20150164 Ver 1_401 Application_20150215

ATLANTIC ENVIRONMENTAL CONSULTANTS, LLC
P.O. Box 3266, Kitty Hawk, NC 27949
(252) 261 -7707 fax [phone]
February 4, 2015
Jennifer A. Burdette
NC DWR, 401 Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650
RE: Moseley — Nationwide #18
Hatteras Village, Dare County
Dear Ms. Burdette,
Enclosed is a Preconstruction Notification Form (PCN) for a Nationwide# 18 permit to
develop a lot located at 57121 Kohler Drive in Hatteras Village, Dare County, North
Carolina.
The proposed impact includes wetland fill in Section 404 wetlands to construct a single
family residence. Wetland impacts were limited to a total of 0.10 acre, which is covered
under a USACE Nationwide 18 General Permit.
We request that you initiate the application process and if have questions or need
additional information please contact me at 252- 261 -7707.
Sincerely,
` Doug Dorman
Atlantic Environmental Consultants, LLC
cc: Kyle Barnes, USACOE

Transmittal Letter
February 4, 2015
Atlantic Environmental Consultants, LLC
PO Box 3266
Kitty Hawk, NC 27949
252 - 261 -7707
dougdorman @embargmail.com
To:
NCDWR - Attention: Jennifer A. Burdette
1650 Mail Service Center
Raliegh, NC 2699 -1650 ��� Moseley PCN
Job Number:
- 'Sut�mittad�uantet`y�,
4 VVe,'are's'endi'n9�.You
'
ie(
Attached
❑ Under Separate Cover via:
4
2/4/15
Shop Drawings
❑ Prints
1
Plans
❑ Other:
Ef
Copy of Letter
❑ Change Order
❑
Samples
❑
Total Quantity
❑ Reproducible
❑
Specification
i
- 'Sut�mittad�uantet`y�,
Date��-
DWG #�
_ „ .,a Des'criptiom�
1
4
2/4/15
2015
Site Plan
1
4
2/4/15
i
PCN Application
1
1
2/4/15
$240 Check made out to NCDENR
��Tliese;are� #ransmitted'a"s checked. below:
For Approval ❑ Approved as Submitted ❑
❑ For Your Use ❑ Approved as Noted ❑
• As Requested ❑ Returned for Corrections ❑
Resubmit copies for approval
Submit [ #] copies for distribution
Return [ #] corrected prints
• For Review and Comment ❑ Revise and Resubmit /Work May Not Proceed
❑ FOR BIDS DUE: [Type text here] ❑ PRINTS RETURNED AFTER LOAN
'tornrnents:
-Copy to:
Josh Pelletier, USACOE
i
Si ure

01/30/2015 02:24PM 2529953825 DENNIS CARROLL PAGE 01/02
Charles & Peggy Moseley
407 -C Freemason Street
Oriental, NC 28571
I, authorize Doug Dorman of Atlantic Environmental Consultants, LLC (AEC)
to act on my behalf as my agent in the processing of applications and to
furnish, upon request, supplemental information in support of the permit
application.
' /
AUTHORIZATION '
6A 4, q
ATE

01/30/2015 02:24PM 2529953625 DENNIS CARROLL PAGE 01/02
Charles & Peggy Moseley
407 -C Freemason Street
Oriental, NC 28571
I, authorize Doug Donnas of Atlantic Environmental Consultants, LLC (AEC)
to act on my behalf as my agent in the processing of applications and to
furnish, upon request, supplemental information in support of the permit
application.
.w A ' AUTHORIZATICiN
V1
ATE

01/30/2015 02:24PM 2529953825 DENNIS CARROLL PAGE 01/02
Charles & Peggy Moseley
407 -C Freemason Street
Oriental, NC 28571
I, authorize Doug Dorman of Atlantic Environmental Consultants, LLC (AEC)
to act on my behalf as my agent in the processing of applications and to
furnish, upon request, supplemental information in support of the permit
application. _
F0.3 M11 01 ' / AUTHORIZATICiN
(wm
ATE

