20110712 Ver 1_401 Application_20110811

20110712
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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Pre-Construction Notification (PCN) Form
A. Applicant Information LULLED
-
1. Processing
1 a. Type(s) of approval sought from the Corps: MISection 404 Permit ? Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 02 or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps? Q/Yes ? No
1d. Type(s) of approval sought from the DWQ (check all that apply):
03(s401 Water Quality Certification - Regular ? Non-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express [Riparian Buffer Authorization
le. Is this notification solely for the record
because written approval is not required? For the record only for DWQ
401 Certification:
? Yes El"No For the record only for Corps Permit:

? Yes 8No
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 2_1?0
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
? Yes to
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes o
2. Project Information
2a. Name of project:
2b. County: k
2c. Nearest municipality /town:
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state project no:
3. Owner Information etlds ?A7Zeu QR~?
3a. Name(s) on Recorded Deed: -<S'ranct,
36. Deed Book and Page No.
Responsible Party (for LLC if
applicable):
?,? •v? c?? & J
3d. Street address: Q to S \.kJ
3e. City, state, zip:

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3f. Telephone no.:
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3g. Fax no.:
3h. Email address:
Page 1 of 10
PCN Form - Version 1.4 January 2009
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:
Agent/consultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 10
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.
Wetland impact
number
Permanent (P) or
Temporary 2b.
Type of impact 2c.
Type of wetland 2d.
Forested 2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other) 2.
Area of
impact
(acres)
W1 - Choose one Choose one Yes/No -
W2 - Choose one Choose one Yes/No -
W3 - Choose one Choose one Yes/No
W4 - Choose one Choose one Yes/No
W5 - Choose one Choose one Yes/No -
W6 - Choose one Choose one Yes/No -
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.
Stream impact
number
Permanent (P) or
Temporary m 3b.
Type of impact 3c.
Stream name 3d.
Perennial (PER) or
intermittent (INT)? 3e.
Type of
jurisdiction 3f.
Average
stream
width
(feet) 3g.
Impact
length
(linear
feet)
S1 - Q Choose one DV,?--CLjr ,y VV ?v (.mot P - LO (r
S2 - P Choose one
v - P - t-10Y ;I-
S3 - Choose one
S4 - Choose one - -
S5 - Choose one
S6 - Choose one
3h. Total stream and tributary impacts 3 6 -F4
3i. Comments:
Page 4 of 10
PCN Form - Version 1.4 January 2009
. Open Water Impacts
X
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
W
the U.S. then individual) list all open water impacts below.
4a. 4b. 4c. 4d. 4e.
Open water Name of waterbody
impact number (if applicable) Type of impact Waterbody Area of impact (acres)
Permanent (P) or type
Temporary
01 - Choose one Choose
02 - Choose one Choose
03 - Choose one Choose
04 - Choose one Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If and or lake construction proposed, then com lete the chart below.
5a. 5b. 5c. 5d. 5e.
Pond ID number Proposed use or Wetland Impacts (acres) Stream Impacts (feet) Upland
purpose of pond (acres)
Flooded Filled Excavated Flooded Filled Excavated
P1 Choose one
P2 Choose one
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:
r v?1
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 t Section D of this form.
6a. Project is in which protected basin? ? Neuse Tar-Pamlico E] Catawba M Randleman ? Other:
6b. 6c. 6d. 6e. 6f. 6g.
Buffer Impact Reason for impact Stream name Buffer Zone 1 Zone 2
number - mitigation impact impact
Permanent (P) or required? (square (square
mporary (T) ra feet feet
B1 '? - rl tl?W 0,-4 U.? - 0r Q,V
10 A, 1 Yes N (? u v
B2 ' . .. r ?i Qtr-A V Yac/ a ?- !mil C
B3 - Yes/No
B4 - Yes/No
135 YeslNo
B6 Yes/No
6h. Total Buffer Impacts:
6i. Comments:
Page 5 of 10
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
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1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
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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
If yes, mitigation is required by (check all that apply): ? DWQ ? Corps

If yes, which mitigation option will be used for this
project? ? Mitigation bank
? Payment to in-lieu fee program

? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
/,3a. Name of Mitigation Bank:

3)6. Credits Purchased (attach receipt and letter) Type: Choose one
Type: Choose one
Type: Choose one Quantity:
Quantity:
Quantity:
. Comments:
Complete if Makin 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: Choose one
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:
. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
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Page 6 of 10
PCN Form - Version 1.4 January 2009
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 Yes o
buffer mitigation?
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.
6c. 6d. 6e.
Zone Reason for impact Total impact Multiplier Required mitigation
(square feet) (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 7 of 10
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
I a. Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules? Yes ? No
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
? Yes
No
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 El"No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
'Drk UQ W d.'? k
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e. Who will be responsible for the review of the Stormwater Management Plan?
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project? ') t r

3b. Which of the following locally-implemented stormwater management programs
apply (check all that apply): ? Phase II
? NSW
? USMP
? Water Supply Watershed
? Other:
3c. Has the approved Stormwater Management Plan with proof of approval been
attached? ? Yes ? No
4. DWQ Stormwater Program Review

4a. Which of the following state-implemented stormwater management programs apply
(check all that apply): E]Coastal counties
?HQW
?ORW

?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 8 of 10
PCN Form - Version 1.4 January 2009
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1a. Does the project involve an expenditure of public (federal/state/local) funds or the El Yes 5]/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)?
1c. 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
letter.) ? Yes ? No
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, 92r es ? No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the-fact permit application? es ? No
if you answered "y

s" to one or both of the above estions provide n explanation of the viol tion(s
T C r1f C to r I Ulit- __A_ (L 4
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3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result It in
ddi
i Yes o
a
t
onal 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.
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.
/V
4
Page 9 of 10
PCN Form - Version 1.4 January 2009
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or

habitat?
? Yes No
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts? ??
? Yes L?t"No
5c. If yes, indicate the USFWS Field Office you have contacted.
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ? Yes 0
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
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
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?

? Yes o
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
8. Flood Zone Designation (Corps Requirement)

8a. Will this project occur in a FEMA-designated 100-year floodplain? ? Yes No
-T--
))6. If yes, explain how project meets FEMA requirements:
T_. What source(s) did you use to make the floodplain determination?

Applicant/Agent's Printed Name Applicant/Agent's Signature
(Agent's signature is valid only if an authorization
letter from the applicant is provided.) Date
Page 10 of 10
Printed -Jul 29, 2011

UNITED STATES
DEPARTMENT OF AGRICULTURE
NATURAL RESOURCES CONSERVATION SERVICE
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