20011466 Ver 1_Complete File_20011005

4?;
Office Use Only' 0 // Form Version April 2001
USACE Action ID No. DWQ No.
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
1. Processing
Check all of the approval(s) requested for this project:
® Section 404 Permit
? Section 10 Permit
? 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s)Requested:NWP #3
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here:
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ?
H. Applicant Information
1. Owner/Applicant Information
Name: T R Gibson, P E INCDOT/Div 6/Division Engineer
Mailing Address: P.O. Box 1150
Fayetteville, NC 28302
Telephone Number: 910-486-1493 Fax Number: 910-486-1959
E-mail Address: teibson(a-dot state nc us
2. Agent 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: same as above
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Paget of 9
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: Bridge 4151 Columbus Coun
2. T.I.P. Project Number (NCDOT Only): B-3146
3. Property Identification Number (Tax PIN):
4. Location
County: Columbus Nearest Town: Brunswick
Subdivision name (include phase/lot number): N/A
Directions to site (include road numbers, landmarks, etc.): 1.3 mile west of 701 on SR-
1429.
5. Site coordinates, if available (UTM or Lat/Long): 34.20°N 78.43°W
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this application:-
Hi hwa application - Eaistin Brid e
7. Property size (acres): Less than 1.0 Ac.
8. Nearest body of water (stream/river/sound/ocean/lake): Cedar Branch
9. River Basin: Lumber River
(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/maps/.)
10. Describe the purpose of the proposed work: Replace structurally deficient bridge with
Page 2 of 9
A new brid e.
11. List the type of equipment to be used to construct the project: Trackhoe Excavator
& Truck Crane
12. Describe the land use in the vicinity of this project: Rural
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.
N/A
V. Future Project Plans
Are any additional permit requests anticipated for this project in the future? If so, describe the
anticipated work, and provide justification for the exclusion of this work from the current
application: N/A
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.
1. Wetland Impacts
Page 3 of 9
indicate on ma acres es/no linear feet
N/A
• 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 httn /h»vw fcma.?o?.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property: 0 ac
Total area of wetland impact proposed: _0 ac
2. Stream Impacts, including all intermittent and perennial streams
Width Perennial or
Stream Impact
Site Number
on ma
t
di
i Type of Impact* Length of
Impact
linear feet Stream Name** Average
Before of SIm act Ileasre stteci 9
e
ca
n
Crossing #l Bridge OLF Cedar Branch 70 Ft. Perennial

t 1' ited to• culv erts and associated rip-rap,
List each impact separately and identify temporary Impacts. Impacts include, but are no im
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
online
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or
W-Ativ.usas.gov. Several internet sites also allow direct download and printing of USGS maps (e.g.,
www.mapquest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: OLF
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S.
Open Water Impact Type of Impact* Area of Name of Waterbod Type of Waterbod
Page 4 of 9
Site Number Impact
indicate on ma acres
N/A
(if applicable) (lake, pond, estuary, sound,
bav. ocean, etc.)
List each impact separately and identify temporary impacts. Impacts include. but are not limited to: fill, excavation, dredging
flooding. drainage, bulkheads, etc.
VII.
4. Pond Creation
, associated wetland and stream impacts should be
If construction of a pond is proposed
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. ? wetlands
Pond to be created in (check all that apply): ? uplands ? stream
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.):
Size of watershed draining to pond: Expected pond surface area:
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.
Propose to replace an existin5 span timber and concrete bridge (85.OOAL) with a 2 span
reinforced concrete and steel bride 125.0 OAL . Pro osed brad a will increase now
characteristics while reducin existing impacts to the waterway.
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
Page 5 of 9
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
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/ncwetiands/strmgide.html.
1. 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.
Miti ation not re uired.
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
Page 6 of 9
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at littnl/1i2o enr state nc us/Nvra/index.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ® No ?
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer 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.
Page 7 of 9
Impact Multiplier
Zone* (saw feet) 1.5

Required
Total I I i
Zone I extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
if buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
XI. Stormwater (DWQ Only)
Describe impervious acreage (both existing in orrand de proposed)
protect ersurfacea acreage on the site.
and wetlands
Discuss stormwater controls proposed
downstream from the property.
Erosion and sedimentation Wan shall be incorporated into the construction se uence.
XII. Sewage Disposal (DWQ Only)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
N/A
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit 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
Page 8 of 9
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).
None
D
Applicant agent's Signature /Dat'e
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
US Army Corps Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Office Alexander Cherokee Iredell Mitchell
US Army Corps of Engineers Avery Clay Jackson Polk
151 Patton Avenue Buncombe Cleveland Lincoln Rowan
Room 208 Burke Gaston Macon Rutherford
Asheville, NC 28801-5006 Cabarrus Graham Madison Stanley
Telephone: [phone] Caldwell Haywood McDowell Swain
Fax: [phone] Catawba Henderson Mecklenburg Transylvania
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham
US Army Corps Of Engineers Alleghany Edgecombe Lee Stokes
6508 Falls of the Neuse Road Ashe Franklin Nash Surry
Suite 120 Caswell Forsyth Northampton Vance
Raleigh, NC 27615 Chatham Granville Orange Wake
Telephone: [phone] Davidson Guilford Person Warren
Fax: [phone] Davie Halifax Randolph Wilkes
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare Lenoir
Post Office Box 1000 Camden Gates Martin
Washington, NC 27889-1000 Carteret* Green Pamlico
Telephone: [phone] Chowan Hertford Pasquotank
Fax: [phone] Craven Hyde Perquimans
Wilmington Regulatory Field Office Anson Duplin Onslow
US Army Corps Of Engineers Bladen Harnett Pender
Post Office Box 1890 Brunswick Hoke Richmond
Wilmington, NC 28402-1890 Carteret Montgomery Robeson
Telephone: [phone] Columbus Moore Sampson
Fax: [phone] Cumberland New Hanover Scotland
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
Page 9 of 10
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STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY.
GOVERNOR
NCDENR Division of Water Quality
Robert Ridings
2321 Crabtree Blvd.
Suite 250
Raleigh, NC 27604-2260
OCTOBER 15, 2001
LYNDO TIPPETT
SECRETARY

RE: NCDENR WQC 3290 / USACE NWP#3
DWQ# 011466 - Bridge #151 Replacement - Columbus County (B-3146)
DWQ# 011469 - Bridge #1 Replacement - Columbus County (B-3439)
DWQ# 011468 - Bridge #2 Replacement - Bladen County (B3411)
DWQ# 011467 - Bridge #197 Replacement - Robeson County (B-3367)
Dear Mr.Ridings:
Enclosed, please find two courtesy copies for bridge replacement projects within Division 6. The
projects will be completed in compliance with NCDENR Division of Water Quality General
Certification 3290 and USACE Nationwide Permit #3.
The PCN's for these projects were mailed by Division 6 Bridge Maintenance Department to
NCDENR for review under USACE NWP#31. Richard Spencer of the USACE has determined
that the projects will be permitted as NWP#3. Please disregard all previous notifications
pertaining to the above referenced projects.
If you should have any questions or comments regarding this notification, please feel free to
contact me.
cc: Richard Spencer, USACE
L.L. Upole, P.E.
Sincerely,
James . Rerko, PWS
Division 6 Environmental Officer
P. O. Box 1150, Fayetteville, NC 28302-1150 - Telephone [phone] - Fax [phone]
W A r?9Qc
`? r
O ^<
Michael F. Easley
Governor
William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Gregory Thorpe
Division of Water Quality
October 10, 2001
DWQ# 011466 TIP # B-3146
DWQ# 011467 TIP # B-3367
DWQ# 011468 TIP # B-3411
DWQ# 011469 TIP# B-3439
L. L. Upole, Jr. P. E.
Division Bridge Maintenance Engineer
P. O. 1150
Fayetteville, NC 28302
Dear Mr. Upole:
On October 05, 2001, your applications for 401 Water Quality Certifications for projects in
Bladen, Columbus, and Robeson Counties were received by the N.C. Division of Water Quality.
Please note that beginning January 1, 1999, the N.C. General Assembly passed legislation requiring
payment of a fee for all 401 applications. Your applications are being put on hold since no payment
was received with the packages. The fee for applications is $200 for projects impacting less than an
acre of wetland and less than 150 linear feet of streams. For projects impacting one or more acres of
wetland or 150 or more feet of streams, the fee is $475. In order for DWQ to review and process your
request, you must send a check in the appropriate amount made payable to the N.C. Division of
Water Quality. Please refer it to DWQ Project #011466, DWQ Project # 011467, DWQ Project #
011468 and DWQ Project # 011469.
Please call me at 919-733-1786 or visit our web site at http://h2o.enr.state.nc.us/ncwetiands if
you have any questions regarding this fee.
