20091345 Ver 1_401 Application_20091209

S-e SEPI
ENGINEERING GROUP
1025 Wade Avenue t",
Raleigh, NC 27605
Tel [phone]
Fax [phone]
sepiengineering.com PAIr
December 21, 2009
US Army Corps of Engineersu i `'???''
Wilmington District A:i
U
Raleigh Regulatory Field Office DEC
3331 Heritage Trade Drive, Suite 105
Wake Forest North Carolina 27587 DENR•W.ATFRL)L+AUTY
Re: Granville Medical Center, Tar-Pamlico River Buffer Authorization
Dear Mr. Alsmeyer:
SEPI Engineering & Construction, Inc (SEPI), on behalf of the Granville Health System,
submits this Section 404/401 Nationwide Permit 39. Concurrent with the submission for
the Section 401 Water Quality Certification (WQC), SEPI requests a Tar-Pamlico River
buffer authorization for the proposed project. The project is located off of US 15 in Oxford,
North Carolina. To accommodate expansion of an existing hospital to meet the needs of the
surrounding community served by the facility, Granville Health System requests this
Section 404/401 Nationwide Permit 39 and Tar-Pamlico buffer authorization.
Project Description
The proposed project involves the expansion of the existing hospital, including an
Emergency Department and Surgery Department addition and a new Boiler/Generator
Plant. The original hospital was constructed in 1939 with additions in 1962, 1974, 1985
and 1998. The hospital exists on a relatively large tract of land (11 acres), and the
proposed project involves hospital expansion in the back portion of the tract. Expansion of
these hospital functions is needed to provide care for the surrounding community served
by the facility. As part of the proposed project, access to the back portion of the site is to be
enhanced to allow for future development of the hospital campus.
The growth of the hospital footprint requires the relocation of existing access roads and
parking areas further east to the back portion of the tract. The existing main hospital
access road currently terminates at the Emergency Department. With the expansion of the
Emergency Department, the access road will be moved to accommodate proposed action to
provide care for the surrounding community served by the facility. There is no other
location to build the access road. It served before as the main entrance to the emergency
room and is planned to also serve as the main entrance for both ambulance and patient
drop off. The other service entry poses a safety issue as incoming traffic will cross rail road
tracks and would be forced to stop if a train was on the tracks.
?SEPI
Page 2
Project Site Investigation
The site for the proposed expansion has been reviewed for wetlands, streams and buffers.
For the proposed expansion site, the Granville County soil map depicts one drainage on the
site, and the US Geologic Survey map also notes a drainage. SEPI reviewed the area
associated with the proposed expansion, and we determined that the drainage is a
jurisdictional stream and is subject to the Tar-Pamlico buffer requirements. There are no
wetlands present in this area for the proposed expansion.
Mr. Martin Richmond of the NCDWQ conducted a site on October 8, 2009. Mr. Richmond
has provided a concurrence letter, and it has been attached to this buffer application.
Project Impacts to Waters of the United States
The layout of the proposed expansion cannot avoid impacts to the jurisdictional stream and
its associated riparian buffer. To access the back portion of the hospital tract, the road
improvements must be made. The existing pipe will be extended to accommodate the
hospital expansion and the access road.
Stream impacts total 60 feet, less than 0.01 acre of surface water. Impacts to the stream
were minimized by implementing a design slope of 2:1.
At this time, no compensatory mitigation for the stream impact is proposed.
Project Impacts to Tar-Pamlico Buffers
The layout of the proposed expansion cannot avoid impacts to the riparian buffer. To
access the back portion of the hospital tract, the road improvements must be made. This
side slope also minimized impacts to the Tar-Pamlico buffer. Table 1 summarizes impacts
to the Tar-Pamlico buffer.
Table 1. Project Buffer Impacts from the Pro osed Hospital Expansion
Buffer Zone 1 5,695 square feet
Buffer Zone 2 9,130 square feet
Based on a review of the "Table of Uses" for the Tar-Pamlico buffer rules, we believe that
the proposed action fits into the category of "Road Impacts other than crossing of streams
and other surface waters subject to this rule".
Granville Health System proposes to pay into the Riparian Buffer Fund to compensate for
impact to the Neuse buffers. Table 2 summarizes the impacts to the buffers and the
required payment.
SeSEPI
Page 3
Table 2. Impacts to buffers and mitigation navment
Buffer
Zone Impact Area
(square
feet Mitigation
Ratio Total
Mitigation Area
(s q. ft. Mitigation
Costs
1 5,695 3 17,085 $16,401.60
2 9,130 1.5 13,695 $13,147.2
Total 30,780 $29,548.80
On behalf of the Granville Health Systems, SEPI has coordinated the payment into the
Riparian Buffer Fund with the Ecosystem Enhancement Program. The EEP has agreed to
provide the required buffer compensation, and a copy of the acceptance letter is attached
to this application for a buffer authorization.
Closing
SEPI asks that the USACE issue a Section 404 NWP 39 for the proposed project to impact 60
feet of stream (<0.01 acre of surface water impact). Additionally, SEPI asks that the NC
Division of Water Quality issue its corresponding 401 WQC and a Tar-Pamlico buffer
authorization for the proposed action. Granville Health System proposes to pay into the
EEP in-lieu fee program for the buffer impacts; no compensatory mitigation for stream
impacts is proposed at this time.
If you have any questions regarding this request, please contact me at [phone].
Thank you for your prompt attention to this matter.
Re
p Tadd
•onmental Division Manager
cc: Ms. Cyndi Karoly, NCDWQ

