20070985 Ver 2_401 Application_20180318

DWR
Division of water Resources
Pre -Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
January 31, 2018 Ver 2.3
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all mandatory questions are answered.
Also, if at any point you wish to print a copy of the E -PCN, all you need to do is right -click on the document and you can print a copy of the form.
Below is a link to the online help file.
https:lledocs.deq.nc.govMaterResources101edocl6247041PCN%20Help%20File%202018-1-30.pdf
A. Processing Information
County (or Counties) where the project is located:*
Forsyth
Is this project a public transportation project?*(�)
f Yes f• No
1a. Type(s) of approval sought from the Corps:*
IJ Section 404 Permit (wetlands, streams and waters, Clean Water Act)
r Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
1b. What type(s) of permit(s) do you wish to seek authorization?*
r% Nationwide Permit (NWP)
r Regional General Permit (RGP)
Nationwide Permit (NWP) Number:
NWP Number Other:
Individual Permit
List all NN numbers you are applying for not on the drop down list.
1c. Type(s) of approval sought from the DWR:*
check all that apply
IJ 401 Water Quality Certification - Regular ❑ 401 Water Quality Certification - Express
F- Non -404 Jurisdictional General Permit ❑ Riparian Buffer Authorization
*
1d. Is this notification solelyfor the record because written approval is not required?
For the record only for DWR 401 Certification:
For the record only for Corps Permit:
r Yes G No
r Yes f• No
1e. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
V so, attach the acceptance letter from mitigation bank or in -lieu fee program
r Yes r No
1f. Is the project located in anyof NC's twenty coastal counties?*

f Yes r No
1h. Is the project located in a designated trout watershed?*
r Yes F No
Link to trout information: http://wAw.saw.usace.army.mil/Missions/Regulatory-Permit-ProgranVAgency-Coordination/Trout.aspx
B. Applicant Information
1a. Who is the Primary Contact?*
Brian North
1b. Primary Contact Email:*
[e-mail]
1c. Primary Contact Phone:*
[phone]
1d. Who is applying for the permit?
m Owner r Applicant (other than owner) r Agent/Consultant
(Check all that apply)
2. Owner Information
2a. Name(s) on recorded deed:
Martin Marietta Materials Inc.
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
Larry Roberts
2d. Address
Street Address
413 S. Chimney Rock Rd
Address Line 2
City
Greensboro
Postal / Zip Code
27409
2e. Telephone Number:
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
..........
State/ Province/ Fbgion
NC
Country
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Salem Stone Quarry Reauthorization
1b. Subdivision name:
(if appropriate)

1c. Nearest municipality/ town:'
Kernersville
1d. Driving directions*
V it is a new project and can not easily be found in a CPS rrapping system Rease provide directions.
4572 High Point Rd, Kernersville, NC 27284 N 36.0263, W -80.1103
2. Project Identification
2a. Property Identification Number:
(tax PIN or parcel ID)
2b. Property size:
(in acres)
2c. Project Address
Street Address
452 High Point Rd
Address Line 2
aty
State / Province / Region
Kernersville
NC
Postal / Zip Code
Country
27284
USA
2d. Site coordinates in decimal degrees
Please collect site coordinates in decimal degrees. Use between 4-6 digits (unless you are using a survey -grade GPS device) after the decimal place as
appropriate, based on how the location was determined. (For example, most mobile phones with GPS provide locational precision in decimal degrees to
map coordinates to 5 or 6 digits after the decimal place.)
Latitude:* Longitude:*
36.0263 -80.1103
ex: 34.208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Spurgen Creek
3b. Water Resources Classification of nearest receiving water:*
WS -III
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Yadkin-PeeDee
River Basin Lookup
4. Project Description
4a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this application:*
Please see Attached Letter and IP Application
4b. Attach an 8 1/2 X 11 excerpt from the most recent version of the USGS topographic map indicating the location of the project site. (for
DWR)
aick the upload button or drag and drop files here to attach document
USGS.pdf 1 MB
File type rrust be pdf

4c. Attach an 8 1/2 X11 excerpt from the most recent version of the published County NRCS Soil Survey map depicting the project site.
(for DWR)
Click the upload button or drag and drop files here to attach docunent
Soil.pdf 1000.07KB
File type crust be pdf
4d. List the total estimated acreage of all existing wetlands on the property:
4e. List the total estimated linear feet of all existing streams on the property:
(internittent and perennial)
4f. Explain the purpose of the proposed project:*
Please see Attached Letter and IP Application
4g. Describe the overall project in detail, including indirect imapacts and the type of equipment to be used:
Please see Attached Letter and IP Application
4h. Please upload project drawings for the proposed project.
Click the upload button or drag and drop files here to attach document
File type rrust be pdf
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
f• Yes r No r Unknown
Comments:
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
r Preliminary C Approved r Unknown f N/A
Corps AID Number:
Example: SAW -2017-99999
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Other:
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5d1. Jurisdictional determination upload
Click the upload button or drag and drop files here to attach docurrent
File type rrust be FDF
6. Project History
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?
F Yes f No r Unknown
6b. If yes, please give the DWR Certification number or the Corps Action ID (exp. SAW -0000-00000).
AID SAW -2007-01841, DWR 20070985
Project History Upload
Cick the upload button or drag and drop files here to attach document
File type must be FDF

7. Future Project Plans
7a. Is this a phased project?*
f Yes r No
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the
proposed project or related activity? This includes other separate and distant crossing for linear projects that require Department of the
Army authorization but don't require pre -construction notification.
D. Proposed Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
r Wetlands rJ Streams -tributaries r Buffers
r- Open Waters r Pond Construction
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. Reason for impact*3b.lmpact 3c. Type of impact*3d. Stream name*
type *
S1 Mine P Excavation
UT to Spurgeon
Map label (e.g. Fbad Crossing 1) Permanent () or
Creek
Temporary (T)
S2 Mine P Excavation
UT to Spurgeon
Ivep label (e.g. Fbad Crossing 1) Permanent (F) or
Creek
Temporary (T)
3e. Stream 3f. Type of 3g. Stream 3h. Impact sqfe
Type* Jurisdiction* width* length*
Perennial Both 2 1,232 2
Perennial (PER) or Average (feet) (linear feet) ,
intemittent (INF) 4
6
4
Intermittent Both
Perennial (FER) or
intermittent (INT)
** All Perennial or Intermittent streams must be verified by DWR or delegated local government.
3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
1,887
3i. Total temporary stream impacts:
0
3i. Total stream and tributary impacts:
656
3j. Comments:
Please see Attached Letter and IP Application
E. Impact Justification and Mitigation
�i�dR.7[• ._FTZ:t�TL%�u �fP11"�1F�ii.7i1
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*
Please see Attached Letter and IP Application
2 655 1
Average(feet) (linearfeet) ,
3
1
0
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*

Please see Attached Letter and IP Application
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?
r Yes r No
2c. If yes, mitigation is required by (check all that apply):
rJ DWR rJ Corps
2d. If yes, which mitigation option(s) will be used for this project?
r- Mitigation bank rJ Payment to in -lieu fee program r Permittee Responsible Mitigation
4. Complete if Making a Payment to In -lieu Fee Program
4a. Approval letter from in -lieu fee program is attached.
V Yes
4b. Stream mitigation requested:
(linear feet)
4c. If using stream mitigation, what is the stream temperature:
4d. Buffer mitigation requested (DWR only):
(square feet)
4e. Riparian wetland mitigation requested:
(acres)
4f. Non -riparian wetland mitigation requested:
(acres)
4g. Coastal (tidal) wetland mitigation requested:
(acres)
4h. Comments
All Mitigation has been paid. A receipt is attached.
6. Buffer mitigation (State Regulated Riparian Buffer Rules) - required by DWR
6a. Will the project result in an impact within a protected riparian buffer that requires buffer mitigation? If yes, you must fill out this entire
form - please contact DWR for more information.
f Yes r No
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
*** Recent changes to the stormwater rules have required updates to this section .***
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection
Rules?
r Yes r No
For a list of options to meet the diffuse flow requirements, click here.
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?
O Yes r No

2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)?*
r Yes
f No
To lookup low density requirement click here 15A NCAC 02H.1003(2).
G. Supplementary Information
1. Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?*
f Yes r No
2. Violations (DWR Requirement)
2a. Is the site in violation of DWR Water Quality Certification Rules (15A NCAC 2H .0500), Isolated Wetland Rules (15A NCAC 2H .1300), or
DWR Surface Water or Wetland Standards or Riparian Buffer Rules (15A NCAC 2B.0200)?
f Yes r No
2b. Is this an after -the -fact permit application?*
r Yes r No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in additional development, which could impact
nearby downstream water quality?*
f Yes r No
3b. If you answered "no," provide a short narrative description.
Please see Attached Letter and IP Application
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
r Yes r Nor N/A
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or habitat?
r Yes r No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
f Yes r No
5d. Is another Federal agency involved?*
r Yes r No r Unknown
5e. Is this a DOT project located within Division's 1-8?*
f Yes r No
5f. Will you cut anytrees in order to conduct the work in waters of the U.S.?*
r Yes r No
5g. Does this project involve bridge maintenance or removal?*
r Yes r No
Link to the NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf
5h. Does this project involve the construction/installation of a wind turbine(s)?**

f Yes r No
5i. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers,
mechanized pile drivers, etc.?*
r Yes r No
If yes, please provide details to include type of percussive activity, purpose, duration, and specific location of this activity on the
property.
nick the upload button or drag and drop files here to attach docurrent
File mast be FDF
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
Data from Previously issued permit for this project
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
f Yes
MEMi .
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
Data from Previously issued permit for this project
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to the State Historic Preservation Office Historic Properties Map (does not include archaeological data: http://gis.ncdcr.gov/hpoveb/
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 status (e.g., National Historic Trust designation or properties significant in North Carolina history and archaeology)?*
r Yes
r No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
National Register of Historic Places
7c. Historic or Prehistoric Information Upload
aick the upload button or drag and drop files here to attach docurrent
File mast be FDF
8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https:Hmsc.fema.gov/portal/search
8a. Will this project occur in a FEMA -designated 100 -year floodplain?*
f Yes
r No
8c. What source(s) did you use to make the floodplain determination?*
Data from Previously issued permit for this project
Miscellaneous
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach docurrent
Letter, Salem Stone, 3-1-2018.pdf
1.26MB
Exhibit 1-3.pdf
4.68MB
Exhibit 4.pdf
5.8MB
Exhibit 5.pdf
6.21 MB
Exhibit 6-7.pdf
3.04MB
Application and Property owner list, Salem Stone, 3-1-2018.pdf
3.66MB
File rrust be FDF or IOA7

Signature
P By checking the box and signing below, I certify that:
• I have given true, accurate, and complete information on this form;
■ I agree that submission of this PCN form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic
Transactions Act');
■ I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic
Transactions Act');
■ I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature; AND
■ I intend to electronically sign and submit the PCN form.
Full Name:*
Thomas L Brown
Signature
IAQ4ra5 Sraw14
Initial Review
.............................................................................................................
Is this project a public transportation project? * (?
f Yes r No
Change only ff needed.
Has this project met the requirements for acceptance in to the review process?
r Yes
f No
BIMS # Assigned*
20070985
Version#*
2
Reviewing Office*
Winston-Salem Regional Office - [phone]
Select Project Reviewer*
Sue Homewood:eads\slhomewood
Is a payment required for this project?*
f No payment required
r Fee received
r Fee needed - send electronic notification
What amout is owed?*
f $240.00
r $570.00

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Source: Esri, DigitalGlobe, GeoEye, Earthstar Geographics,CNES/Airbus DS, U SDA, USGS, AeroGRID, IGN, and the GIS UserCommunity
USGS The National Map: National Boundaries Dataset, NationalElevation Dataset, Geographic Names Information System, NationalHydrography Dataset, National Land Cover Database, NationalStructures Dataset, and National Transportation Dataset; U.S. CensusBureau - TIGER/Line; HERE Road Data
Tributary B
Tributary C
Tributary A