20040290 Ver 1_Complete File_20040226

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February 27, 2004
Anson County
DWQ Project No. 040290
Secondary Road Improvements to SR 1616 (White Road)
APPROVAL of 401 Water Quality Certification with Additional Conditions
Mr. Benton G. Payne, P.E., Division Engineer
NCDOT Division 10
716 West Main Street
Albemarle, North Carolina 28001
Dear Mr. Payne:
You have our approval, in accordance with the attached conditions and those listed below, to incur 43
linear feet of permanent and 20 linear feet of temporary impacts to Jack's Branch in order to make
improvements to SR 1616 (White Road) in Anson County. The project will be constructed in accordance
with your application dated February 23, 2004 (received February 26, 2004). After reviewing your
application, we have decided that this fill is covered by General Water Quality Certification Nos. 3366
and 3404 corresponding to the U.S. Army Corps of Engineers Nationwide Permit Numbers 33 and 14. In
addition, you should acquire any other federal, state or local permits before you proceed with your project
including (but not limited to) Sediment and Erosion Control, Non-Discharge and Water Supply
Watershed regulations. This approval will expire with the accompanying §404 permit unless otherwise
specified in the Water Quality Certification.
This approval is only valid for the purpose and design that you described in your application except as
modified below. If you change your project, you must notify us in writing, and you may be required to
send us a new application. If the property is sold, the new owner must be given a copy of this
Certification and approval letter and is thereby responsible for complying with all conditions. If total
wetland fills for this project (now or in the future) exceed one acre, or if stream impacts exceed 150 linear
feet, compensatory mitigation may be required as described in 15A NCAC 2H.0506 (h) (6) and (7). For
this approval to be valid, you must follow the conditions listed in the attached certification and any
additional conditions listed below.
Construction shall be performed so that no violations of state water quality standards, statutes, or
rules occur.
¦ Erosion and sediment control practices must be in full compliance with all specifications
governing the proper design, installation and operation and maintenance of such Best
Management Practices in order to protect surface water quality standards.
¦ The erosion and sediment control measures for this project must equal or exceed the proper
design, installation, operation and maintenance outlined in the most recent version of the
North Carolina Sediment and Erosion Control Planning and Design Manual. These devices
shall be maintained on all construction sites, borrow sites, and waste pile (spoil) projects,
including contractor-owned or leased borrow pits associated with the projects included under
this Certification.
¦ If this project requires borrow pit sites, the erosion and sediment control measures must equal
or exceed the proper design, installation, operation and maintenance outlined in the most
recent version of the North Carolina Surface Mining Manual.
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
North Carolina Division of Water Quality, 401 Wetlands Certification Unit,
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
919-733-1786 (phone), 919-733-6893 (fax), hftp://h2o.enr.state.nc.us/ncwetlands/
Mr. Benton Payne, P.E.
DWQ 040290
February 27, 2004
¦ Any reclamation measures and implementation must comply with the reclamation in
accordance with the requirements of the Sedimentation Pollution Control Act.
2. No waste, spoil, solids, or fill of any kind shall occur in wetlands, waters, or riparian areas
beyond the footprint of the impacts depicted in the Preconstruction Notice Application. All
construction activities, including the design, installation, operation, and maintenance of sediment
and erosion control Best Management Practices, shall be performed so that no violations of state
water quality standards, statutes, or rules occur.
3. Sediment and erosion control measures shall not be placed in wetlands or waters to the maximum
extent practicable. If placement of sediment and erosion control devices in wetlands and waters
is unavoidable, they shall be removed and the natural grade restored within six months of the date
that the Division of Land Resources has released the project.
4. NCDOT is encouraged to use onsite vegetation and materials for streambank stabilization when
practicable.
5. Riparian vegetation must be reestablished within the construction limits of the project by the end
of the growing season following completion of construction.
6. Stormwater should be directed to vegetated buffer areas, grass lined ditches or other means
appropriate to the site for the purpose of pre-treating stormwater runoff, and must not be routed
directly into streams. Mowing of existing vegetated buffers is strongly discouraged, so that they
may be utilized for stormwater sheet flow.
7. Where fish passage is present or where significant aquatic life may be present upstream (and
where practicable), culverts should be oversized and buried to prevent perched culverts. If
oversized piping cannot restore aquatic life passage by reconnecting the stream ecosystem, riprap
installation should be accomplished in a manner to provide or restore water channels downstream
to help facilitate aquatic life movement.
