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HomeMy WebLinkAbout20230383 Ver 1_401 Application_20230310Staff Review Form Environmental Quality Updated September 4, 2020 Staff Review Does this application have all the attachments needed to accept it into the review process? * Yes No ID#* 20230383 Version* 1 Is this project a public transportation project? * Reviewer List:* Select Reviewing Office: * Submittal Type: * Yes No Seren Homer:Seren.Homer@ncdenr.gov Winston-Salem Regional Office - (336) 776-9800 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: 12/23/2022 Project Contact Information Name: Heather LaGamba Who is submitting the information? Email Address: hlagamba@pilotenviro.com Project Information Project Name: Shelton Lake Dam Is this a public transportation project? Yes No Is the project located within a NC DCM Area of Environmental Concern (AEC)? Yes No Unknown Is this project connected with ARPA funding? Yes No County (ies) Forsyth Please upload all files that need to be submited. Click the upload button or drag and drop files here to attach document 8927_Shelton Lake Dam_USACE PCN and JD Request_3.10.23.pdf Only pdf or kmz files are accepted. Describe the attachments or comments: 7.77MB PCN for 401 WQC 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: Wentz-10. MYef Submittal Date: 3/10/2023 Is filled in automatically. Preliminary ORM Data Entry Fields for New Actions ACTION ID #: SAW- 2022- Prepare file folder ❑ 1. Project Name [PCN Form A2a]: Shelton Lake Dam Begin Date (Date Received): Assign Action ID Number in ORM ❑ 2. Work Type: ❑✓ Private ❑ Institutional ❑ Government ❑ Commercial 3. Project Description / Purpose [PCN Form 133d and 133e]: The site contains a pond and wooded land. The pond dam is scheduled for repairs 4. Property Owner / Applicant [PCN Form A3 or A41: OBrien Southern Trenching 5. Agent / Consultant [PNC Form A5 — or ORM Consultant ID Number]: David Brame/Pilot Environmental, Inc. 6. Related Action ID Number(s) [PCN Form B5b]: 7. Project Location— Coordinates, Street Address, and/or Location Description [PCN Form Blb]: 4003 Max Drive 36.137023 ° /-80.380482 ° 8. Project Location— Tax Parcel ID [PCN Form Bla]: 5897-21-3737.00 9. Project Location — County [PCN Form A2b]: Forsyth 10. Project Location — Nearest Municipality or Town [PCN Form A2c]: Winston-Salem 11. Project Information — Nearest Waterbody [PCN Form 132a]: Tomahawk Creek 12. Watershed / 8-Digit Hydrologic Unit Code [PCN Form 132c]: Upper Yadkin/03040101 Authorization: Section 10 ❑ Section 404 ❑✓ Regulatory Action Type: ❑ Standard Permit ✓ Nationwide Permit # Regional General Permit # ✓ Jurisdictional Determination Request Section 10 and 404 ❑ ❑ Pre -Application Request ❑ Unauthorized Activity ❑ Compliance ❑ No Permit Required Revised 20150602 �I • i4 N•:: -�l H CARD-INA [n A i'G n i ro¢n =1 Q uai tty Office Use Only Corps Action ID no. [Click to enter.] Date received: 12/23/2022 DWR project no. :lick enter.] Date received: [Click to enter.] Site Coordinates: Latitude (DD.DDDDDD): 36.135973' Longitude (DD.DDDDDD): 80.380618' Form Version 4.3, April 20, 2022 Pre -Construction Notification (PCN) Form (Ver. 4.2, January31, 2022)J 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: httos://edocs.dea.nc.aov/WaterResources/DocView.asr)x?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) : 12/23/2022 Page 1 of 21 PCN Form Version 4.3- April 20, 2022 A. Processing Information County (counties) where project is located: * Forsyth Additional (if needed). Is this a NCDMS project? * (Click yes only if NCDMS is the applicant or co- ❑ Yes 0 No applicant) Is this a public transportation project? (Publicly funded municipal, state, or federal road, rail, ❑ Yes N No or airport project) Is this a NCDOT project? ❑ Yes N No If yes, NCDOT TIP or state project number: Click to enter. If yes, NCDOT WBS number: Click to ente N 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 N No Please provide the date of the previous submission. * Click to enter a date. N 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 N No NWP number(s) (list all numbers ): NWP 3 RGP number(s) (list all numbers ): Click to enter. Are you a federal applicant? ❑ Yes N 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): N 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 0 No 1e. Is this notification solely for the record because written approval is not required? * For the record only for DWR 401 Certification: ❑ Yes N No For the record only for Corps Permit: ❑ Yes N No 1f. Is this an after -the -fact permit/certification application? ❑ Yes N No Page 2 of 21 PCN Form Version 4.3-April 20, 2022 1 g. Is payment into a mitigation bank or in -lieu fee program proposed for ❑ Yes 0 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 N No 1i. Is the project located within an NC DCM Area of Environmental ❑ Yes N No ❑ Unknown Concern (AEC)? * 1j. Is the project located in a designated trout watershed? ❑ Yes N 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: httr)://www.saw.usace.army.miI/Missions/Regulatory-Permit- Program/Agency-Coordination/Trout.aspx Page 3 of21 PCN Form Version 4.3-April 20, 2022 B. Applicant Information 1 a. Who is the primary contact? * Tracy O'Brien 1b. Primary Contact Email: * tobrien@obriensouthern.com 1c. Primary Contact Phone: * (###)###-#### 336-969-0460 1d. 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: * OBRIEN SOUTHERN TRENCHING INC 2b. Deed Book and Page No.: 3597/710 2c. Contact Person (for corporations): Tracy O'Brien 2d. Address * Street Address: PO Box 849 Address line 2: Click to enter. City: Rural Hall State/ Province/ Region: North Carolina Postal/ Zip Code: 27045 Country: United States 2e. Telephone Number: (###)###-#### 336-969-0460 2f. Fax Number: (###)###-#### Click to enter. 2g. Email Address: * tobrien@obriensouthern.com 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 21 PCN Form Version 4.3-April 20, 2022 4. Agent/ Consultant (if applicable) 4a. Name: David Brame 4b. Business Name: Pilot Environmental, Inc. 4c. Address: Street Address: 743 Park Lawn Court Address line 2: Click to entr City: Kernersville State/ Province/ Region: North Carolina Postal/ Zip Code: 27284 Country: United States 4d. Telephone Number: (###)###-#### 336-708-4617 4e Fax Number: (###)###-#### Click to entr 4f. Email Address: dbrame@pilotenviro.com 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 of21 PCN Form Version 4.3-April 20, 2022 C. Project Information and Prior Project History 1. Project Information 1 a. Name of project: * Shelton Lake Dam 1 b. Subdivision name (if appropriate): Click to enter. 1c. Nearest municipality/town: * Winston-Salem 2. Project Identification 2a. Property identification number (tax PIN or parcel ID): 5897-21-3737.00 2b. Property size (in acres): 15 2c. Project Address: Street Address: 4003 Max Drive Address line 2: Click to enter. City: Winston-Salem State/ Province/ Region: North Carolina Postal/ Zip Code: 27045 Country: United States 2d. Site coordinates in decimal degrees (using 4-6 digits after the decimal point): * Latitude (DD.DDDDDD): * 36.135973° Longitude (-DD.DDDDDD): *-80.380618° 3. Surface Waters 3a. Name of nearest body of water to proposed project: * Tomahawk Creek 3b. Water Resources Classification of nearest receiving C water: * The Surface Water Classification map may be found at this link: https://ncdenr.maps.arcqis.com/apps/webappviewer/index.html?id=6e125ad7628f494694e259c80dd64265 Yadkin-PeeDee 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 030401011303 located: * The Find Your HUC map may be found at this link: https://ncdenr.maps.arcgis.com/apps/Publiclnformation/index.html?appid=ad3a85aOc6d644aOb97cdO69db238ac3 Page 6 of 21 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: * The site consists of the Shelton Lake Dam. The site consists of a pond and maintained dam. The dam previously outletted from a standpipe into a perennial stream. The standpipe has deteriorated and no longer functions. The pond has currently been drawn down in preparation of repairs. Wetlands are not located on the site. The surrounding properties contain wooded land and residential development. 4b. Have Corps permits or DWR certifications been obtained for this ❑ Yes X No ❑ 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 text. 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. NA 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 75 linear feet and perennial) on the property: 4g1. List the total estimated acreage of all existing open waters on the 10 acres property: 4h. Explain the purpose of the proposed project: The purpose of the proposed project is to repair an outlet structure that is no longer working. 4i. Describe the overall project in detail, including the type of equipment to be used: * The overall project includes the construction of a new outlet pipe for Sheltons Lake. The outlet structure will be constructed on the west side of the dam and discharge back into the existing stream channel. In order to provide non -erosive flows back to the stream channel, the outlet structure and discharge elevation will be placed at the stream elevation and a riprap dissipater will be installed downstream. The rirrap dissipater will be installed at the existing streambed elevation. To facilitate the repairs, excavating and grading the site is necessary. Graders, haulers, excavators and other heavy equipment will be used during construction. 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 X No If yes, describe the type of dredging, the composition of the dredged material, and the locations of disposal area. Click to enter text Page 7 of21 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 ❑ No ❑ Unknown proposed impact areas? Comments: The wetlands were delineated by Pilot Environmental. A USACE JD request has been provided in conjunction with this PCN request and is attached. 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): Click to enter Name (if known): David Brame/Michael Brame 5c. If 5a is yes, who delineated the jurisdictional Agency/Consultant Company: Pilot Environmental areas? Other: flick to enter 5d. List the dates of the Corps jurisdictional determination or State determination if a determination was made by either agency. A JD request is attached. A JD has not been issued. 5d1. Attach jurisdictional determinations. 6. Future Project Plans 6a. Is this a phased project? ❑ Yes X No 6b. If yes, explain. 'lick tn enter 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. No 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) 5897-20-7999.00/2460 Lake Forest Dr Adams, Garland;Adams, Vicky 2460 Lake Forest Dr Winston Salem, NC 27106 5897-10-8976.00 - 0 Lake Forest DR Muss, Loretta 1388 Fearrington Post Pittsboro, NC 27312 8. Scheduling of activity: To be completed within the next 1-6 months. Page 8 of21 PCN Form Version 4.3-April 20, 2022 D. Proposed Impacts Inventory Impacts Summary ❑ Wetlands 0 Streams - tributaries 1 a. Where are the impacts associated with your project ❑ 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 Click to enter Y/N ;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 Temp/ 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: Wetland impacts are not proposed Page 9 of21 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 3a 3b. 3c. 3d. 3e. 3f. 3g. 3h. Site #* Impact Impact Impact Type* Stream Name* Stream Jurisdiction Stream Width Impact length Reason* Duration* Type* Type* (avg ft) * (linear ft) S1 Temp Temporary Dewatering SA Perennial Both 20 7 Construction Impact S2 Keyed -in Permanent Fill (Incl. SA Perennial Both 54 11 RipRap Riprap) S3 Outlet Permanent Crossing/ SA Perennial Both 22 15 Structure Culvert Installation 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 0 linear ft impact: 3i2. Total permanent stream 76 linear ft impacts: M. Total temporary stream 20 linear ft impacts: 34. Total stream and ditch 96 linear ft impacts: Page 10 of 21 PCN Form Version 4.3- April 20, 2022 3j. Comments: S1 — Stream location 1 includes 7 LF (140 SF) of temporary impact for construction activities and for coffer dam and pump around located downstream of the work area. S2 — Stream location 2 includes 54 LF (625 SF) of permanent impact with riprap that will be keyed into the existing stream bed elevation. S3 — Steam location 3 includes 15 LF (340 SF) of permanent fill for installation of the new outlet structure. Page 11 of21 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 Choose one Click to enter. 02 Click to enter. Temp/ Perm Click to enter. Choose one Choose 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: Open water impacts are not proposed. The pond will be retored to its normal pool level 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 to Click to Click to enter. enter. enter. enter. enter. enter. enter. P2 Choose one Click to Click to Click to Click to Click to Click to Click to enter. enter. enter. enter. enter. enter. enter. 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 to enter. enter. enter. enter. enter. enter. enter. 5g. Comments: Ponds are not being constructed. 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 12 of 21 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 X❑ 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. 133 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter. 134 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. 136 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter. 137 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter. 138 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: Buffer impacts are not proposed. Please attach supporting documentation (impact maps, plan sheets, etc.) for the proposed project. Page 13 of21 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: The applicant has designed the proposed repair to avoid impacts to additional remainder of the stream. The riprap dissipater should improve erosive flow velocities into the stream. The structure was designed to impact as little amount of stream as possible and still be able to function as intended. 1 b. Specifically describe measures taken to avoid or minimize proposed impacts through construction techniques: The clearing limits will be surveyed, staked and silt fencing and clearing limit fencing will be used. Disturbed areas will be promptly seeded and mulched to limit sediment from entering downgradient waters. Slope matting will be used on steep slopes. 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: Mitigation is not proposed. 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 Page 14 of21 PCN Form Version 4.3-April 20, 2022 4h. Comments: Mitigation is not proposed. 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. ,lick to enter 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 X 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 INC Division of Mitigation Services. 6i. Comments: Mitigation is not proposed. Page 15 of21 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 0 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/energy-mineral-land-resources/energy-mineral-land-permit- guidance/stormwater-bmp-manual). Associated supplement forms and other documentation must be provided. ❑ Level Spreader What Type of SCM are you ❑ Vegetated Conveyance (lower seasonal high water table- SHWT) providing? ❑ Wetland Swale (higher SHWT) (Check all that apply) ❑ Other SCM that removes minimum 30% nitrogen ❑ 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? ❑ Yes 0 No 2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)? * 0 Yes ❑ No To look up low density requirements, click here: http://reports.oah.state. nc.us/ncac/title%2015a%20-%20environmental%20guaIity/chapter%2002%20- %20environmental%20manage ment/subchapter%20h/15a%20ncac%2002h%20.1003.pdf 2c. Does this project have a stormwater management plan (SMP) ❑ Yes 0 No reviewed and approved under a state stormwater program or state - approved local government stormwater program? 0 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? ❑ Local Government (Check all that apply.) ❑ State If you have local government approval, please include the SMP on their overall impact map. Local Government Stormwater Programs ❑ Phase II ❑ USMP ❑ NSW ❑ Water Supply Page 16 of21 PCN Form Version 4.3-April 20, 2022 Please identify which local government stormwater program you are using. Guilford County State Stormwater Programs ❑ Phase II ❑ HQW or ORW ❑ Coastal Counties ❑ Other Comments: Click to enter. Page 17 of21 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 ❑Yes X 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 X No NEPA or SEPA final approval letter.) Comments: The project does not require a NEPA or SEPA. 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: Additional development is not anticipated as a result of the proposed project. 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? I ❑ Yes ❑ No X 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. Click to enter. Page 18 of21 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 ❑ No species or habitat? (IPAC weblink: https://www.fws.gov/ipac/ ffws.govl) 5b. Have you checked with the USFWS concerning Endangered Species ❑ Yes 0 No Act impacts? * 5c. If yes, indicate the USFWS Field Office you have contacted. Choose one 5d. Is another federal agency involved? ❑ Yes 0 No ❑ Unknown If yes, which federal agency? Click to enter. 5e. Is this a DOT project located within Divisions 1-8? * ❑ Yes 0 No 5f. Will you cut any trees in order to conduct the work in waters of the U.S.? * ❑ Yes 0 No 5g. Does this project involve bridge maintenance or removal? * ❑ Yes 0 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 0 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 0 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) Page 19 of21 PCN Form Version 4.3-April 20, 2022 5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat? * US Department of the Interior — Fish and Wildlife Service Official Species List from IPaC The tri-colored bat (Proposed Endangered), bog turtle (Threatened due to similarity of appearance), dwarf -flowered heartleaf (Threatened), Schweinitz's sunflower (Endangered), and monarch butterfly (Candidate) are included by the IPaC as federally listed species that have been identified within the vicinity of the site. Bat hibernacula is not located on the site. Trees that could afford suitable summer roosting habitat are present within wooded areas adjacent to the work area that will be left undisturbed. Limited clearing will be required to complete the repairs. Large trees will not need to be removed. Additionally, known occurrences are not identified within 2 miles of the site. Based on the small amount of clearing that will be required, the proposed project is not likely to adversely affect bat species that occur in the area. The impact areas do not contain bogs, wetlands or suitable habitat for the bog turtle. The areas of proposed impact and areas immediately adjacent to the proposed impact contain a maintained dam and open forested areas. Suitable habitat for the sunflower is not present. The Monarch butterfly is a candidate species that is not subject to provisions of the ESA or consultation with the service. The proposed project is not likely to adversely impact this species. 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 0 No El Unknown Will this project affect submerged aquatic vegetation? * ❑ Yes X No ❑ Unknown Explain: Click to enter. 6b. What data source(s) did you use to determine whether your site would impact Essential Fish Habitat? Essential Fish Habitat Mapper — NOAA Fisheries 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.,qov/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? * NC Historic Preservation Office's HPOWEB 2.0. Historic properties that are listed or are eligible for listing on the National Register for Historic Places were not identified on the site or proximate to stream and wetland impacts. A copy of the SHPO Map is included as an attachment. 7c. Attach historic or prehistoric documentation. Page 20 of 21 PCN Form Version 4.3- April 20, 2022 8. Flood Zone Designation (Corps Requirement) Link to the FEMA Floodplain Maps: https://msc.fema.,qov/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? FEMA Firm Map (Drawing 4) H. Miscellaneous Comments: Click to enter. Attach pertinent documentation or attachments not previously requested 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: * David S. Brame Signature: 3/10/2023 Page 21 of 21 PCN Form Version 4.3- April 20, 2022 AGENT AUTHORIZATION This form authorizes Pilot to act as our agent in stream/wetland matters including U.S. Army Corps of Engineers and North Carolina Division of Water Resources field verification and permitting. Property Address: ���j 14 C. Y_- D � ,,.& M- ,,, S s,-' A& Owner Information: Name: c t t t :sctf M r�.t� Lr�.