20141102 Ver 1_401 Application_20141014

E
McGill
A S S O C I A T E S
October 14, 2014
US Army Corps of Engineers
Asheville Regulatory Field Office
151 Patton Ave., Room 208
Asheville, NC 28801 -5006
Attn: Tasha Alexander
RE: Alexander County Water Improvements Project
Pre- Construction Notification, NWP #12
Dear Ms Alexander:
On behalf of our client, County of Alexander, please find enclosed a PCN application for
the referenced project dated October 13, 2014. The purpose of the project is to provide
for the long range water needs of the County, eliminate dead -end water lines and improve
water circulation within the system. A NWP -12 is requested to complete the proposed
work at one stream crossing site with only temporary impacts. One courtesy copy of the
PCN application is being provided to the NCDENR, Division of Water Resources and
one copy of the PCN application is being provided to the NC Wildlife Resource
Commission. McGill Associates, P.A. is the Authorized Agent (form included) and
should be copied on all project correspondence. Please let us know if you have any
questions or comments.
Sincerely
Y Cas �; L
McGill Associates, P.A.
Program Services Manager- Environmental
Cc: Central Office, NCDWR
Doug Besler, NCWRC
W. Darrel Robertson, PE, Alexander County Engineer
Environmental 0 Planning o Finance
HcGill Associates, PA. - 3764 Ronringer Road, Banner Elk, North Carolina 28604
O.fice: 828 -397 -6946 - Fax: 828 - 297 -1982

2C X41102
11 C.
W ATG
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Page 1 of 13
PCN Form — Version 1.3 December 10, 2008 Version
Pre - Construction Notification PCN Form
A. Applicant Information
1.
Processing
1 a.
Type(s) of approval sought from the
Corps:
®Section 404 Permit ❑Section 10 Permit
1 b.
Specify Nationwide Permit (NWP) number: 12 or General Permit (GP) number:
1 c.
Has the NWP or GP number been verified by the Corps?
FE] 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
1h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes
® No
2.
Project Information
2a.
Name of project:
Bethlehem - Ellendale Water System Improvements
2b.
County:
Alexander
2c.
Nearest municipality / town:
Taylorsville
2d.
Subdivision name:
N/A
2e.
NCDOT only, T.I.P. or state
project no:
3.
Owner Information
1014 jUl
3a.
Name(s) on Recorded Deed:
NCDOT Right -of -Way, Alexander County L EENR - wATE
3b.
Deed Book and Page No.
0211/0125
R pERMrT7jN�
3c.
Responsible Party (for LLC if
applicable):
W Darrell Robertson, PE, County Engineer (see Section 4 below)
3d.
Street address:
3e.
City, state, zip:
3f.
Telephone no.:
3g.
Fax no.:
3h.
Email address:
Page 1 of 13
PCN Form — Version 1.3 December 10, 2008 Version

4.
Applicant Information (if different from owner)
4a
Applicant is
❑ Agent ® Other, specify County Utility Service Provider
4b
Name
W Darrell Robertson, PE, County Engineer
4c
Business name
_,(if applicable)
Alexander County
4d
Street address
621 Ldedoun Road
4e
City, state, zip
Taylorsville, North Carolina 28681
4f
Telephone no
828 -632 -1000
4g
Fax no
N/A
4h
Email address
drobertson @alexandercountync gov
5.
Agent/Consultant Information (if applicable)
5a
Name
John C. Was
5b
Business name
(if applicable).
McGill Associates, P.A
5c `Street address.
3764 Rommger Rd
5d
City, state, zip_
Banner Elk, NC 28604
5e
Telephone no
S,
(828) 297 -6946
5f
Fax no
(828) 297 -1982
5g
Email address
john vdas @mcgdlengineers com
Page 2 of 43
PCN Form — Version 1 3 December 1`0, 2008 Version

B.
Project Information and Prior Project History
1.
Property Identification
1a
Property identification no (tax PIN or parcel ID)
Project Site is in the Right -of -Way of Blankenship Rd
(SR -1152)
1 b
Site coordinates (in decimal degrees)
Latitude 35 8676 Longitude - 812797
(DD DDDDDD) (-DD DDDDDD)
1 c
Property size,
N/A acres
2.
Surface Waters
2a
Name of nearest body of water (stream, river, etc.) to
Middle Little River
proposed project
2b
Water Quality Classification of nearestireceiving water
C
2c
River basin:
Catawba
Page-3 of 13
PCN Form — Version 1 3 December 10, 2008 Version