8. Where practicable, culverts that are less than 48-inch in diameter should be buried to a depth
equal to or greater than 20% of their size to allow for aquatic life passage. Culverts that are 48-
inch in diameter or larger should be buried at least 12 inches below the stream bottom to allow
natural stream bottom material to become established in the culvert following installation and to
provide aquatic life passage during periods of low flow. These measurements must be based on
natural thalweg depths. This may require increasing the size of the culvert to meet flow
conveyance requirements. If any of the existing pipes are perched, they shall be removed and
replaced, and re-installed correctly, unless demonstrated that this is topographically unfeasible.
All waters must flow through without freefalling or damming on either end of the culverts during
low flow conditions, to maintain aquatic life and/or fish passage.
9. The dimension, pattern and profile of the stream, above and below the crossing, should not be
modified by widening the stream channel or reducing the stream depth. Disturbed floodplains
and streams should be restored to natural geomorphic conditions.
10. Riprap should be minimized and installed in a manner so as not interfere with aquatic life passage
during low flow conditions. Riprap placed for bank stabilization should be limited to the
streambank below the high water mark and vegetation should be used for stabilization above the
high water mark.
11. If concrete is used, work must be accomplished so that wet concrete does not contact the stream
water. This will lessen the chance of altering the stream's water chemistry and causing a fish kill.
12. Heavy equipment must be operated from the banks rather than in the stream channel in order to
minimize sedimentation and reduce the likelihood of introducing other pollutants into the stream.
13. All mechanized equipment operated near surface waters must be regularly inspected and
maintained to prevent contamination of stream waters from fuels, lubricants, hydraulic fluids, or
other toxic materials.
14. The presence of equipment in the channels must be minimized. Under no circumstances must
rock, sand or other materials be dredged from the wetted stream channel under authorization of
this permit, except in the immediate vicinity of the culverts.
Mr. Benton Payne, P.E.
DWQ 040290
February 27, 2004
15. Removal of vegetation and grading and backfilling at the stream crossing and adjacent to stream
should be minimized. Native trees and shrubs should be planted along the streambank to
reestablish the riparian zone and provide long-term erosion control and cover for fish and wildlife
in the vicinity of the road crossing and along the streams within the dedicated rights of "way.
Backfill materials should be obtained from upland sites.
16. Upon completion of the project, the NCDOT shall complete and return the enclosed "Certificate
of Completion" form to notify NCDWQ when all work included in the §401 Certification has
been completed. The responsible party shall complete the attached form and return it to the
401/Wetlands Unit of the NC Division of Water Quality upon completion of the project NCDOT
is strongly advised to send in photographs upstream and downstream of each structure to
document correct installation.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing.
You must act within 60 days of the date that you receive this letter. To ask for a hearing, send a written
petition that conforms to Chapter 150B of the North Carolina General Statutes to the Office of
Administrative Hearings, 6714 Mail Service Center, Raleigh, N.C. 27699-6714. This Certification and its
conditions are final and binding unless you ask for a hearing.
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water
Act. If you have any questions, please telephone Ms. Cynthia Van Der Wiele at 919.733.5715 or Mr. Ken
Averitte of the Fayetteville Regional Office at 910.486.1541.
Sincerely,
j
lan W. Klimek, P.E.
Attachment
Pc: Wilmington District Corps of Engineers
Steve Lund, USACE Asheville Field Office
NCDWQ Fayetteville Regional Office
Central Files
File Copy
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STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY DIVISION OF HIGHWAYS W. LYNDo TIPPETT
GOVERNOR February 23, 2004 SECRETARY
U. S. Army Corps of Engineers b"VETLAP;DS 1 `01 GROUP
Asheville Regulatory Field Office r)
Attention: Mr. Steve Lund, MS, PWS FEB 2 (i 2004
151 Patton Avenue, Room 208
Asheville, NC 28801-5006 WATER (UnLI (Y uECT10N
Subject: Secondary Road Improvements to SR 1616 (White Road), Anson County. State
Work Order No. 10C. 004011 (DWQ Minor Permit Fee 5200.00).
Dear Mr. Lund:
The North Carolina Department of Transportation (NCDOT) proposes to upgrade SR 1616 from
(White Road), in Anson County. SR 1616 is an unpaved roadway that will be upgraded to a
paved roadway. The total project length is 0.51 mile.
