20100472 Ver 1_More Info Received_20100624

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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification PCN Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the
Corps:
®Section 404 Permit El Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: NWP39 or General Permit (GP) number:
1 c. Has the NWP or GP number been verified by the Corps? ? Yes ® No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
? 401 Water Quality Certification - Regular ® Non-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express ? Riparian Buffer Authorization
1 e. Is this notification solely for the record
because written approval is not required? For the record only for DWQ 401
Certification:
? Yes ? No For the record only for Corps Permit:

® Yes ? No
1f. Is payment into a mitigation bank or in-lieu fee program proposed for mitigation
of impacts? If so, attach the acceptance letter from mitigation bank or in-lieu
fee program. ? Yes ® No
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ? Yes ® No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes ® No
2. Project Information
2a. Name of project: MEDFORD
2b. County: BURKE
2c. Nearest municipality / town: MORGANTON
2d. Subdivision name: N/A D
2e. NCDOT only, T.I.P. or state
project no:
3. Owner Information 10
3a. Name(s) on Recorded Deed: CHARLES JOHN MEDFORD UNDSAN D 11!aiEROUAUTy
3b. Deed Book and Page No. 1895/547-550
3c. Responsible Party (for LLC if
applicable): CHARLES JOHN MEDFORD
3d. Street address: 809 ZELINE AVE., NE
3e. City, state, zip: VALDESE, NC 28690
3f. Telephone no.: [phone]
3g. Fax no.:
3h. Email address:
Page I of 10
PCN Form - Version 1.3 December 10, 2008 Version
4. Applicant Information (if different from owner)
4a. Applicant is: ? Agent ? Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name: RANDY HEFNER
5b. Business name
(if applicable): CLAYTON HOMES
5c. Street address: 1230 CONOVER BLVD
5d. City, state, zip: CONOVER, NC 28613
5e. Telephone no.: [phone]
5f. Fax no.: [phone]
5g. Email address: R081 @clayton.net
Page 2 of 10
PCN Form - Version 1.3 December 10, 2008 Version
B. Project Information and Prior Project History
1. Property Identification
1 a. Property identification no. (tax PIN or parcel ID): 1791-19-0869
1 b. Site coordinates (in decimal degrees): Latitude: 46•x'1.94 )N Longitude: ?jj -tFg, 3'J
(DD.DDDDDD) (-DD.DDDDDD)
1 c. Property size: 36.22 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project: Tributary of Bailey Fork
2b. Water Quality Classification of nearest receiving water. WS-IV
2c. River basin: Catawba River
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:
Wooded area with single family lots
3b. List the total estimated acreage of all existing wetlands on the property:
N/A
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
2,700 Ift
3d. Explain the purpose of the proposed project:
Install culvert for private drive access to home site
3e. Describe the overall project in detail, including the type of equipment to be used:
Stream crossing for private drive. Backhoe, bulldozer, and dump truck
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past? ? Yes ? No ®Unknown
Comments:
4b. If the Corps made the jurisdictional determination, what type
of determination was made? ? Preliminary ? Final
4c. If yes, who delineated the jurisdictional areas? Agency/Consultant Company:
Name (if known): 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? Yes ? No ®Unknown
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
Isthiss phased project?? Yes No
F
plain.
Page 3 of 10
PCN Form - Version 1.3 December 10, 2008 Version
C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
? Wetlands ® Streams - tributaries ? Buffers
? Open Waters ? Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a. 2b_ 2c. 2d. 2e. 2f.
Wetland impact Type of jurisdiction
number - Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ - non-404, other) (acres)
Temporary
El W1 ? P ? T Yes [I Corps
? No ?DWQ
W2 ? P ? T ? Yes ? Corps
? No ? DWQ
W3 ? P ? T ? Yes ? Corps
? No ? DWQ
W4 ? P ? T ? Yes ? Corps
? No ? DWQ
W5 ? P ? T ? Yes ? Corps
? No ? DWQ
W6 ? P ? T ? Yes ? Corps
No
[I ?DWQ
2
T
t
l
l
g.
o
a
wet
and impacts
2h
C
.
omments:
3
Stre
I
.
am
mpacts
If there are perennial or intermittent stream impacts (including
question for all stream sites impacted. temporary impacts) proposed on the site, then complete this
3a 3b
.
Stream impact
number - .
Type of impact 3c.
Stream name 3d.
Perennial 3e.
Type of jurisdiction 3f.
Average 3g.
Impact
(C (PER) or
intermittent orps - 404, 10 stream length
Temporary (T)
(INT)? DWQ - non-404, width (linear
other) (feet) feet)
S1 ? P ? T Crossing Tributary ® PER ® Corps
'
? INT ® DWQ 2.5 25'

S2 ? P ? T ? PER
? INT ? Corps
? DWQ
S3 ? P ? T ? PER
? INT ? Corps
? DWQ
S4 ? P ? T ? PER
? INT ? Corps
? DWQ
S5 ? P ? T ? PER
? INT ? Corps
? DWQ

S6 ? P ? T ? PER
? INT ? Corps
? DWQ
3h
Total
t
.
s
ream and tributary impacts
'

3i. Comments: 25
Page 4 of 10
PCN Form - Version 1.3 December 10, 2008 Version
4. Open Wager Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individually list all open water impacts below.
4a.
Open water 4b.
Name of waterbody 4c. 4d. 4e.
impact number -
Permanent (P) or (if applicable) Type of impact Waterbody type Area of impact (acres)
Temporary
01 ?P?T
02 ?P?T
03 ?P?T
04 ?P?T
411 Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If and or lake construction proposed, then complete the chart below.
5a 5b
. . 5c. 5d. 5e.
Pond ID
Proposed use or purpose Wetland Impacts (acres) Stream Impacts (feet) Upland

number
of
ond (acres)
p

IlA Flooded Filled Excavated Flooded Filled Excavated Flooded
P2
5f. Total
5g. Comments:
5h. Is a dam high hazard permit required?
? Yes ? No If yes, permit ID no:
xpected pond surface area (acres):
ze of pond watershed (acres):
r
k.
ethod of construction:
. uffer Impacts ( for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If an impacts require mitigation, then you MUST fill out Section D of this form.
6a.

Project is in which

protected

basin?
? Neuse ? Tar-Pamlico ? Other:
? Catawba ? Randleman
6b. 6c 6d

Buffer impact
number -
Permanent (P) or
TeMporary (T) .

Reason
for
impact .

Stream name
6e.
Buffer
mitigation
required?
6f.
Zone 1 impact
(square feet)
6g
Zone 2 impact
(square feet)

B1 ?P?T ?Yes
? No

B2 ?P?T ?Yes
? No

83 ?P?T ?Yes
? No

6h. Total buffer impacts
6i. Comments:
Page 5 of 10
PCN Form - Version 1.3 December 10, 2008 Version
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1 a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State? ? Yes ? No
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps

2c. If yes, which mitigation option will be used for this
project? ? Mitigation bank

? Payment to in-lieu fee program
? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type Quantity
3c. Comments:
4. Complete If Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: ? warm ? cool ?cold
4d. Buffer mitigation requested (DWQ only): 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 1.3 December 10, 2008 Version
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 ? Yes ? No
buffer 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)
Zone 2 1.5
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
PCN Form - Version 1.3 December 10, 2008 Version
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules? ? Yes No
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
Comments: ? Yes ? No
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? 0.24 acres %
2b. Does this project require a Stormwater Management Plan? ? Yes ® No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why: 1 % impervious proposed for site
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?
3b. Which of the following locally-implemented stormwater management programs
apply (check all that apply):
3c. Has the approved Stormwater Management Plan with proof of approval been
attached?
4. DWQ Stormwater Program Review
4a. Which of the following state-implemented stormwater management programs apply
(check all that apply):
4b. Has the approved Stormwater Management Plan with proof of approval been
attached?
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements?
5b. Have all of the 401 Unit submittal requirements been met?
? Certified Local Government
? DWQ Stormwater Program
? DWQ 401 Unit
? Phase 11
? NSW
? USMP
? Water Supply Watershed
? Other.
? Yes ? No
? Coastal counties
? HQW
? ORW
? Session Law 2006-246
? Other:
? Yes ? No

? Yes ? No
? Yes ? No
Page 8 of 10
PCN Form - Version 1.3 December 10, 2008 Version
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
la. Does the project involve an expenditure of public (federal/state/local) funds or the
use of public (federal/state) land? ? Yes No
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State ? Yes ? No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c. If you answered 'yes' to the above, has the document review been finalized by the
State Clearing House? (if so, attach a copy of the NEPA or SEPA final approval
letter.) ? Yes ? No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ? Yes ® No
or Riparian Buffer Rules (15A NCAC 213 .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): Started work
before obtaining permits
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in
additional development, which could impact nearby downstream water quality? ? Yes No
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
Septic field
Page 9 of 10
PCN Form - Version 1.3 December 10, 2008 Version
6. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
habitat?
? Yes No
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts?
? Yes ® No
5c. If yes, indicate the USFWS Field Office you have contacted. ? Raleigh
? Asheville
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
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?

? Yes No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? ? Yes ® No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination? FEMA Map 3710179200)

Randy Hefner
Applicant/Agents Printed Name
pplicant/Agent's Si ature
(Agent's signatu is valid only if an authorization letter from the applicant
is rovided.
Date
Page 10 of 10
PCN Form - Version 1.3 December 10, 2008 Version
AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID:
STREET ADDRESS: 3 `? 3,5 -54-r
Mor 40n 4( ag SS
Please print:
Property Owner:
c- /71-rd
The undersigned, registered property owners of the above noted
/ property, do hereby authorize
ct Lri c? of r-(G
rYle S
(Contractor / Agent) (Name of firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of this
permit or certification and any and all standard and special conditions armed.
Property Owner's Address (if different than property above):
Telephone: A Z S ) 41/- S -,? ?SU
We hereby certify the above information submitted in this application is true and accurate to the best of
our knowledge.
Owners Signature
Date: