20120155 Ver 1_401 Application_20120212

P O Box 244 Bunnlevel NC 28323 [phone]
Feb 7, 2012
Raleigh Regulatory Field Office
US Army Corps of Engineers
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
Re Preliminary Jurisdictional Determination and NW12 for the City of Randleman Sewer
Improvements
John Thomas,
Wetland delineation was conducted for the above referenced property on _Weaver Street in
Randleman NC All wetland determinations were made in accordance with the 1987 US Army Corps
of Engineers Wetland Delineation Manual and the Atlantic and Gulf Coastal Plain Regional
Supplement The property perimeter was walked and several traverses were conducted across the
interior of the subject site Areas that meet the required criteria for wetlands were observed and
delineated as shown on the attached wetland delineation map Enclosed are copies of maps wetland
data sheets preliminary JD forms and pertinent site information for your use in preparation for a site
review /,jurisdictional confirmation of flagged wetland/ stream boundaries
Directions Project area is located approximately 0 5 miles north of the US -220 Business crossing over
the Deep River in downtown Randleman Disturbance area is located at the end of Weaver Street along
a private easement parallel to the UT to Deep River
The following is pertinent site information
Owner City of Randleman
Applicant City of Randleman
Address 101 Hilliary Street
Randleman NC 27317
336 495 -7500
D
Parcel ID Numbers FEg 1 3 2012
Property Location See attached maps DENR WATER Nearest Named Water body Deep River �n 'SANDSTORM ghRBRMCH
Lat/Long of Site 35 830023 N 79 796887 W
Maps See attachment
USGS Quad Name 124 000 Randleman Quadrangle
Tract Size See Attachment
Approximate Wetland Size See attachment
Please contact me if there is any additional information you need regarding site conditions
Thank you
Sincerely
Adam Carter
Wetland Solutions

January 23 2012
Owner Information
Name City of Randleman
Mailing Address 101 Hilliary Street
City State Zip Randleman NC 27317
Telephone # [phone]
Pro a Descri tion
Project Name City of Randleman Sewer System Improvements
Address See Attachment
PIN # See Attachment
County Randolph County
I J GHA•RLES 1Mc:GoUGAty as owner /agent of the above referenced
property /project authorize Mr Adam Carter of Wetland Solutions LLC to access the property
owners land for mapping wetlands and installing monitoring well equipment
MAZZ444o 4 IM`6ou6P#Q PR
1 23 la
Date

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City of Randleman
Sewer Main Realignment @Weaver Street
2010 Aerial with 2' NCDOT Contours
310 sgft Wetland Impact
314 sgft Wetland Impact
20' (L) x 15' (W)
Stream Impact
US -220 Business
V47
Weaver Street
Proposed 8" Sewer Main
Parallel to Existing (739 ft)
m
Existing Sewer Line
— Proposed Sewer Line
Proposed Wetland Impacts
Wetland Delineation
0 Project Disturbance Area
_ roads
NCDOT 2' Contours
0 200 400 800 1,200 1,600 2,000 2,400 2,8 Feet f
NOTE: All boundaries and distances are considered approximate.
This represents a preliminary map prepared from points obtained by
GPS and data from online sources. A PLS survey of delineated areas ry
and review and approval by the U.S. Army Corps of Engineers i
is recommended prior to specific site planning.

City of Randleman
Sewer Main Realignment @Weaver Street
2010 Aerial with Wetland Delineation
314 sgft Wetland Impact
20' (L) x 15' (V)
Stream Impact
I
310 sqft Wetland Impact l
00
:D C
A
00 O O O
00 v,0
O
0 -
To Weaver Street
Proposed 8" Sewer Main
Parallel to Existing (739 ft),
- - - Existing Sewer Line
Proposed Sewer Line
Proposed Wetland Impacts
Wetland Delineation
0 Project Disturbance Area
roads
0 40 80 160 240 320 400
NOTE: All boundaries and distances are considered approximate.
This represents a preliminary map prepared from points obtained by
GPS and data from online sources. A PLS survey of delineated areas
and review and approval by the U.S. Army Corps of Engineers
is recommended prior to specific site planning
480 560
Feet
Y1Ftl SON ions

City of Randleman
Sewer Main Realignment @Weaver Street
NRCS Soils
310 sgft Wetland Impact
314 sqft Wetland Impact
20' (L) x 15' (W)
Stream Impact
US -220 Business
CbC
Weaver Street
ne)
Proposed 8" Sewer Main
Parallel to Existing (739 ft)
Existing Sewer Line
Proposed Sewer Line
- Proposed Wetland Impacts
Wetland Delineation
BaD
Project Disturbance Area
W I — roads
0 200 400 800 1,200 1,600 2,000
NOTE: All boundaries and distances are considered approximate.
This represents a preliminary map prepared from points obtained by
GPS and data from online sources. A PLS survey of delineated areas
and review and approval by the U.S. Army Corps of Engineers
is recommended prior to specific site planning.
2,400 2,800
FE
Wufl ns

City of Randleman
Sewer Main Realignment @Weaver Street
USGS Topographic Vicinity Map
(
J
J r 1
trf ; , ►,
ti
jf t Wetland Impact
S
r' l
a r•. At
314 sqft Wetland Impact
20' (L) x 15' (W)
Stream Impact
ti a
ti .� tit y jo
I Weaver Street
m
r-
I
I r
i �.
Op
r r
t
Proposed 8" Sewer Main
Parallel to Existing (739 ft)
• •a
US -220 Business
4V * _
L
V
0 200 400 800 1,600
Existing Sewer Line
— Proposed Sewer Line
Proposed Wetland Impacts
Wetland Delineation
0 Project Disturbance Area
roads
2,000
NOTE: All boundaries and distances are considered approximate.
This represents a preliminary map prepared from points obtained by
GPS and data from online sources. A PLS survey of delineated areas
and review and approval by the U.S. Army Corps of Engineers
is recommended prior to specific site planning.
2,400 2,800
i
vptIaoa Solutions

WETLAND DETERMINATION DATA FORM — Atlantic and jGulf Coastal Plain Region
.� I?I �l /' J 1- Z
— 3—Z I
Project/Site V oycr s 'rfee,: f _ 22r-(4&0 Or City /County /
OAA Lf R Sampling Date
Applicant/Owner C.14 e i' uo� �e db cv�, State _AI Sampling Point J
Investigator(s) AA,-` (.tke,+e -"' Section Township Range �,g"d e►9� a -j
Landform (hdisiope terrace etc ) �4 It c H Local relief (concave convex none) _{ & L' Slope (°/) _-
Subregion (LRR or MLRA) L XW /y Lat . 9L ) QG%Z Ts Long 19 7�ag y Datum 161
Soil Map Unit Name C, er 11 1501 )'A n s ?-I\ ine.1 C.'er rol iQb CY NWI classification 9.n /,.> ✓ l�+�i�
Are climatic / hydrologic conditions on the site typical for this time of year? Yes tl-," No (If no explain in Remarks )
Are Vegetation Sod or Hydrology significantly disturbed?
Are Vegetation Sod
or Hydrology naturally problematic?
Are Normal Circumstances present? Yes No
(if needed explain any answers in Remarks )
SUMMARY OF FINDINGS — Attach site map showing sampling point locations transects important features etc
Hydrophytic Vegetation Present? Yes No Is the Sampled Area
Hydnc Soil Present? Yes No within a Wetland? Yes No >/
Wetland Hydrology Present? Yes No E�5
Remarks (,'l� f �'L� ����►
HYDROLOGY
Wetland Hydrology Indicators
Secondary Indicators (minimum of two required)
Primary Indicators (minimum of one is required
check all that apply)
_ Surface Sod Cracks (B6)
_ Surface Water (Al)
_ Water-Stained Leaves (139)
_ Sparsely Vegetated Concave Surface (B8)
_ High Water Table (A2)
_ Aquatic Fauna (B13)
_ Drainage Patterns (B10)
_ Saturation (A3)
_ Marl Deposits (B15) (LRR U)
_ Moss Trim Lines (B16)
_ Water Marks (B1)
_ Hydrogen Sulfide Odor (Cl)
_ Dry- Season Water Table (C2)
Sediment Deposits (62)
_ Oxidized Rhizospheres on Living Roots (C3)
_ Crayfish Burrows (C8)
_
_ Drift Deposits (63)
_ Presence of Reduced Iron (C4)
_ Saturation Visible on Aerial Imagery (C9)
_ Algal Mat or Crust (64)
_ Recent Iron Reduction in Tilled Sods (C6)
_ Geomorphic Position (D2)
_ Iron Deposits (65)
_Thin Muck Surface (C7)
_ S w Aquitard (D3)
Inundation Visible on Aerial Imagery (B7)
_ Other (Explain in Remarks)
FAC-Neutral Test (D5)
Field Observations
Surface Water Present? Yes No
J�epth (inches)
Water Table Present? Yes No
(inches)
Saturation Present? Yes No
Depth
Depth (inches)
Wetland Hydrology Present? Yes No
includes capillary fringe)
Describe Recorded Data (stream gauge monitoring well aerial photos previous inspections) if available
Remarks
US Army Corps of Engineers Atlantic and Gulf Coastal Plain Region – Interim Version

&Til I I
Sampling Point
Profile Description (Describe to the depth needed to document the Indicator or confirm the absence of indicators)
Depth Matrix
inches Color (moist) /
Redox Features
Color (moist) / Tyne Loc Texture Remarks
��fG
j,, f L
,+
y g y
LZ 27,
'Type C= Concentration D =De letion RM= Reduced Matrix CS= Covered or Coated Sand Grains 2Location PL =Pore Limn M= Matrix
Hydric Sod indicators
Indicators for Problematic Hydric Soils
Histosol (Al)
_ Polyvalue Below Surface (S8) (LRR S T U) _ 1 cm Muck (A9) (LRR O)
—
Histic Epipedon (A2)
_Thin Dark Surface (S9) (LRR S T U) _ 2 cm Muck (A10) (LRR S
_
Black Histic (A3)
_ Loamy Mucky Mineral (F1) (LRR O) _ Reduced Vertic (F18) (outside MLRA 150A B)
_
Hydrogen Sulfide (A4)
_ Loamy Gleyed Matrix (F2) _ Piedmont Floodplain Sods (F19) (LRR P S T)
Stratified Layers (A5)
_ Depleted Matrix (F3) _ Anomalous Bright Loamy Soils (1720)
_
Organic Bodies (A6) (LRR P T U)
_Redox Dark Surface (F6) MLRA 1538
_
_ 5 cm Mucky Mineral (A7) (LRR P T U)
_ Depleted Dark Surface (F7) _ Red Parent Material (TF2)
Very Shallow Dark Surface (TF12) (LRR T U)
_ Muck Presence (A8) (LRR U)
1 cm Muck (A9) (LRR P T)
_ Redox Depressions (F8) _
_ Marl (F10) (LRR U) _ Other (Explain in Remarks)
_
_ Depleted Below Dark Surface (A11)
_ Depleted Ochnc (F11) (MLRA 151)
Iron Manganese Masses (F12) (LRR O P T) 3Indicators of hydrophytic vegetation and
_ Thick Dark Surface (Al2) _
Coast Prairie Redox (A16) (MLRA 150A) _ Umbric Surface (1713) (LRR P T U) wetland hydrology must be present
_
Sandy Mucky Mineral (S1) (LRR O S)
_ Delta Ochric (F17) (MLRA 151) unless disturbed or problematic
_
Sandy Gleyed Matrix (S4)
_ Reduced Vertic (1718) (MLRA 150A 1508)
_
Sandy Redox (S5)
_ Piedmont Floodplain Soils (F19) (MLRA 149A)
_
_ Stripped Matrix (S6)
_ Anomalous Bright Loamy Sods (F20) (MLRA 149A, 153C 15313)
Dark Surface (S7) (LRR P S T U)
Type
Depth (inches)
CA 100(d
Hydric Sod Present? Yes No
7tle- 5)-�-e�
foe-e-1 Alls-u� 6 &, rt4)1�
US Army Corps of Engineers Atlantic and Gulf Coastal Plain Region — Interim Version

VEGETATION — Use scientific names of plants
(Plot size v —6V -3c' -f h
5
7
/ Cover Species? Status
QV — �s•-
,5/ N 0
l; =Total Cover
i
a t) , = Total Cover
Shrub Stratum (Plo size � Id k ` r )
1 A I�/ —may
3
4
5
6
7 ®
= Total Cover
Herb Stratum (Plot size )
2
3
4
5
6
7
8
9
10
11
12
= Total Cover
Woody Vme Stratum (Plot size It) Piz
2
3
Sampling Point
Dominance Test worksheet
Number of Dominant Species
That Are OBL FACW or FAC O (A)
Total Number of Dominant
Species Across All Strata
(B)
Percent of Dominant Species
That Are OBL FACW or FAC
u (A/B)
Prevalence Index worksheet
Total A over of. Multiply bv.
OBL species x 1 =
FACW species x2=
FAC species x3=
FACU species x 4 =
UPL species x 5 =
Column Totals (A) (B)
Prevalence Index = B/A =
-6.1bominance Test is >50 /
_ Prevalence Index is 53 0'
Problematic Hydrophytic Vegetation' (Explain)
'Indicators of hydnc sod and wetland hydrology must
be present unless disturbed or problematic
of
Tree - Woody plants excluding woody vines
approximately 20 ft (6 m) or more In height and 3 In
(7 6 cm) or larger in diameter at breast height (DBH)
Sapling - Woody plants excluding woody vines
approximately 20 ft (6 m) or more in height and less
than 3 in (7 6 cm) DBH
Shrub - Woody plants excluding woody vines
approximately 3 to 20 ft (1 to 6 m) in height
Herb - All herbaceous (non woody) plants including
herbaceous vines regardless of size Includes woody
plants except woody vines less than approximately
3 ft (1 m) in height
Woody vine - All woody vines regardless of height
4 Hydrophytic
5 Vegetation
�e = Total Cover Present?
narks (If observed list � morphological adaptations below) t I
M "� p� 9�, VG(.t, I" �Yt C l"OLd 0111 2"51 ), 1 l P
Yes No
US Army Corps of Engineers Atlantic and Gulf Coastal Plain Region - Interim Version

ATTACHMENT
PRELIMINARY JURISDICTIONAL DETERMINATION FORM
BACKGROUND INFORMATION
A REPORT COMPLETION DATE FOR PRELIMINARY JURISDICTIONAL
DETERMINATION (JD)
B NAME AND ADDRESS OF PERSON REQUESTING PRELIMINARY JD
City of Randleman
101 Hilliary Street
Randleman NC 27317
C DISTRICT OFFICE, FILE NAME, AND NUMBER Raleigh
D PROJECT LOCATION(S) AND BACKGROUND INFORMATION Project
area is located approximately 0 5 miles north of the US -220 Business crossing
over the Deep River in downtown Randleman Disturbance area is located at the
end of Weaver Street along a private easement parallel to the UT to Deep River
(USE THE ATTACHED TABLE TO DOCUMENT MULTIPLE WATERBODIES
AT DIFFERENT SITES)
State NC County /parish/borough Randolph City Randleman
Center coordinates of site (lat/long in degree decimal format) Lat
35 830023° N Long 79 7968870 W
Universal Transverse Mercator 17N
Name of nearest waterbody UT to Deep River
Identify (estimate) amount of waters in the review area
Non - wetland waters 1200 linear feet 15 width (ft) and /or 0 413 acres
Cowardin Class
Stream Flow Perennial
Wetlands 0 01433 acres
Cowardm Class Forested
Name of any water bodies on the site that have been identified as Section 10
waters
Tidal
Non -Tidal
E REVIEW PERFORMED FOR SITE EVALUATION (CHECK ALL THAT
APPLY)
❑ Office (Desk) Determination Date
❑ Field Determination Date(s)

1 The Corps of Engineers believes that there may be jurisdictional waters of the
United States on the subject site and the permit applicant or other affected party
who requested this preliminary JD is hereby advised of his or her option to
request and obtain an approved jurisdictional determination (JD) for that site
Nevertheless the permit applicant or other person who requested this
preliminary JD has declined to exercise the option to obtain an approved JD in
this instance and at this time
2 In any circumstance where a permit applicant obtains an individual permit or
a Nationwide General Permit (NWP) or other general permit verification requiring
pre construction notification (PCN) or requests verification for a non reporting
NWP or other general permit and the permit applicant has not requested an
approved JD for the activity the permit applicant is hereby made aware of the
following (1) the permit applicant has elected to seek a permit authorization
based on a preliminary JD which does not make an official determination of
jurisdictional waters (2) that the applicant has the option to request an approved
JD before accepting the terms and conditions of the permit authorization and
that basing a permit authorization on an approved JD could possibly result in less
compensatory mitigation being required or different special conditions (3) that
the applicant has the right to request an individual permit rather than accepting
the terms and conditions of the NWP or other general permit authorization (4)
that the applicant can accept a permit authorization and thereby agree to comply
with all the terms and conditions of that permit including whatever mitigation
requirements the Corps has determined to be necessary (5) that undertaking
any activity in reliance upon the subject permit authorization without requesting
an approved JD constitutes the applicants acceptance of the use of the
preliminary JD but that either form of JD will be processed as soon as is
practicable (6) accepting a permit authorization (e g signing a proffered
individual permit) or undertaking any activity in reliance on any form of Corps
permit authorization based on a preliminary JD constitutes agreement that all
wetlands and other water bodies on the site affected in any way by that activity
are jurisdictional waters of the United States and precludes any challenge to
such jurisdiction in any administrative or judicial compliance or enforcement
action or in any administrative appeal or in any Federal court and (7) whether
the applicant elects to use either an approved JD or a preliminary JD that JD
will be processed as soon as is practicable Further an approved JD a proffered
individual permit (and all terms and conditions contained therein) or individual
permit denial can be administratively appealed pursuant to 33 C F R Part 331
and that in any administrative appeal jurisdictional issues can be raised (see 33
C F R 331 5(a)(2)) If during that administrative appeal it becomes necessary
to make an official determination whether CWA jurisdiction exists over a site or
to provide an official delineation of jurisdictional waters on the site the Corps will
provide an approved JD to accomplish that result as soon as is practicable
This preliminary JD finds that there may be waters of the United States on the
subject project site and identifies all aquatic features on the site that could be
affected by the proposed activity based on the following information

SUPPORTING DATA Data reviewed for preliminary JD (check all that apply
- checked items should be included in case file and where checked and
requested appropriately reference sources below)
® Maps plans plots or plat submitted by or on behalf of the
applicant/consultant see attached
® 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 /delineation 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 124 000
Randleman Quadrangle
® USDA Natural Resources Conservation Service Soil Survey
Citation NRCS Soil Survey
http / /datagateway nres usda gov /GDGOrder aspx
❑ National wetlands inventory map(s) Cite name
❑ State /Local wetland inventory map(s)
❑ FEMA/FIRM maps
❑ 100 -year Floodplain Elevation is N /A(National Geodectic Vertical Datum of
1929)
® Photographs ® Aerial (Name & Date) Randolph County 2010 NAIP
or ❑ Other (Name & Date)
❑ Previous determinations) File no and date of response letter
® Other information (please specify) engineering plans
IMPORTANT NOTE The information recorded on this form has not
necessarily been verified by the Corps and should not be relied upon for
later iurisdictional determinations
Signature and date of
Regulatory Project Manager
(REQUIRED)
ki
w
Signature and ate of
person requesting preliminary JD
(REQUIRED unless obtaining
the signature is impracticable)
7 Z(/ 1 Z

20 120 15 5
Office Use Only
Corps action ID no
DWQ project no
Form Version 1 3 Dec 10 2008
Page 1 of 11
PCN Form — Version 13 December 10 2008 Version
Pre - Construction Notification PC Form
A Applicant Information
1
Processing
la
Type(s) of approval sought from the
Corps
®Section 404 Permit ❑Section 10 Permit
lb Specify Nationwide Permit (NWP) number NW 12 or General Permit (GP) number ».
1 c
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
1g
Is the project located in any of NC s twenty coastal counties if yes answer 1h
below
❑ Yes
® No
1h
Is the project located within a NC DCM Area of Environmental Concern (AEC)? I
❑ Yes
® No
2
Project Information
2a
Name of project
City of Randleman Sewer Improvements @ Weaver Street
2b
County
Randolph
2c
Nearest municipality I town
Randleman
2d
Subdivision name
N/A
2e
NCDOT only T I P or state
project no
N/A
3
Owner Information
3a
Name(s) on Recorded Deed
Hilliard Brothers (PIN 7765372868)
3b
Deed Book and Page No
992/31
3c
Responsible Party (for LLC if
applicable)
City of Randleman
3d
Street address
101 Hilliary Street
3e
City state zip
Randleman NC 27317
3f
Telephone no
336 -495 7500
3g
Fax no
336 -495 7500
3h
Email address
cmcgougan@marziano- mcgougan corn
Page 1 of 11
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
Adam Carter
5b
Business name
(if applicable)
Wetland Solutions LLC
5c
Street address
P O Box 244
5d
City state zip
Bunnlevel NC 28323
5e
Telephone no
[phone]
5f
Fax no
5g
Email address
wetlandsolutionsnc @yahoo com
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)
PIN 7765372868
Latitude 35 830023 N Longitude
lb Site coordinates (in decimal degrees)
79 796887 W
(DD DDDDDD) ( DD DDDDDD)
1 c Property size
12 86 acres
2 Surface Waters
2a Name of nearest body of water (stream river etc) to
UT to Deep River
proposed project
2b Water Quality Classification of nearest receiving water
Class C
2c River basin
Cape Fear Basin Stream Index 17 (10 5)
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
Along Weaver Street residential lots have been cleared along the road frontage sections for many years Behind these
homes this tract of land is undeveloped and encompasses a natural drainageway in the landscape This UT to Deep
River collects stormwater runoff from these lots and upstream areas and conveys to Deep River Land use in the
immediate vicinity is urban residential
3b List the total estimated acreage of all existing wetlands on the property
Less than 1 acre this tract estimated
3c List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
1200 perennial estimated
3d Explain the purpose of the proposed project
The purpose of this project is to relocate the existing sewer line which has been eroded from the stream banks and now lies in
the middle of the creek bed A new sewer main will be constructed parallel to the existing line approximately 10 up the bank
allowing for stabilization of the creek bed and minimizing the chance for a sanitary sewers dl
3e Describe the overall project in detail including the type of equipment to be used
The proposed impacts will allow the owner to construct an 8 PVC sewer main parallel for approx 750 feet The
excavation and installation will be accomplished with a trackhoe and smaller supporting equipment
4 Jurisdictional Determinations
4a Have junsdictional 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
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 Wetland Solutions LLC
Name (if known) Adam Carter Wetland Solutions LLC
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?
515 If yes explain in detail according to help file instructions
Page 3 of 11
PCN Form — Version 1 3 December 10 2008 Version

6 Future Project Plans
6a Is this a phased project'? ❑ Yes ® No
6b If yes explain
Page 4 of 11
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
W1 ❑ P ®T
Excavation /Fill
® Yes
❑ No
® Corps
® DWQ
0 00712 ac
310 sqft
W2 ❑ P ®T
Excavation /Fill
® Yes
❑ No
® Corps
® DWQ
0 00721 ac
314 sqft
W3 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W4 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W5 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W6 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
2g Total wetland impacts
0 01433 ac
(614 sqft)
2h Comments The attached site plan includes impacts totaling 614 sqft of stream
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 [:]POT
Excavation /Fill
UT Deep River
® PER
❑ INT
® Corps
® DWQ
15
20
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
[I Corps
❑ INT
❑ DWQ
3h Total stream and tributary impacts
20 If
(300 sqft)
31 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
01 ❑P ❑T
02 ❑P
03 ❑P
04 ❑P ❑T
4f Total open water impacts
4g Comments
6 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
P2
5f Total
5g Comments
5h Is a dam high hazard permit required
❑ Yes ❑ No If yes permit ID no
51 Expected pond surface area (acres)
51 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 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
impact
required?
131 ❑P ❑T
El Yes
❑ No
B2 ❑P ❑T
El Yes
❑ No
B3 ❑P ❑T
El Yes
❑ No
6h Total buffer impacts
61 Comments
Page 6 of 11
PCN Form — Version 1 3 December 10 2008 Version

D Impact Justification and Mitigation
1 Avoidance and Minimization
la Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
The project was designed to avoid jurisdictional waters to the extent that is practicable given the minimum design criteria
established by NCDENR DWQ The construction corridor has been located up the bank to maintain the least impact to the
stream bank while maintaining minimum design slope per DWQ requirements
1 b Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
Temporary erosion control measures will be utilized throughout construction Erosion control measures may include silt
fences seeding and mulching and gravel check dams installed where appropriate The finished system will prevent future
erosion and sedimentation for long term benefit to the adjoining property
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
❑ 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 7 of 11
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
la
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?
< 5 %
2b
Does this project require a Stormwater Management Plan?
❑ Yes ® No
2c
If this project DOES NOT require a Stormwater Management Plan explain why The proposed linear impacts to wetlands
will provide the City of Randleman with enough room to construct the sewer main away from the stream bank while
providing future access to the sewer easement per DWQ requirements Currently less than 5% impervious surface is
present from the residential lots that drain to this location
2d
If this project DOES require a Stormwater Management Plan then provide a brief narrative description of the plan
❑ Certified Local Government
2e
Who will be responsible for the review of the Stormwater Management Plan?
❑ DWQ Stormwater Program
❑ DWQ 401 Unit
3
Certified Local Government Stormwater Review
3a
In which local government s jurisdiction is this project?
❑ Phase II
3b
Which of the following locally implemented stormwater management programs
❑ NSW
❑ USMP
apply (check all that apply)
❑ Water Supply Watershed
❑ Other
3c
Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
4
DWQ Stormwater Program Review
❑ Coastal counties
❑ HQW
4a
Which of the following state implemented stormwater management programs apply
❑ ORW
(check all that apply)
❑ Session Law 2006 246
❑ Other
4b
Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ Yes ❑ No
5
DWQ 401 Unit Stormwater Review
5a
Does the Stormwater Management Plan meet the appropriate requirements?
❑ Yes ❑ No
5b Have all of the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 9 of 11
PCN Form — Version 13 December 10 2008 Version

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) lands
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 CG &L Project # CS370662 02
Determination of Minor Construction Activity March 18 2011
2
Violations (DWQ Requirement)
2a
Is the site in violation of DWQ Wetland Rules (15A NCAC 2H 0500) Isolated
Wetland Rules (15A NCAC 2H 1300) DWQ Surface Water or Wetland Standards
❑ Yes
® No
or Riparian Buffer Rules (15A NCAC 2B 0200)?
2b
Is this an after the fact permit application?
❑ Yes
® No
2c
If you answered yes to one or both of the above questions provide an explanation of the violation(s)
3
Cumulative Impacts (DWQ Requirement)
3a
Will this project (based on past and reasonably anticipated future impacts) result in
❑ Yes
® No
additional development which could impact nearby downstream water quality?
3b
If you answered yes to the above submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy if you answered no provide a short narrative description
The proposed impacts will allow the City of Randleman to repair an existing sanitary sewer main behind
occupied
residential lots No future development will occur at this site
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
Existing home sites utilize Randleman s public sewer system via this section of sewer main replacement
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
E:1 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 DENR Div of Parks and Recreation Natural Heritage Element Occurrences NC DENR Div of Parks and
Recreation Natural Heritage Program Raleigh North Carolina
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 Habitat9
South Atlantic Habitat and Ecosystem IMS available at http / /ocean flondamanne org /efh_coralhms/viewer htm
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?
8 Flood Zone Designation (Corps Requirement)
8a Will this project occur in a FEMA designated 100 year floodplain?
❑ Yes ® No
8b If yes explain how project meets FEMA requirements
8c What source(s) did you use to make the floodplain determination
http / /www ncdot org/ it/ gis/ DataDistribution /FEMAFIoodData/default html
Adam Carter
Applicant/Agent s Printed Name
Applicant/Agent s Signature
Date
(Agents signature is valid only if an authorization letter from the applicant
is provided
Page 11 of 11
PCN Form — Version 13 December 10 2008 Version

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