Ver 1 - 401 Application - 12/4/2017

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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
2
Page 1 of 11
PCN Form - Version 1.3 December 10, 2008 Version
Pre -Construction Notification (PCN) Form
A.
Applicant Information
1.
Processing
1a.
Type(s) of approval sought from the
Corps:
Section 404 Permit ❑ Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 7 or General Permit (GP) number:
1c.
Has the NWP or GP number been verified by the Corps?
;X Yes ❑ No
1d.
Type(s) of approval sought from the DWQ (check all that apply):
401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
le.
Is this notification solely for the record
because written approval is not required?
For the record only for DWQ 401
Certification:
❑ Yes 9No
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 ,NNo
1g.
Is the project located in any of NC's twenty coastal counties. If yes, answer 1h
below.
❑ Yes ® No
1h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes ® No
2.
Project Information
2a.
Name of project: 11
2b.
County: U i
2c.
Nearest municipality / town:
-2d--Sulstfi
e.
on y,l. . or s a e
projec
3.
Owner Information
3a.
Name(s) on Recorded Deed:
S <
3b.
Deed Book and Page No.
Z
3c.
Responsible Party (for LLC if
applicable):
104'
3d.
Street address:
" n `2<— rQ�c i
3e.
City, state, zip:
A4 ✓R'i'✓Ce I Ate 270v
3f.
Telephone no.:
33 (o 3 S 4 22-&
3g.
Fax no.:
3h.
Email address:
WA IQ- Z ('!k5a ma d wt
2
Page 1 of 11
PCN Form - Version 1.3 December 10, 2008 Version

-4. Applicant Inf6ft6tion (if different b6m
4a. Applicant is:
El Agent El I Other, specify:
4b. 'Name -
4c. Business.name.
(if. applicable):'
40. Street address:
4e. City, state;, -zip:
4f.- Telephohe:ho:
4g. Rik -no.:
4h. Emaitaddress:
5. AgenUConsuliant.Informapoln' (ifapplicable)
5a. Name',
-5b. Business name.
(if applicable):.
5c. Street ad dre 8(.
5d. City,-!a�, ,.zip:
6e. Tele one ho.'
5f; Ox no::
5g. Email address:
Page 2 of 'll

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
r '. 5 9i�,3
1 b. Site coordinates (in decimal degrees):
Latitude: Longitude: -
(DD.DDDDDD) . (-DD.DDDDDD)
1c. Property size:
acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
+ �T
proposed project:
2b. Water Quality Classification of nearest receiving water.
2c. River basin: map is available at
,
Cth O C i z --�39
http://h2o.enr.state.nc.us/admin/maps/
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:
FP l 6 A a � � �, 64E � CC ri��en7 1�Yj1(tA
3b. List the total estimated acreage of all existing wetlands on the property: 0
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3d. Explain the purpose of the proposed project:
T f,. e �l�z 9 yr A,
3e. Describe the overall project in detail, including the type of equipment to be used:
f ��, e e) wu 4 e- �� -� u
tt.sz �IeofPIS, 740��;�:..t y,egWe-
C: r/ -e u l4 n c� a A
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lee Move � � trl �/��. C`)/rCiC
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Page 3 of 11
PCN Form — Version 1.3 December 10, 2008 Version

4. Jurisdictional Deterniinations
Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for ' th - is'pi�oo.erty_ I
project (including all prior,phases) in the, past?
Comments:
Yes El No. E]'UnknoWn
4b. If the Corps made the JurisdictionalAetermination, what type
of determination was made?
❑ Preliminary E] Final
4c. If yes, who delineated the jurisdictional'areasT
Name (if known):
Agency/Consultant, Company:
Othsir.
4d. If yes, list the dates of the Corps jurisdictional determin6tlonsor State determinations and attach documentation.
5.. Project History
5a. Have pennits orcertifications ,been requ6sted'or obtained for
this project. (including, all prior phases) 1n the,papf?
-1 yes E],,Unknbwn,
5b; If yes, explain in detail:6dd6rding,to'"tWO file* instructions.
6. Future Project Plans
6a. Is this a phased project?
I El Yes No
6b. If yes, explain.
Pag&A,of'l 1