01/30/2015 02:24PM 2529953825 DENNIS CARROLL PAGE 01/02
Charles & Peggy Moseley
407 -C Freemason Street
Oriental, NC 28571
1, authorize Doug Dorman of Atlantic Environmental Consultants, LLC (AEC)
to act on my behalf as my agent in the processing of applications and to
furnish, upon request, supplemental information in support of the permit
application. _
IN mu A
75V
EfFff

01/30/2015 02:24PM 2529953825 DENNIS CARROLL PAGE 01/02
Charles & Peggy Moseley
407 -C Freemason Street
Oriental, NC 28571
1, authorize Doug Dorman of Atlantic Environmental Consultants, LLC (AEC)
to act on my behalf as my agent In the processing of applications and to
furnish, upon request, supplemental information in support of the permit
application.
WA
FAR.41,2141
AUTHO-RIZAT16N ,
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ATE

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GENERAL NOTES
1) THIS PLAT IS SUBJECT TO ANY FACTS THAT MAY BE
DISCLOSED BY A FULL AND ACCURATE PRE SEARCH
2) DEED REFERENCE MADE TO
DB - JJ5, PG - 4JJ
DR - 1736, PG - 125
DARE COUNTY REGIS7RY
3) PROPERTY ZONED R2 -AH
4) FIRM ZONE -AE -/90'
SUBJECT TO CHANGE BY F E M A
5) PIN jf 06959517021012
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N/F IDONNIE A WILLIAMS, Jr
SUSAN H. WILLIAMS
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SURVEY INFORMATION PROVIDED BY
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CHARLES & PEGGY MOSELEY
HATTERAS VILLAGE
HATTERAS TOWNSHIP — DARE COUNTY — NORTH CAROLINA
30' 0' 60' 120' 180'
,4TLANT /C ENV11?0N1W-N1T4Z CONMZT,4 NT5 LLC
GRAPHIC SCALE 1 "= 60' P.O. 901r ,3266, K /TTY H,491hf N.C. 27949
(252)291 -7707, e -mail dougdorma17&9e177borgmo17 com
FILE 2015 DATE 2/4/15 REVISED

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GENERAL NOTES
1) THIS PLAT IS SUBJECT TO ANY FACTS THAT MAY BE
DISCLOSED BY A FULL AND ACCURATE T77LE SEARCH
2) DEED REFERENCE MADE TO
DB — 335, PG — 433
DB — 1736, PG — 125
DARE COUNTY REGISTRY
3) PROPERTY ZONED R2 —AH
4) FIRM ZONE -AE -/90'
SUBJECT TO CHANGE BY F E M A
5) PIN j' 06959517021012
N/F
FRANKLIN D BURROUGHS
WINONA P BURROUGHS
EXISTING
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PAMLICO SOUND
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NOT TO SCALE
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I
N/F IDONNIE A WILLIAMS, Jr
SUSAN H. WILLIAMS
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I
I
I
I
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N/F IDONNIE A WILLIAMS, Jr
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SURVEY INFORMATION PROVIDED BY
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1
1
SITE PLAN
CHARLES & PEGGY MOSELEY
HATTERAS VILLAGE
HATTERAS TOWNSHIP — DARE COUNTY — NORTH CAROLINA
30' o' so'
120' 180'
ATL,017C ENtV /I?ONMENTAL
CON5LTAN75, LLC
GRAPHIC SCALE
1 "= 60'
P.O, 90X . 266, K /TTY H,4{W, N.C. 27949
(252)261 -7707, e -ma// 1ougdo,-ma17@embargmc17 com
FILE 2015 DATE 2/4/15
REVISED

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GENERAL NOTES
1) THIS PLAT IS SUBJECT TO ANY FACTS THAT MAY BE
DISCLOSED BY A FULL AND ACCURATE T77LE SEARCH
2) DEED REFERENCE MADE TO
DS - 335, PG - 433
DB - 1736, PG - 125
DARE COUNTY REGISTRY
3) PROPERTY ZONED R2 -AH
4) FIRM ZONE -AE -/90'
SUBJECT TO CHANGE BY F E M A
5) PIN ,¢' 06959517021012
N/F
FRANKLIN D BURROUGHS
WINONA P BURROUGHS
\\ \Y RPµ, l
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SITE PLAN
CHARLES & PEGGY MOSELEY
HATTERAS VILLAGE
HATTERAS TOWNSHIP - DARE COUNTY - NORTH CAROLINA
so' o' 60'
120' 180'
ATLANT /C ENV /RON#Ll-NTAL
CONSULTANTS, LLC
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P.O. 901r ,3266, K /TTY 114WK, N.C. 27949
(252)261 -7707, e -moi/ dougdonmon®embargmai/.com
FILE 2015 DATE 2/4/15
REVISED

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2) DEED REFERENCE MADE TO
DB — 335, PG — 433
DB — 1736, PG — 125
DARE COUNTY REGISTRY
3) PROPERTY ZONED R2 —AH
4) FIR M ZONE " AE " / 9 0'
SUBJECT TO CHANGE BY F E M A
5) PIN j' 06959517021012
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LOCATION MAP
NOT TO SCALE
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SUSAN H WILLIAMS
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NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory Ecosystem Enhancement Program Donald R van der Vaart
Governor Secretary
February 4, 2015
Charles and Peggy Moseley
407 -C Freemason St
Oriental, NC 28571 Expiration of Acceptance: August 4, 2015
Project: Moseley Residence County: Dare
The purpose of this letter is to notify you that the North Carolina Ecosystem Enhancement Program (NCEEP) is willing to accept
payment for compensatory mitigation for impacts associated with the above referenced project as indicated in the table below Please
note that this decision does not assure that participation in the NCEEP will be approved by the permit issuing agencies as mitigation
for project impacts It is the responsibility of the applicant to contact these agencies to determine if payment to the NCEEP will be
approved You must also comply with all other state, federal or local government permits, regulations or authorizations associated
with the proposed activity including SL 2009 -337 An Act to Promote the Use of Compensatory Mitigation Banks as amended by
S.L 2011 -343.
This acceptance is valid for six months from the date of this letter and is not transferable If we have not received a copy of the
issued 404 Permit/401 Certification /CAMA permit within this time frame, this acceptance will expire. It is the applicant's
responsibility to send copies of the permits to NCEEP Once NCEEP receives a copy of the permit(s) an invoice will be issued based
on the required mitigation in that permit and payment must be made prior to conducting the authorized work The amount of the ln-
Lieu Fee to be paid to NCEEP by an applicant is calculated based upon the Fee Schedule and policies listed at www nceep net.
Based on the information supplied by you in your request to use the NCEEP, the impacts that may require compensatory mitigation
are summarized in the following table The amount of mitigation required and assigned to NCEEP for this impact is determined by
permitting agencies and may exceed the impact amounts shown below
Im act
River
Basin
CU
Location
Stream (feet)
Wetlands (acres)
Buffer I
(Sq Ft)
Buffer Ii
(Sq Ft )
Cold
Cool
Warn
Riparian
Non- Riparian
Coastal Marsh
Tar - Pamlico
03020105
0
0
0
0
020
0
0
0
Upon receipt of payment, EEP will take responsibility for providing the compensatory mitigation The mitigation will be performed
in accordance with the N.0 Department of Environment and Natural Resources' Ecosystem Enhancement Program In -Lieu Fee
Instrument dated July 28, 2010
Thank you for your interest in the NCEEP If you have any questions or need additional information, please contact Kelly Williams at
(919) 707 -8915
Sincerely,
Jame Stanfill
Asset Management Supervisor
cc Kyle Barnes, USACE- Washmgton
Doug Dorman, agent
1652 IUa l Service Center, Raleigh North Carolina 27699 -1652
Phone [phone] k Internet www nceep net
An Eq -ia; pportdn;:y +Affirmative jcuon Employer— Made in part `•om recycled paper

NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Charles and Peggy Moseley
407 -C Freemason St
Oriental, NC 28571
Project: Moseley Residence
Ecosystem Enhancement Program Donald R van der Vaart
Secretary
February 4, 2015
Expiration of Acceptance: August 4, 2015
County: Dare
The purpose of this letter is to notify you that the North Carolina Ecosystem Enhancement Program (NCEEP) is willing to accept
payment for compensatory mitigation for impacts associated with the above referenced project as indicated in the table below Please
note that this decision does not assure that participation in the NCEEP will be approved by the permit issuing agencies as mitigation
for project impacts It is the responsibility of the applicant to contact these agencies to determine if payment to the NCEEP will be
approved You must also comply with all other state, federal or local government permits, regulations or authorizations associated
with the proposed activity including SL 2009 -337 An Act to Promote the Use of Compensatory Mitigation Banks as amended by
S L 2011 -343
This acceptance is valid for six months from the date of this letter and is not transferable If we have not received a copy of the
issued 404 Permit/401 Certification /CAMA permit within this time frame, this acceptance will expire. It is the applicant's
responsibility to send copies of the permits to NCEEP Once NCEEP receives a copy of the permit(s) an invoice will be issued based
on the required mitigation in that permit and payment must be made prior to conducting the authorized work The amount of the In-
Lieu Fee to be paid to NCEEP by an applicant is calculated based upon the Fee Schedule and policies listed at www.nceep net
Based on the information supplied by you in your request to use the NCEEP, the impacts that may require compensatory mitigation
are summarized in the following table The amount of mitigation required and assigned to NCEEP for this impact is determined by
pe itting agencies and may exceed the impact amounts shown below
1m act
River
Basin
CU
Location
Stream (feet)
Wetlands (acres)
Buffer I
(Sq Ft)
Buffer ii
(Sq Ft )
Cold
Cool
Warm
Riparian
Non- Riparian
Coastal Marsh
Tar- Pamlico
03020105
0
0
0
0
1 020
0
0
0
Upon receipt of payment, EEP will take responsibility for providing the compensatory mitigation The mitigation will be performed
in accordance with the N C Department of Environment and Natural Resources' Ecosystem Enhancement Program In -Lieu Fee
Instrument dated July 28, 2010
Thank you for your interest in the NCEEP If you have any questions or need additional information, please contact Kelly Williams at
(919) 707 -8915
Sincerely,
Jame Stanfill
Asset Management Supervisor
cc. Kyle Barnes, USACE- Washington
Doug Dorman, agent
1652 Mad Service Center, Ra,eigh North Carolina 27699 -1652
Phone [phone] Internet www,nceep net
An Equal Opport,mt,y +Affirmative At Employer — Made in part �om ecycled paper

#VAs
NR
North Carolina Department of Environment and Natural Resources
Pat McCrory Ecosystem Enhancement Program Donald R van der Vaart
Governor Secretary
February 4, 2015
Charles and Peggy Moseley
407 -C Freemason St.
Oriental, NC 28571 Expiration of Acceptance: August 4, 2015
Project: Moseley Residence County: Dare
The purpose of this letter is to notify you that the North Carolina Ecosystem Enhancement Program (NCEEP) is willing to accept
payment for compensatory mitigation for impacts associated with the above referenced project as indicated in the table below Please
note that this decision does not assure that panccipation in the NCEEP will be approved by the permit issuing agencies as mitigation
for project impacts It is the responsibility of the applicant to contact these agencies to determine if payment to the NCEEP will be
approved You must also comply with all other state, federal or local goveinmentpermits regulations or authorizations associated
with the proposed activity including SL 2009 -337 An Act to Promote the Use of Compensatory Mitigation Banks as amended by
S.L 2011 -343
This acceptance is valid for six months from the date of this letter and is not transferable If we have not received a copy of the
issued 404 Permit/401 Certification /CAMA permit within this time frame, this acceptance will expire. It is the applicant's
responsibility to send copies of the permits to NCEEP Once NCEEP receives a copy of the permit(s) an invoice will be issued based
on the required mitigation in that permit and payment must be made prior to conducting the authorized work The amount of the ln-
Lieu Fee to be paid to NCEEP by an applicant is calculated based upon the Fee Schedule and policies listed at www.nceep.net.
Based on the information supplied by you in your request to use the NCEEP, the impacts that may require compensatory mitigation
are summarized in the following table. The amount of mitigation reqwred and assigned to NCEEP for this impact is determined by
permitting agencies and may exceed the impact amounts shown below
Im act
River
Basin
CU
Location
Stream (feet)
Wetlands (acres)
Buffer I
(Sq Ft)
Buffer II
{Sq Ft )
Cold
Cool
I Warm
Riparian
Non - Riparian
Coastal Marsh
Tar - Pamlico
03020105
0
0
0
0
020
0
0
0
Upon receipt of payment, EEP will take responsibility for providing the compensatory mitigation The mitigation will be performed
in accordance with the N.0 Department of Environment and Natural Resources' Ecosystem Enhancement Program In -Lieu Fee
Instrument dated July 28, 2010
Thank you for your interest in the NCEEP If you have any questions or need additional information, please contact Kelly Williams at
(919) 707 -8915
Sincerely,
Jame Stanfill
Asset Management Supervisor
cc Kyle Barnes, USACE- Washington
Doug Dorman, agent
1652 Mal Service Center, Ra eigh North Carolina 27699 -1652
Phone [phone] Internet www nceep net
An Equai Opportdmty t Affirmative Act on Employer — Made it part `,om ecycled paper

#.7A
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory Ecosystem Enhancement Program Donald R van der Vaart
Governor Secretary
February 4, 2015
Charles and Peggy Moseley
407 -C Freemason St
Oriental, NC 28571 Expiration of Acceptance: August 4, 2015
Project: Moseley Residence County: Dare
The purpose of this letter is to notify you that the North Carolina Ecosystem Enhancement Program (NCEEP) is willing to accept
payment for compensatory mitigation for impacts associated with the above referenced project as indicated in the table below Please
note that this decision does not assure that participation in the NCEEP will be approved by the permit issuing agencies as mitigation
for project impacts It is the responsibility of the applicant to contact these agencies to determine if payment to the NCEEP will be
approved You must also comply with all other state, federal or local government permits regulations or authorizations associated
with the proposed activity including SL 2009 -337. An Act to Promote the Use of Compensatory Mitigation Banks as amended by
S L 2011 -343.
This acceptance is valid for six months from the date of this letter and is not transferable If we have not received a copy of the
issued 404 Permit/401 Certification /CAMA permit within this time frame, this acceptance will expire. It is the applicant's
responsibility to send copies of the permits to NCEEP, Once NCEEP receives a copy of the permit(s) an invoice will be issued based
on the required mitigation in that permit and payment must be made prior to conducting the authorized work The amount of the In-
Lieu Fee to be paid to NCEEP by an applicant is calculated based upon the Fee Schedule and policies listed at www.nceep net
Based on the information supplied by you in your request to use the NCEEP, the impacts that may require compensatory mitigation
are summarized in the following table The amount of mitigation required and assigned to NCEEP for this impact is determined by
pe itting agencies and may exceed the impact amounts shown below.
Impact
River
Basin
CU
Location
Stream (feet)
Wetlands (acres)
Buffer I
(Sq Ft)
Buffer i i
(Sq Ft )
Cold
Cool
Warm
Riparian
Non - Riparian
Coastal Marsh
Tar - Pamlico
03020105
0
0
0
0
020
0
0
0
Upon receipt of payment, EEP will take responsibility for providing the compensatory mitigation The mitigation will be performed
in accordance with the N C Department of Environment and Natural Resources' Ecosystem Enhancement Program In -Lieu Fee
Instrument dated July 28, 2010
Thank you for your interest in the NCEEP If you have any questions or need additional information, please contact Kelly Williams at
(919) 707 -8915
Sincerely,
Jame Stanfill
Asset Management Supervisor
cc Kyle Barnes, USACE - Washington
Doug Dorman, agent
1652 Mail Service Center, Raleigh North Carolina 27699 -1652
Phone 919 - 707 -89761 Internet www nceep net
An Equal vpport,inity %Affirmative Action Employer — Made in part f om,ecycled paper

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2 0 1 5 0 1 6 4
Office Use Only
Corps �Qtaon n _
DWQ p,8Ject no
Form Vernon 1 ec 10 2008
Page 1 of 11
PCN Form — Version 1 3 December 10, 2008 Version
Pre - Construction Notification PC Form
A. Applicant Information
1.
Processing
la
Type(s) of approval sought from the
Corps
®Section 404 Permit El Section 10 Permit
1 b Specify Nationwide Permit (NWP) number 18 or General Permit (GP) number
1 c
Has the NWP or GP number been verified by the Corpse ❑ 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
1g
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
Moseley Property
2b
County
Dare
2c
Nearest municipality / town
Hatteras
2d
Subdivision name
None
2e
NCDOT only, T I P or state
project no
N/A
3.
Owner Information
3a
Name(s) on Recorded Deed
Charles & Peggy Moseley
3b
Deed Book and Page No
1736/0125
3c
Responsible Party (for LLC if
applicable)
none FEB 0 9
3d
Street address
_201S
407 -C Freemason Street
3e
City, state, zip
Oriental, NC 28571 401 & B1 FER RESOURCES
3f
Telephone no
3g
Fax no
N/A
3h
Email address
Peggydmoseley @yahoo com
Page 1 of 11
PCN Form — Version 1 3 December 10, 2008 Version

4.
Applicant Information (if different from owner)
4a
Applicant is
® Agent ❑ Other, specify
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
Doug Dorman
5b
Business name
(if applicable)
Atlantic Environmental Consultants, LLC
5c
Street address
PO Box 3266
5d
City, state, zip
Kitty Hawk, NC 27949
5e
Telephone no
252 - 261 -7707
5f
Fax no
252- 261 -7707
5g
Email address
dougdorman @embargmail com
Page 2 of 11
PCN Form — Version 1 3 December 10, 2008 Version

B. Project Information and Prior Project History
1. Property Identification
1a Property identification no (tax PIN or parcel ID)
959517021012
lb Site coordinates (in decimal degrees).
Latitude 35 221830 Longitude - 75 68451
(DD DDDDDD) ( -DD DDDDDD)
1c Property size
1 046 acres
2. Surface Waters
2a Name of nearest body of water (stream, river, etc ) to
Pamlico Sound
proposed project
2b Water Quality Classification of nearest receiving water
SA
2c River basin
Pamlico Sound
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
Undeveloped single family lot Property located in developed residential area of Hatteras Village
3b List the total estimated acreage of all existing wetlands on the property
0 86 acres
3c List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
None
3d Explain the purpose of the proposed project
A home is to be constructed on the vacant lot and some wetlands need to provide setbacks to septic system
3e Describe the overall project in detail, including the type of equipment to be used
Project includes Fill in one (1) area of Section 404 wetlands (0 10 ac) Equipment utilized for this project to include an
excavator or backhoe, a dump truck will bring in fill material During construction silt fence will be placed at the wetland
interface to prevent intrusion of fill material into wetlands not permitted for fill
4. Jurisdictional Determinations
4a Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
® Yes ❑ No ❑ Unknown
project (including all prior phases) in the past?
Comments Meeting with Corp 2/18/15
4b If the Corps made the jurisdictional determination, what type
❑ preliminary ❑ Final
of determination was made?
4c If yes, who delineated the jurisdictional areas?
Agency /Consultant Company Atlantic Environmental
Consultants, LLC
Name (if known) Doug Dorman
Other
4d If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
Kyle Barnes - Metttng set to confirm on 2/18/15
5. Project History
5a Have permits or certifications been requested or obtained for
❑ Yes ® No ❑ Unknown
this project (including all prior phases) in the past?
5b If yes, explain in detail according to "help file" instructions
Page 3 of 11
PCN Form — Version 1 3 December 10, 2008 Version

6. Future Project Plans
6a Is this a phased project? ❑ Yes ® No
6b If yes, explain
Page 4 of 11
PCN Form — Version 1 3 December 10, 2008 Version

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
2b
2c
2d
2e
2f
Wetland impact
Type of Jurisdiction
number —
Type of impact
Type of wetland
Forested
(Corps - 404, 10
Area of impact
Permanent (P) or
(if known)
DWQ — non -404, other)
(acres)
Temporary T
W1 ®P ❑ T
404 wetland fill
Scrub shrub
Yes
® No
® Corps
® DWQ
010
W2 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W3 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W4 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W5 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W6 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
2g. Total wetland impacts
0 035
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
3b
3c
3d
3e
3f
3g
Stream impact
Type of impact
Stream name
Perennial
Type of Jurisdiction
Average
Impact
number -
(PER) or
(Corps - 404, 10
stream
length
Permanent (P) or
intermittent
DWQ — non -404,
width
(linear
Temporary (T)
(INT)?
other)
(feet)
feet)
S1 ❑ P ❑ T
❑ PER
❑ Corps
❑ 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
31 Comments
Page 5 of 11
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
4a
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
4f. Total open water impacts
4g Comments
S. 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
511 Total
5g Comments
5h Is a dam high hazard permit required
❑ Yes ❑ No If yes, permit ID no
51 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.
❑ Neuse ❑Tar- Pamlico F] 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 T
impact
required?
❑Yes
B1 ❑P ❑T
❑ No
B2 ❑P ❑T
❑Yes
❑ No
B3 ❑P ❑T
El Yes
❑ No
6h Total buffer impacts
61 Comments
Page 6 of 11
PCN Form —Version 1 3 December 10, 2008 Version

D. Impact Justification and Mitigation
1. Avoidance and Minimization
la Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
Due to the limited area of uplands on the lot it is difficult to avoid any impacts to the wetlands. The septic system has been
placed as far away from the wetlands as possible and a bed septic system will be used which reduce the size of the drainfield
by 50%
1 b Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
The adjacant property owners are allowing the Moseley's to use there existing driveway and construct a driveway extension
through there property to further avoid additional impacts to the wetlands Constructing a bed septic system will reduce the
size of the dramfield by 50%
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
®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
0 20 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 7 of 11
PCN Form — Version 1 3 December 10, 2008 Version

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a Will the project result in an impact within a protected riparian buffer that requires
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
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 8 of 11
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 riparian 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 why
❑ Yes ❑ No
Comments
2.
Stormwater Management Plan
2a
What is the overall percent imperviousness of this project?
5%
2b
Does this project require a Stormwater Management Plan?
❑ Yes ® No
2c
If this project DOES NOT require a Stormwater Management Plan, explain why Exisitng residential lot Stormwater rules
do not apply
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?
Dare County
❑ Phase II
❑ NSW
3b
Which of the following locally - implemented stormwater management programs
❑ USMP
apply (check all that apply)
❑ Water Supply Watershed
® Other County Standards
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?
5.
DWQ 401 Unit Stormwater Review
5a
Does the Stormwater Management Plan meet the appropriate requirements?
® Yes ❑ No
5b
Have all of the 401 Unit submittal requirements been met?
® Yes ❑ No
Page 9 of 11
PCN Form — Version 1 3 December 10, 2008 Version

F. Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
la
Does the project involve an expenditure of public (federal /state /local) funds or the
El 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 Ripanan Buffer Rules (15A NCAC 2B 0200)?
2b
Is this an after - the -fact permit application?
❑ Yes
® No
2c
If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s)
3.
Cumulative Impacts (DWQ Requirement)
3a
Will this project (based on past and reasonably anticipated future impacts) result in
❑ Yes
® No
additional development, which could impact nearby downstream water quality?
3b
If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy If you answered "no," provide a short narrative description
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
Bed wastewater system
Page 10 of 11
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 concerning Endangered Species Act
® Yes ❑ No
impacts?
® Raleigh
5c If yes, indicate the USFWS Field Office you have contacted
❑ Asheville
5d What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
Contacted a Biologist with the USFWS Field office
6. Essential Fish Habitat (Corps Requirement)
6a Will this project occur in or near an area designated as essential fish habitat?
❑ Yes ® No
6b What data sources did you use to determine whether your site would impact Essential Fish Habitat?
The wetland area would not support 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
❑ 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?
Contacted Lee Abbott, Assistant State Archeologist for a determation
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 Construction be elevated above designated flood plain
requirements for this location and approved by local municapalities prior to construction
8c What source(s) did you use to make the floodplain determination? Dare County flooplain maps
Doug Dorman
2/4/15
Applicant/Agent's Printed Name
Date
icant/Acient's Signature
(Agent's signature is valid only if an authorization letter from the applicant
is provided }
Page 11 of 11
PCN Form — Version 1 3 December 10, 2008 Version