20040949 Ver 1_Complete File_20040610

Mr. J.M. Mills, PE
July 27, 2004
DWQ#04-1073
Page 4
DWQ Project No.: 0 y - County
(?- U1 L. =v. c
Applicant: ,V6-e6 )T- b/ yi S / o.J ?-
ProjectName: rfY/2??-tom f2,A rk7'?'/? ????
Date of Issuance of 401 Water Quality Certification: ?6 O `f
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, 1621 Mail Service Center, Raleigh, NC,
27699-1621. This form may be returned to DWQ by the applicant, the applicant's authorized agent, or
the project engineer. It is not necessary to send certificates from all of these.
Applicant's ,Certification` \
I, ) m Y`h? 1 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
I, J?/Lrz y er4-vt./G_? _?_ ,.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.ftid irit8nl o?the 401 Water Quality Certification and Buffer Rules,
the approve specific ions, an oer sLf?orting materials.
Signature: `. Date: r L3 -0
Engineer's ertification
Partial Final
I, , as a duly registered Professional Engineer in the State
of North Carolina, having been authorized to observe (periodically, weekly, full time) the construction of
the project,for the Permittee 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
wAr?9P?
55
May 19, 2005
Guilford County
DWQ Project No. 04-0949 Modification
Fairfax Rd extension
Mr. J.M. Mills, P.E.
Division Engineer, Division 7
North Carolina Department of Transportation
1584 Yanceyville Street
Greensboro, North Carolina, 27415
Dear Mr. Mills:
You have our approval, in accordance with the conditions listed below, to impact approximately 6205
square feet of Randleman Watershed Buffer in order to construct a gravel road extension (to be used as a
residential driveway access) to Fairfax Rd in Guilford County. This approval is a modification to an
approval dated June 18, 2004.
This approval is valid solely for the purpose described in your letter dated June 8, 2004. Should your
project change, you must notify the Division of Water Quality (Division). For this approval to remain
valid, you must adhere to the conditions listed below.
1. No modifications will be made to the existing stream crossing within the right of way.
2. The gravel road/driveway will be placed as far as practicable away from the stream while still in
the existing right of way.
3. Only vegetation within the proposed gravel road/driveway and shoulder will be removed.
4. A vegetative buffer of the maximum feasible width will remain in place between the proposed
gravel road and the stream except at the stream crossing.
If you have any questions, please contact Sue Homewood at 336-771-4600 extension 287 or
[e-mail].
Sincerely,
4 Alan W. Klimek, P.E.
cc: Jerry Parker, Division Environmental Officer, NCDOT Division 7
Wetlands/401 Unit
Winston Salem Regional Office @ D
Central Files D
JUN 1 2005
DENR - WATER QUALITY
LkqVAlEf? B`Z4NC11
N. C. Division of Water Quality 1650 Mail Service Center Raleigh, NC 27699-1650 [phone]
Customer Service: 1 800 623-7748
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
A y.
14CDEha
O?O? W A T ?RpG
W
O - ?
June 18, 2004
Guilford County
DWQ Project No. 04-0949
Fairfax Rd
WETLANDS/ 401 GROUP
Mr. J.M. Mills, P.E.
Division Engineer, Division 7
North Carolina Department of Transportation
1584 Yanceyville Street
Greensboro, North Carolina, 27415
Dear Mr. Mills:
JUN 2 4 2004
WAFER QUALITY SECTION
You have our approval, in accordance with the conditions listed below, to impact approximately 3,250
square feet of Randleman Watershed Buffer in order to construct a gravel road extension (to be used as a
residential driveway) to Fairfax Rd in Guilford County. The approved construction shall be in accordance
with your request letter dated June 8, 2004.
This approval is valid solely for the purpose described in your letter. Should your project change, you
must notify the Division of Water Quality (Division). For this approval to remain valid, you must adhere
to the conditions listed below.
1. No modifications will be made to the existing stream crossing within the right of way.
2. The gravel road/driveway will be placed as far as practicable away from the stream while still in
the existing right of way.
3. Only vegetation within the proposed gravel road/driveway will be removed.
4. A minimum 10 to 20 foot vegetative buffer will remain in place between the proposed gravel road
and the stream except at the stream crossing.
If you have any questions, please contact Sue Homewood at 336-771-4600 extension 252 or
[e-mail].
/9,? Alan W. Klimek, P.E.
cc: Jerry Parker, Division Environmental Officer, NCDOT Division 9
Wetlands/401 Unit
Winston Salem Regional Office
Central Files
Alan W. Klimek, P.E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Sincerely,
V WIT
NCUEP,'
N. C. Division of Water Quality 1650 Mail Service Center Raleigh, NC 27699-1650 [phone]
Customer Service: 1 800 623-7748
r
.mot,
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY
GOVERNOR
June 8, 2004
Ms. Beth Barnes
Wetlands/401 Unit.
NC DENR Division of Water Quality
1650 Mail Service Center
Raleigh, NC 27699
(Two Copies)
Sue Homewood .
NC DENR Division of Water Quality
Winston-Salem, NC 27107
Courier Number 13-15-01
(Two Copies)
N
LYNDO TIPPETT
. SECRETARY
WETLANDS/ 401 GROUP
JUN 1 0 2004
WATER QUALITY SECTION
Subject: Guilford County, Gravel access on Fairfax Road WBS Element T#34£320.3.19
To Whom It May Concern:
The North Carolina Department of Transportation (NCDOT) proposes to construct a gravel road
within an existing right-of-way of Fairfax Road in Greensboro, NC. The project lies within the
Randleman Watershed and is within 50 feet of Reddicks Creek. In an effort to obtain the necessary
permits for the subject gravel road, we are providing a pre-construction notification application with
supporting documentation. We believe this project can be permitted as a "No Practical Alternative "
permit within the Randleman Watershed.
It is the department's opinion that the project has been designed to have minimal disturbance,
to provide maximum nutrient removal and erosion protection, to have least adverse effects on
aquatic life and habitat, and to protect water quality to the maximum extent practical through the
use of best management practices.
The following information is being provided to satisfy conditions of General Water Quality Certification.
P. O. Box 14996 Greensboro, NC 27415-4996
Telephone No. [phone] Fax No, [phone]
7
PROJECT INFORMATION
Road Name SR Number Project Length
miles Classification
Fairfax Road N/A N/A Rural
River Basin: DWQ
ID Water Quality
Designation % Impervious
Surface
Cape Fear 17-8-(0.5) WS-IV* N/A
Buffer Rulesa Buffer Rule Conditions where applicable)
Yes Request "No Practical Alternative" Permit
Protected Species
Presentb Mapped Historic
Pro erti& CAMA
AEC Essential Fishery
Habitat
No No No No
a Separate documentation attached as needed: b See the attached 1Jndangered
Species Review Sheet for further information: e When Applicable - See the attached
Historic Review Letter for further information
GRAVEL ROAD CONSTRUCTION
Site Fairfax Road Stream Type Perennial
Station
Fairfax Road 50 ft X380. ft ROW Proposed 13 ft X 365 ft gravel road
Road
Construction Dewatering N/A
Method Device*
Burial Depth N/A (no pipe replacements nor E/C Plan NIA
extensions Date
Construction As soon as practicable Duration One week
Date
Impacts (ft.) The Department is projecting no direct impacts to nearby streams and through
the utilization of Best Management Practices, no cumalative impacts to nearby
streams
Special
Conditions
Restoration N/A
Plan
RCP = reinforced concrete pipe; CMP = Corrugated metal pipe; CMPA = Corrugated metal pipe arch; E/C = Erosion
control. "A less intrusive dewatering device may be used in lieu of the one proposed.
P. O. Box 14996 Greensboro, NC 27415-4996 Telephone No. [phone] Fax No. [phone]
AlUflP:IIZATION IIIFORLIATION
Impacts will be minimized by strict enforcement of Best Management Practices for the protection of
surface waters and wetlands, restrictions against the staging of equipment in or adjacent to waters
of the US, and coordination (including a pre-construction meeting) with the Division Environmental
Officer.
LUTIGATION WFORMATION
Stream mitigation is not anticipated, as the impacts to any individual stream do not exceed 150 feet
Wetland mitigation is not anticipated, as wetland impacts do not exceed 0.10 acres and do not
occur in a unique natural wetland.
APPLICATI011 INF01=TI01f
Enclosed please find the Pre-construction Notification Form and supporting documentation for the
above referenced project. If you have any questions or need any additional information, please
contact Dennis Johnson at [phone] or Jerry Parker at [phone]. Your time and effort
are appreciated.
Sincerely,
14V\
M. J. . Mills, P.E.
D vision ngineer, Division 7
Enclosures
CC: Jerry Parker. NCDOT
Chris Kirkman, NCDOT
Barry Harrington, NCDOT
S. Lane Hall, NCDOT
P. O. Box 14996 Greensboro, NC 27415-4996 Telephone No. [phone] Fax No. (336) 3343637
Office Use Only: Form Vcrsion May 2002
,-z r
USACE Action ID No. DWQ No.-
(If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A".)
I. Processing
1. Check all of the approval(s) requested for this project:
_ Section 404 Permit X Riparian or Watershed Buffer Rules
? Section 10 Permit ? Isolated Wetland Permit from DWQ
® 401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested: Randleman Buffer Permit
(Request for No Practical Alternative)
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 (verify availability with NC)ARP prior to submittal of PCN), complete
section VIII and check here: ?
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
Environmental Concern (see the top of page 2 for further details), check here: ?
H. Applicant Information
1. Owner/Applicant Information
Name: Mr. J M Mills P.E, Division Engineer - Division 7
Mailing Address: P.O. Box 14996
Greensboro NC 27415-4996
Telephone Number: [phone] Fax Number: (336 3) 34-3673
E-mail Address: mmills@a dot state nc us
2. Agent/Consultant 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: Jerry Parker
Company Affiliation: Division Environmental Officer
Mailing Address: P.O. Box 14996
Greensboro, NC 27415-4996
Telephone Number: [phone] Fax Number: [phone]
E-mail Address: jParker o dot state nc us
Page I of 9
III. 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: Fairfax Road Gravel Driveway
2. T.I.P. Project Number or State Project Number (NCDOT Only): WBS Element 34820.3.19
3. Property Identification Number (Tax PIN): Not Applicable
4. Location
County: Guilford Nearest Town:Greensboro
----- -------
Subdivision name (include phase/lot number): Not Applicable
Directions to site (include road numbers, landmarks, etc.):
The project is in southwest Greensboro. From I40 near Greensboro take the High Point
Road exit and head west towards High Point for approximately 1.8 miles to Hilltop Road.
Turn right onto Hilltop Road and go approx 0.4 miles ( V Traffic Signal) to Fairfax Road.
Turn left on Fairfax Road and go 0.5 miles to Roland Road. Fairfax Road will appear to end
but the 50 ft wide right-of-way actually extends beyond Roland Road which is where the
gravel driveway is proposed.
5. Site coordinates, if available (UTM or Lat/Long): See the attached USGS map.
(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. Property size (acres): Not Applicable
7. Nearest body of water (stream/river/sound/ocean/lake). Reddicks Creek
8. River Basin: Cape Fear
Page 2 of 9
(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/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: Unused 50 ft wide Right of Way that connects Fairfax Road
from Roland Road to Topping Drive
10. Describe the overall project in detail, including the type of equipment to be used: The
project will involve placing a gravel road within an existing, but unused right-of-way, in
order to allow access to a nearby residence that will lose it's regular access due to the
construction of the Greensboro Western Loop The existing unused right-of-way is 50 ft wide
and approximately 380 feet long._The proposed gravel road is approximately 13 ft wide and
365 feet long and is proposed to be placed entirely within the existing unused right-of-way. A
stream (Reddicks Creek) exists within the right-of-way that runs parallel to the right-of-wav
but along the outside boundaries The stream runs along; the western boundary of the north
portion of the right-of-way and then crosses through and existing 40 ft long _pipe-and runs
along the eastern boundary and eventually outside of the right-of-wagon the southern portion
of the existing _rigbt-of-wav The stream is within the Randleman Watershed and therefore
subject to the Randleman Buffer Rules The gravel road is proposed to be placed as- far as
practicable away from the stream while still in the Right-of-Way and without changing the
existing ditch line The project will involve removing only those trees that are within the 13
ft wide gravel road and any bottom disturbing activity will only take place within the
alignment of the proposed gravel road The proposed gravel road will be placed mostly
along the outer limits of Zone 1 and inner limits of Zone 2 as measured from top of bank
landward In order to minimize impacts the road will be aligned to the opposite side of the
stream (to the east) in northern portion and (to the west) in the southern portion of the
project A minimum 10 to 20 ft vegetative buffer will remain in place between the proposed
gravel road and the stream except where there is the perpendicular pipe crossing. The
existing 40 ft pipe will remain and will not be extended. Equipment used will be standard
road construction equipment (trackhoe grader, backhoe and bulldozer).
