20100555 Ver 2_ePCN Application_20210424

DWR
Division of Water Resources
Initial Review
Pre -Construction Notification (PCN) Form
April 4, 2021 Ver 4
Has this project met the requirements for acceptance in to the review process?*
✓ Yes
✓ No
Is this project a public transportation project?*
CYes r No
Change Only if needed.
BIMS # Assigned* Version#*
20100555 2
Is a payment required for this project?*
( No payment required
✓ Fee received
✓ Fee needed - send electronic notification
Select Project Reviewer*
Stephanie Goss:eads\szgoss
Information for Initial Review
la. Name of project:
COURTESY COPY - Drainage Culvert Maintenance Project
la. Who is the Primary Contact?*
Fred Royal
lb. Primary Contact Email:*
[e-mail]
Date Submitted
4/24/2021
Nearest Body of Water
Booker Creek
Basin
Cape Fear
Water Classification
NSW IV
Site Coordinates
Latitude:
39.9132 N
A. Processing Information
Reviewing Office *
Raleigh Regional Office - [phone]
lc. Primary Contact Phone:*
[phone]
Longitude:
-79.0558 W
County (or Counties) where the project is located:
Orange
Is this a NCDMS Project
✓ Yes G No
Is this project a public transportation project?*
✓ Yes G No
Pre -Filing Meeting Information
Is this a courtesy copy notification?*
(7 Yes r No

la. Type(s) of approval sought from the Corps:
17 Section 404 Permit (wetlands, streams and waters, Clean Water Act)
r Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
Has this PCN previously been submitted?*
( Yes
C- No
Please provide the date of the previous submission.*
8/18/2010
1b. What type(s) of permit(s) do you wish to seek authorization?
17 Nationwide Permit (NWP)
r Regional General Permit (RGP)
r Standard (IP)
lc. Has the NWP or GP number been verified by the Corps?
6' Yes C No
Nationwide Permit (NWP) Number: 03 - Maintenance
NWP Numbers (for multiple NWPS):
Id. Type(s) of approval sought from the DWR:
7 401 Water Quality Certification - Regular
r Non-404 Jurisdictional General Permit
r 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:
For the record only for Corps Permit:
If. Is this an after -the -fact permit application?*
C- Yes ( No
r 401 Water Quality Certification - Express
r Riparian Buffer Authorization
lg. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
C- Yes C• No
lg. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
✓ Yes C- No
Acceptance Letter Attachment
1h. Is the project located in any of NC's twenty coastal counties?
C- Yes f No
1j. Is the project located in a designated trout watershed?
C- Yes r' No
B. Applicant Information
Id. Who is applying for the permit?
I Owner 17 Applicant (other than owner)
le. Is there an Agent/Consultant for this project?*
( Yes C- No
2. Owner Information
2a. Name(s) on recorded deed:
Kite Realty Group
2b. Deed book and page no.:
Deed Book 90, Page 28
2c. Contact Person:
Matthew Van Dyke, Senior Project Manager
2d. Address
a Yes C No
F Yes C- No

Street Address
30 South Meridian Street, Suite 1100
Address Line 2
aty State / Province / Region
Indianapolis Indiana
Rstal / Zip (.ode Country
46204 USA
2e. Telephone Number: 2f. Fax Number:
[phone]
2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
3a. Name:
Fred Royal
3b. Business Name:
Royal Water Resources, PLLC
3c. Address
Street Address
5207 Clear Run Drive
Address Line 2
Qly State / Rovince / Region
Wilmington NC
Postal / ZZp Code Country
28403 USA
3d. Telephone Number: 3e. Fax Number:
[phone]
3f. Email Address:*
[e-mail]
4. Agent/Consultant (if applicable)
4a. Name:
Fred Royal
4b. Business Name:
Royal Water Resources, PLLC
4c.Address
Street Address
5207 Clear Run Drive
Address Line 2
air State / Province / Region
Wilmington NC
Postal / Zip aide Country
28403 USA
4d. Telephone Number: 4e. Fax Number:
[phone]
4f. Email Address:*
[e-mail]
Agent Authorization Letter*
Authorized Agent.pdf 368.98KB
C. Project Information and Prior Project History
1. Project Information
1b. Subdivision name:
('rf appropriate)
The Shops at Eastgate
lc. Nearest municipality/ town:
Town of Chapel Hill
2. Project Identification

