20120390 Ver 1_401 Application_20120412

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20120390
RE. EIVED
�F WArFA 7 N r Dent of ENR
p ti Office Use Only
AP � 17 1012 t Corps action ID no
° ` Winston Salem ° DWQ project no
Rep anal Office Form Version 14 January 2009
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V
Page 1 of 10
PCN Form - Version 1 4 January 2009
Pre - Construction Notification (PCN) For
A
Applicant Information 0
1
Processing
1a
Type(s) of approval sought from the Corps
ection 404 Permit ❑ Section 10 Permit
1b Specify Nationwide Permit (NWP) number j ) or General Permit (GP) number
1c
Has the NWP or GP number been verified by the Corps?
Ines ❑ No
1d
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
KYes ❑ No
For the record only for Corps Permit
❑ Yes 1y*o
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 N0
1 g
Is the protect located in any of NC s twenty coastal counties If yes answer 1 h
below
❑Yes ['Nlo
1h
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes E,No
2
Project Information
2a
Name of project
2b
County
S
2c
Nearest municipality / town
luu U IL/ Lis
APR
2d
Subdivision name
2e
NCDOT only T I P or state project no
3
Owner Information y NR Gyp R All
ng.
3a
Name(s) on Recorded Deed
�r eBranch
3b
Deed Book and Page No
gel
3c
Responsible Party (for LLC if
applicable)
3d
Street address
3/1( Vor-1,
3e
City state zip
r
A2,12 1,4 G ?o a G
3f
Telephone no
v? 3 e/g 3 6 _ i
3g
Fax no
33& 3 6­2 35 d9
3h
Email address
C d C- /0 '
V
Page 1 of 10
PCN Form - Version 1 4 January 2009

4 Applicant Information (if different from owner)
4a Applicant is
❑ Agent ❑ Other spdcify
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
5b Business name
(if applicable)
5c Street address
5d City state zip
5e Telephone no
5f Fax no
5g Email address
Page 2 of 10

C Proposed Impacts Inventory
1 Impacts Summary
1a Which sections were completed below for your project (check all that apply)
❑ Wetlands Streams — tributaries ❑ Buffers ❑ Open Waters ❑ Pond Construction
2 Wetland Impacts
If there are wetland impacts proposed on the site then complete this question for each wetland area impacted
2a
Wetland impact
number
Permanent (P) or
Temporary T
2b
Type of impact
2c
Type of wetland
2d
Forested
2e
Type of Jurisdiction
Corps (404 10) or
DWQ (401 other)
2f
Area of
impact
(acres)
W1
Choose one
Choose one
Yes /No
W2
Choose one
Choose one
Yes /No
W3
Choose one
Choose one
Yes /No
W4
Choose one
Choose one
Yes /No
W5
Choose one
Choose one
Yes /No
W6
Choose one
Choose one
Yes /No
2g Total
Wetland Impacts
2h Comments
3 Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site then complete this
question for all stream sites impacted
3a
Stream impact
number
Permanent (P) or
Temporary (T)
3b
Type of impact
3c
Stream name
3d
Perennial (PER) or
intermittent (INT)?
3e
Type of
Jurisdiction
3f
Average
stream
width
(feet)
3g
Impact
length
(linear
feet)
S1
Choose one -J\C :> V z
xtkQ/.)
a`�►�'
��}}n
1 5
�'
S2
Choose one
S3
Choose one
S4
Choose one
S5
Choose one
S6
Choose one
3h Total stream and tributary impacts
& Comments
Page 4 of 10
PCN Form — Version 1 4 January 2009

Page 3 of 10
PCN Form — Version 1 4 January 2009
Project Information and Prior Project History
1
Property Identification
1a
Property identification no (tax PIN or parcel ID)
to 76--r / e.
1b
Site coordinates (in decimal degrees)
I Latitude ,3 3/' �;ti Longitude
1c
Property size
1 acres
2
Surface Waters
2a
Name of nearest body of water to proposed project
t. e- r s ko- — S i ��--
2b
Water Quality Classification of nearest receiving water
2c
River basin
3
Project Description
3a Describe the a fisting cond tions on the site a9d the gen ral land use in the vicinity of the project at the gme of this
application .S © /2 P� l0 / oO e! o 5 S 5 • /on�� /c7 ��oT, � �J
T,h/2 Gi�vG �GtjhC I` 6'L,,O �5 �rylJ .�' /[�¢� , Q��o ct DK)tl via�LP. -,180
o—ree,L 64/1 r5 &110d, ' n a 6 � �eG71 0/i
3b
List the total estimated acreage of all ex sting wetlands on the property 1JooL —
3c
List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
3d
Explain the purpose of the proposed project ��p,p j� t✓rt �O� ry� G ro-) I oe1
3e Describe the overall project in detail including the type of equipment to be used (�(�� F�qG/ l�oG
sp ,?1, d lo 0-Sint yt lctr �1! l�ot �bo
Q / are o r 0
4
Jurisdictional Determinations
4a
Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
&Yes ❑ No ❑ Unknown
Comments
4b
If the Corps made the jurisdictional determination what type
of determination was made?
❑ Preliminary ❑ Final
4c
If yes who delineated the jurisdictional areas?
Name (if known) �2 bCY`Ccn� Oo-,
Agency /Consultant Company
Other M
4d
If yes list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
L��ko IZ
6
Project History
5a
Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
❑ Yes 0�o ❑ 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 3 of 10
PCN Form — Version 1 4 January 2009

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 indiv ually list all open water impacts below
4a
Open water
impact number
Permanent (P) or
Temporary
4b
Name of waterbody
(if applicable)
4c
Type of impact
4d
Waterbody
type
4e
Area of impact (acres)
01
Choose one
Choose
02
Choose one
Choose
03
Choose one
Choose
04
Choose one
Choose
4f Total open water impacts
4g Comments
5 Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below
5a
Pond ID number
5b
Proposed use or
purpose of pond
5c
Wetland Impacts (acres)
5d
Stream Impacts (feet)
5e
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f Total
5g Comments
5h Is a dam high hazard permit required?
❑ Yes ❑ No If yes permit ID no
51 Expected pond surface area (acres)
5f 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 Project is in which protected basin?
❑ Neuse ❑ Tar Pamlico ❑ Catawba ❑ Randleman ❑ Other
6b
Buffer Impact
number —
Permanent (P) or
Temporary
6c
Reason for impact
6d
Stream name
6e
Buffer
mitigation
required?
6f
Zone 1
impact
(square
feet )
6g
Zone 2
impact
(square
feet
B1
Yes /No
82
Yes /No
B3
Yes /No
B4
Yes /No
B5
Yes /No
B6
Yes /No
6h Total Buffer Impacts
61 Comments
Page 5 of 10

D Impact Justification and Mitigation
1 Avoidance and Minimization
1a Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
1b Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
�� o �c�- v% J` 66- � 4• u 5 e S I /� Al2c4e.,
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 KNo
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 Choose one
Type Choose one
Type Choose one
Quantity
Quantity
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
Choose one
4d Buffer mitigation requested (DWQ only)
square feet
4e Riparian wetland mitigation requested
acres
4f Non riparian wetland mitigation requested
acres
4g Coastal (tidal) wetland mitigation requested
r acres
4h Comments
6 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 6 of 10
PCN Form — Version 1 4 January 2009

6 Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a Will the project result in an impact within a protected riparian buffer that requires
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
6,e
Required mitigation
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
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
Page 7 of 10

E
Stormwater Management and Diffuse Flow Plan (required by DWQ)
1
Diffuse Flow Plan
la
Does the protect include or is it adjacent to protected riparian buffers identified
❑ Yes eNo
within one of the NC Riparian Buffer Protection Rules?
1b
If yes then is a diffuse flow plan included? If no explain why
❑ Yes ❑ No
2
Stormwater Mana ement Plan
2a
What is the overall percent imperviousness of this project?
C)
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
2e
Who will be responsible for the review of the Stormwater Management Plan?
3
Certified Local Government Stormwater Review
3a
In which local governments 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
❑Yes ❑ No
attached?
5
DWQ 401 Unit Stormwater Review
5a
Does the Stormwater Management Plan meet the appropriate requirements?
❑ Yes ❑ No
5b
Have all of the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 8 of 10
PCN Form — Version 1 4 January 2009

F
Supplementary Information
1
Environmental Documentation (DWQ Requirement)
la
Does the project involve an expenditure of public (federal /state /local) funds or the
❑ Yes
�No
use of public (federal /state) land?
1 b
If you answered yes to the above does the project require preparation of an
environmental document pursuant to the requirements of the National or State
❑Yes
❑ No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c
If you answered yes to the above has the document review been finalized by the
State Clearing House? (If so attach a copy of the NEPA or SEPA final approval
letter)
❑ Yes
❑ No
Comments
2
Violations (DWQ Requirement)
2a
Is the site in violation of DWQ Wetland Rules (15A NCAC 2H 0500) Isolated
Wetland Rules (15A NCAC 2H 1300) DWQ Surface Water or Wetland Standards
[]Yes
No
or Riparian Buffer Rules (15A NCAC 213 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
l`j 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
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
Page 9 of 10
PCN Form — Version 1 4 January 2009

5 Endangered Species and Designated Critical Habitat (Corps Requirement)
5a Will this project occur in or near an area with federally protected species or
habitat
❑ Yes No
5b Have you checked with the USFWS concerning Endangered Species Act
Impacts?
❑ Yes ffNo
5c If yes Indicate the USFWS Field Office you have contacted
5d What data sources did you use to determine whether your site would Impact Endangered Species or Designated Critical
Habitat?
6 Essential Fish Habitat (Corps Requirement)
6a Will this protect occur In or near an area designated as essential fish habitat?
❑ Yes No
6b What data sources did you use to determine whether your site would Impact Essential Fish Habitat?
7 Historic or Prehistoric Cultural Resources (Corps Requirement)
7a Will this project occur in or near an area that the state federal or tribal
governments have designated as having historic or cultural preservation
status (e g National Historic Trust designation or properties significant In
North Carolina history and archaeology)?
❑ Yes ® No
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?
Applicant/Agent s Pnnted Name
Applicant/Agent s Signature
(Agent s signature Is valid only if an authorization
letter from the applicant is provided
Date
jeae.o.t H� s� X66;5
Page 10 of 10

Dennison, Laurie
From Homewood Sue
Sent Thursday April 19 2012 3 32 PM
To Dennison Laurie Strickland Bev
Subject another courtesy
Attachments D00041912 04192012122007 pdf Holy Cross Missionary baptist church pre app map Mpg
Sue Homewood
NC DENR Winston Salem Regional Office
Division of Water Quality
585 Waughtown Street
Winston Salem NC 27107
Voice (336) 7714964
FAX [phone]
E mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties

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