of warF9
o? oG Office Use Only:
Corps action ID no.
° DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification PC Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the
Corps:
®Section 404 Permit El Section 10 Permit
1b. Specify Nationwide Permit (NWP) number: 39 or General Permit (GP) number:
1 c. Has the NWP or GP number been verified by the Corps? ? Yes ® No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
® 401 Water Quality Certification - Regular ? Non-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express ® Riparian Buffer Authorization
1 e. Is this notification solely for the record
because written approval is not required? For the record only for DWQ 401
Certification:
? Yes ® No For the record only for Corps Permit:

? Yes ® No
1f. Is payment into a mitigation bank or in-lieu fee program proposed for mitigation
of impacts? If so, attach the acceptance letter from mitigation bank or in-lieu
fee program. ® Yes ? No
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ? Yes ® No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes ® No
2. Project Information
2a. Name of project: Granville Medical Center
2b. County: Granville
2c. Nearest municipality / town: Oxford
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state
project no:
3. Owner Information
3a. Name(s) on Recorded Deed:
3b. Deed Book and Page No.
3c. Responsible Party (for LLC if
applicable):
3d. Street address: 1010 College Drive
3e. City, state, zip: Oxford, NC 27565
3f. Telephone no. 919.690.3000
3g. Fax no.:
3h. Email address:
Page 1 of 11
PCN Form -Version 1.3 December 10, 2008 Version
4. Applicant Information (if different from owner)
4a. Applicant is: ? Agent Other, specify:
4b. Name: Gerry Leighton
4c. Business name
(if applicable): Granville Health System
4d. Street address: 1010 College Drive
4e. City, state, zip: Oxford, NC 27565
4f. Telephone no.: 919.690.3000
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name: Phillip Todd
5b. Business name
(if applicable): SEPI Engineering Group
5c. Street address: 1025 Wade Avenue
5d. City, state, zip: Raleigh, NC 27605
5e. Telephone no.: 919.789.9977
5f. Fax no.: 919.789.9591
5g. Email address: [e-mail]
Page 2 of 11
PCN Form - Version 1.3 December 10, 2008 Version
B. Project Information and Prior Project History
1. Property Identification
1 a. Property identification no. (tax PIN or parcel ID):
Latitude: 36.325532 Longitude: -
1 b. Site coordinates (in decimal degrees): 78.592491
(DD.DDDDDD) (-DD.DDDDDD)
1 c. Property size: acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to Jordan Creek
proposed project:
2b. Water Quality Classification of nearest receiving water: C; NSW
2c. River basin: Tar-Pamlico
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
Hospital development and associated parking. Forested area along stream corridor on the south side of the tract
3b. List the total estimated acreage of all existing wetlands on the property:
0
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
460 feet
3d. Explain the purpose of the proposed project:
The hospital proposed to expand its facilities. This work requires improving road access to the back part of the hospital
property.
3e. Describe the overall project in detail, including the type of equipment to be used:
the proposed project involves hospital expansion in the back portion of the tract. Expansion of these hospital functions is
needed to provide care for the surrounding community served by the facility. As part of the proposed project, access to
the back portion of the site is enhanced to allow for future development of the hospital campus. Earth moving equipment
used will include bull dozers, pans, tracked hoes, dump trucks, and front end loaders
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past? ® Yes ? No ? Unknown
Comments: Site visit with Martin Richmond of NCDWQ
Raleigh Central office on Oct 8, 2009.
4b. If the Corps made the jurisdictional determination, what type
? Preliminary ? Final
of determination was made?
4c. If yes, who delineated the jurisdictional areas? Agency/Consultant Company: SEPI Engineering Group
Name (if known): Phillip Todd Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
Site visit with Martin Richmond of NCDWQ Raleigh Central office on Oct 8, 2009.
5. Project History
5a. Have permits or certifications been requested or obtained for ? Yes ? No ®Unknow

