20230118 Ver 1_401 Application_20230119

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# *
20230118
Version* 1
Is this project a public transportation project?*
Reviewer List:*
Select Reviewing Office: *
Submittal Type:*
Yes
• No
Andrew Moore:eads\awmoore3
Asheville Regional Office - [phone]
401 Application
Does this project require a request for payment to be sent?*
Yes
No

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:
11/4/2022
Project Contact Information
Name:
Marty Kocot
Who is submitting the information?
Email Address: [e-mail]
Project Information
Project Name: 3122 Hendersonville Road, Fletcher, NC
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)
Henderson
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
10-26-22C3-G RAD I N G. pdf
Site Map.pdf
Site Sketch and V-map.pdf
PCN DWR 11-07-22.pdf
Permission Executed.pdf
Only pdf or kmz files are accepted.
Describe the attachments or
comments:
Full Site Grading Plans.
Site Sketch & Vicinity Map
Authorization from Owner to submit application
Pre -Construction Notification
985.17KB
247.11KB
1.36MB
467.54KB
110.22KB

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:
Submittal Date: 1/19/2023
Is filled in automatically.

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NORTH CAROLINA
Environmental Quality
Water Resources
Office Use Only
Corps Action I D no. [Click to enter.] Date received: [Click to enter.]
DWR project no. Click enter.] Date received: [Click to enter.]
Site Coordinates:
Latitude (DD.DDDDDD): 35.4405
Longitude (DD.DDDDDD):-82.5041
Form Version 4.3, April 20, 2022
Pre -Construction Notification (PCN) Form
(Ver. 4.2, January 31, 2022))
For Nationwide Permits and Regional General Permits and corresponding Water Quality Certifications
Please note: fields marked with a red asterisk are required. The form is not considered complete until all
mandatory questions are answered.
The PCN help document may be found at this link:
https://edocs.deg.nc.gov/WaterResources/DocView.aspx?dbid=0&id=2196924&cr=1
Please ensure you have submitted a pre -filing meeting request at least 30 days prior to submitting this
form, as DWR will not be able to accept your application without documentation of this important first step.
The Division has developed a Pre -filing Meeting Request email address 401 PreFile(a)-ncdenr.gov to accept
the federally required pre -filing meeting request and provide confirmation receipt of submittal . This receipt
or similar documentation will satisfy 40 C.F.R. Section 121.4(a) which states "At least 30 days prior to
submitting a certification request, the project proponent shall request a pre -filing meeting with the certifying
agency." In accordance with 40 C.F.R. Section 121.5(b)(7), and (c)(5), all certification requests must
include documentation that a pre -filing meeting request was submitted to the certifying authority at least 30
days prior to submitting the certification request.
Attach documentation of Pre -Filing Meeting Request to this Application.
Date of Pre -filing Meeting Request (MM/DD/YYYY) : 11/7/2022
Page 1 of 20 PCN Form Version 4.3- April 20, 2022

A. Processing Information
County (counties) where project is located:
Henderson Additional (if needed).
Is this a NCDMS project?
(Click yes only if NCDMS is the applicant or co-
❑ Yes ❑x No
applicant)
Is this a public transportation project?
(Publicly funded municipal, state, or federal road, rail,
❑ Yes ❑x No
or airport project)
Is this a NCDOT project?
❑ Yes ❑x No
If yes, NCDOT TIP or state project number:
Click to enter.
If yes, NCDOT WBS number:
Click to ente
❑x Section 404 Permit (wetlands, streams, waters,
Clean Water Act)
la. Type(s) of approval sought from the Corps:
❑ Section 10 Permit (navigable waters, tidal
waters, Rivers and Harbors Act)
Has this PCN previously been submitted?
❑ Yes ❑x No
Please provide the date of the previous submission.
Click to enter a date.
❑x Nationwide Permit (NWP)
1 b. What type(s) of permit(s) do you wish to seek
❑ Regional General Permit (RGP)
authorization?
❑ Standard (IP)
This form may be used to initiate the standard/ individual permit
process with the USACE. Please contact your Corps
representative concerning submittals for standard permits. All required items can be included as attachments and
submitted with this form.
1 c. Has the NWP or GP number been verified by the Corps?
❑ Yes ❑x No
NWP number(s) (list all numbers ):
Click to enter.
RGP number(s) (list all numbers ):
Click to enter.
Are you a federal applicant?
❑ Yes ❑x No
If yes, please provide a statement concerning compliance with the Coastal Zone Management Act
Click to enter text.
1d. Type(s) of approval sought from DWR (check all that apply):
❑x 401 Water Quality Certification — Regular
❑ 401 Water Quality Certification— Express
❑ Non-404 Jurisdictional General Permit
❑ Riparian Buffer Authorization
❑ Individual 401 Water Quality Certification
Is this a courtesy copy notification
❑ Yes ❑x No
1e. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification:
® Yes ❑ No
For the record only for Corps Permit:
❑ Yes ❑x No
1f. Is this an after -the -fact permit/certification application?
❑ Yes ❑x No
Page 2 of 20 PCN Form Version 4.3- April 20, 2022

