20221001 Ver 2_401 Application_20220720

Staff Review Form
NORTH CAROLINA
Envlronm¢ntcl Qvofiry
Updated September 4, 2020
Staff Review
Does this application have all the attachments needed to accept it into the review process?*
Yes No
ID# *
20221001
Version* 2
Is this project a public transportation project?*
Reviewer List:*
Select Reviewing Office: *
Submittal Type:*
Yes
• No
Amy Annino:eads\amannino
Asheville Regional Office - [phone]
401 Application
Does this project require a request for payment to be sent?*
Yes
No
How much is owed?* $240.00
$570.00

Project Submittal Form
*
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Type: *
For the Record Only (Courtesy Copy)
New Project
Modification/New Project with Existing ID
More Information Response
Other Agency Comments
Pre -Application Submittal
Re-Issuance\Renewal Request
Stream or Buffer Appeal
Pre -Filing Meeting Date Request was submitted on:
6/6/2022
Project Contact Information
Name:
Stephen F Metcalf
Who is submitting the information?
Email Address: [e-mail]
Project Information
Project Name: Bank Stabilization
Is this a public transportation project?
Yes
No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
Yes No Unknown
County (ies)
Jackson
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
DWR Pre -Construction Notification (PCN) Form.pdf
Pre Const Notification Form1-4-2009interactive-
reader-enabled2013-06 (2).pdf
Only pdf or kmz files are accepted.
377.58KB
741.79KB

Describe the attachments or
comments:
1.Bank stabilization barrier of a staked netting system, large rock anchors, live stakes as
proposed by USACE
2. Netting system will be manually installed and staked from the bank as much as possible.
Plan to minimize water contact
3. Rocks will be installed from the top of the bank and placed one at a time utilizing an
excavator located on the horizontal land above the bank.
4. Except for the excavator moving rock to the bank face, all work will be done manually on the
river bank with little impact to the river. Some rock will be placed in the river as foundation for
the rock wall. The rock wall will be dry laid one on top of the other with no cement or concrete
utilized.
Sign and Submit
By checking the box and signing box below, I certify that:
• I, the project proponent, hereby certifies that all information contained herein is true, accurate, and complete to the
best of my knowledge and belief.
• I, the project proponent, hereby requests that the certifying authority review and take action on this CWA 401
certification request within the applicable reasonable period of time.
• I agree that submission of this online form is a "transaction" subject to Chapter 66, Article 40 of the NC General
Statutes (the "Uniform Electronic Transactions Act");
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General
Statutes (the "Uniform Electronic Transactions Act");
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a
written signature; AND
• I intend to electronically sign and submit the online form.
Signature:
e4e,pete,,e 9(7-ifeee,e
Submittal Date: 07/20/2022
Is filled in automatically.

DWR
IDIOM— of Water Resources
Pre -Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
April 13, 2022 Ver 4.3
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all mandatory questions are answered.
Also, if at any point you wish to print a copy of the E-PCN, all you need to do is right -click on the document and you can print a copy of the form.
Below is a link to the online help file.
https://edocs.deq.nc.govfVVaterResources/0/edoc/624704/PCN / 20Help/ 20File/ 202018-1-30.pdf
A. Processing Information O
Pre -Filing Meeting Date Request was submitted on:
6/6/2022
If this is a courtesy copy, please fill in this with the submission date.
County (or Counties) where the project is located:"
Jackson
Is this a NCDMS Project"
0Yes ONo
Click Yes, only if NCD MS is the applicant or co -applicant.
Is this project a public transportation project?"
O Yes OO No
This is any publicly funded by municipal,state or federal funds road, rail, airport transportation project.
la. Type(s) of approval sought from the Corps:"
❑O Section 404 Permit (wetlands, streams and waters, Clean Water Act)
❑ Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
Has this PCN previously been submitted?"
O Yes
O No
1 b. What type(s) of permit(s) do you wish to seek authorization?"
❑O Nationwide Permit (NWP)
❑ Regional General Permit (RGP)
❑ Standard (IP)
1c. Has the NWP or GP number been verified by the Corps?"
Yes • No
Nationwide Permit (NWP) Number: 13 - Bank Stabilization
NWP Numbers (for multiple NWPS):
401 404
List all NVV numbers you are applying for not on the drop down list.
1 d. Type(s) of approval sought from the DWR:
check all that apply
❑O 401 Water Quality Certification - Regular ❑ 401 Water Quality Certification - Express
❑ Non-404 Jurisdictional General Permit ❑ Riparian Buffer Authorization
❑ Individual 401 Water Quality Certification
1e. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification: O Yes O No
For the record only for Corps Permit: Q Yes 0 No

