20150800 Ver 1_401 Application_20150815

WITHERS �. C R,A VEN EL
August 5, 2015
US Army Corps of Engineers
Regulatory Field Office
Mr. David Shaeffer
3331 Heritage Trade Drive
Suite 105
Wake Forest, NC 27587
ENGINEERS I PLANNERS I SURVEYORS
NC- Division of Water Resources
401 & Buffer Permitting Unit
Ms. Karen Higgins
1617 Mail Service Center
Raleigh, North Carolina 27699
Re: Crosspointe Church Expansion — NWP 39 PCN Submittal
Cary, Wake County
Corps AID #SAW - 2014 -00835
W &R Project #02130433.10
Dear Mr. Shaeffer and Ms. Higgins,
On behalf of Crosspointe Church at Cary, we are requesting authorization from the USACE to use
NWP 39 for 209 if of permanent stream impacts and 35 if of temporary stream impacts for
construction of a secondary access road to Indian Wells Road and sewer line as part of expansion of
the existing Crosspointe Church facilities. We are also requesting a 401 WQC from NCDWR for the
above referenced impacts.
The project is ±38 acres in size and is located at 6911 Carpenter Fire Station Road in Cary, Wake
County (Latitude: 35.822782 °N; Longitude: - 78.877818 1W). The project is located in the Cape Fear
River basin (HUC 03030002) and onsite waters drain to Panther Branch. The Water Quality
Classification for Panther Creek is WS -V; NSW and the Stream Index Number is: 16- 41-1-17-3•
Proposed Proiect
The proposed project consists of the expansion of the existing facilities and parking at Crosspointe
Church to accommodate a new YMCA, which will occur entirely within uplands. The proposed
expansion will require a secondary access road connecting to Indian Wells Road. The secondary
access road is necessary to handle the additional traffic the YMCA will produce, and is a
requirement by the Town of Cary. The project also includes the construction of a new private pump
station and forcemain, which will pump wastewater to an existing collection system north of Indian
Wells Road. The proposed pump station and forcemain will replace the existing undersized private
pump station and forcemain that flows to Carpenter Fire Station Road.
Proiect History
David Shaeffer with the Corps of Engineers preliminarily approved the wetland delineation
associated with the portions of the project located within the Crosspointe Church property during a
site meeting on May 22, 2014 (AID SAW - 2014 - 00835.00). We are requesting issuance of the JD in
conjunction with issuance of the NWP 39•
1410 Commonwealth Drive I Suite 1011 Wilmington, NC 28403 1 tel: [phone] fax: [phone]
www.withersravenet.com I License No. C -0832

Crosspointe Church Expansion — NWP 39 PCN
8/5/15
Proposed Impacts
The proposed impacts consist of 209 if of permanent stream impacts and 35 if of temporary stream
impacts.
The proposed 209 if of permanent stream impacts are necessary for construction of two stream
crossings for the secondary access road to Indian Wells Road. The 209 if of permanent impacts
include the impacts from the fill for the culvert, as well as impacts from the rip -rap dissipator pad.
The proposed 35 if of temporary stream impacts will occur from a perpendicular sewer crossing
(Impact #1 — 22 lf), and a temporary diversion ditch (Impact #4 — 13 lf) to allow for work to be
completed in the dry.
Avoidance and Minimization
Prior to site plan design, the applicant requested that a detailed wetland delineation be conducted
so that impacts to wetlands and "waters" could be minimized.
There are no proposed impacts for the construction of the YMCA building and additional parking
within the main campus.
The proposed permanent wetland impacts have been minimized by crossing the streams at
perpendicular angles. Additionally, headwalls have been utilized to stabilize road fill to avoid
additional impacts from traditional backslopes. Please note that the impacts associated with the
southernmost stream crossing (Impact #5 & 6) will occur to an unimportant, intermittent stream. A
Corps Stream Quality Form specific to the stream at Impact #5 & 6 has been provided as an
Appendix.
Furthermore, rip -rap dissipaters have been designed for the rip -rap will be installed so that the top
of the rip -rap matches the pre- construction elevation of the stream bed. This design allows for the
rip -rap lined section of stream to continue functioning as a natural stream by maintaining natural
water depths and allowing for passage of aquatic life.
Temporary stream impacts have been minimized to only a perpendicular sewer crossing (Impact #1)
and temporary disturbance for a temporary diversion ditch (Impact #4).
Mitigation
Corps — No Mitigation Proposed
The proposed project will result in a total of 209 if of permanent stream impacts. Of these impacts,
95 if of permanent impacts (Impact 5 & 6) will occur to an unimportant intermittent stream with very
little functional value, for which mitigation is not proposed. Only 114 if of permanent impacts are
proposed to important streams with high functional value. Therefore, the total permanent stream
impacts subject to mitigation is less than 150 If, and therefore the applicant is not proposing
mitigation for 404 requirements.
WITHERS & RAVENEL Page 2 of 3
ENGINEERS I PLANNERS I SURVEYORS

