20201484 Ver 1_401 Application_20210419

Staff Review Form
Updated September 4, 2020
Staff Review
Does this application have all the attachments needed to accept it into the review process?*
6* Yes r No
ID#* Version* 1
20201484
Is this project a public transportation project?*
Reviewer List:*
Select Reviewing Office:*
Submittal Type:*
r Yes
r No
Alan Johnson:eads\adjohnsonl
Mooresville Regional Office - [phone]
401 Application
Does this project require a request for payment to be sent?*
C'
Yes
No
How much is r $240.00
owed?* C' $570.00

Project Submittal Form
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.
Project Type:*
✓ For the Record Only (Courtesy Copy)
✓ New Project
✓ Modification/New Project with Existing ID
✓ More Information Response
✓ Other Agency Comments
✓ Pre -Application Submittal
✓ Re-Issuance\Renewal Request
✓ Stream or Buffer Appeal
Pre -Filing Meeting Information
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.
Attach documentation of Pre -Filing Meeting Request here:
DWR Pre -Filing Meeting Request Form.pdf
Date for Meeting Request 10/16/2020
ID# 20201484 Version 1
Project Contact Information
Name: Heather LaGamba
who is submitting the inforrration?
Email Address: [e-mail]
Project Information
Project Name:
Reece Gibson
Is this a public transportation project?
r Yes
a No
51.42KB
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
r Yes r No r Unknown
County (ies)
Stanly
Please upload all files that need to be submited.

Dick the upload button or drag and drop files here to attach document
6137.1_Reece Gibson_PCN Appl ication_4.1 5.21 .pdf 191.56KB
Only pdf or krrz files are accepted.
Describe the attachments
or comments:
PCN for 401 WQC.
Sign and Submit
.....................................................................................................................................................................................................................
117 By checking the box and signing box below, I certify that:
• I, the project proponent, hereby certifies that all information contained herein is true, accurate, and complete to
the best of my knowledge and belief.
• I, 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 agree that submission of this online 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 online form.
Signature:
(W i et, 40. iMpreci
Submittal Date: Is filled in automatically.

5GTE , .,.
NORTH CAROLINA
Environmental Quality
Water Resources
Office Use Only
Corps Action ID no. SAW— 2020-01836 Date received: 4/15/2021
DWR project no. _Click enter.] Date received: [Click to enter.]
Site Coordinates:
Latitude (DD.DDDDDD): 35.222676°
Longitude (DD.DDDDDD): -80.456591°
Form Version 1.5. September 2020
Pre -Construction Notification (PCN) Form
(Ver. 1.5, September 2020)
For Nationwide Permits and Regional General Permits and corresponding Water Quality Certifications
Please note: fields marked with a red asterisk are required. The form is not considered complete until all mandatory
questions are answered.
The online help file may be found at this link:
https://edocs.deq. nc.gov/WaterResou rces/0/edoc/624704/PCN%20He I p%20File%202018-1-30. pdf
The help document may be found at this link:
http://www.saw. usace.armv.mil/Missions/Regulatory-Permit-Program/Permits/2017-Nationwide-Permits/Pre-
construction-Notification/
Before submitting this form, please ensure you have submitted the Pre -Filing Meeting Request Form as DWR will not be
able to accept your application without this important first step. The Pre -Filing Meeting Request Form is used to satisfy 40
C.F.R. Section 121.4(a) which states "At least 30 days prior to submitting a certification request, the project proponent shall
request a pre -filing meeting with the certifying agency." In accordance with 40 C.F.R. Section 121.5(b)(7), and (c)(5), all
certification requests must include documentation that a pre -filing meeting request was submitted to the certifying authority
at least 30 days prior to submitting the certification request.
Attach documentation of Pre -Filing Meeting Request to this Application.
Date of Pre -filing Meeting Request (MM/DD/YYYY) : 10/16/2020
DWR ID # 20201484 Version 1 (If applicable)
A. Processing Information
County (counties) where project is located:
Stanly Additional (if needed).
Is this a public transportation project?
(Publicly funded municipal, state, or federal road, rail,
or airport project)
❑ Yes ❑x No
Is this a NCDOT project?
❑ Yes ❑x No
If yes, NCDOT TIP or state project number:
Click to enter.
If yes, NCDOT WBS number:
Click to enter.
1 a.
Type(s) of approval sought from the Corps:
❑x Section 404 Permit (wetlands, streams, waters,
Clean Water Act)
❑ Section 10 Permit (navigable waters, tidal
waters, Rivers and Harbors Act)
Page 1 of 21
PCN Form - Version 1.5, September 2020