Since , y,
Robert Ridings
cc: Central Files
File Copy
North Carolina Division of Water Quality, 401 Wetlands Certification Unit,
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
(NO 719 170C /.J.-% 010 799 ROM /f,-% LNn•/11.7.. - n4,0- - ue1n.....n11n-41 I

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I aINCIIcvillc, N. C. 29102
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Wilminvton I(ccolalnt? I icld (Mice
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I O( 'A I I( )fJ SR 1.129 ( Yoeeirtg ( *cdol Branch
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A%'c :It(- Imtcicliltg hctcwillt :nt application pockagc and copies of N C. OcImittncnt of I ranshnrtidion
I I\dtanlic. I'nit eketchee (11latt and IM161c) ae a IM11 ctl a ltrcljecl inVOlving Iltc reltlaeentcnl ctfen existing
ht idg, , :. ith a nccv htidy,c. I Ito lxojccl ehould he let to contract in 2002.
.I„ ont kI I Im'Icdge, no wcllands nre ntvoivcd and Iola) fill in woler is expected to he Iess than (.1.01 acre. This bridge is
not I(,c.1lcd in o high quality water atco.
I'Ira•:c tc\ icw tide ntalctial, and it oddilional inllorutalion is needed, please comae) our ollicc.
I hank wu fot your coopctation and a sistancr in This ntallcr.
Siuc?crcly,
Di%i,:ion litid)w Maintcnnnce I ligincer
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Pre-Constructit?n Notification (PCN) Application Form
For Section 404 and/or Section 10 Nationwide, Itegional and Cencral Permits, Section 401
General Water Qnalifv Certifications, 111(1 Riparian Buffer and Watershed Buffer Rules
I his 161111 is IO he used Iow projects qualifying for any of the U.S. Arnr_y Corps of higineers' (USACE)
NMIonwidc, Rci,,Imml or General ['ernlits as require([ by Section 404 of' the Clean Water Act anti/or
Section 10 of the Rivers and Ilarhors Art, and fOr the North Carolina [)'vision of' Water Quality's
(UWQ) asslri;llyd (i'eneral 401 Water Qualify Certifications. This firnn is also to be used for any
project rc(Iuirini, ;ipproval under an,v 1111),11-11111 Duffer Rules Implemented by the N.C. Division of Water
Quality. 11is [mill should not he used it you are requesting an Individual 404 Permit or Individual 401
Water Quality Certification. The USACI; Individual Permit application 16rm is available online at
hllp;,' `w?? w.sa,? .usa0c.army.nlil.'wellands'I'crrn_ahp.htn?.
'I lie IISA('I, is the Ic;1d regulatory ;tt?•cnry. To rcvicw the requirements for the use of Nationwide,
Regional or (irneral permits, and to dctemmic which permit applies to your project, please go to the
USACI`, yd-lf0 at filth:,'; ?? ?? « s;t?, u;;100.ar111y.nril!well;uuls?'rrgtour._Iilni, oI• contact one of the field
oflices li"tc(l E11 the end of this applicafion. The wehsite also lists the responsible project manager for
each county in North Carolina and provides additional inl6rlnation regarding the identification and
regulation of wvll;mds and waters of the t I.S.
The UWQ issuCS a corresponding Certil1cation (General or Individual), and cannot tell the applicant
which 401 Ccrtihicatton will ;apply until the. 404 Permit type has been determined by the USACI.?.
Applicants ;ire encouraged to visit UWQ's 401/Wetlands Unit website al
http:'1h-'1.rnr.?t;110.nr.us'ncwctlands to read ;shout current requirements iOr the 401 Water Quality
Certilicalion I'rograrn and to detcrn?inc whether or not iZipnrian Buflcr Rules are applicable. The
applicant is also advised to read the full text OI'the General Certification (C.(') matching; the specific 404
PCI.11111 re(iucsi0d. In some cases, written approval fir some (icneral Certifications is not required,
provided Thal the applicant adheres to all conditions of the (;C. Applicants lacking access to the internet
should CuntaOt D) \Vs Central OMice in Raleigh at (()19) 733-1780.
I rout `Vnter; ('oordination - Spcri;II Coordination with the North Carolina Wildlife IZesources
Connnissiou (N('WiZC) is also required li)r projects occurring; in any of North Carolina's twenty-five
counties Ihal 01111;1111 Iroul waters. In such cases, tile applicant should contact the appropriate NCWRC
regional Coordinalor (listed by County on (he last page ofthis application).
('AMA Coordination - I f tlic. project oCCUrs in any of'North C larohna's twenty coastal counties (listed on
file last rige idIbis application) the 0pp1iC;u11 should also contact the North Carolina Division of Coastal
P m w I of I
I
,AL
Management (D('M) at [phone]. DCM will determine whether or not the protect involves a
designaled Arca (fl' I'llviromllcnfal Concern, ill which case DCM will act as the lead permitting agency.
In such cases, DCNI will require a Coasl;ll Arca Management Act (('AMA) Permit and will coordinate
the 404/401 Pcrllllls.
