20170637 Ver 1_SR 1526A, Application_20170523

STA`I'E C�F NORTH CAROLINA
DE�'AI�TNI�N�T OF T'RA.NSPO�TATI�N
R()l' CO�YER
Gc�vQuvprz
�ay 2�, 2�17
Mr. Eric Alsmey�r
T.�. S. AA,immy Ca�-ps of �n�i��eers
Raleigh Re�ulatory Field Oftice
3331 �-Ieritage Trade Dz-�ve, Suite 105
�J4'�lce �'orest, I�C 2�5$7
S�bj ect: Natioa�wide Permit # 1�
SR 1�2bA, Sampson Road
Watauga County, Norkh �arolula
Projecf Num�er: i1C.095ll0 {DWR P�rmit Fee: �57D)
Dear Mr. Alszneyer:
JA�S H� TROG�?�ON, I�I
S�c�ra.x�
The NC Departinent of T�anspoartation is scheduled to grade, drai�, base a.nc� p�ve SR
1 S26A, Sa�npson Road in Watauga Calznty. �'otal project �ength is 2.1 inil�s. Irr��e�vious
�ur�face area will increase by about 0.51 acres. This �roject w�l� r�quire ihe a�eplaceanent
or ins�al�aticsn af r�au�tiple wet pipes, underdrain, instream riprap dissipaters ���.�e tc� slope}
ana wetland cu#�drainage as shown belc�w:
�t�eae�l 1��� a���a
�t����am E�i�tin� �'��E �rop���d I2��arap 'i'ata�
�F��rnk��r Size �Fi e 5ize Im �ets De�ateren� Im acts
23+SG11�.'- �Ione 42_' FiII & � � �2
Uilderdrain
26T65' 4G'x 24'" 48'� 3b" �0 2�1 32
34+6(1 �t. - - 27' Gabion 1� 37
35+Q31°� 39'x 24" yU0'x 36" 1 Q� 0 71
35+SQ s-�. _ 45' Gabian 1(} 55
42+�81 35'a: 40" 55'� 42" l(➢ �0 50
65+60 lt. - U s�o e eut i 4 10 24
65+g 1� 31'x 18" 51 '?� 24" 10 1� 40
76+961 ��'x ] 8" 46'�: 24" 1Q 2Q 3�
� 03+51 �°`' � _ 1(} 0 1 Q
Perrnanent Sireambed Fil� = 219' Barnk �t�bilization — 72'
T'em ora Dewaterin =1(10' Toia[ Pro'ect I�n a�ts = 39r'
,��nrrf,,,�: t�+r�X� ss:
NC i)rPA1tTMENT OP "d"RANSP(�RT.47'1C�N
pN1SlON 1 ]
801 STATGSV1l.LE RCIAD
N�RTH WILKF,SBORi]. h�C 28659
T�le�}aorre: (336) 667-911 1
Faz: (336) 667-�1�49
Castomer Sers�ice: 1-$77-368-4968
FYebsare: v�n�nv.ncdot.trov
Lacatrort:
A�DI�SS ?
CFTY, N� ZI['

Mr. Eric Alsrneysr
SR 1526A, Sampsan Road
May 23, 2017
� If buried, i:hese pipe slopes woEtid e�ceed 6% grade. As a result, we are not propasing
to bury these pipes since any fish passage would be very u.nlikely and head cuts would be
prabable. A riprap pad will be placed in the streambed at the outlet of these pipes to
reduce scour. These pipes will lilcely be perei�ed after instalIation.
2 This strEam begans at the existing toe of fill. We will be insialling ►xnderdrain hexe
befare filling but there does nat appear to be a realistic way to dewater during
eonstruction.
3 Pipe length is excessive here due to the heavy skew af the stream crossin�.
4 There is an old driveway at 103+51 lt. that appears to have hit a spring when constructed
years ago. Water emanating from the ground has created a small wetland over time
which drains to our ditch line and t�iraugh o�.r cross line pipe. We are proposing to install
underdrain at this location to try to sta.bilize our cut slope and instali a box and new pipe
system. Stream features begin at the existing pipe outlet at statian 104+00 rt. We will
install a 10' long in-st�eaxn dissipater there due to slope. All of the impacts on the cut
side were called wetland. Tatal wetland cut/drainage = D.12 acres. There doesn't appear
to be a realistic way to dewater this axea during construction.
The pipes at stations 26+65 axzd 35+03 carry UT #2 to Joes Creek (class: C; Trout) in the
Yadkin River Basin. The remaining wet cross line pipes carry different UTs to Jaes
Creek. The existing large pipes carrying J�es Creek near stations 53+00, 61+fl0 and
108+50 will be retained.
The areplacement of the cvet cross line pipes will require temporaxy dewatering. An
impervious sandbag dike will be constructed upstreanr� of the existing pipes to creat� a
srnall pool. Clea� water will tezx�porarily be pumped arouud ti�e cvnstruction areas and
will be discharged downstream. Any dirty water located inside of the construciion areas
will be pumped into a silt bag if necessary. ()nce the new pipes are in place, the
impervious dikes will be removed and precanstruction streambed elevations will be
restored_
This project was reviewed fox the presence of threataned and enda.ngered species in the
field and I have also included a query of the NCNIIP data.base. Based an tl�e project area
mapped with my request, the database search indicates that there are no records for rare
species, important natural cammunities, or canservation/managed areas within the
proposed project boundary. There will be approximately 4.4 acres af tree curiing at tbe
project Iocation due to cut and fll wark. The NLEB is listed as a pxotected species in this
county but the project daes not fall within 0.25 miles of any red H[JC identified in the
SLOPES spelled out in the Nationwide Permit Regional Conditions. We do not
anticipate any ixrzpact to any other fed�rally listed species.
Cultuxal resaurce coinpliance work has been completed. No archaeological resources or
historic properties will be affected i�y this project {s�e attached).

Mr. Eric Alsmeyer
SR I52bA, Sampson Road
May 23, 2017
The praject izx�pacts are not significant in nature and should nat remove ar degrade
existing water qualzry uses. Stormwater will be rauted through grass or rock lined
ditch�s, depending on the ditch line siape, Dissipater pads will be installed at pipe outlets
as appropriate. Pipe sizes used will be the minimum necessary to create a safe roadway.
By utilizing the erasion cantarol measures outlined in the attachtnents to this application,
downstream water quality stan.dards will be protected. Overall water quality in the area
will be improved by paving the ABC travel lanes. All appropriate BMPs will be used
during constructiQn.
Attached is a Preconstruction Notification Form, plan sheets with proposed erosion
control measures, a marked county �nap and a marked tapography rxiap.
By copy of this electranic letter, it is requested thai Mrs. Marla Chambers with the North
Carolina Wildlife Resources Commission comment directly to yau concerning the �#04
Nationwide Permit application with a copy sent to rne. Please note that a trout buffer
variance will be requested for land disturl�ance from stations 25+SQ — 2b+27 (rt.), 26+84
—28+67 (l�.}, 35+G8 — 36+10 (rt.}, 40+26 — 41+33 (lt.), 48+97 — 50+40 (lt.j, 59+92 —
60+5{} (lt.) ar�d 61�-67 — 6�+19 (lt.}.
By capy of this electronic letter, it xs requested that the Divisian of Water Resources,
401JWetlands Unit, issue the appropriate pernnit for construction nf this project. It is
requested that any comments related to the 401 certification be electronically forwarded
directly to me witli a copy sent to the US Army Corps of Engineers.
We woutd like to begin. corLstructifln as soan a� possible, If further information is
required, please �et me know. Your early review and consideration will be appreciated.
Sincerely,
/�u�,�"
Heath Slaughter
Division En.viro�vnental Officer
Enclosures
cc: Marla Chambers, I�CWRC
Amy Chapman, Divisior� of Water Resources
Dave Wanucha, Divisian o� Water Resources
Matt Gantt, PE, Division of Land Resources
Doug Eller, District Engineer
Kevin Whittington, County Maintenance Engineer
Zack Sauther, Roadsxde Environmental Field Operations Technician

