20231134 Ver 1_ePCN Application_20230811

DWR
Division of Water Resources
Pre -Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
April 13, 2022 Ver 4.3
Initial Review
Has this project met the requirements for acceptance in to the review process?
Yes
No
Is this project a public transportation project?*
Yes No
Change only If needed.
Pre -Filing Meeting Date Request was submitted on:
7/13/2023
BIMS # Assigned
20231134
Is a payment required for this project?*
No payment required
Fee received
Fee needed - send electronic notification
Reviewing Office*
Winston-Salem Regional Office - (336) 776-
9800
Information for Initial Review
1a. Name of project:
Project Kersey Valley
1a. Who is the Primary Contact?*
Dan Lacz
1b. Primary Contact Email: *
[e-mail]
Date Submitted
8/11/2023
Nearest Body of Water
Richland Creek
Basin
Cape Fear
Water Classification
WS-IV
Site Coordinates
Latitude:
35.924529'
A. Processing Information
Is this project connected with ARPA funding?
Yes No
County (or Counties) where the project is located:
Guilford
Is this a NCDMS Project
Yes No
Longitude:
-79.936801 °
Version#*
1
What amout is owed?*
$240.00
$570.00
Select Project Reviewer*
Seren Homer:[e-mail]
1c. Primary Contact Phone: *
[phone]
O

Is this project a public transportation project?*
Yes No
1a.Type(s)of approval sought from the Corps:
Section 404 Permit (wetlands, streams and waters, Clean Water Act)
Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
Has this PCN previously been submitted?*
Yes
No
1b. What type(s) of permit(s) do you wish to seek authorization?
Nationwide Permit (NWP)
Regional General Permit (RGP)
Standard (IP)
1c. Has the NWP or GP number been verified by the Corps?
Yes No
Nationwide Permit (NWP) Number: 18 - Minor Discharges
NWP Numbers (for multiple NWPS):
1d. Type(s) of approval sought from the DWR:
401 Water Quality Certification - Regular
Non-404 Jurisdictional General Permit
Individual 401 Water Quality Certification
401 Water Quality Certification - Express
Riparian Buffer Authorization
le. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification: Yes No
For the record only for Corps Permit: Yes No
1f. Is this an after -the -fact permit application? *
Yes No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
Yes No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
Yes No
1h. Is the project located in any of NC's twenty coastal counties?
Yes No
1j. Is the project located in a designated trout watershed?
Yes No
B. Applicant Information
1d. Who is applying for the permit?
Owner Applicant (other than owner)
le. Is there an Agent/Consultant for this project?
Yes No
2. Owner Information
2a. Name(s) on recorded deed:
Farmers & Merchants Bank
2b. Deed book and page no.:
007323,01568;007323,01568;007323,01568
2c. Contact Person:

2d. Address
Street Address
221 N Main Street
Address Line 2
City
Salisbury
Postal / Zip Code
28144
2e. Telephone Number:
[phone]
2g. Email Address:*
Dan. [e-mail]
3. Applicant Information (if different from owner)
3a. Name:
Dan Lacz
3b. Business Name:
QTR Development Partners
3c.Address
Street Address
120 Village Road
Address Line 2
city
Green Village
Postal / Zip Code
07935
3d. Telephone Number:
[phone]
3f. Email Address:*
Dan. [e-mail]
4. Agent/Consultant (if applicable)
4a. Name:
Jennifer Robertson
4b. Business Name:
Atlas Environmental Inc.
4c.Address
Street Address
338 S. Sharon Amity Road
Address Line 2
city
Charlotte
Postal / Zip Code
28211
4d. Telephone Number:
[phone]
4f. Email Address:*
[e-mail]
C. Project Information and Prior Project History
1. Project Information
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality / town:
Archdale
2. Project Identification
State / Province / Region
North Carolina
Country
USA
2f. Fax Number:
State / Province / Region
New Jersey
Country
USA
3e. Fax Number:
State / Province / Region
North Carolina
Country
USA
4e. Fax Number:
O

2a. Property Identification Number:
211677, 161772, 161633
2b. Property size:
27.15
2c. Project Address
Street Address
1661 Kersey Valley Rd
Address Line 2
city
Archdale
Postal / Zip Code
27263
3. Surface Waters
3a. Name of the nearest body of water to proposed project:"
Richland Creek
3b. Water Resources Classification of nearest receiving water:'
WS-IV
3c. What river basin(s) is your project located it *
Cape Fear
3d. Please provide the 12-digit HUC in which the project is located.
030300030103
4. Project Description and History
State / Province / Region
North Carolina
Country
USA
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 current land use of the review area is almost entirely forested. A power line right of way runs horizontally in the Southwest portion of the review area and a sewer line runs vertically in
the Eastern portion of the review area. The surrounding land use predominantly consists of residential and commercial developments along with forested land. Interstate 85 runs parallel to
the Southern boundary of the review area. The Western portion of the review area abuts the encompassing property boundary of several off -site structures including the Wat Lao American
Buddhist Center, a wireless communications tower owned by American Tower Corporation, and a private residential home.
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?
Yes No Unknown
If yes, please give the DWR Certification number or the Corps Action ID (exp. SAW-0000-00000).
SAW-2023-01050
4f. List the total estimated acreage of all existing wetlands on the property:
0.047 acres
4g. List the total estimated linear feet of all existing streams on the property:
1271 If.
4h. Explain the purpose of the proposed project:*
The project's purpose is for the construction of an industrial building with 277,500 square feet under roof with associated driveways, parking areas, utilities, and additional infrastructure.
41. Describe the overall project in detail, including indirect impacts and the type of equipment to be used: *
One unavoidable wetland impact is proposed as Impact W1 to wetland WL 3000 as 0.043 acre of permanent fill. This impact is required to provide secondary road access. The total area
of wetland impacts under the NWP 18 is 0.043 acres. Heavy machinery will be required for the construction of the project.
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
Yes No
Comments:
5b. If the Corps made a jurisdictional determination, what type of determination was made?
Preliminary Approved Not Verified Unknown N/A
Corps AID Number:
SAW-2023-01050
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known): Atlas Staff
Agency/Consultant Company: Atlas Environmental Inc.
Other:
O Unknown
5d. List the dates of the Corp jurisdiction determination or State determination if a determination was made by the Corps or DWR
Application was submitted May 17, 2023.
6. Future Project Plans

6a. Is this a phased project?*
Yes No
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the proposed project or related activity?
No.
D. Proposed Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
Wetlands Streams -tributaries Buffers
Open Waters Pond Construction
2. Wetland Impacts
O
2a1 Reason (1)
2b. Impact type*(?)
2c. Type of W. *
2d. W. name
2e. Forested*
2f. Type of Jurisdicition *
(?)
29. Impact
area *
W1
road
P
Bottomland Hardwood Forest
WL 3000
Yes
Both
0.043
(acres)
2g. Total Temporary Wetland Impact
0.000
2g. Total Wetland Impact
0.043
2i. Comments:
E. Impact Justification and Mitigation
1. Avoidance and Minimization
2g. Total Permanent Wetland Impact
0.043
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:
The project has been designed and engineered to avoid and minimize impacts to the greatest extent possible. No stream impacts are proposed, and
only one wetland impact is proposed. Over 70 % of the Waters of the United States on -site have been avoided. The total linear feet of streams on site
(1,271 LF) have been avoided completely along with WL 1000 (0.004 acres).
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:
Grading along the roads minimizes impacts to all streams onsite, and minimizes impacts to wetlands.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for impacts to Waters of the U.S. or Waters of the State?
Yes No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
Wetland impacts do not exceed 0.10 acres.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection Rules?
Yes No
What type of SCM are you providing?
Level Spreader
Vegetated Conveyance (lower SHWT)
Wetland Swale (higher SHWT)
Other SCM that removes minimum 30 % nitrogen
Proposed project will not create concentrated stormwater flow through the buffer
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?
Yes No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)?
Yes No
Q
V

2c. Does this project have a stormwater management plan (SMP) reviewed and approved under a state stormwater program or state -approved local government stormwater program?
Yes No
N/A - project disturbs < 1 acre
2d. Which of the following stormwater management program(s) apply:
Local Government State
Local Government Stormwater Programs
Phase II NSW USMP Water Supply
Please identify which local government stormwater program you are using.
Local: High Point
Comments:
Local program satisfies Phase II SW requirements
G. Supplementary Information
1. Environmental Documentation
la. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?
Yes No
2. Violations (DWR Requirement)
2a. Is the site in violation of DWR Water Quality Certification Rules (15A NCAC 2H .0500), Isolated Wetland Rules (15A NCAC 2H .1300), or DWR Surface Water or Wetland Standards or
Riparian Buffer Rules (15A NCAC 2B .0200)? *
Yes No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project result in additional development, which could impact nearby downstream water quality?
Yes No
3b. If you answered "no," provide a short narrative description.
not a Phased project
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?
Yes No N/A
4b. 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.
Connection to municipal water and sewer
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or habitat?*
Yes No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?
Yes No
5c. If yes, indicate the USFWS Field Office you have contacted.
Raleigh
5d. Is another Federal agency involved?*
Yes No
5e. Is this a DOT project located within Division's 1-8?
Yes No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?
Yes No
5g. Does this project involve bridge maintenance or removal?
Yes No
5h. Does this project involve the construction/installation of a wind turbine(s)?*
Yes No
Unknown
5i. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers, mechanized pile drivers, etc.?
Yes No

5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
Site reconnaissance, IPAC and NHP
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
Yes No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?
Essential Fish Habitat Mapper
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal governments have designated as having historic or cultural preservation status? *
Yes No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
Site reconnaissance, SHPO buffer map
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? *
Yes No
8c. What source(s) did you use to make the floodplain determination?
National Flood Hazard Layer
Miscellaneous
O
Please use the space below to attach all required documentation or any additional information you feel is helpful for application review. Documents should be combined into one file when
possible, with a Cover Letter, Table of Contents, and a Cover Sheet for each Section preferred.
Click the upload button or drag and drop files here to attach document
Project Kersey Valley ePCN docs compressed.pdf 10.04MB
File must be PDF or KMZ
Comments
Signature
By checking the box and signing below, I certify that:
• The project proponent hereby certifies that all information contained herein is true, accurate, and complete to the best of my knowledge and belief'; and
• The project proponent hereby requests that the certifying authority review and take action on this CWA 401 certification request within the applicable reasonable period of time.
• I have given true, accurate, and complete information on this form;
• I agree that submission of this PCN form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act");
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act");
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature; AND
• I intend to electronically sign and submit the PCN form.
Full Name:
Allyson Sinclair
Signature
Date
8/11/2023
L