20180757 Ver 1_401 Application_20180618

i/ WithersRavenel
May 18 2018
William Elliot
Ashville Regulatory Field Office
US Army Corps of Engineers
151 Patton Avenue, Room 208
Asheville, North Carolina 28801-5006
Sue Homewood
North Carolina Division of Water Resources
450 West Hanes Mill Road, Suite 300,
Winston-Salem, NC 27105
20180757
NC Department of
Environmental Quality
Received
E�ri�+ %u kki
Winston-Salem
Regional Office
RE: PCN Application (NW 12) - Town of Pilot Mountain Emergency Temporary Sewer Protection
Town of Pilot Mountain, Surry County, NC
Dear Mr. Elliot and Ms. Homewood:
Thank you both for the assistance you provided us for this project in your previous discussions with Todd St.
John. Please find the attached Preconstruction Notification Application (PCN) for a Nationwide Permit 12 for
the Town of Pilot Mountain Emergency Temporary Sewer Protection project (See Figure 1). The purpose of
the project is to provide temporary protection measures for existing sewer lines in two separate locations
that have been exposed by erosion. At Site A (Figure 2) a 4" force main and 8" gravity main were exposed by
the breach of the uppermost of two ponds in series reportedly built in the 1940s or 1950s. The channel that
has formed through the breach appears to be perennial. Site B is along the toe of the dam impounding the
lower pond (See Figure 4). In this location, the perennial stream that runs parallel to the two dams has formed
a meander impacting the toe of the lower dam/stream bank exposing the same 4" force main as described
above. Site B Sites A and B are within a Town held utility easement. The proposed construction access routes
are in upland areas and along the top of the dams. The access routes are currently used for access and are
covered in mostly herbaceous vegetation.
Site A: The temporary protection measures for Site A include providing supported casing for the sewer lines
intended to relieve stresses on the PVC pipe that could cause them to fail. There is no permanent proposed
fill within the channel footprint in this location.
Site B: The temporary protection at Site B includes reconstructing the bank/dam toe. A rock toe protection is
proposed to be constructed to bankfull elevation or less and backfilled with clean native material. The stream
thalweg will also be relocated closer to its original location. The thalweg (deepest part of the stream) will be
relocated closer to the stream channel's original location
JUN
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7011 Albert Pick Road, Suite G I Greensboro, NC 27409
Office: 336.605.3009 1 Fax: [phone] www.withersravenel.com I License No. C-0832
Asheville ( Cary I Greensboro I Pittsboro I Raleigh I Wilmington

%0 WithersRavene[
Permanent solutions are being considered for both sites. These include relocating the sewer lines and
performing environmental restorations that will provide better protection for the sewer lines where they
could interact with the streams or be impacted other erosion such as breaches. In any event, the Town is
required by its Collection System Permit (included) to protect the exposed sewer lines. Sue Homewood of
NCDWR has both Sites A and B previously. It is not known if any final stream determinations were made:
however, it is assumed that both channel features are considered to be perennial streams.
Sincerely
WlthersRavenei
Michael R. Koser, P.E.
Project Manager
Attachments:
PCN Form
Agent Authorization
Figure 1-
Location Map
Figure 2
-Overview
Figure 3
- Site A
Figure 4
-Site B
Figure 5 -1:24,000 USGS Mapping
Figure 6 -USDA
Soil Survey
Exhibit 1-
Site A Protection
Exhibit 2- Site B Protection
Exhibit 3
- Photo Pages
Exhibit 4
- Sewer Collection Permit
Exhibit 5
- FEMA Map
Exhibit 6-
NCNHP Letter

o�pF W ATF9OG
I 1 >
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
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Page 1 of 13
PCN Form —Version 1.3 December 10. 2008 Version
Pre -Construction Notification PCN Form
A. Information
1.
-Applicant
Processing
1 a.
Type(s) of approval sought from the
Corps:
®Section 404 Permit El Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: NW 12 or General Permit (GP) number:
1c.
Has the NWP or GP number been verified by the Corps?
® Yes
❑ No
1 d. 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
1 e.
Is this notification solely for the record
because written approval is not required?
For the record only for DWQ 401
Certification:
❑ Yes ® No
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
1 h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes
® No
2.
Project Information
2a.
Name of project:
Town of Pilot Mountain Emergency Temporary Sewer Protection
2b.
County:
Surry
2c.
Nearest municipality / town:
Pilot Mountain
2d.
Subdivision name:
N/A
2e.
NCDOT only, T.I.P. or state
project no:
N/A
3.
Owner Information
3a.
Name(s) on Recorded Deed:
See Figure 2 for the various property owner information. Applicant is a municipality.
3b.
Deed Book and Page No.
3c.
Responsible Party (for LLC if
applicable):
3d. Street address:
3e.
City, state, zip:
r
3f.
Telephone no.:
3g.
Fax no.:
3h. Email address:
WWIT
OT 20
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Page 1 of 13
PCN Form —Version 1.3 December 10. 2008 Version

4. Applicant Information (if different from owner)
4a. Applicant is:
❑ Agent ® Other, specify: Municipality
4b. Name:
Michael Boaz, Town Manager
4c. Business name
(if applicable):
Town of Pilot Mountain
4d. Street address:
124 W. Main Street
4e. City, state, zip:
Pilot Mountain, NC 27041
4f. Telephone no.:
336-444-3000
4g. Fax no.:
2c. River basin:
4h. Email address:
[e-mail]
5. Agent/Consultant Information (if applicable)
5a. Name:
Michael Koser, P.E.
5b. Business name
(if applicable):
WithersRavenel
5c. Street address:
7011 Albert Pick Road, Suite G
5d. City, state, zip:
Greensboro, NC 27409
5e. Telephone no.:
336-605-3009
5f. Fax no.:
5g. Email address:
[e-mail]
B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
See Figure 2.
1 b. Site coordinates (in decimal degrees):
Latitude: 36.372040 Longitude: - 80.488920
(DD.DDDDDD) (-DD.DDDDDD)
1c. Property size:
See Figures 2, 3, and 4
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project:
UT to Pilot Creek
2b. Water Quality Classification of nearest receiving water:
C
2c. River basin:
I Upper Pee Dee
Page 2 of 13
PCN Form — Version 1.3 December 10, 2008 Version

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:
The project is located in Pilot Mountain, Surry County, NC. A Location Map is included as Figure 1 is included with this
submittal.
Sites A and B (the Project Areas) are within a Town held sewer utility easement (See Figure 2). Site A and B include
existing sewer lines and are within or adjacent to the footprints of two dams reportedly constructed in the 1940s and
1950s as carp fishing ponds. Recent erosion has exposed existing PVC (material) sewer lines that need to be protected
as they are prone to failure in their current condition. The sewer lines were reportedly installed in the early 2000s. The
access for Sites A and B are open and maintained as accesses around the ponds or sewer easements
Site A (Figure 3) is within a breach of the upper pond dam/natural ground that reportedly formed when the outlet device
between the upper and lower pond became inoperable causing water to flow over the dam/natural ground in the location
of the breach. The drained upper pond footprint has since become colonized by wetland herbaceous vegetation that will
not be impacted as part of this project. However, a channel has formed within the breach that is likely considered to be a
jurisdictional stream and appears to have perennial flow. The channel is deeply incised through the dam/natural ground,
exposing the 8" PVC gravity sewer main and 4" PVC force main. The sewer mains are currently being supported with a
temporary metal framework (see Photo 1, Exhibit 3). The channel flows roughly perpendicular to the exposed sewer
lines. The channel that emanated from the breached dam enters a larger perennial channel that flows to Site B.
Site B is along the toe of the dam impounding the lower pond (See Figure 4). In this location, the perennial stream that
runs parallel to the lower dam has formed a meander impacting the toe of the lower dam/stream bank exposing the 4"
PVC sewer force main. The section of exposed sewer main is approximately 20 feet long (See Photo 5, Exhibit 3). The
ordinary high water channel (bankfull) is wide in this location due to the instability and movement of the stream channel.
The construction access routes Sites A and B are in upland areas and along the top of the dams. The accesses are
actively used and are covered in mostly herbaceous vegetation.
3b. List the total estimated acreage of all existing wetlands on the property:
There were no wetlands noted within the construction footprints of Site A or Site B or within the construction accesses.
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
The two jurisdictional streams within the Project Area boundaries are two separate streams. The stream reach within Site
A construction footprint is approximately 20 feet long. The stream reach within the Site B stabilization area is
approximately 30 feet long.
3d. Explain the purpose of the proposed project:
The Town desires to provide temporary protection for sewer lines exposed by erosions at Sites A and B to prevent
damage to the sewer lines while a permanent realignment or repair measures are developed. The Town's Sewer
Collection System Permit (No. WQCS00112) requires that the system be maintained to prevent discharge to land or
surface waters. The exposure of the lines leaves them at higher risk of failure.
Page 3 of 13
PCN Form — Version 1.3 December 10, 2008 Version

3e. Describe the overall project in detail, including the type of equipment to be used:
Site A: The project at Site A includes providing temporary measures to protect a 4" PVC force main and 8" PVC gravity
sewer line exposed when a breach formed through a dam/natural ground sometime after 2010, exposing the sewer lines.
The temporary measures include providing supported casing for the sewer lines intended to relieve stresses on the PVC
pipe that could cause them to fail. This measure is meant to serve to protect the sewer lines until a permanent solution
can be developed. To avoid potential impacts, Site A will be accessed via existing maintenance/access corridors (See
Figure 2). The objective of the work is to provide an encasement to support the two sewer lines and temporarily stabilize
the channel banks and overbanks at the points where the sewer lines enter the dam walls. There is no permanent
proposed fill within the channel footprint at Site A. Temporary impacts are anticipated within the channel footprint (See
Figure 3) by the construction process, but the channel will be restored to the existing elevation and profile. The pipe
encasement should be above the normal highwater of the channel. The proposed measures are intended to not increase
impoundment of the upstream former pond bed (See Exhibit 1). The work will be conducted using machinery typically
used for utility construction and maintenance.
Site B: The project at Site B includes protecting the 4" PVC force main sewer line that has been exposed by recent
excessive stream erosion. The sewer line is located along the toe of a dam reportedly constructed in the 1940s or 1950s
(See Exhibit 3 — Photos). The stream meandered into the dam/bank toe exposing the sewer line. Reconstructing the
bank/dam toe and relocating the stream's thalweg (deepest part of the stream) closer to its original location is intended to
be a temporary measure until a permanent solution can be developed. The thalweg will be relocated closer to its original
location as demonstrated in Figure 4 and Exhibit 2. To avoid potential impacts, Site B will be accessed via existing
maintenance/access corridors (See Figures 2 and 4). The proposed work includes temporarily reestablishing the original
stream bank/dam toe by constructing a rock stream toe to approximately bankfull elevation (normal high water) and
backfilling with clean native material and relocating the stream thalweg closer to its original location (See Exhibit 2). In
order to avoid additional stream impacts and to construct the rock toe and provide backfill material, sheeting will be
placed along the back face of the dam and the construction materials will be slid down the sheeting with a goal of
preventing damage to the exposed sewer line. The material will be brought in using dump trucks along the route shown in
Figure 2. The instream work will be accomplished using a small excavator that will access the site via the route shown in
Figure 2. Rock will be placed beneath the sewer main to support it prior to the construction of the rock toe and thalweg
relocation to prevent damage to the pipe. The rock toe will be constructed to or below the bankfull elevation
(approximately 1' to 2'). Due to the small size of the channel, The construction equipment can be positioned outside of the
low flow path of the stream.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
❑Yes ❑ No ®Unknown
ro ect (including all nor phases) in the past?
P 1 (� 9 P� P )�
Comments: NCDWR has visited the site recently.
4b. If the Corps made the jurisdictional determination, what type
El Preliminary El Final
of determination was made?
4c. If yes, who delineated the jurisdictional areas?
Agency/Consultant Company: WithersRavenel
Name (if known): Todd St. John visually evaluated sites and
Other:
construction access routes for jurisdictional features.
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
Sue Homewood of NCDWR has indicated that she visited the project sitesrecently. It is not known if any final
determinations were documented.
5. Project History
5a. Have permits or certifications been requested or obtained for
❑ Yes ❑ No ® Unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instructions.
Page 4 of 13
PCN Form — Version 1.3 December 10, 2008 Version

6. Future Project Plans
6a. Is this a phased project? ® Yes ❑ No
6b. If yes, explain.
The Town expects to develop a permanent resolution for these sewer lines once it determines and is able to fund a
permanent solution. The specific solution has not been identified at this time, but the potential solutions being considered
are discussed in the cover letter.
Page 5 of 13
PCN Form — Version 1.3 December 10, 2008 Version

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. 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
W1 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W2 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W3 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W4 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W5 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W6 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
2g. Total wetland impacts
2h. Comments: There are no wetland impacts associated with this project
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)
S1 ®P ❑ T
Utility Stabilization
UT to Pilot Creek
® PER
❑ INT
❑ Corps
® DWQ
10
20
S2 ®P ❑ T
Utility Stabilization
UT to Pilot Creek
® PER
❑ INT
® Corps
® DWQ
15
30
S3 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S4 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S5 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S6 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
3h. Total stream and tributary impacts
50
3i. Comments: Stream impacts are for emergency stabilization of an exposed sewer line.
Page 6 of 13
PCN Form —Version 1.3 December 10, 2008 Version

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic 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 of 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: There are no open water impacts proposed for this project.
5. Pond or Lake Construction
If pond or lake construction proposed, the 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
K Total
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
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 El Tar -Pamlico ❑Other:
Project is in which protected basin?
❑ Catawba ❑ Randleman
6b.
6c.
6d.
6e.
6f.
6g.
Buffer impact
number —
Reason
Buffer
Zone 1 impact
Zone 2 impact
Permanent (P) or
for
Stream name
mitigation
(square feet)
(square feet)
Temporary
impact
required?
B1 ❑P❑T
F-1 Yes
❑ No
B2 ❑ P ❑ T
❑ Yes
❑ No
B3 ❑P❑T
❑Yes
❑ No
6h. Total buffer impacts
6i. Comments:
Page 7 of 13
PCN Form — Version 1.3 December 10, 2008 Version

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Construction access for both Sites A and B is along existing maintenance corridors that do not cross streams or wetlands. Fill
within the channel at Site A has been avoided. Fill within the stream at Site B is proposed to be in the footprint of the existing
dam and stream bank (prior to the erosion). The channel thalweg will be relocated closer to the original location of the
channel.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Access for both sites will be along existing maintenance/easement corridors. Materials will be brought to Site B by sliding
them down sheeting allowing for the use of smaller equipment to reconstruct the bank toe. The stream is small enough for the
equipment to be positioned outside the low flow channel.
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
El 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 Program
4a. Approval letter from in -lieu fee program is attached.
❑ Yes
4b. Stream mitigation requested:
linear feet
4c. If using stream mitigation, stream temperature:
❑ warm ❑ cool ❑cold
4d. Buffer mitigation requested (DWQ 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:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 8 of 13
PCN Form — Version 1.3 December 10, 2008 Version

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation?
❑ Yes ® No
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
Zone
6c.
Reason for impact
6d.
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 mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund).
6h. Comments:
Page 9 of 13
PCN Form — Version 1.3 December 10, 2008 Version

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified
❑ Yes ® No
within one of the NC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
Comments: No impervious area will be added. The project is to only protect existing
❑ Yes ® No
sewer mains.
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
0%
2b. Does this project require a Stormwater Management Plan?
❑ Yes ® No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:: There will be no impervious cover
added. The project is to protect existing sewer lines exposed by erosion.
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?
❑ DWQ Stormwater Program
❑ DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
❑ Phase II
❑ NSW
3b. Which of the following locally -implemented stormwater management programs
❑ USMP
apply (check all that apply):
❑ Water Supply Watershed
❑ Other:
3c. Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
4. DWQ Stormwater Program Review
❑ Coastal counties
❑ HQW
4a. Which of the following state -implemented stormwater management programs apply
❑ ORW
(check all that apply):
❑ Session Law 2006-246
❑ Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
5. DWQ 401 Unit 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 10 of 13
PCN Form — Version 1.3 December 10, 2008 Version

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the
® Yes ❑ No
use of public (federal/state) land?
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)?
1 c. 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 ® No
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
❑ Yes ® No
additional development, which could impact nearby downstream water 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.
N/A
Page 1 1 of 13
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
WR reviewed the NC Natural Heritage Program database, located at http://www.ncnhp.org/web/nhp/home to identify if
there were any known occurrences of endangered species on or near the proposed project. The review of the NHP data
did not identify any occurrences of federally listed threatened or endangered species or critical habitat on the subject
property or within 1.0 miles of the project. Site reviews did not identify any potential habitat for any federally protected
species known to occur in Surry County, except for the Northern Long Eared Bat.
Potential habitat for the northern Long-eared bat (NLEB) is listed as mature forest with trees over 3" DBH, which is used
for roosting during the day. The proposed project area contains forested areas with trees over 3" DBH, and therefore is
considered potential northern long eared bat habitat. The USFWS Final 4(d) rule for the Northern Long -Eared bat
specifies that tree removal within the White Nose Syndrome (WNS) Zone is not prohibited as long as it occurs more than
0.25 miles from known hibernacula and does not result in destroying known occupied maternity roost trees, or any other
trees within a 150 ft -radius from the maternity tree, during the pup season (June 1 — July 31). The proposed project is not
located within 0.25 miles of any known hibernacula, nor is there any known maternity roost trees present on the project.
Additionally, clearing of mature forest between June 1 st and July 31 Si is not anticipated for construction of the proposed
project. Therefore, WR concludes that the project "may affect, but is not likely to adversely affect" the northern long-
eared bat. See attached NCNHP letter.
6. 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 Habitat3•
There are no waters classified as EFH in Surry County. • 1
7. Historic or Prehistoric Cultural Resources (Corps Requirement) JU D
7a. Will this project occur in or near an area that the state, federal or tribalSr
�FNR fB
governments have designated as having historic or cultural preservation
in
❑ Yes �I'l QUA(
�F1% Ti'
status (e.g., National Historic Trust designation or properties significant
North Carolina history and archaeology)?
14'00,
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
WR reviewed the NC State Historic Preservation Office's online database, located at: http://gis.ncdcr.gov/hpoweb/, to
determine if there were any known historic or cultural resources within or in the vicinity of the proposed project. The
database review did not identify any known resources within or in the vicinity of the proposed project.
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? NC Floodmaps.com
Page 12 of 13
PCN Form — Version 1.3 December 10, 2008 Version

Michael Koser
5/18/2018
Applicant/Agent's Printed Name Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant
is provided.)
Page 13 of 13
PCN Form - Version 1.3 December 10, 2008 Version

1/ WithersRavenel
NoOur People. Your Success.
AUTHORITY FOR APPOINTMENT OF AGENT
The undersigned Owner Town of Pilot Mountain (Client) does hereby appoint
WithersRavenel. Inc. as its agent for the purpose of petitioning the appropriate local, state
and federal environmental regulatory agencies - including the US Army Corps of Engineers
(USACE) and NC Division of Water Resources (NCDWR) - for: a) review and approval of the
jurisdictional boundaries of onsite jurisdictional areas (wetlands, surface waters, riparian
buffers, etc.) and/or; b) preparation and submittal of appropriate environmental permit
applications/requests for the sewer repairs as located in the attached exhibit.
The Client does hereby authorize that said agent has the authority to do the following acts
on behalf of the owner:
(1) To submit appropriate requests/applications and the required
supplemental materials;
(2) To attend meetings to give representation on behalf of the Client.
(3) To authorize access to subject property for the purpose of
environmental review by appropriate regulatory agencies.
This authorization shall continue in effect until completion of the contracted task or
termination by the Client.
Agent's Name, Address & Telephone:
WithersRavenel, Inc.
115 MacKenan Drive
Cary, NC 27511
Tel. [phone]
Date: 4/16/2018
Signature of Client:
James Michael Boaz Town Manager
(Name - Print) (Title)
4LIkl,14-1—
(Signature)
124 W Main Street, Box 1
Mailing Address
Pilot Mountain NC 27041
City State Zip
Phone: [phone]
Email: [e-mail]
115 MacKenan Drive I Cary, NC 27511
t: 919.469.3340 1 f: 919.467.6008 www.withersravenel.com I License No. C-0832
Cary I Greensboro ( Pittsboro I Raleigh I Wilmington

soov­
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11
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Photo 4 — Site A construction access from west side
21 Page

Exhibit 3 — Photo Pages
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Photo 6 — Site B - Tha
31 Page

Exhibit 3 — Photo Pages
Photo 7 — Site B — Construction access
Photo 8 — Site B construction access around lower pond
41 Page

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Water Resources
ENVIRONMENTAL QUALITY
December 12, 2016
Mr. Ronald Holt, Public Works Director
Town of Pilot Mountain
124 West Main Street, Box 1
Pilot Mountain, NC 27041
Subject: Permit No. WQCS00112
Town of Pilot Mountain
Town of Pilot Mountain Collection System
Surry County
Dear Mr. Holt:
PAT MCCRORY
DONALD R. VAN DER VAART
10,11 1
S. JAY ZIMMERMAN
In accordance with your application received October 17, 2017, we are forwarding herewith Permit No.
WQCS00112, dated December 12, 2016, to the town of Pilot Mountain for the operation and maintenance of
the subject wastewater collection system.
This permit shall be effective from April 1, 2017 until March 31, 2025 and shall be subject to the conditions
and limitations specified herein. It is your responsibility to thoroughly review this permit. Please pay particular
attention to the monitoring and reporting requirements in this permit and any special conditions.
Changes have been made to the boiler plate language of the permit. Most of the changes are for clarification
purposes, however Condition 1(3) has been removed. The Department of Environmental Quality (DEQ)
believes that condition was included erroneously in previous permits. It was included based on proposed
rulemaking by EPA which was never promulgated and, in the continued absence of Federal regulations, DEQ
lacks authority to include such language in a permit. DEQ will continue to exercise enforcement discretion
when evaluating sanitary sewer overflows that may be considered to be beyond the reasonable control of the
Permittee. A highlighted copy of the permit identifying the changes made is available at:
http://ncdenr.s3.amazonaws.com/s3fs-
public/Water%20Quality/Surface%2OWater%20Protection/PERCS/WCS%20(Collection%20System)/Updated
%20W QCS%20Te m p late%2015.05.18%20(h igh I ighte d ). pdf
For purposes of permitting, the collection system is considered to be any existing or newly installed system
extension up to the wastewater treatment facility property or point of connection with a separately owned
sewer system. The collection system is considered all gravity lines, pump stations, force mains, low pressure
sewer systems, STEP systems, vacuum systems, etc. and associated piping, valves and appurtenances that
help to collect, manage and transport wastewater to a wastewater treatment plant under the Permittee's
ownership or maintained and operated by the Permittee through a perpetual legal agreement. Satellite
systems are systems tributary to the Permittee's collection system but those collection systems are not owned
or maintained by the Permittee. The system description provided on Page 1 of this permit is meant to provide
a general idea about the size of the system and may not be all inclusive of the collection system at the time of
permit issuance or afterward.
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Phone: [phone] Internet: www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer - Made in part by recycled paper

Town of Pilot Mountain Collection System
December 12, 2016
A discharge of wastewater to the environment from the Permittee's wastewater collection system prior to
reaching the wastewater treatment facilities is referred to herein as a Sanitary Sewer Overflow (SSO). The
evaluation of enforcement options after an SSO will be determined considering all relevant information
available or requested of the Permittee. Compliance with all conditions of the permit as well as a►I statutes
and regulations pertaining to the wastewater collection system must be maintained or appropriate
enforcement actions may be taken as noted in Condition VI(2).
A reportable SSO is an SSO greater than 1,000 gallons to the ground or an SSO of any amount that reaches
surface water (including through ditches, storm drains, etc.). Reporting requirements including the required
verbal report and written report to the appropriate regional office are referenced in Condition IV(2). Form
CS-SSO can be downloaded from the SSO Reporting area at:
http://ncdenr.s3.amazonaws.com/s3fs-
Public/W ater%20Qua l ity/Su rface%2OWater%20Protection/PERCS/WCS%20(SSO%2ODocuments)/CS-
SSO(2015).doc
A notice of deficiency (NOD), notice of violation (NOV), civil penalty, and/or a moratorium on the addition of
waste to the system may be issued if adequate justification for an SSO is NOT submitted to the regional office.
In order to submit a claim for justification of an SSO, you must use Part II of form CS-SSO with additional
documentation as necessary. DWR staff will review the justification claim and determine if enforcement
action is appropriate. Please be advised that the information needed to justify a spill is very comprehensive.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing upon written request within thirty days following the receipt of this permit.
This request must be in the form of a written petition, conforming to Chapter 1508 of the North Carolina
General Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC
27699-6714. Unless such demands are made, this permit shall be final and binding.
If you have questions regarding compliance, contact the appropriate regional office. If you need additional
information concerning this permit, please contact Steve Lewis at [phone].
Sincerely,
for S. Jay Zimmerman, P.G.
Director, Division of Water Resources
by Deborah Gore, Supervisor
Pretreatment, Emergency Response, Collection System Unit (PERCS)
enclosure: Permit No. WQCS00112
cc: Winston-Salem Regional Office, Water Quality Regional Operations
Water Resources Central Files — WQCS00112
Maureen Kinney, NC Operators Certification Program (electronic)
PERCS Files (electronic)

FLOOD HAZARD INFORMATION NOTES TO USERS
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North Carolina Department of Natural and Cultural Resources
Natural Heritage Program
Governor Roy Cooper Secretary Susi H Hamilton
NCN H D E-5936
May 2, 2018
Troy Beasley
Withers & Ravenel
115 MacKenan Drive
Cary, NC 27511
RE: Pilot Mtn - Lola Ln Sewer Repair; 02170679.00
Dear Troy Beasley:
The North Carolina Natural Heritage Program (NCNHP) appreciates the opportunity to provide information
about natural heritage resources for the project referenced above.
A query of the NCNHP database, based on the project area mapped with your request, indicates that there are
no records for rare species, important natural communities, natural areas, or conservation/managed areas
within the proposed project boundary. Please note that although there may be no documentation of natural
heritage elements within the project boundary, it does not imply or confirm their absence; the area may not have
been surveyed. The results of this query should not be substituted for field surveys where suitable habitat exists.
In the event that rare species are found within the project area, please contact the NCNHP so that we may
update our records.
The attached `Potential Occurrences' table summarizes rare species and natural communities that have been
documented within a one -mile radius of the property boundary. The proximity of these records suggests that
these natural heritage elements may potentially be present in the project area if suitable habitat exists and is
included for reference. Tables of natural areas and conservation/managed area within a one -mile radius of the
project area, if any, are also included in this report.
Please note that natural heritage element data are maintained for the purposes of conservation planning, project
review, and scientific research, and are not intended for use as the primary criteria for regulatory decisions.
Information provided by the NCNHP database may not be published without prior written notification to the
NCNHP, and the NCNHP must be credited as an information source in these publications. Maps of NCNHP
data may not be redistributed without permission.
The NC Natural Heritage Program may follow this letter with additional correspondence if a Dedicated Nature
Preserve (DNP), Registered Heritage Area (RHA), Clean Water Management Trust Fund (CWMTF) easement,
or Federally -listed species are documented near the project area.
If you have questions regarding the information provided in this letter or need additional assistance, please
contact Rodney A. Butler at rod ney.butler(a)ncdcr.gov or 919.707.8603.
Sincerely,
NC Natural Heritage Program
MAILING ADDRESS Teleohone. [phone] LOCATION
1651 Mail Service venter www.ncnhp.org 121 West Jones Street
Raleigh. NC 27654-1651 Raleigh, NC 27603

Natural Heritage Element Occurrences, Natural Areas, and Managed Areas Within a One -mile Radius of the Project Area
Pilot Mtn - Lola Ln Sewer Repair
Project No. 02170679.00
May 2, 2018
NCNHDE-5936
No Element Occurrences are Documented Within a One -mile Radius of the Project Area
No Natural Areas are Documented Within a One -mile Radius of the Project Area
Managed Areas Documented Within a One -mile Radius of the Project Area
Managed Area Name Owner Owner Type
Pilot Mountain State Park NC DNCR, Division of Parks and Recreation State
Pilot Mountain State Park Dedicated Nature Preserve North Carolina Department of Natural and State
Cultural Resources, Division
Definitions and an explanation of status designations and codes can be found at httPS7//ncnhde.natureserve.org/content/help. Data query generated on May 2, 2018; source: NCNHP, Q2 April 2018. Please resubmit your
information request if more than one year elapses before project initiation as new information is continually added to the NCNHP database.
Page 2 of 3

NCNHDE-5936: Pilot Mtn - Lola Ln Sewer Repair
may t, to ( a
DProject Boundary
D Buffered Project Boundary
Managed Area (MAREA)
Page 3 of 3
1:20,960
0 0 175 0.35 0.7 mi
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