Office Use Only:
Corps ac#ion id no.
DWQ project no. _ _
Form Version 1.3 Dec 1 Q 2Q08
Pre-Construction Notifcation C Form
A. A licant Infa�rmation
1. Processing
1 a. Type(s) af appro�al sought from the
Corps: �$ection 404 Permit ❑ Sectian 1 Q Permit
1b. Specify Nationwide Permit (NINP) number: 14 or General Permit (GI') number:
1 c. Has the NWP or GP number been r►erified by the Corps? ❑ Yes � No
1 d. Type(s} o# approVal soughf from the DWQ {check all that apply):
� 401 Water Quality Certi�ication — Regular ❑ Non-404 Jurisdictional G�neral Permit
❑ 40'I Water Quafity Certification — Express ❑ Ripar�an Buffer Authorization
1 e. ls this notification solely far the record For the record only for DWQ 401 For the record oNy for Corps Permit:
beeause written approval is not required? Certification:
❑ Yes � No ❑ Yes � N�
1f. Is payment into a mitigatian bar�k or in-lieu fee program praposed for mitigation � Yes ❑ No
of impacts? If sa, attach the acceptance letter from mitigation bank or in-lieu
fee program.
1g. Is the project lacated '+n any af NCs kwenty coastal counties. If yes, answer 1 h ❑ Yes � IVo
betow.
1 h. Is the project Eocated withirt a NC DCM Area of Environmental Goncem (AEC)? ❑ Yes � No
2. Project Infarmation
2a. Name of project: SR 9526A, Sampson Road
2b. Couniy: Watauga
2c. Nearest municipality 1 tawn: A�ro
2d. Subdivision name:
2e. NCDOTonIy,T_I.P.orstate 13C.�95�10
prajecfi no:
3. Owner Informatiore
3a. fUame(s) on Recorded Qeed: NCp07
3b. Deed Book and Page No.
3c. Respansible Party (for LLG if
appiicable):
3d. S#reet address: 801 StatasviiEe Road
3e. City, state, zip: Nar#h Wilkesbora, NC 28659
3f. Telephone no.: 336-903-920�
3g. Fax no,: 336-667-4549
3h. �mai1 address: [e-mail]
Page 1 of 10
PCN Form — Ve�-sior� 1.3 December 10, 20q8 Version

4. Applicant Information (if d1f%rent from owner)
4a Applicant is: ❑ Ageni ❑ �ther, specify:
4b. Name:
4c. Business name
(if appficable):
4d. 5treet address:
4e. eity, state, zip:
4f_ Telephone na.:
4g. Fax na.:
4h. Email addr�ss:
5. AgentlConsultani Informatior� (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5ti. City, state, zip;
5e. Telephone no.:
5F. Fax no.:
5g. Err�ail address:
Page 2 af 10
PCIV Form — Version 'i.3 December 1p, 20Q8 Version

B. Project Information and Prior Project Histary
1. Property Iden�i�ication
1a. Property identification no. (tax PIN or parcel ID}_
1 b. Site coardinates (ir� decimal degrees): Latitude: 3�.15308 Langitude: - 81.59706
{DD. DDDdpD} (-DD_ bDDf7O�)
1 c. Property size: 12.7 acres
2. Surface Waters
2a. Name af n�arest body of water (stream, ri�er, etc.) ta UTs ta .�oes Creek
proposed project:
2b. Water Quality Classificatinn of nearest receivi�g water: C; Trout
2c. River basin: Yadkin
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the �icinity of the project at the time of this
applicatian:
Unpa�ed secondary road in a rural area..
3b. �ist the total es#imated acreage af all existing wetlar�ds on the property:
0.12 acres
3c. List the tatal estirnated linear fee# of all existing streams (intermittent and perennial) on the praperty;
500 linear feet
3d. Explain the purpose of the proposed project:
Secondary Road Improuement
3e. �escribe the o�erall project in detail, including the type af equipment to be used:
See attached cover [etter.
4. Jurisdictional Determinaiions
4a. Have jur�sdictianal wetland or stream de#erminatipns by the
Corps or State been requested or ob#ained fo? this prnperty 1 ��res � No ❑ Unknown
project (including aii prior phases) ir� the pasi.
Comments:
4b. If the Corps made the jurisdic#ional determination, what type
of determination was made? ❑ Preliminary ❑ Finaf
4c. If yes, who d�linea#ed ihe jurisdictional areas? Agency/Consultant Company:
Name (if known): Other:
4d. If yes, list the dates of the Carps jurisdictiona� deterrninations ar S#ate d�terminatia�s and attach docurnentation.
5. Project History
5a. Have permits or certifications been requested or abtained for � Yes � No ❑ Unknown
this project (incfuding al! prior phases) in the past?
5b. If yes, explain in detaiE according to "help file" instructions.
6. Future Project Plans
Ba. Is this a phased prnject? ❑ Yes � No
6b_ If yes, explain.
Page 3 of 1 a
PCN Form — Version 1.3 December 10, 2008 Version

C. P�ropased lmpacts In�entvry
1. Irxtpacts Summary
1 a. Which sections were completed below for your project {check ail that apply):
� Wetlands � Streams - tributaries ❑ BufFers
� �pen Waters ❑ Pand Construction
2. Wetland Impacts
If there are wetiand impacts prapased on the site, then camplete this question for eacf� wetland area impacted.
2a. 2b. 2c. 2d. 2e. 2f.
Wetland impact Type of jurisdiction
number — Type of impact Type of wetland �orested (Corps - 404, 10 Area of impact
Perm�nent (P) pr (if known) DWQ — non-404, other) (acres)
iem ora
W1 � P❑ T Cut/underdrain seep ❑ Yes � Corps d.12
� No � DWQ
W2 ❑ P❑ T ❑ Yes ❑ Corps
❑ hio ❑ DWQ
W3 ❑ P[] T ❑ Y'es ❑ Corps
❑ No [] DWQ
W4 ❑ P❑ T ❑ Yes ❑ Carps
❑ No ❑ DWQ
w� � P 0.� [] Yes ❑ Corps
❑ No ❑ DWQ
W6 ❑ P[,] T ❑ Yes ❑ Corps
❑ No ❑ DWQ
2g, Total wetfand impacts p, � 2
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temparary impacts) proposed on the siie, then camplete this
question for all stream sites impacted.
3a_ 3b. 3c. 3d. 3e. 3f, 3g.
Stream impact �`ype of impact Stream name Perennial Type ofjurisdiction Average Impact
number - PER ar
( ) {Corps - 4Q4, 7 0 str�am length
Permanent (P) or intermittent pWqr _ non_q.p,� width (linear
Temporary {T) {INT)? ot#�er} (feet) feet)
S1 � P❑ T Fil! & underdrain uT #1 to ,ioes � PER � Corps � 42
Creek ❑ 11VT � DWQ
�� ��, �� Piping, Riprap and Ui #2 to Jves � PER � Corps � 3�
dewatering Creefc ❑ !NT � DWQ
S3 � P� T Gabion and UT #2 to Joes � PER � Corps 2 ��
ctewatering Creek ❑ INT � DWQ
S4 � P � T Piping & Rip�ap UT #2 to Joes � PER � Corps 2 .��
diss�pater pad Creek ❑ INT � DWQ
SS � P� T Gabion and U7' #2 to Joes I� PER � Corps � 5�
dewatering Creek ❑ INT � DWQ
S6 ❑ P[] T �'�P�ng, Riprap and UT #3 to Joes � PER � Corps 2 5d
dewatering Creek ❑ INT � DWQ
3h. Total stream and tributary impacts
3i. Camments:
Page 4 of 10
PCN Form — Versian 1.3 Decemher 10, 2008 Version