1g.
Is payment into a mitigation bank or in -lieu fee program proposed for
❑ Yes
❑x No
mitigation of impacts?
If yes, attach the acceptance letter from mitigation bank or in -lieu fee program.
1 h.
Is the project located in any of NC's twenty coastal counties? *
❑ Yes
❑x No
1 i.
Is the project located within an NC DCM Area of Environmental
❑ Yes
❑x No ❑ Unknown
Concern (AEC)? *
1j.
Is the project located in a designated trout watershed? *
❑ Yes
❑x No
If yes, you must attach a copy of the approval letter from the appropriate Wildlife Resource Commission Office.
Trout information may be found at this link: http://www.saw.usace.army.miI/Missions/Regulatory-Permit-
Program/Agency-Coordination/Trout.aspx
Page 3 of 20 PCN Form Version 4.3- April 20, 2022

B. Applicant Information
1a.
Who is the primary contact?
Marty Kocot PE Landworks Engineering
1 b.
Primary Contact Email:
[e-mail]
1 c.
Primary Contact Phone: (###)###-####
828.230.7958
1 d.
Who is applying for the permit/certification? (check
all that apply)
® Owner ❑ Applicant (other than owner)
1 e.
Is there an agent/consultant for this project?
® Yes ❑ No
2.
Landowner Information
2a.
Name(s) on Recorded Deed:
Kompo Family Company, LLC
2b.
Deed Book and Page No.:
3945/618
2c.
Contact Person (for corporations):
Carr Swicegood
2d.
Address
Street Address:
418 McDowell Street
Address line 2:
Click to enter.
City:
Asheville
State/ Province/ Region:
NC
Postal/ Zip Code:
28803
Country:
Click to enter.
2e.
Telephone Number: (###)###-####
828-779-9020
2f.
Fax Number: (###)###-####
Click to enter
2g.
Email Address:
[e-mail]
3.
Applicant Information (if different from owner)
3a.
Name:
Click to enter.
3b.
Business Name (if applicable):
Click to enter.
3c.
Address:
Street Address:
Click to enter.
Address line 2:
Click to enter.
City:
Click to enter.
State/ Province/ Region:
Click to enter.
Postal/ Zip Code:
Click to enter.
Country
Click to enter.
3d.
Telephone Number: (###)###-####
Click to enter.
3e
Fax Number: (###)###-####
Click to enter.
3f.
Email Address:
Click to enter.
Page 4 of 20 PCN Form Version 4.3- April 20, 2022

4.
Agent/ Consultant (if applicable)
4a.
Name:
Marty Kocot, PE
4b.
Business Name:
Landworks Engineering, PLLC
4c.
Address:
Street Address:
PO NBox 1922
Address line 2:
Click to enter.
City:
Asheville
State/ Province/ Region:
NC
Postal/ Zip Code:
28802
Country:
USA
4d.
Telephone Number: (###)###-####
828-230-7958
4e
Fax Number: (###)###-####
Click to entr
4f.
Email Address:
[e-mail]
Agent Authorization Letter:
Attach a completed/signed agent authorization form or letter. A sample form may be found at this link:
https://www.saw.usace.army. mil/Missions/Reg ulatory-Permit-Program/Permits/2017-Nationwide-Permits/Pre-
construction-Notification/
Page 5 of 20 PCN Form Version 4.3- April 20, 2022

