20160633 Ver 1_Application_20160624

Hugh Creed Associates, Inc. P.A.
Consulting Engineers & Land Surveyors
1306 W. WENDOVER AVENUE P O. BOX 9623
GREENSBORO, N C. 27408 GREENSBORO, N C. 27429
TELE [phone] OR [phone]
FAX: [phone]
TRANSMITTAL
DATE: June 23, 2016
PROJECT/CLIENT: Brintle's Travel Plaza
TO: NC DWQ WBSCP Unit, Raleigh
' • ►/ . u11111111111111 -- - -
NUMBER OF:
MYLAR(S)
ORIGINAL(S)
TO BE DELIVERED ❑
TO BE PICKED UP ❑
PRINT(S)
OTHER
TO BE MAILED
OTHER
FOR REVIEW/COMMENT ❑ FOR APPROVAL
FOR SUBMITTAL ❑ AS REQUESTED ❑
CONCAENTS:
Enclosed are:
5 copies PCN
2 full size sets of drawings
3 11 x 17 sets of drawings
Thank you
Mary Smith
KASmith MaryUransmittal.docx
SEPIA(S)
FOR YOUR USE ❑

201 60 633
UF WA9OG COURTESY Office Use Only:
COPYCorps action ID no.
DWQ project no.
Form 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:
Q Section 404 Permit ❑ Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 12 or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps?
❑ Yes Q No
1d. Type(s) of approval sought from the DWQ (check all that apply):
Q 401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
1e. Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification:
❑X Yes ❑ No
For the record only for Corps Permit:
❑ Yes Q 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
or in -lieu fee program.
❑ Yes Q No
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1h
below.
❑ Yes Q No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes Q No
2. Project Information
2a. Name of project:
Brintle's Travel Plaza
2b. County:
Surry
2c. Nearest municipality / town:
Mt. Airy
2d. Subdivision name:
N/A
2e. NCDOT only, T I.P. or state project no:
N/A Ju
3. Owner Information
3a. Name(s) on Recorded Deed:
Brintle Enterprises, Inc., Tab Plaza Property, LLC ,� FRR
3b. Deed Book and Page No.
DB 1359, pg. 924, DB 1419, pg. 681 F
3c. Responsible Party (for LLC if
applicable):
Thomas A. Brintle
3d. Street address:
125 Plaza Lane
3e. City, state, zip:
Mt. Airy, NC 27030
3f. Telephone no.:
336-970-9324
3g. Fax no.:
3h. Email address:
[e-mail]
Page 1 of 10
PCN Form — Version 1.4 January 2009

4. Applicant Information (if different from owner)
4a. Applicant is: ❑ Agent ❑ Other, specify:
4b. Name:
4c. Business name
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name:
Norris Z. Clayton
5b. Business name
(if applicable):
Hugh Creed Associates, Inc., P.A.
5c. Street address:
1306 W. Wendover Ave.
5d. City, state, zip:
Greensboro, NC 27408
5e. Telephone no.:
336-275-9826
5f. Fax no.:
336-275-3379
5g. Email address:
[e-mail]
Page 2 of 10

B. Project Information and Prior Project History
1. Property Identification
1 a. Property identification no. (tax PIN or parcel ID):
408000604744, 408004509335
1 b. Site coordinates (in decimal degrees):
Latitude: 36.487 Longitude: -80.749
1 c. Property size:
25.21 acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
Little Fisher River
2b. Water Quality Classification of nearest receiving water:
C
2c. River basin:
Yadkin Pee -Dee
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 site is an existing truck stop with restaurant, fueling, truck wash, and motel facilities. These facilities are served by an on-site sewage treatment
plant on the north side of the property. The plan is to abandon this treatment plant and tie into city sewer that is being extended to the
site along W.
Pine St The new outfall will cross Little Fisher River to be into the city's sewer line
3b. List the total estimated acreage of all existing wetlands on the property: 0.1
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: 610
3d. Explain the purpose of the proposed project:
Run a sewer outfall from an existing on-site treatment plan that is to be abandoned and tie into the new sewer extension from Mt. Airy's sewer.
3e. Describe the overall project in detail, including the type of equipment to be used:
Outfall line will be cleared using chainsaws, and dozers. Sewer line will be installed using a trackhoe. Erosion control measures will be installed.
4. Jurisdictional Determinations
4a Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property / ❑ Yes ❑ No ❑X Unknown
project(including all prior hases in thepast? Comments:
4b. If the Corps made the jurisdictional determination, what type
of determination was made? ❑ Preliminary ❑ Final
4c. If yes, who delineated the jurisdictional areas? ultant 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
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past? ❑Yes ❑ No © Unknown
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project? ❑ Yes ❑X No
6b. If yes, explain.
Page 3 of 10
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
❑ Wetlands Q 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.
Wetland impact Type of impact Type of wetland Forested Type of jurisdiction
2f.
Area of
number Corps (404,10) or
er
Permanent(PTor
impact
ma neat DWQ (401, other)
(acres)
W1 -
Choose one
Choose one
YeslNo
_
W2 -
Choose one
Choose one
Yes/No
_
W3 -
Choose one
Choose one
Yes/No
-
W4 -
Choose one
Choose one
Yes/No
-
W5 -
Choose one
Choose one
Yes/No
-
WS -
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.
Stream impact Type of impact Stream name Perennial (PER) or Type of Average
3g.
Impact
number intermittent (INT)? jurisdiction stream
Permanent (P) or
len th
9
Temporary (T) width
(linear
(feet)
feet)
S1 T Type In (Other) Little Fisher River PER Corps 20
S2 P Type In (Other) Little Fisher River PER Corps 20
40
10
S3 - Choose one
S4 - Choose one
S5 - Choose one
S6 - Choose one
3h. Total stream and tributary impacts
50
3i Comments:
Sanitary sewer crossing
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 Men water impacts below.
4a.
Open water
4b.
Name of waterbody
4c.
4d.
4e.
impact number
Permanent (P) or
(if applicable)
Type of impact
Waterbody
Area of impact (acres)
Temporary
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
type
below If any impacts require mitigation, then ou MUST fill out Section D of this form.
01 -
6a. Project is in which protected basin?
Choose one
Choose
6b. 6c. 6d. 6e. 6f.
Buffer Impact Reason for impact Stream name Buffer Zone 1
number —
02 -
Permanent (P) or
Choose one
Choose
Temporary T
03 -
(square
Choose one
Choose
feet
04 -
Yes/No
Choose one
Choose
4f. Total open water impacts
4g. Comments:
S. Pond or Lake Construction
If pond or lake construction proposed, the 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?
[] Yes E] 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 ou 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.
Buffer Impact Reason for impact Stream name Buffer Zone 1
number —
6g
Zone 2
Permanent (P) or
mitigation impact
impact
Temporary T
required? (square
(square
61 -
feet
feet
Yes/No
B2 -
Yes/No
B3
Yes/No
B4 -
Yes/No
65
Yes/No
66
Yes/No
6h. Total Buffer Impacts:
6i. Comments:
Page 5 of 10

D. Impact Justification and Mitigation
I. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Options of running the sewer line on the east side of the river were looked into, but with existing buildings, parking lots, underground tanks and lines,
and elevation changes, it was deemed prohibitive. Therefore the outfall would need to cross the river to the undeveloped side, and run to the city's line
NC
in Hwy 89. The outfall was designed to cross the river at right angle to minimize disturbance.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
The line crosses the river and it banks at a right angle. A temporary damming of the river with diversion piping through the construction site
is
proposed with installation immediately before crossing, and removal immediately after crossing.
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 ❑X 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
project?
❑ Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
Type: Choose one Quantity:
3b. Credits Purchased (attach receipt and letter) Type: Choose one Quantity:
Type: Choose one Quantity:
3c. Comments:
4. Complete if Making a Payment to In -lieu Fee Program
4a. Approval letter from in -lieu fee program is attached. ❑ Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: Choose one
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
S. 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 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
buffer mitigation? ❑ Yes ❑X No
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
, ''L__ __L__
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
1a. Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules? Yes Q No
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
❑ Yes ❑ No
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
o�
2b Does this project require a Stormwater Management Plan? ❑ Yes Q
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
Project does not increase site built upon area
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 government's iurisdiction iS this nrniacl9
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
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
o 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
I. Environmental Documentation (DWQ Requirement)
la. Does the project involve an expenditure of public (federal/state/local) funds or the
use of public (federal/state) land? ❑ Yes ❑X No
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, El Yes ❑X 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
additional development, which could impact nearby downstream water quality? [O]Yes Q No
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 meth�oyds and disposition (non -discharge or discharge) of wastewater generated from
the The existing treosed atment atmentt plant on-site teor `is being available
6y thishprolecf and the Ise er is being run to the Mt Airy sewer system
Page 9 of 10
PCN Form — Version 1.4 January 2009

6. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
habitat? ❑ Yes ❑X No
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts? ©Yes ❑ No
50. If yes, indicate the USFWS Field Office you have contacted. _
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
USFWS - Raleigh Webeite - www.fws.gov/raleigh/species/cntyllsUsurry.himl
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?❑ Yes
® No
NOAA Esse6b. What ntial Fish Habitat GIata sources did S Data ou ndetermine to Fish
ventory- M dAtlantic website - www.habital.noaa our site would gov/p otect onteifhlneMnv index himl
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur In or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
status (e.g., National Historic Trust designation or properties significant in Yes ® No
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
NC State Historic Preservation Office Wabsite - www.gis.nodcr.gov/hpoweb/default.htm
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA -designated 100 -year floodplain?
® Yes ❑ No
8b. If yes, explain how project meets FEMA requirements:
After the stream crossing the disturbance within the flood plain will be reconstructed to the original stream bank contours.
80. What source(s) did you use to make the floodplain determination?
FIRM Map 3711408000J 08/18/2009
Thomas A. Brintle
Applicant/Agent's Printed Name
� T
vw
Applicant/Agent's Signature
(Agent's signature Is valid only it an authorization
Page 10 of 10
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