USACE Permits - Submit one copy of (his 1;01-111, along with supporting narratives, maps, data f-ornls,
photos, ctc. to the applicable l ISA(_T Rel,ulatory Field Office (addresses are listed at the end of this
application). I Ipon receipt of an application, the I1SACF will determine ifthe application is complete as
soon as possible, not to exceed 30 clays. 'I his I'( 'N form is designed for the convenience of the applicant
to address ill li0rnlalloll deeds liu- all IISA(T Nationwide, Regional or General permits, as well as
inlinnlatlon required ti)r State authoriiallons, certifications, and coordination. Fully providing the
information rcquested on this 1,01-111 will rcsull in a complete application for any of the 11SA(T
N;1lionwidc, Rct!Ional or ( icneral permits. To review the Illlllillium amount of* information that must he
provided filr a complete PCN for each 11SA(T Nationwide permit, sec Condition 13, 65 Fed.Reg. 12803
(M,1rch 9, 2000), available at
hlfp:ii??ww.sa???.us;ice.r.lrnly_nliL/}yctlands/nwhfinall?c?lRe ?l,l.
I'rocessint" Iilncs v;rry by permit and hegira once the application has been determined to be complete.
I'Icase contacl fhc aIpproprlalc regul,llory licld ollice liar speeilie. answers to permit processing periods.
401 Walter Qualify' Certificatirm or Mnffer Rides - All inliOrn1.111011 is required unless otherwise stated
as optional. Incomplete applications will he returned. Submit seven collated copies of all USACI?
Permit nullcrials to Ills Division of Water Quality, 401/We1lands Unit, 1050 Mail Service Center,
Raleigh, NC, 1)1/0 9-1(50. 11' written approval is required or specifically requested for a 401
Ccrtilicallot], then a non-refundable application Ice is required. In brief, if'pro.ject impacts include less
than one acrr of cumulative wetland/watcr impacts and less than 150 Icet cumulative impacts to
streams, then a Ice of $2(10 is re(luired. If either ol'these thresholds is exceeded, then a Ice of $475 is
required. A check Amide out to the North Carolina Division ol* Water Quality, with the specific name of
file project or applicant identified, should be stapled to the front ol'the application package. For more
information, sec the DWQ wchsitc at hltp:char.slatc.nc.us/ncwellands/lecs.html. The fee must be
attached with the application unless the applicant is a federal agency in which case the check may he
issued Cron1 a scpar;llc office. In su-h cases, the project must be identifiable on the U.S. Treasury check
so that it can be credited to the appropriate project. 11'written approval is sought solely for Buffer Rules,
the application fee (foes not apply, and the applicant should clearly state (in a cover letter) that only
1luftcr Rule approval is sought in writing. Wetlands or waters of the U.S. may not be impacted prior to
issuance. or waiver of i Section 401 Water Quality Certification. I_Jpon receipt of a complete application
I'Or a 401 Certification, the Division of Water Quality has 60 days to prepare a written response to the
applicant. This play include a 401 Cellilication, an on-hold letter pending receipt of additional
requested infirrrn;Hloll, or denial.
P; we .'. t, I I?

Office Ilse 01111'; I o m Version April 2001
611466
UtiA('F, Action 11) No. I)W(1 No.
If(Illy particular item is not apphc;lhle to this project, please enter "Not Applicable" or "N/A" rather than
Icavinf, the space blank.
1. Processing
I . Check all of the approval(s) rrtlucsted 1<)r this project:
Section 404 Permit
`;cction 10 Permit
['],101 Walcr (1n.11ity ('crtilieation
[ Riparian or Watershed MOTO- Rules
'. N:lionwidc, Regional oi- General Permit NUlllhcr(S) Requested:
?. II Ibis notilicalion is solely a courtesy copy because written approval for the 401 Certification
i,? not rctitIircd, check here:
1. II p;ivn?cnt into the North ('arolina Wetlands Restoration Program (NCWRP) is proposed for
nlit it;atloll of Impacts (sce section Vill - Mitigation), check hare: ?
II. Applic;?nllnfornuilion
1. O\vncr/Applicant In161-nlatloll
Namc:
Mmling Address: -------- ---- -
'I cleplionc Numhcr. l/' / ?( I ?1 j - - Fax Number -..'110 /?-1--
I?-maiI Address: _._SFA-Q
Z. A>>cnt Inlitrniation (A signcd and dated copy of the Agent Authorization letter must be
attached ifthe Agent has signatory authority li?r the owner/applicant.)