C. Pr,606sed-ImpActs Invibritbry
1. Impacts Summary
Ia. Which, section were completed below fo.r,your 0rdj6dt,(qhe&alI that apply);
Wetlands Stredms - tributaries 0 Buffers
.0 Open Water's Pond Construction
2. Wetiand Impacts
ff there are-wetland impacts proposed on the site, -then complete this-luestion for each wetland qrea.impqcled.
2a.
2b.
2c.
2d.
'2e.,
2f.
Wqtl6rfd impact
Type of Jurisdiction
numb6r -
Type of impact
Type of wetland
Porested
(Corps - 404, 10
Ar6a of impact
Permanent (P) or
(if known)
DWQ - non-404, other)
(acres)
Tem ora
W1 ETP 1 0 T
0 Ye§.
El Corps,
o
[]'DWQ
W2- 0 P [:1T
Yes,
O'Corps
0 DWQ
-',c
0
—
W3. 0 P'D T
0 Yes
0,CbrOs
❑ No
DWO
W4 El P L] T'
El Yes
El No
FI-G.D I rp �si.
❑DV,
W5 OP-OT
0 Yes
El No
El.porps,
EIDWQ
W6 El P
0 Y6s-
El No
0 Corps,
0 DWQ
29; 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.
X.
3d.
3e.
X
Stream impact
Type of impact
Stream name
Perenni6l
type of jurisdiction
Average
Impact
nuMbe(-
or
(Corps- 404, 10
stream
length
Permanent (P) or
"(PER)
intermittent
DWQ - non-404;
width
(linear
Temporary (T)
(WTP_�,�'
other)
�feet)
feet)
,S! 'El PU T
El *K-
INT11
[-1,c6rps
DWQ
E-1-P D T
:E1 PER
❑'INT
CIC br . ps
DW.0
S3: F1 P.*EjT
E3�PER--
D Corps
DWQ
S4 El P El T
❑P ERN
11 INT
El Corps
❑ DWQ
S5 El P El T
El PER
EDNT—E]
apprps
E),4Q
-S6 C1 P [] T'
❑ PER:
El WT
D Cor
11 1326\1
3-hl. Total stream.a..:_ tributary Impacts
3i. Comments:
Page s -of 11

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the A antic Ocean, or any other open water of
the U.S. then indiv" ually list all open water impacts below.
4a.
4b. �-
4c. 4d.
4e.
Open water
Name of waterbody
impact number —
(if applicable)
Ty Impact Waterbody type
Area of impact (acres)
Permanent (P) or
Temporary
01 ❑P❑T
_
02 ❑P❑T
03 ❑P❑T
04 ❑P❑T
0. Total open water Impacts
4g. Comments:
S. 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
lilt �r , a�' ' ,��
`a
-is,
0
P2
5f. Tota I
5g. Comments_ �y �F + I � -
!A e-ti-YA
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
�'�Ct2 zS
5j. Size of pond watershed (acres):
C ii�.0_4'
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 ❑ Tar-Pamlico ❑ Other:
Project is in which protected basin?
❑ Catawba ❑ Randleman
6b.
6c.
6d.
6f.
6g.
Buffer impact
number —
Reason
Buffer
Zone 1 impact
Zone 2 impact
Permanent (P) or
for
Stream me
mitigation
(square feet)
(square feet)
Temporary
impact
required?
B1 ❑P❑T
El Yes
❑ No
B2 ❑ P ❑ T
❑ Yes
No
❑P❑T
EJ\YB3
❑Neo\
6h. Total buffer impacts
6i. Comments:
Page 6 of 11

D. Impact Justification and Mitigation
1. AV6ldance-.",.dfid Minimization
'Ta. S,pebificWly'.4escribe measures taken, to,'aVoid or minimize the proposed. impacts in designing project.
CJ-Y-L(Y-0
b. S06cifidAlly d6tdti be measures taken to avoid.br minimize the, proposed impacts*through construction techniques.
I. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compeftiatory Mitigation for
impacts itb.Waters:bf the U:S. or Waters of'the State?
❑ Yes ANO
-2b. 'if yes, mitigation isrequired by (check allthat.apply):
E] DWQ [I Corps
2c. If yes, which%mitigation :option be used fdr-this
9
project?
El Mitigation bank
El Payment to, ihmlieu, fee program
El Permitted Responsible Mitigation
3. 'Complete if Using a Mitigation Bank
Name Mitigation Bank:
OfT
3b. Crddits,ftrchased (attach receipt .and', lett I er)
Type!
Quantity,
3c. Comments:'
4. Completelif Making, a. Paymdrit1to In4idu Fee Pr "ram
4a..Approval'16fterItorn in -lieu fee;
[e-mail]'Y6$
Ab. Stream mitigation requested:''
linear'feet
4d... Iflusing'strearn mitigation, strerl6mperature,
0 warm , 0 cool, Elcoid
4d. Buffer mitigation rejue§ Q6 n1y):
sjuare-feet
- ted:
4e. Riparian Vetl'and,VAg6tion requos -
lacres
4f. Non -riparian M06nd mitigation ,requested: -
acres
4g. `Coastal (tiff I)
iacres,
4h. Comments:
Pa.ge 7 of 11
PCN Form — Version 1,.8 December -I 0, 2008 Version

5 Complete -if-us1iid,-gpefmiite*e-,R4t;gdttiibteiMlilgatloo-Plan- -::-"
5a. If using a permittee responsible mitigation plan, provide a-clescriptionofth�eosed mitigation plan.
S. Buffbe-Mitiption (State RegiAted RIpulan Buftr Rules) d by-DWQ
6a. Will the project result'in'-ah impact vAthin a protected NOW* buffer that requires
buffer mitigation? EAs. yott Will have to fill.oUt'this-e;- e!f�on _ olease
contact theState for more information.
❑Yes El No
6b. If'yds, then identify the square feet dfirrioa ach'zone.cif the riparian butler that, requires, mitigati - on.. Calculate the
&moOnt6f.rnitigati 0-6required.
Zone
6d.
Reason forimpact;
pOict,
/6d.
�O tail impact'
(square feet)
Multiplier
6e.
ReOUMcl.riiitigation
(square feet
Zone 1
'3 (2 forZatawbaa)
zone',2
1.5
6f. Total buffer mitigation requited:
6g: 'Itbuffermitigption isrequired, -discuss whatAypeQf'mitigation is proposed (e.g., payment t6,prival:6 rhitigation-bahk,
permittee redponsible npatian'buffpi restoration; pay aft.approved in
me -HOW-fe& fund).
6K Comments:
Page 8 of 11

'E. Stormwate� Management:and.DMute Flow Plan:(required by DWQ)
1. Diffuse FIdW:Plan r
1a.. Does the project include or iwitadjacent toy protected nparian buffers identified
❑'Yes No
within;oneof the NC Riparian Buffer Protection Rules?
1b. If yesthen rs a diffuse:flowplan included? If'no °explain why:
❑'Yes❑ No•
Comments:
2 Stormwater Management Plan .
-2a. What'.is the overall percent imperviousness of this project?
Q %
2b: Doesahis;projeci require. a:8tormwater Management Plan?.
❑ Yes No
2c:. If this project -DOES NOT require;a'Stormwater.Management Plan, explain why:
2d. If:this projectDOES require a-Stormwater Management: -Plan; then provide a brief; narrative description of the;plan:
0
alater
Certified'Sto
2e. Who 011 -bel -be responsible.for-the review of.'the:.Stormwater, Management Plan?'
rmGovernment
El rT wProgram
❑, Q 401 Unit
3. Certified Local GoVernment`Storrriwater. Review.
3a. In whichlocal government's jurisdiction: is this project? .
7�mientgrams
❑ Phase II
3b.. Which of the following locally-irriplemented,storrif% atermana
El NSW
❑
apply (check -all that''apply):
-
Water
ElWaterSupply Watershed
❑ .Other'
.:3c. Has,the approved StormwaterManagement,Pl with --proof of�approval been
,Q Yes- El No
attached?
1
4. DWQ §tonmwaterProgram Review ,
❑ Coastal, counties
❑ HQW
4a;. Which of the followng'state=., .piemented stormwater'management'programs,apply
❑ ,ORW
(check.all:#hat apply):
❑ Session -Law 2006-246
❑ Other,
4b. Hasihe.approv tormwatw Management Plar °with proof of approval been
❑'Yes. El. No
attached?
S: DWQ.401 it Storrnwater'Review
5a., Does the Storiiwater Manageriment;Plan meet the;appropriate requirements?❑Yes
ElNo
5b. Have all of'the 401 Unit -submittal requirements been, met?
Cl Yes ❑ No
Page 9 of 11
PCN Form — Version, 1.3 December 10'.j2008 Version

-F. Supplementalry Information
1: Environmental_ Documentation (DWQ Requirement)
1a Dce. _h '...P. d�tureP1 ofPuilic.,(federal/stateAocal)funds ortie-
❑ Yes �Noo
Publ'c federal/state and?
'1b If youAn§wered`yes° to the'. above, doesthd project require preparation of an '
environmental document: pursuantto the-requirements;of the National or State.
❑Yes .❑ No
(North Carolina) Environmental:Policy Act (NEPNSEPA)?
1c. if you.answered"yes°ao the above, has.the;document review beWfinali ed by#W
State Clearing House? (If so, attach a copy'of the' NEPA or SEPA final approvaf
El. Yes ❑ No-
Tetter)
Comments:
2. Violations (DWO Requirement)
•2a Is the:site•in violation of DWQ Wetland Rules,(1.5A-N6AC 2H 0500),'Isolated
Wetland `Rules (15A NCAC 2H'.1 300) DWQ Surface Water orWetIbnd Standards,
❑ yes N01
or Riparian Buffer Rules (15A NCAC 2B :0200)?
.2b: Is this an after -the -fact permit application?
❑ Yes VNo
2c. if you;answered "yes' to one:or both of the above questions, proyidwan expiarnation.of the. violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a Will;this project (based on past;and reasonably anticipated futurd-impacts) result in
❑'Yes No:
additional development, Which could impact nearby,down_stream water quaiity?
3b. If" ou;answered,° es" to�the;above; submit.a q ialitatwe or-Auantitative cumulative impact analysis in acco\\rdance with the
y y.
most recent DWQ policy: if you answered "no,° provide, a short.narrative'descriptlon:
4. Sewage Disposal (DWQ Requirement)
4a, Clea lydetail the ultimate treatment:_methods and disposition.(non-discharge,''ocdischarge) of wastewater generated'from
the proposed.project, or av ilable capacity of the subject:facili y
Page 10:of.11
PCN, Forme. -Version fi: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?
❑ 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?
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
Yes ❑ No
TO
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?
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:
8c. What source(s) did you use to make the floodplain determination?
plicant/Ager5t s Printed Name
A plicant/Agent's Signature
to
(Agent's signature is valid only K an authorization letter from the applicant
is rovided.
Page 11 of 11

<j> Latitude
36.02793476
360 1'40.56514" N
Longitude
-80.46188448
80" 2742.78413" W
.w- Altitude
203.00 meters
0 Accuracy
4.00 meters
Ck Last Update
Nov 1, 2017 13:26:08
Nc Department of
Environin:ntal Quality
Received
DEEC 0 4 611
4 Winston-Salem
Regional Office .r
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