C. Propos� Impacts Inventory
1 _ Impacts Summary
1 a. Which sections were completed below for your projeci (check all that apply):
� Wetlands � Sireams - tribukaries ❑ Buffers
❑ Open Waters ❑ Pond Constructinn
2. We�and Impacts
If there are wetlanc! irnpacts pra�ased on the site, then complete this question for each wet�and area impacted.
2a. 2b. Zc. 2d. 2e. 2f.
Wetland impact Type of jurlsdiction
number — Type of irt�pact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) pr (if known) DWQ — non-4d4, other) (acres)
Tem ora
W1 � P � T Cutlunderdrain seep ❑ Yes � Corps � 12
� No � DWQ
W2 ❑ P❑ T ❑ Yes ❑ Corps
❑ No ❑ DWQ
�� ❑ R � �. � Yes ❑ Corps
❑ No ❑ DWQ
W4 ❑ P � T ❑�eS ❑ Corps
❑ No ❑ DWQ
W� ❑ p � T ❑ Yes ❑ Corps
❑ No ❑ DWQ
W6 � p � -� ❑ Yes ❑ Gorps
❑ �Jd ❑ DWQ
2g. Total wetland impacts p.��
2h. Gomments:
3. Stream Impacts
tf there are perennial or intermittent stream impacts (incEuding temporary impacts) propased an the site, ther� complete this
ques#+on for all stream sites impac#ed.
3a. 3b. 3c. 3d. 3e. 3f. 3g.
Stream impact Type of impact Strear� name Perennial Type af jurisdiction A�erage �mp��
number - (PER) or (Corps - 404, 10 stream length
Permaneni (P) or intermittent DWQ — non-4Q4, wldth {linear
Temporary (T) (�N�i? other) (feet) feet}
�� � p�.� Riprap and UT #4 ta Jaes � P�R � COP�]5 2 24
dewatering Creek ❑ INT � DWQ
S2 � P� T piping, Riprap and L!T #4 to Joes � PER � Corps 2 ��
dewatering Creek ❑ INT � QWQ
S3 � P� T Pipe, riprap and UT #5 to Joes � PER � Corps � 30
dewatering Cre�k ❑ INT � DWQ
S4 � P❑ T Riprap dissipater UT #6 to Joes � PER � Corps 2 ��
pad Creek ❑ INT � DWQ
55 ❑ P[] T ❑ PER ❑ Carps .
❑ INT ❑ DWQ
SB ❑ P[] T ❑ PER ❑ Corps
❑ INT ❑ DWGt
3h. Total stream and tribuqry impacts 397'
3i. Comments: Streami�ed fifl = 219', Dewatering = 1 DQ', Bank Stabilization = 72'
Page 4 of 1(}
PCN Farm — Version 1.3 December 1 Q, 2008 Version

�l. Qpen Water Impacts
lf there are proposed impacts to lakes, pands, estuaries, tributaries, s�unds, #he Atlantic Ocean, or any other open water o#
the U.S. then individually list all open water impacts belaw.
4a. 4b. 4c. 4d. 4e.
Open wafier Name of waterbody
impact number — (if appiicabl�) iype of im�aet Waterbody type Area of impaet {acres)
Permanent {P) or
Tem ora
O1 ❑P❑T
�2 ❑P❑T
03 ❑P�T
04 ❑P❑T
4f. Tatal open water impacts
4g. Comr�ents:
5. Pond or Lake Construction
If �nd or lake construction ro osed, then corr� lete the chart below.
5a. 5b. 5c. 5d. 5e.
We#fantE Impacts (acres) Stream Impacts (feet) Upiand
Pond I❑ Proposed use or purpose (acres)
number af pond
Flaoded Filied Exca�ated Flooded Filled Excavated Fiooded
P1
P2
Sf. Total
5g. Comments: N!A
5h, is a dam high hazard permi# requErecE?
❑ Yes � IVo If yes, permit ID na:
5i. Expected pond surface area (acres}:
5j. Size of pond watershed (acres}:
5k. Me#hod of construc#ion:
6. Buffer Impacts (far DWQ}
If project will impac# a protected riparian buffer, then complete the chart below. If yes, then individually list all fouff�r impacts
helow. If an im acts re uire miti atio�, then ou MUST fili vut 5ection D of this form.
6a.
� Neuse ❑ Tar-Pamlico ❑ Other:
Project is in which protected basin? ❑ Catawba ❑ Randleman
6b. 6c. 6d_ 6e_ 6f. 6g.
Buffer impact
number— Reason BufFer Zone 1 impac# Zone 2 impact
Permanent (P) or far Stream nam� mitigation (square feet} (square feet}
iem ara im act re uired?
B1 ❑POT ❑Yes
❑ No
82 ❑P❑T ❑Yes
❑ No
63 ❑ P [] T ❑ Y�s
❑ No
Gh. Tatal buffer i�pacts
6i. Comments:
Page S of 10
PCN Form — Version 1.3 �ecember 9 a, 2008 Version

D. Impact Justification and Mifigation
1. Avoidance and Minimization
1a. Specifcaliy describe measures taken ta avoid or minimize the �roposed impacts in designing project.
Proposed pipe lengths are the shortest needed ta adequately cans#ruct the roadway. Road is shifted away from streams
where possible.
1 b. S�ec�cally describe rrfeasures taken to avoid ar minimize the propased impacts thirough canstructian techniques.
All appropriate BMPs will be used during construction.
2. Cvmpensatory Mitigation for Impac#s to Waters of the U.S. ar Waters of the State
2a. Does the project require Gompensatory Mitigation far � Yes ❑ No
impacts to Waters af the� L1.S. or Waters of the State7
2b. If yes, mitigation is required by {check ali that apply): ❑ DWQ � Corps
� Mitigation bank
2c. If yes, which mitigation optinn wif! be used for this
project? ❑ Payment tn in-lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Using a MitFgation Bank
3a. Name af Mitigation Bank:
3b. Credits Purchased (attach receipt aRd letter) Type Quantity
3c. Comments:
4. Cornplete if Making a Payment to In-lieu Fee Program
4a. Approva! letter from in-lieu fee program is attached. � Yes
4b. Stream mitigation requesied: 438 Gnear feet
4c. ff using stream mitigation, stream temperature: ❑ warm ❑ coai �cold
4d. Buffer mitigation requested {DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. fVon-riparian wetland mitigation �equested: acres
4g. Coastal (tidal) wetland �nitigation requested: acres
�4h. Comments:
5. Complete if Using a Pern�ittee Responsible Mitigation Plan
5a. If using a permittee responsibfe mifigation plan, pro�ide a descriptian of the proposed mitigation pEan.
Page6o#��
PChJ Forrr� — Versifln 1_3 December 10, 2008 Version

6. Buffer Mitigation (Stafe Regula#ed Riparian Buffer Rules} — required by DWQ
6a. Will ti7e project result in an impact within a protecied riparian bufFer that requires ❑ Yes � No
6uffer mitigation?
6b. If yes, then identify the square feet of irnpact to each zane of the riparian buffef that requires mitigation. Caleulate the
amaunt of mitigation required.
6c. 6d. 6e.
�on� Reason fot irrtpact 7otal impac# Multipiier Required mitigatian
(square fes#) (sguare feet)
�one 1 3 (2 for Catawba)
Zone � �.�
6f. Total huffer mitigation required:
6g_ If buffer mitigatian is required, discuss what type of mitiga#ion is proposed (e.g., paymer�t to private mitigatian bank,
permittee responsible riparian buffer resto�tion, payment inta an appravecf in-lieu fee #und).
6h. Comments:
Page i of 1 D
PC�! Form — Versian 'f.3 �ecember 1(7, 2008 Version

E. Stormm�rater M�nagement and DifFuse Flow pian (required by DWQ}
7. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to pratected riparian buffers identified � Yes � No
within one of the fVC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan includ�ed"? If no, explain why.
Commer�#s: ❑ Yes ❑ No
2. Stormwa#er Mana ement Plan
2a. What is the overall percent imperviousness of khis project? 40 %
2b. Daes this project require a Stormwater Manag�ment Plan? � Yes ❑ No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES rec#uire a Stormwater Management Plan, then prQ�ide a brief, naRative description of the plan:
See cover letter.
❑ Certified Local Go�ernment
2e. Who will be responsible for the review of the Starmwa#er Managerr►ent Plan? ❑ DWQ Stormwater Program
� DWQ 401 Uni#
3. Certified Lflcal GovernrrEent Stormwater Review
3a. In which local go�emmenYs jurisdiction is this project?
❑ Phase Il
3b. Which of #he follQwing lacally-�mplemented stormwater management prograrras � NSW
apply (check all that apply}: ❑ USMP
❑ Wat�r Supply Watershed
❑ Other:
�c. Has the appraved Stormwater Managemen# Pian with prQof of approval been ❑ Yes ❑ No
attached?
4. DWQ Starmwater Pro ram Review
❑ Coastai counties
❑ HQW
�4a. Which of the following state-implemen#ed stormwa#er management programs appfy � pRW
(check all tha# apply): ❑ 5ession Law 2006-24fi
❑ Other:
4b. Has th�; appro�ed Starmwater Management Plan with praof of appra�al been
attached? ❑ YE5 ❑ No
5. DWQ 40'I llnit 5tormwater Review
5a. Does the Siormwaier Management Plan m�et the apprapriate requirements? �] Yes ❑ No
5b. Ha�e alf of the 401 Unit submittal requirements been met? ❑ Yes ❑ No
Page S of 1 a
PCN Form — Version 1.3 December 10, 2008 Version

F. 5upplementary Information
1. Environmentai Documentation (DWQ Requirement)
1a. Does the proj�ct involve an expenditure of public (federal/statellocal) funds or ihe � Yes ❑ No
use of public (federallstate) land?
1 b. If you answered �yes' to the above, does the praject require preparation of an
environmental docur�en# pursuant to the requirements of the �lai�onaf or State ❑ Yes � Na
(North Carolina) Environmental Policy Act (NEPAlSEPA}?
1c. If you answered "yes" #a the aborre, has the document review been fnaGzed by the
State Clearing House? {If so, a#tach a capy of #he NEPA ar 5EPA final approvaf
letter.) ❑ Yes ❑ No
Gamments:
2, Violations (DWQ RequiremeRt)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .Q50Q), isolated
Wet�and Ruies (i 5A NCAC 2H .130D), DWQ Surtace Water nr Wetland Standards, ❑ Yes � No
or Riparian Bt�ffer Rules (15A �1CAC 26 .020U)?
2b. Is this ar� after-the-fact permit app6ea#ion? ❑ Yes � No
2c. If you answered "yes° to one or both of the abo�e questians, pro�ide an exp�anation of the �iolation(s):
3. CumulatiWe lmpacts (DWQ Reqe�irement�
3a. Will this projeet (based on past and reasonabiy anticipated future impacts) result in � Y�� � M4
additior�al developtxEeni, which could impact nearby dnwnstream water quaiity?
3b. !f yo�a answered "yes" to the above, submit a quaGtativ�e or quanti#ative cumulative impact anafysis in accordance with th�
most reeen# DWQ policy. If you answered "no," provide a short narrative descriptian.
4. Sewage Disposal (DWQ Requirement�
4a. Clearly detaif the uftimate ireatment rnethods and dispositian (non-discharge or discharge) of wastewater generated from
the proposed project, or availal7le eapacity af the subject facility.
NIA
I'age9Qf1Q
PCN Form — Version 1.3 December 10, 2fl08 Version

5. �ndangered Species and Designated Critical Halaita# {Corps Requir�ement)
5a. WiIE this project occu� in or near an area with #ederally protected species or � Y�$ ❑ Na
hahitat?
5b. Have you checked with the iJSFWS conceming �ndangered 5pecies Act � Yes � No
impacts?
❑ Raleigh
5c. If yes, indieate the USFWS Field Office you have cflntacted.
❑ Asheville
5d. What data sources did you use to determine whether your site would impact Endangered 5peeies or Designated Critical
Habitat?
NHP, GIS and visua{ observatio�. NLEB habitat is present but not near red HUC
6. �ssential Fish Ha6itai (Corps Requiremenfi)
6a. Will this project occur in or near an area designateti as essential fish habitat? ❑ Yes � No
6b. What data saurces did you use to determine whether your site would impact Essentia� Fish Habitat?
NOAA
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, fed�ral ar tribai
goverrtments have designated as ha�ing historic ar cultural preservation � Yes � No
status (e.g., �Vational His#oric Trust designation or properties signifrcant in
NorEh Caralina history and archaeology)?
7b. What data sources did you use to deterrnine whether your site wauld impact historic or archeological resources?
Project was reviewed by the IVCDOT HEU_ fdo surrreys were required.
8. Flood Zone Designatian (Corps RequErement)
8a. Will this prajec� accur in a��MA-designated 90�-year floodplain? ❑ Yes � No
8b. If yes, explain how project mee#s FEMA requir�ments:
8c. What source(s) did you use to ma�e the #laorfplain determinatian? nefloodmaps
r. Heath Slaughter p�� 1/�/�,�/i,i, � 5123117
�1 Gt�i'
Applicant/�ent's Printed Name ApplicantfAgen ' ignature Date
(Agen#'s nature is val3d only if an a arizatian letter from the applicant
is rovidesE.)
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PGN Form — Versian 1_3 December 1 d, 2DD8 Version