20211118 Ver 1_401 Application_20210714

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
20211118
Is this project a public transportation project?*
r Yes
r No
Reviewer List:* Sue Homewood:eads\slhomewood
Select Reviewing Office:*
Winston-Salem Regional Office - [phone]
Does this project require a request for payment to be sent?*
r
Yes
r
No

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:*
r 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
Project Contact Information
Name: Heather LaGamba
Who is submitting the inforrration?
Email Address: [e-mail]
Project Information
Project Name:
Lewisville-Clemmons Rd
Is this a public transportation project?
r Yes
No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
r Yes r No r Unknown
County (ies)
Forsyth
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
5548.2 1930 Lewisville-Clemmons
10.17MB
Rd_PCN 07.10.21.pdf
Only pdf or krre files are accepted.
Describe the attachments
or comments:
For Record Only
Sign and Submit
17 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:
1; :Wcedet raffrrtr
Submittal Date: Is filled in autorretically.

Preliminary ORM Data Entry Fields for New Actions
ACTION ID #: SAW- 2020-00420
Prepare file folder ❑
Begin Date (Date Received):
Assign Action ID Number in ORM
1. Project Name [PCN Form A2a]: 1930 Lewisville-Clemmons Road
2. Work Type: ZPrivate
Institutional
Government ❑ Commercial
3. Project Description / Purpose [PCN Form B3d and B3e]:
See Attached
4. Property Owner / Applicant [PCN Form A3 or A4]: Gordon Hendrix
5. Agent / Consultant [PNC Form A5 — or ORM Consultant ID Number]:
Brad Luckey/ Pilot Environmental, Inc.
6. Related Action ID Number(s) [PCN Form B5b]:
7. Project Location — Coordinates, Street Address, and/or Location Description [PCN Form B lb]:
1930 Lewisville-Clemmons Road, Clemmons, Forsyth County, North Carolina
36.054558°,-80.393807°
8. Project Location — Tax Parcel ID [PCN Form Bla]: 5884-81-0709
9. Project Location — County [PCN Form A2b]: Forsyth County
10. Project Location — Nearest Municipality or Town [PCN Form A2c]: Clemmons
11. Project Information — Nearest Waterbody [PCN Form B2a]: Blanket Creek
12. Watershed / 8-Digit Hydrologic Unit Code [PCN Form B2c]: 03040101
Authorization: Section 10 fl Section 404 ❑
Regulatory Action Type:
❑ Standard Permit
❑ Nationwide Permit #
Regional General Permit #
❑ Jurisdictional Determination Request
Section 10 and 404 ❑
❑Pre -Application Request
n Unauthorized Activity
F7 Compliance
FINo Permit Required
Revised 20150602

DWR Pre -Filing Meeting Request Form
Contact Name*
Contact Email Address*
Project Owner*
Project Name*
Project County*
Owner Address:*
Is this a transportation project?*
Heather LaGamba
[e-mail]
The Lake at Belmont, LLC
Lewisville-Clemmons Rd
Forsyth
Street Address
PO Box 10888
Address Line 2
City State / Rovince / Region
Greensboro NC
Fbstal / Zip Code Country
27404 USA
(' Yes c: No
Type(s) of approval sought from the DWR:
l 401 Water Quality Certification - I— 401 Water Quality Certification -
Regular Express
I— Individual Permit I— Modification
I— Shoreline Stabilization
Does this project have an existing project ID#?*
(' Yes c: No
Do you know the name of the staff member you would like to request a meeting with?
Sue Homewood
Please give a brief project description below and include location information.*
The applicant does not request a meeting. The applicant may submit
a
request for 401 WQC.
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 *
W�0
Submittal Date 6/8/2021

NORTH CAROLINA
Environmental Quality
Water Resources
Office Use Only
Corps Action ID no. [Click to enter.]
DWR project no. [Click enter.]
Site Coordinates:
Latitude (DD.DDDDDD): 36.054558
Longitude (DD.DDDDDD): 80.393807
Form Version 1.5, September 2020
Date received: [Click to enter.]
Date received: [Click to enter.]
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.deg.nc.qov/WaterResources/0/edoc/624704/PCN%20Help%20File%202018-1-30.pdf
The help document may be found at this link:
http://www.saw.usace.army.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) *: 6/8/2021
DWR ID # Click to enter. Version Click to enter. (If applicable)
A. Processing Information
County (counties) where project is located: *
Forsyth 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.
la.
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

1b. 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.
lc. 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
ld. Type(s) of approval sought from the DWR (check all that apply):
❑ 401 Water Quality Certification — Regular ❑ 401 Water Quality Certification— Express
❑ Non-404 Jurisdictional General Permit ❑ Riparian Buffer Authorization
❑ Individual 401 Water Quality Certification
1 e. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification:
o Yes ❑ No
For the record only for Corps Permit:
❑ Yes ❑x No
1f. Is this an after -the -fact permit/certification application?
❑ Yes ❑x No
lg. 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?
Chris Parr
1 b.
Primary Contact Email:
[e-mail]
lc.
Primary Contact Phone: (###)###-####
336.382.4523
1 d.
Who is applying for the permit/certification?
all that apply)
(check
• Owner 0 Applicant (other than owner)
1 e.
Is there an agent/consultant for this project?
o Yes ❑ No
2. Landowner Information
2a. Name(s) on Recorded Deed:
Hendrix commercial and Ind Ent Inc.
2b. Deed Book and Page No.:
1976/3561
2c. Responsible Party (for corporations):
Gordon Hendrix
2d. Address
Street Address:
3650 Cephis Drive
Address line 2:
Click to enter .
City:
Clemmons
State/ Province/ Region:
North Carolina
Postal/ Zip Code:
27012
Country:
U.S.
2e. Telephone Number: (###)###-####
Click to enter.
2f. Fax Number: (###)###-####
Click to enter.
2g. Email Address:
Click to enter.
3.
Applicant Information (if different from owner)
3a.
Name:
Chris Parr
3b.
Business Name (if applicable):
Parr Construction Inc.
3c.
Address:
Street Address:
PO Box 4088
Address line 2:
Click to enter.
City:
Greensboro
State/ Province/ Region:
NC
Postal/ Zip Code:
27404
Country
U.S.
3d.
Telephone Number: (###)###-####
336.382.4523
3e
Fax Number: (###)###-####
Click to enter.
Page 3 of 21
PCN Form - Version 1.5, September 2020

3f. Email Address: *
[e-mail]
4. Agent/ Consultant (if applicable)
4a. Name: *
Bradley Luckey
4b. Business Name:
Pilot Environmental, Inc.
4c. Address: *
Street Address:
PO Box 128
Address line 2:
Click to enter.
City:
Kernersville
State/ Province/ Region:
NC
Postal/ Zip Code:
27285
Country:
U.S.
4d. Telephone Number: * (###)###-####
336.708.4997
Click to enter.
4e Fax Number: (###)### 111111!/
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:
https://www.saw.usace.army.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
1 a.
Name of project: *
1930 Lewisville Clemmons Rd
1 b.
Subdivision name (if appropriate):
Click to enter.
lc.
Nearest municipality/town: *
Clemmons
2.
Project Identification
2a.
Property identification number (tax PIN or parcel ID):
5884-81-0709
2b.
Property size (in acres):
38.7
2c.
Project Address:
Street Address:
1930 Lewisville Clemmons Road
Address line 2:
Click to enter.
City:
Clemmons
State/ Province/ Region:
NC
Postal/ Zip Code:
27012
Country:
U.S.
2d.
Site coordinates in decimal degrees (using 4-6 digits
after the decimal point): *
Latitude (DD.DDDDDD): * 36.054558
Longitude (-DD.DDDDDD): *-80.393807
3.
Surface Waters
3a.
Name of nearest body of water to proposed project: *
Blanket Creek
3b.
Water Resources Classification of nearest receiving
water: *
WS-IV
The Surface Water Classification map may be found at this link:
https://ncdenr.maps.arcgis.com/apps/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: *
030401011302
The Find Your HUC map may be found at this link:
https://ncdenr. maps.arcgis.com/apes/Publiclnformation/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: *
A single family residence and horse barn are located on the site. The remainder of the site consist of maintained
grassed areas and wooded land. The site is located within a mixed use of Clemmons, Forsyth County, North
Carolina.
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):
[Click to enter.]
.[Click to enter.]
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 8Y2 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:
1.91 acres
4g. List the total estimated linear feet of all existing streams (intermittent
and perennial) on the property:
2,140 linear feet
4g1. List the total estimated acreage of all existing open waters on the
property:
2.83 acres
4h. Explain the purpose of the proposed project: *
The purpose of the proposed project is to construct and provide access to a multi -family residential development.
4i. Describe the overall project in detail, including the type of equipment to be used: *
The overall project includes the development of the site with a multi -family residential development containing 13
apartment buildings, parking areas, landscaped/greenspace areas and amenities including clubhouse, swimming pool,
outdoor playground, open space and dog park. In order to facilitate the proposed development and access to the site, it
is necessary to impact a wetland. 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? *
0 Yes ❑ No ❑Unknown
Comments:
Click to enter text.
5b.
If 5a is yes, who delineated the jurisdictional
areas?
Name (if known): David Brame/Bradley Luckey
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-2020-00420
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.
5.28.20
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 ❑x No
6b. If yes, explain.
Click to enter
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 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):
❑x Wetlands ❑ Streams - tributaries
❑ Buffers ❑ Open Waters
❑ Pond Construction
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
Fill (Incl.
Riprap)
Permanent
Unnamed
Unknown
No
Corps
0.085
W2
Choose one
Temp/
Perm
Click to enter
Choose one
YIN
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 fr-
entt,
W6
Choose one
Temp/
Perm
Click to enter
Choose one
Y/N
Choose one
Click t^
en
2g1. Total temporary wetland impacts
0 ac
2g2. Total permanent wetland impacts
0.085 ac
2g3. Total wetland impacts
0.085 ac
2h. Comments:
Wetland Impact 1 (Wetland WB 1-28) will permanently impact 0.085ac (3,700SF) of maintained herbaceous wetlands
associated with the access and development of the site. Temporary impacts to wetlands are not proposed. Mitigation
for permanent wetland impacts is 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
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S2
Choose 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 onF
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:
Click to enter. linear ft
3i3. Total temporary stream impacts:
Click to enter. linear ft
3i4. Total stream and ditch impacts:
Click to enter. linear ft
3j. Comments:
Stream impacts are not proposed.
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)*
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 to
enter.
Click to
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 ente
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:
Buffer impacts are not required.
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
1 a.
Specifically describe measures taken to avoid or minimize the proposed impacts through project design: *
Initial site plans would have resulted in the impact to the entirety of Pond PA, Wetland WA and Wetland WB. The
applicant redesigned initial site plans and reduced the site plan by four apartment buildings. The applicant has
designed the site to utilize and existing culvert to provide access to the western portion of the site, thus avoiding
impact to Pond PA and Wetland WC.
The applicant is constructing retaining walls ranging from 15 to 23 feet in height to avoid additional impact to the
remainder of Wetland WA.
There is approximately 1.91 acres of wetlands, 2,140 linear feet of stream channel and 2.83 acres of open waters
located on the site. The 2,140 linear feet of stream channel, 2.83 acres of open waters and remaining 1.825 acres of
wetlands are being avoided.
1 b.
Specifically describe measures taken to avoid or minimize proposed impacts through construction techniques: *
The disturbance limits will be staked and silt fence, rock checks or other temporary sediment and erosion control
measures will be located within the most down -gradient area within Wetland Impact 1 (Wetland WB 1-28) The
sediment and erosion control devices will prevent sediment from being discharged into down -gradient waters and
wetlands. A rock/stone french drain will be installed within the impact limits of the wetland and filled over top with
clean fill to final proposed grades.
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 ente, .
Type: Choose one
Quantity Click to ente
Type: Choose one
Quantity Click to enter.
Attach receipt and/or approval letter.
3c. Comments:
Click to enter.
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
Page 13 of 21
PCN Form - Version 1.5, September 2020

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.army.mil/ribits apex/f?p=107:27:2734709611497::NO:RP:P27 BUTTON KEY:O
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
4h.
Comments:
dick 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?
El 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.
lick to enter.
choose one
lick to enter.
Zone 2
Click to enter.
Click to enter.
choose one
Click to enter.
6f. Total buffer mitigation required
Olick to enter.
6g. If buffer mitigation is required, is payment to a mitigation bank or
NC Division of Mitigation Services proposed?
El Yes ❑ No
6h. If yes, attach the acceptance letter from the mitigation bank or NC Division of Mitigation Services.
6i. Comments:
Click to enter.
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
Vegetated Conveyance (lower seasonal high water table- SHT)
❑ 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? *
El Yes ❑x No
2b.
Does this project meet the requirements for low density projects as
defined in 15A NCAC 02H .1003(2)?*
El Yes ❑x 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) *
❑x 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 *
❑x Phase II
❑ NSW
❑ USMP
❑x Water Supply
Please identify which local government stormwater program you are using.*
Clemmons
State Stormwater Programs *
❑Phase II
❑ Coastal Counties
❑ HOW or ORW
❑ Other
Comments:
SWMP will be approved by Clemmons prior to impacts occurring.
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):
;lick 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 proposed.
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 ❑ 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.
Existing sanitary sewer services are available from Lewisville-Clemmons Road. Impacts associated with sewer crossings is not
proposed.
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.qov/ipac/ [fws.gov1)*
o 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.?
• Yes ❑x No
5g.
Does this project involve bridge maintenance or removal?
❑ Yes ❑x No
Link to NLEB SLOPES document: http://saw-req.usace.army.mil/NLEB/1-30-17-signed NLEB-
S LOP ES&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?
US Department of the Interior — Fish and Wildlife Service Official Species List from IPaC
2 listed species are identified on the IPaC report. Suitable habitat for bog turtles or "similar in appearance"
species is not located on the site. Regarding the Northern long-eared bat, neither hiberncula nor suitable
summer roosting habitat trees are located within the Project area. Based on a review of the
Jun_1_2016_NLEB_HUC12 NLEB shapefiles obtained from the Asheville Ecological Services Field Office
website, the 12 digit HUC with the nearest confirmed hibernation and/or maternity sites is located more than 90
miles from the site. Based on the distance to known hibernation and maternity sites, lack of suitable summer
roosting habitat and availability of similar suitable habitat, we have made the determination that the proposed
project will have no effect to NLEB.
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://clis.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 0 No
7b.
What data source(s) did you use to determine whether your site would impact historic or archeological
resources?
NC Historic Preservation Of rice's HPOWEB 2.0. Historic properties were not identified in the project area.
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
0 No
8b. If yes, explain how the project meets FEMA requirements.
'lick to anfar
8c. What source(s) did you use to make the floodplain determination?
National Flood Hazard Layer froom FEMA Web Map Service — Drawing 4
Page 20 of 21 PCN Form - Version 1.5, September 2020

H. Miscellaneous
Comments:
f lirlc fn cnfcr
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: Bradley Luckey
Digitally signed by Bradley Luckey
Signature: Bradley Luckey I .,o 2L07 011830:32i104'OOvim omerus
0
11 /2/2020
Page 21 of 21 PCN Form - Version 1.5, September 2020

Proposal for Environmental Services
Pilot Proposal 5548.2
June 10, 2021
AGENT AUTHORIZATION
This form authorizes Pilot to act as our agent in stream/wetland matters including U.S. Army
Corps of Engineers and North Carolina Division of Water Resources field verification and
permitting.
Property Address: _ ! i L._..[.uiU . ait s ko.e
% [Ck),vo&Sr&)Cr
Applicant information:
Name:
Address:
Telephone Number:
Fax Number:
E-mail Address:
Signature:
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Date: tad /
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1. BOUNDARY AND EXISTING TOPOGRAPHICAL INFORMATION WAS PROVIDED BY SGROI LAND SURVEYING,
PLLC ON MAY 8, 2019.
2. CONTRACTOR TO VERIFY ALL DIMENSIONS AND EXISTING FEATURES PRIOR TO CONSTRUCTION.
3. INVERTS FOR EXISTING UTILITIES SHALL BE VERIFIED BY THE CONTRACTOR PRIOR TO CONSTRUCTION.
4. MATERIALS AND WORKMANSHIP TO CONFORM WITH STANDARDS AND SPECIFICATIONS OF LOCAL
JURISDICTIONAL AUTHORITIES.
5. POWER, PHONE, CABLE AND GAS SERVICE INSTALLATIONS SHALL BE COORDINATED WITH LOCAL UTILITY
PROVIDERS
6. ALL WATER INSTALLATIONS AND MATERIALS SHALL BE IN ACCORDANCE WITH THE REQUIREMENTS OF
SOUTHERN PINES UTILITIES AND NCDENR.
7. FIRE HYDRANTS MUST BE IN PLACE AND FUNCTIONAL BEFORE COMBUSTIBLE CONSTRUCTION BEGINS ON
SITE.
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1. ALL FILL SHALL BE PLACED IN LIFTS UNDER THE DIRECTION OF INDEPENDENT
SOILS TESTING AGENCY.
2. ALL STORM SEWER SHALL BE INSTALLED AND BACKFILLED UNDER THE
SUPERVISION AND TESTING OF AN INDEPENDENT SOILS TESTING AGENCY.
3. IMPORTED FILL SHALL BE SUITABLE STRUCTURAL FILL AND APPROVED FOR
PLACEMENT BY THE GEOTECHNICAL ENGINEER
4. ANY SEDIMENT TRACKED ONTO STREETS WITHIN THE DEVELOPMENT MUST BE
CLEANED DAILY.
5. CONTRACTOR TO ENSURE THAT ALL ROOF DRAINAGE DISCHARGES IN A
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6. CONTRACTOR SHALL ENSURE POSITIVE DRAINAGE SO THAT RUNOFF WILL
FLOW BY GRAVITY AWAY FROM BUILDINGS AND ACROSS SWALES, DITCHES OR
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7. STORMWATER PIPE SHALL BE WATER -TIGHT 0-RING GASKETED, WITH A
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GENERAL NOTES:
1. BOUNDARY AND EXISTING TOPOGRAPHICAL INFORMATION WAS PROVIDED BY SGROI LAND SURVEYING,
PLLC ON OCTOBER 5, 2020.
2. CONTRACTOR TO VERIFY ALL DIMENSIONS AND EXISTING FEATURES PRIOR TO CONSTRUCTION.
3. INVERTS FOR EXISTING UTILITIES SHALL BE VERIFIED BY THE CONTRACTOR PRIOR TO CONSTRUCTION.
4. MATERIALS AND WORKMANSHIP TO CONFORM WITH STANDARDS AND SPECIFICATIONS OF LOCAL
JURISDICTIONAL AUTHORITIES.
5. POWER, PHONE, CABLE AND GAS SERVICE INSTALLATIONS SHALL BE COORDINATED WITH LOCAL UTILITY
PROVIDERS
6. ALL WATER INSTALLATIONS AND MATERIALS SHALL BE IN ACCORDANCE WITH THE REQUIREMENTS OF
VILLAGE OF CLEMMONS UTILITIES AND NCDENR.
7. FIRE HYDRANTS MUST BE IN PLACE AND FUNCTIONAL BEFORE COMBUSTIBLE CONSTRUCTION BEGINS ON
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2. ALL STORM SEWER SHALL BE INSTALLED AND BACKFILLED UNDER THE
SUPERVISION AND TESTING OF AN INDEPENDENT SOILS TESTING AGENCY.
3. IMPORTED FILL SHALL BE SUITABLE STRUCTURAL FILL AND APPROVED FOR
PLACEMENT BY THE GEOTECHNICAL ENGINEER
4. ANY SEDIMENT TRACKED ONTO STREETS WITHIN THE DEVELOPMENT MUST BE
CLEANED DAILY.
5. CONTRACTOR TO ENSURE THAT ALL ROOF DRAINAGE DISCHARGES IN A
MANNER SO THAT IT IS ROUTED THROUGH THE PROPOSED BMP.
6. CONTRACTOR SHALL ENSURE POSITIVE DRAINAGE SO THAT RUNOFF WILL
FLOW BY GRAVITY AWAY FROM BUILDINGS AND ACROSS SWALES, DITCHES OR
OVERLAND SHEET FLOW.
7. STORMWATER PIPE SHALL BE WATER -TIGHT 0-RING GASKETED, WITH A
MINIMUM PRESSURE RATING OF 10 PSI.
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JOB NUMBER 2020-10
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United States Department of the Interior
FISH AND WILDLIFE SERVICE
Asheville Ecological Services Field Office
160 Zillicoa Street
Asheville, NC 28801-1082
Phone: [phone] Fax: [phone]
http://www.fws.gov/nc-es/es/countyfr.html
In Reply Refer To:
Consultation Code: 04EN1000-2021-SLI-0723
Event Code: 04EN1000-2021-E-01738
Project Name: 1930 Lewisville Clemmons Rd.
July 10, 2021
Subject: List of threatened and endangered species that may occur in your proposed project
location or may be affected by your proposed project
To Whom It May Concern:
The attached species list identifies threatened, endangered, proposed and candidate species, as
well as proposed and final designated critical habitat, that may occur within the boundary of your
proposed project and/or may be affected by your proposed project. Although not required by
section 7, many agencies request species lists to start the informal consultation process and begin
their fulfillment of the requirements under section 7(c) of the Endangered Species Act (Act) of
1973, as amended (16 U.S.C. 1531 et seq.).
This list, along with other helpful resources, is also available on the U.S. Fish and Wildlife
Service (Service) —Asheville Field Office's (AFO) website: https://www.fws.gov/raleigh/species/
cntylist/nccounties.html. The AFO website list includes "species of concern" — species that
could potentially be placed on the federal list of threatened and endangered species in the future.
Also available are:
Design and Construction Recommendations
https://www.fws.gov/asheville/htmls/project review/Recommendations.html
• Optimal Survey Times for Federally Listed Plants
https://www.fws.gov/nc-es/plant/plant survey.html
• Northern long-eared bat Guidance
https://www.fws.gov/asheville/htmls/project review/NLEB in WNC.html
• Predictive Habitat Model for Aquatic Species
https://www.fws.gov/asheville/htmls/Maxent/Maxent.html
New information based on updated surveys, changes in the abundance and distribution of
species, changed habitat conditions, or other factors could require modifications of these lists.

07/10/2021
Event Code: 04EN1000-2021-E-01738 2
Please note that under 50 CFR 402.12(e) of the regulations implementing section 7 of the Act,
the accuracy of the species lists should be verified after 90 days. This verification can be
completed formally or informally as desired. The Service recommends that verification be
completed by visiting the ECOS-IPaC website or the AFO website (the AFO website dates each
county list with the day of the most recent update/change) at regular intervals during project
planning and implementation for updates to species lists and information. An updated list may
be requested through the ECOS-IPaC system by completing the same process used to receive the
enclosed list or by going to the AFO website.
The purpose of the Act is to provide a means whereby threatened and endangered species and the
ecosystems upon which they depend may be conserved. Under sections 7(a)(1) and 7(a)(2) of
the Act and its implementing regulations (50 CFR 402 et seq.), Federal agencies are required to
utilize their authorities to carry out programs for the conservation of threatened and endangered
species and to determine whether projects may affect threatened and endangered species and/or
designated critical habitat.
A Biological Assessment is required for construction projects (or other undertakings having
similar physical impacts) that are major Federal actions significantly affecting the quality of the
human environment as defined in the National Environmental Policy Act (42 U.S.C. 4332(2)
(c)). For projects other than major construction activities, the Service suggests that a Biological
Evaluation similar to a Biological Assessment be prepared to determine whether the project may
affect listed or proposed species and/or designated or proposed critical habitat. Recommended
contents of a Biological Assessment are described at 50 CFR 402.12 and on our office's website
at https://www.fws.gov/asheville/htmis/project review/assessment guidance.html.
If a Federal agency (or their non-federal representative) determines, based on the Biological
Assessment or Biological Evaluation, that listed species and/or designated critical habitat may be
affected by the proposed project, the agency is required to consult with the Service pursuant to
50 CFR 402. In addition, the Service recommends that candidate species, proposed species, and
proposed critical habitat be addressed within the consultation. More information on the
regulations and procedures for section 7 consultation, including the role of permit or license
applicants, can be found in the "Endangered Species Consultation Handbook" at: http://
www.fws.gov/endangered/esa-library/pdf/TOC-GLOS.PDF.
Though the bald eagle is no longer protected under the Endangered Species Act, please be aware
that bald and golden eagles are protected under the Bald and Golden Eagle Protection Act (16
U.S.C. 668 et seq.), and projects affecting these species may require additional consultation (see
hops://www.fws.gov/southeast/our-services/permits/eagles/). Wind energy projects should
follow the wind energy guidelines (http://www.fws.gov/windenergy/) for minimizing impacts to
migratory birds (including bald and golden eagles) and bats.
Guidance for minimizing impacts to migratory birds for projects including communications
towers (e.g., cellular, digital television, radio, and emergency broadcast) can be found at: http://
www. fws. gov/migratorybirds/CurrentBirdlssues/Hazards/towers/towers. htm;
http://www.towerkill.com; and http://www.fws.gov/migratorybirds/CurrentBirdlssues/Hazards/
towers/comtow.html.

07/10/2021
Event Code: 04EN1000-2021-E-01738 3
We appreciate your concern for threatened and endangered species. The Service encourages
Federal agencies to include conservation of threatened and endangered species into their project
planning to further the purposes of the Act. Please include the Consultation Tracking Number in
the header of this letter with any request for consultation or correspondence about your project
that you submit to our office.
Attachment(s):
• Official Species List
• Migratory Birds
• Wetlands

07/10/2021
Event Code: 04EN1000-2021-E-01738 1
Official Species List
This list is provided pursuant to Section 7 of the Endangered Species Act, and fulfills the
requirement for Federal agencies to "request of the Secretary of the Interior information whether
any species which is listed or proposed to be listed may be present in the area of a proposed
action".
This species list is provided by:
Asheville Ecological Services Field Office
160 Zillicoa Street
Asheville, NC 28801-1082
[phone]

07/10/2021
Event Code: 04EN1000-2021-E-01738 2
Project Summary
Consultation Code: 04EN1000-2021-SLI-0723
Event Code: 04EN1000-2021-E-01738
Project Name: 1930 Lewisville Clemmons Rd.
Project Type: DEVELOPMENT
Project Description: Residential
Project Location:
Approximate location of the project can be viewed in Google Maps: https://
www.google.com/maps/@36.054542999999995,-80.39381806962987,14z
Counties: Forsyth County, North Carolina

07/10/2021
Event Code: 04EN1000-2021-E-01738 3
Endangered Species Act Species
There is a total of 2 threatened, endangered, or candidate species on this species list.
Species on this list should be considered in an effects analysis for your project and could include
species that exist in another geographic area. For example, certain fish may appear on the species
list because a project could affect downstream species.
IPaC does not display listed species or critical habitats under the sole jurisdiction of NOAA
Fisheriesl, as USFWS does not have the authority to speak on behalf of NOAA and the
Department of Commerce.
See the "Critical habitats" section below for those critical habitats that lie wholly or partially
within your project area under this office's jurisdiction. Please contact the designated FWS office
if you have questions.
1. NOAA Fisheries, also known as the National Marine Fisheries Service (NMFS), is an
office of the National Oceanic and Atmospheric Administration within the Department of
Commerce.
Mammals
NAME
Northern Long-eared Bat Myotis septentrionalis
No critical habitat has been designated for this species.
Species profile: https://ecos.fws.gov/ecp/species/9045
Reptiles
NAME
Bog Turtle Clemmys muhlenbergii
Population: U.S.A. (GA, NC, SC, TN, VA)
No critical habitat has been designated for this species.
Species profile: https://ecos.fws.gov/ecp/species/6962
STATUS
Threatened
STATUS
Similarity of
Appearance
(Threatened)
Critical habitats
THERE ARE NO CRITICAL HABITATS WITHIN YOUR PROJECT AREA UNDER THIS OFFICE'S
JURISDICTION.

07/10/2021 Event Code: 04EN1000-2021-E-01738
Migratory Birds
Certain birds are protected under the Migratory Bird Treaty Act1 and the Bald and Golden Eagle
Protection Actz.
Any person or organization who plans or conducts activities that may result in impacts to
migratory birds, eagles, and their habitats should follow appropriate regulations and consider
implementing appropriate conservation measures, as described below.
1. The Migratory Birds Treaty Act of 1918.
2. The Bald and Golden Eagle Protection Act of 1940.
3. 50 C.F.R. Sec. 10.12 and 16 U.S.C. Sec. 668(a)
The birds listed below are birds of particular concern either because they occur on the USFWS
Birds of Conservation Concern (BCC) list or warrant special attention in your project location.
To learn more about the levels of concern for birds on your list and how this list is generated, see
the FAQ below. This is not a list of every bird you may find in this location, nor a guarantee that
every bird on this list will be found in your project area. To see exact locations of where birders
and the general public have sighted birds in and around your project area, visit the E-bird data
mapping tool (Tip: enter your location, desired date range and a species on your list). For
projects that occur off the Atlantic Coast, additional maps and models detailing the relative
occurrence and abundance of bird species on your list are available. Links to additional
information about Atlantic Coast birds, and other important information about your migratory
bird list, including how to properly interpret and use your migratory bird report, can be found
below.
For guidance on when to schedule activities or implement avoidance and minimization measures
to reduce impacts to migratory birds on your list, click on the PROBABILITY OF PRESENCE
SUMMARY at the top of your list to see when these birds are most likely to be present and
breeding in your project area.
NAME BREEDING SEASON
Rusty Blackbird Euphagus carolinus
This is a Bird of Conservation Concern (BCC) throughout its range in the
continental USA and Alaska.
Wood Thrush Hylocichla mustelina
This is a Bird of Conservation Concern (BCC) throughout its range in the
continental USA and Alaska.
Breeds elsewhere
Breeds May 10 to Aug
31
Probability Of Presence Summary
The graphs below provide our best understanding of when birds of concern are most likely to be
present in your project area. This information can be used to tailor and schedule your project
activities to avoid or minimize impacts to birds. Please make sure you read and understand the

07/10/2021
Event Code: 04EN1000-2021-E-01738 2
FAQ "Proper Interpretation and Use of Your Migratory Bird Report" before using or attempting
to interpret this report.
Probability of Presence ( 1)
Each green bar represents the bird's relative probability of presence in the 10km grid cell(s) your
project overlaps during a particular week of the year. (A year is represented as 12 4-week
months.) A taller bar indicates a higher probability of species presence. The survey effort (see
below) can be used to establish a level of confidence in the presence score. One can have higher
confidence in the presence score if the corresponding survey effort is also high.
How is the probability of presence score calculated? The calculation is done in three steps:
1. The probability of presence for each week is calculated as the number of survey events in
the week where the species was detected divided by the total number of survey events for
that week. For example, if in week 12 there were 20 survey events and the Spotted Towhee
was found in 5 of them, the probability of presence of the Spotted Towhee in week 12 is
0.25.
2. To properly present the pattern of presence across the year, the relative probability of
presence is calculated. This is the probability of presence divided by the maximum
probability of presence across all weeks. For example, imagine the probability of presence
in week 20 for the Spotted Towhee is 0.05, and that the probability of presence at week 12
(0.25) is the maximum of any week of the year. The relative probability of presence on
week 12 is 0.25/0.25 = 1; at week 20 it is 0.05/0.25 = 0.2.
3. The relative probability of presence calculated in the previous step undergoes a statistical
conversion so that all possible values fall between 0 and 10, inclusive. This is the
probability of presence score.
Breeding Season ( )
Yellow bars denote a very liberal estimate of the time -frame inside which the bird breeds across
its entire range. If there are no yellow bars shown for a bird, it does not breed in your project
area.
Survey Effort (I)
Vertical black lines superimposed on probability of presence bars indicate the number of surveys
performed for that species in the 10km grid cell(s) your project area overlaps. The number of
surveys is expressed as a range, for example, 33 to 64 surveys.
No Data (—)
A week is marked as having no data if there were no survey events for that week.
Survey Timeframe
Surveys from only the last 10 years are used in order to ensure delivery of currently relevant
information. The exception to this is areas off the Atlantic coast, where bird returns are based on
all years of available data, since data in these areas is currently much more sparse.
• probability of presence breeding season 1 survey effort — no data

07/10/2021
Event Code: 04EN1000-2021-E-01738 3
SPECIES JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Rusty Blackbird
BCC Rangewide ++++ ++++ ++++ ++++ ++++ ++—+ -�+— —+++ ++++ ++++ ++I+ ++++
(CON)
Wood Thrush BCC Rangewide ++++ ++++ ++++ +++1 +1+1 ++— t 1111 1111 ++++ ++++ ++++ ++++
(CON)
Additional information can be found using the following links:
• Birds of Conservation Concern http://www.fws.gov/birds/management/managed-species/
birds-of-conservation-concern.php
• Measures for avoiding and minimizing impacts to birds http://www.fws.gov/birds/
management/project-assessment-tools-and-guidance/
conservation-measures.php
• Nationwide conservation measures for birds http://www.fws.gov/migratorybirds/pdf/
management/nationwidestandardconservationmeasures.pdf
Migratory Birds FAQ
Tell me more about conservation measures I can implement to avoid or minimize impacts
to migratory birds.
Nationwide Conservation Measures describes measures that can help avoid and minimize
impacts to all birds at any location year round. Implementation of these measures is particularly
important when birds are most likely to occur in the project area. When birds may be breeding in
the area, identifying the locations of any active nests and avoiding their destruction is a very
helpful impact minimization measure. To see when birds are most likely to occur and be breeding
in your project area, view the Probability of Presence Summary. Additional measures or permits
may be advisable depending on the type of activity you are conducting and the type of
infrastructure or bird species present on your project site.
What does IPaC use to generate the migratory birds potentially occurring in my specified
location?
The Migratory Bird Resource List is comprised of USFWS Birds of Conservation Concern
(BCC) and other species that may warrant special attention in your project location.
The migratory bird list generated for your project is derived from data provided by the Avian
Knowledge Network (AKN). The AKN data is based on a growing collection of survey, banding,
and citizen science datasets and is queried and filtered to return a list of those birds reported as
occurring in the 10km grid cell(s) which your project intersects, and that have been identified as
warranting special attention because they are a BCC species in that area, an eagle (Eagle Act
requirements may apply), or a species that has a particular vulnerability to offshore activities or
development.
Again, the Migratory Bird Resource list includes only a subset of birds that may occur in your
project area. It is not representative of all birds that may occur in your project area. To get a list
of all birds potentially present in your project area, please visit the AKN Phenology Tool.

07/10/2021
Event Code: 04EN1000-2021-E-01738 4
What does IPaC use to generate the probability of presence graphs for the migratory birds
potentially occurring in my specified location?
The probability of presence graphs associated with your migratory bird list are based on data
provided by the Avian Knowledge Network (AKN). This data is derived from a growing
collection of survey, banding, and citizen science datasets .
Probability of presence data is continuously being updated as new and better information
becomes available. To learn more about how the probability of presence graphs are produced and
how to interpret them, go the Probability of Presence Summary and then click on the "Tell me
about these graphs" link.
How do I know if a bird is breeding, wintering, migrating or present year-round in my
project area?
To see what part of a particular bird's range your project area falls within (i.e. breeding,
wintering, migrating or year-round), you may refer to the following resources: The Cornell Lab
of Ornithology All About Birds Bird Guide, or (if you are unsuccessful in locating the bird of
interest there), the Cornell Lab of Ornithology Neotropical Birds guide. If a bird on your
migratory bird species list has a breeding season associated with it, if that bird does occur in your
project area, there may be nests present at some point within the timeframe specified. If "Breeds
elsewhere" is indicated, then the bird likely does not breed in your project area.
What are the levels of concern for migratory birds?
Migratory birds delivered through IPaC fall into the following distinct categories of concern:
1. "BCC Rangewide" birds are Birds of Conservation Concern (BCC) that are of concern
throughout their range anywhere within the USA (including Hawaii, the Pacific Islands,
Puerto Rico, and the Virgin Islands);
2. "BCC - BCR" birds are BCCs that are of concern only in particular Bird Conservation
Regions (BCRs) in the continental USA; and
3. "Non -BCC - Vulnerable" birds are not BCC species in your project area, but appear on
your list either because of the Eagle Act requirements (for eagles) or (for non -eagles)
potential susceptibilities in offshore areas from certain types of development or activities
(e.g. offshore energy development or longline fishing).
Although it is important to try to avoid and minimize impacts to all birds, efforts should be made,
in particular, to avoid and minimize impacts to the birds on this list, especially eagles and BCC
species of rangewide concern. For more information on conservation measures you can
implement to help avoid and minimize migratory bird impacts and requirements for eagles,
please see the FAQs for these topics.
Details about birds that are potentially affected by offshore projects
For additional details about the relative occurrence and abundance of both individual bird species
and groups of bird species within your project area off the Atlantic Coast, please visit the
Northeast Ocean Data Portal. The Portal also offers data and information about other taxa besides
birds that may be helpful to you in your project review. Alternately, you may download the bird
model results files underlying the portal maps through the NOAA NCCOS Integrative Statistical

07/10/2021
Event Code: 04EN1000-2021-E-01738 5
Modeling and Predictive Mapping of Marine Bird Distributions and Abundance on the Atlantic
Outer Continental Shelf project webpage.
Bird tracking data can also provide additional details about occurrence and habitat use
throughout the year, including migration. Models relying on survey data may not include this
information. For additional information on marine bird tracking data, see the Diving Bird Study
and the nanotag studies or contact Caleb Spiegel or Pam Loring.
What if I have eagles on my list?
If your project has the potential to disturb or kill eagles, you may need to obtain a permit to avoid
violating the Eagle Act should such impacts occur.
Proper Interpretation and Use of Your Migratory Bird Report
The migratory bird list generated is not a list of all birds in your project area, only a subset of
birds of priority concern. To learn more about how your list is generated, and see options for
identifying what other birds may be in your project area, please see the FAQ "What does IPaC
use to generate the migratory birds potentially occurring in my specified location". Please be
aware this report provides the "probability of presence" of birds within the 10 km grid cell(s) that
overlap your project; not your exact project footprint. On the graphs provided, please also look
carefully at the survey effort (indicated by the black vertical bar) and for the existence of the "no
data" indicator (a red horizontal bar). A high survey effort is the key component. If the survey
effort is high, then the probability of presence score can be viewed as more dependable. In
contrast, a low survey effort bar or no data bar means a lack of data and, therefore, a lack of
certainty about presence of the species. This list is not perfect; it is simply a starting point for
identifying what birds of concern have the potential to be in your project area, when they might
be there, and if they might be breeding (which means nests might be present). The list helps you
know what to look for to confirm presence, and helps guide you in knowing when to implement
conservation measures to avoid or minimize potential impacts from your project activities,
should presence be confirmed. To learn more about conservation measures, visit the FAQ "Tell
me about conservation measures I can implement to avoid or minimize impacts to migratory
birds" at the bottom of your migratory bird trust resources page.

07/10/2021 Event Code: 04EN1000-2021-E-01738
Wetlands
Impacts to NWI wetlands and other aquatic habitats may be subject to regulation under Section
404 of the Clean Water Act, or other State/Federal statutes.
For more information please contact the Regulatory Program of the local U.S. Army Corps of
Engineers District.
Please note that the NWI data being shown may be out of date. We are currently working to
update our NWI data set. We recommend you verify these results with a site visit to determine
the actual extent of wetlands on site.
FRESHWATER POND
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• -80.408164 36.060956 Degrees
1930 Lewisville-clerrirnans rd x
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Approximate 38.7'AcreTract
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Pilot Project 5548

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1930 Lewisville-Clemmons Road
Approximate 38.7-Acre Tract
Clemmons, Forsyth County, NC
Pilot Project 5548

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LEGEND
Site Boundary
Drawing 2A
USDA Soil Survey
Of Forsyth County, NC
Published 1976, Sheet 36
Not To Scale
PILOT
PILOT Eh4I RONM ENTF.L. INC
Published Soil Map
1930 Lewisville-Clemmons Road
Approximate 38.7-Acre Tract
Clemmons, Forsyth County, NC
Pilot Project 5548

LEGEND
Site Boundary
Freshwater anergem
pre.h°"te.p"."m~o/Sh,.0
Estuarine and Marine ocopwate,
m cstua//nca"uMa,/no
F""h°=te.w,"u
uke
x*°,m~
Other
Drawing 3
U3FVV3NVV|
Wetlands Mapper
Scale: l" =4OO'
NVV|Map
193OLevvisvi||e'C|ennnnonsRoad
Approximate 38.7'AcreTract
C|ennnnons, Forsyth County, NC
Pilot Project 5548

LEGEND
Site Boundary
1 %Annual Chance Flood Hazard
▪ Regulatory Flood ray
▪ Sped al Floodvay
Area of Undetermined Flood Hazard
▪ 0.2%Annual Chance Flood Hazard
▪ Future Conditions 1 %Annual Chance Flood Hazard
I4 Area with Reduced Risk Due to Levee
Drawing 4
National Flood Hazard Layer
From FEMA Web Map Service
Scale: 1" = 500'
PILOT
PILOT Eh 4 RONM ENTF.L. iNC
FEMA FIRM
1930 Lewisville-Clemmons Road
Approximate 38.7-Acre Tract
Clemmons, Forsyth County, NC
Pilot Project 5548

WG 1-18
(0.12 ac)
SD
(40 LF)
sc
(580 LF)
SA
(1,200 LF)
Q DP-3
O DP-4
SB
(320 LF)
FLAG NUMBERS/INFO
WETLAND FLAGS =
STREAM FLAGS =
Stream Flags = Limits
Wetland Flags = 153
Total Flags = 153
WF 49-53
(0.03 ac)
WF 1-48
(1.18 ac)
V//////9
Y//////21
WD 1-17
(0.10 ac)
WE 1-25
(0.14 ac)
4
O DP-1
DP-2
tit
WC 1-8
(0.02 ac)
1
(0.01 ac)
THE LOCATIONS OF FEATURES SHOWN ON THIS MAP ARE PRELIMINARY. THEY HAVE NOT BEEN
NCDEQ-DWR. THIS EXHIBIT INCLUDES GPS LOCATIONS OF DELINEATED FEATURES. DELINEATION
2.14.2020.
77.
1
rmaakit
LEGEND
Site Boundary
Stream
Wetlands
Pond
Flag Number
Culvert
Data Point
( WA 1-5
DP-1 01
VERIFIED BY THE USACE AND/OR THE
CONDUCTED BY PILOT PERSONNEL ON
Drawing 5
Satellite Imagery from ESRI
and Pilot GPS Data
Scale: 1" = 350'
Date: 2.18.2020
PILOT ENVI PONM ENTF.L. INC
Wetland Map
1930 Lewisville-Clemmons Road
Approximate 38.7-Acre Tract
Clemmons, Forsyth County, NC
Pilot Project 5548

Requestor:
Address:
Telephone Number:
E-mail:
Size (acres)
Nearest Waterway
USGS HUC
U.S. ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Action Id. SAW-2020-00420 County: Forsyth U.S.G.S. Quad: NC- Clemmons
NOTIFICATION OF JURISDICTIONAL DETERMINATION
Parr Investments
Chris Parr
1813 Pembroke Road, Suite F
Greensboro, NC 27408
336-382-4595
ch ris(a,p a rrinvestm ents. co m
Nearest Town Clemmons
River Basin Upper Pee Dee
Coordinates Latitude: 36.054558
Longitude: -80.393807
Location description: The review area is located on the west side of Lewisville-Clemmons Road; approximately 1 mile north of
the intersection of Lewisville-Clemmons Road and South Peace Haven Road. PIN: 5884-81-0709. Reference review area
description shown in Jurisdictional Determination Request package entitled "Drawing 1, USGS Topographic Map".
38.7
Blanket Creek
03040101
Indicate Which of the Following Apply:
A. Preliminary Determination
There appear to be waters, including wetlands on the above described project area/property, that may be subject to Section 404
of the Clean Water Act (CWA)(33 USC § 1344) and/or Section 10 of the Rivers and Harbors Act (RHA) (33 USC § 403). The
waters, including wetlands have been delineated, and the delineation has been verified by the Corps to be sufficiently accurate
and reliable. The approximate boundaries of these waters are shown on the enclosed delineation map dated 2/18/2020. Therefore
this preliminary jurisdiction determination may be used in the permit evaluation process, including determining compensatory
mitigation. For purposes of computation of impacts, compensatory mitigation requirements, and other resource protection
measures, a permit decision made on the basis of a preliminary JD will treat all waters and wetlands that would be affected in any
way by the permitted activity on the site as if they are jurisdictional waters of the U.S. This preliminary determination is not an
appealable action under the Regulatory Program Administrative Appeal Process (Reference 33 CFR Part 331). However, you may
request an approved JD, which is an appealable action, by contacting the Corps district for further instruction.
❑ There appear to be waters, including wetlands on the above described project area/property, that may be subject to Section 404
of the Clean Water Act (CWA)(33 USC § 1344) and/or Section 10 of the Rivers and Harbors Act (RHA) (33 USC § 403).
However, since the waters, including wetlands have not been properly delineated, this preliminary jurisdiction determination
may not be used in the permit evaluation process. Without a verified wetland delineation, this preliminary determination is
merely an effective presumption of CWA/RHA jurisdiction over all of the waters, including wetlands at the project area, which
is not sufficiently accurate and reliable to support an enforceable permit decision. We recommend that you have the waters,
including wetlands on your project area/property delineated. As the Corps may not be able to accomplish this wetland
delineation in a timely manner, you may wish to obtain a consultant to conduct a delineation that can be verified by the Corps.
B. Approved Determination
❑ There are Navigable Waters of the United States within the above described project area/property subject to the permit
requirements of Section 10 of the Rivers and Harbors Act (RHA) (33 USC § 403) and Section 404 of the Clean Water Act
(CWA)(33 USC § 1344). Unless there is a change in law or our published regulations, this determination may be relied upon for
a period not to exceed five years from the date of this notification.
❑ There are waters, including wetlandson the above described project area/property subject to the permit requirements of Section
404 of the Clean Water Act (CWA) (33 USC § 1344). Unless there is a change in the law or our published regulations, this
determination may be relied upon for a period not to exceed five years from the date of this notification.
❑ We recommend you have the waters, including wetlands on your project area/property delineated. As the Corps may not be
able to accomplish this wetland delineation in a timely manner, you may wish to obtain a consultant to conduct a delineation that
can be verified by the Corps.
❑ The waters, including wetlands on your project area/property have been delineated and the delineation has been verified by
the Corps. The approximate boundaries of these waters are shown on the enclosed delineation map dated DATE. We strongly

SAW-2020-00420
suggest you have this delineation surveyed. Upon completion, this survey should be reviewed and verified by the Corps. Once
verified, this survey will provide an accurate depiction of all areas subject to CWA jurisdiction on your property which, provided
there is no change in the law or our published regulations, may be relied upon for a period not to exceed five years.
❑ The waters, including wetlands have been delineated and surveyed and are accurately depicted on the plat signed by the
Corps Regulatory Official identified below onDATE. Unless there is a change in the law or our published regulations, this
determination may be relied upon for a period not to exceed five years from the date of this notification.
❑ There are no waters of the U.S., to include wetlands, present on the above described project area/property which are subject to the
permit requirements of Section 404 of the Clean Water Act (33 USC 1344). Unless there is a change in the law or our published
regulations, this determination may be relied upon for a period not to exceed five years from the date of this notification.
❑ The property is located in one of the 20 Coastal Counties subject to regulation under the Coastal Area Management Act (CAMA).
You should contact the Division of Coastal Management in Morehead City, NC, at [phone] to determine their
requirements.
Placement of dredged or fill material within waters of the US, including wetlands, without a Department of the Army permit may
constitute a violation of Section 301 of the Clean Water Act (33 USC § 1311). Placement of dredged or fill material, construction or
placement of structures, or work within navigable waters of the United States without a Department of the Army permit may
constitute a violation of Sections 9 and/or 10 of the Rivers and Harbors Act (33 USC § 401 and/or 403). If you have any questions
regarding this determination and/or the Corps regulatory program, please contact Bryan Roden -Reynolds at 704-510-1440 or
brvan.roden-revnolds(a,u sace.army.com.
C. Basis For Determination: Basis For Determination: See the preliminary jurisdictional determination
form dated 5/28/2020.
D. Remarks: None.
E. Attention USDA Program Participants
This delineation/determination has been conducted to identify the limits of Corps' Clean Water Act jurisdiction for the particular site
identified in this request. The delineation/determination may not be valid for the wetland conservation provisions of the Food Security
Act of 1985. If you or your tenant are USDA Program participants, or anticipate participation in USDA programs, you should request
a certified wetland determination from the local office of the Natural Resources Conservation Service, prior to starting work.
F. Appeals Information (This information applies only to approved jurisdictional determinations as indicated in B.
above)
This correspondence constitutes an approved jurisdictional determination for the above described site. If you object to this
determination, you may request an administrative appeal under Corps regulations at 33 CFR Part 331. Enclosed you will find a
Notification of Appeal Process (NAP) fact sheet and request for appeal (RFA) form. If you request to appeal this determination you
must submit a completed RFA form to the following address:
US Army Corps of Engineers
South Atlantic Division
Attn: Phillip Shannin, Review Officer
60 Forsyth Street SW, Room 10M15
Atlanta, Georgia 30303-8801
In order for an RFA to be accepted by the Corps, the Corps must determine that it is complete, that it meets the criteria for appeal
under 33 CFR part 331.5, and that it has been received by the Division Office within 60 days of the date of the NAP. Should you
decide to submit an RFA form, it must be received at the above address by Not applicable.
**It is not necessary to submit an RFA form to the Division Office if you do not object to the determination in this correspondence.**
RODEN REYNOLDS.BRYAN.KENNETH.1263385574 DDitllaea2o2 os.dbyROgDENRREENOLDS.BRYAN.KENNETH.1263385574
Corps Regulatory Official:
Date of JD: 5/28/2020 Expiration Date of JD: Not applicable

SAW-2020-00420
The Wilmington District is committed to providing the highest level of support to the public. To help us ensure we
continue to do so, please complete the Customer Satisfaction Survey located at
http://corpsmapu.usace.army.mil/cmapex/f?p=136:4:0
Copy furnished:
Agent: Pilot Environmental, Inc.
Spencer Burnett
Address: P.O. Box 128
Kernersville, NC 27285
Telephone Number: 336-310-4527
E-mail: sbu rnett(apilotenviro.com
Land Owner: Hendrix Enterprises
Gordon Hendrix
Address: 6350 Cephis Drive
Clemmons, NC 27012
Telephone Number: 336-978-1329
E-mail: info(a,hendrixenterprisesnc.com

PROCESS AND
NOTIFICATION OF ADMINISTRATIVE APPEAL OPTIONS AND
REQUEST FOR APPEAL
Applicant: Parr Investments Chris Parr File Number: SAW-2020-00420 Date: 5/26/2020
Attached is:
See Section below
❑
INITIAL PROFFERED PERMIT (Standard Permit or Letter of permission)
A
❑
PROFFERED PERMIT (Standard Permit or Letter of permission)
B
❑
PERMIT DENIAL
C
❑
APPROVED JURISDICTIONAL DETERMINATION
D
/1
PRELIMINARY JURISDICTIONAL DETERMINATION
E
SECTION
Additional
or
I - The following identifies your rights and options regarding an administrative appeal of the above decision.
information may be found at or http://www.usace.army.mil/Missions/CivilWorks/RegulatoryProgramandPermits.aspx
the Corps regulations at 33 CFR Part 331.
A: INITIAL PROFFERED PERMIT: You may accept or object to the permit.
• ACCEPT: If you received a Standard Permit, you may sign the permit document and return it to the district engineer for fmal
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all
rights to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the
permit.
• OBJECT: If you object to the permit (Standard or LOP) because of certain terms and conditions therein, you may request
that the permit be modified accordingly. You must complete Section II of this form and return the form to the district
engineer. Your objections must be received by the district engineer within 60 days of the date of this notice, or you will
forfeit your right to appeal the permit in the future. Upon receipt of your letter, the district engineer will evaluate your
objections and may: (a) modify the permit to address all of your concerns, (b) modify the permit to address some of your
objections, or (c) not modify the permit having determined that the permit should be issued as previously written. After
evaluating your objections, the district engineer will send you a proffered permit for your reconsideration, as indicated in
Section B below.
B:
•
•
PROFFERED PERMIT: You may accept or appeal the permit
ACCEPT: If you received a Standard Permit, you may sign the permit document and return
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and
signature on the Standard Permit or acceptance of the LOP means that you accept the permit
rights to appeal the permit, including its terms and conditions, and approved jurisdictional
permit.
APPEAL: If you choose to decline the proffered permit (Standard or LOP) because of
you may appeal the declined permit under the Corps of Engineers Administrative Appeal
it to the district engineer for fmal
your work is authorized. Your
in its entirety, and waive all
determinations associated with the
certain terms and conditions therein,
Process by completing Section II of
the division engineer within 60 days
this form and sending the form to the division engineer. This form must be received by
of the date of this notice.
C: PERMIT DENIAL: You may appeal the denial of a permit under the Corps of Engineers Administrative Appeal Process by
completing Section II of this form and sending the form to the division engineer. This form must be received by the division
engineer within 60 days of the date of this notice.
D:
information.
•
•
APPROVED JURISDICTIONAL DETERMINATION: You may accept or appeal the
ACCEPT: You do not need to notify the Corps to accept an approved JD. Failure to notify
date of this notice, means that you accept the approved JD in its entirety, and waive all
APPEAL: If you disagree with the approved JD, you may appeal the approved JD under
Administrative Appeal Process by completing Section II of this form and sending the form
approved JD or provide new
the Corps within 60 days of the
rights to appeal the approved JD.
the Corps of Engineers
to the district engineer. This form
must be received by the division engineer within 60 days of the date of this notice.
E: PRELIMINARY JURISDICTIONAL DETERMINATION: You do not need to respond to the Corps regarding the
preliminary JD. The Preliminary JD is not appealable. If you wish, you may request an approved JD (which may be appealed),
by contacting the Corps district for further instruction. Also you may provide new information for further consideration by the
Corps to reevaluate the JD.

SECTION II - REQUEST FOR APPEAL or OBJECTIONS TO AN INITIAL PROFFERED PERMIT
REASONS FOR APPEAL OR OBJECTIONS: (Describe your
proffered permit in clear concise statements. You may attach
objections are addressed in the administrative record.)
reasons for appealing the decision or your objections to an initial
additional information to this form to clarify where your reasons or
ADDITIONAL INFORMATION: The appeal is limited to a
record of the appeal conference or meeting, and any supplemental
clarify the administrative record. Neither the appellant nor the
review of the administrative record, the Corps memorandum for the
information that the review officer has determined is needed to
Corps may add new information or analyses to the record.
the location of information that is already in the administrative
However, you may provide additional information to clarify
record.
POINT OF CONTACT FOR QUESTIONS OR INFORMATION:
If you have questions regarding this decision and/or the
appeal process you may contact:
District Engineer, Wilmington Regulatory Division
Attn: Bryan Roden -Reynolds
Charlotte Regulatory Office
U.S Army Corps of Engineers
8430 University Executive Park Drive, Suite 615
Charlotte, North Carolina 28262
If you only have questions regarding
also contact:
Mr. Phillip Shannin, Administrative
the appeal process you may
Appeal Review Officer
South Atlantic Division
CESAD-PDO
U.S. Army Corps of Engineers,
60 Forsyth Street, Room 10M15
Atlanta, Georgia 30303-8801
Phone: [phone]
RIGHT OF ENTRY: Your signature below grants the right of entry to Corps of Engineers personnel, and any government
consultants, to conduct investigations of the project site during the course of the appeal process. You will be provided a 15 day
notice of any site investigation, and will have the opportunity to participate in all site investigations.
Date:
Telephone number:
Signature of appellant or agent.
For appeals on Initial Proffered Permits send this form to:
District Engineer, Wilmington Regulatory Division, Attn: Bryan Roden -Reynolds, 69 Darlington Avenue, Wilmington, North
Carolina 28403
For Permit denials, Proffered Permits and Approved Jurisdictional Determinations send this form to:
Division Engineer, Commander, U.S. Army Engineer Division, South Atlantic, Attn: Mr. Phillip Shannin, Administrative
Appeal Officer, CESAD-PDO, 60 Forsyth Street, Room 10M15, Atlanta, Georgia 30303-8801
Phone: [phone]

PRELIMINARY JURISDICTIONAL DETERMINATION (PJD) FORM
BACKGROUND INFORMATION
A. REPORT COMPLETION DATE FOR PJD: 5/26/2020
B. NAME AND ADDRESS OF PERSON REQUESTING PJD: Parr Investments, Chris Parr, 1813 Pembroke
Road, Suite F, Greensboro, NC 27408
C. DISTRICT OFFICE, FILE NAME, AND NUMBER: Wilmington District, Lewisville-Clemmons Road,
SAW-2020-00420
D. PROJECT LOCATION(S) AND BACKGROUND INFORMATION: The review area is located on the
west side of Lewisville-Clemmons Road; approximately 1 mile north of the intersection of Lewisville-
Clemmons Road and South Peace Haven Road. PIN: 5884-81-0709. Reference review area description shown
in Jurisdictional Determination Request package entitled "Drawing 1, USGS Topographic Map".
(USE THE TABLE BELOW TO DOCUMENT MULTIPLE AQUATIC RESOURCES
AND/OR AQUATIC RESOURCES AT DIFFERENT SITES)
State: NC County: Forsyth City: Clemmons
Center coordinates of site (lat/long in degree decimal format): Latitude: 36.054558 Longitude: -80.393807
Universal Transverse Mercator:
Name of nearest waterbody: Blanket Creek
E. REVIEW PERFORMED FOR SITE EVALUATION (CHECK ALL THAT APPLY):
Z Office (Desk) Determination. Date: 03/09/2020
® Field Determination. Date(s): 05/22/2020
TABLE OF AQUATIC RESOURCES INREVIEW AREA WHICH "MAY BE" SUBJECT TO
REGULATORY JURISDICTION
Feature
Latitude
Longitude
Estimated
Type of aquatic
Geographic authority to
(decimal
degrees)
(decimal
degrees)
amount of
aquatic
resources in
review area
resources (i.e.,
wetland vs. non-
wetland waters)
which the aquatic
resource "may be"
subject (i.e., Section 404
or Section 10/404)
(acreage and
linear feet, if
applicable
SEE ATTACHED TABLE
1. The Corps of Engineers believes that there may be jurisdictional aquatic resources in the
review area, and the requestor of this PJD is hereby advised of his or her option to request
and obtain an approved JD (AJD) for that review area based on an informed decision after
having discussed the various types of JDs and their characteristics and circumstances when
they may be appropriate.
2. In any circumstance where a permit applicant obtains an individual permit, or a Nationwide
General Permit (NWP) or other general permit verification requiring "pre- construction
notification" (PCN), or requests verification for a non -reporting NWP or other general
permit, and the permit applicant has not requested an AJD for the activity, the permit
applicant is hereby made aware that: (1) the permit applicant has elected to seek a permit
authorization based on a PJD, which does not make an official determination of
jurisdictional aquatic resources; (2) the applicant has the option to request an AJD before
accepting the terms and conditions of the permit authorization, and that basing a permit
authorization on an AJD could possibly result in less compensatory mitigation being
required or different special conditions; (3) the applicant has the right to request an

individual permit rather than accepting the terms and conditions of the NWP or other
general permit authorization; (4) the applicant can accept a permit authorization and
thereby agree to comply with all the terms and conditions of that permit, including
whatever mitigation requirements the Corps has determined to be necessary; (5)
undertaking any activity in reliance upon the subject permit authorization without
requesting an AJD constitutes the applicant's acceptance of the use of the PJD; (6)
accepting a permit authorization (e.g., signing a proffered individual permit) or undertaking
any activity in reliance on any form of Corps permit authorization based on a PJD
constitutes agreement that all aquatic resources in the review area affected in any way by
that activity will be treated as jurisdictional, and waives any challenge to such jurisdiction
in any administrative or judicial compliance or enforcement action, or in any administrative
appeal or in any Federal court; and (7) whether the applicant elects to use either an AJD or
a PJD, the JD will be processed as soon as practicable. Further, an AJD, a proffered
individual permit (and all terms and conditions contained therein), or individual permit
denial can be administratively appealed pursuant to 33 C.F.R. Part 331. If, during an
administrative appeal, it becomes appropriate to make an official determination whether
geographic jurisdiction exists over aquatic resources in the review area, or to provide an
official delineation of jurisdictional aquatic resources in the review area, the Corps will
provide an AJD to accomplish that result, as soon as is practicable. This PJD finds that
there "may be" waters of the U.S. and/or that there "may be" navigable waters of the U.S.
on the subject review area, and identifies all aquatic features in the review area that could
be affected by the proposed activity, based on the following information:

SUPPORTING DATA. Data reviewed for PJD (check all that apply) Checked items are included in the administrative
record and are appropriately cited:
▪ Maps, plans, plots or plat submitted by or on behalf of the PJD requestor:
Map: Drawings 1-5
▪ Data sheets prepared/submitted by or on behalf of the PJD requestor. Datasheets:
▪ Office concurs with data sheets/delineation report.
❑ Office does not concur with data sheets/delineation report. Rationale:
❑ Data sheets prepared by the Corps:
❑ Corps navigable waters' study:
❑ U. S. Geological Survey Hydrologic Atlas:
❑ USGS NHD data:
❑ USGS 8 and 12 digit HUC maps:
® U.S. Geological Survey map(s). Cite scale & quad name- Drawing 1, USGS Topographic Map (1:24,000
Clemmons and Winston-Salem West, NC)
▪ Natural Resources Conservation Service Soil Survey. Citation: Drawing 2, Web Soil Map (Web Soil Survey of
Forsyth County) and Drawing 2A, Published Soil Map (Soil Survey of Forsyth County Sheet 36 Dated 1976)
® National wetlands inventory map(s). Cite name- Drawing 3, NWI Map (USFWS NWI Mapper)
❑ State/local wetland inventory map(s):
▪ FEMA/FIRMmaps: Drawing 4, FEMA FIRM (National Flood Hazard Laver)
❑ 100-year Floodplain Elevation is: (National Geodetic Vertical Datum of 1929)
® Photographs: ® Aerial (Name & Date): Drawing 5, Wetland Map (Dated 02/18/2020)
or ❑ Other (Name & Date):
❑ Previous determination(s). File no. and date of response letter:
❑ Other information (please specify):
IMPORTANT NOTE: The information recorded on this form has not necessarily been verified by the Corps
and should not be relied upon for later jurisdictional determinations.
RODEN Digitally signed by RODEN
REYNOLDS.B RYAN.KEN N ETH.12
REYNOLDS.BRYAN.KE 63385574
N N ETH.1263385574 Date: 2020.05.28 10:49:16
-04'00'
Signature and date of Regulatory Signature and date of person requesting PJD
staff member completing PJD (REQUIRED, unless obtaining the signature is
5/28/2020 impracticable)'
1 Districts may establish timeframes for requester to return signed PJD forms. If the requester does not respond within the established
time frame, the district may presume concurrence and no additional follow up is necessary prior to fmalizing an action.

Feature
Latitude
(decimal
degrees)
Longitude
(decimal
degrees)
Estimated
amount of
aquatic
resources in
review area
(acreage and
linear feet, if
applicable
Type of aquatic
resources (i.e.,
wetland vs. non-
wetland waters)
Geographic authority to
which the aquatic
resource "may be"
subject (i.e., Section 404
or Section 10/404)
Stream SA
36.05481000
-80.39705700
1,200 linear feet
Non -wetland
404
Stream SB
36.05343900
-80.39716800
320 linear feet
Non -wetland
404
Stream SC
36.05421600
-80.39768300
580 linear feet
Non -wetland
404
Stream SD
36.05367500
-80.39789200
40 linear feet
Non -wetland
404
Wetland WA
36.05546500
-80.39205500
0.01 acre
Wetland
404
Wetland WB
36.05517500
-80.39157000
0.31 acre
Wetland
404
Wetland WC
36.05422800
-80.39292000
0.02 acre
Wetland
404
Wetland WD
36.05491900
-80.39410100
0.1 acre
Wetland
404
Wetland WE
36.05482300
-80.39524100
0.14 acre
Wetland
404
Wetland WF 1-
36.05417000
-80.39709800
1.18 acre
Wetland
404
48
Wetland WF
49-53
36.05485500
-80.39612100
0.03 acre
Wetland
404
Wetland WG
36.05407200
-80.39820300
0.12 acre
Wetland
404
Open Water PA
36.05533700
-80.39318400
2.83 acre
Non -wetland
404

WG 1-18
(0.12 ac)
SC
(580 LF)
SA
(1,200 LF)
WF 49-53
(0.03 ac)
WD 1-17
` (0.10 ac)
WE 1-25
(0.14 ac)
SD
(40 LF)
SB
(320 LF)
FLAG NUMBERS/INFO
WETLAND FLAGS =
STREAM FLAGS =
Stream Flags = Limits
Wetland Flags = 153
Total Flags = 153114
f THE LOCATIONS OF FEATURES SHOWN ON THIS MAP ARE PRELIMINARY. THEY HAVE NOT BEEN VERIFIED BY THE USACE AND/OR THE
NCDEQ-DWR. THIS EXHIBIT INCLUDES GPS LOCATIONS OF DELINEATED FEATURES. DELINEATION CONDUCTED BY PILOT PERSONNEL ON
2.14.2020.
WF 1-48
(1.18 ac)
PA
(2.83 ac)
WC 1-8
(0.02 ac)
(0.01 ac)
AO*.
t
WB 1-28
(0.31 ac)
LEGEND
Site Boundary
Stream
Wetlands
Pond
Flag Number
Culvert
Data Point
( WA 1-5
DP-1 Q l
1////////
I///////A
Drawing 5
Satellite Imagery from ESRI
and Pilot GPS Data
Scale: 1" = 350'
Date: 2.18.2020
yl
PILOT �' a
PILOT ENV k O Y U E N t h l. I k C
Wetland Map
1930 Lewisville-Clemmons Road
Approximate 38.7-Acre Tract
Clemmons, Forsyth County, NC
Pilot Project 5548