►.c. Address: ra Telephone Number: �_3 3-4 1-- 96 '— D Cn 0 _,.. Fax Number: E-mail Address: Signatu re: �_ _,5) 7,gc�� COD � 9 h0 MA Shelwin n ct. o ^ won Well Tr. i` o- j Lake / Forest a� V o Santa Maria Dr. Tomahawk Dr. I 66.1 \ I I VICINITY MAP NOT TO SCALE X 4. \ \ 72.5 \\ \ / \� \�X 8 Y f � \ / II � II \\ ' II 841 83; MAI CR 831 82`' 821 Salem Rd. Heritage ks \Oa Ct. CL Q 0- 1X SHELTON LAKE W.E. 861.2± OUTLET PAD PROFILE 1 inch = 10 ft. (Vertical) I/* I III � i TgRTRIe��\\ \ I� l �828 \\ co EXISTING STREAM IMPACTS S1 - Temporary Construction Impacts: 07 Linear Feet, 140 ft2 S2 - Keyed -in Riprop Impacts: 54 Linear Feet, 625 ft2 S3 - Outlet Structure Installation: 15 Linear Feet, 340 ft2 I fS \\ S2 omo 000il I / lll� ' lb� / i ' I 835 / ( 16" DIP w I ' ' --- — > � za I�? — J I Scaler -1- 1`nch = 10 ft. I 6.6 r 827.5 / CID t 7 ,840) - --��� 234 LF 1 1 1 1 \ \ \\ \ \ 845 \ EXISTING CONDITIONS TOPOGRAPHY FROM FORSYTH COUNTY GIS _—__--_—_---- ---- =— _ _ — =--=_—__=—_--- ----- -----1 \ % \ I �� \ _-----_---- — _------_------------ ---_— — — — — ---- > 2005 PLANIMETRICS -------- — ------ — _ _ ---- _ _ --_�� / — — — _ _---_---_ — _ _--_—_— 855 —_ — 0 _ Scale: 1 inch = 100 ft. =-- = -- ------ = --- — — -- —oo--------_ -- J 860 --- - ��—_— — 862 ------ — ----- -- -- --_-- —�----------- J�'_- 40 / x 863.1' — — — — — — x 862.7' x 862.5' x 862.5' x862.3' x862.5' 862 — — / L — — — \ p� u6X _ — ------------ 862 ----- _ 35 ----------------- 860=_____---__ ___ _------_____-- ---- ----- _----- 862 — _ — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — _— — — — — — — _— — — — _— _ _ _ — — — — — — — 30 25845=20 ----—�_— \ \\ \ I I North �� 838.1'838.5 40' 80' 120' SHEL, T O �l / 839.3' \ I I Scale: 1 inch = 40 fit. " 839.6' x ­ 1 1 1 Consulting Engineers 514 Edwards Rd Rural Hall, NC 27045 (336)945-0302 JLipka@LPK-Consulting.com Land & Infrastructure Development Solutions Copyright Reserved These documents and all data, plans, specifications and other information contained herein are the sole and exclusive property of LPK Consulting, PA., and may be used only in connection with the project for which these documents have been prepared by L P K Consulting, PA., and for no other purpose. Any Unauthorized use ofthese documents for any purpose shall be at the user's sole risk, without liability to LPK Consulting, PA All rights of design are reserved to LPK Consulting, PA. Permit -Seal �\ t I I I t I, tT11 CAR111 / LPK ; CONSULTING, - PA `P No. C-3385 ` OF NU' �++*+N+1'i.ln fry�I ,.k M A? 7 AL 94 ;x iF .� NOT FOR CONSTRUCTION Q w U Q z 0 w oCl) X= R 0 Q �N J Z O I— J w 2 Client O'Brien Southern Trenching Tracy O'Brien PO Box 849 Rural Hall, NC 27045 tobrien@obriensouthern.com P: (336) 969-0460 M: (336) 345-2041 Title Stream Impacts Plan Revision Date Issued Date Permit Review 03,06.2 Project No.: 21-0702 Designed By: JDL Drawn By: JDL Date: August 2021 Scale: As Noted Sheet No. C-9 United States Department of the Interior FISH AND WILDLIFE SERVICE Asheville Ecological Services Field Office 160 Zillicoa Street Asheville, NC 28801-1082 Phone: (828) 258-3939 Fax: (828) 258-5330 In Reply Refer To: Project Code: 2023-0054634 Project Name: Shelton Lake Dam March 10, 2023 Subject: List of threatened and endangered species that may occur in your proposed project location or may be affected by your proposed project To Whom It May Concern: The enclosed species list identifies threatened, endangered, proposed and candidate species, as well as proposed and designated critical habitat, that may occur within the boundary of your proposed project and/or may be affected by your proposed project. The enclosed species list fulfills the requirements of the U.S. Fish and Wildlife Service (Service) under section 7(c) of the Endangered Species Act (Act) of 1973, as amended (16 U.S.C. 1531 et seq.). Please note that new species information can change your official species list. Under 50 CFR 402.12(e) of the regulations implementing section 7 of the Act, the accuracy of this species list should be verified after 90 days. The Service recommends you visit the ECOS-IPaC website at regular intervals during project planning and implementation to ensure your species list is accurate or obtain an updated species list. The purpose of the Act is to provide a means whereby threatened and endangered species and the ecosystems upon which they depend may be conserved. Under sections 7(a)(1) and 7(a)(2) of the Act and its implementing regulations (50 CFR 402 et seq.), Federal agencies are required to utilize their authorities to carry out programs for the conservation of threatened and endangered species and to determine whether projects may affect threatened and endangered species and/or designated critical habitat. A biological assessment (BA) or biological evaluation (BE) should be completed for your project. A BA is required for major construction activities (or other undertakings having similar physical impacts) considered to be Federal actions significantly affecting the quality of the human environment as defined in the National Environmental Policy Act (42 U.S.C. 4332(2) (c)) (NEPA). For projects other than major construction activities, the Service suggests that a BE be prepared to determine effects of the action and whether those effects may affect listed species and/or designated critical habitat. E?ects of the action are all consequences to listed species or critical habitat that are caused by the proposed action, including the consequences of other 03/10/2023 activities that are caused by the proposed action. A consequence is caused by the proposed action if it is reasonably certain to occur and would not occur "but for" the proposed action.. Recommended contents of a BA/BE are described at 50 CFR 402.12. More information and resources about project review and preparing a BA/BE can be found at the following web link: https://www.fws. gov/office/asheville-ecological-services/asheville-field-office-online-review- process-overview. If a Federal agency determines listed species and/or designated critical habitat may be affected by the proposed project, the agency is required to consult with the Service pursuant to 50 CFR 402. The Service is not required to concur with "no effect" determinations from Federal action agencies. If consultation is required, the Service recommends that candidate species, proposed species, proposed critical habitat, and at -risk species be addressed within the consultation. More information on the regulations and procedures for section 7 consultation, including the role of permit or licensed applicants, can be found in the "Endangered Species Consultation Handbook" at the following web link: https://www.fws.gov/media/endangered-species-consultation- handbook. Migratory Birds: In addition to responsibilities to protect threatened and endangered species under the Act, there are additional responsibilities under the Migratory Bird Treaty Act (MBTA) and the Bald and Golden Eagle Protection Act (BGEPA) to protect native birds from project - related impacts. Any activity, intentional or unintentional, resulting in take of migratory birds, including eagles, is prohibited unless otherwise permitted by the Service (50 C.F.R. Sec. 10.12 and 16 U.S.C. Sec. 668(a)). More information about MBTA and BGEPA can be found at the following web link: https://www.fws.gov/program/migratory-birds. We appreciate your consideration of Federally listed species. The Service encourages Federal agencies to include conservation of threatened and endangered species in their project planning to further the purposes of the Act. Please contact our staff at 828-258-3939, if you have any questions. In any future correspondence concerning this project, please reference the Consultation Code which can be found in the header of this letter. Attachment(s): • Official Species List • USFWS National Wildlife Refuges and Fish Hatcheries • Migratory Birds • Wetlands 03/10/2023 OFFICIAL SPECIES LIST This list is provided pursuant to Section 7 of the Endangered Species Act, and fulfills the requirement for Federal agencies to "request of the Secretary of the Interior information whether any species which is listed or proposed to be listed may be present in the area of a proposed action". This species list is provided by: Asheville Ecological Services Field Office 160 Zillicoa Street Asheville, NC 28801-1082 (828) 258-3939 03/10/2023 PROJECT SUMMARY Project Code: 2023-0054634 Project Name: Shelton Lake Dam Project Type: Dam - Maintenance/Modification Project Description: The site contains a dam that is scheduled for repairs Project Location: The approximate location of the project can be viewed in Google Maps: https: www. google.com/maps/(a)36.1359731,-80.38069440105897,14z 0 I== Counties: Forsyth County, North Carolina 03/10/2023 3 ENDANGERED SPECIES ACT SPECIES There is a total of 4 threatened, endangered, or candidate species on this species list. Species on this list should be considered in an effects analysis for your project and could include species that exist in another geographic area. For example, certain fish may appear on the species list because a project could affect downstream species. IPaC does not display listed species or critical habitats under the sole jurisdiction of NOAA Fisheriesi, as USFWS does not have the authority to speak on behalf of NOAA and the Department of Commerce. See the "Critical habitats" section below for those critical habitats that lie wholly or partially within your project area under this office's jurisdiction. Please contact the designated FWS office if you have questions. 1. NOAA Fisheries, also known as the National Marine Fisheries Service (NMFS), is an office of the National Oceanic and Atmospheric Administration within the Department of Commerce. MAMMALS NAME STATUS Tricolored Bat Perimyotis subflavus Proposed No critical habitat has been designated for this species. Endangered Species profile: https:Hecos.fws.gov/ecp/species/10515 REPTILES NAME STATUS Bog Turtle Glyptemys muhlenbergii Similarity of Population: U.S.A. (GA, NC, SC, TN, VA) Appearance No critical habitat has been designated for this species. (Threatened) Species profile: https:Hecos.fws.gov/ecp/species/6962 INSECTS NAME STATUS Monarch Butterfly Danaus plexippus Candidate No critical habitat has been designated for this species. Species profile: https:Hecos.fws.gov/ecp/species/9743 03/10/2023 4 FLOWERING PLANTS NAME STATUS Schweinitz's Sunflower Helianthus schweinitzii Endangered No critical habitat has been designated for this species. Species profile: https:Hecos.fws.gov/ecp/species/3849 CRITICAL HABITATS THERE ARE NO CRITICAL HABITATS WITHIN YOUR PROJECT AREA UNDER THIS OFFICE'S JURISDICTION. 03/10/2023 USFWS NATIONAL WILDLIFE REFUGE LANDS AND FISH HATCHERIES Any activity proposed on lands managed by the National Wildlife Refuge system must undergo a 'Compatibility Determination' conducted by the Refuge. Please contact the individual Refuges to discuss any questions or concerns. THERE ARE NO REFUGE LANDS OR FISH HATCHERIES WITHIN YOUR PROJECT AREA. 03/10/2023 MIGRATORY BIRDS Certain birds are protected under the Migratory Bird Treaty Act! and the Bald and Golden Eagle Protection Actz. Any person or organization who plans or conducts activities that may result in impacts to migratory birds, eagles, and their habitats should follow appropriate regulations and consider implementing appropriate conservation measures, as described below. 1. The Migratory Birds Treat. Act of 1918. 2. The Bald and Golden Eagle Protection Act of 1940. 3. 50 C.F.R. Sec. 10.12 and 16 U.S.C. Sec. 668(a) The birds listed below are birds of particular concern either because they occur on the USFWS Birds of Conservation Concern (BCC) list or warrant special attention in your project location. To learn more about the levels of concern for birds on your list and how this list is generated, see the FAQ below. This is not a list of every bird you may find in this location, nor a guarantee that every bird on this list will be found in your project area. To see exact locations of where birders and the general public have sighted birds in and around your project area, visit the E-bird data mapping tool (Tip: enter your location, desired date range and a species on your list). For projects that occur off the Atlantic Coast, additional maps and models detailing the relative occurrence and abundance of bird species on your list are available. Links to additional information about Atlantic Coast birds, and other important information about your migratory bird list, including how to properly interpret and use your migratory bird report, can be found below. For guidance on when to schedule activities or implement avoidance and minimization measures to reduce impacts to migratory birds on your list, click on the PROBABILITY OF PRESENCE SUMMARY at the top of your list to see when these birds are most likely to be present and breeding in your project area. BREEDING NAME SEASON Bald Eagle Haliaeetus leucocephalus Breeds Sep 1 to This is not a Bird of Conservation Concern (BCC) in this area, but warrants attention Jul 31 because of the Eagle Act or for potential susceptibilities in offshore areas from certain types of development or activities. Black -billed Cuckoo Coccyzus erythropthalmus Breeds May 15 This is a Bird of Conservation Concern (BCC) throughout its range in the continental USA to Oct 10 and Alaska. https:Hecos.fws.gov/ecp/species/9399 03/10/2023 BREEDING NAME SEASON Chimney Swift Chaetura pelagica Breeds Mar 15 This is a Bird of Conservation Concern (BCC) throughout its range in the continental USA t0 Aug 25 and Alaska. Golden Eagle Aquila chrysaetos Breeds This is not a Bird of Conservation Concern (BCC) in this area, but warrants attention elsewhere because of the Eagle Act or for potential susceptibilities in offshore areas from certain types of development or activities. https:Hecos.fws.gov/ecp/species/1680 Prairie Warbler Dendroica discolor Breeds May 1 This is a Bird of Conservation Concern (BCC) throughout its range in the continental USA to Jul 31 and Alaska. Prothonotary Warbler Protonotaria citrea Breeds Apr 1 to This is a Bird of Conservation Concern (BCC) throughout its range in the continental USA Jul 31 and Alaska. Red-headed Woodpecker Melanerpes erythrocephalus Breeds May 10 This is a Bird of Conservation Concern (BCC) throughout its range in the continental USA t0 Sep 10 and Alaska. Rusty Blackbird Euphagus carolinus Breeds This is a Bird of Conservation Concern (BCC) only in particular Bird Conservation Regions elsewhere (BCRs) in the continental USA Wood Thrush Hylocichla mustelina Breeds May 10 This is a Bird of Conservation Concern (BCC) throughout its range in the continental USA to Aug 31 and Alaska. PROBABILITY OF PRESENCE SUMMARY The graphs below provide our best understanding of when birds of concern are most likely to be present in your project area. This information can be used to tailor and schedule your project activities to avoid or minimize impacts to birds. Please make sure you read and understand the FAQ "Proper Interpretation and Use of Your Migratory Bird Report" before using or attempting to interpret this report. Probability of Presence ( ,) Each green bar represents the bird's relative probability of presence in the 10km grid cell(s) your project overlaps during a particular week of the year. (A year is represented as 12 4-week months.) A taller bar indicates a higher probability of species presence. The survey effort (see below) can be used to establish a level of confidence in the presence score. One can have higher confidence in the presence score if the corresponding survey effort is also high. How is the probability of presence score calculated? The calculation is done in three steps: The probability of presence for each week is calculated as the number of survey events in the week where the species was detected divided by the total number of survey events for 03/10/2023 3 that week. For example, if in week 12 there were 20 survey events and the Spotted Towhee was found in 5 of them, the probability of presence of the Spotted Towhee in week 12 is 0.25. 2. To properly present the pattern of presence across the year, the relative probability of presence is calculated. This is the probability of presence divided by the maximum probability of presence across all weeks. For example, imagine the probability of presence in week 20 for the Spotted Towhee is 0.05, and that the probability of presence at week 12 (0.25) is the maximum of any week of the year. The relative probability of presence on week 12 is 0.25/0.25 = 1; at week 20 it is 0.05/0.25 = 0.2. 3. The relative probability of presence calculated in the previous step undergoes a statistical conversion so that all possible values fall between 0 and 10, inclusive. This is the probability of presence score. Breeding Season( ) Yellow bars denote a very liberal estimate of the time -frame inside which the bird breeds across its entire range. If there are no yellow bars shown for a bird, it does not breed in your project area. Survey Effort (1) Vertical black lines superimposed on probability of presence bars indicate the number of surveys performed for that species in the 10km grid cell(s) your project area overlaps. The number of surveys is expressed as a range, for example, 33 to 64 surveys. No Data (—) A week is marked as having no data if there were no survey events for that week. Survey Timeframe Surveys from only the last 10 years are used in order to ensure delivery of currently relevant information. The exception to this is areas off the Atlantic coast, where bird returns are based on all years of available data, since data in these areas is currently much more sparse. ■ probability of presence ■ breeding season I survey effort — no data SPECIES JAN FEB TIITIITII II II TIITIITII MIIAII+R IIATIPTIR I MAY AY I IJUINII �JUL AUG SEP OCT �I �NOV � DEC Bald Eagle Non -BCC I11� i�jjiiij11++++}+ ++++ Vulnerable mono Black -billed 4 11 1 I F1111 ++++ +++1 Cuckoo 1+ BCC Rangewide (CON) Chimney Swift BCC Rangewide +11144l -I I I I I I I I �����1111111111 1111 1110l 11 ++ 1 ++1 (CON) 03/10/2023 4 Golden Eagle ++++ Non -BCC ++++ ++++ ++++ ++++ ++++ ++++ ++++ ++++ ++++ +0++ ++++ Vulnerable Prairie Warbler +++ I I I I I I I I I I I I ICJ I I I I I I I I BCC Rangewide ` (CON) Prothonotary Fr ++++++++++++�;;;;t; ++++ ++++ ++++ ++++ ++++ Warbler BCC Rangewide (CON) Red-headed + 1 I EMMM F ++* Woodpecker T+TT +T++ + ++++ I* I I I I F� J' J J j j�+ ++++ 0+0+ ++++ ++0+ BCC Rangewide --- (CON) Rusty Blackbird BCC -BCR 00*0 +00111$$ *+++ ++++ ++++ Wood Thrush BCC Rangewide ++1I I I I 44 4d 1111 1iii 57i ++++ +++' ++++ ++++ ++++ (CON) Additional information can be found using the following links: • Birds of Conservation Concern https://www.fws.gov/program/migratory-birds/species • Measures for avoiding and minimizing impacts to birds https://www.fws.gov/library collections/avoidins7-and-minimizinv--incidental-take-mis7ratorv-birds • Nationwide conservation measures for birds https://www.fws.gov/sites/default/files/ documents/nationwide-standard-conservation-measures.pdf MIGRATORY BIRDS FAQ Tell me more about conservation measures I can implement to avoid or minimize impacts to migratory birds. Nationwide Conservation Measures describes measures that can help avoid and minimize impacts to all birds at any location year round. Implementation of these measures is particularly important when birds are most likely to occur in the project area. When birds may be breeding in the area, identifying the locations of any active nests and avoiding their destruction is a very helpful impact minimization measure. To see when birds are most likely to occur and be breeding in your project area, view the Probability of Presence Summary. Additional measures or permits may be advisable depending on the type of activity you are conducting and the type of infrastructure or bird species present on your project site. What does IPaC use to generate the list of migratory birds that potentially occur in my specified location? The Migratory Bird Resource List is comprised of USFWS Birds of Conservation Concern (BCQ and other species that may warrant special attention in your project location. 03/10/2023 5 The migratory bird list generated for your project is derived from data provided by the Avian Knowledge Network (AKN). The AKN data is based on a growing collection of survey, banding, and citizen science datasets and is queried and filtered to return a list of those birds reported as occurring in the 10km grid cell(s) which your project intersects, and that have been identified as warranting special attention because they are a BCC species in that area, an eagle (Eagle Act requirements may apply), or a species that has a particular vulnerability to offshore activities or development. Again, the Migratory Bird Resource list includes only a subset of birds that may occur in your project area. It is not representative of all birds that may occur in your project area. To get a list of all birds potentially present in your project area, please visit the Rapid Avian Information Locator (RAIL,) Tool. What does IPaC use to generate the probability of presence graphs for the migratory birds potentially occurring in my specified location? The probability of presence graphs associated with your migratory bird list are based on data provided by the Avian Knowledge Network (AKN). This data is derived from a growing collection of survey, banding, and citizen science datasets. Probability of presence data is continuously being updated as new and better information becomes available. To learn more about how the probability of presence graphs are produced and how to interpret them, go the Probability of Presence Summary and then click on the "Tell me about these graphs" link. How do I know if a bird is breeding, wintering or migrating in my area? To see what part of a particular bird's range your project area falls within (i.e. breeding, wintering, migrating or year-round), you may query your location using the RAIL Tool and look at the range maps provided for birds in your area at the bottom of the profiles provided for each bird in your results. If a bird on your migratory bird species list has a breeding season associated with it, if that bird does occur in your project area, there may be nests present at some point within the timeframe specified. If "Breeds elsewhere" is indicated, then the bird likely does not breed in your project area. What are the levels of concern for migratory birds? Migratory birds delivered through IPaC fall into the following distinct categories of concern: 1. "BCC Rangewide" birds are Birds of Conservation Concern (BCC) that are of concern throughout their range anywhere within the USA (including Hawaii, the Pacific Islands, Puerto Rico, and the Virgin Islands); 2. "BCC - BCR" birds are BCCs that are of concern only in particular Bird Conservation Regions (BCRs) in the continental USA; and 3. "Non -BCC - Vulnerable" birds are not BCC species in your project area, but appear on your list either because of the Eagle Act requirements (for eagles) or (for non -eagles) potential susceptibilities in offshore areas from certain types of development or activities (e.g. offshore energy development or longline fishing). 03/10/2023 6 Although it is important to try to avoid and minimize impacts to all birds, efforts should be made, in particular, to avoid and minimize impacts to the birds on this list, especially eagles and BCC species of rangewide concern. For more information on conservation measures you can implement to help avoid and minimize migratory bird impacts and requirements for eagles, please see the FAQs for these topics. Details about birds that are potentially affected by offshore projects For additional details about the relative occurrence and abundance of both individual bird species and groups of bird species within your project area off the Atlantic Coast, please visit the Northeast Ocean Data Portal. The Portal also offers data and information about other taxa besides birds that may be helpful to you in your project review. Alternately, you may download the bird model results files underlying the portal maps through the NOAA NCCOS Integrative Statistical Modeling and Predictive Mapping of Marine Bird Distributions and Abundance on the Atlantic Outer Continental Shelf project webpage. Bird tracking data can also provide additional details about occurrence and habitat use throughout the year, including migration. Models relying on survey data may not include this information. For additional information on marine bird tracking data, see the Diving Bird Study and the nanotag studies or contact Caleb Spiegel or Pam Lorin. What if I have eagles on my list? If your project has the potential to disturb or kill eagles, you may need to obtain a permit to avoid violating the Eagle Act should such impacts occur. Proper Interpretation and Use of Your Migratory Bird Report The migratory bird list generated is not a list of all birds in your project area, only a subset of birds of priority concern. To learn more about how your list is generated, and see options for identifying what other birds may be in your project area, please see the FAQ "What does IPaC use to generate the migratory birds potentially occurring in my specified location". Please be aware this report provides the "probability of presence" of birds within the 10 km grid cell(s) that overlap your project; not your exact project footprint. On the graphs provided, please also look carefully at the survey effort (indicated by the black vertical bar) and for the existence of the "no data" indicator (a red horizontal bar). A high survey effort is the key component. If the survey effort is high, then the probability of presence score can be viewed as more dependable. In contrast, a low survey effort bar or no data bar means a lack of data and, therefore, a lack of certainty about presence of the species. This list is not perfect; it is simply a starting point for identifying what birds of concern have the potential to be in your project area, when they might be there, and if they might be breeding (which means nests might be present). The list helps you know what to look for to confirm presence, and helps guide you in knowing when to implement conservation measures to avoid or minimize potential impacts from your project activities, should presence be confirmed. To learn more about conservation measures, visit the FAQ "Tell me about conservation measures I can implement to avoid or minimize impacts to migratory birds" at the bottom of your migratory bird trust resources page. 03/10/2023 WETLANDS Impacts to NWI wetlands and other aquatic habitats may be subject to regulation under Section 404 of the Clean Water Act, or other State/Federal statutes. For more information please contact the Regulatory Program of the local U.S. Army Corps of Engineers District. Please note that the NWI data being shown may be out of date. We are currently working to update our NWI data set. We recommend you verify these results with a site visit to determine the actual extent of wetlands on site. RIVERINE • R5UBH FRESHWATER FORESTED/SHRUB WETLAND • PF01Ch FRESHWATER POND • PUBHh 03/10/2023 IPAC USER CONTACT INFORMATION Agency: Pilot Environmental, Inc Name: David Brame Address: 743 Park Lawn Court City: Kernersville State: NC Zip: 27284 Email dbrame@pilotenviro.com Phone: 3363104527 NCHPO HPOWEB Ce `.0%4f jo z J � _ o LL C- e mos or ?1// c; Sj3ririg F0S " 5 faot'etid 005. Ln 3/10/2023, 2:25:20 PM Surveyed Only individual resources & centerpoints Surveyed Only Surveyed Only, Gone DOE individual resources & centerpoints DOE, Gone Counties (outline) W Black Jack #c, h'} I r °f m ex P� 1'r dl. iz a 41L ,a FYOW Jessie Thomas "Jessie Pete" Conrad Hou u U FRrTH splicr16eadow Lo FY0642` brm a 09mid Hou-"e 7amah2rwk Or = - W o ry � - 3 Wi n dw-ur1h Dr FY0673 •ZJglar House r FY0672 Frederick Leonard Ziglar House FY=3 House s Birrhdale Dr RV'0`ll.'ripOd Rd Tj O O ' Gbinhoob v0pAV d 1:18,056 0 0.13 0.25 0.5 mi 0 0.2 0.4 0.8 km State of North Carolina DOT, Esri, HERE, Garmin, INCREMENT P, NGA, USGS North Carolina State Historic Preservation Office State of North Carolina DOT, Esri, HERE, Garmin, INCREMENT P, NGA, USGS David Brame From: Heather LaGamba Sent: Friday, December 23, 2022 9:54 AM To: 401 PreFile@ncdenr.gov Subject: Pre -File Notice - Shelton Lake Dam Repair - Max Drive (8927) We would like to submit a Pre -filing Notice for the following project: Project Name: Shelton Lake Dam Repair - Max Drive (8927) Project Owner: Lamour Faith Beata Project Owner's Address: 2440 Lake Forest Drive, Winston-Salem, NC 27106 Project County: Forsyth Type of project/Approval Sought: 401 WQC, Pre -Application Request Meeting Declined Thank you and have a wonderful day! Sincerely, Heather LaGamba 336.345.9536 (c) 336.310.4527 (o) P.O. Box 128 Kernersville, NC 27285 www.pilotenviro.com hlagamba@pilotenviro.com Jurisdictional Determination Request US Army Corps ai Engineers VViPnirUbri DnAiial This form is intended for use by anyone requesting a jurisdictional determination (JD) from the U.S. Army Corps of Engineers, Wilmington District (Corps). Please include all supporting information, as described within each category, with your request. You may submit your request via mail, electronic mail, or facsimile. Requests should be sent to the appropriate project manager of the county in which the property is located. A current list of project managers by assigned counties can be found on-line at: http://www.saw.usace.aM.mil/Missions/Re ul�atoryPermitProaram/Contact/CountyLocator.aspx, by calling 910-251-4633, or by contacting any of the field offices listed below. Once your request is received you will be contacted by a Corps project manager. ASHEVILLE & CHARLOTTE REGULATORY FIELD OFFICES US Army Corps of Engineers 151 Patton Avenue, Room 208 Asheville, North Carolina 28801-5006 General Number: (828) 271-7980 Fax Number: (828) 281-8120 RALEIGH REGULATORY FIELD OFFICE US Army Corps of Engineers 3331 Heritage Trade Drive, Suite 105 Wake Forest, North Carolina 27587 General Number: (919) 554-4884 Fax Number: (919) 562-0421 INSTRUCTIONS: WASHINGTON REGULATORY FIELD OFFICE US Army Corps of Engineers 2407 West Fifth Street Washington, North Carolina 27889 General Number: (910) 251-4610 Fax Number: (252) 975-1399 WILMINGTON REGULATORY FIELD OFFICE US Army Corps of Engineers 69 Darlington Avenue Wilmington, North Carolina 28403 General Number: 910-251-4633 Fax Number: (910) 251-4025 All requestors must complete Parts A, B, C, D, E, F and G. NOTE TO CONSULTANTS AND AGENCIES: If you are requesting a JD on behalf of a paying client or your agency, please note the specific submittal requirements in Part H. NOTE ON PART D — PROPERTY OWNER AUTHORIZATION: Please be aware that all JD requests must include the current property owner authorization for the Corps to proceed with the determination, which may include inspection of the property when necessary. This form must be signed by the current property owner(s) or the owner(s) authorized agent to be considered a complete request. NOTE ON PART D - NCDOT REQUESTS: Property owner authorization/notification for JD requests associated with North Carolina Department of Transportation (NCDOT) projects will be conducted according to the current NCDOT/USACE protocols. NOTE TO USDA PROGRAM PARTICIPANTS: A Corps approved or preliminary JD may not be valid for the wetland conservation provisions of the Food Security Act of 1985. If you or your tenant are USDA Program participants, or anticipate participation in USDA programs, you should also request a certified wetland determination from the local office of the Natural Resources Conservation Service, prior to starting work. Version: May 2017 Page 1 Jurisdictional Determination Request A. PARCEL INFORMATION Street Address: 4003 Max Drive City, State: Winston-Salem, NC County: Forsyth Parcel Index Number(s) (PIN): 5897-21-3737.00 B. REQUESTOR INFORMATION Name: David Brame, Pilot Environmental, Inc. Mailing Address: Post Office Box 128 Kernersville, NC 27285 Telephone Number: 336-310-4527 Electronic Mail Address: dbrame@pilotenviro.com Select one: I am the current property owner. I am an Authorized Agent or Environmental Consultant' Interested Buyer or Under Contract to Purchase Other, please explain. C. PROPERTY OWNER INFORMATION` Name: Obrein Southern Trenching Mailing Address: PO Box 849 Rural Hall, NC 27045 Telephone Number: 336-969-0460 Electronic Mail Address: tobrien@obriensouthern.com 1 Must provide completed Agent Authorization Form/Letter. 