20220044 Ver 1_401 Application_20220105

Staff Review
Does this application have all the attachments needed to accept it into the review process?*
Yes No
ID# *
20220044
Version* 1
Is this project a public transportation project?* Yes
• No
Reviewer List: * Sue Homewood:eads\slhomewood
Select Reviewing Office: * Winston-Salem Regional Office - [phone]
Submittal Type:* 401 Application
Does this project require a request for payment to be sent?*
Yes
No
How much is owed?* $240.00
$570.00

Project Submittal Form
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.
Project Type: * For the Record Only (Courtesy Copy)
New Project
Modification/New Project with Existing ID
More Information Response
Other Agency Comments
Pre -Application Submittal
Re-Issuance\Renewal Request
Stream or Buffer Appeal
Project Contact Information
Name: Heather LaGamba
Who is submitting the information?
Email Address: [e-mail]
Project Information
Project Name: Center Grove Church Rd
Is this a public transportation project?
Yes
No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
Yes No Unknown
County (ies)
Forsyth
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
5343.1_Grove Park_PCN_1.5.2022.pdf 6.36MB
Only pdf or kmz files are accepted.
Describe the attachments or
comments:
PCN for 401 WQC
Sign and Submit
By checking the box and signing box below, I certify that:
• I, the project proponent, hereby certifies that all information contained herein is true, accurate, and complete to the
best of my knowledge and belief.
• I, the project proponent, hereby requests that the certifying authority review and take action on this CWA 401
certification request within the applicable reasonable period of time.
• I agree that submission of this online 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 online form.
Signature:
0. 16�11-11 ,
Submittal Date: Is filled in automatically.

Preliminary ORM Data Entry Fields for New Actions
ACTION ID 4: SAW- 2020-02230 Begin Date (Date Received): 1.5.2022
Prepare file folder ❑ Assign Action ID Number in ORM ❑
1. Project Name [PCN Form A2a]: Center Grove Church Road
2. Work Type: ZPrivate ❑Institutional ❑Government ❑ Commercial
3. Project Description / Purpose [PCN Form 133d and 133e]:
The site is an approximate 40-acre tract located south of Center Grove Church Road in Clemmons, Forsyth County, North Carolina.
The site contains wooded land and fields. The site is proposed for residential development.
4. Property Owner / Applicant [PCN Form A3 or A4]: Sandra and Paul Ivey
5. Agent / Consultant [PNC Form A5 — or ORM Consultant ID Number]:
Pilot Environmental/Michael Brame
6. Related Action ID Number(s) [PCN Form 135b]:
7. Project Location —Coordinates, Street Address, and/or Location Description [PCN Form Blb]:
Center Grove Church Road, Clemmons, Forsyth County, North Carolina
36.0483300,-80.4239580
8. Project Location —Tax Parcel ID [PCN Form Bla]: 5873-89-8489
9. Project Location — County [PCN Form A2b]: Forsyth County
10. Project Location — Nearest Municipality or Town [PCN Form A2c]: Clemmons
11. Project Information — Nearest Waterbody [PCN Form 132a]: Yadkin River
12. Watershed / 8-Digit Hydrologic Unit Code [PCN Form 132c]: Yadkin Pee Dee / 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

nA�
NORTH CAROLINA
Environmental Quality
Water Resources
Office Use Only
Corps Action ID no. 2020-02230 Date received: 1/5/2022
DWR project no.
Date received: 1/5/2022
Site Coordinates:
Latitude (DD.DDDDDD): 36.048230'
Longitude (DD.DDDDDD): 80.423948'
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) *: Click or tap to enter a date.
DWR ID # Click to enter. 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.
1 d. 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
1 g. 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?
Greg Garrett
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 ❑x 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:
Paul D. Ivey, Trustee
2b.
Deed Book and Page No.:
002897/01449
2c.
Responsible Party (for corporations):
Paul Ivey
2d.
Address
Street Address:
306 Pipers Lane
Address line 2:
Click to 'M ILIM .
City:
Myrtle Beach
State/ Province/ Region:
North Carolina
Postal/ Zip Code:
29575
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:
Greg Garrett
3b.
Business Name (if applicable):
RS Parker Homes, LLC
3c.
Address:
Street Address:
502 Hickory Ridge Drive
Address line 2:
Clicktu MILM.
City:
Greensboro
State/ Province/ Region:
NC
Postal/ Zip Code:
27409
Country
US
3d.
Telephone Number: (###)###-####
[phone]
3e
Fax Number: (###)###-####
UICK io enier.
Page 3 of 21 PCN Form - Version 1.5, September 2020

3f. Email Address: [e-mail]
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
1 a. Name of project:
Grove Park
1 b. Subdivision name (if appropriate):
Click to enter.
1 c. Nearest municipality/town: *
Clemmons, NC
2.
Project Identification
2a.
Property identification number (tax PIN or parcel ID):
5873-89-8489.00
2b.
Property size (in acres):
40
2c.
Project Address:
Street Address:
Center Grove Road
Address line 2:
Click to ente,
City:
Clemmons
State/ Province/ Region:
NC
Postal/ Zip Code:
29575
Country:
U.S.
2d.
Site coordinates in decimal degrees (using 4-6 digits
after the decimal point):
Latitude (DD.DDDDDD): 36.048230'
Longitude (-DD.DDDDDD):-80.423948'
3. Surface Waters
3a. Name of nearest body of water to proposed project:
Yadkin River
3b. Water Resources Classification of nearest receiving
WS-Iv
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
030401011501
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 site contains wooded land and fields. Surrounding properties contain residential and agricultural
structures, a church, fields and wooded land.
4b.
Have Corps permits or DWR certifications been obtained for this
❑ Yes ❑X No ❑ Unknown
project (including all prior phases) in the past?
4c.
If yes, please give the DWR Certification number and/or Corps
2020-02230
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
0.846 acres
property:
4g.
List the total estimated linear feet of all existing streams (intermittent
3,110 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 30 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 30 lot single family residential subdivision. In order to facilitate the
proposed development and access 16 of the lots, it is necessary to cross an intermittent stream. In order to access,
construct and maintain septic on the site, it is necessary to cross a perennial 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 November 13, 2019. Pilot submitted a PJD request on November
18, 2019. Pilot met Mr. Bryan Rhoden -Reynolds with the USACE on February 11, 2020 (Corps Action ID SAW-2020-
02230). A PJD was issued on February 20, 2020. The USACE concurred with the delineation as depicted on Drawing
5 (attached).
Name (if known): David Brame/Michael Brame
5b. If 5a is yes, who delineated the jurisdictional
Agency/Consultant Company: Pilot Environmental
areas?
Other: slick to entei
5c. If the Corps made a jurisdictional determination,
❑X Preliminary ❑ Approved ❑ Emailed Concurrence
what type of determination was made?
❑ Not Verified ❑ Unknown
Corps AID number (ex. SAW-0000-00000):
SAW — 2020-02230
Page 6 of 21 PCN Form - Version 1.5, September 2020

5d. List the dates of the Corps jurisdictional determination or State determination if a determination was made by
either agency.
USACE — PJD issued February 20, 2020.
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.
The site is proposed for residential development. In order to access 16 of the 30 lots, a road crossing must be
constructed. In order to access, construct and maintain the septic field, as additional crossing must be installed.
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
Choose one
Click to
Perm
enter
W2
Choose one
Temp/
Click to enter
Choose one
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:
Wetlnd 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
Temp/ Perm
Unnamed (SB)
Intermittent
Both
3.67/3.58/6
118/12/15
S2
Crossing/ Culvert
Temp/ Perm
Unnamed (SA)
Perennial
Both
6.19/6.71/13.3
57/60/15
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:
247 linear ft
36.
Total temporary stream impacts:
30 linear ft
3i4.
Total stream and ditch impacts:
277 linear ft
3j.
Comments:
Stream Crossing 1 — Proposed Culvert Impact = 118 linear feet/474 square feet, Proposed Rip Rap (to be keyed
in) = 12 linear feet/43 square feet, Proposed Pump Around/Coffer Dam = 15 linear feet/90 square feet.
Stream Crossing 2 — Proposed Culvert Impact = 57 linear feet/353 square feet, Proposed Rip Rap (to be keyed
in) = 60 linear feet/403 square feet, Proposed Pump Around/Coffer Dam = 15 linear feet/200 square feet.
Total Cuvert Impacts = 175 linear feet/827 square feet/0.019 acres
Total Rip Rap Impacts = 72 linear feet/446 linear feet/0.011 acres
Temporary Impacts = 30 linear feet/290 square feet/0.007 acres
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 the wetlands on the site and the remainder
of the streams. The road crossings have been designed as narrow as practicable to minimize impacts to the streams.
Head walls and endwalls are being used to minimize impacts. The remaining roads, lots, utilities and septic fields
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. 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:
Mitigation is not required or proposed.
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 ❑x 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

❑ Phase II ❑ USMP
Local Government Stormwater Programs
❑ NSW ❑x Water Supply
Please identify which local government stormwater program you are using.
Winston-Salem
❑ Phase II ❑ HQW or ORW
State Stormwater Programs
❑ Coastal Counties ❑ Other
Comments:
A SWMP was required under the low density provisions and will be submitted to the Winston-Salem for review
and approval.
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
requirements of the National or State (North Carolina) Environmental
❑ Yes ❑ No
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 ❑x 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 on -site septic systems. In order to access, construct and maintain one of the septic
fields, it is necessary to impact a stream. The septic lines will be located in the shoulder to avoid additional impactds.
The proposed impacts are included in Section D of this application. Other impacts are not anticipated or 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.
:,hoose 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 ❑x No
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
7 listed species are identified on the IPaC report (attached). The Red Cockaded Woodpecker, Neuse River Waterdog,
Carolina Madtom, Atlantic Pigtoe, Dwarf Wedgemussel, Monarch Butterfly and Michaux's Sumac are federally listed
species. Potential habitat for these species is not located on the site.
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?
❑ Yes
❑x No
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:
Click to enter.
Page 18 of 21 PCN Form - Version 1.5, September 2020

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
preservation status (e.g., National Historic Trust designation or
❑ Yes ❑x No
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. Two "survey only"
properties are depicted on adjacent property southeast of the site. 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:
Please let me know if you need additional information in order to process this application.
Attach pertinent documentation or attachments not previously requested
I. Signature *
0 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
Michael D,g,tAy,,g—d by Michael Brame
DN: m=Mi N I Brame, o=Pilot
Signature: e ,o me tzl,lnc.,o
Brame D— 202..01.05P50tl.170 0 e US
1 /5/2022
Page 21 of 21 PCN Form - Version 1.5, September 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: oc,�,_r olrovc bhuwckn
CkC-M'AgY\s, t� c
Owner Information: f
Name: RE)
Address:
Telephone Number: 31:1
Fax Number:
E-mail Address:
brq&or�ry ek �JdP_u, f1, c--c w\
Signature: a,Date; � Q � 1 Lo1',)1

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: 0 Center Grove Church Rd
Clemmnns NC ?7nl?
Paul lwe
Owner Information:
Address: 306 Pipers Lane
Telephone Number:
Fax Number:
252-241-6208
Address:.. - 0_n - @ _ .r
JURISDICTIONAL DETERMINATION REQUEST
D. PROPERTY ACCESS CERTIFICATION
By signing below, I authorize representatives of the Wilmington District, U.S. Army Corps of
Engineers (Corps) to enter upon the property herein described for the purpose of conducting on -
site investigations, if necessary, and issuing a jurisdictional determination pursuant to Section
404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors Act of 1899. I, the
undersigned, am either a duly authorized owner of record of the property identified herein, or
acting as the duly authorized agent of the owner of record of the property.
Pahl n Ivan
Print Name
Capacity: Owner — Authorized Agent
12,102/2019
01 59 PM EST
Date
Signature

11/6/2019
Print Property Info
Property Summary
Tax Year: 2019
REID
5873898489000
PIN 5873-89-8489
Property Owner Ivey, Paul D Trustee
Location Address
0 Center Grove Church RD
property Description L0033 BL4402
Owner's Mailing Address 306 Pipers LN
Myrtle Beach SC 29575
Administrative Data
Transfer Information
Property Value
Old Map #
576838
Deed Date 6/18/2009
Total Appraised Land Value $515,500
Market Area
70003
Deed Book 002897
Total Appraised Building Value
Township
LEWISVILLE
Deed Page 01449
Total Appraised Misc
Improvements Value
Planning
COUNTY WIDE
Revenue Stamps
Jurisdiction
Total Cost Value $515,500
Package Sale Date
City
Total Appraised Value -valued $515,500
Package Sale Price
CLEMMONS FIRE
By cost
Fire District
DIST
Land Sale Date 6/18/2009
Other Exemptions
Spec District
COUNTYWIDE FIRE
Land Sale Price
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
39.93
Total Taxable Value $515,500
Total Living Area
0
Permit Date
Total Gross Leasable Area
0
Permit #
Building Summary
Misc Improvements Summary
Card Unit Measure Type Base
# Quantity Price
No Data
Total Misc Improvements Value Assessed:
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: 39.93
Zoning Soil Class Description Size
AG RES-ACREAGE 39.93 BY THE ACRE PRICE
Total Land Value Assessed: $515,500
Ownership History
Owner Name
Current Ivey, Paul D Trustee
1 Back Rivers, Emma Hege
Calculated Acres: 40.53
Rate Land Adjustment
$18,500 TOPOGRAPHY-85.00
SHAPE-95.00
Land Value
$515,500
Deed Type
% Ownership Stamps Sale Price Book
Page
Deed Date
DEED
100 0 002897
01449
6/18/2009
DEED
100 0 000000
00000
1/1/1995
Notes Summary
Building Card Date
tellus.co.forsyth.nc.us/Ircpwa/PrintPRC.aspx?PARCELPK=82254
Line
Notes
1/2

ffi/L:iNIM]
Building Card
Print Property Info
Date Line Notes
No Data
tellus.co.forsyth.nc.us/Ircpwa/PrintPRC.aspx?PARCELPK=82254 2/2

U.S. ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Action Id. SAW-2019-02230 County: Forsyth U.S.G.S. Quad: NC- Clemmons
NOTIFICATION OF JURISDICTIONAL DETERMINATION
Requestor: Sandra B. Ivey Family Trust
Paul Ivey
Address: 306 Pipers Lane
Myrtle Beach, SC 29775
Telephone Number: 336-701-9110
E-mail: hope.harris(a)allentate.com
Size (acres) —40 Nearest Town Clemmons
Nearest Waterway Yadkin River River Basin Upper Pee Dee
USGS HUC 03040101 Coordinates Latitude: 36.04833
Longitude:-80.423958
Location description: The review area is located on the south side of Center Grove Church Road; approximately 0.5 miles west
of the intersection of Center Grove Church Road and Lasater Road. PIN: 5873-89-8489. Reference review area description
shown in Jurisdictional Determination Request nackage entitled "Drawing L USGS Tonogranhic Mad'.
Indicate Which of the Following Apply:
A. Preliminary Determination
® There appear to be waters, including wetlands on the above described project area/property, that may be subject to Section 404
of the Clean Water Act (CWA)(33 USC § 1344) and/or Section 10 of the Rivers and Harbors Act (RHA) (33 USC § 403). The
waters, including wetlands have been delineated, and the delineation has been verified by the Corps to be sufficiently accurate
and reliable. The approximate boundaries of these waters are shown on the enclosed delineation map dated 11/18/2019. Therefore
this preliminary jurisdiction determination may be used in the permit evaluation process, including determining compensatory
mitigation. For purposes of computation of impacts, compensatory mitigation requirements, and other resource protection
measures, a permit decision made on the basis of a preliminary JD will treat all waters and wetlands that would be affected in any
way by the permitted activity on the site as if they are jurisdictional waters of the U.S. This preliminary determination is not an
appealable action under the Regulatory Program Administrative Appeal Process (Reference 33 CFR Part 331). However, you may
request an approved JD, which is an appealable action, by contacting the Corps district for further instruction.
❑ There appear to be waters, including wetlands on the above described project area/property, that may be subject to Section 404
of the Clean Water Act (CWA)(33 USC § 1344) and/or Section 10 of the Rivers and Harbors Act (RHA) (33 USC § 403).
However, since the waters, including wetlands have not been properly delineated, this preliminary jurisdiction determination
may not be used in the permit evaluation process. Without a verified wetland delineation, this preliminary determination is
merely an effective presumption of CWA/RHA jurisdiction over all of the waters, including wetlands at the project area, which
is not sufficiently accurate and reliable to support an enforceable permit decision. We recommend that you have the waters,
including wetlands on your project area/property delineated. As the Corps may not be able to accomplish this wetland
delineation in a timely manner, you may wish to obtain a consultant to conduct a delineation that can be verified by the Corps.
B. Approved Determination
❑ There are Navigable Waters of the United States within the above described project area/property subject to the permit
requirements of Section 10 of the Rivers and Harbors Act (RHA) (33 USC § 403) and Section 404 of the Clean Water Act
(CWA)(33 USC § 1344). Unless there is a change in law or our published regulations, this determination may be relied upon for
a period not to exceed five years from the date of this notification.
❑ There are waters, including wetlandson the above described project area/property subject to the permit requirements of Section
404 of the Clean Water Act (CWA) (33 USC § 1344). Unless there is a change in the law or our published regulations, this
determination may be relied upon for a period not to exceed five years from the date of this notification.
❑ We recommend you have the waters, including wetlands on your project area/property delineated. As the Corps may not be
able to accomplish this wetland delineation in a timely manner, you may wish to obtain a consultant to conduct a delineation that
can be verified by the Corps.

SAW-2019-02230
❑ The waters, including wetlands on your project area/property have been delineated and the delineation has been verified by
the Corps. The approximate boundaries of these waters are shown on the enclosed delineation map dated DATE. We strongly
suggest you have this delineation surveyed. Upon completion, this survey should be reviewed and verified by the Corps. Once
verified, this survey will provide an accurate depiction of all areas subject to CWA jurisdiction on your property which, provided
there is no change in the law or our published regulations, may be relied upon for a period not to exceed five years.
❑ The waters, including wetlands have been delineated and surveyed and are accurately depicted on the plat signed by the
Corps Regulatory Official identified below onDATE. Unless there is a change in the law or our published regulations, this
determination may be relied upon for a period not to exceed five years from the date of this notification.
❑ There are no waters of the U.S., to include wetlands, present on the above described project area/property which are subject to the
permit requirements of Section 404 of the Clean Water Act (33 USC 1344). Unless there is a change in the law or our published
regulations, this determination may be relied upon for a period not to exceed five years from the date of this notification.
❑ The property is located in one of the 20 Coastal Counties subject to regulation under the Coastal Area Management Act (CAMA).
You should contact the Division of Coastal Management in Morehead City, NC, at [phone] to determine their
requirements.
Placement of dredged or fill material within waters of the US, including wetlands, without a Department of the Army permit may
constitute a violation of Section 301 of the Clean Water Act (33 USC § 1311). Placement of dredged or fill material, construction or
placement of structures, or work within navigable waters of the United States without a Department of the Army permit may
constitute a violation of Sections 9 and/or 10 of the Rivers and Harbors Act (33 USC § 401 and/or 403). If you have any questions
regarding this determination and/or the Corps regulatory program, please contact Bryan Roden -Reynolds at 704-510-1440 or
b rvan.roden-revnoldsnn ,u sace.armv.mil.
C. Basis For Determination: Basis For Determination: See the preliminary jurisdictional determination
form dated 2/20/2020.
D. Remarks: None.
E. Attention USDA Program Participants
This delineation/determination has been conducted to identify the limits of Corps' Clean Water Act jurisdiction for the particular site
identified in this request. The delineation/determination may not be valid for the wetland conservation provisions of the Food Security
Act of 1985. If you or your tenant are USDA Program participants, or anticipate participation in USDA programs, you should request
a certified wetland determination from the local office of the Natural Resources Conservation Service, prior to starting work.
F. Appeals Information (This information applies only to approved jurisdictional determinations as indicated in B.
above)
This correspondence constitutes an approved jurisdictional determination for the above described site. If you object to this
determination, you may request an administrative appeal under Corps regulations at 33 CFR Part 331. Enclosed you will find a
Notification of Appeal Process (NAP) fact sheet and request for appeal (RFA) form. If you request to appeal this determination you
must submit a completed RFA form to the following address:
US Army Corps of Engineers
South Atlantic Division
Attn: Phillip Shannin, Review Officer
60 Forsyth Street SW, Room 1OM15
Atlanta, Georgia 30303-8801
In order for an RFA to be accepted by the Corps, the Corps must determine that it is complete, that it meets the criteria for appeal
under 33 CFR part 331.5, and that it has been received by the Division Office within 60 days of the date of the NAP. Should you
decide to submit an RFA form, it must be received at the above address by Not applicable.
**It is not necessary to submit an RFA form to the Division Office if you do not object to the determination in this correspondence.**
RODEN Digitally signed by RODEN
REYNOLDS.BRYAN.KENNETH.1263385574
Corps Regulatory Official: REYNOLDS.BRYAN.KENNETH.1263385574 Date: 2020.02.20 09:07:09 -05-00-
Date of JD: 2/20/2020 Expiration Date of JD: Not applicable

SAW-2019-02230
The Wilmington District is committed to providing the highest level of support to the public. To help us ensure we
continue to do so, please complete the Customer Satisfaction Survey located at
http://corpsmapu.usace.army.mil/cm_apex/f?p=136:4:0
Copy furnished:
Agent:
Pilot Environmental, Inc.
Spencer Burnett
Address:
P.O. Box 128
Kernersville, NC 27285
Telephone Number:
336-310-4527
E-mail:
sburnettna,pilotenviro.com

NOTIFICATION OF ADMINISTRATIVE APPEAL OPTIONS AND PROCESS AND
REQUEST FOR APPEAL
Applicant: Sandra B. Ivey Family Trust, Paul Ivey File Number: SAW-2019-02230
Date: 2/20/2020
Attached
is:
See Section below
❑
INITIAL PROFFERED PERMIT Standard Permit or Letter ofpermission)
A
❑
PROFFERED PERMIT Standard Permit or Letter ofpermission)
B
❑
PERMIT DENIAL
C
❑
APPROVED JURISDICTIONAL DETERMINATION
D
M1
PRELIMINARY JURISDICTIONAL DETERMINATION
E
SECTION I - The following identifies your rights and options regarding an administrative appeal of the above decision.
Additional information may be found at or http://www.usace.army.miUMissions/CivilWorks/RegulatoryProgramandPermits.asi)
or the Corps regulations at 33 CFR Part 331.
A: INITIAL PROFFERED PERMIT: You may accept or object to the permit.
• ACCEPT: If you received a Standard Permit, you may sign the permit document and return it to the district engineer for final
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all
rights to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the
permit.
• OBJECT: If you object to the permit (Standard or LOP) because of certain terms and conditions therein, you may request
that the permit be modified accordingly. You must complete Section II of this form and return the form to the district
engineer. Your objections must be received by the district engineer within 60 days of the date of this notice, or you will
forfeit your right to appeal the permit in the future. Upon receipt of your letter, the district engineer will evaluate your
objections and may: (a) modify the permit to address all of your concerns, (b) modify the permit to address some of your
objections, or (c) not modify the permit having determined that the permit should be issued as previously written. After
evaluating your objections, the district engineer will send you a proffered permit for your reconsideration, as indicated in
Section B below.
B: PROFFERED PERMIT: You may accept or appeal the permit
• ACCEPT: If you received a Standard Permit, you may sign the permit document and return it to the district engineer for final
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all
rights to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the
permit.
• APPEAL: If you choose to decline the proffered permit (Standard or LOP) because of certain terms and conditions therein,
you may appeal the declined permit under the Corps of Engineers Admilstrative Appeal Process by completing Section II of
this form and sending the form to the division engineer. This form must be received by the division engineer within 60 days
of the date of this notice.
C: PERMIT DENIAL: You may appeal the denial of a permit under the Corps of Engineers Administrative Appeal Process by
completing Section II of this form and sending the form to the division engineer. This form must be received by the division
engineer within 60 days of the date of this notice.
D: APPROVED JURISDICTIONAL DETERMINATION: You may accept or appeal the approved JD or provide new
information.
• ACCEPT: You do not need to notify the Corps to accept an approved JD. Failure to notify the Corps within 60 days of the
date of this notice, means that you accept the approved JD in its entirety, and waive all rights to appeal the approved JD.
• APPEAL: If you disagree with the approved JD, you may appeal the approved JD under the Corps of Engineers
Administrative Appeal Process by completing Section II of this form and sending the form to the district engineer. This form
must be received by the division engineer within 60 days of the date of this notice.
E: PRELIMINARY JURISDICTIONAL DETERMINATION: You do not need to respond to the Corps regarding the
preliminary JD. The Preliminary JD is not appealable. If you wish, you may request an approved JD (which may be appealed),
by contacting the Corps district for further instruction. Also you may provide new information for further consideration by the
Corps to reevaluate the JD.

SECTION II - REQUEST FOR APPEAL or OBJECTIONS TO AN INITIAL PROFFERED PERMIT
REASONS FOR APPEAL OR OBJECTIONS: (Describe your reasons for appealing the decision or your objections to an initial
proffered permit in clear concise statements. You may attach additional information to this form to clarify where your reasons or
objections are addressed in the administrative record.)
ADDITIONAL INFORMATION: The appeal is limited to a review of the administrative record, the Corps memorandum for the
record of the appeal conference or meeting, and any supplemental information that the review officer has determined is needed to
clarify the administrative record. Neither the appellant nor the Corps may add new information or analyses to the record.
However, you may provide additional information to clarify the location of information that is already in the administrative
record.
POINT OF CONTACT FOR QUESTIONS OR INFORMATION:
If you have questions regarding this decision and/or the
If you only have questions regarding the appeal process you may
appeal process you may contact:
also contact:
District Engineer, Wilmington Regulatory Division
Mr. Phillip Shannin, Administrative Appeal Review Officer
Attn: Bryan Roden -Reynolds
CESAD-PDO
Charlotte Regulatory Office
U.S. Army Corps of Engineers, South Atlantic Division
U.S Army Corps of Engineers
60 Forsyth Street, Room 1 OM15
8430 University Executive Park Drive, Suite 615
Atlanta, Georgia 30303-8801
Charlotte, North Carolina 28262
Phone: [phone]
RIGHT OF ENTRY: Your signature below grants the right of entry to Corps of Engineers personnel, and any government
consultants, to conduct investigations of the project site during the course of the appeal process. You will be provided a 15 day
notice of any site investigation, and will have the opportunity to participate in all site investigations.
Date:
Telephone number:
Signature of appellant or agent.
For appeals on Initial Proffered Permits send this form to:
District Engineer, Wilmington Regulatory Division, Attn: Bryan Roden -Reynolds, 69 Darlington Avenue, Wilmington, North
Carolina 28403
For Permit denials, Proffered Permits and Approved Jurisdictional Determinations send this form to:
Division Engineer, Commander, U.S. Army Engineer Division, South Atlantic, Attn: Mr. Phillip Shannin, Administrative
Appeal Officer, CESAD-PDO, 60 Forsyth Street, Room 1OM15, Atlanta, Georgia 30303-8801
Phone: [phone]

PRELIMINARY JURISDICTIONAL DETERMINATION (PJD) FORM
BACKGROUND INFORMATION
A. REPORT COMPLETION DATE FOR PJD: 2/20/2020
B. NAME AND ADDRESS OF PERSON REQUESTING PJD: Sandra B. Ivey Family Trust, Paul Ivey, 306
Pipers Lane, Myrtle Beach, SC 29775
C. DISTRICT OFFICE, FILE NAME, AND NUMBER: Wilmington District, Center Grove Church Road, SAW-
2019-02230
D. PROJECT LOCATION(S) AND BACKGROUND INFORMATION: The review area is located on the south side
of Center Grove Church Road: approximately 0.5 miles west of the intersection of Center Grove Church Road and
Lasater Road. PIN: 5873-89-8489. Reference review area description shown in Jurisdictional Determination Request
package entitled "Drawing 1, USGS Topographic Map".
(USE THE TABLE BELOW TO DOCUMENT MULTIPLE AQUATIC RESOURCES AND/OR
AQUATIC RESOURCES AT DIFFERENT SITES)
State: NC County: Forsyth City: Clemmons
Center coordinates of site (lat/long in degree decimal format): Latitude: 36.04833 Longitude:-80.423958
Universal Transverse Mercator:
Name of nearest waterbody: Yadkin River
E. REVIEW PERFORMED FOR SITE EVALUATION (CHECK ALL THAT APPLY):
❑ Office (Desk) Determination. Date:
® Field Determination. Date(s): 02/13/2020
TABLE OF AQUATIC RESOURCES INREVIEW AREA WHICH "MAY BE" SUBJECT TO REGULATORY
JURISDICTION.
Estimated amount of
Type of aquatic
Geographic authority to
Latitude (decimal
Longitude (decimal
aquatic resources in
resources (i.e.,
which the aquatic resource
11may
Site Number
degrees)
degrees)
review area (acreage
wetland vs. non -
be" subject (i.e.,
and linear feet, if
wetland waters)
Section 404 or Section
applicable
10/404)
SEE ATTACHED TABLE
1) The Corps of Engineers believes that there may be jurisdictional aquatic resources in the review
area, and the requestor of this PJD is hereby advised of his or her option to request and obtain an
approved JD (AJD) for that review area based on an informed decision after having discussed the
various types of JDs and their characteristics and circumstances when they may be appropriate.
2) In any circumstance where a permit applicant obtains an individual permit, or a Nationwide General
Permit (NWP) or other general permit verification requiring "pre- construction notification" (PCN), or
requests verification for a non -reporting NWP or other general permit, and the permit applicant has
not requested an AJD for the activity, the permit applicant is hereby made aware that: (1) the permit
applicant has elected to seek a permit authorization based on a PJD, which does not make an official
determination of jurisdictional aquatic resources; (2) the applicant has the option to request an AJD
before accepting the terms and conditions of the permit authorization, and that basing a permit
authorization on an AJD could possibly result in less compensatory mitigation being required or
different special conditions; (3) the applicant has the right to request an individual permit rather than
accepting the terms and conditions of the NWP or other general permit authorization; (4) the applicant
can accept a permit authorization and thereby agree to comply with all the terms and conditions of that

permit, including whatever mitigation requirements the Corps has determined to be necessary; (5)
undertaking any activity in reliance upon the subject permit authorization without requesting an AJD
constitutes the applicant's acceptance of the use of the PJD; (6) accepting a permit authorization (e.g.,
signing a proffered individual permit) or undertaking any activity in reliance on any form of Corps
permit authorization based on a PJD constitutes agreement that all aquatic resources in the review area
affected in any way by that activity will be treated as jurisdictional, and waives any challenge to such
jurisdiction in any administrative orjudicial compliance or enforcement action, or in any
administrative appeal or in any Federal court; and (7) whether the applicant elects to use either an AID
or a PJD, the JD will be processed as soon as practicable. Further, an AID, a proffered individual
permit (and all terms and conditions contained therein), or individual permit denial can be
administratively appealed pursuant to 33 C.F.R. Part 331. If, during an administrative appeal, it
becomes appropriate to make an official determination whether geographic jurisdiction exists over
aquatic resources in the review area, or to provide an official delineation of jurisdictional aquatic
resources in the review area, the Corps will provide an AID to accomplish that result, as soon as is
practicable. This PJD finds that there "may be" waters of the U.S. and/or that there "may be"
navigable waters of the U.S. on the subject review area, and identifies all aquatic features in the
review area that could be affected by the proposed activity, based on the following information:

SUPPORTING DATA. Data reviewed for PJD (check all that apply)
Checked items should be included in subject file. Appropriately reference sources below where
indicated for all checked items:
® Maps, plans, plots or plat submitted by or on behalf of the PJD requestor:
Map: Drawings 1-5
® Data sheets prepared/submitted by or on behalf of the PJD requestor.
® Office concurs with data sheets/delineation report.
❑ Office does not concur with data sheets/delineation report. Rationale:
❑ Data sheets prepared by the Corps:
❑ Corps navigable waters' study:
❑ U.S. Geological Survey Hydrologic Atlas:
❑ USGS NHD data.
❑ USGS 8 and 12 digit HUC maps.
® U.S. Geological Survey map(s). Cite scale & quadname: Drawing 1, USGS Topographic Map (1:24,000
Clemmons, NC)
® Natural Resources Conservation Service Soil Survey. Citation: Drawing 2, Web Soil Map (Web Soil Survey of
Forsyth County) and Drawing 2A, Published Soil Map (Soil Survey of Forsyth County)
® National wetlands inventory map(s). Cite name: Drawing 3, NWI Map (USFWS NWI Mapper)
❑ State/local wetland inventory map(s):
® FEMA/FIRM maps: Drawing 4, FEMA FIRM (National Flood Hazard Layer)
❑ 100-year Floodplain Elevation is: (National Geodetic Vertical Datum of 1929)
® Photographs: ®Aerial (Name & Date): Drawing 5, Wetland Map (Dated 11/18/2019)
or ❑Other (Name & Date):
❑ Previous determination(s). File no. and date of response letter:
❑ Other information (please specify):
IMPORTANT NOTE: The information recorded on this form has not necessarily been
verified by the Corps and should not be relied upon for later Jurisdictional determinations.
RODEN
Digitally signed by RODEN
REYNOLDS.BRYAN.KENN ET
REYNOLDS.BRYAN.KE H.1263385574
NNETH.1263385574 Date: 2020.02.2009:06:27
-05'00'
Signature and date of Regulatory
staff member completing PJD
2/20/2020
Signature and date of person requesting PJD
(REQUIRED, unless obtaining the signature is
impracticable)1
1 Districts may establish timeframes for requester to return signed PJD forms. If the requester does not respond within the
established time frame, the district may presume concurrence and no additional follow up is necessary prior to finalizing an
action.

Estimated amount of
Geographic authority to
Type of aquatic
Latitude (decimal
Longitude
aquatic resources in
resources (i.e.,
which the aquatic resource
"may
Feature
review area (acreage
be" subject (i.e.,
degrees)
(decimal degrees)
wetland vs. non-
and linear feet, if
Section 404 or Section
wetland waters)
applicable
10/404)
Wetland
36.0464030
-80.4263760
0.485 acre
WA 1-10
Wetland
404
Wetland
36.0463250
-80.4258900
0.127 acre
Wetland
WA 15-
404
23
Wetland
36.0470750
-80.4237360
0.033 acre
Wetland
WA 24-
404
13
Wetland
36.0474710
-80.4230840
0.007 acre
Wetland
WA 32-
404
36
Wetland
36.0485580
-80.4227840
0.074 acre
Wetland
WB 1-5
404
Wetland
36.0476360
-80.4228750
0.041 acre
Wetland
WC 1-5
404
Wetland
36.0476680
-80.4227170
0.079 acre
Wetland
WC 6-11
404
Stream
36.0473840
-80.4235860
1,700 linear feet
SA
Non -wetland
404
Stream
36.0488260
-80.4231840
630 linear feet
SB
Non -wetland
404
Stream
36.0476560
-80.4228010
780 linear feet
SC
Non -wetland
404

FLAG NUMBERS/INFO
END
Site Boundary
Perennial Stream
Intermittent Stream
WETLAND FLAGS =
Wetlands
STREAM FLAGS =
Stream Flags = Limits wa 1-s Flag Number
Wetland Flags = 48
Total Flags = 48 DP-1 O Data Point
1.
THE LOCATIONS OF FEATURES SHOWN ON THIS MAP ARE PRELIMINARY. THEY HAVE NOT BEEN VERIFIED BY THE USACE AND/OR THE NCDEQ-
DWR. THIS EXHIBIT INCLUDES GPS LOCATIONS OF JURISIDICTIONAL FEATURES. DELINEATION CONDUCTED BY PILOT PERSONNEL ON 11.13.19.
Drawing 5 Wetland Map
Satellite Imagery from ESRI .. Center Grove Church Road
•;: ,..
and Pilot GPS Data E ¢� - Approximate 40-Acre Tract
Scale: 1" = 300'`—" `� Clemmons, Forsyth County, NC
Date: 11.18.19 P�L� Pilot Project 5343
rIIGT t%�• ao vMiN1AL. lMt

p
Drawing
USGSTopographic Map
C|ernrnona, NC Quadrangle
Scale: 1"=2�000'
iL
LEGEND
Site Boundary
USGS Topographic Map
Center Grove Church Road
Approximate 4O-AoreTract
=C|ernrnona,Forsyth County, NC
0 PI Pilot Project 5343

41"mi v 111. a.r 1/ : s
wwry
PcD?
Pa F
Z� VIM p&C f
... '�` per.
En D
wi PaC
CCC NMF� VaD� , PaD ,
Aft L
PaC
r-
{ ter_ Pi
H!C
_ - �VaD i �►
EnC i" EnC C PaS
VOID PAD Pftc / •
• a g •; •
•1
a
f PaC
F'c� A `� � � Ct B P�� C� Cs
r = POC t PaC
'am � �
A rpal
�1 4 Pa ® _ •
dD
1 PaC PaC
Pa YaC
POC ��` CCR ff,, `•
/ ApB l �:� LEGEND
P11% / VaD
parc f # Site Boundary
Drawing 2A Published Soil Map
USDA Soil Survey �:; : y.t_-s .. ;,' ;y Center Grove Church Road
Of Forsyth County, NC Approximate 40-Acre Tract
Published 1976, Sheets 36 & 43 J ` Clemmons, Forsyth County, NC
Not To Scale P1 Pilot Project 5343
P I L 0 T L A Y k 0 4 M i N 1 A L. 0 N C

a.
} I
` . � ,�� . •. � tit �1� � 1 . F .
t �-
Q.
�• 1
A*P
I 7k
y
LEGEND
Site Boundary
Freshwater Emergent
E � ` Freshwater Forested/Shrub
Estuarine and Marine Deepwater
Estuarine and Marine
Freshwater Pond
Lake
Riverine
Other
Drawing 3 NWI Map
r
�
Center Grove Church Road
USFWS NWI
Approximate 40-Acre Tract
Wetlands Mapper �','z ` Clemmons Forsyth Count NC
Scale: 1" = 300' '"' y y'
Pi
Pilot Project 5343
PILOT E N V- R O 4 E N r A L. I N C

•
Ilk A
A
AL.
LEGEND
Site Boundary
196 . Annual Chance Flood Hazard
OR egul@tory Floodway
Sped @I Fl oodffay
Area of Undetermined Flood Hazard
0.2%Annu@1 Chance Flood Hazard
Future Conditions 1 '/. Annual Chance Flood Hazard
Area with R educed Risk Due to Levee
F
Drawing 4 EMA FIRM
National Flood Hazard Layer Center Grove Church Road
From FEMA Web Map Service Approximate 40-Acre Tract
Scale: 1" = 300' Clemmons, Forsyth County, NC
Pilot Project 5343

-7 R. r 7
4 �
r."
m
sB
(630 LF)
WB 1-5
(0.074 ac)
ti
-u
S
,k
WC 6-11
SA (0.079 ac)
(1,700 LF)] w
SC
(780 LF)
WC 1-5
WA 1-10 WA 32-36 (0.041 ac)
(0.485 ac) (0.007 ac)
ODP2 WA24-31
DP-1 (0.033 ac) y +4�eof� I
O j 1
04
WA 15-23 LEG E N D
(0.127 ac)
Site Boundary
4G NUMBERS/INFO �`
Perennial Stream
4 +'
Intermittent Stream
FLAGS =
:LAGS = Wetlands
ags = Limits F s�}, 1
� WA 1-5 Flag Number
:lags = 48
s = 48 DP-1 Data Point
JIONS OF FEATURES SHOWN ON THIS MAP WERE VERIFIED BY MR. BRYAN RODEN-REYNOLDS WITH THE USACE ON 2.11.2020.
BIT INCLUDES GPS LOCATIONS OF.IURISIDICTIONAL FEATURES. DELINEATION CONDUCTED BY PILOT PERSONNEL ON 11.13.2019.
L 1
Drawing 5 Wetland Map
Satellite Imagery from ESRI r
- ''� Center Grove Church Road
and Pilot GPS Data - •'= "� Approximate 40-Acre Tract
Scale: 1" = 300' h-' Clemmons, Forsyth County, NC
Date: 2.12.2020 Pi WT Pilot Project 5343
P I L O T E N V - R O M M E N C A L. 1 N C

RS PARKER HOMES, LLC.
502 HICKORY RIDGE DR.
GREENSBORO, NC 27409
CONTACT: GREG GARRETT
E: [e-mail] `R
P: [phone]
,l
N8926'31'W
G
�I ^
J j �
/ N/P
CHRISTOPHER P COLLINS
8496 CENTER GROVE CHURCH RD.
PIN:5873-89-4787 J
DB. 2G70, PG. 0843
ZONING:AG
83„S CENTER GROVE CH RO
I GIEMMGNS NG
PIN: 5874-90-OB
I DR. ]521, PG. 42 I
N/F ZONING. AG
MARK E SGRO ECHURCH
381 CENTER MONS CHURCH 0 22
CLEMMONS NC C V
PIN: 58]4-80-8837 N MICHAEL G. ARAPIAN
C8. 2791, PG. 1.H H 8336 CENTER GROVE CHURCH RD.
ZONING:AG PIN:5874-90-4622
of DB. 3247, PG. 3631
to 1\ ZONING:
N89-52-20- 7 2DoM- 1'
O 26265± SF//�
IVE OPEN SPACE U v
0.55 ACRES g650±(ASS
U U
-24319± SF 026± F
O 0
7715± SF 3909± SF)
0 043+ -1��
4354 ^19981± SF(Z)
1 �20236± S
7743± SF
ACTIVE EN SP
0.65P ACREO E
STR A B4851± 3
CROSSING 1
e
20055± SF/
\ 14 \/�
20389± SF,:.
U 22744±
DANIELNR N CHURCH
Q 9ryS 2 10664± SF 22483± SF
8580 CENTER GROVE CHURCH RD. 1
PIN: 585. PG. D69
DB. 3135, PG. 00693 26 ZONING
473± SF 25421 ± SF
20679± SF
25
1 b 24 2020± SF
419± SF 23 6885± SF
20 17585± SF
23369± SF
I J / 1270.0V Total
LINEAR
ACERAGE
RIP RAP
TYPE
IMPACT
OF IMPACT
IMPACT
PERMENANT
1751
0.019 AC
0.01 AC
STREAM
TEMPORARY
30'
0.007 AC
—
STREAM IMPAC
STREAM
CROSSING 2
STREAM/ WETLAND
IMPACT MAP
GROVE PARK
N/F
CENTER GROVE BAPTIST CHURCH
8750 LASATER RD.
PIN: 5883-09-0774
DB. 1—, PG. 2811
ZONING:
l
SCALE: 1 "=250'
GREEN MOUNTAIN
ENGINEERING, PLLC
7A WENDY CT
GREENSBORO, NC 27409
Tel: [phone]
CERTIFICATE NO. P-0826
www.greenmountainengineers.com

INV 118 LF & 474 cc
�
OUT:773.62 I SF PERMANENT I
o STREAM IMPACT
01
I 01
ST —119 I
+22ALLUMINUM
1+ 0
C
HEADWALL
15 LF & 90 SF
TEMPORARY
SANDBAG COFFERED
DAM FOR PUMP
AROUND METHOD
(SEE DETAIL)
79(
ALUMINUM
WI N GWALL
HEADWALL
IN\
77(
RS PARKER HOMES,
502 HICKORY RIDGE
GREENSBORO, NC 2
CONTACT: GREG GARRETT
E: [e-mail]
P: [phone]
FES—D INV OUT:770.80
�\ INTERMITTENT
43 SF OF KEYED STREAM
+. 0 IN RIP RAP
12'Lx11'Wx1'D RIP
RAP OUTLET
KEYED INTO
STREAM BANK L
TEMPORARY SILT
FENCE
7409
790
�:_
STREAM OUTFALL SIDE
HALL BE RESTORED AND
1AINTAINED TO
'RECONSTRUCTION
;ONDITIONS.
M:1
SCALE: 1 "=40' H
:TOBE 1"=4'V
11'
INTO GREEN MOUNTAIN
OIL ENGINEERING, PLLC
7A WENDY CT
GREENSBORO, NC 27409
770 Tel:[phone]
CERTIFICATE NO. P-0826
www.greenmountainengineers.com
STREAM/ WETLAND IMPACT MAP
GROVE PARK
STREAM/ WETLAND IMPACT MAP
GROVE PARK

INV
OUT: 746.42
15 LF & 200 SF _
TEMPORARY
SANDBAG COFFERED;"�" ---�
DAM FOR PUMP — - — - -
AROUND METHOD
(SEE DETAIL) ALLUMINUM
HEADWALL
719.55
76
ACC
IFA
CMP PIPE INLE_
TO BE IMBEDDE1
1' INTO NATIVE
SOIL
74
57 LF &
353 SF
PERMANENT
PERENM
STREAM AL
IMPACT INV OUT:745.00 _ STREAM
n
n
m
cnI
STP-121
403 SF OF KEYED
IN RIP RAP
FES-E 60'Lx16.5'W@PIPE,
30'Wx2.25'D RIP
RAP OUTLET
KEYED INTO
STREAM BANK
TEMPORARY SILT
FENCE
760
__SS
ROAD
SUBGRADE
PROPOSED
GRADE
ALUMINI,
ALUMINUM
WINGWALL
HEADWALL
ENDWAL
OUT:
38'7,6
CMP
746.42
INV
Of
� 121
66"
3 95q
INV
OUT:74
EXISRADETING
G
CMP PIPE T
IMBEDDED 1'
MINIMUM IN
NATIVE SOIL
NOTE:
STREAM OUTFALL SIDE
M SHALL BE RESTORED AND
MAINTAINED TO
PRECONSTRUCTION
CONDITIONS.
150
D.00
60'Lx16.5'WOPI PEx3O'Wx2.25'D
RIP RAP OUTLET KEYED
INTO STREAM BANK
0 BE SCALE: 1"=40' H
1 "=4' V
TO
GREEN MOUNTAIN
740 ENGINEERING, PLLC
7A WENDY CT
0+00 0+75 GREENSBORO, NC27409
Tel: [phone]
CERTIFICATE NO. P-0826
www.greenmountainengineers.com
IRS PARKER HOMES, LLC.
502 HICKORY RIDGE DR.
CONTACT: GREG GARRETT STREAM/ WETLAND IMPACT MAP
E: [e-mail] GROVE PARK
P: [phone]

LINEAR
ACERAGE
RIP RAP
TYPE
IMPACT
OF IMPACT
IMPACT
PERMENANT
175'
0.019 AC
0.01 AC
STREAM
TEMPORARY
30'
0.007 AC
—
STREAM IMPAC
Q�
=o
0
PLAN VIEW MATH PuuP
NOT TO SCALE
1. BEGIN STREAM CROSSING IN THE MORNING ON A DAY WHEN
THERE IS NO CHANCE FOR RAIN.
2. SET UP HIGH —CAPACITY PUMP AND SAND —BAG BERM
SYSTEM AS SHOWN.
3. INSTALL SPLASH OUTLET AT DISCHARGE END OF PIPE, (SEE
DETAIL).
4. OPERATE PUMP AS NEEDED, CONTINUOUS OR PERIODICALLY
DEPENDING ON FLOWS.
5. SECURE PUMP INFLOW AND OUTFLOW PIPES IN PLACE WITH
STAKES AND CABLE OR ROPES AS NEEDED TO PREVENT
MOVEMENT.
RS PARKER HOMES, LLC.
502 HICKORY RIDGE DR.
GREENSBORO, NC 27409
CONTACT: GREG GARRETT
E: [e-mail]
P: [phone]
6. AFTER THE STORM CULVERT IS PLACED
IN THE STREAM, REBUILD THE STREAM
BANKS AND ARMOR THEM WITH RIP —RAP
GREEN MOUNTAIN
ENGINEERING, PLLC
7A WENDY CT
GREENSBORO, NC 27409
Tel: [phone]
CERTIFICATE NO. P-0826
www.greenmountainengineers.com
STREAM/ WETLAND IMPACT MAP
GROVE PARK

d r NCmew Rnenawn� x .>W B2D x — a r
0 n -' -- n, maps—g—iages-Mpp+ 79-671¢bdp,x5639MMW251d515¢d7 -c g= Z, m --
■ LiiJ4a Lez tmo b j (' No"Ol ou- ama iw.n +. eae. v_ we y wepetu_ 53 F E� r ■ A d S tlr o-a �a=r,zyi ■