11. Explain the purpose of the proposed work: To provide access to a nearby residence that
will lose it's regular access due to the construction of the Greensboro Western Loop..
IV. 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.
Not Applicable
Page 3 of 9
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application,
Not Applicable
VI. 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
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
Provide a written description of the proposed impacts: Except for potential runoff, the
Department does not anticipate My impacts to the nearby stream. Runoff is expected to be
captured by the ten to twenty foot wide vegetative buffer that will remain between the proposed
gravel road and the existing stream.
1. Individually list wetland impacts below:
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, rill,
excavation, flooding ditching/drainage, 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 Kate Maps
(FIRM), or FEMA-approved local floodplam maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
onIineathttl2://w%v%v.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.) Indicate if wetland is isolated (determination of isolation to be made by USACE only).
List the total acreage (estimated) of all existing wetlands on the property: Not Applicable
Total area of wetland impact proposed: Not Applicable
Page 4 of 9
2. Individually list all intermittent and perennial stream impacts below:
Stream Impact Length of Average Width Perennial or
Site Number Type of Impact* Impact Stream Name** of Stream Intermittent?
(indicate on (linear feet) Before Impact (please specify)
ma
Buffer Area 13 ft X 365

Fairfax Road Disturbance (No
direct impact to ft gravel
road (4745
Reddicks Creek Approx. one to
three feet
Perennial
stream) so in Zone
1 and 2
See below*

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated np-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, 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.uses.gov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com,
www.mapquest.com, etc.).
*Cumulative impacts (linear distance in feet) to all streams on site: Project should not result
in an increase in cumalative impacts to the stream. The topography is flat which should
minimize velocity of any potential runoff and allow the ten to twenly foot vegetative buffer
to capture most of the runoff.
3. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.) below:
Open Water Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres
Name Wate)
(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 limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation
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.): Not Applicable
Page 5 of 9
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.): Not Applicable
Size of watershed draining to pond: N/A Expected pond surface area: N/A
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.
In order to minimize impacts the road will be aligned to the opposite side of the stream (to the
east) in the northern portion and (to the west) in the southern portion of the project in order to
create the greatest practicable distance between the proposed road and the stream within the
existing ri hg t-of-way A minimum 10 to 20 ft vegetative buffer will remain in place between
the proposed gravel road and the stream except where there is the perpendicular pipe crossing
Impacts will be minimized by strict enforcement of Best Management Practices for the
protection of wetland and surface waters, restrictions against the staging of equipment in or
adjacent to waters of the US and coordination (including a pre-construction meeting) with the
Division Environmental Officer.
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
Page 6 of 9
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.
A finding of insignificant impact is anticipated, therefore a mitigation plan is not provided.
Cumulative impacts are less than 150 feet The maximum amount of impact to a single
stream is approximately zero linear feet No Outstanding Resource Waters, federally
protected species or their habitats or essential fishery habitats occur in the project area. The
project is not located in a High Quality Water.
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP). Please note it is the applicant's responsibility to contact the NCWRP at
[phone] to determine availability and to request written approval of mitigation prior
to submittal of a PCN. 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): Not Applicable
Amount of buffer mitigation requested (square feet): Not Applicable
Amount of Riparian wetland mitigation requested (acres): Not Applicable
Amount of Non-riparian wetland mitigation requested (acres): Not Applicable
Amount of Coastal wetland mitigation requested (acres): Not Applicable
IX. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federal/state) funds or the use of public
(federal/state) 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
Page 7 of 9
X. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
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.
Will the 'project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 213 .0250 (Randleman Rules and
Water Supply Buffer Requiremeiits),'or other (please identify Randleman )?
Yes X No _ If you answered "yes", provide the following information:
Requesting a "No Practical Alternative" permit for impacts.
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 N/A 3
2 N/A 1.5
Total N/A
* Zone 1 extends out 30 feet perpendicular from neat 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.
Not Applicable
XI. Stormwater (required by DWQ)
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.
Not Applicable
XII. Sewage Disposal (required by DWQ)
Page 8 of 9
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.
Not Applicable
XIII. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 211.0500) or any Buffer Rules?
Yes ? No
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).
4pli ant/Agent's Signature I DAte
(Agent's ignatpre is valid only if an authorization letter from the applicant is provided.)
Page 9 of 9
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