20210527 Ver 1_401 Application_20210324

DWR
Division of Water Resources
Pre -Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
October 26, 2020 Ver 3.3
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all mandatory questions are answered.
Also, if at any point you wish to print a copy of the E-PCN, all you need to do is right -click on the document and you can print a copy of the form.
Below is a link to the online help file.
https://edocs.deq.nc.gov/WaterResources/0/edoc/624704/PCN % 20Help % 20File % 202018-1-30.pdf
A. Processing Information
County (or Counties) where the project is located:*
Currituck
Is this a NCDMS Project*
C Yes r No
nick Yes, only t NOM is the applicant a co -applicant.
Is this project a public transportation project?*
C Yes l No
This is any publicly funded by rrunicipal,state a federal funds road, rail, airport transportation project.
la. Type(s) of approval sought from the Corps:*
17 Section 404 Permit (wetlands, streams and waters, Clean Water Act)
n Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
Has this PCN previously been submitted?*
C Yes
G No
1b. What type(s) of permit(s) do you wish to seek authorization?*
17 Nationwide Permit (NWP)
I— Regional General Permit (RGP)
I— Standard (IP)
This form may be used to initiate the standard/individual permit process with the Corps. Please contact your Corps representative concerning submittals for standard permits. All required items that
are not provided in the E-PCN can be added to the miscellaneous upload area located at the bottom of this form.
lc. Has the NWP or GP number been verified by the Corps?*
6 Yes C No
Nationwide Permit (NWP) Number: 18 - Minor Discharges
NWP Numbers (for multiple NWPS):
List at MN numbers you are applying fa not on the drop dawn list.
ld. Type(s) of approval sought from the DWR:*
check all that apply
17 401 Water Quality Certification - Regular
r Non-404 Jurisdictional General Permit
1 Individual Permit
Pre -Filing Meeting Information
1401 Water Quality Certification - Express
r Riparian Buffer Authorization
Before submitting this form please ensure you have submitted the Pre -Filing Meeting Request Form as we will not be able to accept your application without this important first step. The Pre -Filing
Meeting Request Form is used in accordance with 40 C.F.R. Section 121.4(a) "At least 30 days prior to submitting a certification request, the project proponent shall request a pre -filing meeting with the
certifying agency" and in accordance with 40 C.F.R. Section 121.5(b)(7), and (c)(5) all certification requests shall include documentation that a pre -filing meeting request was submitted to the certifying
authority at least 30 days prior to submitting the certification request. Click here to read more information on when this form is needed prior to application submission or here to view the form.
ID# Version
Pre -fling Meeting or Request Date*

3/11/2021
Attach documentation of Pre -Filing Meeting Request here:*
DWR Pre -Filing Meeting Request Form.pdf 50.75KB
le. Is this notification solely for the record because written approval is not required?
*
For the record only for DWR 401 Certification: F' Yes r No
For the record only for Corps Permit: r Yes t No
If. Is this an after -the -fact permit application?*
r Yes f No
lg. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
If so, attach the acceptance letter fromnitigation bank or in -lieu fee program
a Yes r No
Acceptance Letter Attachment
Click the upload button or drag and drop files here to attach docunent
Letter of Credit Availability - Quible - 982 Cruz Bay Court 03102021.pdf
FlLErYFEM15T BET
1h. Is the project located in any of NC's twenty coastal counties?*
6 Yes rNo
1i. Is the project located within a NC DCM Area of Environmental Concern (AEC)?*
r Yes
G No r Unknown
1j. Is the project located in a designated trout watershed?*
C Yes a' No
319.29KB
Link to trout information: http://wnnw.saw.usace.army.mil/Missions/Regulatory-Permit-Program/Agency-Coordination/Trout.aspx
B. Applicant Information
la. Who is the Primary Contact?*
Brian D. Rubino
lb. Primary Contact Email:*
[e-mail]
Id. Who is applying for the permit?*
p Owner
(Check all that apply)
le. Is there an Agent/Consultant for this project?*
Yes No
2. Owner Information
2a. Name(s) on recorded deed:*
SF Corolla Bay LLC
2b. Deed book and page no.:
DB 1526, PG 394
2c. Responsible party:
(for Corporations)
lc. Primary Contact Phone:*
(xxx)aw-xxxx
[phone]
17 Applicant (other than owner)
2d.Address*
Street Address
PO Box 90
Address tine 2
(Sty State / Province / Region
Kill Devil Hills NC
Postal / Zip Code Country
27948 USA
2e. Telephone Number:*
bcodxxx-xxxx
[phone]
2f. Fax Number:
(xxx)xxx-xxxx

