20061289 Ver 1_COMPLETE FILE_20060809

0F WATF
? ? * Rp Nlichacl P. Easley, Governor
William G. Ross Jr., Secretary
?? 1 (1 !11 North Carolina Department of Environment and Natural Resources
`` w N Alan W. Klimek, P.E. Director
Division of Water Quality
November 7, 2006
DWQ Project # 06-1289
Haywood County
CERTIFIED MAIL
RETURN RECEIPT REQUESTED 7005 0390 0001 3553 2012
Ross Adickman
Carolina Mountain Ventures
3800 South Ocean Drive
Suite 228
Hollywood, FL 33019
Subject Property: Crestview Point
Haywood County
RETURNED AS INCOMPLETE
Dear Mr. Adickman:
A t -
On August 9, 2006, the Division of Water Quality (DWQ) received your application to
impact 180 linear feet of streams to construct the proposed Crestview Point project.
The DWQ has determined that your application was incomplete and/or provided
inaccurate information as discussed below. The DWQ will require additional information
in order to process your application to impact protected wetlands and/or streams on the
subject property. Therefore, unless we receive the additional information requested
below, we will have to move toward denial of your application as required by 15A NCAC
2H .0506 and will place this project on hold as incomplete until we receive this
additional information. Please provide the following information so that we may
continue to review your project.
Additional Information Requested:
1. 15A NCAC 02H .0506 (b)(4) requires that any project not result in cumulative [or
secondary] impacts. A qualitative analysis of cumulative impacts must be
performed in accordance with
http://www.ncwaterguality.org/ncwetiands/documents/InteriminternalPolicyCumulati
velmpact.doc This must include a discussion as to how Lots 93 and 112 will be
accessed without further impacts to waters or buffers.
401 Wetlands Certification Unit
1650 Mail Service Center, Raleigh, North Carolina 27699-1650
2321 Crabtree Boulevard, Suite 250, Raleigh, North Carolina 27604
Phone: [phone] / FAX [phone] / Internet: http://h 2o. en r. state. no. us/ncwetiands
North Carolina
rhatuivily
An Equal Opportunity/Affirmative Action Employer- 50% Recycled/10% Post Consumer Paper
Crestview Point
Page 2 of 2
November 7, 2006
2. Your submitted plan indicates that there will be 294 linear feet of impacts (as
scaled off the plans) without considering possible impacts for access to the above-
mentioned lots. Mitigation must include 2:1 mitigation for all water impacts for this
entire project. Mitigation can be satisfied (with agreement to accept from the EEP)
with payment into the Ecosystem Enhancement Program (294 linear feet * 2:1
ration * $232/linear foot = $136,416) for this phase alone.
3. As this is Phase 5 of the Crestview Point subdivision, an accurate accounting of all
prior impacts must be submitted. Should all prior impacts exceed 300 linear feet,
the Authorization request should be withdrawn and an individual Water Quality
Certification must be applied for. Lastly, all impacts must be mitigated for. A plan
with mitigation which complies with the State's published Mitigation Requirements
must be included.
4. 15A NCAC 02H .0506 (g) requires a demonstration of minimization of impacts.
Impact minimization has not been sufficiently addressed. A discussion regarding
the minimization of impacts must be presented.
In the application, there is no reference as to how the buffers on-site will be protected. As
it is inappropriate for the future owners to protect the buffer from themselves, this area
(and all protected areas) must be held in a conservation easement in the name of a third
party who is organized specifically for the protection of aquatic resources or binding deed
restrictions which require the approval of the DWQ prior to any deed language changes.
As you have no authorization under Section 401 of the Clean Water Act for this activity,
and work within waters of the state would be a violation of North Carolina General
Statutes and Administrative Code. Please call Ms. Cyndi Karoly at 919-733-1786 or Mr.
Kevin Barnett at 828-296-4657 if you have any questions this matter.
Sincerely,
J
Roger C. Edwards, Regional Supervisor
Division of Water Quality
Surface Water Protection Section
RCE1khb
cc: 401 Permitting Unit, Central Office
USACE Asheville Regulatory Field Office
David McHenry, Wildlife Resources Commission
File Copy
Central Files
Filename: 06-1289.CrestviewPoint.Add-Info
?QF WAT?RQ Michael F. Easley, Governor
William G. Ross Jr., Secretary
?- North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
September 14, 2006
DWQ Project # 06-1289
Haywood County
CERTIFIED MAIL: RETURN RECEIPT REQUESTED
7005 3110 0003 5474 0202
Ross Adickman
Carolina Mountain Ventures
3800 South Ocean Drive
Suite 228
Hollywood, FL 33019
Subject Property: Crestview Point
Haywood County
REQUEST FOR MORE INFORMATION
Dear Mr. Adickman:
T '1,7
S E P 2 0 2006