-_----
('untpanyAfliliafion:
Nhilins, Address:
clephonc Numhcr: Fax Numhcl:___
I`-mail Address
P we 1 of 1

i
111. Project Information
Attach a vicinity map clearly showing file location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing propc?ty
boundaries and development plans in relation to surrounding properties. Both the vicinity slap
and site plan must include a scaly and north arrow. The spccilic fi?olpriuts of' all buildings,
impervious surfaces, or other facilities must be included. It' possible, the naps and plans should
include the appropriate USGS 'topographic Ouad Map and NRCS Soil Survey with the properly,
boundaries outlined. Plan drawings, or other- maps may he included at the applicant's discretion,
so long as the property is clearly defined. Fm administrative and distribution purposes, the
USACG requires information to be submitted on sheets no larger than I I by I Tisch ti?rmat;
however, DWQ may accept paperwork of any slit. DWO prefers full-si/e construcliit??
drawings rather than a seyucntial sheet version of the full-SlIC pl:u?s. II' full sile plans are
reduced to a small scale Midi that the final version is illegible, the applicalit ?? ill be 111101nred that
the pro.jcct has been placed on hold until decipherable slaps are provided.
I. Nall1C lit 11'l1 eel: ?F m ( / t' ru n- ] P
2. T.I.P. Project Number (N('I)O"I' Ollly):
3. Property Identification Number ("tax PIN)'
4. Location /
('aunty:---L`'--/??!m? y _'? _ - - .. - _ _ Nl?aresl Down: ??1'!t1?._; ?: ?_
Subdivision name (include phase/lot number): -- k lfl
Directions to site (include road numbers, lan(1marks, (tc.): P),
1. rl ( r •' 5. Site coordinates, if available (I )'I'M or I.at/tong): (__; I
(Note- ll'projcct is linear, such as a road or utility line, attach a shed thnl separately lists the
coordinates tier each crossing of a distinct wateibody.)
6. Describe tyre existing land use or condition ol'the site al the lime of this application:
7. Property size (acres):
K. Nearest body ot'water (sUeiurr/river/sound%uccanilake?: l E ?t?l f _?, t / _ _
9. River Basin:_ - -Lcsr?r l' ?_ 1'_
(Note - this must be one of North C'arolina's s(ventecu designated major river basins. The
River Basin Wrap is available at III lt):/!h?o.cru.."Ll le.nc.us!adIII in%Imps ".)
10. Describe the purpose ol'thc proposed work:
P;Ige -t (,f I ,
A?
I I. List the type of-equipment to he used to construct the project:__ _ i"Ig4- C-A,,14 A 7e C _
i(Pi 0 ? (lltv'L_ .. -
12. 1)escrihe the land usC in the vicinity oI•this proicct: k',f
IV. Prior Project Ilislory
I1• jurisdictional determinations and/or permits have hcen requested and/or obtained for this
project (including all prior phases of' the same subdivision) in the past, please explain. Include
the I ISACF Action II) NLImhcl OWO Project NLnnhCl-, application date, and date permits and
certcatiMIS were issued or withdrawn. Provide photocopies of' previously issued permits,
ccrtilicatiorts or other useful inlirrmalicm. Describe previously approved wetland, stream and
hul•icr impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued Jill- prior segments of the same T.I.P. project, along with
construction schedules.
V. I uture• Project flans
Ale any additional permit reolucsts anticipated li>r this project in the future? If so, describe the
anlicipated work, and provide justification firr the exclusion of this work from the current
V1. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or age ?l'r:) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the projcct. The applicant must also
IM-MRlc justilication f(rr these impacts in Section VII helow. All proposed impacts, permanent
and temporary, mtasl he 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 Illah, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation lin-nts should lie included as appropriate. Photographs may be
included at the ..applicant's discretion. If this proposed impact is strictly for wetland or stream
milip'llion, list and describe the impact in Section VIII below. if additional space is needed for
listing or elescrihlion, please attach a separate sheet.
1. Wetland Impacts
Wetland Intpnrt
Site Number I y1)c of Impart"
(indiralr on neap)
At ea o Located within Distance to
Impact 100-year I loodplain** Nearest Stream 1 ype of Wetland***
(acre") (yes/no) (linear feet)
Patte 5 of 12
AL
1st each imlim'I separately and identify 11111), ar} itulrtcts. Imlrocts include but are not limile•d to: mechanized clearing, grading, fill,
+ exca align. Iloodilig, ditching/drainage, etc. Vol ;d;uns, separalcly list impacts clue to holh snuclute and flooding.
++ 11111 ti car H"odplains arc identified Through the I cdcml I:n,crgency Management Agency's (FF.MA) Flood Insurance Rate Maps
(I IRM). of l l % IA 1pptnvc•d local lloodplain limps. M,tps arc availahlc lhrough the l t.MA Map Service Center tit 1-900-358-9616, or
onlin( at 11IIp, cc c\ cc Icma gm
+ + I is ;, ccll,nnl tvpc that bcsl dcscaihcs w(IL1n,l to he impacted tirshwalcr/saltwater marsh, forested wetland, heaver pond,
('moliml 11;1?% hog, clc.l
I J'st the total acrcagc (cslinlatc(I) ol'cxisting wetlands on the property:___-- ?-
'I oral area (A,wcllalld Impact proposcd:__ _ -- - -- ?? _ _----._--..-- ---_ _-._-----___- --
). ?trcanl Impacts, including, all intermittent and hcrcnnial Strcafns
Stream Impart h,111011 of Avcragc Width Perennial or
Sit(, Numb(r Iypoohirttpact* 11111mcl Stream Name** oI Scram Intermittent'?
(indicate on nulp) (linom lcm) Hefore Impact (Lilease s cify)
" List each impact separately and identify temporary impacts. Impacts include, but are not limitcxl to: culverts and associated rip-rap,
danr: (scparatcly list impacts lour to holh slructu« • and flooding), relocation (include linear feet before and after, and net loss/gain),
slahih/i Ilion activities (cement wall, rip-rap, clih wall, gahio11s, etc.), excavalion, ditching./straightening, etc. 1f stream relocation is
ptopos(d, plans and profiles showing the lines h,olprinl for holh the original and relocated streams must be included.
** Shcanl n;nncs can he tinntd on tISGS t tpographic maps. If a stream has 11o name, list its t11' (unnamed tributary) to the nearest
do?cnslar:ana witned ;Ircotn inlo which it Ilows. I'SGS nlnps arc amdlahlc through the IISGS at 1-800-358-9616, or online at
wn.u:r:. a Several inicillo sites al•:o allow thiccl download ;111(1 plinting of IISGS Inaps (e.g., )y?ti_w.topo/.imc.conl,
cc , .u1.11 ,lu ^:I com, elk ).
('tlJnulative impaclS (linear distance in ICcl) to all S11-Cams on site:--___C?
',. Ol)rn Walcr Inll)aclS, including Lakcs, fonds, L,;stuarics, Sounds, Atlantic Occan and any
other Watcrol'the U.S.
O poll W;IICr Impact Area of hype of Waterbody nle Silo Numb rr I ' 1'pc t u pa cf mpact Na, of Walcrbody lake, pond, estuary, sound,
of I* I
(if applicahle)
(indicate on IM11') bay, ocean, etc. _--
I'aeo 6 of 12
A&

Proposed use or purpose of' pond (e.g., livestock watering, i rigation, aesthetic, trout por>d,
local stonnwater requirement, etc.):.
--- ---- - ----------
Size of watershed draining to pond --- -_ Expected pond surface area: _.__
DWQ - In accordance with 15A NCAC 211 .051)(), mitigation may be required by the NC
Division of Water Quality tier projects involving greater than or equal to one acre ol'impacts to
freshwater wetlands or gn-eater than or equal to 150 linear [ et of' total impacts to perennial
streams,
USACE - In accordance with the Final Notice of Issuitnce and Modification of Nationwide
Permits, published in the Federal Rcgistcr on March 9, 201111, mitigation will he required when
Page 7 of I _'
ViI. Impact Justification (Avoidance and Minimization)
List each impact sepurutely anti identity tollpoaaay i11y,wis. 1111pauls inrlmIC, hul aaC 1101 H1111101 l0: fill, Lxcavali0u, dredLing,
flooding, drainage, bulkheads, etc.
4. Pond Creation
If construction of it pond is proposed, associated wetland and stream intpacls 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/cnthankmer?t, excavation, installation of'
draw-down valve or spillway, etc.):.-- -----/ h)
Specifically describe measures taken to avoid the proposed impacts. It may he useful to provide
information related to site constraints suc=h as topography, building ordinances, accessibility, and
financial viability of the project. The applicant 111ay 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. It' applicable, discuss construction
tech nniques to be followed daring consU-uctiun to reduce Impacts.
kt_ll/u?-
V111. Mitigation
A&.
necessary to ensure that adverse effects to the aquatic environment are minimal. ]'actors
including sire 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. 1"Aarllples 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 bUflcrs to protect open waters such as streams; and replacing losses of
aquatic resource liulctions and values by creating, restoring, enhancing, or preserving similar
functions and values, pretcrahlc in the sank watcrshed.
If nliligalion is required filr this project, a copy of the mitigation plan must be attached in order
Iilr I ISM T or UWQ to consider (he application complete for processing. Any application
lacking .I required mitigation plan or NCWRI' collcUrrCnce shall be placed on hold as
incomplctc. Ali applicant may also choose to review the current guidelines for stream restoration
in UWO's Dral't "Technical Guide lilr Stream Work in North Carolina, available at
htlp:/ 1120.0ll.still c.I-1c.us'ncvvcllands!strm?L'Idc,1111111.
I . Provide a brief description ol'the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
andior Inap, ifol'l'site), aflccled stream and river basin, type and amount (acreage/linear feet)
of nliligation proposed (restoration, cnhanccnlcnl. creation, or preservation), a plan view,
prescrvatloll Illel'11,11115111 (c.g., decd restrictions, conservation easement, etc.), and a
description ol,thc current site condilions and proposal method of construction. ]'lease attach
a separate sheet if*trlore space is needed.
2. Mitigation play also be made by payment into the North Carolina Wetlands Restoration
Prograrll (NCWIZP) with the NMIZ11's written agreement. Check the box indicating that
you would like to pay into the N('WRP. Please note that payment into the NCWRP must be
reviewed and approved befilrc it can be used to satisl'y mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NMRP is available as an option. For additional information regarding the application
process I'M the NCWRP, check the NCWRP website at http: /IQo.crlr siatPatL_u /wrp/index htnt. It'
use ol'the NCWIZI' is proposed, please check the appropriate box on page three and provide
111c 1,01lowing ill 1,01-111,111011:
Amount ohslrcanl mill galion ra ucslcd linccu- Icet
P,Ip,c R ol, I"),

Amount of buffer mitigation 1'egticstcd (s(1uare. feet):__-. 0
Amount of Riparian wetland mitigation re(lucstcd (acres):--o_
Amount of Non-ripat ian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation rc(lueslcd (acres):___
IX. h,nvironmenlal Documentation (DWQ Only)
I )oes the project involve an cxpcnditure of public funds or the use of public (federal/state/local)
land?
Yes N1 No
11' ves, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Ftivironmental Policy Act (NEPA/SEPA)?
Note: If you arc not sure whether it NEPA/SFPA document is required, call the SETA
coordinator at [phone] to review current thresholds fi?r environmental documentation.
Yes ? No [_A]
I f vcs, has the docunlcaal review bcctl lilwil cd by the State C'learinghouse'? If so, please attach a
copy ol'the NITA or SFPA linal approval letter.
Yes ? Nu I\l
X. PI-oposed Impacts on Rip:uri:1n :uul watershcti 13uffers (DWQ Only)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justiIIcatloll fun- these impacts in Section VII above. All proposal impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
ntap, whether or not impacts arc 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 buflcrs identified within 15A NCAC 2B .0233
(Neuse), 15A NCAC 213 .0259 (Tar-Pamlico), 15A NCAC 213 .0250 (Randleman Rules and
Water Supply 13u11er Rc(Iuirenrcnts), or other (please identify---..__.__.___ _ -)?
l'cs [_] No N Ifyou answered "yes", provide the following information:
Identify the Square IM 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
1111116111 let's.
l.onc' Impact Required
Multiplier
(s(tuare Feet) Miti ation
I 3
1.5
I otal _
/.one I extends out 30 feet Imrhendicular front near kink of channel: lone 2 extends an
additional 20 feet 11(1111 the cdgv ol'Y.nne I.
P;wc9of 12

II'luI11CI mitigation is rcyuircd, plrrsc dlscLiss wlraI tyl?c of mitigation is proposed (i.e., Donation
of Property, Conscr-valioI I l?ascnrrnl, Riparian Buflcr Restoration / F 116anccment, Preservation or
P;Ivn?cnt into the Riparian I1uf,lcr Itcsloration Fund). Please attach all appropriate intorrnation as
idcutilicd within 15A NCAC 211 .02,12 of-.0200.
X1. titnrn?IN:?ter (DWO (h?ly)
M."Wlll)c impervious acrcagc (holli existing and proposed) vca:sus total acreage on the site.
I>stornwyater controls proposed in order to prolect surtircc waters and wetlands
downstrcan? If-oin the property.
/1. / /)
XII. Sewage Disposal ([)\\IQ Or?ly)
Clearly detail Ihe. ullinrale trcalnrcnl nrcthods and disposition (non-discharge or discharge) of
wastew;ilcr generated I•roin the proposed proiccl, or availahle capacity ofthe subject facility.
X111. Violatirn?s (DwQ (hill-)
Is this site in violation of, DWQ Welland Rides (1 5n NCAC 211 .0500) or any 13uftcr Rules?
Yes ] No
LL)IJ
Is this an alto the-fact perrr?it application's
Ycs 1-1 No N
XIV. Other Circumstances (Oplional):
It is the applicant's responsibility to submit file application sufficiently in advance of desired
construction dates to allow processing lime lot- thesc pcrinits. Ilowever, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (c.g., draw-down schedules fir lakes, dates associated with Endangered and
Threatened Spccics, accessibility problems, or other issues outside of the applicant's control).
1';11,,. H) „I" I ."

11
&? ?f Lc ! / Z ? lU 1---
ApplWont /Ageit's , ignalurc Date
(Agent's sipuiturc is valid ()Illy it an autl)()riiatlon letter li-om the applicant is provided.)
US Army Corps Of 11:nghwers Field Offices and County Coverage
Asheville Regulatory Field Olficc Alexander Cherokce Iredell Mitchell Union
I )ti All) IV ('IIIps 111 1'11 gllleet5 Avcly Clay .1"Ickson Polk Watauga
151 PItlon Avcnnc IWilconlbc Cleveland Lincoln Rowan Yancey
Rnonl 'OX Itulke ( iastou Macon Rutherford
Asheville, N(' 'X` 01 ',006 1 akllrns (indmill Madison Slanley
Iclcphoflc: (X "tl ,'"%I "1851 Caldwell 1laywood McDowell ,, waiIt
fax: (X'X) :'71 -I} ,X C;Ilawha Ilenderson Mecklenburg Iransylvania
Ralclgll RI'I'III;IIi'r\' I Icld OIlt(r ALIlnllmc 1)11111,1111 IohliStoll Rockingham Wilson
I IS Atim ('OIp,s ( H I llpinccls Allcglimiy I dgecon)hC I ce Stokes Yadkin
6S(1X I ;ills of Ihl• NcIrw Road A dw Franklin Nash Surry
Still(. I 'U ('aswdl I-of-mll Notlhamptou Vance
R;Ilcit'11, N(' :17h I ? (AmIll Ill ( imliville ( )rlllpe Wake
clcph„nc (') 10) 8 76.X44I Dm idsoll (iuilfold Person Warren
I?;Ix: (O19) X76 S.'Xl I)avic IIaIiI'll r Randolph Wilkes
WnshinpUm Rcttulaloly Field ()nice I?r;IulilII ('tit rit tick lulu's Tilt
I IS Arnly (',lips ( )I I ng.inccrs Beetle Dam Lenoir Tyrrell
Post (>Ifirc ItO\ ]OO(I ('anldcn Gates Martin Washington
Washington. N(' '7XX9 1000 Cartcrc(* ( if cell I'onllico Wayne
Iclcp1wile: (JS') O75 1616 ('how;ul 1let Hold Pasyuotank
I:aX: ('S.') 075 111)1) ('lavrn IIWe Per(Iuinlans *C'roatan Nati onal Forest Only
WiltnillOon Rc,'llhioty Field Officc Anson Uu111in Onslow
IS AImv ('orps OI I'nginccrs Itlmlcn Ihit licit Pender
Post Oflicc liox I,X00 I;runslwick Iloke Richmond
?Vilnlington, N(' ;1X4O?-IVM Carlcl0 Montgomery Robeson
I clcphonc: (1)11)1 'S 1451 I 0411111hus Moore Sampson
fax: (9I0) 2S1 4(I;?5 ('unlhcrland New Ilanover Scolland
US Fis
I IS Dish ;Ind wildlife Scrvice
Ralcii'h hold ( It li( c
Post (Mice It(", t t7)6
Ralei),h. NC :'76:16 37'6
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It anti Wildlife Service / National N`
IS Fish and Wildlilc Scryicc.
Asllc6llc I-icld Office
1611 /.illicoa Slrccl
Asheville, N(' 28X01
1(1cphone:(8 'X)665-1195
larine Fisheries Service
National Marinc Fisheries Service
I habitat Conservation Division
Pivers Island
Hcaulort, NC ?X516
'I clephone: [phone]
North Carolina State Agencies
Division of WaIrl ()utility
401 Wcll,nlds [;fill
1650 Mail ticI ice('( nlcr
Ralel('ll, N(' '.7609 16511
I cleplwlw (91 O) 7-t t-1 7X6
ax: (()19) 7 11;
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Division of Water Quality
Wetlands Rcsloration Progrurl
1619 Mail Service Center
Ralcwh, N(` '769(1-1619
fclcphonc: (919) 73.1 S'118
-ax: (91''«.'3i-5311
State Historic Preservation Office
Department 01'Cultural Resources
4617 Mail Service Center
Raleigh, NC 27699-4617
1 clephone: [phone]
Fax: [phone]
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Weston I'icflnnnlt Region C(x,nlinatol
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KerneNviliv. NC 17194 "M M)
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