2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
3a. Name:*
David & Joan Normandy-Dolberg
3b. Business Name:
Of applicable)
3c. Address*
Street Address
10721 Sandy Run Trail
Address Line 2
aty State / Bovine / Region
Fairfax Station VA
Postal / ZZp Code Country
22039 USA
3d. Telephone Number:*
[phone] 3e. Fax Number:
(xxx)xxx-xxxx (x)x)xxx-xxxx
3f. Email Address:*
jdolberg@cox. net
4. Agent/Consultant (if applicable)
4a. Name:*
Brian D. Rubino
4b. Business Name:
(if applicable)
Quible & Associates P.0
4c. Address*
Street Address
PO Box 870
Address Line 2
aty
Kitty Hawk
Postal / Zip Code
27949
4d. Telephone Number:*
[phone]
()-
4f. Email Address:*
[e-mail]
Agent Authorization Letter*
Rease provide the Agent Authorization Letter if you are subtitling this docunent.
Signed Auth Normandy-Dolberg.pdf
Lot 34 Authorization Statement SF Corolla Bay.pdf
RLETYFEMST BEFCF
State / Bovine / Region
NC
Country
USA
4e. Fax Number:
(xx(pax-xocK
197.41KB
C. Project Information and Prior Project History
1. Project Information
la. Name of project:*
982 Cruz Bay Court
1b. Subdivision name:
(d appropriate)
Corolla Bay
lc. Nearest municipality/ town:*
Corolla
2. Project Identification

2a. Property Identification Number: 2b. Property size:
(tax RN or parcel ID) On acres)
9936-42-5108 0.29
2c. Project Address
Street Address
982 Cruz Bay Court
Address Line 2
Criy State / Bovine / Fegion
Corolla NC
Postal / Zip Code Country
27927
2d. Site coordinates in decimal degrees
Please collect site coordinates in decimal degrees. Use between 4-6 digits (unless you are using a survey -grade GPS device) after the decimal place as appropriate, based on how the location was
determined. (For example, most mobile phones with GPS provide locational precision in decimal degrees to map coordinates to 5 or 6 digits after the decimal place.)
Latitude:* Longitude:*
36.352529 -75.826349
ex: 34.208504-77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Currituck Sound
3b. Water Resources Classification of nearest receiving water:*
SC
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Pasquotank
3d. Please provide the 12-digit HUC in which the project is located.*
030102051306
River Basin Lookup
4. Project Description and History
4a. 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 is currently undeveloped uplands and wetlands. Adjacent parcels include single family residences and undeveloped uplands and wetlands.
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?*
r Yes r No r Unknown
4d. Attach an 8 1/2 X 11 excerpt from the most recent version of the USGS topographic map indicating the location of the project site. (for DWR)
Click the upload button or drag and drop files here to attach document
MOSSEY ISLANDS.pdf 1.72MB
Ale type rrust be Of
4e. Attach an 8 1/2 X 11 excerpt from the most recent version of the published County NRCS Soil Survey map depicting the project site. (for DWR)
Click the upload button or drag and drop files here to attach document
NRCS_Soil_Map.pdf 403.19KB
Rle type must be pdf
4f. List the total estimated acreage of all existing wetlands on the property:
0.16
4g. List the total estimated linear feet of all existing streams on the property:
(internittent and perennial)
n/a
4h. Explain the purpose of the proposed project:*
Fill of 0.029 acres of wetlands to accommodate a single family residential development.
4i. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:*
The proposed project will consist of filling 0.029 acres of wetlands using dump trucks, skid steer, and silt fencing to contain the proposed fill.
4j. Please upload project drawings for the proposed project.
Click the upload button or drag and drop files here to attach document
P99006-Iot34-NAT18-031021.pdf
Ale type must be pdr
357.24KB
5. Jurisdictional Determinations

5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
c Yes
C- No C Unknown
Comments:
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
C- Preliminary P Approved r Not Verified C- Unknown r N/A
Corps AID Number:
Example: SAW-2017-99999
SAW-2008-00770
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Other:
5d. List the dates of the Corp jurisdiction determination or State determination if a determination was made by the Corps or DWR.
03/07/2016
5d1. Jurisdictional determination upload
Click the upload button or drag and drop files here to attach document
Corolla Bay - SAW-2008-00770.pdf
signed-404 corolla bay.pdf
Re type Host be FIT
6. Future Project Plans
6a. Is this a phased project?*
C' Yes n No
91.69KB
553.27KB
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the proposed project or related activity? This
includes other separate and distant crossing for linear projects that require Department of the Army authorization but don't require pre -construction notification.
D. Proposed Impacts Inventory
1. Impacts Summary
la. Where are the impacts associated with your project? (check all that apply):
17 Wetlands
r Open Waters
r Streams -tributaries
r Pond Construction
r Buffers
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
"W." will be used in the table below to represent the word "wetland".
2a. Site #*(9)
1
2a1 Reason*(?)
Residential
Development
2b. Impact type * (?)
P
2c. Type of W.*
Estuarine Woody Wetland
2d. W. name*
Wetland
2e. Forested*
Yes
2f. Type of
Jurisdicition * (')
Corps
2g. Impact
area*
0.029
(acres)
2g. Total Temporary Wetland Impact
0.000
2g. Total Permanent Wetland Impact
0.029
2g. Total Wetland Impact
0.029
2h. Comments:
E. Impact Justification and Mitigation
1. Avoidance and Minimization
la. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*

The proposed fill area has been minimized to achieve the desired single family residential development of this lot. The easting uplands are being
utilized.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Silt fencing will be used to contain all fill proposed. All fill will be sloped in a manner that does not promote erosion.
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 r No
2c. If yes, mitigation is required by (check all that apply):
r DWR fJ Corps
2d. If yes, which mitigation option(s) will be used for this project?
rJ Mitigation bank r Payment to in -lieu fee r Permittee Responsible
program Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
Great Dismal Swamp Restoration Bank
3b. Credits Purchased/Requested (attach receipt and letter)
Type:
Riparian wetland
Quantity:
0.058
Attach Receipt and/or letter
crick the upload button or drag and drop files here to attach docun rt
Letter of Credit Availability - Quible - 982 Cruz Bay Court 03102021.pdf
FILETYFEMST BEFIT
3c. Comments
319.29KB
NC Stream Temperature Classification Maps can be found under the Mitigation Concepts tab on the Wilmington District's RIBITS website.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
***Recent changes to the stormwater rules have required updates to this section .***
1. Diffuse Flow Plan
la. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection Rules?
✓ Yes ( No
For a list of options to meet the diffuse flow requirements, click here.
If no, explain why:
NC Riparian Buffers do not exist within the river basin and all work is outside of the CAMA AEC's and buffers.
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
✓ Yes G No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)?*
a Yes r No
To look up low density requirement click here 15A NCAC 02H .1003(2).
Comments:
G. Supplementary Information
1. Environmental Documentation
la. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?*
✓ Yes (cNo
2. Violations (DWR Requirement)

2a. Is the site in violation of DWR Water Quality Certification Rules (15A NCAC 2H .0500), Isolated Wetland Rules (15A NCAC 2H .1300), or DWR Surface Water or Wetland Standards or
Riparian Buffer Rules (15A NCAC 2B .0200)?*
✓ Yes (No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in additional development, which could impact nearby downstream water quality?*
✓ Yes f No
3b. If you answered "no," provide a short narrative description.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
✓ Yes rNor N/A
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 rNo
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
✓ Yes ( No
5d. Is another Federal agency involved?*
✓ Yes
5e. Is this a DOT project located within Division's 1-8?*
( Yes t No
r No r Unknown
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
NC Natural Heritage Program Database
Consultation Documentation Upload
Click the upload button or drag and drop files here to attach docunent
Ale type mist be FCF
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
✓ Yes rNo
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
No surface waters present within the proposed work area.
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to the State Historic Preservation Office Historic Properties Map (does not include archaeological data: http://gis.ncdcr.gov/hpoweb/
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 f• No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
National Register of Historic Places
7c. Historic or Prehistoric Information Upload
Click the upload button or drag and drop files here to attach docunent
Ale must be FOF
8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https://msc.fema.gov/portal/search
8a. Will this project occur in a FEMA-designated 100-yearfloodplain?*
( Yes rNo
8b. If yes, explain how project meets FEMA requirements:
The project is in an AE and Xflood zone. Development of this nature is allowed in AE and Xzones as long as first floor elevations exceed base flood
elevations.
8c. What source(s) did you use to make the floodplain determination?*
FEMA Flood Maps and nconemap.com

Miscellaneous
Comments
Miscellaneous attachments not previously requested.
Click the upload button or drag and drop files here to attach docurrent
Re mist be FCFor KW
Signature
® By checking the box and signing below, I certify that:
• The project proponent hereby certifies that all information contained herein is true, accurate, and complete to the best of my knowledge and belief; and
• The project proponent hereby requests that the certifying authority review and take action on this CWA 401 certification request within the applicable reasonable period of time.
• I have given true, accurate, and complete information on this form;
• I agree that submission of this PCN form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act");
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act");
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature; AND
• I intend to electronically sign and submit the PCN form.
Full Name:*
Brian Rubino
Signature *
Date
3/15/2021

SIGN UP SHEET
INTERAGENCY/SCOPING MEETING
Scoping Meeting - Hyde County Partners, LLC Tract
Purpose of this meeting is to discuss a proposed project and provide environmental permitting and regulatory
information which will improve communications and the permitting processes.
October 15, 2020 at 9:30 am
Onsite
Name
Agency
Phone
Email
Brian Rubino
Quible & Associates
252-599-6021
[e-mail]
Joe Lassiter
Consultant
252-202-3800
[e-mail]
Mike Strader
Quible & Associates
252-261-3300
[e-mail]
Angie Tooley
Hyde County
Partners
252-795-2026
[e-mail]
Bill Ogburn
Hyde County
Partners
252-943-7548
[e-mail]
Dr. Curtis Richardson
Duke University
Wetland Center
919-613-8006
[e-mail]
Dr. Neal Flanagan
Duke University
Wetland Center
919-613-8087
[e-mail]
Raleigh Bland
USACE
910-251-4564
[e-mail]
Billy Standridge
USACE
910-251-4595
[e-mail]
Maria Dunn
NCWRC
252-948-3916
[e-mail]
Rebekah Martin
USFWS
[e-mail]
Howard Phillips
USFWS
howard [e-mail]
Chris Pullinger
DWR-401
252-948-3918
[e-mail]
Robert Tankard
DWR
josephslassiter@g
mail.com
[e-mail]
Samir Dumpor
DEMLR
252-948-3859
[e-mail]
Lyn Hardison
DEQ
252-948-3842
[e-mail]
An on -site meeting to discuss the wetland restoration component of this project which they are seeking a
Nationwide 27 Permit. It will involve hydrologic restoration that would restore historic wetland conditions
on a large portion of the property by retrofitting and installing new ditch/canal water control structures.
The wetland restoration would restore wetlands that had been impacted from their natural state from the
large perimeter ditches.
NCDEQ WASHINGTON REGIONAL OFFICE
943 WASHINGTON SQUARE MALLWASHINGTON, NC 27889 252-946-6481, FAX [phone]
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SIGN UP SHEET
INTERAGENCY/SCOPING MEETING
Name
Attendance
Response
Hardison, Lyn
Meeting Organizer
None
Raleigh W SAW Bland
Required Attendee
Accepted
billy.w.standridge
Required Attendee
Accepted
[e-mail]
Required Attendee
None
[e-mail]
Required Attendee
None
Pullinger, Robert C
Required Attendee
Accepted
Dunn, Carl
Required Attendee
None
Dumpor, Samir
Required Attendee
Accepted
Brian Rubino
Required Attendee
None
[e-mail]
Required Attendee
None
[e-mail]
Required Attendee
None
Michael Strader
Required Attendee
Accepted
Dunn, Maria T.
Required Attendee
None
Tankard, Robert
Required Attendee
Accepted
Martin, Rebekah
Required Attendee
Accepted
Phillips, Howard
Required Attendee
None
Bodnar, Gregg
Required Attendee
Declined
NCDEQ WASHINGTON REGIONAL OFFICE
943 WASHINGTON SQUARE MALLWASHINGTON, NC 27889 252-946-6481, FAX [phone]
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