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
The Bethlehem - Ellendale Water System Improvements Project is ,a linear utility project that,wdl install 23,000,linear feet,of
waterline in the Right -of -Way of four state roads (see,Project description, 3e) The Project will cross seven unnamed
tributaries to Middle Little, River and Middle Little River once (refer to the) Project Overview Map) Five of,the stream
crossings (Crossings 4 -8) will be completed by trenching above existing piped conveyances that will not impact surface
waters Two stream crossings (Crossings 1 & 2) will be completed by bore and jack, and directional drilling, that will not
impact surface, waters or cause disturbance to stream beds One stream crossing (Crossing 3) will be open cut trenched
due to underlying bedrock that restricts boring`techniques (see engineer's field notes, dated 8- 25 -14) Stream Crossing 3
is referred,to as the Project Site
The Project Site is located on an unnamed perennial tributary to Middle Little River in the Right -of -Way of Blankenship
Road UT- Middle Little River is a mapped USGS blueline,stream and•averages Vin width within the Project Site The
Project Site is located 15 -20' upstream and east of an existing 72" RCP that conveys flow under Blankenship Road The
area immediately surrounding the Project Site is dominated by shallow surface bedrock
The larger area surrounding the Project Site consists of rural single- family residences, small farms, and undeveloped
property made up of open fields, wooded areas with moderately hilly terrain
3b
List the total estimated acreage of all existing wetlands on the property,
N/A
3c
List the total estimated linear feet of'all.existing streams (intermittent and perennial) on the property
Tributaries on the property have not been delineated beyond the Project Site
3d
Explain the purpose of the proposed project
The Bethlehem - Ellendale Water System Improvements Project will provide expanded public water service to the Citizens
of Alexander,County and improve circulation in the existing Alexander County Water System
3e
Descnbe,the,overall project in detail, including theAype of,equipment to,be used
The Bethlehem - Ellendale Water System Improvements Project involves the,construction of approximately 23,000 linear
feet of 12 -inch and 8 -inch diameter water mains, upgrades to an existing Bethlehem'water booster pump station and the
addition of a new 600,000 gallon; finished- water, ground storage tank at the existing Ellendale tank site. The water mains
will connect to existing dead -end lines to create a new expanded Ellerdale service area and will extend from Devil Track
Road, Blankenship Road, Teague Town Road and Bowman Cutover Road. Water line installation at stream Crossing 1
(attached sheet C -101) will be•completed by directional drilling.and will consist of ductile lined pipe to be installed under
the stream bed,with 36 "''of separation Waterline °installation at stream Crossing 2 (attached sheetiC -108) will be
completed by bore and hack and,will consist of a;20" steel casing, 0 25 "wall thickness,, for the pipe segment under the
stream Stream Crossing 3 (attached sheet C -112) was originally planned for installation without any stream bed
disturbance by boring and jacking. However the discovered presence of bedrock prohibits the planned "non- disturb"
installation method Therefore, the County respectfully requests that stream Crossing 3 be permitted under the jursdiction
of NWP -12 with all impacts to,the stream being temporary (Steam Impact Site S -1)
Water line installation at Crossing 3 will be,completed,using a track hoe with mounted rock hammerand mini- excavator
according to the following process spoil area established, setback minimum of 10' from streambank and encircled with
sediment fence.for temporary storage of excavated streambed andhbank material, temporary pipe with washed stone
embedment setup in,stream channel to ensure Work is performed in the dry (refer to attached plansheet C -504 forlypical
Trenching Details), trench is dug or rock hammered perpendicular, across stream channel to specified.elevation; trench
bottom is lined with washed stone (6" min ), ductile lined pipe is installed on top of stone embedment, excavated stream
bed material is backfilled in 6" lifts to pre- existing stream bed elevation, disturbed stream banks are graded back to match
adjoining bank grade and dimensions, stabdization,of disturbed.stream banks and 30' buffer is completed by installing coir
matting and seeding with temporary erosion control seedmix, overseeded with riparian seedmix, and, covered with straw
to ensure seed germination All temporary water diversion materials removed from the stream channel
Page 4 of 1`3
PCN Form — Version 1 3 December 10, 2008 Version

