20240435 Ver 1_Calebs Creek_PCN_20240314

NORTH CAROLINA
Environmental Quality
Water Resources
Office Use Only
Corps Action ID no. [Click to enter.] Date received: [Click to enter.]
DWR project no. :,lick enter.] Date received: [Click to enter.]
Site Coordinates:
Latitude (DD.DDDDDD): 36.062387
Longitude (DD.DDDDDD):-80.091225
Form Version 4.3, February 22, 2024
Pre -Construction Notification (PCN) Form
(Ver. 4.3, February 22, 2024)
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://www. deg. nc. gov/water-resources/pcn-help-document-last-updated-1162024
Page 1 of 22 PCN Form Version 4.3- February 22, 2024

A. Processing Information
County (counties) where project is located:
Forsyth Additional (if needed).
Is this an ARPA project?
❑ Yes 0 No
If yes, ARPA project number:
" The project number can be found on the "Letter of Intent to Fund"
(LOIF) or "Offer and Acceptance Letter". If you are unable to locate
Click or tap here to enter text.
your DWI ARPA Funding Project Number, please contact Corey
Basinger at core y.basinger(cilncdenr.gov for further assistance.
Is this a NCDMS project?
(Click yes only if NCDMS is the applicant or co-
❑ Yes 0 No
applicant)
Is this a public transportation project?
(Publicly funded municipal, state, or federal road, rail,
❑ Yes 0 No
or airport project)
Is this a NCDOT project?
❑ Yes 0 No
If yes, NCDOT TIP or state project number:
Click to enter.
If yes, NCDOT WBS number:
Click to enter.
0 Section 404 Permit (wetlands, streams, waters,
Clean Water Act)
1 a. Type(s) of approval sought from the Corps: *
❑ Section 10 Permit (navigable waters, tidal
waters, Rivers and Harbors Act)
Has this PCN previously been submitted? *
❑ Yes 0 No
Please provide the date of the previous submission. *
Click to -ntr
❑ Nationwide Permit (NWP)
1 b. What type(s) of permit(s) do you wish to seek
El Regional General Permit (RGP)
authorization?
0 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.
1c. Has the NWP or GP number been verified by the Corps?
0 Yes ❑ No
NWP number(s) (list all numbers ):
Click to enter.
RGP number(s) (list all numbers ):
Click to enti
Are you a federal applicant?
❑ Yes 0 No
If yes, please provide a statement concerning compliance with
the Coastal Zone Management Act
Click to enter tex
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
0 Individual 401 Water Quality Certification
Is this a courtesy copy notification
❑ Yes 0 No
Page 2 of 22 PCN Form Version 4.3- February 22, 2024

1 e.
Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification:
❑ Yes
Z No
For the record only for Corps Permit:
❑ Yes
X No
1f.
Is this an after -the -fact permit/certification application?
❑ Yes
® 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
M No
1 i.
Is the project located within an NC DCM Area of Environmental
Concern (AEC)?
❑ Yes
® No ❑ Unknown
1j.
Is the project located in a designated trout watershed?
❑ Yes
® 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.miI/Missions/Regulatory-Permit-
Prog ram/Agency-Coordi nation/Tro ut.aspx
Page 3 of 22 PCN Form Version 4.3- February 22, 2024

B. Applicant Information
1 a.
Who is the primary contact?
Jeff Harbour
1 b.
Primary Contact Email:
[e-mail]
1c.
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:
BOMA North Carolina, LLC
2b.
Deed Book and Page No.:
Glick to ent�
2c.
Contact Person (for corporations):
Click to enter.
2d.
Address
Street Address:
836 Good Hope Drive
Address line 2:
City:
Castle Rock
State/ Province/ Region:
CO
Postal/ Zip Code:
80108
Country:
USA
2e.
Telephone Number: * (###)###-####
[phone]
2f.
Fax Number: (###)###-####
2g.
Email Address:
[e-mail]
3.
Applicant Information (if different from owner)
3a.
Name:
BOMA North Carolina, LLC
3b.
Business Name (if applicable):
`:lick to ent,
3c.
Address:
Street Address:
836 Good Hope Drive
Address line 2:
Click to entr
City:
Castle Rock
State/ Province/ Region:
CO
Postal/ Zip Code:
80108
Country
USA
3d.
Telephone Number: (###)###-####
[phone]
3e
Fax Number: (###)###-####
3f.
Email Address:
[e-mail]
Page 4 of 22 PCN Form Version 4.3- February 22, 2024

4. Agent/ Consultant (if applicable)
4a. Name:
Jeff Harbour
4b. Business Name:
Terracon
4c. Address:
Street Address:
2401 Brentwood Road
Address line 2:
City:
Raleigh
State/ Province/ Region:
NC
Postal/ Zip Code:
27604
Country:
USA'
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/Req uIatory-Permit-Prop ram/Pe rmits/2017-Nationwide-Permits/Pre-
construction-Notification/
Page 5 of 22 PCN Form Version 4.3- February 22, 2024

C. Project Information and Prior Project History
1. Project Information
la. Name of project:
Caleb's Creek
1 b. Subdivision name (if appropriate):
ck to enter.
1c. Nearest municipality/town:
Kernersville
2.
Project Identification
2a.
Property identification number (tax PIN or parcel ID):
6874-80-0354, 6874-54-9305, 6874-86-7026
2b.
Property size (in acres):
875
2c.
Project Address:
Street Address:
7435 Watkins Ford Rd
Address line 2:
O Teague Lane
City:
Kernersville
State/ Province/ Region:
NC
Postal/ Zip Code:
Click to enter.
Country:
Click to ente,
2d.
Site coordinates in decimal degrees (using 4-6 digits
after the decimal point):
Latitude (DD.DDDDDD): 36.062387
Longitude (-DD.DDDDDD):--80.091225
3. Surface Waters
3a. Name of nearest body of water to proposed project:
Abbots Creek
3b. Water Resources Classification of nearest receiving
WS-III
water:
The Surface Water Classification map may be found at this link:
https:Hexperience.arcgis.com/experience/7073e9l 22ab74588b8c48ded34c3df55/
Yadkin-PeeDee
3c. In what river basin(s) is your project located?
,00se additional (if needed)
3d. Please provide the 12-digit HUC in which the project is
030401030202
located:
The Find Your HUC map may be found at this link:
https:Hncdenr.maps.arcqis.com/apps/Publiclnformation/index.html?appid=ad3a85a0c6d644a0b97cd069db238ac3
Page 6 of 22 PCN Form Version 4.3- February 22, 2024

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 Caleb's Creek site is comprised of large tracts of undeveloped woodlands, open land that was formerly used
for agriculture and also a former golf course was located on what is now thre 875-acre Calebs Creek site. The
site is surrounded primarily by single family resudential and some agriculture areas. Significant growth in thi spart
of Forsyth County has spurred the need for additional housing, both sing;e family and multi -family. Caleb's
Creek is proposed to help provide a large portion of this much needed housing.
4b. Have Corps permits or DWR certifications been obtained for this
0 Yes ❑ No ❑ Unknown
project (including all prior phases) in the past?
If yes, please give the DWR Certification number and/or Corps
[Click to ent_
Action ID (ex. SAW-0000-00000):
jClick to enter.]
Attach any pertinent project history documentation
4b2. Is any portion of the work already complete?
0 Yes ❑ No
If yes, describe the completed work.
Approximately 175 acres of land has been developed or is currently being developed. These areas have been
determined to not incur any impacts to protected aquatic respources. The proposed roadway impacts that were
applied for under the above referenced applications; were not completedas that application was subsequently
withdrawn due to time Iimts for additional information being exceeded.
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.
Glick to enter te.
4d. Attach an 8'/2 x 11" excerpt from the most recent version of the USGS topographic map indicating the location of
the project site.
4e. Attach an 8'/z 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
+/- 70 acres
property:
4g. List the total estimated linear feet of all existing streams (intermittent
+/- 47,000 linear feet
and perennial) on the property:
4g1. List the total estimated acreage of all existing open waters on the
+/- 19 acres
property:
4h. Explain the purpose of the proposed project:
Purpose is to develop residential housing for this area of Forsyth County
4i. Describe the overall project in detail, including the type of equipment to be used:
Please refer to attachment documentation
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 0 No
If yes, describe the type of dredging, the composition of the dredged material, and the locations of disposal area.
Click to enter text
Page 7 of 22 PCN Form Version 4.3- February 22, 2024

5.
Jurisdictional Determinations
5a.
Have the wetlands or streams been delineated on the property or in
® Yes ❑ No ❑ Unknown
proposed impact areas?
Comments:
DICK w U.
5b.
If the Corps made a jurisdictional determination,
❑ Preliminary ❑ Approved X Emailed concurrence
what type of determination was made? `
❑ Not Verified ❑ Unknown ❑ n/a
Corps AID number (ex. SAW-0000-00000):
SAW-2015-01697
Name (if known): Click to enter
5c.
If 5a is yes, who delineated the jurisdictional
Agency/Consultant Company: Terracon
areas?
Other: Click to eI.
5d.
List the dates of the Corps jurisdictional determination or State determination if a determination was made by
either agency.
SAW-2015-01697 onsite reviews held on 7/25/2023, 8/24/2023, and 9/19/2023 with Sam Dailey and Terracon
5d1.
Attach jurisdictional determinations.
6. Future Project Plans
6a. Is this a phased project?
® Yes ❑ No
6b. If yes, explain.
Construction will occur in phases; however this permit request is intended to cover all necessary impacts with
one permit action
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.
Click to enter..
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)
See attached
8. Scheduling of activity:
Click to enter.
Page 8 of 22 PCN Form Version 4.3- February 22, 2024

D. Proposed Impacts Inventory
Impacts Summary
® Wetlands ® 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.
2a1.
2b.
2c.
2d.
2e.
2f.
2g.
Site #
Impact
Impact
Wetland Type
Wetland Name
Forested
Jurisdiction
Impact Area
Reason/Type
Duration
?*
Type*
(ac)
W1
Fill (Incl.
Permanent
Headwater
W6
Yes
Both
0.24
Ri pra p)
Forest
W2
Road/
Permanent
Headwater
W8
Yes
Both
0.06
Driveway
Forest
Crossing
W3
Fill (Incl.
Permanent
Headwater
W3
Yes
Both
0.05
Ri pra p)
Forest
W4
Other
Permanent
Bottomland
W43
Yes
Both
0.30
Hardwood
Forest
W5
Other
Permanent
Headwater
W43
Yes
Both
0.17
Forest
Hand
Temporary
Bottomland
U-2 Crossing
Yes
Both
0.03
W6
Clearing
Hardwood
Forest
Hand
Temporary
Bottomland
U-3 Crossing
Yes
Both
0.02
W7
Clearing
Hardwood
Forest
Hand
Temporary
Bottomland
U-6 Crossing
Yes
Both
0.02
W8
Clearing
Hardwood
Forest
Hand
Temporary
Bottomland
U-7 Crossing
Yes
Both
0.03
W9
Clearing
Hardwood
Forest
W10
Hand
Temporary
Headwater
U-8 Crossing
Yes
Both
0.03
Clearing
Forest
W11
Hand
Temporary
Headwater
U-9 Crossing
Yes
Both
0.02
Clearing
Forest
Hand
Temporary
Bottomland
U-12 Crossing
Yes
Both
0.02
W12
Clearing
Hardwood
Forest
Page 9 of 22 PCN Form Version 4.3- February 22, 2024

Hand
Temporary
Bottomland
U-13 Crossing
Yes
Both
0.16
W13
Clearing
Hardwood
Forest
Hand
Temporary
Bottomland
U-15 Crossing
Yes
Both
0.03
W14
Clearing
Hardwood
Forest
Hand
Temporary
Bottomland
U-16 Crossing
Yes
Both
0.001
W15
Clearing
Hardwood
Forest
2g1.
Total temporary wetland impacts
0.37 ac
2g2.
Total permanent wetland impacts
0.82 ac
2g3.
Total wetland impacts
1.19 ac
2h.
Type(s) of material being discharged and the amount of each type in cubic yards:
Click to enter text
2i.
Comments:
Click to enter text.
Page 10 of 22 PCN Form Version 4.3- February 22, 2024

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
T1-Road
Permanent
Crossing/
UT Abbot
Intermittent
Both
2.3
50
crossing
Culvert
Creek
S2
T2 - Road
Permanent
Crossing/
UT Abbot
Perennial
Both
9.5
95
crossing
Culvert
Creek
S3
T3-Road
Permanent
Crossing/
UT Abbot
Per/Int
Both
12
75
crossing
Culvert
Creek
S4
T4-Road
Permanent
Crossing/
Abbott Creek
Perennial
Both
15
75
crossing
Culvert
S5
T5-Road
Permanent
Crossing/
UT Abbot
Intermittent
Both
5.5
75
crossing
Culvert
Creek
S6
T6-Road
Permanent
Crossing/
UT Abbot
Perennial
Both
26
75
crossing
Culvert
Creek
S7
T7-Road
Permanent
Crossing/
Abbott Creek
Perennial
Both
22
80
crossing
Culvert
S8
T8-Road
Permanent
Crossing/
Abbott Creek
Perennial
Both
15
140
crossing
Culvert
S9
T9-Road
Permanent
Crossing/
UT Abbot
Intermittent
Both
6.5
75
crossing
Culvert
Creek
S10
T10-Road
Permanent
Crossing/
UT Abbot
Perennial
Both
4.3
75
crossing
Culvert
Creek
S11
U-4 Crossing
Temporary
Workpad/
UT Abbot
Intermittent
Both
5
30
Causeway
Creek
S12
U-5 Crossing
Temporary
Workpad/
Abbott Creek
Intermittent
Both
5
30
Causeway
S13
U-6 Crossing
Temporary
Workpad/
UT Abbot
Intermittent
Both
5
20
Causeway
Creek
S14
U-7 Crossing
Temporary
Workpad/
Abbott Creek
Perennial
Both
15
15
Causeway
S15
U-8 Crossing
Temporary
Workpad/
UT Abbot
Intermittent
Both
5
20
Causeway
Creek
S16
U-9 Crossing
Temporary
Workpad/
UT Abbot
Intermittent
Both
5
20
Causeway
Creek
S17
U-12 Crossing
Temporary
Workpad/
UT Abbot
Intermittent
Both
5
20
Causeway
Creek
S18
U-13 Crossing
Temporary
Workpad/
UT Abbot
Perennial
Both
15
20
Causeway
Creek
S19
U-15 Crossing
Temporary
Workpad/
UT Abbot
Intermittent
Both
5
20
Causeway
Creek
S20
U-16 Crossing
Temporary
Workpad/
Abbott Creek
Perennial
Both
15
20
Causeway
Page 11 of 22 PCN Form Version 4.3- February 22, 2024

3i1. Total jurisdictional ditch
0 linear ft
impact:
3i2. Total permanent stream
815 linear ft
impacts:
M. Total temporary stream
235 linear ft
impacts:
3W Total stream and ditch
1050 linear ft
impacts:
3j. Comments:
S1-S10 are from permanent road crossing impacts. S11-S20 are from temporary utility line construction
Page 12 of 22 PCN Form Version 4.3- February 22, 2024

4.
Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other
open water of the U.S., individually list all open water impacts in the table below.
4a.
Site #
4a1.
Impact Reason
4b.
Impact
Duration*
4c.
Waterbody Name*
4d.
Activity Type*
4e.
Waterbody
Type*
4f.
Impact area
(ac)*
01
Click to enter.
Temp/ Perm
Click to enter.
Choose one
Choose one
Click to enter.
02
Click to enter.
Temp/ Perm
Click to enter.
Choose one
Choose one
Click to enter.
03
Click to enter.
Temp/ Perm
Click to enter.
Choose one
Choose one
Click to enter.
04
Click to enter.
Temp/ Perm
Click to enter.
Choose one
Choose one
Click to enter.
05
Tam^/ D-
Click to enter.
Choose one
Choose one
Click to enter.
4g.
Total temporary open water impacts
Click to enter. ac
4g.
Total permanent open water impacts
Click to enter. ac
4g.
Total open water impacts
Click to entc ac
4h.
Comments:
Click to enter.
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
Click t,
Click to
lick to
Click to
Click to
Click
lick
P1
:hoose one
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:
Click to enter
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:
Clicl
Page 13 of 22 PCN Form Version 4.3- February 22, 2024

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: lick 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.
I Il V
Click to enter.
c 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
Click to enter.
Y/N
Click to enter.
Click to enter.
B13
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B14
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B15
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B16
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B17
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B18
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B19
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B20
Choose one
�emp/ 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:
DICK L,
Please attach supporting documentation (impact maps, plan sheets, etc.) for the proposed project.
Page 14 of 22 PCN Form Version 4.3- February 22, 2024

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 project has been through multiple design iterations as described in the report and supporting documentation
1b. Specifically describe measures taken to avoid or minimize proposed impacts through construction techniques:
The project has sifnificantly minimized impacts though construction rtechniques for the road crossings.
Headwalls and wing walls are being used and side slopes are being proposed to help minimize impact to
streams and wetlands.
2. Compensatory Mitigation for Impacts to Waters of the U.S., Waters of the State, or Riparian Buffers
2a. If compensatory mitigation is required, by whom is it required? ® DWR ® Corps
(check all that apply)
2b. If yes, which mitigation option(s) will be used for this ® Mitigation Bank
project? * (check all that apply) ® In Lieu Fee Program
❑ Permittee Responsible Mitigation
3. Complete if using a Mitigation Bank
(Must satisfy NC General Statute143-214.11 (d1).)
3a. Name of mitigation bank:
Click to enter.
3b. Credits purchased/requested:
Type: Choose one
Quantity Click to enter.
Type: Choose one
Quantity Click to enter.
Type: choose one
Quantity Click to enter.
Attach receipt and/or approval letter.
3c. Comments:
The permitte is seeking the necessary SOAs from either a mitigation bank or NCDMS
4.
Complete if Using an In Lieu Fee Program
4a.
Attach approval letter from in lieu fee program.
4b.
Stream mitigation requested:
Click to ente- 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)
httips:Hribits.oips.usace.army.mil/ords/fZLF107-.2::::::
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 15 of 22 PCN Form Version 4.3- February 22, 2024

4h. Comments:
The permittee is currently seeking the proper mitigation credits first from a private mitigation bank and then any
remaining needs through the in -lieu fee program
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.
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 0 No
that requires buffer mitigation?
If yes, please complete this entire section — please contact DWR for more information.
6b.
If yes, identify the square feet of impact to each zone of the riparian buffer that requires
mitigation. Calculate the
amount of mitigation required in the table below.
6c.
6d.
6e.
Zone
Reason for impact
Total impact
Multiplier
Required mitigation
(square feet)
(square feet)
Zone 1
Click to enter.
Click to enter.
Choose one
Click to enter.
Zone 2
Click to enter.
Click to Pr'
^h^^�^ ^^^
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 0 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:
Click to �.._
Page 16 of 22 PCN Form Version 4.3- February 22, 2024

F. Stormwater Management and Diffuse Flow Plan (DWR requirement)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers
❑ Yes 0 No
identified within one of the NC Riparian Buffer Protection Rules?
1 b. All buffer impacts and high ground impacts require diffuse flow or other form of stormwater treatment. If the
project is subject to a state implemented riparian buffer protection program, include a plan that fully documents
how diffuse/dispersed flow will be maintained.
All Stormwater Control Measures (SCM) must be designed in accordance with the NC Stormwater Design
Manual (https:Hdeg.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permit-
guidance/stormwater-bmp-manual).
Associated supplement forms and other documentation must be provided.
❑ Level Spreader
What Type of SCM are you
❑ Vegetated Conveyance (lower seasonal high water table- SHWT)
providing?
❑ Wetland Swale (higher SHWT)
(Check all that apply)
❑ Other SCM that removes minimum 30% nitrogen
❑ Proposed project will not create concentrated stormwater flow through the
buffer
For a list of options to meet the diffuse flow requirements, click here.
Attach diffuse flow documentation.
2.
Stormwater Management Plan
2a.
Is this an NCDOT project subject to compliance with NCDOT's
Individual NPDES permit NCS000250?
❑ Yes 0 No
2b.
Does this project meet the requirements for low density projects as
defined in 15A NCAC 02H .1003(2)?
❑ Yes 0 No
To look up low density requirements, click here:
http://reports.oah.state. nc. us/ncac/title%2015a%20-%20environ mental%20guality/chapter%2002%20-
%20environmental%20management/su bchapter%20h/15a%20ncac%2002h%20.1003. pdf
2c.
Does this project have a stormwater management plan (SMP)
ElYes 0 No
reviewed and approved under a state stormwater program or state Tapproved
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?
0 Local Government
(Check all that apply.)
❑ State
If you have local government approval, please include the SMP on their overall impact map.
0 Phase II ❑ USMP
Local Government Stormwater Programs
❑ NSW 0 Water Supply
Page 17 of 22 PCN Form Version 4.3- February 22, 2024

Please identify which local government stormwater program you are using.
Kernersville
State Stormwater Programs ❑x Phase II ❑ HQW or ORW
❑ Coastal Counties ❑ Other
Comments:
Project engineer responsible for the preparation and approval of the SMP.
Page 18 of 22 PCN Form Version 4.3- February 22, 2024

G. Supplementary Information
1. Environmental Documentation
1 a. Does the project involve an expenditure of public (federal/state/local)
❑ Yes 0 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:
Click to enter.
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 0 Yes ❑ 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):
A portion of the site was subject to a a sediment and erosion control violation that resulted from extreme weather
events during the late fall/early winder of 2023. It is my understanding that these violations were addressed with
the City of Kernersville and DEMLR.
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 0 No
downstream water quality?
3b. If you answered "no", provide a short narrative description:
This project is being developed as a single and complete project and is not dependant on or considered to be a
driver of other development
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? ❑ Yes 0 No ❑ N/A
Page 19 of 22 PCN Form Version 4.3- February 22, 2024

4b. If yes, describe in detail the treatment methods and dispositions (non -discharge or discharge) of wastewater
generated from the proposed project. If the wastewater will be treated at a treatment plant, list the capacity
available at that plant.
Click to enter.
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected
® Yes ❑ No
species or habitat? (IPAC weblink: https://www.fws.gov/ipac/ ffws.govl)
5b. Have you checked with the USFWS concerning Endangered Species
❑ Yes ® No
Act impacts?
5c. If yes, indicate the USFWS Field Office you have contacted.
Choose one
5d. Is another federal agency involved?
❑ Yes ® No ❑ Unknown
If yes, which federal agency?
UucK 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 ® No
5g1. If yes, have you inspected the bridge for signs of bat use such as
staining, guano, bats, etc.? Representative photos of signs of bat use
❑ Yes ❑ No
can be found in the NLEB SLOPES, Appendix F, pages 3-7.
Representative photos of signs of bat use can be found in the NLEB SLOPES, Appendix F, pages 3-7. Link to
NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-30-17-signed NLEB-SLOPES&apps.pdf
If you answered yes to 5g1, did you discover any signs of bat use? *
❑ Yes ❑ No ❑ Unknown
If yes, please show the location of the bridge on the permit drawings/ project plans
5h. Does this project involve the construction/ installation of a wind
turbine(s)?
❑ Yes ❑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,
ElYes ❑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
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated
Critical Habitat?
Terracon has conducted a habitat assessment and also completed surveys for Schweinitz's sunflower in the fall
of 2023 in those areas that were found to represent potnetila habitat. No federal protected species are reported
on a current NCNHP report as being inside of or within one mile of the project area.
Attach consultation documentation.
Page 20 of 22 PCN Form Version 4.3- February 22, 2024

6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as
an Essential Fish Habitat?
El Yes ®No
Is there submerged aquatic vegetation (SAV) around
the project vicinity?
❑Yes ®No ❑Unknown
Will this project affect submerged aquatic vegetation?
❑ Yes ❑x No ❑ Unknown
Explain: Click to ente
6b. What data source(s) did you use to determine whether your site would impact Essential Fish Habitat?
NOAA
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
El 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?
NCSHPO clearance letter is included with this submittal
7c. Attach historic or prehistoric documentation.
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 ❑ No
8b. If yes, explain how the project meets FEMA requirements.
No impacts requiring FEMA coordination are proposed
8c. What source(s) did you use to make the floodplain determination?
NC Floodmaps
H. Miscellaneous
Comments:
Click to enter.
Attach pertinent documentation or attachments not previously requested
Page 21 of 22 PCN Form Version 4.3- February 22, 2024

I. Signature *
® 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: Jeff Harbour
�gbo u r, Digitally signed r, Harbour, Jeff W
Signature: CI c — —Hareneralbou s, W,
—General Users,
Jeff W DateI202403.114u141843-04c00'
Date: Click to enter.
Page 22 of 22 PCN Form Version 4.3- February 22, 2024