2 Documentation of ownership also needs to be provided with request (copy of Deed, County GTS/Parcel/Tax Record). Version: May 2017 Page 2 Jurisdictional Determination Request D. PROPERTY ACCESS CERTIFICATION',4 By signing below, I authorize representatives of the Wilmington District, U.S. Army Corps of Engineers (Corps) to enter upon the property herein described for the purpose of conducting on - site investigations, if necessary, and issuing a jurisdictional determination pursuant to Section 404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors Act of 1899. I, the undersigned, am either a duly authorized owner of record of the property identified herein, or acting as the duly authorized agent of the owner of record of the property. Print Name Capacity: ❑✓ Owner [:]Authorized Agents Date Attached Signature E. REASON FOR JD REQUEST: (Check as many as applicable) ❑ I intend to construct/develop a project or perform activities on this parcel which would be designed to avoid all aquatic resources. ❑ I intend to construct/develop a project or perform activities on this parcel which would be designed to avoid all jurisdictional aquatic resources under Corps authority. I intend to construct/develop a projector perform activities on this parcel which may require authorization from the Corps, and the JD would be used to avoid and minimize impacts to jurisdictional aquatic resources and as an initial step in a future permitting process. ❑✓ I intend to construct/develop a projector perform activities on this parcel which may require authorization from the Corps; this request is accompanied by my permit application and the JD is to be used in the permitting process. ❑ I intend to construct/develop a projector perform activities in a navigable water of the U.S. which is included on the district Section 10 list and/or is subject to the ebb and flow of the tide. ❑ A Corps JD is required in order obtain my local/state authorization. ❑ I intend to contest jurisdiction over a particular aquatic resource and request the Corps confirm that jurisdiction does/does not exist over the aquatic resource on the parcel. ❑ I believe that the site may be comprised entirely of dry land. ❑ Other: For NCDOT requests following the current NCDOT/USACE protocols, skip to Part E. ' If there are multiple parcels owned by different parties, please provide the following for each additional parcel on a continuation sheet. 5 Must provide agent authorization form/letter signed by owner(s). Version: May 2017 Page 3 Jurisdictional Determination Request F. JURISDICTIONAL DETERMINATION (JD) TYPE (Select One) ❑� I am requesting that the Corps provide a preliminary JD for the property identified herein. A Preliminary Jurisdictional Determination (PJD) provides an indication that there may be "waters of the United States" or "navigable waters of the United States"on a property. PJDs are sufficient as the basis for permit decisions. For the purposes of permitting, all waters and wetlands on the property will be treated as if they are jurisdictional "waters of the United States". PJDs cannot be appealed (33 C.F.R. 331.2); however, a PJD is "preliminary" in the sense that an approved JD can be requested at any time. PJDs do not expire. ❑ I am requesting that the Corps provide an approved JD for the property identified herein. An Approved Jurisdictional Determination (AJD) is a determination that jurisdictional "waters of the United States" or "navigable waters of the United States" are either present or absent on a site. An approved JD identifies the limits of waters on a site determined to be jurisdictional under the Clean Water Act and/or Rivers and Harbors Act. Approved JDs are sufficient as the basis for permit decisions. AJDs are appealable (33 C.F.R. 331.2). The results of the AJD will be posted on the Corps website. A landowner, permit applicant, or other "affected party" (33 C.F.R. 331.2) who receives an AJD may rely upon the AJD for five years (subject to certain limited exceptions explained in Regulatory Guidance Letter 05- 02). ❑ I am unclear as to which JD I would like to request and require additional information to inform my decision. G. ALL REQUESTS Map of Property or Project Area. This Map must clearly depict the boundaries of the review area. Size of Property or Review Area — 2.61 acres. ❑ The property boundary (or review area boundary) is clearly physically marked on the site. Version: May 2017 Page 4 Jurisdictional Determination Request H. REQUESTS FROM CONSULTANTS Project Coordinates (Decimal Degrees): Latitude Longitude 36.1370230 -80.380482 A legible delineation map depicting the aquatic resources and the property/review area. Delineation maps must be no larger than l 1x17 and should contain the following: (Corps signature of submitted survey plats will occur after the submitted delineation map has been reviewed and approved).6 ■ North Arrow ■ Graphical Scale ■ Boundary of Review Area ■ Date ■ Location of data points for each Wetland Determination Data Form or tributary assessment reach. For Approved Jurisdictional Determinations: Jurisdictional wetland features should be labeled as Wetland Waters of the US, 404 wetlands, etc. Please include the acreage of these features. Jurisdictional non -wetland features (i.e. tidal/navigable waters, tributaries, impoundments) should be labeled as Non -Wetland Waters of the US, stream, tributary, open water, relatively permanent water, pond, etc. Please include the acreage or linear length of each of these features as appropriate. Isolated waters, waters that lack a significant nexus to navigable waters, or non - jurisdictional upland features should be identified as Non -Jurisdictional. Please include a justification in the label regarding why the feature is non jurisdictional (i.e. "Isolated", "No Significant Nexus", or "Upland Feature"). Please include the acreage or linear length of these features as appropriate. For Preliminary Jurisdictional Determinations: Wetland and non -wetland features should not be identified as Jurisdictional, 404, Waters of the United States, or anything that implies jurisdiction. These features can be identified as Potential Waters of the United States Potential Non -wetland Waters of the United States, wetland, stream, open water, etc. Please include the acreage and linear length of these features as appropriate. ul Completed Wetland Determination Data Forms for appropriate region (at least one wetland and one upland form needs to be completed for each wetland type) e Please refer to the guidance document titled "Survey Standards for Jurisdictional Determinations" to ensure that the supplied map meets the necessary mapping standards. http://www.saw.usace.army.mil/Missions/Regulatory-Permit- Pro gram/Jurisdiction/ Version: May 2017 Page 5 Jurisdictional Determination Request RICompleted appropriate Jurisdictional Determination form • PJDs, please complete a Preliminary Jurisdictional Determination Form' and include the Aquatic Resource Table • AJDs, please complete an Approved Jurisdictional Determination Form' Vicinity Map Aerial Photograph R] USGS Topographic Map ❑� Soil Survey Map RIOther Maps, as appropriate (e.g. National Wetland Inventory Map, Proposed Site Plan, previous delineation maps, LIDAR maps, FEMA floodplain maps) Landscape Photos (if taken) NCSAM and/or NCWAM Assessment Forms and Rating Sheets ❑ NC Division of Water Resources Stream Identification Forms ❑ Other Assessment Forms ' www.saw.usace.army.mil/Portals/59/docs/re"latory/regdocs/JD/RGL 08-02_App A Prelim_ JD_ Form_fillable.pdf ' Please see http://www.saw.usace.army.mil/Missions/Re ug latory-Permit-Program/Jurisdiction/ Principal Purpose: The information that you provide will be used in evaluating your request to determine whether there are any aquatic resources within the project area subject to federal jurisdiction under the regulatory authorities referenced above. Routine Uses: This information may be shared with the Department of Justice and other federal, state, and local government agencies, and the public, and may be made available as part of a public notice as required by federal law. Your name and property location where federal jurisdiction is to be determined will be included in the approved jurisdictional determination (AJD), which will be made available to the public on the District's website and on the Headquarters USAGE website. Disclosure: Submission of requested information is voluntary; however, if information is not provided, the request for an AJD cannot be evaluated nor can an AJD be issued. Version: May 2017 Page 6 AGENT AUTHORIZATION This form authorizes Pilot to act as our agent in stream/wetland matters including U.S. Army Corps of Engineers and North Carolina Division of Water Resources field verification and permitting. Property Address: ���j 14 C. Y_- D � ,,.& M- ,,, S s,-' A& Owner Information: Name: c t t t :sctf M r�.t� Lr�.