20220054 Ver 1_Shoreline Stabilization_20220110

Submission Form
I. Applicant Information [15A NCAC 02H .0502(a)]
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.
Primary Contact Email* [e-mail]
Please provide an email address for payment and requests for more information here.
Owner Information:
Name: *
William Derek Tilley
Email: *
[e-mail]
Phone Number:
[phone]
(xxx)xxx-xxxx
Mailing Address: *
Street Address
566 Laurel Cove Road
Address Line 2
City
Statesville
Postal / Zip Code
28677-2476
Is there an agent working on the project?* Yes
No
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:* Tilley Dredge and Shoreline
State / Province / Region
NC
Country
US
If your project has a formal name please use this. If your project does not have a formal name, please identify your project
by the owner name and proposed activity (Jones Property Access Road, Smith Guest House, etc.) List in parentheses
any other names that have been used to identify the project in the past.
1. Provide a vicinity map (i.e. street map) clearly showing the location of the property with respect to
local landmarks such as towns, rivers, and roads.*
Upload File
• Look up address

Property Address Lookup: * Street Address
566 Laurel Cove Road
Address Line 2
City
State / Province / Region
Statesville
NC
Postal / Zip Code
Country
28677-2476
US
Latitude: * 35.679502 Longitude: *
-80.970141
2. Provide a detailed site plan showing property boundaries and proposed locations of vegetation clearing,
structures (buildings, retaining walls, docks, impervious surfaces, etc.), rip rap, excavation or dredging below
Full Pond/ Normal Water Level elevations, and construction access corridors. You may use the diagram under
section 12.normal pool lake level/normal water level *
Tilley Site Plan and Dredge Disposal
2. I SMB
Forms.pdf
Tilley Duke Energy Excavation
5.51 MB
Application.pdf
Please use the diagram at the link below:
https:Hedocs.deq.nc.gov/WaterResources/0/edoc/616616/Shoreline%20Layout.docx
3. Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale of some sort- a yard
stick, shovel handle, etc.)
Tilley Photographs.pdf 761.62KB
4. Location of the property (where work is to be conducted)
Nearest Town: * Statesville
County: * Iredell
Lake/ river/ ocean adjacent to Norman
property:
Subdivisions name or site address:* Laurel Cove Lot 23„ 566 Laurel Cove Rd, Statesville, NC 28677
Include phase/lot number
Directions to site: *
From I-77 NB, Exit 42, Left onto US-21 NB thru Troutman, Left onto Old
Mountain Road, Left onto Buffalo Shoals Road, Left onto Laurel Cove
Road. Property is at the end of the road straight ahead.
Please include road names and numbers, landmarks etc.
5. Describe the existing land use or condition of the site at the time of this application:
Residential
Residential, undeveloped, etc.
6. Property Size 1.102
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
Shoreline refresh with Class A and B rip -rap for shoreline stabilization
and erosion control. Dredge area around new dock location for boating
access.

8. How will the work be done?* ✓ From Land
✓ From Water
9. Total amount of disturbance below the normal pool lake level/ normal water level: *
(including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
5,226 sf
square feet
10. Total amount of disturbance above the normal pool lake level/ normal water level and 50 feet land-
ward: *
(including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
500 sf construction
corridor
square feet
11. Please describe the vegetation above the normal pool lake level/ normal water level and 50 feet landward to
be impacted: *
(number of trees, for instance)
None
Sketch:
Application Fee:
Once the application has been accepted. You will need to send a corresponding fee in with the appropriate DWR#. The
application fee is as follows (pursuant to G.S. 143-215.3D):
a $240.00 for impacts to lake (below normal water level) of less than 1 acre
a $570.00 for impacts to lake (below normal water level) of greater or equal to 1 acre
By digitally signing below, I certify that:
o I, the project proponent, hereby certifies that all information contained herein is true, accurate, and complete to the best
of my knowledge and belief
o 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.
o I agree that submission of this Shoreline Stabilization online form is a "transaction" subject to Chapter 66, Article 40 of
the NC General Statutes (the "Uniform Electronic Transactions Act');
o 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');
a 1 understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the Shoreline Stabilization online form.
Full Name:* Donna P. Hrko
Signature:
Submittal Date: 1/10/2022

Initial Review
Is this accepted into the review process?* Yes No
Project Number:* 20220054 Version: *
Select Reviewer:*
Select Reviewing Office:
Has payment been received?*
What amount is owed?*
Doug Perez:eads\djperez
Mooresville Regional Office - [phone]
No Payment Needed
Fee Received
• Need Fee - send electronic notification
• $240.00
$570.00

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO:
STREET ADDRESS;
566 Laurel Cove Road
Statesville, NC 28677
Please print:
PLAN NO:
Owner: William Derek Till
Property Owner;
PARCEL ID: 4710479898
The undersigned, registered property owners of the above noted property, do herebyauthorize
Donna P. Hrko
(Contractor/Agent)
of Lancaster Custom Dock and Lift Systems, Inc.
(Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of this
permit or certification and any and all standard and special conditions attached.
Property Owners Address (if different than property above):
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate tothe
best of our knowledge,
Authorized Signature
12-1-2021
Date
Authorized Signature
Date