Transportation and highway laws of North Carolina (G.S. 136-44.6, 136-44.7, 136-44.7A, 136-
44.8 and 136-44.9) require the NCDOT to develop annual work programs for construction and
maintenance of secondary roads. These general statutes specifically set forth requirements for
annual construction and paving of existing unpaved roads. Paving of these roads is performed in
priority order as established by the NCDOT for each unpaved road within a given county. This
number is based on characteristics of each road, including number of homes, schools, churches,
businesses, industries, recreational facilities, traffic counts, presence of school bus routes, and
value as a thoroughfare. SR 1616 is scheduled for paving in the 2004-2005 Secondary Roads
Construction Program.
Protected Species
The subject project has been reviewed for the presence of listed threatened and endangered
species. It has been determined that the construction of this project will have no effect on any
listed plant or animal species.
Impacts to Waters of the United States

This project cannot be completed without impacts to waters of the United States. The project lies
in the Yadkin River Basin (Hydrologic Unit # 03040105), affecting the drainage an unnamed
tributary to Jack's Branch. There will be approximately 43 linear feet of permanent impacts to an
existing intermittent stream channel as a result of the proposed construction.
716 Nest Main Street, Albemarle, NC 28001 • [phone] • Fax [phone]

Table 1 includes information related to site number, stream name, existing pipe length (ft),
existing pipe width (in), proposed replacement or extended pipe length (ft) and width (in).
Tahle 1.:Imnacts to Streams from improvements to SR 1616 (White Road)
site ! Existing 1 Existing Proposed Proposed
No. -J Stream-Name Length Width Length ! Width 1
feet 9 inches i feet ! inches .
Sta. 15+ UT to Jack's Branch 25' 15" 48' 30"
Note: "UT' refers to unnamed tributary.
Avoidance/Minimization
All wetlands or surface waters not affected by the project will be protected from unnecessary
encroachment. No staging of construction equipment or storage of construction supplies will be
allowed in or near wetlands or surface waters.
The side slopes have been steepened to the extent possible and the proposed roadway adjusted to
lessen the impacts to jurisdictional sites. Sedimentation and erosion control Best Management
Practices for the protection of wetlands and surface waters will be enforced during project
construction. Continued coordination will occur between maintenance forces and the Division
Environmental Officer during construction in an effort to minimize impacts to jurisdictional sites.
Summary
The purpose of this letter is to request authorization to construct the proposed project under
Section 404 Nationwide Permit (NWP) 14. Application is also made to the North Carolina
Division of Water Quality (NCDWQ) for the Section 401 Water Quality Certificate (WQC) No.
GC3404 that is required in order to construct this project.
If you have any questions or need any additional information concerning this project, please fee
free to contact Mr. Larry Thompson, Division Environmental Officer, at [phone].
Sincerely, /0-c? ?ALXC
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?4 66X /- C-
Benton G. Payne, P. E.
Division Engineer
BGP/LBT
cc: Mr. John Dorney, NCDWQ
Ms. Marella Buncick, USFWS
Ms. Marla Chambers, NCWRC
Ms. Leslie Reynolds, CME
Mr. Mike Walden
Mr. Larry Thompson
Area Field Operations Unit
.V
Office Use Only: 4 0990 Form Version April 2001
USACE Action ID No. DWQ No.
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
I. Processing
Check all of the approval(s) requested for this project:
® Section 404 Permit
? Section 10 Permit
® 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: Nationwide 14
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 (see section VIII - Mitigation), check here: ?
II. Applicant Information
Owner/Applicant Information
Name: N C Department of Transportation
Mailing Address: 716 West Main Street
Albemarle NC 28001
Telephone Number: [phone] Fax Number:__704) 982-3146
E-mail Address:
2. Agent 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: Benton G Payne P. E.
Company Affiliation: Division Engineer
Mailing Address: 716 W. Main Street
Albemarle NC 28001
Telephone Number: [phone] Fax Number: [phone]
E-mail Address: bpayn dot state nc us
Pagel 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: SR 1616 (White Road)
2. T.I.P. Project Number (NCDOT Only): N/A
3. Property Identification Number (Tax PIN): N/A
4. Location
County: Anson County Nearest Town: Ansonville
Subdivision name (include phase/lot number): N/A
Directions to site (include road numbers, landmarks, etc.): From Ansonville, travel west on
SR 1418 (Ansonville - Polkton Road), turning right onto SR 1616 (White Road).