4.
Jurisdictional Determinations
Aa
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?
Comments
El Yes ED No Unknown
4b
If the Corps made the jurisdictional determination, what type
of determination was made?
❑ Preliminary ❑ Final
4c
If yes, who delineated the jurisdictional areas?
Name (if,known)- Sean Martin
Agency /Consultant,Company McGill Associate, PA
Other
4d
If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
5.
Project History
5a
Have permits or certifications been requested or obtained for
this project;(including all;pnor.phases);in the past?
❑ Yes ❑ No ® Unknown
5b
If yes, explain in detail according to- "help file" instructions
6.
Future Project Plans
6a
Is this a phased project?
❑ Yes ® No
6b
If yes, explain
Page 5 of 13
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 ® Streams - tributaries ❑ Buffers
❑ Open Waters ❑ Pond Construction
2 Wetland Impacts
If there are wetland impacts proposed,on the site, then complete this question foreach wetland area impacted.
2a
2b
2c
2d
2e
2f
Wetland impact
Type of'lunsdiction
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
W1 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W2 ❑ P 0 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
2K Comments:
3. Stream Impacts
If there are perenrnal,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'lunsdiction
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)
S1 ❑ P ®T
Fill
UT- Middle Little
® PER
® Corps
g
30
River
❑ INT
❑ DWQ
S2 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S3 ❑ P ❑ T
❑ PER
❑ Corps
❑ 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
30
31 Comments Proposed stream impacts at S -1 will be temporary and stream will be restored to pre - existing conditions.
Page 6 of 13
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 all open water impacts below
4a.
-list
4b.
4c
4d
4e
Open water
Name of waterbody
impact number —
(if applicable)
Type of impact
Waterbody type
Area of impact (acres)
Permanent (P) or
Temporary
01 ❑P ❑T
02 ❑P ❑T
03 ❑P ❑T
04 ❑P ❑T
4E Total open water,impacts
4g Comments
5. Pond or Lake Construction
If pond or lake construction proposed, then complete the chart- below
5a
5b
5c
5d
5e
Wetland Impacts (acres)
Stream Impacts (feet)
Upland
Pond ID
Proposed use or purpose
(acres)
number
of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
5f. Total
5g Comments
5h Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no
51 Expected pond surface area (acres)_
51 Size of,pond watershed (acres)
5k Method of construction
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below If yes, then individually list all buffer impacts
below If an aim acts require mitigation, then you MUST fill out Section D of this form
6a.
❑ Neuse ❑Tar- Pamlico ❑Other
Project;is'in which protected basin?
'® 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)
Temporary
impact
required?
B1 ❑ P ❑ T
❑'Yes
❑ No
B2 ❑ P ❑ T
❑ Yes
❑ No _
B3 ❑P ❑T
❑Yes
❑ No
6h. Total,buffer impacts
61 Comments The project is not,withm,an area with regulated riparian buffer rules
Page 7of13
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 impactsan designing project
Five stream crossings (4 -8) will be,installed over existing piped,conveyances in the - Right -of -Way of state roads and will not
impact surface waters Two,stream crossings (A'& 2) will bore under stream beds and wall, not impact surface,waters�or disturb
stream `beds
1 b Specifically describe measures taken to avoid or minimize the proposed impacts °through construction techniques
Impacts at stream Crossing 3 will be temporary Stream impacts will be minimized by performing work in the dry, restoring the
stream bank and channel to pre - existing grade and dimension, and stabilizing disturbed stream banks and 30' buffer areas
with native riparian species
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
projects
❑' Mitigation ° bank
El' 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 __FQuant1tY
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 Ripanan`wetland mitigation requested
acres
4f Non - npanan wetland mitigation requested
acres
4g Coastal (tidal) wetland mitigation requested
acres
4h Comments '
5. Complete if Using a Permittee Responsible Mitigation Plan
5a lft sng :a permittee responsible mitigation plan, provide a,description of the4lproposed mitigation plan
Page 8 of 13
PCN Forme— 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
buffer mitigation?
❑ Yes ® No
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
Zone
6c
Reason for impact
6d
Total impact
(square feet)
Multiplier
6e
Required mitigation
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
15
6f Tota[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 9 of 13
PCN Form — Version 1 3 December 10, 2008 Version

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1.
Diffuse Flow Plan
la
Does the project include or °is it adjacent to,protected npanan buffers identified
Yes No
within one of'the NC Riparian Buffer Protection Rules
1 b
If yes, then is a diffuse flow plan included? If no, explain why
❑ Yes ❑ No
Comments
2.
Stormwater Management Plan
2a
What is the overall percent imperviousness of this project?
0%
2b
Does this project require a Stormwater Management Plan?
❑ Yes ® No
2c
If3this project DOES NOT require a,Stormwater Management Plan, explain why Stormwater rules,are not applicable to
projects under NWP -12
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 Manage►nent;Plan?
'❑ DWQ Stormwater, Program
❑ DWQ 401 'Unit
3.
Certified Local Government Stormwater Review
3a
In which local government's junsdiction,is this project?
Alexander County
,❑'Phase 11
3b
Which of the following locally - implemented stormwater management programs
❑ NSW
❑ 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 ® No
attached? -
S.
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 10 of 13
PCN Form — Version 13 December 10, 2008 Version

F.
Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
la
Does the prolec6rivolve an expenditure of public,(federal /state /local) funds or the
® Yes
❑ No
use of public (federal /state) land?
lb ,lf�you answered '"yes" to,the above, does the project require preparation of an
environmental document pursuant to the requirements,of the National or State
M' 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)
Comments State of N C issued,a Categorical Exclusion (CE) to the project in 2012
® Yes
❑ No
based on the original plans Please see attached SEPA documentation However,
due to the finding of bedrock at Crossing 3, the plans have been changed and the
project is applying for a new CE concurrent to this NWP -12 application
2.
Violations (DWQ Requirement)
2a
Is the site in violation of DWQ Wetland Rules (15A NCAC 2H 0500), Isolated
Wetland'Rules,(15A NCAC 2H 1300), DWQ Surface Water or Wetland Standards,
❑ Yes
® No
or Riparian Buffer Rules (15A NCAC 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," provides short narrative,descnption
The pupose of the Bethlehem - Ellendale Water System Improvements Project is to provide public water
service to rural
areas of Alexander County including area public schools and fire =stations
4.
Sewage Disposal (DWQ Requirement)
4a
Clearly detail the ultimate treatment methods, and disposition (non - discharge or discharge) of wastewater generated from
the proposed,prolect, or available capacity of the subject facility
The proposed project will not causefadditional wastewater to be generated
Page 11 of 13
PCN Form — Version 1 3 December 10, 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,conceming Endangered Species Act
® Yes ❑ No
impacts?
5c If yes, indicate the USFWS Field Office you have contacted.
❑ Raleigh
® Asheville
5d. What data sources did you use to determine whether your,site would impact Endangered Species or Designated Critical
Habitat?
The Asheville USFWS office has;been contacted, regarding the potential existence of T &E species and theirhabitat for
the entire project area on April 20, 2011 as part of a SEPA scoping process. USFWS determined no protected species or
critical habitat existed in the project area
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?
http-1/www. habitat. noaa. gov/ protechon /efh/habitatmapper.htmi
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 orproperties 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?
NC State Historic Preservation Office response letter to a 2011 inquiry as, part of the projects SEPA scoping process
determined no archeological or historical areas of interest in the project area Website search completed by McGill
Associates revealed one historical structure on Bowmans Cutover Road`that•is not a significant historical structure; listed
as having been Surveyed Only (SO).
8. Flood' Zone Designation (Corps, Requirement)
8a Will this project occurin a FEMA- designated 100 -year floodplain?
® Yes ❑ No
8b. If yes, explain how project meets FEMA requirements: Middle Little River'has mapped FEMA floodplain at Crossing 1.
Crossing 1 will be completed by directional boring thus not affecting surface conditions or changing surface elevations in
the mapped floodway. Temporary pits dug to complete directional boring will be re -filled once work is complete.
8c. What,source(s) did you use to make the floodplain determination? http: //www ncfloodmaps.coml
John C. Was
/C / /S //y
Applicant/Agents Printed Name
Applicant/Agents Signature
Date
(Agents signature ismalid only if an authorization letter from the applicant
is irovided.
Page 12 of 13
PCN Form — Version 1.3 December 10, 2008 Version

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION
LOT NO. PLAN
STREETADDRESS: 2381 Blankenship Road
Tavlorsville North Carolina 28681
Property Owner: NCDOT R/W Alexander County
PARCEL ID,
Property Owner: W. Darrell Robertson PE, County Engineer
The undersigned, registered property owners of the above noted property, do hereby authorize
John C. Vdas /RJ Mozeley ,-of. McGill Associates. P.A.
(Contractor/ Agent) (Name of Consulting Firm)
To act on my behalf and take all'actions,necessary for the processing, issuance and acceptance of,this
permit or certification and any,and all standard and special conditions attached.
Property Owner's Address (if different than property above)
621 Liled'oun Road Tavlorsville North Carolina 28681
Telephone: [phone]
We hereby certify that,the,above information submitted in this applicatiorils true and accurate to the
best of our knowledge.
Author ed Signature
Authorized Signature
Date. UG/ya'W ':�? 9 �%l¢ Date:

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TOPO MAP Bethlehem - Ellendale Water System Improvements@McGM
PCN APPLICATION
OCTOBER 10, 2014 ALEXANDER COUNTY, NORTH CAROLINA A S S O C I A T E S
ENGINEERING - PLANNING - FINANCE
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35° 57TN
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3 Soil Map — Alexander County, North Carolina 3
(Bethlehem - Ellendale Water System Improvements)
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Conservation Service National Cooperative Soil Survey Page 1 of 3

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Map Unit Legend
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usDk Natural' Resources Web Sod Survey 10/10/2014
Conservation Service National Cooperative Sod Survey Page 3 of 3

LEGEND
Crossing above piped conveyances
-----: Q in R /W; no surface water impacts
% Crossing to be bored under
/ 1 O
jurisdictional waters in R /W; no
surface water impacts
O Crossing to be open cut trenched
across jurisdictional waters in R /W;
BLANKENSHIP NORTH temporary surface water impacts
12* WATER UNE Proposed Water Line Route, in R/W
Crossing 2
Crossing 4
Crossina 5 r \
� �y�s
Crossing 3
Ro Impact Site S -1
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RD Crossing 6
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BETHLEHEM - EI .I ENDALE
OVERVIEW MAP WATER SYSTEM MPROVENBRq'IS McGill
P C N APPLICATION A S S O C I A T E S
OCTOBER 13, 2014 ALEXANDER COUNTY ENVIRONMENTAL SERVICES
NORTH CAROLINA

McGill Associates P.A.
124019th St., Lane NW
Hickory, North Carolina 28601
(828) 328 -2024
PROJECT OBSERVATION REPORT
(ALL ENTRIES IN INK)
DATE °�`� i
DAY OF S (/M ` T W T F S
WEEK `�
TIME �) -?
ARRrVED / V L
AM.
PM
TIME AM
pEpgRTEp PM
WEATHER ® CLEAR O OVERCAST ❑ RAW O SNOW E3 OTHER
24HOURSINPAST
C � �� IN.
lJ�
HIGH
TEMPERATURE- r`
LOW TEMPERATURE
CONTRACTOR L
[il CLEAN & FUNCTIONAL
❑ REPAIR/MAINTENANCE REQUIRED ❑ SEE COMMENTS BELOW
TRAFFIC CONTROL 0 SIGNS
® CONES FLAGMEN ❑ WA
GRADED AREAS (SLOPESIFILLS) ❑ SEEDED
0PROTECTED ❑ OTHER LJOKkl*NG
PROJECTFOREMAN" "'
OPERATOR
lr
SKILLED /
1
OTHER �-
EQUIPMENT TRACK EXCAVATOR z
RUBBER TIRE
EXCAVATOR
RUBBER
TIRE
LOADER
DUMP TRUCK
OTHER
SUBCONTRACTOR L i A
/� r
FOREMAN!
SUBCONTRACTOR
FOREMAN
SUBCONTRACTOR
FOREMAN
OWNERS REP
VISITORS
® WATER LINE ❑ SEWER LINE INSTALLATION
Sta to Sta.
❑ WATER LINE ❑ SEWER LINE TESTING
Sta to Sta.
❑ ROAD CONSTRUCTION Sta to Sta.
WORK AREA CLEAN -UP ❑ GOOD
© ACCEPTABLE
[]INADEQUATE ❑ SEE COMMENTS BELOW
EROSION & SEDIMENTATION CONTROL MEASURES IN PLACE ❑ NIA ® YES
❑ NO ❑ SEE COMMENTS BELOW
EROSION & SEDIMENTATION CONTROL MEASURES
[il CLEAN & FUNCTIONAL
❑ REPAIR/MAINTENANCE REQUIRED ❑ SEE COMMENTS BELOW
TRAFFIC CONTROL 0 SIGNS
® CONES FLAGMEN ❑ WA
GRADED AREAS (SLOPESIFILLS) ❑ SEEDED
0PROTECTED ❑ OTHER LJOKkl*NG
Su'8` 66Y6
S %lo l VZ C' -111 — •S 611CC4 ufirC�.
i l'trsn+ — Y
�7R8
REV'. 12M
CFR'S SIGNATURE
❑ PAGE 2 FOR ADDITIONAL REMARKS
DATE

Photo One: View looking to the
south along Blankenship Road.
Group of trees on the left abut UT-
Middle Little River and Stream
Impact Site S -1. Proposed water
line will cross the unnamed
tributary perpendicularly
approximately 15 -20' from the edge
of Blankenship Road. Crossing will
be installed using an open cut
trench that will incur temporary
impacts to the stream bed and
banks. All temporary impacts will
be mitigated and stabilized. No
changes to stream bed and bank
dimension or grade will result.
Photo Two: View looking to the
east from Blankenship Road at UT-
Middle Little River in center of
photo. Proposed water line to cross
8' wide perennial tributary (S -1)
approximately 15 -20' from edge of
the road.
Photo Three: View looking to the
north along Blankenship Road.
Proposed water line crossing (S -1)
is on the right of photo near the
group of trees, approximately 15 -20'
from the right edge of the road.
PHOTO SHEET BETHLEHEM - ELLENDALEOMcGM
PCN APPLICATION WATER SYSTEM IMPROVEMENTS PROJECT
OCTOBER 10, 2014 A S S O C I A T E S
ALEXANDER COUNTY, NORTH CAROLINA ENGINEERING PLANNING FINANCE
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Categorical Exclusion Review Checklist for DWSRF Projects
Applicant WIF #
PWSID � _ - _ P&S Serial #
........................................................................................................................................................... ...............................
Required for all Categorical Exclusions (CE's)
Cross Cutting Authority Responsible Agency, Action(s) Taken & Dates
Archeological and Historic Preservation Act
North Carolina Cultural Resources for signoff.
of 1974, Pub. L. 86 -523, as amended
, ❑, B�nket letter from applicant OK?
LvMomments from agency OK? JPF,3 f i(,4iw,.1 Z
National Historic Preservation Act of 1966,
PL 89 -665, as amended
Z6, /Nf}
Protection of Wetlands, Executive Order
USACE
11990
❑ By "no permits required" comment letter from USACOE _ ____
F] By sealed & signed "no jurisdiction" blanket comment letter from
applicant's engineer
By sealed & signed "no permits required" blanket comment letter from
applicant's engineer �+9V') 2
❑ By sealed & signed "all permits in place" blanket comment letter from
applicant's engineer
Endangered Species Act, Pub. L. 93 -205. as
uSpifs for signoff
amended
LJComments from USFWS OK .74-0 `-`PA-11
❑ By sealed &signed blanket letter from applicant's engineer for project
Fish and Wildlife Coordination Act, Pub. L.
85 -624, as amended
scopes that don't require comments (see factsheet) _ -__ ___
❑ By sealed & signed blanket letter from applicant's engineer after 30 days
Wild and Scenic Rivers Act, Pub. L. 90 -542,
as amended
pass without USFWS comment J
Environmental Justice, Executive Order
Loans and Grants group and Regional Engineer
12898
Based on the discussions with the regional engineer during the priority review
period :
1. Does the potentially affecte mmunity include an EJ community?
❑ Yes No
2. Are there significant environmental impacts likely to fall
disproportionately on minority and/or low- income members of the
community and/or tribal�resces?
El Yes 5' No
Coas tal Barrier Resources Act, Pub. L. 97-
Division of Coastal Management (DCM)
348
1. Is this project located in any of the following counties: Beaufort, Bertie,
Brunswick, Camden, Carteret. Chowan, Craven, Currituck, Dare, Gates,
Hertford, Hyde, New flanover. O nslow, Pamlico, Pasyuotank, Pender,
Perquimans, Tyrrell, and W rnglon?
❑ Yes o
2. if the answer to question # 1 is "Yes ", then DCM must find if the project is
Coastal Zone Management Act, Pub. L 92-
583, as amended
in an Area of Environmental Concern (AFC) established by the Coastal
Resources Commission. Is it in one of these AFC's?
❑ Yes ❑ No DCM Response Date:
3. If the answer to question #2 is "Yes", then the project requires a CAMA
permit. Does the project have a CAMA permit?
❑ Yes ❑ No _ CAMA Permit Date: _
❑ CE posted on Web? (optional)
7o print on green paper S: IPH4 MPW. 5�SRF17emplates tCheeklistsiCl:= XcutleCheckoffs 2012- 02- 09.doc Page I of l

RegUipst for Categofta8 Exclusion
febmr- Substantive Envit6nm6rital Review.
Instructions
1 Provideth'e,DEH :number- ,for'the`project',for which;you are, requesting;considerifion
,2 Please fill out the applicant's "formal n- aj me; "lf yoware:a county,authority, plea g specify whicH county- "County.
Water DistncfVll " -is not- an;acceptaOle :,name," }ABC County Water l7isthctVll "is acceptable
'3 Please checkeall ;applicable,exclusions. Fail'ur'e to`check =qr appllcable exclusion will re - i n th&fJjedtion,6f your
,4 Either, the ` "authorizedirepfesentatiVe,4 or the ProfessionaLEngineer responsible for the PER =must sign the form! -If
the`PE,signs the form, it -must include the' PE seal
DEH No::', 1650
Applicant: Alexander County„ Northtarolina
Aleza6der'`County Water System Improvements; Construction of,approximately 21;100 linear feet
Project of waterlines hd,assoaated appurtenances on Blankenship Road,-Devil Track-Road „and Teague
Description Town-Road;%a ,400,000 gallon water storage,tank; and a water booster station ,upgrade;in
Bethlehem
We;certify- -that the project descnbed,,in the application for,state -suppl aed,financial•assistance meets all,of the applicable
general c'r'iteria listed m 15A ;NCAC,01 C 0408 (1),.a nr consists solely of activities exempted:ynder the specific critena
of 15A NCAC 016. 0408,(2),cfiecked below
Pfease`Check-afl the.Euclusi6n(6) that apply
❑ Potable ,water sys terns ,iricluding`the:construction or rehabilitation, of ;wells for waterisupply purposes with
assoaatedgroundwater withdrawals :of.less °tharn1,000;000�gallons per day,where suctrwithdrawals are "not
expected to'cause.alterations in established land use pattems, or degradation of_,groundwater,o� surface water
quality.
[15A NCAC'01G- 0408 „(2)(c)]
Other potable.water, systems,mcluding the following”
❑ Improvements °to water treatment;plants,that involve less than.1,000,000 gallons per day added capacit _and
total design,,withdrawak less than.oneA h,of the 7-'day, 1'0- year'low flow of the3contribuigg- stream,
[1'54 NCAC,,01C 0408 (2)(b)Q)]
❑ Improvements not intend'ed'to'add ' capacity to the,facility,- f15A-NCAC 01Cti 0408 (2)(b)(11)]'
® Installation ofwaterhnes and;aPpurtehbnces'ih existing rights -of- way °fo'r'streefs or utilities, -or water lines and
appurtenances less than five'm les in lengtKand haVirg only'directiorial, bore strearri crossings or no stream
crossings,r[NCGS
&J1 3k-I 2(11 & 15A NCAC -01C ,0408,(2)(0)(iii)]
[� Construction,of,water tanks,=or booster pumping.or;;secondary or remcte.,Aisinfection stations,-'
L 5A.NCAC_01 C - 0408,(2)(b)(iV)]
❑ Dams less than 25 feet in height and having,less,than _50:acre -feet or storage capacity [15A NCAC- 616-0908
(2)(h)],(Notes- #1 Dam - projects are ineligible for•federally recognized CEr #2 Only off- s,Eream (aw -water
reservoirs for pre treatment purposes are eligible for SRF "U ding )
We further certrf)r`-that- the - project does not have -,a significant direct, indirect,- cumulative,or secondary adverse
environmental`impact,as desenbed'in;15A NCACII01 C 0306, and that none of the following descnptions apply to the
project.
Xppricdlion- Supplemerit'foi, PEN R funding' ssistoncet for Dnnking,Vdoter I'rolects Page Idiot' 5