Crosspointe Church Expansion — NWP 39 PCN
8/5/15
DWR — 209 Lf of Stream Mitigation Proposed
Per Condition 10 of Water Quality Certification NO-389o, the 209 if of permanent stream impacts will
require mitigation at a 1:1 mitigation ratio. Therefore, the applicant proposes to purchase 209 if of
offsite stream mitigation credits. Please note that there is currently no stream mitigation available
in private mitigation banks servicing the Cape 02 basin. Therefore, the applicant proposes to
purchase 209 if of stream mitigation from the Division of Mitigation Services. A copy of the DMS
Letter of Acceptance has been provided as an Appendix.
Stormwater Management Plan
The proposed stormwater management plan consists of the expansion of the existing wet detention
pond to accommodate and treat the additional runoff created by the new impervious area from the
facilities expansion. Diffuse flow will be achieved through a level spreader below the outfall of the
pond.
The current request is for 209 if of permanent stream impacts and 35 if of temporary stream impacts
(see the attached maps and PCN for details).
Please feel free to call if you have questions or require additional information.
Sincerely,
Troy Beasley
Environmental Scientist
Attachments:
• PCN Form
• Agent Authorization
• USGS Quad
• Wake County Soil Survey
• Corps Stream Quality Forms
• DMS Letter of Acceptance
• Impact Exhibits
WITHERS & RAVENEL Page 3 of 3
ENGINEERS I PLANNERS I SURVEYORS

O�O�_ W ATF9QG
Elm
1. Processing
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre - Construction Notification (PCN) Form
A. Applicant Information
1 a. Type(s) of approval sought from the
Corps: ®Section 404 Permit El Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 39 or General Permit (GP) number:
1 c. Has the NWP or GP number been verified by the Corps? ® Yes
1d. Type(s) of approval sought from the DWQ (check all that apply):
® 401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
❑ No
1 e. Is this notification solely for the record For the record only for DWQ 401 For the record only for Corps Permit:
because written approval is not required? Certification:
❑ Yes ® No ❑ Yes ® No
1f. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation ® Yes ❑ No
of impacts? If so, attach the acceptance letter from mitigation bank or in -lieu
fee program.
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h ❑ Yes ® No
below.
1 h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)? ❑ Yes
2.
Project Information
2a.
Name of project:
Crosspointe Church Expansion
2b.
County:
Wake
2c.
Nearest municipality / town:
Cary
2d.
Subdivision name:
2e.
NCDOT only, T.I.P. or state
project no:
3.
Owner Information
3a.
Name(s) on Recorded Deed:
Crosspointe Church at Cary
3b.
Deed Book and Page No.
Book: 8834; Page: 2480
3c.
Responsible Party (for LLC if
TJ Terry
applicable):
3d.
Street address:
6911 Carpenter Fire Station Road
3e.
City, state, zip:
Cary, NC 27519
3f.
Telephone no.:
919 - 469 -9111
3g.
Fax no.:
3h.
Email address:
tj @crosspointe.org
� No �
i
Page 1 of 12
PCN Form — Version 1.3 December 10, 2008 Version

4.
Applicant Information (if different from owner)
4a.
Applicant is:
❑ Agent ❑ Other, specify:
4b.
Name:
4c.
Business name
(if applicable):
4d.
Street address:
4e.
City, state, zip:
4f.
Telephone no.:
4g.
Fax no.:
4h.
Email address:
5.
Agent/Consultant Information (if applicable)
5a.
Name:
Troy Beasley
5b.
Business name
Withers and Ravenel
(if applicable):
5c.
Street address:
1410 Commonwealth Drive, Suite 101
5d.
City, state, zip:
Wilmington, NC 28403
5e.
Telephone no.:
910 - 256 -9277
5f.
Fax no.:
910 - 256 -2584
5g.
Email address:
tbeasley @withersravenel.com
Page 2 of 12
PCN Form — Version 1.3 December 10, 2008 Version

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
1 b. Site coordinates (in decimal degrees):
1 c. Property size:
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project:
2b. Water Quality Classification of nearest receiving water:
2c. River basin:
PIN 0735549587
Latitude: 35.822782 °N Longitude: - 78.877818 °W
(DD.DDDDDD) (- DD.DDDDDD)
±38 acres
Panther Creek (Stream Index: 16- 14- 1 -17 -3
WS -IV; NSW
Cape Fear - 03030002
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
The project area currently consists of a mixture of existing cleared area in the northern portion for the expansion of
the main campus facilites, and undeveloped woodlands in the southern portion of the site where the impacts will
occur. The general land use in the vicinity consists of a mixture or residential, commercial and institutional land
use.
3b. List the total estimated acreage of all existing wetlands on the property:
±0.009 ac
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
±2,293 If
3d. Explain the purpose of the proposed project:
The purpose of the proposed project is to expand the existing Crosspointe Church facilities to accommodate a new
YMCA and additional parking on the main campus. The expansion requires an additional access road to Indian Wells
Road, as well as upgrades to the sewer facilities.
3e. Describe the overall project in detail, including the type of equipment to be used:
The proposed project consists of the construction of a new building to house a YMCA, as well as additional parking,
which will be located entirely in uplands. The proposed expansion will require a secondary road connection from the
main campus to Indian Wells Road, as required the Town of Cary as a condition of approval of the project. The project
also includes the construction of a new private pump station and forcemain, which will pump wastewater to an existing
collection system north of Indian Wells Road. The proposed pump station and forcemain will replace the existing
undersized private pump station and forcemain that flows to Carpenter Fire Station Road. The proposed project will be
constructed using standard commercial construction equipment and techniques.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past? ®Yes El No El Unknown
Comments:
4b. If the Corps made the jurisdictional determination, what type
of determination was made? Preliminary El Final
4c. If yes, who delineated the jurisdictional areas? Agency /Consultant Company: W &R
Name (if known): Martin Richmond Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
David Shaeffer with the Corps of Engineers preliminarily approved the wetland delineation associated with the portions of
the project located within the Crosspointe Church property during a site meeting on May 22, 2014 (AID SAW -2014-
00835.00). We are requesting issuance of the JD in conjunction with issuance of the NWP 39.
Page 3 of 12
PCN Form — Version 1.3 December 10, 2008 Version

5. Project History
5a. Have permits or certifications been requested or obtained for ❑ Yes ❑ No
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project? ❑ Yes ® No
6b. If yes, explain.
® Unknown
Page 4 of 12
PCN Form — Version 1.3 December 10, 2008 Version

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
❑ Wetlands ® Streams - tributaries ❑ Buffers
❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a. 2b. 2c. 2d. 2e. 2f.
Wetland impact Type of jurisdiction
number — Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ — non -404, other) (acres)
Temporary (T)
W1 ❑P ❑T
2g. Total wetland impacts
2h. Comments:
❑ Yes ❑ Corps
❑ No ❑ DWQ
ac
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a.
3b.
3c.
3d.
3e.
3f.
3g.
Stream impact
Type of impact
Stream name
Perennial
Type of jurisdiction
Average
Impact
number -
(PER) or
(Corps - 404, 10
stream
length
Permanent (P) or
intermittent
DWQ — non -404,
width
(linear
Temporary (T)
(INT)?
other)
(feet)
feet)
Impact 2
Rip -Rap
UT to Panther
® PER
® Corps
8'
40 If
® P ❑ T
Dissipator
Creek
❑ INT
® DWQ
Impact 3
Road /Culvert
UT to Panther
® PER
® Corps
8'
74 If
® P ❑ T
Crossing
Creek
El INT
® DWQ
Impact 5
Road /Culvert
UT to Panther
❑ PER
® Corps
3'
20 If
®P ❑ T
Expansion
Creek
® INT
® DWQ
Impact 6
Rip -Rap
UT to Panther
❑ PER
® Corps
3'
75 If
® P ❑ T
Dissipator
Creek
® INT
® DWQ
Total Permanent Stream Impacts
209 If
Impact 1
Sewer Crossing
UT to Panther
® PER
® Corps
6'
22 If
❑ P ®T
Creek
❑ INT
®DWQ
Impact Temporary
❑ P ® T Diversion for
Construction
3h. Total stream and tributary impacts
3i. Comments:
UT to Panther ❑ PER ® Corps
Creek ® INT ® DWQ
4' 13 If
Total Temporary Stream Impacts 35 If
244 If
Page 5 of 12
PCN Form — Version 1.3 December 10, 2008 Version

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individually list all open water impacts below.
4a. 4b. 4c. 4d. 4e.
Open water Name of waterbody
impact number - (if applicable) Type of impact Waterbody type Area of impact (acres)
Permanent (P) or
Temporary (T)
01 ❑P FIT
02 ❑P ❑T
03 ❑ PEI T
04 ❑P ❑T
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed, then complete the chart below.
5a. 5b. 5c. 5d. 5e.
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID Proposed use or purpose (acres)
number of pond
Flooded Filled Excavated Flooded Filled Excavated Flooded
P1
P2
5f. Total
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If any impacts require mitigation, then you MUST fill out Section D of this form.
6a.
❑ Neuse ❑ Tar - Pamlico ® Other: Jordan
Project is in which protected basin? ❑ Catawba ❑ Randleman
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number - Reason
Buffer Zone 1 impact Zone 2 impact
Permanent (P) or for
Stream name mitigation (square feet) (square feet)
Temporary (T) impact
required?
131 ❑P ❑T
❑Yes
❑ No
B2 ❑P FIT
❑Yes
❑ No
B3 ❑P ❑T
F1 Yes
❑ No
6h. Total buffer impacts
6i. Comments: Impacts to Jordan Lake buffers will be permitted through the Town of Cary as the delegated
Page 6 of 12
PCN Form - Version 1.3 December 10, 2008 Version

municipality.
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply):
2c. If yes, which mitigation option will be used for this
project?
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter)
3c. Comments:
4. Complete if Making a Payment to In -lieu Fee Program
® Yes ❑ No
® DWQ ❑ Corps
❑ Mitigation bank
® Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
Type
Quantity
4a. Approval letter from in -lieu fee program is attached.
® Yes
4b.
Stream mitigation requested:
209 linear feet
4c.
If using stream mitigation, stream temperature:
® warm ❑ cool ❑cold
4d.
Buffer mitigation requested (DWQ only):
square feet
4e.
Riparian wetland mitigation requested:
acres
4f.
Non - riparian wetland mitigation requested:
acres
4g.
Coastal (tidal) wetland mitigation requested:
acres
4h.
Comments:
5.
Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 7 of 12
PCN Form — Version 1.3 December 10, 2008 Version

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires ❑ Yes ® No
buffer mitigation?
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
6c. 6d. 6e.
Zone Reason for impact Total impact Multiplier Required mitigation
(square feet) (square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund).
6h. Comments:
Page 8of12
PCN Form — Version 1.3 December 10, 2008 Version

