20201695 Ver 1_5180.1-Cottage Hill Sub_PCN_9.9.2021_20210909

Preliminary ORM Data Entry Fields for New Actions
ACTION ID 4: SAW- 2020-01267 Begin Date (Date Received): 9.9.21
Prepare file folder ❑ Assign Action ID Number in ORM ❑
1. Project Name [PCN Form A2a]: Cottage Hill Subdivision
2. Work Type: ZPrivate ❑Institutional ❑Government ❑ Commercial
3. Project Description / Purpose [PCN Form 133d and 133e]:
The site is proposed for single-family residential development.
4. Property Owner / Applicant [PCN Form A3 or A41: 806 Gibb Street, LLC
5. Agent / Consultant [PNC Form A5 — or ORM Consultant ID Number]:
Pilot Environmental, Inc.
6. Related Action ID Number(s) [PCN Form 135b]: SAW-2018-01547, Previous JD & PCN
7. Project Location —Coordinates, Street Address, and/or Location Description [PCN Form Blb]:
Gibb Street and Robinhood Road
36.1202040,-80.335039"
8. Project Location —Tax Parcel ID [PCN Form Bla]: Multiple -see attached (all same owner)
9. Project Location — County [PCN Form A2b]: Forsyth
10. Project Location — Nearest Municipality or Town [PCN Form A2c]: Winston-Salem
11. Project Information — Nearest Waterbody [PCN Form 132a]: Muddy Creek
12. Watershed / 8-Digit Hydrologic Unit Code [PCN Form 132c]: 03040101
Authorization: Section 10 ❑ Section 404 ❑✓
Regulatory Action Type:
❑ Standard Permit
✓ Nationwide Permit 4
Regional General Permit 9
Jurisdictional Determination Request
Section 10 and 404 ❑
❑Pre -Application Request
❑ Unauthorized Activity
❑ Compliance
❑ No Permit Required
Revised 20150602

ID#* 20201695
Version* 1
Regional Office * Winston-Salem Regional Office - [phone]
Reviewer List* Sue Homewood
Pre -Filing Meeting Request submitted 11/6/2020
Contact Name* Bradley S. Luckey
Contact Email Address* [e-mail]
Project Name* Cottage Hill Subdivision
Project Owner* 806 Gibb Street, LLC
Project County* Forsyth
Owner Address: Street Address
11 Brokestone Avenue
Address Line 2
aty
State / Province / Pegion
Winston-Salem
NC
Postal / Zip axle
Country
27101
USA
Is this a transportation project?* (' Yes (' No
Type(s) of approval sought from the DWR:
W 401 Water Quality Certification - F 401 Water Quality Certification -
Regular Express
F- Individual Permit F- Modification
F Shoreline Stabilization
Does this project have an existing project ID#?*
C Yes (-- No
Do you know the name of the staff member you would like to request a meeting with?
Sue Homewood
Please give a brief project description below.*
Applicant does not request a meeting. The applicant may submit a request
401 WQC.
Please give a couple of dates you are available for a meeting.

Please attach the documentation you would like to have the meeting about.
pdf only
By digitally signing below, I certify that I have read and understood that per the Federal Clean Water Act Section
401 Certification Rule the following statements:
This form completes the requirement of the Pre -Filing Meeting Request in the Clean Water Act Section 401 Certification
Rule.
1 understand by signing this form that I cannot submit my application until 30 calendar days after this pre -filing
meeting request.
1 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
r 0. .61 r�+.A,,
Submittal Date 11/6/2020