C. Project Information and Prior Project History
1. Project Information
1 a. Name of project: *
3122 Hendersonville Road Commercial Site
1 b. Subdivision name (if appropriate):
Click to enter.
1c. Nearest municipality/town: *
Fletcher
2.
Project Identification
2a.
Property identification number (tax PIN or parcel ID):
9653-63-7344
2b.
Property size (in acres):
4.94
2c.
Project Address:
Street Address:
3122 Hendersonville Road
Address line 2:
Click to enter.
City:
Fletcher
State/ Province/ Region:
NC
Postal/ Zip Code:
28732
Country:
USA
2d.
Site coordinates in decimal degrees (using 4-6 digits
after the decimal point): *
Latitude (DD.DDDDDD): * 35.4405
Longitude (-DD.DDDDDD): *--82.5041
3. Surface Waters
3a. Name of nearest body of water to proposed project: *
Cane Creek
3b. Water Resources Classification of nearest receiving
Class C
water: *
The Surface Water Classification map may be found at this link:
httr)s:Hncdenr.maps.arcqis.com/apes/webappviewer/index.html?id=6el 25ad7628f494694e259c80dd64265
French Broad
3c. In what river basin(s) is your project located? *
Choose additional (if needed)
3d. Please provide the 12-digit HUC in which the project is
06010105
located:
The Find Your HUC map may be found at this link:
https:Hncdenr.maps.arcqis.com/apps/Publiclnformation/index.html?appid=ad3a85aOc6d644aOb97cdO69db238ac3
Page 6 of 20 PCN Form Version 4.3- April 20, 2022

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:
Former commercial site discharge from Baldwin Circle (R-2213) through existing NCDOT 36 inch RCP culvert.
Intermittent flow during storm events.
4b. Have Corps permits or DWR certifications been obtained for this
❑ Yes ❑ No ❑x Unknown
project (including all prior phases) in the past?
If yes, please give the DWR Certification number and/or Corps
[Click to enter.]
Action ID (ex. SAW-0000-00000):
IClick to enter.]
Attach any pertinent project history documentation
4b2. Is any portion of the work already complete?
❑ Yes ❑x No
If yes, describe the completed work.
Click to enter te>
4c. List of other certifications or approvals/denials received from other federal, state or local agencies for work
described in this application not related to the 404 or 401.
('UnL 4n nn+nr 4c
4d. Attach an 8'Y2 x 11" excerpt from the most recent version of the USGS topographic map indicating the location of
the project site.
4e. Attach an 8'Y2 x 11" excerpt from the most recent version of the published County NRCS Soil Survey map
depicting the project site.
4f. List the total estimated acreage of all existing wetlands on the
0 acres
property:
4g. List the total estimated linear feet of all existing streams (intermittent
165 linear feet
and perennial) on the property:
4g1. List the total estimated acreage of all existing open waters on the
0 acres
property:
4h. Explain the purpose of the proposed project:
45 ft. +/- culvert extension to provide site grading and driveway access to Baldwin Circle per NCDOT Driveway
requirements.
4i. Describe the overall project in detail, including the type of equipment to be used:
Install a inlet and extend the culvert approximately 45 feet to the property line utilizing typical construction
equipment such as a trackhoe.
4j. Attach project drawings/site diagrams/depictions of impact areas for the proposed project.
4k. Will this activity involve dredging in wetlands or waters?
® Yes ❑ No
If yes, describe the type of dredging, the composition of the dredged material, and the locations of disposal area.
Just excavation and installation of suitable bedding material for the culvert installation. Excavated material to be
disposed of on site.
Page 7 of 20 PCN Form Version 4.3- April 20, 2022

5.
Jurisdictional Determinations
5a.
Have the wetlands or streams been delineated on
the property or in
❑ Yes ❑x No ❑ Unknown
proposed impact areas?
Comments:
The stream channel is visible observable.
5b.
If the Corps made a jurisdictional determination,
❑ Preliminary ❑ Approved ❑ Emailed concurrence
what type of determination was made?
❑ Not Verified ❑ Unknown ❑ n/a
Corps AID number (ex. SAW-0000-00000):
^lick to nnta-
Name (if known): Click to enter.
5c.
If 5a is yes, who delineated the jurisdictional
Agency/Consultant Company: Click to enter.
areas?
Other: Click to enter.
5d.
List the dates of the Corps jurisdictional determination or State determination if a determination was made by
either agency.
'link to PntPr
5d1.
Attach jurisdictional determinations.
6. Future Project Plans
6a. Is this a phased project?
® Yes ❑ No
6b. If yes, explain.
Mass grading of the site but buildout of individual commercial buildings may be phased.
Are any other NWP(s), regional general permit(s), or individual permit(s) used, or intended to be used, to
authorize any part of the proposed project or related activity? This includes other separate and distant crossings
for linear projects that require Department of the Army authorization but don't require pre -construction
notification.
Potential MSD Sewer extensions to serve the site.
7. Addresses of adjoining property owners, lessees, etc. whose property adjoins the waterbody (if more than can be
entered here, please attach a supplemental list)
Ruby F. Hendrick, 65 Baldwin Circle, Fletcher, NC 28732 PIN 9653-63-7600
8. Scheduling of activity:
December 2022
Page 8 of 20 PCN Form Version 4.3- April 20, 2022

D. Proposed Impacts Inventory
Impacts Summary
❑ Wetlands ❑x Streams - tributaries
1 a. Where are the impacts associated with your project ❑x Buffers ❑ Open Waters
(check all that apply):
❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, complete this table for each wetland area impacted.
2a.
Site #
2a1.
Impact
Reason/Type
2b.
Impact
Duration
2c.
Wetland Type
2d.
Wetland Name
2e.
Forested
?
2f.
Jurisdiction
Type
2g.
Impact Area
(ac)
W1
Choose one
emp/ Perm
Choose onE
,lick to enter
Y/I\
;hoose one
Click to enter
W2
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
W3
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
W4
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
W5
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
W6
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
W7
Choose one
-emp/ Perm
Choose onE
Click to enter
Y/N
choose one
Click to enter
W8
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
W9
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
W10
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
W11
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
W12
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
W13
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
W14
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
W15
Choose one
Temp/ Perm
Choose one
Click to enter
Y/N
Choose one
Click to enter
2g1. Total temporary wetland impacts
Click to enter. ac
2g2. Total permanent wetland impacts
Click to enter. ac
2g3. Total wetland impacts
Click to enter. ac
2h. Type(s) of material being discharged and the amount of each type in cubic yards:
Click to enter text.
2i. Comments:
Click to enter text.
Page 9 of 20 PCN Form Version 4.3- April 20, 2022

3. Stream Impacts
If there are perennial or intermittent stream/ tributary impacts (including temporary impacts) proposed on the site,
complete this table for all stream/ tributary sites impacted.
** All Perennial or Intermittent streams must be verified by DWR or delegated local government
Site #
3a
Impact
Reason
3b.
Impact
Duration
3c.
Impact Type
3d.
Stream Name
3e.
Stream
Type
3f.
Jurisdiction
Type
3g.
Stream Width
(avg ft)
3h.
Impact length
(linear ft)
S1
Culvert Ext.
Permanent
Excavation
Un-named Trib
to Cane Creek
Intermittent
Both
3
45
S2
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S3
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S4
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S5
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S6
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S7
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S8
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S9
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S10
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S11
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S12
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S13
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S14
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S15
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S16
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S17
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S18
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S19
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S20
Click to enter
Temp/ Perm
Choose one
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
3i1. Total jurisdictional ditch
impact:
Click to enter. linear ft
3i2. Total permanent stream
impacts:
Click to enter. linear ft
M. Total temporary stream
impacts:
Click to enter. linear ft
34. Total stream and ditch
impacts:
45 linear ft
3j. Comments:
lick to enter.
Page 10 of 20 PCN Form Version 4.3- April 20, 2022

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., individually list all open water impacts in the table below.
4a.
Site #*
4a1.
Impact Reason
4b.
Impact
Duration*
4c.
Waterbody Name*
4d.
Activity Type*
4e.
Waterbody
Type*
4f.
Impact area
(ac)*
01
Click to enter.
Temp/ Perm
Click to enter.
Choose one
:hoose one
Click to enter.
02
Click to enter.
Temp/ Perm
Click to enter
Choose one
-hoose one
Click to enter.
03
Click to enter.
Temp/ Perm
Click to enter.
Choose one
Choose one
Click to enter.
04
Click to enter.
Temp/ Perm
Click to enter.
Choose one
Choose one
Click to enter.
05
Click to enter.
Temp/ Perm
Click to enter.
Choose one
Choose one
Click to enter.
4g.
Total temporary open water impacts
Click to enter. ac
4g.
Total permanent open water impacts
Click to enter. ac
4g.
Total open water impacts
Click to enter. ac
4h.
Comments:
Click to enter.
5.
Pond or Lake Construction
If pond or lake construction is proposed, complete the table
below. (*This
does NOT include offline stormwater
management ponds.)
5a.
5b.
5c.
5d.
5e.
Pond ID
Proposed use or
Wetland Impacts (ac)
Stream
Impacts (ft)
Upland
#
purpose of pond
Impacts (ac)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
Click to
Click to
Click to
Click to
Click tc
Click to
Click to
enter.
enter.
enter.
enter.
enter.
enter.
entF
P2
Choose one
Click to
Click to
Click to
Click to
Click to
Click to
Click to
enter.
enter.
enter.
enter.
enter.
enter.
entF
P3
Choose one
Click to
Click to
Click to
Click to
Click to
Click to
Click to
enter.
enter.
enter.
enter.
enter.
enter.
enter.
5f.
Total
Click to
Click to
Click to
Click to
Click to
Click to
Click
enter.
enter.
enter.
enter.
enter.
enter.
ente
5g.
Comments:
Click to enter.
5h.
Is a dam high hazard permit required?
❑ Yes ❑ No
If yes, permit ID no.:
Click to enter.
5i.
Expected pond surface area (acres):
Click to enter.
5j.
Size of pond watershed (acres):
Click to enter.
5k.
Method of construction:
Click to enter.
Page 11 of 20 PCN Form Version 4.3- April 20, 2022

6. Buffer Impacts (DWR requirement)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts.
6a. Project is in which protected basin(s)?
(Check all that apply.)
❑ Neuse ❑ Tar -Pamlico ❑ Catawba
❑ Jordan ❑ Goose Creek ❑ Randleman
❑ Other: Click to ente
Site #*
6b.
Impact Type*
6c.
Impact Duration*
6d.
Stream Name*
6e.
Buffer
Mitigation
Required?*
6f.
Zone 1 Impact*
(sq ft)
6g.
Zone 2 Impact*
(sq ft)
131
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter
B2
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter
B3
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter
B4
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter
B5
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B6
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B7
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B8
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B9
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B10
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
1311
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B12
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B13
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B14
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B15
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B16
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B17
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B18
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B19
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter
Click to enter.
B20
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
6h. Total temporary impacts:
Zone 1: Click to enter. sq ft
Zone 2: Click to enter. sq ft
6h. Total permanent impacts:
Zone 1: Click to enter sq ft
Zone 2: Click to enter. sq ft
6h. Total combined buffer impacts:
Zone 1: Click to enter. sq ft
Zone 2: Click to enter. sq ft
6i. Comments:
UICK to enter.
Please attach supporting documentation (impact maps, plan sheets, etc.) for the proposed project.
Page 12 of 20 PCN Form Version 4.3- April 20, 2022

E. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts through project design:
Collect and treat the runoff from the first inch of rainfall per Henderson County.
1 b. Specifically describe measures taken to avoid or minimize proposed impacts through construction techniques:
Stormwater Quality and Stormwater Quantity Post Development Treatment Required
2. Compensatory Mitigation for Impacts to Waters of the U.S., Waters of the State, or Riparian Buffers
2a. If compensatory mitigation is required, by whom is it required? ❑ DWR ❑ Corps
(check all that apply)
2b. If yes, which mitigation option(s) will be used for this ❑ Mitigation Bank
project? (check all that apply) ❑ In Lieu Fee Program
❑ Permittee Responsible Mitigation
3. Complete if using a Mitigation Bank
(Must satisfy NC General Statute143-214.11 (d1).)
3a. Name of mitigation bank:
Click to enter.
3b. Credits purchased/requested:
Type: Choose one
Quantity Click to enter.
Type: Choose one
Quantity Click to enter.
Type: Choose one
Quantity Click to enter.
Attach receipt and/or approval letter.
3c. Comments:
Click to enter.
4.
Complete if Using an In Lieu Fee Program
4a.
Attach approval letter from in lieu fee program.
4b.
Stream mitigation requested:
Click to enter. linear feet
4c.
If using stream mitigation, what is the stream temperature:
Choose one
NC Stream Temperature Classification Maps can be found under the Mitigation Concepts tab on the Wilmington
District's RIBITS website: (Please use the filter and select Wilmington district)
https://ribits.usace.army.miI/ribits apex/f?p=107:27:2734709611497::NO:RP:P27 BUTTON KEY:O
4d.
Buffer mitigation requested (DWR only):
Click to enter. square feet
4e.
Riparian wetland mitigation requested:
Click to enter. acres
4f.
Non -riparian wetland mitigation requested:
Click to enter. acres
4g.
Coastal (tidal) wetland mitigation requested:
Click to enter. acres
4h.
Comments:
lick to enter.
Page 13 of 20 PCN Form Version 4.3- April 20, 2022

