20140981 Ver 1_401 Application_20140914

ENVIRONMENTAL SERVICES, INC
524 New Hope Road
Raleigh, NC 27610
919 -212 -1760 / Facsimile 919- 212 -1707
www .environmentalservicesinc.com
MEMORANDUM
TO: Ms. Karen Higgins
NCDWR, 401 & Buffer Permitting
1617 Mail Service Center
Raleigh, NC 27699 -1617
FROM: Jeff Harbour
DATE: September 10, 2014
RE: PCN for Pond and Outfall Maintenance
On behalf of Stocks Engineering and Nash County Hospital, please find the enclosed PCN
requesting authorization to ,conduct some pond outfall maintenance.

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20140981
Office Use Only:
Corps action ID
DWQ project n
Form Version 1 nuary`3009 -- f I
Page 1 of 10
PCN Form — Version 1.4 January 2009
Pre - Construction Notification (PCN) Form I
DENR_vwV = `-- °--- -J
A.
t � BUFFER PERMITTING
Applicant Information
1.
Processing
1a.
Type(s) of approval sought from the Corps:
® Section 404 Permit ❑ Section 10 Permit
1b.
Specify Nationwide Permit (NWP) number: 3 or General Permit (GP) number:
1c.
Has the NWP or GP number been verified by the Corps?
❑ Yes N No
1d.
Type(s) of approval sought from the DWQ (check all that apply):
N 401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express N 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 N No
For the record only for Corps Permit:
❑ Yes N 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 ❑ N
1g.
Is the project located in any of NC's twenty coastal counties. If yes, answer 1h
below.
❑ Yes ❑X No
1h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes ❑X No
2.
Project Information
2a.
Name of project:
Nash Healthcare Systems Pond Outfall Maintenance
2b.
County:
Nash
2c.
Nearest municipality / town:
Rocky Mount
2d.
Subdivision name:
NA
2e.
NCDOT only, T.I.P. or state project no:
NA
3.
Owner Information
3a.
Name(s) on Recorded Deed:
Nash Healthcare Systems
3b.
Deed Book and Page No.
3c.
Responsible Party (for LLC if
applicable).
Rick Holmes
3d.
Street address:
2460 Curtis Ellis Drive
3e.
City, state, zip:
Rocky Mount, NC 27804
3f.
Telephone no.:
252- 962 -8000
3g.
Fax no.:
3h.
Email address:
Page 1 of 10
PCN Form — Version 1.4 January 2009

4.
ApplicantInformation (if differentfrom 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
EmaiLaddress:
5.
Agent/Consultant Information (if applicable)
5a
Name
Kevin Varnell
5b
Business °name
(if applicable)-
Stocks Engineering
5c. Street,address
1100 Eastern Avenue, PO Box 1108
5d 'City, state, zip
Nashville; NC 27856
5e
Telephone no
252 -459 -8196
5f
Fax no.
5g
Email address-
kvamell @stocksengineenng corn
Page 2 of 10

B. Project Information and,Prior Project History
1. Property Identification
1a, Property identification no (tax PIN or parcel ID)
1b Site coordinates (in,decimal degrees)
Latitude 35.9749 Longitude 77 8554
1c Property size
acres
2. Surface Waters
2a Name of nearest body of water to proposed project-
Stoney Creek
2b Water Quality Classification of nearest receiving water
C, NSW
2c. River basin: J
Tar- Pamlico
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project aVthe time of this
application
Existing pond associated with Nash Co Hospital Proposed work area is along back side of earthen dam Land use is forested and commercial
3b ,List the total estimated acreage of all existing wetlands on the property 0 05
3c. List the total estimated linear feet of all existing,streams, (intermittent,and perennial), on the property 150
3d- Explain the purpose of the proposed project -
Existing outfall pipe is fading Propose to re -route outfall into the existing scour hole where current out fall discharges Scour hole will be rip- rapped
3e. Describe the overall projecOn,detad; including the type,of equipment to be used
New out fall pipe will exist SE corner of pond and follow base�of dam to discharge in scour hole Typical.equipment will be used
4. Jurisdictional Determinations
4a Haveijunsdictional wetland or stream determinattons,by the
Corps or State-been requested or obtained for this property /
project (including all prior phases) in the past?
❑ Yes X❑ No ❑ Unknown,
Comments -
4b If the,C6rps made the junsdichonal�determination, what type
of determination was made?
'❑ Preliminary ❑ Final
4c, If,yes, who delineated the jurisdictional areas
Name (if known).�JeffMarbour
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 orcertifications been requested or obtained,for
this project (including all prior phases) inAhe pasty
❑Yes El No X'llnknown
5b If yes, explain in detail according to "help file" instructions
6. Future,Project Plans
6a `Is this a phased project?
❑ Yes ❑X No
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 completed'below for your project,(check all that apply) -
❑ Wetlands ❑X Streams — tributaries ® Buffers ❑, Open Waters ❑ Pond Construction
2. Wetland Impacts
If there_ are wetland impacts proposed on the site, then complete this question for each wetland area Impacted
2a.
Wetland Impact
number
Permanent (P) -or ,
Temporary
2b
Type of,impact
2c
Type of wetland
2d
Forested
2e
Type of jurisdiction
Corps (404,10) or
DWQ (401, other)
2f.
Area of
Impact
(acres)
W1 -
Choose one
Choose one
Yes/No
-
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
-
W6 -
Choose one
Ctioose one
Yes/No
-
2g Total Weiland Impacts:
0
2h Comments
3. Stream Impacts
If there are perennial or'mtermittent stream Impacts (Including temporary Impacts) proposed on the.site, then complete this
question for all stream,sltes Impacted
3a
Steam Impact
number
Permanent (P) or
Temporary (T)
3b
Type of Impact
3c
Stream name
3d
Perennial (PER), or
Intermittent (INT)?
3e.
Type of
jurisdiction
3f
Average
stream
width
(feet)
3g
Impact
length
(linear
feet)
S1 P
�Stabdization
UT to Stoney Creek
PER
Corps
8
12
S2 -
Choose one
-
-
S3 -
Choose,one
-
-
S4 -
Choose one
-
-
S5 -
Choose one
-
-
S6 -
Choose one
-
-
3h Total stream and tributary impacts
31 Comments
Impact to is the existing scour hole where the current,pipe discharges This scour hole serves as the origin point for the stream It'wdl be'stabd¢ed
with 200 cubic yards of rip -rap to keep it from enlarging and eroding The rip -rap wdl'be placed below the OHWL in the scour hole
Page 4 of 10
PCN Form — Version 14 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 irldivii ually list all open water impacts below
4a
Open water
Impact number
Permanent (P) or
Tem ora T
4b
Name of, waterbody
(if applicable)
4c
Type,of Impact
4d
Waterbody
type
4e
Area of Impact (acres)
01 -
Choose one
Choose
O2 -
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 or lake construction proposed, the complete the chart below
Sa
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?
E] Yes No If yes, permit ID no
5i Expected pond surface area (acres),
5j Size of pond watershed (acres) -
5k. Method of construction
6. Buffer Impacts (for bWQ)
If project willaimpact a protected riparian buffer, then complete the chart below If yes, then individually Iist,all buffer impacts
below. If any�impacts require miti atlon, then you MUST fill out'Sectlon D,of this form
6a. Project is in which protected'basin?
Neuse OX Tar - Pamlico E] Catawba ❑ Randleman ❑ Other
6b
Buffer Impact
number—
Permanent (P) or
Temporary
6c
Reason for impact
6d
Stream name
6e
Buffer
mitigation
required
6f
Zone 1
impact
(square
feet )
6g
Zone,2
impact
(square
feet
61 P
pon&out fall maintenance
No
2,000
600
B2 P
new out fall pipe
No
499
686
63 _
r Yes/No
B4 -
Yes/No
B5 -
Yes/No
B6 -
Yes/No
6h Total Buffer Impacts: 2,499 1,286
61 Comments. B 1 impact results from �having,to add a 2' berm to the, edge, of the existing pond an the SE corner to prevent by -pass of the new out fall
structure_ Work should fall under dam maintenance.activities (Exempt) or Protection,of existing structures, facilities, etc (Allowable)
Page 5 of 10

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 project has been designed to avoid any wetland impacts or impacts to the actual stream channel itself Only the,scour hole�wnll be affected
1b Specifically describe.measures taken to avoid or minimize the proposed jim pactsthrough construction techniques
All necessary BMPs will be,used dunng'the construction phaseAo prevent.degradation of receiving waters
2. Com ensato ,'Miti ation 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 ❑X 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
❑ Permittee Responsible Mitigation
3. Complete ifUsing a Mitigation Bank
3a Name,of Mitigation Bank
3b Credits Purchased (attach receipt,and letter)
Type Choose one
Type, Choose one
Type Choose one
Quantity
Quantity
Quantity
3c Comments
4._ Complete if-Malkin g 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
Choose one
4d Buffer mitigation requested (DWQ only)
square feet
4e Riparian wetland mitigation requested
acres
4f Non - riparian wetlan6mitigation 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 6 of 10
PCN Form — Version 14 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
❑ Yes ❑X No
buffer mibgation'?
6b If yes, then identify the square feet oYimpact to each zone of the npanan,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 If 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 in -lieu fee fund)
6h. Comments
Page 7 of, 10

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,npanan buffers identifled
Yes ❑ No
within one,of the NC Riparian Buffer Protection Rules?
lb
If yes, then is a diffuse flow plan included? If no, explain why
SMP isnot necessary for this maintenance activity Sed and Eros Control Plan,wdl be utilized during
❑ Yes Q No
construction
2.
Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
2b
Doesthis, ro ect,re uire a3tormwater Management Plan?
❑ Yes No
2c
If this project DOES NOT require a Stormwater Management Plan, explain why
2d
If this project DOES require a Stormwater Management Plan, then provide a brief, narrative.descnption of the plan
2e.
Who will be responsible for the review of the Stormwater Management Plan?
3.
Certified Local Government'Stonnwater Review
3a
In which local ovemmenYs jurisdiction is,this project?
❑ 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
El 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
❑ Yes ❑ No
attached?
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 8 of 10
PCN Form — Version 1 4 January 2009

,F. Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
1a
Does the project involve -an expenditure,of public (federal /state /local) funds or the
❑ Yes X❑ 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
❑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
letter)
❑ Yes No
❑
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 X❑ No
or Riparian Buffer,Rules (15A NCAC 2B- 0200)?
2b
Is this an after - the -fact permit application?
❑Y.es © No
2c.
If you answered "yes" to one,or,both of the above questions, provide an explanation of the violation(s)
3.
Cumulative Impacts (bWQ Requirement)
3a
Will this project (basedjon pastand 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
4.
Sewage Disposal (DWQ Requirement)
4a
Clearly detail the ultimate treatment methods and disposition (non - discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the>subject.facdity
WA
Page 9 of 10
PCN Form = Version 1 4 January 2009

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
[j Yes XQ No
impacts?
6c. 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?
Onsite review for suitable habitat
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ❑ Yes XQ No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
NOAA EFH Waterbody List
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 Zx 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?
NO SHPO; Area previously disturbed from original pond construction
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA- designated 100 -year floodplain?
❑ Yes QX No
8b. If yes, explain how project meets FEMA requirements:
Be. What source(s) did you use to make the floodplain determination?
NO Floodmaps
V f N VO4-Kt'
Applicant/Agents Printed Name A plicant/Agent's Signature Date
(Agent's signature is valid only if an authorization
letter from the applicant is provided.)
Page 10 of 10

Stocks Engineering, PA
�estw%vlg the Fktare, Today.
I, Rick Holmes, Director of Plant Services for Nash Health Care Systems, give Stocks Engineering, P.A.
permission to act on our behalf with regards to the submittal and permitting of the Pond Maintenance Plan.
Rick Holmes, Director of Plant Services
J. Michael Stocks, PE 252.459 8196 Ivoice)
1100 Eastern Avenue 252.459.8157 ifax)
PO Box 1108 252.903.6891 lmobile)
Nashville. NC 27856 msiocks(stocksengmeenng com

ACME Mapper 2.1 - 4.5 km Stiff of Lake Gaston NC
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STOCKS ENGINEERING, P.A.
Mount North Carolina
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1100 EASTERN AVENUE PHONE [phone]
P 0 BOX 1108 FAX [phone]
MOBILE [phone]
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NASHVILLE, NC 27856
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