20211478 Ver 1_Pre-Construction Notification (PCN) Form (10) (1)_20211008

DWR
Division of Water Resources
Pre -Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
June 1, 2021 Ver 4.1
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.
Also, if at any point you wish to print a copy of the E-PCN, all you need to do is right -click on the document and you can print a copy of the form.
Below is a link to the online help file.
https://edoes. deq. n e.gov/WaterResou rces/0/ed oc/624704/PCN % 20 Help / 20F i le / 202018-1-30. pdf
A. Processing Information
County (or Counties) where the project is located:*
Wake
Is this a NCDMS Project*
r Yes C No
Click Yes, only if NCDlvS is the applicant a co -applicant.
Is this project a public transportation project?
O Yes F No
This is arty publicly funded by m ricipal,state a federal funds road, rail, airport transpafatm project.
1a. Type(s) of approval sought from the Corps:*
Section 404 Permit (wetlands, streams and waters, Clean Water Act)
❑ Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
Has this PCN previously been submitted?*
O Yes
O No
1 b. What type(s) of permit(s) do you wish to seek authorization?*
IJ Nationwide Permit (NWP)
r Regional General Permit (RGP)
r Standard (IP)
1c. Has the NWP or GP number been verified bythe Corps?*
r Yes F No
Nationwide Permit (NWP) Number:
NWP Numbers (for multiple NWPS):
List all NJVnurbers ycu are applying fa not cn the drop dawn list.
1d. Type(s) of approval sought from the DWR:*
check all that apply
401 Water Quality Certification - Regular
r Non-404 Jurisdictional General Permit
r Individual 401 Water Quality Certification
Pre -Filing Meeting Information
39 - Commercial/Institutional Developments
r 401 Water Quality Certification - Express
IJ Riparian Buffer Authorization
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.
Is this a courtesy copy notification?
r Yes E No
ID#
Version
Pre -fling Meeting or Request Date *

8/31 /2021
Attach documentation of Pre -Filing Meeting Request here:*
Cickthe upload button or drag and drop files here to attach dccurrent
DWR Pre -Filing Meeting Request Form (26) (1).pdf 49.58KB
File type crust be FDF
............ ............................................................ .........................................................................
1e. Is this notification sole lyfor the record because written approval is not required?
*
For the record onlyfor DWR401 Certification: r- Yes F No
For the record onlyfor Corps Permit: r- Yes F No
1f. Is this an after -the -fact permit application?*
C Yes (-- No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
If so, attach the acceptance letter from ratigabon bank or in -lieu fee program
6 Yes O No
Acceptance Letter Attachment
Cickthe upload button or drag and drop files here to attach dccurrent
Neu -Con SOA- Blackbird - Oasis Church (2).pdf 142.08KB
FiLEiYFE MJST BE FDF
1 h. Is the project located in any of NC's twenty coastal counties?*
r Yes (-- No
1j. Is the project located in a designated trout watershed?*
r Yes E No
Link to trout information: http://www.saw.usace.army.mil/Missions/Regulatory-Permit-Progra"Agency-Coordination/Trout.aspx
B. Applicant Information
la. Who is the Primary Contact?*
Sean Clark
1c. Primary Contact Phone:*
1b. Pri mary Contact Email:*
(xxx)xxx-xxxx
[e-mail]
[phone]
1d. Who is applying for the permit?
W Owner
❑ Applicant (other than owner)
(Check all that apply)
le. Is there an Agent/Consultant for this project?*
F Yes r No
2. Owner Information
2a. Name(s) on recorded deed:*
Holly Springs Foursquare Church dba'Oasis Church'
2b. Deed book and page no.:
DB 017183; PG 00121
2c. Contact Person:
(fa Corporations)
Todd Davis
2d. Address*
Sheet Address
1828 RALPH STEPHENS RD
Address Line 2
aty
State / Aovince / Pegicn
Holly Springs
NC
Postal / Zp Code
Country
27540
USA
2e. Telephone Number:*
(xxx)xxx-xxxx
[phone]
2f. Fax Number:
(xxx)xxx-xxxx

2g. Email Address:*
[e-mail]
4. Agent/Consultant (if applicable)
4a. Name:*
Ian McMillan
4b. Business Name:
(d applicable)
Sage Ecological Services, Inc.
4c. Address*
Street Address
3707 Swift Drive
Address Line 2
atY
Raleigh
Postal / Zp Code
27606
4d. Telephone Number:*
[phone]
(xxx)xxx-xxxx
4f. Email Address:*
[e-mail]
State / Aovince / Pe3icn
NC
Country
USA
4e. Fax Number:
(xxx)xxx-xxxx
C. Project Information and Prior Project History
1. Project Information l^J
1a. Name of project:*
Oasis Church
1b. Subdivision name:
(d appropriate)
1c. Nearest municipality / town:
*
Holly Springs
2. Project Identification
2a. Property Identification Number:
2b. Property size:
(tax RN a parcel ID)
(in acres)
0648757407
8.29
2c. Project Address
Street Address
1828 RALPH STEPHENS RD
Address Line 2
aty
State / Aovince / Pe3icn
Holly Springs
NC
Postal / Zp Code
Country
27540
USA
2d. Site coordinates in decimal degrees
Please collect site coordinates in decimal degrees. Use between 4-6 digits (unless you are using a survey -grade GPS device) after the decimal place as appropriate, based on howthe location was
determined. (For example, most mobile phones with GPS provide locational precision in decimal degrees to map coordinates to 5 or 6 digits after the decimal place.)
Latitude:* Longitude:*
35.6332-78.8395
ex: 34.208504-77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Basal Creek
3b. Water Resources Classification of nearest receiving water:*
B;NSW
Surface Water Lookup

3c. What river basin(s) is your project located in?*
Neuse
3d. Please provide the 12-digit HUC in which the project is located.*
030202010901
River Basin Lookup
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 8.29-acre Site is made up of one parcel located southeast of the intersection of Ralph Stephens Road and Castaway Court in Holly Springs, Wake County, NC. The Site is currently
undeveloped; however, clearing and grading in the northwestern corner of the Site has been completed. The drainages within the site are dominated by hardwoods with interspersed
loblolly pines. Surrounding areas are a mix of undeveloped wooded areas, residential subdivisions, and agricultural land.
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?
r Yes E No r Unknown
4f. List the total estimated acreage of all existing wetlands on the property:
1.814
4g. List the total estimated linear feet of all existing streams on the property:
(internittent and paenrial)
675
4h. Explain the purpose of the proposed project:*
The purpose of this project is to develop the site as the Oasis Church with amenities, stormwater controls, and parking to provide the congregation a permanent building to worship in.
4i. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:*
The proposed impacts result from one road crossing (culvert extension), fill slopes for parking, stormwater control, and other onsite amenities. Heavy equipment typically used for utility
installation projects (e.g., backhoes, bulldozers, etc.) will be utilized.
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
6' Yes C No O Unknown
Comments:
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
O Preliminary r Approved C- Not Verified r- Unknown r N/A
Corps AID Number:
Exarrple: SAW-2017-99999
See attached correspondence from USACE
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known): David Gainey
Agency/Consultant Company: Sage Ecological Services, Inc.
Other:
5d. List the dates of the Corp jurisdiction determination or State determination if a determination was made bythe Corps or DWR.
See attached correspondence from USACE
6. Future Project Plans
6a. Is this a phased project?*
r Yes F No
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the proposed project or related activity? This
includes other separate and distant crossing for linear projects that require Department of the Army authorization but don't require pre -construction notification.
D. Proposed Impacts Inventory
1. Impacts Summary
la. Where are the impacts associated with your project? (check all that apply):
rJ Wetlands Streams -tributaries rJ Buffers
r 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.

"W." will be used in the table below tore present the word "wetland".
Reason *M
2b. Impact type*(?)
2c. Type of W.
2d. W. name*
2e. Forested*
�2Fflype of
Jurisdicition*(?)
2g. Impact
area*
Site 1
Culvert and rip -rap
P
Headwater Forest
�WA
Yes
Both
0.029
(acres)
Site 1
Fill slopes
P
Headwater Forest
WA
Yes
Both
0.087
(acres)
Site 1
Fill slopes
P
Headwater Forest
WA
Yes
Both
0.027
(acres)
Site 1
Fill slopes
T ]Headwater
Forest
WA
Yes
Both
0.011
(acres)
Site 1
Culvert and rip -rap
T
Headwater Forest
WA
Yes
Both
0.034
(acres)
Site 2
Utility piers
P
Headwater Forest
WA
Yes
Both
0.003
(acres)
Site 2
Utility piers JL
Headwater Forest
WA
Yes
Both
0.009
acres)
2g. Total Temporary Wetland Impact
0.054
2g. Total Permanent Wetland Impact
0.146
2g. Total Wetland Impact
0.200
2i. 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.
"S." will be used in the table below to represent the word "stream".
3a. Reason for impact*(?) 3b.lmpact type * 3c. Type of impact* 3d. S. name * �3e. Stream Type * �]f. Type ofwidth *3*h.Impact
(?) urisdiction* length
Road crossing Permanent Culvert Tributary B Intermittent Both 4 119
1 9 Y
Avaage (feet) (linear feet)
** All Perennial or Intermittent streams must be verified by DWR or delegated local government.
3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
119
3i. Total temporary stream impacts:
0
3i. Total stream and ditch impacts:
119
3j. Comments:
6. Buffer Impacts (for DWR)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts below
6a. Project is in which protect basin(s)? *
Check all that apply.
Q Neuse r Tar -Pamlico
❑ Catawba r Randleman
❑ Goose Creek r Jordan Lake
❑ Other
1I6b. Impact Type"(?) 116c. Per or Temp"(?) 116d. Stream name" 116e. Buffer mitigation required?- 116f. Zone 1 impact" 1I6g. Zone 2 impact"

Site 1 - Road Crossing - Allowable Upon
P
Tributary B
No
3,853 -]
3,850
Authorization
(square fee[)
(square feet)
S71Road Crossing - Allowable Upon
T
Tributary B
No
297
225
Aon
(square feet)
(square feet)
Site 2 - Road Crossing - Allowable Upon
P
Tributary B
No
3,224
2,432
Authorization
(square feet)
(square feet)
Site 2 - Road Crossing - Allowable Upon
T
Tributary B
No
169
199
Authorization
(square feet)
(square feet)
6h. Total buffer impacts:
Zone 1 Zone 2
Total Temporary impacts: 466.00 424.00
Zone 1 Zone 2
Total Permanent impacts: 7,077.00 6,282.00
Zone 1 Zone 2
Total combined buffer impacts: 7,543.00 6,706.00
6i. Comments:
E. Impact Justification and Mitigation U
1. Avoidance and Minimization
la. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*
The site was designed to reduce impacts to streams and wetlands on the Site. There are 1.814 acres of onsite wetlands of which only 0.146 acres are
proposed to be permanently impacted. There are 675 linear feet of onsite stream of which only 119 linear feet are proposed to be permanently
impacted.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Construction fencing will be used to define the construction corridor and prevent any accidental additional impacts. The Project will be phased so as to
prevent large areas of land disturbance that could contribute to sediment runoff into the streams and wetlands.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for impacts to Waters of the U.S. or Waters of the State?
F Yes r No
2c. If yes, mitigation is required by (check all that apply):
rd DWR W Corps
2d. If yes, which mitigation option(s) will be used for this project?
rd Mitigation bank r Payment to in -lieu fee r- Permittee Responsible
program Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
Resource Environmental Solutions, LLC and Wildlands Holdings III, LLC
3b. Credits Purchased/Requested (attach receipt and letter)
.............................................................................................................................................. ................
Type: Quantity:
Non -riparian wetland 0.12
Riparian wetland 0.03
3c. Comments
Resource Environmental Solutions, LLC, will provide 0.03 riparian wetland mitigation credits, and Wildlands Holdings III, LLC, will provide 0.12 non -
riparian wetland mitigation credit for the project.
NC Stream Temperature Classification Maps can be found under the Mitigation Concepts tab on the Wilmington District's RIBITS website.
6. Buffer mitigation (State Regulated Riparian Buffer Rules) - required by DWR

6a. Will the project result in an impact within a protected riparian buffer that requires buffer mitigation? If yes, you must fill out this entire form - please contact DWR for more
information.
f Yes r No
F. Stormwater Management and Diffuse Flow Plan (required by DWR) U
*** Recent changes to the stormwater rules have required updates to this section .***
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?
r Yes r No
1 b. All buffer impacts and high ground impacts require diffuse flow or other form of stormwater treatment. If the project is subject to a state implemented riparian buffer protection
program, include a plan that fully documents how diffuse flowwill be maintained.
All Stormwater Control Measures (SCM)s must be designed in accordance with the NC Stormwater Design Manual. Associated supplement forms and other documentation shall be
provided.
What type of SCM are you providing?
r Level Spreader
❑ Vegetated Conveyance (lower SHWT)
❑ Wetland Swale (higher SHWT)
[;Z Other SCM that removes minimum30% nitrogen
rl Proposed project will not create concentrated stormwater flowthrough the buffer
(check all that apply)
For a list of options to meet the diffuse flow requirements, click here.
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
r Yes r No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)? *
r Yes r No
To look up lowdensity requirement click here 15A NCAC 02H .1003(2)
2c. Does this project have a stormwater management plan (SMP) reviewed and approved under a state stormwater program or state -approved local government stormwater
program?
O Yes No
O N/A - project disturbs < 1 acre
Hnt: projects that have vested righs, exerrptiors, a grandrathering fron state a locally inplerented stormater programs a projects that satisfy state a locally-inplerrentei stormater programs through use of carrnnity irrlieu programs should answer no
to this question.
3. Stormwater Requirements
3a. Select whether a completed stormwater management plan (SMP) is included for review and approval or if calculations are provided to document the project will not cause
degradation of downstream surface waters.*
C Stormwater Management r Antidegradation
Plan Calculations
Comments:
The applicant requests the 401 Certification approval be conditioned to require the stormwater management plan be approved before any approved impacts may be conducted.
G. Supplementary Information 6
1. Environmental Documentation
la. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?*
C Yes (-- No
2. Violations (DWR Requirement)
2a. Is the site in violation of DWR Water Quality Certification Rules (15A NCAC 2H .0500), Isolated Wetland Rules (15A NCAC 2H .1300), or DWR Surface Water or Wetland Standards or
Riparian Buffer Rules (15A NCAC 2B .0200)? *
f Yes (-- No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in additional development, which could impact nearby downstream water quality?*
r' Yes r No
3b. If you answered "no," provide a short narrative description.

This is a stand alone project and not likely to be a catalyst for additional development.
4. Sewage Disposal (DWR Requirement)
4a.Issewage disposal required by DWR for this project?*
6 Yes r Nor N/A
4b. 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.
Municipal sewer is available o the site.
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?
r Yes (-- No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
f Yes (-- No
5d. Is another Federal agency involved?*
r Yes r= No
5e. Is this a DOT project located within Division's 1-8?*
r Yes r No
5f. Will you cut anytrees in order to conduct the work in waters of the U.S.?*
6' Yes r No
5g. Does this project involve bridge maintenance or removal?*
f Yes C_' No
Link to the NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-1,0-17-signed_NLEB-SLOPESRapps.pdf
5h. Does this project involve the construction/installation of a wind turbine(s)?'*
r Yes G No
r Unknown
5i. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers, mechanized pile drivers, etc.?*
r Yes E No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
A review of the NCNHP database dated September 20, 2021, indicates no known occurrences of federally protected species on or within 1.0 mile of
the Site.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
r Yes r• No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
NOAA Essential Fish Habitat Mapper
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to the State Historic Preservation Office Historic Properties Map (does not include archaeological data: http://gis.neder.gov/hpoweb/
7a. Will this project occur in or near an area that the state, federal or tribal governments have designated as having historic or cultural preservation status (e.g., National Historic
Trust designation or properties significant in North Carolina historyand archaeology)?*
r Yes (-- No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
A review of the NCSHPO database indicates five historic properties within 0.5 mile of the Site. Three properties are listed as "Surveyed Only" and two
properties are listed as "Surveyed Only - Gone." No historic properties are listed on the Site.
8. Flood Zone Designation (Corps Requirement)
Link to the FEMAFIoodplain Maps: https://rrse.fema.gov/portal/search
8a. Will this project occur in a FEMA-designated 100-year floodplain?
r Yes r• No
8c. What source(s) did you use to make the floodplain determination?*
FEMA Panel No. 3720064800J, effective 5/2/2006
Miscellaneous

Comments
Attachments:
Pre -construction Notification (PCN) Application Form
PCN Cover Letter
Agent Authorization Form
Figure 1-USGS Site Vicinity Map
Figure 2-Soil Survey Site Vicinity Map
Figure 3-PJD Wetland Sketch Map
Figure 4-NCSHPO Map
NCNHP Database Report
Impact Map
USACE ORM Spreadsheet
USACE PJD Approval
NCDWR Buffer Determination Letter
Please use the space below to attach all required documentation or any additional information you feel is helpful for application review. Documents should be combined into one
file when possible, with a Cover Letter, Table of Contents, and a Cover Sheet for each Section preferred.
Oickthe upload button a drag and drop files here to attach dccunent
02 - Oasis Church PCN Cover Letter Final.pdf
143.47KB
03 - 2-signed AGENT AUTHORIZATION FORM for 2018.27.pdf
191.37KB
04 - Figure 1 - 1828 USGS.pdf
2.21 MB
05 - Figure 2 - 1828 Soils.pdf
2.34MB
06 - Figure 3-PJD Sketch Map.pdf
679.27KB
07 - Figure4 - SHPO.pdf
286.46KB
08 - NHP Report - Oasis Church 09-20-2021.pdf
1011.83KB
09 - Oasis Church Enviro Impact Maps Set-2nd Submittal (1) (3).pdf
2.33MB
10 - ORM_Upload_Sheet_ Consolidated_NWPR_20200626 (2021.052) (8).xlsm - Impacts.pdf
30.49KB
11 - USACE PJD approval email for 1828 Ralph Stevens Road Submittal.pdf
186.75KB
12-NCDWR Buffer Determination Letter (NBRRO #19-253) for 1825 Ralph Stephens Road Site.pdf
3.95MB
File mst be FLF a IQvI7
Signature
[;a By checking the box and signing below, I certify that:
• The project proponent hereby certifies that all information contained herein is true, accurate, and complete to the best of my knowledge and belief'; and
• The project proponent hereby requests that the certifying authority review and take action on this CWA401 certification request within the applicable reasonable period of time.
• I have given true, accurate, and complete information on this form;
• I agree that submission of this PCN form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act");
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act");
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature; AND
• I intend to electronically sign and submit the PCN form.
Full Name:*
Ian McMillan
Signature *
Date
9/27/2021