20100973 Ver 1_401 Application_20101110

North Carolina Secretary of State
x
CORPORATIONS
North Carolina
Elaine F. Marshall DEPARTMENT of THE
Secretary SECRETARY OF STATE
PO Box 29622 Raleigh, NC 27626-0622 [phone]
Date: 8/3112010
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Names
Page 1 of 1
Name Name Type
NC AMELIA PROPERTIES, LLC LEGAL
Li [rifted Liability Company Information
SOSID:
Status:
Effective Date:
Dissolution Date:
Annual Report Due Date:
Citizenship:
State of Inc.:
Duration:
ered Agent
1080167
Current-Active
1/22/2009
DOMESTIC
NC
PERPETUAL
Agent Name:
Office Address:
ONLINE ORDERS HICKORY NC 28601
tart An Order
New Payment Procedures Mailing Address: 1642 6TH ST. DR. NW
- HICKORY NC 28601
CONTACT US incipal Office
C
I orporations Division
Office Address: NO ADDRESS
TOOLS.
ry of State Home
ry of State Site Map
e Page
Mailing Address:
CATHEY, AMELIA S.
1642 5TH ST. DR. NW
NO ADDRESS
http://www.secretary.state.nc.us/corporations/Corp.aspx?PitemId=9039982 8/31/2010
2 0 1 0 0 9 7 3
July 7, 2010
US Army Corps of Engineers
Asheville Regulatory Field Office
151 Patton Avenue
Room 208
Asheville, North Carolina 28801-5006
Name:
Address: A•4,?? ?
PIN:
Telephone: X28 3112, - 005to To Whom It May Concern:

Please accept this letter as an authorization for Blue Ridge Environmental
Consultants PA and its employees to be signatory agents in all matters related to
404/401 permitting applications.
Thank You,
7?? e / Gt 4Z)10 r 7?7 p 5 ?-
20100973
o?oF warF,?oG
O T
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 ?? Py
1. Processing
1 a. Type(s) of approval sought from the
Corps: T Section 404 Permit ? Section 10 Permit
IM
ib. Specify Nationwide Permit (NWP) number: 39 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):
X 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 X No For the record only for Corps Permit:

? Yes )C 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 X No
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ? Yes X No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes X No
2. Project Information
2a. Name of project: Amelia Properties Site- Fast Food Project
2b. County: Ashe
2c. Nearest municipality / town: West Jefferson
2d. Subdivision name: N/A
2e. NCDOT only, T.I.P. or state
project no: N/A
3. Owner Information Al
3a. Name(s) on Recorded Deed: Amelia Properties LLC
3b. Deed Book and Page No. 394/0019
3c. Responsible Party (for LLC if
applicable): O
3d. Street address: 1642 5" St Dr. NW
3e. City, state, zip: Hickory, NC 28601
3f. Telephone no.: NA
3g. Fax no.: N/A
3h. Email address: N/A
Page I of-1-0
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: Derek Goddard
5b. Business name
(if applicable): Blue Ridge Environmental Consultants, P.A.
5c. Street address: 467 Calloway Gap Rd.
5d. City, state, zip: - West Jefferson, NC 28694
5e. Telephone no.: 828-964-9349
5f. Fax no.: N/A
5g. Email address: [e-mail]
Page 2 of 10
B. Project Information and Prior Project History
1. Property Identification
1 a. Property identification no. (tax PIN or parcel ID): z z --- 3s,
1 b. Site coordinates (in decimal degrees): Latitude: 36.382185 Longitude: - 81.486742
(DD.DDDDDD) (-DD.DDDDDD)
1 c. Property size: .893 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project: UT to Beaver Creek
2b. Water Quality Classification of nearest receiving water: C+ TR
2c. River basin: New 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:
Commercial Lot
3b. List the total estimated acreage of all existing wetlands on the property:
0 acres
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
486 ft
3d. Explain the purpose of the proposed project:
To provide for onsite development of a fast food development and required parking
3e. Describe the overall project in detail, including the type of equipment to be used:
The project seeks to install a 36" CCP in 145' of stream channel. The pipe will be buried 20% to allow for aquatic
passage. A pump around will take place in order to install the pipe in the dry.
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?
Comments:
M Yes X No ? Unknown
4b. If the Corps made the jurisdictional determination, what type
of determination was made? El Preliminary Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known): Unknown 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? El Yes SC 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.
F.
Page-3-of-1-0
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 X 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 T
? Yes Corps
W1 P T No ? DWQ
W2 ? P ? T ? Yes
? No ? Corps
? DWQ
W3 ? P ? T ? Yes
? No ? Corps
? DWQ
W4 ? P ? T ? Yes
? No ? Corps
? DWQ
W5 ? P ? T ? Yes
? No ? Corps
? DWQ
W6 ? P ? T ? Yes
? No ? Corps
? DWQ
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. 3b. 3c. 3d. 3e. 3f. 3g•
Stream impact Type of impact Stream name Perennial Type of jurisdiction Average Impact
number - (PER) or (Corps - 404, 10 stream length
Permanent (P) or intermittent DWQ - non-404, width (linear
feet)
Temporary (T) (INT)? other) (feet)

S1 P
X 171 T Culvert UT to Beaver

Creek PER

? INT Corps

DWQ
2
145
S2 P ? T PER
? INT Corps
DWQ
? PER ? Corps
S3 ? P ? T ? INT ? DWQ
? PER ? Corps
S4 ? P ? T ? INT ? DWQ
? PER ? Corps
S5 ? P ? T ? INT ? DWO
? PER ? Corps
S6 ? P ? T ? INT ? DWQ
3h. Total stream and tributary impacts 145 .
3i. Comments:
Page 1 of-4-0
PCN Form - Version 1.3 December 10, 2008 Version
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 type Area of impact (acres)
Permanent (P) or
Temporary
01 ?P?T
02 ?P?T
03 ?P?T
04 ?P?T
4f. 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.
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID Proposed use or purpose (acres)
number of pond
Flooded Filled Excavated Flooded Filled Excavated Flooded
P1
P2
5f. Total
5g. Comments:
5h. Is a dam high hazard permit required?
? 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 ou MUST fill out Section D of this form.
6a.
? Neuse ? Tar-Pamlico ? Other:
Project is in which protected basin? NA ? Catawba ? Randleman
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number - Reason Buffer Zone 1 impact Zone 2 impact
Permanent (P) or for Stream name mitigation (square feet) (square feet)
Temporary impact required?
Bi ?P?T ?Yes
? No
B2 ? P ? T ? Yes
? No
B3 ? P ? T ? Yes
? No
6h. Total buffer impacts
61, Comments:
Page 5 of 10
D. Impact Justification and Mitigation
1. Avoidance and Minimization
ia. Specifically describe measures taken to avoid or minimize the proposed Impacts In designing project.
This property lies within the commercial district of the town of West Jefferson and along a designated future growth and
development area. To achieve the desired and required parking areas for this track to be developed the property owner
must culvert the stream channel. Alternative, such as relocation are not feasible because of the site topography.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Stringent erosion control standards for sensitive water sheds will be adhered too. Work will be conducted from top of the
bank whenever possible. The installation of the pipe will utilize a pump around procedure to work in the dry. Additionally
the non-impacted stream has no riparian buffer. The owner will plant a riparian buffer of 25' on both sites of the channel at
a density of 420 stems per acre.
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 X 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.
F?age-ti-OH-U
PCN Form - Version 1.3 December 10, 2008 Version
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by DWO
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation? ? Yes X No
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.

Zone 6c.
Reason for impact 6d.
Total impact
(square feet)
Multiplier 6e.
Required mitigation
(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
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 ? Yes X 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.
? Yes ? No
Comments:
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? 0 %
2b. Does this project require a Stormwater Management Plan? ? Yes No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why: Project is in forested, rural setting. All
stormwater is diffuse flow over vegetated surfaces.
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
? Certified Local Government
2e. Who will be responsible for the review of the Stormwater Management Plan? ? DWQ Stormwater Program
? DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
? Phase II
? NSW
3b. Which of the following locally-implemented stormwater management programs ? USMP
apply (check all that apply): ? Water Supply Watershed
? Other:
3c. Has the approved Stormwater Management Plan with proof of approval been ? Yes ? 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): ? Session Law 2006-246
? Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
? Yes ? No
attached?
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? ? Yes ? No
Pag-C-8-of t
PCN Form - Version 1.3 December 10, 2008 Version
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the El Yes ® No
use of public (federal/state) land?
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)?
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
? Yes ® No
letter.)
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 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.
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.
N/A
Page-9 v -
PCN Form - Version 1.3 December 10, 2008 Version
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or Yes ® No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act ® Yes ? No
impacts?
®
Raleigh
5c. If yes, indicate the USFWS Field Office you have contacted. ® Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
http://www.ncnhp.org - http://www.saw.usace.army.mil/WETLAND/esa - http://www.fws.gov/nc-es/es/es.html
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?
http://ocean.floridamarine.org/efh_coralfims/viewer.htm
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 ? Yes ® No
status (e.g., National Historic 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?
http://www.hpo.ncdcr.gov
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: No rise to the flood way will occur.
8c. What source(s) did you use to make the floodplain determination? http://www.ncfloodmaps.com
Derek Goddard 7/21/2010
Applicant/Agent's Printed Name Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant
Is provided.)
Page 10 of 10

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