20140790 Ver 1_401 Application_20140714

Kimley> »Horn
July 23, 2014
Mr. David L. Shaeffer
US Army Corps of Engineers
Raleigh Regulatory Field Office
3331 Heritage Trade Drive, Suite 105
Wake Forest, NC 27587
Ms. Karen Higgins
NC Division of Water Resources
401 & Buffer Permitting Unit
512 North Salisbury Street
Raleigh, NC 27604
RE: Nationwide Permit 12 Application Package
Rex Hospital Sewer Upgrade Project
Raleigh, Wake County, North Carolina
Dear Mr. Shaeffer and Ms. Higgins:
On behalf of our client, Rex UNC Healthcare, Kimley -Horn is submitting the attached pre- construction
notification application (PCN) for authorization under Nationwide Permit (NWP) 12 for the above
referenced project, located north of Lake Boone Trail between the Rex Hospital Campus and Wycliff
Road in Raleigh. Also included with this application package is a preliminary jurisdictional
determination request with supporting documentation. Kimley -Horn delineated jurisdictional features
within the study area on January 10, 2011. One jurisdictional perennial stream (stream SA) flows
through the project area, and has been impounded near Wycliff Road to create pond PA, which is
also within the project area. The site was reviewed by James Graham with the NC Division of Water
Resources (DWR) on May 1, 2014, and the buffer determination documentation has been attached.
Rex UNC Healthcare is working in cooperation with the City of Raleigh Public Utilities Department
(CORPUD) to upgrade the existing sewer line in an existing utility easement that services Rex
Hospital. The existing sewer line ranges from 8" to 10 ", and will be upgraded along the current
alignment to a 10 " -15" pipe as necessary throughout the corridor. The increase in capacity will better
serve the hospital and accommodate anticipated development on the campus while minimizing
failures in this reach. The existing easement is 20' wide throughout the corridor, but to allow for
equipment access and material storage and staging, a temporary construction easement will be
obtained throughout the majority of the alignment.
Permanent impacts will result from the placement of fill material within the three existing easement
crossings of the jurisdictional stream feature. Due to heavy development in the watershed, the stream
is severely eroded with failing banks near the existing crossing. In order to stabilize the stream
channel after the completion of the project and maintain the long -term integrity of the stream and
banks above the sewer line, the channel will be armored with riprap at two of the crossings. The third
crossing is adjacent to a large pit where stream SA briefly daylights between two piped reaches. An
existing manhole will be replaced that will impact the stream bank, and fill material will need to be
placed within the boundary of the ordinary high water mark (OHWM) of SA. Due to the impact

Kimley »>Horn
Page 2
location, the PCN documents 18 LF of permanent stream impact along the centerline, however
impacts will be limited to the edge of the OHWM in this reach, avoiding the main channel of SA.
Unavoidable buffer impacts will also result from the proposed project, as stream SA is subject to
Neuse River Basin Riparian Buffer Rules. Although CORPUD has historically maintained the 20'
utility easement along the sewer alignment, areas of the easement may not have been maintained
over the last 10 years. The existing easement, as well as additional temporary construction
easement, will be cleared for construction access. All areas disturbed by the proposed activity will be
re- seeded. Forested areas in Zone 1 of SA's riparian buffer will be cleared due to parallel impacts, so
mitigation has been proposed at a ratio of 3:1 for these impacts.
As shown on the attached plan sheets and permit drawings, there are multiple areas where the
construction corridor runs parallel to stream SA, and the limits of disturbance will be within 10 feet of
the top of bank. Efforts were made to increase the setback where possible to meet Condition 10 of
GC 3884, however due to site constraints created by topography, adjacent sewer connections, and
the proximity of the sewer line to the stream and subject pond PA, 10' was not possible at every
location. For these reasons, Rex UNC Healthcare formally requests an exemption to condition 10 GC
3884 for this project.
All impacts to streams and buffers previously discussed have been minimized to the extent practical.
Stream crossings were located and designed within the original sewer alignment and easement, and
pipe bursting installation techniques will be utilized where practical in order to minimize impacts.
The following attachments are included in this submittal:
• PCN Application Form
• Agent Authorizations with Easement Plat
• Figures
• NCDWQ Stream Identification Form
• USACE Stream Quality Assessment Worksheet
• Mitigation Bank Statement of Availability
• Plan Sheets and Permit Drawings
• NCDWR 401 Application Fee of $240
If there is any additional information you need to assist in the processing of this NWP and
jurisdictional determination application package, please do not hesitate to contact me at
jason.hartshorn @Kimley - Horn.com or (919) 678 -4155.
Sincerely,
Jason Hartshorn
Attachments
Cc: Julie Parham, P.E., Kimley -Horn
Chad Lefteris, Rex UNC Healthcare
3001 Weston Parkway, Cary, NC 27513

000 WAT�"Q' $ PAID
O Y
2 0 1 4 0 7 9 0
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Page 1 of 11
PCN Form — Version 1.3 December 10, 2008 Version
Pre - Construction Notification (PCN ) Form
A. Applicant Information
1.
Processing
1a.
Type(s) of approval sought from the
Corps:
®Section 404 Permit El Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 12 or General Permit (GP) number:
1c.
Has the NWP or GP number been verified by the Corps?
❑ 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
1 e.
Is this notification solely for the record
because written approval is not required?
For the record only for DWQ 401
Certification:
❑ Yes ® 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:
Rex Hospital Sewer Upgrade
2b.
County:
Wake
2c.
Nearest municipality / town:
Raleigh
2d.
Subdivision name:
n/a
2e.
NCDOT only, T.I.P. or state
project no:
n/a
3.
Owner Information
3a.
Name(s) on Recorded Deed:
City of Raleigh Public Utilities Department (easement)
3b.
Deed Book and Page No.
n/a
3c.
Responsible Party (for LLC if
applicable):
Aaron Brower "—
j p
"- - -
—t 11/7; —
3d.
Street address:
PO Box 590
3e.
City, state, zip:
Raleigh, NC 27602
„
3f.
Telephone no.:
919 - 996 -4540
3g.
Fax no.:
n/a UTKF2 QJALIIY
3h.
Email address:
[e-mail]
" "` `"81em
Page 1 of 11
PCN Form — Version 1.3 December 10, 2008 Version

4.
Applicant Information (if different from owner)
4a
Applicant is
'❑ Agent ® Other, specify. Rex,UNC Healthcare
4b
Name.
Chad Lefteris
4c
Business name
(if applicable)-
Rex Hospital
4d
Street address:
4420 Lake Boone Trail
4e
City, state, zip
Raleigh, NC 27607
4f
Telephone no
919 -784 -3390
4g
Fax no.
n/a
4h
Email address
chad leftens @rexhealth com
5.
Agent/Consultant Information (if applicable)
5a
Name,
Jason Hartshorn
5b
Business name
(if applicable)
Kimley -Horn and Associates, Inc
5c
Street address:
3001 Weston Parkway
5d
City, state, zip.
Cary, NC 2751'3
5e
Telephone no.
919 - 678 -4155
5f
Fax no :
n/a
5g
Email address
Cason hartshorn @kimley -horn com
B.
Project Information and Prior'Project,History
1.
Property Identification
1a. Property identification no (tax PIN or parcel ID)
n/a (linear utility easement)
1 b
Site coordi -nates (in decimal degrees)
Latitude 35 818371 Longitude: - 78.696515
(DD DDDDDD) ( -DD DDDDDD)
1c
Property size
3.9 acres
2.
SurfaceMaters
2a
Name of nearest body of water (stream,, river, etc) to
proposed project
House Creek
2b
Water Quality Classification of nearest receiving water
C,NSW
2c
River basin
Neuse
Page 2 of 11
PCN Form — Version 1 3 December 10, 2008 Version

3.
Project Description
3a
Describe the existing co_ nditions on the site and the general land use in the vicinity of the project at the time of this
application
Land use in the vicinity of the project area is urbanized development with a combination of commercial, institutional, and
multi -family residential The project corridor traverses multiple small natural areas that are maintained yards and forested
bottom lands between multiple roadway crossings,
3b
List the total estimated'acreage of all existing wetlands on the property
0 acres
3c List the total estimated linear feeLof all existing streams (intermittent and perennial) on the property.
165
-3d
Explain the purpose of the proposed project
The proposed protect will upgrade the existing aging and undersized sewer hne,currently providing service to Rex,
Hospital in order to accommodate anticipated increases in service demand The project will, replace the pipe along the
same horizontal alignment throughout the corrdior, but the vent cal alignment will be modified in some areas to correct
grade issues in the current installation
3e., Describe -the overall project in detail, including the type of equipment to be used-
The proposed project,will replace the existing sewer pipe, which is comprised of various sizes along the alignment
spanning from 8" to 10 ". The replacement pipe will range from 10 "`to 15" as necessary throughout the corridor. Primarily
the sewer,upgrade will occur via open cut trench, however pipe bursting will be used to minimize impacts in certain
sections where practical
4.
Jurisdictional Determinations
4a
Have'jurisdictional wetland or stream determinations,by the
Corps or State been requested or obtained for this property /
El Yes ®No El Unknown
project (including all prior phases) in the past?
Comments
4b
If the Corps made the jurisdictional determination, what, type
❑ preliminary ❑ Final
of determination was.made?
4c
If yes, who delineated the jurisdictional areas?
Agency /Consultant Company.
Name (if'known)
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
❑ Yes ® No ❑ Unknown
this project (including all prior phases) in the past?
5b
If,yes, explain in detail according to "help file" instructions
n/a
6.
Future Project Plans
6a
Is this a phased project?
❑ Yes ®No
6b
If yes, explain
n/a
C
Proposed Impacts Inventory
1,
Impacts Summary
1a
Which sections were completed below for your project (check all that apply)
❑
Wetlands ® Streams - tributaries ® Buffers
❑
Open Waters ❑J Pond Construction
Page 3 of 11
PCN Form — Version 1 3 December 10, 2008 Version

