20011852 Ver 1_Complete File_20011218

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Michael F. Easley
Governor
William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D.
Acting Director
Division of Water Quality
DWQ Project No.: \ \ g s Z, County: o w c.
Applicant: N c %s cN =
Project Name: -
Date of Issuance of 401 Water Quality Certification: i I
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer
Rules, and any subsequent modifications, the applicant is required to return this certificate to the
401/Wetlands Unit, North Carolina Division of Water Quality, 1650 Mail Service Center, Raleigh, NC,
27699-1650. This form may be returned to D.WQ by..the applicant, the applicant's authorized ageizt, or the
project engineer. It is not necessary to send certificates from all of these.
Applicant's Certification
I,- Cc-sGC" ?er1G y? , hereby state that, to the best of my abilities, due care and
diligence was used in the observation of the construction such that the construction was observed to be built
within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the
approved plan-Wd specific ions, and other supporting materials.
Cionafi?ra• f _ben. r _ , ?n?(_ .. Th*o• /? - 7 9.. ? ?
Agent's Certification
hereby state that, to the best of my abilities, due care and
diligence,was used in the observation of the construction such that the construction was observed to be,built
within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the
approved plans and specifications, and other supporting materials.
Signature: Date:
If this project was designed by a Certified Professional
I, , as a duly registered Professional (i.e., Engineer,
Landscape Architect, Surveyor, etc.) in the State of North Carolina, having been authorized to observe
(periodically, weekly, full time) the construction of the project, for the Permitee hereby state that, to the.
best of my abilities, due care and diligence was used in the observation of the construction such that the
construction was observed to be built within substantial compliance and intent of the 401 Water Quality
Certification and Buffer Rules, the approved plans and specifications, and other supporting materials.
Signature Registration No. Date
WETLANDS/ 401 GROUP
JAN 0 5 2004
WATER QUALITY SECTION
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Div. 9 Engineers Office
Division of Water Quality 1650 Mail Service Center Raleigh, NC 27699-1650
Wetlands/401 Unit: [phone]
Fax: [phone]

©?O? W AT ?RQG
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Michael F. Easley
Governor
William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D.
Acting Director
Division of Water Quality
DWQ Project No.: 01 18 S 1 - County: R D w& n
Applicant: IV C 00'T
Project Name: I&r 0 11067
Date of Issuance of 401 W ter Quality Certification: _
0
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer
Rules, and any subsequent modifications, the applicant is required to return this certificate to the
401/Wetlands Unit, North Carolina Division of Water Quality, 1650 Mail Service Center, Raleigh, NC,
27699-1650.. This form may be returned to D:WQ by. the applicant, ,thc applicant's authorized agent, or the
project engineer. It is not necessary to send certificates from all of these.
Applicant's Certification
I, _?7oitG '? l_. - hereby state that, to the best of my abilities, due care and
diligence was used in the observation of the construction such that the construction was observed to be built
within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the
approved plansAnd specifi!gg io and other supporting materials.
hereby state that, to the best of my abilities, due care and
diligence,was used in the observation of the construction such that the construction was observed to be,built
within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the
approved plans and specifications, and other supporting materials.
Signature: Date-
Agent's Certification
If this project was designed by a Certified Professional
as a duly registered Professional (i.e., Engineer,
Landscape Architect, Surveyor, etc.) in the State of North Carolina, having been authorized to observe
(periodically, weekly, full time) the construction of the project, for the Permitee hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the construction such that the
construction was observed to be built within substantial compliance and intent of the 401 Water Quality
Certification.and Buffer Rules, the approved plans and specifications, and other supporting materials.
Signature Registration No. Date
3T l,lf' ' /401 ?Ijj,p
JAP4 2 2004
,w
°^ + La /ji1,?- Div
NR
Division of Water Quality 1650 Mail Service Center Raleigh, NC 27699-1650
Wetlands/401 Unit: [phone]
Fax: [phone]
WAIF Michael F. Easley, Governor
0?0 AQG WilliamG. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
\
co r Gregory J. Thorpe, Ph.D.
Acting Director
p Division of Water Quality
January 1, 2002
Rowan County
DWQ Project No. 011852
Bridge No. 107 on SR 1005
APPROVAL of 401 Water Quality Certification with Additional Conditions
Ms. Diane Hampton, Environmental Officer
NCDOT Division 9
2125 Cloverdale Avenue
Winston-Salem, NC 27055
Dear Ms. Hampton:
You have our approval, in accordance with the attached conditions and those listed below, to impact
130 linear feet of Riles Creek in order to replace Bridge No. 107 on SR 1005 in Rowan County. The
project should be constructed in accordance with your application dated December 6, 2001 (received
December 18, 2001). After reviewing your application, we have decided that this fill is covered by
General Water Quality Certification No. 3289 corresponding to the U.S. Army Corps of Engineers
Nationwide Permit Number 14. In addition, you should acquire any other federal, state or local
permits before you proceed with your project including (but not limited to) Sediment and Erosion
Control, Non-Discharge and Water Supply Watershed regulations. This approval will expire with the
accompanying 404 permit unless otherwise specified in the Water Quality Certification.
This approval is only valid for the purpose and design that you described in your application except as
modified below. If you change your project, you must notify us, in writing, and send us a new
application. If the property is sold, the new owner must be given a copy of this Certification and
approval letter and is thereby responsible for,complying with all conditions. If total wetland fills for
this project (now or in the future) exceed one acre or stream impacts exceed 150 linear feet,
compensatory mitigation may be required asdescribed in 15A NCAC 2H.0506 (h) (6) and (7). For
this approval to be valid, you must follow the conditions listed in the attached certification and any
additional conditions listed below.
1. NCDOT shall adhere to Best Management Practices for the Protection of Surface Waters (March
-1997) and requirements for WS-IV waters: - - - - - -
2. The culvert required for this project shall be installed in such a manner that the original stream
profile is not altered (i.e. the depth of the channel must not be reduced by a widening of the
streambed). Existing stream dimensions are to be maintained above and below the location of
the bridge replacement. The culvert shall be installed one foot below the stream to allow for fish
and other wildlife movement.
3. All work shall be performed during low flow conditions.
4. The presence of equipment in the channels must be minimized. Under no circumstances must
rock, sand or other materials be dredged from the wetted stream channel under authorization of
this permit, except in the immediate vicinity of the culverts.
5. Existing vegetated buffers shall not be mowed in order to utilize it for storm water sheet flow.
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)
919-733-1786 (phone), 919-733-6893 (fax), httpJ/h2o.enr.state.nc.us/ncwetlands/
6. Use of rip-rap for bank stabilization is to be minimized; rather, native vegetation is to be planted
when practical. If necessary, rip-rap must be limited to the stream bank below the high water
mark, and vegetation must be used for stabilization above high water.
7. Rock silt screens at culvert outlets shall be removed at project completion.
Upon completion of the project, the NCDOT shall complete and return the enclosed
"Certificate of Completion" form to notify NCDWQ when all work included in the §401
Certification has been completed. The responsible party shall complete the attached form
and return it to the 401/Wetlands Unit of the NC Division of Water Quality upon
completion of the project.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory
hearing. You must act within 60 days of the date that you receive this letter. To ask for a hearing,
send a written petition that conforms to Chapter 150B of the North Carolina General Statutes to the
Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, N.C. 27699-6714. This
certification and its conditions are final and binding unless you ask for a hearing.
This letter completes the review of the Division of Water Quality under Section 401 of the Clean
Water Act. If you have any questions, please telephone Ms. Cynthia Van Der Wiele at 919.733.5715
or Mr. Pete Colwell of the Mooresville Regional Office at 704.663.1699.
Sincerely,
ry J. Thorpe,.
t' L Director
Attachment .
Pc: Wilmington District Corps of Engineers
Corps of Engineers Raleigh Field Office
NCDWQ Mooresville Regional Office
Central Files .
File Copy
FILE COPY
TO: Mr. Eric Alsmeyer, USACOE
Raleigh Field Office
FROM: Maryellen Haggard, DOT Permit Coordinator
Habitat Conservation Program
DATE: December 20, 2001
SUBJECT: NCDOT bridge replacement of No. 107 on SR 1005 over Riles Creek, Rowan
County
The North Carolina Department of Transportation (NCDOT) is requesting a concurrence
letter from the North Carolina Wildlife Resources Commission (NCWRC) to obtain a 404 permit
from the U.S. Army Corps of Engineers. Biologists on staff with the NCWRC have reviewed
the proposed improvements and are familiar with habitat values of the project area. These
comments are provided in accordance with the provisions of the Fish and Wildlife Coordination
Act (48 Stat. 401, as amended; 16 U.S.C. 661-667d) and the Clean Water Act of 1977 (33 U.S.C.
466 et seq.).
NCDOT proposes to replace the existing bridge with three bottomless reinforced concrete
box culverts 14'x 7'. This action will impact 130 linear feet of Riles Creek. The project will not
impact trout waters. We are pleased that bottomless culverts will be used. We will not object to
the project as proposed provided that the following conditions are implemented:
1. Disturbance of the stream channel must be limited to only what is necessary
to install the culverts. Heavy equipment should be operated from the bank
rather than in the stream channel in order to minimize sedimentation and
reduce the likelihood of introducing other pollutants into the stream.
2. Stream conditions above and below the culvert should be maintained at the
appropriate widths and depths to provide sediment transport and aquatic life
movement. Where disrupted, natural floodplain benching should be restored.
3. Stringent erosion control measures should be installed where soil is disturbed
and maintained until project completion.
4. Temporary or permanent herbaceous vegetation should be planted on all bare soil
within 15 days of ground disturbing activities to provide long-term erosion control.
We encourage NCDOT to uttlift orisite-4e&tation and materials for streambank
stabilization, to minimize the :use of r'iprap (or hard stabilization methods) and to
maximize the use of native vegetation for stabilization and shade.
5. Work must be accomplished so that wet concrete does not contact stream
water.
Thank you for the opportunity to review and comment on this project during the early
planning stages. If you have any questions regarding these comments, please contact me at (336)
527-1549.
cc: Cynthia Van Der Wiele, NCDWQ
Diane Hampton, NCDOT
FILE COPY 011852
STATE of NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY LYNDO TIPPET
GovERNOR SECRETARY
December 6, 2001
SUBJECT: Rowan County - SR 1005 Bridge 107 Richfield Road 40, }
Mr. John Dorney
NC Division of Water Quality
4401 Reedy Creek
Raleigh, NC 27607
Dear Mr. Dorney,
In an effort to obtain the necessary permits for the subject bridge replacement, we are providing a
pre-construction notification application with supporting documentation and $200.00 fee for the
replacement of bridge number 107 in Rowan County. There are no wetlands to be impacted and there will
be 130 feet of stream impacts. There were no endangered species present during a field inspection
conducted on December 6, 2001. We propose to replace the old timber and steel girder bridge with three
reinforced concrete box culverts with no bottoms using the natural channel for the bottom at the same
location. We believe this project can be accomplished under nationwide permit numbers 14 and 33.
By copy of this letter, we are also seeking approval from the State Historic Preservation Office, the
Corps of Engineers, the Fish and Wildlife Service and the NC Wildlife Resources Commission. Therefore,
we are submitting the enclosed material to them.
If you have any questions, comments or need additional information after reviewing this material,
please contact me at [phone]. Thank you for your cooperation in this matter.
Respectfully, Q
Diane K Hampton, P.E.
Division Environmental Engineer
Enclosures
CF: Mr. Pat Ivey, P.E., Division Engineer Pry YMFNT
Mr. George Teague, Bridge Maintenance Superintendent RECEIVED
File I
Division of Highways • Division Nine • 2125 Cloverdale Avenue, Winston-Salem, NC 27103
Telephone [phone] • Fax [phone] • Courier Box 13-12-04
h
Office Use Only: Form Version April 2001
USACE Action ID No. DWQ No.
any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
iving the space blank.
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: NW-14, NW-33
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: ?
Applicant Information
1. Owner/Applicant Information
Name: NC Department of Transportation - Division 9
Mailing Address: 2125 Cloverdale Ave.
Winston-Salem NC 27055
Telephone Number: 336-761-2613 Fax Number: 336-761-2606
E-mail Address:
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: Diane Hampton. PE. DEO
Company Affiliation: NCDOT - Division 9
Mailing Address: 2125 Cloverdale Ave.
Winston-Salem NC 27055
Telephone Number: 336-761-2613 Fax Number: 336-761-2606
E-mail Address: [e-mail]
PAYMENT
RFM! fry
Page 3 of 12

M. 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 107 - SR 1005 Richfield Road
2. T.I.P. Project Number (NCDOT Only): N/A
3. Property Identification Number (Tax PIN): N/A
4. Location
County: Rowan Nearest Town: Gold Hill
Subdivision name (include phase/lot number): N/A
Directions to site (include road numbers, landmarks, etc.): Take US Hwy 52 south from
Gold Hill approx. 1.5 miles, turn left onto SR 2356, go approx. 4.0 miles, turn right onto SR
1004, go 0.2 miles, turn right onto SR 1005 Richfield Road, go approx. 1.0 mile to bridge.
5. Site coordinates, if available (UTM or Lat/Long): 35030'12"N 80015'11"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:
Rural bridge site
7. Property size (acres): N/A
8. Nearest body of water (stream/river/sound/ocean/lake): Riles Creek
9. River Basin: Yadkin
(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/.)

Page 4 of 12

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10. Describe the purpose of the proposed work: to replace old bridge with new on same
location. using three reinforced concrete bottomless box culverts 14' by 7'.
11. List the type of equipment to be used to construct the project: standard bridge construction
equipment including a trackhoe
12. Describe the land use in the vicinity of this project: rural / agricultural
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.
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
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
Page 5 of 12

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
Wetland Impact
Site Number
indicate on ma)
Type of Impact* Area of
Impact
(acres Located within
100 year Floodplain**
es/no) Distance to
Nearest Stream
linear feet)
Type of Wetland***
N/A

List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/dramage, 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 httv://www.fema.aov.
*** 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: none
Total area of wetland impact proposed: none
2. Stream Impacts, including all intermittent and perennial streams
Stream Impact
Site Number
(indicate on ma)
Type of Impact* Length of
Impact
ear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
lease specify)
I Bottomless Culvert 130 Riles Creek 25 Perennial

List each impact separately and identify temporary impacts. Impacts include, but are not limit to: culverts and associated rilmap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gam),
stabilization activities (cement wall, rip-rap, crib wail, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included
' Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usas.gov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.tgpozone.com,
)&ww.rnWNuest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: 130 feet
Page 6 of 12
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3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U. S.
Open Water Impact
Site Number
indicate on ma)
Type of Impact* Area of
Impact
(acres) Name of Waterbody
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.
N/A

* List each impact separately and identify temporary impacts. Impacts include, but are not lumted to: nu, excavation, creagmg,
flooding, drainage, bulkheads, etc.
4. Pond Creation N/A
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
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:-
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
The bridge is aging and may become unsafe in the near future for the travelling public. The
NCDOT proposes to install three RCBC's on footings which will have no bottoms. The natural
channel will be the bottom This alternative is much more cost effective than a bridge supported
on piles It also is the most environmentally friendly method of box culvert usage. These
culverts will insure the passage of fish and other aquatic organisms All efforts to insure erosion
control and to minimize the placement of rip rap will be made Natural materials will be used to
stabilize the banks where possible Construction will be completed in a timely fashion to not
upset the natural and human community.
Page 7 of 12

VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.us/ncwetlands/strmgide.html.
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.
N/A
Page 8 of 12
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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
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 http•//h2o enr state.nc.us/wrp/index.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
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 N
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 Butlers (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.
Page 9 of 12
1
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No ® If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
,?
Zone Impact
(square feet
Multiplier Required
Mitigation
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
XL
XH.
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.
Stormwater (DWQ Only)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
N/A
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
XM. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ? No
Page 10 of 12
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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
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 h11p://h2o enr.sWe.nc.us/wrp/index.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
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.
Page 9 of 12
1
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 M If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
*
Zone Impact
(square feet
Multiplier Required
Mitigation
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
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.
XL Stormwater (DWQ Only)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
N/A
XH. 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
XM. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 211.0500) or any Buffer Rules?
Yes ? No
Page 10 of 12

Is this an after-the-fact permit application?
Yes ? No
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
c
Z
Applicant/Agent's Signature Daie
(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
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
Page I I of 12
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