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Water Resources 1SA NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
ENVIRaNM EN AL QUALITY
FORM: SSGP 02-2017
Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
Full Pond/ PLormal Water Level
� r ■. li �I �
Shoreline
ii lza� W ilk to e.
cillyn + 0.r3d -ka e+r
ac-V, Q ba-v7
)i i e v)4- barn 1r',
Plan View
FORM: SSGP 02-2017
Full Pond/ Normal water Level
" ngore" iine ` r
2 ft. x 15D fc
addittdW clearing
lfn(C .ry
La ke
(At Full Pond/ Normal Water Level)
�>redqe �[Q x 41•)
W ►+l�t-'req � r< �'� � 5 7� sir
&I,r,rldor
Lake
IAI Full Ponds No l Wary Level)
Existing dock
/ 30 ft.7 ft
3Ftx lsoft
Below 1c11 pond/ NWL
arxlsaft
R ip ra p ahpNe Full pond/ PfWL
A
AMPLE
Page 1 of 3
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Plan View

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CATAWBA RIPARIAN BUFFER NOTIFICATION FORM
Project Name/address: �{ r As county: 1 r 1
A t j .re 5 eSv I l le, iN C• 8c� 77
Owner: V V, i is Y 1 ;
Print I &, .
Contractor/agent:
Print
igna
The approval is for the purpose and design described in yoGr application. Impacts not indicated in the
application is a violation of the Buffer Rule. Site specific work should be provided in the application, [15A
NCAC 02H .0506 and 15A NCAC 02B .0243(8)]
Trees are not allowed to be removed from Zone 1 of the Buffer (within 30 ft of the full pond elevation), unless
approved. Exception, those trees that are severely undermined along the immediate shoreline can be
removed. Minimal shaping and sloping along the immediate shoreline is allowed. [15A NCAC 02B .0243(6)]
Benching and grading in the buffer is not allowed. Excessive disturbance of ground cover. [15A NCAC 02B
.0243(6)]
Beaches, impervious patios, impervious walkways, etc. are not allowed in the buffer unless specifically
approved by the Division. There are limitation on size for decks. [15A NCAC 02B. .0243(4) and (6)]
Work to be conducted from land must indicate an access and indicate any trees that are to be removed. The
work corridor should be described. The approved access corridor shall be restored. Staging, spoil, construction
material must be outside the buffer. [15A NCAC 02H .0502 and 15A !NCAC 028.0243 (4), (6), (8)]
Stormwater cannot be piped or channeled for direct discharge to the lake. All constructed stormwater
discharges must be at the natural elevation and discharged prior to entering the buffer directed as diffuse or
sheet flow at non -erosive velocities to the lake. [15A NCAC 02B .0243(5), (6)]
Acknowledgement of Notijicotion
hereby state that I have been informed of the Catawba
Riparian Buffer Rule. Any work conducted A the buffer, not specifically stated in the application and approved
by the Division of Water Resources (DWR), is a violation and subject to enforcement. Due diligence will be
taken such that the construction will be built within substantial compliance and intent of the 401 Water
Quality Certification and Buffer Rules, the approved plan(s) and specification(s), and other supporting
materials.
Signature (owner): t Date:

1/6/22, 11:36 AM
Property Data
Iredell County
Property Data
Parcel Number: 4710479898,000
Inquiry Date: 1/6/2022
Disclaimer: While every effort is made to keep information provided over the internet accurate and up-to-date, the County does not certify
the authenticity or accuracy of such information, No warranties, express or implied, are provided for the records and/or mapping data
herein, or for their use or interpretation by the User.
Property Map
1
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Owner/Property Info
Tax Account Number: 80067064
Old Parcel Number: iso3Lo1000Aa23
Owner Name: TILLEY WILLIAM ❑
Nlalling Address: 566 LAUREL COVE RD STATESVILLE NC 28677
Property Location: LAUREL COVE RD
Lot Number: 23
Legal Description: LAUREL COVE SHTA PB9-41-11A
Municipal information
Township Code: 15
City Code: oo
Neighborhood Code: 15017
Value Information - Cguent ygar Pro p Rerpcd Card {P�}
Building Value: 608750
Other Building Features: 18460
Land Value: 322000
Tax Assessed Value: 949210
Deferred: o
Land Information - &eg stl er of Deeds n ' Search
web3.mobile311.com/IredellReportlreport.aspx?PIN=4710479898.000
1/2

116/22, 11:36 AM
Date Recorded
20191025
Exemption
Null
Document Type Deed Book Dead Page
wa 19E 1006
Tax Code I Tax Code 2
C ADVLTAX Null
Property Data
Plat Book & Page
9-41
Tax Code 3
FR06ADVLTAX
Land Area Land Type Zoning
1.25 AC R20
Tax Code 4 Tax Code 5
Null Null
zoning Contact
Info.
Iredell County
7D4.878.3119
Harmony
704,878.3118
Love Valley
704-878.3118
City of Statesville
704,878.3575
Town of Troutman
704.528,7600
Town of Mooresville
704.662.7040
Village of Davidson
704.892.7591
web 3.mobi1e311.CamllredeIIReportlrepart -aspx7PI N=471 G479898,000 212

1/6122, 1:51 PM ConnectGlS Feature Report
https://ired e11.con nectgis.00m/DownloadFile, ashx?i=_ags_mapc12837bba4d944ee9623e8cf2597583bx.htm&t=print ill

DREDGE SPOIL ❑ spngai_ FARM
Project Name/address: r r 1'ev V,� i r
y Co
po 1
ltliroen�rress;
G VuIQ�I MTY�YPr
Parcel #:
Parcel/lot size
Dl
Disposal area required (sq ft and/or acreage)
Ire-A77—
.
Acknowledgement of ►votlf►cvtifl
1, er , am aware that the site must adhere to all state regulations
and rules r garding sediment and erosion control and water quality. And give permission for
Name of Individual and Company
to dispose of their dredge material at the above stated location
Owner:
5 Pri t ! 5igna ure
Date: 1 !
Along with form, please provide:
.-Aerial of parcel/lot (County G15j
Photo of proposed spoil site
Identified proposed spoil site

Iredel! County
Property Data
Disclaimer: While every effort is made to keep Information provided over the interneL accurate and up-to-date, the County does not certify
the authenticity or accuracy of such information. No warranties, express or implied, are provided for the records and/or mapping data
herein, or for their use or interpretation by the User,
Owner/Property Lnfo
Tax Account Number: 77374349
Old Parcel Number: 1702N04000A001
Owner Name: BIG DADDYS OF LAKE NORMAN
Mailing Address: 1162 a1VER HWY MOORESVILLE NC 28117
Property Location: ROBINSON RD
Lot dumber: PT1
Legal De5crlption: WEST LAKE VALLEY PB11-52 BIG DADDYS ANNEX PI345-79
t-Ulalcipal [[irarmatlon
Township Code: 17
City Code: o3
Neighborhood Code: 03060
Value Infr:-- Cument-Yekr PrDppg itecord C�..(_j
Building Value. 0
Other Building Features: 9390
Land Value: 207480
Tax Assessed Value: 21686o
Deferred:

w
Date Recorded
19911T
Tax In€ormatian
ExCMptiarl
Nell
Regist ❑ D Qnline Searc
Document Type peed Book peed Page Plat BOOK
WQ SZ3
933 45-79
AA Oil Tot Ining
2,73 AC fx
Tax Code 1 Tax Cade
C AOVLTAx Tax Code 3
Tax Code 4 Tbx Code 5
CI03ADVLTAX Null
Null
Null
t-Urrent Zorlillu Cr iltar! r
Iredell County
7U4.878.3118
Harmony
704.878.3118
Love Valley
704.878.3118
City Of Statesville
7M-878.3575
Town of Troutman
704,52s.7600
Town of Mooresville
Village of Davi(Ison
704-662,7040
704.892.7591

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Printed October 19, 2021
See Below for Disclaimer
Addresses
lnfrasM,-t ,re
honRe.idential Use
Residential Use
Streets
€tlterftate
Ramp
US H,4y
` State Hrr3r
Malrr Road
Local Road
Residential
l n: Private
inactive
Parcels Hooks
jP�aarcels
L_;
;,::rPPP Parcel Labels
City LimitS
Iop 1I. �1 " ; Lake Normar
f
fredell Courttyline
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NC Cout'1tie5
S r �^ ' : ' iE Feet
'ha maps prepared for this website are generated from recorded deeds, plats, and other public records. risers of these maps are hereby notified that the informationrrovided herein should be verified. Iredetl County assumes no legal responsibilities for any of the information contained on this site. Users are advised that the use of
ny of this information is at their awn risk- All maps an this site were prepared using a 1000411- Grid based upon the North Carolina State Plane Coordinate System from
he 1993 North American Datum. The delinquent real proporty tax overlay is updated monthly. The inforrnatton presented is not intended m be used or relied upon as
,fficial not iceaf tax liens- For additional information rvnarriinn rss .. ....__ ____

Dune Energy Lake Services
Guidance for Completing an Excavation Permit Application
Note: If you are proposing excavation in association with the permitting of a new
or expanded facility under the Marina or Conveyance Programs, you do not need
to complete this application. Instead, you should incorporate the excavation
request into the permit application for the marina/conveyance using the
appropriate application.
Step 1: Contact Duke Energy Lake Services
Complete "Part I" of the application and develop a drawing of the proposed excavation area.
Contact Duke Energy Lake Services to schedule a site visit. Lake Services will conduct a site
visit to determine if Duke Energy will accept an excavation permit application for the proposed
work. If the Lake Services representative determines the application process may procee,
he/she will initial Part I of the application. d
Step 2: Draft Application Development
Complete Parts II-III.A-G and. Part V of the Excavation Permit Application.
Step 3: Agency Consultation
Send the draft application developed during Step 2 to the agencies for review and comment on
the proposed activity. Refer to the Agency / Organization List available from Duke Energy to
determine which federal, state, regional, and local agencies and organizations require
consultation or review.
Note; Duke Energy reserves the right to require consultation with additional organizations
beyond those included in the Agency / Organization List.
Each agency / organization must be provided at Ieast 30 days prior notification. Evidence must
be provided (e.g., response letter or Certified Mail receipt} in the complete application to show
each agency / organization was given the opportunity to review the proposal.
Consultation letters must be dated within the two years preceding Duke Energy's receipt of the
application. All permits must be valid at time of application and have a term longer than the
Projected schedule for completing the permitted project.
What to Ex ect Durin A--ncy Review and Comment:
■ You will typically receive a letter from each agency / organization either documenting its
concurrence with your proposal, requiring additional information, recommending
modifications, or offering no comment. You must address each agency's / organization's
comments with a follow-up letter and in your final application as described in part IV.
• If you do not receive any documentation from an agency / organization within 30 days of its
receipt of your proposal, you must provide the agency / organization with a follow-up letter
requesting comment on your proposal within 15 days from the date of the follow-up letter. If
You still do not receive any response as a result of the second letter, type "NO RESPONSE"
Duke Energy Page 1 of 13
Excavation Program rev 10/1r1019

at the top of the follow-up letter and include it in the application along with proof of the
agency's 1 organization's receipt of the letter (e.g., Certified Mail receipt). You may proceed
with the application process recognizing, however, that if its comments came later in the
application process, you will be required to address them.
From the United States army Corps of Engineers {Corps}: (* * Note — The Corps may have
additional forms to submit for your proposal and an additional fee.) If the excavation can be
done under the requirements of the General Permit (GP) or a Nationwide Permit (NWP), you
will typically receive a copy of the Corps' tear sheet documenting authorization and
providing any additional instructions. If the excavation isn't covered under the GP or a
NWP, you'll be required to obtain an individual 404 Dredge and Fill permit from the Corps.
You must receive written documentation from the Corps that your application either (1)
meets the requirements of the GP or a NWP or (2) the proper 404 Dredge and Fill permit has
been received before Duke Energy can process your application.
From the North Carolina Department of Environmental Quality (NCDEQ), Division of
Water Resources: (Vote NCDEQ may have additional forms to submit for your proposal
and an additional fee) If the proposal meets the requirements of the Clean Water Act Sect.
40I Water Quality Certification, you will typically receive a letter from the NCDEQ Division
of Water Resources documenting Sect. 401 Certification and providing any additional
instructions. You may also receive a letter requiring additional information or
recommending modifications. You must receive wri en documentation from NCDEQ
noting any required Sect. 401 Certification has been received before Duke Energy can
process your application.
• From the North Carolina Wildlife Resources Commission (NCWRC); If you do not receive
any documentation from the NCWRC within 30 days of their receipt of your application, you
may proceed with the application process without submitting a follow-up request,
recognizing however if comments come in later in the application process, you will be
required to address them.
From the South Carolina Department of Health and Environmental Control (SCDHEC):
(Note --- SCDHEC may have additional forms to submit for your proposal and an additional
fee) The SCDHEC conducts a joint application process with the [USACDE in S.C. If the
proposal meets any applicable requirements of the Clean Water Act Sect_ 401 Water Quality
Certification, you will typically receive a letter from SCDHEC documenting Sect. 401
Certification and providing any additional instructions. You may also receive a letter from
USACDE requiring additional information for the agencies participating in the joint
application process. You must receive written documentation from SCDHEC noting Sect.
401 Certification has been received if required before Duke Energy can process your
application.
■ From the South Carolina Institute ofArchaeology andAnthropology (SCL4A). The applicant
must wait 30 days after receiving the signed postal returned receipt. If a response from
SCIAA has not been received by this time you may proceed with the application process
without submitting a follow-up request, recognizing however if comments come in later in
the application review process, you will also be required to address them,.
Duke Energy
Excavation Prograrn Page 2 of 13 rev 1011n019

Step 4: Final Application & Submittal to Duke Energy
Following the consultation process, finalize the application. The final application submitted to
Duke Energy should incorporate all comments and recommendations provided by agencies and
organizations during the agency consultation process as well as copies of all permits received. In
addition to the final application include the following:
• One check payable to Duke Energy for the application fee and security deposit
• If applicable, a separate check payable to the appropriate Habitat Enhancement Program fund
• Signed Excavation Program Applicant's Agreement
Note: Co -applicants must also submit the application fees and applicable 1EP fees with the
application.
Duke Energy Page 3 of 13 rev lO1lPZ0I9
Excavation Program

Duke Enierey Excavation permit Application Form
FOR DUKE ENERGV USE DAILY
Duke File No.
Application Fee S Security Deposit S Chock # Date Recv'd
Initials
—
Date of Duke Energy Lake Services, applicant and/or contractor on -site inspections Date 96 Z � ' C Initials-i 91—
Date Final Protection/Avoidance Ares Markings Field - Verified
Approved to Stan Work By * :
luitials
Date
Date Completion Required (P)Int) 09+)
Date of Any Approved Extension Initials
Date Passed Closeout Inspection* lnkWS
Any Stop Work orders or SMG Violations*? (check one) Oyes ONO (If Yes. expla n in pART V)
Date Deposit Refunded Initials Date Permit Database Updated Initials
* Forward copy of approved application (all pages, plus any attachments that Deice Energy changed) heck to applicant
Orders with application. with Approval Letter and high iigltt any changes. File copies of Approval and Close-ottt Checklists and any Stop Work
Part L Applicant information (Please Print)
Name Telephone 7 - q -1 -, - 'r1;
Email address: + 1 11
e Address Mailing Address (f di, f�erent)
r VTIA
18 7
Contractor Company '
G.
Contractor Contact Person Telephone 9- o
Contractor Email. Address: �t -CIo � m
LAKE LOT INFORMATION
Pars: 97(0��� g�a
Lake Qr_tnCounty 1LL City V 1 State N—C Tax Map No. - 1
Subdivision r CON e. Lot 1 Section No. Z�J Lot Sine 1. cres
`� �c3dr1;'lonctl�n�c�.L
Duke Energy Page 4 of 13
Excavation Program rev 101112019

Duke MUM Excavation Permit Anplication Form
Are there any Co -Applicants*? (check one) OYes MNo (If Yes, include names, street
addresses or lot numbers, pier numbers, phone numbers, and email addresses in Part V —
Additional Information)
* Co -Applicants exist when the proposed work is being done under a single application, will be
performed by a single contractor as one continuous project, and is done to benefit multiple
owners / lease holders of Project -front properties within a single development. There can be no
more than 4 co -applicants in addition to the lead applicant on any application.
Do not continue the application until an on -site inspection has been conducted between a
Duke Energy Lake Representative and the applicant and/or the excavation contractor.
.NOTE: InWalling this portion of the application by a Lake Representative in no way
constitutes approval or eminent approval of the excavation or any other lake use permitting
activity.
Date of on -site inspection 16 Zi3 w u
Initials (Duke Energy)( 1 Cif—
(applicant/contractor) .
Duke Energy Page 5 of 13
Excavation Program rev 1411)2019

Duke Enem Excavation Permit Application Form
Part II. Description of Project
A. Basic Information
l . Type of excavation: (check one)
2. Purpose of excavation: (check one)
❑ Water Intake Channel
❑ Other (spew):
3. Lake user category: (check one)
❑Commercial Marina
❑other (specify):
XNew excavation ❑ Maintenance excavation
1d Boat Access Channel
❑ Wastewater Discharge Channel
ICt dvate ❑Residential Marina
❑Public
4. Max. Excavation Area Dimensions (ft): Length I
Width Depth
(Note: include additional area dimensions if necessary so response to #5 below equals max. area
dimensions in #4)
5. VoIume of Excavated Material (TOTAL for the project): Cubic yards
6. Type of material removed (applicant determines by field sample ifpractical): C �d y -j11 �- 4 dal
7. Excavation Site area: Acre (s) Disposal Site area: It 0Acres)
8. Total Disturbed Area (including equipment staging area): %CO Acre (s)
9. Does the project meet the requirements of the applicable General Permit? (check one)
Des Jo
10. Do you claim title to the disposal area? (check one) ❑Yes No
11. Do you claim title to the equipment staging area? (check one) Yes Vo
12. Are there any water -treatment facilities within 50 feet of the proposed excavation area?
(check one) Yes �o
(If Yes, specify):
13. How will the excavated material be entrapped and the erosion controlled? (e.g. see attached
orosionD condtrol plan and disposal area design): �r� e %N'1+11 iD y-ecLC tj e 1�Ca80,Q
yb��cr� . 'Vl(Xce MC4P-r,Cd6 m 110?ge- bar e� aul awa
MPA �CYiS Q.nd inw5o� dispo-axlsi+e
Duke

Duke Ene>ry Exeavation Permit Application Form
14. Type(s) of excavation equipment to be used: Lonr� reQc� 1tC c�Ver�pY. t 5y, Q r+reach
IS. Will waters or wetlands be crossed in transporting equipment to or from the site?
(check one) NYes ONo
(Ifyes, explain)
t-Ail laoa �t rner►}�� �ra�+r, F teeca¢n ,►��1 ►IC4S+er Cumm o>� t�cc� �;., ' �a��- �'h
r', ems. 51 �`G 0 n L-CLV' e N o rmcc �
15. WilI return water re-enter the reservoir? (Check one) ❑Yes ONo
(If Yes, specify points) of re-entry and show on Excavation Area Drawing) VIA
17. Is there an existing facility (e.g. pier) that access is beingmaintained to by conduc ing the
excavation`? ❑Yes *o New pi er 4 dodgy be Consfr=.
(If Yes, provide the existing permit number. IfN , i elude a sca� drawing o the pro osed L
facility). Permit # X-ei, chef rr tVC�}e �46 �t�1 et, �vie;r .- 'D li)cad ❑ r� .
18. Total planned duration of the work (Include f rst equipment mobilization, excavation
through final mitigation meal e complete):
START �_ 1 FINISH 1
(Month) (Year) (Month) (Year)
Duke Energy Page 7 of 13 rev ] 011 r1o19
Excavation Program

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Duke Enem Excavation Permit Annlication Form
C. Applicant's SjgqgqjM
Comments:
Applicant Name (print)
Applicant Signature* 1 1y
Y---Date }
Co -Applicant Name (print)
Co -Applicant Signature* Date
Co -Applicant Name (print)
Co -Applicant Signature* Date
Co-Applieant blame (print)
Co -Applicant Signature* Date
Co -Applicant Name (print)
Co -Applicant Signature's Date
*Per my signature, the information provided in this application is correct to the best of my
knowledge.
Duke Energy Page 10 of 13
rev 10/1/2019
Excavation Program

Duke Enera Excavation Permit Avelication Form
Part III. Additional Information
A. Deed and Survey Plat: A copy of the deed and registered survey plat or other instrument
under which each applicant and co -applicant claims title to the affected property (the
shoreline adjoining the excavation area, equipment staging area, area crossed by any spoil
and return water lines, and the disposal area). if the applicant(s) is(are) not the owner(s) of
said property, then forward a copy of the deed and registered survey plat or other instrument
under which the owner(s) claim title plus written authorization from the owner(s) to carry
out the project on their land.
B. Excavation Area Drawing: An accurate drawing of the area to be excavated The drawing
must show at a minimum, a North arrow; the boundaries and acreage of the proposed
excavation area and equipment staging areas; lake, county, city, cove, tributary, road and
subdivision names and lot numbers (as applicable); property corners far project front lots;
the full pond elevation contour and lines dividing the cove width into equal thirds (as
applicable); approximate volume in cubic yards of the material to be excavated; point(s) of
return water re-entry; the boundaries of any adjoining areas that are to be specifically
avoided or protected during the work and the location (address) of the disposal area for the
excavated material. [NOTE: A copy of this drawing must also be provided to the
excavation contractor to ensure restricted areas are not impacted.]
C. Disposal Area Drawing: An accurate drawing of the proposed design for the disposal area.
The drawing must show at a minimum, a North arrow; the boundaries and acreage of the
Proposed disposal area; lake, county, city, cove, tributary, road and subdivision names and
Iot numbers (as applicable); the full pond elevation contour (unless disposal is well away
from the lake); the boundaries of any adjoining areas that are to be specifically avoided or
protected during the work; the location (address) of the excavation area from which the
material came and a statement of the disposal area's capacity with all dimensions labeled
that were used in the volume calculation. [NOTE: A copy of this drawing must also be
provided to the excavation contractor to ensure restricted areas are not impacted.]
Also note for projects larger than one (1) acre in North Carolina, including excavated,
equipment staging, and disposal areas, you must submit an erosion control lan. For
projects larger than two (2) acres in South Carolina, including excavated, equipment staging
and disposal areas, you must submit an erosion control plan. For projects < two (2) acres in
South Carolina, you must submit a completed standard reporting form for construction sites
disturbing two (2) acres or less to the South Carolina Dept. of Health and Environmental
Control (SCDHEC) - Stormwater Management
D, Vicinity Map and Driving Directions; A vicinity map and directions by road showing
directions to both the excavation area and disposal area. Include the latitude and longitude of
both the excavation area and the disposal area.
Part IV. Agency Reviews and Approvals
Begin this section with a summary table of all agencies consulted and applicant response to
agency comments as shown in the example table below. Agencies should be listed in the order
Duke Energy Page I I of 13
Excavation Program rev 10/D20I9

Duke Energy Excavation Permit Avylication Form
shown in the Agency/Organization List. Consultation letters must be dated within the two years
preceding Duke Energy's receipt of the application.
Table IV-i. Sam le A enc Comment and Response Table
Agency Comment
The activity is approved as
A eny 2
The on -site well provides drinking water to the
public.. Please contact Mr, Smith to discuss the
proposed changes and potential issues
associated with our ro osal.
You must contact us immediately if
endangered species are located during the
course of construction,
Azencv 3
Contacted Mr. Smith on 111120xx. No
further action needed.
Applicant will contact Agency -2if
endangered species are located during
construction
Requested agency comments on 111124xx and NA
again on 21I120xx. No response as of
2116120xx.
fI ersc 4
Section 401 Water Quality Certification Applicant will comply with the conditions of
the 401 Water Quality Certification
Following the table of agency comments and applicant responses, include a table of permits and
certifications issued by the reviewing agencies. As with the table of agency comments and
applicant responses, agencies should be listed in the same order as they are listed in the
Agency/Organization List.
Table IV-2. Sam le Agency Permits and Certifications Table
Agency Permit/Certification Name Date of Date of
Issuance Ex iratio
Agency l Surface Water Withdrawal Permit
Agency 2 , Section 401 Water Quality Certification
Following the two summary tables, include a copy of all correspondence to and from any local,
regional, state and federal agencies or other organizations with which you are required to consult,
including any required permits (e.g., Section 401 water quality certifications, Section 404
dredge/fill permits, building permits, etc.) or other approvals or comments which have been
obtained from these organizations regarding this activity. Include a copy of any local, regional,
state or federal regulations or guidelines that will be followed. All permitting issues must be
resolved and clearly documented. Correspondence should be organized in the order the agencies
are listed on the Agency/Organization list with the applicant's request for comments followed by
additional correspondence in chronological order. All permits must be valid at time of
Duke Energy Page 12 of 13
Excavation Program rev 1011Y2019

Duke EnerLyv Excavation -Permit Application Form
application and have a term longer than the projected schedule for completing the permitted
project.
Part V. Additional Information
Provide relevant additional information. Reference previous parts as applicable. Include the
FERC-required Environmental Assessment if you were directed to do so during the initial site
visit. If there are co -applicants, this is where their information would be provided (see Part I).
Duke Energy
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DUKE ENERGY DIRECTIONS BY ROAD FORM
Lake Use Permit Applicants and Contractors: Ease of locating the proposed project
site canhavea big impact on permitting processing time. Please complete this form and
return it along with your completed application to:
DUKE ENERGY
CIO LAKE SERVICES — EC 12 Q
526 SOUTH CHURCH STREET
CHARLOTTE, NC 28202
Applicant's Name: William Derek Tilley
Street Address (at lake): 566 urel Cove Road
Lake Name: Norman
Subdivision Name: Laurel Cove
Property Section:
Lot #:
City: Statesville County: Iredell
State: NC Zip: 28677
Telephone: [phone]
Directions (from major road or highway):
From I-77 NB Exit 42, Left onto US-21NB, Left onto Old Mountain Road, Left
onto Buffalo Shoals Road, Left onto Laurel Cove Road. Property is straight
ahead at the very end of the road.
Descriptive Structure(s) on Property (i.e. brick garage, white fence, mobile
home, etc.)
*Note: Please use the back of this form if desired to draw us a map to the site.

DUKE ENERGY DIRECTIONS BY ROAD FORM
EANCASTER CUSTOM DOCKS DISPOSAL SITE
Lake Use Permit Applicants and Contractors: Ease of locating the proposed project
site canhavea big impact on permitting processing time. Please complete this foam and
return it along with your completed application to:
DUKE ENERGY
C/O LAKE SERVICES —EC 12 Q
526 SOUTH CHURCH STREET
CHARLOTTE, NC 28202
Applicant's Name:
Street Address (at lake): 1 l 62 River Hi wa Mcoresviile NC � g 1 l �
Lake Name: Norman
Subdivision Name: _kig Dadd 's of
Property Section: Lot #:
City: Mooresville County: Ired ll
State: NC
Zip: 28I 17
Telephone: _ 744-,;61-
Directions (from major road or highway): From 1-77 NB, Exit 36, Left onto NC-
1 SD WB, Disposal Area is on the right behind Big Daddy's Restaurant
Complex.
Descriptive Structure(s) on property (i.e. brick garage, white fence, mobile
home, etc.)
*Note: Please use the back of this foram if desired to draw us a map to the site.

097to
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Excavation Project User's Agreement Utter
yy (Please fill in the blanks. Please Print)
k
Date j- Z_L_
TO, Duke Energy
c/o Lake Services - EC 12Q
526 S. Church. Street
Charlotte, NC 28202
RE: Excavation For. (S,%bdivision,and Lqt #'s or Other
(LakelCountylaty)
(Applicant's full name) i hereby agrees to comply with all
recommendations, requirements and/or conditions of D e Energy, General Permit(s) (if
applicable) and other federal, sVte and 1pcal agency requirements pertaining to the application to
excavate for the purpose of a
In addition, Ilwe have read and agree to comply with Duke Energy's current Shoreline
Management Plan (SMP) or other applicable guidelines, much of which is repeated herein, and
understand that written authorization must be obtained from Duke Energy prior to beginning any
activity within the Federal Energy Regulatory Commission (FERC) project boundary or on Duke
Energy property associated with a reservoir, collectively referred to as Project Boundary. The
excavation will be completed as described in the approved application and within eighteen (1 S)
months from the date of written approval by Duke Energy, unless specifically noted otherwise in
the application or unless I/we obtain approval for a single, time extension (maximum of one year)
in writing from Duke Energy. I/we understand that if the SMP or other applicable guidelines or
rules change during any extension period, Ilwe will be expected to comply with the new
requirements to the maximum extent practicable. Ilwe also recognize that failure to complete the
excavation within this build -out period will require the filing of a new application within the then_
current SMP or other applicable guidelines and the new application must include any applicable
fees and security deposits.
Ilwe attest to be the owner(s) or lease holder(s) of the land immediately adjoining the Project
Boundary where the excavation activity is to take place, or if not the owner or lease holder, Ilwe
have included proof of title to the property and written authorization from the owner(s) or lease
holder(s) to carry out the proposal within the Project Boundary adjacent to their land.
I/we attest to be the owner(s) or lease holder(s) of the land that will be used for equipment
staging and disposal of excavated material or if not the owner or lease holder, ]Ave have included
proof of title to the property and written authorization from the owner(s) or lease holder(s) to
carry out the work on their land.
Duke
&bc:W Page 1
PXV: wraoxn

Ilwe understand that all excavation work must lie done directly in front of mylour property and as
specified in Duke Energy's approval. Uwe also understand that access channels must run
Perpendicular to the shoreline white within the third of the cove area that is nearest mylour
property.
1/we understand that for proposed excavations, I1we must notify the appropriate local, state and
federal agencies in advance of the activity by sending them a completed copy of Duke Energy's
Excavation Permit Application Form and other required information. I/we understand that
written authorization and/or other permits may be required by some of these agencies and such
required authorizations must be olstained before Uwe submit the final application to Duke
Energy.
At FERC-licensed reservoirs, Ilwe understand that except for maintenance excavations, any
excavation exceeding 2000 cubic yards of material removed or any excavation or shoreline
stabilization work needed to support an application that requires FERC review does itself require
specific review and approval by the FERC before Duke Energy can issue any approvals.
Ilwe agree that unless specifically approved otherwise in the application, explosives will not be
used as part of this excavation activity.
I/we understand that every reasonable effort must be made to minimize any adverse impact on
fish, wildlife and other natural resources.
Ilwe understand that applicants in South Carolina proposing excavations that are not covered
under the General Permit, or are greater than 150 cubic yards, must receive prior written
authorization from the South Carolina Department of Health and Environmental Control
(SCDHEC) or the US Army Corps of Engineers (as applicable) before submitting the completed
application to Duke Energy.
Ilwe agree that excavation activities will not occur during the months of March, April, May and
June because of the potential impacts to fish spawning areas.
Ilwe understand that trees and vegetation growing within or adjoining the lake play an important
role in its overall environmental condition, and the ecological benefit the vegetation has on fish
and wildlife habitat directly supports a sound and healthy lake environment. Uwe also understand
that unauthorized removal of shoreline vegetation (e.g. button bushes, willows, cattails, etc,)
and/or disturbance of the shoreline buffer may result in suspension or denial of lake use
Permitting requests, forfeiture of security deposits and require re-establishment of vegetation at
mylour expense, particularly if the disturbance is found to be in violation of state or local
ordinances or impacts FERC project buffers-
1
/we agree all excavated material will be placed in upland areas, landward of the Project
Boundary, and confined to prevent erosion and sedimentation back into the lake or nearby
streams.
Duce EMW Page 2
Rev: 416xnx0

Uwe agree to adequately stabilize all excavated material and all disturbed shoreline to prevent
erosion and runoff into the lake.
Ihve understand that the double handling of excavated material will not be allowed; therefore, all
excavated material must be placed above the Project Boundary in one handling.
Uwe have designed the hydraulic excavation process (if any will he awed) so that return water re-
enters the lake in the same general vicinity and cove as the excavation, to the maximum extent
practicable.
Uwe agree that the proposed excavation will not be for the purpose of creating additional
shoreline, will not alter the Project Boundary or the full pond contour, and will not impact
threatened or endangered species, historic properties, or environmentally -important areas, unless
special public entity provisions were made in the application.
.Uwe recognize that it is mylour responsibility to clearly locate in the field and label on mylour
work area drawings any areas that require specific protection or avoidance during this excavation
work. Examples of these protection/avoidance areas include but are not limited to, any
Environmental Areas, Natural Areas or Impact Minimization Zones as identified by Duke
Energy; jurisdictional wetlands; historic properties; rare or threatened species; and buried gas,
water, sewer, electric or communications lines. Uwe agree to provide rrrylour contractor with a
copy of these work area drawings showing these areas to stress the necessary protection
measures.
Ilwe agree that if any archaeological resources (e.& pottery shards, Indian artifacts, etc.) are
discovered during the excavation, work shall be hatted immediately. Ilwe will then notify Duke
Energy and the State Historic Preservation Office to determine what measures, if any, Ilwe must
Pursue to protect or salvage the archaeological resources.
Ihve agree that any excavation from within the Project Boundary will not exceed the volume as
outlined in the application and will remove and disturb onlywhat is abso k1XAgqq1g.,M to
achieve the project's stated purpose.
Ilwe agree to be fully responsible for the permitted lake use and Ilwe understand that this
responsibility is considered to transfer automatically along with ownership and leases of the
adjoining tract.
Uwe understand Duke Energy representatives may issue Stop Work Directives for violations of
the SMP or other applicable guidelines and other consequences may result from such violations,
including but not limited to suspension or cancellation of approved permits, increases in fees,
modification or removal of non -complying structures and restoration of disturbed areas at mylour
own expense or loss of any consideration for future lake use permits. Uwe agree to immediately
comply with any Stop Work Directives, to fully cooperate with Duke Energy and other agencies
as necessary, and to perform the necessary remedial actions within the specified time frame.
°A" EwW Page 3
xs.: a+ataxa

I/we agree to develop any required mitigation plans and to complete any required mitigation
activities at my/our own expense within the specified time frames. 1/we recognize that the
excavation work is not considered complete and deposits will not be refunded until the
Mitigation requirements (if any) have been satisfactorily fulfilled.
duri e to noti Duke Ener hone when the excavation is initiated. and to ensure th t
Burin the excavation jgL16wilt t Duke Ener 's in royal letter in a clear wate r f
bag at the job site and vi ible from the ater's e.
I/we agree to notify Duke Energy in writinn when the excavation is completed (including any
required mitigation measures) and that the excavation was completed per the approved
application, so a close-out inspection can be performed.
IAve recognize security deposits will not be refunded if any violations of the SMP, other
applicable guidelines, or this user's agreement occur.
I/we understand there will be no change in hydro project operations as a result ofthe excavation
and/or utilization of the excavated area.
I/we agree to maintain the work area in a safe condition and to fully indemnify and save Duke
Energy harmless from any and all claims, liability, loss or damage that may anise from this
excavation project.
Ilwe understand that this user's agreement does not, in any way, constitute the transfer of any
rights in real property and that mylour use and enjoyment of FERC project and Duke Energy
lands and waters shall not hinder the general public's iawfui use and enjoyment of the same.
Sincerely,
%! -Applicant's Name (Print) Applicant's signature
Co -Applicant's Name {Print)
Co -Applicant's Name (Print)
Co -Applicant's Natne (print]
CO -Applicant's Name (Print)
Co -Applicant's signature
CO -Applicant's Signab=
Co -Applicant's Signature
Co -Applicant's Signature
Duke rnw Page 4
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