JD
(REQUIRED, unless obtaining
the signature is impracticable)
0

Project Name:
b/V
Project Address:
.10-3 /
PROPERTY OWNER CERTIFICATION
1, the undersigned, a duly authorized owner of record of the
property/properties identified herein, do authorize
representatives of the US Army Corps of Engineers (Corps) to
enter upon the property herein described for the purpose of
conducting on -site investigations and issuing a determination
associated with Waters of the US subject to Federal jurisdiction
under Section 404 of the Clean Water Act and/or Section 10 of
the Rivers and Harbors Act of 1889.
_Mt Z / and G(, 7M e- -
Property Owner(s) (Please Print)
Date
Property Owner(s) signature
zt
AGENT AUTHORIZATION L,
The undersigned property owner (or authorized representative of
the property owner) does hereby authorize Environmental
Services, Inc. to act on behalf of the owner (or authorized
representative) and take all necessary actions necessary for the
preparation, submittal, processing, issuance, and/or acceptance
of the jurisdictional determination, permit and/or certification.

Signature of the Owner (or Authorized
Representative) ZD o
44k&p-,q &,Qc1Z 11 -
Printed Name of the�vner (or Authorized Representative)

Table 1. Water resources within the study area.
Site
Cowardin
Estimated amount of
Class of aquatic
number
Latitude
Longitude
Class
aquatic resource in
resource
review area
S1
35.47378 N
80.84705 W
riverine
1,458 If, 0.13 ac
non -section 10 — non -
wetland, perennial
S3
35.47468 N
80.85181 W
riverine
63 If, <0.01 ac
non -section 10 — non -
wetland, seasonal
W1
35.47429 N
80.85079 W
PFO
0.10 ac
non -section 10 —
wetland
W2
35.47402 N
80.85000 W
PFO
0.03 ac
non -section 10 —
wetland
W3
35.47407 N
80.85012 W
PFO
0.03 ac
non -section 10 —
wetland
W4
35.47477 N
80.85152 W
PFO
0.01 ac
non -section 10 —
wetland

7 vi
to
el iu§
Project Location "` }} , •
�, (± 10.5 acres)
8.8 - -
--
dill
AJO
d;
� • Z r I 1�
It
_,� Z ■ ` y
dii
13 Project Location
j l
0 550 1,100 `•'
Miles • �. �.4 '
1 inch equals 1,100 feet
Source: ACME Mapper 2.1, f f �--•�
USGS Cornelius (NC) Quadrangle, 1993.
Disclaimer: The information depicted on this figure is for • J-
i,formational purposes only and was not prepared for, and is
not suitable for legal or engineering purposes. • -
' r
ENVIRONMENTAL Project: ER13152.00
SERVICES, INC. Project Location
9401-C Southern Pine Boulevard nn Date: Sept 2014
Charlotte, North Carolina 28273 M t. Zion Site
(704, 523-7225 Mecklenburg County, North Carolina Drwn/Chkd: JB/JH
704) 523-7226 Fax (
®ivvv Esi
www.environmentalservicesinccomI Figure: 1

' k '
z
il�r�i
_��.
:.� .
?'A
� W�v I
Project Location
(± 10.5 acres)
V.
fI
f �•
Project Location* r; r
*Location and extent is approximate.
Source: USDA Web Soil Survey - , Soils Legend
(Not drawn to scale)
'! SYMBOL FULL NAME
Disclaimer: The information depicted on this figure is for CeB2 Cecil sandy clay loam, 2 to 8 percent slopes, moderately eroded
informational purposes only and was not prepared for, and is CeD2 Cecil sandy clay loam, 8 to 15 percent slopes, moderately eroded
not suitable for legal or engineering purposes. HeB Helena sandy loam, 2 to 8 percent slopes
ENVIRONMENTAL Project: ER13152.00
SERVICES, INC. NRCS Soils
9401-C southern Pine Boulevard Date: Sept 2014
Charlotte, North Carolina 28273 M t . Zion Site
[phone] Mecklenburg County, North Carolina Drwn/Chkd: JB/JH
[phone] Fax
oiws rsi
www environmenfalservicesinc.com Figure: 2

J
t
1
Project Boundary (10.53 ac.±)
0 Jurisdictional Wetland*
Jurisdictional Stream*
'Location and Extent is approximate.
0 125 250
Feet
Sources: NAIP Imagery (2013); Mecklenburg
County; Project Boundary approximated by ESI.
Disclaimer: The information depicted on this figure is for informational
purposes only and was not prepared for, and is not suitable for legal or
engineering purposes. This information presented is not for regulatory -
review and is intended for use only by a Professional Land Surveyor
prior to regulatory review.
ENVIRONMENTAL
SERVICES, INC.
524 S. New Hope Road
Raleigh, North Carolina 27610
[phone]
(919 212-1707 Fax
www.enwronmentalsemicesinc.com
0
Jurisdictional Areas
Mt. Zion Site
Mecklenburg County, North Carolina
FQ:
Wetlands
W1 = 0.10 ac.±
W2 = 0.03 ac.±
W3 = 0.03 ac.±
W4 = 0.01 ac.±
Streams
S1 = 1,457.61'
S3 = 63.47'
Project: ER13152.00
Date: Oct. 2014
Drwn/Chkd: MR/JH
Figure: 3
Path: \\Ralfile2\data\GeoGra\Projects\2013\152\fig\Jurisdictional Areas v03.mxd Date: 10/28/2014 12:04:47 PM

VV I) ° g
WETLAND DETERMINATION DATA FORM — Eastern Mountains and Piedmont
Project/Site: Cornelius Nursing Home Site City/County: Cornelius/Mecklenburg County Sampling Date: 19 Aug, 2014
Applicant/Owner: Autumn Care Cornelius State: NC Sampling Point: QA4 upland
Investigator(s): ESI - JBenton Section, Township, Range: N!A'r
Landform (hillslope, terrace, etc.): hillslope Local relief (concave, convex, none): concave Slope (%): 15%
Subregion (LRR or MLRA): MLRA 136 of LRR P Lat: 35.47407 N Long: 80.85012 W Datum: WGS-84
Soil Map Unit Name: Helena sandy loam, 2 to 8 percent slopes NWI classification: upland
Are climatic / hydrologic conditions on the site typical for this time of year? Yes ✓ No (if no, explain in Remarks.)
Are Vegetation , Soil , or Hydrology significantly disturbed? Are "Normal Circumstances" present? Yes ✓ No
Are Vegetation , Soil , or Hydrology naturally problematic? (If needed, explain any answers in Remarks.)
SUMMARY OF FINDINGS — Attach site map showing sampling point locations, transects, important features, etc.
Hydrophytic Vegetation Present? Yes ✓ No Is the Sampled Area
Hydric Soil Present? Yes No ✓ within a Wetland? Yes No ✓
Wetland Hydrology Present? Yes No ✓
Remarks:
Data point is non -jurisdictional. This form represents wetland QA
HYDROLOGY
Wetland Hydrology Indicators:
Secondary Indicators (minimum of two required)
Primary Indicators (minimum of one is required; check all that apply)
_ Surface Soil Cracks (B6)
_ Surface Water (Al)
_ True Aquatic Plants (1314)
_ Sparsely Vegetated Concave Surface (138)
High Water Table (A2)
_ Hydrogen Sulfide Odor (Cl)
_ Drainage Patterns (B10)
_ Saturation (A3)
_ Oxidized Rhizospheres on Living Roots (C3)
_ Moss Trim Lines (B16)
_ Water Marks (61)
_ Presence of Reduced Iron (C4)
_ Dry -Season Water Table (C2)
_ Sediment Deposits (132)
_ Recent Iron Reduction in Tilled Soils (C6)
_ Crayfish Burrows (C8)
_ Drift Deposits (133)
_ Thin Muck Surface (C7)
_ Saturation Visible on Aerial Imagery (C9)
_ Algal Mat or Crust (134)
_ Other (Explain in Remarks)
_ Stunted or Stressed Plants (D1)
_ Iron Deposits (135)
_ Geomorphic Position (D2)
Inundation Visible on Aerial Imagery (137)
_ Shallow Aquitard (D3)
_ Water -Stained Leaves (139)
_ Microtopographic Relief (D4)
_ Aquatic Fauna (B13)
_ FAG -Neutral Test (D5)
Field Observations:
Surface Water Present? Yes No
✓ Depth (inches): N/A
Water Table Present? Yes No
✓ Depth (inches): >20
Saturation Present? Yes No
✓ Depth (inches): >20
Wetland Hydrology Present? Yes No ✓
includes capillary fringe)
Describe Recorded Data (stream gauge, monitoring well, aerial photos, previous inspections), if available:
Remarks:
The hydrologic criterion has not been met.
US Army Corps of Engineers Eastern Mountains and Piedmont —Version 2.0

VEGETATION (Four Strata) — Use scientific names of plants.
Tree Stratum (Plot size: 30 }
1 Liquidambar styraciflua
2 Liriodendron tulipifera
3 Acer rubrum
4 Quercus phellos
5.
6.
7.
8.
Sapling/Shrub Stratum (Plot size: 30 )
1 Liquidambar styraciflua
2 Ligustrum sinense
3 Acer rubrum
4.
5.
6.
7.
8.
9.
10.
Herb Stratum (Plot size: 30 }
1 Microstegium vimineum
2
Rubus argutus
3.
4.
5.
6.
7.
8.
9.
10.
11,
12.
Woody Vine Stratum (Plot size: 30 }
1 Smilax rotundifolia
2
Vitis rotundifolia
3.
4.
5.
6.
Remarks: (Include photo numbers here or on a separate
The hydrophytic vegetation criterion has been met.
Sampling Point: QA4 upland
Absolute
Dominant Indicator
Dominance Testworksheet:
% Cover
20
Species?
Y
Status
FAC
Number of Dominant Species
That Are OBL, FACW, or FAC: 8 (A)
k'
20 Y FACU
15
Y
FAC
Total Number of Dominant
Species Across All Strata: 11 (B)
Percent of Dominant Species
That Are OBL, FACW, or FAC: 72.73% (A/B)
15 Y FAC
Prevalence Index worksheet:
Total % Cover of: Multiply by:
70%
= Total Cover
OBL species x 1 = 0
FACW species x 2 = 0
15
Y
FAC
FAC species x 3 = 0
5
Y
FACU
FACU species x 4= 0
5
Y
FAC
UPL species x 5= 0
Column Totals: (A) 0 (B)
Prevalence Index = B/A = 0
Hydrophytic Vegetation Indicators:
_ 1 - Rapid Test for Hydrophytic Vegetation
✓ 2 - Dominance Test is >50%
_ 3 - Prevalence Index is 53.0'
25°!°
= Total Cover
— 4 - Morphological Adaptations' (Provide supporting
data in Remarks or on a separate sheet)
10
Y
FAC
— Problematic Hydrophytic Vegetation' (Explain)
5
Y
FACU
15% = Total Cover
5 Y FAC
5 Y FAC
10% = Total Cover
'Indicators of hydric soil and wetland hydrology must
be present, unless disturbed or problematic.
Definitions of Four Vegetation Strata:
Tree — Woody plants, excluding vines, 3 in. (7.6 cm) or
more in diameter at breast height (DBH), regardless of
height.
Sapling/Shrub — Woody plants, excluding vines, less
than 3 in. DBH and greater than 3.28 ft (1 m) tall.
Herb —All herbaceous (non -woody) plants, regardless
of size, and woody plants less than 3.28 ft tall.
Woody vine — All woody vines greater than 3.28 ft in
height.
Hydrophytic
Vegetation
Present? Yes ✓ No
a
US Army Corps of Engineers Eastern Mountains and Piedmont —Version 2.0 i
I