1f. Is this an after -the -fact permit application?"
Yes O No
1g. 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.
O Yes OO No
Acceptance Letter Attachment
Click the upload button or drag and drop files hereto attach document
FILE TYPE MUST BE PDF
1 h. Is the project located in any of NC's twenty coastal counties?"
Yes • No
1j. Is the project located in a designated trout watershed?"
0Yes ONo
Linkto trout information: http://www.saw.usace.army.miI/Missions/Regulatory-Permit-Program/Agency-Coordination/Trout.aspx
B. Applicant Information
1a. Who is the Primary Contact?"
Stephen F. Metcalf
1c. Primary Contact Phone:"
1 b. Primary Contact Email" (xxx)xxx-xxxx
[e-mail] [phone]
1d. Who is applying for the permit?"
Owner O Applicant (other than owner)
(Check all that apply)
1e. Is there an AgentlConsultant for this project?"
vYes �)No
2. Owner Information
2a. Name(s) on recorded deed:"
Stephen F. Metcalf & Wife
2b. Deed book and page no.:
Book 1198 Page 32
2c. Contact Person:
(for Corporations)
2d.Address*
Street Address
508 S. Wayehutta Road
Address Line 2
City
State / Province / Region
Cullowhee
North Carolina
Postal /Zip Code
Country
28723
USA
2e. Telephone Number:"
(xxx)xxx-xxxx
[phone]
2f. Fax Number:
2g. Email Address:"
[e-mail]
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:"
Metcalf Bank Stabilization
1b. Subdivision name:
(if appropriate)
u
U
lJ
1c. Nearest municipality/town:"
Cullowhee

2. Project Identification
lJ
2a. Property Identification Number:
2b. Property size:
(tax PIN or parcel ID)
(in acres)
7559-82-9975
0.9
2c. Project Address
Street Address
508 S. Wayehutta Road
Address Line 2
City
State / Province / Region
Cullowhee
NC
Postal /Zip Code
Country
28723
USA
2d. Site coordinates in decimal degrees
Please collect site coordinates in decimal degrees. Use between 4-6 digits (unless you are using a survey -grade GPS device) after the decimal place as appropriate, based on how the location was
determined. (For example, most mobile phones with GPS provide locational precision in decimal degrees to map coordinates to 5 or 6 digits after the decimal place.)
Latitude:" Longitude:"
35.30781-83.16019
ex: 34.208504-77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:"
Tuckaseegee River
3b. Water Resources Classification of nearest receiving water:"
WS-I I I, B,Tr
Surface Water Lookup
3c. What river basin(s) is your project located in?"
Little Tennessee
3d. Please provide the 12-digit HUC in which the project is located."
06010203
River Basin Lookup
4. Project Description and History
4a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this application:"
PROJECT AREA
*19A part of Tuckasee River. Cleared .27A property adjacent to Tuckaseegee River.. 0.44A across South Wayahutta Road with house
*Land undeveloped adjacent to Tuckaseegee.
GENERAL LAND USE
*Residential area. Some homes located adjacent to the Tuckaseegee and some such as mine have property adjacent to the river with homes set back some distance
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?"
O Yes OO No O Unknown
4f. List the total estimated acreage of all existing wetlands on the property:
No wetlands
4g. List the total estimated linear feet of all existing streams on the property:
(intermittent and perennial)
118.75 (survey)
4h. Explain the purpose of the proposed project:"
Bank stabilization
4i. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:
1.Bank stabilization barrier of a staked netting system, large rock anchors, live stakes as proposed by USACE
2. Netting system will be manually installed and staked from the bank as much as possible. Plan to minimize water contact
3. Rocks will be installed from the top of the bank and placed one at a time utilizing an excavator located on the horizontal land above the bank.
4. Except for the excavator moving rock to the bank face, all work will be done manually on the river bank with little impact to the river. Some rock will be placed in the river as foundation
for the rock wall. The rock wall will be dry laid one on top of the other with no cement or concrete utilized.
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?"
Yes No 0 Unknown

Comments:
Tuckaseegee River
5b. If the Corps made a jurisdictional determination, what type of determination was made?"
O Preliminary O Approved O Not Verified O Unknown O N/A
Corps AID Number:
Example: SAW-2017-99999
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Other:
5d. List the dates of the Corp jurisdiction determination or State determination if a determination was made by the Corps or DWR.
Preliminary approval per David Brown USACE Regulatory Specialist via email sent 3/2/22. Per email, project authorized under Nationwide Permit 13 for bank stabilization. Specifics of
requirements outlined in the email.
Mr. Brown required contact with DWR for review of 401 requirements to be approved before construction is initiated. Copy of PCN application attached to this application.
6. Future Project Plans
6a. Is this a phased project?"
Yes O No
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the proposed projector related activity? This includes other
separate and distant crossing for linear projects that require Department of the Army authorization but don't require pre -construction notification.
no
D. Proposed Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
❑ Wetlands J Streams -tributaries Buffers
r- Open Waters O Pond Construction
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.
"S." will be used in the table below to represent the word "stream".
3a. Reason for im pact" (?)
3b.lmpact type"
3c. Type of impact"
3d. S. name"
3e. Stream Type"
M
3f. Type of
Jurisdiction"
3g. S. width"
3h. Impact
length"
S1
Bank Stabilization
Permanent
Bank Stabilization
Tuckaseegee
Perennial
Both
140
Average (feet)
119
(linear feet)
** All Perennial or Intermittent streams must be verified by DWR or delegated local government.
3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
119
3i. Total temporary stream impacts:
0
3i. Total stream and ditch impacts:
119
3j. Comments:
E. Impact Justification and Mitigation
1. Avoidance and Minimization
la. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:"
1. USACE contact and preliminary approval
2. Review of PCN requirements.
3. Review of construction requirements and plans to reduce river impact
V

1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:"
1. Reduce or avoid river contact as much as possible.
2. Use minimal heavy equipment except to move and locate large rocks for bank stabilization.
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?
C Yes No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
Not a watershed or located on ocean shore
NC Stream Temperature Classification Maps can be found under the Mitigation Concepts tab on the Wilmington District's RIBITS website.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
*** Recent changes to the stormwater rules have required updates to this section .***
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection Rules?
u Yes No
For a list of options to meet the diffuse flow requirements, click here.
If no, explain why:
Land adjacent to the river bank has not been disturbed. Two large trees will remain on river bank.
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?"
to Yes � No
Comments:
There are no structures on this .27A property next to the river
There is a house across the street which is part of the property which is 1200 square feet on one level.
Property consists of .27A adjacent to Tuckeseegee River and .44A across a gravel road = .71 A = 30927.6 square feet
1200 / 30927.6 = 0.039 = 3.9
G. Supplementary Information
1. Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?"
Yes No
2. Violations (DWR Requirement)
2a. Is the site in violation of DWR Water Quality Certification Rules (15A NCAC 2H .0500), Isolated Wetland Rules (15A NCAC 2H .1300), or DWR Surface Water or Wetland Standards or
Riparian Buffer Rules (15A NCAC 2B .0200)?"
Yes No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in additional development, which could impact nearby downstream water quality?"
Yes " No
3b. If you answered "no," provide a short narrative description.
no other permanent construction planned for this property
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?"
u Yes V No c9 N/A
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
u
5a. Will this project occur in or near an area with federally protected species or habitat?"
Yes No

5b. Have you checked with the USFWS concerning Endangered Species Act impacts?"
Yes C- No
5d. Is another Federal agency involved?"
Yes No
5e. Is this a DOT project located within Division's 1-8?"
O Yes 0• No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?"
O Yes 0• No
5g. Does this project involve bridge maintenance or removal?"
O Yes 0• No
Link to the NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf
5h. Does this project involve the construction/installation of a wind turbine(s)?*"
O Yes 0• No
O Unknown
5i. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers, mechanized piledrivers, etc.?"
O Yes 0• No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?"
Internet search
Adjacent subdivision call River Club has structures and land similar to my bank stabilization project.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?"
Yes O No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?"
NOAA had none listed in western NC
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to the State Historic Preservation Office Historic Properties Map (does not include archaeological data: http://gis.ncdcr.gov/h/hpoweb/
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 status (e.g., National Historic Trust
designation or properties significant in North Carolina history and archaeology)?"
O Yes 0• No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?"
internet search
8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https:Hmsc.fema.gov/portal/search
8a. Will this project occur in a FEMA-designated 100-yearfloodplain?"
Yes No
8b. Ifyes, explain how project meets FEMA requirements:
The only permanent structure in 100 flood plain is small corner of existing structure.
Bank stabilization will be designed to minimize 100 flood damage as much as possible.
8c. What source(s) did you use to make the floodplain determination?"
Survey of property and, as a result, compliance with insured property in 100 year flood plain
Miscellaneous
Comments
PCN for DWR requirements attached.
U
Please use the space below to attach all required documentation or any additional information you feel is helpful for application review. Documents should be combined into one file when
possible, with a Cover Letter, Table of Contents, and a Cover Sheet for each Section preferred.
Click the upload button or drag and drop files here to attach document
Pre Const Notification Forml-4-2009interactive-reader-enabled2013-06 (2).pdf 741.79KB
File must be PDF or KMZ
Signature

OO By checking the box and signing below, I certify that:
• The project proponent hereby certifies that all information contained herein is true, accurate, and complete to the best of my knowledge and belief', and
• The project proponent hereby requests that the certifying authority review and take action on this CWA 401 certification request within the applicable reasonable period of time.
• have given true, accurate, and complete information on this form;
• agree that submission of this PCN form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act"),
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act"),
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature, AND
• I intend to electronically sign and submit the PCN form.
Full Name:"
Stephen F. Metcalf
Signature"
a, Si�V ewleaw
Date
6/6/2022

w A rE�QG
T.
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Pre -Construction Notification (PCN) Form
A.
Applicant Information
1.
Processing
1 a.
Type(s) of approval sought from the Corps:
❑ Section 404 Permit ❑ Section 10 Permit
1 b.
Specify Nationwide Permit (NWP) number: or General Permit (GP) number:
1c.
Has the NWP or GP number been verified by the Corps?
❑ Yes ❑ No
1d.
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
1g.
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:
2b.
County:
2c.
Nearest municipality / town:
2d.
Subdivision name:
2e.
NCDOT only, T.I.P. or state project no:
3.
Owner Information
3a.
Name(s) on Recorded Deed:
3b.
Deed Book and Page No.
3c.
Responsible Party (for LLC if
applicable):
3d.
Street address:
3e.
City, state, zip:
3f.
Telephone no.:
3g.
Fax no.:
3h.
Email address:
Page 1 of 10
PCN Form — Version 1.4 January 2009

4. Applicant Information (if different from owner)
4a. Applicant is:
❑ Agent ❑ Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 10

B.
Project Information and Prior Project History
1.
Property Identification
1a.
Property identification no. (tax PIN or parcel ID):
1 b.
Site coordinates (in decimal degrees):
Latitude: Longitude:
1c.
Property size:
acres
2.
Surface Waters
2a.
Name of nearest body of water to proposed project:
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:
3b.
List the total estimated acreage of all existing wetlands on the property:
3c.
List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3d.
Explain the purpose of the proposed project:
3e.
Describe the overall project in detail, including the type of equipment to be used:
4.
Jurisdictional Determinations
4a.
Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (includingall prior phases)in the past?
❑ Yes ❑ No ❑ Unknown
Comments:
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):
Agency/Consultant Company:
Other:
4d.
If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5.
Project History
5a.
Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
❑Yes ❑ No ❑ Unknown
5b.
If yes, explain in detail according to "help file" instructions.
6.
Future Project Plans
6a.
Is this a phased project?
❑ Yes ❑ No
6b.
If yes, explain.
Page 3 of 10
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. 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 for each wetland area impacted.
2a.
Wetland impact
number
Permanent (P) or
Temporary T
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
Choose one
Yes/No
2g. Total Wetland Impacts:
2h. Comments:
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.
Stream 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
Choose one
S2
Choose one
S3
Choose one
S4
Choose one
S5
Choose one
S6
Choose one
3h. Total stream and tributary impacts
3i. Comments:
Page 4 of 10
PCN Form — Version 1.4 January 2009

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then indivi ually 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
Choose one
Choose
02
Choose one
Choose
03
Choose one
Choose
04
Choose one
Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below.
5a.
Pond ID number
5b.
Proposed use or
purpose of pond
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If any impacts require mitigation, then you MUST fill out Section D of this form.
6a. Project is in which protected basin?
❑ Neuse ❑ Tar -Pamlico ❑ Catawba ❑ Randleman ❑ Other:
6b.
Buffer Impact
number —
Permanent (P) or
Temporary T
6c.
Reason for impact
6d.
Stream name
6e.
Buffer
mitigation
required?
6f.
Zone 1
impact
(square
feet)
6g.
Zone 2
impact
(square
feet
B1
Yes/No
B2
Yes/No
B3
Yes/No
B4
Yes/No
B5
Yes/No
B6
Yes/No
6h. Total Buffer Impacts:
6i. Comments:
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.
1 b.
Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
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
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: Choose one
Type: Choose one
Type: Choose one
Quantity:
Quantity:
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:
Choose one
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 1.4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
❑ 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)
Zone 1
3 (2 for Catawba)
Zone 2
1.5
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
1 a.
Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules?
❑ Yes ❑ No
1 b.
If yes, then is a diffuse flow plan included? If no, explain why.
❑ Yes ❑ No
2.
Stormwater Management Plan
2a.
What is the overall percent imperviousness of this project?
2b.
Does this 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:
2e.
Who will be responsible for the review of the Stormwater Management Plan?
3.
Certified Local Government Stormwater Review
3a.
In which localgovernment's jurisdiction is thisproject?
3b.
Which of the following locally -implemented stormwater management programs
apply (check all that apply):
❑ Phase II
❑ NSW
❑ USMP
❑ Water Supply Watershed
❑ Other:
3c.
Has the approved Stormwater Management Plan with proof of approval been
attached?
❑Yes ❑ No
4.
DWQ Stormwater Program Review
4a.
Which of the following state -implemented stormwater management programs apply
(check all that apply):
❑Coastal counties
❑HQW
❑ORW
❑Session Law 2006-246
❑Other:
4b.
Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ 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 8 of 10
PCN Form — Version 1.4 January 2009

F.
Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
1 a.
Does the project involve an expenditure of public (federal/state/local) funds or the
❑ Yes ❑ No
use of public (federal/state) land?
1 b.
If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State
❑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:
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," 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 facility.
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
habitat?
❑ Yes ❑ No
5b.
Have you checked with the USFWS concerning Endangered Species Act
impacts?
❑ Yes ❑ No
5c.
If yes, indicate the USFWS Field Office you have contacted.
-
5d.
What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
6.
Essential 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?
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
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
❑ Yes ❑ No
7b.
What data sources did you use to determine whether your site would impact historic or archeological resources?
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur 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 determination?
Applicant/Agent's Printed Name
Date
Applicant/Agent's Signature
(Agent's signature is valid only if an authorization
letter from the applicant isprovided.)
Page 10 of 10