• the proposed activity may have a potential for significant adverse effects on wetlands; surface waters such as
rivers, streams and estuaries; parklands; game lands; prime agricultural or forest lands; or areas of local, state or
federally recognized scenic, recreational, archaeological, ecological, scientific research or historical value,
including secondary impacts, or would threaten a species identified on the Department of Interior's or the state's
threatened and endangered species lists; [15A NCAC 01C .0306 (1)] or
• the proposed activity could cause changes in industrial, commercial, reside itial, agricultural, or silvicultural land
use concentrations or distributions which would be expected to create adverse water quality, instream flow, air
quality, or ground water impacts; or affect long -term recreational benefits, fish, wildlife, or their natural habitats;
(15A NCAC 01C .0306 (2)] or
• the proposed activity has secondary impacts, or is part of cumulative impacts, not generally covered in the
approval process for the state action, and that may result in a potential risk to human health or the environment;
[15A NCAC 01C .0306 (3)].
Therefore, we believe our project is eligible for consideration for a CE from the State's environmental assessment
review processes and request that the State of North Carolina concur with our determination.
We understand that the State of North Carolina may determine that the proposed activity is of such an unusual nature
or has such widespread implications that a concern for its environmental effects has been identified by DENR or
expressed to DENR. We understand that, in this case, the activity may be ineligible for CE under 15A NCAC 01C
.0306(4).
We recognize that this request supplies information sufficient only for state - financed assistance underthe 15A NCAC
01 J and 01 L rules. If we are applying (either additionally or exclusively) for federally- financed assistance under the
Drinking Water State Revolving Fund Program, additional steps (including obtaining comment letters and publicizing
the requested action) apply.
Douglas G. Chapman, PE
Aut c ized re en a Printed Name
thor d Repres ntative Signature & Date
McGill Associates, P.A., Senior Project Manager
Authorized Representative Title
Sta se Ottfy (Review)
!r
Reviewed by.
Department Appr6v
A" 2-C) I
Application Supplement for DENR Funding Assistance for Drinking Water Projects Page I I of 25

NC iDWO Stream Identification Form Version 4.11
Date: \ _ - ,L'
Project/Site ,cNern- ltendo(e
w °� w34 vP
Latitude:
Evaluator:
v
County: �"T to
Longitude:
10
1
2
Total Points:
Stream Determination (circle-me )
Other "'e0&
Stream is at least intermittent
d i 19 or erennial rf 2 30'
Ephemeral Intermittent erea
nni
e.g Quad Name: 5-(
A. Geomorphology Subtotal_= � i .5
Absent
Weak
Moderate
Strong
18 Continuity of channel bed and bank
10
1
2
3
Z. Sinuosity of channel along thalweg
0
1
2
3
3. In- channel structure: ex. riffle -pool, step -pool,
n le of sequence
0
1
_ _ 1
3
4. Particle size of stream substrate
0
1
2
3
5. Active /relict floodplain
No 0
1
2
3
6. Depositional bars or benches
0
1
2
3
7. Recent alluvial deposits
0
2
3
8. Headcuts
0
1
2
3
9. Grade control
0
0.5
1
1.5
10. Natural valley
0
0.5
1
1.5
11. Second or greater order, channel
No ='0
Yes(- 3
° artificial ditches arei not rated; see discussions in manual
`B. Hvdroloav (Subtotal = 14.S )
12. Presence- of,Baseflow
0
1
2
3
13. Iron oxidizing bacteria
0
1
2
3
14. Leaf litter
C1.
1
0.5
0
15. Sediment on plants or debris `
0--
0.
_ _ 1
1.5
16. Organic debris lines or piles
0
0.5
1
1.5
17. Soil -based evidence of high water table?
No 0
Yes = 3
C. Bioloav (Subtotal = 7 )
18. Fibrous roots in streambed
3
2
1
0
19. Rooted upland plants in streambed
C3
2
1
0
20. Macrobenthos (note diversity and,abundance)
10
1
2
3
21. Aquatic Mollusks
0
1
2
3
22. Fish
E
0.5
1
1.5
23. Crayfish
0.5
1
1.5
24. Amphibians
.0.5
_
1 _ _
1.5
25. Algae
0 _ _
0.5
1
1.5
26. Wetland plants in streambed
FACW = 0.75; OBL = 1.5
Other 0
'perennial streams may also be identified using other methods. Seep. 35 ofmanual.
Notes:
Sketch: