20211145 Ver 1_Shoreline Stabilization_20210723

Submission Form
Pre -Filing Meeting Information
Before submitting this form please ensure you have submitted the Pre -Filing Meeting Request Form as we will not be able
to accept your application without this important first step. The Pre -Filing Meeting Request Form is used in accordance
with 40 C.F.R. Section 121.4(a) "At least 30 days prior to submitting a certification request, the project proponent shall
request a pre -filing meeting with the certifying agency" and in accordance with 40 C.F.R. Section 121.5(b)(7), and (c)(5)
all certification requests shall include documentation that a pre -filing meeting request was submitted to the certifying
authority at least 30 days prior to submitting the certification request. Click here to read more information on when this
form is needed prior to application submission or here to viewthe form.
Attach documentation of Pre -Filing Meeting Request here:
Nordblom Meeting Request.pdf 49.47KB
Pre -fling Meeting or Request Date 6/1/2021
ID# Version
I. Applicant Information [15A NCAC 02H .0502(a)]
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.
Primary Contact Email * [e-mail]
Rease provide an err -ail address for payment and requests for pure infornation here.
Owner Information:
Name: * Robert & Shirley Nordblom
Email: * [e-mail]
Phone Number:* [phone]
(xxx)xxx-xxxx
Mailing Address:* Street Address
2008 Old Wildlife Club Dr
Address Line 2
City
State / Frovince / Region
Nebo
NC
Fbstal / Zip Code
Country
28761
us

Is there an agent working on the F Yes
project?* r No
Agent/Consultant Information
Name: *
Carissa Parker
Company Affiliation: *
Bennick Enterprises
Email:*
[e-mail]
Phone Number:*
[phone]
(XXX)XXX-XXXX
Address:*
Street Address
7836 US Hwy 70 E
Address Line 2
City
Nebo
Fbstal / Zip Code
28761
Asigned and dated copy of the Agent Authorization letter:*
auth letter.pdf 212.45KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:* OWC5
State / Province / Region
NC
Country
US
If your project has a formal name please use this. If your project does not hake a formal name, please identify your project by
the owner name and proposed activity (Jones Property Access Road, Smith Guest House, etc.) List in parentheses any
other names that have been used to identify the project in the past.
1. Provide a vicinity map (i.e. street map) clearly showing the location of the property with respect
to local landmarks such as towns, rivers, and roads.*
r Upload File
r Lookup address
Property Address Lookup:*
Latitude:* 35.746860
Street Address
2008 Old Wildlife Club Dr
Address Line 2
City
Nebo
Fbstal / Zip Code
28761
State / Province / Region
NC
Country
US
Longitude:* 81.918410
2. Provide a detailed site plan showing property boundaries and proposed locations of vegetation clearing,
structures (buildings, retaining walls, docks, impervious surfaces, etc.), rip rap, excavation or dredging
below Full Pond/ Normal Water Level elevations, and construction access corridors. You may use the
diagram under section 12.normal pool lake level/normal water level*
site plan.pdf 407.3KB
Please use the diagram at the link below:

https://edocs.deq.nc.gov/WaterResources/0/edoc/616616/Shoreline%20Layout.docx
3. Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale of some sort- a
yard stick, shovel handle, etc.)*
Nordblom.pdf 387.46KB
4. Location of the property (where work is to be conducted)
Nearest Town:* Nebo
County:* McDowell
Lake/ river/ ocean adjacent to Lake James
property:
Subdivisions name or site address:* Old Wildlife Club lot 5 2008 OWC DR
hclude phasellot number
Directions to site:*
From Morganton take Hwy 126 / Turn onto Old Wildlife Dr / TR onto
Old Wildlife Club Dr to property
Rease include road narres and numbers, landmarks etc.
5. Describe the existing land use or condition of the site at the time of this application:*
Residential
Fbsidential, undeveloped, etc.
6. Property Size 1.5
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
50' Shoreline stabilization by barge, height will be 5 '
8. How will the work be done?* F From Land
W From Water
9. Total amount of disturbance below the normal pool lake level/ normal water level:*
(including all clearing, backfill, excavation, rip rap, retaining walls, etc.)
100
square feet
10. Total amount of disturbance above the normal pool lake level/ normal water level and 50 feet
land -ward:*
(including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
150
square feet
11. Please describe the vegetation above the normal pool lake level/ normal water level and 50 feet
landward to be impacted:*
(nunber of trees, for instance)
2 TREES LESS THAN 6" WILL BE REMOVED TO COMPLETE THIS
PROJECT. THEY WILL BE REPLACED INCH FOR INCI-L WITH
TREES TOTALING THE SAME DIAMETER ANY REMAINING
DISTURBED AREA WILL HAVE MULCH APPLIED TO IT
Sketch:
Application Fee:
Once the application has been accepted. You will need to send a corresponding fee in with the appropriate DWR#. The

application fee is as follows (pursuant to G.S. 143-215.3D):
0 $240.00 for impacts to lake (below normal water level) of less than 1 acre
0 $570.00 for impacts to lake (below normal water level) of greater or equal to 1 acre
By digitally signing below, I certify that:
o I, the project proponent, hereby certifies that all information contained herein is true, accurate, and complete to the
best of my knowledge and belief
o 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.
o I agree that submission of this Shoreline Stabilization online form is a "transaction" subject to Chapter 66, Article 40 of
the NC General Statutes (the "Uniform Electronic Transactions Act');
o 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');
0 1 understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the Shoreline Stabilization online form.
Full Name:* Carissa Parker
Signature:
C415$4 r4 J�-

Initial Review
Is this accepted into the review
process?*
Project Number:* 20211145
Select Reviewer:*
Select Reviewing Office
Has payment been received?*
What amount is owed?*
rYes allo
Version:* 1
Amy Annino:eads\amannino
Asheville Regional Office - [phone]
r No Payment Needed
r Fee Received
r Need Fee - send electronic notification
r $240.00
f $570.00

ROBERT & SHIRLEY NORDBLOM
LAKE JAMES
OLD WILDLIFE CLUB 5
TO: NORTH CAROLINA DIVISION OF WATER RESOURCES
I GIVE CARISSA PARKER, OF BENNICK ENTERPRISES, LLC.,
PERMISSION TO SIGN AS MY AGENT ON MY APPLICATION FOR
SHORELINE STABILIZATION.
SIGNATURE (S) d tt
j me'��
DATE G / 21 202, 1

Contact Name*
Carissa Parker
Contact Email Address*
[e-mail]
Project Owner*
Robert & Shirley Nordblom
Project Name*
OWC 5
Project County*
McDowell
Owner Address:*
Street Address
19 Anchor Cove Ct
Address Line 2
aty
Bluffton
Postal / Zip axle
29910
Is this a transportation project?*
C Yes c: No
Type(s) of approval sought from the DWR:
F- 401 Water Quality Certification - W 401 Water Quality Certification -
Regular Express
F- Individual Permit F- Modification
W Shoreline Stabilization
Does this project have an existing project ID#?*
C Yes c: No
State / Province / Pegion
SC
Country
USA
Do you know the name of the staff member you would like to request a meeting with?
Amy Annino
Please give a brief project description be low and include location information.*
50' Shoreline stabilization by barge
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.
1 understand by signing this form that I cannot submit my application until 30 calendar days after this pre -filing
meeting request.
I 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 *
GA rS #,4 �A�q
Submittal Date 6/1/2021

Afovdblom State of North Carolina
Department of Environment and Natural Resources , IraDivision of Water Resources
Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL QUALITY FORM: SSGP 02-2017
Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
Full Pond/ Normal Water
Shoreline
Plan View
Lake
(At Full Pond/ Normal Water Level)
Old W IdGr� Gib
3
� l ,
3'x50,
FORM: SSGP 02-2017 Page 1 of 3