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COPY
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Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Page 1 of 12
PCN Form — Version 1.3 December 10, 2008 Version
Pre -Construction Notification (PCN) Form
A. Applicant Information
1.
Processing
1 a.
Type(s) of approval sought from the®
Corps:
Section 404 Permit Section 10 Permit
❑
0 9 0,8
1b. Specify Nationwide Permit (NWP) number: NWP 12 or General Permit (GP) number:
1c.
Has the NWP or GP number been verified by the Corps?
❑ Yes
® No
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
1 e.
Is this notification solely for the record
because written approval is not required?
For the record only for DWQ 401
Certification:
® Yes ❑ No
For the record only for Corps Permit:
❑ Yes ® 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
® No
1 g.
Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
❑ Yes
® No
1 h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes
® No
2.
Project Information
2a.
Name of project:
Pecan Lane Sanitary Sewer Improvements
2b. County:
Forsyth nn
Iff
i"19
2c.
Nearest municipality / town:
Kernersville
IN
I
2d.
Subdivision name:
2e.
NCDOT only, T.I.P. or state
project no:
3.
Owner Information
FF R HIILNGJ
3a.
Name(s) on Recorded Deed:
Davis, William S.
3b.
Deed Book and Page No.
1213/125
3c.
Responsible Party (for LLC if
applicable):
3d.
Street address:
1509 Pecan Lane
3e.
City, state, zip:
Kernersville, NC 27284
3f.
Telephone no.:
3g.
Fax no.:
3h.
Email address:
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: Developer
4b. Name:
Mr. Joe Jaynes
4c. Business name
(if applicable):
Cracker Barrel Old Country Store, Inc.
4d. Street address:
307 Hartman Drive
4e. City, state, zip:
Lebanon, TN 37087
4f. Telephone no.:
615.444.5533
4g. Fax no.:
615.235.4056
4h. Email address:
[e-mail]
5. Agent/Consultant Information (if applicable)
5a. Name:
Bradley S. Luckey
5b. Business name
(if applicable):
Pilot Environmental Inc.
5c. Street address:
PO Box 128
5d. City, state, zip:
Kernersville, NC 27285
5e. Telephone no.:
336.708.4997
5f. Fax no.:
5g. Email address:
[e-mail]
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):
Site Parcel -6874-09-6817. Easement obtained by
applicant is project area.
1 b. Site coordinates (in decimal degrees):
Latitude: 36.08031 Longitude: - 80.11446
(DD.DDDDDD) (-DD.DDDDDD)
1 c. Property size:
Linear acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
Fiddlers Creek
proposed project:
2b. Water Quality Classification of nearest receiving water:
Class C
2c. River basin:
Yadkin
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 sewer line crossing contains undeveloped wooded land. Structures are not located on the site. The site is located in
a residential area of Kernersville
3b. List the total estimated acreage of all existing wetlands on the property:
0 ac
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
—100LF
3d.. Explain the purpose of the proposed project:
The purpose of the proposed project is provide sanitary sewer services to occupants and future occupants in the vicnity of
Pecan Lane, including the applicant.
3e. Describe the overall project in detail, including the type of equipment to be used:
The overall project consists of santitary sewer services for occurpants and future occupants in the vicinity of Pecan Lane.
The proposed sewer line alignment connects to an existing sewer line northeast of the proposed crossing. The remainder
of the proposed sewer line will be located within the right-of-way of Pecan Lane. To facilitate installation of the sewer line
and sewer line crossing, clearing and stumping/grubbing will be necessary in the vicinity of the stream crossing. The
remainder of the line will not requrie clearing. Graders, haulers, excavators and other heavy equipment will be used
during sewer line installation.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
❑ Yes ® No ❑ Unknown
project (including all prior phases) in the past?
Comments:
4b. If the Corps made the jurisdictional determination, what type
El Preliminary El Final
of determination was made?
4c. If yes, who delineated the jurisdictional areas?
Agency/Consultant Company: Pilot Enviromental, Inc.
Name (if known): Bradley Luckey/Michael Brame
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifications been requested or obtained for
❑ Yes ® No ❑ Unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instructions.
Page 3 of 12
PCN Form — Version 1.3 December 10, 2008 Version

6. Future Project Plans
6a. Is this a phased project? ❑ Yes ® No
6b. If yes, explain.
The project is not part of a phased project. Impacts to streams/wetlands, outside of those proposed in this appilication,
are not anticipated as a result of the proposed project.
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
❑ Yes
❑ Corps
❑ No
❑ DWQ
W2 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W3 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W4 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W5 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W6 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
2g. Total wetland impacts
2h. Comments: Wetland impacts are not being proposed.
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)
S1 ❑ POT
Excavation/Pump
Around
Fiddlers Creek
® PER
❑ INT
® Corps
❑ DWQ
4
40
S2 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S3 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S4 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S5 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S6 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
3h. Total stream and tributary impacts
40
3i. Comments: The proposed sewer line crossing will temporarily impact 40 linear feet of stream by open cut excvation/backfill
and pump around. Areas of temporary impact will be restored to similar pre -construction conditions.
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
02 ❑P
03 ❑P
04 ❑P❑T
4E Total open water impacts
4g. Comments: Open water impacts are not being proposed.
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
K Total
5g. Comments: Construction of ponds/lakes are not being proposed.
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 El Tar -Pamlico ®Other: Yadkin
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?
B1 ❑P❑T
El Yes
❑ No
B2 ❑P❑T
El Yes
❑ No
B3 ❑P❑T
F1 Yes
❑ No
6h. Total buffer impacts
6i. Comments: The site is located within the Yadkin Pee -Dee River Basin. Buffer impacts are not being proposed.
Page 6 of 12
PCN Form —Version 1.3 December 10, 2008 Version

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.
The sewer line crossing has been designed in an area that is relatively straight and with little meanders, given the location of
existing sewer line for connection. Additionally, the sewer line has been designed to cross Fiddlers Creek in an area with no
wetland impact. The project will not result in net loss of Waters or aqutic habitat. Additionally, the sewer line's permament
maintainence easement has been designed to the narrowest width possible.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
The clearing limits will be staked and silt fence will be used. A temporary coffer dam will be installed upgradient of the
proposed crossing location. During excavation/backfill, water will be pumped around the construction footprint. Appropriate
stream bank protection will be provided in the channel during construction. All excavated material will be immediately removed
from the stream crossing area and temporarily stock piled to be used for back fill. The top one foot of stream bed excavation
will be stockpiled seperately and used as the last one foot of stream bed backfill. Upon completion of the sewer line
installation, the temporary sand bag coffer dams will be removed and flow will be restored. Following construction, disturbed
banks will be restored to similair pre -construction conditions, matted and seeded/live staked.
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?
❑ Yes ® No
2b. If yes, mitigation is required by (check all that apply):
❑ DWQ ❑ Corps
2c. If yes, which mitigation option will be used for this
project?
❑ Mitigation bank
❑Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter)
Type
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:
❑ 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
buffer mitigation?
❑ Yes ® 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.
Zone
6c.
Reason for impact
6d.
Total impact
(square feet)
Multiplier
6e.
Required mitigation
(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.
❑ Yes ❑ No
Comments:
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
%
2b. Does this project require a Stormwater Management Plan?
❑ Yes ® No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why: imprevious surfaces are not being
generated by the proposed project
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
❑ Certified Local Government
2e. Who will be responsible for the review of the Stormwater Management Plan?
❑ DWQ Stormwater Program
❑ DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
❑ Phase II
3b. Which of the following locally -implemented stormwater management programs
❑ NSW
❑ USMP
apply (check all that apply):
❑ Water Supply Watershed
❑ Other:
3c. Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
4. DWQ Stormwater Program Review
❑ Coastal counties
❑ HQW
4a. Which of the following state -implemented stormwater management programs apply
❑ ORW
(check all that apply):
❑ Session Law 2006-246
❑ Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements?
❑ Yes ❑ No
5b. Have all of the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 9 of 12
PCN Form — Version 1.3 December 10, 2008 Version

F.
Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
1 a.
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)?
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
❑ Yes
® No
letter.)
Comments: A NEPA or SEPA is not required as part of this project.
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.
We are not aware of additional development that will impact nearby downstream water quality.
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.
Wastewater will not be generated by the proposed project.
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?
E] Raleigh
5c. If yes, indicate the USFWS Field Office you have contacted.
❑ Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
PEI consulted the Natural Heritage database for the Kernersville, NC Quadrangle, the quadrangle that contains the site.
Northern long eared bat is identified as a federally listed threatened species. Hibernacula is not located with one quarter
mile of the project area. Additionally, the project area is not known to occur within 150 feet of known summer roosting
trees. Trees that afford suitable summer roosting habitiat are located within the proposed project area. The applicant will
rely on the 4(d) rule for tree removal activites assoicated with the NLEB. Other federally protected species were not
identified on the quadrangle that contains the site.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
❑ Yes ® No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
Based on our knowledge of the site, the site is not located in or near an area designated as essential fish habitat. Best
management practices and the use of temporary sediment and erosion control devices will prevent sediment from entering
down -gradient waterbodies which may contain fish.
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?
PEI consulted the NCSHPO historic properties website to determine if protected cultural resources are located within the
proposed project area (Drawing 6). The map does not depict eligible for listing cultural recourse within 800 feet of the
project area.
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: Manholes in the 100 year floodplain are above 100 year flood
elevations.
8c. What source(s) did you use to make the floodplain determination? 3710687400J, 3710686400J 371068500J
Digitally signed by Bradley S. Luckey
DN: cn=Bradley S. Luckey, o=Pilot
Bradley S. Luckey
Environmental, Inc., ou,
.�yrF ..
email=[e-mail], c=US
9/19/16
,i Date: 2016.09.1910:38:14 -04'00'
Date
Applicant/Agent's Si nature
Applicant/Agent's Printed Name
Page 11 of 12
PCN Form — Version 1.3 December 10, 2008 Version

(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

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project: CRACKER BARREL - PECAN LANE CD's
scale: V=40'(H); 1"=4'(V) sheet 3 Of 5
description: 404 IMPACT EXHIBITS
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VERTICAL SEPARATION
BETWEEN STREAM INVERT TO
CROWN OF PROPOSED 8"
DIP SANITARY SEWER LINE
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900
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TYPE 'B" MANH
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VENT LEV: 915
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KERNE S MILL -FIDDLERS
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601 N. TRADE STREET, SUITE 200
C0002 st i m m e l i WINSTON SALEM, NC 27101
E www.stimmelpa.com 336.723.1067
LANDSCAPE ARCHITECTURE CIVIL ENGINEERING LAND PLANNING
EXHIBIT 4
date: 9/14/2016 job #: 12-133
project: CRACKER BARREL - PECAN LANE CD's
scale: NTS sheet 4 of 5
description: 404 IMPACT EXHIBITS
PUMP -AROUND DETAILS
PROPOSED 8"
10' TEMP. 15' PERM. SS 15' TEMP.
IMPACT DUE TO MAINTENANCE IMPACT DUE TO
PUMP AROUND CORRIDOR PUMP AROUND
PLAN VIEW
IMPERVIOUS
SHEETING
BASE FLOW + 1 FOOT
WORK AREA (2 FOOT MINIMUM)
—i 1=iii —i 1
SECTION A—A
CROSS—SECTION
OF SANDBAG DIKE
TEMPORARY BYPASS
PUMP -AROUND
SCALE: NTS
01

V -01I st i mme 1601 N. TRADE STREET, SUITE 200
WINSTON-SALEM, NC 27101
www.stimmelpa.com 336.723.1067
LANDSCAPE ARCHITECTURE CIVIL ENGINEERING LAND PLANNING
EXHIBIT 5
date: 9/14/2016 job #: 12-133
project: CRACKER BARREL - PECAN LANE CD's
scale: V=4011-1); 1"=4'(V) sheet 5 of 5
description: 404 NPACT EXHIBITS
PUMP -AROUND DETAILS
STRAW BALE
DIKE OR BERM
1.5 FT
MIN.
6 FT MIN.
6 FT
MIN.
A
3 FT
B
Ivv vv
A
PLAN VIEW
1.5 FT
�— FLOW
i
FILTER
FABRIC
4 TO 6
INCH RIPRAP
SECTION A—A
2 TO 3 FT
REBAR OR
STAKES FOR
STRAW BALES
6 IN.
3 FT
—
—_
MIN.
_—
4 INCH
_—
MINIMUM
DEPTH
SECTION B—B
TEMPORARY
PUMP
BASIN
DETAIL
SCALE: NTS

AGENT AUTHORIZATION
This form authorizes PEI to act as our agent in stream/wetland matters including U.S. Army
Corps of Engineers and North Carolina Division of Water Resources field verification and
permitting.
Property Address: 11a -4 At (d UAiDM `/Oss fPdt�
F'v-'.sV h 6Pa^¢�/_
W -A946 - 'OJe 'nf /VL
Owner Information:
Address: bAckV 41%Pet (DQ t �Df P
n a 'AR e
k "a Aon r rV 7 pg 7
Telephone Number: tP 15- �Iy �_ 9,513 3
Fax Number.. � 15— 5�1 3J — T pJ h
E-mail Address:
rM
iDp 1aVAeS tiP/ (' ('GiGkt?r b4troe )I e V/),-)
JURISDICTIONAL DETERMINATION REQUEST
SECTION D -PROPERTY OWNER CERTIFICATION
I, the undersigned, a duly authorized owner of records of the property/properties identified
herein, do authorize representatives of the Wilmington District, U.S. Army Corps of Engineers
(Corps) to enter upon the property herein described for the purpose of conducting on-site
investigations and issuing a determination associated with Waters of the U.S. subject to Federal
jurisdiction under Section 404 of the Clean Water Act and/or Section 10 of the Rivers and
Harbors Act of 1899.
Clop J -61 Y/ LVS A r lod vt PF /I b �7 a4
Property Own a pri t) Date
Prope

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Q� Drawing 1 USGS Topographic Map
N
USGS Topographic Map Proposed Sewer Improvements
Kernersville, NC Quadrangle Pecan Lane
9� Kernersville, North Carolina
a SCALE: 1" = 2,000' PEI Project 1323.1
"-V 06014
`f o ,

Drawing 3
USFWS NWI
Wetlands Mapper
NOT TO SCALE
�NVIIto
�
C.. Z
PEI All
LEGEND
NWI Map
Proposed Sewer Improvements
Pecan Lane
Kernersville, North Carolina
PEI Project 1323.1
Corridor
Centerline
NWI Designations
Freshwater Emergent
_
Freshwater ForestediShrub
Estuarine and marine Deepwater
E stuanne and Marine
Freshwater Pond
Lake
-'
Riven:ne
Cather
NWI Map
Proposed Sewer Improvements
Pecan Lane
Kernersville, North Carolina
PEI Project 1323.1

Drawing 6
N.C. SHPO HPO GIS Website
Not to Scale
N.C. SHPO HPO GIS Map
N
Proposed Sewer Improvements
Pecan Lane
Kernersville, North Carolina
PEI Project 1323.1

