20120645 Ver 1_401 Application_20120612

06/26/2012 17 09 9197887159 NCDWQRRO PAGE 02/11
20120645
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Corps action 10 no
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Form Vernon 1 4 January 2009
Pre-Construction Notification (PCN) Form
A Applicant Information
7 Processing
18 Type(s) of approval sought from the Corps
❑ Section 404 Permit ❑ Section 10 Permit
1 b Specrfy Nationwide Permr (NWP) number 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 Junsdrehonal General Permit
❑ 401 Water Quality Certification - Express R117arrart gRiFFA hm4zation
1 e Is this notificabon solely fir the record For the record only for DWQ
For the record only for Corps Permit
because wntten approval is not required? 401 Certification
❑ Yes ❑ No
❑ Yes ❑ No
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Page 1 of 10
PCN Form - Version 1 4 January 2009
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3b List the total estimated acreage of all existing wetlands on the property
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4 Junsdictional Detemmnations
49 HAVRI it�1:11 am by f _
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❑ Yees No ❑ UnkiWM
cummaft
4b If the Corps made the junsdlctional determination what type
preliminary ❑ Final
of determination was made
4c �` d��IF�'ds
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❑ Yes No
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06/26/2012 17 09 9197887159 NCDWORRO PAGE 05/11
C Proposed Impacts Inventory
1 Impacts Summary
1a Which sections were completed below for your project (check all that apply)
❑ Wetlands ❑ Streams — tributaries prpJ�f9rs ❑ Open Waters ❑ Pond Construction
2 Wetland Impacts
If there are wetland impacts proposed on the site then complete this question for each wetland area impacted
2a
Wetland impact
number
Permanent (P) or
Temporary
2b
Type of impact
2c
Type of wetland
2d
Forested
2e
Type of jurisdiction
Corps (404 10) or
DWO (401 other)
2f
Area of
impact
(acres)
W1
Choose one
Choose one
YesINO
W2
Choose one
Choose one
YeslNo
W3
Choose one
Choose one
Yen/No
W4
Choose one
Choose one
Yes/No
W5
Choose one
Choose one
YesMo
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)v
3e
Type of
Jurisdiction
3f
Average
stream
width
(feet)
3g
Impact
length
(linear
feet)
S1
Choose one
S2
Choose one
S3
Choose one
$4
Choose one
S5
Choose one
S6
Choose one
3h Total stream and tributary Impacts
1 Comments
Page 4 of 10
PCN Form — Version 14 January 2009

06/26/2012 17 09 9197887159 NCDWQRRO PAGE 06/11
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 indivi usliv list all open water impacts below
4a I
Open water
impact number
Permanent (P) or
TemporarV
4b
Name of waterbody
(if applicable)
4c
Type of impact
4d
Waterbody
type
4e
Area of impact (acres)
O1
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 Dond or lake construction proposed the complete the chart below
5a
Pond ID number
5b
Proposed use or
purpose of pond
50
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)
5j Size of pond watershed (acres)
5k Method of construction
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
ad — Fwd —w oV m
Neuse Tar Pamlico ❑ Catawba ❑ Randleman ❑ Other
6b
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6d
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B3
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B4
YeslNo
as
YeWNo
Be
YeWNo
6h Total Ruf%r Impacts
5 �j
61 twt�
Page 5of10

06/26/2012 17 09 9197887159 NCDWORRO PAGE 07/11
D Impact Justification and Mitigation
1
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2 Compensatory Mitigation for Impacts to Waters of the U S or Waters of the State
2a Does the project require Compensatory Mitigation for
impacts to Waters of the U S or Waters of the State?
❑ Yes ❑ No
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
❑ Permdtee Responsible Mitigation
3 Complete if Using a Mite at+on 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
W 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 6of10
PCN Form —Version 14 January 2009
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06/26/2012 17 09 9197887159 NCDWORRO PAGE 08/11
6
tffi = regedPrl i�by
i w
p�parr bFer iati Nequnrs
Yes ,�j No
%i��li
6b'yt�
i'tl�bt't SIT Torte df# PrpartiA the �o t'�le
6� �ft
�t4 a aCi
mu- rpTm r
a i n
Zone 1
3 (2 for Catawba)
Zone 2
1 5
6f"if 1f�t�oltpir8d�
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Page 7 of 10

06/26/2012 17 09 9197887159 NCDWQRRO PAGE 09/11
E
Stormwater Management and Diffuse Flow Plan (required by DWG)
1
f
�'� �i11�. .�,�yy,-�, � � r��hdrl fiu�ers ii�eM�ie�
��'1Si �EfOlf�ill�$�
��
J
❑ No
ash wiry
❑ Yes
j No
r
2
Stormwater Management Plan
2a
What is the overall percent imperviousness of this project'7
%
2b
Does this ro ect 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 provides beef narrative description of the plan
2e
Who will be responsible for the review of the Stormwater Management Plan?
3
Certified Local Government Stormwater Review
3a
In which local government s jurisdiction is this ro W'7
3b
Which of the following locally Implemented stormwater management programs
apply (check all that apply)
0 Phase II
❑ NSW
USMP
Water Supply Watershed
Other
3c.
Has the approved Stormwater Management Plan with proof of approval been
attached
[]Yes
❑ No
4
DWQ Stormwater Program Review
42
Which of the following state implemented Stormwater management programs apply
(check all that apply)
ElCoastal counties
❑ HOW
ORW
BSesslon Law 2006 -246
0Other
4b
Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ Yes
❑ No
S
DWQ 401 Unit Stormwater Review
S3
Does the Stormwater Management Plan meet the appropriate requirements?
Yes
❑ No
5b
Have all of the 401 Unit submittal requirements been mete
❑ Yes
❑ No
Page 8 of 10
PCN Forst — Version 14 January 2009

06/26/2012 17 09 9197887159 NCDWQRRO PAGE 10/11
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?
lb
If you answered yes to the above does the prcject require preparation of an
environmental document pursuant to the requirements of the National or State
❑Yes ❑ No
(North Carolina) Environmental Policy Act (NEPA/SEPA)7
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
❑ Yes ❑ No
letter)
Comments
2
Violations (DWQ Requirement)
2a
Is f "i $ V 4 � '0 � NOS -
�' n��
Yes No
���
f
2b
❑`Vi Ro
'elf' �s pt'ovidl afrifr�ttil�6tlrr(s)
3
Cumulative Impacts (DWQ Requirement)
3a
i� J#Itf�tVoi WW1"
❑Yes to
tt' e%�y+ t1►11 m11wtw
3b
w
�
fPte�9f'1�"�iii�pi"i5 �� rattraR'�+e'�on
N�
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 9of10
PCN Form — Version 14 January 2009

06/26/2012 17 09 9197887159 NCDWORRO PAGE 11/11
5 Endangered Species and Designated Critical Habitat (Corps Requirement)
$a 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 ❑ No
5c If yes indicate the USFWS Field Office you have contacted
-
5d What data sources did you use to determine whether your Site would impact Endangered Species or Designated Critical
Habitat?
6 Essential Fish Habitat (Corps Requirement)
6a Will this project occur in or near an area designated as essential fish habitat?
❑ Yes ❑ 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 floodpiain determination?
JO)4 � T
1lfli9k��e ��
Page 10 of 10