20181080 Ver 1_More Info Received_20180914

Strickland, Bev
From: Brad Luckey <[e-mail]>
Sent: Friday, September 14, 2018 7:53 AM
To: Homewood, Sue
Subject: [External] FW: Drummond Place
Attachments: combined drawings_BSL_9.10.18.pdf, 09 -03 -03 -Corrected PCN -Drummond Place.pdf,
Buffer Impact Table.pdf
Confirm receipt please....:). Thanks Sue.
Sincerely,
Bradley S. Luckey, PWS
336.708.4997 (c)
336.310.4527 (o)
PO Box 128
Kernersville, NC 27285
www.pilotenviro.com
[e-mail]
From: Brad Luckey
Sent: Monday, September 10, 2018 4:51 PM
To:'Homewood, Sue' <[e-mail]>
Cc: Roden Reynolds, Bryan K CIV (US) <Bryan. K. Roden [e-mail]>
Subject: RE: Drummond Place
Good Afternoon Sue,
Please find the below responses and attachments on behalf of the applicant. Please let me know if you require
additional information. Thanks.
DWR Comment 1): Please provide an overall plan sheet C1 that shows all Jordan Lake buffers. Please identify building
envelopes and drainfield limits on any lots with buffers to ensure that lots are buildable without further disturbance to
the buffers. Please note that deed notifications will be required on all lots with streams, buffers or wetlands present.
Applicant Response: Please see attached sheet C1. The applicant acknowledges the general condition requirements
that deed notifications are required on all lots with streams, buffers or wetlands present.
DWR Comment 2): The Jordan Buffer Rules table of uses states that road crossings are exempt if less than 40 linear feet
of stream is disturbed. It does not specify permanent versus temporary disturbance. Since more than 40 feet of
disturbance will occur for the installation of the culvert and riprap pad, please revise the PCN to include a buffer
authorization request, and fill out the buffer impact table.
Applicant Response: Please find the attached updated PCN that includes allowable without mitigation impacts to
riparian buffers.
1

DWR Comment 3): The requirement for diffuse flow of stormwater into the buffer is applicable to the entire
site/project, not just the utility maintenance road. Please provide a diffuse flow plan that clearly shows how stormwater
from Drummond Estates Dr and Harthill Dr, as well as stormwater from impervious surfaces on individual lots (driveway,
roof drains etc) will be managed.
Applicant Response: Following discussions with Division stormwater representatives, the applicant has designed scour
pools at the discharge point of concentrated stormwater flow into the riparian buffer. The attached drawings include
the calculations utilized for design of the scour pools. Please note that the use of scour pools to meet diffuse flow
requirements will result in permanent impact to Zone 2 of the riparian buffer. As such, the applicant has amended the
attached PCN to request buffer authorization for the proposed scour pools. Changes to the PCN outside of Section C.6
have not been made.
Sincerely,
Bradley S. Luckey, PWS
336.708.4997 (c)
336.310.4527 (o)
PO Box 128
Kernersville, NC 27285
www.pilotenviro.com
[e-mail]
From: Homewood, Sue [mailto:[e-mail]]
Sent: Monday, August 27, 2018 8:17 PM
To: Brad Luckey <[e-mail]>
Cc: Roden Reynolds, Bryan K CIV (US) <Bryan. K. Roden [e-mail]>
Subject: Drummond Place
Brad,
A few items needed for this application:
1. Please provide an overall plan sheet C1 that shows all Jordan Lake buffers. Please identify building envelopes
and drainfield limits on any lots with buffers to ensure that lots are buildable without further disturbance to the
buffers. Please note that deed notifications will be required on all lots with streams, buffers or wetlands
present.
2. The Jordan Buffer Rules table of uses states that road crossings are exempt if less than 40 linear feet of stream is
disturbed. It does not specify permanent versus temporary disturbance. Since more than 40 feet of disturbance
will occur for the installation of the culvert and riprap pad, please revise the PCN to include a buffer
authorization request, and fill out the buffer impact table.
3. The requirement for diffuse flow of stormwater into the buffer is applicable to the entire site/project, not just
the utility maintenance road. Please provide a diffuse flow plan that clearly shows how stormwater from
Drummond Estates Dr and Harthill Dr, as well as stormwater from impervious surfaces on individual lots
(driveway, roof drains etc) will be managed.
Thanks,
Sue Homewood
Division of Water Resources, Winston Salem Regional Office
Department of Environmental Quality

336 776 9693 office
336 813 1863 mobile
Sue. [e-mail]
450 W. Hanes Mill Rd, Suite 300
Winston Salem NC 27105
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.

Legend
.. — .. — PROPERTY LINE
— - - — - - — PROPOSED PROPERTY LINE
— - - — - - — PROPOSED LOT LINE
-..._..._..._..._...- EXISTING STREAM
--�—LL— WETLANDS
APPLICANT:
SHUGART MANAGEMENT, INC.
221 JONESTOWN ROAD
WINSTON SALEM, NC 21104
CONTACT: GREG GARRETT
EMAIL: GREGOSHUGARTMANAGEMENT.COM
PHONE: [phone]
TOTAL AREA: 36.18 ACMES
TOTAL LOTS: 35 LOTS
DENSITY: 0.91 LOTS/ACRE
JURISDICTION: FORSYTH COUNTY
PARCEL ID: 6891-12-6545.00
PARCEL ID : 6891-22-0491.00
ZQdll�a
JURISDICTION: FORSYTH COUNTY
ZONING: RS -20 (SINGLE-FAMILY RESIDENTIAL)
PROPOSED USE: SINGLE FAMILY RESIDENTIAL
NOTE: THIS SITE IS LOUT DENSITY AND COMPLIANT WITH THE
WATERSHED REGULATIONS FOR THE LAKE 13RANDT
WATERSHED, BALANCE OF THE WATERSHED. ALL LOTS ARE
GREATER THAN 20000 SF.
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BEAVER CREEK
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NOTE: DEED NOTIFICATIONS WILL BE REQUIRED ON ALL
LOTS WITH STREAMS, BUFFERS OR HETLANDS PRESENT.
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STREAM GROSS 1 N6 IMPACT: UTILITY GROSS 1 N6 NOTE:
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PERMANENT HETLAND IMPACT HITHIN BUFFERS. NO PERMANENT MAINTENANCE AND 30' ��II I IIII� w >04
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DRUMMOND ESTATES CT. PERMANENT STREAM IMPACT (CULVERT): 40 LF
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PUMP AROUND DETAIL
NOTES:
AROUND DIKES SHALL NOTOUTSIDE• DISTURESEDAMPACT
LIMITS SHOWN ON
THROUGH2, INSTALL PUMP -AROUND DIVERISON AND DEWATER THE CONSTRUCTION ZONE
DEWATERING DEVICE,s .. r. SHALL STAGE THE LIMITS OF
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SEE SHEET G3.3 FOR SCOUR HOLE DETAILS
(NOTE: SCOUR HOLE TO BE INSTALLED PARALLEL
TO GONTOUR GRADE)
SCOUR HOLE
W
STORM FEATURE
DIA.
GFS
PIPE INV
BASE WIDTH
DEPTH
EXIT VELOGITY
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(NOTE: SCOUR HOLE TO BE INSTALLED PARALLEL
TO GONTOUR GRADE)
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SCOUR HOLE IMPACT:
ZONE 2 BUFFER IMPACT
LINE 501-500 420 SF (.010 AG)
LINE 601-600 550 SF (.0130)
Legend
SEE SHEET 03.3 FOR SCOUR HOLE DETAILS
(NOTE: SCOUR HOLE TO BE INSTALLED PARALLEL
TO CONTOUR GRADE)
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--LL—�—
UIETLANDS
—
LIMITS OF DISTURBANCE
PIPE INV
STREAM IBUFFER
DEPTH
DRAINAGE FEATURE
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(NOTE: SCOUR HOLE TO BE INSTALLED PARALLEL
TO CONTOUR GRADE)
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STORM FEATURE
DIA.
GFS
PIPE INV
BASE WIDTH
DEPTH
EXIT VELOGITY
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24"
1.44 FPS
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SEE SHEET 03.3 FOR SCOUR HOLE DETAILS
(NOTE: SCOUR HOLE TO BE INSTALLED PARALLEL
TO CONTOUR GRADE)
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DATE- 9/10/18

A PIPE
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SQUARE PREFORMED
SCOUR HOLE (PSH)
(RIPRAP IN BASIN NOT
SHOWN FOR CLARITY);
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W A
(STANDARD„ I
ROLL WIDTH)
PERMANENT SOIL
REINFORCEMENT MATTING
(PSRM). PSRM SHALL BE
SEEDED WITH VEGETATION
AT INSTALLATION.
Figure 4-2. Plan view: typical preformed scour hole layout and components
PIPE PSRM
(d=15" OR 18") � INSTALL LEVEL AND
FLUSH WITH NATURAL
� 0 DEPTH OF SCOUR HOLE GROUND
1?� (I' MIX - S MAX.)
�. NATURAL
INFLOW GROUND
acfzs?��r
LINER: CLASS B RIPRAP
WITH TYPE 2 FILTER FABRIC MIN. 1'TUCK
BASE
WIDTH
Figure 4-3. Profile view: preformed scour hole cross section
DESIGN CRITERIA
A summary of additional design information follows.
DESIGN CRITERIA SUMMARY
0 The base of the scour hole is square (See Figure 4-3). The width is calculated
as follows:
Base width = 3 X Discharge pipe size
O Riprap must be Class B (d50 = 8 inches).
O Minimum width of the PSRM apron is the standard PSRM roll width.
O PSRM must be tucked a minimum of 1 foot underneath the filter fabric and
natural ground around the perimeter of the scour hole.
O Scour hole must be installed in a flat area.
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IDATE- 9/4A5 1

Buffer Impact
Number -
Permanent (P) or
Temporary (T)
Reason for Impact
Stream
Name
Buffer
Mitigation
Required?
Zone 1 impact (SF)
Zone 2 Impact (SF)
Road Crossing 1
Road Crossing
Unnamed
No
835
1,400
Line 1001-1000
Stormwater BMP
Unnamed
No
0
533
Line 401-400
Stormwater BMP
Unnamed
No
0
263
Line 501-500
Stormwater BMP
Unnamed
No
0
420
Line 601-600
IStormwater BMP
Unnamed
INo
1 01
550
Total Buffer
Impacts
835
3,166

Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Page 1 of 11
PCN Form — Version 1.3 December 10, 2008 Version
Pre -Construction Notification (PCN) Form
A. Applicant Information
1.
Processing
1 a.
Type(s) of approval sought from the
Corps:
®Section 404 Permit El Section 10 Permit
1b.
Specify Nationwide Permit (NWP) number: NWP 29 or General Permit (GP) number:
1c.
Has the NWP or GP number been verified by the Corps?
❑ 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
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 1 h
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:
Drummond Place
2b.
County:
Forsyth
2c.
Nearest municipality / town:
Kernersville
2d.
Subdivision name:
Drummond Place
2e.
NCDOT only, T.I.P. or state
project no:
3.
Owner Information
3a.
Name(s) on Recorded Deed:
SMI Properties, LLC
3b.
Deed Book and Page No.
003357/04414
3c.
Responsible Party (for LLC if
applicable):
Mr. Brian Shugart
3d.
Street address:
221 Jonesville Road
3e.
City, state, zip:
Winston Salem, NC 27104
3f.
Telephone no.:
336.765.9661
3g.
Fax no.:
3h.
Email address:
[e-mail]
Page 1 of 11
PCN Form — Version 1.3 December 10, 2008 Version

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 Information (if applicable)
5a.
Name:
Bradley S. Luckey
5b.
Business name
(if applicable):
Pilot Environmental Inc.
5c.
Street address:
PO Box 128
5d.
City, state, zip:
Kernersville, NC 27285
5e.
Telephone no.:
336.708.4997
5f.
Fax no..-
o.:5g.
5g.
Email address:
[e-mail]
Page 2 of 11
PCN Form — Version 1.3 December 10, 2008 Version

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
6897126408
1 b. Site coordinates (in decimal degrees):
Latitude: 36.14214 Longitude: - 80.04482
(DD.DDDDDD) (-DD.DDDDDD)
1 c. Property size:
35 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
Beaver Creek
proposed project:
2b. Water Quality Classification of nearest receiving water:
WS -III, NSW
2c. River basin:
Cape Fear
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 site contains undeveloped wooded land and agricultural fields. Residential structures are located on portions of the
site. The site is located in a residential/rural area of Kernersville, Forysth County, North Carolina
3b. List the total estimated acreage of all existing wetlands on the property:
—1.5 Acres
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
—2,500 LF perennial stream
3d. Explain the purpose of the proposed project:
The purpose of the proposed project is to provide wastewater treatment and long term maintenane access to wastewater
septic systems.
3e. Describe the overall project in detail, including the type of equipment to be used:
The overall project consists of development of the site with a residential sub -division. In order to provide maintenance
access and wastewater services, an access road and 3 wastewater utility line crossings are necessary. To facilitate
development of the site and construction of the proposed stream crossings, clearing and grading portions of the site are
necessary. Graders, haulers, excavators and other heavy equipment will be used during site construction.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
®Yes El No El Unknown
project (including all prior phases) in the past?
Comments: SAW -2016-01703
4b. If the Corps made the jurisdictional determination, what type
®Preliminary E] Final
of determination was made?
4c. If yes, who delineated the jurisdictional areas?
Agency/Consultant Company: Pilot Environmental, Inc.
Name (if known): Bradley Luckey/Michael Brame
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
SAW -2016-01703=9.13.16. DWR=10.17.16
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 3 of 11
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 project is not part of a phased project. Impacts to streams/wetlands, outside of those proposed in this application,
are not anticipated as a result of the proposed project.
Page 4 of 11
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 T
W1 ❑ P ®T
Sewer Line
PFO
® Yes
❑ No
® Corps
® DWQ
0.026
W2 ❑ P ®T
Sewer Line
PFO
® Yes
❑ No
® Corps
® DWQ
0.036
W3 ®P ®T
Culvert Fill/Pump
PFO
® Yes
® Corps
0.062/0.046
Around
❑ 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
0.062/0.108
2h. Comments: The road crossing will permanently impact 0.062 acres of wetlands from culvert fill and temporarily impact
0.046 acres of wetlands from de -watering pump around. Sewer line crossing #1 will temporarily impact 0.026 acres of
wetlands. Sewer line crossing #2 will temporarily impact 0.036 acres of wetlands. The sewer line crossings will include de-
watering stream pump around and open cut/backfill sewer line installation. Temporary impacts from the road/utility crossings
will be resorted to similair pre -construction grade and planted.
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
Sewer Line
Unnamed
® PER
❑ INT
® Corps
® DWQ
6
20
S2 ❑ P ® T
Sewer Line
Unnamed
® PER
❑ INT
® Corps
® DWQ
6
20
S3 ❑ P ® T
Sewer Line
Unnamed
® PER
❑ INT
® Corps
® DWQ
6
20
S4 ® P ® T
Culvert Fill/Rip-
Unnamed
® PER
® Corps
6
40/30/50
Rap/Pump Around
❑ INT
® DWQ
S5 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S6 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
3h. Total stream and tributary impacts
40/30/110
3i. Comments: Sewer line crossings #1-3 will cumulatively result in temporary impact to 60 linear feet of perennial stream
channel 20 LF/crossing). The proposed road crossing will permanently impact 40 linear feet of stream channel with culvert fill
Page 5of11
PCN Form — Version 1.3 December 10, 2008 Version

and 30 linear feet with keyed in rip -rap dissipater. Additionally, the proposed road crossing will temporarily impact 50 linear
feet of stream channel with pump around. Areas of temporary impact from the sewer line and road crossings will be restored
to similair pre -construction beds/banks conditions, matted and seeded.
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.
Open water
impact number —
Permanent (P) or
Temporary T
4b.
Name of waterbody
(if applicable)
4c.
Type of impact
4d.
Waterbody type
4e.
Area of impact (acres)
01 ❑P❑T
02 ❑P❑T
03 ❑P❑T
04 ❑P❑T
4f. Total open water impacts
4g. Comments: Open water impacts are not proposed.
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below.
5a.
Pond ID
number
5b.
Proposed use or purpose
of pond
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
K Total
5g. Comments: Construction of ponds/lakes are not proposed.
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:
Page 6 of 11
PCN Form — Version 1.3 December 10, 2008 Version

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: Lake Jordan
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 T
impact
required?
131 ❑P❑T
❑Yes
❑ No
B2 ❑P❑T
F-1 Yes
❑ No
B3 ❑P❑T
❑Yes
❑ No
6h. Total buffer impacts
6i. Comments: The proposed project will unavoidably impact riparian buffers associated with the road crossing, utility
crossings and to maintain diffuse flow requirements of the site. The attached table outlines the proposed impacts that are
allowable without mitigation. The utility line crossings have been designed in a manner that is an exempt activity and
authorization for these impacts are not being requested. Mitigation is not proposed for the unavoidable impact to riparian
buffers.
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
The road crossing location was selected in an area of stream that is relatively straight with few meanders. The applicant has
further demonstrated avoidance and minimization of stream impacts by proposing to construct approximately 2.5 feet tall
culvert head/end walls and utilize 2:1 road side slopes. Furthermore, the Applicant has designed rip -rap stabilization measure
to be keyed into existing grades of beds and banks to 30 linear feet of stream channel.
The remainder of the larger residential subdivision has been designed to avoid impact to WoUS and Lake Jordan buffers.
There are approximately 2,500 linear feet of perennial stream channel and 1.5 acres of wetlands located on the site. The site
has been designed to avoid approximately 1.44 acres of wetlands and 2,430 linear feet of perennial stream.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
The clearing limits will be staked and silt fence will be used. Temporary coffer dams will be installed upgradient of the
proposed culvert and sewer line trench. During construction, water will be pumped around the construction footprint.
Appropriate stream bank protection will be provided in the channel during construction and all excess excavated material will
be immediately removed from the stream bank crossing area. The top 1 foot of stream bed material will be stored in upland
areas and used to backfill the top 1 foot of the excavation trench for the sewer line crossings. Upon completion of the
culvert/utility line installation, the temporary sand bag coffer dams will be removed and flow will be diverted through the culvert
or across the sewer lines. Disturbed banks will be restored to similar pre -construction conditions, matted and seeded/live
staked.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
❑ Yes ® No
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply):
❑ DWQ ❑ Corps
❑ Mitigation bank
2c. If yes, which mitigation option will be used for this
❑Payment to in -lieu fee program
project?
❑ Permittee Responsible Mitigation
Page 7 of 11
PCN Form — Version 1.3 December 10, 2008 Version

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.
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 8 of 11
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: Concentrated flow will not be discharged to the buffers. The proposed
❑ Yes ® No
road is not impervious and will sheet flow into buffers.
2.
Stormwater Management Plan
2a.
What is the overall percent imperviousness of this project?
Low Density %
2b.
Does this project require a Stormwater Management Plan?
❑ Yes ® No
2c.
If this project DOES NOT require a Stormwater Management Plan, explain why: Based on the overall development being
low density, a stormwater management plan is not requried.
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
3b.
Which of the following locally -implemented stormwater management programs
❑ NSW
F1 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
attached?
❑ Yes ® No
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 9 of 11
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
letter.)
❑ Yes
® No
Comments: We are not aware of a NEPA or SEPA being requried.
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.
We are not aware of additional development that will impact nearby downstream water quality.
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.
Wastewater will be treated on-site. Impacts outside of those proposed within this application are not anticipated
for
wastewater
treatment.
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?
E] 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?
The USFWS List of federally protected species for Forsyth County identifies: Bog turle (T=S/A , NLEB (T) and small-
anthered bittercress (E). Based on our site observations, suitable habitat for the bog turtle and small anthered bittercress
are not located on the site. Suitable summer roosting habitat for NLEB is located on the site. However, the site is not
located within 150' of known summer roost trees or 1/4 mi of known hibernacula. Therefore, the applicant will rely on the
final 4(d) rule for NLEB and removal of suitable summer roosting trees should not be restricted.
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 Habitat?
Based on our knowledge of the site, the site is not located in or near an area designated as essential fish habitat. Best
management practices and the use of temporary sediment and erosion control devices will prevent sediment from entering
down -gradient waterbodies which may contain fish.
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?
NC SHPO HPO GIS Website (attached).
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? FEMA FIRM 3710689700K
Digitally signed by Bradley S. Luckey
-' DN: cn=Bradley S. Luckey, o=Pilot
Environmental, Inc., ou,
Bradley S. Luckey
r� email=[e-mail],
9.10.18
c=US
Applicant/Agent's Printed Name
r"' ,)niRn9.1n 1hs2sh-n4'oo'
Applicant/Agent's Signature
Date
(Agent's signature is valid only if an authorization letter from the applicant
is provided.
Page 11 of 11
PCN Form — Version 1.3 December 10, 2008 Version