this project (including all prior phases) in the past? n
5b. If yes, explain in detail according to "help file" instructions.
Page 3 of 11
PCN Form - Version 1.3 December 10, 2008 Version
6. Future Project Plans
6a. Is this a phased project? ? Yes ® No
6b. If yes, explain.
Page 4 of 11
PCN Form -Version 1.3 December 10, 2008 Version
C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
? Wetlands ? Streams - tributaries ® Buffers
? Open Waters ? Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a. 2b. 2c. 2d. 2e. 2f.
Wetland impact Type of jurisdiction
number - Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ - non-404, other) (acres)
Temporary T
W1 ? P ? T ? Yes ? Corps
? No ? DWQ
W2 ? P ? T ? Yes ? Corps
? No ? DWQ
W3 ? P ? T ? Yes ? Corps
? No ? DWQ
W4 ? P ? T ? Yes ? Corps
? No ? DWQ
W5 ? P ? T ? Yes ? Corps
? No ? DWQ
W6 ? P ? T ? Yes ? Corps
? No ? DWQ
2g. Total wetland impacts
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a. 3b. 3c. 3d. 3e. 3f. 3g.
Stream impact Type of impact Stream name Perennial Type of jurisdiction Average Impact
number - (PER) or (Corps - 404, 10 stream length
Permanent (P) or intermittent DWQ - non-404 width (linear
Temporary (T) (INT)? ,
other) (feet) feet)
S1 ®P ? T Pipe Extension/ UT Jordan Creek ® PER ® Corps 4 60
access road ? INT ® DWQ
S2 ? P ? T ? PER ? Corps
? INT ? DWQ
S3 ? P ? T ? PER ? Corps
? INT ? DWQ
S4 ? P ? T ? PER ? Corps
? INT ? DWQ
S5 ? P ? T ? PER ? Corps
? INT ? DWQ
S6 ? P ? T ? PER ? Corps
? INT ?DWQ
3h. Total stream and tributary impacts 60
3i. Comments:
Page 5of11
PCN Form - Version 1.3 December 10, 2008 Version
4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individually list all open water impacts below.
4a.
Open water
impact number -
Permanent (P)
or Temporary
T 4b.
Name of waterbody
(if applicable) 4c.

Type of impact 4d.

Waterbody type 4e.

Area of impact (acres)
01 ?P?T
02 ?P?T
03 ?P?T
04 ?P?T
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If and or lake construction proposed, then complete the chart below.
5a.

Pond ID 5b.