On August 9, 2006, the Division of Water Quality (DWQ) received your application to
impact 180 linear feet of streams to construct the proposed Crestview Point project. The
DWQ has determined that your application was incomplete and/or provided inaccurate
information as discussed below. The DWQ will require additional information in order to
process your application to impact protected wetlands and/or streams on the subject
property. Therefore, unless we receive the additional information requested below, we
will have to move toward denial of your application as required by 15A NCAC 2H .0506
and will place this project on hold as incomplete until we receive this additional
information. Please provide the following information so that we may continue to review
your project.
Additional Information Requested:
1. 15A NCAC 02H .0506 (b)(4) requires that any project not result in cumulative [or
secondary] impacts. A qualitative analysis of cumulative impacts must be
performed in accordance with
htto://www.ncwateraualitv.ora/ncwetlands/documents/interiminternalPolicvCumulati
velmpact.doc This must include a discussion as to how Lots 93 and 112 will be
accessed without further impacts to waters or buffers.
401 Wetlands Certification Unit
1650 Mail Service Center, Raleigh, North Carolina 27699-1650
2321 Crabtree Boulevard, Suite 250, Raleigh, North Carolina 27604
Phone: [phone] / FAX [phone] / Internet: http://h2o.enr.state.nc.us/ncwetlands
NorthCarolina
,Va/umIllf
An Equal Cpportunity/Affirmative Action Employer - 50% Recycled/10% Post Consumer Paper
Crestview Point
Pa0e 2of 3
September 15, 2006
2. Your submitted plan indicates that there will be 294 linear feet of impacts (as
scaled off the plans) without considering possible impacts for access to the above-
mentioned lots. Mitigation must include 2:1 mitigation for all water impacts for this
entire project. Mitigation can be satisfied (with agreement to accept from the EEP)
with payment into the Ecosystem Enhancement Program (294 linear feet * 2:1
ration * $232/linear foot = $136,416) for this phase alone.
3. As this is Phase 5 of the Crestview Point subdivision, an accurate accounting of all
prior impacts must be submitted. Should all prior impacts exceed 300 linear feet,
the Authorization request should be withdrawn and an individual Water Quality
Certification must be applied for. Lastly, all impacts must be mitigated for. A plan
with mitigation which complies with the State's published Mitigation Requirements
must be included.
4. 15A NCAC 02H .0506 (g) requires a demonstration of minimization of impacts.
Impact minimization has not been sufficiently addressed. A discussion regarding
the minimization of impacts must be presented.
5. In the application, there is no reference as to how the buffers on-site will be
protected. As it is inappropriate for the future owners to protect the buffer from
themselves, this area (and all protected areas) must be held in a conservation
easement in the name of a third party who is organized specifically for the
protection of aquatic resources or binding deed restrictions which require the
approval of the DWQ prior to any deed language changes.
Please respond before May 26, 2006 by sending this information to both the 401
Permitting Unit at:
Mrs. Cyndi Karoly
401 Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
and to the Asheville Regional Office at:
Kevin Barnett
Surface Water Protection Section
2090 US HWY 70
Swannanoa, NC 28778
If we do not hear from you before May 26, 2006, we will assume that you no longer
want to pursue this project and we will consider the project as withdrawn.
Crestview Point
Page 3of 3
September 15, 2006
This letter only addresses the application review and does not authorize any impacts to
wetlands, waters or protected buffers. Please be aware that any impacts requested
within your application are not authorized (at this time) by the DWQ. Please call Mr.
Kevin Barnett at 828-296-4657 if you have any questions regarding or would like to set
up a meeting to discuss this matter.
Sincerely,
RogTr C' Edwards, Regional Supervisor
Division of Water Quality
Surface Water Protection Section
RCE1khb
cc: Clifford G. Sechser, P.L.S.
Sechser Precision Surveying and Mapping, PLLC
134 Miller Street
Waynesville, NC 28786
401 Permitting Unit, Central Office
USACE Asheville Regulatory Field Office
David McHenry, Wildlife Resources Commission
Mark Pruett, Haywood County Inspections
File Copy
Central Files
Filename: 06-1289.CrestviewPoint.Add-Info
Triage Check List
Date: 8/14/06
Kevin Barnett, Asheville Regional Office
To:
60-day Processing Time: 8/09/06 to 10/07/06
From: Cyndi Karoly Telephone: [phone]
Project Name: Crestview Point
DWQ #:06-1289
County: Haywood
The file attached is being forwarded to you for your evaluation.
Please call if you need assistance.
? Stream length impacted
? Stream determination
Wetland determination and distance to blue-line surface waters on USFW topo maps
? Minimization/avoidance issues
? Buffer Rules (Neuse, Tar-Pamlico, Catawba, Randleman)
? Pond fill
Mitigation Ratios
? Ditching
? Are the stream and or wetland mitigation sites available and viable?
? Check drawings for accuracy
Is the application consistent with pre-application meetings?
? Cumulative impact concern
Comments: As per our discussion regarding revision of the triage and delegation processes,
please review the attached file. Note that you are the first reviewer, so this file will need to be
reviewed for administrative as well as technical details. If you elect to place this project on hold,
please ask the applicant to provide your requested information to both the Central Office in
Raleigh as well as the Asheville Regional Office. As we discussed, this is an experimental, interim
procedure as we slowly transition to electronic applications. Please apprise me of any
complications you encounter, whether related to workload, processing times, or lack of a "second
reviewer" as the triage process in Central had previously provided. Also, if you think of ways to
improve this process, especially so that we can plan for the electronic applications, let me know.
Thanks!
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F WAIF
1
Pre-Construction Notification (PCN) Application Form
For Section 404 and/or Section 10 Nationwide, Regional and General Permits, Section 401
General Water Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This form is to be used for projects qualifying for any of the U.S. Army Corps of Engineers' (USACE)
Nationwide, Regional or General Permits as required by Section 404 of the Clean Water Act and/or
Section 10 of the Rivers and Harbors Act, and for the North Carolina Division of Water Quality's
(DWQ) associated General 401 Water Quality Certifications. This form is also to be used for any
project requiring approval under any Riparian Buffer Rules implemented by the N.C. Division of Water
Quality. This form should not be used if you are requesting an Individual 404 Permit or Individual 401
Water Quality Certification. The USACE Individual Permit application form is available online at
w,vvw.saw.usace.army.mil/wet]ands/Permits.html.
The USACE is the lead regulatory agency. To review the requirements for the use of Nationwide,
Regional or General permits, and to determine which permit applies to your project, please go to the
USACE website at w-ww.saw.usace.army.mil/Wetlands/index.htm], or contact one of the field offices
listed on page 3 of this application. The website also lists the responsible project manager for each
county in North Carolina and provides additional information regarding the identification and regulation
of wetlands and waters of the U. S.
The DWQ issues a corresponding Certification (General or Individual), and cannot tell the applicant
which 401 Certification will apply until the 404 Permit type has been determined by the USACE.
Applicants are encouraged to visit DWQ's 401/Wetlands Unit website at
http://h2o.enr.state.nc.us/ncwetlands to read about current requirements for the 401 Water Quality
Certification Program and to determine whether or not Riparian Buffer Rules are applicable. The
applicant is also advised to read the full text of the General Certification (GC) matching the specific 404
Permit requested. In some cases, written approval for General Certifications is not required, provided
that the applicant adheres to all conditions of the GC. Applicants lacking access to the internet should
contact DWQ's Central Office in Raleigh at [phone].
Trout Waters Coordination - Special coordination with the North Carolina Wildlife Resources
Commission (NCWRC) is required for projects occurring in any of North Carolina's twenty-five
counties that contain trout waters. In such cases, the applicant should contact the appropriate NCWRC
regional coordinator (listed by county on page 4 of this application) prior to submittal of the application.
Updated 11/1/2005
Page 1 of 12
Coastal Area Management Act (CAMA) Coordination - If the project occurs in any of North Carolina's
twenty coastal counties (listed on page 4) the applicant should contact the North Carolina Division of
Coastal Management (DCM). DCM will determine whether or not the project is within a designated
Area of Environmental Concern, in which case DCM will act as the lead permitting agency. In such
cases, DCM will require a CAMA Permit and will coordinate the 404/401 Permits.
The applicant may also choose to coordinate with the United States Fish and Wildlife Service to ensure
that the proposed project will have no impact upon any endangered or threatened species or critical
habitat as regulated by the Endangered Species Act, and the State Historic Preservation Office, North
Carolina Department of Cultural Resources to ensure that the proposed project will have no impact upon
any properties listed or eligible for listing on the National Register of Historic Places. Compliance with
these regulations is required to be eligible for any Department of the Army permit. The addresses for
both agencies are listed on page 3 of this application.
USACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms,
photos, etc. to the applicable USACE Regulatory Field Office. Upon receipt of an application, the
USACE will determine if the application is complete as soon as possible, not to exceed 30 days. This
PCN form is designed for the convenience of the applicant to address information needs for all USACE
Nationwide, Regional or General permits, as well as information required for State authorizations,
certifications, and coordination. Fully providing the information requested on this form will result in a
complete application for any of the USACE Nationwide, Regional or General permits. To review the
minimum amount of information that must be provided for a complete PCN for each USACE
Nationwide permit, see Condition 13, 67 Fed. Reg. 2090 (Jan. 15, 2002), available at
http:/hvww usace army.mil/inet/functions/cw/cecwo/rep 2002nwps.pdf. Processing times vary by
permit and begin once the application has been determined to be complete. Please contact the
appropriate regulatory field office for specific answers to permit processing periods.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise stated
as optional. Incomplete applications will be returned. Submit seven collated copies of all USACE
Permit materials to the Division of Water Quality, 401/Wetlands Unit, 1650 Mail Service Center,
Raleigh, NC, 27699-1650. If written approval is required or specifically requested for a 401
Certification, then a non-refundable application fee is required. In brief, if project impacts include less
than one acre of cumulative wetland/water impacts and less than 150 feet_cumulative- impacts- to-
- streams then a fee of $200 is required. If either of these thresholds is exceeded, then a fee of $475 is
required. A check made out to the North Carolina Division of Water Quality, with the specific name of
the project or applicant identified, should be stapled to the front of the application package. For more
information, see the DWQ website at http://l12o.ehnr.state.nc.us/ncwet]ands/fees.litm]. The fee must be
attached with the application unless the applicant is a federal agency in which case the check may be
issued from a separate office. In such cases, the project must be identifiable on the U.S. Treasury check
so that it can be credited to the appropriate project. If written approval is sought solely for Buffer Rules,
the application fee does not apply, and the applicant should clearly state (in a cover letter) that only
Buffer Rule approval is sought in writing. Wetlands or waters of the U.S. may not be impacted prior to
issuance or waiver of a Section 401 Water Quality Certification. Upon receipt of a complete application
for a 401 Certification, the Division of Water Quality has 60 days to prepare a written response to the
applicant. This may include a 401 Certification, an on-hold letter pending receipt of additional
requested information, or denial.
Updated 11/1/2005
Page 2 of 12
US Army Corp s Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Office Alexander Caldwell Haywood McDowell Swain
US Army Corps of Engineers Allegliany Catawba Henderson Mecklenburg Transylvania
151 Patton Avenue Aslne Cherokee Iredcll Mitchell Union
Room 208 Avery Clay Jackson Polk Watauga
Asheville, NC 28801-5006 Buncombe Cleveland Lincoln Rowan Yancey
Telephone: [phone] Burke Gaston Macon Rutherford
Fax: [phone] Cabarrus Graham Madison Stanley
Raleigh Regulatory Field Office Alamance Franklin Nash Surry
US Army Corps Of Engineers Caswell Forsyth Northampton Vance
6508 Falls of the Ncuse Road Chatham Granville Orange Wake
Suite 120 Davidson Guilford Person Warren
Raleigh, NC 27615 Davie Halifax Randolph Wilkes
Telephone: [phone] Durham Johnston Rockingham Wilson
Fax: [phone] Edgecombe Lee Stokes Yadkin
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare Lenoir
Post Office Box 1000 Camden Gates Martin
Washington, NC 27889-1000 Carteret* Green Pamlico
Telephone: [phone] Chowan Hertford Pasquotank
Fax: [phone] Craven Hyde Perquimans
Wilmington Regulatory Field Office Anson Duplin Onslow
US Army Corps Of Engineers Bladen Harnett Pender
Post Office Box 1890 Brunswick Hoke Richmond
Wilmington, NC 28402-1890 Carteret Montgomery Robeson
Telephone: [phone] Columbus Moore Sampson
Fax: [phone] Cumberland New Hanover Scotland
North Carolina State Agencies
Division of Water Quality
401- Wetlands Unit ---- -
1650 Mail Service Center
Raleigh, NC 27699-150
Telephone: [phone]
Fax: [phone]
Division of Water Quality
Ecosystem Enhancement Program
1652 Mail Service Center
Raleigh, NC 27699-1652
Telephone: [phone]
Fax: [phone]
Pitt
Tyrrell
Washington
Wayne
*Croatan National Forest Only
State Historic Preservation Office
Department Of Cultural Resources
4617 Mail Service Center
Raleigh, NC 276994617
Telephone: [phone]
Fax: [phone]
US Fish and Wildlife Service / National Marine Fisheries Service
US Fish and Wildlife Service US Fish and Wildlife Service National Marine Fisheries Service
Raleigh Field Office Asheville Field Office Habitat Conservation Division
Post Office Box 33726 160 Zillicoa Street Pivers Island
Raleigh, NC 27636-3726 Asheville, NC 28801 Beaufort, NC 28516
Telephone: [phone] Telephone: [phone] Telephone: [phone]
Updated 11/1/2005
Page 3 of 12
CAMA and NC Coastal Counties
Division of Coastal Management
400 Commerce Avenue
Morehead City, NC 28557-3421
Telephone: [phone]
Fax: [phone]
Western Piedmont Region Coordinator
3855 Idlewild Road
Kerncrsville, NC 27284-9180
Telephone: [phone]
Mountain Region Coordinator
20830 Great Smoky Mtn. Expressway
Waynesville, NC 28786
Telephone: [phone]
Fax: [phone]
Beaufort Chowan Hertford Pasquotank
Bertie Craven Hyde Ponder
Brunswick Currituck New Hanover Perquimans
Camden Dare Onslow Tyrrell
Carteret Gates Pamlico Washington
NCWRC and NC Trout Counties
Alleghany Caldwell
Ashe Mitchell
Avery Stokes
Burke Surry
Buncombe Henderson
Cherokee Jackson
Clay Macon
Graham Madison
Haywood McDowell
Watauga
Wilkes
Polk
Rutherford
Swain
Transylvania
Yancey
APPLICATION FORTM BEGINS ON PAGE 5. PLEASE DO NOT SUBMIT PAGES I - 4.
Updated 11/1/2005
Page 4 of 12
Office Use Only: Form Version March 05
USACE Action ID No. DWQ No. 0 0 6 1 2 8 9
(tf arnv natticular item is not analicable to this project, please enter "Not Applicable" or "N/A".)
1.
H.
I-
1. Check all of the approval(s) requested for this project:
Section 404 Permit ? Riparian or Watershed Buffer Rules
? Section 10 Permit ? Isolated Wetland Permit from DWQ
401 Water Quality Certification ? Express 401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested: A W P 3 9
Processing
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
4. If payment into the North Carolina Ecosystem Enhancement Program (NCEEP) is proposed
for mitigation of impacts, attach the acceptance letter from NCEEP, complete section VIII,
and check here: ?
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
Environmental Concern (see the top of page 2 for further details), check here:
o cc?_ a? ::=3 ?:
Applicant Information
1. Owner/Applicant Information
Name: b. t N A AW
Mailing Address: ?5 b oo 5 O G f A t3 M
l?\? J ?iln?a _ ?V/? 33 014
AUG 0 9 2006
r
Telephone Number:g6_ 4?5o -78ib Fax Number: 78(t .g 13338
E-mail Address:
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent has signatory authority for the owner/applicant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:_
Fax Number:
Updated 11/1/2005
Page 5 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project:
2. T.I.P. Project Number or State Project Number (NCDOT Only): ?U
Property Identification Number (Tax PIN):
4. Location W
County: J f Nearest Town:
Subdivision na e (include phase/lot number): Q-?f 141 (z t"JT -
Directions to site (include road numbers/names, landmarks, etc.):
5. Site coordinates (For linear projects, such as a road or utility line, attach a sheet that
separately lists the coordinates for each crossing of a distinct waterbody.)
Decimal Degrees (6 digits minimum): ON oW
-- --
6. Property size (acres). 670 ? AG ? S -
7. Name of nearest receiving body of water:

8. River Basin: r01aLI'k 13(Zan`D
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at littp://112o.eilr.state.ne.us/admin/maps /.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: Kk;S
V .J n
Updated 11/1/2005
Page 6 of 12
10. Dpcribe the overall project in detail, including the type of equipment to be used:
L-J e, -fa w n.-r n A eG tU ao r4r_-t Ida Q.1L_ VC, t Nb FF? RX 1A
N % 't
IV.
V.
VI.
11. Expl the purpose of the proposed work:
4NN 1,NSTA"ATto14
Prior Project History

if jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
andVI pr vide justification for the exclusion of this work from the current application.
L 'Do NOT /x.01 14'- . 10 N-Tlati 4 t%yTV&,g GwS rplus
j, +" IT tyt? F%PtSIA o ? 1_416 Deli eL Pq Mr-,J-C
Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. Each impact must be
-listed separately in the tables below (e.g., culvert installation should_be_listed separately from
riprap dissipater pads). Be sure to indicate if an impact is temporary. All proposed impacts,
permanent and temporary, must be listed, and must be labeled and clearly identifiable on an
accompanying site plan. All wetlands and waters, and all streams (intermittent and perennial)
should be shown on a delineation map, whether or not impacts are proposed to these systems.
Wetland and stream evaluation and delineation forms should be included as appropriate.
Photographs may be included at the applicant's discretion. If this proposed impact is strictly for
wetland or stream mitigation, list and describe the impact in Section VIII below. If additional
space is needed for listing or description, please attach a separate sheet.
1. Provide a written description of the proposed impacts: Po r'. (-, C P.1. S S t 65
Updated 11/1/2005
Page 7 of 12
2. Individually list wetland impacts. Types of impacts include, but are not limited to
mechanized clearing, grading, fill, excavation, flooding, ditching/d inage, etc. For dams,
-hr 1-+ imnnrtc rtna to tenth ctntctnre and flooding. 0 7P11

Wetland Impact
Site Number
(indicate on map)

Type of Impact Type of Wetland

(e.g., forested, marsh,
herbaceous, bog, etc.) Located within
100-year
Floodplain
(es/no) Distance to
Nearest
Stream
(linear feet) Area of
Impact
(acres)

Total Wetland Impact (acres)
3. List the total acreage (estimated) of all existing wetlands on the property: S +
4. Individually list all intermittent and perennial stream impacts. Be sure to identify temporary
impacts. Stream impacts include, but are not limited to placement of fill or culverts, dam
construction, flooding, relocation, stabilization activities (e.g., cement walls, rip-rap, crib
walls, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is proposed,
plans and profiles showing the linear footprint for both the original and relocated streams
must be included To calculate acrea a multi 1 length X width, then divide b 43,560.
Stream Impact
Number
(indicate on ma)
Stream Name
Type of Impact Perennial or
Intermittent? Average
Stream Width
Before Impact Impact
Length
(linear feet) Area of
Impact
(acres)
V•r ? VI r ? . d Z
IJ n
1" • 0 Z

Total Stream Impact (by length and acreage)
5. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.). Open water impacts include, but are not limited to
fill excavation dredging- flooding. drainage, bulkheads, etc.
Open Water Impact
Site Number
(indicate on ma) Name of Waterbody
(if applicable)
Type of Impact Type of Waterbody
(lake, pond, estuary, sound, bay,
ocean, etc.) Area of
Impact
(acres)

Total Open Water Impact (acres)
Updated 11/1/2005
Page 8 of 12
6. List the cumulative impact to all Waters of the U.S. resulting from the project.
Stream Impact (acres):
Wetland Impact acres :
Open Water Impact (acres):
Total Impact to Waters of the U. S. acres
Total Stream Impact (linear feet):
7. Isolated Waters
Do any isolated waters exist on the property? ? Yes WTo
Describe all impacts to isolated waters, and include the type of water (wetland or stream) and
the size of the proposed impact (acres or linear feet). Please note that this section only
applies to waters that have specifically been determined to be isolated by the USACE.
Pond Creation
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Current land use in the vicinity of the pond:
Size of watershed draining to pond:
VII. Impact Justification (Avoidance and Minimization)
Expected pond surface area:
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why-these design options were not feasible. Also discuss how impacts- --
were minimized once the desired site plan was developed. If applicable, discuss construction
acts.
tec ni es to be ollowed durin construction t reduce ?PVQ)-C>%%'/1StOtJ
t VJ"b v Ulz.o??n,,rcf;
o. b
rN ?n! r".1 A - 'ti/t n A f eN GoAj ft.d 1 47 t-Al
,-?
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Updated 11/1/2005
Page 9 of 12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on January 15, 2002, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCEEP concurrence shall be placed on hold as incomplete.
An applicant may also choose to review the current guidelines for stream restoration in DWQ's
Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.us/ncwetlands/strmgide.litmi.
Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
J 0 (!LS A-A D otliayTtOti
2. Mitigation may also be made by payment into the North Carolina Ecosystem Enhancement
Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at
[phone] to determine availability,_ and written approval from the NCEEP indicating
that they are will to accept payment for the mitigation must be attached to this form. For
additional information regarding the application process for the NCEEP, check the NCEEP
website at http:Hh2o. enr. state. nc.us/wrp/index.htm. If use of the NCEEP is proposed, please
check the appropriate box on page five and provide the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres
Amount of Coastal wetland mitigation requested (acres):
Updated 11/1/2005
Page 10 of 12
IX.
X.
Environmental Documentation (required by DWQ)
1. Does the project involve an expenditure of public (federal/state/local) funds or the use of
public (federal/state) land? Yes ? No
2. If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No ?
3. If yes, has the document review been finalized by the State Clearinghouse? If so, please
attach a copy of the NEPA or SEPA final approval letter. Yes ? No ?
Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
1. Will the project impact protected riparian buffers identified within 15A NCAC 213 .0233
(Meuse), 15A NCAC 213 .0259 (Tar-Pamlico), 15A NCAC 02B .0243 (Catawba) 15A NCAC
2B .0250 (Randleman Rules and Water Supply Buffer Requirements), . or other (please
identify V Yes ? No ?
2
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3 (2 for Catawba)
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from the top of the near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
If buffer mitigation is required, please discuss what
Donation of Property, Riparian Buffer Restoration /
Riparian Buffer Restoration Fund). Please attach all
within 15A NCAC 2B .0242 or.0244, or.0260.
If "yes", identify the square feet and acreage of impact to each zone of the riparian buffers.
If buffer mitigation is required calculate the required amount of mitigation by applying the
buffer multipliers.
type of mitigation is proposed (i.e.,
Enhancement, or Payment into the
appropriate information as identified
Updated 11/1/2005
Page 11 of 12
XI. Stormwater (required by DWQ)
Describe impervious acreage (existing and proposed) versus total acreage on the site. Discuss
stormwater controls proposed in order to protect surface waters and wetlands downstream from
the property. If percent impervious surface exceeds 20%, please provide calculations
d monstrating total proposed impervious level. 'rta ek W? C.
SfoeN? WA'SLL
P•6 r1f!f_0TnATra - I C% 0-U4 ib .'l(IbAM est
XII. Sewage Disposal (required by DWQ)
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.
PTIL O, S ?.aGtA r
XIII. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes JR No ?
Is this an after-the-fact permit application? Yes A No ?
XIV. Cumulative Impacts (required by DWQ)
Will this project (based on past and reasonably anticipated future impacts) result in additional
development, which could impact nearby downstream water quality? Yes ? No ?
If yes, please submit a qualitative or quantitative cumulative impact analysis in accordance with
the most recent North Carolina Division of Water Quality policy posted on our website at
http://112o.enr.st,ite.nc.us/newetiands. If no, please provide a short narrative description:
XV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
ThreatWed Species„ accessibility problems, or other issues outside of the applicant's control).
7)G
Applicant/Agent's Signature LuLv
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Updated 11/1/2005
Page 12 of 12
gr
AIJI; 0 9 2006
DENh • WATER UUALITY
WETLANDS AND STOft',1WATER BRANCH
?0? wAT 9Q
?0: G
> a r
2 0 0 0 1 2 8 9
Pre-Construction Notification (PCN) Application Form
For Section 404 and/or Section 10 Nationwide, Regional and General Permits, Section 401
General Water Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This form is to be used for projects qualifying for any of the U.S. Army Corps of Engineers' (USACE)
Nationwide, Regional or General Permits as required by Section 404 of the Clean Water Act and/or
Section 10 of the Rivers and Harbors Act, and for the North Carolina Division of Water Quality's
(DWQ) associated General 401 Water Quality Certifications. This form is also to be used for any
project requiring approval under any Riparian Buffer Rules implemented by the N.C. Division of Water
Quality. This form should not be used if you are requesting an Individual 404 Permit or Individual 401
Water Quality Certification. The USACE Individual Permit application form is available online at
www.saw.usace.army.i-niI/wetiands/Permits.html.
The USACE is the lead regulatory agency. To review the requirements for the use of Nationwide,
Regional or General permits, and to determine which permit applies to your project, please go to the
USACE website at www.saw.usace.army.mil/wetlands/index.htm], or contact one of the field offices
listed on page 3 of this application. The website also lists the responsible project manager for each
county in North Carolina and provides additional information regarding the identification and regulation
of wetlands and waters of the U. S.
The DWQ issues a corresponding Certification (General or Individual), and cannot tell the applicant
which 401 Certification will apply until the 404 Permit type has been determined by the USACE.
Applicants are encouraged to visit DWQ's 401/Wetlands Unit website at
littp://h2o.enr.state.nc.us/ncwetlands to read about current requirements for the 401 Water Quality
Certification Program and to determine whether or not Riparian Buffer Rules are applicable. The
applicant is also advised to read the full text of the General Certification (GC) matching the specific 404
Permit requested. In some cases, written approval for General Certifications is not required, provided
that the applicant adheres to all conditions of the GC. Applicants lacking access to the internet should
contact DWQ's Central Office in Raleigh at [phone].
Trout Waters Coordination - Special coordination with the North Carolina Wildlife Resources
Commission (NCWRC) is required for projects occurring in any of North Carolina's twenty-five
counties that contain trout waters. In such cases, the applicant should contact the appropriate NCWRC
regional coordinator (listed by county on page 4 of this application) prior to submittal of the application.
Updated 11/1/2005
Page 1 of 12
Coastal Area Management Act (CAMA) Coordination - If the project occurs in any of North Carolina's
twenty coastal counties (listed on page 4) the applicant should contact the North Carolina Division of
Coastal Management (DCM). DCM will determine whether or not the project is within a designated
Area of Environmental Concern, in which case DCM will act as the lead permitting agency. In such
cases, DCM will require a CAMA Permit and will coordinate the 404/401 Permits.
The applicant may also choose to coordinate with the United States Fish and Wildlife Service to ensure
that the proposed project will have no impact upon any endangered or threatened species or critical
habitat as regulated by the Endangered Species Act, and the State Historic Preservation Office, North
Carolina Department of Cultural Resources to ensure that the proposed project will have no impact upon
any properties listed or eligible for listing on the National Register of Historic Places. Compliance with
these regulations is required to be eligible for any Department of the Army permit. The addresses for
both agencies are listed on page 3 of this application.
USACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms,
photos, etc. to the applicable USACE Regulatory Field Office. Upon receipt of an application, the
USACE will determine if the application is complete as soon as possible, not to exceed 30 days.. This
PCN form is designed for the convenience of the applicant to address information needs for all USACE
Nationwide, Regional or General permits, as well as information required for State authorizations,
certifications, and coordination. Fully providing the information requested on this form will result in a
complete application for any of the USACE Nationwide, Regional or General permits. To review the
minimum amount of information that must be provided for a complete PCN for each USACE
Nationwide permit, see Condition 13, 67 Fed. Reg. 2090 (Jan. 15, 2002), available at
http://www.usace.army.mil/inet/functions/ew/cecwo/reJ2002nwps.pdf. Processing times vary by
permit and begin once the application has been determined to be complete. Please contact the
appropriate regulatory field office for specific answers to permit processing periods.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise stated
as optional. Incomplete applications will be returned. Submit seven collated copies of all USACE
Permit materials to the Division of Water Quality, 401/Wetlands Unit, 1650 Mail Service Center,
Raleigh, NC, 27699-1650. If written approval is required or specifically requested for a 401
Certification, then a non-refundable application fee is required. In brief, if project impacts include less
than one acre of cumulative wetland/water impacts and less than- 150_ feet- -cumulative - impacts-.to
streams,-then a fee of $200 is required. If either of these thresholds is exceeded, then a fee of $475 is
required. A check made out to the North Carolina Division of Water Quality, with the specific name of
the project or applicant identified, should be stapled to the front of the application package. For more
information, see the DWQ website at http://li2o.clinr.state.ne.us/ncwetlands/fees.litml. The fee must be
attached with the application unless the applicant is a federal agency in which case the check may be
issued from a separate office. In such cases, the project must be identifiable on the U.S. Treasury check
so that it can be credited to the appropriate project. If written approval is sought solely for Buffer Rules,
the application fee does not apply, and the applicant should clearly state (in a cover letter) that only
Buffer Rule approval is sought in writing. Wetlands or waters of the U.S. may not be impacted prior to
issuance or waiver of a Section 401 Water Quality Certification. Upon receipt of a complete application
for a 401 Certification, the Division of Water Quality has 60 days to prepare a written response to the
applicant. This may include a 401 Certification, an on-hold letter pending receipt of additional
requested information, or denial.
Updated 11/1/2005
Page 2 of 12
US Army Corps Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Office Alexander Caldwell Haywood McDowell
US Army Corps of Engineers Alleghany Catawba Henderson Mecklenburg
151 Patton Avenue Ashe Cherokee Iredell Mitchell
Room 208 Avery Clay Jackson Polk
Asheville, NC 28801-5006 Buncombe Cleveland Lincoln Rowan
Telephone: [phone] Burke Gaston Macon Rutherford
Fax: [phone] Cabanas Graham Madison Stanley
Raleigh Regulatory Field Office
US Army Corps Of Engineers
6508 Falls of the Neuse Road
Suite 120
Raleigh, NC 27615
Telephone: [phone]
Fax: [phone]
Alamance Franklin Nash Surry
Caswell Forsyth Northampton Vance
Chatham Granville Orange Wake
Davidson Guilford Person Warren
Davie Halifax Randolph Wilkes
