20061548 Ver 1_COMPLETE FILE_20060921

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Mr. Bobby Arnold Blakely
3857 Fox Meadow Road
Trinity, NC 27370
OCT 2 6 2006
UENR - WATER QUALITY
WETLANDS AND STORMINATER BRANCH
APPROVAL of 401 Water Quality Certification with Additional Conditions
Dear Mr. Blakely:
Alan W. Klimek, P.E. Director
Division of Water Quality
October 20, 2006
DWQ# 06-1548
Davidson County
You have our approval, in accordance with the attached conditions, to impact by excavation 0.48 acre (21,000
square feet) of open waters for the purpose of removing sediment from around an existing pier on High Rock
Lake located on your property at 309 Kirkman Road in Southmont, Cotton Grove Township, Davidson
County, as described in your application received by the Division of Water Quality on September 21, 2006.
After reviewing your application, we have determined that this activity is covered by General Water Quality
Certification Number 3492, which can be viewed on our . web site • at
http://www.ncwaterquality.org/wetlands.html. This Certification allows you to use Regional General Permit
Number 198200030 when it is issued by the U.S. Army Corps of Engineers. In addition, you should secure
any other applicable federal, state or local permits before you proceed with your project, including (but not
limited to) those required by Sediment and Erosion Control, Non-Discharge, and Water Supply Watershed
regulations. Also, this approval will expire when the accompanying 404 permit (Regional General Permit)
expires unless otherwise specified in the General Certification.
This approval is valid only for the purpose and design that you have described in your application. If you
change your project, you must notify us in writing, and you may be required to send us a new application for a
new certification. If the property is sold, the new owner must be given a copy of the Certification and
approval letter and is thereby responsible for complying with all conditions. If total fill for this project (now
or in the future) exceeds one acre of wetland or 150 linear feet of stream, compensatory mitigation may be
required as described in 15A NCAC 2H .0506 (h). For this approval to be valid, you must follow the
conditions listed in the attached certification, as well as the additional conditions listed below:
1. The following impacts are hereby approved as long as all other specific and general conditions of the
Certification are met. No other impacts, including incidental impacts, are approved:
Amount Approved Plan Location or Reference
Waters 0.48 acre 309 Kirkman Road (Parcel Number 0603300000015),
Southmont, Cotton Grove Township, Davidson County
None Carolina
Nturully
North Carolina Division of Water Quality
Wetlands Certification Unit 1650 Mail Service Center Raleigh, NC 27699-1650 Phone [phone] FAX [phone]
2321 Crabtree Blvd. Raleigh, NC 27604-2260 Internet hfttp//:www.ncwaterguality.org
Customer Service Number: 1-877-623-6748
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
An Equal Opportunity/Affirmative Action Employer - 50% Recycled/10% Post Consumer Paper
Mr. Bobby Arnold Blakely
Page 2, DWQ# 06-1548
October 20, 2006
2. Appropriate sediment and erosion control measures which equal or exceed those outlined in the most
recent version of the North Carolina Erosion and Sediment Control Planning and Design Manual or the
North Carolina Surface Mining Manual (available from the Division of Land Resources at NCDENR
regional offices or the central office), whichever is more appropriate, shall be designed, installed and
maintained properly to assure compliance with the North Carolina water quality standards that are
applicable to lakes and reservoirs. Such measures must equal or exceed the requirements specified in
the most recent version of the North Carolina Sediment and Erosion Control Manual. These measures
must be maintained on all construction sites, borrow sites, and waste pile (spoil) sites, including
contractor owned and leased borrow pits, which are associated with the project.
3. Sediment and erosion control measures shall not be placed in wetlands or waters to the maximum extent
practicable. If placement of sediment and erosion control measures in wetlands or waters is
unavoidable, they shall be removed and the natural grade restored within six months of the date that the
project is completed or, if applicable, within six months of the date that the project is released by the
North Carolina Division of Land Resources.
4. No waste, spoil, solids, or fill of any kind shall occur in wetlands, waters, or riparian areas beyond the
footprint of the impacts depicted in the Pre-Construction Notification. All construction activities,
including the design, installation, operation, and maintenance of sediment and erosion control "Best
Management Practices" shall be performed so that no violations of state water quality standards,
statutes, or rules occur.
5. Upon finishing the project, the Applicant shall fill out and return the enclosed "Certificate of
Completion" to notify NCDWQ when all work included in the §401 Certification has been completed.
This certificate should be returned to the 401/Wetlands Unit of the NC Division of Water Quality at the
address listed on the form.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing. You
must act within 60 days of the date that you receive this letter. To ask for a hearing, send a written petition
which conforms to Chapter 150B of the North Carolina General Statutes to the Office of Administrative
Hearings, 6714 Mail Service Center, Raleigh, N.C. 27699-6714. This certification and its conditions are final
and binding unless you ask for a hearing.
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water Act.
If you have any questions, please telephone Daryl Lamb in the DWQ Winston-Salem Regional Office at 336-
771-4959 or Ian McMillan in the Wetlands/401 Central Office in Raleigh at 919-715-4631.
Sincerely,

Alan W. Klimek, P.E.
AWK/cdl
Mr. Bobby Arnold Blakely
Page 3, DWQ# 06-1548
October 20, 2006
Attachments
cc: Mr. John Thomas, U. S. Army Corps of Engineers, Raleigh Regulatory Field Office
Winston-Salem DWQ Regional Office
Central Files
Wetlands/401 File Copy
Triage Check List
Date: 10/23/06 Project Name: Bobby Arnold Blakely
DWQ#: 06-1548
County: Davidson
Daryl Lamb, Winston-Salem Regional Office
To:
60-day processing time: 10/20/06 - 12/18/06
From: Cyndi Karoly Telephone: [phone]
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 (Meuse, 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!

OCTOBER 18th 2006
C) b - IS?iB
BOBBY BLAKELY
30gKIRKMAN ROAD
LEXINGTON,NORTH CAROLINA
27292
REVISIONS FOR EXCAVATION AT 309 KIRKMAN ROAD,
LEXINGTON,NORTH CAROLINA:
TO WHOM IT MAY CONCERN:
AFTER MEETING WITH DARYL LAMB OF QUALITY WATER
CONTROL, WE HAVE MADE A FEW REVISIONS
TO MY ORIGINAL COPIES OF EXCAVATION FOR 309 KIRKMAN
ROAD, LEXINGTON,NC.
PLEASE SEE ATTACHED COPIES FOR YOUR RECORDS,'
THANKYOU,
BOBBY BLAKELY
ANY QUESTIONS:
336-861-5564
ago
o 1 0 1o
OC .VrP????R t
i Office Use ( )wv: .. I'nrtt't Vciaivtt A1,11
.;lt
I ISA('F Action ID No. DWQ No. O l0 --
(11,any >>a 0c+ilat item is not applicahlc t(r this nro,lco, phrase titter "Not Applicable" or "N/A".)
t. Processing
II.

