20140507 Ver 1_401 Application_20140514

20140507
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Pre - Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the Corps:
Section 404 Permit ❑ Section 10 Permit
1b. Specify Nationwide Permit (NWP) number: or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps?
m/yes ❑ No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
1e. Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification:
XYes ❑ No
For the record only for Corps Permit:
❑ Yes No
1f. Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in -lieu fee program.
❑ Yes No
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
(� Yes ❑ No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes No
2. Project Information
2a. Name of project:
E W jr}
2b. County:
v Y Q PLV
2c. Nearest municipality / town:
V R�_ C) C_
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state project no:
3. Owner Information
3a. Name(s) on Recorded Deed:
C_ E> -%T
3b. Deed Book and Page No.
j� f2_Ce L` 5 — (D p t L+19 6_9P19 "Z
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3c. Responsible Party (for LLC if
applicable):
3d. Street address:
V �S ,
3e. City, state, zip:
Yj eP" N j11 C_
3f. Telephone no.:
3g. Fax no.:
3h. Email address:
G, v—' Vl L , Iii V
Page 1 of 10
PCN Form — Version 1.4 January 2009
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4. Applicant Information (if different from owner)
4a. Applicant is:
❑ Agent ❑ Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 10

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): LaA S
1 N 6
1b. Site coordinates (in decimal degrees): Latitude: -j5 `3 LZ 5 96 Longitude: '-j bye 7 C)
1c. Property size: 2-,B1 acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
S O -J
2b. Water Quality Classification of nearest receiving water:
' H ' M
2c. River basin:
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3. Project Description \� (Z„\ VC V9 A- CC
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application: I
3b. List the total estimated acreage of all existing wetlands on the property: \ o
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3d. ^J Explain
a� A `i �C S `� �Y'aioS
G 0--�� V E�/�i__�th� jp 3eV project:
C - s, ,3 P- V c-e- sZ
3e. Describe the overall project in detail, including the type of equipment to be used: J� �� 2.0
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4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
Yes ❑ No ❑ Unknown
Comments:
4b. If the Corps made the jurisdictional determination, what type
of determination was made?
❑ Preliminary inal
4c. If yes, who delineated the jurisdictional areas?
Name (if known): JA D(Z-MN cS RA-A 1b e
Agency /Consultant Company:
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
❑Yes° No ❑Unknown
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project?
❑ Yes EErNo
6b. If yes, explain.
Page 3 of 10
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts °Summary
1a Which 'sections Were�dompleted below for your- project (check, all,that'apply)•
[ Wetlands ❑ Streams —4 ibutanes ❑ Buffers ❑ Open Waters ❑ Porid Construction
2. Wetland.lmpacts
If'there -are wetland'impacts proposed on the site, then complete this question for each wetland area impacted
Wetland impact Type of impact Type of wetland Forested Type Corps 40jurisdiction or Area impact
2a 2b 2c 2d. 2e T-s
P- ( )
r
number DWQ (401, other)
Permanent or
Temporary �T
W1 - Choose one .f—" - LL Choose one f itAE 'FLA 1 woe Yes /No - •® o (7, t.�°.�
W2 -
Choose one
Choose one
Yes /No
-
W3 -
Choose one
Choose one
Yes /No
-
W4 -
Choose one
Choose one
Yes /No
-
W5 -
Choose one
Choose one
Yes /No
-
Choos "e one
`Choose one
`Yes /No
Wg -
2g. Total Wetland Impacts:
2h Comments:
3. Stream Impacts N -4 P"t
or intermittent stream impacts (including temporary impacts) proposed onAhe site, then complet0his,
If there,are perennial
question fof all stream sites impacted
3a 3b. 3c. 3d 3e. 3f. 3g
Stream impact Type of impact Stream name Perennial,(PER) or Type of Average Impact,
length
number intermittent (INT)? ,jurisdiction stream
width (linear
Permanent (P) or
(feet) feet)
'Temporary (T) =
Choose one
-
-
S1' -
_S2 -
Choose one
_ -
-
S3 -
Choose one
-
-
S4 -
Choose one
-
-
S5 -
Choose one
-
-
S6 -
Choose one
-
-
3h Total stream and tributary,impacts
3i Comments,
Page 4 of 10
PCN Form — Version 1.4 January 2009