WETLAND DETERMINATION DATA FORM — Eastern Mountains and Piedmont
Project/Site: Pecan Lane Sewer Extension City/County: Kern ersville/Forsyth Sampling Date: 9.7.16
Applicant/Owner: State: North Carolina Sampling Point: DP -1
Investigator(s): Luckey/Brame Section, Township, Range:
Landform (hillslope, terrace, etc.) Floodplain Local relief (concave, convex, none):
Slope (%): 1 Lat: Long: Datum:
Soil Map Unit Name: Hatboro Loam NWI Classification:
Are climatic / hydrologic conditions on the site typical for this time of year? Yes X No (If no, explain in Remarks.)
Are Vegetation , Soil , or Hydrology _significantly disturbed? Are "Normal Circumstances" present? Yes X
Are Vegetation _,Soil or Hydrology naturally problematic? (If needed, explain any answers in Remarks.)
No
SUMMARY OF FINDINGS — Attach site map Showing sampiing point locations, transects, important features, etc.
Hydrophytic Vegetation Present? Yes X No
Is the Sampled Area
Hydric Soil Present? Yes No X within a Wetland? Yes No X
Wetland Hydrology Present? Yes No X
Remarks
HYDROLOGY
Wetland Hydrology Indicators:
Secondary Indicators (minimum of two required)
Primary Indicators (minimum of one is required; check all that apply)
Surface Soil Cracks (136)
Surface Water (Al)
_ True Aquatic Plants (1314)
Sparsely Vegetated Concave Surface (B8)
High Water Table (A2)
_ Hydrogen Sulfide Odor (Cl)
Drainage Patterns (610)
Saturation (A3)
_ Oxidized Rhizospheres on Living Roots (C3)
Moss Trim Lines (616)
Water Marks (B1)
_ Presence of Reduced Iron (C4) _
Dry -Season Water Table (C2)
Sediment Deposits (132)
_ Recent Iron Reduction in Tilled Soils (C6) _
Crayfish Burrows (C8)
Drift Deposits (B3)
Thin Muck Surface (C7) _
Saturation Visible on Aerial Imagery (C9)
Algal Mat or Crust (134)
_ Other (Explain in Remarks) _
Stunted or Stressed Plants (D1)
Iron Deposits (65)
_
Geomorphic Position (D2)
_
Inundation Visible on Aerial Imagery (67)
_
Shallow Aquitard (D3)
_
_ Water -Stained Leaves (139)
Microtopographic Relief (D4)
Aquatic Fauna (B13)
_
FAC -Neutral Test (D5)
Field Observations:
Surface Water Present? Yes No X
Depth (inches):
Water Table Present? Yes No X
Depth (inches): >12"
Wetland Hydrology Present? Yes No X
Saturation Present? Yes No X
Depth (inches): >12"
_
(includes capillary fringe)
Describe Recorded Data (stream gauge, monitoring well, aerial photos, previous inspections), if available:
Remarks:

VEGETATION (Four Strata) - Use scientific names of plants.
Sampling Point DP -1
Remarks: (Include photo numbers here or on a separate sheet.)
Dominance Test worksheet:
Absolute
Dominant
Indicator
Tree Stratum
(Plot size: 30' )
% Cover
Species?
Status
Number of Dominant Species
1.
Lirodendron tulipifera
30
Y
FAC
That Are OBL, FACW, or FAC: 6 (A)
2.
Acer saccharum
15
Y
FACU
3.
Carya illinoinensis
5
N
FACU
Total Number of Dominant
Species Across All Strata: 10 (B)
4
5.
Percent of Dominant Species
6
That Are OBL, FACW, or FAC: 60 (A/B)
7.
8.
Prevalence Index worksheet:
50
= Total Cover
Total % Cover of: Multiply by:
OBL species x 1 =
Sapling/Shrub Stratum
(Plot size: 30' )
FACW species X2=
1.
Oxydendrum arboreum
5
Y
UPL
FAC species X3=
2.
Juniperus virginiana
5
Y
FACU
FACU species X4=
3.
Acer rubrum
5
Y
FAC
UPL species X5=
4. Prunus serotina 5 Y FAC
5
Column Totals: (A) (B)
6.
Prevalence Index = B/A =
7.
8.
Hydrophytic Vegetation Indicators:
g.
_ 1 - Rapid Test for Hydrophytic Vegetation
10.
X 2 - Dominance Test is > 50%
_ 3 - Prevalence Test is 5 3.0'
20 = Total Cover
- Morphological Adaptations' (Provide supporting
Herb Stratum
(Plot size: 30' )
_4
data in Remarks or on a separate sheet)
1.
Toxicodendron radicans
10
Y
FAC
2.
Lonicera japonica
5
Y
FAC
_Problematic Hydrophytic Vegetation' (Explain)
3.
'Indicators of hydric soil and wetland hydrology must
4
be present, unless disturbed or problematic.
5.
Definitions of Vegetation Strata:
6.
7.
Tree - Woody plants, excluding vines, 3 in. (7.6 cm)
or more in diameter at breast height (DBH),
regardless of height.
8.
g
10.
11.
Sapling/Shrub - Woody plants, excluding vines, less
12.
than 3 in. DBH and greater than 3.28 ft (1 m) tall.
15
= Total Cover
Herb - All herbaceous (non -woody) plants, regardless
of size, and woody plants less than 3.28 ft tall.
Woody Vine Stratum
(Plot size: 30' )
1.
Vitus rotundifolia
10
Y
FAC
Woody vine - All woody vines greater than 3.28 ft in
2.
height.
3.
4'
Hydrophytic
5•
Vegetation
6.
Present? Yes X No
10
Remarks: (Include photo numbers here or on a separate sheet.)

SOIL
Sampling Point:
DP -1
Profile Description: (Describe to the depth needed to document the indicator or confirm the absence of indicators.)
Depth Matrix
Redox Features
(inches) Color (moist) %
Color (moist) % Type' Loc' Texture Remarks
0-18 10YR 6/5 100
SCL
'Type: C=Concentration, D=De letion, RM=Reduced Matrix, CS=Covered or Coated Sand Grains.
'Location: PL=Pore Lining, M=Matrix.
Hydric Soil Indicators:
Indicators for Problematic Hydric Soils':
Histosol (A1)
Dark Surface (S7)
2 cm Muck (A10) (MLRA 147)
Histic Epipedon (A2)
Polyvalue Below Surface (S8) (MLRA 147, 148)
Coast Prairie Redox (A16)
Black Histic (A3)
Thin Dark Suface (S9) (MLRA 147, 148)
(MLRA 147, 148)
Hydrogen Sulfide (A4)
Loamy Gleyed Matrix (F2)
Piedmont Floodplain Soils (F19)
Stratified Layers (A5)
Depleted Matrix (F3)
(MLRA 136, 147)
2 cm Muck (A10) (LRR N)
Redox Dark Surface (F6)
Red Parent Material (TF2)
Depleted Below Dark Surface (A11)
Depleted Dark Surface (F7)
Very Shallow Dark Surface (TF12)
Thick Dark Surface (Al2)
Redox Depressions (F8)
Other (Explain in Remarks)
Sandy Mucky Mineral (S1) (LRR N,
Iron Manganese Masses (F12) (LRR N,
MLRA 147, 148)
MLRA 136)
Sandy Gleyed Matrix (s4)
Umbric Surface (F13) (MLRA 136, 122)
3lndicators of Hydrophytic vegetation and
Sandy Redox (S5)
Piedmont Floodplain Soils (F19) (MLRA 148)
wetland hydrology must be present, unless
Stripped Matrix (S6)
disturbed or problematic.
Restrictive Layer (if observed):
Type:
Hydric Soil Present?
Yes No X
Depth (inches):
Remarks: