20110685 Ver 1_401 Application_20110711

Dennison, Laurie
From: Homewood, Sue
Sent: Thursday, July 21, 2011 12:46 PM
To: Dennison, Laurie
Cc: Strickland, Bev
Subject: RE: courtesy project
Attachments: D00072111-001.tif
Here's another, sorry to keep adding to your workload.
Sue Homewood
NC DENR Winston-Salem Regional Office
Division of Water Quality
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Dennison, Laurie
Sent: Thursday, July 21, 2011 12:44 PM
To: Homewood, Sue
Subject: RE: courtesy project
DWQ 11-0684... Bev just needs to scan in
L-
From: Homewood, Sue
Sent: Thursday, July 21, 2011 11:40 AM
To: Dennison, Laurie; Strickland, Bev
Subject: courtesy project
Hey Laurie,
Can you please enter this PCN in BIMS as a courtesy, I have to send a hold letter on it. Thanks.
Sue Homewood
NC DENR Winston-Salem Regional Office
Division of Water Quality
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
1
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
201 1 0685
?Ot?1FR
l i?l I O??1D?•.•?
Office Use Only:
Corps action 10 no,
DWQ project no:
Form Version 1.3 Occ 10 2008
Pre-Construction Notification C Form
A. A Ucant lnfotrwaNon
1. Procossing
1 a. Type(s) of approval sought from the
Corps:
® Section 404 Permit ? Section 10 Permit
CO. P
Y
1b. Specify Nationwide Permit (NWP) number: 39 or General Permit (GP) number: -
1c. Was the NWP or GP number been verified by the Corps? ? Yes ® No
1d, Type(s) of approval sought from the OWQ (check all that apply):
? 401 Water Quality Certification - Regular ? Non-404 Jurisdictional General Permit
Q 401 Water Quality Certification - Express ? Riparian Buffer Authorization
ie. Is this notification solely for the record
because written approval is not required? For the record only for DWQ 401
Certification:
? Yes ? No For the record only for Corps Permit:

? Yes ® No
1f. is payment into a mitigation bank or in-lieu fee program proposed for mitigation
of impacts If so, attach the acceptance letter from mitigation bank or in-lieu
fee program. ? Yes ® No
19. Is the project located in any of NC's twenty coastal counties, If yes, answer 1h
below, ? Yes ® No
1 h. Is the project located within a NC 0CM Area of Environmental Concern (AI:C)? ? Yes No
2. Project Information
2a. Name of project: Blaise Baptist Church Access Road
2b. County: Davie
2c. Nearest municipality I town: Mocksville
2d. Subdivision name:
2e. NG001',only, T.I.P. or state
project no: JU(_ 2 1

2 j
.
J
3. Owner Information DENR - CtVATEIt A?

3a. Name(s) on Recorded Deed: William Junker (PIN 57297$6528)
James Daugherty (PIN 5729650599)
Blaise Baptist Church (PIN 5729748796)
3b. Deed Book and Page No.
3c. Responsible Party (for LLC if
applicable):

3d. Street address: William Junker. 136 Triple J Lane
James Daugherty: 5449 Hundley Road
Slaise Baptist Church: 134 Blaise Church Road

