20120370 Ver 2_401 Application_20120812

M cl -REED
<IN4&C
UPS Ground
TO: NCDENR/DWQ 401 Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650
ATTENTION- Ian McMillan
WE ARE SENDING: ❑ Originals ® Prints
❑ Specifications ❑ Calculations
LETTER OF TRANSMITTAL
DATE: August 16, 2012
PROJECT NO: 02815 -0004
TASK NO: 40
RE: QE Academy Expansion
NWP 12 Submittal
DWQ 12 -0370 V 2,
TRANSMITTAL NO:
PAGE 1 OF 1
❑ Shop Drawings ❑ Samples
® Other -
Quantity Drawing No. Rev. Description Status
I 5 I I I PCN Form – Version 1.3 for NWP 12 _ _ _ —
5 Agent Authorization Form% Zit
5 Quad/Vicinity Map
5 PCN: S1 -001 Temporary Stream Impact Map
1 Return of Application Letter
1 COE Permit ID #201200619
1 1 I I $240 application fee (check 66346)
Issue Status Code: A. Preliminary B. Fabrication Only C. For Information D. Bid
E. Construction F. For Review & Comments G. For Approval H. See Remarks
Action Status Code: 1. No Exceptions Taken 2. Make Corrections Noted 3. Other
4. Amend & Resubmit 5. Rejected - See Remarks
REMARKS:
This package was previously returned for lack of the application fee. It is attached now. Thanks,
243 NORTH FRONT STREET, WILMINGTON, NC 28401 (910) 343 -1048 FAX [phone]
cc: David Lisle/Lisle Arch. /trans only McKIM & CREED, INC.
File –Trans � LEE, U !:/
File scan 28150004/40/COE/120412 D DO
NWP Resubmittal �
AUG 1 7 201�i e
rr
arga t Gray
DENR - WATER QUALITY

2co1;0001� (4-0
�
I�CDETIR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Chuck Wakild, P.E. Dee Freeman
Governor Director Secretary
June 13, 2012
DWQ Project # 12 -0370
Forsyth County
CERTIFIED MAIL: RETURN RECEIPT REQUESTED
Quality Education Academy
5012 C Lansing Drive
Winston Salem, North Carolina 27105
Subject Property: Seed in the Soil — QE Academy
RETURN OF APPLICATION
Dear Sir/Madam:
On April 13, 2012, the Division of Water Quality (DWQ) received your application dated March 27, 2012
2010. On April 17, 2012, DWQ issued a Request for More Information letter requesting a $240
permitting fee based on the NW 12 General Certification (GC3884) and the noted stream impact. As of
today, the DWQ has not received the requested fee or a response.
For this reason your permit application is hereby considered returned. Once you have redesigned your
project to address the problems and inadequacies with your application as it was submitted, you will need to
reapply for DWQ approval. This includes submitting a complete application package with the appropriate
fee.
Please be aware that you have no authorization under Section 401 of the Clear Water Act for this activity
and any work done within waters of the state would be a violation of North Carolina General Statutes and
Administrative Code. Please call Mr. Ian McMillan at 919- 807 -6364 or me at 919 -807 -6360 if you have
any questions or concerns.
Sincerely,
C
Karen i gg ins etl Inds ffers- Stormwater, -
Compliance and Permittin WeBSCaPe), Supervisor
KAH/ jd
cc: U.S. Army Corps of Engineers - Raleigh Regulatory Field Office
Sire Homewood, DWQ Winston Salem Regional Office — via email
McKim & Creed, Inc, Margaret Gray, 243 N Front St, Wilmington NC 28401
Filename: 12- 0370SeedintheSoilQEAcademy (Forsyth)Retumed_Appl ication
Wetlands. Buffers. Stormwater, Compliance and Permitting Unit (WeBSCaPe)
1650 Mail Service Center. Raleigh, North Carolina 27699 -1650
Phone' 919 -807 -63001 FAX. [phone]
Internet: http Yportal ncdenr.orgiweblwq'ws
An Equal Oppoit unity I Ai iririative Action'EmNlovei

:w I 0�1564`40
U.S. ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Action ID. 201200619 County: Forsyth USGS Quad: Winston -Salem East
GENERAL PERMIT (REGIONAL AND NATIONWIDE) VERIFICATION
Property Owner / Authorized Agent: Quality Education Academy / Simon Johnson
Address: 5012 C Lansing Drive ff%opmy
Winston- Salem, North Carolina 27105
Telephone No.: 336 744 -7138
Size and location of property (water body, road name /number, town, etc.): Sewer connector property for The Quali
Education Academv located off of Lansing Drive, adiacent to a tributary of Brushy Fork Creek, in Winston-
Salem, Forsyth County, North Carolina. Property is adiacent to Brushy Fork Creek which is a tributary of the
Yadkin River
Description of projects area and activity: Mechanized landclearing, excavation and the discharge of fill material
associated with the construction of a gravity sewer connector resulting in 20 linear feet of temporary stream
channel impacts to the jurisdictional waters of Brushy Fork Creek.
Applicable Law: ® Section 404 (Clean Water Act, 33 USC 1344)
❑ Section 10 (Rivers and Harbors Act, 33 USC 403)
Authorization: Regional General Permit Number:
Nationwide Permit Number: NW 12
Your work is authorized by the above referenced permit provided it is accomplished in strict accordance with the attached
conditions and your submitted plans. Any violation of the attached conditions or deviation from your submitted plans may subject the
pennittee to a stop work order, a restoration order and/or appropriate legal action.
This verification will remain valid until the expiration date identified below unless the nationwide authorization is modified,
suspended or revoked. If, prior to the expiration date identified below, the nationwide permit authorization is reissued and /or
modified, this verification will remain valid until the expiration date identified below, provided it complies with all requirements of
the modified nationwide permit. If the nationwide permit authorization expires or is suspended, revoked, or is modified, such that the
activity would no longer comply with the terms and conditions of the nationwide permit, activities which have commenced (i.e., are
under construction) or are under contract to commence in reliance upon the nationwide permit, will remain authorized provided the
activity is completed within twelve months of the date of the nationwide permit's expiration, modification or revocation, unless
discretionary authority has been exercised on a case -by -case basis to modify, suspend or revoke the authorization.
Activities subject to Section 404 (as indicated above) may also require an individual Section 401 Water Quality Certification. You
should contact the NC Division of Water Quality (telephone [phone]) to determine Section 401 requirements.
For activities occurring within the twenty coastal counties subject to regulation under the Coastal Area Management Act (CAMA),
prior to beginning work you must contact the N.C. Division of Coastal Management.
This Department of the Army verification does not relieve the permittee of the responsibility to obtain any other required Federal,
State or local approvals /permits.
If there are any questions regarding this erification, any of the conditions of the Permit, or the Corps of Engineers regulatory
program, please contact John Thomas @ 554 -4884 eA 25.
Corps Regulatory Official
Expiration Date of Verification � 04/17/2014
Date: 04/17/2012
The Wilmington District is committed to providing the highest level of support to the public. To help us ensure we continue to do so,
please complete the attached customer Satisfaction Survey or visit htn:G,www, saw. usace .arrny.mil /WETLANDS /index.html to
complete the survey online.
Page 1 of 2

ib;, , r
Determination of Jurisdiction:
❑ Based on preliminary information, there appear to be waters of the US including wetlands within the above described project area.
This preliminary determination is not an appealable action under the Regulatory Program Administrative Appeal Process
( Reference 33 CFR Part 331).
❑ There are Navigable Waters of the United States within the above described project area 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.
® There are waters of the US and/or wetlands within the above described project area subject to the permit 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.
❑ The jurisdictional areas within the above described project area have been identified under a previous action. Please reference
jurisdictional determination issued . Action ID
Basis of Jurisdictional Determination: Property has tributary of Brushy Fork Creek that flows to the Yadkin River and the
Atlantic Ocean. This iurisdictional determination is only for the waters /wetlands proposed for impacts associated with this
Nationwide Permit and does not include any other waters /wetlands that may be located on the property.
Appeals Information (This information applies only to approved jurisdictional determinations.)
Attached to this verification is an approved jurisdictional determination. If you are not in agreement with that approved jurisdictional
determination, you can make an administrative appeal under 33 CFR 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
Wake Forest, North Carolina 27587
In order for an RFA to be accepted by the Corps, the Corps must determine that it is complete, that it meets the criteria for appeal
under 33 CFR part 331.5, and that it has bep received by the District Office within 60 days of the date of the NAP. Should you
decide to submit an RFA form, it must beeived at the aboye address by June 17, 2012.
* *It is not necessary to submit an RF4 Toro to the District Office if you fro not object to the determination in this correspondence. **
Corps Regulatory Official:
Date 04/17/2012
SURVEY PLATS, FIELD SKE CH, WETLAND DELINEA ION FORMS, PROJECT PLANS, ETC., MUST BE
ATTACHED TO THE FILE COPY OF THIS FORM, IF REQUIRED OR AVAILABLE.
Copy Furnished: Margaret Gray, McKim & Creed, 243 North Front Street, Wilmington, NC 28401
Page 2 of 2

�a- b3']DV2-
o2ot wnrF,yoG Office Use Only:
y g Corps action ID no.
o DWQ project no.
Form Version 1.3 Dec 10 2008
Pre - Construction Notification CN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the
Corps: ®Section 404 Permit ❑Section 10 Permit
u
1 b. Specify Nationwide Permit (NWP) number: 12 or General Permit (GP) number:
1c. Has the NWP or GP number been verified 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 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
le. Is this not cation 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 1 h
below.
❑ Yes
® No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes
❑ No
2. Project Information
2a. Name of project:
Seed in the Soil - QE Academy
2b. County:
Forsyth
2c. Nearest municipality I town:
Winston -Salem
' f
2d. Subdivision name:
NA
2e. NCDOT only, T.I.P. or state
project no:
NA
7 j U 12
3. Owner Information yy fir`^
4U�
3a. Name(s) on Recorded Deed:
Quality Education Academy _ ._
:�S z and
3b. Deed Book and Page No.
2686, 937
3c. Responsible Party (for LLC if
applicable):
3d. Street address:
5012 C Lansing Dr.
3e. City, state, zip:
Winston- Salem, NC 27105
3f. Telephone no.:
336 -744 -7138
3g. Fax no.:
3h. Email address:
Page ] of 10
PCN Form — Version 1.3 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:
Margaret Gray
5b. Business name
(if applicable):
McKim & Creed, Inc.
5c. Street address:
243 North Front St.
5d. City, state, zip:
Wilmington, NC 28401
5e. Telephone no.:
910 -343 -1048
5f. Fax no.:
910- 251 -8282
5g. Email address:
[e-mail]
Page 2 of 10
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):
6847 -45- 1746.00
1 b. Site coordinates (in decimal degrees):
Latitude: 36.20575 Longitude: - 80.20575
(DD.DDDDDD) (- DD.DDDDDD)
1c. Property size:
7.82 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project:
Brushy Fork Branch
2b. Water Quality Classification of nearest receiving water:
C
2c. River basin:
Yadkin -Pee Dee
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:
Existing conditions - educational facility. Adjacent land uses - residential and light commercial
3b. List the total estimated acreage of all existing wetlands on the property:
Riparian stream wetlands - 722 LF x 5' average = 0.08 acres
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
Stream - 722 LF
3d. Explain the purpose of the proposed project:
A 31,693 SF building additional and ancillary drives, sidewalk and stormwater pond
3e. Describe the overall project in detail, including the type of equipment to be used:
Track hoe, dump truck, excavator, bull dozer and road grader
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property 1
project (including all prior phases) in the past?
Comments:
❑ Yes ❑ No ® Unknown
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):
Agency /Consultant Company:
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
6. 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 3 of 10
PCN Form — Version 1.3 December 10, 2008 Version

C. Proposed Impacts Inventory
1- Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
❑ Wetlands ® Streams - tributaries ❑ Buffers
❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
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
❑ Yes
❑ No
❑ Corps
❑ DWQ
W2 ❑ P ❑ T
❑ Yes
❑ No
❑ Corps
❑ DWQ
W3 ❑ P ❑ T
❑ Yes
❑ No
❑ Corps
❑ DWQ
W4 ❑ P ❑ T
❑ Yes
❑ No
❑ Corps
❑ DWQ
W5 []PEI T
❑ Yes
❑ No
❑ Corps
❑ DWQ
W6 ❑ P ❑ T
❑ Yes
❑ No
❑ Corps
❑ DWQ
2g. Total wetland impacts
NA
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.
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
Gravity sewer
Brushy Fork
® PER
® Corps
5
20
installation
Branch
❑ INT
® DWQ
S2 ❑ P ❑ T
❑ PER
❑ INT
❑ Corps
❑ DWQ
S3 ❑ P ❑ 7
[I PER
❑ INT
❑ Corps
❑ DWQ
S4 ❑ P ❑ T
❑ PER
❑ INT
❑ Corps
❑ DWQ
S5 ❑ P ❑ T
❑ PER
❑ INT
❑ Corps
❑ DWQ
S6 ❑ P ❑ T
❑ PER
❑ INT
❑ Corps
❑ DWQ
3h. Total stream and
tributary impacts
20
3i. Comments:
Page 4 of 10
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❑T
03 ❑P ❑T
04 ❑P ❑T
4f. Total open water impacts
NA
4g. Comments: NA
5. Pond or Lake Construction
If Pond or lake construction proposed, then complete the chart below.
58.
5b.
5c.
5d.
5e.
Wetland Impacts (acres)
Stream Impacts (feet)
Upland
Pond ID
Proposed use or purpose
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
number
of pond
P1
P2
5f. Total
5g. Comments: NA
5h. Is a dam high hazard permit required?
❑ Yes ®No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
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: NA
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)
im act
required?
-Temporary
B1 [:]POT
❑Yes
❑ No
B2 ❑P ❑T
❑Yes
❑ No
B3 ❑P ❑T
❑Yes
❑ No
6h. Total buffer impacts
NA
6i. Comments: NA
Page 5 of 10
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.
Perpindicular crossing at narrow stream section
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Utilize erosion control measures, and restore channel to pre- existing stream conditions with no impediment to channel flow
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: NA
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. Suffer 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: NA
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.
NA
Page 6 of 10
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: NA
Page 7 of 10
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?
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?
32%
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:
High density stormwater pond
® 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?
Winston -Salem
® 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
❑ HOW
4a. Which of the following state - implemented stormwater management programs apply
❑ ORW
(check all that apply):
❑ Session Law 2006 -246
® Other: NA
4b. Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ Yes ® No
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements?
® Yes ❑ No
5b. Have all of the 401 Unit submittal requirements been met?
® Yes ❑ No
Page 8 of 10
PCN Form — Version 1.3 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
[:1 Yes ® No
use of public (federal /state) land?
1b. If you answered "yes' to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State
❑ Yes ❑ No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
❑ Yes ❑ No
letter.)
Comments: NA
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
0 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.
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.
Connection to a public sewer system via gravity sewer
Page 9of10
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 0 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?
Natural Heritage Program data base
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?
South Atlantic Fishery Management Council EFH document
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?
State Historic Preservation Office data base
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA - designated 100 -year floodpiain?
❑ Yes ® No
8b. if yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodpiain determination? FEMA Map
Margaret Gray
March 27, 2012
Applicant/Agent's Printed Name
p nt/Agent's Sign
Date
(Agents signature is val' y if an authorization Rer from the applicant
is provided)
Page 10 of 10
PCN Form — Version 1.3 December 10, 2008 Version

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