20161169 Ver 1_401 Application_20161116

Andrew Moore
North Carolina Department of Environmental and Natural Resources, Division of Water Resources
2090 U.S. 70 Highway
Swannanoa, NC 28778-8211
John Watts
220 Canoe Drive
Mill Spring, NC 28756
Mr. Brown,
You will find enclosed my request for authorization for to preform shoreline stabilization and
remediation on my property, Lot D-38, 220 Canoe Dr. Lake Adger Development, Mill Spring, NC.
Included are a check for evaluation fees, Corps Submittal Sheet, Pre -Construction Notification Form,
Jurisdictional Determination Form and several drawings showing location of property, location of work
on property and proposed methodology of construction.
The included Drawings are:
Drawing 1 of 6: Lake Adger Development in general, Polk County, NC. Untitled Placemark is 220 Canoe
Drive, Lot D-38
Drawing 2 of 6: Canoe Drive, Section D, Lake Adger Development, Untitled Placemark is 220 Canoe Dr.
Lot D-38
Drawing 3 of 6: 220 Canoe Drive, Lot D-38 on Canoe Drive and adjacent lots. rNOV282016D
Drawing 4 of 6: Location Key for proposed shoreline work
Drawing 5 of 6: Detail of position of hardscape on Lot d-38.
Drawing 6 of 6: Typical Cross Section of proposed stone work.
The reason for this request is over the past 16 years we have owned this lot changes in lake activities
since development have caused some loss of shoreline and subsequent environmental degradation. It is
recognized lost shoreline cannot be recouped but hoped with this work stopped and will assist in
returning this section to an eco -friendly stretch on the lake.
Like requests have been sent to:
Andrea Leslie — NC Wildlife Resources Commission
David Brown, PG - USACE Wilmington District - Asheville Regulatory Field Office
Cathy Ruth — Polk County Office of Planning and Zoning
RECEIVED
Division of Water Hewurm
� 01 1 2016
Water nuarty Realonal 0mroons
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I understand there is to be some communication among these offices as such requests are approved. I
appreciate a speedy resolution to this request so if I have not included all necessary please contact me
as to what else needs to be supplied.
Thank you for your assistance, time, and efforts in the resolution to my request.
John R. Watts
220 Canoe Drive
Mill Spring, NC 29756
828-894-5874
[e-mail]

Corps Submittal Cover Sheet
Please provide the following info:
1. Project Name
Watts Shoreline Remediation.
2. Name of Property Owner/Applicant: John R. and Mary Kay Watts
3. Name of Consultant/Agent: N/A
U
5.
'Agent authorization needs to be attached.
Related/previous Action ID number(s): N/A
Site Address: 220 Canoe Drive
6. Subdivision Name: Lake Adger Development - Lot D-38
7. City: Mill Spring
8.
a
County: Polk
Lat: 3 5: 33 & G 7
10. Quadrangle Name:
11. Waterway: Lake Adger
12. Watershed: Green River
Long: -82.21180 (Decimal Degrees Please)
13. Requested Action:
X Nationwide Permit # / 3
General Permit #
Jurisdictional Determination Request
Pre -Application Request
The following information will be completed by Corps office:
AID:
Prepare File Folder Assign number in ORM Begin Date
Authorization: Section 10 Section 404
Project Description/ Nature of Activity/ Project Purpose:
Site/Waters Name:
Keywords:

OI0j
� 11AT�q�G
I IL.J_w`7�
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Page 1 of 13
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 E] Section 10 Permit
1 b.
Specify Nationwide Permit (NWP) number: 13 or General Permit (GP) number: n/a
--Fn—yesI'll
1 c. Has the NWP or GP number been verified by the Corps?
1d. Type(s) of approval sought from the DWQ (check all that apply):
X 401 Water Quality Certification – Regular ❑ Non -404 Jurisdictional General Pe m'
❑ 401 Water Quality Certification – Express ❑ Riparian Buffer Authorization
o
�nl, lbu
LVIU
E -WA ERRE oURCES
1 $ BUFFER PERMITTIN
1 e.
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 ® 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:
220 Canoe Drive Shoreline Stabilization
2b.
County:
Polk
2c.
Nearest municipality / town:
Mill Spring
2d. Subdivision name:
Lake Adger Develpment
2e.
NCDOT only, T.I.P. or state
project no:
3.
Owner Information
3a.
Name(s) on Recorded Deed:
John R. and Mary Kay Watts
3b.
Deed Book and Page No.
Book 262 / Page 82
3c.
Responsible Party (for LLC if
applicable):
3d.
Street address:
220 Canoe Drive
3e.
City, state, zip:
Mill Spring, NC 28756
3f.
Telephone no.:
828-894-5874
3g.
Fax no.:
3h. Email address:
[e-mail]
Page 1 of 13
PCN Form – Version 1.3 December 10, 2008 Version

4. Applicant Information (if different from owner)
4a. Applicant is:
❑ Agent ❑ Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 13

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
P55-344
1 b. Site coordinates (in decimal degrees): - if you can't get
these, just include a very good vicinity map
Latitude: 35.33667 Longitude: -82.21180
(DD.DDDDDD) (-DD.DDDDDD)
1c. Property size:
1.54 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project:
Lake Adger (Green River)
2b. Water Quality Classification of nearest receiving water:
WS4V; CA
2c. River basin: map is available at
hftp://h2o.enr.state.nc.us/admin/maps/
Upper Broad (03050105)
Page 3 of 13
PCN Form — Version 1.3 December 10, 2008 Version

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 a developed rural residential tract of land. The general land use in the vicinity of the property is
developed rural residential, undeveloped forested land, and agricultural land.
3b. List the total estimated acreage of all existing wetlands on the property: Unknown
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
0 linear feet of shoreline on Lake Adger
3d. Explain the purpose of the proposed project
Protection of existing shoreline from further erosion. The property was purchased in Spring of 2000 and the
dock installed at that time. In the ensuing years the dock has twice had to be moved due to the erosive acting of
boat wakes. Approximately 2' of shoreline has been lost to erosion.
3e. Describe the overall project in detail, including the type of equipment to be used:
To apply in appropriate manner geotextile matting covered with filter gravel topped with Rip -Rap or as required
by covenant and restrictions approved textured stone. In order to preserve shoreline and existing flora a barge
will be used to transport materials to site and work will be done by hand. In addition to hardscape covering live
staking of appropriate type will be applied.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
El Yes ® No ❑ Unknown
project (including all prior phases) in the past?
Comments:
4b. If the Corps made the jurisdictional determination, what type
El 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.
Page 4 of 13

5. 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 projed?
❑ Yes X No
6b. If yes, explain.
Page 5 of 13

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
W1 ❑ P ❑ T
❑ Yes
❑ No
❑ Corps
❑ DWQ
W2 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W3 ❑ P ❑ T
❑ Yes
❑ No
❑ Corps
❑ 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:
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 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
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
3i. Comments:
Page 6 of 13

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 indivi ually 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
01 ®P [--IT
Lake Adger
Shoreline Stabilization
Lake
Less than .01 a
02 ®P❑T
03 ❑P❑T
04 ❑P❑T
4f. Total open water impacts
Less than .01 a
4g. Comments: Propose to apply 100+1- linear feet of hardscaping to ensure shoreline stabilization.
5. Pond or Lake Construction
If pond or lake construction proposed, then complete the chart below.
5a.
5b.
5c.
5d.
5e.
Wetland Impacts (acres)
Stream Impacts (feet)
Upland
Pond ID
Proposed use or purpose
(acres)
number
of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
5f. Total
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If any impacts require mitigation, then you MUST fill out Section D of this form.
6a.
❑ Neuse E] Tar -Pamlico E] Other:
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
impact
required.
B1 ❑P❑T
El Yes
❑ No
B2 ❑P❑T
El Yes
❑ No
❑Yes
B3 ❑P❑T
❑ No
6h. Total buffer impacts
6i. Comments:
Page 7 of 13

D.
Impact Justification and Mitigation
1.
Avoidance and Minimization
la. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project. All work will be
done from a barge. Rip -Rap and other materials will be delivered by barge and work done by hand to eliminate any
deleterious impact to shoreline.
b.
Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques. No
materials will be delivered by land, there will be no excavation, no work done from shore and the shoreline profile will not
be disturbed.
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
El Payment to in -lieu fee program
project?
❑ Permittee Responsible Mitigation
Page 8 of 13
PCN Form — Version 1.3 December 10, 2008 Version

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.
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? If yes, you will have to fill out this entire form — please
contact the State for more information.
❑ 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 9 of 13

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:
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 10 of 13
PCN Form — Version 1.3 December 10, 2008 Version

F.
Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
la. Does the project involve an expenditure of public (federal/state/local) funds or the
❑ Yes
❑ No
use of public (federal/state) land?
1 b.
If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State
❑ Yes
❑ No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c.
If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
❑ Yes
❑ No
letter.)
Comments:
2.
Violations (DWQ Requirement)
2a.
Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards,
❑ Yes
❑ No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b.
Is this an after -the -fact permit application?
❑ Yes
❑ No
2c.
If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3.
Cumulative Impacts (DWQ Requirement)
3a.
Will this project (based on past and reasonably anticipated future impacts) result in
❑ Yes
❑ No
additional development, which could impact nearby downstream water quality?
3b.
If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
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 11 of 13
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? Latest Corps Heritage database. USFWS map for northern long-eared bat (NLEB) consultation areas.
Property is not within consultation areas for NLEB, but within NLEB known range.
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?
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?
Latest Corps Heritage database.
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: By meeting or exceeding all required standards using best
management practices and procedures. The project involves no changes to natural and existing topography, does not
impede any runoff waters or change natural movement of waters, nor involves disturbance of land or buildings. A side
benefit expected is a reduction of silt caused by boat wakes settling on Brim and Bass beds in the adjacent shallow
waters and improving hatch.
8c. What source(s) did you use to make the floodplain determination? Latest on-line FIRM/FEMA North Carolina, Panel
0549, Map No. 3710054900J, September 3, 2008
Johh R. wa-L-tS
P k��
2 Nov. 2016
Applicant/Agents Printed Name
Date
Applicant/Agents Signature
(AgentsVsigre vadly if an authorization letter from the applicant
is
Page 12 of 13

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925'
PROPERTY LINE
22,5' ROAD EASEMENT
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911.6' ELEVATION
LIMIT OF WORK
EXISTING DOCK
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gag' LOCATION KEY FOR PROPOSED SHORELINE REMIDIATION
MARY KAY & JOHN WATTS
LOT D-38 220 CANOE DR.
WATTS 220 CANOE DR. I SCALE 1:100 I LOCATION KEY FOR SHORELINE WORK
DWG.NO. 4 OF 6 1 DATE: 19 OCTJ 6

Z
911.6 ELEVATION
LAKE ADGER
CONTINUE LIVE STAKING STONE WITH LIVE STAKING
TO PROPERTY LINE APPX. 50 TO NORTH
925 ELEVATION
WATTS 220 CANOE DR. 1 SCALE 1:25
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DOCK
STONE WITH LIVE STAKING
TO PROPERTY LINE APPX. 50'
POSITION OF STONE WORK FOR REMIDIATION I DWG.NO. 5 OF 6 1 DATE: 19 OCT.' 16

UNALTERED BANK
913' ELEVATION
TEXTURED STONE OVERTOPPING APRON
91 1.6' WATER LINE
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WATTS 220 CANOE DR. I NO SCALE I TYPICAL SHORELINE REBUILD CROSSECTION I DWG.NO. 6 OF 6 1 DATE: 19 OCT.'16

Jurisdictional Determination Request
US Army Corps
of Engineers
WNwom DOW
This form is intended for use by anyone requesting a jurisdictional determination (JD) from the
U.S. Army Corps of Engineers, Wilmington District (Corps). Please include all supporting
information, as described within each category, with your request. You may submit your request
to the appropriate Corps Field Office (or project manager, if known) via mail, electronic mail, or
facsimile. A current list of county assignments by Field Office and project manager can be
found on-line at: http://www.saw.usace.army.miI/Missions/Re uIatoryPermitProgram.aspx , by
telephoning: 910-2514633, or by contacting any of the field offices listed below:
ASHEVILLE REGULATORY FIELD OFFICE
US Army Corps of Engineers
151 Patton Avenue, Room 208
Asheville, North Carolina 28801-5006
General Number: [phone]
Fax Number: [phone]
RALEIGH REGULATORY FIELD OFFICE
US Army Corps of Engineers
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
General Number: [phone]
Fax Number: [phone]
WASHINGTON REGULATORY FIELD OFFICE
US Army Corps of Engineers
2407 West Fifth Street
Washington, North Carolina 27889
General Number: [phone]
Fax Number: [phone]
WILMINGTON REGULATORY FIELD OFFICE
US Army Corps of Engineers
69 Darlington Avenue
Wilmington, North Carolina 28403
General Number: 910-251-4633
Fax Number: [phone]
Version: December 2013 Page 1

Jurisdictional Determination Request
INSTRUCTIONS:
All requestors must complete Parts A, B, C, D, E and F.
NOTE TO CONSULTANTS AND AGENCIES: If you are requesting a JD on behalf of a
paying client or your agency, please note the specific submittal requirements in Part G.
NOTE ON PART D — PROPERTY OWNER AUTHORIZATION: Please be aware that all JD
requests must include the current property owner authorization for the Corps to proceed with the
determination, which may include inspection of the property when necessary. This form must be
signed by the current property owner to be considered a complete request.
NOTE ON PART D - NCDOT REOUESTS: Property owner authorization/notification for JD
requests associated with North Carolina Department of Transportation (NCDOT) projects will be
conducted according to the current NCDOT/USACE protocols.
NOTE TO USDA PROGRAM PARTICIPANTS: A Corps approved or preliminary JD may not
be valid for the wetland conservation provisions of the Food Security Act of 1985. If you or
your tenant are USDA Program participants, or anticipate participation in USDA programs, you
should also request a certified wetland determination from the local office of the Natural
Resources Conservation Service, prior to starting work.
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Jurisdictional Determination Request
A. PARCEL INFORMATION
Street Address: 220 Canoe Drive
City, State: Mill Spring, NC 28756
County: Folk
Directions: From Silver Creek Road tum right on to Lake Adger Parkway, drive 2 miles, find Canoe straight ahead,
220 Canoe Dr. on right 2/3's way down Canoe Dr.
Parcel Index Number(s) (PIN): F55-344
B. REQUESTOR INFORMATION
Name:
Mailing Address:
Telephone Number:
Electronic Mail Address t
Mary Kay and john R. Watts
220 Canoe Dr. Mill Spring, NC 28756
828-894-5874
[e-mail]
Select one:
❑✓ I am the current property owner.
❑ I am an Authorized Agent or Environmental Consultant
❑ Interested Buyer or Under Contract to Purchase
❑ Other, please explain.
C. PROPERTY OWNER INFORMATION
Name: Mary Kay and John R. Watts
Mailing Address: 220 Canoe Dr. Mill spring, NC 28756
Telephone Number: 828-894-5874
Electronic Mail Address3: i Y w 32-&:,,a jid s ri . G c .o&,
❑✓ Proof of Ownership Attached (e.g. a copy of Deed, County GIS/Parcel/Tax Record data)
l?/3 r ,ZG,Z /,24. Sz
1 If available
2 Must attach completed Agent Authorization Form
3 If available
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Jurisdictional Determination Request
D. PROPERTY OWNER CERTIFICATION
I, the undersigned, a duly authorized owner of record 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.
Property Owner (please print)
Owner Signature
JURISDICTIONAL DETERMINATION TYPE
Select One:
2N -at'. '14
Date
F] I am requesting that the Corps provide a preliminary JD for the property identified herein.
This request does include a delineation.
❑ I am requesting that the Corps provide a preliminary JD for the property identified herein.
This request does NOT include a delineation.
I am requesting that the Corps investigate the property/project area for the presence or
absence of WoUS5 and provide an approved JD for the property identified herein. This
request does NOT include a request for a verified delineation.
F] I am requesting that the Corps delineate the boundaries of all WoUS on a property/project
area and provide an approved JD (this may or may not include a survey plat).
F] I am requesting that the Corps evaluate and approve a delineation of WoUS (conducted
by others) on a property/project area and provide an approved JD (may or may not
include a survey plat).
4 For NCDOT requests following the current NCDOT/USACE protocols, skip to Part E.
5 Waters of the United States
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Jurisdictional Determination Request
F. ALL REQUESTS
❑✓ Map of Property or Project Area (attached). This Map must clearly depict the boundaries
of the area of evaluation.
❑ Size of Property or Project Area 1.54
acres
10 i I verify that the property (or project) boundaries have recently been surveyed and marked
by a licensed land surveyor OR are otherwise clearly marked or distinguishable.
G. JD REQUESTS FROM CONSULTANTS OR AGENCIES
(1) Preliminary JD Requests:
❑✓ Completed and signed Preliminary Jurisdictional Determination Form6.
❑ Project Coordinates: 35.33667 Latitude -82.21180 Longitude
Maps (no larger than 11x17) with Project Boundary Overlay:
0✓ Large and small scale maps that depict, at minimum: streets, intersections, towns
[✓ Aerial Photography of the project area
❑ USGS Topographic Map
❑ Soil Survey Map
❑ Other Maps, as appropriate (e.g. National Wetland Inventory Map, Proposed Site
Plan, previous delineation maps, LIDAR maps, FEMA floodplain maps)
6 See Appendix A of this Form. From Regulatory Guidance Letter No. 08-02, dated June 26, 2008
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Jurisdictional Determination Request
Delineation Information (when applicable):
Wetlands:
❑ Wetland Data Sheets$
Tributaries:
❑ USACE Assessment Forms
❑ Upland Data Sheets ❑ Other Assessment Forms
(when appropriate)
❑ Landscape Photos, if taken
❑ Field Sketch overlain on legible Map that includes:
■ All aquatic resources (for sites with multiple resources, label and identify)
■ Locations of wetland data points and/or tributary assessment reaches
■ Locations of photo stations
■ Approximate acreage/linear footage of aquatic resources
(2) Approved JDs including Verification of a Delineation:
❑ Project Coordinates:
Latitude Longitude
Maps (no larger than 11 x 17) with Project Boundary Overlay:
❑ Large and small scale maps that depict, at minimum: streets, intersections, towns
❑ Aerial Photography of the project area
❑ USGS Topographic Map
❑ Soil Survey Map
❑ Other Maps, as appropriate (e.g. National Wetland Inventory Map, Proposed Site Plan,
previous delineation maps)
1987 Manual Regional Supplements and Data forms can be found at:
http://www.usace.army.mil/Missions/CivilWorks/RegulatoryProgramandPermits/reg supp.aspx
Wetland and Stream Assessment Methodologies can be found at:
http://portal.ncdenr.org/c/document library/get file?uuid=76f3c58b-dab8-4960-ba43-45b7faf06f4c&groupld=38364 and,
http://www.saw.usace.army.mil/Portals/59/docs/regulatory/publicnotices/2013/NCSAM Draft User Manual 130318.pdf
8 Delineation information must include, at minimum, one wetland data sheet for each wetland/community type.
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Jurisdictional Determination Request
Delineation Information (when applicable):
Wetlands:
❑ Wetland Data Sheets9
Tributaries:
❑ USACE Assessment Forms
❑ Upland Data Sheets ❑ Other Assessment Forms
(when appropriate)
❑ Landscape Photos, if taken
❑ Field Sketch overlain on legible Map that includes:
• All aquatic resources (for sites with multiple resources, label and identify)
• Locations of wetland data points and/or tributary assessment reaches
• Locations of photo stations
• Approximate acreage/linear footage of aquatic resources
Supporting Jurisdictional Information (for Approved JDs only)
❑ Approved Jurisdictional Determination Form(s) (also known as "Rapanos
Form(s)")
❑ Map(s) depicting the potential (or lack of potential) hydrologic connection(s),
adjacency, etc. to navigable waters.
9 Delineation information must include, at minimum, one wetland data sheet for each wetland/community type.
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Jurisdictional Determination Request
I. REQUESTS FOR CORPS APPROVAL OF SURVEY PLAT
Prior to final production of a Plat, the Wilmington District recommends that the Land
Surveyor electronically submit a draft of a Survey Plat to the Corps project manager for
review.
Due to storage limitations of our administrative records, the Corps requires that all hard-
copy submittals include at least one original Plat (to scale) that is no larger than 11"x17"
(the use of match lines for larger tracts acceptable). Additional copies of a plat, including
those larger than 11 "x 17", may also be submitted for Corps signature as needed. The
Corps also accepts electronic submittals of plats, such as those transmitted as a Portable
Document Format (PDF) file. Upon verification, the Corps can electronically sign these
plats and return them via e-mail to the requestor.
(1) PLATS SUBMITTED FOR APPROVAL
Must be sealed and signed by a licensed professional land surveyor
1-1 Must be to scale (all maps must include both a graphic scale and a verbal scale)
F] Must be legible
Must include a North Arrow, Scale(s), Title, Property Information
F1Must include a legible WoUS Delineation Table of distances and bearings/metes
and bounds/GPS coordinates of all surveyed delineation points
nMust clearly depict surveyed property or project boundaries
F] Must clearly identify the known surveyed point(s) used as reference (e.g. property
corner, USGS monument)
F1When wetlands are depicted:
• Must include acreage (or square footage) of wetland polygons
• Must identify each wetland polygon using an alphanumeric system
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Jurisdictional Determination Request
1-1 When tributaries are depicted:
• Must include either a surveyed, approximate centerline of tributary with
approximate width of tributary OR surveyed Ordinary High Water Marks
(OHWM) of tributary
• Must identify each tributary using an alphanumeric system
• Must include linear footage of tributaries and calculated area (using approximate
widths or surveyed OHWM)
• Must include name of tributary (based on the most recent USGS topographic
map) or, when no USGS name exists, identify as "unnamed tributary"
F] all depicted WoUS (wetland polygons and tributary lines) must intersect or tie -to
surveyed project/property boundaries
F] Must include the location of wetland data points and/or tributary assessment
reaches
Must include, label accordingly, and depict acreage of all waters not currently
subject to the requirements of the CWA (e.g. "isolated wetlands", "non -
jurisdictional waters"). NOTE: An approved JD must be conducted in order to
make an official Corps determination that a particular waterbody or wetland is not
jurisdictional.
F] Must include and survey all existing conveyances (pipes, culverts, etc.) that
transport WoUS
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Jurisdictional Determination Request
(2) CERTIFICATION LANGUAGE
F]When the entire actual Jurisdictional Boundary is depicted:
include the following Corps Certification language:
"This certifies that this copy of this plat accurately depicts the boundary of the jurisdiction
of Section 404 of the Clean Water Act as determined by the undersigned on this date.
Unless there is a change in the law or our published regulations, the determination of
Section 404 jurisdiction may be relied upon for a period not to exceed five (5) years from
this date. The undersigned completed this determination utilizing the appropriate Regional
Supplement to the 1987 U.S. Army Corps of Engineers Wetlands Delineation Manual."
Regulatory Official:
Title:
Date:
USACE Action ID No.:
11 When uplands may be present within a depicted Jurisdictional Boundary:
include the following Corps Certification language:
"This certifies that this copy of this plat identifies all areas of waters of the United States
regulated pursuant to Section 404 of the Clean Water Act as determined by the
undersigned on this date. Unless there is change in the law or our published regulations,
this determination of Section 404 jurisdiction may be relied upon for a period not to exceed
five years from this date. The undersigned completed this determination utilizing the
appropriate Regional Supplement to the 1987 U.S. Army Corps of Engineers Wetlands
Delineation Manual."
Regulatory Oficial.
Title:
Date:
USA CE Action ID No.:
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Jurisdictional Determination Request
(3) GPS SURVEYS
For Surveys prepared using a Global Positioning System (GPS), the Survey must include
all of the above, as well as:
be at sub -meter accuracy at each survey point.
include an accuracy verification:
One or more known points (property corner, monument) shall be located with the
GPS and cross-referenced with the existing traditional property survey (metes and
bounds).
1-1 include a brief description of the GPS equipment utilized.
Version: December 2013 Page 11