Proposed use or purpose of 5c.
Wetland Impacts (acres) 5d.
Stream Impacts (feet) 5e.
Upland
(acres)
number pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
K Total
5g. Comments:
5h. Is a dam high hazard permit required?
? Yes ? No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
Page 6 of 11
. PCN Form -Version 1.3 December 10, 2008 Version
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If any impacts require mitigation, then you MUST fill out Section D of this form.
6a.
? Neuse ®Tar-Pamlico ? Other:
Project is in which protected basin? ? Catawba ? Randleman
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number- Reason Buffer Zone 1 impact Zone 2 impact
Permanent (P) for impact Stream name mitigation (square feet) (square feet)
or Temporary required?
T
Pipe
61 ®P ? T Extension/ ® Yes 5,695 9,130
access ? No
road
B2 ?P?T ?Yes
? No
B3 ?P?T ?Yes
? No
6h. Total buffer impacts 5,695 9,130
6i. Comments:
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Stream impacts cannot be avoided. Slopes are 2:1.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Sediment fencing will be implemented to note the limits of construction.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for ? Yes ® No
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps
? Mitigation bank
2c. If yes, which mitigation option will be used for this project? ? Payment to in-lieu fee program
? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type Quantity
Page 7 of 11
PCN Form - Version 1.3 December 10, 2008 Version
3c. Comments:
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ® Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: ? warm ? cool ?cold
4d. Buffer mitigation requested (DWQ only): 30,780 square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation? ® Yes ? No
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.

Zone 6c.
Reason for impact 6d.
Total impact
(square feet)
Multiplier 6e.
Required mitigation
(square feet)
Zone 1 Pipe Extension/access road 5,695 3 (2 for Catawba) 17,085
Zone 2 Pipe Extension/ access
road 9,130 1.5 13,695
6f. Total buffer mitigation required: 30,780
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
The applicant proposes payment to EEP for the other impacts to buffer zones. The EEP has agreed to accept
responsibility of implementing the buffer mitigation on behalf of the applicant.
6h. Comments:
Page 8 of 11
PCN Form - Version 1.3 December 10, 2008 Version
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified ® Yes ? No
within one of the NC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
® Yes ? No
Comments:
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? 6.98%
2b. Does this project require a Stormwater Management Plan? ® Yes ? No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
? Certified Local Government
2e. Who will be responsible for the review of the Stormwater Management Plan? ? DWQ Stormwater Program
? DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project? Oxford
? Phase II
3b. Which of the following locally-implemented stormwater management programs ? NSW
? USMP
apply (check all that apply): ? Water Supply Watershed
? Other:
3c. Has the approved Stormwater Management Plan with proof of approval been ? Yes ® No
attached?
4. DWQ Stormwater Program Review
? Coastal counties
? HQW
4a. Which of the following state-implemented stormwater management programs apply ? ORW
(check all that apply):
? Session Law 2006-246
? Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
attached? ? Yes ® No
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? ? Yes ? No
5b. Have all of the 401 Unit submittal requirements been met? ? Yes ? No
Page 9 of 11
PCN Form - Version 1.3 December 10, 2008 Version
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the ? Yes ® No
use of public (federal/state) land?
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State ? Yes ? No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.) ? Yes ? No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ? Yes ® No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the-fact permit application? ? Yes ® No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in ? Yes ® No
additional development, which could impact nearby downstream water quality?
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
The additional sewage resulting from hospital expansion will be collected and transportated by the Oxford public sewer
system and will be treated at the WWTP.
Page 10 of 11
PCN Form - Version 1.3 December 10, 2008 Version
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or ? Yes ® No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act ? Yes ® No
impacts?
?
Raleigh
5c. If yes, indicate the USFWS Field Office you have contacted. ? Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
GIS map data was reviewed on December 21, 2009. The source of the data included NC Natural Heritage Program GIS
shapefile data from May 28, 2009.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ? Yes ® No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
NCDWQ Environmental Sensitivity Maps from Granville County, 2007 were assessed.
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation ? Yes ® No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
NC SHPO GoogleEarth kmz points located on (or near) the key feature in individually listed properties, and at or near the
centroid of the areas covered by historic districts were examined. Date of the data was from May 12, 2009
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? ? Yes ® No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination? FIRM Panel 1913J and 1923J; Map # 3720192300J
and #3720191300J

Phillip Todd Ll?
Z
'
Applicant/Agent's Printed Name A li ant/Agent
s Signature Date
(Agent's signVtUre is valid only if an authorization letter from the applicant
is rovided.
Page 11 of 11
PCN Form - Version 1.3 December 10, 2008 Version
s
HCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
November 2, 2009
Phillip Todd
SEPI Engineering
1025 Wade Avenue
Raleigh NC 27605
Nov 0 5 2009
NBRRO#09-150
Granville County
BASIN:
® Neuse (15A NCAC 213.0233) ? Tar-Pamlico (15A NCAC 213.0259)
Ephemeral/Intermittent/Perennial Determination ? Isolated Wetiand Determination
Project Name: Granville Medical Center
Location/Directions: Property is located at 1010 College Street in Oxford.
Subject Stream: UT to Jordan Creek
Date of Determination: October 8, 2009
Feature E/11P* Not
Subject Subject Start@ Stop@ Stream
Form Pts. Soil
Survey USGS
To o
A P X Culvert 32.5 X X
* 11IP = Ephemeral/Interntitterlt/Pet•ennial
Explanation: The feature(s) listed above has or have been located on the Soil Survey of Granville County, North
Carolina or the most recent copy of the USGS Topographic map at a 1:24,000 scale. Each feature that is checked
"Not Subject" has been determined not to be a stream or is not present on the property. Features that are checked
"Subject" have been located on the property and possess characteristics that qualify it to be a stream. There may be
other streams located on your property that do not show up on the maps referenced above but, still may be
considered jurisdictional according to the US Army Corps of Engineers and/or to the Division of Water Quality.
This on-site determination shall expire rive (5) years from the date of this letter. Landowners or affected
parties that dispute a determination made by the DWQ or Delegated Local Authority that a surface water
exists and that it is subject to the buffer rule may request a determination by the Director. A request for a
determination by the Director shall be referred to the Director in writing c/o Cyndi Karoly , DWQ
Wetlands/401 Unit, 2321 Crabtree Blvd., Raleigh, NC 27604-2260. Individuals that dispute a determination
by the DWQ or Delegated Local Authority that "exempts" a surface water from the buffer rule may ask for
an ad judicatory hearing. You must act within 60 days of the date that you receive this letter. Applicants are
hereby notified that the 60-day statutory appeal time does not start until the affected party (including
downstream and adjacent landowners) is notified of this decision. DWQ recommends that the applicant
conduct this notification in order to be certain that third party appeals are made in a timely manner. To ash
No hCarolina
North Carolina Division of Water Quality Raleigh Regional Office Surface Water Protection
Intemet: www.ncwatefquality.org 1628 Mail Service Center Raleigh, NC 27699-1628
Phone [phone] Customer Service
FAX [phone]
An Equal OpportunitylAfftrmative Action Employer- 50% Recycled/10% Post Consumer Paper
Granville Medical Center
Granville County
November 2, 2009
Page 2 of 2
for a hearing, send a written petition, which conforms to Chapter 15013 of the North Carolina General
Statutes to the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, N.C. 27699-6714. This
determination is final and binding unless you ask for a hearing within 60 days.
The (owner/future owners) should notify the Division of Water Quality (including any other Local, State, and
Federal Agencies) of this decision concerning any future correspondences regarding the subject property
(stated above). This project may require a Section 4041401 Permit for the proposed activity. Any inquiries
should be directed to the Division of Water Quality (Central Office) at (919)-733-1786, and the US Army
Corp of Engineers (Raleigh Regulatory Field Office) at (919)-876-8441.
Respectfully,
Martin Richmond
Environmental Specialist
cc: Wetlands/ Stormwater Branch, 2321 Crabtree Blvd, Suite 250, Raleigh, NC 27604
RRO/SWP File Copy
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i
v4ortn Loaroiina ulvislon or vvater uuallty - Jtream wentlrlcatlon corm version 3.i
Date: 9/29/2009 Project: Granville Health Latitude:
System
Evaluator: Phillip Todd Site: Drainage A Longitude:

Total Points: 38.5 County: Granville Other:
Stream is at least intermittent
if -19 or perennial if -30
A. Geomorphology (Subtotal = 19 ) Absent Weak Moderate Strong
1. Continuous bed and bank 0 1 2 3
2. Sinuosity 0 1 2 3
3. In-channel structure: riffle-pool sequence 0 1 2 3
4. Soil texture or stream subsrtate sorting 0 1 2 3
5. Active/relic floodplain 0 1 2 3
6. Depositional bars or benches 0 1 2 3
7. Braided channel 0 1 2 3
8. Recent alluvial deposists 0 1 2 3
9. Natural leveees 0 1 2 3
10. Headcuts 0 1 2 3
11. Grade controls 0 0.5 1 1.5
12. Natural valley or drainageway 0 0.5 1 1.5
13. Second or greater order channel on existing
USGS or NRCS map or other documented
evidence.

No = 0

Yes = 3

ED. nyuruwyy tOuuwtai = g
14. Groundwater flow/discharge 0 1 2 3
15. Water in channel and >48 hrs since rain, or 0 1 2 3
water in channel--dry or growing season
16. Leaflitter 1.5 1 0.5 0
17. Sediment on plants 0 0.5 1 1.5
18. Organic debris lines or piles (Wrack lines) 0 0.5 1 1.5
19. Hydric soils (redoximorphic features) present? No=O Yes=1.5
C. Biology (Subtotal = 11.5 1
20. Fibrous roots in channel 3 2 1 0
21. Rooted plants in channel 3 2 1 0
22. Crayfish 0 0.5 1 1.5
23. Bivalves 0 1 2 3
24. Fish 0 0.5 1 1.5
25. Amphibians 0 0.5 1 1.5
26. Macrobenthos (note diversity and abundance) 0 0.5 1 1.5
27. Filamentous algae; periphyton 0 1 2 3
28. Iron oxidizing bacteria/fungus 0 0.5 1 1.5
29. Wetland plants in streambed FAC=0.5 FACW=0.75 OBL=1.5 SAV=2.0 Other=0
Notes:
0.22 inches precip on 9-28-09.
Channel approximately 3 feet wide.
ATTACHMENT
PRELIMINARY JURISDICTIONAL DETERMINATION FORM
BACKGROUND INFORMATION
A. REPORT COMPLETION DATE FOR PRELIMINARY JURISDICTIONAL
DETERMINATION (JD): December 21, 2009
B. NAME AND ADDRESS OF PERSON REQUESTING PRELIMINARY JD:
Phillip Todd (SEPI Engineering) -1025 Wade Ave Raleigh NC 27605
C. DISTRICT OFFICE, FILE NAME, AND NUMBER:
D. PROJECT LOCATION(S) AND BACKGROUND INFORMATION:
The property is located at 1010 S. College Street on Highway US 15,
approximately 1 mile north of Oxford, NC
(USE THE ATTACHED TABLE TO DOCUMENT MULTIPLE WATERBODIES
AT DIFFERENT SITES)
State:NC County/parish/borough: Granville City: Oxford
Center coordinates of site (lat/long in degree decimal format):
Lat. 36.325532° N, Long. -78.592491 ° W.
Universal Transverse Mercator: 17N
Name of nearest waterbody: Jordan Creek
Identify (estimate) amount of waters in the review area:
Non-wetland waters: 460 linear feet: 4 width (ft) and/or acres.
Cowardin Class: Riverine
Stream Flow: Perennial
Wetlands: 0 acres.
Cowardin Class: N/A
Name of any water bodies on the site that have been identified as Section 10
waters:
Tidal: None
Non-Tidal: None
E. REVIEW PERFORMED FOR SITE EVALUATION (CHECK ALL THAT
APPLY):
? Office (Desk) Determination. Date:
? Field Determination. Date(s):
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.
This preliminary JD finds that there "maybe" 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:
2
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):
® Maps, plans, plots or plat submitted by or on behalf of the
applicant/consultant: SEPI Engineering and Construction, Inc.
® 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:
? 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 Oxford
Quad.
® USDA Natural Resources Conservation Service Soil Survey.
Citation: Granville County NC Soil Survey 1997.
? National wetlands inventory map(s). Cite name:
? 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):
? Previous determination(s). File no. and date of response letter:
? Other information (please specify):
IMPORTANT NOTE: The information recorded on this form has not
necessarily been verified by the Corps and should not be relied upon for
later jurisdictional determinations.
Signature and date of
Regulatory Project Manager
(REQUIRED)
Signature and date of
person requesting preliminary JD
(REQUIRED, unless obtaining
the signature is impracticable)
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PROGRAM
December 17, 2009
Gerry Leighton
Granville Health System
1010 College Street
Oxford, NC 27565 Expiration of Acceptance: September 17, 2010
Project: Granville Medical Center County: Granville
This letter revises one issued November 3, 2009. The purpose of this letter is to notify you that the North Carolina Ecosystem
Enhancement Program (NCEEP) is willing to accept payment for impacts associated with the above referenced project. Please note
that this decision does not assure that the payment will be approved by the permit issuing agencies as mitigation for project impacts. It
is the responsibility of the applicant to contact these agencies to determine if payment to the NCEEP will be approved. You must also
comply with all other state federal or local government permits regulations or authorizations associated with the proposed activity
including SL 2009-337: An Act to Promote Compensatory Mitigation by Private Mitigation Banks
This acceptance is valid for nine months from the date of this letter and is not transferable. I: we have not received a copy of the
issued 404 Permit/401 Certification/CAMA permit within this time frame, this acceptance will expire. It is the applicant's
responsibility to send copies of the permits to NCEEP. Once NCEEP receives a copy of the permit(s) an invoice will be issued based
on the required mitigation in that permit and payment must be made prior to conducting the authorized work. The amount of the In
Lieu Fee to be paid to NCEEP by an applicant is calculated based upon the Fee Schedule and policies listed at www.nceep.net.
Based on the information supplied by you the impacts that may require compensatory mitigation are summarized in the following
table.
River CU Stream (feet) Wetlands (acres) Buffer I Buffer lI
Basin Location (Sq. Ft.) (Sq. Ft.)
Cold Cool Warm Riparian Non-Riparian Coastal Marsh
Impact Tar- 03020101 0 0 0 0 0 0 5,695 9,130
Pamlico
Credits Tar 03020101 0 0 0 0 0 0 17,085 13.695
Pamlico
Upon receipt of payment, EEP will take responsibility for providing the compensatory mitigation. If the regulatory agencies require
mitigation credits greater than indicated above, and the applicant wants NCEEP to be responsible for the additional mitigation, the
applicant will need to submit a mitigation request to NCEEP for approval prior to permit issuance. The mitigation will be performed
in accordance with the Memorandum of Understanding between the N.C. Department of Environment and Natural Resources and the
U.S. Army Corps of Engineers dated November 4, 1998.
If you have any questions or need additional information, please contact Kelly Williams at [phone].
4ire erely,
D. Gilmore, PE
ctor
cc: Cyndi Karoly, NCDWQ Wetlands/401 Unit
Phillip Todd, agent
File
Prot" atir .fta t&

e*n
NCDENR
North Carolina Ecosystem Enhancement Program, 1652 Mail Service Center, Raleigh, NC 27699-1652 / 919-715-0476 / www.nceep.net
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PNGINURInc GROUP
1025 Wade Avenue
Raleigh, NC 27505
Tel [phone]
Fax [phone]
seplenglneering.com
AGENT AUTHORIZATION FORM
All Blames to Be Filled in By the Current Landowner or Municipal Official
Name: GmAt N [4cpm,-v1 ?(8c ••
Address: A-(Xv < ta1?G G CZ• _.......- __-_-
Phone: ( ClkoC? G90
` GtKf1tJV?th-G- NttcRt-?,
Pro,ject Name/Description: SEPI Project. H V-,N)QC1 Q l? -
Date: 2l-QVz)1--1
Department of the Army
U.S. Army Corps of Engineers, Wilmington District
P.O. Box 1890
Wilmington, NC 28402
Attn: G?Z-c AC -f r`'??lC fL.
Field Office: - Q,q1gN
Re: Wetlands and Streams Related. Consulting and Permitting
To Whom It May Concern:
I, the current landowner or municipal official, hereby designate and authorize SEPI Engineering Group, Inc,
to act in my behalf as my agent in the processing of permit applications, to furnish upon request
S11 lemental information in support of applications, ete. from this day forward, the clay of
This notification supersedes any previous correspondence concerning the agent for this project.
Notice: This authorization, for liability and professional colurtesy reasons, is valid only for
government officials to enter the property when accompanied by SEPI staff. You should call SE, PI to
arrange a pi'iOir to visiti,ig the site.
BY: r ' f r
1 'f1 UVI ' 1 ICY: v -?
Print Name of Landowner's or Municipal Signature of Iaan?lowiner or Municipal
Official's Natnne
cc: NCDENR •- Division of Water Quality
Attention: Ms. Cyndi Karoly
Mail Service Center 1650
Raleigh, NC 27699-1650