2 Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for el ach wetland area impacted
2a
2b.
2c
2d.
2e
2f
Wetland impact
Type of jurisdiction
number —
Type of impact
Type of wetland
Forested
(Corps -,404, 10
Area of impact
Permanent (P) or
(if known)
DWQ,— non -404, other)
(acres)
Temporary T
W1 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W2 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W3 ❑ P ❑ T
❑{Yes
❑ Corps
❑' No
❑ DWQ
W4 ❑ P ❑ T,
❑ Yes
❑ Corps
No
❑ DWQ
W5 ❑ P ❑ T
❑Yes
❑ Corps
❑ No
❑ DWQ
_
W6 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
2g. Total wetland impacts
2h Comments. No wetland impacts will result from the proposed project
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted
3a.
3b
3c
3d
3e
3f
3g"
Stream impact
Type of impact
Stream name
Perennial
Type of jurisdiction
Average
Impact
number -
(PER)�or
(Corps - 404, 10
stream
length
Permanent (P) or
intermittent
DWQ — non -404,
width
(linear
Temporary (T)
(INT)?
other)
(feet)
feet)
Impact 2
S1 ® P ❑ T
Open cut trench,
backfill, placement of
Stream ,SA — UT
® PER
® Corps
5
51
to House Creek
❑ INT
❑ DWQ
rip rap
Impact 3
Open cut trench,
backfll, placement of
Stream SA — UT
❑ PER
® Corps
5
18
S2 ® P E] T
to House Creek
❑ INT
❑ DWQ
rip rap
-
Impact 4
Open cut trench,
backfill; manhole
Stream SA — UT
'M PER
®Corps
5
40
S3 ® P ❑ T
replacement
to House Creek
� ❑INT
❑DWQ
S4 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S5 ❑ P ❑ T
'❑ PER
❑ Corps
❑ INT
❑ DWQ
S6 ❑ P ❑'T
❑,PER
❑ Corps
❑ INT
❑ DWQ
3h Total stream,and tributary impacts
109
31 Comments. Impacts to jurisdictional streams within the project area will result from,the placement of nprap along the
stream banks and within the streambed for purposes of channel stabilization Due to,heavy development in the watershed,
the stream,systems in the project area are�heavdy,eroding causing high volumes of sediment to be washed downstream To
help protect the banks and the.sewer line, permanent nprap fill will be placed to armor the channel Additionally, the placed rip
rap will serve to improve downstream water quality by,acting as,a,constructed riffle; oxygenating the channel and dissipating
energy in a reach that has been historically impacted by severe erosion
"Note Stream impactsVere numbered to match the corresponding buffer impact area, and since no stream, impacts will
result at impact,zone 131 (buffer impacts only) there is no stream impact 1
Page 4 of 11
PCN Form — Version 1.3 December 10, 2008 Version

4. Open Water Impacts
Ifithere are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U S then individually 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
Waterbody type
4e
Area of impact (acres)
01 ❑P ❑T
02 ❑P ❑T
03 ❑P ❑T
-
04 ❑P ❑T
4L,Total,open water impacts
4g Comments No open water impacts will result from the proposed construction
5. Pond or Lake'Construction
If and or lake construction proposed, then com lete 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
Flooded
P1
P2
5f. Total
5g Comments No ponds or lakes will be constructed as part of the proposed project
5h Is a dam high hazard permit required
❑ Yes ❑ No If yes, permit ID no
51. Expected pond surface area (acres)
n/a
5l Size of pond watershed (acres)
n/a
,5k Method of construction
n/a
Page 5of11
PCN,Form'- Version 1.3 December 10, 2008 Version

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 im acts,re_ uire mitigation, then you MUST fill out'Section D of this form
6a.
® Neuse [I Tar-Pamlico ❑Other
Project is in which protected basin?
❑ Catawba ❑ Randleman
6b
6c
6d
6e
6f
6g
Buffer impact
number —
Reason for
Buffer
Zone 1 impact
Zone.2 impact
Permanent (P)
impact
Stream name
mitigation
(square feet)
(square feet)
or Temporary
required?
T
B1 ❑ P ®`T
Open cut
Stream SA - UT`to House,
Nos
2,586'41
5,151 83
and backfill
Creek
®
62 P' ®T
Open cut
Stream SA - UT to House
El Yes
4,437 40
5,390.02
and backfill
Creek
® No
B2 ® P [-IT
Stream SA to House
614.96
1,543.65
aOd backfill
Creek
Nos
B3 ❑ P ® T
Open cut
Stream SA - UT to House
2,049.01
2,969.30
and backfill
Creek
® No
B4 ❑ P ® T
Open cut
Stream SA - UT to House
❑ Yes,
6,034.57
6,06091
and backfill
Creek
®, No
B4 ®P ❑ T
Open cut
`Stream SA - UT to House
® Yes,
2,578.82
1,070.22
and backfill
Creek
❑_No
6h. Total buffer impacts
18,301 17
22,185 93
61 Comments Buffer impacts to both,Zone 1 ,and Zone 2 of jurisdictional Stream SA will occur`in the, project area as a result',of
the sewer pipe replacement and the construction of a temporary construction easement The existing utility easement corridor
will be utilized throughout the project area: However, along much of the corridor a temporary construction easement will also
be needed for equipment access After project completion, the temporary construction easement will be re- vegetated
Permanent impacts,to Zones 1 and 2 will occur due to the removal of forested buffer within the'temporary construction
easement All other buffer impacts will be temporary in nature Per NCDWR Neuse River Basin riparian buffer rules, only
permanent, impacts resulting from parallel impacts to Zone 1 will requirernitigation.
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
The proposed sewer line replacement will follow the same horizontal alignment as the existing structure with all construction
activities, except for the temporary construction easement, occurring within th&existing utility easement The temporary
construction easement is necessary for egwprrfent access =during construction, but will be revegetated after completion of the
sewer upgrade installation.
1 b Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
Impacts to streams and wetlands will be minimized wherever possible throughout the construction process by avoiding °stream
and wetland features wherever possible Staging and construction access will be located in upland areas throughout the
corridor, and silt fencing will be rnstalled'around the permitted'limits of disturbance to ensure all equipment is located within
the project corridor at all times Best Management'Practices (BMP) and measures will be used'to reduce stormwater impacts
to receiving waters and minimize runoff from the construction sites
Page 6 of 11
PCN Form — Version 1 3 December 10, 2008 Version

2. Compensatory Mitigation for Impacts to Waters of the U.S., or Waters of the State
2a Does the project require Compensatory Mitigation for
impacts-to Waters of the U S or Waters of the - State?
❑ Yes ® No
2b. If yes, mitigation is required by (check all that apply)-
❑ DWQ ❑ Corps
2c If yes, which mitigation option will be used for this project?
❑ Mitigation bank
❑ Payment to in -lieu fee program
El Permittee Responsible Mitigation
3. Complete if "Using a'Mitigation Bank
3a Name of Mitigation Bank n/a
3b Credits Purchased' (attach receipt and letter)
Type
Quantity
3c Comments. n/a
4. Complete if Making a Payment to In -lieu Fee Program
4a Approval letter from in -lieu fee program is attached
❑ Yes
4b Stream mitigation requested
linear feet
4c If using stream mitigation, stream temperature
❑ warm ❑ cool ❑cold
4d. Buffer mitigation requested,(DWQ only)
square feet
4e Riparian wetland mitigation requested-
acres
4f Non - riparian wetland mitigation requested
acres
4g Coastal (tidal) wetfand 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
n/a
Page 7 of 11
PCN Form — Version 1.3 December 10, 2008 Version

6. Buffer Mitigation-(State Regulated Riparian Buffer Rules) —required by DWQ
6a Will the project result in an impact within a protected riparian buffer that requires
® Yes ❑ No
buffer mitigation?
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation Calculate the
amount of mitigation required
6c
6d_
6e
Zone
Reason for impact
Total impact
Multiplier
Required mitigation
(square feet)
(square feet)
Parallel Impacts due to Utility
Zone 1'
line construction and
3,193 78
3 (2 for Catawba)
9,581 34
construction access
Zone 2
1 15
6f Total buffer mitigation required:
9,582
6g If buffer mitigation is required, discuss what type of mitigation is proposed (e g , payment to pnvate7mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund)
Mitigation for unavoidable,parallel impacts in Zone 1 of the riparian buffer associated`with stream nS&resulting from the
proposed construction will be accomplished through the purchase of 3`d party mitigation credits The Neuse Buffer
Umbrella Bank will be utilized and 9,582 credits have been reserved for the proposed construction The total buffer
impacts requiring mitigation are 3,193 78 square feet, and'after applying the Zone 1 multiplier for this watershed, the
required 9,582 buffer credits,wdl be purchased to compensate for the unavoidable impacts.
6h Comments Mitigation has been proposed for both unavoidable parallel impacts to Zone 1 ,and for °perpendicular crossing
impacts with a maintenance corridor greater than 10' in Zone 1 of the riparian, buffer associated with stream SA, a
tributary to House Creek Impact areas will be stabilized and re- seeded after construction.
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1., 'Diffuse,Flow Plan
1a Does the project`include or'is it adjacent to protected riparian buffers identified
® Yes ❑ No
within one of the NC Riparian Buffer Protection Rules?
1b If yes, then, is a diffuse flow plan included? If no, explain why
Comments The proposed project will replace a buried, utility line in' place, along the
® Yes ® No
existing alignment, and existing drainage patterns and capacities will be
maintained No new stormwater runoff will be generated
Page 8 of 11
PCN Form — Version 1.3 December 10, 2008 Version

2.
Stormwater Mana ement Plan
2a-
What is the overall percent imperviousness of this project?
< 1 %
2b
Does this project require a Stormwater Management Plan?
❑ Yes ® No
2c
If this project DOES NOT require a Stormwater Management Plan, explain why
The impervious area along the sanitary sewer easement is existing No new impervious area will be added as a result of the
sewer upgrade.
2d
If'this project DOES require a Stormwater Management Plan, then provide,a brief, ,narrative,description of the plan•
n/a
® Certified Local Government
2e
Who will be responsible for the review of the Stormwater Management Plan?
❑ DWQ Stormwater Program
❑ DWQ 401 Unit
3.
Certified Local Goveirnment'Stormwater Review
3a.
In which local,government'sjjurisdiction is`this,prolect?
Raleigh
® Phase II
® NSW
3b
Which of the following locally - implemented stormwater management programs
❑ USMP
apply (check all that apply)
❑ Water Supply Watershed
❑ Other
3c 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
❑ ORW
(check all that apply)*
❑ Session Law 2006 -246
❑ Other
4b Has the approved Stormwater Management Plan'with proof of approval been
attached?
El Yes No
5.
DWQ 401 Unit Stormwater Review
5a
Does the Stormwater Management Plan meet the appropriate requirements?
® Yes ❑ No
5b
Have all of the 401 Unit submittal requirements been met?
® Yes ❑ ,No
Page 9 of 11
PCN Form — Version 1.3 December 10, 2008 Version

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
la Does the project involve an expenditure of public (federal /state /local) funds or the
❑ Yes ® No
use of public (federal /state) land?
1b If you answered "yes" to the above, does,the project require preparation of an
environmental document pursuant to the requirements of the National or State
❑°Yes ❑ No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of'the NEPA or SEPA final approval
❑ Yes ❑ No
letter )
Comments n/a
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'Ripanan Buffer Rules (15A NCAC 2B 0200)?
2b Is this an after - the -fact permit application?
❑ Yes ® No
2c If you answered "yes" to,one or both of the above questions, provide an explanation of the violation(s)
3. Cumulative Impacts (DWQ Requirement)
3a Will this project (based on past and reasonably anticipated future impacts) result in
® Yes ❑ No
additional development, which could impact nearby downstream water quality?
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short°narrative description
The proposed project is necessary" to accommodate an existing deficiency in the capacity of the City of Raleigh's sanitary
sewer for current flows and planned future growth of the Rex Hospital campus Currently, no other development has been
proposed in the area, however in order to minimize future impacts to jurisdictional features, Rex UN C, Healthcare is
oversizing the sewer line sufficiently to accommodate the, potential for additional service connections
4. Sewage Disposal (DWQ Requirement)
4a, Clearly detail the ultimate treatment methodstand disposition (non - discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility
The project will not generate wastewater, but will carry wastewater -flows to the City of Raleigh wastewater treatment plant
Page 10 of•11
PCN Form — Version 1, 3 December 1'0, 2008 Version

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
❑ Yes ® No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
❑ Yes ® No
impacts?
❑ Raleigh
5c. If yes, indicate the USFWS Field Office you have contacted.
❑ Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
NC Natural Heritage Program Element Occurrence Database (Updated April 2014) indicates no known occurrences
within the project area or within one mile of the project area. Habitat is not present in the study area for dwarf
wedgemussel, red - cockaded woodpecker, or Michaux's sumac. Land use in the project study area is mostly residential,
commercial, and institutional. The corridor is historically disturbed and well maintained through mowing and chemical
treatment. Therefore, the proposed project will have no effect on any federally listed threatened or endangered species.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
❑ Yes ® No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
The NOAA Essential Fish Habitat Mapper (reviewed July 2014) was reviewed and no essential fish habitat or habitat
areas of particular concern were found within the project area.
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
❑ Yes ® No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
The NCDENR State Historic Properties Office Map was reviewed (July 2014), and no historic resources occur within the
project area. The closest historic resource (HPO Site ID: WA4044; Status: SLID) is located approximately 3,200 feet
southeast from the project study area. Since the proposed project will replace an existing underground utility line in a
highly developed area, the proposed project will have no effect on the historic property.
B. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA- designated 100 -year floodplain?
❑ Yes ® No
8b. If yes, explain how project meets FEMA requirements: n/a
8c. What source(s) did you use to make the floodplain determination?
FEMA DFIRM Panels 3720078500J and 3720079500J, both effective May 2, 2006, were reviewed. The project area is
outside of any FEMA mapped flood hazard zone.
44
XZ
-77 /11�
Z App icant/Agent's Signature
Applicant/Agent's Printed Name
Date
(Agent's signature is valid only if an authorization letter from the applicant
is provided.)
Page 1 1 of 11
PCN Form — Version 1.3 December 10, 2008 Version

AGENT AUTHORIZATION FORM
Name: REX UNC Healthcare — Chad Lefteris
Address: 4420 Lake Boone Trail, Raleigh, NC 27607
Phone: [phone]
E -Mail: chad.lefteris @rexhealht.com
Project Name /Description: Rex Sewer Upgrade Project, 2810 Blue Ridge Road, Raleigh, NC 27607
Date:
The Department of the Army
U.S. Army Corps of Engineers, Wilmington District
Field Office: Raleigh
Re: Wetland Related Consulting and Permitting
To Whom It May Concern:
I hereby designate and authorize Kimley -Horn and Associates, Inc. to act in my /our behalf as my /our
agent solely for the purpose of processing Jurisdictional Determinations, Section 404 permits /Section
401 Water Quality Certifications applications, and Neuse River Water Supply Watershed Riparian
Buffer Determinations, and to furnish upon request supplemental information in support of applications,
etc. from this day forward until successful completion of the permitting process or revocation by the
owner.
In addition, 1, the undersigned, a duly authorized owner of record of the property /properties identified
herein, do authorize representatives of the Wilmington District, U.S. Army Corps of Engineers (Corps)
to enter upon the property herein described for the purpose of conducting on -site investigations and
issuing a determination associated with Waters of the U.S. subject to Federal jurisdiction under Section
404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors Act of 1899.
Authorized this theoC�day of
nt Propert Owner's Name Propert wnc, s Signature
Cc: Karen I liggins
NC Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650

AGENT AUTHORIZATION FORM
Name: City of Raleigh Public Utilities, Department
Address: PO Box 590 Raleigh NC 27602
Phone: 919 =996 -4540
E -Mail: Aaron. Brower(aDraleighnc.gov
Project Name /Description: Rex Sewer Upgrade Project
Date: 7/15/2014
The Department of the Army
U.S. Army Corps of Engineers, Wilmington District
Field Office: Raleigh
Re: Wetland Related Consulting and Permitting
To Whom It May Concern:
I hereby designate and authorize Kiml"ey -Horn and Associates, Inc. to act in my /our`behalf as my /our
agent solely °for the purpose of processing Jurisdictional Determinations, Section 404 permits /Section
401 Water Quality Certifications applications, and Neuse River Water Supply Watershed Riparian
Buffer Determinations, and to fLi upon request supplemental information in support of applications,
etc. from this day forward until successful completion of the permitting process or revocation by the
owner.
In addition, I, the undersigned, a representative of the duly authorized owner of record of the easements
identified herein, do authorize representatives of the Wilmington District, U.S. Army Corps of
Engineers (Corps) to enter upon the, casement herein described, for the purpose of conducting on -site
investigations and issuing a deterrnination.associated with Waters of'the U.S. subject to Federal
jurisdiction under Section 404 of the Clean' Water Act and/or Section 10 of the Rivers and Harbors Act
of 1899.
Authorized this the day of
Print Easement Owner Representative's Name Easement OWner Representative's Signature
Cc: Karen Higgins
NC Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650

1971P000351
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FIGURES

M
Project Location
ay
cll.
oe1f
OHNSTON
Legend
Project Study Area
KimleyOHorn
r
o�
G
co
N
�`a9e
eve
Lake Boone
ooa N
OX
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G e
<ed
G /en Aden
G /eh Caen
Wade Avenue
Feet
0 3,000 61000
Figure 1: Vicinity Map
Rex Sewer Upgrade
Raleigh, North Carolina
Wake County
July 10, 2014

dOp
dIF
CI
}
�.44
�! 11 fir, : -s �. •' � 1
itiL � L
1 t]
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Legend a
Project Study Area `:` *� _� 0 700 1,400
Feet
Figure 2: USGS Topographic Map (Raleigh West, 1987)
Rex Sewer Upgrade
Kimley > >> Horn City of Raleigh, North Carolina
Wake County
July 10, 2014

_ w
V,
1
•' I
t r •• r
Legend t.-
Streams,
Open Waters' •
FI Project Area s •
M�t�O
LA i I v �.
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i
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Figure 3: Site Features Map
Rex Sewer Upgrade
Raleigh, North Carolina
Wake County
July 10, 2014

`p
L
Legend
C1 Project Study Area
Kimley >>> Horn
MVW-------,J=
L .
,lie - 4. .:
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500 1,000
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Figure 4: NRCS Soil Survey (Wake County, 1970)
Rex Sewer Upgrade
Raleigh, North Carolina
Wake County
July 10, 2014

STREAM DATA FORMS

North Carolina Division of Water Quality - Stream Identification Form, Version 4.11
Date: 11/15/2012
Project/Site SA
Latitude 35.8189
Evaluator A Reusche, KHA
County. Wake
Longitude. - 78.6954
Total Points: 415
0
1
2
Stream Determination (circle one)
Other
Stream is at least intermittent
Ephemeral Intermittent Perennial
e g Quad Name Raleigh West
if z 19 or perennial if 2 30
3
3�
A. Geomorphology Subtotal = 27
­AA& nt'�
� ;Vlleak
�yMode_iate °�
tfrong, '
p
„Sco�e.
1a. Continuity of channel bed and bank
0
1
2
3
3
2 Sinuosity of channel along thalweg
0
1
2
3
3�
3 In- channel structure ex riffle -pool, step -pool, �npple-
ool se uence
0
1
2
3
3
4 Particle size of stream substrate
0
1
2
3
3,
5 Active /relic flood lain
0
1
2
3
2{
6 Depositional bars or benches
0
1
2
3
_"3,
7. Recent alluvial deposits _
_0
1
2
3
1, _
8 Headcuts
0
1
2
3
_ 31
9. Grade control
0
0 5
1
1 5
1.5
10 Natural valley
0
0 5
1
1.5
1:5,
'11 Second or greater order channel
No = 0
Yes = 3
3;
arunciai uncnes are not rates, see aiscussions in manual
B. Hydrology Subtotal = 85
12 Presence of Baseflow
0
1
2
3
1
13_ Iron oxidizing bacteria
0
1
2
3
3_ i
14 Leaf litter
15
1
05
0
1
15 Sediment on plants or debris
0
05
1
1.5
0.5'
16, Organic debris lines or piles
0
05
1
15
A
17 Soil -based evidence of high water table?
No = 0
Yes = 3
T
C. Biology Subtotal =
18 Fibrous,roots in streambed
3
2
1
0
53- _
19 Rooted upland plants in streambed
3
2
1
0
3_ i
20 Macrobenthos note diversity and abundance
0
1
2
3
0
21 Aquatic Mollusks
0
1
2
3
0
22 Fish
0
05
1
1.5
0
23.. Crayfish
0
05
1
1 5
y 0_
24 Amphibians
0
05
1
1 5
0'
25 Algae
0
05
1
1 5
0�
26. Wetland plants in streambed
FACW = 0 75, OBL
= 1 5, Other = 0
0
'perennial streams may also be identified using other methods See p 35 of manual
Notes Stream A was flowing during the site visit No macrobenthos were
observed, however, SA is obviously perennial based on the strong presence of
geomorphology,and hydrology Therefore, macrobenthos are likely present.
Segments of the channel are piped within the corridor

USACE AID #.
DWQ#
Site # (indicate on attached map)
STREAM QUALITY ASSESSMENT WORKSHEET
Provide the following information for the stream reach under assessment:
1. Applicant's name: City Of Raleigh 2. Evaluator's name: Anna Reusche
3. Date of evaluation: 11/15/2012 4. Time of evaluation: 9.00 am
5. Name of stream: SA 6. River basin: Neuse
7. Approximate drainage area: 100 acres 8. Stream order:. Second Order
9. Length of reach evaluated: 300 feet 10. County: Wake
11. Site coordinates (if known): prefer in decimal degrees. 12. Subdivision name (if any):
Latitude (ex. 34.872312): 35.8189 Longitude (ex. - 77.556611): 78.6954
Method location determined (circle): E PSE✓ ropo Sheetbttho (Aerial) Photo /GIS[Jther GISather
13. Location of reach under evaluation (note nearby roads and landmarks and attach map identifying stream(s) location):
SA flows into the project area from the northwest, east of Rex Hospital. SA flows southeast and borders the south of the project corridor. The stream is piped in sections within the corridor.
14. Proposed channel work (if
15. Recent weather conditions: 0.2 inches of rain in the last 48 hours.
16. Site conditions at time of visit: Cloudy with drizzling rain.
17. Identify any special waterway classifications known: nSection 10 Tidal Waters Essential Fisheries Habitat
OTrout Waters 0outstanding Resource Waters 21 Nutrient Sensitive Waters IIWater Supply Watershed. (I -IV)
18. Is there a pond or lake located upstream of the evaluation point? YES If yes, estimate the water surface area: 0.07
19. Does channel appear on USGS quad map? YES 20. Does channel appear on USDA Soil Survey? YES
21. Estimated watershed land use: 60 % Residential
10 % Forested
22. Bankfull width: 5
24. Channel slope down center of stream: 13FIat (0 to 2 %)
25. Channel sinuosity: Straight 00ccasional bends
30 % Commercial _% Industrial _% Agricultural
_% Cleared / Logged _% Other
23. Bank height (from bed to top of bank): 3
Gentle (2 to 4 %) DModerate (4 to 10 %) E[Steep ( >10 %)
✓Frequent meander OVery sinuous Braided channel
Instructions for completion of worksheet (located on page 2): Begin by determining the most appropriate ecoregion based on
location, terrain, vegetation, stream classification, etc. Every characteristic must be scored using the same ecoregion. Assign points
to each characteristic within the range shown for the ecoregion. Page 3 provides a brief description of how to review the
characteristics identified in the worksheet. Scores should reflect an overall assessment of the stream reach under evaluation. If a
characteristic cannot be evaluated due to site or weather conditions, enter 0 in the scoring box and provide an explanation in the
comment section. Where there are obvious changes in the character of a stream under review (e.g., the stream flows from a pasture
into a forest), the stream may be divided into smaller reaches that display more continuity, and a separate form used to evaluate each
reach. The total score assigned to a stream reach must range between 0 and 100, with a score of 100 representing a stream of the
highest quality.
Total Score (from reverse): 55 Comments:
Stream A was flowing during the site visit. No macrobenthos were observed, however, likely present. Segments of the channel
are piped within the corridor.
Evaluator's Signature e� 1� �``° ^� Date 11/15/2012
This channel evaluation form is intended to be used only as a guide to assist landowners and environmental professionals in
gathering the data required by the United States Army Corps of Engineers to make a preliminary assessment of stream
quality. The total score resulting from the completion of this form is subject to USACE approval and does not imply a
particular mitigation ratio or requirement. Form subject to change - version 06/03. To Comment, please call 919 - 876 -8441 x 26.

SA
STREAM QUALITY ASSESSMENT WORKSHEET
* These characteristics are not assessed in coastal streams.
ECOREGION POINT
RANGE
#
CHARACTERISTICS
SCORE
Coastal
Piedmont
Mountain
Presence of flow / persistent pools in stream
1
no flow or saturation = 0• strong flow = max oints
0 - 5
0-4
0 - 5
4
2
Evidence of past human alteration
extensive alteration = 0• no alteration = max points)
0 -6
0 -5
o -s
1
3
Riparian zone
0-6
0-4
0-5
2
no buffer = 0• contiguous, wide buffer = max points)
Evidence of nutrient or chemical discharges
4
extensive discharges = 0• no discharges = max points)
0-5
0-4
0-4
2
,.�
Groundwater discharge
U,
no discharge = 0• springs, seeps, wetlands etc. = max points)
0- 3
0- 4
0- 4
4
Presence of adjacent floodplain
6
no floodplain = 0• extensive floodplain = max points)
0-4
0 - 4
0-2
2
�i
7
Entrenchment / floodplain access
a
(deeply entrenched = 0; frequent flooding = max points)
0-5
0-4
0-2
3
Presence of adjacent wetlands
no wetlands = 0; large adjacent wetlands = max points)
0-6
0 - 4
0-2
9
Channel sinuosity
0-5
0-4
0-3
4
extensive channelization = 0; natural meander = max points)
Sediment input
10
(extensive deposition= 0; little or no sediment = max points)
0-5
0-4
0-4
2
Size & diversity of channel bed substrate
1 l
fine homogenous = 0• large, diverse sizes = max points)
NA*
0-4
0 - 5
4
Evidence of channel incision or widening
12
(deeply incised = 0; stable bed & banks = max points)
0-5
0 - 4
0-5
2
13
Presence of major bank failures
0-5
0 - 5
0-5
2
severe erosion = 0• no erosion stable banks = max points)
Root depth and density on banks
H
14
no visible roots = 0; dense roots throughout = max points)
0 - 3
0-4
0 - 5
2
Impact by agriculture, livestock, or timber production
15
substantial impact =0; no evidence = max points)
0-5
0 - 4
0-5
4
Presence of riffle- pool/ripple -pool complexes
16
no riffles/ripples or pools = 0• well-developed = max points)
0-3
0-5
0-6
5
17
Habitat complexity
Habitat
0-6
0 - 6
0-6
6
or no habitat = 0• frequent, varied habitats = max points)
Canopy coverage over streambed
18
no shading vegetation = 0; continuous canopy = max points)
0-5
0 - 5
0-5
3
Substrate embeddedness
19
(deeply embedded = 0; loose structure = max
NA*
0-4
0-4
3
20
Presence of stream invertebrates (see page 4)
0-4
0 5
0- 5
0
(no evidence = 0; common numerous types = max points)
-
21
Presence of amphibians
O
(no evidence = 0; common numerous types = max points)
0-4
0-4
0-4
0
O
22
Presence of fish
0-4
0-4
0-4
0
no evidence = 0; common, numerous types = max p oints
Evidence of wildlife use
23
0-6
0-5
0-5
0
no evidence = 0; abundant evidence = max points)
Total Points Possible
100
100
100
TOTAL SCORE (also enter on first page)
55
* These characteristics are not assessed in coastal streams.