4. Open Water Impacts
If there,are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the- Atlantic,Ocean, or any other open water of
the,U S then indiv' ua'lly list all open water impacts below.
4a
Open water
impact number
Permanent,(P.) or
Temporary T
4b.
Name of waterbody
(if applicable)
4c
Type of impact
4d
Water body
type
4e
Area of impact (acres)
01 -
Choose one .Choose
02 -
Choose one 'Choose
03 -
Choose one
Choose
04 -
Choose one
Choose
4f. Total open water impacts
4g Comments:
5. Pond,or Lake Construction
If pond kor I_ake•construction ro osed, then complete the chart below
5a
Pond'ID number
5b
Proposed use or
purpose of pond
5c
Wetland Impacts (acres)
5d
Stream Impacts (feet)
5e
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f., Total:
5g Comments
5h Is a,dam high hazard permit'required?
❑ Yes ❑ No If yes, permit ID no:
51 Expected pond surface area (acres)
5j, Size,of pond watershed (acres)-
5k. Method of construction
6. Buffer Impacts (for`DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below If any impacts-require mitigation,. then vou,MUST fill outlSecfion D of this forma ,
6a. Project is in which protected basin?
❑ Neuse ❑ Tar - Pamlico ❑ .Catawba ❑ Randleman ❑ Other.
6b.
Buffer Impact'
number—
Permanent, (P) or
Temporary T
6c_
Reason for impact
6d
Stream name
6e.
Buffer
mitigation
required?
6f
Zone 1
impact
(square
feet )
6g
Zone 2
impact
(square
feet
B1 -
Yes /No
B2 -
Yes /No
B3 -
Yes /No
B4 -
Yes / No
,B5 -
Yes /No
B6 -
Yes /No
6h. Total Buffer'lmpacts:
61 Comments.
,;� Page 5 of 10

'D. Impact Justification, and Mitigation, _
1. ,Avoidance and Minimization
la Specifically describe - measures taken to avoid or minimize the propose r�pa in d ng pro P"' ®�
y. ,�; 1_�
1 b.. Specificallydescribe measures taken to avoid or minimize the proposed impacts through construction techniques
2. Comp ensato - Mitigation for - Impacts, to Waters of the, U.S. or Waters of the,State
2a. Does the project require Compensatory Mitigation for ❑ Yes No
1
impacts- to'Watefs +of the U.S or Waters of the State?
2b If yes, mitigation is required 6y °(check all that apply)
El _ DWQ Corps
❑ Mitigation bank
2c If yes, which mitigation option will be used for this,
❑ Payment to in -lieu fee program
project?
❑ Permittee Responsible,Mitigation
3. Complete if Using a Mitigation Bank
, 3a. �Name,of mitigation Bank.
Type. Choose one Quantity
3b. Credits Purchased (attach receipt and letter) Type- Choose one Quantity"
Type Choose one Quantity.
3c Comments:
4
4. Com Mete if Making�a Payment to In -lieu Fee Pro ram
4a Approval letter from an =lieu fee program is,attached ❑. Yes
4b Stream mitigation, requested - linear feet
4c. If using'stream mitigation, stream temperature- Choose one
4d. Buffer mitigation requested (DW,Q only).
square feet _
4e. Riparian wetland mitigation requested - acres
4f Non - nparian wetland mitigation requested` acres
4g Coastal (tidal) wetland "mitigation requested: acres -
4h Comments
5. Complete if Using a Permittee Responsible Mitigation Plan
5a If using a permittee responsible mitigation plan,-provide a description of, the proposed, mitigation plan.
Page,&of 10 -
PCN Form — Version 1.4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) —required by DWQ
6a Will the project result in an,impact within a protected riparian buffer that requires
buffer mitigation?
Yes [ No
7�
6b. If yes, then'identify the square feet of'impact to each zone, of the riparian buffer that requires mitigation. Calculate,the
amount of mitigation required
6c
6d.
6e.
Zone
'Reason for impact
Total impact
Multiplier
'Required;mitigation,
(square feet)
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
15
6f Total buffer mitigation required:
6g. •lf,buffer mitigation is required, discuss what type of mitigation is proposed (e g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved m- lieu- fee,fund)
6h Comments
Page 7 of 10

E. Stormwater,Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan,
1 a. Does,the project include or is it adjacent to protected riparian buffers identified
❑ Yes bkNo
withimone of the NC Riparian Buffer Protection Rules?
-
1 b If yes, then is a diffuse flow plan included? If no, explain why.
Yes '❑ No
❑
2. Stormwater Management Plan
2a What is the overall percent imperviousness of this project,
%
-
2b Does this rd ect require a,Stormwater Management Plan?
No
❑Yes
2c. If,this project DOES NOT requireaa Stormwater Management Plan, explain
V '� V-- �L FC-4 �
2d. If this project DOES require a Stormwater Management Plan, then provide a brief,' narrative description of the plan
2e. Who will be responsible for,the review of the Stormwater Management Plan?
3. Certified Local Government Stormwater Review
3a In which local overnment% 'urisdiction isthis project?
-
- -
❑ Phase II
❑ NSW
3b. Which of the following locally - implemented stormwater management programs
❑ USMP
apply (check all that apply):
Water Supply Watershed,
Other-
8c. Has the approved Stormwater Management Plan with proof of approval been
[]Yes No
attached?
,4- DWQ Stormwater Program Review
❑Coastal counties
❑HQW -
4a' Which of the following state - implemented stormwater management. programs apply
El Won Law 2006 -246
(check all that apply)'
❑Other
4b Has the approved Stormwater Management Plan with proof'of approval been
❑ yes ❑ No
attached?
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet`the appropriate requirements ?'
E] Yes ❑ No
rh Have all of the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 8 of °10
PCN Form — Version 1.4 January 2009

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
la Does the project involve an expenditure of public (federal /state /local) fund's or the
El Yes
No
use of public (federal /state) land?
1 b If you answered "yes "'to the above, does the project require preparation of an
environmental document pursuant,to the,requirements of the National,or State
El Yes
❑ "No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
16 'If you answered "yes' to the above, has the document review been.fnalized by the
State Clearing House? (If so, attach a.copy of the NEPA or SEPA final approval
Yes
Q No
letter .')
Comments
2. Violations (DWQ Requirement),
2a 'Is the site in violation of DWQ Wetland'Rules (15A NCAC 2H 0500), Isolated
Wetland Rules (15A NCAC °2H 1300), DWQ Surface Water or Wetland Standards,
❑,Yes
No
or Riparian Buffer Rules (15A -NCAC 2_B .0200)?
- _
215. Is this an after - the -fact permit application?
❑Yes
4
No
2c. If you answered "yes" to one or,both of the above questions, provide amexplanation of'the- violation(s):
3. Cumulative,lmpacts,(MCI Requirement)
3a Will this project (based on past and reasonably anticipated future impacts) result in
El Yes
No
additional development, whicNcould impact,nearby downstream water quality?
,3b. Ifyou answered —yes" to th&above, submit a qualitative or quantitative cumulative impact analysis in accordance,with the
most recent DWQ policy If you answered "no," provide a short narrative description
4. Sewage Disposal (DWQ Requirement)
4a Clearly detail°the ultimate'treatment`mefhods and disposition (non'-discharge or dischargb);of wastewater
generated from
the proposed project, or,avadable capacity of the subject facility. p
Page 9 of 10
PCN Form — Version 1.4 January 2009

,5. Endangered Species <and Designated Critical Habitat (Corps Requirement)
5a. Will this protect ,occur in or near an area with federally protected species or
Yes No
habitat?
5b Have you',checked with the USFWS concerning Endangered Species;Act
No'
impacts?
,Yes
5c If yes, indicate,the USFWS!Field;Office you,have contacted
-
5d What data sources did you use to determine,whether your site,would.impact* Endangered Species,or Designated Critical
Habitat?
6. Essential' Habitat,(Corps Requirement)
6a. Will this project occur in or near an,area designated,as essential fish habitat?
Yes No
F- o
6b What data sources did you use to,determin&whether your site would impact Essential FishAabitat?
7. Historic or Prehistoric Cultural Resources, (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments haveAesignatedsas having historic or cultural preservation
National.Histodc
Yes No
status (e g , Trust designation or properties significant in
7j
North Carolina history- and archaeology)? -
7b. What data sources did you use to,determine whether your site.would impact historic or archeological- resources?
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur 6 a FEMA- designated 100 -year floodplain?
Yes ❑ No,
8b. If yes, explain how,project meets FEMA requirements -
8c, What source(s) did you use to make the floodplain determination?
o rNf\— G1S
✓l*` 6
Appllcant/Agent's Printed Name
Applicant/Agent's SI 9 nature
Date
(Agent's signature is valid only if an authorization
letter from the,applicant is providefl
Page 10 of 10

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Birmingham, AL - 800- 251 -9134 Chattanooga, TN - 800- 251 -9134 Huntsville, AL - 205 -880 -7773 Raleigh, NC - 919 - 781 -3226
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Corporate Office: Knoxville, Tennessee 423 -588 -7691 • Toll Free 800 - 251 -9134 • Telefax 423 -588 -9845
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Greenville, SC - 800 -442 -7955 Nashville, TN - 800 - 782 -3769