20030184 Ver 1_COMPLETE FILE_20030218

TOWN OF KERNERSVILLE
PUBLIC WORKS DEPARTMENT
Randy E. McCaslin, Town Manager
Timothy G. Shields, Director
P.O. Drawer 728
Kernersville, NC 27285-0728
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7002 2410 0001 1665 5006
February 11, 2003
Wetlands/401 Water Quality Certification Unit
Division of Water Quality
1621 Mail Service Center
Raleigh, NC 27699-1621
Dear Review Engineer:
720 McKaughan Street
Telephone [phone]
FAX [phone]
030184
Please find attached two courtesy copies of the Pre-Construction Notification (PCN) Application
Form. I have submitted this PCN to the Army Corps of Engineers with the intent of obtaining a
Nationwide Permit #39 for a project located in Kernersville, Forsyth County. One copy is for
your office and the other copy is for the Regional Office.'
If you have any questions or need additional information, call me at [phone], or email me
at: aderf(a,ci.kernersville.nc.us
Sincerely,

Franz Ader, P.E.
Project Engineer
Attachments
Office Use Only: Form Version May 2002
USACE Action ID No. DWQ N60 0 g
(If any particular item is not applicable to this project, please enter "Not Applicab e" or "N/A".)
1.
II.
Processing
1. Ch ck all of the approval(s) requested for this project:
0 Section 404 Permit ?
? Section 10 Permit ?
? 401 Water Quality Certification
2. Nationwi a Regional or General Permit Number(s) Requested: (\ U3P 3 q
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: [w
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (verify availability with NCWRP prior to submittal of PCN), complete
section VIII and check here: ?
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
Environmental Concern (see the top of page 2 for further details), check here: ?
Applicant Information
Owner/Applicant Information
Name: -1-nut t l nf7- K E2tit?RStl LLE
Mailing Address: 7 X
k ERN E- ASV 1 L LE. IS C,
a27aSg- 07AS
Telephone Number: _q 9l0 - (? `i 16 Fax Number: 3b6 ... 9 9 Ga - 9?Sy
E-mail Address:
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent has signatory authority for the owner/applicant.)
Name: P rRA-NZ- AAv&-K
Company Affiliation: -100tJ nF KEKt?i LL.5-
Mailing Address: d-<A/hE-
Telephone Number: -3S6-9616-6460- Fax Number: 336-gq 6 -4054
E-mail Address: Ch A& ,-,F (2,C.,. ke -ners,4 i Ite. r c-, us
2 i d ? llU//
a or atershedB r R
lW Q
W
Page 5 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
in d JX opriate USGS Topographic Quad Map and NRCS Soil Survey with the property
bps med. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
US,A E'requires information to be submitted on sheets no larger than 11 by 17-inch format;
'however; DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: L-006MEW pR%v? i-t_:O c t oo
2. T.I.P. Project Number or State Project Number (NCDOT Only):. N/A-
3. Property Identification Number (Tax PIN):_ [?SfS{o-b- (o6?S
4. Location
County: V:bRSyl-q Nearest Town: Kr-_*(V _5Q#LLE
Subdivision name (include phase/lot number):wIN
Directions to site (include road numbers, landmarks, etc.*,&)y bb N. -1-o 6opy4i+AMgp= _sj-
Cf'2orh S(KN. -40) t Cio a.5 nn, 5 4TZ c Um F i"'Watmo n1 n xox 130 Q:s e?tim
i L ab im &R?; 61b cs:r/1 aftrm Lcl1?&UiatJ bR PeoTECI-00 Qyi> EL&Ap
5. Site coordinates, if available (UTM or Lat/Long): L -r. 36 0-711a L00Ar 90 ,V 3'3R"
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Property size (acres): 1.. q!.
7. Nearest body of water (stream/river/sound/ocean/lake): ReeDy FyAk CKEEyK
8. River Basin: C/(P- Fkqq-A.
(Note - this must, be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/niaps/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: -TAC sib is cuggAah: J miKF-D W 1Zs2SiPOWIAL
AND o&rlmmciAL u5C$,
Page 6 of 12
10. Describe the overall project in detail, including the type of equipment to be used:
L&W6u%oyJ DR:. wk -sC- E1C1°r.11 pE3 -m,> LANINEGT 6RAUN) AV15.
_T1 eje_*L. O&J%9MOPM U3%L.L, -"OLC --H?ll!.C'Cdx Nc?s d D?1 cm?"'sl't?C ,
_&i,AQCal 1, fl02.M?S;A M-2 ar l M 6%e= - ZviNf1 ON A PM&-A MI.
11. Explain the purpose of the proposed work:_ -rttC R(K otsi5-- is To 1 Ar-iLtrATE
-neAFF?c FIL-00 ra :MC M1 A.
IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application.
-rw ra of Kj RtRWOZS'VtLt.E Uo?S NO 4N'- .?PAT5 ANu RAT14P,15-
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
Page 7 of 12
1. Provide a written description of the proposed impacts: 4rCCAM «,ossi rJ& w t° u
Rle- P-AP
2. Individually list wetland impacts below:
Wetland Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres Located within
100-year Floodplain**
es/no) Distance to
Nearest Stream
linear feet
Type of Wetland***

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http://www.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.) Indicate if wetland is isolated (determination of isolation to be made by USACE only).
List the total acreage (estimated) of all existing wetlands on the property:
Total area of wetland impact proposed:
3. Individually list all intermittent and perennial stream impacts below:
Stream Impact
Site Number
indicate on ma
Type of Impact* Length of
Impact
linear feet
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
leasespecify)
el (-4kkr F 5? k oaK caeg-t< 94, Wrenn,

F List each impact separately and identity temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usgs.gov. Several intemet sites also allow direct download and printing of USGS maps (e.g., www.tonozone.com,
ynkrwanapquest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: I ? -F+,
Page 8 of 12
4. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.) below:
Open Water Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres
(if Name applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.
NA

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
5. Pond Creation
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.): N/A
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.): N JA
Size of watershed draining to pond: Olpt Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
-M E ROAD CXTI'? o cJ q N D fit, t 1 CP "93?_K 4n5S t N [T IS
t1Rc_& {E -rbwA or- KEt2nPStlfl_.Lf' 2D 1:?-fcnj : ARie
??,? ?-r n dry ?? C E?"-r 5?jto C Qr- =XA uJ,
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Page 9 of 12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.us/ncwetlands/strmaide.htmi.
Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP). Please note it is the applicant's responsibility to contact the NCWRP at
[phone] to determine availability and to request written approval of mitigation prior
to submittal of a PCN. For additional information regarding the application process for the
NCWRP, check the NCWRP website at hM2://h2o.enr.state.nc.us/w.rp/index.htni. If use of
the NCWRP is proposed, please check the appropriate box on page three and provide the
following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
IX. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federal/state) funds or the use of public
(federal/state) land?
Yes ? No
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No ?
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No ?
X. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No ? If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet Multiplier Required
Mitigation
1 3
2 1.5
Total
Lone i extends out .w teet perpenatcular from near bank of channel; Gone L extends an
additional 20 feet from the edge of Zone 1.
Page 11 of 12
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or. 0260.
XI. Stormwater (required by DWQ)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
XII. Sewage Disposal (required by DWQ)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ? No ?
Is this an after-the-fact permit application?
Yes ? No ?
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
OL!11,1 ?--7--0_-k
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 12 of 12
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http://topozone.com/map.asp?z=17&n=3997127&e=584637&s=25&u=2 2/7/2003
Site Plan
Longview Drive Extension
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1
site
\crPa°t #
stfeaR`
Lat 36.07.13
Long 80.03
135 LF, 84" Dia.,10 Gauge,
3"x1" Corrugated Alluminum Pipe
1
135 LF, 96" Dia., 10 Gauge,
3"x1" Corrugated Alluminum Pipe 135 LF, 84" Dia., 10 Gauge,
3"x1" Corrugated Alluminum Pipe
Proposed Extension
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Office Use Only: U V prm?Version May 2002
USACE Action ID No. DWQ No. U V
(If any particular item is not applicable to this project, please enter "Not
1.
II.
Processing
1. Check all of the approval(s) requested for this project:
1gSection 404 Permit ?
? Section 10 Permit ?
? 401 Water Quality Certification
Riparian
Isolated

2. Nationwl a Regional or General Permit Number(s) Requested:MLJP 3 R
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: L
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (verify availability with NCWRP prior to submittal of PCN), complete
section VIII and check here: ?
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
Environmental Concern (see the top of page 2 for further details), check here: ?
Applicant Information
Owner/Applicant Information
Name: "' w A inF K CRN?aSVI LLE
Mailing Address:
kEttNER.S?iLL , NC.
a-719,9- ®7as
Telephone Number: 33G-'J9(&- (.41 G Fax Number: 3b6 ° 9 9 & _ .+V6 y
E-mail Address:
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent has signatory authority for the owner/applicant.)
Name: f rRAdz- Aaa1Z
Company Affiliation: -buyQ nE KMRN I LL1'
Mailing Address: -?AmE --
Telephone Number: 33 0 -9616 - 6 4" Fax Number: 336-qq 6 -40 q
E-mail Address: n a& r-F (2,Ce,, ke,rners') i I ie,lc., US
Page 5 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
xperv rfaces, or other facilities must be included. If possible, the maps and plans should
include th a propriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: I.-0n16Vk" V>p tXTE:.t+i,C iUtJ
2. T.I.P. Project Number or State Project Number (NCDOT Only): NIA
3. Property Identification Number (Tax PIN): 61386-69- 663-85
4. Location
County: 'i--bRSy7'l{ Nearest Town: KCR(VC2.5Q4LLE_
Subdivision name (include phase/lot number): t4 IN
Directions to site (include road numbers, landmarks, etc. y bb N. +0 GepetAttAf"f:!Q, s"1-
CF2om BGK&z;-46) Cm, ,;L5 m L.S.5:3T& aI w FMwdrAlN r AoS"QS AMP
n:,%=_6dj6&A2?,, 61d Mil ?h _ esAt -0 LcNC-0iaW bR pQa11-7 GT[a END o1- .25 5. Site coordinates, if available (UTM or Lat/Long): LA-T.31, n-71 a `'r LoNG- 90 ra3/39 //
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Property size (acres): 1,96- 8eaLX:ri
7. Nearest body of water (stream/river/sound/ocean/lake): ?,K? FbAI- cREM
8. River Basin: GA-<- FW3rj ,
(Note - this musty be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: il(C Si rtE" IS c u.Rir ,?! m (xep W TLCSi 0CWt A L
8N_2_ Cco"tlU"iAL u5 5
Page 6 of 12
10. Describe the overall project in detail, including the type of equipment to be used:
j.&mj6u%V,3 Dig. wiu- 3C EXn---r7o;? -rc CANNE::7-r &9ALIN) /AVE.
n4pr!_aLt, O&1%9ft1ffWT LOIL - 33WQL. -4:JE? EVLJ 1X rJ6- r Dtl lp llll?Si
11. Explain the purpose of the proposed work:_-rttC PuKro
s157 15 -rn -FAc iL IT-ATC
-Ig-A er-IC PLO U3 to ::ftc AZCA-
IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
N4k
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application.
:J,aE" °rvwrJ of KgnRA1e ?-<V i L LC 90067 NOT q ntT C ? PA-15 A Nu P(.i m ie.c
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
Page 7 of 12
1. Provide a written description of the proposed impacts: 4T2EAM cy-ossi NCB w tl:it
RIP- 2AP
2. Individually list wetland impacts below:
Wetland Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres Located within
100-year Floodplain**
es/no Distance to
Nearest Stream
linear feet
Type of Wetland***

List each impact separately and identity temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at hap:%/www.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.) Indicate if wetland is isolated (determination of isolation to be made by USACE only).
List the total acreage (estimated) of all existing wetlands on the property:
Total area of wetland impact proposed:
3. Individually list all intermittent and perennial stream impacts below:
Stream Impact
Site Number
indicate on ma
Type of Impact* Length of
Impact
linear feet
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
leasespecify)
Pr' G" - 5` 8 DPY- cem,_y? 9A, ,e ,r eAn1A

List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usgs.gov. Several internet sites also allow direct download and printing of USGS maps (e.g., ww-w.topozone.com,
www.manquest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: 13?
Page 8 of 12
4. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.) below:
Open Water Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres Name of Waterbody

applicable)
(if Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.
NA

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
5. Pond Creation
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.): N/fit
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.): N /A
Size of watershed draining to pond: 0 Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
1% E (LOAD EXTe-NQ 0 (-.) AND A S Ca o :fF C R EEX e'_f05'r t 0 &- 1-5
jM )1P.tick Py i -tN 15: -row T) of K Et2n15V f _.L,?'' '-M _l za6JZ_r F-J p? PFle'
* =134C E&--- ,?D12C cE =XW,
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Page 9 of 12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic' resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.us/ncwetlands/strmgide.html.
Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP). Please note it is the applicant's responsibility to contact the NCWRP at
[phone] to determine availability and to request written approval of mitigation prior
to submittal of a PCN. For additional information regarding the application process for the
NCWRP, check the NCWRP website at http://h2o.enr.state.nc.us/wrp/index.htm. If use of
the NCWRP is proposed, please check the appropriate box on page three and provide the
following information:
Amount of stream mitigation requested (linear feet): C-
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
IX. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federal/state) funds or the use of public
(federal/state) land?
Yes ? No
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No ?
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No ?
X. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No ? If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 11 of 12
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
XI. Stormwater (required by DWQ)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
XII. Sewage Disposal (required by DWQ)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ? No ?
Is this an after-the-fact permit application?
Yes ? No ?
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
oal.-,
a--7-
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 12 of 12
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