20110685 Ver 1_More Info Received_20110725

Strickland, Bev
From: Homewood, Sue
Sent: Monday, July 25, 2011 11:43 AM
To: Strickland, Bev; Dennison, Laurie
Subject: FW: Blaise Lane - Davie County
Attachments: Blaise Baptist Church.pdf
Please put this in with file 11-0685. Thanks.
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: Suzanne Knudsen rmai1to:SKnudsen6smeinc.com1
Sent: Monday, July 25, 2011 10:44 AM
To: Homewood, Sue
Subject: Blaise Lane - Davie County
Hi Sue
Thanks for speaking with me this morning. Attached, please find a pdf of a portion of the PCN package. So that the
document could be a reasonable size to email, the pdf excludes appendices that contained Protected Species
Assessment, JD Package, Data Forms, Site Photographs and Agency correspondence... if desired; I can make a separate
.pdf of these appendices.
As we discussed (and outlined in the attachment), Blaise Lane will be a NCDOT maintained road to serve Blaise Baptist
Church and will follow NCDOT BMP Manual to treat stormwater. Blaise Lane will have a 60-foot ROW that includes a 20-
foot wide asphalt-paved, two way travel lane and a 6-foot earthen shoulder along both sides of the pavement. No curb
and gutter
I apologize for not providing you a courtesy copy of the PCN package at time of the submittal... but I will on future projects
in your area.
Please let me know if you need further information.
Thanks again
Suzanne
Suzanne L. Knudsen, C.E.
Natural Resources Project Scientist
&VAk Am
&mE
ENGINEERING INTEGRITY.
S&ME, Inc.
9751 Southern Pine Boulevard
Charlotte NC 28273
Ph: 704-523-4726
Fax: [phone]
Mobile: [phone]
sknudsenAsmeinc.com
www.smeinc.com
This electronic message is subject to the terms of use set forth at www.smeinc.com/email. If you received this message in error please advise the sender by reply
and delete this electronic message and any attachments.
Please consider the environment before printing this email.
CORPS SUBIV11TiAL COVER SWEET
Please provide the following info:
1. Project Name: Blaise Church Access Road
2. Name of Property owner/Applicant: Blaise Baptist Church
3. Name of Consultant/Agent: S&ME, Suzanne Knudsen
Agent Authorization needs to be attached
4. Related/Previous Action ID Number(s): N/A
5. Site Address: 134 Blaise Church Road
& Subdivision Name: N/A
7. City: Mocksville
8. County: Davie County, North Carolina
9. Lat: 35.923°N Long. 60.598°W (Decimal Degrees Please)
10. Quadrangle Name: Mocksville [NC] (1969)
11. Waterway: Tributary and wetland draining to Bear Creek
12. Watershed: South Yadkin River
13. Requested Action:
X Nationwide Permit # 39
General Permit #
X Jurisdictional Determination Request
Pre-Application Request
The following information will be completed by Corps office:
AID:
Prepare File Folder
Authorization: Section 10
Section 404
Assign number in ORM
Project Description/Nature of Activity/Project Purpose:
Begin Date
Site/Waters Name:
Keywords:
S&ME
June 8, 2011
U.S. Army Corps of Engineers
Raleigh Regulatory Field Office
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
Attention: Mr. John Thomas
Reference: Pre-Construction Notification and
Request for Jurisdictional Determination
Blaise Baptist Church Access Road
Mocksville. North Carolina
S&ME Project No. 1357-11-007
S&ME Proposal No. 1357-24040-11
Dear Mr. Thomas:
E-71-ILE C y
S&ME, Inc. (S&ME) is hereby submitting a Pre-Construction Notification (PCN) along with
a Request for Jurisdictional Determination for the proposed Blaise Baptist Church Access
Road. The project will involve construction of a 445 linear foot (If) access road to serve the
Blaise Baptist Church and will result in permanent impacts to 95 if of perennial stream
(Stream 1) and 0.013 acre of riparian shrub/scrub wetland (Wetland A). S&ME has been
retained by Blaise Baptist Church to provide services related to project authorization under
Nationwide Permit (NWP) No. 39 - Commercial and Institutional Development. In support
of this PCN we have included the following:
• Figures: Site Vicinity Map (Figure 1), USGS Topographic Map (Figure 2), 2007
Aerial Photograph/Approximate Waters of the U.S. (Figure 3), Soil Survey Map
(Figure 4), Blaise Lane Project Impacts (Figure 5), and Blaise Lane Cross Section
(Figure 6);
• Appendix I: PCN and Agent Authorization Form;
• Appendix II: Site Photographs;
• Appendix III: Approved Jurisdictional Determination Form and attachments;
• Appendix IV: U.S. Army Corps of Engineers (USACE) Routine Wetland Data Form,
USACE Stream Quality Assessment Worksheet and N.C. Division of Water Quality
(DWQ) Stream Identification Form;
• Appendix V: Protected Species Assessment; and
• Appendix VI: Agency Correspondence.
S&ME, INC. / 9751 Southern Pine Boulevard / Charlotte, NC 28273-5560 / p 704.523.4726 f 704.525.3953 / www.smeinc.com
Pre-Construction Notification/Request for Jurisdictional Determination SWE Project No. 1357-11-007
Blaise Baptist Church Access Road June 8 2011
PROJECT INFORMATION
The proposed access road, Blaise Lane, will be a North Carolina Department of
Transportation (NCDOT) maintained street that will serve the existing Blaise Baptist Church
located west of U.S. Highway 601 and south of Interstate Drive in Mocksville, NC. NCDOT
has approved Blaise Lane to have a 60-foot wide right-of-way that includes a 20-foot wide
asphalt-paved, two way travel lane and a six foot earthen shoulder along both sides of the
pavement. Blaise Lane will originate at Interstate Drive and extends southeast for
approximately 445 feet before terminating adjacent to an existing parking lot at Blaise Baptist
Church (0.61 acre).
The proposed access road will cross portions of three parcels (Davie County Parcel
Identification Numbers 5729756528, 572850599, and 5729748796). The project corridor
consists of maintained herbaceous vegetation at its origin near Interstate Drive, with dense
vegetation comprising the remainder of the corridor. Blaise Lane will provide members,
employees, and visitors of Blaise Baptist Church a safe route to access the church. The
current access road terminates at US Highway 601 near Interstate 40. The volume of traffic
on US Highway 601 creates dangerous conditions for those entering and exiting the church.
Blaise Lane will originate at Interstate Drive which will extend to US Highway 601 at a
traffic signal.
A 36-inch high-density polyethylene pipe (HDPE) culvert will be installed under Blaise Lane
and will connect to an existing 36-inch HDPE culvert located to the north. The location and
illustrations of the project corridor are depicted on the attached Site Vicinity Map (Figure 1),
USGS Topographic Map (Figure 2), 2007 Aerial Photograph (Figure 3), Soil Survey Map
(Figure 4), and Blaise Lane Project Impacts (Figure 5).
REGULATED SURFACE WATERS DELINEATION
On April 13, 2010 and again on April 15, 2011, Ms. Suzanne Knudsen with S&ME visited the
project corridor and conducted a regulated surface waters delineation to determine the
location of waters of the U.S., including wetlands. The delineation was conducted utilizing
currently accepted methods for wetland determination, as set forth in the 1987 Corps of
Engineers Wetlands Delineation Manual and corresponding Piedmont Regional Supplement
Guide. Stream assessments were conducted in accordance with DWQ and USACE guidelines.
Field review of the project corridor identified one unnamed tributary to Bear Creek (Stream 1)
and one riparian wetland (Wetland A). Stream 1 is classified as relatively permanent water
with year-round flow (perennial). The headwaters of Stream 1 originate within the project
corridor and flow off-site to the southwest. The channel of Stream I was incised and
exhibited groundwater influence, base flow, and silty substrate. An existing 36-inch HDPE
culvert flows into the headwaters of Stream 1. Wetland A is a jurisdictional shrub/scrub
wetland and exhibited a high water table, inundation, hydric vegetation, and hydric soils.
Vegetation in Wetland A was dominated by a dense shrub/scrub layer and pockets of
emergent vegetation in areas of inundation.
Representative photographs of the project corridor and jurisdictional features identified are
included in Appendix Il, and the locations of photographs and the delineated area along the
2
Pre-Construction Notification/Request for Jurisdictional Determination SWE Project No. 1357-11-007
Blaise Baptist Church Access Road June 8 2011
project corridor are indicated on Figure 3. An Approved Jurisdictional Determination form
was prepared and is incorporated with this PCN for verification (Appendix III). A Completed
DWQ Stream Identification Form and a USACE Wetland Determination Form for the Eastern
Mountains and Piedmont are included in Appendix IV.
PROPOSED PROJECT IMPACTS AND PROJECT DESCRIPTION
Permanent project impacts include 95 if of Stream I and 0.013 acre of Wetland A. These
impacts are broken down as follows and illustrated on Figure 5:
® 73 if of Stream 1 and 0.009 acre of Wetland A associated with 378 square feet of fill
material to accommodate footprint of Blaise Lane
• 22 If of Stream I and 0.004 acre of Wetland A associated with 162 square feet of 9
inch-sized riprap at outfall of HDPE culvert
PROTECTED SPECIES AND CULTURAL RESOURCES
Protected Species
To comply with applicable sections of the Endangered Species Act (ESA) of 1973 (16 USC
1531-1543), S&ME conducted a review of the U.S. Fish & Wildlife Service (USFWS) list of
federally protected species (updated June 23, 2010) documented within Davie County, North
Carolina. This review identified one protected plant species. Listed flora and its federal
status are identified in Table 1.
Table 1: Federally Protected Flora and Fauna Summarv
Species Federal Rank' County Status Habitat Present
Rhus michauxii
Michaux's sumac E Current Yes
c = cnuangereu
In addition to the USFWS database review, S&ME also consulted the North Carolina Natural
Heritage Program (NCNHP) Geographic Information Systems (GIS) database Virtual
Workroom and Element Occurrence (EO) Database for a listing of EOs of endangered or
threatened species within or near the project corridor. The EO Database did not reveal
documented occurrences of federally protected species within a two-mile radius of the project
corridor.
On April 15, 2011, S&ME completed a field reconnaissance for the presence of federally
protected species and their habitat for the 0.61 acre project corridor. Potential habitat
(roadside and edges of artificially maintained clearings) was present for Michaux's sumac
along Interstate Road at the origin of the project corridor (Photo 1). No individuals of this, or
other Rhus species, were observed during the field reconnaissance. A Protected Species
Assessment prepared for the proposed project is included in Appendix V.
On April 19, 2011, S&ME forwarded scoping letters to the USFWS and NCNHP presenting
the findings of the field reconnaissance and requesting comment and/or additional information
these agencies may have regarding federally protected species in or near the project corridor.
On May 10, 2011, the USFWS responded stating that no populations of federally protected
species are known to occur along the project corridor. The USFWS further indicated that
3
Pre-Construction Notification/Request for Jurisdictional Determination SWE Project No. 1357-11-007
Blaise Baptist Church Access Road June 8 2011
because the project corridor is in close proximity to aquatic resources, measures to control
sediment and erosion should be installed prior to ground disturbance. Additionally, the
USFWS requested that native vegetation be used to stabilize disturbed areas.
On May 3, 2011 the NCNHP responded stating that review of their database did not reveal the
presence of protected species within the project corridor. The NCNHP further stated that
although record review did not reveal the presence of federally protected species, a field
review for threatened and endangered species should be conducted if the site is determined to
contain suitable habitat for listed species. As stated previously, a field review was conducted
along the project corridor and no federally protected species were observed.
Cultural Resources
On April 19, 2011, S&ME consulted with the State Historic Preservation Office (SHPO)
requesting their comments on the proposed project and additional information regarding
cultural resources in the vicinity of the project corridor. On May 2, 2011 the SHPO
responded, stating that their record review did not indicate the presence of historic resources
near the proposed access road and therefore, declined to comment.
Please see Appendix VI for correspondence between S&ME and SHPO, USFWS and
NCNHP regarding this project.
AVOIDANCE AND MINIMIZATION
The proposed project has been designed to minimize the impacts to jurisdictional features to
the extent practicable. Impacts to Stream 1 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 I 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.
Nine inch riprap 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 of Environment and Natural Resources Erosion and Sediment Control Planning
and Design Manual.
REGULATORY CONSIDERATIONS
Following construction, temporarily disturbed areas will be stabilized and restored to original
grade and elevation. The proposed project should not result in permanent changes in pre-
construction elevation contours, or stream dimension, pattern or profile, beyond those
described in this application. Excess material will be removed to a high ground disposal area.
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
4
Pre-Construction Notification/Request for Jurisdictional Determination S&ME Project No. 1357-11-007
Blaise Baptist Church Access Road June 8 2011
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.
The project is in compliance with the regional conditions of the NWP and conditions of the
DWQ Water Quality Certification. These conditions include the following:
• stormwater runoff will be treated in accordance with the practices described in the
NCDOT BMP Manual.
• 20 percent of the 36" HDPE 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.
• Effort will be made to maintain the existing channel slope
• Riprap will be buried such that the original stream elevation is restored and maintained
• After construction; disturbed areas will be restored and seeded.
MITIGATION
The proposed permanent impacts to 95 if of stream and 0.013 acre of wetland are less than
typical mitigation thresholds of 150 if of jurisdictional stream and 0.10 acre of wetland. As
stated previously, impacts have been avoided and minimized to the maximum extent
practicable. Appropriate mitigation for the proposed project includes avoidance and
minimization procedures implemented during the design phase of the proposed project.
We do not anticipate that Blaise Baptist Church will be required to provide additional
compensatory mitigation since avoidance and minimization efforts have been undertaken in
the planning process, and total impacts to jurisdictional wetlands and waters of the U.S. are
less than the threshold of NWP No. 39.
CLOSING
By copy of this correspondence and completed PCN, we are requesting your written
concurrence with this application for project authorization under NWP No. 39 as well as
verification of the Jurisdictional Determination for the project corridor. If you desire
additional information, please feel free to contact Suzanne Knudsen at 704.523.4726 or
[e-mail].
Sincerely,
S&M E
uzanne L. Knudsen, C.E. Joey Lawler, P.W.S.
Natural Resources Staff Professional Senior Project Manager
Senior Review by Dane Horna, P.E.
CC: Mr. Joey Kennedy, Blaise Baptist Church, file
5
• Figure 1 - Site Vicinity Map
• Figure 2 - USGS Topographic Map
• Figure 3 - 2007 Aerial Photograph/Approximate Waters of
the U.S.
• Figure 4 - Soil Survey Map
0 Figure 5 - Blaise Lane Project Impacts

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- S &M E
Checked by: DDH Mocksvllle, North Carolina
Date: 4-15-11
Nk. Project No.: 1357-11-007

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Pre-Construction Notification Form
Agent Authorization Form
OHO W A-r RO
O i:?. vTM Y
LM
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification C Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the
Corps:
tqS404 Permit El Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 39 or General Permit (GP) number:
1c. 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):
? 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 ? 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
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ? Yes ® No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes ® No
2. Project Information
2a. Name of project: Blaise Baptist Church Access Road
2b. County: Davie
2c. Nearest municipality / town: Mocksville
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state
project no:
3. Owner Information

3a.
Name(s) on Recorded Deed: William Junker (PIN 5729756528)
James Daugherty (PIN 5729850599)
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
Blaise 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, NC 27028
3f. Telephone no.:
3g. Fax no.:
3h. Email address:
Page I of 12
PCN Form - Version 1.3 December 10, 2008 Version
4. Applicant Information (if different from owner)
4a. Applicant is: ® Agent ? Other, specify:
4b. Name: Mr. Joey Kennedy
4c. Business name
(if applicable): Blaise Baptist Church
4d. Street address: c/o 147 Hickory Drive
4e. City, state, zip: Mocksville, NC 27028
4f. Telephone no.: 336.751.3639
4g. Fax no.: 336.751.1696
4h. Email address: [e-mail]
5. Agent/Consultant Information (if applicable)
5a. Name: Ms. Suzanne Knudsen
5b. Business name
(if applicable): S&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
5g. Email address: [e-mail]
Page 2 of 12
PCN Form - Version 1.3 December 10, 2008 Version
B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): NCPIN# 5729756528, 5729850599, 5729748796
1 b. Site coordinates (in decimal degrees): Latitude: 35.923 Longitude: - 80.598
(DD.DDDDDD) (-DD.DDDDDD)
1 c. 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. 12-108-18(1))
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 Blaise 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 Blaise
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 /
? 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 S&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).
5. Project History
5a. 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, 2008 Version
6. Future Project Plans
6a. Is this a phased project? ? Yes ® No
6b. If yes, explain.
Page 4 of 12
PCN Form - Version 1.3 December 10, 2008 Version
C. Proposed Impacts Inventory
1. Impacts Summary
1a. Which sections were completed below for your project (check all that apply):
® Wetlands ® 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
W1 ® P ? T fill Shrub/scrub ® Yes
? No ® Corps
? DWQ 0.009
W2 ® P ? T rip rap Shrub/scrub ® Yes
? No ® Corps
? DWQ 0.004
W3 ? P ? T ? Yes ? Corps
? No ? DWQ
W4 ? P ? T ? Yes ? Corps
? No ? DWQ
W5 ? P ? T ? Yes ? Corps
? No ? DWQ
W6 ? P ? T ? Yes ? Corps
? No ? DWQ
2g. Total wetland impacts 0.013
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
Temporary (T) (INT)? other) (feet) feet)
S1 ®P ? T fill Stream 1 ® PER
? INT ® Corps
® DWQ 3 73
S2 ® P ? T rip rap Stream 1 ® PER
? INT ® Corps
? DWQ 3 22
S3 ? P ? T ? PER ? Corps
? INT ? DWQ
S4 ? P ? T ? PER ? Corps
? INT ? DWQ
S5 ? P ? T ? PER ? Corps
? INT ? DWQ
S6 ? P ? T ? PER ? Corps
? INT ? DWQ
3h. Total stream and tributary impacts 95
3i. Comments:
Page 5 of 12
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 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 ?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 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 impacts require mitigation, then you MUST fill out Section D of this form.
6a.
Project is in which protected basin?
6b. 6c. 6d.
Buffer impact
number - Reason
Permanent (P) or for
Temoorarv (T) impact
131 ?P?T
B2 ?P?T
B3 ?P?T
6i. Comments:
? Neuse ? Tar-Pamlico ? Other:
? Catawba ? Randleman
6e. 6f. 6g.
Buffer
Stream name mitigation
required?
? Yes
? No
? Yes
? No
? Yes
? No
6h. Total buffer impacts
Zone 1 impact Zone 2 impact
(square feet) (square feet)
Page 6 of 12
PCN Form -Version 1.3 December 10, 2008 Version
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. 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 1 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 NCDOT BMP Manual.
• 20 percent of the 36" HDPE 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 of 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; mitigation is required by (check all that apply): ? DWQ ? Corps
? Mitigation bank
2c. If yes, which mitigation option will be used for this
El 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
PCN Form - Version 1.3 December 10, 2008 Version
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): 0 square feet
4e. Riparian wetland mitigation requested: 0 acres
4f. Non-riparian wetland mitigation requested: 0 acres
4g. Coastal (tidal) wetland mitigation requested: 0 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.
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by DWQ
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:
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:
I
Page 8 of 12
PCN Form - Version 1.3 December 10, 2008 Version
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 ® 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? NA %
2b. Does this project require a Stormwater Management Plan? ? Yes ® 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, na rrative 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 the following locally-implemented stormwater management programs ? NSW
? 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
attached? ? Yes ? No
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
Page 9 of 12
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 ? Yes ® No
use of public (federal/state) land?
1b. 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)?
1 c. 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.
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
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?
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 by S&ME 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? ? 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 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:
8c. What source(s) did you use to make the floodplain determination? FEMA floodplain maps availible from
www.ncfloodmaps.com
1
Suzanne Knudsen, C.E. 6-7-11

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 11 of 12
PCN Form - Version 1.3 December 10, 2008 Version
Page 12 of 12
PCN Form - Version 1.3 December 10, 2008 Version
ItS&ME
AGENT AUTHORIZATION FORM
Date: Q Y- / 3 //
Project inrormation
S&MF. Project Name: Blaise Church Access Road
Type of Project: Jurisdictional Determination and Nationwide Permitting Services
location: lnterstate Drive, Mocksville, North Carolina
Property Owner/Representative Information
Business Name: i s ?•,? t Q a? f ^i f C? v rC
Mailing Address:
City, State, Zip Code;
v Ile 7 V z d
Telephone No. 3 3 (? . 7 .S - 3 3 I
Contact: ?'O e ? I? ? ?, ? e ? ?/ 3.3 -7 S 1- Ij q o q ? ? 3.3 3
X41 -7 i,'il-ORV DQ,'Le-
muc,?c,t?%1??? "svL a74 3d
Ascent Information
Business ;Name: S&ME, Inc.
Street Address: 9751 Southern Pine Boulevard
City, State, Zip Code: Charlotte, NC 28273
._...........
Telephone No. [phone]
Contact: Ms. Suzanne Knudsen, C_F.
Authorization:
I Yo_ on behall'of
(Contact gnature)
_f e- e cy7_f'S'>< 1?) u re'? hereby authorize
(Name of Landowner or Representative)
S&ME, Inc. to act as agent for the above-mentioned project.
6d Wdab:TT TTOE 2T -add 969TTSL922: 'ON Xdd Ho?nHO 1SIlddH 3SIH_17: WO?Id