►.c. Address: ra Telephone Number: �_3 3-4 1-- 96 '— D Cn 0 _,.. Fax Number: E-mail Address: Signatu re: �_ _,5) 7,gc�� 12/22/22, 9:21 AM about:blank Image Area of Interest (AOI) Information Area : 113,680.37 ft2 Dec 22 2022 9:20:48 Eastern Standard Time 1.1 c Basic Info Report 26T 61 .; q N:l e1-2-17.I111 0 v ti- � F k, cv r Address Points ------ Easement 0 Forsyth County Boundary 2101 & Aeri al I ma gery Streets Red: Barad-1 Parcels Green: Band-2 Parcels - Mai ling Labels Blue: Band-3 .......... Legal Lot Lines 1:1.129 0 4.01 0.01 0.03 mi 0 0.01 0.02 0.04 kir) FEAAA.MnFe yh Fos^ CwmyTaw A7mmi,1—,-- about:blank 1/2 12/22/22, 9:21 AM Parcel Information about:blank Current Owner Current Owner Total Assessed Recorded # Parcel ID 1 2 Value ($) Acreage Zoning Area(ft2) 5897-31- LAMOUR FAITH 1 0259.000 B EATA 211100 2.61 RS9 113,680.37 Official Address Information # I Address Zip Code Use Description 1 2440 LAKE FOREST DR 27106 Residential Building, Single Family Zoning is as of January 1st. Area calculation is computer generated estimate only, not used in Tax Assessment or Valuation. For official tax related information, please contact Forsyth County Tax Administration 336-703-2300 Count about:blank 2/2 12/22/22, 9:20 AM Print Property Info Forsyth County Property Record Card Property Summary Tax Year: 2022 REID 5897310259000 PIN 5897-31-0259 Property Owner LAMOUR, FAITH BEATA 2440 Lake Forest DR L0026J BL4611 2440 Lake Forest Dr Location Address Property Description Owner's Mailing Address Winston Salem NC 27106 Administrative Data Plat Book & Page Old Map # Market Area Township Planning Jurisdiction City Fire District Spec District Land Class History REID 1 History REID 2 Acreage Permit Date Permit # 588870 594871 VIENNA COUNTY WIDE VIENNA COUNTYWIDE FIRE 1.01-SFD Dwelling 2.61 Transfer Information Deed Date Deed Book Deed Page Revenue Stamps Package Sale Date Package Sale Price Land Sale Date Land Sale Price Improvement Summary Total Buildings Total Units Total Living Area Total Gross Leasable Area 8/21 /2018 003421 00470 $500 8/21 /2018 $250,000 1 0 1,827 0 Property Value Total Appraised Land Value $58,500 Total Appraised Building Value $151,600 Total Appraised Misc $1,000 Improvements Value Total Cost Value $211,100 Total Appraised Value -valued By $211,100 Cost Other Exemptions Exemption Desc Use Value Deferred Historic Value Deferred Total Deferred Value Total Taxable Value $211,100 https://Ircpwa.ncptscloud.com/forsyth/PrintPRC.aspx?PARCELPK=90415 1 /3 12/22/22, 9:20 AM Building Summary Card 1 2440 Lake Forest DR Building Details Bldg Type RESIDENTIAL Units 0 Living Area (SQFT) 1827 Number of Stories 1.00 Style RANCH Foundation MASONRY Frame MASONRY Exterior BRICK Const Type Heating Forced Warm Air Air Cond NONE Baths (Full) 2 Baths (Half) 0 Extra Fixtures 0 Total Plumbing 6 Fixtures Bedrooms 3 CARPET - Floor HARDWOOD Roof Cover Asphalt Shingle Roof Type GABLE Main Body (SQFT) 1827 Addition Summary Story Type 1.00 CARPORT GOOD 1.00 PATIO LC 1.00 LANDING AVERAGE 1.00 OPEN FRAME PORCH 1.00 PATIO AVERAGE 1.00 BASEMENT-FIN-AVG-NR 1.00 BASEMENT-UNFIN-CF 1.00 LANDING AVERAGE-R Building Sketch Print Property Info Building Description Year 1964 1992 Built Effective Year Additions 8 Remodeled 0 FIREPLACE AVERAGE (2.00) ADD Interior Adj FIREPLACE AVERAGE (1.00) Other Features Photograph Building Total & Improvement Details Grade C 100% Percent Complete 100 Total Adjusted Replacement $229,738 Cost New Physical Depreciation (% AVER Bad) 34% Depreciated Value $151,627 Economic Depreciation (% 0 Bad) Functional Depreciation (% 0 Bad) Total Depreciated Value $151,627 Market Area Factor 1 Building Value $151,600 Misc Improvements Value $1,000 Total Improvement Value $152,600 Assessed Land Value Assessed Total Value Code Area CARP 375 PATI 264 LAND 30 OPEN 192 PATI 192 BASE 550 BASE 1277 LAND 1 https://Ircpwa.ncptscloud.com/forsyth/PrintPRC.aspx?PARCELPK=90415 2/3 12/22/22, 9:20 AM Print Property Info Misc Improvements Summary 4611 026J 01 02/15/2007 Card Unit Base Eff Phys Depr Econ Depr Funct Depr Common Interest Measure Type o 0 0 o Value # Quantity Price Year (/o Bad) (/o Bad) (/o Bad) (/o Good) 1 32x22 DIMENSIONS BARN- $20.00 1964 90 0 29 $1,000 FRM-R Total Misc Improvements Value Assessed: $1,000 Land Summary Land Class: 1.01-SFD Dwelling Deeded Acres: 2.61 Zoning Soil Class Description Size Rate RS9 RES-LOT 1.00 BY THE UNIT PRICE $40,000 Total Land Value Assessed: $58,500 Ownership History Owner Name Current LAMOUR, FAITH BEATA 1 Back Shellberg, Amy M 2 Back Shellberg, Steven R/ Shellberg, Amy M 3 Back Boles, Vernice P Notes Summary Building Card No Data Calculated Acres: 2.61 Size Adj. Factor Land Adjustment Land Value LOCATION-90.00 $58,500 TOPOGRAPHY-95.00 SHAPE-95.00 SIZE ADJUSTMENT-180.00 Deed Type %Ownership Stamps Sale Price Book Page Deed Date DEED 100 500 $250, 000 003421 00470 8/21 /2018 DEED 100 0 003268 04127 1 /25/2016 DEED 100 286 $143, 000 002184 02463 6/29/2001 DEED 100 0 000883 00151 6/10/1964 Date Line Notes https://Ircpwa.ncptscloud.com/forsyth/PrintPRC.aspx?PARCELPK=90415 3/3 { ' : � '� � - - ._. ..'_ +- � - '� � -� _i - �' .ram+ r - � ... - •• �. �� .- ��? r .r ' � .E� b - �}F I•� is � '��� �� a N.:St, ' SQL �1\ 15 � � • TT4. + •• � {•• 4 "' � �'S, • _ , ti ,]I 'd x. LYA � _ � _ . l — ,4�e�.��_` _=-F="r'�' t '. 5-� - -I rL �F' �• k Drawing 1 USGS Topographic Map Vienna, Rural Hall, Clemmons and Winston-Salem West, NC Quadrangles Scale: 1" = 2,000' PILM PILOT E4 5" RO •IM :NTAL. I%C . - LEGEND Site Boundary USGS Topographic Map Shelton Lake Dam Approximate 4.5-Acre Tract Winston-Salem, Forsyth County, NC Pilot Project 8927 I ^ — ` ' -` ---- .�� - zwnp LEGEND Site Boundary Web Soil Map 0ran«n�� ' ' Shelton Lake Dam USDA Web Soil Survey ' ofForsyth County, NC Approxirnate4.5-AoreTract ` ~ Winston-Salem, Forsyth County, NC Scale: 1, = ZOO, Drawing 2A USDA Soil Survey of Forsyth County, NC Published 1976 Scale: 1" = 200' tP L 0 T Ek !' RU 4M NTAL. h C Published Soil Map Shelton Lake Dam Approximate 4.5-Acre Tract Winston-Salem, Forsyth County, NC Pilot Project 8927 I AL. A' 11"�' J t... 4 "s, JA I a. N �'LEGEND k SIW Pkikin-Jo-y Frc-AviAcr ErrilrrdLn I Frkshwator FL5t&.T1M/5hrub ELjal im dli id Marino D4xpwAv Uwarim and Marine it frcAmEtcr Pond Lam NWI Map Drawing 3 Shelton Lake Dam USFWS NWI Approximate 4.5-Acre Tract Wetlands Mapper Winston-Salem, Forsyth County, NC Scale: 1" = 200' Pilot Project 8927 I11. ;J I LEI eersru-� - +.. a e LEGEND Site Boundary 91 %Annual Chance Flood Hazard MRegulatory Floodsvay Y-. p Sped al Flood ny Area of Undetermined Flood Hazard " a ' 0.2%Annual Chance Flood Hazard �! Future Conditions 1 %Annual Chance Flood Hazard rdAre@with Reduced Risk Due to Levee R �+ Drawing 4 National Flood Hazard Layer ` FEMA FIRM Shelton Lake Dam ;w Approximate 4.5-Acre Tract pp from FEMA Web Map Service Scale: 1" - 1 000' �.;���� Winston-Salem, Forsyth County, NC - , PILOT E%V-PONN-NTAL. KC Pilot Project8927 •,t � i � -bk �, C11�• 'ry I TIC i- ■ 0i.5'Ad! �.� LEGEND Site Boundary 0 Pond Perennial Stream DP-10 Data Point Drawing 5 Aerial Imagery from ESR and Pilot GPS Data Scale: 1" = 200' Date: 3.10.2023 THE LOCATIONS OF FEATURES SHOWN ON THIS MAP ARE PRELIMINARY. THEY HAVE NOT BEEN VERIFIED BY THE USACE. DELINEATION COMPLETED BY PILOT ON DECEMBER 21, 2023. Wetland Map :,: Shelton Lake Dam �, --- Approximate 4.5-Acre Tract 'L Winston-Salem, Forsyth County, NC P fRILOT' Exh"6nNlu=uT,,t. p'C Pilot Project8927 C .,de_Cotle HUM_Cade NWPR_Oeieimiee_C PA NORTH OLINA Li LACUSTRINF N- 15ACRE PJO404 30l3 OT A0300522° Tomahawk Qeek SA SOUTH C OLINA R5 RIV NE Ling 75 FOOT PJO404 30135T11° A030000T Tomahawk Qeek U.S. Army Corps of Engineers OMSControl#:0710-xxxx,Exp:Pending WETLAND DETERMINATION DATA SHEET— Eastern Mountains and Piedmont Region Requirement Control Symbol EXEMPT. See ERDC/EL TR-07-24; the proponent agency is CECW-CO-R (Authority. AR336-15,paragraph 52a) Project/Site: Shelton Lake Dam City/County: Winston-Salem/Forsyth Sampling Date: 12.21.22 Applicant/Owner: O'Brien State: NC Sampling Point: DP-1 Investigator(s): David Brame/Michael Brame Section, Township, Range: NA Landform (hillside, terrace, etc.): Floodplain Local relief (concave, convex, none): flat Slope (%): 0-2 Subregion (LRR or MLRA): LRR P, MLRA 136 Lat: 36.135776' Long:-80.380520' Datum: wgs 84 Soil Map Unit Name: CID: Clifford sandy loam NWI classification: upland Are climatic / hydrologic conditions on the site typical for this time of year? Yes X No (If no, explain in Remarks.) Are Vegetation Soil or Hydrology significantly disturbed? Are "Normal Circumstances' present? Yes X No Are Vegetation Soil or Hydrology naturally problematic? (If needed, explain any answers in Remarks.) SUMMARY OF FINDINGS — Attach site map showing sampling point locations, transects, important features, etc. Hydrophytic Vegetation Present? Yes No X Is the Sampled Area Hydric Soil Present? Yes No X within a Wetland? Yes No X Wetland Hydrology Present? Yes No X Remarks: HYDROLOGY Wetland Hydrology Indicators: Secondary Indicators (minimum of two required) Primary Indicators (minimum of one is required: check all that apply) —Surface Soil Cracks (136) _ Surface Water (Al) —True Aquatic Plants (1314) _ Sparsely Vegetated Concave Surface (138) _ High Water Table (A2) _ Hydrogen Sulfide Odor (Cl) —Drainage Patterns (1310) _ Saturation (A3) —Oxidized Rhizospheres on Living Roots (C3) _ Moss Trim Lines (1316) —Water Marks (131) _ Presence of Reduced Iron (C4) _ Dry -Season Water Table (C2) —Sediment Deposits (132) _ Recent Iron Reduction in Tilled Soils (C6) _ Crayfish Burrows (C8) _ Drift Deposits (133) —Thin Muck Surface (C7) _ Saturation Visible on Aerial Imagery (C9) —Algal Mat or Crust (134) _ Other (Explain in Remarks) —Stunted or Stressed Plants (D1) _ Iron Deposits (135) _ Geomorphic Position (D2) _ Inundation Visible on Aerial Imagery (137) —Shallow Aquitard (D3) —Water-Stained Leaves (139) _ Microtopographic Relief (D4) Aquatic Fauna (1313) FAC-Neutral Test (D5) Field Observations: Surface Water Present? Yes No X Depth (inches): Water Table Present? Yes No X Depth (inches): Saturation Present? Yes No X Depth (inches): Wetland Hydrology Present? Yes No X (includes capillary fringe) Describe Recorded Data (stream gauge, monitoring well, aerial photos, previous inspections), if available: Remarks: ENG FORM 6116-4-SG, JUL 2018 Eastern Mountains and Piedmont —Version 2.0 VEGETATION (Four Strata) - Use scientific names of plants. Sampling Point: DP-1 Tree Stratum (Plot size: 30 ) 1. Liriodendron tulipifera 2. Quercus alba 3. Quercus nigra 4. 5. 6. 7. 50% of total cover: 38 Sapling/Shrub Stratum (Plot size: 15 ) 1. Liquidambar styraciflua 2. Fagus grandifolia 3. Acer rubrum 4. Carya tomentosa 5. 6. 7. 8. 9. 50% of total cover: 15 Herb Stratum (Plot size: 5 ) 1. Ilex opaca 2. Allium canadense 3. Hedera helix 4. Polystichum acrostichoides 5. Smilax rotundifolia 6. 7. 8. 9. 10. 11. 50% of total cover: 15 Woody Vine Stratum (Plot size: 30 ) 1. Toxicodendron radicans 2. 3. 4. 5. Absolute Dominant Indicatc % Cover Species? Status 45 Yes FACU 20 Yes FACU 10 No FAC 20% of total cover: 15 10 Yes FACU 5 No FAC 10 Yes UPL 30 =Total Cover 20% of total cover: 6 5 Yes FACU 5 Yes FACU 10 Yes FACU 5 Yes FACU 5 Yes FAC 30 =Total Cover 20% of total cover: 6 10 Yes FAC 10 =Total Cover 50% of total cover: 5 20% of total cover: 2 Remarks: (Include photo numbers here or on a separate sheet.) Dominance Test worksheet: Number of Dominant Species That Are OBL, FACW, or FAC: 2 (A) Total Number of Dominant Species Across All Strata: 10 (B) Percent of Dominant Species That Are OBL, FACW, or FAC: 20.0% (A/B) Prevalence Index worksheet: Total % Cover of: Multiply by: OBL species 0 x 1 = 0 FACW species 0 x 2 = 0 FAC species 35 x 3 = 105 FACU species 100 x 4 = 400 UPL species 10 x 5 = 50 Column Totals: 145 (A) 555 (B) Prevalence Index = B/A = 3.83 Hydrophytic Vegetation Indicators: _ 1 - Rapid Test for Hydrophytic Vegetation -2 - Dominance Test is >50% _ 3 - Prevalence Index is 53.01 4 - Morphological Adaptations' (Provide supporting data in Remarks or on a separate sheet) Problematic Hydrophytic Vegetation' (Explain) Indicators of hydric soil and wetland hydrology must be present, unless disturbed or problematic. Definitions of Four Vegetation Strata: Tree- Woody plants, excluding vines, 3 in. (7.6 cm) or more in diameter at breast height (DBH), regardless of height. Sapling/Shrub -Woody plants, excluding vines, less than 3 in. DBH and greater than or equal to 3.28 ft (1 m) tall. Herb -All herbaceous (non -woody) plants, regardless of size, and woody plants less than 3.28 ft tall. Woody Vine -All woody vines greater than 3.28 ft in height. Hydrophytic Vegetation Present? Yes No X ENG FORM 6116-4-SG, JUL 2018 Eastern Mountains and Piedmont - Version 2.0 SOIL Sampling Point: DP-1 Profile Description: (Describe to the depth needed to document the indicator or confirm the absence of indicators.) Depth Matrix Redox Features (inches) Color (moist) % Color (moist) % Types Loc2 Texture Remarks 0-4 10yr 4/4 100 Loamy/Clayey 4-18 7.5yr 4/6 100 Loamy/Clayey Type: C=Concentration, D=Depletion, RM=Reduced Matrix, MS=Masked Sand Grains. 2Location: PL=Pore Lining, M=Matrix. Hydric Soil Indicators: Indicators for Problematic Hydric Soils3: _ Histosol (Al) _ Polyvalue Below Surface (S8) (MLRA 147, 148) _ 2 cm Muck (A10) (MLRA 147) _ Histic Epipedon (A2) —Thin Dark Surface (S9) (MLRA 147, 148) —Coast Prairie Redox (A16) _ Black Histic (A3) _ Loamy Mucky Mineral (F1) (MLRA 136) (MLRA 147, 148) _ Hydrogen Sulfide (A4) _ Loamy Gleyed Matrix (F2) _ Piedmont Floodplain Soils (F19) _ Stratified Layers (A5) _ Depleted Matrix (F3) (MLRA 136, 147) _ 2 cm Muck (A10) (LRR N) _ Redox Dark Surface (F6) _ Red Parent Material (F21) _ Depleted Below Dark Surface (A11) _ Depleted Dark Surface (F7) (outside MLRA 127, 147, 148) —Thick Dark Surface (Al 2) _ Redox Depressions (F8) —Very Shallow Dark Surface (F22) —Sandy Mucky Mineral (S1) _ Iron -Manganese Masses (F12) (LRR N, _ Other (Explain in Remarks) _ Sandy Gleyed Matrix (S4) MLRA 136) _ Sandy Redox (S5) _ Umbric Surface (F13) (MLRA 122, 136) 3Indicators of hydrophytic vegetation and _ Stripped Matrix (S6) _ Piedmont Floodplain Soils (F19) (MLRA 148) wetland hydrology must be present, Dark Surface (S7) Red Parent Material (F21) (MLRA 127, 147, 148) unless disturbed or problematic. Restrictive Layer (if observed): Type: Depth (inches): Hydric Soil Present? Yes No X Remarks ENG FORM 6116-4-SG, JUL 2018 Eastern Mountains and Piedmont —Version 2.0 PRELIMINARY JURISDICTIONAL DETERMINATION (PJD) FORM BACKGROUND INFORMATION A. REPORT COMPLETION DATE FOR PJD: March 10, 2023 B. NAME AND ADDRESS OF PERSON REQUESTING PJD: David Brame, Pilot Environmental, Inc. Post Office Box 128, Kernersville, North Carolina 27285 C. DISTRICT OFFICE, FILE NAME, AND NUMBER: Wilmington, Shelton Lake Dam, SAW 2022- D. PROJECT LOCATION(S) AND BACKGROUND INFORMATION: The site is located at 4003 Max Drive in Winston-Salem, NC. The site contains a pond and wooded land. The dam is proposed for repairs. (USE THE TABLE BELOW TO DOCUMENT MULTIPLE AQUATIC RESOURCES AND/OR AQUATIC RESOURCES AT DIFFERENT SITES) State: North Carolina County/parish/borough: Forsyth County City: Winston-Salem Center coordinates of site (lat/long in degree decimal format): Lat.: 36.137023' Long.:-80.380482' Universal Transverse Mercator: WGS 84 Name of nearest waterbody: Tomahawk Creek E. REVIEW PERFORMED FOR SITE EVALUATION (CHECK ALL THAT APPLY): ❑ Office (Desk) Determination. Date: ❑ Field Determination. Date(s): TABLE OF AQUATIC RESOURCES INREVIEW AREA WHICH "MAY BE" SUBJECT TO REGULATORY JURISDICTION. Site Latitude (decimal Longitude Estimated amount of Type of aquatic Geographic authority to Number degrees) (decimal degrees) aquatic resources in resources (i.e., which the aquatic resource review area (acreage wetland vs. non- "may be" subject (i.e., and linear feet, if wetland waters) Section 404 or Section applicable 10/404 PA 36.1362030 -80.3805220 1.5 Non -wetland 404 SA 36.1357710 -80.3806690 75 Non -wetland 404 1) The Corps of Engineers believes that there may be jurisdictional aquatic resources in the review area, and the requestor of this PJD is hereby advised of his or her option to request and obtain an approved JD (AJD) for that review area based on an informed decision after having discussed the various types of JDs and their characteristics and circumstances when they may be appropriate. 2) In any circumstance where a permit applicant obtains an individual permit, or a Nationwide General Permit (NWP) or other general permit verification requiring "pre- construction notification" (PCN), or requests verification for a non -reporting NWP or other general permit, and the permit applicant has not requested an AJD for the activity, the permit applicant is hereby made aware that: (1) the permit applicant has elected to seek a permit authorization based on a PJD, which does not make an official determination of jurisdictional aquatic resources; (2) the applicant has the option to request an AJD before accepting the terms and conditions of the permit authorization, and that basing a permit authorization on an AJD could possibly result in less compensatory mitigation being required or different special conditions; (3) the applicant has the right to request an individual permit rather than accepting the terms and conditions of the NWP or other general permit authorization; (4) the applicant can accept a permit authorization and thereby agree to comply with all the terms and conditions of that permit, including whatever mitigation requirements the Corps has determined to be necessary; (5) undertaking any activity in reliance upon the subject permit authorization without requesting an AJD constitutes the applicant's acceptance of the use of the PJD; (6) accepting a permit authorization (e.g., signing a proffered individual permit) or undertaking any activity in reliance on any form of Corps permit authorization based on a PJD constitutes agreement that all aquatic resources in the review area affected in any way by that activity will be treated as jurisdictional, and waives any challenge to such jurisdiction in any administrative or judicial compliance or enforcement action, or in any administrative appeal or in any Federal court; and (7) whether the applicant elects to use either an AID or a PJD, the JD will be processed as soon as practicable. Further, an AID, a proffered individual permit (and all terms and conditions contained therein), or individual permit denial can be administratively appealed pursuant to 33 C.F.R. Part 331. If, during an administrative appeal, it becomes appropriate to make an official determination whether geographic jurisdiction exists over aquatic resources in the review area, or to provide an official delineation of jurisdictional aquatic resources in the review area, the Corps will provide an AID to accomplish that result, as soon as is practicable. This PJD fords that there "may be" waters of the U.S. and/or that there "may be" navigable waters of the U.S. on the subject review area, and identifies all aquatic features in the review area that could be affected by the proposed activity, based on the following information: SUPPORTING DATA. Data reviewed for PJD (check all that apply) Checked items should be included in subject file. Appropriately reference sources below where indicated for all checked items: ❑ Maps, plans, plots or plat submitted by or on behalf of the PJD requestor: Map: ® Data sheets prepared/submitted by or on behalf of the PJD requestor. ❑ Office concurs with data sheets/delineation report. ❑ Office does not concur with data sheets/delineation report. Rationale: ❑ Data sheets prepared by the Corps: ❑ Corps navigable waters' study: ❑ U.S. Geological Survey Hydrologic Atlas: ❑ USGS NHD data. ❑ USGS 8 and 12 digit HUC maps. ® U.S. Geological Survey map(s). Cite scale & quad name: Drawing 1 ® Natural Resources Conservation Service Soil Survey. Citation: Drawings 2 & 2A ® National wetlands inventory map(s). Cite name: Drawing 3 ❑ State/local wetland inventory map(s): ® FENWFIRM maps: Drawing 4 ❑ 100-year Floodplain Elevation is: (National Geodetic Vertical Datum of 1929) ® Photographs: ®Aerial (Name & Date): Drawing 5 or ❑Other (Name & Date): ❑ Previous determination(s). File no. and date of response letter: ❑ Other information (please specify): IMPORTANT NOTE: The information recorded on this form has not necessarily been verified by the Corps and should not be relied upon for later jurisdictional determinations. Signature and date of Regulatory staff member completing PJD March 10, 2023 Signature and date of person requesting PJD (REQUIRED, unless obtaining the signature is impracticable)1 1 Districts may establish timeframes for requester to return signed PJD forms. If the requester does not respond within the established time frame, the district may presume concurrence and no additional follow up is necessary prior to finalizing an action.