20081310 Ver 1_401 Application_20080808

G'CM3
Engineering, P.L.L.C.
Civil & Structural Design Services
3031 Spring Fancy Lane
Indian Trail, N.C. 28079
Phone [phone]
Fax [phone]
Email GCM3C)windstream.net.
August 19, 2008
NCDENR
Mooresville Regional Office
Attn: Mr. Barry Love
610 E. Center Ave. Suite 301
Mooresville, N.C. 28115
Re: Project ID No. Union 2009-008
White Oak Manor of Waxhaw Project
Waxhaw-Indian Trail Road (S.R.1008) Waxhaw, N.C.
Dear Mr. Love:
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As we discussed, the Owner is preparing to construct the referenced project in Waxhaw, N.C. In order to
construct the 100 bed nursing facility, the applicant will require a 24'-0" wide asphalt driveway and storm
drainage piping to be constructed at the existing unnamed drainage area on the western side of the
property.. Therefore, please find enclosed the following items for your review and comment:
1. Two (2) sets of the Civil design plans.
2. Two (2) copies of the Pre-Construction Notification (PCN) Application Form.
If you have any questions or require any additional information, do not hesitate to contact me.
Very truly yours,
GCM3 ENGINEERING, P.L.L.C.

G. Carter Moore III, P.E.
Enclosures
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08 1 3 1 0
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Office Use Only: Won V4sion N*h 08
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USACE Action ID No. DWQ No. _S: `:r g
(If any particular item is not applicable to this project, please enter "Not Applicable" `,"1 .)
L Processing C)
O
1. Check all of the approval(s) requested for this project: n,
? Section 404 Permit ? Riparian or Watershed li'ffer Rules
? Section 10 Permit ? Isolated Wetland PermitRrom DWQ
FA 401 Water Quality Certification ? Express 401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested: 1+
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
4. If payment into the North Carolina Ecosystem Enhancement Program (NCEEP) is proposed
for mitigation of impacts, attach the acceptance letter from NCEEP, complete section VIII,
and check here: ?
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
Environmental Concern (see the top of page 2 for further details), check here: D? v
II. Applicant Information
1. Owner/Applicant Information AUG 2 6 2008
Name: A UTO M N Cat- Polo 147i 011 UENR - WATER QUAUTY
Mailing Address: P, o . $ v x 4 ?+2 g -WETLANnsAign STORM R BRANCH
4OCKY MOLIA)T.
Telephone Number: 4 h 3 In 2 ?, 5 Fax Number: z S"Z - 4¢ 3 -- ::F o 0
E-mail Address _0 YC @ v o?. ,? c e v p, c o r*)"-
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent has signatory authority for the owner/applicant.)
Name: A) JA-
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Page 5 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and MRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: &) H 1745 4OAr- IqAA)09- OF QAPN 40
2. T.I.P. Project Number or State Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN): 05,11 01) (A,
4. Location
County: U n)i 0 A) Nearest Town: WA X 14 ,4 cd
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.): 6JAx H AW - .1 v p 4 ,,1
7-fLA1 e P-.9 JSe_ load) Z.rOO L? ERS7 o1= N.C. #W V, 16
t ?r???;,la wra_ P-1-4-)' Sc t-e i i 0- Sov t? -G-d-c 04C rvc ,1 . -
5. Site coordinates (Lat/Long or decimal degrees): 34 - fr z b ",L , ? 0 C y Y I - ? t " w
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Property size (acres):
7`1,0.5 Acre)
7. Name of nearest receiving body of water: R Ly yH E C R-C'ex
8. River Basin: (A ,4 L) P3.4
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: () ov z, 0 & S r i t?_

d Vk, 1p.+-/

Page 6 of 12
10. Describe the overall project in detail, including the type of equipment to be used: Co .d-i TR yc. P 't
nr- )oo t3ed A)urr'?N.4 FaC??•?V _ Mec 4-h- z-ed t_4J,*.* cC -/ io-
11. Explain the purpose of the proposed work v ; .? f/ A
a j,Q 4-&- If rog- °l w E N O-C r`o ( -tx ;,I I s.),a. .4r t; f,q z rJ? y
d?lti erw ri^?f' Uf f/ re .
W. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules. X1 J A
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application.
A) t)
VL Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. Each impact must be
listed separately in the tables below (e.g., culvert installation should be listed separately from
riprap dissipater pads). Be sure to indicate if an impact is temporary. All proposed impacts,
permanent and temporary, must be listed, and must be labeled and clearly identifiable on an
accompanying site plan. All wetlands and waters, and all streams (intermittent and perennial)
should be shown on a delineation map, whether or not impacts are proposed to these systems.
Wetland and stream evaluation and delineation forms should be included as appropriate.
Photographs may be included at the applicant's discretion. If this proposed impact is strictly for
wetland or stream mitigation, list and describe the impact in Section VIII below. If additional
space is needed for listing or description, please attach a separate sheet.
1. Provide a written description of the proposed impacts: C'?? ?ts?ru c f• 't of
ct 2 f lisp 1"t If Wry ?c to -tai e+n d -fw o f 2-J
?. Ci rr. t_ ? t r' ? L ?' c-l?'4 i .tea. S ? P '? L -'' i.w ?k • .S `?: oc Q
hzol.
Page 7 of 12
2. Individually list wetland impacts. Types of impacts include, but are not limited to
mechanized clearing, grading, fill, excavation, flooding, ditching/drainage, etc. For dams,
separately list impacts due to both structure and flooding.
Wetland Impact
Site Number

(indicate on map)
Type of Impact Type of Wetland
(e.g., forested, marsh,

herbaceous, bog, etc.) Located within

100-year
Floodplain
es/no) Distance to

Nearest
Stream
(linear feet) Area of

Impact
(acres)
CREAK ClZV?sik 1 p
k'?.4Aws F 1 i :.. l)o 25"ou (`1, l

Total Wetland Impact (acres)
3. List the total acreage (estimated) of all existing wetlands on the property: 0, 0O
4. Individually list all intermittent and perennial stream impacts. Be sure to identify temporary
impacts. Stream impacts include, but are not limited to placement of fill or culverts, dam
construction, flooding, relocation, stabilization activities (e.g., cement walls, rip-rap, crib
walls, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is proposed,
plans and profiles showing the linear footprint for both the original and relocated streams
must be included. To calculate acreage, multiply length X width, then divide by 43.560.
Stream Impact
Number
(indicate on ma)
Stream Name
Type of Impact Perennial or
Intermittent? Average
Stream Width
Before Impact Impact
Length
(linear feet) Area of
Impact
(acres)
CF- C? c (4646 UrNAMtb Fiu /?f<<?.?. ?+ fn' 11 0, a
?Iv.ccM-enf

Total Stream Impact (by length and acreage)
5. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.). Open water impacts include, but are not limited to
fill, excavation, dredging, flooding, drainage, bulkheads, etc.
Open Water Impact
Site Number
(indicate on ma) Name of Waterbody

(if applicable)
Type of Impact Type of Waterbody
(lake, pond, estuary, sound, bay,
ocean, etc.) Area of
Impact
(acres)
A/ A-

Total Open Water Impact (acres)
Page 8 of 12
6. List the cumulative impact to all Waters of the U. S. resultin from the ro ject:
Stream Impact acres): D, ' v
Wetland Impact acres : 0.00
Open Water Impact (acres : -1.00
Total Impact to Waters of the U. S. (acres) 0
LT-otal Stream Impact (linear feet): f 1 t
7. Isolated Waters
Do any isolated waters exist on the property? ? Yes No
Describe all impacts to isolated waters, and include the type of water (wetland or stream) and
the size of the proposed impact (acres or linear feet). Please note that this section only
applies to, waters that have specifically been determined to be isolated by the USAGE.
8. Pond Creation
if construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Current land use in the vicinity of the pond:
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be/followed during construction to reduce impacts.
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CCIA.Pt'rti.c?,O.u 4N GLfry>J ,ajn3ihccCL.^t,0...
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Page 9 of 12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on January 15, 2002, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCEEP concurrence shall be placed on hold as incomplete.
An applicant may also choose to review the current guidelines for stream restoration in DWQ's
Draft Technical Guide for Stream Work in North Carolina, available at
htti)://h2o.enr.!,tate.nc.us/ncwetiands/strrngide.html.
Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Al 2. Mitigation may also be made by payment into the North Carolina Ecosystem Enhancement
Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at
[phone] to determine availability, and written approval from the NCEEP indicating
that they are will to accept payment for the mitigation must be attached to this form. For
additional information regarding the application process for the NCEEP, check the NCEEP
website at httmdh2o.enr.state.nc.usl%vrp/index.htm. If use of the NCEEP is proposed, please
check the appropriate box on page three and provide the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
IX.
X.
Environmental Documentation (required by DWQ)
1. Does the project involve an expenditure of public (federal/state/local) funds or the use of
public (federal/state) land? Yes ? No
2. If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes El No ?
3. If yes, has the document review been finalized by the State Clearinghouse? If so, please
attach a copy of the NEPA or SEPA final approval letter. Yes ? No ?
Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 02B .0243 (Catawba) 15A NCAC
2B .0250 (Randleman Rules and Water Supply Buffer Requirements), or other (please
identify V Yes ? No M
2. If "yes", identify the square feet and acreage of impact to each zone of the riparian buffers.
If buffer mitigation is required calculate the required amount of mitigation by applying the
buffer multipliers.
Zone* , ,? Im +. I Multiplier I IL Required I
2
Total
* zone 1 extends out 30 feet perpendim
additional 20 feet from the edge of "Lone 1.
3 (2 for Catawba)
1.5
the top of the near bank of channel; 7bne 2 extends an
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e.,
Donation of Property, Riparian Buffer Restoration / Enhancement, or Payment into the
Riparian Buffer Restoration Fund). Please attach all appropriate information as identified
within 15A NCAC 2B.0242 or.0244, or.0260. ,?/1.
Page 11 of 12

XL Stormwater (required by DWQ)
Describe impervious acreage (existing and proposed) versus total acreage on the site. Discuss
stormwater controls proposed in order to protect surface waters and wetlands downstream from
the property. If percent impervious surface exceeds 201/o, please provide calculations
demonstrating total proposed impervious level. Fx!s i; w i • KPz e V),0 L1J r4 rL0_= a • 0c
ro d3 ,na P,^d?p z arLa !?/? Zoo ?a,Ft//,cdo o ,?u?t.tlls,I
7 ?i
^ n..?1 d. f y- r w i l / G o t+-? r d Me, d u.? , ,rt a ,,i o .., ,n c .t ./.
? h.1 a- wa..rf sfor„twttev, fs h4 • ?--
XIL Sewage Disposal (required by DWQ)
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.
LJ4.S*eW4-Ti•?' ,;/I Ze, -/rP4.Jtct /„t Uni«,?. C?4,rt?4 ?U/)/it
Udr?-_, s
XHL Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application? Yes ? No
XIV. Cumulative Impacts (required by DWQ)
Will this project (based on past and reasonably anticipated future impacts) result in additional
development which could impact nearby downstream water quality? Yes ? No Q
If yes, please submit a qualitative or quantitative cumulative impact analysis in accordance with
the most recent North Carolina Division of Water Quality policy posted on our website at
bttp://lit©.car..itate.nc.us/ncwetlands. If no, please provide a short narrative description:
XV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
Cons4 sc Lc JV i c ? ?? bt?i w i a ?a/! 2 OOB-
Page 12 of 12
(Agent's signature is valid only if an authorization letter from the applicant is provided.)