20040297 Ver 1_401 Application_20040311

SOF W ATTR p Michael F. Easley, Governor
y William G. Ross Jr., Secretary
co
C North Carolina Department of Environment and Natural Resources
-i
Alan W. Klimek, P.E. Director
Coleen H. Sullins, Deputy Director
Division of Water Quality
March 11, 2004
MEMORANDUM e
N.C. Df:"' � - O EHN
TO: Darryl Lamb i MAR 16 2004 �
Winston- Regional Office !
fnSton-Sefem I
FROM: John Dorney �/ii ✓ gio-nl al Office
RE:
401 Certification Review
Please review the enclosed 401 Certification application by the date listed for the project. Please call me
if you or your staff have any questions, or need assistance in these reviews.
I. Adkins High School
040297.
Forsyth Central Office Received 2/27/04, clock expires 04/26/04
Need RO comments by 04/12/04.
The other enclosed material is for your general information and use as appropriate.
Enclosures
N. C. Division of Water Quality 127 Cardinal Drive Extension [phone] Customer Service
Wilmington Regional Office Wilmington, NC 28405 [phone] Fax [phone]
NODE NIR

Date:
Triage .Check List
a "-7 " ° Project Name: "'s A'� _U00
DWQ#:
County: C
To: ❑ ARO Mike Parker ❑ WaRO Tom Steffens
El FRO Ken Averitte ❑ WiRO Noelle Lutheran
❑ MRO Alan Johnson [Sa'WSRO Daryl Lamb
❑ RRO Steve Mitchell
From: G f-1)6�kZ'
Telephone : (919) 7 3 3 — c
The file attached is being forwarded to your for your evaluation.
Please call if you need assistance.
❑ Stream length impacted
❑ Stream determination
❑ Wetland determination and distance to blue -line surface waters on USFW topo maps
❑ Minimization/avoidance issues
❑ Buffer Rules (Neuse, Tar -Pamlico, Catawba, Randleman)
❑ Pond fill
❑ Mitigation Ratios
❑ Ditching
❑ Are the stream and or wetland mitigation sites available and viable?
❑ Check drawings for accuracy
❑ Is the application consistent with pre -application meetings?
❑ Cumulative impact concern
Comments:

�'�pNPS OF
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Pre -Construction Notification (PCN) Application Form
For Section 404 and/or Section 10 Nationwide, Regional and General Permits, Section 401
General Water Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This form is to be used for projects qualifying for any of the U.S. Army Corps of Engineers' (USACE)
Nationwide, Regional or General Permits as required by Section 404 of the Clean Water Act and/or Section
10 of the Rivers and Harbors Act, and for the North Carolina Division of Water Quality's (DWQ) associated
General 401 Water Quality Certifications. This form is also to be used for any project requiring approval
under any Riparian Buffer Rules implemented by the N.C. Division of Water Quality. This form should not
be used if you are requesting an Individual 404 Permit or Individual 401 Water Quality Certification. The
USACE Individual Permit application I form is available online at
http://www.saw.usace.anny.mil/wetlands/Perm app.htm.
The USACE is the lead regulatory agency. To review the requirements for the use of Nationwide, Regional
or General permits, and to determine which permit applies to your project, please go to the USACE website
at http://vvww.saw.usace.an-ny.mil/wetiands/regtour.htm, or contact one of the field offices listed on page 3
of this application. The website also lists the responsible project manager for each county in North Carolina
and provides additional information regarding the identification and regulation of wetlands and waters of the
U.S.
The DWQ issues a corresponding Certification (General or Individual), and cannot tell the applicant which
401 Certification will apply until the 404 Permit type has been determined by the USACE. Applicants are
encouraged to visit DWQ's 401 /Wetlands Unit website at http://h2o.enr.state.nc.us/ncwetlands to read about
current requirements for the 401 Water Quality Certification Program and to determine whether or not
Riparian Buffer Rules are applicable. The applicant is also advised to read the full text of the General
Certification (GC) matching the specific 404 Permit requested. In some cases, written approval for General
Certifications is not required, provided that the applicant adheres to all conditions of the GC. Applicants
lacking access to the internet should contact DWQ's Central Office in Raleigh at [phone].
Page 1 of 12

Trout Waters Coordination - Special coordination with the North Carolina Wildlife Resources Commission
(NCWRC) is required for projects occurring in any of North Carolina's twenty-five counties that contain
trout waters. In such cases, the applicant should contact the appropriate NCWRC regional coordinator
(listed by county on page 4 of this application) prior to submittal of the application.
Coastal Area Management Act (CAMA) Coordination - If the project occurs in any of North Carolina's
twenty coastal counties (listed on page 4) the applicant should contact the North Carolina Division of
Coastal Management (DCM). DCM will determine whether or not the project is within a designated Area of
Environmental Concern, in which case DCM will act as the lead permitting agency. In such cases, DCM
will require a CAMA Permit and will coordinate the 404/401 Permits.
The applicant may also choose to coordinate with the United States Fish and Wildlife Service to ensure that
the proposed project will have no impact upon any endangered or threatened species or critical habitat as
regulated by the Endangered Species Act, and the State Historic Preservation Office, North Carolina
Department of Cultural Resources to ensure that the proposed project will have no impact upon any
properties listed or eligible for listing on the National Register of Historic Places. Compliance with these
regulations is required to be eligible for any Department of the Army permit. The addresses for both
agencies are listed on page 3 of this application.
USACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms,
photos, etc. to the applicable USACE Regulatory Field Office. Upon receipt of an application, the USACE
will determine if the application is complete as soon as possible, not to exceed 30 days. This PCN form is
designed for the convenience of the applicant to address information needs for all USACE Nationwide,
Regional or General permits, as well as information required for State authorizations, certifications, and
coordination. Fully providing the information requested on this form will result in a complete application
for any of the USACE Nationwide, Regional or General permits. To review the minimum amount of
information that must be provided for a complete PCN for each USACE Nationwide permit, see Condition
13, 65 Fed. Reg. 12893 (March 9, 2000), available at
http://www.saw.usace.army.mil/wetlands/nwpfinalFedReg_pdf. Processing times vary by permit and begin
once the application has been determined to be complete. Please contact the appropriate regulatory field
office for specific answers to permit processing periods.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise stated as
optional. Incomplete applications will be returned. Submit seven collated copies of all USACE Permit
materials to the Division of Water Quality, 401/Wetlands Unit, 1650 Mail Service Center, Raleigh, NC,
27699-1650. If written approval is required or specifically requested for a 401 Certification, then a non-
refundable application fee is required. In brief, if project impacts include less than one acre of cumulative
wetland/water impacts and less than 150 feet cumulative impacts to streams, then a fee of $200 is required.
If either of these thresholds is exceeded, then a fee of $475 is required. A check made out to the North
Carolina Division of Water Quality, with the specific name of the project or applicant identified, should be
stapled to the front of the application package. For more information, see the DWQ website at
http://h2o.ehnr.state.nc.us/ncwetlands/fees.html. The fee must be attached with the application unless the
applicant is a federal agency in which case the check may be issued from a separate office. In such cases, the
project must be identifiable on the U.S. Treasury check so that it can be credited to the appropriate project.
If written approval is sought solely for Buffer Rules, the application fee does not apply, and the applicant
should clearly state (in a cover letter) that only Buffer Rule approval is sought in writing. Wetlands or
waters of the U.S. may not be impacted prior to issuance or waiver of a Section 401 Water Quality
Certification. Upon receipt of a complete application for a 401 Certification, the Division of Water Quality
Page 2 of 12

has 60 days to prepare a written response to the applicant. This may include a 401 Certification, an on -hold
letter pending receipt of additional requested information, or denial.
US Army Corps Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Office
Alexander
Caldwell
Haywood
McDowell
Swain
US Army Corps of Engineers
Alleghany
Catawba
Henderson
Mecklenburg
Transylvania
151 Patton Avenue
Ashe
Cherokee
[redell
Mitchell
Union
Room 208
Avery
Clay
Jackson
Polk
Watauga
Asheville, NC 28801-5006
Buncombe
Cleveland
Lincoln
Rowan
Yancey
Telephone: [phone]
Burke
Gaston
Macon
Rutherford
Fax: [phone]
Cabarrus
Graham
Madison
Stanley
Raleigh Regulatory Field Office
Alamance
Franklin
Nash
Surry
US Army Corps Of Engineers
Caswell
Forsyth
Northampton
Vance
6508 Falls of the Neuse Road
Chatham
Granville
Orange
Wake
Suite 120
Davidson
Guilford
Person
Warren
Raleigh, NC 27615
Davie
Halifax
Randolph
Wilkes
Telephone: [phone]
Durham
Johnston
Rockingham
Wilson
Fax: [phone]
Edgecombe
Lee
Stokes
Yadkin
Washington Regulatory Field Office
Beaufort
Currituck
Jones
Pitt
US Army Corps Of Engineers
Bertie
Dare
Lenoir
Tyrrell
Post Office Box 1000
Camden
Gates
Martin
Washington
Washington, NC 27889-1000
Carteret*
Green
Pamlico
Wayne
Telephone: [phone]
Chowan
Hertford
Pasquotank
Fax: [phone]
Craven
Hyde
Perquimans
*Croatan National Forest Only
Wilmington Regulatory Field Office
Anson
Duplin
Onslow
US Army Corps Of Engineers
Bladen
Harnett
Pender
Post Office Box 1890
Brunswick
Hoke
Richmond
Wilmington, NC 28402-1890
Carteret
Montgomery
Robeson
Telephone: [phone]
Columbus
Moore
Sampson
Fax: [phone]
Cumberland
New Hanover
Scotland
North Carolina State Agencies
Division of Water Quality
Division of Water Quality
State Historic Preservation Office
401 Wetlands Unit
Wetlands Restoration Program
Department Of Cultural Resources
1650 Mail Service Center
1619 Mail Service Center
4617 Mail Service Center
Raleigh, NC 27699-1650
Raleigh, NC 27699-1619
Raleigh, NC 27699-4617
Telephone: [phone]
Telephone: [phone]
Telephone: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]
Page 3 of 12

US Fish and lWildlife Service / National Marine Fisheries Service
US Fish and Wildlife Service
Raleigh Field Office
Post Office Box 33726
Raleigh, NC 27636-3726
Telephone: [phone]
US Fish and Wildlife Service
Asheville Field Office
160 Zillicoa Street
Asheville, NC 28801
Telephone: [phone]
CAMA and NC Coastal Counties
National Marine Fisheries Service
Habitat Conservation Division
Pivers Island
Beaufort, NC 28516
Telephone: [phone]
Division of Coastal Management
Beaufort
Chowan
Hertford
Pasquotank
1638 Mail Service Center
Bertie
Craven
Hyde
Pender
Raleigh, NC 27699-1638
Brunswick
Currituck
New Hanover
Perquimans
Telephone: [phone]
Camden
Dare
Onslow
Tyrrell
Fax: [phone]
Carteret
Gates
Pamlico
Washington
Western Piedmont Region Coordinator
3855 Idlewild Road
Kernersville, NC 27284-9180
Telephone: [phone]
Mountain Region Coordinator
20830 Great Smoky Mtn. Expressway,
Waynesville, NC 28786
Telephone: [phone] i
Fax: [phone]
I
I
I
NCWRC and NC Trout Counties
Alleghany
Caldwell
Watauga
Ashe
Mitchell
Wilkes
Avery
Stokes
Burke
Surry
Buncombe
Henderson
Polk
Cherokee
Jackson
Rutherford
Clay ,
Macon
Swain
Graham
Madison
Transylvania
Haywood
McDowell
Yancey
Page 4 of 12

