20071490 Ver 1_Application_20070924

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STATE OF NORTH CAROLINA sr~Mwq~ NCH
DEPART7VIENT OF TRANSPORTATION
MICHAEL F. EASLEY LYNDO TIPPETT
GOVERNOR SECRETARY
August 29, 2007
US Army Corps of Engineers
Regulatory Field Office
6508 Falls of Neuse Road, Suite 120
Raleigh, NC 27615 0
ATTENTION: Mr. Andy Williams
NCDOT Coordinator
Dear Sir:
Subject: Notice of Intent to Use Section 404 Nationwide Permit 13 for the replacement of Bridge No.
89 on SR 2627 (Candy Creek Rd.) over Rose Creek, Rockingham County. Federal Project No.
BRZ-2627(1), WBS No. 33596.1.1, State Project No. 8.2511601, T.I.P. B-4254, Division 7.
Please see the enclosed permit drawings, and design plans for the subject project. A copy of the
Categorical Exclusion (CE) is available upon request. The North Carolina Department of Transportation
(NCDOT) proposes to replace Bridge No. 89 over Rose Creek. The project involves replacing the
current bridge on its existing location. The proposed structure will be a 100-foot, precast/prestressed box
beam bridge and will span Rose Creek. The bridge will provide a clear roadway width of 29-feet 10-
inches. The approaches will consist of two 12-foot lanes with 8-foot shoulders on either side. During
construction, traffic will be detoured onto existing secondary roads.
IMPACTS TO WATERS OF THE UNITED STATES
The project is located in the Cape Fear River Basin (sub-basin 03-06-01). This area is part of Hydrologic
Cataloging Unit 03030002 of the South Atlantic-Gulf Coast Region. Four wetlands and two jurisdictional
streams, Rose Creek and an unnamed tributary to Rose Creek (UT1), are located within the project area.
The section of Rose Creek crossed by the subject bridge has been assigned Stream Index Number 16-8
(8/3/92) by the N.C Division of Water Quality. Rose Creek has a best usage classification of C, NSW.
UT1 does not have separate best usage classification and therefore share that of its receiving waters,
Rose Creek.
No designated Outstanding Resource Waters (ORW), High Quality Waters (HQW), Water Supply I (WS-
I), or Water Supply (WS-II), waters occur within 1.0 mile of the study corridor. Rose Creek is not listed
on the Fina12006 303(d) list of impaired waters for the Cape Fear River Basin. Little Troublesome
Creek is located within 1-mile of the project area and is listed on the Fina12006 303(d) list due to
impaired biological integrity and fecal coliform. Little Troublesome Creek is not listed due to
sedimentation and Rose Creek does not drain directly into Little Troublesome Creek.
MAILING ADDRESS: LOCATION:
NC DEPARTMENT OF TRANSPORTATION TELEPHONE: [phone]$34 Of 272$ CAPITAL BLVD. SUITE 240
PROJECT DEVELOPMENT AND ENVIRONMENTAL ANALYSIS 919-715-1335 RALEIGH NC 27604
NATURAL ENVIRONMENT UNIT
1598 MAIL SERVICE CENTER FAX: [phone]
RALEIGH NC 27699-159$
WEBSITE: WWW NCDOT.ORG

~:
Temporary Impacts
There will be no temporary impacts to wetlands or jurisdictional streams resulting from construction of
the proposed bridge.
Permanent Impacts
A lateral "v" ditch will be used to direct stormwater runoff into Rose Creek. There will be 201inear feet
(0.01 acre) of impacts to Rose Creek resulting from the placement of fill on the channel bank for bank
stabilization. The fill is necessary to evenly distribute the flow from the ditch into Rose Creek and
prevent erosion.
There will be no permanent impacts to wetlands resulting from the construction of the proposed bridge.
Utility Impacts
Construction of the proposed bridge will require the relocation of aerial and underground telephone lines
currently located north of the existing bridge. The lines will be relocated to existing power poles located
south of the bridge. There will be no impacts to jurisdictional resources resulting from the removal or
relocation of the telephone lines.
Bridge Demolition
Existing Bridge No. 89 is approximately 70-feet long with a deck width of 22-feet. The superstructure is
composed a reinforced concrete deck with asphalt wearing surface. The substructure consists of timber
joists supported by timber caps and piles. One bent is located within the water.
All components of the bridge will be removed without dropping any of their components into Waters of
the United States. Best Management Practices for Bridge Demolition and Removal and Protection of
Surface Waters will be followed.
Moratorium
In a letter dated March 19, 2004, the North Carolina Wildlife Resources Commission (WRC) requested a
moratorium on in-stream work from April 1 to June 30 due to a significant fishery for sunfish at the
bridge location. However, the letter incorrectly states that the bridge will cross Little Troublesome
Creek. The proposed project will bridge Rose Creek, which has not been sampled by NCDWQ as part
of the Stream Fish Community Assessment Program.
Therefore, based on the lack of fishery data for Rose Creek as well as the lack of statutory regulations
requiring this moratorium, NCDOT does not believe that this moratorium is warranted.
MITIGATION OPTIONS
Avoidance and Minimization and Comnensatory Mitigation• The NCDOT is committed to
incorporating all reasonable and practicable design features to avoid and minimize jurisdictional impacts,
and to provide full compensatory mitigation of all remaining, unavoidable jurisdictional impacts.
Avoidance measures were taken during the planning and NEPA compliance stages; minimization
measures were incorporated as part of the project design.
Final B-4254 Permit Application
Page 2 of 4

According to the Clean Water Act (CWA) §404(b)(1) guidelines, NCDOT must avoid, minimize, and
mitigate, in sequential order, impacts to waters of the US. The following is a list of the project's
jurisdictional stream avoidance/minimization activities proposed or completed by NCDOT:
Avoidance/Minimization
• The new bridge will be 30 feet longer than the existing bridge, increasing the floodplain under the
bridge.
• The proposed bridge will be replaced on its existing location.
• The proposed project will completely span Rose Creek, allowing for pre-project stream flows to
maintain the current water quality, aquatic habitat, and flow regime.
• Fill slopes will not be located within the wetlands.
• An off-site detour will be utilized during construction.
• Temporary construction impacts due to erosion and sedimentation will be minimized through
implementation of stringent erosion control schedule and use of Best Management Practices (BMPs).
Comnensato~ ation:
NCDOT is not proposing mitigation for the 201inear feet of bank stabilization because there will be no
adverse effects to the stream nor will the project incur loss of Waters of the United States.
FEDERALLY PROTECTED SPECIES
Plants and animals with federal classifications of Endangered (E), Threatened (T), Proposed Endangered
(PE), and Proposed Threatened (PT) are protected under provisions of Section 7 and Section 9 of the
Endangered Species Act of 1973, as amended. As May 10, 2007 the United States Fish and Wildlife
Service (USFWS) website lists two federally protected species for Rockingham County. Table 1 lists the
species and their federal status.
Table 1. Federall Protected S ecies in Rockin ham Coun , NC
Common Name Scientific Name Federal Status Biological Conclusion Habitat
Present
PleuYObema
James spinymussel
collina E No Effect No
Echinacea
Smooth coneflower
l
i E No Effect No
aev
ata
A biological conclusion of "No Effect" was given in the CE for the James spinymussel and the smooth
coneflower. The James spinymussel is known to occur within the Roanoke River Basin in Rockingham
County. However, the project area is located within the Cape Fear River Basin where the James
spinymussel is not known to occur, therefore, no surveys were necessary. North Carolina Natural
Heritage Program (NCNHP) documents no occurrences of the James spinymussel within 1.0 miles of the
project area.
A biological conclusion of "No Effect" was given in the CE for the smooth coneflower. Surveys for the
smooth coneflower were conducted on August 18, 2004 by EcoScience biologists Sandy Smith, Elizabeth
Scherrer, and Scott Davis and on August 2, 2006 by NCDOT biologists Erica McLamb, Susan Thebert,
Sara Easterly, and Chris Underwood. No specimens were observed during either survey and the
biological conclusion of "No Effect" remains valid. North Carolina Natural Heritage Program (NCNHP)
documents no occurrences of the smooth coneflower within 1.0 miles of the project area.
Final B-4254 Permit Application
Page 3 of 4

SCHEDULE
The project calls for a letting of February 19, 2008 (review date of January 22, 2008) with a date of
availability of April 1, 2008. It is expected that contractor will choose to start construction in Apri12008.
REGULATORY APPROVALS
Section 404 Permit: This document hereby serves as a notice of intent to use Section 404 Nationwide
Permit 13 for bank stabilization. Since the activities associated with this project meet all conditions
related to this permit, we are not requesting written authorization.
Section 401 Permit: We anticipate that Section 401 General Water Quality Certification (WQC) 3626
will apply to this project. The NCDOT will adhere to all general conditions of this WQC. Therefore,
written concurrence from the NCDWQ is not required. In accordance with 15A NCAC 2H, Section
.0500 (a) and 15A NCAC 2B, Section .0200, we are providing two copies of this notice to the North
Carolina Department of Environment and Natural Resources (NCDENR), NCDWQ, as notification.
A copy of this application will be posted on the NCDOT website at
http://www.ncdot.org/doh/preconstruct/pe/. If you. have any questions or need additional information,
please call Erica McLamb at 715-1521.
Sincerely,
~.
Gregory J. horpe, Ph.D.
Environmental Management Director, PDEA
w/attachment
Mr. John Hennessy, NCDWQ (2 Copies)
Mr. Travis Wilson, NCWRC
Mr. Gary Jordan, USFWS
Dr. David Chang, P.E., Hydraulics
Mr. Greg Perfetti, P.E., Structure Design
Mr. Victor Barbour, P.E., Project Services Unit
Mr. Mark Staley, Roadside. Environmental
Mr. J. M. Mills, P.E., Division 7 Engineer
Mr. Jerry Parker, Division 7 Environmental Officer
w/o attachment
Mr. Jay Bennett, P.E., Roadway Design
Mr. Maj ed Alghandour, P. E., Programming and TIP
Mr. Art McMillan, P.E., Highway Design
Mr. S. Wade Kirby, PDEA
Mr. Scott McLendon, USACE, Wilmington
Final B-4254 Permit Application
Page 4 of 4

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DIVISION OF HIGHWAYS
ROCgINGHAM COUNTY
PROJECT: 33596.1.1 (R-~25~4)
~/~(~ ~ BRIDGE N0.89 OVER
~.° Jl ROSE CREEg
' ON SR 2627
SHEET ~ OF ~ ~ d 2~ ®06

-WLB WETLAND BOUNDARY ~~ PROPOSED BRIDGE
/~L
WETLAND PROPOSED BOX CULVERT
~~ LL-~~j
L~~1!L1LLlJ DENOTES FILL IN
WETLAND ~~"~ PROPOSED PIPE CULVERT
DENOTES PERMANENT
SURFACE WATER IMPACTS
DENOTES PERMANENT
SURFACE WATER IMPACTS
(POND)
® DENOTES TEMPORARY
FILL IN WETLAND
® DENOTES EXCAVATION
IN WETLAND
DENOTES TEMPORARY
SURFACE WATER IMPACTS
* * * * DENOTES MECHANIZED
** ** * * * CLEARING
--~ ~ FLOW DIRECTION
TB
~- TOP OF BANK
-- WE EDGE OF WATER
---- ~ --- PROP. LIMIT OF CUT
-----F--- PROP. LIMIT OF FILL
-~ PROP. RIGHT OF WAY
----NG----NATURAL GROUND
___ PL __ PROPERTY LINE
12"-48"
(DASHED LINES DENOTE PIPES
EXISTNG STRUCTURES) 54° PIPES
& ABOVE
SINGLE TREE
.. .. WOODS LINE

--~~--

DRAINAGE INLET
ROOTWAD
RIP RAP
O ADJACENT PROPERTY OWNER
OR PARCEL NUMBER
IF AVAILABLE
PREFORMED SCOUR HOLE

LEVEL SPREADER (LS)
-TDE- TEMP. DRAINAGE
EASEMENT
- PDE - PERMANENT DRAINAGE ~ GRASS SWALE
EASEMENT
--EAB-- EXIST. ENDANGERED
ANIMAL BOUNDARY
--EPB-- EXIST. ENDANGERED
PLANT BOUNDARY
~ WATER SURFACE
xx xxx x X LIVE STAKES
O BOULDER
- COIR FIBER ROLLS
~~~®~
DIVISION OF HIGHWAYS
ROCgINGHAM COUNTY
PROJECT: 33596.1.1 (R-~25~4)
BRIDGE N0.89 OVER
ROSE CREEg
ON SR 2627
SHEET ~ OF
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SU1~1~I~I~~ ®F .AFFEC~E~ ~I~®]~EI~~~ ®WNERS

TRACT NO. PROPERTY OWNER ADDRESS SITE NO.
O GREEN.ERNEST & SUSAN JOY 5564 OSCEOLA OSSIPEE ROAD
BROWNS SUMMIT, NC 27214 I

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DIVISION OF HIGHWAYS t
{ .. R~CgINGHAM COUi~TT~
PRO~ECT:33596.1.1--(R-425~}
BRIDGE N0.89 OVER
G ~ I ROSE CREEg
ON SR 2627
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Office Use Only: Form Version March OS
20071 490
USAGE Action ID No. DWQ No.
~u any parncuiar item is not appiicaele to this project, please enter "Not Applicable" or "N/A".)
I. Processing
1. Check all of the approval(s) requested for this project:
® Section 404 Permit ^ Riparian or Watershed Buffer Rules
^ Section 10 Permit ^ Isolated Wetland Permit from DWQ
^ 401 Water Quality Certification ^ Express 401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested: NW 13
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here:
4. If payment into the North Carolina Ecosystem Enhancement Program (NCEEP) is proposed
for mitigation of impacts, attach the acceptance letter from NCEEP, complete section VIII,
and check here: ^
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
Environmental Concern (see the top of page 2 for further details), check here: ^
II. Applicant Information
1. Owner/Applicant Information
Name: Gregory J Thorpe PhD Environmental Management Director
Mailing Address: 1598 Mail Service Center
Raleigh NC 27699-1548
Telephone Number: [phone] Fax Number: [phone]
E-mail Address:
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent has signatory authority for the owner/applicant.)
Name: N/A
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
Page 1 of 9

r
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: Replacement of Bridge 89 on SR 2627 over Rose Creek
2. T.I.P. Project Number or State Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location
B-4254
County: Rockingham Nearest Town: Reidsville
Subdivision name (include phase/lot number): N/A
Directions to site (include road numbers/names, landmarks, etc.): From US29 take exit onto
Candy Creek Rd. (SR2627).
5. Site coordinates (For linear projects, such as a road or utility line, attach a sheet that
separately lists the coordinates for each crossing of a distinct waterbody.)
Decimal Degrees (6 digits minimum): 36.2581 °N 79.6134°W
6. Property size (acres):
7. Name of nearest receiving body of water: Rose Creek
8. River Basin: Cape Fear River Basin
(Note -this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: The project area consists of a mixture agricultural and
forested land.
Page 2 of 9

10. Describe the overall project in detail, including the type of equipment to be used:
Bride No. 89 will be replaced on existing location. Heav~ty excavation equipment will
be used such as trucks dozers cranes and other various equipment necessary for roadway
construction.
11. Explain the purpose of the proposed work: To replace a deteriorating bridge.
IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules. NA
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application.
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. Each impact must be
listed separately in the tables below (e.g., culvert installation should be listed separately from
riprap dissipater pads). Be sure to indicate if an impact is temporary. All proposed impacts,
permanent and temporary, must be listed, and must be labeled and clearly identifiable on an
accompanying site plan. All wetlands and waters, and all streams (intermittent and perennial)
should be shown on a delineation map, whether or not impacts are proposed to these systems.
Wetland and stream evaluation and delineation forms should be included as appropriate.
Photographs maybe included at the applicant's discretion. If this proposed impact is strictly for
wetland or stream mitigation, list and describe the impact in Section VIII below. If additional
space is needed for listing or description, please attach a separate sheet.
1. Provide a written description of the proposed impacts: Jusrisdictional impacts include
placement of permanent fill into Rose Creek.
Page 3 of 9

2. Individually list wetland impacts. Types of impacts include, but are not limited to
mechanized clearing, grading, fill, excavation, flooding, ditching/drainage, etc. For dams,
separately list impacts due to both structure and fl~~cl;nu

Wetland Im act
P
Site Number
(indicate on map) _

Type of Impact _

Type of Wetland
(e.g., forested, marsh,
herbaceous, bog, etc.) __D.
Located within
100-year
Flood lain
p
(yes/no)
Distance to
Nearest
Stream

(linear feet)
Area of
Impact

(acres)
NA

Total Wetland Impact (acres) 0
3. List the total acreage (estimated) of all existing wetlands on the property: 0 acres
4. Individually list all intermittent and perennial stream impacts. Be sure to identify temporary
impacts. Stream impacts include, but are not limited to placement of fill or culverts, dam
construction, flooding, relocation, stabilization activities (e.g., cement walls, rip-rap, crib
walls, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is proposed,
plans and profiles showing the linear footprint for both the original and relocated streams
must be included. To calculate acreage, multiply length X width then divide by 43 560
Stream Impact
Number
indicate on ma
( )
Stream Name
Type of Impact Perennial or

Intermittent? Average
Stream Width

Before Im act Impact ~
Length

(linear feet) Area of
Impact
)
(acres
1 Rose Creek Permanent Fill Perennial 20 20 0.01

Total Stream Impact (by length and acreage) 20 0.01
Page 4 of 9

5. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.). Open water impacts include, but are not limited to
fill, excavation, dredging, flooding, drainage, bulkheads, etc.
Open Water Impact

Site Number
(indicate on ma)
Name of Waterbody
(if applicable)

Type of Impact Type of Waterbody

(lake, pond, estuary, sound, bay,
ocean, etc.) Area of

Impact
(acres)
NA

Total Open Water Impact (acres)
6. List the cumulative impact to all Waters of the U.S. resulting from the project:
Stream Impact (acres): 0.01
Wetland Impact (acres): 0
Open Water Impact (acres): 0
Total Impact to Waters of the U.S. (acres) 0.01
Total Stream Impact (linear feet): 20
7. Isolated Waters
Do any isolated waters exist on the property? ^ Yes ®No
Describe all impacts to isolated waters, and include the type of water (wetland or stream) and
the size of the proposed impact (acres or linear feet). Please note that this section only
applies to waters that have specifically been determined to be isolated by the USACE.
8. Pond Creation
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ^ uplands ^ stream ^ wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.): NA
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Current land use in the vicinity of the pond:
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It maybe useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
Page 5 of 9

techniques to be followed during construction to reduce impacts. Please refer to the cover letter
page 3.
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on January 15, 2002, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCEEP concurrence shall be placed on hold as incomplete.
An applicant may also choose to review the current guidelines for stream restoration in DWQ's
Draft Technical Guide for Stream Work in North Carolina, available at
httt~://h2o.enr.state.nc.us/ncwetlands/stnngide html.
1. Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Compensatory mitigation is not proposed for the minimal stream impacts (201inear feet)
Page 6 of 9

2. Mitigation may also be made by payment into the North Carolina Ecosystem Enhancement
Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at
[phone] to determine availability, and written approval from the NCEEP indicating
that they are will to accept payment for the mitigation must be attached to this form. For
additional information regarding the application process for the NCEEP, check the. NCEEP
website at h~://h2o.enr.state.nc.us/wrp/index.htm. If use of the NCEEP is proposed, please
check. the appropriate box on page five and provide the following information:
Amount of stream mitigation requested (linear feet): NA
Amount of buffer mitigation requested (square feet): NA
Amount of Riparian wetland mitigation requested (acres): NA
Amount ofNon-riparian wetland mitigation requested (acres): NA
Amount of Coastal wetland mitigation requested (acres): NA
IX. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federal/state/local) funds or the use of
public (federal/state) land? Yes ® No ^
2. If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether aNEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ® No ^
3. If yes, has the document review been finalized by the State Clearinghouse? If so, please
attach a copy of the NEPA or SEPA final approval letter. Yes ® No ^
X. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
1. Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 02B .0243 (Catawba) 15A NCAC
2B .0250 (Randleman Rules and Water Supply Buffer Requirements), or other (please
identify )? Yes ^ No
Page 7 of 9

2. If "yes", identify the square feet and acreage of impact to each zone of the riparian buffers.
If buffer mitigation is required calculate the required amount of mitigation by applying the
buffer multipliers.
Im act
Zone* ~ery,,,p ~ e+~ Multiplier *Required
t NA 3 (2 for Catawba)
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from the top of the near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone i .
3. If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e.,
Donation of Property, Riparian Buffer Restoration /Enhancement, or Payment into the
Riparian Buffer Restoration Fund). Please attach all appropriate information as identified
within 1 SA NCAC 2B .0242 or .0244, or .0260. NA
XI. Stormwater (required by DWQ)
Describe impervious acreage (existing and proposed) versus total acreage on the site. Discuss
stormwater controls proposed in order to protect surface waters and wetlands downstream from
the property. If percent impervious surface exceeds 20%, please provide calculations
demonstrating total proposed impervious level. NA
XII. Sewage Disposal (required by DWQ)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ^ No
Is this an after-the-fact permit application? Yes ^ No
XIV. Cumulative Impacts (required by DWQ)
Will this project (based on past and reasonably anticipated future impacts) result in additional
development, which could impact nearby downstream water quality? Yes ^ No
Page 8 of 9

If yes, please submit a qualitative or quantitative cumulative impact analysis in accordance with
the most recent North Carolina Division of Water Quality policy posted on our website at
http://h2o.enr.state.nc.us/ncwetlands. If no, please provide a short narrative description:
XV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
None
Applicarit/Age~it's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
c3.3c~•o
Page 9 of 9

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