5. Complete if Providing a Permittee Responsible Mitigation Plan
5a. If proposing a permittee responsible mitigation plan, provide a description of the proposed mitigation plan,
including mitigation credits generated.
�lirk to nntar
5b. Attach mitigation plan/documentation.
6.
Buffer Mitigation (State Regulated Riparian Buffer Rules) — DWR requirement
6a.
Will the project result in an impact within a protected riparian buffer
❑ Yes ❑ No
that requires buffer mitigation?
If yes, please complete this entire section — please contact DWR for more information.
6b.
If yes, identify the square feet of impact to each zone of the riparian buffer that requires
mitigation. Calculate the
amount of mitigation required in the table below.
6c.
6d.
6e.
Zone
Reason for impact
Total impact
Multiplier
Required mitigation
(square feet)
(square feet)
Zone 1
Click to enter.
Click to enter.
Choose one
Click to enter.
Zone 2
Click to enter.
Click to enter.
Choose one
Click to enter.
6f. Total buffer mitigation required
Click to enter.
6g.
If buffer mitigation is required, is payment to a mitigation bank or
❑ Yes ❑ No
NC Division of Mitigation Services proposed?
6h.
If yes, attach the acceptance letter from the mitigation bank or NC Division of Mitigation Services.
6i.
Comments:
Click to enter.
Page 14 of 20 PCN Form Version 4.3- April 20, 2022

F. Stormwater Management and Diffuse Flow Plan (DWR requirement)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers
❑ Yes ❑x No
identified within one of the NC Riparian Buffer Protection Rules?
1 b. All buffer impacts and high ground impacts require diffuse flow or other form of stormwater treatment. If the
project is subject to a state implemented riparian buffer protection program, include a plan that fully documents
how diffuse/dispersed flow will be maintained.
All Stormwater Control Measures (SCM) must be designed in accordance with the NC Stormwater Design
Manual (https://deg.nc..qov/about/divisions/energv-mineral-land-resources/energv-mineral-land-permit-
guidance/stormwater-bmp-manual).
Associated supplement forms and other documentation must be provided.
❑ Level Spreader
What Type of SCM are you
0 Vegetated Conveyance (lower seasonal high water table- SHWT)
providing?
❑ Wetland Swale (higher SHWT)
(Check all that apply)
❑ Other SCM that removes minimum 30% nitrogen
0 Proposed project will not create concentrated stormwater flow through the
buffer
For a list of options to meet the diffuse flow requirements, click here.
Attach diffuse flow documentation.
2.
Stormwater Management Plan
2a.
Is this an NCDOT project subject to compliance with NCDOT's
Individual NPDES permit NCS000250? *
El Yes El No
2b.
Does this project meet the requirements for low density projects as
defined in 15A NCAC 02H .1003(2)? *
❑ Yes 0 No
To look up low density requirements, click here:
http://reports.oah. state. nc.us/ncac/title%2015a%20-%20environmental%20guality/chapter%2002%20-
%20environmental%20management/subchapter%20h/15a%20ncac%2002h%20.1003.pdf
2c.
Does this project have a stormwater management plan (SMP)
0 Yes ElNo
reviewed and approved under a state stormwater program or state -
approved local government stormwater program? *
❑ n/a — project disturbs < 1 acre
Note: Projects that have vested rights, exemptions, or grandfathering from state or locally implemented
stormwater programs or projects that satisfy state or locally -implemented stormwater programs through use of
community in -lieu programs should answer "no" to this question.
2d.
Which of the following stormwater management program(s) apply?
0 Local Government
(Check all that apply.)*
0 State
If you have local government approval, please include the SMP on their overall impact map.
Local Government Stormwater Programs *
0 Phase II ❑ USMP
❑ NSW ❑ Water Supply
Page 15 of 20 PCN Form Version 4.3- April 20, 2022