SOIL
Sampling Point: QA4 upland
Profile Description: (Describe to the depth needed to document the indicator or confirm the absence of indicators.)
Depth
Matrix
Redox Features
(inches)
Color (moist)
%
Color (moist) % Type Loc
Texture Remarks
0-4
10YR 3/3
100
lo-
4-14
2.5Y 516
60
7.5YR 5/8 40 C M
sa. lo.
14-20
2.5Y 6/4
70
7.5YR 518 30 C M
sa. cl. lo.
'Type: C=Concentration, D=De letion, RM=Reduced Matrix, MS=Masked Sand Grains. 2Location: PL=Pare Lining, M=Matrix.
Hydric Soil Indicators:
Indicators for Problematic Hydric Soils':
_ Histosol (Al)
_ Dark Surface (S7)
_ 2 cm Muck (Al0) (MLRA 147)
_ Histic Epipedon (A2)
_ Polyvalue Below Surface (S8) (MLRA 147, 148)
_ Coast Prairie Redox (A16)
_ Black Histic (A3)
_ Thin Dark Surface (S9) (MLRA 147, 148)
(MLRA 147, 148)
_ Hydrogen Sulfide (A4)
_ Loamy Gleyed Matrix (F2)
_ Piedmont Floodplain Soils (F19)
_ Stratified Layers (A5)
_ Depleted Matrix (F3)
(MLRA 136, 147)
_ 2 cm Muck (A10) (LRR N)
_ Redox Dark Surface (F6)
_ Red Parent Material (TF2)
_ Depleted Below Dark Surface (Al1)
_ Depleted Dark Surface (F7)
_ Very Shallow Dark Surface (TF12)
_ Thick Dark Surface (Al 2)
_ Redox Depressions (F8)
_ Other (Explain in Remarks)
_ Sandy Mucky Mineral (S1) (LRR N,
_ Iron -Manganese Masses (F12) (LRR N,
MLRA 147, 148)
MLRA 136)
_ Sandy Gleyed Matrix (S4)
_ Umbric Surface (F13) (MLRA 136, 122)
31ndicators of hydrophytic vegetation and
_ Sandy Redox (S5)
_ Piedmont Floodplain Soils (F19) (MLRA 148)
wetland hydrology must be present,
_ Stripped Matrix (S6)
unless disturbed or problematic.
Type: bedrock
Depth (inches): 4
The hydric soil criterion has not been met.
US Army Corps of Engineers
Hydric Soil Present? Yes No ✓
t
Eastern Mountains and Piedmont — Version 2.0
)

Vi+'A >i -I =�v 3
WETLAND DETERMINATION DATA FORM — Eastern Mountains and Piedmont
Project/Site: Cornelius Nursing Home Site City/County: Cornelius/Mecklenburg County Sampling Date: 19 Aug, 2014
Applicant/Owner: Autumn Care Cornelius State: NC Sampling Point: QA4 wetland
Investigator(s): ESI - JBenton Section, Township, Range. NIA°
Landform (hillslope, terrace, etc.): seep Local relief (concave, convex, none): concave Slope (%): 15%
Subregion (LRR or MLRA): MLRA 136 of LRR P Lat: 35.47407 N Long: 80.85012 W Datum: WGS-84
Soil Map Unit Name: Helena sandy loam, 2 to 8 percent slopes NWI classification: PFO
Are climatic 1 hydrologic conditions on the site typical for this time of year? Yes ✓ No (If no, explain in Remarks.)
Are Vegetation Soil or Hydrology significantly disturbed? Are "Normal Circumstances" present? Yes ✓ No
Are Vegetation Soil or Hydrology naturally problematic? (If needed, explain any answers in Remarks.)
SUMMARY OF FINDINGS — Attach site map showing sampling point locations, transects, important features, etc.
Hydrophytic Vegetation Present? Yes ✓ No
Is the Sampled Area
Hydric Soil Present? Yes ✓ No within a Wetland? Yes ✓ No
Wetland Hydrology Present? Yes ✓ No
Remarks:
Data point is jurisdictional. Seep wetland. This form represents wetland OA
HYDROLOGY
Wetland Hydrology Indicators:
Secondary Indicators (minimum of two required)
Primary Indicators (minimum of one is required;
check all that apply)
_ Surface Soil Cracks (136)
_ Surface Water (Al)
_ True Aquatic Plants (B14)
_ Sparsely Vegetated Concave Surface (138)
_ High Water Table (A2)
_ Hydrogen Sulfide Odor (Cl)
✓ Drainage Patterns (B10)
_ Saturation (A3)
_ Oxidized Rhizospheres on Living Roots (C3)
_ Moss Trim Lines (1316)
_ Water Marks (131)
_ Presence of Reduced Iron (C4)
_ Dry -Season Water Table (C2)
_ Sediment Deposits (132)
_ Recent Iron Reduction in Tilled Soils (C6)
_ Crayfish Burrows (C8)
_ Drift Deposits (B3)
_ Thin Muck Surface (C7)
_ Saturation Visible on Aerial Imagery (C9)
_ Algal Mat or Crust (134)
_ Other (Explain in Remarks)
_ Stunted or Stressed Plants (D1)
_ Iron Deposits (65)
_ Geomorphic Position (D2)
_ Inundation Visible on Aerial Imagery (B7)
_ Shallow Aquitard (D3)
✓ Water -Stained Leaves (B9)
_ Microtopographic Relief (D4)
Aquatic Fauna (B13)
✓ FAC-Neutral Test (D5)
Field Observations:
Surface Water Present? Yes No
✓ Depth (inches): N/A
Water Table Present? Yes No
✓ Depth (inches): >20
Saturation Present? Yes No
✓ Depth (inches): >20
Wetland Hydrology Present? Yes ✓ No
includes capillary fringe)
Describe Recorded Data (stream gauge, monitoring well, aerial photos, previous inspections), if available:
Remarks:
The hydrologic criterion has been met.
US Army Corps of Engineers
Eastern Mountains and Piedmont — Version 2.0

VEGETATION (Four Strata) - Use scientific names of plants.
Tree Stratum (Plot size: 30 )
1 Acer rubrum
2 Liquidambar styraciflua
3.
4.
5.
6.
7.
8.
Sapling/Shrub Stratum (Plot size: 30 )
1 Liquidam bar styraciflua
2. Ligustrum sinense
3 Ulmus americana
4.
5.
6.
7.
8.
9.
10.
Herb Stratum (Plot size: 30 )
1. Microstegium vimineum
2 Onoclea sensibilis
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Woody Vine Stratum (Plot size:
1. Smilax rotundifolia
2.
3.
4.
5.
6.
Remarks: (Include photo numbers here or on a sei
The hydrophytic vegetation criterion has been met.
19
US Army Corps of Engineers
Sampling Point: QA4 wetland
Absolute
Dominant Indicator
Dominance Testworksheet:
% Cover Species? Status
30 Y FAC
Number of Dominant Species
That Are OBL, FACW, or FAC: 7 (A)
20 Y FAC
Total Number of Dominant
Species Across All Strata: 8 (B)
Percent of Dominant Species
That Are OBL, FACW, or FAC: 87.5% (A/B)
Prevalence Index worksheet:
Total % Cover of: Multiply by:
50°1°
= Total Cover
OBL species x 1 = 0
FACW species x 2 = 0
10
Y FAC
FAC species x 3 = 0
FACU species x 4 = 0
UPL species x 5= 0
10 Y FACU
5 Y FACW
Column Totals: (A) 0 (B)
Prevalence Index = B/A = 0
Hydrophytic Vegetation Indicators:
_ 1 -Rapid Test for Hydrophytic Vegetation
✓ 2 - Dominance Test is >50%
_ 3 - Prevalence Index is :53.0'
_ 4 - Morphological Adaptations' (Provide supporting
data in Remarks or on a separate sheet)
25% = Total Cover
30
Y FAC
- Problematic Hydrophytic Vegetation' (Explain)
15
Y FACW
45% = Total Cover
5 Y FAC
5% = Total Cover
'Indicators of hydric soil and wetland hydrology must
be present, unless disturbed or problematic.
Definitions of Four Vegetation Strata:
Tree - Woody plants, excluding vines, 3 in. (7.6 cm) or
more in diameter at breast height (DBH), regardless of
height.
SapiingtShrub- Woody plants, excluding vines, less
than 3 in. DBH and greater than 3.28 ft (1 m) tall.
Herb -All herbaceous (non -woody) plants, regardless
of size, and woody plants less than 3.28 ft tall.
Woody vine -All woody vines greater than 3.28 ft in
height.
Hydrophytic
Vegetation
Present? Yes ✓ No
Eastern Mountains and Piedmont -Version 2.0

SOIL
Sampling Point: QA4 wetland
Profile Description: (Describe to the depth needed to document the indicator or confirm the absence of indicators.)
Depth Matrix
Redox Features
(inches) Color (moist) %
Color (moist) % Type Co
Texture Remarks
0-4 2.5Y 3/2 100
Iq:
4-10 Gley1 6/10Y 90
7.5YR 5/8 10 C M
si. cl.
10-20 2.5Y 6/2 90
7.5YR 5/8 10 C M
si. cl.
'Type: C=Concentration, D=De letion, RM=Reduced Matrix, MS=Masked Sand Grains.
'Location: PL=Pore Lining, M=Matrix.
Hydric Soil Indicators:
Indicators for Problematic Hydric Soils3:
_ Histosol (Al)
_ Dark Surface (S7)
_ 2 cm Muck (A10) (MLRA 147)
_ Histic Epipedon (A2)
_ Polyvalue Below Surface (S8) (MLRA 147, 148) _ Coast Prairie Redox (A16)
_ Black Histic (A3)
_ Thin Dark Surface (S9) (MLRA 147, 148)
(MLRA 147, 148)
_ Hydrogen Sulfide (A4)
✓ Loamy Gleyed Matrix (F2)
_ Piedmont Floodplain Soils (F19)
_ Stratified Layers (A5)
_ Depleted Matrix (F3)
(MLRA 136, 147)
_ 2 cm Muck (A10) (LRR N)
_ Redox Dark Surface (F6)
_ Red Parent Material (TF2)
_ Depleted Below Dark Surface (At 1)
_ Depleted Dark Surface (F7)
_ Very Shallow Dark Surface (TF12)
_ Thick Dark Surface (Al 2)
_ Redox Depressions (F8)
_ Other (Explain in Remarks)
_ Sandy Mucky Mineral (S1) (LRR N,
_ Iron -Manganese Masses (F12) (LRR N,
MLRA 147, 148)
MLRA 136)
_ Sandy Gleyed Matrix (S4)
_ Umbric Surface (F13) (MLRA 136, 122)
31ndicators of hydrophytic vegetation and
_ Sandy Redox (S5)
_ Piedmont Floodplain Soils (F19) (MLRA 148) wetland hydrology must be present,
_ Stripped Matrix (S6)
unless disturbed or problematic.
Restrictive Layer (if observed):
Type: bedrock
Depth (inches): 4
Hydric Soil Present? Yes ✓ No
Remarks:
The hydric soil criterion has been met.
US Army Corps of Engineers Eastern Mountains and Piedmont —Version 2.0

WETLAND DETERMINATION DATA FORM — Eastern Mountains and Piedmont
Project/Site: Cornelius Nursing Home Site City/County: Cornelius/Mecklenburg County Sampling Date: 19 Aug, 2014
Applicant/Owner: Autumn Care Cornelius State: NC Sampling Point: QB3 upland
Investigator(s): ESI - JBenton Section, Township, Range: N/A=
Landform (hillslope, terrace, etc.): hillslope Local relief (concave, convex, none): concave Slope (%): 15%
Subregion (LRR or MLRA): MLRA 136 of LRR P Lat: 35.47477 N Long: 80.85152 W Datum: WGS-84
Soil Map Unit Name: Cecil sandy clay loam, 8 to 15 percent slopes NWI classification: upland
Are climatic / hydrologic conditions on the site typical for this time of year? Yes ✓ No (If no, explain in Remarks.)
Are Vegetation , Soil , or Hydrology significantly disturbed? Are "Normal Circumstances" present? Yes ✓ No
Are Vegetation , Soil , or Hydrology naturally problematic? (if needed, explain any answers in Remarks.)
SUMMARY OF FINDINGS — Attach site map showing sampling point locations, transects, important features, etc.
Hydrophytic Vegetation Present? Yes No ✓
Is the Sampled Area
Hydric Soil Present? Yes No ✓ within a Wetland? Yes No
Wetland Hydrology Present? Yes No ✓
Remarks:
Data point is non jurisdictional. This form represents wetland QB
Wetland Hydrology Indicators:
Secondary Indicators (minimum of two required)
Primary Indicators (minimum of one is required:
check all that apply)
_ Surface Soil Cracks (136)
_ Surface Water (Al)
_ True Aquatic Plants (B14)
_ Sparsely Vegetated Concave Surface (B8)
_ High Water Table (A2)
_ Hydrogen Sulfide Odor (Cl)
_ Drainage Patterns (1310)
_ Saturation (A3)
_ Oxidized Rhizospheres on Living Roots (C3)
_ Moss Trim Lines (B16)
_ Water Marks (B1)
_ Presence of Reduced Iron (C4)
_ Dry -Season Water Table (C2)
_ Sediment Deposits (132)
_ Recent Iron Reduction in Tilled Soils (C6)
_ Crayfish Burrows (C8)
_ Drift Deposits (B3)
_ Thin Muck Surface (C7)
_ Saturation Visible on Aerial Imagery (C9)
_ Algal Mat or Crust (134)
_ Other (Explain in Remarks)
_ Stunted or Stressed Plants (D1)
_ Iron Deposits (B5)
_ Geomorphic Position (D2)
_ Inundation Visible on Aerial Imagery (137)
_ Shallow Aquitard (D3)
_ Water -Stained Leaves (B9)
_ Microtopographic Relief (D4)
_ Aquatic Fauna (B13)
_ FAC-Neutral Test (D5)
Field Observations:
Surface Water Present? Yes No
✓ Depth (inches): N/A
Water Table Present? Yes No
✓ Depth (inches): ' >20
Saturation Present? Yes No
✓ Depth (inches): >20
Wetland Hydrology Present? Yes No
includes capillary fringe)
Describe Recorded Data (stream gauge, monitoring well, aerial photos, previous inspections), if available:
Remarks:
The hydrologic criterion has not been met.
k
US Army Corps of Engineers Eastern Mountains and Piedmont —Version 2.0

VEGETATION (Four Strata) - Use scientific names of plants.
Tree Stratum (Plot size: 30 )
1 Liriodendron tulipifera
2 Quercus alba
3 Acer rubrum
4.
5.
6.
7.
8.
Sapling/Shrub Stratum (Plot size: 30 }
1 Acer rubrum
2 Ligustrum sinense
3 Liquidambar styraciflua
4.
5.
6.
7.
8.
9.
10.
Herb Stratum (Plot size: 30 )
1 Polystichum acrostichoides
2 Rubus argutus
3.
4.
5.
6.
7.
8.
9.
10.
11.
12,
Woody Vine Stratum (Plot size: 30 )
1 Vitis rotundifolia
2 Toxicodendron radicans
3.
4.
5.
6.
Sampling Point: QB3 upland
Absolute
Dominant Indicator
Dominance Test worksheet:
% Cover
35
Species?
Y
Status
FACU
Number of Dominant Species
That Are OBL, FACW, or FAC: 5 (A)
i'
Total Number of Dominant
Species Across All Strata: 10 (B)
20 Y FACU
15 Y FAC
Percent of Dominant Species
That Are OBL, FACW, or FAC: 50% (A/B)
Prevalence Index worksheet:
Total % Cover of: Multiply by:
70%
= Total Cover
OBL species x 1 = 0
FACW species x 2 = 0
10
Y
FAC
FAC species x 3 = 0
5
Y
FACU
FACU species x 4= 0
UPL species x 5= 0
5 Y FAC
Column Totals: (A) 0 (B)
Prevalence Index = B/A = 0
Hydrophytic Vegetation Indicators:
1 - Rapid Test for Hydrophytic Vegetation
2 - Dominance Test is >50%
_
_ 3 - Prevalence Index is 53.0'
20°I°
= Total Cover
- 4 - Morphological Adaptations' (Provide supporting
data in Remarks or on a separate sheet)
5
Y
FACU
- Problematic Hydrophytic Vegetation' (Explain)
5
Y
FACU
10% = Total Cover
5 Y FAC
5 Y FAC
10% = Total Cover
Remarks: (Include photo numbers here or on a separate sheet.)
The hydrophytic vegetation criterion has not been met.
US Army Corps of Engineers
'Indicators of hydric soil and wetland hydrology must
be present, unless disturbed or problematic.
Definitions of Four Vegetation Strata:
Tree - Woody plants, excluding vines, 3 in. (7.6 cm) or
more in diameter at breast height (DBH), regardless of
height.
Sapling/Shrub - Woody plants, excluding vines, less
than 3 in. DBH and greater than 3.28 ft (1 m) tall.
Herb -All herbaceous (non -woody) plants, regardless
of size, and woody plants less than 3.28 ft tall.
Woody vine - All woody vines greater than 3.28 ft in
height.
Hydrophytic
Vegetation
Present? Yes No
(
Eastern Mountains and Piedmont -Version 2.0

SOIL
Sampling Point: QB3 upland
Profile Description: (Describe to the depth needed to document the indicator or confirm the absence of indicators.)
Depth Matrix
Redox Features
(inches) Color (moist) %
Color (moist) % Type Loc
Texture Remarks
0-4 10YR 3/2 100
los
4-20 2.5Y 713 90
10YR 5/8 10 C M
si. lo.
'Type: C=C once ntration, D=De letion, RM=Reduced Matrix, MS=Masked Sand Grains. 2 Location: PL=Pore Lining, M=Matrix.
Hydric Soil Indicators:
Indicators for Problematic Hydric Soils':
_ Histosol (Al)
_ Dark Surface (S7)
_ 2 cm Muck (A10) (MLRA 147)
_ Histic Epipedon (A2)
_ Polyvalue Below Surface (S8) (MLRA 147, 148) _ Coast Prairie Redox (A16)
_ Black Histic (A3)
_ Thin Dark Surface (S9) (MLRA 147, 148)
(MLRA 147, 148)
Hydrogen Sulfide (A4)
_ Loamy Gleyed Matrix (F2)
_ Piedmont Floodplain Soils (F19)
_ Stratified Layers (A5)
_ Depleted Matrix (F3)
(MLRA 136, 147)
_ 2 cm Muck (Al0) (LRR N)
_ Redox Dark Surface (F6)
_ Red Parent Material (TF2)
_ Depleted Below Dark Surface (All)
_ Depleted Dark Surface (F7)
_ Very Shallow Dark Surface (TF12)
_ Thick Dark Surface (Al2)
_ Redox Depressions (F8)
_ Other (Explain in Remarks)
_ Sandy Mucky Mineral (S1) (LRR N,
_ Iron -Manganese Masses (F12) (LRR N,
MLRA 147, 148)
MLRA 136)
_ Sandy Gleyed Matrix (S4)
_ Umbric Surface (F13) (MLRA 136, 122)
3Indicators of hydrophytic vegetation and
_ Sandy Redox (S5)
_ Piedmont Floodplain Soils (F19) (MLRA 148) wetland hydrology must be present,
_ Stripped Matrix (S6)
unless disturbed or problematic.
Restrictive Layer (if observed):
Type: bedrock
Depth (inches): 4
Hydric Soil Present? Yes No ✓
Remarks:
The hydric soil criterion has not been met.
US Army Corps of Engineers
Eastern Mountains and Piedmont — Version 2.0

WETLAND DETERMINATION DATA FORM — Eastern Mountains and Piedmont
Project/Site: Cornelius Nursing Home Site City/County: Comelius/Mecklen burg County Sampling Date: m _��ug, 2014_
Applicant/Owner: Autumn Care Cornelius State: «CSampling Point: QB}wetland
_
mvoutigamr(s): ee| Jeemon Section, Township, Range: w«w
Lanumrm(moomvm.terrace, etc.): floodplain Local relief (cnncave.convex, none): concave Slope (m):wu___
Subregion (Lmno,MLnx: MLe«1»smLmnr Lat:»«.4r4r/w Long: o»»s1m«» oumm:yVGS-n4___
Soil Map Unit Name: Cecil sandy clay loam, 8 to 15 percent slopes wvwclaoomomovn: rro
Are climatic / hydrologic conditions onthe site typical for this time o,year? Yes / wo(if no, explain innnma,ks.)
Are Vegetation .Soil
____.u,Hydrology ____ significantly disturbed? Are "Normal Circumstances" present? Yes '/ wo_____
Are Vegetation .Soil ____.vrHydrology _____ naturally problematic? (if needed, explain any answers mReme,xo.)
SUMMARY OF FINDINGS — Attach site map showing sampling point locations, transects, important features, etc.
Hydrophytic Vegetation Present? Yes / wu---- Isthe Sampled Area
/
Hvoncaw/p�r sonYes wo_---- within aWetland? vvu v/ wo____—_
Wetland Hydrology Present? Yes No
Remarks:
Data point is jurisdictional. Riparian wetland. This form represents wetland QB
HYDROLOGY
Welland Hydrology Indicators:
Secondary Indicators (minimum of two required)
Primary Indicators (minimum of one is required: check all that apply)
Surface Soil Cracks (136)
Surface Water (Al)
— True Aquatic Plants (B14)
Sparsely Vegetated Concave Surface (B8)
High Water Table (A2)
— Hydrogen Sulfide Odor (Cl)
Drainage Patterns (1310)
V Saturation (A3)
Oxidized Rhizospheres on Living Roots (C3)
Moss Trim Lines (B1 6)
Water Marks (131)
Presence of Reduced Iron (C4)
Dry -Season Water Table (C2)
Sediment Deposits (132)
Recent Iron Reduction in Tilled Soils (C6)
Crayfish Burrows (C8)
Drift Deposits (133)
Thin Muck Surface (C7)
Saturation Visible on Aerial Imagery (C9)
Algal Mat or Crust (B4)
Other (Explain in Remarks)
Stunted or Stressed Plants (D1)
Iron Deposits (135)
Geomorphic Position (D2)
Inundation Visible on Aerial Imagery (137)
Shallow Aquitard (D3)
Field Observations:
Surface Water Present? Yes No
Depth (inches): N/A
Water Table Present? Yes No
Depth (inches): 6
Saturation Present? Yes No
Depth (inches): surface
Wetland Hydrology Present? Yes No
(includes capillary fringe)
Describe Recorded Data (stream gauge, monitoring well, aerial photos, previous inspections), if available:
The hydrologic criterion has been met.
uaArmy Corps mEngineers Eastern Mountains and Piedmont —Version 2.0

VEGETATION (Four Strata) — Use scientific names of plants.
Sampling Point: QB3 wetland
Absolute
Dominant Indicator
Dominance Testworksheet:
Tree Stratum (Plot size: 30 )
% Cover
Species? Status
Number of Dominant Species
1 Acer rubrum
30
Y FAC
That Are OBL, FACW, or FAC: 4 (A)
Total Number of Dominant
2'
3.
Species Across All Strata: 6 (B)
4.
Percent of Dominant Species
5.
That Are OBL, FACW, or FAC: 66.67% (A/B)
6.
Prevalence Index worksheet:
7.
Total % Cover of: Multiply by:
8
30%
= Total Cover
OBL species x 1 = 0
Sapling/Shrub Stratum (Plot size: 30
)
FACW species x 2 = 0
1 Ligustrum sinense
20
Y FACU
FAC species x 3 = 0
2 Acer rubrum
10
Y FAC
FACU species x 4 = 0
3,
UPL species x 5 = 0
4_
Column Totals: (A) 0 (B)
5.
Prevalence Index = B!A = 0
6.
Hydrophytic Vegetation Indicators:
7
1 - Rapid Test for Hydrophytic Vegetation
8
_
✓ 2 - Dominance Test is >50%
9.
3 - Prevalence Index is 53.0'
10.
30%
_ 4 - Morphological Adaptations' (Provide supporting
30
= Total Cover
data in Remarks or on a separate sheet)
Herb Stratum (Plot size: )
Problematic Hydrophytic Vegetation' (Explain)
1.
2.
'Indicators of hydric soil and wetland hydrology must
3•
be present, unless disturbed or problematic.
4.
Definitions of Four Vegetation Strata:
5.
6
Tree — Woody plants, excluding vines, 3 in. (7.6 cm) or
more in diameter at breast height (DBH), regardless of
7.
height.
8.
Sapling/Shrub —Woody plants, excluding vines, less
g.
than 3 in. DBH and greater than 3.28 It (1 m) tall.
0,
10.
Herb — All herbaceous (non -woody) plants, regardless
11.
of size, and woody plants less than 3.28 ft tall.
12.
0%
= Total Cover
Woody vine — All woody vines greater than 3.28 ft in
Woody Vine Stratum (Plot size: 30
)
height.
1 Parthenocissus quinquefolia
15
Y FACU
2 Lonicera japonica
10
Y FAC
3 Toxicodendron radicans 10 Y FAC
4.
Hydrophytic
5•
Vegetation
6.
Present? Yes ✓ No
35% = Total Cover
Remarks: (Include photo numbers here or on a separate sheet.)
The hydrophytic vegetation criterion has been met.
N
US Army Corps of Engineers
Eastern Mountains and Piedmont —Version 2.0

M1
Sampling Point: QB3 wetland
Profile Description: (Describe to the depth needed to document the indicator or confirm the absence of indicators.)
Depth Matrix
Redox Features
(inches) Color (moist) %
Color (moist) °t° Type Loc
Texture Remarks
0-20 2.5Y 412 95
7.5YR 4/6 5 C PL
si. to. oxidized rhizospheres
'Type: C=Concentration, D=De letion, RM=Reduced Matrix, MS=Masked Sand Grains. 2Location: PL=Pore Lining, M=Matrix.
Hydric Soil Indicators:
Indicators for Problematic Hydric Soils':
_ Histosol (A1}
_ Dark Surface (S7)
_ 2 cm Muck (A10) (MLRA 147)
_ Histic Epipedon (A2)
_ Polyvalue Below Surface (S8) (MLRA 147, 148) _ Coast Prairie Redox (A16)
_ Black Histic (A3)
_ Thin Dark Surface (S9) (MLRA 147, 148)
(MLRA 147, 148)
_ Hydrogen Sulfide (A4)
_ Loamy Gleyed Matrix (F2)
_ Piedmont Floodplain Soils (F19)
_ Stratified Layers (A5)
✓ Depleted Matrix (F3)
(MLRA 136, 147)
_ 2 cm Muck (A10) (LRR N)
_ Redox Dark Surface (F6)
_ Red Parent Material (TF2)
_ Depleted Below Dark Surface (A11)
_ Depleted Dark Surface (F7)
_ Very Shallow Dark Surface (TF12)
_ Thick Dark Surface (Al2)
_ Redox Depressions (F8)
_ Other (Explain in Remarks)
_ Sandy Mucky Mineral (S1) (LRR N,
_ Iron -Manganese Masses (F12) (LRR N,
MLRA 147, 148)
MLRA 136)
_ Sandy Gleyed Matrix (S4)
_ Umbric Surface (F13) (MLRA 136, 122)
3Indicators of hydrophytic vegetation and
_ Sandy Redox (S5)
_ Piedmont Floodplain Soils (F19) (MLRA 148) wetland hydrology must be present,
_ Stripped Matrix (S6)
unless disturbed or problematic.
Restrictive Layer (if observed):
Type: bedrock
Depth (inches): 4
Hydric Soil Present? Yes ✓ No
Remarks:
The hydric soil criterion has been met.
US Army Corps of Engineers Eastern Mountains and Piedmont — Version 2.0

NC >nWO Stream identifieation Form Version'4.11
Date: ! j t ,
Projectisite: (')r rtCJ': a
`�
Evaluator. - 1
County: t�,� ��¢„-s
c
Longitude:', r"
i4 T � .
Total Points: J
is least intermittent
Stream Determination (circle one)
Other
Stream at
Ephemeral Intermittent erennial
e.g. Quad Name: (poy-nejv)
if >_ 19 orperennial if ? 30'
A. Geomorphology (Subtotal = I q .5 )
Absent
Weak
Moderate
Strong
18 Continuity of channel bed and bank
0
1
2
3
2. Sinuosity of channel along thalweg
0
1
3
3. In -channel structure: ex. riffle -pool, step -pool,
ripple -pool sequence
0
1
�
3
4. Particle size of stream substrate
0
1
2
3
5. Active/relict floodplain
0
1
2
3
6. Depositional bars or benches
0
1
2
3
7. Recent alluvial deposits
0
1
2
8. Headcuts
1
2
3
9. Grade control
0
0.5
1
1:5
10. Natural valley
0
0.5
1
1.5
11. Second or greater order channel
No = 0
Yes = 3
V.•_••__•
R Wvrirnlnnv lfiiihtntal=v a'�y1 .••
12. Presence of Baseflow
0
1
2
3
13. Iron oxidizing bacteria
0
1
2
3
14. Leaf litter
3.5
1
0.5
0
15. Sediment on plants or debris
0
0.5
1
1.5
16. Organic debris lines or piles
0
0.5
!1
1`.5
17. Soil -based evidence of high water table?
No = 0
Yes = 3
(` Rinlnnv lCiihtntal = _+ 1
1B. Fibrous roots in streambed
r
2
1 '
0
19. Rooted upland plants in streambed
3
2
1
0
20. Macrobenthos (note diversity and abundance)
0
1
2
3
21. Aquatic Mollusks
0
1
2
3
22. Fish
0.5
1
1.5
23. Crayfish
0
0:5
1
1.5
24. Amphibians
0
0:5
1
1.5
25. Algae
0
0.5
1
1:5
26. Wetland plants in streambed
FACW = 0.75;
OBL = 1.5 Other = 0
'perennial streams may also be identified using other methods. See p. 35 of manual.
Notes r .. C C P �i� e'+'
•
o
� }4q
-_'" s " :=. x+ S
id 4
.d`T' .i E. ,'.-8. ..dt 3
'. s.-%w'"
'•,*.;:"r? ": $'v„ 't �+`Y 1 r, +
7 -
Sketch:

S
ATV "Wil Ctrnam 1dPntifiira*inn Farm VPrcinn d-11 �2
Date:
Projectisite: r�1f,4i=¢ gar .
Latitude: s Fq_Ns Pi
Evaluator: ��.�
County:
Longitude:
Longitude: r
Total Points:
Stream is at least intermittent
if>_ 19 or perennial if>_ 30
stream Deter ' ation (circle one)
Ephemeral Intemti n Perennial
Other
e.g. Quad Name: C e. tai
A. Geomorphology (Subtotal = )
Absent
Weak
Moderate
Strong
1a. Continuity of channel bed and bank
0
2
3
2. Sinuosity of channel along thalweg
0
1
2
3
3. In -channel structure: ex. riffle -pool, step -pool,
ripple -pool sequence
0
i)
2
3
4. Particle size of stream substrate
0
1
2
3
5. Active/relict floodplain
0
1
2
3
6. Depositional bars or benches
0
1
2
3
7. Recent alluvial deposits
0
1
2
3
8. Headcuts
0
1
2
3
9. Grade control
0
0.5
1
1.5
10. Natural valley
0
0.5
1
1.5
11. Second or greater order channel
No = 0
Yes = 3
artificial ditches are not rated; see discussions in manual
R Wwriminrry Mithtntai = -71
12. Presence ofBaseflow
0
2
3
13. Iron oxidizing bacteria
0
2
3
14. Leaf litter
1.5
1
0.5
0
15. Sediment on plants or debris
0
0.5
1
1.5
16. Organic debris lines or piles
0
0.5
1
1.5
17. Soil -based evidence of high water table?
No = 0
Yes = 3
(" Rintnnv (Cnh4n4PI = 1
18. Fibrous roots in streambed
3
2
1 "
0
19. Rooted, upland plants in streambed
3
2
1
0
20. Macrobenthos (note diversity and abundance)
0
1
2
3
21. Aquatic Mollusks
0
1
2
3
22. Fish
0
0.5
1
1.5
23. Crayfish
0.5
1
1:5
24. Amphibians
0.5
1
1.5
25. Algae
0.5
1
1.5
26. Wetland plants in streambed
FACW = 0.75; OBL = 1.5 Other '=
"perennial streams may also be identified using other methods. See p. 35 of manual.
Notes: . ' fetich 01 -
wl I I in- 'v-rrJ
, ,
ar (? �F;�vd 's-6 " l Vp'lo"'iLl
L X
a
Sketch:

USACE AID#
DWQ#
Site # (indicate on attached map)
STREAM QUALITY ASSESSMENT WORKSHEET �r `t-
Provide the following information for the stream reach under assessment:
�j (to
1. Applicant's name: 2. Evaluator's name: �.� ,.-, r,,
3. Date of evaluation:
( �;' 4. Time of evaluation:
5. Name of stream: . Yft% , 2 Pt 6. River basin: Jul k"-l" Ae" lC
7. Approximate drainage area I&<<;. ° 8. Stream order:''
9. Length of reach evaluated: 50 10. County:
11. Site coordinates (if known)prefer in decimal degrees. 12. Subdivision name (if any)
Latitude (ex. 34.872312):k� i Longitude (ex.-77.556611): =-
Method location determined (circle): GPS Topo Sheet Ortho (Aerial) Photo/GIS Other GIS Other V£'_ -,
13. Location of reach under evaluation (note nearby roads and landmarks and attach"il'la)iidentifying stream(s) location):
{
14. Proposed channel work (if any): tot
15. Recent Weather conditions Ala no ,
16. Site conditions at time of visit: .f_
17. Identify any special waterway classifications known: Section 10 Tidal Waters _Essential Fisheries Habitat
_Trout Waters _Outstanding Resource Waters Nutrient Sensitive Waters _Water Supply Watershed __(I -IV)
18. Is there a pond or lake located upstream of the evaluation point? "YES Qo' If yes, estimate the water surface area:
19. Does channel appear on USGS quad map? YES NO 20. Does channel appear on USDA Soil Survey? YES kNO
21. Estimated watershed land use: 0 % Residential il % Commercial %'Industrial % Agricultural
i `` % Forested % Cleared / Logged % Other ( )
22. Bankf ill width: 23. Bank height (from bed to top of bank): X s
24. Channel slope down center of stream: Flat (0 to 2%) ":, Gentle (2 to 41/6) _Moderate (4 to 10%) _Steep (>10%)'
25. Channel sinuosity: Straight _,-Occasional bends Frequent meander ' _Very sinuous " Braided channel
Instructions for completion of worksheet (located on page 2): Begin by determining the most appropriate ecoregion based on
location, terrain, vegetation, stream classification, etc. Every characteristic must be scored using the same ecoregion. Assign points -
to each characteristic within the range "shown for the ecoregion. Page 3 provides a brief description of how to review the
characteristics identified in the worksheet. Scores should reflect an overall assessment of the stream reach under evaluation. If a"
characteristic cannot be evaluated due to site or weather conditions, enter 0 in the scoring box and provide an explanation in the
comment section. Where there are obvious changesin the character of a stream under review (e.g., the stream flows from a pasture
into a forest), the stream may be divided into smaller reaches that display more continuity, and a separate form used to evaluate each
reach. The total score assigned to a stream reach must range between 0 and 100, with a score of 100 representing a stream of the
highest quality.
Total Score (from reverse)_ . g Comments: 4
4 ,/b3 r r .a w V 0 ci k�N iii 1 �!-,, —
Evaluator's Signature Date
This channel evaluation fir ' i nei a used only as a guide to assist landowners and environmental professionals in
gathering the data required by the United States Army Corps of Engineers to make a, preliminary assessment of stream,
quality. The total score resulting from the completion of this form is subject to USACE approval and does not imply a
particular mitigation ratio or requirement. Form subject to change — version 06/03. To Comment, please call 919-876-8441 x 26.

STREAM QUALITY ASSESSMENT WORKSHEET
#
CHARACTERISTICS
ECOREGION POINT
RANGE
SCORE'
Coastal
Piedmont
Mountain
1
Presence of flow / persistent pools in stream
0-5
0 - 4
0-5
_.
(no flow or saturation = 0; strong flow = max points)
2
Evidence of past human alteration
0-6
0-5
0-5
(extensive alteration = 0; no alteration - max points
3
Riparian zone
0 - 6
0-4
0-5
(no buffer = 0; contiguous, wide buffer = max points)
4
Evidence of nutrient or chemical discharges
0-5
0-4
0-4
(extensive discharges = 0; no discharges = max points)
a
5
Groundwater discharge
0-3
0-4
0-4
1 C
(no discharge = 0; springs, seeps, wetlands, etc. = max points)
6
Presence of adjacent floodplain
0_ 4
0-4
0-2
>,
(no floodplain= 0; extensive floodplain = max points)
7
Entrenchment / floodplain access
0-5
0-4
0-2
(deeply entrenched = 0; frequent flooding = max paints)
8
Presence of adjacent wetlands
0-6
0-4
0-2
(no wetlands = 0; large adjacent wetlands = max points)
9
Channel sinuosity
0-5
0-4
0-3
(extensive channelization = 0; natural meander = max paints)
10
Sediment input
0-5
0-4
0-4
(extensive deposition= 0; little or no sediment = max points)
11
Size & diversity of channel bed substrate
NA*
0-4
0-5
(fine, homogenous = 0; large, diverse sizes = maxpoints)
12
Evidence of channel incision or widening
0-5
0-4
0-5
>4
(deeply incised = 0; stable bed & banks = max points)
N
13
Presence of major bank failures
0-5
0-5
0-5
(severe erosion = 0; no erosion, stable banks = max points)
G�
14
Root depth and density on banks
0-3
0-4
0-5
F..,,
(no visible roots = 0; dense roots throughout = max points)cr
15
Impact by agriculture, livestock, or timber production
0-5
0 4
0-5
(substantial impact =0; no evidence = max points)
16
Presence of riffle-pool/ripple-pool complexes
0-3
0 -5
0-6 _
2.
(no riffles/ripples or pools = 0; well -developed = max points)
l?
Habitat complexity
0-6
0-6
'2.0-6
E"
N
(little or no habitat = 0; frequent, varied habitats = max points)'
�
18
Canopy coverage over streambed
0-5
0-5
0-5
,x
(no shading vegetation = 0; continuous canopy'=max paints) "'
�
19
Substrate embeddedness
NA*
0-4
0-4
(deeply embedded = 0; loose structure = max)
20
Presence of stream invertebrates (see page 4)
0-5
0-5
no evidence = 0` common numerous types = maxpoints)0-4
Cz�
21
Presence of amphibians
0-4
0-4
0-4
©
no evidence = 0; common, numerous types = max points
4
G
22
Presence of fish
0-4
0-4
0-4
*0
no evidence = 0; common, numerous types = maxpoints)
23
Evidence of wildlife use
0-6
0-5
0-5
(no evidence = 0; abundant evidence = max points)
Total Points Possible
100
100
100
TOTAL SCORE_ ,(also enter on first page)
* These characteristics are not assessed in coastal streams. `
2

USACE AID# DWQ # Site # (indicate on attached map)
STREAM QUALITY ASSESSMENT WORKSHEET
Provide the following information for the stream reach under assessment:'
1. Applicant's name:
3. Date of evaluation: Y Tl a-
5. Name of stream: -VT 4 ;r ° 1 • s
7. Approximate drainage area ( of-,
2. Evaluator's name: FNA - J P2L,
4. Time of evaluation:
6. River basin: 4 ` c.ak j Nc . 1
8. Stream order:
9. Length of reach evaluated: 0 4 a 10. County: 1OO1t.0 1Z,", 0-
11. Site coordinates (if known): prefer in decimal degrees. 12. Subdivision name (if any): f-14A
Latitude (ex. 34.872312): Longitude (ex.-77.556611): 7411 W
Method location determined (circle): GPS Topo Sheet Ortho (Aerial) Photo/GIS 1 ther GI Other / ,��ti �r t 9 /? (,
13. Location of reach under evaluation (note nearby roads and landmarks and attach2i-t identifying stream(s) location):
�. tx c
r'o 0 a t #r C.,, t
1`i1
14. Proposed channel work (if any): T6 D
15. Recent weather conditions A10X (0y- L14 r (W .1 in o,
16. Site conditions at time of visit: 4 ! C h wr, I '° _'` a ") � ) I--J C
17. Identify any special waterway classifications known: _Section 10 Tidal Waters ` _Essential Fisheries Habitat
_Trout Waters _Outstanding Resource Waters Nutrient Sensitive Waters _Water Supply Watershed (I -IV)
18. Is there a pond or lake located upstream of the evaluation point? YES i TO elf yes, estimate the water surface area:
19. Does channel appear on USGS quad map? YES 20. Does channel appear on USDA Soil Survey? YES O
21. Estimated watershed land use: .", °lo Residential a ff % Commercial % Industrial _% Agricultural
1'O % Forested % Cleared / Logged _% Other ( )
22. Bankfull width: ' ' ` 23. Bank height (from bed to top of bank): ' `
24. Channel slope down center of stream: _Flat (0 to 21/4) _Gentle (2 to 4%) Moderate (4 to,10%) _Steep (>10%)
25. Channel sinuosity: Straight X Occasional bends Frequent meander Very'sinuous'' Braided channel
Instructions for completion of worksheet (located on page 2): Begin by determining the most appropriate ecoregion based on
location, terrain, vegetation, stream classification, etc. Every characteristic must be scored using the same ecoregion Assign points
to each characteristic within the range shown for the ecoregion. Page 3 provides a brief description of how to review the
characteristics identified in the worksheet. Scores should reflect an overall assessment of the stream reach under evaluation. If a
characteristic cannot be evaluated due to site or weather conditions, enter 0 in the scoring box ,and provide an explanation in the "
comment section. Where there are obvious changes in the character of a stream under review (e.g., the stream flows from a pasture
into a forest), the stream may be divided into smaller reaches that display more continuity, and a separate form used to evaluate each
reach. The total score assigned to a stream reach must range between 0 and 100, with a score of 100, representing a.stream of the
highest quality.
Total Score (from reverse): Comments: �� t� "�� c a t I J s i
s: .s4f t- .� v 0o -tl�
Evaluator's Signature' Date
This channel evaluation fo i d o be used only as a guide to assist` landowners and environmental professionals in
gathering the data required by the United States Army Corps of Engineers to make a preliminary assessment of stream
quality. The total score resulting from the completion of this form is subject to USACE approval and does not imply a
particular mitigation ratio or requirement. Form subject to change - version 06/03. To Comment, please call 919-876-8441 x 26.
U

STREAM QUALITY ASSESSMENT WORKSHEET
#
CHARACTERISTICS
ECOREGION POINT
RANGE
SCORE
Coastal
Piedmont
Mountain `
1
Presence of flow / persistent pools in stream
0-5
0 —'4
0-5
no flow or saturation = 0; strong -flow = maxpoints)
2
Evidence of past human alteration
0-6
0-5
0-5
(extensive alteration = 0; no alteration = max points) `
3
Riparian zone
0-6
0-4
0-5
(no buffer = 0; contiguous, wide buffer = max points)
4
Evidence of nutrient or chemical discharges
0-5
0-4
0-4
(extensive discharges = 0; no discharges = max points)
a
Groundwater discharge
0-3
0-4
0-4
U5
no discharge = 0; springs, seeps, wetlands, etc. = max points)
6
Presence of adjacent floodplain
0-4
0-4
0-2
y,
(no floodplain = 0; extensive floodplain = max points)
Entrenchment / floodplain access
0-5
0-4
0-2
p-'
(deeply entrenched = 0• frequent flooding= max points)
8
Presence of adjacent wetlands
0-6
0-4
0-2
(no wetlands = 0; large adjacent wetlands = maxpoints)
9
Channel sinuosity
0-5
0-4
0-3
(extensive channelization = 0; natural meander = max points)
10
Sediment input
0-5
0-4
0-4
(extensive deposition= 0; little or no sediment = max points)
1 I
Size & diversity of channel bed substrate
NA*
0-4
0-5
(fine, homogenous = 0; large, diverse sizes = max points)
12
Evidence of channel incision or widening
0-5
0-4
0-5
�.,
(deeply incised = 0; stable bed & banks = max points)
„F*
13
Presence of major bank failures
0-5
0-5
0-5
3
►-a
(severe erosion = 0; no erosion, stable banks = max points)
14
Root depth and density on banks
0-3
0-4
0-5
F„
(no visible roots = 0; dense roots throughout = max points)
CO)
IS
Impact by agriculture, livestock, or timber production
0-5
0 4
0-5
(substantial impact =0; no evidence = max points)
16
Presence of riffle-pool/ripple-pool complexes
0-3
0-5
0-6
(no riffles/ripples or pools = 0; well -developed = max points)
a
17
Habitat complexity
0-6
0-6
0-6
(little or no habitat = 0; frequent, varied habitats = max points)
,
18
Canopy coverage over streambed
0-5
0-5
0—
(no shading vegetation = 0; continuous canopy = max points)
19
Substrate embeddedness
NA*
0-4
0-4
`2
(deeply embedded = 0; loose structure = max)
J
20
Presence of stream invertebrates (see page 4)
0-4
0-5
0 -5
1
(no evidence = 0; common numerous —
types —max points)
�
21
Presence of amphibians
0-4
0-4
0-4
O
(no evidence = 0; common numerous types = maxpoints)
O22
Presence of fish
0-4
0-4
0-4
(no evidence = 0; common, numerous types = maxpoints)
23
Evidence of wildlife use
0-6
0-5
0-5
(no evidence = 0; abundant evidence = max points)
"
Total Points Possible
100
100
100
TOTAL SCORE: (also enter on first page)
'
* These characteristics are not assessed in coastal streams.
2

Sl, w11w2
APPROVED JURISDICTIONAL DETERMINATION FORM W3 W 4
U.S. Army Corps of Engineers
This form should be completed by following the instructions provided in Section IV of the JD Form Instructional Guidebook.
SECTION 1: BACKGROUND INFORMATION
A. REPORT COMPLETION DATE FOR APPROVED JURISDICTIONAL DETERMINATION (JD):
B. DISTRICT OFFICE, FILE NAME, AND NUMBER:
C. PROJECT LOCATION AND BACKGROUND INFORMATION: Mt. Zion Site
State: NC County/parish/borough: Mecklenburg City: Cornelius
Center coordinates of site (lat/long in degree decimal format): Lat. 35.47491' N, Long. 80.84986' W.
Universal Transverse Mercator: 17S 513621 3925721
Name of nearest waterbody: South Prong West Branch Rocky River
Name of nearest Traditional Navigable Water (TNW) into which the aquatic resource flows: Pee Dee River
Name of watershed of Hydrologic Unit Code (HUC): Rocky 03040105
M Check if map/diagram of review area and/or potential jurisdictional areas is/are available upon request.
❑; Check if other sites (e.g., offsite mitigation sites, disposal sites, etc...) are associated with this action and are recorded on a
different JD form.
D. REVIEW PERFORMED FOR SITE EVALUATION (CHECK ALL THAT APPLY):
❑ Office (Desk) Determination. Date:
❑ Field Determination. Date(s):
SECTION II: SUMMARY OF FINDINGS
A. RHA SECTION 10 DETERMINATION OF JURISDICTION.
There Are'no "navigable waters ofthe U.S." within Rivers and Harbors Act (RHA) jurisdiction (as defined by 33'CFR part 329) in the
review area. [Required]
Waters subject to the ebb and now of the tide.
❑ Waters are presently used, or have been used in the past, or may be susceptible for use to transport interstate or foreign commerce.
Explain:
B. CWA SECTION 404 DETERMINATION OF JURISDICTION.
There Are "waters of the U.S." within Clean Water Act (CWA) jurisdiction (as defined by 33 CFR part 328) in the review area. [Required]
1. Waters of the U.S.
a. Indicate presence of waters of U.S. in review area (check all that apply): r
TNWs, including territorial seas
Wetlands adjacent to TNWs
Relatively permanent waters (RPWs) that flow directly or indirectly into TNWs
Non-RPWs that flow directly or indirectly into TNWs
Wetlands directly abutting RPWs that flow directly or indirectly into TNWs
[] Wetlands adjacent to but not directly abutting RPWs that flow directly or indirectly into TNWs'
Wetlands adjacent to non-RPWs that flow directly or indirectly into TNWs
Impoundments ofjurisdictional waters
Isolated (interstate or intrastate) waters, including isolated wetlands
b. Identify (estimate) size of waters of the U.S. in the review area:
Non -wetland waters: approximately 1,458 linear feet: 4 width (ft) and/or acres.
Wetlands: 0.17 acres.
c. Limits (boundaries) of jurisdiction based on: Established by OHWM
Elevation of established OHWM (if known): Established by RGL 05-05 guidelines.
2. Non -regulated waters/wetlands (check if applicable):a
Potentially jurisdictional waters and/or wetlands were assessed within the review area and determined to be not jurisdictional.
Explain:
Boxes checked below shall be supported by completing the appropriate sections in Section III below.
z For purposes of this form, an RPW is defined as a tributary that is, not a TN W and that typically flows year-round or has continuous flow at least "seasonally"
(e.g., typically 3 months). -
a Supporting documentation is presented in Section III F

SECTION III: CWA ANALYSIS
A. TNWs AND WETLANDS ADJACENT TO TNWs
The agencies will assert jurisdiction over TNWs and wetlands adjacent to TNWs. If the aquatic resource is a TNW, complete
Section III.A.1 and Section III.D.I. only; if the aquatic resource is a wetland adjacent to a TNW, complete Sections HI.A.1 and 2
and Section III.D.L; otherwise, see Section IIIM below. 3.
1. TNW
Identify TNW:
Summarize rationale supporting determination:
2. Wetland adjacent to TNW
Summarize rationale supporting conclusion that wetland is "adjacent":
B. CHARACTERISTICS OF TRIBUTARY (THAT IS NOT A TNW) AND ITS ADJACENT WETLANDS (IF ANY):
This section summarizes information regarding characteristics of the tributary and its adjacent wetlands, if any, and it helps
determine whether or not the standards for jurisdiction established under h npnnos have been met.
The agencies will assert jurisdiction over non -navigable tributaries of TNWs where the tributaries are "relatively permanent
waters" (RPWs), i.e. tributaries that typically flow year-round or have continuous flow at least seasonally (e.g., typically 3
months). A wetland that directly abuts an RPW is also jurisdictional. If the aquatic resource is not a TNW, but has year-round
(perennial) flow, skip to Section III.D.2. If the aquatic resource is a wetland directly abutting a tributary with perennial flow,
skip to Section III.D.4.
A wetland that is adjacent to but that does not directly abut an RPW requires a significant nexus evaluation. Corps districts and
EPA regions will include in the record any available information that documents the existence of a significant nexus between a
relatively permanent tributary that is not perennial (and its adjacent wetlands if any) and a traditional navigable water, even
though a significant nexus finding is not required as a matter of law.
If the waterbody4 is not an RPW, or a wetland directly abutting an RPW, a JD will require additional data to determine if the
waterbody has a significant nexus with a TNW. If the tributary has adjacent wetlands, the significant nexus evaluation must
consider the tributary in combination with all of its adjacent wetlands. This significant nexus evaluation that combines, for
analytical purposes, the tributary and all of its adjacent wetlands is used whether the review area identified in the JD request is
the tributary, or its adjacent wetlands, or both. If the JD covers a tributary with adjacent wetlands, complete Section III.B.] for
the tributary, Section IILB.2 for any onsite wetlands, and Section III.B.3 for all wetlands adjacent to that tributary, both onsite
and offsite. The determination whether a significant nexus exists is determined in Section IILC below.
1. Characteristics of non-TNWs that flow directly or indirectly into TNW
(i) General Area Conditions:
Watershed size: P'ickl,ist
Drainage area: Pick Lis(
Average annual rainfall: inches
Average annual snowfall: inches
(ii) Physical Characteristics:
(a) Relationship with TNW:
❑ Tributary flows directly into TNW.
❑ Tributary flows through Pick List tributaries before entering TNW.
Project waters are Pick List river miles from TNW.
Project waters are Pick List river miles from RPW.
Project waters are Pick List aerial (straight) miles from TNW.
Project waters are Pick List aerial (straight) miles from RPW.
Project waters cross or serve as state boundaries. Explain:
Identify flow route to TNW5:
Tributary stream order, if known:
a Note that the Instructional Guidebook contains additional information regarding swales, ditches, washes, and erosional features generally and in the and
West. h
Flow route can be described by identifying, e.g., tributary a, which flows through the review area, to flow into tributary b, which then flows into TNW.

(b) General Tributary Characteristics (check all that apply):
Tributary is: ❑ Natural
❑ Artificial (man-made). Explain:
❑ Manipulated (man -altered). Explain:
Tributary properties with respect to top of bank (estimate):
Average width: feet
Average depth: feet
Average side slopes: Pick List.
Primary tributary substrate composition (check all that apply):
❑ Silts ❑ Sands ❑ Concrete
❑ Cobbles ❑ Gravel ❑ Muck
❑ Bedrock ❑ Vegetation. Type/% cover:
❑ Other. Explain:
Tributary condition/stability [e.g., highly eroding, sloughing banks]. Explain:
Presence of run/riffle/pool complexes. Explain:
Tributary geometry: Pick List
Tributary gradient (approximate average slope): %
(c) Flow:
Tributary provides for: Pick List
Estimate average number of now events in review area/year: Pick List
Describe flow regime:
Other information on duration and volume:
Surface flow is: Pick List. Characteristics:
Subsurface flow: Pielt List. Explain findings:
❑ Dye (or other) test performed:
Tributary has (check all that apply):
❑ Bed and banks
❑ OHWM6 (check all indicators that apply):
❑ clear, natural line impressed on the bank
❑
❑ changes in the character of soil
❑
❑ shelving
❑
❑ vegetation matted down, bent, or absent
❑
❑ leaf litter disturbed or washed away
❑
❑ sediment deposition
❑
❑ water staining
❑
❑ other (list):
❑ Discontinuous OHWM.7 Explain:
the presence of litter and debris
destruction of terrestrial vegetation
the presence of wrack line
sediment sorting
scour
multiple observed or predicted flow events
abrupt change in plant community
If factors other than the OHWM were used to determine lateral extent of CWA jurisdiction (check all that apply):
High Tide Line indicated by: ❑ Mean High Water Mark indicated by:
❑ oil or scum line along shore objects ❑ survey to available datum;
❑ fine shell or debris deposits (foreshore) ❑ physical markings;
❑ physical markings/characteristics ❑ vegetation lines/changes in vegetation types.
❑ tidal gauges
❑ other (list):
(iii) Chemical Characteristics:
Characterize tributary (e.g., water color is clear, discolored, oily film; water quality; general watershed characteristics, etc.).'
Explain:
Identify specific pollutants, if known:
6A natural or man-made "discontinuity in the OHWM does not necessarily sever jurisdiction (e.g., where the stream temporarily flows underground, or where
the OHWM has been removA.by development or agricultural practices). Where there is a break in the OHWM that is unrelated to the waterbody's flow
regime (e.g., flow over a rockoutcrop or through a culvert), the agencies will took for indicators of flow above and below the break
'Ibid.

(iv) Biological Characteristics. Channel supports (check all that apply):
❑ Riparian corridor. Characteristics (type, average width):
❑ Wetland fringe. Characteristics:
❑ Habitat for:
❑ Federally Listed species. Explain findings:
❑ Fish/spawn areas. Explain findings:
❑ Other environmentally -sensitive species. Explain findings:
❑ Aquatic/wildlife diversity. Explain findings:
2. Characteristics of wetlands adjacent to non-TNW that flow directly or indirectly into TNW
(i) Physical Characteristics:
(a) General Wetland Characteristics:
Properties:
Wetland size: acres
Wetland type. Explain:
Wetland quality. Explain:
Project wetlands cross or serve as state boundaries. Explain:
(b) General Flow Relationship with Non-TNW:
Flow is: Pick List. Explain:
Surface flow is: Pick List
Characteristics:
Subsurface flow: Pick List. Explain findings:
❑ Dye (or other) test performed:
(c) Wetland Adjacency Determination with Non-TNW:
❑ Directly abutting
❑ Not directly abutting
❑ Discrete wetland hydrologic connection. Explain:
❑ Ecological connection. Explain: .
❑ Separated by berm/barrier. Explain:
(d) Proximity (Relationship) to TNW
Project wetlands are Pick List river miles from TNW.
Project waters are Pick List aerial (straight) miles from TNW.
Flow is from: Pick List.
Estimate approximate location of wetland as within the Pick List floodplain.
(ii) Chemical Characteristics:
Characterize wetland system (e.g., water color is clear, brown, oil film on surface; water quality; general watershed
characteristics; etc.). Explain:
Identify specific pollutants, if known:
(iii) Biological Characteristics. Wetland supports (check all that apply):
❑ Riparian buffer. Characteristics (type, average width):
❑ Vegetation type/percent cover. Explain:
❑ Habitat for:
❑ Federally Listed species. Explain findings:
❑ Fish/spawn areas. Explain findings:
❑ Other environmentally -sensitive species. Explain findings:
❑ Aquatic/wildlife diversity. Explain findings:
3. Characteristics of all wetlands adjacent to the tributary (if any)
All wetland(s) being considered in the cumulative analysis: Pick List
Approximately ( ) acres in total are being considered in the cumulative analysis.

For each wetland, specify the following:
Directly abuts? (Y/N) Size (in acres) Directly abuts? (Y/N) Size (in acres)
Summarize overall biological, chemical and physical functions being performed:
C. SIGNIFICANT NEXUS DETERMINATION
A significant nexus analysis will assess the flow characteristics and functions of the tributary itself and the functions performed
by any wetlands adjacent to the tributary to determine if they significantly affect the chemical, physical, and biological integrity
of a TNW. For each of the following situations, a significant nexus exists if the tributary, in combination with all of its adjacent
wetlands, has more than a speculative or insubstantial effect on the chemical, physical and/or biological integrity of a TNW.
Considerations when evaluating significant nexus include, but are not limited to the volume, duration, and frequency of the flow
of water in the tributary and its proximity to a TNW, and the functions performed by the tributary and all its adjacent
wetlands. It is not appropriate to determine significant nexus based solely on any specific threshold of distance (e.g. between a
tributary and its adjacent wetland or between a tributary and the TNW). Similarly, the fact an adjacent wetland lies within or
outside of a floodplain is not solely determinative of significant nexus.
Draw connections between the features documented and the effects on the TNW, as identified in the Rapanos Guidance and
discussed in the Instructional Guidebook. Factors to consider include, for example:
® Does the tributary, in combination with its adjacent wetlands (if any), have the capacity to carry pollutants or flood waters to
TNWs, or to reduce the amount of pollutants or flood waters reaching a TNW?
® Does the tributary, in combination with its adjacent wetlands (if any), provide habitat and lifecycle support functions for fish and
other species, such as feeding, nesting, spawning, or rearing young for species that are present in the TNW?
® Does the tributary, in combination with its adjacent wetlands (if any), have the capacity to transfer nutrients and organic carbon that
support downstream foodwebs?
® Does the tributary, in combination with its adjacent wetlands (if any), have other relationships to the physical, chemical, or
biological integrity of the TNW?
Note: the above list of considerations is not inclusive and other functions observed or known to occur should be documented
below:
1. Significant nexus findings for non-RPW that has no adjacent wetlands and flows directly or indirectly into TNWs. Explain
findings of presence or absence of significant nexus below, based on the tributary itself, then go to Section IILD:
2. Significant nexus findings for non-RPW and its adjacent wetlands, where the non-RPW flows directly or indirectly into
TNWs. Explain findings of presence or absence of significant nexus below, based on the tributary in combination with all of its
adjacent wetlands, then go to Section IILD:
3. Significant nexus findings for wetlands adjacent to an RPW but that do not directly abut the RPW. Explain findings of
presence or absence of significant nexus below, based on the tributary in combination with all of its adjacent wetlands, then go to
Section IILD:
D. DETERMINATIONS OF JURISDICTIONAL FINDINGS. THE SUBJECT WATERS/WETLANDS ARE (CHECK ALL
THAT APPLY):
1. TNWs and Adjacent Wetlands. Check all that apply and provide size estimates in review area:
Q TNWs: linear feet width (fl), Or, acres.
[] Wetlands adjacent to TNWs: acres.
2. RPWs that flow directly or indirectly into TNWs.
M Tributaries of TNWs where tributaries typically flow year-round are jurisdictional. Provide data and rationale indicating that
tributary is perennial: Strong geomorphologie, hydrologic, and biologic indicators. Depicted on USGS topographic map.'
0 Tributaries of TNW where tributaries have continuous flow "seasonally" (e.g., typically three months each year) are
jurisdictional. Data supporting this conclusion is provided at Section IIL13. Provide rationale indicating that tributary flows'
seasonally:

Provide estimates forjurisdictional waters in the review area (check all that apply):
Z Tributary waters: 1,458 linear feet 4 width (ft).
Other non -wetland waters: acres.
Identify type(s) of waters:
3. Non-RPWs8 that flow directly or indirectly into TNWs.
Waterbody that is not a TNW or an RPW, but flows directly or indirectly into a *W, and it has a significant nexus with a
TNW is jurisdictional. Data supporting this conclusion is provided at Section IILC.
Provide estimates forjurisdictional waters within the review area (check all that apply):
Tributary waters: linear feet width (ft).
Other non -wetland waters: acres.
Identify type(s) of waters:
4. Wetlands directly abutting an RPW that flow directly or indirectly into TNWs.
Wetlands directly abut RPW and thus are jurisdictional as adjacent wetlands.
Z Wetlands directly abutting an RPW where tributaries typically flow year-round. Provide data and rationale
indicating that tributary is perennial in Section IILD.2, above. Provide rationale indicating that wetland is
directly abutting an RPW: The wetlands are hydrologically connected to the RPW, therefore they are jurisdictional.
Wetlands directly abutting an RPW where tributaries typically flow "seasonally." Provide data indicating that tributary is
seasonal in Section III.13 and rationale in Section III.D.2, above. Provide rationale indicating that wetland is directly
abutting an RPW:
Provide acreage estimates forjurisdictional wetlands in the review area: 0.17 acres.
5. Wetlands adjacent to but not directly abutting an RPW that flow directly or indirectly into TNWs.
Wetlands that do not directly abut an RPW, but when considered in combination with the tributary to which they are adjacent
and with similarly situated adjacent wetlands, have a significant nexus with a TNW are jurisidictional. Data supporting this
conclusion is provided at Section IILC.
Provide acreage estimates forjurisdictional wetlands in the review area: acres.
6. Wetlands adjacent to non-RPWs that flow directly or indirectly into TNWs.
Wetlands adjacent to such waters, and have when considered in combination with the tributary to which they are adjacent and
with similarly situated adjacent wetlands, have a significant nexus with a TNW are jurisdictional. Data supporting this
conclusion is provided at Section III.C.
Provide estimates for jurisdictional wetlands in the review area: acres.
7. Impoundments of jurisdictional waters.9
As a general rule, the impoundment of a jurisdictional tributary remains jurisdictional.
Demonstrate that impoundment was created from "waters of the U. S.," or
Q Demonstrate that water meets the criteria for one of the'categories presented above (1-6), or
�] Demonstrate that water is isolated with a nexus to commerce (see E below).
E. ISOLATED [INTERSTATE OR INTRA-STATE] WATERS, INCLUDING ISOLATED WETLANDS, THE USE,
DEGRADATION OR DESTRUCTION OF WHICH COULD AFFECT INTERSTATE COMMERCE, INCLUDING ANY
SUCH WATERS (CHECK ALL THAT APPLY):"
Q which are or could be used by interstate or foreign travelers for recreational or other purposes.
frorn which fish or shellfish are or could be taken and sold in interstate or foreign commerce.
0 which are or could be used for industrial purposes by industries in interstate commerce.
Interstate isolated waters. Explain:
Other factors. Explain:
Identify water body and summarize rationale supporting determination:
'See Footnote # 3.
9 To complete the analysis refer to the key in Section III.D.6 of the Instructional Guidebook.
10 Prior to asserting or declining CWA jurisdiction based solely on this category, Corps Districts will elevate the action to Corps and EPA HQ for
review consistent with the pdkcess described in the Corps/EPA Memorandum Regarding CWA Act Jurisdiction Following Rapanos.

Provide estimates for jurisdictional waters in the review area (check all that apply):
Tributary waters: linear fect width (Ft).
Other non -wetland waters: acres.
Identify type(s) of waters:
Wetlands: acres.
F. NON -JURISDICTIONAL WATERS, INCLUDING WETLANDS (CHECI{ ALL THAT APPLY):
If potential wetlands were assessed within the review area, these areas did not meet the criteria in the 1987 Corps of Engineers
Wetland Delineation Manual and/or appropriate Regional Supplements.
Review area included isolated waters with no substantial nexus to interstate (or foreign) commerce.
❑ Prior to the Jan 2001 Supreme Court decision in "SWANCC," the review area would have been regulated based solely on the
"Migratory Bird Rule" (MBR).
Waters do not meet the "Significant Nexus" standard, where such a finding is required for jurisdiction. Explain:
Other: (explain, if not covered above):
Provide acreage estimates for non -jurisdictional waters in the review area, where the sole potential basis ofjurisdiction is the MBR
factors (i.e., presence of migratory birds, presence of endangered species, use of water for irrigated agriculture), using best professional
judgment (check all that apply):
Non -wetland waters (i.e., rivers, streams): linear feet width (ft).
Lakes/ponds: acres.
Other non -wetland waters: acres. List type of aquatic resource:
Wetlands: acres.
Provide acreage estimates for non -jurisdictional waters in the review area that do not meet the "Significant Nexus" standard, where such
a finding is required for jurisdiction (check all that apply):
Non -wetland waters (i.e., rivers, streams): linear feet, width (ft).
Lakes/ponds: acres.
Other non -wetland waters: acres. List type of aquatic resource:
Wetlands: acres.
SECTION IV: DATA SOURCES.
A. SUPPORTING DATA. Data reviewed for JD (check all that apply - checked items shall be included in case file and, where checked
and requested, appropriately reference sources below):
Maps, plans, plots or plat submitted by or on behalf of the applicant/consultant:
Data sheets prepared/submitted by or on behalf of the applicant/consultant.
❑ Office concurs with data sheets/delineation report.
❑ Office does not concur with data sheets/delineation report.
Data sheets prepared by the Corps:
El Corps navigable waters' study:
[ U,S. Geological Survey Hydrologic Atlas:
❑ USGS NHD data.
❑ USGS 8 and 12 digit HUC maps.
U.S. Geological Survey map(s). Cite scale & quad riame:1:24,000 Cornelius.
USDA Natural Resources Conservation Service Soil Survey. Citation: Soil Survey of Mecklenburg County, NC.
National wetlands inventory map(s). Cite name: USFWS NWI online wetlands mapper.
State/Local wetland inventory map(s):
FEMA/FIRM maps:
100-year Floodplaur Elevation is: (National Geodectic Vertical Datum of 1929)
Photographs: ❑ Aerial (Name & Date):
or ® Other (Name & Date):Site photographs, 8/19/14.
Previous determination(s). File no. and date of response letter:
El Applicable/supporting case law:
El Applicable/supporting scientific literature:
❑ Other information (please specify):
B. ADDITIONAL COMMENTS TO SUPPORT JD: This form represents stream S 1 and wetlands W 1, W2, W3 and W4.

53
APPROVED JURISDICTIONAL DETERMINATION FORM
U.S. Army Corps of Engineers
This form should be completed by following the instructions provided in Section IV of the JD Form Instructional Guidebook.
SECTION I: BACKGROUND INFORMATION
A. REPORT COMPLETION DATE FOR APPROVED JURISDICTIONAL DETERMINATION (JD):
B. DISTRICT OFFICE, FILE NAME, AND NUMBER:
C. PROJECT LOCATION AND BACKGROUND INFORMATION: Mt. Zion Site
State: NC County/parish/borough: Mecklenburg City: Cornelius
Center coordinates of site (lat/long in degree decimal format): Lat. 35.47491 ° N, Long. 80.84986' W.
Universal Transverse Mercator: 17S 513621 3925721
Name of nearest waterbody: South Prong West Branch Rocky River
Name of nearest Traditional Navigable Water (TNW) into which the aquatic resource flows: Pee Dee River
Name of watershed or Hydrologic Unit Code (HUC): Rocky 03040I05
Check if map/diagram of review area and/or potential jurisdictional areas is/are availahle upon request.
❑'; Check if other sites (e.g., offsite mitigation sites, disposal sites, etc...) are associated with this action and are recorded on a
different JD form.
D. REVIEW PERFORMED FOR SITE EVALUATION (CHECK ALL THAT APPLY):
El Office (Desk) Determination. Date:
❑ Field Determination. Date(s):
SECTION II: SUMMARY OF FINDINGS
A. RHA SECTION 10 DETERMINATION OF JURISDICTION.
There ACe no "navigable waters of the U.S." within Rivers and Harbors Act (RHA) jurisdiction (as defined by 33 CFR part 329) in the
review area. [Required]
Waters subject to the ebb and flow of the tide.
El Waters are presently used, or have been used in the past, or may be susceptible for use to transport interstate or foreign commerce.
Explain:
B. CWA SECTION 404 DETERMINATION OF JURISDICTION.
There Are "waters of the U.S." within Clean Water Act (CWA) jurisdiction (as defined by 33 CFR part 328) in the review area. [Required]
1.
Waters of the U.S.
a. Indicate presence of waters of U.S. in review area (check all that apply): r
TNWs, including territorial seas
Wetlands adjacent to TNWs
Relatively permanent watersz (RPWs) that flow directly or indirectly into TNWs
Non-RPWs that flow directly or indirectly into TNWs
❑ Wetlands directly abutting RPWs that flow directly or indirectly into TNWs
❑ Wetlands adjacent to but not directly abutting RPWs that flow directly or indirectly into TNWs
Wetlands adjacent to non-RPWs that flow directly or indirectly into TNWs
Impoundments of jurisdictional waters
[] Isolated (interstate or intrastate) waters, including isolated wetlands
b. Identify (estimate) size of waters of the U.S. in the review area:
Non -wetland waters: approximately 63 linear feet: 2.5 width (11) and/or acres.
Wetlands: acres.
c. Limits (boundaries) of jurisdiction based on: Noiishetl_6 0HWM7
Elevation of established OHWM (if known): Established by RGL 05-05 guidelines.
2. Non -regulated waters/wetlands (check if applicable):'
Potentially jurisdictional waters and/or wetlands were assessed within the review area and determined to be not jurisdictional.
Explain:
Boxes checked below shall be supported by completing the appropriate sections in Section III below.
2 For purposes of this form, an RPW is defined as a tributary that is not a TNW and that typically flows year-round or has continuous flow at least "seasonally"
(e.g., typically 3 months).
Supporting documentation is presented in Section IILE

SECTION III: CWA ANALYSIS
A. TNWs AND WETLANDS ADJACENT TO TNWs
The agencies will assert jurisdiction over TNWs and wetlands adjacent to TNWs. If the aquatic resource is a TNW, complete
Section IILA.1 and Section IILD.I, only; if the aquatic resource is a wetland adjacent to a TNW, complete Sections III.A.1 and 2
and Section III.D.L.; otherwise, see Section IILB below.
1. TNW
Identify TNW:
Summarize rationale supporting determination:
2. Wetland adjacent to TNW
Surmarize rationale supporting conclusion that wetland is "adjacent":
B. CHARACTERISTICS OF TRIBUTARY (THAT IS NOT A TNW) AND ITS ADJACENT WETLANDS (IF ANY):
This section summarizes information regarding characteristics of the tributary and its adjacent wetlands, if any, and it helps
determine whether or not the standards for jurisdiction established under Rapanos have been met.
The agencies will assert jurisdiction over non -navigable tributaries of TNWs where the tributaries are "relatively permanent
waters" (RPWs), i.e. tributaries that typically flow year-round or have continuous flow at least seasonally (e.g., typically 3
months). A wetland that directly abuts an RPW is also jurisdictional. If the aquatic resource is not a TNW, but has year-round
(perennial) flow, skip to Section III.D.2. If the aquatic resource is a wetland directly abutting a tributary with perennial flow,
skip to Section III.D.4.
A wetland that is adjacent to but that does not directly abut an RPW requires a significant nexus evaluation. Corps districts and
EPA regions will include in the record any available information that documents the existence of a significant nexus between a
relatively permanent tributary that is not perennial (and its adjacent wetlands if any) and a traditional navigable water, even
though a significant nexus finding is not required as a matter of law.
If the waterbody4 is not an RPW, or a wetland directly abutting an RPW, a JD will require additional data to determine if the
waterbody has a significant nexus with a TNW. If the tributary has adjacent wetlands, the significant nexus evaluation must
consider the tributary in combination with all of its adjacent wetlands. This significant nexus evaluation that combines, for
analytical purposes, the tributary and all of its adjacent wetlands is used whether the review area identified in the JD request is
the tributary, or its adjacent wetlands, or both. If the JD covers a tributary with adjacent wetlands, complete Section III.B.1 for
the tributary, Section III.B.2 for any onsite wetlands, and Section III.B.3 for all wetlands adjacent to that tributary, both onsite
and offsite. The determination whether a significant nexus exists is determined in Section III.0 below.
1. Characteristics of non-TNWs that flow directly or indirectly into TNW
(i) General Area Conditions:
Watershed size: South Prong West Branch Rocky River approximately 7 square.miles
Drainage area: 10 acres
Average annual rainfall: 42.8 inches
Average annual snowfall: 6.4 inches
(ii) Physical Characteristics:
(a) Relationship with TNW:
❑ Tributary flows directly into TNW.
® Tributary flows through 6 tributaries before entering TNW.
Project waters are 30;(6r4nore) river miles from TNW.
Project waters are ] or less) river miles from RPW.
Project waters are 30 (or:more) aerial (straight) miles from TNW.
Project waters are 1 (or,le"ss) aerial (straight) miles from RPW.
Project waters cross or serve as state boundaries. Explain:
Identify flow route to TNW5: UTs to South Prong West Branch Rocky River - South Prong West Branch Rocky River -
West Branch Rocky River - Rocky River - Pee Dee River.
4 Note that the Instructional Guidebook contains additional information regarding swales, ditches, washes, and erosional features generally and in the arid
West. A
s Flow route can be described by identifying, e.g., tributary a, which flows through the review area, to flow into tributary b, which then flows into TNW.
}
i'

Tributary stream order, if known: l"
(b) General Tributary Characteristics (check all that apply):
Tributary is: ® Natural
❑ Artificial (man-made). Explain:
❑ Manipulated (man -altered). Explain:
Tributary properties with respect to top of bank (estimate):
Average width: 2.5 feet
Average depth: 1 feet
Average side slopes: 2:1.
Primary tributary substrate composition (check all that apply):
® Silts ® Sands ❑ Concrete
❑ Cobbles ® Gravel ❑ Muck
❑ Bedrock ❑ Vegetation. Type/% cover:
❑ Other. Explain:
Tributary condition/stability [e.g., highly eroding, sloughing banks]. Explain: channel is stable.
Presence of run/riffle/pool complexes. Explain: weak.
Tributary geometry: Relatively straight
Tributary gradient (approximate average slope): 10 %
(c) Flow:
Tributary provides for: Seasonal flow
Estimate average number of flow events in review area/year: 2� (orgCeater)
Describe flow regime: weak flow at time of field visit.
Other information on duration and volume:
Surface flow is: Discrete. Characteristics:
Subsurface flow: Unknown. Explain findings:
❑ Dye (or other) test performed:
Tributary has (check all that apply):
® Bed and banks
® OHWM6 (check all indicators that apply):
® clear, natural line impressed on the bank
❑
® changes in the character of soil
❑
❑ shelving
® vegetation matted down, bent, or absent
® leaf litter disturbed or washed away
❑
® sediment deposition
❑
❑ water staining
❑
❑ other (list):
❑ Discontinuous OHWM.' Explain:
the presence of litter and debris
destruction of terrestrial vegetation
the presence of wrack line
sediment sorting
scour
multiple observed or predicted flow events
abrupt change in plant community
If factors other than the OHWM were used to determine lateral extent of CWAjurisdiction (check all that apply):
rl High Tide Line indicated by: ❑ Mean High Water Mark indicated by:
❑ oil or scum line along shore objects ❑ survey to available datum;
❑ fine shell or debris deposits (foreshore) ❑ physical markings;
❑ physical markings/characteristics ❑ vegetation lines/changes in vegetation types.
❑ tidal gauges
❑ other (list):
(iii) Chemical Characteristics:
Characterize tributary (e.g., water color is clear, discolored, oily film; water quality; general watershed characteristics, etc.).
Explain: water color is clear.
Identify specific pollutants, if known:
6A natural or roan -made' discontinuity in the OHWM does not necessarily sever jurisdiction (e.g., where the stream temporarily flows underground, or where
the OHWM has been removed by development or agricultural practices). Where there is a break in the OHWM that is unrelated to the waterbody's flow
regime (e.g., flow over a rock)outcrop or through a culvert), the agencies will look for indicators of flow above and below the break.
'Ibid.

(iv) Biological Characteristics. Channel supports (check all that apply):
® Riparian corridor. Characteristics (type, average width): forested, >100 feet.
❑ Wetland fringe. Characteristics:
❑ Habitat for:
❑ Federally Listed species. Explain findings:
❑ Fish/spawn areas. Explain findings:
❑ Other envirommentally-sensitive species. Explain findings:
❑ Aquatic/wildlife diversity. Explain findings:
2. Characteristics of wetlands adjacent to non-TNW that flow directly or indirectly into TNW
(i) Physical Characteristics:
(a) General Wetland Characteristics:
Properties:
Wetland size: acres
Wetland type. Explain:
Wetland quality. Explain:
Project wetlands cross or serve as state boundaries. Explain:
(b) General Flow Relationship with Non-TNW:
Flow is: Pick List. Explain:
Surface flow is: Pick List
Characteristics:
Subsurface flow: Pick List. Explain findings:
❑ Dye (or other) test performed:
(c) Wetland Adjacency Determination with Nan-TNW:
❑ Directly abutting
❑ Not directly abutting
❑ Discrete wetland hydrologic connection. Explain:
❑ Ecological connection. Explain: .
❑ Separated by berrn/barrier. Explain:
(d) Proximity (Relationship) to TNW
Project wetlands are Pick List river miles from TNW.
Project waters are Pick List aerial (straight) miles from TNW.
Flow is from: Vick List.
Estimate approximate location of wetland as within the PiekList floodplain.
(ii) Chemical Characteristics:
Characterize wetland system (e.g., water color is clear, brown, oil film on surface; water quality; general watershed
characteristics; etc.). Explain:
Identify specific pollutants, if known:
(iii) Biological Characteristics. Wetland supports (check all that apply):
❑ Riparian buffer. Characteristics (type, average width):
❑ Vegetation type/percent cover. Explain:
❑ Habitat for:
❑ Federally Listed species. Explain findings:
❑ Fish/spawn areas. Explain findings:
❑ Other environmentally -sensitive species. Explain findings:
❑ Aquatic/wildlife diversity. Explain findings:
3. Characteristics of all wetlands adjacent to the tributary (if any)
All wetland(s) being considered in the cumulative analysis: Picky ist
Approximately ( ) acres in total are being considered in the cumulative analysis.

For each wetland, specify the following:
Directly abuts? (WN) Size (in acres) Directly abuts? (WN) Size (in acres)
Summarize overall biological, chemical and physical functions being performed:
C. SIGNIFICANT NEXUS DETERMINATION
A significant nexus analysis will assess the flow characteristics and functions of the tributary itself and the functions performed
by any wetlands adjacent to the tributary to determine if they significantly affect the chemical, physical, and biological integrity
of a TNW. For each of the following situations, a significant nexus exists if the tributary, in combination with all of its adjacent
wetlands, has more than a speculative or insubstantial effect on the chemical, physical and/or biological integrity of a TNW.
Considerations when evaluating significant nexus include, but are not limited to the volume, duration, and frequency of the flow
of water in the tributary and its proximity to a TNW, and the functions performed by the tributary and all its adjacent
wetlands. It is not appropriate to determine significant nexus based solely on any specific threshold of distance (e.g. between a
tributary and its adjacent wetland or between a tributary and the TNW). Similarly, the fact an adjacent wetland lies within or
outside of a floodplain is not solely determinative of significant nexus.
Draw connections between the features documented and the effects on the TNW, as identified in the Rapanos Guidance and
discussed in the Instructional Guidebook. Factors to consider include, for example:
• Does the tributary, in combination with its adjacent wetlands (if any), have the capacity to carry pollutants or flood waters to
TNWs, or to reduce the amount of pollutants or flood waters reaching a TNW?
• Does the tributary; in combination with its adjacent wetlands (if any), provide habitat and lifecycle support functions for fish and
other species, such as feeding, nesting, spawning, or rearing young for species that are present in the TNW?
• Does the tributary, in combination with its adjacent wetlands (if any), have the capacity to transfer nutrients and organic carbon that
support downstream foodwebs?
• Does the tributary, in combination with its adjacent wetlands (if any), have other relationships to the physical, chemical, or
biological integrity of the TNW?
Note: the above list of considerations is not inclusive and other functions observed or known to occur should be documented
below:
1. Significant nexus findings for non-RPW that has no adjacent wetlands and flows directly or indirectly into TNWs. Explain
findings of presence or absence of significant nexus below, based on the tributary itself, then go to Section III.D:
2. Significant nexus findings for non-RPW and its adjacent wetlands, where the non-RPW flows directly or indirectly into
TNWs. Explain findings of presence or absence of significant nexus below, based on the tributary in combination with all of its
adjacent wetlands, then go to Section III.D:
3. Significant nexus findings for wetlands adjacent to an RPW but that do not directly abut the RPW. Explain findings of
presence or absence of significant nexus below, based on the tributary in combination with all of its adjacent wetlands, then go to
Section 11I.D:
D. DETERMINATIONS OF JURISDICTIONAL FINDINGS. THE SUBJECT WATERS/WETLANDS ARE (CHECK ALL
THAT APPLY):
1. TNWs and Adjacent Wetlands. Check all that apply and provide size estimates in review area:
Q TNWs: linear feet width (il), Or, acres.
El Wetlands adjacent to TNWs: acres.
2. RPWs that flow directly or indirectly into TNWs.
Q Tributaries of TNWs where tributaries typically flow year-round are jurisdictional. Provide data and rationale indicating that
tributary is perennial:
Tributaries of TNW where tributaries have continuous flow "seasonally" (e.g., typically three months each year) are
jurisdictional. Data supporting this conclusion is provided at Section IILB. Provide rationale indicating that tributary flows
seasonally: Good substrate sorting and bankfall bench. Headcut with baseflow and hydric soils present.
B;

Provide estimates for jurisdictional waters in the review area (check all that apply):
M Tributary waters: 63 linear feet 2.5 width (ft).
Other non -wetland waters: acres.
Identify type(s) of waters:
3. Non-RPWs8 that flow directly or indirectly into TNWs.
Waterbody that is not a TNW or an RPW, but flows directly or indirectly into a T� W, and it has a significant nexus with a
TNW is jurisdictional. Data supporting this conclusion is provided at Section IILC.
Provide estimates for jurisdictional waters within the review area (check all that apply):
Tributary waters: linear feet width (ft).
Other non -wetland waters: acres.
Identify type(s) of waters:
4. Wetlands directly abutting an RPW that flow directly or indirectly into TNWs.
[] Wetlands directly abut RPW and thus arejurisdictional as adjacent wetlands.
n Wetlands directly abutting an RPW where tributaries typically flow year-round. Provide data and rationale
indicating that tributary is perennial in Section III.D.2, above. Provide rationale indicating that wetland is
directly abutting an RPW:
Wetlands directly abutting an RPW where tributaries typically flow "seasonally." Provide data indicating that tributary is
seasonal in Section III.13 and rationale in Section III.D.2, above. Provide rationale indicating that wetland is directly
abutting an RPW:
Provide acreage estimates for jurisdictional wetlands in the review area: acres.
5. Wetlands adjacent to but not directly abutting an RPW that flow directly or indirectly into TNWs.
Wetlands that do not directly abut an RPW, but when considered in combination with the tributary to which they are adjacent
and with similarly situated adjacent wetlands, have a significant nexus with a TNW are jurisidictional. Data supporting this
conclusion is provided at Section IILC.
Provide acreage estimates for jurisdictional wetlands in the review area: acres.
6. Wetlands adjacent to non-RPWs that flow directly or indirectly into TNWs.
Wetlands adjacent to such waters, and have when considered in combination with the tributary to which they are adjacent and
with similarly situated adjacent wetlands, have a significant nexus with a TNW are jurisdictional. Data supporting this
conclusion is provided at Section IILC.
Provide estimates for -jurisdictional wetlands in the review area: acres.
7. Impoundments of jurisdictional waters.9
As a general rule, the impoundment of a jurisdictional tributary remain sjurisdictional.
El Demonstrate that impoundment was created from "waters of the U.S.," or
[] Demonstrate that water meets the criteria for one of the'categories presented above (1-6), or
Demonstrate that water is isolated with a nexus to commerce (see E below).
E. ISOLATED [INTERSTATE OR INTRA-STATE] WATERS, INCLUDING ISOLATED WETLANDS, THE USE,
DEGRADATION OR DESTRUCTION OF WHICH COULD AFFECT INTERSTATE COMMERCE, INCLUDING ANY
SUCH WATERS (CHECK ALL THAT APPLY):'0
j] which are or could be used by interstate or foreign travelers for recreational or other purposes.
j from which fish or shellfish are or could be taken and sold in interstate or foreign commerce.
E] which are or could be used for industrial purposes by industries in interstate commerce.
Interstate isolated waters. Explain:
Other factors. Explain:
Identify water body and summarize rationale supporting determination:
'See Footnote # 3.
To complete the analysis refer to the key in Section III.D.6 of the Instructional Guidebook.
10 Prior to asserting or declining CWA jurisdiction based solely on this category, Corps Districts will elevate the action to Corps and EPA HQ for
review consistent with the phcess described in the Corps/EPA Memorandum Regarding CWA Act Jurisdiction FollowingRapanos.

Provide estimates for jurisdictional waters in the review area (check all that apply):
Tributary waters: linear feet width (ft).
Other non -wetland waters: acres.
Identify type(s) of waters:
Wetlands: acres.
F. NON -JURISDICTIONAL WATERS, INCLUDING WETLANDS (CHECK ALL THAT APPLY):
If potential wetlands were assessed within the review area, these areas did not meet the criteria in the 1987 Corps of Engineers
Wetland Delineation Manual and/or appropriate Regional Supplements.
Review area included isolated waters with no substantial nexus to interstate (or foreign) commerce.
❑ Prior to the Jan 2001 Supreme Court decision in "SWANCC," the review area would have been regulated based solely on the
"Migratory Bird Rule" (MBR).
Waters do not meet the "Significant Nexus" standard, where such a finding is required forjurisdiction. Explain:
El Other: (explain, if not covered above):
Provide acreage estimates for non jurisdictional waters in the review area, where the sole potential basis of jurisdiction is the MBR
factors (i.e., presence of migratory birds, presence of endangered species, use of water for irrigated agriculture), using best professional
judgment (check all that apply):
El Non -wetland waters (i.e., rivers, streams): linear feet width (ft).
Lakes/ponds: acres.
[] Other non -wetland waters: acres. List type of aquatic resource:
E] Wetlands: acres.
Provide acreage estimates for non -jurisdictional waters in the review area that do not meet the "Significant Nexus" standard, where such
a finding is required for jurisdiction (check all that apply):
Non -wetland waters (i.e., rivers, streams): linear feet, width (ft).
EJ Lakes/ponds: acres.
0 Other non -wetland waters: acres. List type of aquatic resource:
Wetlands: acres.
SECTION IV: DATA SOURCES.
A. SUPPORTING DATA. Data reviewed for JD (check all that apply - checked items shall be included in case file and, where checked
and requested, appropriately reference sources below):
Maps, plans, plots or plat submitted by or on behalf of the applicant/consultant:
Data sheets prepared/submitted by or on behalf of the applicant/consultant.
❑ Office concurs with data sheets/delineation report.
❑ Office does not concur with data sheets/delineation report.
EJ Data sheets prepared by the Corps:
Corps navigable waters' study:
U.S. Geological Survey Hydrologic Atlas:
❑ USGS NHD data.
❑ USGS 8 and 12 digit HUC maps.
U.S. Geological Survey map(s). Cite scale & quad name:1:24,000 Cornelius.
® USDA Natural Resources Conservation Service Soil Survey. Citation: Soil Survey of Mecklenburg County, NC.
National wetlands inventory map(s). Cite name: USFWS NWI online wetlands mapper.
State/Local wetland inventory map(s):
FEMA/FIRM maps:
100-year Floodplain Elevation is: (National Geodectic Vertical Datum of 1929)
Photographs: ❑ Aerial (Name & Date):
or ® Other (Name & Date):Site photographs, 8/19/14.
Previous determination(s). File no. and date of response letter:
EJ Applicable/supporting case law:
Applicable/supporting scientific literature:
Other information (please specify):
B. ADDITIONAL COMMENTS TO SUPPORT JD: This form represents stream S3.