1. Clieck all of the approval(s) requested for this project: ;" .ULIvID
Section 404 Permit Riparian or Watershed Buffer Rules
Section 10 Permit ? Isolated Wetland Permit from DWQ
401 Water Quality Certiteat) on ? Express 401 Water Quality Certification
?. Nationwide, Regional or (;encral Permit Number(s) Rcqucst:ed:_ 9jc2 - 4>4563&
_
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: 11
4. f f payrnent into the North Carolina Ecosystem Lnhancunicnt Program (NCELP) is proposed
for mitigation of impacts, attach the acceptance letter from NCELP, complete section' Vlll,
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 Manageme t Area of
Fnvironmental Concern (see the top of page 2 for further details), check here., Ng ON
?
?5 O D
Applicant Information OCT 2 0 2006
1. Owner/A plieant I
Naincf:-116
Mailing Address:_
-on
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QENR - WATER QUALITY
Telephone Number: Fax Number: -
E-mail Address: Y bfa???t? ?' firt???. r t'• f'. c'•m _
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent s signatory authority for the owner/applicant.)
Name: "S M r i L\j
Company Affiliation: !~
Mailing Address: 4k.--f 3 _.-_
Telephone Number_-
E-mail Address: h?t +
Fax Number:
Ill. Project Int%Wr Ination
Attach ,? vicinity map clearly shovvin the location of the property With respec.i to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing; property
bOUndarles s.tnd development- plans M. relation to surrOtlnding properties. Both the vicinity snap
and situ plat; must include a scale, and north arrow. 'Fine specific footprints of' Lill hijildings,
impervious surfaces, or other faci!ilics 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. 1?'or administrative and distribution purposes, the
USACH requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. nWQ 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:
3 I aReA u -
2. T. 1.1-3. Project Number or State Project Number (NCDO•C Only):
M!i
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3. Property IdentiCcation Number (Tax PIN):_ 9 1 aO -- Cdr- - S J , eMAO -
4. Location
County: Otl1 , 45 o n _ Nearest Town: 41) cf :%?,-
r c - ,ct r 1-.f i _
Subdivision name (include phase/lot number): fi t, LL =
Directions to site (include road numbers/names, landmarks, etc.): M.g p (r44i e /.?
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.)
/ l°w
Decimal Degrees (6 digits minimum): ON
6. Property size (acres):
7. Name of nearest receiving body of water: J-1 I 'JA 8. River Basin: (1 ?? ( Y? ?? i Yes C -
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at littt)//l 20 enr.state».c.us/adminhnat)s/.)
9. Describe the existing conditions on the site and general land use inthe vicini of the project
at the time of this jpplication: F?
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;cktiividually IiA wetl=1 impacLi Types of impact :t1 ude, he are not Jimifod to
r x liaurttzoc? clear, rucfir. fill, excavation. l & 4wh'nW c, ctc. Fc• dams,
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lrst 3iaipacttt dais to both structure and t#sietog,.
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3. List the wW aemage(eatimated) of all existing wrotl ran the
4, hwhvidually loot all int, iamt asst pwvOcial st.*elfittl itq . Be tt so kkMay tmgwwy
ice, Strmm u pwu inchWe,, but are not limited to plec t of Ififl or sail cl=
cvi air ,, flooditt& r im. etaibi izrdmi activitim (C. ., 00"d wailq, tip-mp, c
walla, gabi m, etc.), excevat . ditchir hAWSbt in& etc. If ? 4DC46ft is PmPO$W.,
plans its parat km slw%ing the tincar fit for both the ex' ti A'JW rCkK*%W StiMris
must be iarrclii d. To cam Vie, to kin4y, k X. wig„ t di?ida
tsurn tre?ac t ? .. A"PW i ""Aarror e??€
l lrar i Sk"M Name Tyw of aid we WWO 14T40
't`otal 8ttrwn f?? I and ac)
S. lltxlEitrid"ft fit ail Open er impacts (bob was k Pon". "Ood". WOW$, MWvUC
tl and my Qthm WSW Of 60 1,.m). oPon W-Ir itapWO 4**w Ov limned to
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Q' '? IMPM . IV?erorc af' `'ate?rbvc.+y T"s of W?
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Atiodmis" 4Q no Our")
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Teat (span Waver trgow{wow) j .?, ....?

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(?. I_Jst flu" cumulative impact to all tir'atcrs of the U.S. resultrn); Irom the-p>olcct:
tittcain Impact (acrcs)
Wctl,ind h-11-pact, (a(i s):
Open Water Impact (acre 5)._ ?.
Total Impact to Wailers of the 1.1 S (acres) Q ,
Total Stream Impact (linear feet)
VII.
8.
Mid Creation'
Isolated Waters
Do any isolated waters cxist on the property?. 0 Yes X No
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 USACF,.
If construction of a. pond is proposed, associatcci 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,
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:
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
techniques to be followed during construction to reduce impacts. -_ ? _ .
(U tYV-1 CLC- `>
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. N l A
USAC k In accordance wi(h the Final Notice oi_' lssuancc and Modification of Nationwide
Pcrrr?it?,, publislu;d ill the Fccdc.ri?1 t:_egistcr oil January IS, 2002, mitigation will he required when
r?cc,cS:;?lr.v to ensure that adverse. cftects to the aquatic crnvirownent arc. minimal. Factors
inc1_1cling sire and type of proposed impact and function and relative value of the impacted
aqpi,.itic resource will be considered in d-etermirring acceptability of appropriate and pi cable
niitigalion as proposed. f?xamplcs ol'rnitigat.ion that may he appropriate and practicable include,
but a.rc: r?ot lirnii?ed to: rcclucin}, the size of' the project; establishing and maintaining wetland
and/or upland vegetated bu11ers 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 l)SACI or DWQ to consider the application complete for processing, Any application
lacking a required ?nitigation 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
I?i(t2o ?.nt.,sta(c.i1? us/??c??cat-land,/st??t?,;?de.h ill l-.
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 0ffsite), affected streatn 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 casement, etc.), and a
description of tine current site conditions and proposed method of construction. Please attach
a separate sheet ifnn.ore space is needed.
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 forth. For
additional information regarding the application process for the NCEEP, check the NCEEP
website at http_//112c?.enrst_rtt_e.r c.L?s/wtp/iindc .httn, If use of the NCI EP 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):__
AmoLtrlt of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):__ .
IX. Environmental Documentation (required by DWO)
1. Does the project ,involve ?ni expenditure of public (fedcral/state/local) Cunds or the use of
public (Ibderal/state) land? Yes E] No
2. If' yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Tsnvironnrcnts?tl Policy Act (NE{)A/S.P1'A)?
Note: If' you are nol? sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds 1br environmental documentation.
Yes ? No ?
3. It' yes, has the document review been finalized by the State Clearinghouse? If so, please
attach a copy of the NF.PA or SEPA final approval letter, Yes ? No
X. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
r
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 mast be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
imp, whether or not impacts are proposed to the buffers, Correspondence fror.n 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
(Neese), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 02B .0243 (Catawba) 15A NCAC
213 .0250 (Randleman Rules and Water Supply Buffer Requirements), or other (please
identify - __----- --- T -_) ? Yes ? No LI/I
2. 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 Multiplier Required
(square feet) Mitigation
I 3 (2 for Catawba)
2 1.5
Total --I-- -----1 J
* 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.
3. 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.
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Davidson Co., NC -- Printable Map y
Davidson Co., NC
Parcels
Page 1 of 1
Parcel Number: 0603300000015
Pl n Id: 6720-04-81-0202
Oi~
BLAKELY BOBBY ARNOLD SR ET ALS
309 KIRKMAN ROAD
LEXINGTON NC 27292-0000
Properly Address:
0 KIRKMAN DR
Additional information :
L15 SK1038-470
LAKE DR
Land Units: 1.93 AC
Deed Book: 1638 Pg: 470
Deed Date: 812512005
Account Number: 000009060244
Township: Cotton Grove
Exempt Code:
Building Value: $15,810
Other Building Value: $8,420
Land Value: $38,250
Mard"A value: $62,480
Assessed Value: $62,480
Dell?Lrred value: $0
DISCLA R: The inform tion contained on this ppe is NOT to be conattued or used as a "Isgal description". Ma;
infoffnation is believed to be accurate but accuracy is not guaranteed.
INt Avww.web&.net Anderson & Amclifts, k?c_ htt :/Mww.&ndww=com
Davidson Co., NC -- Printable Map
Davidson Co., NC
Parcels
Parcel Number: 0603300000015
Pin Id: 6720-04-81-0202
Owner:
BLAKELY BOBBY ARNOLD SR ET ALS
309 KIRKMAN ROAD
LEXINGTON NC 27292-0000
Property Address:
0 KIRKMAN DR
Additional Information
L15 SK1636-470
LAKE DR
Land Units: 1.93 AC
Deed Book: 1638 Pg: 470
Deed Date: 8/25/2005
Account Number: 000009080244
Township: Cotton Grove
Exempt Code:
Building Value: $15,810
Other Building Value: $8,420
Land Value: $38,250
Market Value: $82,480
Assessed Value: $82,480
Defamed Value: $0
Page I of 1
DISCLAIMER: The information contained on this page is NOT to be construed or used as a "legal description". MW
information is believed to be accurate but mcuracy is not guaranteed..
hW:/Mrww.wsbW$.rW Anderson 6 Assockda. Inc. MM:llwww.andessoc.cnm
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OCTOBER 18th 2006
o? -- ?S?l g
BOBBY BLAKELY
309 KIRKMAN ROAD
LEXINGTON,NORTH CAROLINA
27292
REVISIONS FOR EXCAVATION AT 309 KIRKMAN ROAD,
LEXINGTON,NORTH CAROLINA:
TO WHOM IT MAY CONCERN:
AFTER MEETING WITH DARYL LAMB OF QUALITY WATER
CONTROL, WE HAVE MADE A FEW REVISIONS
TO MY ORIGINAL COPIES OF EXCAVATION FOR 309 KIRKMAN
ROAD, LEXINGTON,NC.
PLEASE SEE ATTACHED COPIES FOR YOUR RECORDS,
THANKYOU,
BOBBY BLAKELY
ANY QUESTIONS:
336-861-5564
3
99 Q5 w15
U
O C T 2 0 2006
WETIL008R WATER QUALITY
AND STORMWATER BRANCH
i Office Use 0111v: l??:rrlil versiwl,A-Llf-h
No. L) Lk?
I'SA(1' Action JD No. llWQ 1 _ -- ......_?
(11 ,:Illy a(ticular itc:nt,s nol rpplicablc (o this project, please enter "Not Applivable" or "N/A".)
1. Processing
Clieck 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
U 401 Water Quality Certification ? I=sxpress 40) Water Quality Certification
3. Nationwide, Regional or Gencral Permit Nuinber(s) RcgLicsted: ??? ` C3?D<3U
3. if this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here, El
4. If payment into the North Carolina Ecosystem Enhancement Program (N(`EEP) is proposed
for initigation 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 Manageinei t Area of
Environmental Concern (see the top of page 2 for further details), check ???
II. Applicant Information vrla- D
O C T 2 0 2006
1. Owner/ApplieantlnforMation I
I Cf k t r DENR - WATER QUALITY
Name:
01- AW H
Mailing Address: ?L.? K11-(?1 it1 IC;AC? _
ncA
Telephone Number: $.6 by Fax Number:
E-mail Address: V bicJke,l Ted vi'k-4. r 1?. (,Cm
2.
Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent 1 as signatory authority for the owner/applicant.)
Name:_ IiE u'AD r y\ e- Lz ryill n a e bY-A
Company Affiliation: ^
Mailing Address:
Telephone Number:', 4? =
E-mail Address: tilt- +
Fax Number:
Ill. Project lnFir mitiou
Attach a vicinity map clearly shrnvir?j the location of the property yvith respect 10 local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development pla??s in relation to surrounding properties, Holh the vicinity slap
anci site plan must include a scale and north arrow. The specific footprints of all ouildi.nj s,
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 lone; as the property is clearly defined. For administrative and distribution purposes, the
11SACE 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 lull-size construction
drawings rather than a sequential sheet version of the full-sire 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-- B l aReA q - h ntni f?j1h' 1_1o?IIC? ?' n1
2. T.1. P. Project Number or State Project Number (NCDOT Only):.--------.____'..'__ ?__.----T
3. Property Identification Number (Tax PIN): J 1912 A4
4. location
County: al d5 c I Nearest Town: M) [; ? ; ;,t(,i /] Jll .
Subdivision name (include phase/lot number):._QA:?!tf-?- tl -rZ,ct 1l -tifi; - _
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 1 tt/_T_d__ °W
6. Property size (acres):_
7. Name of nearest receiving body of water: Ac a, k(,Z. _
8. River Basin: 1 a Ci k l n River (Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at 1ittp://112o enr.sLate,n.c.us/adrnU ma s/,)
9. Describe the existing conditions pn the site and general tan use in the vicim of the
at the time of this.annlication: f?t e, -"I'& r %4- r'n f ry) 6) A-
E f 1'rt f_ d; I , t q i r J '
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ti. 1 ,1st the cumulative crnpact i o a l l 1katers of the U .S. resulting horn the tect.
Stream [m pact (acres)-
Wet iaz id Im?aact (aci es): __--------------- --
- - - ------- Q.
Chen Water linhact (acres) A
Total Impact to Waters of the 11.S -(acres)
Total Stream impact (linear lc.ct): __.-_- ---_..__ -_------_.----?---_ .-_
7. Isolated Waters
Do any isolated waters exist on the property?. ? Yes ?J No
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 USAGE.
I 0
8. Pond Creation' /V/A
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,
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, diactwu construction
techniques to be followed during construction to reduce impacts.__ _ _ F
L
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. N 1 A

11, In accordance wish the final Notice of Issuance and Modification of Nationwide
1'crnrit';, published in the hedcral Register on Januai-y 15, .1002, mitigation will be required when
necessary to ensure that adverse effects to the aquatic clivironment.axe 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. 1?x,unples of mitigation that may be appropriate and practicable include,
but are. not limited to: reducing the sire of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resoyree 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
- httj?.//1.12o.eiir_ state. nc,t s/ucwE?Clartc?s/st.rari?ide.Iltrttl.
Provide a brief description of the proposed mitigation plan. The descripticfi 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.
NZA
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 WEEP, check the NCEEP
website at littt?://h2o enr statemg.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):_-
IX. Environmental Documentation (required by DWQ)
I. Does the project involve: are expenditure of public (federal/state/Ioca4) funds or the use of
pilbIic (fcdera.l/state) land? Yes EJ No (_ -
2. It' yes, does the project require preparation of an environmental document pursuant to the
requirements of' the National or North Carolina Environrraental Policy Act (NEPA/SEPA)?
Note: if you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordirta?or, at [phone] to review current thresholds for environmental documentation.
Yes ? No U
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 EJ No
Y. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
? M
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state arrd Local buffers associated with the project. The applicant must also.provide.
Justification for these impacts in Section VII above. All proposed impacts mttsibe listed herein,
and must be clearly identifiable on the accompanying site plan. All buffer% 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 2B .0233
(Neuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC. 02B .0243 (Catawba) 15A NCAC
213 .0250 (Randleman Rules and Water Supply Buffer. Requirements), or other (please
identify Yes F? Nc> [i.
2. 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.
7.one* Impact Required
(square feet) Multiplier Mititzatiot
3 (2 for Catawba)
2 1.5
Total
" Zone I extends out 30 feet perpendicular from the top of the near bank of chwmel; Zone 2 extends an
additional 20 feet from the edge of Zonc 1.
3. 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 2B .0242 or .0244, or .0260. ba
Jr
?torllvwntcr (.required by M Q)
1.0ino and -nrojlo "a.' y tw, "lli, site. Discus,,;
?t7?L3ttf?i16
t!€_ 17!LS?ss'f(t t(' 11f t'i'1;"YlE !!'1l?liavS€slSg ?tl:f;:!+.'C" s'"t 'c}-? i'? ???,.,riSt' ?)iiiYti kit
Sewage Dixp("xl (required by DWQ')
C'lear?y detail thc Ultimate; treat-metif rnetho&, arvi disposition lawn thsuha4rg or d,sch: rgc) of
WR4ti'VdNti'1 sac` "It:l'ltt'Sl 1 'ss1 i (ltc' I?? N)C'(? +ltt !<; 1 si 3.1[ttllKl?i?' `. ?lt)lii ti ?. c"}t l11#:' A:1 Gtlitt:
a?
1>. ttsi- i?,? ii, v:+.elt3ti?•! of F)WO Wtetland Nl(_'!\. ` _'# 1
Y;;;;
is 0115 al-i permit No 00
74.1'x'. Cumulative Impacts (required by DWQ)

Will this pmjixt (htLszd on past and reasonably anticipated huture impacts! resui ill additipint,
i evelopnwv? , which coiild inlpar_t ne )y downstretlrn water quality", yev, ?. No
If ves, pleasc: sulltt;it a qualitative or quantitative cumulative i,lapaCt analysis in accord ce with
the rriost recent North Carolina Division (>i' Water Quality pokey poeed on our website at t
:Itty:'I'll2") crii StAte.ni:-,av`t1C\Avltlands l Cltl, 1?lt Vii; Art)41t1C i tii'imi riarrafive escriptipw t
- 1. -1-1- - -.1-1 -1--l- -- - . - ..... ?-
_7+,, - -" 1"'7 . _., f1. ' . t"--
XV. Other Circnt stances (4ptioaal): /?'j / A,
It is the applicant's responsibility to submit the application sufficiently in advance of desired
c;ct_rtstrlie?ti+:?li dates to allow prcx.essing tithe for tlte,4e pennits. Howevcr, an applicant e»ay
chaosc to list ccrostraints assnciatc d with construction or sequencing tha may impose Iitnits on
work scriedules (e.g., draw-down schedules for lakes, dates anocta with. F Wl axxl
'1 hrcaten'W tiles c.ic,?, acv-essihility prohlews, o(- other issues (,iltgides of the applicant's control).
Applia gent's Sillpeature Date
k'Ageiit's signature is valid only if an authorization letter fmtri tile; applicant is provil.lecl l
t'' 1;" 12 of 12
Davidson Co., NC - Printable Map a P"W 1 of 1
Davidson Co., NC
..
Parcels
wa.+o.+ NmMsr: 0603300000015 La"Vmft 1MAC
! uft 4004441 ?0- W-_ 0-1 M : 111 : 470
ai1mm
BLAKELY DOMW AMXX D BR ET AM Account NMWAw. ------
309 TownsW: 0000
C?vw
LEXONPV W 21 -0000 do- tCaM:
o d "w SIN Iq Vslw: $15,610
of w 8u0di ft Vaiw: $6,430
AddNlonel mow : Land Va1w: D
LIS NK1436490 Mrlart Valve: 541,400
LAKE OR Valve: sm,4w
: $0
014G'i.A The bft nation oontminsd on this ?T to be ca ftmW or wad as a 1"0 desw* on". M*
icMiornnYoc? is bslsMed b be but accsxaW1s#w quan%md.

Davidson Co., NC -- Printable Map ti lie l of I
Davidson Co., NC
"I
Patael Mwalm- 09033110000015 nand UMW- V AC
ft W. 6720-04-81-O m Ord ?Odt: 1S? 470
Owner. Do" Dab:
BLAKELY BOBBY AIMU D SR ET ALS Acct l ffi w m 00000OOO0244
3W KNOGYW nxVM Te w *W: Conlon Orove
LEXPOMN HC 27M-OW lbtstnpt Code:
Nopstltt Address: MuNdinp Vakw: $96,810
0 KPJGA i DR Other SuNdinB Veins: $8,420
Addit mW UNbtn a"- : t.,mtd V&%**. $
LIS BKIGW470 Medan Voko: $0,480
LAKE OR Assessed Vakm: $02,400
NO Value: so
OIOCL 1l: This k*MINIM conimkmd on Nib pap is NOTU M construed or used se a lspl ,f c lplom 0. UK
inlornslton Is beloved b be saawele but i 0 - or Y is not g -s - Assd.
hop: waw.we4fs.nM Miason & Ag@6drMa Mc. 1 MalyrwAn*mmu m

1?13.

a
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f

W I? G N / r
T ? ?rtJa / Y ?' I S' o cJ ,,? ? j=

Triage Check List
Date: 9/26/06
Project Name: Bobby Arnold Blakely
DWQ#: 06-1548
County: Davidson
Daryl Lamb, Winston-Salem Regional Office
To:
60-day processing time: 9/21/06 - 11/19/06
From: Cyndi Karoly Telephone: [phone]
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 (Meuse, 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!
S
?U"!e 4.Jsc F}rte's
?. I'roc..c.ssi:I
0d
. I c?rui Version ivl?il .: (?
2 o 0 4
i ? ??;;1.E'@?; ;?ctiolt a;"1 I?lo.
wQ o
(f :my ; acin lotto clan is no( pplk;ahlc lc. ihn pro,jcci, 1)icase rlcl.ci "Nut ilpp)cc,abic" or "tv1t1".)
I. (;'hock Ill o('tltc approval(s) reCltlcstcd (or this proJect:
X1 c;ctlorl 404 f1cl'Inlt 1-1 RiPafian or bVatrrshcd fiu:f fer.lZulc;s
?. Section 10 Permit ? Isolated Wetland Permit Prone D) A Q
4401 Water Qua.lily Ccrtifica(iorl ? lsxpress 401 Water Quality Ccrtitication
2. Nationwide, Regional (V (3011cral Permit NLII11bCI-(S) 12CCIL1CStCCI:/95t? .- ??t>>CJ;3?j _
If, this notification is solely a courtesy copy bCCa(ISC written approval for the -401 C:'erli(ication
i?, not required, check hero: ]
?h 1f')<lynlcnt into the North Carolina. E;cosystcm l nhanccrncnt Program (NCC F, I') is proposed
for mitigation of ilrlpack, attach the acceptance letter front NCB EP, complete section Vlll,
and chock hcrc: ]
5. IPyour 1)1'0icct is located in any o('North Carolina's twent}, coastal counties (listecl oll page
4), and the Project is within I North Carolina Division of Coastal Managemetlt Area o('
1`1101-ollnlctltal Concern (see the top of'page 2 for further details), check het" ? u V
IL. Applicant Information D
S E P 2 1 2006
1. Owner/Applicant .Inlort?ation
Name: DENR - WATER QUALITY
1 t n l WETLANDS AND sroRMWATER BRANCH
Mailing Address:_ ?1 ?_i r(?t'?'y.'l_r i 1 , AC1 _--
I'C1C1)holle NL11l1bCr: ,? D i :?,j ( Fax NLI bcr:
E-mail Address: h cL{'r?I ??ic°t, 1-)'. LCm
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent 1 as signatory authority for the owner/applicant.)
Name:- Al e (A 0 , yy?
. cxtLy
Collipany Alfiliatlow L Lle?" , T -
Majling Address:_ 4.5 _-? _p
GS Y1 Ci(1C?
I 13L r'). C)
Telephone Number 334 -
-
f?-mail Address: h-1 I., k
2 1-- Fax Number:
P'wc5of12
v
Mak. Pl'()j('C'i i11it;lrliC':€ilOkt
Attach ,, vici.)Zity s11ap cl(,arly „Llmvilq; dic location of' the propcrt), with respect to )oc.,11
landil-mlks such as towns, rivers' '11-1(1 roads. Also provide a detailed site plan showill ; prop ;rty
boundaries ,.Intl cicvelopnlenl plans in relation t:o surroundilI ; proj:)crlies. 13c7ti the vici)Itty neap
and sit(, Man MUSt include a scalc: and north arrow. The specific footprints of all bl.lildill? s
inlperviolls surfaces, or Other fa.ci!ilies must be Ilicludcd. lfj)ossible, the neaps and plans should
include the appropriate USGS 7'opoj;rapl1ic Quad Neap and N.RC,S Soil Survey with Clio properly
boundaries outlined. PhIll dh?awilll;R, or other maps ma.y be included at the applicant's discret.iou,
so loaf, as the property is clearly delinecl. For aclnlinislrtltive and distribution purposes, the
t.1SACls requires information to be submitted on sheets no larger than 1.1 by 17-inch format;
however, DWQ may accept paperwork of any si•z..e. D\VQ prefers full-size construction
drawinf s rather than a Sequential shect version of the full-sire plans. If full-size plans arc
reduced to a small scale such that the :final version is illegible, the applicant will be inforn)cd that.
the pl-o,jec.t has been placccl on hold until deciphefable neaps are provided.
1. Name of project:
B) 4-ke-1 ) a1 C_ )'6::?t eilhf G. 14o me- ZZkc I-Uc1
2. Project Number or State Project Number (NCDOT Only):
3. Proj.lerty ldcntification Numbcr (Tax PIN): ' [„ = ))?k - ,' 1 . ?)
4. Location
County: ,C ?' c?c? j Nearest Town: nf' Z
Subdivision name (itlclude phase/lot number): ` 1
Directions to site (include road numbers/names, landmarks, ctc.):???f}ch
5. Site coorclinates (For linear projects, such as a road or utility line, attach a sheet that
separately lists the coordinates for each crossing of a distinct watcrbody.)
Decimal Degrecs (6 dlglts Illlllilllulll): °N "W
6. Property size (acres): Ci ?'?(! 1'E%?
7. Name of nearest receiving body of water: j-+ 1 lk 1R (4" k kt?
8.
River Basin:_ A j Y(? -
(Note - this must be one of North Carolina's seventeen designated major river basins
River Basin map is available at htl'j7?III120_el"I I'.Stale_11C.llSl?lCj11"17.11h11aj?sL)
The
ject
9. Describe the existing conditions on the site and general landl use in the vicini of the
at the time of this pplication: i CAE (-i I' k / /-o F rcr11 ?r') ) r

Pmw 0 or I
10. I n c rilw 0!"' ovcrall prof cct ill ci Lc1i!. inclu(lirlf; the typc of r,c!uipilic ill to be u;,cxi: X L2 ?'C{ ?..
-6 A5 R - -' rZAL
I I. 1:?'XjAiin file puI-po,;e of:ih., ? >roposrc work: GG?L'. I CItC t'
1 1. ._.l ---?._.?? ? c?_.__ - -_??? .C? Y_L?(,?_cZf<_'C.?_??-?c. c???tY?c i'1?_ -
1V
.v
Prior Project: History
i1 luriscaiclional determinations an(1/or permits have been rcclueslod and/or obinined for this
1)rojc::ct (inc:.luding a.ll prior Ilhclscs of the same subdivision) in the past, please explain. Include
the USA 'I? /fiction 11) Number, DWQ Project Number, application date:, and date pcrnlits i.Ind
certifications were issued or •,vithdranvn. Provide photocopies of previouSly issued pcrnlits,
ccrl:ilic Itioils or other uscfc!I information. Describe previously approved MIC0a11d, strcanl and
buffer imp;.lcls, along with associated mitigation (where applicable). if l)lis is a NC:DO`C' pro.jecr,
list and describe pcrnlits issued for prior segments of the smile T..LP. project, Along with
C011A ICliOll schcdLIiCS.-_-___
Viltiire. Project: Plans
Are any future permit regUOStS allt]ClpatCCI lot' tills 1)1'0fCct7 If So, describe tile anticipated work,
and provide justification for tale exclusion of this work front the cui'reilt application.
V1, Proposed Impacts to Waters of the United States/Wagers of the State
It is the applicant's (or agent's) responsibility to determine, delineate and neap all impacis to
wetlands, open water, and stream. channels aissociatcd with the project. Bach 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 all.
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 si -cam 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: ?(? ?7? ??(;7'«t ? l ?j ? ? ? ? d t { )ail l?° ?:.
2. Individually list wetland iwpaoLs. Types of' impacts Include, but are not. limilcd to
muclialli/ed Clearing, grad ing, fill, excavation, flooding, <iitclmig/drain a_ge, etc. 1'or dat'ris,
sea rtely list impacts duC to both structure and noodin
.
?
f n?afcd ???iuun Distance to 11\i" i of
Wetland Impact i

' "type of Wetland
1(10-ycar
hcarest I
Impact
Site Number I
ypc ofImpact.
l (c.g., forested, marsh, Floodplain ; Stream (acres) I
(indicate on map) herbaceous, bog, etc.) 1

1? lr? _I i
Total Wetland Impact (acres) I
-___-.___.?_ '
3. Dist the total acreage (estimated) of all existing wetlands on the property:
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, darn
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
rnnct hn innlnclnd Tm mnlmnlnte anrr>.nun mrnltiniv length X width. then divide by 43,560.
Stream Impact
Number
indicate on ma
Stream Name
Type of Impact Pcremrial or
Interrruttent? Average
Stream Width
Before Impact Impact
Length
linear feet Area of
Impact
acres
Ap?

---------- ------ -- -
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 Pxmvatinn dre.doinsr flnnding droinnoe_ hulkheads. 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
-?_ - - - ?P
-
-? Total Open Water Impact (acres)
Page 9 of 12
0. cinnlilativu illlp1l(.J (o 11 1 V,,-.ltcrs of tine resuhills.?: from the projc cl:
ir, 1 1 l111p R't (a i 51
j cfl,in(.1 Inpact (iI I c c.;
j Upcn Watcr Irrll);_;cl (;scrc.5);
i
Total 1i11pact to Mik rs (l? ?llc U.S. (au icy)
I otal Sts-cam Illlp ic,t (lil ,lr 1,0 0):
7. lsolatc(1 Waters
Do any isolated waters exist on the property? ? Yes No
Describe all IlllpaClS to isolated \?atCl'S, and include the typo ofwater (weti,111(l of stream) Gild
the size of` the propo,cd 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 h 1
if construction of a pulld is proposed, ;.iSsociatui/wetland all(] strealll impacts should he
inclu(Ic(1 above in the \A/ctland and stroanl impact sections. Also, flic propose([ pond should
be describe([ here and illustrated on any maps irlclu(Icd with this application.
Pond to be created in (check all that apply): [] uplands [] stream E:j Nvetlan(Is
DC.Scribc the method of construction (e.g., dam/embankment, excavation, installation of'
draw-down valve or spillway,
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local Stol'mwatei' requirement, etc.): __
Current land use in the vicinity of the pond: _ _
Sire of watershed draining to pond: --- Bxpectcd pond surface area:
NA L Impacd: Justification (Avoidance and Minimization)
Speci lically describe measures taken to avoid the proposed impacts. It may be useful to provide
Inf'orlllatioll 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 payouts, and explain. why these design options were not :feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discus construction
techniques to be followed during construction to reduce irnpacts. ? /
VIII. Mitigation
DWQ - In accordance wit.. 15A NCAC 2H .0500, mitigation may be required by the NC
.Division of Water Quality for prOlcets 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.
,/31/2004 00:14 AM Xoeldyn• Technologies 334 ?71 T490 19/12
USAGE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on January 15, 2002, mitigation will he required when
necessary to ensure that adverse effects to the aquatic environment arc minimal. Factors
including size and type of proposed impact slid 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 USAGE 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
.httR //Qo.enr.state.nc.us/ncwetlands/stnngide.html.
Provide a brief description of the proposed mitigation plan. The description should provid>v
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 shed if more space is needed.
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.uc.us/w /rp 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): /UM
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres): _
Amount of Non-riparian wetland mitigation requested
Amount of Coastal wetland mitigation requested (acres):
o.....+lnnci)
dprather
dprather
Microsoft Word - mso3E6.doc
06/03/04 10:45 AM
i X. P;.<lvlru,lyre.?zt?d }ur6Ctrif`r2titlifll (required by DAVQ)
1. Ooc; the l rojuc.[ involve t!I] expenditnrc of public (federal/k. c/local) fifflds or the use of
puhlic(I;der,.tllstttl.c) Yes [-_; No
:'_. If yes, c ocs the project require prepart.llion of an environniental doc.unient pilr:,uant. to the
1'eclllit-CInCntS of Lhc Nillollal or North Carolina Lnvlronniental I'oJicy Act (Ni;l?A/SIsPA)?
Note: If you arc not sl.irc whel}lcr a N PA./SEPA document is required, call tile SE"FIA
coordinator at [phone] to review current (hresliolds for environmental docutlleitatloll.
Yes E--] No E]
3, If yes, has the document review been finalized by the We Clcarin<.,,house? 11' so, please
attach it copy of the ?4EPA or SLPA final approval letter. Yes Ej No [_
I?rohosed Impacts on Riparian and Watershed Buffers (required by DWQ)
It is the applicant's (or agent's) responsibility to determine, delineate and neap all impacts to
I-CC(llll-cd state and local buffers associated NOT the prolcct. The applicant lllttst also proAde.
.lust ltcatton for these impacts in Section V11 above. All propose(] impacts must: be listed herclll,
and mtlsl he clearly Idcnd iable on the acconMunying site plan, All buffers must be shown on a.
map, whether or not impacts are proposed to [lie buffers. Correspondence from (lie DWQ
Regional OfMce 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 2B 1233
(Ncrlsc), 1.5A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 02:13 .0243 (Caum-ba) 15A NCAC
2B .0250 (Randleman Rules and Water Supply Buffer Requirements), or other (please
i(lentil:y -__ -T )? Yes ? No ['
2. If "yes", identify the square feet and acreage of impact to cash zone of the riparian buffers.
Jf buffer mitigation is required calculate file required amount of mitigation by applying the
buffer multinlicrs.
Impact I Muiliplicr I Required
%onc*
(square let) Mitimation
3 (2 Wr Catawba)
2 1.5
Atal
`r lone I cxlen(1s out 30 fcct perpendicular from the top of the near bank of channel; /one 2 extends an
additional 20 feet fi•om the edge of lone 1.
3. 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 2B.0242 or.0244, or .0260.
Pam I1 of 12
aI. ;°wrota rn woicr (required hN ;MV(1h
)?3Crlt>C 'liili?l'Vioi.i:i ,iCre`a?'c ?.? t.?llil?{ ,ill(( tV'opilSC:i? vcl•Sus t?)IC:,
:--tormxv,ltel- Controls pCOpoti:;cl 11-1 olio to protc:,t sm'l'acC waters ami \Vn:;::all(1?: (1t_``;1a:.St!l'.'i!li (roll?
i;w 1 (?'
? propurfv. If 1)e1ccnt 11t1pervIou5 Surlaec• c??c?ds t);.,, p1c:1st, ll1e????t.? G:,1lolll?tio??s
d"llion;A atlmv iolal nloi)osccf ilnpe"thous cvcl. f
X11. Sewage Disposal (required by DWQ)
C'le,u'ly detail the ultimate treatment methods and disposition (non-dis(harge or discharge) ol'
wastewater generated from the hroposcd project, of ,lvmlahlo capacily ol'thc. sllbjccl facility,
q ?L? ti toe- f'her- i° eta 41 iJi? s?ruc?(t ?p ??'?' ,, ,f ?; ra5 rG n Gtr ICY
Xtll. v?ffie?P; ?Q
Is this site Ill violLltioll of Ml'(-3 Wetland Rti cs (1 SA NC AC' 211 J)50tl) M- clll_y VllfCcr Ilule?s ,
No [I?
Is this all after-thc-fact permil clpplic,ltioll'' Yc.s No
XIV. Cumulative Impacts (required by DWQ)
Will this project Chased oil past anti reasonably anticipated 1uture'impacts) result in additional
developme.lrt, which could impact nearby clownstrecim water quality? YUs D-I No
If yes, please submit a qualitative or quantitative cumulative impact analysis in accordance with
the most recent North Carollml Division of Water Quality policy posted on our Nv6site at
1Ittp 1'I1,12o e nr.slatc .l1c,IIs/iicw(tl,11I&S. 11' no, ple lse )roe ids a short narrative description: keg-? etv+**!
at-
XV. Other Circumstances (Optional): A ,; / / 11\
It is the applicant's responsibility to submit the application sufficient(yill 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 oil
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or ether issues outside of the applicant's control).

ApplicaiAl'Agent's Signature Date
(Agent's signature is valid only if an authorization letter From the applicant is provided)
11,n, e 12 cif 12
bavidson Co., NC -- Printable Map
Davidson Co., NC
Parcels
Page 1 of 1
Parcel Number: 0603300000015
Pin Id: 6720-04-81-0202
Owner:
BLAKELY BOBBY ARNOLD SR ET ALS
309 KIRKMAN ROAD
LEXINGTON NC 27292-0000
Property Address:
0 KIRKMAN DR
Additional Information
L15 BK1638-470
LAKE DR
Land Units: 1.93 AC
Deed Book: 1638 Pg: 470
Deed Date: 8/25/2005
Account Number: 000009080244
Township: Cotton Grove
Exempt Code:
Building Value: $15,810
Other Building Value: $8,420
Land Value: $38,250
Market Value: $62,480
Assessed Value: $62,480
Deferred Value: $0
DISCLAIMER: The information contained on this page is NOT to be construed or used as a "legal description". Mar
information is believed to be accurate but accuracy is not guaranteed.
http://www.webgis.net Anderson & Associates, Inc. http://www.andassoc.com
f
Davidson Co., NC -- Printable Map
Davidson Co., NC
Page 1 of 1
-3 2 5
63
1 1 / r' r f ? ,F•? ?-_ ]711
4 01
d21J
YW)
?.? '-'1' ?? Y '_lt 1r., ii ?f,•f,'` --.,--.,??: yam,.
;1.:17 ti
°2'J3 :,21.1
12 ,213 1-j 3 ?? ; 1:i" f ?a117 ,' f
1 44 , ; r ? J/./ ? I
011
I?e?.:?lti ?? t1C_1.4 ?• _''l_...C' 1 ? 11--J ?'?7 .. ?..? ! .. j/
Parcels
Parcel Number: 0603300000015 Land Units: 1.93 AC
Pin Id: 6720-04-81-0202 Deed Book: 1638 Pg: 470
Owner: Deed Date: 8/25/2005
BLAKELY BOBBY ARNOLD SR ET ALS Account Number: 000009080244
309 KIRKMAN ROAD Township: Cotton Grove
LEXINGTON NC 27292-0000 Exempt Code:
Property Address: Building Value: $15,810
0 KIRKMAN DR Other Building Value: $8,420
Additional Information : Land Value: $38,250
L15 BK1638470 Market Value: $62,480
LAKE DR Assessed Value: $62,480
Deferred Value: $0
DISCLAIMER: The information contained on this page is NOT to be construed or used as a "legal description". Mar
information is believed to be accurate but accuracy is not guaranteed.
http:ttwww.webgis.net Anderson & Associates, Inc. http://www.andassoc.com

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(I f !111)' palm ulm the j l L; not Ipph; Inlc try Ihn t?rolcr t, picase cartel ,Vut ?1pj>hi chic, ry??r. iV/?\ ,)
i. T'eo(.',essi'Itl,
If.
.? I
L Chock all of to approval(s) requostcd for this project::
K eclion -'104 Permit ? Riparian or Watershed 1.3u('(:er fZulr:.s
Suction 10 Permit ? Isolated Welland Permit from D\,W
401 Water Quality Ccrti[icatiort ? L;xpress 40l Water Qt.tality C'ertif'ication
?. Na(ionwidc, Regional or General Permit Number(s) Request:ed:JC?S??
If this notification is solely a courtesy copy becausc written approval for [he -=101 Certifical:ion
1?, not requited, check Here:
?h Lf pay111Cnt into the Noah Carolina 1. cosystc111 E,n11aneurncnt. lhogranl (NCCLP) is proposed
for mitigation of inlpacl:s, attach the acccptancc Ict er from NOW, complete section VII[,
and check here:
5. If your project is located in any of Noah C'arolina's twenty coastal counties (listed on page
41 and the project is within a North Carolina Division of Coastal Management Area of
Iinvironnlcntal Concern (see the top of page 2 for further details), check her
np111icai;lt Inf•orn>tatiou I
S E P 2 1 2006
1. Owner/A??plicanl hlforll?ation __// j DENR - WATERQUAL;TY
Nan1c:- ?" t'` n ?. / 1_ ?? I G+; /.?_? WETLNOSMID STORMWATER BRANCH
Mailing Address: = t- -
-- ??? 9 i I?K?i'/1 rl 1?/ll?l
?L O C% i i .
Tcl.cphonc Number: '3E- ! Pax Number:
E-mail Address:_ L,,_hlcth VIOLA, CC,ri
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent 1;as signatory authority for the owner/applicant.)
Name: ?U M
Company Affiliation: •) t- - I
Mailing Address: ?.LKA JDI,mh?&

I CJCpnonC Number:3-3? - ? 42 = ?? I Fax Number:
F,,-mail Address: A'ti-, k ?11
?
We 5 of 12
N.9il. Project ?)i6:+7'?it•:Ei,.kokt
Attach s, vici.ajity aI1ap clearly shr ?•vinF.. the location of* 1.110 pro(irrty with respuci to )oc;.+l
I,aaldrnarl ;;uc;h as Wris, rivert and roads. Also provide a detailed Me p1mi shoe, i i propcr(y
houndaHos and development plans in rclatiotl to Surrounding prol)cr(ics. L3otl1 the vicinity map
and situ n1us1: include a ?;cr11e and north arrow, The specilic footprint;: of all buildinf s
impervious surt1100% or other AcilNK must be included. lfpossible, the maps and plans should
include the appropriate USGS Topographic Quad Ylap and N.RCS Soil Survey with the property
boundaries ontllned. Plan dra"WgS, or other maps may he Aluded at the applicant's diawdon,
so lone; as the property is clearly defined. For administrative and distribution purposes, the
USAM requires information to he submitted on sheets no larger than l l by 17-inch format;
however, DWQ may accept pap0rworlc of any size. DWQ pre:ers full-siz0 construction
chowinf s rather than a sequential sheet version of the full-sire plans, Il- fulksizc 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 deciphcrahle maps are provided.
1. Name ofprojcet:

2. T.I.P. Project Number or S(atC Project Number (NCDOT Only):
River 13asin: ? 1 ?? - l a 1 - _
(Note - this must be one of North Carolina's seventeen designated major river basins.
River Basin map is available at lit(h://1?2?_rtr_st?> e n.us/'ldiri_in/ijicll?s/.)
o nA e'_ 1-,k(4 "Ci
3. Property Identification Number (Tax PIN): ;n' ' C J-- - ?,'j L ? - 11 ----
4. Location
County: Nearest Town: Ll ><-l O ,
Xi'Lt?, _E1_ll c
Subdivision name (include phase/lot number):
Directions to site (include road numbers/names, landmarks, etc.):
5. Site coordinates (tor linear projects, Such as a road or utility line, attach a sheet that
separately lists the coordinates for each crossing or a distinct waterbody.)
Decimal Degrees (6 digits minimum): - "N A/ 1A W
6. Property size (acres): , q
'O'

7• Name of nearest receiving body of water: 'I4 )'-1 :1 ?"? I?cl?f ?-!i
8
The
9. Describe the existing conditions on the site and general /land use iin_ the vicinilIy of the project
at the tl111e of this'- pphcatlon:" P 61 de R+ lI(x I 1-ClAtz", f rC'r) Y ?V/%) ?) t?Y
Y
.f
1QPV 6 "r I?
10. Dc,,xrihc? 0!", , overall projc(.-l ill clct,lil; inclu/?linlr, tllc tyl)c cr; c cl lil)n,?;ru to he
C'l ?` (?• ?? (`I \.Gt? L 1'?.S?r'{ ,'? L'.?1 1 r 11L(? ? l_?? U s""? ? ? ? ? ,_
, G!C?_ _c it ! U-Xk i r}? ? CA'V? LeX .L45; n - ?
1 1 . Hxp!ilill 1110 purpose) Of t11c ) roposcd ldork:
1
CL??{1i?.{-_..( /o?L
I1?. Prior Project History
II jurisdictional detcl'111111,11oils amd/or permits 11IIVi bcell requested 111(1/01- ob1a11led f01' fills
i)rojCG1 (Il1ClLldillg all I)rior philses of the sable subdivision) ill tllc; past, please cxl)laill. lnClude
the USACJ' ,' Action lU Number, DWQ :Project Number, application date, and date permits and
certifications were issued ol• 'XithdraWil. Provide pholocopies of previously issued permits,
ccrtlllclltlolls of other uscflll iilfoi-mation. Describe 1)I-CVloLlsly ipproved \ved,111d, strealil xild
buffer iruplcts, along with associated mitigation (where applicable). 1-f phis is i NC',D0'1, project,
list alld describe perrilits issued ('of- prior segments of the sa111e '1',1.P. project, along with
consl: LIC60n schedules.------- /Nk
1 1 -_+--- ------ _--
V. Future. Project Plans
Are any future permit requests anticipated for this project? 11'so, describe the ;anticipated Nvork,
arld provide justification for the CXCILI?ion of this work li-onl the clarrcnt appliCatiOll.
L 'A
V(. Proposed Impacts to Waters of' tile United States/Waters of the Suite
It I's the 11Tlicallt's (of agent's) responsibility to cletel'I11111e, delineate and map all impacts to
wetlands, open water, mid sti-caill challllcls associated with the project. Bach iMINICt lllLlst be
listed scpm'atcly ill the tables below (e.g., culvert installation should be listed separately from
riprap dissipater Imcls). Be sure to indicate if an impact is tcmporuy. All proposed impacts,
pcrmauent and temporary, must be listed, and must be labeled and clearly identifiable on an
accompanying site plan. All wetlands and waters, and all streams (intcrlnittcnt and perennial)
S1101-11d be shown on a delineation map, whether or not impacts are proposed to these systems.
Wetland and stream evalUatlon 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.
I . Provide a written description of the pro posed impacts: (F= 11 'l I 'Cl ' '; Llc { anc C.
)oJ
2. lndivi?tuall?I list wetland Types of impaols i11c ludc?, but arc not lilril??(l )
1MA:ha11ricd clearing, grridin,?, bil, c?:cavation, floodint„ ?ti1c1_in)?,%drainac;e, etc_ For dwil.s,
Iar?,icly list un tuCturc and flooding
Sci
pacts due to hou st t f ocal? u i
d ??ilhi? Uis' x.c in t\i, t of
I - ofWetland
Wetland lm,;;, i Type
Site Number Type of Impact (c.g., lbrested, marsh, IOU ) c u t? c ue t tmp u t
loodhlaui SUcZnt (a, acs)
(ind icak, o? map) ? ? herb a coos, hog, ctc.) ? i
(rcernol (linear feet)
Total Wetland Impact (acres)
3. List. the total acreage (estimated) of all existing wetlands on the property: 4. Individually list all intennittcnt and perennial stream impacts. Be stire to identify temporary
impacts. Stream impacts include, but are not limited to placement of filT 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 acreage, multiply length X width, then divide by 43,560.
Stream Impact Average Impact T Area of
Number Stream Name Type of Impact I Perennial or Stream Width T Length Impact
t Intermittent?
indicate on ma Before Im act linear feet acres
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 Type of Waterbody Area of
Name ppliWatercableb) ody Type of Impact (Lake, pand estuary' sound, bay' Impact
Site Number (if applicable)
(indicate o m
n ap- --- ocean, etc,)-------- acres
Total Open Water Impact (acres)

0. 1.,"cl f.tl.; C'11tlIIllatlvr rolls at;t to 111 V, ;.hers of the tt.`, 1C5llltlilf. f-oill the pr0??!Gf:
;irr i n inlpa C
- ---- -----------
j Well,nld Impact (ac 1c ;)
j U lctl Water Irnp acl ,,c:rc;s j
1'0 u.l I Impact 10 Watc rs of the U.S. (acres)
- - --
I otal Stream Inlpai (_ (lil ar ice I).--
7. 1,,mlatcd \A'aters
Do any isolated waters exist on the property? L] Yes No
Describe all impacts to isolated waters, and include the type of'waleu• (WCtlalul Or stream ') aucL
the size of the proposed impact (acres of- linear [bot), Please note that this section only
applies to waters that have specifically been determined to be isolated by the USACB.
8. Pond Creation
['\-
11' COI1StRiCtl011 01 a. pond is pl•OpOSCCI, f.SSOClatccINvctIalld and S1rGa111 impacts should be
included above in [IlC wetland and stream impact sections. Also, (:he proposed pond should
be described here and HILISira.ted on any tllaps included with this application.
Pond to be created in (check all that apply): Lj uplands [] stream Lj wetlands
Describe the method Of' CO1lStrllCtton (e.g., d im/embankment, excavation, installation of'
draw-clown valve or spillway, etc.): __
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
IOCal StOI.11DA1 1101- rCgUire111Cnt, etc.): _ _
Current land use in the vicinity of the pond: _
Sire of watershed chaining to pond: _ Lxpect:ed pond surface area:_ _
V11. impact:;lustification (Avoidance and Minimization)
Specifically describe measurcS taken to avoid the proposed impacts. It may be useful to provide
infbrmation 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, discus Construction
techniques to be followed during construction to reduce impacts.
V111. Mitigation A
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.
/31/2006 0018 AM
Xeelayne Technologies 775 ?17 749S lull,
USACT . In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits. published in the Federal Register on January 15, 2002, mitigation will he requited when
necessary to ensure that atdversc effects to the aquatic environment are rinnimal. Factors
including siie and type of proposed impact and function acid relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Lixamples 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 USAGE 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
ht /Wo.enr.state.nc.us/newetlands/stiingide.html.
Provide a brief description of the proposed mitigation plan. The description should provid+c
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. [
t,
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 hqp://h2o.enr.state.nc.us/wfp index.htw. 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): .__k 1,4
Amount ol'buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres) __,- _
Amount of Non-riparian wetland mitigation requested
Amount of Coastal wetland mitigation requested (acres):

dprather
dprather
Reflection Print
06/07/04 08:04 AM
I X, 1,;nv w...'tirtental li}ura!?!!e?at,t :calu k"required by DNO Q)
1. Doc"s tho project irrvo)v(, "m expenditure of public (I deraUsf;.!.te/local) funds or the use of
public, (icderal/Stat.c) Luid? Yes ( No L"r
`'. IF yes, sloes the prc,jccl require preparal:ion of an cnvifonmental docurrtent pursaianl. to the
requirements of 1.11e National or North Carolina Enviror!ntcntal Policy Act (NF;I'A/SE,1)A)?
Note: if you are, not sure whc(1!cr a NEPA/SEPA document is required, call tile Sl--",]-)A
coordinator at [phone] A review current (hresholds for environmental documentation.
Yes [] No I[
3, If yes, Ins the doeummlt review been finalized by the .State Clearinghouse.? If so, please
attach a copy of the N1 PA or SEPA final approval letter. Yes iVo (-„
K Proposed Ifl pacts on Mpadan and Watershed Buffers (required by DwQ)
It is the applicant's (or agent's) responsibility to determine, delineate and rnap all impacts to
rcquircd state and local buffers associated with dic prqicct. 71he applicant must also prov%..
justiHendon Al. these impacts in Section VII above. All proposed impacts must be listed herein,
and must he clearly idcr!tiliablc on the accompanying site plan. All buffers must be shown on a.
map, whether or not impacts arc proposed to the buffers. Correspondence from the DAVQ
Regional Office tnay 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 2B .0233
(NCLISe), 15A NCAC 2B ,0259 (Tar-Pamlico), 15A NCAC 0213 .0243 (Catawba) 15A NCAC
2I3 .0250 (Randleman Rules and Water Supply Buffer Requirements), or other (please
idcntify_...... )? Yes ? No [?J/
2. 1f "yes", identify the square feet and acreage of impact to each zone of the; riparian ME,
1f buffer mitigation is required calculate the required amount of mitigation by applying the
buffer multipliers.
F Gone Impact Multiplier -squired l
--- (square feet) -- TNlitiea-ton
I
l 3 (2 for Catawba)
- -- - --- ----- -- --
- - Tool
Zone I extends out 30 feet perpendicular from the top of the near bank of channel; "Lone 2 extends an
additional 20 I'ect from the edge of Zone J.
3. If buffer mitigation is required, please discuss what type of mitigation is proposed (Q,
Donation of Property, Riparian Buffer Restoration / Enhancement, or Payment. into the
Riparian Buffer Restoration Rind). Please attach all appropriate information as identified
within 15A. NCAC 213.024.2 or.0244, or ,0260.
Pane I 1 of 12
ei. •. l:is i:iiti elf Ci l-i e(wil-cd hIN' '01A (? l
i)i ilwl ViOu, ICt Ccl{'t i,'.x :Riiil,? <il;ll 11ro 11(l.'`iC(i) yU{'?!„, tCt;d ac;I:01:
tUi? l\?-;l;i., c)litl'o!S l!1',lp(? ;:;Cl Hl or(Jul tl) fro! l.
uc pl-o pl III ll O<(l+ Ill 1lT11yG1 ?1??1.+J Ill l?? "?,tt,'?(?y tl`: , I)?t!?iSi' I?1G"ei+1?'.ilc'lil;ii.i??il4
Smare Disposal (required by DW(G)
l'icarly detail the ultimate treatment methods amd disposition (non"-(115cl:ar-c or clischarge) of,
lwastcw"If r t-jollt'f<itcd Il-mil illc nvoposc l hrt Ic`-ct, (1l aviltlahlc capmjl'-' Id ililt sui) Oct Giclllty.
All _ x C.? v f cl to r E ?(_ l?L1 j ll -- } - P L ' C'.<.. ??? ?c?!lt- k t _ r: f-
ct r?# ros,c? r, L?ntJ ki fl-
10, 4,-), !e eta 5_ r G { he r t ?,ltri in s?,^ucLtr?y +c
1
Is ifiis .site ill vlokition of DWO \ c(lantl l?u'es (1.5A VAC 211 .n?(A)) ,,1 ,uly 1,31if(%r IZule-s"
Yom, No =
L.
Is ihis an <If1cr-the-f,lr1 llernlil lll?plic<ltion? I ` No ? .'
XIV. Cumulative impacts (required by DWQ)
Will this pro,1cct (hascd on past and reasonably anticipated l'ulurc'impacts) result ill additional
(levelopmel-11, which could irupact licarby downshcalu water quality`' Ycs I No
FPX
I I- ves, please suhmit a qualitative rn' quantitilt] vc cumulative impact analysis in accordance with
the trios( recent North Carolina Division of Water Quality policy posted on our wciisitc a1
httt) i?hi?O cn1.Stitt rlc'.Uti%ni',vc.tidtld`'?. Jt n??, ple,l?c ?ri?Vld%a ?hol"t narrative iIOSCrIptiQn:_t'Scc?en+?i?
XV. Other Circumstances (Optional): kil P\
It is the applicant's responsibility to submit the application suffieientl_y in advance of desired
cor?struc-tion dates to allow processing time for iliesc permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose lin-its on
work schedules (e.g., draw-clown schedules for lakes, dates associated with Endangered find
"threatened 'Species, accessibility problems, or other issues outside of the applicant's control).
pp
lic4aA
gent's Signature Date
(Agcnt's sirnaturc is valid only if an authorixafion letter From tic applicant is provided.)

Davidson Co., NC -- Printable Map
Davidson Co., NC
Parcels
Page P of 1
Parcel Number: 0603300000015
Pin Id: 6720-04-81-0202
Owner:
BLAKELY BOBBY ARNOLD SR ET ALS
309 KIRKMAN ROAD
LEXINGTON NC 27292-0000
Property Address:
0 KIRKMAN DR
Additional Information
L15 BK1638-470
LAKE DR
Land Units: 1.93 AC
Deed Book: 1638 Pg: 470
Deed Date: 8/25/2005
Account Number: 000009080244
Township: Cotton Grove
Exempt Code:
Building Value: $15,810
Other Building Value: $8,420
Land Value: $38,250
Market Value: $62,480
Assessed Value: $62,480
Deferred Value: $0
DISCLAIMER: The information contained on this page is NOT to be construed or used as a "legal description". Mar
information is believed to be accurate but accuracy is not guaranteed.
http://www.webgis.net Anderson & Associates, Inc. http://www.andassoc.com
'ISavidson Co., NC -- Printable Map Page l of 1
Davidson Co., NC
74
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won
Parcels
Parcel Number: 0603300000015 Land Units: 1.93 AC
Pin id: 6720-04-81-0202 Deed Book: 1638 Pg: 470
Owner: Deed Date: 8/25/2005
BLAKELY BOBBY ARNOLD SR ET ALS Account Number: 000009080244
309 KIRKMAN ROAD Township: Cotton Grove
LEXINGTON NC 27292-0000 Exempt Code:
Property Address: Building Value: $15,810
0 KIRKMAN DR Other Building Value: $8,420
Additional Information : Land Value: $38,250
L15 BK1638-470 Market Value: $62,480
LAKE DR Assessed Value: $62,480
Deferred Value: $0
DISCLAIMER: The information contained on this page is NOT to be construed or used as a "legal description". Mar
information is believed to be accurate but accuracy is not guaranteed.
http://www.webgis.net Anderson & Associates, Inc. http://www.andassoc.com

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