20130952 Ver 1_401 Application_20130913

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20 1 30952
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Pre - Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1a. Type(s) of approval sought from the Corps:
❑ Section 404 Permit ❑ Section 10 Permit
1b. Specify Nationwide Permit (NWP) number: or General Permit (GP) number.
1 c. Has the NWP or GP number been vedfed by the Corps?
❑ Yes ❑ No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
❑ 401 Water Quality Certification - Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification - Express .[ .Riparian Buffer Authorization
1e. Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification:
❑ Yes ❑ No
For the record only for Corps Permit:
❑ Yes ❑ No
It 1s payment into a mitigation bank or in -lieu fee program proposed for:
mitigation of impacts? If so, attach the acceptance letter from mitigation bank,
-or to -lieu fee program.;
❑ -Yes ❑ No
1g. Is the project located In any of NC's twenty coastal counties. If yes, answer 1fi
below.
❑Yes ;� No
.1h. Is the project located wdhin a NC DCM Area of Environmental Concom (AEC)?.
❑ Yes ❑ No
2. Project Informatfori
-------------- --- - - - - -- - --
2a. '; Name of project
'2b. County:;
e
2c. kdarest municip; kGty / town:
g;
2d. Subdivision name:
vom5v Nf i I I S
2e. NCDOT only, T.I.P. or state project no:
3; 'Owner Information'
3a. Name(s) on Recorded Deed:.
mu ; Qu Ibe
3b. Deed Book and Page No.
S d
!X Responsible Party (for LLC if;
applicable):;
3d. Street address:'
p e I va-
139. City, state, zip:
DVA a7
Z. Telephone no.:,
I q - ill -
3g. Fax no.:,
-
-3h. Email address:
Page 1 of 10
PCN Form - Version 1.4 January 2009

4. Applicant Information (if different from owner)
4a. Applicant is:;
❑ Agent ❑ Other, specify:
4b. Name:
MAMAe 1:1t .Saves 4Sbn . bncoc!
4c. Business name
(f applicable):
SPi re jo 4 S Lt—c
4d. Street address:
1en 2 S
4e. City, state, zip:
a-i Lo I
4f. Telephone no.:
. -7 _ 7
49. Fax no.:
A. Email address:
f" IM ho gf n as-Or.1, n
5. Ageni/Consultant information (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:,
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 10
eA M

Pr *1nformsA6rj',*fiO Prior
_.!�iRject History)
Y-
E .Step at ;Qrid670–M-1 gogkeii)-) I 0*&i
Lig t-�go qlq
(2) ,'Surface Waters)
,2a. Name of nearest body of water to prop osed PrOled)
!2b. Water Quality Classification ol"nearest receiving water:;
2c. River basin.*,:
e,
'
A; Project biscilpeon:
,3a. Dftcrii 9 the existing conditions on the site and the general land use In the vicinity of the pi 41 th time of thij
0 project is
-application:, CurreAot Y"W, &we 1'::r ovRr-Orow.-I, O'er lTeer C."d
VS ;JA#JO/) , Aor-b6-''� " bul'id /)OW sin"qte &P19,e 01-7 A004.
3b. List the total estimated acreage of all existing wetlands on the property:
-3c. Ust the total estimated linear feet of all misting streams (intermittent and perennial) on the property:: ert_ Zs`
:3d. Explain the purpose df-16e proposed project:
3e. Describe the overall project in detail, including the type of equipment to be used: dos!-r"alb").
cca-'Ll, Irite- pe► -VOL&I e%Vh-,"d,%4
4. Jurisdictional Determinations
4a. Have NrisdiOldnal wetland or stream determinations by the'
p obtained ,R9r,�at4Jg!.I1eqrti&qMe !a
Cops I
.AgEob . net
*bjebt OW6ding A prior phases) in Nijiit?,
Yes- ❑ W 13 OnK�o­w­n­-
:Comments:,
4b. If the Corps made the jurisdictional determination, what type
of determination was made?
❑ Preliminary ❑ Final
4c. If yet, who delineated the Jurisdictional areasf
Narn6(If known):.
-'Agency/C*o'n'sidtantCo*m"pan
Other'. . Y:
4d. -if yes, list the dates of the Corps jurisdictional determinations or State determinations -----
and attach documentation.
11 3 13
.34
5. 'Project History
-'6a- D - T:
�Acatlons'been req
jy8'OerrOI4.*.-" requested or obtained 'to
Afils pipject (including all prior phases) In the pas
E]Yii ONo, ❑'Unknown
-5b. If yes, explain in detail according to'help, filer instructions.]
S. 'Future Protect Plans`
❑ Yes No
Ob. 'If yes, explain.;
,Page 3, of 10) -
PQM,FF6i
( t%--.
F,4V&O-rMTf-4'%IAnuary 2009)

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
❑ Wetlands ❑ Streams — tributaries ❑ lBuffers ❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland Impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
Wetland impact
number
Permanent (P) or
Temporary
2b.
Type of impact
2c.
Type of wetland
2d.
Forested
2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other)
2f.
Area of
impact
(acres)
W1 -
Choose one
Choose one
Yes/No
-
W2 -
Choose one
Choose one
Yes/No
-
W3 -
Choose one
Choose one
Yes/No
W4 -
Choose one
Choose one
Yes/No
W5 -
Choose one
Choose one
Yes/No
we -
Choose one
Choose one
Yes/No
2g. Total
Wetland Impacts:
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary Impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a.
Stream Impact
number
Permanent (P) or
Temporary ()
3b.
Type of Impact
3c.
Stream name
3d.-
Perennial (PER) or
intermittent (INT)?
3e.
Type of
jurisdiction
3f.
Average
stream
width
(feet)
3g.
Impact
length
(linear
feet)
S1 -
Choose one
-
S2 -
Choose one
-
S3 -
Choose one
S4 -
Choose one
-
S5 -
Choose one
-
SO -
Choose one
3h. Total stream and tributary
Impacts
3i. Comments:
Page 4 of 10
PCN Form — Version 1.4 January 2009

D. Impact Justification and Mitigation
1. 'Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed #*i O� project.
GOOJ%nJ fa,.�l nod- G'ncl�c.t, ,�� jjc er2oye.
1 b. Specifically describe measures"taken to avoid or minimize the proposed impacts through construction techniques.`
0 k�Fr i4' mite *0 bd +,+ %110 f,.'or 4 + Ai,,,g
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2s. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
❑ Yes ❑ No
2b. if yes, mitigation is required by (check all that apply):
❑ DWQ ❑ Corps
2c. If yes, which mitigation option will be used for this
project?
❑ Mitigation bank
❑ Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter)
Type: Choose one
Type: Choose one
Type: Choose one
Quantity:
Quantity:
Quantity:
3c. Comments:
4. Complete If Making a Payment to In -lieu Fee Pro ram
4a. Approval letter from in -lieu fee program is attached.
❑ Yes
4b. Stream mitigation requested:
linear feet
4c. If using stream mitigation, stream temperature:
Choose one
4d. Buffer mitigation requested (DWQ only):
square feet
4e. Riparian wetland mitigation requested:
acres
4f. Non - riparian wetland mitigation requested:
acres
4g. Coastal (tidal) wetland mitigation requested:
acres
4h. Comments:
6. Complete If Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form —Version 1.4 January 2009

4. Open Water Impacts
If there are proposed Impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individual list all open water impacts below.
49.
Open water
impact number
Permanent (P) or
Temporary
4b.
Name of waterbody
(if applicable)
4c.
Type of impact
4d.
Waterbody
type
4e.
Area of impact (acres)
01 -
Choose one
Choose
02 -
Choose one
Choose
03 -
Choose one
Choose
04 -
Choose one
Choose
4f. Total open water Impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed. then complete the chart below.
5a.
Pond ID number
5b.
Proposed use or
purpose of pond
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
51. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If spy Impacts require miti atiori, then you MUST fill out Section D of this form.
6a. Project is in which protected basin?
;R Neuse ] Tar - Pamlico ❑ Catawba []Randleman ❑ Other:
6b.
`Buffer Impact•
:number —;
.Permanent (P) or,
iTe
6c.
= Reason for impact;
6d.
-Stream name
6e.
Ouiteri
mitigation
;requiredf
6f.
:Zone 1)
Impact
(square
:feet ;
8g,
Zone 2i
impact
(square
;fee i
61 -
fl—AA .t4:1- FJ y cx%&K
Yes/No
132 -
Yes/No
133 -
Yes/No
B4 -
Yes/No
B5 -
Yes/No
Be -
Yes/No
6h. Total Buffer Impacts:
61. Comments:
Page 5 of 10

S. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWO
6a. Will the project result in an impact within "a protected riparian buffer that requires`
buffer mitigation ?,
0 Yes No
1 9
6b. If yes, then identify the square feet of impact to each zolis of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.;
.Zone
tic
Reason for impact
6d.;
Total impact
.(square feet)
Multiplier
tie.
Required mitigation
(square feet)",
Zone 1
3 (2 for Catawba)
Zone 2
1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation Is proposed (e.g., payment to "private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund).,
6h. Comments:
Page 7 of 10

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. .Diffuse Flow Plan'
1a. Does the project include or is it adjacent to protected riparian buffers Identified
.within one of the NC Riparian Buffer Protection Rules ?_
❑Yes' ❑ ;No'
1b. If yes, then is a diffuse flow plan Included? If no, explain why.-
Yes ❑ No
2. Stormwater Mana ement Plan
2a. What is the overall percent imperviousness of this project?
%
2b. Does this project require a Stormwater Management Plan?
❑ Yes ❑ No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e. Who will be responsible for the review of the Stormwater Management Plan?
3. Certified Local Government Stormwater Review
3a. In which local governmenrs Jurisdiction is this project?
3b. Which of the following locally- implemented stormwater management programs
apply (check all that apply):
❑ Phase II
❑ NSW
® USMP
Water Supply Watershed
❑ Other:
3c. Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ Yes ❑ No
4. DWQ Stormwater Program Review
4a. Which of the following state - implemented stormwater management programs apply
(check all that apply):
❑Coastal counties
❑HQW
BSesslon ORW
Law 2006 -246
❑Other.
4b. Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ Yes ❑ No
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements?
❑ Yes ❑ No
5b. Have all of the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 8 of 10
PCN Form —Version 1.4 January 2009

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1a. Does the project involve an expenditure of public ( federa lstatellocaq funds or the
❑ Yes
❑ No
use of public (federal /state) land?
1b. If you answered "yes' to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or Slate
❑ Yes
❑ No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c. 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:
2. Violations (DWQ Requirement)
2a..Is the site in violation of DWQ Wetland Rules (15A NCAC 21­1.6500). Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards,:
❑ Yes
No
:or Riparian Buffer Rules (M NCAC 28.0200) ?i
2b. ;Is this an after - the -fact parmit application?
❑Yes
No
2c: If you answered wyes7 to one or both of thier above questions, provide an explanation of thie violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future Impacts) result In
❑Yes
j�No
additional development, which could impact nearby downstream water quality ?
/
3b. If you answered Nos* to the above, submit a qualitative or quantitative cumulative impact�Onaiyshi in accordance with the•
most recent DWQ policy.*jijroii ariswereii "no; provide a short narrative description:
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non - discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
Page 9of10
PCN Form —Version 1 .4 January 2009

. A
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
habitat?
❑Yes ❑ No
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts?
❑ Yes ❑ No
Sc. If yes, indicate the USFWS Field Office you have contacted.
-
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
6. Essential Fish Habitat (Corps Requirement)
ea. Will this project occur in or near an area designated as essential fish habitat? ❑ Yes ❑ No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
❑ Yes ❑ No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA- designated 100 -year floodplain?
13 'Yes ❑ No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?
Appficant/Agenrs Printed Name.
Applicant/ is Signature
(Agent s stnatm Is agd onV B an authodzatlm,
;letter from the appllcW Is muted.
Do
Page 10 of W