1 b. Permit type(s)?
❑x Nationwide Permit (NWP)
❑ Regional General Permit (RGP)
❑ Standard (IP)
This form may be used to initiate the standard/ individual permit process with the USACE. Please contact your Corps
representative concerning submittals for standard permits. All required items can be included as separate attachments
and submitted with this form.
1 c. Has the NWP or GP number been verified by the Corps?
❑ Yes ❑x No
NWP number(s):
NWP 29
RGP number(s):
Click to enter.
1d. Type(s) of approval sought from the DWR (check all that apply): *
❑x 401 Water Quality Certification — Regular ❑ 401 Water Quality Certification— Express
❑ Non-404 Jurisdictional General Permit ❑ Riparian Buffer Authorization
❑ Individual 401 Water Quality Certification
le. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification: *
❑ Yes ❑x No
For the record only for Corps Permit: *
❑ Yes ❑x No
1f. Is this an after -the -fact permit/certification application?
❑ Yes ❑x No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts?
• Yes ❑x No
If yes, attach the acceptance letter from mitigation bank or in -lieu fee program.
1 h. Is the project located in any of NC's twenty coastal counties?
❑ Yes ❑x No
1 i. Is the project located within an NC DCM Area of Environmental
Concern (AEC)?
El Yes ❑x No El Unknown
1j. Is the project located in a designated trout watershed?
❑ Yes ❑x No
If yes, you must attach a copy of the approval letter from the appropriate Wildlife Resource Commission Office.
Trout information may be found at this link: http://www.saw.usace.army.mil/Missions/Regulatory-Permit-
Program/Agency-Coordination/Trout.aspx
Page 2 of 21 PCN Form - Version 1.5, September 2020

B. Applicant Information
la.
Who is the primary contact?
Reece Gibson
1 b.
Primary Contact Email:
Click to enter.
1 c.
Primary Contact Phone: (###)###-####
[phone]
1 d.
Who is applying for the permit/certification?
all that apply)
(check
el Owner 0 Applicant (other than owner)
1 e.
Is there an agent/consultant for this project?
el Yes ❑ No
2. Landowner Information
2a. Name(s) on Recorded Deed:
Trust River Road
2b. Deed Book and Page No.:
1527/475
2c. Responsible Party (for corporations):
Reece Gibson
2d. Address
Street Address:
4512 River Road
Address line 2:
Click to enter.
City:
Stanfield
State/ Province/ Region:
North Carolina
Postal/ Zip Code:
28163
Country:
U.S.
2e. Telephone Number: - (###)###-####
[phone]
2f. Fax Number: (###)###-####
[phone]
2g. Email Address:
uiicK to enter.
3.
Applicant Information (if different from owner)
3a.
Name:
Click to enter.
3b.
Business Name (if applicable):
Click to enter.
3c.
Address:
Street Address:
Click to enter.
Address line 2:
Click to enter.
City:
Click to enter.
State/ Province/ Region:
Click to enter.
Postal/ Zip Code:
Click to enter.
Country
Click to enter.
3d.
Telephone Number: - (###)###-####
Click to enter.
3e
Fax Number: (###)###-####
Click to enter.
Page 3 of 21
PCN Form - Version 1.5, September 2020

3f. Email Address:
Click to enter.
4. Agent/ Consultant (if applicable)
4a. Name: *
Michael T. Brame
4b. Business Name:
Pilot Environmental, Inc.
4c. Address: *
Street Address:
743 Park Lawn Court
Address line 2:
Click to enter.
City:
Kernersville
State/ Province/ Region:
NC
Postal/ Zip Code:
27284
Country:
U.S.
4d. Telephone Number: * (###)###-####
336.708.4620
4e Fax Number: (###)###-####
Click to enter.
4f. Email Address: *
[e-mail]
Agent Authorization Letter:
Attach a completed/signed agent authorization form or letter. A sample form may be found at this link:
httbs://www.saw. usace.armv. mil/Missions/Regulatory-Permit-Program/Permits/2017-Nationwide-Permits/Pre-
construction-Notification/
Page 4 of 21 PCN Form - Version 1.5, September 2020

C. Project Information and Prior Project History
1.
Project Information
la.
Name of project:
Stanfield Valley Subdivision
1 b.
Subdivision name (if appropriate):
Stanfield Valley Subdivision
lc.
Nearest municipality/town: *
Stanfield, NC
2.
Project Identification
2a.
Property identification number (tax PIN or parcel ID):
556301488696, 556301498092, 556302592553,
556302682581
2b.
Property size (in acres):
34.5
2c.
Project Address:
Street Address:
Renee Ford Road and River Road
Address line 2:
Click to enter
City:
Stanfield
State/ Province/ Region:
NC
Postal/ Zip Code:
28163
Country:
U.S.
2d.
Site coordinates in decimal degrees (using 4-6 digits
after the decimal point):
Latitude (DD.DDDDDD): 35.222676°
Longitude (-DD.DDDDDD): --80.456591 °
3.
Surface Waters
3a.
Name of nearest body of water to proposed project:
Rock Hole Creek
3b.
Water Resources Classification of nearest receiving
water:
Class C Waters
The Surface Water Classification map may be found at this link:
https://ncdenr.maps.arcgis.com/apes/webappviewer/index.html?id=6e125ad7628f494694e259c80dd64265
3c.
In what river basin(s) is your project located?
Yadkin-PeeDee
Choose additional (if needed)
3d.
Please provide the 12-digit HUC in which the project is
located:
030401050704
The Find Your HUC map may be found at this link:
https://ncdenr.maps.arcgis.com/apes/PublicInformation/index.html?appid=ad3a85a0c6d644a0b97cd069db238ac3
Page 5 of 21 PCN Form - Version 1.5, September 2020

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 contains fields and wooded land.
4b. Have Corps permits or DWR certifications been obtained for this
project (including all prior phases) in the past?
• Yes ❑x No ❑ Unknown
4c. If yes, please give the DWR Certification number and/or Corps
Action ID (ex. SAW-0000-00000):
SAW — 2020-01836
[Author]
Attach any pertinent project history documentation
4d. Attach an 8% x 11" excerpt from the most recent version of the USGS topographic map indicating the location of
the project site.
4e. Attach an 8% x 11" excerpt from the most recent version of the published County NRCS Soil Survey map
depicting the project site.
4f. List the total estimated acreage of all existing wetlands on the
property:
0.096 acres
4g. List the total estimated linear feet of all existing streams (intermittent
and perennial) on the property:
2,460 linear feet
4g1. List the total estimated acreage of all existing open waters on the
property:
0 acres
4h. Explain the purpose of the proposed project:
The purpose of the proposed project is to construct a 49-lot single family residential subdivision.
4i. Describe the overall project in detail, including the type of equipment to be used:
The overall project includes the construction of a residential subdivision. Construction of the subdivision includes
constructing access roads and installing utilities. In order to facilitate the proposed development, it is necessary to
install a road crossing that will impact 124 linear feet (0.0148 acres) of stream channel with a culvert, 10 linear feet
(0.0012 acres) of stream channel with rip rap that is to be keyed in and 40 linear feet (0.0048 acres) of stream channel
associated with a pump around. To facilitate the development of the site, clearing and grading the site is necessary.
Graders, haulers, excavators and other heavy equipment will be used during grading and construction of the site.
4j. Attach project drawings/site diagrams/depictions of impact areas for the proposed project.
5.
Jurisdictional Determinations
5a.
Have the wetlands or streams been delineated on the property or in
proposed impact areas?
Yes ❑ No ❑Unknown
Comments:
Delineated by Pilot Environmental June 2018 and verified by USACE August 8, 2018.
5b.
If 5a is yes, who delineated the jurisdictional
areas?
Name (if known): David Brame/Michael Brame
Agency/Consultant Company: Pilot Environmental
Other: Click to enter
5c.
If the Corps made a jurisdictional determination,
what type of determination was made?
❑x Preliminary ❑ Approved ❑ Emailed Concurrence
❑ Not Verified ❑ Unknown
Corps AID number (ex. SAW-0000-00000):
SAW— 2020-01836
Page 6 of 21
PCN Form - Version 1.5, September 2020

5d. List the dates of the Corps jurisdictional determination or State determination if a determination was made by
either agency.
10/22/2020
5d1. Attach jurisdictional determinations.
Page 7 of 21 PCN Form - Version 1.5, September 2020

6. Future Project Plans
6a. Is this a phased project?
► Yes ❑ No
6b. If yes, explain.
This is a proposed 49-lot single family residential subdivision. A road is stubbed onto adjoining property east of
the site. There are no immediate plans to extend the subdivision to the east. The developer is aware that
impacts from future phases are considered cumulative.
Are any other NWP(s), regional general permit(s), or individual permit(s) used, or intended to be used, to authorize
any part of the proposed project or related activity? This includes other separate and distant crossings for linear
projects that require Department of the Army authorization but don't require pre -construction notification.
No other permits have been used or are intended to be used.
Page 8 of 21 PCN Form - Version 1.5, September 2020

D. Proposed Impacts Inventory
1. Impacts Summary
1 a. Where are the impacts associated with your project
(check all that apply):
❑ Wetlands
❑ Buffers
❑ Pond Construction
❑x Streams - tributaries
❑ Open Waters
2. Wetland Impacts
If there are wetland impacts proposed on the site, complete this table for each wetland area impacted.
2a.
Site #
2a1.
Impact
Reason/Type
2b.
Impact
Duration
2c.
Wetland Name
2d.
Wetland Type*
2e.
Forested
?*
2f.
Jurisdiction
Type*
2g.
Impact Area
(ac)
W1
Choose one
Temp/
Perm
Click to enter
Choose one
Y/N
Choose one
Click to
enter
W2
Choose one
Temp/
Perm
Click to enter
Choose one
Y/N
Choose one
Click to
enter
W3
Choose one
Temp/
Perm
Click to enter
Choose one
Y/N
Choose one
Click to
enter
W4
Choose one
Temp/
Perm
Click to enter
Choose one
Y/N
Choose one
Click to
enter
W5
Choose one
Temp/
Perm
Click to enter
Choose one
Y/N
Choose one
Click to
enter
W6
Choose one
Temp/
Perm
Click to enter
Choose one
Y/N
Choose one
Click to
enter
2g1. Total temporary wetland impacts
Click to enter. ac
2g2. Total permanent wetland impacts
Click to enter. ac
2g3. Total wetland impacts
Click to enter. ac
2h. Comments:
Wetland impacts are not proposed.
Page 9 of 21 PCN Form - Version 1.5, September 2020

3. Stream Impacts
If there are perennial or intermittent stream/ tributary impacts (including temporary impacts) proposed on the site,
complete this table for all stream/ tributary sites impacted.
** All Perennial or Intermittent streams must be verified by DWR or delegated local government
Site #
3a.
Impact Reason/
Type
3b.
Impact
Duration
3d.
Stream Name
3e.
Stream
Type
3f.
Jurisdiction
Type
3g.
Stream Width
(avg ft)
3h.
Impact length
(linear ft)
S1
Crossing/ Culvert
Temp/ Perm
Unnamed
Perennial
Both
5.2
40/124/10
S2
Thoose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S3
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S4
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S5
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S6
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S7
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S8
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S9
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S10
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S11
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S12
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S13
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S14
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S15
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
3i1. Total jurisdictional ditch impact:
Click to enter. linear ft
3i2. Total permanent stream impacts:
134 linear ft
3i3. Total temporary stream impacts:
40 linear ft
3i4. Total stream and ditch impacts:
174 linear ft
3j. Comments:
In order to access two lots within the subdivision and in order to provide access to an adjoining tract owned by the
same applicant, it is necessary to install a road crossing that will impact 124 linear feet (0.0148 acres) of stream
channel with a culvert, 10 linear feet (0.0012 acres) of stream channel with rip rap that is to be keyed in and 40 linear
feet (0.0048 acres) of stream channel associated with a pump around.
Page 10 of 21 PCN Form - Version 1.5, September 2020

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., individually list all open water impacts in the table below.
4a.
Site #
4b.
Impact Reason/
Type
4c.
Impact
Duration
4d.
Waterbody Name
4e.
Waterbody
Type*
4e1.
Jurisdiction
Type
4f.
Impact area (ac)k
01
Choose one
Temp/
Perm
Click to enter.
Choose one
Choose one
Click to enter.
02
Choose one
Temp/
Perm
Click to enter.
Choose one
Choose one
Click to enter.
03
Choose one
Temp/
Perm
Click to enter.
Choose one
Choose one
Click to enter.
04
Choose one
Temp/
Perm
Click to enter.
Choose one
Choose one
Click to enter.
4g. Total temporary open water impacts
Click to enter. ac
4g. Total permanent open water impacts
Click to enter. ac
4g. Total open water impacts
Click to enter. ac
4h. Comments:
Open water impacts are not proposed.
5. Pond or Lake Construction
If pond or lake construction is proposed, complete the table below. (*This does NOT include offline stormwater
management ponds.)
5a.
Pond ID
#
5b.
Proposed use or
purpose of pond
5c.
Wetland Impacts (ac)
5d.
Stream Impacts (ft)
5e.
Upland
Impacts (ac)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
Click tL.
enter.
Click tk.
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
P2
Choose one
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
5f. Total
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
5g. Comments:
Pond or lake construction is not proposed.
5h. Is a dam high hazard permit required?
❑ Yes ❑ No
If yes, permit ID no.:
Click to enter.
5i. Expected pond surface area (acres):
Click to enter.
5j. Size of pond watershed (acres):
Click to enter.
5k. Method of construction:
Click to enter.
Page 11 of 21 PCN Form - Version 1.5, September 2020

6. Buffer Impacts (DWR requirement)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts.
6a. Project is in which protected basin(s)?
(Check all that apply.)
❑ Neuse ❑ Tar -Pamlico ❑ Catawba
❑ Jordan ❑ Goose Creek ❑ Randleman
❑ Other: Click to enter.
Site #*
6b.
Impact Type*
6c.
Impact Duration*
6d.
Stream Name*
6e.
Buffer
Mitigation
Required?*
6f.
Zone 1 Impact*
(sq ft)
6g.
Zone 2 Impact*
(sq ft)
B1
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B2
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B3
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B4
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B5
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B6
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B7
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B8
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B9
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B10
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
6h. Total temporary impacts:
Zone 1: Click to enter. sq ft
Zone 2: Click to enter. sq ft
6h. Total permanent impacts:
Zone 1: Click to enter. sq ft
Zone 2: Click to enter. sq ft
6h. Total combined buffer impacts:
Zone 1: Click to enter. sq ft
Zone 2: Click to enter. sq ft
6i. Comments:
The site is located in the Yadkin River Basin.
Please attach supporting documentation (impact maps, plan sheets, etc.) for the proposed project.
Page 12 of 21 PCN Form - Version 1.5, September 2020

E. Impact Justification and Mitigation
1.
Avoidance and Minimization
la.
Specifically describe measures taken to avoid or minimize the proposed impacts through project design:
The applicant has designed the remaining roads, utility lines and lots/pads to avoid additional impacts to streams and
wetlands. The remaining approximate 2,286 linear feet of stream and 0.096 acres of wetlands are being avoided.
1 b.
Specifically describe measures taken to avoid or minimize proposed impacts through construction techniques:
The clearing limits will be surveyed, staked and silt fencing and clearing limit fencing will be used. Disturbed areas will
be seeded and mulched to limit sediment from entering downgradient waters. Slope matting will be used on steep
slopes.
2. Compensatory Mitigation for Impacts to Waters of the U.S., Waters of the State, or Riparian Buffers
2a. If compensatory mitigation is required, by whom is it required? *
(check all that apply)
❑ DWR ❑ Corps
2b. If yes, which mitigation option(s) will be used for this
project? (check all that apply)
❑ Mitigation Bank
❑ In Lieu Fee Program
❑ Permittee Responsible Mitigation
3. Complete if using a Mitigation Bank (Must satisfy NC General Statute143-214.11 (d1).)
3a. Name of mitigation bank:
Click to enter.
3b. Credits purchased/requested:
Type: Choose one
Quantity Click to enter.
Type: Choose one
Quantity Click to enter.
Type: Choose one
Quantity Click to enter.
Attach receipt and/or approval letter.
3c. Comments:
Mitigation is not required or proposed.
4. Complete if Using an In Lieu Fee Program
4a. Attach approval letter from in lieu fee program.
4b. Stream mitigation requested:
Click to enter. linear feet
4c. If using stream mitigation, what is the stream temperature:
Choose one
NC Stream Temperature Classification Maps can be found under the Mitigation Concepts tab on the Wilmington
District's RIBITS website: (Please use the filter and select Wilmington district)
https://ribits.usace.armv.mil/ribits apex/f?p=107:27:2734709611497::NO:RP:P27 BUTTON KEY:0
4d. Buffer mitigation requested (DWR only):
Click to enter. square feet
4e. Riparian wetland mitigation requested:
Click to enter. acres
4f. Non -riparian wetland mitigation requested:
Click to enter. acres
4g. Coastal (tidal) wetland mitigation requested:
Click to enter. acres
Page 13 of 21
PCN Form - Version 1.5, September 2020

4h. Comments:
Click to enter.
5. Complete if Providing a Permittee Responsible Mitigation Plan
5a. If proposing a permittee responsible mitigation plan, provide a description of the proposed mitigation plan,
including the amount of mitigation proposed.
Click to enter
5b. Attach mitigation plan/documentation.
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — DWR requirement
6a. Will the project result in an impact within a protected riparian buffer
that requires buffer mitigation?
❑ Yes ❑x No
If yes, please complete this entire section — please contact DWR for more information.
6b. If yes, identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required in the table below.
Zone
6c.
Reason for impact
6d.
Total impact (square
feet)
Multiplier
6e.
Required mitigation
(square feet)
Zone 1
Click to enter.
Click to enter.
:,hoose one
Click to enter.
Zone 2
;lick to enter.
Click fo enter
" hnnca nna
Click to enter.
6f. Total buffer mitigation required
Click to enter.
6g. If buffer mitigation is required, is payment to a mitigation bank or
NC Division of Mitigation Services proposed?
❑ Yes ❑ No
6h. If yes, attach the acceptance letter from the mitigation bank or NC Division of Mitigation Services.
6i. Comments:
Buffer mitigation is not required or proposed.
Page 14 of 21 PCN Form - Version 1.5, September 2020

F. Stormwater Management and Diffuse Flow Plan (DWR requirement)
1.
Diffuse Flow Plan
1 a.
Does the project include or is it adjacent to protected riparian buffers
identified within one of the NC Riparian Buffer Protection Rules?
❑ Yes ❑x No
1 b.
All buffer impacts and high ground impacts require diffuse flow or other forms of stormwater treatment. If the
project is subject to a state implemented riparian buffer protection program, include a plan that fully documents
how diffuse flow will be maintained.
All Stormwater Control Measures (SCM) must be designed in accordance with the NC Stormwater Design
Manual (https://deq.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permit-
quidance/stormwater-bmp-manual).
Associated supplement forms and other documentation must be provided.
What Type of SCM are you
providing?
(Check all that apply)
❑ Level Spreader
El Vegetated Conveyance (lower seasonal high water table- SHVVT)
❑ Wetland Swale (higher SHWT)
❑ Other SCM that removes minimum 30% nitrogen
❑ Proposed project will not create concentrated stormwater flow through the
buffer
For a list of options to meet the diffuse flow requirements, click here:
Attach diffuse flow documentation.
2.
Stormwater Management Plan
2a.
Is this an NCDOT project subject to compliance with NCDOT's
Individual NPDES permit NCS000250?
❑ Yes ❑x No
2b.
Does this project meet the requirements for low density projects as
defined in 15A NCAC 02H .1003(2)?
❑x Yes El No
To look up low density requirements, click here:
http://reports.oah.state.nc.us/ncac/title%2015a%20-%20environmental%20quality/chapter%2002%20-
%20environmental%20management/subchapter%20h/15a%20ncac%2002h%20.1003.pdf
2c.
IS the project over an acre?
❑x Yes ❑ No
2d.
Does this project have a stormwater management plan (SMP)
reviewed and approved under a state stormwater program or state-
approved local government stormwater program?
❑ Yes ❑x No
Note: Projects that have vested rights, exemptions, or grandfathering from state or locally implemented
stormwater programs or projects that satisfy state or locally -implemented stormwater programs through use of
community in -lieu programs should answer "no" to this question.
2e.
Which of the following stormwater management program(s) apply?
(Check all that apply)
❑ Local Government
❑ State
If you have local government approval, please include the SMP on their overall impact map.
Page 15 of 21
PCN Form - Version 1.5, September 2020

Local Government Stormwater Programs
❑Phase II ❑ USMP
❑ NSW ❑ Water Supply
Please identify which local government stormwater program you are using.
No state or local stormwater program
State Stormwater Programs
El Phase II El HQW or ORW
❑ Coastal Counties ❑ Other
Comments:
The total impervious surfaces are calculated to be 16.82%. No stormwater plan is required. To be confirmed by
Stanly County.
Page 16 of 21 PCN Form - Version 1.5, September 2020

G. Supplementary Information
1.
Environmental Documentation
1 a.
Does the project involve an expenditure of public (federal/state/local)
funds or the use of public (federal/state) land? *
❑ Yes
❑x No
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 (North Carolina) Environmental
Policy Act (NEPA/SEPA)?
❑Yes
❑ No
lc.
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:
A NEPA or SEPA is not required.
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),
DWR Surface Water or Wetland Standards or Riparian Buffer Rules
(15A NCAC 2B .0200)?
❑ Yes ❑x No
2b. If you answered "yes" to the above question, provide an explanation of the violation(s):
Click to enter.
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 ❑x No
3b.
If you answered "no", provide a short narrative description:
Additional development as a result of the proposed development is not anticipated at this time.
3c.
If yes, attach a qualitative or quantitative cumulative impact analysis (.pdf) in accordance with the most recent
DWR policy.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?
❑ Yes ❑x No ❑ N/A
4b. If yes, describe in detail the treatment methods and dispositions (non -discharge or discharge) of wastewater
generated from the proposed project. If the wastewater will be treated at a treatment plant, list the capacity
available at that plant.
Wastewater generated at the residences when constructed will be treated in individual septic systems. Impacts for
sewer infrastruture will not be required.
Page 17 of 21
PCN Form - Version 1.5, September 2020

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? (IPAC weblink: https://www.fws.gov/ipac/ ffws.govl) *
►11 Yes ❑ No
5b.
Have you checked with the USFWS concerning Endangered Species
Act impacts?
❑ Yes ❑x No
5c.
If yes, indicate the USFWS Field Office you have contacted.
Choose one
5d.
Is another federal agency involved?
❑ Yes ❑x No ❑ Unknown
If yes, which federal agency?
Click to enter.
5e.
Is this a DOT project located within Divisions 1-8?
❑ Yes ❑x No
5f.
Will you cut any trees in order to conduct the work in waters of the
U.S.?
aYes El No
5g.
Does this project involve bridge maintenance or removal? *
❑ Yes ❑x No
Link to NLEB SLOPES document: http://saw-req.usace.armv.mil/NLEB/1-30-17-signed NLEB-
SLOPES&apps.pdf
5h.
Does this project involve the construction/ installation of a wind
turbine(s)?
El Yes ❑x No
If yes, please show the location of the wind turbine(s) on the permit drawings/ project plans (attach .pdf)
5i.
Does this project involve blasting and /or other percussive activities
that will be conducted by machines, such as jackhammers,
mechanized pile drivers, etc.?
❑ Yes ❑x No
If yes, please provide details to include type of percussive activity, purpose, duration, and specific location of this
activity on the property (attach .pdf)
5j.
What data sources did you use to determine whether your site would impact Endangered Species or Designated
Critical Habitat?
USFWS Endangered and Threatened Species List — Stanly County
3 federally listed species are identified in Stanly County. Habitat for the Bald Eagle and Schweinitz's sunflower are not
located on the site or within the proposed area of impact. The site contains potential summer roosting habitat for the NLEB.
However, based on a review of the Asheville Field Office website's June_1_2016_NLEB_HUC12 NLEB shapefiles, the 12-
digit HUC with the nearest confirmed hibernation and/or maternity sites is located more than 80 miles from the site. Incidental
take that occurs beyond one quarter mile of a known hibernation site or 150 feet of a known occupied maternity roost during
the pup season (June 1-July 31) is exempt from ESA requirements under the final 4(d) rule. The project is not likely to
adversely affect these species.
Attach consultation documentation.
6.
Essential Fish Habitat (Corps Requirement)
6a.
Will this project occur in or near an area designated as
an Essential Fish Habitat?
El Yes
❑x No
Are there submerged aquatic vegetation (SAV) around
the project vicinity?
El Yes
❑x No
El Unknown
Page 18 of 21
PCN Form - Version 1.5, September 2020

Will this project affect submerged aquatic vegetation?
❑ Yes ❑x No ❑ Unknown
Explain: Click to enter.
6b.
What data source(s) did you use to determine whether your site would impact Essential Fish Habitat?
Essential Fish Habitat Mapper— NOAA Fisheries
Page 19 of 21 PCN Form - Version 1.5, September 2020

7.
Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to the State Historic Preservation Office Historic Properties Map (does not include archaeological data):
http://q is. n cd cr.g ov/h powe b/
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 ❑x No
7b.
What data source(s) did you use to determine whether your site would impact historic or archeological
resources?
NC Historic Preservation Offices HPOWEB 2.0
7c.
Attach historic or prehistoric documentation.
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-year floodplain? *
❑ Yes ❑x No
8b. If yes, explain how the project meets FEMA requirements.
;lick to enter
8c. What source(s) did you use to make the floodplain determination?
National Flood Hazard Layer froom FEMA Web Map Service — FEMA Panel 3710556200K
Page 20 of 21 PCN Form - Version 1.5, September 2020

H. Miscellaneous
Comments:
(`lint fn a -
Attach pertinent documentation or attachments not previously requested
I. Signature*
❑x By checking the box and signing below, I, as the project proponent, certify to the following:
• The project proponent hereby certifies that all information contained herein is true, accurate, and complete, to
the best of my knowledge and belief;
• 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;
• The project proponent hereby agrees 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");
• The project proponent hereby agrees to conduct this transaction by electronic means pursuant to Chapter 66,
Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act");
• The project proponent hereby understands that an electronic signature has the same legal effect and can be
enforced in the same way as a written signature; AND
• As the project proponent, I intend to electronically sign and submit the PCN/online form.
Full Name: Michael T. Brame
Signature:
11/2/2020
Page 21 of 21 PCN Form - Version 1.5, September 2020

DWR Pre -Filing Meeting Request Form
ID#*
Regional Office *
Reviewer List*
20201484
Version*
1
Mooresville Regional Office - [phone]
Alan Johnson
Pre -Filing Meeting Request submitted 10/16/2020
Contact Name * David Brame
Contact Email Address* [e-mail]
Project Name* Renee Ford Road
Project Owner* Trust River Road
Project County* Stanly
Owner Address: Street Address
4512 River Road
Address Line 2
City State / Rovince / Region
Stanfield NC
Fbstal / Zip Code Country
28163 United States
Is this a transportation project?* C Yes ( No
Type(s) of approval sought from the DWR:
IW 401 Water Quality Certification - I— 401 Water Quality Certification -
Reg ula r Express
I— Individual Permit I— Modification
I— Shoreline Stabilization
Does this project have an existing project ID#?*
C Yes ( No
Do you know the name of the staff member you would like to request a meeting with?
I do not want a meeting
Please give a brief project description below.*
Notice of 30 day pre -filing meeting request to submit PCN for 401 WQC for
above project.
Please give a couple of dates you are available for a meeting.

Please attach the documentation you would like to have the meeting about.
pdf only
By digitally signing below, I certify that I have read and understood that per the Federal Clean Water Act Section
401 Certification Rule the following statements:
• This form completes the requirement of the Pre -Filing Meeting Request in the Clean Water Act Section 401 Certification
Rule.
• I understand by signing this form that I cannot submit my application until 30 calendar days after this pre -filing
meeting request.
• !also understand that DWR is not required to respond or grant the meeting request.
Your project's thirty -day clock started upon receipt of this application. You will receive notification regarding meeting location
and time if a meeting is necessary. You will receive notification when the thirty -day clock has expired, and you can submit an
application.
Signature
.g66,frt�
Submittal Date 10/16/2020