2a. Property Identification Number:
9799-25-5527
2c. Project Address
Street Address
1800 East Franklin Street
Address Line 2
2b. Property size:
13.828
CRY State / Province / legion
Chapel Hill NC
Postal / Zip Code Country
27514 USA
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Booker Creek
3b. Water Resources Classification of nearest receiving water:*
NSW IV
3c. What river basin(s) is your project located in?*
Cape Fear
3d. Please provide the 12-digit HUC in which the project is located.
030302097517
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:*
High density retail shopping center. The project site has a concrete box culvert conveying Booker Creek under the parking lot.
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?*
6 Yes r No C Unknown
If yes, please give the DWR Certification number or the Corps Action ID (exp. SAW-0000-00000).
SAW-2010-01835
Project History Upload
2010-07-13 - Eastgate Crossing - Completed PNC Form.pdf 5.43MB
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)
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)
4f. List the total estimated acreage of all existing wetlands on the property:
less than one acre
4g. List the total estimated linear feet of all existing streams on the property:
800 LF (primarily within the box culvert)
4h. Explain the purpose of the proposed project:*
The purpose of this project is to remove accumulated sediment from approximately 80 linear feet of stream (up -stream end of the box culvert) and approximately 800 linear feet of box
culvert.
4i. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:*
The project will include temporary impacts due to heavy equipment (excavator) to install a coffer dam at the up -stream end of the project, by-pass pump the stream and remove
sediment with smaller equipment, such as skid steers. The box culvert entrance and exit has existing rip -rap pads previously installed for the equipment to work off of. Direct yet
temporary impacts include the sediment accumulation removal along the open channel of approximately 80 linear feet at the up -stream end of the box culvert and approximately 50
linear feet at the downstream end, where the existing rip rap pad is located. All open channel disturbances will be restored with native vegetation.
4j. Please upload project drawings for the proposed project.
2021-04-20 - Eastgate Crossing - Culvert Clean Out Project -Permit Set - Signed_Sealed.pdf 15.8MB
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
6 Yes
Comments:
C No C Unknown
Booker Creek is a perennial stream as determined by the Town of Chapel Hill staff.
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
C Preliminary 6' Approved C Not Verified C Unknown C N/A
Corps AID Number:
SAW-2010-01835

5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Other:
Andrew Williams
USACOE Wilmington District
5d. List the dates of the Corp jurisdiction determination or State determination if a determination was made by the Corps or DWR
August 18, 2010
5d1. Jurisdictional determination upload
6. Future Project Plans
6a. Is this a phased project?*
r Yes ( No
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?
NO
D. Proposed Impacts Inventory
1. Impacts Summary
la. Where are the impacts associated with your project? (check all that apply):
r Wetlands
r Open Waters
3. Stream Impacts
rJ Streams -tributaries
✓ Pond Construction
r Buffers
SI
3a. Reason for impact (?)
sediment removal
3b.Impact type*
Temporary
3c. Type of impact*
Excavation
3d. S. name*
Booker Creek
3e. Stream Type*
(?)
Perennial
3f. Type of
Jurisdiction*
Corps
3g. S. width*
12
Average (feet)
3h. Impact
length*
130
(linear feet)
3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
0
3i. Total stream and ditch impacts:
130
3i. Total temporary stream impacts:
130
3j. Comments:
Impacts are temporary. No discharges are proposed. Full restoration of open channel banks with native vegetation is proposed.
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:
Project temporary impacts only include coffer dam and use of existing rip rap pads on both ends of the box culvert.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:
Use of the existing rip rap pads and removal of accumulated sediment areas only.
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?
r Yes t: No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
Maintenance and temporary impacts of approximately 130 linear feet.
�F. Stormwater Management and Diffuse Flow Plan (required by DWR)
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?

r Yes ( No
If no, explain why:
Commercial area.
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
C Yes r No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)?
C Yes G No
2c. Does this project have a stormwater management plan (SMP) reviewed and approved under a state stormwater program or state -approved local government stormwater
program?
6 Yes
C N/A - project disturbs < 1 acre
2d. Which of the following stormwater management program(s) apply:
I7 Local Government r State
Local Government Stormwater Programs
17 Phase II r NSW r USMP r Water Supply
Please identify which local government stormwater program you are using.
Town of Chapel Hill
C No
Comments:
The Town of Chapel Hill regulates this shopping center in relation to Phase 2 NPDES stormwater management.
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?*
CYes GNo
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)?*
rYes GNo
3. Cumulative Impacts (DWR Requirement)
3a. Will this project result in additional development, which could impact nearby downstream water quality?*
CYes No
3b. If you answered "no," provide a short narrative description.
This is a maintenance project to remove accumulated sediment and restore all disturbed stream banks.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
C Yes G No r 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?*
C Yes r No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
C Yes f No
5d. Is another Federal agency involved?*
C Yes
5e. Is this a DOT project located within Division's 1-8?
C Yes F No
f No r Unknown
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?
C Yes f No
5g. Does this project involve bridge maintenance or removal?
C Yes F No

5h. Does this project involve the construction/installation of a wind turbine(s)?*
✓ Yes (7 No
5i. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers, mechanized pile drivers, etc.?
✓ Yes G No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
See SAW-2010-01835
Consultation Documentation Upload
2010-07-12 - Eastgate Crossing - Drainage Culvert Improvements - Project Narrative.pdf 958.58KB
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
✓ Yes f• No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
See SAW-2010-01835
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?*
✓ Yes ( No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
See SAW-2010-01835
7c. Historic or Prehistoric Information Upload
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain?*
6 Yes CNo
8b. If yes, explain how project meets FEMArequirements:
No fill is proposed.
8c. What source(s) did you use to make the floodplain determination?*
NCDEM and NFIP maps
Miscellaneous
Comments
This is a maintenance project that occurs appro>amately every 10 years to remove accumulated sediment. This is the second project of this kind. SAW-2010-01835 was issued initially
for this same project. See attached permit from 2010.
Miscellaneous attachments not previously requested.
Signature
*
17 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:
Fredric Royal
Signature
y-2rv'rdd�
Date
4/24/2021

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID: 9799-25-5557
STREET ADDRESS: 1800 EAST FRANKLIN STREET (EASTGATE SHOPPING CENTER)
CHAPEL HILL, NC 27514
Please print:
Property Owner: MARK S. JENKINS - KITE REALTY GROUP
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
FRED ROYAL, PE of ROYAL WATER RESOURCES PLLC
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
30 S. MERIDIAN STREET SUITE 1100, INDIANAPOLIS, IN 46204
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Aut orized 'ignature
Date:( Ti (ZOZ•(
Authorized Signature
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Project Narrative
July 12, 2010
Project: Drainage Culvert Improvements
(Accumulated sediment and debris removal)
Location: Eastgate Shopping Center, Chapel Hill, NC
Owner: Federal Realty Investment Trust, Rockville, MD.
Project Engineer: Royal Water Resources, PLLC
Background
Eastgate Shopping Center was constructed in the floodplain and directly on -top of a perennial
stream in the 1960's and prior to local, state and federal regulations (eg: FEMA, Clean Water
Act, 401, Resource Conservation District, etc.) regulations of today. As a result, the shopping
center placed Booker Creek in a box culvert structure of approx. 600 feet in length and
approximately 9' X 14' in area. The structure is constructed of cement block walls on a spread
footing and reinforced concrete pan joists. In approx. 2001, the culvert was improved with a
reinforced concrete bottom, headwalls and wingwalls and repairs were made to the block wall
spread footings as necessary. The structure is aligned under the parking lot, private access
drive (public right of way) and a portion of the commercial building. The inlet is adjacent to
NCDOT right of way near Franklin St. and its outlet is behind the center. FRIT property
completely contains the culvert and most of the open channel flowing directly into and out of
it.
Also as a result of the box culvert and flat grade (approx. 0.5%), sediment, vegetation and
debris accumulates throughout the culvert and immediately up -stream and down -stream in the
open channel. Approximately every 5 years, this sediment removal will be required to ensure
that it functions to the maximum extent practicable and to help mitigate infrequent flooding
events at the center.
Proposed Project
The proposed work includes the excavation of accumulated sediment and organic materials by
installing two (upper and lower) coffer dams and pumps to de -water the work zone area where
the sediment is to be removed. Base flows of Booker Creek will be pumped through the box in
a pipe and discharged just downstream of the lower coffer dam onto a rip -rap pad prior to

entering the stream. Internal drainage will be pumped out of the work zone by the lower pump.
High flows will overtop the HDPE lined coffer dams.
The work will be performed by small, tracked excavation equipment and hauled off -site to a
permitted land fill. All applicable confined space/OSHA regulations will be adhered to. The
stream bed will be permanently hardened (at-grade/existing thalweg elevation) at the limited
culvert discharge locations shown for future sediment removal access and to reduce scour in
the open channel. No permanent fill in the floodway is proposed. This hardened material will
not inhibit the movement of aquatic species as it will be submerged to the thalweg elevation
and will likely completely silt over in a matter of weeks due to the very low velocities. All other
rock and materials will be removed and the site will be completely restored to a natural state
using erosion control matting and native plant species.
Known or likely permits required:
1. Town of Chapel Hill Zoning Compliance and Resource Conservation District
Encroachment permits ($433 fee)
2. NC Division of Water Quality Courtesy Review (no fee)
3. US Army Corps of Engineers Nationwide 3 for maintenance (no fee)
4. NCDOT right of way encroachment and traffic warning signage (no fee)
The project is estimated to take 2-3 weeks, depending on the weather. Please provide any
comments or questions directly to Fred Royal, PE, CFM :
[e-mail] or by telephone at [phone].
Thank you for your attention to this proposed maintenance project.

1
i 1
o-f------ roc,
I; �1�
Office Use Only:
Corps action ID no.
1'�i 1
o'
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre -Construction Notification (PCN) Form
A. Applicant Information
1. Processing
la. Type(s) of approval sought from the
Corps:
Section 404 Permit ❑ Section 10 Permit la Co�2�'Es
f Z.Ei-1
1 b. Specify Nationwide Permit (NWP) number: , or General Permit (GP) number:
lc. Has the NWP or GP number been verified by the Corps?
EI Yes M2- t❑ No
�/iltr A.u�
1d. Type(s) of approval sought from the DWQ (check all that apply): 3-\tz(ro
401 Water Quality Certification — Regular ❑ Non-404 Jurisdictional General Permit a� 3
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization ►' 1) p CDuR'--�'E5:1 12P4,14e4.�
1 e. Is this notification solely for the record
because written approval is not required?
VS5
For the record only for DWQ 401
Certification:
aYes NI No
For the
•
la
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
3
No
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
❑ Yes Et, No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes Et No
2. Project Information
2a. Name of project:
D
D g I)a j,4,A 6-S a 4.4 &All ii, 3��_,.P4` P1tgwa rNVI-,�-''TS
2b. County:
0R 44. S
2c. Nearest municipality / town:
"Z H,1,r I, L. j R 1,
2d. Subdivision name:
,N9A
2e. NCDOT only, T.I.P. or state
project no:
JA
3. Owner Information
3a. Name(s) on Recorded Deed:
J'g. P$,r?r , F&I g...: 8 NI VS `';',-'1 g,' 9-r --23e, � )-.
3b. Deed Book and Page No.
a 0! VQ, q 4) jf *cXS A
3c. Responsible Party (for LLC if
applicable):
1
/VU fl c.ig4 L n1Wiz, pi 0
3d. Street address:
/i 9 /1 ft7 5, j>; ;
3e. City, state, zip:
,r; =a S, L t-Tj =d 1 d ,4' : 2.2. l CIS a 4 9 3 '
3f. Telephone no.:
a q ?fj
3g. Fax no.:
(' Z4 °'
3h. Email address:
9
r?--"A T G?(s1,2 � a 0 co 4-12,103c"6-4 h q d t'2�, s C &-,Al
Page 1 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:
FJJU7a adz ,f,_ ,,L
5b. Business name
(if applicable):
Taal 1 Q,. - is,. 5 0 &,,s r_ c� L.( .
5c. Street address:
y, 4 ,
5d. City, state, zip:
Pa e� r 0,a 7. "4o co 7,, .3- 3 V
5e. Telephone no.:
a q) ,g — g q -)r
5f. Fax no.:
/4.4.
5g.Email address:
row Ai1 t era -(a) m,�9, ,A , ct,g,r�
i
Page 2 of 10
PCN Form — Version 1.3 December 10, 2008 Version

B. Project Information and Prior Project History
1. Property Identification
la. Property identification no. (tax PIN or parcel ID):
lb. Site coordinates (in decimal degrees):
Latitude: Longitude:-
(DD.DDDDDD) (-DD.DDDDDD)
1 c. Property size:
acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project:
Oo k Sit d y;-,k
2b. Water Quality Classification of nearest receiving water:
Ai 5 sil jIj
2c. River basin:
y, A,rP F .4
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the
application: oe ,
project at the time of this
3b. List the total estimated acreage of all existing wetlands on the property:
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
¢: L.. 00 �-- P.E, /`
_ tit., d K r
.� d � s d u!� L. �.y�..,.,�/�, �'u ,"� t�;J4:.�J a..� 4 u� °�, ti; �a.lr' c,�"� `�/� d
,7`1'
3d. Explain the purpose of the proposed project: �i
3e. Describe the overall project in detail, including the type of equipment to be.used:
a
4. Jurisdictional Determinations b'
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
Comments: 1)c,c.(''` C'i� )-< 93 ,4 '%Vi.:;'d; -� 5.1
❑YesNo ❑Unknown
4. i,'-a ,-,
4b. If the Corps made the jurisdictional determination, what type
of determination was made? s
il-
❑ Preliminary ❑ Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known): �O.o,q,l c , ;�,rr.,
Agency/Consultant Company:
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifications been requested or obtained for
this this project (including all prior phases) in the past?
❑Yes J� No ❑Unknown
,Ur
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project?
❑ Yes jo
6b. If yes, explain.
Page 3 of 10
PCN Form — Version 1.3 December 10, 2008 Version

C. Proposed Impacts Inventory
1. Impacts Summary --
la. Which sections were o 761eted below for your project (check all that apply):
❑ Wetlands Di Streams - tributaries ❑ Buffers
❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
Wetland impact
number —
Permanent (P) or
Temporary (T)
2b.
Type of impact
2c.
Type of wetland
(if known)
2d.
Forested
2e.
Type of jurisdiction
(Corps - 404, 10
DWQ — non-404, other)
2f.
Area of impact
(acres)
W1 ❑ P ❑ T
DV
❑ Yes
❑ No
❑ Corps
❑ DWQ
W2 ❑ P ❑ T
II
Yes
❑ No
❑Corps
❑ DWQ
W3 ❑ P ❑ T
❑ Yes
❑ No
❑
■
Corps
DWQ
W4 ❑ P ❑ T
❑ Yes
❑ No
MICorps
■
DWQ
W5 ❑ P ❑ T
❑ Yes
❑ No
❑
❑
Corps
DWQ
W6 ❑P❑T
❑Yes
❑ No
❑Corps
■
DWQ
2g. Total wetland impacts
ke
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—
(1
3e.
Type of jurisdiction
(Corps - 404, 10
DWQ /non-404,
Jother)
3f.
Average
stream
width
(feet)
3g.
Impact
length
(linear
feet)
S 1 ❑ P
12, LS0A.0 d:' l).e.. d:.0
s5>h,ka,v.'
m, r
!x1%4"' ?L..4" '-
U P E R
❑ INT
EI-ClV" ps
EI'DWQ
/
/fi'
6-
/30
S2 ❑ P ❑ T
❑ PER
❑ INT
❑ Corps
❑ DWQ
S3 ❑ P ❑ T
❑ 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
/ 3O''
-�
3i. Comments: A.V)so 4 ,0-- 1r1"13y`lb. ,Ae. is,'v0 ,)C (.c-Y Al.
e ),A, so-- '
rs �
11-4,411,1
a
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.
Open water
impact number -
Permanent (P) or
Temporary (T)
4b.
Name of waterbody
(if applicable)
4c.
Type of impact
4d.
Waterbody type
4e.
Area of impact (acres)
01 ❑P❑T
ir
Y .� v
02 ❑P❑T
03 ❑P❑T
V
04 ❑P❑T
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed, then complete the chart below.
5a.
Pond ID
5b.
Proposed use or purpose
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(acres)
number
of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
j /G d
P2
5f. Total
/
5g. Comments: ,x
Is a dam high hazard permit required?
Yes CrNic' If yes, permit ID no:5h.
❑
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. )e.);Z.->,4r w4a
Project is in which protected basin? f /,.r*f ''er
❑ Neuse ❑Tar -Pamlico `.Other:
❑ Catawba ❑ Randleman
6b.
Buffer impact
number -
Permanent (P) or
Temporary (T) ;.
6c.
Reason
for
impact
6d.
Stream name
6e.
Buffer
mitigation
required?
6f.
Zone 1 impact
(square feet)
6g.
Zone 2 impact
(square feet)
B1 ❑P�,
�%j� \
j LL i��JY
� iV;Vy�- t}�/? re"l
//f
McWD�
Yes
ei��_ �%
l '}"'
p p
?„6.'(1.
�'
B2 ❑ P ❑ T
Yes
❑ No
B3 ❑P❑T
❑Yes
❑ No
6h. Total buffer impacts
4 I/s2
Li )
6i. Comments: r °- ,(2.).f,, i i-3 :re), ram.-1ds v 4- , ,;. ',f; ; -,®,
1 i Y 9f � ,) •,
Page 5 of 10
PCN Form - Version 1.3 December 10, 2008 Version

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
:De—,- ,aA,y i
. ,d-J�-on , Y .,4-7 " 1-4-,t -CrE )!-,1=-'�
.1--,, —eN.;ljy .s, Al' ;&t:._ c. ri /
_.
.a_•+;'v��
2. Compensatory Mitigafor Impacts to Waters of the U.S. or Waters of the State a
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
❑ Yes ®^
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 A D
�°j
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter)
Type
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:
❑ warm
•
cool ❑cold
4d. Buffer mitigation requested (DWQ only):
square feet
4e. Riparian wetland mitigation requested:
acres
4f. Non -riparian wetland mitigation requested:
acres
4g. Coastal (tidal) wetland mitigation requested:
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 6 of 10
PCN Form — Version 1.3 December 10, 2008 Version

. 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 ❑ 1�0
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
Zone 1
6c.
Reason for impact
Zone 2
A
6d.
Total impact
(square feet)
Multiplier
3 (2 for Catawba)
1.5
6f. Total buffer mitigation required:
6e.
Required mitigation
(square feet)
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund).
6h. Comments:
Page 7 of 10
PCN Form — Version 1.3 December 10, 2008 Version

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
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? I
I.
s
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
Comments: .
^�
❑ Yes ENO
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? A)/
%
2b. Does this project require a Stormwater Management Plan? ,1
❑ Yes (
2c. If this project DOES NOT require a Stormwater Management Plan, explain why: 5E,��3z_ L, Lf
1
fyt,k 9,y4,
1
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the
plan:
2e. Who will be responsible for the review of the Stormwater Management Plan?
❑ Certified Local Government
❑ DWQ Stormwater Program
❑ DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
la,,,,),,...) c1/444 ,
3b. Which of the following locally -implemented stormwater management programs
apply (check all that apply):
g- ase II
❑ NSW
❑ USMP
❑ Water Supply Watershed
❑ Other:
3c. Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ Yes 12'No
4. DWQ Stormwater Program Review
4a. Which of the following state -implemented stormwater management programs apply
(check all that apply):
❑ Coastal counties
❑ HQW
❑ ORW
❑ Session Law 2006-246
❑ Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ Yes U-Ntr
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? , /4
❑ Yes ❑ No
5b. Have all of the 401 Unit submittal requirements been met?
es ❑ No
Page 8 of 10
PCN Form — Version 1.3 December 10, 2008 Version

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the
use of public (federal/state) land?
❑Yes o
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
1 c. 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.)
Comments:
❑ Yes ❑ No
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,
or Riparian Buffer Rules (15A NCAC 2B .0200)?
—.
❑ Yes 2i410
2b. Is this an after -the -fact permit application?
❑ Yes (21'No y_
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
additional development, which could impact nearby downstream water quality?
❑ Yes s
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.
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5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
habitat?
❑ Yes �] No
5b. Have you checked with the UPS concerning Endangered Species Act
impacts? /✓43v4A1.- wea-tT/g_GzE. P206024 "
Yes ❑ No
5c. If yes, indicate the US VS Field Office you have contacted.
Raleigh
❑ Asheville
5d. What data sources did you use to determine
Habitat?
NC. h1ATUR.�4t.
whether your site would impact Endangered Species or Designated Critical
,E,2A1e �O 4'ctr4M QIo-n dat "a,6a�
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
❑ Yes
6b. What data sources /did you use to determine whether your site would impact Essential Fish Habitat?
rA.Mt- .4AdaG-e. Cop -;4.- --42.4.4 M-/1-44 @ '4-15'-19-g 7,
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?
'"" Di CI; -e-- 1¢ MC- cit 74odF. Dt-441E2 .
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain?
L< Yes ❑ No
8b. If yes, explain how project meets FEMA requirements: 14 0 Flu
8c. What source(s) did you use to make the floodplain determination?T1VE y1JQM P4,0FGS •
Date
Applicant/Agent's Printed Name
e
Applicant/Agent' Signature
(Agent's signature is valid only if an authorization letter from the applicant
is provided.)
Page 10 of 10
PCN Form — Version 1.3 December 10, 2008 Version