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified ® Yes ❑ No
within one of the NC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
Comments: The proposed stormwater management consists of the expansion of the
existing wet detention pond to accommodate the additional runoff from the ❑ Yes ® No
proposed facilities expansion. The stormwater management plan is being reviewed
and approved by the Town of Cary as the Certified Local Government entity.
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? 23.2% for the entire campus
2b. Does this project require a Stormwater Management Plan? ® Yes ❑ No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
The stormwater management plan consists of expansion of the existing wet detention pond to accommodate the
additional runoff of the proposed facilities expansion.
2e. Who will be responsible for the review of the Stormwater Management Plan?
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
3b. Which of the following locally - implemented stormwater management programs
apply (check all that apply):
3c. Has the approved Stormwater Management Plan with proof of approval been
attached?
4. DWQ Stormwater Program Review
4a. Which of the following state - implemented stormwater management programs apply
(check all that apply):
4b. Has the approved Stormwater Management Plan with proof of approval been
attached?
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements?
5b. Have all of the 401 Unit submittal requirements been met?
® Certified Local Government
❑ DWQ Stormwater Program
❑ DWQ 401 Unit
Town of Cary
® Phase II
® NSW
❑ USMP
❑ Water Supply Watershed
❑ Other:
❑ Yes ® No
❑
Coastal counties
❑
HQW
❑
ORW
❑
Session Law 2006 -246
❑
Other:
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Page 9 of 12
PCN Form — Version 1.3 December 10, 2008 Version

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1a. Does the project involve an expenditure of public (federal /state /local) funds or the ❑ Yes ® No
use of public (federal /state) land?
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State ❑ Yes ❑ No
(North Carolina) Environmental Policy Act (NEPA /SEPA)?
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 NEPA or SEPA final approval
letter.) ❑ Yes ❑ No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ❑ Yes ® No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after - the -fact permit application?
❑ Yes ® No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in ❑ Yes ® No
additional development, which could impact nearby downstream water quality?
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
The proposed project consists of the expansion of an existing church facility, and will not result in additional development.
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non- discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
Town of Cary sanitary sewer
Page 10 of 12
PCN Form — Version 1.3 December 10, 2008 Version

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or ® Yes ❑ No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act ❑ Yes ® No
impacts?
5c. If yes, indicate the USFWS Field Office you have contacted. ❑ Raleigh
❑ Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
W &R reviewed the NC Natural Heritage Program database, located at httos:// ncnhde .natureserve.orq /content/mao to
identify if there were any known occurrences of endangered species on or near the proposed project. The review of the
NHP data did not identify any occurrences of endangered species or critical habitat on the subject property or within 1.0
miles of the project, see attached NCNHP project review letter. Site reviews did not identify any occurrences of, or
potential habitat for, federally protected species known to occur in Wake County, except for the Northern Long Eared Bat.
Potential habitat for the northern Long -eared bat (NLEB) is listed as mature forest with trees over 3" dbh, which is used
for roosting during the day. Since the entire project area consists of mature forest over 3" DBH, there is potential northern
long eared bat habitat present. In an email from USFWS dated April 15, 2015, the USFWS has specified that a project
may result in an adverse effect on the NLEB is there will be cutting or destroying of mature forest within 0.25 miles of an
known roosting site, or if the project involves the cutting or destroying of known, occupied roost trees during the pup
season (June 1St — July 31St). The nearest known active roost tree site is in Currituck County. Therefore, the proposed
project is not located within 0.25 miles of any known roost trees. Furthermore, clearing of mature forest between June 1 st
and July 31 st is not anticipated for construction of the proposed project. Therefore, W &R concludes that the project "may
affect, but is not likely to adversely affect" the northern long -eared bat.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? I ❑ Yes ❑ No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
There are no waters classified as EFH in Wake County.
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation ❑ Yes ® No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
W &R reviewed the NC State Historic Preservation Office's online database, located at: htto: / /gis.ncdcr.gov /hi)oweb /, to
determine if there were any known historic or cultural resources within or in the vicinity of the proposed project. The
database review did not identify any known resources within or in the vicinity of the proposed project.
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA- designated 100 -year floodplain? I ❑ Yes ® No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination? www.ncfloodmaDs.com
Page 11 of 12
PCN Form — Version 1.3 December 10, 2008 Version

Troy Beasley — W &R / �
08/05/15
Authorized Agent
Date
Applicant/Agent's Printed Name Applicant /Agent's Signature
(Agent's signature is valid only if an authorization letter from the applicant
is provided.)
Page 12 of 12
PCN Form — Version 1.3 December 10, 2008 Version

AGENT AUTHORIZATION

WITHERS � RAVENEL
ENGINEERS I 'PLANNERS I SURVEYORS
AUTHORITY FOR APPOINTMENT OF AGENT
The undersigned Owner Crosspointe Church at Cary (Client) does hereby appoint Troy
Beaslev / Withers & Ravenel, Inc. as his, her, or it's agent for the purpose of petitioning the
appropriate local, state and federal environmental regulatory agencies (US Army Corps of
Engineers, NC Division of Water Quality, NC Division of Coastal Management, local
municipalities, etc.) for: a) review and approval of the jurisdictional boundaries of onsite
jurisdictional areas (wetlands, surface waters, riparian buffers, etc.) and /or; b) preparation and
submittal of appropriate environmental permit applications /requests for the Crosspointe Church
property (PIN 0735549587), located at 6911 Carpenter Fire Station Road in Carv, Wake
Countv.
The Client does hereby authorize that said agent has the authority to do the following acts on
behalf of the owner:
(1) To submit appropriate requests /applications and the required supplemental
materials;
(2) To attend meetings to give representation on behalf of the Client.
(3) To authorize access to subject property for the purpose of environmental
review by appropriate regulatory agencies.
This authorization shall continue in effect until completion of the contracted task or termination by
the Client.
Agent's Name, Address & Telephone
Trov Beaslev / Withers & Ravenel, Inc.
1410 Commonwealth Drive, Suite 101
Wilmington, NC 28403
Tel. [phone]
Date:
Signature of Client:
(Name - Print) (Title)
I (Signature)
Mailing Address
City State Zip
Phone:
Email:
115 MacKenan Drive I Cary, NC 275111 tel.: [phone] fax: [phone] www.withersravenet.com I License No. C -0832
1410 Commonwealth Drive I Suite 1011 Wilmington, NC 28403 1 tel: [phone] fax: [phone]
7011 Albert Pick Road I Suite G I Greensboro, NC 27409 1 tel: [phone] fax: [phone]

USGS QUAD &
WAKE CO. SOIL SURVEY

GRAPHIC SCALE
0 1000 2000
1 inch = 2000 ft.
JtAK: K-
h ^o� (l
I
\To�NS
0 sa
o
300--
0
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0
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0 Q\Sy
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R Carpenter
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55i ,
V� 300 -�. � �- . -;_�Q
350
30p
350
6
CROSSPOINTE CHURCH EXPANSION USGS QUAD - GREEN LEVEL
CARY WAKE COUNTY NORTH CAROLINA
N
■N ;INEERf 1 PLANNER; 1 SURVEYORS

GRAPHIC SCALE
0 300 600
1 inch = 600 ft.
M rrt-s,-- $r
350
350
E�? �S RD �
Q o,
�Y ;M
vr-
0
omr- 7-wrmj
a r enter
CROSSPOINTE CHURCH EXPANSION USGS QUAD - GREEN LEVEL WITHERS �.\VENEL
ENGINEERS 1 PLANNERS I SURVEYORS
GARY WAKE COUNTY NORTH CAROLINA

GRAPHIC SCALE J wsC
0 300 600 ` V C r B 2 CrB2
WsB2 Wy (�2
1 inch = 600 ft. 4A -
WsC2 CrC2 , % GrB2
ood
WsE �' � — 5 CrC2 G�
CrC2 1 y � urc
wsC2 WSC2 wsG2 wsC2
.4 WsB2
ry _
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-r CrB2
ME!
-. - - -
, wsC2 ' 1
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2
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CrB2
WsB2 '� ws62
se WsC2 �
Ws G2
wscz
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WsE _ C rC2
wsC2
WsE rC
E V� O
CROSSPOINTE CHURCH EXPANSION
CAR, WAKE COUNTY NORTH CAROLINA
WAKE CO. SOIL SURVEY - SHEET 35
WITHERS & RAVENEL
ENGINEERS 1 PLANNERS I SURVEYORS

CORPS STREAM QUALITY FORM
FOR IMPACT #5 & 6

USACE AID# DWQ # Site # (indicate on attached map)
rin_� STREAM QUALITY ASSESSMENT WORKSHEET 0.
Provide the following information for the stream reach under assessment: rr
1. Applicant's name: Cwross ffAr- CAS 2. Evaluator's name:. 9a0..z
3. Date of evaluation: E ;? 4. Time of evaluation: 4100 PM F
5. Name of stream: Lt - -'D 7" .t Cree k- 6. River basin:--c L,� F -ew - Z
7. Approximate drainage area: 8. Stream order: A
9. Length of reach evaluated: 155- ir -ro4wj S�rearn
11. Site coordinates (if known): prefer in decimal degrees.
Latitude (ex. 34.872312): 36-, g 7_2r78'2_ A)
10. County: Wake,
12. Subdivision name (if any):
Longitude (ex - 77.556611): -W' 919 8 n c w-)
Method location determined (circle): GPS Topo Sheet Ortho (Aerial) Photo /GIS Other GIS Other
13. Location of reach under evaluation (note nearby roads and landmarks and attach map identifying stream(s) location):
rrenn nrf31h o4-+"41aXS S-1
14. Proposed channel work (if any): -G�r�
15. Recent weather conditions: Q i rt w4.n
16. Site conditions at time of visit: UnAcuelooeek Ala -ndos
17. Identify any special waterway classifications known: Section 10 _Tidal Waters _Essential Fisheries Habitat
_Trout Waters _Outstanding Resource Waters V Nutrient Sensitive Waters _Water Supply Watershed (I -IV)
18. Is there a pond or lake located upstream of the evaluation point? YES Ol� f yes, estimate the water surface area:
19. Does channel appear on USGS quad map? YES 9) 20. Does channel appear on USDA Soil Survey? YES NO
21. Estimated watershed land use: W % Residential !D% Commercial % Industrial % Agricultural
30 % Forested % Cleared / Logged % Other r
i
22. Bankfull width: 3 �� 23. Bank height (from bed to top of bank): M"
24. Channel slope down center of stream: !Flat (0 to 2 %) Gentle (2 to 4 %) _Moderate (4 to 10 %) _Steep ( >10 %)
25. Channel sinuosity: Straight V Occasional bends Frequent meander _Very sinuous Braided channel
Instructions for completion of worksheet (located on page 2): Begin by determining the most appropriate ecoregion based on
location, terrain, vegetation, stream classification, etc. Every characteristic must be scored using the same ecoregion. Assign points
to each characteristic within the range shown for the ecoregion. Page 3 provides a brief description of how to review the
characteristics identified in the worksheet. Scores should reflect an overall assessment of the stream reach under evaluation. If a
characteristic cannot be evaluated due to site or weather conditions, enter 0 in the scoring box and provide an explanation in the
comment section. Where there are obvious changes in the character of a stream under review (e.g., the stream flows from a pasture
into a forest), the stream may be divided into smaller reaches that display more continuity, and a separate form used to evaluate each
reach. The total score assigned to a stream reach must range between 0 and 100, with a score of 100 representing a stream of the
highest quality. Ji7 rr��
Total Score (from reverse):
�O Comments: - wr+ 1 n+vm; #erl� '°+I!'a4r,,A � I55 /l b
a Eve& 01 a&-C C e + onLu recie've s aflaver0 runa4:F. Voerw G6-%r, `z
Evaluator's Signature /� Date Fr/ T0_5-
This channel evaluation form is intend d to be used only a guide to assist landowners and environmental professionals in
gathering the data required by the nited States Army Corps of Engineers to make a preliminary assessment of stream
quality. The total score resulting from the completion of this form is subject to USACE approval and does not imply a
particular mitigation ratio or requirement. Form subject to change - version 06/03. To Comment, please call 919 - 876 -8441 x 26.

