20150989 Ver 1_401 Application_20150915

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Fo�Version 1.4 January 2009
Pre - Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the Corps: If Section 404 Permit ❑ Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number. w`� or General Permit (GP) number
I1 c. Has the NWP or GP number been verified by the Corps? [dyes ❑ No
1 d. TypeV 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
1 e. Is this notification solely for the record For the record only for DWQ For the record only for Corps Permit:
because written approval is not required? 401 Certification:
Ees dNo ❑ Yes M No
1f. Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank ❑ Yes dNo
or in -lieu fee program.
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h ❑ Yes E240
below.
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ❑ Yes ❑ No
2. Project Information
2a. Name of project: Lo\tje r (Tr0.56n
2b. County: UnC-0 k P,
2c. Nearest municipality / town: Gj \A j tj
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state project no: I
3. Owner Information
3a. Name(s) on Recorded Deed:
13b. Deed Book and Page No.
3c. Responsible Party (for LLC if
applicable):
3d. Street address:
3e. City, state, zip:
3f. Telephone no.:
3g. Fax no.:
3h. Email address:
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DNision of Water Resources
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PCN Form - Version 1.4 January 2009
Water Ouatity Redonal 0rierations
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4. Applicant Information (if different from owner)
14a. 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:
1 5. Agent/Consultant Infonnation (if applicable)
5a. Name:
15b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 10

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): I Latitude:
1c. Property size:
2. Surface Waters
2a. Name of nearest body of water to proposed project:
2b. Water Quality Classification of nearest receiving water.
2c. River basin:
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Longitude:
10 acres
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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: 5�Y`u'%L►�u Wab Ciarrta3ex4 Ckttr,'v-n k' ql► Lock, 'e.('
3b. List the total estimated acreage of all existing wetlands on the property:
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3d. Explain the purpose of the proposed project:
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3e. Describe the overall project in detail, including the type of equipment to be used: Rte: r e-XI�f"; Sfi�
n:�f-e,
�e c1ebr'1 s -from -#- v kA6Voad C) u{ arna ayxLe r- b rl
a ttoo � �G 5sa G.
4. Jurisdictional Determinations °� '�'� .9
4a. Have jurisdictional wetland or stream determinations by the ❑ Yes Ly No ❑ Unknown
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past? Comments:
4b. If the Corps made the jurisdictional determination, what type ❑ Preliminary ❑ Final
of determination was made?
4c. If yes, who delineated the jurisdictional areas? Agency /Consultant Company:
Name (if known): Other.
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
S. Project History
15a. Have permits or certifications been requested or obtained for I []Yes �o Unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to 'help file" instructions.
16. Future Project Plans
6a. Is this a phased project?
6b. If yes, explain.
❑ Yes QKNo
Page 3 of 10
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
3b.
3c. 3d. 3e. 3f.
3g.
Stream impact
1 a. Which sections were com leted below for your project (check all that
apply):
Impact
number
❑ Wetlands L� Streams — tributaries
❑ Buffers
❑ Open Waters
❑ Pond Construction
2. Wetland Impacts
width
(linear
Temporary m
If there are wetland impacts proposed on the site, then complete this question for each wetland
area impacted.
S1 I
2a. 2b. 2c.
2d.
2e.
2f.
Wetland impact Type of impact
Type of wetland
Forested
Type of jurisdiction
Area of
number
Choose one
Corps (404,10) or
impact
Permanent (P) or
S3 -
Choose one
DWQ (401, other)
(acres)
Temporary m
S4 -
Choose one
- -
W1 - Choose one
Choose one
Yes/No
-
W2 - Choose one
Choose one
Yes/No
-
W3 - Choose one
Choose one
Yes/No
-
W4 - Choose one
Choose one
Yes/No
-
I` W5 Choose one
Choose one
YesMo
W6 - Choose one
Choose one
Yes[No
-
2g. Total Wetland Impacts:
2h. Comments:
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 (PER) or Type of Average
Impact
number
intermittent (INT)? jurisdiction stream
length
Permanent (P) or
width
(linear
Temporary m
(feet)
feet))
S1 I
1 nose one
J
S2 -
Choose one
S3 -
Choose one
- -
S4 -
Choose one
- -
S5 -
Choose one
- -
S6 -
Choose one
- -
3i. Comments:
3h. Total stream and tributary impacts
r4r, via I11
Page 4 of 10
PCN Form - Version 1.4 January 2009

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.
below. If any impacts require mitigation, then you MUST fill out Section D of this form.
4a. 4b. 4c.
4d. 4e.
Open water Name of waterbody
❑ Randleman ❑ Other.
impact number (if applicable)
Type of impact Waterbody Area of impact (acres)
Permanent (P) or
type
Temporary (T)
Buffer Zone 1
01 -
Choose one Choose
02 -
Choose one Choose
03 -
Choose one Choose
04 -
Choose one Choose
feet)
4f. Total open water impacts
14g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed, ther complete the chart below.
5a_ 5b. 5c. 5d. 5e.
Pond ID number Proposed use or Wetland Impacts (acres) Stream Impacts (feet) Upland
purpose of pond (acres)
Flooded Filled Excavated Flooded Filled Excavated
P1 Choose one
P2 Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard permit required? I ❑ 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. Project is in which protected basin? ❑ Neuse ❑ Tar - Pamlico ❑ Catawba
❑ Randleman ❑ Other.
6b. 6c. 6d.
6e. 6f.
69.
Buffer Impact Reason for impact Stream name
Buffer Zone 1
Zone 2
number—
mitigation impact
impact
Permanent (P) or
required? (square
(square
Temporary (T)
feet)
feet)
131 -
Yes/No
B2 -
Yes/No
B3 -
Yes/No
B4 -
YeslNo
B5 -
Yes/No
B6 -
Yes/No
6h. Total Buffer Impacts:
6i. Comments:
Page 5 of 10

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1 a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
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1 b. Specifically describe measures taken to avoid or minimize the proposed im acts through construction techniques.
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2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for ❑ Yes ❑ No
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply): ❑ DWQ ❑ Corps
❑ Mitigation bank
2c. If yes, which mitigation option will be used for this ❑ Payment to in -lieu fee program
project?
❑ Permittee Responsible Mitigation
3. Complete if Using a Miti gation Bank
3a. Name of Mitigation Bank:
Type: Choose one Quantity:
3b. Credits Purchased (attach receipt and letter)
3c. Comments:
Type: Choose one
Type: Choose one
4. Complete if Making a Payment to In -lieu Fee Program
4a. Approval letter from in -lieu fee program is attached.
4b. Stream mitigation requested:
4c. If using stream mitigation, stream temperature:
4d. Buffer mitigation requested (DWQ only):
4e. Riparian wetland mitigation requested:
4f. Non - riparian wetland mitigation requested:
4g. Coastal (tidal) wetland mitigation requested:
4h. Comments:
❑ Yes
linear feet
Choose one
square feet
acres
acres
acres
5. Complete if Using a Perrnittee Responsible Mitigation Plan
Quantity:
Quantity:
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form — Version 1.4 January 2009

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 I ❑ 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 7 of 10

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
within one of the NC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
2b. Does this project require a Stormwater Management Plan?
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e. Who will be responsible for the review of the Stormwater Management Plan?
3. Certified Local Government Stormwater Review
3a. In which local governments jurisdiction is this project?
3b. Which of the following locally- implemented stormwater management programs
apply (check all that apply):
13c. Has the approved Stormwater Management Plan with proof of approval been
attached?
14. 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?
❑ 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 8 of 10
PCN Form — Version 1.4 January 2009

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
la. Does the project involve an expenditure of public (federal/state/local) funds or the ❑ Yes [J 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)?
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 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? QYes ❑ No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
j, vl�e - k abo oA
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in I ❑Yes 2No
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.
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_
Page 9 of 10
PCN Form — Version 1.4 January 2009

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts?
5c. If yes, indicate the USFWS Field Office you have contacted.
❑ Yes Q/No
[( Yes ❑ No
. skewl (lam
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
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6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? I ❑ Yes Evfhlo
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
U6 Fla 1
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 La 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?
8. Flood Zone Designation (Corps
8a. Will this project occur in a FEMA - designated 100 -year floodplain?
[ryes 0 No
8b. If yes, explain how project meets FEMA requirements: i;�Yr1'E'�Q �o►r'G�IOV�) J,S, -}P� 6s4e-
4ere, was conntipte. SIB co• -,cl Acl crl +La4-
sb.e, d:d �' >n� a `I no c- be t COc- 4'-C-:. x+ ;avn -qcr- -t't'-e, work.
8c. What source(s) did you use to make the floodplain determination?
1�w�sV�SIQ��
Applicant/Agent's Printed Name
Applicant(AgenYs Sig ure
(Agent's signature is valid only if an authorization
letter from the applicant is provided.)
Page 10 of 10
9 -« 15
Date

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