20220896 Ver 2_PCN - REVISED Long Creek Village Site__Forsyth County_NC_8-28-23_20230828

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NORTH CAROLINA
Environmental Quality
Water Resources
Office Use Only
Corps Action ID no. SAW-2022-00653 Date received: [Click to enter.]
DWR project no. 20220896 v1 Date received: [Click to enter.]
Site Coordinates:
Latitude (DD.DDDDDD): 36.205302
Longitude (DD.DDDDDD):-80.319172
Form Version 4.3, April 20, 2022
Pre -Construction Notification (PCN) Form
(Ver. 4.2, January 31, 2022))
For Nationwide Permits and Regional General Permits and corresponding Water Quality Certifications
Please note: fields marked with a red asterisk are required. The form is not considered complete until all
mandatory questions are answered.
The PCN help document may be found at this link:
https:Hedocs.deg. nc.gov/WaterResources/DocView.aspx?dbid=0&id=2196924&cr=1
Please ensure you have submitted a pre -filing meeting request at least 30 days prior to submitting this
form, as DWR will not be able to accept your application without documentation of this important first step.
The Division has developed a Pre -filing Meeting Request email address 401 PreFile(a)-ncdenr.gov to accept
the federally required pre -filing meeting request and provide confirmation receipt of submittal . This receipt
or similar documentation will satisfy 40 C.F.R. Section 121.4(a) which states "At least 30 days prior to
submitting a certification request, the project proponent shall request a pre -filing meeting with the certifying
agency." In accordance with 40 C.F.R. Section 121.5(b)(7), and (c)(5), all certification requests must
include documentation that a pre -filing meeting request was submitted to the certifying authority at least 30
days prior to submitting the certification request.
Attach documentation of Pre -Filing Meeting Request to this Application.
Date of Pre -filing Meeting Request (MM/DD/YYYY) : 4/19/2022
Page 1 of 23 PCN Form Version 4.3- April 20, 2022

A. Processing Information
County (counties) where project is located:
Forsyth Additional (if needed).
Is this an ARPA project?
❑ Yes ❑x No
If yes, ARPA project number:
The project number can be found on the "Letter of Intent to Fund"
(LOIF) or "Offer and Acceptance Lette('. If you are unable to locate
Click or tap here to enter text.
your DWI ARPA Funding Project Number, please contact Corey
Basinger at [e-mail] for further assistance.
Is this a NCDMS project? *
(Click yes only if NCDMS is the applicant or co-
❑ Yes ❑x No
applicant)
Is this a public transportation project?
(Publicly funded municipal, state, or federal road, rail,
❑ Yes ❑x No
or airport project)
Is this a NCDOT project?
❑ Yes ❑x No
If yes, NCDOT TIP or state project number:
Click to enter.
If yes, NCDOT WBS number:
Click to enter.
❑x Section 404 Permit (wetlands, streams, waters,
Clean Water Act)
la. Type(s) of approval sought from the Corps:
❑ Section 10 Permit (navigable waters, tidal
waters, Rivers and Harbors Act)
Has this PCN previously been submitted?
❑x Yes ❑ No
Please provide the date of the previous submission.
6/30/2022
❑x Nationwide Permit (NWP)
1 b. What type(s) of permit(s) do you wish to seek
❑Regional General Permit (RGP)
authorization?
❑ Standard (IP)
This form may be used to initiate the standard/ individual permit
process with the USACE. Please contact your Corps
representative concerning submittals for standard permits. All required items can be included as attachments and
submitted with this form.
1 c. Has the NWP or GP number been verified by the Corps?
® Yes ❑ No
NWP number(s) (list all numbers):
NWP 29
RGP number(s) (list all numbers ):
Click to enter
Are you a federal applicant?
❑ Yes ❑ 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):
❑ 401 Water Quality Certification — Regular
❑ 401 Water Quality Certification— Express
❑ Non-404 Jurisdictional General Permit
❑ Riparian Buffer Authorization
❑ Individual 401 Water Quality Certification
Is this a courtesy copy notification
❑ Yes ❑x No
Page 2 of 23 PCN Form Version 4.3- April 20, 2022

1 e.
Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification:
❑ Yes
❑x No
For the record only for Corps Permit:
❑ Yes
❑x No
1f.
Is this an after -the -fact permit/certification application?
❑ Yes
❑x No
1g.
Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts?
® Yes
❑ No
If yes, attach the acceptance letter from mitigation bank or in -lieu fee program.
1 h.
Is the project located in any of NC's twenty coastal counties?
❑ Yes
❑x No
1 i.
Is the project located within an NC DCM Area of Environmental
Concern (AEC)?
❑ Yes
❑x No ❑ Unknown
1j.
Is the project located in a designated trout watershed?
❑ Yes
❑x No
If yes, you must attach a copy of the approval letter from the appropriate Wildlife Resource Commission Office.
Trout information may be found at this link: http://www.saw.usace.army.mil/Missions/Regulatory-Permit-
Program/Agency-Coordination/Trout.aspx
Page 3 of 23 PCN Form Version 4.3- April 20, 2022

B. Applicant Information
1 a.
Who is the primary contact?
Johnathan McCall
1 b.
Primary Contact Email:
[e-mail]
1 c.
Primary Contact Phone: (###)###-####
704-774-1964
1 d.
Who is applying for the permit/certification? (check
all that apply)
❑ Owner 0 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:
BHR Land Holdings, LLC
2b.
Deed Book and Page No.:
003501 - 00374
2c.
Contact Person (for corporations):
Ben Russell
2d.
Address
Street Address:
4389 Indian Trail Fairview Road
Address line 2:
Click to enter.
City:
Indian Trail
State/ Province/ Region:
NC
Postal/ Zip Code:
28079
Country:
USA
2e.
Telephone Number: * (###)###-####
707-288-7826
2f.
Fax Number: (###)###-####
Click to enter.
2g.
Email Address:
[e-mail]
3.
Applicant Information (if different from owner)
3a.
Name:
Johnathan McCall
3b.
Business Name (if applicable):
Carolina Development Services, LLC
3c.
Address:
Street Address:
2627 Brekonridge Centre Drive
Address line 2:
Click to enter.
City:
Monroe
State/ Province/ Region:
NC
Postal/ Zip Code:
28110
Country
USA
3d.
Telephone Number: (###)###-####
704-774-1964
3e
Fax Number: (###)###-####
Click to enter.
3f.
Email Address:
[e-mail]
Page 4 of 23 PCN Form Version 4.3- April 20, 2022

4. Agent/ Consultant (if applicable)
4a. Name:
S. Paul Petitgout
4b. Business Name:
Lowrys Environmental & Ecological Services, LLC
4c. Address:
Street Address:
1823 Quinn Road
Address line 2:
Click to enter.
City:
Chester
State/ Province/ Region:
SC
Postal/ Zip Code:
29706
Country:
USA
4d. Telephone Number: (###)###-####
803-992-0910
4e Fax Number: (###)###-####
Click to enter.
4f. Email Address:
[e-mail]
Agent Authorization Letter:
Attach a completed/signed agent authorization form or letter. A sample form may be found at this link:
https://www.saw.usace.army. mil/Missions/Regulatory-Permit-Program/Permits/2017-Nationwide-Permits/Pre-
construction-Notification/
Page 5 of 23 PCN Form Version 4.3- April 20, 2022

C. Project Information and Prior Project History
1. Project Information
la. Name of project: *
Long Creek Village
1 b. Subdivision name (if appropriate):
none
1 c. Nearest municipality/town: *
Rural Hall, NC
2.
Project Identification
2a.
Property identification number (tax PIN or parcel ID):
6809-96-6493
2b.
Property size (in acres):
150
2c.
Project Address:
Street Address:
Mizpah Church Road
Address line 2:
Click to ente
City:
Rural Hall
State/ Province/ Region:
NC
Postal/ Zip Code:
27045
Country:
USA
2d.
Site coordinates in decimal degrees (using 4-6 digits
after the decimal point):
Latitude (DD.DDDDDD): 36.205302
Longitude (-DD.DDDDDD):--80.319172
3. Surface Waters
3a. Name of nearest body of water to proposed project:
Muddy Creek
3b. Water Resources Classification of nearest receiving
C
water:
The Surface Water Classification map may be found at this link:
httr)s:Hncdenr. mar)s.arcg is.com/apes/webappviewer/index. html?id=6el 25ad7628f494694e259c8Odd64265
Yadkin-PeeDee
3c. In what river basin(s) is your project located?`
noose aaaluonal (if needed)
3d. Please provide the 12-digit HUC in which the project is
030401011302
located:
The Find Your HUC map may be found at this link:
https:Hncdenr.maps.arcqis.com/apps/Publiclnformation/index.html?appid=ad3a85aOc6d644aOb97cdO69db238ac3
Page 6 of 23 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 contains timbered land and wooded land. A pond, designated as Paitts Lake, is located on thewestern
portion of the site. Several streams are located throughout the site, including Muddy Creekon the western
portion. Wetlands are located adjacent to the streams. The wetlands are separated from surrounding uplands by
topographic, vegetation and/or soil breaks. The surrounding properties consists of roads, wooded lands and
residential development.
4b. Have Corps permits or DWR certifications been obtained for this
® Yes ❑ No ❑ Unknown
project (including all prior phases) in the past? *
If yes, please give the DWR Certification number and/or Corps
SAW-2022-00653
Action ID (ex. SAW-0000-00000):
20220896 v1
Attach any pertinent project history documentation
02. Is any portion of the work already complete?
❑ Yes ❑x No
If yes, describe the completed work.
N/A
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.
NCDOT — no geogrid within the right of way — This is the reason for revising the PCN application
4d. Attach an 8'h x 11" excerpt from the most recent version of the USGS topographic map indicating the location of
the project site.
4e. Attach an 8'h 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
5.24 acres
property:
4g. List the total estimated linear feet of all existing streams (intermittent
7,150 linear feet
and perennial) on the property:
4g1. List the total estimated acreage of all existing open waters on the
13.5 acres
property:
4h. Explain the purpose of the proposed project:
The purpose of the proposed project is to construct a residential subdivsion. However, due to NCDOT requiring
the removal of geogrid from their rights of way, the permittee is required to re -submit this PCN application due to
changes in the impact areas that are required to remove the geogrid from the NCDOT rights of way.
4i. Describe the overall project in detail, including the type of equipment to be used:
The overall project includes the proposed construction of the Long Creek Village residential subdivision. The
residential subdivision will consist of 325 single family residential lots, 59 apartment units and associated
amenities. The site will be located on 110 acres and contain 3.5 units per acre with 30.6 built upon acres. The
site will contain 6 permanent stormwater ponds. The site will connect to existing sewer infrastructure on the site.
Four entrances, two to the residential subdivision and 2 to the apartment complex are required to satisfy
development and safety ordinances. Two culverted stream/wetland crossings (one will be a bottomless culvert)
are proposed in order to facilitate the proposed development and provide dual access to the residential
subdivision. Wetland impacts are proposed to facilitate construction of the roadways, sidewalk and lots. To
facilitate the development of the site, clearing and grading the site is necessary. Graders, haulers, excavators
and other heavy equipment will be used during grading and construction of the site.
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
Page 7 of 23 PCN Form Version 4.3- April 20, 2022

If yes, describe the type of dredging, the composition of the dredged material, and the locations of disposal area.
N/A
Page 8 of 23 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 area was delineated by Pilot Environmental in December 2019.
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):
^lirk fn An+a-
Name (if known): David Brame/Michael Brame
5c.
If 5a is yes, who delineated the jurisdictional
Agency/Consultant Company: Pilot Environmental
areas?
Other: Click to enter
5d.
List the dates of the Corps jurisdictional determination or State determination if a determination was made by
either agency.
March 25, 2022 — confirmed by Ms. Samantha Dailey — email concurrence
5d1.
Attach jurisdictional determinations.
6. Future Project Plans
6a. Is this a phased project?
❑ Yes ❑x No
6b. If yes, explain.
N/A
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 other permits are intended to be used.
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)
N/A
8. Scheduling of activity:
ASAP once all permits are issued.
Page 9 of 23 PCN Form Version 4.3- April 20, 2022

D. Proposed Impacts Inventory
Impacts Summary
❑x Wetlands ❑x 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
Culvert
Permanent
Bottomland
Hardwood
Forest
DWA
Yes
Both
0.173
W2
Culvert
Permanent
Bottomland
Hardwood
Forest
DWC
Yes
Both
0.140
W3
Fill (Incl.
Riprap)
Permanent
Headwater
Forest
DWB
Yes
Both
0.087
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
Mick to enter
Y/N
Choose one
Click to enter
2g1. Total temporary wetland impacts
0.0 ac
2g2. Total permanent wetland impacts
0.4 ac
2g3. Total wetland impacts
0.4 ac
2h. Type(s) of material being discharged and the amount of each type in cubic yards:
Clean Fill; ±200 cubic yards
Page 10 of 23 PCN Form Version 4.3- April 20, 2022

2i. Comments:
Three wetlands are proposed for impact.
Impact #1 (W1 A + W1 B = 7,516 sq ft (0.173-ac)) Bottomless Culvert Fill
Impact #2 (W2 = 6,078 sq ft (0.140-ac)) Traditional Culvert Fill
Impact #3 (W3 = 3,780 sq ft (0.087-ac)) Lot Fill
Page 11 of 23 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
Bottomless
Permanent
Other
DSB
Perennial
Both
4
146
Culvert
Crossing
S2
Rip Rap Apron
Permanent
Fill (Incl.
DSB
Perennial
Both
4
15
Riprap)
S3
Coffer Dam
Temporary
Dewatering
DSB
Perennial
Both
4
5
S4
Coffer Dam
Temporary
Dewatering
DSB
Perennial
Both
4
20
S5
Traditional
Permanent
Crossing/
DSD
Perennial
Choose one
1.5
215
Culvert
Culvert
Crossing
S6
Rip Rap Apron
Permanent
Fill (Incl.
DSD
Perennial
Choose one
1.5
15
Riprap)
S7
Coffer Dam
Temporary
Dewatering
DSD
Perennial
Choose one
1.5
5
S8
Coffer Dam
Temporary
Dewatering
DSD
Perennial
Choose one
1.5
15
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
0.0 linear ft
impact:
3i2. Total permanent stream
245 LF fill impacts 146 LF shading impact linear ft
impacts:
36. Total temporary stream
45 linear ft
impacts:
3i4. Total stream and ditch
436 linear ft
impacts:
Page 12 of 23 PCN Form Version 4.3- April 20, 2022

3j. Comments:
S-1 through S-4: Installation of a bottomless culvert (no loss of waters, only shading impact)
S-1: 146 LF (584 sq ft (0.013-ac)) bottomless culvert (no loss of waters, shading only)
S-2: 15 LF (60 sq ft (0.001-ac)) Class 1 rip -rap keyed in to stream bed elevation (no loss of waters)
S-3: 5 LF (7.5 sq ft (0.0002-ac)) Downstream temporary coffer dam
S-4: 20 LF (80 sq ft (0.002-ac)) Upstream temporary coffer dam
TOTAL IMPACTS BOTTOMLESS CULVET CROSSING: 186 LF (744 sq ft0.017-ac))
Total Permanent Impacts: Shading 146 LF (584 sq ft (0.013-ac)) No Loss of Waters
Total Permanent Impacts: Rip Rap 15 LF (60 sq ft (0.001-ac)) No Loss of Waters
Total Temporary Impacts: 25 LF (87.5 sq ft (0.0022-ac))
S-5 through S-8: Installation of traditional box culvert
S-5: 215 LF (322.5 sq ft (0.007-ac)) box culvert
S-6: 15 LF (22.5 sq ft (0.0005-ac)) Class 1 rip rap keyed in to stream bed elevation (no loss of waters)
S-7: 5 LF (7.5 sq ft (0.0002-ac)) Downstream temporary coffer dam
S-8: 15 LF (22.5 sq ft (0.0005-ac)) Upstream temporary coffer dam
TOTAL IMPACTS TRADITIONAL CULVERT CROSSING: 250 LF (375 sq ft (0.009-ac))
Total Permanent Impacts: Culvert 215 LF (322.5 sq ft (0.007-ac))
Total Permanent Impacts: Rip Rap 15 LF (22.5 sq ft (0.0005-ac)) No Loss of Waters
Total Temporary Impacts: 25 LF (30 sq ft (0.0007-ac))
Page 13 of 23 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
;lick 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
:,lick 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
I 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:
N/A
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 tc,
Click tc
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:
N/A
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:
N/A
Page 14 of 23 PCN Form Version 4.3- April 20, 2022

6. Buffer Impacts (DWR requirement)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts.
6a. Project is in which protected basin(s)?
(Check all that apply.)
❑ Neuse ❑ Tar -Pamlico ❑ Catawba
❑ Jordan ❑ Goose Creek ❑ Randleman
❑ Other: Click to enter.
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.
132
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.
135
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.
139
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
,lick 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
lick 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:
N/A
Please attach supporting documentation (impact maps, plan sheets, etc.) for the proposed project.
Page 15 of 23 PCN Form Version 4.3- April 20, 2022

E. Impact Justification and Mitigation
1. Avoidance and Minimization
1 a. Specifically describe measures taken to avoid or minimize the proposed impacts through project design:
The applicant has designed the proposed development to avoid impacts to the remaining streams and wetlands
located on the site. In order to develop the site and provide the required dual access and to construct the project,
the proposed impacts could not be avoided. Civil design, such as minimizing the entranceway widths, use of
headwalls and endwalls and use of retaining walls were used to further reduce impacts to streams and wetlands.
Unfortunately, the design called for geogrid to be placed within the NCDOT rights of way, which NCDOT later
remarked was unacceptable. Therefore, the design has been altered to remove the geogrid from the rights of
way.
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. The use of a bottomless culvert for one of the crossings also minimizes the direct
impacts to one of the streams (no loss of waters).
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? ❑x DWR ❑x 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:
Brushy Mountain Mitigation Bank
3b. Credits purchased/requested:
Type: Riparian Wetland
Quantity 0.75
Type: Choose one
Quantity Click to enter.
Type: Choose one
Quantity Click to enter.
Attach receipt and/or approval letter.
3c. Comments:
0.75 Riparian Wetland Credit (acre) was purchased from Restoration Systems as required by the original permit.
However, an additional 0.05 credit (acre) needs to be purchased to satisfy the new impacts. Unfortunately, the
Brushy Creek Mitigation Bank does not have any additional Riparian Wetlands Credits available. Additionally,
there are no other private mitigation banks that have Riparian Wetland Mitigtation Credits The remaining 0.05
Riparian Wetland Credits will be supplied by NC Division of Mitigation Services.
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
Page 16 of 23 PCN Form Version 4.3- April 20, 2022

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.mil/ribits apex/f?p=107:27:2734709611497::NO: RP:P27 BUTTON KEY:O
4d.
Buffer mitigation requested (DWR only):
0 square feet
4e.
Riparian wetland mitigation requested:
0.4 acres
4f.
Non -riparian wetland mitigation requested:
0 acres
4g.
Coastal (tidal) wetland mitigation requested:
0 acres
4h.
Comments:
Since Riparian Wetland Mitigation Credits are not available from Restoration Systems at the Brushy Creek Bank
Site (and no Riparian Wetland Mitigation Credits are available at any other private mitigation banks, NCDMS has
been contacted and will provide the remaining Riparian Wetland Mitigation Credits
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.
N/AN/A
5b. Attach mitigation plan/documentation.
6.
Buffer Mitigation (State Regulated Riparian Buffer Rules) — DWR requirement
6a.
Will the project result in an impact within a protected riparian buffer
❑ Yes ❑ No
that requires buffer mitigation?
If yes, please complete this entire section — please contact DWR for more information.
6b.
If yes, identify the square feet of impact to each zone of the riparian buffer that requires
mitigation. Calculate the
amount of mitigation required in the table below.
6c.
6d.
6e.
Zone
Reason for impact
Total impact
Multiplier
Required mitigation
(square feet)
(square feet)
Zone 1
Click to enter.
Click to enter.
Choose one
Click to enter.
Zone 2
:,lick to enter.
Click to enter.
Choose one
Click to enter.
6f. Total buffer mitigation required
Click to enter.
6g.
If buffer mitigation is required, is payment to a mitigation bank or
❑ Yes ❑ No
NC Division of Mitigation Services proposed?
6h.
If yes, attach the acceptance letter from the mitigation bank or NC Division of Mitigation Services.
6i.
Comments:
Buffer mitigation is not proposed.
Page 17 of 23 PCN Form Version 4.3- April 20, 2022

F. Stormwater Management and Diffuse Flow Plan (DWR requirement)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers
❑ Yes ❑x No
identified within one of the NC Riparian Buffer Protection Rules?
1 b. All buffer impacts and high ground impacts require diffuse flow or other form of stormwater treatment. If the
project is subject to a state implemented riparian buffer protection program, include a plan that fully documents
how diffuse/dispersed flow will be maintained.
All Stormwater Control Measures (SCM) must be designed in accordance with the NC Stormwater Design
Manual (https://deg.nc.gov/about/divisions/energv-mineral-land-resources/energv-mineral-land-permit-
guidance/stormwater-bmp-manual).
Associated supplement forms and other documentation must be provided.
❑ Level Spreader
What Type of SCM are you
❑ 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?
El Yes ❑x No
2b.
Does this project meet the requirements for low density projects as
defined in 15A NCAC 02H .1003(2)?
❑ Yes ❑x No
To look up low density requirements, click here:
http://reports.oah.state.nc. us/ncac/title%2015a%20-%20environmental%20guality/chapter%2002%20-
%20environ mental%20management/subchapter%20h/15a%20ncac%2002 h%20.1003. pdf
2c.
Does this project have a stormwater management plan (SMP)
❑x Yes ❑ No
reviewed and approved under a state stormwater program or state -
approved local government stormwater program?
❑ n/a — project disturbs < 1 acre
Note: Projects that have vested rights, exemptions, or grandfathering from state or locally implemented
stormwater programs or projects that satisfy state or locally -implemented stormwater programs through use of
community in -lieu programs should answer "no" to this question.
2d.
Which of the following stormwater management program(s) apply?
❑ Local Government
(Check all that apply.)
❑x State
If you have local government approval, please include the SMP on their overall impact map.
Local Government Stormwater Programs
❑x Phase II ❑ USMP
❑ NSW ❑ Water Supply
Page 18 of 23 PCN Form Version 4.3- April 20, 2022

Please identify which local government stormwater program you are using.
City of Winston Salem, NC
State Stormwater Programs I ❑x Phase II ❑ HQW or ORW
❑ Coastal Counties ❑ Other
Comments:
A SWVIP has been submitted to the City of Winston- Salem for review and approval.
Page 19 of 23 PCN Form Version 4.3- April 20, 2022

G. Supplementary Information
1. Environmental Documentation
1 a. Does the project involve an expenditure of public (federal/state/local)
❑ Yes ❑x No
funds or the use of public (federal/state) land?
1 b. If you answered "yes" to the above, does the project require
preparation of an environmental document pursuant to the
requirements of the National or State (North Carolina) Environmental
El Yes El No
Policy Act (NEPA/SEPA)?
1 c. If you answered "yes" to the above, has the document review been
finalized by the State Clearing House? (If so, attach a copy of the
❑ Yes ❑ No
NEPA or SEPA final approval letter.)
Comments:
A NEPA or SEPA is not required.
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):
DICK 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 as a result of the proposed development is not anticipated.
3c. If yes, provide a qualitative or quantitative cumulative impact analysis in accordance with the most recent DWR
policy. (Attach .pdo
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project? 1 ® Yes ❑ No ❑ N/A
4b. If yes, describe in detail the treatment methods and dispositions (non -discharge or discharge) of wastewater
generated from the proposed project. If the wastewater will be treated at a treatment plant, list the capacity
available at that plant.
Sewage will be discharged into an existing sewer line that is located on the site. The sewer line will be bored
beneath Muddy Creek. Additional impacts associated with sewage disposal are not proposed.
Page 20 of 23 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: hftps://www.fws.gov/ipac/ ffws.govl)
5b.
Have you checked with the USFWS concerning Endangered Species
❑ Yes ❑x No
Act impacts? *
5c.
If yes, indicate the USFWS Field Office you have contacted.
Choose one
5d.
Is another federal agency involved?
❑ Yes ❑x No ❑ Unknown
If yes, which federal agency?
Click to enter.
5e.
Is this a DOT project located within Divisions 1-8?
❑ Yes ❑x No
5f.
Will you cut any trees in order to conduct the work in waters of the
U.S.?
®Yes El No
5g.
Does this project involve bridge maintenance or removal?
❑ Yes ❑x No
5g1.
If yes, have you inspected the bridge for signs of bat use such as
staining, guano, bats, etc.? Representative photos of signs of bat use
❑ Yes ❑ No
can be found in the NLEB SLOPES, Appendix F, pages 3-7.
Representative photos of signs of bat use can be found in the NLEB SLOPES, Appendix F, pages 3-7. Link to
NLEB SLOPES document: http:Hsaw-reg.usace. army. mil/NLEB/1-30-17-signed
NLEB-SLOPES&apps.pdf
If you answered yes to 5g1, did you discover any signs of bat use? -
❑ Yes ❑ No ❑ Unknown
If yes, please show the location of the bridge on the permit drawings/ project plans
5h.
Does this project involve the construction/ installation of a wind
turbine(s)?
❑ Yes ❑x No
If yes, please show the location of the wind turbine(s) on the permit drawings/ project plans (attach .pdo
5i.
Does this project involve blasting and /or other percussive activities
that will be conducted by machines, such as jackhammers,
❑ Yes ❑x No
mechanized pile drivers, etc.?
If yes, please provide details to include type of percussive activity, purpose,
duration, and specific location of this
activity on the property (attach .pdo
Page 21 of 23 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
4 listed species are identified on the IPaC report (attached). The Northern long-eared bat, bog turtle, Schweinitz's
Sunflower and Monarch butterfly are included by the IPaC as federally listed species identified within the project
area. Bat hibernacula is not located on the site. The site contains areas of limited or low quality suitable summer
roosting habitat. Similar or higher quality suitable summer roosting habitat was observed on surrounding
properties. Percussive activities including blasting or driving piles are not anticipated as a result of construction
of the proposed project. Based on a review of the June_ 1_2016 NLEB_HUC12 NLEB shapefiles obtained from
the Asheville Ecological Services Field Office website, the 12-digit HUC with the nearest confirmed hibernation
and/or maternity sites is located more than 75 miles from the site. Based on the distance from known hibernacula
and roost trees and the availability of similar suitable habitat on nearby properties, the proposed project is not
likely to adversely affect the Northern long-eared bat.
Neither the crossing nor the areas proximate to the crossing contain suitable habitat for the remaining species.
According to the natural heritage program, documented occurrences of Schweinitz's sunflower are located 12.5
miles and farther from the site. The bog turtle is listed due to similarity of appearance and the Monarch butterfly
is a candidate 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 ❑x No El Unknown
Will this project affect submerged aquatic vegetation?
❑ Yes ❑x No ❑ Unknown
Explain:
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://qis.ncdcr.gov/hpoweb/
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural
preservation status (e.g., National Historic Trust designation or
❑ Yes ❑x No
properties significant in North Carolina history and archaeology)?
7b. What data source(s) did you use to determine whether your site would impact historic or archeological
resources?
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 22 of 23 PCN Form Version 4.3- April 20, 2022

8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https:Hmsc.fema.gov/portal/search
8a. Will this project occur in a FEMA-designated 100-year floodplain? *
❑ Yes ❑x No
8b. If yes, explain how the project meets FEMA requirements.
8c. What source(s) did you use to make the floodplain determination?
National Flood Hazard Layer from FEMA Web Map Service — Drawing 4 ( Attached)
H. Miscellaneous
Comments:
Please let me know if you need additional information in order to process this application.
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: * S. Paul Petitgout
Signature:
Date: * 8/28/2023
Page 23 of 23 PCN Form Version 4.3- April 20, 2022

Lowrys Environmental &
Ecological Services, LLC
1823 Quinn Road
Chester, South Carolina 29706
Phone [phone]
August 28, 2023
US Army Corps of Engineers
Regulatory Branch
Charlotte Field Office
North Carolina Division of Water Resources
401 and Buffer Permitting Branch
Winston Salem Field Office
RE: Long Creek Village Site
Nationwide Permit 29 (NCDWR Certification No. 4256)
City of Winston-Salem, Forsyth County, North Carolina
Lowrys Environmental & Ecological Services, LLC (LEES) has prepared a permit application
for the use of Nationwide Permit 29 (NCDWR Certification No. 4256) in order for the applicant
to construct a new residential development. The project area is located at the intersection of N.
Main Street and Elm Road in the City of Winston Salem, Forsyth County, North Carolina.
The following documents, figures, etc. are provided to aid in your review of the project. Should
you have any questions regarding the project, please do not hesitate contacting me. We look
forward to working with you on this project.
Sincerely yours,
S. Paul Petitgout
President/Managing Member
Attachments

TABLE OF CONTENTS
Previous 404/401 Permit Application Package (prepared by Pilot Environmental)
Original Issued USACE Permit SAW-2022-00653
Original Issued NCDWR Permit 20220896 VI
Agent Authorization and Right of Entry Documentation
General Location Figures
Engineering Figures
Mitigation Information

PREVIOUS 404/401 PERMIT
APPLICATION PACKAGE
(prepared by Pilot Environmental)

Staff Review
Does this application have all the attachments needed to accept it into the review process?*
Yes No
ID# *
20220896
Version* 1
Is this project a public transportation project?* Yes
No
Reviewer List: * Sue Homewood:eads\slhomewood
Select Reviewing Office:* Winston-Salem Regional Office - [phone]
Submittal Type:* 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:
4/19/2022
Project Contact Information
Name: Heather LaGamba
Who is submitting the information?
Email Address: [e-mail]
Project Information
Project Name: Long Creek Village (Mizpah Church Rd)
Is this a public transportation project?
Yes
No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
Yes No Unknown
County (ies)
Forsyth
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
5462.1_Long Creek Village_PCN_6.30.22.pdf 18.01MB
Only pdf or kmz files are accepted.
Describe the attachments or
comments:
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:
7Yt. el� ,��ar�irt�rr
Submittal Date: Is filled in automatically.

Preliminary ORM Data Entry Fields for New Actions
ACTION ID #: SAW - 2022 - 00653 Begin Date (Date Received):
Prepare file folder ❑ Assign Action ID Number in ORM ❑
1. Project Name [PCN Form A2a]: Mizpah Church Road- Long Creek Village
2. Work Type:✓Private ❑Institutional Government ❑Commercial
3. Project Description / Purpose [PCN Form 133d and 133e]:
The site is an approximate 150-acre tract located off of Mizpah Church Road in Rural Hall, Forsyth County, North Carolina that is
proposed for residential development The site contains wooded land and timbered land.
4. Property Owner / Applicant [PCN Form A3 or A41: BHR Land Holdings/Carolina Developement Service:
5. Agent / Consultant [PNC Form A5 — or ORM Consultant ID Number]:
Pilot Environmental / David Brame
6. Related Action ID Number(s) [PCN Form 135b]: SAW - 2022 - 00653
7. Project Location— Coordinates, Street Address, and/or Location Description [PCN Form Blb]:
Mizpah Church Road in Rural Hall, Forsyth County, North Carolina
36.205437°,-80.320500°
8. Project Location— Tax Parcel ID [PCN Form B 1 a]: 6809-96-6493
9. Project Location — County [PCN Form A2b]: Forsyth County
10. Project Location —Nearest Municipality or Town [PCN Form A2c]: Rural Hall
11. Project Information —Nearest Waterbody [PCN Form 132a]: Muddy Creek
12. Watershed / 8-Digit Hydrologic Unit Code [PCN Form 132c]: Yadkin Pee Dee / 03040101
Authorization: Section 10 ❑ Section 404 U
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

n
�4 `
FORTH CAROLINA
Enviranmen tat Quality
Water Resources
Office Use Only
Corps Action ID no. [Click to enter.) Date received: [Click to enter.)
DWR project no. [Click enter.) Date received: [Click to enter.)
Site Coordinates:
Latitude (DD.DDDDDD): 36.205302'
Longitude (DD.DDDDDD): 80.319172'
Form Version 1.5, September 2020
Pre -Construction Notification (PCN) Form
(Ver. 1.5, September 2020)
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 online help file may be found at this link:
https://edocs.deg.nc.govlWaterResources/0/edocl6247041PCN%2OHelp%2OFile%202018-1-30. pdf
The help document may be found at this link:
http://www.saw.usace.army.miI/Missions/Regulatory-Permit-Program/Permits/2017-Nationwide-Permits/Pre-
construction-Notification/
Before submitting this form, please ensure you have submitted the Pre -Filing Meeting Request Form as DWR will not be
able to accept your application without this important first step. The Pre -Filing Meeting Request Form is used to 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.
4/19/2022
DWR ID # Click to enter. Version Click to enter. (If applicable)
A. Processing Information
County (counties) where project is located: *
Guilford Additional (if needed).
Is this a public transportation project? *
(Publicly funded municipal, state, or federal road, rail,
❑ Yes ❑x No
or airport project)
Is this a NCDOT project?
❑ Yes ❑x No
If yes, NCDOT TIP or state project number:
Click to enter.
If yes, NCDOT WBS number: *
Click to enter.
❑x Section 404 Permit (wetlands, streams, waters,
Clean Water Act)
la. Type(s) of approval sought from the Corps:
❑ Section 10 Permit (navigable waters, tidal
waters, Rivers and Harbors Act)
Page 1 of 21 PCN Form - Version 1.5, September 2020

0 Nationwide Permit (NWP)
1 b. Permit type(s)?
❑ Regional General Permit (RGP)
❑ 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 separate attachments
and submitted with this form.
1 c. Has the NWP or GP number been verified by the Corps?
❑ Yes 0 No
NWP number(s):
NWP 29
RGP number(s):
Click to enter.
1d. Type(s) of approval sought from the DWR (check all that apply):
0 401 Water Quality Certification — Regular ❑ 401 Water Quality Certification— Express
❑ Non-404 Jurisdictional General Permit ❑ Riparian Buffer Authorization
❑ Individual 401 Water Quality Certification
1 e. Is this notification solely for the record because written approval is not required? "
For the record only for DWR 401 Certification: "
❑ Yes 0 No
For the record only for Corps Permit: "
❑ Yes 0 No
1f. Is this an after -the -fact permit/certification application? "
❑ Yes 0 No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts?
® Yes ❑ No
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 0 No
1 i. Is the project located within an NC DCM Area of Environmental
Concern (AEC)?
❑ Yes 0 No ❑ Unknown
1j. Is the project located in a designated trout watershed?
❑ Yes 0 No
If yes, you must attach a copy of the approval letter from the appropriate Wildlife Resource Commission Office.
Trout information may be found at this link: http://www.saw.usace.army.mil/Missions/Re ug latory-Permit-
Program/Agency-Coordination/Trout.aspx
Page 2 of 21 PCN Form - Version 1.5, September 2020

B. Applicant Information
1 a.
Who is the primary contact? *
Jonathan McCall
1 b.
Primary Contact Email: *
[e-mail]
1 c.
Primary Contact Phone: * (###)###-####
[phone]
1 d.
Who is applying for the permit/certification? (check
all that apply)
❑ Owner 0 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: *
BHR Land Holdings, LLC
2b.
Deed Book and Page No.:
003501 - 00374
2c.
Responsible Party (for corporations):
Ben Russell
2d.
Address '
Street Address:
4389 Indian Trail Fairview Road
Address line 2:
Click to enter.
City:
Indian Trail
State/ Province/ Region:
NC
Postal/ Zip Code:
28079
Country:
United States
2e.
Telephone Number:
707-288-7826
2f.
Fax Number: (###)###-####
Click to enter.
2g.
Email Address: *
[e-mail]
3.
Applicant Information (if different from owner)
3a.
Name:
Jonathan McCall
3b.
Business Name (if applicable):
Carolina Development Services, LLC
3c.
Address:
Street Address:
2627 Breckenridge Centre Dr
Address line 2:
Click to enter.
City:
Monroe
State/ Province/ Region:
North Carolina
Postal/ Zip Code:
28110
Country
US
3d.
Telephone Number: (###)###-####
704-774-1964
3e
Fax Number: (###)###-####
Click to enter.
Page 3 of 21 PCN Form - Version 1.5, September 2020

3f. Email Address: [e-mail]
4. Agent/ Consultant (if applicable)
4a. Name: *
David S. Brame
4b. Business Name:
Pilot Environmental, Inc.
4c. Address:
Street Address:
743 Park Lawn Court
Address line 2:
Click to enter.
City:
Kernersville
State/ Province/ Region:
NC
Postal/ Zip Code:
27284
Country:
U.S.
4d. Telephone Number: * (###)###-####
[phone]
4e Fax Number: (###)###-####
Click to enter.
4f. Email Address:
[e-mail]
Agent Authorization Letter:
Attach a completed/signed agent authorization form or letter. A sample form may be found at this link:
https://www.saw. usace.army.mil/Missions/Regulatory-Permit-Program/Permits/2017-Nationwi de-Permits/Pre-
construction-Notification/
Page 4 of 21 PCN Form - Version 1.5, September 2020

C. Project Information and Prior Project History
1. Project Information
1 a. Name of project: *
Long Creek Village
1 b. Subdivision name (if appropriate):
none
1 c. Nearest municipality/town: *
Rurall Hall, NC
2.
Project Identification
2a.
Property identification number (tax PIN or parcel ID):
6809-96-6493
2b.
Property size (in acres):
150
2c.
Project Address:
Street Address:
Mizpah Church Road
Address line 2:
Click to enter.
City:
Rurall Hall
State/ Province/ Region:
NC
Postal/ Zip Code:
27045
Country:
U.S.
2d.
Site coordinates in decimal degrees (using 4-6 digits
after the decimal point):
Latitude (DD.DDDDDD): * 36.205302'
Longitude (-DD.DDDDDD): *-80.319172°
3. Surface Waters
3a. Name of nearest body of water to proposed project:
Muddy Creek
3b. Water Resources Classification of nearest receiving
C
water:
The Surface Water Classification map may be found at this link:
hops://ncdenr.maps.arcgis.com/apps__ ppviewer/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
030401011302
located:
The Find Your HUC map may be found at this link:
https://ncdenr.maps.arcgis.com/apes/Publiclnformation/index.html?appid=ad3a85aOc6d644aOb97cd069db238ac3
Page 5 of 21 PCN Form - Version 1.5, September 2020

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 contains timbered land and wooded land. A pond, designated as Paitts Lake, is located on the
western portion of the site. Several streams are located throughout the site, including Muddy Creek
on the western portion. Wetlands are located adjacent to the streams. The wetlands are separated
from surrounding uplands by topographic, vegetation and/or soil breaks. The surrounding properites
consists of roads, wooded lands and residential development.
4b.
Have Corps permits or DWR certifications been obtained for this
i] Yes X No ❑ Unknown
project (including all prior phases) in the past? *
4c.
If yes, please give the DWR Certification number and/or Corps
[Click to enter.]
Action ID (ex. SAW-0000-00000):
[Click to enter.]
Attach any pertinent project history documentation
4d.
Attach an 8'h x 11" excerpt from the most recent version of the USGS topographic map indicating the location of
the project site.
4e.
Attach an 8'/2 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
5.24 acres
property:
4g.
List the total estimated linear feet of all existing streams (intermittent
7,150 linear feet
and perennial) on the property:
4g 1.
List the total estimated acreage of all existing open waters on the
13.5 acres
property:
4h.
Explain the purpose of the proposed project:
The purpose of the proposed project is to construct a residential subdivsion.
4i.
Describe the overall project in detail, including the type of equipment to be used:
The overall project includes the proposed construction of the Long Creek Village residential subdivision. The
residential subdivision will consist of 325 single family residential lots, 59 apartment units and associated amenities.
The site will be located on 110 acres and contain 3.5 units per acre with 30.6 built upon acres. The site will contain 6
permanent stormwater ponds. The site will connect to existing sewer infrastructure on the site. Four entrances, two to
the residential subdivision and 2 to the apartment complex are required to satisfy development and safety ordinances.
Two culverted stream/wetland crossings are proposed in order to facilitate the proposed development and provide dual
access to the residential subdivision. Wetland impacts are proposed to facilitate construction of the roadways,
sidewalk and lots. To facilitate the development of the site, clearing and grading the site is necessary. Graders,
haulers, excavators and other heavy equipment will be used during grading and construction of the site.
4j.
Attach project drawings/site diagrams/depictions of impact areas for the proposed project.
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or in
® Yes ❑ No ❑ Unknown
proposed impact areas?
Comments:
The site was delineated by Pilot Environmental in December 2019.
Name (if known): David Brame/Michael Brame
5b. If 5a is yes, who delineated the jurisdictional
Agency/Consultant Company: Pilot Environmental
areas?
Other: Click to enter.
Page 6 of 21 PCN Form - Version 1.5, September 2020

5c. If the Corps made a jurisdictional determination,
❑ Preliminary ❑ Approved 0 Emailed Concurrence
what type of determination was made? *
❑ Not Verified ❑ Unknown
Corps AID number (ex. SAW-0000-00000):
SAW-2022-00653
5d. List the dates of the Corps jurisdictional determination or State determination if a determination was made by
either agency.
March 25, 2022 — confirmed by Ms. Samantha Dailey. E-mail concurrence attached
5d1. Attach jurisdictional determinations.
Page 7 of 21 PCN Form - Version 1.5, September 2020

6. Future Project Plans
6a. Is this a phased project?
® Yes X No
6b. If yes, explain.
The site is a proposed single phase development. No additional phases are proposed.
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 other permits are intended to be used.
Page 8 of 21 PCN Form - Version 1.5, September 2020

D. Proposed Impacts Inventory
Impacts Summary
0 Wetlands 0 Streams - tributaries
la. 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.
2a 1.
2b.
2c.
2d.
2e.
2f.
2g.
Site #"
Impact
Impact
Wetland Name`
Wetland Type`
Forested
Jurisdiction
Impact Area
Reason/Type`
Duration`
?"
Type
(ac)
W1
Culvert
Permanent
DWA
Bottomland
Yes
Both
0.156
Hardwood
Forest
W2
Culvert
Permanent
DWC
Bottomland
Yes
Both
0.130
Hardwood
Forest
W3
Fill (Incl.
Permanent
DWA
Bottomland
Yes
Both
0.047
Riprap)
Hardwood
Forest
W4
Fill (Incl.
Permanent
DWA
Bottomland
Yes
Both
0.078
Riprap)
Hardwood
Forest
W5
Fill (Incl.
Permanent
DWB
Headwater
Yes
Both
0.0867
Riprap)
Forest
W6
Choose one
temp/
Click to enter
Choose one
Choose one
Click to
Perm
enter
2g1.
Total temporary wetland impacts
0 ac
2g2.
Total permanent wetland impacts
0.499 ac
2g3.
Total wetland impacts
0.499 ac
2h.
Comments:
Five wetland impacts are proposed.
Wetland impact W1 (W1A/W1 B) is for impact associated with the northern
entranceway and required bottomless arch culvert and riprap dissipater. Wetland impact W2 is for impact associated
with the eastern entranceway and required traditional culvert and riprap dissipater. Wetland impacts W3 and W4 are
for impact associated with side slopes
to accommodate lots 41, 42 and the cul-de-sac. Wetland impact W5 is for
impact associated with the construction
of Bearskin Loop roadway and associated sidewalks and lots 191, 209 and
210.
Page 9 of 21 PCN Form - Version 1.5, September 2020

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.
3d.
3e.
3f.
3g.
3h.
Site #-
Impact Reason/
Impact
Stream Name
Stream
Jurisdiction
Stream Width
Impact length
Type
Duration
Type
Type
(avg ft)
(linear ft)
S1
Other
Temporary
DSB
Perennial
Both
4
0
S2
Fill (Incl. Riprap)
Permanent
DSB
Perennial
Both
4
15
S3
Dewatering
Temporary
DSB
Perennial
Both
4
5
S4
Dewatering
Temporary
DSB
Perennial
Both
4
20
S5
Crossing/ Culvert
Permanent
DSD
Perennial
Both
1.5
202
S6
Fill (Incl. Riprap)
Permanent
DSD
Perennial
Both
1.5
15
S7
Dewatering
Temporary
DSD
Perennial
Both
1.5
5
S8
Dewatering
Temporary
DSD
Perennial
Both
1.5
15
S9
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S10
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S11
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S12
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S13
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S14
Choose one
Temp/ Perm
Click to enter
Per/lnt
Choose one
Click to enter
Click to enter
S15
Choose one
Temp/ Perm
Click to enter
Per/lnt
Choose one
Click to enter
Click to enter
3i1.
Total jurisdictional ditch impact:
Click to enter. linear ft
3i2.
Total permanent stream impacts:
232 linear ft
M.
Total temporary stream impacts:
45 linear ft
3i4.
Total stream and ditch impacts:
277 linear ft
3j.
Comments:
S1 — Stream location 1 includes installation of a bottomless arch culvert. There will be no permanent or
temporary fill associated with installation of the bottomless arch culvert.
S2 — Stream location 2 includes 15 LF (60 SF) of fill associated with a riprap dissipater downstream of the
bottomless arch culvert. Riprap will be installed flush with the existing stream bed.
S3 — Stream location 3 includes 5 LF (20 SF) of temporary fill for coffer dam located downstream of the
bottomless arch culvert if needed during installation of the bottomless arch culvert.
S4 — Stream location 4 includes 20 LF (80SF) of temporary fill for coffer dam located upstream of the bottomless
arch culvert if needed during installation of the bottomless arch culvert.
S5 — Stream location 5 includes 202LF (303 SF) of permanent fill for the installation of a traditional culvert,
headwalls and endwalls at the eastern crossing.
S6 — Stream location 6 includes 15 LF (22.5 SF) of permanent fill with a riprap dissipater downstream of the
traditional culvert to be installed flush with the exisiting stream bed.
S7 — Stream location 7 includes 5 LF (7.5 SF) of temporary fill for coffer dam located downstream of the
traditional culvert.
S8 — Stream location 8 includes 15 LF (22.5 SF) of temporary fill for coffer dam located upstream of the traditional
culvert.
Page 10 of 21 PCN Form - Version 1.5, September 2020

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.
4b.
4c.
4d.
4e.
4el .
4f.
Site #*
Impact Reason/
Impact
Waterbody Name'
Waterbody
Jurisdiction
Impact area (ac)*
Type'
Duration*
Type"
Type'
01
Choose one
Tempi
Click to enter_
Choose one
Chooseone
Click to enter
Perm
02
Choose one
Tempi
Click to enter.
Choose one
Choose one
Click to enter.
Perm
03
Choose one
Tempi
Click to enter_
Choose one
Choose one
Click to enter.
Perm
04
Choose one
Temp!
Click to enter.
Choose one
Choose one
Click to enter.
Perm
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.
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 ?o
Clic�: to
Click to
Click to
Click to
Click to
nrite—
cnter
enlcr
enter.
enter.
enter.
enter
P2
Choose one
Click to
Click to
Click io
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:
Pond or lake construction is not proposed.
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:
Clidr, to ire; .
Page 11 of 21 PCN Form - Version 1.5, September 2020

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.}
J Neuse J Tar -Pamlico J Catawba
;J Jordan —1 Goose Creek J Randleman
J Other: Click to enter.
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
Ternpl Perm
Click to enter.
YIN
Click to enter.
Click to enter
62
Choose one
Tempi Perm
Click to enter.
YIN
Click to enter.
Click to enter.
B3
Choose one
Temp/ Perm
{lick to enter.
YIN
Click to enter.
Click to enter
B4
Choose one
Temp/ Perm
Click to enter.
YIN
Click to enter.
Click to enter
135
Choose one
Temp/ Perm
Click to enter.
YIN
Click to enter.
Click to enter
136
Choose one
Temp/ Perm
Click to enter.
YIN
Click to enter.
Click to enter.
B7
Choose one
Templ Perm
Click to enter.
YIN
Click to enter
Click to enter
138
Choose one
Temp/ Perm
Click to enter.
YIN
Click to enter.
Click to enter
89
Choose one
Temp/ Perm
Click to enter_
Y/N
Click to enter.
Click to enter
B10
Choose one
Temp/ Perm
Click to enter.
YIN
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:
Click to enter.
Please attach supporting documentation (impact maps, plan sheets, etc.) for the proposed project.
Page 12 of 21 PCN Farm - Version 1.5, September 2020

E. Impact Justification and Mitigation
1. Avoidance and Minimization
1 a. Specifically describe measures taken to avoid or minimize the proposed impacts through project design:
The applicant has designed the proposed development to avoid impacts to the remaining streams and wetlands
located on the site. In order to develop the site and provide the required dual access and to construct the project, the
proposed impacts could not be avoided. Civil design, such as minimizing the entranceway widths, use of headwalls
and endwalls and use of retaining wallswere used to further reduce impacts to streams and wetlands-
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 X Corps
(check all that apply)
2b. If yes, which mitigation option(s) will be used for this N Mitigation Bank
project? ` (check all that apply) L-1 In Lieu Fee Program
LJ Permittee Responsible Mitigation
3. Complete if using a Mitigation Bank
(Must satisfy NC General Statute 1 43-214A 1 (d1).)
3a. Name of mitigation bank:
Brushy Mountatin Mitigation Bank
3b. Credits purchased/requested:
Type: Riparian Wetland
Quantity 0.499
Type: Choose one
Quantity Click tc, enter.
Type: Choose one
Quantity Clif;k to ,r,ter
Attach receipt and/or approval letter.
3c. Comments:
A Statement of Availability (SoA) provided by Restoration Systems, LLC is attached.
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.mil/ribits apexlf?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 13 of 21 PCN Form - Version 1.5, September 2020

4h. Comments:
❑MS has been contacted and will used to secure wetland mitigation credits should private bank credits not be
available at the time of purchase.
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 the amount of mitigation proposed.
Click to enlef.
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
p Yes -x7 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 (square
Multiplier
Required mitigation
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
p Yes ::1 No
NC Division of Mitigation Services proposed?
6h.
If yes, attach the acceptance letter from the mitigation bank or NC Division of Mitigation Services.
6i.
Comments:
Buffer mitigation is not proposed.
Page 14 of 21 PCN Form - Version 1.5, September 2020

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 N 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 forms of stormwater treatment. If the
project is subject to a state implemented riparian buffer protection program, include a plan that fully documents
how diffuse flow will be maintained.
All Stormwater Control Measures (SCM) must be designed in accordance with the NC Stormwater Design
Manual (ht(ps://deg.nc..qov/about/divisions/ener.gy-mineral-land-resources/energy-mineral-land-permit-
gu ida ncelstormwater-bmp-ma nua I).
Associated supplement forms and other documentation must be provided.
U 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
LJ 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 N No
2b. Does this project meet the requirements for low density projects as
defined in 15A NCAC 02H .1003(2)?'
❑ Yes N No
To look up low density requirements, click here:
http://reports.oah.state.nc.us/ncac/title°Io2015a°Io20-`/`20environmenta1`/`20quality/chapter`/`2002`/020-
%20environmental%20managementlsubchapter%20h/15a%20ncac%2002h%20.1003.pdf
2c. IS the project over an acre?
N Yes ❑ No
2d. Does this project have a stormwater management plan (SMP)
reviewed and approved under a state stormwater program or state-
N Yes ❑ No
approved local government stormwater program? .
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.
2e. 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.
Page 15 of 21 PCN Form - Version 1.5, September 2020

Z Phase ll �:] USMP
Local Government Stormwater Programs
J NSW J Water Supply
Please identify which local government stormwater program you are using.'
City of Winston-Salem
x] Phase 14 HQW or ORW
State Starmwater Programs
J Coastal Counties J Other
Comments:
A SWMP has been submitted to the City of Winston-Salem for review and approval.
Page 16 of 21 PCN Form - Version 1.5, September 2020

G. Supplementary Information
1. Environmental Documentation
1a. Does the project involve an expenditure of public {federal/state/local}
_ 1 Yes Z 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 El No
Policy Act (NEPAISEPA)? .
1c. If you answered "yes" to the above, has the document review been
finalized by the State Clearing House? (if so, attach a copy of the
J Yes J No
NEPA or SEPA final approval letter.)
Comments:
A NEPA or SEPA is not required.
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),
DWR Surface Water or Wetland Standards or Riparian Buffer Rules —1 Yes No
(15A NCAC 2B .0200)?
2b. If you answered "yes" to the above question, provide an explanation of the violation(s)
Click 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 Z No
downstream water quality? '
3b. If you answered "no", provide a short narrative description:
Additional development as a result of the proposed development is not anticipated.
3c. If yes, attach a qualitative or quantitative cumulative impact analysis (.pdf) in accordance with the most recent
DWR policy.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?* I ® Yes J No J 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.
Sewage will be discharged into an existing sewer line that is located on the site. The sewer line will be bored beneath
Muddy Creek. Additional impacts associated with sewage disposal are not proposed.
Page 17 of 21 PCN Form - Version 1.5, September 2020

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? (I PAC weblink: httt s://www.fws.gov/i/ipac/ jfws.govl)
5b.
Have you checked with the USFWS concerning Endangered Species
❑ Yes X No
Act impacts? *
5c.
If yes, indicate the USFWS Field Office you have contacted.
Choose one
5d.
Is another federal agency involved?
❑ Yes X No ❑ Unknown
If yes, which federal agency?
Click to enter.
5e.
Is this a DOT project located within Divisions 1-8? *
❑ Yes X No
5f.
Will you cut any trees in order to conduct the work in waters of the
U.S.? *
®Yes ❑ No
5g.
Does this project involve bridge maintenance or removal? `
❑ Yes X No
Link to NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-30-17-signed NLEB-
SLOPES&apps. pdf
5h.
Does this project involve the construction/ installation of a wind
turbine(s)?
El 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)
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
4 listed species are identified on the IPaC report (attached). The Northern long-eared bat, bog turtle, Schweinitz's
Sunflower and Monarch butterfly are included by the IPaC as federally listed species identified within the project area.
Bat hibernacula is not located on the site. The site contains areas of limited or low quality suitable summer roosting
habitat. Similar or higher quality suitable summer roosting habitat was observed on surrounding properties.
Percussive activities including blasting or driving piles are not anticipated as a result of construction of the proposed
project. Based on a review of the June _1_2016_NLEB _HUC12 NLEB shapefiles obtained from the Asheville
Ecological Services Field Office website, the 12-digit HUC with the nearest confirmed hibernation and/or maternity sites
is located more than 75 miles from the site. Based on the distance from known hibernacula and roost trees and the
availability of similar suitable habitat on nearby properties, the proposed project is not likely to adversely affect the
Northern long-eared bat.
Neither the crossing nor the areas proximate to the crossing contain suitable habitat for the remaining species.
According to the natural heritage program, documented occurrences of Schweinitz's sunflower are located 12.5 miles
and farther from the site. The bog turtle is listed due to similarity of appearance and the Monarch butterfly is a
candidate species.
Attach consultation documentation.
Page 18 of 21 PCN Form - Version 1.5, September 2020

6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as
an Essential Fish Habitat?
U Yes Z No
Are there submerged aquatic vegetation (SAV) around
the project vicinity? "
El Yes 0 Na El Unknown
Will this project affect submerged aquatic vegetation?
LJ Yes Z No LJ Unknown
Explain: Crick u) w-ivei.
fib. What data source(s) did you use to determine whether your site would impact Essential Fish Habitat?
Essential Fish Habitat Mapper — NOAA Fisheries
Page 19 of 21 PCN Form - Version 1.5, September 2020

7. Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to the State Historic Preservation Office Historic Properties Map (does not include archaeological data)-
http://gis.ncdcr.gov/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
El Yes No
properties significant in North Carolina history and archaeology)?
7b. What data sources) did you use to determine whether your site would impact historic or archeological
resources?
NC Historic Preservation Office's HPOWFB 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,
8. Flood Zone designation (Corps Requirement)
Link to the FEMA F000dplain Maps: https://msc.fema.gov/portal/search
8a. Will this project occur in a FEMA-designated 100-year floodplain? "
❑ Yes x7 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?
National Flood Hazard Layer from FENIA Web Map Service — Drawing 4 (Attached)
Page 20 of 21 PCN Form - Version 1.5, September 2020

H. Miscellaneous
Comments:
Please let me know if you need additional information in order to process this application.
Attach pertinent documentation or attachments not previously requested
I. Signature
.21 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:
6/30/2022 I�
Page 21 of 21 PCN Form - Version 1.5, September 2020

Proposal for En viron men to/ Services
Pilot Proposal5462.1
February 24, 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: rv,-,�Zecz h [-InUrc [.. Q_j .
Applicant Information:
1►kTi, -3
Address:
uvt D�I1 ✓U
Telephone Number
Fax Number:
E-mail Address: Ci Ci- C ,",jLL\ —chef t •
Signatu re Vtu I U Date: 3 -1— 7-§ z L
R

DocuSign Envelope ID: 8F24AF5B-8852-44D7-9DC5-C1938DFE43DF
Proposal for Environmental Services
Pilot Proposal5462.1
February 24, 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: Mizpah Church Road
Winston Salem. NC
Owner Information: BHR Land Holdings, LLC
Address: 4389 Indian Trail Fairvew Road, Indian Trail, NC 28079
Telephone Number: 704-288-7826
Fax Number:
E-mail Address: [e-mail]
JURISDICTIONAL DETERMINATION REQUEST
D. PROPERTY ACCESS CERTIFICATION
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.
Ben Russell
Print Name
Capacity: _X Owner _ Authorized Agent
3/7/2022
cuftned by:
1° u& Assa
Signature
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tv.y aty -•-•• - - UWA aa-a� DWA 72-80 DWA 53.71 DWA 33-52 OWA 27-32
(OM6 ac] M.011 ac) 10.106 ac] (0.687 ac) (0.347 ac) [Q,U3Q ac}
SW A 10-131
24.38 O
,. P-2
. 10.037 ac]
—. OSC Q 4P 1
Pants Lake 3WA 29.33
(13.5 ac) {0.042 ac]
SWA 14-13
{0.002 ac]
SWE 1.10 550 SWA 21-23
[0.092 ac] 1100 LFj (0.021 ac) SWA 19.20
[0.003 ar}
sWC 1-9
10.025 ac]
SWD1-7
10.116 acj
FLAG NUMBERS/INFO
SSA [50 LF) ❑N'A 19.25
[0 037 acj
11,070 LF}
SSC
t
y 558
[30 LF]
DS8
[2, 880 LF]
SWA 16.18 SWB 1-18 DWB 1-17 •
{0.003 ac] OWA 95.101
[0.152 ac) (0.086 ac] ra.150 ac) DWC 54.57
[0.076 ar} OWC 1-s3
10.652 ar]
DSO
(1,4Qo IF)
H■
LEGEND y
Site Bound
Stream
Wetland
'' Pond
WETLAND FLAGS = ' 4 WA 5 Flag Numb.
STREAM FLAGS =
Stream Flags = Limits * " Culvert
Wetland Flags = 299
Total Flags = 299 f1 a;; - sf ' oP-1 • Data Point
..erg-. � __ � �'_- ��"• - .� � �!'�• �' _
THE LOCATIONS OF FEATURES SHOWN ON THIS MAP WERE VERIFIED BY MS. SAMANTHA DAILEY WITH THE USACE {SAW
EXHIBIT INCLUDES GPS LOCATIONS OF DELINEATED FEATURES. DELINEATION CONDUCTED BY PILOT PERSONNEL ON 12.18.19
0 SA 2
{130 LFj
❑SA 1
1260 LFj
i
QWA 4-18
I0.293 ac]
Drawing 5 Wetland Map
Satellite imagery from ESRI,; ``•,; Mizpah Church Road
and Pilot GP5 Data ;;`t. # Approximate 150-Acre Tract
Scale: 1" = 750' - r Rural Hall, Forsyth County, NC
Date: 12.20.19 PII..�T k%] Pilot Project 5452
• I. 1 t 9 1 I h y L 0 Y M 1 7Y I A L- N i Jr

0
:j I ff I

no
lkm ..
IWO
Q � 1
CAD y'
p E�
R
la •ti
4A1111 ikl��i
1
E; O
P 1 W{IU LL r_
90 }� LEGEND
Site Boundary
Web Soil Map
Drawing 2 � Mizpah Church Road
USDA Web Soil Survey tP
},
of Forsyth County, NC Approximate 150-Acre Tract
Rural Hall, Forsyth County, NC
Scale: 1 = 1,000 P1�k,04Pilot Project 5462
IILM I N1AI. INC

Drawing 2A Published Soil Map
USDA Soil Survey ,',i ,f Mizpah Church Road
Of Forsyth County, NC ti I Approximate 150-Acre Tract
Published 1976, Sheet 9 J Rural Hall, Forsyth County, NC
Not To Scale PILOTPilot Project 5462
f tilCf I%Y a,-9-IM I PO A I. - NE

"I\
W
a",
LEGEND
Site Boundary
Freshwater Emergent
i Freshwater Forested/Shrub
>_ Estuarine and Marine Deepwater
Estuarine and Marine
Freshwater Pond
Lake
� Rirrerine
- ❑t}It'r
ir>t
NWI Map
Drawing 3 Mizpah Church Road
USFWS NWI
Wetlands Mapper " ' Approximate 150-Acre Tract
Scale: 1" = 1,000' Rural Mall, Forsyth County, NC
Pilot Project 5462
I ILOi 1!•Y iOrIMIM1Al. AMC,

'PANE
71 D62/2
122
�P
�Z_00!�'J
AV
r
D rawi ng 4
psi..
3,
F4/
r, -4u'+
Wril�
sV
%"I
etf. '1;'2;'2("0:) _,"dl
W
r LEGEND
Site Boundary
1 %Annual Chance Flom Hazard
! Regulators Floodwayr
e Sped al Flood"
Area of U ndeterm ined Flood Hazard
0.2%Annual Chance Flood Hazard
Fifure Conditions 10/.Annual Chance Flood Hazard
Area with Reduced Risk Due to Levee
FEMA FIRM
National Flood Hazard Layer j . Mizpah Church Road
From FEMA Web Map Service Approximate 150-Acre Tract
Scale: 1" = 1 000' �,, r: Rural Hall, Forsyth County, NC
f
' PIWT Pilot Project 5452
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Muddy (0.096 acj (0.011 at] DWA 72.80 DWA 53.711 DWA 33-52 DWA 27-32
Creek 10,106 ac] (0.687 ac] 10.347 ac} (0.030 ac)
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(0.003 acj SWA 16-18 SWB 1-18 DWB 1-17
SWC 1.9 (0.003 ac) (0.152 ac} DWA 85.101
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Site Boundary
Stream
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FLAG NUMBERS/INFO
- Pond
WETLAND FLAGS =
STREAM FLAGS = wa 1 s Flag Number
Stream Flags = Limits • Culvert
Wetland Flags = 299 - �z r • -
Total Flags = 299 - 'Y DP-1 Data Paint
HE LOCATIONS OF FEATURES SHOWN ON THIS MAP WERE VERIFIED BY MS. SAMANTHA DAILEY WITH THE USACE (SAW-2022-00653). THIS
EXHIBIT INCLUDES GPS LOCATIONS OF ❑ELINEATED FEATURES. DELINEATION CONDUCTED BY PILOT PERSONNEL ON 12.18.19.
_Abililliff, 7
Drawing 5 Wetland Map
Satellite Imagery from ESRI Mizpah Church Road
and Pilot GP5 Data
X' Approximate 150-Acre Tract
Scale: 1" = 750' # ' f
Rural Hall, Forsyth County, NC
Date: 12.20.19 PT M n L. , r+ Pilot Project 5462

JIf'y} k IRk7'Rl'N'p FF.
N C
United States Department of the Interior
7 .;/
s, ?, FISH AND WILDLIFE SERVICE
'Octr 3''A Asheville Ecological Services Field Office
160 Zillicoa Street
Asheville, NC 28801-1082
Phone: [phone] Fax: [phone]
In Reply Refer To: June 17, 2022
Project Code: 2022-0055608
Project Name: Long Creek Village
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

06/17/2022
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 BABE can be found at the following web link:
httDS://www. fws. Gov/off ice/a slieville-ecological-services/ashe ville-field-off ice-online-review-
1141I .S-MO era _WPAraTA
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-
handhonk.
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/migratoU-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

06/17/2022
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 he 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
[phone]

06/17/2022
Project Summary
Pr❑ject Code: 2022-0055608
Event Code: None
Project Name: Long Creek Village
Project Type: Residential Construction
Project Description: The site is an approximate 156 acre tract that is being considered for
residential development.
Project Location:
Approximate location of the project can be viewed in Google Maps: https:ll
www.google.com/maps/(a736.2054687,-80.32430593638288,14z
f9�
Counties: Forsyth County, North Carolina

06/17/2022
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
Fisheries, 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.
NAME STATUS
Northern Long-eared Bat Myotis septentrionalis Threatened
No critical habitat has been designated for this species.
Species profile: https:llecos.fws.gov/ecp/species/9045
Reptiles
NAME STATUS
Bog Turtle GIyptemys 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:llecos.fws.gov/ecp/species/6962
Insects
NA N* STATUS
Monarch Butterfly Donaus plexippus Candidate
No critical habitat has been designated for this species.
Species profile: https:llecos.fws.gov/ecp/species/9743

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4
Flowering Plants
NAME STATUS
Schweinitz's Sunflower HeIianthus schweinitzii Endangered
No critical habitat has been designated for this species.
Species profile: https:Ilecos,fws,govlecpisaecies13849
Critical habitats
THERE ARE N❑ CRITICAL HABITATS WITHIN YOUR PROJECT AREA UNDER THIS OFFICE'S
JURISDICTION.

06/17/2022
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.

06/17/2022
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 Treaty 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 Haltaeetus 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 Alas ka.
htt s:llecos. fws. ovlec Is p ecies19399

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BREEDING
NAME
SEASON
Cerulean Warbler Dendroica cerulea
Breeds Apr 28
This is a Bird of Conservation Concern (BCC} throughout its range in the continental USA
to Jul 20
and Alaska.
https:l/e cos, fws, govle cpls n e c i e s129 74
Eastern Whip -poor -will Antrostomus vociferus
Breeds May 1
This is a Bird of Conservation Concern {BCC} throughout its range in the continental USA
to Aug 20
and Alaska.
Kentucky Warbler Oporornis formosus Breeds Apr 20
This is a Bird of Conservation Concern (BCC) throughout its range in the continental USA to Aug 20
and Alaska.
Prairie Warbler Dendroica discolor Breeds May 1
This is a Bird of Conservation Concern ($CC) 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 to Sep 10
and Alaska.
Rusty Blackbird Euphagus carolinus Breeds
This is a Bird of Conservation Concern (BCC) only in particular Bird Conservation Regions elsewhere
(SCRs) 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.

06/17/2022 3
How is the probability of presence score calculated? The calculation is done in three steps:
1. 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
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
weer 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.
SPECIES
Bald Eagle
Non -BCC
Vulnerable
U probability of presence breeding season I survey effort — no data
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Black-bilied
Cuckoo + I I+ I+ I I I I tttt tftt ! 1] 1 k I I i f i I I I i I I I 11 I TT I I T
Cuckoo

06/17/2022
4
BCC Rangewide
(CON)
Cerulean Warbler
I I I I t I t I I I I I I I I
Ott
BCC Rangewide
t+ ttt + +t
(CON)
Eastern Whip -poor -
will
T J�� ++++ + 1 11 f t t1 I I I I
T
BCC Rangewide
(CON)
Kentucky Warbler
BCC Rangewide
j
(CON)
Praire Warbler
1Rangewide
BCC
++++ ++++ ++++ *0 111
(CON)
Prothonotary
I- I t t-H � t t I! [ I I I I
Warbler
T T
BCC Rangewide
(CON)
Red-headed
.
.1
Woodpecker
IT� �
11 i f l
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BCC Rangewide
(CON)
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Rusty Blackbird I f 1 I I I 1 I I I I I
BCC -BCR I I I 14++ ++++ + i 1 1 ++++ ++++ ++++ so++ ++1+
Thrush
BCC Rangewide ++++ ++++ ++++ +l!! 11 I I 1 1111 I � I l 1 1 1 I I I I I 11 11 1 I f 1 1 1 1 E
BCC
(CON)
Additional information can be found using the following links:
■ Birds of Conservation Concern https://WWW.fWS.gov/VrWraM/migratory-birds/species
• Measures for avoiding and minimizing impacts to birds https://www.fws.gov/libou/
collections/avoidin c!-and-minimizing-inciden tal-take-miv-ratorv-birds
• Nationwide conservation measures for birds https://www.fws.gov/sites/default/files/
documents/nationwide-standard-conservation-measures .pd f
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

06/17/2022
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 migratory birds potentially occurring in my specified
location?
The Migratory Bird Resource List is comprised of USFWS Birds of Conservation Concern
(BCC) and other species that may warrant special attention in your project location.
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 AKN Phenology Tool.
What does IPaC use to generate the probability of presence graphs for the migratory birds
potentially occurring in my specified Iocation?
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, migrating or present year-round in my
project 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 refer to the following resources: The Cornell Lab
of Ornithology All About Birds Bird Guide, or (if you are unsuccessful in locating the bird of
interest there), the Cornell Lab of Ornithology Neotropical Birds guide. 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);

06/17/2022
2. "BCC - SCR" 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).
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
throughouz 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 Loring.
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,

06/17/2022
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.

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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
• Riverine
FRESHWATER FORESTED/SHRUB WETLAND
• Palustrine

06/17/2022
IPaC User Contact Information
Agency: Pilot Environmental, Inc
Name: David Brame
Address: 743 Park Lawn Court
City:
Kernersville
State:
NC
Zip:
27284
Email
[e-mail]
Phone:
3363104527

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David Brame
From: Heather LaGarnba
Sent: Tuesday, April 19, 2022 4:11 PM
To: Homewood, Sue; Montalva, Sheri A
Subject: Pre -File Notice - tong Creek Village (Mizpah Church Rd - 5462.1)
Sue/Sherri,
We would like to submit a Pre -filing Notice for the following project -
Project Name: Lang Creek Village (Mizpah Church Rd - 5462.1)
Project Owner: Carolina Development Services
Project Owner's Address: 2627 Brekenridge Centre Drive, Monroe, North Carolina 28110
Project County: Forsyth
Type of project/Approval Sought: 401 WQC, Pre -Application Request Meeting Declined
Sincerely,
Heather LaGarinba
336.345.9536 (c)
336.310.4527 (o)
P.O. Box 128
Kernersviile, NC 27285
W W W.,l ilotnnviro.com
hlagamba@, ; iIatenv:•:.corn

Restoration Systems, LLC
1101 Haynes St. Suite 211
Raleigh, North Carolina
Ph: [phone]
Fx: [phone]
Statement of Mitigation Credit Availability
Brushy Mountain Mitigation Bank
June 27, 2022, 2022
Army Corps of Engineers
Re: Availability of Compensatory Wetland Credits
Project: Long Creek Village
Project Location: Minapah Church Road, Winston-Salem, Forsyth County, NC -Yadkin 03040101
Permittee: Mr. Johnathan McCall
Carolina Development Services, LLC
2627 Brekonridge Centre Drive
Monroe, North Carolina 28110
This document confirms that 1 Wetland Credits [Credits] from the Brushy Mountain Mitigation
Bank (Bank) are currently available and 0 or a portion may be used, once transferred, for
compensatory mitigation relative to the Long Creek Village project.
The Applicant may ultimately purchase the Credits, if they are available, following Permit issuance.
Should the Applicant purchase the Credits at that time, we will complete and execute the Mitigation
Credit Transfer Certificate (Certificate) within five (5) days of receipt of the full purchase price.
We will additionally provide copies of the completed and executed Certificate to the Applicant, the
Division of Water Resources (DWR) and, if needed, other regulatory agencies. In addition, we will
provide DWR with an updated copy of the BanWs Ledger, reflecting the transaction. Transaction
information in the updated Bank Ledger will include relevant Permit and Applicant information as
well as the number and resource type of the debited Credits.
Should your office have any questions, please contact me at 919.334.9118.
Sincerely,
BARRETT JENKINS
Restoration Systems, LLC
[e-mail]

ORIGINAL ISSUED USAGE PERMIT
SAW-2022-00653

U.S. ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Action Id. SAW-2022-00653 County: Forsyth U.S.G.S. Quad: NC -Rural Hall
GENERAL PERNHT (REGIONAL AND NATIONWIDE) VERIFICATION
Permittee:
Carolina Development Services, LLC
Jonathan McCall
Address:
2627 Breckenridge Centre Drive
Monroe, North Carolina 28110
Telephone Number:
[phone]
E-mail:
imccall(&carolina-development.com
Size (acres) 150 Nearest Town Rural Hall
Nearest Waterway Muddy Creek River Basin Yadkin
USGS HUC 03040101 Coordinates Latitude: 36.205437
Longitude:-80.3205
Location description: The project area is identified as an approximate 150-acre tract of land located on Forsyth County, North
Carolina Parcel 6809966493. This parcel is located west of the intersection of Bethania Rural Hall Road and Mimah Church
Road, in Rural Hall, Forsyth County, North Carolina. Work in waters of the United States (U.S.) will occur within the
headwaters of Muddy Creek, a direct tributary of the Yadkin River (8-di0t HUC: 03040101).
Description of projects area and activity: The applicant, Carolina Development Services, LLC, has requested a department of
the Armv authorization to discharge fill material into waters of the U.S. in coniunction with the construction of the Long
Creek Village residential development. Proiect activity will involve the construction single and multi-familv residential lots
along with associated infrastructure and amenities. Implementation of the proposed project will permanently impact 0.374
acre of wetland and 202 linear feet (0.007 acre) of stream channel, and temporarily impact 45 linear feet of stream channel.
Proiect activity will also involve the placement of a riprap dissipator along 15 linear feet of stream channel. Upon proiect
completion, all temporarily disturbed areas would be returned to their pre -disturbed elevations and contours.
The proposed proiect activity will also involve the installation of a bottomless arched culvert which would result in indirect
impacts to 87 linear feet (0.08 acre); including 15 linear feet of riprap. This impact is not considered a loss.
Compensatory mitigation is required at a minimum of 1:1 mitigation to impact ratio for all wetland losses that exceed 1/10-
acre. Therefore, the applicant has proposed to purchase 0.75 wetland mitigation units from Restoration Systems, LLC's RS
Yadkin 01 UMBI, Brushy Mountain Mitigation Bank, to offset the loss of aquatic function to 0.374 acre of wetland.
Applicable Law(s): © Section 404 (Clean Water Act, 33 USC 1344)
❑ Section 10 (Rivers and Harbors Act, 33 USC 403)
Authorization: Nationwide Permit 29 (residential developments)
SEE ATTACHED NWP GENERAL, REGIONAL, AND/OR SPECIAL CONDITIONS
Your work is authorized by the above referenced permit provided it is accomplished in strict accordance with the attached
Conditions, your application signed and dated 6/30/2022, and the enclosed plans dated 9/8/2022. Any violation of the attached
conditions or deviation from your submitted plans may subject the permittee to a stop work order, a restoration order, a Class
I administrative penalty, and/or appropriate legal action.
This verification will remain valid until the expiration date identified below unless the nationwide and/or regional general permit
authorization is modified, suspended or revoked. If, prior to the expiration date identified below, the nationwide and/or regional general
permit authorization is reissued and/or modified, this verification will remain valid until the expiration date identified below, provided
it complies with all requirements of the modified nationwide permit. If the nationwide and/or regional general permit authorization
expires or is suspended, revoked, or is modified, such that the activity would no longer comply with the terns and conditions of the
nationwide permit, activities which have commenced (i.e., are under construction) or are under contract to commence in reliance upon
the nationwide and/or regional general permit, will remain authorized provided the activity is completed within twelve months of the
date of the nationwide and/or regional general permit's expiration, modification or revocation, unless discretionary authority has been
exercised on a case -by -case basis to modify, suspend or revoke the authorization.

Activities subject to Section 404 (as indicated above) may also require an individual Section 401 Water Quality Certification. You
should contact the NC Division of Water Resources (telephone [phone]) to determine Section 401 requirements.
For activities occurring within the twenty coastal counties subject to regulation under the Coastal Area Management Act (CAMA), prior
to beginning work you must contact the N.C. Division of Coastal Management Morehead City, NC, at [phone].
This Department of the Army verification does not relieve the permittee of the responsibility to obtain any other required Federal, State
or local approvals/permits. If there are any questions regarding this verification, any of the conditions of the Permit, or the Corps of
Engineers regulatory program, please contact Samantha Dailey at [phone], EXT. 22or Samantha.J.Dailcvnusace.armv.mil.
Corps Regulatory Official: Ia4l� P� Date: 10/06/2022
Expiration Date of Verification: 3/14/2026
The Wilmington District is committed to providing the highest level of support to the public. To help us ensure we
continue to do so, please complete the Customer Satisfaction Survey located at
hM2:HcoKpsmapu.usace.ariny.mil/cm apex/f?p=l36:4:0
Copy furnished:
Agent: Pilot Environmental, Inc.
David Brame
Address: 743 Park Lawn Court
Kernersville, North Carolina 27284
Telephone Number: [phone]
E-mail: dbrame( )pilotenviro.com
Property Owner: BHR Land Holdinp_s, LLC
Ben Russell
Address: 4389 Indian Trail Fairview Road
Indian Trail, North Carolina 28079
Telephone Number: [phone]
E-mail: benAyinnaclehomcusa.net

SAW-2022-00653
SPECIAL CONDITIONS
a. In order to compensate for impacts associated with this permit, mitigation shall be provided in accordance
with the provisions outlined on the most recent version of the attached Compensatory Mitigation Responsibility
Transfer Form. The requirements of this form, including any special conditions listed on this form, are hereby
incorporated as special conditions of this permit authorization.

Action ID Number: SAW-2022-00653 County: Forsyth
Permittee: Carolina Development Services, LLC
Project Name: Lone Creek Village
Date Verification Issued: 10/06/2022
Project Manager: Samantha Dailey
Upon completion of the activity authorized by this permit and any mitigation required by the permit,
sign this certification and return it to the following address:
US ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Attn: Samantha Dailey
Raleigh Regulatory Office
U.S Army Corps of Engineers
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
or
[e-mail]
Please note that your permitted activity is subject to a compliance inspection by a U. S. Army Corps of
Engineers representative. Failure to comply with any terms or conditions of this authorization may
result in the Corps suspending, modifying or revoking the authorization and/or issuing a Class I
administrative penalty, or initiating other appropriate legal action.
I hereby certify that the work authorized by the above referenced permit has been completed in
accordance with the terms and condition of the said permit, and required mitigation was completed in
accordance with the permit conditions.
Signature of Permittee
Date

U.S. ARMY CORPS OF ENGINEERS
Wilmington District
Compensatory Mitigation Responsibility Transfer Form
Permittee: Carolina Development Services, LLC
Project Name: Long Creek Village
Action ID: SAW-2022-00653
County: Forsyth
Instructions to Permittee: The Permittee must provide a copy of this form to the Mitigation Sponsor, either an approved
Mitigation Bank or the North Carolina Division of Mitigation Services (NCDMS), who will then sign the form to verify the
transfer of the mitigation responsibility. Once the Sponsor has signed this form, it is the Permittee's responsibility to ensure
that Wilmington District Project Manager identified on page two is in receipt of a signed copy of this form before conducting
authorized impacts, unless otherwise specified below. If more than one Mitigation Sponsor will be used to provide the
mitigation associated with the permit, or if the impacts and/or the mitigation will occur in more than one 8-digit Hydrologic
Unit Code (HUC), multiple forms will be attached to the permit, and the separate forms for each Sponsor and/or HUC must be
provided to the appropriate Mitigation Sponsors.
Instructions to Sponsor: The Sponsor verifies that the mitigation requirements (credits) shown below have been released and
are available at the identified site. By signing below, the Sponsor is accepting full responsibility for the identified mitigation,
regardless of whether they have received payment from the Permittee. Once the form is signed, the Sponsor must update the
bank ledger and provide a copy of the signed form and the updated ledger to the Permittee, the Project Manager who issued the
permit, the Bank Project Manager, and the District Mitigation Office (see contact information on page 2). The Sponsor must
also comply with all reporting requirements established in their authorizing instrument.
Permitted Impacts and Compensatory Mitigation Requirements:
Permitted Impacts Requiring Mitigation* 8-digit HUC and Basin: 03040101, Yadkin River Basin
Stream Impacts (linear feet)
Wetland Impacts (acres)
RiparianRiverine
Warm
Cool
Cold
Riparian Non-Riverine
Non -Riparian
Coastal
0.374
*If more than one mitigation sponsor will be used for the permit, only include impacts to be mitigated by this sponsor.
Compensatory Mitigation Requirements: 8-digit HUC and Basin: 03040101, Yadkin River Basin
Stream Mitigation (credits)
Wetland Mitigation (credits)
Riparian
Riparian Non -
Warm
Cool
Cold
Non -Riparian
Coastal
Riverine
Riverine
0.75
Mitigation Site Debited: Restoration Systems, LLC's RS Yadkin 01 UMBI, Brushy Fork Mitigation Bank
(List the name of the bank to be debited. For umbrella banks, also list the specific site. For NCDMS, list NCDMS. If the
NCDMS acceptance letter identifies a specific site, also list the specific site to be debited).
Section to be completed by the Mitigation Sponsor
Statement of Mitigation Liability Acceptance: I, the undersigned, verify that I am authorized to approve mitigation
transactions for the Mitigation Sponsor shown below, and I certify that the Sponsor agrees to accept full responsibility for
providing the mitigation identified in this document (see the table above), associated with the USACE Permittee and Action
ID number shown. I also verify that released credits (and/or advance credits for NCDMS), as approved by the Wilmington
District, are currently available at the mitigation site identified above. Further, I understand that if the Sponsor fails to provide
the required compensatory mitigation, the USACE Wilmington District Engineer may pursue measures against the Sponsor to
ensure compliance associated with the mitigation requirements.
Mitigation Sponsor Name:
Name of Sponsor's Authorized Representative:
Signature of Sponsor's Authorized Representative Date of Signature
Page 1 of 2 Form Version 10 June 2020 updated

CESAW-RG (File Number, SAW-2022-00653)
Conditions for Transfer of Compensatory Mitigation Credit:
• Once this document has been signed by the Mitigation Sponsor and the District is in receipt of the signed form, the
Permittee is no longer responsible for providing the mitigation identified in this form, though the Permittee remains
responsible for any other mitigation requirements stated in the permit conditions.
• Construction within jurisdictional areas authorized by the permit identified on page one of this form can begin only after
the District is in receipt of a copy of this document signed by the Sponsor, confirming that the Sponsor has accepted
responsibility for providing the mitigation requirements listed herein. When NCDMS provides mitigation for authorized
impacts conducted by the North Carolina Department of Transportation (NCDOT), construction within jurisdictional areas
may proceed upon permit issuance; however, a copy of this form signed by NCDMS must be provided to the District
within 30 days of permit issuance. NCDOT remains fully responsible for the mitigation until the District has received this
form, confirming that the Sponsor has accepted responsibility for providing the mitigation requirements listed herein.
• Signed copies of this document must be retained by the Permittee, Mitigation Sponsor, and in the USACE administrative
records for both the permit and the Bank/ILF Instrument. It is the Permittee's responsibility to ensure that the District
Project Manager (address below) is provided with a signed copy of this form.
• If changes are proposed to the type, amount, or location of mitigation after this form has been signed and returned to the
District, the Sponsor must obtain case -by -case approval from the District Project Manager and/or North Carolina
Interagency Review Team (NCIRT). If approved, higher mitigation ratios may be applied, as per current District guidance
and a new version of this form must be completed and included in the District administrative records for both the permit
and the Bank/ILF Instrument.
Comments/Additional Conditions: A letter from Restoration Systems, LLC, confirming they are willing and able to
accept the applicant's compensatory mitigation responsibility, dated 6/27/2022 was included with the preconstruction
notification.
This form is not valid unless signed below by the District Project Manager and by the Mitigation Sponsor on Page 1. Once
signed, the Sponsor should provide copies of this form along with an updated bank ledger to: I) the Permittee, 2) the District
Project Manager at the address below, 3) the Bank Manager listed in RIBITS, and 4) the Wilmington District Mitigation
Office, 3331 Heritage Trade Drive, Suite 105, Wake Forest, NC27587 (or by email to SAWMIT(a usace.army.mil). Questions
regarding this form or any of the permit conditions may be directed to the District Mitigation Office.
USACE Project Manager: Samantha Dailey
USACE Field Office: Raleigh Regulatory Office
US Army Corps of Engineers
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
Email: [e-mail]
Saotl Z�11
10/06/2022
USACE Project ManagVr Signature Date of Signature
Current Wilmington District mitigation guidance, including information on mitigation ratios, functional assessments, and
mitigation bank location and availability, and credit classifications (including stream temperature and wetland groupings) is
available at http://ribits.usace.army."l

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ORIGINAL ISSUED NCDWR PERMIT
20220896 VI

DocuSign Envelope ID: AB5AADC8-9DB8-4825-8B62-5027B7AE0328
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHAM E. ROGERS, JR.
Director
NORTH CAROLINA
Environmental Quality
October 3, 2022
DWR # 20220896
Forsyth County
Carolina Development Services LLC
Attn: Mr. Jonathan McCall
2627 Breckenridge Center Dr
Monroe NC 28110
Delivered via email to: [e-mail]
Subject: Approval of Individual 401 Water Quality Certification
Long Creek Village Residential Development
Dear Mr. McCall:
Attached hereto is a copy of Certification No. WQC005221 issued to Mr. Jonathan McCall and Carolina
Development Services LLC, dated October 3, 2022. This approval is for the purpose and design described
in your application. The plans and specifications for this project are incorporated by reference as part of
this Water Quality Certification. If you change your project, you must notify the Division and you may be
required to submit a new application package with the appropriate fee. If the property is sold, the new
owner must be given a copy of this Certification and is responsible for complying with all conditions. [15A
NCAC 02H .0507(d)(2)].
This Water Quality Certification does not relieve the permittee of the responsibility to obtain all other
required Federal, State, or Local approvals before proceeding with the project, including those required
by, but not limited to, Sediment and Erosion Control, Non -Discharge, Water Supply Watershed, and
Trout Buffer regulations.
This Water Quality Certification neither grants nor affirms any property right, license, or privilege in any
lands or waters, or any right of use in any waters. This Water Quality Certification does not authorize
any person to interfere with the riparian rights, littoral rights, or water use rights of any other person
and does not create any prescriptive right or any right of priority regarding any usage of water. This
Water Quality Certification shall not be interposed as a defense in any action respecting the
determination of riparian or littoral rights or other rights to water use. No consumptive user is deemed
by virtue of this Water Quality Certification to possess any prescriptive or other right of priority with
D E Q�� North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 W. Hanes Mill Rd, Suite 300 1 Winston-Salem, North Carolina 27105
NORTH CPAO.IN.4
336.776.9800

DocuSign Envelope ID: AB5AADC8-9DB8-4825-8B62-5027B7AE0328 Carolina Development Services LLC
DWR#20220896
Individual Certification #WQC005221
Page 2 of 12
respect to any other consumptive user regardless of the quantity of the withdrawal or the date on which
the withdrawal was initiated or expanded.
Upon the presentation of proper credentials, the Division may inspect the property.
This Water Quality Certification shall expire on the same day as the expiration date of the corresponding
Section 404 Permit. The conditions shall remain in effect for the life of the project, regardless of the
expiration date of this Water Quality Certification.
Non-compliance with or violation of the conditions herein set forth may result in revocation of this
Water Quality Certification for the project and may also result in criminal and/or civil penalties.
If you are unable to comply with any of the conditions of this Water Quality Certification you must notify
the Winston-Salem Regional Office within 24 hours (or the next business day if a weekend or holiday)
from the time the permittee becomes aware of the circumstances.
The permittee shall report to the Winston-Salem Regional Office any noncompliance with, and/or any
violation of, stream or wetland standards [15A NCAC 02B .0200] including but not limited to sediment
impacts to streams or wetlands. Information shall be provided orally within 24 hours (or the next
business day if a weekend or holiday) from the time the permittee became aware of the non-compliance
circumstances.
This approval and its conditions are final and binding unless contested [G.S. 143-215.5].
This Certification can be contested as provided in Chapter 150B of the North Carolina General Statutes by
filing a Petition for a Contested Case Hearing (Petition) with the North Carolina Office of Administrative
Hearings (OAH) within sixty (60) calendar days. Requirements for filing a Petition are set forth in Chapter
150B of the North Carolina General Statutes and Title 26 of the North Carolina Administrative Code.
Additional information regarding requirements for filing a Petition and Petition forms may be accessed at
http://www.ncoah.com/ or by calling the OAH Clerk's Office at [phone].
A party filing a Petition must serve a copy of the Petition on:
William F. Lane, General Counsel
Department of Environmental Quality
1601 Mail Service Center
Raleigh, NC 27699-1601
If the party filing the Petition is not the permittee, then the party must also serve the recipient of the
Certification in accordance with N.C.G.S 15013-23(a).
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 W. Hanes Mill Rd, Suite 300 1 Raleigh, North Carolina 27105
NORTH CAROL I NA i
336.776.9800

DocuSign Envelope ID: AB5AADC8-9DB8-4825-8B62-5027B7AE0328 Carolina Development Services LLC
DWR#20220896
Individual Certification #WQC005221
Page 3 of 12
This letter completes the Division's review under section 401 of the Clean Water Act and 15A NCAC
02H .0500. Please contact Sue Homewood at 336-776-9693 or [e-mail] if you have
any questions or concerns.
Sincerely,
ED�'ocuSiiggned 1by,
l�Vn. �JM0.Ct
145849E225C94EA...
Lon T. Snider
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ— WSRO
Electronic cc: David Brame, Pilot Environmental Inc.
Samantha Dailey, USACE Raleigh Regulatory Field Office
Olivia Munzer, NCWRC
Todd Bowers, EPA
DWR 401 & Buffer Permitting Branch Electronic file
North Carolina Department of Environmental Quality I Division of Water Resources
D E Q�� Winston-Salem Regional Office 1 450 W. Hanes Mill Rd, Suite 300 1 Raleigh, North Carolina 27105
NORTH CARO,INA
336.776.9800

DocuSign Envelope ID: AB5AADC8-9DB8-4825-8B62-5027B7AE0328
Carolina Development Services LLC
DWR#20220896
Individual Certification #WQC005221
Page 4 of 12
NORTH CAROLINA 401 WATER QUALITY CERTIFICATION
CERTIFICATION # WQC005221 is issued in conformity with the requirements of Section 401, Public Laws
92-500 and 95-217 of the United States and subject to North Carolina's Regulations in 15 NCAC 02H .0500
and 15A NCAC 0213.0200, to Mr. Jonathan McCall and Carolina Development Services LLC, who have
authorization for the impacts listed below, as described within your application received by the N.C.
Division of Water Resources (Division) on July 5, 2022 and subsequent information on July 27, 2022,
September 12, 2022 and September 30, 2022, and by Public Notice issued by the Division on July 5, 2022.
The State of North Carolina certifies that this activity will comply with water quality requirements and
the applicable portions of Sections 301, 302, 303, 306, 307 of the Public Laws 92-500 and PL 95-217 if
conducted in accordance with the application, the supporting documentation, and conditions
hereinafter set forth.
The following impacts are hereby approved. No other impacts are approved, including incidental
impacts. [15A NCAC 02H .0506(b)]
Type of Impact
Amount Approved (units)
Permanent
Amount Approved (units)
Temporary
Strea m
Site S1-S3 — shading from
bottomless arch culvert
87 (linear feet)
25 (linear feet)
Site S4-S3 —culvert
-riprap apron*
202 (linear feet)
15 (linear feet)
20 (linear feet)
404/401 Wetlands
Site W-1A
0.047 (acres)
0 (acres)
Site W-113
0.110 (acres)
0 (acres)
Site W-2
0.130 (acres)
0 (acres)
Site W-3
0.087 (acres)
0 (acres)
*Mitigation not required
This approval requires you to follow the conditions listed in the certification below.
CONDITIONS OF CERTIFICATION [15A NCAC 02H .0507(c)]:
Mitigation must be provided for the proposed impacts as specified in the table below. The Division
has received an acceptance letter from the Restoration Services LLC sponsored Brushy Mountain
Mitigation Bank (Mitigation Bank) to meet this mitigation requirement. Until the Mitigation Bank
receives and clears your payment, and proof of payment has been provided to this Office, no
impacts specified in this Authorization Certificate shall occur. For accounting purposes, this
Authorization Certificate authorizes payment to the Mitigation Bank to meet the following
compensatory mitigation requirement
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 W. Hanes Mill Rd, Suite 300 1 Raleigh, North Carolina 27105
NORTH CAROL I NA i
336.776.9800

DocuSign Envelope ID: AB5AADC8-9DB8-4825-8B62-5027B7AE0328
Carolina Development Services LLC
DWR#20220896
Individual Certification #WQC005221
Page 5 of 12
Compensatory Mitigation
River and Sub -basin
Required
Number
Wetland
0.374 (acres)
Yadkin River
03040101
Citation: 15A NCAC 02H .0506(c), 15A NCAC 02H .0507(c)
Justification: A project that affects waters shall not be permitted unless the existing uses, and the
water quality to protect such uses, are protected. In determining that the proposed activity will
comply with state water quality standards (including designated uses, numeric criteria, narrative
criteria and the state's antidegradation policy), the project must provide for replacement of existing
uses through compensatory mitigation.
2. The Permittee shall secure an approved stormwater management plan (SMP) from the City of
Winston-Salem / Forsyth County before any impacts authorized in this certification occur.
Citation: 15A NCAC 02H .0506, 15A NCAC 02H .0507(c)
Justification: Surface water quality standards require that conditions of waters be suitable for all best
uses provided for in state rule (including, at minimum: aquatic life propagation, survival, and
maintenance of biological integrity, wildlife, secondary contact recreation; agriculture), and that
activities must not cause water pollution that precludes any best use on a short-term or long-term
basis.
3. All wetlands, streams, and surface waters located within 50 feet of the construction area on the
project site shall be clearly marked (example- orange fabric fencing) prior to any land disturbing
activities and must be maintained on the property until the project phase is completed.
Citation: 15A NCAC 02H .0506(b)(2), 15A NCAC 02H .0507(c)
Justification: A project that affects waters shall not be permitted unless the existing uses, and the
water quality to protect such uses, are protected. In determining that the proposed activity will
comply with state water quality standards (including designated uses, numeric criteria, narrative
criteria and the state's antidegradation policy), the Division must evaluate if the activity has avoided
and minimized impacts to waters, would cause or contribute to a violation of standards or would
result in secondary or cumulative impacts.
4. The permittee shall report to the DWR Winston Salem Regional Office any noncompliance with,
and/or any violation of, stream or wetland standards [15A NCAC 02B .0200], including but not limited
to sediment impacts to streams or wetlands. Information shall be provided orally within 24 hours (or
the next business day if a weekend or holiday) from the time the permittee became aware of the non-
compliance circumstances.
Citation: 15A NCAC 02H .0506(b), 15A NCAC 02H .0507(c)
Justification: Timely reporting of non-compliance is important in identifying and minimizing
detrimental impacts to water quality and avoiding impacts due to water pollution that precludes any
best use on a short-term or long-term basis.
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 W. Hanes Mill Rd, Suite 300 1 Raleigh, North Carolina 27105
NORTH CAROL I NA i
336.776.9800

DocuSign Envelope ID: AB5AADC8-9DB8-4825-8B62-5027B7AE0328 Carolina Development Services LLC
DWR#20220896
Individual Certification #WQC005221
Page 6 of 12
5. No waste, spoil, solids, or fill of any kind shall occur in wetlands or waters beyond the footprint of
the approved impacts (including temporary impacts).
Citation: 15A NCAC 02H .0506, 15A NCAC 02H .0507(c)
Justification: Surface water quality standards require that conditions of waters be suitable for all best
uses provided for in state rule (including, at minimum: aquatic life propagation, survival, and
maintenance of biological integrity, wildlife, secondary contact recreation; agriculture), and that
activities must not cause water pollution that precludes any best use on a short-term or long-term
basis.
6. All construction activities shall be performed and maintained in full compliance with G.S. Chapter
113A Article 4 (Sediment and Pollution Control Act of 1973). Regardless of applicability of the
Sediment and Pollution Control Act, all projects shall incorporate appropriate Best Management
Practices for the control of sediment and erosion so that no violations of state water quality
standards, statutes, or rules occur.
Citation: 15A NCAC 02H .0506(b), 15A NCAC 02H .0507(c), 15A NCACO28 .0200, 15A NCAC 02B
.0231
Justification: A project that affects waters shall not be permitted unless the existing uses, and the
water quality to protect such uses, are protected. Activities must not cause water pollution that
precludes any best use on a short-term or long-term basis. As cited in Stream Standards: (12) Oils,
deleterious substances, or colored or other wastes: only such amounts as shall not render the waters
injurious to public health, secondary recreation, or to aquatic life and wildlife, or adversely affect the
palatability offish, aesthetic quality, or impair the waters for any designated uses, and (21) turbidity
in the receiving water shall not exceed 50 Nephelometric Turbidity Units (NTU) in streams not
designated as trout waters and 10 NTU in streams, lakes, or reservoirs designated as trout waters;
for lakes and reservoirs not designated as trout waters, the turbidity shall not exceed 25 NTU; if
turbidity exceeds these levels due to natural background conditions, the existing turbidity level shall
not be increased. As cited in Wetland Standards: (c)(1) Liquids, fill or other solids, or dissolved gases
shall not be present in amounts that may cause adverse impacts on existing wetland uses, and (3)
Materials producing color or odor shall not be present in amounts that may cause adverse impacts
on existing wetland uses.
7. Sediment and erosion control measures shall not be installed in wetland or waters except within the
footprint of temporary or permanent impacts otherwise authorized by this Certification. If placed
within authorized impact areas, then placement of such measures shall not be conducted in a
manner that results in dis-equilibrium of any wetlands, streambeds, or streambanks. Any silt fence
installed within wetlands shall be removed from wetlands and the natural grade restored within two
(2) months of the date that DEMLR or locally delegated program has released the specific area
within the project to ensure wetland standards are maintained upon completion of the project.
Citation: 15A NCAC 02H .0506(b), 15A NCAC 02H .0507(c), 15A NCAC 028 .0200, 15A NCAC 02B
.0231
Justification: A project that affects waters shall not be permitted unless the existing uses, and the
water quality to protect such uses, are protected. Activities must not cause water pollution that
precludes any best use on a short-term or long-term basis. As cited in Stream Standards: (12) Oils,
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 W. Hanes Mill Rd, Suite 300 1 Raleigh, North Carolina 27105
NORTH CAROL I NA i
336.776.9800

DocuSign Envelope ID: AB5AADC8-9DB8-4825-8B62-5027B7AE0328 Carolina Development Services LLC
DWR#20220896
Individual Certification #WQC005221
Page 7 of 12
deleterious substances, or colored or other wastes: only such amounts as shall not render the waters
injurious to public health, secondary recreation, or to aquatic life and wildlife, or adversely affect the
palatability offish, aesthetic quality, or impair the waters for any designated uses, and (21) turbidity
in the receiving water shall not exceed 50 Nephelometric Turbidity Units (NTU) in streams not
designated as trout waters and 10 NTU in streams, lakes, or reservoirs designated as trout waters;
for lakes and reservoirs not designated as trout waters, the turbidity shall not exceed 25 NTU; if
turbidity exceeds these levels due to natural background conditions, the existing turbidity level shall
not be increased. As cited in Wetland Standards: (c)(1) Liquids, fill or other solids, or dissolved gases
shall not be present in amounts that may cause adverse impacts on existing wetland uses, and (3)
Materials producing color or odor shall not be present in amounts that may cause adverse impacts
on existing wetland uses.
8. Erosion control matting that incorporates plastic mesh and/or plastic twine shall not be used along
streambanks or within wetlands.
Citation: 15A NCAC 02H .0506(b), 15A NCAC 02H .0507(c)
Justification: A project that affects waters shall not be permitted unless the existing uses (including
aquatic life propagation and biological integrity), and the water quality to protect such uses, are
protected. Protections are necessary to ensure any remaining surface waters or wetlands, and any
surface waters or wetlands downstream, continue to support existing uses during and after project
completion. The Division must evaluate if the activity has avoided and minimized impacts to waters,
would cause or contribute to a violation of standards, or would result in secondary or cumulative
impacts.
9. If the project is covered by NPDES Construction Stormwater Permit Number NCGO10000 or NPDES
Construction Stormwater Permit Number NCG250000, full compliance with permit conditions
including the erosion & sedimentation control plan, inspections and maintenance, self -monitoring,
record keeping and reporting requirements is required.
Citation: 15A NCAC 02H .0506(b), 15A NCAC 02H .0507(c); 15A NCAC 028 .0200, 15A NCAC 02B
.0231
Justification: A project that affects waters shall not be permitted unless the existing uses, and the
water quality to protect such uses, are protected. Activities must not cause water pollution that
precludes any best use on a short-term or long-term basis. As cited in Stream Standards: (12) Oils,
deleterious substances, or colored or other wastes: only such amounts as shall not render the waters
injurious to public health, secondary recreation, or to aquatic life and wildlife, or adversely affect the
palatability offish, aesthetic quality, or impair the waters for any designated uses, and (21) turbidity
in the receiving water shall not exceed 50 Nephelometric Turbidity Units (NTU) in streams not
designated as trout waters and 10 NTU in streams, lakes, or reservoirs designated as trout waters;
for lakes and reservoirs not designated as trout waters, the turbidity shall not exceed 25 NTU; if
turbidity exceeds these levels due to natural background conditions, the existing turbidity level shall
not be increased. As cited in Wetland Standards: (c)(1) Liquids, fill or other solids, or dissolved gases
shall not be present in amounts that may cause adverse impacts on existing wetland uses, and (3)
Materials producing color or odor shall not be present in amounts that may cause adverse impacts
on existing wetland uses.
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 W. Hanes Mill Rd, Suite 300 1 Raleigh, North Carolina 27105
NORTH CAROL I NA i
336.776.9800

DocuSign Envelope ID: AB5AADC8-9DB8-4825-8B62-5027B7AE0328 Carolina Development Services LLC
DWR#20220896
Individual Certification #WQC005221
Page 8 of 12
10. All work in or adjacent to streams shall be conducted so that the flowing stream does not come in
contact with the disturbed area. Approved best management practices from the most current
version of the NC Sediment and Erosion Control Manual, or the NC Department of Transportation
Construction and Maintenance Activities Manual, such as sandbags, rock berms, cofferdams, and
other diversion structures shall be used to minimize excavation in flowing water.
Citation: 15A NCAC 02H .0506(b), 15A NCAC 02H .0507(c), 15A NCAC 028 .0200
Justification: Surface water quality standards require that conditions of waters be suitable for all best
uses provided for in state rule, and that activities must not cause water pollution that precludes any
best use on a short-term or long-term basis. As cited in Stream Standards: (12) Oils, deleterious
substances, or colored or other wastes: only such amounts as shall not render the waters injurious to
public health, secondary recreation, or to aquatic life and wildlife, or adversely affect the palatability
offish, aesthetic quality, or impair the waters for any designated uses, and (21) turbidity in the
receiving water shall not exceed 50 Nephelometric Turbidity Units (NTU) in streams not designated
as trout waters and 10 NTU in streams, lakes, or reservoirs designated as trout waters, for lakes and
reservoirs not designated as trout waters, the turbidity shall not exceed 25 NTU; if turbidity exceeds
these levels due to natural background conditions, the existing turbidity level shall not be increased.
11. Culverts shall be designed and installed in such a manner that the original stream profiles are not
altered and allow for aquatic life movement during low flows. The dimension, pattern, and profile
of the stream above and below a pipe or culvert shall not be modified by widening the stream
channel or by reducing the depth of the stream in connection with the construction activity. The
width, height, and gradient of a proposed culvert shall be such as to pass the average historical low
flow and spring flow without adversely altering flow velocity. If the width of the culvert is wider than
the stream channel, the culvert shall include multiple boxes/pipes, baffles, benches and/or sills to
maintain the natural width of the stream channel. If multiple culverts/pipes/barrels are used, low
flows shall be accommodated in one culvert/pipe and additional culverts/pipes shall be installed
such that they receive only flows above bankfull.
Placement of culverts and other structures in streams shall be below the elevation of the streambed
by one foot for all culverts with a diameter greater than 48 inches, and 20% of the culvert diameter
for culverts having a diameter less than or equal to 48 inches, to allow low flow passage of water
and aquatic life. If the culvert outlet is submerged within a pool or scour hole and designed to
provide for aquatic passage, then culvert burial into the streambed is not required.
For structures less than 72" in diameter/width, and topographic constraints indicate culvert slopes
of greater than 2.5% culvert burial is not required, provided that all alternative options for flattening
the slope have been investigated and aquatic life movement/connectivity has been provided when
possible (e.g. rock ladders, cross -vanes, sills, baffles etc.). Notification, including supporting
documentation to include a location map of the culvert, culvert profile drawings, and slope
calculations, shall be provided to DWR 30 calendar days prior to the installation of the culvert.
When bedrock is present in culvert locations, culvert burial is not required, provided that there is
sufficient documentation of the presence of bedrock. Notification, including supporting
documentation such as a location map of the culvert, geotechnical reports, photographs, etc. shall
be provided to DWR a minimum of 30 calendar days prior to the installation of the culvert. If
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 W. Hanes Mill Rd, Suite 300 1 Raleigh, North Carolina 27105
NORTH CAROL I NA i
336.776.9800

DocuSign Envelope ID: AB5AADC8-9DB8-4825-8B62-5027B7AE0328 Carolina Development Services LLC
DWR#20220896
Individual Certification #WQC005221
Page 9 of 12
bedrock is discovered during construction, then DWR shall be notified by phone or email within 24
hours of discovery.
Installation of culverts in wetlands shall ensure continuity of water movement and be designed to
adequately accommodate high water or flood conditions. When roadways, causeways, or other fill
projects are constructed across FEMA-designated floodways or wetlands, openings such as culverts
or bridges shall be provided to maintain the natural hydrology of the system as well as prevent
constriction of the floodway that may result in destabilization of streams or wetlands.
The establishment of native woody vegetation and other soft stream bank stabilization techniques
shall be used where practicable instead of rip -rap or other bank hardening methods.
Citation: 15A NCAC 02H .0506(b), 15A NCAC 02H .0507(c)
Justification: Surface water quality standards require that conditions of waters be suitable for all
best uses provided for in state rule, and that activities must not cause water pollution that precludes
any best use on a short-term or long-term basis. Ensuring that structures are installed properly in
waters will ensure that surface water quality standards are met and conditions of waters are
suitable for all best uses.
12. Application of fertilizer to establish planted/seeded vegetation within disturbed riparian areas
and/or wetlands shall be conducted at agronomic rates and shall comply with all other Federal,
State and Local regulations. Fertilizer application shall be accomplished in a manner that minimizes
the risk of contact between the fertilizer and surface waters.
Citation: 15A 02H .0506(b), 15A NCAC 02H .0507(c), 15A NCAC 02B .0200, 15A NCAC 02B .0231
Justification: A project that affects waters shall not be permitted unless the existing uses, and the
water quality to protect such uses, are protected. Activities must not cause water pollution that
precludes any best use on a short-term or long-term basis. As cited in Stream Standards: (12) Oils,
deleterious substances, or colored or other wastes: only such amounts as shall not render the waters
injurious to public health, secondary recreation, or to aquatic life and wildlife, or adversely affect the
palatability of fish, aesthetic quality, or impair the waters for any designated uses. As cited in
Wetland Standards: (c)(1) Liquids, fill or other solids, or dissolved gases shall not be present in
amounts that may cause adverse impacts on existing wetland uses, and (3) Materials producing
color or odor shall not be present in amounts that may cause adverse impacts on existing wetland
uses.
13. If concrete is used during construction, then all necessary measures shall be taken to prevent direct
contact between uncured or curing concrete and waters of the state. Water that inadvertently
contacts uncured concrete shall not be discharged to waters of the state.
Citation: 15A 02H .0506(b), 15A NCAC 02H .0507(c), 15A NCAC 028 .0200, 15A NCAC 028 .0231
Justification: A project that affects waters shall not be permitted unless the existing uses, and the
water quality to protect such uses, are protected. Activities must not cause water pollution that
precludes any best use on a short-term or long-term basis. As cited in Stream Standards: (12) Oils,
deleterious substances, or colored or other wastes: only such amounts as shall not render the waters
injurious to public health, secondary recreation, or to aquatic life and wildlife, or adversely affect the
North Carolina Department of Environmental Quality I Division of Water Resources
le�D E QiQ� Winston-Salem Regional Office 1 450 W. Hanes Mill Rd, Suite 300 1 Raleigh, North Carolina 27105
NORTH CAROLINA i
336.776.9800

DocuSign Envelope ID: AB5AADC8-9DB8-4825-8B62-5027B7AE0328 Carolina Development Services LLC
DWR#20220896
Individual Certification #WQC005221
Page 10 of 12
palatability offish, aesthetic quality, or impair the waters for any designated uses. As cited in
Wetland Standards: (c)(1) Liquids, fill or other solids, or dissolved gases shall not be present in
amounts that may cause adverse impacts on existing wetland uses, and (3) Materials producing
color or odor shall not be present in amounts that may cause adverse impacts on existing wetland
uses.
14. Any rip -rap required for proper culvert placement, stream stabilization, or restoration of temporarily
disturbed areas shall be restricted to the area directly impacted by the approved construction
activity. All rip -rap shall be placed such that the original streambed elevation and streambank
contours are restored and maintained and shall consist of clean rock or masonry material free of
debris or toxic pollutants. Placement of rip -rap or other approved materials shall not result in de-
stabilization of the stream bed or banks upstream or downstream of the area or be installed in a
manner that precludes aquatic life passage.
Citation: 15A NCAC 02H .0506(b), 15A NCAC 02H .0507(c)
Justification: Surface water quality standards require that conditions of waters be suitable for all best
uses provided for in state rule, and that activities must not cause water pollution that precludes any
best use on a short-term or long-term basis. The Division must evaluate if the activity has avoided
and minimized impacts to waters, would cause or contribute to a violation of standards, or would
result in secondary or cumulative impacts.
15. Any rip -rap used for stream or shoreline stabilization shall be of a size and density to prevent
movement by wave, current action, or stream flows, and shall consist of clean rock or masonry
material free of debris or toxic pollutants. Rip -rap shall not be installed in the streambed except in
specific areas required for velocity control and to ensure structural integrity of bank stabilization
measures.
Citation: 15A NCAC 02H .0506(b), 15A NCAC 02H .0507(c), 15A NCAC 028 .0201
Justification: Surface water quality standards require that conditions of waters be suitable for all best
uses provided for in state rule, and that activities must not cause water pollution that precludes any
best use on a short-term or long-term basis. The Division must evaluate if the activity has avoided
and minimized impacts to waters, would cause or contribute to a violation of standards, or would
result in secondary or cumulative impacts.
16. All mechanized equipment operated near surface waters shall be inspected and maintained
regularly to prevent contamination of surface waters from fuels, lubricants, hydraulic fluids, or other
toxic materials. Construction shall be staged in order to minimize the exposure of equipment to
surface waters to the maximum extent practicable. Fueling, lubrication, and general equipment
maintenance shall be performed in a manner to prevent, to the maximum extent practicable,
contamination of surface waters by fuels and oils.
Citation: 15A NCAC 02H .0506(b), 15A NCAC 02H .0507(c), 15A NCAC 028 .0200, 15A NCAC 02B
.0231
Justification: A project that affects waters shall not be permitted unless the existing uses, and the
water quality to protect such uses, are protected. Activities must not cause water pollution that
precludes any best use on a short-term or long-term basis. As cited in Stream Standards: (12) Oils,
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 W. Hanes Mill Rd, Suite 300 1 Raleigh, North Carolina 27105
NORTH CAROL I NA i
336.776.9800

DocuSign Envelope ID: AB5AADC8-9DB8-4825-8B62-5027B7AE0328 Carolina Development Services LLC
DWR#20220896
Individual Certification #WQC005221
Page 11 of 12
deleterious substances, or colored or other wastes: only such amounts as shall not render the waters
injurious to public health, secondary recreation, or to aquatic life and wildlife, or adversely affect the
palatability offish, aesthetic quality, or impair the waters for any designated uses. As cited in
Wetland Standards: (c)(1) Liquids, fill or other solids, or dissolved gases shall not be present in
amounts that may cause adverse impacts on existing wetland uses, and (3) Materials producing
color or odor shall not be present in amounts that may cause adverse impacts on existing wetland
uses.
17. Heavy equipment working in wetlands shall be placed on mats or other measures shall be taken to
minimize soil disturbance and compaction.
Citation: 15A NCAC 02H .0506(b), 15A NCAC 02H .0507(c), 15A NCAC 028 .0231
Justification: Wetland standards require maintenance or enhancement of existing uses of wetlands
such that hydrologic conditions necessary to support natural biological and physical characteristics
are protected, populations of wetland flora and fauna are maintained to protect biological integrity
of the wetland; and materials or substances are not present in amounts that may cause adverse
impact on existing wetland uses.
18. In accordance with 143-215.85(b), the permittee shall report any petroleum spill of 25 gallons or
more; any spill regardless of amount that causes a sheen on surface waters; any petroleum spill
regardless of amount occurring within 100 feet of surface waters; and any petroleum spill less than
25 gallons that cannot be cleaned up within 24 hours.
Citation: 15A NCAC 02H .0507(c), N.C.G.S 143-215.85(b)
Justification: Person(s) owning or having control over oil or other substances upon notice of
discharge must immediately notify the Department, or any of its agents or employees, of the nature,
location, and time of the discharge and of the measures which are being taken or are proposed to be
taken to contain and remove the discharge. This action is required in order to contain or divert the
substances to prevent entry into the surface waters. Surface water quality standards require that
conditions of waters be suitable for all best uses provided for in state rule (including, at minimum:
aquatic life propagation, survival, and maintenance of biological integrity, wildlife, secondary
contact recreation; agriculture), and that activities must not cause water pollution that precludes
any best use on a short-term or long-term basis.
19. The permittee and their authorized agents shall conduct all activities in a manner consistent with
State water quality standards (including any requirements resulting from compliance with §303(d)
of the Clean Water Act), and any other appropriate requirements of State and Federal Law.
Citation: 15A NCAC 02H .0506(b), 15A NCAC 02H .0507(c)
Justification: Surface water quality standards require that conditions of waters be suitable for all best
uses provided for in state rule, and that activities must not cause water pollution that precludes any
best use on a short-term or long-term basis. The Division must evaluate if the activity has avoided
and minimized impacts to waters, would cause or contribute to a violation of standards, or would
result in secondary or cumulative impacts.
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 W. Hanes Mill Rd, Suite 300 1 Raleigh, North Carolina 27105
NORTH CAROL I NA i
336.776.9800

DocuSign Envelope ID: AB5AADC8-9DB8-4825-8B62-5027B7AE0328 Carolina Development Services LLC
DWR#20220896
Individual Certification #WQC005221
Page 12 of 12
20. The permittee shall require its contractors and/or agents to comply with the terms and conditions of
this certification in the construction and maintenance of this project, and shall provide each of its
contractors and/or agents associated with the construction or maintenance of this project with a
copy of this Water Quality Certification. A copy of this Water Quality Certification shall be available
at the project site during the construction and maintenance of this project.
Citation: 15A NCAC 02H .0506(b); 15A NCAC 02H .0507(c)
Justification: Those actually performing the work should be aware of the requirements of this 401
Water Quality Certification to minimize water quality impacts.
This approval to proceed with your proposed impacts or to conduct impacts to waters as depicted in
your application shall expire upon expiration of the 404 Permit. The conditions in effect on the date of
issuance shall remain in effect for the life of the project, regardless of the expiration date of this
Certification. [15A NCAC 02H .0507(c)]
This, the 3Ld day of October 2022
ED�ocuSiigggned /by:
(�I/n. JM0.Ct'
145B49E225C94EA...
Lon T. Snider
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ— WSRO
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 W. Hanes Mill Rd, Suite 300 1 Raleigh, North Carolina 27105
NORTH CAROL I NA i
336.776.9800

AGENT AUTHORIZATION AND RIGHT OF
ENTRY DOCUMENTATION

AGENT AUTHORIZATION FORM
PROJECT NAME: Long Creek Village
PARCEL ID: 6809-96-6493
PROJECT STREET ADDRESS: Mizpah Church Road, Winston Salem, Forsyth County, NC
PROPERTY OWNER(S): Carolina Development Services, LLC
PROPERTY OWNER'S ADDRESS: 2627 Brekonridge Centre Drive
Monroe, NC 28110
PHONE: [phone]
The undersigned, registered property owners) of the above noted property, do liereby autliorize
S. Paul Petitgout, of Lowrvs Environmental & Ecological Services, LL a
(Contractor / Agent) (Name of consulting firm)
to act on my belialf and take all actions necessary for the processing, issuance and acceptance of this
Jurisdictional Determination, Permit or Certification and any and all standard and special conditions attaclied.
By signing below, I autliorize representatives of the Wilmington District, U.S. Army Corps of Engineers
(Corps) and/or NC Division of Water Resources (NCDWR)- to enter upon the property herein described
(accompanied by the autliorized agent) for the purpose of conducting on -site investigations, if necessary, and
issuing a jurisdictional determination and/or permit pursuant to Section 404/401 of the Clean Water Act
and/or Section 10 of the Rivers and Harbors Act of 1899. I, the undersigned, am a duly autliorized owner of
record of the property identified herein.
I liereby certify the above information submitted in thisjurisdictional determination/application is true and
accurate to the best of our knowledge.
, �t tit AUTHORIZED SIGNATURE:
DATE: 4/6/23

GENERAL LOCATION FIGURES

Feet
�.
1 inch equals 2,000 feet - -- � LEGEND �
Source: USGS Rural Hall, NC Topo
Disclaimer: The information depicted on this figure is for � � i �
Site Boundary
informational purposes only and was not prepared for, and
is not suitable for legal or engineering purposes. - ' .. `+• •; e 7 ��
Mizpah Church Road Site Lowrys Environmental 8�
Rural Hall, Forsyth County, North Carolina
USGS 1:24,000 Topographic Map Ecological Services, LLC
Drawn By: SPP Date: 7-23-23 Rev. 1823 Quinn Road
Chester, South Carolina 29706
Project Mgr. SPP Scale: 1:24,000 Sheet: 1 803-992-0910

Original Graphics by Pilot Environmental, Inc.
fib �
r
• u�. o
.lam
Q
Mizpah Church Road Site
±150-acres
CAD
QW,
wT:
a�xxJ
9
uu4:+
' TTT
Mizpah Church Road Site
0 500 1,000
Feet-
1 inch equals 1,000 feet LEGEND
Source: USDA NRCS Web Soil Survey
Disclaimer: The information depicted on this figure is for _ Site Boundary
informational purposes only and was not prepared for, and
is not suitable for legal or engineering purposes.
Mizpah Church Road Site Lowrys Environmental 8�
Rural Hall, Forsyth County, North Carolina
USDA NRCS Soil Survey Map (Web Soil Survey) Ecological Services, LLC
Drawn By: SPP Date: 7-23-23 Rev. 1823 Quinn Road
Chester, South Carolina 29706
Project Mgr. SPP Scale: 1:12,000 Sheet: 2a 803-992-0910

Original Graphics by Pilot Environmental, Inc.
Apr-
Mizpah Church Road Site
±150-acres
m�
6,
--�--f �t• LEGEND
Mizah Church Road Site Site Boundary
p ! Freshwater Emergent
o soo 1,000 ! Freshwater Forested/Shrub
ik
! Estuarine and Marine Deepwater
Feet ••r ! Estuarine and Marine
1 inch equals 1,000 feet _ _ •� ' ! Freshwater Pond
Source: USFWS Wetlands Mapper i Lake
d
Disclaimer: The information depicted on this figure is for Riverine
informational purposes only and was not prepared for, and
is not suitable for legal or engineering purposes. !Other
Mizpah Church Road Site Lowrys Environmental 8�
Rural Hall, Forsyth County, North Carolina
USFWS National Wetlands Inventory Map Ecological Services, LLC
Drawn By: SPP Date: 7-23-23 Rev. 1823 Quinn Road
Chester, South Carolina 29706
Project Mgr. SPP Scale: 1:12,000 Sheet: 3 803-992-0910

PANEL
3710680900J
e ff. 1 1`212 009
Disclaimer: The information depicted on thisared f is for
informational purposes only and was not prepared for, and
is not suitable for legal or engineering purposes.
Mizpah Church Road Site
Rural Hall, Forsyth County, North Carolina
FEMA National Flood Hazard Layer Map
Drawn By: SPP Date: 7-23-23 Rev.
Project Mgr. SPP Scale: 1:12,000 Sheet: 4
LEGEND
Site Boundary
1 %Annual Chance Flood Hazard
Regulatory Floodwary
Sped all FI oodvay
Area of Undetermined Flood Hazard
0.2%Annual Chance Flood Hazard
OF tiure Conditions 1 V.Annual Chance Flood Hazard
WreawithReduced Rid Due to Levee
Lowrys Environmental 8,
Ecological Services, LLC
1823 Quinn Road
Chester, South Carolina 29706
803-992-0910

Original Graphics by Pilot Environmental, Inc.
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FLAG NUMBERS/INFO
WETLAND FLAGS =
STREAM FLAGS = was-s Flag Number
Stream Flags = Limits �■ Culvert
Wetland Flags = 299 _
Total Flags = 299 - Qn-i Data Point
HE LOCATIONS OF FEATURES SHOWN ON THIS MAP WERE VERIFIED BY MS. SAMANTHA DAILEY WITH THE USACE (SAW-2022-00653). TH
XHIBIT INCLUDES GPS LOCATIONS OF DELINEATED FEATURES. DELINEATION CONDUCTED BY PILOT PERSONNELON 12.18.19.
Mizpah Church Road Site Lowrys Environmental 8�
Rural Hall, Forsyth County, North Carolina
Wetlands Map Ecological Services, LLC
Drawn By: SPP Date: 7-23-23 Rev. 1823 Quinn Road
Chester, South Carolina 29706
Project Mgr. SPP Scale: Not to Scale Sheet: 5 803-992-0910

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MITIGATION INFORMATION

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
MARC RECKTENWALD
Director
Johnathan McCall
Carolina Development Services, LLC
2649 Breckonridge Centre Drive
Monroe, NC 28110
Project: Long Creek Village
NORTH CAROLINA
Environmental Quality
August 10, 2023
Expiration of Acceptance: 2/11/2024
County: Forsyth
The purpose of this letter is to notify you that the NCDEQ Division of Mitigation Services (DMS) is willing to
accept payment for compensatory mitigation for impacts associated with the above referenced project as
indicated in the table below. Please note that this decision does not assure that participation in the DMS in -
lieu fee mitigation program will be approved by the permit issuing agencies as mitigation for project impacts.
It is the responsibility of the applicant to contact permitting agencies to determine if payment to the DMS will
be approved. You must also comply with all other state, federal or local government permits, regulations or
authorizations associated with the proposed activity including G.S. § 143-214.11.
This acceptance is valid for six months from the date of this letter and is not transferable. If we have not
received a copy of the issued 404 Permit/401 Certification within this time frame, this acceptance will
expire. It is the applicant's responsibility to send copies of the permits to DMS. Once DMS receives a copy
of the permit(s) an invoice will be issued based on the required mitigation in that permit and payment must
be made prior to conducting the authorized work. The amount of the in -lieu fee to be paid by an applicant is
calculated based upon the Fee Schedule and policies listed on the DMS website.
Based on the information supplied by you in your request to use the DMS, the impacts for which you are
requesting compensatory mitigation credit are summarized in the following table. The amount of mitigation
required and assigned to DMS for this impact is determined by permitting agencies and may exceed the
impact amounts shown below.
River Basin
Impact Location
8-di it HUC
Impact Type
Impact Quantity
Yadkin
03040101
Riparian Wetland
0.40
Upon receipt of payment, DMS will take responsibility for providing the compensatory mitigation. The
mitigation will be performed in accordance with the In -Lieu Fee Program instrument dated July 28, 2010.
Thank you for your interest in the DMS in -lieu fee mitigation program. If you have any questions or need
additional information, please contact [e-mail].
Sincerely,
Av�t�u�
FOR James. B Stanfill
Deputy Director
cc: Paul Petitgout, agent
North Caraltna Department of Environmental Quality I Division of Mitigation Services �Aw
217 West Jones Street l 1652 Mail Service Center I Raleigh. North Carolina 27699-1652
oeoaiunen�mEmsrommeri n 919,707.8976

U.S. ARMY CORPS OF ENGINEERS
Wilmington District
Coll, vellsatory N its ation Responsibil4i Transfer Farm
Permittee: Carolina Development Services, LLC
Project Name: Long Creek Village
Action ID: SAW-2022-00653
County: Forsyth
instructions to Permit tee: The Pennittee trutst provide a copy ur this lisrnt to the Mitigation Spomor, either an approved
Mitigation [lank or the North Carolina Division of Mitigation Services (NCDMS), who will then sign cite ['orm to verity the
transfer of the mitigation responsibility. Once the; Sponsur has signed this form, it is the Perinittec's respunsihility to ensure
that Wilmingioil District Pr❑jcct Marr:tgcr identilicd on page two is in receipt ofa signed copy ol'this 11onn before candue:titig
authorized impacts, unless otherwise specified below. II' Mort than tine Mitigation Sponsor will be used to provide the
mitigation associated with the permit, or if the impacts and/or the mitigation �ki11 occur in more than one R-digit Ilytlrologic:
Unit Code (HUC:), multiple Forms will be attached to the permit. and the separate forms for each Sponsor andlor 110U must be
provided to the appropriate Mitigation Sponsors.
Instructions to Sponsor: The Sponsor vertrIC; that the nnhgation requirements (credits) shown below have been released and
,are available at the identified Etc. By signing below, the Sponsor is accepting, full responsibility Inr the identified mitigation,
regardless ❑I"whether tlicy hove received payment from the f'enrrittee. Once the limn is signed. the Sponsor must update the
bank ledger and provide n copy oi'the signets furtn and the updated ledger to the PermtMe. the Project Manager who issued the
permit, the Hank Project Manager, and the District Mitigation C]ffice (see contact information on page 2). The Sponsor must
also comply with all reporting, requiwnrettts established in their authorizing instrument.
Permitted impacts and Compensatory Mitigation Requirements:
Permitted Impacts
Stream Im
Wann
uiring Witi ation* 8-digit HUC and Basin: 03040101, Yadkin River Basin
linear Ceet) Wetland Irnoacts (acresI
Cool Cold Riparian
Riverine Riparian Non-Riverine Non -Riparian TCoastl
0.374
*If more than one mitigation sponsor will be used for the permit, only include impacts to be mitigated by this sponsor.
ipensatcrry N11ti atdon Require S-di It HUC and Basin: 03040101. Yadkin River Basin
Stream Mitigation (credits) Wetland Mitigation credits.
Warm Cool Cold Riparian Riparian Non-
Non -Riparian Coastal
Riverine Riverine
0.75
Mitigation Site Debited: Restoration Systems. LLC's RS Yadkin 01 UMBI Mushy Fork Mitigation Bank
(List the name of the bank to be debited. For umbrella banks, also list the specific site. For NCDMS, list NCDMS. If the
NCDMS acceptance letter identifies a specific site, also list the specific site to be debited).
Section to be completed by the Mitigation Sponsor
Statement of litigation Mabilily Acceptance: 1, the undemiglicd, verify that I am authorized to approvC mitigutitin
transactions lior the Mitigation sponsor shown below, and I t:crtil'y that the Sponsor agrees to accept lull responsibility tin'
providing the rnitigatian identifictl in this document (see the table nbove), associate[l with the USAU Pennitice and :lctian
iI) number sho;vn. I also verily that releascol urvdits (and/or advance credits for NC I)MS), as approved by the Wilmington
Districl. ttrc currently availahlc at the mitigation site identified al�avc. Further, I understand that irtile Sponsor fail. to provide
lire required cttmpcosat❑ry Mitigation, the USACE Wilmington District Engineer tnay pursue nteasures agaitrst the Sponsor to
cnsurc eomphancc associated with the mitigation requirements.
Mitigation Sponsor Name: Restoration S stems, LLC (�
Name of Sponsor's A1korized Representative: o �,L r(y er
t /— 2 r
resentatevc Date of Sienature
Page] oft t onn Version 10 June 2020updared