3e. City, state, zip: William Junker: Mocksville, NC 27028
James Daugherty: Winston Salem NC 27106
Blaise Baptist Church, Mocksville, NO 27028
3f. Telephone no.:
F Fax no.:
Email address:
Rage I of 12
PCN Form - Version 1.3 December 10, 2008 Version
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U.S. Army Corps of Engineers
Raleigh Regulatory Field Office
3331 Heritage Trade Drive
suite 105
'Take Forest, North Carolina 27587
Phone: [phone]
Fax: [phone]
FAX COVER SHEET
Date:
Message to:
From:
Total number of pages including cover page; I ?( .
If all pages are not received, please call [phone],
Remarks. c.? j ?'??'? C C e?J "ter'
? ??.r VIU
T00'd LLST# 9313 IKId 30KSA TZ60 Z95 6T6 90:9T 110Z.21" ID
4. Applicant Information (it different from owner)
4a. Applicant is: (2 Agent Q Other, specify:
4b. Name: Mr. Joey Kennedy
4C. Business name
(if applicable): 613ise Baptist Church
4d. Street address:
_
.. c/o 147 Hickory Drive
.
4e. City, state, zip: ._ Mocksville, NC 27028
4f. Telephone no.., 336.761 .3639
49. Fax no.: 336.7$1,1696
4h. Email address: [e-mail]
6. AgenVConsultant Information (if applicable)
5a. Name: Ms. Suzanne Knudsen
Sb. Business name
(if applicable): $&ME, Inc.
5c. Street address: 9711 Southern Pine Boulevard
5d. City, state, zip, Charlotte, NC 28273
5e_ Telephone no.: 704.523-4726
5f. Fax no.., 704-565-4929
59. Email address: [e-mail]
Page 2 of 12
PCN Form - Version 1.3 December 10,'2008 Version
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B. Project Information and Prior Project History
1. Property Identification
?a, Property identification no. (tax PIN or parcel ID): NCPIN# 5729756528, $729850599, 5729748796
1b. Site coordinates (in decimal degrees): Latitude: 35.923 Longitude: - 80.598
(04,000000) (-oo.oDoOoo)
1c. Property size: <10 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to Bear Creek
proposed project:
2b. Water Quality Classification of nearest receiving water: Class C (Index No. 12-108-180))
2c. River basin: South Yadkin River (0304102)
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:
The subject property is composed of maintained lawn and densely vegetated woodland. The surrounding property use is
light commercial, retail and residential development.
3b. List the total estimated acreage of all existing wetlands on the property:
< 0.10 acre (Wetland A) delineated.
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
300 If (Stream 1) delinated
3d. Explain the purpose of the proposed project:
The purpose of the proposed project is to construct an access road to 6laise Baptist Church from Interstate Drive.
3e. Describe the overall project in detail, including the type of equipment to be used:
95 if of the headwaters of Stream 1 and 0.013 acre of Wetland A will be filled to accodomate the construction of Maise
Lane and attendant features. Equipment to be used on the job includes industry standard construction and grading
equipment such as trackhoes, dozers, pavers, trucks and cranes.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property I ? Yes ? No ® Unknown
project (including all prior phases) in the past?
Comments: .
4b. If the Corps made the jurisdictional determination, what type ? preliminary ? Final
of determination was made?
4c. If yes, who delineated the jurisdictional areas? Agency/Consultant Company:
Name (if known): Other.
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
A request for Jurisdictional Determination is included with this permit application based on field jurisdictional review
performed April 13, 2010 and again on April 15, 2011 by S8,ME, Jurisdictional boundaries are depicted on the 2007
Aerial Photograph (Figure 3) and a portion of the surveyed wetland delineation showing project impacts (Figure 5).
6. Project History
Sa. Have permits or certifications been requested or obtained for ? Yes ® No ? unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file' instructions.
Page 3 of 12
PCN Form - Version 1.3 December 10, 2009 Version
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S. Future Project Plans
6a, Is this a phased project? Q Yos No
bb. if yes, explain,
Page 4 of 12
PCN Form -Version 1.3 December 10, 2008 Version
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C. Proposed Impacts inventory
impacts Summary
1$. Which sections were completed below for your project (check all that apply):
Wetlands Streams - tributaries ? Buffers
Q Open Waters ? Pond Construction
2. Wettand impacts
if there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
28. 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)
Tem ora T
W1 ®P ? T fill Shrub/scrub Yes
? No ® Corps
? OWQ 0.009
W2 J3P ? T rip rap Shrub/scrub ® Yes
? No JS Corps
? DWQ 0,004
W3 O P ? T 0 Yes C] Corps
? No ? DWQ
W4 ? P [] T ? Yes ? Corps
? No ? DWQ
W5 ? P ? T ? Yes ? Corps
? No ? DWQ
W6 ? P O T ? Yes ? Corps
? No ? DWQ
2g, Total wetland impacts 0.013
2h, Comments:
3. Stream Impatts
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. 39.
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 OWQ - non-404, width (linear
Temporary (T) (INT)? other) (feet) feet)
S1 [3 P ? T fill Stream 1 a PAIR D?Q 3 73
S2 ®P ? T rip rap Stream 1 ® PER
? INT ® Corps
? OWQ 3 22
S3 ? P ? T ? PER ? Corps
? INT ? DWQ
S4 ? P ? T ? PER ? Corps
? INT ? DWQ
S5 ? PC) T ? PER ? Corps
? INT 1] OWQ
S6 ? P ? T ? PER (D Corps
? INT ? DWQ
3h. Total stream an d tributary impacts 95
3i_ Comments:
Page S of 12
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4. Open Water Impacts
If there are propose d.impacts to takes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individually list all open water impacts below,
4a, 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 T
01 ?P?T
02 ?P?T
03 ?POT
04 ?P?T
4f. Towl open water impacts
49. Comments:
5. Pond or Uke Construction
If and or lake construction proposed, then com fete the chart below.
$a. 5b. 5c. 5d. 5e.
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID Proposed use or purpose (acres)
number of pond
f=looded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
SE Total
$g. Comments:
5h. is a dam high hazard permit required?
Q Yes ? No If yes,. permit 10 no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k, Method of constniction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. if an imp acts require miti anon then you MUST fill out Section d of this form.
6a.
? Neuse ? Tar-Pamlico ? Other:
Project is in which protected basin? ? Catawba ? Randleman
6b. 6c. 6d. 6e. 61'. 69.
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?
131 ?P?T ?Yes
? No
B2 ?P?T ?Yes
? No
83 ?P?T ?Yes
? No
6h. Total buffer impacts
6i. Comments:
Page 6 of 12
PCN Form -Version 1.3 December 10, 2008 Version
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D. Impact Justification and Mitigation
1. Avoidancs and Minimization
1 a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project,
The proposed project has been designed to minimize the impacts to jurisdictional features to the extent practicable, Impacts
to Stream t have been minimized by locating the crossing furthest north and connecting to an existing culvert so that impacts
will be limited to 95 If of the origin of Stream 1 and 0.013 acre to Wetland A. During the project review process, other crossing
locations were reviewed and the current location was chosen because it results in the least amount of impact to Stream 1 and
Wetland A, Due to future site plans by the property owner of the northern adjacent parcel, Blaise Lane could not be placed
further north to avoid jurisdictional features.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Appropriate sediment and erosion control practices outlined in the most recent version of the "North Carolina Sediment and
Erosion Control Planning and Design Manual" and approved by the local governing authority will be in compliance with
specifications governing the proper design, installation, operation and maintenance of such Best Management Practices to
comply with the appropriate turbidity water quality standard. Sediment and erosion control measures will be removed and the
original grade restored within two months after the Division of Land Resources has released the project.
To avoid and minimize impacts through construction techniques, the following will be implemented;
• stormwater runoff will be treated in accordance with the practices described in the NCOOT 8MP Manual.
• 20 percent of the 36' HOPE culvert will be placed below the elevation of streamflow to allow low flow passage of
water and aquatic life
- Appropriate measures will be taken during construction to allow flow and circulation patterns of waters of the U.S, to
remain unaffected.
• Riprap will be buried such that the original stream elevation is restored and maintained
• Riprap armoring at the exit of the culvert has been sized to the recommended minimum extents to prevent scour and
meet the erosion control requirements of the North Carolina department or Environment and Natural Resources Erosion and
Sediment Control Planning and Design Manual; work will be done in accordance with general and regional conditions of NWP
No. 39.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for ? Yes ®No
impacts to waters of the U, S. or Waters of the State?
2b, If yes, rnilisation is required by (check all that apply): Q OWQ Cl Corps
© Mitigation bank
2c. if yes, which mitigation option will 4e used for this
? Payment to in-lieu fee program
project?
? Permittee Responsible Mitigation
3, Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type Quantity
Page 7 of 12
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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 0 coot Ocold
4d. Buffer mitigation requested (UWQ only); 0 square feet
4e. Riparian wetland mitigation requested: 0 acres
4f. Non-riparian wetland mitigation requested: b acres
49. Coastal (tidal) wetland mitigation requested: 0 acres
4h. Comments:.
6. Complete it Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan,
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by OWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation? ? Yes ? 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:
69. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permatee responsible riparian buffer restoration, payment into an approved in-lieu fee fund),
6h. Comments:
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E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified ? Yes ® No
within one of the NC Riparian Buffer Protection Rules?
1b. If yes, then is a diffuse flow plan included? If no, explain why,

Comments: ? Yes ? NO
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? NA %
2b. Does this project require a Stormwater Management Plan? ? Yes 12 No
2c, If this project DOES NOT require a Stormwater Management Plan, explain why: linear transportation project
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
3b. Which of tree following locally-implemented stormwater management programs ? NSW
? USMP
apply (check all that apply); ? Water Supply Watershed
Q Other;
3c. Has the approved Stormwater Management Plan with proof of approval boen ? 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
attached? ? Yes ? No
5, DW© 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? [3 yes ? No
5b. Have all of the 401 Unit submittal requirements been met? 0 Yes ? No
Page 9 of 12
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F, Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federalistate/local) funds or the Q Yes S 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 Q 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 Mouse? (If so, attach a copy of the NEPA or SEPA final approval
letter.) Q Yes ? No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (1$A NCAC 2H .0500), Isolated
Welland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ? Yes No
or Riparian Buffer Rules (15A NCAC 26,0200)?
2b. Is this an after-the-fact permit application? Q 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 Q Yes ® No
additional development, which could impact nearby downstream water quality?
3b. It 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.
The installation of the proposed access road will service Blaise Baptist Church only and therefore no additional growth in
development will occur as a result of this project,
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.
No wastewater will be generated by the proposed project.
Page 10 of 12
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S.. 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?
Sc. if yes, indicate the USFWS Field Office you have contacted. © Raleigh
® Asheville
5d What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
USFWS county list for North Carolina and the NCNHP website. No active NCNHP element occurences of federally
protected species were identified within a two-mile radius of the project site. Scoping letters were sent to NCNHP and
USFWS Asheville Field Regulatory Office on 04.19.11. Potentially-suitable habitat for federally protected species in the
county, Michaux's sumac, was observed Gy SSME biologists within the project corridor; however, no individuals were
observed. A response letter from USFWS received 05.10.11 indicated that they had no record of federally listed
endangered or threatened species or their habitats occuring in the project area.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? Q Yes ® No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
The project is not located near costal areas where North Carolina's areas of Essential Fish Habitat have been designated.
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?
A scoping letter was provided to SHPO on 04.19.11 _ A response of no impact to cultural resources was received on
05.02.11.
8. Flood Zono Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year'floodpl3in? Q Yes QR No
8b. If yes, explain how project meets FEMA requirements:
8C. What source(s) did you use to make the floodplain determination? FEMA floodplain maps availible from
www,ncfloodmaps,com

Suzanne Knudsen, C.L. 6-7-11

Applicant/Agent's Printed Name plicarlUAgenfs Signature Date
(Agent's Signature is valid only if an authorization toUer from the applicant
is provided.)
Page 1 t of 12
PCN Form - Version 1.3 December 10, 2008 Version
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?• Approximate Location of Project Corridor
Sourca' USGS 1969 Mocks_ _ vil1eN?Z Topographic Map
Scala: As Shown USGS TOPOGRAPHIC MAP
figure;
Drawn by: SLK S&ME glaise Baptist Church Access Road
Checked by: DDH Mocksville, North Carolina A
Date: 4.15.11 Project No.! 1357-11.007

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--- Approximate Location of Project Corridor 60=0: uavie Gounty, NG (31,$ website
® Approximate Location Of Blaise Baptist Church
Mapped Soil Units Within the Project Corridor-
POC2 - Pacolet sandy clay loam 8 -15 percent slopes, eroded
M$B - Mocksville sandy loam, 2 to 8 percent slopes
MSD - Mocksville sandy loam, 15 to 45 percent slopes
Scale: NTS SOIL SURVEY MAP
Drawn by: SLK S&ME
Blaise Baptist Church Access Road
Checked by: OOH Mocksville, North Carolina
Date: a-1$-11 Project No., 1357.11.007
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AGENT AUTHORIZATION FORM
Dew, e) y- 13 --
)roiect Information
&MF. Project Name: Blaise Church Access Road
Type of Project: Jurisdictional lletzrmnwlion and Nationwidc ling Sjv'lees
Location: Interstate Drive, Mocksville, North Carolina
Property OwnerfRepresentative Information
8u5ineSS 1\'arne: J'
Meiling Address: n Oct
City, Mate, Zip Code:
_ J'h a t?'.t. v ; Jl ? ?y C 1 '7 z ?
'r'clcPhone No. T3 3 7._s` J - 3 la ... ... .
Contact: Toes ec? " 33(v,751-542) goq..?333
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Agent Information
Business Name; S&ME, Inc.
Street Address: 9751 Southern Pinc Boulevard
City, State-, Zip Code, Charloue, NC 28273
7elephonc No. {704} 523-4726
Casttact: Ms. Suzanne Knudsen, C. r
Autho6ution:
I ????cr?.< e.5.. on behalf of
(Contac ' gnature)
r' a ,J 9 0 E 74 t ?S,4 C1 rr 4 hcrrhy authorise
(Name of Landowner or Representative:)
S&M1;, Inc. to act as agent for the above-mentioned project.
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PON Form -Version 1.3 December 10, 2008 Version
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