20120118 Ver 1_401 Application_20120212

Setting the Standard for Service
Geotechnlcal Construction Materials Environmental Facilities NC Registered Engineering Firm F 1078
20120118
Ms Karen Higgins
February 2 2012
NC DWQ 401/Wetlands Unit P�
1650 Mad Service Center
Raleigh NC 27699 1650
Subject Pre - Construction Notification Application D
Request for 401 Water Quality Certification
Triad Baptist Church
1306 Masten Drive r EB 1/
Kernersvdle Forsyth County North Carolina _ 6 2012
ECS Project 09 19746 -C DENR WATERQuALIn,
�Ga AND S TOR,`,ryyATER B�MCH
Dear Ms Higgins
Please find five copies of the Pre - Construction Notification Application for the above referenced
site The site is located at 1306 Masten Drive in Kernersvdle and consists of an approximate
5 89 acre tract The site contains wooded land The site is being developed with necessary
parking children s recreational areas a maintenance budding and a stormwater pond to
accommodate the proposed expansion of Triad Baptist Church which is located on adjacent
property west of the tract where the impacts will occur ECS completed a wetland delineation on
the site in August 2011 Mr John Thomas with the U S Army Corps of Engineers (USACE)
and Ms Sue Homewood with the NC Division of Water Quality (DWQ) venfied the delineation
on September 13 2011
On behalf of Triad Baptist Church I am requesting that a 401 Water Quality Certification be
issued to authorize the permanent impact (culvert and np rap) to 299 linear feet of mitigable
stream channel (USACE 1 1 DWQ 1 1) and the permanent impact (fill) to 0 06 acres of
wetland Due to the amount of wetland impacts being less than 0 10 acres mitigation for
wetland impacts is not required Compensatory mitigation is proposed through the NC
Ecosystem Enhancement Program (EEP) to purchase 299 linear feet of stream credits (EEP
acceptance letter attached) The proposed mitigation should satisfy the USACE and NC DWQ
mitigation requirements Private mitigation banks have been contacted and do not have
available credits There are no additional wetland or stream impacts proposed at this time
4811 Koger Boulevard Greensboro NC 27407 T 336 856 7150 F 336 856 7160 www ecslimited corn
ECS Carolinas LLP ECS Florida LLC ECS Mid Atlantic LLC ECS Southeast LLC ECS Texas LLP

Request for 401 Water Quality Certification
Thad Baptist Church 1306 Masten Drive
Kemersvdle Forsyth County North Carolina
ECS Project 09 19476 C
Please feel free to contact me at (336) 856 -7150 if you have any questions concerning this
request or if additional information is required Thank you in advance for your timely
consideration of this matter
Sincerely
ECS Caro etas, LLP
4 +�
Bradley S Luckey
Environmental Staff Project Manager
Michael T Brame PWS
Environmental Principal
Attachments Pre Construction Notification Application
401 Water Quality Certification Fee -$570 00

ot w arF9
o� QG
� Y
2 0 1? n 1 1 8
Office Use Only
Corps action ID no
DWQ project no
Form Version 13 Dec 10 2008
Page 1 of 12
PCN Form — Version 13 December 10 2008 Version
Pre- Construchon Notification C Form
A Apphcant Information
kA
M
1
Processing
la
Type(s) of approval sought from the
Corps
®Section 404 Permit ❑Section 10 Permit
1b Specify Nationwide Permit (NWP) number NWP 39 or General Permit (GP) number
1c
Has the NWP or GP number been venfied by the Corps?
® Yes
❑ No
1d
Type(s) of approval sought from the DWQ (check all that apply)
® 401 Water Quality Certification — Regular ❑ Non -404 Junsdicbonal General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
1e
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
If
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
1g
Is the project located in any of NC s twenty coastal counties If yes answer 1 h
below
❑ Yes
® No
1h
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes
® No
2
Project Information
2a
Name of project
Triad Baptist Church 1306 Masten Drive
2b
County
Forsyth
2c
Nearest municipality / town
Kemersvdle
2d
Subdivision name
2e
NCDOT only T I P or state
project no
D
At
ftu
3
Owner Information
3a
Name(s) on Recorded Deed
Aegis Family Health Centers
6
3b
Deed Book and Page No
Book 1963 Page 2428 6th
ENR WATER
3c
applicable) e le Party (for LLC if
Triad Baptist Church
` NiRB&4N(
3d
Street address
1175 South Main Street
3e
City state zip
Kemersvdle North Carolina 27284
3f
Telephone no
[phone]
3g
Fax no
(336) 854 -4892
3h
Email address
dmoore11 @tnad rr com
Page 1 of 12
PCN Form — Version 13 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
Bradley S Luckey
5b
Business name
(if applicable)
ECS Carolinas LLP
5c
Street address
4811 Koger Boulevard
5d
City state zip
Greensboro NC 27407
5e
Telephone no
[phone]
5f
Fax no
[phone]
5g
Email address
bluckey @ecshmited com
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)
6875 59 3118 00
Latitude 361077977 Longitude
1 b Site coordinates (in decimal degrees)
80 098253
(DD DDDDDD) (DD DDDDDD)
1c Property size
5 89 acres
2 Surface Waters
2a Name of nearest body of water (stream river etc ) to
Smith Creek
proposed project
2b Water Quality Classification of nearest receiving water
Class III
2c River basin
Yadkin
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 site contains undeveloped wooded land The site is located in a commercial and residential area of Kemersvdle
3b List the total estimated acreage of all existing wetlands on the property
0 118 acres
3c List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
517 56 feet
3d Explain the purpose of the proposed project
The purpose of the proposed project is to accommodate the expansion of Triad Baptist Church The expansion includes
an addition onto the existing Triad Baptist Church which is located on adjacent property west of the tract where the
impacts will occur The expansion will encroach into the existing parking area and will eliminate 281 existing parking
spaces The expansion will result in the need for 493 additional parking spaces The church has a 5 89 acre parcel (tract
where impacts will occur) under contract to accommodate the necessary parking construct a stormwater pond a
maintenance structure and a small recreational area for children The proposeed project will impact 299 linear feet of
stream channel and 0 06 acres of wetland
3e Describe the overall project in detail including the type of equipment to be used
The project includes the construction of a 80 246 square foot budding addition that will accommodate for the expansion of
educational children services and recreational areas assoicated with Triad Baptist Church In addition an ampitheater is
being constructed In conjunction with the construction activities on adjoining property the parcel where the impacts will
occur will be developed with necessary parking a children s recreational area a maintenance budding and a stormwater
pond To develop the site as proposed it is necessary to clear and grade the site As part of the grading 299 linear feet
of stream channel will be piped with 48 RCP In addition it is necessary to fill 0 06 acres of wetland
Graders haulers excavators and cranes will be used during the grading and construction activities on the site
4 Jurisdictional Determinations
4a Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
Yes ❑ No El Unknown
project (including all prior phases) in the pasty
Comments John Thomas and Sue Homewood
4b If the Corps made the jurisdictional determination what type
ED Preliminary ®Final
of determination was made
4c If yes who delineated the jurisdictional areas?
Agency /Consultant Company ECS Carolinas LLP
Name (if known) Bradley Luckey
Other
4d If yes list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
Corps = September 26 2011 DWQ = September 15 2011
Page 3 of 12
PCN Form — Version 1 3 December 10 2008 Version

5 Project History
5a Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
❑ Yes ® No ❑ Unknown
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 4 of 12
PCN Form — Version 1 3 December 10 2008 Version

C Proposed Impacts Inventory
1 Impacts Summary
la 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 assoicated
with Culvert/Rip
® Yes
® Corps
0 06
Rap
[:1 No
❑DWQ
W2 []PMT
❑ Yes
❑ Corps
❑ No
❑ DWQ
W3 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W4 ❑ P [IT
❑ Yes
❑ Corps
❑ No
❑ DWQ
W5 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W6 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
2g Total wetland impacts
2h Comments 0 06 acres of wetlands will be filled during the construction of the proposed parking area Because the amount
of impacted wetlands is less than 0 10 acres mitigation is not proposed for the wetland impact
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
Culvert/ Rip Rap
Unnamed
® PER
❑ INT
® Corps
® DWQ
4
299
S2 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
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
299
31 Comments 299 linear feet of stream will be impacted by the project The stream has been classified mitigable by the U S
Army Corps of Engineers and must be mitigated for at a 1 1 ratio DWQ requires a 1 1 mitigation ratio as well The mitigation
will be satifies through payment to the EEP
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 No open water impacts are proposed
5 Pond or Lake Construction
If pond 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
Stormwater
0 268
P2
5f Total
5g Comments At least 85% TSS
5h Is a dam high hazard permit required
❑ Yes No If yes permit ID no
51 Expected pond surface area (acres)
0 268
5j Size of pond watershed (acres)
810
5k Method of construction
Excavated in high ground
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 any 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
B1 ❑P ❑T
.-required?
❑Yes
❑ No
B2 ❑ P ❑ T
❑ Yes
❑ No
B3 ❑P ❑T
El Yes
❑ No
6h Total buffer impacts
61 Comments The site is located within the Yadkin River basin in an area that has been designated as Class III Waters
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
Because of the proposed expansion of Triad Baptist Church on the property immediately west of the site parking spaces are
needed to fulfill Triad Baptist Church and Town of Kemerswlle parking requirements Triad Baptist Church has no other
practical site alternatives that will meet their parking requirement Triad Baptist Church property is situated where alternative
sites to increase parking areas could not be constructed north of their property due to Kemersvdle Road /commercial
development or south and west of their property due to the location of Smith Creek and commercial development
The other alternative is for the church to relocate This is not a practical alternative due to economic population base and
location constraints In addition the church would likely be resituated in a less developed area of Kemersville and would likely
have greater environmental impacts to a greenfield site and socio economic impacts
The proposed parking areas will impact 299 linear feet of stream channel and 0 06 acres of wetlands In order to minimize
impacts headwalls and endwalls have been designed that are approximately 6 feet tall The slopes in the area of the impact
are proposed to be 2 1 the maximum allowed
The stream that is being impacted is poor quality The stream originates onto the site from a culvert discharging from a
stormwater pond on adjacent property The pond receives stormwater from a developed area of Kernersvdle which contains a
large percentage of impervious surfaces The stream quality is compromised and provides little habitat for aquatic species
There is approximately 0 118 acres of wetlands and approximately 517 56 linear feet of stream channel that exists on the site
The remaining 0 058 acres of wetlands and approximately 218 56 linear feet of stream channel are being avoided In addition
undisturbed buffers (inner 30 feet on both sides of stream) and vegetated buffers (outer 70 feet on both sides of stream) will
be established on the portions of the stream channel that will not be impacted (View Exhibits)
1 b Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
The clearing limits will be staked and silt fence will be used A temporary coffer dam will be installed upgradient of the
proposed culvert within the area of stream that will be permanently impacted with np rap During construction water will be
pumped around or diverted into by pass channels in the construction area All temporary impacts will take place within the
limits of the permitted impacts Upon completion of culvert installation the temporary sand bag coffer dams will be removed
and stream flow will be diverted through the culvert Following construction disturbed slopes will be stabilized with permanent
seeding matting and temporary slope linings Best management practices will be implemented during construction activities to
avoid sediment discharge into downgradient streams and wetlands A Temporary Culvert Crossing Pump Around for
Culvert Installation exhibit is included on the Culvert Crossing Plan generated by Fleming Engineering that is included as an
attachment
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
®Payment to in lieu fee program
projects
❑ Permittee Responsible Mitigation
3 Complete if Using a Mitigation Bank
3a Name of Mitigation Bank
3b Credits Purchased (attach receipt and letter)
I Type
Quantity
Page 7 of 12
PCN Form — Version 1 3 December 10 2008 Version

3c Comments Mitigation banks do not have enough available credits in this watershed
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
300 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 EEP has accepted 300 feet of stream credits (EEP Acceptance Letter is attached)
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
j 15
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 The site is located within an area that is not subject to the state mandated riparian buffer rules Therefore
buffer mitigation is not proposed and should not be required
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
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?
lb
If yes then is a diffuse flow plan included? If no explain why
Comments The site is located in an area that is not subject to state mandated
❑ Yes ® No
riparian buffer rules
2
Stormwater Management Plan
2a
What is the overall percent imperviousness of this project?
2844%
2b
Does this project require a Stormwater Management Plan?
® Yes ❑ No
2c
If this project DOES NOT require a Stormwater Management Plan explain why
2d
If this project DOES require a Stormwater Management Plan then provide a brief narrative description of the plan
A 0 268 acre stormwater pond has been designed to treat stormwater runoff The stormwater pond has been designed to
treat at least 85% total suspended solids The current proposed construction will create 28 44% impervious surfaces
The stormwater pond has been designed to treat stormwater based on the site being
28 44% impervious The
stormwater plan is being mailed to the Town of Kemersvdle for review and is not included in this permit application
❑ 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?
Kemersvdle
® Phase II
3b
Which of the following locally implemented stormwater management programs
❑ NSW
❑ USMP
apply (check all that apply)
® Water Supply Watershed
® Other Salem Lake
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 Salem Lake Water
Supply
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
Page 9 of 12
PCN Form — Version 1 3 December 10 2008 Version

5b Have all of the 401 Unit submittal requirements been mete
ToYes ❑ No
F Supplementary Information
1 Environmental Documentation (DWQ Requirement)
1a Does the project involve an expenditure of public (federal /state /local) funds or the
❑ Yes ® No
use of public (federal /state) land?
lb 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 A NEPA or SEPA is not required as part of this project
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
We are not aware of additional development that will result which will impact nearby downstream water quality
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
Wastewater from the church will be discharged into the City of Winston Salem /Forsyth County Sewer services No new
lines will be connected aside from the buildings additions No stream or wetland impacts will occur that are assoicated with
sewage disposal
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?
ECS consulted the Natural Heritage Program Website to determine if federally protected endangered or threatened
species inhabit the Kemersville NC Quadrangle (the quadrangle that contains the site) There are no federally listed
protected endangered or threatened species that have been identified on this quadrangle
6 Essential Fish Habitat (Corps Requirement)
6a Will this project occur in or near an area designated as essential fish habitats
❑ Yes ® No
6b What data sources did you use to determine whether your site would impact Essential Fish Habitat?
Based on our knowledge of the site the site is not located in or near an area designated as essential fish habitat We did
not observe fish inhabiting the stream during our site visits Best management practices and the construction of stormwater
ponds will prevent sediment from entering down gradient waterbodies which may contain fish
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?
We reviewed the SHPO Map (http / /gis ncdcr gov /hpoweb /) to identify historic and /or archaeological resources of the site
The SHPO map did not identify historic and /or cultural resources on the site or in the vicinity of the site A copy of the map
is included as an attachment
In addition to the SHPO map we have reviewed aerial photographs dating back to 1951 The site has contained
undeveloped wooded land since at least 1951
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 The 100 Year floodplain encroaches onto the southern portion of
the tract where the impacts will occur However impacts will not occur in the 100 Year Floodplain (View exhibits)
8c What source(s) did you use to make the floodplain determination? FEMA Map Panel 3710687500J Attachments
Bradley S Luckey
2212
Applicant/Agents Printed Name
Date
Applic t/Agent s Signature
A ents si nature is valid only if an authorization letter from the applicant
Page 11 of 12
PCN Form — Version 1 3 December 10 2008 Version

Appraa am s 69 Acre rracl
1306ID &Vn Road
Kern Ab*Cxoft
a ORIMU -p it, wit
ECS CarOlOws, LLP
AGENT AUTHORIZATION
This form authorizes ECS to act as our agent in stream/wetland matters including U S Army
Corps of Engineers and North Carolina Division of Water Quality field verification and permit
application
Property Address
Owner Information
Name i�r� 1
A� N G .ry-t.S
Address -3240 C L S R d
AP7
GCE Moat NG 7 OIZ
Telephone Number 33(0 716 ^ 76 6
Fax Number
E mail Address c` �, v MG t✓
Signature
Date 07 i aO LL
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Dwight Moore
Triad Baptist Church
1175 South Main St
Kernersville NC 27284 Expiration of Acceptance May 1 2012
Protect 1306 Masten Drive County Forsyth
The purpose of this letter is to notify you that the North Carolina Ecosystem Enhancement Program (NCEEP) is willing to accept
payment for compensatory mitigation for impacts associated with the above referenced protect as indicated in the table below Please
note that this decision does not assure that participation in the NCEEP will be approved by the permit issuing agencies as mitigation
for project impacts It is the responsibility of the applicant to contact these agencies to determine if payment to the NCEEP will be
approved You must also comely with all other state, federal or local government permits regulations or authorizations associated
with the nronosed activity including SL 2009 337 An Act to Promote the Use of Compensatory Mitigation Banks as amended by
S L 2011 343
This acceptance is valid for six months from the date of this letter and is not transferable If we have not received a copy of the
issued 404 Permit1401 Certification/CAMA permit within this time frame, this acceptance will expire It is the applicant s
responsibility to send copies of the permits to NCEEP Once NCEEP receives a copy of the pertnit(s) an invoice will be issued based
on the required mitigation in that permit and payment must be made prior to conducting the authorized work The amount of the In
Lieu Fee to be paid to NCEEP by an applicant is calculated based upon the Fee Schedule and policies listed at www nceep net
Based on the information supplied by you in your request to use the NCEEP the impacts that may require compensatory mitigation are
summarized in the following table The amount of mitigation required for this impact is determined by permitting agencies
Upon receipt of payment EEP will take responsibility for providing the compensatory mitigation The mitigation will be performed in
accordance with the N C Department of Environment and Natural Resources Ecosystem Enhancement Program In Lieu Fee
Instrument dated July 28 2010
Thank you for your interest in the NCEEP If you have any questions or need additional information please contact Kelly Williams at
[phone]
Sincerely
Micha Ilison
Deputy Director
cc Karen Higgins NCDWQ Wetlands /401 Unit
John Thomas USACE Raleigh
Sue Homewood NCDWQ Winston Salem
Bradley Luckey agent
File
Rutoru29 F Prot" Our .fta&
TA
CCDENR
North Carolina Ecosystem Enhancement Program 1652 Mad Service Center Raleigh NC 27699 1652 / 919 715 0476 / www nceep net
River
CU
Stream (feet)
Wetlands (acres)
Buffer I
Buffer II
Basin
Location
(Sq Ft)
(Sq Ft)
Cold
Cool
Warm
Riparian
Non Riparian
Coastal Marsh
1�pact
Yadkin
03040101
0
0
300
Up to
0
0
0
0
075
Upon receipt of payment EEP will take responsibility for providing the compensatory mitigation The mitigation will be performed in
accordance with the N C Department of Environment and Natural Resources Ecosystem Enhancement Program In Lieu Fee
Instrument dated July 28 2010
Thank you for your interest in the NCEEP If you have any questions or need additional information please contact Kelly Williams at
[phone]
Sincerely
Micha Ilison
Deputy Director
cc Karen Higgins NCDWQ Wetlands /401 Unit
John Thomas USACE Raleigh
Sue Homewood NCDWQ Winston Salem
Bradley Luckey agent
File
Rutoru29 F Prot" Our .fta&
TA
CCDENR
North Carolina Ecosystem Enhancement Program 1652 Mad Service Center Raleigh NC 27699 1652 / 919 715 0476 / www nceep net

U S ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Action Id 201101736 County Forsyth U S G S Quad Kernersville
NOTIFICATION OF JURISDICTIONAL DETERMINATION
Property Owner /Agent Triad Baptist Church COPY
Address 1175 South Main Street
Kernersville, NC 27284
Telephone No
Property description
Size (acres) 589 Nearest Town Kernersville
Nearest Waterway Smith Creek River Basin Yadkin River
USGS HUC 03040101 Coordinates N 361058969 W 80 0993970
Location description Proposed facib!y expansion property for Triad Baptist Church off of 1306 Masten Drive
adjacent to a tributary of Smith Creek_ in Kernersville Forsyth County North Carolina
Indicate Which of the Following Apply
A. Preliminary Determination
Based on preliminary information, there maybe wetlands on the above described property We strongly suggest you have
this property inspected to determine the extent of Department of the Army (DA) jurisdiction To be considered final a
jurisdictional determination must be verified by the Corps This preliminary determination is not an appealable action
under the Regulatory Program Administrative Appeal Process ( Reference 33 CFR Part 331)
B Approved Determination
There are Navigable Waters of the United States within the above described property subject to the permit requirements of
Section 10 of the Rivers and Harbors Act and Section 404 of the Clean Water Act Unless there is a change in the law or
our published regulations this determination may be relied upon for a period not to exceed five years from the date of this
notification.
X There are waters of the U S including wetlands on the above described project area subject to the pernut requirements of
Section 404 of the Clean Water Act (CWA)(33 USC § 1344) Unless there is a change in the law or our published
regulations this determination may be relied upon for a period not to exceed five years from the date of this notification
_ We strongly suggest you have the wetlands on your property delineated Due to the size of your property and/or our
present workload, the Corps may not be able to accomplish tins wetland delineation in a timely manner For a more timely
delineation you may wish to obtain a consultant To be considered final any delineation must be verified by the Corps
The waters of the U S including wetland on your project area have been delineated and the delineation has been verified
by the Corps We strongly suggest you have this delineation surveyed Upon completion this survey should be reviewed
and verified by the Corps Once verified this survey will provide an accurate depiction of all areas subject to CWA
jurisdiction on your property which provided there is no change in the law or our published regulations may be relied
upon for a period not to exceed five years
X The waters of the U S including wetlands have been delineated and surveyed and are accurately depicted on the plat
signed by the Corps Regulatory Official identified below on 9/26/2011 Unless there is a change in the law or our
published regulations this deterrrunation may be relied upon for a period not to exceed five years from the date of this
notification
There are no waters of the U S to include wetlands present on the above described property which are subject to the
permit requirements of Section 404 of the Clean Water Act (33 USC 1344) Unless there is a change in the law or our
published regulations this determination may be relied upon for a period not to exceed five years from the date of this
notification
Page 1 of 2

Action ID
The property is located in one of the 20 Coastal Counties subject to regulation under the Coastal Area Management Act
(CkMA) You should contact the Dn ision of Coastal Management in Washington \iC at (2-)2) 946 6481 to determine
their requirements
Placement of dredged or fill material within watcrs of the US and/or «etlands without a Department of the Army permit may
constitute a violation of Section 301 of the Clean Water Act (33 USC § 1311) If you have any questions regarding this
determination and/or the Corps regulatory program please contact John Thomas at 919 5544884 ext 25
C Basis For Determination
There are stream channels ..,.thin i our Pro ect site which are tributaries of Smith Creek itihich flows into
River and the Atlantic Ocean the Yadkin
D Remarks
E Appeals laformatton (This information applies only to approved Jurisdictional deter minahons as indicated in
B above)
This correspondence canstihctes an appraved junsdretional determination for the above described site If you object to this
determination, YOU My request an administrative appeal under Corps regulations at 33 CFR part 331 Enclosed you will find a
Notification of Appeal Process (NAP) fact sheet and request for appeal (RFA) form If you request to appeal this
determination you must submit a completed RFA form to the following address
District Engineer Wilmington Regulatory Division
Attn Jean Gibby Project Manager
Raleigh Regulatory Field Office
3331 Heritage Trade Drive Suite 105
Raleigh North Carolina 27615
In order for an RFA to be accepted by the Corps the Corps must determine that it is complete that it meets the critena for
appeal under 33 CFR part 3315 and that it has been received by the District Office within 60 days of the date of the NAP
Should you decide to submit an RFA form t must be received at the above address by November 2011
* *It is not necessary to submit an RFA rm o the District Office if you do not object to the determination in this
correspondence **
Corps Regulatory Official
Date 09/26!2011 Expiration Date 09/26/2016
The Wihnuigton District is committed to providing the highest level oFsupport to the public To help us ensure we continue to
do so please complete the Customer Satisfaction Survey located at our website at httt f //regulatory usacesurvev coin/ to
complete the survey online
Copy furrushed
Brad Luckey ECS Carolinas LLP 4811 Koger Boulevard Greensboro NC 27407
Page 2 of 2

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North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H Sullins Dee Freeman
Governor Director Secretary
September 15 2011
Mr Bradley Luckey
ECS Carolinas LLP
4811 Koger Boulevard
Greensboro NC 27407
Subject Property 1306 Masten Dr Kernersville NC Forsyth County
On Site Determination for Apphcabdity to the NLtigation Rules (15A NCAC 2H 0506(h)
Dear Mr Luckey
On September 13 2011, at your request and in your attendance Sue Homewood conducted an on site
determination to review a feature located on the subject property for mtermittent/perenmal determinations with
regards to the above noted state regulations John Thomas with the US Army Corps of Engineers ( USACE)
was also present at the site visit The feature that was reviewed is identified on the attached map
The Division acknowledges the areas and boundaries identified as junsdictional wetlands by the USACE The
channel identified on the attached map was determined to be a perennial stream throughout the entire property
boundary
Please note that at the time of this letter, all intermittent and perennial stream channels and jurisdictional
wetlands found on the property are subject to the mitigation rules cited above These regulations are subject to
change in the future
The owner (or future owners) should notify the DWQ (and other relevant agencies) of this decision in any
future correspondences concerning this property This on site determination shall expire five (5) years from the
date of this letter
Landowners or affected parties that dispute a determination made by the DWQ or Delegated Local Authority
that a surface water exists and that it is subject to the buffer rule may request a determination by the Director A
request for a determination by the Director shall be referred to the Director in wntmg c/o Cyndz Karoly DWQ,
401 Oversight/Express Review Permitting Unit, 2321 Crabtree Blvd Suite 250, Raleigh NC 27604 2260
Individuals that dispute a determination by the DWQ or Delegated Local Authority that "exempts' surface
water from the buffer rule may ask for an adludicatory hearing You must act within 60 days of the date that
you receive this letter Applicants are hereby notified that the 60 day statutory appeal time does not start until
North Carolina Division of Water Quality Winston -Salem Regional Office
Locaton 585 Waughtown St Winston -Salem North Carolina 27107
Phone 336 - 771-50001 FAX 336 - 771 -46301 Customer Service 1- 877 -623 -6748
Internet: www ncwaterqualdy org
An Equal Opportunity 1 Affirmative Acton Employer
NofffiCarohna
Naturally

Bradley Luckey
September 15 2011
Page 2 of 2
the affected party (including downstream and adjacent landowners) is notified of this decision DWQ
recommends that the applicant conduct this notification in order to be certain that third party appeals are made
in a timely manner To ask for a hearing send a written petition which conforms to Chapter 150B of the North
Carolina General Statutes to the Office of Administrative Hearings, 6714 Mail Service Center Raleigh N C
27699 6714 This determination is final and binding unless you ask for a hearing within 60 days
This letter only addresses the applicability to the mitigation rules and the buffer rules and does not approve any
activity within Waters of the United States or Waters of the State or their associated buffers If you have any
additional questions or require additional information please contact me at 336 7714964 or
sue homewood@ncdenr gov
Smcerely
Sue Homewood
DWQ Winston Salem Regional Office
Enclosures USGS Topo Map
ECS Survey Map
cc John Thomas, USACE Raleigh Regulatory Office (via email)
DWQ Winston Salem Regional Office

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WETLAND DETERMINATION DATA FORM - Eastern Mountains and Piedmont
profeWSite Approximate 5 89 Acre Tract/1306 Masten Dmre C WCounty Kemersmlle/Forsyth Sampling Date July 28 2011
Applicent/Owner Tnad Baptist Church State NC Sampling Point DP 1
Investigator(s) Brad Luckey ECS David Brame ECS Section Township Range
L.andform (hillslope terrace etc) Bottomland Lops relief (concave convex none) Slope (%) 1%
Subregion (LRR or MLRA) Let Long Datum
Soil Map Unit Name Dan River loam NWI classification
Are climatic / hydrologic conditions on the site typical for this tune of year? Yes ✓ No (If no explain in Remarks )
Are Vegetation . Soil or Hydrology significantly disturbed? Are Normal Circumstances present? Yes No
Are Vegetation . Soil or Hydrology naturally problematic? (If needed explain any answers in Remarks )
SUMMARY OF FINDINGS - Attach site map showing sampling point locations transects important features etc
Hydrophylfc Vegetation Present? Yes v No b the Sampled Area
Hydric Soil Present? Yes No within a Weiland? Yes V No
Wetland Hydrology Present? Yes No
The three sampling criteria are present The sampling point is located within a wetland
HYDROLOGY
Wetland Hydrology Indicators
Secondary Indicators (mim mum of two reautred)
Primary Indicators (minimum of one Is reouired check all that aooly)
— Surface Sod Cracks (B6)
Surface Water (Al)
_ True Aquatic Plants (614)
` Sparsely Vegetated Concave Surface (B8)
_ High Water Table (A2)
_ Hydrogen Sulfide Odor (C1)
Drainage Patterns (810)
_ Saturation (A3)
_ Oxidized Rhmospheres on Living Roots (C3)
_ Moss True Lines (B16)
Water Marks (131)
_ Presence of Reduced Iron (C4)
Dry- Season Water Table (C2)
_ Sediment Deposits (132)
_ Recent Iron Reduction in Tilled Soils (C6)
_ Crayfish Burrows (C8)
_ Drift Deposits (133)
_ Thin Muck Surface (C7)
_ Saturation Visible on Aerial Imagery (C9)
_ Algal Mat or Crust (134)
_ Other (Explain in Remarks)
_ Stunted or Stressed Plaids (D1)
_ Iron Deposits (B5)
_ Geomorphic Position (D2)
_ Inundation Visible on Aerial Imagery (67)
_ Shallow Aqudard (133)
Water - Stained Leaves (69)
_ Micxotopogrephic Relief (134)
_ Aquatic Fauna (1313)
_ FAC- Neutral Test (135)
Field Observabons
Surface Water Present? Yes No
*' Depth (inches)
Water Table Present? Yes No
Depth (inches) 5
Saturation Present? Yes No
If Depth (inches)
Wetland Hydrology Present? Yes ✓ No
includes ca ila frin e
Describe Recorded Data (stream gauge monitoring well aerial photos previous inspections) if available
Remarks
Wetland hydrology indicators are present
US Army Corps of Engineers Eastern Mountains and Piedmont – Interim Version

VEGETATION (Four Strata) — Use scientific names of plants
30 feet . _�.__ __ ......................,..
Tree Stratum (Plot sae ) Cover Species? Status
1 AcerrubnAn 20 Yes FAC
2 Lrquidambar styraciflua 20 Yes FAC+
3
4
5
6
7
8
=
Sapling/Shrub Stratum 40 Total Cover (Plot sae 30 feet )
1 Llgustrum sinense 15 Yes FAC
2
3
4
5
6
7
8
9
10
=
Herb Stratum (Plot size 30 feet 15 Total Cover )
1 Boehmena cyclindnca 25 Yes FACW+
2 Impatiens capensis 20 Yes FACW
Sampling Point. DP 1
Number of Dominant Species
That Are OBL FACW or FAC 5 (A)
Total Number of Dominant
Species Across All Strata 5 (B)
Percent of Dominant Species
That Are OBL FACW or FAC 100% (A/B)
Total % Cover of
Mulboly by
OBL species
x 1 =
FACW species 2
x2= 4
FAC species 3
x3= 9
FACU species
x 4 =
UPL species
x5=
Column Totals 5
(A) 13 (B)
Prevalence Index =
B/A = 26
_ 1 Rapid Test for Hydrophyhc Vegetation
2 Dominance Test is >50%
! 3 Prevalence Index is 53 0'
—4 Morphological Adaptations' (Provide supporting
data In Remarks or on a separate sheet)
_ Problematic Hydrophybc Vegetation' (Explain)
3 I 'Indicators of hyddc sod and wetland hydrology must
be present unless disturbed or problematic
4 _
5 _
6
7
8 _
9 _
10 _
11 _
12 _
=
Woody Vine Stratum (Plot sae 5 Total Cover
e 30 feet )
1 _
2 _
3 _
4
5
6
= Total Cover
rcemanm pncivas pnoto numaers nam or an a separate s
The dominant vegetation is hydrophytic
Strata
Tree – Woody plants excluding vines 3 In (7 6 cm) or
more in diameter at breast height (DBH) regardless of
height
Sapling/Shrub– Woody plants excluding vines less
than 3 in DBH and greater than 3 28 It (1 m) tall
Herb – All herbaceous (non - woody) plants regardless
of size and woody plants less than 3 28 ft tall
Woody vine – All woody vines greater than 3 28 ft In
height
Hydrophytic
Vegetation
Present? Yes No
US Army Corps of Engineers Eastern Mountains and Piedmont– Interim Version

SOIL
Sampling Point. DP 1
Profile Description (Describe to the depth needed to document the indicator or confirm the absence of indicators )
Depth Matrix Redox Features
rinc hes) Color (moist) Color (moist) oc Texture Remarks
0-5 7 5YR 412 100 Loam
5-12 7 5YR 6/1 60 7 5YR 5/8 40 C M Loam
'Type C=Concentrabon D= Depletion RM= Reduoed Matrix MS= Masked Sand Grains location PL =Pore Linina M= Matrix.
Hydric Soil Indicators
Indicator: for Problematic Hydric Sods'
_ Histosol (Al)
_ Dark Surface (S7)
_ 2 cm Muds (A10) (MLRA 147)
_ Histic Epipedon (A2)
_ Polyvalue Below Surface (S8) (MLRA 147 146)
_ Coast Prairie Redox (A16)
_ Black HisLc (A3)
_ Thin Dark Surface (S9) (MLRA 147 148)
(MLRA 147 148)
_ Hydrogen Sulfide (A4)
_ loamy Gleyed Matrix (F2)
_ Piedmont Floodplam Soils (F19)
_ Stratified Layers (A5)
Depleted Matrix (F3)
(MLRA 136 147)
_ 2 an Muck (A10) (LRR N)
_ Redox Dark Surface (F6)
_ Red Parent Material (TF2)
_ Depleted Below Dark Surface (A11)
_ Depleted Dark Surface (F7)
_ Very Shallow Dark Surface (TF12)
_ Thick Dark Surface (Al2)
_ Redox Depressions (F8)
_ Other (Explain in Remarks)
_ Sandy Mucky Mineral (S1) (LRR N
_ Iron- Manganese Masses (F12) (LRR N
MLRA 147 148)
MLRA 136)
_ Sandy Gleyed Matrix (S4)
_ Umbdc Surface (F13) (MLRA 136 122)
'Indicators of hydrophytic vegetation and
_ Sandy Redox (S5)
_ Piedmont Floodplain Sods (F19) (MLRA 148)
wetland hydrology must be present,
_ Stripped Matrix (S6)
unless disturbed or problematic
Type
Depth (inches)
Hydnc soil Indicators are present
Hydric Soil Present? Yes V No
US Army Corps of Engineers Eastem Mountains and Piedmont — Interim Version

WETLAND DETERMINATION DATA FORM - Eastern Mountains and Piedmont
Pro)ect/Site Approximate 5 89 Acre TracN1306 Masten Drive Cdy/County. Kemerswlle /Forsyth Sampling Date July 28 2011
Applicant/Owner Triad Baptist Church State NC Sampling Point: DP 2
Investigator(s) Brad Luckey ECS David Brame ECS Section Township Range
Landfonn (hdlslope terrace etc) Bottorniand Local relief (concave convex none) Slope ( %) I%
Subregion (LRR or MLRA) Let Long Datum
Soil Map Unit Name Clifford sandy loam NWI classification
Are climatic / hydrologic conditions on the site typical for this time of year? Yes ✓ No (If no explain in Remarks )
Are Vegetation . Soil . or Hydrology significantly disturbed? Are Normal Circumstances present? Yes ✓ No
Are Vegetation . Sod or Hydrology naturally problematic? (If needed explain any answers in Remarks )
SUMMARY OF FINDINGS - Attach site map showing sampling point locations transacts important feotures etc
Hydrophytic Vegetation Present? Yes No Is the Sampled Area
Hydnc Sod Present? Yes No within a Wetland? Yes No
Wetland Hydrology Present? Yes No
Hydnc soil and wetland hydrology indicators are not present The sampling point is not located
within a wetland
HYDROLOGY
Wetland Hydrology indicators
Secondary Indicators (minimum of two required)
Primary Indicators (minimum of one is required. check all that aooly)
_ Surface Soil Cracks (B6)
_ Surface Water (A1)
_ True Aquatic Plants (B14)
_ Sparsely Vegetated Concave Surface (68)
_ High Water Table (A2)
_ Hydrogen Sulfide Odor (C1)
_ Drainage Patterns (1310)
_ Saturation (A3)
_ Oxidized Rhmospheres on Living Roots (C3)
_ Moss Tnm Lines (616)
_ Water Marks (B1)
_ Presence of Reduced Iron (C4)
_ Dry- Season Water Table (C2)
_ Sediment Deposits (B2)
_ Recent Iron Reduction in Tilled Soils (C6)
_ Crayfish Burrows (C8)
_ Drift Deposits (B3)
_ Thin Muck Surface (C7)
_ Saturation Visible on Aerial Imagery (C9)
_ Algal Mat or Crust (134)
_ Other (Explain in Remarks)
_ Stunted or Stressed Plants (131)
_ Iron Deposits (B5)
_ Geomorphic Position (D2)
_ Inundation Visible on Aerial Imagery (137)
_ Shallow Aqudard (133)
_ Water - Stained Leaves (B9)
_ Microtopographic Relief (134)
_ Aquatic Fauna (B13)
_ FAC- Neutral Test (135)
Field Observations
Surface Water Present? Yes No
Depth (inches)
Water Table Present? Yes No
Depth (inches)
Saturation Present? Yes No
Depth (inches)
411
Wetland Hydrology Present? Yes No
ncludes capillary fringe)
Describe Recorded Data (stream gauge monitoring well aerial photos previous inspections) If available
Remarks
Wetland hydrology indicators are not present
US Army Corps of Engineers Eastern Mountains and Piedmont — Interim Version

VEGETATION (Four Strata) — Use scientific names of plants
Tree Stratum (Plot size 30 feet ) Cover Soecies7 Status
1 Acer rubrum 15 Yes FAC
2 Lcqucdambar styraciflua 15 Yes FAC+
3 Comus flonda 5 Yes FACU
4
5
6
7
8
35
Saalina/Shrub Stratum (Plot sme 30 feet
1
= Total Cover
2
3
4
5
6
7
8
9
10
Wt = Total Cover
Herb Stratum (Plot age 30 )
1 Hedera helix 60 Yes NI
2 Parthenoassus qumquefolra 10 Yes FAC
3
4
5
6
7
8
9
10
11
12
=
Woody Vine Stratum (Plot size 30 feet ) 70 Total Cover
1 Toxuedendrom radicans 10 Yes FAC
2
3
4
5
6
10 = Total Cover
or on a
Sampling Point DP 2
Dominance Test worksheet•
Number of Dominant Species
That Are OBL FACW or FAC 4 (A)
Total Number of Dominant
Species Across All Strata 6 (B)
Percent of Dominant Species
That Are OBL FACW or FAC 66% (AB)
Total % Cover of
Multiply by*
OBL species
x 1 =
FACW species
x2=
FAC species 4
x3= 12
FACU species 1
x4= 4
UPL species 1
x5= 5
Column Totals 5
(A) 21 (B)
Prevalence Index = B/A = 4 2
_ 1 Rapid Test for Hydrophytic Vegetation
2 Dominance Test is >50%
_ 3 Prevalence Index is 53 0'
_ 4 Morphological Adaptations' (Provide supporting
data in Remarks or on a separate sheet)
_ Problematic Hydrophyflc Vegetation' (Explain)
'Indicators of hydric sod and wetland hydrology must
be present unless disturbed or problematic
Tree — Woody plants excluding vines 3 in (7 6 cm) or
more in diameter at breast height (DBH) regardless of
height
sapling/Shrub — Woody plants excluding vines less
than 3 in DBH and greater than 3 28 ft (1 m) tail
Herb — All herbaceous (non - woody) plants regardless
of size and woody plants less than 3 28 ft tail
Woody vine — All woody vines greater than 3 28 It in
height
Hydrophytic
Vegetation
Present? Yes No
US Army Corps of Engineers Eastern Mountains and Piedmont— Interim Version

SOIL Sampling Point DP 2
Profile Description (Describe to the depth needed to document the Indicator or confirm the absence of Indicators)
Depth Matrix
Redox f5estures
(inches) Color (moist) %_
Color (moist) TjI ep� Lo
Texture Remarks
0-3 10 YR 4/3 100
sandy loam
3-12 10YR 5/6 100
loam
'rype, C-- Concentration D =De lebon RM= Reduoed Matrix MS= Masked Sand Grains
kocalon PL--Pore Lining M=latnx
Hydric Soil Indicators
Indicators for Problematic Hydric Soils'
_ Histosol (Al)
_ Dark Surface (S7)
_ 2 an Muck (A10) (MLRA 147)
_ Histnc Epipedon (A2)
_ Polyvalue Below Surface (S8) (MLRA 147
148) _ Coast Prasie Redox (A16)
Black Histic (A3)
_ Thin Dark Surface (Sg) (MLRA 147 148)
(MLRA 147 148)
_ Hydrogen Sulfide (A4)
_ Loamy Gleyed Matrix (172)
_ Piedmont Floodplain Soils (Fig)
_ Stratified Layers (A5)
_ Depleted Matron (F3)
(MLRA 136,147)
— 2 cm Muck (A10) (LRR N)
_ Redox Dark Surface (F6)
_ Red Parent Material (TF2)
_ Depleted Below Dark Surface (At 1)
_ Depleted Dark Surface (F7)
_ Very Shallow Dark Surface (TF12)
— Thick Dark Surface (At 2)
_ Redox Depressions (F8)
_ Other (Explain in Remarks)
_ Sandy Mucky Mineral (St) (LRR N
_ Iron - Manganese Masses (F12) (LRR N
MLRA 147 148)
MLRA 136)
_ Sandy Gleyed Matrix (S4)
_ Umbric Surface (F13) (MLRA 136,122)
3Indicators of hydrophy6c vegetation and
_ Sandy Redox (S5)
_ Piedmont Floodplain Sods (Fig) (MLRA 148) wetland hydrology must be present,
_ Stripped Matrix (S6)
unless disturbed or problematic
Restrictive Layer (if observed)
Type
Depth (inches)
Hydnc Soil Present? Yes No It
Remarks
Hydnc soil Indicators are not present
US Army Corps of Engineers Eastern Mountains and Piedmont – Interim Version

APPROVED JURISDICTIONAL DETERMINATION FORM
U S Army Corps of Engineers
This form should be completed by following the instructions provided in Section IV of the JD Form Instructional Guidebook
SECTION I BACKGROUND INFORMATION
A REPORT COMPLETION DATE FOR APPROVED JURISDICTIONAL DETERMINATION (JD)
B DISTRICT OFFICE FILE NAME AND NUMBER Raleigh 1306 Masten Drive 0919746C
C PROJECT LOCATION AND BACKGROUND INFORMATION 1306 Masten Drive
State North Carolina County/pansh/borough Forsyth City Kenersville
Center coordinates of site (lat/long in degree decimal format) Lat 36105669 ® Long 80 099086
Universal Transverse Mercator
Name of nearest waterbody Smith Creek
Name of nearest Traditional Navigable Water (TNW) into which the aquatic resource flows Yadkin River
Name of watershed or Hydrologic Unit Code (HUC) Yadkin
Check if map /diagram of review area and/or potential jurisdictional areas is/are available upon request
Check if other sites (e g offsite mitigation sites disposal sites etc ) are associated with this action and are recorded on a different JD
form
D REVIEW PERFORMED FOR SITE EVALUATION (CHECK ALL THAT APPLY)
EM
Office (Desk) Determination Date
Field Determination Date(s)
SECTION H SUMMARY OF FINDINGS
A RHA SECTION 10 DETERMINATION OF JURISDICTION
Therewo navigable waters of the US within Rivers and Harbors Act (RHA) junsdiction (as defined by 33 CFR part 329) in the review area
[Required]
Waters subject to the ebb and flow of the tide
Waters are presently used or have been used in the past or may be susceptible for use to transport interstate or foreign commerce
Explain
B CWA SECTION 404 DETERMINATION OF JURISDICTION
i
There 1@ waters of the US within Clean Water Act (CWA) jurisdiction (as defined by 33 CFR part 328) in the review area [Required]
1 Waters of the U S
a. Indicate presence of waters of U S in review area (check all that apply) i
FRE TNWs including territorial seas
Wetlands adjacent to TNWs
Relatively permanent waters (RPWs) that flow directly or mdirectly into TNWs
Non RPWs that flow directly or mdirectly into TNWs
Wetlands directly abutting RPWs that flow directly or mdirectly into TNWs
Wetlands adjacent to but not directly abutting RPWs that flow directly or mdirectly into TNWs
Wetlands adjacent to non RPWs that flow directly or mdirectly into TNWs
Impoundments of junsdictional waters
Isolated (interstate or intrastate) waters including isolated wetlands
b Identify (estimate) size of waters of the U S in the review area
Non wetland waters 4001mear feet 4width (ft) and/or acres
Wetlands 0 3 acres
c. Limits (boundaries) of Jurisdiction based on INWIN
Elevation of established OHWM (if known)
2 Non regulated waters /wetlands (check if applicable) 3
Potentially jurisdictional waters and/or wetlands were assessed within the review area and determined to be not jurisdictional
Explain
' Boxes checked below shall be supported by completing the appropriate sections in Section III below
2 For purposes of this form an RPW is defined as a tributary that is not a TNW and that typically flows year round or has continuous flow at least seasonally (e g
typically 3 months)
' Supporting documentation is presented in Section III F

SECTION III CWA ANALYSIS
A TNWs AND WETLANDS ADJACENT TO TNWs
The agencies will assert jurisdiction over TNWs and wetlands adjacent to TNWs If the aquatic resource is a TNW complete Section
HI.A 1 and Section III D 1 only if the aquatic resource is a wetland adjacent to a TNW complete Sections III A 1 and 2 and Section
III D 1 otherwise see Section III B below
TNW
Identify TNW
Summarize rationale supporting determination
Wetland adjacent to TNW
Summarize rationale supporting conclusion that wetland is adjacent
B CHARACTERISTICS OF TRIBUTARY (THAT IS NOT A TNW) AND ITS ADJACENT WETLANDS (IF ANY)
This section summarizes information regarding characteristics of the tributary and its adjacent wetlands if any and it helps determine
whether or not the standards for jurisdiction established under Rapanos have been met.
The agencies will assert jurisdiction over non navigable tributaries of TNWs where the tributaries are "relatively permanent waters"
(RPWs) i e tributaries that typically flow year round or have continuous flow at least seasonally (e g. typically 3 months) A wetland
that directly abuts an RPW is also jurisdictional If the aquatic resource is not a TNW but has year round (perennial) flow skip to
Section III D 2 If the aquatic resource is a wetland directly abutting a tributary with perennial flow skip to Section IILD 4
A wetland that is adjacent to but that does not directly abut an RPW requires a significant nexus evaluation Corps districts and EPA
regions will include in the record any available information that documents the existence of a significant nexus between a relatively
permanent tributary that is not perennial (and its adjacent wetlands if any) and a traditional navigable water even though a significant
nexus finding is not required as a matter of law
If the waterbody° is not an RPW or a wetland directly abutting an RPW a JD will require additional data to determine if the
waterbody has a significant nexus with a TNW If the tributary has adjacent wetlands the significant nexus evaluation must consider
the tributary in combination with all of its adjacent wetlands This significant nexus evaluation that combines for analytical purposes
the tributary and all of its adjacent wetlands is used whether the review area identified in the JD request is the tributary or its adjacent
wetlands or both If the JD covers a tributary with adjacent wetlands complete Section IILB 1 for the tributary Section I LB.2 for any
onsite wetlands and Section III B3 for all wetlands adjacent to that tributary both onsite and offsite The determination whether a
significant nexus exists is determined in Section III C below
1 Characteristics of non TNWs that flow directly or indirectly into TNW
(i) General Area Conditions
Watershed size 61M
Drainage area 6
Average annual rainfall 42 7 inches
Average annual snowfall 9 1 inches
(n) Physical Characteristics
(a) Relationship with TNW
❑ Tributary flows directly into TNW
® Tributary flows through I tributaries before entering TNW
Project waters are river miles from TNW
Project waters are river miles from RPW
Project waters are aenal (straight) miles from TNW
Project waters are aerial (straight) miles from RPW
Project waters cross or serve as state boundaries Explain
Identify flow route to TNWS Unnamed tributary to Smith Creek which flows into Smith Creek flows into Kerners Mill Creek
which flows into Salem Lake which flows into Salem Creek which flows into Muddy Creek which flows into the Yadkin River
Tributary stream order if known
(b) General Tributary Characteristics (check all that apply)
` Note that the Instructional Guidebook contains additional information regarding swales ditches washes and erosional features generally and in the and West
5 Flow route can be described by identifying, e g tributary a, which flows through the review area, to flow into tributary b which then flows into TNW

Tributary is ® Natural
❑ Artificial (man made) Explain
❑ Manipulated (man altered) Explain
Tributary properties with respect to top of bank (estimate)
Average width 4 feet
Average depth 1 feet
Average side slopes I
Primary tributary substrate composition (check all that apply)
® Silts ® Sands ❑ Concrete
❑ Cobbles ® Gravel ❑ Muck
❑ Bedrock ❑ Vegetation Type /% cover
❑ Other Explain
Tributary condition/stability [e g highly erodmg, sloughing banks] Explain Stable
Presence of run/nflle/ ool complexes Explain
Tributary geometry
Tributary gradient (approximate average slope) 2 %
(c) Flow
Tributary provides for
Estimate average number of flow events in review area/year
Describe flow regime
Other information on duration and volume
Surface flow is Characteristics
Subsurface flow Explain findings
❑ Dye (or other) test performed
Tributary has (check all that apply)
® Bed and banks
® OHWM6 (check all indicators that apply)
® clear natural line impressed on the bank
®
the presence of litter and debris
❑ changes in the character of soil
❑
destruction of terrestrial vegetation
❑ shelving
❑
the presence of wrack line
❑ vegetation matted down, bent, or absent
❑
sediment sorting
❑ leaf litter disturbed or washed away
❑
scour
❑ sediment deposition
❑
multiple observed or predicted flow events
® water staining
❑
abrupt change in plant community
❑ other (list)
❑ Discontinuous OHWM 7 Explain
If factors other than the OHWM were used to determine lateral extent of CWA junsdiction (check all that apply)
® High Tide Line indicated by ® Mean High Water Mark indicated by
❑ oil or scum line along shore objects ❑ survey to available datum
❑ fine shell or debris deposits (foreshore) ® physical markings
❑ physical markings/charactenstics ❑ vegetation lines/changes in vegetation types
❑ tidal gauges
❑ other (list)
(m) Chemical Characteristics
Characterize tributary (e g water color is clear discolored oily film water quality general watershed characteristics etc ) Explain
Water color is Clear
Identify specific pollutants if known
6A natural or man made discontinuity in the OHWM does not necessarily sever jurisdiction (e g where the stream temporarily flows underground, or where the
OHWM has been removed by development or agricultural practices) Where there is a break in the OHWM that is unrelated to the waterbody s flow regime (e g flow
over a rock outcrop or through a culvert) the agencies will look for indicators of flow above and below the break
'lbid

(iv) Biological Characteristics Channel supports (check all that apply)
❑ Riparian corridor Characteristics (type average width)
❑ Wetland fringe Characteristics
® Habitat for
❑ Federally Listed species Explain findings
❑ Fish/spawn areas Explain findings
❑ Other environmentally sensitive species Explain findings
® Aquatic /wildlife diversity Explain findings Salamanders and Amphibians
2 Characteristics of wetlands adjacent to non TNW that flow directly or indirectly into TNW
(i) Physical Characteristics
(a) General Wetland Characteristics
Properties
Wetland size acres
Wetland type Explain
Wetland quality Explain
Project wetlands cross or serve as state boundaries Explain
(b) General Flow Relationship with Non TNW
Flow is Explain
Surface flow is
Characteristics
Subsurface flow Explain findings
❑ Dye (or other) test performed
(c) Wetland Adiacency Determination with Non TNW
❑ Directly abutting
❑ Not directly abutting
❑ Discrete wetland hydrologic connection Explain
❑ Ecological connection Explain
❑ Separated by berm/bamer Explain
(d) Proximity (Relationship) to TNW
Project wetlands are river miles from TNW
Project waters are aerial (straight) miles from TNW
Flow is from
Estimate approximate location of wetland as within the floodplam
(u) Chemical Characteristics
Characterize wetland system (e g water color is clear brown oil fihn on surface water quality general watershed characteristics
etc ) Explain
Identify specific pollutants if known
(w) Biological Characteristics Wetland supports (check all that apply)
❑ Ripanan buffer Characteristics (type average width)
❑ Vegetation type /percent cover Explain
❑ Habitat for
❑ Federally Listed species Explain findings
❑ Fish/spawn areas Explain findings
❑ Other environmentally sensitive species Explain findings
❑ Aquatictwildlife diversity Explain findings
3 Characteristics of all wetlands adjacent to the tributary (if any
All wetland(s) being considered in the cumulative analysis
Approximately ( ) acres in total are being considered in the cumulative analysis

For each wetland, specify the following
Directly abuts9 (Y/N) Size (in acres) Directly abuts9 /N Size (in acres)
Summarize overall biological cherrucal and physical functions being performed Water filtration storage and aquatic habitat
C SIGNIFICANT NEXUS DETERMINATION
A significant nexus analysis will assess the flow characteristics and functions of the tributary itself and the functions performed by any
wetlands adjacent to the tributary to determine if they significantly affect the chemical physical and biological integrity of a TNW
For each of the following situations a significant nexus exists if the tributary in combination with all of its adjacent wetlands has more
than a speculative or insubstantial effect on the chemical physical and/or biological integrity of a TNW Considerations when
evaluating significant nexus include but are not limited to the volume duration and frequency of the flow of water in the tributary and
its proximity to a TNW and the functions performed by the tributary and all its adjacent wetlands It is not appropriate to determine
significant nexus based solely on any specific threshold of distance (e.g between a tributary and its adjacent wetland or between a
tributary and the TNW) Similarly the fact an adjacent wetland Ices within or outside of a floodplam is not solely determinative of
significant nexus
Draw connections between the features documented and the effects on the TNW as identified in the Rapanos Guidance and discussed in
the Instructional Guidebook. Factors to consider include for example
• Does the tributary in combination with its adjacent wetlands (if any) have the capacity to carry pollutants or flood waters to TNWs or to
reduce the amount of pollutants or flood waters reaching a TNW9
• Does the tributary in combination with its adjacent wetlands (if any) provide habitat and hfecycle support functions for fish and other
species such as feeding, nesting, spawning, or rearing young for species that are present in the TNW9
• Does the tributary in combination with its adjacent wetlands (if any) have the capacity to transfer nutrients and organic carbon that
support downstream foodwebs9
• Does the tributary in combination with its adjacent wetlands (if any) have other relationships to the physical chemical or biological
integrity of the TNW9
Note the above list of considerations is not inclusive and other functions observed or known to occur should be documented below
1 Significant nexus findings for non RPW that has no adjacent wetlands and flows directly or indirectly into TNWs Explain findings
of presence or absence of significant nexus below based on the tributary itself, then go to Section III D
Significant nexus findings for non RPW and its adjacent wetlands where the non RPW flows directly or indirectly into TNWs
Explain findings of presence or absence of significant nexus below based on the tributary in combination with all of its adjacent wetlands
then go to Section III D
Significant nexus findings for wetlands adjacent to an RPW but that do not directly abut the RPW Explain findings of presence or
absence of significant nexus below based on the tributary in combination with all of its adjacent wetlands then go to Section III D
DETERMINATIONS OF JURISDICTIONAL FINDINGS THE SUBJECT WATERS/WETLANDS ARE (CHECK ALL THAT
APPLY)
1 TNWs and Adjacent Wetlands Check all that apply and provide size estimates in review area
TNWs lmear feet width (ft) Or acres
Wetlands adjacent to TNWs acres
RPWs that flow directly or indirectly into TNWs
® Tributaries of TNWs where tributaries typically flow year round are jurisdictional Provide data and rationale indicating that tributary
is perennial
Tributaries of TNW where tributaries have continuous flow seasonally (e g typically three months each year) are jurisdictional
Data supporting this conclusion is provided at Section III B Provide rationale indicating that tributary flows seasonally
Provide estimates for jurisdictional waters in the review area (check all that apply)

Tributary waters Imear feet width (ft)
Other non wetland waters acres
Identify type(s) of waters
Non RPWss that flow directly or indirectly into TNWs
® Waterbody that is not a TNW or an RPW but flows directly or indirectly into a TNW and it has a significant nexus with a TNW is
jurisdictional Data supporting this conclusion is provided at Section III C
Provide estimates for junsdictional waters within the review area (check all that apply)
Tributary waters linear feet width (ft)
Other non wetland waters acres
Identify type(s) of waters
Wetlands directly abutting an RPW that flow directly or indirectly into TNWs
® Wetlands directly abut RPW and thus are jurisdictional as adjacent wetlands
® Wetlands directly abutting an RPW where tributaries typically flow year round Provide data and rationale
indicating that tributary is perennial in Section III D 2 above Provide rationale indicating that wetland is
directly abutting an RPW
Wetlands directly abutting an RPW where tributaries typically flow seasonally Provide data indicating that tributary is
seasonal in Section III B and rationale in Section III D 2 above Provide rationale indicating that wetland is directly abutting an
RPW
Provide acreage estimates for junsdictional wetlands in the review area 0.3acres
Wetlands adjacent to but not directly abutting an RPW that flow directly or indirectly into TNWs
Wetlands that do not directly abut an RPW but when considered in combination with the tributary to which they are adjacent and with
sumlarly situated adjacent wetlands have a significant nexus with a TNW are junsidictional Data supporting this conclusion is
provided at Section III C
Provide acreage estimates for junsdictional wetlands in the review area acres
Wetlands adjacent to non RPWs that flow directly or indirectly into TNWs
IM Wetlands adjacent to such waters and have when considered in combination with the tributary to which they are adjacent and with
similarly situated adjacent wetlands have a significant nexus with a TNW are jurisdictional Data supporting this conclusion is
provided at Section III C
Provide estimates for junsdictional wetlands in the review area acres
Impoundments of jurisdictional waters 9
As a general rule the impoundment of a junsdictional tributary remains jurisdictional
Demonstrate that impoundment was created from waters of the U S or
Demonstrate that water meets the criteria for one of the categories presented above (1-6) or
Demonstrate that water is isolated with a nexus to commerce (see E below)
ISOLATED [INTERSTATE OR INTRA STATE] WATERS INCLUDING ISOLATED WETLANDS THE USE DEGRADATION
OR DESTRUCTION OF WHICH COULD AFFECT INTERSTATE COMMERCE INCLUDING ANY SUCH WATERS (CHECK
ALL THAT APPLY) io
which are or could be used by interstate or foreign travelers for recreational or other purposes
from which fish or shellfish are or could be taken and sold in interstate or foreign commerce
which are or could be used for mdustrW purposes by industries in interstate commerce
Interstate isolated waters Explain
Other factors Explain
Identify water body and summarize rationale supporting determination
Provide estimates for jurisdictional waters in the review area (check all that apply)
Tributary waters Imear feet width (ft)
BSee Footnote # 3
9 To complete the analysis refer to the key in Section III D 6 of the Instructional Guidebook
10 Prior to asserting or declining CWA jurisdiction based solely on this category Corps Districts will elevate the action to Corps and EPA HQ for review
consistent with the process described in the Corps/EPA Memorandum Regarding CWA Act Junsdiction Following Rapanos.

® Other non wetland waters acres
Identify type(s) of waters
® Wetlands acres
NON4URISDICTIONAL WATERS INCLUDING WETLANDS (CHECK ALL THAT APPLY)
® If potential wetlands were assessed within the review area, these areas did not meet the criteria in the 1987 Corps of Engineers Wetland
Delineation Manual and/or appropriate Regional Supplements
® Review area included isolated waters with no substantial nexus to interstate (or foreign) commerce
❑ Prior to the Jan 2001 Supreme Court decision in SWANCC the review area would have been regulated based solely on the
Migratory Bird Rule (MBR)
Waters do not meet the Significant Nexus standard, where such a finding is required for Jurisdiction Explain
Other (explain, if not covered above)
Provide acreage estimates for non Jurisdictional waters in the review area, where the sole potential basis of Junsdictton is the MBR factors (i e
presence of migratory buds presence of endangered species use of water for irrigated agriculture) using best professional Judgment (check all
that apply)
Non wetland waters (i a rivers streams) linear feet width (ft)
Lakes/ponds acres
Other non wetland waters acres List type of aquatic resource
Wetlands acres
Provide acreage estimates for non Jurisdictional waters to the review area that do not meet the Significant Nexus" standard, where such a
finding is required for jurisdiction (check all that apply)
IM Non wetland waters (i a rivers streams) linear feet, width (ft)
Lakes/ponds acres
Other non wetland waters acres List type of aquatic resource
Wetlands acres
SECTION IV DATA SOURCES
A SUPPORTING DATA Data reviewed for JD (check all that apply checked items shall be included in case file and, where checked and
re uested, appropriately reference sources below)
Maps plans plots or plat submitted by or on behalf of the applicant/consultant ECS Wetland Maps
Data sheets prepared/submitted by or on behalf of the applicant/consultant.
❑ Office concurs with data sheets/delineation report
❑ Office does not concur with data sheets/delmeahon report
Data sheets prepared by the Corps
Corps navigable waters study
U S Geological Survey Hydrologic Atlas
❑ USGS NHD data.
❑ USGS 8 and 12 digit HUC maps
U S Geological Survey map(s) Cite scale & quad name 2000 /Kemersville
USDA Natural Resources Conservation Service Soil Survey Citation NCSS Websrte
National wetlands inventory map(s) Cite name
State/Local wetland inventory map(s)
FEMA/FIRM maps Panel Number 3710687500)
100 -year Floodplam Elevation is (National Geodectic Vertical Datum of 1929)
Photographs ® Aerial (Name & Date) Forsyth County GIS /2010
or ❑ Other (Name & Date)
Previous determination(s) File no and date of response letter
Applicable /supporting case law
Applicable /supporting scientific literature
Other information (please specify)
B ADDITIONAL COMMENTS TO SUPPORT JD An unnamed tributary to Smith Creek crosses the site Wetlands directly abut the unamed
tributary to Smith Creek in the review area.

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