NCDWR BUFFER
DETERMINATION LETTER

AM-KYWA
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
May 16, 2014
Kimley Horn and Associates
Jason Hartsorn
P.O. Box 33068
Raleigh, NC 27635
John E. Skvarla, III
Secretary
Subject: Buffer Determination Letter
NBRRO# 14 -104
Wake County
Determination Type:
Buffer Call
Isolated or EIP Call
® Neuse (15A NCAC 2B.0233)
Stop@
❑ Tar - Pamlico (15A NCAC 26 .0259)
❑ Ephemeral /Intermittent/Perennial Determination
SA
❑ Isolated Wetland Determination
❑ Jordan (15A NCAC 26 .0267)
throughout
Project Name: Rex Sewer
Location/Directions: Property is located in between Rex Hospital and Lake Boone trail
Subject Stream: Ut to Crabtree Creek
Determination Date: May 01, 2014
Staff: James Graham
Feature/Flag
Not
Subject
Subject
Start@
Stop@
Soil
Survey
USGS
To o
SA
X
throughout
throughout
X
X
SB
X
X
SC
X
Flag SC 1 pipe
outlet
X
X
SBA
X
SAC
X
Pond A
PA
X
X
Pond B
(PB)
X
X
NoLCarollna
Admura!!ry
North Carolina Division of Water Resources 1628 Mail Service Center Raleigh, NC 27699 -1628 Phone [phone]
Internet: www.ncwaterguality.org Location: 3800 Barrett Drive Raleigh, NC 27609 Fax [phone]
An Equal Opportunity /Affirmative Action Employer- 50% Recycled /10% Post Consumer Paper

Rex Sewer
Wake County
May 16, 2014
Page 2 of -2
Explanation- The feature(s) listed above has or have been located on the Soil Survey of Wake County, North
Carolma or the most recent copy of the USGS Topographic, map at a 1.24,000 scale Each feature that is checked
"Not Subject" has been determined not to be a stream or is not present on the property Features that are checked
"Subject" have been located on the property and possess characienst►cs that qualify it to be a stream There may be
other streams located on your property that do not show up on the maps referenced above but, still may be
considered jurisdictional according to the US Army Corps of Engineers and/or to the Division of Water Resources
(DWR)
This on -site determination shall expire five (5) years from the,date of this letter. Landowners or affected parties that
dispute a determination made by the DWR or Delegated Local Authority may request a determination by the
Director. An appeal request must be made within sixty (60) days of date of this letter or from the date the affected
party (including downstream and /or adjacent owners) is notified of this letter. A request for a determination by the
Director shall be referred to the Director in wasting c/o Karen Higgins, DWR WeBSCaPe Unit, 1650 Mail Service
Center, Raleigh, NC 27699.
This determination is final and binding unless, as detailed above, you ask for a hearing or appeal within sixty (60)
days.
The owner /future owners should notify the Division of Water Resources (including any other Local, State, and
Federal Agencies) of this decision concerning any future correspondences regarding the subject property (stated
above). This project may require a Section 404/401 Permit for the proposed activity. Any inquiries - should be
directed to,the Division of Water Resources (Central Office) at (919)- 807 -6300, and the US Army Corp of Engineers
(Raleigh Regulatory Field Office) at (919) -554 -4884.
If you have questions regardmg this determination, please feel free to contact James Graham at (919) 791 -4256
Respectfully, /
�x J"�7
Danny Smith, Supervisor
Water Quality Section
Raleigh Regional Office
cc. RRO /SWP File Copy

_r-
^�
e
k; v wtr
SA
4'
SA
K.:
• SA
SBA SAC
(secondary flood
flow into PB}
+fir �I � t ` •. l,° ; l. •r P ��
SC
SA
•� o "v *tile
r! � : / •s
Legend 1' -
-�- Streams►
Project Corridor ^ , *' - s IT-
Open Waters;
t Vie•
150 300 450 600 z 45, =
Fee , " OnWa �` n is, NC 91
Figure 3: Site Features Map (Aerial 2012)
iCimley : >�� i�arn Rex Sewer Upgrade
Raleigh, North Carolina
Wake County

a
1 ,, Air7M-!
wV Lol Alfo
ALdM
sew.
•
-ps -
4*-
IL
0 250 500 Feet
Legend
Project Corridor 't
Aw

ENVIRONMENTAL BANC AND
EXCHANGE (EBX) STATEMENT
OF AVAILABILITY FOR RIPARIAN
BUFFER MITIGATION CREDITS

Forrest Creek Riparian Buffer Mitigation Bank
Neuse Buffer Umbrella Bank
Upper Neuse Buffer - Nutrient Reduction Bank
Statement of Availability July 23, 2014
NC Division of Water Quality U.S. Army Corps of Engineers
Ms. Katie Merritt Mr. Eric Alsmeyer
401 Oversight /Express Permitting Unit Regulator Project Manager
1650 Mail Service Center Raleigh Regulatory Field Office
Raleigh, NC 27699 -1650 3331 Heritage Trade Center, Suite 105
Wake Forest, NC 27587
Re Project: Sewer Upgrade to Existing Pipe Servicing Rex Hospital
This document confirms that Rex UNC Healthcare (Applicant) for the Sewer Upgrade to Existing
Pipe Servicing Rex Hospital, has expressed an interest to utilize 9,582 Square Feet of Riparian
Buffer Mitigation Credits from either of the EBX Neuse Riparian Buffer Umbrella Mitigation
Bank (Rudolph Site and Arrington Bridge II sites) Forrest Creek Riparian Buffer Mitigation Bank,
EBX Upper Neuse Riparian Buffer Umbrella Bank (Ezell, Hatley, Cedar Grove sites) all located in
the Neuse HUC 03020201. As the Bank Sponsor for all sites, EBX attests to the fact that
mitigation is available for transfer upon permit issuance at this time.
Banker will notify applicant if the 9,582 Square Feet of-Riparian Buffer Mitigation become
considered "At Risk" of not being available prior to permit issuance. Credits are not considered
secured until payment in full is received from the applicant resulting in the issuance of a and
Affidavit of Sale by the bank acknowledging that the applicant has fully secured credits from the
bank,and the Banker has accepted full responsibility for the mitigation obligation requiring the
credits /units.
The Banker will issue the Affidavit of Sale within three (3) days of receipt of the Purchase Price.
Banker shall provide to Applicant with a copy of the Affidavit of Sale and a documented copy of
the debit of credits from the Bank Official Credit Ledger(s) showing the permit number and the
resource type secured by the applicant. A copy of the Affidavit of Sale, with an updated Official
Credit Ledger will also be sent to regulatory agencies showing the proper documentation.
If any questions need to be answered, please contact me at 239 - 872 -1678
Best ,R,�eigardss
Matthew R. Fisher
EBX
909 Capability Drive Suite 3100. Raleigh, NC 27606

PRELIMINARY JURISDICTIONAL
DETERMINATION REQUEST

Jurisdictional Determination Request
0
US Army Corps
of Engineers
Wilmington District
This form is intended for use by anyone requesting a jurisdictional determination (JD) from the
U.S. Army Corps of Engineers, Wilmington District (Corps). Please include all supporting
information, as described within each category, with your request. You may submit your request
to the appropriate Corps Field Office (or project manager, if known) via mail, electronic mail, or
facsimile. A current list of county assignments by Field Office and project manager can be
found on -line at: http: / /www.saw.usace.army.mil/ Missions /Regulato!yPermitProgram.aspx , by
telephoning: 910 -251 -4633, or by contacting any of the field offices listed below:
ASHEVILLE REGULATORY FIELD OFFICE
US Army Corps of Engineers
151 Patton Avenue, Room 208
Asheville, North Carolina 28801 -5006
General Number: (828) 271 -7980
Fax Number: (828) 281 -8120
RALEIGH REGULATORY FIELD OFFICE
US Army Corps of Engineers
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
General Number: (919) 554 -4884
Fax Number: (919) 562 -0421
WASHINGTON REGULATORY FIELD OFFICE
US Anny Corps of Engineers
2407 West Fifth Street
Washington, North Carolina 27889
General Number: (910) 251 -4610
Fax Number: (252) 975 -1399
WILMINGTON REGULATORY FIELD OFFICE
US Army Corps of Engineers
69 Darlington Avenue
Wilmington, North Carolina 28403
General Number: 910 -251 4633
Fax Number: (910) 251 -4025
Version: December 2013 Page 1

Jurisdictional Determination Request
INSTRUCTIONS:
All requestors must complete Parts A, B, C, D, E and F.
NOTE TO CONSULTANTS AND AGENCIES: If you are requesting a JD on behalf of a
paying client or your agency, please note the specific submittal requirements in Part G.
NOTE ON PART D — PROPERTY OWNER AUTHORIZATION: Please be aware that all JD
requests must include the current property owner authorization for the Corps to proceed with the
determination, which may include inspection of the property when necessary. This form must be
signed by the current property owner to be considered a complete request.
NOTE ON PART D - NCDOT REQUESTS: Property owner authorization/notification for JD
requests associated with North Carolina Department of Transportation (NCDOT) projects will be
conducted according to the current NCDOT/USACE protocols.
NOTE TO USDA PROGRAM PARTICIPANTS: A Corps approved or preliminary JD may not
be valid for the wetland conservation provisions of the Food Security Act of 1985. If you or
your tenant are USDA Program participants, or anticipate participation in USDA programs, you
should also request a certified wetland determination from the local office of the Natural
Resources Conservation Service, prior to starting work.
Version: December 2013 Page 2

Jurisdictional Determination Request
A. PARCEL INFORMATION
Street Address:
City, State:
County:
Directions:
See attached Figure 5 Property Parcels' PIN Table
Parcel Index Number(s) (PIN): See attached Figure 5 Property Parcels' PIN Table
B. REQUESTOR INFORMATION
Name:
Mailing Address:
Telephone Number:
Electronic Mail Address:
Jason Hartshorn, Kimley -Horn and Associates, Inc
3001 Weston Parkway, Cary, NC 27513
919 -678 -4155
Cason hartshorn @kimley -horn com
Select one:
❑ I am the current property owner.
❑✓ I am an Authorized Agent or Environmental Consultant
❑ Interested Buyer or Under Contract to Purchase
❑ Other, please explain.
C. PROPERTY OWNER INFORMATION
Name: City of Raleigh Pulic Utilities Department (easement)
Mailing Address: P O Box 590
Raleigh, NC 27602
Telephone Number.
Electronic Mail Address3:
❑ Proof of Ownership Attached (e.g. a copy of Deed, County GIS/Parcel /Tax Record data)
' If available
z Must attach completed Agent Authorization Form
3 If available
Version: December 2013 Page 3

Jurisdictional Determination Request
D. PROPERTY OWNER CERTIFICATION
I, the undersigned, a duly authorized owner of record, of the property /properties identified herein,
do authorize representatives of the Wilmington District, U.S. Army Corps of Engineers (Corps)
to enter upon the property herein described for the purpose of conducting on -site investigations
and issuing a determination associated with Waters of the U.S. subject to Federal Jurisdiction
under Section 404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors Act of
1899.
Property Owner (please print) Date
m_
Property Owner Signature
E. JURISDICTIONAL DETERMINATION TYPE
Select One:
I am requesting that the Corps provide a preliminary JD for the property identified herein.
This request does include a delineation.
I am requesting that the Corps provide a preliminary JD for the property identified herein.
This request does NOT include a delineation.
❑ I am requesting that the Corps investigate the property /project area for the presence or
absence of WOUS5 and provide an approved JD for the property identified herein. This
request does NOT include a request for a verified delineation.
I am requesting that the Corps delineate the boundaries of all WoUS on a property /project
area and provide an approved JD (this may or may not include a survey plat).
I am requesting that the Corps evaluate and approve a delineation of WoUS (conducted
by others) on a property /project area and provide an approved JD (may or may not
include a survey plat).
° For NCDOT requests following the current NCDOT /USACE protocols, skip to Part E.
5 Waters of the United States
Version: ,December 2013 Page 4

F
C
F6-/]
Cep
Jurisdictional Determination Request
ALL REQUESTS
Map of Property or Project Area (attached). This Map must clearly depict the boundaries
of the area of evaluation.
Size of Property or Project Area 3 88
acres
I verify that the property (or project) boundaries have recently been surveyed and marked
by a licensed land surveyor OR are otherwise clearly marked or distinguishable.
JD REQUESTS FROM CONSULTANTS OR AGENCIES
(1) Preliminary JD Requests:
❑— Completed and signed Preliminary Jurisdictional Determination Form6.
P/ Project Coordinates: 35 818371
Latitude -78 696515
Maps (no larger than 11 x 17) with Project Boundary Overlay:
Longitude
RV Large and small scale maps that depict, at minimum. streets, intersections, towns
Aerial Photography of the project area
a USGS Topographic Map
❑✓ Soil Survey Map
Other Maps, as appropriate (e.g. National Wetland Inventory Map, Proposed Site
Plan, previous delineation maps, LIDAR maps, FEMA floodplain maps)
6 See Appendix A of this Form. From Regulatory Guidance Letter No. 08 -02, dated June 26, 2008
Version. December 2013 Page 5

Jurisdictional Determination Request
Delineation Information (when applicable):
Wetlands:
❑ Wetland Data Sheets
Tributaries:
❑V USACE Assessment Forms
❑ Upland Data Sheets 0 Other Assessment Forms
(when appropriate)
❑ Landscape Photos, if taken
❑ Field Sketch overlain on legible Map that includes:
• All aquatic resources (for sites with multiple resources, label and identify)
• Locations of wetland data points and/or tributary assessment reaches
• Locations of photo stations
• Approximate acreage /linear footage of aquatic resources
(2) Approved JDs including Verification of a Delineation:
❑ Project Coordinates:
Latitude
Longitude
Maps (no larger than 11 x 17) with Project Boundary Overlay:
❑ Large and small scale maps that depict, at minimum: streets, intersections, towns
❑ Aerial Photography of the project area
❑ USGS Topographic Map
❑ Soil Survey Map
❑ Other Maps, as appropriate (e.g. National Wetland Inventory Map, Proposed Site Plan,
previous delineation maps)
7 1987 Manual Regional Supplements and Data forms can be found at:
http / /www usace army mil/ Missions/ CivilWorks/ RegulatoryProgramandPermits /reg supp aspx
Wetland and Stream Assessment Methodologies can be found at:
http //portal ncdenr ors /c /document library /set file ? uuid= 76f3c58b -dab8- 4960- ba43- 45b7faf06f4c &groupld =38364 and,
http / /www saw usace army md/ Portals 159 /docs /regulatory /publicnotices /2013 /NCSAM Draft User Manual 130318 pdf
8 Delineation information must include, at minimum, one wetland data sheet for each wetland /community type
Version: December 2013 Page 6

jurisdictional Determination Request
Delineation Information (when applicable):
Wetlands:
❑ Wetland Data Sheets
Tributaries:
❑ USACE Assessment Forms
❑ Upland Data Sheets ❑ Other Assessment Forms
(when appropriate)
❑ Landscape Photos, if taken
❑ Field Sketch overlain on legible Map that includes.
• All aquatic resources (for sites with multiple resources, label and identify)
• Locations of wetland data points and/or tributary assessment reaches
• Locations of photo stations
• Approximate acreage /linear footage of aquatic resources
Supporting Jurisdictional Information (for Approved JDs only)
❑ Approved Jurisdictional Determination Form(s) (also known as "Rapanos
Form(s)")
❑ Map(s) depicting the potential (or lack of potential) hydrologic connection(s),
adjacency, etc. to navigable waters.
9 Delineation information must include, at minimum, one wetland data sheet for each wetland /community type
Version: December 2013 Page 7

Jurisdictional Determination Request
I. REQUESTS FOR CORPS APPROVAL OF SURVEY PLAT
Prior to final production of a Plat, the Wilmington District recommends that the Land
Surveyor electronically submit a draft of a Survey Plat to the Corps project manager for
review.
Due to storage limitations of our administrative records, the Corps requires that all hard -
copy submittals include at least one original Plat (to scale) that is no larger than 11 "x 17"
(the use of match lines for larger tracts acceptable). Additional copies of a plat, including
those larger than 11 "x 17 ", may also be submitted for Corps signature as needed. The
Corps also accepts electronic submittals of plats, such as those transmitted as a Portable
Document Format (PDF) file. Upon verification, the Corps can electronically sign these
plats and return them via e-mail to the requestor.
(1) PLATS SUBMITTED FOR APPROVAL
❑ Must be sealed and signed by a licensed professional land surveyor
❑ Must be to scale (all maps must include both a graphic scale and a verbal scale)
❑ Must be legible
❑ Must include a North Arrow, Scale(s), Title, Property Information
Must include a legible WoUS Delineation Table of distances and bearings /metes
and bounds /GPS coordinates of all surveyed delineation points
❑ Must clearly depict surveyed property or project boundaries
❑ Must clearly identify the known surveyed point(s) used as reference (e.g. property
corner, USGS monument)
❑ When wetlands are depicted:
• Must include acreage (or square footage) of wetland polygons
• Must identify each wetland polygon using an alphanumeric system
Version: December 2013 Page 8

Jurisdictional Determination Request
❑ When tributaries are depicted:
• Must include either a surveyed, approximate centerline of tributary with
approximate width of tributary OR surveyed Ordinary High Water Marks
(OHWM) of tributary
• Must identify each tributary using an alphanumeric system
• Must include linear footage of tributaries and calculated area (using approximate
widths or surveyed OHWM)
• Must include name of tributary (based on the most recent USGS topographic
map) or, when no USGS name exists, identify as "unnamed tributary"
all depicted WoUS (wetland polygons and tributary lines) must intersect or tie -to
surveyed project /property boundaries
❑ Must include the location of wetland data points and/or tributary assessment
reaches
❑ Must include, label accordingly, and depict acreage of all waters not currently
subject to the requirements of the CWA (e.g. "isolated wetlands ", "non -
jurisdictional waters "). NOTE: An approved JD must be conducted in order to
make an official Corps determination that a particular waterbody or wetland is not
jurisdictional.
❑ Must include and survey all existing conveyances (pipes, culverts, etc.) that
transport WoUS
Version: December 2013 Page 9

Jurisdictional Determination Request
(2) CERTIFICATION LANGUAGE
When the entire actual Jurisdictional Boundary is depicted:
include the following Corps Certification language:
"This certifies that this copy of this plat accurately depicts the boundary of the jurisdiction
of Section 404 of the Clean Water Act as determined by the undersigned on this date.
Unless there is a change in the law or our published regulations, the determination of
Section 404 jurisdiction may be relied upon for a period not to exceed five (5) years from
this date. The undersigned completed this determination utilizing the appropriate Regional
Supplement to the 1987 U.S. Army Corps of Engineers Wetlands Delineation Manual."
Regulatory Official:
Title:
Date:
USA CE Action ID No.:
When uplands may present within a depicted Jurisdictional Boundary
include the following Corps Certification language:
"This certifies that this copy of this plat identifies all areas of waters of the United States
regulated pursuant to Section 404 of the Clean Water Act as determined by the
undersigned on this date. Unless there is change in the law or our published regulations,
this determination of Section 404 jurisdiction may be relied upon for a period not to exceed
five years from this date. The undersigned completed this determination utilizing the
appropriate Regional Supplement to the 1987 U.S. Army Corps of Engineers Wetlands
Delineation Manual."
Regulatory Official:
Title:
Date:
USACE Action ID No.:
Version: December 2013 Page 10

Jurisdictional Determination Request
(3) GPS SURVEYS
For Surveys prepared using a Global Positioning System (GPS), the Survey must include
all of the above, as well as:
❑ be at sub -meter accuracy at each survey point.
include an accuracy verification:
One or more known points (property corner, monument) shall be located with the
GPS and cross - referenced with the existing traditional property survey (metes and
bounds).
❑ include a brief description of the GPS equipment utilized.
Version: December 2013 Page 11

ATTACHMENT A
PRELIMINARY JURISDICTIONAL DETERMINATION FORM
BACKGROUND INFORMATION
A. REPORT COMPLETION DATE FOR PRELIMINARY JURISDICTIONAL
DETERMINATION (JD):
B. NAME AND ADDRESS OF PERSON REQUESTING PRELIMINARY JD:
Kimley -Horn and Associates, Inc, ATTN Jason Hartshorn on behalf of REX UNC Healthcare
3001 Weston Parkway, Cary, NC 27513
C. DISTRICT OFFICE, FILE NAME, AND NUMBER:
D. PROJECT LOCATION(S) AND BACKGROUND INFORMATION:
(USE THE ATTACHED TABLE TO DOCUMENT MULTIPLE WATERBODIES AT DIFFERENT
SITES)
State: NC County /parish /borough: Wake County City. Raleigh
Center coordinates of site (lat/long in degree decimal format):
Lat. 35 818371 °N; Long. 78 696515 °W.
Universal Transverse Mercator: 17
Name of nearest waterbody: House creek
Identify (estimate) amount of waters in the review area:
Non - wetland waters:
165' (SA) linear feet: 5' (SA) width (ft) and /or 0 005 (PA) acres.
Cowardin Class: Rivenne (SA), Lacustnne (PA)
Stream Flow: Perennial (SA)
Wetlands: N/A acres.
Cowardin Class: N/A
Name of any water bodies on the site that have been identified as Section 10
waters-
Tidal: N/A
Non - Tidal: N/A

E. REVIEW PERFORMED FOR SITE EVALUATION (CHECK ALL
APPLY):
❑ Office (Desk) Determination. Date:
❑ Field Determination. Date(s):
THAT
SUPPORTING DATA. Data reviewed for preliminary JD
(check all that apply - checked items should be included in case file and,
Where checked and requested, appropriately reference sources below):
❑✓ Maps, plans, plots or plat submitted by or on behalf of the
applicant/consultant: Kimley -Horn and Associates, Inc
❑ Data sheets prepared /submitted by or on behalf of the
applic nt/consultant.
Office concurs with data sheets /delineation report.
Office does not concur with data sheets /delineation report.
❑ Data sheets prepared by the Corps:
❑ Corps navigable waters' study:
❑ U.S. Geological Survey Hydrologic Atlas:
❑ USGS NHD data
❑ USGS 8 and 12 digit HUC maps
❑✓ U.S. Geological Survey map(s). Cite scale & quad name: 1 24,000 Raleigh West
0 USDA Natural Resources Conservation Service Soil Survey.
Citation: Wake County (1970)
❑ National wetlands inventory map(s). Cite name:
❑ State /Local wetland inventory map(s):
❑ FEMA/FIRM maps:
❑ 100 -year Floodplain Elevation is:
(National Geodectic Vertical Datum of 1929)
QPhotographs: ❑ Aerial (Name & Date): NC oneMap orthoimagery (2012) or
❑ Other (Name & Date):
❑ Previous determination(s). File no. and date of response letter:
❑ Other information (please specify):
2

1. The Corps of Engineers believes that there may be jurisdictional waters of the
United States on the subject site, and the permit applicant or other affected party
who requested this preliminary JD is hereby advised of his or her option to
request and obtain an approved jurisdictional determination (JD) for,that site.
Nevertheless, the permit applicant or other person who requested this
preliminary JD has declined to exercise the option to obtain an approved JD in
this instance and at this time.
2. In any circumstance where a permit applicant obtains an individual permit, or
a Nationwide General Permit (NWP) or other general permit verification requiring
"pre- construction notification" (PCN), or requests verification for a non - reporting
NWP or other general permit, and the'permit applicant has not requested an
approved JD for the activity, the permit applicant is hereby made aware of the
following: (1) the permit applicant has elected to seek a permit authorization
based on a preliminary JD, which does not make an official determination of
jurisdictional waters; (2) that the applicant has the option to request an approved
JD before accepting the terms and conditions of the'permit authorization, and
that basing a permit authorization on an approved JD could possibly result in less
compensatory mitigation being required or different special conditions; (3) that
the applicant has the right to request an individual permit rather than accepting
the terms and conditions of the NWP orother general permit authorization; (4)
that the applicant can accept a permit authorization and thereby agree to comply
with all the terms and conditions of that permit, including whatever mitigation
requirements the Corps has determined to be necessary, (5) that undertaking
any activity in reliance upon the subject permit authorization without requesting
an approved JD constitutes the applicant's acceptance ,of the use of the
preliminary JD, but that either form of JD will be processed as soon as is
practicable; (6) accepting a permit authorization (e.g., signing a proffered
individual permit) or undertaking any activity in reliance on, any form, of Corps
permit authorization based on a preliminary JD constitutes agreement that all
wetlands and other water bodies on the site affected in any way by that activity
are jurisdictional waters of the United States, and precludes any challenge to
such jurisdiction in any administrative or judicial compliance or enforcement
action, or in any administrative appeal or in any Federal court; and (7) whether
the applicant elects to use either an approved JD or a preliminary JD, that JD
will be processed as soon as is practicable. Further, an approved JD, a proffered
individual permit (and all terms and conditions contained therein), or individual
permit,denial can be administratively appealed pursuant to 33 C.F:R. Part 331,
and that in any administrative appeal, jurisdictional issues can be raised (see 33
C.F.R. 331.5(a)(2)). If, during that administrative appeal, it becomes necessary
to make an official determination whether CWA jurisdiction exists over a site, or
to provide an official delineation of jurisdictional waters on the site, the Corps will
provide an approved JD to accomplish that result, as soon as is practicable.
3

This preliminary JD finds that there "may be "waters of the United States on the
subject project site, and identifies all aquatic features on the site that could be
affected by the proposed activity, based on the following information:
IMPORTANT NOTE: The information recorded on this form has not
necessarily been verified by the Corps and should not be relied upon for
later jurisdictional determinations.
L_-
Signature and date of
Regulatory Project Manager
(REQUIRED)
4
Signature and date of
person requesting preliminary JD
(REQUIRED, unless obtaining
the signature is impracticable)

Estimated
amount of
Site
Class of aquatic
Latitude
Longitude
Cowardin Class
aquatic
number
resource
resource in
review area
SA
35.81883
- 78.697166
Riverine
165 linear feet
non - section 10 —
non -tidal
PA
35.817968
- 78.694576
Lacustrine
0.005 acres
non - section 10 —
non -tidal

AGENT AUTHORIZATION FORM
Name: REX UNC Healthcare — Chad Lefteris
Address: 4420 Lake Boone Trail, Raleigh, NC 27607
Phone: [phone]
E -Mail: [e-mail]
Project Name/Description: Rex Sewer Upgrade Project, 2810 Blue Ridge Road, Raleigh, NC 27607
Date:
The Department of the Army
U.S. Army Corps of Engineers, Wilmington District
Field Office: Raleigh
Re: Wetland Related Consulting and Permitting
To Whom It May Concern:
I hereby designate and authorize Kimley -Horn and Associates, Inc. to act in my /our behalf as my /our
agent solely for the purpose of processing Jurisdictional Determinations, Section 404 permits/Section
401 Water Quality Certifications applications, and Neuse River Water Supply Watershed Riparian
Buffer Determinations, and to furnish upon request supplemental information in support of applications,
etc. from this day forward until successful completion of the permitting process or revocation by the
owner.
In addition, I, the undersigned, a duly authorized owner of record of the property /properties identified
herein, do authorize representatives of the Wilmington District, U.S. Army Corps of Engineers (Corps)
to enter upon the property herein described for the purpose of conducting on -site investigations and
issuing a determination associated with Waters of the U.S. subject to Federal jurisdiction under Section
404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors Act of 1899.
Authorized this thZ;C day of
nt Propert Owner's Name Propert w* 0s Signature
Cc: Karen Higgins
NC Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650

AGENT AUTHORIZATION FORM
Name: City of Raleigh Public Utilities Department
Address: PO Box 590, Raleigh, NC 27602
Phone: [phone]
E -Mail: Aaron. Brower(cD-raleighnc.gov
Project Name /Description: Rex Sewer Upgrade Project
Date: 7/15/2014
The Department of the Army
U.S. Army Corps of Engineers, Wilmington District
Field Office: Raleigh
Re: Wetland Related Consulting and Permitting
To Whom It May Concern:
I hereby designate and authorize Kimley -Horn and Associates, Inc. to act in my /our behalf as my /our
agent'solely for the purpose of processing Jurisdictional Determinations, Section 404 permits /Section
401 Water Quality Certifications applications, and Neuse River Water Supply Watershed Riparian
Buffer Determinations, and to furnish upon request supplemental information in support of applications,
Etc. from this day forward until successful completion of the permitting process or revocation by the
owner.
In addition, I, the undersigned, a representative of the duly authorized owner of record of the easements
identified herein, do authorize representatives of the Wilmington District, U.S. Army Corps of
Engineers (Corps) to enter upon the easement herein described for the purpose of conducting on -site
investigations and issuing a determination associated with Waters of the U.S. subject to Federal
jurisdiction under Section 404 of the Clean Water Act and /or Section 10 of the Rivers and Harbors Act
of 1899.
Authorized this the day of
A c �
Print Easement Owner Representative's Name Easement Owner Representative's Signature
Cc: Karen Higgins
NC Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650

Project Location
+0
ea
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Legend
Project Study Area
Kimley »)Horn
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Lake Boone
o °a N
of
teed
G
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G /en Faeh
Wade Avenue
Feet
0 3,000 6,000
Figure 1: Vicinity Map
Rex Sewer Upgrade
Raleigh, North Carolina
Wake County
July 10, 2014

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Legend a
Project Study Area "� 0 700 1,400
Feet
i t
Figure 2: USGS Topographic Map (Raleigh West, 1987)
Rex Sewer Upgrade
Kimley > >> Horn City of Raleigh, North Carolina
Wake County
July 10, 2014

dl . ..
•'► rr,
r
3f f r a
SA F ;`
PB
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Legend
vn
�--
Streams �``.�.�;� "�
Open Waters !.• p �� Ry
Project Area
.an ,,���� / - rl "i -.�• •11i: is � i .� '
300 600
Fee Map N► n r I f r ationandlAnalysis. NC 911.
� Kimley » >Horn
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Figure 3: Site Features Map
Rex Sewer Upgrade
Raleigh, North Carolina
Wake County
July 10, 2014

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•
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Legend Ir
14
UA
Project Study 1 11 111

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-T
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LLA
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`fly Ate,'. j'', I ` �•�. f 1 o�estview Rd' ;�r �'"=t` , .Is" -'" ..•� � � IR.`
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s : � - _ *` ! '� ��' ` 1 a� � mss• . i � ��_ `��, r :°- a
500 1,000
Feet
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Legend
Affected Parcels
r 1 .�
a� �^ . den• � � •
Wake County Parcels (June 2014) 1
Project Study Area
N n Ma N r me fo'r' hi I f afio nd '° I `si 911
r.I'1., • Bo rd �„ r
Figure 5: Wake County Property Parcels Map
Rex Sewer Upgrade
Kimlv.y , �'r") Raleigh, North Carolina
Wake County
July 10, 2014

North Carolina Division of Water Quality - Stream Identification Form„ Version 4.11
Date 11/15/2012
Project/Site SA
Latitude. 35.8189
Evaluator. A Reusche, KHA
County Wake
Longitude - 78.6954
Total Points: 41.5
Stream Determination (circle one)
Other
Streamlis at least intermittent
Ephemeral Intermittent Perennial
e g Quad Name Raleigh West
2- 19 or perennial if a 30
0
1
A. Geomorphology Subtotal= 27
Absent,
l.,.Weak °�
'Modefate
�- $trong,,5
S c — oieP,
1a Continuity of channel bed and bank
0
1
2
3
3
2 Sinuosity of channel along thalweg
0
1
2
3
3' _
3 In- channel structure- ex. riffle -pool, step -pool, ripple-
ool se uence
0
1
2
3
3
4 Particle,size of stream substrate
0
1
2
3
3"
5 Active /relic flood lain
0
1
2
3
2
6. Depositional bars or benches
0
1
2
3
a
7 Recent alluvial deposits
0
1
2
3
1
8 Headcuts
0
1
2
3
3'
9_ Grade control
0
0 5
1
1 5
1.5
10 Natural valley
0
0 5
1
1 5
1':5
11 Second or greater order channel
No = 0
Yes = 3
3,
artificial ditches are not rated, see discussions in manual
B Hydrology Subtotal= 85
12. Presence, of Baseflow
0
1
2
3
3
13 Iron oxidizing bacteria
0
1
2_
3
0'- a
'14 Leaflltter,
15
1
05
0
'1 _
15 'Sediment,on plants or debris
0
05
1
15
; 0.5,
16 Organic debris lines or piles
0
0.5
1
15
Zt 7
17 Soil -based evidence of high water tables
T No = 0
Yes = 3
`� l, '_
C. Biology Subtotal=
18. Fibrous roots in streambed
3
2
1
0
3
19 Rooted upland plants in streambed
3
2
1
0
3. --_
20 , Macrobenthos note diversity and abundance
0
1
2
3
0
21. Aquatic Mollusks
0
1
2
3
0, _
22, Fish
0
05
1
15
0 �_
23 Cra yfish
0
0.5
1
15
'07
24 Amphibians
0
0.5
1
1.5
25_ Algae
0
05
1
1 5
0,-
26' Wetland plants in streambed
FACW = 0 75, OBL
= 1 5, Other = 0
0
'perennial streams may also be identified using other methods See p 35 of manual
Notes Stream A was flowing during the site visit No macrobenthos were
observed, however, SA is obviously perennial based on the strong presence of
geomorphology and hydrology Therefore, macrobenthos are likely present
Segments of the channel are piped within the corridor

_ USACE AID#
DWQ #,
Site # (indicate on attached map)
STREAM QUALITY ASSESSMENT WORKSHEET
Provide the following information for the stream reach under assessment:
1. Applicant's name: City of Raleigh
2. Evaluator's name: Anna Reusche
3. Date of evaluation: 11/15/2012
4. Time of evaluation: 9 :00 am
5. Name of stream: SA
6. River basin: Neuse
7. Approximate drainage area: 100 acres
8. Stream order:, Second Order
9. Length of reach evaluated: 300 feet
10. County: Wake
11. Site coordinates (if known): prefer in decimal degrees. 12. Subdivision name (if any):
Latitude (ex. 34.872312): 35.8189 Longitude (ex. - 77.55661 1 ): - 78.6954
Method location determined (circle): ✓bl?SO✓ I'opo Shee[DXtho (Aerial) Photo /GISather GISED31ther
13. Location of reach under evaluation (note nearby roads and landmarks and attach map identifying stream(s) location):
SA flows into the project area from the northwest, east of Rex Hospital. SA flows southeast and borders the south of the project corridor. The stream is piped in sections within the corridor.
14. Proposed channel work (if any):
15. Recent weather conditions: 0.2 inches of rain in the last 48 hours.
16. Site conditions at time of visit: Cloudy with drizzling rain.
17. Identify any special waterway classifications known: OSection 10 Tidal Waters Essential Fisheries Habitat
,Trout Waters 0outstanding Resource Waters 21 Nutrient Sensitive Waters Dwater Supply Watershed. (I -IV)
18. Is there a pond or lake located upstream of the evaluation point? YES If yes, estimate the water surface area: 0.07
19. Does channel appear on USGS quad map? YES 20. Does channel appear on USDA Soil Survey? YES
21. Estimated watershed land use: 60 % Residential
10 % Forested
30 % Commercial _% Industrial _% Agricultural
_% Cleared / Logged _% Other
22. Bankfull width: 5 23. Bank height (from bed to top of bank): 3
24. Channel slope down center of stream: OFlat (0 to 2 %) OGentle (2 to 4 %) DModerate (4 to 10 %) Osteep ( >10 %)
25. Channel sinuosity: Straight 00ccasional bends ✓Frequent meander Overy sinuous Braided channel
Instructions for completion of worksheet (located on page 2): Begin by determining the most appropriate ecoregion based on
location, terrain, vegetation, stream classification, etc. Every characteristic must be scored using the same ecoregion. Assign points
to each characteristic within the range shown for the ecoregion. Page 3 provides a brief description of how to review the
characteristics identified in the worksheet. Scores should reflect an overall assessment of the stream reach under evaluation. If a
characteristic cannot be evaluated due to site or weather conditions, enter 0 in the scoring box and provide an explanation in the
comment section. Where there are obvious changes in the character of a stream under review (e.g., the stream flows from a pasture
into a forest), the stream may be divided into smaller reaches that display more continuity, and a separate form used to evaluate each
reach. The total score assigned to a stream reach must range between 0 and 100, with a score of 100 representing a stream of the
highest quality.
Total Score (from reverse): 55 Comments:
Stream A was flowing during the site visit. No macrobenthos were observed, however, likely present. Segments of the channel
are piped within the corridor.
Evaluator's Signature 1� '`X"4� Date 11/15/2012
This channel evaluation form is intended to be used only as a guide to assist landowners and environmental professionals in
gathering the data required by the United States Army Corps of Engineers to make a preliminary assessment of stream
quality. The total score resulting from the completion of this form is subject to USACE approval and does not imply a
particular mitigation ratio or requirement. Form subject to change - version 06/03. To Comment, please call 919 - 876 -8441 x 26.

SA
STREAM QUALITY ASSESSMENT WORKSHEET
* These characteristics are not assessed in coastal streams.
ECOREGION POINT
RANGE
#
CHARACTERISTICS
SCORE
Coastal
Piedmont
Mountain
1
Presence of flow / persistent pools in stream
0 5
0-4
0 5
4
no flow or saturation = 0• strong flow = max points)
-
-
Evidence of past human alteration
1
extensive alteration = 0; no alteration = max points)
0-6
0-5
0-5
3
Riparian zone
0-6
0-4
0-5
2
no buffer = 0; contiguous, wide buffer = max points)
4
Evidence of nutrient or chemical discharges
0
0
0
2
extensive discharges = 0; no discharges = max points)
-5
-4
-4
Groundwater discharge
0-3
0 - 4
0-4
4
U5
no discharge = 0; springs, see s, wetlands etc. = max points)
Presence of adjacent floodplain
y�
6
no floodplain = 0; extensive floodplain = max points)
0-4
0 - 4
0-2
2
Entrenchment / floodplain access
0- 5
0- 4
0- 2
3
p"
(deeply entrenched = 0; frequent flooding = max points)
8
Presence of adjacent wetlands
0-6
0-4
0-2
0
no wetlands = 0; large adjacent wetlands = max points)
9
Channel sinuosity
0-5
0-4
0-3
4
extensive channelization = 0; natural meander = max points)
10
Sediment input
0-5
0-4
0-4
2
extensive deposition= 0• little or no sediment = max oints
1 1
Size & diversity of channel bed substrate
NA*
0-4
0 - 5
4
fine, homogenous = 0; large, diverse sizes = max points)
1 2
Evidence of channel incision or widening
0 5
0-4
0 5
2
(deeply incised = 0; stable bed & banks = max points)
-
-
13
Presence of major bank failures
0-5
0 - 5
0-5
2
severe erosion = 0; no erosion, stable banks = max points)
d
14
Root depth and density on banks
0-3
0 4
0-5
2
H
no visible roots = 0; dense roots throughout = max points)
-
Impact by agriculture, livestock, or timber production
15
0-5
0 - 4
0-5
4
substantial impact =0• no evidence = max points)
16
Presence of riffle - pool/ripple -pool complexes
0-3
0-5
0-6
5
no riffles/ripples or pools = 0; well-developed = max points)
17
Habitat complexity
Habitat
0-6
0 - 6
0-6
6
or no habitat = 0; frequent, varied habitats = max points)
Canopy coverage over streambed
18
no shading vegetation = 0; continuous canopy = max points)
0-5
0 - 5
0-5
3
19
Substrate embeddedness
NA*
0-4
0-4
3
deeply embedded = 0; loose structure = max
20
Presence of stream invertebrates (see page 4)
0-4
0 5
0-5
0
no evidence = 0; common, numerous types = max oints
-
V►
21
Presence of amphibians
0-4
0-4
0-4
0
O
no evidence = 0; common, numerous types = max points)
O
22
Presence of fish
0 -4
0 -4
0 -4
0
no evidence = 0• common numerous types = max p oints
P�-4
23
Evidence of wildlife use
0-6
0-5
0
no evidence = 0; abundant evidence = max points)
0-5
Total Points Possible
100
100
100
TOTAL SCORE (also enter on first page)
55
* These characteristics are not assessed in coastal streams.