20140992 Ver 1_401 Application_20140914

2 0 1 4 0 9 9 2
Office Use Only
Corps action ID no j1h
DWQ protect no Q rd
Form Version 1 3 Dec 10 2008
Pre- Canstruction Notification PC Form
A. Applicant Information
1. Processing
- -a
la Type(s) of approval sought from the
Corps
Section' 404 Permit
S ❑ Section 10 °ermit
1b Specify Nationwide Permit,(NWP) number 1 or General Permit (GP) number
1c Has the NWP or GP number been vanfieri by thin rr%ang) K Yes Lj IVO
1 d Type (s) of approval sought from the DWQ ( check all that apply)
Y)
' 401 Water Quality Certification – Regular ❑ Non -404 Jurisdictional General Permit
401 Water Quality Certification – Express a ❑ Riparian Buffer Authorization
1 e Is this notification solely for the record For the record only for DWQ 401 For the record only for Corps Permit
because
written approval is not required? Certification i
❑ Yes ® No I ❑ Yes No
if Is payment into a mitigation bank or in -lieu fee program proposed for mitigation
❑ Yes
of impaccs? If so, attach the acceptance letter from mitigation bank or in
® No
-lieu
fee program
r1 g Is the project located in any NC's twenty
of coastal counties If yes answer 1 h
❑ Yes No
below
1h Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes No
2. Progect information
2a Name of project
AC1� 40 Po ND
2b County
DoR>{Arn
2c Nearest mu oicipality / town
u2 Wqw�
Subdivision name_
_2d
2e NCDOT only, T I P or state
L✓ Ls d ( r
project no
3. Owner Infar, rnatior,
U
S E P 1 9 2014
3a Name(s) on Recorded Deed
3b Deed Book and Page No
3c Responsible Party (for LLC if
-- -
applicable)
3d Street address
i
3900 3tv►n,s �� �
3e City, state, zi
�- P
Htt.�.seo ouG N C. 2.,1^ -1
3f Telephone no
q j q 1 j o ID�
3g Fax no
3h Email address
G
Page 1 of 10
PCN Form –Version 1 3 December 10, 2008 Version
r

4. Applicant Information (if different from owner)
4a Applicant is
❑ Agent ❑ Other, specify 0 wo c- R
4b Name
JogN Rirtm -My-
4c Business name
(if applicable)
�Au, &ST4RPR11Sf;S
4d Street address
3© OO 61 V k WS Ra, PP
4e City, state, zip
WILL-5 uG 14
4f Telephone no
-
4g Fax no
-
4h Email address
[30.c.X L!0 E G MAIL_ • owl `
5. Agent/Consultant Information (if applicable)
5a Name
5b Business name
(if applicable)
5c Street address
5a City, state, zip
5e Telephone no
5f Fax no
5g Email address
Page 2 of 10
PCN Form - Version 1 3 December 10, 2008 Version
r

B. Project Information and Prior Project History „
1. Property Identification
1a Property identification '"no (tax PIN or parcel ID)
0805 ®1 - Ob^ 251"1
lb Site coordinates (in decimal degrees)
i atitude '313,10 Longitude
DDDDDD)' ( -DD DDDDDD)
p acres
1c Property size
2. Surface Waters
2a Name of nearest -body of water (stream, river, etc) to
�t_E %t V l"c'
proposed project
i 2b Water Quality Classification of nearest receiving water
2c River basin
3. Project Description
3a Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application
c K r+ERr+M-MNT'
lea s-r' D fORen ARavmD (, Rw-y -rgh r ;5 vY c�i vet jii.VH� -�1.1 vii
3b List the total estimated acreage of all existing wetlands on the property
/A
3c List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
1$00
3d Explain) the purpose of the proposed project
Z•73 PQAA Pomb Fop. Cjkmpts,14 5AR., rj6, i�EG feA ons r! suppitc- fall TWA
3e Describe the overall project in detail, including the type of equipment to be used
QU^i..1+T) oZE P_
4. Jurisdictional Determinations
4a Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past ? -
® Yes ❑ No ❑ Unknown
Comments--- - - - -- — _ _ -- — -- -
- - - - - - -- - -- - -- --
4b if the Corps made the jurisdictional determination, what type
of determination
Preliminary ❑ Final
was made)
4c If yes, who - delineated the jurisdictional areas? > IxTip
Agency /Consultant Company Ca #p5 o F E"6( tj �
Name (if known) F- Rtr- ALSME't P_ RIC-AlAortp
Other i
4d If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
6. Project History
5a Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
❑ Yes ® No ❑ Unknown
5b If yes, explain in detail according to "help file" instructions
i
6. Future Project Plans
6a Is this a phased project? ❑ Yes E4 No
Vv n yGa, IVAPIdill
Page ? of 1 v
PCN Form - Version 1 3 December 10, 2008 Version

C Proposed Impacts Inventory
1 Impacts Summary
la Which sections were completed below for your project (check all that apply)
❑ Wetlands 5Q Streams - tributaries ' X Buffers
❑ Open Waters ® Pond Construction
2 Wetland Impacts �
If there are wetland impact's proposed on the site, then complete this question for each wetland area impacted
2a
2b
2c
2d
2e
Welland impact
number -
Type of impact
Type of wetland
Forested
Type of jurisdiction
(Corps - 404, 10
Area of impact
Permanent (P) or
(if known)
DWQ - non -404, other)
(acres)
Temporary
.
❑ Yes
❑ Corps
W1 P ❑ T
❑
❑ No
❑ DWQ
_
❑ Yes
El Corps
W2 ❑ P ❑ T
❑ No
❑ DWQ
W3 ❑ P ❑ T
❑ Yes
❑ Corps
r
❑'No
❑ DWQ
❑ Yes
El Corps
W4 ❑ P ❑ T
_
❑ No
❑ DWQ
❑ Yes
❑ Corps
W5 ❑ P ❑ T
❑ No
❑ DWQ
El Yes
❑ Corps
W6 El P ❑ T
❑ No
❑ DWQ
2g. Total wetland impacts
y
2h Comments ki 1A
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
length
number - (PER) or (Corps - 404, 10 stream
width (linear
Permanent P or intermittent DWQ - non -404, d . r
(feet) feet)
Temporary (T) (INT)? other)
S1 ® P ❑ T
DA's
S 1
El INT
® INT
Corps
® DWQ
I�+
1� t `
43 0
Ca•�•Stau c rtv�
S2 P ❑ T
�'�O .N(,-
�
� �
❑PER
CA INT
.Corps
DWQ
rr
Zr�
770
[] PER
El Corps
S3 ❑ P F-1 T
❑ INT
❑ DWQ
❑ PER
El Corps
S4 ❑ P ❑ T
❑ INT
❑ DWQ
❑ PER
El Corps
S5 ❑ P ❑ T
❑ INT
❑ DWQ
El PER ❑ Corps ,
S6 ❑ P ❑ T ❑ INT ❑ DWQ
?(go
3h Total stream and tributary impacts.
31 Comments
Page 4 of 10
PCN Form - Version 1 3 December 10, 2008 Version

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 Individually list all open water Impacts below l
4a
4b
4c
4d
4e
Open water
;`Jame of waterbody
-
Impact number —
(If applicable)
Type of Impact
"Waterbody type,
Area of Impact (acres)
Permanent (P) or
-'
Temporary T
01 ❑P ❑T
02 ❑P ❑T
-
03 ❑P ❑T
04 ❑ P ❑ T
4f. Total open water impacts
4g Comments
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below
5a
5b
5c 7
15d
5e I
Pond ID
I Proposed use or purpose
1A1 +i ,. a �. + r.
v vetla� its 1 i pac'Is �aU-I vat
Stream impacts (feet)
p I
upland
number
of pond
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
7:Rfti4- A17e'M Ft 5K P
%
30
-
R
P2
K Total —
-1� 0
'�.0
3
5g Comments
5h Is a aam nigh hazard permit required?
❑ Yes DjNo If yes, permit ID no
5i Expected pond surface area (acres)
Z b
5J Size of pond watershed (acres)
5k Method of construction
�Arn
6. Buffer Impacts (for u'vVQ)
If project will impact a protected riparian buffer, tnen complete the chart below If yes, then individually list all buffer impacts
below If any impacts require mitigation, then you MUST fill out Section D of this form
6a.
Project !s in which protected basin'
tR Neuse ❑ Tar - Pamlico ❑ Other
❑ Catawba ❑ Randleman
6b 6c 6d
6e 6f 6g
Buffer Impact
number — Reason
Buffer Zone 1 impact Zone 2 Impact
Permanent (P) or for Stream name
mitigation (square feet) (square feet)
Tem ora T impact
required?
B1 ❑P ❑T1�
❑Yes
❑ No
B2 ❑P FIT
❑Yes
❑ No
B3 ❑P ❑T
El Yes
❑ No
6h Total buffer impacts
61 Uomments A
Page S of 10
PCN Form — Version 1 3 December 10, 2008 Version

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
lb Specifically describe measures aken to avoid or minimize the proposed impacts through construction techniques
VaING NAavti L- -Tf- aGLA k
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 [KNo
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 if Using a Mitigation Bank
3a Name of Mitigation Bank
3b Credits Purchased (attach receipt and letter)
Type
Quantity
3c Comments
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) 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 1 3 December 10, 2008 Version

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a Will the protect result in an impact within a protected riparian buffer that requires
❑ Yes Tuo
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)
Zone 1
3 (2 for Catawba)
Zo^e 2
7 J
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)
All (nm ment,
Pa ^y ^c i of i v
PCN Form — Version 1 3 December 10, 2008 Version
0

3
S'
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1.
Diffuse Flow Plan
1 a
Does the project include or is it adjacent to protected ripanan buffers identified
Yes ❑ No
within one of the NC Riparian Buffer Protection Rules?
lb
If yes, then is a diffuse flow plan included? If no, explain wtly
El Yes �. No
Comments o �,
r�R r c � 5 �a�u
2.
Stormwater Management Plan
2a
What is the overall percent imperviousness of this project?
%
2b
Does this project require a Stormwater 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 description of the plan
.❑ 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 Government Stormwater Review
3a
In which local government's 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
❑ 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 E] 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 3 December 10, 2008 Version
V

r
F
F.
Supplementary Information
1.
WV­
Environmental Documentation (DWQ Requirement) r
1 a
Does the project ,evolve an expenditure of public (federal /state /local) funds or the
El Yes
No
use of public (federal /state) land
lb
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 )
r–i V....
u ��
n A 1.
u Imu
Comments
2.
Violations (DWQ Requirement)
2a
Is the site in viplation of DWQ Wetland Rules (15A NCAC 2H 0500), Isolated
Wetland Rule's (15A NCAC 2H 1300), DWQ Surface Water or Wetland Standards,
❑ Yes
❑ No
or Riparian � Buffer Rules (15 A N , %C 28 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,.(DuM 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
4__
Sewagei) isposal _(DW_Q_Requirement)�____ —___
4a
Clearly detail the ulzimate treatment methods and disposition (non - discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility
No SF"kIG-E Dt5Pa5AL inNOt.Vtr,Q
I
Page 9 of i 0
PCN Form – Version 1 3 December 10, 2008 Version

t
1.
t
rt
1'
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 Feld Office you have contacted
❑ Asheville
5d What data sources did you use to determine whether your site would impact Endangered Species -or Designated Critical
Habitats ER tG n
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?
t�vNVERSA`Ro^+ tr1iT(i GR1C �< -Sa'lE C R-
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?
(�Pv%veaSa'Tto---,- us 1TH f-RtC
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
8c What source(s) did you use to make the floodplain determinations Co r0(ERSAT 1 8^1 ��sra �R�C ALSME
Applicant/Agent's Printed Name
Date
, Applican Signature
Oat
(Agent's si ens valid only if an authorization letter from the applicant
is provided )
Page 10 of 10
PCN Form — Version 1 3 December 10, 2008 Version

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