Durham Johnston Rockingham Wilson
Edgecombe Lee Stokes Yadkin
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare Lenoir
Post Office Box 1000 Camden Gates Martin
Washington, NC 27889-1000 Carteret* Green Pamlico
Telephone: [phone] Chowan Hertford Pasquotank
Fax: [phone] Craven Hyde Pcrquimans
Wilmington Regulatory Field Office
US Army Corps Of Engineers
Post Office Box 1890
Wilmington, NC 28402-1890
Telephone: [phone]
Fax: [phone]
Division of Water Quality
_-- 401- Wetlands Unit-- ---- - -- -- _- .
1650 Mail Service Center
Raleigh, NC 27699-1850
Telephone: [phone]
Fax: [phone]
US Fisl
US Fish and Wildlife Service
Raleigh Field Office
Post Office Box 33726
Raleigh, NC 27636-3726
Telephone: [phone]
Anson Duplin Onslow
Bladen Harnett Pender
Brunswick Hoke Richmond
Carteret Montgomery Robeson
Columbus Moore Sampson
Cumberland New Hanover Scotland
North Carolina State Agencies
Division of Water Quality
- Ecosystem-Enhancement Program
1652 Mail Service Center
Raleigh, NC 27699-1652
Telephone: [phone]
Fax: [phone]
i and Wildlife Service / National IN
US Fish and Wildlife Service
Asheville Field Office
160 Zillicoa Street
Asheville, NC 28801
Telephone: [phone]
Pitt
Tyrrell
Washington
Wayne
Swain
Transylvania
Union
Watauga
Yancey
*Croatan National Forest Only
State Historic Preservation Office
Department: Of Cultural Resources
4617 Mail Service Center
Raleigh, NC 27699-4617
Telephone: [phone]
Fax: [phone]
[arine Fisheries Service
National Marine Fisheries Service
Habitat Conservation Division
Pivers Island
Beaufort, NC 28516
Telephone: [phone]
Updated 11/1/2005
Page 3 of 12
CAMA and NC Coastal Counties
Division of Coastal Management
400 Commerce Avenue
Morehead City, NC 28557-3421
Telephone: [phone]
Fax: [phone]
Western Piedmont Region Coordinator
3855 Idlewild Road
Kernersville, NC 27284-9180
Telephone: [phone]
Mountain Region Coordinator
20830 Great Smoky Mtn. Expressway
Waynesville, NC 28786
Telephone: [phone]
Fax: [phone]
Beaufort Chowan Hertford Pasquotank
Bertie Craven Hyde Pender
Brunswick Cutrituck New Hanover Perquimans
Camden Dare Onslow Tyrrell
Carteret Gates Pamlico Washington
NCWRC and NC Trout Counties
Alleghany Caldwell
Ashe Mitchell
Avery Stokes
Burke Surry
Buncombe Henderson
Cherokee Jackson
Clay Macon
Graham Madison
Haywood McDowell
Watauga
Wilkes
Polk
Rutherford
Swain
Transylvania
Yancey
APPLICATION FORM BEGINS ON PAGE 5. PLEASE DO NOT SUBMIT PAGES 1 - 4.
Updated 11/1/2005
Page 4 of 12
Office Use Only' Form Version March 05
USACE Action ID No. DWQ No. 2 0 0 6 1 2 8 9
(Tf anv nmlinilnr item is not aUnlicable to this moiect. please enter "Not Applicable" or "N/A".)
1. Processing
1. Check all of the approval(s) requested for this project:
Section 404 Permit ? Riparian or Watershed Buffer Rules
? Section 10 Permit ? Isolated Wetland Permit from DWQ
401 Water Quality Certification ? Express 401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested: A W P 3 9
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
4. If payment into the North Carolina Ecosystem Enhancement Program (NCEEP) is proposed
for mitigation of impacts, attach the acceptance letter from NCEEP, complete section VIII,
and check here: ?
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Man ement Area of
Environmental Concern (see the top of page 2 for further details), check her
H. Applicant Information" AUG 0 9 LUUb
1. Owner/Applicant Information 1 A 11 t DE NR - WATER QUALITY
RMCH
Name: -? /? A.2b t l N A A0V4_rA t5"Nt ,ITy'WS
Mailing Address: 3 S oo S • 0 G JA, 0 'tit. S? ?? E ZZ?i
l& \k_awnA ts V-t.A '33 1314
Telephone Number:q6t{. CKO ?78Vb Fax Number:78(, -513-3383
E-mail Address:
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent has signatory authority for the owner/applicant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number
Updated 11/1/2005
Page 5 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project:
2. T.I.P. Project Number or State Project Number (NCDOT Only): /a
3. Property Identification Number (Tax PK:
4. Location W p.
County: '? b• t W f Nearest Town:
Q
Subdivisionnanle (include phase/lot number): G .?sS t'Jr
Directions to site (include road numbers/names, landmarks, etc.):
y65-
5. Site coordinates (For linear projects, such as a road or utility line, attach a sheet that
separately lists the coordinates for each crossing of a distinct waterbody.)
Decimal Degrees (6 digits minimum): ON oW
6. Property size (acres): AG S
7. Name of nearest receiving body of water: ?a G ao C E V__
8. River Basin: ?1 tj t,%A 5CZ?On. D
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o enr state.nc.us/admin/mans/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: S (D( ,i-f i A. V JD_
Updated 111112005
Page 6 of 12
,,?cribe the overall project in detail, including the type of equipment to be used:
10. D,Fe
}i.JS-(Au. A.-(le A e ,2o AD p.l U1 O2VL- VS t Nb F03 VX%A
?
11. Expl the purpose of the proposed work:
9A.N _S#1 S T Ik" A T to a _ A ,3 4 G R-o SS t ?a
IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and pr1vide justification for the exclusion of this work from the current application.
\ . 01 A-. _ .1 __. A _ a .e . _ ..n rt•r r- b.i J C.i -ri.!}r CA.tASS (/JVS
to 0
VI. Proposed Impacts to Waters of the United States/Waters of the State
it is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. Each impact must be
listed separately in the tables below (e.g.,_culvert _installation _should_be-listed _separately_from
riprap dissipater pads). Be sure to indicate if an impact is temporary. All proposed impacts,
permanent and temporary, must be listed, and must be labeled and clearly identifiable on an
accompanying site plan. All wetlands and waters, and all streams (intermittent and perennial)
should be shown on a delineation map, whether or not impacts are proposed to these systems.
Wetland and stream evaluation and delineation forms should be included as appropriate.
Photographs may be included at the applicant's discretion. If this proposed impact is strictly for
wetland or stream mitigation, list and describe the impact in Section VIII below. If additional
space is needed for listing or description, please attach a separate sheet.
1. Provide a written description of the proposed impacts: go l,, z-., C .(Lem S S t ts_ 6S
Updated 11/1/2005
Page 7 of 12
2. Individually list wetland impacts. Types of impacts include, but are not limited to
mechanized clearing, grading, fill, excavation, flooding, ditching/d inage, etc. For dams,
c,narafs-1w lict imnnetc due to hnth structure and floodina. 0 P•

Wetland Impact
Site Number
(indicate on map)

Type of Impact Type of Wetland

(e.g., forested, marsh,
herbaceous, bog, etc.) Located within
100-year
Floodplain
(yes/no) Distance to
Nearest
Stream
(linear feet) Area of
Impact
(acres)

Total Wetland Impact (acres)
3. List the total acreage (estimated) of all existing wetlands on the property: S1: ACtU-s
4. Individually list all intermittent and perennial stream impacts. Be sure to identify temporary
impacts. Stream impacts include, but are not limited to placement of fill or culverts, dam
construction, flooding, relocation, stabilization activities (e.g., cement walls, rip-rap, crib
walls, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is proposed,
plans and profiles showing the linear footprint for both the original and relocated streams
mii,t hP incl„ded To calculate acreal?e- multiDly length X width, then divide by 43,560.
Stream Impact
Number
(indicate on ma)
Stream Name
Type of Impact Perennial or
Intermittent? Average
Stream Width
Before Impact Impact
Length
(linear feet) Area of
Impact
(acres)
I Vr P N Ir o .oz
? •oZ
p oz

Total Stream Impact (by length and acreage)
Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.). Open water impacts include, but are not limited to
fill excavation dredging. floodinn. drainaae. bulkheads. etc.
Open Water Impact
Site Number
(indicate on ma) Name of Waterbody

(if applicable)
Type of Impact Type of Waterbody
(lake, pond, estuary, sound, bay,
ocean, etc.) Area of
Impact
(acres)

Total Open Water Impact (acres)
Updated 11/1/2005
Page 8 of 12
6. List the cumulative impact to all Waters of the U.S. resulting from the project.
Stream Impact (acres):
Wetland Impact acres :
Open Water Impact (acres):
Total Impact to Waters of the U. S. acres
Total Stream Impact (linear feet):
7. Isolated Waters
Do any isolated waters exist on the property? ? Yes Vo
Describe all impacts to isolated waters, and include the type of water (wetland or stream) and
the size of the proposed impact (acres or linear feet). Please note that this section only
applies to waters that have specifically been determined to be isolated by the USACE.
Pond Creation
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., damfembankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Current land use in the vicinity of the pond:
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
tecl?nlg?zes to be followed durin construction tp reduce impacts.
G„ ilh.A 14A,i i,aKen t6VN.t.I N C_ SvQ)-o1V1StoN OP_rj1 &,jC&
&-, r-, (,nr1t,"i / A -?'/An 6j?oA(oN 60 "J-re,1 17 t_'kd --
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Updated 11/1/2005
Page 9 of 12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on January 15, 2002, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCEEP concurrence shall be placed on hold as incomplete.
An applicant may also choose to review the current guidelines for stream restoration in DWQ's
Draft Technical Guide for Stream Work in North Carolina, available at
http•//h2o enr state nc us/ncwetlands/strm?,,ide.litml.
Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
G( (21 AAD oNJUVATcOll,
2. Mitigation may also be made by payment into the North Carolina Ecosystem Enhancement
Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at
[phone] to determine availability, and written approval from the. NCEEP indicating-
that they are will to accept payment for the mitigation must be attached to this form. For
additional information regarding the application process for the NCEEP, check the NCEEP
website at http•//h2o enr state.nc.us/wrp/index.htm. If use of the NCEEP is proposed, please
check the appropriate box on page five and provide the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):- i
Updated 11/1/2005
Page 10 of 12
IX. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federal/state/local) funds or the use of
public (federal/state) land? Yes ? No
ILq
2. If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No ?
If yes, has the document review been finalized by the State Clearinghouse? If so, please
attach a copy of the NEPA or SEPA final approval letter. Yes ? No ?
X. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
2
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 213 .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 02B .0243 (Catawba) 15A NCAC
2B .0250 (Randleman Rules and Water Supply Buffer Requirements), or other (please
identify V Yes ? No ?
If "yes", identify the square feet and acreage of impact to each zone of the riparian buffers.
If buffer mitigation is required calculate the required amount of mitigation by applying the
buffer multipliers.

Zone* Impact
(square feet)
Multiplier Required
Mitigation
1 3 (2 for Catawba)
2 1.5
Total
* Zone I extends out 30 feet perpendicular from the top of the near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e.,
Donation of Property, Riparian Buffer Restoration / Enhancement, or Payment into the
Riparian Buffer Restoration Fund). Please attach all appropriate information as identified
within 15A NCAC 213 .0242 or.0244, or.0260.
Updated 11/1/2005
Page 11 of 12

XI. Stormwater (required by DWQ)
Describe impervious acreage (existing and proposed) versus total acreage on the site. Discuss
stormwater controls proposed in order to protect surface waters and wetlands downstream from
the property. If percent impervious surface exceeds 20%, please provide calculations
demonstrating total proposed impervious level. ?ta-FP? w, R( J o
t'1 _ r - a r.i_ !h rr A n AAA Alf S T OerLLWla'S'4_
XH. Sewage Disposal (required by DWQ)
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.
6L PTIL 0 -S (tGU UtIr
XIIL Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes 2[ No ?
Is this an after-the-fact permit application? Yes A No ?
XIV. Cumulative Impacts (required by DWQ)
Will this project (based on past and reasonably anticipated future impacts) result in additional
development, which could impact nearby downstream water quality? Yes ? No ?
If yes, please submit a qualitative or quantitative cumulative impact analysis in accordance with
the most recent North Carolina Division of Water Quality policy posted on our website at
http•//l12o enr state,nc.us/ncwetlands. If no, please provide a short narrative description:
XV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Tlirgitened Specj4, accessibility problems, or other issues outside of the applicant's control).
Z3 /06
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Updated 11/1/2005
Page 12 of 12
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GENERAL NOTES: / ~ i I ~ ~ i '
- A~~~ PROPERTY CORNERS NOT DESCR]BE~2 ARE "COMPUTES POINTS" ~ ~ ' r-- % i
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3 -ACREAGE CA~CU~ATED 8Y CGORDiNATE COMPUTATfON METH~~C. ~ ~ ~ ~ ~
4 - TH;S S'U'RVEY ~~IEETS THE REOUiREMENTS OF A CLASS "A" SURVEY. ~ 1
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6 - A~~ RCADS SHOWN HEREON ARE PRIVATELY MAIN?AIMED UNLESS O,HER'hISE NDTEG ~ ~ ~ p,..; c
7 -PROPERTY SURVEYED IS NOT iN A FOOD HAZARD AREA.
8 - THERE IS NO RECOVERABLE HORIZONTAL CONTROL WITHIN 2000 . ~ U ~ Z I
9 - NORTH ;S PLAT NORTH AS PER PLAT CABINET "C", SLOT 42C? ~ ~ ti 2 10 ~
10 THE PROPERTY SHOWN HEREON IS SUBJECT TO THE RULES, REGU~a~IONS. ~ ~ z , I j
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NO? SOWN HEREON, MAY EXIST [N THE PUBL}C RECORDS OF THIS COUN'Y. ~ ~ ~ ,,.,L ~ ~ ~ ~ THIS 5'~RVEY REFLECTS ONLY WHA? WAS OBSERVED ON THE GROUND, ~ ~ ~ i ~ CJ ~ ! ~ / , ~a~W'OGG ~ iP, ,~~~,''.TY MAP
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