Please identify which local government stormwater program you are using.
Henderson County
State Stormwater Programs * 0 Phase II ❑ HQW or ORW
❑ Coastal Counties ❑ Other
Comments:
Click to enter.
Page 16 of 20 PCN Form Version 4.3- April 20, 2022

G. Supplementary Information
1. Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local)
❑ Yes ❑x No
funds or the 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 (North Carolina) Environmental
El Yes El No
Policy Act (NEPA/SEPA)?
1 c. 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
❑ Yes ❑ No
NEPA or SEPA final approval letter.)
Comments:
Click to enter.
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),
Federally Non -Jurisdictional Wetlands /Classified Surface Waters
❑ Yes ❑x No
(15A NCAC 2H. 1400) DWR Surface Water or Wetland Standards or
Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. If you answered "yes" to the above question, provide an explanation of the violation(s):
AICK to enter.
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
❑ Yes ❑x No
downstream water quality?
3b. If you answered "no", provide a short narrative description:
45 ft. Culvert extension to the Property line
3c. If yes, provide a qualitative or quantitative cumulative impact analysis in accordance with the most recent DWR
policy. (Attach .pdf)
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project? 1 ® Yes ❑ No ❑ N/A
4b. If yes, describe in detail the treatment methods and dispositions (non -discharge or discharge) of wastewater
generated from the proposed project. If the wastewater will be treated at a treatment plant, list the capacity
available at that plant.
Public Metropolitan Sewage District Gravity Sewer Extension
Page 17 of 20 PCN Form Version 4.3- April 20, 2022

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected
❑ Yes ❑x No
species or habitat? (IPAC weblink: https://www.fws.gov/ipac/ ffws.govl)
5b. Have you checked with the USFWS concerning Endangered Species
❑ Yes ❑x No
Act impacts?
5c. If yes, indicate the USFWS Field Office you have contacted.
Choose one
5d. Is another federal agency involved?
® Yes ❑ No ❑ Unknown
If yes, which federal agency?
USACE
5e. Is this a DOT project located within Divisions 1-8?
❑ Yes ❑x No
5f. Will you cut any trees in order to conduct the work in waters of the
U.S.? *
® Yes ❑ No
5g. Does this project involve bridge maintenance or removal? *
❑ Yes ❑x No
5g1. If yes, have you inspected the bridge for signs of bat use such as
staining, guano, bats, etc.? Representative photos of signs of bat use
❑ Yes ❑ No
can be found in the NLEB SLOPES, Appendix F, pages 3-7.
Representative photos of signs of bat use can be found in the NLEB SLOPES, Appendix F, pages 3-7. Link to
NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-30-17-signed NLEB-SLOPES&apps.pdf
If you answered yes to 5g1, did you discover any signs of bat use? *
❑ Yes ❑ No ❑ Unknown
If yes, please show the location of the bridge on the permit drawings/ project plans
5h. Does this project involve the construction/ installation of a wind
turbine(s)?
❑ Yes ❑x No
If yes, please show the location of the wind turbine(s) on the permit drawings/ project plans (attach .pdf)
5i. Does this project involve blasting and /or other percussive activities
that will be conducted by machines, such as jackhammers,
❑ Yes ❑x No
mechanized pile drivers, etc.?
If yes, please provide details to include type of percussive activity, purpose, duration, and specific location of this
activity on the property (attach .pdf)
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated
Critical Habitat?
fws website
Attach consultation documentation.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as
an Essential Fish Habitat?
❑ Yes ❑x No
Is there submerged aquatic vegetation (SAV) around
the project vicinity?
El Yes ❑x No El Unknown
Will this project affect submerged aquatic vegetation?
❑ Yes ❑x No ❑ Unknown
Page 18 of 20 PCN Form Version 4.3- April 20, 2022

Explain: Click to enter
6b. What data source(s) did you use to determine whether your site would impact Essential Fish Habitat?
fws website
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to the State Historic Preservation Office Historic Properties Map (does not include archaeological data):
http://,qis.ncdcr.gov/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
❑ Yes ❑x No
properties significant in North Carolina history and archaeology)?
7b. What data source(s) did you use to determine whether your site would impact historic or archeological
resources?
Click to enter.
7c. Attach historic or prehistoric documentation.
8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https://msc.fema.gov/portal/search
8a. Will this project occur in a FEMA-designated 100-year floodplain?
❑ Yes ❑x No
8b. If yes, explain how the project meets FEMA requirements.
Click to enter.
8c. What source(s) did you use to make the floodplain determination?
Henderson County and FEMA mapping
H. Miscellaneous
Comments:
Click to ent—
Attach pertinent documentation or attachments not previously requested
Page 19 of 20 PCN Form Version 4.3- April 20, 2022

I. Signature *
❑x By checking the box and signing below, I, as the project proponent, certify to the following:
• The project proponent hereby certifies that all information contained herein is true, accurate, and complete, to
the best of my knowledge and belief;
• 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;
• The project proponent hereby agrees 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");
• The project proponent hereby agrees to conduct this transaction by electronic means pursuant to Chapter 66,
Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act");
• The project proponent hereby understands that an electronic signature has the same legal effect and can be
enforced in the same way as a written signature; AND
• As the project proponent, I intend to electronically sign and submit the PCN/online form.
Full Name: Marty Kocot, PE Landworks Engineering, PLLC
Signature: Marty Kocot
Date: 11 /7/2022
Page 20 of 20 PCN Form Version 4.3- April 20, 2022

Permission for Agent and/or Attorney to act on behalf of Owner(s)
Date: October 25, 2022
Henderson County site Development
240 Second Avenue East
Hendersonville, NC 28792
Dear Henderson County Office :
As you may know, I am acting as Agent / Attorney for Kompo Famil Company, LLC to apply for all
permits pertaining to development and construction associated with property located at
3122 Hendersonville Road Fletcher, NC but more legally known at Property Identification Number (PIN)
9653-63-7344 documented at the Henderson County Courthouse
Land Records Office located at 85 Grove Street, Hendersonville, NC 28792,
I hereby give my / our permission to Long Shoals Partners, LLC to submit any plans or apply
for permits required for this project, I / We are also giving permission for any land disturbing activity to take
place on our property without our presence, but understand it is our ultimate responsibility if any damage is
caused during construction to this property or any other property.
Kompo Family Company, LLC
Signed
Land Owner of Record (Spell out exactly as on land records)
I, 1� l(016, , a Notary Public for the State of ,�1 t�A , County of
4 /j�,�', )rj-J , do hereby certify that �'A" �i, i��dT�6'"G ? S personaii a eared
before me this o7S" day of QGT" 202,aand acknowledge the due
execution of the forgoing permission form. Witness my hand and official seal,
JILL At EK
COMM481on 05#dp
Expire$ Jen"rY22,�9
Sanded TtV, tNot�y 2423
ins^L ( ) ( /

Permission for Agent and/or Attorney to act on behalf of Owner(s)
Date: October 25, 2022
Henderson County Site Development
240 Second Avenue East
Hendersonville, NC 28792
Dear Henderson County Office :
As you may know, I am acting as Agent / Attorney for Kompo Family Company, LLC to apply for all
permits pertaining to development and construction associated with property located at
3122 Hendersonville Road, Fletcher, NC but more legally known at Property Identification Number (PIN)
9653-63-7344 documented at the Henderson County Courthouse
Land Records Office located at 85 Grove Street, Hendersonville, NC 28792.
Martin Kocot, PE
I hereby give my / our permission to Landworks Engineering, PLLC to submit any plans or apply
for permits required for this project. I / We are also giving permission for any land disturbing activity to take
place on our property without our presence, but understand it is our ultimate responsibility if any damage is
caused during construction to this property or any other property.
Signed by prope
Kompo Family Company, LLC Signed
Land Owner of Record (Spell out exactly as on land records)
.W -j----
f L /" �6di •Kam- a Notary Public for the State of r1-0 iZ 4 IM County of
do hereby certify that jq11..`/ t�i'"t�['.s persona�lY aP�ear:d
before me this a2 5— day of +`` C rQ aeQ 209 Pand acknowledge the due
execution of the forgoing permission form. Witness my hand and official seal,
4ILLM. INERIIE
* # G4mmis�doa # � 28 2i2S
Aa
QFFifl��s
n n