20140063 Ver 1_401 Application_20140114

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20940063
Office Use Only
Corps action ID no
DWQ project no
Form Version 14 January 2009
Page 1 of 10
PCN Form -Version 14 January 2009
}
Pre - Construction Notification (PCN) Form
A.
Applicant Information
4
1.
_
Processing u
la
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
1c
Has the NWP or GP number been venfied by the Corpse
T C,Yes ❑ No
1d
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
le
Is this notification solely for the record
because wntten approval is not required?
For the record only for DWQ
401 Certification
❑ Yes I4 No
For the record only for Corps Permit
❑ Yes Pg No
1f
is 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 in -lieu fee program
❑ Yes No
1g
Is the project located in any of NC's twenty coastal counties If yes, answer 1 h
below
® Yes ❑ No
1 h Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes RI No
2.
Project Information
2a
Name of project
0y.\ S t ►r o A
2b
County
Cdr
2c
Nearest municipality / town
C S
2d
Subdivision name
l�
2e
NCDOT only, T I P or state project no
/V
3.
Owner Information
3a
Name(s) on Recorded Deed
rl Vic, mss oa5c,, . L 7 20l
3b
Deed Book and Page No
3�� -
3c
Responsible Party (for LLC if
applicable)
ny
IV 14
3d
Street address s'
op� ~� (Q 1 W
3e
City, state, zip
G a 3
3f
Telephone no
I �02 -3S7- 0(/ (o
3g
Fax no
3h
Email address
I pr1yyCe-9S,1g s h �►1A+ r COm
Page 1 of 10
PCN Form -Version 14 January 2009

4 Applicant Information (if different from owner)
4a Applicant is
❑ Agent ❑ Other, specify
4b Name
4c Business name
(if applicable)
4d Street address
4e City, state, zip
0 Telephone no
4g Fax no
4h Email address
5 AgenVConsultant 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

B.
Project Information and Prior Project History
1.
Property Identification
1a
Properly identification no (tax PIN or parcel ID)
1 b
Site coordinates (in decimal degrees)
Latitude 3 to - 57 Cqq (v, Longitude 7 fp 1 3 633
1c
Property size
a acres
2
Surface Waters
2a
Name of nearest body of water to proposed protect
T o1 m' dil e, Swam
2b
Water Quality Classification of nearest receiving water
CC N S W
2c
River basin
Ch vi n
3
Project Description
3a
Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this_
application C,-�rC�., l��A1n� I 5 Uri(Ui►n��Se. i 1rn.lw•�l. C�rr� Si��
3b
List the total estimated acreage of all existing wetlands on the property N
3c
List the total estimated linear feet of all existing streams (intermittent and perennial) on the property a
3d
Explain the purpose of the proposed protect Zr,S -VrAk 3 -'ctvw, c,,ro 9.1 ^6 A"b GLr O"S -�" pOSJ-
3e Describe the overall project in detail, inclu ing th type of equipment to be used '
� J
4
Jurisdictional Determinations
4a
Have tunsdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
Yes ❑ No ❑ Unknown
Comments
4b_ If the Corps made the jurisdictional determination, what type
of determination was made?
❑ Preliminary �`] Final
4c
If yes, who delineated the jurisdictional areas?
Name (if known) r
Agency /Consultant Company
Other
4d If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
Cor'P5vii S; -' ►a-�3 112,
5.
Project History
5a
Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
® Yes ❑ No ❑ Unknown
5b
If yes, explain in detail according to "help file" instructions
K W X9
6
Future Project Plans
6a
Is this a phased project?
❑ Yes No
6b
If yes, explain Al / A-
Page 3 of 10
PCN Form — Version 14 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
la Which sections were completed below for your project (check all that apply)
❑ Wetlands Streams — tributaries ❑ Buffers ❑ 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
-
W6 -
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 (T)
3b
Type of impact
3c
Stream name
3d
Perennial (PER) or
intermittent (INT)7
3e
Type of
jurisdiction
3f
Average
stream
width
(feet)
3g
Impact
length
(linear
feet)
S1 .P -
Choose one- I
W T 4bm: dd
'� � _
Q
S2 -
Choose one
-
S3 -
Choose one
-
-
S4 -
Choose one
-
S5 -
Choose one
-
-
S6 -
Choose one
-
-
3h Total stream and tributary impacts
31 Comments
Page 4 of 10
PCN Form — Version 14 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 indiv ually list all open water impacts below
4a
Open water
impact number
Permanent (P) or
Temporary
4b
Name of waterbody
(d applicable)
4c
Type of impact
4d
Waterbody
type
4e
Area of impact (acres)
01
Choose one
Choose
O2 -
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, the 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
Pt
Choose one
P2
Choose one
5f Total:
5g Comments
5h Is a dam high hazard permit required
❑ Yes ❑ No If yes, permit ID no
51 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 any impacts require mitigation, then you MUST fill out Section D of this form
6a. Project is in which protected basin?
❑ Neuse ❑ Tar - Pamlico ❑ Catawba ❑ Randleman ❑ Other
6b
Buffer Impact
number —
Permanent (P) or
Temporary
6c
Reason for impact
6d
Stream name
6e
Buffer
mitigation
required?
6f
Zone 1
impact
(square
feet )
6g
Zone 2
impact
(square
feet
B1 -
Yes/No
B2 -
Yes/No
B3 -
Yes/No
B4 -
Yes/No
B5 -
Yes/No
B6 -
Yes/No
6h Total Buffer impacts:
61 Comments
Page 5 of 10

