20190267 Ver 1_PCN Form Submission_20190228

DWR - -.,,
l bion of Water tXefearces
Pre -Construction Notification (PCN) Form
September 29, 2018 Ver 3
Initial Review
Has this project met the requirements for acceptance into the review process?*
k5 Yes
C No
Is this project a public transportation project?*
C Yes O No
Change only if needed.
BIMS # Assigned*
Version#*
20190267
1
Is a payment required for this project?
C No payment required
What amout is owed?*
C Fee received
G $240.00
O Fee needed - send electronic notification
C $570.00
Reviewing Office* Select Project Reviewer*
Fayetteville Regional Office - [phone] Chad Turlington:eads\ccturlington
Information for Initial Review
Ia. Name of project:
Shannon
1a. Who is the Primary Contact?*
Jim Ba#er
I b. Primary Contact Email:*
[e-mail]
Date Submitted
2/28/2019
Nearest Body of Water
Little Raft Swamp
Basin
Lumber
Water Classification
C; SW
Site Coordinates
Latitude:
34.85400
Longitude:
-79.19109
1c. Primary Contact Phone:*
[phone]
A. Processing Information W
County (or Counties) where the project is located:
Hoke
Is this project a public transportation project?*
C Yes M, No
1a. Type(s) of approval sought from the Corps:
V Section 404 Permit (Wetlands, streams and waters, Clean Water Act)
r Section 10 Permit (navigable waters, tidal Waters, Rivers and Harbors Act)
1 b. What type(s) of permit(s) do you wish to seek authorization?
V Nationwide Permit (MNP)
r Regional General Permit (RGP)
r Standard (IP)

tc. Has the NWP or GP number been verified by the Corps?
O Yes O No
Nationwide Permit (NWP) Number:
NWP Numbers (for multiple NWPS):
Id. Type(s) of approval sought from the DWR:
m 401 Water Quality Certification - Regular
❑ Non -404 Jurisdictional General Permit
❑ Individual Permit
14 - Linear transportation
Is. Is this notification solely for the record because written approval is not required?
For the record onlyfor DWR 401 Certification:
For the record only for Corps Permit:
❑ 401 Water Quality Certification - Express
❑ Riparian Buffer Authorization
1f. Is this an after -the -fact permit application? *
O Yes M No
Ig. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
O Yes O No
19. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
O Yes O No
Acceptance Letter Attachment
SAW -2018-01238 NWP 14.pdf 893.92KB
1h. Is the project located in any of NC's twenty coastal counties?
O Yes O No
1j. Is the project located in a designated trout watershed?
O Yes d No
B. Applicant Information
1d. Who is applying for the permit?
❑ Owner R Applicant (other than owner)
Is. Is there an Agent/Consultant for this project?
O Yes O No
2. Owner Information
2a. Name(s) on recorded deed:
Benjamin Isaac
2b. Deed book and page no.:
1160 329
2c. Responsible party:
2d. Address
Street Address
161 Branch Road
Address Line 2
aty
Red Springs
Postal / Zip Cade
28377
2e. Telephone Number:
[phone]
2g. Email Address:*
jim.ba)[e-mail]
3. Applicant Information (if different from owner)
3a. Name:
Colette Baugh
State / Rwince / ftion
NC
(buntry
us
2f. Fax Number:
O Yes O No
O Yes O No

3b. Business Name:
Verimn Wireless
3c.Address
Street Address
8921 Research Drive
Address Line 2
aty
Charlotte
Postal / Zip Code
28262
3d. Telephone Number:
[phone]
3f. Email Address:*
[e-mail]
C. Project Information and Prior Project History
1. Project Information
ib. Subdivision name:
Of apprWiate)
1c. Nearest municipality/town:
Red Springs
2. Project Identification
2a. Property Identification Number:
294400001389
2c. Project Address
Street Address
288 Ruff Road
Address Lie 2
CKY
Red Springs
Postal / Zip Code
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Little Raft Swamp
3b. Water Resources Classification of nearest receiving water:*
C; SW
3c. What river basin(s) is your project located in?*
Lumber
3d. Please provide the 12 -digit HUC in which the project is located.
03040203
4. Project Description and History
State/RVAMIR40M
NC
Country
us
3e. Fax Number:
2b. Property size:
3
State / Province / Fbgian
NC
4a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this application:*
Mostly wooded land with a residential structure.
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?*
[` Yes (I No O Unknown
4c. If yes, please give the DWR Certification number or the Corps Action ID (exp. SAW -0000-00000).
SAW -2018-01238
Project History Upload
SAW -2018-01238 NWP 14.pdf
893.92KB
4d. Attach an 81/2 X 11 excerpt from the most recent version of the USGS topographic map indicating the location of the project site. (for DWR)
4e. Attach an 8 1/2 X 11 excerpt from the most recent version of the published County NRCS Soil Survey map depicting the project site. (for DWR)
4f. List the total estimated acreage of all existing wetlands on the property:

0.26
4g. List the total estimated linear feet of all existing streams on the property:
4h. Explain the purpose of the proposed project:*
Construction of a telecommunications tomer and associated access road to provide cell coverage in the area.
41. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:*
A gravel road will be installed to provide access to a 100' x 100' feet lease area that veil have a cell tower and associated equipment. A culvert will be installed in a small wetland area for
the road to cross. 0.05 acres of wetland impact is proposed. See attached PCN approval for site plans.
4j. Please upload project drawings for the proposed project
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?
O Yes C No
Comments:
5b. If the Corps made ajurisdictional determination, what type of determination was made?*
O Preliminary C Approved C Not Verified C Unknown C WA
Corps AID Number:
5c. If 5a is ves. who delineated the jurisdictional areas?
Name (if known): Jennifer D'Augustine
Agency/Consultant Company: Terracon
Other:
C Unknown
5d. List the dates of the Corp jurisdiction determination or State determination if a determination was made bythe Corps or DWR
10-1-2018
5d1. Jurisdictional determination upload
6. Future Project Plans
6a. Is this a phased project?*
C Yes d No
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the proposed projector related activity?
D. Proposed Impacts Inventory.'
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
m Wetlands ❑ Streams -tributaries ❑ Buffers
❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
!a. Site #* (?) 2a1 Reason (?) 2b. Impact type * (?) 2c. Type of W. 2d. W. name * 2e. Forested* 2f. Type of 2g. Impact
Jurisdicition*(?) area*
access P Riverine Swamp Forest Wetland a Yes Both 0.050
(acres)
2g. Total Temporary Wetland Impact
0.000
2g. Total Wetland Impact
0.050
2h. Comments:
2g. Total Permanent Wetland Impact
0.050
E. Impact Justification and Mitigation L^1

1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:
Locating the road at the area of smallest wetland width. Only 0.05 acres proposed for impact.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:
Culvert size chosen to minimize impact. Appropriate BMPs to avoid secondary impact.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for impacts to Waters of the U.S. or Waters of the State?
C Yes r No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
Less than 0.10 acres of impact
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection Rules?
C Yes C: No
If no, explain why:
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?
C Yes P, No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H.1003(2)?
C Yes C No
Comments:
G. Supplementary Information 6
1. Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?*
C Yes r No
2. Violations (DWR Requirement)
2a. Is the site in violation of DWR Water Quality Certification Rules (15A NCAC 21-1.0500), Isolated Wetland Rules (15A NCAC 21-1.1300), or DWR Surface Water or Wetland Standards or
Riparian Buffer Rules (15A NCAC 2B.0200)?*
C Yes r No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project result in additional development, which could impact nearby downstream water quality?*
O Yes G No
3b. If you answered "no," provide a short narrative description.
Just a cell tower development. No future construction
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
(' Yes F No C WA
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or habitat?*
C Yes C No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
E Yes C No

5c. If yes, indicate the USFWS Field Office you have contacted.
Raleigh
5d. Is another Federal agency involved?*
r Yes C No
What Federal Agency is involved?
FCC
5e. Is this a DOT project located within Division's 1-8?
C Yes r No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?
r Yes C No
5g. Does this project involve bridge maintenance or removal?
C Yes r No
Sh. Does this project involve the construction/installation of a wind turbine(s)?*
C Yes r No
C Unknown
51. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers, mechanized pile drivers, etc.?
C Yes r No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
IPAC
Consultation Documentation Upload
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
C Yes r No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
EFH Mapper
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal governments have designated as having historic or cultural preservation status?*
C Yes r No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
Arch Survey performed
7c. Historic or Prehistoric Information Upload
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA -designated 100 -year floodplain?*
C Yes r No
8c. What source(s) did you use to make the floodplain determination?*
FEMA FIRM map
Miscellaneous
Comments
Miscellaneous attachments not previously requested.
Signature
*
r7 By checking the box and signing below, I certify that:
• I have given true, accurate, and complete information on this form;
• I agree that submission of this PCN form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act');
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act');
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature; AND
• I intend to electronically sign and submit the PCN form.
Full Name:
Jim baxter

Signature
Date
2/28/2019

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO.
STREET ADDRESS: Z
Please print:
Property Owner:
Property Owner:
PARCEL ID: Z I y 10rX)Q ( 3 F q
L
The undersigned, registered property owners of the above noted property, do hereby authorize
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above)
rAd
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
rized Signature
Date:
Authorized Signature
Date: