20201627 Ver 1_Shoreline Stabilization_20201209

Submission Form
Pre -Filing Meeting Information
Before submitting this form please ensure you have submitted the Pre -Filing Meeting Request Form as we will not be able
to accept your application without this important first step. The Pre -Filing Meeting Request Form is used in accordance
with 40 C.F.R. Section 121.4(a) "At least 30 days prior to submitting a certification request, the project proponent shall
request a pre -filing meeting with the certifying agency" and in accordance with 40 C.F.R. Section 121.5(b)(7), and (c)(5)
all certification requests shall include documentation that a pre -filing meeting request was submitted to the certifying
authority at least 30 days prior to submitting the certification request. Click here to read more information on when this
form is needed prior to application submission or here to viewthe form.
Attach documentation of Pre -Filing Meeting Request here:
DWR Pre -Filing Meeting Request Form.pdf 51.67KB
Pre -fling Meeting or Request Date 10/28/2020
ID# 20201627 Version 1
I. Applicant Information [15A NCAC 02H .0502(a)]
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
Primary Contact Email * [e-mail]
Rease provide an email address for payrrent and requests for pure information here.
Owner Information:
Name: * Adam Berry
Email: * [e-mail]
Phone Number:* [phone]
(xxx)xxx-xxxx
Mailing Address:* Street Address
110 Shore Mist Ct
Address Line 2
City
State / Frovince / Region
Statesville
NC
Fbstal / Zip Code
Country
28677-2053
US

Is there an agent working on the F Yes
project?* r No
Agent/Consultant Information
Name:*
Randy Jordan
Company Affiliation:*
Lyfe Marine, Inc.
Email:*
[e-mail]
Phone Number:*
[phone]
(XXX)XXX-XXXX
Address:*
Street Address
19109 W. Catawba Ave.
Address Line 2
Suite 200
City
Cornelius
Fbstal / Zip Code
28031
Asigned and dated copy of the Agent Authorization letter:*
Berry_Agent_Auth.pdf 2.03MB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name: * Adam Berry Shoreline
State / Province / Fbgion
NC
Country
United States
If your project has a formal name please use this. If your project does not hake a formal name, please identify your project by
the owner name and proposed activity (Jones Property Access Road, Smith Guest House, etc.) List in parentheses any
other names that have been used to identify the project in the past.
1. Provide a vicinity map (i.e. street map) clearly showing the location of the property with respect
to local landmarks such as towns, rivers, and roads.*
r Upload File
r Lookup address
Property Address Lookup:* Street Address
110 Shore Mist Ct
Address Line 2
City
Statesville
Fbstal / Zip Code
28677-2053
Latitude:* 35.672608
State / Province / Fbgion
NC
Country
US
Longitude:*-80.962088
2. Provide a detailed site plan showing property boundaries and proposed locations of vegetation clearing,
structures (buildings, retaining walls, docks, impervious surfaces, etc.), rip rap, excavation or dredging
below Full Pond/ Normal Water Level elevations, and construction access corridors. You may use the
diagram under section 12.normal pool lake level/normal water level*
Adam Berry Shoreline Diagram.pdf 281.13KB

Please use the diagram at the link below:
https://edocs.deq.nc.gov/WaterResources/0/edoc/616616/Shoreline%2OLayout.docx
3. Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale of some sort- a
yard stick, shovel handle, etc.)*
Adam Berry photol.jpg
6.13MB
Adam Berry photo2. jpg
6.1 MB
Adam Berry photo3.jpg
5.19MB
Adam Berry photo 4.jpg
5.78MB
4. Location of the property (where work is to be conducted)
Nearest Town:* Statesville
County:* Iredell
Lake/ river/ ocean adjacent to Norman
property:
Subdivisions name or site address:* 110 Shore Mist Ct. Statesville, NC 28677
Include phase/lot nunber
Directions to site:*
77-N to exit 42. Turn left onto NC-115 to left onto Talley St. to left onto
E. Monbo Rd to right onto Creek Cove Ln. to left onto Shore Mist Ct.
Aease include road narres and nunbers, landmarks etc.
5. Describe the existing land use or condition of the site at the time of this application:*
Residential
Pesidential, undeveloped, etc.
6. Property Size 1.03
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
New shoreline stabilization: shape the bank, install geo-tech fabric and a
layer of Class "B" rip rap (110 lineal ft.)
8. How will the work be done?* I7 From Land
r From Water
9. Total amount of disturbance below the normal pool lake level/ normal water level:*
(including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
660
square feet
10. Total amount of disturbance above the normal pool lake level/ normal water level and 50 feet
land -ward:*
(including all clearing, backfill, excavation, rip rap, retaining walls, etc.)
110
square feet
11. Please describe the vegetation above the normal pool lake level/ normal water level and 50 feet
landward to be impacted:*
(number of trees, for instance)
Grassy yard, dirt bank

Sketch: Adam Berry Shoreline Diagram.pdf 281.13KB
Application Fee:
Once the application has been accepted. You will need to send a corresponding fee in with the appropriate DWR#. The
application fee is as follows (pursuant to G.S. 143-215.3D):
0 $240.00 for impacts to lake (below normal water level) of less than 1 acre
0 $570.00 for impacts to lake (below normal water level) of greater or equal to 1 acre
By digitally signing below, I certify that:
o I, the project proponent, hereby certifies that all information contained herein is true, accurate, and complete to the
best of my knowledge and belief
o I, the project proponent, hereby requests that the certifying authority review and take action on this CWA 401
certification request within the applicable reasonable period of time.
o I agree that submission of this Shoreline Stabilization online form is a "transaction" subject to Chapter 66, Article 40 of
the NC General Statutes (the "Uniform Electronic Transactions Act');
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
0 1 understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the Shoreline Stabilization online form.
Full Name:* Randy Jordan
Signature:
1?a14d1,T0I b1014

Initial Review
Is this accepted into the review
process?*
Project Number:* 20201627
Select Reviewer:*
Select Reviewing Office
Has payment been received?*
What amount is owed?*
rYes allo
Version:* 1
Alan Johnsomeads\adjohnsonl
Mooresville Regional Office - [phone]
r No Payment Needed
r Fee Received
r Need Fee - send electronic notification
r $240.00
f $570.00

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO: 29 PLAN NO:
STREET ADDRESS:
110 Shore Mist Ct.
Statesville, NC 28677
Please print:
Property Owner: Adam Berry �1
Property Owner: &t, 5O �j
PARCEL ID: 4710753404.000
The undersigned, registered property owners of the above noted property, do herebyauthorize
_Randy Jordan , of
(Contractor/Agent)
Lyfe Marine, Inc.
(Name of consulting 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 attached.
Property Owners Address (if different than property above):
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate tothe
best of our knowledge.
Authorized S' natur
9 z(D
Date
Authorized Signature
Date

Lake
(At Full Pond/Normal Water Level)
Normz
SI
Please approximately sketch the following information on this plan, length of shoreline
(provide dimensions for each item, such as 10 ft x 100 ft)*:
1. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
3. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
4. Location of any proposed structures such as buildings, retaining walls, docks, etc.
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors
FORM: 55GP 10-2013 Page 3 of 3

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,

Lake
(At Full Pond/Normal Water Level)
Normz
SI
Please approximately sketch the following information on this plan, length of shoreline
(provide dimensions for each item, such as 10 ft x 100 ft)*:
1. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
3. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
4. Location of any proposed structures such as buildings, retaining walls, docks, etc.
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors
FORM: 55GP 10-2013 Page 3 of 3

DWR Pre-Fil ing Meeting Req u est Form
ID#*Ve rsion *
Re gional Office *
Re v ie we r List *
Contact Name *
Contact Email Addre ss *
Proje ct Name *
Proje ct Owne r *
Proje ct County *
Owne r Addre ss:
Is this a transportation proje ct?*
Type (s) of approv al sought from the DWR:
Doe s this proje ct hav e an e xisting proje ct ID#?*
Do you know the name of the staff me mbe r you would like to re que st a me e ting with?
Ple ase giv e a brie f proje ct de scription be low.*
Please give a couple of dates you are available for a meeting.
20201627 1
Mooresville Regional Office - [phone]
Alan Johnson
Pre-Filing Me eting Reque st submitte d 10/28/2020
Randy Jordan
[e-mail]
Adam Berry Shoreline
Adam Berry
Iredell
City
Statesville
State / Province / Region
NC
Postal / Zip Code
28677
Country
United States
Street Address
110 Shoremist Court
Address Line 2
Suite 200
Yes No
401 Water Quality Certification -
Regular
401 Water Quality Certification -
Express
Individual Permit Modification
Shoreline Stabilization
Yes No
Alan Johnson
New shoreline stabilization for approximate 110 lineal feet. Installing Class
"B" Rip Rap; shaping the bank; install Geo-tech fabric.
Ple ase attach the docume ntation you would like to hav e the me e ting about.
Signature
Submittal Date
11/4/2020
pdf only
By digitally signing below, I certify that I have read and understood that per the Federal Clean Water Act Section
401 Certification Rule the following statements:

· This form completes the requirement of the Pre-Filing Meeting Request in the Clean Water Act Section 401 Certification
Rule.
· I understand by signing this form that I cannot submit my application until 30 calendar days after this pre-filing
meeting request.
· I also understand that DWR is not required to respond or grant the meeting request.

Your project’s thirty-day clock started upon receipt of this application.  You will receive notification regarding meeting location
and time if a meeting is necessary.  You will receive notification when the thirty-day clock has expired, and you can submit an
application.
10/28/2020