20100083 Ver 1_401 Application_20100310

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Corps action ID no.
° DWQ project no.
Form Version 1.4 January 2009
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1a. Type(s) of approval sought from the Corps: ? Section 404 Permit Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: or General Permit (GP) number: `i '"J
1 c. Has the NWP or GP number been verified by the Corps? E Yes ? No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
? 401 Water Quality Certification - Regular ? Non-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express ? Riparian Buffer Authorization
le. Is this notification solely for the record
because written approval is not required? For the record only for DWQ
401 Certification:
®'Yes ? No For the record only for Corps Permit:

? Yes Q No
If. Is payment into a mitigation bank or in-lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in-lieu fee program.
? Yes No
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ? Yes Q No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes E] No
2. Project Information W aj4 z - ,W 'a' 2- 110
2a. Name of project: r , ..r We S r R , K P ",W_
2b. County: N ft
2c. Nearest municipality / town: (r r ; o.v q MAR 1
71,
2d. Subdivision name: (J/

2e. NCDOT only, T.I.P. or state project no: DEMIR-WARROM,
MTIAMS AM AM MAW-r
3. Owner Information
3a. Name(s) on Recorded Deed: o v r- -'r I e t'J , I , Q M. 3 F o «?'
3b. Deed Book and Page No. 33
2? 3
3c. Responsible Party (for LLC if
applicable):
L
3d. Street address: [/ o Z S .. d v e e s e
3e. City, state, zip: CAP r a e v V 14 : - 3 -3
?-
3f. Telephone no.: S ''7 - YOU _ 5-
3g. Fax no.:
3h. Email address: C a r -e w ?vt f e Cox , A.) N-e-
Page 1 of 10
PCN Form - Version 1.4 January 2009
4. Applicant Information (if different from owner)
4a. Applicant is: ? Agent ? Other, specify:
4b. Name: L o f b ,? 7
4c. Business name
(if applicable):
4d. Street address: 3 a •? K s R o f
4e. City, state, zip: IV C- a 8 5r3 a
4f. Telephone no.: ?-S r ?- 3 i C f' S a o J 3 S y
4g. Fax no.:
4h. Email address: J LA 4,e 5® _ b r t r i 2 C r
5. AgentlConsultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 10
B. Project Information and Prior Project History
1. Property Identification
la. Property identification no. (tax PIN or parcel ID):
1b. Site coordinates (in decimal degrees): Latitude: ? , - Longitude:
1c. Property size: -, acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
2b. Water Quality Classification of nearest receiving water:
2c. River basin: ! ..
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
3b. List the total estimated acreage of all existing wetlands on the property: -,
r
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3d. Explain the purpose of the proposed project:
,
3e. Describe the overall project in detail, including the type of equipment to be used:
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
ro'ect (including all prior phases) in the past? ®''Yes ? No ? Unknown
Comments:
4b. If the Corps made the jurisdictional determination, what type
of determination was made?
? Preliminary Q Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known): Agency/Consultant Company:
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
"
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past? Byes ? No ? Unknown
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project? ? Yes ? No
6b. If yes, explain.
Page 3 of 10
PCN Form - Version 1.4 January 2009
C. Proposed Impacts Inventory
1. Impacts Summary
1a. Which sections were completed below for your project (check all that apply):
? Wetlands ? Streams - tributaries ?'Buffers ? Open waters ? Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
Wetland impact
number
Permanent (P) or
Temporary 2b.
Type of impact 2c.
Type of wetland 2d.
Forested 2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other) 2f.
Area of
impact
(acres)
W1 - Choose one Choose one Yes/No -
W2 - Choose one Choose one Yes/No -
W3 - Choose one Ch se one Yes/No -
W4 - Choose one Chfoo a ne Yes/No -
W5 - Choose one Choose one Yes/No -
W6 - Choose one Choose one Yes/No -
2g. Total Wetland Impacts:
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a.
Stream impact
number
Permanent (P) or
Temporary m 3b.
Type of impact 3c.
Stream name 3d.
Perennial (PER) or
intermittent (INT)? 3e.
Type of
jurisdiction 3f.
Average
stream
width

(feet) 3g.
Impact
length
(linear

feet)
S1 - Choose one
S2 - Choose one _
S3 - Choose one
S4 - Choose one }
S5 - Choose one
S6 - Choose one
3h. Total stream and tributary impacts
3i. Comments:
Page 4 of 10
PCN Form - Version 1.4 January 2009
4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individual) list all open water impacts below.
4a. 4b. 4c. 4d. 4e.
Open water Name of waterbody
impact number (if applicable) Type of impact Waterbody Area of impact (acres)
Permanent (P) or type
Temporary
01 - Choose one Choose
02 - Choose one Choose
03 - Choose one Choose
04 - Choose one Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed, then complete the chart below.
5a. 5b. 5c. 5d. 5e.
Pond ID number Proposed use or Wetland Impacts (acres) Stream Impacts (feet) Upland
purpose of pond
(acres)
Flooded Filled Excavated Flooded Filled Excavated
P1 Choose one
P2 Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard pe it uire?r ; ? Yes ? No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWO)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If an impacts require mitigation, then you MUST fill out Section D of this form.
6a. Project is in which protected basin?
1
[:14euse ?Tar-Pamlico ? Catawba ? Randleman ? Other:
6b. 6c. 6d. 6e. 6f. 6g.
Buffer Impact Reason for impact Stream name Buffer Zone 1 Zone 2
number - mitigation impact impact
Permanent (P) or required? (square (square
Temporary feet feet
B1 - Lti• . ?.??,.,r,?

B2 - .? _
i t L
Yesl?lo'>
/
B3 - Yes/No
64 - Yes/No
B5 - Yes/No
B6 -
Yes/No
6h. Total Buffer Impacts:
6i. Comments:
Nage 5 of l u
D. Impact Justification and Mitigation
1. Avoidance and Minimization
la. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
71
yr ?"
2. Com nsato Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for ? Yes No
impacts to Waters of the U.S. or Waters of the State? a
12b. If yes, mitigation is required by (check all that apply): I ? DWQ Oros
Mitigation bank ''`? .,, ?1`?
2c. If yes, which mitigation option will be used for this
project? ? Payment to in-lieu fee program
? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
Type: Choose one Quantity:
3b. Credits Purchased (attach receipt and letter) Type: Ch se one Quantity:
Type: Ch,,;sd op?- Quantity:
3c. Comments:
4. Complete if Makin a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: Choose one
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete If Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form - Version 1.4 January 2009
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
b
ff
? Yes [-tvo
u
er mitigation?
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
6c. 6d. 6e.
Zone Reason for impact Total impact Multiplier Required mitigation
(square feet) (square feet)
Zone 1
. /3 2-for Catawba)

Z

one 2 v

.5
T
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
6h. Comments:
Page 7 of 10
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified [J'Yes ? No
within one of the NC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
[:I' es ? No
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? J %
2b. Does this project require a Stormwater Mana ement Plan? ? Yes 13No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
t

2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e. Who will be responsible for the review of the Stormwater Management Plan?

3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
? Phase 11
3b. Which of the following locally-implemented stormwater management programs ? NSW
U P
apply (check all that apply): ?
E] Wr Supply Watershed
? Other:
3c. Has the approved Stormwater Management Plan with proof of approval been ? Y Y ? No
attached?
4. DWQ Stormwater Program Review
[]Coastal counties
?HQW
4a. Which of the following state-implemented stormwater management programs apply ORW `
//
(check all that apply): Sessibn Lalw 2006-246
[]Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
? Yes
) ? No
attached? r
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? ? Yes ! ? No

5b. Have all of the 401 Unit submittal requirements been met? eyes ? No
Page 8 of 10
PCN Form - Version 1.4 January 2009
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
la. Does the project involve an expenditure of public (federal/stateAocal) funds or the 0 Yes El No
use of public (federal/state) land?
1b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State ? Yes P No;
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
l
tt
? Y
er.)
e es PNo
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, E]Yes ? No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the-fact permit application? [Yes ? No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):

3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in Yes [-? No
additional development, which could impact nearby downstream water quality?
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
i U,;-k;_
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.

Page 9 of 10
PCN Form - Version 1.4 January 2009
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
h
bi
?
? Yes []'No
a
tat
5b. Have you checked with the USFWS concerning Endangered Species Act
i
? Yes ? No
mpacts?
5c. If yes, indicate the USFWS Field Office you have contacted. -

5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?

6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ? Yes [ No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?

7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
stat
s
N
ti
l Hi ? Yes EJNo
u
(e.g.,
a
ona
storic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
I Li .
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? T -UYes ? No
8b. If yes, explain how project meets FEMA requirements:

8c. What source(s) did you use to make the floodplain determination?

15 1> ?U o

ApplicanVAgent's Printed Name Applicant/ ent's Signature Date
(Agent's signature is valid only if an authorization
letter from the applicant is provided.)
Page 10 of 10
12-19-2008
TO: NC DEPARTMENT OF ENIVIRONMENT AND NATURAL RESOURES
1. THE CLEARING FOR THE SHELTER AND BOAT RAMP STARTED ABOUT
APRIL 15, 2009. I DID NOT GET APPROPRIATE PERMITS OR AUTHORIZATION
BECAUSE I DID NOT KNOW THIS WAS REQUIRED, BECAUSE THE HUNTING
CLUB NEXT TO THIS CLUB HAS ALWAYS CUT TREES OR BUILT PIERS
WHENEVER THEY WANTED TO DO SO.
2. I DID NOT KNOW PERMITS WERE REQUIRED, I THOUGHT THE LAND
OWNERS COULD USE THERE LAND AS THEY WANTED TO.
3. SEE ATTACHED MAP.
I HAVE A MEETING WITH EMILY N. JERNIGAN ON TUESDAY @ 10:00, 12-22-
2009.
4.
A. IF THE NCDENR WILL ALLOW ME, I WILL PLANT SOME TREES AND
PLANT SOME GRASS SEEDS
B. WHEN THE CREEK STOPS FLOODING SO I CAN GET IN THE AREA, I WILL
PHYSICAL ROLL THE CONCRETE INTO A BUCKET SO THE CONCRETE CAN
BE PLACED WITH THE OTHER CONCRETE IN THE PILE..
THE MEETING ON 12-22-2009 IS FOR APPLYING FOR A PERMIT FOR PLACING
THE CONCRETE ON THE SIDES OF THE PATH, HOWERVER THE CONCRETE
WILL BE MOVED AND NOT PLACED ON THE SIDE OF THE PATH UNTIL I
HAVE THE PERMIT IN HAND.
C. I WILL CONTACT ANTHONY SCARBRAUGH WITH NCDENR ON THE
MATTER
D. I WILL CONTACT ANTHONY SCARBRAUGH WITH NCDENR SO I CAN BE
DIRECTED/MANAGED IN GETTING EVERYTHING IN ORDER
5. THE SHELTER HAS BEEN TAKEN, AND AT THE PRESENT TIME THE
SHELTER IS LOCATED ON A TRAILER. THE SHELTER IS GOING TO BE
PLACED ON A HILL.
I PLAN TO GET A 4 WHEEL OLD TYPE FARM TRAILER STEEL FRAME ON
WHEELS, I AM GOING TO HAVE STEEL POST WELDED ON THE FRAME, And
THEN I PLAN TO HAVE A FRAME BUILT FOR A SHELTER THAT THE ROOF
WILL FOLD DOWN. WHEN THE SHELTER IS BUILT, I WILL EMAIL A
PICTURE OF THE SHELTER TO THE DIVISION OF WATER QUALITY,
BECAUSE I KNOW THE DIVISION OF WATER QUALITY WILL GET A PHONE
CALL INFORMING YOU THAT I HAVE ANOTHER SHELTER HAS BEEN BUILT.
I WILL NOT LEAVE THE SHELTER ON WHEELS AT THE CREEK BECAUSE I
FEEL SOMEONE WILL ROLL THE SHELTER IN THE CREEK. I HAVE ALREADY
HAD SOME PROPERTY DAMAGE AT THE HUNTING CLUB.
I THOUGHT ABOUT PUTTING A SIGN ON THE SITE, SAYING, DO NOT CUT
ANY TREES. BUT THIS WOULD ENCOURAGE SOMEONE TO CUT THE TREES,
JUST TO CAUSE PROBLEMS.
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