5. Site coordinates, if available (UTM or Lat/Long): 35°5'25.42" N/8019'37.91" W
(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. Describe the existing land use or condition of the site at the time of this application:
Rural/Agricultural
7. Property size (acres): N/A
8. Nearest body of water (stream/river/sound/ocean/lake): Jack's Branch
9. River Basin: Yadkin (Hydrologic Unit 03040105)
(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/.)
Page 2 of 9
10. Describe the purpose of the proposed work: Grade drain base pave and erosion control to
bring existing gravel road in compliance with standard safety design specifications. Work
will require replacing one culvert (see plan sheets)
11. List the type of equipment to be used to construct the project: Heavy construction equipment
(backhoe track hoe excavator, grader, boom truck dump trucks etc.).
12. Describe the land use in the vicinity of this project: Mixed Use - Agricultural/Residential
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.
N/A
V. Future Project Plans
Are any additional permit requests anticipated for this project in the future? If so, describe the
anticipated work, and provide justification for the exclusion of this work from the current
application: N/A
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
Page 3 of 9
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
1. Wetland Impacts
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
feet
Type of Wctland***

' List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mecnanized clearing, gmauig, nu.
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 Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http://w%,,w.fe nagov.
••• List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond.
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property: N/A
Total area of wetland impact proposed: N/A
2. Stream Impacts, including all intermittent and perennial streams
Stream Impact
Site Number
indicate on ma)
Type of Impact* Length of
Impact
linear feet
Stream Name** Average Width of
Stream Before
Impact Perennial or
Intermittent?
leasespecify)
Sta. # 15+27 30" x 48' RCP 43' UT to Jack's Branch Approx. 2' Intermittent

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-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,
w-ww.mannucst.com, etc.).
Page 4 of 9
Cumulative impacts (linear distance in feet) to all streams on site: 43 feet of permanent
impacts 20 feet of temporM impacts
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S.
Open Water Impact
Site Number
indicate on ma
Type of Impact Area of
Impact
acres Name of Waterbody
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: till, excavation, dreogmg
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.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
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.
Any wetlands or surface waters not impacted by the project will be protected from unnecessary
encroachment No staging of construction equipment will be allowed in or near wetlands or
waters of the United States. Strict enforcement of sedimentation and erosion Best Management
Practices for the protection of wetlands and surface waters will be enforced during all phases of
project construction
Page 5 of 9
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
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.us/ncwetlands/strmgide.htmi.
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.
No mitigation is proposed for this project
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
Page 6 of 9
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at httn•/m2o.enr.st itc.nc.iis/wm/l*ndcx.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):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
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 ?
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
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 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No ® If you answered "yes", provide the following information:
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.
Page 7 of 9
Zone' Impact
(square feet Multiplier Required
Mitigation
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near 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.
N/A
XI. Stormwater (DWQ Only)
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.
The existing gravel base road is an avera.,e 20 feet in width the proposed improvements will be
20 feet in width There will not be an increase in impervious area as a result of this project being
constructed.
Temporary dewatering and all appropriate Best Management Practices for sediment and erosion
control will be implemented during _pipe rep lacement/extension activities.
XH. Sewage Disposal (DWQ Only)
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 8 of 9
XUL Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.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).

Applicant Agent's Sig e l Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 9 of 9
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GoC Prepared by:
_ North Carolina
- - Departmeut of Trampartatlon
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Date,tanuary 27, 2004
B B ' This map Is Intended for Internal DOT use only.
g j For all other uses; no warranties of any sort.
MsA f Including accuracy, fitness, or mercbantablllty,
am mpmsy this produrL
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O?O? W AT ?9QG
DWQ Project No.: O'lOZ!J C) County:
Applicant:
Project Name:
Date of Issuance of 401 Water Quality )Certification:
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, 1650 Mail Service Center, Raleigh, NC,
27699-1650. 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, , 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, G Gsr" , hereby state that, to the best of my abilities, due care
and diligence wis used in the`bbservation 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 approver i an specifications, and other supporting mat rials.
Signature. u Date: 1
i
i
If this prV was designed by a Certified Professional
I, , as a duly registered Professional (i.e.,
Engineer, Landscape Architect, Surveyor, etc.) in the State of North Carolina, having been authorized
to observe (periodically, weekly, full time) the construction of the project, for the Permitee 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
2?1\
North Carolina Division of Water Quality, 401 Wetlands Certification Unit,
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
919-733-1786 (phone), 919-733-6893 (fax), httpIlh2o.enr.state.nc.us/ncwetlands/
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
ftiCDEP;{