20110708 Ver 1_401 Application_20110811

SOIL & WATER 2 °' "' ° a
CALDWELL SOIL AND WATER CONSERVATION DISTRICT
120 Hospital Avenue NE* Lenoir, NC 286455 • (828)-758-1111
July 20, 2011
NCDWQ401 Wetlands Unit
1650 Mail Service Center i
T
Raleigh, NC 27699-1650
x
To Whom It May Concern:
Please review the Preconstruction Notification (PCN) for Caldwell Memorial Hospital.
If you have any questions, contact me at 828-758-1111 or 828-439-9727, ext. 3.
Thanks for your consideration.
Sincerely,
Kevin K Clark
Caldwell SWCD

•
201 10708
o?0F W A r?9?G
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>_ y
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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification PCN Form
A. Applicant Information
1. Processing
1a. Type(s) of approval sought from the
Corps:
®Section 404 Permit ? Section 10 P Am-1- t
#A-
1 b. Specify Nationwide Permit (NWP) number: 27 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
n. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes ® No
2. Project Information
2a. Name of project: Caldwell Memorial Hospital (Caldwell Senior Center)
2b. County: Caldwell
2c. Nearest municipality / town: Lenoir
2d. Subdivision name: N/A
2e. NCDOT only, T.I.P. or state
project no:
3. Owner Information U .
3a. Name(s) on Recorded Deed: Caldwell Memorial Hospital yyUENR - I g4
Of 141 I!
nd

3b.

Deed Book and Page No. s

0782/0103 0082 0.00
P
wad &anch
3c. Responsible Party (for LLC if
applicable): Jim Smith
3d. Street address: 650 PENNTON AVENUE SW
3e. City, state, zip: Lenoir, NC 28645-1890
3f. Telephone no.: 828-757-5152
3g. Fax no.:
3h. Email address:
Page I of 11
PCN Form - Version 1.3 December 10, 2008 Version
4. Applicant Information (if different from owner)
4a. Applicant is: ? Agent ? Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name: Kevin Clark
5b. Business name
(if applicable): Caldwell Soil and Water Conservation District
5c. Street address: 120 Hospital Avenue
5d. City, state, zip: Lenoir, NC 28645
5e. Telephone no.: 828-758-1111
5f. Fax no.: 828-758-7257
5g. Email address: [e-mail]
Page 2 of 11
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): 2749957177
Latitude: 35.9085 Longitude: - 81.5330
1 b. Site coordinates (in decimal degrees): (DD.DDDDDD) (-DD.DDDDDD)
1 c. Property size: 4.9 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to Unamed Ut to Lower Creek
proposed project:
2b. Water Quality Classification of nearest receiving water: C thenWS-IV
2c. River basin: Catawba
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 project area is in a residential area with lawn on both sides of the stream that bisecs the property. The streambanks
are failing. Vertical banks with sparse vegetation continues to erode during storm events.
3b. List the total estimated acreage of all existing wetlands on the property:
0
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
270' according to Caldwell County GIS Mapping
3d. Explain the purpose of the proposed project:
The purpose of the project is to stabilize the streambanks.
3e. Describe the overall project in detail, including the type of equipment to be used:
The project design was furnished by the Division of Soil and Water Conservation Engineer. This design will utilize
bioengineering techniques for stream restoration. Equipment used for the project will be one or more of the following; a
hydraulic excavator, front end loader, rubber tire backhoe, farm tractor and dump truck.
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.
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.
6. Future Project Plans
6a. Is this a phased project? ? Yes ® No
6b. If yes, explain.
Page 3 of 11
PCN Form - Version 1.3 December 10, 2008 Version
Page 4 of 11
PCN Form - Version 1.3 December 10, 2008 Version
C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
? Wetlands ® 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 ? Yes ? Corps
? No ? DWQ
W2 ? P ? T ? Yes ? Corps
? No ? DWQ
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
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
realigntment plus
Ut to Lower Creek
® PER
? INT
® Corps
® DWQ 5.2
Bankfull
55
bank shaping Width

S2 ®P ®T 1 Rock Cross
Vane
Ut to Lower Creek ® PER

?INT ® Corps

®DWQ 5.2
Bankfull
15
Width
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 70
3i. Comments:
Page 5 of 11
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, the n 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.
? Neuse
? Tar-Pamlico ? Other:
Project is in which protected basin? ? Catawba ? Randleman
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number- Reason Buffer Zone 1 impact Zone 2 impact
Permanent (P) or for Stream name mitigation (square feet) (square feet)
Temporary T impact required?
B1 ?P?T ?Yes
? No
B2 ? P ? T ? Yes
? No
B3 ?P?T ?Yes
? No
6h. Total buffer impacts
6i. Comments:
Page 6 of 11
PCN Form - Version 1.3 December 10, 2008 Version
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1 a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
The work will be bank shaping except for an in-stream rock structure at the upstream portion of the project and stream
realignment in the center section of the project.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
All graded areas will be seeded. The new streambank profile will be protected by erosion control matting as vegetation is
being established. Woody plants (livestakes and/or rooted seedlings) will be a vital part of the final stabilization.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State? ? Yes ® No
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps

2c. If yes, which mitigation option will be used for this

project? ? Mitigation bank

El Payment to in-lieu fee program

? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type Quantity
3c. Comments:
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: ? warm ? cool ?cold
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 7of11
PCN Form - Version 1.3 December 10, 2008 Version
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:
Page 8 of 11
PCN Form -Version 1.3 December 10, 2008 Version
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?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
? Yes ? No
Comments:
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? 0%
2b. Does this project require a Stormwater Management Plan? ? Yes ® No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why: This project establishes a riparian buffer
along the stream corridor.
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
? Certified Local Government
2e. Who will be responsible for the review of the Stormwater Management Plan? ? DWQ Stormwater Program
? DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
? Phase II
? NSW
3b. Which of the following locally-implemented stormwater management programs ? USMP
apply (check all that apply): ? Water Supply Watershed
? Other:
3c. Has the approved Stormwater Management Plan with proof of approval been ? Yes ? No
attached?
4. DWQ Stormwater Program Review
? Coastal counties
? HQW
4a. Which of the following state-implemented stormwater management programs apply ? ORW
(check all that apply): ? Session Law 2006-246
? Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
? Yes ? No
attached?
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? ? Yes ? No
5b. Have all of the 401 Unit submittal requirements been met? ? Yes ? No
Page 9 of 11
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?
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State ? Yes ® No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
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.
No new impervious surfaces are planned.
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non-discharge or discha rge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
No wastewater being generated.
Page 10 of 11
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?
NC Natural Heritage Program Virtual Workroom
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?
NOAA Essential Fish Habitat Mapper
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?
Request for Cultural Review, CRS, NRCS, 1835 Assembley Street, Room 950, Columbia, SC 29201
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year flood plain? Z Yes No
8b. If yes, explain how project meets FEMA requirements: Project will be implemented using natural stream design
techniques
8c. What source(s) did you use to make the floodplain determination? NC Floodplain Mapping Program
Jim Smith
Applicant/Agent's Printed Name Appllcant/Agent's Signature Date
s signature is valid only if an authorization letter from the applicant
is rovided.
Page 11 of 11
PCN Form - Version 1.3 December 10, 2008 Version
650 Pennton Avenue Southwest, Lenoir, NC - Google Maps
Address 650 Pennton Ave SW
Go 1g e maps Lenoir, NC 28645
Page 1 of 1
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Conservation Plan Map Date: 5/19/2011
Customer(s): CALDWELL MEMORIAL HOSPITAL Field Office: LENOIR PROGRAM DELIVERY POINT
Agency: Caldwell Soil and Water Conservation Distric
District: CALDWELL COUNTY SOIL & WATER CONSERVATION DISTRICT Assisted By: Kevin Clark
Approximate Acres: 4.9 Land Units:
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Name: LENOIR Location: 035' 54'46.5" N 081- 32' 29.6" W
Date: 7/1/111 Caption: Caldwell Memorial Hospital
Scale: 1 inch equals 2000 feet CR review
Lenoir Quad
Copyright (C) 1997, Maptech, Inc
Markers
Name: Gerald Bolick
Short Name: GrldBI
Coordinates: 035° 59' 10.1" N, 081° 33' 01.4" W
Name: Caldwell Memorial Hospital
Short Name: Cldwll
Coordinates: 035° 54' 30.4" N, 081 ° 31' 58.8" W

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