20180022 Ver 1_401 Application_20180118

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Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre -Construction Notification (PCN) Form
A. Applicant Information
1. Processing 24
1a. Type(s) of approval sought from the
Corps:
Section 404 Permit El Section 10 Permit
10
1b. Specify Nationwide Permit (NWP) number: 26.1 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):
19401 Water Quality Certification - Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification - Express ❑ Riparian Buffer Authorization
1e. 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 �No
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: 2
2b. County: /
2c. Nearest municipality / town: ,
-2e. on y, .. .ors a e
proje
3. Owner Information
3a. Name(s) on Recorded Deed:
�' t 2 /1e_
3b. Deed Book and Page No.
6 0 b9 F144 11 84 G, Z gs
3c. Responsible Party (for LLC if
applicable):
3d. Street address:
Yl
3e. City, state, zip:
/q j/pWce_ I Ive , 2700
3f. Telephone no.:
-3 3 S 4 2 ZG
3g. Fax no.:
3h. Email address:
Z A lkt le- 2 (% Cd
2
Page 1 of 11
PCN Form - Version 1.3 December 10, 2008 Version
FA

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 Informs ' n (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street add re :
5d. City, stat , zip:
5e. Tele'p one no.:
5f. F x no.:
5g. Email address:
Page 2 of 11

B. Project Information and Prior Project History
1. Property Identification
la. Property identification no. (tax PIN or parcel ID):
1b. Site coordinates (in decimal degrees):
Latitude: Longitude: - ?0#4W19
(DD.DDDDDD) - (-DD.DDDDDD)
1c. Property size:
acres l/
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
+ rC
proposed project:
2b. Water Quality Classification of nearest receiving water:
k3 S )\J1
2c. River basin: map is available at
http://h2o.enr.state.nc.us/admin/maps/
,Z �
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:
II ,
,P • l' 6r1 40�
3b. List the total estimated acreage of all existing wetlands on the property:
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
cJ /c;P//'ne- M I <o l- 4 /1 GC Pe el,4/I 4 /
3d. Explain the purpose of the proposed project:
T
3e. Describe the overall project in detail, including the type of equipment to be used:
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Page 3 of 11
PCN Form — Version 1.3 December 10, 2008 Version

4.
Jurisdictional Determinations
4a.
Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
XYes ❑ No ❑ Unknown
project (including all prior phases) in the past?
Comments:
El Preliminary E] Final
4b. If the Corps made the jurisdictional determination, what type
of determination was made?
4c.
if yes, who delineated the jurisdic ional areas?
Agency/Consultant Company:
Name (if known):
Other: -DLO
4d.
If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5.
Project History
5a.
Have permits or certifications been requested or obtained for
El Yes jNo E] Unknown
this project (including all prior phases) in the past?
5b.
If yes, explain in detail according to "help file" instructions.
6.
Future Project Plans
6a.
Is this a phased project?
❑ Yes No
6b.
If yes, explain.
Page 4 of 11

C. Proposed Impacts Inventory
1. Impacts Summary
1a. 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 T
\
❑ Ye
❑ Corps
W1❑ P ❑ T
o
❑ DWQ
W2 ❑ P ❑ TYes
El Corps
❑ DWQ
o
❑ Yes
El Corps
W3 ❑ P ❑ T
El No
DWQ
W4 ❑ P ❑ T
❑ Yes
El No
Fleorps
El DV
W5 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W6❑ P ❑
El 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)
❑
❑ Corps
S1 ❑ P ❑ T
INT
❑ DWQ
S2 ❑ P ❑ T
❑ PER
❑ INT
❑ Corps
❑ DWQ
S3 ❑ P [-]T
PER
❑IMIT,
El Corps
E] DWQ
S4 ❑ P ❑ T
❑ PER
❑ INT
❑ Corps
❑ DWQ
S5 ❑ P ❑ T
❑ PER
❑ INT
C311c,orps
❑ OWQ
E] PER
❑Cor
S6 ❑P❑T
❑ INT
❑ DWQ
3h. Total stream a d tributary Impacts
3i. Comments:
Page 5 of 11

4. Open Water Impacts
If there are proposed impacts to lakes, ponds,
estuaries, tributaries, sounds, the A tic Ocean, or any other open water of
the U.S. then individually list all open water impacts below.
4a. 4b.
4c'
4d.
4e.
Open water Name of waterbody
impact number — (if applicable)
Type f impact Waterbody type
Area of impact (acres)
Permanent (P) or
Temporary
01 ❑P❑T
02 ❑P❑T
03 ❑P❑T
04 ❑P❑T ,
4f. 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
P2
5f. Tota I
5g. Comments: ��-i , ' ' S Y1 + ( LA I 0C p,clxY)
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
W3 ac2zS
5j. Size of pond watershed (acres):l�e
.
5k. Method of construction:
r
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?
ata ba ❑ Randleman
6b.
6c.
6d.
6f.
6g.
Buffer impact
\
tBuffer
number —
Permanent
Reason
for
Zone 1 impact
Zone 2 impact
(P) or
Stream
meation
(square feet)
(square feet)
Temporary
impact
red?
131 ❑P❑T
El Yes
❑ No
B2 ❑P❑T
El Yes
No
B3 ❑P❑T
❑QN
No
6h. Total buffer impacts
6i. Comments:
Page 6 of 11

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
x" Icrj�'_� I I n Lppee- P�� an OC G�,c�n' l
b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
❑ Yes No
2b. If yes, mitigation is required by (check all that apply):
❑ DWQ ❑ Corps
2c. If yes, which mitigation option will be used for this
project?
❑ Mitigation bank
❑ Payment to in-lieu fee program
❑ Permittee Responsible Mitigation
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 Pr ram
4a. Approval letter from in-lieu fee program is 91106hed.
❑ Yes
4b. Stream mitigation requested:
linear feet
4c. If using stream mitigation, strea emperature:
❑ warm ❑ cool ❑cold
4d. Buffer mitigation requests -( WQ only):
square feet
4e. Riparian wetland rniglftion requested:
acres
4f. Non-riparian w fand mitigation requested:
acres
4g. Coastal (tid I) wetland mitigation requested:
acres
4h. Comments:
Page 7 of 11
PCN Form —Version 1.3 December 10, 2008 Version

5. Complete if lasing a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the p posed mitigation plan.
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — r Ired by DWQ
6a. Will the project result in an impact within a protected ripan buffer that requires
buffer mitigation? If you will have to fill out this e e form — l2lease
contact the State for more information.
El Yes ❑ No
6b. If yes, then identify the square feet of impac each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
Zone
6c.
Reason for impact
Ad.
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 mitigption is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee re ponsible riparian buffer restoration, payment into an approved in -lieu fee fund).
6h. Comments:
Page 8 of 11

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
la. Does the project include or is it adjacent to protected riparian buffers identified
❑ Yes] No
within one of the NC Riparian Buffer Protection Rules?
1b. 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?
C) %
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?
❑ DW0,8tormwater Program
❑ Q 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
❑ Phase II
El
mgrams
3b. Which of the following locally-implemented stormwater mans ent pro
El USMP
El
apply (check all that apply):
❑ Water Supply Watershed
❑ Other:
3c. Has the approved Stormwater with proof of approval been
❑ Yes ❑ No
ManagementPll
attached?
4. DWQ Stormwater Program Review
❑ Coastal counties
[:1 HQW
4a. Which of the following state-' plemented stormwater management programs apply
E]ORW
(check all that apply):
ElSession Law 2006-246
❑ Other.
4b. Has the approv tormwater Management Plan with proof of approval been
❑ Yes E] No
attached?
5. DWQ 401 VhIt 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 9 of 11
PCN Form —Version 1.3 December 10, 2008 Version

F. Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
1a.
Does the project involve an expenditure of public (federal/state/local) funds or the
land?
❑YesNo
use of public (federal/state)
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)?
1c.
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 VNO
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
additional development, which could impact nearby downstream water
❑ YesNo
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.
P IJP
Page 10 of 11
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?
❑ 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?
S. 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?
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?
'�kpllcant/AgerlYs
N
Punted me a
plicant/Agent's Signature
Date
(Agent's signature is valid only if an authorization letter from the applicant
isprovided.)
Page 11 of 11

<j> Latitude
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