Proposal for Environmental Services
Pilot Proposal 5180.1
November 6, 2020
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: O L"BT ST'
IAI-S AI'C. 2?(0
Applicant Information:
Name: S r t LL
Address:
Telephone Number:
Fax Number:
E-mail Address:
Signature: ru—Date:— 7 is 0Z, /
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Print Property Info
Property Summary
Tax Year: 2019
REID 6806544996000 PIN 6806-54-4996 Property Owner 806 GIBB STREET LLC
Location Address 800 Gibb ST property Description L0071C BL3467 Owner's Mailing Address 11 BROOKSTOWN AVE
WINSTON-SALEM NC 27101
Administrative Data
Transfer Information
Property Value
Old Map #
600862
Deed Date
3/21/2018
Total Appraised Land Value
$53,700
Market Area
606865
Deed Book
003395
Total Appraised Building Value
$15,300
Township
WINSTON-SALEM
Deed Page
03030
Total Appraised Misc
Improvements Value
Planning Jurisdiction
COUNTY WIDE
Revenue Stamps
$153
Total Cost Value
$69,000
City
WINSTON-SALEM
Package Sale Date
3/21/2018
Total Appraised Value -valued By
$69,000
Fire District
Package Sale Price
$76,500
Cost
Spec District
Land Sale Date
Other Exemptions
Land Class
1.01-SFD Dwelling
Land Sale Price
Exemption Desc
History REID 1
Use Value Deferred
History REID 2
Improvement Summary
Historic Value Deferred
Acreage
3.82
Total Buildings
1
Total Deferred Value
Permit Date
Total Units
0
Total Taxable Value
$69,000
Permit #
Total Living Area
1,080
Total Gross Leasable Area
0
Building Summary
Card 1 800 Gibb ST
Building Details
Building Description
Building Total & Improvement Details
Bldg Type
RESIDENTIAL
Year Built 1905 Effective Year 1960
Grade
C-10
90%
Units
0
Additions 6 Remodeled 1964
Percent Complete
100
Living Area (SQFT)
1080
Interior Adj
Total Adjusted Replacement
$85,977Cost
Number of Stories
1.00
Other Features
New
Style
RANCH
AVER
Physical Depreciation (% Bad)
Foundation
MASONRY
7ER
Frame
MASONRY
Depreciated Value
$18,055
Exterior
BRICK
Economic Depreciation (%
15
Bad)
Const Type
Functional Depreciation (%
0
HeatingForced
Warm
Bad)
Air
Total Depreciated Value
$15,347
Air Cond
NONE
Market Area Factor
1
Baths (Full)
1
Building Value
$15,300
Baths (Half)
0
Misc Improvements Value
Extra Fixtures
0
Total Improvement Value
$15,300
Total Plumbing
3
Fixtures
Assessed Land Value
Bedrooms
2
Assessed Total Value
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9/20/2019
Print Property Info
Floor
CONCRETE
Roof Cover
Asphalt Shingle
Roof Type
GABLE
Main Body (SQFT)
1080
Addition Summary
Story
Type
LANDING LC
LANDING LC
CARPORT AVERAGE
BASEMENT-UNFIN-CF
LANDING LC-R
LANDING LC-R
Building Sketch
Photograph
Misc Improvements Summary
Code
Area
LAND
20
LAND
20
CARP
392
BASE
120
LAND
1
LAND
1
Card Unit Base Eff Phys Depr Econ Depr Funct Depr MigrAdj (% Common Interest
# Quantity Measure Type Price Year (% Bad) (% Bad) (% Bad) Good) (% Good) Value
1 1 SIZE BARN- $5.60 2017 4 15 0 22
FIRM
Total Misc Improvements Value Assessed:
Land Summary
Land Class: 1.01-SFD Dwelling Deeded Acres: 3.82
Zoning Soil Class Description Size
RS9 RES-HOMESITE 1.00 BY THE ACRE PRICE
RS9 RES-ACREAGE 2.82 BY THE ACRE PRICE
Total Land Value Assessed: $53,700
Ownership History
Owner Name
Current 806 GIBB STREET LLC
1 Back Samuel M Lineback Irrevocable Trust/ Lineback,
Samuel Thomas Trustee/ Mustin, Cheryl L Trustee/
Lineback, Phillip Wayne Trustee
2 Back Lineback, Samuel M
3 Back Lineback, Samuel M
4 Back Lineback, Samuel M/ Lineback, Beulah R
Calculated Acres: 3.71
Rate Land Adjustment Land Value
$55,500 LOCATION-60.00 $18,600
TOPOGRAPHY-70.00
ACCESS-80.00
$37,000 LOCATION-60.00 $35,100
TOPOGRAPHY-70.00
ACCESS-80.00
%
Sale
Deed Type
Stamps
Book
Page
Deed Date
Ownership
Price
WARRANTY-
100
153
$76,500 003395
03030
3/21/2018
DEED
DEED
100
0
003099
01304
2/14/2014
DEED
100
0
003099
01304
12/31/2012
DEED
100
0
002867
02873
7/30/2009
DEED
100
0
002867
02873
1/2/2009
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Owner Name
5 Back Lineback, Samuel Monroe
Notes Summary
Building Card
No Data
Print Property Info
Deed Type % Stamps Sale
Ownership Price
DEED 100 0
Date
Line
Book Page Deed Date
001033 00429 1/12/1972
Notes
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9/20/2019
Property Summary
Tax Year: 2019
REID 6806548860000 PIN
Location 803 Gibb ST property
Address Description
Administrative Data
Old Map #
606862
Market Area
606865
Township
WINSTON-SALEM
Planning
COUNTY WIDE
Jurisdiction
City
WINSTON-SALEM
Fire District
Spec District
91.00-Vacant SF
Land Class
Res
History REID 1
History REID 2
Acreage 7.7
Permit Date
Permit #
Building Summary
Misc Improvements Summary
Card Unit Measure Type Base
# Quantity Price
No Data
Total Misc Improvements Value Assessed:
Print Property Info
6806-54-8860 Property Owner
L0501 BL3467 PL68-
006 Owner's Mailing
Address
Transfer Information
Deed Date
Deed Book
Deed Page
Revenue Stamps
Package Sale Date
Package Sale Price
Land Sale Date
Land Sale Price
Improvement Summary
Total Buildings
Total Units
Total Living Area
Total Gross Leasable Area
3/21 /2018
003395
03040
806 GIBB STREET LLC
11 BROOKSTOWN AVE
WINSTON-SALEM NC
27101
Property Value
Total Appraised Land Value
$139,900
Total Appraised Building Value
Total Appraised Misc
Improvements Value
Total Cost Value
$139,900
Total Appraised Value -valued
$139,900
By cost
Other Exemptions
Exemption Desc
Use Value Deferred
Historic Value Deferred
Total Deferred Value
Total Taxable Value
$139,900
Eff Phys Depr (% Econ Depr (% Funct Depr (% Common Interest (% Value
Year Bad) Bad) Bad) Good)
Land Summary
Land Class: 91.00-Vacant SF Res Deeded Acres: 7.7
Zoning Soil Class Description Size
RS9 RES-ACREAGE 7.70 BY THE ACRE PRICE
Total Land Value Assessed: $139,900
Ownership History
Owner Name Deed Type
Current 806 GIBB STREET LLC WARRANTY -DEED
Calculated Acres: 7.7
Rate Land Adjustment Land Value
$37,000 LOCATION-85.00 $139,900
TOPOGRAPHY-80.00
SHAPE-95.00
ACCESS-80.00
EASEMENT-95.00
% Ownership Stamps Sale Price Book Page Deed Date
100 0 003395 03040 3/21/2018
Notes Summary
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Building Card
Print Property Info
Date Line Notes
No Data
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Print Property Info
Property Summary
Tax Year: 2019
REID 6806555323000 PIN
Location Address 806 Gibb ST pro
Administrative Data
6806-55-5323 Property Owner 806 GIBB STREET LLC
perty Description L0071 B BL3467 Owner's Mailing Address 11 BROOKSTOWN AVENUE
WINSTON-SALEM NC 27101
Old Map #
600862
Market Area
606865
Township
WINSTON-SALEM
Planning Jurisdiction
COUNTY WIDE
City
WI NSTON-SALEM
Fire District
Spec District
Land Class
1.01-SFD Dwelling
History REID 1
History REID 2
Acreage
0.8
Permit Date
Permit #
Building Summary
Card 1 806 Gibb ST
Building Details
Bldg Type
RESIDENTIAL
Units
0
Living Area (SQFT)
1500
Number of Stories
1.00
Style
RANCH
Foundation
MASONRY
Frame
MASONRY
Exterior
BRICK
Const Type
Heating
Forced Warm Air
Air Cond
NONE
Baths (Full)
1
Baths (Half)
0
Extra Fixtures
0
Total Plumbing
3
Fixtures
Bedrooms
3
Transfer Information
Deed Date
3/21/2018
Deed Book
003395
Deed Page
03020
Revenue Stamps
$170
Package Sale Date
3/21/2018
Package Sale Price
$85,000
Land Sale Date
Land Sale Price
Improvement Summary
Total Buildings 1
Total Units 0
Total Living Area 1,500
Total Gross Leasable Area 0
Building Description
Year Built 1958 Effective Year 1988
Additions 5 Remodeled 0
ADD FIREPLACE
AVERAGE (1.00)
Interior Adj FIREPLACE
AVERAGE (2.00)
Other Features
Property Value
Total Appraised Land Value
$31,200
Total Appraised Building Value
$85,200
Total Appraised Misc
$200
Improvements Value
Total Cost Value
$116,600
Total Appraised Value -valued
$116,600
By cost
Other Exemptions
Exemption Desc
Use Value Deferred
Historic Value Deferred
Total Deferred Value
Total Taxable Value
$116,600
Building Total & Improvement Details
Grade
C+5
105%
Percent Complete
100
Total Adjusted Replacement
$156,527
Cost New
Physical Depreciation (%
AVER
Bad)
36%
Depreciated Value
$100,177
Economic Depreciation (%
15
Bad)
Functional Depreciation (%
0
Bad)
Total Depreciated Value
$85,150
Market Area Factor
1
Building Value
$85,200
Misc Improvements Value
$200
Total Improvement Value
$85,400
Assessed Land Value
Assessed Total Value
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9/24/2019
Print Property Info
CARPET -
Floor
HARDWOOD
Roof Cover Asphalt Shingle
Roof Type GABLE
Main Body (SQFT) 1500
Addition Summary
Story Type
Code
Area
CARPORT AVERAGE
CARP
440
PATIO AVERAGE
PATI
220
LANDING GOOD
LAND
15
BASEMENT-UNFIN-CF
BASE
1500
LANDING GOOD-R
LAND
1
Building Sketch
Photograph
Misc Improvements Summary
Card Unit Base Eff
Phys Econ
Funct
Migr Adj
Common
Measure Type Price Year
# Quantity
Depr (% Depr (%
Depr (% (/o o Good)
Interest (% Value
Bad) Bad)
Bad)
Good)
1 24x20 DIMENSIONS GAR/CB/FLOOR/FIN $25.00 2017
2
0 0 3
$200
Total Misc Improvements Value Assessed: $200
Land Summary
Land Class: 1.01-SFD Dwelling Deeded Acres: 0.8
Calculated Acres: 0.8
Zoning Soil Class Description Size
Rate
Land Adjustment
Land Value
RS9 RES-LOT 1.00 BY THE UNIT PRICE $27,500
LOCATION-105.00
$31,200
ACCESS-90.00
SIZE ADJUSTMENT-120.00
Total Land Value Assessed: $31,200
Ownership History
Owner Name
Current 806 GIBB STREET LLC
1 Back Samuel M Lineback Irrevocable Trust/ Lineback,
Samuel Thomas Trustee/ Mustin, Cheryl L Trustee/
Lineback, Phillip Wayne Trustee
2 Back Lineback, Samuel M
3 Back Lineback, Samuel M
4 Back Lineback, Samuel M/ Lineback, Beulah R
5 Back Lineback, Samuel Monroe
6 Back Lineback, Samuel Monroe
7 Back Lineback, Samuel Monroe
%
Sale
Deed Type
Stamps
Book
Page
Deed Date
Ownership
Price
WARRANTY-
100
170
$85,000 003395
03020
3/21/2018
DEED
DEED
100
0
003099
01304
2/14/2014
DEED
100
0
003099
01304
12/31/2012
DEED
100
0
002867
02873
7/30/2009
DEED
100
0
002867
02873
1/2/2009
DEED
100
0
000000
00000
1/1/2005
DEED
100
0
000000
00000
1/1/2001
DEED
100
0
000000
00000
1/1/1997
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9/24/2019
Notes Summary
Building Card
No Data
Print Property Info
Date Line Notes
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9/24/2019
Property Summary
Tax Year: 2019
Print Property Info
REID 6806555433000 PIN 6806-55-5433 Property Owner 806 GIBB STREET LLC
Location Address 800 Gibb ST property Description L0071A BL3467 Owner's Mailing Address 11 BROOKSTOWN AVE
WINSTON-SALEM NC 27101
Administrative Data
Old Map #
600862
Market Area
606865
Township
WINSTON-SALEM
Planning
COUNTY WIDE
Jurisdiction
City
WINSTON-SALEM
Fire District
Spec District
91.00-Vacant SF
Land Class
Res
History REID 1
History REID 2
Acreage 0.53
Permit Date
Permit #
Building Summary
Misc Improvements Summary
Card Unit Measure Type Base
# Quantity Price
No Data
Total Misc Improvements Value Assessed:
Transfer Information
Deed Date
Deed Book
Deed Page
Revenue Stamps
Package Sale Date
Package Sale Price
Land Sale Date
Land Sale Price
Improvement Summary
Total Buildings
Total Units
Total Living Area
Total Gross Leasable Area
3/21 /2018
003395
03035
$50
3/21 /2018
$25,000
Property Value
Total Appraised Land Value
$16,600
Total Appraised Building Value
Total Appraised Misc
Improvements Value
Total Cost Value
$16,600
Total Appraised Value -valued By
$16,600
Cost
Other Exemptions
Exemption Desc
Use Value Deferred
Historic Value Deferred
Total Deferred Value
Total Taxable Value
$16,600
Eff Phys Depr (% Econ Depr (% Funct Depr (% Common Interest (% Value
Year Bad) Bad) Bad) Good)
Land Summary
Land Class: 91.00-Vacant SF Res Deeded Acres: 0.53
Zoning Soil Class Description Size
RS9 RES-LOT 1.00 BY THE UNIT PRICE
Total Land Value Assessed: $16,600
Ownership History
Owner Name
Current 806 GIBB STREET LLC
Calculated Acres: 0.53
Rate Land Adjustment
$27,500 UTILITY-80.00
LOCATION-105.00
SHAPE-90.00
ACCESS-80.00
Land Value
$16,600
Deed Type % Stamps Sale Book Page Deed Date
Ownership Price
WARRANTY- 100 50 $25,000 003395 03035 3/21/2018
DEED
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[:I`zl-` 11R1
Owner Name
1 Back Samuel M Lineback Irrevocable Trust/ Lineback,
Samuel Thomas Trustee/ Mustin, Cheryl L Trustee/
Lineback, Phillip Wayne Trustee
2 Back Lineback, Samuel M
3 Back Lineback, Samuel M/ Lineback, Beulah R
4 Back Lineback, Samuel Monroe
5 Back Lineback, Samuel Monroe
6 Back Lineback, Samuel Monroe
Notes Summary
Building Card
No Data
Print Property Info
%
Sale
Deed Type
Stamps
Book
Page
Deed Date
Ownership
Price
DEED
100
0
003099
01304
2/14/2014
DEED
100
0
003099
01304
12/31/2012
DEED
100
0
002867
02873
1/2/2009
DEED
100
0
000000
00000
1/1/2005
DEED
100
0
000000
00000
1/1/2001
DEED
100
0
000000
00000
1/1/1997
Date Line Notes
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9/20/2019
Property Summary
Tax Year: 2019
Print Property Info
REID 6806558602000 PIN 6806-55-8602 Property Owner 806 GIBB STREET LLC
Location Address 4230 Robinhood RD property Description L0131 BL3467 Owner's Mailing Address 11 BROOKSTOWN AVE
WINSTON-SALEM NC 27101
Administrative Data
Transfer Information
Old Map #
600862
Deed Date
Market Area
606865
Deed Book
Township
WINSTON-SALEM
Deed Page
Planning
COUNTY WIDE
Revenue Stamps
Jurisdiction
Package Sale Date
City
WINSTON-SALEM
Package Sale Price
Fire District
Land Sale Date
Spec District
Land Sale Price
Land Class
91.00-Vacant SF
Res
Improvement Summary
History REID 1
Total Buildings
History REID 2
Total Units
Acreage
2.54
Total Living Area
Permit Date
Total Gross Leasable Area
Permit #
Building Summary
Misc Improvements Summary
Card Unit Measure Type Base
# Quantity Price
No Data
Total Misc Improvements Value Assessed:
3/21 /2018
003395
03048
$148
3/21 /2018
$74,000
Property Value
Total Appraised Land Value
$42,900
Total Appraised Building Value
Total Appraised Misc
Improvements Value
Total Cost Value
$42,900
Total Appraised Value -valued By
$42,900
Cost
Other Exemptions
Exemption Desc
Use Value Deferred
Historic Value Deferred
Total Deferred Value
Total Taxable Value
$42,900
Eff Phys Depr (% Econ Depr (% Funct Depr (% Common Interest (% Value
Year Bad) Bad) Bad) Good)
Land Summary
Land Class: 91.00-Vacant SF Res Deeded Acres: 2.54
Zoning Soil Class Description Size
RS9 RES-LOT 1.00 BY THE UNIT PRICE
Total Land Value Assessed: $42,900
Ownership History
Owner Name Deed Type
Current 806 GIBB STREET LLC WARRANTY -DEED
1 Back Easter, William T/ Easter, Mary Jones DEED
2 Back Easter, William T/ Easter, Mary Jones DEED
Calculated Acres: 2.54
Rate Land Adjustment Land Value
$27,500 UTILITY-80.00 $42,900
LOCATION-85.00
TOPOGRAPHY-90.00
SHAPE-85.00
SIZE ADJUSTMENT-300.00
% Ownership Stamps Sale Price Book Page Deed Date
100 148 $74,000 003395 03048 3/21/2018
100 0 002410 00673 6/30/2008
100 0 002410 00673 10/3/2003
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9/20/2019
Notes Summary
Building Card
No Data
Print Property Info
Date Line Notes
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9/20/2019
Property Summary
Tax Year: 2019
Print Property Info
REID 6806559337000 PIN
6806-55-9337 Property Owner 806 GIBB STREET LLC
Location Address 0 Gibb ST Property
Description L0077 BL3467 Owner's Mailing Address 11 BROOKSTOWN AVE
WINSTON-SALEM NC 27101
Administrative Data
Transfer Information
Property Value
Old Map # 600862
Deed Date 3/21/2018
Total Appraised Land Value $57,200
Market Area 606865
Deed Book 003395
Total Appraised Building Value
Township WINSTON-SALEM
Deed Page 03045
Total Appraised Misc
Improvements Value
Planning COUNTY WIDE
Revenue Stamps $131
Jurisdiction
Total Cost Value $57,200
Package Sale Date
City WINSTON-SALEM
Total Appraised Value -valued By $57,200
Package Sale Price
Fire District
Cost
Land Sale Date 3/21/2018
Other Exemptions
Spec District
Land Sale Price $65,500
Exemption Desc
Land Class 91.00-Vacant SF
Res
Use Value Deferred
Improvement Summary
History REID 1
Historic Value Deferred
Total Buildings
0
History REID 2
Total Deferred Value
Total Units
0
Acreage 3.26
Total Taxable Value $57,200
Total Living Area
0
Permit Date
Total Gross Leasable Area
0
Permit #
Building Summary
Misc Improvements Summary
Card Unit Base
Measure Type
Eff Phys Depr (% Econ Depr (%
Funct Depr (% Common Interest (%
Value
# Quantity Price
Year Bad) Bad)
Bad) Good)
No Data
Total Misc Improvements Value Assessed:
Land Summary
Land Class: 91.00-Vacant SF Res
Deeded Acres: 3.26
Calculated Acres: 3.28
Zoning Soil Class Description
Size
Rate Land Adjustment
Land Value
RS9 RES-LOT
1.00 BY THE UNIT PRICE
$27,500 UTILITY-80.00
$57,200
LOCATION-85.00
TOPOGRAPHY-85.00
SHAPE-90.00
SIZE ADJUSTMENT-400.00
Total Land Value Assessed: $57,200
Ownership History
Owner Name
Deed Type % Ownership
Stamps Sale Price Book Page
Deed Date
Current 806 GIBB STREET LLC
WARRANTY -DEED
100 131 $65,500 003395 03045
3/21/2018
1 Back Fishel, Aubrey S
DEED
100 35 $35,000 001657 02987
12/29/1988
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9/20/2019
Notes Summary
Building Card
No Data
Print Property Info
Date Line Notes
tellus.co.forsyth.nc.us/Ircpwa/PrintPRC.aspx?PARCELPK=53403 2/2

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9/24/2019 Print Property Info
Property Summary
Tax Year: 2020 - Value subject to change, property assessment under review
REID 6806559830000 PIN 6806-55-9830
0 Robinhood RECOMBINATION SURVEY FOR ARDEN GROUP
Location RD Property L0079A BL3467 PL69-063
Address Description
Administrative Data
Transfer Information
Old Map #
600862
Deed Date
Market Area
606865
Deed Book
Township
WINSTON-SALEM
Deed Page
Planning
COUNTY WIDE
Revenue Stamps
Jurisdiction
Package Sale Date
City
WINSTON-SALEM
Package Sale Price
Fire District
Land Sale Date
Spec District
Land Sale Price
Land Class
91.00-Vacant SF
Res
Improvement Summary
History REID 1
Total Buildings
History REID 2
Total Units
Acreage
0.13
Total Living Area
Permit Date
Total Gross Leasable Area
Permit #
Building Summary
Misc Improvements Summary
Card Unit Measure Type Base
# Quantity Price
No Data
Total Misc Improvements Value Assessed:
2/6/2019
003445
00779
$24
2/6/2019
$12,000
o
Property Owner 806 GIBB STREET
LLC
11 BROOKSTOWN
Owner's Mailing AV
Address WINSTON-SALEM
NC 27101
Property Value
Total Appraised Land Value
Total Appraised Building Value
Total Appraised Misc Improvements
Value
Total Appraised Value
Other Exemptions
Exemption Desc
Use Value Deferred
Historic Value Deferred
Total Deferred Value
Total Taxable Value
Eff Phys Depr (% Econ Depr (% Funct Depr (% Common Interest (% Value
Year Bad) Bad) Bad) Good)
Land Summary
Land Class: 91.00-Vacant SF Res Deeded Acres: 0.13
Zoning Soil Class Description Size
RS9 RES-LOT 1.00 BY THE UNIT PRICE
Total Land Value Assessed:
Ownership History
Owner Name Deed Type
Current 806 GIBB STREET LLC DEED
1 Back 806 GIBB STREET LLC QUITCLAIM -DEED
2 Back HARRISON. SHARON/ DEMBINSKI. MARK WARRANTY -DEED
Calculated Acres: 0.13
Rate Land Adjustment
$0 LOCATION-65.00
SIZE ADJUSTMENT-65.00
Land Value
% Ownership
Stamps
Sale Price Book
Page
Deed Date
100
24
$12,000 003445
00779
2/6/2019
100
0
003445
00783
2/6/2019
100
0
003330
02277
1 /31 /2017
tellus.co.forsyth.nc.us/Ircpwa/PrintPRC.aspx?PARCELPK=174580 1 /2

9/24/2019
Notes Summary
Building Card
No Data
Print Property Info
Date Line Notes
tellus.co.forsyth.nc.us/Ircpwa/PrintPRC.aspx?PARCELPK=174580 2/2

NORTH CAROLINA
Environmental Quality
Water Resources
Office Use Only
Corps Action ID no. SAW-2020-01267 Date received: [Click to enter.]
DWR project no. 20201695 Date received: [Click to enter.]
Site Coordinates:
Latitude (DD.DDDDDD): 36.119734'
Longitude (DD.DDDDDD): 80.335026'
Form Version 1.5, September 2020
Pre -Construction Notification (PCN) Form
(Ver. 1.5, September 2020)
For Nationwide Permits and Regional General Permits and corresponding Water Quality Certifications
Please note: fields marked with a red asterisk are required. The form is not considered complete until all mandatory
questions are answered.
The online help file may be found at this link:
https:Hedocs.deg.nc.gov/WaterResources/0/edocl6247041PCN%2OHelp%2OFile%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) : 11/6/2020
DWR ID # 20201695 Version 1 (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,
❑ Yes ❑x No
or airport project)
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.
❑x Section 404 Permit (wetlands, streams, waters,
Clean Water Act)
la. Type(s) of approval sought from the Corps:
❑ Section 10 Permit (navigable waters, tidal
waters, Rivers and Harbors Act)
Pagel of 21 PCN Form - Version 1.5, September 2020

❑x Nationwide Permit (NWP)
1 b. Permit type(s)?
❑ Regional General Permit (RGP)
❑ Standard (IP)
This form may be used to initiate the standard/ individual permit process with the USACE. Please contact your Corps
representative concerning submittals for standard permits. All required items can be included as separate attachments
and submitted with this form.
1 c. Has the NWP or GP number been verified by the Corps?
❑ Yes ❑x No
NWP number(s):
NWP 29
RGP number(s):
Click to enter.
1d. Type(s) of approval sought from the DWR (check all that apply):
❑x 401 Water Quality Certification — Regular ❑ 401 Water Quality Certification— Express
❑ Non-404 Jurisdictional General Permit ❑ Riparian Buffer Authorization
❑ Individual 401 Water Quality Certification
1e. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification: *
❑ Yes ❑x No
For the record only for Corps Permit: *
❑ Yes ❑x No
1f. Is this an after -the -fact permit/certification application?
❑ Yes ❑x No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts?
❑ Yes ❑x No
If yes, attach the acceptance letter from mitigation bank or in -lieu fee program.
1 h. Is the project located in any of NC's twenty coastal counties?
❑ Yes ❑x No
1 i. Is the project located within an NC DCM Area of Environmental
Concern (AEC)?
❑ Yes ❑x No ❑ 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
1 a.
Who is the primary contact?
Justin Mendenhall
1 b.
Primary Contact Email:
[e-mail]
1 c.
Primary Contact Phone: (###)###-####
[phone]
1 d.
Who is applying for the permit/certification? (check
all that apply)
® Owner ❑ Applicant (other than owner)
1 e.
Is there an agent/consultant for this project?
® Yes ❑ No
2.
Landowner Information
2a.
Name(s) on Recorded Deed:
806 Gibb Street LLC
2b.
Deed Book and Page No.:
3395/3048
2c.
Responsible Party (for corporations):
Justin Mendenhall
2d.
Address
Street Address:
11 Brookstown Avenue
Address line 2:
-;licktu IVI RIM.
City:
Winston-Salem
State/ Province/ Region:
North Carolina
Postal/ Zip Code:
27101
Country:
U.S.
2e.
Telephone Number: * (###)###-####
[phone]
2f.
Fax Number: (###)###-####
Click to eniei.
2g.
Email Address: *
[e-mail]
3.
Applicant Information (if different from owner)
3a.
Name:
Click to enter.
3b.
Business Name (if applicable):
Click to enter.
3c.
Address:
Street Address:
Click to enter.
Address line 2:
Click to enter.
City:
Click to enter.
State/ Province/ Region:
Click to enter.
Postal/ Zip Code:
Click to enter.
Country
Click to enter.
3d.
Telephone Number: * (###)###-####
Click to enter.
3e
Fax Number: (###)###-####
Click to enter.
Page 3 of 21 PCN Form - Version 1.5, September 2020

3f. Email Address: Click to enter.
4. Agent/ Consultant (if applicable)
4a. Name: *
Michael T. Brame
4b. Business Name:
Pilot Environmental, Inc.
4c. Address: *
Street Address:
743 Park Lawn Court
Address line 2:
Click to enter.
City:
Kernersville
State/ Province/ Region:
NC
Postal/ Zip Code:
27284
Country:
U.S.
4d. Telephone Number: * (###)###-####
[phone]
4e Fax Number: (###)###-####
Click to enter.
4f. Email Address: *
[e-mail]
Agent Authorization Letter:
Attach a completed/signed agent authorization form or letter. A sample form may be found at this link:
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
la. Name of project: *
Cottage Hills Subdivision
1 b. Subdivision name (if appropriate):
Cottage Hills
1 c. Nearest municipality/town: *
Winston-Salem, NC
2.
Project Identification
2a.
Property identification number (tax PIN or parcel ID):
6806-64-0766.00
2b.
Property size (in acres):
18
2c.
Project Address:
Street Address:
Gibb Street
Address line 2:
Click to enter.
City:
Winston-Salem
State/ Province/ Region:
NC
Postal/ Zip Code:
27101
Country:
U.S.
2d.
Site coordinates in decimal degrees (using 4-6 digits
after the decimal point): *
Latitude (DD.DDDDDD): 36.119734'
Longitude (-DD.DDDDDD):-80.335026'
3. Surface Waters
3a. Name of nearest body of water to proposed project:
Muddy Creek
3b. Water Resources Classification of nearest receiving
Class C
water:
The Surface Water Classification map may be found at this link:
https://ncdenr.maps.arcqis.com/apps/webappviewer/index.html?id=6e125ad7628f494694e259c80dd64265
Yadkin-PeeDee
3c. In what river basin(s) is your project located?
Choose additional (if needed)
3d. Please provide the 12-digit HUC in which the project is
030401011303
located:
The Find Your HUC map may be found at this link:
https://ncdenr.maps.arcgis.com/apps/Publiclnformation/index.html?appid=ad3a85aOc6d644aOb97cdO69db238ac3
Page 5 of 21 PCN Form - Version 1.5, September 2020

4.
Project Description and History
4a.
Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of
this application:
The western portion of the site has been cleared and graded and contains single family residential lots.
Residences have been constructed on several of the lots and additional residences are under construction on
other lots. The remainder of the site contains wooded land. The site is located in a residential area of Winston-
Salem.
4b.
Have Corps permits or DWR certifications been obtained for this
® Yes ❑ No ❑ Unknown
project (including all prior phases) in the past?
4c.
If yes, please give the DWR Certification number and/or Corps
SAW-2020-01267
Action ID (ex. SAW-0000-00000):
jClick to enter.]
Attach any pertinent project history documentation
4d.
Attach an 8'h x 11" excerpt from the most recent version of the USGS topographic map indicating the location of
the project site.
4e.
Attach an 8'h 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
0.15 acres
property:
4g.
List the total estimated linear feet of all existing streams (intermittent
890 linear feet
and perennial) on the property:
4g1.
List the total estimated acreage of all existing open waters on the
0 acres
property:
4h.
Explain the purpose of the proposed project:
The purpose of the proposed project is to construct a 29 lot single family residential subdivision.
4i.
Describe the overall project in detail, including the type of equipment to be used:
The overall project includes the construction of a 29 lot single family residential subdivision. In order to facilitate the
proposed development and access three of the lots, it is necessary to cross a stream. 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 ® Yes ❑ No ❑ Unknown
proposed impact areas?
Comments:
The site was delineated by Pilot Environmental on September 26, 2019. Pilot submitted a PJD request on 11.25.2020.
Pilot was notified by Mr. Rhoden -Reynolds with the USACE that the Corps issued a NWP 29 and a PJD for this area to
the Arden Group on October 2, 2018 (Corps Action ID SAW-2018-01547). Pilot was not involved in the previous
delineation or permitting activities and has not been provided with a copy of the PJD or PCN.
Based on conversations with Mr. Steve Causey with Allied Engineering, the crossing was initially designed by another
engineering group and permitted for a public road under the former site plan. The road has since been redesigned to
be a private drive. The private drive is narrower and will reduce the impacts that were previously proposed and
permitted. The purpose of this application is to provide information for the new proposed impacts and request a permit
modification or a new PCN (USACE discretion).
Page 6 of 21 PCN Form - Version 1.5, September 2020

Name (if known): David Brame/Michael Brame
5b. If 5a is yes, who delineated the jurisdictional
Agency/Consultant Company: Pilot Environmental
areas?
Other: Previously delineated by others as well.
5c. If the Corps made a jurisdictional determination,
0 Preliminary ❑ Approved ❑ Emailed Concurrence
what type of determination was made?
❑ Not Verified ❑ Unknown
Corps AID number (ex. SAW-0000-00000):
SAW — 2018-01547
5d. List the dates of the Corps jurisdictional determination or State determination if a determination was made by
either agency.
USACE issued a PJD and a PCN. Pilot does not have copies of the PJD or PCN. Mr. Rhoden -Reynolds
indicated that the USACE has them on file.
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.
'lick 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
Impacts Summary
1 a. Where are the impacts associated with your project
(check all that apply):
❑ Wetlands
❑ Buffers
❑ Pond Construction
❑x Streams - tributaries
❑ Open Waters
2. Wetland Impacts
If there are wetland impacts proposed on the site, complete this table for each wetland area impacted.
2a.
2a1.
2b.
2c.
2d.
2e.
2f.
2g.
Site #
Impact
Impact
Wetland Name
Wetland Type*
Forested
Jurisdiction
Impact Area
Reason/Type
Duration
?*
Type*
(ac)
W1
Choose one
Temp/
Click to enter
Choose one
Y/N
Choose one
Click to
Perm
enter
W2
Choose one
Temp/
Click to enter
Choose one
Y/N
Choose one
Click to
Perm
enter
W3
Choose one
Temp/
Click to enter
Choose one
Y/N
Choose one
Click to
Perm
enter
W4
Choose one
Temp/
Click to enter
Choose one
Y/N
Choose one
Click to
Perm
enter
W5
Choose one
Temp/
Click to enter
Choose one
Y/N
Choose one
Click to
Perm
enter
W6
Choose one
Temp/
Click to enter
Choose one
Y/N
Choose one
Click to
Perm
enter
2g1. Total temporary wetland impacts
Click to enter. ac
2g2. Total permanent wetland impacts
Click to enter. ac
2g3. Total wetland impacts
Click to enter. ac
2h. Comments:
Wetland impacts have been avoided and are not proposed.
Page 9 of 21 PCN Form - Version 1.5, September 2020

3.
Stream Impacts
If there are perennial or intermittent stream/ tributary impacts (including temporary impacts) proposed on the site,
complete this table for all stream/ tributary sites impacted.
** All Perennial or Intermittent streams must be verified by DWR or delegated local government
Site #
3a.
Impact Reason/
Type
3b.
Impact
Duration
3d.
Stream Name
3e.
Stream
Type
3f.
Jurisdiction
Type
3g.
Stream Width
(avg ft)
3h.
Impact length
(linear ft)
S1
Crossing/ Culvert
Permanent
Unnamed
Perennial
Both
5
64/34
S2
Dewatering
Temporary
Unnamed
Perennial
Both
5
12
S3
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S4
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S5
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S6
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S7
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S8
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S9
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S10
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S11
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S12
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S13
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S14
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S15
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
3i1.
Total jurisdictional ditch impact:
Click to enter. linear ft
3i2.
Total permanent stream impacts:
64/34 linear ft
36.
Total temporary stream impacts:
12 linear ft
3i4.
Total stream and ditch impacts:
110 linear ft
3j.
Comments:
64 linear feet (320 square feet or 0.0073 acres) of stream channel will be permanently impacted with a culvert
and associated fill. 34 linear feet (170 square feet or 0.0039 acres) of stream channel will be permanently
impacted with rip rap that is to be keyed in. 12 linear feet (60 square feet or 0.0014 acres) of stream channel will
be temporarily impacted by a cofferdam and associated pump around.
The total permanent stream impacts (excluding keyed -in rip rap) is to 64 linear feet (0.0073 acres) of stream
impact. It is below the mitigation threshold. Therefore, mitigation should not be required and is 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.
4b.
4c.
4d.
4e.
4e1.
4f.
Site #
Impact Reason/
Impact
Waterbody Name
Waterbody
Jurisdiction
Impact area (ac)'
Type
Duration
Type*
Type
01
Choose one
Temp/
Click to enter.
Choose one
Choose one
Click to enter.
Perm
02
Choose one
Temp/
Click to enter.
Choose one
Choose one
Click to enter.
Perm
03
Choose one
Temp/
Click to enter.
Choose one
Choose one
Click to enter.
Perm
04
Choose one
Temp/
Click to enter.
Choose one
Choose one
Click to enter.
Perm
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.
5b.
5c.
5d.
5e.
Pond ID
Proposed use or
Wetland Impacts
(ac)
Stream
Impacts (ft)
Upland
#
purpose of pond
Impacts (ac)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
Click to
Click tL
Click to
Click to
Click to
Click to
Click to
enter.
enter.
enter.
enter.
enter.
enter.
enter.
P2
Choose one
Click to
Click to
Click to
Click to
Click to
Click to
Click to
enter.
enter.
enter.
enter.
enter.
enter.
enter.
5f.
Total
Click to
Click to
Click to
Click to
Click to
Click to
Click to
enter.
enter.
enter.
enter.
enter.
enter.
enter.
5g.
Comments:
Pond or lake construction is not proposed.
5h.
Is a dam high hazard permit required?
❑ Yes ❑ No
If yes, permit ID no.:
Click to enter.
5i.
Expected pond surface area (acres):
Click to enter.
5j.
Size of pond watershed (acres):
Click to enter.
5k.
Method of construction:
Click to enter.
Page 11 of 21 PCN Form - Version 1.5, September 2020

6. Buffer Impacts (DWR requirement)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts.
6a. Project is in which protected basin(s)?
(Check all that apply.)
❑ Neuse ❑ Tar -Pamlico ❑ Catawba
❑ Jordan ❑ Goose Creek ❑ Randleman
❑ Other: Click to enter.
Site #*
6b.
Impact Type*
6c.
Impact Duration*
6d.
Stream Name*
6e.
Buffer
Mitigation
Required?*
6f.
Zone 1 Impact*
(sq ft)
6g.
Zone 2 Impact*
(sq ft)
B1
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B2
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B3
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B4
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B5
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B6
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B7
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B8
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B9
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B10
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
6h. Total temporary impacts:
Zone 1: Click to enter. sq ft
Zone 2: Click to enter. sq ft
6h. Total permanent impacts:
Zone 1: Click to enter. sq ft
Zone 2: Click to enter. sq ft
6h. Total combined buffer impacts:
Zone 1: Click to enter. sq ft
Zone 2: Click to enter. sq ft
6i. Comments:
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:
The applicant has designed the proposed development to avoid impacts to other streams and wetlands. A headwall
and endwall are designed to minimize impacts to the stream. Rip rap is being keyed in to the existing bed to maintain
the current stream bed. The remaining roads, lots and utilities have been designed to avoid additional impacts to
jurisdictional areas.
1 b. Specifically describe measures taken to avoid or minimize proposed impacts through construction techniques:
The clearing limits will be surveyed, staked and silt fencing and clearing limit fencing will be used. Coffer dams will be
used to minimize sediment discharge during construction activities. Disturbed areas will be seeded and mulched to
limit sediment from entering downgradient waters. Slope matting will be used on steep slopes.
2. Compensatory Mitigation for Impacts to Waters of the U.S., Waters of the State, or Riparian Buffers
2a. If compensatory mitigation is required, by whom is it required? * ❑ DWR ❑ Corps
(check all that apply)
2b. If yes, which mitigation option(s) will be used for this ❑ Mitigation Bank
project? * (check all that apply) ❑ In Lieu Fee Program
❑ Permittee Responsible Mitigation
3. Complete if using a Mitigation Bank
(Must satisfy NC General Statute143-214.11 (d1).)
3a. Name of mitigation bank:
Click to enter.
3b. Credits purchased/requested:
Type: Choose one
Quantity Click to enter.
Type: Choose one
Quantity Click to enter.
Type: Choose one
Quantity Click to enter.
Attach receipt and/or approval letter.
3c. Comments:
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
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
Page 13 of 21 PCN Form - Version 1.5, September 2020

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

F. Stormwater Management and Diffuse Flow Plan (DWR requirement)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers
❑ Yes ❑x No
identified within one of the NC Riparian Buffer Protection Rules?
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://deg.nc.gov/about/divisions/energv-mineral-land-resources/energv-mineral-land-permit-
guidance/stormwater-bmp-manual).
Associated supplement forms and other documentation must be provided.
❑ Level Spreader
What Type of SCM are you
❑ Vegetated Conveyance (lower seasonal high water table- SHWT)
providing?
❑ Wetland Swale (higher SHWT)
(Check all that apply)
❑ 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)?
❑x Yes ❑ No
To look up low density requirements, click here:
http://reports.oah.state.nc.us/ncac/title%2015a%20-%20environmental%20guality/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-
❑x Yes ❑ No
approved local government stormwater program?
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?
❑x Local Government
(Check all that apply)
❑ 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

❑x Phase II
❑ USMP
Local Government Stormwater Programs
❑ NSW
❑ Water Supply
Please identify which local government stormwater program you are using.
Winston-Salem
❑ Phase II
❑ HQW or ORW
State Stormwater Programs
❑ Coastal Counties
❑x Other
Comments:
The development is less than 2 units per acre.
A SWMP was required under the low
density provisions and has
been approved by the City of Winston-Salem.
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)
❑ Yes ❑x No
funds or the use of public (federal/state) land? *
1 b. If you answered "yes" to the above, does the project require
preparation of an environmental document pursuant to the
❑ Yes ❑ No
requirements of the National or State (North Carolina) Environmental
Policy Act (NEPA/SEPA)?
1 c. If you answered "yes" to the above, has the document review been
finalized by the State Clearing House? (If so, attach a copy of the
❑ Yes ❑ No
NEPA or SEPA final approval letter.)
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),
DR Surface Water or Wetland Standards or Riparian Buffer Rules El Yes ❑x No
W
(15A NCAC 2B .0200)?
2b. If you answered "yes" to the above question, provide an explanation of the violation(s):
Click to enter.
3. Cumulative Impacts (DWR Requirement)
3a. Will this project (based on past and reasonably anticipated future
impacts) result in additional development, which could impact nearby
❑ Yes ❑x No
downstream water quality?
3b. If you answered "no", provide a short narrative description:
Additional development as a result of the proposed development is not anticipated.
3c. If yes, attach a qualitative or quantitative cumulative impact analysis (.pdo in accordance with the most recent
DWR policy.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project? I ® 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.
Sewage will be discharged into an existing sewer line that crosses the site. The sewage from the lots located east of
the stream crossing will be discharged into lines that will be buried within the road corridor to avoid additional impacts
to the stream. Additional impacts associated with sewage disposal are 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
® Yes ❑ No
species or habitat? (IPAC weblink: https://www.fws.gov/ipac/ Ifws.govl)
5b.
Have you checked with the USFWS concerning Endangered Species
❑ Yes ❑x No
Act impacts?
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 ElNo
5g.
Does this project involve bridge maintenance or removal? *
❑ Yes ❑x No
Link to NLEB SLOPES document: http://saw-reg.usace. army. mil/NLEB/1-30-17-signed NLEB-
SLOPES&apps.pdf
5h.
Does this project involve the construction/ installation of a wind
turbine(s)?
❑ Yes ❑x No
If yes, please show the location of the wind turbine(s) on the permit drawings/ project plans (attach .pdo
5i.
Does this project involve blasting and /or other percussive activities
that will be conducted by machines, such as jackhammers,
❑ Yes ❑x No
mechanized pile drivers, etc.?
If yes, please provide details to include type of percussive activity, purpose, duration, and specific location of this
activity on the property (attach .pdo
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
3 listed species are identified on the IPaC report (attached). The bog turtle, Schweinitz's sunflower and northern long-
eared bat are listed as federally protected species.
Federally protected bog turtles do not occur on the site and there are no plans to transport turtles that are similar in
appearance to or from the site. Suitable habitat for Schweinitz's sunflower was not observed on the site.
Wooded areas on the site could afford suitable summer roosting habitat for northern long-eared bats. Similar habitat
was observed on nearby properties. Based on a review of the June_1_2016_NLEB—HUC12 NLEB shapefiles obtained
from the Raleigh 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. Therefore, tree clearing outside of the pup season
(June 1 to July 31) is not likely to adversely affect the NLEB. If tree clearing activities cannot be conducted outside of
the pup season, then the applicant will rely on the final 4(d) rule and any take will be considered exempt from the ESA.
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
Page 18 of 21 PCN Form - Version 1.5, September 2020

Are there submerged aquatic vegetation (SAV) around
the project vicinity?
El Yes ❑x No El Unknown
Will this project affect submerged aquatic vegetation?
❑ Yes ❑x No ❑ Unknown
Explain: Dlick 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):
hftp://qis.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
❑ Yes ❑x No
preservation status (e.g., National Historic Trust designation or
properties significant in North Carolina history and archaeology)?
7b. What data source(s) did you use to determine whether your site would impact historic or archeological
resources?
NC Historic Preservation Office's HPOWEB 2.0. Historic properties were not identified on the site or on nearby
properties. A copy of the SHPO Map is included as an attachment.
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? *
i] Yes ❑x No
8b. If yes, explain how the project meets FEMA requirements.
Click to enter.
8c. What source(s) did you use to make the floodplain determination?
National Flood Hazard Layer froom FEMA Web Map Service — Drawing 4 (Attached)
Page 20 of 21 PCN Form - Version 1.5, September 2020

H. Miscellaneous
Comments:
A PJD and a PCN were previously issued for this site (SAW— 2018-01547). The project was redesigned since
the initial submittals and a narrower road is proposed at the previously permitted crossing location. The purpose
of this PCN is to provide updated information such that the PCN can be modified or a new PCN can be issued for
the proposed impacts. It is certainly at the USACE discretion on how the PCN is issued or modified.
Attach pertinent documentation or attachments not previously requested
I. Signature *
❑x By checking the box and signing below, I, as the project proponent, certify to the following:
• The project proponent hereby certifies that all information contained herein is true, accurate, and complete, to
the best of my knowledge and belief;
• The project proponent hereby requests that the certifying authority review and take action on this CWA 401
certification request within the applicable reasonable period of time;
• The project proponent hereby agrees that submission of this PCN form is a "transaction" subject to Chapter
66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act");
• The project proponent hereby agrees to conduct this transaction by electronic means pursuant to Chapter 66,
Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act");
• The project proponent hereby understands that an electronic signature has the same legal effect and can be
enforced in the same way as a written signature; AND
• As the project proponent, I intend to electronically sign and submit the PCN/online form.
Full Name: Michael T. Brame
Digitally zign,d by Micbael Brame
Michael DN cn=Micbael Brame, -Pilot
Signature: EnNrnn--1, lnc., nµ
Brame c-us ero9o9P41=a o�oo.
9/9/2021
Page 21 of 21 PCN Form - Version 1.5, September 2020

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Drawing 2A
USDA Soil Survey
of Forsyth County, NC
Published 1976, Sheet 22 and 29
Not to Scale
i;
PII.O7'
P I L O T E N V I R 0 N M E N 7 A L. I N C
Published Soil Map
Cottage Hill Subdivision
Approximate 18-Acre Tract
Winston-Salem, Forsyth County, NC
Pilot Project 5180

ON
_
Drawing 3
USFWS NWI
Wetlands Mapper
Scale: 1" = 400'
' C
LEGEND
Site Boundary
Freshwater Emergent
Freshwater Forested/Shrub
Estuarine and Marine Deepwater
Estuarine and Marine
Freshwater Pond
Lake
Rivenne
+ MEW Other
ir IM
NWI Map
Cottage Hill Subdivision
Approximate 18-Acre Tract
Winston-Salem, Forsyth County, NC
Pilot Project 5180

Nil
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Mir
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# 4 L
i- "��`�+�'.'�•�'� - off,- • ,� �
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LEGEND w
' 1 Site Boundary
�• - 1IV- AnnuaI r1hance Flood Hazard
R egulatory Floodvay
Sped al Floodvay
Area of Undetermined Flood Hazard
0.2%Annual Chance Flood Hazard
;* } `Future Conditions 1 %Annual Chance Flood Hazard
'� ► Area with Reduced Risk Due to Levee
` FEMA FIRM
Drawing 4
Cottage Hill Subdivision
National Flood Hazard Layer -
from FEMA Web Map Service � `\ `- Approximate 18-Acre Tract
Scale: 1" - 400' PILE] Winston-Salem, Forsyth County, NC
PILOT ENVIR0NMEN7AL•INL Pilot Project5180

6 nApe.!_
Ylip
-.
Y,
. - . L '. � - • - - - fry,. � �
r_
WA 1-16
0.15 Ac.
DP-1 i
DP-2 0
-MOW - FW%E
1 �
sB `
340 LF
LEGEND
4
Site Boundary
Wetland
Perennial Stream _
� Culvert
SA 1-5 Flag Number THE LOCATIONS OF FEATURES SHOWN ON THIS MAP ARE PRELIMINARY. THEY HAVE NOT BEEN
VERIFIED BY THE USACE AND/OR THE NCDEQ-DWR. THEY HAVE NOT BEEN SURVEYED OR
DP-1 O Data Point GEOLOCATED.
Drawing 5 Wetland Map
Aerial Imagery from ESRI Cottage Hill Subdivision
and Pilot GPS Data - - Approximate 18-Acre Tract
' w Winston-Salem, Forsyth County, NC
Scale: 1" = 200' p11.01
Date:9.26.19 . PILOT ENVIR0NMENTAL,INC Pilot Project5180

U.S. Army Corps of Engineers Requirement Control Symbol
WETLAND DETERMINATION DATA SHEET — Eastern Mountains and Piedmont Region EXEMPT
(Authority: AR 335-15,
See ERDC/EL TR-07-24; the proponent agency is CECW-CO-R paragraph 5-2a)
Project/Site: Cottage Hill Subdivision City/County: Winston-Salem/Forsyth Sampling Date: 9/26/19
Applicant/Owner: Arden Group State: NC Sampling Point: DP-1
Investigator(s): Pilot Environmental Section, Township, Range: NA
Landform (hillside, terrace, etc.): Toeslope Local relief (concave, convex, none): Concave Slope (%): 10
Subregion (LRR or MLRA): LRR P, MLRA 136 Lat: 36.119867' Long:-80.334242' Datum: WGS 84
Soil Map Unit Name: Fairview fine sandy loam (FaD) NWI classification: None
Are climatic / hydrologic conditions on the site typical for this time of year? Yes X No (If no, explain in Remarks.)
Are Vegetation Soil or Hydrology significantly disturbed? Are "Normal Circumstances" present? Yes X No
Are Vegetation Soil or Hydrology naturally problematic? (If needed, explain any answers in Remarks.)
SUMMARY OF FINDINGS — Attach site map showing sampling point locations, transects, important features, etc.
Hydrophytic Vegetation Present? Yes X No Is the Sampled Area
Hydric Soil Present? Yes X No within a Wetland? Yes X No
Wetland Hydrology Present? Yes X No
Remarks:
HYDROLOGY
Wetland Hydrology Indicators:
Secondary Indicators (minimum of two required)
Primary Indicators (minimum of one is required: check all that apply)
—Surface Soil Cracks (136)
—Surface Water (Al) —True
Aquatic Plants (1314)
_ Sparsely Vegetated Concave Surface (138)
X High Water Table (A2) —Hydrogen
Sulfide Odor (Cl)
—Drainage Patterns (1310)
X Saturation (A3) —Oxidized
Rhizospheres on Living Roots (C3)
_Moss Trim Lines (1316)
—Water Marks (131) —Presence
of Reduced Iron (C4)
_ Dry -Season Water Table (C2)
—Sediment Deposits (132) —Recent
Iron Reduction in Tilled Soils (C6)
_ Crayfish Burrows (C8)
_ Drift Deposits (133) _Thin
Muck Surface (C7)
—Saturation Visible on Aerial Imagery (C9)
_Algal Mat or Crust (134) _Other
(Explain in Remarks)
_Stunted or Stressed Plants (D1)
—Iron Deposits (135)
_ Geomorphic Position (D2)
_ Inundation Visible on Aerial Imagery (137)
—Shallow Aquitard (D3)
X Water -Stained Leaves (139)
_ Microtopographic Relief (D4)
Aquatic Fauna (1313)
X FAC-Neutral Test (D5)
Field Observations:
Surface Water Present? Yes No
X Depth (inches):
Water Table Present? Yes X No
Depth (inches): 0
Saturation Present? Yes X No
Depth (inches): 0
Wetland
Hydrology Present? Yes X No
includes capillary fringe)
Describe Recorded Data (stream gauge, monitoring well, aerial photos, previous inspections), if available:
Remarks:
ENG FORM 6116-4-SG, JUL 2018 Eastern Mountains and Piedmont — Version 2.0

VEGETATION (Four Strata) - Use scientific names of plants.
Sampling Point: DP-1
Absolute Uominant
Indicator
Tree Stratum (Plot size: 30 )
% Cover Species?
Status
Dominance Test worksheet:
1. Acer rubrum
20 Yes
FAC
Number of Dominant Species
2.
That Are OBL, FACW, or FAC: 6 (A)
3.
Total Number of Dominant
4.
Species Across All Strata: 6 (B)
5.
Percent of Dominant Species
6.
That Are OBL, FACW, or FAC: 100.0% (A/B)
7.
Prevalence Index worksheet:
20 =Total Cover
Total % Cover of: Multiply by:
50% of total cover:
10 20% of total cover:
4
OBL species 10 x 1 = 10
Sapling/Shrub Stratum (Plot size: 15
)
FACW species 30 x 2 = 60
1. Alnus serrulata
10 Yes
OBL
FAC species 40 x 3 = 120
2. Fraxinus pennsylvanica
10 Yes
FACW
FACU species 0 x 4 = 0
3.
UPL species 0 x 5 = 0
4.
Column Totals: 80 (A) 190 (B)
5.
Prevalence Index = B/A = 2.38
6.
Hydrophytic Vegetation Indicators:
7.
_ 1 - Rapid Test for Hydrophytic Vegetation
8.
X 2 - Dominance Test is >50%
9.
X 3 - Prevalence Index is !2.0'
20 =Total Cover
4 - Morphological Adaptations' (Provide supporting
50% of total cover:
10 20% of total cover:
4
data in Remarks or on a separate sheet)
Herb Stratum (Plot size: 5 )
-Problematic Hydrophytic Vegetation' (Explain)
1. Microstegium vimineum
20 Yes
FAC
'Indicators of hydric soil and wetland hydrology must
2. Polygonum persicaria
10 Yes
FACW
be present, unless disturbed or problematic.
Definitions of Four Vegetation Strata:
3. Woodwardia areolata 10 Yes FACW
4.
Tree - Woody plants, excluding vines, 3 in. (7.6 cm) or
5.
more in diameter at breast height (DBH), regardless of
6
height.
7.
Sapling/Shrub - Woody plants, excluding vines, less
8.
than 3 in. DBH and greater than or equal to 3.28 ft
9
(1 m) tall.
10.
Herb - All herbaceous (non -woody) plants, regardless
11.
of size, and woody plants less than 3.28 ft tall.
40 =Total Cover
Woody Vine - All woody vines greater than 3.28 ft in
50% of total cover:
20 20% of total cover:
8
height.
Woody Vine Stratum (Plot size: 30 )
1.
2.
3.
4.
5.
Hydrophytic
=Total Cover
Vegetation
50% of total cover:
20% of total cover:
Present? Yes X No
Remarks: (Include photo numbers here or on a separate sheet.)
ENG FORM 6116-4-SG, JUL 2018 Eastern Mountains and Piedmont - Version 2.0

SOIL Sampling Point: DP-1
Profile Description: (Describe to the depth needed to document the indicator or confirm the absence of indicators.)
Depth Matrix Redox Features
(inches) Color (moist) % Color (moist) % Type LoC2 Texture Remarks
0-18 2.5YR 4/2 90 10YR 4/6 10 C M Loamy/Clayey Prominent redox concentrations
Type: C=Concentration, D=Depletion, RM=Reduced Matrix. MS=Masked Sand Grains.
Hydric Soil Indicators:
_ Histosol (Al)
_ Histic Epipedon (A2)
_ Black Histic (A3)
—Hydrogen Sulfide (A4)
—Stratified Layers (A5)
2 cm Muck (A10) (LRR N)
_ Depleted Below Dark Surface (A11)
_Thick Dark Surface (Al 2)
—Sandy Mucky Mineral(S1)
—Sandy Gleyed Matrix (S4)
—Sandy Redox (S5)
—Stripped Matrix (S6)
Dark Surface (S7)
Restrictive Layer (if observed):
Type:
Depth (inches):
Remarks:
_ Polyvalue Below Surface (S8) (MLRA 147, 148)
_Thin Dark Surface (S9) (MLRA 147, 148)
_Loamy Mucky Mineral (F1) (MLRA 136)
_ Loamy Gleyed Matrix (F2)
X Depleted Matrix (F3)
_ Redox Dark Surface (F6)
_ Depleted Dark Surface (F7)
_ Redox Depressions (F8)
_ Iron -Manganese Masses (F12) (LRR N,
MLRA 136)
_ Umbric Surface (F13) (MLRA 122, 136)
—Piedmont Floodplain Soils (F19) (MLRA 148)
Red Parent Material (F21) (MLRA 127, 147, 148)
2Location: PL=Pore Lining, M=Matrix
Indicators for Problematic Hydric Soi
2 cm Muck (A10) (MLRA 147)
—Coast Prairie Redox (A16)
(MLRA 147, 148)
—Piedmont Floodplain Soils (F19)
(MLRA 136, 147)
—Red Parent Material (F21)
(outside MLRA 127, 147, 148)
_Very Shallow Dark Surface (F22)
Other (Explain in Remarks)
3Indicators of hydrophytic vegetation and
wetland hydrology must be present,
unless disturbed or problematic.
Hydric Soil Present? Yes X No
ENG FORM 6116-4-SG, JUL 2018 Eastern Mountains and Piedmont — Version 2.0

U.S. Army Corps of Engineers Requirement Control Symbol
WETLAND DETERMINATION DATA SHEET — Eastern Mountains and Piedmont Region EXEMPT
(Authority: AR 335-15,
See ERDC/EL TR-07-24; the proponent agency is CECW-CO-R paragraph 5-2a)
Project/Site: Cottage Hill Subdivision City/County: Winston-Salem/Forsyth Sampling Date: 9/26/19
Applicant/Owner: Arden Group State: NC Sampling Point: DP-2
Investigator(s): Pilot Environmental Section, Township, Range: NA
Landform (hillside, terrace, etc.): Hillside Local relief (concave, convex, none): Concave Slope (%): 12
Subregion (LRR or MLRA): LRR P, MLRA 136 Lat: 36.119789' Long:-80.334359' Datum: WGS 84
Soil Map Unit Name: Fairview fine sandy loam (FaD) NWI classification: None
Are climatic / hydrologic conditions on the site typical for this time of year? Yes X No (If no, explain in Remarks.)
Are Vegetation Soil or Hydrology significantly disturbed? Are "Normal Circumstances" present? Yes X No
Are Vegetation Soil or Hydrology naturally problematic? (If needed, explain any answers in Remarks.)
SUMMARY OF FINDINGS — Attach site map showing sampling point locations, transects, important features, etc.
Hydrophytic Vegetation Present? Yes No X Is the Sampled Area
Hydric Soil Present? Yes No X within a Wetland? Yes No X
Wetland Hydrology Present? Yes No X
Remarks:
HYDROLOGY
Wetland Hydrology Indicators:
Secondary Indicators (minimum of two required)
Primary Indicators (minimum of one is required: check all that apply)
—Surface Soil Cracks (136)
—Surface Water (Al) —True
Aquatic Plants (1314)
_ Sparsely Vegetated Concave Surface (138)
_ High Water Table (A2) —Hydrogen
Sulfide Odor (Cl)
—Drainage Patterns (1310)
—Saturation (A3) —Oxidized
Rhizospheres on Living Roots (C3)
_Moss Trim Lines (1316)
—Water Marks (131) —Presence
of Reduced Iron (C4)
_ Dry -Season Water Table (C2)
—Sediment Deposits (132) —Recent
Iron Reduction in Tilled Soils (C6)
_ Crayfish Burrows (C8)
_ Drift Deposits (133) _Thin
Muck Surface (C7)
—Saturation Visible on Aerial Imagery (C9)
_Algal Mat or Crust (134) _Other
(Explain in Remarks)
_Stunted or Stressed Plants (D1)
—Iron Deposits (135)
_ Geomorphic Position (D2)
_ Inundation Visible on Aerial Imagery (137)
—Shallow Aquitard (D3)
—Water-Stained Leaves (139)
_ Microtopographic Relief (D4)
Aquatic Fauna (1313)
FAC-Neutral Test (D5)
Field Observations:
Surface Water Present? Yes No
X Depth (inches):
Water Table Present? Yes No
X Depth (inches):
Saturation Present? Yes No
X Depth (inches):
Wetland
Hydrology Present? Yes No X
includes capillary fringe)
Describe Recorded Data (stream gauge, monitoring well, aerial photos, previous inspections), if available:
Remarks:
ENG FORM 6116-4-SG, JUL 2018 Eastern Mountains and Piedmont — Version 2.0

VEGETATION (Four Strata) - Use scientific names of plants.
Sampling Point: DP-2
Absolute
Uominant
Indicator
Tree Stratum (Plot size: 30 )
% Cover
Species?
Status
Dominance Test worksheet:
1.
Quercus rubra
20
Yes
FACU
Number of Dominant Species
2.
Fagus grandifolia
20
Yes
FACU
That Are OBL, FACW, or FAC: 1 (A)
3.
Oxydendrum arboreum
20
Yes
UPL
Total Number of Dominant
4.
Species Across All Strata: 7 (B)
5.
Percent of Dominant Species
6.
That Are OBL, FACW, or FAC: 14.3% (A/B)
7.
Prevalence Index worksheet:
60
=Total Cover
Total % Cover of: Multiply by:
50% of total cover:
30 20% of total cover:
12
OBL species 0 x 1 = 0
Sapling/Shrub Stratum (Plot size: 15
)
FACW species 0 x 2 = 0
1.
Fagus grandifolia
10
Yes
FACU
FAC species 5 x 3 = 15
2.
Oxydendrum arboreum
10
Yes
UPL
FACU species 55 x 4 = 220
3.
UPL species 30 x 5 = 150
4.
Column Totals: 90 (A) 385 (B)
5.
Prevalence Index = B/A = 4.28
6.
Hydrophytic Vegetation Indicators:
7.
_ 1 - Rapid Test for Hydrophytic Vegetation
8.
2 - Dominance Test is >50%
9.
3 - Prevalence Index is !2.0'
20
=Total Cover
4 - Morphological Adaptations' (Provide supporting
50% of total cover:
10 20% of total cover:
4
data in Remarks or on a separate sheet)
Herb Stratum (Plot size: 5 )
-Problematic Hydrophytic Vegetation' (Explain)
1.
Polystichum acrostichoides
5
Yes
FACU
'Indicators of hydric soil and wetland hydrology must
2.
be present, unless disturbed or problematic.
Definitions of Four Vegetation Strata:
3.
4.
Tree - Woody plants, excluding vines, 3 in. (7.6 cm) or
5.
more in diameter at breast height (DBH), regardless of
6
height.
7.
Sapling/Shrub - Woody plants, excluding vines, less
8.
than 3 in. DBH and greater than or equal to 3.28 ft
9
(1 m) tall.
10.
Herb - All herbaceous (non -woody) plants, regardless
11.
of size, and woody plants less than 3.28 ft tall.
5
=Total Cover
Woody Vine - All woody vines greater than 3.28 ft in
50% of total cover:
3 20% of total cover:
1
height.
Woody Vine Stratum (Plot size: 30 )
1.
Vitis rotundifolia
5
Yes
FAC
2.
3.
4.
5
Hydrophytic
5
=Total Cover
Vegetation
50% of total cover:
3 20% of total cover:
1
Present? Yes No X
Remarks: (Include photo numbers here or on a separate sheet.)
ENG FORM 6116-4-SG, JUL 2018 Eastern Mountains and Piedmont - Version 2.0

SOIL Sampling Point: DP-2
Profile Description: (Describe to the depth needed to document the indicator or confirm the absence of indicators.)
Depth Matrix Redox Features
(inches) Color (moist) % Color (moist) % Type LoC2 Texture Remarks
0-18 7.5YR 4/6 100 Loamy/Clayey
Type: C=Concentration, D=Depletion, RM=Reduced Matrix. MS=Masked Sand Grains.
Hydric Soil Indicators:
_ Histosol (Al)
_ Histic Epipedon (A2)
_ Black Histic (A3)
—Hydrogen Sulfide (A4)
—Stratified Layers (A5)
2 cm Muck (A10) (LRR N)
_ Depleted Below Dark Surface (A11)
_Thick Dark Surface (Al 2)
—Sandy Mucky Mineral(S1)
—Sandy Gleyed Matrix (S4)
—Sandy Redox (S5)
—Stripped Matrix (S6)
Dark Surface (S7)
Restrictive Layer (if observed):
Type:
Depth (inches):
Remarks:
_ Polyvalue Below Surface (S8) (MLRA 147, 148)
_Thin Dark Surface (S9) (MLRA 147, 148)
_Loamy Mucky Mineral (F1) (MLRA 136)
_ Loamy Gleyed Matrix (F2)
_ Depleted Matrix (F3)
_ Redox Dark Surface (F6)
_ Depleted Dark Surface (F7)
_ Redox Depressions (F8)
_ Iron -Manganese Masses (F12) (LRR N,
MLRA 136)
_ Umbric Surface (F13) (MLRA 122, 136)
—Piedmont Floodplain Soils (F19) (MLRA 148)
Red Parent Material (F21) (MLRA 127, 147, 148)
2Location: PL=Pore Lining, M=Matrix
Indicators for Problematic Hydric Soi
2 cm Muck (A10) (MLRA 147)
—Coast Prairie Redox (A16)
(MLRA 147, 148)
—Piedmont Floodplain Soils (F19)
(MLRA 136, 147)
—Red Parent Material (F21)
(outside MLRA 127, 147, 148)
_Very Shallow Dark Surface (F22)
Other (Explain in Remarks)
3Indicators of hydrophytic vegetation and
wetland hydrology must be present,
unless disturbed or problematic.
Hydric Soil Present? Yes No X
ENG FORM 6116-4-SG, JUL 2018 Eastern Mountains and Piedmont — Version 2.0

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