STREAM QUALITY ASSESSMENT WORKSHEET
* These characteristics are not assessed in coastal streams.
ECOREGION POINT
RANGE
#
CHARACTERISTICS
SCORE
Coastal
Piedmont
Mountain
1
Presence of flow / persistent pools in stream
0-5
0 - 4
0-5
no flow or saturation = 0; strong flow = max points)
2
Evidence of past human alteration
0-6
0-5
0-5
(extensive alteration = 0; no alteration = max points)
3
Riparian zone
0-6
0-4
0-5
(no buffer = 0; contiguous, wide buffer = max points)
4
Evidence of nutrient or chemical discharges
0-5
0 - 4
0-4
(extensive discharges = 0; no discharges = max points)
5
Groundwater discharge
0-3
0-4
0-4
no discharge = 0: springs, see s, wetlands, etc. = max points)
V
r•r
6
Presence of adjacent floodplain
0-4
0 - 4
0-2
O
no floodplain = 0; extensive floodplain = max points)
7
Entrenchment / floodplain access
0— 5
0— 4
0— 2
(dee ly entrenched= 0; fre went floodin =max oints)
8
Presence of adjacent wetlands
0-6
0-4
0-2
(no wetlands = 0; large adjacent wetlands = max points)
9
Channel sinuosity
0-5
0-4
0-3
(extensive channelization = 0, natural meander = max points)
10
Sediment input
0-5
0-4
0-4
extensive deposition= 0; little or no sediment = max points)
11
Size & diversity of channel bed substrate
NA*
0-4
0 — 5
(fine, homogenous = 0, large, diverse sizes = max points)
12
Evidence of channel incision or widening
0 -5
0 -4
0 -5
>4
(deeply incised = 0; stable bed & banks = max points)
1-4
13
Presence of major bank failures
0 -5
0 -5
0 -5
(severe erosion = 0; no erosion, stable banks =max points)
14
Root depth and density on banks
0 -3
0 -4
0 -5
(no visible roots = 0; out =max points)
dense roots throu
15
Impact by agriculture, livestock, or timber production
0 -5
0 -4
0 -5
(substantial impact =0; no evidence = max points)
16
Presence of riffle- pool/ripple -pool complexes
0-3
0 - 5
0-6
(no riffles/ripples or pools = 0; well-developed = max points)
17
Habitat complexity
0 -6
0 -6
0 -6
little or no habitat= 0; frequent, varied habitats = max points)
02
18
Canopy coverage over streambed
0-5
0-5
0-5
x
(no shadin g vegetation = 0. continuous canopy = max points
19
Substrate embeddedness
NA*
0-4
0 - 4
(deeply embedded = 0; loose structure = max)
20
Presence of stream invertebrates (see page 4)
0 -4
0 -5
0 -5
>
(no evidence = 0; common. numerous types = max points)
0
21
Presence of amphibians
0-4
0-4
0-4
O
(no evidence = 0. common, numerous ty2es = max points)
O
22
Presence of fish
0 -4
0 -4
fil
(no evidence = 0; common �!� ous es =max oints)
dT IV1 hufo
23
Evidence use
(no evidence = 0; abundant evidence = max points)
0-6
0 - 5
0-5
Total Points Possible
100
100
100
TOTAL SCORE (also enter on first page)
3?
* These characteristics are not assessed in coastal streams.

DMS LETTER OF ACCEPTANCE

AITYWA
I VA
CDEN
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
TJ Terry
Crosspointe Church of Cary
6911 Carpenter Fire Station Rd.
Cary, NC 27519
Project: Crosspointe Church Expansion
Division of Mitigation Services Donald R. van der Vaart
Secretary
August 4, 2015
Expiration of Acceptance: February 4, 2016
County: Wake
The purpose of this letter is to notify you that the NCDENR 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 /CAMA permit 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 at www.nceep.net.
Based on the information supplied by you in your request to use the DMS, the impacts that may require compensatory mitigation 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.
CU I Stream (feet) Wetlands (acres) Buffer I Buffer II
River Basin Location (Sq. Ft.) (Sq. Ft.)
Cold I Cool I Warm Riparian I Non - Riparian I Coastal Marsh
Impact Cape Fear 03030002 I 0 I 0 I 209 0 I 0 I 0 0 0
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 Kelly Williams at (919) 707 -8915.
.B Stanfill
Management Supervisor
cc: David Schaeffer, USACE- Raleigh
Troy Beasley, agent
1652 Mail Service Center, Raleigh, North Carolina 27699 -1652
Phone: 919 - 707 -89761 Internet: www,nceep.net
An Equal Opportunity l Affirmative Action Employer— Made in part from recycled paper

IMPACT EXHIBITS

CARPENTER FIRE
STATION ROAD
I SITE
N
WIE _.A_ ... _ ... _...�
5
.
S
q
A A40 ISVILL
- 4ta�ARK�yAy
VICINITY MAP NTS
I
T-
I
1 �•
I
No. Revision Date By I —ig— AIM s", ' . ]OD
~ °ay CROSSPOINTE CHURCH EXPANSION
ua osn�ne
Checked By Job N.
TB 02IM43 .1 Cary Wake County North Carolina
- ---
i• }
t
i
-------- - - - -'— - - -- - - - - -- - - - -- —
=B 6
_..._..._..._..._ I —
GRAPHIC SCALE
200 0 100 200
RISEN RISEN RISEN
I RISEN RISEN 0
OVERALL IMPACT MAP
(STREAM & WETLAND)
WITHERS & RAVEN EL
ENSINEERS I PLANNERS I SURVEYORS
n o macKenan Dave C— Nolh Gmllna 27511 1,6511 -275 1— ... wlrhersrawn0 — ucenm Nu C—,
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1
WETLAND & STREAM IMPACT SUMMARY
PERMANENT
PERMANENT TEMPORARY TEMPORARY
PERMANENT
TEMPORARY
WETLAND IMPACT WETLAND IMPACT WETLAND IMPACT WETLAND IMPACT
STREAM IMPACT
STREAM IMPACT
MAP
IMPACT# (AC)
(SF) (AC) (SF)
(LF)
(LF)
A
1
-
22 �•',,�
R
2
40
3
74
"
4
-
13
9 C
5
20
-
6
75
TOTALS
0.000
0 0.000 1 0
209
3S
No. Revision Date By I —ig— AIM s", ' . ]OD
~ °ay CROSSPOINTE CHURCH EXPANSION
ua osn�ne
Checked By Job N.
TB 02IM43 .1 Cary Wake County North Carolina
- ---
i• }
t
i
-------- - - - -'— - - -- - - - - -- - - - -- —
=B 6
_..._..._..._..._ I —
GRAPHIC SCALE
200 0 100 200
RISEN RISEN RISEN
I RISEN RISEN 0
OVERALL IMPACT MAP
(STREAM & WETLAND)
WITHERS & RAVEN EL
ENSINEERS I PLANNERS I SURVEYORS
n o macKenan Dave C— Nolh Gmllna 27511 1,6511 -275 1— ... wlrhersrawn0 — ucenm Nu C—,
III

PROPOSED ROLLMAX BIONET PROPOSED
C70OBN EROSION CONTROL PRIVATE FORCE
BLANKET (OR EQUIVALENT) MAIN
FROM TOP OF BANK TO TOP STREAM
OF BANK FOR STABILIZATION
LIMITS OF W�
0
DISTURBANCE
W�
� I1
W
cn
�
TEMPORARY STREAM
W� IMPACT 1 =22 LF E
0
-o
ycn
m U
0
GRAPHIC SCALE
20 0 10 20 40
1 1 1 1
RI• Ra Ra
1 inch = 20 ft.
I No. Revision Date By Deag,er sale
AM t . 20° sheet N.
i °awnay CROSSPOINTE CHURCH EXPANSION STREAM IMPACT 1 WITHERS RAVENEL
i Checkedey mhN<,.
ENGINE RS 1 PLANNERS I SURVEYORS
i iB D7 NW& Town of Cary Wake County North Carolina 1b-- n- Drive. Cary, Nonh —I-2)511 te1: 9,9- 4693340 — withersr --Lcom License No. C -0834

7
j
a
Q
I
\v _
t <G L [
[ [
TEMPORARY-
BYPASS
CHANNEL
LIMITS OF LI
DISTURBANCE
0 I-
PERMANENT
STREAM IMPACT _
3 =74LF
PERMANENT HW -2
STREAM IMPACT 2 7`1
= 40 LF
STREAM l ��
PROPOSED
CLASS 1 RIPRAP HEADWALL
S
U�
x I
I
I TEMPORARY
STREAM IMPACT 4
I =13LF
I
tf
HW -1
PROPOSED
HEADWALL
I
I
PROPOSED
60" RCP
I
LIMITS OF
DISTURBANCE
APRON
40'X1 5'X36" C1
_ I
Revision Date I By I De:i91e1 sale
Drawn By � D11, 7 .�� CROSSPOINTE CHURCH EXPANSION
ua none
Checked By I°h No,
TB muassi Town of Cary Wake County North Carolina
STREAM IMPACTS 2, 3, & 4
** *SEE SHEET D FOR
ADDITIONAL DETAILS
HW 1
HORIZONTAL SCALE: 1 " =50'
VERTICAL SCALE: 1 " =5'
335
EXISTING /
GROUND
330
STREAM
II
325
320
10 +00
335
10 +50
HW 2
HORIZONTAL SCALE: 1" =50'
VERTICAL SCALE: 1 " =5'
EXISTING
GROUND
330 \
325
J
11 +00
320
10 +00 10 +50 11 +00
GRAPHIC SCALE
20 0 10 20 40
I I I
EEC EEC
1 inch = 20 ft.
WITHERS &- RAVENEL
ENGINEERS 1 PLANNERS I SURVEYORS
115 macK —Dave °nh Gmllna 27511 1e1 555- 4521340 aww wnhesraw ,1 — ucenm Nu C-2

7
j
I
STREAM-
LIMITS OF -
DISTURBANCE
CLASS 1 RIF
AP
20'X8'
PERMANENT
STREAM I M PACT 5 =
20 LF
PERMANENT -
STREAM I M PACT 6
= 75 LF
Revision Date I By 11 —ig— so,ie
D.. By *A. ° 07/. /13 CROSSPOINTE CHURCH EXPANSION
ua miwne
Checked By I,,h N.
TB muas&i Town of Cary Wake County North Carolina
** *SEE SHEET D FOR
ADDITIONAL DETAILS
FES 1
HORIZONTAL SCALE: 1 " =50'
VERTICAL SCALE: 1 " =5'
350
EXISTING
GROUND_
340 \ \ r
335
10 +00 10 +50 11 +00
340
)POSED
RCP
HW 2
HORIZONTAL SCALE: 1" =50'
VERTICAL SCALE: 1 " =5'
335 I I
EXISTING
GROUND I I
LIMITS OF 330 l ,
DISTURBANCE V
STREAM IMPACTS 5 & 6
325
10 +00 10 +50 11 +00
GRAPHIC SCALE
20 0 10 20 40
I I I
EEC EEC
1 inch = 20 ft.
WITHERS &- RAVENEL
ENGINEERS 1 PLANNERS I SURVEYORS C
115 1 ac -- Dave °"h Gmfi- 2 7511 1e1 555- 4521340 a,, wnhesraw ,1 — L nm Nu C-2

7
j
a
1' L- 2' MIN
2'
TEMPORARY STREAM BYPASS DITCH
NTS
01"4; 1'
LINE BOTTOM
TARP
PROTECTION
/1 9 -
SECTION
PERMANENT SOIL REINFORCEMENT INSTALL LEVEL
PIPE OUTLET MATTING (PSRM) AND FLUSH WITH
NATURAL GROUND
A
SQUARE PREFORMED >
SCOUR HOLE BASIN S / ` <
(RIP RAP IN
NOT SHOWN FOR
CLARITY)
A \�
PLAN VIE' SCOUR HOLE DETAIL
NTS
s�oiOF
RIPRAP APRON
PIPE OUTLET (SEE DETAIL)
RIP RAP
SECTION A -A
TO MATCH
PRE — CONSTRUCTION
STREAM CONTOUR
RIPRAP DETAIL
NTS
IP RAP
** *SEE SHEETS A -C
FOR STREAM IMPACTS
No. Revision Date By I o ig­ sale
MM t ]O' sheep No.
Drawn By -, CROSSPOINTE CHURCH EXPANSION STREAM IMPACT DETAILS WITHERS RAVENEL
�, „m,t, p
aaekaa By lob NO. lNi1N!!Rf I PLANNERS I fORVlIfORf
TB 02IM4.0 Town ofCary Wake County North Carolina „5 Ma­ Dn,e -nh 27511 1e1 9194691340 wwww,Ihersrew,l —, L N., C­,
v

WITHERS RAVENEL
ENGINEERS I PLANNERS I SURVEYORS
1410 COMMONWEALTH DRIVE, SUITE lol
WILMINGTON, NORTH CAROLINA, 28403
(910) 256 -9277
FAX [phone]
TO: NC Division of Water Resources
512 N. Salisbury Street; 9`h Floor
Raleigh, NC 27604
WE ARE SENDING YOU ® Attached
❑ Shop Drawings ❑ Prints
❑ Copy of Letter ❑ Change order
COPIES DATE NO.
4 8/5/15 02130433.10
1 8/6/15 02130433.10
1 8/6/15 02130433.10
THESE ARE TRANSMITTED as checked below:
LETTER COY TRANSWTTi QL
DATE 8/7/15 I JOB No. 02130433.10
ATTENTION
Ms. Karen Higgins
PHONE#
919 -807 -6363
RE: Crosspointe Church Expansion — Cary, Wake Co.
NWP 39 PCN Submittal
❑ Under separate cover via
❑ Plans ❑ Samples
❑ Diskette ❑
the following items:
❑ Specifications
DESCRIPTION
NWP 39 PCN
$570 Check for Application Fee
CD of PCN
® For approval ❑ Approved as submitted ❑ Resubmit copies for approval
❑ For your use ❑ Approved as noted ❑ Submit copies for distribution
❑ As requested ❑ Returned for corrections ❑ Return corrected prints
❑ For review and comment ❑
❑ FOR BIDS DUE 20 ❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS:
Signature:
Date:
COPY TO: File SIGNED: Troy Beasley
If enclosures are not as noted, kindly notify us at once.