APPLICATION FORM BEGINS ON PAGE 5. PLEASE DO NOT SUBMIT PAGES I - 4.
Page 5 of 12

Office Use Only: Form Version May 2002
USACE Action ID No. DWQ No.
(If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A".)
I. Processing
1. Check all of the approval(s) requested for this project:
❑ Section 404 Permit ❑ Riparian or Watershed Buffer Rules
❑ Section 10 Permit ❑ Isolated Wetland Permit from DWQ
❑ 401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested: NWP #27, NWP #33 And
NWP#39
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 Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (verify availability with NCWRP prior to submittal of PCN), 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: ❑
II. Applicant Information
1. Owner/Applicant Information
Name: Gene Miller Assistant Superintendent, Winston-Salem Forsyth County Schools
Mailing Address: P.O. Box 2513 Winston-Salem NC 27102-2513
Telephone Number 336-727-2533 Fax Number: [phone]
E-mail Address: imoorefi(a,admin.wsfcs.kl2.nc.us
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: Eddie MacEldowna
Company Affiliation: Davis Martin Powell and Associates
Mailing Address: 218 Gatewood Ave High Point NC 27262
Telephone Number: 336-886-4821 Fax Number: 336-886-4458
E-mail Address: emac(a,dmp-inc.com
Page 6 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 NRCS 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: Simon Atkins Academic and Technology High School
2.T.I.P. Project Number or State Project Number (NCDOT Only) n/a
3.Property Identification Number (Tax PIN): Block 3219 Lots I IN and I IU
4.Location
County: Forsyth Nearest Town: Winston-Salem
Subdivision name (include phase/lot number): n/a
Directions to site (include road numbers, landmarks, etc.): Business 40 To HM 158 North, Turn
left on Old Greensboro Road,. Site is '/z mile on right
5.Site coordinates, if available (UTM or Lat/Long):
(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): 60.31 Acres
7.Nearest body of water (stream/river/sound/ocean/lake): Winston -Lake - Frazier Creek
8.River Basin: Yadkin River
(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: High School Under Construction - Site was previously wooded
Page 7 of 12

10. Describe the overall project in detail, including the type of equipment to be used: Complete Site
development, parking, drives, utilities and storm drainage for construction of a new high school
11. Explain the purpose of the proposed work: Construction of a new High School meeting the
minimum educational program of the Winston-Salem Forsyth County Schools
IV. 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.
Prior site visit by Division of Water Quality Staff member Jennifer Fryprior to construction start
confirmed that an existing stream on site was intermittent and perennial. This stream is identified as
SI -4 and SI -5 on the attached map.
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.
VI. 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. The applicant must also provide
justification for these impacts in Section VII below. All proposed impacts, permanent and temporary,
must be listed herein, and must be clearly identifiable on an accompanying site plan. All wetlands
and waters, and all streams (intermittent and perennial) must 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: Placement of fill materials for construction
of a baseball stadium
Page 8 of 12

12. Individually list wetland impacts below:
Wetland Impact
Site Number
(indicate on map)
Type of Impact*
Area of
Impact
(acres)
Located within
100 -year Floodplain**
(yes/no)
Distance to
Nearest Stream
(linear feet)
Type of Wetland***
WI -1
TEMP FILL
AND
EXCAVATION
0.10
YES
200
Undetermined
WI -2
FILL
0.15
YES
200
Perennial
SI -3
Excavated and
Restored
250
UT Of Fraizer Creek
Perennial
* List each impact separately and identify temporary impacts. 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.
** 100 -Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps (FIRM), or
FEMA -approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or online at
http://www.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g.; freshwater/saltwater marsh, forested wetland, beaver pond, Carolina
Bay, bog, etc.) Indicate if wetland is isolated (determination, of isolation to be made by USACE only).
List the total acreage (estimated) of all existing wetlands on the property: 2.0 Acres
Total area of wetland impact proposed: 0.10 Temp and 0.15 Permanent
13. Individually list all intermittent and perennial stream impacts below:
Stream Impact
Site Number
(indicate on map)
Type of Impact*
Length of
Impact
(linear feet)
Stream Name**
Average Width
of Stream
Before Impact .
Perennial or
Intermittent?
(please specify)
SI -1
Fill
140
UT Of Fraizer Creek
Undetermined
Undetermined
SI -2
TEMP
RELOCATION
50
UT Of Fraizer Creek
2' +-
Perennial
SI -3
Excavated and
Restored
250
UT Of Fraizer Creek
Perennial
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip -rap, dams
(separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain), stabilization
activities (cement wall, rip -rap, crib wall, gabions, etc.), excavation, ditch ing/straightening, etc. If stream relocation is proposed, plans and
profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest downstream
named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at www.usgs.gov. Several
internet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com, www.maP9uest.com, etc.).
44
Cumulative impacts (linear distance in feet) to all streams on site: 440'
14. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic Ocean
and any other water of the U.S.) below:
Page 9 of 12

Open Water Impact
Site Number
(indicate on map)
-Type of Impact*
Area of
Impact
(acres)
Name ofWaterbody
(if applicable)
Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging, flooding,
drainage, bulkheads, etc.
15. Pond Creation . N/A
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.):
Size of watershed draining to pond: Expected pond surface area:
IL 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.
S
ite designs were selected to avoid impacts to stream SI -4 and SI -5. Unon consultation with the US
Army Corps of Engineers and The North Carolina Division of Water Quality the proposed
baseball stadium design was modified to allow restoration of stream SI -2 and SI -3
III. 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 10 of 12

USACE — In accordance with the Final Notice of Issuance and Modification of Nationwide Permits,
published in the Federal Register on March 9, 2000, 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 NCWRP 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
http://h2o.enr.state.nc.us/ncwetlands/strmgide.html.
16. 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.
Stream SI -2 and SI -3 will be mitigated. A check dam will be installed in the original location
of Stream SI -2 and base stream flow that presently drains to the sediment basin will be redirected
back to its original location. The stream channel will be allowed to re-establish itself and will be
reviewed to determine if additional restoration procedures will be required.
17. Mitigation may also be made by payment into the North Carolina Wetlands Restoration Program
(NCWRP). Please note it is the applicant's responsibility to contact the NCWRP at (919) 733-
5208 to determine availability and to request written approval of mitigation prior to submittal of a
PCN. For additional information regarding the application process for the NCWRP, check the
NCWRP website at http://h2o.enr.state.nc.us/wrp/index.htm. If use of the NCWRP 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):
IV. Environmental Documentation (required by DWQ)
Page 11 of 12

Does the project involve an expenditure of public (federal/state) funds or the use of public
(federal/state) land?
Yes ❑ No ❑
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 (919)
733-5083 to review current thresholds for environmental documentation.
Yes ❑ No ❑
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 ❑
V. 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 (Neuse),
15A NCAC 213 .0259 (Tar -Pamlico), 15A NCAC 2B .0250 (Randleman Rules and Water Supply
Buffer Requirements), or other (please identify )?
Yes ❑ No ❑ If you answered "yes", provide the following information:
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*
Impact
(square feet)
Multiplier
Required
Mitigation
1
3
2
1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation of
Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Page 12 of 12

Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 213..0242 or .0260.
VI. Stormwater (required by DWQ)
Describe impervious acreage (both 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.
Site will have an impervious percentage of 20.33%
VII. 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.
Public sewer will be provided at this site
VIII. 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 ❑
IX. 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).
Page 13 of 12

Applicant/Agent's Signature
Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 14 of 12

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