20091106 Ver 1_Major Variance_20091202

OFFICE USE ONLY: Date Received
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State of North Carolina, Department of Environment and Natural Resources, Division of Water Quality
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"General" Major Variance Application Form -
Randleman Lake Water Supply Watershed: Protection and Maintenance
of Riparian Areas Rule (Randleman Buffer Rule) for PUBLIC ROAD
CONSTRUCTION, IMPROVEMENT & MAINTENANCE ACTIVITIES (As
approved by the Water Quality Committee of the Environmental
Management Commission on February 14, 2002)
NOTE: To constitute a complete application, all of the information requested in this form must be
provided. Incomplete applications will be returned to the applicant. The original and two copies of the
completed "General" Variance Application Form and any attachments must be sent to the DWQ 401
Wetlands Transportation Unit, 1650 Mail Service Center, Raleigh, NC 27699-1650 and one copy must
be sent to the Piedmont Triad Regional Water Authority (PTRWA), 2216 W. Meadowview Rd,
Wilmington Bldg., Suite 204, Greensboro, NC 27407 to constitute a complete submittal.
This form may be photocopied for use as an original.
Part 1: General Information
1. Applicant's name (the Division Engineer, project manager, person responsible for project):
2.
Print Owner/Signing Official (person
Name: MJL k Mc lfo
Title: PrOA554"Xi
Street address:
City, State, Zip:
Telephone:
Fax:
for the property and its compliance)
3. Contact person who can answer questions about the proposed project:
Name: eic/," A-rdrews
Telephone: (?l?) 965-7",593
Fax: c( f1 ) t51 - 7o z4
Email: ( 1 riO r.(, 4.,(rcwxC;) 54otwkc-c.M
4. Project Name (Subdivision, facility, or establishment name - consistent with project name on
plans specifications, letters, operation and maintenance agreements, etc.):
5. Location of Facility
Street address:
City, State, Zip:
County:
Latitude/longitude: -7q . 1711 ' 31b
.016
6. Directions to facility from nearest major intersection (Also

Version 3: January 2006

7. Stream to be impacted by the proposed activity:
Stream name ffor unnamed streams label as "UT to the nearest named stream):
Stream classification [as identified within the Schedule of Classifications 15A NCAC 2B
.0311 (Cape Fear River Basin)]: X15 -?M'-
Part 2: Proposed Activity
(Please include attachments if additional explanation is necessary)
1. Description of proposed activity:
• Also, please attach a map of sufficient details to accurately delineate the boundaries of
the land to be utilized in carrying out the activity and to show the location and dimension
of any disturbance in the riparian buffers associated with the activity.
2. What is the total area of buffer impact? Zone 1: 2031 it2
Zone 2: 130 ft2
3. State the reasons why this activity cannot be practically accomplished without a general
major variance approval. State what measures have been taken to minimize or eliminate
disturbance to the riparian buffers:
AIn
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4.
5. How do you intend to provide mitigation if required under Condition No. 7 of the variance?
(Attach a mitigation plan if you intend to satisfy the mitigation requirement through the
restoration of riparian buffers.)
Variance Request Form, page 2
Version 3: January 2006 .
If sheet flow of concentrated runoff cannot be achieved prior to entering the buffers, then
please provide information on any on-site stormwater management facilities (e.g., grassed
swales, extended detention wetlands) that will be used to control nutrients and attenuate flow
(attach construction details and site locations for these facilities):
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6. Please explain the practical difficulties or hardships that would result from the strict
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Part 3: Applicant's Certification
I, 2rG?ar? A"~ 5 (print or type name of person
listed in Part I, Item 2), certify that the information included on this permit application form is
correct, that the project will be constructed in conformance with the approved plans and that the
deed restrictions in accordance with Part 5 of this form will be recorded with all required permit
conditions.
Signature:
Date:
Title:
Variance Request Form, page 3
Version 3: January 2006

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Guilford County, NC
GREENSBORO
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HIGH POINT
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Figure 1 - Vicinity Map
Deep River Road Relocation
NCDOT Roads
Hydrography
GREENSBORO
HIGH POINT
JAMESTOWN
J
Miles
0 0.5 1 2

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41-
1
NA
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Figure 2 - USGS Topographic Map
Deep River Road Relocation
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USGS 7.5 Topo Quad:
Guilford
F-I Project Area
Feet
0 625 1.250 2 50(1