D. Impact Justification and Mitigation
1 Avoidance and Minimization
1a Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
iY11 W„ v.v.� o.•- co.. -0-F 1- ,�.` h e.ta� �. � av: tiw ,C�ti C�V S A F �. AGC�S
-F+p �,rL,��S �.� �'vS � (j -c.r� c�eJ^' 2.1 � �►1� U
lb Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
1Nt. VtNC CN i r w 1^ Y, V GxcAZ Ano +r e^-, y-\v_ccc_G s G r� �D ((� (2) t��J Axc�e
w B.I� �'U-�, tY1 • v
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?
❑ Yes ff'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 N
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 Program
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 - npanan wetland mitigation requested
acres
4g Coastal (tidal) wetland mitigation requested
acres
4h Comments
5 Complete if Using a Permittee Responsible Mitigation Plan
5a If using a per ittee responsible mitigation plan, provide a description of the proposed mitigation plan
Page 6 of 10
PCN Form — Version 14 January 2009

6 Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a Will the project result in an impact within a protected riparian buffer that requires
Yes No
buffer mitigation?
6b if yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation Calculate the
amount of mitigation required
6c
6d
6e
Zone
Reason for impact
Total impact
Multiplier
Required mitigation
(square feet)
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
15
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
la
Does the project include or is it adjacent to protected riparian buffers identified
❑ Yes No
within one of the NC Riparian Buffer Protection Rules?
lb
If yes, then is a diffuse flow plan included? If no, explain why
❑ Yes ❑ No
2.
Stormwater Management Plan
2a
What is the overall percent imperviousness of this project?
2b
Does this project require a Stormwater Management Plan?
❑ Yes ONo
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 well be responsible for the review of the Stormwater Management Plan?
3.
Certified Local Government Stormwater Review
3a
In which local government's jurisdiction is this project?
❑ Phase II
❑ NSW
3b
Which of the following locally - implemented stormwater management programs
apply (check all that apply)
HWater Supply Watershed
❑ Other
3c
Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
4. DWQ Storrwater Program Review
[]Coastal counties
❑HQW
4a
Which of the following state - implemented stormwater management programs apply
❑ORW
(check all that apply)
❑Session Law 2006 -246
❑Other
4b
Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
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?
1Z r— ❑ No
Page 8 of 10
PCN Form — Version 14 January 2009

F. Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
la
Does the project involve an expenditure of public (federal /state /local) funds or the
❑ Yes No
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 requirements of the National or State
❑ Yes ❑ No
(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 NEPA or SEPA final approval
❑ Yes ❑ No
letter)
Comments
2
Violations (DWQ Requirement)
2a
Is the site in violation of DWQ Wetland Rules (15A NCAC 2H 0500), Isolated
Wetland Rules (15A NCAC 2H 1300), DWQ Surface Water or Wetland Standards,
❑ Yes No
or Riparian Buffer Rules (15A NCAC 213 0200)?
2b
Is this an after - the -fact permit application?
❑Yes No
2c
If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s)
3.
Cumulative Impacts (DWQ Requirement)
3a
Will this project (based on past and reasonably anticipated future impacts) result in
❑ Yes CQNo
additional development, which could impact nearby downstream water quality?
3b
If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy If you answered "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 lava, capacity of the subject facility � `
o ('p+. V�— W 0.� 0.71�c
-
�fable
O r S 14-C, J ✓O `^ `"�' ON
Page 9 of 10
PCN Form — Version 14 January 2009

5 Endangered Species and Designated Critical Habitat (Corps Requirement)
5a Will this project occur in or near an area with federally protected species or
❑Yes �.No
habitat?
5b Have you checked with the USFWS concerning Endangered Species Act
Yes ❑ No
impacts?
5c If yes, indicate the USFWS Field Office you have contacted�`g�g
h �y ►�p 5 j,
5d What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat? �-,,,e2p 5\
6 Essential Fish Habitat (Corps Requirement)
6a 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
Yes No
Phi
status (e g , National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b What data sources did you us determine whether your site would impact historic or archeological resources?
�a )l e.Zg�,
8. Flood Zone Designation (Corps Requirement)
8a Will this project occur in a FEMA - designated 100 -year floodplam?
19 Yes ❑ No
8b If yes, explain how project meets FEMA requirements
C,ove4- 4- s I24-�_ AO c�cw r`oa des��►. low
8c What source(s) did you use to make the floodplam determination? �� U
v==- -= ��
% '� ie!
Applicant/Agent's Printed Name
D
Applicant/Agent's Signature
( Agent's signature is valid only if an authorization
letter from the applicant is provided
Page 10 of 10

r'�5
V
U.S. ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Action Id SAW - 2013 -00495 County Gates U S.G S Quad VA- WHALEYVILLE
GENERAL PERMIT (REGIONAL AND NATIONWIDE) VERIFICATION
Penmttee• + Mrs. Princes Watson
Address 7801 Morning Glen Lane
Alexandria, VA. 22315
Telephone Number
Size (acres) 1.58
Nearest Waterway Buckland Mill Branch
USGS RUC 3010205
Location description The project area is located
town of Gates in Gates County, North Carolina.
Nearest Town Gates
River Basin Albemarle. North Carolina, Virginia.
Coordinates Latitude 36.509967
Longitude - 76.713633
on the south side Hof Willeyton Road approximately three miles east of the
Description of projects area and activity Applicant is proposing to install a driveway crossing through jurisdictional waters and
wetlands. Appropriately sized culvert and earthen fill will be utilized to construct the driveway crossing for a single family
dwelling.
Applicable Law ® Section 404 (Clean Water Act, 33 USC 1344)
❑ Section 10 (Rivers and Harbors Act, 33 USC 403)
Authorization. Regional General Permit Number or Nationwide Permit Number 14
SEE ATTACHED RGP or NWP GENERAL, REGIONAL AND SPECIAL CONDITIONS
Your work is authorized by the above referenced permit provided it is accomplished in strict accordance with the attached
conditions and your submitted application and attached information dated December 3. 1013. Any violation of the attached
conditions or deviation from your submitted plans may subject the permittee to a stop work order, a restoration order and/or
appropriate legal action.
This verification will remain valid until the expiration date identified below unless the nationwide authorization is modified,
suspended or revoked If, prior to the expiration date identified below, the nationwide permit authorization is reissued and/or
modified, this venfcation will remain valid until the expiration date identified below, provided it complies with all requirements of
the modified nationwide permit If the nationwide permit authorization expires or is suspended, revoked, or is modified, such that the
activity would no longer comply with the terms and conditions of the nationwide permit, activities which have commenced (i e, are
under construction) or are under contract to commence in reliance upon the nationwide permit, will remain authorized provided the
activity is completed within twelve months of the date of the nationwide permit's expiration, modification or revocation, unless
discretionary authority has been exercised on a case -by -case basis to modify, suspend or revoke the authorization
Activities subject to Section 404 (as indicated above) may also require an individual Section 401 Water Quality Certification You
should contact the NC Division of Water Quality (telephonc-919--80-7--63001 to determine Section 401 requirements
For activities occurring within the twenty coastal counties subject to regulation under the Coastal Area Management Act (CAMA),
prior to beginning work you must contact the N C Division of Coastal Management in Elizabeth City, NC, at (252) 264 -3901
This Department of the Army verification does not relieve the permittee of the responsibility to obtain any other required Federal,
State or local approvals /permits
If there are any questions regarding this verification, any of the conditions of the Permit, or the Corps of Engineers regttlatory
program, please contact K le Barnes at 910 - 2514584 or Kyle.W.BarnesAlusace.armv.mil
Corps Regulatory Official- Date: December 18, 2013
Expiration Date of Verification- 18, 2017

rn
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100 0 100 200
GRAPHIC SCALE
NOTES:
1 ) THIS PROPERTY IS SUBJECT TO ALL SETBACK
AND EASEMENT REQUIREMENTS SET FORTH BY GATES
COUNTY
2) THIS SURVEY WAS PERFORMED WITHOUT THE
TITLE REPORT AND MAY NOT REFLECT
BENEFlT OF A /
ALL EASEMENTS, RESTRICTIONS OR ENCUMBRANCES
THAT AFFECT THE SUBJECT PARCEL /
3) AREA BY COORDINATE METHOD
/ o /
CERTIFICATE OF ACCURACY
I, PAUL J TOTI, CERTIFY THAT THIS MAP WAS DRAWN
\ UNDER MY SUPERVISION FROM AN ACTUAL SURVEY MADE
BY ME DEED DESCRIPTION FOUND IN P.C. 3. SL, 30_ M.
� INDICATED BOUNDARIES NOT
FROM INFORMATION F CLEARLY
OUND IN P.X_
/ b115 1P �y 3. SL 30, M. 4. THAT THE RATIO OF PRECISION AS
,p sa CALCULATED IS 1 10,000 + THAT THIS PLAT MEETS THE
N/F �� \ REQUIREMENTS OF THE STANDARDS OF PRACTICE FOR
/
010 ,r,� _ LAND SURVEYING IN NORTH CAROLINA 21 NCAC 561600
O j \ WITNESS MY ORIGINAL IGNATURE, REG BER, AND
RMAL PARCEL \ SEAL THIS 10 DAY OF NUARY, 2014
s•
PC. 3, SL 3Q M. 4 \ t
`mss 9� d \ ' a F 0 '•-�(
LEGEND \ \ 5 _
— — EXISTING PROPERTY —R/W LINE \
PROPOSED R/W LINE c, \
0 EXISTING MONUMIENTATION
O
N/F
\ _D _B _23_2, PG. 908 mss` 1
L, 3L. 81, M. 1 \ _y
X11001318 \ s1
y 1 j �` \
\ \ 01 o� F
Ir
/y moo.
bro M 12 e e
2sa gy �
i h5 6O 160 N�
Y�0
Line Table
Line #
Length
Direction
L1
40.081
NO' 20' 07 81 "W
L2
23.259
S86' 01' 50.83 "W
L3
9.145
N56' 00' 45.93 "E
L4
51.770
N86° 01' 50.83 "E
L5
31.839
NO* 20' 07.81 "W
/ \ N/F
LOT 1
L N/F \ P.C. 3, SL 30, M. 4
RESIDUAL PARCEL \
PC. 3, SL. 30, M. 4 \
RIGHT OF WAY PLAT
FOR
HARRISON- TAYLOR ESTA
HASLETT TOWNSHIP
GATES COUNTY
D.B. 237, PG. 692
P.C. 1, SL 56, M. 2
#0400894
TE
NORTH CAROLINA
SCALE 1" = 100' PLAN STATUS Bowman Consulting Group, Ltd C -3556
JOB No4841 -01 -001 145 East Rich Boulevard, Suite
Elizabeth City, NC 27909
DATE 2014 -01 -10 Phone [phone]
FILE No 13035 Fax [phone] owm n
www bowmanconsulting com
SHEET 1 OF 1 DATE DESCRIPTION © Bowman Consulting Group, Ltd % a N S U L T I N G